The situation:

It has long been accepted that addiction is a chronic, relapsing illness and when relapse occurs-as it commonly does after even the very best of treatments- one can only applaud when drug users return for additional care and support. The fact that ‘many users can’t fully recover from their addictions’ merely reflects the complexity of the problem.

In our state, drug treatment is strictly disciplinarian and abstinence oriented with little or no flexibility and thus relapsed rates are high. Drug users are mistreated and everyday, we hear of gross human rights abuses that go on in the name of demand reduction.

It is very difficult, if not impossible, to change drug users lifestyle simply through the traditional/conventional approach. It takes a holistic approach to promote change in a drug users lifestyle, encouraging the use of safer practice, reducing the transmission risk for themselves, their families and to have affordable treatment service available if their choice is to abstain from drugs.

It is also required to take initiatives in motivating and raising concerns among drug users, particularly the next GEN-X, so that they do not switch to injecting, if ever they had to use drugs. The stability and normalcy those programs can bring to the lives of drug users is a moral triumph over anti-drug hysteria.

Why is it then that in a state like Manipur, a comprehensive HIV prevention strategy for drug users has been rarely implemented in time and on a sufficient scale to prevent HIV epidemics?

Both HIV/AIDS treatment and drug substitution therapy for drug users constitute the critical element of a comprehensive response. The W.H.O. fully recognize the overwhelming evidences that both methadone and Buprenorphine are highly effective treatments for drug dependence and prevention of HIV/AIDS.

For the first time, the substitution program looks through a tunnel of vision through the words & feelings of real hard-core drug users, who openly tell their true stories and speak about their experiences of substitution treatment and describing their lives without drugs.

“I need not bother about my next dose. Now, I am more concerned about my health, my earnings and above all been able to adhere to ARV therapy.” Many of them have managed to re-establish their family ties and renew their physical health.

Barriers to substitution therapy:

Even though there are legal substitution/pharmacotherapy services available in the country with the Govt. AIDS policy supporting drug users access to drug substitution, till date there has been little govt. initiatives and even among the stakeholders to explore this option. In many settings, there are limited complementary services and appropriate referral avenues for IDUs seeking additional supports, including treatment options and services for PLWHAs.

There are no pharmacotherapy services available widely in the state to cover the increasing number of IDUs. Drug treatment in the state is, in general, focused on D.I.C. based short-term detoxification with the exception of treatment centres sponsored by MOSJ&E. The services are expensive and few drug users can afford it.

The needs of increasing number of female drug users continued to be overlooked, with the treatment services or model still not acceptable for them. After care and follow-up services are very rare in our setting and, as a result, it’s not very surprising to find the relapse rate to be so high.

Traditional drug treatment works for roughly one quarter of users or even less—substitution treatment offers an option for the other three quarters. Ending drug dependency is the goal of substitution therapy. It is means of reducing the users’ impact on public order and public health until durable solution are reached.

Without (substitution) therapy, the only things waiting for drug users are overdose, prison, HIV, the vicious circle of addiction and the humiliation of sanction being imposed by various civil society organizations. The above facts could be summed up from the words of Sunil Aheibam, a Service provider of substitution programmes.

“Buprenorphine treatment is about helping all patients, not just those’ good patients’ who are immediately able to refuse hard drugs”, he says,” it’s about moving away from the utopia of curing everyone to the practicality of helping everyone, even the most helpless,” “Social support for addicts once they complete treatment is entirely lacking.”

Overcoming ignorance

The beneficiaries of the current buprenorphine program has struggled against almost overwhelming odds to persuade the people who matters and raising maximum vocals that its introduction is the need of the hour to help control a burgeoning drug-addiction crisis and the aging public health. It certainly, was an uphill task. Even the big guns of the society presume that buprenorphine used to wean addicts off opiod drugs are unethical and wrong headed as they replace one addiction with another.

The drug using populace deeply appreciates the NEIHRN’s role when R.K. Raju was at its helm of affairs, his active and courageous role and vital part in raising awareness about substitution therapy and raising the concerns of people using drugs in particular. The inclusion of pharmacotherapy in the NACP Phase-III could be attributed to the suppressed and sustained activism on the part of buprenorphine beneficiaries. It is indeed an eye opening for the NACO officials and a healthy step welcome by all and sundry.

The above-mentioned service provider laments, “ Sadly, the opponents of substitution chose not a scientific and pragmatic but a moralistic approach to discussing the problem “ “A second lesson learned is that achieving good results required us to work closely with our clients for a rather long period of time —one whole year! We agreed to working long hours, learned to be tolerant when waiting for abstinence, and enjoyed even the slightest positive changes. Our experience also demonstrates that Buprenorphine is only a small part of changing a client’s behaviour.”

Treatment includes the influence of doctors and medical professionals, as well as other program participants. “We found that clients responded. Furthermore, the implementation of this therapy is contrary to the interests of criminal groups and corrupt police forces that make a fortune off the drug problem.”

“Providing treatment for the opiate-dependent patient is difficult, but it is also a great privilege, and enormously gratifying! It is fine to dream of “the best,” but meanwhile we must seize the opportunity that exists today to provide “the good” to every single person who needs and wants help, and who may well die without it. This is precisely what is meant by “harm reduction,”

I have delved into the Webster and Oxford to find the exact meaning of “Hypocrites” with regard to harm reductioner’s and still am yet to find its true synonyms. It’s very ironical to learn those activists who profess to be Harm Reduction Net-workers are coincidental with the same protagonists who were very vociferous about substitution program as a “Harm Maximization” programme way back in the year 2000 when SASO piloted a two year program under the management of H. Umesh Sharma.

It seems very strange and amusing when this writer surf the Internet to browse upon a certain publication of an article “ Substitution therapy—HARM REDUCTION or HARM MAXIMISATION” web-casted on Manipur Online. All this resulted in a number of misconceptions that surround the true meanings of substitution therapy. Harm reduction is being diluted and turned into a dirty word. This is being done masterfully at the highest levels including medical practitioners by a shift from harm reduction to a zero tolerance approach.

This has caused confusion over harm minimization and harm maximization; a third entity to further this confusion is the well-timed “feasibility of such therapy”. Well, if we do not work to reduce harm, we will end up by maximizing it and not by buprenorphine.

The lessons learned from such pilot program are relatively consistent with the recent E.H.A sponsored program, which is due to lapse in September while the state already has the capacity to provide such therapy to nearly all the IDUs covering the harm reduction programs. Only less than a thousand drug users’ are currently able to access this treatment.

In whose hands are we going to hand over the fates of the rest of the fifty thousand drug users as per the UNAIDS figure? How many more lessons do we need to be learned or wasn’t there enough pilot programs to be put on a trial basis? At least, we are tired and fed up of being guinea pigs for the umpteenth times before the menace takes over.

The most serious concern is when rumours fly that a program’s fate hangs in the balance and that the people who have been stabilized by buprenorphine and have resumed active lives, yet still depend on a substitute, may be cut off.

Termination of a program is every patient’s worst nightmare. Oh gentlemen, gentlemen you are not playing fair, for you it’s a trifle, for us a matter of life and death.