The Lao PDR - The Compulsory Drug Detention Centres (CDDCs) - 2/4 "In the name of treatment&qu

• How do the centers work ?

Technically the centers in Lao PDR provinces are the property of the governors and of their administration, which can allow significant managerial and conditions facility differences in between them. But in reality, the local security forces often run the premises (1). In any cases, there is no national model, nor common standards for CDDCs in Lao PDR as the running of the premises is left to the discretion of the local authorities. In the Somsanga centre, the budget is around $30c per day and per inmate. In some centers managed by other provinces, the budget can be sometimes three times higher than in the Capital city (2).

Although Lao PDR signed and ratified the International Convention on Civil and Political Rights (ICCPR), a former detainee from Somsanga described to HRW the punishment of detainees who had attempted to escape as rather common and violent: “The room captains beat them until they were unconscious. Some were kicked, some [beaten] with a stick of wood. The police were standing nearby and saw this. The police told the room captains to punish them because the police would be held responsible for any successful escapes.” (2012) Conditions in Somsanga are so deplorable that “Human Rights Watch received reports of numerous suicides and attempted suicides involving ingesting glass, swallowing soap, or hanging.” (HRW, 2012) However, it is also important to realize that the situation of inmates within the worst of the CDDCs will remain far better in term of living conditions than within a facility of the current Lao PDR prison system. This in no case aims at playing down the living conditions in CDDCs but rather to keep in mind than for some time, presumed drug consumers would also have ended up there.

Due to recent seemingly perceived as positive legal reforms, people in the centers are now legally considered as “victims” and not as “criminals”. But the craft of this process is double: on one hand, the supposedly progressive legal term of “victim” attached to drug users in Lao PDR gives the authorities the possibility to consider drug use as an administrative infraction. Consequently, the government is able to place people in “treatment centers”, without requiring to process individuals through the costly and heavily bureaucratic judicial machinery of the communist state. On the other hand, people put in the centers can be held indefinitely as no judgement is declared on their case (3). This is important to explain if one is to understand the reasons behind the presence of non-substance users within these centers, the government labeled “undesirables”. For the others, “treatment” is arguably an overly-stated word.

• The "treatments"

For the ASEAN Inter-Parliamentary Assembly (AIPA) meeting held in Brunei in 2013, “Somsanga Treatment and Rehabilitation Centre in Vientiane Capital plays an important role in preventing, educating and rehabilitating drugs addicts and providing them with job skills so they can re-enter the society, contributing to socio-economic development of Lao PDR.” (AIFOCOM, 2013) However, whether the inmates conditions have improved in between the claimed institutional shift from the security to a health oriented perspective, “the basic operating principle of Somsanga – routine, en masse detention without due process, denial of effective drug dependency treatment, and physical abuse – is no different from centers across the region.” (HRW, 2012)

Former detainees from Somsanga reported to HRW that “they could access some form of evidence-based treatment if their families paid for it, but reports suggested that only a minority of detainees were able to access treatment in this way. Most detainees had only the physical exercises and classes that teach abstinence from drug use.” (HRW, 2012) The investigation further reported that, “no one described receiving effective, evidence-based drug dependency treatment. In fact, upon their release, traumatized and marginalized by their families and society, those we spoke with talked about broken lives and greater vulnerability to HIV infection or overdose.” (HRW, 2012) In Somsanga, no doctors nor nurses are present on the premises (4).

The response to prohibited substance use in Lao PDR has for decades focused on reducing opium production (supply reduction) and rates of drug use (demand reduction) through rather harsh punishments. However, harm reduction services, especially finding new ways to respond to injecting drug use (IDU) - because of growing HIW transmission rates - recently became a topic of interest for some segments of the Lao government (most notably, the Minister of Health (MoH)). The concept has only been recently introduced and progresses are minimal. In this regard, although, evidently not widely available, the administrations of the centers have ultimately accepted the principle and the concept of drug therapy substitution, which is a major ideological shift and often the hardest part to accept when moving towards harm reduction practices. As the concept is slowly being approved, protocols, medical standards and best practices are still far from being reached.

Harm reduction is part of the Lao PDR National HIV/AIDS/STI Strategy 2011–2015 (Lao PDR, 2010, p. 25) which contains policies advocating for the concept, including “measures to increase awareness of the vulnerability of drug users, to ensure an enabling legal and policy environment for harm reduction, and to expand behavioural change interventions including safe injecting.” (Sychareun and al., 2012) Emerging and relying on outreach work, the policy applications remain scarce and entirely dependent on outside donors. However, one thing is important to recognize. Among the obstacles, the multiple actors involved in the process cannot come to term on a common translation of the concept in phasa lao, - the most commonly used language in the country - or at least one that could capture its true meaning. This obviously slows the implementation down.

As we have seen in a precedent article, law enforcement agents remain poorly informed on process, feasibility and appropriateness of harm reduction services in the Lao context. Most of the institutional actors interviewed by researchers in an article published by the Harm Reduction Journal, “hold negative attitudes towards the introduction of harm reduction and saw it as promoting the use of new prohibited drugs. They saw it as inappropriate for the Laos context and against the law.” (Sychareun & al., 2012) One of the most important components of a harm reduction strategy and pertinent to the case of the CDDCs, is the service of treatment substitution, defined as “a medical treatment that involves replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid.” (NEPOD, 2004)

As opium use was the most notorious form of illicit consumption known to the authorities, this related-treatment is the most “widely” developed. Opium tincture doses, produced by the government, are being given on a daily basis to inmates in Somsanga. The use of such substitution products causes several issues, especially regarding the fact that it has no effect whatsoever on methamphetamine users which represent the vast majority of substances users in CDDCs. Also, if the same dose is given to prisoners, it can arguably render the treatment inefficient, even for opium users, as substitution treatments need to be individually and medically assessed. In order to find proper substitution treatment for potential abusers, you need personal evaluation as to determine what the user consumes, in what form and to what extent. It is also closely linked to the physiological evaluation of the patient which will present specificities that need to be taken into account in order to establish the correct protocol. All these parameters are lacking in the CDDCs of the country.

Methadone (5) treatment remains highly controversial in the Lao PDR, and the price attached to the development of a large scale and complete program platform is deemed too expensive for the moment regarding the current, mild - but rising - heroin use in the country. As such, cost is perceived by observers to be probably the biggest barrier to the implementation of such programs in Laos, rather than simple ideological constraint. But the the situation may change following the rapid increase in Injecting Drug Use (IDU) practices among substance users.

Methadone treatment has strong evidence based results and has been proven to “reduce criminality, mortality from overdose, and the spread of HIV, and it improves social outcomes ranging from employment to family stability.” (Kleiman & al., 2011) The product is long acting, a dose keeping a heroin abuser from withdrawal symptoms for around 24h. In this regard, being on methadone can help maintain a “normal” life, as the patient does not experience “nod off”, intoxication, and can, for example, safely drive. The simple fact that the product can be purchased legally and quite cheaply, means that problematic users would not have to potentially commit crime in order to sustain their habit. The treatment encounters strong objection within political environments, such as in the Lao PDR’s and Southeast Asians’ countries where the commitment to a “drug-free" society is still strong, at least in the public discourse. To many officials, this equals to helping “addicts” maintain their habit. In this regard, methadone remains a “drug” for the Laotian authorities.

Concerning methamphetamines, the product has for a long time, simply been ignored by the CDDCs authorities. This may be about to change and this is not necessarily a positive evolution. “Bongsen”, is a relatively new herbal plant product, firstly used and manufactured in Vietnam, and which is now being regarded by Lao PDR authorities as a potential substitute and treatment for methamphetamine users in the different national and provincial CDDCs, notably in Somsanga. For the government, again, the name you give to certain things remains highly important in the public sphere. As such, Bongsen is not labelled as a “drug” per say but rather, as a “medicament” which makes the use of the substance acceptable for the authorities. The production seem to be controlled by a family with close ties to Vietnam political leadership (6) which could explain in part, the access and interest of the Lao government for the product. Dr Manivone Thikeo, drug-related health specialist from WHO has declared the substance to be a “hoax” and an inadequate substitute for a stimulant such as methamphetamine.

The problem is that there is currently, in the world, no treatment substitution for stimulant-type substances, such as methamphetamine and cocaine. In the absence of such service, alongside acupuncture sessions, the solution comes down to what is called “talk therapy”, which amounts “to trying to persuade someone whose life and brain have effectively been highjacked by a tremendously powerful reinforcer to stay away from that reinforcer, using only words.” (Kleiman & al., 2011) This form of treatment needs trained professionals, which could employ well-tested techniques such as cognitive-behavioral therapy and motivational interviewing. In this regard, the aims of the treatment include much more than the drug consumption, and could address general health, legal status, employment, family and other social relations. Needless to say that Lao PDR is far from currently achieving this level of care towards perceived “drug-addicts”.

Ultimately the issue is linked with public and institutional perceptions that you can not consume certain drugs and not being labeled an "addict" or a problematic user. Consuming specific products is perceived as rather harmless and often encouraged (such as with alcohol which remains the biggest drug health-realted issue in the country), while getting caught even once using methamphetamine or any opioids, make you a potentially dangerous member of and for society which need to be dealt with.

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(1) Interview conducted on the 15/10/15 with UNODC Consultant

(2) Interview conducted on the 15/10/15 with UNODC Consultant

(3) In the HRW reports, “individuals described being detained for up to fifteen months in Lao PDR.” (HRW, 2012)

(4) Interview conducted on the 15/10/15 with UNODC Consultant

(5) Methadone is “a synthetic chemical that binds to the same receptors as heroin and the other opiates. It is longer-acting than heroin, meaning that someone using methadone does not experience the rapid cycle of euphoria and craving typical of heroin abuse.” (Kleiman & al., 2011) It can either be used as a detoxification aid “weaning” the problematic user from heroin by giving the patient diminishing doses to help palliate the withdrawal symptoms, till eventually reaching the zero administration step; or it can also be used as a longer-term therapy which is called “methadone maintenance” by giving a steady dose to the abuser in substitute of heroin.

(6) Interview conducted on the 27/10/15 with Dr Manivone Thikeo from the WHO Lao PDR office

• (AIFOCOM, 2013) ASEAN Inter-Parliamentary Assembly, Country Progress Report On Drug Situation in Lao PDR, The Tenth Meeting of the AIPA Fact-Finding Committee (AIFOCOM) to Combat the Drug Menace , Bandar Seri Begawan, Brunei Darussalam, 12th-16th May 2013, http://aipalama.aipa.devdara.me/wp-content/uploads/2014/03/Country-Report_Lao-PDR.pdf, Accessed: 02/07/15.

• (HRW, 2012) Human Rights Watch, Torture in the Name of Treatment - Human Rights Abuses in Vietnam, China, Cambodia, and Lao PDR, New York, July 24, 2012, https://www.hrw.org/report/2012/07/24/torture-name-treatment/human-rights-abuses-vietnam-china-cambodia-and-lao-pdr, Accessed: 11/07/15.

• (Kleiman & al., 2011) M. A. R Kleiman, J. P. Caulkins & A. Hawken, Drugs and drug policy - What everyone needs to know, Oxford University Press, new York, 2011.

• (Lao PDR, 2010) The Government of the Lao PDR, National HIV/AIDS/STI Strategy 2011–2015, 2010, http://www.aidsdatahub.org/sites/default/files/documents/NSAP_2011_15_English_Final.pdf, Accessed: 22/10/15.

• (NEPOD, 2004) R. P. Mattick; E. Digiusto; C. Doran; S. O’Brien; M. Shanahan; J. Kimber; N. Henderson; C. Breen; J. Shearer; J. Gates & A. Shakeshaft, “National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendations”, Monograph Series No. 52, Australian Governement, Department of Health and Ageing, 2004.

• (Sychareun & al., 2012) V. Sychareun, V. Hansana, S. Phommachanh, V. Somphet, P. Phommavongsa, B. Tenni, T. Moore, and N. Crofts, “Defining and redefining harm reduction in the Lao context”, Harm Reduction Journal, 2012; 9: 28, Published online 2012 Jul 9. doi 10.1186/1477-7517-9-28, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404925/, Accessed: 13/07/15.