In an effort to depart from the Compulsory Center for Drug Users (CCDU), Malaysia has initiated the Cure and Care Service Center program (CCSC) to provide a community based treatment program (CBTx) engaging a multitude of services related to drug and substance abuse, rehabilitation to drug users, dependents and recovering persons. The objective of this study is to identify the outcome of the CCSC service. The population of this study is the clients of CCSC during the span of its operation (2011-2012). A total of 10 CCSCs were randomly chosen with reference to its location in the 4 zones (North, South, East & Central) of Peninsular Malaysia. A total of 232 clients responded to the outcome study. The study found that the outcome of drug rehabilitation program at CCSC is generally positive. The main outcome is that clients’ involvement in criminal activities has reduced significantly after they have completed their program at CCSC. The consumption of ketum leaves extracts, alcohol, drugs, and even drug injecting behavior have also reduced significantly. Almost 20% of the clients gained employment after their discharge from the program. Also, about a third of the clients have changed their lifestyle; they took care of their health, engaged in physical activities and exercises; played sports; took their medicine and maintained their leisure time. Some are involved in religious activities, and almost half of the clients have been seen to have made that change. Around 20% has started to renew relationships with their parents, siblings, and other family members. A smaller number got involved in intimate relationships and marriage. Many clients managed to obtain more permanent jobs, engaged in recreational, sports activities, and enhanced relationship with family. Overall the outcome of the CCSC program was found to be successful.

Keywords: Alcohol; Anti Drug; Drug control; Community-based treatment; Self-management skills; Therapeutic approaches

CCDUS: Compulsory Centre for Drug Users; HIV: Human Immunodeficiency Virus; CBTx: Community-Based Treatment; CCSC: Cure and Care Service Centre; STI: Short-Term In-patient; NADA: National Anti-Drug Agency; ODF: Outpatient Drug-Free; ASSIST: Alcohol, Smoking and Substance Involvement Screening Test; DDA-TR: Drug Dependent Treatment and Rehabilitation; C&C: Cure and Care Program

The existence of drug addiction treatment centers especially the Compulsory Centre for Drug Users (CCDUs) has been observed in many countries since the onset of drug problem in the Asia region.¹ In Southeast Asia countries, there are various forms of CCDUs such as drug treatment center, drug detention center, drug prison and many more. Frequently, ‘boot camp’ modality is used with emphasis on discipline, religious values, and socially acceptable behaviour. Drug users mandated for drug treatment were often labelled as inmates.² Little medical attention was given to these ‘inmates’ and many contracted communicable diseases such as hepatitis, STIs, HIV, Tuberculosis as a result of their drug use, drugs injections, multiple sexual partners, poor living conditions, and very tight living quarters in the detention centres.³

At present, over 300,000 men, women, and children suspected of using drugs are detained in some 1,000 compulsory centres for drug users (CCDUs) in East and South East Asia alone.¹ The large number of drug dependents registered at CCDU is because most often they were legally mandated by Drug (or Anti Drug) laws in their country to undergo treatment here.

Almost all of these CCDUs are free or parents have to pay a minimal fee for treatment and rehabilitation as compared to receiving treatment in hospitals, voluntary units or private treatment centres. As a point of comparison, in Malaysia, private treatment at private centres cost between US300 to US3000 dollars; in Indonesia is between USD250 to USD5.000; in the Philippines it costs between USD600 to USD 8,000 and Thailand between USD500 to USD5,000 as compared to government CCDU which is generally free of charge.⁴

Many CCDUs infringed the human rights of drug addicts undergoing treatment. Detention of people in such centres has also been reported to involve a range of other measures that violate human rights, including sub-standard conditions, forced labour, physical and sexual violence, and lack of access to health care including HIV prevention services, among others.^1,5-7 On top of that, the non-evidenced treatment practices left no positive outcome to people receiving treatment.⁸ This issue was highlighted by 12 United Nations agencies in 2012, amongst others including increased vulnerability to HIV and tuberculosis infection as well as insufficient legal safeguards and judicial review. As an alternative to compulsory drug detention and rehabilitation centres, the UN agencies advocate for states to make available voluntary, evidence-informed, rights-based health and social services in the community.^1,9

The International Network of Drug Treatment and Rehabilitation Resource Centres¹⁰ defines community based drug treatment as an integrated model of treatment in the community. It includes services from detoxification through to aftercare and also involves the coordination of any number of non-specialist services that are needed to meet client's needs. A key focus of community based treatment is on reaching people that are affected by the harms of substance abuse with limited access to services; Integrate drug treatment and rehabilitation programmes into the community; Health and social services; Community participation; and Sustainability and accountability to the community.

One pertinent issue faced by Asian countries is the well-established drug control laws and emerging drug laws for mandatory treatment and rehabilitation. The same situation is faced by Malaysia; however the government set up an innovative project to harmonize between the country’s drug laws, addressing the CCDUs and human rights issue.¹¹ The Cure and Care project was established in 2010 in response to low treatment outcome such as high-relapse rates, poor re-employment capacities and re-engagement in criminal behaviour associated with CCDUs. Here, the Government, through the National Anti-Drug Agency (NADA) began gradually to move away from CCDUs and introduced a number of evidence and community-based treatment (CBTx) services for illicit drug users. Since then, Malaysia has made considerable progress in the provision of voluntary drug treatment and rehabilitation.^9,11

The statistics related to mandatory treatment in Malaysia is also evident to these new initiatives. The number of drug addicts caught under the Drug Dependent Act 1983 (Treatment & Rehabilitation) peaks at 38,672 in the year 2004. At this time, drug treatment and rehabilitation is mostly conducted at government CCDUs, also known as “Pusat Serenti” for a period not less than two years. Voluntary treatment centres are still very limited, and many do not practice evidence-based drug treatment. In 2008, the government permitted the prescription of MMT by private medical practitioners for treatment of opiate dependents. Many came forward to pay for the treatment, ranging between 10 to 25 USD per treatment. In addition, the Ministry of Health also dispensed free methadone through NADA. As a result, the number of drug dependents arrested in 2010 decreased to 23,642. Then, in 2010, the Malaysian government initiated the Cure and Care Project, and the number caught in 2011 and 2012 reduced to 11,154 and respectively 9,015.^11,12

The first Malaysian CBTx is the Cure and Care Service Centre (CCSC) that was established in the drug-stricken area of Chow Kit, in the city of Kuala Lumpur. CCSC also function as an outreach centre, providing counseling, medical check-ups, psychosocial programs, methadone maintenance therapy, spiritual and moral education, and support for integration. About 100-150 clients visited CCSC Chow Kit daily; and over a span of 1 year, more than 200 were referred to the C&C Clinics for treatment, and more than 500 were referred to the methadone program at hospitals in Kuala Lumpur. Additional NGO-operated CCSC were also set up in the city of Ipoh and the rural area at Jengka Pahang to address many drug dependents and IDUs that need access to such services.¹¹

CCSC was modelled after the Outpatient Drug-Free (ODF). Flynn et al.¹³ stated that ODF “are characterized by a wide range of therapeutic approaches such as cognitive-behavioral, insight-oriented, supportive and 12-step” to provide treatment and rehabilitation services to people dependent on drugs and other substance. CCSC also use the Short-Term In-patient (STI) model where clients can stay in for up to 30 days. In addition, CCSC also employ the halfway house and drop-in-center model for clients who would like to drop in for services such as meals, to wash and bathe, and some medical treatments.

At CCSC, Clients will be evaluated by using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST); they will be grouped by their addiction or substance use severity scores that they obtained, i.e. low, medium, and high. Their initial intervention program at the CCSC will be guided by their severity score. For example, those obtaining a low severity score (0-3) will be given counseling and guidance (3 sessions); self-management skills (3 sessions); and the early recovery package (1 session).

For clients with moderate ASSIST score (4-26), they will get guidance and counseling (6 sessions); relapse prevention (6 sessions); support group (12 sessions); family development (6 sessions); self-management skills (3 sessions); moral and religious program (12 sessions); outing and recreation (3 sessions); and social integration (3 sessions). If the client requires MMT, they will undergo another medical assessment before they are put in this long term program.

For clients who scored high on ASSIST, they will get guidance and counseling (12 sessions); relapse prevention (12 sessions); support group (12 sessions); family development (12 sessions); self-management skills (12 sessions); moral and religious program (12 sessions); sports and recreation (12 sessions); health education (3 sessions); and social integration (3 sessions). Similarly, if the client requires MMT, they will undergo another medical assessment before they are put in this long term program. Upon completing the stay in the program, they will join the day visit group to continue their rehabilitation program.¹²

Under these initiatives, the Malaysia's Government didn't change any of its drug laws. The Drug Dependent Act (Treatment and Rehabilitation) (1983) is still being used to arrest drug addicts, but as shown in the above statistics, the number has been reduced over the years. The current UNODC-endorsed CBTx initiatives operates within the existing legal framework they developed an open system with community based services and comprehensive inter-agency collaboration. This is one of the drug treatment and rehabilitation model in Asian countries acknowledged by UNODC to be considered as applicable in countries with strict laws on drugs but with much interest in human rights and public health.⁹

The questions arise on the effectiveness of the CCSC program. Is it effective? What is the outcome of the program? Do drug users and addicts who accessed the services get referred to a more elaborated treatment program if needed? Can they be integrated back to society? This study will provide some answers to these questions pertaining to the outcome of the program after more than 2 years of operations.

The objective of this study is to identify the outcome of the CCSC program with specific reference to using illicit drugs and substances; engagement in criminal activities; taking care of one’s health; changes in lifestyle; employment status; social reintegration; religious and spiritual activities; and establishing relationships and marriage.

This study uses a cross sectional survey method using structured interview to ascertain data pertaining to the effectiveness of the CCSC program. The population of the study are clients who have accessed to the services provided by CCSC throughout its operation period of 2011-2012. A total of 10 CCSCs were selected for this purpose. Each sampled CCSC provided the researchers with a list of clients that have accessed their service from 2011 to 2012. Clients were chosen among those who have access to services for at least 6 months prior to the interview. About 30 clients were randomly sampled from each list from the selected CCSC. The number of clients involved in the study is as reflected in (Table 1).

These clients were interviewed by the researchers based on outcome indicators as listed in (Table 3). These indicators were compiled from expected outcomes of drug treatment and rehabilitation programs stated by WHO and UNODC:^13-17 they are drug and substance use, alcohol consumption, health related behaviour (visits to doctors, general health care); social indicators (improving family relations, social involvement); career and employment (part time and full time employment, income); involvement in religious practice and involvement in criminal activities.

The interview session is conducted in a one-to-one setting. The interviewers will introduce themselves and the purpose of the study. There are ice-breaking sessions with the respondent before the first question is asked. The interviewers reported positive sessions with the respondents, and that none of them stated their disagreement to answer any questions. The interview sessions lasted between 15 to 20 minutes.

A range of 30 to 48 clients were identified from the CCSC participating in this study; 232 respondents provided information and feedback pertaining to their activities and situations prior to gaining access to services provided by CCSC and after they have gone through programs at CCSC (Table 1). Most of the clients that accessed CCSCs services came in voluntarily (n=240); only about 25% were mandated by the criminal justice system. About 50% of the clients are stay in clients at the CCSC (Table 2).

The findings are the outcome of the CCSC program as indicated in (Table 1). A total of nine (9) indicators were used which are drug and substance use (5 items); health care (5 items); employment (3 items); familial relations (2 items); intimate relationship (2 items); societal involvement (1 item); religious involvement (2 items); self-development (3 items) an legal (1 item) (Table 3).

It was observed that drug and substance use has reduced across the board; 316 respondents used drugs before they entered CCSC and only 10 respondents said that they still use drugs after obtaining service from CCSC. Despite using illicit substances, respondents informed the interviewers that the quantity has been reduced because they wanted to go for the full treatment. For drug injectors, the number involved was reduced from 185 to 23 persons; consuming alcohol also reduced from 192 to 36 persons; drinking ketum has reduced from 100 to 17, and those involved with glue or inhalant sniffing also reduced drastically from 50 to none.

The second outcome indicator is healthcare. This study found that there is an increase in the number of respondents using methadone from 152 to the present 197 clients. The number of respondents who went to see medical doctors for health reasons also increased from 152 before they came to CCSC to 197 after following the CCSC program. Similarly those who take medication for their illnesses increased from 134 people to 282. Respondents who started healthy lifestyle such as exercising also increased from 110 to 282. These findings indicated that between 20 to 35% of respondents have practiced healthier lifestyle after they attended the programs at CCSC.

On the issue of employment, a small amount, about 20% of clients managed to gain employment after following the CCSC program. This is a positive indicator because drug addicts in Malaysia have addressed over the years the issue of unemployment after their treatment program. This study observed that the numbers of clients involved in part time employment reduced from 57.9% to 48.2%; whereas more has gained a more permanent employment, from 90 to 141 clients. As a result, more clients reported an increase in their monthly income.

The next outcome indicator is positive relationships with significant others. There is an increase of 17.7% respondents reporting that they have and maintain positive relationships with their parents; and 18.6% reporting positive relations with their siblings and other family members. However, respondents who start to engage in intimate relationships reduced from 49.7% to 33.8%; and those who tie the knot also reduced from 33.4% to 25.3%. Interestingly, during the interview sessions, respondents inform the researchers that they are putting more effort to gain a better employment before they settle down and plan for a family.

One of the programs at CCSC is to reintegrate clients back into society. This yields positive results when more respondents said they are involved with societal activities. Some of these are religious activities at the local surau or mosque (Muslim place of worship). This is in line with respondents’ increased involvement with religious activities; 47% more said they started to pray; and those who practice the teachings of their religion increased from 35.1% to 74%.

Other indicators are client’s engagement in sports, recreational activities and study for self-development, all of which saw an increase after they participated in the CCSC program. But one of the biggest differences is that less numbers are now involved in criminal activities ranging from petty theft to peddling drugs; 186 clients reported being involved in crime before CCSC, and after they have gone through the program, the number decreased to only 23 persons, a reduction of 50.9% from the sample studied in this research.

The CCSC program is one of the innovative approaches that were put forward by the Malaysian government to attract more clients among people who use illicit drugs and substances to seek voluntary drug treatment and rehabilitation in their community.¹² Malaysia is known for its very stringent drug laws. The Dangerous Drug Act, 1952 impose mandatory death sentence on drug traffickers carrying as little as 15 grams of heroin or morphine; 40 grams of cocaine; 200 grams of cannabis; 2000 grams of coca leave or 50 grams of ATS. There have been several international reactions towards this capital punishment imposed on traffickers; however such strict laws not only exist in Malaysia but in many Asian countries.¹¹

In 1983, the Drug Dependent (Treatment and Rehabilitation) Act (DDA-TR) was passed by the parliament and has the power to bring any person addicted to drugs to a mandatory treatment program made available by the government for a period of not more than 2 years in the Serenti Drug Treatment Centers (CCDU) and another additional 2 years in the community.

Furthermore, the DDA (Revised 2002) Act A1167 also imposes a very severe punishment on drug addicts and the repeated offenders. Drug addicts who relapse and use drugs after going through the Serenti Government Rehabilitation Program twice will be imprisoned for 3 to 5 years and canned for not more than 3 times. If they relapse for the fourth time, they can be imprisoned for 7 to 13 years and canned between 3 to 6 times.

In the past, many drug addicts have been captured under these Acts to undergo mandatory treatment. Relapse is high and this can be seen as soon as the offenders leave the Serenti CCDUs. Even the community based treatment that follows the 2 years treatment program in the institution is not deemed effective.¹¹ The drug treatment program seems to be collapsing under its very weight. Recovering drug addicts are not able to lead a productive life like getting a decent job.¹⁸

However, after drug addiction was declared by WHO as a relapsing disease, Malaysia has made significant changes to its approach to treating drug offenders. More voluntary programs were erected replacing many mandatory treatment centers. The Cure and Care program (C&C) that started in 2010 have attracted many international visitors. This was because Malaysia did not change any of its drug laws, but there is a policy shift towards evidence-based treatment. MMT and other OST were also placed in by the Malaysian Ministry of Health. As a result, many drug addicts surface seeking voluntary treatment and the free MMT that is provided by the government. Since then, the numbers or drug addict arrested reduced drastically.

This study demonstrates the positive outcome of the Community Based Treatment (CBTx) called the Cure and Care Service Center (CCSC). Over a short span of time, clients of CCSC have reduced their drug use, do not inject drugs, practice a healthier life style, and do not involve in criminal activities. Public views were positive; many wanted to know how successful the C&C program was. Clients reported a higher level of satisfaction towards the services provided by CCSC and they do not feel that they are sanctioned by the society. As a result, businesses are taking chance to offer employment for recovering addicts with better terms, conditions, and income.^2,18 The whole process of positivity is taking place within the drug addict community in the CCSC program, and we are hoping more positive results in the near future.

None.

The author declares no conflict of interest.

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