Despite increasing levels of injecting drug use, evidence-based drug treatment programmes have been slow to take root in Nepal.
A national opioid substitution therapy programme supported by German Development Cooperation points the way forward to integrated care for people who inject drugs.
Like many people who are dependent on opioids, Prashant Maharjan and Rajesh Desar have learned that it’s one thing to stop using drugs and another thing altogether to stay off them for good.
In their early twenties, Prashant and Rajesh are close friends who grew up on the outskirts of Kathmandu and began injecting drugs while still in school. Troubles quickly mounted: tensions with family members, strained relationships with friends, financial problems and, eventually, the abandonment of their studies.
At the urging of their families, they tried to quit and entered a privately-run inpatient rehabilitation programme. However, the abstinence-based approach to treatment didn’t work for long: ‘In rehab, they told us what to do down to every last detail,’ Prashant explains. ‘But as soon as we came out, we started using again.’
A different approach to managing drug dependence
Last year the young men heard about a different approach to managing drug dependence and enrolled in an opioid substitution therapy (OST) programme run by SPARSHA, a non-governmental organisation (NGO) in Kathmandu. Every day they pay a visit to a two-room OST clinic at the SPARSHA compound where a nurse dispenses their personalised doses of liquid methadone, a long-acting opioid which eliminates symptoms of withdrawal and limits their cravings for drugs.
Prashant and Rajesh also meet regularly with trained counsellors and are seen periodically by the programme’s medical doctor, who monitors and adjusts their methadone doses and can refer them to other health services they might require.
‘Our approach is to deal with the whole person,’ says Prawchan K.C., the programme manager at SPARSHA. ‘It isn’t enough to simply give people methadone and expect them to keep coming back.’
Reducing opioid use and its harmful effects
The OST clinic at SPARSHA is part of a growing national OST programme administered by Nepal’s Ministry of Health, in cooperation with the Ministry of Home Affairs, and supported technically by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ). A detailed case study about the national programme, and learnings generated during its establishment, has recently been published as part of the German Health Practice Collection.
The World Health Organization recommends OST as an effective intervention for reducing opioid use and the harms associated with it, and for improving the quality of life of people dependent on opioids. Patients who are stabilised on OST are less likely to inject drugs and therefore less likely to overdose or to become infected with blood-borne diseases, such as HIV or hepatitis. They no longer need to spend time – and money – acquiring illicit opioids and are less likely to engage in criminal activities to finance illicit drug use. They are also more likely to be able to maintain normal daily routines, hold down a job and participate in family life.
A national opioid substitution therapy programme for Nepal
Since 2009 advisors with a German-supported harm reduction project have worked with government and civil society partners in Nepal to build up the pillars of a national OST programme, including a policy framework, secure mid-term financing, and local capacity to deliver clinical and psychosocial services.
Approximately 900 patients are currently enrolled in OST at 11 different sites in four of Nepal’s five regions. Since 2009, more than 3,500 people have taken part in the programme.
‘The coverage of OST is still too low,’ says Patricia Kramarz, the former Chief Technical Advisor for the GIZ-implemented harm reduction project, ‘but over the past seven years the project has helped to lay the groundwork for a much larger programme. The key elements are now in place for OST to be scaled up.’ With financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Nepalese authorities are currently planning to expand OST to another 10 sites.
‘Nepal is gradually moving in the direction of a more public-health oriented approach to drug use, thanks to years of advocacy by groups of former and current drug users’ says Bikash Nepal, a technical advisor with GIZ. ‘In keeping with the slogan “No Decision About Us Without Us,” the drug using community not only participates in planning and policy processes related to drug control policy, but is also directly involved in implementing programmes in communities.’
NGOs help to deliver an integrated model of care
One of the most innovative aspects of Nepal’s OST programme is the central role played by NGOs in the provision of OST services. Each OST site is comprised of a medical unit and a social support unit, which is managed by a local NGO made up of former drug users.
The medical team, staffed by trained OST doctors and nurses, is responsible for clinical assessments, setting and dispensing doses, and referring patients on for other health services.
Staff at the social support unit handle all other aspects of the programme: They raise awareness of OST in the community and recruit patients, undertake psychosocial assessments of new patients and accompany them during their initiation into treatment. They also provide continuous counselling to patients stabilised on maintenance doses, supporting them as they re-build personal relationships, establish new daily routines and re-enter the workforce.
A peer-led approach to psychosocial support
In a country with few qualified psychologists and social workers, ex-drug users in Nepal are directly involved in providing psychosocial support services to OST patients. With support from GIZ, a group of German and Nepalese harm reduction experts, ex-drug users and social workers jointly developed a training curriculum aimed at teaching the basics of outreach, peer education and counselling to staff of the social support units. Thus far, more than 90 people have been trained.
As a result of their drug-using backgrounds, these ‘lay social workers’ have great credibility with OST patients and also understand, from personal experience, the complex health and social challenges which many people dependent on drugs face. Their direct involvement ensures that OST services are provided in a friendly and stigma-free environment.
There are risks to this approach, however. Regular direct contact with active drug users may increase the chance that ex-users relapse, for example, and some ex-users may have difficulty remaining objective about others’ situations given their own personal histories. Programme managers at the OST sites are attuned to these challenges and monitor the social workers closely to ensure quality, professional services.
OST offers a pathway to stability
OST is not a magic bullet: some people drop out of treatment and relapse, others struggle to accept that they may need to be on substitution therapy indefinitely. For many patients, however, OST offers a chance to re-build parts of their lives which have been negatively affected by drug use.
‘Other forms of treatment I’ve tried are based on hard and fast rules. They tell you exactly what not to do in order to stay off drugs,’ says Prashant Maharjan. ‘OST is different. What I appreciate is that it buys me time to think about myself, to prioritise problems one by one, and to take steps to solve them.’
For Prashant and his friend, Rajesh, OST is providing a pathway to stability. Since enrolling in the programme, the two young men have resumed their studies and are managing to keep up with their school work. They have completed a computer training course, which was arranged by the SPARSHA counsellors as a reward for their good performance in the programme, and are now looking for part-time jobs.
For many years people in Nepal who repeatedly tried, and failed, to stop using drugs had no alternatives available to them. Now, they do.