Crossing the Redline: Two Issues that Need Urgent Improvement in China’s Methadone Maintenance Treatment

Crossing the Redline:
Two Issues that Need Urgent Improvement in China’s
Methadone Maintenance Treatment

WANG Wen

I went to visit my friend Q in County M of Yunnan Province on July 20, 2009. We had a jolly meeting, cheerful about this rare reunion. At dinner, I asked him which clinic he
would be referred to for methadone maintenance treatment (MMT) when attending a conference in Kunming two days later. Q smiled and said that there was no need for a referral. He could just take a small bottle to his clinic the next day for an extra dose that would cover his two-day visit in Kunming. Methadone, according to national regulations, is not allowed to be taken outside the clinic. However, Q’s clinic in County M is uncommonly brave in crossing this redline. How can this be?

As Q explained to me, MMT has been established in his county for a few years.Because of increased policing, the relapses of some MMT patients, and patients’ limited
financial resources, nearly half of the 100 initial users in County M have stopped treatment.In order to stop further attrition of patients, the clinic has taken steps to adapt the national guidelines to local circumstances. For example, methadone is carried to hospitals when patients are not healthy enough to make it to the clinic, and small doses are supplied to patients going on trips.

The problem of patient retention is not just seen in County M, but it is common throughout the province. For example, another methadone clinic in Yunnan that I recently visited had once reached more than 400 patients, but this number has decreased over time to about 200 patients. In the face of patient loss, shouldn’t the clinics reconsider how to optimize their strategy to serve the community by drawing more people into treatment? There are two issues that need to be urgently addressed to improve the national MMT sites.

Issue 1: It is too difficult to enter the national methadone program. To enter into national methadone maintenance treatment, patients used to have to meet the following requirements: a) be at least 20 years of age; b) have been in a compulsory detoxification center at least twice, or once in a reeducation-through-labor camp; c) have a local household registry (hukou) and a permanent home; and d) display full capacity for civil conduct. HIV-positive clients were only required to meet c) and d).

In practice, local authorities in some cities have made adaptations based on real circumstances. For example, requirement b) is replaced with having undergone either
compulsory detoxification or voluntary detoxification; and according to the current rules, a non-local opiate dependent individual can apply to enroll in a treatment clinic with a
six-month temporary residence permit. Still, the present rules make it quite difficult to enter the program. It is evident that many drug users, such as those less than 20 years of age or those who worry that registering at the clinic will allow the police to know of their drug use, are still blocked from seeking treatment.

Case 1: Not long ago, W, a drug user from Shijingshan District in Beijing, was referred by a local harm reduction group to a methadone clinic in town. Since he had never been in a compulsory detoxification center or reeducation-through-labor camp, he could not enroll in the clinic. The doctor suggested that W either go register with local police authorities and obtain their consent, or supply a receipt and medical files that proved he had been in a voluntary rehab center. W rejected the first option for fear of the troubles that might ensue from being registered with the police, but he had never undergone a voluntary rehab program. He asked what other ways he could enroll. The doctor offered him an alternative: he could stay in their inpatient department for a week of voluntary rehab, so as to obtain the required certificate. It was sound advice, except that W could not afford the over 300 RMB daily cost to stay there as long as a week. In the end, W failed to enroll.

Issue 2: The clinics are too rigid in regulating access of methadone I consulted the expression in Article 2, Section 3, Clause 4 of the “Statement on the Regulations of Narcotic and Psychotropic Drugs in Rehabilitation Treatment,” issued by the State Food and Drug Administration on June 25, 2006, which says: “organizations implementing drug maintenance treatment, in use and storage of methadone oral solutions, shall comply with the rules on the use and storage of narcotic drugs in the ‘Regulation Rules of Narcotic and Psychotropic Drugs.’” However, the “Regulation Rules of Narcotic and Psychotropic Drugs” states:
Medical and rehabilitation organizations, for the purpose of rehab treatment, are eligible for the use of methadone or other narcotic and psychotropic drugs that the state has ascertained to be used in rehab treatment. Specific regulation rules shall be made by the State Council departments which are responsible for drug supervision and management, public security, and health. (Article 45)
Having compared the statements of the two documents cited above, I understand that in regulating methadone in maintenance treatment, the decisive role is played by the
National Methadone Working Group, a body composed of the Ministry of Health, the Ministry of Public Security, and the State Food and Drug Administration. However, the
“Provisional Rules of Community-based Drug Maintenance Treatment for Heroin Addicts in Pilot Sites,” jointly issued by the three ministries, says:
Pilot Organizations are responsible for day-to-day treatment, including supervision of users to take the medicine on site, psychological counseling, prevention counseling and service, urine testing, and management of files and drugs. (Chapter 5 Implementation, Article 4
Treatment and Patient Management)

This means that patients can only take their medication in the clinic. While this provision makes the management of clinics easier by saving the implementing staff from worrying about diversion, it is a rigid measure that is problematic in reality.

Case 2: In a city of Yunnan, where one of the earliest MMT programs took place, many MMT users are HIV positive. In the hospital that houses HIV patients, MMT users
often are admitted for inpatient care to have their opportunistic infections treated. When I went with a local grassroots group to visit this hospital, many HIV-positive MMT patients told us that their biggest trouble was the burden of having to figure out how to make the daily trip to the methadone clinic for treatment. A number of these patients were bedridden, and while the healthier patients could hire a taxi for clinic visits, the ones in more severe
conditions could only resort to heroin smuggled into the hospital.

Case 3: Living in a city of Yunnan, Z was a MMT patient. In June 2008, even though she was quite pregnant, she had to laboriously make the trip to the methadone clinic every day for treatment. When we saw her late in her pregnancy, Z confided to us that what worried her most was how to take methadone when her expected delivery date was near, and while in the hospital for childbirth. In fact, Z’s concern is a common one for pregnant women who are also MMT patients. When we met again with Z later, we asked her how she tried to maintain MMT through her late pregnancy and delivery. Z said that she was strong enough to visit the methadone clinic during late pregnancy, but she encountered an awkward situation after she’d been taken to the hospital awaiting childbirth. She was an older mother, and the only safe option was a C-section. By that
time she wasn’t able to visit the methadone clinic any more, so her family went instead to ask for special care. The doctor replied that taking methadone outside of the
clinic was prohibited according to the rules of the National Methadone Working Group. Failing that, her family in the end found her heroin to “substitute” methadone.

Overcoming barriers to treatment

We all know that, in order to be an effective harm reduction strategy, methadone clinics need to enroll more injecting drug users into treatment, and thus reduce crime and public health problems arising from shared needles. Innovative clinics willing to “cross the redline” are already showing us how to overcome restrictions to achieve better outcomes.

A few days ago, I made a visit to a county in the city of Lincang, where the local methadone clinic’s practice is even more flexible than in County M. In the words of local
MMT patients, the doctors at this clinic “are like [their] own siblings.” These healthcare workers allow clients who have a good track record of adherence to take three days of
methadone at a time, greatly reducing the burden of the patients. I have a friend X who goes to this methadone clinic from the other side of the county. Before, X used to spend up to six hours on the bus to make the roundtrip journey. After a few months, her doctor evaluated her adherence level and decided that X could have more freedom. Now my friend picks up her medicine once a week at her local bus station, and she only has to make the cross-county journey once a month to see her doctor. No doubt the clinic bears some risks in doing this. I asked my friend, “How do the staff reduce the risk of diversion?” X explained that the clinic is located on the Chinese-Burmese border, where illicit drugs are more accessible than methadone. In
other words, the concern existing in many clinics that patients might sell their methadone holds no water there. Furthermore, the doctors work hard to instruct and follow up with patients before and during their treatment. With those who just recently enrolled, the clinic conducts urine tests randomly. Doctors offer highly adherent patients take-home doses as an incentive. This particular example, of course, cannot be given universal application throughout the country, but nonetheless it is a praise-worthy experiment in delivering MMT services that “cross the redline.”

“Bold” clinics are already making great strides in providing people-centered services and increasing enrollment and adherence at their clinics by neglecting the written rules of the National Methadone Working Group and adapting practices to meet local  circumstances. A number of strategies, including creating monthly rewards for MMT
patients who pass urine tests, offering incentives for patients who recruit peers for the treatment, and finding creative ways to reduce the financial and time-related burdens of accessing the clinics, are already bearing fruit in certain parts of the country. The practices in County M and Lincang verify the truth of the old saying: “When you come to a dead end, alter your bearings and find a new way.” These people-centered methods deserve broader application.

In October 2008, my colleagues and I attended the 10th National Seminar on Drug Dependency in Xi’an where we met a German doctor who is an expert in opiate substitution therapy. I remember him telling us, “In Germany, we think addicts are fit to do any work except piloting an airplane. At my clinic, we have at least eight different substitution options from which our patients can choose. The methadone treatment in China right now is like what ours was 20 years ago.” His words put us to shame. I hope, if we ever meet him again, I can proudly tell him that there are advances in China’s methadone maintenance treatment, and that we are catching up with the front-runners of the world. I hope that national regulations can be changed to ease the entry requirements of the clinics and increase the accessibility and flexibility of methadone maintenance treatment to patients. In the meantime, the first step is for more clinics to “cross the redline” and offer people-centered services.

Written on August 1, 2009 in Honghe, Yunnan
Revised on August 31, 2009 in Kunming
Reference documents:
1. “Statement on the Regulations of Narcotic and Psychotropic Drugs in Rehabilitation Treatment,” issued by the State Food and Drug Administration on June 25, 2006.

2. “Provisional Rules of Community-based Drug Maintenance Treatment for Heroin Addicts in Pilot Sites,” jointly issued by the Ministry of Health, Ministry of Public Securityand State Food and Drug Administration, 2003.

Special thanks to my colleagues and community friends who supplied the cases cited in
this article.