Opioid Use Disorder (OUD) in Malaysia

Vicknasingam, PhD Professor and Director

Centre for Drug Research, Universiti Sains Malaysia

• Population: 32 million • Federal constitutional

monarchy • Islam is the largest and official

religion (61%)• Major heroin abuse problem

since the 1970s and ATS since the 2000

• Proximity to Golden Triangle

Introduction

Historically in Malaysia opium was the main drug used. In 1970s, heroin became the most popular drug used in the country. More recently (2000s), amphetamine type stimulants (ATS) have become popular.

In the past, Malaysia’s drug policy has been based on a prohibitionist approach. Treatment and rehabilitation approaches for people who use drugs (PWUDs) were limited to abstinence-based institutional programs, mostly penitentiary-based.

In the early 2000s, in response to the HIV epidemic, which was concentrated among people who inject heroin, Malaysia introduced and disseminated medical treatments and supportive services for people with opioid use disorder

Timeline of onset of heroin and ATS use in Malaysia

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Pro

po

rtio

n in

itia

tin

g ill

icit

use

of

eac

h s

ub

stan

ce

Heroin ATS

(Chawarski et al. Drug Alcohol Depend, 2012)

Introduction of medication assisted treatment (MAT) and supportive services in Malaysia

- Buprenorphine was approved in 2002

• Currently, approximately 380 general medical practice offices offer agonist maintenance treatments for ~10,000 patients

- Methadone approved in 2003

• Currently, there are about 100,000 patients in 520 government and 369 private general practitioners run MMT centres

- Needle and syringe exchange programs (NSP) began in 2006

C&C

PUSPE

N

• Median time to relapse to opioid use post-release or post-treatment, from

• Compulsory drug detention center participants 31 days

• Voluntary drug treatment center participants 352 days

• Voluntary based participants had an 81% decreased chance of opioid relapse compared to compulsory participants

Wegman et al. Lancet Global Health 2017

Poor outcome of incarceration-based rehabilitation in Malaysia

Current drug use practices

• Most heroin using individuals use multiple substances, for example, heroin is used frequently with benzodiazepines and ATS

• In Malaysia, data on heroin or opioid overdoses are not routinely collected

• It has been reported, that street heroin purity has decreased from between 30%-50% in the 1980s to between 3%-5% lately (Sulaiman et al. Drug Test Anal, 2017).

• Low street heroin purity may lead to increased drug injecting practices

Laws concerning people who use drugs (PWUDs) in Malaysia

Section 3(1) of the Drug Dependants (Treatment and Rehabilitation) Act 1983 (DDTR 1983) - allows an enforcement officer to take into custody any person reasonably suspected to be drug dependent is applied primarily for people who use opioids (PWUOs). Under subsequent Section 6(1), the detained individual is evaluated by a government medical officer to be certified as drug dependent, Based on the recommendation of a National Anti-Drugs Agency officer, the court could order the detained person to either a) be sent to a Rehabilitation Centre for two years before undergoing community supervision for another two years, or b) receive community supervision by the National Anti-Drugs Agency, consisting of counselling and random urine drug tests, for two to three years.

Section 15(1) of the Dangerous Drug Act 1952 (DDA 1952) - under this section, consuming, taking, or self-administering any dangerous drugs, or being present in premises where dangerous drugs may be consumed, taken, or administered is punishable by a fine not exceeding MYR 5,000 (~ USD 1,240) or imprisonment not exceeding two years. This section is applied together with subsequent Section 38B(1) which states that after criminal punishment, the convicted individual should undergo two to three years of community supervision.

Section 39C of the Dangerous Drug Act 1952 (DDA 1952) - imposes increased penalties for PWUDs with prior admissions or convictions. Specifically, two previous admissions and/or convictions under section 15(1)(a) can extend the prison term to between five to seven years and result in between three to nine whipping strokes. Additional previous convictions increase the years of imprisonment and the number of whipping strokes.

Number of PWUDs detained under section 6(1) of DDTR 1983 and section 15(1) of DDA 1952

10,660 9,9285,497

8,147 8,283 8,027

84,205 85,00480,925

75,46580,386

62,318

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

2015 2016 2017 2018 2019 2020

Section 6(1) Section 15(1)

Vicknasingam et al. Int J Drug Policy (2021)

Number of PWUDs detained under section 39C of DDA 1952

430

1432

2347

2552

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2016 2017 2018 2019

Section 39C

Vicknasingam et al. Int J Drug Policy (2021)

Global AIDS Monitoring 2020, Malaysia HIV/AIDS Progress Report

Medications for opioid use disorder coverage among PWID

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

2016 2017 2018 2019

cove

rage

OUD medication coverage (%)

OUD medication coverage (%)

OUD medication coverage has

increased from about 30% in

2016 to almost 90% in 2019.

HIV-related data on key populations in Malaysia

FSW MSM PWID TG

Population size estimatea 22,000 220,000 75,000 37,000

HIV prevalenceb 6.3% 21.6% 13.5% 10.9%

Know their HIV statusb 35.1% 43.3% 38.9% 43.0%

ART participationb 22.5% 62.6% 34.6% 34.0%

Condom used during last

sexb 83.5% 65.4% 25.7% 83.3%

aSize Estimation of Key Population Malaysia, 2018bIBBS 2017

Conclusions

- Existing laws concerning PWUDs in Malaysia are not aligned with current medical conceptualization of substance use disorders- The laws and the ways they are applied need to be revised

- High numbers of PWUDs are being detained rather than offered voluntary treatment

- Costly and ineffective detention-based institutional rehabilitation programs should be replaced with voluntary, evidence-based treatment programs

- Further expansion of medication assisted treatments (MAT) is needed, including for imprisoned PWUDs

- Increased participation rates of PWUDs in HIV testing is needed

- Barriers to ART participation among PWUDs with HIV need to be eliminated to significantly increase ART participation rates among PWUDs with HIV in Malaysia

Thank you