Community-based programs have proven to be a more effective alternative for drug addicts than government-run rehabilitation centres. But with meth use on the rise - supplanting heroin injection - organisations and users grapple with social stigma and shaky funding

Down a back alley in Phnom Penh’s Chbar Ampov neighbourhood, a handful of men and women are ushered into a non-descript house filled with a row of wooden beds. Many appear nervous. A mother and child are asleep on one of the beds, where they will remain until the centre closes at 5pm.

Inside, a fast-talking Khmer-American man, Vutthy, wipes sweat from his brow. He has just driven a man in on his motorbike from the Khmer-Soviet Friendship Hospital to fill his methadone prescription.

The middle-aged Vutthy – who prefers to be identified by his first name only – is one of those running the drop-in centre today. It is managed by the non-governmental organisation Korsang, which was founded by an American deportee in 2004 to provide harm-reduction services like counseling and needle exchanges for people who inject drugs (PWIDs for short).

Vutthy hops behind a desk to register the new arrivals, who are here for free HIV and syphilis blood tests, clean needles and a fresh toothbrush. “The pinprick results only take 10 minutes, but these guys, they get impatient, antsy. A lot of them don’t want to hang around for too long,” he says, passing a care package across the desk to a middle-aged man. He gives him a warm greeting and tells him to wait with the others.

Building trust

The Korsang centre is a bare-bones operation, but it services an estimated 1,000 PWIDs in Phnom Penh. And it works. By using an incentivised referral system, the organisation encourages those who use its services to seek out other users in their communities and bring them in for help.

When a drug user returns for bloodwork or a checkup, he or she receives 10,000 riel (about $2.50) for each friend or neighbour they bring with them. Sam Pann, the centre’s manager, says connecting with drug users is a matter of building their trust. It’s the reason Korsang employees look so casual in the field, he explains.

“We talk to them like a friend,” he says. “If you show up dressed in uniforms, or like [you’re] out of a GQ ad, they won’t talk to you. Period.” Ritthy*, a former drug user from a community in Stung Meanchey commune he says is rife with drug abuse, has been recruiting for Korsang’s incentive program alongside his brother Vanny* for several years.

“After I became aware of Korsang, I immediately introduced drug users that I knew. It doesn’t mean I can convince all of the drug users who I know [to come], because sometimes they don’t want to,” he says. Ritthy says that thanks to Korsang, he stopped injecting heroin in 2011, but he still struggles with an addiction to crystal methamphetamine, or ice. He continues to bring others with him for his follow-ups.

“It is a good strategy to convince drug users to be part of a network, because we know how to talk with drug users. Normal people don’t know about the difficulty and they don’t know about the process of using drugs,” he says.

Korsang’s official policy is to service users who inject, as funding from international donors targeting drug users is typically linked to HIV/AIDS prevention. (Korsang draws funding from USAID’s President’s Emergency Plan for Aids Relief.)

According to one civil society consultant, linking funding to HIV/AIDS prevention is a product of the difficulty of selling donors on the simple premise of helping drug addicts, who are often stigmatised in the public eye.

But servicing those who smoke drugs, especially meth – the consumption of which is linked to risky behaviour such as unprotected sex – is increasingly viewed as a necessary measure to fight the spread of HIV, too.

Reaching out

Vanny has also ditched the needle, although the scars on his hands belie his old habit. Like his brother, he still uses ice. He says the most difficult recruits are addicts from wealthier backgrounds. “They don’t come in order to protect their identities,” he says. His observation highlights the lack of treatment options for drug users in the Kingdom.

The alternatives to voluntary services such as Korsang are boot camp-style rehabilitation centers like Orkas Khnom, which is run by the government. (There are eight such centres nationally.) Vanny says his parents sent him and Ritthy there three times.

“It was hard to live there, because we lived in one place, with no free space,” he says. And it did little, if anything, to help his addiction. A larger and more straight-laced outfit working in drug rehabilitation is Mith Samlanh. Those who volunteer for their programs have access to multiple weeks of detox and rehab – depending on the severity of the case – followed by vocational training programs in a variety of trades.

In a drug-afflicted area just north of central Phnom Penh, a doctor, social worker and counselor invite a handful of community members to speak and receive clean needles. Mith Samlanh has worked with some of these individuals for as long as a decade.

Many have relapsed, like Sophal*, of the capital’s Meanchey district, a former meth smoker and dealer who took two tries to overcome his addiction. Part of it, he says, was the stigma.

“Drug users are bad,” Sophal says. “I cannot blame people [who judge], as they are feeling the same way I felt about myself.”

He is not alone. “Many of [the drug users] have come to Mith Samlanh’s center and failed, so they return to these communities where they can be amongst themselves and not feel different,” the field team social worker explains.

Such difficult cases are made easier, they say, once Mith Samlanh is able to recruit at least one community member – someone who fellow users might listen to.

Once an individual gets clean, he or she can become a volunteer peer educator with the possibility of becoming a community outreach worker and receiving a $60 monthly compensation. Bopha* is one such outreach worker – one of three in a community of 200 families where she says an estimated 50 or 60 percent of residents use drugs, mostly meth.

It’s a significant drop from the estimated 90 percent Mith Samlanh encountered when it first began working there. She says she came to Phnom Penh from her native Tbong Khmum province in her twenties. Working late nights as a karaoke hostess, she was compelled to consume alcohol on the job and discovered ice as both a way of keeping focus and staying awake.

When she first came to the city from the province, Bopha had never encountered meth. Now, she notes that “there’s more there [in Tbong Khmum] than here”. Since 2001, meth use has been detected in every province, and evidence suggests prevalence in some rural areas is comparable to that of the capital.

Currently, the stimulant constitutes more than 85 percent of all drug use nationally, according to the National Authority for Combating Drugs. Bopha says that in the three years she has worked for Mith Samlanh, she has managed to change a few people’s behaviour, and brought many more to help. “I explain how it will affect them,” she says.

Strain and stigma

Mith Samlanh program manager Pin Sokhom says that of the 2,000 drug users the organisation assists, about 450 are injection users. The rest are almost all meth smokers. As with Korsang, helping non-injection users requires them to seek funding separate from that earmarked for HIV prevention. That funding, Sokhom says, is harder to obtain, putting Mith Samlanh’s programs under constant strain.

But Sokhom also says that meth smoking can be viewed as an increasing HIV risk factor. As such, he sees that funding gap as a concern. The HIV rate among PWIDs has remained relatively steady over the years, hovering at about 24 percent. Meanwhile, the HIV rate among meth smokers has quadrupled from only 1.1 percent in 2006 to 4.4 percent in 2012, all while the meth-smoking population has also grown.

According to Marie-Odile Edmond, of UNAIDS, meth smokers have reported higher rates of symptoms of sexually transmitted infections in the past year. They are also less likely to have access to healthcare services, she adds.

The government, for its part, has in the past two years recognised that its rehabilitation camps are not an effective solution, and sought to promote community-based treatment alternatives.

In April 2015, the prime minister signed a sub-decree to establish a committee for drug treatment and rehabilitation. Chaired by Minister of Health Mam Bunheng, the committee is tasked with creating a new policy vis-à-vis drug rehabilitation, which it does in consultation with organisations such as Mith Samlanh.

It’s a slow process: Sokhom, of Mith Samlanh, says the committee is still in the development phase. And as donors continue to act on their long-term intent to transfer responsibilities for existing programs to the government, looking to alternatives from local organisations is what could make the difference.

Stigma sometimes remains a barrier to seeking help – from the criminalisation of drug possession to social marginalisation. But for Bopha, the outreach worker, two factors changed everything: the realisation that as a mother her family depended on her, as well as social ostracism. She knows that such feelings could prompt others to seek help.

“Someone who is not a drug user doesn’t experience those feelings,” she says.

*Names have been changed to protect identities.