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No easy options for addicts in need of treatment

No easy options for addicts in need of treatment


In Banteay Meanchey, residents exercise long hours every day.

H ing Socheat says yama has destroyed her son.

Since the 19-year-old started getting high five years ago, he's become increasingly volatile, lashing out at his parents and stealing to pay for drugs.

But Socheat believes she's found a cure: boot camp.

So on a recent Thursday, the mother sat at Banteay Meanchey's military site for users, pleading for Colonel Rath Sreang to admit her son. Sreang considered the request, smiling authoritatively as dozens of recovering users did jumping jacks and military drills on the facility's grounds.

Though hours of daily exercise may be a crude approach to drug rehabilitation, parents have flocked to the Banteay Meanchey camp since it opened in 2002. They have few other options.

"We have no choice other than this choice," Socheat said. "We cannot control him anymore - maybe they can."

While drug use rates have shot up since 2000, there is still no national infrastructure for treating adult addicts, said Graham Shaw, program officer for the United Nations Office on Drugs and Crime (UNODC). Some organizations, such as Mith Samlanh, offer credible treatment, but only for target populations.

Yet with demand comes supply. Recently, facilities have begun sprouting up throughout the country, claiming to wean users off their drugs of choice. Even the government has joined the trend, with officials urging the Phnom Penh municipality to open a state-run, compulsory treatment center in the near future. The only problem is, there's little regulation of such ventures.

"There are lots of new centers, but we need to develop a minimum standard of service," said Martin Lutterjohann, a visiting psychotherapist and advisor with the National Authority for Combating Drugs. "We don't want people to see this as a business opportunity and just start packing in addicts."

To prevent this from happening, Lutterjohann, one of the country's few drug treatment experts, has set out to visit every new clinic and facility in Cambodia.

But he admitted "adequate" treatment here doesn't always meet western criteria.

"We need to adapt methods to the Cambodian situation," said the German citizen. "They don't have many resources, so we want to establish a simplified treatment protocol."

Local cures needed

When experts talk about drug addiction in Cambodia, they mean amphetamine addiction. Nearly 80 percent of the country's drug users take some form of amphetamine-type stimulant (ATS), such as yama pills or crystal methamphetamine.

Even in developed countries, treating ATS addiction is a chancy undertaking. Complex rehabilitation programs have been developed to address specific drug addictions, but they don't always work in Asia, where services are usually fewer and the cultural context is different.

Before Thailand began its hard line "war on drugs" in 2003, an adapted version of the Matrix Model - developed in the US to treat cocaine users by informing them of cognitive damage caused by drug use - met with some success in fighting methamphetamine addiction, Lutterjohann said. Nonetheless, in rural Thailand, the Matrix Model proved too difficult to implement, he said.

"It depends on the art of counseling to be successful, and there weren't enough qualified professionals."

In Cambodia, centers would face even greater challenges in trying to introduce such a complex treatment model. There are only 26 psychiatrists in the country, 17 of whom live in Phnom Penh, said Cambodian psychiatrist Dr Oum Nhel.

Cognitive behavioral therapy, another popular method for treating ATS addiction, would also prove unworkable in the Cambodian context, Lutterjohann said. The method requires addicts to work with counselors in determining what situations and emotions serve as triggers for their drug use - and to then develop strategies to alter those associations.

"It's just too complicated for Cambodia," he said.

Given the lack of local professional resources, Lutterjohann said doctors should try to harness beliefs and attitudes prevalent in Cambodian society.

"For example, people here are not rational thinkers; their belief is not in psychotherapy," he said. "They believe in magic and we can use that, have people visit traditional healers as part of their treatment."

Battambang prepares

Lutterjohann took all this into consideration when he set out to explore one of Cambodia's newest treatment centers recently. He became interested in the planned facility - located in Battambang province - when he heard it would serve the general population.

"Street children in Cambodia are pretty well taken care of [in terms of drug outreach]" he said. "So far, none of drug treatment has been geared toward normal teenagers. That's a problem."

Kasun Baunat, director of the national program for mental health, runs a small treatment program for teenagers out of a private house in Phnom Penh. But, in order to safeguard patients' privacy, he doesn't let outsiders inspect the clinic.

Normal teenagers in Battambang need drug rehab resources. Use of ATS has grown every year since 2001 and Saen Sonal, head of the province's anti-drug trafficking police, estimates that 20 to 30 percent of Battambang's teenagers use such drugs.

"We've learned to recognize the behavior of users," Sonal said. "They grind their teeth, don't trust anybody and yawn a lot [when coming down from a high]."

To address the province's drug use, the NGO Community Development Action, the chief of police and chief of the military decided to create a center on land donated by military officers. Construction began in December and private investors are expected to supply the $50,000 in building costs.

Because treatment will be free, the center will be funded by donations from a variety of sources.

On a recent Wednesday, Lutterjohann, accompanied by Nhel, traveled the two hours of rough and dusty road leading from Battambang town to the facility's site.

"For six months of rehab, a remote center isn't a bad idea," Lutterjohann said. "People will think twice before running away."

Though the two-hectare field was still largely undeveloped - save for a couple of semi-constructed dormitories and a small reservoir - the center's future staff had ambitious plans.

As Lutterjohann and Nhel toured the site, facility Director Im Luom from CDA, explained that patients will have daily activities, including vocational training and possibly group counseling sessions.

Luom also hopes the center can provide medications, such as anti-depressants and anti-anxiety pills, to treat symptoms of withdrawal. But he added that such medical donations would depend on the local health department.

Builders have already started to construct a swimming pool that will offer cheap relief from the side effects of going cold turkey. Though now a jagged hole in cracked earth, Luom said the pool will eventually serve as a cool-down area for addicts.

After inspecting various buildings, Lutterjohann and Nhel huddled to exchange their observations.

"They plan on 500 patients here, from around the country, which is a big job," Lutterjohann said. "But it's a large space. They have room for sport, growing vegetables, and the air is fresh here."

Nhel seemed a bit more cautious. "I think that they have no idea about treatment," he countered.

Lutterjohann pointed out that they could both help establish and oversee competent treatment, especially since Nhel will be moving back to Battambang.

Nhel had another concern. "What about a crisis center for those with severe symptoms?" he asked. At Sihanouk Hospital in Phnom Penh, where Nhel is doing his residency, doctors often restrain patients going through withdrawal by tying them to bed posts with bandages.

"We don't want this to be Vietnamese-style treatment," Lutter-johann said. "If we use a lot of restraints, it starts to look like prison, and that's not good."

The Colonel

Colonel Rath Sreang isn't worried about such impressions. His military-style camp for addicts is known for its rigor and discipline.

The Gendarmerie-run Banteay Meanchey site has become so popular, authorities in Battambang opened a smaller version of the facility around six months ago.

But Sreang is quick to note that parents prefer his camp because of its strong reputation - and that the entire project came about as a result of his general benevolence.

"I created the center not just to control, but to treat addicts," he said, the picture of militarism is his fitted dark green uniform and blue beret. "It was my idea to create a center for charity, and it's been a success thanks to the goodwill of me and my officers."

Since the facility opened in 2002, it has housed and released 335 drug addicts. Though Sreang admitted he didn't have specific statistics on relapse rates, he said around 80 percent of users who return to a supportive home environment stay off drugs. Those lacking a strong familial base often relapse.

Sreang takes a hands-on role in all aspects of the camp - from admittance to daily activities and eventual release.

When users first enter the facility, Sreang often helps "interrogate" them about their drug habits.

"They're asked when they use the drug and how much so we can evaluate the level of addiction," Sreang said. "They cannot lie or avoid the questions."

Most of the addicts brought to Banteay Meanchey use either yama pills or crystal methamphetamine. The latter is much more expensive (about $120 for one chi) and individual users at the camp have stolen up to $200,000 to support their habits, Sreang said.

"If I were to wear [crystal meth] I would look richer," joked Lieutenant Or Borin, the facility's vice-director, motioning to his jewel-encrusted rings. "It is much more expensive than gold."

It's also highly addictive. Users are kept in a locked room on the site while experiencing the initial pain of withdrawal. Recovered addicts serve as 24-hour suicide watch guards.

"Sometimes they're so weak, they can't even walk, just like old people," Sreang said. "So we have two people hold them up and teach them how to walk again."

Soon, he claims, they're ready to run.

Monkey bar rehab

Eleven days after arriving at the camp, ex-heroin user Leang Chaunheng, 30, was not only running but doing push-ups, swinging across monkey bars and executing military drills. A few bloody patches covered his arms and torso from where he'd fallen during exercises.

"I feel weak and dizzy," he said. "I'm having diarrhea five times a day while we're running."

Sreang said users quickly get over such discomforts and are able to complete the five- to six-hour daily regimen of strenuous exercise the camp requires. Military officers wish they could offer medication to help ease the symptoms of withdrawal, but Sreang said the facility does not have enough money for such luxuries.

In addition to physical education, patients attend two classroom lessons every week where they learn about the effects of drugs, risk of HIV infection, and Khmer cultural traditions. During these sessions, military policemen can also serve as counselors, Sreang said.

"We instruct in a very nationalistic style," he said.

When users have learned all the camp's lessons - educational, physical and behavioral - they're ready to go home. Sreang himself makes the decision in every case.

"First, I look at their appearance, to see if they're still affected by the drug," he said. "Then I evaluate to see if they've changed their attitude."

Patients also give a urine sample for testing before they leave. Though scientists generally acknowledge ATS drugs remain in a user's system no more than three days, Sreang insisted that substances can linger in the body for three to six months.

Sometimes patients test positive even after several months at the camp, and he said they have no way to access drugs while there.

"There is strict control here, no sneaking in drugs," he said, somewhat defensively. "Even smoking is banned - you cannot bring a lighter on this property."

Tough love

Whether or not the camp ever strays from its tough reputation, it's not, in scientific terms, a progressive approach to drug rehabilitation.

"The view of ODC is that, other than Mith Samlanh, there are no real rehabilitation and treatment services of quality in Cambodia," Shaw said. "There's a willingness to try to address the problem, but places need help in developing credible services."

Shaw hopes that a Japanese-funded training program, slated to start in the next few months, will help change this situation. The three-year project allocates money for educating those interested in working with drug users and provides funds for implementing rehabilitation services.

Even though Cambodia doesn't have the resources to undertake complicated psychological techniques, Shaw said the country has its own advantages in fighting drug use.

"Cambodia has many benefits if you approach it from a community-based rehab standpoint," he said. "The communities here are still quite strong."

But until there are better solutions, Socheat and other parents will continue to shuttle their kids to facilities like Banteay Meanchey.

"Colonel Rath Sreang told me to go to Battambang, because the camp is too full," she said. "But I will not give up. I know he is the only one who can save my son."


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