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2 Diterbitkan Oleh: AGENSI ANTIDADAH KEBANGSAAN KEMENTERIAN DALAM NEGERI Aras 3-6, Bangunan Two IOI Square, IOI Resort, Putrajaya, Malaysia. Tel: Faks: Hak cipta terpelihara oleh AGENSI ANTIDADAH KEBANGSAAN JURNAL ANTIDADAH MALAYSIA 2 Cetakan Pertama 2007 Hak cipta terpelihara. Semua bahagian dalam buku ini tidak boleh diterbitkan semula, disimpan dalam cara yang boleh dipergunakan lagi, ataupun dipindahkan dalam sebarang bentuk atau sebarang cara, sama ada dengan cara elektronik, fotologi, mekanik, rakaman dan sebagainya sebelum mendapat izin bertulis daripada AGENSI ANTIDADAH KEBANGSAAN. Atur Huruf dan Reka Bentuk Kulit: Persada Ilmu Dicetak oleh: Percetakan Nasional Malaysia Berhad ii

3 PENAUNG : Y. Bhg. Dato Haji Sabran bin Napiah Ketua Pengarah Agensi Antidadah Kebangsaan KUMPULAN EDITOR : Ketua Pengarang Y. Bhg. Profesor Dr. Mahmood bin Nazar Mohamed Timbalan Ketua Pengarah (Operasi) Agensi Antidadah Kebangsaan Ahli- Ahli Y. Bhg. En. Tanasengran Sinnathambi Timbalan Ketua Pengarah (Pengurusan) Agensi Antidadah Kebangsaan En. Mohd Rohani bin Mat Diah Pengarah Dasar, Perancangan dan Penyelidikan Agensi Antidadah Kebangsaan Tuan Haji Lasimon bin Matokrem Pengarah Rawatan dan Pemulihan Agensi Antidadah Kebangsaan Y. Bhg. Dr. Sabri bin Zainudin Zainul Pengarah Penguatkuasaan dan Keselamatan Agensi Antidadah Kebangsaan Tuan Haji Izhar bin Abu Talib Pengarah Pencegahan Agensi Antidadah Kebangsaan PEMBANTU EDITOR : Pn. Rohaida bt. Shariff En. Megat Khas bin Sulong En. Khairi bin Ab. Razak Pn. Rokiah bt. Jusoh SETIAUSAHA : Pn. Nor Akmal bt. Embong Agensi Antidadah Kebangsaan PEJABAT EDITOR : Bahagian Dasar, Perancangan dan Penyelidikan Agensi Antidadah Kebangsaan iii

4 LEMBAGA PENASIHAT: Y. Bhg. Lt. Kol. Prof. Dato Dr. Haji Kamarudin bin Hussin ( Naib Canselor UniMAP ) / PEMADAM ) Y. Bhg. Professor Dr. Md. Shuaib bin Che Din, Dekan Sekolah Psikologi dan Kerja Sosial, UNIMAS Y. Bhg. Professor Dr. Suradi bin Salim, Ketua Jabatan Jabatan Pendidikan Psikologi dan Kaunseling (UM) En. Abd. Halim bin Mohd Hussin, Fakulti Kepimpinan dan Pengurusan, Universiti Sains Islam Malaysia Tuan Mazdi bin Abdul Hamid Penasihat Undang-undang AADK Y. Bhg. Dr. Mahmud bin Mazlan Substance Abuse Research Center, Muar, Johor Y. Bhg. Dato Dr. Faisal bin Hj. Ibrahim Bahagian Kawalan Penyakit, KKM Bahagian Sekolah, Jabatan Sekolah, Kementerian Pelajaran Malaysia Pengarah Jabatan Siasatan Jenayah Narkotik Polis DiRaja Malaysia Pengarah Rawatan & Pemulihan Dadah, Jabatan Penjara Malaysia iv

5 Kajian Pengaruh Dadah di Kalangan Pelajar Baru 1-12 Institusi Pengajian Tinggi Kamarudin Hussin Abd. Majid Mohd Isa Abdull Halim Abdul Husili Hussin Mohd Amran Hasan Keberkesanan Program Kaunseling Rawatan dan Pemulihan Dadah dari Perspektif Penghuni Pusat Serenti Zulkhairi Ahmad Mahmood Nazar Mohamed Needle Syringe Exchange Program in Malaysia Faisal Hj. Ibrahim Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts Abd. Halim Mohd Hussin Mardziah Hayati Abdullah Harm Reduction Programme in Thailand Usaneya Perngparn Relapse Prevention: Strategies and Techniques James F.Scorzelli The Relationship Between the Age of Onset for Delinquent Behavior and Chronic Drug Abuse Among Adolescents Mohd Muzafar Shah bin Hj. Mohd Razali v

6 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Sabitha Marican Mahmood Nazar Mohamed Rosnah Ismail Peranan Kerohanian dalam Menangani Gejala Dadah Yuseri bin Ahmad Sapora bt. Sipon Marina Munira Abdul Mutalib Demographic Determinants of the Drug Abuse Problem Among Secondary School Students in an Urban Area Rafidah Aga Mohd Jaladin Cyber Counseling for Addiction and Drug Related Problems Huzili Hussin Irma Ahmad Mohamad Hashim Othman Drug Dependants Treatments and Rehabilitation: From Cold Turkey to Hot Turkey Abdul Rani bin Kamarudin vi

7 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey DRUG DEPENDANTS TREATMENTS AND REHABILITATION : FROM COLD TURKEY TO HOT TURKEY Dr Abdul Rani Bin Kamarudin 1 ABSTRACT This article concerns the treatment and rehabilitation of drug dependants in Malaysia and it assesses the country s drug policy in dealing with problem drug takers since the introduction of compulsory treatment and rehabilitation of certified drug dependants since It looks at the strength and weaknesses of the Cold Turkey method of treatment which until very lately has been the thrust in the government s policy, and recently, the maintenance on drug prescription to drug dependants. Given the limitations in achievement of residential treatment and rehabilitation cum the cold turkey method, there is now renewed readiness on the government s part to adopt the maintenance on drug prescription for treating and rehabilitating drug dependants, hence gradually moving away from the cold turkey approach. Central to the maintenance on drug prescription for treating and rehabilitating drug dependants is the concept of harm reduction, and this concept will be duly discussed. The experience of United Kingdom in dealing with the treatment and rehabilitation of drug dependants through maintenance on drug prescription cum harm reduction is also highlighted to drive the point why the cold turkey method of treating and rehabilitating drug dependants is by now a spent force, and why it is also high time that more leeway should be given to the medical approach rather than penal. 1 Associate Professor, Ahmad Ibrahim Kulliyyah of Laws, International Islamic University, Malaysia; LL.B Hons (IIUM 1988); MCL (IIUM -1990); PhD in Law (Exeter 2002); Nonpracticing Advocates & Solicitors (High Court of Malaya 1991 & 1992) & Peguam Syarie (KL & NS 1996) Dr Abdul Rani bin Kamarudin, m/s

8 JURNAL ANTIDADAH MALAYSIA ABSTRAK Artikel ini memberi tumpuan kepada aspek rawatan dan pemulihan penagih dadah di Malaysia dengan meneliti Dasar Dadah Negara yang menguruskan masalah penyalahgunaan dadah sejak tatacara rawatan dan pemulihan dadah yang wajib diperkenalkan pada tahun Ia melihat kepada kekuatan dan kelemahan kaedah rawatan Cold Turkey yang menjadi teras kepada dasar kerajaan masa itu dan kini. Pada masa ini, terdapat kesediaan daripada pihak kerajaan untuk menerima kaedah pengekalan melalui preskripsi dadah kepada mereka yang bergantung kepada dadah yang mana sedikit sebanyak ia menunjukkan bahawa dasar dadah telah mula bergerak meninggalkan kaedah Cold Turkey. Pendekatan pengurangan kemudaratan merupakan asas kepada kaedah pengekalan pengantungan dadah juga dihuraikan. Pengalaman United Kingdom dalam menjalankan pendekatan pengurangan kemudaratan dibincangkan dalam konteks. Oleh yang demikian, dasar kini lebih memandu program kepulihan ke arah pendekatan perubatan dan bukannya undangundang. INTRODUCTION Under Article 38 of the Single Convention on Narcotics Drugs, 1961, parties are required to take all practical measures for the prevention of narcotics drug abuse or psychotropic substances and for the early identification, treatment, education, aftercare, rehabilitation and social reintegration of the persons involved. 2 On 8 th - 10 th June 1998, a United Nations drug summit attended by presidents, prime ministers and senior ministers from 150 countries met at New York and adopted a global strategy to tackle the worldwide drug problem. The three-day special session of the General Assembly adopted a political declaration, which among others commits government to substantially reduce illicit drug demand and supply by The Assembly also adopted a declaration on the principles of demand reduction to guide governments in setting up effective drug prevention, treatment and rehabilitation programs. 2 Malaysia is a party to all three United Nations Conventions, namely, the Single Convention on Narcotics Drugs 1961, the 1971 Convention on Psychotropic Substances, as amended by the 1972 Protocol, article 20 of the 1971 Convention on Psychotropic Substances, and the United Nations Convention against Illicit Trafficking in Narcotic Drugs and Psychotropic Substances see Malaysia s National Narcotics Agency 1998 Annual Report, at pg 76, Ministry of Home Affairs, Kuala Lumpur. Dr Abdul Rani bin Kamarudin, m/s

9 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey THE EARLY STAGES OF COMPULSORY TREATMENT AND REHABILITATION In the early 1970s, treatment facilities that were available for drug dependants in Malaysia were associated with psychiatric and general hospitals. There were no centres for the psychosocial rehabilitation of drug dependants. On 1 st October 1975, the Minister of Welfare Services appointed 24 hospitals as detection and detoxification centres (7 detoxification and 17 Detection Centres). The detection centres were there to ensure that a person would be identified as a drug dependant through appropriate tests and observations. These detoxification centres had supportive therapy for the physical building up of the patient and the treatment of other accompanying physical complications. 3 Compulsory treatment and rehabilitation of drug dependants at approved institutions was introduced in 1975 as section 37B of the Dangerous Drugs Act 1952, giving social welfare officers and police officers the power to require a drug dependant to undergo treatment. There was also a provision to enable a drug dependant to undergo treatment voluntarily. 4 Nevertheless, there were very few rehabilitation homes in 1975 to cope with the huge number of drug addicts and the rate of relapse and recidivism among drug addicts was fairly high. 5 Section 37B was repealed in 1977 and substituted with Part VA comprising of 25 sections, namely section 25A to 25O providing better treatment and rehabilitation structures to drug dependants. With that, a drug dependant may be ordered to undergo treatment and rehabilitation at a rehabilitation centre for a period between six months and one year or a two-year supervision. 6 Since 1976, every registered medical practitioner, including the government medical officer is obliged to notify the Director-General of any person he treats for drug dependency. Unauthorized treatment and rehabilitation of any drug dependant is not permitted, save those who are lawfully providing medical treatment to any person in relation to any physical or mental condition arising from or involving or relating to the drug dependency of such person. 7 This is to strengthen the control against drug misuse, and indirectly ensure that no drug dependant 3 Central Narcotics Bureau, Malaysia (1977), The Drug Abuse Problem in Malaysia, at pg Dangerous Drugs (Amendment) Act A293/75. 5 Syed M. Haq (1990), Three Decades of Drugs Abuse on the Malaysian Scene, at pg 16, 22, 24-25, Universiti Kebangsaan Malaysia, Bangi, Malaysia 6 Dangerous Drugs (Amendment) Act A389/77. 7 Section 18 & 16(5), Drug Dependants (Treatment and Rehabilitation) Act Dr Abdul Rani bin Kamarudin, m/s

10 JURNAL ANTIDADAH MALAYSIA can evade or escape from undergoing treatment and rehabilitation lawfully. 8 ONE STOP TREATMENT AND REHABILITATION CENTRES The development of rehabilitation centres in 1976 was in response to the urgency and seriousness of the drug problems then prevailing. With these centres, a suspected or certified drug dependant could undergo examination, detection, detoxification, counseling, vocational, physical restoration, moral and civic education, agricultural and training under one roof. Accordingly, this psychosocial rehabilitation programme has officials from a variety of disciplines who work as a team to rebuild the personality of an addict. Officers and staff placed in these one-stop centres comprise of social workers (social welfare officers and assistants), psychologists, medical officers, religious teachers, youth, agricultural, education and military personnel, industrial trade instructors and security officers. 9 The number of centres had steadily risen to 21 by early 1995 with a total capacity of 10, By the end of November 1997, there were 28 of these centres with a total capacity of 12, Both military and ex-military personnel seconded to these centres deliver military-like training to the residents. The objectives are to instil discipline and achieve the physical restoration of the residents. Vocational training and or socio-economic projects, such as agriculture and livestock farming serve to provide residents with coping skills. The residents undergo 4 phases of treatment and rehabilitation. In phase one (3-5 months period), a resident undergoes orientation (civic classes), physical restoration (drills), counseling, moral and spiritual rehabilitation. Physical training, religious, moral and civic education, and counseling hours are reduced as a resident proceeds to the next phase. At the same time, vocational training and or socio-economic projects are greatly increased as a resident 8 House of Representatives, Parliamentary Debate, the Dangerous Drugs (Amendment) Ordinance 1952, 14 th January 1976, at pg , Malaysia. 9 Read the House of Representatives (Parliamentary Debate), 2 nd and 3 rd reading of the Drugs Dependants (Treatment and Rehabilitation) Act 1983 s Bill, 25 th March 1983, pg ; House of Representatives (Parliamentary Debate), 2 nd and 3 rd reading of Dangerous Drugs (Forfeiture of Property) Act 1988 s Bill, 24 th March 1988, pg 36-71, at pg 69; National Narcotics Agency (1997), Kenali dan Perangi Dadah, Ministry of Home Affairs, Malaysia, at pg Abdul Malik bin Hj. Ishak (1995), Re; Some Legal Aspects of the Drugs Problem in Malaysia A Perspective, Malaysian Current Law Journal, Vol. 1, cxxv-cxxxi at pg cxxvi 11 National Narcotics Agency (1997), Maklumat Dadah Semasa Special Edition, at pg. 1& 27, Ministry of Home Affairs, Kuala Lumpur, Malaysia; National Narcotics Agency, Narcotics Report 1996, at pg. 47, Ministry of Home Affairs, Kuala Lumpur, Malaysia Dr Abdul Rani bin Kamarudin, m/s

11 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey proceeds from one phase to another. In phase two (4-7 months), in addition to his daily routine as above, a resident participates in vocational training. In phase three (4 7 months), a resident is given job attachments. In phase four (4-5 months), a resident is allowed to visit his family, is involved in socio-economic projects as well as re-entry programmes. 12 The Medical Officer is responsible for overseeing medical welfare, including the medical treatment of the residents. 13 The Director-General, who has superintendence over all matters relating to the apprehension, treatment and rehabilitation of drugs dependants under the Drug Dependants (Treatment and Rehabilitation) Act 1983, may shorten a resident s period of residence in the centre, if he had already completed a period of twelve months for reasons that appear to him to be sufficient for such person. The Director-General could with the Minister s consent, discharge a resident if the period of residence already served is less than twelve months for special reasons pertaining to the welfare of such person. 14 The period of residency in the centre is meant to be flexible, allowing the period of each resident to be assessed on a case-by-case basis. Accordingly, a resident in the centre can be discharged earlier to undergo supervision. These centres help take away the element of supply by severing the demand for drugs when drug dependants are rounded up and confined for treatment. Compulsory residential treatment and rehabilitation presents an important means to stabilize the chaotic lifestyles of many drug addicts or drug-misusing offenders. Under this regime of treatment and rehabilitation, the effect of achieving improvements in drug dependants personal health and inculcating a positive attitude should not be underestimated. 15 It reduces the acceptability of drugs to young people and increases the safety of every community from drug related crimes. In fact coercive treatment ensures that drug misusers get into treatment early, and keeps them in treatment. 16 In Malaysia, drug dependants in prison undergo physical 12 National Narcotics Agency, Narcotics Report 1996, Ministry of Home Affairs, Malaysia, pg 41 43; Scorzelli, Drug Abuse: Prevention and Rehabilitation in Malaysia, at pg 93 95, Universiti Kebangsaan Malaysia, 1987, 13 Rule 28, Drug Rehabilitation Centre Rules, Section 12; Prior to the Drug Dependants (Treatment and Rehabilitation) (Amendment) Act A1018/98, the discretion was with the Board of Visitors. See also Rule 78, 79 & 80, Drug Rehabilitation Centre Rules, Advisory Council on the Misuse of Drugs (1996), Drug Misusers and the Criminal Justice System, in Part 3: Drug Misusers and The Prison System - An Integrated Approach, pg 18, London. 16 Hough, M. (1996) Drugs Misuse and the Criminal Justice System: A Review of the Literature, Home Office Drugs Prevention Initiative, Paper 15, at pg 8 of 11, chapter 4: Communities Penalties. London: Home Office. Dr Abdul Rani bin Kamarudin, m/s

12 JURNAL ANTIDADAH MALAYSIA treatment, and psychological rehabilitation through counseling, sports and recreation. The programme imitates the therapeutic community approach in instilling positive values in life. Treatment and rehabilitation in prison includes detoxification, orientation, physical restoration, moral and civil education, medication and counseling. A model drug inmate would be given unpaid vocational/trade training and recreational benefits. Incentives are given to residents with good attitude and wages are given for doing work. 17 THE SERIOUSNESS OF THE DRUG PROBLEM On the 19 th of February 1983, drug misuse was declared as the main threat to national security. The declaration was made because drug addiction could reach epidemic proportions if a tough stand was not taken to address the menace. 65% of the addicts were young men between the age of 20 and 29. They represented the backbone and hope of the nation s future. The adverse effect on the uncontrolled drug addiction and trafficking could threaten the socio-economic well-being, spiritual and natural culture of the nation s population, hence undermining national resilience and national security. 18 The then Home Affairs Minster, Dato Musa Hitam when tabling the Dangerous Drugs (Amendment) Act A553/83 before the House of Representatives on 24 th March 1983, spoke of the growing seriousness of the drug problem that threatened and had threatened national security and integrity - it was not merely a social problem. The then Prime Minister, Dato Seri Dr Mahathir Mohammed, on the 10 th of September 1983, following a Cabinet decision signed the National Security Council Directive number 13. The Directive provided for the setting up of an Anti-Narcotics Committee under the National Security Council. Consequently, the earlier Cabinet Committee on Narcotics and all bodies set up on its instruction at federal and state levels were dissolved. The Directive also provided for the establishment of an Anti-Narcotics Task Force to serve as Secretariat to the Anti-Narcotics Committee and to be responsible in carrying out a planned, integrated and coordinated antidrug efforts. Thus, the Narcotics Secretariat was replaced with the Anti- 17 National Narcotics Agency (1997), Kenali dan Perangi Dadah, at pg National Narcotics Agency, Laporan Dadah, 1997, Ministry of Home Affairs, Malaysia at pg 12; National Narcotics Agency, Kenali dan Perangi Dadah, at pg 48; National Narcotics Agency, Narcotics Report 1996, Ministry of Home Affairs, Malaysia, at pg 7; Anti Narcotics Task Force, Narcotics Report 1995, Ministry of Home Affairs, Malaysia, at pg 9; Anti Narcotics Task Force, Narcotics Report 1994, Ministry of Home Affairs, Malaysia, at pg 5. Dr Abdul Rani bin Kamarudin, m/s

13 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey Narcotics Task Force. 19 The Anti-Narcotics Task Force was subsequently put under the jurisdiction of the Ministry of Home Affairs with effect from 8 th May The Anti-Narcotics Committee and the Anti-Narcotics Task Force were dissolved on the 7 th February 1996, and in their place, the National Narcotics Council and a department under the Ministry of Home Affairs known as the National Narcotics Agency were established in an effort to restructure the government machinery to prevent and control the drug situation. The Agency serves as Secretariat to the Council and is responsible for all aspects of national anti-drug efforts. 20 The National Narcotic Agency has now been renamed as the National Anti-Drugs Agency. DRUG DEPENDANTS (TREATMENT AND REHABILITATION) ACT 1983 The Malaysian government eventually felt that the time had come for a comprehensive Act that could specifically and seriously deal with the treatment and rehabilitation of drug dependants. The government pointed out that the Dangerous Drugs Act 1952 had become overly complicated in its attempt to achieve a number of objectives simultaneously. It would be more effective to produce another Act, which concentrates on the treatment and rehabilitation of drug dependants. In 1983, Drug Dependants (Treatment and Rehabilitation) Act 1983 was enacted to replace and repeal part VA of the Dangerous Drugs Act 1952, the provisions that deal with treatment and rehabilitation. 21 Section 38A and 38B were correspondingly introduced in the Dangerous Drugs Act Section 38A of that Act enables the court to send a drug offender under the age of 18 years for treatment and rehabilitation under the Drug Dependants (Treatment and Rehabilitation) Act 1983, if it is expedient to do so. It however excludes serious drug offences of trafficking, cultivation or possession under section 39B, 6B and 39A of the Dangerous Drugs Act, 1952 respectively. Understandably, these offences were considered 19 Anti-Narcotics Task Force, Narcotics Report 1995, pg 4 5, Ministry of Home Affairs, Malaysia; Anti Narcotics Task Force, Narcotics Report 1994, pg 2 4, National Security Council, Prime Minister s Department, Malaysia,; Yahya Ismail, Cawangan Antidadah: Peranan Dalam Memerangi Pengedaran/ Penagihan Dadah, Pengaman, Majalah, Polis DiRaja Malaysia (1995), vol.47, page 6-15, at pg National Narcotics Agency, Narcotics Report 1996, at pg 3 4; National Narcotics Agency, Laporan Dadah 1997, Ministry of Home Affairs, Malaysia, at pg Act 283/83 -passed on the 16 th April Dangerous Drugs (Amendment) Act 283/83, passed on 16 th April See section 29 and 30, of Drug Dependants (Treatment and Rehabilitation) Act 1983 (Act 283): w.e.f. 16 th April Dr Abdul Rani bin Kamarudin, m/s

14 JURNAL ANTIDADAH MALAYSIA grave and serious. A punitive approach to curb the growing drug menace that was seen as threatening the social fabric of society was preferred here. Under section 38B of the Dangerous Drugs Act 1952, the court is required to order a person convicted of the offence of self-administration of dangerous drugs to undergo supervision between two to three years under the Drug Dependants (Treatment and Rehabilitation) Act 1983, after having completed his prison term. 23 A drug addict could still be charged with the offence of self-administration under Section 15 of the Dangerous Drugs Act 1952, and if convicted could be sent to prison, which also has parallel treatment and rehabilitation facilities. 24 Section 3 of the Drug Dependants (Treatment and Rehabilitation) Act 1983, enables an officer (rehabilitation officer or any police officer not below the rank of sergeant or any police officer in charge of a police station) to take into custody any person he reasonably suspects to be a drug dependant. 25 He could be detained for twenty-four hours at any appropriate place for the purpose of undergoing tests. The officer may release him on bail (with or without surety), if the tests cannot be held or completed within twenty-four hours. Beyond that period, the officer would have to produce him before a magistrate for an order to detain him for up to 14 days. The magistrate may release him on bail-bond (with or without surety) to attend at such time and place as may be mentioned in the bond for the purpose of undergoing tests. Where tests have been done but the result is yet to be obtained, the magistrate may release him on bail (with or without surety) to appear at such place and time, as may be mentioned in the bond to receive the result of the tests. 26 A person who is detained for suspicion of being a drug dependant must be a certified drug dependant before a magistrate can make an order for his treatment and rehabilitation. 27 An assessment of his drug dependency will be made, which means that he is obliged to do all acts or procedures that the rehabilitation officer, or government medical officer or practitioner deems necessary. 28 Section 2 of the Drug 23 Public Prosecutor v Ng Hock Lai [1994] 4 CLJ The Public Prosecutor determines the charge he prefers (section 376 of Criminal Procedure Code). 25 Social welfare officer was deleted from the definition of officer by the Drug Dependants (Treatment and Rehabilitation) (Amendment) Act A1018/ Section 3 & 4, Drug Dependants (Treatment and Rehabilitation) Act Section 6(1), Drug Dependants (Treatment and Rehabilitation) Act Section 5, Drug Dependants (Treatment and Rehabilitation) Act 1983; Public Prosecutor v Soh Teh Foh [1990] 2 MLJ High Court Dr Abdul Rani bin Kamarudin, m/s

15 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey Dependants (Treatment and Rehabilitation) Act 1983, defines a drug dependant as someone who through the use of any dangerous drug, undergoes a psychological and sometimes physical state, which is characterized by behavioral and other responses including the compulsion to take drugs on a continuous or periodic basis, in order to experience the psychological effect, and to avoid the discomfort of its absence. Urine tests serve to corroborate clinical assessments. The magistrate must decide whether a drug dependant should reside in a rehabilitation centre for a two-year period and thereafter undergo supervision, or otherwise supervision for 2 to 3 years under an officer (rehabilitation officer or police officer), where treatment and rehabilitation may be carried out. 29 A drug dependant placed on supervision whether in the first instance or subsequent to being discharged from the centre or prison, 30 has conditions imposed upon him. These conditions relate to his residence, reporting of his whereabouts, abstaining from drugs, undergoing tests (as and when required by the officer) and attending rehabilitation programs. Breaching these conditions is an offence and punishable with imprisonment of up to three years or whipping of up to three strokes or both. 31 It is considered that an experimental drug dependant or a new addict does not require an intensive or long period of rehabilitation in the centre. What is needed is counseling and therapy, not forgetting that other factors such as co-operation from the society, family, stable employment and user friendly environment is equally instrumental in keeping him free of drugs. This is done through intensive supervision involving a rehabilitation officer, parents and local leaders. Supervision is a community-based programme that is designed for a drug dependant who does not need residential rehabilitation. It includes orientation, discussion, evaluation and review of rehabilitation objective or plan, urine tests, counseling, work placement, family and society involvement. Supervision inevitably works best for drug dependants with families, relatives, employer or peer s co-operation and support. However, the paramount consideration in deciding whether a drug dependant is placed 29 Section 6(1), Drug Dependants (Treatment and Rehabilitation) Act Prior to this 1983 Act, treatment and rehabilitation in rehabilitation centre was for six months only or a twoyear supervision by a social welfare officer (see Dangerous Drugs (Amendment) Act A389/ 77 & A413/77). 30 See section 38B, Dangerous Drugs Act Section 6(2), as amended by the Drug Dependants (Treatment and Rehabilitation) (Amendment) Act A1018/1998. Dr Abdul Rani bin Kamarudin, m/s

16 JURNAL ANTIDADAH MALAYSIA in the centre or on supervision is his own motivation towards his treatment and rehabilitation. A problem drug user however, is a threat to himself and the society. His activities and craving for drugs inevitably results in the emergence of new addicts, particularly among his peers and colleagues. He would peddle drugs to support his habit and is likely to commit drug-related crimes. Preventive enforcement in the centre would positively keep this menace in check. These centres enable the intake of many drug dependants for treatment and rehabilitation, hence severing the demand and supply of controlled drugs. Ultimately, it is the determination of drug dependants to stay free from drugs that is crucial and central to the success of the rehabilitation programme. 32 The Supreme Court in Ang Gin Lee v Public Prosecutor held that there is no appeal to or revision by the High Court from the order of the magistrate under section 6 of the Act. The order by the magistrate was not an order pronounced by a Magistrate s court in a criminal case or matter for the purpose of section 307(I) of the Criminal Procedure Code. The reason given by the court was that, the criminal jurisdiction of the Magistrate court is provided in section 85 of the Subordinate Courts Act of Thus, the power of the magistrate to make an order under section 6 was conferred on the magistrate as distinct from the Magistrates court. 33 Moreover, a drug dependant under the Act is not charged with any offence nor he is convicted of any charges. THE COLD TURKEY TREATMENT METHOD Since 1977, the treatment and rehabilitation concept practiced in Malaysia has been the cold-turkey` approach i.e. without the use of substitute drugs. Its strategy is to rehabilitate drug dependants to be effective members of society, by severing their dependency on illicit drugs and preventing recidivism. Hence, it works towards sustaining the attitudinal and behavioral change of the recovering addicts to remain free from illicit drugs. Treatment and rehabilitation in Malaysia through opiate maintenance was stopped in 1977, because it does not eradicate dependence and could be abused. A drug dependant may have built up remarkable tolerance, hence may need a higher dosage, which leads to increased health risks from overdose and respiratory problems. Furthermore, it could also cause the patient to find other drugs, the moment the effects of the substitute drugs lose their effect (it may well be due to a smaller dosage of the methadone itself). There is also no 32 National Narcotics Agency (1997), Kenali Dan Perangi Dadah, at pg 52-53, & [1991] 1 MLJ Supreme Court. Dr Abdul Rani bin Kamarudin, m/s

17 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey guarantee especially of drug addicts undergoing outpatient maintenance treatment that they would abstain from taking drugs illicitly. Similarly, providing needles and syringes to addicts is not a guarantee that the same will not be shared or used more than once. Such a policy would also convey the wrong signal as to drug taking. Moreover, such a move is incompatible with Malaysia s policy of a lifestyle free from drugs. 34 Furthermore, maintenance on methadone would also not work with nonopiate misusers (e.g. cocaine) or multi-drug misusers, thus making inpatient detoxification seemingly the only solution. Treatment and rehabilitation centres, however, amount to centralization and imprisonment, making it less accessible for drug dependants to get support from families and friends. It may also however, operate as a place for some addicts to establish their drug networking and thus detrimental to their rehabilitation upon their release. The Malaysian government is quite lost, bearing in mind that the treatment and rehabilitation centres have been in Malaysia for quite a long time, yet the relapse rate at times is 75 %, 35 and may even be higher i.e. 85%. 36 It is now conceded that 75% to 80% of drug dependants relapse after their discharge from rehabilitation centres. There are now an estimated of 293,000 identified drug addicts between the age of 21 to 29 years old despite an overwhelming budget of RM200 million spent in 2005 on treatment and rehabilitation and RM 92 million in just the first 4 months of Datuk Wira Abu Seman, the Deputy Minister of Federal Territories said that the campaign against drug misuse for the past 20 years amounting to RM 1.3 billion failed to achieve its goal due chiefly to society s attitude of dumping the problem solely unto the government National Narcotics Agency (1997), Kenali Dan Perangi Dadah, at pg 27, 63 67; See also Hough, M. (1996) Drugs Misuse and the Criminal Justice System: A Review of the Literature, Home Office Drugs Prevention Initiative, Paper 15 at pg 2 of 3 of Executive Summary, and pg 3 of 11 of chapter 4: Communities Penalties. 35 Berita Harian Online (1998b) Mahkamah Berhak Tentukan Hukuman, Wednesday, 6 th January 1998; Singapore Straits Times (1999a) Spruce up offices to curb drug abuse, August 29, 1999: /straitstimes.asia1.com.sg/reg/mal html; Singapore Strait Times, 400,000 workers lost to drug abuse: KL, August 30, 1999: html 36 Parliamentary Debate, House of Representatives, 25 th April 2000, pg at pg a survey by PEMADAM on 24,000 residents revealed that 85% are relapse cases. This percentage was, however, disputed by the Deputy Home Affairs Minister. 37 Rohana Mohd Nawi reporting for Berita Harian Tuesday, 27 th Jun 2006, at pg 17, Hanya 25 Peratus Pelatih Pusat Serenti Dipulihkan, in an interview session with Deputy Minister of Internal Security, Datuk Mohd Johari Baharun, after the launching of the International Anti-Narcotics and State of Kelantan Anti-Narcotics Carnival in Kota Baru, Kelantan. 38 Utusan Malaysia (oleh Norizan Abdul Muhid), Kempen Antidadah Gagal, Kerajaan Rugi RM 1.3 Billion, at pg 30, Tuesday 27 th June Dr Abdul Rani bin Kamarudin, m/s

18 JURNAL ANTIDADAH MALAYSIA MAINTENANCE ON DRUG PRESCRIPTION & HARM REDUCTION Malaysia has however, taken a pilot scheme since March 1997 to supplement the cold turkey treatment with maintenance on the Naltrexone drug prescription. Maintenance on Naltrexone is believed to be able to cut down relapse up to 30% by the year 2003 and its effectiveness has been proven in Singapore, United States, Canada and Germany. More enlightened is the willingness of the Malaysian Government to fully fund those addicts who undertake the program. The intake of addicts to the program would be increased in accordance with the available funding. The pilot scheme runs along the line of compulsory treatment and rehabilitation. Selected candidates with good motivation, family support and good job prospects upon the completion of their duration of treatment and rehabilitation are given Naltrexone to see whether it is effective in stopping recidivism. They are required to take Naltrexone 3 months prior to being released from a rehabilitation centre, and to continue taking it for another 12 months. The scheme is for two and a half years, and is expected to be completed by the year Naltrexone is an opiate antagonist, and it counters the opiates desired effect or its desired properties, so that an opiate taker who succumbs to temptation experiences none of its effects, and probably will not bother to try it again. It is taken orally and because its effects last for up to 72 hours, it requires only a thrice-weekly administration. Although theoretically simple, Naltrexone administration does not provide an easy answer to opiate dependence. It requires a high degree of motivation on the part of the patient to continue taking the drug, which should be administered under supervision, either by a relative or at the clinic, so as to make sure that it is taken. Naltrexone works best on those with a history of stable relationships and employment, and who have a lot to lose, if they resume opiate abuse. 39 This scheme is identical to the maintenance on prescriptions of drug addicts in the United Kingdom (UK), where addicts are encouraged to maintain a steady and stable life on prescription until such time when they are deemed ready for withdrawal. The advantages are that addicts can be weaned off the drug after a period of time, while maintaining a steady and stable life and career. Furthermore, under maintenance, there is no stigma of detention. It is also very humane, cost-effective and 39 Berita Harian Online, Naltrexone Berupaya Bantu Penagih, 10 th January 1998; See also National Narcotics Agency, Laporan Dadah 1997, at pg 72 73, Ministry of Home Affairs, Kuala Lumpur, Malaysia. Dr Abdul Rani bin Kamarudin, m/s

19 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey practical. In contrast, those treated in boot camps when released, are less prepared or less able to face the vagaries of life in the real world because of the confinement. A lengthy detention period for treatment is disruptive because it puts an abrupt end to the life and career of the drug dependant as a person. Residential treatment and rehabilitation should therefore be limited to special cases only. Supervision of addicts in cooperation with doctors at private drug treatment clinics or the National Narcotics Agency provides a positive treatment and rehabilitation environment, as long as there is proper and consistent monitoring and reporting. An addict can off course be sent to prison, if he breaches his conditions of supervision. It will do Malaysia a lot of good if maintenance on a script is given a bigger role in the treatment and rehabilitation of drug dependants. Residential treatment and rehabilitation can be very costly and the results may not be conclusively better than the maintenance treatment. However, certain drug dependence has no specific treatment, and detoxification with medical and constant careful supervision seems to be the only option. In-patient detoxification or a limited period of detention in the centre therefore would seem most appropriate. 40 The move to reconsider the cold turkey method to maintenance on drug prescription (such as methadone, subutex) was because the current treatment and rehabilitation of drug dependants was considered a failure, and the Prime Minister Datuk Abdullah Ahmad Badawi was unhappy that the relapse rate was almost as high as 90%. 41 The government has turned around its policy almost 360 degrees to not only treat addicts on maintenance of drug therapy prescription but also to supply needles and condoms to drug dependants to control the spread of HIV. However, the final decision will be made in consultation with the National Fatwa (Islamic legal ruling) Council. The Deputy Prime Minister, Datuk Najib Tun Razak, when opening the 30 th National PEMADAM annual general assembly in Perak Darul Redzuan on 25 th June 2005 said that harm reduction is a drastic step necessitated under dire conditions and is allowed under Islamic law. He said that there were 64, 000 people infected with HIV and if drastic actions were not taken, an estimated 200,000 to 300, 000 people would be infected within the next two or three years. 42 The Health Minister, Chua Soi Lek on 4 th 40 Bucknell and Ghodse (1991), Misuse of Drugs, at pg 80 81, Waterlow Publishers. London 41 Berita Harian, Malaysia Timbang Kaedah Baru Pulih Penagih, at pg 1, 21 st January The Star Newspaper, Islamic Way For Needle, Condom Programme, at pg 2, Monday 27 th June Dr Abdul Rani bin Kamarudin, m/s

20 JURNAL ANTIDADAH MALAYSIA September 2005 said that treatment and rehabilitation based on harm reduction vis a vis giving of free needles and condoms which was supposed to commence in October 2005 was rescheduled to January 2006 to lay down more systematic rules, training of staffs and the implementation. However, prescribing problematic drug dependants with drug prescriptions on methadone took off as planned in October This method of treatment and rehabilitation was done in a few major cities and would be monitored after six months, and if proven successful, it would be implemented nationwide. 43 The deputy health minister Datuk Dr Abdul Latiff Ahmad also said that drug addicts who have voluntarily undergone replacement therapy treatment with methadone can continue doing so for the rest of their lives. The therapy treatment on methadone was to help addicts get back to society. There were 1,200 drug addicts who had undergone the treatment nationwide since October 2005 with 18 centres in government hospitals, health clinics and selected private clinics. This maintenance on methadone drug prescription scheme is expected to cater for 15,000 drug addicts by The deputy health minister also said that based on the National Anti-Dadah Agency, there were some 130,000 registered drug addicts in the country. 44 Obviously, doctors given permission by the Ministry of Health to lawfully prescribe drug dependants on drug maintenance such as subutex and methadone should not act irresponsibly by selling them to non-drug dependants. 45 PERMANENT RELAPSING NATURE OF DRUG DEPENDENCY It is a fact that many and probably most drug dependent individuals take a long time to learn to live without drugs. Though, liberal prescriptions do not seem to lead to a reduced use of illicit drugs any more than abstinence after a prison sentence, drug withdrawal is merely the first stage of treatment and will be ineffective unless followed by the all-important process of rehabilitation. It has been proven for opiates and the same may be true for other drugs that minor symptoms of abstinence may persist for months after the last dose of opiate. In other words, subtle physiological and psychological changes may last long after drug withdrawal, predisposing the individual to relapse. 46 This 43 Utusan Malaysia (by Sadatul Mahiran Rosli), Jarum, Kondom Percuma Mulai Januari, at pg 1 & 4, Monday, 5 th September The Star Newspaper, Lifelong Meth Treatment for Addicts, Friday, 10 th February 2006, at pg New Straits Times, New Programme to Help Addicts Kick the Habit, at pg 13,Tuesday, 25 th May 2004; Berita Harian, Perangi Gejala Dadah Usaha Berterusan, at pg 17, Tuesday 27 th June See Bucknell and Ghodse (1991) Misuse of Drugs, pg 71, Waterlow Publishers. London Dr Abdul Rani bin Kamarudin, m/s

21 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey outcome is common for all treatment approaches. 47 Detoxifying is the first part of the treatment and not really that difficult to accomplish, but preventing relapse or recidivism is the main problem. This relapsing condition is even acknowledged by local drug expert Dr Mahmud Mazlan that the craving for drugs seem to be permanent, and a former drug addict may easily be tempted into taking drugs again even though he may have been free of drugs for 100 years: Drug taking, he warned, even on a couple of occasions is a one way ticket to hell. He claims that drug dependants undergoing maintenance treatment on drug Buprenorphine prescription achieved 65 % success between 6 to 12 months compared to the cold turkey method success rate of 20%. More importantly, the drug dependants are able to work and be with their family members. 48 Maintenance on drug prescription as a pragmatic and effective mode of treatment and rehabilitation of drug dependence cum harm reduction is also shared by lecturer, Dr Rusli Ismail of Molecule Medication Research Institute, Universiti Sains Malaysia, Kelantan. 49 TREATMENT AND REHABILITATION IN UK The treatment of addicts in the United Kingdom (UK) is the responsibility of the local health authorities. 50 Special clinics (drug treatment clinics) funded by the health or social services and mainly staffed by nurses and/or social workers working with doctors exists for the treatment of drug dependants receiving maintenance prescription, while rehabilitation is the statutory responsibility of the social services. The National Health Service (NHS) and the Community Care Act 1990 imposed a duty on local authorities to assess the needs of, and arrange for provisions of residential and other services for drug misusers. Under the community care legislation, there are social services funds and social care for drug misusers including residential rehabilitation. The community drug team would normally consist of senior level executives from local authorities (e.g. City or County representatives), health authorities (a community nurse and administrative staff working with a consultant psychiatrist and/or with links to GP), local criminal justice agencies (a social worker or probation officer) and other representatives, 47 Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 2 of 3 of the Executive Summary. Home Office Drugs Prevention Initiative, paper 15, London: Home Office 48 Laporan Shafinaz Sheik Maznan, Ketagihan Dadah Ubah Fungsi Otak dengan pakar penagihan dan psikiatri, Dr Mahmud Mazlan, Mingguan Malaysia, at pg 27, Ahad, 1hb Februari Rusli Ismail, Tukar Paradigma Tangani Dadah, Utusan Melaysia, at pg 6, Thursday, 9 th December National Health Services Act 1977 (as directed by the Secretary of State for Social Services). Dr Abdul Rani bin Kamarudin, m/s

22 JURNAL ANTIDADAH MALAYSIA for example, from the voluntary sector. 51 Social workers are vitally important members of the multi-disciplinary team of drug treatment clinics. 52 Rolleston Committee & the Brain Committee 53 The treatment in Britain for drug dependence is mainly via the methadone maintenance. This is in accordance with the recommendation of the Rolleston Committee, who in its 1926 report stated that the problem of drug addiction must be regarded as a manifestation of disease, and not as a mere form of vicious indulgence. In other words, a drug is taken in such cases not for the purpose of obtaining pleasure, but in order to relieve a morbid and overpowering craving. The Committee also stated that relapse appeared to be the rule and that permanent cure was an exception. The Committee concluded that it was legitimate to use heroin and morphine for the relief of pain due to organic disease such as inoperable cancer, even if it might lead to addiction. It also concluded that it was legitimate to use such drugs for the treatment of addicts by the gradual reduction method, as part of the treatment plan. Finally, and more controversially, it concluded that it was legitimate to prescribe such drugs for persons who would otherwise develop such serious symptoms that they could not be treated in private practice, and for those who were capable of living a normal and useful life, so long as they took a certain quantity, usually small. The responsibility for dealing with them therefore lay with the medical profession, and not with the authorities dealing with law enforcement. In other words, it was the doctor s right to prescribe drugs, if he judged them necessary for the treatment of his patient and was not challenged. The problem of drug addiction however, had increased at the beginning of the 1960s, and the majority of the new addicts were recreational rather than therapeutic (in the sense of becoming dependent 51 Cabinet Office Press Release, Government s Largest-Ever Push To Tackle Drug Menace, CAB 182/98, 1 st September 1998, Cabinet Office: London; Institute for the Study of Drug Dependance UK Trends and Update, at content Cabinet Office Press Release, Working Together To Make A Difference, CAB 214/98, 21 st October 1998, Cabinet Office: London. 53 Advisory Council on the Misuse of Drugs (1982), Treatment and Rehabilitation Report of the Advisory Council on the Misuse of Drugs, at pg 7-9, Department of Health and Social Security. London: Her Majesty Stationery Office; Bucknell & Ghodse (1991), Misuse of Drugs, at pg 6-7 & 9; Central Office of Information, The Prevention and Treatment of Drug Misuse in Britain, at pg. 3 5, London: Central Office of Information, Reference Division, October 1978; Social Morality Council (1975), Education and Drug Dependence, at pg 21-22, Metheun Educational Ltd, London Dr Abdul Rani bin Kamarudin, m/s

23 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey on opiates usually morphine or, after 1945, pethidine, in the course of medical treatment). However, an interdepartmental Committee of the Ministry of Health chaired by Sir Russel Brain (Brain Committee) was able to report in November 1960, that no change was required in the British approach to drug addiction because the situation had not changed appreciably in the years since the issue of the Rolleston report. The overall picture later changed for the worse and the Brain Committee reconvened in July 1964 to consider whether their 1961 advice in relation to the prescribing of addictive drugs by doctors needed revision. There had been significant increases in the number of persons known at some time in the year to be addicted to dangerous drugs (from 454 addicts in 1959 to 753 addicts in 1964), and in particular of known heroin addicts (from 68 addicts to 342 addicts over the same period). An added cause for concern was that these new addicts had not originally taken the drugs for therapeutic purposes, but were young addicts introduced into heroin in other ways. In its second report, it stated that the increase in the number of drug addicts was attributed to a few unscrupulous doctors who prescribed large quantities of dangerous drugs, and thus created a surplus in the market conducive towards recruiting of new addicts. In 1962, one doctor alone had prescribed for addicts no fewer than 600,000 normal doses of heroin. There were other examples just as bad, but these doctors were acting legally under the law as it then stood. The Brain Committee made extensive proposals to limit the number of doctors authorized to supply heroin and cocaine to addicts, and to ensure that the supply of such drugs only took place in a setting where there was a comprehensive range of treatment facilities for drug dependency. They also suggested that treatment centres should have the power to detain addicts compulsorily. Legislative Controls The Dangerous Drugs Act of 1967 implemented the recommendations of the Second Brain Committee s report, with the exception to compulsory detention. The Home Secretary was given power to make regulations that require medical practitioners to furnish particulars of patients who were addicts, and to prohibit medical practitioners, unless specifically authorized (notably doctors working in treatment centres) from prescribing specified drugs to addicts. Under that Act, the Dangerous Drugs (Supply to Addicts) Regulations 1968, which came into force in early 1968, made it obligatory for a medical practitioner to notify the Chief Medical Officer of the Drugs Branch of the Home Office, when he discovered a patient who was dependent on heroin or cocaine. Dr Abdul Rani bin Kamarudin, m/s

24 JURNAL ANTIDADAH MALAYSIA With the exception of heroin (diamorphine) and cocaine, where specially licensed doctors could prescribe these drugs when they are being used in the treatment of people regarded as addicts, i.e. for so-called maintenance treatment, the long established right of a doctor to prescribe controlled drugs without restriction was maintained. In practice, licenses have only been issued to doctors working in treatment centres, hospitals and other special institutions. However, there is no bar on their prescription for the relief of pain in organic disease (in the case of heroin) or as local anesthetic (cocaine). That Act too, gave the Home Secretary power over any medical practitioner who contravenes the regulations. These regulations of notifying addicts had been re-enacted, essentially unchanged as the Misuse of Drugs (Notification of and Supply to Addicts) Regulations 1973 (S.I. no. 799). 54 Rule 3 of Regulation 1973 required a doctor who attended an addict to furnish within seven days a written notification to the Chief Medical Officer at the Home Office of the personal particulars of the addict, unless the controlled drug was required for the purpose of treating organic disease or injury. If possible, the name, address, sex, date of birth and national health number, together with the date of attendance and the name of the drug or drugs concerned should be given. There was no such status as registered addict because these notifications were used only to compile the Addicts Index (strictly confidential) used for epidemiological data, as a check against addicts seeking simultaneous treatment from more than one clinic or doctor, and as an early warning of possible over prescribing. 55 This notification was limited to persons addicted to one of the drugs listed in the Schedule to the Regulations. Regulation 3(2)(b) made it unnecessary for a doctor to furnish a notification, if one had already been given within the last twelve months. 56 These statutory requirements on doctors to notify treatment of addicts were revoked on 14 th May 1997 by the Misuse of Drugs (Supply to Addicts) Regulations The restricted range of drugs on which the index focused over the past three decades, meant that its usefulness for epidemiological research had become limited, as more and newer drugs gained popularity amongst drug misusers. 54 Central Office of Information (1978), The Prevention and Treatment of Drug Misuse in Britain, at pg 4; Bucknell and Ghodse (1991), Misuse of Drugs, at pg 7; Leech and Jordan (1973), Drugs for Young People: Their Use and Misuse, pg 44, The Religious Education Press, Pergamon Press Ltd Hill hall, Oxford. 55 ACMD (1982) Treatment & Rehabilitation-Report of the Advisory Council on the Misuse of Drugs, at pg See section 10 (h) and (i), Misuse of Drugs Act Dr Abdul Rani bin Kamarudin, m/s

25 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey Furthermore, there was also the question of the high costs of maintaining the index in the face of alternative database systems. 57 Information about how many people are asking for help with drugs problem is now collected regionally (Regional Drug Misuse Databases). Thus, the closure of the addicts index is logical in that it overlapped with the other helpseeking treatment-led indicator, the Regional Drug Misuse Databases, overseen by the Department of Health. This system utilizes a regional reporting structure based on returns from specialist drug and alcohol agencies, GPs, police, surgeons, some hospital departments and prison medical officers. Annual reports are available through the Department of Health s Statistical Bulletin. Regional returns provide data referring to the sex of individuals, area of the return, drugs misused, injecting behavior and agency treatment episodes. 58 At present, the power of control over medical practitioners and pharmacists are provided by section 12 to 17 of the Misuse of Drugs Act There are provisions for a tribunal to advise the Home Secretary in respect to practitioners. The Home Office is primarily responsible for the policy and for administering the legislation concerning the misuse of dangerous drugs, including the licensing of doctors to treat addicts and the disciplining of doctors who prescribe irresponsibly. The Home Secretary may issue licenses to certain doctors authorizing them to supply heroin and cocaine to addicts. Generally, any medical practitioner can treat patients with problems of drug dependence, although only those with a license from the Home Office may prescribe those drugs. 59 Drug Action Team Community drug teams offer greater opportunities for drug misusers to maintain positive relationships, find stable employment, develop through educational and training courses, and gain access to good quality medical services and counseling support to help achieve a drug-free lifestyle. The drug team may be based in a hospital or clinic, or may be 57 Corkery J.M. (1997), Statistics of Drug Addicts Notified to the Home Office, United Kingdom, 1996, at pg 3, Home Office Research and Statistics Directorate, Issue 22/97, London: Home Office. 58 Parker, Bury and Egginton (1998), New Heroin Outbreaks Amongst Young People in England and Wales, at pg 11, Home Office Police Research Group: Crime Detection and Prevention Series paper 92, London: Home Office; United Kingdom Home Office Annual Report : Chapter 9 - Drugs. 59 Section 30, Misuse of Drugs Act 1971; Regulation 4, Misuse of Drugs (Notification of and Supply to Addicts) Regulations Dr Abdul Rani bin Kamarudin, m/s

26 JURNAL ANTIDADAH MALAYSIA based in the community or local authority boundaries. Their interventions commonly involve assessment and counseling, sometimes detoxification and prescribing. Activities include advocacy work, child protection work, complementary therapy, writing of court reports, and liaison with the criminal justice system, with prisons and probation officers and referrals on to other services. The majority described their approach as based on concepts of harm-reduction but with abstinence being the ideal eventual goal. They aim is at improving the quality of life of substance misusers by prescribing methadone (for opiate users) in place of heroin, offering advice and counseling and encouraging safer drug use and where appropriate, abstinence. In the case of some addicts, the prescriptions of methadone were available over a longer period of time to discourage a return to street drug misuse and the additional risk of physical harm inherent with drug injecting, such as HIV and Hepatitis. Patients may be referred on to mental health services, specialized services such as Genito- Urinary Medicine or HIV services and to residential rehabilitation as appropriate. The team is also in contact with self-help groups. 60 Drug-Treatment Clinic The first stage for an addict seeking treatment is usually to register with an outpatient clinic. This is a clinic that is attached to a hospital and staffed by psychiatrists, social workers, nurses, and probably probation officers. Some clinics have day centres where the addict can spend a good deal of time. Patients may be referred for treatment by their general practitioner or other doctors or by a social worker, probation officer or another agency. Some refer themselves, although some clinics insist on a formal referral letter from another doctor. A probation officer may have clients who are drug dependants, who agree or are obliged to undergo treatment and rehabilitation as requirements of probation under the Criminal Justice Act 1991, 61 or as an additional requirement to his probation order imposed by the Courts under section 3(1) of the Powers of the Criminal Courts Act Even though the Criminal Justice Act 1991 introduced treatment and rehabilitation of drug offenders, their consent was still required. 62 The requirement for consent for community sentences for offences has, however, been removed by the Crime 60 ACMD (1996), Drug Misusers and the Criminal Justice System. Part 3: Drug Misusers and the Prison System - An Integrated Approach, at pg 15; See also Institute for the Study of Drug Dependence (1998), UK Trends and Update, in content As amended by Criminal Justice Act 1993, & supplemented by Criminal Justice and Public Order Act Section 1A of the Powers of the Criminal Courts Act Dr Abdul Rani bin Kamarudin, m/s

27 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey (Sentence) Act Therefore, it is now by no means certain that any probationer receiving treatment as an outpatient under the terms of his license is a volunteer. All the outpatient centres may refer patients for in-patient treatment for withdrawal and for supportive treatment during acute episodes of their condition. The support of social work, occupational therapy, and other specialized departments of the hospital are equally available where in-patient treatment is given. Patients may be admitted into in-patient facilities for assessment, for stabilization of dosages, for detoxification and for treatment of the complications of drug dependence. They may remain in hospital for a period, which may be on or off drugs. In-patient detoxification is essential for those who are severely dependent on sedative hypnotic drugs because of the risks associated with their withdrawal. 63 If an addict wishes to come off all drugs, he will probably be admitted into an in-patient unit (although some addicts come on and off, on an outpatient basis). Once withdrawal is complete, the major task of encouragement to abstain from drugs commences. In this manner, treatment and rehabilitation become almost indistinguishable terms. A long period of after-care is inevitably necessary after the discharge because much of the work of treating the causes of addiction must be done outside hospitals. Co-operation between medical staffs, social workers and lay organizations is therefore crucial. Assessment of Drug Dependency At the clinic, an accurate diagnosis of a patient s dependent status is essential, as regular prescription of opiates could convert an occasional user into an addict. A clinical/social assessment on a multi-disciplinary basis needs to be thoroughly done and this usually takes 2-3 weeks. Various means are used to gauge the presence and extent of addiction, including biochemical tests to establish the actual fact of drug use. The diagnosis of opiate dependence also relies heavily on urine tests being positive for opiates. A careful history is taken, including the age at first use, subsequent drug taking, injecting, medical complications, etc. Checks are made at the drug misuse databases to ensure that the patient is not already obtaining drugs from another centre. A patient is not normally accepted at his or her first appearance, but is asked to return on at least one further occasion, so that it can be ascertained whether he 63 Bucknell and Ghodse (1991), Misuse of Drugs, at pg 74 and 80; Leech and Jordan (1973), Drugs for Young People: Their Use and Misuse, at pg Dr Abdul Rani bin Kamarudin, m/s

28 JURNAL ANTIDADAH MALAYSIA or she is using the drugs in question persistently. 64 In practice, there are wide variations in assessment, treatment and prescribing policies, depending on the facilities and the available staffs, the needs of the individual patient and the philosophy of the clinic. Some clinics operate on a non-opiate prescription policy. 65 Prescribing The clinic has to decide whether it is justifiable to prescribe drugs, either as a prelude to gradual withdrawal or for maintenance therapy, if the patient is genuinely addicted. The aim is to stabilize the patient and enable him or her to function normally in the community until he or she is motivated to accept the withdrawal treatment. If the patient is diagnosed as being physically dependent on opiates, an opiate will be prescribed. The dose to be prescribed is decided individually, the aim being to prescribe the minimum dose so that the patient has to take it all personally to prevent the onset of the withdrawal syndrome, and has no surplus, either to produce euphoria or to sell. In some areas, the risk of diversion of supplies of the drugs prescribed is avoided by posting prescription forms to retail pharmacists willing to undertake this type of dispensing, usually on a daily basis in the first instance. In other words, the patient goes to the pharmacy each day to collect the day s supply, with two days supply on Saturdays since pharmacies are generally closed on Sundays. 66 Some clinicians are prepared to continue the maintenance prescription over an indefinite period of time to enable stabilization, but lately this is less commonly accepted. More recently there has been a marked trend away from opiate maintenance for newly notified addicts, and strenuous, often repeated, attempts are made to effect opiate withdrawal and to encourage a drug free lifestyle, though the option of maintenance treatment for opiate dependence remains. 67 This could be due to the fact that the drugs they had received legitimately for many years, has diminished for good their prospect of becoming drug-free in the foreseeable future. Another reason is, many drug misusers have little or no wish to opt for rehabilitation, and seek medical help for the sole 64 Central Office of Information (1978), The Prevention and Treatment of Drug Misuse in Britain, at pg 21; Bucknell and Ghodse (1991), Misuse of Drugs, at pg ACMD (1982), Treatment & Rehabilitation - Report of the Advisory Council on the Misuse of Drugs, at pg 14-15, & Central Office of Information (1978), The Prevention and Treatment of Drug Misuse in Britain, at pg 21-22; Bucknell and Ghodse (1991), Misuse of Drugs, at pg ACMD (1982), Treatment and Rehabilitation - Report of the Advisory Council on the Misuse of Drugs, at pg 27; Bucknell and Ghodse (1991), Misuse of Drugs, at pg 73. Dr Abdul Rani bin Kamarudin, m/s

29 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey purpose of obtaining drugs. 68 This is so as indefinite maintenance on prescribed opiates is permissible and theoretically possible, even though, it may lead to a state of chronic dependence. Clinic staffs in such situations merely operate in the manner of a vending machine issuing prescriptions. They become frustrated by their therapeutic impotence and frequent confrontations with patients about which drugs should be prescribed and as well as the dosage. 69 Furthermore, addicts who are expected to attend treatment clinics, whereby after stabilization they are to be weaned off drugs, rarely do so, and often remain on opiate (methadone) maintenance. 70 Harm Reduction On the other hand, a policy not to prescribe drugs at clinics would without doubt deter opiate misusers from seeking treatment, and hence induce an illicit market in drug dealing. It would also prompt them to turn to doctors in general practices who are prepared to prescribe on a regular basis. The problem then is that they do not have the resources to provide the full range of support services needed for the treatment and rehabilitation of drug misusers. General practitioners in the UK are quite free to prescribe any drugs (e.g. methadone is mostly dispensed by retail pharmacists for unsupervised use) they consider to be appropriate in the treatment of addiction, with the exception of diamorphine, cocaine and dipanone, which can only be prescribed under special licence. 71 On the other hand, continued maintenance prescribing has not prevented a substantial growth in drug misuse or the availability of the drug in the illegal market. 72 Addicts undergoing treatment sometimes also use illicit supplies of drugs other than those prescribed. 73 This has prompted an 68 ACMD (1982), Treatment and Rehabilitation - Report of the Advisory Council on the Misuse of Drugs, at pg 33; Flemming, Philip M. (1995), Prescribing Policy in the UK- A Swing Away from Harm Reduction?, International Journal of Drug Policy, Vol. 6, No. 3, Bucknell and Ghodse (1991), Misuse of Drugs, at pg Bucknell and Ghodse (1991), Misuse of Drugs, at pg 73; Leech and Jordan (1973), Drugs for Young People: Their Use and Misuse, at pg Section 30, Misuse of Drugs Act 1971; Regulation 4, Misuse of Drugs (Notification of and Supply to Addicts) Regulations 1973; Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 3 of 11 of chapter 4: communities penalties. 72 ACMD (1982), Treatment and Rehabilitation - Report of the Advisory Council on the Misuse of Drugs, at pg 28 and 33; HM Government (1998), The Government s Ten-Year Strategy for Tackling Drugs, pg 1 of 3; Greenwood, J. (1991) Persuading General Practitioners to Prescribe Good Husbandry or a Recipe for Chaos, British Journal of Addiction, Vol. 87, 1992; at ; Flemming, Philip M. (1995), Prescribing Policy in the UK- A Swing Away from Harm Reduction?, International Journal of Drug Policy, Vol. 6, No. 3, Central Office of Information (1978), The Prevention and Treatment of Drug Misuse in Britain, at pg 22; Bucknell and Ghodse (1991), Misuse of Drugs, at pg 73. Dr Abdul Rani bin Kamarudin, m/s

30 JURNAL ANTIDADAH MALAYSIA approach whereby a contract is agreed between patients and staffs before opiates are prescribed for the first time. Opiate prescription is only part of the contract, which includes weekly attendance, getting a job wherever possible, and giving up illicit drug use. The dose of opiate is gradually reduced over an agreed period (a few months), and other goals towards a drug free lifestyle are worked on simultaneously. This approach reduces confrontations between staffs and patients regarding drug dosage and enables them to work together towards other goals, putting the drug abuse into its true perspective. Repeated assessment of the patient s drug dependency may be necessary, if the prescription is to continue. 74 The Edinburgh Community Problem Service (EDCPS) for example, in liaison with a general practitioner would ask a drug dependant offered a script to agree to a schedule of medication, regular contact with a key worker and random urine checks. Continued use of street drugs by mouth or injection would risk the cessation of the script. ECDPS would also not tolerate any lost scripts or aggression to the surgery staff members. The agreement would be reviewed periodically to evaluate changes in behavior etc. 75 Prescribing is generally used to attract drug users to the services offered, help stabilize the patient s lifestyle, reduce harmful injecting and the spread of diseases such as AIDS or HIV, remove the need to deal in drugs thus reduces the supply, causes an impact upon criminal offending (particularly acquisitive crimes), and enables a therapeutic relationship between the drug taker and clinicians. The basic rationale for drug substitution and maintenance is that of harm reduction: if some people are unable to quit using drugs, both users and society at large benefit if these users, i.e., addicts, are able to switch from the black market drugs of indeterminate quality, purity or potency to legal drugs, of known purity and potency, obtained from physicians, pharmacies and other legal channels. The risks of overdose and other medical complications decline; the motivation and need for addicts to commit crimes to support their habits drop; for addicts are more likely to maintain contact with drug treatment and other services, and more able and likely to stabilize their lives and become productive citizens. 74 Bucknell and Ghodse (1991), Misuse of Drugs, at pg Greenwood, J. (1992), Persuading General Practitioners to Prescribe Good Husbandry or a Recipe for Chaos, at pg. 2 & 3 of 10. Dr Abdul Rani bin Kamarudin, m/s

31 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey The objective of this conciliatory and reciprocal approach is to make contact with as many drug users as possible, in order to offer a broad spectrum of services. These might range from services intended to support continued drug use in a safer manner (for example, needle exchanges or advice on safer sex) to opportunities for detoxification or support for abstention. The strength of the programme lies in the fact that it enables treatment to be carried out by helping the client to develop a more stable lifestyle, and dose reduction and the achievement of abstinence can then be approached within this context. The ultimate goal without doubt is abstinence, though it may take years to realize, but stability on a prescription without illicit drug use is conceded to be less harmful than chaotic, illicit multiple drug use. In order to establish this, regular monitoring is essential, which includes urine tests, psychiatric and therapeutic help when required. These arguments have been reinforced by the advent of AIDS. Intravenous drug-abusers are high-risk groups for AIDS and an important route for the transmission of HIV into the general heterosexual population. The ACMD has brought out three reports on AIDS and drug misuse in 1988, 1989 and Its report on AIDS and drug misuse of 1988 and 1989, acknowledged that AIDS was more of a threat to the individual and the public s health than drugs. Its 1993 report stated that the methadone maintenance programme were beneficial for both the individual and the public s health. Maintenance is one way of keeping clients in treatment, whilst other therapeutic processes can take place. In other words, it may provide the client both the time and environment he requires to acquire the confidence and strength to change: 76 Harm reduction is however, only a short-term strategy. Drug substitution and maintenance experiments have shown that prescribing reduces both illegal heroin use and related crimes. It also revealed that those on higher dosages, aimed for maintenance rather than abstinence fared even better. 77 It must, however, be emphasized that though maintenance on prescription reduces crime and has health benefits to society, it still does not remove the dependency of the addicts, and thus it is acknowledged that the reductions and benefits are at most 76 Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 7 of 11, chapter 4: Communities Penalties. 77 Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 2 of 3 of Executive Summary, and pg 3 of 11 of Chapter 4: Community Penalties; The Lindesmith Centre, Focal Point: Drug Substitution and Maintenance Approaches, at pg 1 and 2 of 4 11th September 98. Dr Abdul Rani bin Kamarudin, m/s

32 JURNAL ANTIDADAH MALAYSIA superficial or superimposed. 78 Furthermore, such a policy has its inherent risks and dangers, as it may lead to the widespread use of drugs in society, rather than abstention. The maintenance treatment favored in the UK can lead to chronic dependence on drugs as well as the danger that once tolerance is developed, addicts would strive to acquire more potent drugs illicitly. Moreover, the prescribed methadone can be sold to subsidize the illicit purchase of heroin, which is dearer. Prescribing as a panacea to drug related harm is an oversimplified response to the drug problem. Addicts on a methadone prescription could still continue to use street heroin as well, and may therefore continue to raise money for heroin through crime. The leakage of prescribed drugs in significant quantities onto the illicit market is inevitable because the methadone prescribed may fail to meet addicts needs. 79 For many addicts, remaining on a prescription for a long time seems to be the rule. Furthermore, despite the considerable benefits of methadone (like crime reduction, client stabilization, reduction of illicit drug use) there is little evidence of success in weaning heroin users off methadone. 80 The Home Office Police Research Group study New Heroin Outbreak Amongst Youth in England and Wales made recommendations for better and more widely available drug services for young people, which do not involve the routine prescribing of methadone as a first instance. Further, it accepted that maintenance on prescriptions should not and cannot be a first response to the treatment of drug addicts except in a desperate situation, namely for detoxification.81 Prescribing drugs is not an effective answer to drug dependency. It leads to spillage or leakage in the illicit drug market, and encourages complacency in the addicts and in the society as well. The Brixton Drug Project in London asserted that over the past ten years, the British drug strategy has been nothing 78 Parker, Bury & Egginton (1998), New Heroin Outbreaks Amongst Young People in England & Wales, at pg HM Government (1998) Tackling Drugs to Build a Better Britain: The Government Ten-Year Strategy for Tackling Drug Misuse; Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 3 of 11, chapter 4: Communities Penalties; See also Central Office of Information (1987), The Prevention and Treatment of Drug Misuse in Britain, at pg ACMD (1982), Treatment & Rehabilitation - Report of the Advisory Council on the Misuse of Drugs, at pg 1; Central Office of Information (1978), The Prevention & Treatment of Drug Misuse in Britain, at pg 22, and Parker, Bury and Egginton (1998), New Heroin Outbreaks Amongst Young People in England and Wales, at pg vii and 56; Home Office News Release 314/98, Tackling Drugs in Northumberland: George Howarth Launches New Project, 3 rd November 1998, London: Home Office. Dr Abdul Rani bin Kamarudin, m/s

33 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey more than harm-reduction. Harm reduction honestly is not about eradicating drug addiction or dependence, but rather, of reducing drugrelated problems. The provision of drugs arguably will help addicts avoid the illicit market, HIV/AIDS and acquisitive crime. However, prescription by general practitioners as a first step has the potential to pave the way to drug use, not abstention, unless there is clear advice and guidelines. It also sends a wrong signal to the addicts themselves and their peers that drug taking is not a taboo. The harm reduction policy, which should be a short-term strategy, inevitably continues in practice to be a permanent and integral part of the treatment and education policy, though such a move is technically an affront to the criminal justice system. It is like an indirect endorsement to drug use in the face of its widespread use in the society. What it amounts to is a pragmatic response to the fact that drug use cannot be curtailed. The view is that, the least that can be done is to ensure that it is used responsibly to reduce the drug related problems. It might be thought that this is an acceptable response, as far as the health issue is concerned, but quite incompatible with the criminal justice system. The UK Central Drugs Co-ordination Unit, in its document published in May 1995 titled Tackling Drugs Together recognized the need to take effective action by vigorous law enforcement, accessible treatment and new emphasis on education and prevention to: increase the safety of communities from drug-related crime; reduce the acceptability of drugs to young people; and to reduce the health risks and other damages related to drug misuse, through multi-agency coordination at national and local levels. The Home Office Minister, George Howarth told senior police officers that though much of the Government s emphasis in the ten-year strategy, Tackling Drugs to Build a Better Britain, is on treatment, education and harm reduction, enforcement is still a priority. 82 The recent Public Entertainments Licenses (Drug Misuse) Act 1997 introduced in May 1998 enables the local authorities to shut down clubs immediately where the operators cannot, or will not, deal with a serious problem of drug misuse on the premises. The UK Government s White paper Tackling Drugs Together, 1995 is silent on harmreduction. The strategy or the ultimate goal must be to ensure that people 82 HM Government (1998), Tackling Drugs to Build a Better Britain: The Government Ten-Year Strategy for Tackling Drug Misuse, Cm 3945, London: Home Office. (1998), in Aim (ii): Communities To Protect our Communities from Drug-Related Anti-Social and Criminal Behaviour, pg 1 of 3; Home Office News Release 219/98, Minister Praises Police Commitment to Tackling Drugs, 15 th June, 1998, London: Home Office. Dr Abdul Rani bin Kamarudin, m/s

34 JURNAL ANTIDADAH MALAYSIA do not take drugs in the first place, but if they do, they should be helped to become and remain drug free. The UK government does not condone drug taking or support any initiatives that could be interpreted as such. It however acknowledged that there would always be those, who through ignorance or other reasons will misuse drugs, whatever the consequences. For these people, information and facilities aimed at reducing the risks should be provided because that may save lives. However, such information must be coupled with the unambiguous message that abstinence from drugs is the only risk-free option. Sections (Drug Treatment and Testing Orders) of the Act which received Royal Assent on the 31 st July, 1998, introduced a new community penalty, the Drug Treatment and Testing Order (DTTO), which is aimed at those who are convicted of crime(s) to fund their drug habit and who show a willingness to co-operate with treatment. DTTO was created in order to break the links between drug misuse and other types of offences, thereby preventing further offences. Section 61 allows the court with the offenders consent, to order the offender to undergo treatment for their drug problem, either in tandem with another community order, or on its own. Unlike the Criminal Justice Act 1991, proof of drug misuse is not necessary so long as the court is satisfied that the offender is a dependent drugmisuser. It is open to the court, with the offender s consent, to order a drug test before sentencing, which may assist in the court s assessment of whether the offender is a dependent drug-misuser. The order is available for any offender aged 16 or over whom the court considers is dependent on drugs and is assessed as being a suitable candidate for treatment. It is a community order within the meaning of section 6 of the Criminal Justice Act 1991 and will last between six months to three years. Section 62 requires that the order specify the nature of the treatment required, whether the treatment is residential or non-residential, its location, the frequency of drug testing, and the petty session area where the offender will reside. Section 62 (1) requires the offender to submit for treatment with a view to the reduction or elimination of his dependency on or the propensity to misuse drugs. The offender is thus obliged to provide samples for testing at such times or in such circumstances as may be determined by the treatment provider. The offender may have ulterior motives for consenting to the order without seriously wanting to change. Section 63 therefore enables the court to periodically review the offender s DTTO progress from the probation officer s written report. The report would necessarily include the results of drug tests or the regularity of the offender s attendance at appointments. It will also include judgments by the treatment provider on the offender s attitude Dr Abdul Rani bin Kamarudin, m/s

35 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey and the responses to the treatment programme. Hence, the treatment provider s confidentiality policy must be compatible with the necessary provision of information to the Probation Service and the court. DTTO provides that the offender should liaise (not to frustrate the supervision) with the officer responsible, if the letter and spirit of the order is to be achieved. During the review, the court may amend the order. If the offender does not consent, it may revoke the order and re-sentence the offender for the original offence with the possibility of a custodial sentence. Since addiction is a relapsing condition, the court needs to recognise that a degree of failure must be viewed as part of the treatment process, and not by itself a breach of the DTTO orders. The manner and extent of the failure to comply with the requirements of the order, rather than simply not responding well to the treatment needs to be distinguished by the court. Section 64 therefore ensures that the offender knows the effect and meaning of the order, and the consequences of failing to comply with it. The prison practices a policy aimed at reducing the demand and supply of drugs in prison. Accordingly, it will not tolerate the presence and use of illicit drugs in its establishments, and mandatory drug testing remains the centrepiece of this punitive supply-focused strategy. Consequently, the harm reduction approach is less important in the treatment and rehabilitation of inmates with a drug problem. The ACMD (1996) 83 was of the view that the harm reduction measures should be accorded a more important role than was allowed in view of the legal, medical and practical issues prevalent in prison. The ACMD (1996) believed that the consequences of drug misuse in terms of violence, intimidation and extortion are as important as the impact on the individual s health. The prison programme (varies from prison to prison) includes detoxification services, therapeutic communities, education, and counseling. Detoxification through education prescribing of methadone or other drugs is normally the case, though the practice is less common than under the NHS treatment. Usually, a limited number of prison staff such as probation officers, psychologists and hospital officers can provide basic help and advice, and the Medical Officer is responsible for providing detoxification, which is done more quickly, and on a much more limited basis than in the community. These facilities are in-house, but may also use expertise from other agencies, particularly from the 83 ACMD (1996), Drug Misusers and the Criminal Justice System. Part 3: Drug Misusers and the Prison System - An Integrated Approach, at pg 33-34, 38 and Dr Abdul Rani bin Kamarudin, m/s

36 JURNAL ANTIDADAH MALAYSIA drug action teams. There is no provision for needle exchange or other services to minimize the harm from drug use. The best help usually comes from the small number of drug agencies around the country who specialize in working in prisons, and whom most prisoners prefer because they are seen as independent from the prisons, and as having specialist knowledge. These agencies provide counseling, group work programs, information, support and advice, and try to link prisoners into drug services in the community when they go to court or are due to leave prison. This partnership with other drug-related agencies may continue after their release from prison. 84 Since 1995 (Prison Rule 86), prisoners will be required to provide urine sample for testing purposes, and it is a disciplinary offence for inmates to use controlled drugs without medical authorization. Drug testing on prisoners is done at reception and randomly throughout their sentences. Those prisoners suspected of taking drugs, or those prisoners who have persistently tested positive over a period of time, will be tested most frequently. Though prison inmates cannot be forced to provide a sample for testing, refusal to provide a sample (not necessarily urine) for testing is a disciplinary offence. The same goes for adulterating or substitution of the sample given. Prisoners who test positive are subject to a range of punishments, including additional days of imprisonment, or the loss of privileges and earnings. 85 CONCLUSION The non-prescribing policy of Malaysia on therapeutic drugs in the past for purposes of weaning and stabilization would mean that a drug dependant seeking treatment and rehabilitation would have to think very hard. This policy could in actual fact deter problem drug takers from seeking treatment, though giving prescriptions liberally may lead to dependence or spillage of the same into the illicit market. Further, there is also no guarantee that an addict undergoing treatment (whether 84 ACMD (1996), Drug Misusers and the Criminal Justice System. Part 3: Drug Misusers and The Prison System - An Integrated Approach, at pg 36, 70-71; Hellawell, K. (1998) Making the Community A Safer Place; Cabinet Office Press Release 276/98, 18 th December 1998, London: Cabinet Office; Hough (1996), Drugs Misuse and the Criminal Justice System: A Review of the Literature, at pg 2 3 of 6, Chapter 5: Intervention in Prisons; Durham/Darlington Drug Action Team Home Homepage, Prison Matters: What Help Is There for Drug Users in Prison? in 85 Flynn N. (1995) Drugs in Prison: Another quick fix?, pg 2 of 4, Drugs Edition, Issue Four, in - Release Publications Ltd, London; ACMD (1996), Drug Misusers and the Criminal Justice System. Part 3: Drug Misusers and the Prison System - An Integrated Approach, at pg Dr Abdul Rani bin Kamarudin, m/s

37 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey for gradual withdrawal or on maintenance) would not take drugs illicitly (even by way of acquisitive crime). Harm reduction is less about eradicating drug addiction or dependence than reducing drug-related problems. Thus, Malaysia s initial cold turkey approach is quite justified i.e. abstinence from drugs is the only risk-free option. As such, it is important not to overlook the acknowledged benefit inherent with maintenance on prescription in terms of health, drug use, offences and social integration. Stabilization of clients for a longer period of time till such a period when he is prepared for withdrawal might seem the most practical avenue, particularly for hard-core addicts who are hooked for good. The cold turkey approach is idealistic and impractical. It must be recognized that the problem of drug addiction or misuse is also undeniably a medical one. The best approach for dealing with and combating the drug problem is one that combines effective enforcement with humanity. In this respect, the Malaysian Dangerous Drugs Act 1952 makes referral to treatment and rehabilitation, in accordance with the Drug Dependants (Treatment and Rehabilitation) Act Treating drug addiction through medical and educational supervision within the criminal justice system is the best way forward, preserving proportionality and therefore fairness. Malaysia must exercise a certain degree of patience and restraint, so that stabilization and weaning are acceptable methods of treating addicts, especially for those who have taken drugs for many years. A certain degree of failure to come off the drugs must be viewed as part of the treatment process and not by itself a breach of the order. Addiction is a relapsing condition, and so a degree of failure must be viewed as part of the treatment. The manner and extent of the failure to comply with the requirements of the order, rather than simply not responding well to the treatment would have to be distinguished by the treatment provider. However, the period should not be very long and should not lead to chronic dependence of the drugs being prescribed. Malaysia has now acknowledged that opiate maintenance has its benefits. With proper and careful use of it on drug dependants, there is no reason why drug dependants could not eventually be weaned. The responsibility has to be entrusted to the services and advisory centre or private doctors or private clinics (in liaison with the centre) to review the progress report of the drug dependants. It would also help to take the pressure off the limited numbers of boot camps with the heavy financial burden they face. Promising drug dependants from rehabilitation centres could be released early to undergo supervision at private centres or the Dr Abdul Rani bin Kamarudin, m/s

38 JURNAL ANTIDADAH MALAYSIA government s drug treatment clinics, as a transition into society. Progress reports of every drug dependant at private centres have to be submitted to the nearest government advisory and services centre or the National Anti-Drugs Agency for evaluation. The probation like form of supervision is a good move that signals to the discharged drug dependants that any untoward relapse to drugs cannot be tolerated. Putting penal sanctions for relapse is inevitable and is no more different than undergoing treatment as part of a probation order. Drug dependants must also be forewarned that they must show progress and be committed to the terms and conditions of the supervision. Punishing them for breaching the terms and conditions is therefore justified, provided that the breaches are because of the manner and extent of the failure to comply with the requirements of the order, rather than not responding well to the treatment provider. Mandatory drug testing in prison for drug inmates is also inevitable to curb drug misuse in prison, so that it doesn t become a nesting ground for the misuse of drugs. Penalization or disciplinary actions are inevitable to ensure compliance. Efforts must however, be taken to ensure that they get treatment and rehabilitation in the prison as well as after their discharge. Rehabilitation centres should not be the main thrust in the treatment and rehabilitation of drug dependants. Given the fact that most drug dependants need a longer time to learn to live without drugs, their treatment and rehabilitation for the period should not be done in confinement, except for special cases, namely on medical grounds (problem drug takers). The patient must immediately thereafter be put on supervision and their family must be made responsible in monitoring him. The period of residency should be limited, as opposed to what is now being currently practiced. Residential treatment should not be prolonged but designed merely to stabilize the problem drug takers, or reserved for critical cases. Its role should end there. The answer therefore is to make available conveniently accessible multi-disciplinary drug treatment clinics in many localities, to effectively monitor patients who are put on a drug prescription for weaning and gradual withdrawal. Even though these measures may or may not be able to affect permanent recoveries, at least they do not constitute severe intrusions into human rights and may help some addicts. More leeway has to be given to the more open and decentralized drug treatment clinics with facilities for detoxification, stabilization, the supervision and monitoring of drug dependants on an outpatient basis, and possibly inpatient basis too. Dr Abdul Rani bin Kamarudin, m/s

39 Drug Dependants Treatments and Rehabilitation : From the Cold Turkey to Hot Turkey Prolonged residential treatment and rehabilitation is not necessary, especially when outpatient treatment and rehabilitation is no less effective. Keeping a drug dependant incarcerated for a lengthy period can be counter-productive because treatment and rehabilitation cannot work in confinement. It also highlights the need for Malaysia to give more emphasis to supervision, and reconsider the entrenched idea against maintenance on prescriptions when treating addicts. Supervision, which requires the drug dependants to regularly register with the service and advisory centre, or the police station, achieve the same effect as confining addicts at boot camps. It also allows a drug dependant the time he needs to kick the drug habit, and at the same time avoid causing major disruptions in terms of his finance, family and social circumstances. There is also no stigma. These are important factors of treatment and rehabilitation the Malaysian government perhaps seems to have overlooked and is now seriously re-evaluating. Malaysia should not be overzealous to obtain quick results. Zerotolerance policy need not mean opposing maintenance on prescription for the stabilization and weaning of addicts. In fact, it is compatible with the aims of the zero-tolerance policy. It is the doctor-client relationship that matters most. Flexibility is important, especially when the period of treatment and rehabilitation of drug dependants is inevitably very long and resources tend to be limited. Supervision at localized multi disciplinary drug treatment clinics allow a drug dependant the time he needs to kick the drug habit while continuing his socio-economic activities, which is also vital to the rehabilitation process. Here the concept of harm reduction and maintenance on a script are intertwined, as are both sides of the same coin. Prolonged residential treatment and rehabilitation, and the cold turkey approach, have fared no better than the UK s approach. Given the lack of evidence that any of these treatments are effective, the individuals rights and freedoms should be protected. Here, UK s practice is less invasive than Malaysia. Malaysia has decided to be patient by extending the deadline to make the country narcotics-free by end of 2015 since declaring it as enemy of the State in Drug taking is only a symptom. There is no easy and fast way to eradicate the drug menace and Malaysia needs to be more sensitive in treating and rehabilitating drug dependants the way drinkers and smokers are tolerated. What is required is, to deal severely against those who intentionally and illicitly cultivate, supply and finance drug taking. Dr Abdul Rani bin Kamarudin, m/s

40 JURNAL ANTIDADAH MALAYSIA With the move from the cold turkey to maintenance on drug prescription and the harm reduction approach, it is also high time that the families of drug dependants play a proactive role physically and monetarily in their treatment and rehabilitation by not making treatment and rehabilitation centres as their easy dumping ground. Drug dependants and their families should also realize that they too have to find ways to change and improve themselves, and they should also look into the possibility of training their own drug dependants to be selfemployed or worthy of employment. Without these, the treatment and rehabilitation by the government, no matter how superb would eventually go down the drain. The question is whose fault is it then (the government or the individuals)? The government can only do to a certain extent, but families are equally responsible for the end products of their own members. It is never too late to ponder what the Prime Minister Datuk Seri Dr Mahathir (as he then was) said in May 2003 that inculcation of good values and proper education is the key to success in eradicating drug misuse in the younger generation, and severe punishment alone could not possibly wipe out the drug menace in the society. He emphasized that parents too must inculcate in their children the heinous nature of narcotic drugs if misused or unlawfully used New Straits Times, Dr Mahathir on the Only Way to Rid the Country of Drug Scourge, at pg 2, 20 th May Dr Abdul Rani bin Kamarudin, m/s

41 Cyber Counseling for Addiction and Drug Related Problems CYBER COUNSELING FOR ADDICTION AND DRUG RELATED PROBLEMS Huzili Hussin & Irma Ahmad 1 Mohamad Hashim Othman 2 ABSTRACT Drug abuse is not a new issue in Malaysia. The Prime Minister of Malaysia had announced drug as the number one national enemy. According to the National Anti-Drugs Agency, there were 289,763 individuals addicted to drugs from 1988 until At present, government, private agencies as well as the NGOs are taking initiatives towards reducing the demand for drugs. One such initiative is the cyber counseling service which was implemented by the National Association for the Prevention of Dadah - PEMADAM, a national NGO that focuses on drug prevention programs. This paper highlights a few drug abuse cases handled by a registered counselor who is also a reference person and volunteer counselor for PEMADAM. This paper will further discuss on how the cyber counselor responds to his clients and the approaches that were used by the counselor to handle his clients in cyber space. This paper also elaborate on the possible service and effectiveness of cyber counseling to overcome drug problems and outline suggestions for practical cyber drug counseling service for the Malaysian public. ABSTRAK Penagihan dadah bukanlah satu isu baru di Malaysia. Yang Amat Berhormat Perdana Menteri Malaysia telahpun mengisytiharkan bahawa dadah adalah musuh nombor satu negara. Menurut perangkaan Agensi Antidadah Kebangsaan (AADK), terdapat seramai 289,763 individu yang menagih dadah di Malaysia dari tahun 1988 hingga Sekarang ini, pihak kerajaan, agensi 1 Universiti Malaysia Perlis (UniMAP) 2 Pensyarah, Universiti Sains Malaysia (USM) Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

42 JURNAL ANTIDADAH MALAYSIA swasta dan juga NGO telah mengerakkan pelbagai inisiatif ke arah mengurangkan permintaan terhadap dadah. Satu daripada usaha sedemikian ialah perkhidmatan kaunseling siber yang digerakkan oleh PEMADAM, sebuah NGO kebangsaan yang memberi tumpuan kepada pencegahan penagihan dadah. Artikel ini memaklumkan beberapa kes penagihan dadah yang diurus oleh seorang kaunselor berdaftar yang juga bertindak sebagai pakar rujuk dan kaunselor sukarela untuk PEMADAM. Artikel ini seterusnya membincangkan bagaimana kaunselor siber bertindak ke arah klien dan pendekatan yang telah digunakan bagi mengurus klien beliau dalam ruang siber. Pada masa yang sama, artikel ini akan menghuraikan kemungkinan perkhidmatan keberkesanan kaunseling siber dalam mengatasi masalah dadah serta menggariskan beberapa cadangan untuk perkhidmatan kaunseling siber kepada masyarakat Malaysia secara lebih praktikal. INTRODUCTION Drug abuse is not a new issue. It is how governments of the world look at it. At one time, drug was a trading commodity. But since the Geneva Convention (No.1) in 1925, Geneva Convention (No.2) in 1931 and New York Narcotics Declaration in 1961 governments started re-thinking the impacts of drug abuse on societies. Now NGOs, such as PENGASIH, PENDAMAI and PEMADAM are taking initiatives and efforts towards demand reduction. One of the initiatives is through cyber counseling services. There are various definitions for cyber counseling. In fact, terms such as online therapy, e-therapy and internet counseling have similar definitions with cyber counseling but with different terminologies. However, in this study, cyber counseling is defined based on the term coined by John Grohol (2000) that is the process of interacting with the counselor online in an ongoing series of conversations over time. Meanwhile Feltham and Dryden, (2004) defined cyber counseling as counseling, that is counseling by electronic means. Some growth in this took place in the late 1990s and it seems set to expand if problems of confidentiality can be addressed. Some clients prefer its privacy, easy access and ability to use from home, but some counselors lament that it undermines the importance of the relationship. In different variants, it is also known as online and cyber therapy. According to Grohol (2000), the development of cyber counseling started in It began with a simulated psychotherapy session between Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

43 Cyber Counseling for Addiction and Drug Related Problems computers at Stanford and UCLA during the International Conference on Computer Communication in October, He also pointed out that the earliest known organized service to provide mental health advice online was Ask Uncle Ezra. It is a free service offered to students of Cornell University in Ithaca and it has been in continuous operation since September, David Sommers is considered to be the primary pioneer of e-therapy as he was the first to establish a free-based Internet service. In 1997, a nonprofit society named International Society for Mental Health Online (ISMHO) was formed to promote the understanding, use and development of online communication, information and technology for the mental health community. While in Malaysia, there are many universities and other agencies such as government and non-government agencies offering help via internet. For drug issues, PEMADAM and the National Anti-Drugs Agency (NADA) have developed a website for the drug addicts to communicate with the selected counselors via s. In other words, it offers cyber counseling services for the drug addicts. Thus in the 21 st century, it is clear that interaction between counselor and his clients is not only through face to face session but also through the internet. ISSUES IN CYBER COUNSELING Cyber counseling is a new leading edge. There are potential benefits and also some risks. According to Grohol (2000) the potential benefits of receiving cyber counseling may include: 1) clients are able to send and receive messages at any time, day or night and at any place; 2) clients are able to take as long as they want to compose, and have the opportunity to reflect upon the messages; 3) clients automatically have a record of communications to refer to later; and 4) clients feel less introverted than in person ( Clients also should be informed about the potential risks such as messages not being received and confidentiality being breached. According to Ainsworth (2001) s could fail and not be received if they are sent to the wrong address and confidentiality could be breached in transit by hackers or internet service providers or at either end by others with access to the account or the computer. Other than potential benefits and risks, there are also some issues that need to be raised in cyber counseling. Ainsworth Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

44 JURNAL ANTIDADAH MALAYSIA ( org/imhs/issues.htm) pointed out that clients should ask themselves four questions about cyber counseling. They are: i. Is cyber counseling right for me? ii. Who is the counselor? iii. Is it effective? and iv. Is it confidential? Cyber counseling is not appropriate for every condition. It is not for people who are in the midst of a serious crisis such as suicide. In cyber counseling, clients need to communicate to the counselor via e- mail. Thus they must be comfortable to write expressively, informally and with some detail. Cyber counseling is also a new field. Thus it may have some risks. When counselor and client meet in virtual reality, the client should be informed of the name of counselor, the qualifications and how to confirm the existence of the counselor. Thus it will expose the personal background of the counselor and reduce the risk of misuse of identity which may occur. Cyber counseling will never replace the traditional face-to-face method. However, it is not meant to replace the traditional counseling but it is another way of caring and helping. Ainsworth (2001) found out that 90% of the people who seek help online say that it helped them. Communicating to a counselor via is probably as safe as talking to one in person. Cyber counselors will take their responsibility seriously to protect the privacy and confidentiality as long as there are no other person who can gain access to the account. According to Tuti Iryani Mohd Daud et al. (2005), the U.S. Department of Education 2003 reported 59% of children and adolescent use the internet. However, the percentage for Malaysian adolescents is not available. Nevertheless according to the Malaysian Communications and Multimedia Commission 2004, the number of internet subscribers in Malaysia has increased up to 8 times within the past 6 years. REVIEW OF LITERATURE The empirical studies of cyber counseling are few and far between. However, online support groups for a variety of mental health issues such as eating disorder, sexual abuse, breast and other cancer, HIV and substance abuse/addiction have been studied. According to Laszlo et al. (1999) most studies used small groups which limit their external validity. Because the literature in this area is scarce, we have included Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

45 Cyber Counseling for Addiction and Drug Related Problems some findings from other studies that could influence the discussion on the effectiveness of cyber counseling. Based on the reports by the Surgeon General s Report on Mental Health 1999 (cited from one out of five Americans have been diagnosed with psychological problems and nearly two-third of them never seek help. According to Ainsworth (2001), the primary reason for them not to seek help is the stigma. They are too embarrassed to talk to a therapist. In this study, cyber counseling is used as a method of treatment because it offers more privacy for the drug addicts to voice their feelings and their problems. Shernoff, (2000) found out that cyber counseling has increased the additional complexity to treatment. He pointed out that cyber counseling allows his clients to send him immediate and brief s if something very pertinent to what they are working on happens between the sessions. In other words, through s, his clients do not have to waste their time jotting down the event or feelings and bringing them to the next session. This could avoid the client from forgetting important events or feelings from the perspective of the past several days. Thus, this could give opportunity to the counselor to glimpse into a deeper level of his clients feelings. Another benefit of cyber counseling is it can be done at any time and place as long as both the counselor and the client have access to the internet and accounts. Laszlo, Esterman and Zabko (1999) stated that one of the reasons why cyber counseling is effective is both the client and counselor do not have to sit down at the same time for the counseling session. In other words, clients are free to send their s anytime they want to and the counselor will have more time to respond to the e- mails. Almost every counselor will have various types of clients with different background and work. Some clients need to travel and are not able to attend all the face-to-face sessions. Shernoff, (2000) stated that because not all his clients are able to attend the face-to-face session; he decided to do it via . According to him, cyber counseling allows his clients to send an to reflect on the issues that they are working on and to share all feelings or any practical issues that arise in their lives. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

46 JURNAL ANTIDADAH MALAYSIA Although it is not as ideal as a face-to-face session or even a phone session, it keeps the interactions alive. Tuti Iryani Mohd. Daud et.al, (2005) who described the pattern of help seeking behavior using the internet and perceived efficacy of the internet, found that two thirds of 362 subjects sought help from informal sources like parents, siblings and friends. On the other hand, the percentage of those seeking help from formal sources like mental health professionals, other health professionals, telephone crisis hotlines and the internet were very low. The research also showed that only 10% of the subjects thought that internet had helped them a lot in dealing with their problems effectively. Meanwhile 51% of the subjects perceived that seeking help on the internet only helped them a little. Grohol (1997) pointed out that there were three advantages in choosing cyber counseling as an alternative. They are an increased perception of anonymity, ease of contact and expert opinion from all over the world. As the internet is an open network, communicating through it means communicating without boundaries. Clients can contact the counselors at anytime and anyplace and they manage to get opinions from experts all around the world to treat them or to get a second opinion on their problems. Roles, (2006) stated privacy and anonymity by are more appealing and comfortable (cited from Suler (2001) supported this statement. According to Suler, one of the attractions of online counseling for some clients might be its anonymity. The anonymity and convenience may break down some of the barriers to seeking help on personal problems. In other words, you can be more open when you are at your keyboard than in person with a professional. While others were discussing more into the advantages of cyber counseling, Stephen Snow criticized and questioned this service. In his article (cited in he questioned whether online counseling is ethical to be practiced nowadays. He questioned the confidentiality and privacy as well as the client and counselor s identification and disclosure. There is no doubt that clients who use the computer at work are subjected to corporate policies such as their s being read. John J. Paris, (2001) supported this point of Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

47 Cyber Counseling for Addiction and Drug Related Problems view. The computer equipment belongs to the employer, so does everything in it. (Cited in ethicsonline.html/). Grohol (1997) pointed out that the disadvantage of online counseling is the lack of nonverbal communication. Cyber counseling is different from telephone counseling. Stuart Klien (1997) hypothesized that the lack of visual cues intensifies the need to listen and the ability to listen. However, in cyber counseling, the session is done via . Thus, it does not involve listening. In fact this modality lacks nearly all nonverbal cues. However, Grohol (1997) stated again that exchanges allows for greater thought and elaboration on one s emotions. In conclusion, cyber counseling or counseling online is not meant to be a replacement for face-to-face psychotherapy. It may be an important source of help for you as you face a variety of challenges in life. Cyber counseling offers an opportunity for you to communicate about the dilemmas you are facing with a professional as a guide for consultation, feedback and support. THEORY AND APPROACHES IN CYBER COUNSELING There is no doubt that there are naturally needs for improvising or an adaptation of the psychotherapeutic concepts and theories in cyber counseling due to the lack of face-to-face contact. In fact, there are a number of writers who proposed a variety of practice possibilities and theoretical modalities that can be potentially adapted to cyber counseling. The Crisis Intervention Theory as suggested by Polauf ( :1998) could be an effective framework. He termed it as an based crisis intervention. Parad & Parad, (1990) defined crisis intervention as a process of actively influencing psychosocial functioning during a period of disequilibrium in order to alleviate the immediate impact of disruptive stressful events and to help mobilize the manifest and latent psychological capabilities and social resources of persons directly affected by the crisis. He suggested that the problem should be framed during initial messages (cited from Laszlo et al. 1999). Polauf ( ; 1998) further describes that the process starts upon receiving the initial Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

48 JURNAL ANTIDADAH MALAYSIA from the client. He said that counselors should explore the problem and reframe it in cognitive terms after receiving the initial . This could help to instill hope, reduce the client s anxiety, develop trust and allow them some space. Thus the client feels that he or she is listened to and is understood. To promote the client s autonomy and sense of competence, the formulation of concrete and attainable goals should be collaboratively agreed between the client and the counselor. According to Laszlo et al. (1999), this process should include symptom reduction, restoration of functioning, insight into stressors and increased repertoire of problem solving skills. Polauf ( ; 1998) added towards the end, a specific time frame is then set up within which goals can be met and during which structured and active interventions are used. Cognitive-behavioral intervention could be compatible in this study because they rely on conscious processes and thinking. Beck, (1976, cited in Laszlo et al., 1999) stated that cognitive theory works on examining the individual s thought processes, detecting cognitive error and helping the individual to develop alternatives and be more flexible in understanding the individual/self and environment via re-framing techniques. Gabriel and Holden (1999) recommend a possible adaptation in text-to-text intervention by looking at the emergent patterns in text to be intervened on (cited in Laszlo et al., 1999). They are over-generalization, excessive responsibility, predicting without sufficient evidence, making self-referential statements and turning situations into catastrophes and only focusing on the negatives. These emergent patterns give cue to begin restructuring the individual s thought processes and to foster change. Narrative therapy is another approach that could be used in this study. According to White, (1990) narrative therapy is based on a theory of interpretation and holds (cited in Laszlo et al., 1999). It is focused on people s expression on experiences in their lives. Laszlo et al., (1999) said that as the clients tell the story of their problems, the therapist will explore their interpretation of the story and bring forth the contradictory or ambiguous experiences of their subjective reality. Then, the therapist works on externalizing and re-framing the problem in a manner that is more enabling and empowering to its resolution. Laszlo et al., (1999) mentioned that generally this process occurs face-to-face but it can Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

49 Cyber Counseling for Addiction and Drug Related Problems happen easily through writing and therefore via- . In fact, Murphy and Mitchell (1998), consider the writing process could enhance the externalization of the problem (cited in Laszlo et al., 1989). This is because as the client views their issues on the computer screen; it could promote therapeutic changes. CASE STUDIES OF DRUG ADDICTION ISSUES Cyber counseling services for drug addiction cases have been implemented systematically by PEMADAM in the mid of Previously, all the clients shared their experiences in a specific column provided by PEMADAM. However, there were no responses or feedback given to them. Due to the vast responses given by the society to the column, PEMADAM has been suggested to offer cyber counseling services to help those target groups. Recently, PEMADAM gathered more than thirty counselors to support this cyber counseling. Generally, all the counselors will be given usernames and password to access all the problems sent by the clients to the portal. Initially, all the problems that are sent by clients will be received by the secretariat before they are distributed to the volunteering counselors. The most important thing is that, all discussions between the counselor and client are confidential. In order to get feedback on the cyber counseling services, PEMADAM will arrange a series of meeting with the volunteer counselors to discuss the problems that occurred throughout the process of cyber counseling. At the same time, they also share their views on related issues that have been pointed out by clients. Basically, all the cases that are related to drug addiction are divided into two aspects. Firstly, the issues that relate to problems faced by the drug addicts themselves. Secondly, are the problems faced by the drug addicts families or relatives such as their parents, siblings and spouse. This paperwork will portray three cases on problems faced by the drug addicts and three cases on problems faced by their families. It is to be informed that, all cases portrayed in this paperwork have been edited by the writer so that it will be suitable for academic purposes. This is because, the entire original context written by clients consists of short formed sentences and some of them have used inappropriate and foul language. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

50 JURNAL ANTIDADAH MALAYSIA Problems That Been Faced by the Drug Addict Case 1 : I was an acute drug addict. I was released from prison three months ago, charged for having ATS pills. While in prison, I met a lady who at that time was my counselor. Now, after being released, I still keep in touch with her. The problem is, I have fallen in love with her. Now at the age of 28, I have the desire to get married. I already have a job as a construction worker. But I am HIV positive. Can I proceed with my desire to marry her? Does my action make any sense? What shall I do? Case 2 : I am 26 years old and am married with a child. I started drug addiction when I was 15 years old and at that time I was addicted to marijuana. Now, I am into heroine and I find it too hard to control this addiction. The worst moment in my life came about when I was accused of raping a girl although in the beginning it took place with the consent given by the girl (at the time of the incident, I was under the influence of heroine). Due to that incident, I ran away from my village. The police are now tracking me. I regret what I have done. I miss my wife and child. I still don t know what to do and where to go. I am sick and am suffering due to my addiction to heroine. I still have hope to rebuild a new life just like other people. Please help me start! Case 3 : I have been having problems with drugs for more than 10 years. Now I am taking subutex. However, that medicine is hard to find and is always out of stock. I can t control myself and must take subutex and now I am addicted to it. Recently, I have been disturbed by a mystic voice. I even tried to kill myself because I couldn t stand to hear those voices mocking me! I once asked my wife to tie me up and to chain me when I was highly addicted to the drug. I am saddened by my condition. What can I do to return to the right path? Problems Faced By Drug Addicts Families Case 4 : I just got married to the girl of my choice. The major problem that I am facing right now is that both my father and mother in-law are drug addicts. However, they are divorced now. My mother in-law has just been released from prison. In the beginning, I wanted to take care of her but she preferred to stay with her old friends. As a result, now she has started her old habit; drug addiction. My father in-law, on the other hand always asks money from my wife. I am so depressed with this Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

51 Cyber Counseling for Addiction and Drug Related Problems situation because my salary is low and at the same time, there are lots of things that I need to do for my family. Is it possible for me to divorce my wife if this problem still persists? Case 5 : I have been married since In the beginning of our marriage, we were happy. In fact, we now have a child. However, my husband started to change when he was offered a better job. Finally, he was drawn into drug addiction. I can still hardly believe that my husband is a drug addict even though I ve witnessed him inject morphine, subutex, dormicum, ATS pills etc. Initially, I tried to think positively. I even accompanied my husband to get treatment for his addiction on methadone and subutex. However, he did not obey the doctor s advice. I became very disappointed. He always mixes subutex and dormicum and injects to his body. My husband acts like a person who has lost his mind when he is high on drugs. I ran away from him four times. However, each time I ran away, I felt sympathetic and returned. He always promised to change each time I came back to him. But, the promises were never fulfilled. Now I m staying with my family. I am trying to get a divorce but I can t seem to do it because of his persuasions. I also pity my child who misses his father very much. What should I do? I m too weak and scared to make the decision. Case 6 : I am so disappointed with my father and my sister who do not want to quit taking drugs. My mother and I have advised them so many times but they are still the same. I am embarrassed to face society. I am afraid that my other siblings will follow their footsteps. Please help me get out of this problem. APPROACHES THAT HAVE BEEN IMPLEMENTED IN THE CASE STUDIES Every approach that is implemented in counseling should be based on objectives. According to Burks & Stefflre, (cited in George & Cristiani, 1990) the main reason for counseling services is to help the client to understand and to state their views on life and to learn how to achieve their objectives based on the right choices and problem solving skills. Mizan et al. (1998) pointed out that the good thing of using the counseling approach is that it guides clients to search for the factor within them that led to the issues or problems. The ability to accept themselves as the cause of the problem is very important in the changing process. In fact in Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

52 JURNAL ANTIDADAH MALAYSIA the counseling process, it also helps the clients to understand and to accept their weaknesses as one of the source of the problem and how they are exposed to the problem. Thus, in this discussion, the focus is on the clients and their roles in the problems and not on the problems that they are facing. According to Albert Ellis (cited in Amir Awang, 1987) counselors should understand the qualities of human beings first before they could offer their services to their clients. According to Ellis; A human being is born with a potential to think or not to think rationally. In other words, a human being is given a brain which enables him or her to differentiate between good and bad, right and wrong and logical and illogical things. Human beings also naturally yearn to take care of themselves in order to achieve happiness, to think and to convey their ideas, to love and to be loved and finally to move towards nirvana. On the other hand, human beings also naturally yearn to ruin themselves, to avoid from thinking, to hold onto things, to continually do mistakes, to believe in the supernatural, to be impatient, to blame themselves and to avoid from progressing towards nirvana. Furthermore, Ellis stressed that there are lots of irrational beliefs in an individual s life. Some of them are as follows: i. A person should be loved and accepted by others and the society. ii. Human misfortune is caused by external pressure and humans only have little ability to control them from becoming disappointed and disturbed. iii. Humans tend to think that all their past will be the grounds for their actions now. They cannot get rid of the pressure from their past. iv. They think that a person who wants to be accepted as a useful person must be those who are very efficient, multi skilled and is successful in every field. According to Amir Awang (1987), the approaches that can be used to help the clients are through counseling therapy and group counseling. The important thing is the counselors should play their roles whether through persuasion, propaganda, questioning, challenging or putting up a demonstration in order to get rid of those irrational beliefs they Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

53 Cyber Counseling for Addiction and Drug Related Problems have. Some of the implementations that could be applied to the clients are: i. Encouraging the clients to get hold of their philosophy or views on living and that it is not necessary to burden their lives with negative values. ii. Clients are asked to challenge or question their own belief system with certain proofs and evidence. iii. Clients are asked to prove why they should feel bad or worse if something they do does not work. Noraini Ahmad (1996) views the counselors roles as not just to give advice but more into the introspection process. For example; counseling services should help them to understand themselves and the reality of life, to make some realistic plans in their lives, to be a responsible person and to be a person who will function as they rightly should. Thus, based on the discussion above, the best approach that could be implemented by counselors is by making them understand and realize on their own on how they should accept the reality for every problem and to develop actions that could be taken to overcome those problems. Before a counselor decides which implementation will fit and work on the drug addicts and their families, he or she should first understand the concept of drugs and its implications towards oneself and the society. According to the National Anti-Drug Association (1998), drug is a psychoactive component which could cause complications on the nerve system, lead to physical and psychology dependency and badly affect the health and social function of an individual. Mahmood & Md Shuaib Che Din (2003) explained that drug addicts become addicted to drugs for several reasons. However, the major reason why they could not stop from becoming addicted is because they want to avoid the withdrawal syndrome. For those who are addicted to heroine, the withdrawal syndrome will appear 4-6 hours after taking the last dosage. Drug addicts will face several problems such as diarrhea, stomachache, cold, sweat, morning sickness, fear and panic. The climax for this syndrome will be after 24 hours till 72 hours. They will face other problems such as insomnia and panic without any specific reasons. All these syndromes will disappear if they take the drug again but with a higher dosage. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

54 JURNAL ANTIDADAH MALAYSIA Drugs are divided into a few categories. Among them are the plant-based ones such as cannabis, ganja, heroine and morphine. The other one is the synthetic drug which is also known as ATS (Amphetamine-type-stimulants). ATS is very popular nowadays. In fact, this type of drug is found widely in the form of pills and is well known such as ecstasy and pil kuda. This type of drug is very dangerous because it could cause the drug addict to become aggressive and could cause substantial damage to their brains. In Malaysia, drug addicts are classified into two categories. They are the acute drug addicts and the novice drug addicts. Acute drug addicts are those who have been taking drugs for 10 years and have undergone treatments more than twice at the rehab centre. Novice drug addicts are those who have been taking drugs for a short period of time and have gone for treatment once or are yet to go for any treatments. According to Abdullah Al-Hadi & Iran Herman, (1997) drug addicts will lose their own pride and not respect their own parents. They treat the slums as their home, they no longer take care of themselves and are often involved in crime. Based on a research done by Yahya Don (2000), addiction to drugs will lead them to commit crimes in two situations: The impact of drugs will lead them to criminal thoughts as their feelings are no longer stable. The costs of drugs are also very high thus will lead drug addicts to criminal activities in order to support their addiction. Not only that, drug addicts also show some changes physically such as becoming very thin, weak and aggressive. They are also highly exposed to HIV due to their sexual habits and the tendency to share needles. In this study, the approaches that are used to deal with drug addicts differ from the approaches used for the drug addicts families. The approaches are : Case 1 : Based on the input given by the client, it is clearly stated that he cannot accept the reality that he is HIV positive. He has plans to start a new life after being freed from prison. At the same time he assumes that society will accept him back. Thus to him, there should be no problem Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

55 Cyber Counseling for Addiction and Drug Related Problems in marrying his previous counselor. In this case, it shows that the client has a few irrational beliefs within him. Therefore, the counselor has to try to make his client understand that for the time being, there is no cure for HIV and he should accept it. In fact, HIV can be transmitted through sexual and intimate relationships. Not only that, the counselor also needs to explain to his client that all the good values that were shown by his previous counselor, such as her caring nature, is in fact part of her job. This is because one of the counselor s roles in conducting counseling is to build a conducive relationship with the client. The counselor also needs to suggest that the client continues his treatment because he was an acute drug addict; so his tendency to relapse is high. Finally, the counselor also needs to advise the client to be a volunteer at the Malaysian AIDS Association. Although he is HIV positive, he can use his experience to save other people from becoming involved in activities that could lead them to contract HIV. Case 2 : In this case, the client has run away from his village and has left his wife and child. He did this because he was accused of raping a girl and now he is being tracked down by the police. Thus the counselor should advise him to surrender himself to the police and return to his family. The counselor can also list out the advantages and disadvantages of listening to him or otherwise. The counselor also should explain to his client that for overcoming drug addiction, support from family members is very important. Case 3 : Based on the input given, it is clearly stated that the client s level of addiction is very serious. This is based on how he described the hallucination that he is facing at the moment. Thus, the counselor advises him to get treatment as soon as possible. He could get the treatment at the clinic which uses methadone and subutex. The counselor also explains the risks that he has to face if he does not get the treatment. The client will also be told how lucky he is to have a supportive wife. Thus, the counselor advises him not to feel ashamed or scared. He should prepare himself to be strong and to gain support from his family. Overall, the approaches that have been implemented to drug addicts and former addicts are focused on making them think rationally and to accept the reality of life before they could plan some other approach to overcome their problems. It was stressed to the client to accept the Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

56 JURNAL ANTIDADAH MALAYSIA fact that the best way to cure their addiction is through professional treatment, their own strength and will power as well as the support from their families. Case 4 : Issues that have been pointed out by the client concerns his father and mother in-law who are addicted to drugs. As a result, the client feels confused and has decided to divorce his wife. Thus, the counselor should try to make the client understand that his problem actually concerns his father and mother in-law. His wife is merely a victim of circumstances. The counselor explains to the client that the addiction issue needs to be addressed through a special treatment conducted by a group of specialists. The counselor also lists out several places that he could contact for help. Finally, he also advises his client to give full support to his wife in facing this problem. Case 5 : Based on the problem, it shows that the client could not accept the reality that her husband is a drug addict. She is frustrated because her husband has disappointed her by not following the doctor s advice. Not only that, she is still in love with her husband although she ran away from him four times. Thus to help her, the counselor has to list out the characteristics of drug addicts and their attitude. The counselor also tries to make the client understand that addiction to drugs can only be treated at a professional institution. The counselor also mentions that her love for her husband is something to be praised but in reality; she should look at other factors too. Thus, her wish to divorce her husband should be seen in a variety of contexts. It should not be solely based on the reason that her husband is a drug addict. She could do it for other reasons such as her husband being incapable of maintaining a harmonious marriage and family. Case 6 : In this case, the client has expressed his frustration towards his father and his sister who are addicted to drugs. As a result, he feels ashamed to face society. He is also afraid that their habit could influence his other siblings. Thus, the counselor explains to his client that drug addiction can happen to anyone. The most important thing is that, he should not feel ashamed to bring his father and his sister to the drug rehabilitation centre. This is because only through rehabilitation treatment could their addiction be cured. The counselor agrees that the attitude of his father and his sister could influence the other siblings. Thus, the counselor advises his client to increase his Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

57 Cyber Counseling for Addiction and Drug Related Problems confidence level and strength to face this problem rationally and not emotionally. In conclusion, the approaches that have been implemented by the counselor to the drug addicts families are based on real facts of the drug addicts condition and attitude. The counselor also stressed the fact that drug addiction can only be cured through professional treatment. The counselor also reminded his clients not to be emotional in dealing with drug addiction. In fact, the most important thing is they should support each other and be strong. EFFECTIVENESS OF CYBER COUNSELING SERVICES As noted before, the empirical studies of cyber counseling are few and far between. Thus, there is no specific method that could be used to measure the effectiveness of cyber counseling in this study. In order to strengthen this services, all the problems that occur whether related or not with the system and the processes of implementing; as well as the response from the clients have been highlighted and given full attention. Based on the cases that have been discussed earlier in this paper, out of the six cases, only four responded to the feedback given by the counselor. The counselor has come up with three possibilities on why the other two clients did not respond to the feedback. The possibilities are: i. They do not have access to a computer or internet at home. Probably, when they sent the initial messages, they used their friends computer or sent it from a cyber café. ii. They received the feedback. They understood and were satisfied with the feedback or advices given to them. They probably thought that it was not important to respond and give their feedback because they already understood what to do or they already got what they were looking for. iii. They receive the feedback but they cannot accept the feedback given to them. Probably they still cannot accept the reality of life. In other words, they are not satisfied with the feedback given to them and they may have used other channels to help them overcome the problem. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

58 JURNAL ANTIDADAH MALAYSIA Based on the responses given by the clients, the counselor found out that it is difficult to conclude whether the client could accept and benefit from the comments and suggestions. This is because; the responses given by the clients were too short and simple: Thank you for your advice and point of view. I will try my best to overcome it. Although all the responses given by the client were simple and short, the counselors still sent them some supportive phrases with the hope that it would benefit them all. CONCLUSION AND RECOMMENDATION Based on this study, the counselor found out that he did not achieve the satisfaction in handling those cases via cyber counseling. However, due to the rapid changes in the IT world, every counselor should prepare themselves for this service as well as other challenges. In Malaysia, the awareness of using cyber counseling services is still at the novice stage. The counselor gives two probabilities for this situation. Firstly, there are still many Malaysians who cannot afford to own a computer. Secondly, they probably prefer to use the traditional method of counseling, which is face-to-face counseling rather than cyber counseling. However, we should use all methods that we have in handling drug addiction issues. This is because these issues could harm our country if we do not give it our full attention. It is hoped that cyber counseling services could be reinforced and more counseling centres could be opened, if possible one center for each district so that more drug addicts will be able to come forward to seek help. It is also hoped that both the government and the private sector could train more counselors in handling drug addiction cases so that more services could be offered to them. Finally, the anti-drug campaign should be done comprehensively and extensively to ensure the society is united to say NO to drugs! Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

59 Cyber Counseling for Addiction and Drug Related Problems REFERENCES Abdullah Al Hadi & Iran Herman. (1997). Penagihan Dadah Mengikut Kaum, Diri, Keluarga dan Persekitaran. Kuala Lumpur: ADK Agensi Dadah Kebangsaan. (1998). Kenali dan Perangi Dadah. Kuala Lumpur: ADK Ainsworth, M. (2006). ABS s of Internet Therapy. Downloaded from www. metanoia.org/imhs/alliance.htm [2006, July 6] Amir Awang. (1987). Teori dan Amalan Psikoterapi. Pulau Pinang: Universiti Sains Malaysia Colombo Plan Drug Advisory Programme, (2003). ATS Prevention : A Guidebook for Communities, Schools and Workplaces. Colombo, Sri Lanka. Colombo Plan Drug Advisory Programme. (2003). Development of Family and Peer Support Groups: A Handbook on Addiction Recovery Issues. Colombo, Sri Lanka. Feltham, C. & Dryden, W. (2005). Dictionary Of Counseling, 2 nd Edition. UK: Whurr Publisher Ltd. George, R.L. & Christiani, T.S. (1990) Counseling: Theory and Practice (3 rd Edition), Englewood Cliffs, N.J: Prentice Hall. Grohol, J.M. (1997). Why online psychotherapy? Because there is a need. Downloaded 5/8/06 from the World Wide Web Haas, C. (2000). Entangled in the net. Counseling Today, pp International Society for Mental Health Online (2000). Suggested Principles for the Online Provision of Mental Health Services. Downloaded from [2006, July 5]. Laszlo, J.V., Esterman, G. & Zabko, S. (1999) Therapy over the Internet? Theory, Research and Finances. CyberPsychology & Behavior, 2(4), p Mahmood Nazar Mohamad & Md. Shuaib Che Din. (2003). Memulihkan Penagih Tegar: Implikasi kepada Modaliti Masa Kini. Pengurusan Perkhidmatan Kerja Sosial di Malaysia, Sintok: Universiti Utara Malaysia. Mizan Adiliah Ahmad Ibrahim & Halimatun Halaliah Mokhtar. (1998). Kaunseling Individu: Apa dan Bagaimana. Shah Alam: Fajar Bakti Sdn. Bhd. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

60 JURNAL ANTIDADAH MALAYSIA Noraini Ahmad. (1996). Senario Kaunseling. Kuala Lumpur: Berita Publishing Sdn. Bhd. Polauf, J. (1998). Psychotherapy on the Internet, theory, and technique. [Online] from world wide web [2006, July 5] Polouf, J. ( ) as a Modality for Crisis Intervention. [Online] from World Wide Web [2006, July 6] Reimer-Reiss, Marti (2000). Utilizing Distance Technology for Mental Health. Journal of Mental Health Counseling, 22, Roles, P. (2006). Online Counseling. Downloaded from World Wide Web [2006, July 6] Shernof, M. (2000) Cyber Counseling for Queer Clients and Clinicians. Downloaded 5/7/06 from World Wide Web Snow, S. Download game monopoly offline 3d bahasa indonesia gratis. (2001). Is Online Counseling Ethical? Downloaded from the World Wide Web [2006, July 5] Tuti Iryani Mohd Daud, Zasmani Shafiee, Wan Salwina Wan Ismail, Nik Ruzyanie Nik Jaafar, Abqariyah Yahya & Zaharah Sulaiman. (2005). The Pattern Of Help Seeking Behaviour Using The Internet Among Adoloscent. Prosiding Persidangan Kaunseling Universiti Malaya Kuala Lumpur: Fakulti Pendidikan Universiti Malaya. Yahya Don. (2000). Penagihan Dadah dan Perlakuan Jenayah: Cabaran Kepada Pusat Serenti dan Masyarakat Masa Kini. Prosiding Seminar Kebangsaan Kerja Sosial Sintok: Universiti Utara Malaysia. Huzili Hussin, Irma Ahmad & Dr. Mohamad Hashim Othman, m/s

61 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area DEMOGRAPHIC DETERMINANTS OF THE DRUG ABUSE PROBLEM AMONG SECONDARY SCHOOL STUDENTS IN AN URBAN AREA Rafidah Aga Mohd Jaladin 1 ABSTRACT The demographic determinants among students with drug abuse problem were investigated in order to identify the high-risk factors of drug abuse. An examination of records and an informal interview were used as methods of collecting data. It was predicted that male students in their late adolescence whose parents are both working and are living in poor conditions, are more prone to drug abuse than others. Findings indicated a mixture of results. The main predictors for drug abuse were gender and age but the other predictor variables were inconclusive. The adolescents' personality and the quality of family involvement were also discussed to account for the results. ABSTRAK Penentu demografi bagi pelajar yang mempunyai masalah dengan penyalahgunaan dadah diteliti bagi mengenal pasti faktor-faktor berisiko tinggi ke arah penggunaan dadah. Data kajian ini dikumpul melalui penelitian ke atas rekod dan temu duga tidak formal. Kajian ini meramalkan bahawa pelajar laki-laki di tahap akhir zaman remaja yang kedua-dua ibubapa mereka bekerja, hidup dalam suasana tempat tinggal yang tidak begitu kondusif dan persekitaran yang mempunyai dadah adalah lebih cenderung untuk menyalahgunakan dadah berbanding dengan pelajar dari latar belakang yang berlainan. Dapatan kajian menemui hasil yang berbeza-beza. Peramal utama untuk penyalahgunaan dadah ialah gender dan umur, dan variabel 1 Department of Educational Psychology and Counselling, Faculty of Education, University of Malaya Rafidah Aga Mohd Jaladin, m/s

62 JURNAL ANTIDADAH MALAYSIA peramal lain tidak dapat dirumuskan. Personaliti dan kualiti penglibatan keluarga bagi seseorang remaja turut dibincangkan bagi memberi penerangan kepada dapatan yang ditemui. INTRODUCTION In many countries, drug abuse is no longer a common issue. In fact, drug abuse has become the most serious and contagious problem that affects all countries and all levels of society (DSP Dzuraidi Ibrahim, 2002). The most worrisome aspect of this issue is that drug abuse has overpowered quite a number of adolescents in our society. Here, 'adolescent' refers to the student population aged between 11 to 18 years old (Papalia & Olds, 1998). Due to this, the Malaysian government launched an Anti-Drug Campaign at the national level on 19th February This campaign was carried out because of three foreseeable risks: (i) drug addiction may reach an epidemic level if there was no strict law and enforcement carried out to prevent its spread; (ii) the target group of drug addiction is mainly youths and adolescents who are the country's future leaders and the hope of the nation; and (iii) the addiction and distribution of drugs have affected the harmony and security of the country economically, socially, and politically (Ee Ah Meng, 1997). However, there seemed to be a lack of response from the community in helping to prevent this social ill. As a result, the government has taken an aggressive measure by declaring the year 2003 as the year for seriously combating the drug abuse problem. The theme for the year was Perangi Dadah Habis-habisan. Statistical report showed that in 1970, there were 711 drug addicts in our country (Ee Ah Meng, 1997). However, the number kept on increasing as the years went by, as shown in Table 1. Current data from the statistical report in 2003 showed that there was a substantial increment in the number of drug addicts with a total number of 36,996 drug addicts all together (Sistem Maklumat Dadah Kebangsaan -NADI, 2003). A total of 695 adolescents below the age of 18 were involved in drug abuse. The distribution of these addicts according to their levels of education is tabulated in Table 2. Based on this data, it is expected that the number will increase if no proper measures are taken. Rafidah Aga Mohd Jaladin, m/s

63 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area Table 1 : Total Number of Drug Addicts Traced According to Case Status New Relapse Total Year Number Percentage NumberPercentage Number Percentage (%) (%) (%) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Source: National Drug Information System (NADI, 2003) Table 2 : The Distribution of Drug Addicts Among Students According to Their Levels of Education Year Primary Form 1 Form 2 Form 3 Form 4 Form 5 Form 6 University/ school Colleges % 48.73% 10.55% 24.36% 22.55% 32.00% % 0.72% 3.23% 9.32% 17.56% 20.79% 0.00% 48.03% % 0.49% 2.70% 9.31% 14.46% 20.83% 20.59% 31.37% % 1.10% 5.74% 11.92% 22.52% 22.08% 36.42% % 3.90% 5.64% 14.75% 25.16% 49.02% Source: National Drug Information System (NADI, 2003) Rafidah Aga Mohd Jaladin, m/s

64 JURNAL ANTIDADAH MALAYSIA Since drug abuse cases among students (especially those in secondary schools) are worrisome, corrective and preventive measures should be taken in order to reduce the number of drug addicts among students. However, due to limited time, energy, resources, and not to mention financial assistance, the corrective and preventive measures cannot be implemented on all students. As an alternative, it is best to focus on those students who are categorized as vulnerable or in the highrisk groups. Unfortunately, there aren't many studies that examined the predictors of students' involvement in drug abuse. Thus, there is a great need for parents, teachers, policy makers, law enforcers and the education ministry to understand the basic information regarding those who are vulnerable or the high-risk group. This basic information encompasses the demographic details of those students who have been convicted for drug abuse crimes. The present study examines the demographic details of students convicted for drug abuse crimes in terms of gender, age, number of siblings, parental vocational status, home location and home environment. The study is also interested to find out the reasons and resources of drug abuse. Specifically, the study has the following objectives: i. To examine the demographic determinants of students convicted for drug abuse crimes; ii. To identify the source of involvement of these students in drug abuse; and iii. To identify the drug resources available to students. Based on these objectives, there are three research questions that need to be addressed in this study: i. What are the demographic determinants of students convicted for drug abuse crimes? ii. What are the sources of involvement that make the students become drug addicts? iii. What are the means of getting the drugs? For the purpose of this study, 'drug' is defined as a psychoactive chemical substance that is used as medicine or narcotics. Whereas, 'drug abuse' refers to a drug that is taken for non-medicinal reasons (usually Rafidah Aga Mohd Jaladin, m/s

65 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area for mind-altering effects); drug abuse can lead to physical and mental damage and (with some substances) dependence and addiction (Agensi Dadah Kebangsaan, 2003). Drug abuse also means the use of one or more type(s) of drug by means of injection, inhalation, drinking, sniffing, or any other ways that can cause the person stupor or become subconscious. Drug abuse also refers to improper and excessive use of drug to alter consciousness. 'Student' refers to an adolescent within the schooling age range and is still studying at any private or government school. LITERATURE REVIEW Previous studies have found that many reasons contribute to the involvement of students in drug abuse. Some of these reasons summarized by Ee Ah Meng (1997) are as follows: i. The curiosity to know the effects of drugs; ii. the ignorance of the dangers of drug abuse; iii. Peer influence and the desire to be accepted into a group; iv. A means of seeking inner peace when faced with life problems such as inability to cope with failures in examinations, love, or life in general; v. A means of forgetting worries, hardship in life and bad experiences; vi. On impulse without considering the possible consequences of drug abuse; vii. Lack of love from parents; viii. Boredom towards schools and school activities; ix. Loneliness because of exclusion from peer group; x. Inability to adapt to life in the city where there is so much stress and life pressures; and xi. Parents give their children too much pocket money. Contrary to popular belief, poverty is not linked with drug abuse unless deprivation is extreme (Hawkins, Catalano & Miller, 1992). Papalia and Olds (1998) also listed a number of characteristics of young individuals and the environment that make them likely to misuse drugs: Rafidah Aga Mohd Jaladin, m/s

66 JURNAL ANTIDADAH MALAYSIA i. Poor impulse control and a tendency to seek out sensation rather than to avoid harm (which may have a biochemical basis), ii. Family influences (such as a genetic predisposition to alcoholism, parental use or acceptance of drugs, poor or inconsistent parenting practices, family conflicts, and troubled or distant family relationships), iii. Difficult temperament, iv. Early and persistent behavior problems, particularly aggression, v. Academic failure and lack of commitment to education, vi. Peer rejection, vii. Association with drug users, viii. Alienation and rebellion, ix. Favorable attitudes towards drug abuse, and x. Early initiation into drug abuse. The earlier young people start misusing drugs, the more frequent they are to use it, and the greater the tendency for them to abuse it. Based on this discussion, it can be summarized that the reasons for adolescent students to abuse drugs can be categorized into two main factors: the individual and the environment. Examples of the subcomponents of the individual are gender, age, race/ethnicity, the number of siblings, education status, and parental vocational status. On the other hand, examples of the components of the environment are the location of the house, type of housing area, and the home environment. Unfortunately, there are still insufficient studies in the local context that have looked closer into each of these factors. Therefore, this study is very significant because it strives to examine some of these demographic details listed above among students who have been convicted for committing drug abuse crimes. The selected predictor variables are as follows: Gender An extensive study conducted by Jenkins (1995) has reviewed some studies to investigate the role of gender in school delinquency. Based on the review, girls have consistently been found to have lower levels of delinquency than boys. Riley (1987) provided some explanation for the findings by reporting that offenses made by teenage girls could be related Rafidah Aga Mohd Jaladin, m/s

67 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area more to low levels of parental supervision and negative attitude toward schools and not peer-group associations which often characterizes crimes committed by teenage boys. Thus, in the present study, it is expected that girls would be less likely involved in drug abuse than boys. Age Generally, age is positively associated with delinquency (Jenkins, 1995). The most critical age that signifies serious involvement in delinquency is during adolescence. Previous studies have shown that serious involvement in delinquency rose during early adolescence and peaked in the middle to late teens (Dusek, 1987; Gottfredson & Hirschi, 1990). However, there was no specific age range mentioned in those studies. Papalia and Olds (1998) provided some information concerning agespecific rates for the prevalence of high-risk behaviors. They commented that across ethnic and social-class lines, many young adolescents (aged 12 to 14) used drugs, drove while being intoxicated, and are sexually active. They further argued that these behaviors increased throughout the teenage years. For these reasons, it is predicted that as age increases, the involvement in drug abuse also increases. Number of Siblings A number of studies have concluded that family size is a factor in delinquent behavior (see Jenkins, 1995 for details). In large families (four or more children), parents may have less time to attend teacher conferences and PIBG (Parent-Teacher Association) meetings, to check on homework, or to monitor the school discipline problems of each child and may have less money to buy basic necessities. Furthermore, Jenkins (1995) reported that parents of large families have less time to supervise their children, thus leave the setting of behavioral standards to older siblings, peers or schools. For these reasons, it is predicted that students who commit drug abuse come from large families (four or more siblings) and not from small families (less than four siblings). Parental Vocational Status There aren't any direct studies investigating the role of parents' vocational status in the students' involvement in delinquent behaviors. However, studies investigating the role of socioeconomic status (SES) of parents in relation to the students' achievement are abundant. Thus, it can be deduced that if both parents are working, they may have higher income thus making the SES of the family higher. Rafidah Aga Mohd Jaladin, m/s

68 JURNAL ANTIDADAH MALAYSIA SES seems to affect the amount and quality of verbal interaction between parents and children (Papalia & Olds, 1998). Besides that, SES is a powerful factor in educational achievement through its influence on family atmosphere, on the choice of neighborhood, and on parents' way of rearing children. Is the family stable and harmonious, or conflictridden? Do the parents talk to their children? What goals do they have for their children, and how do they help them achieve their goals? Do parents show interest in schoolwork and expect children to go to college? Whether a family is rich or poor, the answers to questions like these are important; but the answers are more likely to be in favor of the higherincome, better-educated family (White, 1982). Children of poor and uneducated parents are more likely to experience negative family and school atmospheres and more stressful events (Felner et al., 1995). Thus, it is hypothesized that students who come from a family whose parents are both working are more at risk to drug abuse than those who come from a family with only one parent working. If both parents work, they have less time to have quality interaction with their children, and less time to be involved in their children's schooling. House Location The neighborhood a family can afford generally determines the quality of life a person may have. House location determines the quality of schooling available, as well as opportunities for higher education; and the availability of such opportunities, along with the neighborhood's peer groups' attitude, can affect the motivation and the students' involvement in school crimes (Papalia & Olds, 1998). Studies have shown that house location is greatly influenced by SES and poverty factors. Many studies reported that poor children are also at high risk of injury, unhealthiness, and problematic behavior. Many poor families live in crowded and poor sanitary housing areas and the children may lack adequate supervision, especially when the parents are at work. They are more likely than other children to suffer from lead poisoning, hearing and vision loss, and iron-deficiency anemia, as well as stress-related conditions such as asthma, headaches, insomnia, and irritable bowel. They also tend to have more behavioral problems, psychological disturbances, and learning disabilities (Brown, 1987; Egbuono & Starfield, 1982; Santer & Stocking, 1991; and Starfield, 1991). Thus, in this study, it is predicted that students who live in an unhealthy area, such as squatters, will be more involved in drug abuse than those living in proper housing areas. Rafidah Aga Mohd Jaladin, m/s

69 Home Environment Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area Papalia and Olds (1998) stated that the family's SES, including financial resources and the parents' educational background, could have a major influence on the children's school achievement. In one study of 90 rural African American families with their firstborn children between the ages of 9 to 12 years old, it was found that parents with education were more likely to have higher incomes and to be more involved in the child's schooling. Higher-income families also tended to be more supportive and harmonious. Children growing up in a positive family atmosphere, whose mothers were involved in their schooling, tended to develop better self-regulation and perform better in school (Brody, Stoneman, & Flor, 1995). Thus, SES in itself does not determine school achievement and delinquent involvement; it is its effects on family life that can make a difference. Family factors such as a chaotic home environment, ineffective parenting, and lack of attachments and nurturing are thought to be among the most significant risk factors for substance abuse. Others include social/environmental factors such as excessive shyness, aggressive classroom behavior, academic failure, poor social coping skills, involvement with deviant peers, and perceptions of approval of substance use among peers in the school and community (NIDA, 1997). In the present study, it is predicted that students who reported of having an unsatisfactory home environment would tend to be more likely involved in drug abuse than those who reported a satisfactory home environment. METHODOLOGY Forty-three secondary school students who have been confirmed to be involved in drug abuse by the Unit Pendidikan Pencegahan Dadah (PPDa) were the participants of this study. All participants were male students aged between 15 to 17 years old and the mean age was They were Form 3, 4, and 5 students from various schools in Bangsar, Sentul, Pudu and Keramat zones. The questionnaire used in this study is called the Borang Biodata Pelajar Ujian Urin Positif. It comprises of three attachments: The first attachment is the demographic information section and it consists of 28 items; the second attachment is the supervision section for recording school attendance; and the third attachment is the supervision section for recording students' misconduct in schools. Rafidah Aga Mohd Jaladin, m/s

70 JURNAL ANTIDADAH MALAYSIA The questionnaire was designed by the PPDa unit. The reliability and validity of the instrument was never reported and investigated. However, the form has been extensively used to record detailed information of students who have positive results in the urine test for drugs since For the purpose of this research, only items 8 (gender), 9 (form), 16 (usage stage), 19 (parents /guardian s background: father s and mother's occupation), 20 (number of siblings), 21 (house location), 22 (house condition), 25 (source of drugs), and 26 (cause of involvement) from the demography section were examined and analyzed. The rest of the items were not included in this study because they were beyond the scope of this study and thus classified as strictly private and confidential. The data were collected and analyzed by using an examination of records method. In order to substantiate the finding and to get further information regarding some of the items, an informal interview was carried out. The interviewer was a drug education-and-prevention officer who was in-charge of the files and records of the students confirmed having drug abuse problems. Most of the analyses use frequency distribution to present the findings. PROCEDURE The procedure involved several parties such as the school authorities, the National Anti-Drug Agency, and the PPDa Unit. Firstly, the PPDa Unit officers informed the school administration regarding the specific details of the date and time to carry out the urine test. The urine test was carried out randomly. The urine test was administered to both male and female students of various ethnicity, different educational levels and student bodies (such as prefects and librarians). The students were tested randomly with the help of the National Anti-Drug Agency. If the results were positive, the PPDa Unit officers informed the school principals to collect detailed information of the convicted students by using the Borang Biodata Pelajar Ujian Urin Positif. Once comprehensive information of the students was obtained, the school counselors conducted counseling sessions to help those students to rehabilitate. On the other hand, by using a special logbook, the PPDa Unit officers act as supervisors to monitor the counseling sessions. Up to this stage, the main task of the PPDa Unit was to continuously design several appropriate rehabilitative and preventive programs to speed up the rehabilitation process of the students who tested positive for drugs. The researcher's main task, on the other hand, was to Rafidah Aga Mohd Jaladin, m/s

71 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area examine every single completed form collected by the PPDa Unit officers (with the permission of the PPDa Unit) and to carry out data analysis on these records. RESULTS AND DISCUSSION Generally, the results showed mixed findings. The main predictors for drug abuse were found to be the gender and age factors but the other predictor variables were inconclusive. Gender Based on the examination of records, it was found that all drug abuse offenders were male students. This finding is consistent with Jenkins's (1995) and Riley's (1987) findings, which suggest that males are more prone to commit drug abuse crime than females. It was argued that the gender differences in personality development could be the explanation for this finding (Papalia & Olds, 1998). Popular belief holds that boys and girls develop differently; that girls mature earlier and are more empathic, and that boys are more aggressive. But in 80 years of research about development, this belief has rarely been investigated scientifically. Now, a statistical analysis of 65 studies of personality growth involving 9000 participants has found that adolescent girls apparently do mature earlier in some ways than boys (Cohn, 1991). Thus, this concludes that adolescent males are in the high-risk group for drug abuse. Age Based on the records, it was found that there were three age groups among the drug abuse offenders: 15 year olds (25.58%), 16 year olds (39.53%), and 17 year olds (34.88%). The mean age for them was years old. This finding does not support the hypothesis, which predicts that older adolescents commit drug abuse more than the younger ones. The explanation for this finding could be the education system in Malaysia. In Malaysia, there are two major achievement examinations for secondary students: the Penilaian Menengah Rendah or PMR for Form Three students (aged 15 years old) and the Sijil Pelajaran Malaysia or SPM for Form Five students (aged 17 years old). These two examinations are important for students' academic placement and achievement. Thus, school authorities place special attention in monitoring the academics and discipline of these two age-groups. However, the Form Four students (aged 16 years old) are more relaxed because theirs is considered as the 'honeymoon year'. This Rafidah Aga Mohd Jaladin, m/s

72 JURNAL ANTIDADAH MALAYSIA indicates that the Form Four students get less attention from the school authorities as well as parents. Due to this, they spend more time with their peers and get easily influenced by them. Number of Siblings As for the number of siblings, there seems to be a bell-shaped pattern of findings to illustrate the family size of the drug abuse offenders. Figure 1 presents the details of this finding. Figure 1 : The Number of Siblings of The Drug Abuse Offenders Percentage (%) The finding was quite surprising and did not support the earlier hypothesis. Figure 1 depicts that there is a critical number of siblings (i.e., ranging from 4-6) that most drug abuse offenders have. Most of them have four to six siblings in the family. One explanation for this finding could be due to the family trend in today's society. Most big families in the urban area have only four to six children. Only a very small percentage of urban families have more than six children. Since a majority of these families have four to six children, there is a tendency that these children might get less supervision and parental control. Thus, there is a high tendency for them to abuse drugs. Parental Vocational Status Number of Siblings Based on the data, it was found that the drug abuse offenders have the following percentage distribution for parental vocational status: (1) only the father works (44.19%), (2) both parents work (32.56%), (3) only the mother works (11.63%), and (4) both parents do not work (9.30%). The finding did not support the hypothesis and did not present any specific Rafidah Aga Mohd Jaladin, m/s

73 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area pattern. Based on the record, it was hard to determine whether those students who reported that only the father works or only the mother works came from single-parent families or not. If they did, Jenkins (1995) has sufficient explanation to account for the high percentage of 44.19% and 11.63% (which totals up to 55.82%) (See Jenkins, 1995 for details). However, if this assumption is invalid, it is hard to draw any specific conclusion. Moreover, previous studies have shown that among the family variables, the largest coefficients were the bond between mother and child, followed by family drug problems. The bond between father and child, parental supervision, and family aggression were relatively weak predictors of adolescent drug use. This was unexpected because most researches show that parental supervision influences the likelihood of delinquency (Glueck & Glueck, 1950; Hirschi, 1995; Sampson & Lanb, 1993). House Location The finding for this variable is quite surprising and did not support the hypothesis. It was found that the majority of the drug abuse offenders lived at residential parks or Taman Perumahan (58.14%), followed by other dwellings such as flats (16.28%), squatters (11.63%), and villages (4.65%). This suggests that the house location itself does not determine the students' involvement in drug abuse. It is the quality of the neighborhood that makes a difference. The lifestyle of the city folks could be the explanation for this finding. In the city, people mainly live in terrace houses or flats. Most areas in the city have been developed into proper housing areas. The Taman Perumahan is mushrooming all over the city. Very few people live in other types of accommodation. Thus, the high percentage could be due to the high probability of people staying at Taman Perumahan. Hence, house location could also be the main predictor for the students' involvement in drug abuse. However, one can still explain the findings from the peer socialization perspective. One of the main reasons why students are involved in drug abuse is peer influence. Compared to other types of housing location, Taman Perumahan is the most common place for students to socialize. Hence, there is a high tendency for adolescent residents to meet deviant peer groups and to be involved in drug abuse. Overall, the findings indicated that it is the accessibility to peer socialization that predicts students' involvement in drug abuse rather than the location of the house itself. Rafidah Aga Mohd Jaladin, m/s

74 JURNAL ANTIDADAH MALAYSIA Home Environment This is another surprising finding revealed by the data. Contrary to the earlier hypothesis, it was found that most drug abuse offenders reported that they evaluated their home environment as good (53.49%) and satisfactory (23.26%). This means that most of them are satisfied with their living conditions. Hence, it strengthens the earlier contention that most students commit drug abuse not only because of the environmental factors but due to their personal traits too. In addition to the above findings, it was also reported that the reasons given by these students to account for their involvement in drug abuse were consistent with the reasons given by previous studies. The characteristics of the self such as impulsiveness, curiosity, and the desire for sensation, serve as the roots of delinquency (Papalia & Olds, 1998). The characteristic of the environment refers to peer pressure or to escape from overwhelming problems, and thereby endanger their present and future physical and psychological health. Of course, these characteristics do not necessarily cause drug abuse, but they are fairly reliable predictors of it. It can be deduced that when there are more risk factors present; the probability of an adolescent or a young adult to abuse drug becomes greater. Surprisingly, two participants reported that their family was the reason why they were involved in drugs: family conflict (after a quarrel between the participant and his father) and family history of drug problems (the participant's brother was a drug addict). This finding is consistent with Hawkins et al. (1992) who identified four family characteristics that influence the likelihood of adolescent drug use: (a) low levels of bonding with the family; (b) poor and inconsistent family management practices; (c) family conflict, and (d) family alcohol and drug behavior and attitude. The implication of this heavily relies on the role of the family in preventing the use and abuse of drugs among secondary school students. The data also contained information on the accessibility to drugs. Most participants reported that they get drugs mainly from their friends, i.e., they either bought it from their friends or shared it with them. Consistent with other researches, this study found that those who used drugs tended to have close friends who also used drugs. Perhaps the Rafidah Aga Mohd Jaladin, m/s

75 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area critical question for prevention is how to minimize the involvement of students with their drug-abusing peers. Previous studies indicated that students who were religious tended not to have close friends who use drugs (Bahr and Maughan, 1998). Thus, religious involvement may be an important protective factor that helps to decrease the probability of a young person to choose friends who are drug addicts. This is important because religion has been ignored in the research on risk and protective factors. CONCLUSION Although a great majority of adolescents do not abuse drugs, a significant minority does. This study has illustrated the demographic determinants that could predict the high-risk group among the secondary school students in some areas in Wilayah Persekutuan. The study showed that male students aged 16 years old are more vulnerable than others to abuse drugs. Thus, gender and age are the main predictors for supervision and prevention purposes. The study also showed that those who come from fairly large families with four to six siblings are also at risk. On the other hand, the house location, the parents' vocational status, and the home environment do not have strong predictive values. However, these factors are also important to be considered for prevention purposes. The present study also highlights the importance of close supervision by parents and teachers in handling drug abuse problems among secondary school students. The aspect that needs closer supervision is peer socialization. The study also has some limitations: 1. The finding is limited by the number of items permissible to be revealed to the public; 2. The questionnaire is not comprehensive enough to provide students' demographic details; 3. Some of the items are not clear in meaning, for example, items 22 and 26; and 4. The sample size is insufficient to draw conclusions on the population. Rafidah Aga Mohd Jaladin, m/s

76 JURNAL ANTIDADAH MALAYSIA Thus, it is recommended that future researches should address these limitations and perhaps also consider the following suggestions for improvement: 1. To interview some of the drug abuse offenders in order to substantiate the findings and to get data from a different perspective; 2. To investigate the supervision records of absenteeism and misconduct behaviors of the drug abuse offenders in their respective schools; 3. To investigate and establish the reliability and validity of the questionnaire; and 4. To use a qualitative approach in the study. Rafidah Aga Mohd Jaladin, m/s

77 Demographic Determinants of Drug Abuse Problem Among Secondary School Students in an Urban Area REFERENCES Bah, S.J, & Maughan, S.L. (1998). Family, religiosity, and the risk of adolescent drug use. Journal of Marriage and the Family, 60(4), Brody, G.H., Stoneman, Z., & Flor, D. (1995). Linking family processes and academic competence among rural African American youths. Journal of Marriage and the Family, 57, Brown, J.L. (1987). Hunger in the U.S. Scientific American, 256(2), Cohn, L.D. (1991). Sex differences in the course of personality development: A meta-analysis. Psychological Bulletin, 109, Dzuraidi Ibrahim (2002). Ceramah Penyalahgunaan Dadah. Fakulti Pendidikan, Universiti Malaya. Dusek, J.B. (1987). Adolescent Development and Behavior. Eaglewood Cliffs, NJ: Prentice-Hall. Ee Ah Meng (1997). Perkhidmatan Bimbingan dan Kaunseling (2 nd Ed). Shah Alam: Fajar Bakti Sdn. Bhd. Egbuono, L., & Starfield, B. (1982). Child health and social status. Pediatrics, 69(5), Felner, R.D., Brand, S., Dubois, D.L., Adan, A.M., Mulhall, P.F., & Evans, E.G. (1995). Socioeconomic disadvantage, proximal environmental experiences, and socioemotional and academic adjustment in early adolescence: Investigation of a mediated effect. Child Development, 66, Glueck, S. & Glueck, E. (1950). Unraveling Delinquency. New York: Commonwealth Fund. Gottfredson, M. & Hirschi, T. (1990). A General Theory of Crime. Stanford, CA: Stanford University Press. Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse programs. Psychological Bulletin, 112(1), Hirschi, T. (1995). The family. In J.Q. Wilson, J. Petersilia (Eds.), Crime (pp ). San Francisco: ICS Press. Jenkins, P.H. (1995). School delinquency and school commitment. Sociology of Education, 68, Rafidah Aga Mohd Jaladin, m/s

78 JURNAL ANTIDADAH MALAYSIA Papalia, D.E. & Olds, S.W. (1998). Human Development (7 th ed.). USA: McGraw- Hill. Riley, D. (1987). Sex Differences in Teenage Crime: The Role of Lifestyle (Home Office Research and Planning Unit, No.20). London: Her Majesty s Stationery Office. Sampson, R. & Laub, J. (1993). Crime in the Making: Pathways and Turning Points Through Life. Cambridge, MA: Harvard University Press. Santer, L.J. & Stocking, C.B. (1991). Safety practices and living conditions of low income urban families. Pediatrics, 88(6), Sistem Maklumat Dadah Kebangsaan, NADI (2003). Maklumat Dadah Agensi Dadah Kebangsaan, Kementerian Dalam Negeri, Putrajaya. Starfield, B. (1991). Childhood morbidity: Comparisons, clusters, and trends. Pediatrics, 88(3), White, K.R. (1982). The relation between socioeconomic status and academic achievement. Psychological Bulletin, 91(3), Rafidah Aga Mohd Jaladin, m/s

79 Peranan Kerohanian Dalam Menangani Gejala Dadah PERANAN KEROHANIAN DALAM MENANGANI GEJALA DADAH Yuseri bin Ahmad Sapora bt. Sipon Marina Munira Abdul Mutalib 1 ABSTRAK Pelbagai pendekatan pencegahan dan pemulihan telah digunakan untuk menyelesaikan masalah penagihan dadah dan salah satu yang sering dibincangkan ialah pendekatan agama. Artikel ini membincangkan tatacara menangani masalah dadah dengan melihat kepada perspektif agama sebagai satu alternatif yang boleh memantapkan kerohanian generasi pewaris. Elemen ini sangat berperanan sebagai benteng sahsiah yang boleh menghalang individu daripada terjebak dengan masalah-masalah sosial hari ini. Antara perkara-perkara yang dihuraikan di dalam kertas kerja ini ialah peranan agama dalam kehidupan manusia, manusia sebagai khalifah Allah dan pemegang amanah, unsur-unsur yang membentuk manusia seperti unsur qalb (hati), aql, nafs, yang dilihat berperanan untuk menghalang manusia daripada terjebak dengan gejala ini dan cara-cara pembersihan jiwa melalui tingkatan-tingkatan nafs di dalam Islam. ABSTRACT A multitude of prevention and rehabilitation approaches have been used to solve the problem of drug addiction and one that was frequently discussed is the religious approach. This article discusses the method to solve the drug problem by adopting views from the religious perspective as an alternative that is capable to strengthen the spirituality of the present generation. This element plays an important role as a deterrant factor that can assist individuals from getting involved in social ills. The issues presented in this article include the role of religion in human lives; humans as the Caliph of 1 Universiti Sains Islam Malaysia Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

80 JURNAL ANTIDADAH MALAYSIA Allah on earth representing those who can be trusted; fundamental elements that form humans such as qalb, aql and nafs, of which are seen as taking on the role of preventing humans from getting involved with these social problems. Also discussed here are the methods for spiritual cleansing through the levels of nafs in Islam. PENGENALAN Masalah dadah adalah masalah sejagat dan satu-satunya masalah sosial paling rumit yang sedang dihadapi oleh negara. Sehubungan itu, pihak kerajaan telah membelanjakan beratus-ratus juta ringgit dalam memerangi gejala penagihan dadah namun masih lagi belum menampakkan keberkesanan yang positif. Walaupun terdapat organisasi-organisasi yang sentiasa berkempen untuk pencegahan dadah tetapi masalah ini masih menjadi masalah utama negara. Apa yang paling membimbangkan ialah penyalahgunaan dadah dalam kalangan remaja semakin berleluasa dan masih belum dapat diselesaikan. Di samping itu, penyalahgunaan dadah berkait rapat dengan bermacam penyakit sosial seperti pelacuran, lepak dan perjudian. Perkara inilah yang banyak menggugat dan memudaratkan keadaan sesebuah negara sama ada dalam bidang ekonomi, sosiobudaya, politik mahupun keselamatan. Gejala sosial negatif yang berlaku akhir-akhir ini benar-benar mencabar emosi dan intelek mereka yang prihatin terhadap nilai-nilai kemanusiaan. Hampir setiap pakar dalam pelbagai bidang telah memberikan pandangan mengenai cara-cara mengatasi gejala sosial ini. (Muhammad Yusuf Khalid, 2005, 82) Masing-masing berusaha untuk memperlihatkan melalui kajian-kajian yang dijalankan, faktorfaktor utama yang menyumbang kepada masalah ini serta bagaimana usaha atau cara-cara untuk menghalang gejala ini daripada terus menular dalam masyarakat kita. Yusuf (2005) ada menyatakan di dalam tulisannya antara faktor penyumbang kepada masalah sosial yang kian meruncing ini adalah disebabkan oleh kurangnya penghayatan agama terutamanya dalam kalangan generasi muda dan belia yang menjadi penyumbang utama kepada statistik masalah sosial termasuk penyalahgunaan dadah. Ternyata, semua pihak amat prihatin terhadap musuh nombor satu negara ini dan pelbagai usaha telah direncana dan dilaksanakan untuk melihat satu generasi yang bebas daripada belenggu dadah. Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

81 Peranan Kerohanian Dalam Menangani Gejala Dadah Berdasarkan Laporan Buletin Dadah AADK Bil:1.2006, sepanjang suku pertama tahun 2006 iaitu dari Januari hingga Mac, seramai 7,001 orang penagih dadah telah dikesan. Mereka terdiri daripada 2,933 orang (41.89%), penagih baru dari 4,068 orang (58.11%) penagih berulang. Keseluruhannya berlaku peningkatan sebanyak 1.32% berbanding tempoh masa yang sama tahun lalu (6,910 orang). Taburan jumlah penagih yang dikesan menunjukkan, Kedah mencatatkan bilangan penagih paling ramai dikesan berbanding negeri-negeri lain iaitu seramai 1,282 orang diikuti Pualau Pinang (1,086), Perak (1,000), Kelantan (843) dan WP Kuala Lumpur (756). Jumlah penagih terkumpul yang direkodkan oleh Agensi Antidadah Kebangsaan sejak tahun 1988 hingga Mac 2006 adalah seramai 292,696 orang iaitu kira-kira 1.10% daripada jumlah penduduk Malaysia. Jadual 1 : Taburan Penagih yang Dikesan Mengikut Negeri Pada Tahun 2006 Negeri Bil Kedah 1282 Pulau Pinang 1086 Perak 1000 Kelantan 843 WP K.Lumpur 756 Johor 565 Selangor 459 Melaka 210 Sarawak 210 Pahang 201 N.Sembilan 179 Terengganu 86 Perlis 67 Sabah 57 WP Labuan - Jumlah 7001 Sumber : Buletin Dadah AADK Bil:1/2006 Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

82 JURNAL ANTIDADAH MALAYSIA Jadual 2 : Penagih Dadah yang Berdaftar dengan Agensi Dadah Kebangsaan ( ) Negeri Jumlah Jumlah Ratio Penagih Penagih Populasi Kepada Populasi (1:1 000) Johor 24,965 2, Kedah 12,605 1, Kelantan 15,297 1, Melaka 7, Negeri Sembilan 11, Pahang 13,537 1, Perak 26,941 2, Perlis 2, Pulau Pinang 26,941 1, Sabah 8,422 2, Sarawak 2,144 2, Selangor 27,488 4, Terengganu 10, WPKL 30,783 1, Sumber : NADI 2002 PROFIL PENAGIH Profil penagih-penagih yang dikesan bagi tempoh Januari hingga Mac 2006 adalah 97.94% adalah lelaki dan sebanyak 72.73% terdiri daripada kaum Melayu. Majoriti iaitu sebanyak 69.60% terdiri daripada golongan belia dan majoriti adalah berumur antara tahun % berpendidikan hingga sekolah menengah di mana 89.74% mempunyai pekerjaan yang kebanyakan adalah buruh am % mengakui mula terjebak dengan dadah disebabkan oleh pengaruh kawan. Faktor-faktor lain yang menyebabkan individu terlibat dengan dadah ialah untuk keseronokan, perasaan ingin tahu, rangsangan, tahan sakit dan tekanan jiwa. Kesan Secara ringkasnya, dadah menunjukkan kesan ketagihan dalam bentuk pergantungan fizikal, mental dan emosi. Kesan fizikal dapat dilihat Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

83 Peranan Kerohanian Dalam Menangani Gejala Dadah daripada beberapa aspek. Ini termasuk pengaruhnya terhadap sistem penting pada tubuh manusia seperti sistem pernafasan, saraf, jantung, metabolisme dan otot-otot. Dengan lain perkataan, keadaan mereka tidak terurus, proses kehidupan akan terjejas dan menjadi tidak normal. Kadar pernafasan menjadi lebih pendek dan perlahan, kadar degupan jantung berkurangan, tubuh menggigil akibat penurunan kadar metabolisme badan. Selain daripada itu, mata penagih akan menjadi merah dan kuyu serta serta badan akan terjejas (Dzulkifli Abdul Razak, 2002). Kesan Mental dan Emosi Kesan ini lazimnya dipanggil kesan psikologi iaitu kesan akibat pengaruh dadah pada otak dan minda. Ini termasuk rasa seronok dan khayal (euphoria). Mereka seakan-akan tidak berpijak di alam nyata. Pada masa yang sama seseorang itu hilang kawalan diri dan pemikiran. Sekiranya bekalan dadah tidak diperoleh mereka akan berasa keluh kesah, gian dan amat menderita. Penagih boleh bertindak ganas dan hilang kawalan emosi. Apabila rasa ketagih berterusan, penagih akan mungkin mengalami gangguan mental dan menjadi tidak waras. Penagih mula melakukan sesuatu yang tidak masuk akal yang berlawanan dengan tatasusila dan peradaban masyarakat. Kesan Sosial Dari kesan sosial pula, kebanyakan penagih akan hilang minat dan tidak mempedulikan tanggungjawab terhadap pekerjaan, keluarga serta masyarakat sekeliling. Prestasi dan disiplin kerja merosot, tingkah laku dan sikap berubah daripada apa yang biasa diamalkan. Mereka juga tidak menghiraukan keselamatan diri. Kebanyakan penagih tidak tinggal bersama keluarga. Mereka hidup di tempat-tempat yang tersorok atau terpencil untuk memudahkan mereka menggunakan dadah. PERANAN AGAMA DALAM KEHIDUPAN MANUSIA Agama ISLAM yang diturunkan kepada manusia bersifat rahmatan lil alamin iaitu penganugerahan rahmat yang tidak ternilai kepada sekalian makhluk ciptaan Allah sepertimana yang dikhabarkan di dalam al-quran, Surah al-anbiya ayat 107 yang bermaksud Dan tiadalah Kami mengutuskan Engkau (Wahai Muhammad), melainkan untuk menjadi rahmat bagi seluruh alam. Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

84 JURNAL ANTIDADAH MALAYSIA Rahmat ditakrifkan sebagai satu kebaikan yang berterusan. Malah sebagai Muslim kita percaya bahawa rahmat ini akan berkekalan selagi mana manusia itu berada utuh di atas landasan agama. Maka, rahmat dan agama ternyata mempunyai satu rabitah yang tidak boleh dipisahkan sama sekali dalam hidup manusia. Sepertimana dinukilkan di dalam al-quran, Aku telah sempurnakan bagi kamu agama kamu, dan Aku telah cukupkan nikmatku kepada kamu, dan Aku telah redakan Islam itu menjadi agama untuk kamu. (Al-Maidah, 5: 3). Ini kerana agama berupaya membentuk dan menjadikan manusia lebih berdisiplin dan sentiasa akur kepada fitrah semula jadi yang sesuai dengan kehendak dan naluri seorang insan. Sebagai Muslim kita mengakui agama Islam adalah agama yang benar akan tetapi ramai saudara seislam kita yang mengalami krisis nilai yang sangat mendukacitakan. Sepatutnya Islam diturunkan untuk membimbing manusia ke jalan yang benar tetapi apa yang terjadi adalah sebaliknya. Ini adalah kerana Islam tidak dihayati dan tidak diamalkan, maka Islam tidak akan menjadi rahmat sebaliknya menjadi satu fenomena alam yang biasa seperti sejarah. (Muhammad Yusuf Khalid ) Malah, gejala sosial yang kian meruncing ini membuktikan bahawa lemahnya iman pemuda-pemudi kita akhirakhir ini serta kurangnya penghayatan kerohanian terhadap ajaran agama Islam itu sendiri. Hadis Nabi SAW riwayat Muslim ada menyebut bahawa; Seseorang tidak akan mencuri ketika dalam keadaan beriman, dan seseorang tidak akan berzina selagi mana dia beriman. Jika diamati hadis ini sedalamdalamnya bolehlah disimpulkan bahawa seseorang yang mempunyai penghayatan agama yang tinggi mampu menjadi benteng diri yang boleh menghalang seseorang itu daripada terjerumus dengan masalah krisis nilai dan keruntuhan akhlak. Fitrah manusia yang diciptakan juga mampu bertindak selari dengan kehendak Ilahi seperti mana ia diciptakan untuk mengenal siapa Penciptanya, seterusnya mendekatkan diri dan mengakui KetuhananNya (Muhammad Asad. 2003). Justeru, manusia yang lari atau terpesong daripada fitrah ini ialah manusia yang tidak kenal siapa Tuhannya malah terpesong jauh dengan fenomena-fenomena yang rosak nilainya serta jauh sekali diterima oleh akal fikiran dan perasaan seseorang manusia. Ini sesuai dengan kata-kata seorang ulama tersohor Islam Abu Hassan al-syaziliyy: Sesiapa berupaya mengenali dirinya serba Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

85 Peranan Kerohanian Dalam Menangani Gejala Dadah lemah, akan mengenali Tuhannya yang Maha Berkuasa, sesiapa yang mengenali dirinya akan mati, akan mengenali Tuhannya Yang Kekal Abadi, sesiapa yang mengenali dirinya sebagai makhluk yang diciptakan akan mengenali Tuhannya Yang Maha Pencipta. INSAN : KHALIFAH DAN PEMEGANG AMANAH ALLAH Allah berfirman di dalam surah al-ahzab, ayat 72 yang bermaksud Sesungguhnya Kami telah bentangkan amanah ini kepada langit dan bumi, tetapi ditolak dan mereka meminta belas kasihan, sebaliknya manusia menerima amanah ini walaupun sesungguhnya manusia jahil dan menzalimi diri mereka sendiri. Amanah iaitu tanggungjawab sebagai khalifah Allah inilah yang menyumbang kepada raison d etre iaitu sebab kewujudan dan kejadian manusia ketika diciptakan manusia pertama iaitu Adam a.s untuk mentadbir alam ini. Jelas di dalam ayat di atas, Allah telah menawarkan amanah ini kepada makhluk lain seperti langit, bumi dan gunung-ganang tetapi ternyata semuanya takut untuk memikulnya. Faruqi (1992) di dalam bukunya al-tawhid: Its Implications for Thought and Life menyebut; The trust or divine will, which no heaven and earth can realize is the moral law which demands freedom from the agent. In heaven and earth the will of God is realized with the necessity of natural law. (p.5) Amanah yang tidak mampu dipikul oleh makhluk lain ini ialah amanah meletakkan akhlak dan nilai di tempatnya dan menjadikan ia sebagai pedoman manusia di mana ia memerlukan sepenuh kebebasan dalam setiap tindakan manusia. Natijahnya, manusia diberi dua pilihan sama ada memilih jalan yang benar atau jalan yang tidak diredai oleh Tuhannya. Dan Kami telah menunjukkan kepadanya dua jalan, (jalan kebaikan untuk dijalaninya, dan jalan kejahatan untuk dijauhi)? (Al-Balad, 90 : 10) Sesungguhnya manusia diciptakan dengan tujuan yang satu iaitu memikul beban amanah yang telah dipilih oleh manusia sendiri dan ia bukanlah untuk sesuatu yang sia-sia. Kejadian Adam dan Hawa keduakeduanya juga membawa misi Tuhan iaitu bersama-sama merealisasikan amanah ini dan seterusnya bertindak sebagai khalifah Allah yang memakmurkan bumi ini dengan kalimah-kalimah Allah yang benar. Malah, pengusiran Adam dan Hawa ke muka bumi ini juga dilihat sebagai terkandung dalam ilmu Allah yang Maha Agung. (Ibrahim Zain, 1998) Pengurniaan amanah ini kepada manusia merupakan satu penghormatan dan kelebihan yang mana dapat dilihat sebelum manusia Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

86 JURNAL ANTIDADAH MALAYSIA diciptakan, Allah SWT telah pun meletakkan manusia di atas satu kedudukan yang amat mulia di sisinya. Sehinggakan para malaikat turut sama mempersoalkan kedudukan ini yang jelas digambarkan di dalam surah al-baqarah ayat 30 di mana Allah berfirman yang bermaksud, Bahawasanya Aku mengetahui apa yang engkau tidak ketahui. Ini juga menggambarkan betapa Allah memandang tinggi akan makhluk ciptaan- Nya ini iaitu manusia. TANGGUNGJAWAB MANUSIA Faruqi (1992) pernah menyebut bahawa, Since everything is created for a purpose the totality of being no less the realization of that purpose must be possible in space and time. (13) Oleh kerana manusia dijadikan untuk menunaikan satu tanggungjawab yang telah direncanakan, maka pelaksanaan kepada beban tugas itu mestilah sesuatu yang mampu dilaksanakan oleh manusia. Atau dengan kata lain, manusia dibekalkan dengan keupayaan-keupayaan ini. Justeru, melalui tindakan dan keupayaan inilah manusia akan dinilai, dan juga ia akan dipersoalkan di hadapan Tuhan yang Maha Agung. UNSUR KEROHANIAN Manusia dicipta oleh Allah SWT dengan mempunyai dua unsur yang utama. Selain jasad yang merupakan unsur zahir bagi manusia terdapat unsur lain yang lebih penting iaitu roh yang sebenarnya menjadi hakikat diri insan. Namun begitu terdapat juga beberapa istilah lain yang berkaitan dengan unsur roh ini seperti aql, nafs, dan qalb yang sebenarnya menunjukkan kepada zat diri yang sama tetapi berbeza dari segi peringkat seseorang itu berada. Sebagaimana jasad yang perlu kepada penjagaan dan makanan agar ia menjadi sihat dan bertenaga, begitu jugalah roh ini memerlukan penjagaan dan rawatan agar ia sentiasa segar dan bersifat positif dalam menjalani kehidupan seharian. Sebenarnya kekuatan kerohanian inilah yang paling diperlukan oleh manusia bagi mengawal dirinya agar tidak terjebak ke dalam perkara-perkara negatif seperti penagihan dadah contohnya. Justeru itu kita perlu mengenal diri sendiri dengan mengenali istilah-istilah yang disebutkan tadi supaya ia dapat digunakan sebagai benteng dalaman bagi mengekang gejala sosial yang kini semakin parah. ROH Kita tidak didedahkan menerusi sumber syariat mengenai hakikat sebenar roh. Di dalam al-quran Allah SWT berfirman: Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

87 Peranan Kerohanian Dalam Menangani Gejala Dadah Surah al-isra, 17: 85 Terjemahannya.. dan mereka bertanya kepada kamu tentang roh, katakan bahawa roh itu adalah urusan Tuhanku. Menurut Imam al-ghazali roh adalah Latifah 2 yang dengannya manusia dapat memahami dan mengerti, ia sesuatu yang menakjubkan yang datang daripada Tuhan dan tidak mampu segala akal untuk memahami hakikatnya. (al-ghazali jilid 3 : 5). Oleh kerana roh adalah sesuatu yang tidak dijelaskan hakikatnya oleh al-quran dan hadis maka para ulama membataskan perbahasan mereka tentang roh ini kepada dua sudut iaitu: 1. Mengembalikan roh kepada pengetahuannya yang asal 2. Mengembalikan kesempurnaan pengabdiannya kepada Tuhannya Pada asal kejadian, roh sebenarnya mengenal Allah sebagai pencipta dan mengakui kehambaannya pada Allah SWT. Namun setelah ia bercampur dengan jasad dan bergelumang dengan anasir-anasir luar yang mendatang maka pengetahuan dan kehambaannya pada Tuhan itu semakin hilang akibat faktor persekitarannya. Ini sebagaimana yang disabdakan oleh Rasulullah SAW : Riwayat al-bukhari Maksudnya : Manusia dilahirkan dalam keadaan fitrah (bersih, suci, kenal Tuhan) maka kedua-dua ibu bapanyalah yang mencorakkannya sama ada menjadikannya Yahudi, Nasrani atau Majusi). Faktor-faktor luaran itu mula mempengaruhi roh dan akibatnya roh itu semakin menjauh daripada pengetahuan dan kehambaan asalnya pada Allah SWT. (Said Hawwa, 1999: 43) Apabila roh semakin jauh daripada Allah SWT maka ia sebenarnya semakin mendekat kepada hawa nafsunya yang sentiasa mendorong 2 Istilah Sufi: Makna asalnya adalah kelembutan. Setiap isyarat yang terlalu halus untuk difahami yang tidak dapat diungkapkan dengan kata-kata seumpama ilmu rasa. (al-jurjani. 1991) Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

88 JURNAL ANTIDADAH MALAYSIA melakukan dosa dan maksiat. Oleh itu untuk membolehkan seseorang itu meninggalkan kejahatan dan maksiat maka perlulah rohnya dikembalikan kepada asal pengetahuan dan kehambaannya pada Allah SWT. Untuk mengembalikan roh pada asalnya memerlukan kepada mujahadah dan perlu diikuti jalannya yang sudah digariskan sendiri oleh Allah SWT di dalam al-quran. Said Hawwa dalam kitabnya Tarbiyyatuna al-ruhiyyah menjelaskan bahawa jalan untuk mengembalikan roh pada asalnya adalah dengan memiliki ilmu yang sahih, bergaul dengan ahli ilmu dan zikir pada Allah SWT. Ilmu yang sahih yang perlu diketahui ialah ilmu tentang sifatsifat Allah SWT yang maha sempurna dan ilmu tentang melakukan ibadah dengan ikhlas pada Allah. Untuk memperolehi ilmu ini maka perlulah bertanya pada ahlinya. Firman Allah SWT: Surah al-furqan, 25: 59 Maksudnya: Maka bertanyalah tentangnya (Allah) kepada yang lebih mengetahui. Mengenai zikir pula ia amat diperlukan kerana sabda Rasulullah SAW di dalam sebuah hadis Qudsi bahawa Allah SWT berfirman : Riwayat al-bukhari dan Muslim Maksudnya: dan Aku (Allah) bersama dengannya (hamba) apabila dia berzikir kepadaku. Maka Allah SWT akan bersama-sama dengan hamba yang berzikir mengingatinya. Kesannya adalah sangat banyak, antaranya ia akan dipelihara oleh Allah dan terjaga daripada tersilap dan tergelincir dalam kehidupan. QALB Perkataan Qalb bermaksud hati. Perkataan ini digunakan untuk menunjukkan hati yang zahir iaitu jantung manusia, dan hati yang bukan zahir iaitu hati nurani manusia. Dalam al-quran perkataan qalb ini banyak disebut oleh Allah dan apabila disebut ia bermaksud hati yang Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

89 Peranan Kerohanian Dalam Menangani Gejala Dadah bukan zahir. Qalb diertikan sebagai Latifah Rabbaniyyah atau unsur halus yang bersifat rabbani atau yang dibangsakan kepada rabbani dan mempunyai hubungan dengan jantung hati jasmani. (Mohd Sulaiman Yasin : 195) Dalam hadis Rasulullah SAW menjelaskan bahawa hatilah yang menjadi penentu seseorang itu menjadi baik atau jahat. Menurut Islam hati inilah yang menjadikan manusia hidup dengan kehidupan yang sebenar dan ia jugalah yang menjadikan manusia sebenarnya mati dalam hidupnya. Hati juga menjadi tempat bagi iman, taqwa, ikhlas, amanah dan tempat mengambil peringatan. Sebaliknya hati juga menjadi tempat kekufuran dan kemunafikan. Ia juga menjadi tempat bagi segala sifat terpuji dan sifat tercela. Justeru, hati manusia boleh jadi ia sakit atau ia sihat. Di antara penyakit hati ialah kekufuran, kesesatan, kemunafikan, kesangsian kepada tanda-tanda kebenaran dan kesempurnaan Allah, berat hati daripada berjihad di jalan Allah, kerakusan hati kepada maksiat, kederhakaan kepada perintah Allah, bersifat dengan sifat-sifat tercela seperti takabbur, hasad, riya, marah, bakhil, khianat, hubbul jah, hubbul mal, mengikut hawa nafsu, buruk sangka dengan Allah, putus asa daripada rahmat Allah, memusuhi dan membenci ulama dan lainlain. Manakala hati yang sihat pula sudah tentulah hati yang tidak mempunyai penyakit-penyakit yang telah disebutkan. Hati yang sihat disebut sebagai hati yang salim (sejahtera). Di antara sifat hati yang salim ialah hati yang sentiasa kembali kepada Allah. Hati orang yang kembali kepada Allah ialah mereka yang mempunyai sifat seperti rasa takut kepada Allah, penyerahan kepada Allah, tawakal, mengingati ayat-ayat Allah, bersih daripada bentuk kesyirikan dan penyembahan taghut, bertaqwa dan yang paling asas sekali ialah tetap mendirikan solat dan rukun-rukun Islam yang lain. (Mohd Sulaiman Yasin, 1992 : 200) Oleh itu bagi merawat hati yang berpenyakit, sebahagian daripada ulama merumuskan terdapat lima penawar iaitu: Membaca al-quran Mengosongkan perut (puasa) Qiyamullail Memohon keampunan dan rahmat di waktu sahur Menduduki majlis para solihin Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

90 JURNAL ANTIDADAH MALAYSIA AQL Menurut Imam al-ghazali aql adalah sumber bagi ilmu dan asas ilmu. Maka ilmu dinisbahkan kepada aql adalah seumpama buah bagi pokok, atau cahaya bagi matahari, atau melihat bagi mata. Justeru, salah satu maksud aql yang ditakrifkan oleh al-ghazali ialah mengetahui hakikat sesuatu perkara. (al-ghazali,1987, j1 : 5). Takrifan seperti ini adalah merujuk kepada hasil daripada sesuatu perkara itu. Maka ilmu itu adalah hasil daripada kewujudan akal yang mana dengan ilmu itu manusia boleh membezakan mana yang baik dan mana yang buruk, seterusnya memilih untuk melakukan yang baik atau yang buruk. Pada peringkat ini seseorang manusia itu selalunya akan berperang dengan nafsunya dalam memilih mana yang mahu dibuat, kerana kemahuan akal yang dibantu oleh ilham malaikat itu mahu melakukan kebaikan tetapi kemahuan nafsu yang disokong pula oleh was-was syaitan mahukan sebaliknya. Dalam keadaan sedemikian sekiranya seseorang itu menggunakan daya akal untuk melawan, mengawal dan bermujahadah terhadap hawa nafsunya maka hatinya akan menjadi tempat penurunan malaikat untuk mencampakkan ilham yang memberikan kebaikan kepadanya sama ada dalam bentuk peringatan, panduan atau makluman. (Mohd Sulaiman Yasin, 1992: 191) Ulama juga membahagikan aql kepada dua jenis iaitu aql taklifi dan aql syar i. Aql taklifi (akal yang menerima bebanan hukum) dimiliki oleh semua manusia selagi ia tidak gila, dan dengan adanya akal itu maka manusia menjadi mukallaf. Ini adalah peringkat aql yang paling rendah. Aql syar i pula ialah aql yang dimiliki oleh manusia yang mampu mengawal nafsunya kepada taat pada Allah, di samping mengenal Tuhannya dan tunduk kepadanya. Dalam keadaan manusia ini, berlaku pertembungan antara kemahuan nafsu dan kemahuan akalnya maka apakah yang seharusnya dia buat untuk menjauhkan dirinya daripada maksiat tersebut. Said Hawwa menjelaskan dalam masalah ini, katanya Terdapat beberapa perkara, sama ada dia meningkatkan cahaya hatinya, meninggikan kejiwaannya, mengikuti jalan yang betul untuk memenuhi syahwatnya dalam batas-batas yang dibenarkan, ataupun dia mengendurkan dorongan syahwatnya dengan cara latihan seperti mengawal pemakanan, memenatkan tubuh badannya, mengurangkan makan, Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

91 Peranan Kerohanian Dalam Menangani Gejala Dadah menjauhkan diri daripada faktor-faktor yang menaikkan nafsu dan sebagainya, semua itu adalah sebahagian daripada rawatan bagi Muslim mengatasi maksiat, dan menang melawan maksiat itu sebenarnya adalah aql. (Said Hawwa, 1999: 49) Inilah aql syar i yang perlu ada pada diri setiap Muslim bagi mengatasi maksiat. NAFS Kalimah ini selalunya merujuk kepada hawa nafsu yang mengajak kepada kejahatan. Imam al-ghazali menjelaskan bahawa kalimah ini mempunyai dua pengertian. Yang pertama ia bermaksud daya marah dan syahwat yang ada pada manusia. Penggunaan ini sering digunakan oleh ahli tasawuf kerana mereka memaksudkan dengan nafs itu ialah asal yang menghimpunkan segala sifat-sifat mazmumah pada manusia. Contohnya mereka mengatakan mestilah ada mujahadah nafsu dan mematahkannya. Pengertian kedua pula ialah Latifah yang menjadikan manusia itu pada hakikatnya. Ia adalah diri manusia dan zatnya. (al-ghazali, 1987, jilid 3: 5) Pengertian ini membawa maksud bahawa manusia yang sebenarnya adalah pada nafs (diri)nya, bukan pada jasadnya. Adapun jasad hanyalah alat yang akan patuh pada segala kemahuan nafsnya. Peringkat-peringkat Nafs Seperti yang telah dijelaskan bahawa hakikat manusia yang sebenarnya adalah pada diri nafsnya, semakin tinggi tahap nafsnya itu maka semakin tinggilah tahap kemuliaan seseorang, sebaliknya semakin rendah tahap nafsnya maka semakin rendahlah tahap kemuliaannya. Justeru, para ulama membahagikan nafs kepada beberapa peringkat. Hanya disebut di sini empat yang utama sahaja iaitu: Nafs Ammarah Nafs Lawwamah Nafs Mulhimah Nafs Mutma innah 1. Nafs Ammarah - Ini adalah peringkat nafs yang paling rendah sekali. Bahasa Melayu menyebutnya sebagai nafsu amarah. Al-Quran menyifatkan peringkat ini sebagai peringkat yang menyuruh kepada kejahatan semata. Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

92 JURNAL ANTIDADAH MALAYSIA Firman Allah SWT: Surah Yusuf, 12: 53 Maksudnya : Sesungguhnya nafsu itu sentiasa menyuruh kepada kejahatan. Pada peringkat ini diri insan itu telah dikuasai sepenuhnya oleh unsur kejahatan dan kerendahan sehingga manusia itu menjadi hamba kepada hawa nafsunya. Malah dia tidak berasa apa-apa sesalan di atas kejahatan yang dilakukannya. Pada peringkat ini seseorang perlu bermujahadah melawan nafsu syahwahnya dengan mendidik nafsunya supaya ia meningkat ke peringkat yang kedua iaitu nafs lawwamah. 2. Nafs Lawwamah Firman Allah SWT: Surah al-qiyamah, 75: 2 Maksudnya : Aku bersumpah dengan diri yang mencela. Dinamakan dengan Lawwamah kerana diambil daripada ayat Quran di atas. Pada peringkat ini diri nafs insan itu sudah meningkat daripada yang pertama kerana pada peringkat ini seseorang yang melakukan dosa akan berasa menyesal di atas perbuatannya. Dirasakan dalam dirinya semacam ada sesuatu yang mengutuk dan mencela. Adanya suara kutukan atau celaan dari dalam diri ini menunjukkan bahawa nafsnya masih hidup, walaupun berpenyakit tetapi penyakit itu masih belum parah menjadi barah, dan masih menerima rawatan dan pemulihan melalui usaha tazkiyah untuk kembali sembuh dan sihat. (Mohd Sulaiman Yasin, 1992: 189) 3. Nafs Mulhimah Dinamakan Mulhimah (yang memberi ilham) berdasarkan firman Allah SWT dalam surah al-syams ayat 8: Maksudnya: Serta mengilhamkannya (diri) jalan yang membawa kepada kejahatan dan yang membawanya kepada bertaqwa. Ayat ini menjelaskan bahawa diri manusia boleh menerima suatu saranan dalam dirinya sama ada yang berunsur kejahatan atau berunsur Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

93 Peranan Kerohanian Dalam Menangani Gejala Dadah kebaikan. Peringkat ini adalah lebih baik daripada peringkat kedua kerana kebarangkalian seseorang itu melakukan dosa tidak begitu kuat. Maksudnya hati yang menjadi markas bagi nafs manusia sentiasa menjadi tempat pertarungan antara lintasan malaikat dan lintasan syaitan. Hanya berbeza dari segi kuat atau lemahnya salah satu daripada dua unsur tersebut. Kuat atau lemahnya adalah bergantung kepada sejauh mana kuat atau lemahnya mujahadah kita untuk menentang hawa nafsu, dan untuk mempergunakan akal bagi memikirkan kebenaran Allah dan ayatayatnya. (Mohd Sulaiman Yasin, 1992 : 192) 4. Nafs Mutma innah Ia bermaksud jiwa yang tenang. Inilah peringkat nafs yang ingin dicapai oleh oleh manusia hasil daripada mujahadahnya melawan nafsu. Pada peringkat ini nafs seseorang itu akan mudah terasa dengan kesalahan dosa. Ukuran dan timbangan ke atas sesuatu amalan kebaikan semakin halus. Ketenangannya bukan sahaja dinikmati oleh dirinya tetapi juga oleh orang sekelilingnya. Peringkat ini tidak dapat dirasakan melainkan setelah diri insan merasakan seperti mana yang disebutkan oleh Mohd Sulaiman Yasin, (1992: 192) Tenang dengan hukum-hukum Allah dan manhajnya Tenang dengan qada dan taqdirnya Tenang dengan mengingati Allah Khusyuk dalam ibadah Menghayati konsep kehambaan diri kepada Allah Sentiasa kembali pada Allah Hatinya sihat daripada segala penyakit-penyakitnya Firman Allah SWT: Surah al-fajr, 89: Maksudnya: Wahai jiwa yang tenang, kembalilah kepada Tuhanmu dengan hati yang puas lagi diredhainya. KAITAN PERINGKAT NAFS DENGAN ISTILAH SEBELUMNYA Apabila diteliti keempat-empat peringkat nafs ini maka didapati ia tidak terkeluar daripada lingkungan istilah-istilah lain yang telah dijelaskan sebelum ini iaitu aql, qalb dan roh. Penjelasannya adalah seperti berikut; (Mohd Sulaiman Yasin, 1992: 194) Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

94 JURNAL ANTIDADAH MALAYSIA 1. Apa yang dimaksudkan dengan al-nafs (nafsu) dalam istilah ini ialah diri insan yang tertumpu kepada keinginan (syahwah) dan hawa nafsunya yang rendah. Inilah dia yang dinamakan Nafs Ammarah. 2. Apa yang dimaksudkan dengan aql pula ialah diri insan yang telah dikawal daripada kebebasan keinginan nafsunya dan dikekang dengan tali syariat. Walaupun demikian ia masih dipengaruhi oleh nafsu rendahnya. Ini adalah Nafs Lawwamah. 3. Manakala qalb pula adalah diri insan yang telah agak tenang daripada nafsu kerendahan dan kejahatan tetapi masih dalam perubahan (bolak-balik) antara lalai dan sedar. Cahaya dalam dirinya sudah mula memancar. Ini adalah Nafs Mulhimah. 4. Akhirnya istilah roh merupakan keadaan diri insan yang sudah meningkat kepada sifat damai dan tenang, damai kembali kepada Allah dan tenang dengan mengingatinya. Ia adalah Nafs Mutma innah. RAWATAN UNTUK KELUH KESAH DAN PEMBERSIHAN HATI Al-Quran menjelaskan bahawa manusia dicipta dalam keadaan keluh kesah. Akibat keluh kesah itulah banyak berlakunya perlakuan salah dan tidak bermoral termasuklah penagihan dadah. Lalu rawatan kepada keluh kesah itu dijelaskan sendiri oleh Allah SWT sebagai kemudahan bagi manusia untuk mengikutinya. Firman Allah dalam surah al-maarij ayat 19-35: Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

95 Peranan Kerohanian Dalam Menangani Gejala Dadah Maksudnya: Sesungguhnya manusia dicipta bersifat keluh kesah lagi kikir. Apabila ia ditimpa kesusahan ia berkeluh kesah. Dan apabila mendapat kebaikan ia amat kikir, kecuali orang yang mengerjakan solat, yang mereka itu tetap mengerjakan solatnya, dan orang-orang yang dalam hartanya tersedia bahagian tertentu, bagi orang (miskin) yang meminta dan orang yang tidak mempunyai apa-apa (yang tidak mahu meminta), dan orang-orang yang mempercayai hari pembalasan, dan orang-orang yang takut terhadap azab Tuhannya, kerana sesungguhnya azab Tuhan mereka tidak dapat orang berasa aman (daripada kedatangannya), dan orang-orang yang memelihara kemaluannya, kecuali terhadap isteri-isteri mereka atau hamba-hamba yang mereka miliki, maka mereka dalam hal ini tiada tercela. Barangsiapa mencari yang sebalik itu maka mereka itulah orang-orang yang melampaui batas, dan orang-orang yang memelihara amanahamanah dan janjinya, dan orang-orang yang memberikan kesaksiannya, dan orang-orang yang memelihara solatnya, mereka itu (kekal) di syurga lagi dimuliakan. Said Hawwa menjelaskan bahawa sifat keluh kesah ini (yang utamanya terlalu resah ketika musibah, dan tidak bersyukur ketika dapat nikmat) tidak dapat diatasi oleh manusia melainkan apabila terhimpun padanya sifat-sifat berikut: solat, infaq, membenarkan hari akhirat, rasa gerun dengan azab Allah, memelihara kemaluan, dan memberikan kesaksian dengan penuh kebenaran dan keadilan. Sesiapa yang terhimpun padanya sifat-sifat ini hatinya akan terlepas daripada penyakit dan mendapat sihat. Apabila seseorang benar-benar mencapai sifat-sifat ini maka secara automatiknya sifat keluh kesah akan hilang daripadanya. (Said Hawwa, 1999: 155) Para ulama juga telah menggesa agar kita melakukan perkaraperkara berikut sebagai amalan harian kita bagi mempertingkatkan tahap nafs kita ke tahap yang lebih tinggi: 1. Solat berjemaah, termasuk Solat Rawatib, Qiyamullail dan Solat Duha 2. Istighfar tidak kurang 100 kali 3. Membaca: Tidak kurang daripada 100 kali. Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

96 JURNAL ANTIDADAH MALAYSIA 4. Selawat ke atas nabi SAW tidak kurang daripada 100 kali 5. Membaca surah al-ikhlas tiga kali 6. Membaca al-quran 7. Membaca doa-doa bagi setiap perbuatan seperti doa makan, tidur, masuk/keluar rumah dan sebagainya 8. Perbanyakkan zikir-zikir yang sangat dituntut seperti istighfar, selawat atas nabi, tahlil, tasbih, tahmid dan sebagainya yang kita digesa agar melakukannya RUJUKAN Al-Quran dan terjemahannya. Al-Ghazali, Abu Hamid Muhammad b. Muhammad al-ghazali. Ihya Ulum al-din, Jilid 1&3, Kaherah: Dar al-rayyan Li al-turath. Al-Jurjani, Ali b. Muhammad al-sayyid al-syarif. (1991). Kitab al-ta rifat. Kaherah: Dar al-rasyad. Buletin Dadah AADK. Bil:1/2006. Dzulkifli Abdul Razak Dadah: Senario Sejagat Yang membimbangkan. Ismail Al-Faruqi. (1992). Al-Tawhid: Its Implications for Thought and Life. Kuala Lumpur: IIIT. Mohd Sulaiman Yasin. (1992). Akhlak dan Tasawuf. Bangi: Yayasan Salman. Muhammad Asad Is Religion Relevant Today? dalam Riza Mohamad dan Dilwar Hussain (ed.). Islam The Way of Revival. Kuala Lumpur: IIIT. Muhammad Yusuf Khalid. (2005). Gejala Sosial dan Penyelesaiannya dari Perspektif Tasawuf dalam Syamsul Bahri et.al, Membangun Masyarakat Moden Yang Berilmu dan Berakhlak. Fakulti Kepimpinan dan Pengurusan: KUIM. NADI. (2002). Buletin Dadah AADK Bil:1/2006. Said Hawwa. (1999). Tarbiyyatuna al-ruhiyyah. Cetakan ke-6. Kaherah: Darus Salam. Yuseri bin Ahmad, Dr. Sapora bt. Sipon & Marina Munira Abdul Mutalib, m/s

97 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah TREND DAN PUNCA PENGGUNAAN DADAH DI KALANGAN PENAGIH DADAH WANITA DI NEGERI SABAH: IMPLIKASI KEPADA RAWATAN DAN PEMULIHAN DADAH 1 Sabitha Marican 2 Mahmood Nazar Mohamed 3 Rosnah Ismail 4 ABSTRACT The involvement of women with psychoactive drugs is found to be most serious in the state of Sabah as compared to the other states in Malaysia. The National Anti-Drugs Agency (NADA) ranked Sabah 6 th on the severity of incidence of drug addiction with 1,229 drug users identified between the months of January to September, 2005, out of which a total of 686 were women ranging from young adolescents to those in their 40s. Sabahan women drug addicts used drugs not only for its euphoric effect but for various other reasons including to escape from their problems, to maintain their slim figures and to remain beautiful. Syabu is the drug of choice for most Sabahan women addicted to drugs because it is cheaper and can be easily obtained as compared to heroin or other drugs. The purpose of this study is to identify the profile of Sabahan women addicted to drugs, the etiology of drug use and the effect of drugs especially on their mental state. This study employed a cross-sectional survey design on a sample of 96 respondents, purposely selected from drug users and addicts presently undergoing drug treatment and rehabilitation at Pusat Serenti Bachok Kelantan, and those incarcerated at the Kota Kinabalu Women Prison, Tawau and Sandakan Prisons. Among the reasons for using drugs is because they were curious of its effects. Other reasons pertain to adjustment 1 Sebahagian daripada laporan kajian PENGGUNAAN DADAH DI KALANGAN WANITA DI NEGERI SABAH: PROFAIL, PUNCA DAN KESAN, Unit Penyelidikan Psikologi dan Kesihatan Sosial, UMS 2 Profesor Madya, Fakulti Ekonomi dan Pentadbiran, Universiti Malaya (UM) 3 Profesor Psikologi, Universiti Utara Malaysia (UUM) 4 Profesor dan Pengarah, Pusat Penyelidikan dan Inovasi, Universiti Malaysia Sabah (UMS) Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

98 JURNAL ANTIDADAH MALAYSIA and mental problems like wanting to escape from stress, family problems and the intention to commit suicide. The study identified that their early experience with substance use led them to addiction and crime. Many of the Sabahan women addicted to drugs started smoking at the age of 16, drinking alcohol at the age of 17 and first used drugs when they were at an average age of 19.8 years old. For those who were involved in crime, they commited their first act of crime at the age of 21. In conclusion, the study outlined some strategies for the treatment and rehabilitation of female drug addicts. ABSTRAK Di negeri Sabah, statistik penglibatan wanita dengan penagihan dadah kini adalah yang tertinggi berbanding negeri-negeri lain di Malaysia. Perangkaan Agensi Antidadah Kebangsaan (AADK) menunjukkan negeri Sabah menduduki tangga keenam paling atas berbanding negeri-negeri lain di Malaysia dengan jumlah 1,229 orang penagih yang dikesan dari bulan Januari- September Daripada jumlah tersebut, penagih wanita di negeri Sabah yang seramai 686 orang menduduki tangga yang teratas berbanding negerinegeri lain. Penglibatan wanita di Sabah dalam gejala penagihan dadah membabitkan gadis berusia dari seawal remaja sehinggalah kepada wanita yang berusia dalam lingkungan empat puluhan, bukan semata-mata disebabkan kenikmatan dadah itu sendiri tetapi didorong oleh faktor lain seperti ingin menjaga kecantikan dan menguruskan badan. Lebih serius lagi, dadah yang lazimnya digunakan penagih wanita di Sabah adalah dadah jenis syabu kerana ia mudah diperoleh dan lebih murah berbanding heroin dan ganja. Kajian ini diusahakan untuk mengenal pasti profil penagih dadah wanita di negeri Sabah, mengkaji punca-punca yang menyebabkan penglibatan wanita dengan dadah dan mengenal pasti kesan penglibatan wanita dengan dadah terhadap kesihatan mental. Kajian tinjauan keratan rentas terhadap 96 responden yang terdiri daripada pengguna dan penagih dadah wanita di negeri Sabah yang ditempatkan di Pusat Serenti Bachok, Kelantan dan di penjara-penjara sekitar negeri Sabah seperti Penjara Wanita Kota Kinabalu, Penjara Tawau dan juga Penjara Sandakan. Dapatan kajian membentangkan maklumat penggunaan dadah dan pemulihan yang pernah dilalui mereka, yang mana hampir semua dilaporkan menggunakan dadah jenis syabu. Punca-punca penggunaan dadah dikenal pasti, yang mana ramai menggunakan dadah kerana perasaan ingin tahu dan sebab-sebab yang menunjukkan bahawa penagih dadah mempunyai masalah kesihatan mental seperti untuk menghilangkan stres, perpecahan dalam keluarga, melarikan diri daripada masalah dan mencari ketenangan. Kajian ini turut mendapati bahawa pengalaman awal dengan masalah sosial bahan dan mendorong mereka menggunakan dadah. Rata-rata penagih dadah Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

99 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah wanita Sabah mula merokok pada umur 16 tahun, minum minuman keras pada purata umur 17 tahun, menggunakan dadah pada purata umur 19.8 tahun, dan bagi yang terlibat dengan jenayah, umur pertama mereka terlibat dengan perbuatan jenayah ialah 21 tahun. Kajian ini memberi beberapa implikasi dan cadangan yang berkaitan dengan rawatan dan pemulihan penagihan dadah dalam kalangan wanita. PENGENALAN Dadah merupakan satu-satunya masalah keselamatan, sosial dan kesihatan yang sehingga kini masih memberi kesan besar kepada negara. Dari dahulu hingga sekarang, statistik penggunaan dan penagihan terhadap dadah masih belum menunjukkan perkembangan yang positif walaupun pelbagai cara telah dilakukan oleh pihak kerajaan untuk membendung gejala tersebut daripada berleluasa. Penyalahgunaan dadah dalam kalangan masyarakat amat membimbangkan terutama apabila ia mula menular dalam kalangan remaja-remaja sekolah (Mahmood, 2002). Tambahan lagi, kalau dahulu dikatakan kaum lelaki lebih sinonim dengan gejala seperti ini, tetapi kini kaum wanita turut terlibat dengan masalah ini. Perkembangan pesat negara dari aspek sosial dan ekonomi menyebabkan perubahan peranan kaum wanita dari segi kerjaya, tanggungjawab dan identiti. Pelbagai tekanan dihadapi oleh kaum wanita akibat perubahan-perubahan yang berlaku sedikit sebanyak telah menyumbang kepada peningkatan gejala sosial dalam kalangan wanita terutama dalam masalah penagihan dadah. Tambahan pula, dalam kehidupan yang didesak oleh kepentingan materialistik, tidak kurang juga sebilangan wanita terikut-ikut dengan cara hidup sedemikian hinggakan ada yang menggadai nilai serta moral untuk mencapai kemewahan dalam kehidupan. Lantas mereka ini juga terperangkap dalam penggunaan dan penagihan dadah (Mahmood, 2005a). Di negeri Sabah sahaja, statistik penglibatan wanita dalam gejala penagihan dadah kini adalah yang tertinggi berbanding dengan negerinegeri lain di Malaysia (AADK Sabah, 2005). Dalam satu ucapan yang telah disampaikan oleh Y.A.B. Ketua Menteri Sabah, Datuk Musa Haji Aman sempena pelancaran papan tanda kempen antidadah peringkat negeri Sabah pada 22 Disember 2005, keadaan penagihan dadah di Sabah telah menjadi satu fenomena yang amat merunsingkan iaitu mengikut perangkaan daripada Agensi Antidadah Kebangsaan (AADK), negeri Sabah menduduki tangga keenam antara negeri-negeri di Malaysia Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

100 JURNAL ANTIDADAH MALAYSIA dengan jumlah 1,229 orang penagih yang dikesan dari bulan Januari- September Daripada jumlah tersebut, penagih wanita adalah seramai 686 orang dan menduduki tangga yang teratas antara negerinegeri di Malaysia. Penglibatan wanita dengan gejala penagihan dadah bukan semata-mata disebabkan kenikmatan dadah itu sendiri tetapi didorong oleh faktor lain seperti ingin menjaga kecantikan dan menguruskan badan (Mahmood, 2005a) di samping faktor pengaruh suami yang juga menjadi penagih. Adalah diandaikan bahawa faktor gaya hidup memainkan peranan penting dalam tabiat penggunaan dadah dalam kalangan wanita. Lebih berat lagi, dadah yang biasa diambil penagih wanita di Sabah adalah dadah jenis syabu kerana ia mudah diperoleh dan lebih murah berbanding dadah tradisional seperti heroin dan ganja. AADK Negeri Sabah turut menjelaskan bahawa pembabitan wanita di dalam gejala penagihan dadah di negeri Sabah merentas usia dari seawal remaja sehinggalah yang berusia 40-an. Walaupun terdapat peningkatan bilangan penagih wanita di Sabah berbanding negeri-negeri lain di Malaysia, namun tindakan untuk menangani masalah ini di Sabah tidaklah seserius berbanding penagih lelaki. Memandangkan tiada pusat pemulihan khas wanita diwujudkan di negeri Sabah, maka kebanyakan penagih-penagih wanita di negeri Sabah ditempatkan di Pusat Serenti Bachok, Kelantan. Manakala selebihnya akan dirujuk kepada Agensi Antidadah Kebangsaan Negeri Sabah untuk diawasi dan menjalani pemulihan dalam komuniti. Di samping itu terdapat juga penagih wanita yang turut melakukan kesalahan jenayah lain ditempatkan di Penjara Wanita Kota Kinabalu, Penjara Tawau dan Penjara Sandakan untuk menjalani hukuman. Kajian mengenai pembabitan kaum wanita dengan gejala dadah lebih berfokus kepada perubahan peranan wanita akibat perkembangan sosiobudaya dan ekonomi jika dibandingkan dengan peranan kaum lelaki. Kebanyakan pengkaji yang mengkaji tentang wanita dan dadah memperoleh dapatan signifikan yang membezakan antara penagih dadah wanita dan lelaki. Kajian Rosenbaum (1981), Hser (1987), Thom (1995), Nelson-Zlupko et al. (1996), Ettorre (1996), dan Estebanez & Cifuentes (1997) mendapati bahawa penagih wanita mengambil kuantiti dadah yang lebih rendah berbanding penagih lelaki tetapi lebih cepat menjadi ketagih dan lebih gemar mengambil bahan-bahan bersifat sedatif. Jenis dadah yang selalu digunakan adalah berlainan, dan ini Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

101 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah bermakna mereka perlu diberikan rawatan dan pemulihan yang berbeza daripada penagih dadah lelaki. Kebanyakan penagih wanita juga berlatarbelakangkan tahap pendidikan yang rendah, kurang sumber kewangan dan lebih memberi perhatian terhadap usaha untuk meneruskan kehidupan seharian. Ini menunjukkan bahawa mereka terpaksa bergantung kepada orang lain seperti ibu bapa, suami ataupun teman lelaki bagi sumber ekonomi. Lanjutan daripada itu, masalah penagihan dadah dalam kalangan wanita turut memberi kesan terhadap risiko perkembangan normal anak-anak. Bagi wanita yang menggunakan dadah, anak-anak sering terbiar dan diletakkan di bawah penjagaan orang lain seperti ibu bapa dan saudara mara. Mereka tidak dapat menikmati kasih sayang ibu, dan mungkin juga akan belajar menggunakan bahan psikoaktif apabila remaja kelak. Kajian juga mengenal pasti sebilangan pengguna dadah wanita pernah menjadi mangsa penderaan seksual dan fizikal yang mengakibatkan tekanan perasaan yang begitu mendalam (Mahmood, 2005a; 2005b). Tekanan perasaan ini sering diatribusi sebagai sebab mereka mencuba dadah dan lama-kelamaan akan menjadi ketagih. Ini antara sebabnya mengapa penagih wanita lebih mendapat perhatian dari aspek rawatan psikitrik dan mereka lebih kerap mengalami dualdiagnosis kerana pelbagai simptom psikiatrik yang dialami bersamasama dengan penagihan dadah (Khantzian & Treece, 1985; Blume, 1989; Rousanville et al., 1987). Hal ini menyukarkan lagi proses pemulihan penagih dadah wanita. Dual-diagnosis di kalangan penagih wanita bukanlah perkara baru. Hesselbrock, Meyer & Keener (1985) mendapati 80% daripada sampel 90 orang pengguna dadah dan alkohol mengalami dual-diagnosis. Satu perhatian yang agak konsisten melalui banyak kajian ialah episod kemurungan dalam kalangan penagih wanita adalah lebih tinggi berbanding dengan pengguna atau penagih lelaki (Rounsaville & Kleber, 1985; Mahmood, 2005). Malah Hesselbrock, Meyer & Keener (1985) turut menemui gangguan major depression di kalangan penagih wanita. Pelbagai kajian juga mendapati hubungan penagihan dadah dalam kalangan wanita dengan kecelaruan makanan (Bulik, 1997); kecelaruan borderline (Nace et al., 1988) kecelaruan personaliti (Vaglum & Vaglum, 1997), kecelaruan afektif, bulimia, gangguan anxieti dan kecelaruan seksual (Ross, Glaser & Stiasny, 1988) dan kecelaruan panik dan OCD (Hesselbrock, Meyer & Keener, 1985). Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

102 JURNAL ANTIDADAH MALAYSIA Hal ini juga ada kaitan dengan tahap motivasi mereka untuk berubah, bahawa penagih-penagih wanita mempunyai tahap motivasi yang berbeza sama ada dari aspek usaha untuk menghapuskan atau meneruskan ketagihan. Kajian Mahmood dan Edman (1997) umpamanya mendapati penagih dadah wanita lebih cenderung menyalahkan diri mereka sendiri berbanding penagih lelaki, yang bermakna mereka lebih terdedah kepada perasaan bersalah, kurang yakin dan mempunyai harga diri yang rendah. Kajian juga mendapati bahawa apabila penagih-penagih wanita telah mencapai tahap memerlukan sokongan terapeutik yang tertentu, jika tidak ditangani dengan baik, akan membawa kepada masalah dalam mencapai kaedah rawatan yang berkesan (Mahmood 2005a). Selain itu, disebabkan pembabitan wanita dalam gejala dadah yang tidak begitu ketara berbanding lelaki, kajian mendapati bahawa penagih dadah wanita hanyalah golongan minoriti yang tidak diambil peduli oleh sesetengah pihak terutama dalam penyediaan rawatan dan intervensi terhadap proses pemulihan dadah (Stocco, Liacer, DeFazio, Calafat & Mendes, 2000). Sehubungan itu, ada keperluan mendesak untuk mengetahui fenomena penagihan dadah di kalangan wanita di negeri Sabah dan Malaysia amnya serta faktor-faktor yang mempengaruhi penggunaan di samping kesan penagihan dadah. Pembabitan wanita dengan dadah adalah satu gejala yang serius kerana ini akan melibatkan pendedahan kaum wanita kepada risiko kesihatan mental dan fizikal yang akan memudaratkan kualiti kehidupan mereka. Dengan adanya kajian seperti ini, diharap perkhidmatan sistem kesihatan sosial di negara ini dan di negeri Sabah khususnya akan lebih terurus dan akan turut menitikberatkan rawatan dan pemulihan dalam kalangan penagih wanita selain penagih lelaki. Sebagai rumusan, apa yang dinyatakan oleh Duongsaa (1998) telah menjelaskan situasi ini dengan agak jelas, bahawa..it is time to recognize the fact that, because of drug use; many girls and women have been robbed of their identity, their dignity, their quality of life, and their right to protection. It is time to review our development paradigm and strategies, as well as our approaches to the drug issue, in order to make a real change, and that will enable women who are affected by the drug problem to reclaim their humanity and their rights. OBJEKTIF Secara amnya, kajian ini dibuat untuk mengenal pasti profil penagih dadah wanita di negeri Sabah, manakala objektif khusus kajian ini adalah Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

103 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah untuk: i. Mengenal pasti profil penagih dadah wanita negeri Sabah ii. Mengkaji punca-punca menyebabkan penglibatan wanita dengan dadah iii. Menentukan kesan penglibatan wanita dengan dadah terhadap kesihatan mental METODOLOGI Kajian ini menggunakan reka bentuk tinjauan keratan rentas serta kaedah persampelan bertujuan (purposive sampling). Seramai 96 penagih dadah dalam kepulihan bertindak sebagai responden. Mereka ditempatkan di pusat-pusat pemulihan seperti Pusat Serenti Bachok Kelantan, di penjarapenjara di sekitar negeri Sabah seperti Penjara Wanita Kota Kinabalu, Penjara Tawau dan Penjara Sandakan serta mereka yang menjalani pemulihan dalam komuniti (kes pengawasan) di bawah seliaan AADK negeri Sabah. Satu set soal selidik digunakan sebagai instrumen yang dibahagikan kepada 2 bahagian. Bahagian A mengandungi soalan yang berkaitan dengan faktor demografi dan profil penagih meliputi maklumat diri, pekerjaan, pendidikan, keluarga, rakan-rakan, penggunaan dadah dan juga maklumat rawatan dan pemulihan yang perlu dijawab oleh setiap responden. Bahagian B pula mengandungi soalan-soalan yang lebih menjurus kepada kesan negatif penggunaan dadah ke atas diri pengguna. Pasukan kajian mendapatkan keizinan (consent) daripada institusi terlibat dan responden sebelum pengumpulan data bagi memelihara etika penyelidikan. HASIL KAJIAN Sejumlah 13 orang (16.88%) terdiri daripada etnik Bajau, 12 orang (15.58%) etnik Kadazan dan 12 orang (12.99%) terdiri daripada etnik Melayu. Manakala selebihnya adalah daripada etnik-etnik lain. Ini menunjukkan bahawa bilangan penagih dadah wanita lebih ramai di kalangan etnik Bajau berbanding dengan etnik-etnik yang lain. Faktor ini mungkin disebabkan etnik Bajau merupakan etnik yang antaranya paling ramai di Sabah selain daripada etnik Kadazan-Dusun dan Melayu- Brunei (Jadual 1). Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

104 JURNAL ANTIDADAH MALAYSIA Jadual 1 : Penagihan Dadah dengan Merujuk kepada Bangsa Responden Bangsa Bilangan Peratus Bajau Kadazan Melayu Sino-Kadazan & Suluk 5 setiap etnik 2 Bisaya & Cina 4 setiap etnik 2 Filipino & Iban 3 setiap etnik 2 Bugis, Indonesia, Brunei, 2 setiap etnik 5 Murut dan Sungai Visaya, Bidayuh, Bolongan, 1 setiap etnik 8 Dusun, Jawa, Lindayu, Rungus & Tidung Lebih separuh daripada responden beragama Islam iaitu seramai 56 orang (72.2%), diikuti oleh responden yang beragama Kristian seramai 19 orang (24.0%). Selebihnya beragama Buddha iaitu seramai 2 orang (2.6%). Dari segi umur, 77 responden, sejumlah 45 orang (58.4%) berumur di antara tahun, 18 orang berumur tahun (23.4%) dan selebihnya berumur di antara tahun. Hasil ini menunjukkan lebih separuh daripada penagih dadah wanita di negeri Sabah berumur dalam lingkungan tahun. Purata umur responden terlibat dalam penagihan dadah iaitu dalam lingkungan 26 tahun. Penagih wanita dari Sabah yang terlibat dengan dadah terdiri daripada mereka yang mempunyai tahap pendidikan yang sederhana dan hanya sedikit jumlah yang tidak pernah bersekolah ataupun hanya mendapat pendidikan sehingga darjah tiga sahaja iaitu seramai 13 orang (16.9%). Kajian juga mendapati seramai 29 orang (37.7%) pernah mendapat pendidikan dari tingkatan 1 3; 18 orang (23.4%) mendapat pendidikan dari tingkatan 4 5; dan 3 orang lagi (3.8%) pernah bersekolah sehingga ke tingkatan 6 dan ke atas. Data ini menunjukkan mereka yang terlibat dengan dadah bukanlah terdiri daripada mereka yang buta huruf. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

105 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Bilangan rakan-rakan penagih wanita sebelum mereka ditahan adalah agak ramai, yang mana secara purata bilangan rakan-rakan mereka adalah orang. Manakala bilangan rakan yang paling rapat dengan penagih wanita ini sebelum mereka ditahan adalah dalam purata 3.47 orang. Rakan-rakan perempuan penagih wanita dengan tingkah laku negatif, di mana didapati seramai 64 orang (83.1%) responden mempunyai rakan-rakan perempuan yang juga menggunakan dadah, 63 orang (81.8%) responden memiliki rakan perempuan yang perokok manakala 59 orang (76.6%) responden pula mempunyai rakan-rakan perempuan yang minum minuman keras. 4 orang (5.2%) daripada rakan-rakan penagih wanita ini pula turut terlibat dengan jenayah-jenayah lain seperti mencuri, mengedar dadah dan merompak (Jadual 2). Tidak seorang pun rakan-rakan lelaki penagih wanita tersebut terlibat dengan penggunaan dadah. Sungguhpun demikian, tingkah laku negatif lain seperti merokok dan minum minuman keras amat tinggi di mana, 64 orang (83.1%) penagih wanita ini mempunyai rakanrakan lelaki yang merokok dan 63 orang (81.8%) pula mempunyai rakan lelaki yang minum alkohol. Sejumlah 14 orang daripada penagih wanita ini pula memiliki kawan-kawan lelaki yang terlibat dengan beberapa jenayah lain seperti mengedar dadah, merompak, mencuri, pecah rumah, pusher dan suka bergaduh (Jadual 2). Jadual 2 : Penglibatan Rakan-rakan Perempuan dan Laki-laki dengan Tingkah Laku Negatif Tingkah Laku Negatif Perempuan Laki-laki 1. Menggunakan dadah 64 (83.1%) - 2. Merokok 63 (81.8%) 64 (83.1%) 3. Minum minuman keras 59 (76.6%) 63 (81.8%) 4. Jenayah lain (mengedar dadah, 4 (5.2%) 14 (18.2%) merompak, mencuri, pecah rumah, pusher, bergaduh) Jadual 3 pula menunjukkan aktiviti hiburan yang dilakukan penagih wanita bersama rakan-rakan mereka pada waktu lapang. Aktiviti yang paling banyak dilakukan oleh penagih-penagih wanita ini ketika bersama rakan-rakan mereka adalah merokok dan berhibur di Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

106 JURNAL ANTIDADAH MALAYSIA pusat-pusat hiburan seperti disko, konsert dan karaoke, yang mana, 60 orang (77.9%) responden yang diajukan mengatakan ya pada aktivitiaktiviti ini. Ini diikuti dengan aktiviti minum minuman yang memabukkan seperti arak, bir, todi dan air tapai yang dipersetujui oleh 52 (67.5%) responden dan juga aktiviti melepak 49 orang (59.7%). Jadual 3 : Bentuk Hiburan yang Dilakukan Bersama-sama Rakan di Waktu Lapang Item Ya Tidak 1. Merokok 60 (77.9%) 17 (22.1%) 2. Berhibur di pusat hiburan / disko / 60 (77.9%) 17 (22.1%) konsert / karaoke) 3. Lain-lain (game / snuker / 6 (7.8%) 71 (92.2%) beli belah / mengambil dadah / menggunakan dadah) 4. Minum arak / bir / todi / air tapai 52 (67.5%) 25 (32.5%) 5. Melepak 46 (59.7%) 31 (40.3%) 6. Menonton wayang / video 44 (57.1%) 33 (42.9%) 7. Bersukan 32 (41.6%) 45 (58.4%) 8. Judi /nombor ekor / mesin slot 25 (32.5%) 52 (67.5%) 9. Snuker / billiard 23 (29.9%) 54 (70.1%) 10. Melancong 22 (28.6%) 55 (71.4%) 11. Menonton video lucah 12 (15.6%) 65 (84.4%) PENGGUNAAN BAHAN PSIKOAKTIF Sejumlah besar responden penagih wanita ini iaitu 68 orang (88.3%) didapati merokok manakala selebihnya iaitu 9 orang (11.7%) lagi tidak merokok. Mereka merokok buat kali pertama pada umur tahun dengan sisihan piawai sebanyak 5.97 tahun, Rakan-rakan paling mendominasi responden belajar merokok, di mana seramai 37 orang (55.2%) mengatakan mereka belajar merokok daripada rakan-rakan mereka. Ini diikuti dengan 27 orang (40.3%) responden mengatakan diri sendiri dan selebihnya iaitu 3 orang atau 4.5% pula mengatakan orang yang mengajar mereka merokok adalah suami, teman lelaki dan juga ibu bapa mereka. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

107 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Pada masa yang sama, sejumlah 69 orang (89.6%) mengaku merupakan seorang peminum minuman keras manakala selebihnya iaitu 8 orang atau 10.4% pula tidak. Mereka pertama kali minum minuman keras pada kadar umur tahun. Pengaruh yang paling kuat mengajar mereka minum minuman keras, sama seperti juga rokok di mana rata-rata responden penagih wanita ini mengaku bahawa rakanrakan menjadi pengajar utama mereka melakukan kegiatan ini. Seramai 42 orang atau 61.8% responden mengatakan mereka belajar minum minuman keras ini daripada rakan-rakan mereka. Ini diikuti dengan 23 orang penagih mengatakan diri sendiri manakala selebihnya pula iaitu 3 orang mengatakan belajar daripada suami, teman lelaki dan ibu bapa mereka. Ramai penagih dadah terlibat dengan aktiviti jenayah dan ini termasuklah penagih dadah wanita. Sejumlah 16 orang atau 21.6% penagih ini mengatakan pernah melakukan jenayah manakala selebihnya iaitu 58 (78.4%) mengatakan tidak pernah. Purata umur penagih wanita ini mula-mula melakukan jenayah iaitu pada kadar purata umur tahun dengan sisihan piawai sebanyak 4.60 tahun. Antara jenayah yang sering dilakukan oleh penagih wanita ini. Seramai 3 orang (21.4%) mengatakan mereka turut melakukan jenayah mengedar dadah diikuti dengan perbuatan mencuri oleh 2 orang (14.3%) penagih dan selebihnya adalah jenayah-jenayah lain seperti bersubahat dengan kawan, membunuh, memukul, menggugurkan kandungan, seks tanpa nikah, menjual syabu, meragut, merompak dan menyamun orang, yang mana setiap jenayah ini pernah dilakukan oleh setiap seorang (7.1%) responden penagih ini. Purata umur responden mula-mula menggunakan dadah adalah tahun. Secara puratanya, responden kajian ditangkap sebanyak 2.74 kali kerana kesalahan menggunakan dadah. Jadual 4 menunjukkan status responden semasa mula-mula menggunakan dadah, di mana 31 (40.3%) responden telahpun berhenti dari alam persekolahan mereka semasa mula menggunakan dadah. Ini diikuti dengan 21 orang (27.3%) mengambil dadah selepas berkahwin manakala 15 orang (19.5%) lagi mengatakan mereka mula menggunakan dadah ketika masih lagi bersekolah. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

108 JURNAL ANTIDADAH MALAYSIA Jadual 4 : Status Responden Semasa Mula-mula Menggunakan Dadah Item Ya Tidak 1. Masih bersekolah 15 (19.5%) 41 (53.2%) 2. Sudah berhenti sekolah 31 (40.3%) 29 (37.7%) 3. Sudah tamat sekolah 11 (14.3%) 40 (51.9%) 4. Sedang belajar di pusat pengajian tinggi - 50 (64.9%) 5. Sedang bekerja 18 (23.4%) 34 (44.2%) 6. Selepas berkahwin 21 (27.3%) 34 (44.2%) 7. Lain-lain (selepas bercerai, selepas 7 (9.0%) 70 (91.0%) kematian anak, ketika mengambil SPM) Jadual 5 pula menunjukkan majoriti penagih wanita ini mengatakan mula-mula berjinak dengan dadah semasa berada dan bergaul dengan orang lain, di mana 22 orang atau 28.6% responden mengatakan mereka mula berjinak-jinak dengan dadah ketika berada di tempat melepak dan 17 orang responden atau 22.1% pula mengatakannya ketika mereka berada di rumah kawan mereka. Sungguhpun demikian, 15 orang penagih wanita atau 19.5% pula berkata mereka mula berjinak-jinak dengan dadah ketika berada di rumah. Jadual 5 : Tempat di Mana Responden Mula-mula Berjinak dengan Dadah Item Bilangan Peratus 1. Di tempat melepak Di rumah kawan Di rumah Di tempat hiburan Di tempat kerja Di sekolah Jadual 6 memperihalkan sumber kewangan penagih wanita ini untuk membeli dadah. Majoriti penagih wanita ini iaitu 35 orang responden atau 50.7% membeli dadah dengan menggunakan duit sendiri. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

109 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Selain itu, 23 orang (33.3%) pula mengatakan membeli dadah dengan menggunakan duit ibu bapa manakala 9 orang (13.0%) pula dengan cara meminta duit daripada orang yang paling rapat dengan mereka seperti teman lelaki, kekasih atau suami mereka. Hanya 2 orang (3.0%) responden berkata bahawa sumber kewangan untuk membeli dadah adalah dengan mencuri. Jadual 6 : Sumber Kewangan Responden Membeli Dadah Item Bilangan Peratus 1. Duit sendiri Duit ibu bapa Minta teman lelaki / kekasih / suami Mencuri Sejumlah 43 orang penagih wanita atau 57.3% mengatakan mereka mendapat sumber bekalan dadah daripada rakan mereka (Jadual 7). Ini diikuti dengan sumber yang diperoleh daripada pusher iaitu 22 (29.3%) jawapan dan 8 orang (10.7%) responden mengatakan mendapat bekalan dadah daripada pasangan rapat mereka seperti teman lelaki, kekasih atau suami. Hanya 2 orang (2.7%) sahaja yang mendapat bekalan dadah daripada adik beradik mereka. Jadual 7 : Sumber Responden Mendapat Bekalan Dadah Item Bilangan Peratus 1. Diberi oleh rakan Membeli daripada Pusher Diberi oleh teman lelaki / kekasih suami Diberi oleh adik beradik Jadual 8 pula menunjukkan penggunaan jenis dadah di kalangan responden kajian yang terlibat. Hasil kajian mendapati bahawa, kebanyakan penagih dadah wanita di negeri Sabah menggunakan dadah jenis syabu. Daripada 77 orang responden kajian ini, 75 orang (97.4%) penagih wanita ini menggunakan dadah jenis syabu diikuti Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

110 JURNAL ANTIDADAH MALAYSIA dengan dadah jenis marijuana atau ganja dengan 35 orang (45.5%) pengguna dan dadah jenis ekstasi seramai 26 orang atau 33.8% pengguna. Dadah lain yang mendapat tempat dalam kalangan penagih wanita ini adalah seperti kodein atau ubat batuk 20 orang (26.0%) dan heroin 11 orang ( 14.3%) penagih. Jadual 8 : Jenis Dadah yang Digunakan oleh Responden Jenis Dadah Bilangan Peratus 1. Syabu Marijuana/ganja Ekstasi Kodein/ubat batuk Heroin Gam/inhaler/thinners/marker Amfetamin Kokain Pain killer Morfin Subutex Candu Ketamin/rophynol/GHB Methadone Jadual 9 menunjukkan cara penggunaan dadah di kalangan penagih-penagih dadah tersebut di mana, kebanyakan dadah digunakan dengan cara menghisap, iaitu 57 orang (74.0%) penagih yang disoal berkata mereka menggunakan dadah dengan cara menghisap. Bilangan ini tinggi disebabkan oleh penggunaan dadah jenis syabu dalam kalangan penagih wanita yang amat tinggi. Ini diikuti dengan cara makan oleh 14 orang (18.2%) penagih, sementara 5 orang (6.5%) penagih pula menggunakan dadah dengan cara menghidu dan selebihnya iaitu seorang (1.5%) dengan cara suntikan. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

111 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Jadual 9 : Cara Responden Menggunakan Dadah Jenis Dadah Bilangan Peratus 1. Hisap Makan Hidu Suntikan Jadual 10 memaparkan jenis-jenis dadah yang paling kerap digunakan oleh penagih wanita di Sabah. Hasil dapatan menunjukkan majoriti penagih wanita di Sabah ini menggunakan dadah jenis syabu memandangkan ia amat mudah diperoleh dengan harganya yang murah jika dibandingkan dengan dadah jenis lain. Dapatan menunjukkan bahawa, 65 (84.4%) responden ini kerap menggunakan dadah jenis syabu sahaja. Hanya 2 orang (2.6%) responden kerap menggunakan syabu dan ekstasi, sementara 2 orang lagi (2.6%) menggunakan syabu dan ganja. Jadual 10 : Jenis Dadah yang Kerap Digunakan oleh Responden Jenis Dadah Bilangan Peratus Syabu Syabu dan ekstasi Syabu dan ganja Ekstasi; Ganja; Heroin; Marijuana & 1 setiap satu/ 10 Ekstasi; Morfin; Syabu & Heroin; gabungan Syabu, Ganja dan Ekstasi; Syabu & Kokain; Methadone; Subutex; dan Amfetamine Kekerapan responden menggunakan dadah dalam seminggu ialah pada kadar purata 5.20 kali, iaitu mereka menggunakan dadah hampir setiap hari. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

112 JURNAL ANTIDADAH MALAYSIA FAKTOR PENDORONG PENGGUNAAN DADAH Faktor-faktor yang mendorong kepada penggunaan dadah di kalangan wanita di negeri Sabah adalah seperti dalam Jadual 11. Perasaan ingin tahu mendominasi sebanyak 61 orang atau 79.2% daripada responden yang mengikuti kajian ini dengan menyatakannya sebagai punca utama mereka terjebak dengan dadah. Kajian juga mendapati antara penyebab utama wanita mengambil dadah adalah untuk menghilangkan stres seperti yang dinyatakan oleh 56 orang (72.7%) responden kajian ini diikuti oleh faktor jiwa memberontak dan perpecahan keluarga seperti yang dinyatakan oleh 50 orang (64.9%) responden yang menjadikan alasan ini untuk menagih, dan 50 (64.9%) orang lagi mengatakan ingin melarikan diri daripada masalah hidup atau kerunsingan mereka buat sementara waktu. Seramai 47 penagih (61.1%) pula mengatakan mereka menggunakan dadah bertujuan untuk menguruskan badan dan kecantikan. Manakala, punca lain adalah rasa seronok seperti yang dirasakan oleh 42 (54.5%) responden, bekalan mudah diperoleh seperti yang dinyatakan oleh 35 orang (45.5%) penagih wanita ini. Jadual 11 : Sebab-sebab Responden Menggunakan Dadah Sebab-Sebab Penggunaan Dadah Bilangan Peratus Rasa ingin tahu/ingin mencuba % Untuk menghilangkan stres/ kerunsingan % Pengaruh rakan sebaya % Perpecahan keluarga dan pergolakan rumah tangga % Melarikan diri daripada masalah hidup/kerunsingan % Menguruskan badan dan kecantikan % Rasa seronok % Bekalan mudah diperoleh % Jiwa memberontak % Perubatan % Putus cinta % Terpedaya/ditipu % Dipaksa oleh teman/rakan % Pengaruh suami % Dipaksa oleh suami/kekasih/teman lelaki 6 7.8% Untuk membunuh diri 5 6.5% Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

113 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Jadual 12 menunjukkan bahawa rakan memainkan peranan yang besar dalam mempengaruhi responden menggunakan dadah. 54 orang (70.1%) penagih mengatakan bahawa rakan banyak mempengaruhi mereka menggunakan dadah dan diikuti dengan usaha diri sendiri sebanyak 14 orang (18.2%) dan pengaruh suami dan teman lelaki seramai 8 orang (10.4%). Hanya seorang (1.3%) responden mengatakan bahawa ibu bapa banyak mempengaruhi mereka menggunakan dadah. Jadual 12 : Siapakah Paling Banyak Mempengaruhi Responden Menggunakan Dadah Pihak yang Mempengaruhi Responden Bilangan Peratus 1. Rakan Diri sendiri Suami/teman lelaki Ibu bapa Mungkin disebabkan oleh rakan banyak mempengaruhi penggunaan dadah di kalangan penagih-penagih wanita ini, maka tidak hairanlah rakan-rakan juga menjadi tempat mereka berkongsi pengalaman pertama menggunakan dadah. Daripada 77 orang responden kajian ini, seramai 62 orang (83.8%) penagih mengatakan mereka berkongsi pengalaman pertama menggunakan dadah bersama rakan-rakan. Sejumlah 7 orang (9.5%) responden telah berkongsi dengan suami/teman lelaki/kekasih dan 5 orang (6.8%) responden lagi berkata mereka berkongsi pengalaman tersebut dengan keluarga mereka (Jadual 13). Jadual 13 : Responden Berkongsi Pengalaman Pertama Menggunakan Dadah Kongsi Pengalaman Dadah dengan Bilangan Peratus 1. Rakan-rakan Suami/teman lelaki/kekasih Keluarga Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

114 JURNAL ANTIDADAH MALAYSIA Jadual 14 menunjukkan bahawa seramai 19 orang (25.0%) responden penagih wanita mengaku mereka cuba mengajak orang lain menggunakan dadah manakala 57 orang (75.0%) responden lagi mengatakan tidak. Jadual 14 : Pernahkah Responden Mengajak Orang Lain Menggunakan Dadah Responden Mengajak Orang Lain Menggunakan Dadah Bilangan Peratus 1. Ya Tidak Jadual 15 menunjukkan bilangan orang yang cuba dipengaruhi oleh penagih dadah wanita ini, di mana 5 orang (6.5%) di kalangan penagih berkata telah cuba mempengaruhi seorang untuk terlibat dengan dadah, 4 orang (5.2%) responden pula cuba mempengaruhi 5 orang lain, 3 orang responden (3.9%) pula mengaku cuba mengajak 3 orang lain untuk terlibat dengan najis dadah ini. Jadual 15 : Berapa Ramai yang Cuba Dipengaruhi Responden Item Bilangan Peratus 1. 1 orang orang orang orang orang orang Min 6.13 Sisihan Piawai Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

115 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Jadual 16 menunjukkan bilangan orang yang terpengaruh dengan ajakan penagih dadah wanita ini, yang mana seramai 5 orang (31.25%) responden mengatakan mereka telah berjaya mempengaruhi sekurang-kurangnya seorang untuk terlibat dengan dadah, 4 orang (25.0%) pula mengatakan mereka berjaya mempengaruhi 3 orang, 3 orang responden (18.8%) pula berkata telah berjaya mempengaruhi 2 orang untuk terlibat dengan dadah. Adalah amat mendukacitakan bila mana ada 2 orang (12.5%) responden kajian ini mengaku bahawa 30 orang turut terpengaruh dengan ajakan mereka untuk menagih. Jadual 16 : Berapa Ramai yang Terpengaruh untuk Menggunakan Dadah Bilangan yang Terpengaruh Bilangan Peratus 1. 1 orang orang orang orang orang orang Min 6.06 Sisihan Piawai 9.56 Jikalau ditinjau, pihak yang paling berpengaruh mendorong mereka menggunakan dadah adalah rakan-rakan mereka (70.1%) (Rajah 1). Ini adalah benar bagi semua peringkat umur. Jika ditinjau pada tahap umur tahun, kekasih dan diri mereka sendiri turut dilihat sebagai punca utama mereka menggunakan dadah. Dari sini bolehlah dianggarkan bahawa apabila responden memasuki zaman dewasa, walaupun rakan-rakan masih menjadi pengaruh utama, namun ada juga yang dipengaruhi oleh kekasih masing-masing. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

116 JURNAL ANTIDADAH MALAYSIA Rajah 1 : Umur dengan Siapa yang Mempengaruhi Penagih KESAN TERHADAP KESIHATAN MENTAL Objektif kajian yang ketiga ialah untuk menentukan tahap kesihatan mental pengguna dadah wanita dari negeri Sabah. Ini penting kerana ramai wanita menggunakan syabu, sejenis dadah yang telah diketahui kesannya yang menyebabkan 'drug psychosis', dan hal ini disokong oleh pelbagai kajian di mana pengguna dadah wanita turut mengalami kemurungan dan simptom psikiatri lain lebih kerap lagi berbanding penagih lelaki. Jika ditinjau sebab dan kesan dadah digunakan (Rajah 2), antara yang dinyatakan sebab utama ialah untuk mengurangkan stres (72.7%) dan diikuti dengan melarikan diri daripada masalah (64.9%) dan faktor ini menunjukkan bahawa daya tindak penagih wanita terhadap pengawalan masalah adalah lemah, dan menggunakan strategi daya tindak yang tidak dapat membantu kesihatan mental. Penggunaan dadah turut diatribusikan kepada faktor jiwa yang memberontak (39%), perpecahan dan pergolakan rumah tangga (36.4%), putus cinta (22.1%), dan yang paling serius ialah untuk membunuh diri (6.5%). Kajian Mahmood (2005) turut mendapati bahawa sebab penggunaan dadah di kalangan penagih lelaki dan wanita adalah amat berbeza, yang mana wanita lebih terdorong untuk mengelak atau melarikan diri daripada masalah, manakala lelaki pula menggunakannya untuk kesan euforia atau keenakan dadah itu sendiri. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

117 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Rajah 2 : Sebab-sebab Penggunaan Dadah di Kalangan Penagih Wanita Jadual 17 menunjukkan kesan penglibatan wanita dengan dadah ini terhadap kesihatan mental mereka. Hasil kajian mendapati daripada keseluruhan responden yang ditanya, 53 orang (68.8%) responden mengatakan rasa menyesal menggunakan dadah manakala selebihnya 24 orang (31.2%) pula tidak berasa menyesal. Seramai 49 penagih (63.6%) pula berasa malu terhadap diri sendiri dan orang lain diikuti dengan rasa sakit seperti yang dinyatakan oleh 27 orang (35.1%) penagih wanita ini. Sungguhpun demikian, kesan ini tidak pula dirasakan oleh 50 orang responden kajian, malah 24 orang (31.2%) mengaku tidak mengalami perasaan bersalah kerana menggunakan dadah. Dapatan kajian menunjukkan bahawa perasaan ingin tahu mendominasi punca utama penggunaan dadah manakala penyebab utama wanita mengambil dadah adalah untuk menghilangkan stres diikuti dengan faktor jiwa memberontak dan perpecahan keluarga, ingin melarikan diri daripada masalah hidup atau kerunsingan dan ada yang menggunakan dadah bertujuan untuk menguruskan badan dan kecantikan. Kesan dadah juga dilihat memberi sedikit gangguan pada tingkah laku dan mental penagih dadah wanita seperti perasaan hendak membunuh diri atau mati, rasa bersalah, putus asa dan malu, yang mana perkara ini haruslah diberikan tumpuan dalam rawatan dan pemulihan mereka. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

118 JURNAL ANTIDADAH MALAYSIA Jadual 17 : Kesan Negatif Penggunaan Dadah No. Kesan Negatif Penggunaan Dadah Bilangan Peratus 1. Rasa menyesal Ya % Tidak % 2. Rasa malu Ya % Tidak % 3. Rasa sakit Ya % Tidak % 4. Tidak rasa bersalah Ya % Tidak % 5. Rasa putus asa Ya % Tidak % 6. Rasa seperti mahu mati Ya % Tidak % 7. Rasa hendak bunuh diri Ya % Tidak % IMPLIKASI KEPADA PEMULIHAN Sebilangan besar penagih dadah wanita menggunakan dadah selepas mereka berhenti sekolah dan kerana pengaruh kawan sebaya, bukan sahaja di tahap umur remaja, tetapi juga di tahap awal dan lanjut dewasa. Sebilangan besar juga menggunakan dadah dalam dan di tempat-tempat hiburan. Pendedahan awal kepada rokok dan alkohol juga kelihatan sebagai sesuatu yang agak lazim di kalangan kumpulan ini. Setelah bekerja, mereka membeli dadah dengan menggunakan pendapatan sendiri, tetapi bagi yang belum bekerja, mereka menggunakan wang daripada ibu bapa. Hal ini seharusnya diambil kira dalam merangka strategi rawatan dan pemulihan penagih wanita. Di samping itu, terdapat pelbagai kajian menemui bahawa wanita lebih terdedah kepada masalah jiwa, penyesuaian, mental atau psikiatri Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

119 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah (Bulik,1987, Duongsaa, 1989; Hesselbrock et al., 1985; Nace et al., 1986; Ross et al, 1988; dan Stocco et al., 2000). Kajian ini turut menemui bahawa di kalangan penagih wanita Sabah, dadah yang sering mereka gunakan ialah syabu, sejenis dadah ATS yang boleh membawa kepada kerosakan urat saraf dan otak. Kerosakan ini akan menyebabkan berlakunya 'drug psychosis', yang mana simptomnya adalah seperti halusinasi, delusi, paranoia dan ada kalanya kemurungan yang teruk. Keadaan ini dikukuhkan lagi dengan maklumat bahawa penggunaan dadah adalah kerana sebab-sebab seperti hendak menghilangkan kerungsingan (72.7%), melarikan diri daripada masalah (64.9%), menenangkan jiwa yang memberontak (39.0%), melepaskan diri daripada masalah perpecahan keluarga dan pergolakan rumah tangga (36.4%), melupakan masalah putus cinta (22.1%) dan ada sebilangan yang menggunakan dengan niat untuk membunuh diri (6.5%). Hal ini menunjukkan bahawa aspek penyesuaian, ketenangan emosi, penggunaan strategi daya tindak yang membantu menyelesaikan masalah, ketenangan dan kestabilan jiwa perlu diambil kira dalam rangka rawatan dan pemulihan wanita. Penelitian Mahmood (2005a; 2005b) mendapati bahawa gangguan-gangguan mental seperti ini telah membawa kepada episod kemurungan, yang juga pernah didokumentasikan oleh Vaglum et al. (1985) di kalangan wanita alkoholik. Ini bermakna khidmat psikiatri harus disediakan untuk pemulihan penagih wanita. Bagi mereka yang mengalami kemurungan dan psikosis lain, penilaian menyeluruh perlu dilakukan bagi mengetahui tahap kecelaruan yang dialami dan intervensi tingkah laku serta perubatan harus disediakan. Tambahan pada itu, bagi penagih wanita yang menghadapi masalah penyesuaian, maka haruslah diwujudkan 'partner in recovery' agar mereka boleh berkongsi pengalaman, emosi dan masalah dengan rakan sebaya (Mahmood 2003; Mahmood & Yunos 2004; Yunos & Mahmood, 2004). Tatacara ini didapati berkesan dalam rawatan dan pemulihan dadah secara TC yang dijalankan di Rumah Pengasih Malaysia (Yunos et al; 2004). Selain itu pengisian kepada jiwa yang kosong juga amat penting (Mahmood et al, 1997; Mahmood, 1995; 1999; Nelson-Zlupko, 1996). Sebilangan signifikan penagih yang ditemui adalah beragama Islam, dan Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

120 JURNAL ANTIDADAH MALAYSIA kebanyakan mereka amat kurang pengetahuan mengenai agama, apatah lagi melakukan ibadah seperti yang dituntut agama Islam. Memperkenalkan Islam semula secara mendadak mungkin akan menyebabkan mereka menolak terus agama. Oleh yang demikian, strategi pintar perlu dirangka oleh pakar agama bagi meniup semula jiwa Islam ke dalam diri mereka secara perlahan-lahan agar ia dapat diterima dengan rela hati. Keperluan ilmu agama ini diakui oleh penagih wanita yang mana 90.9% merasakan pendidikan agama sebagai penting kerana itu adalah pengisian jiwa yang bermakna kepada mereka untuk membantu menahan diri daripada terus menggunakan dadah. Pada masa yang sama, dalam sesi temu duga yang dijalankan di pusat-pusat pemulihan, mereka turut mengatakan bahawa kaedahnya perlulah sesuai dan berkesan. Walaupun usaha rawatan dan pemulihan dapat dimantapkan untuk penagih wanita, namun yang lebih penting ialah usaha untuk mencegah mereka daripada terlibat dengan penggunaan dadah. Pengaruh rakan sebaya, masalah disiplin di sekolah, sikap ambil peduli ibu bapa serta masyarakat adalah antara faktor yang harus diintegrasikan dalam program pendidikan pencegahan dadah. Kempen hubungan kekeluargaan, gaya hidup sihat serta kepentingan pembelajaran boleh digerakkan untuk membentuk pemikiran serta sikap remaja, ibu bapa dan masyarakat untuk bersama bergerak ke arah keharmonian kehidupan. RUJUKAN Agensi Dadah Kebangsaan. (2005). Laporan Dadah Negeri Sabah. Blume, S. B. (1988). Dual-diagnosis: Psychoactive substance dependence and the personality disorders, Journal of Psychoactive Drugs, 81(2): Bulik, C. M. (1987). Drug and alcohol abuse by bulimic women and their families, American Journal of Psychiatry, 144: Duongsaa, U. (1998). Women and Drugs: From Hard Realities to Hard Solutions. Seminar on Women, Gender and Drugs. Washington D. C. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

121 Trend dan Punca Penggunaan Dadah di Kalangan Penagih Dadah Wanita di Negeri Sabah: Implikasi kepada Rawatan dan Pemulihan Dadah Hesselbrock, M. N., Meyer, R. E. & Keener, J. J. (1985). Psychopathology in hospitalized alcoholics, Arch. Gen. Psychiatry, 42: Hser, E A.(1987). Sex differences in addict careers. First initiation of use. American Journal Drug Alcohol Abuse, 13 (1): Khantzian, E. J. & Treece, C. (1985). DSM-III psychiatric diagnosis of narcotic addicts, Arch. Gen. Psychiatry, 42: Mahmood, N. M. (1995). Peranan Keluarga dalam Pencegahan Relapse. Paper presented at the Workshop on Relapse Prevention and Counseling. 15 December, Home Ministry, Kangar, Perlis, Malaysia. Mahmood, N. M. (1999). Familial relationship and receptivity to drug rehabilitation programme: The Case of heroin addicts. Paper presented at the VI th European Congress of Psychology, July 4-9 th, Rome, Italy. Mahmood, N. M. (2002). Drug use among youth: A changing pattern. Paper presented at the 4 th Global Conference on Drug Abuse Prevention. May, 13-17, Penang, Malaysia. Mahmood, N. M. (2002). The influence of good familial relationship with the propensity to be drug free. A study amongst Malaysian psychoactive drug abusers. Poster presented at the Hawaii International Conference on Social Science, June 11-15, Honolulu, Hawaii. Mahmood N. M. (2003). Strategi daya tindak penagih berulang dan ringan: Implikasi kepada kaunseling penagihan, Malaysian Journal of Counseling (PERKAMA), 10, Mahmood, N. M. (2005a). Depression among female drug users in Malaysia. Paper presented at the Women s World 2005: 9 th International Interdisciplinary Congress on Women, June 19-24, Seoul, Korea. Mahmood, N. M. (2005b). Dual-diagnosis among women addicted to drugs Implications for gender-specific rehabilitation, Plenary paper presented at the Persidangan Psikologi Malaysia 2005, 31 st July 2 nd Aug., Kota Kinabalu, Sabah. Mahmood, N. M. & Edman, J. L. (1997). Differences in attribution styles among male and female heroin addicts. Malaysian Journal of Psychology (PSIMA), 11, Mahmood N. M. & Mohd Yunos Pathi Mohd. (2004). The role of family in preventing drug addiction. Paper presented at the 2 nd Asian Seminar on Family Support Group Network, 3-7 May, Colombo, Sri Lanka. Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

122 JURNAL ANTIDADAH MALAYSIA Mahmood, N. M., Nadiyah Elias & Noor Azizah Ahmad (1997). Pembinaan Moral di Kalangan Remaja. Paper presented at the Seminar for the Strengthening of Societal Moral Standards, th Nov., Universiti Malaya, Kuala Lumpur, Malaysia. Mohd Yunos Pathi & Mahmood, N. M. (2004). Kepentingan kumpulan sokongan keluarga dalam konteks rawatan dan pemulihan. Keynote address presented at the 1 st ASEAN Seminar on the Effect of Addiction on Families June, Kuala Lumpur. Nace, E. P. & Saxon, J. J. (1986). Borderline personality disorder and alcoholism treatment: A one-year follow-up study, J. Stud. Alcohol, 47: Nelson-Zlupko, L., (1996). Women in recovery. Their perception of treatment effectiveness. Journal of Substance Abuse Treatment. 13 (1): Rosenbaum, M. (1981). Women on Heroin. New Jersey: Rugers University Press. Ross, H. E., Glaser, F. B. & Stiasny, S. (1988). Sex differences in the prevalence of psychiatric disorder in patients with alcohol and drug problems, British Journal od Addicion, 83: Rounsaville, B. J. & Kleber, H. D. (1985). Untreated opiate addicts: How do they differ from those seeking treatment?, Arch. Gen. Psychiatry, 42: Rounsaville, B. J., Dolinsky, Z. S., Babor, T. F. & Meyer, R. E. (1987). Psychopathology as a predictor of treatment outcome in alcoholics, Arch. Gen. Psychiatry, 44: Thom, B. (1995). Research issues concerning women and treatment provision. Women and substance misuse, Brighton. Stocco, P., Liacer, J. J., DeFazio, L., Calafat, A. & Mendes, F. (2000). Women Drug Abuse in Europe: Gender Identity. Vaglum, S. & Vaglum, P. (1985). Borderline and other mental disorders in alcoholic female psychiatric patients: A case control study, Psychopathology, 18: Prof. Madya Dr. Sabitha Marican, Prof. Dr. Mahmood Nazar Mohamed & Prof. Dr. Rosnah Ismail, m/s

123 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents THE RELATIONSHIP BETWEEN THE AGE OF ONSET FOR DELINQUENT BEHAVIOR AND CHRONIC DRUG ABUSE AMONG ADOLESCENTS Mohd Muzafar Shah bin Hj. Mohd Razali 1 ABSTRACT The aim of this study is to investigate whether chronic drug abusers begin their involvement in delinquent behaviors at a significantly early age than non-chronic abusers. The total participants of this study consisted of 138 male adolescents from a drug treatment and rehabilitation center. Their ages ranged between 17 to 21 years old. The instruments used in this study are an adaptation version of the Measuring Risk and Protective Factors For Drug Abuse and Other Delinquents Behavior and the Drug Use Screening Inventory. The result shows that the majority of the chronic drug abusers began their involvement in delinquent behaviors at a significantly early age than the non-chronic abusers. The implications of this study towards developing counseling and preventive efforts are also discussed. ABSTRAK Tujuan kajian ini adalah untuk mengkaji sama ada penagih dadah kronik mula terlibat dengan tingkah laku delinkuen di tahap umur yang muda berbanding dengan penagih yang tidak kronik. Peserta yang terlibat dengan kajian ini adalah 138 orang remaja dari pusat rawatan dan pemulihan dadah. Julat umur mereka adalah di antara 17 hingga 21 tahun. Alat-alat ukuran yang digunakan dalam kajian ini adalah versi adaptasi Pengukuran Faktor Risiko dan Perlindungan bagi Penyalahgunaan Dadah 1 Lecturer, Department of Guidance and Counseling, Faculty of Cognitive Sciences and Human Development, University Pendidikan Sultan Idris (UPSI) Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

124 JURNAL ANTIDADAH MALAYSIA dan Tingkah Laku Delinkuen lain dan Inventori Saringan Penyalahgunaan Dadah. Dapatan kajian menunjukkan bahawa kebanyakan daripada penagih dadah kronik terlibat dengan tingkah laku delinkuen pada peringkat umur yang lebih awal berbanding dengan penagih yang tidak kronik. Implikasi kajian untuk membentuk usaha kaunseling dan pencegahan turut dibincangkan. INTRODUCTION The drug abuse problem in Malaysia, which was once perceived as a social malaise has, became a threat to national security. The government in 1983 elevated the drug problem to an unprecedented level of priority by declaring it as a security concern (Scorzelli, 1987). However, after two decades of the government s declaration on drugs as the country s number one enemy, the problem seems to be in the state of coming to an endless point. Despite the efforts done by the government and the support from various non-governmental organizations to control and prevent the drug menace, what has happened instead is the other way round as the situation has gotten more serious. According to Tay (1996), the incidence rate is deemed to be a reliable indicator on the dynamics of the spreading as well as the magnitude of drug abuse in Malaysia whereby the number of new addicts has increased from 7,389 persons in 1990 to 13,140 persons in 1995, of which is an increase of 77.8%. Besides that, the rate of relapse among addicts is also of great concern to the government. Mohamad Hussain and Mustafa (2001) stated that studies conducted have noted that 90% of them return to using heroin within six months after being discharged from the Serenti rehabilitation centres. About 40% claimed that they only maintain a drug free life for a duration of one month before returning to heroin again. In fact, there are relapsed addicts who have been in the Serenti rehabilitation centers for not less than five times. Yet they still return to abusing heroin after being discharged from the center. In cognizance of the seriousness of the drug problem, the government in 2003 declared war against drugs. The drug menace is not merely a problem among adults but has gradually influenced adolescents including school pupils too. The Ministry of Education (2003) reported that from 1992 to 2002, a total of Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

125 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents 2,643 pupils had been detected as being involved in various drug related offenses. Navaratnam (1992) estimated that for every single drug addict, there are another five individuals who are at risk of getting involved in this destructive habit. Therefore, based on his estimation and from the 1992 to 2002 drug abuse report by the educational ministry, there are approximately 13,000 teenagers who are potential drug abusers. The National Anti-Drugs Agency (2005) reported that there is a new trend among young people taking drugs such as amphetamine and ecstasy. According to Mohamad Hussain and Mustafa (2001), amphetamine is a stimulant drug, which has powerful effects on the brain. It can produce psychosis and for the chronic user, he or she will have labile mood and at times be violent. Ecstasy is a hallucinogenic drug and its effects are similar to amphetamine. These drugs are available in discos and nightclubs and are usually used to alter moods so that the user can dance and sing throughout the night without feeling exhausted. Malaysia is striving fast to be a developed nation by the year It cannot afford to have its younger generation crippled by drugs. These young people are the backbone of the country and the future of this country is in their hands. In order to achieve its vision, the country needs young people who are energetic and have the capability to contribute to the development of the country. Therefore, much effort must be taken by all parties in order to ensure a healthy, safe and productive life for all Malaysians. PROBLEM STATEMENT The age of onset for delinquent behavior is an important risk factor for drug abuse occurrences among adolescents. Delinquent behaviors such as smoking, sniffing glue and alcohol consumption are related to drug abuse. Cigarettes, alcohol and marijuana are known as the gateway drugs. Research has shown that young people are unlikely to use marijuana if they have not already used cigarettes or alcohol (Coombs and Ziedonis, 1995). Mohamad Hussain and Mustafa (2001) reasoned out that although not all smokers will be drug abusers but research among drug addicts found that all them are smokers. Numerous studies have also found a positive relationship between delinquency and drug abuse, with minor delinquency or deviant acts Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

126 JURNAL ANTIDADAH MALAYSIA typically preceding the onset of drug abuse (Brook et.al. 1998, DeWit & Silverman, 1995; Newcomb, 1992; Oetting & Beauvais, 1986; Petraitis et. al, 1995). Kandel, in her stage theory of drug abuse mentioned that participation at the first level puts adolescents at risk for progression to the next stage (Coombs and Ziedonis, 1995). The progression of these stages mentioned also included the age factor and the type of drugs used by those young users. For example, Kilpatrick et al. (2000) stated that drug abuse initiation at an early age increases the risk of dysfunctional use or abuse in later years. According to the National Institute on Drug Abuse (1997), research has shown that the earlier anyone gets involved in abusing drugs, the higher the risk for him or her to develop into a chronic user. For example, if an individual was to get involved in abusing drugs at the age of 12 and if this habit continuously surrounded his life, then by the age of 20 he might already be very much addicted to drugs. Of course, at this point of time great effort should be taken to help them recover and lead a normal life. However, this is easier said than done because drugs have completely taken control of their entire lives. In other words, for this particular group of drugs addicts, they cannot function as a normal person without taking drugs daily. Most of the researches on risk factors for drug abuse among adolescents have been conducted in other countries especially in the United States. It is from those studies that researchers develop various drug prevention models such as the information model, effective model and social influence models. Coombs and Ziedonis (1995) said that research on how drug abuse begins and continues has clear implications to the prevention program s goals and strategies. For example, keeping children or adolescents who have already experimented drugs from continuing the abusive patterns will probably require different and more intensive programs than those designed for the general population. In Malaysia, not many studies are conducted in the area of drug prevention although the problem is considered as the national number one enemy and the government has declared war against it. Thus, it is high time that more researches are needed in this area so as to develop effective prevention programs in the Malaysian context. Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

127 OBJECTIVE OF STUDY The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents This research is part of a larger study and its aim is to investigate the relationship between the age of onset for delinquent behaviors and chronic drug abuse among adolescents. In this research delinquent behavior refers to smoking, sniffing glue and drinking beer. RESEARCH QUESTIONS i. What is the user level of severity of consequences for drug abuse among adolescents? ii. Is there a difference on the age of onset for smoking among chronic drug abusers and non-chronic drug abusers? iii. Is there a difference on the age of onset for sniffing glue among chronic drug abusers and non-chronic drug abusers? iv. Is there a difference on the age of onset for drinking beer among chronic drug abusers and non-chronic drug abusers? METHODOLOGY This study was conducted at the Serenti Drug Rehabilitation Center in Karak, Pahang Darul Makmur. It is a drug treatment and rehabilitation center specifically for male adolescents. This center is run by the National Anti-Drugs Agency. The respondents of this study were 138 male adolescents whose age ranged between 17 to 21 years old. INSTRUMENTATION Two sets of instruments were used in this study. The first instrument is an adaptation of measuring risk and protective factors for drug abuse and other delinquent behaviors. It consisted of 140 items of which there are three questions concerning the particular age at which the respondents experimented with smoking, sniffing glue and drinking alcohol (For example: How old were you when you first smoked a cigarette, even if it was just a puff?; How old were you when you first sniffed glue to get high?; How old were you when you first drank beer, even just a sip?). The onset ages for the three items were categorized as never; 17 years old and above; years old; years old; 12 years old and below. The original instrument was developed by Arthur et al. (2002). The adapted instrument has Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

128 JURNAL ANTIDADAH MALAYSIA been through the process of translation into Bahasa Melayu and tested for its content validity and reliability. The Cronbach alpha for the adapted instrument is.88. The second instrument is an adaptation of one of the domains from the Drug Use Screening Inventory (DUSI) to measure the gradation of involvement and severity of consequences for drug abuse. It comprises of fifteen questions with either a yes or a no answer. (For example: Have you had a craving or a very strong desire for drugs?; Have you had to use more and more drugs to get the effect you desire?; Did you break the law or rules because you were high on drugs?). The score is computed by counting the endorsements ( yes responses = 1; no responses = 0). Subsequently, the total number of yes responses is divided by 15 and the quotient is then multiplied by 100. The overall severity index has a range of 0 100%. Cut-off scores for diagnosis are not provided but an overall density index exceeding 15% is considered as significant (Tarter, 1990). For the purpose of this study, respondents with a score of 0 15% were classified as non-chronic users. Respondents with scores of % were classified as chronic drug users. The original instrument was developed by Ralph Tarter (1990). The adapted instrument has been through the process of translation into Bahasa Melayu and has been tested for its content validity and reliability. The Cronbach alpha for the adapted instrument is.81. PROCEDURES One of the ways to examine the relationship between the age of onset for delinquent behavior and chronic drug abuse among adolescents is to compare the age at which the chronic drug abusers and nonchronic drug abusers began their abusive behaviours. DATA ANALYSIS The data was analyzed by using the Statistical Package for the Social Science (SPSS) version 11. The statistical procedure used in this study was the cross tabulation between the age of onset for smoking, sniffing glue and drinking alcohol with two levels of severity of consequences namely the non-chronic user and the chronic user. Meanwhile the onset ages for the three delinquent behaviors were grouped as follows: Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

129 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents Never ; 17 years old and above ; years old ; years old ; 12 years old and below. FINDINGS Research Question 1 : What is the user level of severity of consequences for drug abuse among adolescents? Table 1 shows the respondents user level of severity of consequences for drug abuse. Out of the 138 respondents who tested for their level of severity of consequences for drug abuse, 29% (40) were non-chronic users and 71% (98) were considered as chronic users. This implies that the majority of them are categorized as chronic drug users. Table 1 : Respondents User Level of Severity of Consequences for Drug Abuse User level Frequency Percentage Non chronic user Chronic user Total Research Question 2 : Is there a difference on the age of onset for smoking between chronic drug abusers and non-chronic drug abusers? Table 2 shows the comparison between the age of onset for smoking between non-chronic users and chronic users. The findings indicate that all of them are smokers. For both non-chronic and chronic users, the majority started smoking at the age of 12 years and below and as they got older the lesser the rate of first time smokers. In relationship to the age of onset for smoking, it is found that the majority of the chronic users started smoking at an earlier age than non-chronic users. This indicates that the earlier a drug addict starts smoking, the more chronic the user level of severity for drug abuse is. Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

130 JURNAL ANTIDADAH MALAYSIA Table 2 : Comparison Between the Age of Onset for Smoking and the User Level Age of onset User level Non chronic user Chronic user Total Never yrs. old and above 7.5% (3) 2% (2) 3.6% (5) yrs. old 17.5% (7) 10.2% (10) 12.3% (17) yrs. old 32.5% (13) 21.4% (21) 24.6% (34) 12 yrs. old and below 42.5% (17) 66.3% (65) 59.4% (82) Total 100% (40) 100% (98) 100% (138) Research Question 3 : Is there a difference on the age of onset for sniffing glue among chronic drug abusers and non-chronic drug abusers? Table 3 shows the comparison between the onset age for sniffing glue between non-chronic users and chronic users. The findings of the comparison on the age of onset for sniffing glue shows that not all of them had experienced it, the majority had never sniffed glue before. For the chronic users who sniffed glue, the majority had experienced it between 13 to 14 years old whereas for the non-chronic user they experienced it at an older age that is between 15 to 16 years old. This shows that the earlier a drug addict starts sniffing glue, the more chronic the user level of severity for drug abuse is. Table 3 : Comparing the Age of Onset for Inhaling Glue or Gum and the User Level Age of onset User level Never 17 yrs. old and above yrs. old yrs. old 12 yrs. old and below Total Non chronic user 62.5% (25) 10% (4) 15% (6) 7.5% (3) 5% (2) 100% (40) Chronic user 30.6% (30) 8.2% (8) 18.4% (18) 32.7% (32) 10.2% (65) 100% (98) Total 39.9% (55) 8.7% (12) 17.4% (24) 26.4% (35) 8.7% (82) 100% (138) Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

131 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents Research Question 4 : Is there a difference on the age of onset for drinking beer among chronic drug abusers and non-chronic drug abusers? Table 4 shows the comparison age of onset for drinking beer between non-chronic users and chronic users. The findings show that not all of them had experienced drinking beer. For the chronic user who has had experienced drinking beer, the majority of them experienced it at the age of 15 to 16 years old whereas for the non-chronic user they experienced it at an older age of 17 years and above. This shows that the earlier a drug addict starts drinking beer, the more chronic the user level of severity for drug abuse is. Table 4 : Comparing the Age of Onset for Drinking Beer and the User Level Age of onset User level Non chronic user Chronic user Total Never 30% (12) 9.2% (9) 15.2% (21) 17 yrs. old and above 35% (14) 25.5% (25) 28.3% (39) yrs. old 25% (10) 30.6% (30) 29% (40) yrs. old 10% (4) 28.6% (28) 23.2% (32) 12 yrs. old and below 6.1% (6) 4.3% (6) Total 100% (40) 100% (98) 100% (138) DISCUSSION AND IMPLICATION The findings on the respondents' user level of severity of consequences for drug abuse clearly shows that addiction is not categorized at any one level but it is of different levels for both the chronic user and the non-chronic user. It also shows that the majority of the respondents who are adolescents with drug abuse problems are classified as chronic users. Being a chronic drug user at a young age leads to a bigger problem whereby they develop a 'no drugs, no life' syndrome. In other words, drugs have taken control of their entire lives and they have to take drugs in order to maintain a normal life as others do. Putting them into the drug treatment and rehabilitation program is the right thing to do so that they can cope and manage their addiction. Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

132 JURNAL ANTIDADAH MALAYSIA In order to make the rehabilitation program more effective, it is suggested that chronic and non-chronic drug users be separated. As it is now, both users are treated with a single modality namely the 'tough and rugged' approach or are put into the Therapeutic Community program. By putting the two groups together, more harm is done because it is likely that the non-chronic users will learn and gain knowledge of many more drugs in the market. As a result they may want to try and experiment with other drugs that had been introduced by their friends at the center as soon as they leave the center. It is probably due to this factor that the rate of relapse among addicts who had undergone the drug treatment and rehabilitation programs in Serenti is becoming higher. Overall, the pattern of results is clear. Findings from the relationship between the age of onset for smoking, sniffing glue and drinking beer and chronic drug abuse indicates that the majority of the chronic drug abusers began their involvement in those three delinquent behaviors at a significantly earlier age than other abusers. The research on the relationship between the age of onset and chronic drug abuse among adolescents has clear implications for the prevention program's goals and strategies. There is a need for an effective strategy to curb and prevent drug abuse among adolescents. This could be well suggested by the implementation of drug prevention education in schools (Fisher & Harrison, 2000; Pagliero & Pagliero, 1996; Sales, 2004). The rationale is that children spend many of their waking hours in the classrooms (Tay, 1996). Schools have a captive audience that encompasses nearly everyone in the appropriate age range for primary prevention. They also provide opportunities for face-to-face communication and feedback, both of which enhance the prospects for changing behavior (Fisher & Harrison, 2000). They are micro communities within which a wide variety of educational, environmental and policy strategies can be implemented with respect to drugs. Schools are a fulcrum between homes and the wider community, through which communication and influence can pass in both directions (Tay, 1996). School counselors must take a vital role in leading the effort to not only prevent the influence of drugs at schools but at the same time Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

133 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents they have to draw up strategies to overcome the problem of gateway drugs namely cigarettes, inhalants and alcohol. School counselors have the advantage of providing school-based programs with the support from parents, community and other societal institutions. They must be proactive so as to develop drug preventive programs at the primary, secondary and tertiary level. They have to work with the school management to set up their own school s anti-drug policy as what schools are doing now to have their own visions and missions. In relation to this matter, school counselors should continuously run drug prevention programs instead of having it as an ad hoc program or at a certain time of the year, that is as a day or a week of anti-drugs campaign. Risk reduction programs and activities should address risks at or before the time they become predictive of later problems. Intervening early to reduce risk is likely to minimize the effort needed and maximize the outcome (Howell et. al., 1995). Interventions at the primary level should not only be focusing on giving information on the various kinds of drugs in the market and the dangers of it but more importantly is to impart the knowledge of how to resist the influence of abusing drugs. Therefore, school counselors must equip their students with the essential interpersonal skills such as managing feelings (being aware of and understanding their own feelings; learning to manage negative emotions such as anger, fear and hurt; developing self-confidence; and developing assertion skills in resisting pressures to use drugs), decision making (setting goals; gathering information; generating alternatives; evaluating the results of a decision; making the right choice by saying 'no' to drugs), communication (sending clear messages; listening; learning positive strategies for handling conflicts and solving problems) and personal skills (handling stress; time management; thinking positively; and setting achievable goals). CONCLUSION The influence of drug abuse is still prevalent in our society and if it is left unattended or if no preventive measures are taken, we will be in a critical situation when this phenomenon becomes totally out of control. If more and more of our young citizens come under the influence of drugs then many more social problems will occur because it is related to other delinquent and anti-social behaviors. In the long run this multiple effect problem will create chaos within the family and the community Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

134 JURNAL ANTIDADAH MALAYSIA and greatly ruin the vision envisaged by the government to be a developed nation by the year Therefore, continuous prevention efforts to overcome the drug abuse problem must begin at an early age because the earlier they start experimenting drugs then the sooner they will become addicted to it. It is high time for all concerned parties at various levels including the individual, family, school, community, voluntary organizations and the government to work collectively in order to overcome this problem for a better future for our coming generations and our beloved nation. Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

135 The Relationship Between Age of Onset For Delinquent Behaviour and Chronic Drug Abuse Among Adolescents REFERENCES Arthur, M.W., Hawkins, J.D., Pollard, J.A., Catalano, R.F. & Baglioni Jr., A.J. (2002). Measuring risk and protective factors for substance use, delinquency, and other adolescent problem behaviors. Evaluation Review. 26, 6, Brook, J.D., Brook, D.W., de la Rosa, M., Fernando, D., Rodriguez, E., Montoya, I.D., & Whiteman, M. (1998). Pathways to marijuana use among adolescents: cultural/ecological, family, peer, and personality influences. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 7, Coombs, R.H. & Ziedonis, D. (eds) (1995). Handbook on drug abuse prevention. A comprehensive strategy to prevent the abuse of alcohol and other drugs. Boston: Allyn and Bacon. DeWit, D.J. & Silverman, G. (1995). The construction of risk and protective factor indices for adolescent alcohol and other drug use. Journal of Drug Issues. 25, 4, Fisher, G.L. & Harrison, T.C. (2000). Substance abuse: Information for school counselors, social workers, therapists and counselors (2 nd ed.). Boston: Allyn and Bacon. Glantz, M. & Pickens, R. (eds) (1992). Vulnerability to drug abuse. Washington D.C.: American Psychological Association. Hawkins, J.D., Catalano, R.F. & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescnce and early adulthood: implictions for substance abuse prevention. Psychological Bulletin, 112, 1, Howell, J.C., Krisberg, B., Hawkins, J.D. & Wilson, J.J. (eds) (1995). A sourcebook. Serious, violent & chronic juvenile offenders. Thousand Oak: SAGE Publications. Kilpatrick, D.G., Acierno, R., Saunders, B., Resnick, H.S., Best, C.L. & Schnurr, P.P. (2000). Risk factors for adolescent substance abuse and dependence: data from a national sample. Journal of Consulting and Clinical Psychology, 68, 1, Malaysia, Ministry of Education (2003). Drug abuse and inhalants report in schools. Kuala Lumpur: KPM. Malaysia, National Anti Drug Agency (2005). Statistics of drug addicts. Putrajaya: AADK. Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

136 JURNAL ANTIDADAH MALAYSIA Mohamad Hussin Habil & Mustafa Ali Mohd (2001). Managing drug addiction: mission is possible. Ampang: Penerbitan Salafi. National Institute on Drug Abuse (1997). Drug abuse prevention for at-risk individuals. NIH Publications No Rockville: National Institute on Drug Abuse. Navaratnam, V. (1992). An overview of drug abuse problem in Asia with specific to youth. Kertas kerja yang dibentangkan di 14 th IFNGO Conference, 7 11 Disember. Kuala Lumpur. Newcomb, M.D. (1992). Understanding the multidimensional nature of drug use and abuse: The role of consumption, risk factors, and protective factors. In M. Glantz & R. Pickens(eds). Vulnerability to drug abuse. Washington D.C.: American Psychological Association. Oetting, E.R. & Beauvais, F. (1986). Peer cluster theory : Drugs and the adolescent. Journal of Counseling and Development, 65, Pagliero, A.M. & Pagliero, L.A. (1996). Substance use among children and adolescents: Its nature, extent, and effects from conception to adulthood. New York: John Wiley & Sons, Inc. Petraitis, J., Flay, B.R. & Miller, T.Q. (1995). Reviewing theories of adolescent substance use: organizing pieces in the puzzle. Psychological Bulletin, 117, 1, Sales, A. (2004). Preventing substance abuse. A guide for school counselors. USA: CAPS Press. Scorzelli, J. (1987). Drug abuse: Prevention and rehabilitation in Malaysia. Bangi: UKM Publisher. Tarter, R. (1990). Evaluation and treatment of adolescent substance abuse: A decision tree method. Journal of Drug and Alcohol Abuse, 16, Tay, B.H. (1996). Evaluation of drug abuse prevention programmes in Malaysia. Drugs: education, prevention and policy. 3, 2, Mohd Muzafar Shah bin Hj. Mohd Razali, m/s

137 Relapse Prevention: Strategies and Techniques RELAPSE PREVENTION: STRATEGIES AND TECHNIQUES James F. Scorzelli 1 ABSTRACT This article presents some views of strategies and techniques of relapse prevention in the context of drug treatment and rehabilitation in Malaysia. It outlines some strategies for relapse prevention, with the primary focus on anxiety reduction among drug dependents through several approaches such as spiritual, muscle relaxation and emotional imagery techniques. However, in Malaysia, focus should be given to finding employment for recovering drug dependents because they had a positive employment record before they were brought in for treatment and rehabilitation. The article also touches on the service delivery system of the drug rehabilitation program which among others suggests capacity building of personnel involved in the program. ABSTRAK Artikel ini membentangkan strategi dan teknik pencegahan penagihan semula dengan merujuk kepada program rawatan dan pemulihan dadah di Malaysia. Ia menggariskan beberapa strategi pencegahan penagihan semula dengan memberi tumpuan kepada pengurangan kebimbangan melalui beberapa pendekatan seperti kerohanian, teknik-teknik penyantaian otot dan pembayangan perasaan. Walaupun demikian, di Malaysia, tumpuan harus diberikan kepada mencari pekerjaan untuk mereka yang menghadapi masalah kebergantungan kepada dadah kerana mereka mempunyai rekod pekerjaan yang agak baik sebelum dimasukkan ke program pemulihan dadah. Artikel ini turut menyentuh isu mengenai sistem penyampaian perkhidmatan yang antara lainnya mencadangkan peningkatan keupayaan kakitangan yang berkhidmat dengan program rawatan dan pemulihan dadah. 1 Professor Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, USA Prof. Dr. James F. Scorzelli, m/s

138 JURNAL ANTIDADAH MALAYSIA INTRODUCTION Drug abuse is a major health concern and has reached epidemic proportions. The seriousness of drug abuse as a threat to the security of a country was best illustrated when Malaysia, on February 19, 1983, declared its drug problem a national emergency and launched a massive effort in law enforcement, preventive education and rehabilitation to eliminate this drug or dadah menace. When drug abuse is discussed, one often fails to mention the vast contributions of medical research which has resulted in the discovery of a wide variety of drugs and antibiotics, which besides eliminating many of our most feared diseases, have been responsible for the world s present level of technology and scientific sophistication. Few of us would dare question the importance and benefits of Pasteur s discovery of vaccines in 1828, the development of sulfur drugs, or the development and use of tranquillizers to treat the mentally ill. The fact that the world is small pox-free is still difficult for many people to comprehend and because of the discovery of the Salk vaccine; parents no longer need to fear the dreaded child crippler of polio. Although these medical miracles have been of immense benefit to humankind, they have also contributed to the mentality that drugs are a panacea, and can cure all of our ills. The enormous amphetamine epidemic that Japan faced after World War II was caused by both poor regulation and the belief that amphetamines could provide a person with the extra energy and zip necessary to help in the rebuilding of his or her war torn country. In fact, most of today s dangerous drugs were at one time viewed as panaceas. Morphine was supposed to be a non-addictive anesthetic or analgesic. A similar view was held when heroin was first synthesized. In fact, it took the medical profession 13 years before they acknowledged that a person could become physically dependent on heroin. Although the discovery of LSD was by accident, it was initially viewed as a possible treatment for schizophrenia and lauded for its mind expanding qualities. Therefore, it is the belief that drugs can be used as a means of problem solving and/or as a life organizing factor that contributes to abuse. Furthermore, I sincerely believe that a person must make a commitment that he or she wants to be drug-free. If not, I don t feel that any intervention strategy will be effective. Prof. Dr. James F. Scorzelli, m/s

139 Relapse Prevention: Strategies and Techniques I recall an old study that indicated that a person who simply decided to stop using drugs was as successful at maintaining sobriety as someone that avails him or herself to any of the numerous treatment interventions. Thus, I support the stages of change put forth by James Prochaska and Carlo DiClemente. It is interesting to note that Prochaska s interest in self change for the addict was aroused out of his anger and disappointment at not being able to help a person who was an alcoholic and was frequently depressed. That person was his father, who denied that he had a problem with alcohol, refused professional help and died when Prochaska was a junior in college. Anyway, the theory of self-change involves six stages including Pre-contemplation, Contemplation, Preparation, Action, Maintenance and Termination. In Pre-contemplation, although others may believe the person has a problem with drugs, he or she denies it and the issues that others see as problems are viewed by the person as trusted ways of coping and as being under control. In Contemplation, the person admits that he or she has a drug problem and tries to understand how things got to be the way they are. He or she acknowledges that change is necessary but that the intended effort will be in the future. The person will delay any attempts to stop until there are perfect conditions. Unfortunately, there are never perfect conditions in life. In Preparation, the person is certain that the right decision is to stop taking drugs and makes arrangements to do so. The plan should be specific and realistic. In Action, the person takes the necessary steps that were developed during the Preparation stage. In Maintenance, he or she acknowledges a vulnerability to resort to old ways but makes a sustained effort to avoid relapses. In Termination, old behavior or cravings no longer tempt the person, and he or she has no fear of relapse. In this theory, it is important to note that the therapist acknowledges that a slip does not constitute a relapse. Among selfchangers, 20% or less are completely successful in the first attempt and it is normal to recycle several times. RELAPSE REVOLVING DOOR SYNDROME A major problem with treating drug abusers is the high recidivism rate. In America, research studies have indicated that the relapse rate (based on the use of one year as the time period) can range from 50% to 75%. I often use the term, revolving door syndrome when discussing the treatment of the drug abuser. That is, the addict comes for treatment, leaves and then returns. Prof. Dr. James F. Scorzelli, m/s

140 JURNAL ANTIDADAH MALAYSIA In Malaysia, 1986 as a reference date to record drug addits in the country, and based on that, the relapse rate is approximately 75%. There are two ways to look at recidivism and drug usage. The first view is that of the self-help movement or the 12 steps, such as Narcotics Anonymous. Their belief is that addiction is a disease and has no cure. Furthermore, relapse is a normal part of the disease process and can be expected since it may take many relapses before a person is able to maintain sobriety. Although this view has many supporters, and if applied to Malaysia, would indicate that your high relapse rate should be expected because addiction is a disease. Furthermore, the government should be tolerant because it may take a released inmate several attempts before he or she can maintain sobriety. A Learning Process Another view, which I adhere to, is that addiction is a learning process. That is, people learn either consciously or unconsciously, to become addicts and then they assume a deviant identity. They become addicts because of their positive expectations of the effects of drugs. Therefore, if a drug resulted in no positive effects, a person would not be motivated to take it. Thus, I believe a possible treatment approach for the opiate dependent is the use of opiate antagonists. These are drugs that block the receptor sites in the brain and prevent an opiate from occupying the site and having its effect. Nevertheless, this approach is not used in Malaysia. High-risk Situation With respect to relapse, I believe that it occurs when a person is in a high risk situation. This may pertain to a place, people or things (straw, needle or pipe). If the individual has good coping skills, he or she should be able to resist the temptation of drug usage. By resisting, he or she feels better, is reinforced and his or her self-efficacy is enhanced. With respect to rehabilitation and prevention, it is important to help clients identify their high risk situations and then to teach them how they can be avoided. However, this is often easier said than done in that an inmate who is released from a center may find him or herself among previous acquaintances who use drugs or in situations where drugs are used. If the person has poor coping mechanisms, then he or Prof. Dr. James F. Scorzelli, m/s

141 Relapse Prevention: Strategies and Techniques she will use it voluntarily. When this is done, there is often self-blame and guilt, which unfortunately will lead to relapse. Service Delivery System In trying to explain the high relapse rate in Malaysia, one first must look at the rehabilitation model. This model is excellent in that research indicates that the longer a drug addict is confined to a treatment facility, the greater will be his or her chances of recovery. Thus, the 16-month program in a rehabilitation center should enhance sobriety. Because this is not happening, one must now look at the service delivery system. In order to truly help the drug abuser, who is in a rehabilitation center, the counselors must be well trained and competent in dealing with the substance abusers. The training received at the Islamic Science University of Malaysia (USIM) and Universiti Malaysia Sabah (UMS) is an example of this level of competency. Furthermore, the religious teachers should be competent in the area of drug abuse. He should know the causes of addiction and have an understanding of the effects of drugs. Finally, there is a need for trained, well-qualified occupational therapists. An occupational therapist is a professional who helps a client have an independent and productive life. They can help improve the person s coping skills, time management skills and help them develop activities that they can enjoy. They can plan work activities and assess whether the client is able to work, as well as develop recreational activities. It is important to note that sometimes drug abuse results from boredom in that the person does not know what to do with his or her free time. STRATEGIES In addition to improving the qualifications of the personnel in the rehabilitation centers, in the remainder of this presentation I will also propose two strategies that I feel would be effective in helping the inmate develop good coping skills so that he or she can resist temptation once he or she is released. First of all, when one reviews the research about factors which help maintain sobriety, one finds evidence of a variety of personality Prof. Dr. James F. Scorzelli, m/s

142 JURNAL ANTIDADAH MALAYSIA correlates and environmental factors that are supposedly related to sobriety or relapse. The personality correlates range from anti-social behavior to depression, while the environmental factors consist of things such as unemployment and family dysfunction. However, there are only two things that always appear consistent and this is anxiety reduction and employment. There is a belief among many that drug addicts take drugs as a means of self-medication. Among opiate addicts, there is a belief that drug usage is ultimately for anxiety reduction. Thus, one can find many research and position papers that discuss the importance of anxiety reduction in treating the opiate dependent. Within the last two years, I have conducted two empirical studies, on drug addiction and recidivism. The first consisted of reviewing the psychological evaluations of 266 drug addicts, of which 75% or 200 were opiate dependent. Of this group, 140 or 70% had anxiety disorders. The majority consisted of white, single males and the mean age was 28.6 years. The results of the study indicated that there was a significant relationship among the opiate dependent and a diagnosis of an anxiety disorder. The anxiety disorders of the sample ranged from panic disorders to generalized anxiety disorder. In a follow-up that involved a letter and a phone call, 77 or 55% of those clients with an anxiety disorder responded. Among the 77 clients, 54 or 70% stated that they sought out treatment for their anxiety. The treatment consisted of methadone maintenance that included weekly drug counseling sessions, the use of benzodiazepines with a psychiatrist and individual counseling. All these clients stated that their anxiety was either eliminated or significantly reduced. Furthermore, all of them had a negative urinalysis for opiate use. Therefore, this small study was supportive of the research that indicates that anxiety reduction may be one way to help a client maintain sobriety. However, anxiety reduction only pertains to opiod abuse, and does relate to cannabis, ecstasy or shabu the other drugs that are causing difficulties in Malaysia. I believe that anxiety reduction is beneficial in itself and the beneficial results would carry over. This reminds me of what I do when I teach a class in substance abuse. Prof. Dr. James F. Scorzelli, m/s

143 Relapse Prevention: Strategies and Techniques I always ask the students whether they smoke cigarettes. Of those that raise their hands, I then ask them to give the reasons for smoking. In all cases, the first reason given by the students is to reduce tension, stress or anxiety. I find this amusing, since you all know that nicotine is a stimulant, and it will not cause someone to relax. Yet, all the students still have the false belief that cigarette smoking results in relaxation. Spiritual Approach There are many ways to help a person reduce his or her anxiety. Among them are meditation and yoga as well as centering prayer. With respect to the latter, centering prayer is a spiritual technique in which a person focuses on a religious name, such as a prophet or God, closes his or her eyes, and repeats the name many times silently. As he or she does that, the tension leaves one s body. Of course, a person would have to believe in God to use the centering prayer. Progressive Muscle Relaxation The last two methods are referred to as muscle relaxation and emotive imagery. In muscle relaxation, a person tightens each of his muscle groups for 10 seconds three times. It takes about 30 minutes to go through the process but when completed the person is completely relaxed. For example, make a fist. Make it tighter, tighter and then release it. As you release, for a few microseconds, you felt the tension leave your hands and wrists. Thus, that body part was relaxed. The technique begins at your toes, and ends at your forehead in that you tighten the muscle group and then release it. With practice, a person can complete the exercises in less time. Emotional Imagery Emotional imagery involves the use of your active imagination in that you are actually imagining being in a specific situation. Basically, a client is asked to describe two situations, other than drug usage, which are relaxing to him or her. Once the situations are described, the client is asked to imagine as vividly as he or she can, that he or she is in the situation. When the person does that, he or she is relaxed and will not be anxious. In summary, these approaches are really counter conditioning or that you cannot stand and sit down at the Prof. Dr. James F. Scorzelli, m/s

144 JURNAL ANTIDADAH MALAYSIA same time, or in these examples, it is impossible to be anxious if you are relaxed. Thus, I am suggesting that when you counsel an inmate in a rehabilitation center or prison, that you help him or her learn how to reduce his or her anxiety through any of these methods. Although I personally prefer muscle relaxation or emotive imagery, any one of these techniques will be effective. Therefore, once released the inmate is now able to reduce his or her anxiety without taking an opiate. Employment The last approach is employment, and again, I would like to briefly describe an empirical research study that I have conducted. In this study, a group of 110 opiate dependent patients of an outpatient detoxification center was the initial sample, and with their informed consent, demographic information, which included their employment status, was collected. The mean age of the group was 30.2 years, and most were white, single males. Briefly, outpatient detoxification is a medical approach in which a physician, with a specialty in addiction medicine, helps a client medically withdraw from a substance. Basically, the patient will see the physician seven times during a twoweek period, and he or she is given a prescription for two days that includes anti-anxiety drugs, drugs to relieve nausea, muscle aches, diarrhea, chills, and all the signs of physical withdrawal. Each time the person sees the physician, he or she is given a urinalysis to ensure that he or she is still drug-free. After two weeks, the person is now free of the addictive drug, and a follow-up appointment is made for six months. Sometimes the patient may be prescribed an opium antagonist, or if he or she is an alcoholic, antabuse or campral. Campral is a new drug that when combined with counseling helps an alcoholic maintain sobriety. Once the demographic information was collected, each client was given the MMPI-2, which is a personality test that assesses psychopathology. Briefly, the MMPI was developed in 1941 by a physician J. Charnley McKinley, and a psychologist, Starke Hathaway. The purpose of the test was to identify psychiatric disorders. Although the test was unable to do so, it did provide a thorough description of a person s abnormal behavior. The test has three validity scales and ten clinical scales. Since there are numerous studies about the MMPI, Prof. Dr. James F. Scorzelli, m/s

145 Relapse Prevention: Strategies and Techniques many supplementary scales have been developed during the last 50 odd years. However, in my study, I only used the original clinical scales. I will provide a brief overview of the MMPI for the benefit of those who has not been exposed to the instrument. First of all, the validity scales include a L or fake good scale, a F or fake bad scale and a K, or defensive scale. A high score on any of these scales may invalidate the test, since a high score on L or Lie would artificially deflate the clinical scores, a high F (eccentric responses that only 10% of the normal ones endorsed) would artificially elevate the clinical scales, and a high score on the K scale would artificially deflate the clinical scores. The clinical scales include: Scale 1 is anxiety related to bodily concerns or hypochondrias, Scale 2 is depression, Scale 3 measures anxiety or a person s inability to deal with any type of stress, referred to as hysteria; Scale 4 is immoral or sociopathic behavior, referred to as psychopathic deviate; Scale 5 is for masculine-feminine. When first developed, there was a belief that homosexuality was abnormal, and thus, if you are a male and got a high score it would indicate that your interests, likes and dislikes were more like women. Thus, the scale measures stereotype attitudes of women and men. When I was a child, only women were nurses and only men were police officers. But now as you know, there is no longer that much of gender biasness in the world of work and I usually ignore this scale. Scale 6 is paranoia; Scale 7 is really a measure of obsessive-compulsiveness; Scale 8 is schizoprehenia; Scale 9 is hypomania or hyper activity and agitation while Scale 10 is social-introversion. A high score on this scale indicates that the person is introverted. The test uses t-scores, mean 50 and s.d. of 10. Based on the 1989 revision (MMP-2) a high score is 65 or above and a low score is 35 and below. After six months, the clients were recontacted for a follow-up visit. Of this initial group, only 65 could be contacted, and of this 65, most had relapsed (self-report and positive urinalysis). A discriminate function analysis was used to determine what factors could discriminate clients who maintained sobriety versus those who relapsed. First of all, there were no significant differences between the sober group and those who relapsed on any of the MMPI- 2 scales. Surprisingly, most of the clinical scales, especially the three Prof. Dr. James F. Scorzelli, m/s

146 JURNAL ANTIDADAH MALAYSIA anxiety scales were very high and the validity scale of F was high for both groups of subjects. Therefore, the clinical scales may have been artificially elevated, but again t-tests indicated no significant differences between the groups. In fact, the only significant factor was employment in that those who maintained sobriety versus those who relapsed were more likely to be employed. The relationship between employment and sobriety again supported the literature on methods that prevent relapse. With respect to Malaysia, I feel that if inmates were provided with suitable employment upon their release, this employment would enhance their self-esteem, increase their self-efficacy, and decrease the risk of relapse. Even though work does not have to involve paid employment and can pertain to any physical or mental activity, it is usually described in the framework of an activity resulting in some type of financial reimbursement. Most people, when asked, Why do you work? will probably indicate that they work in order to provide for themselves and their families with the basic needs of food and shelter. However, there are also other reasons that people work, and it may involve such things as a higher standard of living, contributing to humankind, a feeling of accomplishment, or that work is fulfilling and provides a sense of intrinsic satisfaction. Ideally, this last reason, a sense of intrinsic satisfaction, is of major importance when discussing the meaning of work, and is the best criteria in determining whether a person has obtained an optimal level of vocational adjustment. This is well illustrated by Japan, in that fostering employee satisfaction among its workers, the country has become a major industrial power, and has the second highest gross national product in the world (GNP). As previously stated, there is a relationship between drug abuse and un/under employment. I apologize for the oldness of the data, but in a study in 1984, when there were only six rehabilitation centers in the country, approximately 83% of the inmates were employed before their detention. However, in examining the positions held by these drug abusers, the jobs were mainly unskilled and transitory in nature. In fact, in a survey of 300 inmates at the Pusat Serenti Rehabilitation Center, 19.7% were previously unemployed (compared to the national rate of 9%) and most of their jobs were unskilled, with Prof. Dr. James F. Scorzelli, m/s

147 Relapse Prevention: Strategies and Techniques labourer, being the most frequently identified occupation. Now, it would be interesting to examine the employment rates in 2006, but I believe they may be similar. That is, the inmates worked only to obtain the basic needs of food and shelter, and that their work was not intrinsically satisfying. Many drug abusers are unable to find or keep employment because of the lack of basic behaviors necessary for employment. Therefore, before one can implement vocational training and placement programs, attention must be focused on correcting these deficit behaviors. The term work adjustment training refers to the procedure and is frequently the first step in the process of community reintegration. As stated, the occupational therapist can help the inmate with preparation for the eventual entry into the world of employment. This may be incorporated into any work related activity, and enables a client to understand the importance of work factors such as production rates, quality of work, role of supervisors, how to get along with fellow employees, proper dressing and other work related behaviors. The drug abuser, because of an unsteady employment history and related personality problems may lack those appropriate work behaviors that many of us take for granted. In helping the client correct these hindrances to employment, counseling, group discussions and simulated work are helpful. Moreover, transitional or supported work can be beneficial. This involves a job structuring technique in which a worker or group of workers (work crew) are provided with subsidized employment. The work brigade at the palm oil estates would be an example of this in Malaysia. As can be seen, it is important that vocational counseling or work adjustment training is implemented in the rehabilitation centers. Furthermore, it would be helpful if all the major corporations or companies in the country would agree to hire a selective number of inmates, based on the recommendations of the rehabilitation staff. By providing jobs, that involved a career ladder, inmates would have an incentive to remain drug free. Furthermore, a job which is satisfying will enhance one s self-esteem, strengthen self-efficacy, which in turn strengthens one s coping skills. Prof. Dr. James F. Scorzelli, m/s

148 JURNAL ANTIDADAH MALAYSIA CONCLUSION In closing, I would like to caution the audience that these are only my views and opinions, that I am a foreigner, and not a Malaysian. Yet all positions that were taken are backed by research. Therefore, if the personnel in the rehabilitation centers are well trained, anxiety reduction is utilized during counseling, and the inmates receive vocational counseling, work adjustment training and suitable employment, the relapse rate in Malaysia should significantly decrease. Prof. Dr. James F. Scorzelli, m/s

149 Harm Reduction Programme in Thailand HARM REDUCTION PROGRAMME IN THAILAND Usaneya Perngparn 1 ABSTRACT This article is specifically on the harm reduction programme that has been in practise in Thailand in the past as well as the present on-going project. The Thai government s initiative in declaring war against drugs has greatly helped in this programme. The working group on HIV and Drug Risk Reduction have outlined six projects, from public awareness right up to the prevention of HIV in prisons. Careful implementation and coordination would be the key success factors in order to make these projects successful. ABSTRAK Artikel ini adalah berkenaan program harm reduction yang dijalankan di Thailand. Dalam usaha memerangi dadah, kerajaan Thai telah pun mengisytiharkan program antidadahnya pada peringkat nasional. Enam projek telah dikenal pasti oleh jawatankuasa HIV dan Drug Risk Reduction. Ianya meliputi program kesedaran awam sehingga kepada usaha mengelak jangkitan HIV di penjara. Program-program ini memerlukan perancangan yang rapi dan dijalankan secara teratur untuk memastikan ikejayaannya. Epidemiology of Drug Use in Thailand Among the many drugs used in Thailand, opium has its longest history of usage dating back to the year This was when it was legalized and by the 20 th century, opium dens were common. After the closure of many opium dens over the past 40 years, in 1959, opium smoking and selling were finally banned. This change of policy resulted in a shift to 1 Drug Dependence Research Centre (WHOCCR), Institute of Health Research, Chulalongkorn University Bangkok, Thailand Usaneya Perngparn, m/s

150 JURNAL ANTIDADAH MALAYSIA the usage of heroin, and consequently, heavy importing of the substance. (Poshyachinda 1982) 2. In the 1970 s, injecting heroin and smoking cannabis, opium, morphine and methamphetamine (yaba) increased tremendously. It wasn t until the mid 1990 s that heroin s popularity weakened, and the drug trend towards amphetamine-type-stimulants (ATS) amplified, which in turn has driven the price increase of heroin. (Office of the Narcotics Control Board (ONCB), Thailand ; Farrell et al ). The most common method used for heroin is by injecting of which the rate of users rose from about 50% in 1994 to nearly 80% by the end of that decade. By 2001, heroin accounted for only approximately 10% of the illicit drug market; however, in Bangkok there were still 40,000 heroin users of whom 90% were injecting themselves (ESCAP/UNODC/ UNAIDS 2001) 5. The age range of heroin users is older than that of ATS users. In 2002, an estimated 0.5% of the general population abused opiates (UNODC 2004a) 6. The first stimulant abuse epidemic occurred in the late 1970s, concurrent with the second wave of the heroin epidemic. Since then, local manufacturing of ATS increased dramatically, with methamphetamine, ephedrine, and caffeine being common ingredients in ATS tablets. As indicated by law enforcement statistics, the ATS retail market expanded extensively and women over the age of 40 were assuming a progressively greater role in the retail distribution of ATS (Poshyachinda et al 2000) 7. ATS is most commonly smoked or ingested, though there have been reports of injecting. The transition to ATS in Thailand is described in several reports. 2 Poshyachinda V 1982, Heroin in Thailand. Bangkok: Drug Dependence Research Center, Institute of Health Research, Chulalongkorn University 3 Office of the Narcotics Control Board 1996, A Rapid Survey of Impact from Heroin Price Escalation on Illicit Retail Distribution and the Users. Bangkok 4 Farrell M, Ali R, Ling W, Marsden J 2002, The Practices and Context of Pharmacotherapy of Opioid Dependence in South-East Asia and Western Pacific Regions. Department of Mental Health and Substance Dependence, World Health Organization. Geneva 5 ESCAP/ UNODC/ UNAIDS 2001, Injecting Drug Use and HIV Vulnerability: Choices and Consequences in Asia and the Pacific. Report to the Secretary General for the Special Session of the General Assembly on HIV/AIDS. Bangkok 6 UNODC 2004a, World Drug Report. Volume 2: Statistics. Vienna 7 Poshyachinda V, Perngparn U and Danthumrongkul V 2000, The Amphetamine-Type- Stimulants Epidemic in Thailand: A Case Study of the Treatment, Student, and Wage Laborer Populations. CEWG Community Epidemiology Work Group, National Institute on Drug Abuse Usaneya Perngparn, m/s

151 Harm Reduction Programme in Thailand From 1990 to 2002, heroin users being arrested and treated were decreasing, ATS users were markedly increasing and reached its peak in Nevertheless, the War on Drugs policy in Thailand has affected the reduction of ATS usage. The comparison of the 2001 and 2003 national household surveys on drug abuse also confirmed the decreasing trend of ATS usage but the trend of club drugs and kratom (mitragynine or biak/ketum a term commonly used by Malaysians) have also increased (Poshyachinda et al 2005) 8. Although, the data on heroin users showed minimal decreases, the sample size was too small to indicate a definite interpretation (The Administrative Committee of Substance Abuse Academic Network, ONCB, Thailand 2004) 9. However, ATS was still the most prominent drug used in According to recent reports assessing the impact on drug users who inject themselves in Chiang Mai, northern Thailand (Vongchak et al 2005) 10, most of them who could not obtain heroin turned to alcohol, ATS and sleeping pills as substitutes. Subsequently, the use of cannabis increased in Mookdaharn, Nakornpanom and Sakonakorn. In addition, volatile substances are particularly used by the younger population. Epidemiology of HIV/AIDS in Thailand Two decades have passed since the first case of acquired immunodeficiency syndrome (AIDS) was reported in ,12,13 The rapid outbreak among high risk groups of which the best known were the intravenous injection drug users (IDU) and the female commercial sex worker (CSW), has changed considerably mainly due to strong national responses. 8 Poshyachinda V, Sirivongse ANA, Aramrattana A, Kanato M, Assanangkornchai S, Jitpiromsri S 2005, Illicit Substance Supply and Abuse in : An Approach to Assess the Outcome of the War on Drug Operation. Drug and Alcohol Review (September), 24, The Administrative Committee of Substance Abuse Academic Network, Office of Narcotic Control Board 2004, 2003 National Household Survey on Drug Abuse. Bangkok 10 Vongchak T, Kawichai S, Sherman S, Celentano DD, Sirisanthana T, Latkin C, Wiboonnatakul K, Srirak N., Jittiwutikarn J and Aramrattana A The influence of Thailand s 2003 war on Drugs Policy on Self-reported Drug Use among Injection Drug Users in Chiang Mai, Thailand. International Journal of Drug Policy 16: Bureau of Epidemiology, Ministry of Public Health 1984.Weekly Epidemiological Surveillance Report,15(39): Phanuphak P, Locharernkul C, Panmuong W and Wide H A Report of Three Case of AIDS in Thailand, Asian Pacific J. Allerg Immun, 3: Limsuwan A, Kanapa S. and Siristonapun Y Acquired Immune Deficiency Syndrome in Thailand. A report of Two Cases, J Med Assoc Thai, 69(3): Usaneya Perngparn, m/s

152 JURNAL ANTIDADAH MALAYSIA Sentinel surveillance was introduced in June Henceforth, the HIV epidemic in Thailand can be presented in four categories, i.e. firstly in IDUs, secondly among sex workers, thirdly among the male partners of sex workers and finally the general population (World Bank 2000) 14. In 2003, approximately 1.7% of the 36 million population, between the ages of years, were reported to be HIV positive (UNAIDS 2004b) 15, predominantly through male-female sexual activity and drug abuse by way of injecting. The national HIV prevalence among injecting drug users remains high at 45% in 2004 despite its reduction from its peak in the late 1990s. The high HIV prevalence among IDUs was reported in Bangkok and in the southern region in recent years, rising from 40% in 1995 to 57% in 2002 (MOPH Thailand 2000/2001) 16. In addition, HIV incidence among IDUs was shown to range from 5.8 /100 (personyears) in central Thailand to about 8.5 /100 (person-years) in northern Thailand at the turn of the century (Vanichseni et al ; Celentano et al ). HIV prevalence among ATS users was about 2.4% in 2001 (Vongsheree et al 2001) 19 : i.e., significantly higher than the national adult HIV prevalence (1.7%). There is also a report revealing % infection among non-intravenous drug users who received treatment in Thanyarak Hospitals, and % infection among nonintravenous drug users who received treatment at the Drug Treatment Center in Chiang Mai (Perngparn et al 2005) World Bank Thailand s Response to AIDS; Building on Success, Confronting the Future. Bangkok 15 UNAIDS 2004b. Epidemiological Fact Sheet on HIV and STIs: Thailand. Geneva 16 MOPH (Ministry of Public Health Thailand) 2000/ HIV/AIDS Prevalence. Division of Epidemiology. Bangkok 17 Vanichseni S, Choopanya K, Des Jarlais D, Sakuntanga P, Kityaporn D et al HIV among Injecting Drug Users in Bangkok: The First Decade. J AIDS : Celentano D, Hodge M, Razak M, Beyrer C, Kawichai S, et al HIV-1 Incidence among Opiate Users in Northern Thailand. American Journal of Epidemiology. 149(6): Vongsheree et al High HIV-1 Prevalence among Methamphetamine Users in Central Thailand, J Med Assoc Thai : Sep; 84(9) Perngparn U and Sirinirand P Mid-term Review on National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand : Drug Dependents, Bangkok Usaneya Perngparn, m/s

153 Harm Reduction Programme in Thailand HIV and Drug Risk Reduction Thailand has implemented three major HIV prevention strategies for IDUs, i.e. psychosocial services including the outreach programme, sterile needle and syringe access, and the drug dependence treatment. The Ministry of Public Health has used media campaigns to disseminate information on HIV transmission as part of the psychosocial services since the early 1990s. Needle exchange and syringe distribution trials started on a pilot basis in Bangkok and some areas of the northern region (Gray ; Vanichseni et al ). In southern Thailand, while no needle and syringe exchange exist, IDUs can purchase equipment legally and at very low cost from local pharmacies (Perngmark et al 2003) 23. District hospitals nationwide continuously offer short-term, tapered methadone treatment, although many addicts eventually resume drug use and return to the clinic (Saelim et al 1998) 24. Nevertheless, there are a few clinics, most of them in Bangkok, which offer long-term maintenance therapy (Choopanya et al 2003) 25. According to the National policy, the Working Group on HIV and Drug Risk Reduction has categorized its operations into the following three periods. The 1 st Period Under Task Force on IDU in 2000 to Mid-2003 : The Taskforce on IDU in Thailand was formed in accordance with the recommendations of the 2000 World Bank s Social Monitor report. In 2000, it was affirmed that Thailand should continue its prevention and care efforts through three taskforces including the taskforce on condom promotion, on IDU and opportunistic infection (OI). The taskforces on condoms and OI functioned for two years and were 21 Gray J Operating Needle Exchange Programmes in the Hills of Thailand. AIDS Care. 7(4): Vanichseni S, Des Jarlais DC, Choopanya K, et al Sexual Risk Reduction in a Cohort of Injecting Drug Users in Bangkok, Thailand. J Acquir Immune Defic Syndro. 37(1): Perngmark P, Celentano DD, and Kawichai S Needle Sharing among Southern Thai Drug Injectors. Addiction. 98: Saelim A, Geater A, Chongsuvivatwong V, Rodkla A, Bechtel GA Needle Sharing and High-Risk Sexual Behaviors among IV Drug Users in Southern Thailand. AIDS Patient Care and STDs. 12: Choopanya K, Des Jarlais DC, Vanichseni S, Mock PA, Kitayaporn D, Sangkhum U, Prasithiphol B, Hiranrus K, van Griensven F, Tappero JW, Mastro TD HIV Risk Reduction in a Cohort of Injecting Drug Users in Bangkok, Thailand. J AIDS. 33(1): Usaneya Perngparn, m/s

154 JURNAL ANTIDADAH MALAYSIA abolished. This is due to the shift in focus on social marketing by promoting condom vending machines in public institutions, whereas OI was merged into the early national health insurance scheme. Under international pressures on Thailand s drug situation and policy, the taskforce on IDU was in a dilemma, fighting unstably in putting IDU as a social agenda within the movement of HIV/AIDS national response. More difficulties mound from the rigid mandatory roles among the concerned government bodies and there is a lack of coordination especially when the issue became more complicated. This period ended when the changing atmosphere led to more acceptance on the harm reduction approach before the world AIDS Conference took place in Thailand. The 2 nd Period Under Harm Reduction Working Group - Mid Mid 2005 : Under this period, the taskforce changed its name to Harm Reduction Working Group. In July 2004 the group was active in hosting the XV International AIDS Conference. At the opening of the Conference, the Prime Minister emphasized harm reduction among IDUs and urged it as a national policy. The 3 rd Period Under Thai Working Group on HIV and Drug Risk Reduction - Mid Present : From mid 2005, while the ongoing outreach project was being implemented under the 1 st joint plan and was gaining momentum of partnership among key organizations including Department Medical Services by Thanyarak Institute, NGOs, Universities and TDN, more members and partners were interested in participating in the Harm Reduction Group especially the planning meeting to develop the 2 nd Joint Plan of Action for The draft plan is currently under technical review and will be finalized soon. By 2007, Thailand ensured increased access to the utilization of effective, comprehensive and holistic prevention, treatment, care and support services for HIV/AIDS and IDUs. It is a prominent challenge for Thailand to implement this joint plan with a moreharmonized working process among partners under the supervision of the Thai HIV/AIDS and Drug Risk Reduction group. The draft plan is outlined as follows: Usaneya Perngparn, m/s

155 Harm Reduction Programme in Thailand Joint Plan of Action on HIV/AIDS and Drug Risk Reduction in Thailand for Project Title Objectives Major Activities Key Outputs 1. Public awareness advocacy on stigma and discrimination, law and policy 1. a) Stigma & discrimination reduced b) Community participation & public awareness/ positive perception increased c) Policy related Information developed and shared consistently d) Policy related activities are continuously implemented e) Policy and law harmonized at appropriate levels f) Campaigning publications developed and utilized. 1.a) Organise a national event (Conference/ seminar) b) Organise community forums and workshops c) Develop policy implementation Guidelines d) Develop campaigning publications 1.a) Increased participation of drug users and partners, b) Policy involvement activities and resource included in the national plan to support activities under the plan c) Legal documents and policy guidelines introduced. d) Public coverage with good quality materials through campaigning and distribution. 2. Finding evidence based and concerning issues related to drugs and HIV/AIDS 2.1 Evidence based and evaluative Information provided to decision makers and the public 2.1 Research/ Survey/on evidence concerned such as: a) To address public attitude b) Access to MMT policy and technical documents, ART Guidelines, VCT for IDUs guidelines etc. c) TB guideline 2. a) Evidence based and evaluative reports on each issue b) Policy document on MMT, technical guidelines on ART-IDUs and VCT. c) TB document 26 With complement from Mr. Sompong Chareonsuk, UNAIDS, Thailand Usaneya Perngparn, m/s

156 JURNAL ANTIDADAH MALAYSIA Project Title Objectives Major Activities Key Outputs 2.2. a) HIV/AIDS and Drugs situation updated b) Existing services documented and shared. c) A national workshop attended by policy makers, technical officers and practitioners 2.2 a) Mapping of recent studies and results. b) Mapping of existing services c) National Workshop to present each map 2.2. a) Study reports presented and submitted b) Two maps c) Numbers of decision makers, national experts/ academics and practitioners attending the national workshop 3. Drug and HIV/AIDS outreach programme (on-going) 3.1 Access to information and service increased 3.1. a) Building outreach teams composed of existing treatment center personnel and partners, including peer educators and outreach workers through recruitment and training b) Set up VCT and organize related training on VCT for IDUs c) NSP 3.1. a) Number of service providers and partners trained b) Peer to peer outreach coverage in major provinces (Bangkok, Chiang Mai and Songkla) is achieved. c) Two best practices are documented Usaneya Perngparn, m/s

157 Harm Reduction Programme in Thailand Project Title Objectives Major Activities Key Outputs 4. Comprehensive care and treatment services 4. a) Comprehensive capacity of service providers strengthened with active participation of drug users and partners b) Comprehensive Health care services system consistently and completely developed with active participation from the community 4. a) Workshop for health providers and care givers on how to provide HIVAIDS patients and TB on effective ART b) Develop one-stop service for holistic care in hospitals, drugs treatment centers and health centers (MMT, CBT, ART, TB, Alternative treatment) c) Activities to encourage networking of IDUs with HIV/ AIDS and families d) Integration of key drop-in centers in major regions into existing health care 4. a) More DUs to receive quality services b) Increased satisfaction of clients - effective referral system in place for friendly continuous services - more PWAs with HIV/ AIDS TB & BBD receive services c) Number of networks 5. Comprehensive HIV prevention in prison 5. HIV prevalence among IDUs in prisons is reduced 5.a) Training of officers, prisoners and NGO staffs on VCT / education / counseling / access to condom b) Conduct regular briefings and meetings with key officers on VCT and IEC 5. a) Number of officers, prisoners and NGO staff trained. b) Number of condoms distributed in targeted prisons. c) Appropriate IEC materials developed and used specifically for prisoners and partners. Usaneya Perngparn, m/s

158 JURNAL ANTIDADAH MALAYSIA Project Title Objectives Major Activities Key Outputs 6. Programme coordination and management 6. Programme coordination effectiveness under the joint plan is increased. 6. a) Recruit a programme coordinator b) Set up a programme management system with the budget plan and monitoring activities 6. a) Programme coordinator is contracted and tasks and responsibilities are completed b) Work plan is done by the Coordinator Usaneya Perngparn, m/s

159 Harm Reduction Programme in Thailand REFERENCES 1. Administrative Committee of Substance Abuse Academic Network, Office of Narcotic Control Board, Thailand National Household Survey on Drug Abuse. Bangkok 2. Bureau of Epidemiology, Ministry of Public Health Weekly Epidemiological Surveillance Report, 15 (39): Celentano D, Hodge M, Razak M, Beyrer C, Kawichai S, et al HIV-1 Incidence among Opiate Users in Northern Thailand. American Journal of Epidemiology, 149(6): Choopanya K, Des Jarlais DC, Vanichseni S, Mock PA, Kitayaporn D, Sangkhum U, Prasithiphol B, Hiranrus K, van Griensven F, Tappero JW, Mastro TD HIV risk reduction in a cohort of injecting drug users in Bangkok, Thailand. J AIDS, 33(1): ESCAP/ UNODC/ UNAIDS Injecting drug use and HIV vulnerability : choices and consequences in Asia and the Pacific. Report to the Secretary General for the Special Session of the General Assembly on HIV/AIDS. Bangkok 6. Farrell M, Ali R, Ling W, Marsden J The practices and context of pharmacotherapy of opioid dependence in South-East Asia and Western Pacific Regions. Department of Mental Health and Substance Dependence, World Health Organization. Geneva 7. Gray J Operating needle exchange programmes in the hills of Thailand. AIDS Care, 7(4): Limsuwan A, Kanapa S. and Siristonapun Y Acquired immune deficiency syndrome in Thailand. A report of two cases, J Med Assoc Thai, 69(3): MOPH (Ministry of Public Health Thailand. 2000/ 2001 HIV/AIDS prevalence. Division of Epidemiology. Bangkok 10. Office of the Narcotics Control Board, Thailand A rapid survey of impact from heroin price escalation on illicit retail distribution and the users. Bangkok. 11. Perngmark P, Celentano DD, and Kawichai S Needle sharing among southern Thai drug injectors. Addiction, 98: Usaneya Perngparn, m/s

160 JURNAL ANTIDADAH MALAYSIA 12. Perngparn U and Sirinirand P Mid-term review on national plan for the prevention and alleviation of HIV/AIDS in Thailand : Drug dependents. Bangkok 13. Phanuphak P, Locharernkul C, Panmuong W and Wide H A report of three case of AIDS in Thailand, Asian Pacific J Allerg Immun, 3: Poshyachinda V Heroin in Thailand. Bangkok: Drug Dependence Research Center, Institute of Health Research, Chulalongkorn University 15. Poshyachinda V, Perngparn U and Danthumrongkul V The amphetamine-type stimulants epidemic in Thailand: A case study of the Treatment, student, and wage laborer populations. CEWG community epidemiology work group, National Institute on Drug Abuse. 16. Poshyachinda V, Sirivongse ANA, Aramrattana A, Kanato M, Assanangkornchai S, Jitpiromsri S Illicit substance supply and abuse in : An approach to assess the outcome of the War on Drug operation. Drug and Alcohol Review (September), 24, Saelim A, Geater A, Chongsuvivatwong V, Rodkla A, Bechtel GA Needle sharing and high-risk sexual behaviors among IV drug users in southern Thailand. AIDS Patient Care and STDs. 12: UNODC a World Drug Report. Volume 2: statistics. Vienna 19. UNAIDS. 2004b Epidemiological fact sheet on HIV and STIs : Thailand. Geneva 20. Vanichseni S, Choopanya K, Des Jarlais D, Sakuntanga P, Kityaporn D et al HIV among injecting drug users in Bangkok : the first decade. J AIDS: Vanichseni S, Des Jarlais DC, Choopanya K, et al Sexual risk reduction in a cohort of injecting drug users in Bangkok, Thailand. J Acquir Immune Defic Syndro. 37(1): Vongchak T, Kawichai S, Sherman S, Celentano DD, Sirisanthana T, Latkin C, Wiboonnatakul K, Srirak N, Jittiwutikarn J and Aramrattana A The influence of Thailand s 2003 War on Drugs policy on selfreported drug use among injection drug users in Chiang Mai, Thailand. International Journal of Drug Policy 16: Vongsheree et al Thailand, J Med Assoc Thai : Sep; 84(9): World Bank Thailand s response to AIDS; building on success, confronting the future. Bangkok Usaneya Perngparn, m/s

161 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts READING TO RECOVER: EXPLORING BIBLIOTHERAPY AS A MOTIVATIONAL TOOL FOR RECOVERING ADDICTS Abd. Halim Mohd Hussin 1 Mardziah Hayati Abdullah 2 ABSTRACT Bibliotherapy is a technique for structuring interaction between the client and the therapist based on mutual sharing of literature in fulfilling the client s therapeutic needs. It is also a form of supportive psychotherapy in which carefully selected reading materials are used. A study was conducted to explore the use of bibliotherapy with addicts undergoing treatment and rehabilitation in a government-aided rehabilitation center in Malaysia. The center employs the psychosocial modality in its approach to treatment and rehabilitation, in which counseling is one of the components. The respondents in the study consisted of ten inmates from the center, who were selected based on their readiness to change using the URICA Stage of Change instrument screening process, which placed them at the Stage of Contemplation before the study began. A series of six group counseling sessions were conducted with these ten respondents. At the first session, each inmate was assigned one narrative for reading. The narratives were selected from a collection of stories on the real-life experiences of successfully rehabilitated Malaysian addicts, compiled earlier by a group of counselors. Over the next five sessions, the respondents were encouraged to discuss their feelings and thoughts about the rehabilitated addicts in the stories and to reflect on their own recovery process. After the last session, the URICA was used again to determine the respondents stage of change. The findings show that reading the narratives had a positive motivational impact on the respondents beliefs about their potential to change and helped them move from the Contemplation Stage to the Action Stage. The sessions also reshaped their beliefs about the recovery process and helped them 1 Islamic Science University of Malaysia (USIM) 2 Faculty of Modern Languages and Communication, Universiti Putra Malaysia (UPM) Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

162 JURNAL ANTIDADAH MALAYSIA feel less alone. The results suggest that bibliotherapy is worth exploring further as a tool for motivating recovering addicts. However, careful planning and the selection of suitable materials is an issue to be considered, as are exposure and training in the application of the technique. ABSTRAK Kaedah bibliotherapy secara definisinya adalah satu teknik untuk menstrukturkan interaksi di antara seseorang pelanggan dengan ahli terapi. Ianya adalah berdasarkan persefahaman kedua-dua pihak untuk memastikan keperluan terapi pelanggan tersebut akan dapat dipenuhi. Ia juga merupakan satu kaedah berbentuk supportive psychotheraphy di mana bahan-bahan bacaan yang terpilih sahaja akan diguna pakai. Satu kajian telah dijalankan untuk mengkaji penggunaan bibliotherapy di kalangan penagih dadah yang sedang menjalani rawatan pemulihan di sebuah pusat pemulihan dadah kerajaan di Malaysia. Pusat ini mempraktikkan kaedah psychosocial modality dalam proses rawatan pemulihannya. Salah satu komponen rawatan ini adalah khidmat kaunseling. Responden kajian ini adalah terdiri daripada 10 orang bekas penagih dadah pusat ini. Mereka telah dipilih berdasarkan tahap kesediaan mereka untuk melakukan sesuatu perubahan. Tahap mereka ini telah ditentukan melalui ukuran URICA Stage of Change di mana mereka kesemuanya berada di tahap Contemplation di tahap awal kajian ini (iaitu sebelum kajian bermula). Sebanyak 6 siri kaunseling secara berkumpulan telah dijalankan ke atas kesepuluh responden kajian ini. Di sesi pertama, setiap responden telah diberikan tugasan membaca. Bahan bacaan yang diberikan adalah di antara satu koleksi pengalaman sebenar bekas penagih dadah yang berjaya dipulihkan. Lima sesi seterusnya pula bertujuan menggalakkan para responden untuk meluahkan perasaan dan fikiran mereka mengenai bekas penagih dadah yang berjaya dipulihkan serta mengimbas kembali proses pemulihan para responden sendiri. Selepas sesi terakhir, URICA digunakan sekali lagi untuk memastikan tahap kesediaan responden untuk berubah. Kajian menunjukkan bahawa bahan bacaan yang diedarkan telah memberikan satu impak motivasi positif terhadap kepercayaan para responden mengenai potensi mereka untuk mengalami proses perubahan. Ianya juga telah membantu mengubah tahap para responden dari Contemplation kepada tahap Action. Kesemua sesi tersebut juga telah mengubah persepsi mereka mengenai proses pemulihan secara positif. Di samping itu, sesi-sesi tersebut telah membantu mengurangkan tahap keseorangan yang telah dialami mereka sebelum ini. Hasil kajian ini menunjukkan bahawa kaedah bibliotherapy mempunyai potensi menjadi salah satu alat motivasi untuk para penagih dadah yang sedang menjalani proses pemulihan. Walau bagaimanapun, bahan bacaan yang Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

163 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts diberikan perlulah dirancang dan dipilih dengan teliti. Di samping itu, tahap pendedahan dan latihan juga seharusnya dipantau dengan sebaiknya dalam aplikasi teknik ini. INTRODUCTION In the past decades, the repertoire of methods available for helping people cope with problems has increased with the introduction of numerous alternative approaches. One such approach has utilized the art of enabling catharsis. Catharsis refers to the cleansing of emotions brought about by expressing oneself through some form of art, such as music, movement, painting or writing. This approach includes bibliotherapy. The term bibliotherapy comes from biblio, or books, (from the Greek vivlion which means book) and from the Greek therapeia, or therapy. Bibliotherapy generally refers to the use of books literary works in particular to help people cope with problems such as emotional conflict, mental illness, or changes in their lives (Pardeck, 1994). Themes that may be found in literature include separation and divorce, child abuse, foster care, and adoption. In addition to helping people with problems, bibliotherapy is also employed in enhancing the well being of individuals who are not necessarily faced with such difficulties, but who could benefit from effective change, as well as personality growth and development (Lenkowsky, 1987; Adderholdt-Elliott & Eller, 1989). The aim of bibliotherapy practitioners is to help people of all ages to understand themselves and to cope with problems by providing literature relevant to their personal situations and developmental needs at appropriate times (Hebert & Kent, 2000). REACTIVE AND INTERACTIVE APPROACHES IN BIBLIOTHERAPY Bibliotherapy dates back to the 1930s when librarians began compiling lists of written material that helped individuals modify their thoughts, feelings, or behaviors for therapeutic purposes. Counselors selected and prescribed chosen literature for clients experiencing problems by working in tandem with librarians who had greater familiarity with literary themes (Pardeck, 1994). The underlying premise of bibliotherapy has always been that clients identify with literary characters similar to themselves, an association that helps the clients release emotions, gain new directions in life, and explore new ways of interacting (Gladding & Gladding, 1991). However, since the 1930s, bibliotherapy practice has varied in its approach and focus. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

164 JURNAL ANTIDADAH MALAYSIA The earlier, more traditional approach tended to be more reactive in its approach in that the process focused on getting individuals to react positively or negatively to the reading material. More recently, however, the therapeutic process has been given a more interactive dimension, a development that is consistent with experiential theories of Reader Response that views reading as a transactional process between reader and text. Based on Rosenblatt s publication of The Reader, The Text, The Poem in 1978, experiential Reader Response theories propose that during the reading process, readers become emotionally involved, construct alternative worlds and conceptualize characters, events and settings, create visual images, connect the text with their own experiences, and evaluate their own experiences against what happens in the texts (Beach, 1993). In other words, readers interact with texts, becoming part of the intellectual and emotional process as each story unfolds. As they attempt to process what is being communicated at the deepest level, readers engage in activities that help them reflect on what they read, such as group discussion and dialogue journal writings (Palmer, et al., 1997; Anderson & MacCurdy, 2000; Morawski & Gilbert, 2000). The readers also interact with their faciltators or counselors through discussion and therapeutic interactions (Hynes & Hynes-Berry, 1986, p. 10). These activities are aimed at helping readers make a positive alternation or modification in behavior or attitude (Myers, 1998). The use of literature in the helping process has translated into therapeutic methods employed for various purposes. In clinical bibliotherapy and bibliocounselling, skilled practitioners use therapeutic methods to help individuals experiencing serious emotional problems. Classroom teachers, however, are more likely to use developmental bibliotherapy, which involves helping normal students in their general health and development. While the focus of bibliocounselling is on helping people cope with problems as and after the problems arise, developmental bibliotherapy focuses on helping teachers identify the concerns of their students and address the issues before problems arise. The latter approach can also be used to guide students through predictable stages of adolescence so that they are equipped with some knowledge of what to expect as well as examples of how other teenagers have dealt with the same concerns (Hebert & Kent, 2000). Hynes and Hynes-Berry use literature in a broad sense to include print, video and creative writing materials (Schumaker, Wantz, & Taricone, 1995). Thus, clients may be asked to consume literature through reading or viewing, or to create literature in the form of writing, painting Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

165 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts or movement. The benefits of these techniques are similar regardless of the medium used and they all require careful planning. BASIC STAGES IN BIBLIOTHERAPY Activities in bibliotherapy are generally designed to provide information; provide insight; stimulate discussion about problems; communicate new values and attitudes; create awareness that other people also have similar problems and provide realistic solutions to problems. The process goes through four basic stages (Pardeck, 1993) namely identification, selection, presentation and follow-up. Identification and Selection During the first two stages, the clients needs must be identified, and appropriate stories or poems are selected to match their particular problems. One of the aims of bibliotherapy is to help readers feel relieved that they are not the only ones facing a specific problem or that they are the only ones who possess certain personality traits. Thus, the characters in the literature should resemble the readers in some aspects of behaviour or they should experience circumstances very similar to those of the readers. The materials also need to be age-appropriate so that the readers can better relate to the content. The reading level should also be appropriate so that the readers will not have to struggle excessively to make sense of what goes on, as the focus should be on drawing parallels between literary characters and real-life characters. However, there should be enough depth in the stories or poems to enable a discussion of the issues. In addition, the books must provide correct information about a problem while not imparting a false sense of hope (Pardeck, 1994). Clearly, the selection process takes a great deal of skill and insight. Obtaining the opinions of other teachers or helpers can be extremely useful and sharing resources with is one way of developing a repertory of literary materials. Presentation After the books or literary pieces have been selected, they must be presented carefully and strategically so that the clients are able to see similarities between themselves and the book s characters. Eventually, readers have to learn vicariously how to solve their problems by reflecting on how the characters in the book solve theirs (Hebert & Kent, 2000); this can also be seen as the copying of character behaviours (Gladding & Gladding, 1991). Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

166 JURNAL ANTIDADAH MALAYSIA The procedure used in the helping process need not vary greatly from normal interactive literature lessons in the classroom. During such lessons, teachers and students may begin by reading a book or poem. The literary material provides students with characters to react to and common experiences to discuss after the reading. In individual or group bibliocounselling, one way to begin is to have the individual or group read a piece of literature before a session. During the session, the participants are asked to talk about their reaction to what they have read. For example, if the assigned book is The Blind Men and the Elephant: An Old Tale from the Land of India (Quigley, 1959), participants are guided to see that personal perceptions differ according to experience. A discussion of the central theme can then lead to a more personalized examination of its meaning by individuals (Gladding & Gladding, 1991). In addition to the examination of themes, however, participants have to be helped to relate to one or more characters presented in the books or poems. An alternative method is for counselors to get each participant to share a piece of literature that has a special significance to him or her. As he or she talks, the participant must be helped to realize what the story means to him or her, and why it has an impact. If this technique is carried out in a group setting, other participants may also identify themselves with particular characters. Follow-up Once the participants can identify with relevant characters, they enter the follow-up stage during which they share what they have learnt about themselves as a result of identifying with and examining the literary characters and their experiences. This cathartic activity is designed to help readers come to terms with their problems and to cleanse themselves emotionally. They may express catharsis verbally during oral discussion or writing, or nonverbal means such as art (Sridhar & Vaughn, 2000), role-playing, creative problem solving, or self-selected options for students to pursue individually (Hebert & Kent, 2000). Once catharsis has occurred, the clients can be guided to gain further insight into the problem. Examples of activities suggested by Sridhar and Vaughn (2000) for this purpose include the following: Develop a summary of the book, through the point of view of a character other than that who is the focal point of the story. Create a diary for a character in the story. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

167 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts Write a letter from one character in the book to another, or from the student to one of the characters. Compose a different ending to the story. Compose a Dear Abby letter that a book character could have written about a problem situation (Pardeck, 1995). Such activities help readers study issues from a variety of perspectives, and in doing so, they may obtain solutions to their own problems. THE ROLE OF THE HELPER The success of the bibliotherapy program depends largely on how well helpers play their role throughout the entire process. Helpers must carefully design a programme that will take the clients through the stages of the therapy and they must be able to carry it out effectively. To do so, bibliotherapy helpers need to draw from the basic principles of a counsellor s behaviour such as being non-judgemental and empathic, and being good listeners. In addition to these essential counselling skills, bibliotherapy helpers also need to develop a familiarity with a reasonably wide range of literary materials on various themes, perhaps by enlisting the assistance of literature teachers and librarians. The helpers must also be effective facilitators who can help readers see aspects of their own behaviour or problems in the literary materials, and later help the readers participate in cathartic activities. A basic knowledge of literary appreciation would also be an advantage, as literary materials often make use of metaphors or images that, if explored, can provide readers with a framework for viewing or not viewing their problems in specific ways. For example, Robert Frosts s poem The Road Not Taken looks at each of us as a traveller and compares the choices we make in life to roads one is well travelled and secure, the other is unfamiliar and possibly full of risks and uncertainties. The poem leads us to ponder the question: Which road is more worth taking? In the poem, Frost voices the concern that knowing how way leads on to way, I doubted if I should ever come back, and ends the poem with the decision the Traveller finally makes. A helper who is able to read into this metaphor and the poet s meaning can introduce the poem to readers who are struggling with life s choices themselves Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

168 JURNAL ANTIDADAH MALAYSIA perhaps with career paths or more immediate concerns such as whether or not to befriend someone to help them view the choices as roads on which they have to travel. Frost s words suggest that readers could take a safer route: explore the different ways one path could lead, before making a decision. On the other hand, the poem could also encourage readers to take the plunge and explore the less travelled path. A sensitive helper can, through skilfully facilitated discussion, capitalise on this metaphoric representation of life to help readers draw parallels between poetry and real life. Whichever path readers end up with, the realisation that there are others who face the same situation would leave them feeling less lonely and the discussions would definitely help them attain greater insight into their own inclinations. Although the development of literary appreciation seems at first glance to be unrelated to the practice of counselling and helping, they are in fact not so far removed from each other. Reading and discussing literary material involves activities such as restating or paraphrasing, clarifying, questioning, summarizing and reflection strategies that are also employed in the counselling domain. Thus, the exercise of literary appreciation actually complements and may even enhance counselling skills. It is important to remember that unlike traditional counselling sessions in which only the counsellor is expected to paraphrase, summarise, question and clarify, both helper and client in a bibliotherapy approach apply these strategies in studying the literary material. This shared activity helps create a complementary and reciprocal relationship between both parties constructing a common ground for discussions. BENEFITS AND LIMITATIONS OF BIBLIOTHERAPY In addition to the how of conducting bibliotherapy, practitioners also need to be aware of potential benefits and pitfalls associated with this procedure. Bibliotherapy has obvious value in that it provides the opportunity for the participants to recognize and understand themselves, their characteristics, and the complexity of human thought and behaviour. It may also promote social development as well as garner the love for literature in general, and reading in particular (Gladding & Gladding, 1991). It reduces feelings of isolation that may be felt by people with problems. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

169 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts The effectiveness of bibliotherapy, however, may be limited by several factors, including the unavailability of materials on certain topics, as well as the lack of materials in certain languages. This problem is especially relevant for counselling practitioners in the multi-ethnic context of Malaysia. For this reason, it would be beneficial for a network of bibliotherapy practitioners to include literature teachers and writers in addition to counsellors, so that lists of books on specific themes may be compiled and shared. Another limitation to the bibliotherapy approach is a possible lack of client readiness and willingness to read. In order for the approach to work, clients must be willing to take time to read and reflect on the material. The material and presentation must therefore be attractive and relevant enough to the clients to stimulate and sustain their interest. Clients may also project their own motives onto the characters and thus reinforce their own perceptions and solutions. In addition to that, participants may be defensive, thus discounting the actions of the characters and failing to identify with them, or even end up using them as scapegoats. Some of these limitations can be overcome through the continuation of the process itself, role-playing, and the use of group discussions (Gladding & Gladding, 1991). Facilitator limitations are also a challenge: facilitators may have limited knowledge of human development and developmental problems as well as inadequate knowledge about appropriate literature. Facilitators thus need to be properly trained and exposed to a repertoire of literature suitable for use in bibliotherapy. One other limitation may lie in the bibliotherapy process itself: for example, clients may be unwilling to discuss areas that are uncomfortable, or facilitators may insist on making a point at the client s expense. The process is also limited if both the client and the counsellor only dwell on surface issues. These limitations can be addressed by suspending sessions until both parties are ready and willing to work, by taping and critiquing selected sessions so that facilitators can monitor their own reactions to certain clients or problem areas, and by revisiting issues in stories that have been treated superficially in previous sessions (Gladding & Gladding, 1991). Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

170 JURNAL ANTIDADAH MALAYSIA OBJECTIVES OF STUDY The objectives of this study are to examine the suitability of bibliotherapy technique as a recovery tool for helping recovering addicts in a counseling process and to investigate the impact of reading true success stories of total recovery addicts at the stage of change and the motivation to change amongst recovering addicts. METHODOLOGY Ten recovering addicts undergoing counseling in a rehabilitation program were given true success stories of recovered addicts to read. Six counseling sessions applying the bibliotherapy technique were conducted with them over a period of six consecutive weeks. They were pre-tested and post-tested on their readiness to change using URICA -the Readiness to Change Instrument and the level of selfesteem. INSTRUMENTS URICA Stage of Change: A translated version of the Stage of Change Questionnaire, consisting of 30 items to measure the level of readiness to change, was used. The five stages of change are pre-contemplation, contemplation, preparation, action, and maintenance. Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or less aware of their problems. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Preparation is the stage that combines intention and behavioral criteria. Individuals at this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors, this stage extends from six months to an indeterminate period past the initial action. Rosenberg Self Esteem Scale - An adapted and translated version of Rosenberg Self- Esteem Scale of 10 items that describe the level of self esteem of personal self. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

171 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts DATA COLLECTION PROCEDURE A series of counseling sessions were conducted where issues of recovery were discussed based on the true stories of successfully recovering addicts. Session 1: Getting Acquainted a. Structuring of the group process. Clients were given information on the purpose of the group work and the responsibilities of group members. Structuring includes rules and regulation, expectations, involvement and as well as other issues related to group procedures and protocols. b. Distribution of reading material. Clients were given literatures of true story of recovering addicts to be read through by each of the group members. c. Pre-test using Rosenberg Self Esteem Scales & URICA were conducted. Session 2 to Session 5 Group process and sharing of experiences, feelings, thought, insight and other related issues leading to the motivation to change from the article read. Every member was given the opportunity to share their feelings, thoughts and responses to the respective articles they have read. Session 6: The Post-test and Termination of the Counseling Process Post-tests were conducted using the same instruments to investigate changes that may have taken place in terms of their readiness to change. During the termination process, every individual was given the opportunity to reflect what they felt and what they have in mind regarding changes, getting into a normal life as well as developing their personal beings. FINDINGS The findings of the study show that bibliotherapy can be used as an approach or recovery tool in addition to other recovery tools in helping addicts on their journey to recovery. The following are the results of the psychometric test URICA- used to measure the readiness to change. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

172 JURNAL ANTIDADAH MALAYSIA Res- Type Number Number Statements pon- Pre- test of of years of Post-test and dent Drug addicted relapses thoughts R1 Contemplation Opiate 5 3 Action Never thought there are people who can gain total recovery R2 Contemplation Opiate 4 3 Action Would like to follow what the client in the literature have done R3 Contemplation ATS 6 5 Preparation Don t know if he can ever recover but it seems that there are people who can do it. That means I can too. R4 Contemplation Opiate 3 2 Action Motivated by the fact that there are people who managed to get out of this loop. R5 Contemplation ATS 4 3 Action Gain confidence and wants to follow the footstep of that person in the literature R6 Contemplation ATS 4 3 Action Wants to speak to family members to seek for help because that person in the literature managed to gain recovery with the support of his family R7 Contemplation Opiate 2 1 Maintenance Very highly motivated and has hope R8 Contemplation Opiate 2 1 Maintenance Believe in self and will stay strong with the believe that he will recover. R9 Contemplation ATS 3 2 Action It s difficult to go through but other people have managed to do it. R10 Contemplation ATS 5 4 Preparation Don t really know if he can because the family members have given up on him and he has no where to return. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

173 Reading to Recover: Exploring Bibliotherapy as a Motivational Tool for Recovering Addicts Based on the table, the use of literature has a strong influence of the perception of respondents towards change. All respondents demonstrated a change of attitude in which they viewed that there was room for improvement in themselves. Those respondents who were still engaged with their families hoped to be able to talk to their families about their plan of action to change. The following are the post-test result of self esteem levels amongst respondents using Rosenberg Self-Esteem Scale ( SA- Strongly Agree, A- Agree, D- Disagree, SD- Strongly Disagree). Items R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 On the whole, I am satisfied with myself D D SD D A A SA SA A SD At times, I think I am not good at all A SA A A A A A A A SA I feel that I have a number of good qualities A A A A A A SA SA SA A I am able to do things as well as most other people A D SD A SA SA SA SA SA A I feel I do not have much to be proud of SA D A A D D D D A A I certainly feel useless at times SA A A A D D D D A SA I feel that I am a person of worth, at least on an equal plane as others A A D A A A SA SA A A I wish I could have more respect for my self SA SA SA SA SA SA SA SA SA SA All in all, I am inclined to feel that I am a failure D D A D D D SD SD D A I take a positive attitude towards myself D A A A A A A A A D DISCUSSION There is evidence of change in behavior as an outcome from the bibliotherapy technique in working with addicts. Literature consisting of true accounts of successful recovering addicts can be a helpful recovery tool to boost motivation to change as well as to help improve cognitive distortion of individuals who are in the treatment process. Sharing true stories of recovering addicts helps clients to investigate and be aware of their personal strengths in preparing themselves to change. Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

174 JURNAL ANTIDADAH MALAYSIA Addiction counselors need to use various approaches when working with addicts especially in helping develop the addicts emotional and psychological levels as well as personal beliefs about the treatment and the ability to change. CONCLUSION Bibliotherapy is a potentially powerful method for counsellors to use at different levels and types of cognitive distortion and personal beliefs. In order to establish a strong bibliotherapy program in an institution, practitioners must present the procedure as a non-threatening one, starting by calling the process biblioguidance, for instance. They must also solicit the input and advice of colleagues, parents, and administrators. Nevertheless, they must always be alert and aware of the limitations of bibliotherapy. REFERENCES Adderholdt-Elliott, M. & Eler, S. H. (1989). Counseling students who are gifted through bibliotherapy. Teaching Exceptional Children, 22(1), Anderson, C. M. & MacCurdy, M. M. (2000). Writing and healing: Toward an informed practice. Urbana, IL: National Council of Teachers of English. Gladding, S. T. & Gladding, C. (1991). The ABCs of bibliotherapy for school counselors. School Counselor, 39(1), Hebert, T. P. & Kent, R. (2000). Nurturing social and emotional development in gifted teenagers through young adult literature. Roeper Review, 22(3), Lenkowsky, R. S. (1987). Bibliotherapy: A review and analysis of the literature. Journal of Special Education, 2(2), Morawski, C. M. & Gilbert, J. N. (2000). Developmental interactive bibliotherapy. College Teaching, 48(3), Myers, J. E. (1998). Bibliotherapy and DCT: Co-constructing the therapeutic metaphor. Journal of Counseling and Development, 76(3), Palmer, B. C. Biller, D. L., Rancourt, R. E. & Teets, K. A. (1997). Interactive bibliotherapy: An effective method for healing and empowering emotionally-abused women. Journal of Poetry Therapy, 11(1), Pardeck, J. T. (1993). Literature and adoptive children with disabilities. Early Child Development and Care, 91, Pardeck, J.T. (1994). Using literature to help adolescents cope with problems. Adolescence, 29(114), Sridhar, D. & Vaughn, S. (2000). Bibliotherapy for all. Teaching Exceptional Children, 33(2), Abd. Halim Mohd Hussin & Dr. Mardziah Hayati Abdullah, m/s

175 Needle Syringe Exchange Program in Malaysia NEEDLE SYRINGE EXCHANGE PROGRAM IN MALAYSIA Faisal Hj. Ibrahim 1 ABSTRACT The pilot Malaysian Needle Syringe Exchange Program (NSEP) commenced operations at 3 sites in February and March The sites involved are AARG Alternatif Community Centre in Jelutong, Penang (ACC); Intan Life Zone in Ngee Heng, Johor Bahru (ILZ); Pusat Komuniti Ikhlas in Chow Kit, Kuala Lumpur (PKI). From February 2006 to February 2007, the sites distributed approximately 83,800 NSEP kits (containing 4 needles and syringes, antiseptic swabs and cotton balls). The rate of return of used injecting equipment for new ones steadily increased since the program started, and now approximates at 60%, which is commendable for a new program. Needle syringe exchange has occurred through more than 34,300 contacts with more than 4,300 different clients. IDUs who have participated in needle exchange are male (96%), Malay (76% ) and over the age of 30 (77% ). The majority (72%) of needle exchanges have occurred through the outreach; the dropin centres provide a wider range of referrals and some other services that cannot be provided in the outreach setting. Other services provided through the NSEP include discussions with clients on safer usage (27,947), and safer sex (8,832), as well as written resources (3,238) and sessions with a case worker (1,259). There have been numerous referrals to other services, including health/medical services (281), voluntary counselling and testing for HIV (130), drug/alcohol treatment (51), methadone (119) and welfare or legal services (72). There have been some positive signs of behavioral change occurring amongst injecting drug users (IDUs) in the 3 pilot NSEP areas. There has been a significant reduction in the number of IDUs passing on their injecting equipment to others, and also a reduction of the use of street/port doctors. However, there is much more that needs to be done. There are still many IDUs who are reusing injecting equipment of others and are not always using a new and clean needle. The behaviour survey also showed that knowledge of Hepatitis C is very poor amongst these IDUs, with approximately 40% of them who have not heard of Hepatitis C, and very few who know how the virus is transmitted. 1 Dato Dr. Faisal Hj. Ibrahim, Coordinator NSEP Program, Ministry of Health. Dato Dr. Faisal Hj. Ibrahim, m/s

176 JURNAL ANTIDADAH MALAYSIA A high proportion of participants reported risky sexual behaviour in the last month. As such the first year of the pilot NSEP has seen the successful commencement of NSEP activities at all 3 sites, with adherence to the National Standard Operating Policy and the Sites Standard Operating Procedures. ABSTRAK Program Pertukaran Jarum Suntikan (NSEP) Malaysia diadakan secara percubaan (perintis) pada bulan Februari dan Mac di tiga tempat. Tempat atau kawasan yang terlibat membabitkan AARG Alternative Community Centre (ACC) di Jelutong, Penang; Intan Life Zone (ILZ) di Ngee Heng, Johor Bahru; dan Pusat Komuniti Ikhlas (PKI) di Chow Kit, Kuala Lumpur. Sejak Februari 2006 hingga Februari 2007, ketiga-tiga pusat berkenaan telah mengagihkan lebih kurang 83,300 kit NSEP (yang setiap satu mengandungi 4 jarum dan syringe, cecair antiseptik dan kapas). Kadar pemulangan set alat suntikan yang telah digunakan bagi mendapatkan set suntikan yang baru menunjukkan peningkatan yang berterusan, sejak program tersebut bermula sehingga mencecah 60 % sekarang. Pertukaran peralatan suntikan tersebut sekarang telah melibatkan seramai 34,300 perhubungan dengan lebih daripada 4,300 klien yang berbeza. Para penagih yang menggunakan jarum suntikan (IDUs) yang terlibat di dalam program ini adalah lelaki (96%), Melayu (76%) dan berusia sekitar 30-an (77%). Sebahagian besar daripada program pertukaran jarum penyuntik (72%) dilaksanakan melalui outreach ; pusat drop in yang menyediakan lebih banyak kemudahan rujukan dan perkhidmatan yang tidak dapat disediakan di tempat-tempat lain. Kemudahan-kemudahan lain yang turut disediakan melalui program NSEP ini termasuklah penerangan kepada klien tentang peri pentingnya penggunaan jarum suntikan secara yang lebih selamat (27,947), dan hubungan seks secara lebih selamat (8,832), selain daripada penyediaan rujukan bertulis (3,238) dan sesi bersama pekerja kes (1,259). Terdapat juga beberapa keadaan di mana rujukan terhadap perkhidmatan lain turut dilakukan termasuklah perkhidmatan kesihatan dan perubatan (281), kaunseling secara sukarela dan ujian HIV (130), rawatan bagi ketagihan arak dan alkohol (51), methadone (119), serta khidmat perundangan dan kebajikan (72). Terdapat beberapa perubahan perlakuan yang positif dikesan di kalangan para penagih yang terbabit dalam projek perintis di ketiga-tiga kawasan di atas. Bilangan perkongsian jarum suntikan di kalangan para penagih dadah mengalami penurunan yang ketara serta penurunan penggunaan jarum suntikan secara jalanan (port doctors). Di sebalik perubahan-perubahan positif tersebut, masih banyak yang perlu dilakukan. Masih ada penagih dadah yang tidak menggunakan jarum suntikan yang baru, sebaliknya berkongsi jarum suntikan atau mengitar semula jarum suntikan yang telah digunakan oleh penagih lain. Kajian perilaku turut menunjukkan bahawa pengetahuan tentang Hepatitis C di kalangan para penagih yang menggunakan jarum suntikan adalah amat rendah, dengan hampir Dato Dr. Faisal Hj. Ibrahim, m/s

177 Needle Syringe Exchange Program in Malaysia 40% daripada mereka sama sekali tidak pernah mendengar tentang Hepatits C serta hanya sejumlah kecil daripada mereka yang tahu tentang bagaimana virus tersebut disebarkan. Sebilangan besar daripada peserta pada bulan lepas dilaporkan mengamalkan hubungan seks secara berisiko. Walau bagaimanapun, dapatlah disimpulkan bahawa Projek Perintis NSEP pada tahun pertama di tiga buah tempat telah menampakkan kejayaan, dengan mematuhi peraturan-peraturan yang ditetapkan di bawah National Standard Operating Policy dan Sites Standard Operating Procedures. INTRODUCTION The report is the final progress report for the Needle Syringe Exchange Program (NSEP) pilot. The three sites currently operating the Pilot NSEP are AARG Alternatif Community Centre in Jelutong, Penang (ACC); Intan Life Zone in Ngee Heng, Johor Bahru (ILZ); and Pusat Komuniti Ikhlas in Chow Kit, Kuala Lumpur (PKI). The aim of the evaluation of the pilot NSEP is to assess the feasibility of NSEP in the Malaysian context and whether the pilot NSEP can act as an appropriate model for future expansion in Malaysia. The objectives of the evaluation of the pilot NSEP are to assess whether: 1. the sites have successfully implemented the pilot NSEP according to the Standard Operating Policy (SOP) 2. the pilot NSEP has reached the targeted injecting drug users in the 3 selected areas 3. the pilot NSEP has brought about a change in unsafe injecting behaviour amongst injecting drug users (IDUs) 4. the pilot NSEP has improved access for IDUs participating in this project to HIV prevention education and health and welfare services and community criticism OBJECTIVE 1: IMPLEMENTING THE NSEP ACCORDING TO THE SOP Needle and Syringe Suitability At the start of the program, the clients from the 3 NSEP sites complained about the quality of needles and syringes provided. In response to these complaints, the Monitoring and Evaluation Unit undertook an assessment Dato Dr. Faisal Hj. Ibrahim, m/s

178 JURNAL ANTIDADAH MALAYSIA of the acceptability of needles and syringes. Over time, this problem was addressed and has largely been overcome by working together with State Health Office (JKN) and the MOH at large. As a follow up to the previously conducted needle assessment, a client satisfaction survey was conducted amongst 150 clients in February Clients were opportunistically recruited (50 from each site; 40: outreach clients, 10: DIC clients). The survey showed that 79% of client agreed that the quality of needles given out now is good, 88% that the syringe quality is good. At ACC and ILZ, about 90% - 95% of clients are happy with the currently provided needles and syringes. But, this is not the case at PKI, where 38% of clients disagree or slightly disagree that the quality of needles currently provided is good and 24% of clients had similar opinions on the quality of the syringes provided currently. This indicates that quality issues have largely (but not completely) been resolved in the view of the clients, with issues remaining for PKI clients. A staff survey on the issue of needle and syringe suitability showed that 76% of staff agree or slightly agree that the quality of needles and syringes given out now is good. Approximately 14% of staff disagreed, emphasising the fact that in the view of the staffs, this issue has not been completely resolved. Overall the two surveys showed that the needles and syringes provided since the initial batch of NSEP kits have improved considerably and been of a more acceptable quality and more suitable sizes for clients. The pilot program has highlighted the importance of obtaining regular client input from all sites and target areas before selecting needles and syringes to procure and distribute. Standard Operating Policy All sites have exceeded the target number of clients doing needle exchange by the end of the pilot program (target 400 clients at each site by Feb 2007: actual figures = ACC 1109; ILZ 2285; PKI 1600). However, on average each client has attended less than once per week, with the number of contacts per month for clients ranging from 2.2 to 3.4 for this past 1 year, rather than the forecast number of 8 to 9. Therefore the expected number of contacts per month with clients has not been reached (target contacts in February 2007: ACC 810, ILZ 900, March 2007: PKI 1010). However, these figures do satisfy the latest WHO definitions of regular client as discussed below. Staffs are aware that some clients will not meet them twice in some weeks, so discussions with clients and judgement regarding demand Dato Dr. Faisal Hj. Ibrahim, m/s

179 Needle Syringe Exchange Program in Malaysia informs how many NSEP kits are provided for individuals. As a result, the average number of kits provided at each contact is approximately 2 per visit according to data collected from February 06 to February 07 (ACC 1.4; ILZ 2.7; PKI 2.6). The reasons for providing more than 1 kit at a time include: one needle could be used for no more than 1 or 2 injections before it became blunt (remembering that most IDUs in Malaysia inject 3-5 times per day); clients who have veins that are difficult to find may pierce the skin a number of times before finding a vein, making the needle blunt after only one drug injection. In addition most of these clients are mobile, and the service is only available for a limited number of hours, so they may not come into contact twice per week and therefore need the equipment to cover a longer time period. In combination with the number of client contacts for needle exchange, this has resulted in less than the expected number of kits per month being distributed in the first few months, but more than expected in July to September in ILZ and PKI on average (Figure 1). From October 2006 to March 2007, the number of kits distributed per month in PKI fell below target, as the number of contact was much lower than expected. ILZ was continuing to distribute more kits per month than expected till December ACC has continuously distributed fewer kits than expected throughout the programme. An alternative to providing only kits is to also stock and encourage clients to take additional needles. A single syringe per day for a number of injections is probably usually adequate, but as needles may become blunt faster, more than one needle per day may be needed. This may be a good compromise between cost constraints and best public health practice. Figure 1 : Target and Actual Number of NSEP Kits 1 Distributed by Each Site Each Month 1 A kit contains 4 needles and 4 syringes, disinfectant swabs and cotton balls. Dato Dr. Faisal Hj. Ibrahim, m/s

180 JURNAL ANTIDADAH MALAYSIA Numbers of Needles and Syringes Provided and Returned Approximately 83,830 NSEP kits (670,640 needles and syringes) have been supplied since the program began (Table 1). The return rate of used injecting equipment returned by clients for disposal has been 58% of the quantity of needles and syringes distributed since the start of the program. Overall, since the beginning of the program the return rate has gradually improved (Figure 2). More than 4,500 used items have been collected by the staff from the ground, giving a slightly higher overall return rate of 60%, and particularly raising ACC s return rate to 43% through collection of nearly 3,700 items. Many things influence return rates, including client trust, understanding of the need to return items and mobility, relationship with port doctors, and especially police activities. Table 1 : Provision of Sterile Needles and Syringes, and Disposal of Used Needles and Syringes Site ACC, PP (17/02/06 17/02/07 ILZ, JB (24/02/06 24/02/07) PKI, KL (23/03/06 23/03/07) Total Number of kits given to clients Number of extra needles Number of used needles returned for disposal ,034 Number of used syringes returned for disposal ,466 % Return rate (items returned / items given out) Figure 2 : Return Rates of Used for New Injecting Equipment at Each Site by Month Dato Dr. Faisal Hj. Ibrahim, m/s

181 Needle Syringe Exchange Program in Malaysia In the last quarter, all sites showed a decrease in return rates. This can largely be attributed to a sizeable port with a busy port doctor becoming inactive following police raids, and regular clients from there becoming hard to find. The fear of being caught with injecting paraphernalia is another significant factor affecting return rates. Even though the Guidelines for Police in relation to NSEP have been signed and the said document has been widely distributed to all police stations, there are still police officers who are unaware and have little knowledge of the programme. Given the relative short period of this programme and the coverage that is expected, this is not a surprising finding. This is further discussed in the section below on Client ID cards. Overall the return rate at the DIC is higher than the outreach despite more needle exchanges occurring on the outreach at all 3 pilot sites (Figure 3). This could be due largely to the education provided to the clients on the importance of returning used needles and syringes. DICs provide a relatively safe and enabling environment which allows lengthy discussion with clients to ensure return. This can be a challenge at the outreach, where clients, and potentially the outreach workers, are exposed to the threat of arrest. At times the bustling activities at the ports amongst clients can be distracting for clients to discuss with the outreach workers as the clients main priority is to use drugs to avoid withdrawal. Therefore, the outreach workers have to be patient to allow clients to complete their activities before engaging in discussions and exploring with clients the challenges in returning used injecting equipment. Considering all these factors, an overall return rate that is close to 60% after one year of the pilot program is encouraging as reported return rates for different NSEP programs worldwide have varied widely between %. Figure 3 : Return Rate at DIC and Outreach. Dato Dr. Faisal Hj. Ibrahim, m/s

182 JURNAL ANTIDADAH MALAYSIA OBJECTIVE 2 : TO ASSESS WHETHER THE PILOT NSEP HAS REACHED THE INJECTING DRUG USERS IN THE 3 SELECTED AREAS Number of Clients and Contacts With Services The total number of contacts and the number and proportion of these contacts that are specifically for needle syringe exchange (NSE) services are shown for each site in Table 3 for the entire time of operation as a NSEP site. The total number of contacts varies substantially between sites, probably related to how established the DIC for each site was before NSEP services commenced, rather than the amount of time the NSE service has been functioning. The proportion of contacts that involved NSE was also substantially different between sites, but did not correlate to the number of contacts. In PKI, this proportion was much lower than the other sites, reflecting PKI s historical role in providing many other services to a range of client types. More than 51,500 contacts with the NSEP sites for various services have occurred in 1 year, with nearly 34,400 of these involving needle exchange. Table 2 shows the total number of clients (based on counting the client ID code as unique) and the number and proportion of clients using the NSE service. A high proportion (74%) of all clients in ACC and ILZ are accessing the NSE service, indicating that the majority of clients are part of the target audience. The same is not true for PKI, again reflecting the fact that PKI has had a long established DIC that is utilised by a wide range of people. DIC data collection forms were adjusted after the program commencement to collect client drug use status (IDU, DU and non drug user). Data indicates that 30-40% of PKI clients, 80-90% of, ACC clients, and 70-80% of ILZ clients are IDUs. Table 2 : Number of Clients and Contacts Total and Subset Using Needle Exchange Services Site ACC, PP 17/2/06-17/2/07 ILZ, JB 24/2/06-24/2/07 PKI, KL 23/3/06-23/3/07 Number of Contacts (client may be counted many times) Number of Contacts for Needle Syringe Exchange % of Contacts Involving Needle Syringe Exchange Number of Unique Clients (based on client ID code) Number of Clients Who Have Done Needle Exchange % of Clients Who Have Done Needle Syringe Exchange Total * Based on client ID code where needles and syringes have been taken and/or returned. Note: a client code will only be counted once in the entire 12 months, so the total will not equal monthly totals added together because a client may be counted in more than one month. Dato Dr. Faisal Hj. Ibrahim, m/s

183 Needle Syringe Exchange Program in Malaysia While focusing their efforts on IDU clients using the NSE service, the pilot sites are keen to provide a comprehensive and holistic service that also allows services access to non-idus. This is particularly relevant as an individual s using behaviour may change repeatedly over time, and it is important that they feel welcome to access services that will minimise the harm of their activities. There is, however, some potential harm with having a DIG where ex-idus (including those on MMT) mix with current IDUs, and the sites should be mindful of this and refer non- IDU clients to other agencies wherever possible. Given that there is limited services that meet the needs of ex-idus, development and funding of these additional services such as skills training and job placement are urgently required. Number of Regular and Irregular Client A recent technical paper from WHO and UN defines regular at tenders/ clients as those who are in regular contact with NSEP. The principle behind this definition is to capture IDUs who come at least once a month or more over a period of time and not just IDUs who come regularly on a weekly basis compared with those who only came once (one off visit). Therefore, taking into consideration this definition, clients for this, pilot NSEP is divided into 2 broad categories, i.e. regular clients and irregular clients. Regular clients are defined as having attended NSEP more than once monthly (at least 2 times) since February 2006 to January Whereas irregular clients are defined as having attended once only (one off visit) during the entire program. Overall, 62% of NSEP clients are regular clients and 38% are irregular clients (Figure 4). The proportion of regular clients at all sites in the first quarter was between 38% to 60% (Figure 5). ACC maintained higher number of regular clients followed by PKI and ILZ. For all sites, there are a substantial number of irregular clients, which may be influenced by many factors including client mobility, drug supply and availability, police raids and arrest, acceptability of NS equipment, length of time since that first NSE, trust and rapport with NSEP staff, operation hours and frequency of contact opportunities (Figure 6). The reality of the needle exchange client contact is considerably different from the target that was set at the beginning of the program, but confirms to the latest WHO/UN recommendations. Therefore, it is important to consider the internationally recommended definition together with the reality of clients pattern of use of the services to redefine the term regular and irregular client in the SOP. Dato Dr. Faisal Hj. Ibrahim, m/s

184 JURNAL ANTIDADAH MALAYSIA Figure 4 : Regularity of Service Use Over Figure 5 : Regular Clients at Each Site by Months Figure 6 : Irregular Clients at Each Site by Month Dato Dr. Faisal Hj. Ibrahim, m/s

185 Client Demographics Needle Syringe Exchange Program in Malaysia The vast majority of clients who have done needle exchange in the one year of the pilot NSEP are male (Figure 7). There are very few clients below the age of 20 years (Figure 8), with the age group proportions similar for sites after 12 months as they were after 6 months; ACC has had a significant increase in the number of clients aged 40 and above; ILZ served a significantly large number of clients aged years and years in the last quarter; while PKI has had a significant shift to more clients aged 40 and above. The majority of clients who have done needle exchange are Malay, with a higher proportion of Chinese and Indian in ACC than elsewhere (Figure 9). Ethnicity proportions are similar to those at 12 months; at ILZ and PKI there has been an increase in the proportion of Chinese and Indian clients. Figure 7 : Gender of Clients Who Have Done Needle Exchange in 12 Months of NSEP Pilot at Each Site Figure 8 : Age Group of Clients Who Have Done Needle Exchange in 12 Months of NSEP Pilot at Each Site Dato Dr. Faisal Hj. Ibrahim, m/s

186 JURNAL ANTIDADAH MALAYSIA Figure 9 : Ethnicity of Clients Who Have Done Needle Exchange in 12 months of NSEP Pilot at Each Site Two Models (DIC and outreach) for Reaching the Population The two models being used for the NSEP pilot have different advantages and disadvantages, and in combination should facilitate the provision of a comprehensive harm reduction service. Staffs said the DIC is a safe place for clients where their needs can be taken care of, however the fixed location and hours may reduce accessibility, and entering the DIC may mark a client as an IDU. The outreach can reach more clients, and in their own space where they may feel more comfortable; however it can be difficult or dangerous to find clients. Overall there is little difference in demographics (gender, age, and ethnicity) of clients using the outreach and the DIC in the 12 months (Figure 10). Most needle exchange service occurs through the outreach, with 79% of needles & syringes given out through the outreach, 77% of needle exchange clients being seen through the outreach, and 72% of all needle exchange contacts being through the outreach (Figure 11). Based on client codes, there are many needle exchange clients who have used services at both DIC and the outreach (ACC 171, ILZ 329, PKI 309). Despite more needle exchanges occurring through the outreach, overall the return rate of used for new injecting equipment is higher at the DIC as discussed in objective 1 on the needle and syringe suitability (Figure 3). At ACC and PKI, the proportions of NSE contacts are about Dato Dr. Faisal Hj. Ibrahim, m/s

187 Needle Syringe Exchange Program in Malaysia Figure 10 : Demographics of Clients Who Have Done Needle Exchange in 12 Months of NSEP Pilot, Comparing the Outreach and the DIC Service Models [A: gender, B: age group, C: ethnicity] (Outreach, n = 3822 ; DIC, n = 1162) Gender of clients who have done needle exchange in 12 months on NSEP pilot, shown by point of contact with service - all sites Age group of clients who have done needle exchange in 12 months on NSEP pilot, shown by point of contact with service - all sites Ethnicity of clients who have done needle exchange in 12 months on NSEP pilot, shown by point of contact with service - all sites Dato Dr. Faisal Hj. Ibrahim, m/s

188 JURNAL ANTIDADAH MALAYSIA the same for both the outreach and DIC. At ILZ, the contacts for NSE at the outreach are significantly higher than DIC. Overall, the outreach model is more effective in reaching the target population and must be emphasized during the scale up. Figure 11 : Number of Contacts for NSE Through DIC and the Outreach Number of contacts for needle exchange through DIC and outreach OBJECTIVE 3: TO ASSESS WHETHER THE PILOT NSEP HAS BROUGHT ABOUT A CHANGE IN UNSAFE INJECTING BEHAVIOUR AMONGST IDUS IN THE 3 TARGET SITES Assessment of Behavioural Changes A behaviour surveillance survey (BSS) of 300 IDUs in the three cities (100 per location) where pilot sites operate was conducted shortly after the NSEP commenced at all three sites in April A second BSS was repeated in February 2007, 12 months after the commencement of NSEP by the M&E Unit. Participants were selected through the targeted snowball sampling. It is important to note that this was not a longitudinal cohort study and therefore the participants from the two studies were not necessarily the same individuals. As personal information was not collected for the purposes of the study, identification of individuals who may have participated in both surveys was not possible. This method of recruitment is acknowledged and accepted, as it is the only alternative way to gather data from population whose members do not congregate in fixed location such as IDUs. The purpose of doing the BSS at the start of the programme and upon conclusion of the pilot was to get some baseline data of HIV risk behaviour at the start and for assessment of behavioural changes that may have occurred. Dato Dr. Faisal Hj. Ibrahim, m/s

189 Needle Syringe Exchange Program in Malaysia Participants were asked standardised questions about their drug use habits, sexual behaviour, and knowledge of HIV and Hepatitis C. Rapid tests for HIV were also conducted at all locations. Although ideally the first round of BSS should have been conducted prior to the commencement, in reality it was only conducted after NSEP had commenced at all 3 sites, due to the lack of manpower and capacity within the unit. Unsafe Injecting Behaviour Amongst IDUs From the two BSS, the majority (88%) of participants were male, the average age was 38, and the average time of injecting drugs was 12 years. During the 1 st BSS, approximately 44% of IDUs interviewed had obtained needles and syringes from the NSEP, while in the 2 nd BSS about 88% of IDUs were clients of the NSEP. A high proportion of participants reported injecting risk behaviour in the last month, being ever re-using someone else s needle or syringe (52%) in the 1 st BSS. The 2 nd round of BSS indicated (56%) of participants reported of having ever used someone else s needle and syringe in the last month. This reported increase was not statistically significant. However, it points to the need to ensure consistent risk reduction and behaviour change messages are given alongside the needle and syringe exchange. It is also important to remember that behavioural change is gradual and the provision of clean injecting equipment alone does not appear to be sufficient to motivate major changes in contextual risk behaviors. 0ther factors such as sample size and study design buisness whereby the 1 st round BSS was only conducted after the commencement and police activities might have an impact why a significant change was not observed. However, more detailed data analysis revealed positive results. About 43% of IDUs in the 2 nd BSS reported passing on their used equipment, a significant decrease compared to 56% during the 1 st BSS (p <0.01). The 2 nd BSS showed a reduction in the proportion of IDUs using the services of street/port doctors from 42% to 33% during the 1 st BSS. This was a significant (p<o.o25) positive change, as street / port doctors have been acknowledged as a major factor in accelerating HIV transmission amongst IDUs. Dato Dr. Faisal Hj. Ibrahim, m/s

190 JURNAL ANTIDADAH MALAYSIA Figure 12 : Reported Injecting Risk Behaviours Within the Preceding 1 Month Amongst IDUs (1st round, n = 300 and 2nd round, n = 300 BSS results) Those whose HIV rapid test was positive were more likely to report passing on their used equipment (58%) within the preceding 1 month during the 1 st BSS. The 2 nd BSS indicated that there has been a significant reduction (p<o.o21) in the proportion (44%) of HIV positive IDUs reporting this risky behaviour. This represents a vital step in the efforts to interrupt HIV transmissions. One of the key elements that increases and promotes episodes of safer injecting behaviour is the frequency of using new and clean needles and injecting equipment. During the 1 st BSS, 49% of IDUs reported always using new and clean needles and syringes in the last month compared to (41%) during the 2 nd BSS. This change was however not statistically significant. Significant change may not have been observed in IDUs reporting always using new and clean needles and injecting equipment as the 1 st BSS was conducted several months after commencement, therefore clients were already accessing new and clean needles. Dato Dr. Faisal Hj. Ibrahim, m/s

191 Needle Syringe Exchange Program in Malaysia OBJECTIVE 4 : TO ASSESS WHETHER THE PILOT NSEP HAS IMPROVED ACCESS (FOR IDUS PARTICIPATING IN THIS PROJECT) TO HIV PREVENTION, EDUCATION & HEALTH AND WELFARE SERVICES Knowledge of HIV and hepatitis among IDUs In the 2 nd BSS, all of the respondents have heard of HIV/AIDS. About 75% of respondents demonstrated correct basic knowledge about HIV 11. This is a vast improvement compared to the previous BSS (42% had sufficient knowledge on HIV/AIDS). Knowledge about Hepatitis C was considerably lower than for HIV, but the 2 nd BSS did show slight improvement in the level of Hepatitis C knowledge amongst IDUs compared to the 1 st. The proportion of IDUs who have heard about Hepatitis C, and know its mode of transmission (Figure 13) has increased slightly. But, more has to be done to educate IDUs as the level of knowledge regarding Hepatitis C is very low with only 40% of those surveyed knew about this virus. Figure 13 : IDU Knowledge About Hepatitis C Virus and Transmission (BSS 2 nd round results) HIV Prevention Education Printed information: In addition to providing verbal information, NSEP staff have provided clients with written resources on HIV, and information about the DIC and NSEP (Table 5). There is an urgent need for more Information, Education, Communication (IEC) materials tailored for IDUs, most specifically about safer usage, safer sex, abscesses and blood borne viruses. Dato Dr. Faisal Hj. Ibrahim, m/s

192 JURNAL ANTIDADAH MALAYSIA Malaysian Aids Council (MAC) is in the process of developing more IEC materials. It is important that IEC materials are appropriate for the target audience. Focus groups with IDUs have been conducted to help ensure that the materials are suitable for the target group and effectively convey key messages. Currently there are two items on safer injecting and blood borne viruses available. More appropriate IEC materials must be developed as IEC materials can be extremely beneficial for helping to convert brief outreach encounters into potential safe behaviour promoting interactions. Written resources covering information about referrals services will also be extremely useful in helping act as a bridge to other health services. MAC must ensure that appropriate IEC materials in other topics such as vein care, abscess management and overdose are developed and made available to all sites before the scale up takes place. The delay in the development of more IEC materials has definitely hampered the ability of NSEP staff to effectively educate clients. Case Worker Sessions and Verbal Education: Approximately a third of all contacts with the pilot sites led to education around risk reduction and behaviour change education being conducted (Table 3). Initial education efforts have focused on the importance of not sharing needles and syringes and on explaining the appropriate use of the content of the NSEP kits. As the site staff became more experienced, other subjects were discussed with clients such as the importance of not sharing cookers, water, vein care and abscess prevention. MAC started supplying cookers (bottle caps) to ACC and PKI, while ILZ was supplied with small glass bottles used as cookers (Figure 19). The NSEP kits should consider the provision of cookers and sterile water which are vital to reduce the risk of infection to blood borne viruses (HIV and Hepatitis C) and other pathogens. Only 1-2% of service contacts have resulted in a client having a session with a case worker (2 case workers per site). The number of case worker sessions may be influenced by the needs of the clients, the approachability, experience and skills of the DIC staff and the rapport developed with clients. The low number of sessions may be as result of high staff turnover, as most case workers at all sites have resigned or switched roles at all sites. During this 1 year pilot program, there has been no formal training sessions conducted specifically for case workers on case management based on harm reduction principles. MAC should make this a priority before scale UD. Dato Dr. Faisal Hj. Ibrahim, m/s

193 Needle Syringe Exchange Program in Malaysia Table 3 : Services Provided by NSEP Sites to Clients, Number and Percentage of All Contacts Site Case Worker Sessions Safer Using discussion Safer Sex discussion Written Resources Total Contacts ACC, PP 17/02/06-17/02/07 ILZ, JB 24/02/06-24/02/07 PKI, KL 23/03/06-23/03/07 35 (1%) 8914 (30%) 6102 (21%) 1062 (4%) (3%) (44%) 1372 (6%) 1721 (8%) (2%) 8587 (22%) 1359 (4%) 455 (2%) Total Provision of Referral to Drug, Health and Welfare Agencies at Client s Request Referral to services : In the first year of operation, each site has provided a range of referrals for the clients (Table 4). There have been a total of 799 referrals, with approximately 36% of referrals to health and medical services. About 9% have been welfare or legal referrals, which usually consist of obtaining IG for clients, required for job applications. When a referral is given to a client, all 3 sites usually provide transport and someone to accompany the client. This has proved very successful in helping clients to attend referrals. However, a single referral will often take between 2-4 hours time for one staff member. This can be an added burden on staffs in the longer run. Volunteers can be engaged to ensure sustainability of referrals as the client base grows. Only about 7% of referrals have been to MMT, a number far less compared to the demand and has resulted in long waiting lists. Most clients are referred for MMT to private clinics, where clients are required to pay for the methadone, which is often prohibitively expensive for most of these clients who do not have steady incomes. There are very few appropriate services available in Malaysia to meet the needs of IDUs within a reasonable distance of the NSEP DICs, which places pressure on NSEP staff who are committed to helping clients, but in such situations are unable to. For example, ACC has provided no referrals for methadone maintenance treatment because there is no government provider of this service on the Penang Island, with the nearest provider being more than an hour away on the mainland. In addition, NSEP sites must establish links with referral agencies so Dato Dr. Faisal Hj. Ibrahim, m/s

194 JURNAL ANTIDADAH MALAYSIA that referrals are more likely to be appropriate, efficient and supported. This requires significant time and investment in building such links. The client satisfaction survey indicated that several clients who were interviewed did not have their National Identity Card (IC) with them (ACC: 8, ILZ: 17, PKI: 16), i.e. they have lost their IC and could not afford the fee required for a replacement IC. Having an IC is extremely important in Malaysia, as it is required for admission to hospitals, schools, and at the workplace. Clients who do not have an IC might face difficulties in seeking health and medical services and securing jobs. NSEP sites should assist clients in obtaining IC with help from the Welfare and Registration Department. Table 4: Number of Referrals Provided by NSEP Sites for Clients Site ACC, PP 17/02/06-17/02/07 Health, Medical Referrals 54 Voluntary Counseling & Testing Referalls 22 Drug/Alcohol Treatment Referalls 15 Methadone Treatment Referrals 0 Welfare or Legal Referrals 39 ILZ, JB 24/02/06-24/02/ PKI, KL 23/03/06-23/03/ Total Provision of Safe Sex Education and Condoms to Encourage Safer Sex Practices In the recently conducted BSS, about 60% of participants reported having sex in the last month, but the percentage of these clients reporting that they always used condoms was low. However, the proportion of those always using condoms with regular partners has increased compared to the previous BSS (Figure 14). The proportion of those always using a condom during sex with casual partners decreased compared to the previous BSS. Overall, the number of IDUs who do not always use a condom is much higher compared to those who use condoms consistently (Figure 15). Safer sex education and appropriate condom promotion strategies need to be emphasized to promote safer behaviours amongst IDUs. Of those who reported having sex in the last month, 44% reported having sex with more than one category of partner (regular, casual, sold sex, or bought sex). These results highlight the ongoing risk of HIV transmission to the sexual partners of IDUs and into the general Dato Dr. Faisal Hj. Ibrahim, m/s

195 Needle Syringe Exchange Program in Malaysia community. This highlights the importance for continuing the provision of both safe sex education and condoms to IDUs. Figure 14 : Sex Risk Behaviour Amongst IDUs Who Reported That They Always Used a Condom Figure 15 : Sex Risk Behaviour Amongst IDUs Who Did Not Always Use a Condom In the staff survey, opinions about condoms varied considerably. In the 1 st BSS, nearly half of the staff who were surveyed disagreed that most clients used the condoms provided in the kits, as staffs had noticed that condoms were being discarded by clients who do not use them. Therefore, condoms are currently provided to clients upon request to reduce wastage. The proportion of staff who agreed or slightly agreed that there were some clients who wanted more condoms to be provided has increased (Figure 16) compared to the previous staff survey. Dato Dr. Faisal Hj. Ibrahim, m/s

196 JURNAL ANTIDADAH MALAYSIA Figure 16 : Staffs Opinion on Provision of Condom OBJECTIVE 5: TOASSESS WHETHER THERE HAVE BEEN UNINTENDED NEGATIVE CONSEQUENCES OF THE PILOT NSEP. Increased Drug Use (Initiation/Frequency/Duration) From the 2 nd BSS, it was noted that approximately 98% of IDUs injected at least once daily compared to 95% in the 1 st BSS, indicating that the provision of free needles and syringes through the NSEP has not resulted in increased drug use. The mean duration of injecting amongst the clients in both surveys was 12 years, indicating that the majority of the clients are long term drug users. The NSEP is attracting those drug injectors who are many years into their drug careers and are most likely to be amenable to both harm reduction and drug prevention interventions. Interventions also need to contact drug injectors earlier in their careers to give them the opportunity to access services before they suffer too many adverse social and health consequences. Reports from police officers have indicated no increase in the number of injecting drug users since the start of NSEP, but instead police have observed a rise in amphetamine type stimulant usage for the last year. Dato Dr. Faisal Hj. Ibrahim, m/s

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