Christopher Morrison
Walls and bars: some residential rehabilitation services in Indonesia offer few creature comforts for recovery
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Sulis leans forward and lights another clove cigarette, the sharp light from his match temporarily illuminating his soft features. For a second the smell of the freshly lit tobacco is everything, before the roar of the gas burner and the crackle of spitting fat snap me back to the warung. Looking around nervously, he sees that the road-side stall is emptying. He draws a long breath and looks me in the eye before telling me what I had already suspected. 'I have relapsed,' he says. 'I started using again three months ago. Now it's back to everyday.'
Sulis is a heroin addict. Raised in Jakarta and introduced to drugs in his late teens, he moved to Yogyakarta three years ago to begin rehabilitation. His story is a common one (and Sulis is not his real name). Illicit drug use has shaped his life: his relationships, his health, his employment and his involvement with police. In Jakarta he had tried residential programs, but moving to Yogyakarta offered him a chance for a new beginning, a chance to get clean away from the prying eyes of a family that had all but given up on him. After nearly three years clean he considered himself a former addict and was established as a mentor within Yogyakarta's drug treatment community. But as his work commitments and his social circles in his new city grew, so did his exposure to drugs. And now he was opiate-dependant all over again.
Across the globe, a number of treatment types are generally available for chronic drug users. Short-term supervised withdrawal is one, long-term rehabilitation another. Both tend to work best for users who have recognised that their drug use is a problem and have committed to doing something about it. By entering a residential rehabilitation facility – as Sulis did when he first moved to Yogyakarta – a drug user hopes to have some 'time out' before reintegrating gradually into the community and hopefully staying clean. Nevertheless, the United Nations Office on Drugs and Crime reports that around the world, 70 per cent relapse after exiting such treatment programs; other estimates put the figure closer to 90 per cent. Clearly rehab is not a cure-all strategy, though for some it can be effective.
When people who use drugs are forced into residential treatment settings, relapse rates are higher still. Many users are unwilling or unable to remain abstinent; for these people, detox and rehabilitation have little long-term benefit. There is now irrefutable evidence from within Indonesia and without to suggest that counselling, support, peer education (formal or informal guidance from ex-users), and prescribed substitution therapies (such as methadone or buprenorphine, both of which are used to manage heroin dependence) lead to a reduction in drug-related harm, more resilient change among drug users, and are a more cost-effective use of limited resources.
Available treatment services
Yogyakarta's drug treatment services are typical of those offered in most Indonesian cities. Driven by the non-government sector, the meagre funding on offer seems not to deter an army of volunteer workers whose enthusiasm and determination to make a difference are truly remarkable. Two collective farms offer live-in recovery programs, faith-based organisations operate a few small scale (eight- to ten-bed) rehabilitation programs, and several other not-for-profit services run one drop-in centre (including a needle distribution program) and other peer support programs.
There is a distinct preference for withdrawal and rehabilitation programs over other treatment types
It was only relatively recently that the local and national government entered the fray, establishing a secure rehabilitation centre on the city's fringe in 2004. The government has also funded short-term buprenorphine prescriptions and in-patient medicated withdrawal centres. But the vast majority of government spending is dedicated to reducing supply through law enforcement measures, and reducing demand through community education programs. Most funding is channelled into high-profile programs that demonstrate the government’s commitment to a ‘Drug Free Indonesia’. The result is a distinct preference for withdrawal and rehabilitation programs over other treatment types.
Sulis is at a loss. Having been active as a leader at his rehabilitation facility, he does not want to tell his senior mentor that he has relapsed. Doing so would mean starting the twelve-month program again from the beginning. Other residential treatments are more military in nature, and he baulks at the thought of entering a boot-camp or being subjected to harsh discipline behind a barbed wire fence. He has tried buprenorphine treatment. However, in Indonesia opiate substitution is not usually used to maintain a person’s dependence (as it is in many other countries), but rather to mitigate withdrawal symptoms for a brief period. When the two-week prescription ended, he relapsed to intravenous heroin use immediately. Now he has exhausted his options. The state labels him a 'junkie' (a borrowed English term which he hates) and demands that he cease using, but fails to offer appropriately targeted support systems. And there is one more complication: Sulis is HIV positive.
Dying for a fix
As a registered recipient of anti-retroviral medication (used to keep the symptoms of HIV at bay), and a mentor within the community, Sulis is well-versed in the potential spread of the virus. His connections within the treatment sector also mean that he has access to the few services that are available for existing users. He has been able to obtain sterile injecting equipment through the city's only needle and syringe provider.
Other users are not so lucky; the widespread determination to push the Drug Free goal means that many are driven underground. Legislation introduced in 1997 states that a person caught in possession of one gram of heroin can be imprisoned for up to ten years. This means that active users who out themselves as 'junkies' and make contact with support services run enormous risks, particularly in light of the sometimes rocky relations that outreach workers have with police, government and the wider treatment community. In Yogyakarta and many other Indonesian cities, peer educators have been arrested for associating with known drug users; police often demand to know the identities of their clients. For many users, remaining hidden, borrowing used needles and avoiding potential exposure to authorities seems the safer option, despite the risk of contracting HIV.
Over the last ten years HIV/AIDS has spread rapidly in Indonesia. After recording a nation-wide prevalence in the ten of thousands in the late 1990s, in 2007 the National AIDS Commission (KPA) estimated that there were between 169,000 and 216,000 Indonesians living with HIV. The correlation between the rise in new infections and an exponential increase in drug use is unmistakable. Between 1997 and 2000, the number of users across the country grew three-fold, and over the following five years doubled again. By 2005, the National Narcotics Board estimated that between 2.9 million and 3.9 million of the nation’s 230 million people were active drug users. A 2006 Department of Health study found that, of these, 191,000 to 248,000 regularly administered drugs intravenously – a risk behaviour that accounts for 80 per cent of new HIV infections.
Fear and loathing
Responses to the dual ‘evils’ of substance use and HIV/AIDS have saturated Indonesian media over recent years. The same is true in Yogyakarta, where numerous groups enter schools and universities with their own variations of the 'Say No to Drugs' slogan. One popular youth internet site carries the phrase 'Narkoba, 'nggak banget deh bo' (Drugs, no way!), and bumper stickers, street graffiti and television advertisements echo the message that drugs and HIV are a real and present threat. Governments at all levels have littered the countryside with billboards that provide information about blood borne viruses, the virtue of being drug-free, or combinations of the two: ‘AIDS: Because of Drugs, Live in Shame, Even Die in Shame.’
Sulis is caught in an imbalanced treatment sector – which fails to recognise relapse as a natural step on the road to recovery – and a criminal justice system determined to pounce
Sulis smiles. He has long been critical of the single-minded nature of the Indonesian response to illicit substance use, the stigmatisation of users, and the lack of formal supports to help them avoid potential harms. Now having relapsed, he is again a member of the group on whose behalf he had been lobbying.
Availability of information about drugs and HIV is not a problem, but how to best transform this knowledge into behaviour change is a hotly contested point. Despite showing in-depth understanding of the dangers of sharing injecting equipment, Indonesian drug users continue to use dirty needles. Some within the treatment sector feel that more punitive measures are the answer: heavier sentences should compliment increases to funding and coordination of supply reduction and demand reduction strategies. By making drugs and needles harder to obtain, they argue, the number of drug users and new HIV infections will drop. Sulis does not agree. For him and his friends, the legal consequences of drug use have never been a deterrent. Longer sentences and heavier fines are unlikely to have any effect, other than to drive them underground; when that happens, drug users do not have access sterile injecting equipment or other support services. With the landscape tinder dry, HIV spreads like wildfire.
Caught in between
Sulis paddles the remnants of an ice block around the bottom of his glass mug, paying no mind to the boy folding up the wooden benches around us. He needs to go back to the rehab centre, he says. Late night absences arouse too much suspicion and he wants to avoid all the questions he can. Sulis knows he is fortunate to have supports within the treatment community, but the overwhelming emphasis on rehabilitation and abstinence puts him off using them. News of his relapse would not be taken well. Despite his personal connections, Sulis is caught in an imbalanced treatment sector – which fails to recognise relapse as a natural step on the road to recovery – and a criminal justice system determined to pounce. Rather than see him as a potential resource who could help reduce the spread of HIV and limit the other effects of substance use, Indonesia chooses to define him by his drug use: as a junkie and a criminal. ii
Christopher Morrison (c.morrison3@pgrad.unimelb.edu) is a drug and alcohol counsellor in Melbourne and a Master of Public Health student at Melbourne University.