This study compares the cost-effectiveness of centre-based compulsory rehabilitation (CCT) for substance abuse with community-based methadone maintenance treatment (MMT) in Hai Phong City, Vietnam. The project forms the basis for Thu Vuong's PhD.
Prof Robert Ali
University of Adelaide
Dr Giang Le
Hanoi Medical University
Dr Nhu Nguyen
Currently, in Vietnam, there are two dominant drug dependence treatment approaches. The first one is centre-based compulsory treatment (CCT) which has been implemented for more than 20 years. If someone in the community is identified as using illicit drugs, they would be encouraged by the community leaders to go through community-based detoxification treatment. If they fail to stop illicit drug use after several treatment attempts, they are to be sent to centre-based compulsory detention for up to 2 years without the benefit of due process or legal safeguard. The services in these centres include education on the dangers of illicit drug use, moral teaching, labour therapy and limited one-size-fits-all vocational training activities. This modality is common in many countries in Southeast Asia. The UN publicly criticises this modality because it violates human rights principles. Currently, about 35% of the total 140,000 registered dependent drug users are kept in these centres. Funding for this modality is solely from the Government.
The other treatment modality is methadone maintenance treatment (MMT), which has been available in Vietnam for 7 years. MMT is voluntary. It provides a legal and safe maintenance opioid for the duration of a person’s life where required. MMT is recommended by WHO/UNAIDS/UNODC as currently the most effective treatment for heroin addiction. Currently, 30% (35,000 out of 120,000 dependent heroin users) are in treatment with funding mainly from international donors.
Vietnam became a middle income country in 2010. This means funding from international donors for the existing community-based drug addiction treatment service have been declining, most substantially in the period of 2014-2018. The Government of Vietnam wants to have evidence of the cost-effectiveness of the two dominant drug dependence treatment approaches in Vietnam for more evidence-informed decision-making in drug treatment and resource allocation.
To compare the effectiveness and cost-effectiveness of center-based compulsory rehabilitation (CCT) for substance abuse with community-based methadone maintenance treatment (MMT) in Hai Phong City, Vietnam.
The key comparison parameters focus on:
1) the proportion of heroin use
2) the number of drug-free days
3) The proportion of drug-related criminal behaviours
4) The proportion of people with drug-use related blood-borne virus risk behaviours
5) and the proportion of people with overdose incidents
6) Monthly illicit drug spending
The research follows internationally recognised guidelines for costing substance use treatment interventions and standard economic principles for cost estimations and analysis of cost-effectiveness of the two drug dependence treatment approaches. For this study a treatment provider perspective is adopted. The design and methods for costing and measurement of effectiveness of CCT (Part A) and MMT (Part B) are described below.
Part A (focuses on measuring the costs and effectiveness of CCT):
Primary data on the costs to Government and participants who are placed into the treatment were collected. To measure the effectiveness of the CCT modality, a total of 208 CCT-released participants (sample size based on power analysis) were interviewed about their drug use and drug-related problems at baseline (after their release from CCT) and at 3, 6 and 12 month follow-up interviews.
Primary data were collected to measure the effectiveness of CCT. A combined retrospective and prospective longitudinal cohort design was used. A total of 208 CCT released participants (sample size based on power analysis) were enrolled as soon as they were released from CCT centres. Interviews were conducted using a structured questionnaire. Data were collected to determine drug use behaviours and other related behaviours of the study participants for the 3 months prior to entry into the centres. Follow-up interviews after 3, 6 and 12 months focused on the same questions. At baseline and follow-up interviews, urine drug screening were also conducted and compared to participants’ self-report drug use. Although urine drug screenings were performed throughout this study, the use of self-reported data allowed us to measure reductions in illicit opioid use, not abstinence only.
Part B (focuses on measuring the costs and effectiveness of MMT:
Secondary data from two studies (2009 MMT costing study and 2009 MMT cohort study) were used. Additional data on MMT costing were also collected. These include opportunity costs of participating in MMT treatment (on 314 MMT patients) and costing of buildings and land for MMT clinics.
Comparing CCT with MMT represents an in-quivalence in time horizon because CCT is defined as a two-year rehabilitation process (time-limited) whereas MMT is more than two years and can be a life-time treatment for many people (on-going). In order to minimise this ‘inequivalence in time horizon’, the three-year time horizon is framed for both modalities, which includes 2 years and 12 months. For CCT, it is the 2 years of rehabilitation plus the 12 months follow-up in the community. For MMT, it is the 2 years of previous cohort study follow-up (secondary data) plus an additional 12 months follow-up (primary data).
All activities have been completed and the PhD dissertation was awarded in June 2016.
Vuong, T., Nguyen, N., Le, G., Ritter, A., Shanahan, M., Ali, R., Pham, K., Vuong, T, A, Dinh, T. Economic evaluation comparing centre-based compulsory drug rehabilitation with community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam. Plenary presentation at the annual NDARC annual symposium, Sydney, 15 September 2015.
Vuong, T., Nguyen, N., Le, G., Ritter, A., Shanahan, M., Ali, R., Pham, K., Vuong, T, A, Dinh, T. Economic evaluation comparing centre-based compulsory drug rehabilitation with community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam. Official 60-page report for the Government of Vietnam (in English and Vietnamese), April 2015.
Vuong, T., Nguyen, N., Le, G., Ritter, A., Shanahan, M., Ali, R. The politics of conducting research around compulsory treatment in Vietnam. Oral presentation at the annual DPMP symposium, Sydney, Australia, 1 December 2014.
Vuong, T., Ali, R., Baldwin, S., & Mills, S. (2012). Drug policy in Vietnam: A decade of change? International Journal of Drug Policy. 23(4), 319-326.
Vuong, T., Shanahan, M., Nguyen, N., Le, G., Ali, R., Pham, K., Vuong, T.T., Dinh, T. and Ritter, A., 2016. Cost-effectiveness of center-based compulsory rehabilitation compared to community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam. Drug and Alcohol Dependence, 168, pp.147-155.