Addicts Buying Dangerous Drug 'Cocktails' at Clinics

PENANG, Malaysia, Dec 23 (IPS) - From the outside it appears like any other private medical clinic, though a little shabby. But a closer look reveals something unusual.
First, the 'patients' are predominantly male adults. Every few minutes one of them walks into the clinic, steps up to the counter and produces a card or booklet. Words are exchanged. The patient then walks into an adjoining room -- and less than a minute later, walks out.
What happens inside the room is anyone's guess. But the managers of two drug rehabilitation drop-in centres told IPS that certain private general practitioners are dispensing legitimate drug substitutes and potentially dangerous -- though also legitimate -- substances to drug addicts a little too freely.
Drug substitutes such as Subutex (buprenorphine) or, more recently in Malaysia, methadone, are legitimately used by doctors to reduce the craving among drug addicts without producing many of the harmful side-effects of illegal drugs such as heroin.
On their own, these substitutes may be effective in treating addicts -- but they can be potentially deadly when mixed with other substances.
Close supervision is required. When drug addicts are prescribed Subutex, for instance, doctors often issue them instructions to help them monitor the dosage and their consumption of the drug.
The booklet carries a printed warning: ''You are reminded that Subutex cannot be injected or taken together with Benzodiazepines (sleeping pills such as Dormicum) or alcohol. It may result in breathing difficulties or death to Subutex users.''
But this is precisely what some drug addicts are doing to get a quick and easily available fix. They mix these drugs and inject the 'cocktail' into themselves.
Dormicum (midazolam) belongs to the benzodiazepine family of drugs and is used as a sedative. It can induce amnesia and is often given to patients before traumatic surgery. At very high dosages, it can trigger a heart attack and stop the lungs from working. Taken repeatedly, it can also be addictive.
Benzodiazepine users quickly develop tolerance to the intoxicating effects of the drugs, which narrows the safety margin between an intoxicating and a lethal dose.
The fairly easy availability of the cocktail ingredients at private clinics worries the two drug rehab centre managers, who declined to be identified for fear of repercussions.
Addicts taking Subutex or methadone need to be closely monitored, said one of them. "You cannot give them benzodiazepines (as well). These addicts, when they are provided with benzodiazepines, will inject it into themselves with either methadone or Subutex."
''There is no such thing as using benzodiazepines in treating drug addiction," he stressed, adding that he has received threatening phone calls for highlighting the easy availability of these drugs and their abuse.
One recovering addict told IPS that such benzodiazepines can be easily obtained from ''no fewer than 10 clinics in town'' in this northern Malaysia port city. He said he used to take four or five tablets of midazolam or 20-30 tablets daily of valium, either alone or mixed with heroin. ''I know about a hundred addicts who are on these types of drugs.''
He is now upset with the doctors who sold him these pills, because addicts on a high from this cocktail become unaware of what they are doing. ''This is worse than heroin -- and the doctors (who sell benzodiazepines) know it. They are selling it for profit.''
Last year, authorities raided two clinics in Kuala Lumpur and seized 1,280 midazolam pills. But the problem persists.
The other rehab centre manager told IPS of the tragic case of a HIV-positive middle-aged addict who died last month after injecting himself with a cocktail of Subutex and midazolam, both obtained from a general practitioner's clinic.
''I urge doctors and pharmacists who give out Subutex to properly monitor the programme of administration of these drugs and not to abuse them,'' said the manager, pointing out that Subutex dosage should be gradually reduced over time. "Certain doctors appear to be looking for profits and not the treatment. They are indiscriminately giving out these drugs to addicts.''
At the drop-in centre he manages, he provides addicts with only two mg of Subutex a day and gradually reduces it to 0.5 mg after about 10 days, before stopping it altogether.
He believes some addicts may be taking up to six mg of Subutex daily and injecting themselves with a dangerous mixture of Subutex and midazolam.
''Anyway, now that the government is focusing on treatment using methadone, Subutex should be stopped,'' added the manager.
There are guidelines for the use of Subutex, one experienced general practitioner told IPS. ''You are supposed to reduce the amount gradually,'' said Dr T Jayabalan, who often advises consumers about their rights. ''Unfortunately, doctors generally don't follow the schedule.''
Jayabalan said doctors are supposed to help the addicts kick their habits but often the psychological aspect of addiction is not adequately addressed: ''Most of these addicts have instead become addicted to Subutex.''
''It's also a well known fact that there are clinics dealing with benzodiazepines, such as midazolam,'' he added.
Some say methadone is less prone to abuse, but the first rehabilitation centre manager says addicts can just as easily mix methadone with other substances and inject the cocktail.
A surgeon working at a private hospital here was equally concerned. ''The authorities should stop allowing the casual sale of these psychotropic drugs in the private sector so that addicts cannot get a supply of these 'legitimate' drugs such as the benzodiazepines, which are now available in some of the clinics in town,'' he said in an interview.
IPS contacted the Malaysian Medical Association and Ministry of Health about these concerns but got no response to its inquiries at either place.
Time is not on authorities' side. One private physician treating drug addicts told IPS he estimates there are some 600,000 drug addicts in the country and this could rise to two million within a decade.
Errant doctors have to be reined in fast. ''The only way out is for the enforcement people to do their duty'' and curb the availability of these substances, says another doctor at a private hospital in the capital Kuala Lumpur.