Indigenous treatment for drug dependence in Thailand

Vichai Poshyachinda

United Nations Educational, Scientific and Cultural Organization (UNESCO)
7 place de Fontenoy,
75700 Paris, FRANCE

The following article is reprinted from:
Impact of Science on Society no. 133 (Vol. 34, No. 1) 1984: “Man’s addictions and how to deal with them”

The text may be freely reproduced and translated provided that mention is made of the author and source.

The author, a physician, is associate professor and chief, Drug Dependence Research Centre, Institute of Health Research, in Bangkok. Dr Poshyachinda wishes to thank Professor Dr Payom Tantiwatana, of the Faculty of Pharmacy at Chulalongkorn University, for her significant contribution to this article. He adds that ‘without her knowledge of herbal medicine, this report could not have been completed’. The author’s address at his institute is: 5^th Flow, Institute Building 2, Soi Chulalongkorn 62, Pyathai Road, Bangkok (Thailand).

Treatment for drug dependence in Thailand, available for more than a century, is administered in Buddhist temples and is based on herbal medicine. The rate of success of this farm of treatment is at least equal to that based on modern drugs, begun about twenty-five years ago. This confirms the valuable contribution of the traditional cultural and social environments to the cure and rehabilitation of drug dependants. The need to study further such therapeutic experience is emphasized.

The history of opium dependence in Thailand has existed for many centuries. In the early days, society witnessed behavioural manifestations and suffered devastating problems related to opium dependence. Society attempted to contain and eradicate its problems by legally enforced control. But records exist also that reveal experience and knowledge based on therapeutic practice. This knowledge and its techniques could be specified as the earliest indigenous development in Thailand of treatment for opium dependence.

Although modern drug-dependence treatment has been widely established since 1959, the service can hardly meet the need for treatment of the country’s large and widespread population dependent on drugs. In response to need and perhaps out of the humanitarian concern for the suffering of those dependent on drugs, a fair number of treatment techniques are again emerging from the public sector-concurrent with but independent of services emerging from modern medical institutions. Thousands of the drug-dependent have already received this indigenous treatment. Even though the effectiveness of many of these indigenous models remains unclear, the evidence as to their remarkable acceptability by drug-users and their partial success are undeniable. Because modern treatment cannot yet claim dramatic success, it is perhaps time to appraise critically the indigenous practice. The key to its success (or failure) can be valuable knowledge in the further development of appropriate treatment for drug dependence.

Historical review

The withdrawal signs and symptoms of opium dependence - yawning, feeling hot and cold, weakness, nausea, vomiting, and death from diarrhoea - were clearly described in the edict of King Rama II that declared the prohibition of the purchase, sale and smoking of opium (1801).¹ Later, this knowledge was officially prescribed as the diagnostic criteria of opium dependence for violators of the opium-smoking prohibition who would not confess.² A description of the treatment for opium dependence first appeared in a royal decree prohibiting the smoking of opium (1809).³ This decree advocated self-treatment by a gradual reduction of the daily dose until complete abstinence by the addict.

The earliest major report on the treatment for opium dependence appeared in official records during the reign of King Rama V. This report summarizes information gathered in 1908 and subsequent experience with the experiment in treatment between June 1909 and July 1910.⁴

The information assembled in 1908 revealed that opium dependence was being treated by many types of medicine, most of which contained opium dross mixed with other ingredients. There was a special recipe, called Japanese medicine, by which the drug dependant could effectively replace the smoking of opium, taking one tablet each morning and one each evening. This medicine induced a feeling of intoxication inferior to the euphoric effect of opium smoke. The conclusion was reached that the opium smoker became dependent on this medicament rather than on opium. Another method for treatment by herbal medicine (see box) was studied extensively by interviewing a traditional Chinese healer and his clients. At that time, this treatment had been given to twenty-four opium dependants. All but one had relapsed to the use of opium. Interviews were made of four of the patients, one of whom was the non-relapsed subject just mentioned.

Herbal treatment for opium addiction
The dependent subject is first given a physical examination, for patients having tuberculosis, cancer or fever cannot be treated. (A patient with fever can be treated after disappearance of his fever.) The best time for treatment is during the rainy and cold seasons. On the first day, the patient takes opium as usual. Recipe A is given the first time in the evening, between 5 and 6 o’clock. During the night, recipe A is given three times: at 9, at midnight and at 3 in the morning. On the second day, recipe A is given at dawn, at 9 a.m., then at 2, then at 5 p.m. and during the night as in the first night. The same procedure is repeated on the third day. If there is much restlessness during the second day, the intervals between doses can be shortened. If there are signs of throat irritation, the patient can be given recipe B.
The patient usually has no abnormal signs and symptoms the first day. Diarrhoea and a craving for opium commonly occur the second day; on the third day, the diarrhoea is more severe, and some patients may be delirious. There may be a relationship between the severity of these signs and symptoms and the degree of dependence. Close surveillance is required during the second and third days of treatment. On the fourth day, the patient takes steam-baths in the morning, noon and evening (see recipe C); during the two days following, the patient steam-bathes in the morning and evening only. The diarrhoea and craving for opium will stop on the fourth day.
The total time of treatment is thus six days.
Recipe A (powdered drug):
Pomegranate rind (Punica granatum Linn.)	2 portions	}
Bark of pomegranate root	1 portion	}	Combine to form first part
Bark of lime root (Citrus limon Burm.)	1 portion	}
Bark of Plumeria acuminata Ait.	1 portion	}
Root of Datura metel Linn.	2 portions	}	Combine to form second part
Seed of Datura metel Linn.	1 portion	}
The six ingredients are dried in the sun and ground to powder, the Plumeria acuminata Ait. and Datura metel Linn. also being roasted before grinding.
The ingredients are stored separately, then mixed before use. Each dose weighs about 1.1 g, taken as a suspension in hot water.
Recipe B (for irritation of the throat):
Use table salt mixed with lime juice, to which is added a trace of Borneol (a camphor-like preparation, the name of which is related to Borneo). Take as required to relieve irritation.
Recipe C (for steam-bath):
Loves of Zingiber cassumunar Roxb.
Salt
Betel (Piper betel Linn.) leaves
Leaves of Blumea balsamifera DC
Jasmine (Fasminum sambac Ait.) leaves
Guava (Psidium guajava Linn.) leaves
Pomegranate (Punica granatum Linn.) leaves
Leaves of Piper longum Linn.
Krathum (Anthocephalus cadamba) leaves
The ingredients are mixed in equal portions, amounting to about two large handfuls for a large pot of water. The water should cover the ingredients and be heated to the boiling point. The steaming pot is then brought to the steam-bath, to which it is added.
(Note: The above is taken from a document originally prepared in the Thai language.)

After the interviews, the traditional Chinese healer was recruited in the official service and entrusted with the treatment of opium-dependent convicts. Treatment was also offered to public volunteers. Between June 1909 and July 1910, 375 cases were treated: 201 convicts and 174 volunteers. The report on these stated that there were no relapses and that, furthermore, no physical danger was observed. No description was offered, however, as to the method of evaluation or its duration. Five additional cases were then treated under close observation of the authorities, from the preparation of the medicine to the termination of the treatment.

The report concluded that this treatment with herbal medicine has three distinct advantages. First, the treatment is applicable to all opium-smokers, regardless of the duration of their dependence; the treatment is contra-indicated in opium smokers suffering from complications of tuberculosis or fever. Secondly, after treatment, the patient is not only free from the craving for opium; he is also repelled by the smell of opium smoke. And, thirdly, a relapse towards the use of opium can occur only because of a determination to smoke the product (rather than because of a craving).

In addition to this report, there is also a record of the experience of four physicians (two Thai and two foreign) who, after learning the procedure, had treated two groups of opium smokers - two and nine cases, respectively. After treatment, the subjects were asked to try opium-smoking under observation. Both groups showed signs of revulsion to the smell of opium smoke, and vomited on attempting to smoke. One subject was interviewed one year after treatment; he reported a persistent feeling of repulsion to the smell of opium smoke and that he lacked a craving for opium.

Because of these encouraging observations, the authorities launched another clinical trial with the study of thirty-three cases.⁵ The study of these treatments was rather similar to what is described in the report mentioned above. The follow-up (although the number of cases and time elapsed were not specified) revealed two cases of relapse.

Current indigenous treatment

To Thais (particularly the rural population), the Buddhist temple is not only a religious institution; it is an all-embracing sanctuary where people commonly enter in order to seek education, counselling, temporary shelter and even the treatment of illness. The strong belief in Buddhism is witnessed by the fact that much of the rural population, frequent drinkers of alcoholic beverages, will abstain during the Buddhist Lent. Priests are fully aware of the public’s recognition and expectations regarding their role in society. Hence it is most natural that the tremendous need of the drug-dependent population for treatment should lead them to the welcoming hands of the temple. Countless drug dependants, through their own volition or because of family coercion, have entered priesthood in search of abstinence from drugs. Throughout the country, a vast number of Buddhist temples and their priests serve in this role at the present time. The methods of care, the experience and its results, behind temple walls, remain an unrivalled pool of traditional knowledge.

During the last two decades, a few of the temples have gradually developed into treatment centres for drug dependence. They have become well known not only in Thailand, but abroad as well. The treatment records of centres such as that of Tam Kraborg in Saraburi Province, the Tam Talu centre in Ratchaburi Province, and Wat Pah Pang in Chiangmai Province show registration of patients from Burma, India, the Lao People’s Democratic Republic, Malaysia, Singapore and elsewhere. The number of drug dependants treated is fairly large, e.g. 35,962 cases at Tam Kraborg between 1966 and 1977,⁶ about 10,000 cases at Tam Talu between 1973 and 1997,⁷ and 3,483 at Wat Pah Pang between July 1977 and December 1978;⁸ at Wat Tha Shee Sri Su Munklaram, there were 1,893 cases between 1975 and 1979.

Treatment method in Buddhist temples

It should be mentioned at this point that the following material is derived, through arbitrary selection, from the five well-known centres; Tam Kraborg and Tam Talu, Wat Pah Pang and Wat Sri Soda, and Wat Tha Shee Sri Su Munklaram. These are considered to have unique approaches to treatment. It is beyond the scope of this report to provide detailed descriptions of each temple’s treatment method, but some have already been reported elsewhere.^9-13

All temples have an interview procedure to confirm the voluntary motivation of each patient. The Tam Kraborg centre has the most elaborate procedure, whereby the patient learns in detail of the treatment’s procedures and regulations and he is asked to reconsider carefully whether he still wishes to enter treatment. For admission to treatment, an identification document is commonly required, and the client must fill and sign an enrolment form. The registrant is required to be accompanied by a parent or other senior relative to certify the enrolment form.

Various types of records are kept relating to basic demography, history, and types of drug use. Physical fitness to receive treatment is evaluated according to the knowledge and means available locally. Some temples having volunteer health workers can give professional physical examinations. Registrants appearing too weak or having obvious, complicating illness are usually barred from treatment.

The treatment proper to each temple has its own characteristics. Wat Sri Soda uses spiritual treatment, with the patient carrying out a mock funeral of his evil self. Its implication is the rebirth of a new, clean person. Herbal medicines are not used. The dependant on opiates who has severe withdrawal problems is given relief by taking tablets containing some opium. Intensive counselling and religious teaching are offered.

Patients at Tam Kraborg and Tam Talu are required to take a vow of abstinence for life, on the occasion of a religious ceremony, and a regimen of herbal medicine taken orally follows. At Tam Kraborg, a herbal steam-bath is taken in conjunction with the taking of herbal medicine orally. At Tam Talu, supportive treatment is given in the form of patent drugs-tonic and vitamins, while at Tam Kraborg none is given. After treatment with herbal medicine, a period of physical recuperation follows, accompanied by periodic counselling and religious teaching.

Various forms of physical exercise are encouraged. After this period, the patients can elect to enter the priesthood - but they must demonstrate their sincerity in this respect. The length of time they spend in the priesthood is determined, of course, by their own wishes. At Wat Pah Pang and Wat Tha Shee, the treatment relies solely on herbal medicine. The former uses herbal medicine taken only orally, while the latter supplements herbal remedies taken orally with herbal steam-baths.

Medications and mock funerals

Unlike the historical record concerning herbal medications, the recipes for herbal medicine are not currently known outside the temple. Tam Talu is the only temple using three recipes; each is reserved for clients who are dependent on specific drugs. One recipe is reserved for those dependent on opiates, while another is kept for those dependent on solvents and cannabis. The third recipe is used in cases of dependence on kratom (Mitragyna speciosa), a local herb containing the stimulant mitragynine, C₂₃H₃₀N₂O₄.

The other temples have only one recipe, but the dosage is varied according to the severity of dependence and the physical condition of the subject. Observation of the effects on patients, however, demonstrate two types of response. The recipes used at Wat Pah Pang, Tam Talu and Wat Tha Shee induce semi-consciousness or unconsciousness and delirium for periods of a half a day to a day and a half. It is obvious that such an effect is meant to counteract the signs and symptoms of physical withdrawal from the opiates. The herbal action is most likely via the central nervous system.

The herbal remedy used at Tam Kraborg is uniquely different from the others. Severe vomiting is the immediate and only reaction. A priest relates that the herbal substances dean the body of the toxicity produced by the addictive drug. The intended effects of the herbs, in this case, are not totally different from the aims of the mock funeral at Wat Sri Soda. The difference lies in the physical and spiritual means applied. The Tam Kraborg treatment is remarkable from another point of view, too: no attempt is made to relieve the patient of the physical suffering attending the signs and symptoms of withdrawal. The severe vomiting for five consecutive days aggravates, furthermore, the physical suffering - almost as an intentional punishment (although such has never been alluded to).

Among the counselling and religious teachings practised, only the Tam Talu method includes meditation.

Administering treatment

Buddhist temples, like other religious institutions, are supported by public contributions, and their services are subsidized by the community. Tam Traborg and Tam Talu have a high turnover of patients and groups of patrons who organize fund-raising and assist in the temples’ financial management, For the treatment of addicts, there is no regular charge. In some centres, however, where the duration of treatment is fairly long, the administrative organizers advise the patients and their families that contributions are appreciated for the subsistence of their patients.

The daily activities in these temples associated with treatment services require much manpower, and the resident priests and lay volunteers are the temples’ principal resources. Mutual assistance among the patients is another remarkably consistent aid. In Wat Pah Pang and Wat Tha Shee, treatment lasts a few days only and consists of treatment with herbal medicine. The patient’s accompanying parents and relatives take care of the patient until his discharge, and the temples need practically no additional help. Minimal assistance to maintain the simple facilities is easily provided by the resident priests and a few lay volunteers.

Outcome of treatment

In general, then are no drop-outs from treatment at the temples of Tam Kraborg and Tam Talu, there, the duration of the programmes is extremely short and the patients are treated by herbal medicine most of this time. The treatment procedures simply allow no chance that a drop-out will occur. The extended treatment at Tam Talu, however, and the severe physical suffering in the Tam Kraborg programme over a ten-day period have resulted in only a few drop-outs among thousands of patients.

As to drug abstinence, all the temples try to evaluate the outcome by whatever means are feasible under the circumstances. Information is received directly from the abstainers or their families when they return to the temple in order to express their gratitude. Postal inquiries have been conducted by some temples but, because of a lack of systematic approach, the impressions reported by the temples cannot be taken as reliable evaluations. Even so, a certain degree of success is a fact.

Follow-up studies of groups treated at Tam Kraborg and Wat Tha Shee were carried out by the Drug Dependence Research Centre, Institute of Health Research, Chulalongkorn University. In this Tam Kraborg group, the abstinence me after discharge among heroin users from Bangkok was about 20 per cent and, among those from provincial cities, about 30 per cent. Most recidivists resumed using heroin within three months. The users were spending less money on the drug, however; the Bangkok recidivists were spending (on average) about 30 per cent, and those from provincial towns about 40 per cent of what they had spent in the thirty day before admission. The employment status of about 60 per cent of the heroin users reporting abstinence was unchanged, and an improvement was reported in about 30 per cent of the cases. One-third of me recidivists showed further deterioration in their employment status, half remained the same, and about 10 per cent reported improvement.¹⁴ The opium smokers (coming mostly from provincial centres) had an abstinence rate of about 50 per cent after six months. Their employment status remained unchanged, but it is to be noted that this group was fairly stable economically to begin with.¹⁵

The group from Wat Tha Shee is quite different from that at Tam Kraborg. Instead of being dependants on opiates, these are alcoholics in the majority (about 73 per cent), whereas the opiate dependants constitute about 4 per cent of the group. The group’s abstinence rate six months after discharge is about 60 per cent. The employment status of mot cases (70 per cent) after treatment remains the same, and the rates of improvement and deterioration are about the same.

A few comments

The historical record reflects the existence of a perhaps truly indigenous treatment for opium dependence, as practised in a community by a traditional healer, with its subsequent development by public authorities into an institutionalized programme. The treatment described has depended upon herbal medicine alone. Among the herbs specified in recipe A, Datura metel Linn. appears to be the main ingredient. All parts of this plant contain hyoscyamine, hyoscine and atropine - the first two of these alkaloids having psychotropic action that can induce unconsciousness and hallucination.

Tolerance to the anti-opiates has not been properly studied. In 1978, a physician reported the results of a clinical trial conducted in a rural hospital, using the herbal medicine recipe. His subjects comprised twenty-nine opium dependants and three heroin-takers. A sensation of repulsion to the smoke from opium and heroin was reported in all cases, according to a control study made after the treatment. A follow-up study, made after an unspecified interval, indicated a relapse rate of 23.6 per cent.¹⁶ The results of this study, although still inconclusive (according to its author), confirm to a certain extent observations found in the historical record. Further study is much needed in order to understand the pathological action of the alkaloids and other active ingredients of the recipe. The real potential of the herbal medication thus remains obscure.

The brief descriptions of the current, indigenous practices found in the various temples may suffice to demonstrate that - though the treatment was developed in the temples - a certain degree of knowledge concerning modern medical treatment has been blended with the purely native knowledge. The complexity of the treatment has ranged from simple to high, and the uncomplicated treatment by herbal medicine may not be totally lacking a psychological component. Belief in the competence of the religious institution can be a very subtle element in the mind of the patient, inspiring him to enter treatment and supporting him to continue drug abstention after his discharge.

The absence of drop-outs during treatment reflects rather clearly the acceptability of the treatment process, and there are probably many intangible elements influencing this factor. The sanctity of the temple probably offers considerable attraction to those dependent on drugs, whose behaviour is both illegal and antisocial. The sentiments of the transgressor make him particularly sensitive to all forms of threat, even the perceived but unexpressed menace of rejection. The religious domain offers security and, additionally, moral forgiveness rooted deeply in our culture and traditions. The uniqueness of what is offered is founded on a sincere intention to help. Procedures that may appear punitive are justified unquestionably in the best interests of the patient. Modern treatment, with its aura of humanity combined with legal immunity, may compete with the temple only with difficulty.

Community participation; religious codes

The voluntary nature of the personnel engaged in care ensures a dedication leading to an atmosphere of caring and efficiency. There are many advantages to this. To the patient, the feeling of care imparts a sense of peaceful relaxation, it creates a rapport of trust, too. The willingness to serve on the part of the staff reduces bickering conflict and self-centred animosity towards the tiring work. Daily tasks become optimized of themselves, so that there is no need to institute authoritarian management. Another subtle advantage is the absence of a need for an obligatory system of rewards made by management. The whole combination relieves the temple of economic strain and a complex managerial task.

Treatment at the temples is perhaps the closest thing to an ideal model in terms of community participation. Funding support, volunteer staff and family involvement demonstrate the general public’s active engagement, as well as that of both the local community and of families, in the treatment programme.

It would be highly prejudiced to believe that the programme of temple treatment is without disadvantages. The lack of modern knowledge in pharmacology and pathologic physiology, for example, probably causes the temples some difficulty concerning toxicity related to treatment by herbal medicine. Although the efficacy of the herbal recipes is still unclear, acutely systematic observation - through well-designed trial-and-error studies - should be able to enhance the intended effect. The question remains, of course, whether it is feasible to do so, given the currently incomplete state of our knowledge of herbal medicine.

The strong element of community participation which helps to create and maintain the temple treatment lacks a firm organizational infrastructure essential and crucial to the stability and continuity of such service. A large centre suffers more in this respect than a small one because of the heavy dependence upon a fairly large group of patrons for administrative support. The task of maintaining the service is, indeed, taxing to the patrons. There are times when the service must be suspended, to be resumed later, because of lack of management assistance. Such irregularity prevents the temples from offering the full potential of their services. A similar disadvantage is evident among the volunteer personnel. Few can maintain their contributions over extended periods.

Religious codes establishing limits to the activities of the priesthood, particularly in regard to financial matters, leave the temples depending totally upon lay volunteers. With the best of intentions, mismanagement can occur, bringing an undeserved taint to the religious institution. The heavy load causes a strain on the obligatory religious liturgy, adducing much controversy on the orthodoxy of a temple’s overall activities.

Conclusion

Regardless of philosophical considerations, there is no doubt that current indigenous treatment for drug dependence undertaken by the Buddhist temples has brought a major social service to (otherwise unmet) needs of the populace dependent on drugs. And this contribution is one not only in humanitarian service, but also one nude to knowledge and technology in general. Much of this valuable contribution has not yet come to the attention of the official administration and the scientific community. There has been encouraging evidence of such cognizance in recent years, but it is still far from adequate.

Notes

1-16. (Because most of the literature cited by the author is in the Thai language, interested readers should contact the Editor to obtain the author’s complete bibliography by post.)