A REVIEW ON THE BUDDHIST TEMPLE DRUG DEPENDENCE TREATMENT IN THAILAND
Vichai Poshyachinda: Drug Dependence Research Centre, Institute of Health Research, Chulalongkorn University, Bangkok 10330, Thailand.
Paper prepared for the Meeting of WHO Substance Abuse Collaborating Centres, Geneva, Switzerland. 13-14 September 1993.
Opium and cannabis were the main addictive natural products used and abused extensively in Asia for centuries. Their dependence liability and the great danger of their dependence to individuals and countries were well known. There were uncountable records and publications of all forms that described the licit and illicit trades, pattern of use and abuse, political upheaval of nations and the legal and enforcement interventions. The need and attempt to treat opium dependence occurred in concurrent to the problems over the centuries yet there appeared comparatively much less records and documents in this respect. When countries in east Asia became aware of heroin epidemic in the 1960s and 1970s, the magnitude of the problem and the threat to national security and social and economic development prompted countries to apply all intervention measures including treatment. Traditional practitioners and religious institutions in many countries of the region were described as providers of services that often implied the preference of parents and families of drug dependents and the communities and the accessibility of the services to the general population (1, 2).
The following presentation is specifically on the treatment and rehabilitation of the drug dependants provided by Buddhist temples in Thailand. The description of the treatment, their development over the past 3 decades and the limit knowledge on outcomes is aimed toward demonstrating the fundamental merits and operative constraints observed from the natural history of the services. The materials do not constitute extensive reviews of reports on the temple treatment services but purposely selected to serve the aim of this communication.
I. HISTORICAL BACKGROUND
The Royal Edict of King Rama II on the prohibition of the purchase, sale and smoking of opium in 1811 described yawning, hot and cold flushes, weakness, nausea, vomiting, diarrhoea and mortality as the results from acute opium withdrawal (3). Few years later in 1819, another Royal Decree on prohibition of opium smoking recommended self treatment of opium dependence by gradual decrease of daily opium dose over long period of time (4). These legislative statements probably reflected the knowledge from years of observing opium smoking. They constituted the early traditional knowledge on opium withdrawal signs and symptoms and treatment approach to opium smoking.
The opium franchise policy adopted by King Rama IV, King Mongkut, on the first year of his reign in 1851 led to the eventual spread of opium smoking into practically all social classes including Buddhist priests (5). King Rams V himself recognised opium smoking as a threat to the national security and declared his intention to irradicate opium smoking from the country in 1908 (6). There were a number of traditional drugs then that claimed efficacy in treating opium smoking. These were found to contained opium dross mixed with other ingredients. A particular herbal medicine recipe of a Chinese healer was extensively studied by closely observed a series of treatment in few groups of volunteered opium dependents, in all more than 400 cases. The post treatment follow up was carried out for varying period of time. Conclusion was made by foreign and Thai doctors observing the treatment trials that the herbal medicine was quite efficacious and noted further that the medicine seemed to also had preventive effect against relapse to opium smoking (7, 8). There was no further report on traditional indigenous treatment of opium smoking until the emergence of the drug dependence treatment by few Buddhist temples in the 1960s.
The opium franchise was terminated in December 1958 when the Government decided to passed the law prohibiting the possession, sale and use of opium again. The rapid change of the national drug dependence problem brought about by this major legal intervention indirectly initiated the evolution of traditional opium smoking treatment into the present day Buddhist temple drug dependence treatment programmes. The connection was clearly examplified in the historical development of the treatment service at the Tam Kraborg Temple (TKB) [webmaster note: Alternatively transliteralised/spelt as Wat Tham Krabok]. In anticipation of the great demand for opium dependence treatment to be precipitated by the enactment of the opium prohibition law on January 1st, 1959, the law gave the responsibility of opening opium dependence treatment services in all general hospitals in the country to the Ministry of Public Health (9). According to the number of opium smokers voluntarily registered in December 1958, not less than 70,000 opium smokers would have to abstain from their dependency within the first 6 months of 1959. Furthermore, a heroin epidemic broke out at the end of the same year. Many opium dependents changed to heroin use and new young adolescent heroin user population were observed (10). Due to the short notice and limit resources only a large drug dependence hospital of 250 beds could be open in 1959. Other general hospitals could only gave some simple symptomatic treatment to a small number of cases. Until 1961, there were only 15 hospitals that earned official license for drug dependence treatment (11). The total capacity for drug dependence treatment at that time was about 600 beds. It should be mentioned that all drug dependence treatment then was carried out by in-patient programme. The provision of treatment service was obviously far from meeting the great demand. The critical need for opium dependence treatment was perceived by a nun in Saraburi Province from observing opium dependence and withdrawal in the community. She had inherited the knowledge of herbal medicine treatment for various diseases from her ancestor. Her benevolent nature inspired the trial of herbal medicine for opium dependence treatment around 1960. Her attempt eventually resulted in the unique herbal medicine recipe of the TKB. She passed away in mid 1960s. Her nephew and confident disciple, Pra Chamroon Parnchan the present abbot of TKB, continued with the refining of the herbal medicine and developed the treatment process into a systematic regimen. The treatment inspired considerable belief in the clients and their family. In only a few years, the treatment service of the TKB became widely known throughout the country. The fame and prestige of the TKB was further enhanced by the International Mag Sai Sai Award for public service that the abbot received in 1975.
Between the end of the 1960s and early 1970s, another four Buddhist temples apart from the TKB also became well known for their drug dependence treatment services. These were the Wat Sri Soda (WSS) and Wat Pah Pang (WPP) in Chiangmai Province, northern region, the Tam Talu Centre (TT) in Ratchaburi Province, central region south to Bangkok and Wat Tha Shee Srisumungklaram (WTS) in Roi-et Province, north-eastern region. Only the TKB and WTS still provided the services after 1980 to the present. The rest closed their services in the 1970s. The WSS service was mainly targeted for hill tribe opium smokers. In 1975, the government opened the hill tribe drug dependence treatment unit in Chiangmai city not very far from the temple. The abbot closed the temple drug dependence treatment service because he felt that the treatment need was already served by appropriate agency. The other two temples discontinued their services because of failure in administration and funding support.
II. THE TREATMENT APPROACHES
Buddhism had always exerted an intangible deterrence on alcoholic beverage drinking from the distant past. Because the five principal codes of Buddhist doctrine include refrain from alcoholic beverage drinking, many Thais observed sobriety during the months of Buddhist lent in the rainy season between July and October. Traditional Thais have quite a strong belief in the value of education provided by the temple in maturing a man for family life. Most men enter priesthood for a period before marriage. Parents generally encouraged the practice with great enthusiasm. Some perceive this tradition as their duty to see that their son received ordination. This tradition was extended to ordination of delinquent offsprings with the belief that the life and teaching in the temple will reform the conduct. When drug dependence was recognised as a problem. It was quite natural for the people to look toward the temple as an institution for drug dependence rehabilitation. Although in each year a considerable number of the drug dependents went through the moral and behavioural reform process of the temple, there was no systematic record or study to estimate the extent and efficacy which the temple had served the public in this respect.
II.A. Temple rehabilitation
Since the end of the 1970s, the Council of Social Welfare (CSW) under the Patronage of His Majesty the King, the premier national co-ordinator of non-governmental agencies, the Treatment Division of the Office of Narcotics Control Board (ONCB), Office of the Prime Minister, the national co-ordinator on drug abuse policy and planning and the Department of Religious Affairs of the Ministry of Education had continuously fostered the traditional temple rehabilitation by organised and subsidised the ordination of the drug dependents after detoxification and drug offenders after complete their term of incarceration who wished to enter priesthood. The efforts were aimed toward studying the feasibility and outcome of religious rehabilitation. Temples in all regions were informed of the programmes’ objectives and the responsibility to take care of the drug dependents after ordination in ways the temple considered appropriate to facilitate drug abstinence. The ONCB kept the list of the temples that expressed willingness to host the volunteered drug dependents after ordination. Beginning in 1986 on alternate year, the ONCB organised short course to inform supervisory priests selected by host temples on drug causing dependence, drug dependence problem and modern treatment method. The basic rehabilitation measures common in all temples were begging aim in the early morning, praying sessions after breakfast and in the evening, periodic teaching on Buddism and participation in various chores of the temple. These daily activities were actually the regular activities of the priest. The drug dependents from few treatment centres and the drug offenders in Bangkok were recruited by given counsel on the religious rehabilitation programme. Those who volunteered were ordained and sent to live in host temples. A period of 3 months to one year was frequently recommended for the rehabilitation. However, the decision on time to remain in priesthood was generally left to the temple and the volunteer to settle. The reporting of outcomes from the temple and the follow-up carried out by the CSW and ONCB were rather irregular.
II.B. Temple treatment
The treatment approaches of the five temples mentioned earlier had been described elsewhere (12,13,14). The following description is more of a resume of the essential characteristics and comments that were expected to have direct relevancy to the merits and constraints of the temple intervention programme.
The admission process of all the temples were fairly similar. The clients were informed of the treatment procedure and regulations. The clients had to confirm their voluntary decision to enter the treatment and expressed their willingness to comply comply with the regulations. Intake registration often required identification document. The WTS had special request for family attendance throughout the short treatment of 2-3 days. The family had to take full responsibility of caring for the client. All temples kept records of demographic data in varying extent. Status of physical health and chronic diseases were screened by interview and observation. The temple do not accept cases with poor physical health such as severe debilitation or having life threatening acute or chronic diseases. At the WTS, public health workers from District Public Health Office assisted in screening health status. However for other temples, the screening was carried out by non-professional registration personnel.
The treatment proper constituted of various combinations of religious rite, herbal medicine, moral counselling, religious teaching and vocational training. The WSS used funeral ceremony to initiate the treatment process. The clients carried out a mock funeral cremating their own evil self that dependent to drug. The ceremony implied the rebirth of a new clean life. The clients underwent detoxification without replacement drug. Severe withdrawal signs and symptoms were treated with Dover’s tablet, an antidiarrheal patent medicine containing opium. The TT and TKB required pledging vow of life time abstention from using all intoxicants including alcoholic beverage at the beginning of the treatment. After pledging the vow, herbal medicine was given. The TT gave supplement treatment with modem patent medicine such as tonic and vitamins. The TKB had herbal steam bath supplement to the herbal medicine and a range of optional vocational training in agricultural work, garment manufacturing and car repair etc. Another vow pledging ceremony was the last step before discharged. The WPP and WTS applied herbal medicine as the main treatment. The WTS applied herbal steam bath after the effect of the herbal medicine wore off.
The effect of the herbal medicine used by the WPP, TT and WTS induced immediate semiconsciousness or unconsciousness and delirium for about 1/2-1 day. The herbal medicine of the TKB was uniquely different from other temples. It induced immediate vomiting of about 10-15 minutes. The recipe of the herbal medicine was never released by any temple. All claimed the originality of their recipe.
Periodic moral counselling and religious teaching were given without specific procedure by all temples. The TT occasionally prescribed meditation.
As mentioned earlier only the WTS and TKB continuously provided service until the present. The treatment process and the management of the WTS had not changed much. This was most likely due to the simplicity and brevity of the process. On the contrary, the treatment process of the TKB changed quite a lot in detail. In the 1970s the treatment required 10 day compulsory admission. During the first 5 days, the daily treatment was a drink of the purging herbal medicine in the morning and a session of herbal steam bath in the afternoon. The remaining 5 days were rest period to recuperate from the strenuous first phase. Other rehabilitation services, the moral counselling, religious teaching, recreational parties in the evening and vocational training were optional for those who felt strong enough. Clients could volunteered to stayed longer in the rehabilitation programme or enter priesthood subjected to the abbot’s consent. At present, the client was requested to stay for 1 month. The drinking of herbal medicine and vomiting in the morning were the only daily treatment activities in the first five days. A daily dose of another herbal medicine tablet was given during the next five days. The daily regimen in the last 20 days were herbal steam bath and a dose of yet another herbal medicine to strengthen the physical health. A similar range of vocational training was still offered. Another vow pledging closed the treatment programme as before. The much extended treatment period certainly reduced the clients’ physical stress. However, the management of care had to cope with more cumulative number of clients and increase in activities.
It was evident that some modern treatment knowledge such as physical health screening by health workers, supportive treatment with patent medicine and vocational training and certain component of present day social practice such as personal identification in registration and record keeping assumed a role in the religious treatment process. However, the principal treatment approach still based on authentic indigenous traditional knowledge and belief very much alive in the thinking and perception of the common people. The objectives and the mechanism of the treatment, except for the recipes of the herbal medicines, were simple, clear and credible to the clients, their families and the communities irrespective of the scientific or legal correctness. The active participation of the clients and their families in the treatment process reinforce their responsibilities and commitment to the treatment objectives. These inherent qualities in combination with the belief in the benevolence and sanctity of the temple most likely inspired strong acceptability and supports from the clients and communities.
III. MANAGEMENT AND FUNDING
Buddhist temples were built and maintained from public donation. Affluent and influential individuals or families frequently gave major donation and organised fund raising. Many temples had a group of patrons that continue assisting the temple in support fund and management for generations. Since religious code prohibits priest from involvement with financial matters, there were always lay volunteers who assist in managing the fund and activities. Temples with large contributions commonly established proper non-profit foundation to systematically taking care of the finance and management of daily activities. Major decision on utilisation of the fund was in general made by or with the endorsement of the abbot. This management tradition allows for considerable variation in the management system for examples number and quality of the management staff and auditing system etc. Management could either be under close supervision of the abbot or partially delegated to lay assistants responsibility.
III.A. Temple rehabilitation
The change in number of resident priests in Buddhist temples occurs all the time. Traditional Thais commonly enter and remain in priesthood during Buddhist lent. So there is an annual in number of resident priests during this period. This regular cyclic change makes the temple well adapted to fluctuation in number of resident priests. To host few priests for the rehabilitation programme can is hardly a taxing burden except for the continuous surveillance of conduct of individual priest which is not a common practice of any temple. The management and cost of the temple rehabilitation programme mostly related to recruitment and ordination. According to the CSW and ONCE project’s reports, the fund required for ordination averaged about US$70 - 100 per case. After ordination the person became a part of the priest community in the temple subsisted modestly from community donation.
III.B. Temple treatment
The short treatment at the WTS did not require much time or complicated activities. The caring of clients by the family took the main load of management away from the temple. Furthermore the temple served only few hundred cases per year. At any point in time only a few cases were treated. Therefore the need for extensive accommodation and assistances never arose. Successful treatment cases inspired considerable gratitude and faith in the clients and their families. These naturally developed into a network of patrons that continued to contribute funding support and advocated the temple services to many others. The fund management was in general taken care of by assistance from lay volunteers. The abbot and few assistant priests ministered the actual treatment as a part of the regular activities in the temple.
The provision of standing drug dependence treatment service for thousands of volunteered drug dependents annually at the TKB certainly needed system management and patient care well beyond the regular function of a temple. Apart from the pilgrimage period, the temple maintained between 100-200 priests and hundreds of clients in residence. On the average about 50-75% of the priests were former clients. Together they carried out all the temple chores in systematic collaborations. Example could be observed in the major task of daily catering services that the priest organised the supplies transportation to the temple and the clients volunteered their labour in the cleaning and cooking. The abbot and a small group of priests supervised the daily activities. Specific treatment operations such as admission and intake registration, the vow pledging ceremony, drug dispensing, steam bath and vocational training etc. were assigned to the responsibility of assistance priest. From the beginning of the service in the early 1960s the effort of the temple inspired great admiration and respect from the public and influential officials. The ONCB and the CSW were among the long term supporters of the TKB programme since the 1970s. They had been instrumental in obtaining annual governmental budget allocation and co-ordinated contributions from international agencies. Buildings, equipment for vocational training, utilities and supplies had been granted to support the temple activities. Nevertheless a fair share of the temple operation cost through the years still came from the patrons and public donations in fund as well as in kind. At present, clients that had no fund can received free treatment service subjected to the abbot’s consent. Those that could afford to maintain their own subsistence while residing in the temple were asked to deposit cash about US$ 4 per day in advance. The clients received coupon that could exchange for commodities and meals according to their choice. At the end of the treatment, the remaining sum could be reimbursed. In the 1970s, the temple either provided or charged the daily subsistence cost at about US$ 1 only.
The temple patrons had established the TKB Foundation in the early 1980s. The TKB Foundation had since then served as administration office conducting most managing activities in contact with parties outside the temple. The vocational training had been able to produce income generating products such as ready-to-ware student uniform, herbal medicine and cosmetics. Some agricultural products such as rice and vegetables from the vocational rehabilitation activities partly supplied the temple basic need. Some were used in bartering for other commodities. The retail outlet network of the temple products Were mostly former clients that had been able to rehabilitate themselves into well established professions and trades. The long years of public services had in fact created a substantial network of contributors that linked with the temple through the Foundation management system.
Between mid 1970s to the present the temple had grown from a temple/therapeutic establishment of few buildings and simple wooden accommodations into a fair size community of more than 20 concrete buildings, some of two and three stories with small houses and row of food stalls scattering around. The treatment service area that housed accommodations for clients and part of the priests and service personnel, treatment hall and rest area was well separated from the main compound of the temple by a fence. The abbot prohibited outsiders from trespassing into this compound without permission.
The TKB had the longest period of service compared to other temples and also yield the largest number of clients per year. The temple started keeping systematic admission records in 1963. Between 1963 and 1977, the TKB recorded treating 35,962 drug abusers. The other temples also had quite a large client turnover as well during the later half of 1970s, about 10,000 cases at TT between 1973-1977 (15), 3,483 cases at WPP between July 1977 - December 1978 (16) and 1,893 cases at the WTS between 1975-1979 (17). The annual service of these temples were together in the same level as the Thanyarak Hospital the largest government in-patient treatment hospital, of 250 beds. The annual number of clients of the Thanyarak Hospital between 1967-1976 varied between about 2,000 - 5,200 cases.
The government declared drug dependence the priority national problem for the first time in 1976, Since then there was continuous development of new treatment services in both the government and non-government sectors. The ONCB in collaboration with the Department of Medical Services, Ministry of Public Health started collecting intake data with standard interview form from all treatment service units in the country under obligatory Public Health Regulation. From 1980 to the present, the treatment intake statistics of the TKB and WTS demonstrated a fairly stable pattern of client demographics and geographical distribution. Through the 1980s while the number of drug dependence treatment service units increased from 45 - 138 and total treatment cases raised from about 30,000 to 60,000 cases per year, the two temples annual intakes varied between 2.5 - 5.3% of the total. This share was about half of the services provided by private hospitals and clinics which ranged from about 6.7 - 10% of the total although the number of private service units gradually increased from 5 to 19 in the 1980s. The TKB and WTS temples located in the central and north-eastern regions respectively but their clients came from all provinces in the whole country. About 1/3 were residents of Bangkok and the Central region. Foreign nationals constituted about 4% (Figure 1).
FIGURE 1. Regional distribution of temple treatment population.
The statistics on type of substance abused demonstrated that the clients of the government and private services were from 95 - 100% heroin or opium users while the temple treatment had between 55 - 70%. Considering only the heroin users, the temple services served more percentages of residents from provincial areas than Bangkok, 3 - 5.5% and 1.0 - 2.0% of annual total respectively. Most of the non-opiate treatment population were either cannabis or inhalant users. About 15 - 35% of the total cannabis treatment population used the temple services. The percentages increased to 30 - 45% for the inhalant treatment population. Each year there were between 200 - 450 admissions of alcoholics in the drug dependence treatment services. This number did not represent the total number of alcoholics treatment population because general hospitals over the whole country were the main providers of alcoholics treatment. Nevertheless it was interesting to observed that 30 - 80% of this small number were treated by the temples. The percentages of the heroin and opium users from either Bangkok or provincial areas that reported no previous treatment experience or new case in the annual temple treatment population were consistently higher than the new cases in other government and private treatment services with one exception of clients population from Bangkok that entered private hospitals (Figure 2). The most remarkable difference in characteristics was the level of average income. The average income of the clients of the temple services were definitely lower than those that entered the other government and private treatment services (Figure 3).
V. TREATMENT OUTCOME
Between 1980 - 1987, the CSW ordained 59 drug dependents into priesthood. One year was set as the target period for remaining in priesthood. After ordination they were distributed to temples in 12 provinces. Twenty five persons, 41.8%, took leave from priesthood before 1 year. Eleven, 18.6%, and twenty three persons, 39.0%, remained in priesthood up to 1 year or more respectively. Since the follow up period ended in 1991, the period of remaining in priesthood from 4 years and above were controlled by the time at ordination. Seventeen cases, 28.8%, were in this category. The religious education provided by the temple were divided into 3 levels. Thirty nine cases volunteered to enrol in the religious education. Five cases successfully graduated from the 3rd level. Another 8 and 26 cases managed to passed the 2nd and 1st level (18).
The ONCB carried out a similar programme of temple rehabilitation starting in 1987 and still continued implementing the study. Sixty one cases were ordained between 1987 - 1991. Systematic data collection was attempted to follow the progress by distributing questionnaire to the temple to report back. Forty temples in 25 provinces participated in the programme. Outcome up to the end of 1992 revealed that thirty three cases, 55.2%, remained in priesthood and above 1 year. 68.9% of those leaving priesthood before 1 years relapsed to drug use.
Among the group of 8 cases ordained in 1987, was a unique case. He maintained frequent correspondence with the officer in charge of the project who also made periodic visits. After one year, he went on pilgrim to many distant areas. Finally he settled down in a small cave in a remote district in the north-eastern region. His piety, virtue and kindness inspired great respect from the communities in that area. Soon after he initiated a fund raising campaign for needy students in collaboration with a local school. He received considerable contributions from the communities to support the students. His activities became even more successful in the following year, the fund received were large enough to support children in 6 schools with uniforms and learning facilities. News of his benevolence spread widely. His cave became an active place providing religious and moral teaching for children. He had ordained another ex-drug dependent who came to him and remained as his assistance until the present. The communities had donated fund and built few small accommodations for the activities.
FIGURE 2. Percentage of new opiate treatment population in government and private services and Buddhist temple programme: 1983 - 1990.
A.New heroin users treatment population
FIGURE 3. Average income of heroin dependence treatment population in government and private services and Buddhist temple programme: 1983 - 1990.
BAHT/MONTH
The temple rehabilitation programme adopted the Buddhist traditional practice with very little modification. The new component was the case recruitment which stressed voluntary enrolment which was an assumed indication of motivation. Although there was no detail report on drug use behaviour in most follow up record. The host temples participating in the CSW programme reported good conduct for all that remained in priesthood for 3 years or more. This information most likely indicated drug abstinence. It was hard to believe that relapse to drug use could be overlooked by close observation that long. If this assumption is correct then, the rehabilitation was successful in 29% of the case for 3 year drug abstinence under voluntary retention in the programme. Evidences also demonstrated that those that remained in priesthood shorter than 2 years relapsed to drug use in majority after leaving the temple. The relapse to drug use and delinquency while still in priesthood introduced some deleterious impact on the temple. The behaviour unpredictably disrupted the regular activities of the temple, burnt out the supervisory priests and damaged the reputation and sanctity of the temple which resulted in estranged the community from the temple. A fair number of temples that had these undesirable experience had subsequently resigned from the programme.
There was no recent systematic study of the temple treatment outcome. Earlier reports on follow up study of clients at TKB and WTS temples during the end of the 1970s revealed practically no dropout during the treatment period. For heroin users at the TKB, abstinence rate at six months after discharged were about 20 and 30% for clients from Bangkok and provincial areas respectively. Most relapsed case started using heroin within the first 3 months after discharge (19). Follow up of WTS clients that the majority were alcoholics demonstrated 60% abstinence at 6 months after discharge (20). Partial outcome of the temple treatment could be observed from reports of relapsed cases that re-entered the treatment at other service units. Caution should be made in the interpretation of this data since whatever small percentages of abstinence together with the relapsed cases that did not re-enter treatment did not appear in the statistics. The data on duration of abstinence after discharge of these relapsed cases indicated that in early 1980s the abstinence duration of the temple treatment population was much longer than the government and private services (21,22). However in the later part of the decade this partial indicator of abstinence efficacy of the temple treatment drifted down considerably leaving not much margin of drug abstinence duration over other services (Figure 4).
FIGURE 4. Heroin abstinence rated of previous 1st treatment of relapsed cases that sought 2nd treatment.
The intake records demonstrated that currently the temples contributed a considerable share of the annual inpatient treatment services. Perhaps more significant, the population that entered the temple were from different economic class, apparently serving the poor while the private inpatient services were serving the affluent. The nation wide coverage most likely indicated the belief of the people in the temple services. The same belief possibly played an important influence on the drug abstinence rate as well. The substantial share of non-opiate dependents services probably reflected the non substance specific orientation of the temple treatment which seemed well aligned with the behavioural control need of the general population.
VI. MERITS AND CONSTRAINTS
First of all it is foreseeable that to integrate drug dependence treatment or rehabilitation into a sustainable temple function will need a wide spread concurrence attitude and belief among the priests and lay population on the religious, ethical and moral suitability of the role and responsibility. Variation in agreement could be expected in different communities and will be the major constraint to developing drug dependence treatment service in the temples on a large scale or as an alternative system of modern drug dependence treatment. The report of the successful case under the ONCB temple rehabilitation programme illustrated the natural expansion of the religious institution service into other community which ensured the concurrence of ideology and attitude of the institution and the public. The service for drug dependents was extended to different locality and operated with ideal self reliance concept under full community support in just a few years. However, the case demonstrated the non-systematic nature of the service expansion which implies that the temple service programme expansion cannot be planned in the same way as hospital services.
VI.A. Temple rehabilitation
The preliminary attempts of the CSW and the ONCB in the temple rehabilitation albeit not a rigourous study, yielded many encouraging indications. The adoption of existing traditional temple practice implicated possibility of minimal cost and time in developing large system of residential rehabilitation from thousands of temples widely distributed in the country. The facility could be accessible to and well accepted by people of all classes and different type of communities. The behavioural reform efficacy is surprisingly promising. The quite high rehabilitation retention and the extended drug abstinence duration were probably to a considerable extent, due to the good motivation and faith in religious institution of the clients. The service coverage will depend heavily on the percentages of drug dependents that carry the belief and motivation to enrol voluntarily. The management of care and supervision certainly need further development particularly on the prevention and control of disruptive behaviour. A good screening process for enrolment, recruitment and preparedness of host temples are probably among the key components in developing effective programme.
VI.B. Temple treatment
It was probably not an over statement to say that all temple treatment services were to a large extent sustained by the personality and prestige of the priest that command high respect and faith among clients and the communities. The self help approach and extensive public contribution made the temple a unique model in self reliance, a status practically unattainable by modem governmental hospital services. Nevertheless recognition should be made that the fairly complete treatment services provided by the temple in essence, changed the traditional function of the temple into a full fledge welfare institution. For small service like the WTS the image of a Buddhist temple was retained to a fair extent. The extensive service provided over many years by the TKB gradually changed the temple into a new kind of therapeutic religious institution that no longer carried the image and religious atmosphere of a Buddhist temple. The treatment of large number of cases together did not allow for intimate communication and relationship to develop between the clients and the priests. Apart from the striking changes in physical environment, the most apparent changes over these long years was the gradual disappearance of the valuable therapeutic environment of peace and the non-verbal expression of care between all parties concern. These changes were perhaps partly responsible for the downward drift of the statistical decline in abstinence efficacy.
Because opiate dependence treatment contained explicit life threatening risk particularly among the poor physical health, traditional treatment in temple without certified professional assistance raised the contentious ethics of safety in health care service. The impact of difficulties in management was clearly demonstrated by the short life service in a number of temples. The present situation was far from ideal. The constraint on management of health care service actually embedded in the fundamental difference in ideology between the treatment services and religion. There seems to be no simple solution to future development.
The temple treatment services contained the definite merits of cost effectiveness from community support and self help treatment approaches. The services also inspired high acceptability and faith from clients and public. These inherent merits were raw material waiting to be develop into a viable and effective treatment and rehabilitation for large population coverage accessible to target groups of all social and economic classes. However, the replication of the programme elsewhere remains a contention that required more careful studies to understand the mechanism of the service and the key component of system development.
CONCLUDING REMARKS
Experience thus far from the rehabilitation and treatment of drug dependence by the temples in Thailand demonstrated many merits that seemed to specifically related to the traditional means and ways of their development and the religious milieu of the country. There were many obvious benefits on drug dependence demand reduction and attractive components in the treatment model that some of which were closely related to the non-replicable personal charisma of individuals. Description of drug dependence services of religious institutions that applied traditional medicine, belief in rituals and personal charisma in Asian countries was referred to at the beginning of this communication. Yet the services seemed to attract little attention of the authority. What constitute the lack of interest may be a crucial issue to elucidate in order to further develop the valuable potential of religious institutions in the field of drug dependence treatment and prevention in any country. The intrinsic virtue of the temple in public welfare is a delicate and fragile treasure. To apply this valuable treasure probably need sophisticated and understanding hands unlike other scientific knowledge that could be applied and transferred systematically in large scale. Inappropriate application of religious institution in the worldly welfare service could render highly damaging long term impact difficult to justified by the immediate and limited benefits of transient behavioural modification.
ACKNOWLEDGEMENT
The author wishes to thank the Treatment Division, Office of the Narcotics Control Board, Office of the Prime Minister and the NGO Anti-Narcotics Co-ordinating Center, National Council on Social Welfare of Thailand for the permissions to use the records of their ordination programmes for drug dependents. Sincere thanks and deep appreciation were due to Mrs. Yaowamal Kratuengarn and Mrs. Puanglek Khunawat of the above agencies respectively for their industrious persuit of the programme implementations with dedication and tenecity against all odds from limit resources. Without their valuable contributions there can never be any material in this respect for this communication.
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