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When visiting other countries, it is customary to pay close attention to the local laws that apply, Indonesia is no exception. Like in many countries, Indonesia has Capital Punishments for Possession and Trafficking of illegal drugs. Possession is punishable by 4 to 12 years of imprisonment. If the drugs exceed 1 kilogram for raw drugs like marijuana or 5 grams for processed drugs like heroin and cocaine , a maximum punishment of life imprisonment may be imposed. If the volume of drugs exceeds 1 kilogram for raw drugs or 5 grams for processed drugs , the death penalty may be imposed. Smoking is also prohibited in Public Transport. Designated smoking areas are a must in other types of public places and office buildings. Travellers could bring a maximum of cigarettes, 50 cigars or grams of tobacco and a reasonable amount of perfume per adult. As a country with Muslims as the majority, alcohol drinking is prohibited by the laws of the religion and frowned upon. However, since Indonesia is a country with diverse cultures and religions, currently there are no alcohol bans being enforced in Indonesia, with the exception of Aceh. Also prohibited, driving while under the influence of alcohol. The legal age for drinking in Indonesia is 21 years old. Those who are caught drinking outside the legal age will face serious punishment or charges from the authorities. Those who overstay within the 60 days period will have to pay a daily fine of IDR up to 1 million per day. Those who overstayed more than 60 days will face deportation and possible blacklisting. Alternatively, foreigners can have the international driving permit issued in their home country before they leave, but this may need to be endorsed by the Indonesian licensing office in Jakarta once they arrive. The age limit to drive in Indonesia after obtaining the Indonesian driving license issued by the Indonesian National Police Polri is 17 years old. In Indonesia, people drive on the left-hand side of the road, and standard international driving laws apply. The speed limit is 50kph in urban areas in Indonesia, and kph on a motorway, but the only proper motorways in the country are in Java. Gambling is prohibited in Indonesia, it is considered completely illegal for both locals and foreigners. There are no proper casinos in the country, and those who practice gambling may find severe punishments by authorities and thrown to jail. Indonesia has different systems for landlines and mobile phones: landlines use area codes, while mobile phones do not. For landline area codes, the digit '0' is added in front when dialling domestic long distance from within Indonesia, but is always omitted when calling from abroad. Important note for foreigners visiting Indonesia, be sure to carry your passport with you at all times as a form of identification as a precaution measures. Chances are you won't need it, but there is always a chance that you may be required to do so. This is the official website of the Ministry of Tourism, Republic of Indonesia. The contents listed on this website are intended for informational purposes rather than commercial. Any displayed sale is meant as a token of partnership and will always redirect you to our partners' sites. Local Law When visiting other countries, it is customary to pay close attention to the local laws that apply, Indonesia is no exception. What is the drinking age in Indonesia? What is the Age Limit to Drive in Indonesia? What is the speed limit in Indonesia? Visit our other website.

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Official websites use. Share sensitive information only on official, secure websites. Despite the rise of stimulant use, most harm reduction programs still focus on people who inject opioids, leaving many people who use methamphetamine PWUM underserviced. In Asia, especially, where methamphetamine prevalence has overtaken opioids prevalence, harm reduction programs assisting PWUM are rare. The few existing innovative practices focusing on methamphetamine use lie underreported. Understanding how these programs moved their focus from opiates to methamphetamine could help inspire new harm reduction responses. Hence, this paper analyzes a newly implemented outreach program assisting methamphetamine users in Jakarta, Indonesia. This case study is part of a more extensive research on good practices of harm reduction for stimulant use. For this case study, data was collected through Indonesian contextual documents and documents from the program, structured questionnaire, in-depth interviews with service staff and service users, a focus group discussion with service users, and in-loco observations of activities. For this paper, data was reinterpreted to focus on the key topics that needed to be addressed when the program transitioned from working with people who use opioids to PWUM. Four key topics were found: 1 getting in touch with different types of PWUM and building trust relationships; 2 adapting safer smoking kits to local circumstances; 3 reframing partnerships while finding ways to address mental health issues; and 4 responding to local law enforcement practices. The meaningful involvement of PWUM was essential in the development and evaluation of outreach work, the planning, and the adaptation of safer smoking kits to local circumstances. Also, it helped to gain understanding of the broader needs of PWUM, including mental health care and their difficulties related to law enforcement activities. Operating under a broad harm reduction definition and addressing a broad spectrum of individual and social needs are preferable to focusing solely on specific interventions and supplies for safer drug use. This paper presents a critical analysis of one of the seven case studies presented in a research about good harm reduction practices for people who use stimulants \[ 1 \]. To our knowledge, this was the first harm reduction-oriented project in Southeast Asia focused on providing outreach work services for PWUM. The present article explores and describes this case in more detail and pays special attention to the process of redirecting its harm reduction program from assisting people who inject opioids to assisting people who smoke methamphetamine. Nowadays, the project provides PWUM with oral information and leaflets on methamphetamine, mental health issues, drug use and use disorder, and health impacts of methamphetamine use. Karisma also distributes safer smoking kits and works on developing a network of services to address PWUM needs further. From the critical analysis of this case study, four key topics arose that need to be addressed when a program transitions from working with people who use opioids to PWUM. These are \[ 1 \] getting in touch with different types of PWUM and building trust relationships \[ 2 \]; adapting safer smoking kits to local circumstances \[ 3 \]; reframing partnerships while finding ways to address mental health issues; and \[ 4 \] responding to local law enforcement practices. The following pages of this section describe the context, including some background on the rise of stimulants use and the Indonesian case. A second section explains the methodology of the study. A final section concludes with the most relevant points harm reduction organizations need to pay attention to when operating similar transitions. In recent years, several regions in the world have witnessed an increase in the use of stimulants. According to the World Drug Report , amphetamine-type substances ATS are the second most commonly used illicit drug — after cannabis. ATS are a group of chemically and structurally related synthetic drugs that are powerful central nervous system stimulants. They increase the activity of the dopamine and noradrenaline neurotransmitter systems and raise levels of dopamine and norepinephrine in the brain \[ 2 \]. It is estimated that around ATS are the dominant drug of choice in Asia \[ 2 \], where methamphetamine prevalence has overtaken heroin prevalence since \[ 5 \]. Methamphetamine is structurally similar to amphetamine, but it is more potent, and its effects typically last longer. On the illegal market, methamphetamine is sold in pill, powder, or crystalline forms. In East and Southeast Asia, methamphetamine in tablet form is common. These pills, generally called yaba , are typically of low purity and may contain several other psychoactive substances in addition to methamphetamine. While pills are generally taken orally, or sometimes crushed and smoked, the crystals — referred to as shabu, ice, or crystal meth — can be smoked or injected. Powdered methamphetamine is usually adulterated with an additional substance such as caffeine, dextrose, or lactose and can be taken orally, intranasally snorted , or dissolved and injected. In Southeast Asia, as in the rest of the world, most of the harm reduction services available in the region focus on people who inject opioids. Most traditional harm reduction interventions are funded under the umbrella of HIV prevention, focusing on interventions such as needle and syringe programs NSP and HIV testing and treatment. The development of such interventions has been particularly challenging in East and Southeast Asia. Although harm reduction has been accepted as a legitimate approach to addressing drug use in several Asian countries, the leading treatment for people who use ATS is compulsory abstinence-oriented treatment in residential centers. Human rights abuses have been reported in many of those centers, and the compulsory inpatient strategy lacks proof of effectiveness \[ 6 \]. People who use ATS rarely use harm reduction services, largely because they do not identify with problematic opioid use. They often belong to different networks of users and thus do not perceive harm reduction services as relevant to them \[ 6 \]. Besides, the use of stimulants brings new social and health challenges, and many existing harm reduction programs face the difficult dilemma of wanting to address an unassisted population but perceiving themselves as lacking the knowledge or resources to do so. Fortunately, some innovative harm reduction practices to address stimulants exist brought about by harm reduction organizations rooted in the field. Programs like these have an in-depth knowledge of the context and the needs of the community of people who use drugs PWUD. Nevertheless, many of these practices tend to remain unknown to the broader public, due to insufficient documentation and dissemination. Studies available e. Understanding these learning processes can improve our knowledge of harm reduction efforts and may constitute a powerful tool to inspire other organizations to build new harm reduction responses. Although its validity has been strongly criticized, the only national survey on drug use presents similar results to UNODC estimates, with methamphetamine, locally called shabu , as the second most popular drug in the country \[ 11 , 12 \]. Jakarta, Denpasar, Batam, Medan, and Makassar are the cities with the highest prevalence of methamphetamine use in Indonesia \[ 9 \]. The rights of PWUD are often violated by forced drug testing, detention, compulsory treatment, and extortion \[ 14 \]. Despite the punitive regulations, harm reduction is legally supported \[ 15 \], and harm reduction services are available throughout the country. The majority of these, however, continue to offer services for people who inject heroin only. NSP are offered by NGOs and primary health care services, and opioid treatment programs OTPs are carried out by public health services in primary health care clinics called Puskesmas. The case described in this study was the first harm reduction outreach work project in Southeast Asia to focus on stimulant drugs. The project is run by 11 paid staff members — 5 of which are outreach workers — and 17 voluntary outreach work peers in Jakarta. The program operates since mid and is coordinated by Karitas Sani Madani Foundation Karisma , a community-based organization set up in by people whose lives had been affected by problematic drug use. In , the organization got international funding to provide outreach work for people who inject drugs PWID — who mainly used heroin — in Jakarta. In , having run a solid NSP program for over a decade, the organization started noticing a drastic drop in the uptake of needles and syringes. If before they were distributing up to 20, needles a month, by the number was down to a couple of hundreds. It was so hard to find new people who used heroin. At the same time, we saw the rise of methamphetamine. And we really wanted to engage with and help people who use drugs. Up to , national and international funding covered NSP programs only. When in international funding to work with PWUM was made available through Mainline, Karisma started developing the only project offering harm reduction for people who use shabu in Indonesia. A needs assessment \[ 9 \] helped identify priorities for a pilot intervention: two drug hotspots in Jakarta, a focus on health consequences associated with methamphetamine use, and the specific harms caused by risky sexual behavior. Outreach work started in July , and the team had to overcome the challenges of transitioning from reducing harms of opioids to reduce harms of methamphetamine use. The key learning points of this transition are the focus of this paper. This article presents an in-depth exploration and critical analysis of a case study previously reported in a larger investigation \[ 1 \]. This more extensive study, led by the first author, aimed at collecting and producing evidence of effective harm reduction interventions for people who use stimulants. In addition to a literature review on harm reduction interventions for people who use stimulants, seven case studies were described on good regional practices. Selection of these cases was based on a combination of the literature review and consultation with over 50 harm reduction projects and experts in more than 30 countries. The data collected for the original case study was used in the present article. Collection of data was carried out by the first author and followed the methodology described in the main study \[ 1 \], consisting of the following components:. An online structured questionnaire for management sent by email before the field visit, collecting data on the amount of PWUM assisted, finances, partners of the project, and services offered. In-depth interviews with eight service providers and two service users. These interviews addressed the objectives, activities, population assisted, network, successes, and challenges in assisting PWUM and future expectations of the program. In-depth interviews and focus groups were audio-recorded and fully transcribed; field observations were typed-out. Qualitative data was analyzed using deductive thematic analysis \[ 17 \]. Data from the structured questionnaire complemented the qualitative information concerning numbers of people assisted and funding. No review by a formal ethical committee was requested for the main study, as the type of involvement of participants did not fall under the Dutch act for medical and academic research with human subjects WMO. To comply with ethical issues and data protection guidelines, participant organizations signed an informed consent form allowing for the disclosure of its data, to ensure a transparent and comprehensive description of their programs. Moreover, all interview and focus group discussion participants signed a consent form assuring their anonymity and had the right to withdraw from the study at any moment. All anonymized data was stored at a secured and backed-up server, only accessible to the research team. For the quotes used in the paper, each respondent is distinguished by a number, and SU refers to service user, while P refers to a professional working at the harm reduction program. These topics are further described and discussed in the following sections. After the start of the outreach program in , the first challenge the team faced was how to access PWUM. Not surprisingly, they felt they lacked sufficient knowledge about PWUM and their needs. Because initially, the team lacked staff with experience of shabu use, they had difficulties accessing PWUM. To address this, they added peer educators with lived experience of methamphetamine use to the team. The role of peer educators is to help outreach workers reach PWUM in their communities. The peer educators spread information and supply for safer drug use among people in their direct surroundings. The more experienced peer educators also helped the outreach team to open new spots for outreach work, based on their contacts in a specific area. Consequently, the outreach workers now cover hotspots in all districts of Jakarta. At the time of this research, 17 people with lived experience of drug use were actively involved as peer educators or another voluntary project support. Peers explained that their role is to share their knowledge of shabu harm reduction with their friends and contacts and functioning as a role model. I know that they are not living healthily Meaningfully involving peers in the program also helped the outreach team to better understand the needs and experiences of PWUM. At first, the outreach workers who were used to assisting people who use opioids found it very challenging to deal with this new population that focuses more on the benefits than on the risks of their drug use. Peers helped the outreach team realize that it is not that people cannot see any harms caused by their use, or that they do not need any help, but that they have their reasons for focusing on the benefits of shabu use. Indeed, many PWUM interviewed for our case study said they like the effects of shabu as it enables them to be more active and productive. It makes you more productive. Thus, the meaningful involvement of PWUM in the program was a fundamental step towards understanding service users and building harm reduction strategies for PWUM. Karisma not only invited peers to join the outreach work but also to help plan, develop, and evaluate the program. During these meetings, participants discuss the results of outreach strategies and try to find solutions for challenges. One of these ideas was the inclusion of a female outreach worker in the team. This female outreach worker provides separate assistance for women who do not feel comfortable mixing in groups with male service users. Karisma acknowledges women who use shabu that have separate needs. They sell sex for money to buy meth more easily or become meth couriers and are taken advantage of; they are offered just a little bit of money or meth as a reward. When women are arrested, they are also more prone to exploitation by police. They are more closed and secretive in terms of their drug use. In , the program expanded its interventions to cover hotspots of shabu use in all districts of Jakarta. In the same year, outreach reported reaching around PWUM. Epidemiology and public health students from Atma Jaya University joined outreach workers during their activities and recorded the process. By comparing these fieldwork notes with the needs assessment \[ 18 \], a local step-by-step guidebook on how to conduct outreach for people who use shabu was developed. Together with the university, outreach workers discovered that there are two generations of PWUM in the streets of Jakarta, each one with specific habits and networks. They are former heroin locally known as putaw users who can no longer find heroin. Very often, shabu is the first illicit drug they have tried. Most PWUM from both the old and the young generation combine methamphetamine with one or more other substances to help them come down. Alcohol, cannabis, and benzodiazepines are the most common choices, with methadone also being used by former heroin users who are currently in OTP. Knowledge of the differences between the two PWUM groups allowed for the program to provide for more appropriate harm reduction education. Therefore, in comparison to the younger generation, they have more knowledge of care providers, blood-borne diseases, and safer sexual practices, as well as safer drug use practices. With them, outreach workers can focus on information and counseling related to the specifics of methamphetamine in comparison to heroin. They also address the heroin craving that many of these older generations PWUM have and educate them on harmful mixtures of uppers and downers. With the younger generation, outreach workers focus more on basic methamphetamine information and other drug effects, safer sexual practices, and safer drug use. They also include more information on where and how to search for institutionalized help, as the younger PWUM are not used to contacting care providers. Younger PWUM, according to the outreach team, are less inclined to sit and talk for a long time. Thus, they benefit from more creative and dynamic approaches. In one area, for instance, a peer educator is involving younger PWUM in doing volunteer jobs at their local community. It keeps them busy, and it helps to improve the relationship between PWUM and the community. Another outreach worker noticed that younger PWUM are often playing games on their mobile phones and started playing the same games to understand them better. Acknowledging the differences in the preferences of younger and older generations also allowed for more specific adaptations related to the distribution of supplies for safer drug use, as will be explained under topic 2. Karisma started distributing safer smoking kits in These kits consist of a lighter, aluminum foil, straws, and informative leaflets Fig. While distributing the kits, outreach workers and peer educators also provide harm reduction information. The large majority of PWUM assisted by Karisma, from either generation, tend to smoke methamphetamine. The few cases of people injecting the drug are from people who were used to injecting their heroin. To smoke shabu , people normally use homemade bongs. Bongs are made from plastic cups or old bottles — such as small glass bottles of eucalyptus oil or plastic bottles — in which they make holes and attach a straw. PWUM prefer small bottles because it is easier to inhale the smoke. They generally prefer bongs over pipes as they feel the smoke is softer or less aggressive to inhale. The two generations tend to have different preferences when building their bongs. The young generation of users does not use foil as in Fig. Due to the strict drug regulations in Indonesia, carrying supplies for drug use can result in police harassment, along with the risk of being reported as a user and sent to forced drug treatment. In this context, oftentimes pipettes are preferred over glass pipes. They are less obviously linked to shabu use and, therefore, less risky when stopped by the police. Home-made plastic bong and foil. It shows a peer outreach worker demonstrating how PWUM build and use their homemade bongs. Glass bong with glass pipe. Picture taken by the first author during fieldwork observation, inside a room people rent to use shabu. Bongs like this can be rented at the place. Both generations of PWUM tend to smoke shabu in groups, partially to reduce the cost of using. By pooling money together as a group, PWUM can assure a high for everyone. Sharing is part of a ritual not only related to drug use but also food and spaces. In this context, despite knowing the risks, PWUM admit to having difficulties not sharing their smoking equipment. For this reason, the staff would like to add a silicone mouthpiece to the distributed safer smoking kit. That way PWUM can still share bongs — they just have to replace the mouthpiece — and fewer bongs have to be carried around, potentially resulting in less police harassment. At the time of our study visit, however, Karisma had insufficient funding to buy such silicon mouthpieces. In consultation with service users, the team developed an alternative interim solution: the distribution of plastic straws in the kits. PWUM were already using plastic straws to build their homemade bongs, usually stolen from juice boxes sold at convenience stores. Commonly, people would share straws among the group, whether they are smoking in a bong or chasing the dragon smoking on foil. With a wider distribution of straws — together with harm reduction information — the program aims to increase the individual use of straws and to decrease risks of sharing smoking equipment. Plastic straws are not the ideal instrument to smoke methamphetamine, as the plastic can burn, and people can inhale toxic vapors. However, budgets are limited, and some PWUM are so used to their smoking methods that switching to a potentially less harmful method can be complicated. Thus, teaching harm reduction methods that can be applied to their more harmful pipes is a pragmatic harm reduction alternative \[ 19 \]. Addressing sharing cultures and unhealthy habits requires more than the distribution of safer smoking kits alone, and the outreach team tries to address this during their visits to the areas where PWUM get together to use the drug, so-called hotspots. The outreach workers have found out that giving a voice and space to those PWUM who refuse to share is an effective strategy contributing to gradual change. Service users reflect that, in their cultural context, not sharing involves developing sensitivity skills to be able to say no without offending others. By discussing their strategies on how they deal with these issues, they manage to inspire others not to share as well. Important factors here were the differences between younger and older generation preferences as well as the legal context. Thus, they aim to build a network with care providers, who could assist PWUM through various services, especially around mental health issues. For example, we have around 18 to 20 primary health clinics that provide services for people using drugs. P6, male. Some of the previously established partnerships for projects working with people who inject heroin also run effectively for PWUM. Those who also use heroin can get access to methadone or buprenorphine in OTP, and people who inject have access to NSP. People who would like to stop using can easily access drug treatment for rehabilitation, even though most drug treatment centers in Indonesia do not work with evidence-based treatment models. Karisma also runs its rehabilitation center and refers PWUM who are motivated to quit to this center. The most challenging partnerships are with law enforcement and mental health agencies. A significant and long-lasting challenge is the relationship with the police. We invite them to our events, but they never show up. These narcotics police mostly work undercover. Repeated police harassment continues to happen and creates a lot of stress and distrust in the lives of PWUM. This is discussed in more detail under topic 4. Assuring mental health care for PWUM is another main challenge for this new project. One of the problems is that, according to our interviewees, the average person in Indonesia does not understand what mental health services entail. Most people associate mental health with insanity and do not understand or talk about depression, anxiety, or stress in these terms. To get more insight into how they may approach mental health issues, the outreach team started organizing focus group discussions with PWUM. They found that people were experiencing effects like paranoia and hallucinations but tended to ignore these issues. An added challenge here is that mental health care services in Jakarta are not prepared to work with PWUM. The few times in which people searched for, help was not available. If they approach health facilities, normally the health workers do not have enough information for them. To address this challenge, in , the outreach team planned nine informative events to discuss mental health at different health facilities. Local doctors were invited to talk to PWUM about mental health and the types of services offered by the centers. Outreach workers brief the doctors beforehand on the appropriate language to use with the population. At the time of the research, two of these meetings had happened. Between 15 and 20 PWUM were present in each session. This generated some positive results as it helped people recognize potential mental health issues:. They realized that what they experienced was in fact related to mental health. That was new for them. Nevertheless, the meetings were only partially successful. Services can be free of charge if people have national health insurance, but most PWUM in Indonesia do not because they do not have the necessary legal documents e. According to Karisma staff, social workers are hard to find in Jakarta. There are few, and they mostly work from inside the ministries instead of close to the field. At the time of this study, the Karisma team was in the process of organizing a partnership with the national Ministry of Health and the Provincial Health Department to discuss counseling issues for PWUM. The country has national guidelines for harm reduction, which do not include ATS, and Karisma expressed the need to include specific issues for PWUM in these guidelines. Karisma, the Ministry of Health, representatives of the Atma Jaya University, the 18 primary health care facilities which have Compulsory Reporting Institutions 2 , and counselors for addiction were all invited to an initial meeting to kickstart the partnership. Additional steps have been taken by Mainline and Atma Jaya, which have worked in on a training for physicians and primary health care staff. Together with Karisma, these organizations are lobbying for integration of mental health care and support for people who use shabu in the primary health care system. In this process, the recognition of mental health symptoms and appropriate public health staff responses need to be negotiated. Besides, PWUM definitions of mental health need to be considered without blindly enforcing medical classifications. A harsh police approach creates much mistrust among PWUM. The PWUM interviewed for this study all said to have been arrested at least once or to know someone who has been arrested because of drug use. Undercover narcotics police officers infiltrate user groups to find dealers and report users to rehab, in an effort to curb the trade and use of methamphetamine. The fear of being reported to the narcotics police provides outreach workers and peer educators with challenges; people are generally reluctant to allow newcomers into their drug-using circles. Are you a policeman?! Consequently, extra time needs to be invested in establishing a trust relationship with new contacts. Sometimes you just come and they PWUM immediately leave out of suspicion. So, to really get that person involved and really want to listen to you, that takes time. In the current legal situation, human rights and legal protection for PWUM are of vital importance. Previous contact with human rights and legal organizations had already been established for people who inject opioids, and these also work for PWUM. They refer PWUM who get caught with a small amount of shabu but are still prosecuted as dealers to these partners. Article of the National Narcotics Law states that possession of less than a gram of shabu is considered to be for personal use. According to staff and service users, however, when somebody gets arrested with a small quantity of drugs e. Yeah… Indonesia. At PKNI or LBHM, they will be asked about the background of the person: whether they have undergone drug treatment for rehabilitation or whether they have accepted any health services. They collect proof that the person is indeed someone who uses drugs and not a dealer. Strict law enforcement increases the mental health burden of PWUM. The threat of being caught promotes feelings of paranoia among service users. Moreover, shabu use tends to increase feelings of paranoia. In order to avoid police attention, PWUM prefer to use shabu indoors, which has led to a market of room rentals. In some drug use hotspots, there are rooms where people can both buy and use shabu ; other rooms are strategically located close by a dealer spot and are rented out just for shabu use. Outreach workers adapted their fieldwork to work more closely with the people renting out these spaces. These landlords get in touch with many PWUM daily and can become a contact point for spreading information on safer drug use. The lack of knowledge of the initial outreach work team regarding the experiences and needs of PWUM was the first challenge met by the team, which they managed to overcome by meaningfully involving peers. The practice of involving peers in outreach work is considered to be very effective to engage PWUS \[ 20 \] and other marginalized and hard-to-reach populations \[ 21 , 22 \]. Peers are trusted more easily because they share norms, experiences, language, and background. This makes it easier to convey honest harm reduction education and information \[ 23 , 24 \]. Peer outreach is known to be particularly effective for safer drug use education and distribution of supplies \[ 25 \]. There is a growing recognition of the need for more meaningful involvement of community members in public health programming \[ 26 \]. Particularly for services that need to consider new user groups such as people who smoke methamphetamine, including beneficiaries in a meaningful way is a crucial strategy. This means not only having people working in service delivery as voluntary peers but also involving them in the whole program set up and evaluation. Strict local drug policies and law enforcement practices which harm ed people who use opioids continued to harm PWUM. The growing demand and availability of methamphetamine have also led to specific practices such as undercover police in user groups, which has increased distrust among PWUM and posed challenges for a starting outreach program. This threat has exacerbated paranoid episodes experienced by PWUM and in general increased the mental health burden already imposed by the use of methamphetamine. Intensive police interventions and the specific preferences of the younger generation of PWUM have both challenged the outreach team to adapt the safer smoking kits they distribute. Sharing safer smoking paraphernalia, for instance, is not just an Indonesian phenomenon and has been well documented elsewhere. Methamphetamine use often takes place in a group setting where sharing is common, part of the culture, and not the result of an inability to buy or access new and clean supplies \[ 29 \]. Even when using safer smoking kits, people may continue to share pipes for several personal and social reasons \[ 28 , 30 \]. These reasons include unfamiliarity with services; experiencing craving and feeling the compulsion to use immediately; being gifted drugs or pipes; or occasional smokers who do not carry the right equipment \[ 31 — 35 \]. Especially for females, the sharing of pipes is also frequently the result of power relations, which renders them vulnerable \[ 31 , 36 \]. The context of strict policing in Indonesia often discourages PWUM from adopting safer smoking practices such as carrying glass bongs or glass pipes. When PWUM avoid carrying pipes for fear of police intervention, distributing mouthpieces can be a good and affordable harm reduction alternative. When PWUD resist adopting safer smoking kits, teaching harm reduction methods that can be applied to their more harmful pipes is a pragmatic harm reduction alternative \[ 19 \]. This is a pragmatic harm reduction solution in the current political and cultural circumstances. In a more ideal situation, however, service users would have access to a drop-in center run by outreach workers, including a safe space to consume their drugs. An increasing body of evidence shows that drug consumption rooms can reduce harms and risky behavior in people who use stimulants and who smoke their drugs \[ 31 , 37 \]. Harms such as the spread of infectious diseases, mental health problems, and the exacerbation of social problems may be reduced through interventions offered at the DCRs, such as the distribution of safer smoking kits, education on safer drug use, access to health and social services, and the stimulation of self-control. Besides, many of the benefits of supervised injection facilities also apply to facilities for people who smoke: they provide a safe, non-rushed environment, prevent overdose fatalities, and prevent public disorders; users have access to sterile equipment; and they lead to an increase in access of social and health services \[ 35 \]. In a inventory among 43 DCRs in Europe, Canada, and Australia, stimulants — including meth amphetamines, crack cocaine, cocaine, and cathinones — were the substances most commonly used by service users, irrespective of route of administration. Almost just as common was the use of heroin, followed by a combination of opiates and stimulants speedballing. Forty-one of these DCRs offered spaces for safe injection; 31 also offered spaces for smoking, with 22 DCRs also facilitating spaces for sniffing; 34 allowed for at least 2 different means of drug administration inject, snort, or smoke , either in separate spaces or in the same room \[ 38 \]. Unfortunately, drug regulations in Indonesia do not allow for drug consumption rooms. Finally, addressing mental health harms while reframing the connections previously established with care services was another key topic in the transition from reducing harms of opioids to reducing harms of methamphetamine use. The use of stimulants may trigger or exacerbate various mental health problems, such as anxiety, eating problems, depression, paranoia, sleep disruption, and psychotic episodes e. For more severe symptoms, crisis interventions by mental health professionals are recommended \[ 6 \]. However, staff working with PWUS in a harm reduction setting can apply several simple techniques to provide assistance to PWUS suffering from paranoid thoughts, anxiety, or hallucinations \[ 2 , 41 \]. While waiting for the networking investments with mental health professionals to bear fruit, outreach workers try to meet PWUM needs by offering an attentive ear and helping users to reflect upon their perceived drug-using problems. Several service users said the support offered by the team helped them to increase self-care and self-esteem. Sharing their stories helped them to find solutions to underlying problems causing problematic use. These conversations and meetings also helped them to get more social and less isolated. Recent years have seen a rise in the use of non-injected stimulant drugs around the world. Nevertheless, most of the harm reduction services available still focus on people who inject opioids, leaving many PWUS unassisted. Several harm reduction programs face the challenge of adapting their activities to reach non-injecting stimulant use and could greatly benefit from lessons of earlier innovative practices. Especially in Southeast Asia, the few programs which already succeeded in transitioning from assisting people injecting opioids to assisting PWUS remain unknown to the broader public; their learning processes, however, may be a tool to inspire others to build new harm reduction practices. To contribute to filling in this gap, this paper has described the learning process of a harm reduction project working with people who use methamphetamine in Jakarta, Indonesia. The project has built on previous work with people who inject opioids to reinvent itself as an outreach project that addresses the needs of PWUM. Four critical elements in this change were explored in detail. These occurred in the process of getting in touch with different types of PWUM; adapting safer smoking kits to local circumstances; and reframing partnerships with other services while addressing mental health issues as well as responding to local law enforcement practices. The meaningful involvement of PWUM in all levels of the project — planning, running, and evaluating — was essential to making sure their perspectives were understood and included in the interventions. This occurred in the development and evaluation of outreach work, the planning and distribution of safer smoking kits, and the understanding of PWUM broader needs, including mental health care and the preferences of younger and older generations. Additionally, pioneering a project with a population that has not been reached before requires extra effort in networking, sensitizing partners, and working toward service integration. Pioneering in a context of strict drug regulations and law enforcement also requires extra efforts and time in building trust with PWUD. This may require a compromise between maximizing the reach of the project and ensuring the quality of assistance and time needed to bond with PWUD in this initial phase. Operating under a broad harm reduction definition was another overarching point. The aim of harm reduction is to reduce all harms associated with drug use. These may be health harms, which certainly extend beyond HIV, but also include social or economic harms such as acquisitive crime, corruption, over-incarceration, violence, stigmatization, marginalization, and harassment. This means re-centering the program on PWUM and on increasing their quality of life, rather than focusing solely on specific interventions or safer drug use supplies. Mental health care needs to receive special attention. The recognition of mental health symptoms and appropriate medical responses need to be negotiated, and PWUM perceptions of mental health symptoms need to be acknowledged, without blindly enforcing medical classifications. Furthermore, the perceived positive effects of using stimulants need to be considered when planning new harm reduction responses for these drugs. Increasing the investment from the national government is essential to that. Karisma has partnered with other harm reduction organizations, Pukesmas, and local government branches to write national guidelines on how to run harm reduction programs for PWUM. Such guidelines would make national government funding more feasible, as most of the health clinics in Jakarta only provide services in the presence of a national guideline. Once a national guideline is available, it becomes possible to budget for activities. In addition to securing national funding, encouraging international donors to step in and support harm reduction efforts without a primary focus on HIV prevention is crucial. This can help to increase the number of harm reduction projects addressing stimulant use in Indonesia and in the region. Since mid, a similar project has been started in Makassar, Sulawesi island, Indonesia, also supported by Mainline. The new project is integrating the lessons drawn from Jakarta. A new project focusing on reducing mental health harms of stimulants use has also started in , in Vietnam. Finally, more research is needed on the key topics of programs that need to address when transitioning from reducing harms for opiates use to reducing harms for methamphetamine. The present article builds its findings on data collected for a slightly different question, and more in-depth information could be acquired when designing research to focus specifically on this shift. Moreover, this case study addresses the shift from opiates to methamphetamine in a specific setting of strict drug policies and with a project which is a pioneer in assisting PWUM in the region. Different topics may arise as important in settings where harm reduction finds better support and projects with PWUM are further developed. We acknowledge the contribution of Mac Busz and the two anonymous reviewers of this article. Their critical comments and suggestions have immensely improved the quality of the study. RR was the lead author of this article and carried out the case study described here. Both JJB and SW have helped discussing the analysis during the main study and have critically reviewed the present manuscript. All authors read and approved the final manuscript. All respondents signed an informed consent referring to their participation in the research. The organization responsible for the program described in this paper signed a consent form. During this study all three authors were working for the Mainline Foundation, the international funder of the case study described in this paper. It is at the Compulsory Reporting Institutions that an assessment is made to determine which service the people who were reported as using drugs need. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Harm Reduct J. Find articles by Rafaela Rigoni. Find articles by Sara Woods. Find articles by Joost J Breeksema. Received Feb 1; Accepted Nov 14; Collection date Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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