Deepak Yadav Anju Dhawan Seema YadavDeepak Yadav , Anju Dhawan, Seema Yadav. NDDTC. AIIMS , New Delhi. India

U l t d b t b i t t i d• Unemployment and substance abuse intertwinedlong before an individual seeks treatment.Th t f th d hi h b th t• The rate of the drug use higher by more than twotimes for unemployed persons (18.5%) than thoseemployed fulltime (8 8%) or part time (9 4%) amongemployed fulltime (8.8%) or part time (9.4%) amongadults aged 18 years or older,

(NHADU   6)(NHADU, 2006)

E l t t diti ll h t b iEmployment traditionally has not been a primaryfocus or an explicitly stated goal of treatment forsubstance abusesubstance abuse

(Shepard and Reif 2004).

G i d l iGained popularity:› Consistence evidence in substance use evaluationresearch showing that employment is linked to positiveresearch showing that employment is linked to positiveclinical outcomes.

(NIDA, 1981,Brewington et al 1987 , Deren &, Randell 1990, Yadav et  al 2006  and ).

O    th  th   f th  b t  di t   f • One among the three of the best predictors of successful substance abuse treatment outcome, th   th  t  b i   d t  f il   t the other two being adequate family support and lack of coexisting mental illness 

(SAMHSA 2000)(SAMHSA 2000).

• Enhanced occupational functioning leads to a decrease in substance use with some studies decrease in substance use with some studies reporting the probability of abstinence up to 2 5%2.5%.

(Shepard and Reif 2004).

E l t l d  t  Employment leads to: Protective barrier against relapse (NIDA, 1981 &  Greenwood 

)2001).

Reduction in anti social behavior.d lf d lImproved self‐esteem and interpersonal 

relationship.(Prochaska &Velicer, 1997; Cernkovich & Giordano, 2001), 

Better treatment retention. (Platt, 1995). 

E ft li i th i t f i f lEven after realizing the importance of gainfulemployment in the management of substance usedi d it i d f th l t d idisorder it remained one of the neglected area interms of allocation of funds.

(SAMHSA  )(SAMHSA 2000).

Developing countries : No social security , Lowprioritypriority.

( )(Yadav et al 2006)

Open market

Options Micro finance

Micro credit

SHG

Mi fi f t th i i ll l tMicrofinance refers to the provision small loans topoor or low‐income group , including consumers andthe self employedthe self‐employed.In the past few years, savings‐led microfinance has 

i d  iti       ff ti    t  b i    gained recognition as an effective way to bring very poor families low‐cost financial services. For e ample  in India the National Bank for example, in India the National Bank for Agriculture and Rural Development (NABARD) finances more than 500 banks that lend funds to finances more than 500 banks that lend funds to self‐help groups (SHGs). 

Mi dit i th t i f llMicrocredit is the extension of very smallloans(microloans) to the unemployed, to poorentrepreneurs and to others living in poverty who areentrepreneurs and to others living in poverty who arenot considered bankable. These individuals lackcollateral, steady employment and a verifiable creditcollateral, steady employment and a verifiable credithistory and therefore cannot meet even the mostminimal qualifications to gain access to traditionalq gcredit.

E  th     t  f  h f  d      f    i  Even these are out of reach for drug users , for  various reasons : 

IndividualIndividual.Social .

Outreach program in high pre alence  poor socio economic Outreach program in high prevalence  poor socio economic background community  at Delhi. The center offers multipronged interventions aimed at The center offers multipronged interventions aimed at management of the substance use related problems.Opioid agonist (Buprenorphine) maintenance or Opioid agonist (Buprenorphine) maintenance or antagonist (Naltrexone), and disufiram, acamprosate or naltrexone for opioid and alcohol dependent patients respectively. The non pharmacological interventions include motivation improvement, relapse prevention and family counseling and spiritual programs. 

NDDTC  i  fi     t d  t  f th  NDDTC micro finance program stemmed out of the need of the patients:

Drug use is expensiveDrug use is expensive.The financially drained family’s inability to make   financial contribution.financial contribution.Lack of trust/ stigma.Unfavorable response from open job markets .p p jUnique need of patients receiving agonist maintenance Treatment .

U b k blUn‐bankable.No collateral.

(No bank account (any way 80% in India do not have a bank account). (Neelkani :  Imagining India 2009)

Out of social security provisions.Majority are engaged in unorganized self employment ventures. ( No need to reinvent the wheel).No acceptance by family or society even after abstinence.

All these patients have been successfully treated (with OST) to result in 

abstinence  However  they didn’t get abstinence. However, they didn t get gainful employment despite abstinence. Thus, they were enabled through micro‐

credit to earn their livelihoods and credit to earn their livelihoods and reintegration into the mainstream 

Th   i   d  f th   ti t  t  h  fl ibl  The unique need of these patients to have flexible working hours to enable them to maintain regular followfollow.Long working hours and intensive nature of the physically demanding job  physically demanding job. And most important enhancing self efficacy and confidenceconfidence.

M ti ti  th   ti t  t   t t  ki  Motivating the patients to start working. Skill assessment. Explain to him the logistics and finalizing the type of work they wanted to pursue.(Group process)Individualized plan.Arranging the seed money to procure material or tools to start the work.Art of living an international humanitarian non profit organization  came for support .

R i i  th    If  ibl  i l t  f Reviewing the progress. If possible involvement of family members. M ti ti  hi  t   t   d  b tl    Motivating him to return and subsequently save money.E  hi  t   d th   kEncourage him to expand the work.

• Drug user • Drug user .• Age 18‐ 50 years 

On treatment for last 3 months• On treatment for last 3 months.• Willing to receive standard treatment as well as 

Occupational rehabilitation services Occupational rehabilitation services • Regular follow up during the last three months‐ not 

missed more than 15 days in last 3 months ssed o e t a 5 days ast 3 o t s• Self‐report of drug use less than 7 days per month in 

last 2 months) Unemployed since last 3 months p y 3• Subjects from a defined catchment area.

S   h i l ill    di bilit  d  t   hi h Severe physical illness or disability due to which person may be unable to participate in the program. P   f  hi t i  ill   tl  Presence of psychiatric illness currently .Refusal to participate in the program.

C dl   ki  &  lli  • Candle making & selling. • Electrical , • Plumbing, • Painting, g,• Gardening,• Toys selling• Toys selling• Pea nut , fruit selling, tea vending.• Driving.• Small shops (general and tailoring)p g g

C lt ll   t dCulturally accepted,Feasible,Therapeutic,Accepted by the patient,Low cost intensive.Based on treatment need of the patient.p

A t  id     R   6   M  S D Amount paid     Rupees 560 +‐ Mean S.D Days taken to start working      1 week Days taken to start repayment:  10 daysDays taken to repay the entire amount S.D credit : One  month(mean SD)Percentage repaid the credit: 74 %Occupational status (Percentage currently working after 6 months): 74%.

• Small ventures which do not require specialized • Small ventures which do not require specialized training and has flexible working hours suited best for the patients with substance use disorderp

• Has more surviving skills• Shift to mainstream jobsj• Changed Family relations• Self efficacySe e cacy• Reduced anti social behavior• Attitude towards the treatment centre a tool to Attitude towards the treatment centre a tool to 

relationship building• Retention

P iblPossibleService orientation than pure commercial venturesNeed based SHG formationUn‐bankableNeed Intervention to make them bankableNeed Intervention to make them bankableMicrocredit Civil society initiative

NATIONAL DRUG DEPENDENCE TREATMENT CENTER,

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

NEW DELHINEW DELHI