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123VIII : Treatment, Aftercare and Rehabilitation

Treatment,Aftercare andRehabilitation

CHAPTER VIII

R. Ray

Treatment,Aftercare andRehabilitation

124 VIII : Treatment, Aftercare and Rehabilitation

Treatment for substance use disorder is an attempt toaccomplish cessation of drug-taking by bringing about achange in the subject’s behaviour. Modalities vary and arevery diverse. This is due to different conceptual issuesrelated to genesis (etiology) and development of the processof regular drug consumption. As a result, there are manymethods of treatment. Classifying these various methodsis not easy and will not be attempted here. Common issues,themes and generalities are discussed.

Further, an attempt has been made to present a broadscenario of various treatment methods available in thecountries covered in the report. Specific availabletreatment methods as practiced are also presented in thevarious box items by individual contributors. Theseexplicit intervention modalities give a broad overview ofthe variety available in the region. However, some of theseare practiced in very selected and small number of centresand do not reflect national programmes and strategies.Finally, administrative issues involving country treatmentprogrammes would not be discussed as these have alreadybeen addressed in the chapter on national drug demandreduction (chapter VI).

A large number of persons are involved in providing careto subjects with substance use disorder. They includegeneral physicians, mental health specialists, socialworkers, nurses, lay volunteers, spiritual and religiousleaders, self-help organizations and even recovered patients(ex-addicts). There is considerable difference of opinionamong them on ‘models’ of dependence and how best totreat them.

MODELSA model is an abstraction or a conceptual form to understandand address a phenomenon.

Moral Model: Drug dependent persons are viewed asamoral individuals and drug-taking is a sinful act. Thusthey require punitive measures or spiritual therapy, andtreatment would take place in correctional settings or byreligious teachers.

Hedonistic Model: Here it is assumed that people takedrugs primarily for pleasure. Hence, treatment would meaninitiating an alternate pleasurable activity (high) which isnot chemically induced.

Learning Model: Drugs have strong reinforcing properties.These compounds induce a state of well being or removea painful emotional state viz. anxiety and pain. Drug-takingis associated with such orgasmic states which arerewarding, thereby leading to the strengthening of drug-taking behaviour. Thus treatment would mean the processof unlearning and the acquisition of new skills.

Bio-psychosocial Model: It is assumed that drug dependencecan be readily understood in the context of a neuro-biological and psychosocial model. The state of prolongeddrug consumption manifests itself as an “illness” with aspecific set of symptoms. Affected individuals areconsidered sick. Further, it is viewed as a chronic non-infective disorder. Because of its chronic nature, treatmentcan only modify and alter the course. “Cure” as understoodby the treatment of certain (infective) diseases does notapply here. The “sickness” can be controlled, as is seenwith lifestyle diseases like hypertension. Use of long termmedicines (viz. methadone, naltrexone) would constitutepharmacological (biological) treatment whereascounselling, residential care facility (viz. therapeuticcommunity) would be socio-cultural (psychosocial)treatment. Such a concept is currently accepted amongmany experts, notably health specialists. This model iswidely used in countries in the region, as is evident fromNational Master Plans and data on treatment.

LEVELS OF CAREThere are various levels of care, from the least complex tothe most comprehensive modality. However, the morecomplex levels are available only in tertiary care centresor apex centres and are not necessarily the most desirable.Often brief and simple interventions would suffice and arecost-effective. A large number of subjects would need helpin small towns (district hospitals) and rural settings (PrimaryHealth Centres - PHC) where high degrees of expertisewould not be available. Thus simple cost-effectiveprogrammes need to be developed. Various levels of caremay be categorized as level 1—where acute care isprovided, level 2—brief interventions are offered, and level3—long term therapies are available.

Availability of level 1 services for treatment of overdose isexceedingly important. This would mean upgrading ofcasualty services, emergency rooms, availability of lifesupport systems and narcotic antagonists. Wherever

CHAPTER VIII

TREATMENT, AFTERCARE AND REHABILITATIONR. Ray


intravenous drug use or widespread heroin use is seen,overdose, accidental or otherwise, can be expected. Here,saving a life is of utmost importance. Additional life savedcan be several times greater than that by preventiveservices. However, in India most casualty/emergency roomsin public hospitals, including N.E. States, do not have Inj.Naloxone (a life saving drug for opiate overdose), thoughit is manufactured in India. Camp detoxification wouldbelong to level 1 and has been practised in India and SriLanka. (For the camp approach, see Box Items 26 and 27in the next chapter.) This is popular and has been found tobe reasonably successful where no other facilities exist.

LEVELS OF CARE

Level 1: Management of acute intoxication, overdoseand detoxification

Level 2: Brief therapies - pharmacotherapy, psycho-social intervention

Level 3: Long term care, complex therapy and monitoredfollow-up

PHASES OF TREATMENTLevels of care and phases of treatment are linked issues. Inthe initial and middle phases, efforts are on to make theperson free of all intoxicants and initiate the process ofreintegration. During the late phase, healthy lifestyle, andalternate coping strategies are taught. Thus the duration oftreatment would be variable. Treatment is usually multi-modal, i.e. ‘drug’ and ‘non-drug’ therapy. A subject mayneed extensive intervention in any one of the modalities.In the initial and middle phases mostly medicalinterventions are carried out. The late phase usuallyconstitutes psychosocial therapy.

SETTINGA setting is the actual physical site where treatment is offered.In recent times, most countries have favoured specializedtreatment centres. This is also evident in the region. However,there has been a conscious attempt in the health sector tointegrate these efforts with the general health care system(India, Sri Lanka) or psychiatric hospitals (Bangladesh,Nepal). Most of the NGOs are dedicated centres. It is alsoimportant to remember that many patients report to variousgeneral medical or surgical OPDs and to non-specialistswith ailments directly attributable to excess drugconsumption. These are often not recognized and subjectsgo undetected. It is thus important to identify them and offerprompt treatment in non-specialized settings as well. Manygeneralists feel reluctant to deal with persons with drugabuse, as they are unsure about treatment modalities andperceive them as undesirable and anti-social. Such an

attitude is anti-therapeutic. Further, linkages betweenspecialized centres are weak. In the event of complications,such lacunae are very glaring. Thus training non-specialistphysicians is very necessary. This is elaborated upon in asubsequent chapter (chapter XIV).

There is also the issue of hospitalization. Quite a fewprofessionals are accustomed to thinking that most subjectswith drug dependence require to be admitted in an in-patient setting (short/long term stay). In fact, a majority donot require admission. They can be treated very well fromOPDs, community clinics and through domicillary care.Some, of course, need to be admitted and guidelines forboth the facilities (OPD or in-patient) can easily bedeveloped by nodal centres.

In-patient treatment is expensive and keeping in mind thefinancial constraints, out-patient or a less intensivetreatment setting is recommended. Treatment fromcommunity clinics and exclusive OPD treatment need afair clinical trial. Experiences from All India Institute ofMedical Sciences, New Delhi, and several other projectsshowed that treatment through routine community clinicsand district level centres without in-patient facility is veryfeasible. Only about 3-5 per cent of these subjects neededin-patient care (Drug Dependence Treatment Centre,1996a, b; Mohan and Ray, 1997). Other than thesetraditional settings, treatment can be provided in policestations or prisons (see Box Item-19) as well. Finally, peopledo report to private sector hospitals, private medicalpractitioners or private therapists. Generally, people fromhigher socio-economic sections tend to favour theseexpensive settings. The choice of a treatment setting is moreoften a self-selection process by the subjects themselves.

TREATMENT SETTINGS

Specialized de-addiction centresCommunity clinicsGovernment, non-government centresPrivate sectorNon-specialized setting - general medical, surgical OPD,

dispensaryPsychiatric hospitalCamp approachPrisonOPDWard

A national programme must examine the issues ofdifferential costs of treatment in various settings and a

continued on page 129


Tihar Jail in New Delhi is today a complex of five prisons.These are characterized by overcrowding — the totalpopulation of prisoners is about 9500, against a housingcapacity of about 3300. Less than 15 per cent of theprisoners are convicts. There are about 50,000 newadmissions to these prisons every year, and 90 per cent ofthe prison population changes every three months.Approximately fifteen drug dependent prisoners areadmitted to Tihar prisons every day. Seventy to a hundredheroin dependents are undergoing medically supervizeddetoxification in two facilities run by the administration atany given time. Detoxification from alcohol is not a featureof these facilities. The heroin detoxification programme issimilar to one found in such a facility outside the prison.

In May, 1993, a dynamic Chief of Prisons started the PrisonsReform Programme. Popularly called the New DelhiModel, the programme focused on (a) introduction of thecommunity (NGOs and individuals) into the prison, (b)creating a community within the prison, and (c)participatory management. Till then, treatment of drugdependents was limited to a detoxification programmeunder medical supervision and out-patient follow-up.AASRA1 was invited in August, 1993, to set up a post-detoxification (re)habilitation programme for heroindependent prisoners. We started our work in August, 1993,in Central Jail/Prison No. 4. The present Chief of Prisonshas strengthened, multiplied and consolidated the prisons’efforts in this area.

Since the entire population to be dealt with by AASRAconsisted of prisoners under judicial custody and notconvicts, with frequent uncontrollable admissions anddischarges, available designs of prison rehabilitationprogrammes could not be used. The new programmedesigned for the purpose was implemented in four stages.The prisoners had been housed in a facility (ward)consisting of three barracks. The drug dependents werenot properly isolated from other prisoners (one barrack heldprisoners suffering from tuberculosis and another housed“blood relatives” in prison for any crime). The first stepwas to segregate the drug dependents from other prisoners.

The “addicts ward” was the darkest area in the prison —inmates used to break all the light bulbs to avoid detectionof drug use. Heroin use was a daily occurrence. Theinmates were looked down upon as hopeless; frequentquarrels and false accusations were common. The rod wasnot used sparingly. Most of these prisoners spent their days“hanging around” the ward, and the “have-nots” werevirtual slaves to the “haves”.

THE INITIAL SET-UPAfter an initial needs assessment, one found thatrudimentary groups that existed were of about three to fiveindividuals. To set up a culture conducive to rehabilitation,the prisoners were grouped into “families” consisting ofabout twenty prisoners. Four to five such groups wereassigned to each family. To start with, the existing “peckingorder” was maintained. Each rudimentary group leader wascalled “big brother” and one of the big brothers was called“family head”. This selection was by consensus. A set ofcardinal rules was framed with the support of residents toevaluate pro- and anti-social behaviour. New admissionswere distributed amongst the families to minimizedisruption of culture.

Felt needs were initially met by AASRA through donationsof items of daily use such as toiletry, footwear, and clothes.Indoor and outdoor games were supplied and a televisionset was provided in each barrack. There was a commonconcern about the welfare of those prisoners who did notget visitors and others were encouraged to promote theculture of sharing. Over the first eight months, a communityfeeling of brotherhood had developed. By a process ofpromotion and demotion based on demonstrated pro-socialbehaviour, the “big brothers” and “family heads” becameislands around whom new residents could be safelyhoused. The controlled bonding experiment was foundsuccessful.

NEW DELHI MODEL PARIVARNew Delhi Model Parivar is a mutual self-help, peer-ledtherapeutic community. (Parivar means family, or a systemof families.) This has been replicated over time and now

1AASRA: ‘An Association for Scientific Research on Addiction’ is a registered, non-governmental organization, not funded by the government.

BOX ITEM - 19

TREATMENT PROGRAMMES FOR DRUG DEPENDENTS IN AN INDIAN PRISON

H.S. Sethi



there are four of these communities in Tihar Jail. Thetherapeutic community programmes house about 500 to550 recovering heroin dependent residents; about 180 inJail 4 (a four-year old community), about 200 in Jail 3 (atwo-year old community), about 65 in Jail 2 (an eight-monthold community), and about 75 in Jail 1 (a fifteen-month oldcommunity). This comprises over five per cent of the totalpopulation of Tihar prisons. It is estimated that about 10 percent of the prison population merits admission into thesecommunities at any one time.

About 5000 heroin dependent individuals have beenadmitted to the therapeutic community programmes in thepast four years. These have been all males, over the age of21 years. About thirty per cent are illiterate and anothertwenty per cent are educated till class five (primary school).One-third of these are under-trial prisoners for possession/sale of narcotics, one third for thefts, and about one-thirdfor violence or under the Arms Act. Less than one per centare in for heinous crimes. There are very few injecting drugusers. After November, 1995, all drug dependents haveentered the community after a three to ten day detoxificationtreatment. About half of the residents leave the rehabilitationprogramme in three months when they are discharged fromprison by the courts. Less than five per cent of the residentsstay for longer than one year.

Seniors, “family heads” and “big brothers”, act as role modelsto other members of the community. A five member convictteam, three permanent warders, a permanent head warderand assistant superintendent are assigned to the community,which is under the direct supervision of the superintendentof the respective prison. In addition, seven senior residentprisoners serve as teachers, team leaders, and supervisors.Staff members from AASRA (a psychiatrist, two psychologists,a social worker, and two experience-trained counsellors forthe four communities) serve as trainers, facilitators, andrational authorities.

Components of New Delhi Model ParivarThe three components of the programme are:

I. Philosophy/Culture—Value/Principle Based LifestyleChange:Principles used are humaneness (insaniyat), patience(dhiraj), mutual self-help and community building (bhai-chara), responsible concern (zimmeydari bharesambhand), honesty in word and deed (sacchayee),respect for elders and affection for juniors (adar/pyar),trust (vishwas), responsibility for one’s own actions(zimmeydari), awareness (chetna, ahasas), acceptance(sweekar), and integrity (imandari). The programmecaters to the development of these principles. A drugdependent’s personality undergoes change as a resultof dependence, and the negative features of this are seenas the focus for change. Sharing one’s recovery, one’sgrowth and one’s privileges highlight mutual self-help.“What goes around, comes around” sets the culture ofthe community.

Mutual Self-Help—AASRA Welfare & Recreation Fund:Contributions by those getting visitors (mulakkats) arematched rupee-for-rupee by AASRA. Items such asfootwear, soap, oil and toothbrushes are bought fromthis money and given free to those with no visitors.Cloth donated by AASRA is used to make clothes forthe non-mulakkatees. Games and educational materialare also bought from this fund. Television sets and wallclocks, sewing machines, candle making equipmentand computers were donated by AASRA and by otheragencies. The more educated teach the less educated.Focussed peer support is offered to those who haverecently entered the community and are getting offdrugs.

II. Structure:(1) Hierarchy (of small brother, big brother and family

head)—The families are named according to theprinciples stated above. It provides a group withinwhich there is a chance for sharing each other’s joysand sorrows. Family members protect each other, andcater to each other’s needs. “I am my brother’s keeper”is each big brother’s basic motto. Selection of a pro-social big brother is central to correction and(re)habilitation in this peer-led model. The family headsand supervisors form the community’s ‘panchayat’ orlocal governing body. Representatives from this bodyare sent to the prison panchayat.

(2) The daily activities are scheduled in a way to promoterecovery. Counselling is done in groups. Education,meditation, mood making sessions, sharing one’srecovery, concept seminars, family groups, community

Treatment in an Indian Prison, AASRA



meetings, barrack meetings, anger and grief workouts,educational and recreational games are some of theactivities that form part of the curriculum. Psychodramais used effectively. These activities are integral tocommunity building. The work ethic is strengthened.Participation in Vipassana meditation is encouraged.Video feedback, when allowed, is an important toolfor recovery.

III. Confrontation and Shaping Behaviour:Behaviour is shaped by a system of rewards andconsequences. Chances for promotion and privileges arebased on demonstrated pro-social behaviour anddemotions for anti-social behaviour. Pull-up is a verbalreprimand for an objectionable behaviour and this isfollowed by a demonstration of the expected behaviour.Structured Learning Experience or Contract is used forrepeated objectionable behaviour. This experientiallearning is designed to correct specific behaviours byhighlighting the faulty attitude, e.g., one who is constantlylate for meetings is assigned the duty to have everyoneassemble for a meeting; a person who frequently leavesa meeting is assigned to be gate-keeper during meetings.Repeated demonstration of a faulty attitude by a residentis corrected in encounter groups set up for specificsituations.

Behaviour ChartEveryone in the ward is listed according to family andhierarchy within the family, on the notice board. Eachperson is rated for behaviour everyday by a senior — thesmall brothers by big brothers, big brothers by family heads,and family heads by staff supervisors, staff by AASRA andprison officers. A five colour code is used. Officers onrounds are encouraged to look up this chart and call outthe names of those with black and red marks for reprimandand those with green and blue marks for commendation.

Incident / Reception RegisterEvery event in the community is recorded in this register,from who enters/exits the community and commitmentsmade by new residents, to negative behaviour/incidentsand action taken. The main activities of the communityare also recorded here.

The Monitoring SystemThe reception room of the AASRA ward is the monitoringcentre for the community. Round-the-clock shifts of twopersons from each barrack comprise the MonitoringSystem. At night, any untoward incidents are reportedimmediately to the warder for appropriate action. Duringthe day, incidents are reported to the warder, head warder,assistant superintendent, and when necessary to the deputysuperintendent and superintendent. The chief monitor is

responsible for setting up and supervising learningexperiences. This system has prevented suicides, quarrelsand drug-taking.

Drug free status is monitored periodically through randomurine tests for presence of narcotics. This test is conductedby the AIIMS (All India Institute of Medical Sciences, NewDelhi) Drug De-addiction Centre. All samples are screenedusing TLC and about ten per cent of the samples confirmedby GLC. Over eighty per cent of samples test negative formorphine (heroin).

INDICATORS OF CHANGEThe New Delhi Model Parivar is recognized as a significanttreatment programme for drug de-addiction by the prison,and a stream of visitors and dignitaries visit the programme.The residents wear a sense of pride and an increased self-esteem among the prison community. They value thepositions of big brother and family head.

Where once inmates needed 45 minutes to gather for ameeting, they now assemble in less than 5 minutes —demonstrating increased discipline, a higher sense ofresponsibility and respect for authority. Silence is observedwhen requested and excuses to leave meetings are lessfrequent. Quarrels have decreased — showing better copingwith feelings of anger — and the rod is seldom used.

Heroin smuggling and use has drastically reduced, thanksto better detection and control of supply as well as longerabstinence. Fewer inmates are tempted to take heroin evenwhen it does reach the ward (better impulse control). Thereare longer periods of abstinence as verified by regularurinalysis. The practice of false accusations has decreased(more respect for others). Consequences are taken withless resistance (increased power of the community as wellas sense of accountability in residents). Transgressions areowned up to more easily (greater honesty). Recently, theincreased and voluntary participation in the project formaking the pond, aviary, landscaped garden and waterfallin the prison reflect incorporation of the work ethic(increased sense of community). The quality of sharing hasimproved, showing improved communication skills andexperiential learning.

Major LacunaeThe programme does not select who should enter thecommunity. Weeding out is done when a residentrepeatedly breaks the cardinal rules. There is no controlover the duration of a resident’s stay in the programme —the duration of stay in prison is decided by the courts.More trained counsellors are needed. There are noresources to set up a contact or follow-up programme aftera resident leaves the prison.



public health approach would favour moderate to lowcost intervention programmes. Residential careprogrammes, i.e. ward and therapeutic community areexpensive and governments’ support cannot be expectedas is seen in the region.

CARE GIVERSSeveral people are involved in providing treatment and amulti-disciplinary team is the norm. Commonly, they are:psychiatrist, general medical doctor, nurse, psychologist,and social worker. Their background, training andexpertise differ. Thus the role of each team member isdistinct. There are, however, some grey areas. Certainservices can be offered by more than one category ofstaff especially after in-service training. To illustrate, anurse can carry out the following activities besidesdispensing medicines:l obtaining history of drug abusel assessment of patient and his relativesl counselling the patient and his relatives.

These should be reinforced and opportunities should beprovided for in-service training so as to encourage broaderparticipation. This is even more evident in a communityclinic where strict division of roles should be discouraged.However, in a traditional hospital setting some amount ofclarity of roles and earmarking of responsibilities would avoididentity crises and interpersonal conflicts. The thrust of acountry programme may depend upon the absolute numberof service providers available from various disciplines.

India has the largest number of physicians per capita amongthe five countries in this region for which data is available.In the mid-1990s, India had about one doctor per 2439population, as against 16,667 in Nepal. This is reflected invery high involvement of doctors in providing care(secondary level). Thus treatment is more medicalized.However, the nurse:population ratio is much better in SriLanka (about 1:1754) as against India (about 1:3333).Unfortunately nurses have not been very involved intreatment of drug dependent subjects in this region andare underutilized. In Australia, however, nurses are involvedin a very big way. Hospital beds per 1000 population inthe mid-1990s were around 2.8 in Sri Lanka and 0.7 inIndia. In the other three countries namely Bangladesh,Nepal and Bhutan, there are insufficient doctors, nursesand hospital beds. Thus it would be easier for Sri Lanka todevelop in-patient care (brief to medium/ long term stay)than the other countries in the region. No such data wereavailable for other categories of staff employed in de-addiction centres. It can reasonably be estimated thatinvolvement of non-medical staff would be much more inthe other countries and this is actually so, as seen in theMaster Plans. In many countries, demand reduction is

carried out principally by NGOs who have a large numberof voluntary workers. This brings down the cost and theprogramme is much more cost-effective overall. Data onselected health parameters, expenditure on health asregards percentage of GDP as well as central government’sexpenditure of these countries is listed in annexures 5-7.

TREATMENT GOALSIt is expected that treatment should result in a state ofpermanent abstinence. Often, this does not happen andalternate goals need to be pursued. Thus intervention isdirected towards decrease of harm posed by continueddrug use. Moreover, treatment should also attempt toimprove occupational functions, health, social functionsand role performance in addition to cessation of druguse. Additional efforts are thus required to achieve betterquality of life and improvements in these areas are notalways equivalent or parallel. During treatment these alsoneed to be looked into.

TREATMENT GOALS

AbstinenceImprovement of health, social and occupational functionsOverall improvement in quality of lifeHarm minimization

Harm MinimizationMany subjects cannot achieve permanent abstinencefollowing an episode of treatment. This is most obviousamong patients with opioid dependence. In the best oftreatment centres, about 60-70 per cent of drug usersrelapse within three months of treatment in an OPD-drug-free programme. The alternative goal of harmminimization is both pragmatic and achievable.

HARM MINIMIZATION

Reduce adverse consequencesDetermine priorityDecrease transmission of communicable diseasesEducation on drug consumption and performance

impairmentAvoid hazardous drug-taking situationsMaintenance programmeNeedle exchange programme, use of bleachComprehensive health education

Here, treatment is directed towards reducing the adversehealth, social and economic consequences of drug use


without necessarily eliminating use. The principle of sucha strategy acknowledges that the risks due to drug use arehierarchical (less severe to most severe). The mostdamaging consequences viz. transmission ofcommunicable diseases (the spread of HIV and/or hepatitisthrough needle sharing) should receive priority. Variousmeasures to achieve this are safe public health policy,determination of priorities, limit setting and use ofsubstitute medicines.

Several of these measures have already been initiated inthe region. In Nepal, methadone maintenance and needleexchange have been initiated. See Box Items 20 and 21for more in this regard. In India, buprenorphinemaintenance programmes have been carried out in morethan one centre. Further, in Nepal and India, linking drugabuse management with HIV/AIDS control has beenattempted and is likely to be pursued actively in the healthsector in the near future.

The Ministry of Health and Family Welfare, Governmentof India, in three recent workshops (June 1996, July 1996and June 1997) have deliberated upon harm minimizationand several practical measures have been proposed. Thevarious steps recommended were:l Measures to protect the communityl Comprehensive drug demand programme to be

pursued jointly by the central health ministry and Statehealth departments

l Decentralized service with provision of buprenorphinemaintenance therapy, methods to shift to less harmfulroute of drug use

l Community participationl Networking of specialized GO and NGO treatment

centresl Development of an appropriate health educational

programme towards minimizing intoxicated behaviourand adverse health consequences

l Provision of other specific strategies like supply ofbleach, syringe/needle exchange programme, revivalof opium registry in rural India.

Finally, these workshops stated that a harm minimizationprogramme does not promote legitimization of oradvocate drug use.

THERAPEUTIC APPROACHES

There are, broadly speaking, two main approaches: (a)pharmacotherapy, and (b) psychosocial therapy.Treatment usually comprises a judicious mix of both theforms. However, depending upon the individual’s need,a person receives extensive treatment of any onemodality. Psychosocial therapies are helpful in maintaining

sobriety and are practised during the post-detoxificationphase. Individual, group and family counselling are offered.These are discussed later in the chapter (passim) and inseveral box items (19, 22, 23).

PHARMACOTHERAPYAlthough, various drugs exert differential effects on thebody, management principles are common to a large extent.Pharmacotherapy is useful for: (a) reversal of acute effects(intoxication or overdose), (b) amelioration of withdrawalsymptoms (detoxification), (c) decline of craving andprevention of relapse, and (d) restoration of normalphysiological functions. Specific medicines to treat any ofthese conditions are not described here. Certain commonprinciples and recent advances are discussed.

Considerable advancements have been made towards thedevelopment of specific agents for the above purposes.However, these have been used only sparingly. Many areusually skeptical about the use of any “drug” (medicine)to treat drug abuse. This is more so as the field is crowdedwith non-medical experts, social activists who discouragethe use of a “drug” to treat drug abuse. Even when thesemedicines are used they are not prescribed rationally; aninadequate dose has been used in many countries. Toillustrate, naltrexone, a drug to ensure abstinence wasprescribed for only 1-3 per cent of treated patients in USA(Orken et al., 1995). Naltrexone is manufactured andavailable in India but has not been prescribed by many.Clinicians need to prescribe this medicine and ensurecompliance. Efficacy of medicines can be enhanced bysimple measures like supervised and contractualpharmacotherapy. These will ensure compliance andminimize drop-out. Inadequate dosage of medicines (viz.very low dose of tablet buprenorphine) have also beenused, resulting in inefficacy.

Several novel compounds have been developed. Thesecould help treat opioid dependency. To list a few: longacting methadone (LAAM), NMDA antagonist, rectifyingpeptide, partial mu-agonist, enkephalin degradingenzyme inhibitors (Rapaka and Sorer, 1995) and anotherpotent narcotic antagonist, nalmefene (Dixon et al., 1986).Even long acting (depot preparations) narcotic antagonistshave been developed. These have been developed in themedications development division of NIDA, USA. Quitea few are orally active. Some have undergone clinicaltrial, while some will soon be similarly tested. However,currently, effective medications exist only for alcohol,opiate and nicotine dependence. Benzodiazepineantagonists have been developed and a cannabisantagonist is undergoing trial. Some of these are availablein the region or are likely to be available in the near future.



Many subjects with drug dependence cannot achieveabstinence following an episode of treatment and this ismost obvious among injecting drug users (IDUs). It hasbeen observed that about 70-80 per cent of IDUs relapseto drug use within three months of treatment. Thus analternative goal to minimize the harm posed by continueddrug use has been considered. Here attempts are madeto reduce adverse health, social and economicconsequences of drug use without eliminating it. Themajor focus is to contain the spread of communicablediseases and thus reduce the health hazards associatedwith drug use. It has been estimated that in Nepal among40,000-50,000 drug users (total), about 40-50 per centare IDUs. Needle exchange is a component under theharm reduction programme carried out by the Life-savingand Life giving Society (LALS) in Nepal.

The needle exchange programme has been quitecontroversial all over the world including Nepal. Manyhave felt that it may make drug problems worse by beingseen to condone and thereby encourage drug use.

In Nepal too, the term “harm reduction” was annoying tothe general public and offensive to authorities. In the past,most often IDUs were arrested and put into jail eventhough there was no legal provision against possessingor trading syringes for any purpose. However, it was seenthat most restarted drug use immediately after they cameout of the prison. The scene has changed at present. Now,a drug user is arrested only if he/she attempts/commits acrime. Advocacy and initiatives carried out through thisprogramme have resulted in society and the law acceptingthis programme as a treatment modality, though a minorsolution and not the ideal one.

THE PROGRAMMEThe needle exchange programme in Nepal began in 1991with the primary objective of preventing the IDUs and theirsexual partners being infected from bloodborne diseasesincluding HIV/AIDS. The mission was to reduce drugrelated harm among IDUs through education, counselling,health care and distribution of harm reduction materials,i.e. bleach, sterile water and needle exchange. This is thefirst harm reduction programme with a needle exchangecomponent in this region.

The IDUs are identified through outreach activities andare counselled on drug addiction, HIV/AIDS and healthcare services. Subsequently, they are provided with bleach,sterile water and exchange of needles — along witheducation on sterilizing injecting equipment.

METHOD OF DISPENSINGThis is a street based outreach programme. Full-timeoutreach workers visit the field everyday. Altogether, 64spots have been identified (46 areas in Kathmandu and 18in Lalitpur districts). Two-third of the spots are visited oneven days (three days) and one-third on odd days (twodays) with advance information to the clients. Subjects fromadjoining areas also drop-in for the services.

Needles are exchanged on a one-to-one basis. However,the number of needles exchanged are limited upto a certainamount according to average daily use by the user; this isto control misuse.

STAFF INVOLVEDThe programme started with one volunteer. A completecontingent of staff is now available to cover wider areas.The outreach workers work as teams and each teamconsists of a nurse, ex-user and social worker. The workbegan with two teams and since 1994, three teams havebeen functioning. After recruitment all the staff were trainedon acquiring knowledge about the activities and developingappropriate attitudes towards drug users. They were toldabout the need to maintain confidentiality, anonymity aboutthose receiving help, and to be non-judgmental and non-coercive towards them. The outreach workers meet everyweek where problems and specific plans for the week(s)ahead are discussed. The ex-users in the team help to a)include new drug users, b) gain confidence of the clients,c) understand their feelings, and d) develop a positiveattitude towards clients.

ACTIVITIES1. Exchange of disposable syringes (1 ml) and needles.

Needles are always exchanged with syringes incomplete sets.

2. Health education: Clients are educated on HIV/AIDS,STDs and hepatitis B, along with personal health issues.

BOX ITEM - 20

HARM REDUCTION PROGRAMMES IN NEPAL:A SPECIAL FOCUS ON THE NEEDLE EXCHANGE COMPONENT

Shiba Hari Maharjan



They are also counselled on seeking early treatment incase of any need.

3. Counselling of drug users.

4. Focus group discussion to induce behaviour changes.

5. Close coordination with authority and police.

6. Training of staff, both from LALS and other agenciesfrom the region.

The exchanged contaminated syringes/needles are put ina tin box and burnt every alternate day.

PERSONS REGISTEREDIn the beginning, only Kathmandu district was covered.Subsequently, in 1993, Lalitpur district was also included.The total number of ever contacted persons increasedfrom 450 (1993) to 1025 (1997) in the past 5 years. About60 per cent of them are in regular contact (at least oncein four weeks) and it is estimated that 60 per cent of thetotal IDUs residing in these two districts are in contactwith the programme. Among female IDUs who are incontact with the programme, a large majority arecommercial sex workers.

EVALUATIONThe periodic process evaluation of the programme (1991-94) has shown that among 424 individuals only a quarterused this service only as their source for needles. Theyalso availed of other services available like referral to adetoxification centre, health education, knowledge on safeinjecting practices and other options for positive living.Prevalence of injecting practices at two points of timeshowed the following figures:

1991 1994(N = 127) (N = 200)

STDs 18 (14.2%) 13 (6.5%)Hepatitis B 7 (5.5%) 13 (6.5%)HIV 2 (1.6%) 2 (1.0%)

Further, it showed that among clients who were in regularcontact there was an increase in knowledge of transmissionof various communicable diseases, utilization of othertreatment services available, use of safe injecting practicesand safe sexual practices. There was a decrease of injectionrelated abscesses and high risk behaviours like sharing ofinjecting equipment, frequency of drug injection andnumber of sexual partners.

Thus, overall the programme has been successful.

PROBLEMS, DIFFICULTIES AND CONSTRAINTSIt has been seen that the clients generally use multi-drugsand under the effects of drugs, more so under the effects ofstimulants (amphetamines), they ask for money and otherunnecessary items. The staff are thus sometimes veryuncomfortable.

Many staff have felt that working with drug userscontinuously for a long period is unrewarding for severalreasons such as slow change of attitude of the community,drug related deaths and lack of appreciation inspite of fieldbased hard work. This has resulted in staff burnout.

Since harm reduction activities are a comparatively newmodel of intervention, implemented by intermediate levelof staff, the donors show lack of enthusiasm. Further, theprogramme does not permit the staff to charge the clients.It is thus entirely a donor dependent programme whichhas its inherent problems.

Drug users are a mobile population. As a result, the deliveryof care including counselling is often disrupted. Re-establishing contact takes time.

LESSONS LEARNTThe need for human contact along with needle exchangecannot be over emphasized. A large number of drug usershave very inadequate knowledge on drug related harm.They need to be educated on infection control andprevention measures. Many are not aware of varioustreatment facilities and need to be informed. Hence, needleexchange programmes should not operate in isolation. Suchan activity needs to be coupled with other human servicesincluding health care.

Recruiting ex-users is extremely beneficial for the successof such a programme. Further, the staff not only needadequate training but also need to be confident of his/herown strengths and various facets of programmeimplementation.

To conclude, the needle exchange component plays a vitalrole in harm reduction strategies in changing behaviourand preventing the spread of bloodborne diseases includingHIV/AIDS.



INTRODUCTION AND BACKGROUNDMethadone hydrochloride was first developed in Germanyas an opiate substitute during World War II, and is nowused chiefly in detoxification and maintenance therapyfor opioid dependence. It is a relatively long-actingsynthetic diphenyl heptane-derivative opioid agonist.

It is effective when administered orally, parenterally andrectally. The bioavailability after oral intake is about 80per cent. The initial duration of action is from 4 to 6 hoursbut is increased to 22-48 hours with repeatedadministration. It is metabolized in the liver and excretedby the kidneys. The usual oral analgesic dose of methadonefor non-tolerant individuals is in the range of 5 to 15 mg.(Jaffe and Martin, 1985). Methadone overdose can causedeath mainly by respiratory depression and the lethal dosein non-tolerant individuals varies from 0.8 to 1.5 mg/kg ofbody weight. Opioid dependent individuals can toleratea much higher dosage. However, tolerance soon disappearsafter withdrawal and overdose may occur if methadone istaken at previous levels. Most deaths from methadoneoverdose, however, have been associated with thesimultaneous use of alcohol, benzodiazepines and othercentral nervous system depressant drugs (Swiss NarcoticSubstance Commission, 1996).

Methadone substitution treatment was first introduced in1963 by pharmacologist Vincent Dole and psychiatristMary Nyswander at Rockfeller University in New York.(Dole and Nyswander, 1965). The inclusion criteria formethadone maintenance treatment then were as follows:l Minimum age of 21l History of heroin dependence for at least four yearsl No history of alcohol dependencel Heroin addicts who failed in other treatment pro-

grammesLater on, changes were made. The minimum age waslowered and the duration of heroin dependence wasreduced to two years.

The use of methadone as a substitution treatment for heroindependence is based mainly on these findings:l Opioid dependence is a disease characterized by a

permanent metabolic deficiency, which is best managedby exogenous opiates like methadone

l Long term use of methadone would lead to toleranceto methadone and cross-tolerance to all other opiates(viz. heroin), making them less effective to produceeuphoria

l Craving for heroin is reducedl Effects of oral dose last for 24-36 hoursl Once stabilized on methadone no prominent signs of

intoxication, withdrawal and behavioural impairmentare seen.

Many well designed studies have shown that methadonemaintenance is very effective for heroin dependence andpatients maintained on methadone are less likely to beHIV positive than those not on methadone (Cooper, 1983;Chaisson et al., 1989; Strang, 1990). Only some minorand readily reversible side effects of prolonged methadoneuse have been reported (Kreek, 1993); there are noconvincing reports of teratogenicity (Novick et al., 1993).Methadone maintenance programmes have been evaluatedextensively and most studies have found it very useful.

The number of drug users is on the rise in Nepal and a vastmajority of them are dependent on heroin andbuprenorphine. Injecting drug use (IDU) has gone upsharply in the country since the late 1980s, mainly becauseof the appearance of buprenorphine on the drug scene(Shrestha, 1997). Relapse within the first three months ofdetoxification treatment is as high as 90 per cent (Shrestha,1989).

Considering these facts and the increasing deaths frominjecting drug use, His Majesty’s Government of Nepaldecided to run a Methadone Clinic on a trial basis andthis was started in the Mental Hospital on January 23,1994.

OBJECTIVES OF METHADONE CLINICl To maintain selected opioid dependents on methadone

for a prolonged period in order to prevent relapse andto thus facilitate rehabilitation and social reintegration.

l To reduce the risk of HIV, hepatitis and other infectionsamong drug users and, through them, among thegeneral population.

l Detoxification of opiate users on an out-patient basis.l To reduce the risk of overdose deaths among drug users.

BOX ITEM - 21

METHADONE MAINTENANCE PROGRAMME

N.M. Shrestha



INCLUSION CRITERIA FOR METHADONEDETOXIFICATIONl At least a six-month history of opioid dependencel Absence of multiple drug dependencel No dependence on alcoholl Absence of serious psychopathologyl Willingness to abide by the rules of the clinic

INCLUSION CRITERIA FOR METHADONEMAINTENANCEl At least two years history of opioid dependencel Failure in other treatment programmes on least on two

occasionsl No history of multiple drug dependencel No history of alcohol dependencel No serious psychopathologyl Willingness to abide by the rules of the clinic

REGISTRATION OF THE CASEEach new case is assessed by a psychiatrist and the decisionmade regarding the suitability of methadone treatment, asper the inclusion criteria mentioned above. After this initialassessment, the client is assessed periodically andwhenever needed on the basis of feedback received fromthe staff. Each person has a separate case sheet with recentpassport size photo affixed. Medical records are maintainedin strict confidence.

DOSE OF METHADONEIt was very difficult to decide the initial dose of methadonebecause of uncertainty of the contents and purity of streetheroin. Drug users often demanded a higher dose ofmethadone. Thus, the first two clients were given 20 mgand were observed for one hour for any signs ofintoxication. They came back the next day with signs ofwithdrawal; the dose of methadone was increased to 30mg and they were observed again. The next day the dosewas increased to 40 mg. Currently the dose requirementis decided upon current (last one week) consumptionpattern, severity of withdrawal symptoms, duration ofdependence and physical examination. The dose isincreased or decreased depending upon signs ofintoxication/withdrawal. It has been our experience thatfor stabilization:l 70 per cent needed 40 mg/day,l 20 per cent needed 60 mg/day,l 8 per cent needed 50 mg/day,l and 2 per cent needed 80 mg/day.

OPERATION OF THE CLINICThe clinic functions every day including weekends andgovernment holidays. The staff is overseen by apsychiatrist and consists of a trained nurse and a medicaldoctor. The subjects have to swallow the prescribed dose

in front of the nurse. No “take home” dose is allowedbarring exceptional situations. The methadone tablets,40 mg each, are imported from Switzerland withpermission to import from the Ministry of Home Affairs.Thus lower dose dispensing means crushing the tabletsand dividing them into strengths of 10 or 20 mg each. Aregister kept in the clinic logs the dose consumed,withdrawal symptoms, side effects, clinical suspicion ofillicit drug and alcohol use and any misbehaviour in theclinic. Each subject pays Nepalese rupees 0.50 per mg ofmethadone per day (US $ 1 = Nepalese rupees 63). Themoney is utilized to import these tablets.

CUSTODY OF METHADONEThe methadone tablets are kept in a cupboard which isdouble locked. The nurse is supplied with only 1000 tabletsof methadone at a time. Fresh stock is supplied only aftercareful verification of utilization. As methadone is acontrolled drug, the annual report of consumption ofmethadone is sent to the Division of Narcotics Control,Ministry of Home Affairs.

RESULTS

Table ATotal subjects registered as on 31.1.97 : 120Total subjects on maintenance at present : 60Subjects on methadone for detoxification only : 20Subjects dropped out : 30Died : 3Foreign nationals : 7

Among the three subjects who died, two died due tooverdose of alcohol, benzodiazepines and methadone, andone due to a drug related physical illness. Out of the 60subjects who are on maintenance, it was seen thatsubstantial improvement in physical and mental health wasreported by 96-98 per cent of the subjects, and all (100per cent) reported improvement in social and occupationalfunctioning and self-image. The improvements reportedwere verified by their family members.

PROBLEMS, DIFFICULTIES AND CONSTRAINTSl Use of additional psychotropic drugs and alcohol by

the clientsl Drop-out without giving noticel Bargaining for higher dose of methadonel Asking for “take home” provisionl Difficulty in getting suitable alternative staff to work in

the clinicl Threats to the staff (on rare occasions)

However, the only major problem perceived in the clinicis the use of additional psychotropic drugs and alcohol.



CONCLUSIONS AND RECOMMENDATIONSl A retention rate of 75 per cent and the substantial

improvements seen in various parameters indicate asignificant positive impact of the programme.

l Psychosocial interventions may further help to increasethe retention rate.

l This programme shows that clinical assessment by anexperienced psychiatrist is sufficient for the diagnosisof opioid dependence and to judge the suitability forthe methadone maintenance programme.

l Though urine analysis may help to diagnose opioiddependence and to confirm our suspicion about illicitdrug use, this facility is not a must in every clinic.However, this provision should be available for rareoccasions.

l At least two staff should be trained to work in the clinic.

l Age per se should not be a limiting factor for entry intothe programme.

l It has already been recommended to the Governmentof Nepal to expand this programme in the country in aphased manner.

REFERENCES:1. Chaisson, R.E., P. Bacchetti, D. Osmond, B. Brodie,

M.A. Sande and A.R. Moss (1989). ‘Cocaine Use andHIV Infection in Intravenous Drug Users in SanFrancisco’. Journal of American Medical Association,261: 561-65.

2. Cooper, J.R. (1983). ‘Introduction’. In Research on theTreatment of Narcotic Addiction XII-XVI, J.R. Cooper,F. Altman, B.S. Brown and D. Czechowiez (Eds).Rockville, Maryland: National Institute of Drug Abuse,DHHS Publication.

3. Dole, V.P. and M. Nyswander (1965). ‘A MedicalTreatment for Diacetylmorphine (heroin) Addiction’.Journal of American Medical Association, 193: 80-4.

4. Jaffe, J.H. and W.R. Martin (1985). ‘Opioid Analgesicsand Antagonists’. In The Pharmacological Basis ofTherapeutics, 7th ed, A.G. Gilman, L.S. Goodman andE. Murad (Eds). USA: Macmillan.

5. Kreek, M.J. (1993). ‘Health Consequences Associatedwith the Use of Methadone’. In Research on theTreatment of Narcotic Addiction—State of the Art, J.R.Cooper et al., (Eds). Rockville: NIDA TreatmentResearch Monograph Series, DHHS Publication No.(ADM) 83-1281, pp. 456-82.

6. Novick, D.M., B.L. Richman, J.M. Friedman, C. Fried,J.P. Wilson, A. Townley and M.J. Kreek (1993). ‘TheMedical Status of Methadone Maintenance Patients inTreatment for 11-18 years’. Drug and AlcoholDependence, 33: 235-45.

7. Shrestha, N.M. (1989). ‘A Study of Drug DependentCases Admitted to the Treatment Centre of DAPAN’.Paper prepared for SAARC Meeting of NGOs on DrugAbuse Prevention, Islamabad, 2-4 April.

8. Shrestha, N.M. (1997). Alcohol and Drug Problems: AHandbook for Medical Professionals and other HealthCare Workers, 1st ed. Khatmandu: HMG/Nepal andWHO, pp. 30-34.

9. Strang, J. (1990). ‘Intermediate Goals and the Processof Change’. In AIDS and Drug Misuse: The Challengefor Policy and Practice in the 1990s, Strang, J. and G.V.Stimson (Eds). London: Routledge.

10. Swiss Narcotic Substance Commission (1996). A SwissMethadone Report: Narcotic Substitution in theTreatment of Heroin Addicts in Switzerland, 3rd ed.Geneva: Swiss Federal Office of Public Health andAddiction Research Foundation.



Thus clinicians must update their knowledge, be awareof effective dosage and prescribe rationally. It is not ourintention to suggest a simple pharmacological answer fortreatment of drug dependence. These medicines must becombined with psychosocial therapies. Eclecticism ratherthan integration is easy to achieve and should beattempted.

INDIGENOUS SYSTEMSSeveral countries in this region have long establishedalternate approaches to treat disease. These include theayurvedic system, yoga, unani, etc. Please see Box Item-24 for details.

OUTCOME

It is expected that subjects must improve followingtreatment. This needs to be documented in a formal wayand such evidence can be of four kinds:1. Evidence that treatment is better than no treatment2. Systematic studies documenting outcome on several

parameters following treatment3. Superiority of one treatment modality over another4. Anecdotal/hearsay evidence of recovery following

treatment

It is now universally accepted that abstinence is not thesole criteria of successful outcome. The improvementmust be reflected in the subject’s total functioning. Thisincludes improvement of physical health, psychologicaladjustment, social and occupational functions and qualityof life. Reduction or cessation of drug-taking is just oneaspect and often recovery may not be evidentsimultaneously in all the areas. Thus these broad areasshould be assessed independently and appropriateintervention should be initiated. These are the tasks duringaftercare and rehabilitation. There are a number of toolsand assessment instruments available which could be veryeasily adopted, or a norm for a particular culture (country)can be developed. Indian versions of a number of theseinstruments are available viz. Addiction Severity Index(ASI) (McLellan et al., 1985; Hindi adaptation - Tripathiet al., 1993), Subjective Well Being Inventory (SUBI) (Selland Nagpal, 1992).

Not all subjects require the same intensity of treatment.Several researchers have proposed that the intensity oftreatment should be determined by the subject’scharacteristics. In other words, there should be somematching between intensity, duration and treatmentmodality with the person’s pre-treatment variables (patient-treatment matching). A well designed study has beencarried out by the National Institute of Alcoholism and

Alcohol Abuse (NIAAA), USA. A clinical research guide,guidelines for clinical management and three interimmanuals have been developed from this multisite trial ofProject MATCH (USDHHS, 1992). The manuals cover (a)twelve step facilitation therapy, (b) motivationenhancement therapy, and (c) cognitive behavioural copingskills therapy. Even though these are for management ofalcohol abuse, the concepts can be easily applied to drugabuse treatment programmes as well. Some of the institutesin India have carried out these therapies and preliminaryobservations are available. These manuals are not meantas exclusive research tools and are very much applicablein day-to-day clinical practice. Individual institutions inthe region need to try patient-treatment matching and sharetheir experiences with others.

OUTCOME

Treatment vs. no treatmentMeasurement of outcome against multiple parametersSuperiority of one treatment modality over anotherTreatment efficacySubject-treatment matching

Two outcome studies have been carried out in Indiarecently, one with funding from the Indian Council ofMedical Research (study period 1989-91), and another byWHO, SEARO (study period 1993-94). In the first study(Mohan et al., 1993) carried out in three cities, 183 opiateusers received a standard treatment package comprisingfour weeks’ hospital stay where they were detoxified,attended six sessions of group counselling and were thenon an out-patients drug free follow-up programme.Outcome was assessed at 1 year and 2 years post treatment.Of the original cohort there was considerable attrition, 39per cent at 1 year and 60 per cent at 2 years. Among thosewho could be assessed, it was seen that 37 per cent and53 per cent were markedly improved and did not use anyopiate for 21 days or longer, in the previous one month atthe end of 1 year and 2 years respectively. About 34 percent (at 1 year) and 45 per cent (at 2 years) had symptomssuggestive of opiate dependence (regular drug use). Thisstudy had a high drop-out rate and the subjects were noton any maintenance medication. The other study (Mohanand Ray, 1997) was community based; out of the originalcohort of 108 heroin dependent subjects, 65 qualified for11 months’ follow-up and 93 per cent could be interviewed(drop-out 7 per cent). In this project the subjects were ontablet buprenorphine maintenance (1.2-1.8 mg/day).Further, they received intensive group, family andvocational counselling and repeated domicillary contactby the field staff. The results showed that (a) in the previous


month, 62 per cent had not used any heroin, (b) an additional8 per cent had used only sporadically between 1-7 days,and (c) 75 per cent had not used any other substitute opiatesor alcohol. Overall, there was improvement in several otherspheres also as evident from ASI and SUBI scores and otherassessment procedures. Feeling of positive well being (SUBI)increased significantly and was within the normative range.Thus a large number of subjects were helped with tabletbuprenorphine and psychosocial intervention. This, inspiteof the fact that the intensity of treatment was moderate,none needed extensive care and the subjects improved. It isproposed to expand these efforts.

RELAPSESuccessful treatment of withdrawal status does not preventcontinued use of addictive substances. Relapse is a frequentoccurrence in the course of substance use disorders andabout 60-70 per cent of cases relapse at least once duringa year following treatment. Thus, it is important tounderstand relapse for effective treatment. Some authorshave distinguished between ‘lapse’ which is the initial useand ‘relapse’ which connotes continued drug use. Variousmedical therapies (antagonist, agonist) and psychosocialinterventions (cognitive - behavioural, improved copingskills) are needed. Thus the treating staff need to besensitized to and trained on these aspects. Relapseprevention and management methods need to beundertaken according to available professional expertiseand acceptability by patients. Other than professional help,self-help groups and informal help are also useful. In arecent SAARC workshop, “Relapse Prevention andManagement”, held in New Delhi, India (September, 1997),various issues related to relapse and its management werediscussed. Countries represented were: India, Maldives,Nepal, Pakistan and Sri Lanka. Following the presentationof country profiles, technical papers and the discussion,several agreements were reached. To minimize relapse,the group suggested that:l Demand reduction programmes should be linked with

appropriate preventive education activitiesl Long term medication and appropriate psychosocial

intervention should be initiated.l Harm minimization strategies should receive higher

priority.Several other initiatives to strengthen demand reductionactivities in the SAARC region were also suggested.

AFTER CARE AND REHABILITATIONIt has been stated earlier that treatment is often acombination of medicines and psychosocial interventions.Various psychosocial interventions include brief, extendedcounselling (single or group), attending self-help groupmeetings (Narcotics Anonymous - NA, Box Item-22), andpsychological therapies to prevent relapse (cognitive -

behavioural). A practical guide on carrying out grouppsychosocial interventions, based on experiences from atreatment centre in India is available (Drug DependenceTreatment Centre, 1996c).

However, quitting drug-taking is not enough as manysubjects would need special effort and supervised supportto start a drug free life. Recovery is a process and newadjustments are needed. Issues important in such aprocess are: a) management of craving, b) appropriateresponse to a drug offer situation, c) preventing relapse, d)leading a productive life style, and e) improved quality oflife. Thus through follow-up visits and appropriate aftercareservice the person is rehabilitated.

In realistic terms rehabilitation involves a) listing ofhandicaps, and b) listing of assets. Fortunately, mostsubjects do not lose any skills due to drug addiction, unlikethe case with certain medical or psychiatric illnesses.However, the social stigma can make them unemployable.Potential or previous employers are extremely apprehensiveabout giving an(other) opportunity to a recovering addict.Thus aftercare workers need to sensitize employers to theseissues. In India, intervention at the work site has beeninitiated in a collaborative project (ILO-UNDCP-Ministryof Welfare — Box Item-29).

Efforts towards rehabilitation would involve improvedsocial functioning and better coping skills. In this region,organizations for formal help towards rehabilitation arefar too few. Often the responsibility lies with the family.Hence, resource mobilization means enlisting support fromthe family; alternatively, medium to long term stay in anon-hospital residential care (TC - therapeutic community,see Box Item-23) is of help. However, TC programmes areexpensive and the non-completion rate is generally high.

Mostly, NGOs in the region have been involved inproviding specialized rehabilitation services. Therecovering subjects attend individual, group and familytherapy sessions. In some centres harm reduction strategiesinvolving methadone maintenance, buprenorphinemaintenance, needle exchange programmes have alsobeen initiated to facilitate rehabilitation. Experiences inthis regard from the region are discussed in another chapter(X). Social networking and acquisition of new habits arecrucial towards successful rehabilitation.

Rehabilitation has also been successfully implementedthrough community based activities as is seen in the nextchapter (IX), and box items on open community approach(Box Item-27) and community based organization (BoxItem-28).



Narcotics Anonymous is a non-profit fellowship or societyof men and women for whom drugs had become a majorproblem. We are recovering addicts who meet regularlyto help each other stay clean. It was started in Log Angeles,California, USA, in July 1953, with several other addictsand some members of Alcoholics Anonymous, who hadfaith in us and the programme. This a programme ofcomplete abstinence from all drugs. There is only onerequirement for membership, the desire to stop using drugs.Our programme is a set of principles written so simplythat we can follow them in our daily lives. The mostimportant thing about them is that they work.

The name of our programme does seem incongruous withour philosophy and with the varied nature of ourmembership, given the connotation of the word “narcotics”today. In fact, when our fellowship first broke away fromAlcoholics Anonymous, we called ourselves “AddictsAnonymous”. Two separate fellowships, both callingthemselves “AA” was not such a clean break though. Soour founders chose the name Narcotics Anonymous. Atthe time, “narcotics” referred to all drug categories, and so“Narcotics Anonymous” was a reasonable choice as thename of our fellowship. The original title, then, did reflectour philosophy of not being focussed on a specific drug ordrugs. Unfortunately, the word “narcotics” later becomeassociated with a particular drug category.

If we were to broaden our focus beyond drug addiction toinclude other types of addiction, we believe we wouldseriously damage the atmosphere of identification in ourmeetings. Yet, we must keep our focus specific enough toprovide clear identification for our new members. Thebalance we strive for is a delicate one.

There are no strings attached to Narcotics Anonymous.We are not affiliated with any other organizations, we haveno initiation fees or dues, no pledges to sign, no promisesto make to anyone. We are not connected with anypolitical, religious or law enforcement groups, and areunder no surveillance at any time. Anyone may join us,regardless of age, race, sexual identity, creed, religion orlack of religion. We are not interested in what or how muchany addict uses, what they have done in the past, howmuch or how little they have but only in what they want to

do about their drug problem and how we can help. Wehave learnt from our group’s experience that those whokeep coming back to our meetings regularly stay clean.

We feel that our approach to the disease of addiction iscompletely realistic for the therapeutic value of one addicthelping another is without parallel. We feel that our wayis practical, for one addict can best understand and helpanother addict, given the empathy between the two. Webelieve that the sooner we face our problems within oursociety, in everyday living, the sooner we becomeacceptable, responsible and productive members of thatsociety.

The only way to keep from returning to active addiction isnot to take that first dose of drug. We believe that onedose of any drug is too many and thousand doses notenough. We put great emphasis on this, for we know fromour experience that when we use drugs in any form orsubstitute one for another, we release our addiction all overagain. Thinking of alcohol as different from other drugshas caused a great many addict’s to relapse. Before wecame to Narcotics Anonymous many of us viewed alcoholseparately. But we cannot afford to be confused about this.Alcohol is a drug. We are people with the disease ofaddiction who must abstain from all drugs in order torecover.

In NA we believe that addiction is a physical, mental andspiritual disease that affects every area of our lives. Thephysical aspect of our disease is the compulsive use ofdrugs, the inability to stop using once we have started.The mental aspect is the obsession, or overpowering desireto use, even when we are destroying our lives. And thespiritual part is our total self-centredness. We felt that wecould stop whenever we wanted to, despite all evidence tothe contrary. Denial, rationalization, guilt, embarrassment,dereliction, degradation, isolation and loss of control areonly some of the results of our disease. This disease isprogressive, incurable and fatal, if allowed to continueunabated. We believe that our disease can be arrestedone day at a time. Like a diabetic needs regular doses ofinsulin to arrest diabetes, our disease can be arrested bynot having that first dose of any drug, and coming to ameeting.

BOX ITEM - 22

NARCOTICS ANONYMOUS—ITS ROLE IN RECOVERY

Public Information Sub-Committee, Delhi Area, NA



How we got this disease is of no immediate importance tous. We are concerned with recovery. In NarcoticsAnonymous, our disease of addiction gives us a commonstanding and here we are introduced to the Twelve Steps,which become the solution to our disease, by theirapplication in our daily lives. They are:

1. We admit that we are powerless over our addiction,that our lives have become unmanageable.

2. We believe that a Power greater than ourselves canrestore us to sanity.

3. We make a decision to turn our will and our lives tothe care of God, as we understand him.

4. We make a searching and fearless moral inventory.

5. We admit to God, to ourselves and to another humanbeing the exact nature of our wrongs.

6. We are entirely ready to have God remove all thesedefects of character.

7. We humbly ask Him to remove our shortcomings.

8. We make a list of all persons we have harmed, andbecome willing to make amends to them all.

9. We make direct amends to such people whereverpossible, except when to do so would injure them orothers.

10. We continue to take personal inventory and when weare wrong promptly admit it.

11. We seek through prayer and meditation to improveour conscious contact with God as we understand Him,praying only for knowledge of His will for us and thepower to carry that out.

12. Having had a spiritual awakening as a result of thesesteps we try to carry this message to addicts, and topractise these principles in all our affairs.

There is a special feeling for addicts when they discover thatthere are other people who share their difficulties, past andpresent. At meetings we share with other addicts, ask questionsand learn more about our disease. We learn new ways tolive. Whenever we reach out for help, we receive it.

NA meets regularly, at a specified place and time, andrecovery is based on the Twelve Steps and Twelve Traditionsof Narcotics Anonymous as enumerated above. There are

two basic types of meetings: those open to the generalpublic and those closed to the public (for addicts only).Meeting formats vary widely from groups to group.Whatever the type or format a group uses for its meetings,carrying the message of recovery to the addict who is stillsuffering is the primary purpose of our meetings. For this,we strive to provide a suitable and reliable environment ofrecovery.

At first we can do little more than attend meetings. Meetingskeep us in touch with where we have been, but importantlywith where we could go in our recovery. We becomeacquainted with the fellowship and its principles and beginto put them into action. Our friends in the fellowship helpus. Clean, we face the world together.

To ensure that the atmosphere of recovery is maintainedconsistently in our meetings, we in Narcotics Anonymousbase the functioning of the group on our Twelve Traditions.These protect the groups from any digression from ourprimary purpose. They are :

1. Our common welfare should come first; personalrecovery depends on NA unity.

2. For our group purpose, there is but one ultimateauthority — a loving God as He may express himselfin our group conscience. Our leaders are but trustedservants, they do not govern.

3. The only requirement for membership is a desire tostop using.

4. Each group should be autonomous, except in mattersaffecting other groups or NA as a whole.

5. Each group has but one primary purpose — to carrythe message to the addict who still suffers.

6. NA groups ought never endorse, finance or lend theNA name to any related facility or outside enterprise,lest problems of money, property or prestige divert usfrom our primary purpose.

7. Every NA group ought to be self-supporting, decliningoutside contributions.

8. Narcotics Anonymous should remain forever non-professional, but our service centres may employspecial workers.

9. NA, as such, ought never be organized but we maycreate service boards or committees directlyresponsible to those they serve.



10 Narcotics Anonymous has no opinion on outside issues;so the NA name ought never be drawn into publiccontroversy.

11. Our public relations policy is based on attraction ratherthan promotion; we need always maintain personalanonymity at the level of press, radio and films.

12. Anonymity is the spiritual foundation of all ourTraditions, ever reminding us to place principle beforepersonalities.

Our service structure is solely geared towards fulfilment ofour primary purpose. Our message is that an addict, anyaddict, can stop using drugs, lose the desire to use, andfind a new way to live. Our service structure is depictedby the following diagram:

Individual member

Group

Area Service Committee

Regional Service Committee

World Service Committee

In this structure, power is derived from the individualmember, whereby he/she is involved in all the decisionmaking processes. All subsequent levels of service havebeen created as a means to fulfill the needs of eachindividual member of Narcotics Anonymous. That is whythose of us involved in service consider ourselves “trustedservants” of NA.

Narcotics Anonymous started in India in Mumbai in theearly eighties and then spread to other cities, namelyBangalore, Calcutta, Chennai, Imphal and Pune.

About 1200 persons are members of NA in these cities.

Besides these cities, NA groups also exist in Chandigarh,Jallandhar, Hyderabad, Bhubaneshwar, Guahati, Shillong,and Aizwal. We also know of the existence of NA in Nepal,Bangladesh and Pakistan. For further information aboutNarcotics Anonymous in this region, the following addresscan be contacted:

World Service OfficeP.O. Box # 9999Van Nuys, CA 91409United States

Narcotics Anonymous practices cooperation but does notaffiliate itself with other treatment facilities. Our sixthtradition is self-explanatory: “An NA group ought neverendorse, finance or lend the NA name to any related facilityor outside enterprise lest problems of money, property orprestige divert us from our primary purpose.” The PublicInformation Sub-committees carry the NA message todoctors, clergy, law, law enforcement agencies, media etc.,who are likely to come into contact with the still sufferingaddict.

As will be noticed, one of the constantly recurring conceptsin our literature is that of a Higher power or God of ourunderstanding. This God could well be different for eachindividual member. For many of us God may simply bewhatever force keeps us clean. Ours is a spiritualprogramme and not a religious one. Our concept of Godcomes not from dogma but from what we believe and fromwhat works for each of us. Each member is free to develophis own understanding of a power greater than himself.

In this article, we have tried our best to share the philosophyof Narcotics Anonymous and to communicate a basicstructure of the fellowship and how it functions. NarcoticsAnonymous is all this and much more. We, as members,are grateful that we have a chance today to live a social,useful and productive life.



The idea of Therapeutic Community (TC) was originallyconceived by T.F. Main and later popularized by MaxwellJones (1953) in England who summed up the objective,the underlying basic philosophy thus: “the cultural pressureof the (Therapeutic) Community is directed towards thepatient’s acceptance of a more useful social role, whichmay then appear desirable because of his growingidentification with the group”.

The aim is to provide a social setting in which patients areable to enhance their self-esteem by assuming greaterresponsibility, and to make greater use of the therapeuticpotential of the whole staff.

In the words of A. Wilmer: ‘It seeks continually to solve itsproblems in terms of interpersonal relations by helpingthe patient to identify himself with a social group andthrough identification modify his social attitude andbehavior because of his growing awareness of his role inrelationship to other people’.

It emphasizes the importance of socio-environmental andinter-personal influences on the therapy, management,resocialization and rehabilitation of the long term patient.

After detoxification the subject needs to be nurtured by anin-house programme with its goal of enabling him to re-enter the larger community as a successfully functioningdrug free individual through the reorientation of his lifestyle.

Entry into a therapeutic community calls for considerableinitiative on the part of a prospective resident. Not onlymust he be successful in the intake interview but he mustbe deeply motivated to join the programme. Thus, thosewith insufficient motivation would fail to benefit from atherapeutic community as strong motivation provides anexplicit and self-designed reason for a successful applicantto avail of treatment. Although the social status of a newresident is typically low, the neophyte is restricted as topersonal possessions, personal visitors and telephone calls.He is assigned household tasks and is expected to performthem well, show concern for fellow residents and to obeythe basic rules (no physical violence, substance abuse, etc.).Adherence to the foregoing will evoke increasing degreesof freedom.

The ideal programme is holistic and termed “whole personrecovery” going beyond the three modules of primary,secondary and tertiary, with the treatment matrix varyingfor each patient and the duration ranging from threemonths to one year depending largely on the motivationof the person.

Generally, it entails a strict daily routine in a protectedenvironment, of time management of meals, sleep,therapeutic duty assignment, relaxation, yoga andmeditation with group and individual psychotherapy.Strict observance leads to inculcation of strong innerdiscipline. The patient and the counsellor work togetherto identify personal problems and set goals leading to abetter life.

Briefly, by living in a TC the subject learns to develop,strengthen and maintain relationships with self, God andothers around him. Honesty, trust, gratitude, acceptanceand faith are sought to be made part of the recoveringperson’s psyche.

Thus re-entry into the larger community is accomplishedin steps, from being a regular resident to living outside theTC while attending regular group meetings, within thecommunity. As time progresses the patient is dischargedfrom the TC and then considered rehabilitated.

FACILITIES IN THE REGIONThe Kripa Foundation has a total of eleven such facilitiesin India. These are at Calcutta, Darjeeling, Delhi, Goa,Imphal, Kohima, Mangalore, Mumbai, Shillong and Vasai.In all, there are ten counselling centres, six de-addictioncentres and ten treatment and rehabilitation centrescovering seven States and one union territory

Organizations like Support, specializing in reaching outto the street child avail of the Kripa Foundation’s treatmentfacility for aftercare of these children. The ILO project ofcommunity based rehabilitation (CBR) has broughtorganizations working in the slums of “Dharavi” inMumbai to offer facilities of Kripa to rehabilitate addictsin their own environment. The Sion Hospital UrbanHealth Centre has been responsible in making the projectsuccessful.

BOX ITEM - 23

THERAPEUTIC COMMUNITY

Fr. Joe Pereira



There is a continuous flow of referrals from numerouscompanies and organizations with Employees AssistanceProgrammes (EAP) for aftercare of these affected individuals.

PERSONAL CLINICAL EXPERIENCE FROM ONESUCH FACILITY

StructureIn this piece, we shall confine ourselves to the TC at Andheri(W), Mumbai, also known as DAC. This facility is on thethird floor of the Municipal Hospital, Bhardawadi, Andheri(W), occupying an area of 6700 sq feet, one-third of whichis allocated for the male facility, one-eighth for the femalefacility and the remaining area for counselling rooms,counsellor rooms, hall and library, office, pantry, etc.

Description of Affected PersonsThirty males and seven females from various strata ofsociety usually undergo treatment at any point of time. Amajority are dependent on alcohol, a few on multiple drugsand are referred by the medical fraternity, the legal, religiousand mental health fields, AA, EAP programmes ofcompanies and ILO’s CBR project at Dharavi. Theprogramme is suitably adapted to individual needs.Common tasks for subjects are assignments to elevate theirself-esteem, self-image, and a sense of responsibility.

StaffThe Project-in-Charge, in this case a senior counsellorhimself a recovered addict, is resident on the premises.He is assisted by a psychologist and three experimentalpeer counsellors with ancillary staff. The medical teamcomprises a senior psychiatrist, an allopathic physicianand a homeopathic doctors with support staff like nurses,ward-boys, yoga instructors, group therapists, occupationaland recreational therapists, etc.

RolesThe role of the psychiatrist and the physician are marginalin the Kripa model. The psychiatrist assists in dual diagnosisand plays a support role while the physicians’, nurses’ andward-boys’ role is confined largely to assisting the addictin detoxification and thereafter in a supportive role. Nursesassist in record-keeping and relevant documentation whilethe ward-boys, themselves recovering addicts, assist in theday-to-day running of the TC.

Any shortfall in manpower is made up by recovered addictswho volunteer their services from the rehab component ofthe facility.

Nature of Activity and InterventionsThe Kripa Foundation utilizes minimal medication. Thecore treatment package is multi-disciplinary in nature,

consisting of a modified Minnesota model; yoga, zen,vippasana and even tai-chi. The treatment itself is anabsorbing, intensive experience covering group therapy,recreational therapy and combining the twelve step wayof life as advocated by Alcoholics Anonymous andNarcotics Anonymous. This twelve step way of life hasproved to be most beneficial in bringing about a spiritualrevolution within the addict. Yoga therapy is interwoveninto the Kripa model.

Kripa conducts its programme in three phases; 5 to 10days are required for detoxification, following whichcoping strategies are suggested and the individuals arehelped to understand their addiction. The third phase,i.e. rehabilitation, involves returning to normal life whiletaking into account the self-acknowledged problems ofaddiction.

The highly structured daily schedule begins at 5.30 amwith a wake-up call and ends with lights out at 10.30 pm.Each day begins with a half-hour meditation session,followed by work therapy, group sessions on reading,writing, reflection, sharing feelings, afternoon yogasessions, and a short meditation period before bedtime.

Every week the medical, para-medical and counselling staffhold clinical meetings to review the progress of each patientand to devise, or rather revise, the existing programmebased on his motivation and patient specific needs.

Duration/Length of StayThe length of stay of the patients at Kripa varies from patientto patient. The recommended period of stay fromdetoxification through de-addiction and rehabilitation is144 days by which time the patient is able to reintegratehimself into normal life. The reintegration is possible onlyif the patient is willing to undergo changes in his lifestyle.During his stay at Kripa, the patient is expected to strictlyadhere to the schedule in the facility which helps instructuring time and bringing about orderliness in life.

OutcomeBetween January and September, 1997, a total of 1248patients were admitted to the various treatment centres(N=11) of the Kripa Foundation. Six per cent weredischarged after successful completion of treatment andabout 20% were still undergoing treatment. About 17%left treatment prematurely.

After discharge, some patients are transferred to othercentres for further rehabilitation. In order to sustain therecovery process, following their discharge patients are alsorequired to report periodically for AA meetings, group andpeer discussions, adopt a sponsor, etc.



FinancesThe Kripa Foundation receives funding from both publicand private sources; the Ministry of Welfare, Governmentof India supports part of the activities and the MunicipalCorporation gives concessions in rates for water and otherutilities. In case of Employees Assistance Programmes thecost of treatment is reimbursed by the companies. Some-times private donations are also available.

Constraints/DifficultiesThe space available is limited so we have to restrictadmissions. Often, there are long delays in getting fundsfrom the Ministry of Welfare. Due to paucity of funds, atthis time we have no income generation activities, whichare an essential component of the rehabilitationprogramme.

Other IssuesAt Kripa we have come to realize that “whole personrecovery” requires four key steps: (1) practical guidance,

(2) encouragement, (3) successful role models who canshare their own experiences, and (4) a peer learning group,who share goals of lifestyle change. A learning groupoften provides each of the four factors in some measure.Above all, it can generate social learning conditions anda culture of change and growth for each member. Thus,Therapeutic Community living instills in a member thestrength and confidence to give up the drug habit andreorient his lifestyle.

It is precisely this embrace which is epitomized as under:“For my brother who was dead has come to life again, waslost and is found”. It is through this message of hope, graceand a chemical free existence that the Kripa Foundation isbringing about a healthy lifestyle and belief in humanrelationships both in individuals and in society.



ROLE OF FAMILYIn this region close family ties are a strong point. Thus,any efficient programme should attempt to involve thefamily in treatment. While the family is expected to providehelp for the subject undergoing treatment, it must not beforgotten that the family also needs help. Often due to thesubject’s drug-taking the family is distressed and familymembers’ worries and apprehensions should be lessened.During follow-up and in the later part of the treatment phase(rehabilitation) family members’ involvement should bemore intense. Several remedial measures can be initiatedby them, viz. the family can ensure better compliance fortreatment, ensure medication and bring the subject earlyfor treatment in the event of a relapse. Simple commonsenseadvice would often suffice. Detailed principles andmethods of family therapy have been avoided here.Interested readers would find them on any standardtextbook on substance use disorder management.

OTHER ISSUES

Several other factors influence treatment and outcome. Theseare availability of and access to treatment facilities, utilizationby the persons who need them most, organization,management of treatment centres, motivation of treating staffand finally economic cost and financing of treatmentprogrammes. Information on most of these issues is veryscanty from countries in the sub-region. In a large study inUSA (Epidemiological Catchment Area Programme), it wasreported that, overall, persons with substance use disorderutilized various ambulatory addiction services and admissionfacilities. About 83 per cent of treated persons were seen inat least one professional setting and 36 per cent utilizedvoluntary support networks - VSN (e.g., NarcoticsAnonymous). The professional sector accounted for 55 percent of these visits and support networks for 45 per cent ofthese visits. The visit rate to the professional sector(psychiatric centre, alcohol/drug unit, general hospital, healthsystem) was 10.8 visits per person per year, and 20.6 visitsper person per year in the VSN sector. About 14 per cent oftotal subjects with substance use disorder were admitted toa ward (in-patient) at least once. It was also seen that a largenumber of persons were seen in non-speciality settings aswell (Narrow et al., 1993).

Thus it can be seen that the overall utilization of serviceswas high and a majority were treated from OPD, i.e. theywere not admitted to any in-patient facility and treatmentby all professionals and non-specialists was carried out.Data from certain government treatment centres in India,(published and unpublished) shows that between 30-40per cent of patients discontinue treatment (drop-out) soonafter initiation in a routine treatment facility. Among thosewho visited more than once, the average visit per person

over a 6-month period was 8 (close to findings by Narrowet al., 1993). In a district based community treatment centrein India, about 25 per cent visited more than six times in ayear (between March 1996 and February 1997), and about30 per cent dropped out (unpublished data, DrugDependence Treatment Centre, AIIMS). However, in theresearch study on treatment and outcome (buprenorphinemaintenance) it was seen that 43 per cent of the subjectsmade 20 or more visits in 11 months (study period 1993-94) (Mohan and Ray, 1997). In another study it was seenthat those who dropped out from treatment were under-prepared or poorly motivated. In psychological terms, theywere in the “pre-contemplation phase” rather than in the“contemplation” or “action” stage. Thus many subjects,even though they have reported to treatment centres, wouldneed additional help to enhance motivation to participatein treatment and increase their commitment to change(Samanta Ray et al., 1997).

About 3.9 - 6.5 per cent of total patients were admitted tothe in-patient facility in a year over a six year period (1989-94) in an apex centre in India (Drug Dependence TreatmentCentre AIIMS, 1996a). In Sri Lanka, between 81 - 98 percent of all admissions took place in the government facilitybetween 1991-95 (NDDCB, 1996).

COMPARATIVE STUDY, 1994A study of organization and management of substanceabuse treatment centres in Delhi was carried out (Rizvi,1994). This study was sponsored by WHO, SEARO.Altogether 15 centres were studied; GO - 5, NGO - 7 andprivate sector - 3. Information on the organization,management and performance of these centres wascollected through questionnaires and interview schedulesfrom 109 professionals at these centres, 72 patients and35 family members of patients.

GO vs. NGO vs. Private Sectorl Employee strength was higher in GOs than NGOsl In most GOs and private centres, care of psychiatric

patients was a higher priority, substance abusetreatment was a secondary responsibility

l Hierarchy was significant in GO and not so in NGO/private sector

l Role clarity and responsibility of an individual was lessclear in NGOs

l NGOs had higher bed strength and higher patient loadl Infrastructure was grossly inadequate in all three

sectors, more so in NGOs.

Professionals Involved in Treatmentl In general they were young: between 30-40 years of agel Most professionals in GOs and the private sector had

academic qualifications relevant to their present job


l About 56 per cent in NGOs displayed a mismatchbetween their academic qualifications and job roles.

Work Load / Job Satisfactionl Patient load as per individual professional in GOs and

private centres was lower than in NGOsl Majority of the professionals had high level of work

motivation but moderate level of job satisfactionl Professionals in NGOs and private centres had low

level of motivation.

Treatment Programmel On an average these patients visited seven times before

their admission to the GO and NGO centersl Treatment was free in GO centres, very expensive in

private centres and moderate (Indian rupees upto 1000per person, about US $ 26) in NGO centres for in-patient treatment for 15 days

l Most often, patients were admitted for 11-15 days; insome cases for 21-30 days

l Treatment modality was flexible and no centres hadmade any effort towards patient-treatment matching

l Drop-out rates were highl Family members were not adequately involved in the

treatment processl Many in-patient facilities were not totally drug free,

i.e. illicit substances made their entry in the wardl The rehabilitation programme in most of these centres

was grossly inadequate.(Rizvi, 1994)

The author offered several suggestions for improvement.These included specialized training for centre professionals,enhanced treatment duration, provision for well co-ordinated rehabilitation programmes and upgrading ofinfrastructure and other facilities.

ECONOMIC ASPECTS

Some authors have examined the area of hospital economicsand financing of health care in developing countries. Mosthave felt that there are several inadequacies. These includetechnical inefficiency, little provision of incentives forimproved performance and most hospitals (in-patientfacility) have relied almost exclusively on governmentfinancing (Newbrander et al., 1992). In a large countrylike India, where delivery of health care is largely theresponsibility of State governments, central government’scontributions to state health spending are based onmatching grants. Thus States that are already spending moreare rewarded. This reinforces inter-State differences inhealth spending. It is difficult to get cost estimates fromgovernment hospitals. However, it appeared that for general

health care the lowest income group spends much more(about 24 per cent of annual income), as against the higherincome group (about 4 per cent of annual income) onprivate medical expenditure. Care in a private centre isvery expensive. Further, it has been seen that in this region,India spends much more money on secondary/tertiary carehospitals and medical training/research. This has beenachieved at the expense of basic health care. Another groupof experts felt that the total volume of resources was not amajor constraint in India (Deolalikar and Vashishta, 1996).India spends considerably more on health (per cent of GDP)than most other countries in Asia (Annexure 6). The abovediscussion is not specifically addressed to the drug de-addiction programme in the government sector. However,this is the general milieu of the health system in which thetreatment of drug dependent individuals operates ingovernment hospitals.

As important as assessing the outcome and efficacy of aprogramme, is estimating cost of a treatment method andthen analyzing its cost-effectiveness. Such an exercise at-tempts to determine which course of action should bepursued, given scarce resources. A well designed out-come study (follow-up) is quite expensive. Rarely canthe subjects be randomly assigned to a given treatmentmodality in drug abuse research. Ethical dilemmas donot permit a group to receive ‘no treatment’ for the pur-pose of comparison. Thus there are severe limitations inquantifying the efficacy of a given treatment modality inmonetary terms. Some others have attempted to addressthe issue of a cost-benefit analysis. Basically, an econo-mist’s view of expenditure towards treatment is used. Es-timating the cost of a drug abuse treatment programme isnot very difficult. However, calculating benefits is muchmore complicated. Societal/individual benefit/loss due todrug abuse is even more difficult to compute. Assessingthe value of less tangible benefits or future long term ben-efits in family interaction in arithmetic and financial termsis very difficult. Still, many have attempted to do this.NIDA, USA, has developed guidelines to examine theseissues. It has been suggested that such studies should lookinto (a) individual programme profile, (b) treatment mo-dality, and (c) summary report. Actual post-treatmentoutcome data are frequently not available during suchan exercise. The data is thus imprecise. However, suchstudies set in motion the process of improving basic datagathering systems towards more exhaustive evaluation(Des Jarlais et al., 1981; Cartwright and Kaple, 1991). Asyet, not much effort has been made, nor much interestshown in the sub-region with regard to calculating theeconomic cost of drug abuse, cost-effectiveness and fi-nancing of treatment programmes. Soon the countries inthe region will require such exercises to improve deliv-ery of drug abuse treatment. Economists and profession-


als engaged in treatment would have to work together. Itis obvious from the above description that planning acost-effectiveness study is very tedious.

An alternative project/modality evaluation would be to lookfor standards of good clinical practice, scientific soundness,treatment effectiveness, and credibility of outcomeparameters. In a quasi-experimental fashion, a processevaluation can be carried out and has been recommendedby WHO. A treatment modality can be categorized as lowintervention (only pharmacotherapy) or high intervention(high dose pharmacotherapy and other psychosocialtherapy). Additionally, treatment compliance, treatmentretention and subject’s satisfaction should be looked intoto decide on the soundness of a programme.

COUNTRY PROFILES

Development of treatment services in this region hasalready been discussed in the chapter on national drugdemand reduction programmes (chapter VI). Hence theseare summarized here. Various focussed descriptions on anumber of intervention strategies are presented as box itemsin this chapter by several authors. Community basedtreatment is discussed in the next chapter.

BANGLADESHThe first exclusive treatment centre for drug dependencewas established by the government in early 1988 with abed strength of 25, subsequently upgraded to 40. Three morecentres in three cities have subsequently been set up, eachwith 5 beds. Currently, there are ten other treatment centresin the NGO sector and their bed strength varies between 6and 75 beds (a total of 190 beds are available).

Two very distinct treatment models have been developed.The “Medical Model” is practised mostly in the governmenttreatment centres staffed by medical professionals. Theother, the “Ashram Model”, is run by non-medical socialactivists in the NGO sector. Most of the centres have bothresidential and out-patient facilities with varying degreesof emphasis on rehabilitation. Detoxification is still theprimary emphasis. There is one exclusive treatment centrefor women though it is mostly underutilized. There areplans to develop a community based camp approach andinclude the existing general health care facilities (PHCs -tertiary care hospitals) in future. The activities are monitoredby the Department of Narcotics Control (DNC).

INDIAIn India, treatment centres have been established both ingovernment hospitals supported by the Ministry of Healthand by NGOs supported by the Ministry of Welfare. So far,

in the health sector, 72 centres in various States have beenestablished. Seven of these are located in premier teachinghospitals of the country, and 64 in various State medicalcolleges, district hospitals, and civil hospitals; one centrein a prison is supported by the health ministry. They receivefinancial grants for infrastructure development and somefor recurring expenditure as well. The strengthening of thesecentres has been proposed. The Project Management Cell,Government of India, monitors the activities, delivery ofcare, service load, etc. periodically (Country Profile, India).

Till March 1977, the Ministry of Welfare had established218 counselling centres and 123 de-addiction centres (allNGOs). In 1996-97, a total of 3,05,098 persons wereregistered and 1,14,831 were detoxified. About 3500 bedsare available between these centres. Besides providing shortterm treatment, these centres also carry out variouscommunity awareness activities, rehabilitation andaftercare services. The activities are monitored by thecentral Ministry of Welfare (Country Profile, India). A largenumber of NGOs are active. These include services inprisons and community based organizations. Otherfacilities include self-help groups like NA (see Box Item-22), indigenous systems of medicine (see Box Item-24)and private practitioners.

MALDIVESThe Ministry of Health has already initiated certainmeasures. The government has established one residentialrehabilitation centre (temporary); the permanent one hasbeen constructed and will be operational very soon.Counselling services are available in one governmenthospital. One NGO is complementing the various effortsinitiated by the government.

NEPALAt present most of the activities are carried out by NGOs.There is, however, one government treatment centre with12 beds. There are five active NGOs, and between themthey have 102 beds. There is one therapeutic communitycentre functional in a prison. From January, 1994, Nepalhas had an established centre for methadone maintenancethrough a government mental hospital (see Box Item-21),and another for various harm minimization activitiesincluding a needle and syringe exchange programme, since1997 (see Box Item-20). Ministry of Home, NarcoticControl Division and DADRP are the nodal agencies forimplementation (Country Profile, Nepal).

SRI LANKAThere are four de-addiction centres with a total of 143beds in the government sector. Several NGOs (about 22)are active under the organization FONGOADA. Betweenthem, they have 30 beds. Rehabilitation and aftercare


services are carried out with social and community support.Low cost intervention strategies including the campapproach, domiciliary care and open community approachhave been clinically tested and popularized. Treatmentservices are also available in one prison. Between 1991 and1995 a total of 6344 admissions took place and most weremales (99 per cent). NDDCB is the nodal agency for alldrug abuse control programmes including treatment andaftercare services (NDDCB, 1996; Country Profile, Sri Lanka).

Several NGOs have been very active in this region. Asubsequent chapter (X), with Box Items (30-35), outlinesthese activities.

To conclude, it can be seen that there are variouscomponents of a treatment programme of variable intensityand duration. Not every centre needs to do everything.What is important is that subjects should have a choiceand a wide array of treatment services should be available.In an area (town/city) where prevalence of drug use is high,particularly injectible opiate use, measures must be takento upgrade hospital casualty service. Lives can be savedthrough emergency medical interventions and use of opiateantagonists. It should be the responsibility of thegovernment to upgrade casualty and make naloxoneavailable. This is the most cost-effective measure.

Treatment of drug dependence disorder receives lowpriority in a developing country where there are many othercompeting priorities. However, some measures have beeninitiated in the region and some centres are functioningwell. There are still several systemic inefficiencies. Theseneed to be looked into, evaluated and modified.Appropriate tools and methodologies have been developedelsewhere, and these can be easily applied in this regiontoo. Of course, nothing can be planned and no progresscan take place without a good data base. Thus, a systemmust be developed for collection and dissemination ofinformation, with a nodal agency. After some progress ismade, quantitative as well as qualitative data onorganizational structure, treatment efficacy, outcome andeconomic aspects of delivery of care should be examined.Even with limited financial outlay quite a few of the aboveare possible and the delivery of care can improve. Thiswould mean money well spent. Resources from formalfunding institutions for rehabilitation will be limited, andthis will thus be the responsibility of families. However,there is no cause for despair as family ties are quite strongin the region. Thus with the family’s involvement adequaterehabilitation will be possible. For some individuals, whodo not have adequate social support, the government willneed to step in.


RESOURCE DOCUMENTS

1. Cartwright, WS and JM Kaple (Eds) (1991): ‘EconomicCost, Cost-Effectiveness, Financing and Community-based Drug Treatment’. NIDA. Research MonographSeries no. 113.

2. Deolalikar, A and P Vashishta (1996): ‘The Health andMedical Sector in India: Potential Reform and Problem’.Centre on Institutional Reform and the Informal Sector,(IRIS) University of Maryland, USA. - India WorkingPaper no. 9.

3. Des Jarlais, DC, S Deren and DS Lipton (1981): ‘Cost-Effectiveness of Studies in the Evaluation of SubstanceAbuse Treatment’. In Substance Abuse - ClinicalProblem and Perspectives, JH Lowinson and P Ruiz(Eds). William and Wilkins, Baltimore.

4. Dixon, R, J Hower, J Gentile, H Hsu, J Hsiao, D Garg,D Weidler, M Meyer and R Tuttle (1986): ‘Nalmefene:Intravenous Safety and Kinetics of a New OpioidAntagonist’. Clinical Pharmacological Therapeutics,19: 49-53.

5. Drug Dependence Treatment Centre (1996a): ‘DrugDependence Treatment Centre — A Brief Sketch’. AllIndia Institute of Medical Sciences, New Delhi.

6. Drug Dependence Treatment Centre (1996b):‘Community Treatment for Substance Use Disorder’.All India Institute of Medical Sciences, New Delhi.

7. Drug Dependence Treatment Centre (1996c): ‘HandBook on Psycho-educational Group Therapy—Recovery from Alcohol and Drug Dependence’. AllIndia Institute of Medical Sciences, New Delhi.

8. McLellen, AT, L Luborsky, L Cacciola, J Griffith, F Evans,HL Barr and CP O’Brien (1985): ‘New Data from theAddiction Severity Index’. The Journal of Nervous andMental Disease, 173: 412. (Hindi Adaptation - Tripathi,BM, et.al., 1993)

9. Mohan, D, DR Purohit, P Sitholey, BM Tripathy, R Ray,NG Desai, HK Sharma, DK Sharma, AB Sethi and SETewari (1993): ‘Collaborative Study on Narcotic Drugsand Psychotropic Substances’. Report submitted to IndianCouncil of Medical Research (ICMR).

10. Mohan, D and R Ray (1997): ‘Community Based Treat-ment for Heroin Dependence in an Urban Slum ofDelhi’. Report submitted to WHO, SEARO, New Delhi.

11. Narrow, WE, DA Regier, DS Rae, RW Manderscheidand BZ Locke (1993): ‘Use of Services by Persons withMental and Addictive Disorders’. Archive of GeneralPsychiatry, 50: 95-107.

12. National Master Plan, Bangladesh (1991).

13. National Master Plan, India (1994).

14. National Master Plan, Nepal (1992).

15. National Master Plan, Sri Lanka (1993).

16. NDDCB (1996) : Hand Book of Drug Abuse Informa-tion, 1991-1995.

17. Newbrander, W, H Barnum and J Kutzin (1992):Hospital Economics and Financing in DevelopingCountries. WHO, Geneva.

18. Orken, LS, JD Blaine and JJ Boren (Eds) (1995):‘Integrating Behaviour Therapies with Medications inthe Treatment of Drug Dependence’. NIDA, ResearchMonograph Series no. 150.

19. Rapaka, RS and H Sorer (Eds) (1995): ‘Discovery ofNovel Opioid Medications’. NIDA, ResearchMonograph Series no. 147.

20. Report on SAARC Workshop (1997): ‘RelapsePrevention and Management’, New Delhi, India.

21. Rizvi, IA (1994): ‘A Comparative Study of Organisationand Management of Substance Abuse Treatment andRehabilitation Centres in Delhi’. Report submitted toWHO, SEARO, New Delhi.

22. Samanta Ray, PK, R Ray and K Chandirmani (1997):‘Predictors of Inpatient Treatment Completion ofPatients with Heroin Dependence’. Indian Journal ofPsychiatry, 39: 282-87.

23. Sell, H and R Nagpal (1992): ‘Assessment of Subjective


Well Being’. Regional Health Paper, WHO, SEARO,no. 24.

24. UNDP (1997): Human Development Report. OxfordUniversity Press, New York.

25. United Nations, ESCAP (1995): ‘Community BasedDrug Demand Reduction’. Report on five demonstra-tion projects.

26. United States Department of Health and HumanServices (USDHHS), National Institute of Alcoholismand Alcohol Abuse (1992): (1) ‘Twelve Step FacilitationTherapy Manual’; (2) ‘Motivation Enhancement

Therapy Manual’; (3) ‘Cognitive-Behavioural CopingSkills Therapy Manual - A Clinical Research Guide forTherapists Treating Individuals With Alcohol Abuse andDependence’.

27. Westermyer, J (1985): Clinical Guide to Alcohol andDrug Problems. Praeger, Philadelphia.

28. WHO (1993): ‘Approaches to Treatment of SubstanceAbuse’. Geneva.

29. WHO (1997): ‘Regional Health Report’. WHO, SE AsiaRegion.


The increasing sophistication of modern medicine, risingadministrative costs and the parallel expansion in trainingand specialization has led to the skyrocketing of healthcare costs all over the world. This has led to a situationwhere even people in developed countries have inadequatehealth coverage, though people in this region (South Asia)are probably the worst affected.

According to WHO, traditional medicines are the primarysources of health care for 80 per cent of the world’spopulation. Fortunately, India and many other countriesin the region have well developed and effectiveIndigenous Systems of Medicine (ISM) — Ayurveda,Siddha, Unani, Tibbi, Yoga and Naturopathy. Thesesystems have been in vogue in the Indian subcontinentfor centuries and continue to provide medical relief tothe majority of the people of this region. Now fresh effortsare being made to develop these systems so that they canmake an even more significant contribution to the healthcare systems of this country.

These systems come from an established tradition and arebased on their own fundamental principles. However,traditional medicine usually elicits one of four attitudes.

Monopolistic : Modern medical doctors have the soleright to practice medicine.

Tolerant : Ayurvedic practitioners or those ofother indigenous systems of medicineare not officially recognized, but arefree to practice on the condition thatthey do not claim to be registeredmedical doctors.

Parallel : Practitioners of both modern andAyurvedic systems are officiallyrecognized. They serve their patientsand offer their services throughseparate mechanisms.

Integrated : Modern and traditional systems ofmedicine are jointly practiced. Thishas been discouraged in India but isprevalent in China and Vietnam.

INSTITUTIONAL STATUS OF ISM IN INDIA ANDOTHER SOUTH EAST ASIAN COUNTRIES

IndiaThere are at present more than 0.5 million listedpractitioners of Ayurveda, Unani and Siddha, excludingYoga and Naturopathy. Broadly, every alternate villagein India has one practitioner of ISM. The Central Councilof Indian Medicine was established in 1970 to regulateeducation and standardize professional practice. Threeseparate research councils for the disciplines of Ayurvedaand Siddha, Unani, Yoga and Naturopathy under theSocieties Registration Act were set up from March 1978onwards to conduct research on fundamental andapplied aspects. These are fully financed by theDepartment of Indian Systems of Medicine, Governmentof India. The Drug and Cosmetic Act was modified in1970 to regulate proprietary and classical preparationsof Ayurveda, Siddha and Unani. The pharmacopoeialaboratory at Ghaziabad, UP, working under thePharmacopoeia Committee of the Government of India,supervises quality control measures. Recently, apharmaceutical corporation for ISM has becomefunctional at Haldwani, UP.

Currently, India has about 14,000 dispensaries, 2300hospitals and 8000 pharmacies of ISM. The majority ofthese (90 per cent) practice Ayurveda. Altogether, 180institutes impart training — 30 are postgraduate institutes,two are national institutes.

ISMs offer diverse services and are to be found largely inrural rather than urban areas. They are operated by boththe public and private sector.

Apart from India, other countries like Bangladesh,Myanmar, Nepal, Sri Lanka, and Thailand have a largenumber of ISM practitioners and training institutions oftraditional medicine, especially Ayurveda.

Sri LankaThere is a separate Ministry of Indigenous Medicine witha Department of Ayurveda and the Sri Lanka DrugsCorporation. The Department of Ayurveda includes theAyurvedic Medical Council, Ayurvedic Research

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FACILITIES AND SERVICES UNDER INDIGENOUS SYSTEMS OF MEDICINE

V.N. Pandey



Committee, Ayurvedic Education and Hospital Board andAyurvedic Drugs Formulatory Committee. There are sixherb gardens and 42 Ayurvedic hospitals at the district levelin rural areas. The Bandarnaika Memorial AyurvedicResearch Institute at Colombo undertakes higher educationand training. A department of Siddha Medicine has beenestablished in the University of Jaffna.

BhutanMost traditional Bhutanese physicians practice theTibetan system of medicine. At the Tibetan School ofMedicine established at Dharamshala in HimachalPradesh in India, 30 students are given four years trainingin Tibetan medicine. There is a small dispensary atThimphu where medicines are prepared from raw drugsavailable in Bhutan, and dispensed. The indigenoussystem of medicine in Bhutan is a modification of theindigenous system of medicine in India. Many Lamasstudy Ayurvedic literature in Tibetan monasteries; theirphysicians are called Tonsa.

METHODS OF TREATING DRUG DEPENDENTDISORDERS: AYURVEDA, YOGA, UNANI, ANDNATUROPATHYIt has been seen that various treatment centres apply thetechniques of Yoga and Naturopathy successfully, as partof allopathic treatment and relaxation therapy.Simultaneously other ISMs especially Ayurveda, Siddhaand Unani can also provide beneficial effects in theprevention and cure of drug addicts. Their use in thetreatment of drug addicts is easily accessible to all, andcheap as well. Unlike allopathic treatment, alternativesystems of medicine have few side effects. However, nosystematic approach to the problem has been worked outand most of these systems have been used in conjunctionwith each other.

AyurvedaThe problem of addiction was recognized by Ayurvedicpractitioners very long ago. Characterized as Madatyaya(Panatyaya), this was sub-classified into four stages —Panatyaya, Parmada, Panajeerna and Panavibhrama. Theapproach from the Vedic period onwards has been to treataddiction through ‘Satvavajaya’ (psychotherapy) andPanchakarma therapy (five purificatory measures), alongwith selected drug preparations.

The system of Ayurveda outlines the problem of drug abuseunder the Tridoshas (3 humours) and Srotodusti (micro- aswell as macro-channels). It has been argued that theultimate manifestations of the Sapta-Dhatus (Rasa, Rakta,Mans, Moda, Asthi, Majjia and Shukra) contain less ojas.Different schools of Ayurveda have variations in theirtreatment of drug abuse. Some others prescribe Sadvritpalan

(personal hygiene), dietic regimen, precautions for seasonalvariations, and seasonal alternatives to provide overallsolutions.

The above contentions can be summarized as part ofSatvavajay (socio-psychotherapy) and Yuktivyapashrayachikitsa (medical measures clubbed with single andcompound preparations specifically designed for thispurpose).

Select treatment suggestions: Mentions of treatment forspecific abuses in the classics are scattered andindividualized. Certain studies have been made and theseshould be disseminated among addicts. The treatment canbe rendered both through OPD (out-patient departments)and through a resident scheme. Here are a few examplesof treatment:l Kairala tail, Madhuyasti, Anutaill Shirodhara (Dharakalpa) Takra Dhara, Amalki,

Kashyaya, Yastimadhu tail, Brahmi taill Pizhinchil (Karaliya method)l Aswagandha Skrirpakal Bastil Drugs:

a. Panak, e.g. Imali, Anardana, Kakam, Falsab. Amla Takra, e.g. Amla Tandra, Panir ka Pani (Phate

doodh ka whey) Khajoor, Munakkac. Nimboo and Nimboo preparationsd. Hepato-protective drugs of Ayurveda (Kutaki,

Kakamanchi, Rohitak, Kasani, Amrita, Bringraj)l Medya Rasayana Ashwagnadha, Mandukparni, Vacha,

Shankhapushpi, Brahmil Virechan (according to requirements of the patient)l Single drugs [Ashwagandha, Shankhapushpi,

Jatamansi, Yastinadhu, Brahami, Shatavari Vishmusti,Parasik Yavani, Hingu, Rai, Souf (seeds), Sua (seeds),Vacha, Tulsi Mangari, Kapi Kacchhu, Sarpagandha,Shivpriya, Dasuharidra]

l Compound drugs (Saraswat Churna, Brahmi Ghrita,Brahma Rasayan, Kalayan Ghrita)

l Aahaar (Diet) [Ojovridhi aahaar, e.g. milk, Mung,Parushak (Falsa) Kapitha, Dadim, Khajur, Amala,Munakka, etc.]

Unani and TibbiThe Unani system of medicine has been prevalent in Indiafor centuries. The system advocates a simple and balancedway of life and the medicines used for treatment of drugabuse are mostly from natural sources. The Unani systemrecognizes the influence of surroundings and ecologicalconditions on the state of people’s health, and lays greatstress on keeping water, food and air free from pollution.Certain selected measures for treatment of narcoticaddiction are discussed below.



Domiciliary Treatment:Majoon, Hilteet, Abhal, Junds Bedastar, Fil Fil Siyah,and sugar, 3 parts of the total weight; 6 gm two times aday with Joshanda of Darchini 6 gm, water 180 ml.Hub-e-Zahar Mohra, two pills two times a day. Afiunand RaswathHub-e-Jidwar 2 pills with Kameera-e-Gauzaban JidwarOod-e-Saleeb wala 6 gm. Rogan-e-Badam — massageon cervical and dorsal vertebrae. Aab Zan, with hotsalt water (external hot water bath), Saboos-e-Isphagul,6 gm at bed time.

YogaYoga can very successfully act as a complement to anysystem of medicine and has been used to treat drug addictsin many cases. It helps to strengthen the individual’s willpower and self-esteem, and lends them a sense ofdiscipline.

Cleansing processes such as Jalneti, Vastra-Dhauti, Kuijal,Sutra Neti, Shankh Prakshalan, etc., are generallyprescribed to all drug addicts. The purpose is to keep thesystem internally clean, and the yogic cleaning processhelps to eliminate toxins produced within the system. Theentire alimentary canal from the mouth to the rectum isthoroughly cleaned, and this can also reduce the severityof withdrawal symptoms experienced by the addict.

Selected asanas are advised, depending on the addict’sage and physical condition. Some 84 asanas are found tobe effective, including Tarasan, Padmasan, Sidhasan,Bhujangasan, Dhanurasan, Pawan Muktasan,Gomukhasan, Gorud Asan, Sankatasan, Vajrasan, Kagasan,Dhruwwasan, Padangusthasan, Urdha Sarvargasan, andShalabhasan. These help to tone up the nervous system,and exercise all the joints and muscles of the body and themovement of the spine in all the four directions—forward,backward, right and left.

Pranayama, i.e. regulation and control of breath is a veryuseful technique. Sitali, Sitkari, Ujjai and Lom Vilam aresome of the Pranayams advised to addicts, but must beperformed under expert guidance.

Meditation is another very effective means of keepingoneself quiet and peaceful. If taught under expert guidanceit may lessen the severity of withdrawal symptoms andhelp the addict in dealing with psychological andpsychosomatic problems.

Nature cureNature cure treatments are hospital based and last fromabout four to six weeks. The hospital should have a naturaland encouraging environment, which helps the patient to

recover faster. Patients are under the direct care andsupervision of Naturopathy physicians. Group meetingswith family members and friends are arranged to educatethem during the treatment and follow-up periods. Furtherprogress is monitored through OPD follow-up.

Nature cure camps for 30 days can also be conducted atvarious places. The principle of treatment for all types ofdrug addiction is the same but may vary from patient topatient, depending on the withdrawal symptoms. Thereare three stages:l Detoxification stage—mild and extensive cleansingl Soothing stagel Constructive stage.

General line of treatment: The general nature cureprocedures adopted in treatment of drug addicts are asfollows:l Colon cleansing — Mud packs and colon

irrigations. (Hot, cold, luke-warm, or hot and cold alternate,as may be required)

l Hip Bathsl Sitz Baths — Hot or cold or alternate, they

produce wide-ranging effectsdepending upon duration andwater temperature.

These measures stimulate the elimination processes andalso tone up the nervous system. Several types ofhydrotherapy measures are also employed to inducedifferent physiological and therapeutic effects.

OtherChromotherapy can also be used to treat drug addicts. Blue,green and brown (yellowish red) colours are employedaccording to the patients’ condition; charged water, sugarsand oils are also used. Blue is used for nervous conditionsand for cooling effects; green for sedative effects and brown(yellowish red) for stimulating effects and as a pain killer.Glasses, lamps and clothing of different colours may alsobe employed. For body aches, pains, cramps, depression,fatigue and many other conditions, hand, belt and vibratormassage can be employed to considerable effect.

Deep breathing procedures are very useful for drug addicts.This helps not just the respiratory system, but can alter themental condition of the addict in beneficial ways. Jogging,walking, jumping, running and physical exercise is alsoadvised.

General body building and hygienic measures,psychotherapy, spinal manipulations, reflexo-therapy, sunbaths, mud baths etc. are employed according to



requirements. In about 30-40 days, addicts who haveundergone this line of treatment tend to adapt themselvesto the natural way of life. Many find it easier to regulatetheir day-to-day activities on a normal and natural basis.

ISM’S FUTURE ROLEWhile discussing the acceptance of the role of ISM and itspractitioners in the treatment of dependence disorders thefollowing guidelines are suggested:

l ISM systems may be accepted as they stand.l Popular practices from ISM may be assessed and then

accepted.l The specific areas which have gained prominence in

ISM may be allowed to constitute the specializedcomponent of the medical care of such patients.

l The specialities of ISM systems of medicine should bepractised where modern medicine is unable to makeany headway.

REFERENCES:1. Bedi, Ramesh (1972). ‘Herbal Wealth of Bhutan’. Visit

report, November.2. Bulletin NY. Acad. Med. 72: 646. Supplement 2, 1995.3. Charak (1949). The Charak Samhita, 6 vols., trans. Shri

Gulab Kunverba Ayurveda Society, Zam Nagar.4. Chopra, Pawan (1992). ‘A Report on Participation in

the 3rd International Ayurveda Conference at Bali,Indonesia, 3-6 September’.

5. Gajandeera, Chandrasi (1995). Sri Lanka country paperpresented at the 4th international conference on globalhealth through the Ayurveda challenge for the 21stcentury. Colombo, 29 November.

6. Gupta, O.P. (1987). ‘A Report on Consultancy onMedicinal and Aromatic Plants’. Report on researchunder technical programme, Hanoi, 4-16 September.

7. Pandey, V.N. (1988). ‘A Report on Participation in the1st World Conference on Oriental Medicine and Yogaat Bangkok, Thailand, 22-29 May’.

8. Razzack, M.A. (1986). ‘Principles and Practices ofTraditional Systems of Medicine in India’. Paperpresented at the consultation on the promotion anddevelopment of traditional medicine by WHO,Geneva, 29 November - 2 December.

9. Saxena, Shobha (1997). ‘Psycho-social Implications ofDrug Addiction: Multi-pronged Prevention StrategyNeed of the Hour’. Paper presented at the internationalconference on global health law, New Delhi, 5-7December.

10. Sharma, Vd. Hari Narain (1967). Astang HridayamNirnai. Sagar Press, Bhaidaini, Varanasi.

11. Shastri, Ambika Datt (1987). Sushruta SamhitaChaukhambha, trans. Sanskrit Series, Varanasi.

12. WHO (1997). SEA Trade Med. Annex. 8: 33.


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