Out-patiesnt treatment of opium addicts: report of a pilot proj ect in Shiraz

Sections

The setting of the project
Addict population and the treatment cohort
The method of treatment
Findings and outcome of treatment
Findings and outcome of treatment
Acknowledgement
Bibliography

Details

Author: M.R. MOHARRERI,
Pages: 31 to 39
Creation Date: 1976/01/01

Out-patiesnt treatment of opium addicts: report of a pilot proj ect in Shiraz

M.D., M.R. MOHARRERI,
Assistant Professor of Psychiatry, Pahlavi University and Regional Officer of Drug Addiction and Rehabilitation Services, Ministry of Social Welfare, Shiraz, Iran

Traditional methods of treatment relying on hospitalization and intensive medical care have proved unsatisfactory in terms of outcome; they also require an interruption in the ordinary social and economic activities of the addict. The general unavailability of physicians and in-patient treatment facilities in developing countries make such an approach to the problem of addiction even more impractical. In view of these practical problems experiments with short-term in-patient and/or long-term out-patient treatment methods are of particular value for the development of necessary supportive services in developing countries. The present study outlines the results of such an experimental programme launched in a provincial city, Shiraz, in Iran.

The nature and extent of narcotic addiction in Iran has been reviewed by Azarakhsh (1972) and Mclaughlan and Quinn (1974), who found that the main problem was opium addiction. Moharreri and Mehryar (1975a) presented a detailed historical account of the development of opium addiction in Iran and current medico-legal aspects. As an indication of the extent of the problem it may suffice to note that there are over 170,000 officially registered opium addicts in this country of whom over 50 per cent are below the age of 60. This figure, which corresponds to over 50 per 10,000 of Iran's total population, is believed to represent only between one-third to one-half of the real number of the addict population. The magnitude of the problem of providing treatment facilities for these addicts may be better illustrated by reference to the fact that the total number of medical doctors authorized to practise psychiatry is under 120; and of this number over 80 per cent live in Tehran. Moreover, in 1974 there was only one hospital, located in Tehran, specializing in the treatment of drug addiction.

The setting of the project

Shiraz is the administrative capital of the southern province of Fars and has, over the past decade, enjoyed one of the highest rates of urban growth in Iran. With its long-standing reputation as one of the main centres of Iranian civilization, the city has re-established its scientific and cultural leadership by founding a modern university of national and international reputation (Pahlavi University) and by organizing the annual Shiraz Arts Festival. The population of the city which was around 270,000 in 1966, is estimated to have reached 370,000 by 1975. Besides being the administrative and economic city of the Fars Province (population over 2,000,000), Shiraz has developed into one of the main centres of Iran's growing tourism industry. Recent years have also witnessed considerable investment in the electronic and related industries in Shiraz by the Iranian Govern- ment, which is bound to bring about a drastic change in the traditional set-up and occupational activities of the population of this city. All in all, this is a rapidly growing urban centre where mental health and addiction problems are bound to follow an upward trend.

Addict population and the treatment cohort

The number of officially registered opium addicts in Shiraz city was just over 7,000 in 1974. Of this number, over 53 per cent were below the age of 60, and were under the obligation to seek treatment for their addiction. The total number of opium addicts is estimated to be between 15,000-21,000. During the period covered by this study (August 1973-April 1975), 533 cases were seen by the author in one of the three main out-patient treatment facilities with which he is associated:

  1. The Mental Health Clinic of the Provincial Health Department run by the author on a three days per week basis. Patients attending this clinic mainly belong to economically lower income groups seeking free treatment.

  2. A private psychiatric clinic (in the evenings) catering mainly for upper and middle class income groups who can pay for their treatment.

  3. A part-time clinic run by one of the university hospitals, Hafiz hospital, which attracts mainly students, employees of the university and government employees covered by existing health insurance schemes.

The Treatment Team consisted of the following personnel: one psychiatrist (director of the project); two psychiatric residents in their second year of residency; five health-corps workers-young women with a degree in psychology who are trained and required to spend about two-thirds of their military service working with the public health department. They were responsible for interviewing the patients and filling out questionnaires reported on elsewhere (Moharreri and Mehryar 1975b). One assistant social worker (female) who, in collaboration with the health-corps workers helped with the preparation of case reports, the collection of data, the follow up, and supervision of patients. One assistant pharmacist for handling prescriptions, and other hospital staff, as required. It should be noted that all the personnel listed above combined working on this project with their other day-to-day duties.

The method of treatment

It consisted of the following sequence of activities:

  1. Interviews with patients and taking case histories.

  2. Selection of cases for out-patient or in-patient treatment on the basis of information collected in stage 1.

  3. Preparation of the patient for out-patient treatment by motivating him for and giving him guidance on the problems and process of treatment.

  4. Establishment of a drug regimen. The drugs used were either methadone or an "opium pill" developed by the Iranian Ministry of Health. The latter contains opium extract (80 mg) and Largactil (Chlorpromazine, 8 mg). The dosage varied according to the type, severity and duration of addiction and in some cases starded with up to 30 "opium pills" or 120 c.c. of methadone per day. Reduction of the dosage was gradual but flexible, its amount varying according to the established need and tolerance of each case. Duration of therapy was between 40 to 60 days.

Regular contact with patients was maintained throughout the treatment period. Simple psychotherapy of a supportive nature was offered by women of the health corps. In some cases it was continued for six months. Patients were followed up regularly after the termination of drug treatment. This was done either through visits to clinics by patients at given intervals or through home visits by the assistant social worker. A major difficulty in this respect was that some patients had given false or incomplete addresses. During follow-up visits, a forty-item questionnaire detailing the course of post-treatment adjustment was filled in for each patient.

No side-effects were observed in cases treated with methadone. In cases treated by "opium pills", however, dry mouth, constipation, and other side-effects usually associated with Largactil use were not uncommon. Psychotropic drugs were prescribed whenever indicated, either to deal with the psychological effects of withdrawal or to counterbalance the physical side-effects of the "opium pill". Some inevitable abuse and black marketing of prescribed drugs were also noted and immediately dealt with.

Findings and outcome of treatment

During the period of this study 533 cases were seen. Of these, 186 patients completed the prescribed course of treatment. The were considered as "successfully treated" cases Of the remaining 347 cases treatment had to be terminated in 20 cases because there was evidence that medication was misused for black marketing or trafficking in opium. In 65 cases (12.2 per cent), addicts who had an appointment did not turn up and treatment did not start. Another 54 cases (10.1 per cent), admitted to treatment shortly before the follow-up, did not complete the prescribed treatment procedures. Seventeen cases could not be traced for follow-up. Leaving these cases aside, there were 191 cases where treatment did not seem to be successful; it had to be discontinued. This number corresponds to 35.8 per cent of the original group and is slightly higher than the number of cases (186 = 34.9 per cent) that are considered to have been successfully treated. Table 1 summarizes the maintenance regimen used with these two groups. The main point of interest in table 1 is that a slightly higher proportion of addicts treated by the "opium pills" is found in the successful group. The success rate is highest among the small group treated with a combination of "opium pills" and Methadone.

Socio-economic characteristics of the successfully treated group are presented in tables 2 to 5. In these and the following tables the three sub-groups treated in different facilities are presented separately. From table 2 it would appear that the majority subjects are young, only 23 (12.4 per cent) of them being over 50 years old. Tables 3 and 4 indicate the low socio-economic status of the majority of subjects. This is in line with other evidence on the socio-economic characteristics of opium addicts in Iran (Mehryar and Moharreri, 1975a). In this context the differences between the groups using different treatment facilities are also of interest. The large proportion of married subjects (table 5) tends to confirm the general observation that opium addiction does not necessarily lead to a disruption of family life in Iran.

Tables 6-10 summarize information pertaining to the addictive behaviour. From table 6 it would appear that the majority of cases are opium addicts, the rest being dependent on the "opium pill", heroin, other mixtures and the opium derivative known as Shireh (= extract) in Iran. This is obtained by boiling the residue of smoked opium which accumulates inside the pipe. Only a small minority are reported as heroin addicts (5.9 percent) or dependants on "opium tablets" (4.8 per cent) used for the gradual withdrawal from opium. As to the mode of drug use (table 7), swallowing (45.16 per cent) and smoking (38.71 per cent) or an alternation of both (15.59 per cent) appeared to be the predominant ways of taking the drugs.

TABLE 1

Method of treatment used with success (N=186) and without success (N=191) in the two groups of addicts treated in Shiraz

 

Drug used

 

"Opium pill"

Methadone

"Opium pills" + methadone

 

Number

Percentage

Number

Percentage

Number

Percentage

Treatment successful (N = 186)
117 62.90 47 25.27 22 11.83
Treatment unsuccessful (N = 191)
116 60.73 59 30.89 16 8.38
TOTAL N = 377
233 61.80 106 28.12 38 10.08

TABLE 2

Age distribution of drug addicts treated in the three different settings in Shiraz (N=186)

 

Age group

Clinic

19 years

20-29 years

30-39 years

40-49 years

50-59 years

40 + years

All ages

Public health
2 23 13 12 3 0 53
University hospital
0 28 27 39 8 1 103
Private
0 0 10 9 10 1 30
TOTAL
2 51 50 60 21 2 186

TABLE 3

Educational status of drug addicts treated in the three different settings in Shiraz (N=186)

 

Educational status

Clinic

Illiterate

Elementary school

Secondary school

Higher education

Public health
19 20 13 1
University hospital
26 42 25 10
Private
5 11 10 4
TOTAL
50 73 48 15

TABLE 4

Occupational status of drug addicts treated in three different settings in Shiraz (N=186)

 

Clinic

Occupation

Public health

University hospital

Private

Total

Unspecified
0 2 0 2
Unemployed
3 3 1 7
Retired
0 3 0 3
Farm workers, shepherds, etc.
5 14 6 25
Labourers, janitors
10 15 1 26
Skilled workers, artisans
17 15 5 37
Business
10 18 6 34
Government employee (professional)
5 30 6 41
Student
1 1 3 6
Housewife
2 2 2 6
TOTAL
53 103 30 186

TABLE 5

Marital status of drug addicts treated in three different settings in Shiraz (N=186)

 

Marital status

Clinic

Unknown

Single

Married

Separated

Widowed

Public health
1 21 29 1 1
University hospital
2 15 82 4 0
Private
1 8 19 2 0
TOTAL
4 44 130 7 1

TABLE 6

Type of addictive drug used by a group of addicts treated in three different settings in Shiraz City (N=186)

 

Type of addiction

Clinic

Opium

Shireh

Opium and shireh

Opium pill

Heroin

Other mixtures

Public health
25 12 3 5 5 3
University hospital
68 21 4 4 5 1
Private
23 5 0 0 1 1
TOTAL
116 38 7 9 11 5

TABLE 7

Mode of drug use by addicts treated in three different settings in Shiraz (N=186)

 

Method

Clinic

Unknown

Swallowing

Smoking

Swallowing and smoking

Public health
0 11 32 10
University hospital
1 70 18 14
Private
0 3 22 5
TOTAL
1 84 72 29

TABLE 8

Frequency of drug intake (per day) in a group of opium addicts treated in three different settings in Shiraz (N=186)

 

Frequency of drug intake per day

Clinic

Unknown

Once

Twice

Three times

More than 4 times

Public health
0 1 10 38 4
University hospital
1 12 34 49 7
Private
1 6 9 13 1
TOTAL
2 19 53 100 12

TABLE 9

Duration of addiction in a group of opium addicts treated in three different settings in Shiraz

 

Duration of addiction in years

Clinic

Unknown

<2

2-5

6-10

11-15

More

Public health
1 18 17 11 4 2
University hospital
2 19 35 29 9 9
Private
0 13 10 5 1 1
TOTAL
3 50 62 45 14 12

From table 8 it would appear that the majority of subjects (53.76 per cent) have been taking drugs three times a day; a smaller proportion (28.49 per cent) admit taking drugs twice a day. Table 9 indicates that the majority of subjects have been addicts for less than five years. This is not surprising in view of the relative youthfulness of the group (table 2). Only 14 per cent of subjects have reported an addiction history extending for over 10 years.

The distribution of addicts according to the daily cost of addiction is given in table 10. From this table it would appear that for the majority of subjects (55.38 per cent) the daily cost of opium has been between 1 to 3 US dollars. Usually Shireh is more expensive than opium and heroin costs more than either opium or Shireh.

Information on the duration and outcome of treatment is summarized in tables 11-13. From table 11 it would appear that in a large majority of cases treatment lasted for less than six weeks. Despite this relatively brief duration of treatment, the majority of subjects regarded as successfully treated had not reported any signs of relapse at the time of follow-up. The time interval between the termination of treatment and follow-up varied from less than 4 weeks to over six months (table 12). Of the small group of 21 who had relapsed at the time of follow-up (table 13), 3 had been treated by methadone, 14 had been treated by the "opium pill" and 4 by a combination of the two. Thus, there would seem to be some difference between methadone and the "opium pill" in terms of the probality of later relapse

TABLE 10

Distribution of addicts according to daily cost of addiction

 

Daily cost of addiction (in rials)

Clinic

Unknown

50-200

201-500

501-1501

Public health
2 24 22 5
University hospital
9 60 32 2
Private
0 19 9 2
TOTAL
l1
103 63 9

*$1.0 = 67-70 rials.

TABLE 11

Duration of treatment in a group of opium addicts treated in three different settings in Shiraz

 

Duration of treatment (days)

Clinic

Unknown

<15

16-30

31-44

45-60

More than 61

Public health
5 2 10 2 18 6
University hospital
0 6 19 30 20 28
Private
0 5 11 9 4 1
TOTAL
5 13 40 51 42 35

TABLE 12

The time interval between termination of treatment and the follow-up

 

Time lapse between treatment and follow-up (days)

Clinic

Unknown

<30

31-60

61-90

91-180

More than 181

Public health
12 14 1 6 7 13
University hospital.
1 11 12 6 9 64
Private
2 9 16 3 0 0
TOTAL
15 34 29 15 16 77

TABLE 13

Rate of relapse among the group of opium addicts treated by methadone and "opium pill"

 

Methadone

Opium pill

Methadone + pill

 

Number

Percentage

Number

Percentage

Number

Percentage

Relapse
3 6 14 12 4 8
No relapse
44 94 103 88 18 92
TOTAL
47 100 117 100 22 100

Findings and outcome of treatment

Being the first report on the outcome of out-patient treatment of opium addiction in Iran, the findings of this report should be viewed as being only descriptive and provisional. In view of the lack of any well-defined experimental control over the selection of cases for treatment and the use of different maintenance regimens, the results can hardly be generalized or compared with the outcome of other treatment programmes.

Despite these limitations, the findings may be of interest both in terms of presenting descriptive data on a segment of the addict population in this country and for indicating the feasibility of short-term out-patient treatment of opium addiction. The latter indication has been encouraging enough for the author and his colleagues to have induced them to embark upon an expanded and more rigorous application of methadone maintenance in this part of Iran. It is hoped that the results of this expanded programme will cast further light on the course and outcome of treatment of opium addiction in Iran.

Acknowledgement

The preparation of this paper was partially supported by a research grant from the Research Council of Pahlavi University. The author is also grateful to his colleagues in the Department of Psychiatry, Pahlavi University Medical School-especially Drs. M. Behin and M. Haj-Mohammadi for their ungrudging support of and collaboration with the treatment programme described in this report. The technical assistance of the Director and staff of the Pahlavi Population Centre in the preparation of this report is also gratefully acknowledged.

Bibliography

Azarakhsh, H., "The nature and extent of drug abuse in Iran". CENTO seminar on Public Health and Medical Problems involved in Narcotic Drug Addiction. Tehran: Central Treaty Organization, 1972.

Blum, R. H., ed., Society and Drugs. San Francisco, Tussey-Bass Inc., 1970.

McLaughlin, G.T. and T.M. Quinn, Drug Control in Iran: A Legal and Historical Analysis. Iowa Law Review, 1974, vol. 59, No. 3, pp. 469-524.

Mehryar, A. H. and M.R. Moharreri. Some socio-demographic characteristics of of registered opium addicts in Fars Province. Shiraz: Pahlavi Population Centre, 1975a (mimeographed, in Persian).

Hoharreri, M.R. and A. H. Mehryar. Opium Addiction in Iran. Shiraz: Pahlavi Population Centre, 1975a (mimeographed).