Treatment options in responding to drug misuse problems
Making and maintaining contact with drug misusers
Treatment and rehabilitation strategies
Intervention to achieve changes in life-style
Intervention to treat medical complications associated with drug misuse
Treatment in prisons
Social reintegration strategies
Author: E. TONGUE , D. TURNER
Pages: 3 to 19
Creation Date: 1988/01/01
D. TURNER Standing Conference on Drug Abuse, London, United Kingdom of Great Britain and Northern Ireland
Reducing both the supply of and demand for drugs is a major theme in efforts to control the drug problem. It is essential to recognize that demand-reduction efforts are critical to enable supply-reduction efforts to have realizable goals. The initial goal of any intervention must be the limitation of harm to the individual and society. The primary goal is to reduce the prevalence of drug misuse within the community. The provision of a wide range of integrated approaches is essential if demand-reduction programmes are to be successful in contacting drug misusers, maintaining that contact and successfully assisting the individual through treatment, rehabilitation and social reintegration. The article summarizes the more common approaches to the treatment, rehabilitation and social reintegration of drug-dependent persons.
Reducing both the supply of and demand for illicit drugs has become a major theme in the efforts to control drug problems. The International Conference on Drug Abuse and Illicit Trafficking, which was held at Vienna in June 1987, adopted a Comprehensive Multidisciplinary Outline and a Declaration in which the essential balance between the two elements was emphasized [ 1] . This balance between the relative importance of supply and demand reduction has not always been emphasized, however. At the national and international levels, over the years, supply reduction has consistently been the foremost concern. There is no reason to suppose that it will not re-emerge as the predominant theme as concern grows about the links between illicit drug trafficking and terrorism, international financial dealings and arms supply. It is important, however, to recognize that demand-reduction efforts are essential to enable supply-reduction efforts to have realizable goals.
Reviewing patterns of drug misuse over the last 25 years, it is clear that, as control is achieved over one drug new drugs emerge as drugs of misuse. The regular addition of new drugs controlled under either the Single Convention on Narcotic Drugs, as amended by the 1972 Protocol [ 2] or Convention on Psychotropic Substances 1971 [ 3] is indicative of the rapid emergence of alternatives to controlled drugs as drugs of misuse.
Demand-reduction programmes must inevitably respond to drug problems as they appear. For instance, the control of six amphetamine-like substances was considered by the Commission on Narcotic Drugs every year from 1955 to 1962. Only in 1969, after consistent pressure from the Government of Sweden, supported by the Governments of the United Kingdom of Great Britain and Northern Ireland and the United States of America, and because of the health and social problems caused by these drugs was the adoption of a resolution calling for effective international controls on these substance [ 4-6] .
If the efforts to reduce the supply of and demand for drugs are a response to emerging and identified problems, it is inevitable that the initial goal of any intervention must be the limitation of harm to the individual, society and the international community. The elimination of drug problems, while properly the ideal, is a goal that has been and will continue to be frustrated by the emergence of new drugs. Demand reduction therefore has a major role to play as a means of limiting the growth of drug problems and reducing the harm caused by drug misus [ 7-12] ..
Within the efforts to reduce demand, there are different intervention strategies. These may be aimed at reducing: (a)the number of new recruits to drug use; (b)the harm that may be caused by drug use to the individual and society; and (c)the number of drug users within the community. Each of these strategies has a vital role to play, and no single one can be given the prime responsibility because they are interdependent.
Efforts to reduce the harm caused by drug misuse and to reduce prevalence of drug problems may be placed in three main categories:
Making and maintaining contact with drug misusers;
Treatment and rehabilitation strategies;
Social reintegration strategies.
In the development of demand reduction strategies, it is important to make an assessment of the nature and level of drug problems within a given community. This may be done through surveys and research or through a review of available indicators such as drug-related overdoses, drug users that come to the attention of the authorities, and arrests of drug offenders. Knowledge of patterns of drug misuse provide a basis for targeting intervention strategies, reducing the likelihood of limited resources being misdirected. For instance, the occasional use of psychotropic substances may require concentration on preventive education, accurate information about drugs in order that occasional users might limit harm to themselves and others and outreach work, which can provide advice on the avoidance of particularly harmful practices such as intravenous injection.
The concepts of treatment, rehabilitation and social reintegration have come to imply particular intervention approaches. Treatment is commonly viewed as a medical intervention through the use of substitute drugs, detoxification or the use of other medical approaches. If the goal of treatment is to assist the individual to achieve control over her or his drug use problem, a range of non-medical approaches are equally applicable. For some drug misusers, rehabilitation and social reintegration imply a process of restoration to the state prior to the onset of drug misuse. It is important to recognize that, for many persons, it will be a process of rehabilitation and integration, that is, creating new circumstances and ways of living that the individual has never experienced before. It is perhaps here that one of the major differences between drug and alcohol interventions can be most readily seen. Drug misuse most commonly affects young people with little experience of life. Alcohol problems more commonly affect adults, who have already substantial experience of life, including that relating to employment and personal relations. Thus, for adults, rehabilitation and social reintegration are a process of restoration, but, for drug misusers, there is a need to identify means of supporting new ways of living and of dealing with new experiences without resort to drug use [ 10-12] .
Given the relative immaturity of drug misusers and the predominantly youthful drug misusing population, it may be argued that all identified drug misusers should be taken into treatment compulsorily. It may also be argued that, for the protection of the community, drug misusers should be removed to limit the likelihood that they will draw others into drug misuse. There have been different experiences with compulsory treatment, which may in part be because of the different goals established for compulsory treatment interventions. For instance, the arrest and imprisonment of drug misusers commonly involves the compulsory detoxification of the misuser. Experience has shown, however, that if no other intervention strategy is employed, the individual rapidly returns to drug misuse on release from prison. Where the goal of the intervention strategy is abstinence from drugs, treatment and rehabilitation is most effective when the misuser wishes to achieve abstinence. Without this desire or motivation to change, temporary benefits may be gained by the individual and the community, but relapse into drug misuse is likely to follow rapidly after discharge from compulsory treatment. Thus, intervention strategies must not only offer the techniques of treatment, rehabilitation and reintegration but also stimulate the desire of the drug misuser to change [ 10] .
A common experience in services dealing with drug misusers is that the individual returns to drug misuse after the completion of treatment. It is at times argued that this represents a failure of the services to reduce the level of drug misuse within a community. The corollary is that emphasis should therefore be placed on supply reduction because of the ineffectiveness of demand-reduction approaches. Such arguments are false, however. It would be as valid to argue that supply-reduction approaches should be abandoned because, despite the resources devoted to this area, the supply of drugs has continued to grow. Drug misuse is an activity that can dominate the interests and concerns of the individual to the exclusion of all other considerations. In such circumstances, it is not surprising that a number of attempts to achieve control over drug misuse may be necessary before the individual has sufficient personal and emotional strength to regain independence from drugs. For some, this may require intervention strategies that are in the first instance aimed at containing drug misuse and reducing the involvement of the misuser in criminal and anti-social behaviour. For others, it may involve temporary removal from the community to provide a safe setting, away from the temptation of drugs, where living without drugs can be experienced. A growing body of evidence on relapse and relapse prevention shows that, while a drug misuser may return to drug misuse after treatment and rehabilitation, this is for many a temporary phase. If relapse is seen as any return to illicit drug use, then treatment and rehabilitation may be regarded a failure. If a longer view is taken, however, the evidence strongly supports the view that, after a period of six months or more of contained drug use or abstinence, relapse is greatly reduced and return to chaotic drug misuse is minimized [ [ 8] , [ 9] , [ 13] , [ 14] ].
Current treatment approaches and methods exist that are applicable in most countries. They include methods for treating individuals who display alterations in mood, perception and thinking processes as well as methods for modifying the client's environment. Often therapeutic activities are designed to influence the client's family, her or his home and social situation and/or the required vocational or educational skills. As a result of these approaches, certain facilities, such as hostels and half-way houses, have been utilized in some countries, and various disciplines, such as psychiatry, general medicine, psychology, sociology and social work, education, industrial rehabilitation and vocational guidance, have been brought together in a holistic concept of treatment. Recently, it has been realized that it is difficult if not impossible to separate the concepts of treatment and those of rehabilitation.
Several approaches to the treatment of drug-dependent persons exist within the holistic concept. Each of the professional disciplines concerned with drug dependence has its unique approach to treatment, and it therefore seems that the most effective approach to treatment is an interdisciplinary one. Given that intervention strategies require a range of approaches and involve interaction between the drug misuser, family, culture and community, it is inevitable that no one approach, agency or profession can or should have a monopoly on expertise or the provision of services. A range of disciplines and expertise are required, from medicine to education and training for employment. In this, the family, community groups, religious organizations and self-help organizations have played an important role through the support they have been able to offer both to intervention strategies and to the individual drug misuser. Where community action has been mobilized in the effort to reduce the demand for drugs, prevention, treatment, rehabilitation and social reintegration have all benefited. Because drug misusers inevitably come into contact with a range of services, voluntarily or involuntarily, it is important that these services are able to offer appropriate interventions. In some instances, the interventions are provided by governmental services, for instance within the national health care system or in prisons; in others, they are provided by non-governmental or private organizations. If demand-reduction strategies aimed at reducing the harm to the individual and society are to be effective, it is essential for the services to be available to the individual when she or he needs them. These services should be provided at an easily accessible place and should not be restricted according to the ability of the individual to pay for them [ [ 7] , [ 8] , [ 9] , [ 15] , [ 16] ].
Modalities of treatment may differ in different parts of the world depending on the socio-cultural environment, the type of drug or drugs used and other factors, such as age, sex, religion and employment statu [ 17-20] .
The general concept of treatment could be defined as: (a )a process of crisis solving intervention; and (b) a process to introduce changes in life-style.
It is essential for therapeutic activities to be well-planned, with both long-range and short-term objectives. In the absence of such objectives, the success of therapy may be seriously endangered.
Examples of long-range therapeutic goals might be:
To reduce the extent and seriousness of problems associated with the non-medical use of dependence-producing drugs;
To reduce the prevalence and incidence of drug dependence;
To improve the personal and social functioning of drug-dependent persons;
To develop an ongoing system for the continued planning, evaluation and modification of programme activities, as indicated by changing needs and the results of appraisals of the effectiveness of different policies, approaches and methods in use.
Immediate therapeutic objectives might be:
To bring drug-dependent persons into continuing contact with "helping" personnel;
To encourage those with whom contact is made to accept one or more types of help to improve their life situations;
To improve the personal and social functioning of drug-dependent persons;
To reduce the number of medical complications associated with the unsupervised self-administration of illicit drugs;
To reduce the unlawful or other socially unacceptable behaviour associated with obtaining and using drugs;
To help to reduce the diversion of licitly produced drugs to illicit channels for non-medical use;
To help to prevent the development or to reduce the extent of a black market in illicit drugs by reducing the demand for such drugs.
The broad functions to be performed in the treatment and rehabilitation of drug dependent persons are: case finding; diagnosis or case evaluation; the establishment of immediate and long-term objectives with respect to the person involved; the formulation of a management or treatment strategy, preferably with the participation of the client; the management of medical emergencies and complications associated with the basic problem; behaviour modification; the provision of rehabilitation services (medical, vocational or social); the provision of social services; the provision of continuing follow-up and after- care services; and the periodic evaluation of the effectiveness of therapeutic activities, including rehabilitation [ 8] , [ 9] , [ 21] .
It is clear that there is an overlap and interrelationship between intervention strategies. For instance, through efforts to make and retain contacts with drug misusers, treatment, rehabilitation and social reintegration strategies are all concerned with improving the personal and social functioning of the drug-dependent individual. The particular approach adopted within a given strategy is dependent upon the personnel available and the stage of the drug-using career of the individual involved. Ideally, the sequence of stages of intervention should be followed. It is entirely possible, however, that the drug misuser will make contact with the service that she or he regards as most appropriate for his or her needs at a particular point in time. For instance, an individual may, having established contact with an outreach worker, seek to enter a rehabilitation hostel. This may prove unsuccessful on the first occasion, and the drug misuser may then enter a treatment programme to control her or his drug use and to detoxify before returning to rehabilitation.
Drug misuse is a covert activity that only comes to the notice of the family and community when it has become both a personal and a public problem. The goal of "case finding", that is making and retaining contact with drug misusers, should be defined at the outset. It might be:
To identify and make contact with drug users at an early stage to limit the likelihood of social or medical complications as a consequence of their drug use;
To make contact with drug misusers who are unaware of the treatment and rehabilitation services available to them and to provide them with a link to these services;
To establish contact with drug misusers who are not yet prepared to make contact with helping services and to provide them with counselling, advice and support in order to reduce the harm which may arise from continued drug misuse.
Outreach work was first developed as a means of reaching "unattached" young people in the United States of America. It is built on the traditions of youth and community work and has now become established as an effective means of contacting disadvantaged groups. It was adapted for use with drug misusers who were seen as particularly disadvantaged and isolated from the rest of the community. In recent years, outreach programmes have been directed towards other groups of misusers such as women, the elderly and minorities.
Obviously, reaching drug misusers is the most difficult part of intervention strategies. Recently, treatment programmes have begun to experiment with aggressive outreach approaches to contact and draw misusers into treatment before they lose social and economic supports and become a serious burden to the community.
For outreach work to be effective, trust must be established between the misusers and the outreach worker. Without this, it is possible to make contact but not to retain that contact over a period of time. Outreach work also requires the trust and co-operation of other programmes concerned with drug misuse in a community, such as the police and social and health services, because there will be little if any immediate return from such intervention strategies until trust is established with drug misusers. For instance, it may take as long as six months to establish effective contact with drug misusers, and therefore no referrals to treatment or rehabilitation may be made for some time. The outreach worker, however, may be able to advise and assist drug misusers to limit their drug use and to engage in less dangerous drug misusing behaviour during this period.
Outreach work is most commonly carried out by youth workers or community nurses who have received training in providing help to people away from established centres. Such workers are commonly found in a number of European countries as well as in north America. Recently, former and current drug misusers have been recruited as outreach workers because of their knowledge and experience. Within particular communities, religious leaders and significant figures within the community have also acted as contacts with drug misusers, identifying particular needs and assisting the misusers to achieve effective contact with specialized helping services.
This form of intervention has led to the identification of new and emerging needs and community proposals for drug misuse services. Among these have been telephone counselling and advice lines, self-help groups for the parents and families of drug misusers and self-help groups for drug misusers themselves.
If outreach were a more common modality, it is likely that a much higher proportion of drug misusers would seek help. One of the most important limitations in extending outreach programmes, however, is the general lack of treatment and rehabilitation services available in most countries.
It is unfortunate that relatively little has been written on outreach work among drug misusers, as it appears to be a valuable means of promoting an effective demand-reduction intervention strategy.
Treatment and rehabilitation can be categorized as intervention designed:
To contain, control or eliminate drug misuse;
To provide changes in life-style (behaviour);
To treat medical complications associated with drug misuse.
This intervention category includes: short-term detoxification; long-term detoxification and substitute therapy or maintenance; psychiatric treatment, such as psychotherapy and psychoanalysis; and the psychological approach.
Current research suggests that there is no optimum method for detoxification applicable to all patients. It is suggested that it is most appropriate to individualize the detoxification procedure. Decisions concerning the rate of detoxification, the use of methadone or other detoxification methods, and whether detoxification should be done on an in-patient basis, whether dosing is blind or open, self-regulated or physician-regulated, cannot be generalized and need to be based on the patient's preference, on a clinical assessment of the patient's needs, and on the experience and resources of the treatment staff [ 14] .
The objective of the detoxification procedure is to provide symptomatic relief from the abstinence syndrome while physical dependence is being eliminated. As there is cross tolerance and cross dependence between all opiates, in cases of opiate dependence (e.g. heroine or morphine), any of them can be used to eliminate withdrawal symptoms and to detoxify the addicted person gradually. Methadone has been widely used in the detoxification process, particularly in the 1970s. With the discovery of substances acting as the narcotic antagonists, such as naloxone and naltrexone, these substances are now also being used in the detoxification period with reasonable success. Other pharmaceutical products, such as clonidine, have also been used by some therapists. Acupuncture has been used for detoxification instead of chemical substances, but the effectiveness of acupuncture and its potential role as a means of detoxification needs to be studied further.
The "cold turkey" method of detoxification does not involve the use of any substance to minimize the discomforts of withdrawal symptoms. For example, this method is used in Singapore, its duration being about one to three weeks. During the period of detoxification and following it, counselling and other supportive psychotherapy is necessary. It is also important to point out that supportive psychotherapy, counselling and other rehabilitative services may begin during the detoxification period. The detoxification period may last from 21 to 45 days. The majority of short-term detoxification programmes are conducted on an in-patient basis.
The substitution of illicit opiates by a licit drug, such as methadone, is used in a number of countries. As in short-term detoxification, decisions about appropriate treatment needs should be based on an assessment of the individual client and her or his particular circumstances.
Very important goals of treatment must be to keep drug misusers in contact with the service as well as to assist them to control their chaotic drug misuse and to provide them with adequate tools to function adequately within society. Substitute drug therapy (maintenance) seeks to reduce illicit drug use and its associated criminal and anti-social behaviour and to eliminate the medical complications associated with unsupervised self-administration of illicit drugs. The provision of substitute drugs permits some people to achieve stability and to concentrate their attention on resolving personal problems that had previously been resolved by resorting to illicit drug use. For example, a method of therapy has been developed in out-patient programmes in both the Netherlands and the United Kingdom. It lasts for six months or more, during which time methadone in an oral form is prescribed and a range of supportive therapies are offered. The goal is complete detoxification by the end of the programme.
Prescribing substitute drugs without a time limit, usually referred to as maintenance, is a controversial modality. Before the rapid increase in drug misuse among young people in the United Kingdom in the early 1960s, it was the accepted treatment modality in that country. Initial approaches to drug treatment between 1963 and the early 1970s involved the long-term prescription of heroin and cocaine, both as a means of attracting and retaining drug misusers in treatment and as a means of alleviating some of the pathological effects of drug misuse without necessarily achieving full recovery. Also in the 1960s, work began with the use of methadone as a substitute for opiates. In a maintenance programme, methadone had some advantages over heroin in that it was a longer-acting drug requiring less frequent administration. The results suggested that those persons who were admitted into methadone maintenance had considerably less criminal involvement and were more able to function effectively within the community.
The whole concept of maintenance has been undermined by the approach used to evaluate programmes. While many other programmes have been evaluated as successful though they have shown the relatively small number of persons who have become abstinent (drug free), maintenance has been severely criticized as unethical and ineffective because it has not aimed at or achieved abstinence. Programmes for methadone maintenance have rarely been evaluated on the basis of their success in reducing reliance on illicit drugs, and criminal and anti-social activity or in improving the social functioning of the maintained individual [ 8] , [ 16] , [ 22-24] .
The arguments for and against using methadone maintenance remain current. During the past decade several countries, in addition to the United States, have introduced methadone maintenance programmes either on a pilot basis or as a permanent service (for example, the Netherlands, Sweden and Switzerland). The most outstanding example in the argument for methadone maintenance is found in Hong Kong, where statistics strongly suggest that clients who choose to be on maintenance can function normally in their everyday life. Furthermore, there is evidence that drug-related crime in Hong Kong has substantially decreased since the establishment of maintenance programmes.
It must be emphasized that, in all instances where substitute drugs are used, a range of support services are also needed and are often provided. Thus, substitute therapy can be seen as having two components: long-term detoxification, commonly on an out-patient basis; and maintenance on a substitute drug for an unlimited period of time. The distinction between the two processes, maintenance and long-term detoxification, is often misunderstood.
Psychiatric treatment is provided in both in-patient and out-patient services, sometimes in conjunction with substitute therapy. It offers a large variety of treatment programmes for drug addicts, including milieu therapy, the application of behaviour modification, family therapy, logotherapy and individual and group psychotherapy [ [ 9] , [ 25] ].
The psychological approach emphasizes the importance of individual motives and attitudes in the occurrence of drug misuse. The relationship between internal motives and beliefs and external behaviour, in this instance drug use, gives rise to two important corollaries in approaching the treatment of drug dependence.
The first is the assumption that all behaviour is a result of certain motives and, therefore, all drug dependent behaviour is motivated. The second is that a change in attitude may result in a change in behaviour.
It should be pointed out that the treatment of drug-dependent persons should take into account two aspects, which are described below. The first is to find an alternative to drug use. If it is accepted that drug-dependent behaviour is motivated, then the motives can be isolated and, with a little imagination, alternatives can be provided. These alternatives are not the exclusive domain of any one profession. They require co-operation between physician, sociologist and psychologist and the logistical support of administrators for their implementation.
The second aspect relates to attitudinal change and how this change can be brought about in drug-dependent persons. By far the most important tools by which to change attitudes are education and information. Just as it is impossible to consider approaches to treatment without recourse to the underlying aetiological theory, it is as impossible to conceive an approach to treatment that can succeed without due attention being given to the role of, and necessity for, education.
The intervention modalities that are aimed at achieving changes in lifestyle include therapeutic communities, traditional medicine, acupuncture, yoga and meditation, spiritual or religious approaches (often in combination with other methods), and self-help groups.
Therapeutic communities (TCs) have been established in many countries and were initially modelled after the Maxwell Jones communities for psychiatric patients. The model essentially insists on a high degree of participation by TC residents in decision-making and programme organization.
It has been found necessary to restructure the democratically oriented TC models in response to changes in the residents, demographic and personality structure and in patterns of drug dependence.
Uchtenhagen indicates that the democratic TC model is more adequate, at least in Europe, for abusers of hallucinogenic substances who are looking for a "new identity", whereas persons who are dependent on amphetamines and heroin, who have severe social and personality problems and whose addiction is motivated by an attempt to avoid depression and feelings of annihilation, are less prepared to cope with the unstructured, democratically oriented TCs. The majority of TCs, however, are structured in a hierarchical way and resemble the type of concept adopted by Phoenix House or Daytop, New York. This type of TC is more acceptable as a treatment modality for intravenous drug users [ 9] .
TCs appear to have good results in achieving long-lasting life-style changes with fewer and shorter relapses into drug use and relatively high abstinence rates, higher job satisfaction and work quality, greater contact with non-drug using acquaintances, an improved self-image and greater self-confidence.
It should be pointed out, however, that the TC movement has undergone a number of innovative changes and adaptations in order to be able to respond to the needs of its clients and the larger community it serves. This development has been based on the growing conviction that the most appropriate means of helping drug-dependent persons to return to normal life is through integration in community living, which would make possible their transition and integration into the wider community. Thus, the role of the community and its various elements, such as the social situation, culture, religions, the family, the work-place and schools, is continually emphasized. This recognition has led to a variety of changes and adaptations within individual TCs in many countries, including the introduction of short-term TC programmes, the increased involvement of family members in therapeutic and in reintegration processes.
There are also elements within TCs that have been less successful. For example, drop-out rates within the first four weeks of admission is relatively high (approximately 50 per cent). It is important for TCs to examine their programmes to identify the factors that lead to this high drop-out rate and to develop new approaches that can assist in the retention of residents. It may be helpful to develop a greater participation of residents in planning not only the operation but also the programme of the TC. The rules of many TCs are oriented towards an ideal life-style, which is difficult to maintain outside the artificial life of the community. For instance, complete honesty or direct confrontation are not concepts readily used within the work place or the family. If residents are not assisted to cope with the transition from the TC into the wider community, they may return to drug misuse as a means of coping with the personal and social crises.
The success and content of traditional medicine approaches depend very heavily on the cultural and social environment where they are practised. Reports indicate that certain methods are being used in India, based on the Ayurveda medicine.
In Malaysia, traditional healing is based on archaic animistic beliefs, i.e. that a person is vulnerable to the influence of the supernatural as well as to physical causes. Drug addiction is seen as a result of incorrect behaviour (a predisposing cause) and the presence of a supernatural element, which has negative effects on physical well-being. In view of the cultural or religious background of the population, traditional healers (bomoh) can provide an important treatment modality for some drug addicts. The treatment consists of detoxification, with the help of herbal medicine, physical exercise and balanced nutrition to build up physical health. In other parts of the world, in particular in Africa and Latin America, similar treatment approaches exist.
Acupuncture is used in the detoxification process in Hong Kong, the United States, Vietnam and elsewhere. Ear acupuncture (without electrical stimulation) can be applied and taught effectively in clinical and non-clinical settings at low cost. It is reported that initial ear treatment relieves 90 per cent of the withdrawal symptoms related to heroin or morphine addiction [ 26] . Ear acupuncture has been shown to have a significant preventive effect in the reduction of physical craving patterns. Acupuncture is used in both medical and non-medical settings.
In certain settings, yoga and meditation are used as an important part of behavioural treatment. They include breathing techniques, body postures, and meditation and relaxation techniques as means of providing clients with the tools to improve their personal strength to free themselves of their habits. They have shown certain success in improving interpersonal skills after repeated sessions.
In certain countries, religion plays an important role in the treatment and rehabilitation process. The use of religious teaching as a psychological reinforcement tool has proved to be successful in some countries, e.g. Egypt and Thailand. The role of the mosque, the church or the temple can be significant in the process of counselling, care and social reintegration.
The therapeutic community may be considered an in-patient self-help group, in which drug misusers work together to achieve abstinence; out-patient self-help groups have also been developed in a number of countries.
These self-help groups, such as Narcotics Anonymous, provide a meeting point where former drug misusers and those who have not yet achieved abstinence (but wish to achieve it) can support and encourage others to become and remain drug free. They therefore have provided both a means of gaining motivation to seek treatment and support to the reintegration of former drug misusers.
Another form of self-help group has been an activity in which drug misusers join together to press for adequate treatment and rehabilitation services and to act as a voice for the needs of drug misusers. An example of this kind of self-help is the Junkies Union in the Netherlands.
As well as self-help groups for drug misusers, groups have been formed by the parents, partners and relatives of drug misusers. These groups have recognized that they need support themselves and that, by sharing experience and learning from each other, they may be able to assist drug misusers more effectively.
Drug use and misuse can result in medical complications arising from the effects of the drug, the adulterations and impurities in street drugs, certain modes of drug use and inadequate personal and health care. Treatment must address these issues in order to help drug users to restore their health. For instance, outreach workers, by contacting drug misusers not yet ready to seek help, can act as community health workers and educate misusers about safer modes of drug administration, the dangers of using street drugs, basic hygiene and improvements in the diet.
Other treatment modalities also have an important role in treating medical complications or improving the health of drug misusers. General medical services are often involved in the health care of drug misusers. For instance, hospital emergency rooms may have to deal with drug overdoses and accidents occurring as a result of drug intoxication. In addition to providing immediate treatment, they can act as agents in referring drug misusers to specialized drug services.
A particularly important role in the health care and treatment of medical complications of drug misuse is played by general practitioners and nurses, in particular in the detection of drug misuse and the referral of patients. The early detection of drug misuse before the development of serious medical or social problems allows effective treatment and rehabilitation to be provided within the community without resort to more expensive specialized drug services.
It can be seen that, throughout the process of treatment and rehabilitation, there is considerable need for interlinkages between different professions and modalities. No single approach in itself can readily offer all resources that can be usefully utilized. The sharing of work between non-specialized and specialized services offers the most efficient and effective strategy. Specialized services should be developed only where existing community resources cannot meet the established needs of the community.
Many drug misusers are arrested and placed in a prison, either on remand before trial or to serve a prison sentence after trial. While in prison, the drug misuser will normally be drug-free. The opportunity is therefore given to provide treatment and rehabilitation to reduce the likelihood of a return to drug misuse on release from prison. The range of treatment and rehabilitation interventions described in this paper may be used, the specific ones adopted being dependent on the situation of a given country.
Social reintegration is the process whereby the benefits gained from treatment and rehabilitation are sustained and the drug misuser is assisted to adapt to living within the wider community without recourse to indiscriminate or, if possible, any drug misuse. It may involve: a return to the family; the provision of new housing; the completion of basic education or further education; skills training; unpaid, part-time or full-time employment; an introduction into social and cultural activities and, through this, the development of new friendship networks; an introduction into a self-help group to provide mutual support; residence in a halfway house; or the provision of the names and telephone numbers of people to turn to at times of crisis so that the individual does not feel the need to turn again to drug misuse to resolve personal problems.
Drug misusers often have a poor education, having failed to complete their formal education, and an unsatisfactory work history, with frequent periods of sickness, temporary employment or an extended period of unemployment. When employers can afford to be highly selective in choosing employees, drug misusers are at a considerable disadvantage because they have little evidence to show that they are competent and efficient employees.
Treatment and rehabilitation agencies began to recognize this problem in the 1970s. They observed that individuals who had successfully completed a particular programme were unable to adapt to life in the community. In many parts of the world, therefore, specific strategies were developed to assist in and, sustain the transition into the community.
In some countries, halfway houses are provided where individuals live as they begin employment or resume their education. In these houses, the residents have responsibility for their own lives, preparing food, cleaning and managing their own money. In the houses, other former drug misusers and a small number of therapeutic staff provide a means of support and assistance to residents in coping with the stress of learning to live independently.
Changes have also been made in the length of the therapeutic programme so that greater time can be devoted to the reintegration programme, with many therapeutic communities devoting 6 months out of a 12- or 15-month programme to reintegration.
Some countries have developed specific work training and employment opportunities as a means of assisting the former addict to learn or re-learn work habits, which can help to convince possible employers of the suitability of the former addict as an employee.
Reintegration can be achieved through effective assistance to employees who develop drug problems while at work. Schemes have been developed that seek to identify employees with drug problems at an early point in their drug use. By offering treatment at this stage and by continuing to employ individuals at the work place during treatment, drug users can be successfully reintegrated into the community before they have damaged themselves or their employers, businesses and before more expensive and longer treatment and rehabilitation is necessary.
Drug misuse may be cyclical over a period of years. Many people who engage in drug misuse grow out of their dependence after a number of years. Even in the course of drug misuse, there are often short periods of abstinence.
It is not uncommon for misusers to drop out of treatment or rehabilitation before completing a programme. Therefore, programmes must be prepared to readmit those who have dropped out in order that they might have a further opportunity to achieve control over their drug misuse and, in the long term, abstinence from drug misuse.
There is increasing evidence that, although many drug misusers may experience a temporary relapse at the end of treatment and rehabilitation, after a period of a few weeks or months they achieve long-term stability and abstinence. This strongly suggests that the opportunities offered by treatment, rehabilitation and social reintegration can provide an important means of reducing the demand for drugs and containing drug problems at an earlier stage than if no such help were provided.
All treatment, rehabilitation and social reintegration approaches that have been described in this paper are not applicable in every country, and each one must be adapted to the prevailing situation, including the social, cultural and religious circumstances of a given country.
Report of the International Conference on Drug Abuse and Illicit Trafficking. Vienna, 17-26 June 1987 (United Nations publication, Sales No. E.87.I.18), chap. I, sects. A and B.02
Single Convention on Narcotic Drugs. 1961. as Amended by the 1972 Protocol Amending the Single Convention on Narcotic Drugs. 1961 (United Nations publication, Sales No. E.77.XI.3).03
Convention on Psychotropic Substances 1971 (United Nations publication, Sales No. E.78.XI.3).04
E. Tongue, "Reflections on the development, content and acceptance of the Convention on Psychotropic Substances", in Psychotropic Substances and their Control , R. G. Smart, G. F. Murray and H. D. Archibald, eds. (Toronto, Addiction Research Foundation, 1981).05
J. Calvet, "Prevention policies in France", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence , Ch. Kaplan and M. Kooyman, eds. (Amsterdam, International Council on Alcohol and Addictions, 1986), pp. 89-90.06
R. Cooperstock, ed., Social Aspects of the Medical Use of Psychotropic Drugs (Toronto, Addiction Research Foundation, 1974).07
R. Ashery. ed., Progress in the Development of Cost-Effective Treatment for Drug Abusers . NIDA Research Monograph Series No. 58 (Rockville, Maryland, National Institute of Drug Abuse, 1985).08
J. R. Cooper and others, eds., Research on the Treatment of Narcotic Addiction- State of the Art. Treatment Research Monograph Series (Rockville, Maryland, National Institute on Drug Abuse, 1983).09
A. Uchtenhagen, "Treatment methods, effects and side-effects", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence , Ch. Kaplan and M. Kooyman, eds. (Amsterdam, International Council on Alcohol Addictions, 1986), pp. 299-301.10
G. Paschelke, P. Philipsen and H. Kremer, "The myth of compulsion in long-term clinical rehabilitation treatment of young delinquent drug abusers", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence . Ch. Kaplan and M. Kooyman, eds. (Amsterdam, International Council on Alcohol Addictions, 1986), pp. 99-102.11
Ch. Suwanwela, "Public health perspective in alcoholism and drug dependence", in Proceedings of the 34th International Congress on Alcohol and Drug Dependence (Calgary, Canada, 1985), pp. 395-397.12
A. M. Washton, "Treatment of cocaine abuse", in Problems of Drug Dependence , NIDA Research Monograph Series No. 67 (Rockville, Maryland, National Institute on Drug Abuse, 1985), pp. 263-270.13
Expert Committee on Drug Dependence , Technical Report No. 460 (Geneva, World Health Organization, 1970).14
R. Resnick, "Methadone detoxification from illicit opiates and methadone maintenance", Problems of Drug Dependence, Research Monograph Series No. 67 (Rockville, Maryland, National Institute on Drug Abuse, 1986).15
V. Coleman, Life without tranquillizers (London, J. Piatkus, 1985).16
R. G. Newman, "Evaluating methadone treatment", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence , Ch. Kaplan and M. Kooyman, eds. (Amsterdam, International Council on Alcohol and Addictions, 1986).17
M. D. Glantz, D. M. Peterson and F. J. Whittington, eds., Drugs and the Elderly Adult , NIDA Research Issues No. 32 (Rockville, Maryland, National Institute of Drug Abuse, 1983).18
T. J. Glynn, H. Wallenstein Pearson and M. Sayers, eds., Women and Drugs , NIDA Research Issues No. 31 (Rockville, Maryland, National Institute of Drug Abuse, 1983).19
M. R. Leipman, B. Wolper and J. Vazquez, "An ecological approach for motivating women to accept treatment for drug dependency", in Treatment Services for Drug Dependent Women , B. Glover Reed, G. M. Beschner and J. Mondanaro, eds. (1982), pp. l-61.20
B. A. Ray and M. C. Braude, eds., Women and Drugs. A New Era for Research , NIDA Research Monograph Series No. 65 (Rockville, Maryland, National Institute on Drug Abuse, 1986).21
P. Hadaway, "Then they came for the drug users", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence , Ch. Kaplan and M. Kooyman, eds. (Amsterdam, International Council on Alcohol Addictions, 1986), pp. 39-40.22
W. Buisman, "The development of methadone treatment in the Netherlands", in Papers Presented at the 13 th International Institute on the Prevention and Treatment of Drug Dependence , E. Tongue, ed. (Oslo, International Council on Alcohol and Addictions, 1983), pp. 145-152.23
J. F. Kramer and D. C. Cameron, A Manual on Drug Dependence (Geneva, World Health Organization, 1972).24
B. C. Zangwell and others, "How effective is LAAM treatment? Clinical comparison with methadone", in Problems of Drug Dependence , NIDA Research Monograph Series No. 67 (Rockville, Maryland, National Institute on Drug Abuse, 1985), pp. 249-255.25
K. R. O'Connell, "A behavioural treatment approach to the treatment of cocaine addiction", in Proceedings of the 15th International Institute on the Prevention and Treatment of Drug Dependence , Ch. Kaplan and M. Kooyman. eds. (Amsterdam, International Council on Alcohol Addictions, 1986), pp. 246-249.26
M. O. Smith and others, "Use of acupuncture and herbology in the detoxification of drug addicts", paper presented at the Thirty-third International Congress on Alcoholism and Drug Dependence (Tangiers, Morocco, 1982).