The International Journal of Psychosocial Rehabilitation

Unpacking drug detoxification in Nepal:
 in-depth interviews with participants to identify
reasons for success and failure.

Dr. Chandra Kant Jha, PhD
Holloway Aged Care Services
East Keilor, Victoria

Professor David Plummer
James Cook University & Queensland Health

Kant CK & Plummer D. (2012) Unpacking drug detoxification in Nepal: in-depth interviews with participants 
to identify reasons for success and failure.
International Journal of Psychosocial Rehabilitation. Vol 16(2) 50-61

Dr. Chandra Kant Jha, PhD
13 Bronzewing St
Williams Landing, VIC 3027

Sincere thanks to the participants for sharing their important insights and experiences regarding drug detoxification in Nepal.

Objective: This study conducted an in-depth exploration of the factors which helped people to detoxify from drugs and the factors which led to relapse among 20 participants from Kathmandu and Pokhara in Nepal.
Methods: The research took a phenomenological approach using in-depth interviews for data collection and all data were analyzed using a grounded theory framework.
Results: The study found that detoxification and rehabilitation services for drug users were mostly provided by private organizations. Some of these organizations had a comprehensive plan, trained staff and counselors. Most counselors were ex-drug users, and they functioned as mentors and role models who helped some drug users to realize that successful detoxification from drugs is possible. This approach enabled current drug users to adhere to the detoxification program. These service providers recognized that ‘frustration’ and lack of support are leading causes of a relapse. The best programs included activities to help the drug users to confront these frustrations. Participants who demonstrated a strong ability to manage the frustrations inherent in drug withdrawal were considered to be more able to avoid relapse after discharge.
Conclusions: The evidence-base is lacking concerning successful detoxification and rehabilitation in Nepal. There is also no clear policy on detoxification and rehabilitation services. The Government of Nepal needs to develop guidelines for coordination, supervision, monitoring, evaluation and accreditation of organizations which provide detoxification and rehabilitation services.
Key words: Nepal, drug use, detoxification, rehabilitation, counseling, relapse

The World Health Organization (WHO) estimates that there are between 3.4 and 5.6 million injecting drug users living in South-East Asia (WHO 2008). It is estimated that there are 150,000 drug users in Nepal, of which 5% are female (The Press Institute 2010). Although the region has a predominance of heroin use, the use of pharmaceutical drugs is increasing (usually in a combination of two or more brands, such as buprenorphine, benzodiazepines and antihistamines) (WHO 2008). In the light of increasing HIV and other serious health consequences of injecting drug use, detoxification is becoming a growing priority. High relapse rates raise questions on the contents and efficacy of detoxification programs, which aim to enable drug users to remain drug free in the long term (WHO 2009; WHO 2010).

Traditionally, it has been considered that holding drug users in custody or prison would prevent their access to drugs, and that staying away from drugs for a few months would enable them to live without drugs indefinitely (Fletcher, Lehman et al. 2009; Coviello, Cornish et al. 2010; Lobmaier, Kunoe et al. 2010). However, these approaches have historically fallen well short of expectations, not least because drugs are often accessible in prisons. Moreover, despite staying in custody without drugs, in some cases for years, relapsed after release was common (Jha 2006). Contextual factors, such as, the availability of drugs, peer networks with links to drugs, and not having other means of income generation, contributed to high rates of relapse (Washton 1988; Jha 2006; Wang and Wang 2007; Jha and Madison 2009).

In contrast to the classic “prohibitionist approach” outlined above, a second strategy known as harm reduction emerged as an attractive alternative. Here the focus shifts to a more pragmatic approach, especially safer drug use in the interim until permanent detoxification can be achieved (Ritter and Cameron 2006; Ball 2007; Zador, Lintzeris et al. 2008). A key priority of harm reduction was to minimize HIV and Hepatitis C transmission between drug users. However, this approach was not palatable to many policy makers and bureaucrats, especially where it entailed the distribution of sterile needle and syringe to drug users and their subsequent disposal (Ball 2007; Zador, Lintzeris et al. 2008; Des Jarlais, McKnight et al. 2009). On the contrary, harm reduction was considered to be a ‘recipe’ for encouraging drug use. Although this program showed ground breaking results in containing HIV transmission in other countries, it remained controversial and undermined large-scale implementation of harm reduction in many countries (Ritter and Cameron 2006; Ball 2007; Zador, Lintzeris et al. 2008; Des Jarlais, McKnight et al. 2009), including Nepal (Jha 2006). Although detoxification and rehabilitation was considered to be a core component of harm reduction, these aspects received far less attention than did needle and syringe distribution and disposal. Never-the-less, harm reduction was started in Nepal in 1993 by an NGO in limited parts of the Kathmandu Valley, but from the beginning, the approach was constrained by lack of funding and weak political and bureaucratic support and ultimately it was not sustainable (Expert Forum on Demand Reduction in South and South West Asia 1995; Seminar on harm reduction 2000; Peak, Rana et al. 2001; Jha 2006; Jha and Madison 2009).  

A third strategy for reducing drug use was known as “demand reduction”. This approach emphasized “awareness and education” programs (DADRP 1996). The Ministry of Home Affairs in Nepal has a narcotic control section, which stresses law enforcement, and runs the Drug Abuse Demand Reduction Project (DADRP). DADRP focuses on demand reduction by creating awareness of the risks of drug use among young people (Jha 2006). Although the program probably helped many youths to become aware of drugs, and to avoid the risks associated with drugs (Einstein 2007; Degi 2009), the project does not provide any assistance to current drug users.

NGOs provide the majority of detoxification and rehabilitation services to drug users in Nepal. The duration of detoxification varies from three to twelve months. Most of these NGOs are privately run by ex-drug users, who have devised strategies of detoxification from their personal experiences (Singh 1997; Jha 2006). While there is no doubt that personal experience is extremely valuable, these programs lack a rigorous evidence-based focus and vision. These NGOs do not have trained clinical staff, such as nurses and doctors to provide effective treatment and care to their patients, although a few NGOs consult general physicians for symptomatic treatment if someone experiences intense withdrawal symptoms. In other cases, the ex-drug users provide the same medications that they used for their own detoxification. Some NGOs use a “cold turkey” approach with purely psychological treatment (Jha 2006). The drop-outs from those centers are high largely during the withdrawal phase.

A few major hospitals in Nepal have psychiatric units which provide drug treatment without specific counseling or rehabilitation services. Although the content and effectiveness of rehabilitation process is not documented, a few NGOs provide rehabilitation services. Common rehabilitation activities include ‘Twelve Steps’ ‘Narcotics Anonymous’, yoga, meditation, sport, education, counseling and vocational training (Jha 2006).   

The Government of Nepal provided methadone substitution therapy to some drug users in Kathmandu Valley in 1994, through a mental hospital. Although this program was initially effective in keeping some drug users enrolled in the treatment, drop-outs started to increase (UNGASS 2010). However, this program was severely restrained due to lack of funding, logistical resources and insufficient trained psychiatrists and nurses, which led to its closure. Recently, the government of Nepal initiated a pilot project with buprenorphine and methadone substitution therapy to contain HIV transmission in injecting drug users (IDUs) through two Kathmandu-based hospitals and one Pokhara-based regional hospital. However, the number of the enrolled drug users accessing these hospitals has been documented to be small (UNGASS 2010). The other popular pharmacological combinations used in psychiatric units in Nepalese hospitals are naltrexone and clonidine (Tamrakar and Koirala 2007). Some private clinics provide these treatments to clinic attendees, however, their compliance is not assured. Apparently, hospitals and clinic-based treatments do not incorporate psychological support and rehabilitation services, leading to relapse or discontinuation of the treatment (Singh 1997; Jha 2006; Jha and Madison 2009).

The above outline clearly demonstrates that there is a lack of scientific and evidence-based drug detoxification and rehabilitation services in Nepal. Although a small number of private organizations and hospitals run detoxification services, they do not have solid foundations of evidence, quality and audit. These services lack holistic care and they also lack the technical and clinical capacity to address the issues of detoxifying drug users effectively. Methadone substitution received inconsistent funding and logistical support, and the program subsequently closed. The Government and donors seem to have paid insufficient attention to formulating effective policies and implementing systematic evidence-based strategies, including monitoring and evaluating service providers.

Purpose of the study
Given the complexities around recovery from illicit drug use, this study aims to explore and unpack the major issues associated to drug detoxification and rehabilitation services in Nepal, by exploring the in-depth experiences of drug-users who have attempted drug withdrawal and rehabilitation. The findings will be instrumental for reforming policies and strategies to scale up drug detoxification and rehabilitation services. As the relapse rates are currently very high, the findings will be crucial to plan relapse prevention strategies as well.

In order to explore the complex issues around drug detoxification and rehabilitation, the lived ‘experiences’ of drug user, who sought detoxification and rehabilitation services will constitute a rich source of data for this research. Employing a suitable theoretical approach to study the ‘experiences’ of the participants, has been crucial. Therefore, this study used phenomenology based on Moustakas (Moustakas 1994) as the theoretical framework to explore the meanings embedded in participants’ ‘experiences’, in relation to their efforts to detoxify and rehabilitate from drugs. This version of phenomenology, sometimes known as transcendental phenomenology aims to capture the very central meanings attributed to an object or phenomenon by an individual. These meanings are often embedded in the core of peoples’ experiences (Stroker 1993; Moustakas 1994). Transcendental phenomenology aims to capture the wholeness of human experiences, which have been constructed with direct and indirect interaction with the nearest material and abstract world, which entirely reflects on the surroundings, broader social and cultural contexts (Stroker 1993; Moustakas 1994).  This methodology reflects the need of the research to examine drug related experiences in association with social factors, social context and through the underlying meanings which inform participants experiences and which they use to interpret, understand and regain control over their world.

Learning to use drugs and efforts to quit drugs are entirely the social experiences (Jha 2006). These happen when the individual comes into interaction with other individuals or the circumstances created by people in which drug use or recovery from drug use is possible (Jha 2006; Jha and Madison 2009). While reflecting on participants’ drug use and detoxification experiences, it is crucial to examine their backgrounds, life patterns, life-goals, familial and social contexts, status of drug detoxification and rehabilitation services, government’s health and human related plan, policies, status of support systems and so on. In short, to take an holistic approach which aims to capture meaningful picture, which is as complete as possible.

This study uses grounded theory as a sophisticated tool for data analysis, which leverages the coding of data to generate themes and concepts (Glaser and Strauss 1967). Transcendental phenomenology and grounded theory have similar analytical approaches, as both use coding to reveal major concepts and to develop themes (Glaser and Strauss 1967; Moustakas 1994). In addition, the latter stresses the recruitment of participants with contrasting characteristics, which offers diversity in data, suggesting how the themes can be related to complex social situations (Glaser and Strauss 1967). As the analytical approach of grounded theory employs comparisons and contrasts as well as pattern finding, it is believed that the final results will be particularly rich in meaning and, under the right circumstances, potentially transferrable (Glaser and Strauss 1967; Strauss and Corbin 1998).

Objective: The main objective of this study is to explore the factors, which helped the participants to detoxify from drugs and to stay drug-free, and the factors which led to relapse into drug use in Nepal.

Samples and geographical areas: The study included 20 heroin users (15 males and 5 females) from the Kathmandu Valley and Pokhara. Recruitment was achieved through a combination of purposive and snow ball sampling techniques (Llewellyn, Sullivan et al. 1999; Schofield and Jamieson 1999). The participants were recruited through a number of local detoxification centers and non-government organizations (NGOs) which work with drug users. Participants were between 19 to 45 years of age. An information sheet, which detailed the study, was provided to NGOs, so that the prospective participants could read, and make an informed decision whether or not to voluntarily participate in the study. The study was anonymous, and a range of measures were taken to safeguard the privacy and confidentiality of participants.

Data collection and analysis: In-depth interviews were conducted with participants using methods described by Minichiello et al (Minichiello, Aroni et al. 1995). Each interview was between one and two hours in length.  Emphasis was put on knowing what factors were helpful when stopping drug use; how participants felt while detoxifying; what factors contributed to relapse; and what factors helped them remain drug free. All interviews were conducted in Nepali and then transcribed into English. The meanings in data were captured and summarized using codes. Codes with similar meanings were clustered and then major categories were identified (Glaser and Strauss 1967; Strauss and Corbin 1990). These categories reflected emerging concepts that demonstrated relevance to the research (such as ‘ambivalence’ around drug detoxification in Nepal).

Ethical approval: This study was approved by the ethics committee of the University of New England, Australia.

Limitations of the study: Although some findings are comparable to studies undertaken elsewhere, generalization from this study should only be done with caution. This study attempts to catch as complete picture as possible through sampling of diverse cases, but sampling was not random. The study was more concerned with examining cases in depth than in quantity. What emerged were illustrative cases which can be used as a roadmap for further studies and as a basis for planning in Nepal. Beyond Nepal, there are lessons that can be learned from this study, which people might draw upon.

Another limitation of this study is that it does not attempt to forecast how long former drug users will stay drug-free. A number of factors, including social and economic circumstances seem to contribute to relapse as indicated in this study. The participants were not followed up after the collection of data.  

The participants had both positive and negative experiences regarding the role of drug detoxification centers. Although some participants described the ‘intrinsic factors’ and overall management of drug detoxification centers in positive ways, they were not confident that they would be able to stay drug-free. Some participants were highly critical, arguing that some of these centers were counterproductive in their attempts to quit drugs. Both the positive and negative experiences of the participants associated with drug detoxification centers are discussed below.

Constructive experiences with drug detoxification and rehabilitation centers
Some participants felt that the role of the detoxification centre was instrumental in helping them to quit drugs and to stay drug free. A number of the participants’ concerns relating to detoxification were explored. For example, some participants emphasized the cost of seeking detoxification; the need for support from family members; the importance of providing for very basic needs such as food and shelter; the need to protect their morale; and the need to exhibit caring attitudes. Although these concerns emerged as dominant, participants who were disconnected from family, or who did not have family support, placed even higher priority on those concerns while deciding whether to undergo detoxification. As Seema states:

People from a detoxification centre have helped me to detoxify from drugs. They have provided free treatment. They are providing free food, shelter, love and affection. These are major supports. For a junkie there is no fixed place where they can eat and stay. [Seema]

Seema, who has been left by her husband, felt she had no support from her family for her detoxification. Having free detoxification, including food, shelter, support and affection from staff members of a detoxification centre, was crucial for her attempts to give up drugs.

By and large, participants experienced coping with ‘withdrawal symptoms’ as a major challenge. For example, Bhawana explains her difficulties while not taking drugs and the ways she overcame them:

When I came to a drug rehabilitation centre I became sick due to not taking drugs there. I had many feelings compelling to take drugs. That time I felt that I can’t live without taking drugs. At the same time, I went to the coordinator of that centre and I shared my feelings that I can’t stay here without taking drugs. She counseled me so nicely that the desires to take drugs were automatically changed. If she had threatened or shouted at me, that could not have helped me to detoxify at that stage. I found their approaches of counseling, assuring and giving examples really useful. I liked that in the beginning. [Bhawana, p9]

Bhawana’s narrative highlights crucial issues, which are potentially useful for the rehabilitation centers. At the start of detoxification, drug users are not fully prepared to cope without taking drugs. They are often irrational and agitated when they present. Handling or helping drug users at that stage needs professional skills. However, the research found that there are some rehabilitation centers which do not have skilled staff to help drug users to overcome their desire to take drugs. Mishandling such cases will lead either to conflict or to participants dropping out of the program.

After detoxification, Shailu entered into the rehabilitation phase. In rehabilitation, there were a series of group sessions. These sessions aimed at resolving concerns on the part of detoxifying drug users, including Shailu, which would impede their recovery, in particular how they would cope in life without drugs. In such meetings, they were encouraged to share their worries and opinions and these were discussed interactively. Staff members, those who have already recovered from drugs, and counselors, shared their opinions as well. Shailu states that these interactions helped him to overcome his problems.

There are sharing sessions in the rehab in which fellow brothers, seniors, counselors and staff participate. They are good examples for us. They provide hope, courage and feedback to us. I attend their lectures. [Shailu]

Shailu’s experiences reveal something of how rehabilitation centers work; what their activities are, and how these activities are helpful for drug users to overcome their need for drugs. The data demonstrates how, presumably by providing access to personal experience and support, the activities inside rehabilitation centers strengthen the ‘self-determination’ of drug users to stay drug-free.

The risk while going through the rigors of withdrawal is non-compliance and relapse. Although drug users reported feeling stronger during the supported treatment, staff kept monitoring them for signs that they may relapse. One of the indicators for this assessment was how well drug users handled “delayed gratification”. There was evidence that staff deployed “delayed gratification” with their clients, both as part of the treatment and in order to assess how participants were able to deal with frustrations. As Pralaya’s narratives reveals:

Sometimes we like to go home. In that case, they keep assessing us whether we can be patient and not take drugs. Once I asked for permission to go to my home, but they said not today, but tomorrow. I was a bit disappointed with that. We are supposed to learn to be patient. Although that’s boring, tolerance has been developed. If we face or experience something undesirable, such things also help us to be patient. [Pralaya]

The focus of rehabilitation centers seems to be aimed at helping drug users to become ‘tolerant and patient’ and that relapsing, impatience and intolerance are major concerns. However, changing this whole ‘mindset’ of drug users is very challenging and takes strategic effort.

According to some participants, rehabilitation centers run ‘integrated’ programs. When a drug user detoxifies from drugs, a routine is made for him or her which determines what he or she will need to do at the rehabilitation centre. Those who improve well are asked to conduct sessions for other drug users at the rehabilitation centre. Besides that, they engage in other activities there, including meditation. As Amar says:

There are some detoxifying drug users in the rehabilitation centre. I take classes for them and participate in meditation. We share our problems. I am improving day by day. I feel relaxed there [Amar]

The role of rehabilitation centers, as discussed above, shows that they are shaping drug users knowledge, attitudes and behaviors constructively. Such positive changes appear to be instrumental in detoxifying people from drugs and to prevent relapse. There is a major transition underway in drug users’ lives: at one stage they are living with drugs, at the next they are living without them. While using drugs, they lived a more ‘irresponsible life’; after quitting, they learn to live a ‘responsible life’. The role of rehabilitation centers, is crucial for some drug users to detoxify from drugs, and to prepare them to take control of their new lives.

Dissatisfying experiences with detoxification and rehabilitation centres:

Despite such a constructive contribution on the part of rehabilitation centers, some participants have clearly expressed their disappointment toward the quality of at least some detoxification programs. It was found that some rehabilitation centers lack a daily plan and activities, as well as supervision and monitoring systems. In the absence of these structural elements, participants had a dilemma to know what they could do there. In the absence of appropriate programs, they felt that staying in the rehabilitation centre was counterproductive. As Hairan states:

At a rehabilitation centre we learned about drugs which we didn’t know even existed before. One of the detoxifying drug users shared about a new drug that is ‘mandres’. He told us all about that drug, such as the power and energy it gives, how it works, where it is found, feelings and enjoyment…We learned many bad things there. [Hairan]

In the above narrative, poor management did indeed lead Hairan to use new drugs. Such an experience discouraged Hairan and his colleagues from attending any detoxification centre. This also reflects on the government’s weakness in monitoring these organizations and ensuring the quality of their work. Organizations which work in the drug field or have drug detoxification programs are registered with the Ministry of Home Affairs if they meet certain criteria. If such weaknesses are not addressed, rehabilitation centers may even become implicated in aggravating drug use, rather than helping users to give them up.

Cost and value for money were also a source of dissatisfaction, as illustrated by Baba:
There are many rehabilitation centers these days. They do not provide quality detoxification and rehabilitation programs. All are motivated to make money. Wherever you go charges vary from Rs 6500, Rs 8000 to Rs 10000. Despite charging that amount of money they don’t provide even good food. I have attended 10-12 treatment centers. These days I don’t like to go to any of these rehab centers to detoxify. [Baba]

Baba gave insights into the core aspects of rehabilitation centers. The activities involved in helping people to detoxify from drugs should be competent, efficient and meet certain standards, including the provision of food and other facilities. This highlights the importance of having standardized guidelines and of ensuring the compliance of detoxification centers with those guidelines to ensure the quality of their services. However, such a comprehensive guideline and monitoring system does not appear to be provided by the government. If drug users feel that their services are not helping them to detoxify from drugs effectively, then detoxification will be drawn into disrepute; money belonging to those who often can least afford it will be wasted, and centers will merely become a way of making money and exploiting the vulnerable.

Lack of financial and moral support to homeless drug users:
Raju, an injecting drug user, has good support from his parents. Despite the high fees charged by rehabilitation centers, he attended various. In contrast, many drug users do not have such familial support. Raj, another injecting drug user has not been in contact with his family for several years. Although he is mentally prepared to detoxify, he faces a lack of money to do so.

I have heard about the various organizations, which provide drug detoxification and rehabilitation services but I haven’t heard any of them providing free treatment and services. We don’t have money so that we can’t go for the treatment. Even remembering those organizations name won’t be worthwhile. [Raj]

In Raj’s narrative, he expects that he will be given treatment free of charge, or that some external support will provide help for his detoxification. Although some of these rehabilitation centers receive financial assistance from donor organizations to support poorer drug users to detoxify from drugs, this fact is not known to many drug users. As Ram relates:

I heard some of these organizations are given financial aid by the donor organization. How do they spend this funding? If a drug user goes for the treatment, they charge money. Then, what’s the use of the aid? Donors are helping such organizations not the addicts. [Saroj]

According to Saroj, drug users, as a target group or beneficiaries do not know about what services are available for them and how these services are provided. Both the donor organizations and rehabilitation centers have not promoted their programs widely to drug users. If the organizations are funded by donor agencies to provide services, such as drug detoxification, it is important to disseminate this message to the users. Organizations which lack transparency will be the subject of criticism and their credibility will be in doubt.

Lack of motivation to detoxify from drugs

In contrast to Saroj, who feels that he cannot detoxify from drugs due to a lack of money, Lamjoi’s narrative highlights that ‘interest’ in giving up drugs is another important factor, especially for drug users who come from wealthy family backgrounds. For example, Lamjoi’s brothers and parents are willing to provide him all means of support for the cost for detoxification, food and living. However, he is not ready to take advantage of this.

My younger brothers tell me to quit drugs. They will manage all my food and living expenses. My dad has a paddy farm in the village and he receives a retirement pension. All three younger brothers work and earn money so there is no problem for me. [Lamjoi]

Lamjoi’s ability to afford drugs seems to be a facilitating factor for him to continue using drugs. If Lamjoi detoxifies, his familial support will be crucial to engage him in activities that will be helpful for his rehabilitation.  However, his desire to continue drugs keeps his family’s expectation and their support aside.  He earns money by dealing drugs, which he spends on his own drug use.

This study outlines some of the realities of drug detoxification and rehabilitation in Nepal by exploring the real life experiences of drug users regarding detoxification and rehabilitation. The crucial findings of this study are that many organizations which provide detoxification and rehabilitation do not have a conceptually sound frame work and do not work to consistent standards. The activities undertaken by these organizations occur in an ‘ad hoc’ manner. The study underscores the importance of: counseling and psychological support; overcoming withdrawal symptoms by enhancing personal efficacy; acceptance of drug users; developing coping skills to handle frustrations; role modeling and mentoring; and preparing the drug users to take responsibilities. Managing these issues well was considered to help drug users’ efforts to detoxify and to remain drug free.

When users experienced ‘withdrawal’ symptoms, this led some to drop out of detoxification. The centers which recognized that ‘withdrawal symptoms’ could be a precursor to relapse, developed approaches in advance that were designed to address the needs of drug users both medically and psychologically. This is consistent with findings in other studies where it was found that symptomatic treatments, counseling and psychological supports have been crucial to overcome withdrawal symptoms in heroin users (O'Connor, Marchand et al. 2008; Chuang 2009; Lee and Cameron 2009; Singh and Sharma 2009).

Participants needed to remain free of heroin for at least the few weeks of detoxification. During this time, their self-esteem was compromised. Generally, they experienced mounting frustration, not least because of their withdrawal symptoms and their desire to relieve themselves by using drugs again. Another study highlighted that the drug users who self-reflect on their past lives and deeds, especially in relation to crimes committed to purchase drugs, felt frustrated and found it hard to cope with such frustrations, and that this can lead to relapse (Jha 2006; Einstein 2007; Jha and Madison 2009). In the current study, the staff members at some detoxification centers seemed to be skilled at helping users to overcome such frustrations. They undertook various activities to challenge their ability to cope with the frustrations. It appears that the participants gradually increased their psychological strength to cope with the frustrations associated with detoxification.

Some participants made several attempts to detoxify from drugs, but relapsed. This lowered their confidence in their ability to quit drugs. Some rehabilitation centers recognized the impact of such perceptions on drug users, and employed ex-drug users as mentors and “role models”. These ex-users were able to share their positive experiences of how they could stay drug free. Their experiences motivated some users to remain in detoxification programs, and to follow the day-to-day plans of the centers.

In contrast to above, some organizations did not have a conceptual framework and day-to-day routines designed to address the various needs of the drug users. In the absence of a day-to-day plan, participants had little to distract them from their withdrawal symptoms and their desire to use drugs again to relieve them. In these cases, participants found little support from the detoxification centers to cope. Moreover, because they were poorly supervised, they had ample opportunity to access and continue taking drugs. This finding highlights the urgent need for accreditation of the detoxification and rehabilitation centers, and their compliance with the minimum standards, which is lacking in Nepal.

While relapse is well known among drug users, the lack of standards almost certainly results in more relapses than there should be. Not having clear plans and strategies for detoxification and rehabilitation, indicates that little importance is attached to detoxification and rehabilitation centers and the people who need them. Enrolling in such centers is a financial burden to the users and their families and having programs that are indifferent to their outcome is unacceptable. Such relapses decrease the motivation of the users to seek further detoxification and undermine the credibility of drug treatment more generally.

While the efficacy of these centers remains an ongoing question, a large number of drug users do not have sufficient money to attend the centers. A significant proportion of drug users in Nepal are homeless (Jha 2006; Jha and Madison 2009). Others, who live in a joint family, also tend to live on the street or with drug using colleagues due to intense familial stigma. As far as successful detoxification and rehabilitation is the ultimate goal, the issues of homeless and poorer drug users impose serious challenges. Their drug use is sustained by their dual roles: as drug user and as drug seller. They use the income earned from dealing in drugs to buy drugs and maintain their habit, as well as for their survival needs (Jha 2006; Jha and Madison 2009). Some drug users engage in pick-pocketing and theft (Jha 2006; Jha and Madison 2009). The direct and indirect costs of attending detoxification and rehabilitation centers rule these services out-of-reach for homeless and poorer drug users. For these people integrated and long-term support is needed from government and donor agencies. It will also be crucial to have their health, social, financial, housing and legal needs attended to before undertaking detoxification and rehabilitation. By not addressing these concerns, gaps are left in the continuum of detoxification and rehabilitation, which will lead to relapse eventually. This situation underscores the need to have a long-term vision and support from government and donor organizations. Such a project will provide an opportunity to the street-based and homeless drug users to detoxify from drugs and undertake rehabilitation activities effectively and on a scale that is meaningful.

Although the donor organizations have funded some of the organizations, which work in the drug field, such funding is largely directed at creating awareness and decreasing the risk of HIV transmission. Most detoxification centers are privately operated and have a commercial motive. For many, the cost is simply not feasible and the profit motive is clearly compromising public health.

Conclusions and recommendations:
This study highlights the lack of a formal official conceptual framework concerning drug detoxification and rehabilitation in Nepal. Instead, there has been an ad-hoc approach using various models and inconsistent or absent standards. There is also a clear gap in providing a continuum of services to drug users between their first consultation with a drug detoxification center and follow-up support after their discharge. Complexities around drug addiction have long term implications on socio-cultural, economic, and health grounds, not to mention the well-being of drug users themselves. There is a lack of coordination between the government, family, community and related stakeholders on the issues of drug detoxification and rehabilitation. The following recommendations are deemed to be instrumental:

Partnerships between hospital-based mental health units and community-based NGOs: The study highlights that the private sector alone does not have adequate resources, expertise or capacity to provide holistic detoxification and rehabilitation services. On the other hand, hospital based mental health units who provide detoxification lack rehabilitation services. Therefore, it is crucial to foster collaboration and partnership between hospitals and community-based rehabilitation centers to utilize their services for the continuum of detoxification and rehabilitation services. For example, in the first consultation with a drug user who seeks detoxification, the NGO staff should assess his or her genuine motivation for quitting drugs, and refer to the mental health unit for the detoxification, which may last 2 to 4 weeks. If the mental health unit does not have adequate beds, alternative arrangements should be made to provide pharmacological treatment under the direct supervision of trained clinical staff. After detoxification, the client should be discharged to a well-equipped NGO for 2 to 6 months for rehabilitation, which includes adequate nutrition, trained staff, well structured activities (such as recreation, sporting, meditation, yoga), counseling and psychotherapy, self-help groups, vocational training, family therapy, education and awareness and regular health reviews. NGO staff should assess the determination of patients and the potential for relapse. As unemployment contributes to relapse, the rehabilitation center should also focus on developing vocational skills which may be helpful to get a job after discharge. After completion of rehabilitation, the family-based counseling will be useful to help individuals to receive familial support. After discharge, the rehabilitation center should design a follow up plan in consultation with the ex-drug users and their families, where possible.



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