Background
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.
Methodology:
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.
Results
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.
Discussion:
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.
- Operational guidelines, supervision, monitoring and evaluation:
The Government of Nepal’s drug prevention program and the Ministry of
Health should provide advocacy and leadership by bringing the relevant
drug rehabilitation centers together. Both ministries should conduct
regular meetings with the rehabilitation centers, and develop a common
reporting mechanism on a periodic basis. The Government of Nepal should
have a clear policy, goal and strategies to encourage and support drug
detoxification, promote rehabilitation and provide support to drug
users to avoid relapse. The government should encourage the
rehabilitation organizations to develop their goals and strategies
which will complement the government’s goals. This will help the
rehabilitation centers to comply with the recommended guidelines. Such
a consolidated approach will be worthwhile to evaluate the
effectiveness of the goals and strategies and to measure changes in the
lives of drug users. The government of Nepal should also have a formal
process of accreditation of those organizations, which will contribute
to ensuring the quality of services provided by these organizations.
- Capacity building: While
many such organizations lack clear strategy and approaches, it will be
highly appreciated that the government of Nepal, as a central
coordinating body, organize experts who will gather evidence from other
detoxification and rehabilitation centers, and use these results for
evidence-based practice and to train staff in these organizations.
Capacity building will be crucial to optimize the services of the local
detoxification and rehabilitation centers. The Government of Nepal also
needs to allocate funding, as well as coordinate with donor
organizations to support detoxification and rehabilitation initiatives.
