Khalid A Mufti, Samina Said, Saeed Farooq, Asad Haroon, Abida Nazeer*, Sher Naeem**, Iqbal Hussain***
Horizon, EE32, Nishterabad,
Background: Drug addiction has increased
rapidly during the last 2 decades in
Keywords: Heroin, Drug Addiction, Follow up, Addicts
Heroin addiction is a global problem. The overall picture of the problem is similar internationally, in spite of minor local differences. The treatment
options vary dramatically throughout the world. There are big gaps in services in developing world, causing big gaps in care of these clients
between the developed and the developing world. Some of the causes of this difference include availability of resources, stigma attached to drug
problems, attitudes of people towards drugs, differences in treatments available, religious practices and various social and cultural variables.
There is ample evidence in the Western world that treatment can lead to at least, reduction in drug use and accompanying medical, psychological,
social and public problems.1 In the United Kingdom, the National Treatment Outcome Research Study investigated outcomes for drug dependents
treated in residential and community settings. Substantial reductions across a range of problem behaviours were found 4-5 years after patients
were admitted to national treatment programmes delivered under day-to-day conditions.2
It has been suggested that
detoxification from opiates in a protected environment could have a positive
long-term effect, namely a definitive rejection of the world of drugs, if a
subject with proven motivation to "give up" is carefully selected,
and if the subject is then inserted in a broader social health project.3
Studies from USA have shown that drug treatment outcome is related to the
treatment duration (DARP; 1969-1972, TOPS; 1979-81 & DATOS; 1991-93). However,
this finding has been questioned at least in parts. In a 12 year follow up of
opiate addicted patients, 98% returned to use opiates within 12 months. Another
study of military veterans who used opiates confirmed that substance abuse and
criminal involvement continued over the years. However, a study of military
veterans who had used opiates in
An important question in treating drug addiction is the choice between maintenance or abstinence. In one programme which compared the two treatment approaches, subjects assigned to an abstinence-oriented program were significantly more likely than those assigned to indefinite maintenance to use heroin and amphetamines during the first 2 years of methadone treatment but less likely to use benzodiazepines. Subjects discharged from the abstinence-oriented program were significantly more likely to relapse and return to maintenance treatment. The abstinence-oriented program was also less able to attract heroin addicts into maintenance treatment.6
There is scarcity of research on heroin addiction in the
South East Asia. With this in mind, and to explore the effect of available
treatment on heroin addiction in the long term, this study was conducted. We planned to evaluate effectiveness of a locally run programme for
heroin addiction which uses indigenous resources. The idea as to assess effectiveness of an integrated community based approach in improving
rates of abstinence among heroin addicts. The primary objectives included measurement of the effectiveness of a drug treatment programme in
improving abstinence from heroin dependence among attendees. The secondary objectives included, looking into differences among those who
relapsed and those who did not on different demographic and health measures. Our null hypothesis was that a treatment model is not effective
in helping clients with abstinence.
MATERIAL AND METHODS
The clients were recruited between January 1992 and
March 1993, from
The inclusion criteria included; a DSM IV (Diagnosis and Statistical Manual, 4th Edition) diagnosis of drug dependence and those living within a 10 Kilometre radius of the city centre. The exclusion criteria included; a diagnosis of severe mental illness and an organic brain disorder (e.g., dementia).
This is a cohort design, in which patients who had received an inpatient detoxification treatment, in a hospital, were followed up for 5 years in a community based voluntary organisation.
All the clients received an extended
detoxification programme, for 30 days, at the
The study involved two psychiatrists, 2 social workers, 3 Voluntary workers, 1 clinical psychologist and 1 mental health nurse. The professionals involved were part of the National Health Service except for volunteers who were from Horizon, a Non Government Organisation (NGO).
The criteria used for improvement included; being drug and crime free and being in gainful employment. The criteria for abstinence included being drug free and crimes free.
Initial assessment consisted of diagnostic assessment using DSM-IV Diagnostic criteria for drug addiction, filling in Addiction Severity Index (ASI)7 and carrying out a urine drug screening through Thin Layer Chromatography (TLC). The same assessments were carried out at the end of year, 1,2, 3, 4 and 5. The staffs were trained in ASI for two weeks before the study. ASI is an established measure of drug abuse assessment with acceptable validity and reliability. It has been used with people from different cultures.
Analyses were carried out
using SPSS 10 for windows. Both parametric and non parametric tests were used.
When using parametric tests for binary data, for paired group comparisons a McNemar’s test was used, while a
Of the 100 clients recruited during the study period, at the end of the Year five only 70 clients were connectable. The characteristics of our sample at baseline are described in Table 1.
Analysis at the baseline of the family profiles of the clients showed, that only 2 (2%) lived alone, 42 (42%) lived in a nuclear family system, while 56 (56%), lived in a joint family system. Twenty (20%) reported a history of conflict amongst parents, 30 (30%) reported conflict with cousins, 30 (30%), reported Verbal aggression, while 19 (19%) reported physical aggression among family members. Thirty two (32%) clients reported drug addiction in family (brother 19 (19%), first cousin 10 (10%), father 1 (1%) and uncle 2 (2%). Most of the clients described some kind of a personal or family problem. These included, death of a parent in early childhood 08(08%), childhood labour 51 (51%), family conflicts (Parental, spouse, in laws) 38 (38%), other Social problems 27 (27%) and work place stress 32 (32%).
All the clients used heroin, with an average consumption per day of 1.9 grams (0.5-3.0 grams). Inhalation/smoking was the commonest route of drug use 96 (96%), while Injection 2 (2%) and Sniffing 2 (2%) were less common. The average duration of drug abuse was 06 Years. Most of the clients were introduced to drugs through friends 83 (83%), others included drug pushers 5 (5%), Relatives 7 (7%) and Others 5 (5%). Almost all of our clients used other drugs in addition to heroin. The secondary drugs of abuse were found to be Cannabis in 64 (64%), Alcohol in 7 (7%) and Benzodizepines in 12 (12%). Most clients spent Up to Rs. 50, 67 (67%), with 19 (19%) spending Rs. 50-100, and 14 (14%), spending Rs. 100 or more.
Table-1: Baseline characteristics of the subjects
10 - 20 years 6 6
21 - 30 years 38 38
31 - 40 years 39 39
41 - 50 years 15 15
Above 50 2 2
Mean (SD) age 31 (7.8)
Urban 65 65
Single 54 54
Married 44 44
Divorced 1 1
Remarried 1 1
Illiterate 30 30
Primary 23 23
Secondary 44 44
College 2 2
Postgraduate 1 1
Male 95 95
Female 5 5
Manual Labour 30 30
Skilled 32 32
Self Employed 18 18
Govt. Service 6 6
Jobless 14 14
Up to Rs. 1000 30 30
Rs. 1001 - 2000 40 40
Above Rs. 2000 16 16
No Income 14 14
As far as the history of criminal behaviour was concerned, 89 (89%) of client group had a criminal history, (drug pusher/ possession 61 (68%), Traffic Law violation 22 (25%), Attempted murder 6 (7%), while only 24 (24%) had a history of imprisonment (duration in jail, Up to 6 months 18 (18%), 6 months to 1 year 4 (4%) 1 year to 2 year 2 (2%).
Table 2: Comparison of follow up with baseline medical and psychiatric problems
Baseline (%) Year 5 (%)
Total Medical Problems 51 13
Respiratory 18 4
Cardio vascular disease 7 3
Gastro intestinal 8 3
Skin Disease 4 0
Hepatitis A 4 0
Hepatitis B 2 0
Anaemia 10 2
Total Psychiatric problem 64 17
Major Depression 19 5
Phobic Anxiety 4 1
OCD 1 0
Personality Disorder 17 2
Bipolar affective Disorder 11 5
Schizophrenia 13 4
Table 3: Comparison of follow up with baseline criminal history
Baseline No. (%) Year 5 No (%)
Drug pusher/ possession 61 (61) 0 (0)
Traffic Law violation 22 (22) 6 (8)
Attempted murder 6 (6) 0 (0)
Total 89 (89) 6 (8)
Table 4. Comparison of follow up with baseline; family problems
Baseline No.(%) Year 5 No(%)
Conflict amongst parents 20 (20) 3 (4)
Conflict cousins 31 (31) 2 (3)
Verbal Violence 30 (30) 3 (4)
Physical Violence 19 (19) 0 (0)
A total of 51 (51%), had some form of medical Co-morbidity in the following areas; Respiratory 18 (18%), Cardio vascular disease, 7 (7%), Gastro intestinal 8 (8%) Skin disease 4 (4%), Hepatitis B, 4 (4%), Anaemia 10 (10%). Sixty four clients (64%) had a history of co morbid mental illness; Major depression 19 (19%), Phobic Anxiety 4 (4%), O C D 1 (1%), Personality disorder 17 (17%), Bipolar affective disorder 11 (11%), Schizophrenia 13 (13%).
At the end of the study period, information was available on 70 clients. Of these 16 (23%) had improved, 54 (77%) had relapsed. As far as only abstinence from drugs was concerned, 28% were drug free, while 72% had shown some degree of relapse.
Out of the 30 clients who had dropped out at year 5, 14 changed residence, 2 left for another medical centre, 9 left against medical advice, 3 left the programme for legal reasons, while 2 clients died. Statistical analyses showed there were no significant differences between those who dropped out of the programme and those stayed in terms of age, medical and psychiatric morbidity, family problems and legal problems.
A comparison of groups at baseline and at year 5 showed that clients improved in overall morbidity, criminal history, and other areas of functioning. Statistically significant differences were observed in medical problems [baseline=51%, follow up=19%, (χ2=21, df=1, p=0.000)], psychiatric problems [baseline=64%, follow up=24%, (χ2=6.11, df=1, p=0.013)], crime free [baseline=11%, follow up=91% (χ2=1.5, df=1, p=0.05)], no history of imprisonment during the last 6 months, [baseline 24%, follow up, 3% (χ2=68, df=1, p=0.000)] family problems [baseline=24%, follow up=11% (χ2=53, df=1, p=0.000)], employment [baseline=76%, follow up=87% (χ2=15, df=1, p=0.000)], and in cigarette smoking [baseline=95%, follow up=61%, (χ2=28, df=1, p=0.000).
Fig 1: Flow diagram of five years follow up
When the two groups (improved and relapsed) at the time of the final follow up (year 5) were compared on different measures, statistically significant differences were found in psychiatric co morbidity [improved=3%, relapsed=17%, (χ2=6, df=1, p=0.01)], sexual problems among men [improved=7%, relapsed=64%] (χ2=24.5, df=1, p=0.000)], legal problems [improved=23%, relapse=66% (χ2=21, df=1, p=0.000)]. However, differences were not statistically significant, when the groups were compared for medical morbidity [improved=4%,relapsed=14%, (χ2=3, df=1, p=0.08)], and family problems [improved=3%, relapse=6% (χ2=0.17, df=1, p=0.76)]. The two groups were also different in terms of average age of the participants, [improved=24.5 (16-33), relapsed=44.5 (36-53)].
Fig-2: Rates of abstinence and relapse over five years follow up
Fig-3: Reduction in smoking over five years
This study can confirm some of the trends found internationally in drug abuse. We found high rates of childhood labour, family conflict, violence, history of drug use in family, criminal behaviour and history of conduct disorder during childhood in people who later developed drug dependence. There was a general impression that patients who entered in treatment with severe degree of problems (e.g. crime problem and high severity psychiatric profile) had poor outcome. This has an intuitive appeal.
ASI (Addiction Severity Index) has been used in different cultures, and has been found to be sensitive and adaptive to the needs of different cultures.7,8 The "problem severity profile" of Addiction Severity index with suitable alterations made to local need is easy to be used by a trained volunteer and is reliable and valid in Pakistani culture as well. This instrument can be used as predictor of treatment response and thus matching the patients to treatment programme. We found that patients with less severe psychiatric problems, perform well during the follow up on out patient basis and that those with psychiatric problems need matching in a different set up requiring the services of the experts, e.g., psychiatrists and psychologists. In our set up because of readily available psychiatric intervention, these patients were looked after adequately. Patients without severe family and employment problem performed well, even if they had serious drug and medical problems.
The twenty three percent (23%) improvement rate was based on a stringent criteria, i.e;. being “drug free”, “crime free” and “gainfully employed”. However, when a simpler criteria of being drug free and crime free was used, the rates of improvement increased to 28%. These improvement criteria are more stringent than the routinely used criteria of only being drug free in most other studies. This could be a reason for possible lower rates of the abstinence.
We found that the group on the whole improved on many accounts over the follow up period. These included, medical and psychiatric problems, criminal history, family conflicts, employment and cigarette smoking. This means that even those who did not show improvement on three criteria, showed improvement in other areas of functioning. This therefore gives us hope in the gloomy world of the treatment of drug addiction.
Our analysis, comparing clients at year five, who relapsed and those who improved, showed that clients with high psychiatric co-morbidity, those with histories of criminal behaviour and sexual disorder (only among males) were more likely to relapse. Surprisingly, however, there was no difference between two groups in terms of their medical or family problems profile. We also found that clients who improved were also more likely to be younger than those who did not (mean age of those who improved was 24, while those who relapsed was 44 year). This last finding is consistent with the clinical observation. We should keep in mind however that this does not tell us anything about the actual causality, since we did not perform appropriate statistical analyses (e.g., binary logistic regression).
Due to a very small number of female participants, no statistical comparisons were possible, while taking this into consideration. The results of these analyses therefore, may only be applicable to male patients. Similarly, under reporting partly due to the stigma attached in developing countries and partly due to the strict laws against the drugs, is major hindrance in any study of this nature. It is therefore required that the findings of this study be confirmed through a larger sample and through improved methodology.
Declaration of Interest
2. Gossop M, Marsden J, Stewart D, Kidd T.The National Treatment Outcome Research Study NTORS): 4-5 year follow-up results. Addiction 2003;98(3):291-303.
3. Morino U, Nobili M, Vivalda L (1991). Detoxification from opiates through hospitalization: the long-term results. A longitudinal study of 104 admissions in 1982-1986] Minerva Med;82(4):201-5 (Italian)
4. Vaillant GE. A 12 years follow up of newyork narcotic addicts.3.Some social and psychiatric characteristics. Arch Gen Psychiatry 1966;15(6):599-609.
Oppenheimer E, Laranjeira R.
Health of Cohort of heroin addicts from
6. Caplehorn JR. A comparison of abstinence-oriented and indefinite methadone maintenance treatment. Int J Addict. 1994 Sep;29(11):1361-75.
7. McLellan AT, Luborsky L, Woody GE, O'Brien CP. An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. J Nerv Ment Dis 1980;168(1):26-33.
Hser YI, Anglin D, Powers K. A24 years follow up of
Address for Correspondence:
Dr Khalid A. Mufti, C/O Horizon, EE 32 Nishtarabad,