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154 IX : Community Based Treatment

Community BasedTreatment

CHAPTER IX

Shanti Ranganathan

Community BasedTreatment

155IX : Community Based Treatment

Several government and international agencies haverecommended that drug abuse be dealt with primarily as acommunity problem. Thus intervention strategies wouldmean assisting communities to adopt measures that wouldinvolve community leaders and lead to communityempowerment. In-depth interaction with severalcommunity members from all socio-economic, age andgender groups is needed. India, Nepal and Sri Lanka havedeveloped several projects on community basedintervention, some of which are ongoing.

Most of these programmes have a lesser emphasis on themedical approach, focussing more on comprehensivepsychosocial methods. The activities include prevention,education, health promotion and harm reduction as wellas abstinence oriented treatment methods.

The key points are the mobilization of local resources,involvement of community leaders and de-centralizationof service delivery systems. Affected individuals can in thisway be rehabilitated locally with community resources, incost-effective programmes. The present chapter is basedon our extensive experience gathered from the treatmentof alcoholism carried out in villages in the State of TamilNadu, south India. However, the basic issues covered arethe core concepts involved in organizing any communitybased services for drug abuse. Several other authors enrichthe chapter through their contributions on selected themes(Box Items 25-29).

In Indian villages, several drugs including alcohol areabused. Cannabis is grown illegally in some areas andabused along with alcohol; alcohol is often fortified withpsychotropics (e.g. diazepam) to enhance its potency. Acommunity feels the need to deal with the issue of drugabuse when it faces problems like violence, prematuredeaths or disruption in families due to irresponsible drug-taking by its members. There is a large population of drugabusers and problem drinkers in villages and often thereare no treatment centres available locally. They cannotavail of help from centres in towns since those are oftenboth unreachable and unaffordable. Besides, the treatmentprocess offered in cities may not be relevant to the villagers.Therefore, what are the alternatives? Building newhospitals? Deputing professionals to villages? Openingspecial wings in government hospitals? Organizing campsin villages?

The last alternative seems to be the most viable. In India,rural camps have been an effective way of dealing withmedical problems such as immunization, eye care anddental care.In these camps:l treatment services are made available at the doorstep

of usersl professionals are mobilized to offer their servicesl the community is mobilized to accept help, andl treatment is offered either free or at a low cost.

Treatment for alcoholism and drug abuse can also beprovided through such camps, though the following factorsshould be considered:l Since villagers are daily wage earners, they cannot

afford to stay in treatment for long periods. Theprogramme has to be intensive and short term.

l Many villagers are illiterate, and the treatment processshould therefore be easily understandable and culturespecific.

l Since drug abuse affects the family members and thecommunity at large, involvement of the family and thecommunity members should be an essential part ofthe programme.

COMMUNITY INVOLVEMENT

Drug abuse is not the problem of a single individual — if itis not dealt with, it will become the problem of the entirecommunity. For the community to enjoy a secure and

Community Based Treatment Centre

CHAPTER IX

COMMUNITY BASED TREATMENTShanti Ranganathan


conducive environment, the entire village needs to beinvolved in dealing with drug abuse.

The term ‘community’ means fellowship and signifies agroup of people who live together, relate to each otherand share a sense of belonging or obligation to their group.In Indian villages, there is a feeling of closeness — joy andpain are felt and shared among villagers. This feeling ofoneness can be drawn upon in the community approach.In a closely knit community, the problems arising fromdrug abuse will be felt by all members and it is thus easierto make them see the need to deal with the problem. Thiscommunity empowerment leads to “doing with” rather than“doing for”; responsibilities are shared and ownership restswith the community.

While working with the community, certain constraintshave to be kept in mind:

l In some villages, drinking and drug-taking may beaccepted as part of local life during marriages, deathsand festivals. The abuse of drugs may not be seen asan issue for concern.

l If distilling or selling alcohol and drugs is the majoroccupation for many villagers, they may not providesupport.

l The community may not be aware of the scientific factsabout drug abuse. So they may look at the abuser as aperson “deserving punishment” or as “one who cannotrecover”.

l Some community leaders may themselves be usingdrugs and, therefore, may not have the necessarycredibility in the eyes of the community.

l Involvement in community action requires a lot of timeand energy and, above all, sustained commitment.

Preparing the community to effectively deal with theseissues is the first step in organizing a treatment camp.Besides, the treatment centre cannot expect to arrive inthe village and start providing services. It has to workthrough an already existing organization in the community,which can be called the ‘host organization’.

HOST ORGANIZATIONA few examples of host organizations are schools, voluntaryagencies, rural upliftment societies, churches, etc. —mainly non-governmental agencies. The host organizationshould enjoy the trust and respect of the community. Thisorganization should already be providing help in someareas — for instance, running a school, offering medical

care, uplifting rural women. It should also be familiar withthe members of the community and be aware of theirproblems.

The host organization should provide leadership and haveprior experience in mobilizing community support. Itshould be willing to do a great deal of ground work toprepare the community — creating awareness about theimpact of drug abuse and involving important leaders ofthe community, for example.

Prior to the camp, the host organization identifies the drugabusing population and provides infrastructure to run thecamp. During the camp, it helps in organizing meals forthe patients and staff and in identifying support personsfor patients. It brings in patients for follow-up programmesafter the camp, deals with relapses and provides supportto sustain their recovery. Further details on campdetoxification are discussed in Box Item-25 (Sri Lanka) andBox Ite m-26 (India).

TREATMENT PROCESSOnce the ground work is done, the treatment processbegins. The first step is to assess and strengthen thepatient’s motivation. If the patient is not motivated, areasthat could be motivating factors — a deep concerntowards his children, a sense of worry about his job —have to be identified. To further strengthen the process,family members should be involved. In the secondinterview, the local physician does a medical check upand drug related medical problems should be handled atthis stage.

At the third meeting, medication is prescribed to reducewithdrawal symptoms and to help the patient sleep well.The basic requirement at this stage is to provide hopeand confidence — an assurance that he can lead acomfortable life without taking drugs. Patients who havetaken treatment earlier can also help reinforce motivation.

Community Meeting

continued on page 162


BackgroundHeroin made its entry into Sri Lanka around 1981. Withina few years, the estimated number of dependent personswas 40,000. Since the country was not prepared for dealingwith this new situation, coping mechanisms were deficient.The most deficient area was that of treatment andrehabilitation. Whatever technical know-how that wasnecessary was not freely available, trained personnel weredifficult to come by, and available channels through whichto seek treatment were limited. A few psychiatric unitsoffered detoxification facilities, but not further services orassistance. In this scenario, Professor N. Kodagoda,Medical Faculty of the University of Colombo, wasapproached by a social worker to help a particular slumcommunity in Colombo city affected by the problem. Atreatment camp was planned for that community as a resultof this consultation. Later this activity was developed as amethod for helping heroin dependent persons. The attributesof this method included accessibility and acceptability tothe clientele, affordability, effectiveness, non-medical andnon-specialist intervention, community base andparticipation, harnessing voluntary inputs and a ‘springboard’ effect for reinstatement of the client into his society.

THE MODALITY AND ITS PROGRESSFunctioning of the community based camp method forhelping heroin dependents consists of five stages:

1. Preventive education in locality, combined withmotivation of potential clientele to seek help

2. Preparation of clients for detoxification, familycounselling and organizing community for conductinga camp

3. Detoxification

4. Development of a further treatment/rehabilitation planby clients with the assistance of family members andcommunity leaders

5. Follow-up.

Having started as an experimental innovation, first with aschool in a slum area and then with a temple as the focus,

the camp gradually gained acceptance in the governmentas well as in the non-governmental sector. Camps are nowcomplementary to other institutional methods.

ObjectivesIn its current form, the objectives of the camp method areas follows:

l To detoxify and withdraw a selected group of heroinaddicts

l To re-establish family bonds and reintegrate detoxifiedheroin dependents with their community

l To create awareness in the community of the existenceof the heroin problem in their environment and possibleindividual and collective action

l To develop a sense of responsibility on the part of thepublic and voluntary organizations in supporting theprocess of treatment and rehabilitation

l To give sufficient encouragement to the clients tocommence rehabilitation with confidence

l To follow-up the detoxified persons for furtherrehabilitation action, as and when required.

Organization of CampThe treatment staff and volunteers of the NationalDangerous Drugs Control Board (NDDCB) Project, wheninitiating a camp, reach vulnerable communities, visithouseholds and assess the extent of the drug problem inthe community, conduct simple awareness campaigns andidentify drug dependents and their families. At the sametime they meet community leaders, voluntaryorganizations, and government officials of the area in orderto inform them about the camp and solicit their support.

Community based camps are usually held in a temple, schoolbuilding, or in a community centre which has basic residentialfacilities for 10-15 persons. The duration of a camp is tendays. Specially in non-urban localities, food and drink forresidents and volunteers is prepared at the site by familymembers and community members, free of charge.

BOX ITEM - 25

COMMUNITY BASED DETOXIFICATION CAMPS FOR HEROIN DEPENDENTS

N. Kodagoda and Y. Ratnayake



On admission, each heroin dependent person undergoesa brief medical check-up performed by the Medical Officerof that area, or by another medical person designated forthe purpose. The clients are then briefed on camp routine.Sufficient recreational facilities for inmates are providedin a planned manner during the camp period. In order toprovide opportunities for self-discovery and self-expression,group and individual counselling, meetings, etc. areorganized. Innovative activities are also provided. Religiousactivities, prayer, meditation, etc. help clients to re-establishtheir spiritual and cultural values.

Drug therapy is minimal. Methadone substitution is notoffered. If substitution is used at all, it is with diminishingdoses of codeine. Analgesics are used. Selected cases mayget a dose of sedatives/tranquilizers. Any medical disordersthat may be present in the client are looked after.

The camp is managed by a committee representingcommunity leaders, NGOs and GOs in the area; it is oftenmade responsible for all camp related activities such asproviding food, security and other facilities.

A follow-up plan for each detoxified person is drawn up atthe end of the camp through informal discussions and finallyeach client is assigned to designated follow-up workers forrehabilitation. If there are clients who need/request furthertime for recovery they are admitted to treatment centres ofthe NDDCB. An effort is also made, where possible, to re-instate them in their former employment, or to lead them tonew avenues. Where feasible, withdrawn persons fromprevious camps are used in subsequent ones as campassistants.

Prevention and Other ActivitiesDuring the ten day camp, the organizers often prepare auseful adjunct programme for the community; dentalclinics, eye clinics, cultural evenings and games of sports,religious activities are some of the components. The campclientele may be harnessed to help in these. Theseoccasions are also utilized to impart preventive educationto the community. Video and other A-V aids are made useof on these occasions, while the presence of recoveringdependents helps to alter community prejudices about drugdependence.

IN RETROSPECTThe camp method of treatment of heroin dependentpersons has turned out to be a feasible, acceptable,accessible, and affordable modality, particularly in thecontext of developing countries. It also has the advantagesof the use of community leadership, communityinvolvement, and community resource mobilization. Themethod also gives an identity to community basedorganizations, elevates the priority of drug use relatedissues on NGO agendas, and brings about healthy liaisonbetween GO and NGO sectors.

Three sub-modalities with regard to resources haveemerged from past experience:(a) all expenses borne by the government(b) all expenses born by the concerned NGOs and the

local community(c) a mixture of (a) and (b) above where expenses towards

food in particular are borne by the community.Experience has shown the third sub-modality to be the mostworkable, and effective.



The earliest mention of opium cultivation in India placedit near the Malabar coast in 1551 (Chopra and Chopra,1965). Its use became widespread during the Mughalperiod. In India, the use of opium found social sanctionand much religious acceptance. Moreover, various kindsof medicinal use and the hard lifestyle of people living invillages also helped to spread its use. During our villagevisits for detox camps we found that about 12 per cent ofthe male adult population was addicted to opium (Purohit,1985), while a study sponsored by the Indian Council ofMedical Research (ICMR) reported the prevalence of opiumdependence in Jodhpur city as 1.19 per cent (Mohan et.al.,1993).

There are some popular misconceptions prevailing insociety regarding opium use — “Once an opium addict,always an opium addict”, “If somebody gives up opium,he will either develop a serious illness or die”, etc. Thesemisconceptions prevent a large segment of opium addictsfrom seeking help; besides, they are frequently unaware ofwhere to seek treatment (Purohit, 1988; Purohit andRazdan, 1988).

BASIC PHILOSOPHY AND LOGISTICSIn rural areas the facilities for treatment of opium addictionare very inadequate. Therefore, in keeping with thepopularity of eye and surgical camps, we felt the need toorganize opium de-addiction camps. Initially, a pilot campwas organized in February 1979, in a small village ofJodhpur district, Rajasthan (western India). Learning fromthe experience of the pilot camp, various activities werestreamlined. In October 1983, we moved to another areaand sought community support. Our goal was todemonstrate the feasibility of treatment for opiumdependence in a camp setting with active communityparticipation.

ACTIVITIES BEFORE THE CAMPThe de-addiction camps were organized mostly byvoluntary organizations. Pre-camp activities includeddistribution of pamphlets and posters after choosing avillage. Personal messengers were sent to the adjoiningvillages requesting opium dependent subjects to registerfor the proposed detoxification camp. The registeredsubjects were subsequently informed by post. A suitable

building was chosen and sometimes tents were erected tolodge 30-50 persons. Health authorities were contacted todepute doctors and nursing staff for the duration of thecamp. The organizing agency (NGO) was involved inmobilizing support of key persons, motivating opiumdependent persons, making arrangements for transport,medicines and recreational activities during the camp.Medicines were procured from the government, and inaddition some drugs had to be purchased. A vehicle wasarranged to carry seriously ill patients to a nearby hospitalduring the camp, if it became necessary. Donations wereobtained from charitable trusts and local philanthropists.Grants from the government were also available.

Volunteers from the NGO and the village along with ex-addicts were involved in mobilizing community support andmotivating opium users to come forward for detoxification.These camps required about four to six weeks of preparation(Purohit, 1988; Purohit and Razdan, 1988).

ACTIVITIES DURING THE CAMPOn the appointed day, opium addicts were admitted afterscreening. Any patient with serious physical or mentalillnesses was excluded and referred to a nearby medicalcollege or district hospital. Various socio-demographic anddrug use related information were recorded and clinicalexamination was carried out. Following their admission,all the subjects were requested to deposit their valuablesand personal possessions including opium, if any, with theorganizers. They were searched in case of doubt.

In each camp an inaugural function was organized toeducate them about the ill effects of opium addiction andprepare them for the withdrawal symptoms that could occurdespite treatment. Their morale was boosted by the doctors,organizers, ex-addicts and VIPs who attended the inauguralfunction.

Opium was withdrawn abruptly. Patients were prescribedsymptomatic pharmacotherapy like analgesics, anxiolytics,and hypnotics. Symptoms like anorexia, delirium,diarrhoea, vomiting, etc. were treated suitably.

All the patients were examined by a doctor twice daily,and in addition a doctor and one or two nursing staff were

BOX ITEM -26

DRUG DE-ADDICTION: CAMP APPROACH

D.R. Purohit



available round the clock. Patients who developed seriousillnesses were shifted to the nearest medical college orgovernment hospital.

From the second through the tenth day patients gatheredfor morning and evening prayers, and recreationalactivities. In an informal environment, patients wereprovided supportive and group psychotherapy by doctors.Voluntary workers, social workers and ex-addicts attendedthe patients for rest of the time. They talked to them, listenedto their problems, reassured them and boosted their morale.Non-professionals acted as a significant link between thepatients and the doctors.

Besides these activities, dedicated and selfless servicesrendered by all made a deep impression on patients. Ex-addicts acted as “role-models”. Non-professionals helpedin general management of patients. On the tenth day aclosing function was held with the following aims:l to enable the recovered persons to take a vow to

remain abstinent for rest of their livesl to remove prevailing misconceptions about opium

addictionl to prepare them to tolerate some protracted

withdrawal symptomsl to motivate other addicts to come forward for de-

addictionl to educate and increase awareness about evils of

opium addiction among general population.

It was noticed that withdrawal symptoms appeared 24hours after cessation of opium use, peaked between 3-5days and reduced markedly between 7-10 days. Hencethe duration of the camp was 10 days.

PROFILE OF PATIENTS AND USUAL NUMBERS INA CAMPIn most de-addiction camps the number of patients wasbetween 30 to 50 and we found that a greater number ofpatients made the task difficult. Analysis of patients’ profilerevealed that :l majority of the opium dependent persons were villagers

(78.4 per cent)l majority were illiterate (61.25 per cent)l most were married (91.25 per cent)l most were farmers (72.5 per cent)l all reported oral opium usel mean age of initiation to opium use was 28.5 yearsl mean duration of opium use was 12.5 yearsl majority had used opium once or twice daily (65 per

cent)l majority had no previous attempt at abstinence (56.2

per cent)l mean age at the time of treatment (camp) was 43.2 years

l some had an associated physical or mental illness (18.8per cent)

(Purohit and Sharma, 1990).

HUMAN RESOURCESIn a camp, about 2-3 doctors, including one consultantpsychiatrist, 3-4 nursing staff, and 8-10 volunteers wereavailable. The local community provided free boardingand lodging facilities. The community also providedvolunteers, emotional support to the patients and protectionto staff and organizers. Involvement of the local communitywas the key to the success of the camp.

FOLLOW-UPDe-addicted patients were supplied one week’s medicineand were requested to come for follow-up either to thenearest government hospital, or by contacting theorganizers. By and large, aftercare services were providedby the government hospitals.

Due to lack of resources in terms of man power and budgetaryprovisions, systematic and regular follow-up was done onlyat a few places. From our experience and through a few follow-up studies we found that about 60-70 per cent of patientsremained abstinent following their treatment in the camps atthe end of two years (Purohit and Vyas, 1982). Outcomedepended on the proportion of treated subjects from avillage, contact with other abstinent ex-patients, frequentcontact with an aftercare agency, and social variables in theaddict’s own community (Westermeyer, 1978).

CONCLUSIONInitially, our goal was to demonstrate the feasibility of campdetoxification. Public awareness, education and removalof misconceptions regarding opium use and treatment weresubsequent and additional activities. Opium de-addictionin a community camp was a novel experiment. It has beenreplicated at various places in Rajasthan, Gujarat andHimachal Pradesh by different psychiatrists, physicians andgeneral doctors. It conforms to the concept of communityhealth care where services to the community are providedat its doorstep and according to its needs. Moreover, it isaccessible, acceptable, affordable, cost-effective, moreconducive for group interaction, health education andawareness. It appears to be a better approach for the ruralpopulation of India.

References:1. Chopra, R.N. and I.C. Chopra (1965). Drug Addiction

with Special Reference to India. Centre for Scientificand Industrial Research, New Delhi.

2. Mohan, D., D.R. Purohit, P. Sitholey, B.M. Tripathy, R.Ray, N.G. Desai, H.K. Sharma, D.K. Sharma, A.B. Sethi



and S.E. Tewari (1993). ‘Collaborative Study onNarcotic Drugs and Psychotropic Substances’. Reportsubmitted to ICMR (Indian Council of MedicalResearch).

3. Purohit, D.R. (1985). ‘Drug Addiction Survey ofHariyada and Joliyali Villages of Jodhpur’.(Unpublished)

4. Purohit, D.R. (1988). ‘Community Approach to OpiumDependent Subjects in Rural Areas of Rajasthan’. IndianJournal of Community Psychiatry, 11: 3-5.

5. Purohit, D.R. and V.K. Razdan (1988). ‘Evolution ofCommunity Camp Approach of Opium Detoxification

in North India’. Indian Journal of Social Psychiatry, 4:5-21.

6. Purohit, D.R. and D.K. Sharma (1990). ‘Characteristicsof Hospital and Camp Opium Dependent Subjects’.Journal of Disabilities and Impairments, 3: 115-21.

7. Purohit, D.R. and B.R. Vyas (1982). ‘Opium AddictionTreatment Camp—A Follow-up Study’. Journal ofClinical Psychiatry (India), 6: 55-61.

8. Westermeyer, J. (1978). ‘Treatment Outcome and theRole of Community in Narcotic Addiction’. Journal ofNervous and Mental Diseases, 166: 51-8.



The open sharing of experiences of previous camp patientswill provide optimism and realistic hope to the patients.

Treatment camps are conducted for a period of 15 daysin the village of the patients. This is a residentialprogramme and has medical as well as psychologicalcomponents. Follow-up support is provided for a periodof 12 months.

Treatment focusses on helping the individual give up drugstotally for life, and making improvements in every area ofhis life — work, family, interpersonal relationships, etc.The treatment programme is specifically designed forcamps in rural areas and includes:l Treating physical problems associated with drug abuse

(medical support)l Strengthening belief in a higher power (prayer)l Providing basic information about drug use and abuse

(informative lectures)l Helping them to share the damage caused (group

therapy)l Guiding them to develop short term and long term goals

(counselling)l Strengthening motivation by providing tips to stay sober

(sharing by recovering patients)l Inculcating values through narration of stories (story

telling).

The families of drug abusers should also be encouraged toattend the programme on a non-residential basis. The goalsof family therapy are to enable the family to express thefeelings of shame, anger and hurt that they may havesuppressed for years and to help them develop a caringattitude towards the addict.

It is pertinent to note that rural women display tremendousforebearance and are often willing to let go of the past andsupport their husbands in their recovery. Since it is theirfirst exposure to treatment of this kind, they very quicklydevelop trust in the treatment staff and hope in the processof treatment.

A programme is needed during such community basedactivities for the support persons of those who have receivedtreatment in the camp. Support persons are those who havea keen interest in the welfare of the addict. They may be afamily member (uncle, sister, brother, father-in-law), afriend, neighbour, any other recovered addict living in thesame village, or the person who has brought him fortreatment. The ideal support person does not use drugs,meets the patient frequently and is respected and held inhigh regard by the patient.

The support person can offer assistance if the patient is inneed of a job or if a reconciliation has to be brought aboutbetween him and his family. He makes sure that the patientattends follow-up meetings. In case of relapse, the supportperson can intervene and provide necessary help. Thesupport person can provide information about the recoveryof patients to the treatment agency.

Follow-up is as important as the primary treatmentprogramme. The goals of follow-up are to consolidate thechanges made by the patient during treatment, strengthenhis motivation to lead a drug free life and help him makeimprovements in his quality of life. A counsellor shouldvisit these sites periodically. The treatment team usuallycomprises a doctor, a nurse and a counsellor.

COMMUNITY RESOURCESA local general physician or a licensed medical practitioner(LMP) from the village should be involved in suchcommunity based activities. Since he is likely to be familiarwith the people belonging to that village, he will be ableto help in identifying the persons needing help. He shouldbe able to provide medical assistance to patients prior to,during, and after the camp.

The members of the host organization are vital resourcesin organizing camps.

An Awareness Campaign - Dhaka

Community Mobilization


Recovered addicts from earlier activities including campscan assist the treatment team in bringing new and relapsedpatients to the project team. Treatment is a joint venture ofthe treatment team, the host organization and thecommunity. The counsellor suggests appropriate steps fortheir immediate future and reaffirms their goals; caringencouragement is given by the host organization. Therecovering subjects in the community are successful rolemodels and peers, and co-patients provide mutual supportto one another (Ch’ien and Zackon, 1994).

INVOLVEMENT WITH OTHER PARALLELPROGRAMMESAwareness programmes for villagers on allied fields shouldalso be carried out periodically. For example, we at theTTK Hospital make use of our audio-video van (donatedby UNDCP) to project short films followed by lectures anddiscussions. So far, we have created awareness in thismanner on alcohol abuse, ganja use and HIV/AIDS.

Community based treatment services are also neededin urban areas. Dr. Sell (Box Item-27) discusses aninnovative project—the open community approach—

where rehabilitation can commence before andwithout detoxification. Another very successful projecton drug de-addiction among slum dwellers in Delhiis discussed in Box Item-28. Finally, Box Item-29discusses the collaborative effort of ILO, UNDCP andMinistry of Welfare, Government of India, on acommunity drug rehabilitation and workplaceprevention programme. This is a joint venture betweenthe community and the workplace.

OUR EXPERIENCE

TTK Hospital has conducted more than 45 camps in severalvillages. From our experience, we find that with minimalinfrastructure, quality care can be provided in villages atlow cost. Disulfiram can be used responsibly and acts as apowerful support.

We have used tablet disulfiram very successfully forsubjects with alcohol dependence to promote abstinence.Local doctors are briefed adequately regarding disulfiram-alcohol reactions.

A year or two after treatment, qualitative lifestyle changescan be seen in patients. Typically, they pay back debts, gettheir daughters married, their sons rejoin school, festivalsare celebrated and household articles are bought.

Community education and involvement lead to occasionaldrug users giving up drugs, abstainers continuing as non-users and problem users willingly accepting help.

A well implemented treatment programme results in apositive outcome, which in turn spreads to othercommunities, who can take them as role models andfollow suit.

Anti-Drug Campaign in Colombo


RESOURCES DOCUMENTS

1. Ch’ien, James and Fred Zackon (1994): AddictionRehabilitation — Principles of Effective Programmingfor Developing Nations. International Labour Office,Geneva.

2. Ranganathan, S (1996): The Empowered Community— A Paradigm Shift in the Treatment of Alcoholism.TT Ranganathan Clinical Research Foundation,Chennai.


The open community approach to drug abuse control wasdeveloped in the South East Asia region of WHO in alearning and experimenting process based on ethnographicresearch, over a period of about 15 years.

The realization that drugs of addiction tend to have stronglyunpleasant effects in the uninitiated led us to the assumptionthat strong socialization processes must be at work in theplunge into regular, and perhaps dependent drug use. Thestrength of such socialization or learning processes isequally exemplified by the dependence on aspirin in someareas of North Eastern Thailand, and by the high prevalenceof ‘pseudoheroinism’ in Asia and in the USA —(psychological) dependence with a daily intake of heroinwhich cannot possibly be (physically) addictive. Otherobservations confirmed that social or learning processescan also influence withdrawal symptoms. For example,opiate-like withdrawal symptoms have been reported inaspirin dependent persons in Thailand, and the insistenceon staying awake during the first night of detoxificationhas reportedly led to sound sleep without tranquilizers ina detoxification centre in Colombo.

Hypothesizing that such socialization processes leadingto dependence can best be reversed by socializationprocesses out of dependence (irrespective of physicaladdiction, i.e. by working with dependent persons asgroups rather than individuals), the concept of village-wisedetoxification was introduced for rural opium users inMyitkyina, Myanmar and in Manaklao, Rajasthan, in theearly 1980s. In this approach, outreach workers (often ex-user volunteers) spend time in a village identifying opiumusers, working with them and their families in efforts tocreate optimism and to overcome helplessness andhopelessness. They mobilize the community and finallytake as many of them as possible (ideally, of course, all ofthem) to an institution for detoxification together, as a festiveevent and common achievement.

It was soon realized that there was no need for aninstitution, but that this mass detoxification could be evenmore effectively be done in the communities concerned,under trees, in tents, or in whatever accommodation thecommunity could provide. Thus, following the outreachworkers’ and volunteers’ community mobilization efforts,

a team with some medical support moved into acommunity for mass detoxification, with full communitysupport. We called this the camp approach. It wassuccessfully adapted to rural alcohol problems in TamilNadu, and to urban heroin problems in many parts of Indiaand Sri Lanka.

However, it became clear that this approach still did notseem to sufficiently address the second main componentof dependence or ‘junkyization’ (in addition to perceivedhopelessness and helplessness), a chaotic or meaninglesssocial life. Ethnographic research taught us that dependentpersons tend to have a severely limited ‘social menu’, theirsocial contacts being mainly limited to partners in the drugsub-culture, and even these contacts being erratic andsuperficial. Community based drug demand and harmreduction projects should, therefore, have a strongercomponent of re-building meaningful social lives for thedependent person (irrespective of his/her state of addiction).

There was then, increasing focus on group work withdependents and their families, formation of self-help groupsof (ex-)users and their families; cognitive therapy, in a waythat would re-build meaningful social lives. The goal wasan enrichment of the ‘social menu’ for drug dependentpersons. Such enrichment requires intensive work toincrease community participation, which depends on thedegree to which communities appreciate the contributionof any project to their quality of life. We realized that theneeds perceived by communities and by project staffconverged: re-building a meaningful social life for drugdependents and efforts to assure communities that this willhelp to increase the quality of community life in general.In order to be able to quantify the perception of the qualityof community life, indicators for the quality of communitylife (QOCL) were developed. Thus, the camp approachwas extended to what we came to call the communityapproach to drug abuse control.

When working with drug dependent persons we realizedthat the changes in lifestyle, the un-learning of a socialrole and the process of socializing into a new one, was attimes intolerably upsetting, perhaps frightening, tooambitious a goal to be achieved in a short period of time.The dependent person may at times slip back into his/her

BOX ITEM - 27

THE OPEN COMMUNITY APPROACH TO DRUG ABUSE CONTROL

H. Sell



familiar lifestyle of drug use. We recognized the need toaccept this ‘in-and-out flexibility’ between new and oldlifestyles by adding the word ‘open’ to the concept ofcommunity approach, and abandoning the concept of‘relapse’. In the open community approach, we recognizethat for many drug dependent persons, the main problemis not the ‘medical’ condition of addiction, but the ‘psycho-social’ issue of a dependence related lifestyle and the oftendrastic changes required to change into a new social roleand lifestyle.

It became obvious very early on that the time afterdetoxification is particularly unsuitable for meaningfulrehabilitative work with dependent persons, since theirmental agenda is dominated by drugs and little besides.We firmly believe that the process must be inverted;detoxification can be useful if it follows successfulrehabilitation, i.e. after confidence in coping has beenrestored and a meaningful social life been rebuilt. In fact,in many instances, detoxification is not even necessaryafter successful rehabilitation. One can leave it to theperson to detoxify him/herself: rehabilitation before/without detoxification.

The open community approach is, in the case of opioiddependents, facilitated by oral opioid maintenance. Thisfacilitates the rehabilitative work with dependents inaddition to its recognized effect of harm reduction. Weuse sublingual buprenorphine where available and feasible.We prefer buprenorphine over methadone for severalreasons: withdrawal from buprenorphine is relatively easy;

there is no risk of overdose deaths—an up to four daysdose can be given at once in the case of transportationproblems; and its antagonist effect prevents, from a certaindosage upwards, “topping off” with heroin.

Comparative studies of the effectiveness of methadone vs.buprenorphine as published in international literature areinconclusive although in general slightly more favourabletowards buprenorphine, especially in dependents with alow opiate habit size. These studies, however, do not seemvery relevant in the context of the open communityapproach because they follow the traditional researchparadigms of clinical trials like double blind and randomassignment schemes which are inappropriate to evaluatethe contribution of a drug to the facilitation of socialprocesses.

Wherever an evaluation of the open community approachto drug abuse control has been attempted, it has been foundto be remarkably successful, whether facilitated by oralmaintenance or not. Rates of total abstinence in alcoholand opium dependents of between 60-80 per cent havebeen reported, with similar success rates in urban heroindependents, if some controlled use is also considered asuccess. Perhaps the most significant outcome is theenthusiasm and sense of well being and confidence indoing something useful in outreach workers. Some peopleargue that the approach is soft on drugs, but it is certainlyhard on human dignity and the quality of life ofmarginalized people.



In the mid-1980s Nizamuddin in New Delhi was an areapopulated by refugees from Bangladesh and Bihar. Livingin abject poverty in ramshackle and patchwork jhuggis(single slum dwelling units) among the graves that dot thelandscape, the residents were mainly daily wage kabadi(scrap) workers. Piles of kabadi lay stacked inside andoutside their homes, awaiting sorting for sale to variousdealers. Drug use was common here, with ganja (cannabis)and brown sugar (heroin) being popular.

I remember walking down the narrow slum lanes, garbagepiled near the entrances of huts made of plastic, sheets,mud and wood. When it rained I had to wear my muddysports shoes as the narrow pathways of the slum were slushyand wet. Flies were everywhere, millions of them, and theysometimes got into your mouth when you took a breath ortried to speak. There were lots of kids playing around theslum — dirty, small and underfed children — a result ofthe slum dwellers’ disregard for family planning measures.

A baseline survey by Sharan (Delhi based NGO) in 1989-90 established that heroin use among males was very high.Access to treatment was difficult and in many instances,services were denied since the admission criteria of variousinstitutions put treatment out of reach. Besides, drug usersfrom slum communities were unable to spend longstretches of time in detoxification or rehabilitation centresas they were often the sole earning members in theirfamilies. We realized that the available treatment was notgeared to their needs. After persistent requests forassistance, a decision was made to provide treatmentservices. Sharan already had credibility in the communityas we had been providing health and nutrition services tothe community since 1989.

From 1990, Sharan began to hold periodic detoxificationcamps, under tents in the open field, involving the communityin the detoxification process. However, relapse rates werehigh and most drug users relapsed soon after discharge fromthe camps. There were other changes — by 1992, wediscovered that many users were injecting drugs and that ourresponses did not adequately address various aspects of highrisk behaviour like injecting drug use and the high level ofneedle sharing. Also, due to the frequent relapses, a sense ofhopelessness had started to affect all of us.

In March 1993, after a literature review, we began a sub-lingual buprenorphine substitution programme in an attemptto reduce the frequency of injecting. The objectives of theprogramme were to de-criminalize drug use, provideeconomic benefits to drug users (medications were free) andto reduce both infections and drug use. The staff consistedof a Medical Officer, two health workers and counsellors. Afew months later, we started a mobile buprenorphinedispensing unit that operated on every day of the week;drug users do not stop taking drugs on holidays. A fewvolunteers joined us briefly, but could not handle the all-pervasive poverty and hopelessness and soon dropped out.

Our activities included going to drug users’ houses, sharingtea and talking to them, providing information on HIV/AIDS and the risks associated with injecting, anddistributing daily medications. We often arrived at thehealth clinic early in the morning to find a dozen clientswaiting for us for medication. The clientele grew from 15to 35 to 53, until with funds for the programme that becameavailable from the European Union in 1995, the total roseto more than 1600.

The project office moved from a small room deep insidethe slum where the health and nutrition programme clinicfunctioned to its present site.

We made detailed inquiries about the major drugs beingabused, the mode of administration, the reasons for relapseand the users’ expectations. Through focus groupdiscussions with family and community members andethnographic observation, we came to understand a greatdeal more about the situation of drug abuse.

We have always tried to convey to the clients that once onthe maintenance/substitution programme, if they feel theneed to use drugs, it is our fault; that we have not assessedtheir dosage needs accurately. In our experience, thisapproach helped to establish honesty. From there, we couldeither look at increasing the dosage or look at other waysto help the client. Our services were non-judgemental anddrug users felt free to talk about their drug use pattern.

And we soon began to notice changes. After a couple ofmonths, clients came in looking cleaner, faces bright from

BOX ITEM - 28

FIVE YEARS AT NIZAMUDDIN

Jimmy Dorabjee



washing or bathing, they shaved more often, their clotheswere cleaner than before. Often, clients brought familymembers into the centre, and they began attending peereducation sessions on safer drug use and safer sex. Thegeneral mood and atmosphere among clients became morepositive.

In our experience we have found between 2 mg to 4 mgbuprenorphine is the ideal dose for 90 per cent of our clientswith the remaining 10 per cent needing upto 6 mg, alongwith a few other medications. Out of the 1600 plus clientswe have had so far, only a handful have needed more than4 mg to be maintained comfortably.

Other ServicesBesides buprenorphine maintenance, we also carried outseveral awareness programmes, frequent home/family visitsand provided support and assistance to drug users and theirfamilies. To date, about 80 subjects were detoxified incamps and an additional 50 subjects went through homedetoxification. About 400 subjects have been referred forspecialist medical treatment. Ninety subjects were referredto our detoxification centre and an additional 120 subjectsavailed of our long term rehabilitation programme.

RESULTSOut of our 1611 clients, 25 were women. The majority (69per cent) were heroin users and 449 (28 per cent) wereIDUs. The majority (51 per cent) came from an area outsidea 5 km radius from our centre. It was seen that 645 (58 percent) heroin dependent subjects and 110 (24 per cent) IDUshad reduced their drug consumption considerablyfollowing treatment. There was improvement in health(reduction in abscesses) and in social and occupationalfunctioning. Needle sharing also went down. Overall, thequality of life had improved and about 74 per cent wereemployed. The abuse of buprenorphine tablets dispensedwas rare. Only three subjects had crushed the pills andinjected them.

LESSONS LEARNTl Staff attitude needs constant monitoring. Abstinence

orientation of treatment providers works adversely ontreatment.

l Training and re-orientation of staff must be ongoing.

l Divided doses (two-three times a day) are more suitablethan single daily dose. Take-home doses are alsoneeded for those travelling long distances.

l Once the maintenance dosages are established,most clients respond well in terms of psychosocialfunctioning.

l Besides medication, additional services like indoorgames, counselling facilities, educative sessions onsafer injecting and safer sex, medical check-ups,referrals, home based detoxification and outreach arealso needed as part of a comprehensive treatmentstrategy. These are possible through a drop-in centre.

l The concept of controlled drug use is unfamiliar butachievable by many.

l We should expect that many will abuse the system ifabstinence is the goal.

l Clients sometimes gather pills to be used for a “rainyday” as well as to sell. It is important to shell the tabletsrather than hand them out in the foil wrappers.

l Positive behaviour change occurs only after intensivecontact.

l Peer educators are great as motivators. By giving smalljobs to clients who do well, we can attract a largenumber of patients.

l Though community acceptance is initially difficult, itis possible when religious or community leaders aretaken into confidence and the benefits of theprogramme are explained to them.

l Multi-drug users need a different dosing regimen andare generally not satisfied with buprenorphine tabletsalone.



In India, drug and alcohol issues have largely beenperceived as a medical problem and services have beenlimited to detoxification and care for one to two weeks.However, the results of such efforts are not satisfying andthe relapse rate is high. There is a need to develop acomprehensive programme to deal with this complexproblem.

Work is vital for recovery. Studies have shown that about30-40 per cent of addicts are unemployed. Those who areemployed have to retain their jobs. This is not possible unlessvocational rehabilitation is a part of the programme, andthis component was missing from the Indian programmes.

Against this background, the ILO is executing the projectDeveloping Community Drug Rehabilitation andWorkplace Prevention Programme in collaboration withUNDCP and Ministry of Welfare, Government of India,in ten cities — Bangalore, Calcutta, Chennai, Delhi,Imphal, Jodhpur, Lucknow, Mumbai, Patna and Pune.

The ILO-Reference Model has several distinct features. Theparticipating NGOs identify the catchment area in thecommunity as the project site. In order to assess the needsof the community, a survey on the drug and alcohol useproblem and available community resources is carried out.A time bound Action Plan is developed. Vocationalrehabilitation is an integral part of the project and theemphasis is on imparting and upgrading the occupationalskills of the recovering addicts. Assistance is provided tothem to get a job or start their own income generatingactivities.

In India, despite modern developments and the influenceof western civilization, community plays a vital role inlife. Family, the primary unit of the community, is still verystrong. These two social institutions were not adequatelyinvolved in earlier programmes. In this present project wehave fully involved the families and the community. Thishelps in easy social reintegration of the recovering addicts.The well being of the community and the workplace areinextricably linked. This means that the initiatives to controldrug and alcohol related problems need to be a jointventure between the community and the workplace. Thisis precisely the focus of the project.

There are several partners in the programme, since it isnot possible for one agency to provide all services to itstarget group. City and state level NGO forums have beenformed on the initiative of the project. Networking betweengovernment agencies and NGOs and among NGOsthemselves has developed.

Whole Person Recovery is the main objective of the ILOmodel. As per this model mere cessation of use of drugsand alcohol is not enough. The whole addictive personalityhas to change and the person must change his lifestyle.He has to fulfill the following conditions to signifysubstantial and mature recovery:l Commitment to a drug free lifel Acceptance of higher valuesl Adaptation to work and responsibilityl Social reintegration — in family and communityl De-addictionl Personal growth and self-acceptance.

When a recovering addict stays sober (drug free), notinvolved in criminal activities (crime free), earning hislivelihood and discharging his social obligations (gainfullyemployed) it can then be interpreted that he has achievedWhole Person Recovery (WPR).

For people striving to achieve WPR four factors, popularlyknown as the four keys to change, are necessary. Theseare:

1. Practical guidance from respected person(s) for whatneeds to be done.

2. Caring encouragement for one’s efforts — this is apowerful “fuel” for motivating recovering addicts andmoving them forward.

3. Successful role models who have achieved the goal.4. A peer learning group working together towards that

goal.

As per the project design participating NGOs will continueto get support and they, in turn, will be extending theirtechnical expertise to the individual enterprises inestablishing the workplace prevention programme. Theywill also provide assistance and treatment services forsubjects referred by the enterprises. However, the main

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COMMUNITY DRUG REHABILITATION AND WORKPLACE PREVENTIONPROGRAMME

Mukhtiar Singh



activities of the programme in the workplace will be carriedout by the enterprises themselves through their trainedpersonnel, focussing on awareness creation, healthpromotion, integrating with other programmes ofoccupational safety and health, improving workingconditions, human resource development and productivityenhancement. Efforts will also be made to link up withother programmes in the workplace and the communityto ensure its sustainability. Such links are sure to improvethe programme content, leading to better workingenvironment and improved quality of life of the workers.

After several rounds of discussions with employers’ andemployees’ organizations, and governmental and non-governmental agencies, a strategy was worked out oninitiating steps for the workplace prevention programme.A series of two-day orientation seminars were held atBangalore, Mumbai, Calcutta, Delhi, Chennai and Punein April and May last year. The industries have welcomedthese initiatives. At the Mumbai workshop, the SecretaryGeneral of the Employers’ Federation of India said: “TheILO has taken a very bold step by undertaking such a projectand the government, employers and workers should getinvolved in the project”.

The standard reaction of managers who either refuse toadmit that this problem exists in their company or employthe “hire and fire” approach is being replaced by frankdiscussion and open admission of the existence of theproblem. There is a growing realization of the adverseconsequences of drugs and alcohol at the workplace interms of absenteeism, loss of production, accidents,increased medical and compensation claims, and the need

to take preventive measures. This was aptly voiced by thePresident of the Federation of the Indian Chamber ofCommerce and Industry (FICCI) at the Delhi workshop:“Drugs not only affect productivity of each individual, butalso have a negative impact on fellow workers and canaffect the discipline of the workplace. The neglect of suchproblems would only result in continued and growing lossto the nation as a whole.”

For the first time in India, 11 well known industrial enterpriseshave taken up the workplace prevention programme incollaboration with the government, international agenciesand NGOs. The five-day workshop in Delhi forrepresentatives of the participating enterprises and NGOshelped the participants to go over various concepts and issuesof the programme and develop enterprise-specific draftpolicies and action plans. The commitment of the topmanagement and the support of the employers’ andemployees’ organizations has provided a sound base for theprevention programme. As we go along, the involvement ofmanagers, supervisors, trade unions and workers and theirfamilies will further strengthen it.

By the end of the project, there would be 18 communitybased rehabilitation and 11 workplace preventionprogrammes in place as “model” programmes. In addition,there would be a cadre of trained manpower in the field ofdrug demand reduction. These efforts are bound to give anew direction to the programme to reduce abuse of drugsand alcohol and minimize their adverse consequences onsocial and economic development, thereby ensuringimprovement in quality of life.


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