MUSTAFA is 19 years old, recently ‘released’ from a set-up in the suburbs of Islamabad where he was kept for three months at significant expense. His father cried as he described that, following his discharge, they had to shave the hair off his entire body to get rid of the lice that clung to him. Lack of hygiene was not Mustafa’s greatest challenge. Upon his release, he narrated an account of humiliation, harassment and horror. He never once saw a doctor. What ought to have been a ‘treatment centre’ for drug abuse was, in fact, an ‘abuse centre’ for drug treatment.
One of many unregulated rehabilitation facilities cropping up in urban centres, hundreds of patients suffering from drug abuse and mental disorders find themselves coerced into such set-ups because their blighted families are lost for a direction. They struggle with whether to blame the likes of Mustafa and punish them on moral grounds, incarcerate them on judicial grounds, or treat them on medical grounds. Rehab centres ostensibly offer a perfect solution to all three dilemmas.
Regardless of whether drug abuse is a sin, a crime or a disorder, its harms are evident. Patients suffer from poor health outcomes; high risk of non-fatal and fatal overdoses; and a greater chance of premature death. The family, meanwhile, grieves on account of the social stigma and associated financial burden. Society faces reduced productivity, escalating crime and violence.
Does Pakistan really have a drug policy?
According to recent reports by the UN Office on Drugs and Crime and International Alert, Afghanistan is among the top three opium-producing countries, 43pc of this trade passes through Pakistan. According to an editorial published in this paper recently, despite the fact that Pakistan claims to be ‘poppy-free’ since 2011, it remains a “vital cog in the global opiate trade” and plays a role in controlling trade and cultivation.
In addition to controlling supply, Pakistan must focus on reducing demand. It is estimated that one in every 20 Pakistanis between the ages 15 and 64 is dependent on drugs. While these drugs include opiates, cannabis is the most commonly abused substance.
Last year, the Senate Standing Committee on Interior and Narcotics Control was told that out of seven million people dependent on drugs, a staggering 3m used medicines without prescriptions. These include benzodiazepines, commonly referred to as ‘sleeping tablets’. Shockingly, these are widely prescribed by doctors as well.
Another compelling paradox in our society is the rigorous regulation on sales of alcohol while drugs continue to be sold and commonly used in streets and educational institutions. An estimated 700 people die every day in Pakistan due to drug-related complications. In this high-risk environment, does Pakistan really have a drug policy? And have we outlined strategies to address significant gaps in prevention and treatment services when there is scientific evidence for effective health interventions?
The flourishing quackery Mustafa was subjected to is a reflection of the weaknesses of our healthcare system. Substance abuse is a public health challenge and has been established as a ‘priority’ disorder for low- and middle-income countries by the World Health Organisation. This means that treatment must be offered in primary care. For this to happen, cases of drug abuse disorders must be recorded in health information systems.
All health professionals must be trained to recognise and treat drug abuse. An effective referral system must be established at the grass-roots level and within communities. Widespread awareness campaigns are essential to educate Pakistan’s population, particularly our exploding youth demographic.
The current focus on ‘detoxification’ is also misplaced. It is no secret that 10 out of 10 patients treated at drug centres are likely to relapse. The first principle of treatment is to ‘engage’ the individual in therapy. Patients must be assessed and counselled to enhance ‘motivation’ through a process that includes exploring, understanding, educating and negotiating. Many times, patients are simply not ready to abstain completely, and so the objective of engagement should be to work together to ‘minimise harm’.
Only a few will need specialist care for detoxification, as the majority can slowly withdraw with the help of community supervision. Rehabilitation means addressing psychological conflicts (eg childhood deprivation), social dilemmas (eg unemployment) and associated medical complications. There is a high risk of co-morbidity of drug abuse and mental illnesses. All mental illnesses are treatable; 75pc of all mental health treatment can be provided by primary care physicians.
Acts of condemnation, coercion or chastisement only serve to undermine therapeutic processes. The Afghanistan Independent Human Rights Commission reports that users and addicts are discriminated against and their basic rights violated. Pakistan is unlikely to be markedly different. The prevalence of drug abuse is high, its effects are devastating, and its causes deeply entrenched in complex socio-economic and political processes. Solutions will have to be found accordingly.
The writer is a consultant psychiatrist.
Published in Dawn September 4th, 2016