Qasim A. Moini discusses the options available for detoxification and rehabilitation

Drive along any of Karachi’s main roads and you’ll see a familiar, depressing sight: men, sometimes in groups, sometimes alone, filthy in appearance, huddled while smoking or injecting something. Closer scrutiny will reveal that these are junkies; part of the nearly 630,000-strong opiate-using population the United Nations says exists in Pakistan—with around 80 per cent of them addicted to heroin.

While heroin is the primary substance that is abused, cannabis, considered a ‘soft’, recreational drug, is also widely used, while the use of synthetic ‘party’ drugs such as Ecstasy is said to be on the rise over the past few years, especially amongst the affluent youth.

While the state has made efforts to control drug use and trade in Pakistan, it seems that not enough has been done at the government level to promote treatment and rehabilitation of substance abusers. There are actors in the private sector working in the field of treatment and rehabilitation (with varying degrees of success), yet it has been acutely felt that the state needs to perform better in this area, especially since it is mandated by law to do so.

Dr Saleem Azam, a Karachi-based specialist with over three decades of experience in the field, who runs an NGO and a private facility for drug treatment and rehabilitation, while talking about the difference between rehabilitation and treatment says, “Treatment is a vague term. Lots of things fall under it, such as pre-admission counselling, detoxification and aftercare. All these qualify as drug treatment. Treatment is a long-term process, though people want results in 10 days. The relapse rate can be as high as 90 per cent. People think detoxification is the same as cure. As for rehabilitation, there are several varieties, such as emotional, social, vocational and psychological rehabilitation.”

Dr Murad Moosa Khan, professor and chairman at Aga Khan University’s Department of Psychiatry, when asked whether all patients needing drug treatment need to be hospitalised or if they can be managed at home, said, “The more severe cases need to be hospitalised and the less severe cases can be managed at home. The important factors are the patient’s motivation level, availability of family and medical support and the type of addiction. For example, patients who have been abusing alcohol and heroin for a long time and have withdrawal effects when they decrease the dose invariably need in-patient detoxification as well as those with medical complications.

“Those whose intake is more controlled or those who are using medicines like tranquillisers without increasing their dose over a period of time could do the detoxification at home by gradually cutting down the dose themselves.”

As to whether counselling alone was sufficient or if medicine was needed for detoxification, Dr Khan is of the opinion that “medicines are used to cover the withdrawal effects of the addictive substance. Counselling is useful to deal with the psychological issues. Both are necessary. Medicines are needed to control the withdrawal symptoms. For example, painkillers for body ache, anti-diarrhoeal for diarrhoea or sleeping pills for insomnia and tranquillisers for anxiety and agitation.”

Asked about the government’s role in drug rehabilitation and treatment, Dr Azam pointed out that there was a lot to be desired in the state’s efforts. “There are 13 government agencies working on drug control, led by the Anti-Narcotics Force.Within that there is a department to control drug demand. In government hospitals psychiatry wards do exist, but there are no exclusive drug treatment facilities. Also, HIV-positive patients are not allowed in the ANF facilities (in Islamabad, Quetta and Karachi). Such few centres are not enough for thousands of drug users. It seems the government’s emphasis is on curbing drug supply.”

Coming to the private sector’s role, he says there are NGOs, which operate on a not-for-profit basis, while there are also commercial facilities. “Everyone uses different methods. Torture of patients in order to ‘treat’ them also occurs, which is of concern. There is no government monitoring mechanism to check the running of private treatment facilities. The Control of Narcotic Substances Act of 1997 exists, under which provincial governments are supposed to identify, register and treat patients. The policy exists but its application is rare.”

Dr Saleem Azam pointed out that addiction could lead to crime, domestic violence and social exclusion, amongst other things. “The addict becomes a liability to society if not treated. Charas (a form of cannabis) is not thought of as addictive. Its use among university students is high. However, it can result in drug-induced psychosis.”