Wolcssor oi Clln~c:~lPsychiatry, Uln~clSI ty of Plt tsburgl~,IISA and Dcpuly to bl~nistcrof I!caltll E \fclfarr for ti1Icltli Iran I0Wl IS JIS{ DOlhG IUUUT DRUG WSE
As In othcr countlics a clcar cstlslate of tl~cprcscnt prevalence of op~umaddl ction in Iran is i~llposslblcto glvc. IIo\~cvei, the latest >llnistry of llcalth 2 hclfarc figures sho~rthat thc numbcr of legal opium addlcts \II:c~ 11,1t1 rcnclicd n pcak of norc than 180,000 in 1976, has now bcen rcduccd to 150,000. These addicts conatitute the p~pulationoi' the oplue mal~itcnonceprozran in Iran. I'lw conservative cstln~mThat t~$,iccas many individu.ils are del>endcnt on lillclt Supplies n:nLcs opiunl :~ddictlon to-day's ~~ost pressing publ~chcaltll problcln in. Iran. Ifc ace cutely nwal c of the seriousness of this th~entto our country and bclieve that t11c povernnient has a clear respons~bilityIn meeting this threat head on. In the past few years tlie Govc~nn~entoi Iran has bccn hcavlly engaged in coordinating its efforts with international drug control programs and vital steps have bcen taken in coordination of a multiprongcd attack on tlic problcm. These included thc follo\'ing measures: 1. A Cabinct level council was cstablishcd to develop nntional anti-addict~ongonl- and rccommcnd plogrsms for ~mplcmcntation.
2. Anti-eddictroa 1)lol.l nlllz WCI c ccnt~alizcd untlcr nli inJrpcndcnt
and 1,iorc ;)O\CL\Ifill c~~~t~-~~lJ~~ti~~~ad1:111i1stratlon. 3. ircnt~icn: JIIO~,I,II,I\ \clc \:~cn~,~i:cncdto qcr\,c as lc:,~J .~:;c,lcy
on ndtlon'r l I ug p~ol)l cns
4. Lfforts ~:c~ctl~rcc:c.:l to\:ards proniotlng n 11cv coopcl-ntion in
~~ntl-dddlc:I~~LL cff~j 1s bctaccn thc In\.-cnfor~c~~~cntaulhol I tlcs
and the jud~cidly. 'I111 s \\,is to cnsurc that the pollcc ~souldhave tllc full sur;-ort or the court5 .~gainstapplehcndcd sr?ug~lers
and l,~~owndrug pusllci s, so that the goic~nn~cnt'scffolt> to
lo~tcrdlug sup!'ly 1~111 not foundcr on a fnilurc of prosccutlon.
5. I lnnlly, 01~!1:lnnco \*~slssucd In 1976 for a more st1 ~~lgci~t di~tribut~~,~of OPillal to rcgistercd adl1ct.z in ordcr to I,llnllnize thc nhusc of oplum maintenance program. S~CIficnl ly,
ll~cor din:^^^^. (.I) ~);-ol~il)itcd:'IC 1ssu.lncc of new coupons to
~ndlvldunls;ii~dcr slyly ).cars or age; (b) cancelled ~mmcdiatcly
thr op1ux1 (011po114 for all rey,l:.tc.~-cd ,~clcllctsundcr 50 ycitla of
:lpc; r111d (L) P~:ICC~n Il~irlrlur.1c~lling oi oplum dosage of 5 glallls
per clay fol ?I 1 rcllinllllng -111~1 I cg~stcrcdaddicts ur~dr~60 \.cars
TRCA 1 iIEN r
Until four pcnrs ago, inpatlent dctoxificatlon was the only treatrlcnt sclvice offclccl to add~ctsin Iran. Thc trcntmcnt facilztics kcre dclnpidotcd, and grossly under-staffcd. Ycnrs of ncglrct h,~dt'lhcn thcir toll in pcssinlsm and dcspn~rnlnony, both sdd~ctsand pool ly trnlnrrl tic.~tnlcnt staff. In 1974 a crlticnl asscsa,acnt of thc .~JJicLlantrc.tti~lc~it pl og~nlns \\"IS urlclc~tahclr, and 35 a rcsu!: tll~I ~sl~u11~11)ili~yTo1 tllc txcntrlrnt and rchabllltation of drug addicts \.as tr'lnsferrcd f~onthc Nlnistry of l1~'.11111 to tllc National Iran~anSoclcty for Rchabllltation of thc Dlsablcd (SISRU).
Thc flrst stcps tn',~n1)y ::lCI:D wcrc to rcnoxate the faclllties and llicrcnse tl:c nu:~!)cr of ,1vn1lable bcds. Sllr,~:ltdneously, rqcll-traxned and crpcrlcnccd staff wcrc rccrultcd Morcovcr, intcnsivc on-the-job training I 4s in~tlntcdfor both t.ic existing st'iif and 11cwl) hired para-profcsslonals.
In addit~on,plans I~~CIe made for co~~structlonof new trcatmcnt ccrtcrs In Tehran and provicnes. Tablc I shohs the cxpanslon of thc lnpaticnt capdcity for the traatncnt of thc drug ncdicts slncc thc tal,covcr of rcsponslhllity l~yNISRD. Sucii 11iprovcI:cnts, wh~lcncccssary as the first step, hcrc llnrclly sufflcicnt ns an cff cctlve trentrlrcnt pol ICY. >lorco\rcr, the concept of lrtpat~cnttlcto..~ flcntlon ha3 itself cclnc ::nacl qcruti~ly. Some of the problclns noted with inpat lent detoxification were as follo\ls. Given that 4 or 4 of the 2-3 pcrccnt of adult population addicted to opium, can in theory at least bc considcrcd candidates for inpatient detoxiiicat~on,the capacity for such intcrvcntion did fiot exlst at the tlme. Outside of thc NISRD hospitals dcvotcd to addlcts, little or no capacity c\lstcd for inpatient dctox~flcntlon Thc c\lsting fncilitlcs togcthcr r lth f:ic~litics projcctcd for thc near futurc could not pl ovlJc hospit.11i:ation for cvcn f~vcpcrccrlt ni tll~opLtlln addl~Ls111 'I g~\~c~i)I;:. :'~tnout realistic or posit~vcPI tcrnctivcs, 1t appea~cd~ncv~tnblc that the rcmalnlng 95 pcrc crrt of i ~r:.~dcllcLccI popul.~t~o?i.oulJ. continue to suffcr and to sprcc*(lLhclr 'l~iJlctlonto other nc~lbcrsof soclcty. In addltlon, :!le cffc~tivcnc~,*,01 inp.11 lent deto, if1cat101; ll~d ncver bccn c!criionstr:~tcd In lc\r of tlic lack of capaclty to hospitalize thcsc inJlvldunl\, it appc<~icdthat outpatlent treatment provided the only posltlve nlternntivc It was uncertain whcthcr nasslve fund~ngand hcroic cfrorts to crcate more beds hould be either succczs2ul or cost-cfr~cicnt.
With the above CO~S~C~C~~~.~O~SIn mind, wc cmSarLed gn a massive program of provid~nqoutpatlcnt 5ervicc.s to addicl s thro~-:!~d:ltthe
7ountry. ?able I1 pvcs a sunnnry of t!~:s cont1nuii:g effort.
The c~npllnsis pl,.ccd on out p,~ticntt: cntmcnt In thc c\~ol\.~ng pl ograms, howcvcr, ilrcnt beyo11:l tllc abovc~considcrnt~ons. It was not only cxl)cdlcncy tli~tdict,~tcd thc lrcctl for cxtcnsion of scrvlces. Even if thcrc cxistcd tllc cap'iclty to drvelop the thousands of inpaticnt bcds requilcd for thc tleatmcnt of addicts in an inpationt setting (an ln~possiblcproyositlon), we st111 would have optcd for thc expansion of outpatient services. Since 1970, the experience with outpatient detoxification has provcd not only cqual but supctfor to inpnticnt services for addlcts in countries that produce reliable data nn trentmcnt outcome. Outpatient detoxification with its irnp1ic.J frecdonz and its emphasis on sclf-rclinncc has a grcnt adv.1111.II;C ovcl inpaticcnt sclvlccs: pntlotts are fcrccrl to assumo moro rulf -responsibility. For the majorlty of paticnts riho arc c,~~~c!ids:o~.To1 0u1l)~i':lcnt trcatmcnt as well as the snnllcr nur,l)~r\\.]lo 11ccd IIO\~It':l lt~lr on, thc detoxlfl cation phase of the treainlcnL con st^ tutcs but n relati\rcly small bcginnlng stcp
Vany addlctcd ~ndivldunls,rcp,,~rJlcss of tllc CRLIOC~of tllcir addiction, necd spccial servrccs to hclp not only wlt.11 thcir dependence on opiates but also vith thcir social incnl,lpLtcncc and the emotional mnladjustmcnt that arc frcqucntlv coroll.~~icsLo their addiction. Slncc addict ion 1s rarcly a tcmpol 'iry condl Lion, exclusive reli--cc 611 short-term solutions such as 11~;i.~tlent (1 2,3) dctoxiflcatlon, not uncupcctcdly halt nct 1dli1l iinlvcIc,.!! f,iilLtlr~. ifhat ,'ollo~s 1s a brief Jcscriptlon of a co~nnlrhcns~\*cp~ogr~uat oi servlccs which is (or will bccomc) n\rallable to tllc cclrlictod individuals wllo scck hclp from NISRII.
Mcdical- Dlagnostlc evaluG1tion nrc ~~ndcrtuLonw1t11 pi o1~1ptattelltion to any mcdlcal neccls of thc patient concurrcnt with thc dctoxlficntion program (irrcspcctivc of khcthcr dctoxificatlon 1s c.1~1 icd out in an inpatient or an outpnticnt ~etting).
Psychological: Individual and group psychotherapy, occupntio~ral thcrapy, and rccrcational thcrapy, as wcll a5 cducntion and lcdrning opportunities for tho addicts are to be pro\-~tlcd. Plorcovcr, since sddlct~onis n chronic d~qordcr,thcrc is a nccd for prnctjcnl suppo~t IVC counsclin~.III~ .~dvicc to f.~l~tlli~s.Ihclcfoi c, outlc.lcl~ progrnllls to plo\ ldo counscll~lgor thcl J~)Y 101 ~IJ~~CI~LS,S~)OUSC'S, or significn~ltothers in thc pnticntls lifc arc an i~~tcprnlp:lrl of our comprchcn~ivcproprams. Vo~ation:il Rehab1 lltatlon: Prep31 at~onof thc uncmploycd or undcr-cnploycd .~,ldlctfor galnful rs~ploylncnt is now a 1,tajor goal of trcatmcnt. For c~ampl'c,Ynftabad Ccntcr has the physical capaclty for vocat1on:nl training of lnorc tlr'jil a hunrl~ccl indiv~dunlsat any givm tlmc It is bacLcd up b) all the voratlonal rch?bllitation fac~l~ticsof NISRD. Tllc mnjorlty of addicts a110 complctc their vocat~onaltralnlng at Yaftabad are ablc to more dircctly into compct 1 tive employment . Thcre arc some crltlclsns of the new trc'itncnt program for thc addicts. Thcse crltlclsns nay hc \icwd in tcrns of two separate erg111:cnts. Thc tllrust of thc flrsl CriticiTn is bascc~OII n rnll,cr naive econorzc .LI gumcnt \:i~lch, ns will bcco~~cappal cnt , 1s 111- ioundod when applied to this metllcal ficld. These critics abllo~cthe jdca of uc.lni, h,g!~lv sl:ll lcd ~1i~Ilcd1~t~if and pel sonncl for tl eatnltlrt of addicts. They righteously alguc that allocation of scalcc Ile~lth perso~l~~clfor the trext~llcntof lilorc or less pl~ysicallyl~ealthy hdk\-tdanks sha~plyconflicts with thc ordc~01 prioritics in thc facc of so many unmet medical needs. Such arguments, hortcver, ignore the fact that with the successful control of major infcctious diseases in Iran,- the addiction c]~idcmiclooms as our number onc public health prohlcm. It is a joke to contend as some of thcsc crjtics actually do, that 3dd1ct10n 1~111be "contained" by such things as dcvelopmcnt of strict pun1 t IYC mcasurcs fo~ntl,licts
Vlren tl~c~zsuos foci~s SJ)~C~I~C.II 1y 011 S~)CII~III~ To1 nddiction plojir:lnls, thc nrgunlcnts plcscntcd by tllese crlti~sare rl monunlcnt to thc micapplication of the ill-understood. Thcy ~o all out for lcss cxpc~~s~~~c~'rotl(~coi ntltl ICt i~ntrr3tncnt. Conlprcllcnsivc trccltment l)rogr,llrt; arc \~itl,o~~tdoubi. rlllltc co~tly On thc othcr had, paticnts may bc ~~arcl~ousccl,4113 1,c~t q 11~1on *.ctlL~tivcs~UI tc ~ncxpcnsively.
Such cnrc, hhllc (lcc~ptl\~cl)I ,icnpcnslvc when v~cwedsolcl y in terns of the cost of Iccp:rll: OIIC .I ltl~ctcd~~~divitlunl In a hospital per day, is in rc,ill ty cnoi ~~~ouslycul~c 11sl\c. Infcrior lncdical carc 1s alka) s cxpenslvc, la1gcly bccausc it rnd1.c~ fol chronicity which lnpoverlshcs purse, hc,~lthand splrit. In the fln.il dnalys~s,these crjtics fail tn imdcr~tandor $lotlcc thc ncgativc irnpnct of poor treatment progracs on thc natl~nalc~nti-addlct~on effort In particular, and thereby on tl~rqunllty of lifc a 1h01e. '~hctlirust of the srgulstnts by th2 sccond group of critics are t!ll cctc (1 :i[;a~llst Lllc Cllltp.!i~cllt actdiction trentncnt progrnns. The cxccsscs of thcsc crltlcs IVF~be c\pl,~incdngnillst the 1)a;l.cIrop of
~llsta1~113ssu111j1tlo11-r 2nd bi llcfs nbouL LJIC cupcr~orityof inpaticlit
O\~CI out p:~tlent dctox~flcdt jor~ aliJ rl r;itrncnt. All thesc sten from thc lach of falnilinr~fyof thcsc crit~cswith ncw nyproacl~csto t~cntnrcntof addict~on. Thc an~bulntorydctoxiflrntion oi :ndividuals who havc Jevelopcd a phvslcal dcpcndcnc). is not a new oric Is early as 1970, Gay et a1 (4 had tlcntcd 450 paticnts In the IIcroin Detoxification Clinic in San Frctncisco, on an outpatient basls. It is gcncrally ngi ccd (5,6,7) that witlldrnwal or detoxification is a nccrssnry stcp at sonc point durlng thc trentmcnt of addiction,
1,111 ~aicl)if cvcr, sllould dctc.\iflc.lt 1011 111 itsclf bc COIIS~JCX& nn ntlcilc~,~tctlrat~r~cnt fol- a tlrug dcpcndcnt individual. Viewed as a stcp in thc social rchnh~litntionof thc drug dcpcndcnt individual,
ivwould appear that the st~ccessor failure of tho ovcrnll ttcatmcnt proccss may havc llttle rclationsl~~pto whcthci thc dcto\iflcntion tabcs place in 'In inpatient or an outpatient setting. Revicw of the
avallablc lltcratire supports thts contention, slnce thcle are no ~epo~tsshowing greatcr success In the long run for patlcnts who are detoxified on an inpnticnt basis vcrsus those kho arc detoxificd rn enoutpatient unit It 1s thcrcfore our posxtxon that in the absence of the complicating modlcal lllnesscs which nay require hospitnlizatlon, or the concurrelit addiction to gencrallzcd CNS dcpre2 sants whose ~
over I~ospitnl~z~t Ion for ari overwhclning ma jorlty of narcotzc dependent ~ndlviduals,and its slgnlflcantly 101acr cost. Thesc
+d-wt+t&ges,- *e Itelg*ue, ftnr outwelgir- any gams Lrom thc 3drnxtt.edly closer observation of thc patlent and greatcr control over his contlnu~ngdrug abuse, which arc afforded by an inpatient unit.
The major lcsson to be learned from assessment of these
criticisms, zs that in clinical fields, constructive criticism cannot
prmeed -Prmr pz&mi tomitment to 8 particular id6ologlcal stance or trcnt~ncntapproach. The most important lngrcdicnt of criticism
here should be rcscarcb and clinlcal experience. We are making every effort to cnsurr that the major policy thrirsts of tllc ncw antr-addict! program rcmslns directly foundcd upon oul rcscarch fincllngs ,~nd cl ~~licalcvpc ricnce liorc impel tnntiy. In ordcr to cnsurc tllc sutccss and flc- 1b111t) ~f the rc ~~ldictloiiprogr'rln, a mnssivi* basic c\'dl~~.?tlvi~C~C~IIC~ I: ?' rig I, ~l~~lcntedIn ordcr to nonltor sidc- effc~tsof tllc new p~ o ,r -, a]'(! correct 1tt, ~~nforesccr~~llortcon~lngs.
In SUI~I~~~?~)o:'cr z I 't11 c 1) 51101 t p:'~ ~udof L~I.C,many ili!;,ol tant pl cl ltllnsry 'c,): hnvc I)ecn takcl~which have drab1 lcnlly i~nplovcdthc q~~allt)a]: 1 .I\ aildl)~lityoi t~ cnt~~cntfnciliti~s and scr1.i ccs. f'lic5c acconipl qli-qcn t s , ho~.evcr,play on11 a small ;?art ~n a nntlonal null-addlc'clon progl,irI Sucll a plogran must consls: of oh
1ntri;i-ateJ ~ub1.i pol I c) p,-cLngc nined at prllnary prc\rcrli Lon, co:~rrol of d1ug surp!y, and +I c*ntmcnt nntl lehabil ition ion of ndd~cts. Xqch of rllcsc .ircns is an intcglal p,irt of thc m111ti-iacetcd ni1d:ct:o:: pro11lc.lns. ra~lureIn CIII~one al-ca wrl1 advcrscly nffcct periorirnncc in tlic remalnlng alcns. Tllerciol c, unlcsc, a conccrtcil ciC?rt 1s cal rird out to soo~d:n,~tcpoliclcs and acI LVI tics rn 311 thcs~Inter- rclatcd alcns, the intc of the ncw anti-addiction cn,:lpaign In Iran will not bc much dif ~lodcrniznt~on,ui bnnlzatlon and afflticncc of the past decade, has had as one of its undcslrahlc sidc-cffccts in Iran thc cmersence of \\cstcrrl pnttcrns of tlru: -tl)~rscSIICI~ ns al,t~~~of nlcoliol, iicroin find p'\ ~li~troj\ltil1'11y \el I i tliclc>\, OPIIIIII atidlct Ion Irns tclnailicJ by far thc 111ost salic~itand pcrcl~n~.illypcrsi stullt rlriig p~oblcn~111 Iril~~. Contrary to prcvalci~triyth thc problcm of opiunl ?ddicti~nin Ilorl tlocfo ,lot d.~'(11 ''1 to 1 r 1 I.? 11 ( ~o:y, ,lncl ,ibuse of O~ILII~1s not part of I'cr51.11l c~~ltu~I I licrjt.~~c Ilqe of opium dlcl not go beyond mccl LC lnal ~LIIl,clc,cc, urll 11lc :s 113 111 a Iiundrctl )cars ago, hhcn for the firc,1 tliic t!~tb *~,II\c0:' OilJUl11:(I. r~~rcat~o~ral~UY~IOSC'S WBS initlaied and ci:courrL~i'I),, iorcc5 uf color 1 ~likrnniltl ~r,~pcrlalisi,l.Once l~lit~.at~'(:tll~ .II)UC~C 5111~~~11 wlth .~la:n~ingspccd to thc extent that by 1955 out of n p,>pulaticn of appl c~~lr?,~tcly2fl nlllion pcoplc, it has cst11,~ltcdtll~i t11crc ~CIC1 5 mil 1 ion OPILIII~abusers, roughly 79 of the popul:~t ion tllthouyl, tlils cst~t~~~tedoes not hs\c any sclcrlt~fic undci !~l~:nina~,11cvcrt11~1 c 5s tlic 0111 ern 113s of such ctazgcring d~rnor~s~ons that the Irnnlan par11 '~ment took the radical step of oucl.l\ LI~C111c ~ultiv?Llonof opiulo nonlvl, ,111d iise of opium conp?u+ely. 1'1 rdr~t't1)l) ~t tool, t\ro 10 illrec yc~lrsfor the law to br full)' 111p!~r~~n?ct1,I)~rf t!lc rc-.yLlltkwcrr 11111cdlat.c.III~ dranat~c Suddcn:y,_ opi 111' I)cl Il,le I lr,~rn i l,iuJ c i o tlic ol ti~n,~~y nali and ~JO~IIAIIln the country, and r J :IIIII n \JI t 11 olnum 11)plclit i ful supply in nr is! boi~rlngcountries, however, it was not long bcforc 1'~lgco~g~lnlzcd irlmlnal nctworts came into existc~~cc,and gi nd~rnll)not only opluu, but the easler smuggled heroin bccalnc nvai lablc In 111c I 111ci t nlnrl,ct. The low-enforccmcnt and anti- nnlrot ic trnlt; fc~~rntltl~cirll cl rli ti~l;,~gedIn nn uph~11 and 10~l1lgbattle n~icl tl~c11,1111,111 I'OI CII:I~CII; I~LLJ,ICIIIC~C~ISLII~~~ more ala~ncd. AS the nu~~ll,crof addicts bcgn~lto cl~ral),and the economic and ~0~131Costs col~tinrltd to risc ,ind v~l~c~~~nt ylotcsts to thc of icndinp ncigl~bours rrcnt 111111c(.dcd, tlic Goverll:acl~t as a dcspcrate act of self-protection p~opoqcd.I ncr* 1-jr 10 thc pal-llamcnt \.llich would allow for rcgist~~~tionof adGlcts and llfiiltcd cultivation of opium proportionat to tlic 11cclls of thcY2 rcglstercd addicts At tlic time that thi4 law llas approvcd by tllc I'nrllc~mcntIn 130C, the numbcr of opium addicts 111 the coul~tryhad climbcd to an estilnatcd 400,000 with an addittonsl 12-20 thousand hcloln addlcts. At thc time it was clearly dcclarcd by thc Irnnlan go~cinnentthat the law cns a temporary one and rculd only rcmiin in forcc for so lcng as thc neighbouring countrics ~oiitinuctlto produrc cpium, and tl~itI>,-oduct~on r*f opium in Iran ~ouldcc.~:,c ~mrnctll.itcly ii the neighbourinq countries ngrcc-d to a La11 cn thcil o;>:u*,i p~ociuctlon. Tllc chici suppllcr of rllcgal ol~iunrto Iran in lL)09,Tu~Tcy 1i.1~since svitcl~cdto the "strau" method of Ii~il-vcst~ll~~ts opiul:~, tlli~snlaAlng its opl111n ussurt~i~lcfor recreation purposes, but its sliale of the illcgal op~~lm~narkct has bccn mole than filled by the othcr two opium produciug nelghbouring countries of Afghanistan and Pallstan. Thc Iranian decision to outlaw production of opium, had salutary and Jranot~cresults, but it also showed that in tho absence of regional and intcrnationnl cooperation, a single country is yoncrlcss in cracl~catingthis pllblic health problem withln its borders. A rcp.lonil hnn an tllc p~otl~~ct~onof tl~is dcstruct~vc s~~hstanco or n1.11- 1s ulgclit 1) nscLlcd, but tlic nulnclous ovc~tulcs of thc I1~nlnn~O\IL\~~IIIL and its stcadfast urging for such a ban has, so far met with littlc succcss. As fcllov profcs! ionsls who have seen at flrst hand tl~c dcst,l~c:jon and drvastntlon that op~ateaddlctlon brings to the ind~vldualand h~sfnmlly and havc \iitnesscd thc havoc ~t causes In thc :,oclct), ! 113;)~:thdt YOU will lise whatever persuaslvc pokcrs you Il,117c to co4>v~nceyour pnvcrnnents to respond to our loud and pers L,, tcnt plus from Iran for a rtgloilal ban on opium ploductlon. Our friend., In Afgh,inlstan and Pakistan nust come to realize that rYc and tllcy .Ire deallnp, wlth a serlous and hazardous public health problem. llr~lessthey put an cnd to thcir illegal trafficking of optu7~,our cfforts In Iran nlil continue to lernain foolishly