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Page 1 WAT IS JRAT DONG APATI D'ig ALUSE Iiad; Sussi, M.D 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.
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