Anis-ur-Rehman ( Government Mental Hospital, Peshawar. )
Farah Deeba ( Government Mental Hospital, Peshawar. )
Several studies have been conducted in the NWFP on the demographic features of patients who abuse heroin1,3. However, no study has been specifically conducted on patients who relapse after detoxification from heroin. The following prospective study was carried out at Government Mental Hospital, Peshawar with this aim.
PATIENTS, METHODS AND RESULTS
Data was prospectively collected on 100 consecutive heroin addicts who had been readmitted for detoxification at Mental Hospital, Peshawar. The hospital has a newly constructed 20 bedded addiction unit. All heroin addicts who are either brought by relatives, referred by various agencies or who seek treatment themselves are entertained. No judgement as regards their motivation is made and all patients are offered in-patient detoxification. No outdoor treatment is carried out. Admissions to the addiction unit is on a semi-voluntary basis. At the time of admission an understanding is reached with the patient that he would be expected to stay in hospital for 10 days and discharge during this period would not be agreed to. Patients who refuse to comply with this arrangement are not admitted. The patients in the present study were admitted during the period September, 1989 to December, 1990. Detoxification regimen adopted at this hospital consisted of administration of clonidine, chlordiazepoxide and ibuprofen in gradually reducing doses over an eight day period. Clonidine was used because of its direct action on the opiate withdrawal syndrome by binding presynaptically to alpha-2 receptors to reverse the increased noradrenalin turnover during withdrawal. The use of chlordiazepoxide was based on the rationale that compared to methadone detoxification; it provides a broadly similar effect on withdrawal distress and produces similar completion rates. Ibuprofen was used symptomatically for the relief of withdrawal pains. However, no symptomatic treatment for diarrhoea with atropine (lomotil) was carried out. Instead patients were encouraged to drink plenty of fluids. Phenothiazines were not used in the present study. Subsequent to completion of the withdrawal regimen patients were encouraged to stay for another two days, drug free, to assess any residual withdrawal symptoms. Data was collected through semi-structured interviews either by one or both authors to maintain a high degree of reliability. Information provided by patients was corroborated by interviewing relatives. The mean age of 100 patients was 28 years (range 18-54 years SD ± 6.2). All were males and 42% were married. The majority, i.e., 58% hailed from Peshawar, 37% from settled areas and only 5% patients belonged to tribal areas. Most patients were illiterate (41%) or only had primary schooling (31%); only 17% were matriculates. Seventy one percent had been in some form of employment prior to admission and their monthly income ranged from Rs.500 to 1500. Their main characteristics are listed in the Table.
The majority (70%) spent about Rs.30 per day on heroin and 74% self-supported their addiction. Forty six percent had received help from relatives with purchase of heroin, only 3% received money from friends to this extent. Seven percent had resorted to theft to obtain heroin. Most addicts (75%) initially commenced heroin as a recreational activity. For the vast majority (70%) Government Mental Hospital Peshawar was the only place where they had been previously detoxified. However, 30% had also been admitted to various other units in the city. Fifty three percent of the patients were cigarette smokers and 60% used snuff (naswar), 25% were also abusing other drugs like alcohol, benzodiazepines and opium in addition to cannabis. The majority (89%) were living with their parents. Of the 42% married patients only 11 (26%) were living separately with their wives. While in hospital 89% of the patients were visited by their family members; 95% had previously been helped by their families to give up heroin. No patient was brought by the police but history of the past convictions was reported in 25% cases (information was not available in 30 cases). Twelve percent addicts reported involvement in criminal activities but had not been apprehended by law enforcing agencies, 24% had previously been detained in various prisons, a significant proportion of these were through their families for forced detoxification and were not necessarily involved in criminal offences.
The findings of this study are similar to our previous studies1-3. 3. It is interesting that although the major areas of opium cultivation in Pakistan are the remote, federally administered but politically autonomous tribal areas of the North West Frontier Province (NWFP) along the largely unpoliçed Pakistan- Afghanistan border, very few heroin addicts seeking treatment at the Mental Hospital are from this zone. No clear explanation could be found for this disparity despite the strong possibility of an equally large number of addicts being present in these areas with almost no facilities for detoxification. It is interesting to note that although the majority of addicts had abused cannabis prior to switching over to heroin, the incidence of concomitant cannabis abuse remained high in relapse cases suggesting that cannabis due to its easy availability over a long period of time has become culturally acceptable in this society. Similarly the the striking lack of intravenous drug abuse is similar to previous surveys1-6. Unlike our previous study3, the rate of past convictions is low. It was anticipated that patients who relapse after initial detoxification might be lacking in conventional social support and be moving in a circle which encourages both drug abuse and/or criminal activity with consequent involvement with the law7-9. This finding obviously needs to be replicated. A 25% rate of poly drug abuse excluding cannabis abuse suggests that our sample may have consisted of some inherently delinquent persons. However, the fact that the majority had perceived their families as supportive, even greater than our previous study, i.e., 62%3, may have helped in the prevention of criminal behaviour. Also the duration of addiction of less than 5 years for the majority of addicts, coupled with a mean age of 28 years, would rule out a preponderance of adolescent delinquent drug users in our sample. Moreover the majority of drug addicts in our study were in some form of employment suggesting a stable personality. As opposed to our previous study3 in which 56% of addicts were brought for treatment by relatives or friends, only 39% did so in the present study. On the contrary the number of self-referrals increased from 44% in our previous sample to 69% in the present one. However these comparisons may not be totally valid due to the presence of considerable number of relapse cases (52%) in our previous study. Interestingly, although most heroin abusers were introduced to heroin by friends, subsequently the majority maintained their addiction either through self. support or money obtained from relatives. This would suggest that the role of drug pushers in the North West Frontier Province is minimal. Family members would agree to buy heroin rather than see their relative suffer withdrawal or get into trouble with the law. The findings of Mazhar and Ahmad that 60% of abusers had first started using heroin upon the instigation of friends is Consistent with our results. It is noteworthy that a considerable number of patients were detained in jail prior to their admission to Government Mental Hospital, Peshawar. In many cases this was an attempt by their relatives to keep them off drugs and away from criminal activities. The quantity of heroin consumed per day per person is far in excess of that reported from the West4, this is similar to our previous findings. The purity of street heroin in Pakistan is about 30% (Pakistan Narcotics Control Board, unpublished report). This means that the adjusted mean doses for a Pakistani heroin addict of between 450 mg and 1500 mg are the highest reported in a systematic investigation of this sort4. Whether this would affect the relapse rate can only be estimated in further controlled investigations. The short length of stay in hospital not only reflects the lack of willingness of patients to remain in a mental hospital after their acute symptoms have subsided but also is due to a more open door policy adopted at this hospital. Patients who insist on leaving despite initially agreeing to stay on for ten days are not forcibly detained. Subsequent to discharge if they change their mind and desire to be readmitted, this is still offered to them. Drug addicts have regularly ‘escaped’ from Mental Hospital, Peshawar10 and efforts arc underway to improve recreational facilities and encourage more staff/patient contact during the detoxification period.
The authors should like to thank all the patients who participated in the study and the staff for their cooperation. Mr. Tajammul Hussain and Mr. Masoom Shah, Medical Record Officers helped in detailed record keeping. Mr. lqbal Hussain, Statistician, Research Centre, Pakistan Medical Research Council, Peshawar helped with the statistical analysis. Mr. Farid Iqbal typed the manuscript.
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