The future of treatment in developing countries

1. The future of treatment in developing countries Isidore S. Obot Department of Psychology, University of Uyo Centre for Research and Information on Substance Abuse Uyo, NIGERIA

2. Outline • Prevalence of substance use disorders • Problems • Availability of treatment • The challenges • Delivering effective interventions

3. Sources of data World Health Organization Atlas projects - MH Atlas and SUD atlas WHO GISAH GBD data Published literature Informal survey UNODC information system

4. Prevalence of alcohol dependence among males (15 years+)

5. Annual prevalence of Illicit drug use in Africa (% of 15-64 year-olds)

6. Alcohol, trauma and crime in South Africa In 2002, 46% of non-natural deaths involved persons with BACs equal to or greater than 0.05g/100 ml In 2003, for all causes of deaths 49% had positive BACs (mean of 0.18g/100ml) 39% of trauma patients in Cape Town, Durban and Port Elizabeth had BACs equal to or greater than 0.05/100ml In Cape Town 70% of domestic violence cases are alcohol related Daily average of persons driving under influence increased from 1.8% in 2002 to 2.1% in 2003. Drinking strongly linked to rape, property crimes and weapons-related offences

7. Alcohol related mortality in South Africa • Mortuary-based (x32) system on non-natural deaths (e.g. homicide, suicide, transport related) • Also assess Blood Alcohol Concentrations (BAC): 0.05 gm/100ml (legal limit for driving) • Among adolescents - 70% male - leading causes of death: • Homicide (36.8%) • Transport collisions (33.2%) • 34.7% had +ve BACs • Over 80% with +ve BACs were over .05 gm/100ml (legal limit for driving) • Highest number of BAC +ve cases aged 17-19 years Source:National Injury Mortality Surveillance System (NIMSS) – MRC/UNISA , 2001

8. Alcohol-related problems in Nigeria A disproportionate part of total admissions to tertiary hospitals linked to alcohol presenting as acute intoxication, delirium tremens, alcoholic psychosis, polyneuropathy and liver damage Higher prevalence of pathological liver functioning in Nigeria compared to Germany with higher level of alcohol consumption One of the highest rates of road traffic accidents in the world. Role of alcohol not clearly established. Unintentional injuries accounted for highest proportion (28%) of male alcohol related deaths in 2002 2.6% of disease burden attributable to alcohol

9. Primary drugs of abuse among people in treatment for drug problems in different regions of the world, 2002 Source: UNODC (2004)

10. Primary drugs of abuse in treatment population In most countries cannabis mentioned in 50-100% of new admissions Khat – 75% in Ethiopia Methaqualone – 43% in Namibia and 24% in South Africa Cocaine – 72% in Sao Tome & Principe Opiates (mostly heroin) – Mauritius Inhalants – 35% in Cameroon; 21% in Kenya Source: UNODC, WDR, 2004

11. SOME FINDINGS FROM WHO ATLAS PROJECTS Mental Health Atlas (2005) Substance Use Atlas (2004)

12. Presence of substance abuse policy(Written document containing goals pf prevention and treatment activities related to use, abuse [of] and dependence [on] alcohol, prescription and non-prescription (including illicit) drugs)

13. Availability of interventions for substance use disorders in different regions

14. Health care settings providing treatment for drug use disorders

15. Health care settings providing treatment for alcohol use disorders

16. Sources of Funds for the Treatment of Drug Problems

17. Sources of Funds for the Treatment of Alcohol Problems

18. Professional Groups Involved in the Treatment of Substance Dependence

19. Mental health professionals available in different regions (per 100,000 population, 2005)

20. KEY INFORMANT SURVEY IN 4 COUNTRIES, 2009

21. The future of treatment: What experts in four countries say are the major challenges Brazil 1. Lack of qualified professionals 2. Poor quality of treatment 3. Stigma among professionals (at primary care level) China 1. Discrimination 2. Denial 3. Low level of affordability of treatment

22. The future of treatment: What experts in four countries say are the major challenges India 1. Lack of resources – trained manpower; high cost of pharmacotherapy and treatment Lack of sensitization Negative attitudes to people with SUD and therapeutic nihilism South Africa Limited resources Perception that substance abuse is not a psychiatric issue Stigma

23. Other challenges Cultural and moral attitudes which affect social acceptability Delayed onset of treatment due to poor accessibility Drug diversion Lack of data on treatment and rehabilitation

24. Examples of response to substance use problems in Africa

26. Facing and dealing with the emerging threats of increased drug abuse and associated health and security problems:STRATEGIES

27. Does the future lie in SBI? Experiences from Brazil and South Africa There is hope that widespread adoption of SBI will have impact on alcohol problems in developing countries WHO has funded projects in Brazil and South Africa One seems like a success; the other not quite so There are structural and organizational issues to address, e.g. competing priorities in the clinic, who should carry out the screening, etc.

28. UNODC Treatnet project • International network of drug dependence treatment and rehabilitation resource centres • Initiated in 2005 to deliver and disseminate a variety of effective drug dependence treatment and rehabilitation • 4 priority areas - community based treatment, treatment and rehabilitation in prisons, role of drug treatment in HIV/AIDS prevention and care, reintegration and rehabilitation • Network of resource centres, trainers, multipliers • Many partners -- ILO, RWJF, EMCDDA, UNIADS, NIDA, CICAD

29. Suggested package of care in low income settings Opportunistic screening Start with brief advice to extended interventions Community based treatment of withdrawal (detoxification) Structured relapse prevention Pharmacotherapy Follow up and monitoring in the community Preventive interventions

30. Thank you