(introduction...)

The care of individuals with drug- or alcohol-related problems is not the preserve of any one health profession or group. Medical practitioners, clinical psychologists, social workers, and other less specialized personnel all have important contributions to make. Such care does not have to be provided in an institutional setting; the role of the community health worker has been increasingly emphasized in recent years. Furthermore, the concept of health for all by the year 2000 will become a reality only if problems such as drug dependence and alcohol abuse are handled mainly through primary health care.

The aims of this chapter are to help primary health care workers to define their role in the management of people with drug- and alcohol-related problems and to equip them with the necessary skills. It is assumed that PHC workers see themselves as members of a team of health workers functioning at the community level.

It should be borne in mind that drug and alcohol dependence are often relapsing conditions. It is, therefore, unhelpful if the carer's attitude is judgemental, critical, or moralistic. The patient needs reassurance and understanding, not rebuke and rejection. The life of a drug-dependent person is usually full of crises, and carers should be able and willing to accept this state of affairs and to help the patient deal with it.

Helping a drug-dependent person

Who is a drug-dependent person? First and foremost, he or she is a human being, with feelings and emotions, capable of appreciating help. Drug-related problems may be almost totally buried inside other social, physical, and psychological problems. Furthermore, drug-dependent people may try to ignore their drug problems, even denying that they exist. This denial is a "brick wall" that drug-dependent people erect around themselves. The wall must come down, and the health worker must help to demolish it.

Behind the wall of denial there are usually a number of social, physical, and psychological problems. A female problem drinker, for example, is likely to see herself as an outcast, and others may see her in the same way. She probably spends a great deal of money to satisfy her need for alcohol and is thus relatively poor. Her family is probably embarrassed by her drinking. She may have become unemployed and is sometimes unemployable. With time she might lose her home, her family, and her self-respect. She may suffer from physical illnesses that are a direct consequence of the alcohol abuse, just as she may present with psychological problems, severe depression, anxiety, or even discrete psychiatric syndromes.

It is clear that the problems associated with drug and alcohol abuse are not always medical, but are often social and psychological in nature. Medically, there is not a single physical system in the body that remains untouched by drugs and alcohol. Most mental systems are also affected. Hallucinations and delusions occur and mood changes are very common. Socially, clients often require assistance to help them return to a semblance of normal existence. They may need help to refrain from criminal behaviour, find a home and employment, avoid activities and crises that will precipitate a relapse, and develop new relationships.

Apart from participating in activities to prevent drug and alcohol abuse and in treatment programmes, the primary health care worker has the added responsibility of identifying drug-dependent persons, and individuals with alcohol-related problems, within the community, and of ensuring that they receive treatment at an early stage.

Dealing with such a wide range of problems and activities might seem to be an overwhelming task. Remember, however, that, whenever possible, the PHC worker should obtain the support of a wider team, including volunteers and relatives of the patient. If this is not possible, the PHC worker should at least try to influence a client in the right direction.

It is useful to divide the management of drug- or alcohol-dependent persons into four distinct phases, even though these overlap. They are:

- assessment,
- detoxification,
- specialized interventions,
- follow-up and after-care.

A client may not require detoxification. As a rule, detoxification is called for only when severe withdrawal symptoms are expected to occur following a quick return to abstinence or minimal drug use.

Assessment

Chapter I deals with assessment of the individual as a preparation for action. The main aims of assessment are:

· to obtain as much accurate information as possible about the individual's drug use and any associated problems;

· to try to identify the factors associated with drug abuse in the individual-these may be physical illnesses or social or psychological factors;

· to assist the PHC worker to recognize the strengths and weaknesses of the individual and his/her family, as well as his/her ability to cope with the problems and assist in their management.

A good assessment interview will help to develop a positive, helpful relationship, and will serve to build up a picture of the client's particular problems. As a basis for action, an assessment should provide information relating to the following treatment goals:

· improving social relationships and supports;
· developing confidence in ability to change;
· identifying reasons to change;
· developing alternative activities;
· learning to prevent relapse.

One way of remembering these live goals Remember the word SCRAP which stands for: S = social relationships C = confidence in ability to change R = reasons to change A = alternative activities P = preventing relapse

Detoxification

Of all the drug-dependent people that the PHC worker will see, those who use opiates, or excessive amounts of alcohol, are most likely to experience severe withdrawal symptoms. It is difficult to predict the severity of these symptoms, but the best evidence of what to expect is provided by a client's past experience of withdrawal.

Intense craving, and most of the physical dangers that can result from the sudden termination of a drug, can be forestalled by gradually reducing use of the drug, or by using a substitute. Gradual detoxification may take many months to complete, as is often the case when heroin is replaced by methadone, which is itself gradually withdrawn. Indeed, some therapists are happy to leave their clients on methadone indefinitely. On the other hand, drug substitution during alcohol withdrawal can be completed within a week.

A drug-withdrawal regime will have best chance of success when there is a clear agreement about the need to reduce the drug dose, and about the time-scale involved. In general, it is best to respect the client's views when negotiating a withdrawal strategy. If a patient is keen to stop using drugs very quickly, then this view should be supported, with the option of some adjustment if the experience turns out to be too stressful.

During detoxification it is important that encouragement and reassurance are provided by the PHC worker, friends, and relatives. The need for some form of psychological support cannot be overemphasized.

The support of friends and relatives is essential.

Specialized interventions

Social supports and relationships

A person with a drug- or alcohol-related problem needs to have regular contact with other people, who can often help simply by listening and giving encouragement. One role of the PHC worker is to identify people who might be able to help in this way. They might be relatives or friends, former drug users, a priest, or volunteers.

Another valuable role for the PHC worker is to encourage better communication between clients and their families. One simple method of helping people to communicate is outlined below.

Helping communication

If a husband and wife are communicating badly, the PHC worker should concentrate on teaching them ways of improving their communication skills. First of all select an object, such as a piece of fruit or a stone. Explain that only the person holding the stone is allowed to talk. Give the stone to the husband, who should then talk for about one minute. His wife should then take the stone and summarize what her husband said. When a correct summary has been made, the wife should continue to talk, expressing her own views for about one minute. She then passes the stone back to her husband and he summarizes her statement. This whole cycle is then repeated.

This simple strategy can help to develop good communication skills involving active listening and summarizing.

Helping a family usually involves the following components:

- increasing ability to communicate in order to solve family problems more efficiently;
- increasing the amount of praise, and the frequency of positive comments, within the family;
- reducing the frequency of conversations about negative incidents in the past.

Developing confidence In ability to change

Most people with drug or alcohol problems have tried to change many times. After repeated failures they usually experience feelings of helplessness whenever they try to change, or even when they think about trying. The PHC worker should discuss these feelings and provide encouragement and hope by:

- pointing out that nearly every person suffering from drug problems actually tries to stop many times before finally succeeding;

- discussing any small (or large) successes in the past and pointing out that the same can be achieved again;

- as treatment progresses, keeping an eye open for small successes, praising these, and encouraging the patient to keep trying;

- when a relapse occurs, pointing out that this is bound to happen from time to time; preventing relapse is a skill that has to be learned.

Clarifying reasons for changing

Some patients know exactly why they need to reduce their drug use. If this is the case, then they should be reminded of their reasons regularly and vividly. The following strategy can help:

· Identify the two or three main reasons why the patient should stop or reduce his/her drug or alcohol use. For example:

- to save his/her marriage,
- to improve health and fitness,
- to save money in order to take a family holiday.

· Now find an activity that your patient does regularly every day (e.g., drinks eight cups of tea throughout the day).

· Ask your patient to think about the reasons for stopping or reducing drug or alcohol use and to build up a positive image, e.g., of a good marriage, a healthy body, or a happy holiday.

· Now ask him or her to bring these images to mind every time he or she has a cup of tea; in this way, the patient is more likely to have these images in mind when faced with a tempting situation.

Alternatives to drug use

If a patient lives alone and has no job, no friends, no interests, and no hope, commitment to change will be low and relapse will be likely. The PHC worker should try to get the patient to take up one or more pleasurable activities that do not involve drugs. One possible strategy involves the four steps outlined below:

· devise a short list of possible activities;
· select one or two activities that are of interest to the patient and can be easily taken up;
· obtain the patient's commitment to become involved in these activities;
· take a keen interest in your patient's achievements.

Initially, tasks should be small, specific, and achievable, e.g., walk to the next village and back on Monday, Wednesday, and Friday (not simply, go walking).

Encourage the patient to take up a specific activity.

Preventing relapse

One of the tasks of assessment is to identify high-risk situations and mood states that have, in the past, resulted in relapse. For example:

· a family row;
· when the patient is in the company of a particular person;
· when the patient has a whole weekend ahead with nothing to do.

The PHC worker and the patient should together try to think of ways of coping with or avoiding these situations. List possible coping strategies and then select the most appropriate ones. For example:

Problem:	What to do about my desire to use drugs when I have nothing to do at the weekends?
Solutions:	1. Always plan weekends as far ahead as Wednesday.
	2. If the desire to use drugs starts to increase, then take a bus to go and see an uncle in the country.
	3. Think of the reasons why I have given up drugs when I am doing a pleasurable task, such as digging the garden.
	4. Go for a very long walk.
Selection:	3 and 4.

Crises and relapse situations are bound to occur during the follow-up period. One approach to crisis intervention is to build on a simple but systematic approach to problem-solving, such as the one outlined above. Crisis intervention is described in more detail below.

Follow-up and after-care

Most patients suffer a relapse fairly early. After the first six months, relapse becomes increasingly less likely but can still occur many years after treatment.

Certain factors are associated with relapse. These include poor social and psychological adjustment, as well as incomplete removal of the factors that initially precipitated the disorder (e.g., the same drug-using peer group, the same crippling pain for which the drug was initially prescribed, the same level of depression or anxiety). Crises often occur unexpectedly and no amount of preparation will give absolute assurance that crises will not occur. The answer is prompt and adequate crisis intervention.

The procedure for crisis intervention (or clinical problem-solving) involves three stages:

· clarification of the problem;
· search for a solution;
· decision-making.

Clarification of the problem

· Allow the patient to tell the entire story in his or her own words.

· Help the patient to express fully his or her feelings about the problem: the patient's awareness of these feelings will be a key factor in resolving the crisis.

· Ask specific questions regarding aspects of the problem that you do not understand, that are not clear, or that the patient may not have considered.

· Rephrase the problem as you understand it, and see if the patient agrees with your assessment; if not, repeat the entire process outlined above until you can rephrase the problem in a form that the patient accepts.

· If the problems are complex and overwhelming, identify one problem that can be considered initially.

Search for solution

· Ask the patient to name all the possible ways of resolving the problem.

· Mention any alternatives that may have occurred to you, but not to the patient.

· Help the patient to establish which parts of the problem are most important, and which are least important.

· Assist the patient in deciding which parts of the problem should be addressed immediately, and which can be left until later.

· Help the patient to decide what further information must be obtained in order to resolve the problem.

Decision -making

· Help the patient to decide which features of the problem can be changed, and which features must be accepted (at least temporarily, if not permanently).

· Counsel the patient to make as few far-reaching decisions (such as seeking a divorce or quitting a job) as possible during the period of crisis.

· Help the patient to make any decisions that are immediately necessary.

· Avoid making any decisions on the patient's behalf, unless there is a life-threatening situation (e.g., the patient is delirious or suicidal).

· Invite the patient back to see you at a specific time, in the near future, in order to assess his or her progress.

Many drug-dependent persons find that they are in conflict with others within their immediate environment. The PHC worker has an important role to play in mediating between the patient and these other individuals.

The procedure is as follows:

· Get both sides to express their concerns in their own words; facilitate full expression of the problem, and clarify its nature, by asking questions.

· Ask the drug or alcohol abuser to describe what he or she wants to happen; this might be approval to return home or to resume work.

· Ask the affected person (e.g., family member, work supervisor) to describe what he or she wants to happen, as regards the patient; this might be the patient's return home or resumption of work.

· Inquire whether an agreement can be negotiated between the parties. For example, would the abuser cease drug or alcohol use in return for being reinstated in his/her job' and would the work supervisor reinstate the person if drug or alcohol use were discontinued?

· If the matter can be negotiated up to this stage, it is important to agree on a contingency plan in the event of relapse (since relapses are common, especially in the early stages of recovery). For example, the patient may be suspended from work, or asked to leave work for one week with the first relapse, two weeks with the second relapse and so on.

The basic rules in negotiating a contract: - draw up very clear and specific rules; - ensure that a change for the better is rewarding to all parties; - agree that one or two lapses do not make the agreement null and void.

Finally, it should be emphasized again that, apart from the primary health care worker, there are usually a number of other local people who can be involved in the care and after-care of the client. These include religious and traditional leaders, traditional healers, law enforcement agents, and recovered clients. Religious and traditional leaders are usually very highly regarded, particularly in developing countries. They are guardians of opinion and behaviour, and their potential contribution should not be underestimated. I hey know most families within the community, and they can be very useful in tracing clients who default.

In many developing countries, patients still consult traditional healers more often than they do orthodox health workers. Community-based health programmes for drug- and alcohol-dependent persons are therefore meaningless unless they take account of the important role of traditional healers.

Law enforcement officers are usually seen as agents of punishment. This idea needs to be changed, since the police can be very helpful in a variety of ways. Also, recovered drug-dependent persons can often play a vital role in the treatment of others in the community. Such an activity can not only help the recovered person to stay off drugs, but also give the new patients the confidence and hope that they too can recover completely.

The PHC worker should be ready and willing to refer patients to specialist services, if these are available. Such referrals should be prompt and appropriate, and the PHC worker must therefore know about the existing specialist social and medical resources. Before referring a patient, the PHC worker should carefully explain why, and to whom, he or she is being referred, and what to expect. Therapists should be open and honest. They should enjoy their patients' confidence, and assure them that they will continue to provide help and support.

Total abstinence is not always possible in the short term, and the PHC worker should appreciate the value of a reduction in drug and alcohol use. Furthermore, many patients will fail. They should be encouraged to try again. Relapses are very common and may occur many times before the patient finally achieves success. The therapist should not give up.