Indian J. Prev. Soc. Med. Vol. 37 No. 3& 4, 2006

[ Indian J. Prev. Soc. Med. Vol. 37 No. 3& 4, 2006 PROFILE OF TREATMENT NON-SEEKER HEROIN ADDICTS AND THEIR REASONS FOR NOT SEEKING TREATMENT Braham Prakash 1, Anuj Dhawan 2, (Mrs) Hem Sethi 3 ABSTRACT Research question: why heroin addicts delay or never seek treatment? Objectives: (1) To examine the reasons given for not receiving treatment by regular heroin users who live close to community outreach clinic (AIIMS); (2) To study the profile of heroin users in Trilokpuri; (3) To suggest intervention for treatment non-seekers. Study design: cross sectional. Setting: Trilokpuri (Resettlement Colony), Delhi. Participants: 85 heroin users who have not received treatment for heroin addiction. Tools: DSM IV- criteria for drug dependence and semi structured interview schedule. Statistical analysis: Percentage, mean, standard deviation. Results: Profile chasing was the most common route of intake of heroin. Majority of heroin users were between the age group 21-40years. Mean duration of heroin dependence was 4.11 years. Nuclear type of family was more common. Various occupational group were represented however, transport operator (Drivers) and small businessman were the two largest group. Majority took 1 to 2gm of street level heroin. Peer group influence was the main source of introduction of heroin in 48.62% addicts. Majority of them (42.35%) were illiterate. Lack of awareness about the treatment facilities, need for treatment not felt, not possible to give up heroin (afraid of heroin withdrawals), treatment does not help; concern about child care; can leave on one s own & ashamed to admit problem were found to be the common reasons for not seeking treatment. Barriers to treatment must be addressed if we want to encourage the greater population of untreated heroin user to enter in treatment. Key words: Heroin addicts, Barrier to treatment, Treatment non-seekers. 1. MSSO, National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi- 110 029 2. Associate Professor, National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi- 110 029 3. Mrs. Hem Sethi, Research Officer, National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi- 110 029 Postal Address :Dr. Braham Prakash, H.No. 22, Masih Garh, P.O. Jamia Nagar, New Delhi- 110 025 Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB & Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

INTRODUCTION A number of both medical and non-medical disciplines have expressed concern regarding the large numbers of individuals that fail to present to services, despite experiencing problems similar to those of active help seekers. Among opiate addicts, several studies have identified groups of untreated addicts who report less severe substance use as well as less impairment in psychosocial areas associated with substance abuse with respect to treatment seeking addicts (Graeven 1983) 1. These studies suggest that treated and untreated addicts characterized by greater ability to control their substance use, less prolonged use, and greater likelihood of improving or renouncing drug use without formal intervention. In the United States, Terry & Pellens (1970) 2 work in the 1920s set the precedent for examining the life course of drug abusers. Many years later, Power et al (1992) 3, using data from a national survey, found that untreated male heroin user reported fewer drug related problems in their social functioning (e.g. work, family relationship) and were less likely to use heroin in a problem solving fashion, though they were similar to treated addicts on demographic factors such as class, race. Barriers research has identified a broad range of psychosocial factors that may interfere with help seeking for drug problem and behaviour change. Several client barriers have been consistently identified as potential obstacles to change drug-taking behaviour. These client barriers include: psychosocial risk factors; stigma associated with drug use; and insufficient resources (i.e. social or financial) to support treatment entry and behaviour change. There is evidence to indicate that staff & service characteristics may affect recruitment and retention rate, and treatment outcome. This study examined the reasons given for not receiving treatment by regular heroin users who live close to community outreach clinic (De-Addiction Centre, AIIMS). MATERIALS AND METHODS The study was carried out at Trilokpuri area of Delhi, India. This area falls within the catchments domain of the community out reach clinic of the De-Addiction centre of All India Institute of Medical Sciences in New Delhi. The staff consist of a psychiatrist, a medical social service officer, a staff nurse, all of whom have been with the drug services for about 15 years. A total of 150 respondents were selected from the study area by resorting to purposive sampling procedure, out of which 25 refused to participate in the study, 10 missed the appointment & 30 could not fulfill the set criteria. All subjects for this study were required to meet the following criteria (1) regular use of heroin (three times weekly or more) for at least two years and qualify DSM-IV criteria for drug dependence; (2) evidence of heroin withdrawal symptoms on cessation of the drug; (3) not having any psychiatric illness; (4) to have not sought treatment within the previous three year; (5) gave verbal consent for the study. Finally 85 respondents were interviewed in detail for the purpose of this study. An interview schedule was Indian J. Prev. Soc. Med Vol. 37 No.3& 4 159

used for collecting data. Heroin addicts who had not sought treatment were identified through the chain-referral or Snow ball technique. PROCEDURE Potential subjects were first approached by the local leader/social worker working in that area. Then the author (BP) contacted them to fully explain the purpose and procedure involved in the present study. The interview protocol was developed by the author with the help of professional social workers and psychiatrists of All India Institute of Medical Sciences and included questions about; drug use pattern; and reasons for not seeking treatment. The interview would take about 20-25 minutes to complete. RESULTS The following paragraphs describe the sociodemographic profile of the respondents. The analysis showed that majority (69.41%) of the heroin users in the present study were between age group 21 40 years. Educational status was also reported very low as large numbers 36 (42.35%) were illiterate. Nuclear type of family was more common 55 (64.70%). Various occupational groups were represented however, transport operator / production labour (63.52%) and small businessmen (Sales worker) were the two largest group. Majority (71.76%) of them were employed at the time of study. Furthermore, married respondents were out numbered by unmarried respondents as their percentage were 45 (52.94%) and 18 (21.17%) respectively, 12 (14.12%) were widower and rest 10 (11.76%) were divorced / separated. Majority 68 (80%) were Hindu, followed by Sikh 12 (14.12%) and Christian 5 (5.88%). Table-1: Socio-demographics of Heroin users (N=85) Particulars No. % Age (years) Upto 20 05 5.89 21-30 27 31.76 31-40 32 37.65 41-50 15 17.65 51 & above 06 7.05 Age - Mean SD 34.89±10.0 Education Illiterate 36 42.35 Primary 21 24.71 Middle 14 16.47 Upto 12 th 12 14.12 Graduate 02 2.32 Occupation Sales worker 13 15.29 Service worker 10 11.76 Production labour/ transport 54 63.53 operator Others (Pick pocketing, theft, 08 9.42 drug peddling) Employment status (at the time of study) Employed 61 71.76 Unemployed 22 25.88 Part time employed 02 02.36 Marital status 45 52.94 Unmarried 18 21.18 Divorced/ separated 10 11.76 Widower 12 14.12 Family type Joint / extended 16 18.82 Nuclear 55 64.71 Alone 14 16.47 Hailed from Urban (resettlement colony) 85 100.0 Rural --- --- Religion Hindu 68 80.0 Christian 05 5.88 Sikh 12 14.12 Monthly income of family (Rs.) Below Rs.1000 06 7.06 1000-2500 48 56.47 2501-4500 23 27.06 4501 & above 08 9.41 Mean from Actual values Rs.2431 p.m. Indian J. Prev. Soc. Med Vol. 37 No.3& 4 160

Profile of heroin addicts : In general, the profile of the heroin user in the sample is similar to typical profile of problem drug user in a metropolitan city. Profile of 85 patients included in the sample is presented below: Doses per day: The exact dosage of heroin cannot be measured accurately because the user themselves do not know the exact weight of heroin in packets or Pudias they purchase from vendors. All they can say is the approximate amount of heroin they were consuming in last one month. From the table 2(a) following conclusion emerges. Majority 46 (54.11%) of the patients took 1 to 2 gm of street level heroin. Fourteen (16.48%) of heroin user in the sample were taking zero to ½ gm/day of street level heroin, while 12 (14.12%) were taking more than 2 gm/day. Thirteen (15.29%) were taking ½ to 1gm/day of street level heroin. Duration of dependence: The duration of heroin dependence at the time of study was divided into three categories, namely, 1 to 3 years, 4 to 6yrs and 7-10 years. The results are shown in table 2(b). It shows that majority 53 (62.35%) had been taking it for more than seven years. Next percentage was of those who had been taking heroin for 4-6yrs; 25 (29.41%). Then came the percentage of those who had been taking it for 1-3 years (8.24%). The mean duration of heroin dependence in the sample is 4.11 years. Route of intake: The route of intake of heroin was divided into four categories namely, smoking, chasing, Intravenous / intra muscular. Table 2(c) indicates that 68 (76.41%) of the heroin users identified were as chaser that is they administer the drug by inhaling the vapor coming out of the heated substance. It could be because patients get better effect by this method and there is little wastage of drug. About 10 (11.24%) smoked heroin by mixing it with tobacco. About 7 (7.86%) percent were injector intravenous or intra muscular. Some patients 4 (4.49%) have used multiple routes. Reasons for starting heroin: The etiology of drug use is not known. More specifically it is not known why some people but not others start experimenting with drug (heroin) or continue to them in the same situation and finally why some but not all become dependent on heroin. All these questions create curiosity in the mind of the author to know why people start taking heroin. Table 2(d) shows the main reasons for starting heroin. These are (I) Peer group influence: such as to go along with what friends were doing; to enjoy drug effect with friends were doing. Peer group influence was the main source of introduction of heroin in 53 (48.52%) of heroin user in the present sample (II) Exploration: such as curiosity & desire to see what a drug was like to try anything new. About 17 (15.59%) of heroin user started taking it because of exploratory reasons. (III) Problem solving: such as to relax; to relieve tension, to overcome depression; to get away from problem; to enhance sexual performance & to prove better sexuality. In about 22 (20.18%) of subjects problem solving has been identified as cause of starting heroin. (IV) As a recreation or to get euphoria: such as to get pleasure, feel good; to get high and to produce intense exciting experience. About 10 (9.19%) of subjects in the sample have started taking heroin for pleasure Indian J. Prev. Soc. Med Vol. 37 No.3& 4 161

or recreation. About 7 (6.42%) of subjects in the sample have started taking heroin because it was available in their area. Table- 3 : Reasons for not seeking treatment: In an effort to identify reasons for not seeking help, subjects were interviewed to elicited reasons for their not having sought treatment. The majority 55 (40.61%) reported they had not sought treatment because they did not know where to seek help; 28 (21.05%) said they did not felt the need for treatment as they were enjoying the effect of heroin. The next two most commonly cited reasons were Social Stigma 13 (9.8%) and dislike for treatment package 9 (6.76%). Other endorsed reasons included, dependent children could not be left alone 8 (6.02%), family not extending support for treatment 4 (3%) lose of days work 4 (3%), treatment does not help 4 (3%). Interestingly 3 (2.26%) thought they can leave drugs on their own. DISCUSSION Alcohol and drug abuse and dependence are common disorders in our society and the vast majority of those who recover do so without formal treatment. A number of both medical and non-medical disciplines have exposed concern regarding the large numbers of individuals that fail to present to services despite experiencing problems similar to those of active help seekers. Barriers to treatment must be addressed if we want to encourage the greater population of untreated heroin user to enter in treatment. These barriers might be reduced by a change in public perception of the problem, explaining the role of treatment (Medication). Table - 2: Profile of Heroin Addicts [2a] Distribution of patients according to quantity of Heroin consumed per day in preceding one month. Quantity per day No. % Zero to ½ gm 14 16.48 Between ½ to 1gm 13 15.29 Between 1 to 2gm 46 54.11 More than 2 gm 12 14.12 Total 85 100.0 [2b] Duration of Heroin use Duration in years No. % 1-3 07 8.24 4-6 25 29.41 7-10 53 62.35 Total 85 100.0 Mean duration of dependence 4.11 years (mean from actual values). [2c] Route of Heroin intake (N=85) Route of consumption No. % Smoking 10 11.24 Chasing (inhaling) 68 76.41 Intravenous / intra muscular 7 7.86 Combination of above 4 4.71 Total 89 100.0 Patient has multiple choice [2d] Distribution of patients according to their reasons for starting Heroin (N=85). Reason No. % Peer group influence 53 48.62 Exploration 17 15.59 Problem solving 22 20.18 As a recreation or get euphoria 10 9.19 Availability of heroin 7 6.42 Total 109 100.0 Patient has multiple choice Indian J. Prev. Soc. Med Vol. 37 No.3& 4 162

Table 3: Reasons for not seeking treatment (% Distribution) (N=85) Reasons No. % Need for treatment not felt 28 21.05 Not possible to give up drug 3 2.26 Can leave on one s own 6 4.52 Treatment does not help 4 3.00 Not aware about the treatment facility 54 40.61 Nature of treatment not to patients liking 9 6.76 Social stigma 13 9.78 Lose of day s work 4 3.00 Dependant children could not be left alone 8 6.02 Family not extending support for treatment 4 3.00 Total 133 100.0 Note : Patients have been entered in more than one category where applicable. Family and community involvement to motivate heroin addicts and to inform them about the existing treatment centres. This community based study elicited reasons for not seeking treatment in a sample of heroin users. The principal barriers identified included lack of awareness about the treatment facilities, need for treatment not felt; not possible to give up drug, social stigma, dislike for treatment package/treatment does not help, concern about child care; can leave on ones own and ashamed to admit problem. The study by Marlatt et al. (1997) 4 proposed that psychosocial problem, which are related to substance use, may promote help seeking. There can be several external factors e.g. family, problem at work place etc that influence the decision to seek help. However, mere recognition of the problem may not lead to treatment. Informal advice and suggestions from social net work may also influence treatment seeking. We suggest following interventions to motivate heroin addicts to seek treatment: (1) Assessment and identification of heroin addicts. (2) Educate masses to reduce stigma and enhancing awareness about drug use. (3) Sensitization of primary health care physicians regarding identification and referral to treatment centres. (4) Brief intervention with already identified group / individual. It includes five A s (Ask, advice, assess, Assist and arrangement for fallow up). (5) Community out reach program. It includes school visits, community visits, involvement of local leader, NGOs, Govt. agencies and families of addicts. Indian J. Prev. Soc. Med Vol. 37 No.3& 4 163

(6) Treatment should be free and available to all. Mere building of treatment centres will not be enough. Drug users in the community will have to be motivated informed and encouraged to come forward to seek treatment. REFERENCES 1. Graeven DB, Graveven KA. Treatment and untreated addicts: factors associated with participation in treatment and cessation of heroin use. J Drug Issue 19983; 13:207-217. 2. Terry C and Pellens M. The opium problem. New Jersey: Patterson Smith. 1970. 3. Power R, Hartnoll R, Chalmers C. Help seeking among illicit drug users: some differences between a treatment and non-treatment sample. Int J Addict 1992; 27(8):887-904. 4. Marlatt GA, Tucker JA, et al. Help-seeking by substance abusers: The Role of Harm Reduction and Behavioural-Economic Approaches to Facilitate Treatment Entry and Retention. In OnKen LS et al. Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment. NIDA Research Monograph 165, NIDA, USA. 5. Grant BF. Barriers to alcoholism treatment: Reasons for not seeking treatment in general population sample. J Stud Alcohol 1997; 58:365-371. 6. Copeland J. A qualitative study of barriers to formal treatment among women who self managed change in addictive behaviours. J Subst Abuse Treat 1997; 14(2):183-190. 7. Fergusson MD and Horsood LJ. Psychiatric disorder and treatment seeking in a birth cohort of young adult. Report prepared for Ministry of Health from the Christchurch Health and Development study. Department of Psychological Medicine, Christchurch School of Medicine New Zealand. 1998. 8. The extent, Pattern and Trends of Drug Abuse in India, National Survey. Sponsored by Ministry of Social Justice and Empowerment, Government of India and United National Office on Drug and Crime. Regional Office for South Asia 2004; 99-36. Indian J. Prev. Soc. Med Vol. 37 No.3& 4 164