• Mention introduction of pre-discharge plans with solutions for health and social problems
• Plan needed at individual level, according to the socio-demographic background of the drug addict
• Subsequently, monitor and supervise post-discharge rehab process through individual level follow-up plan; target home visits

Since a high relapse rate is observed among local illicit drug addicts, the introduction of discharge plans incorporating solutions for identified health and social problems, at an individual level, according to the socio-demographic background of the drug addict, is recommended pre-discharge, along with the subsequent monitoring and supervision of the rehabilitation process post-discharge from rehabilitation centres through the formulation of a proper follow-up plan at the individual level targeting home visits. The multidisciplinary team-based support network required in this regard include the staff of rehabilitation centres, the family members of drug addicts, social workers, officers in the criminal justice system, health professionals, and the community.

These observations and recommendations were made in a review on ‘Illicit drug use among Sri Lankan males: Understanding the crisis for prevention and harm reduction', which was authored by I.L.A.N. Darshana (attached to the Ruhuna University’s Community Medicine Department), and published in the Galle Medical Journal's 29th Volume's First Issue, last month.

Illicit drugs are defined as ‘psychoactive substances, the production, sale or use of is prohibited within the prevailing legal system in a given country, and are used, for the long-term, on a regular basis, for a non-medical purpose’ (the World Health Organisation’s ‘Lexicon of alcohol and drug terms’). Heroin, cannabis, opium, cocaine, methamphetamine, hallucinogens and other psychotropic drugs are the commonly used illicit drugs in Sri Lanka. Illicit drug use has been identified as an emerging public health problem in Sri Lanka during the recent decades due to a multitude of factors. According to the National Dangerous Drug Control Board (NDDCB), the number of drug addicts, rehabilitation admissions and drug-related arrests have increased during the past few years. Many individuals and their families have suffered due to drug addiction throughout the world, and Sri Lanka is no exception. It affects a country in many aspects including in the economic, social, health, and educational spheres.

Throughout human history, people have been using some kind of stimulant in the form of alcohol or drugs for various reasons. However, in the recent past, with the introduction of illicit drugs, it has rapidly spread, especially among young males. As illicit drug use is a significant public health problem, especially in males, people who can contribute to national development are finally left as dependents.

By leaving males as dependent on an illicit drug, there is a direct threat to the backbone of the family. This creates a pressing need to reinforce the existing national policy on drug abuse with a focus on developing interventions targeting the health, education, treatment, and rehabilitation of drug users and strengthening the law enforcement agencies to prevent drug use. Therefore, it is a national responsibility to address the illicit drug-use disorder using appropriate mechanisms.

The first study was conducted to assess the patterns, determinants and associated health and social problems of past illicit drug use among incarcerated males in the Galle Prison (N. Darshana, C.J. Wijesinghe and R. Ruben’s ‘Past illicit drug use among incarcerated males in the Galle Prison: A descriptive, cross-sectional study on a single centre experience’, I.N. Darshana, R. Ruben and C. Wijesinghe’s ‘Health and social problems following illicit drug use among males experiencing incarceration in prison: A cross-sectional study on a single centre experience’, and I.L.A.N. Darshana, R. Ruben and C. Wijesinghe’s ‘Previously used substances and predictors of illicit drug use among incarcerated male prisoners in Galle’). The second study was conducted to assess patterns and determinants of drug use and its effects among male drug addicts in selected drug rehabilitation centres and the factors affecting relapse after rehabilitation (I.L.A.N. Darshana, C.J. Wijesinghe and P.V. De Silva’s ‘Patterns and determinants of drug use and its effects among drug addicts in selected drug rehabilitation centres in Sri Lanka and factors affecting relapse after rehabilitation’, N. Darshana, C.J. Wijesinghe and P.V. De Silva’s ‘Assessment of characteristics and exposure to vulnerable factors for drug use among male illicit drug users in Sri Lanka: A multicentre cross-sectional study’, N. Darshana, C. Wijesinghe and V. De Silva’s ‘Problematic level of drug use and its associated factors among illicit drug users in Sri Lanka: Experience from a multicentre study’, I. Darshana, C. Wijesinghe and P. De Silva’s ‘Assessment of motivation for rehabilitation among males with illicit drug use disorder in rehabilitation centres in Sri Lanka', N. Darshana, C. Wijesinghe and V. De Silva's 'Relapse rate following institutionalised rehabilitation of male heroin addicts: A Sri Lankan experience', and N. Darshana, C. Wijesinghe and V. De Silva's 'Predictors of relapse following institutional rehabilitation among drug users in selected rehabilitation centres in Sri Lanka'). 

Study one: Illicit drug use and incarceration 

A significant amount of prison admissions out of the total admissions in many countries, including Sri Lanka, are drugs-related. It has been reported that there have been nearly 80,000 drug-related arrests in Sri Lanka in 2021 with a prevalence of 390 arrests per a general population of 100,000. Nearly 24,000 drug-related prison admissions were reported in 2021 (the NDDCB's Handbook of Drug Abuse Information 2021'). Drug-related offences account for much of the prison admissions, making it a significant social concern. 

Methodology

A cross-sectional study was conducted which assessed past illicit drug use-related behaviour among a random sample of 449 incarcerated males in the Galle Prison. The study sample included adult male prisoners who were convicted, remanded or who had appealed against their convictions. Almost all admissions (more than 99%) to the Galle Prison were males and hence only male prison inmates were included. Prisoners who were mentally unsound to respond to the study questionnaires were excluded. The participants were selected from the Prison register using computer generated random numbers until the required sample size was achieved. 

Results

The study revealed that 48.9% of the inmates were imprisoned due to drug-related offences and that among them, 57.9% were Prison readmissions. Among drug-related offences, the majority (75.5%) were incarcerated for keeping illicit drugs for consumption followed by engaging in crime to obtain money for drugs (11.1%). Past illicit drug use was reported among 57.6%. Cannabis (80.3%) and heroin (58.2%) were identified as the commonly used illicit drug before imprisonment and on a long-term regular basis while polydrug use was reported by 36.2%.

Only 8.3% of illicit drug users had a severe problematic level of addiction followed by substantial (27.2%), moderate (27.5%) and low (37%) levels. A total of 35.4% required in-patient rehabilitation care at a drug rehabilitation centre.

Illicit drug dependence was identified among 56.7% illicit drug users. Past illicit drug use was associated with being of a younger age, being unmarried, engaging in manual work, and the use of alcohol and tobacco products. The Prison inmates in the younger age groups and those with a history of polydrug use were significantly more likely to be addicted to illicit drugs while being of a younger age, having a history of polydrug use, and addiction to illicit drugs, were significantly associated with problematic drug use.

Accidents and injuries (23.2%), dental caries (16.9%), skin diseases (9.1%), respiratory diseases (8.3%) and suicidal attempts (5.1%) were reported as common health problems among incarcerated males in the Galle Prison after the initiation of illicit drug use. At least one health problem was experienced by 43.7 % of these drug users. Of the social problems, legal problems (72.8%), financial problems (51.6%), employment-related problems (26.0%), disputes in the community (23.6%), disrupted family relationships (21.3%), and the disruption of academic activities/education (20.1%), were identified as common problems encountered after the initiation of illicit drug use. At least one social problem was reported by 83% of the drug users.

Prison inmates who had a history of polydrug use, who were addicted to illicit drugs, and had a high level of problematic drug use, were more likely to have health problems and social problems after the initiation of illicit drug use. Previous Prison admissions failed to show an association with the presence of health problems, and the presence of social problems experienced after the initiation of illicit drug use.

Discussion

Drug-related prison admissions, the presence of drug dependence, problematic drug use, and the presence of health and social problems due to illicit drug use were reported in significant amounts among the incarcerated males. Hence, more attention should be directed to addressing those problems through appropriate health and social interventions such as rehabilitation programmes for drug users, and screening for health problems. The identification of inmates with past illicit drug use is required at the time of prison admission, which is important to refer them to proper rehabilitation-related care.

Study two-A: Characteristics of illicit drug users admitted for rehabilitation 

The characteristics of drug users and exposure to vulnerable factors for drug use have geographical heterogeneity throughout the world. Sri Lanka is considered as a transit point for global drug trafficking due to its unique geographical location. Illicit drug use has become a significant public health problem in Sri Lanka. 

Methodology

A cross-sectional study was conducted among 431 institutionalised male drug addicts from five selected rehabilitation centres in four different districts, namely, the Nawadiganthaya (Gampaha), Meth Sevana (Kandy), Mith Sevana (Galle), Seth Sevana (Colombo), and the New Life Rehabilitation Centre (Galle). 

Results

Drug dependence was identified among 97% of illicit drug users. The majority (89.4%) of the sample was addicted to heroin. Cannabis was identified as the gateway drug for illicit drug use for 81% of the drug users. Experimental usage, peer pressure, being unaware about the harmful outcomes of drug use, the ability to conceal drug use-related behaviour from the family, easy accessibility, the previous use of alcohol and tobacco, the history of exposure to psychoactive substance use within the usual living environment, being in a family with inadequate protection, and having an unsatisfactory parenting status, were identified as common characteristics of subjects with illicit drug use disorders and drug use-related behaviour. The age of first drug use was positively cor-related with the age of first alcohol use and first smoking. Ethnicity, the area of residence, the severity of drug use, and the age of initiation of drug use, had statistically significant associations with the presence of vulnerable factors for drug use.

Discussion

Illicit drug use in Sri Lanka varies across the ethno-religious communities, and socio-economic and cultural groups in the country. Heroin was identified as the main dependent drug and cannabis was identified as the illicit gateway drug for drug users while tobacco was identified as the gateway psychoactive substance for psychoactive substance abuse. The adolescent period was identified as a risk period for the initiation of the use of psychoactive substances including illicit drugs. It is clear that the patterns and characteristics of illicit drug use share a geographical heterogeneity throughout the world and geographical homogeneity within the region and within the country. The history of exposure to vulnerable factors for drug use was not uncommon in the sample. 

Study two-B: Problematic level of drug use 

The proper assessment of problematic drug use is useful before selecting to manage as in-patient clients, and to avoid unnecessary admissions to rehabilitation centres. 

Methodology

In the second part of the cross-sectional study, problematic illicit drug use is defined as the ‘drug use that is accompanied by a degree of addiction by which the user is no longer offered the possibility to control his/her use, and that is expressed by psychological and physical symptoms’ (per a Belgian study). 

Results

According to data from N. Darshana, C. Wijesinghe and V. De Silva's 'Problematic level of drug use and its associated factors among illicit drug users in Sri Lanka: Experience from a multicentre study', only 16.9% of illicit drug users undergoing rehabilitation had a severe problematic level of addiction while over half of the sample (54.1%) had a substantial level of addiction. A total of 29% of the illicit drug users (low or moderate levels of addiction) admitted for rehabilitation could in fact be managed as outpatient clients. As in-patient rehabilitation care was recommended only for a substantial or severe level of addiction, this indicated an unnecessary burden on the limited resources. Drug users with a history of exposure to abuse during childhood or adolescence were nearly four times more likely to have a high problematic level of drug use compared to those who did not have a similar history, thus making it the strongest predictor of problematic drug use. In addition, drug users who initiated drug use during adolescence, those who had a high income or those who were non-manual workers were more likely to have a high level of problematic drug use compared to those who initiated drug use during adulthood, those who had a low income or those who were unemployed. The age of the drug user, the area of residence, the duration of drug use, and having a family history of drug use, failed to emerge as significant predictors of the problematic level of drug use.

Discussion

As problematic drug use varied widely, the need for its assessment at the individual level is evident for the better implementation of the rehabilitation process and the effective utilisation of the available resources. The study identified that a considerable proportion of drug users had unnecessary in-patient rehabilitation admissions (29%), causing an overburden on the rehabilitation system. The drug abuse screening test (DAST) 20 was identified as an important tool for the screening of drug addicts to identify the problematic level of drug use and the study recommends its use at the community level and as an admission criterion in deciding the necessity for in-patient treatment or therapy at rehabilitation centres as well as in prisons.

Study two-C: Motivation level for rehabilitation 

Inadequate motivation for rehabilitation among persons with illicit drug use disorder is identified as the main reason for relapse after rehabilitation. Many persons with illicit drug use disorder in Sri Lanka enter into the rehabilitation process due to enforcement by the family or through the legal system and only a few present as self-referrals (P.V. De Silva and P. Fonseka's 'Drug addicts and their behaviour-related to drug addiction among the institutionalised addicts of the Galle District'). To change their illicit drug use-related behaviour, a client must reach a state of readiness and willingness to change. Measuring and addressing ‘individual motivation’ is identified as an important aspect of the rehabilitation process. Recognising the main influences which impact a person’s engagement and retention in rehabilitation programmes is also an important prerequisite for successful rehabilitation.

Methodology

The third part of the cross-sectional study assessed the motivation level for rehabilitation-based on the 'trans-theoretical model' using the validated Sinhala translation of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). The motivation was assessed under the three subscales: Recognition, Ambivalence, and Taking Steps. 

Results

The study found that the majority (52.9%) had a moderate level of motivation for rehabilitation in all three subscales (I. Darshana, C. Wijesinghe and P. De Silva's 'Assessment of motivation for rehabilitation among males with illicit drug use disorder in rehabilitation centres in Sri Lanka'). A high level of motivation for rehabilitation was reported by 23.4%, while a similar proportion (23.7%) reported low motivation. Only the problematic level of drug use and awareness about the adverse consequences of drug use emerged as statistically significant predictors of motivation for rehabilitation.

The participants who reported higher problematic levels of drug use were less likely to have a high motivation for rehabilitation compared to those with a low problematic level. Being aware of the adverse consequences of drug use was more likely to have a high motivation for rehabilitation compared to not being aware of the consequences. The age category, the marital status, and the duration of drug use, failed to show associations with motivation for rehabilitation.

Discussion

The level of motivation for rehabilitation was found to be inadequate among males with drug use disorder and this finding was supported by the high readmission rate. The study emphasised the need for the incorporation of the assessment of the 'readiness to change' into the rehabilitation process to identify those with a low motivation to change drug use-related behaviour. This will facilitate early and rigorous interventions to prevent future relapses. The assessment of motivation for rehabilitation at the beginning of the rehabilitation process is important to plan rehabilitation activities as well as to identify the barriers for change among persons with illicit drug use disorder. Any person with illicit drug use disorder can end up with a relapse despite having a higher motivation level at the beginning unless they maintain their action for at least six months. A repeat assessment of motivation at discharge from the rehabilitation centre will be required, which could also be used as a valuable predictor of long-term rehabilitation for better outcomes. As a significant number of drug users had a lack of motivation for rehabilitation, attention should be directed towards the re-orientation of the rehabilitation programmes for persons with illicit drug use disorder. By incorporating activities into rehabilitation programmes that increase recognition and avoid ambivalence, drug users can be supported to continue those actions even after discharge from the rehabilitation centres.