Prevention of substance use disorders in the community and workplace.

Prevention in the community and at the workplace is a vital component in substance use disorder treatment and management. Mobilizing the community, creating awareness that addiction to substances is a disease, that it is treatable and that treatment is available are all essential. A cost-effective prevention and treatment approach plays a major role in creating drug free communities. Workplace prevention policies to prevent and manage substance use disorders leads to safer work environments, better motivated teams of workers and a productive workforce.

INTRODUCTION

Community

In communities, whether rural or urban, the problem of substance abuse is rampant. Community level studies show varying prevalence, depending on the methodology and scales used for assessment of substance use disorders.[1] The recently concluded mental health survey of India estimates the prevalence of substance use, including alcohol use disorders, at 22.4% of the adult population.[2] The survey also mentions a high treatment gap of 86%. It highlights that the problems are emerging in special populations like children, females and elderly.[3]

Awareness levels of the fact that getting started with alcohol and other drugs can lead to addiction and that addiction is a disease are very low. The strong stigma attached to seeking help is common and widespread, and because of this, the harmful effects to the person and the family are not squarely faced and dealt with. Addiction is guarded as a huge family secret. As the disease progresses, it becomes known to the whole community and rather than referring him/her to the appropriate treatment facility, the community suggests home remedies, rituals and blames the family. Prevention programmes and sensitization is the need of the hour.

Early prevention intervention in the community

Preventing the growth of this problem in communities calls for a multi-pronged approach and must address the various stages of the life cycle of the population and various segments of the community.

School-based awareness programmes for children to impart the messages to them at an early age so that they can make healthy choices in life when they grow up. School based interventions on the awareness of harm from substance use have been carried out sporadically in India. The project MYTRI showed that health promotion among adolescents was beneficial in preventing tobacco use.[4]

Youth groups in the community, who are important role models may be roped in through awareness programmes and also making use of them to in turn to spread the message.

Women self-help groups can be educated as members of such groups may be affected by the family member's drug use and most importantly become co-dependent.

Panchayath leaders or local politicians need to be addressed, as they can support the cause.

Religious heads from the community need to be involved, as they will positively influence the community to seek professional help.

The Collector's office/local government bodies can be periodically approached to give out appropriate public service messages.

The local Public Health Centers need to be equipped with trained staff and appropriate referral mechanism so that early identification and treatment is possible.

Each community has a specific village festival time when substance abuse can increase; at such times, those who do not use mood altering substances - teetotalers can be identified to partner as agents of change.

People in the community who provide job opportunities need to be sensitized.

Local NGOs working in the community need to be made as the focal point of contact.

Awareness needs to be created about the help that is available for the family, educational institution, substance users. This will call for:

Creating a toll-free number for affected individuals or their families or friends to approach.

Posters/pamphlets/notices to be displayed.

Seeking help from the media including print, TV and radio

Health department to be trained for referral and follow up.

IRCAs (Integrated Rehabilitation and Counselling Centre for Addicts) sponsored by Ministry of Social Justice and Empowerment) to be made accessible for persons with addiction for availing free services.

Private doctors need to be sensitized.

Rural camps can be conducted in partnership with appropriate treatment centres and a host organisation from the community.

Websites of Government in state and district level need to display services for addiction management.

Observing all important days like International day against illicit drugs and trafficking, Anti-tobacco day, Gandhi Jayanthi day etc., helps to increase awareness about the problem of substance abuse and addiction.

Law/police departments need to be engaged to prevent legal problems associated with substance use and intervene for persons with substance use in conflict with the law.

Use of social media is an increasingly powerful tool even in rural areas. This can work in both enhancing awareness on treatment as well as be exploited by substance using networks.

Rural Camp Model by T T Ranganathan Clinical Research foundation (TTK Hospital)

The camp approach for treatment of alcohol dependence was popularized by the TTK hospital at Manjakkudi in Tamil Nadu. Treatment of alcohol and drug abuse in a camp setting has been found to have good retention rates and favourable outcome at six months.[5678] With over three decades of experience in addiction management, TTK Hospital has been conducting cost effective rural treatment camps in villages. A brief outline of the process involved is as follows:

Identifying the region for the camp:

Based on the need in the community. Empirical evidence of higher levels of substance use, any survey or studies which indicate this, reports of untoward incidents due to substance use, and lack of availability of treatment facilities in that area may be pointers for identification for the suitability of a camp approach.

A host organisation is very essential to anchor all support and to establish the camp approach of treatment in the rural community. The host organisation will provide staff, space for conducting the camp and leverage their goodwill in the community to organise the camp.

Sensitizing the community takes place by conducting awareness programmes, giving information about the treatment camps, motivating them for taking treatment.

A local physician is identified to provide support during screening, detoxification and for follow- up treatment.

Preparation before the camp

The patients are required to register for the enrolment in the camp three months before its commencement.

The medical doctor examines them, assessment is done, and in case of major physical complications, they are referred to nearby hospitals. Other symptomatic ailments are handled by giving medicines.

The counsellor (psychologist/social worker) does the intake/initial assessment, checks dependence and motivation to quit.

Tips to remain abstinent are given.

During the camp

Team from the treatment agency comprising of counsellors, nurse, driver, arrive at the camp site.

Those who have enrolled for the camp go through the final screening and medical review. After the medical doctor and the counsellor select them based on eligibility criteria, the patients are inducted into the camp schedule.

Camp schedule

Detoxification

Structured programme for 15 days - including counselling, re-educative classes for patients and their family, group therapy, activities, physical exercise/healthy recreation.

Exposure to AA/NA

Discharge with follow up plan

After camp:

- regular follow up plan is made and adhered to

- Home visits are made

- In case of slip/relapse, help is given.

Several other community-based models of care in the community setting in different parts of India have shown the effectiveness of continued care in improving outcome in alcohol and other substance use disorders.[101112]

In a study of patients with alcohol dependence from a lower socio-economic status, weekly follow-up or review in a clinic located within the community showed relatively better drinking and functional outcomes at 3,6 and 9 months as compared to controls.[11] In a one year prospective study of outcome following treatment of addiction, poor outcome was associated with higher psychosocial problems, family history of alcoholism and more frequent follow-up with mental health services.[12]

At the Work place

There are a few studies on workplace related substance use problems in India. A study among industrial workers in Goa using the AUDIT estimated a prevalence of 211/1000 of hazardous drinking.[13]

Assessment of workplace problems related to substance use disorders have neither been systematically addressed nor appropriately addressed. Most existing measures focus on workplace needs rather than on worker's perceptions of difficulties with work and personal life. Recently, a structured tool has been developed in India for assessment of vocational difficulties in persons with substance use disorders.[14]

The rationale for workplace interventions is that the workplace provides a captive population that can be reached by curative and preventive health care programmes and effective monitoring is possible in such settings. An effective three step approach to deal with issues due to substance use at the workplace include the following:

Step one

Developing and implementing a drug free workplace policy, which focuses on:

A clear message that drug use in workplace is prohibited and encourages employees with substance use related problems to voluntarily seek help

A workplace policy that aims to protect the health and safety of all employees, maintain product quality and reputation, safeguard employer's assets from self-destruction and protect organisation's image.

Step two

Educating the appropriate personnel about the intervention methods:

Organising awareness programmes for workers/supervisors/management on a regular basis.

Having IEC materials distributed and displayed in important places.

Developing protocols and guidelines while dealing with employees with substance dependence

Taking reformative action by offering them help.

For supervisors: Describe the problem- prepare a detailed data-based report on employee's job performance deficiencies, including specific dates, absences from work or leave taken, deadlines missed or errors in work.

§ Arrange for a confidential meeting with the employee.

- Discuss the situation as it is, the deterioration in job performance and feedback about it. Use the report to cite dates and events relating to poor performance. These should be fact based and not appear as qualitative statements

- State expectations from the employee clearly.

- If the employee commits to improve, hold him to it and set a commonly agreed date to demonstrate improvement. Do not accept open ended promises.

- Watch for changes – if the job performance does not change, direct him to the HR personnel for further assessment. In turn, they could refer him to a treatment centre. If the employee does not avail help, the administration may proceed with appropriate action.

Few points to be kept in mind while dealing with problem employees:

- Avoid diagnosing the problem and stating that drinking or substance use is the problem, rather focus attention on poor performance.

- Talk about abuse only if one is using substance in the workplace or comes under the influence to work.

- Avoid giving advice. Bear in mind that the disease of addiction has a huge denial associated with it.

- Avoid enabling behaviours like covering up for the employee, getting trapped in his sympathy-evoking tactics and losing one's temper.

Step Three

Sending the employees with substance use for treatment.

Instead of terminating the employee's services, referring a problem employee to a treatment centre and making him a productive employee again has the following benefits:

Ensures problem resolution.

Makes the problem employee productive again.

Helps to refocus on productive issues within the organisation.

Improves the morale and work environment of the organisation.

A few workplace intervention studies for substance use disorders have been carried out in India and found to be effective. The Karnataka State Road Transport Organisation initiated a Workplace Alcohol Prevention Programme and Activity (WAPPA), in the late 1990s. The comprehensive programme provided therapeutic help for employees with substance related problems and included steps to address human resource issues with a view to improving work conditions, employee morale and well-being. An audit conducted after six years showed several improvements among the treated employees, in terms of reduced absenteeism, improved productivity, reduced accidents and improved company image. The audit also revealed other enormous difficult to quantify gains- a healthier, happier workforce, better working environment, better inter-personal relationships, happier families, greater public safety and improved organisational image.[15161718]

Case Vignette

Mr M was working in a reputed car manufacturing company for the past five years. He was a talented worker but was into drinking occasionally when he got into the company. Slowly, drinking became a regular practice. He started to get into a binge pattern of drinking in the weekends and was unable to report to work on Mondays. His supervisor started to notice this, along with the fact that he was getting irritable with team members, not able to complete targets, was borrowing money etc., One day, as he was smelling of alcohol, he was sent home with a warning. This was brought to the notice of the HR personnel department. M was called for counselling. After an initial assessment with him and his wife, the welfare officer took him to the addiction treatment centre for an intake assessment. He was diagnosed with substance abuse disorder and need for treatment and rehabilitation was explained. His wife was asked to attend family therapy programme. The welfare officer presented his case to the management and arranged for his treatment.

He completed his treatment, counselling was provided for him and his family. The welfare officer and his supervisor were called for the support person programme. A follow up plan was developed. He started on his recovery and rejoined work. The welfare officer made home visits and at times accompanied him for his follow up. There were qualitative improvements in his work and personal life which was identified and appreciated by the company. He became a role model in his company, co-workers started to seek his help in getting out of substance dependence. He spoke to his colleagues in staff development programmes to motivate them to make smart choices. Soon, one after the other a few of his affected colleagues also took help and a self-help group was initiated in the company”.

Summary and future directions:

Community

Early intervention is very important targeting all groups in community.

The participation of key stake holders in the community and their involvement is essential.

Awareness programmes in the community need to be done in a comprehensive manner, providing facts, healthy alternatives and messages on how to say ‘No’ to drugs.

A holistic approach is necessary: the linking of prevention activities, medical help, self-help groups and treatment facilities provides wholesome recovery.

Government bodies need to be involved.

Workplace

Periodic awareness programmes to all employees across the hierarchy helps.

Specific programmes for management, supervisory level staff, medical staff who are placed in industries, security department and workers need to be organised separately as their roles are different.

HR personnel need to be trained to help employees with substance use problems by early identification through poor job performance and referral to treatment agencies,

Self-help groups can be formed from among those who are seeking help to quit and recover.

The organisation can bring into implementation practices like not serving alcohol at business meetings or during team lunches.

Posters on healthy alternatives need to be displayed in important places.