The flood of Afghan drugs through Iran, Pakistan, and Central Asia to markets in Europe and the Gulf is helping fuel a growing population of heroin addicts across the region. Many of the affected countries have learned that treating heroin addiction is never easy, particularly when there is no money for therapies such as the methadone-substitution used in the West. As a result, local health experts have sought less expensive, alternative solutions, including efforts in Pakistan to use traditionally strong social ties to help overcome addiction. RFE/RL correspondent Charles Recknagel visits a clinic in Rawalpindi, near Islamabad, to learn how the method works.
Rawalpindi, Pakistan; 26 March 2001 (RFE/RL) -- Three middle-aged addicts are sitting around a table.
One, who is barely lucid, stopped smoking heroin only four days ago. His forehead is covered with cuts and bruises from a street brawl that took place just before his family brought him to the clinic. He is unable to express more than his slurred thanks to the doctor, Nadeem-ur-Rehman, whom he hopes will save him.
"The doctor sahib picked us out of the grave and brought us here."
This man has been here several times before, unable to end his heroin habit despite the clinic's program of 15 days of detoxification followed by 15 days of counseling.
His colleague across the table has been here before, too. He kicked his habit six years ago and had been working since then as a driver and helper in this very same clinic. But he recently married and, the doctor says, relapsed into narcotics under the stress of a new household. Now he has just completed the two-week withdrawal process and is too depressed to say anything.
The third man is alert and optimistic. He is a journalist with one of Pakistan's many English-language publications and -- like the others -- has been in and out of treatment programs before. But he has just finished his 15 days of counseling and is so excited by the strength it has given him that he is extending his stay for another week.
"I have been here for one month. I never used to stay [in a treatment program] for more than 15 days. But now I am staying more than a month. Because I need to be rehabilitated."
Doctor Nadeem is responsible for the journalist's new confidence because he is pioneering a novel approach to treating addiction in Pakistan, where usually addicts are only given a place to safely withdraw and then are sent back onto the street. The withdrawal period can take place in a hospital, where they are placed in the psychiatric ward, or in a private detoxification clinic. In both cases, the addicts receive no medicine beyond tranquilizers to get through the physical pain of the process.
Nadeem's clinic, the privately run Imran Center in downtown Rawalpindi, gives the addicts even less help getting through withdrawal. The clinic administers only mild, non-addictive tranquilizers, aspirin, and medicine to reduce vomiting. But after detoxication it offers them what other clinics do not: two weeks of intensive counseling aimed at reintegrating them into the lives of their families and community.
Nadeem says the idea is to use social bonds to rescue the addicts from the sense of personal isolation that often drives them to use narcotics and then only deepens with addiction. He says the first priority is the family because, in traditional Pakistani society, it is to the family an addict must return if he is to ever reintegrate into the society at large.
Reintegration requires countless hours of counselors and patients speaking together with families, addressing conflicts, and working out solutions. Nadeem says the sessions go like this:
"What is the family problem? What is the problem, why is he taking drugs? Then, the addict has so many complaints about the father, about the brothers, about the sisters. Then we do the counterallegations and allegations. Then we try to solve it."
Nadeem says one sign of the strength of family bonds in Pakistan -- even among dysfunctional families -- is that it is usually relatives who bring addicts in for treatment. By contrast, many addicts in more individualistic Western societies refer themselves for treatment, leaving little room for families to help.
Beyond family relations, Nadeem's rehabilitation program also tries to assure that the recovering addict will have something to occupy his time after he leaves the clinic. The staff contacts non-governmental organizations working in the patient's hometown or city and urges them to let him work with them as a volunteer. If he is educated, he may help with literacy programs. If he is a former taxi driver, he may help as a chauffeur. If he has no skills at all, he does clean-up work.
Nadeem says that only after five or six months of volunteer work will the clinic recommend a patient to try to return to the job market. When he does, the doctors do not encourage him to identify himself as a recovering addict. Social taboos only guarantee the doors would be closed and that the spiral of depression and drug dependency would resume.
But even when a patient follows all these steps to the letter, a final cure can still require years. Nadeem says that 90 to 95 percent of addicts in Pakistan relapse once after treatment, and four out of five of those who relapse once will do so a second time. Still, with each relapse, the number of those who go back to heroin becomes a little smaller, and doctors at Nadeem's clinic say some half of the addicts they work with eventually become drug free.
Or, as Nadeem puts it, relapses are part of therapy. His doctors try to regard them as opportunities to narrow down more precisely why an individual patient reverts to heroin and how the problem can be solved.
In one measure of the clinic's reputation, it has begun to attract Pakistani emigrants who work in Britain and say they have been unable to kick their habits in drug treatment programs there. They come in hope that returning to the support of their families at home will do what methadone and other medicinal treatments have not.
The Imran Center has 30 beds and last year admitted 273 patients. Once addicts come through the clinic's locked wire-mesh door, they cannot be released without the permission of a family member whom they must first designate as a guardian. The families bring food twice a day, guaranteeing their involvement, and pay according to their means.
The patients are aged 17 to 50, and most belong to the lower middle class of small shopkeepers and taxi drivers. One patient, from a rich family, was admitted at age seven and returned several times before dying at age 15. All are men, as heroin is almost exclusively a male drug in Pakistan.
In addition to its four visiting doctors, the clinic staff includes six recovered addicts who have stayed on as employees. They provide a model for the patients and help talk them through the first stages of rehabilitation. The patients say these men help give them the courage to stick through the program themselves. As the recovering journalist puts it:
"I have been using drugs for 20 years. And I never saw a person who quit this habit for even one month or two months. But over here are some people on the staff, one person who has not taken drugs for 10 to 11 years, another hasn't taken drugs for eight years, another hasn't taken for five years. So when you see these people, you say, if he can quit, why can't I?"
Health workers estimate that Pakistan has some two million hardcore addicts who smoke or inject heroin, plus another two million casual users who smoke opiates as well as softer drugs like hashish. The number of addicts has soared since 1979, when heroin was almost unknown in the country and widely considered to be exclusively a Western drug.
The surge in addiction has closely followed Afghanistan's emergence as the world's leading source of opium over the last decades. The Afghan drug routes, which used to only pass through neighboring countries as they move west, now increasingly make detours to serve local markets all along the way.
Rawalpindi, Pakistan; 26 March 2001 (RFE/RL) -- Three middle-aged addicts are sitting around a table.
One, who is barely lucid, stopped smoking heroin only four days ago. His forehead is covered with cuts and bruises from a street brawl that took place just before his family brought him to the clinic. He is unable to express more than his slurred thanks to the doctor, Nadeem-ur-Rehman, whom he hopes will save him.
"The doctor sahib picked us out of the grave and brought us here."
This man has been here several times before, unable to end his heroin habit despite the clinic's program of 15 days of detoxification followed by 15 days of counseling.
His colleague across the table has been here before, too. He kicked his habit six years ago and had been working since then as a driver and helper in this very same clinic. But he recently married and, the doctor says, relapsed into narcotics under the stress of a new household. Now he has just completed the two-week withdrawal process and is too depressed to say anything.
The third man is alert and optimistic. He is a journalist with one of Pakistan's many English-language publications and -- like the others -- has been in and out of treatment programs before. But he has just finished his 15 days of counseling and is so excited by the strength it has given him that he is extending his stay for another week.
"I have been here for one month. I never used to stay [in a treatment program] for more than 15 days. But now I am staying more than a month. Because I need to be rehabilitated."
Doctor Nadeem is responsible for the journalist's new confidence because he is pioneering a novel approach to treating addiction in Pakistan, where usually addicts are only given a place to safely withdraw and then are sent back onto the street. The withdrawal period can take place in a hospital, where they are placed in the psychiatric ward, or in a private detoxification clinic. In both cases, the addicts receive no medicine beyond tranquilizers to get through the physical pain of the process.
Nadeem's clinic, the privately run Imran Center in downtown Rawalpindi, gives the addicts even less help getting through withdrawal. The clinic administers only mild, non-addictive tranquilizers, aspirin, and medicine to reduce vomiting. But after detoxication it offers them what other clinics do not: two weeks of intensive counseling aimed at reintegrating them into the lives of their families and community.
Nadeem says the idea is to use social bonds to rescue the addicts from the sense of personal isolation that often drives them to use narcotics and then only deepens with addiction. He says the first priority is the family because, in traditional Pakistani society, it is to the family an addict must return if he is to ever reintegrate into the society at large.
Reintegration requires countless hours of counselors and patients speaking together with families, addressing conflicts, and working out solutions. Nadeem says the sessions go like this:
"What is the family problem? What is the problem, why is he taking drugs? Then, the addict has so many complaints about the father, about the brothers, about the sisters. Then we do the counterallegations and allegations. Then we try to solve it."
Nadeem says one sign of the strength of family bonds in Pakistan -- even among dysfunctional families -- is that it is usually relatives who bring addicts in for treatment. By contrast, many addicts in more individualistic Western societies refer themselves for treatment, leaving little room for families to help.
Beyond family relations, Nadeem's rehabilitation program also tries to assure that the recovering addict will have something to occupy his time after he leaves the clinic. The staff contacts non-governmental organizations working in the patient's hometown or city and urges them to let him work with them as a volunteer. If he is educated, he may help with literacy programs. If he is a former taxi driver, he may help as a chauffeur. If he has no skills at all, he does clean-up work.
Nadeem says that only after five or six months of volunteer work will the clinic recommend a patient to try to return to the job market. When he does, the doctors do not encourage him to identify himself as a recovering addict. Social taboos only guarantee the doors would be closed and that the spiral of depression and drug dependency would resume.
But even when a patient follows all these steps to the letter, a final cure can still require years. Nadeem says that 90 to 95 percent of addicts in Pakistan relapse once after treatment, and four out of five of those who relapse once will do so a second time. Still, with each relapse, the number of those who go back to heroin becomes a little smaller, and doctors at Nadeem's clinic say some half of the addicts they work with eventually become drug free.
Or, as Nadeem puts it, relapses are part of therapy. His doctors try to regard them as opportunities to narrow down more precisely why an individual patient reverts to heroin and how the problem can be solved.
In one measure of the clinic's reputation, it has begun to attract Pakistani emigrants who work in Britain and say they have been unable to kick their habits in drug treatment programs there. They come in hope that returning to the support of their families at home will do what methadone and other medicinal treatments have not.
The Imran Center has 30 beds and last year admitted 273 patients. Once addicts come through the clinic's locked wire-mesh door, they cannot be released without the permission of a family member whom they must first designate as a guardian. The families bring food twice a day, guaranteeing their involvement, and pay according to their means.
The patients are aged 17 to 50, and most belong to the lower middle class of small shopkeepers and taxi drivers. One patient, from a rich family, was admitted at age seven and returned several times before dying at age 15. All are men, as heroin is almost exclusively a male drug in Pakistan.
In addition to its four visiting doctors, the clinic staff includes six recovered addicts who have stayed on as employees. They provide a model for the patients and help talk them through the first stages of rehabilitation. The patients say these men help give them the courage to stick through the program themselves. As the recovering journalist puts it:
"I have been using drugs for 20 years. And I never saw a person who quit this habit for even one month or two months. But over here are some people on the staff, one person who has not taken drugs for 10 to 11 years, another hasn't taken drugs for eight years, another hasn't taken for five years. So when you see these people, you say, if he can quit, why can't I?"
Health workers estimate that Pakistan has some two million hardcore addicts who smoke or inject heroin, plus another two million casual users who smoke opiates as well as softer drugs like hashish. The number of addicts has soared since 1979, when heroin was almost unknown in the country and widely considered to be exclusively a Western drug.
The surge in addiction has closely followed Afghanistan's emergence as the world's leading source of opium over the last decades. The Afghan drug routes, which used to only pass through neighboring countries as they move west, now increasingly make detours to serve local markets all along the way.