Iraqi professionals experience recovery

With knowledge gained in a four-week learning tour of INOVA Hospital's Comprehensive Addiction Treatment Services (CATS, Fairfax, Va.), UCLA's Pacific Southwest Addiction Technology Transfer Center (PS-ATTC, Los Angeles), Johns Hopkins University, and other prominent research, law enforcement, and treatment sites, a project team from the Iraqi Ministry of Health is now developing plans to launch a substance use treatment center of excellence in Baghdad.

The substance use project team was one of six teams hosted in the U.S. under a six-year partnership between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Iraqi Ministry of Health. The partners aim to rebuild and expand high-quality behavioral health services in Iraq while enhancing services to special health populations in the U.S. The four-member Iraqi substance use treatment project team is led by a consulting psychiatrist, Nesif Al-Hemiary, MD, and also includes a consulting psychiatrist, psychologist, and psychiatric nurse.

“Alcohol, prescription drugs, and tobacco are the main [substance use] issues in Iraq,” says Al-Hemiary, who adds that such use is “highly stigmatizing, more so than in the U.S. “Most people,” he explains, “perceive it as a moral problem rather than a disease and believe that substance abusers are sinful and deserve punishment.” The reason is clear: “The major religion, Islam, forbids alcohol and drug abuse and, frankly, regards them as great sins. Iraqi culture accepts the use of alcohol more than drugs, but dependence or addiction is condemned.”

Over the course of three weeks at INOVA CATS hospital, counseling manager Maria Hadjiyane, MA, LPC, CSAC, says that INOVA CATS showed the Iraqi team “many processes involved in the inpatient detoxification unit-medical protocols, nursing responsibilities, group therapy, creative therapy, assessment processes, treatment planning, and development of an aftercare plan.” This was followed by exposure to “multiple levels of outpatient treatment, the need for a 12-Step or sober support network, structured curriculum, and opiate medication replacement therapy.” Throughout, the INOVA CATS group emphasized the benefits of multidisciplinary approaches to patient care, use of stages of change and motivational interviewing, as well as the therapeutic alliance.

Rick Rawson, PhD, Associate Director of UCLA Integrated Substance Abuse Programs, learned from the Iraqi team that despite the country's close proximity to Iran and Afghanistan, both of which have serious opiate addiction problems, opiate abuse in Iraq is limited.

But, he notes that “one of the priorities [of the Iraqi team] is to develop a process to assess the nature and extent of the psychoactive substance use problem in Iraq.” He adds that at present, “there are virtually no data to guide policymakers in service development priorities.”

Prior to 1980, Iraq had a well-developed psychiatric service system, but during the strife of the past 30 years, many leaders of its behavioral health system left the country, leaving a very overwhelmed and underdeveloped care system for behavioral health. This recent, painful history made trauma-informed treatment a high priority on the visit, particularly the recognition by behavioral health providers that most patients labeled as difficult may be victims of trauma who require additional help.

To address the huge retraining task faced by Iraq, the team also sought insights into developing high-quality training, along with research to guide public policy, inform treatment priorities, support ongoing professional development, and build an infrastructure for continuing care. During a visit to UCLA and its PS-ATTC, the team worked with Treatnet, a program launched by the United Nations Office on Drugs and Crime (UNODC) and led by UCLA's Integrated Substance Abuse Program Center. The goal of Treatnet is to build multilingual training programs to support substance use treatment programs worldwide. Of great interest to the Iraqi team is Treatnet's Arabic-language training curriculum, which could well form the model for developing a new generation of Iraqi treatment professionals.

When asked to note the most important information learned on the visit, Al-Hemiary cited “the different types of substance abuse programs … the highly sophisticated interventions … the drug protocols used for detoxification, [and] the modern technologies used for testing.” His team was also interested in “the motivational interviewing, group, recreational, and movement therapies,” as well as harm reduction strategies, community interventions, and drug courts.

The team's hosts learned as well. “Treatment in Iraq, until now, has primarily been a prolonged course of detoxification concentrating on the biological aspects of the disease, and nothing addressing the psychological or social aspects of the disease,” Hadjiyane explains. “Initially the team relayed a perception of SUDs as a constant cycle of ‘treatment’ followed by relapse, with little hope of recovery. Due to the exposure the team received to various treatment options, studies, and interventions, this perception evolved.”

“It was my opinion,” says Rawson, “that they were very surprised to learn that individuals who become addicted to drugs or alcohol can recover. Apparently in their experience, people who develop addiction disorders rarely, if ever, became functional individuals. They didn't know that recovery is possible.”

Now that the team is back home in Baghdad, Al-Hemiary says “it is time” to start services. “Our goal is to establish a center in Baghdad and train mental health professionals to run such a service.” Near term, that means hiring and training staff and “obtaining medicine and other equipment needed for testing and treatment of patients.” Long term, Al-Hemiary hopes that, in addition to treating patients, “this center will be a site for training and research for the rest of Iraq.”

Behavioral Healthcare 2010 November-December;30(10):22-23