|Year : 2019 | Volume
| Issue : 4 | Page : 211-215
Drug treatment presentations at a treatment centre in southern Nigeria (2015–2018): Findings and implications for policy and practice
Bawo O James1, Sunday O Olotu1, Olaniyi O Ayilara1, Olubukola O Arigbede1, Goodnews I Anozie1, Hope O Ogiku1, Joy O Ariyo2, Veronica Efiong2, Adeola O Adeyelu3, Majesty A Oni3, Dora O Odu4
1 Department of Clinical Services, Drug Abuse Treatment Education and Research Unit, Federal Neuropsychiatric Hospital, Benin-City, Edo State, Nigeria
2 Department of Clinical Services, Clinical Psychology Unit, Federal Neuropsychiatric Hospital, Benin-City, Edo State, Nigeria
3 Department of Clinical Services, Biostatistics Unit, Federal Neuropsychiatric Hospital, Benin-City, Edo State, Nigeria
4 Department of Nursing Services, Federal Neuropsychiatric Hospital, Benin-City, Edo State, Nigeria
|Date of Web Publication||4-Oct-2019|
Dr. Bawo O James
Department of Clinical Services, Drug Abuse Treatment Education and Research Unit, Federal Neuropsychiatric Hospital, P.M.B 1108, Benin-City, Edo State
Source of Support: None, Conflict of Interest: None
Introduction: Recent evidence suggests that rates of drug use and abuse in Nigeria exceed the global average. There is a strong treatment demand for psychoactive drug use disorders in Nigeria; however, it is not known whether available treatment facilities are attending to the array of treatment needs. This audit compares the pattern of presentations at a tertiary facility with a community-based survey. Methods: A review of cases (n = 212) seen at a regional drug treatment facility over a 4-year period, using local data retrieved from the Nigerian Epidemiological Network of Drug Use (NENDU) and comparison with data from the recently published national drug use survey. Results: Nine out of ten clients seen were male (93.4%). About half (49.5%) of the clients used psychoactive substances for the first time between ages 10 and 19 years. Cannabis was the primary drug of use overall and also among males, while females were more likely to present with opiate abuse. Over half had a co-occurring physical or mental disorder, and a minority had received testing for hepatitis C in the past 12 months. Conclusion: Although patterns of drug abuse presentations were consistent with findings from a national community-based survey, there was an under-representation of females in treatment. Implications for policy development and practice are discussed.
Keywords: Policy, psychoactive substance treatment, Southern Nigeria
|How to cite this article:|
James BO, Olotu SO, Ayilara OO, Arigbede OO, Anozie GI, Ogiku HO, Ariyo JO, Efiong V, Adeyelu AO, Oni MA, Odu DO. Drug treatment presentations at a treatment centre in southern Nigeria (2015–2018): Findings and implications for policy and practice. Niger Postgrad Med J 2019;26:211-5
|How to cite this URL:|
James BO, Olotu SO, Ayilara OO, Arigbede OO, Anozie GI, Ogiku HO, Ariyo JO, Efiong V, Adeyelu AO, Oni MA, Odu DO. Drug treatment presentations at a treatment centre in southern Nigeria (2015–2018): Findings and implications for policy and practice. Niger Postgrad Med J [serial online] 2019 [cited 2019 Nov 12];26:211-5. Available from: http://www.npmj.org/text.asp?2019/26/4/211/268593
| Introduction|| |
The recent nationwide survey on psychoactive drug use patterns in Nigeria indicates an overall rate in the country (14.4%) that exceeded the global the global average as at 2016 of 5.6%. While opiates were commonly used and abused in the northern parts of the country, cannabis was more commonly abused in the southern region. The survey also reported that one in four drug users were female, while there was a high proportion of poly drug use (95%) among those classed as 'high-risk' drug users. One in five 'high-risk' drug users were also injecting drugs. High-risk drug users in the survey were classed as those 'who had used opioids, crack/cocaine or amphetamines in the past 12 months, and had used those drugs on at least 5 occasions in the past 30 days'. In the 'south-south' geopolitical zone, rates of drug use came second only to the south-west. Cannabis, pharmaceutical opioids and cough syrups containing codeine were the psychoactive substances commonly used or abused. Notably, the past year cannabis use was higher in this zone compared to the national average.
Presentations at substance abuse treatment facilities serve as epidemiological treatment demand indicators and also help monitor trends. Previous reports from sub-Saharan Africa have identified gaps between the pattern of drug use requiring treatment at substance abuse centres and trends in the community. Factors responsible for these differences have been identified and have helped shape policy and treatment programs over subsequent years.,, This study aimed to provide the current descriptive epidemiological information about treatment demand at a regional substance abuse treatment centre in Benin-City, Nigeria, over a 4-year period (2015–2018) and discuss its implications in light of the recently released nationwide drug use survey as well provide suggestions regarding policy development and practice implication.
| Methods|| |
Ethical clearance and approval was obtained from the Ethics Committee of the Federal Neuropsychiatric Hospital (FNPH), Benin-City, Edo State, Nigeria, on 25 April, 2018 (Protocol Number: PH/A.864/Vol.XIII/201). No identifying information was collected during the review.
This study was conducted at the Drug Abuse Treatment Education and Research Unit of the Federal Neuro-Psychiatric Hospital, Benin-City, Edo State, Nigeria. The unit provides in-patient detoxification, rehabilitation services through a 40-bed facility; an out-patient rehabilitation clinic as well as professional training for substance abuse professionals. It was designated in 2012 as a regional training hub for substance use disorders in Nigeria by the Federal Ministry of Health (FMOH), as well as a model substance use disorder treatment facility. The unit is run by multidisciplinary staff and runs on an adapted Minnesota Model of drug treatment; which is an abstinence model of drug treatment developed around the principles of Alcoholics Anonymous and involving in-patient rehabilitation, a therapeutic community of clients in differing stages of recovery helping one another with guidance and support from staff, client and family education and continuing care.
This audit reviewed case records of participants who had received out-patient and in-patient care at the unit between February 2015 and December 2018.
The Nigerian Epidemiological Network on Drug Use (NENDU) started out in the year 2015 as a collaboration of the United Nations Office on Drug and Crime and the FMOH Nigeria. Through the NENDU, the drug treatment demand information from 11 model drug treatment centres (since 2015) and counselling centres of the National Drug Law Enforcement Agency; (since 2016) across Nigeria are routinely collected and collated. These sites are distributed across the nations' six geopolitical zones and the Federal Capital Territory. This audit reports on local data from the FNPH Benin-City between 2015 and 2018.
Data routinely collected include sociodemographic data (e.g. age, sex and marital status), and drug-related information (e.g. type of drug use, pattern of use and routes of administration). NENDU also routinely collates data on co-occurring disorders, and number of times treatment has been accessed. All persons presenting to the hospital and requesting care for drug use problems (drug use problems alone or comorbid with a psychological disorder) have the NENDU form completed by a trained clinical staff, not later than 2 weeks of intake. Completed forms are entered into an Excel spreadsheet and routinely sent every month to the Drug Demand Reduction Unit in the FMOH.
We analysed the data using a statistical package; SPSS version 22 (IBM Corp, Armonk, NY, USA). We summarised data using proportions and frequencies and presented them in tables. Bivariate comparisons for continuous data were made using the Student's t-test. The level of statistical significance was set at P < 0.05.
| Results|| |
Two hundred and twelve individuals were seen over the 4-year period. A majority were males (n = 198; 93.4%), in the age group of 25–34 years (n = 99; 46.7%), referred by family and friends (n = 185; 87.3%) and living in stable accommodation (n = 203; 95.8%). Slightly over half lived with a parent (n = 131; 61.8%), with 8 in 10 living in urban settings. Most had some or completed tertiary education (n = 134; 63.2%), were single (n = 163; 76.9%). At least half of the individuals were unemployed at treatment entry (n = 124; 58.5%) [Table 1].
Psychoactive drug use patterns
The primary drug of abuse requiring treatment was cannabis (n = 123; 58.0%), followed by alcohol (n = 41; 21.3%) and opiates (n = 33; 15.6%). Almost half reported age at first use within the 10–19 years' age group (n = 105; 49.5%). The age of onset for alcohol and cannabis was earlier (10–19 years) compared to cocaine and opiates (20–29 years). A majority reported polysubstance use (n = 161; 76%). For individuals using more than a substance, most used two (n = 71; 33%) or three substances (n = 56, 26%) [Table 2].
The primary source of psychoactive drugs was street dealers (n = 129; 60.8%), and a majority were receiving treatment for the first time (n = 153, 72.2%). Among those, who used opiates, only 1 (2.9%) individual had been on opiate substitution treatment, which was received when in a rehabilitation program outside the country. A majority funded treatment with the help of family/friends (n = 206; 97.2%) [Table 2].
One hundred and fourteen participants had a co-occurring disorder (53.7%). Among these, most had a mental disorder (n = 87; 76.3%), cardiovascular disease (n = 9; 7.8%) and respiratory disease (n = 6; 5.3%). A majority had received HIV testing (n = 188; 88.6%), however, among a subsample for which hepatitis C screening information was requested, fewer individuals had received testing for hepatitis C virus (n = 21/135; 15.55%). In addition, a minority (n = 9/135; 6.67%) had ever injected drugs [Table 2] and [Table 3].
The average age of females entering treatment was similar to males (32.29 [8.13] years vs. 32.17 [9.51] years; t = 0.05; P = 0.96). Females, had a higher average age of onset of psychoactive substance use (24.57 [4.01] years vs. 20.10 [4.55] years; t = 3.58, P < 0.0001). Females were more likely to report opiates as the primary drug of abuse compared to cannabis in males.
| Discussion|| |
We observe that the pattern of primary drug use necessitating treatment was similar to that from a previous report from the same treatment facility in 2010. We, however, note, that opiate use has significantly increased when compared with the previous study, and this surge may be accounted for by the increase in prescription opioid use. Another recent report from a treatment centre in south-east Nigeria showed low rates of opioid use, though cannabis and alcohol use were common reasons for in-patient care. The 2018 Nigeria drug use survey notes that cannabis use is common in the south-south region of Nigeria, followed by prescription opioids; tramadol and codeine-containing cough syrups. In fact, cannabis use in this zone was higher than the national average. The high rate of cannabis use in this zone is consistent with the high rate reported for cannabis necessitating treatment demand.
We also noted the high proportion of co-occurring disorders. Cannabis use is associated with psychological disorders and explains the necessity by relatives to present at the treatment facility located within a psychiatric hospital. Cannabis grown in Nigeria has a high tetrahydrocannabinol content in relation to cannabidiol, which accounts for a predilection to psychotic and mood disorders., In addition, the abuse of cannabis may increase the incidence of psychotic disorders in at-risk population; adolescent to young adult males. Second, planning for substance abuse treatment services roll-out should incorporate mental health services as psychoactive drug use and co-occurring mental disorders result in poorer outcomes if managed separately rather than in an integrated manner.
We observed that despite the fact that 1 in 4 drug users in Nigeria are women, fewer women are accessing care from the data from this treatment centre (1 in 10). The reasons adduced in the literature may also come to play in this environment. First, there still exists in developing countries such as Nigeria, difficulties for women to access health-care. Stigma, lack of financial independence, treatment cost and limited or non-existent health insurance,,, women being less proactive in treatment seeking  and the absence of programs that are sensitive to the needs of women (domestic violence, child care, sexual assault, drug use in pregnancy, delivery, lactation and sexually transmitted infections).,
Although not everyone using a psychoactive drug requires medical intervention, the numbers seeking and receiving treatment over the 4-year period was small. Although other tertiary facilities are available in the state, the capacity for residential treatment in all these facilities combined is inadequate. Perhaps, developing robust out-patient services in more hospitals in the state may improve treatment access. Low treatment demand rates may be attributed to several factors. Local factors include, inadequate bed capacity (currently at 40 dedicated beds), treatment site location in a mental health facility, which though affords for holistic care of drug use problems and co-occurring physical and mental disorders is often associated with stigma, treatment cost; though low when compared to costs for drug treatment in private settings often limits treatment entrance and engagement. Wider factors adduced include; frequent industrial action by health workers over this period, for which though the treatment facility remained open, there were limited new intakes and the created perception to the public that the facility was closed., Furthermore, a 'moralistic' view (drug use being a self-inflicted problem or a problem of a weak will to stop use) regarding the aetiology of substance use disorders may deter caregivers from seeking care for affected relatives.
Going forward, the disparity between treatment seeking rates and the prevalence of drug use in the region, requires the development and implementation of evidence-backed policy. First, despite the barriers that exist to accessing care for substance use disorders from facilities domiciled in psychiatric hospitals, the number of available treatment facilities, and the capacity of these facilities in the zone is inadequate. The location in an almost exclusively urban setting disenfranchises those who desire treatment but live in rural communities. Indeed, constructing new facilities may incur great cost, but incorporating some level of drug treatment service at primary and secondary level care may bypass the huge financial outlay required to scale up treatment services. Therefore, more centres, in primary and secondary health facilities offering varied services (drop-in centres, harm-reduction units, intensive out-patient services and community services) are needed. Second, the number of skilled professionals are small, and the current proportion of high-risk drug users in the zone means that urgent training and retraining should be prioritised. Finally, services would need to be scaled up and/or integrated into existing programs that cater for the unique needs of women in the region. Available reports show that alcohol use rates were high (17%-43.7%) among pregnant women receiving antenatal care,,, yet there are no protocols to address psychoactive substance use in this target population. This population is key as psychoactive substance use may have deleterious effects on the mother and the unborn child.
Our findings should be interpreted with some caution. First, we used retrospective data from a data reporting system, which may ab-initio limit the quality of data retrieved and utilised. Second, we did not elaborate on mental health problems in this sample since we have previously reported high rates of the use of cannabis and its predilection to psychosis.
| Conclusion|| |
Cannabis is a common reason for the treatment demand for substance abuse services, and we note a rise in prescription opioids abuse. Several barriers need to be surmounted to improve access to evidence-based care in the south-south zone.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]