Treatment of addiction to psychoactive substances is a complex of medical, psychotherapeutic and sociotherapeutic activities implemented by the treatment and prevention institutions of the specialised narcology service of the Republic of Uzbekistan and aims at reaching stable remissions and prevention of the relapse of drug-related diseases.
Thenarcology facilities a model of narcological assistance was introduced into practice that is based on a holistic approach to the satisfaction of the needs of drug-addicted patients in terms of medical, psychological, and social services, which should ensure an improvement in the quality and effectiveness of therapeutic activities, expansion of the list of services, and an increase in the accessibility of treatment and prevention programmes for drug users. The composite elements of this model are detoxification, medical blocking of post-abstinence disorders, inpatient and outpatient rehabilitation, and anti-relapse treatment. Interventions are implemented in strict sequence, with a gradual transfer of the patient fr om the inpatient to outpatient phase of treatment. The final aim is the psychological adaptation of the patient to a life without drugs and their reintegration into society.
In accordance with Article 34 of the Law “On the protection of citizens’ health”, forms and methods allowed by the Ministry of Health of the Republic of Uzbekistan are applied for the treatment of patients with drug addiction and toxicomania. The methods allowed are listed in the “Standards of diagnostics, treatment, and medical and social rehabilitation of drug-addicted patients”. In the organisation of narcological assistance, its main principles are followed:
availability of the provision of narcological assistance (inpatient, outpatient, in the conditions of a day patient facility, in rehabilitation centres, etc.);
equal opportunities of access to receiving qualified medical assistance;
guaranteed anonymous registration (anonymity, confidentiality);
multilayered organisation of narcological assistance;
expert activity (expertise for providing a diagnosis, drug intoxication, use of psychoactive substances, necessity of sending for compulsory treatment);
differentiated monitoring of the drug situation;
coordination, control, and legislative provision of processes of regulation of the system of narcological assistance.
The Republic of Uzbekistan has a drug registration system which includes dispensary registration and prophylactic observation of drug users.
Those persons who perform the non-medical application of psychoactive substances should apply voluntarily or be directed by the law enforcement bodies, as well as by medical facilities, to the narcological facilities of the public health system for medical examination.
In the event of a diagnosis of drug addiction they will be subjected to dispensary registration and dynamic observation in outpatient narcological units. The diagnosis can be made both in outpatient and inpatient conditions, but only by a narcologist and on the basis of a thorough examination.
In the event of disagreement with the diagnosis of drug addiction the citizen can submit a claim to the superior health providers or to a court.
The decision concerning dispensary registration is to be made by the medical consultation commission of the narcology facility. The dispensary registration is performed in the territorial narcological facility of the place of residence of the drug user.
Exclusions apply to persons who applied voluntarily for narcological help to anonymous treatment units. In such cases dispensary observation of the patients is not performed.
Patients with an addiction without remission and persons who applied for narcological assistance for the first time are examined in outpatient conditions not less than once per month. During the dispensary observation period the patients should receive qualified medical assistance ensuring their long-term remission. In the event of steady remission, the period of dispensary observation is set as 3 years. Within the first year of remission, the patient is examined once per month, in the second year once every 2 months, and in the third year once every 3 months.
Dispensary registration is terminated for the following reasons:
steady remission (3 years of full withdrawal from any psychoactive substances, including alcohol);
change of place of residence with departure to outside the territory served by the narcological institution;
sentence of deprivation from freedom for a term longer than 1 year;
Removal from dispensary observation as a result of steady remission takes place on the basis of a decision of the medical consultative commission of the narcological institution wh ere the patient was observed.
In cases of drug use without clinical signs of addiction, the drug users are subject to preventive observation. The purpose of preventive observation is to prevent the development of drug addiction. The examinations of drug users who are on preventive registration are carried out not less than once per month. With full withdrawal from drug use and the absence of signs of dependency, the duration of preventive observation is limited to 1 year. In the event of a continuation of drug use and the development of drug addiction syndrome the patient is transferred to dispensary registration.
A network of specialised narcology facilities is functioning in the republic. It includes the Republican Narcology Centre, 15 narcology dispensaries, (13 of them have inpatient units), 2 narcology inpatient clinics, and 7 narcology units within mental hospitals. Narcology rooms are established in central outpatient clinics.
Drug treatment services to the population are also provided by private clinics.
The chair of narcology and adolescent psychopathology of the Tashkent Institute for the Improvement of Doctors has served as the chief institution of the specialised necrology service. It performs the methodological management of the drug services.
The Ministry of Health organized medical and social rehabilitation units, introduced outpatient and inpatient rehabilitation programs and special methods of psychotherapy in all the structural subdivisions of the narcology service.
The programs of medical and social rehabilitation introduced into narcology facilities use the following psychotherapeutic methods:
group rational psychotherapy, information groups, group training (communicative, sensitive, assertive, creative, stress resistance, body-oriented, anti-relapse) art therapy, continual psychotherapy auto-training, holotropic breathing, transactional analysis, gestalt therapy, cult therapy, emotional stress therapy, family psychotherapy, and psychodiagnostic testing. Work with fellow-addicts is carried out.
Rehabilitation programs accept every patient who applies for help and who has an established diagnosis of addiction to drugs and other psychoactive substances with various levels of potential for rehabilitation. Thus, for the patients with medium rehabilitation potential they use components of the rehabilitation program which help them to reach more or less continuous remission and rehabilitation of personal status. And for the patients with low rehabilitation potential they use harm reduction and minimization of negative consequences (the first step of the program).
The criteria for the admission of patients addicted to psychoactive substances to the program of medical and social rehabilitation are as follows:
preliminary receiving of detoxification therapy course;
presence of the client’s motivation to withdrawal from chemical dependency;
absence of contagious infections in patients (a diagnosis of HIV/AIDS is not a barrier to participation in the programme);
absence of conditions requiring emergency therapeutic interventions.
Programs of medical and social rehabilitation include psychotherapeutic and psychological units, environmental therapy, employment therapy, and work with the family.
Supervision of the quality of the medical assistance provided to drug users is carried out by the Ministry of Health and regional departments of health. Non-governmental organisations are not involved in the process of the supervision of the quality of medical services.
The quality of treatment services is supervised by qualified narcology specialists who go to the regions, by means of direct acquaintance with the organisation of the treatment and rehabilitation process, the condition of the material and technical basis, staffing levels, and the provision of medicaments and medical equipment, as well as intensive study of primary medical documentation (case records, patients’ medical records, etc.), statistical reporting, reflecting on the indicators of the effectiveness of treatment, interviews and examinations of patients for checking on the adequacy of a sel ected range of treatment activities and their conformity with approved standards of diagnostics, treatment, and medical and social rehabilitation.
Alongside this, a new system of score-based evaluation (using a 4-point scale) of the effectiveness of the activity of the narcological and rehabilitation institutions of the republic was introduced.
In accordance with the approved guidelines, an evaluation of the effectiveness of all the main types of activity at all levels of the organizational structure of the narcology service, starting with district rooms and finishing with the Republican Narcology Centre, is performed annually.
To determine the overall assessment of the effectiveness of the narcology service of the region, an assessment of the effectiveness of the assistance provided to every patient registered in the dispensary, with an account of their medical and social indicators, is carried out preliminarily.
Medical indicators include the effectiveness of early identification, treatment, medical and social rehabilitation, and the prevention of complications resulting from drug addiction. Social indicators include assessment of their level of labour and family adaptation and the prevention of anti-social behaviour.
Further, the effectiveness of the activity of each doctor and outpatient and inpatient service of each narcology dispensary, as well as specializedtreatment preventive facilities. In cases of anonymous treatment, a score estimate of its effectiveness is carried out on the basis of interviews with patients and their relatives. A total estimate of the effectiveness of the narcology services of the district, city, region, and republic is calculated.
To understand the principle of this system, let us assess the effectiveness of outpatient assistance to patients with drug addiction and toxicomania – the aspect of the effectiveness of secondary prevention (prevention of the development of addiction in patients who are in the group of preventive registration):
stopping use of psychoactive substances – 1 score
continuation of episodic use of psychoactive substances – 2 scores
transfer from episodic to regular use of psychoactive substances without development of addiction – 3 scores
development (within reporting year) of addiction to psychoactive substances – 4 scores.
The district narcologist determines the corresponding score for each person from the prevention registration group. The scores that are obtained are summed up, and the total score for all the persons on prevention registration is created. The sum of the scores is divided by the number of persons in the registered group; if the result of the division is:
<1 score – the effectiveness is considered as high;
>1 < 2 scores – medium effectiveness;
2 scores – low effectiveness;
4 scores – zero effectiveness.
The legal basis regulating the supervision of the quality of the drug services provided in the republic is represented by the following regulatory acts:
The Law of the Republic of Uzbekistan “On the protection of the health of citizens”, dated August 29, 1996, ensures the guaranteeing of civil rights to health protection fr om the side of the state and protection against discrimination in the event of any disease, including drug addiction. It lays down the principle of the availability of medical assistance for all sections of the population, ensures the right to informed consent to medical intervention and the use only of those therapeutic methods, medical technologies, and medicaments approved for use. Local state authorities are entrusted with supervising the quality of the medical and social assistance provided by the healthcare institutions.
The Law On Drugs and Psychotropic Substances, dated August 19, 1999, guarantees the provision of drug treatment free of charge to drug addicts in the state treatment and prevention facilities, which includes examination, consulting, diagnostics, treatment, and medical and social rehabilitation. Patients who have voluntarily applied for assistance are provided with anonymous treatment. It allows methods and means which are not prohibited by the Ministry of Health of the Republic of Uzbekistan to be used for the treatment of drug addiction and toxicomania.
The law on compulsory treatment of patients with chronic alcoholism, drug addiction, or toxicomania, dated December 9, 1992, established compulsory treatment only by judicial decision on patients with a drug addiction who infringe public order and create a threat to the safety of other people.
Order of the Ministry of Health No. 39 “On the measures for the further improvement of narcological assistance to the population of the republic”, dated January 28, 1998, approves the regulation on narcology dispensaries and the district narcologist and their main tasks and functions, and the performance of annual analysis of effective treatment and preventive assistance on the basis of the statistical processing of officially approved registration documents.
Order of the Ministry of Health No. 278 “On the procedure for the registration and follow-up of persons permitting the misuse of drugs and psychoactive substances and patients with drug addiction and toxicomania” dated July 15, 2005, determines the duration of dispensary registration and intervals at which patients and persons in the group of preventive registration should be examined.
Order of the Ministry of Health No. 433, dated October 12, 2006, sets the standards for the diagnosis, treatment, and medical and social rehabilitation of patients with drug addiction. The standards describe diagnostic procedures, laboratory studies, and methods of treatment, depending on the stage of the disease and the type of psychoactive substance. Standards and medical and social rehabilitation include the stages of the treatment and rehabilitation process, criteria for the evaluation of the effectiveness of rehabilitation work and indications for outpatient and inpatient medical and social rehabilitation, as well as the requirements imposed on the specialists working in the programme of medical and social rehabilitation. To monitor the effectiveness of the programme of medical and social rehabilitation, the annexes to the Standards contain a questionnaire that was developed. The questionnaire includes such information about the patient as their age, gender, and level of rehabilitation potential. It includes data on the conditions under which rehabilitation was carried out, its duration, and the stages that were completed, a list of medical services, the types of therapy used, directions and methods of psychotherapy, and data on the duration of remission after completion of the programme.
Order of the Ministry of HealthNo. 403 “On the improvement of narcological assistance to the population”, dated September 8, 2008, regulates the organisation of medical and social rehabilitation units in all narcology dispensaries which have inpatient units, as well as in narcology clinics and the introduction of outpatient rehabilitation programmes for drug addicts in specialised treatment and prevention facilities for compulsory treatment. It also introduces psychotherapists, clinical psychologists and social workers into the staff. It approves the guidelines on the evaluation of the effectiveness of the activity of narcology facilities and the form of their annual reports on medical and social rehabilitation.
For advanced information on this issue advised to contact the Ministry of Health of the Republic of Uzbekistan.