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Comparison of Iranian Substance Users’ Relapse and Abstinence Duration Between Peer-Supported Vocational Networks and Mid Term Residential Treatment Centers

  • Naghmeh Babaeian
  • Masoomeh MaarefvandEmail author
  • Samaneh Hosseinzadeh
  • Jagdish Khubchandani
Original Article

Abstract

Relapse prevention (RP) programs mainly focus on substance users. However, workplace support and communications with colleagues can also play an important role in RP. This study compared relapse and abstinence duration between a group of Iranian substance users enrolled in a peer-supported vocational network (PVN) and a similar group enrolled in mid term residential treatment centers (MTRTCs). A case–control study was conducted among PVN members (n = 85 cases) and substance users discharged from MTRTCs (n = 85 controls) in Tehran, Iran. Case and control groups were matched for age, age of first substance use, duration of substance use, and date of registration in treatment center or PVN. One step multi-drug Abon rapid drug test in urine samples of participants was conducted to assess abstinence. Majority of the participants were single (44%) and 31–40 years old (48%). Statistically significant differences in abstinence were observed between control and PVN supported case groups. The duration of abstinence was four times higher in the PVN supported case group and MTRTCs’ clients reported relapses three times more than PVN members. PVNs could be effective method for reducing the triggers in workplace and RP among substance users. Additional research on feasibility and cost-effectiveness is suggested for broader and population based implementation of PVNs across cross-cultural settings.

Keywords

Substance use Peer-supported vocational network Rehabilitation Iran 

Introduction

Employment plays a major role in recovery and rehabilitation of substance users. A major indicator of successful treatment and sustained recovery from substance use is employment and social wellbeing [1, 2, 3]. However, substance users’ psychiatric comorbidity, lack of education and professional skills, dwindling financial resources, experiences of stigma and neglect, and lack of social support could affect their probability of employment and relapse [1, 2]. Therefore, effective interventions for relapse prevention should include several strategies that affect the individual and the family and workplace climate of recovering substance users [2, 3, 4].

Vocational Rehabilitation (VR) programs have been explored as cost-effective means for psychosocial rehabilitation and mental wellbeing of recovering substance users. The fundamental premise is that employment may be a vehicle for arranging long-duration abstinence reinforcement by affecting several domains of an individual’s life during and after recovery from substance use [4, 5, 6]. Specifically, peers and employment settings can have a significant and positive effect on employment and implications for substance use treatment and recovery [5, 6].

Magura and colleagues critically reviewed and synthesized three decades of research on the effectiveness of specialized vocational intervention for addiction treatment clients [7]. Factors such as substance use, duration of addiction, previous employment, personal motivation, age and gender of an individual, education and skills, comorbid disorders, treatment type and duration, play an important role in treatment, recovery, and vocational rehabilitation [7, 8]. For example, in one of the largest studies to date on 1453 offenders from 30 sites in California, individuals receiving employment services while in drug treatment were compared with those who did not receive such services. The study had a variety of substance users (e.g. those with comorbid mental disorders, history of crime, multiple substance use disorder, etc.). At 1-year follow-up, rates of employment, income from employment and family or friends, and probability of being paid for work were significantly higher among those who received employment training and social services, and a greater proportion of this group also completed drug treatment [8].

Vocational rehabilitation or employment service programs for substance users in treatment or recovery are predominantly used in western countries. In accordance, much of the extant literature about such programs comes from developed countries [5, 6, 7, 8]. Several countries in the Eastern Mediterranean region are experiencing an upsurge in the prevalence of substance use. However, there is not enough research on evidence-based practices to be implemented for sustained treatment, recovery and rehabilitation of substance users [9, 10]. For example, Iran has more than 4 million drug users in need of treatment services. In addition, more than fifth of all Iranians have a mental disorder, frequently comorbid with substance use [11, 12, 13]. Most of the studies from Iran have focused on prevalence and treatment of substance use in healthcare facility based populations. Research on long-term recovery and rehabilitation in Middle Eastern countries is scant, making it difficult for public health practitioners to implement evidence-based practices for substance users [9, 10, 11, 12, 13, 14].

Relapse (return to substance use after a period of abstinence) and abstinence duration are two main indexes for evaluation of substance use treatment programs. Effects of vocational rehabilitation interventions on relapse and abstinence duration has not been studied in Iran. In an earlier study by our group, we described the experiences of recovered substance users in peer-supported vocational networks (PVNs) in an Iranian context [14]. The PVNs are model vocational rehabilitation services in Iran that recruit substance users in recovery, register them in the network, provide part-time occupation, transit to full-time employment, and help establish their own business or business network for other substance users in recovery. The network managers also provide financial management to reduce risk of relapse during the first 12 months of recovery. The PVNs are entirely run by substance users who have fully recovered or are in the process of recovery [14]. We found that membership in a PVN reduces the risk of strong external triggers in workplaces that cause craving and relapse. However, our study was qualitative in nature and did not compare the experiences and treatment outcomes of PVN members versus those who did not become members of PVNs. The alternate and traditional option for recovering substance users are the Mid Term Residential Treatment Centers (MTRTCs) that provide 28–90 days abstinence-based services for treatment of substance users in Iran. Services in MTRTCs are offered mainly by ex-addicts and focus on developing coping mechanisms and relapse prevention skills. MTRTCs introduce 12-step programs to clients and motivate them to attend self-help group meetings after discharge. MTRTCs follow-up all clients with regularly scheduled appointments in MTRTCs. Both MTRTC and PVN are based on psychosocial and peer-support services for opioid users and offer no medication-assisted treatment. The purpose of this investigation is to quantify the differences in lapse/relapse and abstinence duration between Iranian substance users who enroll in vocational rehabilitation services (e.g. PVNs) compared to those who enrolled in MTRTCs.

Methods

Participants and Procedures

A case–control study was designed to compare substance users who were PVN members (n = 85) and substance users who had been discharged from MTRTCs (n = 85) in Tehran, Iran. Seven PVNs were the principal sites for recruitment of substance users who were members of PVNs (i.e. four food courts, two car repair shops, and one factory). PVNs did not provide services for female substance users. Therefore all participants in this study were male. All male substance users who were registered in PVNs at least 12 months before October 2016 (in period of October 2014 to September 2016) were eligible to participate in the study. To recruit MTRTC clients, we enrolled all individuals from five men’s MTRTCs who had completed at least 28 days of treatment (from October 2014 to September 2016) in the outpatient phase of treatment.

Matching was a way to reduce confounding in our sampling design. So we matched substance users in both groups at recruitment for age, duration of substance use (all substances), age at first substance use, date of registration in PVN or MTRTC (group matching), and main substance at entry to PVN or MTRTC. Variables for matching were selected very carefully based on previously published studies [16, 17]. The recruitment was stopped once matching was completed.

Approval of this study was obtained from the Iranian University of Social Welfare and Rehabilitation Sciences ethical review committee (case number: 931693001). Participation in the study was voluntary and all participants were informed about the research project and recruited via written and oral informed consent. All data were used for research purposes and the participants’ personal data were kept confidential. Participants were informed that they could decide not to participate or withdraw from participation at any time without giving an explanation and that their decision would not affect future treatment services or membership in PVNs.

Measures and Analysis

One step multi-drug Abon rapid drug test was used for the simultaneous, qualitative detection of multiple drugs (presence of any combination of Amphetamine, Barbiturates, Benzodiazepines, Cocaine, Marijuana, Methadone, Methamphetamine, Morphine, Methylenedioxymethamphetamine, Phencyclidine and Tricyclic Antidepressants) and drug metabolites in urine samples of participants. This test is used periodically (at least once in a week for the residents of MTRTCs and PVNs and once in a month after discharge) and routinely to screen all patients in MTRTCs and PVNs in Iran to assess abstinence. The results of all tests during treatment and after discharge are documented by MTRTCs and PVNs. One test positive after enrollment for any kind of drug in MTRTC (for control group) and PVN (for case group) has been defined as lapse/relapse and the duration of abstinence was defined as the duration that all Abon rapid drug tests were negative for participant after enrollment in MTRTC (for control group) and PVN (for case group). A questionnaire was developed in order to collect participants’ demographic characteristics, substance use history, treatment and the results of Abon rapid drug tests. In order to fill the questionnaire we reviewed all documented information in participants’ files in MTRTCs and PVNs from October 2014 to September 2016.

Data on lapse/relapse and abstinence duration were analyzed using SPSS 22 software. In the primary approach, we used descriptive analyses to describe and compare the demographic and background characteristics of participants in both groups. Next, Chi square and Mann–Whitney U test was applied to compare lapse/relapse and abstinence duration between the case (PVN) and control (MTRTC) groups. Statistical significance was established at p < 0.05.

Results

The study included 170 male substance users who had been registered in PVNs (n = 85) or MTRTCs (n = 85) with a mean age of 37.21 (± 7.89) years and an average age of 19.22 years at first use of any substance (with majority of participants reporting substance use before the age of 20 years). The mean duration of substance use for all participants was 15.82 (± 6.76) years. Most of the participants were single (n = 75, 44.1%), had less than 12 years of formal education (n = 104, 61%), and had connections with their family members and met them during the recovery (n = 144, 85%). Opium use and drug injection were the two major types of substance abuse (Table 1).
Table 1

Demographics and background characteristics of participants

Characteristics

Case N (%)

Control N (%)

Total N (%)

Age (years)

 18–30

13 (8)

19 (11)

32 (19)

 31–40

44 (26)

38 (22)

82 (48)

 41–50

23 (14)

26 (15)

49 (29)

 50 <

5 (3)

2 (1)

7 (4)

Age of first substance use (years)

 7–20

60 (35)

56 (33)

116 (68)

 > 20

25 (15)

29 (17)

54 (32)

Education (years)

 < 12

60 (35)

44 (26)

104 (61)

 12

21 (12)

33 (19)

54 (32)

> 12

4 (2)

8 (5)

12 (7)

Marital status

 Married

16 (10)

22 (13)

38 (22)

 Single

35 (21)

40 (24)

75 (44)

 Divorce

22 (13)

14 (8)

36 (21)

 Separated

12 (7)

9 (5)

21 (12)

Injection drug use

 Yes

29 (17)

38 (22)

67 (39)

 No

56 (33)

47 (28)

103 (61)

Type of main substance at treatment entry

 Opiates

47 (28)

39 (23)

86 (51)

 Stimulants

32 (19)

33 (19)

65 (38)

 Others

6 (4)

13 (8)

19 (11)

Relationship with family after recovery

 Yes

68 (40)

77 (45)

145 (85)

 No

17 (10)

8 (5)

25 (15)

Living conditions before recovery

 Family

27 (16)

58 (34)

85 (51)

 Friend

3 (2)

12 (7)

15 (9)

 Alone

8 (5)

10 (6)

18 (11)

 Homeless

47 (28)

5 (3)

52 (31)

N = 170

Two main outcomes of comparison between PVN and MTRTCs were lapse/relapse and abstinence duration (Table 2). Using a Chi square analysis, the proportion of lapse/relapse was higher for MTRTC group (n = 11, 13%) compared to the PVN group (n = 35, 41%) and these differences were statistically significantly (χ2 = 16.20, p < 0.01). Similarly, periods of recovery were evaluated based on abstinence duration via Mann–Whitney tests for group differences in average duration of abstinence. The PVN group substance users had higher duration of abstinence (Mean ± SD = 19.69 ± 16.25 months) compared to the MTRTC group (Mean ± SD = 5.95 ± 5.14 months) and these differences were statistically significant (z = − 6.41, p < 0.001).
Table 2

Case (PVN) and control (MTRTC) group comparison for result of rapid drug test and abstinence duration

Result of rapid drug test

PVN Group N (%)

Control Group N (%)

χ2

p Value

Negative

69 (41)

23 (13)

16.20

< 0.01

Positive

16 (9)

62 (37)

Abstinence

PVN Group M(± S.D)

Control Group M(± S.D)

Z Statistic

p Value

Abstinence duration (months)

19.69 (± 16.25)

5.95 (± 5.14)

− 6.41

< 0.001

N = 170

Discussion

In this first quantitative and comparative study from Iran, we report the benefits of enrolling in a vocational rehabilitation service for substance users in recovery. PVNs as a model for vocational rehabilitation could help retain recovering substance users in continued treatment and promote relapse prevention. PVN is a vocational rehabilitation program which assists clients to obtain and maintain employment. In addition, PVNs provide a variety of services including assessment to determine employment eligibility, vocational peer-counseling and guidance, on the job training and skills, facilitate treatment for substance use, and use robust follow-up techniques. Job search and vocational training are two important components of vocational rehabilitation programs [4, 5, 6, 15]. However, programs which are limited to these two components are not comprehensive. PVNs assist in recovery and abstinence. Because the PVNs included in our study are predominantly managed by recovering or fully recovered substance users, new enrollees get services that are matched to their needs. Employing recovering substance users as part time workers, monitoring recovery, promoting them to full time workers, paying them for work where finances are handled by managers and disbursed through legitimate channels, and encouraging the PVN members to eventually set up their own business or network for other recovering substance users is a sequential process that PVNs have adopted. There is continuous counseling, feedback, and provision of social and health services through the networks. Peers are the central drivers of network routine functions and support each other throughout the recovery and abstinence process while also enabling acquisition of professional skills for greater autonomy of each other. Performing purposeful work that aligns with the individual’s interests allows the person to not only support himself or herself and rely less heavily on others, but it also boosts the individual’s sense of self-worth and provides a greater sense of autonomy [5, 6, 14, 15]. Good communication within the PVNs helps recovering substance users reach their potential and also facilitates social relationships between the client, their families, and colleagues. The PVN structure and function is a comprehensive model that affects multiple domains of a recovering substance user’s life (i.e. social, financial, and psychological) and has advantages over the traditional models of care [3, 4, 5, 6, 7]. Widespread use and implementation of vocational rehabilitation services in Iran is precluded by lack of funding, challenges with collaboration among stakeholders, and government apathy towards substance users in general [13, 14, 15]. Legislation that focuses on regulations and policies that support development of vocational rehabilitation services such as PVNs should be implemented as a population based health promotion practice. Such legislation would also enable and facilitate collaboration between substance use treatment centers and PVNs for substance users who might be eligible for vocational rehabilitation services. Greater awareness about PVNs is also required for other Iranian provinces as our program is limited to Tehran, the capital city of Iran. Across the nation, PVN managers (who are mostly recovered substance users) can be invited to introduce their programs to clients in substance use treatment centers.

The results of this study should be viewed in light of some limitations. This study focused on experiences of PVN members and others recruited through limited number of facilities and may not be generalizable to all facilities and substance users across Iran. Our study used limited measures to compare substance users from PVNs and the traditional MTRTCs. Several other measures of successful treatment and recovery could be used to compare substance users who go through various pathways after discharge (i.e. PVNs and others). Also, we did not have detailed information about the participants’ motivation to quit substances and motivation to be employed. The study population was limited by demographic characteristics (e.g. males only). Broader groups of substance users could be studied and cost-effectiveness and clinical trials should be conducted to assess the efficacy of PVNs. Despite these limitations, our study had the largest sample, is the first of its kind from Iran, and provides a starting point for more rigorous and robust studies that can produce results relevant for consideration in population health promotion practice and policy development.

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Copyright information

© Springer Nature India Private Limited 2018

Authors and Affiliations

  • Naghmeh Babaeian
    • 1
  • Masoomeh Maarefvand
    • 1
    Email author
  • Samaneh Hosseinzadeh
    • 2
  • Jagdish Khubchandani
    • 3
  1. 1.Social Work DepartmentUniversity of Social Welfare and Rehabilitation SciencesTehranIran
  2. 2.Department of BiostatisticsUniversity of Social Welfare and Rehabilitation SciencesTehranIran
  3. 3.Department of Nutrition and Health ScienceBall State UniversityMuncieUSA

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