Method
Among 22 drug rehabilitation centers operating in Kathmandu valley, five centers did not give permission to conduct the study. Therefore based on the feasibility of the study and number of clients residing in those centers, only seven centers were selected for the study using Probability Proportional to Size (PPS) sampling technique. Centers having few numbers of clients (less than 5) were not included in the study. Most of the centers provide residential rehabilitation care for an average of 3 months and all the centers had visiting psychiatrists, who on an absolute need-basis, sanctioned pharmacological treatment. Respondents who were willing to participate, free from any substance withdrawal delirium or ongoing psychotic symptoms but meet the criteria of substance use disorder were included in the study. Those admitted in treatment centers for more than 3 months were excluded to reduce recall bias. The total number of clients participated in final study were 221.
Data were collected by using Nepali version, pretested self administered questionnaire. Questions regarding socio-demographic characteristics and pattern of substance use were developed after extensive literature review. Regarding age of onset of substance use, there is no defined cut off age to indicate early and late onset. For this reason, early onset is defined as the one beginning at age 17 or younger and late onset as 18 or elder, which has been supported by the existing literatures [
1,
5,
20,
21].
Socio-demographic characteristics included: Age; Gender (male, female); Educational level (≤secondary level, >secondary level); Occupation (Economically active, Economically inactive). Regarding education, respondents having education up to class 10 or below it were categorized as equal to or below secondary level and respondents having education above class 10 were categorized as above secondary level. Similarly, in reference to past 1 year status, students and unemployed were classified as economically inactive group whereas respondents engaged in some form of work were labeled as economically active group.
Substance use related characteristics included: Current types of substance use (licit, illicit, both licit and illicit); Current frequency of substance use (<3 times, ≥3 times); Duration of substance use; Relapse after first treatment (relapse, no relapse); Mode of substance use (injecting, non-injecting).
In this study substances were divided into licit (only alcohol), illicit (any illicit substances) and both licit and illicit substances. Tobacco use was not taken into consideration. Illicit substances comprises of opiates (opium, heroin, cough syrup, pain medications); stimulants (cocaine, crack, amphetamines and ecstasy); tranquilizers (diazepam, nitrazepam, alprazolam); inhalants (dendrite, paint thinner, varnish, petrol etc.); hallucinogens (LSD, acid, Ketamine) and cannabis.
Psychosocial problems of substance abusers were assessed by using a standard tool Drug Use Screening Inventory (DUSI-R), which was developed by Dr. Ralph Tarter in 1990. DUSI-R, a self-report questionnaire has dichotomous yes/no responses and quantifies severity of problems in 10 domains: 1) Substance Use, 2) Health Status, 3) Behavior Problems, 4) Psychiatric Disorder, 5) School Performance, 6) Family System, 7) Work Adjustment, 8) Peer Relationships, 9) Social Competence, and, 10) Leisure/recreation. Substance use – The substance use domain contains 15 items and measures the severity of substance use problems in relation to craving for substance use, withdrawal features, legal problems etc.; Health Status – The 10 items of this domain measures health status of individuals with SUDs; Behavior pattern – It contains 20 items that assess the characteristic pattern of behavior of the individuals with SUDs such as impulsivity, aggressiveness, emotional excitability etc.; Psychiatric disorders – This domain includes 20 items that measures the severity of emotional disturbances and psychiatric problems such as anxiety, depression, antisociality, psychotic symptoms etc.; Social competence – The 14 items of social competence measures the behavior of the members of society toward the individual’s personal and social skills required for adaptive functioning in society; Family system – The 14 items of family system assesses the organization of the family, behaviors of family members, pattern of communication, cohesiveness within the family and the relationship with the members; School performance – This domain is included only to those individuals who used to go to school within the past 1 year. Twenty items of school performance measures the severity of problems with respect to school environment, school engagement and academic performance; Work adjustment – Ten items of this domain are used only to those individuals who were engaged in some type of work or job within the past 1 year to measures the severity of problems related to work adjustment; Peer relationship – Fourteen items of this domain assesses the severity of problems in terms of peer selection, peer network and peer relation; Leisure/Recreation – Twelve items of this domain quantifies severity of disturbance in quality of activities during leisure time.
The scores on each domain and the overall problem density index ranged between 0 and 100%. The tool is copyright so permission for the use of the instrument was taken from the owner. Validity and reliability of the DUSI-R have been documented [
22,
23]. For the use of the tool in Nepalese context, first forward translation (from English to Nepali) then backward translation (Nepali to English) was done. Finally, the back translated text was compared with the original text and differences between these two texts were resolved through discussion between translators for ensuring semantic equivalence. The back translated tool was also sent to the original developer of the tool for verification.
To identify the accuracy, adequacy and completeness of the tool, pre testing of the translated instrument was done on 15 respondents of one of the drug rehabilitation center. On the basis of pretesting, necessary modification were made in part I and II of the instrument. Cronbach’s alpha coefficient was computed to determine the reliability of translated (Nepali version) DUSI-R and was 0.89 which showed a high degree of internal consistency among the items. The alpha coefficient of different domain was as follows: Substance use = 0.79, Health status = 0.81, Behavior patterns = 0.82, Psychiatric disorder = 0.84, Social competence = 0.73, School performance = 0.81, Work adjustment = 0.78, Family system = 0.76, Peer relationship = 0.81, Leisure/Recreation = 0.74.
The school performance domain was used only by those respondents who used to go to school within the past 1 year. Similarly work adjustment domain was used by those respondents who were engaged in any form of work within the past 1 year. So, for the calculation of overall problem density index in those respondents who do not have to answer the question regarding that domain, the denominator was adjusted.