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A STUDY OF THE CHARACTERISTICS OF A CLINICAL POPULATION
OF SUBSTANCE MISUSERS IN THE UAE AND AN EXPLORATION OF
SOCIAL DRIFT IN THIS POPULATION
By:
Samya Al Mamari
A dissertation (or thesis) submitted to Johns Hopkins University in
conformity with the requirements for the degree of Doctor of Public
Health (DrPH)
Baltimore (Maryland), USA
June 18, 2018
© 2018 Samya Al Mamari
All Rights Reserved
ABSTRACT
Introduction:
Substance
use
disorder
and
addiction negatively
influence one’s behaviors and actions, and they endanger the health
and welfare of individuals and societies at all levels. The scale of their
destructiveness imposes a clear threat to public health and makes it
one of the biggest public health challenges of modern times.
Aim: This study aims to identify the characteristics of substance
abusers receiving treatment in the National Rehabilitation Center (NRC)
in Abu Dhabi – UAE and explores the phenomenon of social drift among
this population. The study also aims to compare the characteristics of
this clinical population in Abu Dhabi with the characteristics of a
clinical population in Jordan in the Al Ghafri study (2014). In addition,
the study will explore the associations between the nursing interactions
with the patients at the NRC and the patients’ satisfaction with the
service.
Method: A cross-sectional descriptive design was utilized in this study
in the form of a structured questionnaire interview. The study
population is a clinical population (in-patients and out-patients)
receiving treatment for substance use disorder from the National
Rehabilitation Center – NRC. Two hundred fifty patients who met the
inclusion criteria and voluntarily accepted to participate in the study
were invited to take part in the structured interview.
ii
Result: The total sample of the clinical population in this study is 250
patients including 242 males and 8 females (response rate of 94%). The
mean (SD) age of subjects was 28.52 (8.87) years, with the majority of
the patients being under the age of 31 years. 59.6% were single, and
98.8% were educated with the majority at the secondary level and
49.6% were unemployed. The common source of referral was selfreferred (51.6%).
Mood disorders were most frequently reported (51.5%) as a psychiatric
illness. Hypertension and gastritis were the most common medical
problems. Of the 250 participants, 73% were polysubstance users, 18%
used drugs only, and 9% used alcohol only. 98.8% reported that they
were currently smoking. The youngest age of first use of most of
substance was 11 years with a mean (SD) of 17.8 years.
The majority of both groups had moderate severity of dependence (50%,
of substance users and 61.5%, of alcohol users). 32% had a CAGE score
of 2. 72% of the participants had had treatment before. The majority
stated that they would choose the NRC again to receive treatment. More
than 56% did not complete their studies, of whom 68% didn’t complete
their studies because of their addiction.
The study assumed that there are similarities between Jordanian and
NRC clinical population’s profile due to the assumed cultural and
religious
similarities.
The
descriptive
analysis
of
both
clinical
population’s profile revealed the presence of some similarities and
differences. There were no significant associations found between
iii
severity of dependence and the variables studied. The same was found
in the case of social drift. However, highly significant correlation was
found between patient satisfaction and the combined variable of
nursing interaction.
Conclusion: The findings gave useful information on the profile of the
current patient population that could be used for developing and
improving services as well as developing policies and conducting
research. They also provide us with a baseline that could be used to
monitor trends in the future. The study also enabled a comparison with
a regional country with similar culture and demographics. The findings
that nursing interaction is strongly associated with patient satisfaction
have major implications for developing addiction nursing.
iv
ACKNOWLEDGMENT
Overall the experience over the past four years doing this research has
taught me an enormous amount about the research process, the
difficulties involved in primary data collection and how to overcome
them. It has taught me about ethical considerations, literature
searching and reviewing, choosing research designs, statistical analysis
and writing in a language that is not my native language. Although
there have been high points and low points, overall, it has increased my
enthusiasm for research which I intend to continue and also to teach
others.
I would like to devote this dissertation to His Highness Sheikh
Mohammed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi and
Deputy Supreme Commander of the UAE Armed Forces. For his
continuous support for the youth, for teaching us how to serve our
country, for your leadership, your determination and your passion to guarantee
the future of our country. Also, I would like to express my appreciation and
acknowledgement for the endless support and guidance of His
Excellency Dr. Hamad Al Ghafri, the Director General of the National
Rehabilitation. In addition, I am enormously grateful to the patients
who participated in this study.
My special thanks to Professor David, Dr. Lilly and Dr. Shamil for the
time, efforts and advice because without their continuous support and
guidance I would not have able to complete this journey. without them
v
I would not be with you here today. Also, my appreciation is extended
to all the supervisors and mentors who helped me throughout my
study.
I would like also to thank Ms. Fatima Al Suwadi, Dr. Mohamed Alsayed,
Dr. Hisham Al Arabi from the National Rehabilitation Center (NRC) in
Abu Dhabi and Professor Anwar Batieha, Faculty of Medicine- Jordan
University of Science & Technology for their support, assistance
encouragement and valued comments that helped shaped the
production of this thesis.
My special thanks goes to my family for their endless patience, support
and believing in me.
Samya Al Mamari
vi
TABLE OF CONTENTS
ABSTRACT................................................................................................................................... ii
ACKNOWLEDGMENT.................................................................................................................. v
TABLE OF CONTENTS................................................................................................................ vii
LIST OF TABLES ........................................................................................................................... x
LIST OF FIGURES ...................................................................................................................... xiii
1.
CHAPTER ONE: INTRODUCTION ......................................................................................... 1
1.1.
Problem Statement ............................................................................................ 1
1.2.
Significance ........................................................................................................ 4
1.2.1.
2.
1.3.
Social Drift .......................................................................................................... 8
1.4.
Study Aims ......................................................................................................... 9
CHAPTER TWO: SYSTEMATIC LITERATURE REVIEW ......................................................... 12
2.1.
Search Strategy ................................................................................................ 13
2.2.
Overview of Search .......................................................................................... 16
2.3.
Review of Papers.............................................................................................. 20
2.3.1.
Substance Abuse Profile in Arab Countries ..................................................... 23
2.3.2.
Substance/Alcohol Abuse and Social Drift ....................................................... 49
2.4.
3.
Significance of Substance Abuse Problem in the United Arab Emirates ........... 6
Conclusion ........................................................................................................ 51
CHAPTER THREE: METHODLOGY ..................................................................................... 52
3.1.
Study Aims and Hypotheses............................................................................. 52
3.2.
Protection of Human Subjects ......................................................................... 54
3.3.
Study Design, Including Study Population, Controls, and Design .................... 55
3.3.1.
Study Population .............................................................................................. 55
3.3.2.
Sample Size ...................................................................................................... 56
3.3.3.
Study Design..................................................................................................... 57
3.4.
Source of Data.................................................................................................. 58
3.4.1.
The National Rehabilitation Centre (NRC): ...................................................... 58
3.4.2.
The Questionnaire............................................................................................ 59
3.5.
Piloting ............................................................................................................. 64
vii
3.6.
Procedure ......................................................................................................... 66
3.7.
Data Entry and Quality Assurance ................................................................... 67
3.8.
Data Management and Analysis ...................................................................... 68
3.8.1.
Variables and Measures – operational indicators ........................................... 68
3.8.2.
Analysis plan..................................................................................................... 70
3.8.3.
Detailed analysis plan to address research questions ..................................... 71
3.9.
4.
Conclusion ........................................................................................................ 76
CHAPTER FOUR: RESULTS ................................................................................................ 77
4.1.
Response Rate.................................................................................................. 78
4.2.
SECTION ONE: The characteristics of the clinical population of substance
abusers receiving treatment in the NRC (UAE):................................................................... 78
4.2.1.
Part 1: Demographic Data:............................................................................... 78
4.2.2.
Part 2: Addiction History .................................................................................. 84
4.2.2.1.
4.2.3.
4.3.
Substance Abuse and Smoking .................................................................... 84
Part 3: Social................................................................................................... 103
SECTION TWO: Hypothesis # 1: The characteristics of the clinical population of
substance abusers receiving treatment in the NRC will be similar as the clinical population
of substance abusers studied in Al Ghafri - 2014. ............................................................ 112
4.3.1.
Patient Background:....................................................................................... 113
4.3.2.
Psychiatric & Medical Data: ........................................................................... 116
4.3.3.
Substance Abuse and Smoking History: ......................................................... 117
4.4.
SECTION THREE: Hypothesis #2: Severity of Dependence Associations ........ 120
4.5.
SECTION THREE: Hypothesis #3: Social Drift Associations ............................. 122
4.6.
SECTION FOUR: Hypothesis #4: Increased nursing interactions will be
associated with higher level of patient satisfaction with the nursing services ................. 123
4.7.
5.
Conclusion ...................................................................................................... 123
CHAPTER FIVE: DISCUSSION ........................................................................................... 125
5.1.
Main Findings ................................................................................................. 125
5.1.1.
The characteristics of the clinical population of substance abusers receiving
treatment in the NRC (UAE): .......................................................................................... 125
viii
5.1.2.
Hypothesis # 1: The characteristics of the clinical population of substance
abusers receiving treatment in the NRC will be similar as the clinical population of
substance abusers studied in Al Ghaferi’s 2014. ........................................................... 136
5.1.3.
Hypothesis #2: Severity of Dependence Associations ................................... 138
5.1.4.
Hypothesis #3: Social Drift Associations ........................................................ 139
5.1.5.
Hypothesis #4: Increased nursing interactions will be associated with higher
level of patient satisfaction with the nursing services................................................... 139
5.2.
Strengths and Limitations .............................................................................. 142
5.2.1.
Strengths ........................................................................................................ 142
5.2.2.
Limitations...................................................................................................... 143
5.3.
Implications for Practice ................................................................................ 145
5.4.
Implications for Policy .................................................................................... 147
5.5.
Further Research ............................................................................................ 149
5.6.
Overall Conclusions ........................................................................................ 150
APPENDIX – 1: PATIENT INFORMATION SHEET ..................................................................... 151
APPENDIX – 2: CONSENT FORM............................................................................................. 152
APPENDIX – 3: QUESTIONNAIRE ............................................................................................ 153
APPENDIX – 4: NRC IRB APPROVAL ........................................................................................ 165
REFERENCES ........................................................................................................................... 166
CURRICULUM VITA................................................................................................................. 173
ix
LIST OF TABLES
Table 3- 1 Examples of modifications made in the questionnaire ................ 63
Table 3- 2 The Study Hypothesis and their Variables (independent and
dependent) ................................................................................................. 69
Table 4- 1 Frequency Distribution of the participants' Demographic Data .. 80
Table 4- 2 Frequency Distribution of the participants' Psychiatric & Medical
Data ........................................................................................................... 83
Table 4- 3 Frequency Distribution of the participants by Substance of Use 84
Table 4- 4 Frequency Distribution of Substance of Use by age of 1st Use ... 85
Table 4- 5 Frequency Distribution of Current smoking status and smoking
history categorized by gender ..................................................................... 86
Table 4- 6 Frequency Distribution of Current Use of Substance & Alcohol
Over the Past 1-2 Months ........................................................................... 87
Table 4- 7 Frequency Distribution of the Participants' View of the Importance
of Use of Substance & alcohol .................................................................... 87
Table 4- 8 Frequency Distribution of the Participants' Satisfaction of their
Use ............................................................................................................. 88
Table 4- 9 Frequency Distribution of Dependency Criteria for Substance &
Alcohol Users ............................................................................................. 90
Table 4- 10 Frequency Distribution of Severity of Dependency ................... 90
Table 4- 11 Frequency Distribution of CAGE Criteria ................................. 91
Table 4- 12 Frequency Distribution of CAGE Score .................................... 92
Table 4- 13 Frequency Distribution of withdrawal Symptoms .................... 93
Table 4- 14 Frequency Distribution of Previous Treatment Experiences and
Follow ups .................................................................................................. 96
Table 4- 15 Frequency Distribution of Numbers of Previous Inpatient and
Outpatient Treatment Encounter................................................................ 97
Table 4- 16 Frequency Distribution of Participants' Views on how NRC
Respond to their Needs ............................................................................... 98
x
Table 4- 17 Frequency Distribution of Participants' Views on the
Coordination in-between Different NRC Services ........................................ 99
Table 4- 18 Frequency Distribution of Participants' Respond to coming back
to NRC........................................................................................................ 99
Table 4- 19 Frequency Distribution of Participants' Satisfaction with NRC
Nursing Services....................................................................................... 100
Table 4- 20 Frequency Distribution of Family History of psychiatric problem,
addiction problem, suicide problem and the current health status ........... 101
Table 4- 21 Frequency Distribution of Participants' View of Factors
associated with relapse............................................................................. 102
Table 4- 22 Frequency Distribution of Participants' Employment Status .. 104
Table 4- 23 Frequency Distribution of Participants' Employment Type ..... 104
Table 4- 24 Frequency Distribution of perceived effect of addiction on
employment as reported by participants ................................................... 105
Table 4- 25 Frequency Distribution of perceived effect of addiction on
employment as reported by participants ................................................... 107
Table 4- 26 Frequency Distribution of the Substance Users living with the
participants as reported by participants ................................................... 108
Table 4- 27 Frequency Distribution of the Participants’ Education Status 109
Table 4- 28 Frequency Distribution of the Participants’ Marital Status ..... 110
Table 4- 29 Frequency Distribution of the Participants’ Source of Income 111
Table 4- 30 Frequency Distribution of the Participants’ Financial Status . 112
Table 4- 31 Frequency Distribution of the Comparison of Patient
Demographic between Al Ghafri’s study and the current study. ............... 114
Table 4- 32 Chi-square test between the two clinical populations
characteristics .......................................................................................... 116
Table 4- 33 Frequency Distribution of the Comparison of Psychiatric &
Medical Data between Al Ghafri’s study and the current study................. 117
Table 4- 34 Comparison of Substance of Use between Al Ghafri’s study and
the current study ..................................................................................... 118
xi
Table 4- 35 Comparison of current smoking status and smoking history
between Al Ghafri’s study and the current study ...................................... 118
Table 4- 36 Comparison of substance by age of 1st use between Al Ghafri’s
study and the current study ..................................................................... 119
Table 4- 37 Comparison of current use of substance and alcohol between Al
Ghafri’s study and the current study. ....................................................... 120
Table 4- 38 Unadjusted and adjusted Regression analysis of Severity of
Dependence .............................................................................................. 121
Table 4- 39 Unadjusted and adjusted Regression analysis of Social Drift . 122
Table 4- 40 Unstandardized and Standardized Coefficients analysis of
Patient Satisfaction .................................................................................. 123
xii
LIST OF FIGURES
Figure 2- 1 PRISMA Chart – Section One: Substance/Alcohol Use and
Arab Countries ................................................................................ 18
Figure 2- 2 PRISMA Chart – Section Two: Social Drift and
Substance/Alcohol Use and Arab Countries..................................... 19
Figure 3- 1 Data collection Procedure .............................................. 67
xiii
1. CHAPTER ONE: INTRODUCTION
This chapter is an introductory chapter for the dissertation paper. It
describes briefly the problem statement and the significance of the
problem globally and specifically in the UAE. Finally, the aim of the
study and the thesis investigated in this paper will be mentioned at the
end of the chapter.
1.1. Problem Statement
Addiction is defined as “a primary, chronic disease of brain reward,
motivation, memory and related circuitry.” In other words, addiction
negatively influences one’s behaviors and actions. Such behaviors
foster compulsive substance misuse regardless of the destructive
consequences to both individuals and, more widely, the society in which
it takes place. Addiction just like any other chronic diseases has its
relapse and remission cycles. This makes quitting and maintaining
sobriety very difficult and hinders the individual’s ability to fight the
strong drug seeking desires (American Society of Addiction Medicine,
2011). National Institute on Drug Abuse (NIDA) (2016) defined addiction
as “a chronic, relapsing brain disease that is characterized by
compulsive drug seeking and use, despite harmful consequences”. In
both definitions addiction was described as “a brain disease.” due to
the changes in the brain’s structure and functions, which might be
long-term changes and result in self-destructive behaviors.
1
Substance use disorder and addiction endanger the health and welfare
of individuals and societies at all levels. In 2016, the United Nations
Office on Drugs and Crime (UNODC) reported that approximately 247
million people of the adult population worldwide (aged 15-64 years)
used an illicit substance in the 2014, and of those, over 29 million
people have drug use disorders (United Nations Office on Drugs and
Crime, 2016).
Out of the 29 million people who have drug use disorders, 12 million
are drug injectors, and out of this number, 1.6 million are living with
HIV and 6 million are living with hepatitis C. Worldwide, drug-related
deaths in 2014 were estimated at 43.5 deaths per million people aged
15-64, and of those, a third and a half are due to overdose deaths
(United Nations Office on Drugs and Crime, 2016).
In 2010 the global consumption of alcohol of people aged 15 years or
older was around 13.5 grams of pure alcohol per day. Also, about 16%
of those who drink aged 15 years or older are involved in heavy episodic
drinking. In general, as the economic wealth of a country increases, the
alcohol consumption increases and the number of abstainers decreases
(World Health Organization, 2014).
Based on the 2014 Global status report on alcohol and health, around
3.3 million deaths (5.9%) of all deaths in 2012 were related to alcohol
consumption out of which 7.6% of deaths were among males and 4.0%
of deaths were among females. Around 5.1% of the global burden of
2
disease was related to the harmful consumption of alcohol (World
Health Organization, 2014).
According to the 2013 WHO drug use and road safety, over 39,600 road
traffic deaths were due to driving under the influence of illegal
substances. Use of drugs such as amphetamines, benzodiazepines,
cannabis and cocaine resulted in 8.8% to 33.5% road traffic accidents
with fatally injured persons (World Health Organization, 2016) ("Global
status report on road safety: Supporting a decade of action," 2013).
The scale of destruction caused by substance use disorders and alcohol
imposes a clear threat to the public health. It is a major contributor to
family breakdown, domestic violence, child abuse, failure in school, loss
of employment, productivity losses, healthcare costs, and crimes
(National Institue on Drug Abuse, 2016) (United Nation of Drug and
Crime, 2014).
The situation in the Middle East is not different than the rest of the
world. Despite the fact that drug and alcohol use is forbidden legally
and religiously, the prevalence of drug and alcohol use is unexpectedly
high. In fact, Afghanistan is the world’s leading manufacturer of opium
and marijuana. In addition, the number of illegal opiate users in the
region is counted for one fifth of the number of illegal opiate users
worldwide, even though the region has only 6% of the global population
aged 15-64 years (United Nations Office on Drugs and Crime, 2014).
Since the independence of the United Arab Emirates (U.A.E.) in 1971,
several aspects of life have transformed quickly and people moved from
3
Bedouin life into a fairly luxurious life. Proximity to opiate-producing
countries,
long
land
borders
and
extensive
international
air
connections, globalization and rapid social and economic changes
created a rich environment for drug trafficking. In other word, the
problem of drug abuse in the UAE appears to be on the increase, and
there is concern it could become a serious problem in the future
(Sarhan, 1995).
1.2. Significance
Substance use disorders jeopardize individual welfare and threatens
the
communities’
stability,
security
and
economic
and
social
development throughout the world. In fact, the international figures of
mortality rates and the financial costs related to substance use
disorders are alarming. Dealing with substance abuse consequences is
one of the major public health challenges that societies must confront.
The magnitude of the substance use disorder problem is represented
clearly in the disturbing figures of drug-related deaths as they are
always premature and happen at a quite young age. Out of the 207,400
drug-related deaths in 2014, 43.5 deaths per million people were among
those aged 15 – 64. Although, the figures of drug-related deaths
worldwide haven’t changed, these deaths are unacceptable and
preventable. Looking at overdose related deaths, it was reported that
these deaths make approximately a third and a half of all drug-related
deaths, and are due to opioids in most cases (United Nations Office on
Drugs and Crime, 2016).
4
Drug injectors suffer from some of the most severe health-related
conditions due to unsafe drug use practices. High risk of non-fatal and
fatal overdoses, and higher chance of premature death are among the
most common poor health outcomes that drug injectors end up with.
All reported data indicated that one out of seven drug injectors is living
with HIV, and one in two has hepatitis C. UNODC estimated that the
global prevalence of HIV among people who inject drugs is 11.5 percent
and 51 percent is the global prevalence of hepatitis C virus (HCV) among
the drug injectors. The hepatitis B virus (HBV) global prevalence among
people who inject drugs is estimated at 8.4 percent (United Nations
Office on Drugs and Crime, 2016).
The same could be said about the harmful use of alcohol. It caused
approximately 5.9% of all deaths annually and alcohol consumption
attributed to 5.1% of the global burden of disease. Men are more
seriously affected by the harmful use of alcohol than women.
Worldwide, alcohol is attributed to 6.2 percent of all male deaths
compared to 1.1 percent of female deaths. In United States, alcohol is
the fourth leading preventable cause of death. Globally, alcohol misuse
was reported to be the fifth leading cause of premature death and
disability and the first among people between the ages of 15 and 49.
Alcohol is the principal risk factor for death in men ages 15–59, as a
result of injuries, violence and cardiovascular diseases. Also the total
burden of the harmful use of alcohol in men is 7.4 percent compared to
5
1.4 percent in women (World Health Organization, 2014), (National
Institutes on Alcohol Abuse and Alcoholism, 2017).
Road traffic accidents lead to more than a million deaths yearly with
estimated financial consequences to be billions of dollars. An estimated
10.3 million people aged 12 or older reported driving under the
influence of illicit drugs during the year prior to being surveyed (World
Health Organization, 2013).
In the United States alone, the estimated total overall costs of substance
use disorders exceed $600 billion annually, out of which, roughly $193
billion for illicit drugs, and the same for tobacco, while alcohol costs
around $235 billion. Directly and indirectly drug abuse and alcohol are
the underline case of many social problems. Around half of the arrested
individuals for major crimes such as murder, robbery, and assault were
under the influence of illegal drugs (National Council on Alcoholism and
Drugs Dependence, 2015).
1.2.1.
Significance of Substance Abuse Problem in the
United Arab Emirates
Since the union of the seven emirates in 19971, the UAE has undergone
rapid changes in every aspect of life. This rapid development has
required a substantial influx of a foreign and multinational labor force
which has considerably impacted Emirati culture, traditions, and social
and family structures. This in addition to Westernization and
globalization.
6
Substance misuse in the UAE was not viewed as a problem until 1980s,
when the Ministry of Social Affairs observed an increase in the number
of drug users and the amounts used. The problems of mortality, health
and other problems to the individual, families, the social fabric,
including the economy, made Substance misuse a national security
issue. The country analysis report by the World Health Organization
showed that per capita alcohol consumption in the UAE almost doubled
from the period 2003-2005 compared to 2008-2020 (World Health
Organization, 2014). These figures included nationals and expats.
Death from overdose is another statistic that can be added to the
picture (Al Ghafri, Osman, Matheson, & Wanigaratne, 2013).
The UAE is a signatory to the international laws on drug demand
reduction. There is zero tolerance of use of banned substances and
conviction results in a mandatory sentence or treatment and
rehabilitation for those first timers. In terms of the legality of alcohol,
its consumption is only legal for non-Muslims who are 21 years of age
and older within licensed premises. UAE legislation based on Shari’ah
law prohibits a Muslim to consume alcohol in the UAE (Sarhan, 1995),
(Department of Drug Control, 2018).
Based on a study conducted by C.M. Doran (2016), the estimated cost
of addiction was at US$ 5.47 billion in 2012, which equals 1.4% of the
gross domestic product and consisted of lost productivity at US$ 4.79
billion (88%) and criminal behavior at US$ 0.65 billion (12%) (Doran,
2016)
7
Just like the rest of the region, alcohol and drug abuse is becoming a
growing burden on the economy of the United Arab Emirates. This is
due to many reasons such the close proximity to opiate-producing
countries and the rapid social and economic changes. All of these
reasons made the United Arab Emirates an excellent route for
substance trafficking (World Health Organization, 2014).
1.3. Social Drift
It is known in the social epidemiology that there is an inverse
relationship between mental illness and social class. This means that a
person with a mental illness, would have a downward shift in the social
class as the mental illness worsens. Most studies linked social drift with
mental illnesses, especially schizophrenia (Perry, 1997).
As explained earlier, addiction is a chronic relapsing mental illness. So,
it can be claimed that addicted patients might be subject to social drift.
Investigating social drift in the area of substance use disorders and
addiction is uncommon.
Terms such as social status, social class,
social group and socio-economic status are used interchangeably in the
literature. Also, social networks or social capital are used in some
settings. For this study purpose, Al Ghafri’s (2015) definition of social
drift will be used, which is “a downward spiral in an individual’s wealth,
educational achievement, employment status, marital status and family
relationships, social networks (social capital), accommodation and
general status in society”. Furthermore, he included having a criminal
record due to addiction whether it was illicit use or illegal activity to get
8
the substance or resulted from its use such as accidents or murders (Al
Ghaferi, Sayed, & Ali, 2015)
1.4. Study Aims
The aim of this study is to identify the characteristics of substance
abusers receiving treatment from the National Rehabilitation Center
(NRC) in Abu Dhabi – UAE and explore the relationship of social drift
among this population. The study also aims to compare the
characteristics of this clinical population with that of a clinical
population in Jordan carried out by Al Ghafri in 2014. In addition, the
study will explore the associations between the nursing interactions
with the patients at the NRC and the patient satisfaction.
Specific Objectives:
1. To describe the characteristics of a population of substance
abusers in treatment in the National Rehabilitation Center (NRC)
in Abu Dhabi - UAE in terms of demographics, substance use
pattern and history, dependence, relapse history, medical and
psychiatric histories and indicators of social drift (education,
employment, marital, financial and criminal).
2. To assess the current used substance and patterns of behavior
in terms of substance use patterns, dependence and relapse
history.
3. To examine factors associated with relapse from the patient
perspective.
4. To explore patient experiences of treatment.
9
5. To assess in-depth, the association between social drift and
substance use disorders (education, employment, marital,
financial and criminal).
6. To compare the results of this study with a prior study
conducted with a similar population from Jordan results (Al
Ghafri H. , 2014).
7. To examine the relationship between the quality of nursing
interaction and patient satisfaction.
8. And finally, to develop and test a tool for measuring social drift
in the context of drug abuse treatment.
This study will test the following research hypotheses:
1) The characteristics of the clinical population of substance
abusers receiving treatment in the NRC will be similar to the
clinical population of substance abusers studied in Al Ghafri’s
Study (2014).
2) Severity of dependence is associated with:
a. Early initiation of substance use.
b. Longer length of dependence.
c. Presence of a family history of addiction.
d. Lower level of education.
3) Social drift is associated with:
a. Early initiation of substance use.
b. Longer length of dependence.
c. Presence of a family history of addiction.
10
4) Increased nursing interactions will be associated with higher
level of patient satisfaction with the nursing services.
Given the limited number of studies on substance use disorders and
addiction in the UAE, the expected outcomes of this study are to
contribute to the substance use disorders’ literature in the UAE and
provide a useful data for the policymakers. The results of the study
would help in restructuring the existing prevention and treatment
interventions and programs that are currently in use in the UAE.
11
2. CHAPTER TWO: SYSTEMATIC LITERATURE REVIEW
Substance use disorders and addiction are topics that have been
comprehensively studied in the West and a large number of
publications. In contrast, there is a scarcity of reported research in
Muslim Arab communities. This scarcity may be due to these
substances being religiously, socially, and legally prohibited and
disapproved. In addition, the social stigma attached to such cases,
which views addiction as a disgraceful individual event, is a major
barrier to treatment. The same factor may apply to research as
obtaining data from a hidden problem has its inherent difficulties,
explaining the relative scarcity of research publications. However, as a
result of the proximity to opiate-producing countries, globalization and
rapid social and economic changes occurring in these countries, the
urgency of exploring the field of substance use and addiction has
become a necessity in recent years (AlMarri & Oei, 2009).
A systematic comprehensive literature review that was carried out is
described in this chapter. The chapter is divided into two sections. The
first section aimed to look at a collection of credible articles that
describe the characteristics of substance and alcohol users in Arab
countries. The second section examined the connection between
substance and alcohol use and social drift.
12
2.1. Search Strategy
The electronic databases used in this literature review were Academic
Search, EMBASE, PubMed, PsycInfo, MEDLINE, and Web of Science.
The inclusion criteria for articles in the literature review were articles
published from 2001 to 2016, written in English and addressed topics
similar to the research topic. A period of 15 years was chosen because
it was anticipated that a shorter period would yield fewer papers.
The literature search was restricted to published articles appearing in
the above search engines. ‘Grey literature’ consisting of unpublished
reports and articles available on the internet was avoided due to
concerns about accuracy and quality.
All results were examined for relevance to the research topic and the
irrelevant titles and duplicates were excluded. Then, of the remaining
articles abstracts were reviewed and excluded as appropriate. The final
list of relevant articles was examined, summarized and tabulated. The
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) chart was used to illustrate the process and results of the
systematic literature review (Moher D, 2009).
In the first section, the key words used were substance; alcohol; use;
misuse; abuse; dependence, addiction and specific drug names or
groups such as: heroin; narcotics; cocaine; benzodiazepines; cannabis;
sedatives; hallucinogenic; inhalants; khat and amphetamines. Also, key
words like Arab countries; Arab; Gulf Cooperation Council (GCC)
13
countries; UAE; Bahrain; Kuwait; Oman; Qatar; Saudi Arabia. They
were grouped in the following manner:
1. Substance
2. Alcohol
3. Use
4. Misuse
5. Abuse
6. Dependence
7. Addiction
8. Specific drug groups (heroin, narcotics, cocaine,
benzodiazepines, sedatives, cannabis, hallucinogenic, inhalants,
khat, amphetamines).
9. Specific region or countries (Arab countries; Arab; Gulf
Cooperation Council countries; UAE; Bahrain; Kuwait; Oman;
Qatar; Saudi Arabia).
10.
(1 or 2 or 8) and (3 or 4 or 5 or 6 or 7) and 9.
In the second section – social drift, the key words used were social drift;
social decline; social migration; social complications; socio-economic
status; financial status; employment status; social impairment. Also,
other key words were used such as substance; alcohol; abuse; addiction
and specific drug names or groups such as: heroin; narcotics; cocaine;
benzodiazepines; cannabis; sedatives; hallucinogenic; inhalants; khat
and amphetamines. In addition to key words like Arab countries; Arab;
Gulf Cooperation Council (GCC) countries; UAE; Bahrain; Kuwait;
14
Oman; Qatar; Saudi Arabia. They were grouped in the following
manner:
1. Social drift
2. Social decline
3. Social migration
4. Social complications
5. Socio-economic status
6. Financial status
7. Employment status
8. Social impairment
9. Substance
10.
Alcohol
11.
Use
12.
Abuse
13.
Addiction
14.
Specific drug groups (heroin, narcotics, cocaine,
benzodiazepines, sedatives, cannabis, hallucinogenic, inhalants,
khat, amphetamines).
15.
Specific region or countries (Arab countries; Arab; Gulf
Cooperation Council countries; UAE; Bahrain; Kuwait; Oman;
Qatar; Saudi Arabia).
16.
(1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 14) and (9 or 10)
and (11 or 12 or 13) and 15.
15
2.2. Overview of Search
Using the search strategy described above, the number of papers that
were found under section one in the identified database using
substance and Arab countries as the main key words which were
combined with use, misuse, abuse, dependence and addiction
produced 7,018 articles. After applying the selected period (2001 –
2016), the number of articles was reduced to 5,627 articles. From this
total, 263 articles were removed due to duplication, 4,967 articles were
excluded based on their title, and 312 were excluded on the basis of
their abstract. The total number of articles assessed for eligibility was
85. A further 23 articles were excluded due to non-relevance. 62 articles
were included in the final literature review. Three types of papers were
included in the review: original research, systematic reviews and nonempirical papers, which include reviews and overviews. The abovementioned strategy was presented in the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) chart below (Figure
2.1).
Using the same search strategy described above, the number of papers
that were found under section two in the identified database using
social drift and substance/alcohol and Arab countries as the main key
words which were combined with use, abuse, and addiction produced
6 articles. After applying the selected period (2001 – 2016), the number
of articles remained 6 articles. From this total, 4 articles were removed
due to duplication, no articles were excluded based on their title, and
16
no articles were excluded on the basis of their abstract. The total
number of articles assessed for eligibility was 2. No articles were
excluded due to non-relevance, so 2 articles were included in the final
literature review.
The above-mentioned strategy was presented in the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRISMA) chart below
(Figure 2.2).
17
Figure 2- 1 PRISMA Chart – Section One: Substance/Alcohol Use and Arab
Countries
Number of articles identified through
database searching = 7,018
Number of articles identified through
database searching (2001 – 2016) =
5,627
Number of removed
duplicates = 263
Number of articles screened = 5,364
Number of articles
excluded on the basis of
title = 4,967
Number of articles screened = 397
Number of articles
excluded on the basis of
abstract = 312
Number of full-text articles assessed
for eligibility = 85
Number of studies included in
qualitative synthesis = 62
18
Number of articles
excluded on the basis of
relevance = 23
Figure 2- 2 PRISMA Chart – Section Two: Social Drift and Substance/Alcohol
Use and Arab Countries
Number of articles identified through
database searching = 6
Number of articles identified through
database searching (2001 – 2016) = 6
Number of articles screened = 2
Number of articles screened = 2
Number of full-text articles assessed
for eligibility = 2
Number of studies included in
qualitative synthesis = 2
19
Number of removed
duplicates = 4
Number of articles
excluded on the basis of
title = 0
Number of articles
excluded on the basis of
abstract = 0
Number of articles
excluded on the basis of
relevance = 0
2.3. Review of Papers
One of the most important review papers found was a bibliometric
analysis of publications of Middle Eastern and Arab countries to assess
research activity (Sweileh, Zyoud, Al-Jabi, & Sawalha, 2014). The
authors found that although research productivity was relatively low,
an increasing trend was found in research activity level. In this
landmark review that the authors claimed to be the first attempted in
the region, spanning a period between 1900 and 2013, using an
advanced seven steps search strategy, found only 413 research articles.
Of these, 401 were original research articles and 12 were review articles
(Sweileh, Zyoud, Al-Jabi, & Sawalha, 2014).
The review included 18 countries of which, Kingdom of Saudi Arabia,
Lebanon and Egypt were the top three countries, in terms of research
publications, United Arab Emirates being 6th with Somalia, Oman and
Libya being at the bottom of the list. The authors admitted that one of
the weaknesses of this review was that some regional journals such as
the Arab Journal of Psychiatry and the Eastern Mediterranean Health
journal are not included in the Web of Science database they searched.
Nevertheless, it can be concluded that this gives a measure of research
activity in the area of substance misuse in the region (Sweileh, Zyoud,
Al-Jabi, & Sawalha, 2014).
The article ‘Mental health research in the Arab world’ was another
broader review paper covering mental health research in 21 Arab
countries in a 40-year period between 1966 and 2005. The paper found
20
2,213 articles and 11.1% of these covered substance misuse, which
approximated to 245 articles. More than two-thirds of the articles from
the Arab world were published in international journals. A very
important finding of this paper was that there is a huge need for very
informative researches in the field of mental health. Other areas such
as cross-cultural, and religious comparisons are also needed. In
addition, and due to the unique social fabric of the more traditional
Arab countries, genetic studies are highly important and required
(Jaalouk, Okasha, Salamoun, & Karam, 2012).
A more recent publication by Hickey, Pryjmachuk and Waterman
(2016), looked at mental illness research in the GCC countries between
1975 and 2013. The paper found 55 research articles in total and 13
(23%) of which were on substance misuse. Majority of the papers (38%)
were from Saudi Arabia, followed by Kuwait (33%), then Qatar, Bahrain
and the UAE with 9% each and only 2% from Oman. Their findings
highlighted the lack of research into mental health in general and on
substance misuse in specific. One of this review’s limitations was that
most of the research included were cross-sectional studies which gave
only a snapshot of a phenomenon and didn’t not allow for causal
implications to be made. Also, under-representation of women limited
the generalization of findings to the male population. (Hickey,
Pryjmachuk, & Waterman, 2016).
21
Papers covered by this review and published within the current study
selected period would be included in the below sections under different
countries (Hickey, Pryjmachuk, & Waterman, 2016).
The most relevant review to the present study is the Alcohol and
substance use in the Arabian Gulf region paper. This comprehensive
and methodological sound review covered research publications in the
GCC countries (United Arab Emirates (UAE), Bahrain, Kuwait, Kingdom
of Saudi Arabia (KSA), Oman, and Qatar), over a 37- year period
between 1975 and 2007. It covered electronic databases such as
Medline and PsychINFO as well as Arab journals such as Arab Journal
of Psychiatry, Journal of Gulf and Arabian Peninsula Studies, Annals
of Arts and Social Sciences, Dersat Nefseyah, and Annals of Saudi
Medicine. In this comprehensive search of publications spanning 37
years only 60 relevant articles were found (AlMarri & Oei, 2009).
The confidence in this search and the objective of focusing on recent
publications was taken as the justification to restrict the literature
search in the current paper to 15 years from 2001 to 2016. It was felt
that a 10-year period would yield sufficient papers, hence the decision
to have a 16 year period, with a 6 year overlap with the AlMarri and Oei
sturdy (2009). The yield of 62 papers in the current study also is an
indication of the increase in the rate of publications in relation to
substance use and abuse. Instead of reviewing the publications country
by country as is the case in this paper, the AlMarri and Oei paper (2009)
picked out key themes in their review. These themes included,
22
prevalence data, types of substances used, initiation and relapse
issues, treatment protocols, use of standardized instruments in the
studies, attitudes towards substance use and barriers to research. The
current review follows some of these themes on a country by country
basis (AlMarri & Oei, 2009).
Some possible barriers were identified by AlMarri & Qei paper (2009)
that might impose some challenges on substance abuse researches in
this region. Having individuals seeking treatment from substance use
disorders as a pool to recruit from for studies might not be completely
representative of the substance abuse problem in this region. This is
because many individuals with substance abuse problem might not
seek treatment due to of ethical, cultural, social, and legal
considerations. Another reason could be the available number of
treatment facilities and admission criteria as there is a scarcity in the
number of treatment facilities in each country. Most of these facilities;
if not all, treat adult patients only which doesn’t provide a sense of the
substance abuse problem among the younger population. Lack of
female representations in such studies was also highlighted in this
review (AlMarri & Oei, 2009).
2.3.1. Substance Abuse Profile in Arab Countries
As mentioned earlier, the literature search was conducted from the
years of 2000 to 2016 in Arab countries such as, Jordan, Lebanon, Iraq,
Egypt, Saudi Arabia, Kuwait, United Arab Emirates and Yemen using
23
the previously mentioned search strategy. Below is an explanation for
the relevant researches according to countries.
2.3.1.1. Saudi Arabia:
Reflecting its geographical and population size, Saudi Arabia has
produced the largest number of studies on mental health and
substance misuse. Most of the published studies have been conducted
with clinical populations, hence it does not give accurate prevalence
data in the country (AlMarri & Oei, 2009) (Hickey, Pryjmachuk, &
Waterman, 2016).
A study conducted in a hospital in Saudi Arabia to collect basic data on
diverse issues related to substance abuse. 799 patients were surveyed
during their admission for voluntary detoxification in consecutive years
(1995 and 1996). It was found that 68% were under the age of 35. The
youngest age among the sample was 17 and the eldest was 66. 97%
were smokers and 55% started smoking before the age of 15. 31.5%
started to use drugs before the age of 20, with 10 years being the
youngest age to initiate substance use. The study found that 83% of the
participants were heroin users and 91% of them were injecting. 21% of
the injectors had injection related complications, such as Hepatitis C
Virus (69%) or death (0.40%). 17.5% reported having a substance use
problem among their family. 76% of them were siblings, 17% were other
relatives such as cousin and 6.4% were parents. This study highlighted
the existence of a young population of substance users with complex
problems ( Iqbal, 2000).
24
An interesting study conducted by Amir (2001) compared patterns of
substance use in Saudi Arabia and United Arab Emirates as both
countries are similar in many ways (culture, race, language and
religion). 120 male patients receiving treatment at the Damam Hospital
in Saudi Arabia were compared with 79 male patients receiving
treatment in a corrective institution in Dubai (United Arab Emirates).
Type of the substances abused, age at the onset of abuse, the number
of months since the start of abuse, level of education and employment
were studied. Despite the assumed similarity, the researchers found
marked differences (Amir, 2001).
Age of onset of substance abuse problems was significantly lower in the
UAE (18.7 ± 4.6 years) compared to 22.5 ± 3.9 years in Saudi Arabia.
The percentage of heroin users was higher in Saudi Arabia (85%) than
in the UAE (64%). The opposite was true regarding the opium users,
there was 44% of opium users in the UAE compared to 0.8% in Saudi
Arabia. The same was found in the other substance groups; hashish
(87% in UAE compared to 25% in KSA), alcohol (55% in UAE compared
to 31% in KSA), solvents (3.8% in UAE compared to 1.7% in KSA),
sedatives (46.8% in UAE compared to 1.7% in KSA), stimulants (19% in
UAE compared to 8.3% in KSA) and cocaine (20% in UAE compared to
0.8% in KSA). The poly-substance use pattern was also significantly
higher in the UAE compared to KSA (85% compared to 35%) (Amir,
2001).
25
The strength of this study is that the same methodology and same
instruments were used in both groups. On the other hand, a major
weakness of the study was that a hospital clinical population in the
case of KSA was compared with a clinical population in a corrective
institution in the case of the UAE where the severity of problems may
be higher. However, this is an important study showing how substance
using patterns and profiles can vary from country to country, even
when there is geographic proximity and other similarities such as race,
culture and religion, which provides a strong argument for countryspecific profile studies (Amir, 2001).
A study by Abu Madini and his colleagues (2008) examined substance
use patterns and trends among patients admitted at Al Amal Hospital
in Dammam over a period of two decades (between 1986 and 2006).
This study is of particular interest as it gives an indication of the size of
the problem and compares trends (AbuMadini, Rahima, Al-Zahrani, &
Al-Johi, 2008).
In the first decade, the majority were between the ages of 20 to 29 (83%),
never married (60%) and with a low level of education (81%). The study
reported that the relative percentage of amphetamine users increased
from 12% to 48% and cannabis users from 17% to 46%. At the same
time, the study reported a decrease in heroin users from 51% to 22%,
sedative users from 15% to 7% and solvent users from 6% to 2%. The
study also reported an increasing trend in poly-substance use from a
26
mean number of substances per person of 1.32 to 1.56 (AbuMadini,
Rahima, Al-Zahrani, & Al-Johi, 2008).
The weakness of this study is that it only used male subjects and it only
recruited patients from one hospital. If data from the other hospital
were studied with the same methodology, a more accurate picture of
the prevalence rates and profile of drug users in the country could be
obtained. A weakness of any retrospective study is the issues of
accuracy and coding of data (AbuMadini, Rahima, Al-Zahrani, & AlJohi, 2008). Patient’s medical records were not created initially for
research purposes. Also, data are coded to meet the needs of insurance
and other third party companies. This creates biases based on the
intended use of the data.
Another study by Al-Haqwi (2010) looked at the magnitude of the
substance abuse problem from the perceptions of 215 medical students
in Riyadh and examined their views of its possible predisposing causes.
75% of the participants identified alcohol and substance abuse as a real
problem in the community, and it is more common among young
adults. The majority of the students believed that males are more prone
to be alcohol and substance abusers then females as only 1.4% think
that substance abuse problem might affect females. Friends, life
stressors, smoking and curiosity were listed as the most important
predisposing factors for abuse (Al-Haqwi, 2010).
27
An interesting view was highlighted which was the beneficial effect of
alcohol and substance abuse as stress alleviation (Al-Haqwi, 2010).
University life and study in general are among the general life stresses
that should be treated carefully because they could disturb the
students’ well-being of and their academic performance, which
eventually would lead to alcohol or substance abuse. Therefore, it is
highly important to teach students stressors’ safe and effective coping
strategies.
3% of the students indicated that they may use alcohol or some other
substance in the future. The study concluded that there is a serious
need for different preventions and awareness programs that target
medical students and younger adults. These programs must focus on
the risks of alcohol and other substances abuse, stress coping
strategies and counseling (Al-Haqwi, 2010).
A recent cross-sectional study was conducted on male secondary
students in Abha City in Saudi Arabia. The aim was to examine the
history of substance abuse problems among this population. The study
used a self-administered pencil-and-paper questionnaire. It was found
that 38.3% of the students were cigarette smokers and 41.2% of them
started smoking before the age of 16. Alcohol was consumed by 9.3% of
the total during the last month. 56.8% of those who used alcohol, took
alcohol once during the last month and 64.1% got in troubles due to
their alcohol intake. 8.8% of the students were substance users. The
28
main used substance was cannabis (51.4%) followed by glue/solvents
(48.6%) and amphetamine (45.7%) (Al Musa & Al-Montashri, 2016).
Although the study had a small sample of 350 of a potential 3852
student population in the area, it painted a picture of the extent of
substance misuse among students. The results indicated that students
with substance abuse problem showed significantly lower academic
achievements, which requires teachers to take any drop in the student's
academic achievement seriously. Families with working mothers have
a higher probability of substance abuse problem among their children.
The same applies to families with high monthly income. This requires
parents to be more engaged with their children (Al Musa & AlMontashri, 2016).
2.3.1.2. Kuwait:
Al-Kandhari et al., (2007) conducted a study on a clinical population of
237 patients receiving treatment at a Psychological Medicine Hospital.
A questionnaire was developed to explore sociodemographic variables,
drug addiction habits, types of drugs, favorite drugs, effect of substance
abuse on self, relationships with others and work performance. The
questionnaire was self-administered by volunteers recruited for the
project (Al-Kandari, Yacoub, & Omu, 2007).
As is usual in studies from Arabic countries, there were a very low
number of female participants (2 out of a total of 237). The average age
of participants was 33 years ranging from 18 to 67, with 50% were
29
currently married, 38% were single and 20% were divorced or widowed.
Educationally, 6% had elementary education and 22% were college or
university graduates. The majority, 76%, received income from work,
12% received income form their families and 8% from the government
(Al-Kandari, Yacoub, & Omu, 2007).
The results show that 78% reported using heroin, 64% cannabis, 60%
alcohol, 32% cocaine and crack and 23% hypnotics. Half of the sample
reported being addicted for more than 10 years and 23% from five to
ten years. Approximately 75% of the sample reported injecting drugs. A
weakness in this study is that it did not use translated standard
instruments that would have enabled direct comparison with other
studies. However, the study gave a picture of the situation in Kuwait
from the substance abuse perspective (Al-Kandari, Yacoub, & Omu,
2007).
A cross-sectional study was conducted among 1587 male university
students from both private and public universities in Kuwait to examine
the prevalence of substance use and identify the factors associated with
this use among the study sample. The study used a self-administered
survey that was adapted from WHO guidelines titled ‘A Methodology for
Student Drug Use Surveys’ (Bajwa, Al-Turki, Daw, Behbehani, & AlMutairi, 2013).
It was found that there was a total lifetime prevalence of substance use
of 14.4% and the most frequently used substance was cannabis
30
(marijuana/hashish) (11%). Even though, the age of first use varied
depending on the substances the age group of 14–16 years was the
youngest age of initiation of any substance use. The study highlighted
that tobacco smoking is the access to alcohol and substance use.
Multivariate logistic regression model revealed that drug use was
positively associated with age, poor academic performance, high family
income, being an only child, divorced parents, and graduation from a
private high school (Bajwa, Al-Turki, Daw, Behbehani, & Al-Mutairi,
2013).
Through the study, it was clear that alcohol and substance use in
general varied significantly between private university students and
public Kuwait university students. The difference in social and
economic status of the two groups was offered as an explanation
(Bajwa, Al-Turki, Daw, Behbehani, & Al-Mutairi, 2013).
2.3.1.3. United Arab Emirates
UAE is a fast growing country due to discovery of oil, with a rapidly
changing society in keeping with its rapid development. Ghubash and
her colleges conducted a cross-sectional community survey of adult
population in Al Ain to assess the prevalence of mental disorders in the
general population in an attempt to linking it to the socio-cultural
changes that are taking place in the country. The total sample was 1394
adults (Ghubash, Daradkeh, A.A, Al-Manssori, & Abou-Saleh, 2001).
31
The study found that adhering to traditional values was a protective
factor in relation to psychiatric morbidity. Less traditional people in
general were found to have a significantly increased rate of psychiatric
disorder and higher scores on psychopathology measures. Females in
specific, were found to have higher rates of psychopathology the less
traditional they were. In this study, the authors did not report on
substance misuse or specific disorders (Ghubash, Daradkeh, A.A, AlManssori, & Abou-Saleh, 2001).
Data in general on substance abuse from the United Arab Emirates
region is limited. A base-line profile of a UAE clinical population was
provided by Elkashef et al (2013) who published a 10-year retrospective
study of the patients who had received treatment at the National
Rehabilitation Center (NRC) Abu Dhabi. The aim of the study was to
examine the socio-demographic characteristics, patterns of substance
use disorder and the related co-morbid conditions (Elkashef, et al.,
2013).
In their sample of 591 patients, they found that the average age at first
admission was 32.4 (9.6) years. 44% were single, 42% were married,
and 13% were divorced. 60% were unemployed and 33% were either
employed or were students. In their sample 51% did not have a
secondary education, 33% had secondary education and 16% had postsecondary education. In relation to family history, 30% of patients were
from families with a history of alcohol abuse and 16% were from a
32
family with a history of drug abuse, which is a surprising and
interesting finding given the cultural context (Elkashef, et al., 2013).
The sample that Elkashef et al (2013) studied comprised of 77%
voluntary patients and 23% involuntary (ordered by courts and not free
to leave) and there were some significant differences in demographics
between the groups. These were in respect to education level where 67%
of the voluntary patients compared to 47% of the involuntary group
having intermediate or secondary education on the other hand only
14% of the voluntary group had post-secondary education compared to
22% of the involuntary group (p=0.02). There were no other significant
differences in demographics between the two groups (Elkashef, et al.,
2013).
In relation to substance use patterns, the main substance used was
alcohol 41%, cannabis, benzodiazepines, amphetamines and inhalants
accounted for 22%, heroin 16% and a range of prescription drugs such
as tramadol, methadone, codeine, and Xanax, and psychoactive
substance such as kemadrine, artane and khat accounted for 21%.
Since 2009, a dramatic increase in prescription drugs and other
psychoactive substances (polysubstance use) was reported. Elkashef et
al (2013) also found that younger patients (aged 16-26) preferred heroin
use while older patients (aged 37-66) preferred alcohol (Elkashef, et al.,
2013).
33
In relation to blood borne viruses 3% were positive for Hepatitis B and
15% were found to be positive for Hepatitis C and among intravenous
drug users the Hepatitis C prevalence rate was 44%. In relation to comorbidity with psychiatric disorders, the paper reported amalgamated
results of prevalence (presence or absence) of three categories of
disorders (anxiety disorders, mood disorders and psychotic disorders)
in relation to the type of substance used. Alcohol users (25%) and
polysubstance users (16%) recorded the highest prevalence. Elkashef et
al (2013) reported relapse rates using an admittedly crude method
based on a calculation of re-admission to treatment. Using this method,
they reported a 27% relapse rate. They also reported a progressive
reduction of relapse rates at 60% in 2002 to 20% in 2010 (Elkashef, et
al., 2013).
The main criticism of this study is that it is a retrospective study based
on case note analysis, hence reliant on what was written in the case
notes. Case notes are detailed notes in a story telling format which
makes it a time and effort consuming tool to be used for research
purposes, which is different from extracting data from an electronic
information system (EMR) or a cross-sectional survey. As data in EMR
is
easily
retrieved
and
it
reduces
redundant
data capturing.
Nevertheless, it provides a baseline for future comparisons (Elkashef,
et al., 2013).
In 2015, a cohort study was conducted to study the pattern of
substance use in the United Arab Emirates. A total of 250 patients
34
receiving their treatment at the National Rehabilitation Centre (NRC)
were recruited for this study. The mean age was 29.6 years, 58.4% were
singles and 95.6% were current smokers. 56.8% had a family history of
substance use disorder, who were mainly from first degree family
members ( Alblooshi, et al., 2016).
The study also found that substance use disorders correlated with
smoking and marital status. Polysubstance users represented 84.4% of
the study population with the majority of them being among the
youngest age group (19 – 29 years old). The majority of the
polysubstance users used four or more substances. The most common
combination used was alcohol, opioid, cannabis, tranquilizers and one
of three prescribed medications especially among the youngest age
group. Opioid and alcohol were the most commonly used substances.
Correlating substance used with age, the study found that tramadol
use was higher among the youngest age group patients, while heroin
was more commonly used by the older age group patients ( Alblooshi,
et al., 2016).
The results of this study sharply contrasts with the previous Elkashef
et al (2013) study which is from the same center, Polysubstance use
has become established as the dominant pattern of substance misuse.
More than 60% of the polysubstance users use prescribed medication
for non-medical use such as Pregabalin, Procyclidine and Carisoprodol.
Pregabalin was the most common one among the three medications.
One of the documented limitations of this study was lack of female
35
involvement,
which
calls
for
other
studies
that
assess
the
characteristics of female patients and their pattern of use. The
highlighted conclusion of Alblooshi’s study was that there is a sharp
increase in the use of pharmaceutical opioid and prescribed
medications as mixture which imposes a major health threat. This is
due to the overdose and death that could result from the potential
toxicity risk of these mixtures, which requires the local authorities to
take serious actions ( Alblooshi, et al., 2016)
According to AlMarri and his colleagues study (2009), the community
study of prevalence of psychiatric symptomatology in the general public
by Abou-Saleh, Ghubash and Daradkeh in Al Ain Abu Dhabi was one
of the most important and what is described as regionally unique study
as a general population prevalence study in psychiatry had not been
attempted in the region. This study reported a prevalence of substance
use or abuse among men of approximately 9%. No females were
diagnosed with substance abuse. This study does not describe other
characteristics of the respondents (Abou-Saleh, Ghubash, & Daradkeh,
2001).
In Amir study that compared patterns of substance use in Saudi Arabia
and United Arab Emirates as mentioned earlier (2001), it was found
that the age of onset of substance abuse problems in the UAE was 18.7
years. About 42.3% of users in the UAE were addicted to more than one
substance (Amir, 2001).
36
In AlMarri’ study, one of the UAE psychiatric hospitals stated that
within a two-year period (1990-1991), 9.5% of its patients were
admitted for SUD (AlMarri & Oei, 2009).
2.3.1.4. Lebanon
Lebanon is an Arabic speaking county with a population of different
religious groups which is unique in the region.
A study conducted by Karam and his colleges to examine the
comorbidity of substance abuse and psychiatric disorders in acute
general psychiatric admissions. It was considered to be the first
published study from an Arab Near Eastern country to examine this
topic. The study took place in a 22-bed psychiatry and psychology
Inpatient Unit, that treats patients with various psychiatric disorders,
including substance use. The majority of beds are self-paid. The referral
sources could be self- or family members but never by the legal system
(Karam, Yabroudi, & Melhem, 2002).
The mean age was 34.5 ± 11.8 years with no difference in age between
genders and the mean age of abuse initiation was 25.9 ± 10.5 years.
The mean duration of abuse was 8.1 ± 8.5 years. The study found that
out of 1,643 case notes analyzed, 222 (13%) had a history of substance
misuse, 64% of whom had a comorbid condition. The substances that
were abused fell into three categories, which were prescribed
medication
(tranquilizers,
barbiturates,
medicinal
opiates
and
stimulants), illicit substances (cannabis, cocaine, heroin); and alcohol.
37
Alcohol was the most commonly used substance (55%), followed by
heroin (29%), cannabis (28%), cocaine (27%) and tranquilizers (13%).
Only 2% reported using stimulants. Poly-drug abuse was found in 44%
of the sample. 18% to 80% of the psychiatric populations had addictive
disorders,
compared
to
nearly
80%
of
the
substance-abusing
populations having psychiatric disorders (Karam, Yabroudi, & Melhem,
2002).
The authors concluded that the prevalence rates discovered were
comparable with those in the West and that cultural factors and the
war in Lebanon seemed to have no effect on the rates (Karam, Yabroudi,
& Melhem, 2002).
Another study of alcohol use among university students was conducted
in two universities with different socio-demographic characteristics.
The study was carried out in two phases (1991 and 1999). A self-report
anonymous questionnaire was used as a tool to collect information on
the lifetime use and pattern of substances use. The mean age of the
phase I sample was 20.51 ± 1.78 years and the mean age of the phase
II sample was 20.18 ± 1.69 years. It was found that there was a
significant increase in the number of those who tried of alcohol from
phase I to phase II (Karama, Maalouf, & Ghandour, 2004).
The number of males who have tried alcohol were more than females in
both phases. When looking at the age, in phase I older students were
more likely to have ever tried alcohol, whereas in phase II there was no
38
significant age differences observed. The 1999 alcohol lifetime use rates
were comparable with those of Western countries. While in phase II,
Christians were more likely to drink alcohol (87%), compared to the
Druze (67%) and Muslims (43%), there was no significant difference in
alcohol ever use rates across different religions in phase I. The mean
age of onset of drinking was 16.12 ± 2.69 years and it was significantly
earlier in males. Belief in God and practice of religion seemed to reduce
consumption regardless of religion. The study also, found a strong
association between the frequency of physical fights and shoplifting and
the prevalence of use (Karama, Maalouf, & Ghandour, 2004).
As part of the WHO World Mental Health (WMH) Survey Initiative,
Karam and colleagues studied the prevalence of mental illness in
Lebanon including substance misuse. The survey was conducted
between September 2002 and September 2003. 2,857 individuals were
interviewed in a household population survey using the WHO
Composite International Diagnostic Interview (CIDI) version 3. The
results showed that 17% of the respondents met criteria for a DSM-IV
disorder in the last 12 months and 1.3% met criteria for Substance Use
Disorder. Of the population that met case criteria, 32% met criteria for
substance use. The study concluded as they have done previously that
these figures were comparable with Western countries (Karam, et al.,
2006).
Using the Drug Abuse Rapid Situation Assessment and Responses
methodology developed by the United Nations Office for Drug Control
39
and Crime Prevention, Karam and his colleges (2010) conducted a
Rapid Situation Assessment (RAS) study to examine the use of multiple
substances in diverse segments of the Lebanese population. Both
quantitative and qualitative data were collected from high school and
university students, substance users in treatment or in prison or
detention and “street” users (Karam, Ghandour, Maalouf, Yamout, &
Salamoun, 2010).
The study found that the age of first use of substances started as early
as 9 years in the youth sample. 12% of the high school students stated
that they smoke one or more packs of cigarettes per day and 9% of the
university students met criteria for DSM-IV alcohol abuse. Cannabis
represented the most commonly used illicit drug in both high school
and university students, and tranquilizers were the most frequently
misused pharmaceutical substance. Heroin was accountable for 50% of
the admissions for treatment and the most common substance of
arrest. Unperceived need for treatment was the most common reason
for not seeking treatment in non-institutionalized drug users. Around
50% of substance users in treatment and street users were injectors
with a high rate of needle sharing practices. Interestingly about half of
patients in treatment had a history of police arrests, and around onethird of those in prison had ever received prior treatment (Karam,
Ghandour, Maalouf, Yamout, & Salamoun, 2010).
A study that examined the differences between Lebanese adolescents
living in two different countries Lebanon (Muslims) and USA (Christian)
40
in alcohol and substance abuse. There was no association between age
and substance abuse. The study also found that 52% of Christians
reported drinking alcohol compared to 27% of Muslims and 15.5% of
Christians compared to 9.3% of Muslims using illegal substances (Badr,
Taha, & Dee, 2014).
These figures are lower than what was reported by Karam et al., (2004)
study. This might be because Karam et al.’s (2004) study sample were
university students, while in this study, the sample were high school
students. Another reason could be that this study measured alcohol
use in the last year only compared to life time use in Karam et al.’s
(2004). Factors such as religion that forbids alcohol and drugs, close
relationship with the immediate family and less time spent with friends
outside the home are considered protective factor for adolescents (Badr,
Taha, & Dee, 2014)
2.3.1.5. Iraq
An article written by Aqrawi and Humphreys (2009) describes the
substance use problem in Iraq. The authors believed that substance
misuse situation is getting worse in Iraq. Many factors exist that provide
a fertile ground for substance misuse such as violence and the poorly
monitored boarders. Inflation and unemployment resulted in economic
insecurity that feed the increase of misuse of drugs. The fragile
pharmaceutical system in Iraq contributed to illegal sale and
distribution of drugs. In return, many initiatives are in process to fight
this epidemic. For example, the program of substance misuse control
41
under the umbrella of the National Mental Health and Substance Abuse
Council to structure the applicable legislation, and to prioritize
substance misuse in public health programs (Aqrawi & Humphreys,
2009).
From the Inaugural Community Epidemiological Workgroup held in
2012 (Al-Hemiary, Al-Diwan, Hasson, & Rawson, 2014), it was reported
that there is an increasing trend in drug and alcohol use in Iraq,
particularly among females and youth. The report presented a survey
conducted in 2009 that it was reported that lifetime prevalence of
alcohol use in Bagdad was 17.8% and drug use 7.02%. The most
commonly used drugs across the country were sedatives, hypnotics and
benzhexol. This is confirmed in an article by Al Hasnawi et al (2009)
who surveyed 70 psychiatrists with an 83% response rate, regarding
the patients they see and found that benzhexol and anxiolytic
medication including benzodiazepines were the main drugs abused. Al
Hemiary et al. (2014) reported the recent appearance of amphetamine
type substances (Captagon and “crystal” (methamphetamine)). They
noted that the Captagon is the same type of drug that is used in large
quantities in Saudi Arabia. The painkiller tramadol is also a new
substance in Iraq together with Afghan opium (Al-Hemiary, Al-Diwan,
Hasson, & Rawson, 2014).
2.3.1.6. Morocco
A national epidemiological study was conducted to assess the
prevalence of mental disorders in 2009 with a sample of 5498. The
42
study found a prevalence of 5.8% of disorders related to substance use
and 3.4% disorders related alcohol use. There was a highly significant
difference between men for substance use disorders 10% to 0.4% and
alcohol use disorder 5.8% to 0.4%. Overall there was significantly a
higher degree of mental disorders in the female population compared to
males (34% to 20%) (Kadri, et al., 2010).
In a rare study of adolescent drug use in the region and its association
with their academic performance, El Omari et al (2015) examined the
drug use among both male and female high school students. They
surveyed 2139 students in 36 high schools in two Moroccan cities. The
participants were in 10th, 11th and 12th grades with an average age of
15.5 years (SD=2.4) with approximately half the sample female. They
reported that 16% of the females and 40% of the males reported ever
using alcohol, hashish or psychotropic drugs. Unfortunately, the paper
does not report a more detailed breakdown of substances used and
patterns of use. It does however reports that academic performance is
affected according to substance use. Substance use in the past 30 days
was significantly associated with average or below average grades in
both male and female students with males being more affected (El
Omari, et al., 2015).
2.3.1.7. Yemen
There is a long history of Khat (Catha edulis) use in Yemen. There are
records of its use since the 13th century (AlMarri & Oei, 2009). The use
of Khat is widespread in Yemen and its use is often accompanied by
43
smoking (cigarettes and Shisha) and a positive association between the
two substances have been reported (Nakajima, Dokam, Khalil, Alsoofi,
& al'Absi, 2016).
Hence it has been questioned whether Khat acts as a gateway drug to
tobacco smoking. Nakajima et al (2016) found that for concurrent
users, Khat chewing did start before tobacco smoking and that there
were gender differences in the choice of tobacco products, with men
smoking more cigarettes and women showing higher rate of Shisha
smoking. Shisha smoking is also called hookah, waterpipe, or hubble
bubble smoking. It’s a way of smoking tobacco, through a bowl and
tube. The study supported the hypothesis that Khat acts as an entry
point to tobacco smoking, whether it is a gateway for abuse of other
substances is yet to be reported (Nakajima, Dokam, Khalil, Alsoofi, &
al'Absi, 2016).
2.3.1.8. Palestine
A study by Massad et al., (2016) provided insights into perceived
prevalence of alcohol and drug use among Palestinian youth. Their
target sample (n=83) was aged 16–24 years. Although a qualitative
study, they employed 10 focus groups and 17 individual interviews to
arrive at their findings. They reported that almost all participants
confirmed that alcohol use was common and is widely available.
Participants reported that they drank alcohol for many reasons such as
coping with stress, for fun, and out of curiosity. Others drank as a way
to challenge their society or they were influenced by media. They also
44
reported knowledge of use of illicit drugs such as marijuana, cocaine
and heroin. Almost for the same reasons youth used alcohol they used
illicit drugs. In addition to these reasons, some highlighted reasons
such as poor parental control and lack of awareness or sadness
(Massad, et al., 2016).
2.3.1.9. Jordan
Mu’men et al., 2009 conducted a study in Jordan over a five-year period
(2000-2004) reviewing post mortem forensic pathology results for all
autopsies conducted in the National Institute for Forensic Medicine.
Out of a total of 5,789 autopsies, 44 were attributed to drug abuse.
More than 80% were Jordanian males aged from 20 to 60 years (mean
± S.D. = 32.7 ± 7.2). The substances of abuse included alcohol (56.8%
of cases), morphine (36.4%), heroin (15.9%), benzodiazepines (11.4%)
and one case of cocaine. For 75% of the cases, the cause of death was
recorded as accidental and 52.3% death occurred at home. When
looking in specific to drug overdose death, it was found in 50% of cases.
Linking substances to deaths, alcohol was mainly associated with
accidental death, while morphine and heroin were associated with drug
overdose. 56.8% of cases were having injection marks. This study is the
first study that addresses such topic in Jordan (Hadidi, Ibrahim,
Abdallat, & Hadidi, 2009).
A study was conducted to investigate the abuse of prescription and nonprescription drugs in community pharmacies in Jordan. They
distributed using a random method a structured questionnaire to 405
45
pharmacists in the country. 94.1% of the respondents suspected abuse
of decongestants, cough/cold preparations and benzodiazepines. It was
believed that the majority of abusers were males, who were in the age
group of 26 to 50 years (Younes, Wazaify, Yousef, & Tahaineh, 2010).
A cross-sectional, descriptive study was conducted to assess the mental
health consequences of abuse among Jordanian women. The sample
was 95 women who were experiencing intimate partner abuse. Age of
the participants ranged from 15 to
54 years, with a mean age of 32.4 (SD 8.3) years. The professional and
legal services provided for those women included support in relation to
abuse, depression, coping, suicidal ideation, substance use, social
support and self-efficacy (Hamdan-Mansour, Constantino, Shishani,
Safadi, & Banimustafa, 2012).
The most commonly reported form of abuse was psychological abuse.
Applying the Beck Depression Inventory showed that 38.7% of the
abused women had moderate to severe levels of depression. Although
half the women had a low level of perceived social support, abused
Jordanian women reported moderate to very high levels of self-efficacy
and used approach coping strategies more frequently than avoidance
coping. Using the Modified Scale for Suicide Ideation, 15.7% of the
women reported that the desire for death was stronger than the desire
for
life
(Hamdan-Mansour,
Constantino,
Banimustafa, 2012).
46
Shishani,
Safadi,
&
Results showed that the substances most commonly used were caffeine
(82.8%), painkillers (61.3%) and nicotine (26.9%). In addition, alcohol
was used by three women, stimulants were used by five women and 10
took tranquillizers. None had used cocaine, marijuana or hallucinogens
in the past 12 months. Abused women in Jordan face mental health
and psychosocial risks that could compromise their quality of life
(Hamdan-Mansour, Constantino, Shishani, Safadi, & Banimustafa,
2012).
2.3.1.10.
Egypt
A case-control study examined the link between alexithymia and
substance misuse. Alexithymia can be defined as dimensional
personality
trait
which
includes
dysfunction
in
emotional
consciousness, social attachment, and interpersonal connecting. It
also, thought to be a trait that it is affected by drug abuse. In this study,
200 randomly selected substance users were compared with matched
controls. The demographic profile of substance users was not reported
in the results as it was not the aim of the study, but the substance use
picture was reported after stratifying according to levels of alexithymia.
95% of the substance misusing group were polysubstance users, 2%
abused anticholinergics and 2% only benzodiazepines. Looking at the
marital status, 70% of the sample were single, 17% married and 13%
divorced. Only 12% were employed (El Rasheed, 2001).
The study reported that alexithymia was significantly more dominant
in the substance use group as compared to healthy controls.
47
Alexithymia was statistically significant with benzodiazepine abuse and
no persistence in treatment. The study recommended that medical
teams should focus on alexithymia when treating from substance use
disorders. (El Rasheed, 2001).
The characteristics of patients admitted for treatment of substance use
disorders in a private hospital in Egypt was examined by Hasan and his
colleges. The sample was of 324 patients, of whom 91% were male. It
was found that 93% used cannabis, 89% used alcohol, 80% used
prescribed medication, 78% used heroin, 23% used amphetamines,
19% used cocaine and 15% used hallucinogens (Hasan, et al., 2009).
25% of the sample used more than one substance but the study did
not give a detailed breakdown. 21% of the women stated using ecstasy
during the past 30 days and were more likely to be poly-drug users.
84% of the heroin users were injecting it (Hasan, et al., 2009).
Another study looked at the prevalence of substance use and addiction
in Egypt and its sociodemographic correlates. There was a total of
44,000 subjects interviewed from 8 governorates by stratified sampling.
It was found that lifetime prevalence of any substance use varies
between 7.25% and 14.5%. 9.6% of the total subjects were illicit
substances users. This included 3.3% experimental and social use,
4.64% regular use 1.6% substance dependence. In males, the
prevalence of substance use was 13.2% and 1.1% in females. It was
found that the prevalence of substance abuse increases significantly in
48
males with lower financial status, with lower education levels, and in
certain occupations. The onset of substance use was associated with
the 15–19 age group. Cannabis is the most commonly misused drug in
Egypt (Hamdi, et al., 2013).
2.3.2. Substance/Alcohol Abuse and Social Drift
According to what was mentioned above, alcohol and substance use
disorders could lead to disturbing socio-economic consequences which
in return could lead to social drift. Social drift is “defined as an
individual drifting down the socio-economic scale as a result of a mental
illness” (Fox, 1990). Social drift assumption proposes that disability,
disgrace, decreased productivity and increased health expenditure
cause an individual with mental illness to drift into poverty (Fox, 1990).
It was highlighted through few studies that individuals with increased
substance use disorders status are more likely to travel to deprived
neighborhoods due to chronic poverty or to have accessibility to more
alcohol and drugs to test this hypothesis a study was conducted by Buu
and her colleagues (2007) to assess the long term consequence of
individual alcohol use on social migration using a quasi-experimental
residential mobility study of alcoholics in the USA. Their sample
consisted of 206 white alcoholic men who were recruited mainly
through courts records. The residential address at baseline and at a 12year follow-up was studied (Buu, et al., 2007).
49
The study findings showed that individual has greater probability of
remaining or migrating into a poor neighborhood, the greater his/her
alcohol problem is. This showed a strong evidence that social drift is
associated with alcoholism just like the case in psychiatric disorders.
On the other hand, the study also, provided that recovery safeguards
against downward social drift. A number of limitations of the study
prevented it from being generalized such as being carried out with no
women in the sample (Buu, et al., 2007).
Social drift and substance use disorders are not a common topic of
research in general and in Arab countries or the Gulf region. Most of
the studies provided indirect information on social drift in relation to
substance misuse. Others explored the association between substance
use disorders and one form of social drift such as unemployment and
disrupted family relationships.
In Al-Kandari’s study (2007) indirect evidence to support social drift
was found in the form of disrupted family relationships and negative
impact on employment. The study results revealed that more than 50%
of the participants had frequently affected family relationships. 21%
reported that their job performance was negatively affected by their
addiction. This study provided an obvious indirect evidence for some
aspects of social drift in Kuwait ( (Al-Kandari, Yacoub, & Omu, 2007).
Another study in Saudi Arabia examined the impact of heroin on the
social, nutritional and health status of People who are addicted to
50
heroin compared to other drugs of abuse addicts compared to other
drugs of abuse. The study compared 243 heroin addicts with 66 non
heroin addicts who are using other substances. In the social side, the
heroin-addicted group was found to have poor education (53%), a
higher level of unemployment (52%) and broken marriages (8%)
compared to the non-heroin addicted group. However, these differences
did not reach statistical significance (Abalkhail, 2001).
2.4. Conclusion
A systematic comprehensive literature review was carried out into two
sections, the first section looked at a collection of credible articles that
describe the characteristics of substance and alcohol users in the Arab
countries and the second section examined the connection between
substance and alcohol use and social drift.
The available research on alcohol and substance use in Arab countries
is relatively limited. Due to cultural and religious causes, it is difficult
to carry out community-based surveys to estimate the real prevalence
rates of substance use disorders. This is why most of the existing
researches relay on clinical settings or treatment centers to assess the
prevalence, demographics and pattern of use. Despite the benefits
gained from such method, it has some drawbacks.
The same situation applied to substance use disorders and social drift.
There is limited existing published literature on social drift relating to
substance use disorders in general and in Arab countries in specific.
51
3. CHAPTER THREE: METHODLOGY
The research methodology used will be described in this chapter in
detail. The discussion in this chapter will include an explanation of the
study aims and hypothesis and the steps taken to ensure the protection
of human subjects. This will be followed by a detailed description of the
study design including the study population and study sample. The
next section will discuss the source of data and the study instrument
and its development. Finally, the data analyses method and processes,
including data cleaning, creation of a data set, creation of variables and
types of statistical analyses done will be presented.
3.1. Study Aims and Hypotheses
In common with many other places, substance use disorder is an
important public health problem in the Middle East, although this area
remains less explored. In Abu Dhabi the situation is the same with very
little
published
research
on
substance
use
disorders
and
characteristics of the people who have drug problems. However,
examining the characteristics of a clinical population may be the only
approach researchers and policy makers use to gather data about a
health related question and the magnitude of the problem such as
substance use disorders.
The principal focus of the present study is to describe substance use
disorders in Abu Dhabi using a clinical sample receiving treatment at a
well-established center (The National Rehabilitation Center - NRC) as
52
representative of the wider substance abuse population and to explore
the concept of social drift in its relation to addiction in this population.
Further, the study aims to compare its results with the results of a
similar study (Al Ghafri H. , 2014) conducted in Jordan using a similar
methodology.
This study will test the following research hypotheses:
5) The characteristics of the clinical population of substance
abusers receiving treatment in the NRC (UAE) will be similar to
the clinical population of substance abusers studied in Al
Ghafri’s Study (2014) in Jordan, another Arab country.
6) Severity of dependence will be associated with the following – as
found in the literature:
a. Early initiation of substance use,
b. Longer length of dependence,
c. Presence of a family history of addiction, and
d. Lower level of education.
7) Social drift will be associated with the following:
a. Early initiation of substance use,
b. Longer length of dependence, and
c. Presence of a family history of addiction.
8) Increased nursing interactions will be associated with higher
level of patient satisfaction with the nursing services.
53
3.2. Protection of Human Subjects
The research protocol and plan was submitted to the Director General
of the NRC to get his permission on conducting the study. Once the
permission was granted, the proposal was submitted to the NRC IRB
for ethical approval. On the IRB committee meeting, some clarifications
were requested. For example, it was requested to highlight where and
why Dr. Hamad’s questionnaire was modified. Also, the committee
recommended to increase the data collection time to ensure capturing
quality data and reducing the probability of errors occurring. After
completing all requested items, the IRB committee’s final approval was
received on May 2014.
In regard to the participants as discussed earlier, informed consent was
obtained from them prior to enrollment and assurances were made in
the study information sheet provided to all potential study participants
that taking part in the study was voluntary. The study information
sheet stated clearly that all the information would be treated
anonymously and be used only for research purposes. Also, that the
participants’ identity will not be revealed in any publication resulting
from this study. Withdrawal from the study could be at any point of
time during the study with no implications for their treatment process.
Furthermore, contact information for the researcher was provided in
case any of the participants had questions about the study. All of this
information was explained to the participants before starting the
54
process. Only those who volunteered and signed the consent form were
included in the study. The study presented no risks to the participants.
All communication with participants was in the Arabic language. The
face to face interview (questionnaire) took place in a private office in
which suitable room temperature and good lighting was maintained.
The study records and raw data were stored in a locked-cabinet at the
researcher’s home, to which only the researcher has access. Completed
questionnaires and electronic data and all findings will be destroyed
five years after completion of the study.
3.3. Study Design, Including Study Population,
Controls, and Design
3.3.1.
Study Population
The participants in this study are volunteers from the National
Rehabilitation Center (NRC) in Abu Dhabi – UAE who were receiving
treatment as inpatients or outpatients in the center. The study
population is considered a volunteer sample since respondents selfselect themselves into the study. The selection was based on the
following criteria:
3.3.1.1. Inclusion Criteria
a) In-patients, including detoxification patients and rehabilitation
patients,
b) Patients who agree to participate in the study during their
admission to the NRC,
55
c) Patients above 15 years of age,
d) Patients from both genders,
e) Patients who are admitted either voluntarily or non-voluntarily,
f) Inpatients who are already admitted to the NRC, and
g) Outpatients who came to the outpatient clinic for follow up
during the data collection period.
3.3.1.2. Exclusion Criteria
a) Patients who refuse to be in the study,
b) Patients who are re-admitted and were previously interviewed,
c) Patients with severe mental illness, and
d) Patients with severe medical illness.
3.3.2. Sample Size
To determine the sample size for this study to provide sufficient power
to detect statistically significant differences, the below formula was
used. I set the confidence level at 90% and assumed a standard
deviation of 0.5. and a margin of error (confidence interval) of +/- 5%:
Sample Size = (Z-score)2 *standard deviation*(1- standard deviation) /
(margin of error)2
= ((1.645)2 x .5(.5)) / (.05)2
= (2.71 x 0.25) / 0.0025 = 0.6775 / 0.0025 = 271
This means 271 respondents are needed. (Smith, 2013).
Out of 261 patients invited to participate in the Al Ghafri’s study, 250
patients participated (Al Ghafri H. , 2014). So, in order to have an
56
equivalent sample size as Al Ghafri’s study as the main aim of this study
is to compare the characteristics of this clinical population with that of
the clinical population in Jordan in Al Ghafri’s study. Therefore, the
sample size was decided to be 250 patients for the current study.
3.3.3. Study Design
Generally, quantitative descriptive studies are the best techniques to
collect information that demonstrates relationships and describes the
existing situation at a specific point in time. They are convenient for
defined description as they use numbers and for comparison purposes
(Barker, Pistrang, & Elliott, 2016). So, a cross-sectional descriptive
design was used in this study in the form of a questionnaire. Crosssectional studies allow the comparison of many different variables at
the same time, but they may not offer a complete picture about causeand-effect relationships which is not the aim of this study (Institute for
Work & Health, 2015).
In this study, it was expected that the questionnaire approach will offer
a broader and deeper perspective of substance use disorders and
addiction in the UAE from the patient point of view. It was expected that
it would help to gain a comprehensive understanding of the addiction
situation and one of its associated problems which is social drift. The
questionnaire relied on a large sample of NRC patients who meet the
inclusion criteria and voluntarily accept to participate in the study
57
3.4. Source of Data
3.4.1.
The National Rehabilitation Centre (NRC):
The National Rehabilitation Center (NRC) was established in 2002
under the direction of the late President of the United Arab Emirates
(UAE) Sheikh Zayed Bin Sultan Al Nahyan. It provides the principal
source of treatment and rehabilitation for individuals who have various
types of substance use disorders. NRC endeavors to develop its services
to better cater for the community needs following the latest evidence
based methods of drug addiction treatment (National Rehabilitation
Center, 2013).
The NRC has established partnerships with world’s leading academic
institutions,
local
institutions
and
international
organizations,
including McLean-Harvard and NIDA in the US, Maudsley Hospital,
King’s College London and Aberdeen University in the UK, United Arab
Emirates University, Abu Dhabi University and Khalifa University in the
UAE, United Nations Office on Drug & Crime, World Health
Organization, the Colombo Plan and the International Society for
Addiction Medicine (National Rehabilitation Center, 2013).
As the only specialized center in addiction treatment across the UAE,
NRC provides its patients with understanding, care, confidentiality,
medical and psychiatric treatment as well as rehabilitation in order to
reintegrate them back into society and, to be active persons in their
community and to enjoy their normal lives (National Rehabilitation
Center, 2013).
58
At present, the NRC comprises 78 beds for residential treatment and
rehabilitation. The inpatient program provides its services to both male
and female patients with each program being tailored to the specific
gender it treats (National Rehabilitation Center, 2013)
The NRC also has a very active outpatient program that takes care of
patients whose health conditions are not so severe to be inpatients and
it also provides post-treatment services to individuals’ who were
formally inpatients. The medical team in the outpatient program follows
a treatment method called ‘The Way to Recovery’ or internationally
known as ‘Matrix Model’ (Hazelden Betty Ford Foundation, 2017), after
being adapted to UAE cultural context. Over 16 consecutive weeks, the
patient is treated and supervised by a medical team with integrated
specialties (National Rehabilitation Center, 2013).
Based on the NRC monthly report for the month of April 2018, 49.9%
of its patients were younger than 30 years of old. 58.5% were single
and 33.2% were married. Looking at education, the report showed that
37.5% of all patients had a secondary level and 13.9% had a university
degree. The majority of the patients (46.9%) were unemployed. Selfreferral represented the most common source of intake for patients (The
National Rehabilitation Center, 2018).
3.4.2. The Questionnaire
The study used the same questionnaire instrument developed by Al
Ghafri (2014) which is based on validated scales and questionnaire
instruments such as CAGE (Ewing, 1984), and Addiction Severity Index
59
– ASI (McLellan, 1980). This instrument was translated into Arabic
using standard procedures and tested/used on a Jordanian population.
In the paragraphs below, the questionnaire development and its
contents will be explained in more detail (AlGhafri, 2014).
3.4.2.1. Original Questionnaire Development
In Al Ghafri study (2014), the questionnaire instrument was developed
for the purpose to collect data from a clinical population receiving
treatment at the National Addiction Centre (NACT) in Amman – Jordan.
Validated scales were integrated within the questionnaire instrument
such as Addiction Severity Index (ASI) (McLellan, Luborsky, Woody, &
O‟Br, 1980), Maudsley Addiction Profile (MAP) (Marsden, Gossop,
Stewart, & Best, 1998) and CAGE (Ewing, 1984). The final version of
the Al Ghafri questionnaire (2014) was revised and discussed with a
local professor of public health to ensure that all the main areas of
interest were included. The questionnaire was completed in English and
translated into Arabic.
Below is a brief description of the validated scales used to develop the
Al Ghafri questionnaire (2014):
3.4.2.1.1.
Addiction severity index (ASI)
The ASI is a semi-structured clinical interview tool which is widely used
in alcohol and drug abuse assessment and treatment planning because
it is simple to use and is cost effective. It is intended to identify factors
contributing to the patient’s substance abuse problems through
collecting information about specific areas of a patient’s life. The ASI
60
focus on seven possible problem areas which are medical problems,
employment and support, drug use, alcohol use, legal problems,
family/social issues, and psychiatric problems. It was used effectively
to explore problems with adults seeking treatment for substance use
disorders. The ASI has been used widely for treatment planning and
outcome evaluation (McLellan, Luborsky, Woody, & O‟Br, 1980).
In Al Ghafri’s study (2014), questions related to medical status,
employment, financial status, the drug or alcohol use in the past 30
days and route of administrations were included (Al Ghafri H. , 2014).
3.4.2.1.2.
Maudsley Addiction Profile (MAP)
The MAP is a short questionnaire used by an interviewer for treatment
outcome and research applications. It was first developed and validated
in a UK clinical population. It examines the problem from four domains:
substance use, health risk behavior, health symptoms (including
physical health, psychological health), and the fourth domain focus on
personal and social functioning. The original measure has 60 items and
takes on average 12 minutes to complete. It provides a comprehensive
picture of the substance user. There are many similarities between MAP
and the Addiction Severity Index (ASI) and the Opiate Treatment Index
(OTI) (Marsden, Gossop, Stewart, & Best, 1998) . The MAP has not been
used in the Arabian region nor translated into Arabic.
3.4.2.1.3.
CAGE Questionnaire (Ewing, 1984)
CAGE Questionnaire is a simple, easy to administer and easy to
remember alcohol screening tool. It is the most widely used tool because
61
of its effectiveness and efficiency. The acronym “CAGE” reminds the
physician of the four questions which are Cutting down, Annoyance by
criticism, Guilty feelings, and Eye-openers. All of the CAGE questions
were used in Al Ghafri questionnaire (2014).
3.4.2.1.4.
Questionnaire Content:
The questionnaire used in the study has 3 main parts and 93 items. Its
format
included
fixed
choices
and
open-ended
questions
as
appropriate. The three parts of the questionnaire are detailed below.
3.4.2.1.4.1.
Part 1: Demographic information
This section includes items on age, gender, nationality, religion,
marital status, education, and accommodation. Psychiatric and
medical histories are also included.
3.4.2.1.4.2.
Part 2: Substance use and addiction
history
This section includes questions regarding the use of alcohol and
different types of substances such as heroin, benzodiazepines,
narcotics and cannabis. Other information such as the age of first
use, period of use, frequency of use, current usage, and criteria of
dependence were also collected. Questions from Addiction severity
index
(ASI),
Maudsley
Addiction
Profile
(MAP),
and
CAGE
Questionnaire have been incorporated in this section of the
questionnaire.
62
3.4.2.1.4.3.
Part 3: Social drift
Due to lack of literature on social drift, questions related to the
social drift in this study were developed by the research team and
based on the mental health literature. Under this section, questions
focused on social characteristics such as employment history,
accommodation status history, family relationships, and financial
status.
3.4.2.2. Current Questionnaire Development
For the purpose of this study and to fit the UAE culture, the
questionnaire items were revised and some modifications were made
ensuring that there were no analysis implications for the comparison of
the data. For example, under the demographic section – patient
background, the following modifications were made:
Table 3- 1 Examples of modifications made in the questionnaire
Item
Original
Current
Questionnaire
Questionnaire
1. Jordanian
Nationality
2. Other Arab
1. UAE
2. Others
3. Non-Arab
Justifications
Only Emiratis are
treated in the NRC
1. Moslem
Religion
2. Christian
1. Muslim
Linked to previous
3. Jewish
2. Others
question
4. Other
63
Educational
Background
1. Primary
1. Illiterate
2. Preparatory
2. Primary
3. Secondary
3. Preparatory
4. University
4. Secondary
5. Above university
5. University
To capture all
levels of education.
University = BSc,
Mater, PhD
1. Unemployed
Occupation
To be written by
researcher
2. Student 3. Selfemployed
4. Employed
For statistical
reasons.
5. Retired
1. Abu Dhabi
2. Dubai
Address
State Name: Town,
Village, Camp
3. Sharjah
4. Ajman
To fit the UAE
5. Fujairah
6. Ras al-Khaimah
7. Umm al-Quwain
Contact
To be written by
Person
researcher
Not needed as it
Deleted
doesn’t add any
statistical value
In addition to the main three parts, some nursing related questions are
added to assess the status of nursing services in the National
Rehabilitation Center and how nursing is viewed by the substance
abuse patients in order to help improve the nursing role and contribute
to the development of the nursing profession in the addiction field.
3.5. Piloting
The pilot was designed to test the questionnaire in a like sample of
substance abuse patients to assess its validity and feasibility, to
simplify complicated or compound questions, and to provide the
64
researcher with data on issues arising from the questionnaire questions
in order to refine and clarify the final questionnaire.
In Al Ghafri study (2014), a full pilot on ten patients drawn from the
same population as the main sample was conducted. The pilot included
testing all processes starting from patient approach, recruitment,
acceptability
of
documents,
and
finally
administering
the
questionnaire. Feedback was collected from the pilot patients on both
content and administration. As a result, questions regarding sexual
habits were removed as these were found to be embarrassing to
participants. Other questions related to the family relationship were
made more formal and rephrased to avoid ambiguity. The final study
questionnaire was modified accordingly. An additional step was done
which is entering the collected data from the pilot sample in SPSS and
simple descriptive frequencies were run to check for outliers (Al Ghafri
H. , 2014).
In the current study, and after modifying the questionnaire to fit the
UAE culture, the questionnaire was piloted on five patients drawn from
the same population. Pilot patients were asked for their feedback on
both content and administration. The same methodology used in the
study was applied in the pilot for testing purposes. No major changes
were made to the final questionnaire. All data are to be destroyed five
years after the completion of this study.
65
3.6. Procedure
The data collection was conducted between October 2014 till October
2015. During this time face-to-face structured interviews were done by
the researcher (SM) and by a research assistant (FA), who had been
trained on the study protocol and on how to fill out the questionnaire.
Training was provided by the creator of the questionnaire; Al Ghafri.
The structured interviews were conducted in Arabic in a private meeting
room in the center.
Participants were provided with a written patient information sheet in
Arabic, reassuring them of confidentiality and that no effect on their
treatment will take place if they withdraw from the study at any time.
Those who agreed to participate were asked to sign an informed consent
form and then they were asked to sit for the interview to answer the
questionnaire
which
the
researcher
or
researcher
assistant
administered. The completed answered questionnaires were collected
and stored securely. The procedure is outlined in the diagram below.
(Figure 3-1).
66
Figure 3- 1 Data Collection Procedure
Patient who meets the inclusion criteria
Patient
information
sheet
No
Not included
Yes
Consent
form
Not included
No
Yes
Questionnaire
3.7. Data Entry and Quality Assurance
Data were entered by the researcher. After every 50 questionnaires
were entered, data were checked for any errors such as coding,
incorrect entries, and missing entries. In the first two groups of data
(100 questionnaires), several errors were found due to errors in coding
and incorrect entries. All entries were rechecked and errors were
corrected. In the last 150 questionnaires, there were only two coding
errors that were corrected immediately. After completing all data entry,
67
a systematic sample of 25 questionnaires (the fourth questionnaire in
every 10 questionnaires) were checked for errors against the entered
data and no more errors were found. At the same time, data were
randomly checked by the local supervisor as second level of assurance.
Data were stored on a password-protected laptop and the hard copies
of the questionnaires were kept in the researcher’s home office in a
locked cabinet.
3.8. Data Management and Analysis
The data were analyzed using the Statistical Package for Social
Sciences (SPSS) package. The entered data were cleaned before
analysis. The following sections describe the hypothesis variables, and
how the study hypotheses were tested including a detailed explanation
of the analysis plan.
3.8.1. Variables and Measures – operational indicators
The table (Table 3.2) below lists the study hypothesis and their
variables (independent and dependent):
68
Table 3- 2 The Study Hypothesis and their Variables
(independent and dependent)
Hypothesis
H1
Independent
Dependent
variables
variables
Group of variables
Type
Group of
Depends on
variables
variable
H2
Age of first use
Categorical
H3
Education Level
Continuous
Data source
Severity of
Length of
H4
dependence
Binary
dependence
H5
Family History
Binary
Questionnaire
H6
Age of first use
Categorical
H7
Education Level
Continuous
Length of
H8
Social Drift
Binary
dependence
H9
Family History
H10
Nursing interaction
Binary
Patient
satisfaction
69
Binary
3.8.2. Analysis plan
The data were analyzed using an SPSS software package for analysis.
Simple descriptive statistics such as frequencies, percentages, means
(SD) and medians were calculated. Regression analysis was conducted
to explore links between socio-demographic variables and addiction
and treatment variables. The data were compared with the results from
Al Ghafri’s study in Jordan (AlGhafri, 2014).
Associations
appropriate
were
assessed
statistical
for
methods
statistical
such
as
significance
multivariate
using
logistic
regression. For example, one of the hypotheses that was tested in this
study is the association between nursing interaction with substance
abuse patients and patient satisfaction with the nursing services. In
other words, when the nurses’ interaction with the substance abuse
patients increases, the patient satisfaction with the nursing services
will increase. Statistically, if there is a significant linear relationship
between the independent variable X (nursing interaction) and the
dependent variable Y (patient satisfaction) the slope will not equal zero.
The null hypothesis states that the slope is equal to zero
H0:Β=0.
This means that there is no relationship between nursing interaction
and patient satisfaction.
The alternative hypothesis states that the slope is not equal to zero
Ha: Β1 ≠ 0. This means that there is a correlation between
nursing interaction and patient satisfaction.
70
The following logistic regression model will be used to test this
hypothesis:
Y = b0 + b1X1 + b2X2 + ……… bnXn
Y = “patient satisfaction” as the outcome or the dependent variable
X1 is “nursing interaction” as the independent variable
X2 to Xn are potential confounders, such as, health status, sociodemographics, health behaviors, etc.
b1 is the log odds ratio of “patient satisfaction” for “nursing interaction”
after controlling for potential confounding variables.
The significance level in this study will be 0.05. Using sample data, we
will conduct a linear regression t-test to determine whether the slope of
the regression line differs significantly from zero.
3.8.3. Detailed analysis plan to address research
questions
A. To describe the characteristics of a population of substance
abusers in treatment in the National Rehabilitation Center (NRC) in
Abu Dhabi – UAE.
Frequency distribution of the following variables was carried out to
describe the participants: Age, gender, marital status, educational
background, current occupation, address, referral source, medical
history, psychiatric history, smoking, type of substance, age of first use
for all the substances, length of use and family history, employment
71
status and indicators of social drift (education, employment, marital,
financial and criminal).
Analyses: Summary statistics (n, %, mean).
B. To assess the current user substance and patterns of behavior.
Frequency distributions were carried out for all participants and by
subgroups according to substance of abuse for the following variables to
describe current substance abuse and its severity: Drug taking history
over the past month, (frequency of use, importance, satisfaction with life,
time spent in activities, increasing usage over a long period of time);
persistent desire to cut down, continue to use despite its problems, trial
to stop, withdrawal symptoms, including the CAGE score for alcohol and
severity score for alcohol and drug use. Severity scores were computed for
both alcohol and drug use, from questions around: time spent in
activities, increasing usage over a long period of time, persistent desire to
cut down, continue to use despite its problems and attempts to stop.
Analyses: Summary statistics (n, %, mean, (SD) or median).
C. To examine factors associated with relapse from the patient
perspective.
Frequency distributions were conducted for all participants and by
subgroups according to substance of abuse for the following variables:
Perceived dependence, peer pressure, poor attitude, family problems,
role model, unemployment, place, time.
Analyses: Summary statistics (n, %, mean (SD), or median)
72
A new variable was computed for relapse, which was defined as “1=Yes‟
or “0=No” if answered to ‘Is this the first time in treatment?’. A score
was created based on number of previous treatments for those who had
relapsed (1=1 previous treatment, 2=2 previous treatments, 3=3
previous treatments, 4=4 or more previous treatments).
D. To explore patient experiences of treatment.
Frequency distributions were created for all participants and by
subgroups according to substance of abuse for the following variables:
received a treatment, received rehabilitation, number of treatments,
follow up program, number of detoxification courses, number of
rehabilitation courses, services responsive to your needs, care
coordinated, choosing this facility again.
Analyses: Summary statistics (n, %)
E. To assess the association between severity of dependence and
substance abuse (initiation age, length of dependence, presence of
a family history of addiction and level of education.).
Frequency distributions were carried out for all participants and by
subgroups according to substance of abuse for the following variables
to define severity of dependence for both alcohol and substance. Based
on
research,
the
Severity
of
Dependence
Scale
is
a
5-item
questionnaire that provides a score indicating the severity of
dependence. The total score is obtained through the addition of the 5item ratings. The higher the score, the higher the level of dependence
(Gossop, 1995).
73
This was done by answering the following five questions first; do you
spend time in activities searching for the drugs/alcohol?, do you use
large amount of drugs/ alcohol over a long period?, do you have a
persistent desire to cut down or to control taking drugs/ alcohol yet
you have not succeeded?, do you continue to use drugs/ alcohol
despite the fact that it causes you many problems? and have you tried
to stop your habits?. The initial answer for these questions was Yes =
1 or No =2.
To investigate the association between the severity of dependence and
alcohol and substance use, a new variable “severity of dependence
score‟ was computed based on the answers to the above mentioned
five questions. The five questions were recoded as 0 if the answered
was No and 1 if the answer was Yes. A new severity of dependence
score was computed by summing the five answers to give a value
ranging from zero to five. Five indicated the highest level of severity of
dependence.
Then the total severity of dependence for al substance and alcohol was
computed by combining both the alcohol severity of dependence and
substance severity of dependence. To have the final total score of
severity of dependence in a binary format the previous 5- scale score
was recoded in to 0 = low severity (by merging total severity of
dependence score of 1 and 2) and 1 = high severity (by merging total
severity of dependence score of 3, 4 and 5).
Dependent variable: severity of dependence score.
74
Independent variables: Time spent searching for drugs/alcohol, use of
large amount over time, persistent desire to cut down without success,
continue to use despite the problems and trial to stop.
Analyses: Association of the dependent variable with the independent
variable was carried out using the Chi squared test and logistic
regression analyses.
F. To assess the association between social drift and substance abuse
(education, employment, marital, financial and criminal).
Frequency distributions were carried out for all participants and by
subgroups according to substance of abuse for the following variables
to describe social circumstances and social drift: employment status,
type of employment, history of employment, losing job because of
addiction, job affected by addiction, loss of promotion, type of
accommodation, education finished before addiction, education not
finished because of addiction, number of current marriages, number
of previous marriages, income change after addiction.
To consider associations of different factors with social drift a new
variable “social drift score‟ was computed based on the answers to
three questions: losing job because of addiction, education not finished
because of addiction, and income changed after addiction. The score
was developed from these three questions, which might indicate
adverse changes in a person’s social status. The three questions were
recoded as 0 if the answered was No and 1 if the answer was Yes. A
new Social drift score was computed by summing the three answers to
75
give a value ranging from zero to three. Three indicated the highest
level of social drift. To have the final social score in a binary format the
previous 3- scale score was recoded in to 0 = low social drift (by merging
the social drift score of 0 and 1) and 1 = high social drift (by merging
total severity of dependence score of 2, 3 and 4).
Dependent variable: Social drift score.
Independent variables: Type of drug by subgroup, severity of addiction
for drugs and alcohol, and the new variable relapse.
Analyses: Association of the dependent variable with each of the
independent variables was carried out using the Chi squared test and
logistic regression analyses.
3.9. Conclusion
The study aimed at providing a detailed picture of the characteristics of
substance users whom attending the national Rehabilitation Center for
treatment and exploring the notion of social drift among this
population.
Therefore,
a
quantitative
methodology
using
a
questionnaire instrument was used. The questionnaire was developed
by Al Ghafri (2014) and was based on internationally validated scales.
76
4. CHAPTER FOUR: RESULTS
The main findings of the study, which will be broadly structured by the
study hypotheses, will be presented in this chapter. This chapter will
include four main sections. The discussion in the first section will
include a detailed analysis of the characteristics of the clinical
population of substance abusers receiving treatment in the NRC (UAE).
As mentioned earlier, the total sample of the clinical population in this
study is 250 patients including 242 males and 8 females.
This will be followed in the second section by a detailed comparison of
the
current
study
clinical
population
of
substance
abusers’
characteristics with the characteristics of the clinical population of
substance abusers from another study conducted in Jordan on 2014.
Because the Jordan study included a male only sample, the comparison
will be with male sample subset from the current study which is 242
males.
The third section will explore the association between severity of
dependence and substance use initiation age, length of dependence,
presence of a family history of addiction and level of education. The
other association that will be explored in this section will be between
social drift and age of first initiation, length of dependence, and
presence of a family history of addiction. Finally, the association
between the nursing interactions and patient satisfaction with the
nursing services will examined in the fourth section.
77
4.1. Response Rate
Of the 266 subjects invited to participate in this study, 250 (94%)
consented and completed the questionnaire. The reason given by the 16
who did not consent to participate was fear of information leakage to
the police.
4.2. SECTION ONE: The characteristics of the clinical
population of substance abusers receiving treatment in
the NRC (UAE):
4.2.1. Part 1: Demographic Data:
4.2.1.1. Patient Background:
Of the 250 patients, there were 242 (96.8%) males and 8 (3.2%) females.
The youngest among the males was 16, while the youngest age among
the females was 20. The mean (SD) age of subjects was 28.52 (8.87)
years, with the majority of the patients being under the age of 31 years
(71.5%). Only seven were over the age of 50 years. At the time the data
were collected, all of the patients who volunteered to participate in the
study were UAE nationals and were all Muslim. (Table 4.1)
149 (59.6%) of the total sample were single, 82 (32.8%) were married,
18 (7.2%) were divorced, only one (0.4%) reported that he was not living
with his wife and none were widows or widowers. Among the males, 144
(59.5%) were single, 80 (33.06%) were married, 17 (7.02%) were
divorced and one (0.4%) was separated. Out of the 8 females, 5 (62.5%)
78
were single, 2 (25%) were married and one (12.5%) was divorced. (Table
4.1).
98.8% (274/250) of the total sample were educated and only 1.2%
(3/250) didn’t know how to read or write. The majority of the educated
sample were at the secondary level (128 - 51.2%) followed by the
preparatory level (58 - 23.2%), the university level (39 - 15.6%) and last
was the primary level (22 - 8.8%). The same scenario applied to the male
sample, with 127 (52.5%) at the secondary level, 54 (22.3%) at the
preparatory level, 38 (15.75%) at the university level and 20 (8.3%) at
the primary level. 3 (1.2%) out of the 242 males were illiterate. The
female sample were all educated; 4 (50%) at preparatory level, 2 (25%)
at primary level, one (12.5%) at secondary level and one (12.5%) at
university level. (Table 4.1)
49.6% (124) of the total sample were unemployed compared to 36% (91)
who were employed. Of the 91 employed, 11 were self-employed. Almost
all the females were unemployed (87.5%) except one (12.5%) who was
employed. The majority of the males were unemployed (118 – 48.8%).
90 (37.2%) out of the 242 males were employed, with 11 (12%) who were
self-employed. 31 (12.8%) were students and 3 (1.2%) were retired.
(Table 4.1)
79
Table 4- 1 Frequency Distribution of the participants'
Demographic Data
Total
Male
Female
250 (100%)
242 (96.8%)
8 (3.2%)
16-20 yrs.
37 (14.7%)
37 (15.3%)
0 (0%)
21-25 yrs.
88 (35.2%)
85 (35.1%)
3 (37.5%)
26-30 yrs.
54 (21.6%)
51 (21.1%)
3 (37.5%)
31-35 yrs.
18 (7.2%)
17 (7%)
1 (12.5%)
36-40 yrs.
23 (9.2%)
22 (9.1%)
1 (12.5%)
41-45 yrs.
16 (6.4%)
16 (6.6%)
0 (0%)
46-50 yrs.
7 (2.8%)
7 (2.9%)
0 (0%)
Above 51 yrs.
7 (2.8%)
7 (2.9%)
0 (0%)
149 (59.6%)
144 (59.5%)
5 (62.5%)
Married
82 (32.8%)
80 (33.06%)
2 (25%)
Divorce
18 (7.2%)
17 (7.02%)
1 (12.5%)
Widower
0 (0%)
0 (0%)
0 (0%)
Separated
1 (0.4%)
1 (04%)
0 (0%)
Illiterate
3 (1.2%)
3 (1.2%)
0 (0%)
Primary
22 (8.8%)
20 (8.3%)
2 (25%)
58 (23.2%)
54 (22.3%)
4 (50%)
Secondary
128 (51.2%)
127 (52.5%)
1 (12.5%)
University
39 (15.6%)
38 (15.75)
1 (12.5%)
124 (49.6%)
117 (48.3%)
7 (87.5%)
32 (12.8%)
32 (13.2%)
0 (0%)
Self-employed
11 (4.4%)
11 (5%)
0 (0%)
Employed
80 (32%)
79 (4.5%)
1 (12.5%)
Retired
3 (1.2%)
3 (1.2%)
0 (0%)
155 (62%)
151 (62.4%)
4 (50%)
30 (12%)
27 (11.2%)
3 (37.5%)
32 (12.8%)
31 (12.8%)
1 (12.5%)
N (%)
Age Group
Single
Marital Status
Educational
Background
Preparatory
Unemployed
Student
Current Occupation
Abu Dhabi
Dubai
Sharjah
Address or State of
Ajman
13 (5.2%)
13 (5.4%)
0 (0%)
residence
Fujairah
14 (5.6%)
14 (5.8%)
0 (0%
5 (2%)
5 (2.1%)
0 (0%
1 (04%)
1 (0.4%)
0 (0%
129 (51.6%)
124 (51.2%)
5 (62.5%)
30 (12%)
29 (12%)
1 (12.5%)
91 (36.4%)
89 (36.8%)
2 (25%)
Ras Al-Khaimah
Umm AlQuwain
Self
Referral Source
Family
Justice System
80
Compared to the other emirates, Abu Dhabi had the largest number of
patients with 155 (62%). Followed by 65 (26%) were from the northern
emirates and 30 (12%) from Dubai. Analyzing the patients’ distribution
around the emirates based on gender resulted in the majority of
patients coming from Abu Dhabi with 151 (62.4%) males and 4 (50%)
females. More male patients (64 - 26.4%) come from northern emirates
males compared to only one (12.5%) female. On the other hand, more
females (3 - 37.5%) come from Dubai compared to 27 (11.2%) of males.
(Table 4.1)
The common source of referral was self-referred with a total of 129
(51.6%), of whom 124 were males and 5 were females. Referrals from
the justice system came next, with a total of 91 (36.4%), of whom 89
were males and 2 were females. 30 (12%) out of the total referred by
their families to seek treatment; 29 out of the 30 were males with only
one female. (Table 4.1).
4.2.1.2. Psychiatric & Medical Data:
Mood disorders were most frequently reported (129 – 51.5%) as a
psychiatric illness among the total sample, followed by depression (109
– 43.6%). While anxiety disorders were the least reported (106 – 42.4%).
None
of
the
sample
was
reported
as
being
diagnosed
with
schizophrenia. (Table 4.2).
Similar to the psychiatric illnesses distribution among the total sample,
mood disorders were reported by the majority of the male sample (126
81
– 52.1%). The second most reported psychiatric illness was depression
(106 – 43.8%) and the least frequently reported were anxiety disorders
(102 – 42.1%). (Table 4.2).
The picture was different among the female sample. Among females,
anxiety disorders were reported n half of the sample (4 – 50%).
Depression and mood disorders were both reported by 3 females
(37.5%). (Table 4.2).
Looking at the medical history of the total sample, it was found that
hypertension and gastritis were the most common medical problems
that were reported by the same number of participants (31 – 12.4%).
Only 25 (10%) of the 250 reported to have hepatitis. Further breakdown
of the types of hepatitis revealed that hepatitis C (19 – 7.6%) was the
most common type of hepatitis among the total sample. Five (2%)
reported having hepatitis A and only one (0.4%) had hepatitis B.
Diabetes was reported by 13 (5.2%) participants and none mentioned
that they had AIDS. (Table 4.2).
Among the females group, gastritis was the most common medical
problem (3 – 37.5%), followed by hypertension (2 – 25%) and only one
(12.5%) stated that she was diagnosed with diabetes. Hepatitis and
AIDS were not among the medical problems that were reported by
females. (Table 4.2).
Hypertension was identified by 29 (12%) of the male sample which made
it the most common medical problem. Gastritis came next with 28
82
(11.6%) male participants believed to have it. While hepatitis came in
third place with 25 (10.3%) male participants reported that they were
diagnosed with a type of hepatitis. Hepatitis C is the most common type
of hepatitis (19 – 7.9%) among males, while hepatitis B was the least
reported (1 – 0.4%). Five of the 25 male participants who have hepatitis,
have hepatitis A. (Table 4.2).
Table 4- 2 Frequency Distribution of the participants' Psychiatric
& Medical Data
Depression
Psychiatric
History
Schizophrenia
Anxiety disorders
Mood disorders
Hep (A)
Hepatitis
Hep (B)
Hep (C)
Medical
History
AIDS
Hypertension
Diabetes
Gastritis
Total
Male
Female
250 (100%)
242 (96.8%)
8 (3.2%)
Yes (%)
No (%)
Yes (%)
No (%)
Yes (%)
No (%)
109
141
106
136
3
5
(43.6%)
(56.4%)
(43.8%)
(56.2%)
(37.5%)
(62.5%)
250
0
(100%)
0
242
(100%)
0
8
(100%)
106
144
102
140
(42.4%)
(57.6%)
(42.1%)
(57.9%)
129
121
126
116
3
5
(51.6%)
(48.4%)
(52.1%)
(47.9%)
(37.5%)
(62.5%)
4 (50%)
5
5
0
(2%)
(2.1%)
(100%)
4
(50%)
1
225
1
217
0
8
(0.4%)
(90%)
(0.4%)
(89.7%)
(100%)
(100%)
19
19
0
(7.6%)
(7.9%)
(100%)
250
0
(100%)
0
242
(100%)
0
8
(100%)
31
(12.4%)
219
(87.6%)
29
(12%)
213
(88%)
2
(25%)
6
(75%)
13
237
12
230
1
7
(5.2%)
(94.8%)
(5%)
(95%)
(12.5%)
(87.5%)
31
219
28
214
3
5
(12.4%)
(87.6%)
(11.6%)
(88.4%)
(37.5%)
(62.5%)
83
4.2.2. Part 2: Addiction History
4.2.2.1. Substance Abuse and Smoking History:
4.2.2.1.1.
Substance of Use:
Table 4.3 shows the distribution of the sample by type of substance of
abuse. A total of 73% of the sample are polysubstance and alcohol
users, 18% used drugs only, and 9% used alcohol only. The same
distribution applies to both genders. Polysubstance and alcohol users
represent 73% of the male group and 63% of the female group. 17% of
the males reported drugs only and 10% alcohol only. On the other hand,
none of the females reported using alcohol only and the remaining 38%
are drugs users only. (Table 4.3).
Table 4- 3 Frequency Distribution of the participants by
Substance of Use
Gender
Total
Male
Female
Alcohol only
23
10%
0
0%
23
9%
Drugs only
42
17%
3
38%
45
18%
177
73%
5
63%
182
73%
242
100%
8
100%
250
100%
Alcohol + Drugs
Total
4.2.2.1.2.
Age of First Use:
The youngest age of first use of most of substance was 11 years with a
mean (SD) of 17. 8 and oldest age of first use range between 27 and 46.
82% (205) of the total sample used alcohol for the first time in their life
between the ages of 11 and 41. The age of first use among the heroin
84
users was 14 years with a mean (SD) of 20.4. The users of other types
of narcotics also started their first use at the age of 14 with a mean (SD)
of 21.0. Cocaine users started to use at the age of 13 with a mean of
21.1. Both benzodiazepine and other sedatives users reported their first
use before they reach their twelfth birthday. The same pattern was
observed
among hallucinogenic and
amphetamines users.
The
youngest age of first use of cannabis, inhalants and khat was 11 years
old. (Table 4.4).
Table 4- 4 Frequency Distribution of Substance of Use by age of
Benz
Cannabis
Hallu
Inhalants
Khat
Amphet
119
84
201
193
188
114
34
35
156
(82%)
(60%)
(48%)
(34%)
(80%)
(77%)
(75%)
(46%)
(14%)
(14%)
(62%)
11
14
14
13
11
11
12
11
12
12
11
of 1st (SD)
use
Mean
(yrs)
age at 1st use
17.78
20.4
20.96
21.12
18.99
18.97
17.86
18.17
15.44
18.97
20.5
(4.1)
(4.4)
(4.7)
(4.3)
(4.9)
(4.9)
(3.4)
(4.1)
(2.9)
(6.1)
(5.3)
11-20 yrs
168
83
63
43
158
149
155
86
33
25
104
21-30 yrs
33
63
54
37
38
39
31
27
1
7
42
31-40 yrs
2
3
1
4
4
4
2
1
0
3
9
> 41 yrs
2
0
1
0
1
1
0
0
0
0
1
Total (%)
Youngest
reported age
4.2.2.1.3.
Sedative
Cocaine
149
History
Other
Heroin
205
Addiction
Other
Alcohol
Narcotics
1st Use
Nicotine Smoking History:
Table 4.5 illustrates the current smoking status and when the
participants started smoking in relation to their addiction onset. 247
(98.8%) of the total sample reported that they were currently smoking.
85
Of the 247 who are smoking, 223 (90.3%) reported starting smoking
before their addiction. (Table 4.5). 239 (98.8%) of the male sample
reported that they are currently smoking, of whom 216 (90.4%)
mentioned that they were smoking before their addiction. All the
females were smokers at the time of the study with seven (87.5%)
started to smoke before they became addicts. (Table 4.5).
Table 4- 5 Frequency Distribution of Current smoking status and
smoking history categorized by gender
Total
Male
Female
250 (100%)
242 (96.8%)
8 (3.2%)
Yes (%)
Do you smoke?
247
(98.8%)
Was it ......
your addiction
No (%)
3 (1.2%)
Yes (%)
239
(98.8%)
Before
After
Before
223
24
216
(90.3%)
(9.7%)
(90.4%)
4.2.2.1.4.
No (%)
Yes (%)
No (%)
3 (1.2%)
8 (100%)
0 (0%)
After
Before
After
23 (9.6%)
7 (87.5%)
1 (12.5%)
Current Use
The frequency of use for both substances and alcohol during the over
the past 1-2 months was divided into four categories, which were
abstinent, light use, moderate use and heavy. More than 50% of the
total substance users sample (122/227) reported that they had not
been using drugs in the last 1-2 months preceding their admission,
while 23.3% (53/227) reported a heavy use. (Table 4.6).
For alcohol, more than 75% of the participants (157/205) who used
alcohol stated that they didn’t use alcohol during the past 1-2 months,
whereas, 9.3% (19/205) described their use as a light use. (Table 4.6).
86
Table 4- 6 Frequency Distribution of Current Use of Substance &
Alcohol Over the Past 1-2 Months
Current Use
(Past 1-2
Substance
Alcohol
Frequency
%
Frequency
%
Abstinent
122
53.7
157
76.6
Light
24
10.6
19
9.3
Moderate
28
12.3
13
6.3
Heavy
53
23.3
16
7.8
Total
227
100
205
100
months)
Participants were also asked about the overall importance of substance
and alcohol use in their life during the past month. The majority of
participants described the use of substances (55.1%) and alcohol
(84.9%) as not so important. This result goes along with what they
reported as their current use during the past 1 - 2 months. Only 27.3%
(62/227) of substance users and 9.3% (19/205) of alcohol users
described their use as very important. (Table 4.7).
Table 4- 7 Frequency Distribution of the Participants' View of the
Importance of Use of Substance & alcohol
Importance of
Substance
Alcohol
Use
Frequency
%
Frequency
%
Very important
62
27.3
19
9.3
Important
40
17.6
12
5.9
125
55.1
174
84.9
227
100
205
100
Not so
important
Total
87
Table 4- 8 Frequency Distribution of the Participants'
Satisfaction of their Use
Substance
Alcohol
Frequency
%
Frequency
%
74
32.6
44
21.5
36
15.9
34
16.6
A bit satisfied
115
50.7
124
60.5
Not satisfied
2
0.9
3
1.5
Total
227
100
205
100
Very satisfied
Reasonably
satisfied
The last question on current history of use highlighted how satisfied the
participants with substance use in their life were. 50.7% (115/227) of
substance users and 60.5% (124/205) of alcohol users stated that they
were a bit satisfied. 32.6% (74/227) of the substance users and 21.5%
(44/205) of the alcohol users were very satisfied. (Table 4.8).
4.2.2.1.5.
Criteria of Dependence
Dependency criteria for substance and alcohol use were assessed in the
questionnaire using five questions. These questions were asking about
the time spent searching for the addicted substance, using large
amounts of substance or alcohol over a long period, having a persistent
desire to cut down taking without succeeding, continuing to use despite
having many problems, and whether the participant tried to stop or not.
Both substance users (81%, 184/227) and alcohol users (96%,
197/205) stated that they didn’t spend time searching for either
88
substances or alcohol. Most substance users (158%, 31/227) admitted
that they were using large amounts of drugs over a long period of time,
whereas only 31% (64/205) of the alcohol users used large amounts of
alcohol over a long period of time. The vast majority of participants in
both groups had a persistent desire to cut down on their use (79%,
180/227 of the substance users and 59%, 120/205 of the alcohol
users). However, they still continued to use despite many problems
caused by their addiction (88%, 180/227 of the substance users and
64%, 132/205 of the alcohol users), even though they had tried to stop
using (76%, 173/227 of the substance users and 66%,135/205 of the
alcohol users). (Table 4.9).
To measure the severity of dependence among participants, the answers
to the five above questions (yes = 1, no = 0) were calculated. The total
severity of dependence ranged between 0 which means no dependency
and 5 which means high severity of dependence as shown in Table 4.12
below. The majority of both groups had moderate severity of
dependence (50%, 114/227 of substance users and 61.5%, 126/205 of
alcohol users). Followed by high severity of dependence (40%, 93/227)
among substance users and low severity of dependence (26.3%,
54/205) among alcohol users. (Table 4.10).
89
Table 4- 9 Frequency Distribution of Dependency Criteria for
Substance & Alcohol Users
Substance
Do you spend time in
Yes
activities searching for
No
……..
Do you use large amount of
…. over a long period
Do you have a persistent
desire to cut down taking
….. yet have not
succeeded?
Do you continue to use …..
Yes
No
Yes
No
Yes
despite it causes you many
No
problems?
Have you tried to stop your
habits?
Yes
No
Alcohol
Male
Female
Total
Male
Female
Total
41
2
43
8
0
8
(19%)
(25%)
(19%)
(4%)
(0%)
(4%)
178
6
184
192
5
197
(81%)
(75%)
(81%)
(96%)
(100%)
(96%)
124
7
131
64
0
64
(57%)
(87.5%)
(58%)
(32%)
(0%)
(31%)
95
1
96
136
5
141
(43%)
(12.5%)
(42%)
(68%)
(100%)
(69%)
173
7
180
117
3
120
(97%)
(87.5%)
(79%)
(59%)
(60%)
(59%)
46
1
47
83
2
85
(21%)
(12.5%)
(21%)
(42%)
(40%)
(41%)
191
8
180
128
4
132
(87%)
(100%)
(88%)
(64%)
(80%)
(64%)
28
0
47
72
1
73
(13%)
(0%)
(12%)
(36%)
(20%)
(36%)
167
6
173
131
4
135
(76%)
(75%)
(76%)
(65.5%)
(80%)
(66%)
52
2
54
69
1
70
(24%)
(25%)
(24%)
(34.5%)
(20%)
(34%)
Table 4- 10 Frequency Distribution of Severity of Dependency
Severity of
Dependence
0, 1
2, 3
4, 5
Total
Substance
Alcohol
Male
Female
Total
Male
Female
Total
20
(9%)
112
(51%)
87
(40%)
0
(100%)
2
(25%)
6
(75%)
20
(9%)
114
(51%)
93
(40%)
52
(26%)
123
(61.5%)
25
(12.5%)
2
(40%)
3
(60%)
0
(0%)
54
(26.3%)
126
(61.5%)
25
(12.2%)
219
8
227
200
5
205
90
4.2.2.1.6.
CAGE Questionnaire: Alcohol.
Most of the alcohol users (64%, 131/205) felt they had to cut down their
drinking and 55% (112/205) were annoyed by people who criticized
their drinking. Feeling guilty about drinking was commonly reported
among 70% (144/205) of the alcohol users. On the other hand, only
28% (58/205) admitted that they had a drink first thing in the morning.
(Table 4.11). 29% had a CAGE score of 2 or 3. (Table 4.12).
Table 4- 11 Frequency Distribution of CAGE Criteria
Have you ever felt you should
cut down on your drinking
Have you been annoyed by
Yes
No
Yes
people who criticizing your
drinking
No
Have you ever felt guilty about
Yes
your drinking
Have you ever had a drink first
thing in the morning
No
Yes
No
91
Male
Female
Total
128
3
131
(64%)
(60%)
(64%)
72
2
74
(36%)
(40%)
(36%)
111
1
112
(55.5%)
(20%)
(55%)
89
4
93
(44.5%)
(80%)
(45%)
141
3
144
(70.5%)
(60%)
(70%)
59
2
61
(29.5%)
(40%)
(30%)
55
3
58
(27.5%)
(60%)
(28%)
145
2
147
(72.5%)
(40%)
(72%)
Table 4- 12 Frequency Distribution of CAGE Score
0
1
2
3
4
Total
4.2.2.1.7.
Male
Female
Total
15
0
15
(8%)
(0%)
(7%)
39
2
41
(20%)
(40%)
(20%)
64
2
66
(32%)
(40%)
(32%)
60
0
60
(30%)
(0%)
(29%)
22
1
23
(11%)
(20%)
(11%)
200
5
205
Withdrawal Symptoms
Withdrawal symptoms were reported by the majority of the participants
and they varied based on the addicted substance. Insomnia was the
most common withdrawal symptom reported by 93% (210/227) of the
substance users, followed by sweating with 91% (206/227), and body
weakness was the third most commonly reported symptom with 90%
(204/227). On the other hand, headache was the most common
withdrawal symptom reported by 13% (27/204) of the alcohol users,
followed by body weakness with 12% (25/205). Both tremor and
insomnia were reported by 11% of alcohol users (22/205). (Table 4.13).
The same scenario applies to the male substance users and male
alcohol users. Among the male substance users, insomnia was the most
commonly reported symptom by 92% (202/219), then sweating with
90% (198/219) and the third most common symptom was body
92
weakness with 89% (196/219). Looking at the male alcohol users, the
picture didn’t differ from the general one. Headache was reported by
13.5% (27/200) of the male alcohol users, followed by body weakness
with 12% (25/200). 11% of the males who used alcohol experienced
both tremor and insomnia (22/200). (Table 4.13).
The female users had a different withdrawal experience. All eight female
substance users suffered from tremor, nausea, sweating, insomnia and
body weakness. None of the five female alcohol users went through any
withdrawal symptoms. (Table 4.13).
Table 4- 13 Frequency Distribution of withdrawal Symptoms
Substance
Male
Headache
Female
Total
Male
Tremor
Female
Total
Male
Nausea
Female
Total
Male
Vomiting
Female
Total
Alcohol
Yes
No
Yes
No
171
(78%)
7
(87.5%)
48
(22%)
1
(12.5%)
27
(13.5%)
0
(0%)
173
(86.5%)
5
(100%)
178
(87%)
49
(22%)
27
(13%)
178
(87%)
172
(79%)
8
(100%)
47
(21%)
0
(0%)
22
(11%)
0
(0%)
178
(89%)
5
(100%)
180
(79%)
47
(21%)
22
(11%)
183
(89%)
170
(78%)
8
(100%)
49
(22%)
0
(0%)
15
(7.5%)
0
(0%)
185
(92.5%)
5
(100%)
178
(78%)
49
(22%)
15 (7%)
190
((3%)
139
(63%)
6
(75%)
80
(37%)
2
(25%)
9
(4.5%)
0
(0%)
191
(95.5%)
5
(100%)
145
(64%)
82
(36%)
9
(9%)
196
(91%)
93
Male
Sweating
Female
Total
Male
Insomnia
Female
Total
Male
Weakness
Female
Total
Male
Anxiety
Female
Total
Male
Depression
Female
Total
198
(90%)
8
(100%)
21
(10%)
0 (0%)
18
(9%)
0
(0%)
182
(91%)
5
(100%)
206
(91%)
21
(9%)
18
(9%)
187
(91%)
202
(92%)
8
(100%)
17
(8%)
0
(0%)
22
(11%)
0
(0%)
178
(89%)
5
(100%)
210
(93%)
17
(7%)
22
(11%)
183
(89%)
196
(89%)
8
(100%)
23
(11%)
0
(0%)
25
(12.5%)
0
(0%)
175
(87.5%)
5
(100%)
204
(90%)
23
(10%)
25
(12%)
180
(88%)
174
(79%)
7
(87.5%)
45
(21%)
1
(12.5%)
21
(10.5%)
0
(0%)
179
(89.5%)
5
(100%)
181
(80%)
46
(20%)
21
(10%)
184
(90%)
168
(77%)
7
(87.5%)
51
(23%)
1
(12.5%)
20
(10%)
0
(0%)
180
(90%)
5
(100%)
174
(43%)
52
(57%)
20
(8%)
185
(92%)
4.2.2.2. Treatment Experiences.
4.2.2.2.1.
Previous Treatment Experiences
Participants were asked to report any previous drug and alcohol
treatment and follow up experiences they went through prior to this
treatment encounter. Patient’s treatment experiences were assessed in
the bases if the participant went into inpatient, outpatient or if he went
through both experiences. 72% (180/250) of the participants stated
that they had received some type of treatment before. Of those who
being in a type of treatment before this treatment encounter, 22%
94
(39/180) received inpatient treatment, 24% (43/180) had been to
outpatient services and 54% (98/180) went through both inpatient and
outpatient treatment services. (Table 4.14).
Follow ups and after care programs after discharge were another aspect
of treatment experiences participants were asked about. Of the 180 who
received some sort of treatment previously, 60% (108) indicated that
they had engaged in a type of follow up programs. Follow up programs
were sorted into outpatient follow ups, the matrix program and
Emirates House (Halfway house). Most (94%) of the 108 had follow ups
in an outpatient clinic (101/108), 18% (19/108) were enrolled in the
matrix program and only 3% (3/108) were part of the Emirates House.
(Table 4.14).
The number of times a participant received a type of a treatment was
also examined. The maximum number of admissions to inpatient units
was 12 times, whereas the maximum number of outpatient admissions
and readmissions reached 30 times. However, most of the participants
(120/136) were admitted to inpatient program between 1 to 5 times and
the same applied for participants who received outpatient treatments
(89/142). (Table 4.15).
95
Table 4- 14 Frequency Distribution of Previous Treatment
Experiences and Follow ups
Yes
Have you ever received a treatment
No
before this visit
Total
Inpatient
Was it .....
Outpatient
Both
Yes
Did you have a follow up (after care
program) after your discharge
No
Yes
What sort of follow up you receives
(OPD)?
No
Yes
What sort of follow up you receives
(Matrix)?
No
Yes
What sort of follow up you receives
(Emirates House)?
No
96
Male
Female
Total
176
4
180
(73%)
(50%)
(72%)
66
4
70
(27%)
(50%)
(28%)
242
8
250
38
1
39
(22%)
(25%)
(22%)
43
0
43
(24%)
(0%)
(24%)
95
3
98
(54%)
(75%)
(54%)
105
3
108
(60%)
(75%)
(60%)
71
1
72
(40%)
(25%)
(40%)
98
3
101
(56%)
(100%)
(94%)
7
0
7
(4%)
(0%)
(6%)
19
0
19
(18%)
(0%)
(18%)
86
3
89
(82%)
(100%)
(82%)
3
0
3
(3%)
(0%)
(3%)
102
3
105
(97%)
(100%)
(97%)
Table 4- 15 Frequency Distribution of Numbers of Previous
Inpatient and Outpatient Treatment Encounter
4.2.2.2.2.
Current Treatment Experiences
No. of
Male
Female
Total
1
41
0
41
2
33
2
35
3
19
0
19
4
10
0
10
5
13
2
15
6
5
0
5
7
3
0
3
8
1
0
1
9
1
0
1
10
4
0
4
11
1
0
1
12
1
0
1
132
4
136
1
35
/1
36
2
21
0
21
3
12
0
12
4
11
0
11
5
9
0
9
How many times
6
5
0
5
outpatient?
7
9
0
9
8
5
0
5
9
7
0
7
10
6
1
7
< 10
19
1
20
139
3
142
Admission
How many times
inpatient?
Total
Total
Participants were asked to assess their current experience at the NRC
from three aspects; how responsive is the NRC to their needs, how well
is the care is coordinated in-between different services at the NRC and
finally will the participants come back to the NRC for treatment.
97
In regard to the first question, 91% (227/250) of the participants stated
that the NRC was responsive enough to their needs, while 9% (23/250)
thought that the NRC was not responsive. (Table 4.16). A similar
situation was witnessed in regard to coordination of care in-between
services. 97% (242/250) of the sample indicated that the care inbetween services were well coordinated. A small number of participants
(3%, 8/250) viewed the NRC service as unresponsive to their needs and
poorly coordinated. (Table 4.17). The majority (80%, 199/250) of the
total sample stated that they would choose the NRC again to receive
treatment, while 20% (51/250) said they wouldn’t. (Table 4.18).
Table 4- 16 Frequency Distribution of Participants' Views on how
NRC Respond to their Needs
Very responsive
How responsive is
NRC service to your
Responsive
OK
needs
Unresponsive
Very Unresponsive
Total
98
Male
Female
Total
39
2
41
(16%)
(25%)
(16%)
116
4
120
(48%)
(50%)
(48%)
65
1
66
(27%)
(12.5%)
(26%)
16
1
17
(7%)
(12.5%)
(7%)
6
0
6
(2%)
(0%)
(2%)
242
8
250
Table 4- 17 Frequency Distribution of Participants' Views on the
Coordination in-between Different NRC Services
Very well
How well is your care
Well
being coordinated inbetween different
services
Ok
Poorly
Very poorly
Total
Male
Female
Total
44
3
47
(18%)
(37.5%)
(19%)
126
4
130
(52%)
(50%)
(52%)
65
0
65
(27%)
(0%)
(26%)
5
1
6
(3%)
(12.5%)
(2%)
2
0
2
(1%)
(0%)
(1%)
242
8
250
Table 4- 18 Frequency Distribution of Participants' Respond to
coming back to NRC
Will you come back again to
this center
Yes
No
Total
4.2.2.2.3.
Male
Female
Total
192
7
199
(79%)
(87.5%)
(80%)
50
1
51
(21%)
(12.5%)
(20%)
242
8
250
Patient Satisfaction with NRC Nursing
Services
Patient satisfaction with the nursing staff was assessed in the
questionnaire. A total of four questions were asked, three of which
focused on nursing tasks and the fourth asked about patient
satisfaction about nursing care during the admission or OPD visit. 87%
(217/250) of the total sample were able to identify the nursing staff,
66% (165/250) mentioned that they had received counselling therapy
99
from the nursing staff and the nurses where available whenever they
were needed as stated by 92% (229/250) of the participants. Only 5%
(12/250) were unsatisfied by the care received from the nursing staff.
(Table 4.19).
Table 4- 19 Frequency Distribution of Participants' Satisfaction
with NRC Nursing Services
Yes
Were you able to identify nursing
staff?
No
Yes
Did you receive any counselling from
the nursing?
No
Yes
Were the nurses available when you
needed them?
No
Strongly satisfied
How satisfied are you with the care
you received from the nursing staff?
Satisfied
Not satisfied
Male
Female
Total
210
7
217
(87%)
(87.5%)
(87%)
32
1
33
(13%)
(12.5%)
(13%)
158
7
165
(65%)
(87.5%)
(66%)
84
1
85
(35%)
(12.5%)
(34%)
221
8
229
(91%)
(100%)
(92%)
21
0
21
(9%)
(0%)
(8%)
85
6
91
(35%)
(75%)
(36%)
145
2
147
(60%)
(25%)
(59%)
12
0
12
(5%)
(0%)
(5%)
4.2.2.3. Family History
Table 4.22 represents the family history of psychiatric, addiction,
suicide and the current health status of each family member as
reported by the participants. A small number of participants stated
having a family history of psychiatric problems. The same applies to
100
family history of addiction and suicide. When asked about the current
health status of their family members, 53% (133/250) mentioned that
their mothers are ill and 54% (136/250) described their fathers as ill.
In regard to the rest of the family members (sisters, brother, spouses
and children), the majority were healthy as stated by the most of the
participants. (Table 4.20).
Table 4- 20 Frequency Distribution of Family History of
psychiatric problem, addiction problem, suicide problem and the
current health status
Yes
Psychiatric
problem
No
Yes
Addiction problem
No
Yes
Suicide problem
No
Current health
status
Healthy
Ill
Mother
Father
Brother
Sister
Spouse
Children
(n=250)
(n=250)
(n=250)
(n=250)
(n=97)
(n=90)
7
19 (8%)
5
1
1
(1%)
(1%)
11
(4%)
(3%)
(2%)
239
243
231
245
96
(96%)
(97%)
(92%)
(98%)
(99%)
11 (4%)
68 (27%)
250
239
182
248
97
(100%)
(96%)
(83%)
(99%)
(100%)
0
(0%)
3
(1%)
0
(0%)
3
(1%)
2
(1%)
0
(0%)
89 (99%)
0
0
(0%)
(0%)
90 (100%)
0
0
(0%)
(0%)
247
250
247
250
97
(99%)
(100%)
(99%)
(100%)
(100%)
117
114
209
214
86
83
(47%)
(46%)
(84%)
(86%)
(89%)
(92%)
133
136
7
(54%)
36 (14%)
11
(53%)
41 (16%)
(11%)
(8%)
90 (100%)
4.2.2.4. Factors associated with relapse
Of the 250 participants, 72% (180/250) have been in one or more
treatment experiences prior to this interview which means they have
been through relapse. 98% (176) of the 180 were males and 2% (4) were
101
females. Craving was reported as the highest factor associated with
relapse by 91% (163/180) of the participants. Peer pressure ranked
second among all factors by 89% (161/180) of the participants. 86%
(154/180) mentioned unemployment as a reason for relapse. The same
scenario found among the male sample (craving 90%-159, peer
pressure 89%-157 and unemployment 86%-152). On the other hand,
all the four females identified family problems as one of the most
contributing factors to relapse after craving and peer pressure. (Table
4.21).
Table 4- 21 Frequency Distribution of Participants' View of
Factors associated with relapse
Factors
Yes
Craving
No
Yes
Peer pressure
No
Yes
Poor attitude
No
Family
problems
Yes
No
Male
Female
Total
(n=176)
(n=4)
(n=180)
159
4
163
(90%)
(100%)
(91%)
17
0
17
(10%)
(0%)
(9%)
157
4
161
(89%)
(100%)
(89%)
19
0
19
(11%)
(0%)
(11%)
94
2
96
(53%)
(50%)
(53%)
82
2
84
(47%)
(50%)
(47%)
145
4
149
(82%)
(100%)
(83%)
31
0
31
(18%)
(0%)
(17%)
102
Yes
Roll modelling
No
Yes
Unemployment
No
Yes
Place
No
Yes
Time
No
107
2
109
(61%)
(50%)
(61%)
69
2
71
(39%)
(50%)
(39%)
152
2
154
(86%)
(50%)
(86%)
24
2
26
(14%)
(50%)
(14%)
118
3
121
(67%)
(75%)
(67%)
58
1
59
(33%)
(25%)
(33%)
111
3
114
(63%)
(75%)
(63%)
65
1
66
(37%)
(25%)
(37%)
4.2.3. Part 3: Social
4.2.3.1. Employment:
The sample was divided into 4 categories in regard to employment:
employed, not employed, never employed and others. From the total,
there were 32% (80/250) of the participants employed (33%-79 males
and 12.5%-one female). Half (49.6% - 124/250) of the total were not
employed at the time of the interview. 12.8% (32/124) of those were
never employed (11%-27 males and 62.5%-5 females), while 19%
(46/250) were under “others” and were all males. Those 46 were further
divided into students, retired and having their own private business.
69.6% (32/46) were students, 23.9% (11/46) were self-employed or
having a private business and 6.5% (3/46) retired. (Table 4.22).
103
Table 4- 22 Frequency Distribution of Participants' Employment
Status
Employed
Not Employed
Employment
Never Employed
status
Private
Others
Male
Female
Total
79
1
80
(33%)
(12.5%)
(32%)
90
2
92
(37%)
(25%)
(36.8%)
27
5
32
(11%)
(62.5%)
(12.8%)
11
0
11
(23.9%)
(0%)
(23.9%)
3
0
3
(6.5%)
(0%)
(6.5%)
32
0
32
(69.6%)
(0%)
(69.6%)
242
8
250
Retired
Student
Total
The 80 (32%) participants who were employed, were asked to describe
the type of employment they do. 11% (9/80) of them described their
daily work as manual and 38% (30/80) said they were having a
professional job, while 51% (40/80) males and one female were doing
administrative jobs. (Table 4.23).
Table 4- 23 Frequency Distribution of Participants' Employment
Type
Manual
Employment
type
Professional
Administrative
Total
104
Male
Female
Total
9
0
9
(11%)
(0%)
(11%)
30
0
30
(38%)
(0%)
(38%)
40
1
41
(51%)
(100%)
(51%)
79
1
80
73% (138/190) of the total who were employed at any point in their life
reported that they lost their job because of their addiction.
73%
(137/138) of them were males and 33% (1/3) were females. The same
percent of participants (73%, 139/190) stated that their job was
affected by their addiction. Only 4% (7/139) out of them described this
affect as positive while it was negative affect for the others 69%
(132/139) and 3 females). 41% (77/190) lost a chance of promotion
because of their dependence. (Table 4.24).
Table 4- 24 Frequency Distribution of perceived effect of
addiction on employment as reported by participants
Did you lose your job in any of
the above because of
dependence
Yes
Total
(n=187)
(n=3)
(n=190)
137
(73%)
1 (33%)
138
(73%)
50 (27%)
2 (67%)
52 (27%)
No
51 (27%)
0 (0%)
51 (27%)
7 (4%)
0 (0%)
7 (4%)
Yes,
drugs/drinking alcohol, has
positive
your job ever been affected
Yes,
negative
Yes
promotion because of
dependence
Female
No
Since start taking
Did you lose a chance of
Male
129
(69%)
76 (41%)
111
No
(59%)
3 (100%)
1 (33%)
2 (67%)
132
(69%)
77
(41%)
113
(59%)
4.2.3.2. Accommodations
More than 87% (218/250) of the total sample reported that they owned
their own house and 12% (31/250) were living in rented houses. Only
one male participant was homeless. The same picture applied to both
105
gender. 88% (213/242) of the male sample and 62.5% (5/8) of the
females owned the accommodation they are living in. Living in a rented
house was reported by 11.6% (28/242) of the male sample and 37.5%
(3/8) of the females. (Table 4.25).
The majority of the participants were living with their parents (74% 184/250) and their siblings (68% - 169/250). Half (126/250) of the
participants have domestic help living in their homes. The same
situation was found in the male and female sample. Only 18% (45/250)
of the participants lived with others who used drugs or alcohol. When
asked about the importance of maintaining one’s own accommodation,
the majority of the participants viewed it as an important item (94% 234/250). (Table 4.25).
91% (41/45) of the participants who lived with others who used drugs
or alcohol were males and 9% (4/45) were females. The majority lived
with an addict brother (76% - 34/45) and 11% (5/45) of the participants
lived with an addict father. The male sample illustrated the same
results; 76% (31/41) lived with an addicted brother and 12% (5/45)
lived with an addicted father. With the female sample, there was a slight
difference. 75% (3/4) lived with an addicted brother and 25% (1/4) of
lived with an addicted uncle. (Table 4.26).
106
Table 4- 25 Frequency Distribution of perceived effect of
addiction on employment as reported by participants
Accommodation
type
Male
Female
Owned
213 (88%)
5 (62.5%)
Rented
28 (11.6%)
3 (37.5%)
31 (12.4%)
Homeless
1 (0.4%)
0 (0%)
1 (0.4%)
Spouse
79 (33%)
1 (13%)
80 (32%)
Parents
178 (74%)
6 (75%)
184 (74%)
68 (28%)
1 (13%)
69 (28%)
Friends
5 (2%)
0 (0%)
5 (2%)
Alone
11 (2%)
1 (13%)
12 (5%)
Step Parents
12 (5%)
1 (13%)
13 (5%)
163 (67%)
6 (75%)
169 (68%)
22 (9%)
2 (25%)
24 (10%)
122 (50%)
4 (50%)
126 (50%)
Others
53 (22%)
3 (38%)
56 (22%)
Yes
41 (17%)
4 (50%)
45 (18%)
No
201 (83%)
4 (50%)
205 (82%)
Important issues
227 (94%)
7 (87.5%)
234 (94%)
15 (6%)
1 (12.5%)
16 (6%)
Dependent
Children
Who lives with you?
Siblings
Half Siblings
Domestic Help
Does any who is
Total
218
(87.2%)
living with you use
drugs or alcohol?
How do you feel
about maintaining
your
accommodation?
Not important
107
Table 4- 26 Frequency Distribution of the Substance Users living
with the participants as reported by participants
Brother
Does any who is living
with you use drugs or
alcohol? Mention?
Male
Female
Total
(n=41)
(n=4)
(n=45)
3 (75%)
34 (76%)
31
76%)
Father
5 (12%)
0 (0%)
5 (11%)
Friends
4 (10%)
0 (0%)
4 (9%)
Son
1 (2%)
0 (0%)
1 (2%)
Uncle
0 (0%)
1 (25%)
1 (2%)
4.2.3.3. Education
The table below illustrates the perceived effect of drug and alcohol
abuse on the participants’ education status. 43% (108/250) completed
their studies either before their addiction (12% - 31/250) or despite
their addiction (31% - 77/250). More than 56% (142/250) did not
complete their studies of whom 68% (97/142) didn’t complete their
studies because of their addiction, while 32% (45/142) did not complete
their studies because of reasons other than addictions. (Table 4.27).
The total sample, the male sample presented with the same figures.
44% of the participants completed their studies either before their
addiction (13% - 31/242) or despite their addiction (31% - 76/242), and
56% (135/242) did not complete their studies. Two-third (91/135)
didn’t complete their studies because of their addiction, while 33%
(44/135) did not complete their studies because of reasons other than
addiction. None of the female participants completed their studies
before their addiction and only one completed her studies despite her
addiction. 87.5% (7/8) did not complete their studies. 86% (6/7) didn’t
108
complete their studies because of their addiction, and only one did not
complete her studies because of reasons other than her addiction.
(Table 4.27).
Table 4- 27 Frequency Distribution of the Participants’
Education Status
I finished my studies ........
my addiction
Male
Female
Total
Before
31 (13%)
0 (0%)
31 (12%)
Despite
76 (31%)
1 (12.5%)
77 (31%)
135 (56%)
7 (87.5%)
142 (57%)
Not Applicable
I did not complete my studies
Yes
91 (67%)
6 (86%)
97 (68%)
because of my addiction
No
44 (33%)
1 (14%)
45 (32%)
4.2.3.4. Marital Status
42% (106/250) of participants had been married at least once. 23%
(57/250) had married once, 13% (33/250) had married twice, 5%
(13/250) had married three times and only 1% (3/250) had married
four times. 58% of the total (144/250) were never married. The same
percentages were seen in the male sample. Among the females, 38%
(3/8) were married once and 13% (1/8) was married three times. 58%
(140/242) of the males and 50% (4/8) of the females were never
married. (Table 4.28).
One-quarter (26/106) had ended their marriage due to their addiction.
The same percentage was in both male (25/102) and female (1/4)
participants. Around one-third (34/106) of the married participants
were involved in relationships outside their marriage. 78% (83/106) had
dependent children and 82% (68/83) of them were involved in caring
109
for their children; 13% (11/83) of those who had children, used drugs
or drink alcohol in front of their children. (Table 4.28).
Table 4- 28 Frequency Distribution of the Participants’ Marital
Status
Male
Female
Total
One
54 (22%)
3 (38%)
57 (23%)
Two
33 (14%)
0 (0%)
33 (13%)
Three
12 (5%)
1 (13%)
13 (5%)
Four
3 (1%)
0 (0%)
3 (1%)
Not married
140 (58%)
4 (50%)
144 (58%)
Did any of the previous marriages
Yes
25 (25%)
1 (25%)
26 (25%)
ended because of addiction?
No
77 (75%)
3 (75%)
80 (75%)
Do you have another partner
Yes
33 (32%)
1 (25%)
34 (32%)
No
69 (68%)
3 (75%)
72 (68%)
No
20 (20%)
3 (75%)
23 (22%)
Yes (1)
12 (12%)
0 (0%)
12 (11%)
(2-5) children
51 (50%)
1 (25%)
52 (49%)
>5
19 (19%)
0 (0%)
19 (18%)
Are you involved in caring for
Yes
67 (82%)
1 (100%)
68 (82%)
your children?
No
15 (18%)
0 (0%)
15 (18%)
Do you use drugs or drink alcohol
Yes
10 (12%)
1 (100%)
11 (13%)
in front of your children?
No
72 (88%)
0 (0%)
72 (87%)
How many times did you get
married?
other than your wife, such as a
girlfriend?
Do you have dependent children?
4.2.3.5.
Financial Status
The table below shows the source of income for the 250 participants.
Other sources of income represented the highest source on income with
56.4% (141/250), followed by employer (32.4%, 81/250) and the least
was social support (11.2%, 28/250). The other sources of income as
mentioned by the participants were family (80% - 113/141), private
business (11% - 16/141) and financial support given by the NRC (7% 110
10/141). Two participants didn’t have any source of income. (Table
4.29).
Two-thirds (159/250) of the participants reported a change in their
income after their initial usage of drugs/alcohol. The majority of the
participants (48% - 121/250) preferred to spend their money on their
children and family even if it was only 1000 Dirham (US $ 273), while
31% (78/250) of the total would chose to spend it on drug and alcohol.
Food (12% - 29/250) and accommodation (9% - 22/250) were
mentioned by a small number of the participants as a choice to spend
money on. (Table 4.30).
Table 4- 29 Frequency Distribution of the Participants’ Source of
Income
What is your
Male
Female
Total
Employer
80 (33%)
1 (13%)
81 (32%)
Social support
28 (12%)
0 (0%)
28 (11%)
16 (12%)
0 (0%)
16 (11%)
107 (80%)
6 (86%)
113 (80%)
No income
2 (1%)
0 (0%)
2 (1%)
NRC
9 (7%)
1 (14%)
10 (7%)
Business
source of
income?
Others
Family
111
Table 4- 30 Frequency Distribution of the Participants’ Financial
Status
Did your income change
after your initial usage of
drugs/alcohol?
If you have only Dhs
1000 how would you
spend it?
Male
Female
Yes
152 (63%)
7 (88%)
No
90 (37%)
1 (13%)
91 (36%)
Food
29 (12%)
0 (0%)
29 (12%)
74 (31%)
4 (50%)
78 (31%)
20 (8%)
2 (25%)
22 (9%)
119 (49%)
2 (25%)
Fun
4 (9%)
0 (0%)
4 (9%)
Self
41 (91%)
0 (0%)
41 (91%)
Drug and
alcohol
Accommodation
Children &
Family
If there is anything else
Total
159
(64%)
121
(48%)
you would rather spend
Dhs 1000 on (apart from
drugs or alcohol), what is
it?
4.3. SECTION TWO: Hypothesis # 1: The
characteristics of the clinical population of substance
abusers receiving treatment in the NRC will be similar
as the clinical population of substance abusers studied
in Al Ghafri - 2014.
As Al Ghafri’s study has only male participants, therefore, the female
participants in the current sample will be excluded from the
comparison. Also, as the raw data for Al Ghafri’s sample was not
available. It was not possible to carry out any comparative analysis from
means and standard deviation with the available statistical programs.
112
An alternative chi-square online calculator was used (iCalcu.com,
2018).
4.3.1. Patient Background:
In Al Ghafri’s study the 250 participants were all male (100%) and the
youngest age was 18. The mean (SD) age of the participants was 32.28
(8.18) years. 68% of the total were under the age of 36 years (170/250)
and only four were over the age of 50 years. Out of the 250 participants,
Jordanians accounted for 94.4% (236/250) and the remaining 5.6%
(14/250) were of other nationalities. A total of 98% (245/250) of the
participants were Muslim and 2% (5/250) were Christian. 48.8%
(122/250) were married at the time of the study and 38.4% (96/250)
had never been married. A total of 12.8% (32/250) were separated,
widowed, or divorced. In regard to education level, 52% (130/250) were
above preparatory education and only one was illiterate. 80% (200/250)
were employed, of whom 60.1% (121/200) were manual laborers, 26.0%
(52/200) worked
as administrators,
and 13.5% (27/200)
had
professional job. When it comes to referral sources, 66.8% (167/250)
were referred by their families, and 30.8% (77/250) were self-referred.
Only one subject had been referred by the police.
In the current study, there were 96.8% (242/250) male participants.
The youngest age was 16 years. The mean (SD) age was 28.52 (8.87)
years, with the majority of the participants being under the age of 31
years (71% -173/242). Only seven were over the age of 50 years. All the
participants were UAE nationals and were all Muslim. 59.5% (144/242)
113
were single, 33.1% (80/242) were married, 7.0% (17/242) were divorce,
0.4% (1/242) were separated and none was widower. The majority of
the sample completed secondary education (52.5% - 127/242) followed
by preparatory level (22.3% - 54/250), university level (15.7% - 38/242)
and last was primary level (8.3% - 20/242). Only 1.2% (3/242) didn’t
know how to read or write. 48.3% (117/242) of the participants were
unemployed and 32.6% (79/242) were employed. Out of the 79
employed, 51% (40/79) were doing an administrative job, 38% (30/79)
had a professional job and 11% (9/97) had a manual job. Looking at
source of referral, self-referred was the most common with 51.6%
(129/242), followed by the justice system with 36.4%(91/242), and 12%
(30/242) were referred by their families. (Table 4.31).
Table 4- 31 Frequency Distribution of the Comparison of Patient
Demographic between Al Ghafri’s study and the current study.
Al Ghafri’s Study
Current Study
Sample
250
242
Unit
n (%)
n (%)
Males
250
242
Mean (SD)
32.3 (8.1)
28.52 (8.87)
17-20 years
8 (3.2)
37 (15.3)
21-25 years
50 (20)
85 (35.1)
26-30 years
64 (25.6)
51 (21.1)
31-35 years
48 (19.2)
17 (7.0)
36-40 years
36 (14.4)
22 (9.1)
41-45 years
26 10.4)
16 (6.6)
46-50 years
14 (5.6)
7 (2.9)
Gender
Age
114
4 (1.6)
7 (2.9)
236 (94.4)
242 (100)
14 (5.6)
0 (0)
Muslim
245 (98)
242 (100)
Others
5 (2)
0 (0)
Single
96 (38.4)
144 (59.5)
Married
122 (48.8)
80 (33.1)
Divorced
29 (11.6)
17 (7.0)
Widower
2 (0.8)
0 (0)
Separated
1 (0.4)
1 (0.4)
≤51 years
Nationality
National (Jordanian UAE)
Others
Religion
Marital Status
Educational Background
Illiterate
Primary
Preparatory
Secondary
University and above
1
38
81
96
34
(0.4)
(15.2)
(32.4)
(38.4)
(13.6)
3 (1.2)
20 (8.3)
54 (22.3)
127 (52.5)
38 (15.7)
Employment
Not Employed
50 (20)
152 (63)
Employed
200 (80)
90 (37)
167 (66.8)
77 (30.8)
3 (1.2)
1 (0.4)
2 (0.8)
29 (12)
124 (51)
0 (0)
89 (37)
0 (0)
Source of referral
Family
Self
Hospital/Clinic
Police/Justice
Others
System
Using chi-square test in the comparison between the two clinical
populations characteristics, it was found that there is a statistically
significant association between the two populations in material status,
educational background and employment as their p<0.05. with age and
source of referral there was not enough evidence to conclude that the
variables are associated. (Table 4.32).
115
Table 4- 32 Chi-square test between the two clinical populations
characteristics
Marital
Educational
Status
Background
52.81
23.34
16.39
93.12
55.60
7
24
4
1
4
4.04E-09
0.00011
0.0025
0
2.40E-11
Age
Chi-square
DF
P-value
Employment
Source of
referral
4.3.2. Psychiatric & Medical Data:
In Al Ghafri’s study, anxiety was the most common psychiatric
symptom that was reported by 43.6% of the participants (109/250),
followed by depression as reported by 27.2% (68/250). Only 5.2%
(13/250) reported having schizophrenic symptoms. Regarding medical
history, gastritis was the most commonly reported illness by 17.6%
(44/250) of the total sample. 5% of the participants stated being
diagnosed with a type of hepatitis. Hepatitis C was more prevalent (2.4%
- 6/250) than the other hepatitis types. Hypertension was the third
most commonly reported medical illness as it was mentioned by 3.6%
(9/250) of the sample. 0.8% (2/250) of the total reported having
diabetes. Only one participant revealed having HIV. (Table 4.33).
In the current study, mood disorders were the most commonly reported
by 52.1% (126/242). Depression was mentioned by 43.8% of the sample
(106/242), and 42.1% (102/242) stated that they had anxiety
symptoms. Schizophrenia was not reported by anyone. When assessing
the medical history of the participants, hypertension (12.0% -29/242)
and gastritis (11.6% -28/242) were reported by most of the sample.
116
Only 10% (25/250) stated having one type of hepatitis. Mostly hepatitis
C was the most common type of hepatitis among the total sample with
7.9% (19/242). Diabetes was reported by 5% (12/242) of the sample
and none reported having AIDS. (Table 4.33).
Table 4- 33 Frequency Distribution of the Comparison of
Psychiatric & Medical Data between Al Ghafri’s study and the
current study.
Depression
Psychiatric
History
Schizophrenia
Anxiety disorders
Mood disorders
Hepatitis
Medical
History
Al Ghafri’s Study
Current Study
250 (100%)
242 (100%)
Yes (%)
No (%)
Yes (%)
No (%)
68 (27.2)
182 (72.8)
106 (43.8)
136 (56.2)
13 (5.2)
237 (94.8)
0
242 (100)
109 (43.6)
141 (56.4)
102 (42.1)
140 (57.9)
0 (0)
0 (0)
126 (52.1)
116 (47.9)
Hep (A)
2 (0.8)
Hep (B)
4 (1.6)
Hep (C)
6 (2.4)
5 (2.1)
238 (95.2)
1 (0.4)
217 (89.7)
19 (7.9)
AIDS
1 (0.4)
249 (99.6)
0 (0)
242 (100)
Hypertension
9 (3.6)
241 (96.4)
29 (12)
213 (88)
Diabetes
2 (0.8)
248 (99.2)
12 (5)
230 (95)
Gastritis
44 (17.6)
206 (82.4)
28 (11.6)
214 (88.4)
4.3.3. Substance Abuse and Smoking History:
4.3.3.1. Substance of Use
Looking at the sample distribution based on substance of abuse, the
majority of Al Ghafri’s study (41.2% - 103/250) used alcohol only, while
18.8% (47/250) used drugs only. A small number of the total (3.6% 9/250) were alcohol and drugs abusers. (Table 4.34).
117
In the current study, 73% (177/242) of the sample were alcohol and
drugs users, 17% (42/242) used drugs only, and 10% (23/242) used
alcohol only. (Table 4.34).
Table 4- 34 Comparison of Substance of Use between Al Ghafri’s
study and the current study
Alcohol only
Drugs only
Alcohol + Drugs
Al Ghafri’s Study
Current Study
103 (41.2)
23 (10)
47 (18.8)
42 (17)
9 (3.6)
177 (73)
4.3.3.2. Smoking History
Table 4.33 shows the current smoking status and the smoking history,
98% (245/250) of Al Ghafri’s sample were currently smoking, of whom
89.7% (220/245) stated that they started smoking prior to their
addiction. (Table 4.35).
In the current study, 98.8% (239/242) of the total reported that they
were currently smoking, of whom 90.4% (216/242) started smoking
before their addiction. (Table 4.35).
Table 4- 35 Comparison of current smoking status and smoking
history between Al Ghafri’s study and the current study
Dr. Al Ghafri’s
Study
Do you smoke?
Was it ...... your
addiction
Current Study
Yes (%)
No (%)
Yes (%)
No (%)
245 (98)
5 (2)
239 (98.8)
3 (1.2)
Before
After
Before
After
220 (89.7)
25 (4.0)
216 (90.4)
23 (9.6)
118
4.3.3.3. Age of First Use:
The age of first use varied in Al Ghafri’s study according to the
substance used. The youngest age of first use reported was among the
hallucinogenic drugs users and it was 11 years,while the oldest age of
first use was 17 for both heroin users and cocaine users. (Table 4.36).
In the current study, the youngest age of first use of most of substance
was 11 years and oldest age of first use was 14 for both heroin and
other narcotics. (Table 4.36).
Table 4- 36 Comparison of substance by age of 1st use between
Hallu
Inhalants
Khat
Amphet
17
15
15
16
11
13
0
0
11
14
14
13
11
11
12
11
12
12
11
Sedative
13
Other
17
Narcotics
12
Other
Cannabis
Study
Benz
Current
Cocaine
Study
Heroin
Al Ghafri’s
Alcohol
Substances
Al Ghafri’s study and the current study
4.3.3.4. Current Use
In Al Ghafri’s study, there were 147 participants who used drugs only.
68.7% (101/147) of this group were moderate or heavy users. Only 6
(4.1%) were abstinent in the last 1-2 months prior to their admission.
The same results were found among alcohol users group as 76.2%
(103/135) of the participants were moderate or heavy users and 5.9%
(8/135) were abstinent in the last 1-2 months prior to their admission.
(Table 4.37).
119
In the current study, 219 participants used drugs only. 49.2%
(119/219) of whom stated they were abstinent in the last 1-2 months
prior to their admission, while 31.8% (77/219) of the participants were
moderate or heavy users. For alcohol, the majority (76.6% - 157/205)
of the participants reported being abstinent during the past 1-2
months. (Table 4.37).
Table 4- 37 Comparison of current use of substance and alcohol
between Al Ghafri’s study and the current study.
Current Use
Substance
Alcohol
(Past 1-2
months)
Al Ghafri’s Study
Current Study
Abstinent
6 (4.1)
119
(49.2)
Light
39
(26.5)
23 (9.5)
Moderate
46 (31.3)
25 (10.3)
Heavy
55
(37.4)
52
(21.5)
Abstinent
8 (5.9)
152 (76)
Light
23
(17.0)
19 (10)
Moderate
29 (21.4)
13 (7)
Heavy
74
(54.8)
16 (8)
The above section presented the comparison between two clinical
populations; one from Jordan (Al Ghafri, 2014) and one from the UAE.
The assumption was that the characteristics of the two clinical
populations are similar due to the assumed cultural and religious
similarities. The descriptive analysis of both clinical populations’ profile
revealed the presence of some similarities and differences. (Chapter 5).
4.4. SECTION THREE: Hypothesis #2: Severity of
Dependence Associations
The second hypothesis is testing the association between severity of
dependence and substance use initiation age, length of dependence,
120
presence of a family history of addiction and level of education as
follows:
Severity of dependence will be associated with:
a. Early initiation of substance use,
b. Longer length of dependence,
c. Presence of a family history of addiction, and
d. Lower level of education.
Logistic regression analysis was carried out to test the association
between the severity of dependence (dichotomous) and the above
mentioned variables. (n=250). In both unadjusted and adjusted logistic
regression, there were no significant associations found between
severity of dependence and the variables studied as all p-values are
larger than the critical p<0.05.
Table 4- 38 Unadjusted and adjusted Regression analysis of
Severity of Dependence
Characteristics
measured
Initial age (young
age)
Education (below
Secondary)
Family history
(present)
Length of use
(<5years)
Unadjusted
95.0% CI
Odds ratio
(Lower, Upper)
pvalue
Adjusted
95.0% CI
Odds ratio (Lower,
Upper)
pvalue
0.86 (0.42, 1.76)
0.68
0.90 (0.44, 1.85)
0.77
1.14 (0.58, 2.24)
0.71
1.2 (0.6, 2.4)
0.61
1.31 (0.63, 2.69)
0.47
1.30 (0.63, 2.70)
0.48
1.29 (0.61, 2.77)
0.51
1.30 (0.60, 2.83)
0.51
121
4.5. SECTION THREE: Hypothesis #3: Social Drift
Associations
The third hypothesis tested the association between social drift and age
of first initiation, length of dependence, and presence of a family history
of addiction as follows:
Social drift will be associated with the following:
a. Early initiation of substance use,
b. Longer length of dependence, and
c. Presence of a family history of addiction.
Logistic regression analysis was carried out test the association
between social drift (dichotomous) and the above mentioned variables
(n=250). In both unadjusted and adjusted logistic regression, there were
no significant associations found between social drift and the variables
studied as all p-values are larger than the critical p<0.05.
Table 4- 39 Unadjusted and adjusted Regression analysis of
Social Drift
Characteristics
measured
Unadjusted
95.0% CI
Odds ratio (Lower,
Upper)
pvalue
Adjusted
95.0% CI
Odds ratio
(Lower, Upper)
pvalue
Initial age
(young age)
1.35 (0.75, 2.43)
0.33
1.45 (0.80, 2.66)
0.22
Family history
(present)
1.62 (0.92, 2.86)
0.10
1.60 (0.90, 2.85)
0.11
Length of use
(<5years)
1.83 (0.99, 3.39)
0.60
1.84 (0.98, 3.43)
0.57
122
4.6. SECTION FOUR: Hypothesis #4: Increased nursing
interactions will be associated with higher level of
patient satisfaction with the nursing services
The association between the nursing interactions and patient
satisfaction was examined using linear regression analysis. Highly
significant association was found between patient satisfaction and the
combined variable of nursing interaction. The table below shows that
beta value of 0.82 indicates that a change of one standard deviation in
the nursing interaction results in a 0.82 standard deviations increase
in the patient satisfaction.
Table 4- 40 Unstandardized and Standardized Coefficients
analysis of Patient Satisfaction
Model
Unstandardized
Standardized
Coefficients
Coefficients
B
1 (Constant)
Nursing
Interaction
Std.
Error
-0.019
0.042
0.36
0.016
95.0% Confidence
t
Sig.
Beta
0.82
Interval for B
Lower
Upper
Bound
Bound
-0.46
0.65
-0.10
0.06
22.21
.000
0.33
0.39
4.7. Conclusion
The main objective of the study was to build up a profile of substance
users who are attending NRC for treatment, which can be used to shape
treatment and prevention and policies and practices. The study findings
showed that the substance user is single, educated, smoker and
123
unemployed who requested the treatment by himself or herself. The
youngest age of first use of most of substance was 11 years. The
majority of the participants were polysubstance users who are having
moderate severity of dependence. Family history of substance use
disorders was present with 27% of participants reported having an
addicted brother living with them.
The study also, looked at the characteristics of two clinical populations,
one from Jordan and the other one was the substance users who are
receiving treatment at the NRC. The assumption was that they are
similar as they share the same racial origins, the same language, the
same religion and, to some extent, the same cultural background. The
results of the study confirmed the proposed hypothesis and the
characteristics of the two populations were found to be generally
similar.
The second hypothesis examined the association between severity of
dependence and substance use initiation age, length of dependence,
presence of a family history of addiction and level of educational
attainment. No significant associations were found between severity of
dependence and the variables studied. The same was found with the
third hypothesis which tested the association between social drift and
age of first initiation, length of dependence, and presence of a family
history of addiction. The association between the nursing interactions
and patient satisfaction was highly significant.
124
5. CHAPTER FIVE: DISCUSSION
This chapter consists of three main sections. Section one summarizes
the key findings and presents these findings considering the existing
literature. The second section provides a description of the study’s
strengths and
limitations and the
third section explores
the
implications of the study findings on health policy in the UAE and
future research.
5.1. Main Findings
The study aims to identify and examine the characteristics of the
clinical population of substance users in the UAE and explores the
concept of social drift with respect to substance use disorder. The main
findings were drawn from a questionnaire and summarized under the
original objectives.
5.1.1. The characteristics of the clinical population of
substance abusers receiving treatment in the NRC
(UAE):
The mean age of the participants in the current study was 28.5 years
which is similar to the mean age in Amir’s study (2001) which was 27.6
years despite the 14 years difference between the two studies. The
majority of the current study participants were under the age of 30
years and only seven were over the age of 50 years. This is an indicator
of the presence of a younger generation of substance abusers in the
community who require more attention. Seeking treatment at a younger
125
age could be an indication of a better accessibility to treatment or it
could reflect the increase in the community awareness of substance
abuse problems. The same was reported in Abu Madini study (2008)
and Amir’s study (2001). This was supported by the low age of first
initiation of use among the same sample, which was 11 years for most
substances. This was lower than Amir study (Amir, 2001) which was
18.7 years, perhaps indicative of the growth of the substance use
problem in the region.
The majority of the current sample were single, which is consistent with
Elkashef study (2013). This could be explained by having the majority
of study sample younger than 30 years. 98.8% of the current sample
were educated, with the majority being at the secondary level. This
finding is different from Elkashef study (2013) as the majority in that
sample did not have a secondary education. This also is consistent with
the age distribution among the UAE population as more than 80% of
UAE population is aged between 15 and 64 years. (Statista, 2018).
Half (49.6%) of the current sample were unemployed compared to 36%
who were employed. This is another different finding from Elkashef
study (2013) which had 60% of its sample being unemployed and 33%
were either employed or were students. This decrease in the
unemployment rate between the two studies is consistent with the
change in the level of education from the majority being below
secondary level in Elkashef study to the majority having a secondary
level of education in the current study. Also, the current finding can be
126
explained by the decrease in the unemployment rate in the UAE to 3.7%
in 2016 from 4.2% in 2009. This was a result of many government
initiatives that targeted unemployment status in the country (Trading
Economics, 2018).
The most common source of referral was self-referred (51.6%), and
referrals from the justice system came next (36.4%). The same finding
was highlighted by Elkashef et al. (2013). This can be seen as a result
of the NRC’s interventions in awareness raising and prevention. The
National Rehabilitation Centre has a comprehensive prevention
strategy that includes structured and systematized evidence-based
curricula and targeted awareness activities. The strategy is aimed to
reaching sustainable outcomes to reduce social stigma and support
recovery. (The National Rehabilitation Center, 2018).
In relation to co-morbidity illnesses in the population treated at the
NRC, the results showed that the majority of the sample reported
having a psychiatric condition or symptoms. 52.1% reported having
mood disorders, 43.8% reported having depression and 42.1% had
anxiety symptoms. The same was reported by Elkashef et al., (2013)
with minor differences in the illness’ distribution. This finding is
consistent with other studies from the region; e.g., Karam (2002) found
that 64% of those with substance abuse problems had a co-morbid
condition. It must be noted that these are self-reported findings and not
formal diagnoses or case note records.
127
Virtually all (98.8%) of the sample reported that they were currently
smokers, with 90.3% reported starting smoking before their drug
addiction. The same was reported in the Alblooshi study (2016) in the
UAE and by the Iqbal study (2000) in Saudi Arabia. According to the
WHO report on the global tobacco epidemic in 2017, the prevalence of
cigarette smoking among adults was more than 28% and more than
12% among the youth population. (World health Organization, 2017).
In the UAE, the youth tobacco use prevalence was 12.2%, while the
adult tobacco smoking prevalence among male was 28% and 0.9%
among females (World Health Orgnaization, 2017).
Nicotine smoking could be considered as the first acceptable addictive
substance in this region and could act as a gateway for use of other
substances. This is an area that requires serious intervention by policy
makers.
The youngest age of first use of most of substance was 11 years. 82%
of the sample used alcohol for the first time in their life between the
ages of 11 and 41. The same age of initiation was reported for
benzodiazepines, sedatives, cannabis, inhalants and khat use. For
heroin and other types of narcotics, the youngest age of first use was
14 years.
These findings are close to the Iqbal study (2000) findings where 10
years was the youngest age to initiate substance use. In Amir’s study
(2001) the age of first use in the UAE was 18.7 years which is older than
128
the current sample age of first use. The age of initial use being very
young is a red flag that must be taken seriously. According to the
National Institute on Drug Abuse, the use of tobacco, alcohol, and
illegal and prescription drugs is common during adolescence due to
many reasons.
These reasons may include the need to experience
something new, assuming that drugs are harmless, as an attempt to do
better in school, as a solution to deal with a problem and, most
importantly, peer pressure (National Institute on Drug Abuse, 2018).
In the current sample 73% were polysubstance users, 18% used drugs
only, and 9 % used alcohol only. This is consistent with other studies
from the region such as Amir (2001), AbuMadini (2008) and Elkashef et
al. (2013). The reason behind polysubstance abuse is the intent to
experience greater effects from multiple substances. However, this will
increase the possible negative effects of each drug which could result in
unpredictable consequences.
When reporting the current use of alcohol and substance, the majority
of the sample reported that they had not been using in the last 1-2
months preceding their admission. This can be related to the fact that
more than 70% of the sample were engaged in treatment prior to their
entering inpatient treatment. This could be the reason the participants
rated the overall importance of substance and alcohol use in their life
during the past month as “not so important.”
129
In assessing dependency for substance and alcohol use, it was found
that more than 80% of both alcohol and substance users stated that
they didn’t spend much time searching for either drugs or alcohol. This
is an indication of the ease of access of such substances in the UAE.
Clearly more data needs to be collected and the current efforts of Drugs
and Alcohol Demand Reduction in the UAE needs to be carefully
studied and measures taken to address any weaknesses. Policy makers
and law enforcing agencies as well as treatment and rehabilitation
centers must constantly work together to more effectively reduce drug
and alcohol demand. Most of the substance users admitted that they
were using large amounts of drugs over a long period of time, compared
to only 31% of the alcohol users. This could be due to increased
tolerance and complexities of poly-drug use with drug interactions and
use of different drugs for different effects.
When measuring the severity of dependence among participants, it was
found that the majority of both groups had moderate severity of
dependence (50% of substance users and 61.5% of alcohol users). This
could be explained in terms of better access to treatment and patients
seeking treatment early in their careers.
However, 40% of the
substance users were rated as being at high severity of dependence
compared to 26.3% of the alcohol users. This may be an indication that
individuals switch to drugs as they become more severely addicted or
that drugs are more available to users. The religious prohibition of
130
alcohol may also mean that patients are more likely to justify use of
drugs.
The CAGE results were consistent with the severity of dependence as
most of the alcohol users had a CAGE score of 2, which is expected as
the majority of the participants were engaged in treatment.
Withdrawal symptoms varied based on the addicted substance.
Insomnia, sweating and body weakness were the most common
withdrawal symptoms reported by substance users. Headache, body
weakness, tremor and insomnia were the most commonly reported by
alcohol users.
72% of the participants went through previous treatments prior to the
current inpatient treatment episode, with the majority giving a history
of both inpatient and outpatient treatment services. Follow ups and
after care programs after discharge were another aspect of treatment
experience participants had engaged in. This is a strong indicator of
treatment accessibility, availability and affordability. UAE nationals
receive treatment for free regardless of the number of admissions,
simply because addiction is viewed as a relapsing disease and the best
solution to combat this problem is treatment. The antinarcotic law in
the UAE states clearly that “No criminal proceedings shall be instituted
against any abuser of narcotic drugs or psychotropic substances who
voluntarily presents either to the Addiction Treatment Unit referred to
in article 4 or to the Public Prosecution, requesting treatment”
(Department of Drug Control, 2018). Another encouraging step was
131
adding the option of treatment for those reported by their first-degree
relatives
without
any
criminal
proceedings
being
instituted
(Department of Drug Control, 2018).
When assessing the NRC services in terms of responsiveness and
coordination, 91% stated that the NRC was responsive enough to their
needs and 97% indicated that the care in-between services were well
coordinated. The majority stated that they would choose the NRC again
to receive treatment. This is a result of the NRC higher management
commitment to provide the best treatment and rehabilitation services
that meet its patients’ needs. To be able to do this, the NRC regularly
evaluates the programs and the services it provides to its customers
(Elkashef, et al., 2017).
On the other hand, 20% of the participants mentioned that they would
not choose the NRC again to receive treatment. Because this was a
questionnaire-based study, it was difficult to capture in details the
reasons behind this response. Most of the reasons were related to
participants being unsatisfied with ancillary services provided, such as
opportunities for telephone calling and the visitation system. The NRC
policy is that only first-degree relatives are allowed to call and visit after
completing the successful completion of the detoxification program.
This was viewed by participants as freedom restriction. More patients’
awareness and orientation to treatment sessions may be required to
improve patients’ understanding and expectations during their
treatment journey at the NRC.
132
Looking at the family history of psychiatric, addiction, suicide and the
current health status of each family member, it was found that these
problems exist but at a smaller scale. One of the interesting results of
this study was in relation to family history, where 27% of participants
reported having an addicted brother. This also was highlighted under
the accommodation section below. Studies suggested that family
environment contributes to the risk for addiction (Kendler, Ohlsson,
Sundquist, & Sundquist, 2013).
Craving was reported as the highest factor associated with relapse,
followed by peer pressure and unemployment. According to the
literature, urges and cravings to use are the most common factors for
relapse, which was also found in this study (AlMarri & Oei, 2009).
In general, many studies described the demographic profiles a
substance abuser as a young male with limited education who is often
unemployed (AlMarri & Oei, 2009). The findings of this study are
consistent with this general finding. The results in terms of employment
status were discussed earlier.
Further questions were asked to assess the effect of substance use
disorders on employment. 73% of those who were employed reported
losing their job because of their addiction. 69% stated that their job
was affected by their addiction. 41% lost a chance of promotion because
of their dependence. This finding can be considered as strong evidence
for social drift due to their substance use disorders history.
133
More than 87% reported that they owned their own house and 12%
were living in rented houses. The majority of the participants were living
with their parents and their siblings. Maintaining one’s own
accommodation was an important priority in their life. From its
inception, the vision of its founding father H.H. the late Sheik Zayed
Bin Sultan Al Nahyan was to channel the countries resources to build
a world class infrastructure, provide the best of its citizens and
strengthen culture of its society of family cohesion and solidarity among
society members, based on Islamic principles. An outcome of this is a
high level of home ownership but also extended families living together.
UAE nationals enjoy open access to good free education, health
services, housing and other vital infrastructures. The UAE Government
distributes land or offers free housing or housing loans, residential
facilities and maintenance to deserving UAE nationals. In such a
context, it is very difficult to assess the effect of substance use disorders
on accommodation (Government.ae, 2018).
Despite all of this, one participant was homeless which strongly
contradicts what the UAE culture stands for, which are cohesiveness
bound by religious and familial relations and traditional values of
cooperating and sharing.
Out of the 18% who had an addict family member living with them, 76%
lived with an addicted brother and around 11% of the participants lived
with an addicted father, which could explain the low amount of time
134
spent in searching for substance or alcohol as it is already available in
the house.
As explained above, the majority had had a secondary school education.
This can be explained as a result of the free education that the UAE
government provides. Around 56% did not complete their studies for
different reasons, of whom 68% of them did not complete their studies
because of their addiction. This also lends further support to the
concept of social drift as a result of substance use disorders in the UAE.
The consequences of addiction on marital status are very clear in the
results. 25% had ended their marriage due to addiction and around
32% of the married participants were involved in relationships outside
their marriage. This can be taken as further evidence for social drift.
Shockingly, in the UAE context, 13% of those who had children, used
drugs or consumed alcohol in front of their children.
The main source of income identified was the family which is also
another translation of the family unity and cohesiveness. Some 7%
received financial support from the NRC as a tool used in contingency
management to support patients during their treatment journey. Some
two-thirds (64%) of the participants reported a change in their income
after their initial usage of drugs/alcohol, which is a normal
consequence of addiction and an indication of social drift.
135
5.1.2. Hypothesis # 1: The characteristics of the clinical
population of substance abusers receiving treatment in
the NRC will be similar as the clinical population of
substance abusers studied in Al Ghaferi’s 2014.
One of the study aims is to compare Jordanian clinical population from
Al Ghaferi’s study and Emirati clinical population from the current
study. The assumption was that given the cultural similarities between
Abu Dhabi and Jordan the results of the characteristics of the two
populations will be very similar.
UAE and Jordan are both part of the Middle East region. The two
countries are similar in many ways. They share the same racial origins,
the same language, the same religion and, to some extent, the same
cultural background. This suggested that the characteristics of
substance abusers may be similar. Also, the location of both countries
makes them susceptible to similar geographic patterns of drug
trafficking. Both are multinational countries, which expose them both
to new norms and traditions that the citizens of each country can be
influenced by. On the other hand, the two countries differ in terms of
individual income and the standards of living.
The two clinical populations, who were all males, were comparable in
terms of age distribution, educational background, smoking history and
age of first use but differ in terms of material status, employment and
source of referral to treatment. Substance abusers in the UAE were
single, unemployed and they sought treatment by themselves compared
136
to substance abusers in Jordan who were married, employed and
sought treatment under their families’ request.
There is a larger percentage of polysubstance abusers in the UAE, while
there is a larger percentage of alcohol users in Jordan. Comparing the
current use of alcohol and substance use, the UAE sample described it
as being abstinent as they were more engaged into treatment, while the
Jordanian sample described their use as heavy use.
Chi-square test results suggested that there is a statistically significant
difference between the two populations in marital status, educational
background and employment (p<0.05), while, age and source of referral
were not significantly different.
Based on the cultural, religious and geographical location, similarities
in the characteristics of the two clinical populations were expected. Age
and education in the two populations were similar. The typical
substance abuser in both countries is a male younger than 30 years of
age who has secondary education. Based on previous studies,
substance abusers would be less able to find and keep a job, which is
true about the UAE sample. However, the Jordanian data do not
support this hypothesis. Therefore, the proposed hypothesis is accepted
and the characteristics of the two populations are generally similar.
137
5.1.3. Hypothesis #2: Severity of Dependence
Associations
Severity of dependence was measured by the participants’ response to
five questions that addressed the time spent in searching for the
substance, use of large amounts over an extended period of time, the
presence of a persistent desire to cut down or to control drug/alcohol
use without succeeding, and continuing to use despite the problems
that may exist and attempts to stop using.
The second hypothesis addresses the association between severity of
dependence and substance use initiation age, length of dependence,
presence of a family history of addiction and level of educational
attainment. Logistic regression analysis was carried out to test the
association between the severity of dependence (dichotomous) and the
above mentioned variables (n=250). No significant associations were
found between severity of dependence and the variables studied.
These findings are not consistent with the literature, which could be
due to sample size or unique cultural factors of drug users in the UAE.
Alcohol use is prohibited in Islam. Since there are no explicit references
to drug use, some take it is culturally acceptable, although, it is
generally understood that intoxicants are prohibited. In UAE law there
is a mandatory 4 years’ prison sentence if caught using intoxicants
(alcohol or illegal drugs), seeking treatment or opting for treatment
mitigates this sentence. The impact of this on the culture and
138
particularly on young people could be considered unique (Department
of Drug Control, 2018).
5.1.4. Hypothesis #3: Social Drift Associations
Social drift was based on the following variables: losing one’s job
because of addiction, job performance affected by addiction, loss of
promotion
opportunities,
education
not
completed
because
of
addiction, and a change in income after addiction.
The third hypothesis tested the association between social drift and age
of first initiation, length of dependence, and presence of a family history
of addiction. Logistic regression analysis was carried out to test the
association between social drift (dichotomous) and the above mentioned
variables (n=250). In both unadjusted and adjusted logistic regression,
there were no significant associations found between social drift and
the variables studied as all p-values are larger than the critical p<0.05.
5.1.5. Hypothesis #4: Increased nursing interactions will
be associated with higher level of patient satisfaction
with the nursing services
Patients’ satisfaction with the nursing staff at the NRC was assessed in
the questionnaire using four direct questions. Three of the questions
focused on specific nursing tasks and the fourth question directly
inquired about the patients’ satisfaction with nursing care during their
time at the NRC.
139
The majority were able to identify the nursing staff, had received
counselling therapy from the nursing staff and the nurses were
available whenever they were needed. Overall, 95% were satisfied with
the care received from the nursing staff. Looking at the association
between the nursing interactions and patient satisfaction using
correlational and linear regression analysis, a highly significant
association between patient satisfaction and nursing interaction was
found. Given the link between patient satisfaction in treatment outcome
in mental health (e.g., Chue, (2006)) and addictions treatment (e.g.,
Carlson and Gabriel, (2001)), this can be considered an important
finding. This has implications for service development as well as
enhancing the role of the nurse at the NRC.
Addiction is a subspecialty area within the nursing career framework.
It is defined by the service users and the specialized clinical tasks
carried out. Nurses can make positive impacts in the patient’s
treatment journey through accomplishing a range of healthcare
outcomes. They can achieve these outcomes by delivering interventions
that start with conducting the physical and mental assessment,
throughout the treatment trip reaching to the comprehensive recovery
plan. Nurses can add value across a range of public health priorities for
individuals, families and the community. Mental health nurses have an
advanced knowledge of psychosocial practices and the skills to
implement of these practices (Royal College of Nursing, 2017). Whilst
the nurses at the NRC are not mental health nurses, they have had
140
significant in-service training input at the NRC. The finding also
strengthens the case to develop specialized courses such as Diplomas
in mental health and Addiction nursing which are not currently
available in the UAE.
Many studies have linked good nursing care with increased patient
satisfaction. Some studies demonstrated that nurse burnout is a
significant factor influencing how patients’ satisfaction is associated
with their care. Others recognized adjustable changes in the nurses'
work environments, such as, adequate staffing, administrative support,
and better nurses-physician relations that improve nurses' work
environments and eventually reduce patient dissatisfaction (Vahey,
Aiken, Sloane, Clarke, & Vargas, 2004). These factors should be
constantly monitored in order to maintain good nursing conditions.
There are no specialized mental health or addictions nurse training
courses in the UAE or region. Hence, the nurses who work at the NRC
are general nurses. The unique feature is that they have received
considerable amount of training in the form of regular workshops on
counselling skills and psychosocial interventions in addictions. As a
result, they have become skilled in these areas and it is demonstrated
in their interactions with patients. Motivational interventions and
conversations as a result of their training in Motivational Interviewing
can be given as an example.
141
5.2. Strengths and Limitations
5.2.1. Strengths
In research a questionnaire is considered to be a practical method to
collect standardized data from large samples in a fashion that allows
the use of statistics and is relatively cost effective. The questionnaire is
very comprehensive as it studies multiple aspects including patterns,
demographic
information
and
behavior,
which
enable
multiple
comparisons at one point in time. The questionnaire used in this study
was based on internationally validated questionnaires focusing on
aspects of addiction that are universally recognized.
The main strength of this research is that it is one of few studies that
has looked at addiction and the characteristics of substance users in
the UAE, using current data rather than retrospective data. This will
provide a baseline for future comparisons using the same measures.
The results capture the characteristics of a clinical population over a
period of one year which could be generalized, particularly the results
of the male sample. Despite having a small number of female
participants, the results gave a snapshot of the characteristics of female
addicts that can be used as a baseline for future researches. The
inclusion of a female sample however small can be taken as a major
strength as there are very few studies from the region that have reported
on the characteristics of female participants.
142
5.2.2. Limitations
The lack of published studies on the internationally validated
questionnaires, which were used to develop the current questionnaire
being used in an Islamic country could be a considered a potential
weakness as questions of validity could be raised. Another weakness of
this questionnaire is that the participants’ feedback is mainly based on
self-reports of their addictive behaviors, where there is a common
tendency for under-reporting. The questionnaire included many
variables which could be viewed as a possible drawback. (Setia, 2016).
Using only one method approach, a questionnaire, limited gathering indepth information and the elaboration of many aspects of the
participants’ addiction journey, as well as the effect of addiction on their
lives.
It also limited a comprehensive exploration of social drift in
association to drug use in this population. A qualitative component
would have greatly enhanced the study and revealed information that
could not be obtained by the questionnaire alone. This will be of
particular relevance to the cultural aspects. This was a weakness of the
study and it is recommended that future studies include a cultural
component.
Assessing the availability of infectious disease such as hepatitis C in
this group was also limited as the answers were not based on trusted
medical evidence. They were based on a self-report approach which
depends on what the participants understood and wanted to report.
143
The predominant Islamic culture, spirituality is very important in the
UAE. Due to their addiction some patients have drifted away from
religion and spirituality. Reconnecting with religion and spirituality is
seen as part of recovery and is integral to the therapeutic program
based on the biopsychosocial model which is used in the study as its
conceptual framework. However, the spiritual domain was not covered
by the questionnaire which narrowed the scope of the outcomes.
Despite the structured method used in translation and validating the
questionnaire, some questions were confusing and were subjected to
cultural understandings. For example, in the accommodations section
the participant was asked about the type of the accommodation he or
she lives in; “owned” was one of the selections. In Western logic, owned
means owning one’s own house, but culturally, in UAE as in most Arab
countries, living in the parental home could be understood as “own
house.”
An initial aim of the study and one of the hypotheses was to compare
the UAE data with that of Jordan. This was an important aspect of the
study. On the other hand, it also created a weakness in that some of
the structural and linguistic problems like the example above carried
over to this study. With hindsight it may have been better to develop a
questionnaire based on international standard questionnaires for the
purpose of this study, that was more precise and based on the standard
clinical assessment. This way there could be ongoing data collection for
regular comparison.
144
The main limitation of the study was the small number of female
participants and the lack of non-nationals in the study sample, which
could raise a question about generalizing the results.
5.3. Implications for Practice
One of the main findings in this study was the early age of initiation.
Currently, there is no structured addiction treatment program for
adolescents in the UAE, if not in the region. Targeting the early age of
use opens the door for variety of interventions for the adolescent
population that are available. This could include prevention initiatives
and development of specialized and culturally adapted treatment
programs. Early interventions targeting younger adolescents who are
at high risk could improve the cost-effectiveness of investments in
substance use disorders treatment.
School based prevention programs should be considered that are
research-based that positively modify the balance between risk and
protective factors for drug abuse in families, schools, and communities.
Such programs have proved that they can significantly decrease early
use of tobacco, alcohol, and illicit drugs among youth. They support
teachers, parents, and health care professionals and shape youths’
perceptions about the risks of substance use (National Institute on
Drug Abuse, 2018). These prevention programs must be developed in
collaboration with different entities and stakeholders as adolescent
addiction is a problem for the whole country. Parents, schools, media,
145
healthcare facilities and the criminal justice system should all be
involved in developing such programs.
Another practice implication on the emergence of adolescent substance
use disorders is developing evidence-based treatment programs for
those who already substance users. The current treatment rates
propose that most adolescents with substance use disorders receive no
treatment whatsoever which makes it difficult to estimate the treatment
costs. Additionally, the consequences of adolescents’ substance use
disorders costs may stretch across multiple entities that could include
criminal justice system resources, mental health and general medical
care services and the education system (Slade, 2008).
The study highlighted another problematic side which is smoking. A
typical substance abuser is first a smoker. Smoking was mentioned by
different studies as the gateway to addiction especially among
adolescents. In the UAE, the WHO report stated that the prevalence of
smoking among the youth for both sexes was 12.5% in 2015 and it is
on the rise (World Health Organization, 2015).
The direct action to this problem is to include smoking cessation
modalities in addiction treatment facilities as a crucial part of the
treatment, not supplementary. Another action is to make all addiction
treatment facilities smoke-free facilities. On the other side, a mass
general smoking prevention program at the level of the whole
community may be more effective as a public health strategy. Again,
such programs must start as early as preparatory school if not at the
146
elementary level. Anti-tobacco messages in the media and education
campaigns should be directed to parents and adolescents to raise
awareness about the risks of tobacco use. Moreover, and to have
effective preventive programs, messages should be focused on changing
social norms around smoking and provide knowledge and skills to resist
smoking. Research is also needed on smoking patterns of the
population which will be discussed in the next section.
5.4. Implications for Policy
There are a number of implications from the present study for the
continuing process of policy development. Policies regarding substance
misuse in the UAE have been changing and in recent times the NRC
has contributed to this process. Studies such as the present one provide
valuable data to help support policy change. The finding that despite
the laws, enforcement, restrictions and cultural attitudes, the easy
access to drugs and alcohol that the majority of the patients reported
is alarming. This has to be discussed among all the stakeholders
including policymakers, law enforcement agencies, the criminal justice
system, prevention organizations and treatment and rehabilitation
facilities to identify the gaps or weaknesses in the system with the view
of developing policies and interventions to address this issue. The
policies have to be multidimensional and should use information from
all stakeholders as well as research findings. This is the work of a
surveillance center or body, perhaps by the Department of Health.
147
The findings that the severity of dependence among the participants is
moderate and the trend in the average age of patients is downwards is
an indication that addiction services are becoming more accessible and
that it may be capturing people earlier in their addiction. If this is the
case, further review of policies in the direction of easing access to
treatment and raising awareness should be carried out.
The headline finding of age of first use showing a downward trend is an
alarming finding and should be taken very seriously by policymakers.
Policies that put a greater emphasis on school-based prevention work
is urgently needed.
The comparison with similar data collected from a treatment sample
from Jordan, although not in the same timeframe, revealed some
similarities as well as differences. This indicates that even when the
cultural and geographical contexts are similar, patterns of use and
profiles of substance users could be quite different. There is an
argument to work towards policy synchronization in a given region with
similar cultural contexts. A regional forum to discuss each country’s
policies and to learn from each other might lead to joint work towards
synchronization of prevention and treatment efforts. The WHO is a good
vehicle to facilitate this. The NRC as WHO Regional Collaborating
Centre could take a lead in this and call for such a meeting and facilitate
presenting these findings and studies from regional countries.
148
5.5. Further Research
There are a few indications for further research that come out of this
study. Future studies of this nature should include a qualitative
component so that more information on context and culture-related
factors could be gathered. This type of information is helpful to develop
more appropriate and user sensitive treatment programs as well as
reviewing and developing policies. Qualitative data, particularly on
female substance users, are lacking in the literature. This information
is urgently needed for service development as well as policy
development.
The finding that most patients smoked tobacco is an important one.
There is a general lack of studies into smoking in the UAE. The
“Midwakh”, a small pipelike implement that delivers a high dose of
nicotine in a short period of time, is a particular invention of the UAE.
It appears that this is very popular among young people and most of
our patients seem to use it. Yet there are no studies on “Midwakh” use
and substance use in clinical populations. It is recommended that a
study on smoking patterns of the patients at the NRC be carried out as
a matter of priority which includes a measure of their attitude towards
being treated for tobacco use while they are at the NRC. Findings from
such a study will give valuable information to affect prevention
programs and develop interventions for smoking cessation.
The finding that nursing interaction was highly significantly associated
with patient satisfaction indicated that further research into nursing
149
interaction would yield particularly useful information to develop the
much-needed specialization in addiction nursing.
5.6. Overall Conclusions
This is one of the first concurrent studies of clinical population of
substance users in the UAE. The findings provide useful information on
the profile of the current patient population that could be used for
developing and improving services as well as developing policies and
conducting research. It also provides us with a baseline that could be
used to monitor trends in the future.
The study also enabled a
comparison with a regional country with similar culture and
demographics. The findings that nursing interaction is strongly
associated with patient satisfaction has major implications for
developing addiction nursing.
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APPENDIX – 1: PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET
A STUDY OF THE CHARACTERISTICS OF A CLINICAL
POPULATION OF SUBSTANCE MISUSERS IN THE UAE AND AN
EXPLORATION OF SOCIAL DRIFT IN THIS POPULATION
INTRODUCTION
You are being invited to participate in a research study. Before you decide to take part
in this, kindly take time to read the following information carefully and discuss it with
others if you wish. Ask us if there is anything that is not clear or if you would like more
information. Take time to decide whether or not you wish to participate.
Thank you for reading this.
WHAT IS THE AIM OF THIS PROJECT?
To examine the characteristics of known illegal substance users in treatment in the
National Rehabilitation Center – Abu Dhabi and to explore the concept of social drift in
this group
WHY HAVE I BEEN CHOSEN?
The sample size of the study will be all the patients (in - out) of National Rehabilitation
Center – Abu Dhabi.
DO I HAVE TO TAKE PART?
It is up to you to decide whether or not to take part. If you decide to take part you are
still free to change your mind without giving a reason. A decision not to take part, will
not affect the standard of care you receive.
WHAT DO I HAVE TO DO IF I TAKE PART?
The procedure involves filling a questionnaire that will take approximately 30 minutes.
You might be also asked to be interviewed by researcher or researcher assistants.
WILL MY TAKING PART IN THE STUDY BE KEPT CONFIDENTIAL?
Yes. All the information will be treated anonymously and will be used only for research
purposes only. Your identity will not be revealed in any publication resulting from this
study.
CONTACT FOR FURTHER INFORMATION
If you have any questions or concerns about the study, please contact Mrs. Samya Al
Mamari – 02 4467777
We would be pleased to answer any queries you might have.
151
APPENDIX – 2: CONSENT FORM
RESEARCH PARTICIPATION CONSENT FORM
INTRODUCTION
You are being invited to participate in a research study. Your participation in
this research study is voluntary.
You may choose not to participate and you may withdraw your consent to
participate at any time. You will not be penalized in any way should you decide
not to participate or to withdraw from this study.
There are no known risks associated with this research.
All the information will be treated anonymously and will be use only for
research purposes only. Your identity will not be revealed in any publication
resulting from this study
If you have any questions or concerns about the research study, please contact
Samya Al Mamari – 02 4467777
I read the Patient Information Sheet and I understand that my participation in
the study is voluntary and that I am free to withdraw from the study at any
time without giving any reason, without any effect on the standard of care I
receive.
I agree to take part in the study
I don’t agree to take part in the study
Date ………………..


Patient Signature………………………
Name of person taking consent…………………………………………..
Date ………………..
Signature………………………
Researcher ………………………………………………………………………...
Date ………………..
Signature………………………
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APPENDIX – 3: QUESTIONNAIRE
000
STRUCTURED QUESTIONNAIRE
Date: … /….. / ……
Time: ………..
NRC #: ………………
PART 1: DEMOGRAPHIC
Patient Background
1.Gender:
a. Male
b. Female
2. Age: …………………..
3. Nationality:
a. UAE
b. Other …………………..
4. Religion:
a. Muslim
b. Other …………………..
5. Material Status:
a. Single b. Married c. Divorce
d. Widower e. Separated
6. Educational Background:
a. Illiterate
b. Primary
c. Preparatory
d. Secondary e. University
7. Current Occupation:
a. Unemployed
8. Address:
b. Student
a. Abu Dhabi
c. Self-employed
b. Dubai
e. Fujairah
d. Employed e. Retired
c. Sharjah
d. Ajman
f. Ras al-Khaimah
g. Umm al-Quwain
Referral Source
9. Voluntary:
a. Self
b. Family
10. Non-voluntary:
a. Justice System
c. Hospital
d. Others ……….
b. Others …………………………
Psychiatric History
11. Depression:
a. Yes
b. No
c. Don’t know
12. Schizophrenia:
a. Yes
b. No
c. Don’t know
13. Anxiety disorders:
a. Yes
b. No
c. Don’t know
14. Mood disorders:
a. Yes
b. No
c. Don’t know
c. Yes (B)
d. Yes (C)
Medical History
15. Hepatitis:
a. No b. Yes (A)
16. AIDS:
a. Yes
b. No
c. Don’t know
17. Hypertension:
a. Yes
b. No
c. Don’t know
18. Diabetes:
a. Yes
b. No
c. Don’t know
19. Gastritis:
a. Yes
b. No
c. Don’t know
153
e. Don’t know
PART 2: ADDICTION HISTORY
A. History of Substance Abuse / Nicotine Smoking
A.1 Substance Abuse
Substance
Age
First
uses
Period
of use
Freq. of
use
Use in
last 28
days
Route
1. Yes
IV
SM
SN
Alcohol
Heroin
Other Narcotics
Cocaine/Crack
Benzodiazepines
Other Sedatives/
Hypnotics
Cannabis
Hallucinogenic
Inhalants/ Solvents
Khat
Amphetamines
Others ……………..
Code to (Route): IV = intravenous injections. SM= smoked, SN = snorted, O =
Oral
If you answer yes for Others, please mention ----------------------------------------------
A.2 Nicotine Smoking
20. Do you smoke?
a. Yes
b. No
If Yes, go to question No. 21. If No, go to question No. 23,
21. Was it before your addiction?
a. Yes
b. No
22. Was it after your addiction?
a. Yes
b. No
B. Current Use
B.1 Substance Abuse
23. How would you describe your drug taking over the past 1-2 months?
a. Abstinent
b. Light
c. Moderate
d. Heavy
24. In the past month over all, how important were drugs in your life?
154
O
2. No
a .Very important b .Important
c. Not so important
d. Do not know
25. How do you describe your satisfactions with this aspect in your life?
a .Very satisfied
b .Reasonably satisfied
c. A bit satisfied d. Not satisfied
B.2 Alcohol
26. How would you describe your alcohol intake over the past 1-2 months?
a. Abstinent
b. Light
c. Moderate
d. Heavy
27. In the past month over all, how important were alcohol your life?
a .Very important b .Important
c. Not so important
d. Do not know
28. How do describe your satisfactions with this aspect in your life?
a .Very satisfied
b .Reasonably satisfied
c. A bit satisfied
d. Not satisfied
C. Criteria of dependence
C.1 Substance Abuse Dependence
29. Do you spend time in activities searching for the drugs?
a. Yes
b. No
30. Do you use large amount of drugs over a long period?
a. Yes
b. No
31. Do you have a persistent desire to cut down or to control taking drugs yet
you have not succeeded?
a. Yes
b. No
32. Do you continue to use drugs despite the fact that it causes you many
problems?
a. Yes
b. No
33. Have you tried to stop your habits?
a. Yes
b. No
34. If your answer is yes, mention the withdrawal symptoms that appear in you:
Symptoms
Headache
Tremor
Nausea
Vomiting
Sweating
a. Yes
b. No
Symptoms
Insomnia
Weakness
Anxiety
Depression
Others
a. Yes
b. No
If you answer yes for Others, please mention -----------------------------------35. Do you feel that you want to increase the amount of drugs you are using to
reach the same feeling that you used to have in a small amount (with your
current amount)?
a. Yes
b. No
155
C.2 Alcohol Dependence
36. Do you spend time in activities searching for alcohol?
a. Yes
b. No
37. Do you use large amount of alcohol over a long period?
a. Yes
b. No
38. Do you have a persistent desire to cut down or to control taking alcohol yet
you have not succeeded?
a. Yes
b. No
39. Do you continue to use alcohol despite the fact that it causes you many
problems?
a. Yes
b. No
40. Have you tried to stop your habits?
a. Yes
b. No
41. If your answer is yes, mention the withdrawal symptoms that appear in you:
Symptoms
Headache
Tremor
Nausea
Vomiting
Sweating
a. Yes
b. No
Symptoms
Insomnia
Weakness
Anxiety
Depression
Others
a. Yes
b. No
If you answer yes for Others, please mention --------------------------------------------42. Do you feel that you want to increase the amount of alcohol you are
consuming to reach the same feeling that you used to have in a small amount
(with your current amount)?
a. Yes
b. No
D. CAGE Questionnaire: ALCOHOL
43. Have you ever felt you should cut down on your drinking?
a. Yes
b. No
44. Have you been annoyed by people who criticizing your drinking?
a. Yes
b. No
45. Have you ever felt bad or guilty about your drinking?
a. Yes
b. No
46. Have you ever had a drink first thing in the morning to steady your nerves or
get rid of a hangover (Eye- Opener)?
a. Yes
b. No
156
E. Control Measure History
47. Have you ever been received a treatment in a Detoxification and \or
Rehabilitation center before this visit?
a. Yes
b. No
If Yes, go to question No. 48. If No, go to question No. 53,
48. Was it:
a. Inpatient
b. Out Patient
c. both
49. How many times:
a. Inpatient
b. Out Patient
50. Where and how long did you stay inpatient? …………………………………....
51. Did you have a follow up after your discharge?
a. Yes
b. No
52. Describe what sort of follow up you receives?
a. OPD
b. Matrix
c. HWH
53. Do you feel the NRC service is responsive to your need?
a. Very responsive
b. Responsive
c. Ok d. Unresponsive
e. Very Unresponsive
54. What you like and what you don’t like in your treatment?
…………………………………………………………………………………………………
………………………………………………………………………………………………….
55. How well is your care being coordinated in-between different services?
a. Very well
b. Well
c. Ok
d. Poorly
e. Very poorly
56. Were you able to identify nursing staff?
a. Yes
b. No
57. Did you receive any counselling from the nursing?
a. Yes
b. No
58. Were the nurses available when you needed them?
a. Yes
b. No
59. During your stay or attendance (outpatient) at the NRC how satisfied are you
with the care you received from the Nursing staff?
a. Strongly satisfied
b. satisfied
c. not satisfied
60. If you have the chance to choose your treatment facility will you come back
again to this center?
a. Yes
b. No
F. Family history
61. Does any of your family have any psychiatric problems?
157
a. No
b. Mother
c. Father
Spouse/partner
d. Brothers
e. Sisters
f.
g. Children
62. Does any of your family have alcoholism or have a drug addiction problem?
a. No
b. Mother
c. Father
Spouse/partner
d. Brothers
e. Sisters
f.
e. Sisters
f.
g. Children
63. Has any of your family attempted suicide?
a. No
b. Mother
c. Father
d. Brothers
Spouse/partner g. Children
64. What is the current health status of your family members?
I. Healthy :
a. No
b. Mother
c. Father
d. Brothers
e. Sisters
f.
d. Brothers
e. Sisters
f.
Spouse/partner g. Children
II. Ill :
a. No
b. Mother
c. Father
Spouse/partner
g. Childrenwith Relapse
G. Factors Associated
65. Is this your first time for treatment?
a. Yes
b. No
If Yes, go to question No. 67. If No, go to question No. 66,
66. What are your views of relapse? Why you get relapse?
Dependence
effect
Peer pressure
a.
Yes
b.
No
Poor attitude
Family problems
Dependence effect
a.
Yes
b.
No
Unemployment
Place connected to the
addictive behavior
Time connected to the
addictive behavior
Roll modelling
PART 3: SOCIAL
A. Employment
67. Employment Status:
a. Employed - Since: ………….
B. Not Employed - Since…………………
c. Never employed
d. Others, please mention ……………
If you are employed go to Question 68, if not employed go to question 69
68. Type of Employment:
158
a. Manual
b. Professional
c. Administrative
d.
Other,
please
mention…
69. History of Employment:
Current job……………………………………………
Next to current……………………………………….
Second to current…………………………………….
Others, please mention ……………………………..
70. Did you lose your job in any of the above mentions because of your
dependence?
a. Yes
b. No
71. Since you start taking drugs/drinking alcohol, has your job ever been
affected?
a. No
b. Yes, positively
c. Yes, negatively
72. Did you lose a chance of promotion in your job because of your dependence?
a. Yes
b. No
73. What support do you want to progress towards being employed?
a. Literacy
b. Numeric
f.
c. CV writing
Skills
d. References
g.
mention:……………………………………..…
B. Accommodations
159
e. Experience
Others,
please
160
74. Type of Accommodation:
161
a. Owned
……….…
b. Rented
c. Homeless
162
f. Prison
g. Others please mention
75. Who is living with you?
a. Spouse
b. Parents
c. Dependent children
d. Friends
e. Other drug user
f. Others
g. alone
h. Step parents
i. Siblings
j. Half siblings
l.
Live-in
domestic help
76. Do any of the above use drugs or alcohol?
a. Yes
b. No
If Yes, please indicate who ……….……………………….. If No, go to question
No. 77,
77. How do you feel about maintaining your accommodation?
a. Important issues
b. Not important
C. Education
78. I finished my studies before my addiction.
a. Yes
b. No
79. I finished my studies despite my addiction.
a. Yes
b. No
80. I did not complete my studies because of my addiction.
a. Yes
b. No
81. I did not complete my studies because of reasons not related to addiction.
a. Yes
b. No
Others, please mention……………………………………………….
D. Marital history
82. How many times did you get married?
a. One
b. Two
c. Three
83. Number of marriages: Current:………...
d. Four
e. Not married
Past…………
84. Did any of the previous marriages ended because of addiction?
a. Yes
b. No
85. Do you have another partner other than your wife, such as a girlfriend?
a. Yes
b. No
86. Do you have dependent children?
a. No
b. Yes (1)
b. (2-5) children
4- more, (No.
children………………)
87. Are you involved in caring for your children?
a. Yes
b. No
88. If not who is caring for them now?
a. Wife/husband
b. family
c. others ………………………….
163
89. Do you use drugs or drink alcohol in front of your children?
a. Yes
b. No
E. Financial issues
90. What is your source of income?
a. Employer
b. Social support
c.
Other(s),
please
mention……………
91. Did your income change after your initial usage of drugs/alcohol?
a. Yes
b. No
c. Yes, positively
a.
Yes,
negatively
92. If you have only Dhs 1000 how would you spend it them over the following
items:
a. Food
b. Drug and alcohol needs
c. Accommodation
d. Children
& Family
93. If there is anything else you would rather spend Dhs 1000 on (apart from
drugs or alcohol), what is it?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………..
164
APPENDIX – 4: NRC IRB APPROVAL
165
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172
CURRICULUM VITA
SAMYA MOHAMMED AL MAMARI – BScN. MQM.
MPH
PERSONAL DATA
Nationality:
UAE.
Date of Birth:
16thSeptember 1974
Marital Status:
Married
Profession:
Registered Nurse
Current Position:
Director of Nursing
EDUCATION
2011–Currently:
Doctor of Public Health Program
in Health Care Management and
Leadership for the Emirate of Abu
Dhabi
Johns Hopkins Bloomberg School of
Public Health
Abu Dhabi - UAE / Baltimore - USA
2008 – 2011:
Master of Public Health Program
in Health Care Management and
Leadership for the Emirate of Abu
Dhabi
Johns Hopkins Bloomberg School of
Public Health
Abu Dhabi - UAE / Baltimore - USA
2005 – 2007:
Master of Quality Management
University of Wollongong - Dubai UAE
2001 - 2003:
(GPA 3.62)
Bachelor of Science in Nursing
University of Sharjah - Sharjah -UAE
1997 - 2001:
3.03)
Higher Diploma in Nursing (GPA
173
Higher Colleges of Technology
Abu Dhabi Women’s College - Abu
Dhabi - UAE
1992 - 1994:
Practical Nursing Course (93.61%)
School of Medical Services
Zayed Military Hospital - Abu Dhabi UAE
1990-1991:
(75%)
High School Certificate/Science
Women Union - Abu Dhabi - UAE
ATTENDANCE
14th – 15th April, 2018
ASAM 49th Annual Conference
San Diego – USA
12th – 13th March 2018
Hemaya International Forum
Dubai – UAE
26th – 29th Oct 2017
9th ISAM Annual Conference
Addiction Medicine: New Frontier
Abu Dhabi – UAE
24th May, 2012
Scope of Practice User Guide
Dubai – UAE
14th May, 2012 – 19th May, 2012
Substance Abuse & Clinical
Service Intensive Overview
McLean Hospital – USA
15th Feb, 2012 – 16th Feb, 2012
Workshop
Leadership & Team Building
Abu Dhabi – UAE
25th Sep, 2011
Crash Trolley Course
Abu Dhabi – UAE
23rd Sep, 2011 – 24th Sep, 2011
(ITLS)
International Trauma Life Support
- Advance
Abu Dhabi – UAE
11th July, 2011 – 14th July, 2011
Infectious Diseases & Disaster
Response
Abu Dhabi – UAE
28th July, 2011
Nursing
Leadership and Management in
Dubai – UAE
174
10th Dec, 2010
Nephrology Nursing Symposium
Abu Dhabi – UAE
25th Jan, 2009 – 29th Jan, 2009
Fundamentals of the Terrorism
Incident Planning Process Medical
Countermeasures
Abu Dhabi – UAE
16th Nov, 2008 – 20th Nov, 2008
International Practicum on Quality
Improvement & Accreditation
Dubai – UAE
19th July, 2008 – 22nd July, 2008
2nd FME/EDTNA/ERCA Middle East
& Africa Renal Education Program
Prague – Czech Republic
16th May, 2008
Nursing Development Conference:
Committing to Nursing Excellence
Dubai – UAE
Feb, 2005 – Feb, 2007
Leadership for Change Program –
Phase 2
Abu Dhabi – UAE (under WHO &
ICN)
27th, Sep 04-29th, Sep 04:
CRRT and MultiFiltrate Training
Fresenius Medical Care - Dubai UAE
4th June 04- 6th June04:
Peritoneal Dialysis Course
PD Academy / Baxter Company Muscat–Oman
25th Jan 04-28th Jan 04:
Hemodialysis Nurses Training
Fresenius Medical Care - Dubai UAE
Sep 2002-Dec 2003:
Nursing and Health Care
Leadership & Management
University of Sharjah - Sharjah - UAE
EXPERINCE
Oct 2017-till today:
Head of DG Technical Bureau
National Rehabilitation Centre - Abu
Dhabi
July 2013-till today:
Director of Nursing
National Rehabilitation Centre - Abu
Dhabi
175
Jan 2012-July 2013:
Nursing Unit Manager
National Rehabilitation Centre - Abu
Dhabi
Aug 2010-Jan 2012:
Acting Deputy Director of Nursing
Zayed Military Hospital - Abu Dhabi
Aug 2009-Aug 2010:
Acting Director of Nursing
Zayed Military Hospital - Abu Dhabi
July 2007-Aug 2009:
Assistant Director of Nursing
Zayed Military Hospital - Abu Dhabi
Sep 2005-Jan 2012:
Nephrology Unit Manager
Nephrology Unit - Zayed Military
Hospital - Abu Dhabi
March 2005-Sep 2005:
Unit
Deputy In-charge of Nephrology
Nephrology Unit - Zayed Military
Hospital - Abu Dhabi
Feb 2005- Feb 2007:
Part-time Nursing Instructor
School of Medical Services - Zayed
Military Hospital - Abu Dhabi
July 2003-March 2005:
Nurse
Register Nurse (RN)/Dialysis
Nephrology Unit - Zayed Military
Hospital - Abu Dhabi
Jan 1994-August 1997:
Practical Nurse (PN) - Med/Surgical,
ICU, VIP
Zayed Military Hospital - Abu Dhabi
ACHIEVEMENTS/ MEMBERSHIPS
 Awards:
- Abu Dhabi Excellence Award Shortlisted Nominees: January 2017
- Abu Dhabi Medical Distinction Awards Shortlisted Nominees: February
2013
- Rashid Award for Scientific Outstanding: May 2008
- Caring Expert in the Gulf countries First Skill competition: Caring team
won Gold medal in Al Ain. March, 2008
- Caring Expert in the Emirates International Skill competition: Caring
team won Silver medal in Japan. Nov, 2007
 Committees:
176
- NRC Research Committee (member): 2017 till today.
- International Addiction Review Journal (Executive Board member):
2017 till today
- National Committee of Treatment & rehabilitation & Social
Reintegration (member): 2016 till today
- NRC Phase 2 Operational Committee (Head): 2015 till today
- Scientific Committee for Practice (Member): 2010 till today
- UAE Nursing and Midwifery Council (Observer): 2010
- Shaikha Fatma Health Science College Advisory Committee: 2008
- Nursing and Midwifery Advisory committee for the Emirates of Abu
Dhabi: 2007
 Organizing:
- The 2nd Nephrology Nursing Symposium: 30, May 2008
- Nurses International Day Organizing committee: 2007
- 3rd General Assembly – Emirates Nursing Association: 2007
- Child Abuse in UAE Symposium: 2006
- The 1st Nephrology Nursing Symposium: Sep, 2006
 Presentation:
- ISAM 19th Conference: A study of the characteristics of a clinical
population of substance misusers in the UAE. 28th Oct, 2017
- WHO–NRC Regional Capacity Building Workshop for the National
Managers on Development of Services for Prevention and
Management of Substance Use and Substance Use Disorders: Human
Resources Capacity Building. 2nd Nov, 2016
- WHO–NRC Regional Capacity Building Workshop for the National
Managers on Development of Services for Prevention and
Management of Substance Use and Substance Use Disorders: Quality
& Accreditation. 2nd Nov, 2016
- 2nd INCAN: The Human Touch and Nursing Practice. 5th, September
2014
177
- 7th FME Middle East and Africa Renal Nurses Education Program:
Taking Nursing Forward In Middle East & Africa: Stairs To Success 2nd
Dec 2013
- Fatima College Conference: Bridging The Gap Between Nursing
Education and Practice: 15th, March, 2012
- Nephrology Nursing: Where we stand: 10th, Dec 2010
- Nurses International Day: Shared Governance: 12th, May 2009
- Child Abuse in UAE: 2006
 Official Documentation:
- As part of being a member in the Scientific Committee for Practice,
participated in writing and reviewing:

The UAE Registered Nurse Scope of Practice.

The UAE Registered Midwife Scope of Practice:

The UAE Practical Nurse Scope of Practice.

The UAE Practical Midwife Scope of Practice

Positive Environment Document
178
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