Author(s): Farhana Sabri
This paper deliberates an overview of dual diagnosis cases in drug addicts in terms of its emerging challenges and efforts have been made to counter them. Drug addiction problem was declared as a number one nation enemy in Malaysia since 1986 by Prime Minister Dr. Mahathir Mohamad. Many efforts have been putting up in order to combat the drug addiction problem. Malaysia government through National Anti-Drug Agency (NADA) provide treatment not only for drug addicts but also for significant others affected by the life of addict.
Despite the efforts, relapse cases among drug addicts remain crucial and need vigorous attention in every level of care particularly in post-treatment care. In Malaysia, as of December 2010, 983 cases of relapse were reported, a figure that is higher than the 774 cases in 2009 [1]. Ministry of Health then reported, 1, 136 mental health cases that involved suicide were reported within 2007 to 2010, the number increased as compared to 2006. Drug addicts with multiple relapse cases are at increased risk for having personality, emotional disorders or mental health problems, and vice versa.
According to National Institute on Drug Abuse, dual diagnosis is a term that commonly used in describing the occurrence of two disorders in the same person, either at the same time (cooccurring comorbid conditions) or with a time difference between the initial occurrence of one and the initial occurrence of the other (sequentially comorbid conditions). The comorbid pose a double treatment challenge not only for clients, but also for addiction counselor in terms of making assessment and constructing treatment plan [1].
Rehabilitation counselors do not certain what treatment will be best or primary treatment for the client, get sober or mental help? While the involvement of rehabilitation counselors in psychiatric issues seems professionally inappropriate, their actions may necessary considering drug cases rising every year. As a consequence, rehabilitation counselors tend to misdiagnose the case and develop erroneous treatment planning following the diagnosis. Persons with synthetic drug use history more likely to develop severe psychiatric problems regardless age level. Late identifying or tracing those symptoms may enable clients to react aggressively and out of control. For example ‘Amok’ cases (a father murdered his little baby/a son murdered his father for no reasons) keep increasing every year regardless ethnics, and all of them had synthetic drug use history. When refer the case to drug treatment center, there was lacking information about the client mental health status. In addition, ‘Amok’ is not included in DSM 5 as a specific diagnosis, rather as cultural concepts of distress even though it has psychotic symptoms, and hence, does not sufficient to warrant disorders [2].
The challenging situations appear particularly in discriminating between primary and secondary diagnosis. Timing frame of ‘when’ the exact symptom occurred is hard to determine. Particularly with drug addicts with long use history of substance and multiple experienced in treatment program with multiple relapse in cases. This is difficult to determine whether mental disorders precede the addiction or drug disorder trigger or exacerbate mental disorders. In addition, defense mechanism of denial is well accepted among drug addicts, whereby it usually concurrently applies with other defenses such as minimization, rationalization, and sublimation. Hence, they tend to create ‘situation’ that can seem minimized their drug problems and deny associated problems. This situation urges addiction counselors to possess skills in identifying defense mechanisms applied by the client prior to making assessment and diagnosis. As asserted by the Addiction Counseling Competencies Model in the Substance Abuse and Mental Health Service Administration professional counselors are required to be competent in assessing and screening the clients’ employment of denial defenses, rationalization defenses, and other defense mechanisms related to client resistance [3].
A tool that is important in the early phase of assessment is history checking/validating method by checking information given by the client with his/her significant other besides seeking additional information. Another challenge to apply this tool is when the addict has no family or at least has lost contact with his/her relatives due to their addiction problems, and thus, makes this method is time consuming to apply.
The challenging situation also appears from the use of substance itself in terms of its effect and symptoms. It is a trend now that drug addicts’ especially young hoods are moving toward synthetic drugs or designer drugs from traditional drugs. Synthetic drugs cause worse symptoms and accelerate the effects from only couple of use as compared to traditional drugs. For example, marijuana and heroin distort the way neurons work and interfere with the brain’scommunication system whereas amphetamine and cocaine alter the nerve cells that prevent brain chemical from normally recycling.
While traditional drugs abnormally interfere with the neurons and nerve cells of the body of drug addicts, synthetic drugs on the other hand, produce a greatly amplified chemical structure and stay much longer in the brain. The long presence in the brain makes synthetic drugs very harmful to brain cells that can cause an acute brain psychotic reaction including lose contact with reality and act violently. This situation despite several deaths cases associated with designer drugs use alarming the state holder to take a fresh approach program that allows drug addicts to receive an early treatment care. Furthermore, past research findings suggest that the effectiveness of substance abuse treatment programs largely depends upon types of drug used by the individuals, as each type of substance affects drug recovery rates and chances for relapse [4,5].
In 2010, Ministry of Home Affairs Malaysia through National Anti-Drug Agency in collaboration with Non-Governmental Organizations have transformed from compulsory drug detention center to ambulatory approach in providing treatment for drug addicts. Previously, medical treatment and mental health assessment were limited and not the central of drug treatment program. Instead, the treatment program was abstinence-based activity comprising physical training, vocational class and counseling session. Drug addicts also, on court order, were involuntarily admitted to the treatment program following arrest for drug possession or positive urine test on drugs.
Malaysia Cure and Care Clinics (C&C) as an open access treatment center were introduced, which stresses on voluntarily concept and early assessment in drug addicts. The C&C offer both outpatient and inpatient program consisting of drug substitutions therapy, counseling service, medical-related service, women and teen programs, and referrals to aftercare program so called Cure and Care Service Centre (CCSC). The new concept that bounces legal procedures and detention element encourages drug addicts to come willingly and receive the drug treatment. The treatment planning is personalized for each drug addicts, which is determined following a thorough evaluation and interview conducted at entry level. A physician and psychologist are also placed in the evaluation process.
NADA develop a cohesive collaboration with Ministry of Health in countering drug addicts with psychosis disorder co-occurrence with drug use problems. Patients are transferred to General Hospital for further treatment. A psychiatrist or psychologist is placed in drug treatment center once in every week to provide regular mental health checkup to drug addicts and those at early recovery phase or at abstinence stage that demonstrate psychosis symptoms. This method is convenient for them especially for methadone patients as they difficult to skip their work in order to commit appointment procedure with psychiatrist or psychologist in hospital [6].
In summary, dual-diagnosis in drug addiction is a complex situation that emerge challenges and issues for state holders, drug treatment providers, drug addicts themselves, their families and community. Nevertheless, efforts in combating drug addiction problems will never end as to protect the safety of country and the future of its society. Educational institute show their effort by providing professional training program for beginner addiction counselors is bound to be endless. As Malaysian nation is moving forward through the government transformation program that underlying the concept of ‘People first, Performance now’, the people of country strive together to combat the number one nation enemy toward achieving a drug free country in 2020.
