Article / Research Article
MB BCh, MSc Psychiatry, PhD Univ of Kent, Freedom Drugs and HIV Programme, Cairo, Egypt.
Ehab El Kharrat,
MB BCh, MSc Psychiatry, PhD
University of Kent,
Freedom Drugs and HIV Programme,
26 October 2023; 7 December 2023
It is estimated that more than 800 drug rehabilitation centres are operating in Egypt now, with a total of around forty thousand beds. Almost all of these centres apply a 12-Step Therapeutic Community Philosophy. The first steps of this approach can be traced to the year 1989 and along these 34 years, the estimate of clients who achieved stable abstinence is about 120 thousand clients who had a diagnosis of Substance Use Disorder (SUD), with or without a concomitant other psychiatric diagnosis. In this article we shall report on history, development, structure, processes and some highlights of published and original research, and the achievements, challenges and research gaps of this psychosocial approach in this country. Regional and international connections and contexts will also be mentioned.
In the year 1989 two or three significant events in the history of drug rehabilitation in Egypt took place. The Freedom Programme started by establishing the first group of five hard core heroin addicts, through a volunteer group which met twice a week, while each of the former Substance Users met with their volunteer key worker daily. Almost at the same time Hamed A. independently started the first Narcotics Anonymous (NA) meeting in Cairo. Soon after that the Better Life Programme started a residential Daytop model therapeutic community. In 1991 Freedom started its first rehabilitation centre in a modest 5 beds apartment. Around the same timeframe Caritas launched its Cognitive Behavioural Treatment based (CBT) Therapeutic Community.
The programmes had their ups and downs for the next decade in the year 2000 the Freedom Programme evolved into an integrated 12-Step Therapeutic community model with 3 centres. Freedom being a programme of Kasr El Dobarah, a large presbyterian church in Cairo, also had one of the rehabilitation programmes as a Christian perspective 12-Step one. In the year 2000 Freedom also launched an internationally recognized training course, along the years and by the year 2023 this programme grew, to run 54 drug rehabilitation centres, 10 Detoxification Centres, as well as one HIV Outreach/Drop in centre, and its training programme offers addiction counselling training programme currently, simultaneously running 10 courses with 700 students enrolled. The 6 months rehabilitation programme; plus 2 months follow-up, with its daily and weekly schedule became the prototype of all centres in Egypt.
The first attempt to convey professional, practical and spiritual experience on drug rehabilitation from the United Kingdom to Egypt was through David Partington, of Yeldall Christian Centres, in Reading. He conducted a number of trainings to the small group of rehabilitation leaders in Cairo and Alexandria. He then arranged for a 6 weeks visit of the young Dr. Ehab El Kharrat to the UK and the USA in August 1991. The regulations, logistics and programmatic elements of Drug Rehabilitation was thus adapted and applied on a small but slowly growing scale in Egypt. Through this connection Professors of Substance Misuse Psychiatry from the UK and experts from the USA and Europe attended the first conference on a scientific response to addiction in Cairo 1995. One of the leading Professors; Chris Cook visited a few times too between 1995 and 2003. In this period Dr. El Kharrat obtained a PhD form Kent Institute of Medicine and Health Sciences of the University of Kent in Canterbury titled “ A Comparative Study of the Philosophy of Treatment in Substance Misuse Programmes” (1999-2003). By that time Freedom built a large facility for drug treatment and rehabilitation in a reclamation farm, in Wady El Natroun, midway between Cairo and Alexandria, the number of residents rose to 15. Another significant event in this period was the establishment of the International Substance Abuse and Addiction Coalition (ISAAC), with David Partington as the founding Secretary General, one of its aims was to empower addiction workers in two third world countries. A challenge to this was when bringing trainees to the west for training most of them opted not to come back, plus the process was too expensive.
During Dr. El Kharrat 18 months stay in Canterbury for his PhD, he became a trainer in a few courses of both London and Kent Universities. ISAAC decided to provide a training targeting drug and addiction workers from two third world countries, for 6 weeks in Wady El Natroun, Egypt. Dr Jean LaCour. Dean of the NET Institute, Florida USA was joined by other experts and she provided the credentialing of the 240 class room hours. The courses was run under ISAAC and Freedom, and given the name International Substance Abuse and Addiction Centre of Studies (ISAACS) The World Federation of Therapeutic Community recognized the credentialing. The success of the English course led to a growing demand in Egypt in 2002, the 240 hours were spread along 12 weekends monthly modules in Wady. This with the integration of 12-Step TC model marked a paradigm shift in Egypt. Numbers doubled almost every year, Freedom and other centres mushroomed in Egypt to the current (2023) 40,000 beds in more than 800 centres.
The tenure of stay in a drug rehabilitation centre (called halfway house or recovery guest house) became standard to 6 months with another 2 months of follow-up. Four phases of rehabilitation with gradual leaves from the centre, gradual access to phones, pocket many and other privileges. The 7 am to 5 pm daily schedule of activities did not suite the Egyptian culture, activities are conducted on a 10 am to 1 am basis with a siesta/lunch time between 2 pm and 6 pm. Urban and rural locations, and different pay categories with many not-for-profit centres flourished to meet a growing need. The centres are basically run be former users. Many of them received the ISAACS training. The number of Egyptians who received the training is estimated to be 7000, with 2000 trainees from 46 countries. The trainings were provided in English, Arabic and French courses. Later NAADAC “The Association of Addiction Professionals” in the USA provided the credentialing. With the new and synthetic drugs hitting the Egyptian market, and an increased awareness of the role of psychiatrists, psychologists & social workers, their contribution to drug rehabilitation in Egypt has significantly increased.
An international health organization, Family Health International (FHI), started a study on how to reach for People who Inject Drugs (PWID) to prevent the spread of HIV among them. They found that Freedom was the only programme qualified for the task. The first HIV outreach and drop in centre in Egypt was thus launched in 2003. Later 11 other drug rehabilitation programmes joined in. the question of whether 12-Steppers can do outreach for HIV prevention, involving clean needles and safer sex had to be addressed. At first 12-Step groups were extremely suspicious about the work. Freedom called upon the 12th step of carrying the message to suffering addicts as well as called upon the tradition of admitting powerlessness over hurrying the addict into abstinence. The slogan of “Your abstinence is important, but you are more important.” Expressed the methodology of former drug users/ outreach workers inviting their peers in the streets to rehabilitation but if they are not ready they suggest they keep themselves alive by not sharing needles, syringes and paraphernalia, and using condoms. The experiment worked. Through the Freedom centre, 20,000 PWID were reached in the 20 years of operation, an estimate of 15% of them abstained through rehabilitation, a significant change in injection and sexual behaviour was also monitored. For the first group of PWID the results of follow-up meetings with them are shown in the table below:
|First data collection 8/2003 – 3/2005
|6 months Follow-up
|12 months Follow-up
Change In Injection Behaviour: First 628 IDUs:
Freedom and other Drug Rehabilitation Programmes partnered with the Egyptian Ministry of Health (MoH) and FHI in conducting two second generation HIV surveys among key populations Behavioral and Biological Surveillance Surveys (BBSS) in 2006 and 2010. A Response Driven Sampling methodology was applied in both surveys. HIV among both PWID and Men having Sex with Men rose from 1% in 2006 to 7% in 2010 (UNAIDS et al., 2014).
We found no reports on long-term prospective outcome studies of drug rehabilitation in Egypt. However, we report here on an attempt on a large and long-term study carried on by Freedom. In January 2020 Freedom key workers reported on all 2503 residents who were admitted to its 28 drug rehabilitation centres operative during this year. Demographics and abstinence status of this cohort sample was recorded. Then another follow-up on the same sample was conducted January to March 2021. While in January to July 2022: demographics, abstinence status and another 28 questions about these former clients were recorded. Keyworker (counselor)/client reports were verified by randomized urine samples & family members reports. In the Year 3 data collection 467 participants dropped out (including 77 reported dead). However, 82% of the participants were reached in the Year 3 follow-up data collection. 51% of the participants were abstinent in year 3 data collection. 40% of the participants had no relapses at all in the period of the study, while 21% of participants had only one relapse. Graduating the Rehabilitation Programme increased the possibility of abstinence in Year 3 by 263%.70% the participants who were abstinent in Year 1 were abstinent in Year 3. Among those with dual diagnosis only 45% were abstinent in year 3. While 58% of those whose only diagnosis was SUD were abstinent. There were no statistically significant associations between social status and abstinence: Whether the participant is single, married, divorced, or widowed does not impact success of treatment. There was a statistically significant association between socioeconomic conditions and abstinence. Clients from nonsubsidized centres are 40% more likely to achieve abstinence. Interestingly, there was a significant correlation between clients who attempted suicide and abstinence. Those who reported suicidal attempts are 2 times more likely to achieve abstinence than those who did not report attempting suicide.
Several treatment process studies were conducted in cooperation with national and international academic institutions including an interesting PhD thesis on “The Effect of Physical Activity on Rehabilitation of Drug Addicts”. Accepted in 2015 by Helwan University in Egypt this short term follow-up study showed that structured Physical Exercise was found to be more therapeutic than the ordinary sports activities in Wady Centre (Sallama et al., 2014). Similarly, Structured Rational Emotive Therapy sessions were shown to be effective in the improvement of anxiety and negative self-concepts among heroin addicts residents in drug rehabilitation (Mokbal, 2011). A more recent PhD thesis has unexpectedly shown that self esteem deteriorates in the bracket of 3 months in rehabilitation before it improves again (Kostandy et al., 2021).
On another vein an East Anglia University, UK, study probed in depth the behavior and biological indicators of risk behavior among HIV populations within the reach of drug rehabilitation/outreach programmes (Bakhoum et al., 2014; Bakhoum, 2015). A similar project was conducted with George Washington University, USA and an analysis of the HIV outreach (Martinez et al., 2015) and with Columbia University, USA a study on the sociodemographics of PWID was conducxted (Anwar et al., 2022).
One of the factors that contributed to the flourishing of the drug rehabilitation centres in Egypt was its administrative, business and financial model partially informed by a doctorate degree dissertation, accepted in 2013 by the Maastricht School of Management, in the Netherland and titled: Not-For-Profit Healthcare in an Emerging Market: A Case Study of the Implementation of a Quality Management Initiative to Create a Sustainable Drug Rehabilitation Service (Guirguis, 2013).
No licensure is available in Egypt for community-based social drug rehabilitation. With hundreds of “unlicensed” and unsupervised programmes. The MoH of Egypt still insists on imposing a Psychiatric Facility license on them, with exaggerated technical and financial requirements. Many programmes operate under a training centre license or just as guesthouses. Freedom currently advocates mainly with the parliament for an evidence-based approach to the whole issue of drug rehabilitation. On another hand detoxification units operate under license of the MoH, but the requirements of licensing though are more demanding than any place in the world. This creates complex problems to Drug Rehabilitation.
More surveys on the nature of the drug problem in Egypt are needed. But the more urgent need is for outcome prospective studies conducted by a neutral body. A more detailed literature review on the rehabilitation scene in the world to inform treatment process and treatment outcome studies is also needed. We hope to continue for year 5 data collection on the Freedom Outcome Study with external data collection and researchers, and more ambitiously to replicate the study on a national level.
- UNAIDS, UNODC, UNFPA & National AIDS Programme. (2014). An Estimation of Key Affected Populations at Elevated HIV Risk in Egypt.
- Sallama, E. P. A., El Ela Ahmed, A., El-Fattah, A., & El Kharrat, E. (2014). Effect of physical activity on rehabilitation of drug addicts Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Physical Education, Univfersity of Helwan.
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- Anwar, S., El Kharrat, E., Bakhoum, A., El-Sadr, W. M., & Harris, T. G. (2022). Association of sociodemographic factors with needle sharing and number of sex partners among people who inject drugs in Egypt. Glob Public Health, 17(8), 1689-1698. DOI: 10.1080/17441692.2021.1950798
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- Martinez, S., Amira, R., Monica, S. R., Bakhoum, A., & El Kharrat, E. (2018). Cross Sectional Comparison of Behavioral Risk Factors for HIV/HCV in People who Inject Drugs (PWID) in Egypt. The George Washington University. Washington DC. DOI: 10.13140/RG.2.2.18495.97445
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