Drug addiction is a big problem in Zambia. This presentation discusses where we are and what needs to be done

1. Harm Reduction in Zambia
Dr. Ravi Paul
Consultant Psychiatrist
Silver Lining Health Care Limited

2. Definition
• Harm Reduction: Policies and programs which attempt to reduce the
adverse health, social and economic consequences of drug use to
individual users, their families and communities (International Harm
Reduction Association). Principal element is reducing harmful
consequences of drug use without necessarily reducing drug use.
• Harmful consequences include BBIs, social costs, legal aspects

3. Definitions
• Overdose: Taking too much or more than the recommended quantity of a
drug/substance, whether prescription, over-the-counter, legal or illegal, either
accidentally or intentionally resulting in harmful effects to the body’s functions
• Toxicity: this occurs when a person has accumulated too much of a substance in
their bloodstream, leading to adverse effects within the body. It may happen
when the dose taken is too high or the liver or kidneys are unable to clear the
drug from the bloodstream, allowing it to accumulate in the body.
• Withdrawal: A group of symptoms that occur when a person with a substance
use disorder reduces or stops taking the psychoactive substance, thereby
causing him/her to experience physical and physiological disturbances.
• Relapse: A return to drug use after a period of abstinence. It is often
accompanied by reinstatement of dependence symptom

4. MEDICALLY ASSISTED THERAPY
• The ultimate goal of MAT is to reduce harmful:
• health,
• psychological and
• socioeconomic consequences of drug use.

5. AIM OF MAT
• The overall aim of Medically Assisted Therapy (MAT) is to
• Provide clear guidance on the use of medications
• other interventions for opioid agonist maintenance treatment in order to
reduce or stop opioid use,
• enhance physical and mental health status, psychosocial wellbeing and
quality of life for persons with opioid use disorders.

6. Facilities with Harm Reduction Programmes
• Chainama Hills College Hospital
• UTH Clinic 6-Department of Psychiatry
• Ndola Central Hospital
• Livingstone General Hospital: Psychiatry Unit
• Kafue Teen Challenge
• SHARPZ
• REFEDUM
• Great North Academy
• Silver Lining Health Care
• Renaisense

7. Chainama Hill College Hospital
• Rehabilitation Unit
• Basic Medicines for detox
• Naltreoxone Implant
• Suboxone
• Tramadol
• Diazepam
• Restraining Units
• Counseling services ( CETA, CBT, Brief Relapse Prevention)

8. CHCH Challenges…
• Medicines are available but staff not trained to administer
• No training was done for Naltreoxone Implants or Suboxone
• No Opioid Replacement Therapy available
• Stigma of being a “Mental Hospital”
• Shorter stays

9. UTH Clinic 6…Department of Psychiatry
• Hub of training in Mental Health in Zambia
• Have trained around 10 Psychiatrists and over 50 Clinical
Neuropsychologists and Clinical Psychologists
• Offers CETA, CBT, ART, and Psychodynamic Counseling
• All services are offered by trained staff with a masters degree
• Runs once a week Drug and alcohol Clinic
• Mostly a referral unit to CHCH
• Manages SUDs at out-patient level only
• Supports satellite clinics at Kanyama, Chilenje and Matero

10. Challenges…
• No assigned psychiatry beds
• No medicines for detox are available
• No rehabilitation units
• Lack of support from UTH
• Poor collaboration with NGOs

11. Ndola Central Hospital
• 10 -15 assigned psychiatry beds
• In-patient facility available
• Managed by Clinical Officer/ Mental Health Nurse
• Out-patient management with antipsychotics and benzodiazepines
• Alcohol related disorders managed well
• Opioids: No treatment available
• Cannot manage serious intoxication/withdrawals or psychosis
• High prevalence of opioid use
• Clinical Psychologist available

12. Livingstone General Hospital-Psychiatry Unit
• 3 -5 Psychiatry beds
• Out-patient facility more robust
• Run by a Consultant Psychiatrist in the past
• Brief Relapse Prevention, CBT, ART therapy
• Hub for ART therapy
• Well equipped Psychosocial Counseling services (Volunteers)
• Opioid replacement therapy not available
• Naltreoxone tablets

13. Teen Challenge, Kafue
• In-patient rehab unit
• 12 step programme
• Run by Rev. Wafuka and brothers (SDA Church)
• Programme lasts 1 year
• High success rate
• Not an enclosed place, consent necessary, good location
• Only counseling and retention services
• Close collaboration with SLHC (Silver Lining Health Care) for detox

14. SHARPZ (SERENITY HARMS REDUCTION
PROGRAMME ZAMBIA)
• Longest running
• Well trained and highly committed staff
• Involved in many research activities around drug, alcohol and HIV
• CETA-Alcohol, Trauma Focussed Cognitive Behaviour Therapy(TFCBT),
12 Step Programme
• Run in-patient programmes for 1 to 3 months
• Close collaboration with SLHC for detox and other psychiatric services
• Well supported by John Hopkins

15. MIND CHANGE CENTRE AT REPHIDIM
INSTITUTE
• Residential
• Provides scope for improving/continuing education
• Helps school going children mostly
• Close collaboration with SLHC
• Counseling services only

16. Decisive Minds
• Established 2017
• Has strong collaboration with SLHC and other NGOs
• Worked with SLHC on a Project of detox and rehabilitation of 30
opioid dependent individuals
• Works closely with UNODC (ID users)

17. Great North Academy
• Out patient and in-patient services
• Opioid replacement therapy not available
• Staff is able and committed
• Run by Clinical Officer Psychiatry
• Alcohol dependence

18. SILVER LINING HEALTH CARE
• Longest running facility in private
• Out-patient services only
• Day admissions
• Manages emergencies like opioid overdoses, intoxication and severe
withdrawals
• Naltreoxone tabs and implants available and administered to clients
• Disulfiram tabs, Injections and Implants for alcohol abuse
• Benzodiazepines all ranges available
• Tramadol based detox: very successful (Case Study published in
addictions journal)
• Highest success rates with alcohol dependence

19. SILVER LINING HEALTH CARE
• Pycho-social counseling services
• Link up with leading insurance companies
• CBT, ART, CETA trained professionals
• Caters to around 15,000 clients
• Managed by Psychiatrists and Clinical Psychologists
• No in-patient services
• No methadone replacement therapy
• No buprenorphine availability

20. Renaisense
• Run by Psychiatrists
• Counseling services mainly
• Clinical Psychologists well trained in CBT, ART, TFCBT
• No in-patient services
• Minimal use/dispensing of medicines
• Promotion of mental health
• Awareness campaigns

21. Efficacy of the Common Elements Treatment Approach (CETA) for Unhealthy Alcohol Use Among Adults
with HIV in Zambia: Results from a Pilot Randomized Controlled Trial
Jeremy C Kane 1 2, Anjali Sharma 3, Laura K Murray 4, Geetanjali Chander 5, Tukiya Kanguya 3, Stephanie
Skavenski 4, Chipo Chitambi 3, Molly E Lasater 4, Ravi Paul 6, Karen Cropsey 7, Sachi Inoue 8, Samuel
Bosomprah 3, Carla Kmett Danielson 9, Jenala Chipungu 3, Francis Simenda 10, Michael J Vinikoor 3 7
• This randomized controlled trial tested the efficacy of a multi-session, evidence-based, lay
counselor-delivered transdiagnostic therapy, the Common Elements Treatment Approach
(CETA), in reducing unhealthy alcohol use and comorbidities among persons living with
HIV (PLWH) in Zambia. Adult PLWH with (a) unhealthy alcohol use plus mental health or
substance use comorbidities, or (b) severe unhealthy alcohol use were randomized to
receive a single-session alcohol brief intervention (BI) alone or BI plus referral to CETA.
• Outcomes were measured at baseline and a 6-month follow-up and included Alcohol Use
Disorders Identification Test (AUDIT) score (primary), depression and trauma symptoms,
and other substance use (secondary). We enrolled 160 participants; 78 were randomized
to BI alone and 82 to BI plus CETA.
• Statistically and clinically significant reductions in mean AUDIT score from baseline to 6-
month follow-up were observed in both groups, however, participants assigned to BI plus
CETA had significantly greater reductions compared to BI alone (- 3.2, 95% CI - 6.2 to -
0.1; Cohen's d: 0.48). The CETA effect size for AUDIT score increased in line with
increasing mental health/substance use comorbidity (0 comorbidities d = 0.25; 1-2
comorbidities d = 0.36; 3+ comorbidities d = 1.6).
• Significant CETA treatment effects were observed for depression, trauma, and several
other substances. BI plus referral to CETA was feasible and superior to BI alone for
unhealthy alcohol use among adults with HIV, particularly among those with
comorbidities. Findings support future effectiveness testing of CETA for HIV
outcomes among PLWH with unhealthy alcohol use.

22. Randomized Control Trial on Trauma
Focused CBT in Zambia
• The purpose of this study was to study the effectiveness of Trauma
Focused Cognitive Behavioral Therapy in subset of children who are
affected by trauma with significant mental health symptomatology in
order to
• examine the effectiveness of TF-CBT in reducing the severity of mental health
symptoms experienced by traumatized children and adolescents in Lusaka
and
• determine the effectiveness of TF-CBT in reducing HIV risk taking behaviors
and increasing coping strategies and health promotion activities in
traumatized children and adolescents in Lusaka.
• The study was integrated into current programing of the Serenity Harm
Reduction Programme, a community and faith based organization focusing on
mental health and substance use prevention and treatment, and its partners
in 5 compounds.

23. Where do we stand?
• Poor infrastructure
• No proper training in harm reduction: Promoted and enrolled
• Minimal use of tools for identifying the drug and alcohol related problems
(ASSIST; SPIRT; AUDIT;CAGE)
• Research projects promise a lot but failure to disseminate the results
• Most of the psychosocial therapies are westernised and not structured
according to Zambian patterns of drug use
• Pastoral counseling should be robust and encouraged
• ECR programmes should turn into pilot projects
• Bed space provision for SUDs in all district and Provincial Hospitals