Co-Curricular Drug Abuse Treatment in a University: Implementation and Evaluation

Abidemi Olubunmi Bello; Peter Olutunde Onifade; John O. Sotunsa; Mojisola D Ariyo; Elizabeth Okonkwo; Olufikayo O Banjo

doi:10.4172/2324-9005.1000128

Research Article, J Addict Behav Ther Rehabil Vol: 3 Issue: 4

Co-Curricular Drug Abuse Treatment in a University: Implementation and Evaluation

Abidemi Olubunmi Bello¹, Peter Olutunde Onifade², John O. Sotunsa³, Mojisola D Ariyo¹, Elizabeth Okonkwo⁴, and Olufikayo O Banjo⁵
¹Department of Medicine, Babcock University Teaching Hospital, Ilishan, Ogun State, Nigeria
²Drug Addiction Treatment, Education and Research Unit, Neuropsychiatric Hospital, Aro, Abeokuta, Nigeria
³Clinical Services Division, Babcock University Teaching Hospital, Ilishan, Ogun State, Nigeria
⁴Elizabeth Okonkwo, Clinical Psychologist, Babcock University, Ilishan, Ogun State, Nigeria
⁵Olufikayo O Banjo, Principal Counselling Psychologist, Student Support Center, Babcock University, Ilishan, Ogun State, Nigeria
Corresponding author : Abidemi Olubunmi Bello Department of Medicine, Babcock University Teaching Hospital, Ilishan, Ogun State, Nigeria Tel: +2348033529704 E-mail: abigirl26@yahoo.com
Received June 30, 2014 Accepted September 08, 2014 Published September 10, 2014
Citation: Bello AO, Onifade PO, Sotunsa JO, Ariyo MD, Okonkwo E (2014) Co-Curricular Drug Abuse Treatment in a University: Implementation and Evaluation. J Addict Behav Ther Rehabil 3:4. doi:10.4172/2324-9005.1000128

Abstract

Co-Curricular Drug Abuse Treatment in a University: Implementation and Evaluation

Background: Babcock University, Nigeria, screened the students at the point of academic registration and implemented a cocurricular treatment programme for those with positive urine drug test. The aim of this study was to evaluate the immediate outcomes of the programme. Methods: The study was approved by the university’s research ethics committee. The participants were the students who screened positive to urine drug test and were hitherto suspended from school to receive treatment but were offered the option of continuing their studies while receiving treatment in the co-curricular treatment programme. Thirty of the students took the offer and participated in this study. They had a 12-week outpatient drug abuse treatment based on the Living in Balance core curriculum. The main outcome measures were urine drug test and Addiction Severity Index. The client’s satisfaction and treatment perception were also assessed. Results: The 30 clients comprised of 25 (83%) males. Mean age was 21.3 (sd=2.88). The most common primary drug of abuse was cannabis (66.7%). The rate of retention in the programme was 86.7%: The rate of positive urine drug test reduced from 100% pretreatment to 3.8% post treatment. There was 36% - 71% decrease in the domain specific Addiction severity index. There was also significant difference between the pre and post treatment global addiction severity index (z= -0.2845, p=0.004). More than 95% of the clients reported that treatment programme was good or excellent and would refer a friend in need of similar help to the programme. The mean Treatment Perception score by the clients was 28.95 (sd=6.09, min=17, max=40) out of the maximum obtainable of 40.

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Keywords
Co-curricular; Undergraduate; Drug abuse; Treatment; Outcome evaluation
Introduction
Co-curricular activities are programmes and learning experiences within or outside the school that complement, in some way, the academic curriculum but do not earn a student any academic credit [1]. In 2013, the Babcock University, Nigeria, commenced a cocurricular substance misuse treatment programme to allow students who had positive urine drug test to receive treatment while still attending classes. Prior to this time, the university established a zero tolerance policy for substance abuse among the students. As part of the policy, students had routine and random urine drug tests. Those who screened positive the first time were suspended from school and were accepted back only if they produced evidence for completing substance abuse treatment in some recognized treatment units. If positive the second time, the students were expelled. Previous substance use surveys conducted among undergraduates in Nigeria showed varying prevalence rates. A study in three universities in South-Western Nigeria showed that stimulants other than the Amphetamine-types stimulants (ATS) had the highest lifetime prevalence rate (53.4%), followed by Alcohol (35.8%). Cannabis was the most prevalent (7.2%) illicit drug. Thirty-day prevalence rate (23.3%) of stimulants other than ATS was also the highest. Cannabis and opiates other than heroin each had 3.5% 30-day prevalence rates [2]. A study in the Eastern part of Nigeria among undergraduate revealed alcohol as the substance ever used by the highest proportion of the students (66.0%), followed by cannabis (44.0%), and valium (32.9%) [3]. In the Northern part of Nigeria, rates of stimulants other than ATS (67.9%). Alcohol and sedatives were 38.0% and 27.0% respectively [4].
The World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (WHO ASSIST) was administered on the students alongside the 2013 routine drug test. The ASSIST findings indicated that not all the students who misused substances needed inpatient treatment, requiring suspension from school (unpublished data). Therefore those who had no or low risk from substance use were given drug education pamphlet based on the WHO self-help guide [5]. Those with moderate risk were given Brief Intervention [6] in addition to the pamphlet. Those who were positive to urine drug test were offered the co-curricular substance misuse treatment programme as an alternative to the hitherto suspension from school. The therapeutic approach of the programme was based on the Living in Balance (LIB) core curriculum [7]; therefore, the programme is tagged Babcock University Balanced Living Initiative (BUBLIN). The aims of this study were to determine the client’s satisfaction and short term outcomes of the programme.
Materials and Methods
Design and setting
Multiple sets of data were collected through cross-sectional evaluation with the approval of Babcock University Health Research Ethics Committee (Ref: NHREC/17/12/2013). Some of the data were repeated measures. The study was conducted in Babcock University, Nigeria, which is one of the private universities located in the South- Western part of Nigeria, owned and operated by the Seventh Day Adventist Church. It has a teaching hospital, which collaborated with the students’ support centre to establish the substance abuse treatment programme.
Programme implementation
The principles: The programme was established on evidence-based principles of effective substance abuse treatment: that substance abuse is a treatable disease but with no single treatment that is appropriate for everyone; that for treatment to be effective, it must address not only substance use, but multi-domain problems affecting the individual; that an individual’s treatment and services plan must be assessed continually and modified as necessary to ensure it meets his or her changing needs; and that drug use during treatment must be monitored continuously, as lapses during treatment do occur [8].
Treatment model: The core curriculum of the LIB model of treatment formed the backbone of the programme. The curriculum provides a comprehensive, group-oriented treatment framework for use in outpatient, short-term, or long-term residential settings. It emphasizes group process and interaction and is associated with a successful outcome study [7]. The 12 core session topics are: Definitions, Terms, and Self-Diagnosis; Drug Education; What Are Triggers?; Planning for Sobriety; Alcohol and Tobacco; Spirituality; Sex, Drugs, and Alcohol; Stress; Skills for Stress; Negative Emotions; Anger and Communication; and Relapse Prevention. The LIB model has not been previously used among university undergraduate in this environment; however, it has been reported to achieve effective, evidence based treatment outcome in two outpatients settings in Washington DC and Los Angeles where, at the end of treatment, it reduced by 50% the number of days in the past in which cocaine was taken. The reduction was 69% three months after treatment. The effectiveness was comparable to that of twelve-step treatment approach [7].
Personnel and Pre-programme training: Twelve individuals participated in the programme as counselors and session facilitators. They comprised of a psychiatrist, clinical psychologists, psychiatric nurses, social workers, occupational therapist and counselors. They had a series of training on screening with the use of The WHO Alcohol Smoking and Substance Involvement Screening Test (ASSIST), the Addiction Severity Index (ASI), treatment planning, the use of the Living in Balance core curriculum and progressive muscle relaxation technique. The training on ASSIST and ASI were based on the volume A of the UNODC TREATNET training package [9]. The LIB training was based on a 62-slide PowerPoint developed from the LIB facilitator’s guide [7], which provides both the philosophical context for the curriculum and the practical, session-specific information needed to help the facilitator lead and assist clients in the recovery process.
Treatment process: Figure 1 depicts the process flowchart of BUBLIN. The programme started with screening of prospective clients (that is, students with positive urine drug test) to determine their level of involvement with substance. Only those with low to moderate levels of risk were eligible. Individuals with high risk were referred. Since the programme was voluntary, every client was given information about the nature of the programme and the guiding rules and they were required to sign a treatment contract. Each client was then assigned to a named counselor who evaluated the multiple needs of the clients, drew the master problem list and designed the treatment plan in collaboration with the client. A counselor had minimum of 2 and maximum of 3 clients assigned to him. The counselor had individual session with the assigned clients for 60-90 minutes on Mondays to implement and evaluate the multidomain treatment plans while all the clients attended the Living in Balance group psycho-educational sessions on Fridays. There were three simultaneous group sessions, each consisting of 10 clients and facilitated by two counselors. Random urine drug test and periodic re-evaluation of client’s needs were part of the treatment process.
	Figure 1: Flowchart of the treatment programme.
Population
In this program evaluation study, two sets of people participated: the clients and the programme facilitators. The former were the students detected to have positive urine drug test. They were given the option of attending the programme as a co-curricular activity or suspension from school as listed in the school policy. The facilitators were some of the staff of the university working in the university teaching hospital and the students support centre. Since the number of the clients was small, a census was done instead of sampling.
Programme evaluation
The facilitators’ trainings were evaluated with pre- and posttraining tests. The outcome of the programme was evaluated with intake and discharge Addiction Severity Index, and series of random urine drug screen. The client’s satisfaction was evaluated with two instruments, namely, the 8-item Client Satisfaction Questionnaire (CSQ-8) and Treatment Perceptions Questionnaire (TPQ).
Instruments
The Addiction Severity Index (ASI): The Addiction Severity Index (ASI) is an interviewer-administered, semi-structured clinical and research interview for comprehensive evaluation of clients’ problems, treatment planning and outcome evaluation. It assesses clients’ problems in 7 domains, namely, medical, employment/ support status, alcohol, drug, legal, family/social, and psychiatric. The TREATNET version is being used in Nigeria [10]. In addition to generating the master problem list of the client, it also yields composite score for each domain and a global index of addiction that can be used to evaluate the effect of treatment. These score are validated mathematical measures of change in problem status and can be calculated with the excel file available at (http://www.tresearch.org/wp-content/uploads/2012/09/Copy-of-CompScoreCalculation. xls). The minimum and maximum obtainable scores globally and on each domain are 0 and 1 respectively, such that the closer to 1 the score is the more severe the problems of the individual. No norm is used for interpreting the score of ASI; instead, scores are compared to determine effectiveness of treatment [11,12]. Due to the fact that all the participants in this study were all university students, the composite score for the employment/support status was not appropriate and thus not calculated. Not more than two clients were assigned to one counsellor for the purpose of ASI administration, which was done on individual basis on days when group sessions did not take place.
The urine toxicology screening kit: DRUGCHECKR Dip Drug Test manufactured by Express Diagnostic International Incorporation, USA, was used for the urine drug test. The test is based on the principle of competitive immunochemical reaction between a chemically labeled drug (drug protein conjugate) and the drug or drug metabolites which may be present in the urine sample for the limited antibody binding sites. The kit is a one-step immunoassay for the qualitative detection of multiple drugs and drug metabolites in human urine at the following cut off concentrations (ng/ml): Amphetamine (d-Amphetamine) -1000; Barbiturate (Secobarbital) – 300; BUP (Buprenorphine) - 10; BZO (Oxazepam) – 300; COC150 (Benzoylecgonine) -150; Cocaine (Benzolecgonine ) – 300; MDMA (3,4-methylenedioxymethamphetamine) – 500; MET500 (d-Metamphetamine) -500; MET (d-Methamphetamine) – 1000; MTD (Methadone) -300; OPI1300 (Morphine) – 300; OPI (Morphine) – 2000; OXY (Oxycodone) – 100; PCP (Phencyclidine) – 25; PPX (Propoxyphene) -300; TCA (Nortriptyline) -1000; and Cannabis (Tetrahydrocannabinol) – 50 . An internal procedural control is included in the test device. The accuracy and specificity of the drug screen kit is comparable to commercially available drug screen tests [13].
The 8-item Client Satisfaction Questionnaire (CSQ-8): The CSQ-8 is an 8-item, easily scored and administered measurement that is designed to measure client satisfaction with services. The CSQ- 8 is one-dimensional, yielding a homogeneous estimate of general satisfaction with services. It produces a range of 8 to 32, with high scores indicating greater satisfaction. It has been translated into more than 20 languages [14]. The questionnaire was self-administered by all the clients (26) who attended the last group treatment session.
Treatment Perceptions Questionnaire (TPQ): Treatment Perceptions Questionnaire is a 10-item, 5-point likert instrument designed to assess perceptions of clients towards two objects - the treatment staff; and the treatment service, operations and rules [15]. It is scored 0-4 with maximum total of 40. Its internal reliability is between 0.8 and 0.83. [15,16]. The questionnaire was self-administered by all the clients (26) who attended the last group treatment session.
Pre-post training questionnaires for the programme facilitators: The pre-post questionnaires for the training on ASSIT, ASSIST-based Brief Intervention, ASI and treatment planning are part of the Volume A of the UNODC TREATNET training package [9]. They are contained in the modules 1, 2 and 3 of the volume respectively and are each 5-item mixture of best-answer and multipleanswer objective questions. The LIB pre-post questionnaire is 34-item true-false multiple choice instrument. The first 9 items are on general issues relating to screening and treatment options. Items 10-16 are on the nature, principle and applications of LIB. Items 17-20 and 21-24 are on the activities of the facilitator before and during a LIB session respectively. Items 25-28 are on facilitation of role plays while items 29-34 are on facilitating progressive muscle relaxation. UNODC TREATNET Training Satisfaction Survey questionnaire was used to elicit trainees’ perception. It is a 9-item instrument, with the first six being likert scale.
Data analysis
Data was analyzed with SPSS version 16. Data exploration was done with simple frequency, mean and standard deviation. Wilcoxon Signed Ranks test was used to determine the difference in means of repeated measures while Mann-Whitney U test was used to determine the difference in the means of two independent measures. The confidence interval was set at 95% and p<0.05 was taken as significant.
Results
Socio-demographic variables of the facilitators and clients
Table 1 shows the information about the facilitators and the clients. Twenty personnel from various departments attended the series of trainings for facilitators. They were mostly females (55%) and social workers (40%). The program started officially on the 27th of January, 2014 with 30 enrolled clients, 25 (83.5%) of whom were males. Their age ranged between 16 and 26 years, the mean being 21.3 years (sd=2.88). Twelve (40%) of them were in the first year of study, 10 (33%), and the rest were in the intermediate classes. There were all resident in the campus hostels. The most common primary drug of abuse was Cannabis (66.7%) followed by Codeine contained in cough syrup (16.7%).
	Table 1: Facilitators and clients’ variables.
Pre- and post-training evaluation
The post-training mean scores for the three training sessions were significantly higher than the pre-training means: Addiction Severity Index (z=-2.96, p=0.003), Treatment planning (z=-3.42, p=0.001), Living in balance (z=-3.41, p=0.001). All the trainees either strongly agreed or agreed that the training was well organized; the material presented would be easily applicable when working with substance abuse clients; the trainer was receptive to participant comments and questions; the training enhanced their skills in the topic areas; they expected to use the information gained from this training to benefit their clients and were satisfied with the training experience.
Treatment evaluation
Retention, urine drug screen and addiction severity: The rate of retention in the programme was 86.7%: Two were evicted because of repeated positive random urine drug test while in treatment; another 2 were evicted because of rule breaking. The rate of positive urine drug test reduced from 100% pre-treatment to 20% first random test, 13.3% second random and 3.8% post treatment. Table 2 depicts the changes in the addiction severity index of the client before and immediately after treatment The 6-month post treatment evaluation is not included in this report. Thirty clients had the pretreatment evaluation with the ASI but only 11 of them had the immediate post treatment ASI because the evaluation coincided with the end of the academic session and some of the students had left for home before their counsellors got round to administering the ASI . There was no statistical difference in the pre-treatment global addiction severity index of those who had post-treatment ASI evaluation and those who did not (z= -0.28, p=0.8). For the former, there was 36% - 71% decrease in the domain specific severity indices and 61% decrease in the global index. There was also significant difference between the pre and post treatment global index (z= -0.2845, p=0.004) and the pre and post treatment drug use domain scores (z=-1.988, p=0.047).
	Table 2: The Addiction Severity Index pre- and post-treatment.
Client satisfaction and treatment perception: Out of the 26 clients who received the self-administered questionnaires, 24 (92.3%) submitted completed answers. As seen in Table 3, 23 (95.8%) of the clients reported that treatment programme was good or excellent, 24 (100%) that it provided the kind of service they wanted and were satisfied with the amount of help they received. All of them reported that they would refer a friend in need of similar help to the programme and more than three-quarter would come back to the programme if they were to seek help again.
	Table 3: Satisfaction with the BUBLIN service.
The mean Treatment Perception score by the clients was 28.95 (sd=6.09, min=17, max-40) out of the maximum obtainable of 40. As depicted in Table 4, while 3 (12.5%) were not sure, 20 (88.3%) perceived that they were well informed about decisions made about their treatment. Twenty-three (95.9%) and 22 (91.7%) perceived that the counsellors helped to motivate them to sort out their problem and that the counsellors staff were good at their jobs respectively. However, 13 (54.1%) reported they were either unsure or did not like some of the treatment rules or regulation and 6 (25%) perceived that the staff and them had different ideas about what the treatment objectives should be. Also as shown in Table 4, between a fifth and a third of the clients had negative perception towards the attitudes of staff to the kind of help the clients needed, the difference in the ideas the staff and clients had about the treatment objectives and towards the treatment sessions attended.
	Table 4: Treatment perception.
Discussion
There is no known published report on the implementation and evaluation of a university-campus-based, co-curricular drug abuse treatment programme. However, some drug treatment programmes like that of the University of California, Los Angeles [17] incorporated Brief Intervention (BI) treatment into the counseling services of the University.
To the authors’ knowledge, there is currently no co-curricular substance abuse treatment programme set up by a university. This programme had BI as an element and a full-fledged outpatient programme to cater for the students who needed more than BI. The facilitators of the programme had effective training to work in the programme. The programme was effective in significantly reducing the Addiction Severity Index and the rate of positive urine drug test among the clients.
The study was embarked upon to provide a lifeline to clients who screened positive to urine drug test by treating them and helping them to achieve balance in their lives. This kind of evidence based treatment is the first of its kind among university students in Nigeria and perhaps anywhere else. The program was able to achieve abstinence among the clients in line with the zero tolerance drug abuse policy operating in Babcock University. In addition, clients benefited from support group as well as a team of multidisciplinary personnel in addiction recovery programme. Therefore this study can provide initial template for establishing such programme in other universities.
However, it is not certain if the programme was solely responsible for the reduction in rate of positive in- and post-treatment urine drug test. If there was no school policy that suspended clients with repeated in-treatment urine drug test, would the observed treatment outcome be the same? This is a question that can only be answered with a controlled or case-control study design. The highly positive perception of the clients about the programme is a good indirect indicator of the effectiveness of the treatment [15]. Though substantial proportion of clients had negative perception towards some of the items, the mean TPQ score 28 in this study was greater than the 16.8 reported in prison settings, 21.5 in residential settings and the 23.3 in community settings [18].
The administration of ASI to 100% of the clients for pretreatment evaluation was higher than the 46-78% reported in a Nigerian in-patient substance abuse treatment programme [10]. The participation of only 11 (42.3%) of the 26 eligible for the immediate post treatment ASI evaluation was rather low. Reasons for this were not systematically studied but some of the reasons for low rate of ASI administration have been reported to include schedule of staff duty [10]. The counsellors in this evaluated programme were not full-time in the programme. They had their primary duties in their respective departments in the university and the university teaching hospital.
Strengths
The study used international instruments which offer the opportunity of comparing the results across settings and countries.
Limitations
The long term effect of the programme was not evaluated. Sixmonth and one-year follow-up assessment with Addiction Severity Index in addition to urine and hair drug tests will indicate the long term effectiveness or otherwise of the treatment programme.
Recommendations
Co-curricular substance abuse treatment is feasible and has immediate benefits at reducing the addiction severity of the undergraduates and their rates of positive urine drug test. Students with mild to moderate levels of risk from use of psychoactive substances can receive effective treatment alongside their academic programme. A policy to screen all students at the beginning of each academic session and provide treatment for those at high risk of negative consequences of drug use will contribute to the fight against drug abuse among the undergraduates.
References
Great Schools Partnership (2013) The Glossary of Education Reform: Co-curricular, Portland. Onifade PO, Somoye EB, Ogunwobi OO, Fadipe B, Fela-Thomas AL, et al. (2014) Drug use, consequences and perceived accessibility in three Nigerian universities. Open Journal of Psychiatry. 4:60-67. OkozaJ, Aluede O, Fajoju S, Okhiku I (2009) Drug abuse among students of Ambrose Alli University, Ekpoma, Nigeria. European Journal of Social Sciences. 10:85-92. Makanjuola AB, Daramola TO, Obembe AO (2007)Psychoactive substance use among medical students in a Nigerian university. World psychiatry6:112-114. Humeniuk RE, Henry-Edwards S, Ali RL, Meena S (2010) Self Help Strategies for cutting down or stopping substance use - a guide. World Health Organization, Geneva. The ASSIST-linked brief intervention for hazardous and harmful substance use - Manual for use in primary care (2010) World Health Organization, Geneva. Hoffman JA, Landry MJ, Caudill BD (2003) Living in Balance facilitator Guide. Hezelden Foundation, USA. Principles of drug addiction treatment - A research-based guide (2009), In: Abuse NIoD (3rdedtn.) U.S: NIDA, National Institutes of Health, U.S. Department of Health and Human Services. United Nations Office on Drugs and Crime (2008). VOLUME A: Screening, Assessment, and Treatment Planning. Onifade PO, Osisanwo OO, Ganzallo OA, Akinhanmi AO, Amosu SM, et al. (2013) Use of Addiction Severity Index in a Nigerian Drug Abuse Treatment Unit: A Clinical Audit. J Alcoholism Drug Depend 1:107. McGahan P, Griffith J, Parente R, McLellan A. Addiction Severity Index composite score manual. Treatment Research Institute, Philadelphia, PA. TRI (2014) Important Note on Scoring the ASI. Philadelphia, PA. Express Diagnostic Int’l (2012) DrugCheck. Dip Drug Test. Express Diagnostic Int’l, Inc, USA. Matsubara C, Green J, Astorga LT, Daya EL, Jervoso HC, et al. (2013) Reliability tests and validation tests of the client satisfaction questionnaire (CSQ-8) as an index of satisfaction with childbirth-related care among Filipino women. BMC Pregnancy Childbirth 13: 235. Marsden J, Nizzoli U, Corbelli C, Margaron H, Torres M, et al. (2000) New European instruments for treatment outcome research: reliability of the maudsley addiction profile and treatment perceptions questionnaire in Italy, Spain and Portugal. Eur Addict Res 3:115-122. Morris ZS, McKeganey N (2007) Client perceptions of drug treatment services in Scotland, Drug-EducPrevPolic; 1:49-60. Denering LL, Spear SE (2012) Routine use of screening and brief intervention for college students in a university counseling center. J Psychoactive Drugs 44: 318-324. Morris ZS, Gannon M (2008) Drug misuse treatment services in Scotland: predicting outcomes.Int J Qual Health Care 20: 271-276.

Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

Co-Curricular Drug Abuse Treatment in a University: Implementation and Evaluation

Abstract

Keywords

Introduction

Materials and Methods

Results

Discussion

References

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