Drug and alcohol problems know no borders. Annually, the United Nations World Drug Report documents that heroin, methamphetamine, cocaine, alcohol, and prescription drugs negatively impact public health, public safety, and social institutions in countries around the world. In many parts of the Middle East, there is limited data on the nature and extent of alcohol and drug problems. In many countries in the region, governments and universities lack the infrastructure, funds, and expertise to conduct well-designed epidemiological evaluations.
A series of substance abuse needs assessment workshops and clinical training efforts with Middle East health and policy leaders and US participants in the 1990s was the foundation for an agenda of research, training, and capacity-building on alcohol and drug problems in the region. This initial work has led to a program of addiction-related work in the Middle East region involving the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO). The goal for the authors has been to work with public health and clinical leaders in the region to identify the nature and extent of substance use problems, to employ scientifically sound methods to measure and address these problems, and to provide training and technical assistance to help build a well-trained research and clinical workforce in the region. Beyond that, the overarching hope is that the work will help build substance abuse expertise in a context of cooperation across borders and above politics among the people in the region, who all hope for healthy families and drug-free communities.
A seminal event in this endeavor was a meeting on September 5–7, 2005, in which 58 researchers and policymakers from 23 countries and territories gathered in Istanbul, Turkey, for the landmark conference titled “Delivery Systems for Substance Abuse Treatment: An International Conference.” The conference was funded by the US Institute of Peace (USIP), as well as by the US Agency for International Development (USAID), UNODC, WHO, the US Substance Abuse and Mental Health Services Administration, and the US National Institute on Drug Abuse. Participating countries included ten Middle Eastern/Eastern Mediterranean countries, selected European and African countries, and the United States. A central component of the meeting was a series of presentations by each of the country representatives describing the nature and extent of the substance use problems in each country, a description of their prevention and treatment infrastructure, and a discussion of country priorities for data and service development.
One of the most commonly noted service development needs reported in the 2005 Istanbul meeting was the absence of a trained workforce to provide treatment for substance use disorders. While some of the country representatives reported that there were physicians and nurses with expertise in the treatment of substance use disorders, there was virtually unanimous agreement that in all countries represented, there was an inadequate number of individuals trained to deliver non-medical, psychosocial addiction treatment services.
Figure 1: Conference Group Photograph — Istanbul, Turkey [Bosphorus in background. Photograph by Ali Kabas]
Addiction Treatment Workforce Development in Egypt
At the beginning of the 21st century, the addiction treatment system in Egypt consisted of addiction services delivered in private and public treatment programs, as well as in the office practices of psychiatrists. However, in all of these settings, there was a severe shortage of counselors/therapists systematically trained to assess and treat individuals with alcohol and drug problems. With funding from the USAID, and through a memo of understanding between the Medical School at Kasr Al-Ainy (Cairo University) and the UCLA Department of Psychiatry, UCLA Integrated Substance Abuse Programs (ISAP) researchers and teachers and Egyptian colleagues developed an addiction system development program. Activities included implementation of the use of an Arabic-language Addiction Severity Index in Egyptian treatment centers, numerous clinical training workshops on cognitive behavioral therapy, motivational interviewing, and the Matrix Model behavioral treatment approaches, and workshops on addiction pharmacotherapies. Further, UCLA faculty worked with members of the Faculty of Medicine Cairo University (FMCU) on specific, targeted programs, including development of data collection and treatment services for addicted individuals in Egyptian prisons and the investigation of the relationship between drug use and infectious diseases in prisons.
In 2007, UCLA became the lead group for curriculum development for the UNODC Treatnet Program, a worldwide network of training centers in the area of substance use disorder treatment. One of the Treatment Centers was located in Cairo, which was selected as the site for the initial Treatnet training session. The addiction training activities conducted by the Egyptian Treatnet trainers as part of the Treatnet Program, together with the ongoing UCLA training and technical assistance efforts described above, created a “critical mass” of addiction training activity in Cairo that has spurred a desire for a more formalized training program and a process for certifying professionals as addiction counselors. With the opening of the Kasr Al-Ainy Psychiatric Hospital in 2010 and an expansion of addiction treatment and teaching activities, the development of an addiction counselor training program under the auspices of Kasr Al-Ainy has provided the expertise and academic infrastructure for the development of such a training program.
The Kasr Al-Ainy Training Program for Addiction Counselors
At the present time, there are no accredited addiction counselor training programs in the entire Middle East. Although ad hoc addiction training events periodically take place in the region by a variety of groups, including the UNODC Treatnet program, there are no educational programs to provide individuals with a career path into the addiction counseling field. As the health systems in the region build capacity to treat individuals with substance use disorders, there is an increasing need for a workforce to assist the MDs and nurses in the delivery of clinical care. Psychosocial treatment is the current best practice for treating individuals with stimulant use and cannabis use disorders and is a necessary component of treatment even when addiction medications are used. Consequently, the need for well-trained addiction counselors is a priority in developing health systems in the Middle East.
The foundation for the counselor training program is based on the ten-year partnership between FMCU and UCLA, and each group brings a unique set of credentials to the program. Kasr Al-Ainy is a major educational institution in Egypt and the entire Middle East region. Its psychiatric training program has developed a well-recognized cadre of experienced psychiatrists in the area of addiction treatment. The many members of the FMCU have passed the International Society of Addiction Medicine (ISAM) addiction specialty examination and many play leading roles in treatment facilities and addiction efforts in Egypt, as well as with WHO and UNODC in substance use issues in the Middle East region. The UCLA team has an extensive history of conducting international addiction research and providing technical assistance. The key members of the cooperative FMCU and UCLA team are listed below.
The content of the training program will draw heavily from the content of the Treatnet curriculum. The overarching professional development framework will follow the guidelines provided in the Center for Substance Abuse Treatnet (CSAT) Technical Assistance Publication (TAP) Series 21, entitled “Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice,” which provides a consensus review of the essential elements of counselor knowledge. Although the Treatnet materials have been developed for an international audience, the specifications of the framework and specific legal/regulatory considerations for defining professional conduct will be adapted for professionals in Egypt. At present, the plan is for the training program to include 270 hours of didactic coursework, with supervised clinical experience of 2,000 hours. At present, efforts are underway to ensure that the course content and specifications are in compliance with international accreditation groups.
The first week-long training session of this new program was conducted in early June at Kasr Al-Ainy Psychiatric Hospital in Cairo. There were 42 attendees from Egypt. In addition, there were attendees from Palestine and Iraq. Participant feedback was excellent and the second week-long session is being scheduled for fall 2011. As news of this counselor training program has spread, expressions of interest have been made by health leaders from several other countries in the region about having counselor candidates from these countries come to Kasr Al-Ainy for training and/or having FMCU/UCLA faculty assist these countries in the development of their own training courses. There are currently plans underway for teams of professionals from Iraq and Palestine to participate in the future training activities and to use the Kasr Al-Ainy program as a major training resource in the development of their addiction treatment systems.
While the workforce development goals of this project are paramount, the training, technical assistance, and program development activities provide a superb context for a very positive and productive “people to people” opportunity. To date, over 20 US addiction experts and teachers have traveled to Cairo to contribute their expertise and work cooperatively with Egyptian and other Middle East colleagues. In the current wake of the Arab Spring revolutions, attitudes about how countries in this region will relate to the United States are mixed, and there is much uncertainty about the future of Egyptian-US relations. The activities surrounding the development of academic and training partnerships to build a needed portion of the Egyptian health system offers a superb opportunity for cooperative and mutually respectful relationships among Egyptian and US participants. To the extent that this partnership can be of assistance to others in the region, it offers an even larger forum for demonstrating that the context of constructive and meaningful workforce and system development efforts can promote positive human relations between US professionals and their peers in the Middle East region.
The FMCU-UCLA Cooperative Team
The FMCU team is led by the Director of Addiction Psychiatry, Tarek A. Gawad, MD, who is a recent past president of the International Society of Addiction Medicine (ISAM). Other key contributors to the program are Momtaz Abd El-Wahab, MD (Head of Psychiatry Department), Samir Abolmagd, MD (Professor, Department of Psychiatry), Maha Mobasher, MD (Professor, Department of Psychiatry), Salwa Erfan, MD (Professor, Department of Psychiatry), and Rania Mamdouh, MD (Lecturer, Department of Psychiatry).
The key UCLA participants include Richard Rawson, PhD, and Thomas Freese, PhD, both long-time addiction researchers and educators. Dr. Rawson has a 35-year career of addiction clinical work, research, and training and was principal investigator (PI) on the UNODC Treatnet Curriculum Development project. Dr. Freese has a 15-year history of clinical work, research, and training and is currently the PI of the Pacific Southwest Addiction Technology Transfer Center (PSATTC). Grace Kim from UCLA is organizing the training program and will oversee the process of developing accreditation for the program.
. United Nations Office on Drugs and Crime (UNODC), World Drug Report 2011, http://www.unodc.org/documents/data-and-analysis/WDR2011/World_Drug_Rep….
. R. Isralowitz, M. Afifi, and R. Rawson, eds., Drug Problems: Cross-Cultural Policy and Program Development (Westport, CT: Auburn House, 2002).
. J. Tomás-Rosselló, R.A. Rawson, M.J. Zarza et al., “United Nations Office on Drugs and Crime International Network of Drug Dependence Treatment and Rehabilitation Resources Centres: Treatnet,” Substance Abuse, No. 31 (2010), pp. 251–263.