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دسترسپذیری و دسترسی به خدمات درمانی برای افراد مبتلا به اختلالات مصرف مواد مخدر همچنان در سطح جهانی محدود است، زیرا سالانه فقط یک نفر از هر هشت فرد مبتلا به اختلالات مصرف مواد درمان دارویی دریافت میکند. علاوه بر این، در حالی که یک سوم مصرفکنندگان مواد مخدر زنان هستند همچنان تنها یک پنجم یا حتی کمتر تحت درمان قرار میگیرند. اطلاعات مربوط به افرادی که تحت درمان مصرف مواد قرار دارند، بینشی مفید نسبت به روندها و تغییرات جغرافیایی فراهم میکند. با این حال این اطلاعات نه تنها سطح تقاضای این درمان را نشان میدهد (تعداد افرادی که درخواست کمک میکنند یا مثلاً توسط سیستم عدالت قضایی یا خانوادههایشان به مراکز درمانی ارجاع میشوند) بلکه میزان دسترسپذیری و دسترسی به خدمات درمان مواد مخدر را نیز نمایان میکند.
در طول یک و نیم دهه گذشته در همه مناطق به جز آفریقا نسبت ارائه درمان مواد مخدر برای موارد اختلالات مصرف حشیش افزایشی بوده است. در بیشتر مناطق تقریباً نیمی از افرادی که تحت درمان اختلالات مصرف حشیش وارد شدند برای اولین بار تحت درمان قرار گرفته بودند و میانگین سنی آنها ۲۶ سال بود. [۱]اگرچه نسبت افراد درمانشده برای حشیش به عنوان ماده مخدر اصلی در آفریقا رو به کاهش بوده است ولی همچنان رقمی قابل توجه است (۵۰ درصد در سال ۲۰۱۸). مثلاً در غرب و مرکز آفریقا بین سالهای ۲۰۱۴ تا ۲۰۱۷ بیش از ۷ نفر از هر ۱۰ نفری که تحت درمان دارویی قرار داشتند برای اختلالات مصرف حشیش درمان میشدند. نسبت فزاینده افرادی که به دلیل اختلالات مصرف اوپیوئیدها در آفریقا تحت درمان قرار دارند احتمالاً افزایش مصرف این مواد به ویژه ترامادول را در غرب و مرکز این قاره نشان میدهد. در این منطقه، اوپیوئیدها (هروئین و ترامادول) پس از حشیش دومین نوع ماده مخدر متداولی بودند که افراد طی دوره زمانی ۲۰۱۴ تا ۲۰۱۷ به دلیل مصرف آنها به خدمات درمانی دسترسی یافته بودند.
افزایش تقاضای درمان در ارتباط با اختلالات مصرف حشیش در برخی مناطق توجه ویژه میطلبد. در تعریف و شیوه اجرای محتوای درمان اختلالات مصرف حشیش تنوع بالایی وجود دارد. این درمان در حال حاضر شامل مداخلات رفتاری یا روانشناختی-اجتماعی مانند رفتاردرمانی شناختی است (که در آن انواع طرز تفکر غیرمنطقی و منفی به چالش کشیده میشود و مهارتهای مقابلهای جایگزین ترویج میشود) و مصاحبه انگیزشی هم بخشی از این درمان است (که در آن انگیزه شخصی کاربر برای تغییر رفتار خود تسهیل و تشویق میشود. این مداخلات میتوانند از تماس یا غربالگری آنلاین یکباره و مداخله مختصر در یک محیط سرپایی تا یک برنامه درمانی جامعتر شامل درمان سایر بیماریهای همراه در محیط سرپایی یا بستری متفاوت باشد. برخی عوامل مؤثر احتمالی بر تعداد افراد تحت درمان برای اختلالات مصرف حشیش را میتوان چنین برشمرد: تغییر تعداد افرادی که واقعاً به درمان نیاز دارند، تغییرات سیستم ارجاع درمانی، تغییر در آگاهی از مشکلات احتمالی مرتبط با اختلالات مصرف حشیش. و تغییرات دسترسپذیری و دسترسی به درمان این اختلالات مصرف حشیش.
اوپیوئیدها (عمدتاً هروئین) همچنان اصلیترین مواد مخدری هستند که افراد در اروپا (به ویژه اروپای شرقی و جنوب شرق اروپا) و آسیا به دلیل مصرف آنها تحت درمان قرار میگیرند؛ تقریباً ۵۰ درصد از کل پذیرشهای درمانی سال ۲۰۱۸ مربوط به این مواد است. مبتلایان به اختلالات مصرف اوپیوئیدها در مقایسه با مصرفکنندگان سایر مواد مخدر معمولاً در سنین بالاتر (اواسط دهه سی سالگی) وارد فرایند درمان میشوند و بین یک چهارم تا یک سوم آنها برای اولین بار تحت درمان قرار میگیرند. [۵] این ارقام با یافتههای منتشر شده در ادبیات علمی سازگار است، به عنوان نمونه مطالعاتی از اروپا نشان میدهد که سن اعضای گروه مصرفکنندگان اوپیوئیدها در اروپا رو به افزایش است.
درمان مصرف محرکهای نوع آمفتامین در آسیا (عمدتاً برای مصرف مت آمفتامین) و اقیانوسیه (بر اساس دادههای به دست آمده از استرالیا و نیوزیلند) بیشتر از مناطق دیگر است. همانند مصرفکنندگان حشیش، افرادی که برای اختلالات مربوط به مصرف آمفتامینها تحت درمان قرار دارند نیز معمولاً جوانتر از مصرفکنندگان تحت درمان برای اوپیوئیدها هستند (در اواسط بیست سالگی) و بیشتر آنها هم برای اولین بار وارد برنامه درمانی شدهاند. افرادی که برای مصرف متآمفتامین تحت درمان قرار میگیرند بیش از سه چهارم کل افراد تحت درمان در برونئی دارالسلام، کامبوج، جمهوری دموکراتیک خلق لائو، فیلیپین، سنگاپور و تایلند را تشکیل میدهند.
ارائه درمانی که در آن کوکائین اصلیترین ماده مخدر مورد نگرانی محسوب میشود سهم بزرگی از درمان مواد مخدر را در قاره آمریکا، به ویژه در آمریکای لاتین و حوزه کارائیب تشکیل میدهد. در آمریکای لاتین مانند سایر ناحیهها افرادی که به برنامه درمانی اختلالات مصرف کوکائین وارد میشوند معمولاً در میانه دهه سی سالگی خود قرار دارند و ۳۰ تا ۴۰ درصد آنها برای اولین بار تحت درمان قرار میگیرند.
مواجهه با پدیده یکسانی مانند اعتیاد با توجه به تفاوتهای فرهنگی و اجتماعی کشورها با یکدیگر امری غیرممکن است. هر کشوری دارای حافظه تاریخی و ویژگیهای تاریخی، اجتماعی و فرهنگی مختص به خود است که تفاوتهای میان کشورها را رقم زده است. اما در حوزه درمان اعتیاد بیشتر روشهای درمانی برگرفته از دیگر کشورها است؛ جدای از تفاوتهای کلی ایرانیان با مردمان سایر کشورها، این تفاوتها میان استانها، شهرها و مناطق مختلف کشور نیز مشهود است. بنابراین عدم توجه کافی به ویژگیها و خصایص عمومی ایرانیان و خاص مردم هر منطقه در برنامههای طراحی شده حوزه درمان اعتیاد، منجر به هدر رفتن هزینههای بسیار شده است. در واقع زمانی که فردی وارد مسیر درمان اعتیاد میشود، نگرش و دیدگاه او تحت تاثیر روش درمانی قرار میگیرد، بنابراین اگر این روشها متناسب با ویژگیهای خاص مانند خصایص فرهنگی و اجتماعیاش نباشد، ممکن است با مشکلات جدی روبرو شود. به عنوان مثال برخی از روشهای درمانی که در بسیاری از کشورها انجام و در کشور ما هم طرفدار دارد، در برخی از حوزهها با فرهنگ و اجتماع ما ناهمخوان است و بدون لحاظ کردن چالشهای فرهنگی و اجتماعی جامعه در اجرای این روشها عدم تناسبی در باور و عمل افراد متقاضی ترک شکل میگیرد که مشارکت آنها در فرایند درمان را با مشکل روبرو میکند.
یکی از مهمترین ویژگی فرهنگی ایرانیان این است که انعکاس رفتارشان نزد دیگران بسیار مهم و در مواقعی رفتارشان را بر اساس عکسالعمل دیگران تنظیم میکنند. همین امر در مورد افراد معتاد نیز صادق است؛ پیشبینی افراد وابسته به مواد از نحوه مواجهه اعضای خانواده و اجتماع، دوستان؛ همسایهها و اعضای فامیل و … در برابر اعتیادشان و نیز پیامدهایی که به تبع آن رخ میدهد، آنها را به ظاهر سازی وامیدارد، انکار مصرف یکی از نمودهای این ظاهرسازی است. به نوعی میتوان گفت این رفتار آنها برای دور نگه داشتن خود از خطراتی که تصور میکنند با آشکارشدن آنچه در درون واقعیت آنها وجود دارد، ممکن است در رفتار دیگران با آنها تاثیر گذارد و در نتیجه پیامدهای بیشتری داشته باشد. پیشبینی در مورد نحوه برخورد اعضای خانواده در مورد اعتیاد یکی از اعضاء مانند جدایی همسر، طرد توسط خانواده؛ اجبار برای ترک، اخراج از محل کار و غیره.. از جمله موقعیتهایی است که میتواند افراد وابسته به مواد را وادار به ظاهرسازی و کتمان اعتیاد کند.
این ویژگی فرهنگی و اجتماعی میتواند تبعات گوناگونی در درمان اعتیاد در کشور داشته باشد، به ویژه این امر زمانی آشکار میشود که فرد معتاد مجبور شود برای بهبودی مشکل خود را بروز دهد و تجربه درمانگران نشان داده حتی در مواردی که در مورد ماده مصرفی فرد معتاد از او سوال میشود نیز سعی میکند با پنهانسازی نوع مواد مصرفی، موادی مانند تریاک و متادون را که با پذیرش بیشتری از سوی جامعه و دوستان مواجهه است به عنوان ماده مصرفی خود معرفی کند. همچنین حتی در مواقعی که لازم است فرد در مورد خساراتی که به تبع مصرف مواد به وجود آورده و یا حوادثی خصوصی که مصرف مواد برای او خانوادهاش ایجاد کرده، صحبت کند احتمال کتمان و ظاهرسازی بسیار بالا است.
در واقع افرادی که برای درمان و ترک به مراکز ترک اعتیاد مراجعه میکنند، چون با دیگر افراد معتاد احساس همدردی و یک تجربه مشترک دارند، صمیمیت بیشتری بین این افراد به وجود میآید و در نتیجه ارتباط دوستانه افراد در حال درمان بیشتر میشود، اما نکته بسیار مهم در روابط نابرابر بین افراد در حال ترک با روانپزشکان، پزشکان، روانشناسان، درمانگران و مشاورانی است که در کلینیکهای درمان سوء مصرف مواد کار میکنند. در واقع این رابطه میان معتادان در حال درمان و درمانگردان مانند رابطه فرادست و فرودستی است که باعث شد تا افراد معتاد نتوانند با آنها ارتباط موثری بگیرند و مدام در تلاشند تا رابطه خود را کنترل کرده و از پاسخهای دقیق طفره و حتی برخی از مشکلات خود را کتمان و در این شرایط جلب اعتماد بیمار و هدایت او به سمت درمانی موثر و پایدار سخت خواهد بود.
نکته بسیار مهمی که در درمان اعتیاد همواره به عنوان موضوعی که در شکست پروسه درمان مورد اغفال قرار گرفته، عدم آموزش صحیح و مهارت کافی به افراد در حال درمان برای ورود به جامعه است. افراد معتاد و حتی پس از بهبودی خود را جدای از سایر افراد جامعه میبینند، در نتیجه نیاز به افراد یا گروههایی دارند که خود را در آن آشنا و بتوانند حرف دل را بزنند و این نشان از نقص برنامههای حوزه درمان دارد.
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