Selected Papers of William L. White (Part One)
2/21/2021 12:00:00 AM

Selected Papers of William L. White (Part One)

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The Islamic Republic of Iran, in response to the highest rate of opium consumption in the world, has devoted substantial resources to reduce drug availability and address addiction-related problems.


An Addiction Recovery Community within the Islamic Republic of Iran


William L. White

                                       Emeritus Senior Research Consultant

                                               Chestnut Health Systems




The Islamic Republic of Iran, in response to the highest rate of opium consumption in the world, has devoted substantial resources to reduce drug availability and address addiction-related problems. Demand- reduction activities have included residential rehabilitation centers, outpatient treatment centers, and support for addiction recovery mutual aid organizations such as Narcotics Anonymous. The growing role of voluntary non-governmental organizations (NGOs) in supporting addiction recovery in Iran has not been fully described in the professional literature. This report describes one such NGO, Congress 60, which was founded in 1998 and has since grown to 38 branches in Iran with more than 20,000 members. Included in the review are the history, governance, philosophy, and recovery support methods of Congress 60.

Keywords: Iran, Congress 60, Hossein Dezhakam, DST Method, opium tincture




The use of opium and other intoxicants among the people of Iran has a very long history (Matthee, 2005), but problems related to addiction escalated dramatically in the second half of the twentieth century, with estimates of the number of Iranians meeting DSM-IV criteria for substance dependence estimated between 1-4 million (Ahmadi et al., 2007; Mokri, 2002; Razzaghi, Rahnimi, Hosseni, Madani, & Chaterjee, 1999; Sharifi et al., 2012). This rising rate of addiction is in marked contrast to recent overall improvements in health, life expectancy, and education in Iran. Increased opiate addiction is related to a confluence of factors: proximity to Afghanistan—the world’s leading source of opiates—and Pakistan; a youthful population (half under age 19); urbanization and social dislocation; and the financial distress and unemployment exacerbated by UN and EU economic sanctions against Iran (Razzaghi et al., 1999; Shariatirad & Maarefvand, 2013). Surveys of drug use in Iran report a dramatic rise between 1973 and 1978, a decline of use in the early years following the Iranian Revolution, and a subsequent resurgence beginning in the years 1988-1992 (Rahimi- Movaghar, Mohammad, & Razzaghi, 2002). The patterns of drug use in Iran primarily involve the smoking of opium residue (shire and sukhte) in pipes; the ingestion (dissolved in tea) of opium (thariac); and the smoking, inhalation, or injection of heroin, with growth in injection drug use contributing to increases in HIV and HCV infection (Mokri, 2002). Most (71%) of the opium and heroin consumed in Iran is purchased from illicit street dealers, often costing less than a pack of cigarettes. Opium is generally consumed in one’s home or at a coffee or teashop, and heroin is most often consumed in a location outside the home (Razzaghi et al., 1999). A common form of street heroin is called Kerack—not to be confused with crack cocaine, which is rarely used in Iran (Mehrjerdi, 2013; Mohammad, Hassan, & Dariush, 2011). Like heroin dependence, cessation of prolonged opium use produces both an acute and protracted (for months) withdrawal syndrome associated with intense drug cravings and drug-seeking        behaviors, making the challenge not the initiation of recovery but the maintenance of long-term recovery (Rahimi-Movaghar et al., 2009).

The typical profile of persons addicted to opioids in Iran is that of a married (62%) male (95%) between the ages of 14-75 (mean of 35) with limited education (more than half without a high school diploma or college degree) who is supported by and living with family while working in a skilled, semi-skilled, or unskilled job (Ahmadi & Motamed, 2003; Sharifi et al., 2012; Shekarchizadeh, Ekhtiari, Khami, & Virtanen, 2012). Drug use, with opium as the most frequent initial drug, begins most often between the ages of 12-18 and is initiated in the context of friends or family, with nearly half of those entering treatment reporting another person addicted within their family (Day, Nassirimanesh, Shakeshaft, & Dolan, 2006; Mokri, 2002; Sharifi et al., 2012). Women are most frequently introduced to drug use by their drug-using partner (Dolan, Salimi, Nassirimanesh, Mohsenifar, & Mokri, 2011). The majority (75%) of those entering treatment for addiction also present with a co-occurring  psychiatric    illness (Ghanizadeh, Ashkani, & Maany, 2000). Injection drug users are primarily single males between the ages of 20-39 (with a trend toward decreasing age of use; Ataee et al., 2014), with prior histories of addiction treatment and incarceration and high rates of HIV and HCV infection (Eskandarieh et al., 2013; Shahrbabaki et al., 2011; Zamani et al., 2006). Most opium and heroin users in Iran report multiple failed attempts to cease their drug use (Razzaghi et al., 1999).

Cultural and legal responses to addiction have a long history in Iran (Matthee, 2005). Before the 1979 revolution, there was a trend toward the decriminalization and medicalization of addiction with growth in government-funded detoxification, inpatient addiction treatment, pilot outpatient treatment, and ancillary services that included education and vocational rehabilitation. Opium rationing for older addicts also provided an early harm reduction effort in Iran (Afkhami, 2009).

Following the fall of the shah in the 1979 Iranian Revolution, addiction was increasingly viewed through the lens of Islamic moral precepts. The Council of Islamic Revolution in Iran waged a “jihad against sin” that included a ban on poppy cultivation, closing of detoxification and treatment centers, and harsh anti-drug measures—fines, corporal punishment (lashings), incarceration in labor camps, and the possibility of death for drug trafficking (Calabrese, 2007; Figg-Franzoi, 2011). Temporary reductions in opium supplies during this period inadvertently contributed to rising heroin use among opiate-dependent citizens. During the early 1980s, provisions made for distribution of opium to confirmed addicts were reinstituted and some detoxification and rehabilitation centers were opened to receive addicts mandated from the courts, but alarm continued over the rising tide of opiate addiction and the growing percentage of prison inmates incarcerated for drug offenses (Afkhami, 2009; Calabrese, 2007). The allocation of resources for drug supply and drug demand reduction efforts was, however, limited through much of the 1980s due to the Iran- Iraq War.

The late 1990s were marked by a remedicalization of addiction in Iran. This followed increased recognition of rising rates of addiction and injection drug use and growing concern about AIDS and the 25% HIV infection rate among injection drug users (Afkhami, 2009). As a result, the Iranian government recommitted itself to a balance of demand and supply reduction efforts that expanded resources for addiction treatment and recovery support services (Calabrese, 2007). Early prevention and treatment activities were supported and coordinated through the State Welfare Organization (Aliverdinia & Pridemore, 2008). Key milestones included expanded detoxification, inpatient and outpatient treatment, and harm reduction resources, including more than 100 outpatient clinics established by 2000 (Afkhami, 2009). There was widespread use of pharmacotherapy (naltrexone and methadone maintenance) in hospitals (2000), outpatient clinics (2002), and prison clinics (2002). By 2010, Iran’s treatment efforts in the prisons resulted in the largest population (25,000) of methadone-maintained prisoners in the world (Afkhami, 2009; Farnia, Ebrahimi, Shams, & Zamani, 2010; Tanner, 2013). Other milestones included the opening of the first therapeutic communities in Iran (2001; Mokri, 2002) and establishing the Iranian National Center for Addiction Studies (2003) to conduct addiction-related research and professional education and networking (INCAS, 2007). Recognition of the special needs of addicted women led to the development of special treatment services for women (Dolan, Salimi, Nassirimanesh, Mohsenifar, Allsop, et al. 2011; Movaghar, Langroodi, Ahmadi, & Esmaeili, 2011). More than 60 community drop-in centers also provided a mechanism for outreach and intervention, including delivery of health and psychological services, educational information, and distribution of condoms, syringes, and needles. (Afkhami, 2009).

Since 1997, Addiction treatment in Iran has been provided by the government, universities, welfare organizations, private centers, and non-governmental organizations (NGOs; Farnam, 2005). NGO involvement in the prevention, treatment, and recovery support arenas includes harm reduction and treatment projects, Narcotics Anonymous and other recovery mutual aid efforts, and recovery communities that offer voluntary treatment and long-term recovery support. Some of these efforts were quite remarkable in their growth. By 2005, there were more than 4,900 NA meetings a week in Iran with more than 30,000 NA members (Sayyah, 2006), with NA membership since growing to more than 40,000 members (Maltais, 2011). A 2012 survey revealed that NA meetings in Iran made up 26% of all NA meetings worldwide—more than in any country outside the United States (Lavitt, 2014). By the end of 2007, there were 51 government-sponsored treatment centers and 457 private outpatient treatment centers (Mohammadi, 2007). That same year, a program of mandatory treatment of addiction was initiated through which persons with confirmed addictions were diverted at the point of arrest to residential treatment (Rahimi-Movaghar et al., 2011a,b).

The shift in government policy significantly expanded treatment resources in Iran, but there was growing awareness that more needed to be done to support long-term recovery for individuals and families affected by addiction. These concerns were sparked by problems of low one-year treatment retention rates (Ahmadi, 2002; Ahmadi, Babaee-Beigi, Alishahi, Maany, & Hidari, 2004; Ahmadi & Motamed, 2003; Esmaeli, Ziaddinni, Nikravesh, Baneshi, & Nakhaee, 2014; Rouhani, Kheirkhak, Salarieh, & Abedi, 2012), high post-treatment addiction recurrence rates (63-95%;  Mohammadpoorasl  et  al., 2012; Mokri, 2002; Narimani & Sadeghieh, 2008; Rahimi-Movaghar et al., 2011a; Sadir et al., 2013), limited early improvement in quality of life during treatment (Kobra, Mohammad, & Alireza, 2012), and high reported rates of intergenerational addiction (Ahmadi, Arabi, & Mansouri, 2003; Ziaaddini & Ziaaddini, 2005). Reports that these outcomes were influenced by a broad range of biological, psychological, familial, social, and economic factors (Roshani, Jalali, Bidhendi, Ezzati, & Mahboubi, 2014) suggested the potential of wrapping medications in a broader framework of ancillary recovery support services (Moeni, Razzaghi, Mahmood, & Pashaeie, 2014) and the potential role of NGOs in providing frameworks of sustained support for long-term addiction recovery and primary prevention (Calabrese, 2007; Razzaghi et al., 1999). NGOs that perform these broader recovery support functions in Iran include Narcotics Anonymous, Jamiat EhyaieEnsani Kongreh 60 (Congress 60), Anjoman Tavalod-e-Dobare (Rebirth Society), Tavalodi Digar (Another Birth), and Rooyesh e Digar (Re-growth). NGO-based addiction recovery support resources are growing with the Islamic Republic of Iran.

The purpose of this study is to provide a detailed profile of one such NGO— Congress 60—that has become one of the most visible addiction recovery communities in Iran. The efforts of Congress 60 have been briefly mentioned in the popular press (Fathi, 2008) and noted in the professional literature (Dahmardehei & Rafaiee, 2012; Figg-Franzoi, 2011; Tabatabaei-Jafari et al., 2014; Tavakoli, 2013; Tavakoli, Sahaf, Ghaffari, Farhoudian, & Hayatbakhsh, 2012; Zarrindast, Sahraei, & Dejakam, 2010), but no detailed profile of Congress 60 has yet been published. This review of Congress 60 will outline its history, structure of governance, treatment philosophy and methods, and its plans for researching and disseminating its methods. This review is drawn from interviews and written communications with the founder of Congress 60 as well as a review of key publications of the organization.


To be continued...


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