“Pain is inevitable. Suffering is optional.”

----- Haruki Murakami

t a dinner with some young friends recently, there was a lot of discussion about “higher states of consciousness”, psychedelic drugs and mindfulness. The evening, which was capped by a delicious dinner was lubricated by, some “mind-altering compounds” (alcohol and marijuana) and ended uneventfully. It did get me thinking though about the elephant in the room: the rampant and increasing use of illicit substances in Pakistan starting in our schools and colleges. And while alcohol and marijuana can both be problematic, the fact that they are considered “recreational” or even “medicinal” (in the case of marijuana) in the West testifies to their less harmful nature compared to, say, heroin, cocaine or – the latest rage on college campuses and households in Pakistan – “ice” or methamphetamines.

The statistics are grim. Our data is outdated and more recent research is desperately needed but a report by the United Nations Office on Drugs and Crime (UNODC) from 2013 threw up some frightening figures. The number of addicts in Pakistan (in 2013) was 7.6 million (78 percent male and 22 percent female). The number was increasing at a rate of 40,000 per year. Due to its high population, the Punjab is the most affected jurisdiction. People who abuse substances also have a very high incidence of HIV/ AIDS and other blood-borne diseases like hepatitis due to injecting drugs and other unsafe practices.

Anecdotally, all of us know some individuals and families who have been affected by the scourge of drug abuse. June 26 is the International Day against Drug Abuse and Illicit Trafficking, so it is appropriate to remind ourselves of what we are facing and what needs to be done.

My three children, now 22, 20 and 16, have told us numerous horrifying stories of drug dealing and consumption at elite private schools and colleges with some of their friends and class fellows already caught in the claws of this monster.

The people I see in my practice are too numerous to recount: the young school teacher working on his PhD abroad ravaged by “ice” abuse and unable to go on any longer; the architect who spent months in a local rehab recovering from alcohol, marijuana and heroin addiction and is trying now to put her life back together; the driver at my public hospital who got hooked on afeem (raw opium) years ago after someone suggested he start using it to help with his aches and pains (now can’t function without it) – the stories go on and on.

And while drug abuse is everywhere, effective and, more importantly, affordable treatment is nowhere to be found. There are private “drug rehabs” everywhere (clinics and hospitals which claim to treat drug addiction): they advertise on the media and social media and desperate families flock to them for help. But, by and large, they are staffed with poorly trained (or untrained) people since people with expertise in addiction are almost non-existent in Pakistan. Many of these facilities are little better than sub-jails, where addicts from lower income families are herded together like cattle, held for weeks or months and sometimes beaten to within an inch of their lives. Facilities charging millions of rupees for a “course” of treatment also exist but their level of expertise varies from barely adequate to truly abysmal. In our public hospitals, we try to ensure an adequate minimal level of care but we are chronically underfunded and our patient areas are inhospitable places: unsanitary and overcrowded, staffed with doctors and nurses who are always overworked and burned out.

Of course, drugs are everywhere. A friend in Karachi informs me that they can even be ordered over food delivery apps.

But there is a silver lining to the matter as well. In addition to effective treatments now becoming gradually available in Pakistan, our biggest advantage when it comes to dealing with drug abuse is our still intact family system. While acute (short term) treatment of drug abuse is easy enough, requiring 2-3 weeks of medication and perhaps, a brief hospital stay, the real challenge emerges when the person completes a course of detox (short for detoxification, signifying that the initial period of cleansing the body of the drug(s) is complete). After detox, the challenge over the next few months is the absolute necessity of helping the former addict rebuild their life and relationships free of their addiction. For those who have been using drugs for a long time, this can be very tough and there is a need to form new friendships, repair relationships with family and loved ones and begin the hard task of returning to the rather repetitive routine that we all call life: work (or education), responsibilities, bills and so on. During the first few months after sobriety, the urge to escape from all this can be very strong leading to relapse into drug use. The family can play a strong role here in conjunction with treating doctors and psychologists by maintaining the appropriate barriers and boundaries with and around the recovering addict and thus, helping them recover. Addiction, by nature, is a relapsing illness so some slips are to be expected. But, if caught in time, it can be remedied without a full blown lapse into addiction.

For this we need more informed families, drug abuse counsellors and psychologists in schools and colleges where the illness often starts. We need a greater focus on prevention and treatment rather than punitive and ridiculous ideas like drug testing children in schools and colleges that keep surfacing from time to time. Law enforcement has a place in the control of drugs in society but it cannot replace evidence-based, humane and socially appropriate treatment. While drug use like all illnesses, has social causes, the medical aspect cannot be ignored or replaced with moral injunctions or harsh legal penalties.

If we can combine a humane understanding of addiction as an illness that needs treatment, not punishment, with a strong commitment at the local, provincial and federal level to do something, we can make a start in helping millions of families in Pakistan. Medical treatment cannot replace quality education or gainful employment. Doctors are just as helpless in the face of harsh social inequalities and violent phenomena like terrorism or crime as everyone else. But despite these realities, treatment does help. Success stories abound in my own practice: once I persuaded my young school teacher patient to let me talk to his parents; they helped him sober up and rebuild his life. Earlier, I met a man who had struggled with alcohol dependence since his divorce five years ago. Now remarried, he wants to stop drinking and his new wife and young children are his primary motivation. After we did a short course of treatment years ago, he stopped drinking for nearly two years. I am confident he can do so again; and he agrees. We all need a little help when life knocks us down. And a helping hand, rather than a harsh word is always preferable.

The writer is a psychiatrist and a faculty member at King Edward Medical University. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022. He tweets @Ali_Madeeh