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:	Co-Curricular drug abuse treatment in a university: implementation and evaluation
ABSTRACT 
Background: As one of the efforts to help students attain excellence in life, the Babcock University, Nigeria, screened the students at the point of academic registration and implemented a co-curricular treatment programme for those with positive urine drug test who were at low or moderate levels of risk of adverse effect from the use. The aim of this study was to evaluate the immediate outcomes of the programme.
Methods: The programme implementation and evaluation were done in Babcock University, Nigeria. The participants were the students who screened positive to urine drug test who hitherto were 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 rate of retention in the programme was 86.7%: The rate of positive urine drug test reduced from 100% pre-treatment 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). All the clients reported that they would refer a friend in need of similar help to the programme. 
Conclusion: The co-curricular drug abuse treatment programme based on the core curriculum of the Living in Balance therapy had immediate positive outcomes. Students with mild to moderate levels of risk from use of psychoactive substances can receive effective treatment alongside their academic programme. 

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 co-curricular 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 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.

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 (2). Those with moderate risk were given Brief Intervention (3)  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 core curriculum (4).  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. 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. (5).

Treatment Model
The core curriculum of the Living in Balance (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.(4) 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.
 
Personnel and Pre-programme training
Twelve individuals participated in the programme as counselors and session facilitators. They were 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 World Health 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 (6). The LIB training was based on a 62-slide PowerPoint developed from the LIB facilitator�s guide (4), 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. The counselor had individual session with the assigned client for 60-90 minutes on Mondays to implement and evaluate the multi-domain treatment plans while all the clients attended the Living in Balance group psycho-educational sessions on Fridays. Random urine drug test and periodic re-evaluation of client�s needs were part of the treatment process.  

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 obtained 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.

Programme Evaluation
The facilitators� trainings were evaluated with pre- and post-training 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 a 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.(7)  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 ( HYPERLINK "http://www.tresearch.org/wp-content/uploads/2012/09/Copy-of-CompScoreCalculation.xls" http://www.tresearch.org/wp-content/uploads/2012/09/Copy-of-CompScoreCalculation.xls). Because the participants in this study were all university students, the composite score for the employment/support status was not appropriate and thus not calculated.

The urine toxicology screening kit 
The urine toxicology screening kit is a one-step immunoassay for the qualitative detection of multiple drugs and drug metabolites in human urine. The kit screens for most of the psychoactive substances included in the WHO-ASSIST such as tetra-hydrocannabinol, cocaine, amphetamine, methadone, opioids (heroin, morphine and codeine), phencyclidine and sedatives. 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. (8) 


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(9) 

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 services, operations and rules(10). Its internal reliability is between 0.8 and 0.83. (10, 11).

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 (6). They are contained in the modules 1, 2 and 3 of the volume respectively and are each 5-item mixture of best-answer and multiple-answer 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 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). The most common primary drug of abuse was Cannabis (66.7%) followed by Codeine contained in cough syrup (16.7%).

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 after treatment. Thirty clients had the pretreatment evaluation with the ASI but only 11 of them had post treatment 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)

Client satisfaction and treatment perception
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. While 3 (12.5%) were not sure, 20 (88.3%) perceived that they were well informed about decisions made about their treatment (Table 4). Twenty-three (95.9%) and 22 (91.7%) perceived that the staff helped to motivate them to sort out their problem and that the staff was good at their job 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 their treatment objectives should be.


DISCUSSION
There are some drug treatment programmes like that of the of the University of California, Los Angeles (12) which incorporated Brief Intervention (BI) treatment into the counseling services of the University, but to the authors� knowledge, there is currently no co-curricular substance abuse treatment programme set up by a university. The 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 highly positive perception of the clients about the programme is a good indirect indicator of the effectiveness of the treatment (13). However, it is not certain if the programme was solely responsible for the reduction in rate of 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 be the same? This is a question that can only be answered with a controlled or case-control study design.
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. 
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. 


FUNDING: None


















REFERENCES
1.	Great Schools Partnership (2013) The Glossary of Education Reform: Co-curricular. Portland: Great Schools Partnership; Available from:  HYPERLINK "http://edglossary.org/co-curricular/" http://edglossary.org/co-curricular/. [accessed 4 June, 2013]
2.	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. 
3.	World Health Organization (2010) The ASSIST-linked brief intervention for hazardous and harmful substance use - Manual for use in primary care. World Health Organization, Geneva.
4.	Hoffman JA, Landry MJ, Caudill BD (2003) Living in Balance facilitator Guide. Hezelden Foundation,  USA.
5.	National Institute on Drug Abuse (2009). Principles of drug addiction treatment - A research-based guide (December 2009 revision). In: Abuse NIoD, editor. 3rd ed. U.S: NIDA, National Institutes of Health U.S. Department of Health and Human Services.
6.	United Nations Office on Drugs and Crime (2008). VOLUME A: Screening, Assessment, and Treatment Planning. Available from:  HYPERLINK "http://www.unodc.org/ddt-training/treatment/a.html" http://www.unodc.org/ddt-training/treatment/a.html. [accessed 24 May, 2013]
7.	Onifade PO, Osisanwo OO, Ganzallo OA, Akinhanmi AO, Amosu SM, Somoye EB, et al (2013) Use of Addiction Severity Index in a Nigerian Drug Abuse Treatment Unit: A Clinical Audit. J Alcoholism Drug Depend 107. doi: 10.4172/2329-6488.1000107
8.	Express Diagnostic Int�l (2012) DrugCheck. Dip Drug Test. Express Diagnostic Int�l, Inc, USA.
9.	Matsubara C, Green J, Astorga LT, Daya EL, Jervoso HC, Gonzaga EM, 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 and childbirth. 13:235. Epub 2013/12/18.
10.	Marsden J, Nizzoli U, Corbelli C, Margaron H, Torres M, Prada De Castro I, 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 3:115-22. Epub 2000/11/04.
11.	Morris ZS, McKeganey N (2007. Client perceptions of drug treatment services in Scotland. Drug-Educ Prev Polic; 1:49-60.
12.	Denering LL, Spear SE (2012) Routine use of screening and brief intervention for college students in a university counseling center. J Psychoactive Drugs 4:318-24. Epub 2012/12/06.
13.	Morris ZS, Gannon M (2008) Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care 4:271-6. Epub 2008/05/22.









Table 1: Facilitators and clients� variables
n=30Variable n%FacilitatorGender Male 945Female 1155Profession Psychiatrist210Clinical psychologists210Psychiatric nurses630Social workers945Clergy 15Clients GenderMale2583.3Female516.7Age group 16-18 years723.319-22 years1343.323 -26 years1033.3Academic level 100-2001343.3300-4001756.6Primary substance of abuseCannabis 2066.7Codeine contained in cough syrup516.7Alcohol 26.7Cocaine 26.7Heroin 13.3Secondary substance of abuseNone 1136.7Alcohol 723.3Codeine contained in cough syrup516.7Cannabis 310.0Heroin 13.3Sedatives 13.3Cocaine 13.3Amphetamine 13.3










Table 2: the Addiction Severity Index pre- and post-treatment  		
n=11Mean (sd)% reduction Wilcoxon Signed RanksDomainPre treatmentPost treatmentZPMedical0.1358(0.23)0.0404 (0.09)70.26-1.1530.25Alcohol0.04709 (0.09).01362(.027)71.06-1.4830.14Drugs0.0830 (0.07)0.0334 (0.05)59.70-1.9880.047Legal0.0951 (0.19)0.0000 (0.00)100-1.6040.11Family0.1914 (0.14)0.0878 (0.21)54.09-1.7190.09Psychiatric0.1739 (0.156)0.1104 (0.19)36.51-1.6010.11GLOBAL index0.7264 (0.62)0.2858 (0.42)60.66-2.8450.004











Table 3: Satisfaction with the BUBLIN service
n=24Items of satisfactionn%How would you rate the quality of service you have received?Excellent	1250.0Good1145.8Fair14.2Poor00Did you get the kind of service you wanted?yes, definitely520.8yes, generally1979.2No, not really00No, definitely00To what extent has our program met your needs?Almost all of my needs have been met937.5Most of my needs have been met1145.8Only a few of my needs have been met416.7None of my needs have been met00If a friend were in need of similar help, would you recommend our program to him?%Yes, definitely1250.0Yes, I think so1250.0No, I don�t think so00No, definitely not00How satisfied are you with the amount of help you have received?Very satisfied729.2Mostly satisfied1770.8Indifferent or mildly dissatisfied00Quite dissatisfied00The services you received helped you to deal more effectively with your problems?Yes, they helped a great deal937.5Yes, they helped1562.5No, they really didn�t help00No, they seemed to make things worse00In an overall, general sense, how satisfied are you with the service you have received?Very satisfied1145.8Mostly satisfied1145.8Indifferent or mildly dissatisfied14.2Quite dissatisfied14.2If you were to seek help again, would you come back to our program?Yes, definitely1041.7Yes, I think so937.5No, I don�t think so312.5No, definitely not28.3


Table 4: Treatment perception
n=24Perception Strongly Agree (%)Agree (%)Unsure (%)Disagree (%)Strongly Disagree (%)No response (%) The staff have not always understood the kind of help I want0 (0)7 (29.2)2 (8.3)8 (33.3)7 (29.2)0 (0)I have been well informed about decisions made about my treatment8 (33.3)12 (50.0)3 (12.5)0 (0)1 (4.2)0 (0)The staff and I have had different ideas about what my treatment objectives should be3 (12.5)3 (12.5)5 (20.8)8 (33.3)5 (20.8)0 (0)There has always been a member of staff available when I have wanted to talk13 (54.2)6 (25.0)0 (0)2 (8.3)2 (8.3)1 (4.2)The staff have helped to motivate me to sort out my problems13 (54.2)10 (41.7)0 (0)0(0)1 (4.2)0 (0)I have not liked all of the treatment sessions I have attended1 (4.2)4 (16.7)2 (8.3)7 (29.2)10 (41.7)0 (0)I have not had enough time to sort out my problems2 (8.3)4 (16.7)2 (8.3)8 (33.3)8 (33.3)0 (0)I think the staff have been good at their jobs12 (50.0)10 (41.7)1 (4.2)1 (4.2)0 (0)I have received the help that I was looking for10 (41.7)10 (41.7)2 (8.3)1 (4.2)0 (0)1 (4.2)I have not liked some of the treatment rules or regulations1 (4.2)5 (20.8)7 (29.2)7 (29.2)4 (16.7)0 (0)












Figure 1: Flowchart of the treatment programme



















Screening (ASSIST & urine drug)

Risk level 

Drug info /leaflet
(Low threshold)

No/low

High 

ASSIST based brief intervention

 Moderate

12-week living in balance program (Fridays)
12-week individual sessions with counsellor (Mondays)
4 random urine drug tests 

Referral for inpatient treatment 

ASSIST based brief intervention

Intake Addiction Severity index evaluation and treatment planning
(two individual sessions with counsellor)

1ST follow-up Addiction Severity index evaluation

Random drug screen 
(School policy if positive)

(6 month after treatment)
2nd follow-up Addiction Severity index evaluation



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