Introduction

Sarah’s idea is to tackle the drug addiction problem in Lebanon from a very new and creative, scientific based perspective that exists in the west, but has not yet been implemented in the Arab World. Addicts are not out law people she believes, they are just suffering from an illness that can be cured if proper treatment is followed. Sarah founded SKOUN centre in 2003 in the hope of applying an innovative and efficient approach to dealing with the fast growing problem of addiction in Lebanon. Sarah addresses the multi faceted problem on all its levels, treatment, prevention, and advocacy for change. She follows a holistic approach aiming to set a model to be adopted as the Lebanese national anti- drugs strategy and one that can also be easily replicated in the Arab World.

Sara is introducing a new comprehensive and participatory methodology to combat drug addiction among youths in the Levantine area. She aims at changing the societal perception of ex-users for better and fuller integration in society to ensure their full economic and social participation. Sarah has began her work in Lebanon to establish an exemplary model for dealing with addiction that she aims to have adopted by the whole of the Levantine area.

Sarah’s idea adopts a three-pronged approach; first, she positions “addiction” as a disease and not a crime with the aim of improving the image of ex-users for better integration. Secondly, she has introduced a participatory treatment method, where patients participate in the design of their rehabilitation programs in an inclusive and open manner, and where the program builds on the knowledge and skills of the participants. Thus, she also helps in empowering and building the self-confidence and self-esteem of the addicts soon to be ex-addicts. Thirdly, for prevention Sarah has adopted a “Life Skills” program that targets children and youth and thus, she is creating an environment where children learn about addiction with the aim of helping them make the right decisions. Additionally, Sarah lobbies the Lebanese government to legalize maintenance treatment and to change the laws regarding drug users, and to introduce life skills programs in public schools that will enable children and youth to deal with drug issues.

Sarah’s goal is to not only to combat drugs in Lebanon and save hundreds of thousands of lives, but also to establish a holistic and functional model for drug prevention and rehabilitation in the Arab World.

From 1975 to 1991, Lebanon experienced a civil war. This war not only caused civilian casualties and the destruction of its infrastructure, but also had long-term effects on the social and family structure of Lebanese society. Fifteen years later, the consequences of the war remain, and due to a severe recession, the situation has deteriorated even further. As a result, many people remain vulnerable to drug abuse and other high-risk behaviours. This together with the high level of governmental corruption explains why the government never put drug treatment and rehabilitation at the top of its priorities.

Drug consumption habits in Lebanon have evolved over the past decades. Pre 1975 (the year the war in Lebanon started), drugs were taken occasionally and mainly for recreational purposes. During the war, a surge of drug use was found amongst a substantial number of militias. In addition, a surge in the use of pharmaceuticals was found amongst the civilian population.

Today, students seem to form the core group of drug users in Lebanese society. Though we lack scientifically reliable figures, certain trends can be noted.  The number of women involved in drugs is increasing, including hard drugs (cocaine, heroin). Drug addiction is still a highly sensitive and taboo issue in Lebanon, a trend more prevalent than society would like to admit.

Based on research done by Sarah, Red Cross and Family Medicine Association, there is also an increase in the use of licit drugs like alcohol and medications, club drugs like Ecstasy, GHB and Ketamine arrived in Lebanon in 1999. Their use has since exploded and is unfortunately not perceived negatively, and not very well understood by primary care givers Furthermore, Lebanon is a mosaic of 18 different religious sects living in more or less harmony. The political and social life of the country is segmented following confessional considerations. Drugs and alcohol are perceived with a strong judgmental and moralistic approach. They remain taboo subjects that you cannot address directly in prevention and education campaigns, even less from a harm reduction perspective.

There are no official statistics for the consumption of licit and illicit psychoactive substances in Lebanon. The little existing data is not as reliable as one can expect. This is due to the small scope and arbitrary choice of the samples selected, the methodology used and the lack of continuity in the studies. Nevertheless, most of the field workers involved (WHO, CSOs) estimate the number of drug abusers to be at around 20,000 to 25,000 and that is number is regularly increasing in a country whose population is only 3,826,018.

A study undertaken by IDRAC in 2001, based on three samples of the Lebanese population (high school students, university students and other substance using populations), shows that the age of first-time drug users has diminished considerably in the last few years, varying from between 15 to 20 years old, against 25 to 30 at the beginning of the 90’s. It also shows that the frequency of multi-consumption of substances is higher, and that a big majority of that population lacks information on the levels of harmfulness of drugs.

According to statistics presented by Oum El Nour (the only drug rehabilitation centre in Lebanon established 15 years ago), 44% of their patients consumed drugs for the first time between the ages of 15 and 19. The age at which addicts seek treatment varies, but more than a third of patients are between the ages of 25 and 35.  The centre also points out that the percentage of addicts admitted that are younger than 24 has doubled from 20% in 1999 to 40% in 2001.The distribution of the different types of drug used by the patients at Oum el Nour is the following: Heroine 59%, Cannabis 34%, Cocaine 31%, Amphetamine 31% and Alcohol 30%.

The Lebanese mentality still considers that to guarantee the success of treatment, a drug abuser needs to be locked up. Therefore, authorities and the public in general are still very skeptical regarding the efficiency of outpatient rehabilitation centers. For most people, treatment is synonymous with inpatient. Drug abusers are perceived negatively by Lebanese society. Addicts are still considered criminals and are often rejected by their own families. This stigma and isolation increases their reluctance to acknowledge their drug use and to undertake treatment. Reintegrating a satisfying social and professional environment is a big challenge for drug users.

Before Sarah founded Skoun, the only solutions available for drug users seeking treatment in Lebanon were detoxification in the psychiatric department of a hospital that costs and average of 900-1500 USD or prison! No specialized centre that offered rehabilitation from A to Z (detoxification to therapy and after care) existed. Skoun in Arabic has a double meaning, it’s a punctuation that marks a pause in a word and it is also the inner tranquillity and serenity and therefore Skoun would be the place were one can halt to recuperate inner peace. Skoun was the first outpatient centre in the Arab World to open in 2003, treating drug users at whatever stage without being locked up and without being judged.

Dealing with drugs and with addiction is not only a problem that the Lebanese community face using ignorance and denial, but also the government has established the same approach when dealing with the problem. In spite of the fact that in 1998 the law on drugs was ratified by parliament so that a drug user not involved in trading is considered as a sick person and not a criminal; this law is however very rarely applied and the hospitalization or imprisonment of a drug user still depends entirely on the judge’s decision.  Additionally, the government still opposes the legalization of maintenance drugs in spite of their abundance in Lebanon and of them achieving great results in treatment in many other countries. It is been researched and proven that heroin users that go through classic detoxification have a 5-10% chance of staying clean; on the other hand, if they go through maintenance therapy (gradual detoxification using Methadone and Buprenorphine), they have a 70-80% of staying clean.

Lebanon has no national coherent strategy regarding drug treatment or a rehabilitation policy. The drug commission that was supposed to be created since 1999, only happened in June 2005, under the patronage of the Minister of Justice. It only met twice and has taken no practical measures since. Until now, the different ministries have not coordinated their policy regarding drug treatment and rehabilitation, and act independently.

Sarah founded Skoun centre in 2003 in the hope of applying an innovative and efficient approach to dealing with the fast growing problem of addiction in Lebanon. Sarah addresses the multi faceted problem on all its levels, treatment, prevention, and advocacy for change. She follows a holistic approach aiming to establish a model to be adopted as the Lebanese national anti- drugs strategy and one that can also be easily replicated in the Arab World.

To overcome the vastly growing problem of drug addiction in Lebanon in a new and effective manner, Sarah’s idea deals with treatment in the most unconventional manner. Unlike any other well hidden drug rehabilitation centre in the Arab world, Skoun has a central location right in the heart of Beirut student area. This central location serves two purposes, one to be within reach to any one in need regardless of his/her socio-economic background and two, to proclaim to the Lebanese nation that drug addiction is not a stigma and drug addicts do not need to hide for treatments, on the contrary, like any other illness, they need treatment and the support of their family and community. Sarah strongly believes and international research also confirms that addiction is a disease; therefore, addicts need individually tailored psychological as well as physical and psychiatric treatment. Stemming out of its strong belief in freedom of choice and self-recuperation; Skoun is the only existing out patient centre in the Arab World where there is a harm reduction program and patients are not forced into abstinence. Any person with a drug related program walks into Skoun, gets a full medical, psychiatric and psychological assessment and then agrees with the team on what plan to follow. Depending on the person, the treatment program is designed in the form of individual and/or group therapy as well as psychiatric and medical follow up Skoun centre is the only centre that uses cognitive –behavioural therapy, motivational interviewing techniques and maintenance drugs.

Since it was founded in 2003, Skoun has offered treatment to 250 people between the ages of 17-54. Skoun’s patients are from all over Lebanon and from all social and economic backgrounds that sought the help of Skoun because it is the only centre that offered them an alternative strategy for facing their problem. A strategy where they are still respected as human beings who have a free will and who can make a difference in their own lives. Additionally, in a country where a drug user’s choice for rehabilitation is either detoxification in hospitals that has an affordable cost for only the few or prison; Sarah introduces the first comprehensive minimal cost treatment that still respects drug users and believes in their ability to overcome their sickness.

To overcome the negative perception the Lebanese community holds of addiction, addicts and ex-addicts, Sarah not only works with addicts, but also with their family and their friends to help them better understand what he/she is going through and how they can help. Through these sessions, Sarah also works hard to introduce addiction as merely an illness that can be cured and that as any other illness, there should be no shame or dishonour attached to it.

Through Sarah’s treatment strategy, the drug user feels his strength through his/her active participation in designing his/her own treatment program and through the regular support he receives from family and friends.  On monthly basis, Skoun holds a family night for family members and friends of patients to get information on how their close ones are going through and also to better understand that they are many others going through what they are going through and thus action is needed to combat the disease not denial and ignorance.

Sarah also works on the prevention aspect of drug use and her strategy in prevention is just as creative as that of her treatment. Sarah researched international prevention programs and discovered that lecturing and dissemination of anti- drug information are not the best strategy to prevent children and youth from becoming future users; but what really works, is investing the time and effort in building a strong willed character that can make the right decisions at the right time. Accordingly, to spread awareness about drugs and to prevent children and youth from drug use, Sarah implements a life skills program for adolescents (Lions Quest Skills for Adolescence).

She has started implementing the program in seven private schools with 2500 kids receiving it and is currently working on its translation to lobby for its implementation on a national level. Sarah also is running a prevention program in 30 public schools around Lebanon in the form of substance abuse prevention sessions that are given to students, parents and educators. Additionally, she conducted a TOT on the life skills program in 13 Palestinian refugee camps all over Lebanon and in the centres of the Ministry of Social Affairs.

Currently Sarah is lobbying that the (Life Skills) program is adopted by the Ministry of Education and implemented in all public schools. Sarah utilizes any possible opportunity for awareness and publicity of her innovative treatment strategy through marathon events and information booths at any major youth event.

To overcome the governmental policy of ignorance and negligence and to create a better healing environment for drug users, Sarah relentlessly lobbies the government for the change of any law that perceives drug users as criminals or a risk to society. She asks that they be treated as people who suffer from an illness and hence, they have rights. One basic right is to be allowed the best and most successful mean of treatment and research has proven this to be with the use of maintenance drugs that are yet illegal in Lebanon. Sarah has been lobbying the Minister of Health for the legalization of maintenance drugs.

In October 2005, she organized a high visibility international conference about maintenance drugs and its success in drug therapy. She invited Dr. Andrew Tatarsky, from Harm Reduction Psychotherapy and Training Associates, New York, Dr. Robert Newman, from the Baron Edmond de Rothschild Chemical Dependency Institute, New York, Dr. Richard Rawson, from UCLA Integrated Substance Abuse Programs, California, Ms. Susan Keister, Lead Developer of Lions-Quest Programs and Professional Development Workshops, USA, and Mr. Tim Leighton, Head of Professional Education, Training and Research, Clouds House, Salisbury. In addition, she invited Dr. Arash Alaei, from Iran, the Director of Kermanshah Medical University and Shahid Beheshti Medical University; he is the Co-author of the five-year (2003-2008) National Strategy Plan on HIV/AIDS and Harm Reduction Programin Iran. He is also the Director and Deputy of the Pars Research Institute, which is an CSO on HIV/AIDS and Harm Reduction Programs, and Director of International Education and Research Cooperation of the Masih Daneshvari Hospital (WHO Collaboration Centre) and the winner of the WHO “Best practice in HIV/AIDS prevention and care for injecting drug abusers” in 2004. Dr. Arash Alaei was invited to speak about Iran’s experience where maintenance treatment has been in use for 5 years now and where 30,000 people are enrolled. The conference also acted as an open arena for drug patients to give their life testimonies. At the end of the conference, the Minister of Health officially promised to support the legalization of maintenance drugs. Sarah has formed forming a committee of all partners working on drug treatment and prevention to follow up on that promise and turn it into a reality. Sarah here is acting as a major “technology transfer agent” to spread best practices and in so doing, change the whole environment for drug rehab. Her ability to take best practices across borders is indicative of her ability to spread innovation of a systems’ changing idea.

Sarah’s idea strongly influences drug users, families, communities, educational and legal systems.  For a short-term goal, she is working on spreading her outreach and to secure funding in order to institutionalize her model. For a medium term goal, she works through advocacy, media campaigns, conferences and lobbying to have her model adopted by the ministries of Health, Interior, Social Affairs and Education in order for it to become the Lebanese national strategy against drugs. Sarah’s long-term objective is to have this model adopted in the Arab World, as it is one that safeguards nations in parallel with protecting the dignity and rights of drug users. Within 10 years time, Sarah plans that Skoun will be a big inpatient/outpatient center in Lebanon and that it has become a reference in the region. Through partnership, networking, and training, Skoun will spread its model to the Arab World. Skoun team will act as consultants in the region, training and developing their model. Through research in collaboration with similar regional programs in Iran for instance, Skoun will have also become a regional hub for Life Skills training.

As a child, Sarah enjoyed good health, a loving family, and financial comfort. This early and consistent sense of security made her feel an obligation to bring the same comfort to those less fortunate than her.

Sarah’s father, who was always active in their community, had a big influence on her. She remembers that he always spoke to her about her responsibility towards her community and her country. His death, when she was quite young, left her with the feeling that the best legacy one can leave is to help one’s fellow human beings regardless of their religion, race, or socioeconomic background. Sarah’s uncle, who played a key role in bringing her up, was assassinated 11 days after being elected President of Lebanon. These family tragedies increased her awareness of the suffering of others.

During high school, many of Sarah’s friends experimented with drugs. For some, it turned into a destructive habit. She tried listening and preaching, but soon realized that this approach wasn’t working. This experience influenced her educational and professional choices later on. After high school, she moved to France, where she studied clinical psychology, eventually earning a Master’s degree in Psychology and Psychopathology, with an emphasis on addiction. She went on to work in several of the best psychiatric clinics in Paris.

In 2001, she returned to Lebanon so she could put what she learned in France to use for the benefit of her people. She was alarmed by the extent of the drug problem she found when she came home, and immediately started working on intervention programs. She founded Skoun two years later.

Sarah is currently the managing director of Skoun Treatment and Prevention Drug Centre. She is also an executive MBA student at the American University of Beirut. Recently, she decided to study business administration in order to better manage Skoun and financially sustain its activities.