3.1. Advertising Representation of the Centers
In the second phase of the study, November 2012, the number of newspapers that published ads, including the ads of DAT centers, decreased from four newspapers in May 2009 to two newspapers (Hamshahri and Keyhan) in Tehran. Generally, based on the newspapers formal information on their advertising costs, 99 centers paid 406,974,030 Rials (from 2010 to 2013, Iran suffered from severe sanctions by the United Nations, Europe, and the United States, due to its nuclear program. Therefore, the total inflation rate rose to 86.7% in three years (21.5% inflation rate in 2010, about 30.5% in 2011, and 34.7% in 2013). Also, the exchange rate of Iran Rials to US Dollar increased from 11,000 Rials to about 32,000 Rials for US$1 (
12). Thus, to find the increasing-decreasing rates of prices, Iran Rials was worked on, paid by Iranians) (US$12,718) for 1343 newspaper ads in November 2012. Also, on average, each center published 13.57 ads, which cost 4,110,840.8 Rials (US$128.46), and each ad cost about 303,030.3 Rials (US$9.4).
In addition, 1343 newspaper ads of the centers were made from 122 ads, repeated daily, and each ad typically covered 6.51 cm
2 of the newspapers pages. About 93% of them were in grayscale and only 7% of the ads were colored. In addition, 83% of the advertisers used a stereotype to advertise their services and centers based on the findings, and just 17% of the centers used more than one advertising type ( Table 2).
Table 2. Advertising Representations of Drug Treatment Centers in Tehran, November 2012
Variables Sum Value a Advertising cost for clinic, Rial 406,974,030 4110840.8 ± 591299 Number of ads per month 1343 13.57 ± 11.01 Printed area of the ad in month, cm 2 644.08 6.51 ± 3.6 Number of ads types per month 122 1.23 ± 0.52 Colored ad 8 7 Grayscale ad 114 93 Clinics with more than one ad type 17 17
a Values are expressed as mean ± SD or percentage. 3.1.1. Introducing the Center
Through newspaper ads, centers introduced themselves through six main codes: branding information, treatment type, clinical team, center facilities, permission source, and financial issues.
Nonetheless, similar to the previous study results in 2009 (
8), the most important part of this introduction was branding information, including the center name, physician name, address, office phone, and cell phone number.
Generally, 92% of the advertisers called themselves as outpatient DAT clinics and 6% of them were residential on inpatient treatment centers. Besides, 86% of the ads mentioned the name of centers, 98% indicated the office phone numbers, 62% included the address of centers, and 47% mentioned cell phone numbers as their contact information.
Although in May 2009 about 33% of the ads indicated a physician’s name as one of the most important advertising elements, the importance of this item seems to decrease in the social identity of the DAT centers, and only 10% of advertisers in November 2012 used it. The priority of Governmental License increased for the centers, as it was mentioned by 100% of the centers in 2012, compared to 38% in 2009. In November 2012, about 18% of the centers indicated State Welfare Organization License title, code, or both in their ads, but 86% of the clinics highlighted their licenses issued by Ministry of Health in their ads.
Furthermore, the facilities and advantages of centers were advertised by 41% of them through three themes. About one-fifth of the centers pointed to the working time through two codes: day and night (19%) and 24 hours (2%). In addition, the advertisers used three adjective codes of specialized (15%) (having proficiency in drug treatment), calm and relaxing (3%), and healthy (1%) to describe the facilities of their centers.
Besides, the priority of mentioning the members of the medical team was emphasized to attract audience, as 10% of the advertisers pointed to their psychiatrists and 3% indicated the involvement of psychologists in their medical team. Also, a center presented its clinical team as experienced. However, in 2009, only two (3%) centers pointed to their social working team and four (6%) clinics highlighted their psychiatry experts. Meanwhile, the importance of social workers decreased in the field, as none of the ads indicated them during the second one-month research period. Unlike May 2009 study, the frequency of official price code declined and only one ad pointed to it. However, the centers stated some other financial codes, such as insurance (4%), discount (1%), and lowest cost (8%) (
Table 3. Type and Information of Advertisements by DAT Centers
Variebles No. (%) Center facilities Admission capacity 1 (1) Day and night 19 (19) 24 hours 2 (2) Specialized 15 (15) Healthy condition 1 (1) Calm and relaxing environment 3 (3) Center type Outpatient 91 (92) Inpatient 6 (6) Branding information Cell phone number 47 (47) Office phone number 97 (98) Address 61 (62) Physician name 10 (10) DAT center name 85 (86) Financial issue Good offers 1 (1) Discount 1 (1) Lowest cost 8 (8) Prices 1 (1) Insurance 4 (4) Licensing organization License code of Ministry of Health 85 (86) Ministry of Health 16 (16) License code of State Welfare Organization 10 (10) Social Welfare Organization 8 (8) Clinical team Experienced clinical team 1 (1) Social worker 0 (0) Psychologist 3 (3) Psychiatrist 10 (10) Treatment advantageous Craving treatment 0 (0) Without withdrawal pain 1 (1) Without side effects 0 (0) Aftercare services Rehabilitation 1 (1) Follow-up 1 (1) Relapse prevention 1 (1) Treatment duration Gradual 0 (0) Long-term 5 (5) Short-term 6 (6) Just one day 0 (0) Ultra-rapid 0 (0) Rapid 1 (1) Treatment setting Outpatient 9 (9) Inpatient 7 (7) Drug Other drugs 5 (5) Opiates drugs 18 (18) Stimulant drugs 29 (29) Medicine New medicines 13 (13) Naltrexone 0 (0) Methadone 52 (53) Buprenorphine 34 (34) 3.1.2. Treatment Types
Although 79% of the advertisers used a general code, addiction treatment, only 34% of the ads clearly defined the DAT center menu including maintenance, detoxification, or outpatient cognitive behavioral therapy (CBT) for stimulant use disorders based on the matrix model (
11). A comparison between the two periods indicated a decrease in the detoxification treatment, as the previous dominant treatment type. In May 2009, about 66% of the ads pointed to detoxification in their treatment menus, but in November 2012, it decreased to 20%. Furthermore, there was a new emerging code in the treatment menus, matrix (8%), which related to treatment of stimulants addiction. 3.1.3. Treatment Features
In the ads of centers, DAT features were stated in four themes: treatment setting (16%), treatment duration (12%), treatment advantages (1%), and “aftercare services and outcomes” (3%).
In both study phases, 16 advertisers pointed to the treatment setting, including inpatient (
7) and outpatient treatments ( 11). Although only 12% of the ads mentioned it on their treatments representation (three codes), it was indicated by 68% of the ads in May 2009 (six codes). The treatment duration in the ads of centers comprised two categories: long-term and short-term. However, 7% of the centers advertised their short-term treatments by two codes, rapid (1%) and short-term (6%). Nonetheless, they used just one code, long-term (5%), to represent their maintenance treatments. Also, similar to the previous phase, there was little difference between the frequency rates of these two categories.
Furthermore, only one clinic pointed out the treatment advantages as a treatment without withdrawal and pain. Besides, three advertisers assured their audience that the treatment process was followed by aftercare services, including follow-up (1%), rehabilitation (1%), and relapse prevention (1%). However, treatment advantages were mentioned by 30% of the ads in May 2009.
A comparison between ads in the two time periods with regard to drug treatment features showed that such features declined from its dominant position in May 2009, i.e., from 100% of the ads to one-third of them in November 2012. In other words, the importance of treatment features decreased to attract patients to the clinics compared to other factors (
Table 3). 3.1.4. Psychological Services
Approximately 36% of the advertisers mentioned their psychological services. Also, 13% of the centers introduced their psychological team in the advertisements. Besides, similar to the previous study, the majority of the ads used a general code, i.e., consultation (22%), and about 14% applied two rather detailed codes, i.e., couple therapy (8%) and group therapy (6%).
3.1.5. Drugs and Medicines Representation
One of the most important features in drug treatment centers is mentioning the types of drugs involvement, which accounts for more than half of the ads. Interestingly, the mentioned frequency of stimulant drugs (29%) was 11% more than opioid drugs (18%) in the ads of centers.
In addition, 100% of centers advertised their medicines, i.e., methadone, buprenorphine, etc. Similar to the previous study, methadone was the most prescribed medicine, mentioned by 52% of the ads, compared to 39%, in May 2009. Additionally, the importance of buprenorphine increased from 27% in May 2009 to 34% in November 2012. Nonetheless, there was no advertisement for naltrexone. However, about 13% of the centers used a vague code, new pharmacotherapies, previously mentioned by only one clinic in May 2009. A comparison between the two time periods revealed that the medicines and drugs had a more serious role in introducing the centers and attracting their audience, since the medicines were mentioned by just 47% of the ads in May 2009 (
Table 3). 3.2. Results of Phone Interviews
Similar to the previous study, the centers were called to gather more information regarding the treatments and the services they offered a day after the ads were published. Out of 99contacted centers, 87 (87%) centers completed the telephone interview and all of them contested to use their data for the study.
3.2.1. Maintenance Treatments
18.104.22.168. Naltrexone Maintenance Treatment
Based on phone interview results, it seems that naltrexone treatment was eliminated from DAT market in Tehran, although it was the cheapest treatment choice in May 2009. A comparison between the two studies showed that offering naltrexone capsules decreased from 34% of the centers in May 2009 to only 3% of them in November 2012. No center offered naltrexone implant, although it was offered in 27% of the clinics in the previous study.
22.214.171.124. Methadone Maintenance Treatment
Methadone maintenance treatment (MMT) was the most popular treatment in Tehran, as its facilities were offered by 85% of the centers. More than half of this long-term service was presented in a treatment package, including medicines, urine tests, psychological consultations, and other medical services. In addition, MMT typically costs about 1,185,270 Rials (US$37.03) per month, which increased about 16% compared to its cost in May 2009. However, considering the inflation US$ - Iran Rial exchange rates, the cost actually decreased.
126.96.36.199. Buprenorphine Maintenance Treatment
A comparison between two studies demonstrated that buprenorphine maintenance treatment (BMT) grew 28% in Tehran and its availability increased from 59% of centers in 2009 to 83% of the centers in November 2012, which actually was close to MMT rate. Meanwhile, about half of the centers offered BMT package as part of their services, which cost about 1,216,390 Rials (US$38.01) per month, a 51% increase from 591,667 Rials (US$18.4) in May 2009 (
Table 4. The Costs of Different Treatment Programs in Tehran
Variables Values a Maintenance Treatment Program Opium tincture treatment Tincture costs (mn), Rial 2,400,000 ± 257,300 Opium tincture availability 1 (1) Buprenorphine maintenance treatment BMT cost (mn), Rial 1,216,390 ± 560,740 BMT availability 71 (83) BMT availability 35 (49) Methadone maintenance treatment MMT cost (mn), Rial 1,185,270 ± 506,810 MMT availability 74 (85) MMT package 43 (58) Methamphetamine Addiction Treatment Program (No. of the Centers; 42 (48%)) Meth addiction cost Meth addiction treatment costs, Rial/mn 2658000 ± 1722680 Length of meth addiction treatment, d 91.4 ±41.8 Cost of a psychotherapy session, Rial 207700 ± 88080 Psychotherapy in meth addiction treatment Number of psychotherapy sessions 21.37 ± 7.8 Psychiatry services 27 (64) Other psychological interventions (e.g. CRAFT) 1 (3) Matrix treatment program 34 (89) Psychotherapy and consultation 4 (11) Pharmacological treatment in meth addiction Inpatient services 2 (5) Offering buprenorphine 3 (7) Offering methadone 0 (0) Offering unique treatment menu for both opioid and stimulant addiction 3 (7) Offering pharmacological treatment services 18 (43) Meth addiction treatment Meth addiction treatment package 17 (40) Meth addiction treatment availability 42 (48) Residential Addiction Treatment (No. of the Centers; 6 (7%)) Residential treatment costs, Rial 23.3 ± 5.9 Buffet cost 5 (83) Peer group counselling services, Madadyari 6 (100) Social working services 5 (83) State Welfare Organization licensing 6 (100) Psychological services 6 (100) Pharmacological treatment 0 (0) Medical services 6 (100) Compulsory residential treatment 3 (50) Length of residential treatment 2,466,666.7 ± 644310 Drug Addiction Treatment Services and Their Costs Index Average Price, Rial Methadone maintenance 1,185,280 Buprenorphine maintenance 1,216,400 Buprenorphine detoxification 150,000 Opium tincture maintenance program 240,000 Matrix 2,658,000 Residential treatment 2,466,660 Rapid/ultra-rapid detoxification 8,428,570
a Values are expressed as mean ± SD or No. (%). 188.8.131.52. Opium Tincture Maintenance Treatment
Opium tincture (OT) is a new medicine authorized by Iran Ministry of Health and introduced to a few qualified centers in 2011. In the current study, only one clinic offered OT, which cost 2,400,000 Rials (US$75) per month. However, it was reported that 14 DAT centers added OT to their treatment menu in Tehran by 2012 (
13). 3.2.2. Detoxification Programs
184.108.40.206. Buprenorphine Detoxification
Since Iran Ministry of Health prohibited methadone detoxification, it was nearly eliminated from the DAT market. Instead, offering buprenorphine detoxification (BD) treatment method increased in Tehran. Therefore, 99% of these centers have a fixed cost for any buprenorphine dose needed in BD program. However, the cost of such treatment decreased by 165%, and is 1,000,000 ± 107,830 Rials (US$31.25) in Tehran.
220.127.116.11. Rapid Detoxification
Based on telephone interviews, a total of 12 clinics (12%) offered rapid detoxification (RD) (nine centers) or ultra-rapid detoxification (URD) services (three centers). On average, they apply the rapid detoxification process for patients in 5.71 days. Also, RD service costs about 8,428,570 ± 2,752,610 Rials (US$263.39) and URD treatment costs about 4,300,000 ± 829,880 Rials (US$134.37). A comparison between two studies with regard to rapid detoxification price demonstrated that the cost of this treatment rose 44% during three years and it is the most expensive treatment of drug addiction in Tehran; although according to Iran Ministry of Health regulations, URD is still a prohibited medical method in Iran due to low success rate and high adverse events.
3.2.3. Methamphetamine Addiction Treatment Programs
During three years from 2009 to 2012, a new field emerged in the DAT market for the treatment of stimulants addiction focusing on methamphetamine (meth). Based on the telephone interview results, 42 (48%) centers offered methamphetamine addiction treatment and 40% offered it in a complete treatment package, designed for methamphetamine addiction. Meanwhile, 7% of the centers had a unique treatment menu for both opioid and stimulants addiction. Pharmacological treatment menus in Tehran were categorized into seven codes for methadone addiction: tramadol (2%), psychiatric medicines (16%), detoxification medicines similar to opioid addiction cases (2%), buprenorphine (2%), and other medicines (9%), although the national guidelines do not allow using opioid agonist medicines such as tramadol and buprenorphine to treat stimulants addiction (
In addition, 90% of the centers, which provide stimulant treatment program, reported that they offer psychotherapy, including intensive outpatient CBT based on matrix model (89%), consultation (8%), community reinforcement approach and family training (CRAFT), and other psychological interventions (3%), in their meth addiction treatment program. These programs typically include 21.3% psychotherapy sessions, 67% of which included psychiatrists in the treatment team too. Two centers offered inpatient services for meth addiction treatment. Besides, meth addiction treatment on average costs 2,658,000 Rials per month, and took about 91.4 days (
Table 4). 3.2.4. Residential Treatment Programs
There were six residential centers (7%), which advertised residential treatment in the newspapers and all of them participated in the telephone interviews. All of these centers were licensed by State Welfare Organization. Furthermore, their treatment programs included both medical and psychological services. Although 83% of them claimed that they offered pharmacological intervention for their patients, it was limited to analgesics. Besides, 83% of them forced patients to stay during their treatment program, although it is illegal in Iran. None of these centers offered social working services, but instead they attempt to educate rehabilitated patients to help newcomers and called it, Madadyari. Madadyar (occupational therapy assistant) is a rehabilitated patient (peer group counselors) taking a one-year course on drug DAT counseling and works as a counselor in the residential center. These residential treatment programs take 23.3 days and cost 246,666.7 Rials, on average. Furthermore, half of the centers added surcharge to the cost entitled buffet cost (