Comprehensive Program for Women with Substance Use Disorders Station for the Comprehensive Program for Homeless Women Who Use Drugs

Introduction:

One of the most pressing challenges facing many countries today is substance abuse, which directly and indirectly affects the quality of life in both the short and long term. Addiction is among the most serious social harms, and although various policies have been developed to reduce or control it, many of these strategies have been criticized for their lack of effectiveness.

Addiction is a condition in which an individual, due to psychological factors or chemical substances, loses the ability to control repetitive behaviors. External substances—whether plant-based, synthetic, or alcohol—replace the body’s natural opioids. While lack of willpower is not a disease in itself, the damage it causes to the central nervous system leads to its classification as a disorder. Addiction disrupts the brain’s reward-control system, resulting in compulsive behavior. It is a primary, chronic, neurological disease influenced by genetic, physiological, and social factors. Its hallmark is the inability to control a specific behavior despite awareness of its harmful consequences.

Since 1964, the World Health Organization has recommended using the term “drug dependence” instead of “addiction.” Dependence on substances (narcotics, stimulants, alcohol) or harmful habits is a psychiatric and psychological disorder that erodes happiness in the lives of individuals and their families, while also causing widespread social and economic harm. The core feature of opioid dependence is the loss of control over use and continued consumption despite health, family, occupational, and legal problems. In addiction, substance use becomes the sole source of pleasure and satisfaction. The body’s physiological response to repeated drug use leads to temporary relief or stimulation, followed by a persistent craving and dependence. This results in both physical and psychological reliance, with users gradually increasing their dosage.

Therefore, treatment professionals focus not only on physical symptoms but also on psychological issues and emotional healing to ensure effective recovery. Historically, addiction was considered a predominantly male issue, but in recent years, the increasing number of women affected has shifted the landscape. Today, a significant portion of drug users are women. Given their close ties to family, women’s addiction must be addressed with greater urgency. Although not a new phenomenon, women’s addiction often leads to family breakdown and, in some cases, the birth of drug-dependent infants. Raising awareness among women is essential to prevent the expansion of this crisis.

For those already affected, harm reduction programs—which aim to minimize the health, social, and economic consequences of substance use—can help improve their quality of life and potentially reduce dependence over time. Women who use drugs face greater stigma and social rejection than men, leading to isolation and withdrawal. Long-term drug use also affects physical appearance, further distancing them from society. The harder it is to reach these women, the more difficult it becomes to provide services, increasing the scale of harm.

Many individuals who temporarily stop using drugs or complete treatment relapse due to the lack of supportive family structures and safe, drug-free environments. Transitional housing bridges the gap between rehabilitation centers and society, helping individuals reintegrate. During their stay, a team of social workers and psychologists addresses their mental, physical, and social needs, offering skill-building and employment opportunities to empower them to live independently and drug-free.

This initiative targets homeless women who use drugs, based on the belief that their addiction poses deeper and more damaging consequences for society and future generations. The goal is to treat and empower these women, recognizing that societal conditions have made them vulnerable. Ultimately, the program aims to transform their lifestyle so they can choose and experience a better life. Our experience shows that empowerment, employment, and entrepreneurship are key factors in encouraging women to overcome addiction and reducing its destructive impact on society.

Problem Statement

According to the United Nations Office on Drugs and Crime (UNODC), the global number of drug users increased by 30% in 2017 compared to 2009. In 2017, approximately 271 million people worldwide—5.5% of the population aged 15 to 64—were drug users. This rise has led to an increase in drug-related deaths. Estimates show that 585,000 people died due to drug use in 2017. In the United States alone, over 47,000 deaths were recorded, and in Canada, 4,000 drug-related deaths were reported—a 33% increase from 2016.

UNODC data also reveals that nearly 1 in 8 people who inject drugs globally—around 4.1 million individuals—are living with HIV. Injecting drug users are estimated to be 22 times more likely to contract HIV than the general population. Furthermore, more than half of the drug-related deaths in 2017 were linked to untreated hepatitis C, which led to liver cancer. In total, drug use resulted in the loss of approximately 42 million healthy life years in 2017.

In Iran, there is no precise data on the number of women who use drugs, as this issue has long been overlooked. The Drug Control Headquarters reported that in 2011, there were over 3 million drug users in the country, with women accounting for 10% of that population. Colonel Mohammad Bakhshandeh, head of Tehran’s anti-narcotics police, estimated that there are 1,500 women who use drugs in the capital. Although the number of women affected has increased in recent years, it does not surpass the number of men. However, due to women’s roles and responsibilities in Iranian society, they are among the first victims of many social harms. Today, substance use is the most prevalent issue among women and girls in Iran.

Women make up 10% of the global prison population. In Iran, women account for 2.5% to 3% of inmates, with 85% incarcerated for drug-related offenses. Social harm experts believe that the direct and indirect consequences of addiction among women—and the challenges they face—may be ten times greater than those experienced by men. This alone underscores the urgent need to address women’s addiction.

If we estimate that there are 200,000 to 300,000 women who use drugs in Iran, and assume that less than one-quarter engage in high-risk sexual behavior and half have had one to three pregnancies during their addiction, it is foreseeable that over 100,000 unwanted, drug-exposed infants may be born in the near future. Given the illegality of abortion in Iran and serious gaps in legal and infrastructural support, the country is not yet equipped to handle this crisis. Many cities still lack specialized addiction treatment centers for women. Pregnant women and mothers with infants are often referred to inns or non-specialized facilities. In screening programs, women living with HIV are excluded from treatment and denied entry to rehabilitation centers—highlighting the urgent need for targeted prevention and care for women affected by addiction and HIV.

Social rejection is another major issue faced by drug users. Substance use often damages family relationships, leading to estrangement and loss of support. In Iran’s honor-based culture, women’s addiction imposes greater stigma on families. During their addiction, women are frequently subjected to physical, sexual, and psychological abuse, making reintegration into the family even more difficult. As a result, women who attempt to quit drugs often return to high-risk environments due to the lack of safe housing and family support.

In Iran, homelessness has become a lifestyle for many people with addiction. A homeless person is someone without a permanent, safe place to live. Homeless individuals often lack access to adequate housing and suffer from addiction, alcoholism, mental illness, family breakdown, physical illness, and malnutrition. Some die from cold, poor nutrition, or illness. Therefore, providing safe shelters—especially for women—is critically important.

A transitional home is a secure, drug-free shelter for individuals in recovery who cannot yet return to their families. It operates with open doors and flexible hours, allowing residents to leave if they choose. Unlike closed rehabilitation centers, residents are free to stay or leave. These homes are staffed by people in recovery, creating a nonjudgmental environment where residents are supported by peers who understand their struggles. This sense of community helps sustain sobriety and encourages continued treatment.

Given the importance of these issues, the authors of this proposal have identified a critical gap: the absence of a comprehensive center for homeless women with substance use disorders. Such a center should provide tailored addiction treatment and empower women in recovery through skill-building and support, encouraging long-term sobriety. The ultimate goal of this initiative is to help build a better world by supporting socially vulnerable women.

General Objective:

To establish a comprehensive center for treatment, support, empowerment, vocational training, and social reintegration for homeless women who use drugs.

Specific Objectives – Client Outreach:

1. Conduct mobile outreach patrols to deliver initial harm reduction services and engage women who use drugs in known gathering spots.
2. Distribute food at night to identify and build trust with homeless women who use drugs in street hangouts.
3. Launch a women’s overnight shelter to provide services to target groups in accordance with the Welfare Organization’s approved guidelines, and conduct motivational counseling with admitted clients to help them enter the treatment cycle.

Why a Shelter Is Essential Alongside This Project:

Residential centers such as transitional homes inevitably require rules and boundaries to protect the recovery process of both individuals and the group. For example, if a recovering patient relapses while staying in a transitional home, their presence may jeopardize the recovery of others, and they must leave the facility. If an overnight shelter is available nearby, the patient can be referred there, receive motivational counseling, regain the desire to quit, and return to the center’s detox unit—without ending up back on the streets or in unsafe environments. This also ensures they remain connected to the support system.

Additionally, some individuals in street hangouts may have no intention of quitting drug use. A shelter allows them to access harm reduction services—such as hot meals, showers, clothing, and a safe place to sleep—protecting them from dangers like cold weather, malnutrition, illness, and assault. Through case management and expert assessment, the shelter can also serve as a gateway to identify and refer potential clients to treatment centers.

Pre-Treatment and Initial Admission (Screening Phase)

1. Initial Counseling: Conducted by a case management team consisting of a psychologist, physician, and social worker to determine the most effective treatment approach for each patient—whether abstinence-based or maintenance therapy—and refer them to the appropriate units.

2. Maximizing Admissions: Efforts will be made to admit as many referred clients as possible. In coordination with the Welfare Organization, clients with children will be accepted, and their children will be referred to welfare services or other appropriate centers.

3. Screening and Admission: All women who use drugs will be screened and admitted, including those living with conditions such as HIV. Necessary conditions will be provided to ensure their inclusion in the treatment process.

4. Respiratory Conditions: Clients with respiratory illnesses will not be admitted to the center but will not be abandoned. The case management team will actively follow up and refer them to the Welfare Organization or other suitable facilities.

5. Pregnant Clients: Through coordination with the Welfare Organization and the Ministry of Health, pregnant clients will be referred to mother-and-child centers or other specialized facilities.

6. Treatment Duration: The length of treatment will be determined by the case management unit based on the type of substance used. For example, treatment for methamphetamine use will require a minimum of 90 days. Final discharge will depend not only on the client’s physical and psychological readiness but also on the availability of a supportive social and family environment. Assessing and facilitating this is the responsibility of social workers and other case management professionals.

Treatment Phase

7. Provide voluntary, treatment-based care for women with substance use disorders through Methadone Maintenance Therapy (MMT).
8. Offer abstinence-based treatment for women through medium-term residential centers (rehabilitation camps).

Empowerment Phase

9. Establish a safe, drug-free shelter (up to one year) for homeless women in recovery—whether undergoing MMT or discharged from rehab centers: Transitional Home.
10. Conduct individual and group psychological counseling sessions.
11. Provide social work services and case follow-ups.
12. Assist with legal and judicial procedures.
13. Form peer support groups composed of individuals with shared experiences.
14. Teach the Twelve-Step principles of Narcotics Anonymous (NA).
15. Enhance clients’ resilience through life skills training, cognitive therapies, and positive psychology techniques.
16. Educate clients on medication adherence and continuity of addiction treatment.
17. Teach the basics of communal and socially responsible living.
18. Strengthen social relationships and provide strategies to boost self-confidence and self-esteem.
19. Support all clients—regardless of treatment type—in gaining employability and financial independence.
20. Create opportunities to identify and nurture each client’s individual talents and capabilities.

Vocational Training

21. Provide skill development, entrepreneurship opportunities, and job creation through the establishment of rapid-return workshops.
22. Support the discovery and growth of clients’ talents in employment-related fields, boosting their self-esteem and confidence.
23. Through ongoing coordination with the Technical and Vocational Training Organization, clients who complete empowerment workshops will receive official certification. Upon discharge, they can benefit from the privileges associated with these professional credentials—such as access to financial support—and gain employment in other production workshops.
24. Technical qualification certificates will be awarded based on a ranking system that considers training duration, internship performance, individual talent, and effort. This approach fosters motivation and helps prevent feelings of despair, hopelessness, and apathy—key factors contributing to relapse.

Social Reintegration

25. Improve access to psychological support services following addiction treatment.
26. Assist clients in achieving financial independence and starting a new, self-sufficient life.
27. Cultivate social engagement and a sense of compassion toward others.
28. Promote lifestyle change and break the cycle of addiction.

Referral Services

1. Referral of women with substance use disorders and non-acute psychological conditions—such as depression, anxiety disorders, bipolar disorder, etc.—to specialized treatment centers.
2. Referral of pregnant, homeless women with substance use disorders to mother-and-child centers under the supervision of the Welfare Organization.
3. Referral of homeless women (with or without addiction) who suffer from acute psychiatric disorders (e.g., psychosis) to mental health care and residential facilities.
4. Referral of elderly, homeless women in recovery (post-detox and initial treatment) to senior care homes supervised by the Welfare Organization.
5. Referral of homeless women with physical or intellectual disabilities to rehabilitation and care centers for persons with disabilities.
6. Referral of homeless children with substance use disorders to child rehabilitation centers under the Welfare Organization.
7. Referral of clients from the Positive Club for periodic testing and nutritional counseling to medical centers, laboratories, and Positive Clubs.

Technical Resources

– Physical space with appropriate infrastructure to accommodate various patient groups, including abstinence-based clients, those undergoing maintenance therapy, overnight shelter residents, Positive Club members, and empowerment workshop participants
– Equipment for aerobic and group exercise activities
– Vocational training workshops
– Educational tools and materials
– Emergency medical supplies
– Library
– Ambulance

Human Resources

Screening Unit
– 1 physician
– 1 nurse or paramedic
– 1 social worker
– 1 addiction recovery assistant
– 1 psychologist

Overnight Shelter Unit

– 1 social work specialist
– 2 addiction recovery assistants

Mobile Outreach and Night Food Distribution Unit

– 2 addiction recovery assistants
– 1 social worker
– 1 driver with vehicle

Case Management Unit

– Senior psychologist
– Senior social worker
– Multiple social workers (specialized in family/addiction), with one assigned per 15–20 clients

Methadone Maintenance Treatment (MMT) Unit

– A general physician trained in MMT, serving as the technical supervisor
– A technician or professional in nursing, midwifery, or paramedicine
– A psychologist (bachelor’s or master’s level) trained in MMT

Medium-Term Residential Treatment Unit (Rehabilitation Camp)

– A general physician serving as the camp’s technical supervisor
– A psychologist acting as the internal manager of the camp
– Addiction recovery assistants
– Family support assistants

Transitional Home Unit

– A center manager with relevant work experience and at least a master’s degree in fields related to women, social sciences, or humanities, responsible for task coordination and overall supervision
– A psychologist or counselor with at least a master’s degree to support the psychological and social well-being of residents (one psychologist per 15–20 clients)
– A social worker with at least a master’s degree to assist clients with tasks such as recovering lost identity documents, improving family relationships, and handling legal and judicial referrals (one social worker per 15–20 clients), under the supervision of the case management unit
– A peer supporter (someone with at least one year of sobriety) who resides full-time at the center, facilitates recovery meetings, fosters a safe and supportive environment, and maintains direct oversight of residents and center operations

Employment and Empowerment Unit – Transitional Home Residents

– Social services specialist / social worker
– Vocational trainer with strong communication skills and expertise in the relevant profession
– Peer supporter (individual with at least one year of sobriety) working full-time to help create a safe and recovery-oriented employment environment

Employment and Empowerment Unit – Methadone Maintenance Clients

– Vocational trainer with strong communication skills and expertise in the relevant profession
– Social services specialist / social worker
– Addiction recovery assistant working in the workshop

General Staff Across All Project Centers
– Cook
– Cleaner
– Administrative staff
– Maintenance technician
– Security guard

Working Hours
– Screening Unit: 8:00 AM – 12:00 PM
– Case Management Unit: 8:00 AM – 4:00 PM
– Methadone Unit: Morning shift
– Rehabilitation Camp: 24/7
– Transitional Home: 24/7
– Employment Units: Morning and afternoon shifts
– Mobile Outreach Unit: Morning and afternoon shifts
– Overnight Shelter: 5:00 PM – 8:00 AM (next day)

Services Provided
– Harm reduction and food distribution via mobile outreach teams
– Overnight shelter for homeless individuals who use drugs
– Methadone maintenance therapy to support changes in drug use patterns
– Abstinence-based treatment for addiction recovery
– Supportive housing and empowerment programs through educational initiatives
– Entrepreneurship and employment services
– Medical care
– Individual and group motivational counseling and psychotherapy
– Social work services under the supervision of the case management unit, including referrals, follow-ups during and after treatment (e.g., family reunification, locating family members, recovering lost ID cards, monitoring treatment effectiveness, and necessary interventions)
– Referrals to healthcare providers (e.g., gynecologists, infectious disease specialists, psychiatrists)
– Rapid HIV and pregnancy testing, with tailored services for affected clients
– Educational programs in psychosocial domains
– Pre- and post-diagnosis counseling for individuals living with HIV/AIDS, including disclosure support and training on stigma and discrimination coping strategies
– Comprehensive case management services

Monitoring, Evaluation, and Data Collection

To monitor and evaluate the project and assess the effectiveness of services provided by the centers, approved forms from licensing authorities will be completed as individual case files for each client. Monthly and annual reports will be prepared and documented according to the requirements of the licensing and supervisory organizations. Additionally, checklists will be developed and approved by project supervisors to ensure that all center activities align with established standards. Site visits will be conducted throughout the project to observe and assess service quality.

Definitions and Terminology

Case Management:
Case management in treatment is a client-centered system that, based on the individual’s needs, strengths, weaknesses, and willingness, recommends the most appropriate available treatment option. Through specialized teamwork and social work follow-ups before and after discharge, it aims to minimize factors that contribute to relapse.

Abstinence-Based Treatment:
A form of addiction treatment focused on complete abstinence from all narcotics, stimulants, and their derivatives. It includes gradual and natural physical detoxification, as well as psychological, personal, and social recovery.

Maintenance Treatment:
A method of addiction treatment that replaces illegal, short-acting, and expensive substances—often injected and associated with high risks of HIV and hepatitis—with legal, affordable, oral, and long-acting medications. These medications prevent withdrawal symptoms and cravings, and the extended treatment duration allows for meaningful recovery in brain function and personal and social life.

Medium-Term Residential Center

This center provides addiction treatment based on an abstinence-based model. Each inpatient cycle lasts approximately 21 days, during which the client undergoes gradual and natural physical detoxification. Throughout this period, clients also benefit from psychological counseling and peer support group sessions (NA). To achieve personal, social, and psychological recovery, individuals must take responsibility for their healing and actively participate in the process. Passivity in the face of addiction increases the risk of relapse. Case management planning and follow-up play a vital role in facilitating the recovery journey.

Definitions and Terminology

Twelve-Step Principles (NA):
A spiritually oriented program composed of guiding principles designed to support recovery from addiction, addictive behaviors, and related interpersonal challenges. The twelve steps are based on acknowledging personal powerlessness and accepting help from a higher power (as defined by the individual). Originally developed by Alcoholics Anonymous, the program has since expanded to address other forms of addiction.

Step Meetings:
Informal gatherings where individuals in recovery work through the twelve steps under the guidance of a more experienced peer with longer abstinence and recovery experience.

Addiction Recovery Assistant:
A trained peer who understands the nature of addiction and is capable of providing social work support to individuals with substance use disorders.

Psychosis:
A mental condition characterized by persistent delusions and hallucinations, in which the individual loses touch with reality. The Persian equivalent is “ravān-parishi” (psychotic disorder).

Peer Supporter (“Yavar”):
A recovered individual with at least two years of sobriety who offers full-time support within the center to help create a safe and recovery-oriented environment.

Peer (“Hamsān”):
In any treatment model, a peer is someone who shares similar experiences—whether addiction alone, addiction with HIV, or HIV alone—and similar treatment paths, such as abstinence-based therapy, maintenance therapy, or Positive Club membership. Peer support is highly effective in treatment units due to shared lived experience.

Positive Club:
A unit dedicated to providing psychosocial support services to individuals living with HIV/AIDS and encouraging their active participation in activities related to the condition.