Drug Abuse Problems in the Drug Abuse Problems in the Middle EastMiddle East

Richard A. Rawson, Ph.DRichard A. Rawson, Ph.DAdjunct Associate ProfessorAdjunct Associate Professor

Semel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human BehaviorDavid Geffen School of MedicineDavid Geffen School of Medicine

University of California at Los AngelesUniversity of California at Los Angeleswww.uclaisap.orgwww.uclaisap.org

rrawson@mednet.ucla.edurrawson@mednet.ucla.edu

Supported by:Supported by: National Institute on Drug Abuse (NIDA)National Institute on Drug Abuse (NIDA)

Pacific Southwest Technology Transfer Center (SAMHSA)Pacific Southwest Technology Transfer Center (SAMHSA)International Network of Treatment and Rehabilitation Resource Centres (UNODC)International Network of Treatment and Rehabilitation Resource Centres (UNODC)

Drug Abuse in the Middle EastDrug Abuse in the Middle East

R. Srinivasa MurthyR. Srinivasa MurthyEastern Mediterranean Regional Office of World Health Eastern Mediterranean Regional Office of World Health

Organisation, Organisation,

Cairo, Egypt.Cairo, Egypt.

DRUG ABUSE IS PUBLIC HEALTH PRIORITY

EMRO-Countries in Complex Emergencies and Post-Conflict situations

Doctors /10 000 populationDoctors /10 000 population

10 - 20

2 - 10

> 20

< 2

Psychiatrists/100,000Psychiatrists/100,000

0.41.6

0.151.0

0.1 0.2

1.3

1.3

3.4

2.0

0.1

0.041.00.50.5

1.0

2.0

0.8

0.1

Tentative estimate of cannabis resin production and main source countries

7,400 metric tons

Source: World Health Organization, Eastern Mediterranean Regional Office, 2002

OMABAH

SUDIRAUAE

MORKUW

PAKSAAIRQOPT

EGYJOR

LEBSYR

YEMTUN

DJI

0 10 20 30 40 50 60 70 80

%

Risk Factors: Smoking prevalence among men in EMRO

Drug Abuse Pattern in the RegionDrug Abuse Pattern in the Region

Opioids- Afghanistan, Bahrain, Opioids- Afghanistan, Bahrain, Iran, Pakistan, OmanIran, Pakistan, Oman

Khat- Djibouti, Somalia, YemenKhat- Djibouti, Somalia, Yemen

Stimulants-Stimulants-

Regional SituationRegional Situation

Age of starting drugs is decreasingAge of starting drugs is decreasing

Injectable drugs is increasingInjectable drugs is increasing

Women are using drugs more oftenWomen are using drugs more often

Contribution to spread of HIV/AIDSContribution to spread of HIV/AIDS

Majority of the drug abusers are not Majority of the drug abusers are not seeking treatmentseeking treatment

DRUG ABUSE IS PUBLIC HEALTH PRIORITY

The Facts… in the EMR… The Facts… in the EMR… cont’dcont’d

0.16%

0.77%

0.99%

2.15%

3.26%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

Rat

e H

IV P

osi

tive

1999 2000 2001 2002 2003

Year

Rate of HIV Positive tests among IDU by year

The Facts… in the EMRThe Facts… in the EMR

2.15%2.01%

3.63%

7.80%

13.50%

0%

2%

4%

6%

8%

10%

12%

14%

% t

ran

smit

ted

th

rou

gh

ID

U

1998 1999 2000 2001 2002

Year reported

AIDS cases transmitted through IDU

0

10

20

30

40

50

60

70

80

1996 1997 1998 1999 2000 2001 2002 2003

Year

%Al Razi addiction treatment Al Razi addiction treatment unit - % of admissions HIV unit - % of admissions HIV

positivepositive

Innovative Regional InitiativesInnovative Regional Initiatives

Specialised treatment facilities-Specialised treatment facilities- Libya, Kuwait, Libya, Kuwait, Saudi Arabia Saudi Arabia

Prevention through Life skills educationPrevention through Life skills education Eg. Eg. Egypt, Iran, OmanEgypt, Iran, Oman

Harm reduction strategies-Harm reduction strategies- needle exchange, needle exchange, methadone treatment Eg. Iranmethadone treatment Eg. Iran

Triangular clinicsTriangular clinics

Public Mental Health EducationPublic Mental Health Education

Involvement of Religious leadersInvolvement of Religious leaders

Regional Strategy for Substance Regional Strategy for Substance Use and DependenceUse and Dependence

1. 1. Development of National policy- Development of National policy- multi-sectoral with networking;multi-sectoral with networking;

2.Increasing understanding of causes, 2.Increasing understanding of causes, consequences and care;consequences and care;3. Human Resource Development;3. Human Resource Development;4.Wide range of services in 4.Wide range of services in Community;Community;5.Promotion of psychosocial wellbeing 5.Promotion of psychosocial wellbeing and prevention and prevention

Delivery Systems for Delivery Systems for Substance Abuse Treatment Substance Abuse Treatment

in Moroccoin Morocco

Prof. Jallal Toufiq, Prof. Jallal Toufiq, M.D.M.D.

Director of the Director of the National Center for National Center for

Drug Abuse Drug Abuse Prevention and Prevention and

Research Research and the Ar-razi and the Ar-razi

University University Psychiatric HospitalPsychiatric Hospital

Istanbul, TurkeyIstanbul, TurkeySeptember 2005September 2005

National High-School Survey on ATOD use in National High-School Survey on ATOD use in Morocco: n=2446Morocco: n=2446 ; 1994; 1994

drug Point prevalence Life-time prevalence

Tobacco 8.47 21.1

Cannabis 3 8.7

Other drug ~1 6.4

MEDSPAD Pilot study, RabatMEDSPAD Pilot study, Rabatn = 413 (15-17 years), 2003n = 413 (15-17 years), 2003

drug Life-time Prevalence

tobacco 0.24

alcohol 0.14

cannabis 0.11

solvents 0.08

Rabat survey on ATOD use in « street children » ,Rabat survey on ATOD use in « street children » ,n = 51; 1993n = 51; 1993

Age: 8 - 13 Age: 8 - 13

Point prevalence of Point prevalence of inhalant useinhalant use

= = 65 %65 %

Point prevalence of Point prevalence of cannabis use cannabis use

= = 20 %.20 %.

National multicentric survey on drug use in National multicentric survey on drug use in psychiatric setting: n = 3447; 1995 psychiatric setting: n = 3447; 1995

Point prev. of cannabis Point prev. of cannabis use: use: 19,6%19,6%

Percentage cannabis Percentage cannabis users / any drug users: users / any drug users: 84,3%84,3%

Comorbidity cannabis use Comorbidity cannabis use / acute psychotic / acute psychotic disorders + schizo. : disorders + schizo. : 52,7%52,7% ( (pp=0.00) =0.00)

Substance Abuse Related ProblemsSubstance Abuse Related Problems

Living with HIV/AIDSLiving with HIV/AIDS 13.00013.000 HIV/AIDS related deathsHIV/AIDS related deaths 320 320

(reporting problem)(reporting problem) HepatitisHepatitis Other health consequencesOther health consequences Crime, legal consequencesCrime, legal consequences Traffic accidents and domestic violence (alcohol)Traffic accidents and domestic violence (alcohol) Co-morbid psychiatric disorders (cannabis)Co-morbid psychiatric disorders (cannabis)

SUBSTANCE ABUSE AND SUBSTANCE ABUSE AND TREATMENT:TREATMENT:

LEBANON EXPERIENCELEBANON EXPERIENCE

RAMZI HADDAD, M.D.RAMZI HADDAD, M.D.

SKOUN, BEIRUTSKOUN, BEIRUT

HISTORY AND MILESTONESHISTORY AND MILESTONES

1947 : Antinarcotic legislation1947 : Antinarcotic legislation

1975 : Beginning1975 : Beginning of lebanese war; increase of illicit of lebanese war; increase of illicit cultivation and increase of substance abuse among cultivation and increase of substance abuse among militiasmilitias

1990 : End of war; decision of lebanese government to 1990 : End of war; decision of lebanese government to eradicate illicit cultivationseradicate illicit cultivations

1998 : Amendment of 1947 law1998 : Amendment of 1947 law

1999 : Ecstasy introduced to lebanon1999 : Ecstasy introduced to lebanon

2002 : Application of the law concerning BZD 2002 : Application of the law concerning BZD

SUBSTANCE ABUSE SEVERITYSUBSTANCE ABUSE SEVERITY

Heroin, Cannabis, Cocaine, Tobacco, Heroin, Cannabis, Cocaine, Tobacco, BZD, Ecstasy, Alcohol ++/+++BZD, Ecstasy, Alcohol ++/+++

Prescription drugs ( Opioids, Prescription drugs ( Opioids, Trihexyphenidyl ..) ++/+++Trihexyphenidyl ..) ++/+++

Inhalants, Amphetamines, +/++Inhalants, Amphetamines, +/++

Substance abuse related problemsSubstance abuse related problems

Living with HIV/AIDS : 2700Living with HIV/AIDS : 2700

HIV/AIDS related deaths : 200HIV/AIDS related deaths : 200

( Ministry of health,2003 )( Ministry of health,2003 )

Major issues : - psychiatric co-morbidityMajor issues : - psychiatric co-morbidity

- adolescents- adolescents

AVAILABLE SUBSTANCE ABUSE TREATMENTAVAILABLE SUBSTANCE ABUSE TREATMENT

Inpatient detoxificationInpatient detoxification

Physician counselingPhysician counseling

Outpatient counselingOutpatient counseling

PsychotherapyPsychotherapy

Residential rehabilitationResidential rehabilitation

Buprenorphine ??Buprenorphine ??

Other pharmaceuticals therapies : disulfiram, Other pharmaceuticals therapies : disulfiram, naltrexone, nicotine replacementnaltrexone, nicotine replacement

Substance Abuse in Iran; Substance Abuse in Iran; A Brief OverviewA Brief Overview

Rabert Farnam MDRabert Farnam MD

Shiraz Welfare OrganizationShiraz Welfare Organization

Yaas Addiction CenterYaas Addiction Center

Shiraz, IranShiraz, Iran

Iran; facts about drug abuseIran; facts about drug abuse

According to the “Epidemiological Study of According to the “Epidemiological Study of Drug Abuse in IRAN” (2001):Drug Abuse in IRAN” (2001):– Some 3,761,000 people use opioids in Iran.Some 3,761,000 people use opioids in Iran.– About 2,547,000 fit DSM-IV diagnosis for About 2,547,000 fit DSM-IV diagnosis for

opioid abuseopioid abuse..– 1,158,000 meet diagnostic criteria for 1,158,000 meet diagnostic criteria for opioid opioid

dependence.dependence.

Iran; facts about drug abuse Iran; facts about drug abuse (continue)(continue)

About 94% of abusers are male.About 94% of abusers are male.

In 75% of drug abusing individuals In 75% of drug abusing individuals the main habit is ingesting or smoking the main habit is ingesting or smoking opiumopium. .

A A forth forth of Iranian addicts abuse of Iranian addicts abuse heroinheroin, , halfhalf of whom inject the drug. of whom inject the drug.

Iran; facts about drug abuse Iran; facts about drug abuse (continue)(continue)

Alcohol abuse is not so common and Alcohol abuse is not so common and 250,000 abusers are thought to be present 250,000 abusers are thought to be present in the country.in the country.

Amphetamine was a rarity 2 years ago but Amphetamine was a rarity 2 years ago but it isit is rapidly rapidly growing. growing.

Cocaine abuse is still a rarity.Cocaine abuse is still a rarity.

Iran; facts about drug abuse Iran; facts about drug abuse (continue)(continue)

According to data from Iranian Drug Control According to data from Iranian Drug Control Headquarters (DCHQ):Headquarters (DCHQ):– Annually 1,000 tons of opium, heroin and Annually 1,000 tons of opium, heroin and

morphine is consumed in the nation.morphine is consumed in the nation.– Some 5 billion dollars is spent on drugs Some 5 billion dollars is spent on drugs

annually.annually.– Afghanistan produces more than 3,600 tons of Afghanistan produces more than 3,600 tons of

opioids; large quantities are trafficked to Iran.opioids; large quantities are trafficked to Iran.– Iranian police confiscates more 200 tons a Iranian police confiscates more 200 tons a

year. year.

Injection drug abuse in IranInjection drug abuse in Iran

Around 16% of Drug Abusers in Iran have Around 16% of Drug Abusers in Iran have history of IDU.history of IDU.

IDU appears 2-12 years after starting drug IDU appears 2-12 years after starting drug abuse.abuse.

Mean age of starting IDU is 26. Mean age of starting IDU is 26.

Most of IDUs are men between 20-40 years and Most of IDUs are men between 20-40 years and most of needle sharing occurs between 20-29 y most of needle sharing occurs between 20-29 y of age.of age.

Epidemiological Study of Drug Abuse in IRAN (2001)

Current State of HIV/AIDS in IRAN Current State of HIV/AIDS in IRAN

More than 11,200 cases of HIV/AIDS have More than 11,200 cases of HIV/AIDS have been registered. been registered.

Around Around 60%60% of the cases were through of the cases were through needle sharing in IDUs.needle sharing in IDUs.

Estimated 30,000-40,000 HIV/AIDS cases Estimated 30,000-40,000 HIV/AIDS cases are in the country.are in the country.

Needle is availableNeedle is available

From 1996From 1996

Detoxification centers (up to 110 governmental Detoxification centers (up to 110 governmental and around 600 private)and around 600 private)– Using clonidine, rapid detox and ultra-rapid detox!Using clonidine, rapid detox and ultra-rapid detox!– Extensive use of naltrexone*, and moderate use of Extensive use of naltrexone*, and moderate use of

psychotherapy and group interventions. psychotherapy and group interventions.

Inpatient services up to 500 beds in the nation.Inpatient services up to 500 beds in the nation.TCs (more than 35 centers), 2 for TCs (more than 35 centers), 2 for femalesfemalesNA groups and other self-help (more than NA groups and other self-help (more than 12,000 members), separate groups for 12,000 members), separate groups for womenwomenCommunity based networks Community based networks MMT and BMT facilities covering up to 6,000 MMT and BMT facilities covering up to 6,000 clients. clients.

More than 14,000 are on

naltrexone maintenance but formerly it was

20,000

Drug abuse treatment in IranDrug abuse treatment in Iran

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Outpatient detoxification in governmental centers; currently 110 centers

Outpatient detoxification in private centers; currently 600 centers

Narcotic anonymous groups; currently more than 12,000 members

Therapeutic communities; currently > 30 centers

Naltrexone treatment; 14,000 patients in NMT

Pilot MMT projects

MMT in governmental centers; currently >3,500 cases

MMT in private centers and offices; currently 1,000 cases

MMT in prisons; currently 1,500 cases

Buprenorphine registered for substance abuse treatment

Treatment in Iran provided throughTreatment in Iran provided through

Governmental sectorGovernmental sector

UniversitiesUniversities

Welfare OrganizationWelfare Organization

Prison OrganizationPrison Organization

Private centers and officesPrivate centers and offices

NGOs( active in detox – counsellingNGOs( active in detox – counselling

In the recent year up to In the recent year up to 200,000 drug users received 200,000 drug users received some sort of treatment;some sort of treatment;

mostly detoxification and mostly detoxification and short-term psychotherapies.short-term psychotherapies.

Outcome of detox and naltrexone Outcome of detox and naltrexone

maintenance in different citiesmaintenance in different cities City

Number entering treatment

Retention after 6 months

Meshad 189 80 (42.3%)

Rasht 184 35 (19.0%)

Kermanshah 139 13 (9.4%)

Yazd 183 14 (7.7%)

Total 695 142 (20.4%)

Results I: Results I:

Remaining in MMT after 3 months: 79%Remaining in MMT after 3 months: 79%

Remaining in MMT after 6 months: 73%Remaining in MMT after 6 months: 73%

Average daily dose: 77 mg (range 25-Average daily dose: 77 mg (range 25-160mg)160mg)

Average dose in patients finishing 3 Average dose in patients finishing 3 months: 74mgmonths: 74mg

Results II: Results II:

Outcome measures showed that MMT Outcome measures showed that MMT dramatically decreased illicit drug, dramatically decreased illicit drug, intravenous injection, criminal behavior intravenous injection, criminal behavior and violence after 3 months.and violence after 3 months.Clients claim that after initiation on Clients claim that after initiation on methadone they save an average of methadone they save an average of 1,500,000 (~200$) Rials a months.1,500,000 (~200$) Rials a months.The MMT costs only 25$ a month for The MMT costs only 25$ a month for every client. every client.

Delivery Systems for Delivery Systems for Substance Abuse Treatment:Substance Abuse Treatment:

Gaza and the West BankGaza and the West Bank(Palestine Territory) (Palestine Territory)

Mohammed Afifi, M.D., M.Sc.Mohammed Afifi, M.D., M.Sc.Substance Abuse Research CenetrSubstance Abuse Research Cenetr

Istanbul, TurkeyIstanbul, TurkeySeptember 2005September 2005

IntroductionIntroduction

Population (2003)Population (2003)

Estimated Population is 3.7 millions (36.7% in Estimated Population is 3.7 millions (36.7% in Gaza Strip, and 63.3 in the West Bank).Gaza Strip, and 63.3 in the West Bank).Density Rate in Gaza Strip in (3806 person Density Rate in Gaza Strip in (3806 person /Sq.Km –area is 360 sq.km.), while the West /Sq.Km –area is 360 sq.km.), while the West Bank is 408 person /Sq.Km. area is 5800 Bank is 408 person /Sq.Km. area is 5800 sq.km.sq.km.The refugees make up 56% in Gaza Strip, and The refugees make up 56% in Gaza Strip, and 44% of the West Bank Populations.44% of the West Bank Populations.Un-employment: 31%, and 64.9% of families Un-employment: 31%, and 64.9% of families has an income of average 2 USD per day has an income of average 2 USD per day (Poverty line).(Poverty line).

Nature of Substance Abuse ProblemsNature of Substance Abuse Problems(No national figures)(No national figures)

TobaccoTobacco H. schools H. schools 7-18%7-18%Universities Universities 9-50%9-50%

AlcoholAlcohol H. schoolsH. schools 0.3-1.6%0.3-1.6%Universities Universities 3-4%3-4%

Heroin/Cocaine H. schoolsHeroin/Cocaine H. schools 0.8-1.6%0.8-1.6%Universities Universities 0.8-2.9%0.8-2.9%

MarijuanaMarijuana H. schoolsH. schools 1.1-3%1.1-3%Universities Universities 1.2-4.6%1.2-4.6%

EcstasyEcstasy LifetimeLifetime ? ?

Nature of Substance Abuse Problems Nature of Substance Abuse Problems ContinuedContinued

Meth/Amphetamine LifetimeMeth/Amphetamine Lifetime ?? Inhalants Inhalants H. schoolsH. schools 2.6-4.6%2.6-4.6%

Universities Universities 2.4-2.4-4.7%4.7%

Prescription Drugs H. schools Prescription Drugs H. schools 2.5-2.5-4.6%4.6%

Universities Universities 3.3-3.3-4.5%4.5%

Nature of Substance Abuse ProblemsNature of Substance Abuse Problems

Drug injection is a moderate problem Drug injection is a moderate problem especially with heroin, cocaine, and especially with heroin, cocaine, and morphine derivative (pethedine).morphine derivative (pethedine).

Clean needles are available (not free)Clean needles are available (not free)

Substance Abuse Related ProblemsSubstance Abuse Related Problems

Living with HIV/AIDSLiving with HIV/AIDS 55 55 casescases

HIV/AIDS related deathsHIV/AIDS related deaths 25 cases25 cases

The most urgent substance related The most urgent substance related problems include: hepatitis, co-morbid problems include: hepatitis, co-morbid disorders and adolescent drug use.disorders and adolescent drug use.

Treatment SystemTreatment System

Substance abuse treatment in Palestine Substance abuse treatment in Palestine needs to be build from scratch: needs to be build from scratch: – Providing treatment facilitiesProviding treatment facilities– Jailhouse treatment servicesJailhouse treatment services– Adopting proper treatment protocolsAdopting proper treatment protocols– Training health teams for proper protocolsTraining health teams for proper protocols– Reduce the legal sanctions for useReduce the legal sanctions for use– Make treatment available for allMake treatment available for all