Islamic Republic of Afghanistan
STRATEGY PAPER FOR THE PREVENTION AND TREATMENT
OF SUBSTANCE ABUSE
July 2007
By: Drug Demand Reduction Department/ MoPH
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1.
RATIONAL:
The purpose of this document is to make available a concept paper on drug demand reduction
(DDR) strategy in the MOPH. The formulation of a MOPH DDR strategy will provide a national
guide for Afghanistan’s National Development Strategy (ANDS) on drug abuse treatment and
rehabilitation. In addition, it will offer a description of the basic principles that constitute the overall
approach to treatment in the country and will help to establish the goals and objectives for a
national treatment system.
This report details the specific type of DDR and harm reduction (HR) services that are available in
Afghanistan and provides a description of the different responsibilities of each of the public and
non-governmental agencies that play key roles in the planning and development of the national
policies regarding drugs.
2.
CURRENT DRUG USE ENVIRONMENT
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Expert opinion recognizes a general increase of drug misuse and dependence in
the country since 2001.
Contributing demand factors include vulnerability from trauma of war and
extreme poverty.1
A further contributing demand factor is social dislocation of Afghan refugees;
historically to refugee camps in Pakistan and Iran 2 that were influenced by local
drug consumption trends, followed by the return of drug dependent refugee
populations to Afghanistan within the past three years.
The demand trend is also supported by the ready supply of locally produced
opium. This is especially evident in provinces of Badakshan, Nangahar, Balkh,
Herat, Kandahar, Kunduz.
The Afghanistan Drug Use Survey 2005 (UNODC, 2005) estimated a total of
920,000 users of psychotropic substances in the country, of which approximately
740,000 were males and 120,000 females. There were also 60,000 estimated
child drug users.
Almost 150,000 of the total estimated number of drug users were opium users,
with the majority of them consuming daily (86%). An estimate of 50,000 heroin
users was also established in the drug use survey. Inhaling the fumes of heated
heroin (chasing) was the predominant method of administration, mostly done on
a daily basis (86%).
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Heroin use is often associated with comparatively higher risks to public health
because of dependence liability and method of administration that is often by
injection that facilitates transmission of blood born infections such as HIV and
Hepatitis B and C. The 2005 survey identified about 15% (7,500) of all male
heroin users as injectors.
The estimated level of drug use of most drug types is much higher in Central and
Northern Zones than other areas of Afghanistan for both men and women. The
highest level of drug use in the Central Zone is found in Kabul City and
surrounding rural areas. In the Northern Zone the highest estimated levels of
drug use occur in provinces bordering Turkmenistan and Uzbekistan. In other
regional zones, drug use is more evenly distributed across provinces, with higher
levels found in provinces that border Iran or Pakistan.
Treatment admissions in Kabul and elsewhere generally reflect access by opium
using populations, but not heroin using populations.
GOVERNMENT POLICIES AND STRATEGIES
Afghanistan has a National Drug Control Strategy (NDCS, January 2006) to ensure the
achievement of the following four national priorities:
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Disrupting the drugs trade by targeting traffickers and their backers;
Strengthening and diversifying legal rural livelihoods;
Reducing the demand for illicit drugs and treatment of problem drug users;
Developing state institutions at the central and provincial level vital to the delivery of the
government counter narcotics strategy.
The strategy is also supported by a counter narcotics implementation plan. The 2006 version of
the plan emphasizes eight pillars; including demand reduction, alternative livelihoods, eradication,
public awareness, law enforcement, criminal justice, international and regional cooperation and
institution building.
The pillar for demand reduction and treatment of addicts includes primary, secondary and tertiary
prevention activities that are coordinated and monitored by the Demand Reduction Directorate of
the Ministry of Public Health. The NDCS through its Drug Demand Reduction Implementation
Plan (October 2006) proposes the following activities to be implemented for the period 20072009.
Primary prevention
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Development of drug related messages to be incorporated in school curricula (March
2007)
Extra curriculum activities in schools: sports, essay and poster competition, drugs
awareness messages dissemination (September 2007)
Community awareness campaign (July 2007)
Inclusion of workplace-based prevention (July 2007)
Development, production and dissemination of Drug Demand Reduction (DDR) oriented
Information, Education and Communication (IEC) material (July 2007)
Establishment of 34 mosque-based drug prevention and aftercare centres (May-July
2009)
Training of social multipliers: religious leaders, community leaders, generic and
community health workers, police and groups vulnerable to drug use (July 2007)
Awareness creation about drugs and its hazards: community based meetings, seminars
and events; involvements of Mass Media for drug abuse prevention (July 2007)
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Project to establish a Kindergarten as pilot project in Siagard District of Balkh province, in
order to prevent mother employed in carpet weaving administering opium to babies
(2009)
Secondary prevention
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Upgrade,
support
and
continuation
of
present
comprehensive
drug
treatment/rehabilitation services in Afghanistan such as drug treatment and rehabilitation
centres in Kabul (10 beds Nejat and 20 bedded Drug Dependency Treatment CenterDDTC of Ministry of Public Health-MOPH), Herat, Kandahar, Gardiz, Faizabad (10 to 15
bedded residential facilities (July 2007)
Establishment of new comprehensive drug treatment and rehabilitation, drug prevention
and harm reduction services in Helmand, Nangahar and Balkh provinces, each with 20
bedded residential facilities (July 2009)
Continuation of community based treatment centres (drop in centres/outreach activities)
in Kabul (old city, deh Afghanan), Jalalabad, Logar Ghazni and Wakhan of Badakhshan
(June 2007)
Establishment of 8 community based treatment centres in Kunduz, Jawzjan, Maimana,
Ghor, Frah, Zarabg, Ghazni and Bamyan (July 2009)
Establishment of Shortapaha community based treatment and rehabilitation services
(June 2007)
Upgrading of Zandahi Nawin community treatment centre by adding 6 bed residential
services in Kabul (July 2007)
Tertiary prevention/harm reduction services (2007-2009)
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HIV/AIDS projects coordinated by the HIV/AIDS Control Unit of the MOPH
Production of publicity material linking injecting drug use with spread of HIV
HIV/AIDS awareness among young and vulnerable populations
Capacity building of NACP staff
Support to training of health care workers in STI/HIV/AIDS prevention and care
Support to coordination of STI/HIV/AIDS activities
Technical assistance (TA) for drafting national HIV/AIDS Strategic Plan
TA for writing GFATM R6 HIV/AIDS application
Advocacy with religious leaders
Establishment of three Volunteer Confidential Counselling Test Centres (VCCT)
Establishment of a clinical laboratory in the mental health hospital with HIV/AIDS testing
facility
Advocacy project-advocacy tool kit translation, posters and pamphlets
Training of Trainers (TOT) of teachers program
Awareness through education materials in school
The need for the prevention and treatment of substance use is also reflected in a public health
policy that recognizes mental health as part of the basic package of health services.
4.
INSTITUTIONAL FRAMEWORK AND CAPACITY
Government interventions
In 2002, implementation of the national drug control strategy was charged to a Counter Narcotics
Directorate under the National Security Council, and in 2004 the work of the directorate was
raised to cabinet level through the establishment of the MCN. The Ministry is responsible for the
coordination, monitoring and evaluation of all activities related to the NDCS, including the
demand element.
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The MOPH is the line government agency with primary responsibility for delivery of treatment and
rehabilitation services to drug users (including HR services) throughout Afghanistan. The MOPH
is also responsible for developing and implementing programs for drug use and HIV/AIDS
prevention.
Technical monitoring of implementation will be undertaken by Implementing Partners, at the point
of implementation. This process will be overseen by the Demand Reduction Working Group (DR
WG), after consultation between WG and Implementing Partners. Consultations between the two
groups is an important step in which agreement will be reached on monitoring guidelines and
agreed indicators for each activity/project (NDCS, October 2006).
In order to be able to carry out its responsibility in the monitoring process, the WG will undergo
training on monitoring techniques which will be an important part of the next steps.
That mandate is reflected in the NDCS priority on drug demand reduction. At overall level, the
following NDCS benchmarks will be measured (NDCS. Drug Demand Reduction Implementation
Plan, October 2006).
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The level of substance abuse reported reduced by year on year (using 2005 figures as a
baseline)
Training workshops producing a basic understanding of drugs, drug dependency and
drug abuse prevention for 30 social multipliers established in 34 provinces
Training of MOPH in 34 provinces X 50 community healthcare workers (1.700) to work in
community drug abuse prevention, including home-based detox and treatment completed
Residential treatment facilities in major cities and cities with high number of drug addicts
developed/upgraded (Kabul, Herat, Kandahar, Gardiz, Faizabad, Helmand, Nangarhar
and Balkh, Kunduz, Jawzjan, Farah and Ghazni)
Community based treatment facilities and harm reduction (HR) services in selected
provinces developed (Kabul, Jalalabad, Logar, Ghazni, Badakhshan, Kunduz, Jawzjan,
Bamyan, Ghor, Farah, Paktika, Herat, Kandahar and Nimruz)
These NDCS benchmarks will form part of the basis for reporting progress.
The pillar WG will review progress in implementing this plan every 3 months, based on
information from lead implementing agencies.
Activities and responsibilities of governmental organizations
The activities for HIV/AIDS prevention in general are coordinated by the HIV/AIDS control unit of
the MOPH. HR strategies for drug users are coordinated through the harm reduction sub working
group of the national DR WG.
Under an arrangement between UNODC and the MOPH, six Drug Rehabilitation Action Teams
(DRAT) currently operate in six provinces. The teams provide individual counseling and
preventive education services in clinical and outreach settings. In 2005, the same teams were
also associated with community based data collection for the Afghanistan Drug Use Survey.
At the Ministry of Public Health itself, a national drug demand reduction focal point was attached
to the division for primary health care and curative medicine. The ministry is also assisted by one
national staff member assigned by UNODC.
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5.
GUIDING PRINCIPLES FOR THE PREVENTION AND TREATMENT OF SUBSTANCE
ABUSE
Preamble
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Substance abuse is a serious health and social problem in Afghanistan.
Substance abuse produces significant costs in terms of impact on
productivity as a result of premature death and ill health.
Substance abuse strategies should be goal oriented and include specific
measurement criteria.
Cost benefits should be considered in all
elements of the strategies.
Substance abuse strategies are more likely to be effective when they
involve partnerships and a sense of ownership by all relevant
stakeholders, including direct recipients of services.
Guiding Principles
A. Harm Reduction: One goal of a substance abuse strategy is to reduce the use of drugs.
However a first priority should be the decrease of negative consequences of substance
misuse. This focus on HR is intended to minimize the health risks and social problems
associated with the control and use of drugs among individuals, families and
communities. Abstinence from drug use is an important goal for many, but it is not
necessarily the only acceptable goal for all substance abusers. HR involves a
prioritization of goals in which immediate and realizable goals take priority when dealing
with users who are unable or unwilling to abstain from drugs (at least for the present
time). For example the hierarchy of goals for reduction of harm among injecting drug
users might be:
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Reduction or cessation of needle – sharing
Use of oral rather than injectable drugs
Reduction in quantity of drugs consumed; and
Abstinence
B. Continuum of Interventions: There should be a balanced approach in substance
abuse strategies in order to address the full continuum of risks for developing problems
with the use of drugs, including:
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Measures to enhance health and prevent substance abuse problems in the general
population, incorporating a comprehensive analysis of risk and protective factors.
Prevention programs targeted at special high risk groups.
Early detection and intervention for at-risk and excessive substance use.
Individualized treatment and rehabilitation.
C. Program Effectiveness: Programs to control prevent and treat drug problems should be
evidence based, well designed, effectively managed, community based and oriented
toward the needs of the individuals by:
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The collection and analysis of objective scientifically valid information drawn from a
cross section of methodologies including epidemiological studies, cohort studies,
ethnographic research and case studies.
The use of best practices in prevention and treatment programs.
Knowledge transfer that promotes methods for innovations discovered by practitioners
and transferring them to researchers for analysis and wider dissemination.
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Making prevention and treatment programs available to all that need them in a timely
fashion, taking regional and local conditions into account.
Targeting prevention and treatment programs toward specific needs, for example those
who are affected by extreme poverty or those at risk of HIV from injecting drug use.
Offering a variety of services that are tailored to individual needs, assuring that the
intensity of the intervention corresponds to the level of risk with brief interventions
reserved for low risk substance abuse and more intensive interventions for high risk
situations.
Demonstrating sensitivity to different cultural values and perspectives, by incorporating
the perspectives and values into the programs they are intended to serve.
Being sensitive to gender differences in the causes and consequences of drug misuse,
and if warranted, to address those differences in programs for each.
Recognizing that the causes and consequences of drug misuse also vary considerably
by age, and that programs should be sensitive to those differences.
D. Implementation: Programs for the control, prevention and treatment of drug problems
should recruit qualified staff, involve them in key decisions and communicate clearly to
clients and communities regarding program goals and effectiveness.
 Community – based Programs: When appropriate, programs should be community
based. Generally it is preferable to provide services as close as possible to client’s
homes, with more intensive services provided on regional or provincial levels.
 Orientation toward the needs of individuals: Less intrusive interventions should be
preferred over more intrusive. Programs should be client centered. For example clients
and families should be directly involved in setting personal treatment goals. Programs
should ensure that individuals, families and communities are capable of assuming
appropriate levels of responsibility without increasing their sense of powerlessness.
 Ongoing monitoring and evaluation: Programs should be subject to systematic and
ongoing assessment and evaluation for effectiveness.
E. Cost Effectiveness: Programs for the control, prevention and treatment of drug
problems should be evaluated for their cost effectiveness. Cost effectiveness should be
encouraged through partnerships with NGOs and the private sector while also promoting
the development of self help groups. Programs should be coordinated across
government, non government and private sectors to avoid duplication of effort.
6.
GENERAL MEASURES FOR STRENGTHENING DRUG DEMAND REDUCTION IN
AFGHANISTAN
A. Reduction of drug related problems
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Promote public understanding of drug related harms and effective
interventions.
Encourage practices that reduce drug use and drug related harm.
B. Improved access to quality treatment
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Address multiple needs of person.
Build strong partnerships with mental health and treatment services.
Increase involvement of primary health care, general practitioners, and
hospitals in early intervention, relapse prevention and shared care.
C. Develop workforce capacity and systems
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Raise the level of competence and improve the capacity to adopt innovative
programs.
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Analyze and respond to barriers to education and training.
Improve capacity of community based and mainstream organizations to
provide quality substance abuse prevention and treatment programs and
services.
D. Strengthen partnerships
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Within and across government departments, NGOs and the private sector.
Promote multi agency partnerships for prevention, education and treatment.
Support continued partnerships with international agencies and affected
communities.
Cooperate with other government agencies and relevant media to manage
the community impact of substance abuse.
E. Respond to emerging trends
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Establish advisory structure for access to relevant research and the
promotion of proactive attention to emerging drug issues and trends.
Exchange data with the MCN and other stakeholders.
Facilitate research and advice in the development of good practices for
prevention and treatment programs.
Conduct strategic planning workshops.
F. International Cooperation
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Establish priorities for cooperation at multilateral, regional and bilateral
levels.
Access funding mechanisms to support and sustain the strategy for the
prevention and treatment of substance abuse.
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