Drug Abuse Problems in the
Middle East
Richard A. Rawson, Ph.D
Adjunct Associate Professor
Semel Institute for Neuroscience and Human Behavior
David Geffen School of Medicine
University of California at Los Angeles
www.uclaisap.org
rrawson@mednet.ucla.edu
Supported by:
National Institute on Drug Abuse (NIDA)
Pacific Southwest Technology Transfer Center (SAMHSA)
International Network of Treatment and Rehabilitation Resource Centres (UNODC)
Drug Abuse in the Middle East
R. Srinivasa Murthy
Eastern Mediterranean Regional Office of World Health
Organisation,
Cairo, Egypt.
DRUG ABUSE IS PUBLIC HEALTH PRIORITY
EMRO-Countries in Complex Emergencies and Post-Conflict situations
Doctors /10 000 population
<2
2 - 10
10 - 20
> 20
Psychiatrists/100,000
2.0
0.4
0.8
1.6
0.5
1.0
0.15
0.5
1.0
0.04
0.1
1.0
1.3
3.4
1.3
0.1
0.2
2.0
0.1
Tentative estimate of cannabis resin production and main source countries
7,400 metric tons
0
Risk Factors: Smoking prevalence among
men in
EMRO
10
20
30
40
50
60
70
OMA
BAH
SUD
IRA
UAE
80
%
MOR
KUW
PAK
SAA
IRQ
OPT
EGY
JOR
Source: World Health Organization, Eastern Mediterranean Regional Office, 2002
LEB
SYR
YEM
TUN
DJI
Drug Abuse Pattern in the Region
Opioids- Afghanistan, Bahrain,
Iran, Pakistan, Oman
Khat- Djibouti, Somalia, Yemen
Stimulants-
Regional Situation
Age of starting drugs is decreasing
Injectable drugs is increasing
Women are using drugs more often
Contribution to spread of HIV/AIDS
Majority of the drug abusers are not
seeking treatment
DRUG ABUSE IS PUBLIC HEALTH PRIORITY
The Facts… in the EMR… cont’d
3.26%
3.50%
Rate HIV Positive
3.00%
2.50%
2.15%
2.00%
1.50%
0.99%
0.77%
1.00%
0.50%
0.16%
0.00%
1999
2000
2001
2002
Year
Rate of HIV Positive tests among IDU by year
2003
The Facts… in the EMR
AIDS cases transmitted through IDU
13.50%
14%
12%
% transmitted through IDU
10%
7.80%
8%
6%
3.63%
4%
2.15%
2.01%
2%
0%
1998
1999
2000
Year reported
2001
2002
Al Razi addiction treatment
unit - % of admissions HIV
positive
%
80
70
60
50
40
30
20
10
0
1996 1997 1998 1999 2000 2001 2002 2003
Year
Innovative Regional Initiatives
Specialised treatment facilities- Libya,
Kuwait, Saudi Arabia
Prevention through Life skills education
Eg. Egypt, Iran, Oman
Harm reduction strategies- needle
exchange, methadone treatment Eg. Iran
Triangular clinics
Public Mental Health Education
Involvement of Religious leaders
Regional Strategy for Substance
Use and Dependence
1. Development of National policymulti-sectoral with networking;
2.Increasing understanding of causes,
consequences and care;
3. Human Resource Development;
4.Wide range of services in
Community;
5.Promotion of psychosocial wellbeing
and prevention
Delivery Systems for
Substance Abuse Treatment
in Morocco
Prof. Jallal Toufiq,
M.D.
Director of the
National Center for
Drug Abuse
Prevention and
Research
and the Ar-razi
University
National High-School Survey on ATOD use in
Morocco: n=2446 ; 1994
drug
Point prevalence
Life-time prevalence
Tobacco
8.47
21.1
Cannabis
3
8.7
Other drug
~1
6.4
MEDSPAD Pilot study, Rabat
n = 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 » ,
n = 51; 1993
Age: 8 - 13
Point prevalence of
inhalant use
= 65 %
Point prevalence of
cannabis use
= 20 %.
National multicentric survey on drug use in
psychiatric setting: n = 3447; 1995
Point prev. of cannabis
use: 19,6%
Percentage cannabis
users / any drug users:
84,3%
Comorbidity cannabis
use / acute psychotic
disorders + schizo. :
52,7% (p=0.00)
Substance Abuse Related Problems







Living with HIV/AIDS13.000
HIV/AIDS related deaths 320
(reporting problem)
Hepatitis
Other health consequences
Crime, legal consequences
Traffic accidents and domestic violence (alcohol)
Co-morbid psychiatric disorders (cannabis)
SUBSTANCE ABUSE AND
TREATMENT:
LEBANON EXPERIENCE
RAMZI HADDAD, M.D.
SKOUN, BEIRUT
HISTORY AND MILESTONES
1947 : Antinarcotic legislation
1975 : Beginning of lebanese war; increase of illicit
cultivation and increase of substance abuse among
militias
1990 : End of war; decision of lebanese government to
eradicate illicit cultivations
1998 : Amendment of 1947 law
1999 : Ecstasy introduced to lebanon
2002 : Application of the law concerning BZD
SUBSTANCE ABUSE SEVERITY
Heroin, Cannabis, Cocaine, Tobacco,
BZD, Ecstasy, Alcohol ++/+++
Prescription drugs ( Opioids,
Trihexyphenidyl ..) ++/+++
Inhalants, Amphetamines, +/++
Substance abuse related problems
Living with HIV/AIDS : 2700
HIV/AIDS related deaths : 200
( Ministry of health,2003 )
Major issues : - psychiatric co-morbidity
- adolescents
AVAILABLE SUBSTANCE ABUSE TREATMENT
Inpatient detoxification
Physician counseling
Outpatient counseling
Psychotherapy
Residential rehabilitation
Buprenorphine ??
Other pharmaceuticals therapies : disulfiram,
naltrexone, nicotine replacement
Substance Abuse in Iran;
A Brief Overview
Rabert Farnam MD
Shiraz Welfare Organization
Yaas Addiction Center
Shiraz, Iran
Iran; facts about drug abuse
According to the “Epidemiological Study of
Drug Abuse in IRAN” (2001):
– Some 3,761,000 people use opioids in Iran.
– About 2,547,000 fit DSM-IV diagnosis for
opioid abuse.
– 1,158,000 meet diagnostic criteria for opioid
dependence.
Iran; facts about drug abuse
(continue)
About 94% of abusers are male.
In 75% of drug abusing individuals
the main habit is ingesting or smoking
opium.
A forth of Iranian addicts abuse
heroin, half of whom inject the drug.
Iran; facts about drug abuse
(continue)
Alcohol abuse is not so common and
250,000 abusers are thought to be present
in the country.
Amphetamine was a rarity 2 years ago but
it is rapidly growing.
Cocaine abuse is still a rarity.
Iran; facts about drug abuse (continue)
According to data from Iranian Drug
Control Headquarters (DCHQ):
– Annually 1,000 tons of opium, heroin and
morphine is consumed in the nation.
– Some 5 billion dollars is spent on drugs
annually.
– Afghanistan produces more than 3,600 tons
of opioids; large quantities are trafficked to
Iran.
– Iranian police confiscates more 200 tons a
year.
Injection drug abuse in Iran
Around 16% of Drug Abusers in Iran have
history of IDU.
IDU appears 2-12 years after starting drug
abuse.
Mean age of starting IDU is 26.
Most of IDUs are men between 20-40 years and
most of needle sharing occurs between 20-29 y
of age.
Epidemiological Study of Drug Abuse in IRAN (2001)
Current State of HIV/AIDS in IRAN
More than 11,200 cases of HIV/AIDS have
been registered.
Around 60% of the cases were through
needle sharing in IDUs.
Estimated 30,000-40,000 HIV/AIDS cases
are in the country.
Needle is available
From 1996
More than
14,000 are on
Detoxification centers (up to 110 governmental
naltrexone
and around 600 private)
maintenance
– Using clonidine, rapid detox and ultra-rapid detox!
but formerly it
– Extensive use of naltrexone*, and moderate use
of
was 20,000
psychotherapy and group interventions.
Inpatient services up to 500 beds in the nation.
TCs (more than 35 centers), 2 for females
NA groups and other self-help (more than
12,000 members), separate groups for women
Community based networks
MMT and BMT facilities covering up to 6,000
clients.
Drug abuse treatment in Iran
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
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Treatment in Iran provided through
Governmental sector
Universities
Welfare Organization
Prison Organization
Private centers and offices
NGOs( active in detox – counselling
In the recent year up to
200,000 drug users received
some sort of treatment;
mostly detoxification and
short-term psychotherapies.
Outcome of detox and naltrexone
maintenance 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:
Remaining in MMT after 3 months: 79%
Remaining in MMT after 6 months: 73%
Average daily dose: 77 mg (range 25160mg)
Average dose in patients finishing 3
months: 74mg
Results II:
Outcome measures showed that MMT
dramatically decreased illicit drug,
intravenous injection, criminal behavior
and violence after 3 months.
Clients claim that after initiation on
methadone they save an average of
1,500,000 (~200$) Rials a months.
The MMT costs only 25$ a month for
every client.
Delivery Systems for
Substance Abuse Treatment:
Gaza and the West Bank
(Palestine Territory)
Mohammed Afifi, M.D., M.Sc.
Substance Abuse Research Cenetr
Istanbul, Turkey
September 2005
Introduction
Population (2003)
Estimated Population is 3.7 millions (36.7% in
Gaza Strip, and 63.3 in the West Bank).
Density Rate in Gaza Strip in (3806 person
/Sq.Km –area is 360 sq.km.), while the West
Bank is 408 person /Sq.Km. area is 5800
sq.km.
The refugees make up 56% in Gaza Strip, and
44% of the West Bank Populations.
Un-employment: 31%, and 64.9% of families
has an income of average 2 USD per day
(Poverty line).
Nature of Substance Abuse Problems
(No national figures)





Tobacco
H. schools
Universities
Alcohol
H. schools
Universities
Heroin/Cocaine H. schools
Universities
Marijuana
H. schools
Universities
Ecstasy
Lifetime
7-18%
9-50%
0.3-1.6%
3-4%
0.8-1.6%
0.8-2.9%
1.1-3%
1.2-4.6%
?
Nature of Substance Abuse Problems
Continued
Meth/Amphetamine Lifetime
 Inhalants
H. schools
Universities
 Prescription Drugs H. schools
Universities

?
2.6-4.6%
2.4-4.7%
2.5-4.6%
3.3-4.5%
Nature of Substance Abuse Problems
Drug injection is a moderate problem
especially with heroin, cocaine, and
morphine derivative (pethedine).
 Clean needles are available (not free)

Substance Abuse Related Problems

Living with HIV/AIDS
55 cases

HIV/AIDS related deaths
25 cases

The most urgent substance related
problems include: hepatitis, co-morbid
disorders and adolescent drug use.
Treatment System

Substance abuse treatment in Palestine
needs to be build from scratch:
– Providing treatment facilities
– Jailhouse treatment services
– Adopting proper treatment protocols
– Training health teams for proper protocols
– Reduce the legal sanctions for use
– Make treatment available for all