1. 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) 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)

2. Drug Abuse in the Middle East R. Srinivasa Murthy Eastern Mediterranean Regional Office of World Health Organisation, Cairo, Egypt.

3. DRUG ABUSE IS PUBLIC HEALTH PRIORITY

4. EMRO-Countries in Complex Emergencies and Post-Conflict situations

5. Doctors /10 000 population 10 - 20 2 - 10 > 20 < 2

6. Psychiatrists/100,000 0.4 1.6 0.15 1.0 0.10.2 1.3 3.4 2.0 0.1 0.04 1.00.5 1.0 2.0 0.8 0.1

7. Tentative estimate of cannabis resin production and main source countries 7,400 metric tons

8. Source: World Health Organization, Eastern Mediterranean Regional Office, 2002 OMA BAH SUD IRA UAE MOR KUW PAK SAA IRQ OPT EGY JOR LEB SYR YEM TUN DJI 01020304050607080 % Risk Factors: Smoking prevalence among men in EMRO

9. Drug Abuse Pattern in the Region Opioids- Afghanistan, Bahrain, Iran, Pakistan, Oman Khat- Djibouti, Somalia, Yemen Stimulants-

10. 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

11. DRUG ABUSE IS PUBLIC HEALTH PRIORITY

12. The Facts… in the EMR… cont’d

13. The Facts… in the EMR

14. Al Razi addiction treatment unit - % of admissions HIV positive

15. 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

16. Regional Strategy for Substance Use and Dependence 1. Development of National policy- multi-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

17. 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 Psychiatric Hospital Istanbul, Turkey September 2005

18. National High-School Survey on ATOD use in Morocco: n=2446 ; 1994 drugPoint prevalenceLife-time prevalence Tobacco8.4721.1 Cannabis38.7 Other drug~16.4

19. MEDSPAD Pilot study, Rabat n = 413 (15-17 years), 2003 drugLife-time Prevalence tobacco0.24 alcohol0.14 cannabis0.11 solvents0.08

20. Rabat survey on ATOD use in « street children », n = 51; 1993 Age: 8 - 13 Age: 8 - 13 Point prevalence of inhalant use = 65 % Point prevalence of cannabis use = 20 %.

21. 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)

22. 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)

23. SUBSTANCE ABUSE AND TREATMENT: LEBANON EXPERIENCE RAMZI HADDAD, M.D. SKOUN, BEIRUT

24. 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

25. SUBSTANCE ABUSE SEVERITY Heroin, Cannabis, Cocaine, Tobacco, BZD, Ecstasy, Alcohol ++/+++ Prescription drugs ( Opioids, Trihexyphenidyl..) ++/+++ Inhalants, Amphetamines, +/++

26. Substance abuse related problems Living with HIV/AIDS : 2700 HIV/AIDS related deaths : 200 ( Ministry of health,2003 ) Major issues : - psychiatric co-morbidity - adolescents - adolescents

27. AVAILABLE SUBSTANCE ABUSE TREATMENT Inpatient detoxification Physician counseling Outpatient counseling Psychotherapy Residential rehabilitation Buprenorphine ?? Other pharmaceuticals therapies : disulfiram, naltrexone, nicotine replacement

28. Substance Abuse in Iran; A Brief Overview Rabert Farnam MD Shiraz Welfare Organization Yaas Addiction Center Shiraz, Iran

29. 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.

30. 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.

31. 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.

32. 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.

33. 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)

34. 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

35. From 1996 Detoxification centers (up to 110 governmental and around 600 private) –Using clonidine, rapid detox and ultra-rapid detox! –Extensive use of naltrexone*, and moderate use of 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. More than 14,000 are on naltrexone maintenance but formerly it was 20,000

36. Drug 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

37. Treatment in Iran provided through Governmental sector Universities Welfare Organization Prison Organization Private centers and offices NGOs( active in detox – counselling

38. In the recent year up to 200,000 drug users received some sort of treatment; mostly detoxification and short-term psychotherapies. mostly detoxification and short-term psychotherapies.

39. Outcome of detox and naltrexone maintenance in different cities City Number entering treatment Retention after 6 months Meshad18980 (42.3%) Rasht18435 (19.0%) Kermanshah13913 (9.4%) Yazd18314 (7.7%) Total695142 (20.4%)

40. Results I: Remaining in MMT after 3 months: 79% Remaining in MMT after 6 months: 73% Average daily dose: 77 mg (range 25- 160mg) Average dose in patients finishing 3 months: 74mg

41. 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.

42. 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

43. 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).

44. Nature of Substance Abuse Problems (No national figures)  Tobacco H. schools 7-18% Universities 9-50%  AlcoholH. schools 0.3-1.6% Universities 3-4%  Heroin/Cocaine H. schools 0.8-1.6% Universities 0.8-2.9%  MarijuanaH. schools 1.1-3% Universities 1.2-4.6%  EcstasyLifetime ?

45. Nature of Substance Abuse Problems Continued  Meth/Amphetamine Lifetime ?  Inhalants H. schools 2.6-4.6% Universities 2.4-4.7%  Prescription Drugs H. schools 2.5-4.6% Universities 3.3-4.5%

46. 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)

47. Substance Abuse Related Problems  Living with HIV/AIDS55 cases  HIV/AIDS related deaths25 cases  The most urgent substance related problems include: hepatitis, co-morbid disorders and adolescent drug use.

48. 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