1. Substance Abuse Treatment and HIV in Iran
Azarakhsh Mokri MD
Iranian National Center for Addiction Studies (INCAS)
Tehran University of Medical Sciences
Tehran, Iran

2. I. Iran suffers from an intriguing duality of narcotic abuse!
IV Heroin Users; 175,000
Opium Ingestion
Heroin Smoking; 250,000
Opium Smoking

3. Afghanistan produces 3,200 tons each year!

4. Results: Heroin vs. Opium Abusers
Opium Users (n=215)
Heroin Users (n=158)
Age
36.09 ± 11.49
35.23 ± 9.73
Duration of addiction
7.39 ± 6.37
8.81 ± 7.57
Money spent daily on drugs
3.6 ± 2.4 $
9.5 ± 8.4 $*
Marital status
54% married
5.3% divorced
51% married
6% divorced
Employment rate
58%
62%
Years of formal education
9.12 ± 3.58
9.59 ± 3.34
First drug of abuse
97% opium
95% opium
History of IDU
14%
71%*
History of incarceration
33%
63%*
HIV infection rate
4% (n=4 /107)
17%* (n=12/69)
*P<.01

5. Results: Heroin vs. Opium Abusers
Opium Users (n=215)
Heroin Users (n=158)
Age
36.09 ± 11.49
35.23 ± 9.73
Duration of addiction
7.39 ± 6.37
8.81 ± 7.57
Money spent daily on drugs
3.6 ± 2.4 $
9.5 ± 8.4 $*
Marital status
54% married
5.3% divorced
51% married
6% divorced
Employment rate
58%
62%
Years of formal education
9.12 ± 3.58
9.59 ± 3.34
First drug of abuse
97% opium
95% opium
History of IDU
14%
71%*
History of incarceration
33%
63%*
HIV infection rate
4% (n=4 /107)
17%* (n=12/69)
*P<.01

6. Results: Heroin vs. Opium Abusers
Opium Users (n=215)
Heroin Users (n=158)
Age
36.09 ± 11.49
35.23 ± 9.73
Duration of addiction
7.39 ± 6.37
8.81 ± 7.57
Money spent daily on drugs
3.6 ± 2.4 $
9.5 ± 8.4 $*
Marital status
54% married
5.3% divorced
51% married
6% divorced
Employment rate
58%
62%
Years of formal education
9.12 ± 3.58
9.59 ± 3.34
First drug of abuse
97% opium
95% opium
History of IDU
14%
71%*
History of incarceration
33%
63%*
HIV infection rate
4% (n=4 /107)
17%* (n=12/69)
*P<.01

7. We know (or think we know) 2 other facts about opium versus heroin enigma;
Heroin and opium users show similar relapse rates after detoxification
Opium dependence can be pharmacologically as severe as heroin dependence!

8. Detoxification of opium versus heroin abusers

9. II. HIV is highly related to IDU
More than 11,200 cases of HIV/AIDS have been registered and estimated 30,000-40,000 HIV/AIDS cases are in the country.
Around 60% of the cases are infected through needle sharing in IDUs.
If cases with unknown route are omitted 85% and 10% are through IDU and sexual contact, respectively.

10. HIV knowledge
Approximately 97% of drug users (n=61) stated that HIV could be contracted via sharing needles.
Engaging in unprotected sex was seen as an HIV transmission route by slightly more than 80% of individuals.
A high percent of opium and heroin users (20%-30%) believed that casual contacts were transmission paths for HIV as well.

11. Needle/syringe availability
Syringes have been available at low price (<4 cents!) for many years.
Pharmacies are local, widespread and cooperative.
No ban on selling or carrying syringes.

12. Zamani et. al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005, 19:709–716

13. Drug abuse is a crime and drug abusers are arrested!
In some years up to 400,000 people are convicted because of drug related charges.
Most convicts stay 45 days to 6 months in prison.
65% of prisoners are convicted because of drug related charges!
Total prisoners in Iran; 130,000

14. IV Heroin users
Infected with HIV & HCV
Opium users

15. Decriminalizing drug use?!
IV Heroin users
Infected with HIV & HCV
Opium users

16. Meanwhile IV Heroin Users
Implementing other treatments for IV drug users;
Need for more than abstinence models
Governmental specialized centers for IDUs
Free of charge MMT for street drug users
NGO based needle exchange and condom distribution programs
IV Heroin Users
Opium Abusers

17. Specialized Governmental MMT Centers
Offer MMT and MH care for high-risk, high comorbidity clients;
Psychiatrists GP
Psychologists
Social workers
Independent funding
Satellite distribution center
Governmental MMT center

18. ??? MH/SA/STD/HIV joint specialized centers
MH/SA joint specialized centers
Low-risk, low comorbidity High-risk, high comorbidity

19. Patients in MMT and methadone consumption

20. Patients in MMT and methadone consumption

21. Patients in MMT and methadone consumption
Where is the lost methadone?

22. Where is the lost methadone?
Methadone is consumed by opium users for detox and short-term replacement.
Both clients and physicians favor such approach.
Such practice has little proven value.
IV heroin users are excluded at expense of opium smokers!!

24. The Utmost Critical Question
Should opium dependent individuals receive substitution treatment?

25. Methadone: global manufacture and consumption, 1983-2002

26. PHC abstinence oriented interventions
Office-based MMT
PHC abstinence oriented interventions X
Office based
buprenorphine
Tincture of
Opium???
SR morphine
Low-risk, low comorbidity High-risk, high comorbidity

27. Starting with office-based MMT
GP + (social worker+ psychologist + nurse)
Spend 15 days training in academic centers
Get certificate and start work
So far 130 but by end of 2005 planned 300 and next year 600.

28. For more specialized centers
Psychiatrists+ (GP + social worker+ psychologist + nurse)
Psychiatry residents spend 1-3 months rotation at INCAS. Medical students part time for a month.
Chance to interact with patients, other staff, even police and judiciaries

29. MMT Bleach IV Heroin users Infected with HIV & HCV Opium users Needle
exchange
Condoms
Bleach
IV Heroin users
Infected with HIV & HCV
Opium users
Drug
courts
Alternates
to prison

30. But the true wonderful trend!
Massive demand thus large scale supply.
Mobilizing resources and training staff
Providing diversity
Self-organization
Intelligent decision making and control