DRUG PROBLEM IN THE ARAB REGION. Prof. Mehdi PAES

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1 DRUG PROBLEM IN THE ARAB REGION Prof. Mehdi PAES Introduction The Arab region, with about 300 million inhabitants, is composed of 21 countries covering a large geographic area located essentially in North Africa and the Arabic Peninsula. It is bordered by the Atlantic Ocean on the West, the Mediterranean sea on the North, the Arab sea and the Persian golf on the East, and by the Sub Saharan Africa to the South. It is a very heterogeneous region with diverse characteristics not only between one country and another but also within the same country. The GND per capita varies greatly from one country to another ranging from $400 up to $ Amid all these differences, the countries of this region have a lot in common. The most widely practiced religion is Islam and the official language is Arabic. Arabic dialects are the most spoken. Other religions such as Christianity and Judaism are far less practiced. There are some other languages used such as Berber and Kurde. All the Arab countries are developing countries facing many social, economic and political problems. During the last decades they have gone through important social change, a rapid urbanization process, and a fast demographic growth. Thus, the populations of the region are very young. Even though the human and economic resources vary depending on the country, the region still evolves in a very difficult international environment, facing serious economic but also cultural and political problems. Most of these countries have engaged in political reforms with more or less success, aiming to embrace modernism while preserving their cultural identity. The Arab region, like other regions, has experienced the drug use phenomenon for centuries. However, this use was very limited to certain groups of people, institutionalised, socially tolerated and with no serious health or social consequences. Cannabis was widely used in the region, alcohol and opium on a much smaller scale. Other drugs, such as khat was used in very specific areas. Usually the products used were natural with very low active substance. Over the last decades, the characteristics and the scope of the phenomenon have changed dramatically. The situation now tends towards what is happening in other parts of the world. 1

2 Data on drug abuse It is hard to find studies on the drug problem in the region. For years, any data and discussion would be a very sensitive issue. The problem was hidden and not talked about. Nowadays, almost all the countries, with the exception of some, acknowledge the problem and are trying to tackle it. They have realized that the best way of resolving problem is to recognize it and to overcome what were considered political and cultural barriers. Thus, many studies have been carried out in a number of countries of the region over recent years in order to assess the problem. Even though this data is scarce, it is still regularly forwarded to the United Nations agencies working in the field and particularly WHO and UNODC. In fact, it is often partial data gathered from studies with varying levels of depth. The available data varies enormously and depends greatly on the allocated financial and human resources. A great part of the data regarding drug use characteristics are provided by experts and resource persons or by reports issued by treatment centres. They remain, however, very useful as an initial step giving a general idea of the problem in the region. The drug abuse situation in the region Characteristics of the users No social class is spared by the problem. Young people in poor conditions seem to be the most exposed population group to drug abuse, especially drop-outs and street kids. The age of onset seems to be around 20. However, there are some differences between countries. In Lebanon and the Saudi Arabia the age of first use seems to be higher than in Egypt, Morocco and Oman. Men are the most concerned but the number of women using drugs is increasing. The sex ratio of use varies from a country to another but this figure depends on the availability of specific information. The used drugs Due to the means of modern communication and the important exchanges in the light of globalisation, it seems that the availability of drugs has evolved in a significant way over the last years. Therefore, while historically some countries experienced a single use of traditional drugs, such as cannabis in Morocco and Egypt, and the khat in Yemen, currently almost all the known drugs are available in the region. The most common pattern is the use of more than one drug (multi-drug use). If the drug of choice depends on the country, the most used drugs in the region are tobacco, psychotropic drugs and alcohol.the fourth most used drug is cannabis. The use of khat is well known in Yemen, Somalia and Saudi Arabia. 2

3 The use of opiates varies from one country to another. The consumption of opium was noticed in Egypt, Jordan, Kuwait, Lebanon, Palestine and Saudi Arabia. It seems that it was more prevalent in Bahrain. Most of the countries reported a limited use of heroin with the exception of Libya, Egypt and Bahrain where it is more common. The use of cocaine and stimulants such as amphetamines also varies. Although, it seems that it is very limited and less common. Countries like Egypt, Jordan, Palestine, Saudi Arabia, Morocco, Syria and Tunisia have reported the use of inhalants especially by children living in poor conditions. This, still, has not been of interest to researchers and policy makers in the region. The patterns of use Most of the drugs are used in the worldwide fashion. Cannabis is either smoked or eaten mixed in pastries. Psychotropic drug are ingested, volatile substances are inhaled, cocaine is smoked or sniffed, khat is chewed and opium is smoked. Intravenous drug use (IDU) is reported in almost all the countries, its scope is different from one country to another. The data on IDU is partial and not always accurate given the type of methodology used in the region. Heroin is the most injected drug followed by cocaine, opium, certain amphetamine (ATS), buprenorphine and some sedatives. Sharing syringes seems to be a common pattern among users in poor conditions or those having difficulties with accessing clean syringes. The IDU seems to be a big problem in countries like Libya, Egypt and Bahrain, where as it is more limited in Morocco, Algeria and Mauritania. Drug use consequences Drug use is becoming a public health problem in most countries of the region. It leads to numerous consequences at the health, economic, social and legal level. These consequences interfere with the development of the countries of the region and their efforts to respond to the needs of their populations. Apart from its economic cost, drug abuse lead to family dysfunction, social impairment, risk taking behaviour, crime, health and psychological problems as well as economic difficulties. IDU related HIV /AIDS and hepatitis C infection are becoming a serious problem in the region especially among drug injectors and commercial sex workers. 3

4 HIV /AIDS The first AIDS cases in the region were reported in the mid 80 s. The region still has the lowest AIDS prevalence in the world. WHO s estimate of HIV infection prevalence is a around 0.2% of adults. It ranges from 0.01% in Iraq up to 11.75% in Djibouti. It appears that lately the HIV prevalence is increasing due essentially to sexual transmission and to a lower degree, to IDU. Concerning the latter, some studies carried out in treatment centres and penitentiary institutions suggest a prevalence ranging from 0% up to 27%; It appears that Libya, Bahrain and Tunisia have the highest prevalence of HIV infection among IDU, respectively 90%, 73% and 34 %; In other countries like Oman, Syria, Morocco and Lebanon, the IDU related HIV infection rate seems to be lower compared to other parts of the world especially Sub- Saharan countries, and Asia. However the existing data is not always reliable nor is it always based on rigorous study. The reported prevalence is more likely to be underestimated and could rise dramatically at any time. Hepatitis C There is no systematic screening for hepatitis C in the region. It seems that the prevalence of HC is strongly linked to IDU. Almost 90% of reported HC cases in Libya are IDU related. Groups at risk It appears that no social class is spared when it come to the drug use problem in the region. However, there are significant differences among the countries as to high-risk population groups. Yet, the most exposed groups are the children living in poor conditions, prisoners, commercial sex workers and jobless young people. High-school students are also at high-risk of using drugs. Risk factors Most countries of the region have experienced big and rapid social changes, which generate the collapse of the traditional way of living without harmonious alternative models able to meet the needs and expectations of the population. 4

5 This process is marked by a large rural migration, a disintegration of family and social traditional ties, and a loss of cultural references. Whereas it has been a positive moment to advance toward modernism it has also been a period of crisis and disarray. The whole society became fragile representing a strong risk factor for drug use. The openness of these countries, their geographic location, the modern means of communication, mobility and exchanges, have made it easy for drug traffic in the region. The lack of a global policy integrating the promotion of health, that of preventive programmes and human resources qualified in the field of drug abuse prevention and treatment also represent a hurdle in facing the drug abuse problem, adding to that the great lack of financial resources as well. PROTECTIVE FACTORS For many years, most of the countries of the region lived in total denial of the drug abuse problem. Thus, no effort has been made to assess the scope and the nature of the problem nor to put in place preventive programmes. Nowadays, all the countries have, to different degrees, recognised the problem and show a political willingness to resolve it. This change in attitude is a result of numerous factors and represents a major step towards the implementation of appropriate prevention policy in the region. Another positive change is the increasing involvement of professional institutions and NGOS in the field of drug abuse prevention. They have lately shown a lot of enthusiasm and activity despite the lack of financial and human resources. They have accomplished significant actions in the area of research, prevention and to treatment of drug abuse. Despite the already mentioned cultural and social changes, the region is still profiting from certain religious and cultural values contributing as a protective factor. Finally, the family very often continues to be supportive psychologically and socially to its members. It fills the gap in terms of insufficient treatment and rehabilitation programmes. National Policies The majority of the countries have at their disposal, official documents with national plans regarding drug abuse prevention. But, often these documents are formal and very elaborate without a precise and rigorous evaluation of the problem. 5

6 The action plans are seldom implemented on time and according to their first objectives. One of the main explanations for this is that the official coordination of the activity of drug abuse prevention is in the hand of the Ministry of interior. Hence supply reduction efforts prevail in comparison with those of demand reduction either at the health or social level. Most countries have no coordination body with effective decision-making ability aiming to implement a prevention policy based on demand reduction. Prevention Programmes Prevention programmes vary from one country to another. The majority of preventive actions are limited to raising awareness campaigns for the media, the general public, high-school and university, health professionals and the parents. Some countries such as Egypt, Lebanon and Morocco have developed specific preventive actions for populations groups such as street kids or people living with AIDS. In Jordan, a skills education programme has been initiated as a pilot programme. Overall, it appears that most of these programmes are carried out in a limited way, on a short term, without evaluation and without being integrated in a comprehensive plan. Treatment programmes In most countries of the region, the legislation considers drug use as a crime. The law sentence drug users to fines and even imprisonment. However, many countries have developed treatment programmes. Unfortunately, most of these treatment programmes are within general hospitals or psychiatric facility. They often offer only detoxification programmes. The detoxification is mainly based on comfort drugs especially tranquillisers. Clonidine use is rare and there are no use of buprenorphine and methadone. Out patient detoxification is extremely rare. Rehabilitation programmes Rehabilitation programmes, especially community based ones, are also very rare in the region. Some help centres for drug users may exist in some areas due to the involvement of professional and NGOS. Specialized counselling, group therapy, family involvement, self-help groups and therapeutic community, represent very isolated cases in the region. 6

7 Harm reduction programmes No country of the region offers a substitution programme. Oman put in place a methadone maintenance programme ten years ago but had to stop it because of control problems. The cost of syringes is free in most countries but there are no needle-exchange programmes. UN Agencies activity Most countries have collaborated with UN agencies such as WHO, UNODC and UNICEF to carry out actions in the field of drug abuse prevention, in both supply and demand reduction. This led very often to limited and short-term actions. There is still no global strategy for the region. WHO, in September 2002, and UNODC, in October 2003, initiated a very important dynamic in the region, aiming to implement in a structured, integrated and global way the actions based on a strategy of prevention and demand reduction. These two agencies along with other institutions would positively contribute in promoting drug abuse preventive actions in the region. Priority actions The main priority would be the creation of a body with the mission of coordinating the policy of drug abuse prevention with a real decision-making ability. It also needs the allocation of sufficient human and material resources. Its task would be to gather and analyse existing data, to mount a data monitoring and collecting system, to propose legislation amendments and to adapt the legislation to the reality of the region based on what is in place in other parts of the world. This body should also identify key persons, active governmental and non governmental organizations, in order to create networks able to coordinate actions, collect data and elaborate global and comprehensive national plans. Theses plans have to be culturally adapted, meeting all the characteristics of the problems in each country, and being feasible taking into consideration the available resources it also has to set objectives and priorities. All the countries of the region have enough data, human and material resources to establish preventive plans. All that is needed is to mobilize these resources and to establish partnership with other countries of the region as well as with other international institutions especially WHO and UNODC. 7

8 CONCLUSIONS Despite the lack of well-designed and rigorous studies and all the existing gaps, the available data gives an idea, approximate but still close to reality, of the situation of drug abuse in the region. Hence, it appears that the magnitude and the nature of the problem varies depending on the country. It is difficult to know exactly if DRUG ABUSE is a dramatic issue or not in some countries of the region. Some indications rate the problem in the region as moderate in some countries and minor in others. It is moderate in Egypt, Bahrain, Libya, Oman and Jordan. It could be considered as less important in Kuwait, Lebanon, Morocco, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia and Yemen. Data is scarce concerning United Arab Emirates, Djibouti, Iraq and Mauritania. The trend of drug abuse in the region shows an aggravation of the problem. Plus, multi-drug use is the most common pattern. IDU with its very negative health consequences has seemed to increase as well. The age of first use decreases consistently. Young people are at highest-risk. The number of women engaging in drug abuse is also increasing which tremendously affects the family and the society as a whole. About the author: Professor of Psychiatry, Hôpital Ar-Razi, Morocco. Professor Mehdi Paes is a Moroccan citizen. Very early in his career, Prof. Paes focused mainly on prevention, treatment and research related to drug abuse. He rapidly got involved in national and international activities leading to reflection, action and implementation with respect to programs on drug abuse prevention. As a result he was appointed as temporary advisor and consultant for the United Nations in light of programs such as the PSA and the UNDCP. Through his work in the field of drug abuse, considered to be pioneering in Morocco and North Africa, he acquired a great amount of expertise in epidemiological research and prevention techniques applied to addictions. Prof. Paes collaborates with many international NGO's. Furthermore, his work led to the implementation of the National Center on Prevention and Research on Drug Abuse. 8