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UntitledBriefi ng Paper Series
Afghanistan’s Hidden Drug Problem:
The Misuse of Psychotropics
Over the past decade, Afghanistan has gained notoriety as the world’s leading producer of opium and heroin. What is less well known is that, number of problem drug users.1
Apart from dependency, addiction and other health-related problems, problems that affect individuals, Commonly misused psychotropicsfamilies and communities. It is not only the use of illicit substances that leads to problem drug use. It also results from the use of psychotropics — pharmaceutical drugs like painkillers and tranquillisers that have a psychoactive effect — in ways not recommended by a qualifi ed doctor or the manufacturer.
While popular perceptions of drug misuse and dependency in Afghanistan tend to focus on illicit drugs like opium or heroin and to a lesser extent cannabis, evidence suggests that many people also misuse psychotropics. A national survey conducted in 2005 by the United Nations Offi ce on Drugs and Crime (UNODC) and the Ministry of Counter Narcotics looked at the incidence of the non-medical use of controlled substances, including use without a doctor’s About the Author
prescription, for an excessive or unjustifi ed period of time. While David Macdonald is a the estimated numbers of opium users and heroin users were 150,000
sociologist with over 20 and 50,000 respectively, the number of problem pharmaceutical
years’ experience working
on drug demand reduction
issues in the developing 1 The information in this paper comes from interviews with pharmacists,
government offi cials, drug treatment workers, doctors and drug users, as well as from other research reports and anecdotal accounts. All numerical estimates for UNODC’s Afghanistan of drug supply and use in Afghanistan should be treated with caution: while they programme and as an indicate general trends and patterns and may inform policymaking, they are advisor to the Ministries estimates only and cannot be considered as confi rmed numbers. Estimates of drug use and misuse are notoriously diffi cult to calculate, and globally there is a of Counter Narcotics and dearth of reliable information about the magnitude and nature of drug problems. David Macdonald, Drugs in Afghanistan: Opium, Outlaws and Scorpion Tales (London: Pluto Press, 2007), 16-36.
drug users was estimated to be 180,000.2 In Acronyms
2003, an assessment of problem drug use in Kabul city found 14,298 users of pharmaceutical drugs compared to 10,774 opium users and 7,008 heroin users.3 There is a range of types of psychotropic drug misuse in Afghanistan. One problem in particular is the long-term self-medication without a doctor’s prescription using powerful painkillers and tranquillisers such as diazepam (brand name Valium), which is cheap and widely available from While there may be many reasons for such misuse, ict-related poverty, social displacement and mental health problems (including chronic anxiety, depression and post-traumatic stress disorder) are known to have been central drivers Psychotropics are known to be increasingly taken in combination with illicit drugs such as opium and heroin, either through smoking or injection. Overprescribing of psychotropics by doctors and the lack of reliable information about the associated risks and dangers — including possible side effects, intoxication and dependency — also contribute to misuse. For example, it has been reported that very young children are given inappropriate drugs such as psychotropic-based cough syrups or powerful painkillers.
However, the misuse of psychotropics is not a problem limited to Afghanistan. Other developing Psychotropic drugs are pharmaceutical drugs
countries, and indeed several developed ones, such as painkillers and tranquillisers that have also experience similar diffi culties in controlling a psychoactive effect. They make up part of and regulating the supply (by prescription and the category of psychoactive drugs, which are sale from a registered qualifi ed pharmacist) mind-altering substances affecting the central and use (under the supervision of a doctor) of nervous system that can lead to a variety of changes in behaviour, mood and perception.
In Afghanistan it is estimated that up to 80 percent of the psychotropics available have been smuggled into the country without a licence and The UK’s Advisory Council on the Misuse of without testing to determine whether they contain Drugs defi nes a problem drug user of either additives or are counterfeit or out of date. While border controls are weak, so are the control and any person who experiences social, regulation of psychotropics within the country psychological, physical or legal problems itself. The Ministry of Public Health recently related to intoxication and/or the regular established a legal department in its Directorate of excessive consumption and/or dependence 2 UNODC and Ministry of Counter Narcotics, Afghanistan: as a consequence of his own use of drugs Drug Use Survey 2005 (Kabul: UNODC Country Offi ce for Advisory Council on the Misuse of Drugs, “Treatment and UNODC, Community Drug Profi le No. 5: An Assessment of Problem Drug Use in Kabul City (Kabul: UNODC Afghanistan Programme, 2003).
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics Pharmacy to control and monitor pharmacies and any reduction in the availability or increase in the medical institutions and to check whether out-of- price of heroin is likely to lead to increased use date, expired or low-quality medicines are being of a range of psychotropics as substitute drugs, sold. But with over 9,000 registered pharmacies potentially encouraging a burgeoning illicit street that need constant checking by low-paid, under- resourced government offi cials susceptible to bribes and other forms of corruption, this The problems facing Afghanistan in relation to represents a challenge. There is a clear need for the misuse of both licit and illicit drugs, including stricter regulation of the sale and distribution of psychotropics, cannot be solved overnight. They psychotropics from other retail outlets, such as require a long-term strategy and commitment by shops and handcarts in marketplaces, as well as the government and the international community of their “prescription” and purchase from people to tackle them. Even if opium was eradicated, the with no medical qualifi cations or expertise.
country would still have a demand-driven drug problem — with psychotropics at its core. While The supply of and demand for psychotropics are strengthening government institutions to be able inextricably linked to the trade in illicit drugs like to control and regulate the supply and distribution opium, heroin and cannabis. Any steep rise in the cost of psychotropics is necessary, the following are of psychotropics coupled with a decrease in their also essential: better resourced treatment, availability and ease of access may lead problem rehabilitation and harm reduction services for users to substitute pharmaceutical psychotropics problem drug users; training for doctors and with drugs like opium and hashish — both of which pharmacists on the risks and dangers of psychotropic have a long history of social and medical use in drug misuse; and provision of reliable and context-Afghanistan. Current heroin users are increasingly sensitive information for the Afghan public about combining heroin with psychotropic drugs, and the costs and benefi ts of psychotropic drugs.
The global policy framework
By 1971, it was recognised that many psychoactive drugs had not been included in the 1961 Convention, In 1961, the United Nations Single Convention leading to the drafting of the UN Convention on on Narcotic Drugs was developed to prohibit the Psychotropic Substances.4 The 1971 Convention
production and supply of narcotic drugs and drugs was primarily concerned with the scheduling with similar effects, specifi cally cannabis, coca and control of a wide range of drugs classifi ed and opium and their derivatives such as hashish, as psychotropics from pharmaceutical drugs like cocaine, morphine and heroin — except for the amphetamine-type stimulants, barbiturates and purposes of medical treatment and research. benzodiazepine tranquillisers to other psychoactive While the medical use of narcotic drugs such as drugs such as the hallucinogen LSD.
diacetylmorphine (heroin) was recognised as indispensable for the relief of pain and suffering, The 1961 Convention had a negative economic the treaty also stated that: impact on several developing countries that produced plant-derived drugs like cannabis, coca addiction to narcotic drugs constitutes a and opium — all used for centuries in many cultures serious evil for the individual and is fraught as traditional medicines and for recreational and with social and economic danger to mankind. social purposes. Despite these countries seeking similar tough regulations on psychotropics, both This fundamental duality in the nature of the pharmaceutical industry and the states that drugs, illicit or otherwise, continues to trouble produced synthetic drugs formed a powerful lobby politicians, policymakers and healthcare that ensured international regulations in the 1971 practitioners, as it highlights a fundamental dilemma: any drug can have both positive and negative effects, costs and benefi ts, depending 4 Although “psychoactive” and “psychotropic” are on how, where, when and why it is used.
sometimes used interchangeably, in this paper “psychotropic” is used to describe prescription-only, psychoactive pharmaceutical drugs, including narcotic analgesics such as morphine and pentazocine sold as medicines.
Diversion of psychotropics
Afghanistan is a signatory to all of the onto the illicit market
following conventions (although it has not ratifi ed the 1972 Protocol that amended the Several attempted major diversions of psychotropics at the transnational level were reported to the INCB in 2007, including 3 tonnes of phenobarbital (a substance listed in Schedule IV of the 1971 Convention) intercepted between China and Afghanistan and 250,000 ampoules of pentazocine (an opioid analgesic listed in Schedule III of the
1971 Convention) between India and Nigeria.9
Pentazocine has reportedly been used in Afghanistan by both injecting drug users (IDUs) and non-IDUs.10
In 2002 the INCB, following a request from the Chinese authorities, asked the Afghan government Convention were considerably weaker than those to verify the authenticity of an import order for 5 in the Single Convention.5 In essence the UN tonnes (5,000 kg) of diazepam (Valium) from China
conventions limited the acceptable use of narcotic to Afghanistan. The order, far in excess of the 76.6 and psychotropic substances to medical or research kg annual requirement of diazepam for medical purposes only, and they called on member states to and scientifi c purposes already established by the otherwise prohibit the production, distribution and Afghan authorities, was found to be fraudulent and use of psychoactive drugs.6
it was subsequently rejected.11
In 2000, the International Narcotics Control Board These known attempts to fraudulently import 3 (INCB), established by the 1961 Convention as tonnes of phenobarbital and 5 tonnes of diazepam a quasi-judicial control body responsible for into Afghanistan suggest that the illicit trade in monitoring the implementation of the conventions, psychotropics in the country is big business — expressed concern about the wide availability and albeit criminal. What would have happened to inappropriate or non-medical use of controlled such large quantities of these drugs if they had drugs, particularly psychotropics. It was reported entered the country is unknown. There are, that unregulated, excessive drug supply and however, two demand–driven possibilities: they consumption trends in several countries was tending may have been sold over the counter without to escalate, and new problems were emerging.7 The a medical prescription to war-shattered and
increase in supply of psychotropics, while relieving impoverished Afghans seeking alleviation from the suffering of many, led to concern about their their daily psychological and physical suffering; or excessive use through overprescription and self- they would have ended up as additives to street medication, resulting in overconsumption, serious heroin, used by increasing numbers of Afghans. As street heroin is not regularly or accurately tested, there is no way of knowing its level of purity. In many cases, it may not technically be heroin at all, but a chemical cocktail containing a greater proportion of psychotropic substances (like phenobarbital or diazepam) than heroin.
5 A further convention, the 1988 United Nations Convention against Illicit Traffi c in Narcotic Drugs and The diversion of psychotropics from domestic Psychotropic Substances, regulated the precursor licit distribution channels to the illicit drug chemicals used in the manufacture of psychoactive drugs market is also problematic, with benzodiazepine and strengthened provisions against money-laundering tranquillisers one of the most abused groups of these drugs. In developed countries like the United 6 Marcus Roberts, Axel Klein and Mike Trace, Towards States, Canada and some European countries, such a Review of Global Policies on Illegal Drugs (London: diverted drugs are typically bought from illicit Drugscope, 2004), 2. 7 INCB, Report of the International Narcotics Control 9 Board for 2000 (New York: United Nations, 2001).
INCB, Report of the International Narcotics Control Board for 2007 (New York: United Nations, 2008), 22.
8 Hamid Ghodse, “Pain, Anxiety and Insomnia — A Global Perspective on the Relief of Suffering: Comparative Community Drug Profi le No. 5.
Review,” British Journal of Psychiatry, 183 (2003), 15-21.
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics street dealers or over the internet, however in excessive availability and overconsumption. many developing countries, including Afghanistan, These practices include:they can easily be bought over the counter directly from pharmacists or other retailers — even though uninformed prescribing; inconsistent or they are prescription-only drugs. Many developing lax prescribing; wilful and consistent mis- countries do not have the resources to effectively prescribing for misuse; self-prescribing and self- control and regulate the distribution and sale of administration [by health professionals]. The psychotropics — drugs that now also constitute a principal underlying causes of such behaviour profi table business on the illicit market.
appear to be inadequate training; shortage of information; lenient or lax attitudes; lack of a A related problem is the smuggling and misuse sense of professional responsibility; unethical of counterfeit pharmaceutical drugs, including behaviour; personal drug addiction; criminal psychotropics. A 1999 report claimed that many behaviour or direct fi nancial interest.16
pharmaceutical drugs available in Afghanistan and in Afghan refugee communities in Pakistan were: The INCB has expressed concern about developing countries lacking the resources and expertise adulterated, spurious, outdated, unregistered to accurately assess the medical and research and illicitly manufactured in Pakistan and India needs for psychotropics while also addressing the and then illegally imported into Afghanistan.12
shortage in supply of licit drugs to meet patients’ needs — which is itself related to a chronic shortage In 2003, the World Health Organization estimated of medical staff along with inadequate training that up to 35 percent of all counterfeit and information. It also noted that the availability pharmaceuticals worldwide were manufactured of psychotropics in developed countries tends to in India and that 11 percent of all exported exceed requirements and that there is excessive pharmaceuticals from India were counterfeit. This and possibly medically unjustifi ed psychotropic represents a large profi t for the criminal groups drug prescription and consumption in the concerned, potentially equivalent to 17 percent treatment of psychological and social problems.
of the pharmaceutical industry’s annual turnover.13
The World Health Organization estimates that 10 The medicalisation of social problems is also
percent of pharmaceuticals on the global market commonly found in developing countries: some non-
are fake and that 25 percent of those in developing medical problems are at risk of becoming defi ned
countries are counterfeit or substandard.14 More and treated solely in terms of their symptomatic
generally, the international pharmaceutical trade expression as illnesses and disorders. Physical and
has been plagued by well-documented cases of psychological symptoms of the individual brought
criminal corporate behaviour, including price on by social conditions such as homelessness,
fi xing, unsafe manufacturing practices, negligence unemployment, instability and lack of security
and fraud in safety-testing practices, unethical become decontextualised, and attention is
marketing, and the dumping of expired or banned diverted away from their broader socioeconomic
drugs in the developing world.15
and political roots. There is no doubt, however, that both physical and mental health problems Overprescription and overconsumption
cause great pain and distress to many Afghans.
In addition to the diversion of psychotropics onto Mental health concerns
the illicit drug market, inappropriate prescribing practices of controlled psychoactive medicines While there is a range of cultural interpretations and by the medical profession can also lead to defi nitions of what constitutes a mental disorder, globally an estimated 450 million people suffer from 12 UNDCP, Community Drug Profi le No. 1: Problem some form of mental or brain disorder (including Drug Use in Afghan Communities — An Initial Assessment those related to alcohol and substance misuse); (Islamabad: UNDCP Afghanistan Programme, 1999), 9.
of these, 121 million suffer from depression. This means that roughly one in four families has at least one family member who is affected by a Counterfeit Medicines: Some Frequently Asked Questions — May 2005 (http://www.wpro.who.int/media_ mental or brain disorder.17 In countries that have
15 John Braithwaite, Corporate Crime in the Pharmaceutical Industry (London: Routledge & Kegan 17 WHO, World Health Report 2001: Mental Health — Paul, 1984).
New Understanding, New Hope (Geneva: WHO, 2001).
experienced the horror and trauma of war, violent In April 2008, the Afghan government’s Deputy
confl ict and social dislocation — like Afghanistan Minister for Technical Affairs in the Ministry of
— that fi gure is likely to be much higher. The Public Health was quoted as saying that 66 percent
World Health Organization recognises that in such of Afghans suffered from depression or some form
contexts, coupled with urbanisation, poverty and of mental disorder, with mental illness and drug
associated conditions like high unemployment and abuse the most urgent health problems facing the
homelessness, there is limited capacity to address country.20 Six years earlier, a 2002 national mental
mental health problems.18
health survey of adult household members aged 15 years or older concluded that 78 percent of The most common chronic mental health conditions respondents displayed symptoms of anxiety, nearly are anxiety, depression, sleep disorders and post- 70 percent displayed symptoms of depression and traumatic stress disorder — the symptoms of which 42 percent displayed symptoms of post-traumatic may include anger, intrusive memories, irritability stress disorder.21 The survey also showed that in and the inability to concentrate. In rural areas, the last ten years, 62 percent had experienced factors like isolation and limited educational and at least four traumatic events. Despite the economic opportunities can exacerbate mental diffi culties of establishing and tracking accurate and behavioural disorders. In treating mental national data on mental disorders in the Afghan context, given the continuing insecurity, violence, fi ve principal symptoms for which psychoactive social displacement and impoverishment it is clear drugs are commonly prescribed — inability to that substantially reducing the incidence of such cope, depression, anxiety, sleeplessness and endemic chronic mental health problems in the pain — and they have a number of features in common: they are all symptoms that everyone has experienced at some time or other. “Scarred and depressed, more Afghans turn to drugs,” Reuters, 20 April 2008. 21 Barbara Lopes Cardozo, Oleg O. Bilukha, Carol A. Gotway Crawford, Irshad Shaikh, Mitchell I. Wolfe, Michael L. Gerber and Mark Anderson, “Mental Health, Social Functioning and Disability in Postwar Afghanistan”, Journal of the American Medical Association, 292(5) 19 Hamid Ghodse, “Pain, Anxiety and Insomnia,” 15.
II. The Regulatory Environment and
Supply of Psychotropics
Current controls and regulations
was kept by the pharmacist and 1 Af was paid to the Ministry of Health. While any Afghan citizen According to Afghan government offi cials, the with suffi cient capital could open a pharmacy, a importation, sale and domestic manufacture of registered pharmacist had to be employed there, pharmaceutical drugs was more strictly controlled and government restrictions meant that pharmacies and regulated through the Ministry of Health had to be a certain distance from each other. This is before the Soviet invasion in 1979 than it is today. in stark contrast with the situation in Kabul in 2008: Psychotropics were offi cially only available by many pharmacies now operate without a trained or prescription from a registered pharmacy, although qualifi ed pharmacist on the premises. One street there were some “quack” doctors who would in the city has over 40 pharmacies on it, many of provide a prescription for a price. Even the location which are located next door to each other.
of pharmacies was regulated by the Ministry of Health, which ensured that all pharmacists were Since 1979 the illicit as well as the licit import, suitably trained and qualifi ed and that doctors were wholesale and retail sale of psychotropics has issued with offi cial, government-printed prescription pads. A prescription cost 20 Afs22, of which 19 Afs 22 Currently the Afghan currency, the Afghani (Afs), is traded at approximately 50 Afs to the US dollar. The exchange rate before 1980 is unknown.
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics increasingly become a profi table enterprise, in part importation, storage, supply, sale and use of due to the lack of effective institutional controls. pharmaceutical drugs, and they will, on paper at Until 1992, signifi cant production capacity existed least, work towards addressing some of the issues within the country due to a factory that was and complexities identifi ed in this paper.
originally opened in 1968 by the German Hoechst Corporation. Most pharmaceuticals imported Since 2007, under Article 5 of the National Drug legally came through the Ministry of Health by Law, the Drug Regulation Committee in the Ministry way of the state-owned enterprise Avicenna of Counter Narcotics has been responsible for Pharmaceutical Institute.23 But in any war controlling psychotropics (and narcotics) as well economy there are very limited, if any, regulatory as the chemical precursors that are imported into bodies able to prevent smuggled, out-of-date, Afghanistan and used in the manufacture of heroin. counterfeit or adulterated drugs from reaching These drugs are on the Controlled Substances List the consumer. Despite recent attempts by under- that is included in the government’s National resourced Ministry of Public Health24 authorities Licensed Drug List. They require a special import to control the illicit trade in psychotropics, licence, and they are stored and tracked differently prescription-only drugs are still available and compared to other medicines.
frequently sold over the counter without a medical The Drug Regulation Committee consists of fi ve prescription from pharmacies, other retailers in members appointed for a four-year period: two the marketplace and even handcarts. Over the experts from the Ministry of Counter Narcotics; last few decades reports suggest that psychotropic one medical and one pharmaceutical expert We estimate that up to 80 percent of the regional countries psychotropic drugs brought into Afghanistan are illegally smuggled in without an offi cial China and India government import licence. In 2003 the Ministry of Public Health released Health and obtain a certifi cate from the National a National Medicine Policy to ensure that all Board for Psychotropics along with a licence medical drugs were effective, safe, of good from the Drug Regulation Committee. During quality and fairly priced, and that they were 2007, 40 such licences were approved for the prescribed, dispensed and used in a proper manner legal importation of psychotropics from countries appropriate to the needs of the patient. The policy as diverse as Denmark, Egypt, France, Iran, emphasised that the availability of drugs such as Switzerland and the Netherlands.26psychotropics with risks or specialised modes of Once an import licence has been granted, use, including injection, should be subject to psychotropics — like other pharmaceutical drugs imported legally into the country — are kept at Proposed amendments to the Afghan Law of customs for testing by the Directorate of Pharmacy Medicine are currently under review by the in Kabul before being released to the importer. Commission of Health and Public Welfare of the NGOs do not pay any tax on these drugs if they Upper House (Meshrano Jirga) of Parliament. are imported for humanitarian reasons, but private These amendments are designed to facilitate sector importers pay a tax of four percent plus a the control and regulation of the production, two percent value-added tax. Importers frequently complain that the drugs are kept too long at customs, sometimes in inappropriate conditions, 23 Anna Paterson and Asif Karimi, Understanding Markets before being tested and released. It has also been in Afghanistan: A Study of the Market for Pharmaceuticals claimed that the process of importing psychotropics (Kabul: AREU, 2005).
24 In 2003 the Ministry of Health was renamed the 26 Ministry of Counter Narcotics, “List of Legally Imported Narcotic and Psychotropic Drugs for 2007” and 25 Ministry of Health, National Medicine Policy (Kabul: “List of Legally Imported Narcotic and Psychotropic Drugs Transitional Islamic State of Afghanistan, 2003).
is very time-consuming, and the need for several pharmacists to prescribe specifi c medicines.31 A offi cial signatures along the way increases the risk Pakistani psychiatrist claimed that the annual of corruption in efforts to hasten the process.
US$47 million trade in psychotropic drugs in 2003-04 was characterised by poor regulation of The supply chain
prescription and dispensing, noting that: Distribution and sale
In Pakistan, most medicines, including While there are no reliable statistics available, psychotropics, are available over the counter. it has been estimated by government offi cials Pharmacies are not staffed by trained or that up to 80 percent of psychotropics entering qualifi ed personnel and are not regulated by Afghanistan are smuggled over the border with no any professional body. These “chemists” are licence or proper testing. A study conducted in 2005 also important in infl uencing psychotropic sales estimated that the percentage of private sector (hypnotics and tranquillisers), as many patients pharmaceutical imports smuggled into the country present to them with their complaints.32 was between 60 and 80 percent.27 Ministry of Public Health offi cials have also made the reasonable Situated in Kabul’s central Polyclinic, the Legal claim that many smuggled drugs are sold in towns Department of the Directorate of Pharmacy has, closer to the borders, with fewer now reaching since 2005, been responsible for quality control Kabul where there are tighter restrictions in place.
and monitoring the distribution and sale of all pharmaceutical drugs. It is the fi rst government Research suggests that factories in neighbouring body since the 22-year period of Soviet invasion, Pakistan have consistently produced cheap civil war and Taliban rule to take practical steps to substandard or counterfeit pharmaceutical drugs control pharmaceutical medicines imported and sold specifi cally for the Afghan market, where there has in Afghanistan. With few government regulations been less offi cial oversight than in Pakistan itself.28 and functioning control mechanisms in force, Many of the 37 factories located in the North West several banned drugs such as methaqualone and Frontier Province were established during the metamizole were, until recently, easily available in Soviet era at a time when there was little quality Kabul and other parts of the country. Now, in theory control in that area of Pakistan and no licensing at least, any pharmacy found to be selling these requirements for producing drugs that were not banned drugs is liable to face sanctions.
even approved for consumption in Afghanistan. According to one trader, during that period: Currently the Legal Department has a staff of 80 technical inspectors divided among four zones Local manufacturers and traders sent of the city of Kabul, along with another eight their agents to fi nd what was in demand members of a “swift response group” equipped in Afghanistan. Then they would produce with motorcycles. Their job is to control and whatever was in demand and put the required monitor all pharmacies, clinics and hospitals to label on it. Poor quality raw materials were ensure that the medical equipment used is of an used to manufacture these products.29
appropriate standard and that expired, out-of-date and low-quality medicines are not being sold. In 2005 it was reported that, due to increased If a person is found to be selling these types of government controls, Pakistani drug manufacturers drugs, their premises can be temporarily closed were shifting their operations from Peshawar to and they are brought to the Department to account Khyber Agency in the Federally Administered Tribal for themselves. If it is a serious offence, they may Areas.30 The pharmaceutical trade in Pakistan be sent to court; if it is a lesser offence, they is also reportedly rife with corruption, from can be fi ned or have their premises closed for a the bribing of government offi cials to disregard week or longer. The Department also investigates quality control requirements and provision of complaints from the public about overcharging or inducements and incentives to doctors and unqualifi ed people supplying prescriptions. In 2007, inspectors claimed to have collected and destroyed 200 tonnes of smuggled, banned, counterfeit or Paterson and Karimi, Understanding Markets in expired drugs from around the country.
28 J. Khan, Pakistan-Afghanistan Pharmaceutical Market, 31 J.Khan, Pakistan-Afghanistan Pharmaceutical Market.
32 Murad Moosa Khan, “Murky Waters: The Pharmaceutical 29 J. Khan, Pakistan-Afghanistan Pharmaceutical Market, 2.
Industry and Psychiatrists in Developing Societies,” 30 J. Khan, Pakistan-Afghanistan Pharmaceutical Market, 2.
Psychiatric Bulletin, 30 (2006), 85.
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics According to Legal Department staff, a further A spokesperson from the newly formed Drug objective of their work is to attend to the Sellers Association, representing the interests problem of prescription-only drugs, particularly of drug wholesalers (as opposed to importers or psychotropics, being sold over the counter, retailers), reported that the Association wants especially by unqualifi ed or untrained pharmacy smuggling curtailed. Apart from reducing profi ts, staff. To open a pharmacy, an application has to it recognises that many of the medicines smuggled be forwarded to the Minister of Public Health and into the country are of poor quality and often a licence granted by the Legal Department through out of date — posing health risks to consumers. the Directorate of Pharmacy. A licence is then issued If pharmaceutical drugs were produced in and the Department checks to ensure that there is a Afghanistan, and the police and other offi cials qualifi ed professional pharmacist on the premises. were less susceptible to bribes from smugglers, There are now approximately 2,000 registered the association claims the incidence of smuggling pharmacies in Kabul and a total of around 9,800 would decrease. There are a number of companies across the country.33 Many of these pharmacies which have recently been licensed to produce provide medical information and healthcare advice, pharmaceutical drugs in Afghanistan, although it and they commonly sell medicines to customers is likely to be considerable time before they are without a qualifi ed pharmacist on the premises. able to meet the country’s needs.
While offi cially every registered pharmacy needs a licensed pharmacist to operate, there are simply A primary aim of the Drug Sellers Association is not enough qualifi ed pharmacists in the country to to ensure that only quality pharmaceuticals that meet the demand, and anecdotal reports from some are legally imported and tested by the Ministry of pharmacists suggest that pharmacists can simply Public Health are sold in Afghanistan. While drugs “sell” their licence to several different shops for a are imported from many countries — Germany, monthly fee to “legitimise” their business.
Turkey, Russia, China and India, among others — those manufactured in Pakistan under licence from In all provinces where the security situation multinational companies are more popular because permits it, Ministry of Public Health control they are easier and cheaper to import. Iran also mechanisms now exist. However, as in other areas exports drugs to Afghanistan, often at substantially of government, low-paid offi cials are susceptible cheaper prices than other countries; however, to the temptations of corruption, such as being those from Pakistan are generally preferred as they offered a bribe to ignore the sale of expired or are perceived to be of international quality (few poor-quality medicines. Generally in developing international pharmaceutical companies operate countries, as is the case in Afghanistan, offi cial in Iran). It has been reported by drug treatment corruption is most prevalent when salaries are service providers that returned refugees from Iran low, opportunities great and policing weak.34 prefer Iranian drugs since they are more familiar with them, while returnees from Pakistan naturally The psychotropic drug market
Apart from illegal sources or importing directly The Drug Sellers Association acknowledged that themselves, pharmacies can purchase their supplies there are not enough trained pharmacists to of psychotropics from drug wholesalers. In Kabul, provide a rational and professional system for the main wholesale market for pharmaceutical dispensing pharmaceuticals in Afghanistan. As drugs and small-scale medical equipment is in there are limited numbers of doctors, and many the Taimani district of the city, where there are Afghans cannot afford to go to a doctor even if over 130 shops involved in the trade. This signifi es one is available, pharmacists often sell drugs the sheer scale of the market, and such a large without a prescription — whether or not they are number of traders has led to a very competitive trained or qualifi ed. Ideally only a qualifi ed doctor market — wholesalers complain that smuggled, should determine the choice of a patient’s drug tax-free drugs increase supply, push prices down and its dosage, duration and termination, but in Afghanistan this is currently not always feasible.
33 A 2005 study reported that there were “around 13,000 It is important to note that many of these factors licensed private pharmacies in the country” (Paterson and relating to the importation, supply, distribution Karimi, Understanding Markets in Afghanistan, 14).
and prescription of psychotropic drugs are also 34 L. Palmier, “Bureaucratic Corruption and its Remedies,” likely to apply to non-psychotropics, such as in M. Clarke (ed), Corruption: Causes, Consequences and antibiotics and anti-infl ammatory drugs.
Control (London: Frances Pinter, 1983). III. The Misuse of Psychotropics in Afghanistan
If used correctly with a prescription and under the potential for confusion and misunderstanding medical supervision, psychotropic drugs can be about what constitutes a “dangerous drug,” and of great benefi t to consumers. Their misuse is has distinct policy implications.
particularly problematic, however, as it can lead to serious health-related, social and fi nancial Many Afghans are illiterate and unable to problems for the user, their family and the read or understand instructions to safely use community. Compounding this fact is that, in psychotropics. Indeed such instructions may be the Afghan context, these substances may be written in a foreign language, rendering them perceived and treated as medicines (dawa) and not unintelligible to most. Afghans are therefore as drugs or intoxicants (nashaimawad or mukhadir) unlikely to have access to accurate and reliable — which are haram (forbidden) in Islam. This may information about the possible side effects and exacerbate their potential for misuse as the risks risks of intoxication, dependency and addiction and dangers may not be understood or addressed to psychotropics. It has been found that often and the misuse of psychotropics even when prescribed by a doctor; when asked the name healthcare costs can have a negative impact on families’ an enormous impact on livelihoods.35 It was also found that expenditure on healthcare was a key and benzodiazepine tranquillisers like diazepam
factor in creating indebtedness; scarce family (Valium) and lorazepam (Ativan). There are a
assets were often sold to pay for treatments — number of distinct forms of misuse of these
including the purchase of drugs that anecdotal psychotropics, and these can overlap. The main
evidence suggested were ineffective, resulting problems related to the misuse of psychotropics
in people repeatedly spending their resources on based on the available evidence are: long-term
useless medication or having to seek other forms self-medication; polydrug use and illicit injection;
of treatment. In Laghman and Herat provinces, and overprescription and iatrogenic illness.
for example, households spent between nine
and 26 percent of their total income on family Long-term self-medication
Hypnosedatives or benzodiazepine tranquillisers Paradoxically, in many areas of Afghanistan illicit like diazepam are often legitimately prescribed for psychoactive drugs like opium are used medicinally short-term use by medical practitioners for a range for a range of diseases, while a drug like Valium can be of chronic mental health problems such as anxiety, misused, leading to dependency and other problems depression and sleep disorders — all endemic in usually associated with illicit drugs. This creates Community Drug Profi le No. 2: Opium and Other 35 Jo Grace and Adam Pain, Rethinking Rural Livelihoods Problem Drug Use in a Group of Afghan Refugee Women in Afghanistan (Kabul: AREU, 2004), 51-52.
(Islamabad: UNDCP Afghanistan Programme, 1999).
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics the Afghan population. However, in Afghanistan percent take opium, 4 percent take hashish and 4 — as in many other countries in the developing percent take heroin. By contrast, only 20 percent world — when the prescription is fi nished, the drug of women attending a Helmand treatment service can easily be bought over the counter and its use take psychotropics, while 65 percent take opium continued without further medical advice. This is and 10 percent smoke heroin.
most likely to happen if the drug has a desirable effect, but poverty also appears to play a key role. In areas where opium is cultivated and produced, A doctor’s appointment can cost up to 200 Afs; so, it appears to have become the preferred drug after a prescription for psychotropics is fi nished, it since it is easily available and relatively cheap. is cheaper to simply go to the market and buy more The further from opium production an area is, of the drug rather than return to the doctor who the more likely it is that psychotropics are used will charge for a repeat prescription.
there. However, according to one drug treatment coordinator interviewed for this research, both Anecdotal evidence from drug treatment centres women and men who use illicit drugs may also move that operate in Afghan communities suggests to using psychotropics for fi nancial reasons:that nearly every family with easy access to supply has a family member self-medicating with if there is no money for the drug of choice like tranquillisers. Older people who have been using opium, heroin or hashish, these users become such drugs for a long period of time are reputed compelled to use psychotropics, which are much to keep their own stock; when another family cheaper because they are mostly smuggled, tax-free and counterfeit. Also there is less blame or member, even a child, has a problem they simply stigma attached to taking psychotropics, so this “prescribe” the drug for them. In rural areas, can be used as an excuse to take these drugs as especially those engaging in opium cultivation they are considered medicine not an intoxicant. and production, it may be more likely that opium is used rather than a tranquilliser since supply can An outreach programme for female problem drug be easier to access. Both men and women may pass users in Kabul estimated that 30 percent of its on information to each other about the use and clients used only psychotropics, while a number perceived benefi ts of tranquillisers, perpetuating of the 70 percent of clients that used opium non-medically prescribed consumption.
also used psychotropics. At another outreach programme in the city, 50 percent of female clients The 2005 National Drug Use Survey estimated used psychotropics, including the benzodiazepine that more men than women use psychotropics tranquillisers diazepam, chlordiazepoxide, on a daily basis, with some using for consecutive lorazepam and oxazepam.
periods stretching to well over ten years. Of the estimated 180,000 psychotropic drug users In 2003, a study of 200 drug users in Kabul revealed that cited in the survey, 50 percent were men, 30 40 percent had taken psychotropics — 52 men and 28 percent women and the rest children.37 It should women. The most common drug cited was diazepam be noted that because of their social position, (Valium), which was used by almost three quarters women may have been more diffi cult to access (59 respondents) of the psychotropic users. Other by surveyors and therefore possibly constitute a drugs cited included methaqualone, pentazocine and larger, if hidden, population of psychotropic drug lorazepam, along with non-prescription analgesics users than men. Women may also be more likely like ibuprofen and paracetamol.38 than men to talk about healthcare issues with each other and, in doing so, share information It is not only in urban areas that there are problems about access to and use of psychotropics.
related to the self-medication of psychotropics. In February 2001 a study reported that nearly ten According to an NGO responsible for coordinating percent of households in four rural districts in drug treatment services in Gardez (Paktia eastern Afghanistan (Khak-e Jabar in Kabul, Hesarak province), 70 percent of female clients attending in Nangarhar, Azro in Logar and Sayed Karam in community-based drug treatment services take Paktia) had someone misusing psychotropics, with psychotropics, while only 15 percent take opium three to seven percent of the adult population and 13 percent take hashish. In another outreach estimated to be misusing psychotropics on a treatment service in Kandahar, 40 percent of regular basis. The main drugs cited in the study female clients take psychotropics, while 50 were diazepam, lorazepam, methaqualone and 37 UNODC and Ministry of Counter Narcotics, Afghanistan: Drug Use Survey 2005.
Community Drug Profi le No. 5, 21.
pentazocine.39 An earlier study in 1999 of 50 metamizole and phenobarbital, have been added Afghan refugee women in New Akora refugee camp to heroin — by heroin producers, street dealers and outside Peshawar in North West Frontier Province, users themselves. It has been reported in several Pakistan, revealed that more than half were using areas of the country that there is growing use of psychotropics; a third of this group stated they were a diazepam-opium smoking mixture; diazepam using diazepam while nearly two-thirds stated they apparently enhances the effect of opium and helps were using painkillers.40 the user sleep. Drug treatment workers say that various psychotropics are added to opium sold in In all of these studies, the primary reason for Kabul because users do not trust the purity of the taking psychotropics was claimed to be as opium and want a stronger effect from the drug. It medicine to help cope with the problems of daily was also claimed that street dealers may encourage life — both physical and psychological — and to polydrug use and are always eager to advise which alleviate the symptoms of chronic mental health drugs to mix in order to make the effect stronger.
problems. In particular, diazepam was seen as a panacea for a wide range of ills, including Doctors currently engaged in research with street physical pain, anxiety, depression, stress and drug users in Kabul report that many street IDUs sleep disorders attributed mainly to war and and non-IDUs are polydrug users who often mix confl ict-related social upheaval and disruption. heroin with diazepam or phenobarbital. This Long-term self-medication of painkillers is also latter combination is sold on the street as a mix prevalent among those suffering chronic pain called gulbutton and is seen to have a stronger from physical injuries sustained during the many effect than heroin by itself. The antihistamine years of fi ghting in Afghanistan.
and sedative drug Avil is also commonly mixed with heroin before injecting and is preferred to While properly prescribed psychotropics may lemon juice as a mixing agent. In this case, an provide relief in the short term, they tend to ampoule of Avil is added to the heroin to dissolve result in a range of problems if used over a long it without the need for “cooking,” sometimes with period.41 In one study, 96 percent of respondents an ampoule of Valium also added. No distilled reported at least one problem associated with water or cooking is needed to dilute the heroin their use of psychotropics, and 85 percent powder, suggesting that it is relatively pure. reported multiple problems — particularly Research conducted between June 2005 and June related to their health and fi nancial situation.42 2006 on 463 IDUs in Kabul found that 56 percent However, as psychotropic drug users may also be mixed Avil with heroin before injecting it.43 It has using illicit drugs such as alcohol, hashish, heroin been suggested that adding these drugs to heroin or opium, it can be diffi cult to establish which hastens its absorption into the body.
drug is responsible for which problem.
As in other countries, some heroin smokers may Polydrug use and
switch to injecting the drug because the effect is injection of psychotropics
quicker and more pronounced, and it is more cost effective.44 In Kabul, some heroin users claim that Polydrug use refers to the taking of two or more injecting the drug is easier to hide from police than drugs either together or in quick succession. A smoking it.45 When IDUs cannot access or afford psychotropic drug may be used as a psychoactive additive to illicit drugs like heroin before use or it 43 Catherine S. Todd, “HIV, Hepatitis C, and Hepatitis B may be taken separately alongside an illicit drug.
Infections and Associated Risk Behavior in Injection Drug Users, Kabul, Afghanistan,” Emerging Infectious Diseases, While street heroin in Afghanistan is rarely 13(9) (2007).
tested, law enforcement informants suggest that 44 In Burma and Laos, as is likely to happen in Afghanistan, a number of psychotropics, including diazepam, a decline in opium production led to a shortage of heroin and a shift in consumer behaviour — not only from Community Drug Profi le No. 4: An Assessment smoking to injecting heroin but also replacing heroin with of Problem Drug Use in Rural Afghanistan — The GAI Target psychotropics as well as methamphetamine (Transnational Districts (Kabul: UNDCP Afghanistan Programme, 2001).
Institute, Withdrawal Symptoms: Changes in the Southeast Asian Drugs Market, Drug and Confl ict Debate Papers No. Community Drug Profi le No. 2.
41 The Glossary section of this paper provides information 45 In this instance “smoking” refers to the method of on types of problems related to specifi c psychotropics.
use known as “chasing the dragon,” in which the drug is 42 UNODC and Ministry of Counter Narcotics, Afghanistan: usually placed on tin foil and heated underneath, and the Drug Use Survey 2005. resulting fumes are inhaled through a tube.
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics heroin, they may buy pentazocine (Sosegon) or is, 30 tablets —which is far beyond any permitted tramadol to mitigate their withdrawal symptoms. maximum dose, suggesting that either he had This represents a signifi cant potential problem developed a high degree of tolerance to the drug in Afghanistan: if law enforcement interventions or, just as likely, that the drug was substandard. are successful and heroin availability decreases Most of the men present also admitted to using and its price increases, current heroin users Valium, which costs 13 Afs for one ampoule or 10 — both smokers and injectors — may shift to Afs for one strip of 10 mg tablets. It was claimed using substitute drugs, particularly psychotropic by staff at the drop-in centre that some users also analgesics such as Sosegon and tramadol.
buy Mandrax (methaqualone) from pharmacies, although this drug seems to be less commonly Researchers in Kabul report that 85 percent of used than it has been in the past. One staff 273 IDUs they interviewed use Valium or another member said that Mandrax, along with hashish and benzodiazepine tranquilliser — either orally or alcohol, was one of the main drugs available in mixed with heroin and injected — to help them Kabul roughly 20 years ago but that its availability sleep.46 It was informally estimated that 50 percent had decreased signifi cantly since then.
also use tramadol tablets, which cost 40 Afs for a blister strip of ten tablets, although these are While many of the men attending the drop-in becoming more diffi cult for drug misusers to buy centre were homeless and unemployed, a small from pharmacies. Less than 5 percent of the sample number had their own businesses and were reported that they used phenobarbital tablets. IDUs relatively wealthy. This means that they should, claimed that heroin is now more diffi cult to buy in theory, be able to buy better quality drugs. because of police intervention, so psychotropics While securing livelihoods and greater incomes are increasingly added to or substituted for heroin. for drug users does not guarantee that they will IDUs returning from Iran claimed they had used become drug free, providing income-generation Sosegon as refugees there, but pointed out that it activities and vocational training opportunities is diffi cult to buy Sosegon without a prescription at must be seen as an integral part of any treatment pharmacies in Kabul now — although a prescription and rehabilitation programme in an impoverished can be bought from some doctors for up to 200 Afs.
country like Afghanistan. Without an income to support their family and without access to Even in much more remote, rural areas of employment, it is even more likely that drug users the country, it appears that benzodiazepine undergoing a treatment programme will relapse.
tranquillisers have been taken by polydrug users. A study conducted in Badakhshan in 2005 While psychotropic drugs are often mixed with reported that 22 percent of opium users also used heroin before injecting, they can also be injected on tranquillisers — sometimes to mitigate opium their own. During 2007 a drug treatment outreach withdrawal symptoms. These drugs were easily team in the Shor bazaar area of Kabul worked with purchased without a prescription from local 283 female clients, most of whom were polydrug markets in Ishkashim and other locations.47 In users. The drugs reported as having been used the same year in the district of Shughnan, it was included cannabis, heroin, Largactyl, Librium, reported that heroin users were mixing heroin with opium and Valium. Twelve of the women were IDUs psychotropics such as chlorpromazine, diazepam who had returned from Iran and experienced some and diclofenac before smoking it.48 diffi culty in accessing heroin and opium when they arrived in Kabul, leading to some of them injecting Out of a group of 50 male drug users at a drop-in Sosegon. One woman claimed that she injected centre in Kabul in April 2008, most were heroin over 20 ampoules of Sosegon a day.
smokers. Only fi ve were IDUs, and four of these were also using pentazocine. One IDU claimed to While most of the examples in this section were take three blister strips of Valium per day — that taken from Kabul-based studies, injecting drug use has also been reported by treatment services Dr M. Helmand and Dr M. Raza, pers. comm.
in several other areas of Afghanistan, including in 47 Marc Theuss, G.E. Poole and Falak Madhani, Addiction and around towns and cities such as Ishkashim, in the Border Regions of Badakhshan, Afghanistan: Range, Gardez, Herat, Mazar-i-Sharif and Kandahar. While Trajectory and Impacts, unpublished report (Kabul: Aga the drug use patterns of IDUs in these areas are largely unknown, they are likely to follow those Drug Use and Abuse in Afghan Shughnan of IDUs in Kabul with respect to their substitution (Berlin: Institute for East-European Studies, 2005) (http:// Overprescription and iatrogenic illness
is no easy access to a health clinic. They import their own pharmaceuticals and then “prescribe” In 1979 in the United Kingdom, when prescriptions these drugs without knowing enough about their for benzodiazepines peaked at 30 million per year, effects, correct dosage and possible side effects. there was substantial evidence to suggest that It has been claimed that in some villages in Shinwar dependence on such drugs used for sleep disorders district of Nangarhar province over 50 percent of was largely an iatrogenic disease — that is, “a villagers go to such “quacks.” condition created and maintained by doctors.”49 In the case of Afghanistan, “iatrogenic” refers to Claims have been made by a number of NGO those adverse effects or complications relating to treatment centres and by other sources in Kabul the use of psychotropic drugs that are caused by that private residential drug treatment providers or result from medical treatment or advice from in the city are now providing heroin addicts with a a doctor, a pharmacist or an unqualifi ed person pain-free detoxifi cation regime of benzodiazepines dispensing medicine in a pharmacy.
and painkillers, administered both intravenously and orally. They charge $200 for a 15-day residential In Afghanistan, there is a tendency to overprescribe detoxifi cation and “treatment” programme where pharmaceutical drugs, particularly antibiotics, and drug withdrawals are totally pain-free, rather than combinations of medicines are prescribed without providing clients with symptomatic treatment only. proper consideration of their possible side effects. On being discharged, the client is given tranquillisers In 1999 in Nawsad district, Helmand Province, it for up to 6 months; drug users report that only the was reported that there was a particular problem blister strips are provided, with no information about possible side effects or the potential for dependency. When this prescription is fi nished the use of strong prescription medicines for they suffer withdrawal symptoms, as this is the minor ailments is frightening. Shopkeepers of fi rst time they have been drug-free since starting medical stores, rarely qualifi ed pharmacists, the detoxifi cation and treatment programme. At recommend a range of medicines, often this point, they are at signifi cant risk of relapse the most expensive, to make their business and starting to use heroin again. Drug users have profi table and to ensure cure.50
reported to NGO drug treatment providers that when In Afghanistan, iatrogenic disease is one also they return to the clinic they are held responsible
borne of omission; few doctors who prescribe for their own relapse and then have to pay $200 for
psychotropics, or pharmacies that sell them, provide further detoxifi cation, in all likelihood leading to a
adequate information about their risks and dangers continuation of this cycle of addiction.
to patients as well as the attendant risks of self-
medication. A compounding problem is diagnosis and Other problems related to psychotropics
drug prescription by unqualifi ed people working as The most serious problems relating to psychotropics
doctors or pharmacists, risking incorrect diagnoses appear to be: long-term self-medication; and potentially prescribing the wrong drugs.51 overprescription; lack of provision of information Along with the high proportion of low-quality and about their risks and dangers by both qualifi ed and counterfeit drugs, this can spell serious problems unqualifi ed doctors and pharmacy employees; and for consumers, especially those who cannot afford the addition of psychotropics to illicit drugs. As is the fees of better qualifi ed and informed doctors.
There are many anecdotal reports of unqualifi ed the dynamics of the licit and illicit markets are drug prescribing, with semiliterate, inexperienced connected to some extent . on the streets and unqualifi ed people setting themselves up as the distinction between the two apparently “doctor-pharmacists” in rural villages where there However, there are some other signifi cant potential 49 Charles Medawar and Anita Hardon, Medicines out of Control? Antidepressants and the Conspiracy of Goodwill problems and issues in relation to the misuse of (Netherlands: Aksant Academic Publishers, 2004), 35.
psychotropics. One is the possible use of steroids or 50 Anna M. Pont, Blind Chickens and Social Animals: other potentially harmful psychotropics by hakims Creating Spaces for Afghan Women’s Narratives Under the Taliban (Portland, Oregon: Mercy Corps, 2001) 67.
52 Martin Jelsma, “Learning Lessons from the Taliban 51 Anna Paterson and Asif Karimi, Understanding Markets Opium Ban,” International Journal of Drug Policy, 16(2) Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics (herbal medicine practitioners) as additives to dependency and other problems developing. Drug herbal medical preparations. A media report from treatment workers report that infants or very young neighbouring Pakistan claimed that some hakims children taken to a pharmacist because they will there have used steroids and veterinary drugs in not stop crying, or because the family cannot afford their preparations but that people still seek their a doctor, are likely to be given syrups containing services because they charge much lower fees than Avil, phenobarbital or Phenergan. Drugs like these doctors.53 Traditionally many hakims have used should never be given to children under the age of natural psychoactive substances such as hashish two years unless in exceptional circumstances and and opium in some of their preparations; while under strict medical supervision.
there is always a risk that some less scrupulous hakims will use easily available psychotropics as Currently the opioid analgesics buprenorphine additives to these preparations, this risk could and methadone are on Afghanistan’s Essential increase substantially if the availability of opium Drug List for use only in drug-substitution therapy and hashish decreases. With the proliferation programmes as a means of preventing the spread of bodybuilding clubs in Kabul, there have been of HIV and other blood-borne diseases among IDUs anecdotal reports of the misuse of steroids by and drug users at risk of injecting. To date no agency bodybuilders, including by injection.
implementing drug substitution programmes has been granted an import licence for these drugs, A signifi cant problem also exists with children and yet researchers working with street drug users adults taking morphine or other psychotropic- in Kabul in 2008 report that buprenorphine is based cough syrups, which are easily available over already being sold illicitly in Kabul and used by the counter. While they may initially be taken for some IDUs. While the introduction of these drugs genuine medical reasons, if use continues after the is necessary as part of the harm-reduction strategy initial symptoms have stopped, there is a risk of aimed at the prevention of HIV/AIDS among IDUs, their strict control to avoid diversion to the illicit 53 News on Sunday, 25 August 2002.
IV. Policy Implications
With up to 80 percent of psychotropics brought unintended consequence of the current policy illegally into the country, it will remain diffi cult for to eliminate poppy is that as it becomes more authorities to prevent smuggling and fraudulent successful, supply decreases, price increases and practices in relation to these drugs. In the same users of opium and heroin will look for substitute way that Afghanistan’s infamously porous borders drugs — and there is no shortage of psychotropics facilitate the smuggling of illicit drugs like opium to fi ll the gap. Many of these drugs are likely to and heroin out of the country, they also facilitate be counterfeit, out of date or contain dangerous the smuggling of psychotropics into the country. additives, and their effects may be just as harmful Endemic corruption among government offi cials as those arising from the misuse of opium or heroin. and other players in the supply chain means that Under these circumstances, current heroin smokers bribes and kickbacks are an integral part of the are likely to move toward injection of heroin that trade in both opiate and psychotropic drugs.
will increasingly contain psychotropic additives; some heroin injectors will move to injecting The supply and demand sides of the trade in both psychotropics instead as they will be cheaper and illicit and licit drugs are inextricably interwoven. easier to obtain, although they carry their own very It is not only policy concerns about opium poppy serious risks and dangers. Any shift to injecting eradication and its effects on poor rural households, drug use, whether of heroin or psychotropics, or likely to result in “economic crisis, compounded a combination of both, will increase the possibility insecurity and increased political tensions,” that of sharing injecting equipment and risk the warrant thorough consideration.54 Another possible transmission of HIV/AIDS and other blood-borne diseases. In Afghanistan injecting drug use has 54 David Mansfi eld and Adam Pain, Evidence from the already been recognised as one of the main drivers Field: Understanding Changing Levels of Opium Poppy of the spread of HIV/AIDS in the country.
Cultivation in Afghanistan (Kabul: AREU, 2007).
Despite recent attempts by the under-resourced providers. For example, a new and particularly Ministry of Public Health to control the trade in harmful form of crystalline heroin, simply called psychotropic drugs, their popularity and easy “crystal,” has recently emerged in Herat, Kabul availability due to lack of effective regulation and and other locations, although it is unknown whether control mechanisms mean that many Afghans still this drug contains any psychotropic substance.
have access to these drugs through a wide range of outlets and are able to self-medicate. Conversely, Any quick reduction in availability due to there is a risk that if regulations regarding the stricter controls or substantial price increases in trade and sale of psychotropics are more rigorously psychotropics should be avoided. Such proposals enforced and availability is substantially reduced, should be treated with caution; reducing availability a proportion of the users of these drugs will or increasing prices should be graduated. For long-substitute illicit drugs such as opium, heroin, term self-medicators of tranquillisers who can no cannabis or alcohol to cope with their problems. longer fi nd or purchase them, suddenly stopping Furthermore, polydrug users taking both heroin their use is likely to cause severe withdrawal and other illegal drugs as well as psychotropics symptoms; they will need to be provided with are likely to increase their consumption of illicit the opportunity to detox under proper medical drugs if psychotropics increase in price or become supervision using a gradual reduction programme.
more diffi cult to obtain. The structural factors Signifi cant increases in the control and regulation of that engender chronic mental health problems and psychotropics may contribute to the development the need for self-medication with psychotropics of an illicit street market for these drugs, further are unlikely to improve substantially in the near increasing the risk of poor-quality, out-of-date and future. The country also has little capacity for adulterated drugs being sold to vulnerable groups. providing suffi cient counselling, support and other There is already anecdotal evidence of some therapeutic interventions for sufferers. psychotropics being sold by street drug dealers in On the whole, the wide availability of psychotropic Kabul. On the other hand, any substantial increase drugs heightens the risk of new drug mixtures in price or any reduction in the availability of emerging which will carry potential risks and dangers heroin may lead to a growing demand for cheap currently unknown to drug treatment service psychotropics from heroin users, including IDUs.
V. Ways Forward
There are no quick or easy solutions to the have no acceptable use and can only be misused.55 complex problems presented by the misuse of On the other hand, psychotropic pharmaceuticals psychotropic drugs in Afghanistan, especially given are legal if prescribed by a doctor and dispensed by the interaction between the licit and illicit drug a pharmacist and if their use is medically justifi ed. markets. There is a lack of understanding of the However, in Afghanistan many psychotropics are fact that while the controlled use of psychotropics not prescribed or dispensed in the proper way, and for medical purposes may be benefi cial, it is very few consumers have easy access to information easy for this to lapse into misuse and long-term about their short-term and long-term side effects self-medication, resulting in problems related to and potential for misuse and dependency.
side effects, intoxication and dependency.
There is a clear need to provide Afghans with The fact that for centuries both cannabis and opium reliable, practical information to empower them products have been used in traditional medicine and in many areas, including most of South Asia, 55 Permitting households in Afghanistan to grow suffi cient for recreational purposes is often overlooked. opium for their own medical purposes, particularly those The paradox is clear: there should be an obvious in more remote rural areas far from health clinics or distinction, but what constitutes a medicine and reputable pharmacies, is a debate outside the scope of what constitutes an intoxicating drug is unclear. this paper, but one that deserves closer attention. Most These “traditional” psychoactive substances are Afghans over the age of 40 will remember being given some type of opium preparation for cold, cough, toothache or now illegal under statutory law; by defi nition they other symptoms as a child. For many of their own children, this has now been replaced by unregulated psychotropics, with all their related risks and dangers. Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics to make rational choices and decisions about the risks and dangers, the nature of drug dependency types of psychotropic drugs they consume, although and culturally appropriate treatment options for this alone will not necessarily prevent misuse. The the people of Afghanistan.
information made available should spell out the risks, dangers and possible harmful effects of taking While better professional training of pharmacists at psychotropics without proper medical approval and university level is necessary, those currently working prescription, including adverse side effects and the in pharmacies, whether trained or not, should be potential for overdose and dependency, as well as encouraged to provide customers with written the risks of polydrug use and self-medication.
information in Dari and Pashto on the dangers and risks of the psychotropics they are dispensing. For However, while providing this information is those customers who are illiterate, pharmacists — in critical, it should be done in a way that is sensitive conjunction with community health workers — should to the particular context of licit and illicit drug explain these risks and dangers, particularly those use in Afghanistan. For example, overly severe related to the long-term use of psychotropics.
warnings about the potential dangers of using psychotropics quality treatment, rehabilitation and harm reduction services to approach to drug education, in which the risks and dangers of more aware of the potential risks and dangers of monitoring and support is necessary to encourage psychotropics through media campaigns as well as high standards of professional practice and to longer-term educational programmes would also minimise the risk of bribery and other corrupt facilitate the work of the Ministry of Public Health behaviour. While law enforcement has a role to play, in trying to control and regulate their retail trade it must be remembered that increased action against — efforts which are already hindered by a lack the availability and sale of heroin and other illicit of transparent and accountable governance, the drugs may have the unintended consequence of an weakness of the state, endemic corruption and increase in the use of psychotropics as additives to insecurity. such drugs or as substitutes for them.
In this context, it is a complex problem to develop To enable any of these interventions to occur, the interventions to control the trade in psychotropics. international community needs to acknowledge that The most effective interventions are likely to be demand-driven drug problems in Afghanistan require those that take place at the interface between funding to address them just as much as supply-driven the prescriber, the retailer and the consumer problems and the traffi cking of opiate drugs out of of psychotropic drugs. The training of doctors, the country. In the long term, the problems related pharmacists and other healthcare workers — to the misuse of drugs, including psychotropics, may particularly community health workers — is of pose an equally impermeable barrier to human and paramount importance. Professional training economic development in Afghanistan as opium at college and university level should contain cultivation and heroin production.
substantial, rather than token, coverage of the effects of psychotropics and illicit drugs, their Glossary of Psychotropics Used in Afghanistan
The accepted classifi cation of medical drugs worth, agitation and insomnia. These drugs can such as psychotropics usually contains two names also affect memory and concentration.
for each drug: the generic name (beginning All benzodiazepine tranquillisers can cause with a lower-case letter), and the brand name psychological and physical dependence as (beginning with an upper-case letter), for well as what is known as the “benzodiazepine withdrawal syndrome.” People particularly at In Afghanistan, two main categories of risk of dependency are those with a history of psychotropics are misused: analgesics (painkillers) drug addiction and those suffering from chronic and hypnosedatives. The latter category consists pain, long-term mild depression and chronic sleep of drugs that have both hypnotic (sleep-inducing) disorders.57 Rapid withdrawal from benzodiazepines and sedative effects. Among these, there are two that have been taken continuously for more than a types of drugs: the so-called minor tranquillisers, few months can lead to symptoms that are similar mostly the class of chemicals known as the to those of alcohol and barbiturate withdrawal, benzodiazepines; and the major tranquillisers, including seizures, tremors, muscle cramping, mostly referring to barbiturate and barbiturate- type drugs. The minor tranquillisers are used The higher the dose and the longer the drug has for mental health problems that are chronic been taken, the greater the risk of withdrawal but not acute, whereas the more powerful major tranquillisers are now mainly used to symptoms can also occur at standard dosages control severe mental health problems such as and after only short-term use. Benzodiazepine schizophrenia and mania.56 Before the discovery treatment should always be discontinued as soon of benzodiazepines, these major tranquillisers as possible via a gradual dose reduction regime, were used for a much broader range of mental preferably under medical supervision.
Although all benzodiazepines have basically the There is a new class of anti-depressant drugs called same effect, different types can be shorter or selective serotonin reuptake inhibitors (SSRIs), longer acting. The older benzodiazepines like but there is little evidence that these drugs are Valium and Librium are metabolised more slowly, currently being misused in Afghanistan. Some of meaning that their effects last for 12 hours or more. the most popular SSRIs are fl uoxetine (Prozac), If they are taken at night to induce sleep, the user paroxetine (Paxil) and citalopram (Celexa).
may have problems waking up in the morning and remaining alert. If taken during the day, they can Minor tranquillisers
lead to fatigue. Shorter-acting benzodiazepines like This class of psychoactive drugs has varying Ativan and Temazepam, developed to address this properties, including anxiolytic, hypnotic, muscle problem, are more likely to lead to dependency. relaxant and sedative, which are all achieved by If taken at high dosage over a long period and if slowing down the central nervous system. The the use of these drugs is stopped suddenly, severe benzodiazepines have a number of therapeutic withdrawal symptoms including muscle seizures uses for treating symptoms associated with and convulsions are likely to occur.
agitation, anxiety, sleep disorders and seizures. The fi rst benzodiazepine, chlordiazepoxide, was If used for a limited period (no longer than synthesised in 1955, while diazepam appeared in three to four weeks) under medical supervision, 1963 and was soon followed by another 12 in the they are well-tolerated, safe and effective same drug family. The most common ones used drugs for a wide range of conditions. However, and misused in Afghanistan are as follows, with commonly noted side effects associated with diazepam (Valium) by far the most commonly benzodiazepine tranquillisers include excessive sleepiness, dizziness, weakness and unsteadiness. Suddenly stopping after only a few months of daily use may bring on feelings of a loss of self- Alex Baenninger, Jorge Alberto Costa e Silva, Ian Hindmarch, Hans-Juergen Moeller and Karl Rickels, Tyler, Street Drugs (London: Hodder and Good Chemistry: The Life and Legacy of Valium Inventor Leo Sternbach (New York: McGraw-Hill, 2004).
Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics there are several other opiates — drugs derived from the opium poppy such as morphine and codeine — and opioids (synthetic painkillers) that are misused in Afghanistan: • diazepam (Valium)• lorazepam (Ativan) • buprenorphine (Temgesic) — discovered in 1968, it is a semi-synthetic long-acting opioid painkiller derived from thebaine, which is a constituent part of the opium poppy. It is Major tranquillisers (hypnosedatives)
generally administered by the sublingual route (under the tongue) or intravenously, not orally.
This category refers to the barbiturates and • diclofenac (Voltarol, Voltaren) — a non- barbiturate-type drugs, both of which are steroidal anti-infl ammatory drug taken to more powerful and potentially more dangerous reduce infl ammation and as a painkiller. Its substances than the minor tranquillisers. Although over-the-counter use has been licensed in they are powerful hypnosedatives, barbiturates some countries, although not in Afghanistan can contribute to increased aggressiveness and (apart from in cream or gel preparations).
violence, and they have very high addiction potential. They can be taken both orally and • fentanyl (Duragesic) — a potent opioid painkiller with a high potential for abuse • metamizole (Dipyrone, Novalgin) — a painkilling They are practically the most lethal of all and anti-infl ammatory drug that was easily injected substances, and one of the most available in Afghanistan under the brand dangerous to withdraw from.58
names Dipyrone and Novalgin until 2004 when The major tranquillisers found in Afghanistan are: its sale was banned by the Ministry of Public Health. The sale and use of Dipyrone has also • chlorpromazine (Largactil) — a hypnosedative been banned in more than 30 other countries, used mainly as an anti-psychotic in medicine. including the United States, where in 1979 it Like phenobarbital, it intensifi es the central was declared unfi t for human consumption depressive action of drugs with similar activity because it was found to produce a serious side to tranquillisers and heroin. It is used in tablet effect known as agranulocytosis, a dangerous form by street drug users, including IDUs, and it is sometimes mixed with heroin and injected.
• methaqualone (Mandrax) — a drug sold by • omnidol — mainly containing paracetemol, street drug dealers that is still reportedly a non-prescription painkiller, this drug also found in Afghanistan, although its use has contains caffeine and diazepam. Its sale was declined over the past few years. This is banned in neighbouring Pakistan in 2006 by probably due to the increased availability the Drug Registration Board because of its of heroin and the efforts of the Ministry of “irrational” combination of both central Public Health to eradicate methaqualone. First synthesised in 1955 as an anti-malarial central nervous system depressant (diazepam) drug, its powerful effects and potential for drugs, and because the co-administration of abuse were quickly recognised, and its use paracetemol and diazepam is not required in has been banned in most western countries.
• phenobarbital — a barbiturate that usually • pentazocine (Sosegon) — by far the most comes as a white powder and is reportedly commonly reported painkiller misused, often mixed with heroin, increasing the dealer’s as a heroin substitute. Easily available in both profi t but also the risks associated with the tablet and ampoule form, it can be injected on its own or in combination with other drugs. In some countries the use of pentazocine has Analgesics (painkillers)
been banned, and in the United Kingdom its prescription is discouraged as it places While diacetylmorphine (heroin) is still the most undue strain on the heart and can lead to powerful painkiller known to medical science, hallucinations and thought disturbances.
• tramadol — an opioid drug and synthetic • dothiepin hydrochloride (Prothiaden) — an anti-depressant with anxiolytic properties injectable and tablet form. Tramadol is a and the market leader in the Indian anti- controlled substance under Afghanistan’s Essential Drug List (a wise decision given its potential for misuse among IDUs in Kabul); • hyoscine (or scopolamine) — a highly toxic drug however, in other countries it is available that should only be used in very small doses. with, and in some countries without, a normal An overdose can cause delirium, paralysis, prescription. This demonstrates the problem of trying to categorise psychotropics: globally the treatment of nausea, motion sickness and there is often no consensus on the risks and intestinal cramping (as Buscopan), it is also used as a general depressant and an adjunct to narcotic painkillers.
Other psychotropic drugs
• promethazine (Phenergan) — for allergies and • chlorpheniramine maleate (Avil) — an motion sickness (not for children less than antihistamine with sedative properties that two years of age) but with marked sedative/ can be used to dilute heroin before injection. It hypnotic effects. It is a prescription-only drug makes heroin easier to dissolve either directly in the United States but is available over the if in ampoule form or, if used in tablet form, in counter in the United Kingdom, Sweden and distilled water. Users have claimed it prevents allergic reactions such as skin rashes.
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