Special Report

Epidemiologic Report on the Use and Abuse of Psychoactive Substances in 16 Countries of Latin America and the Caribbean1

One of the responsibilities of the World ment of an extensive system for compil- Health Organization (WHO) and the Pan ing and evaluating data on the subject American Health Organization (PAHO) was proposed, and this task was as- is the collection and dissemination of in- signed to PAHO and the Organization of formation on both currently prevalent American States (OAS), in conjunction and emerging health problems. Particu- with other specialized agencies, such as larly important among these problems, the South American Agreement on Nar- by reason of its growing magnitude, is cotic Drugs and Psychotropic Substances the use and abuse of psychoactive sub- (ASEP). These organizations received a stances. WHO is the technical agency of specific mandate to set up an inter- the United Nations charged with imple- American data bank on alcoholism and menting the health-related aspects of in- drug abuse. ternational treaties on narcotics and psy- One of the strategies derived from the chotropic substances. meeting, and one that responded to a re- As part of this responsibility, PAHO quest contained in Resolution XVII of the convened an August 1987 meeting in XXIX Meeting of the PAHO Directing Buenos Aires of the Advisory Group on Council, was a proposal to prepare the Epidemiology of Drug Abuse which epidemiologic profiles of psychoactive had as an aim the undertaking of a pre- substance use in the countries of the cise and practical study of the magnitude Americas, as well as assessments of the of the problems of drug abuse and drug countries’ responses to problems related trafficking and their consequences to this use. throughout the Region for individuals In order for the necessary information and society. At this meeting, establish- to be compiled in a homogeneous man- ner, a data collection guide was prepared This report is a summary of a paper entitled “Per- files epidemiologicos nacionales sobre consumo de and distributed to 16 countries in the Re- alcohol y otras drogas en America Latina,” by gion. Each country was requested to col- Lenn Murrelle, Rodrigo Escalona, and Ramon lect data in the following areas: socio- Florenzano, Center for Alcohol Studies and De- partment of Psychiatry, University of North Caro- demographic and economic indicators ha. Chauel I-Ii& North Carolina. U.S.A. The oa- relative to the production and marketing per. wasLpresented at the II Meeting of ihe of psychoactive substances, the diversion l?4HOWI-IO Study Group on Public Health Rob- lems Related to Alcoholism and Drug Abuse, held of such substances from licit channels, in Miami, Florida, 31 January-3 February 1989. levels of consumption, health indicators

Bulletin ofPAH0 24(Z), 1990 97 that showed the effects of illicit consump- project was assigned to a group of re- tion, the sociocultural framework, gov- searchers at the Center for Alcohol Stud- ernment or health sector responses to ies and the Department of Psychiatry of problems related to the improper use of the University of North Carolina School such substances, rehabilitation and social of Medicine in Chapel Hill, North Caro- reintegration of drug-dependent individ- lina, U.S.A. The present report summa- uals, primary prevention, research, and rizes the data collected. The omission of education and training. one or more of the categories referred to Analysis of the data collected in the 16 above means that such information either countries participating in this stage of the was not available or was unreliable.

ARGENTINA

Production and Marketing of als. Some of the drugs produced are ex- Psychoactive Substances ported, but the market is very small. At the present time the Ministry of Health The most important psychoactive sub- and Social Action does not maintain sta- stances produced in the country are alco- tistics on the production and marketing holic beverages, tobacco, and some psy- of psychoactive medications. There is no chotropic medications. With regard to evidence that clandestine production alcohol, 121,392,277 liters of distilled bev- exists. The Government has the re- erages were produced in 1986, which sponsibility for coordinating the licens- equals 28537,483 liters of absolute alco- ing system for the licit production and hol, for an increase of 23.5% over the pre- control of narcotics and psychotropic vious year. Beer production for that year medications. was 544,590,OOO liters, the approximate There is no state monopoly on the equivalent of 27229,500 liters of absolute production or importation of alcoholic alcohol. beverages, tobacco, or psychotropic Most wine produced is for the domestic substances. market. According to data from the Na- A medical prescription is required for tional Viticulture Institute, authorized the sale of psychoactive drugs. Require- production of wine for domestic con- ments for the dispensing of drugs vary sumption reached a total of 1,856,691,100 according to the list on which a substance liters in 1986, or 213,404,476 liters of ab- appears. Forgery of prescription forms solute alcohol. has been detected. Tobacco production for 1984-1985 was Argentina has a special administration, estimated at 63,220 tons. In 1983 the area the Department of Psychotropic Sub- occupied by tobacco crops was 3.8% of stances and Drugs, which is responsible the total surface devoted to industrial for enforcing the provisions of the 1961 crops and 0.02% of the total agricultural Single Convention on Narcotic Drugs area of the country. The production of and the 1971 Convention on Psychotro- cigars and cigarettes declined in 1980 by pic Substances. 10.1% compared to 1975. Surprise attacks have occurred on mo- Approximately 90% of the production bile units that distribute manufactured of psychoactive medications in Argentina drug products, which are then resold is carried out with imported raw materi- illegally.

98 Bulletin ofPAHO 24(l), 1990 Consumption tional Center for Social Rehabilitation ad- mitted 603 cases (476 males and 127 fe- In 1986, the annual per capita con- males). In the same year the Toxicological sumption of alcoholic beverages for the Care Fund attended 525 outpatient cases population 15 years of age and over was (420 males and 105 females). estimated at 12.8 liters of absolute alco- A research project was carried out in hol, of which 1.3 liters was in distilled 1988 on the nature and magnitude of psy- beverages, 1.3 liters in beer, and 10.2 li- choactive substance abuse cases seen by ters in wine. In that same year the con- hospital emergency services.2 Approxi- sumption of distilled spirits increased by mately 5% of the emergencies seen in a 23%, and that of beer by 27%. one-week period were related to drugs, It is estimated that a third of the coun- and of those, 64% were due to abusive try’s adult population smokes habitually. consumption of alcohol, 20% to the in- Although in recent years the proportion gestion of psychoactive medications, and of smokers has stayed at a constant level, 16% to mixed consumption. a slight reduction in numbers has been There are no beds in general hospitals observed among males, whereas a con- assigned specifically for alcoholic and siderable increase has been detected drug-addicted patients, who are admit- among women. ted to different services depending on the According to data provided by the Ar- particular clinical consequences of their gentine Ministry of Agriculture and Live- drug abuse. Very few cases are attended stock, cigarette sales in 1984 reached by the psychiatric services. 1,772 million packs, while annual per Special mention should be made of a capita consumption was 1,220 cigarettes. study of blood alcohol levels in drivers Per capita consumption has increased by carried out in the Federal Capital in 1978 30% since 1947. by the Institute of Biology and Experi- There is no official information avail- mental Medicine. Blood alcohol levels be- able on the use of psychoactive medica- tween 0.03% and 0.07% represented tions. 14.2% of the sample tested, and levels higher than 0.07% corresponded to 9.1% Health Indicators of the sample. Studies carried out in a hospital in Of the 266 patients hospitalized for im- Buenos Aires in 1985 indicate that the proper use of drugs in the municipal hos- most frequent discharge diagnosis of pa- pitals of the city of Buenos Aires and dis- tients admitted for alcoholism was absti- charged during 1983, 249 cases were nence syndrome (48.8%), followed by a alcohol-related and 17 were associated diagnosis of gastrointestinal hemorrhage with other drugs. Drug-related psychosis (20%).3 Mortality among patients hospi- accounted for 11% of all cases with a dis- talized for diseases associated with exces- charge diagnosis of psychosis. Of pa- sive ingestion of alcohol was 15.4%. In tients discharged with the diagnosis of neurotic personality disorder, 29% of cases were related to abuse of psychoac- 2Hugo A. Miguez and Ricardo W. Grimson, “Con- s&as de urgencia por abuso de sustancias psicoac- tive substances, and 27% to alcohol de- tivas en hospitales de Buenos Aires,” Bol Of Sanit pendence syndrome. Panam 107(4):296-306,1989. Data collected by the National Com- 3H. Rambla and C. Tarasiuk, Diagnbsticos aI egreso de 84 pacientes alcoh6licos internados en el hospi- mission Against Drug Trafficking and tal de San kidro” (Buenos Aires, Mimeographed Drug Abuse indicate that in 1987 the Na- document), 1985.

SpecialReport 99 the same period, overall mortality at the from the Government or international hospital was 11.5%. It was estimated that agencies are trying to develop actions in there is extensive underregistration of al- the area of prevention and treatment. cohol problems as a cause of disease and There are also organizations of parents death. Twenty-five percent of the cases and family members that support and ac- studied had no mention of alcoholism in tively participate in treatment communi- the discharge diagnosis. ties for young addicts. Of the AIDS cases known in 1988, 11 Argentina is a signatory of the Single (6.7%) were intravenous drug addicts, six Convention on Narcotic Drugs of 1961 (3.7%) were bisexual intravenous drug and the Convention on Psychotropic addicts, and one (0.6%) was a homosex- Substances of 1971. Pursuant to these ual intravenous drug addict. Conventions, the Ministry of Health and According to the 1986 report of the Na- Social Action sets standards for the pro- tional Center for Social Rehabilitation,4 duction and marketing of pharmaceutical the use of inhalants appears to be in- products. The National Commission creasing among youth between the ages Against Drug Trafficking and Drug of 12 and 19; another study5 indicated Abuse coordinates all efforts in the cam- that inhalant use began at about age paign against drugs. eight. No specific places are designated for the sale of alcoholic beverages or tobacco, Sociocultural Framework which are sold without restrictions, nor do any provisions control the number of Numerous studies have been carried retail outlets where they may be sold. out on rates of nondrinking and different The legal drinking age is 18. There are no patterns of alcohol consumption. There is regulations governing the advertisement presently a need for more up-to-date and of alcoholic beverages. in-depth studies on attitudes toward drugs in Argentina. Treatment, Rehabilitation, and Information from centralized statistics Social Reintegration from various government security offices indicates that in 1987 a total of 3,839 per- The Ministry of Health and Social sons were arrested for drug-related rea- Action is the institution responsible for sons, of whom 3,389 were males and 450 organizing the treatment of patients with females. Of the total, 10.4% were minors. drug abuse problems. Treatment is financed by the State and Responses to the Improper carried out in public institutions. A por- Use of Drugs tion of the revenues produced from gam- bling is used to finance prevention and Argentina has some private founda- treatment programs. tions that alone or with partial support Many patients with substance abuse problems receive treatment from nonpro- 4V. Otero, et al., “Caracterizaciiin de1 perfil de la fessional organizations of a religious na- demanda y tendencias de1 uso indebido de drogas ture, especially the Andres and the Viaje en 10s Dacientes de1 CENARFSO” Mnistrv of Public fiealth, Buenos Aires, MimeogrAphed dku- de Vuelta (“Return Trip”) Programs, ment), 1986. both patterned on the treatment commu- 5C. Arias, “Observaciones sobre la inhalaci6n de nity models of the UOMO programs in disolventes en menores” (Municipality of San Isi- dro, Centro de Vicente Lbpez, Mimeographed doc- Italy and the DAYTOP programs in the ument), 1986. United States.

100 Bulletinof PAHO24(1), 1990 Although outpatient treatment is avail- also been made by private organizations. able, some approaches used in the pri- Since late 1985, an agreement between vate medical sector involve compulsory three institutions, called the Tripartite hospitalization. To date, no research has Framework Convention, has made it pos- been carried out to determine the relative sible to coordinate research efforts in the effectiveness of the two different treat- area of drug abuse. Current research top- ment modes. ics include drug use among adolescents, Courses designed to combat the smok- detection of families at risk, drug abuse ing habit have been developed and have and the work environment, evaluation of produced promising results. treatment methods, and situations pos- ing relapse risk, among others. Prevention

The primary prevention models that Education and Training have predominated to date are those clas- Based on a study of how the topic of sified by Nowlis as the ethical-legal and drug abuse is currently taught in the medical-health models.6 health, social, and legal science curricula A National Preventive Education Plan in the universities, the suggestion was is in place for the period 1987-1989. Pre- made to strengthen this field of instruc- vention publicity campaigns have also tion at the undergraduate level and to set been designed for television and radio. up a graduate program. The latter initia- tive was begun in late 1986, when an in- Research terdisciplinary specialization program Research is basically financed by the was organized. State, but financial contributions have An agreement was recently signed with the United Nations to train person- 6H. Nowlis, La vet-dad sobre la droga: la droga y la nel in the treatment of drug-dependent educacidn(Paris, UNESCO), 1975. patients.

BOLIVIA

Production and Marketing of ages, and 4,498,600 packs of cigarettes. Psychoactive Substances The psychoactive drugs diazepam, chlordiazepoxide, and phenytoin are The legal psychoactive substances pro- produced domestically. duced in Bolivia are spirits, wines and In addition, there is illegal production fermented beverages, malt beverages, of both alcoholic beverages and drugs potable ethyl alcohol, and tobacco. This (marijuana, cocaine hydrochloride, and production has been increasing consider- cocaine sulfate). It is estimated that the ably each year and is directed almost ex- cultivation and production of coca ap- clusively toward domestic consumption, proximately tripled between 1980 and since exports are not significant. In 1987, 1986. production amounted to 14,905,952 liters Bolivia produces an estimated 765 tons of spirits, 106,002,321 liters of malt bever- of coca paste per year, of which only 400 ages, 2,007,715 liters of fermented bever- to 500 tons are exported. One-third is

SpecialReport 101 transformed into cocaine hydrochloride, proper use of psychoactive substances. A consumed in the country as pitillos. youth survey carried out in 1978 by the The structure of the psychoactive sub- National Bureau for the Control of Dan- stance industry is regulated through li- gerous Substances indicated that 11.2% censing by the Ministry of Industry and of the respondents had tried drugs at one Trade and the Ministry of Social Welfare time or another, and 1.0% admitted to be- and Public Health. Quality and toxicity ing habitual users. A study carried out by control are governed by international ABC Communications in 1986 on a sam- standards. Production is regulated by the ple of 1,219 people between 8 and 25 free market. years of age and one conducted in the The preparation, importation, distribu- same year by the Bolivian Red Cross on tion, and marketing of products that con- 1,536 individuals aged 10 to 25 yielded tain narcotic drugs or psychotropic sub- similar results. The ABC Communica- stances require medical prescription and tions study revealed that the most com- the use of special control forms. To date monly used substances were marijuana no forgeries have been detected. (38.7%) and basic cocaine paste (38.6%), The Bolivian pharmaceutical industry followed by psychoactive drugs (8.8%), does not manufacture narcotic drugs but inhalants (7.5%), and cocaine hydrochlo- imports under regulations set by the ride (6.4%). The Red Cross study found Government. the following percentages of use: mari- Illegal trade in amphetamine drugs juana, 36.3%; cocaine, 8.8%; inhalants, from Brazil has been reported. Also of 6.3%; and gasoline, 6.3%. concern is the discovery of illegal trade in With respect to the age groups at great- pethidine (Demerol), fentanyl, haloperi- est risk of using psychoactive substances, dol, and other medications. research carried out in the Psychiatric Clinic of the City of La Paz between 1981 Consumption and 1984 showed that 83.7% of the alco- holics hospitalized were between 30 and According to data from the Ministry of 59 years of age. On the other hand, the Industry and Trade, 4,498,600 packs of study conducted by ABC Communica- cigarettes were produced in 1987. Do- tions showed that the greatest prevalence mestic consumption was 3,903,225 packs, of psychoactive substance use was in the which means that 87% of the cigarette group aged 20 to 25. Studies done by the production was consumed in the coun- National Institute for Research on Drug try. However, it is suspected that if con- Abuse (INIF) showed that 65% to 70% of traband were considered, the figures for the addicts hospitalized in that institu- domestic consumption would rise. tion were between the ages of 15 and 30. According to estimates made for 1987 Research carried out in Cochabamba be- by the Ministry of Social Welfare and tween 1979 and 1980 revealed that 30% of Public Health, consumption of absolute the respondents over 15 years of age alcohol was approximately 4.3 liters per drank alcohol. The above-mentioned Red capita. This figure did not take into ac- Cross study detected the greatest inci- count home production of chicha (a fer- dence of psychoactive substance use mented maize drink), legal importation among the 16-to-25 age group. This same (which is limited), and contraband research revealed no differences associ- (which is significant). ated with social stratum. Several studies have been carried out Large quantities of psychotropic medi- to estimate the prevalence of the im- cations are smuggled into the country

102 Bulletin ofPAHO 24(Z), 1990 from Brazil (amphetamines), Peru (pro- tion was the second most common cause poxyphene), and Chile (pethidine and of traffic accidents, being involved in fentanyl). Consequently, it is not possible 12.7%. The figure increased to 18.6% in to accurately estimate their consumption. 1986. The effects of drug abuse on the labor sector are difficult to gauge. A follow-up Health Indicators study carried out by the Department of Hygiene and Industrial Safety in three A study done in 1985 by the Psychiatric factories in La Paz found that 7.3% of the Clinic of the National Health Fund in La absenteeism in the first two days of the Paz revealed that 251(26%) of 953 hospi- work week and 1.2% of the work-related talizations were for alcohol problems. Of accidents were directly related to the con- the 251 cases, 223 were males (88.8%) sumption of alcohol. and 28 were females (11.2%). In this same study 4,541 records of outpatient Sociocultural Framework consultations were examined. Of these, 341 were for alcohol-related problems A growing acceptance of alcohol con- (7.5%) and 21 for the use of other drugs sumption has been observed, although (0.5%). These findings seem to indicate consumption patterns vary in different that patients with drug dependency social groups. In the Andean rural area, problems make more use of hospitaliza- women’s participation in drinking alco- tion than of outpatient consultation. hol during civic and religious activities is Data are also available from the INIF, accepted. Among the marginal urban which in its 12 years of activity has in- groups, persons who drink to excess are creased its outpatient coverage and pro- rejected. Men drink heavily, particularly gressively reduced hospitalization. Most with friends on weekends, and becoming voluntarily hospitalized patients are intoxicated is accepted. Other, more re- males, and the unemployed predomi- cent consumption patterns include the nate. According to this same source, a use of alcohol in combination with co- change has been observed in the propor- caine and other drugs in the 15-to-30 age tions of patients treated for addiction to group. various substances. In the first five years The relationship between the abuse of (1976-1980), alcoholism represented psychoactive substances and delin- 38.8% of the demand; multiple drug quency appears to be quite significant; abuse, 25%; and cocaine, 10%. In the fol- however, no systematized information lowing five years (1981-1985), multiple is available in this respect. The same is drug abuse accounted for 40%; alcohol- true for drug abuse among the prison ism, 27%; and cocaine dependence, 20% population. (an increase of 100%). The 1986 and 1987 data continue to reveal a rise in the de- Responses to the Improper mand for treatment by cocaine users Use of Drugs (33%), whereas alcoholism treatment has been relegated to third place. The community makes use of public Little information is available on the re- and private institutions that provide pre- lationship between traffic accidents and vention, treatment, and rehabilitation the use of alcohol and other drugs. Ac- services. Currently there are approxi- cording to statistics collected by the La mately 20 institutions that treat drug ad- Paz Traffic Department, in 1980 intoxica- dicts, concentrated mostly in La Paz,

SpecialReport 103 Santa Cruz, Cochabamba, and Tarija. Social Welfare and Public Health and the Emphasis is placed on rehabilitation. Ministry of Education. The programs are In a survey carried out among health aimed at the entire population, with spe- professionals, 60% of the respondents cial emphasis on the groups at greatest believed that alcohol and drug abuse was risk. Preventive education is provided in a disease and that drug addiction was the schools. Campaigns are carried out more difficult to treat and had worse con- by State and private institutions. To date sequences than alcoholism. Of the re- no evaluations have been made to deter- mainder, 25% considered drug abuse to mine the impact of these plans. be both a disease and a social problem, and 15% considered it to be a vice that warranted punishment. Research d The Government of Bolivia has under- taken a campaign against drug trafficking Financing for research comes almost as a major national priority, working entirely from international agencies. through the National Council for the Pre- There is no national institution responsi- vention of Drug Addiction (CONAPRE), ble for guiding and supervising the re- formed by four ministries, and the Na- search, but the recently established tional Council Against the Improper Use CONAPRE could assume that role. and Illegal Traffic of Drugs. The latter agency defines overall policies; however, the country does not have sufficient re- Education and Training sources to carry them out. Bilateral agreements have been drawn The principal health education institu- up with the United States that have tion is the National Medical Residency strengthened actions against drug traf- System in the Graduate School of the ficking. Universidad Boliviana, which has been training psychiatrists since 1985. All the Prevention health science departments include drug abuse education in their undergraduate The prevention strategies adopted by programs, but they fail to give it suffi- Bolivia are coordinated by the Ministry of cient emphasis.

BRAZIL

Production and Marketing of million bottles of other beverages (wine, Psychoactive Substances whiskey, cognac, vodka, etc.). In 1980 the absolute alcohol content of distilled bev- The alcohol and tobacco products con- erages was 450 million liters. sumed in Brazil are produced entirely The alcoholic beverage industry was in the country. Most psychoactive medi- the fifth fastest growing industry in the cations are made with imported raw country in 1985 (among 25 manufactur- materials. ing companies), and the drug industry In 1984 the legal production of alcoholic was the sixth. beverages was 1,000 million liters of ~JZ- The production of psychoactive drugs chaca, 2,000 million liters of beer, and 400 is regulated by the free market and there

104 Bulletin of PAHO 24(I), 1990 is no State monopoly. Their manufacture, PauIo, Salvador, and P&to AIegre on a marketing, and distribution are subject to sample of 120 young people who lived on control by the National Health Surveil- the street confirmed that drug use among lance Unit, Drug Division, in the Minis- that population had reached alarming try of Health. No information is available proportions. Significant percentages of concerning the diversion of medications these youngsters, between 7 and 17 years into illicit channels. of age, said they had used the foollowing The Drug Division in the Ministry of substances in the past month: tobacco, Health reported that 228 products con- 86%; alcohol, 51%; marijuana, 44%; taining benzodiazepine were marketed in cocaine, 11%; and inhalants, 56%. In ad- the country in 1983. dition, 17% admitted to having used The dispensing of psychoactive drugs Artane (trihexyphenidyl), an anti- is governed by the provisions of the Sin- chohnergic, and 8%, diazepam. gle Convention on Narcotic Drugs of It is interesting to compare the above 1961 and the Convention on Psychotro- figures with those of another study car- pic Substances of 1971. Consequently, ried out in the same year. In a sample of some drugs require a regular doctor’s 20,000primary and secondary school stu- prescription and others require special dents from 10 to 17 years of age in eight prescription forms. Forgery of prescrip- cities, the study found that 76% had used tions and prescription forms has been alcohol on some occasion or another; detected. 58% had used it in the past year (62% of Despite legal regulations governing the males and 55% of females), and 31% in sale of psychoactive medications, these the last month. Tobacco was used in the substances are frequently sold without last year by 16%, marijuana by 1.6%, in- medical prescription. It is common for halants by 9.5%, cocaine by 0.4%, anxy- pharmacy salespeople to be consulted by olitics by 3.5%, hypnotics by 2%, and customers and to prescribe these drugs barbiturates by 1.7%. Another alarming for them. piece of information obtained from this study was that 5% of the students said Consumption they had consumed alcohol on 20 or more days during the last month. Information from 1981 published by the press revealed that the consumption Health Indicators of all alcoholic beverages amounted to 9.1 liters of absolute alcohol per capita per Two studies carried out in low- year. The consumption of cigarettes in socioeconomic-class neighborhoods, the the second haIf of 1986 was estimated at first in 1965 and the second in 1974, 63 packs per year for each individual over found that 6% of the persons in the sam- 15 years of age. In regard to psychotropic ple were “pathological drinkers.” In ad- drugs, data published in 1980 (Pharma- ditional research in a marginal area of the ceuticaZ Market of Brad) estimated that city of Salvador, an alcoholism rate of 17% of Brazilian medical prescriptions 22.6% was discovered. Regarding the use were for psychotropic substances. No of other psychoactive substances, a 1987 data are available on consumption. study done in psychiatric hospitals Patterns of alcohol consumption in Bra- throughout the country indicated that zilian society vary widely and cannot eas- 30% of the hospitalizations for drug de- ily be generalized. pendence were for the use of Cannabis, A study carried out in 1987 in SZo 24% for unspecified drugs, 16% for

SpecialReport 105 cocaine, and 12% for drug-related alcohol to persons under 18 years of age. disorders. The consumption of alcohol during Examination of the relationship be- working hours is also penalized. There is tween alcohol consumption and traffic no public-health-based legislation gov- accidents over a lo-year period (1966 erning the production, importation, and 1975) has revealed that 25% of the drivers export of alcohol, nor are there any regu- involved in accidents had some degree of lations governing the availability of alco- alcoholemia, and in 18% of the accidents hol or its advertising. studied that level reached more than 80 No regulations exist with regard to the mgldl. sale of tobacco. There is a law that pro- Data from the Ministry of Health indi- hibits smoking in some public places, but cate that of the total number of AIDS compliance with its provisions is mini- cases reported up to March 1988 (2,956), mal. Legislation to regulate the advertis- 16.7% (495) had acquired the disease ing of tobacco is pending. through blood, and of these, 39.4% (195) Brazil is a signatory of the international were intravenous drug users. conventions of 1961 and 1971, and conse- quently legal provisions are in force that Responses to the Improper cover the dispensing of psychoactive Use of Drugs medications. Brazil does not have a tradition of orga- Treatment, Rehabilitation, and nized social movements in the area of Social Reintegration drug addiction. Local initiatives, in the form of information campaigns, are just In Brazil no national governmental in- beginning to take shape in the schools in stitution is responsible for addressing the the large cities. problem of drug abuse. People in the Health professionals, at least formally, high-income groups go to private clinics, consider that drug abuse is a disease. and those in low-income brackets seek Some professional organizations, such as care from the public psychiatric services. the Brazilian Association for Studies on At the present time, the centers provid- Alcohol and Alcoholism and the Brazilian ing these services are not systematically Society of Psychobiology, promote re- coordinated. search in this field. At the present time A national alcoholism program has there is no formal communication be- been set up to establish a country-wide tween these organizations and the policy on the treatment and rehabilitation Government. of alcoholics. For the most part, the National legislation has been enacted health professionals responsible for these to regulate the production, trafficking, patients are psychiatrists. General clini- and use of drugs; sentences of up to 15 cians, psychologists, and social workers years in prison are imposed for traffick- also help provide treatment for drug ad- ing. There are also a number of Ministry dicts. No particular treatment approach of Health regulations that control the sale predominates. of drugs containing psychoactive sub- stances. National directives in the area of Prevention drug abuse are established by the Federal Narcotics Council, which is under the au- No national primary prevention pro- thority of the Ministry of Justice. gram exists in the country. A national Legislation exists to prohibit the sale of prevention campaign is currently being

106 Bulletin ofPAHO 24(l), 1990 conducted in the schools with United Na- mals to validation of international tions funds, but its effects have not yet clinical-investigative instruments. There been evaluated. is some collaboration with international centers, but no single institution regu- Research lates or supervises the research. State or federal agencies provide the Education and Training basic mechanism for the financing of re- search. Important prior research has fo- No educational institutions offer spe- cused on the psychopharmacology of cial training for professionals in the area Cannabis safiva and basic and clinical in- of drug abuse. Physicians, who are the formation on alcoholism. principal health professionals involved in New trends in the epidemiologic study treating this problem, do not have access of drug consumption in young people to specific courses at the undergraduate have recently begun to emerge. A variety or graduate level. However, such courses of approaches have been used for this are offered by several professional associ- purpose, ranging from research on ani- ations, which also organize congresses.

CHILE

Production and Marketing of vary. In 1982, approximately US$14 mil- Psychoactive Substances lion was spent for this purpose, with 70% of that amount directed toward television The only psychoactive substances pro- advertising. duced in Chile are alcoholic beverages Tobacco plantations cover a surface and tobacco. The raw materials for all area of 2,500 ha. Most of the production psychoactive medications used in the is consumed domestically, and 15% is ex- country must be imported. ported to the United States. Vineyards account for 1.2% (100,000 The Government controls tobacco pro- ha) of the total cultivated area. Eighty- duction. Eight billion cigarettes are pro- five percent of vineyard production goes duced a year, accounting for 2% of the toward the manufacture of alcohol- gross national product. The expenditure mainly wine-and the remainder for ta- on advertising of tobacco products be- ble grapes for domestic consumption and tween June 1984 and July 1985 was export. In 1980 annual production was US$1.5 million, most of which was used 500-600 million liters of wine and chicha, for television commercials. 200-250 million liters of beer, and 15-20 The Institute of Public Health regulates million liters of distilled beverages. In ad- the importation of psychoactive sub- dition, one million liters of wine and stances. Sale of these products to the chicha, 280,000 liters of beer, and seven public requires “prescription checks” or million liters of distilled beverages were “medical prescriptions on file,” which imported. Wine exports for this same are registered in accordance with the Sin- year reached 18 million liters. gle Convention on Narcotic Drugs of The marketing of alcohol is unre- 1961. So far, benzodiazepines are not stricted. Expenditures on advertising included on any of the lists of specially

SpecialReport 107 controlled drugs, and as a result they Marijuana (Cannabis) is easy to obtain are dispensed with routine medical because hemp is an industrial fiber and is prescriptions. grown extensively in the country. Al- Psychotropic medications, particularly though its cultivation is controlled, thefts amphetamines, anorexigenics, and ben- and clandestine production occur. It is es- zodiazepines, are sometimes diverted to timated that between 40% and 50% of ad- illegal use through the forgery of pre- olescents have smoked marijuana at one scription forms and, on some occasions, time or another, and it is probably used by improper issue of prescriptions by regularly (more than once a week) by 5% physicians. of young people between 12 and 19 years of age, regardless of socioeconomic level. Inhalable solvents are also easy to ob- Consumption tain, especially domestic products such as glue. An estimated 3% to 5% of chil- Seventy percent of the population of dren between 8 and 15 years of age at the the country drinks alcohol. Per capita an- lower, marginalized socioeconomic levels nual consumption is estimated at approx- inhale these substances. imately 40 to 50 liters of wine, 15 liters of Three years ago cocaine was eliminated beer, and one liter of spirits, which from the national drug register, so it is amounts to six or eight liters of absolute now used only illegally. In the northern alcohol. These figures increase by 50% if part of the country, cocaine free base (sul- the population under 15 years of age and fate) is used. It is estimated that 30% of abstainers are excluded, and by another the adults have tried this substance at 20% if clandestine production is taken one time or another. Regular users consti- into account. tute 3% of the urban population in these The rate of alcoholism ranges between areas; they are usually young and 15% and 35% for males and between 0% middle-aged adults from the middle and and 4% for females. upper socioeconomic levels. It is estimated that almost 50% of the Amphetamines and anorexigenics are adult population (over 15 years of age) often obtained illegally. It is probable that smokes cigarettes. Men smoke more than between 3% and 5% of the population 12 women, and there is a direct association to 19 years of age from all socioeconomic between the smoking habit and educa- levels makes some use of these drugs tion level. Annual gross consumption per without proper medical prescription. capita ranges between 600 and 900 ciga- This use is much more prevalent in the rettes. If this figure is corrected to include northern area of the country because of only the adult population and only the the ease with which drugs can be ob- half that smokes, the resulting figures tained from Peru. show that smokers consume six to nine Insufficient control and low cost facili- cigarettes a day. tate the abuse of these drugs. In most According to various studies carried cases they are probably used to calm anx- out in recent years, the psychotropic iety. The abuse of such substances, espe- drugs abused in Chile-mainly by adoles- cially diazepam and flunitrazepam, is cents-are marijuana, volatile solvents, known to occur among adolescents, and cocaine, and certain psychoactive medi- it is estimated that 1% to 2% of the popu- cations (stimulants, amphetamines, ano- lation between 12 and 19 years of age rexigenics, and some of the benzo- uses them for nonmedical purposes. diazepines). They are frequently used in combination

108 Bulletin of PAHO 24(Z), 1990 with other drugs, particularly alcohol cohol in their blood was 48.6% (365 out of and tobacco. 751). Of the 862 suicides recorded during this period, 38.6% were alcohol-related. Health Indicators Sociocultural Framework The various state psychiatric care ser- vices are requested by the courts to deter- In general, the population has a per- mine whether the young people whose missive attitude toward drinking, espe- cases are referred to these services are ad- cially by men. In the low socioeconomic dicted to drugs. This work accounted for strata drunkenness is tolerated and approximately 3% of psychiatric consul- drinking begins at an early age. The situ- tations in 1987. ation is similar with regard to smoking, Although no data from a national prev- which begins during adolescence and alence study are available, consumption increases with age, especially among levels of the principal illegal substances women. are believed to be relatively low, except With regard to psychoactive drugs, possibly in the northern area of the coun- there is a certain indifference toward try, where there is known use of cocaine. marijuana use, but inhalation of volatile For example, between January and Au- solvents and stimulant use cause great gust 1988, 2.5% of the discharge diagno- concern. ses in the psychiatric department of the local hospital in the city of Iquique were Responses to the Improper related to the abuse of cocaine free base. Use of Drugs Data are available from the emergency services on withdrawal symptoms, se- Community response is highly varied vere intoxication, and blood alcohol lev- but is generally directed toward protect- els in drivers involved in traffic accidents. ing the community from the violence The number of drivers arrested for drunk associated with drug abuse. Religious driving declined from 5,400 in 1983 to an organizations, with some professional as- average of 2,900 in 1986 and 1987, a drop sistance, have set up centers for the treat- of 46%. ment and guidance of drug addicts. Of 100 cases of AIDS reported, two All university programs in the health were associated with intravenous drug sciences include courses on alcoholism in use, with infection having occurred their undergraduate curricula; however, abroad. they are insufficient on that subject and, Alcoholism accounts for 4.5% of the moreover, do not include instruction hospital discharges in the country. If about other psychoactive substances. multiple associated diseases were in- The Center for Alcoholism Studies cluded, this figure would rise to 38% of (CEA) and the Ibero-American Associa- all hospitalizations. Likewise, alcoholism tion for the Study of Alcohol Problems is responsible for only 7% of all deaths if (AlEPA) have developed plans for both it is considered as the principal diagno- treatment and academic programs. sis, but for 53% of deaths if all the associ- Chile is a signatory of all the United ated pathologies are taken into account. Nations conventions on the trafficking The association between violent deaths and improper use of drugs. Regulations and alcohol use is significant. Of all limit the places and hours of sale of alco- homicides recorded between 1981 and hol and set the minimum drinking age at 1983, the proportion of persons with al- 21 years. Tobacco is sold practically with-

SpecialReport 109 out restriction, but advertising is cur- has been very extensive in the last 10 rently regulated. The sale of glue contain- years, thanks to the impetus of certain ing organic solvents to persons under 15 national and foreign university institu- years of age is prohibited. tions. The greatest problem with these studies has been the differences in the Treatment, Rehabilitation, and parameters employed, which make com- Social Reintegration parison difficult. Clinical research has been focused mainly on the application Both governmental and nongovern- of self-administered scales (CAGE, mental institutions are involved in these MAST, etc.). activities. Interesting initiatives have been undertaken in various regions of Education and Training the country; however, the problem has not been clearly confronted by means of In view of the existing educational ini- prevention efforts. tiatives, such as the training for general practitioners offered by the Ministry of Research Health and some of the graduate-level programs available in universities, the Epidemiologic research on the use of principal problem is lack of coordination alcohol, tobacco, and other substances between these institutions.

Production and Marketing of these kinds of products to the public is Psychoactive Substances regulated. According to information from the In 1987, 120 million bottles of aguar- Mental Health Section of the Antioquia diente, 30 million bottles of other liquors, Department of Health, illicit dispensing and 1.6 billion bottles of beer were pro- of psychoactive medications occurs only duced in Colombia. No clandestine pro- through contraband from other coun- duction of alcoholic beverages has been tries. reported. The production, distribution, and con- Consumption sumption of psychoactive medications is strictly monitored by the Drug Review Tranquilizers, alcohol, and tobacco are Commission. The list of controlled sub- the three substances whose consumption stances includes narcotic drugs, special is socially accepted. In a study carried out analgesics, barbiturates, amphetamines, in 1987 (Torres de Galvis and Murrelle- anorexigenics and similar drugs, tran- see pp. 12-21), the following prevalences quilizers, and nonbarbituric hypnotics. of consumption per 1,000 population By law, only the Ministry of Health’s were found for these three substances: Revolving Narcotic Drug Fund is em- alcohol, 560; tobacco, 297; and tranquiliz- powered to carry out or authorize the im- ers, 60. Marijuana continues to rank first portation of drugs and remedies. This among illegal substances, with consump- legislation also extends to wholesale dis- tion rates of 19 per 1,000 among men and tributors and retailers. Likewise, sale of 3 per 1,000 among women. Cocaine has

110 Bulletinof PMO24(1), 1990 been displaced by basuca (cocaine paste), “social drinking.” The use of tranquiliz- which is used by 3.3 times as many men ers is also socially accepted. People who as women. smoke in closed spaces are beginning to It is estimated that in urban areas face censure. 81,000 persons consume basuca, of Most of the population opposes the un- whom 19,000 are women, most of them restricted sale of dependency-producing of reproductive age. Marijuana is used by substances. Only 4% of Colombians are about 137,000 people in urban areas, and in favor of the legal sale of marijuana, another 31,000 use cocaine. Alcoholic and 2.5%, of basuca and cocaine. beverages are consumed by over 1,400,OOO women and by a total of more Responses to the Improper than 7,000,OOOindividuals. Alcoholism is Use of Drugs believed to affect about 104 per 1,000 men and 8 per 1,000 women. Steps have been taken recently to es- In terms of high-risk groups, males are tablish foundations and corporations, more likely than females to use psychoac- such as the Colombian Corporation tive substances, with the exception of Against Alcoholism and Drug Abuse tranquilizers. In men, the age group at (SURGIR). That organization began in greatest risk consists of those between 20 Medellfn and has now expanded to other and 24 years of age, and for women those cities. between 16 and 19. The highest preva- In Bogotd there are four Alcoholics lences of cocaine and marijuana use are Anonymous centers that provide advi- found among men in the upper socioeco- sory services and work in prevention, in- nomic classes. The greatest consumption tervention, and treatment of alcoholism of basuca is found among the lower through self-help groups. classes. In a survey conducted among physi- cians in some of the cities in the country, Health Indicators 57% responded that drug abuse was a vice, 20% said that it was a disease, and Of all psychiatric consultations, 0.43% the remainder responded equivocally. are related to alcohol and drug use, Alcoholism was considered to be a vice No precise information is available re- “of social origin’ by 38% of the physi- garding the percentage of the 5,605 psy- cians surveyed, and 51% described it as a chiatric beds in the country that are set disease. aside for the treatment of drug addicts. There does not appear to be any profes- A noteworthy phenomenon is the sional association concerned with drug strong association between the use of abuse. Various professional groups have psychoactive substances and attempted focused attention on the problem, and in suicide, especially among women. The some cases they are able to influence po- strongest correlation is between basuca litical decisions. use and suicide. A law passed in 1986 (Law 30) estab- lished a National Plan for the Prevention Sociocultural Framework and Treatment of Drug Abuse and the Rehabilitation of Drug Abusers. Control Legal drugs are accepted by the com- measures related to alcoholic beverages munity from the standpoint of both mar- and cigarettes are provided in several keting and consumption. There is social laws. rejection of drinking to excess but not of Colombia is a signatory of the 1961 Sin-

SpecialReport 111 gle Convention on Narcotic Drugs, the Research 1971 Convention on Psychotropic Sub- stances, and the South American Agree- The University of Antioquia, through ment on Narcotic Drugs and Psychotro- the National School of Public Health, has pic Substances. It has also established been the principal institution conducting bilateral agreements with neighboring research on the epidemiology of alcohol- countries. ism and drug abuse. The School of Medi- cine of that university is conducting im- Treatment, Rehabilitation, and portant clinical research on the effects of Social Reintegration basuca use. Del Valle University, the Mental Hospi- The Ministry of Health is responsible tal of Antioquia, the Ministry of Health, for carrying out the National Plan the Departments of Health of Antioquia through 14 State drug abuse and alcohol- and Caldas, and the Ministry of Educa- ism services, which operate in hospitals. tion have carried out research in the field There are eight associated private insti- of drug addiction. tutions and many other independent ones that provide prevention, treatment, Education and Training and rehabilitation services. The social se- curity system also provides treatment The Ministry of Public Health provides services for alcoholism and drug abuse. seminars and courses on various drug- related topics for groups of health pro- Prevention fessionals. The Mental Hospital of Antioquia gives courses in which multi- The Family Welfare Institute provides disciplinary teams are trained to provide prevention training for educators. The treatment. It has also held national work- Ministry of Education offers seminars to shops on the use of clinical instruments professors on primary prevention of alco- applied to the study of alcoholism and holism and drug abuse. Efforts are also drug abuse. The National School of Pub- being made to educate parents and com- lic Health in Medellfn offers a course on munity leaders so that they will be able to epidemiologic study of drug abuse, collaborate in prevention activities. In ad- which is designed to train investigators dition, a directory exists of organizations in this area. However, most of the health involved in prevention efforts and treat- sciences schools do not adequately train ment and rehabilitation of alcoholics and professionals to deal with this serious drug abusers. problem.

COSTA RICA

Production and Marketing of gin), and “fine” liquors (whiskey and Psychoactive Substances cordials). The fermented beverages in- clude beer and wine. Both distilled and fermented alcoholic The production of standard liquors be- beverages are produced in Costa Rica. gan to increase in 1971, and that of fine The former include aguardiente (called liquors in 1986. The largest production of guaro), standard liquors (rum, vodka, distilled beverages-11,551,390 liters-

112 Bulletin ofPAHO24(1), 1990 occurred in 1984, and the largest produc- absolute alcohol in the population over tion of beer was in 1987, with a total of 15 years of age has been stable, despite 211,301,700 bottles. an increase of 57.5% in the consumption Up to 1986 between three and five mil- of beer for the period 1980-1987. No in- lion liters of distilled liquors were im- formation is available with respect to to- ported annually. That figure has since de- bacco use. Warehouse dispatching clined to an average of one million liters. records from the Costa Rican Social Secu- With regard to clandestine liquor produc- rity Fund (CCSS) and information re- tion (chirrik or pm), a total of 1,992 garding the importation of diazepam stills were discovered between 1973 and clearly point toward the increased use of 1977, and 1,175,225 liters of these liquors psychotropic drugs in the past year. were confiscated. In 1987 the Institute on Alcoholism and Several laws levy taxes on alcoholic Drug Dependence (IAFA) carried out a beverages, but their purpose is to in- drug use prevalence study based on a crease revenue rather than to help pre- sample of 2,083 subjects. Of the popula- vent alcoholism. tion studied, 3.5% had used illegal drugs In the period 1984-1985,2.3 million kg at least once in their lives; 37.6% of those of cigarette tobacco were produced, who had used drugs used them regu- which represented an increase of 24% larly, and 20% almost daily. The sub- with respect to the previous biennium. In stance most frequently consumed was 1983, 181,845 kg were imported, 98% in marijuana (by 91.4% of the drug users), the form of raw tobacco. followed by solvents, tranquilizers, and Hypnotic, barbiturate, and anxiolytic hallucinogens (8.5% each), and cocaine drugs are produced in Costa Rica, and (5.7%). their production and importation are reg- Seventy-three percent of the popula- ulated by the Government. No data are tion that used illegal drugs also used to- available on the illegal or clandestine pro- bacco, and 81% used alcohol. Of the non- duction or importation of psychoactive consumers of illegal substances, 19.9% drugs. Dispensing requirements include used tobacco and 34.2% alcohol. Fifty- the presentation of a medical prescrip- eight percent of the users were between tion; the registration of physicians, den- the ages of 20 and 29, making this the age tists, and veterinarians authorized to pre- group at greatest risk. Another IAFA scribe such drugs; and the use of official study found that 12% of children and prescription stub books. Extensive legis- young people 7 to 18 years of age in a lation is in force regulating the places marginal population inhaled industrial where psychoactive drugs may be sold. glue fumes. They began this practice at Some cases of counterfeit or altered pre- about 10 years of age and often went on scriptions have been detected. to use marijuana.

Consumption Health Indicators

Information on the per capita con- The IAFA maintains records of the sumption of absolute alcohol, by type of number of persons who request treat- beverage, indicated that in 1987 beer was ment for alcoholism and drug abuse, par- the product most commonly consumed ticularly in the Alcoholic Rehabilitation (1.7 liters), followed by aguardiente and Center and outpatient service. The standard liquors (1.2 liters). CCSS, the institution responsible for Since 1980, per capita consumption of hospital and outpatient clinical services

SpecialReport 113 throughout the country, does not main- be made with regard to attitudes toward tain a specific register of these cases. alcohol use: (1) there is no specific way to The Alcoholic Rehabilitation Center re- categorize the excessive drinker, since the ported a total of 1,737 discharges during term “alcoholic” is reserved for individ- 1987; the average number of days of hos- uals who suffer from the ultimate conse- pitalization was 12.8. Of these patients, quences of the disease; (2) a certain de- 34.1% were between 35 and 44 years of gree of social permissiveness exists with age and 62.5% were between 35 and 54. regard to intoxication; and (3) recognition In 1986, a total of 2,166 discharges follow- of alcoholism as a disease has been slow ing a diagnosis of alcoholism were re- to happen because the concept of vice corded by the CCSS, representing 0.7% (abuse) is tied to the disease (depen- of all discharges. Of these patients, 1,250 dency) in Costa Rican thought. had a diagnosis of alcohol-dependence Most habitual drug users come from syndrome, 302 suffered from alcoholic broken or dysfunctional families and live psychosis, and 247 had alcoholic cirrhosis in marginal socioeconomic conditions of the liver. that often lead them to abandon their CCSS data for the same year indicate homes. However, inveterate users, who 130 discharges following a diagnosis of may also be drug dealers, may find sup- drug addiction, of which 50 had pre- port in their families and even receive sented psychosis, 45 abuse without de- help in preparing marijuana cigarettes pendence, and 35 physical dependence from family members who do not use the on drugs. drug themselves. It appears that the Of a total of 927,644 emergency consul- Costa Rican family does not significantly tations in 1987, 120,594 (13.0%) were re- influence its members not to use drugs. lated to problems secondary to the con- The media have undertaken informa- sumption of alcoholic beverages. In the tion campaigns on drug trafficking, a period 1981-1987, 119,435 traffic acci- problem that has affected the country in dents were recorded, of which 6,003 (5%) recent years. The public openly con- were associated with drunken driving. It demns the illegal traffic, marketing, and is estimated that 30% of absenteeism and distribution of drugs. workplace accidents are caused by alco- holism. Responses to the Improper The death rate from alcoholism in 1986 Use of Drugs was 4.7 per 1,000 population, the highest in the decade. Deaths from homicide and As part of its prevention program, the suicide have increased during the 198Os, IAFA maintains an activity called “Com- but not enough information is available munity Organization and Promotion,” to establish a correlation with the use of aimed at organizing youth and adult drugs and alcohol. groups. Under the direction of a primary health worker, these groups prepare Sociocultural Framework and develop prevention activities and projects designed to channel detected The attitude of the Costa Rican people drug users toward the community health toward the marketing of legal drugs is, in infrastructure or the IAFA itself. general, one of acceptance. The sale of Health professionals view the drug illegal drugs is unconditionally con- problem with great concern, but they re- demned. quire more training in this area. While The following three observations can alcoholism and drug abuse are intellectu-

114 Bdetin of PAHO 24(l), 1990 ally regarded as diseases, the attitude develop programs for treatment, rehabili- manifested toward patients is one of re- tation, and social reintegration. In addi- jection. Various organizations and insti- tion, many communities have organized tutions carry out scientific forums, semi- care systems, some supervised and sub- nars, round tables, and conferences on sidized by the JAFA and others receiving the topic. The IAFA offers training only advisory services and authorization. courses for medical and paramedical pro- The Salvation Army, a private transna- fessionals, and a division has been estab- tional organization, has treatment cen- lished with this objective in mind. ters in various localities in the country. A great deal of anti-drug abuse legisla- Alcoholics Anonymous groups also exist tive action has been achieved. Coordinat- in almost all the cities and play an impor- ing entities have been established at the tant role in the recovery process. highest level, and the IAFA has been In addition to the infrastructure de- granted the power and responsibility of scribed above, some drug addicts receive standardizing, regulating, and coordinat- treatment through Hogares CREA, a net- ing activities related to the country’s alco- work specifically concerned with the re- hol and drug problems. The treatment of habilitation of male addicts, and the Re- patients is carried out mainly by the fugio de la Esperanza. The latter, which is IAFA, working jointly with the CCSS. run by the Salvation Army, was initially Extensive regulation governs the sale created for the treatment of alcoholics but of alcoholic beverages, and in recent is now devoted to the treatment of drug years some measures have been intro- addicts. duced to control cigarette sales and smoking in public places. Research A National Commission on Drug Traf- ficking was recently established to carry Research on drug abuse in Costa Rica is out research on all matters related to this relatively recent and has been geared to problem. the needs of the agencies conducting it. Finally, the National Drug Council In recent years, the IAFA has participated (CONADRO) is made up of the Minis- in some international research efforts ties of Health, Education, Labor, Gov- sponsored by WHO, such as early identi- ernment, Justice, and Security, together fication and treatment of alcoholics, the with the IAFA. Its objective is to provide communications media and health pro- the nation with a common, systematic, motion, and adaptation of clinical instru- and coherent approach to prevention, ments (ASI, MAST, CAGE) to the Costa education, research, control, treatment, Rican setting. No governmental institu- and rehabilitation. The IAFA has pre- tion finances research. The IAFA is by sented CONADRO with a National Inte- law the agency responsible for guiding gration Plan on Drug Abuse as a re- and supervising studies in the area of al- sponse to the problem. coholism and drug abuse.

Treatment, Rehabilitation, Education and Training and Social Reintegration The formal training offered by the uni- The CCSS and the IAFA have clinics versities to future health professionals is and hospitals for the treatment of alco- inadequate on the topic of drug addic- holics and drug addicts. The IAFA is, tion. Since 1984 the IAFA has been giving funded directly by the Government to intensive courses in the Schools of Medi-

SpecialReport 115 tine, Psychology, Social Work, Nursing, In Costa Rica, physicians are not the and Education on alcohol and alcohol- principal health professionals that see ism, and more recently, on drug abuse. persons with drug problems. Efforts In addition, it offers seminars, confer- have been made to ensure that all the ences, and short courses to staff in the professionals in the social service area re- National Health System and to the minis- ceive basic training and to provide a bal- tries and private institutions upon re- anced response to needs. The IAFA quest. In coordination with the Ministry health promoters provide community of Education, trained staff of the IAFA act education and organize groups that carry as advisors and consultants for Costa Ri- out primary prevention projects and can educators in this area. activities.

ECUADOR

Production and Marketing of for the dispensing of narcotics, but not Psychoactive Substances for other psychotropic drugs. Alcohol and tobacco are produced in Consumption Ecuador, but there is no production of psychoactive medications. However, the In 1985 a national survey on the preva- preparation of cocaine free base and co- lence of alcoholism revealed that the per caine hydrochloride has recently gained capita consumption of absolute alcohol importance. among the general population of Ecuador In 1982, 1,880 million cigarettes were was approximately 3.2 liters per year. produced, the equivalent of 94 million This figure rose to 13.9 liters for alco- packs. Alcohol production in 1987 was 70 holics. The study also showed that million liters, of which a portion was ex- “pathological drinking” was associated ported to the Andean region. It is esti- with the wine-producing areas (15 liters mated that the clandestine production per capita and 10% alcoholism in the of alcohol, which is destined almost ex- mountainous regions, as compared with clusively for domestic consumption, is seven liters and l%, respectively, in the three times the volume of controlled eastern portion of the country). The high- production. est rate of alcoholism was found among Practically all psychoactive medications persons 35 to 45 years of age. The male to are imported, either as raw materials for female ratio for this pathology was 9 to 1. subsequent manufacture and packaging The proportion of nondrinkers in the (in laboratories regulated by the Institute country was 23.6%, and they were pre- of Hygiene) or as final products, in accor- dominantly women. dance with international agreements. According to a 1984 survey of school- The only product whose clandestine man- children undertaken by the Office of the ufacture has been reported is methadone. Attorney General, 50% of the students Between 1985 and 1988 the production used alcohol or tobacco. Most began be- of cocaine hydrochloride ranged from 300 tween the ages of 13 and 16, but 20% to 1,000 kg. of the sample had started before the age Special prescription forms are required of 12.

116 Bulletin of PAHO24(1), 1990 A series of investigations carried out by although some control mechanisms have the Mental Health Division between 1979 recently been initiated. There is a dis- and 1984 revealed shifts in the rate of tressing failure to enforce the use of med- consumption of illegal substances among ical prescriptions for psychotropic drugs. students in Quito. In 1979, 13.1% of the respondents admitted having used drugs; in 1982 this figure rose to 16.1%, Responses to the Improper but in 1984 the overall prevalence of con- Use of Drugs sumption declined to 11%. Numerous types of support groups ex- ist within the community. Some have a Health Indicators religious affiliation and others are simply community groups or part of an interna- In 1987, in all the centers where treat- tional network, such as Alcoholics Anon- ment is provided for addicts, 1,259 pa- ymous. tients were treated for drug abuse, of The concept of alcoholism as a disease whom 34.8% used Cannabis, 40.8% co- has gained ground among health profes- caine and its derivatives, 1.7% psychotro- sionals, and this topic is included in their pic medications, and 1.5% inhalants. The university studies. There are some scien- substance of abuse was not known for tific organizations concerned about the 21.1%. There are no statistics on treat- problem, but they have no real involve- ment given to drug addicts in emergency ment in the formulation of health policies. services. The psychiatric hospitals assign Legislation has been enacted to regu- between 5% and 10% of their beds to late traffic in narcotic drugs and to control drug abuse cases. the consumption of some products. Fur- Up to 30% of all traffic accidents are thermore, the Government has largely alcohol- or drug-related. In the first three taken charge of the treatment and social months of 1981 there were 158 accidents rehabilitation of addicts, and it coordi- caused by persons driving under the in- nates prevention plans and formulates fluence of alcohol or drugs in the prov- policies in this regard. A National Plan ince of Pichincha; deaths occurred in 58% for the Control of Illegal Trafficking and of these accidents. the Prevention of Drug Abuse is cur- An increase has been observed in the rently being developed. Ecuador is a sig- prevalences of diseases associated with natory of the international conventions of the use of tobacco. 1961 and 1971 and of the South American The relationship between AIDS and Agreement on Narcotic Drugs and Psy- drug use has not been studied. However, chotropic Substances. intravenous drug use is very infrequent in Ecuador. Treatment, Rehabilitation, and Sociocultural Framework Social Reintegration

According to surveys of the popula- The Ministry of Health is the principal tion, the use of illegal drugs is widely dis- entity responsible for the health care of approved. drug addicts. Some international funding Legal drugs, such as alcohol, are exten- is received, but the principal costs are sively marketed and consumed, and borne by the Government. there are no age restrictions applied to Treatment is provided both in psychiat- their sale. The same is true of cigarettes, ric hospitals and in outpatient clinics.

SpecialReport 117 Prevention are selected from among those recom- mended by the United Nations. A number of governmental institutions have prevention programs. These pro- Education and Training grams include an education component that involves the participation of teachers Courses coordinated by the schools of and guidance counselors and also the medicine and the Ministry of Health training of social educators. provide training for physicians, nurses, psychologists, social workers, and other Research professionals. There are no graduate courses in the universities, but the topic Research is financed mainly by interna- of drug addiction is included in the tional institutions. The instruments used undergraduate curriculum of the health in the epidemiologic study of drug abuse sciences programs.

EL SALVADOR

Production and Marketing of Consumption Psychoactive Substances There are no reliable data on the con- Production and marketing of psychoac- sumption of alcohol, tobacco, or psycho- tive substances in El Salvador are con- tropic drugs in the last year, but economic trolled by the Government through the indicators for the years from 1978 to 1985 Superior Public Health Council, but this showed an increase in consumption. agency lacks the resources and personnel to ensure even minimal control. The Min- Health Indicators istry of Finance, through the Office of In- come Administration, regulates the pro- No statistics are available on the num- duction and marketing of alcohol and ber of persons who request or receive tobacco, but again, it does not have the treatment for the improper use of drugs, resources necessary to monitor retail nor is there information on prevalence of sales. the use of illegal drugs among psychiatric In 1985, 6,188,OOOliters of alcohol were patients. There is no percentage assign- produced. This was about the same level ment of beds for drug abuse in the psy- that had been maintained since 1982. chiatric hospitals. The preparation of psychoactive drugs A study of the prison population is entrusted to private enterprise, with showed that 52.5% of the female and partial governmental inspection. Psy- 42.1% of the male inmates had used ille- choactive substances are also produced gal drugs. Alcohol problems were also and imported clandestinely. observed in 30% of the women and There is a special prescription form for 20.3% of the men. Neither the specific narcotic drugs that is made available to substances nor the criteria used for the physicians upon request in compliance diagnosis of alcoholism were indicated in with the stringent measures set forth in the study. the Drug Regulations of 1962. However, Traffic accidents are among the 10 lead- contraband is known to exist and drugs ing causes of death in the country, but of all kinds can be dispensed to anyone. their relationship to alcohol or other psy-

118 Bulletin ofPAHO 24(l), 1990 choactive substances has not been stud- national conventions of 1961 and 1971 on ied specifically. narcotic and psychotropic drugs. Thirty-two cases of AIDS have been de- tected, of which only two were associ- Treatment, Rehabilitation, and ated with intravenous drug use. Social Reintegration

No specific funds are set aside for the Responses to the Improper treatment of drug-related problems, nor Use of Drugs are there special facilities for this purpose other than the Psychiatric Hospital on the There are no community organizations outskirts of the capital city. There are no that deal with this problem in particular. programs in place for rehabilitation, pri- People seeking help tend to consult a mary prevention strategies, or any kind physician or a pharmacist, depending on of evaluative research. their social stratum. Physicians and other health profession- Research als in El Salvador view drug use as a health problem on the increase. Drug No financing mechanisms exist in the abuse and alcoholism are regarded as dis- country for the development of research, eases. The professionals do not share nor has any research on the subject been the community’s attitudes and tradi- documented. tions. There is no “drug culture” in the country. Education and Training Specific laws and articles concerning drug abuse exist under the Health Code The educational institutions that train of March 1988 and the Civil Code. The health professionals are not adequately Mental Health Department in the Minis- coordinated and do not share common try of Public Health is responsible for objectives. In most cases, instruction on dealing with the drug problem. At the drugs is restricted to a few hours. present time there are no national plans The School of Medicine offers no designed to coordinate the various govem- courses to train future professionals to re- mental or nongovernmental institutions. spond to drug-related problems or to No provisions exist for controlling the treat addicted patients. There is no number of establishments authorized to graduate-level training in the area of sell tobacco or alcohol, but measures are drug abuse. in force to regulate the advertisement of Psychiatrists, trained abroad, are the these products. only professionals equipped to deal with El Salvador is a signatory of the inter- drug-dependency problems.

GUATEMALA

Production and Marketing of moderate increase in production. In 1987, Psychoactive Substances 16,095,563 liters of absolute alcohol were produced, up from 14,386,587 liters in Beer and wine are produced in the 1986, for an increase of 11% in one year’s country. The trend has been toward a time.

SpecialReport 119 The volume of beer production in the consumption of diazepam and (97,454,216 liters) is significant. On the triazolam, both of which are sold without other hand, the amount of alcohol im- medical prescription, making it difficult ported and exported is relatively insignif- to estimate their consumption. icant. Only 247,342 liters of whiskey and The use of inhalants is very widespread 307,942 liters of other distilled beverages among youngsters nine years of age and were imported in 1985. over, especially in peripheral urban The production and sale of tobacco neighborhoods. It is not possible to con- products in 1987 came to 10,001,204 trol the use of marijuana and cocaine. packs of 20 cigarettes each. In 1987, 2.8 A 1982 study by the General Director- million kg of leaf tobacco and 1.2 million ate of Health Services on a sample of kg of shredded tobacco were exported. 2,403 individuals showed higher rates of Guatemala imports raw materials for tobacco use among males. The highest the manufacture of psychotropic and nar- smoking rates were found among men 30 cotic drugs (meprobamate, phenobarbi- to 34 years of age (62.9%) and among tal, pethidine, morphine, and codeine). women 25 to 29 years of age (44.8%). The psychoactive substance industry, as well as the alcohol and tobacco indus- Health Indicators tries, are private activities that operate ac- cording to the free market. Imports are There are no reliable statistics on pa- regulated. Clandestine production of tients who request or receive treatment psychoactive substances is not known or who seek emergency services for drug- and is not believed to occur. related problems. Drugs that contain narcotics and some The Psychiatric Hospital provides spe- psychotropic medications, such as fluni- cific treatment for cases of drug abuse, trazepam, methylphenidate, secobarbi- but very few patients are attended. The tal, and pentobarbital, are controlled sub- prevalence of drug use in the population stances. Their prescription is registered of psychiatric patients is not known, but in the General Directorate of Health Ser- it is not considered to be very high. vices. Prescription forgery and contra- The use of alcohol was involved in ap- band drugs have been detected. Confis- proximately 50% of the 430 traffic acci- cations are frequent, and the following dents in 1986. Their association with the amounts were seized during 1987: 2.52 use of other drugs is unknown. kg of cocaine, 7.25 kg of Cannabis, 108 Alcoholism is not generally regarded as Cannabis resin plants, and 84 “units” of a disease, and consequently the preva- stimulants. The cultivation of poppies lence figures are substantially underre- and Cannabis was recently discovered. corded. Only registered and authorized estab- Thirty-two cases of AIDS have been lishments are permitted to manufacture detected. Two were related to intraven- or distribute psychoactive drugs. ous drug use, which is uncommon in Guatemala. Consumption Sociocultural Framework The consumption of legal psychoactive substances has not been of great impor- The general attitude of the population tance, apparently due to the effectiveness is one of disapproval of illegal drugs, of controls imposed on these substances. with the exception of marijuana, which is However, an increase has been observed accepted among some groups of young

‘I20 Bulletin of PAHO 24(Z), 1990 students. Regional variation exists in this tice it is not enforced. There are no respect. For example, use of marijuana, limitations on the advertisement of alco- cocaine, and inhalants is an urban prob- holic beverages and tobacco. lem. Alcohol and tobacco use is accepted Guatemala is a signatory of the Single by the population. Convention on Narcotic Drugs of 1961 and the Convention on Psychotropic Responses to the Improper Substances of 1971. Use of Drugs Treatment, Rehabilitation, and In Guatemala there are almost 750 Al- Social Reintegration coholics Anonymous groups, 450 of which are located in the capital city. Al- These aspects of the problem have not Anon groups are beginning to be formed, received adequate attention in the coun- in addition to an organization similar to try, and no government institutions have Narcotics Anonymous. In the rural areas, been assigned to deal with them. Some traditional healers are consulted. private organizations have made individ- As a rule, medical professionals are not ual efforts. No primary prevention strat- interested in alcoholism or drug abuse egy has been formulated. and, consequently, these conditions are underdiagnosed. With regard to drug ad- Research dicts, only limited information is avail- able, and an attitude of rejection exists. Only a few surveys have been carried In 1985 the multidisciplinary and multi- out. No organization has been put in sectoral National Commission for the charge of carrying out research, nor is fi- Prevention of Drug and Alcohol Abuse nancing available; thus, research is virtu- was founded. Although it does not yet ally nonexistent. exercise a significant influence, in the fu- ture it could become an entity capable of Education and Training mobilizing resources and promoting ef- fective actions. The principal institutions involved are Government response consists basi- connected with the university. Neverthe- cally of enacting legislation on the pro- less, mental health topics are barely dealt duction and sale of psychoactive sub- with in the School of Medicine’s curricu- stances. However, lack of resources has lum, and no graduate-level courses are hampered effectiveness. For example, offered. most medications are sold without a doc- Two years ago, a program was initiated tor’s prescription, except for narcotics on alcoholism and drug addiction to train and some psychotropic drugs subject to multidisciplinary personnel at the pri- strict control. mary health care level in diagnosis and The Law on Alcohol regulates the pro- treatment. Emphasis has been placed on duction, marketing, importation, and ex- working jointly with Alcoholics Anony- port of alcoholic beverages, but in prac- mous.

SpecialReporf 121 HONDURAS Production and Marketing of Consumption Psychoactive Substances A study carried out in 1979 on the prob- The alcoholic beverages produced in lems of alcohol use and alcoholism in Honduras are beer, rum, and aguar- Honduras found that most male drinkers diente. The tobacco products manufac- started their habit before the age of 15, tured are cigars and cigarettes. Produc- while women started after the age of 17. tion for 1987 was as follows: cigarettes, In rural areas aguardiente and rum are 104,566,OOO packs of 20 each; beer, the drinks of preference, whereas in ur- 153,352,OOO 12-ounce bottles; aguar- ban areas beer is favored. Many cultural diente, 1,683,OOO liters; and rum, traditions and myths about its properties 4,220,OOOliters. encourage the consumption of alcohol. No alcoholic beverages were exported A 1987 study conducted among young in 1986; the most important imports were people in two rehabilitation centers whiskey, beer, and wine. The most im- showed that 51% of the interviewees had portant tobacco exports were leaf tobacco some history of drug use; the inhalation and cigars. of glue was the most common practice. The clandestine production of alcoholic beverages is well documented. In 1985 a study was carried out on the consump- Health Indicators tion of pachangrz (methyl alcohol mixed There are two psychiatric hospitals in with water). Honduras, with a total of 330 beds. The No psychoactive medications are pro- Santa Rosita Hospital contains a 60-bed duced in Honduras. Pharmaceutical unit for alcoholics. houses and hospitals import them with In 1984 and 1985, alcohol-dependency the authorization of the Drug Control syndrome ranked seventh and sixth, re- Board of the Ministry of Public Health, in spectively, as a hospital discharge diag- accordance with the regulations of the In- nosis. It ranked second as a discharge di- ternational Drug Control Board. agnosis from psychiatric hospitals in A signed and stamped medical pre- 1985, at 18.8%; drug-related problems scription issued by the attending physi- ranked ninth, at 1.8%. In 1986 alcohol- cian is required in order for preparations dependency syndrome ranked first containing narcotic or psychotropic among the discharge diagnoses at the drugs to be dispensed to individuals. Santa Rosita Hospital (60.4%) and alco- Strictly controlled drugs require special holic psychosis ranked third (4.7%). prescription forms that may be obtained In the Central District, which has a po- from the Drug Control Board and are is- pulation of 700,000 inhabitants, there sued only to persons who present certi- were 1,530 traffic accidents in 1987, of fied accreditation as physicians. which 175 were alcohol-related. Sixty- Approximately 500 counterfeit pre- four fatalities occurred in those accidents. scriptions have been discovered since 1986, almost all for flunitrazepam. In ad- dition, some psychoactive drugs, includ- Sociocultural Framework ing diazepam, phenobarbital, meproba- mate, lorazepam, and clobazam, enter Smoking is socially accepted, as is the the country through illegal channels. consumption of alcoholic beverages, but

122 Bulletin of PAHO 24(l), 1990 with some limitations in regard to the the majority believe that alcoholism and time and occasion of drinking, the drug abuse are diseases. Professional or- amount consumed, etc. ganizations do not sponsor meetings for The illegal sale of psychoactive medica- persons who work on or have interest in tions is not condemned. In the rural and the problems of drug abuse. marginal urban areas there is less knowl- The governmental institution that deals edge about and less control of psychoac- with the drug problem is the Mental tive substances. Health Division of the Ministry of The use of other drugs, such as mari- Health, through the Honduran Institute juana and cocaine, is strongly disap- for the Prevention and Treatment of Alco- proved of. Inhalants constitute a special holism, Drug Addiction, and Drug case, since their use frequently takes Abuse. place in full view of members of the com- The private organizations working in munity, who appear not to understand this area are involved only in drug addic- the significance of the act and are not tion rehabilitation and prevention and moved to stop it. have no regulatory power. However, There is awareness of drug depen- they will be able to influence drug-abuse dence, but its true importance and di- policies through the National Mental mensions are not known. Health Committee (CONASAM), which is still being organized. This Committee is directly associated with the Mental Responses to the Improper Health Division of the Ministry of Public Use of Drugs Health. Created in 1987, CONASAM is made Drug users tend to seek help for drug up of representatives from various minis- addiction from their family or close ties and private institutions. Its objective friends. In very grave situations, other is to design and execute national plans kinds of help are sought, but not neces- for the campaign against drugs. sarily professional. The reaction to other Two laws pertaining to drugs are the people’s drug addiction problems is one Law Against Illegal Traffic in Narcotic, of indifference. Psychotropic, and Other Dangerous Among the community support organi- Drugs and the Law of the Honduran In- zations are the Comite de la Defensa de la stitute for the Prevention and Treatment Salud de1 Pueblo (Committee for the De- of Alcoholism, Drug Addiction, and fense of the People’s Health) and the Drug Abuse. Comite Sanpedrano Pro-Salud Mental No restrictions exist on the sale of to- (Sanpedrano Committee for Mental bacco. Aguardiente is the only alcoholic Health). beverage that is subject to special sales It would appear that professional help regulations. There is no legal drinking is more frequently sought by members of age. Hours of sale of alcohol are regu- the upper social classes or those with lated, but the limits are not always com- higher levels of education. Traditional plied with. Advertising is not controlled. healers fulfill an important function for Honduras is a signatory of the interna- less educated people in the low-income tional conventions of 1961 and 1971 classes and those living in rural areas. but not of the South American Agree- Health professionals consider drug ment on Narcotic Drugs and Psychotro- abuse to be an important problem, and pic Substances.

SpecialReport I.23 Treatment, Rehabilitation, and phlets, together with the dissemination Social Reintegration of radio programs and talks. Attention is focused particularly on secondary school Planning and organization of drug students. To date, the responsibility for abuse treatment is based on morbidity prevention has rested with the Mental data obtained from the various treatment Health Division of the Ministry of centers in the country and on the health Health. policies that respond to problems of this kind. The Mental Health Division of the Min- Research istry of Public Health carries out its activi- Health research in Honduras is essen- ties at the different levels of care, and tially carried out through two institu- there are referral and interconsultation tions, the Ministry of Public Health and mechanisms that operate between them. the National Autonomous University of In the Government institutions, treat- Honduras. There is no specific budget for ment is provided by psychiatrists and research in general or for research on general practitioners with psychiatric drugs. The Science and Technology Unit training, as well as psychologists. There of the Ministry of Public Health and the are also private, nonprofit religious insti- Office for Scientific Research of the Na- tutions. tional Autonomous University of Hondu- No formal programs for social reinte- ras are the organizations responsible for gration exist. Although no evaluative re- guiding and supervising research or re- search has been carried out, the most search proposals. noteworthy failings are thought to be Work has been done with young peo- the limited care coverage provided at the ple with regard to their involvement with national level, the lack of adequate alcohol and drugs. Some research has structure for rehabilitation, and the been coordinated with other countries. lack of centralized programs for social reintegration. Education and Training Prevention The only institution that provides train- An important measure toward more ef- ing in this area is the Ministry of Public fective primary prevention was establish- Health’s Mental Health Division, ment of the Honduran Institute for the through an undergraduate program for Prevention and Treatment of Alcoholism, medical students. There is also a training Drug Addiction, and Drug Abuse. Enact- program for graduate physicians who ment of laws against the illegal traffic of work in mental health clinics. drugs, community involvement, and the It is not necessary to have completed training of personnel are also steps that graduate-level studies in order to treat have been taken in this direction. addicts in Honduras, since general prac- The principal method of prevention is titioners and psychologists, as well as education, which involves the printing psychiatrists, are trained to provide treat- and distribution of posters and pam- ment for these patients.

124 Bulletin ofPAHO 24(l), 1990 MEXICO

Production and Marketing of warnings of health risks that accompany Psychoactive Substances their misuse. In 1984 approximately 39,125 ha were The alcoholic beverage industry in planted in tobacco. Mexico has developed rapidly since 1960, Special prescriptions are required for in part because the principal firms control the dispensing of narcotics. For other both the basic inputs and production it- psychotropic drugs, an ordinary nonrefil- self. The Government is not economi- lable doctor’s prescription is required. cally involved, except in the pulque in- Forgery of prescriptions has been de- dustry through the Maguey Board of tected, but the extent of such forgery is Trustees; however, it controls the distri- not known. Special prescription forms bution of some of the raw materials re- are delivered to individual physicians quired for production, such as sugar and who are registered and authorized to pre- absolute alcohol. scribe. The prescription must include the The brewing industry is one of the patient’s diagnosis and the signature of most important in the country and one of the attending physician. Medical samples the largest in the world. It is estimated containing narcotic or psychotropic that between 1980 and 1984 the produc- drugs have been prohibited. tion of beverages with low alcoholic con- tent (20” GL) increased by 2.9 million consumption liters. Between 1970 and 1984 the produc- tion of beverages with higher alcoholic Based on domestic sales figures, in 1984 content increased by 10.5 million liters. the per capita alcohol consumption by Beer production increased by 37 million the population over 15 years of age was liters between 1973 and 1984. calculated at 72 liters of alcoholic bever- Given the size of the country and pre- ages (5.4 liters of absolute alcohol). In dominance of rural areas, the illegal man- 1974 that figure was 4.7 liters. It should ufacture of alcoholic beverages and drug be noted that these figures are underesti- smuggling occur frequently and are diffi- mates, since the consumption of untaxed cult to control. beverages is not known. Beer and hard The acquisition, manufacture, prepara- liquor have displaced pulque as the drink tion, packaging, storage, import, export, of choice, especially in urban areas. Con- medical prescription, possession, trans- sumption of brandy, rum, and table wine port, and consumption of narcotic or psy- has also increased considerably. chotropic substances (except inhalable It has been found that absolute alcohol solvents) can only be carried out for med- mixed with soft drinks is used as an in- ical or research purposes and with the toxicating beverage. Household surveys authorization of the Ministry of Health. indicate it is consumed by between 1% However, considerable quantities of mar- and 6% of the general population, possi- ijuana, heroin, and opium are produced bly because of its low cost. illegally in Mexico. In 1986, a study was carried out on Industrial solvents are widely avail- middle-school and high-school students able, although their sale to minors is pro- for comparison with a 1976 survey in or- hibited and their labels must contain der to learn the trends in psychotropic

SpecialReport 125 substance use in the last 10 years. Of the treated, of which 62.2% were alcohol- 9,967 students surveyed in 1986,12% had related. Another study of emergencies used one or more drugs at least once in found that 22% of the incoming patients their lives, excluding tobacco and alco- had positive blood alcohol readings. hol. Between 0.1% and 0.3% of the re- The proportion of traffic accidents in spondents used drugs daily. The most the Federal District that involved intoxi- commonly used substance was inhalants cation increased from 8.3% of all acci- (4.4% of the sample), followed by am- dents in 1968 to 15.9% in 1983. The same phetamines (3.5%), marijuana (3.2%), trend has been observed in the relation- tranquilizers (2.5%), cocaine (l.O%), sed- ship between violence and alcohol con- atives (0.9%), hallucinogens (0.6%), and sumption. Of those incarcerated for heroin (0.5%). homicide, 49% had imbibed alcohol be- A comparison of these figures with fore committing the crime. Of 80 suicides data obtained in 1976 shows increases in in 1980,55% were alcohol-related. the consumption of inhalants (up 3.55%), The improper use of dependency- marijuana (1.6%), cocaine (0.5%), and producing substances is said to affect heroin (0.22%). The consumption of tran- 15% of the labor force and cause losses of quilizers and hallucinogens decreased by approximately four million work hours 0.1% and 0.3%, respectively. The greatest per year. limitation in this study was thought to be Since approximately 1970, drug abuse, that it excluded many drug users because especially the use of inhalants, has been they did not attend school. That assump- one of the most complex public health tion appears to be confirmed by a study problems in Mexico. The abuse of inhal- of minors who worked in the streets, ants increases daily and is now wide- which indicated that 27% had used inhal- spread among children and adolescents; ants occasionally, and 22%, daily. in addition, it is very closely associated The National Health Survey carried out with the rise in juvenile delinquency, in 1987 showed that 17% of the popula- poor school performance, and cases of in- tion over 12 years of age smoked tobacco. toxication seen in emergency services. Of that group, 16.6% smoked more than Data from the Ministry of Health indi- half a pack of cigarettes a day; 68.6% cate that 10% of the hospital beds are oc- smoked between 1 and 10 cigarettes cupied by alcoholics or addicts. In 1986, daily; and 14.8% did not know the num- 16% of the beds in the Juan N. Navarro ber of cigarettes they smoked. Child Psychiatric Hospital were occupied by addicts. Health Indicators The magnitude of the problem of to- bacco use is indicated by the mortality The rate of cirrhosis of the liver ob- rates of diseases associated with this served in Mexico is one of the highest in habit. Heart disease was responsible for the Region. This disease is among the 11.6% of all deaths in 1980, whereas in first 10 causes of mortality for the general 1963 the figure had been 3.7%. This rep- population and is first among the male resents a proportional increase of 54%. population 35 to 54 years of age. In 1983 Lung cancer was among the 20 leading the rate was 34.6 per 100,000 males and causes of death in 1981, with a rate of 4.4 9.9 per 100,000 females. per 100,000 inhabitants in the general In the first half of 1987, 2,403 emer- population and 71.2 per 100,000 persons gency cases related to drug abuse were over 65 years of age.

126 Bulletin ofPMO24(1), 1990 Sociocdtural Framework tude of teachers and parents toward the problem of drug abuse is one of denial, A study carried out in 1984 in a low- grounded in a lack of information and socioeconomic-level community of 70,000 a feeling of inability to cope with the inhabitants to the south of Mexico City problem. found that 90% of the people, regardless of sex or age, rejected the use of drugs. Responses to the Improper However, a permissive attitude was ob- Use of Drugs served among groups of students and workers. There is a general tendency to think The use of illegal drugs and inhalable that the problems of drug dependency solvents occurs mainly among young can be resolved by medical personnel. people. Both in the general population Currently, attempts are being made to and among students, males use more involve the community in prevention drugs than females, except in the case of work. In addition, there are self-help amphetamines. Persons over 24 years of groups such as Alcoholics Anonymous age make more use of prescription drugs and Narcotics Anonymous. The church such as tranquilizers and amphetamines also plays an important role in support- than do youth. ing those who decide to abandon their The areas most affected by the con- habit. sumption of drugs are those near the bor- In recent years the concept of “depen- der with the United States and in the re- dency” as a disease has been gaining gion of Jalisco. Thus far, heroin use has ground. Some organizations, such as the been limited to the northwestern part of Mexican Psychiatric Association, sponsor the country; it is practically nonexistent meetings for those interested in the sub- in the southern part. Similarly, the use of ject. Their work is primarily scientific and cocaine, which is more common among educational. the upper middle class, is more prevalent The General Health Law of 1984 pro- in the northwestern area. The use of in- vides the fundamental legal framework halants is most common in areas on the for programs against alcoholism and outskirts of large cities. drug abuse, which include control of the The differences between the sexes in al- production and sale of narcotics and the cohol consumption are very marked. execution of plans to evaluate and com- Men drink larger amounts than women, bat the problem. Thus far, several institu- and this trend appears to be related to tions have been established to coordinate social pressures. Drinking is most preva- preventive actions. lent among those between 30 and 50 The legal minimum drinking age is 18. years of age. During religious or civil fes- Each state government licenses establish- tivities the consumption of alcoholic bev- ments to sell alcoholic beverages. Adver- erages increases, people drink over a pe- tisements for tobacco and alcoholic bev- riod of several days, and intoxication is erages are not allowed to link their frequent. products to images of calm and joy, at- Some studies suggest that among chil- tribute nutritive or sedative properties to dren and adolescents there are two main them, or depict their use by children or types of drug users: the multiply- adolescents. addicted, with marijuana predominant, Mexico is a signatory of the interna- and inhalers of solvents. tional conventions of 1961 and 1971 and It also has been observed that the atti- reports regularly to the International

SpecialReport 127 Narcotics Control Board of the United grouped into three categories: Program Nations. for Social, Clinical, and Biomedical Re- Each year large quantities of illegal sub- search; Center for Integration and Docu- stances are confiscated and crops are de- mentation of Drug Abuse; and training of stroyed. For example, 394 kg of cocaine investigators. These activities include the were seized in 1982, and 443 in 1984; integration and organization of registra- 3,583 ha of poppies were destroyed in tion systems for cases detected in various 1984, and 25,056 marijuana plants were health agencies; studies to improve diag- destroyed in 1987. nosis, determine trends, and identify subgroups affected; studies to evaluate the action and effects of various sub- Treatment, Rehabilitation, and stances; evaluation of methods of case Social Reintegration identification and timely intervention, treatment, and rehabilitation; and stud- Treatment of drug addicts is carried out ies to determine the effectiveness of pre- in primary care clinics or in general or vention activities. specialized hospitals. Established proce- Financing and advisory services for dures exist for patient referral between these activities come mainly from inter- these institutions. There are also toxicol- national agencies such as PAHO/WHO, ogy modules in the emergency services the National Drug Plan of Spain, and in- as well as Juvenile Rehabilitation Centers stitutions in the United States of Amer- that offer outpatient treatment or hospi- ica. Also involved are national govern- talization free of charge. mental agencies, such as the National Council on Science and Technology Prevention (CONACYT), and private organizations, such as the Social Studies Foundation. In regard to primary prevention, the Attorney General of the country has cre- Education and Training ated the Drug Abuse Treatment Program, which attempts to deal with the problem The Committee on Education is com- comprehensively. Significant prevention posed of several university and govern- activities are carried out in the Juvenile mental institutions. The Autonomous Rehabilitation Centers. University of Mexico includes compre- hensive courses on alcoholism and drug Research abuse in its medical curriculum. In addi- tion, the Mexican Psychiatric Institute The research activities developed by has played a central role in the education agencies and institutions that make up of physicians and other professionals in the Committee on Legislation are this field.

128 Bulletin of PAHO 24(l), 1990 NETHERLANDSANTILLES

Production and Marketing of gency service of St. Elizabeth Hospital. Psychoactive Substances No hospital beds have been assigned for the treatment of addicts. Tobacco is imported for the production Although the relationship between of cigarettes. Beer is produced domesti- AIDS and drug abuse has not been stud- cally, but alcohol is also imported for the ied in the Netherlands Antilles, it does preparation of other beverages. No clan- not appear that such a connection exists destine production of alcoholic beverages there. No direct programs are in place for has been detected. The importation, pro- the prevention of intravenous drug use duction, and sale of alcohol are based on as a risk factor for that disease. the free market. Psychoactive medications are imported Sociocultural Framework and sold on the free market and are sub- ject to some controls. For example, nar- No data are available that relate drug cotics and psychotropic substances can abuse to law-breaking in general or to ju- be sold only by medical prescription, al- venile delinquency specifically, nor do though no special prescription form is re- data exist on drug use in prisons. It has quired. Pharmacists must file a report ev- been observed that a drug abuse problem ery four months on the sale of controlled exists in the workplace and, accordingly, substances. treatment strategies to combat it have been planned. Consumption No studies have been done on the atti- tudes or perceptions of the population or With regard to alcohol consumption, its leaders regarding drug abuse and traf- information is available only for beer. In ficking, but it would appear that not all 1987-1988, a total of 10,423,OOO liters the people condemn the use-and espe- were consumed, representing a marked cially the trafficking-of drugs. It is sus- increase over previous years. Excessive pected that many families of limited eco- prescription of psychoactive substances nomic resources are involved in drug has been documented. According to the trafficking. Office of Pharmaceutical Affairs, 222.5 g of cocaine, 1,067 g of Cannabis, and 85.6 g Responses to the Improper of opium were imported in 1987. Use of Drugs

Health Indicators The Office of Pharmaceutical Affairs, which is part of the Ministry of Health, is The number of persons consulting the responsible for collecting information Mental Health Department for drug and reporting it to the International Nar- abuse problems was 110 in 1984, 104 in cotics Control Board. The Attorney Gen- 1985,106 in 1986,91 in 1987, and 79 up to eral’s Office works closely with the October 1988. Board. There are no statistics documenting the Advertisements for alcoholic beverages demand for medical emergency services may not be aimed at minors and are per- owing to drug abuse. A surveillance sys- mitted on television only between 10 tem has been initiated through the emer- p.m. and 1 a.m. There is no legal drink-

SpecialReport 129 ing age, although the sale of liquor to mi- taken the initiative to organize and carry nors under 16 years of age is not allowed out prevention programs. unless they are accompanied by a parent or legal guardian. No restrictions apply to the sale and use of tobacco. Research The Netherlands Antilles is not a mem- So far, very little research has been ber of the South American Agreement done. A public mental health case regis- on Narcotic Drugs and Psychotropic ter has existed since October 1987. Data Substances. on patients with mental disorders are col- lected to provide a basis for distributing Treatment, Rehabilitation, and information for planning and manage- Social Reintegration ment, to establish a solid foundation for epidemiologic research, and to serve as a Treatment is usually given on an outpa- point of departure for future research. tient basis and consists of individual and group therapy. Wives, husbands, and family members are also included in the Education and Training treatment program. No specific policies have been formulated with regard to re- There are no centers for the training of habilitation programs. professionals in the area of drug abuse, with the exception of the School of Nurs- Prevention ing. Most academic experience is ac- quired in the United States and in the Little has been done in the area of pre- Netherlands. During medical training lit- vention. In view of the notable increase tle attention is given to the problem of in the problem, some communities have addiction.

PANAMA

Production and Marketing of Psychoactive medications are imported Psychoactive Substances by authorized pharmaceutical agencies. In regard to the clandestine production Alcohol, tobacco, and a small amount of psychoactive substances, it is known of phenobarbital and meprobamate are only that certain alcoholic beverages are produced in Panama. Between 1980 and made in the rural areas. There are no offi- 1985 the production of alcoholic bever- cial figures. ages generally tended to increase. The to- Medical prescriptions are required for tal 1986 production of alcohol was the dispensing of psychoactive drugs. 100,546,480 liters, a 15% increase over Special prescription forms are required the 1985 figure of 87,742,209 liters. Beer for dispensing narcotics, and these sub- represented almost 95% of the produc- stances must be handled by the chief tion in 1986. pharmacist, who must be licensed annu- The manufacture of tobacco products ally. In the last five years there have been has declined in recent years: in 1981 it no official reports of forged prescriptions. reached 1,049,732 cigarettes, while in The manufacture, marketing, and dis- 1986 it was 872,755. tribution of psychoactive substances is

130 Bulletin ofPM0 24(l), 1990 controlled by the Government. Up to (10 out of 330); in 1984, 5.9% (22 out of now no diversion of production toward 376); and in 1985,7.0% (26 out of 372). illegal channels has been detected. From 5% to 10% of the beds in the psy- chiatric hospitals or psychiatric services Consumption in general hospitals are set aside for cases of drug abuse. In 1985, 77,845,223 liters of nationally Regarding traffic accidents and alcohol produced beer were sold, but these gross consumption, in 8.7% of all accidents in figures may not be directly indicative of both 1984 (1,776 out of 20,520) and 1985 consumption. Regarding the use of psy- (1,888 out of 21,751), alcoholemia was chotropic medications, the Ministry of demonstrated. Health’s Department of Pharmacy and Up to March 1988 only six cases of Drugs reported the following sales in AIDS associated with the use of intrave- 1987: 8,496 kg of clobazam (Urbadan), nous drugs had been recorded, out of a 18,191 kg of chlordiazepoxide (Librium), total of 47. No studies have analyzed the 26,117 kg of diazepam (Valium), 336,321 relationship between AIDS and adminis- kg of phenobarbital, and 3,440 kg of me- tration of drugs by this method, which is probamate. No national studies have rarely used in Panama. been done on the prevalence of psy- Studies carried out at the end of the choactive substance use. 1970s and the beginning of the 1980s Health Indicators found 5% of the study sample to be “al- coholics” and from 30% to 35% to be “ex- Information is only available on the cessive drinkers” (Deleuze). outpatient demand for government ser- There are no direct indicators of drug vices to treat psychiatric problems related use and abuse. It is estimated that the to alcohol and other drug abuse. Sign& groups at greatest risk are concentrated cant variations in the demand occurred in the metropolitan area, due to the between 1981 and 1985, but no clear higher frequency there of health prob- trends emerged. The total number of lems related to the consumption of psy- cases treated in 1981 was 1,811, while in choactive substances. The use of inhal- 1985 it was 2,707. ants in the juvenile population has not In 1982 and 1983 the numbers of con- been quantified, but is known to exist. sultations for aU diagnoses were consid- erably higher for men than for women, Sociocultural Framework with the exception of “drug psychoses,” The general attitude toward the mar- for which the number of females seeking keting of illegal drugs is one of strong treatment was slightly higher. The male- disapproval. Alcohol consumption is to-female ratio with respect to “alcohol highly accepted, as is the use of tobacco. dependency syndrome” was 5.5 to 1 There is no research on this subject. (with males representing 84.7% of the cases attended). For the diagnosis “drug Responses to the Improper abuse without dependency” the ratio Use of Drugs was 9.8 to 1 (males representing 90.7% of the cases treated). Organizations exist in the community The Social Security Fund’s Psychiatric that are concerned with this problem, Ward showed a steady rise in the per- such as Alcoholics Anonymous and Nar- centage of addicts among all cases cotics Anonymous. treated: in 1983 the proportion was 3.3% A significant proportion of the people

SpecialReport 131 with dependency problems rely on tradi- greatest concentrations of cases and tional medicine (mainly healers). The up- treatment facilities are found in Panama per and middle classes more frequently City; in the rest of the country, coverage use the specialized services. is low. Programs exist to treat alcoholism In general, knowledge of the problem and drug abuse. Efforts are currently be- on the part of nonpsychiatric physicians ing made to coordinate the initiatives of and other health professionals is limited. the various working groups. The approach to alcoholism and drug The governmental institutions that are abuse is frequently moralistic and re- involved in responding to the country’s proachful, and these conditions are not drug problem are the Ministry of Health, seen as diseases. Alcoholics are treated the Social Security Fund, and the Insti- with disdain in emergency rooms. tute of Forensic Medicine, which is re- There are not yet any organizations of sponsible for coordinating the Govern- health professionals interested in the ment’s activities related to psychoactive subject, only civic or community organi- drugs. Treatment is financed by the na- zations that do some preventive work. tional Government, since the work is Coordination with the public sector is done in the country’s general and psychi- limited. atric hospitals, but there is no special Legislation regarding alcoholic bever- budget for this purpose. ages exists to regulate production, alco- The National Psychiatric Hospital, hol content, quality control, wholesale which is under the Ministry of Health, distribution, and advertising. There are has specific programs on alcohol and also standards that govern the location of drugs. Of its 1,000 beds, 5% to 10% are sales establishments and set the mini- used annually for the hospitalization of mum drinking age at 18. However, the addicts. beverages are sold in supermarkets and In the private sector, there are also or- bars and are easily purchased by minors, ganizations that provide treatment spe- either for adults or for their own con- cifically for young people. The mental sumption. health team bears the primary responsi- The legislation regulating tobacco is bility for carrying out treatment in Pan- less strict and more limited. With regard ama, and their approach is basically med- to psychoactive drugs, the country is a ical. In the community, a psychological signatory of the international conven- treatment model is more prevalent. No tions of 1961 and 1971. evaluation of the results is available. Some regulations apply to the advertis- The Ministry of Health and the Social ing of alcoholic beverages and tobacco, Security Fund are responsible for preven- but they are very limited. For example, tion programs, which are oriented an ad cannot show individuals drinking mainly toward adolescents and young liquor or smoking. people. Seminars, workshops, and the communications media (press, radio, Treatment, Rehabilitation, and television) are used most often. There are Social Reintegration no official university programs on pre- vention. The organization of these activities is the responsibility of the Government Research health systems. Almost all regions have specialized mental health teams that treat To date no country-wide research has drug problems in the population. The been done on the use of psychoactive

132 Bulletin of PAHO 24(l), 1990 substances. There have only been some preparation at the undergraduate level, studies on attitudes and forms of con- but it is insufficient. Most of the person- sumption, especially among youth. One nel working on drug abuse receive ade- of the major problems has been the lim- quate training at the graduate level. ited availability of funding. There are no special internships. Psychia- trists have the primary responsibility for Education and Training responding to the dependency problems in the country, and only within their spe- The universities are the principal insti- cialty are courses on drugs included. tutions that carry out education in this Community education basically focuses field. Health professionals receive this on prevention and health promotion.

Production and Marketing of 1970 it was estimated that the rate of ad- Psychoactive Substances diction to this drug was 8.8% in the mar- ginal areas of Lima. In the last 40 years, The country is not a producer of psy- the consumption of alcoholic beverages choactive medications; only preparation has increased enormously. Per capita of pharmaceutical specialties takes place consumption was 2.96 liters of absolute there. Responsibility for the importation alcohol in 1940, 7.22 liters in 1970, and of basic legal drugs lies outside the health 7.65 liters in 1980. The type of alcohol sector. consumed most (57%) is made from A medical prescription is required for sugar cane, but consumption of beer has the purchase of narcotics. Also required increased more than 100% in the last dec- are some type of personal identification, ade. Alcohol consumption is associated commercial or home address, name of with the use of other drugs. person or firm buying the product, and In 1985, one study estimated that place of delivery. These data are also en- 60,000 persons in the cities of Lima and tered in a special registry of sales, duly Callao were “addicted” to psychotro- authenticated by a judge. Forgery of pre- pits, or 4.4% of the population using scriptions for narcotics has been de- these substances. It was calculated that tected. 80% of these were addicted to cocaine The Government controls the manufac- free base. ture, sale, and internal distribution of With regard to the use of inhalants by narcotics, but not of other psychotropics. minors, a 1981 study conducted on a Small-scale diversion of chemical inputs sample of 400 children at the Civil Guard -for example, sodium carbonate, ether, Juvenile Center No. 1 showed that 13% acetone, and sulfuric acid-for the illegal used several drugs, most of which were manufacture of drugs has been found to plastic glues. Of the users, 93% were occur. male and the average age at which they began their habit was 9; 67% lived in Consumption marginal areas, while 33% had no fixed residence. It is important to emphasize Without a doubt, alcoholism consti- that the principal reason for starting in tutes the principal drug dependency. In this group was “curiosity.”

SpecialReport 133 A 1986 national household survey con- the country, after the economy and ter- ducted on a sample of 7,425 inhabitants rorism. In Lima, people are concerned (4,146 in Lima and 3,279 in the provinces) about drug use, while outside the capital revealed an overall prevalence of use (at they are more concerned about drug traf- least once in the respondent’s lifetime) ficking. Lima’s residents believe the drug and prevalence of use in the last year consumed most is cocaine free base, for various psychoactive substances. The while elsewhere it is thought to be alco- six highest overall prevalences corre- hol. In general, the public disapproves of sponded to alcohol (87.2%), tobacco drug use. (67.4%), coca leaves (21.7%), sedatives The association between juvenile delin- (18.5%), analgesics (9.9%), and mari- quency and drug use has not been stud- juana (8.3%). The prevalences of use in ied, nor has the prevalence of the prob- the last year for these same substances lem in the prison population. However, were as follows: alcohol, 34.8%; tobacco, use of cocaine is believed to be a very 19.9%; sedatives, 9.8%; analgesics, 4.0%; serious epidemic because within a few coca leaves, 4.0%; and marijuana, 1.3%. months the drug causes profound per- sonality changes characteristic of psycho- Health Indicators pathology or delinquency. There are no statistics or data for the Responses to the Improper country as a whole on morbidity due to Use of Drugs the abuse of psychoactive substances. The only information available is from In general, drug addicts first seek help the outpatient clinic of Hermilio ValdizPn from family members, then from the reli- Hospital, which has a unit for treatment gious community, and third from profes- of alcoholism and drug abuse. sionals . Alcoholics Anonymous and Nar- Of a total of 1,918 patients treated in cotics Anonymous are organizations they this clinic in 1987, 234 (12.2%) were alco- can turn to, and there are also other com- holics and 487 (25.4%) were drug addicts. munity organizations that refer patients The vast majority (94.5%) of the drug to the health services. abuse patients were males, and 64.1% Both health professionals and the gen- were in the 20-to-29-year age group. Of eral population consider drug abuse to be the 380 beds in the hospital, 15 (4.0%) are an important problem and perceive it as a set aside for addicts. disease. Some professional organizations The death rate associated with drug presently work in this field, such as the abuse is not known. However, use of co- Center for Information and Education for caine free base is believed to cause many the Prevention of Drug Abuse (CEDRO) deaths either directly or indirectly. and the National Association for Preven- Thus far, 280 cases of AIDS have been tion, Treatment, and Rehabilitation from reported. Its association with drug abuse Drug Dependency (COCADIL). How- has not been studied. Intravenous ad- ever, these organizations do not influ- ministration of drugs is infrequent in ence drug abuse policy. Peru. Broad legislation on the subject dates from as early as 1921. In summary, there Sociocultural Framework are regulations regarding production of and trafficking in illegal drugs, especially The population of Peru considers drugs coca. The country is a signatory of the to be the third most important problem in 1961 and 1971 conventions.

134 Bulletin of PAHO24(1), 1990 An interministerial committee is proposed changes in the law, antidrug charged with coordinating pertinent campaigns, information dissemination, actions. A National Plan for Prevention etc. Prevention activities are not orga- and Control of Drugs (1986-1990) is being nized; there is coordination only between implemented under the provisions in the some institutions. The efforts are di- General Drug Law. Decisions are made rected toward children and youth, at the level of the Sectoral Committee on through the communications media. No Drug Control (COMUCOD), which is government institutions are in charge of composed of several ministries. prevention nor are there university pre- The minimum legal drinking age is 18. vention programs. In general, compliance with this provi- sion is poor. Research There are practically no regulations concerning tobacco, with the exception Research is usually financed by the in- that its advertisement on television is vestigators themselves and by some pri- prohibited before 9:00 p.m. This prohibi- vate national and international organiza- tion does not exist for alcohol. tions. Most of the studies are tangential to the drug problem. Some epidemio- logic and clinical studies have been done, Treatment, Rehabilitation, and but in general they were limited to small Social Reintegration samples. To date, cooperative studies with other countries have not been car- Treatment is planned and organized on ried out. the basis of the working group therapy The Ministry of Health, in coordination course. Several approaches are used in with the Ministry of Education, develops combination, including behavior modifi- research programs that include epidemi- cation, treatment communities, and indi- ologic, medical, and scientific studies, to- vidual, group, and family therapy. These gether with technical training for dealing activities are coordinated by the National with the problem of drug addiction. Institute of Mental Health. Care is pro- vided by health services responsible for defined geographic areas. Education and Training Treatment is financed by the Govem- Educational initiatives come principally ment and by Social Security. In addition, from the universities and the health sec- international agencies offer assistance in tor, which have organized multidiscipli- the areas of equipment, training, techni- nary courses or seminars. Very few pro- cal advisory services, and research. fessionals devote themselves specifically to the subject of drug abuse. At present, Prevention there is no specialization in drug abuse and little instruction at the undergradu- The only State rehabilitation center for ate level. The physician is the principal addicts was inaugurated in Lima in 1978. health professional responding to this It uses a cognitive/behaviorallinstitu- problem, with the support of a muhidis- tional treatment model, with activities ciplinary team consisting of psycholo- that foster social reintegration. gists, nurses, social workers, physical Primary prevention strategies include and occupational therapists, and others.

SpecialReport 135 TRINIDADANDTOBAGO

Production and Marketing of 1979 presented blood alcohol levels of Psychoactive Substances 0.08% or greater. In the same hospital, 47% of the males admitted had some Only alcohol and tobacco are produced medical problem related to alcohol. in the country. There is no production of In 1985 the principal health institutions psychotropic medications nor evidence of the country treated 785 patients with of their clandestine production. The free problems associated with the use of market governs distribution of imported drugs, mainly marijuana and cocaine, materials. while in 1987 the same institutions In 1986, 20.2 million liters of beer, 3.4 treated 1,055 such patients, for an in- million liters of stout (malt beer), and crease of 34%. It is believed that cocaine 10.3 million liters of rum were produced abuse accounts for the sharp increase for local consumption. Between 1977 and (580%) in cases of addiction treated be- 1986 the production of rum decreased, tween 1983 and 1987. while the levels of beer and stout produc- tion were maintained, though with con- Sociocultural Framework siderable variations from year to year. The country is a signatory of the inter- Given the broad variety of cultural national conventions of 1961 and 1971. A groups in the country, it is not easy to medical prescription is required for the generalize about attitudes toward drugs. sale of psychoactive drugs, and the pre- However, the use of tobacco and alcohol scription is registered at the pharmacy. appears to be widely accepted. Marijuana The authority to import drugs is also reg- also has the approval of some subgroups ulated. Vendors of psychotropic drugs of the population who cultivate it. Atti- have to obtain authorization annually tudes vary regarding the illegal sale and from the Chemistry, Food, and Drug Di- use of other substances. vision of the Ministry of Health. No di- version of these substances from legal Responses to the Improper channels has been detected. Use of Drugs Health Indicators There has been a broad response to the problem by the community. Several orga- Most patients seeking treatment for nizations concerned with primary pre- alcohol-related problems enter the psy- vention and rehabilitation, especially ori- chiatric hospital. Between 1985 and 1987 ented toward youth and the family, have there was an increase of 20% in the total been formed (e.g., Alcoholics Anony- number of cases treated, from 697 to 835. mous, Narcotics Anonymous). Still, pri- A specialized, 29-bed center exists for the mary health care services are perhaps the treatment of alcoholic patients of both most important sources of care. sexes. Also, some companies have pro- The concept of addiction as a disease is grams to assist employees with alcohol- accepted by most health professionals. related problems. Many of the professional organizations According to data from the most im- incorporate activities related to drug portant general hospital in the country, abuse in their regular programs. 55% of the drivers treated for accidents in The Government recently created a

136 Bulletin ofPAHO24(1), 1990 Council on Alcohol and Drug Abuse, Research which coordinates and supervises pro- grams for drug abuse control at all levels. Up to the present, research in this field The places where alcohol may be sold are has not been coordinated or designed in regulated, and the legal minimum drink- a way that would permit comparison of ing age is 16. The restrictions on advertis- findings. ing are insufficient. No household surveys have been car- ried out because of their high cost. Stud- Treatment, Rehabilitation, and ies are currently under way on the rela- Social Reintegration tionship between AIDS and drug addiction, as well as on alcohol consump- The Ministry of Health is responsible tion and traffic accidents. There are also for the treatment of drug addicts. Treat- some preliminary clinical studies that ment programs are carried out mainly in analyze admissions to drug abuse treat- the psychiatric services of the general ment centers. hospitals and include both outpatient treatment and hospitalization. Most pa- Education and Training tients are referred by the primary health care centers. The major centers of higher education Alcoholics Anonymous and Narcotics participate in training related to drug Anonymous have treatment and rehabili- abuse. Medical students also receive tation centers throughout the entire training in this field within the area of country. Several community organiza- psychiatry. In addition, the subject is in- tions have developed programs that offer cluded in the postgraduate psychiatry support for young people. In addition, program. The Council on Alcohol and there is a private rehabilitation center Drug Abuse is currently attempting to co- that provides hospitalization. ordinate all these efforts.

VENEZUELA

Production and Marketing of psychotropic and narcotic substances are Psychoactive Substances prepared in legally established pharma- ceutical laboratories. Narcotic and psy- In Venezuela, alcohol and tobacco are chotropic medications are dispensed produced, but other psychoactive sub- through pharmacies by prescription only. stances are not. The importation of nar- The sale of psychotropic and narcotic cotic and psychotropic medications has substances to minors is prohibited. increased in recent years. According to Venezuela also has a licensing system unofficial information from the Drug and for the internal distribution of narcotic Cosmetics Division of the Ministry of and psychotropic substances. Require- Health and Social Welfare, prescriptions ments include registration and permis- from dentists and veterinarians for nar- sion for importation, inspection of the cotic and psychotropic drugs have begun imported substances for identification, to appear, an indication of bad profes- permission for preparation, and permis- sional practice. sion for sales and purchases. In addition, Pharmaceutical products that contain the distribution of medical samples to

SpecialReport 137 laboratories, drug stores, and pharma- consumption of national liquors has in- ceutical agents is prohibited. creased and that of imported liquor has Some substances, including tranquiliz- decreased. ers and certain drugs such as propoxy- Since 1984, with the passage of the Or- phene and pethidine, are diverted from ganic Law on Narcotic and Psychotropic legal channels. Substances, a new conception of the drug problem has emerged in the coun- Consumption try, and the search for solutions has been initiated. The drug user is regarded as a No data can be provided on the con- patient who needs treatment, rehabilita- sumption of narcotic and psychotropic tion, and reintegration into society. medications since the information sub- In general, there is now greater aware- mitted monthly by the distributors is not ness of the drug problem by the public, computerized. together with a feeling of powerlessness and fear. However, the idea persists that Health Indicators only young people and members of dis- advantaged social groups are affected by The prevalence of alcoholic psychosis drug addiction. increased significantly between 1982 and The proportion of crime associated 1984, especially in the urban areas, where with alcohol use has been estimated at liquor sales are greater. Alcohol depen- almost 20% in recent years. Between 1978 dency syndrome also increased, as did and 1982 there was an increase in the psychoses from drugs. Mortality due to number of arrests for drunkenness. In these causes showed a slight increase. addition, a study carried out in 1981 The psychiatric hospitals set aside al- found that 4% of a sample of addicts had most no beds for addicts, except for the a history of imprisonment, 26% had been Caracas Psychiatric Hospital, which has tried in court, and 63% had a police 24 beds for drug abuse and another 24 for record. alcoholism. Intravenous administration of drugs is Responses to the Improper not a frequently used method in the Use of Drugs country. However, in recent years an in- crease has been noted. The Organic Law on Narcotic and Psy- chotropic Substances of 1984 consists of Sociocultural Framework 198 articles and six sections, as follows: general provisions, administrative order, Consumption of alcoholic beverages is crimes and consumption of regulated an integral part of Venezuelan social and substances, prevention, procedures, and cultural life. Alcohol is increasingly relied establishment of the National Commis- on for gratification, since it is easily ob- sion Against the Illegal Use of Drugs. Ar- tained, low in cost, and socially accepted. ticle 28 of the Organic Law on the Sale of It is not generally considered to be a Liquor, on Retail Distributors of Alcohol drug. Its consumption by women is in- and Alcoholic Products, establishes the creasing. hours during which alcoholic beverages Venezuela once ranked among the 10 can be sold in Venezuela. Article 9 pro- top countries in whiskey consumption vides the criteria for calculating the num- and was a large consumer of champagne, ber of retail distributors permitted in the but due to the current economic crisis the country. There are many places, how-

138 Bulletin ofPAHO 24(l), 1990 ever, that sell alcoholic beverages without Foundation, which was created in 1985 a license. and has six hospitalization centers that Tobacco may be freely sold in all types function as treatment communities and of commercial establishments and it may seven centers for outpatient care. be sold to children. Some laws have been Up to the present, Social Security has passed prohibiting smoking in specific not been interested in dealing with this places, but they have received very little problem. However, since 1984 indepen- publicity. Consequently, they are un- dent associations giving assistance to ad- known to most of the population and are dicts have proliferated, although they frequently violated. generally lack academically or profes- Since 1981, the advertising of alcohol sionally qualified staff. and cigarettes on radio and television has Very few efforts are being made in the been prohibited. Enforcement of this res- area of social reintegration. There is no olution has been quite satisfactory. research or experience in the country in To date, the taxes on tobacco and alco- this regard. In addition, preventive activ- hol and the increased retail prices per ities have been isolated and spo- unit do not appear to have influenced the radic, limited in scope, and without clear availability of these products in the com- objectives. munity. Venezuela is a signatory of the Single Research Convention on Narcotic Drugs of 1961, the Convention on Psychotropic Sub- Research is being done by only a few stances of 1971, and the South American university and clinical investigators who Agreement on Narcotic Drugs and Psy- are interested in this field. Most of the chotropic Substances. studies are literature reviews rather than field research. Treatment, Rehabilitation, and The National Council on Scientific and Social Reintegration Technological Research (CONICIT) coor- dinates, supervises, and promotes re- Up to now, no planned policy has de- search projects. There are no sources of termined actions in these fields. By law, financing. the Ministries of Health and Social Wel- fare and of Justice are responsible for Education and Training treating prisoners who have problems with alcoholism or drug addiction. How- The institutions that train health pro- ever, they operate only one establish- fessionals have generally provided only ment for the treatment and rehabilita- lectures on drug-related topics. Recently, tion of these patients, the Unit for the there has been some interest in having Treatment of Addicts (UDAF), which students of psychology and social work has a small budget and only modest do internships at a center that treats ad- installations. dicts, something that neither medical stu- The Ministry of Justice has set up some dents nor postgraduate students of psy- orientation centers for outpatient care, chiatry had previously done. but staffing is limited. Since 1987 the UDAF has offered a one- The Ministry of the Family participates year theoretical-practical training course in treatment, rehabilitation, and social re- on drug abuse for psychiatrists and integration through the Jose Felix Ribas graduate-level clinical psychologists.

SpecialReport 139