AFGHANISTAN RESEARCH AND EVALUATION UNIT Briefi ng Paper Series David Macdonald October 2008 Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics Overview Contents Over the past decade, Afghanistan has gained notoriety as the world’s I. Background 3 leading producer of opium and heroin. What is less well known is that, II. The Regulatory according to available evidence, the Environment and country itself also has an increasing Supply of number of problem drug users.1 Psychotropics 6 Apart from dependency, addiction and other health-related problems, III. The Misuse of problem drug use can lead to a wide Psychotropics range of social, economic and legal in Afghanistan 10 problems that affect individuals, Commonly misused psychotropics families and communities. It is not IV. Policy Implications 15 only the use of illicit substances that leads to problem drug use. It also results from the use of psychotropics — pharmaceutical drugs like V. Ways Forward 16 painkillers and tranquillisers that have a psychoactive effect — in ways not recommended by a qualifi ed doctor or the manufacturer. Glossary of Psychotropics While popular perceptions of drug misuse and dependency in Used in Afghanistan 18 Afghanistan tend to focus on illicit drugs like opium or heroin and to a lesser extent cannabis, evidence suggests that many people also misuse psychotropics. A national survey conducted in 2005 by the United Nations Offi ce on Drugs and Crime (UNODC) and the Ministry of Counter Narcotics looked at the incidence of the non-medical About the Author use of controlled substances, including use without a doctor’s prescription, for an excessive or unjustifi ed period of time. While David Macdonald is a the estimated numbers of opium users and heroin users were 150,000 sociologist with over 20 and 50,000 respectively, the number of problem pharmaceutical years’ experience working on drug demand reduction issues in the developing 1 world. He has worked as a The information in this paper comes from interviews with pharmacists, government offi cials, drug treatment workers, doctors and drug users, as well demand reduction specialist as from other research reports and anecdotal accounts. All numerical estimates for UNODC’s Afghanistan of drug supply and use in Afghanistan should be treated with caution: while they programme and as an indicate general trends and patterns and may inform policymaking, they are advisor to the Ministries estimates only and cannot be considered as confi rmed numbers. Estimates of of Counter Narcotics and drug use and misuse are notoriously diffi cult to calculate, and globally there is a Public Health in Kabul. dearth of reliable information about the magnitude and nature of drug problems. David Macdonald, Drugs in Afghanistan: Opium, Outlaws and Scorpion Tales (London: Pluto Press, 2007), 16-36. 1 Afghanistan Research and Evaluation Unit drug users was estimated to be 180,000.2 In Acronyms 2003, an assessment of problem drug use in AIDS acquired immunodefi ciency Kabul city found 14,298 users of pharmaceutical syndrome drugs compared to 10,774 opium users and 7,008 heroin users.3 EC European Commission HIV human immunodefi ciency There is a range of types of psychotropic drug virus misuse in Afghanistan. One problem in particular is the long-term self-medication without a IDU injecting drug user doctor’s prescription using powerful painkillers INCB International Narcotics and tranquillisers such as diazepam (brand name Control Board Valium), which is cheap and widely available from LSD lysergic acid diethylamide pharmacies and other retail outlets. NGO non-governmental While there may be many reasons for such misuse, organisation confl ict-related poverty, social displacement SSRIs selective serotonin and mental health problems (including chronic reuptake inhibitors anxiety, depression and post-traumatic stress disorder) are known to have been central drivers UN United Nations of this problem. UNHCR United Nations High Commissioner for Refugees Psychotropics are known to be increasingly taken in combination with illicit drugs such as opium UNICEF United Nations and heroin, either through smoking or injection. Children’s Fund Overprescribing of psychotropics by doctors UNIFEM United Nations Development and the lack of reliable information about the Fund for Women associated risks and dangers — including possible UNODC United Nations Offi ce on side effects, intoxication and dependency — also Drugs and Crime contribute to misuse. For example, it has been reported that very young children are given UNDCP United Nations International inappropriate drugs such as psychotropic-based Drug Control Programme cough syrups or powerful painkillers. WHO World Health Organization However, the misuse of psychotropics is not a problem limited to Afghanistan. Other developing Psychotropic drugs are pharmaceutical drugs countries, and indeed several developed ones, such as painkillers and tranquillisers that have also experience similar diffi culties in controlling a psychoactive effect. They make up part of and regulating the supply (by prescription and the category of psychoactive drugs, which are sale from a registered qualifi ed pharmacist) mind-altering substances affecting the central and use (under the supervision of a doctor) of nervous system that can lead to a variety of psychotropics for medical reasons. changes in behaviour, mood and perception. In Afghanistan it is estimated that up to 80 percent of the psychotropics available have been The UK’s Advisory Council on the Misuse of smuggled into the country without a licence and Drugs defi nes a problem drug user of either without testing to determine whether they contain licit or illicit substances as: additives or are counterfeit or out of date. While border controls are weak, so are the control and any person who experiences social, regulation of psychotropics within the country psychological, physical or legal problems itself. The Ministry of Public Health recently related to intoxication and/or the regular established a legal department in its Directorate of excessive consumption and/or dependence 2 as a consequence of his own use of drugs UNODC and Ministry of Counter Narcotics, Afghanistan: Drug Use Survey 2005 (Kabul: UNODC Country Offi ce for or other chemical substances. Afghanistan, 2005). Advisory Council on the Misuse of Drugs, “Treatment and 3 UNODC, Community Drug Profi le No. 5: An Assessment Rehabilitation” (London: HMSO, 1982) of Problem Drug Use in Kabul City (Kabul: UNODC Afghanistan Programme, 2003). 2 Afghanistan’s Hidden Drug Problem: The Misuse of Psychotropics Pharmacy to control and monitor pharmacies and any reduction in the availability or increase in the medical institutions and to check whether out-of- price of heroin is likely to lead to increased use date, expired or low-quality medicines are being of a range of psychotropics as substitute drugs, sold. But with over 9,000 registered pharmacies potentially encouraging a burgeoning illicit street that need constant checking by low-paid, under- market in these substances. resourced government offi cials susceptible to bribes and other forms of corruption, this The problems facing Afghanistan in relation to represents a challenge. There is a clear need for the misuse of both licit and illicit drugs, including stricter regulation of the sale and distribution of psychotropics, cannot be solved overnight. They psychotropics from other retail outlets, such as require a long-term strategy and commitment by shops and handcarts in marketplaces, as well as the government and the international community of their “prescription” and purchase from people to tackle them. Even if opium was eradicated, the with no medical qualifi cations or expertise. country would still have a demand-driven drug problem — with psychotropics at its core. While The supply of and demand for psychotropics are strengthening government institutions to be able inextricably linked to the trade in illicit drugs like to control and regulate the supply and distribution opium, heroin and cannabis. Any steep rise in the cost of psychotropics is necessary, the following are of psychotropics coupled with a decrease in their also essential: better resourced treatment, availability and ease of access may lead problem rehabilitation and harm reduction services for users to substitute pharmaceutical psychotropics problem drug users; training for doctors and with drugs like opium and hashish — both of which pharmacists on the risks and dangers of psychotropic have a long history of social and medical use in drug misuse; and provision of reliable and context- Afghanistan. Current heroin users are increasingly sensitive information for the Afghan public about combining heroin with psychotropic drugs, and the costs and benefi ts of psychotropic drugs. I. Background The global policy framework By 1971, it was recognised that many psychoactive drugs had not been included in the 1961 Convention, In 1961, the United Nations Single Convention leading to the drafting of the UN Convention on on Narcotic Drugs was developed to prohibit the Psychotropic Substances.4 The 1971 Convention production and supply of narcotic drugs and drugs was primarily concerned with the scheduling with similar effects, specifi cally cannabis, coca and control of a wide range of drugs classifi ed and opium and their derivatives such as hashish, as psychotropics from pharmaceutical drugs like cocaine, morphine and heroin — except for the amphetamine-type stimulants, barbiturates and purposes