Epidemiology of drug use in Iran

Using opium, both as a medicine and a recreational substance has a very long history in Iran first reports go back to the 17 ^th century.  the first official statistics on this issue dates back to 1943, where the Opium and Alcohol Enforcement Society estimated the number of opium addicts in Iran as to be one and half a million, from the total population of 14 million at that time (Razzaghi 1998). In 1949 it was estimated that 11% of Iranian adults were drug users corresponding to 1.3 million opium addicts. In 1955, Iran introduced its first laws against the cultivation and use of opium (Raid & Costigan 2002)]. Heroin was introduced in Iran in the 60s (Mokri 2002a). In 1969 the government permitted limited and supervised cultivation of opium. At the same time nationwide opium maintenance program for people 60 years and older was initiated. By 1972, Iran's drug addicted population was estimated 400,000 with 105,000 registered opium users. In 1975 it was reported there were 30,000 heroin users in the country, with some of them injecting (Moharreri 1978; Peterson 1978). From 1974 to 1977 a major detoxification program operated throughout Iran. Its emphasis was on out-patient treatment and it served around 30,000 out-patients (Spencer & Agahi (1990-91). To reduce a drug user's habit, coupons for opium tablets for two to three months were provided or methadone treatment was made available (Razzaghi et al 1999; Mehryar & Mohrrari 1978). In 1977, the prevalence of addiction was estimated to be 2.5%, based on a general survey; it should be noted that the number of those having opium coupons was far below this number (Alemi 1978; Siassi & Fozouni 1980a). The programme was also designated as opium maintenance (Siassi & Fozouni 1980b). In 1978, a survey from the National Iranian Society for the rehabilitation of the Disabled showed 94% of registered addicts used opium while 50% of non-registered drug users mentioned heroin. By early 1980 following the revolution, a severe anti-drug campaign was introduced which involved the extensive use of the death penalty for drug trafficking and other punishments for drug addicts (Dalvand et al 1984). Throughout the 1980s and 1990s the courts were sending drug users to mandatory rehabilitation in prison-like settings. In 1994, Iran developed out-patient treatment centres in all 28 provinces and supported the development of Narcotic Anonymous (NA) and other self-help groups. Since the late 1990s the law has allowed treatment-seeking drug users to be excluded from penal punishments (Razzaghi et al 1999).

In the past decade several major surveys on the situation of drug abuse were carried out (year field survey conducted):

1. The Rapid Situation Assessment (RSA) of Drug abuse in Iran (1998): was carried out by the State Welfare Organisation supported by the UNODC. Ten blocks with common cultural and social characteristics and roughly having the same population of 6 million for each region were defined encompassing the whole country. The major urban centre of each region was thereafter selected as the site for the study. The methodology included individual deep interviews with selected dug users and key informants, focus group discussions with drug users and service providers. Drug users from three different settings the prison, treatment centre and drug users from street were recruited. The total number of drug users was estimated through indirect methods and secondary data (Razzaghi et al 1999).
2. The Epidemiology of Substance Abuse in the I.R of Iran (2001): conducted through the Ministry of Health and Medical Education together with the Drug Control Headquarters and supported by the UNODC. The survey was conducted in 53 emergency rooms among 5212 randomly selected individuals in this setting. Urine tests accompanied interviews, collected at the interview site and sent for examination to the Reference Laboratory of the MoHME to back-up and verify accuracy of responses (Yassami et al 2002).
3. Rapid Assessment and Response (RAR), Multi Centre Project on Injection Drug Use (2001): conducted by the State Welfare Organisation and supported by the WHO, was conducted as a part of a multi centre survey to look into injecting drug use in the city of Tehran. 6 districts were selected on the basis of secondary data obtained from drug treatment clinics. Recruitments were carried out according to opportunistic sampling in treatment centres, snowballing in the community and ethnographic observations. Key informants were recruited through purposive sampling (Razzaghi et al 2003).
4. Rapid Situation Assessment of drug Abuse and Dependency in Iran (2004): was carried out through the Dariush Institute of Education and Research of Substance Abuse. All 28 Provinces of Iran were included. A total of 4930 drug users were selected: 452 from treatment centres according to opportunistic sampling, 387 from prisons through random sampling and 4091 from the community by snowball sampling. Key informants were also included according to purposive sampling (Narenjiha et al 2005).

A Rapid Situation Assessment was carried out in Iranian Prisons in 2002 supported by UNODC Iran. Random sampling was employed among all inmates disregarding of status of drug abuse and/ or reason of imprisonment. 54.3% admitted history of opiate abuse prior to incarnation and 30.7% sated to use drugs in prison. Urine screening test of a selected number of inmates was positive in 26% of cases. There was no association between committed crime (drug related versus not related to drugs) in the level of substance abuse of inmates. Drug abuse was significantly more prevalent among depressed and psychotic patients and patients with Obsessive-Compulsive Disorder (OCD) as well as in prisoners with somatisation problems. Drug abuse was reported to be carried out in groups and in night time. Bathrooms were described as suitable places for abuse. Prisoners believed that heroin be injected in half of the cases. Injection was reported to be conducted via shared used syringes and self-made so-called pumps. Sexual contacts were estimated to have a prevalence of 10%. Condoms were reported to be available only for those having intimacy meetings with spouses at the time of the study. Drug use was also reported to exist in female wards with an estimation of prevalence from 10-50% of female inmates using drugs. Injection behaviours among female inmates were reported to be very low (Bolhari et al 2002).

The RSA 1998 estimated the total number of Drug users as 2,000,000 with 1,200,000 addicts and 800,000 recreational users. It revealed that 16% of the interviewees had injected in the month prior to interview and 21.9% were ever injectors. Injection behaviour had been more prevalent in prisons. Mean of onset of injecting any drug was 26.3 (± 6.70) years with 80% of injection cases initiated before 35 years of age. Reasons mentioned for switch to injecting behaviour were 'tolerance' and less costs. Almost all IDUs had a previous history of 5-15 years of opium use prior to injecting. Sharing behaviour was generally reported by 70% of IDUs. 37.5% of the samples from treatment centres and the community had a history of imprisonment (Razzaghi et al 1999).

According to the Epidemiology of Substance Abuse in the I.R of Iran (2001) the total number of those using opioid drugs at the time of interview was 3.7 millions, with 1.16 millions at the level of dependence. The study estimated a total number of ca. 130,000 Injecting Drug users (IDUs) in the country; i.e. 19.2% of heroin users and 55.3% of buprenorhine users (Yassami et al 2002).

According to the RAR study the number of injecting drug users should be at least 100,000 (Razzaghi et al 2003). The same research team has also stated a higher estimation of 200,000 IDUs elsewhere (Razzaghi et al 2006). Typical characteristics of IDUs were identified as: males 21-30y, middle high school education, unemployed, opium initiation drug of abuse. Main reasons for switching mentioned by interviewees were tolerance and costs (Razzaghi et al 2003). Blood play with the syringe in the injection site was often reported as useful (to use the whole available drug with out waste) and pleasurable at the same time (Razzaghi et al 2006). This practice seems to also be conducted in connection with sharing practices similar to Syringe-Mediated Drug Sharing among injecting drug users (SMDS) mentioned in other literature (Grund et al 1996) as a part of IDU subculture. Very often, one of the IDUs more skilful in injecting injects other in the group. Among Iranian IDUs these injectors are referred to as the 'doctor'. Apparently similar practice exists in some other Asian countries, where these injectors are described as by "professional injectors" (Raid and Costigan 2002). Rates of sharing are quite high among those using the services of the 'doctor', as he very often uses the same syringe for many clients, this could multiply the chances of acquiring HIV (Kral et al 1999). Nonetheless apparently about 50% of IDUs inject individually in Iran most of the times. Key informants form pharmacies had stated that 60-70% of syringes purchased are by IDUs. Half of the interviewees had shared injection paraphernalia one to two months prior to interview. Sharing in prisons was stated to be the rule. Reasons for sharing were indicated as difficulty of purchasing syringes in inaccessible hours, hesitance of pharmacists to sell syringes and also financial strains. Reason for avoiding sharing was mentioned to be fear of acquiring HIV (Razzaghi et al 2003).

The RSA of 2004 estimated the total number of drug addicts to be between 1,200,000- 1,800,000. In the same study 12.2% of respondents have stated that their main route of drug use is injecting, 16% have stated that they at least occasionally inject. The life time prevalence of injection was 21.1% versus 28.4% for those with a history of imprisonment. Drugs of injection included more drugs than heroin namely opium (1,6%), Sukhteh and Shireh; i.e. Opium Residue and Juice respectively (1.7%), Ecstasy (2%) cocaine, LSD and other drugs (13.9%). 48.1% of heroin users and 90.7% of buprenorhine users were IDUs as well. 50.6% of IDUs start injecting already under the age of 24 years and only 10.2% in ages above 35 years. Three forth of the IDUs were not informed on consequences of injecting drug use. First injections were made in 62.4% of cases by someone else and only 23.4% had self injected for the first time. Injection is conducted usually in 48.5% of cases at home and in 18.9% in ruins including shooting galleries. Sterile syringes are always used by 55.7% of cases; however 84.5% most commonly use sterile syringes. In 49.5% of cases injection occurs alone. 43% had mentioned that they have some time lent or burrowed an already used syringe. Only 11.6% stated to be knowledgeable on the infection status of a co-injector on the basis of testing. More than 50% inject twice or more often a day. 38.8% of IDUs injects in other sites than extremities: testicular, femoral or neck veins. 38.6% had been arrested in the past year by the police and 29.5% had a history of imprisonment (Narenjiha et al 2005).

The Asian Harm Reduction Network (AHRN) conducted 2003-2004 a multi-site research to gain insight in drug careers -or pathways- of young people and the impact that environmental factors have on these careers as well as on drug use related problems. In addition, data was collected with regards to knowledge, attitudes and practices, related to drug use and HIV/AIDS supported by UNODC Iran. Some key findings included: Only 10% of drug users had not finished primary school. Large proportions of young drug users (16%) had migrated to their city of current residence before they turned 19. Heroin is not the only drug of injection and even 6% of opium users mention injecting it. Injecting drug use seems to lower one's chances to hold a steady job significantly. Most respondents describe the effects of most drugs in a largely positive manner. Sharing injecting equipment and other unsafe injecting practices are quite common (about 40% often or always and near 90% answer differently than never). Being injected by a fellow drug user with a used needle is quite common when one first starts injecting. Desperation, as a result of withdrawal symptoms, is the main reason for not using clean injecting equipment. The cost and effort involved in buying new injecting equipment every time are important factors in sharing needles.  Needles for individual use are often used many times. Most non IDUs are aware of health risks related to injecting and this is a major factor in the decision not to inject. Very few non IDUs would readily start injecting if they were offered to do so. Many IDUs appear to be unaware of the health risks that are associated with injecting. HIV/AIDS is mentioned by few IDUs as a drug use related health risk. For many IDUs, the ritual that accompanies injecting is an important part of its attraction. In crucial switches, factors related to the (perceived) effect of the drug are considered very important. For example, the strength (quicker high) of the new drug scores very high, as well as factors such as relaxation/sleep, suppression of feelings, bored with previous high and to enhance confidence. Expectedly, since injecting creates a quicker high, the strength of the new high is of little importance in switches away from injecting. The addictive nature of injecting is widely recognised amongst IDUs, yet IDUs remain optimistic about the possibility to be able to abstain (De Kort et al 2006).

Prisons are recognised worldwide as important sites for transmission of blood-borne viruses (BBVs). There are two reasons why transmission risks in prison are higher than in the community. First, in most western countries, many prison entrants have histories of injecting drug use, and thus already have high prevalence of BBVs. Second, the lack or under-supply of preventive measures (such as clean needle and syringes or condoms) in most prisons, combined with extreme social conditions, creates extra opportunities for BBV transmission ( Hellard & Aitken  2004). History of imprisonment together with history of injection in prison increases the risk of IV infection several times (Krebs 2006; Bruneau et al 2001, Zamani et al 2006). There is little existing research on HIV and IDU in prisons in developing and transitional countries and in many cases the existing data are not recent enough to provide an accurate picture (Dolan et al 2004).

As already mentioned many drug users in Iran have a history of incarceration and or imprisonment. The rate of re-incarceration seems to be about 30% (UNODC/ Regional Centre of East Asia and Pacific Region 2004). In some years up to 400,000 people are convicted because of drug related charges. Most convicts stay 45 days to 6 months in prison (Mokri 2005).

References

1.      Alemi AA. (1978): The iceberg of opium addiction. An epidemiological survey of opium addiction in a rural community. Drug Alcohol Depend. Mar; 3(2):107-12.

2.      Bolhari J, Alvandi M, Afshar P, Bayanzadeh A, Rezaii M, Rahimi Movaghar A (2002): Assessment of Drug Abuse in Iranian Prisons. United Nations Drug Control Programme (UNDCP) Iran, Drug Control Headquarters (DCHQ) (Farsi, not published)

3.      Bruneau J, Lamothe F, Soto J, Lachance N, Vincelette J, Vassal A, Franco EL. (2001): Sex-specific determinants of HIV infection among injection drug users in Montreal. Cmaj;164:767-73.

4.      Dalvand S, Agahi C, Spencer C. (1984): Drug addicts seeking treatment after the Iranian Revolution: a clinic-based study. Drug Alcohol Depend. Sep;14(1):87-92.

5.      De Kort G,  Vazirian M, Nassirimanesh B (2006): Young people and drugs - Towards a comprehensive health promotion policy - Tehran report, Asian Harm Reduction Network (AHRN) Final Report, Thailand (under Press)

6.      Dolan K, Kite B, Black E, Lowe J, Agaliotis M, MacDonald M, Aceijas C, Stimson GV, Hickman M and Valencia G (2004):  Review of injection drug users and HIV infection in prisons in developing and transitional countries. www.ceehrn.org/EasyCEE/sys/files/IDUand%20HIV%20in%20prisons,%20refgr.pdf

7.      Grund JP, Friedman SR, Synn L, Stern C, Jose B, Neaigus A, Curtis R and Des Jarlais Don C. (1996): Syringe-mediated drug sharing among injecting drug users: Patterns, social context and implications for transmission of blood-borne pathogens. Social Science & Medicine; Volume 42, Issue 5 , March, Pages 691-703

8.      Hellard ME, Aitken CK (2004): HIV in prison: what are the risks and what can be done? Sex Health.;1(2):107-13

9.      Kral AH, Bluthenthal RN, Erringer EA, Lorvick J, Edlin BR. (1999): Risk factors among IDUs who give injections to or receive injections from other drug users. Addiction 94:675-83

10.  Krebs Ch P (2006): Inmate Factors Associated with HIV Transmission in Prison. Criminology & Public Policy, (5): 113 

11.  Mehryar AH, Moharreri MR. (1978): A study of authorized opium addiction in Shiraz city and Fars Province, Iran. Br J Addict Alcohol Other Drugs. Mar;73(1):93-102

12.  Moharreri M.R. 1978. General View of Drug Abuse in Iran and a One-Year Report of Outpatient Treatment of Opiate Addiction in the City of Shiraz. In Peterson R (ed) 1978. The International Challenge of Drug Abuse. National Institute on DrugAbuse Research Monograph 19: pp 69 - 79.

13.  Mokri A. 2002a: Brief Overview of the Status of Drug Abuse in Iran; www.ams.ac.ir/AIM/0253/0253184.htm

14.  Mokri A2002b, Brief Overview of the Status of Drug Abuse in Iran. Arch Iranian Med.; 5(3): 184-90

15.  Mokri A (2005) : Substance Abuse Treatment and HIV in Iran; www.uclaisap.org/dssat2005/presentations/Mokri.htm

16.  Narenjiha H, Rafiey H, Baghestani AH et al. (2005): Rapid Situation Assessment of Drug Abuse and Drug Dependence in Iran, DARIUS Institute (In Farsi, not published)

17.  Razzaghi E. M., et al. (1998): Five year plan for drug demand reduction in Iran. State Welfare Organization,. (In Farsi, not published)

18.  Razzaghi EM, Rahimi A, Hosseini M, Madani S. (1999): Rapid Situation Assessment of Drug Abuse in Iran. Prevention Dept, State Welfare Organization (In Farsi, unpublished Executive Summary in English)

19.  Razzaghi EM, Rahimi Movaghar A (2003): Rapid Assessment and Response, Multi Centre Project on Injection Drug Use; WHO

20.  Razzaghi EM, Rahimi Movaghar A, Green TC and Khoshnood K (2006):  Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran. Harm Reduction Journal, 3:12

21.  Reid G. & Costigan G (2002): Revisiting 'The Hidden Epidemic': A Situation Assessment of Drug Use in Asia in the Context of HIV/AIDS. Macfarlane Burnet Institute for Medical Research and Public Health. Centre for Harm Reduction

22.  Siassi I, Fozouni B. (1980a): Distribution of opium coupons to addicts in Iran: policies and problems. Chem Depend.;4(1-2):127-33

23.  Siassi I, Fozouni B. (1980b): Dilemmas of Iran's opium maintenance program: an action research for evaluating goal conflicts and policy changes. Int J Addict. Nov;15(8):1127-40.

24.  Spencer C and Agahi C (1990-91). Drugs and Iran after the Islamic Revolution; prophesying the next quarter century. The International Journal of Addictions. 25 (2A): pp 171-179.

25.  UNODC/ Regional Centre of East Asia and Pacific Region (2004): Summary Report and Recommendations United Nations Regional Task Force on Drug Use and HIV/AIDS Vulnerability Meeting, Including a Joint Session with WHO Bi-Regional Partners on Harm Reduction. Melbourne, Australia; www.unodc.un.or.th/drugsandhiv/PN/TOR_UN_Task_force_on_drugs_and_HIV-GLH.pdf

26.  hjk Yassami MT, Shahmohammadi D et al (2002): Epidemiology of Drug Abuse in  I.R. Iran; Ministry of Health and Medical Education; Drug Control Headquarters (not published, In Persian)

27.  Zamani S, Kihara M, Gouya MM, et al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centres in Tehran, Iran. AIDS 2005; 19:709-16

28.  Zamani S, Kihara M, Gouya MM, Vazirian M, Nassirimanesh B, Ono-Kihara M, Ravari SM, Safaie A, Ichikawa S. (2006): High Prevalence of HIV Infection Associated With Incarceration Among Community-based Injecting Drug Users in Tehran, Iran. J Acquir Immune Defic Syndr. Apr 24 [Epub ahead of print]