The hill tribes of Thailand, their opium use and addiction
Environmental contamination with opium
Prospect for the future
Author: Charas SUWANWELA,, Vichai POSHYACHINDA,, Prida TASANAPRADIT,, Ayut DHARMKRONG-AT,
Pages: 1 to 19
Creation Date: 1978/01/01
M.D., Vichai POSHYACHINDA,
M.D., Prida TASANAPRADIT,
M.D. Ayut DHARMKRONG-AT,
Institute of Health Research, Chulalongkorn University, Bangkok, Thailand
The area extending from the Kachin hills and Shah plateau of Burma to the mountainous area of northern Thailand and northern Laos known as the Golden Triangle is one of the major opium producing areas in the world. It is infamous for its role as the major source of illicit supply of narcotics to the global drug dependence problem. Much of the opium is exported illicitly but a small portion is consumed by local addicts. The people in this area are therefore not only producers of narcotics but also their victim.
This mountainous area is inhabited by minority ethnic people, referred to as the hill tribes. Historically the people in mainland South-east Asia migrated southward from the central part of China. Between the sixth and twelfth century A.D. the Mon-Kmer group whose ancestors were probably of Polynesian-Micronesian stock, occupied this region. The Karen and the Lawa or Lua probably preceeded the Thai in their migration into this peninsula. The Thai created a Kingdom named Nanchao in southern China about the middle of the seventh century and later under pressure from the Chinese they moved on into the South-east Asian peninsula; the largest momentum was around the thirteenth century. The Thai occupied the rich valleys, displacing the original settlers into the hills. The Karen, the Lawa or Lua and the Kha Mu of Mon-Kmer origin then constitute some of the present day hill tribes. They occupy the lower elevation of about 2,000 feet or less. They are growing rice in terraced hill sides. Some Karen later moved into Thailand from Burma. The last southward migration belonged to the real hill people who under prolonged pressure from the Chinese had adapted to inhabitation in areas of high elevation. Some are nomads but some became settled farmers. They practice swidden or slash-and-burn agriculture--cutting down vegetation, burning it, and utilizing the ashes for fertilizer. The field is used until the land is exhausted. They then move to a new area. The Meo or Hmong, the Yao, the Lahu, the Lisu and the Akha belong to these real hill tribes who occupy the high mountain tops with elevations above 2,000 feet. They developed village communities with many sacrificial rites and social customs that passed down by word of mouth. Each tribe has its own spoken language. They are strong animists, believing in the forces of nature. They have the agricultural technique for the cultivation of opium poppy. Highland rice is also grown, but the yield is low. Suitable land for rice cultivation is limited. These real hill tribes have moved into Thailand only within the last one hundred years. Interaction has taken place between these newcomers and the earlier settlers. The Karen are hired as workers in the poppy fields. Some Karen have tried rather unsuccessfully to grow opium poppy themselves. They also become victims of opium addiction. Estimates of the hill tribe population  ,  ,  ,  , 
*This study was a part of the WHO/UN/Thai Programme for Drug Abuse Control, operated in collaboration with the World Health Organization and the .United Nations Division of Narcotic Drugs, funded by the United Nations Fund for Drug Abuse Control.
The Hill Tribe Population, based on data from Project 1971 (17) Project 1974 (18) and Study 1974 (24)
Population in Thailand
|6 000 000||58 000|
China, Vietnam, Laos
|3 000 000||200 000|
|800 000||19 000|
China, Vietnam, Laos
|400 000||10 000|
|200 000||18 000|
China, Burma, Laos
|100 000||9 000|
China, Burma, Laos
Rate of opium addiction Doi Sam Mun (Lisu)
Number of household
Number of population above 10 years
Number of addicts
Percentage of addict
High income household
Middle income household
Low income household
Result of analysis for opiates of urine from hill tribal villagers
|Numberof urinetest||neg||10-40||41-499||500-2000||2001-6400||> 6400|
No history of use
a This person was proven later to actually be an occasional user.
These hill populations can no longer be considered as isolated people to be left alone. Increasing contact with the outside world, especially the low-land Thai, is inevitable and poses a number of political, social, economic and medical problems. For example, their role as opium producers is one of the leading concerns. The deforestation from swidden agriculture is endangering the nation's water conservation.
In Thailand Christian missionaries have been active in providing medical and other services to the villagers for many years. The Border Patrol Police forces have been stationed in some hill villages and have also served as teachers. HRH the Princess Mother periodically visited these villages and established many schools. His Majesty the King developed the Hill Tribe Development Projects,1 which include agricultural research and training, livestock-raising, handicraft and other community development. The Forestry Department which has the responsibility for these hill areas, has a rather extensive reforestation programme. Some hill people are hired for the programme which provides an additional source of income, as well as a source of modern commodities. The Public Welfare Department has an active Hill Tribe Development Section. Hill Tribe Development and Welfare Centres were established and comprehensive development projects are undertaken.
In 1970, a comprehensive programme was drawn up in collaboration with the United Nations, which led to the signing of an agreement with the Government on 7 December 1971.2 One of the major projects in this programme is crop replacement. In collaboration with His Majesty's Projects, the UN/Thai Programme for Drug Abuse Control (PDAC) is undertaking researches on highland agriculture in which many prospective crops are tried. Five key villages and 20 satellite villages were selected as pilot projects for extension of the crop replacement activity and other development in the hill tribe villages. Agricultural extension stations, schools and in some villages health stations have been erected.
As for the treatment of addicts, a number of Buddhist temples have for years rendered opium withdrawal services by an indigenous medical method. The Ministry of Public Health has also provided treatment both by sending the addicts to the Treatment Centre in Bangkok and by sending medical teams into the villages  ,  ,  ,  . In 1975, the Hill Tribe Addiction Treatment Centre was started at the Chiengmei University Medical School by the UN/Thai PDAC, in collaboration with the Ministry of Public Health and WHO.
In 1976 and 1977 a medical survey team from the Institute of Health Research, Chulalongkorn University, made a survey of the health status and opium use in seven of the UN/Thai PDAC villages (figure 1)  . Health service personnel examined the villagers and a household survey was carried out as a means of gathering information. Opium use and addiction as well as health knowledge and attitudes were included in the inquiries, and urine sample quantitative analysis for opiate alkaloids were carried out by radioimmuno-assay (table 3). Treatment was provided for those found with disease, and health education was given whenever the situation permitted. An independent effort was made to identify all regular opium users through the village health workers and through informed villagers and confirmed opium users during repeated visits. Given the close knit social environment of these villages, and the absence of any punishment for opium use, it is unlikely that many regular opium users escaped identification. An intervention programme is now being tested at a Meo and a Karen village in order to gather information on an appropriate system for health care delivery and related problems as well as to evaluate the impact of health care development ant treatment of opium addicts.
1 See Bulletin on Narcotics, XV:2, 42 (1963) (editor's note).
2 Ibid., XXVI:1, 45 and 63 (1974; previous reports were published in Bulletin on Narcotics, XX:3 (1968) and XXI:1 (1974) (editor's note).
FIGURE 1 - Map of Chiengmai province showing the sites of the UN/Thai PDAC key villages.
The socio-economic system varies among the different tribes which have different languages, customs, beliefs and ways of life  ,  ,  ,[ 6] ,  ,  ,  ,  ,  ,  . For example, the Meo observe a strict patrilineally extended family and have a strong sense of ethnic identity. Wives have to live with their husband's family and serve as the labour force in the family. A Meo rarely marries someone outside his or her tribe. On the other hand the Karen has a less rigid matrilineal society. Many Lisu were found to marry low-land Thai and other tribes.
A common socio-economic pattern, however, can be outlined. In principle, the hill tribes can live rather autonomously, depending on the outside world for only some commodities. They grow rice, maize and opium poppy as well as vegetables. Some tribes also produce peaches, tobacco and other products, the excess of which can be sold to other villages or to the low-land market. Rice is for local consumption. For the Meo rice production is usually enough for only three to, at the most, nine months' consumption. The villagers have to buy rice from the Lawa or the Karen who occupies the lower altitude and use the better yielding wet terraced rice fields. The villagers usually keep livestock such as cows, pigs, chicken and horses. Maize is used to feed pigs and chicken which are used in sacrificial rites. They are later consumed, being the source of animal protein. Opium is the main source of cash income which is used to buy supplementary rice and other commodities such as salt, kerosene and certain luxury items as sewing machines and tin sheets for roofing.
The hill tribe villagers live very close to nature and are at the mercy of nature. The swidden agricultural technology depends on land, labour and climate. The villagers have to move their farmland to a new fertile site after the original one becomes less productive. The success of this system depends on the availability of new or regenerated land for farming. To find this has become more and more difficult in the northern Thailand area. The social custom of extended family helps in providing the required labour force. It can be observed that the wealthiest household in the village is usually the largest one with many generations living together as an extended family. They have to work hard in the farm in order to get satisfactory production. Additional labour for the household farm derives from hired hands. The wealth therefore also depends on the managing ability. The Meo usually hire the Karen to work in their farm. Wealthy Lisu men hire fellow Lisu or Karen or Shan (Thai-Yai). Consequently social and economic classes develop among the hill tribes. Nature also plays an important part in the hill tribal economy. Their farm produce depends greatly on the temperature and rainfall patterns. In certain bad years, the produce is barely enough for them to sustain their living. They have learned to keep excess wealth from good years in the form of silver ornaments and coins. Diseases not infrequently damage their livestock. In a certain year, an epidemic practically wiped out the pigs and chicken in the village.
Some villagers also fall victim to the money-lenders who charge very high interest. Haw living in the village and some low-land Thai serve as merchants and lenders.
Based on the said economic set-up, most hill tribe villagers are poor while some are fairly well off with income higher than the Thailand national average.
The health practice in the village is still primitive, based upon legendary beliefs. Natural beings are thought to be inhabited by spirits - house, village, mountain, stream, forest etc. Human beings possess a soul which can wander out of the body during sleep, sickness or death. The believe in the concept of heaven and hell as the after-world with the presence of gods and ancestor's spirits. Sickness and poor health is thought to be induced by spirits and gods. Nature spirits may be offended; evil spirits may enter the human body; the licence to live as dictated by gods of heaven may expire. Germ theory is practically unknown. The life pattern is dictated by convenience, common sense and customary practice, some of which may have originated from health reasons. Herbs are used to treat the sick, in addition to sacrifices to spirits. Opium is known to be effective as medecine for may conditions.
In some villages, Christian missionaries have been active in providing health care and advice. Government officials from the low-land such as border patrol policemen, forestry officials, public welfare officials and agricultural extension workers are better informed on health matters and have more access to modern drugs than the villagers. Out of necessity, they serve some health needs of the villagers. Quacks from the low-land also roam the villages with modern drugs. Proprietary drugs such as acetyl salicylic acid preparations are available through the village traders. Occasionally villagers go to town in the low-land area for trade and medical care.
From our surveys, the health problems in the hill tribe villages can be summarized as follows:
Population. The birth rate is very high but the population growth is damped by the high mortality rate. Infant mortality rate is especially high. It is therefore imperative that a family planning service is available to the villagers at the same time as the introduction of health cares.
Health education and hygiene. Poor personal hygiene and poor environment is responsible for a number of health problems. The villagers do not have the right concept of health and its promotion. Only through education can a long-term result be expected from a development programme.
Sanitation. Diseases related to faecal contamination of soil such as hook worm, pin worm and round worm are prevalent among the villagers. Houses are usually small and crowded, with poor ventilation. Most villages, being in the hilly terrain, have enough water but the sources are usually contaminated by human and animal excreta. Villagers with few exceptions have no latrine. Improvement of houses and surroundings will contribute to better health.
Preventive care. Preventable communicable diseases exist in the village. Whooping cough and diphtheria are responsible for some deaths among infants. Tuberculosis is a problem in some villages. In other villages the results of tuberculin test were all negative, indicating the absence of tuberculous infection. Increasing contact with the outside world has been seen to bring certain epidemics and is undoubtedly hazardous to the villagers. A vaccination programme should be an important part of the villages health programme.
Endemic diseases. Urinary stones, malaria, thyroid goitres and diseases due to nutritional deficiencies are found to be exceptionally common in some villa- ges. Investigations into these problems are required in order to find the appropriate way of alleviation.
Care of the sick. As stated earlier, no medical care is available in most villages. A satisfactory health care delivery system needs to be established, including primary care as well as a referral system.
Opium, cultivated in the village itself or in neighbouring villages, is usually available to the villagers. Its properties and uses are known to the villagers. In surveying opium users in the village based upon interviews, health examination and urine testing for opiates, three types can be discerned; the addict, the occasional user and the non-user. The usual mode of taking is smoking an opium pipe. Some take opium by mouth. It was also seen applied to skin lesions.
It is impractical to separate the occasional users into experimenters, occasional and habitual users as in some reports dealing with urban populations because of the hill tribe situation; a single person may shift from one to another pattern depending on illness or other factors. The distinction between frequent users and addicts is also not very precise. A person who stated that he was not using opium every day, requested to be detoxified. On the other hand, addicts who personally accepted their undesirable status were using variable amounts of opium with variable frequency. Strong withdrawal symptoms were observed in some addicts during their detoxification, even though they used only small amounts of opium once daily. Addiction to opium therefore can not be based solely upon the amount of drug used or the number of users a day. In our study, a confessed addict means a person who accepts that he needs to use opium daily and would experience withdrawal symptoms in its absence. In the majority of cases it is not difficult to identify an addict, except in his initial stage. In a Meo village with a population of 225, of which 138 were above 10 years of age, there were 7 occasional users, and 11 addicts. e
FIGURE 2 - An opium pipe and smoking utensils which include an oil lamp, metallic cups, iron rods and a lighter. Note a black rod of partly prepared opium in the cup. It belonged to a Meo addict.
FIGURE 3 - (1) A typical opium pipe made of wood and silver; (2) a make-shift opium pipe made of a simple bamboo rod belonging to a poor 16-year-old girl who recently became addicted; (3) an iron wire which was used to prepare opium, and to make a hole in the mass of opium on the pipe as well as guiding opium into the pipe-hole; (4) chunks of raw opium.
1. The smoking process. Opium smoking was observed on several occasions. Most smoke in a lying position on their side in the bedroom or on the couch in the common room while few sit. The smoking utensils included a pipe, a wax lamp, a metal cup, a metal box and an iron wire. The pipe was made of bamboo rod of about 12 to 15 inches long. At the end was an enlarged bowl made of wood, silver or clay. On the side of this bowl was a hole. There usually was a black deposit around this hole from previous smoking. Some poor addicts used a simple bamboo rod with a side hole as their pipe (figures 2 and 3).
They would at first light the wax lamp; the thread was cut to an appropriate length in order to get a proper size of flame. A piece of opium about the size of a thumb was then warmed on the flame and was kneaded between the fingers and on the back of the metal box or in the cup. After a while when the opium became black and had the right texture, it was rolled into a long rod. Part of the rod, one third or one fourth, was used for each smoking. The piece of opium was then attached to the end of the iron wire and again heated on the lamp. It was molded into a round mass.
This mass of opium attached to the iron wire was then placed on the hole to the side of the pipe. A small hole was made through the mass of opium by the iron wire. The opium was then placed on the flame and allowed to burn while the pipe was placed in the mouth. The smoke was inhaled repeatedly. In the meantime the iron wire was used to guide opium residue into the flame at the pipe-hole. This whole process was called a "bong" or "pipe". In each session they would take three or more "pipes" depending on their desire and available opium (figures 4 and 5).
The black deposit on the pipe, around the hole and inside the pipe was collected for subsequent smoking. Some smokers mixed this charred residue with analgesic powder which came in aspirin tablets or in patent packages. It was added to opium to increase the bulk.
2. Reasons for opium use. For each villager especially the occasional users, the reasons for opium use may change with each use. A combination of reasons also occurs and it is difficult for them to state the reason for their continued use and for their eventual addiction. Nevertheless the reasons for use can be classified into 3 groups as follows:
FIGURE 4 - A 56-year-old Meo addict who had used opium for 30 years. He was smoking in his bed. Note also a pack of cigarette which was used both before and after opium smoking.
FIGURE 5 - A group of four Karen hired hands in a Meo's house during an opium smoking break. Three of them were smoking opium in lying position, while the fourth was smoking a self-made cigarette after his opium session.
(a) Opium as a therapeutic drug. As mentioned earlier, the hill tribes are primitive and are suffering from many diseases. Herbs, proprietary drugs and sacrificial offerings are the only available means for treatment of sicknesses. They are not very effective. Opium is known to the villagers to be effective in relieving many illnesses such as pain, diarrhoea and cough. Abdominal pain, headache and backache are among the common reasons given for opium smoking.
For a number of acute illnesses which subside spontaneously, opium may be used only once or for a few days and then discontinued. Some illnesses become chronic and continued use leads to addiction. Peptic ulcer, pulmonary tuberculosis, injuries and urinary stone are among the leading diseases with this potential.
A number of villagers stated that they used opium to relieve general ache and pain. On physical and laboratory examinations no specific disease was found responsible for the complaint except poor general health. Anaemia, malnutrition and parasitic infestations are common among the villagers. Their diet is inadequate; rice and boiled vegetables constitute most meals. Only occasionally meat is available. They have, on the other hand, to work very hard in the field in spite of poor health and improper diet. Overexertion and poor general health may be the origin of general ache and pain for which opium smoking provides a refuge.
(b) Opium as a psychoactive drug. The tranquillizing and euphoric effect of opium smoking is known to the villagers. A number of them stated that they used opium at the time of severe sorrow from bereavement of a beloved one such as wife and children.
Some stated that they used opium because they could not sleep. During certain crises, the situation in the village is tense either from security or economic reasons. Rumour of an impending police raid on opium or of bands of robbers approaching the village creates anxiety which sometimes lasts for weeks. Loss of livestock from epidemics or loss of farm produce from bad weather or other causes results in serious concern and anxiety.
In few instances, behavioural problems could be the reason for opium use and addiction. For example a 16-year-old woman moved into Ban Phui village after her family were all killed in a raid in another province. She was severely depressed and started to use opium. On closer examination she was found to be childish and had frequent quarrels with her husband on trivial matters. The reason for her addiction could be her past experience, which required the only available tranquillizer, opium.
Economic stress may also play a role in the opium use and addiction. In a Lisu village, Doi Sam Mun, villagers of the same tribal designation and similar custom could be divided into three economic classes (table 2). The high income ones were those who owned opium fields and hired fellow villages to work in their farm. They usually had better houses, some with a tin roof and windows. The addiction rate was only less than 2 per cent of adult population. The middle income households also had their own farm which they tended themselves. They hired hands to help at peak activity. During free time, they also worked for the agricultural extension or forestry stations for wages of 20 bahts (about US $1) a day. The addiction rate in this group was 2.9 per cent. In a section of the village, five houses belonged to the poor class. They did note have their own farm and their income was derived from daily employment. About one third of the adults in this group were opium addicts. So far as we could enquire, this situation existed for more than one generation. It is still a moot matter whether opium addiction contributes to the cause of their poverty or is the effect. Nevertheless a child born into this depressed subculture is likely to be subjected to the same socio-economic stress.
Economic stress was also apparent in poor Karen villages which had several addicts. A number of addicts own no farm; they derive their income almost exclusively from daily employment;
(c) Opium as a mean of recreation. In the evening, villagers were seen to sit together around the fireplace in certain houses. Men were chatting, drinking tea or local spirits, and smoking a tobacco water-pipe or cigarettes. Some who were opium addicts would also smoke opium in the nearby couch or bed. Friends who were occasional smokers could join in for some reasons such as illnesses or sorrow, as stated earlier. A new experimenter might have started in this way.
A 40-year-old Meo male at Khun Wang village gave a history of opium addiction since the age of 16. He and a group of friends enjoyed travelling as young men to visit other villages. Out of curiosity and companionship everyone in his group tried opium smoking. Two years later he became addicted.
It was also observed during a funeral ceremony in a Meo village that the host served opium to guests who came to help in the ceremony. As many as four or five addicts were seen lying together smoking opium. New experimenters and occasional users were of course welcome.
This evidence indicates that the habit of opium smoking may be acquired at the time of social gathering when opium is freely available, favoured by a benign attitude towards opium smoking.
3. Attitude toward opium use and addiction. The villagers are indeed aware of the bad effect of opium addiction. We were told that according to the religion of certain Meo groups, addicts could not go through the door to heaven after their death. A number of older villagers, some of whom were opium addicts themselves, stated that younger generations should be discouraged from opium smoking.
In the hill tribe villages, opium smoking is done openly among other members of the family including children. An addict would not hesitate to let us observe or take photographs of the activity. Some young female addicts, of course, are ashamed of their behaviour and smoke in privacy or in the woods. The utensils and opium are usually available in the houses.
In our survey villagers were asked to state whether they considered opium smoking to be good or bad and to give their reasons. Among 46 adults, some of whom were addicts, 70 per cent stated that opium smoking was bad for various reasons, in particular loss of money. Three believed that it was bad except in certain situations namely old age, sickness and for some persons with whom opium smoking was "compatible". Seven considered opium smoking as good; four for its ability to cure certain diseases and three for making people feel better and able to work.
It was very surprising to us to find that the urine test revealed the presence of opiate alkaloids in urine from a large number of villagers, including confirmed non-users. For some non-users the concentration was as high as 1,800 nanogram/ml. Unconscious consumption of opium would be the likely explanation, and this was investigated.
It was observed that Karen addicts were hired to pound and husk rice for Meo. They were paid in opium which was smoked between the work sessions in the Meo's house. As mentioned earlier, addicts use their hands to prepare opium in the process of smoking. They then worked on rice without washing their hands. Rice samples were taken from houses and were analysed for opiates. They were found to contain traces of opium.
Opium poppy seed is used by hill tribe villagers. It was seen eaten raw by childen playing in the poppy field. It was also prepared with sugar into a tasty biscuit. When cooked it was eaten with rice. On New Year's day, rice pastry with poppy seed was prepared in the Lisu village. The seed oil obtained was used in cooking. On sereval occasions members of our survey team took poppy seeds in the form of biscuits or pastry. Analysis of their urine samples repeatedly revealed traces of opiates. Two volunteers were given 5 grams each of poppy seed by mouth and their urine contained as high as 300 nanograms of opiate/ml, at about eight hours after the ingestion. Water extract was made from the poppy seed and analyzed for opiate-alkaloids. It was found to contain 28 microgram of opiate alkaloids in one gram of seed.
Sitting by someone smoking opium in the poorly ventilated house was studied on several occasions. So far it failed to show demonstrable opiate in urine.
Further investigations concerning the source and the possible effects of environmental contamination are in progress.
1. The rate of addiction among hill tribes. The survey conducted by the Government of Thailand in 1965-66 reported that there were relatively few opium smokers among the hill tribes. It estimated that opium addiction was 9.55 per cent of the population for the Meo, 11.17 per cent for the Lahu and 15.9 per cent for the Yao. The United Nations Survey Team  in 1967 referred to these figures and added that there was opium addiction and occasional smoking among other tribes such as the Karen, Akha and Lisu. On the other hand Lewis  , a misionary who spent many years with the Akha, stated that the range was extremely great between villages.
In our survey of six villages (table 4) the rate of addiction varies from 6.6 to 16.8 per cent of the population above 10 years of age. For the village of Ban Khum, many Lahu inhabitants moved to other areas for rice farming during our survey in April. The more active villagers were away and a higher proportion of addicts were encountered.
2. The addiction pattern. Opium use and addiction exists in the hill tribe villages, especially those opium producers for generations. In studying the year of first daily use of opium among 1,382 addicts who were admitted for treatment at Chiengmai Treatment Centre, it is evident that opium addiction has probably been a steady feature. For those older than 40 years of age, the year of first daily use spread rather evenly over the past 20 years (figure 6)
In our interview with three Karen elders in Ban Phui, a Karen village, we were told that opium use and addiction did not exist in the village until the last 30 or 40 years when Meo moved into the neighbourhood and started growing opium poppy. Meo then hired Karen to work on their farm and introduced Karen to opium.
Rate of addiction in surveyed villages
Number of household
Number of population above 10 years
Number of addicts
Percentage of population above 10 years of age
Ban Phui Tai
Ban Khun Wang
Doi Sam Mun
Ban Phui Nuea
Ban Yang Khun Wang
Ban Khob Dong
* For the Lahu in Ban Khum, the figure covers only part of the population because some villagers were away to distant farms during our survey.
FIGURE 6 - The distribution of number of hill tribe addicts according to the years of first daily use of opium. They were among those admitted for treatment at the Hill Tribe Addiction Treatment Centre in Chiengmai. Only those over 40 years of age were shown in this figure. The peaks seen at 1956 and 1966 were probably due to a tendency to recall their opium experience in term of decades rather than years. The distribution shown here indicated that opium addiction was prevalent in this population for a long period of time.
Based on information from those admitted for treatment, all tribes are affected by opium addiction (table 5). Karen, Lahu, Meo and Akha appeared to be more seriously affected than other tribes.
The amount of opium ranged from a half to twenty "mu" m a day 1 mu = 1.5 g). The mean daily amount for those admitted for treatment from all tribes was 3.9 g for men and 3.2 g for women. The Meo and Akha used more than other tribes, the mean was 5.0 and 4.9 g/day, respectively. The amount for each individual was said to increase whenever they were sick or when more opium was available.
The majority smoke opium. A few take it by mouth. Some readjusted the habit to suit their activities. For example, a 56 year-old Meo was addicted since the age of 40. He made opium into pills and took them in the morning and at noon, while he had to work on the farm; this was apparently to prevent withdrawal symptoms. In the evening he smoked his pipe in order to get the full effect. He stated that opium smoking made him slow and unable to work in the field. Oral intake did not have this untoward effect. A number of addicts who wanted to stop the habit changed from smoking to taking it by mouth, as an initial step.
Distribution of opium addicts by tribe, admitted for treatment at the Hill Tribe Addiction Treatment Centre, Chiengmai, October 1975 - December 1976
Number of addicts
Among 75 addicts identified in our intensive survey of tribal villages, the age of addicts ranged from 16 to 75 years. 92 per cent was above 30 years of age. The most frequent age was between 35 and 55 years (59 per cent) (figure 7).
FIGURE 7 - The age distribution of opium addicts who were found in our survey of seven hill tribe villages. THE AGE DISTRIBUTION OF OPIUM ADDICTS, IN HILL TRIBAL VILLAGES. (n = 75)
For those addicts seeking treatment at Chiengmai Treatment Centre, the mean age was 35 years. Younger addicts had more tendency to travel to the Treatment Centre.
The male:female ratio in the village survey was 3:1. The addicts were from all income levels, but the prevalence appeared to be higher among the lower income group.
3. The causes of addiction. As mentioned earlier, the reasons for opium use are many and complex.
Based on the experience in a mobile treatment team, Uneklabh  reported that in 49 per cent of the cases studied addiction was due to physical illness; in 43 per cent the result of mental frustration or sorrow as well as curiosity, while 5 per cent were due to environmental causes. Komkampan and Chaipikusit  surveyed the same group as Uneklabh, and reported different figures; 67 per cent due to physical illness and 24 per cent due to curiosity. In the remaining 9 per cent opium was used to alleviate pain and ache from overwork in the field. Lewis  stated that about 50 per cent of Akha addicts used opiates because of physical illness. He also described the use of opium in a social setting and as a means of recreation.
In our survey, 80 percent (N = 30) of the Meo addicts gave physical illness as its cause. The figures appeared to be slightly lower for other tribes.
4. The effects of addiction. Opium addiction was observed to have detrimental effects on individuals as well as on the socio-economic situation of the community.
(a) Effect on economy. The villagers themselves recognized the loss of individual wealth through opium addiction.
The retail price of opium in the villages varies from 2 to 5 bahts a "mu"; the average is 3 bahts (1 baht = 25 US cents). The average expense for each addict is therefore 9 bahts daily or 3,000 bahts annually.
For the wealthy villagers such as Meo and some Lisu, whose annual income for the household is above 10,000 bahts, the effect of addiction may not be apparent. They are also usually opium producers and can keep part of their produce for their own use. On the other hand the poor villagers who live on wages from labour, 10 bahts a day for Mae Cham and San Pa Tong regions and 20 bahts a day for Chieng Dao and Fang regions, the economic drain is very serious. They hardly have enough money left for food, let alone other less necessary items. This is apparent in the Karen, Lahu and some Lisu tribesmen.
The economic system is also based on managing ability as well as funds for initial investment. There is then limited chance for these poor addicts to find a way out of this vicious cycle of poverty-anxiety-addiction.
(b) Effect on health. Since the primary reason for opium use is frequently illness and poor health and since opium can only suppress the symptoms without curing them, the underlying disease may be masked and continue to progress. Partly out of necessity, the sick will continue to work very hard after their symptoms are suppressed by opium. The disease may then be aggravated. Tuberculosis is a good example. Their life expectancy is therefore shortened.
Many addicts appear thin and pale. Their personal hygiene is worse than that of fellow villagers. Some are rather lazy; they sleep late and work only periodically.
In contrast, it is not unusual to see a villager who has been addicted for 30 or 40 years actively working. They are indeed productive members of the household. These are two extremes with many in-between.
When addicts were asked to recall their ability to work before and after addiction, most stated that they were less productive afterwards. Some, however, could not work at all previously and opium kept them going. For example, a 39-year-old Meo male was addicted for three years because of swelling of both legs and generalized weakness. In early 1975 he had an opium withdrawal treatment. He was able to stay away from opium for 7 months but the leg swelling recurred. He was admitted to the hospital twice and was told to have kidney disease. His condition did not improve after his return from the hospital. He went back on opium and two months later near the end of 1975 he went for a second detoxification. Upon his return to the village the leg swelling returned and he could not work adequately. He decided to go back on opium and has since been able to earn a living as a farmer and as the village's silversmith.
(c) Effect on social status. Addiction is not considered to be a bad habit for aged members of the family. The villagers however are aware of the fact that addicts do not have a bright future and would not make a good spouse. It is more difficult for an unmarried addict to find husband or wife. For example in Ban Khun Wang Meo village, all men and women were married by the age of 20 except one addicted man who remained single at the age of 50.
(c) Effect on the community. Lewis  classified hill tribe villages according to the number of addicts in comparison to the number of households in the village. If there were more addicts than the number of households, the village was considered to be disintegrating.
When a large proportion of the villagers are addicted, one can see the deterioration of the houses and the lack of utilities.
Even though the hill tribe villagers are primitive and uneducated, they are hard-working and intelligent. They are aware of their problems and possess the will to fight for improvement. They know that opium cultivation is illegal. The villagers do not find enjoyment in constantly moving and rebuilding their village, but so far this is the only way of life they have known with their agricultural technique. They are feeling the progressive limitation of the available fertile land. For some tribes, life has been very difficult indeed.
Opium plays an integral part in the villagers' life. It is the main source of cash income and also a means of payment for hired-hands which are essential to the village economy. Opium is also used by the villagers as drugs for treatment of physical illnesses as well as psychological suffering. As a psychoactive substance, it has found its way into the socio-cultural setting of the village life.
To rid the villagers of their opium habit is a difficult and complex task. The availability of medical care alone would not stop the villagers from opium use. On one occasion while our medical team with three qualified medical doctors were in a village, a number of villagers had measles. Symptomatic treatments for fever and cough were given. On the third day of treatment one of the patients, an 18-year-old boy, was given opium to smoke by his father who was also an occasional smoker. The reason given was the persistent cough.
Paradoxically we had given him Brown Mixture for cough which contains opium. The villagers faith in modern medicine needs to be established together with their realization concerning the harmful effects of opium addiction.
Besides, many chronic diseases and pain are not readily amenable to modern medical care and opium will continue to be used in spite of the presence of a health station and health personnel. Change of attitude through education is needed before opium use can be eliminated or limited to certain acceptable conditions.
The health care programme for the villagers needs to be a comprehensive one including family planning, health education, sanitation, preventive measures and care for the sick as well as treatment of addicts. It has to go hand in hand with other community development, namely economic growth and literacy. Considering the limited national resource, the villagers should be helped to be able to help themselves. A programme for training of villagers to be village volunteer medics is being tried. For some villagers, the socio-economic stress appears to be responsible for their opium addiction. Under-development, poverty and ill-health are closely interrelated. Reduction of this stress would require an extensive social and economic reform which is difficult to accomplish.
The treatment of addicts has so far been unsatisfactory. Many treated addicts became readdicted soon after their return to the village. On the other hand, a number of ex-addicts were found to be still off the drug several years after a simple withdrawal treatment. The success depends largely on the individual, especially his or her motivation. In approaching this problem, identification of the interplaying factors in each individual addict is essential in the proper selection of goal and method of approach.
This study is a part of the United Nations/Thai Programme for Drug Abuse Control, operated in collaboration with the World Health Organization and the United Nations Division of Narcotic Drugs with support from the United Nations Fund for Drug Abuse Control.
The authors are very grateful to Mr. I. M. G. Williams, Director of the UN/Thai PDAC who has done far more than his call of duty to assist this study. Without his support, this work could hardly have been done.
They would also like to thank Dr. Somsong Kanchanahut who made available the medical records of the Chiengmai Hill Tribe Treatment Centre.
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