Opium use in two communities of Pakistan - a preliminary comparison of rural and urban patterns

Sections

Abstract
I. Introduction
II. Methods
III Results
IV. Summary and discussion
Acknowledgements

Details

Author: W.H. McGLOTHLIN, M. MUBBASHAR, M. SHAFIQUE, P.H. HUGHES
Pages: 1 to 15
Creation Date: 1978/01/01

Opium use in two communities of Pakistan 1 - a preliminary comparison of rural and urban patterns

Ph.D. W.H. McGLOTHLIN Department of Psychology, UCLA, Los Angeles, California, and National Institute on Drug Abuse career investigator
M.D. M. MUBBASHAR Central Government Hospital, Rawalpindi, Pakistan
M.D. M. SHAFIQUE Mental Hospital, Peshawar, Pakistan
M.D. P.H. HUGHES Division of Mental Health, World Health Organization, Geneva, Switzerland

Abstract

Interviews were conducted to clarify drug use patterns and characteristics of opium users in two communities. Because of the small number of subjects selected from only two communities, the results are not representative of the country as a whole. Nevertheless, in the city of Rawalpindi 90 users were studied and found to have a mean daily opium consumption of 0.9 grams at a cost of Rs. 1.00 ($US 0.10). Opium was taken by mouth once or twice daily. They were solitary users who first used opium as adults, most often for self-treatment of health disorders. The majority were employed males with no history of criminality.

In the rural opium-producing village, 28 users were interviewed. They smoked opium three or four times a day in a social setting and reported a mean daily consumption of 11 grams. They were more likely to use the drug for its social and pleasure effects and to have addicts as close friends. The high dose was associated with adverse effects on work performance and with more severe withdrawal symptoms. The findings suggest different intervention strategies for the two populations.

I. Introduction

A pilot feasibility survey of opium users was conducted in Pakistan in September 1976. Because of the exploratory nature of the study, the small number of subjects and selection of the sample from only two communities, the findings should not be seen as reflecting the patterns of opium use in the country as a whole. In the absence of other data, however, this preliminary study of the characteristics of rural and urban users may be of interest to planners who are developing programmes for opium use in other settings.

1 This was a collaborative study of the Pakistan Narcotics Control Board and the World Health Organization Research and Reporting Project on the Epidemiology of Drug Dependence. The study received financial support from the UN Fund for Drug Abuse Control and administrative support from the UN Division of Narcotic Drugs.

The survey was conducted at an early stage in the implementation of the World Health Organization component of the UN/Pakistan Programme for Drug Abuse Control. The objective was to develop preliminary information relevant to programme planning in communities scheduled for the introduction of prevention, treatment and rehabilitation services. Two samples of opium users were interviewed, one in the urban area of Rawalpindi and the other in a rural poppy-producing village in the North West Frontier Province. The interviews gathered information on drugs used, on dose and pattern of use, and on the characteristics of opiate users. This report reviews the methods used as well as preliminary findings on the differences observed in the two populations.

II. Methods

The interview schedule required 30-45 minutes to administer through an interpreter. It included use of opium by father or other relative prior to the respondent's use, reasons for initial use, amount and cost of opium purchased on the interview day, the duration of use, route of administration, times per day, periods of abstinence and change in amounts used over time. Other questions pertained to effects of opium on health, sexual performance, work, family relations, financial status and to the attitudes of spouse and family towards opium use. Further questions pertained to current employment and income, whether the cost of opium restricted the amount used, the respondent's attitude about terminating use and willingness to apply for treatment if it were available.

URBAN SAMPLE

The urban subjects were interviewed in Rawalpindi in North Central Pakistan with a population of 615,000. As in other parts of the country, opium is available through licensed shops where it can be legally purchased for oral use; opium smoking is illegal. In a separate report (McGlothlin et al., 1978) the authors describe a one day count of opium "vend" customers which they used to estimate the number of opium users in the city to be about 2,800. For the current study 90 vend customers (86 male and 4 female) were interviewed over a period of one week in September 1976. The sampling was essentially random-when an interview was completed the next customer was approached. Although subjects were paid Rs. 10 ($US 1.00) some refusals occurred. Because some customers left before adequate contact could be made, an accurate refusal rate was not obtained. The few persons who indicated they were buying for another party were not interviewed, and no attempt was made to interview the ultimate recipient. Respondents were interviewed in a nearby restaurant or shop and in general were quite co-operative and appeared to have no hesitation in answering questions.

RURAL SAMPLE

Opium is cultivated in the North West Frontier Province of Pakistan-licitly in the settled districts under an elaborate licensing system, and illicitly in the tribal belt where narcotic laws are not applicable at present. To the extent that information is available, opium use appears to be minimal with the exception of certain communities. One such village is Kuria (population 850) in District Swat; it is known to have an exceptionally high rate of opium smoking. The practice began some 40 years ago when a resident of a nearby village settled in Kuria. He had worked for a time in Mardan, and during this period acquired an opium smoking habit. On coming to Kuria he introduced the practice to the local residents and the current estimate of addiction among male adults-supported by two surveys-is at least 50 per cent. One survey (Pakistan Narcotics Control Board, 1975a) attempted to enumerate the total population of smokers frequenting opium dens in the North West Frontier Province, which has an urban population of 1.2 million. Of the 618 opium smokers identified, 112 were located in Kuria and surrounding hamlets. Of the 43 opium dens located in the Province, seven were in Kuria.

In the other survey one-half the households in Kuria were visited and 52 opium addicts were identified (Pakistan Narcotics Control Board, 1975b). In the other five villages sampled in the opium cultivation area, only eight cases of addiction were reported, confirming that the high rate of use in Kuria is atypical.

In the present study, no attempt was made to collect further data on the prevalence of opium use in Kuria. Rather, a convenience sample of 28 users was interviewed over a two-day period. A local school teacher aided in obtaining respondents, who were paid Rs. 5 for their participation.

III Results

DOSE AND PATTERNS OF OPIUM USE

All 90 urban subjects were daily opium users and all but one consumed it only by eating. The mean amount consumed per day was 1.26 grams and two-thirds (67 per cent) took one gram or less per day 2. In reviewing the data, however, the authors noted in that subjects who purchased a one-day opium supply are over-represented in the sample, and they reported higher daily opium consumption than those who purchased for two or more days. The data were therefore weighted to correct this bias toward daily customers and the weighted sample was found to have a mean daily opium consumption of 0.93 grams with 84 per cent taking one gram or less per day. Because government excise opium can be purchased through the vends at Rs. 2.0 per gram and non-government or illicit opium can be purchased through the vends for as little as Rs. 1.00 per gram, most urban users can support their opium habits for Rs. 0.9 ($US 0.09).

Of the 28 rural subjects, 24 smoked, 2 ate and 2 both ate and smoked opium 3.Twelve of the 28 rural users were opium cultivators; for the remaining 16 the mean cost per gram was Rs. 0.3 ($0.03) and the mean cost per day was Rs. 2.9 ($US 0.29). shows their mean daily consumption to be 10.7 grams, which is 11 times the corrected daily consumption of the urban sample.

2 A 1972 survey of vend customers in the city of Lahore reported the mean daily consumption to be 0.8 gms., with 92 per cent using one gram or less per day (Hussain, 1972).

3 The smoking preparation is called mahdak. It is prepared by dissolving opium in water and boiling the solution until a thick paste (chandu) is produced. This is then mixed with charred barley husks and smoked in a water pipe or chilum. In other areas the paste is made into a small ball and heated over a lamp flame. The smoke is inhaled through a long-stemmed pipe with a small opening in the bowl.

TABLE 1

Daily opium consumption: urban sample

 

Interviewed sample (N=90)

Weight sample a (N=256 user days)

Daily consumption (gms.)

Number

Percentages

Number

Percentages

0.5
10 11 44 17
0.5-1
50 56 171 67
1.1-2
22 24 31 12
2.1-5
7 8 9 4
5.1-10
1 1 1 0
TOTAL
90 100 256 100

a The weighted data correct for differences in the daily consumption as a function of the number of days' supply purchased.

TABLE 2

Daily opium consumption: rural sample

Daily consumption (gms.)

Number

Percentages

1.0-2
1 4
2.1-5
5 18
5.1-10
8 28
10.1-15
7 25
15.1-20
3 11
20.1-25
4 14
TOTAL
28 100

Part of this difference in amount consumed is due to the lower efficiency of smoking as opposed to eating opium 4. However, the amount taken in Kuria is also high for an opium-smoking population. In the previously mentioned survey of 618 smokers the mean daily consumption was 4.6 grams (Pakistan Narcotics Control Board, 1975a). Variations in the morphine content of opium in different regions could, of course, account for the difference. As part of this study samples of opium were collected in different communities and their morphine content did in fact vary 5. The one sample collected in the village of Kuria, however, was found to have high morphine content (10.8 per cent). While this suggests mean opium consumption was indeed heavy in Kuria, additional opium samples would need to be analysed to confirm the finding.

4 The authors are not aware of any quantitative assessment of the efficiency of the two modes of administration, but users report much larger amounts are required for smoking than for eating.

5 A mean morphine content from four vend samples in Rawalpindi and Peshawar was 8.9 per cent (range 7.9-9.4 per cent). Two samples of non-excise opium purchased from Rawalpindi vends had a mean morphine content of 10.6 per cent (9.1 and 12.2 per cent). Six other samples from non-vend sources at or near the cultivation area of North West Frontier Province had a mean morphine content of 7.7 per cent (range 4.5-10.8 per cent) and the retail price for the six samples ranged from Rs. 0.3 to Rs. 0.6 per gram.

TABLE 3

Characteristics of urban and rural samples

Characteristic

Urban N=90

Rural N=28

Male (percentages)
96 100
Mean age
46 37
Employed (percentages)
82 86
Occupation-unskilled (percentages)
77 82
Median monthly earnings (U.S. dollars) a
30 35
Education-illiterate (percentages)
68 85
Married or widowed (percentages)
83 86

a Income for those employed.

DEMOGRAPHIC CHARACTERISTICS

Table 3 compares the demographic characteristics of the Rawalpindi and Kuria samples 6. The prevalence of opium addiction among females is believed to be negligible in Rawalpindi. A one-day count of opium vend use in Rawalpindi ( n = 982) and Peshawar ( n = 364) found only 35 or 2.6 per cent to be female (McGlothlin et al., 1968). The earlier survey of some 1,500 vend customers in the city of Lahore and surrounding area found a similarly low proportion (2.8 per cent) of females (Hussain, 1972). Although no female addicts were interviewed in Kuria, various respondents indicated that there were 8 to 10 in the village. This would amount to 4-5 per cent of the adult female population.

The one variable in which there is a difference in the two groups is age, with the urban population being older (mean age 46) than the rural sample (37 years). The reason for this difference will become clear later. It is also noteworthy that the majority of both groups were employed, even though they were drug dependent. Generally they held unskilled jobs with low income and the majority of both samples were illiterate. Of the 16 who were not employed in Rawalpindi, 8 made their living as beggars. Of the 4 who were not employed in Kuria, one was a 12-year old, and 2 indicated they were living on their savings at the time of the interview. The majority of those not employed could not, therefore, be considered as unemployed in the sense that they were looking for or needed work.

CIRCUMSTANCES OF INITIAL OPIUM USE

The reported reasons for initiating use are shown in . The Rawalpindi sample was more likely to report self treatment for various physical complaints and for psychological stress or grief. Although a significant proportion of rural Kuria users attributed their initiation to self treatment of health disorders (22 per cent) the most common reason was for purposes of social interaction. There was also considerable social support for opium use among the rural sample with the father or other members of the immediate family using opium prior to the respondent's initiation for 43 per cent compared with 18 per cent for urban users.

6 The Rawalpindi data presented in tables 3 to 5 are for the unweighted interview sample, with no attempt made to adjust for differences related to number of days' opium supply purchased.

The initial opium supply was obtained from the vends or other sources for the majority (56 per cent) of the Rawalpindi sample. For the remaining 44 per cent of the cases it was initially supplied by family or friends, and only 1 per cent reported initiation by a traditional medical practitioner (Hakim).

DRUG USE HISTORY

Table 5 shows information on drug use history. Most respondents in both samples began to use opium daily almost immediately after initiation. For the Rawalpindi opium eaters, the most common pattern is twice a day-in the morning and evening-and 30 per cent take opium only once daily. For the Kuria sample, who are predominantly opium smokers, 68 per cent use 3 or 4 times per day. In addition to requiring more time to consume the drug, opium smoking appears to be a more social activity; 68 per cent smoke in the public opium dens and 73 per cent smoke opium with three or more other persons. Thus, a significant proportion of the Kuria addict's time is involved in opium smoking and related behaviour. In contrast, opium eating is typically a solitary behaviour involving no time or ritual and 70 per cent of the Rawalpindi sample report no close addict friends.

In contrast to rapidly increasing tolerance to higher dosage among Western intravenous heroin users, the majority of both samples report the amount of opium consumed remains fairly stable over many years. Only one-third had significantly increased their usage over time.

Persons who had stopped opium use were not included in the study because of the method of sampling. However, it is interesting to note that of those using at the time of the interview, only a small proportion had ever stopped for one month or more.

TABLE 4

Reasons for initiating opium use

(Percentages)

Reason

Urban N=90

Rural N=28

Self-treatment of pain, coughs, dysentery, etc
44 22
Psychological stress, grief
9 0
Social interaction
11 48
Curiosity
21 22
Increase energy, avoid tiring
3 0
Sexual
10 4
Other
2 4

TABLE 5

Patterns of use

(Percentages a)

Description

Urban N = 90

Rural N =28

Started daily use immediately after initiation
87 79
Times used per day at interview
   
1 30 0
2 61 32
3 9 32
4 0 36
Amount used over time
   
Increased
33 32
Same
63 68
Decreased
3 0
Abstinent for one month or more
7 18
Daily use of other drugs at some time
   
Tobacco
68 58
Alcohol
1 0
Cannabis
7 0
Sedatives
1 0
Morphine
1 0

a Percentages do not necessarily add to 100. Mean age at first opium use was 32 for the urban and 26 for the rural sample.

Both samples reported negligible daily use of other drugs, except for tobacco. In Kuria, all but one of those using tobacco took it in the form of snuff. Among the Rawalpindi sample, the predominant form was cigarettes. Alcohol use is rare in Pakistan except for the upper classes, and this was true for the current sample.

EFFECTS OF OPIUM USE

Table 6 shows the reported immediate and long-term effects of opium use. The immediate effects are responses to the questions, "How do you feel after taking opium? What does it do for you that you like?" Again the pattern for the Rawalpindi and Kuria samples are quite different. The Kuria opium smoker emphasizes pleasure and mood alteration, whereas the Rawalpindi opium eater emphasizes better function and work performance, and relief of medical symptoms -in addition to the pleasure effect.

Reports of withdrawal symptoms were obtained by the question, "What happens to you if you don't take opium for a day or so?" Responses of restlessness, inability to sleep, cold-like symptoms, etc. were classified as mild. All of the Kuria sample descriptions fell in the severe withdrawal category compared with 59 per cent for the Rawalpindi group.

There was a general belief in both samples that opium use is injurious to health. The most common specific complaint was weakness (20 per cent for Rawalpindi, 64 per cent for Kuria). This might be related to inactivity resulting from opium-induced sedation, particularly for those using large amounts. The belief that opium has an adverse effect on the blood was also frequently expressed, as well as constipation, loss of appetite and indigestion.

TABLE 6

Reported effects of opium use

(Percentages a)

Effect

Urban N = 90

Rural N = 28

Immediate effects
   
Relieves medical symptoms
24 14
Relieves psychological stress
9 0
Better able to function, work
48 7
Pleasure, euphoria, peace, etc.
34 82
Sexual enhancement
9 0
Withdrawal symptoms
   
Severe
59 100
Minor
41 0
Long-term effects
   
Adverse effect on health
76 82
Effect on work
   
Favourable
38 0
None
43 25
Adverse
19 75
Adverse effect on family/social relations
74 65
Adverse effect on financial status
75 68
Effect on sexual functioning
   
Favourable
27 4
None
45 30
Adverse
28 66

a Percentages do not necessarily add to 100 because of multiple reported effects.

The Kuria sample was much more likely to report an adverse effect on work activities. This could be related both to the sedation resulting from large doses and to the greater time devoted to smoking and related social activities. In contrast the Rawalpindi opium eaters reported either no effect (43 per cent) or favourable effects (38 per cent) on work. Typically they stated that opium permitted them to work faster and more easily and that they did not tire as quickly.

The typical Rawalpindi opium eater spends 5 to 15 per cent of his income for the drug, while in Kuria, those not cultivating opium spend 20 to 30 per cent. All of the Kuria sample reported they either cultivated opium or purchased it from their earnings. For the Rawalpindi group, 84 per cent paid for opium from work income, 9 per cent from begging and 7 per cent from family's or friend's support. Only 2 per cent of the Rawalpindi group stated they would use more opium if it were cheaper compared with 23 per cent for the non-cultivating Kuria sample. Thirty-three per cent of the Rawalpindi and 46 per cent of the non-cultivating Kuria sample indicated they sometimes had to borrow money to buy opium.

In spite of the very low cost of opium in Pakistan, the specific comments of the respondents indicate that a significant portion experience financial hardship as a result of their addiction. Five of the 28 in the Kuria sample stated they had sold part or all of their land to support their opium use. Others stated their productivity had declined because they could not work as much as before.

As would be expected, the large amounts of opium consumed by the Kuria sample results in significant depression of sexual functioning. Those reporting favourable effects generally indicate opium use prolongs ejaculation. Respondents frequently reported the initial effect on sexual functioning was positive, but that sexual interest and performance declined with prolonged use.

ATTITUDES TOWARD OPIUM USE

Table 7 shows the respondents' impressions of how others view their opium use. By all indications there is a strong social stigma attached to the behaviour. The most frequently cited reasons for the disapproval by spouse and other family members pertain to health, financial cost, and violation of religious teachings. A surprising number of the Rawalpindi opium eaters were able to conceal their use from wives and other family members. This often occurs when the user is working in the city while his family remains in the village.

The respondents in both samples were adamant that they would not want their children to use opium. The majority of those with unmarried children also indicated their own use was likely to hinder their children from achieving a good marriage. The slang expression for an opium user in Pakistan is "posti" meaning lazy man. Some observers feel that concern over children's prospects is one of the more important motivations for discontinuing use.

TABLE 7

Attitudes toward opium use

(Percentages a)

Attitude

Urban N=90

Rural N=28

Spouse
   
Disapproves
68 83
Unaware of use
22 4
Other family members
   
Disapprove
66 85
Unaware of use
30 4
Attitude of society-disapprove
94 82
Disapprove of children using
98 88
Proportion of close friends using opium
   
None
70 4
Some
28 40
Most or all
2 57

a Percentages do not necessarily add to 100.

The opium users were equally consistent in condemning their own behaviour. All but one individual in the combined Rawalpindi and Kuria sample stated they would like to stop using opium. The reasons included health, finances, social stigma, bad example for children, religion, sexual impotence, and, for some older users, inability to earn money to buy it. All respondents in both samples stated they would like treatment to stop the habit, and almost 90 per cent said they would be willing to spend two weeks in a hospital for this purpose. Of the Rawalpindi sample, 86 per cent indicated that the government should close the vends and provide treatment for addiction. The authors suspect this unanimous desire to give up opium use was partly motivated by the wish of users to give socially desirable responses. Nevertheless, a significant number would no doubt apply for treatment if it were available. Prior to this interview study there has been virtually no organized treatment for addiction in Pakistan, although the Hakims do manufacture an opium pill called "tark-e-afyun" for withdrawal from opium addiction. The dose is slowly reduced over a six-week period.

IV. Summary and discussion

Opium use in Pakistan cities is primarily by eating and addiction is almost exclusively limited to males. Although there is a strong social stigma attached to opium use in Pakistan, the eating of the drug is not proscribed, and it is distributed through some 330 licensed vends throughout the country. Opium smoking and opium dens are illegal; it is generally believed that only a small percentage take the drug in this way, primarily in the rural areas where it is cultivated.

URBAN USERS

The typical opium eater in the urban sample studied uses slightly less than one gram daily and the amount used over an extended period has remained stable or increased very slowly. With the exception of tobacco, he has had no significant experience with other drugs. He spends about Rs. 1.00 ($US 0.10) per day for opium or around 10 per cent of his income. While the opium dose is low he is generally physically dependent on the drug. He initiated use in his thirties for self-treatment of health disorders or stress and has been using it for about 15 years with no significant periods of abstinence. This profile has little in common with the young urban drug user so characteristic of contemporary heroin epidemics, and in some respects the Rawalpindi opium user has similarities to the so called "medical addict" of Western countries.

The great majority of urban opium users wished to be withdrawn from drug dependence. While it is not possible to predict their response to the provision of withdrawal services alone, the data identify certain additional needs to be addressed in planning services. For example, a large proportion of urban subjects began to use opium as self treatment for health disorders suggesting the need for medical examination to assess their current health status. The provision of basic medical care is also likely to be important in preventing their relapse after opiate withdrawal.

Another significant proportion reported that opium use has a positive effect on their work performance and gives them pleasure; this sub-population may not be sufficiently motivated for routine treatments and may require special approaches, or may need to continue their lower dose opium regimen. While a relatively small percentage of urban subjects reported initial opium use to relieve stress, the great majority of both samples appeared to be experiencing family disapproval or rejection because of their drug use and may require various levels of social counselling and in some cases psychiatric treatment.

The urban subjects in our sample appeared to be functioning adequately on their current regimen of rather low dose oral opium. The majority were employed, married, concerned for their children and there was no evidence that they were engaged in criminality. They do not appear to present a great threat to themselves or to their society when compared with the threat posed by smaller numbers of young urban heroin users in some other settings where they are frequently unemployed, criminalized and actively spreading drug dependence to vulnerable youth. One must therefore ask if the results of treatment and rehabilitation programmes elsewhere would lead us to believe that the over-all situation of this rather stable population of addicts would be improved by similar programmes. In order to deal adequately with this question as well as to improve the immediate situation, there appear to be two directions for short-term action. The first is to develop pilot treatment and rehabilitation services in order to determine the proportion of users who will be helped by such demand reduction programmes. The treatment system would have to be experimental in nature and emphasize evaluation research in order to determine which treatment methods are most effective.

The second possibility for short-term action would be to very gradually bring better controls to the current opium vend distribution system by requiring medical examination of vend customers, the recording of some basic epidemiological information and tighter controls over who is able to buy how much opium. This would hopefully have the advantage of preserving the currently stable situation for opium users. If carefully implemented, the users would not be forced to turn to illicit traffickers for their drug supply. Care would be needed to make the transition orderly and to avoid driving the opium-using population underground and possibly into criminality, with the accompanying social and economic costs and disruptive effect upon the addicts, their families and the larger society. Eventually a more formalized structure might be considered such as opium maintenance therapy, pharmacotherapy or an opium registration system. The final structure would, of course, depend upon the legal framework and policy decisions of the government.

Subsequent to the conduct of this study, the authors have heard with interest that the Government of Pakistan has initiated a pilot project to examine the feasibility of registering opium users in two districts of Punjab Province. Drug abuse programme planners both in Pakistan and elsewhere will wish to follow the progress of this project as it will have significant implications for management of opium dependence in the region.

RURAL USERS

The high prevalence of drug dependence in the opium-cultivating village of Kuria is of particular interest in showing that a very large proportion of one community can become dependent while comparable surrounding groups may not be affected. A considerable amount of speculation has been devoted to the question of why one culture adopts a drug which is strongly rejected by another, for example the almost total lack of opium dependence among poppy growers in Turkey compared with a very high rate of social acceptance and dependence in the bordering country of Iran (Akcasu, 1976). Also, there has been a great deal of research in the West aimed at identifying the social and psychological correlates which predict individual susceptibility to opiates and other drugs. Certainly, these findings are meaningful in their particular context. Yet, it is striking how nearly half of the male inhabitants of a geographically defined group, such as the residents of Kuria, can become dependent on opium almost by chance. With the exception of a possible genetic explanation, there is no reason to suspect that the population of Kuria is any different from those in numerous other villages in the opium-cultivating area. It was simply exposed to an apparently influential and proselytizing opium smoker some 40 years ago and the practice came to be accepted.

A number of the comments made on treatment and rehabilitation of the urban users can be applied to the rural population as well. The high dose of daily opium consumption and the reported intensity of withdrawal symptoms among rural subjects, however, would suggest a vigorous medical management régime including medications for diarrhoea and other withdrawal symptoms. If the initial patients have positive withdrawal experiences, this would be quickly communicated to their peers and motivation for treatment in the target population should remain high.

The geographically defined and relatively cohesive population of opium users in Kuria also presents unique opportunities for programme planners. Because the target population can be readily identified and followed, the resources and general strategy for treatment can be carefully planned and evaluated in pre- and post-intervention surveys. There may also be opportunities to mobilize the social structure of the village and the peer group dynamics of the drug users themselves in bringing about an effective and lasting reduction in opium use. One approach would be to consider the advantages of organizing, with agreement of village leaders, mass withdrawal of all opium users in such villages. Those with medical complications would require special arrangements and a visiting health team might be required to assist during the withdrawal period. After-care could be provided by the local health team and by specially trained members of the village.

Because of the critical role that opium use and production play in the way of life and economy of the village, any treatment project, to be successful, should include participation of village leaders in its planning and implementation. If their co-operation can be obtained it may even be possible to consider at some point a serious effort to totally eliminate opium dependence in such villages.

Certainly the eventual solution will not be monolithic or simplistic. We note, for example, that early studies of rural opium users in Thailand (Charas et al., 1978) suggest a higher proportion than reported here of subjects with chronic medical disorders. The successful management of such cases would require a stronger health component than would be suggested from our Kuria village data. The experience in Thailand suggests that basic health services are needed in the rural regions under study in order to provide services and medications as an alternative to opium. In these Thai villages opium is used as an indigenous medicine for management of health disorders such as diarrhoea, pain and cardiorespiratory disorders, and there are no established health services to provide alternatives.

Although opium is also used for symptomatic treatment of health disorders in the village chosen for our study in Pakistan, there is a government hospital located within walking distance of Kuria village. This rural population therefore has a health care system, which may account for the relatively low proportion (22 per cent) who began to use the drug as self treatment for health disorders. In Kuria the provision of basic health services alone would therefore not be expected to have significant impact upon the extent of use. Our Kuria findings are confirmed by the earlier survey of this region in which 52 of the 60 cases studied were from Kuria village (PNCB, 1975b). The influence of friends was given as the cause of their addiction by 80 per cent.

The relatively low proportion of opium smokers reporting initial opium use for purposes of self treatment may reflect a true difference in the rural opium use patterns in Pakistan and Thailand, as two other surveys of rural opium use in Pakistan show a similar trend. In one of the surveys only 17 per cent (102 of 618) of rural and urban smokers interviewed in opium dens in the North West Frontier Province reported physical illness as the cause of their drug dependence (PNCB, 1975a). In the other survey only 23 per cent (70 of 300) of drug users, the majority of which were rural opium users in the Northern Territories (Gilgit), reported their initial drug use was for treatment of health disorders. Certainly the role of self-treatment of health disorders as a major cause of rural opium use needs further clarification. In the present study, however, the general profile of Kuria village opium users, with their younger age and emphasis upon the social and pleasure effects of opium use, would tend to emphasize the need for a strong psychosocial emphasis in the over-all treatment strategy.

GENERAL COMMENT

The estimated size of the chronic opium dependent population and the ready availability of the drug presents a formidable challenge to planners of treatment and rehabilitation services in the two communities studied. Because there has been almost no experience in the treatment of this condition in Pakistan, it will be necessary to first carefully evaluate a variety of promising approaches, and to better clarify the numbers who need and can benefit from treatment before applying such programmes on a large scale. Because it is unlikely that sufficient resources will be available in the near future for expensive, highly sophisticated approaches, the emphasis should be on testing low cost, practical methods and on working within existing institutional structures and health services wherever possible.

Fortunately, there is no evidence of spread of heroin, other injectable drugs or even opium use among urban youth. The epidemiological situation would appear to be stable. This should, however, not give rise to complacency as some countries with large chronic opium-using populations have observed a rapid shift to heroin abuse and criminality when opium availability was suddenly suppressed (Westermeyer, 1976). Considerable caution will have to be exercised so as to avoid a repetition of this experience. At the same time efforts should continue to gradually reduce both the supply and demand for opiate drugs. In this respect the present study, despite its limited scope, does provide baseline information in two communities that can be used at a future date to examine the impact of policy changes, and of opium supply-demand reduction programmes. It was with these possibilities in mind that identifying information was obtained from the interview samples to permit the possibility of future follow-up assessments.

LIMITATIONS OF THE STUDY AND THE NEED FOR ADDITIONAL RESEARCH

Given the small size of the interview samples from only two communities in the current study, it would be important to extend this preliminary work to other cities and to other rural areas of Pakistan. It would be important to determine if the patterns described in this report apply to the larger population. It is also noted that the current study did not include a health examination of study subjects, and future work is needed to clarify the distribution and severity of health disorders among urban and rural opium-using populations. In this way the preventive and therapeutic role of the health system can be more properly defined.

While it is encouraging to learn that virtually all of the opium users in this study indicated they would like to receive withdrawal treatment, the issue needs further clarification. What proportion of opium users would actually accept withdrawal if it were offered? How many would remain abstinent after they were withdrawn? Given the apparently stable situation of many opium users in the urban population, would treatment serve as a de-stabilizing event? For example, how would they function without opium? We recall that a high proportion of urban users felt that the drug improved their work performance; if treatment reduced their capacity to work, would this serve as a motivation to return to opium dependence? The admittedly low percentage of unemployed opium users suggests that the need for employment and vocational assistance may not be great, but this issue should be investigated further. These and other questions that emerge from the data need to be clarified in future research.

Acknowledgements

The authors wish to thank Mr. K. A. Wadud of the Pakistan Narcotics Control Board, Mr. Jorgen Gammelgaard of the UN Pakistan Programme for Drug Abuse Control, and Dr. Umeed Khan and Miss Nigitat Khan of the Central Government Hospital, Rawalpindi for their help in conducting the survey. We also wish to thank the US Drug Enforcement Administration Special Testing Laboratory for performing the opium assays and especially Mr. Charles Carter for arranging these analyses.

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