Intervention approaches for rural opium users
The influence of traffic suppression, crop replacement and socio-economic development in rural demand-reduction programmes
Manpower development and training in prevention and treatment
Priorities for future research and programme development
Author: R. G. SMART , H. D. ARCHIBALD
Pages: 11 to 27
Creation Date: 1980/01/01
H. D. ARCHIBALD Addiction Research Foundation, Toronto, Ontario, Canada
The rate of addiction among adults in the opium-growing areas of South East Asia and the Middle East varies between 3 per cent and 10 per cent. Supply-reduction efforts alone have rarely been successful and programmes aimed concurrently to reduce demand are now being initiated. Primary health care is considered a prerequisite for the success of demand-reduction programmes and includes the training of primary health care workers to assist in prevention programmes as well as in the treatment and rehabilitation of addicted persons. This supply-demand-reduction approach will require careful evaluation of its effectiveness.
*Modified version of a paper prepared for the WHO Workshop on Epidemiclogical and Intervention Programmes in Rural Opium Using Populations, Chiangmai, Thailand, November 1979.
In many countries where the opium poppy is grown, substantial segments of the rural population are dependent upon opium. Such countries include large areas of the "Golden Triangle" including parts of Burma, the Lao People's Democratic Republic and Thailand, as well as areas of India, Iran and Pakistan. The exact number of rural persons dependent upon opium cannot be determined on a world-wide basis. However, the rate of addiction for adults among hill tribes in Thailand varies between 6.6 per cent and 16.8 per cent of the population (Suwanwela and others [ 29] ). The rate of registered addicts in Fars, a rural province of Iran, varies from 1.3 to 15.9 per 1,000 with an average of 7.5 (Mehyrar and Moharreri [ 15] ). In the rural area of Punjab (India) the rate of "regular" use of opium is about 3.7 per cent for males and 2 per cent for females (Ministry of Health and Family Welfare [ 18] ). A study in Buner, Pakistan, where opium is extensively grown, found few addicts except in one village where more than 10 per cent of the inhabitants were addicts (Pakistan Narcotics Control Board [ 21] ). Opium addiction has also been reported to be rare among opium farmers in Turkey (Akcasu [ 1] ). It seems likely that about 3 per cent to I0 per cent of adults in the opium-growing areas of South East Asia and the Middle East may be addicted to opium, with a larger number using opium from time to time and at least some areas reporting much higher rates.
Opium addiction, of course, constitutes a serious health problem for the addicts themselves. It contributes to economic and social hardships for their families and leads (in some instances) to the adoption of opium addiction as a way of life. It is also believed that the existence of these addicts inhibits any solution of the opium-growing problem for the country as a whole. Their presence provides a ready market for farmers who grow opium and indirectly encourages farmers to grow opium for export to cities or other rural areas. If they are growing opium for themselves and their neighbours it seems inefficient not to grow some as a cash crop.
This review is concerned with the application of the supply-demand concept of drug control to rural opium use. It argues for the development of a primary health care approach with treatment and rehabilitation for addicts and the training of primary health care workers who would undertake prevention programmes.
It is recognized that the earlier approach to drug control involved primarily supply reduction via penalties for users and suppression of planting, harvesting and distribution of opium crops. Such programmes appear to have been rarely successful and demand reduction has been added as a major new element. The actual elements in the demand-reduction approach are likely to vary from programme to programme in keeping with local needs and resources and with the different cultures involved.
The supply-demand approach to drug control involves efforts both to restrict the supply of drugs and to reduce the demand for them in the population at risk. Supply-reduction strategies may include crop eradication; replacement of the opium poppy with other crops; increased penalties for drug possession, sale or trafficking; and restrictions on importing of drugs from other areas. Demand-reduction strategies have included activities such as treatment for drug addicts, education of high-risk groups and the general population on the dangers of opium and the provision of drugs which substitute for opium in the treatment of minor ailments such as diarrhea. A more global preventive approach is to provide primary health care which has as its aim the improvement of health in general and only secondarily the prevention of opium use. The components of the primary health care approach are provision of treatment for major diseases; prevention programmes, including improved sanitation and nutrition; and special care for high-risk populations, e.g. mothers, children and old people.
The influence of traffic suppression, crop replacement and socio-economic development in rural demand-reduction programmes
Work has only recently begun on comprehensive supply-demand-reduction programmes, and careful evaluation of their effectiveness has not been completed. In general, the separate influence of crop replacement, traffic suppression and socio-economic development have not been assessed. There are very few areas where all these approaches have been utilized and evaluated.
One instance of a comprehensive programme occurred in China in 1948. Opium use had been a major problem among both rural and urban populations. According to recent reports (e.g. Lowinger [ 14] ), opium use has virtually disappeared in China. During the early 1950s opium crop replacement programmes were initiated, compulsory treatment was provided for addicts and severe penalties were administered to drug traffickers. The programme also had a basis in health education as opium taking was declared to be unhealthy. Although the China experiment in control is an impressive use of a multifaceted approach it may not be a model that can be easily replicated elsewhere. In addition, part of the programme's success may have been due to the emigration of Chinese addicts to neighbouring countries, where some continued their addiction.
The role of traffic suppression in a rural demand-reduction programme is difficult to determine. It is not clear that legal restraint on its own has ever produced large reductions in illicit drug use (see Smart [ 24] , and Bruun and others [ 2] , for reviews). Opium has been the drug traditionally used in rural South East Asia and parts of India, Iran and Pakistan and has had no real competitor. Furthermore, studies by Westermeyer [ 33] , [ 34] make it clear that increasing suppression of opium has had a number of undesirable effects, among them the substitution of heroin for opium for example in Hong Kong, the Lao People's Democratic Republic and Thailand. Other effects have been: (a)an increase in prices of drugs and hence socio-economic hardship for the addict and his family; (b)development of a heroin "industry"; (c)greatercorruption of law enforcement officials; and (d) increased health problems due to the intravenous use of heroin (skin abscesses, serum hepatitis etc.). Opium addicts appear to spend less money on drugs and can maintain their addiction without treatment longer than heroin addicts Westermeyer and Peng [ 37] ).
An additional outcome from increased enforcement against opium may be the disappearance of opium dens. At least some dens in the Lao People's Democratic Republic during the 1960s provided surrogate families to which addicts attached themselves (Westermeyer [ 32] ); they provided meals and served certain recreational and interpersonal needs of addicts.
Finally, it should be noted that many of the opium-growing areas are in geographic locations that are remote, isolated and difficult to reach. Several of these areas are not under complete government or police control and hence any effort at increased enforcement is likely to be very costly or very inefficient and intermittent.
Empirical evaluations of crop replacement programmes are extremely difficult although historical and theoretical analyses abound. Opium is grown in most countries not solely because of the drug needs of the farmers themselves but because it is one of the few cash crops they have. In Burma, Pakistan and Thailand it is grown by farmers who do subsistence farming on very small plots of land. Most grow other crops such as rice and maize in Thailand and wheat, mustard and tobacco in Pakistan. These other crops, however, produce small amounts of cash compared to opium (Walker [ 30] ; Miles [ 17] ; Pakistan Narcotics Control Board [ 21] ). Opium sales help to purchase additional food and the few luxuries which farmers have (Walker [ 30] ) and opium is the drug most commonly used to treat physical illness and psychological problems (Suwanwela and others [ 29] ). Theoretically it should be possible to introduce cash crops to compete with opium and provide farmers with the same amount of cash. In practice this has been extremely difficult. Analyses of the problems have been presented by Geddes [ 6] , Walker [ 30] , Miles [ 17] , Durrenberger [ 4] and Suwanwela and others [ 20] , [ 27] , [ 29] . They can be summarized as follows:
Crops that have the same degree of acceptability to the opium farmer, suit the growing conditions and have the same cash value have been difficult to find (Solomon and Versteeg [ 26] ). Opium, as opposed to other crops, can be grown in soil of low fertility, is not susceptible to disease, is "serviced by a reasonably stable market and can secure the price necessary to purchase the food no longer grown, and finance the building of terraces on which rice can be planted" (McKinnon [ 16] ). Other crops rarely have these same characteristics, especially easy marketability;
Some plans for alternatives to opium farms, such as cattle grazing and reforestation in Thailand, can be accomplished only if opium farmers are moved to other locales. Such activities can result in rebellion by farmers (Geddes [ 6] );
Some plans have been "formulated by technical experts usually without sociological or broad economic advice" (Geddes [ 6] );
Some of the crops grown alongside opium, e.g. rice in Thailand, require attention in a different season. When the farmer is working the opium field it is time which is not taken from his other farming activities (McKinnon [ 16] );
The growing of opium for many farmers is traditional. Peasants are tradition-oriented and resist change in farming practices. For example, among some hill tribe people in Thailand, opium is believed to have a semi-divine origin and special rituals are connected with its growth. Other crops do not have the same status. Opium farmers do not run their farms as capitalist enterprises maximizing profits, but they do try to minimize drudgery. This means that many will be resistant to the introduction of new crops or methods even if they are more profitable (Durrenberger [ 4] ; Walker [ 30] ).
In total, the difficulties summarized above are challenging and provide important considerations to be taken into account in planning programmes in this field. Comprehensive evaluation of crop replacement programmes have not been carried out to include evaluation of their effects on opium use and addiction. Geddes, who was closely connected with a trial scheme in Thailand starting in 1972, stated [ 6] that the project failed to meet most of the criteria suggested as necessary to give hope of success, that it was doubtful if any of the schemes then operating in Thailand would have a major effect on reducing the amount of opium grown, and that opium would continue to be grown at much the current rate so long as there was demand for it and land available. Whether or not Geddes was correct is a matter for debate. It seems likely that crop replacement programmes will be successful only in combination with other initiatives such as treatment of addicts and primary health care. Such initiatives are relatively recent and cannot be evaluated yet for their total effectiveness along with crop replacement.
Despite the difficulties with crop replacement programmes to date, they have a good chance of eventual success. Opium production is difficult for farmers. The activity is labour-intensive and the crop is sensitive to weather conditions and must be harvested in a short period of time. All of these difficulties suggest that crop replacement is a real possibility. For example, experiments with coffee and flowers in Thailand suggest that they are easier to grow, less sensitive to weather and acceptable to farmers. Marketing of these crops has not been a large problem yet and prices for them seem to be stable or even increasing. They seem able to provide an income to farmers equivalent to that provided by opium. However, such programmes do not cover the whole opium-growing area and cannot be expected to wipe out opium production completely.
It may be that crop replacement programmes could be improved with the assistance of the Agency for Small Farmers (ASF), described by the World Bank (Chenery and others [ 22] ). It has been used in India to assist small farmers to change crops. At present, government-organized and government-controlled marketing systems for agricultural products are not common in opium-growing areas of Afghanistan, Burma and Iran, although they are well developed in parts of Pakistan and Thailand. ASF comprises a "combined credit extension, crop insurance and input supply operation". It supplies farmers with new seeds, fertilizers and credit. If the farmer achieves a yield which is less than the break-even point with the new crop he is given the lost funds by ASF. If he achieves more than two or three times the break-even point he pays part of his profit back to ASF for distribution to other farmers. In order for this system to work there is also a need for successful marketing boards. These would assure a floor price for the new crops and would also create floor prices for traditional crops that compete with opium. For example, most Thai hill farmers who grow opium also grow other crops. If they were guaranteed a floor price for these crops above that of opium they would presumably shift to them. These schemes, of course, require substantial planning and outside assistance and do not become self-supporting for some time. However, current crop replacement programmes are also not self-supporting. Marketing boards and ASF-type agencies could be financed by centralized governments but probably not by individual villages.
The role of socio-economic development in reducing demand for opium has not been fully explored. Rural opium users in all countries tend to be very poor in both economic and health terms. They live a marginal existence struggling to farm or work on land with low productivity. In one region of Thailand it is clear that addiction rates are low (1.9 per cent) in high-income groups and very high (33 per cent)in low-income groups (Suwanwela and others [ 25] ). However, Hinton [ 10] has pointed out that opium farmers "have incomes well in excess of the Thai average" and that opium farmers in Thailand have an income several times higher than that of other farmers although they may be poor by Western standards. Also, opium farmers in Pakistan (Pakistan Narcotics Control Board [ 21] ) have more funds than those who do not grow opium. This might suggest that socio-economic development and a rise in per capita income in the area would decrease the number of rural users although not the amount of opium grown. Presumably as opium is grown as a cash crop and the most attractive one at that, farmers could simply sell more of their opium in non-rural areas provided the demand still existed. However, it seems uncertain whether socio-economic development alone would necessarily lead to less opium addiction. Anthropological studies (e.g. Hanks and Hanks [ 8] )in the Mae Kok region of Thailand have claimed that "wherever life can be easily sustained-opium producers will quickly turn to crops of greater return and less meticulous labour-a network of roads and a benevolent patron can speed this change". It should be stated, however, that in this region decreases in opium production could also be attributed to large-scale population movements involving whole villages. There was also a conversion of some of the population studied to Christianity. If per capita incomes are raised this may also make more income available for recreational purposes including drug use. If incomes are raised without health education, the provision of primary health care, and adequate treatment for addicts it does not follow that rural opium addiction will disappear, given the analyses made so far.
Socio-economic development may, of course, mean the virtual disappearance of marginal farming and a large reduction in all types of farming in the opium-producing countries. Development may be seen by some Governments to require the creation of consumer and export-led industries rather than rural development. This will result in mass displacement of rural populations to cities and then the rural opium user may disappear only to become the city opium or heroin user. In this connection officials of the World Bank (Chenery and others [ 23] ) believe that in South East Asia "the long-run comparative advantage of countries in this situation (scarce land and a large rural population) does not lie in agriculture, and long-run development strategy must concentrate on labour-intensive industrialization". Of course such industrialization might reduce the number of rural opium addicts whose addiction is related to their status as peasant farmers. Some addicts would simply emigrate to large cities and industrial towns. In this connection we might note that the emigration of Chinese opium addicts to Hong Kong-an industrial area-apparently cured few addicts.
Rural development is, however, much broader than increased agricultural production and economic growth. The goals of rural development should include more even distribution of income, better employment opportunities, improved health and housing for rural people and a narrowing of the economic gap between rural and city areas (Coombs and Ahmed [ 3] ). Pursuit of this sort of development might well decrease opium use that is created by substandard living conditions and the simple misery of existence. Of course, such rural development will be a slow process, depending upon national economic goals. If national goals are to industrialize as fast as possible, this development will not take place. On the other hand, if rural life is thought to be worth preserving and improving, methods for doing it have been developed (see Coombs and Ahmed [ 3] for a review). It is clear that one reason why rural people stay poor is the urban bias in both government and international development funding (Lipton [ 13] ).
The demand-reduction approach attempts to reduce the need for opium both among addicts and the general population. It involves primary, secondary and tertiary prevention, i.e. the prevention of addiction by education, early identification and treatment of new cases, and the treatment and rehabilitation of fully developed cases of addiction.
The planning of demand-reduction programmes for rural opium use must be based on a basic understanding of the role of opium in the communities in the absence of basic health care services.
The use of opium in most rural areas represents both a form of self-medication and a recreational pursuit. In some areas, too, opium smoking has a ceremonial function. Rural users in most countries use opium for the treatment of physical symptoms such as diarrhea, cough and pain of any sort (Suwanwela and others [ 29] ). It is useful in alleviating the worst symptoms of tuberculosis and dysentery, which are often common. It also relieves the aches and pains which come from overwork on farms without machinery or from intestinal parasites, peptic ulcer, or generally poor health due to malnutrition or old age. In a study by Walker [ 30] most addicts reported that they became addicted during a long illness or after an injury. Usually, there is no adequate way to treat such illnesses without a long, uncomfortable trip to hospital. Many villages lack non-opiate drugs with which to treat cough and diarrhea.
Opium is also used as a general tranquillizing agent. It will relieve anxiety and eliminate sleeplessness and sorrow by its euphoric effects (Sawanwela and others [ 25] ). It is also used as a recreational drug during social occasions and at funerals. One general finding is that there are far fewer female than male addicts in all opium-producing countries. It could be that women have fewer injuries and work-induced pains but this may not account for all of the differences. It seems that attitudes usually do not tolerate opium use and especially addiction by women to the same extent as by men.
A study in one opium-producing area of Thailand (Suwanwela and others [ 22] ) indicated a low level of health and an urgent need for primary health care. Problems of poor nutrition and sanitation, high infant mortality rates and poor personal hygiene were noted as well as endemic diseases such as malaria and goitre. Modem health care was rarely available and there was an over-dependence on opium and certain herbal remedies. However, it should be noted that rural opium use can also occur in situations where primary health care is available. For example, a high rate of addiction was found in a village in Pakistan where there was a hospital (Pakistan Narcotics Control Board [ 21] ). The provision of primary health care is therefore not a panacea but is important for areas lacking such facilities.
It is clear from a review of the literature that a proven technology for reducing opium use does not exist. The only countries which appear to have significantly reduced their opium addiction are China and India. The China experiment has already been described as demanding and difficult to replicate. Kohli [ 12] described the Indian programme, which involved crop replacement, incentives to stop growing opium, licences for cultivators and heavy law enforcement activities. The number of addicts is said to have been reduced from 432,609 in 1958 to 121,178 in 1964. It appears to have been predominately a legal repression programme.
The best approach would appear to be to proceed with a set of multifaceted programmes including primary health care, education, treatment and crop replacement. Because there is no reliable technology it is crucial that all programmes be carefully evaluated. Efforts to decrease the use of opium by rural people may lead to the development of other possibly more serious addictions, for example to heroin, alcohol and barbiturates. Hence, all programmes should be carefully structured and evaluated with this problem in mind.
Prevention covers primary prevention, i.e. the prevention of the onset of new cases of addiction, and secondary prevention, i.e. the prevention of infrequent or frequent opium users from becoming addicted.
Education of the rural population about basic health matters is essential. Poor health standards exist, in part, because of careless methods of handling garbage and animal and human wastes. Dysentery, which is later treated by opium, may occur because latrines and animal stalls are built too close to wells and other water supplies. Diseases are often spread because people do not clean or wash their hands before eating. Chronic coughs may develop into serious pulmonary illness if not treated early enough. Malnutrition occurs because insufficient quantities of fresh vegetables and protein-rich foods are eaten. Sophisticated health education is not generally required and the required health education could be done by health care workers or minimally trained staff. Health workers should be carefully chosen to be acceptable to villagers and wherever possible chosen by the villagers (World Health Organization [ 38] ). Programmes have been developed for training them in a few months. Most of the general health education will require that villagers or farmers do things differently. In some cases community projects to improve health may be carried out, e.g. moving a village well to a new, unpolluted area. The primary health care worker would be responsible for organizing such projects.
Education about drugs will also be required. There are some indications (Walker [ 30] ; Suwanwela and others [ 20] ) that both addicts and users have negative attitudes to opium which are, however, in conflict with positive and permissive ones as well. Education about the harmful effects of opium will probably be most beneficial to young persons and occasional users as they are a high-risk group for addiction. Education about addiction is probably best done in combination with efforts to educate about the use of non-opiate medicines which should be available from primary health care workers.
Basic health care by specially trained workers can remove one of the major reasons for opium use. Workers should be trained to recognize and treat minor illnesses, e.g. dysentery, cough, injuries. They should also be able to recognize serious illnesses requiring hospitalization or quarantine and injuries which they cannot treat. The number of workers per population base depends upon the amount of travel required, the ease of travel and the seriousness of the health problems in the area. Remote areas with many health problems will require more workers per population base. Experience with developing a primary health care programme for hill tribes in Thailand provides important insights into problems and opportunities associated with this kind of development.
A scientific group convened by the World Health Organization (WHO [ 38] ) concluded that non-opiate drugs were available to treat pain, cough and diarrhea and were in many cases more effective than opiates. These drugs could be supplied to primary health care workers who would make them available as necessary either free of charge or at low cost.
As previously stated, in most areas where opium is grown rural dwellers frequently use it and a certain percentage become addicted. However, in Turkey there has been little or no addiction. Akcasu [ 1] questioned some 961 persons in the opium-growing areas of Turkey. Only 3 per cent used opium and virtually none was addicted although most grew opium and had it available in their houses. Opium use is abhorred by villagers, and addicts are discredited and shunned so that they are forced to leave the village. Parents also demonstrate the bitter taste of opium to children by rubbing their fingers in the sticky milk of the poppy. This study suggests that a strong prohibition has been built up over generations against opium use. It also shows that such use is notinevitable among opium farmers. Whether similar prohibitions could be developed in other countries is an open question.
It is recognized that a major element in demand-reduction approaches is the provision of treatment for addicts. Successful treatment restores the health and economic functioning of the addict and improves his family and other social relationships. It also reduces the total demand for drugs and reduces the occurrence of new cases due to persuasion or social influence. Treatment is typically more difficult to manage in rural areas because the population is often scattered. This makes the creation of specialized centres impractical by reason of high costs and poor access to trained staff. Despite these difficulties a number of indigenous and Western-style treatment methods have been developed for opium addiction.
Indigenous methods of treatment for opium addiction seem to be both the oldest and most often used. These methods vary greatly in their complexity from structured programmes to simple efforts that addicts make to decrease their own dosages. Westermeyer [ 31] has described several indigenous methods of treatment and has presented brief case histories of people who used them. These methods include "cold turkey" withdrawal at a Buddhist monastery involving a "supportive psychological milieu", "spiritual inspiration to the abrupt withdrawal" and the activities of a "charismatic" abbot. Other methods include "herbal medications sometimes including opium or alcohol", "milieu care" involving religious ceremonies, instruction of a psychological nature and regimes of gradually decreasing doses inspired by the need to travel or to be able to plant or harvest crops. Some methods involve changing from smoking to eating opium (a method of ingestion which would give lower blood levels and allow work or travel) or shifting to other drugs such as alcohol or barbiturates. Many of these methods are used in combination or in sequence by the same addict, sometimes aided by massage, induced sweating and special food (a thin rice gruel). Although interesting and obviously worthy of further study, indigenous remedies of the type described by Westermeyer [ 31] have apparently received no real evaluation.
An anthropological study by Heggenhougen [ 9] of the treatment of opium addicts by Malaysian bomohs, or traditional healers, has just been completed. There are about 7,000 full-time and 20,000 part-time bomohs in Malaysia, considerably more than the number of physicians. Opium addicts have turned to them for treatment and have approached the Malaysian Government for recognition of their role in the fight against drug abuse. Heggenhougen studied four bomohs who together reported treating more than 300 addicts. The treatment varies somewhat from one bomoh to another but it usually involves the addict being restricted to the bomoh's house, administration of herbal teas, religious discussions, exercise, frequent bathing and the use of a "hatred" charm. Case histories have been presented which indicate a promising approach. However, some of the "teas" contain illegal drugs such as cannabidiol. The treatment is expensive, with a mean cost near $M 300, or about $US 150, and apparently works best with highly motivated patients. The mean income in Malaysia is only $US 830 and the treatment may not therefore be within the reach of most Malaysian addicts. Bomohs have been included as one of the treatment modalities being compared in the Malaysian studies being done by WHO in its epidemiology and case-reporting study.
The most carefully evaluated indigenous method of treatment is offered by the Tam Kraborg Buddhist Temple (Poshyachinda and others [ 5] ). The Tam Kraborg programme is the best known of five temples currently treating opium addicts in Thailand. The main elements are: (a) a strong motivation to be treated; (b) administration of a herbal medicine used as a purge through vomiting and sweating; and (c) a pledge of abstinence from drugs for life. The treatment lasts about 10 days. Interestingly this inexpensive treatment ($US 10 per 10-day session) has been evaluated using methods which are also cheap. A postal follow-up was made using a self-report questionnaire as well as an intensive case follow-up in Bangkok. The postal follow-up underestimated results from the intensive case finding method by only 15 per cent and 25 per cent for heroin and opium, respectively. Abstinence rates at the six-month follow-up were 30 per cent for heroin and 60 per cent for opium users. It is clear from this study that indigenous methods can achieve good results at low costs and that postal follow-up might be considered where these services are reliable.
Modern methods of treatment, with some socio-cultural adaptations, have been described by Westermeyer and others [ 35] , [ 37] for addicts in the Lao People's Democratic Republic and by Gobar [ 7] in Afghanistan. Gobar used tranquillizer-assisted withdrawal for opium addicts. The National Detoxification Center in the Lao People's Democratic Republic provided methadone detoxification in addition to treatment for medical problems. A follow-up study with 25 patients indicated that 16 were abstinent from opium at the end of one year Westermeyer [ 31] ). It was found that addicts who had improved were: (a) socially stable; (b) had successfully completed withdrawal and had their medical problems treated; (c) had continued contact with a supportive person such as a village chief, health worker or missionary; and (d) came from villages where most of the other addicts also received treatment. These results underline the need for post-treatment follow-up and also the need to concentrate on the total addict population in a village rather than treat single cases.
A preliminary study in Thailand (Suwanwela and others [ 22] ) showed that the provision of primary health care and detoxification of addicts had mixed results in Thai villages. In one village only 3 of 12 addicts were thought to be suitable for detoxification treatment and in another, 11 of 12 relapsed within a short time. The results in the latter village were attributed chiefly to poor socio-economic conditions.
A "mobile health team" approach to providing treatment in isolated villages in Pakistan has been reported by Tahseen [ 28] . Teams of doctors and nurses are sent to remote areas for a period of several months. They use both modem methods (pethidine and chlorpromazine injections) and more traditional methods (acupuncture) in promoting withdrawal. Preliminary results are encouraging, but the length of the follow-up period varies from two months to three years, and so success rates cannot yet be stated. Plans are under way to study after-care services and to compare hospital- and village-based detoxification.
Many promising treatment methods, both indigenous and modem in nature, have been used for opium addiction. They contribute indirectly to both primary and secondary prevention, although they are usually thought of as only tertiary prevention.
It is clear that both modern and traditional treatment methods can have an important impact on the number of rural opium addicts. The current needs seem to be for:
Encouragement of traditional and religion-based methods of treatment, particularly those which have low costs;
Development of methods of treatment in conjunction with religious institutions in regions where Muslim and Hindu populations are affected, perhaps through mosques and temples. The most successful cases seem to be the Buddhist temple treatments in Thailand and (perhaps) the Lao People's Democratic Republic. Some methods utilizing the same principles might be tried in non-Buddhist countries;
Development and testing of village detoxification methods of treatment using primary health care workers, perhaps loosely supervised by travelling health teams. Preliminary results in the Lao People's Democratic Republic show the advisability of having all or most addicts in a village treated at the same time. A village health worker would have obvious advantages over travelling teams or city-based teams in identifying and treating such cases.
Development of detoxification programmes in larger centres, probably in collaboration with hospitals and health stations. Cases which failed to detoxify in village programmes or had serious medical problems would be sent to such places. Because this will be costly and time-consuming, programmes should work towards having as few cases as possible to deal with in this way. There is also the risk of village addicts being sent to cities developing the addictions of "the big city"-to heroin, barbiturates or alcohol-and bringing such tastes back to their villages.
It has been stated that few methods of treatment for any sort of opiate addiction are known to be better than no treatment at all (see Ogborne [ 19] for a review). Comparative studies using different forms of treatment are rarely done for any kind of drug user, including rural opium users. There are evaluations of single methods of treatment but apparently no comparative studies with untreated control groups. Early efforts should be made to make such studies, particularly the effects of treatment compared to no treatment, or to primary health care services. This means identifying a similar group of addicts to those being treated and following them up over time, just as the treated addicts are followed. Without such studies it is not certain that the treatments achieve more than natural processes, self-treatment, or spontaneous recovery without treatment. A WHO methodology for evaluation of drug dependence treatment has recently been tested on different types of drug users, including rural opium users, and might be considered in planning such studies.
It is recognized by several groups working with rural opium addicts that rehabilitative services are needed (e.g. Tahseen [ 28] , Suwanwela and others [ 25] ). However, few treatment activities (especially folk treatments) involve such services as after-care, social and family counselling, and vocational rehabilitation. In many cases, that is due to the cost and lack of staff and to the remoteness of the treatment centres from the addicts' homes. In addition, adequate means of planning and managing rehabilitation services for rural opium users seem to be unavailable.
The separation of treatment and rehabilitation into separate activities is often not possible. In most cases the two occur simultaneously and the separation is more bureaucratic than real. Treatment and rehabilitation should be seen as a continuous process, all treatment services including rehabilitation and vice versa.
The classical approach to rehabilitation (see International Labour Organisation [ 11] ) involves: ( a) vocational rehabilitation, e.g. vocational evaluation, job counselling and guidance, selective placement, job preparation and follow-up; ( b) social reintegration which aims to readapt the drug addict to family and community demands; and ( c) follow-up to treatment to determine whether treatment efforts are being successful. The majority of rural opium users live in countries in which such services are sparse, even in large cities. They are even more difficult to obtain in remote farming areas. Also, the relevance of vocational counselling is questionable. The majority of opium addicts are farmers or farm labourers and from peasant societies which feel indentured to the land. Retraining is likely to be unacceptable to many. In addition, the opium-processing areas typically have very few other occupations available apart from farming. Some areas may have cottage industries or forestry projects providing employment but these are likely to be unfeasible unless the addict is also a farmer, as many are part-time activities.
Some rural-based projects developed by the International Labour Organisation have provided retraining. For example, a rural artisan training programme has trained workers in Senegal to manufacture or repair farm implements. A small-scale industry programme in India trained people to develop small-scale industries and artisan activities in underdeveloped village areas. It is important to recognize, however, that the skills needed in rural situations differ from those needed in urban areas and that many training programmes have suffered from an urban bias (Coombs and Ahmed [ 3] ). Too often, programmeshave concentrated on a single skill where clusters of skills are more important and more germane to the situation in rural areas.
In remote rural areas the social and medical institutions which could provide after-care typically do not exist. The only regularly available social group which could do the job is the family. Almost all addicts have families, and in many opium-growing areas families would see after-care by outsiders as gross interference. Special efforts should be made to make families responsible for the after-care of addicts. This might be achieved by encouraging some older son or the head of the family to keep the addict's rehabilitation under review and recommend further treatment as necessary.
Westermeyer and Bourne [ 36] have pointed out that opium addicts in the Lao People's Democratic Republic who recovered typically had someone, e.g. a relative, village chief, health worker or missionary, who took a consistent interest in their improvement. Such people can supplement family members, and treated addicts also can give support to each other when large groups from the same village are treated at the same time.
The recommendations of this paper are to develop primary health care facilities, treatment for addicts and evaluation of programmes. These elements are all inter-related. The major areas for manpower development are these:
and training of primary health care workers. The objectives and content of courses relevant to opium-producing areas have been described (e.g. Suwanwela and others [ 22] ). The workers should preferably come from the villages themselves rather than from larger centres or cities. They should be volunteers approved by the village. Although at least one worker is needed for each village, the actual ratio of workers to population remains to be determined;
Establishment of study courses staffed by physicians and nurses experienced in rural health problems in order to train the workers in basic aspects of public health and medical treatment. This could take place in a local university, health centre or hospital, preferably in the villages or at least close to them to enable villagers to travel to the training centre;
Provision of treatment for addicts. Some detoxification of addicts can be done by village health workers. However, difficult cases or those with medical problems will require treatment at centres established in collaboration with hospitals or health centres;
Elaboration of crop replacement programmes. Trained agricultural workers aware of local cultural and rural conditions may be able to advise on crop substitution and to help run marketing agencies in collaboration with the local farmers. It is possible that one worker could serve in more than one village depending upon the ease of travel and appropriate training courses should be developed and tested;
Evaluation of programmes. It is essential that all programmes be evaluated empirically. One person (possibly drawn from a local university) should be responsible for assessing the outcome of each. programme.
The major implications of our current experience are as follows:
Rural opium use is a problem in most producing countries except Turkey;
There is no certain method of prevention or cure for rural opium use and it has not yet been demonstrated that treating addicts will greatly reduce the size of the problem;
Crop replacement programmes should be integrated with treatment and other health-related activities;
Supply-reduction approaches should take into due consideration the relative isolation of the opium-growing areas;
New programmes should be sensitive to the cultural values and traditions in the areas where they are developed;
A multifaceted approach involving crop replacement, treatment for addicts and prevention via primary health care and health education seems the most realistic approach at the present time;
The development of primary health care facilities in opium-producing areas is important and can also serve preventive and treatment functions vis-a-vis opium addiction. They require support from local hospitals and health care agencies;
New programmes should contain an evaluative component in order to estimate their effectiveness;
Planning and co-ordination at the local level is extremely important; communities must be directly involved in the development and implementation of programmes.
Some major priorities for research and programme development are:
Careful evaluation of all supply-demand-reduction programmes for rural opium use;
Experimentation with marketing agencies and associations for small farmers which minimize economic risks for farmers who change from opium production;
Development and testing of programmes for the training and utilization of primary health care workers;
Development of prevention programmes for primary health care workers;
Experimentation with a wider variety of treatment modalities, especially:
Traditionally based ones of low cost;
Religion-based treatments especially in temples and mosques;
Village detoxification methods using primary health care workers with more sophisticated programmes in health centres or hospitals for difficult cases;
Development of after-care programmes involving the addict's relatives or villagers.
Akcasu, A. A survey on the factors preventing opium use by poppy growing peasants in Turkey. Bulletin on narcotics (United Nations publication), 28:2:13-18, 1976.002
Bruun, K., L. Pan and I. Rexed. The gentlemen's club: international control of drugs and alcohol. Chicago, University of Chicago Press, 1975.003
Coombs, P.H., and M. Ahmed. Attacking rural poverty: how non-formal education can help. Baltimore, Johns Hopkins University Press, 1974.004
Durrenberger, P. A note on Chayanor's economics of sufficiency: drudgery and utility. Conference on Opium Production, Trade and Use in the Golden Triangle, Philadelphia, 1978.005
Evaluation of treatment outcome: the Buddhist Temple Treatment Centre, Tam Kraborg. By V. Poshyachinda and others. Institute of Health Research, 1978.006
Geddes, W. R. Hmong opium and attempts to replace it. Conference on Opium Production, Trade and Use in the Golden Triangle, Philadelphia, 1978.007
Gobar, A. H. Drug abuse in Afghanistan. Bulletin on narcotics (United Nations publication), 28:2:I-11, 1976.008
Hanks, L., and J. R. Hanks. The context of opium production in Chiangmai Province north of the Mac Kok Valley. Conference on Opium Production, Trade and Use in the Golden Triangle, Philadelphia, 1978.009
Heggenhougen, H. K. Preliminary documentation of traditional Malay treatment of drug addicts in Malaysia. University of California, 1978.010
Hinton, P. Non-growers in the matrix of opium production: the case of the Karen. Conference on Opium Production, Trade and Use in Highland Southeast Asia, Philadelphia, 1978.011
International Labour Organisation. Background paper for the Vocational Rehabilitation and Social Reintegration of Drug Dependent Persons. Study on Measures to Reduce Illicit Demand for Drugs. Geneva, Division of Narcotic Drugs, 1979.012
Kohli, D. N. The story of narcotics control in India. Bulletin on narcotics (United Nations publication), 18: 3:3-13, 1966.013
Lipton, M. Why poor people stay poor: urban bias in world development. Cambridge, Harvard University Press, 1977.014
Lowinger, P. The solution to narcotic addiction in the People's Republic of China. American journal of drug and alcohol abuse, 4:165-178, 1977.015
Mehryar, A. H., and M. R. Moharreri. A study of authorized opium addiction in Shiraz City and Fats Province, Iran. British Journal of addictions, 73:93-102, 1978.016
McKinnon, J. M. The Jeremiah Incorporation. Tribal Research Centre, 1978.017
Miles, D. Hill farmers and urban traders: commercial influences on the agricultural output of opium producers in Thailand. Conference on Opium Production, Trade and Use in Highland Southeast Asia, Philadelphia, 1978.018
Ministry of Health and Family Welfare. Drug abuse in India: Report of the Committee appointed by the Government of India, New Delhi, 1977.019
Ogborne, A. Patient characteristics as predictors of treatment outcomes for alcohol and drug abusers. In Research advances in alcohol and drug problems, vol. 4. Y. Israel and others, eds. New York, Plenum, 1978.020
Opium use and addiction in hill tribal villages in Thailand. By C. Suwanwela and others. Conference on Opium Production, Trade and Use in the Golden Triangle, Philadelphia, 1978.021
Pakistan Narcotics Control Board. Socio-Economic Survey of Buner. Islamabad, 1975.022
Primary health care in the hill tribe villages. By C. Suwanwela and others. Institute of Health Research, Bangkok, 1978.023
Redistribution with growth. By H. Chenery and others. Washington, D.C., World Bank, 1976.024
Smart, R. G. Effects of legal restraint on the use of drugs: a review of empirical studies. Bulletin on narcotics (United Nations publication), 28:1:55-65, 1976.025
Socio-economic realities and their implications in the treatment of drug dependent persons. By C. Suwanwela and others. Institute of Health Research, 1978.026
Solomon, R., and H. Versteeg. A review of the development and present state of the illicit international heroin trade. Ottawa, Non-Medical Use of Drugs Directorate, 1978.027
Suwanwela, C., S. Kanchanahuta and Y. Onthuam. Hill tribe opium addicts, a retrospective study of 1382 patients. Bangkok, Institute of Health Research, 1978.028
Tabseen, E. Detoxification of opium users by mobile health teams in rural northern areas of Pakistan. Geneva, World Health Organization, 1978.029
The hill tribes of Thailand, their opium use and addiction. By C. Suwanwela and others. Bulletin on narcotics (United Nations publication), 30: 2:1-19, 1978.030
Walker, A. Opium: its cultivation and use in a red Laku village community. Unpublished manuscript ,1978.031
Westermeyer, J. Folk treatments for opium addiction in Laos. British journal of addictions, 68:345-349, 1973.032
_____ Opium dens: a social resource for addicts in Laos. Archives of general psychiatry, 31:237-240, 1974.033
_____ Opium addiction in Laos; an overview. In Current perspectives in cultural psychiatry. E. Foulks and others, eds. New York, Spectrum, 1977.034
_____ The pro-heroin effects of anti-opium laws in Asia. Archives of general psychiatry, 33:1135-1139, 1976.035
Westermeyer, J., C. Soudaly and E. Kaufman. An addiction treatment program in Laos. The first year's experience. Drug and alcohol dependence, 3:93-102, 1978.036
Westermeyer, J., and P. Bourne. Treatment outcome and the role of the community in narcotic addiction. Journal of nervous and mental diseases, 166:51-58, 1978.037
Westermeyer, J., and G. Peng. Opium and heroin addicts in Laos. A study of matched pairs. Journal of nervous and mental diseases, 164:351-354, 1977.038
World Health Organization. Opiates and their alternatives for pain and cough relief. Geneva, 1972.039
_____ Primary health care: Alma-Ata, 1978. Geneva, 1978.