Drug abuse in Nepal: a rapid assessment study

Sections

ABSTRACT
Introduction
Objectives of the study
Methodology
Results
Conclusion

Details

Author: A. CHATTERJEE , L. UPRETY , M. CHAPAGAIN , K. KAFLE
Pages: 11 to 33
Creation Date: 1996/01/01

Drug abuse in Nepal: a rapid assessment study

A. CHATTERJEE * University of California at Los Angeles, Fogarty International Training Program, School of Public Health, Department of Epidemiology, Los Angeles, California, United States of America
L. UPRETY Tribhuban University, Department of Sociology and Anthropology, Kathmandu
M. CHAPAGAIN New Era, Kathmandu
K. KAFLE Teaching Hospital, Department of Clinical Pharmacology, Maharajgunj, Kathmandu

ABSTRACT

A rapid assessment of drug abuse in Nepal was conducted at different sites, including eight municipalities in the five development regions of the country. To interview various groups of key informants, such methods as semi-structured interviews, in-depth interviews and focus group discussions were used. A snowball sampling strategy for respondents who were drug abusers and a judgemental sampling strategy for the non-drug-using key informants were applied. About one fifth of the sample was recruited from the treatment centres and the rest from the community. Drug abusers in prison were interviewed, and secondary data from treatment centres and prisons analysed. The study revealed that the sample of drug abusers had a mean age of 23.8 years and was overwhelmingly male. Most respondents lived with their families and were either unemployed or students. About 30 per cent of the sample was married. A large majority of the sample had a family member or a close relative outside the immediate family who smoked or drank alcohol and a friend who smoked, drank or used illicit drugs. Apart from tobacco and alcohol, the major drugs of abuse were cannabis, c6deine-containing cough syrup, nitrazepam tablets, buprenor-phine injections and heroin (usually .smoked, rarely injected). The commonest sources of drugs were other drug-using friends, cross-border supplies from India or medicine shops. 'The commonest source of drug money was the family. There has been a clear trend towards the injection of buprenorphine by abusers who smoke heroin or drink codeine cough syrup. The reasons cited for switching to injections were the unavailability and rising cost of non-injectable drugs and the easy availability and relative cheapness of injectables. About a half of the injecting drug users (IDUS) commonly reported sharing injecting equipment inadequately cleaned with water. Over a half of IDUs reported visiting needle-exchange programmes at two of the study sites where such programmes were available. Infection by the human immunodeficiency virus (HIV) appears to be low among IDUs, although systematic surveillance is absent. Two thirds of the sample had experienced sexual intercourse. The last sex partners reported by respondents were commercial sex workers, wives or girl friends. Condom use was low with primary partners and relatively high with sex workers. Treatment facilities, mostly located in the central urban areas of the country, are meagre. An overwhelming majority of drug abusers felt the need to stop abusing drugs. Cost-effective drug treatment and HIV prevention programmes for IDUs are urgently needed in all areas of the country.

*The valuable contributions of Rameswor Shah, Ministry of Home Affairs, Nepal, the country office of the United Nations International Drug Control Programme in Nepal and staff of the National Demand Reduction Project are gratefully acknowledged.

Introduction

Rapid assessment is a research methodology, used to identify the nature and extent of health and social problems and to suggest possible ways to deal with them. It is cheap compared with other standard epidemiological research methods, takes less time, is flexible in its approach and uses a range of qualitative and quantitative research techniques. Various categories of respondents and multiple methods of data collection are used to facilitate analysis and enhance the reliability of the data generated. The rapid assessment method has been applied to study drug abuse in different settings and to develop appropriate interventions. 'Me first study of the drug-abuse situation in Nepal employing the rapid assessment method, jointly conducted by the Government of Nepal and the United Nations International Drug Control Programme (LJNDCP), is described in the present paper.

Nepal is a small landlocked country nestled between India and China, with an area of 147,181 square kilometres divided into mountainous and hilly regions (about two thirds of the total) and the plains. According to the 1991 census, the total population of the country is 18,491,097, of which 49.86 per cent is male. More than 90 per cent of the population lives in rural areas. The literacy rate is 39.6 per cent, the rate for males being 54.5 per cent and that for females 25 per cent. Life expectancy at birth is 54.3 years. More than 80 per cent of the population is engaged in the agrarian sector. The contribution of industry and commmerce to the national economy is insignificant, while that of tourism is substantial. Nepal has had a multi-party democracy with a constitutional monarchy since 1990.

Nepal is a multi-ethnic, multilingual and multireligious society, with 60 castes or ethnic groups having been identified in the 1991 census. In addition to Nepalese, spoken by 50.31 per cent of the population, several other languages (Abadhi, Bhojpuri, Danuar, Gunrung, Hindi, Limbu, Magar, Maithili, Newari, Rai, Rajbansi, Sherpa, Tamang, Thakali, Tharu, Urdu etc.) are spoken. Although Hinduism is the State religion (86.51 per cent of the population being Hindu), the constitution forbids discrimination against other religions. The country is divided into five development regions, namely the central, eastern, western, Midwestern and the far-western regions.

Some drugs such as cannabis and alcohol were traditionally used in Nepal for centuries. The use of cannabis (ganja), which was regulated by social norms, did not create major social problems in the traditional social structure of Nepal. The history of modem drug abuse in Nepal, as most drug specialists believe, dates back to the 1960s, when its ties with the western world began to expand. The sporadic abuse of the 1960s increased in subsequent decades. The types of drugs or substances abused shifted from cannabis to synthetic opiates and sedatives-hypnotics, and their modes of administration also changed from smoking or ingesting to injecting.

Objectives of the study

The major objective of the study was to accurately portray the extent of drug abuse in Nepal and to describe the steps taken, or that need to be taken, to counter such abuse. The rationale for the study is outlined below.

There have been a few studies on drug abuse in Nepal, most of them focused on the etiological or other factors related to drug abuse at Kathmandu. Only a few studies were available from other regions of the country. Moreover, in the absence of any comprehensive national epidemiological data on drug abuse, a rapid assessment was felt to be necessary. Because of the illegal nature of drug abuse, the population of drug abusers is hidden and relatively inaccessible, thus posing particular problems. Continuous information on trends in and patterns of drug abuse is required to plan appropriate interventions. The first comprehensive rapid assessment, covered in the present paper, was carried out with that end in view.

Methodology

Review of the existing literature

An extensive review of the existing literature on drug abuse in Nepal and south-east Asia was undertaken before the study was designed. It was done in two stages: a preliminary stage prior to the survey of all the study sites; and an advanced stage during which the design of the study was finalized. In the latter stage, international studies were also reviewed. The two-stage review permitted a refinement of the methodology on which the study was based.

Study area

The study was conducted in the following eight municipalities of the five development regions of the country: Katmandu and Lalitpur in the central development region; Dharan and Biratnagar in the eastern development region; Pokhara in the western development region; Nepalgunj in the midwestern development region; and Dhangadi and Mahendranagar in the far-western development region.

The above-mentioned sites were selected because of preliminary reports of an alarming rise in drug abuse in all of them.

Design, size and selection of the sample

In the absence of data on the universe of the population of drug abusers in Nepal, it was not possible to use probability sampling for the study. A non-probability sampling method was therefore used. Snowball sampling (chain referral from a few research subjects who initially participated in the study) was used to select the sample of drug abusers.

A purposive or judgemental sampling method was used to select various categories of non-drug-using key informants. Judgemental sampling is characterized by the exercise of good judgement to select various categories of knowledgeable key informants providing good-quality data. A detailed distribution of the sample size in the five development regions is shown in table 1.

It was initially planned to recruit drug abusers from treatment centres in all the selected sites. Given the lack of a treatment centre in the far-western region and the uncooperativeness of the treatment centres in the eastern and the midwestern regions, it was necessary to use a sample consisting of drug abusers in the community who were not undergoing any treatment.

Instruments for data collection

An array of instruments for the collection of data, such as structured questionnaires and guidelines for semi-structured interviews of key informants and for focus-group discussions, as well as check-lists for in-depth interviews, were prepared and field-tested before being finalized. The different instruments were designed to explore the following topics: socio-demographic characteristics of the sample (population) under study; patterns of drug abuse; modes of drug administration; sources of drug supply and expenditure; sexual behaviour; treatment and rehabilitation history; views and perceptions of people on the drug scene; knowledge of risks of HIV, acquired inununodeficiency syndrome (AIDS) and hepatitis; drug-related crimes; perceptions of the drug scene among the community at large; and attitudes towards specific intervention.

Ethnographic observations were made at a few places where drugs were bought and sold. Data were also collected on the different types of treatment and intervention at each site. Secondary data, where available from treatment centres and prisons, were collected and analysed to determine trends in drug abuse.

Recruitment and training of the data collectors

Research assistants and data collectors familiar with the local situation and thus able to ensure liaison with treatment centres and non-govenrmental organizations concerned with drug abuse were recruited in each region. Nine research assistants and an ex-drug-abuser were hired for the study and thoroughly trained in a week-long training programme on the use of the data-collection instruments.

Table 1. Regional distribution of the sample

Item

Easter

Central

Western

Midwestern

Far-western

All regions

Semi-structured interview with doctors, nurses, government and justice officials, UNDCP personnel and staff of treatment centres and other agencies and organizations
20 30 25 15 15 105
Semi-structured interview with drug abusers in treatment centres
10 41 40 1 2 94
Semi-structured interview with family members of drug abusers in treatment centres
9 11 7 5
--
32
Semi-structured interview with drug abusers not in any treatment centre
110 109 85 64 58 426
In-depth interview with drug abusers not in any treatment centre
10 10 10 10 10 50
Individual interview with prison officials
3 3 3 3 3
1 5
In-depth interview with prison inmates
3 6 6 6
--
21
Total
165 210 176 104 88 743
Focus group sessions with prison inmates a
2 4 2 2
--
10
Focus group sessions with drug abusers in methadone programmes a
--
3
--
--
--
3

aThe number indicates the number of focus groups and not the individuals interviewed.

Duration and supervision of the study

The study was divided into the following three phases: a preparatory phase of planning, reconnaissance and design of the study; a month of field work carried out in August and September 1996 under the direction of the field supervisors and the senior members of the national core team; and a phase of data analysis.

The study produced two types of data-quantitative and qualitative. The quantitative data were processed and analysed by computer. The qualitative data in the form of interview transcripts were first carefully read out and all conceptual categories were identified and coded. The relationship between the categories was then worked out by grouping or separating the data as appropriate. Second-order categories were prepared in a similar way by verifying the context of the original descriptions. Finally, third-order categories were made by generalizing from the second-order categories. The qualitative data analysis was done manually. Both the quantitative and the qualitative data were used together in the descriptions.

Since a rapid study was conducted, it did not yield any information about the prevalence of drug abuse. Nor did it provide any insight into the extent and the nature of the problem in rural areas of the country.

Results

Responses to the problem of drug abuse

Drug control legislation and demand reduction activities

The Narcotic Drug Control Act of Nepal was framed in 1976 and has been amended three times. The third amendment (1994) updated the existing law to conform with the provisions of the Single Convention on Narcotic Drugs of 1961 [ 1] as amended by the 1972 Protocol, [ 2] the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988 [ 3] and the Convention on Narcotic Drugs and Psychotropic Substances of 1990 of the South Asian Association for Regional Cooperation.

The Ministry of Home Affairs is the focal agency for drug-control activities. The organizational functions of the National Coordination Committee for Drug Abuse Control, a body established on a multisectoral basis, are also of the highest importance. A separate unit for narcotic drug law enforcement and six other satellite units have been established. In all 75 districts of Nepal the chief district officer serves as drug control officer. UNDCP has cooperated in the preparation of a master plan for drug abuse control and in the implementation of a national project for the reduction of demand.

During the last 17 years, 6,246 persons have been arrested for drug abuse offences in Nepal. Several categories of key informants have identified a number of inadequacies in the existing system of drug abuse control, including the failure to provide the training required to enable administrative and other officials to understand the intricacies of the problem.

Drug treatment and rehabilitation

There are five major drug treatment centres in the Kathmandu valley (central development region). The major modalities of treatment are detoxification and counselling. One of the centres (the Government Mental Hospital) also provides methadone treatment. An analysis of the data of treatment centres in the central development region over a period of five years showed that there was a larger proportion of heroin abusers in the early 1990s. In treatment centres during the last few years, however, there has been a clear increase in the proportion of IDUs who abuse synthetic opiates. In contrast, an analysis of data from a rehabilitation programme for prisoners in the central development region shows that an overwhelming majority of incarcerations were related to the abuse of or trafficking in heroin. Such findings suggest that the laws relating to heroin are more strictly enforced and that heroin abuse is more severely punished as a criminal offence. Three other government hospitals, at Biratnagar (eastern region), Nepalgunj (Midwestern region) and Pokhara (western region), make limited provision for detoxification. Two new treatment centres at Dharan and Pokhara also provide treatment services. The treatment centres are mostly concentrated in the central development region, facilities for drug treatment being very limited in other regions. The number of treatment slots available are few, given the shortage of personnel in the private sector with specialized training in counselling, detoxification and other types of drug treatment.

Several other, mostly non governmental, organizations are contributing to the prevention of drug abuse by conducting campaigns to arouse public awareness of the problem and by promoting education on the subject of drugs as part of the basic school programme. Two organizations, one at Kathmandu and the other at Pokhara, are implementing needle exchange programmes, providing outreach and teaching IDUs about methods of harm reduction. [ 4]

Characteristics of the drug abusers studied

Socio-demographic characteristics of the sample

The study revealed that most of the drug abusers were young adult males (see table 2). The mean age of the sample from the far-western region (25.7 years ± 5.3) was significantly more (p<0.002) than the national average (23.8 years ± 4.4), and that from the Midwestern region (22.0 years ± 4.7) significantly less (p<0.002). The number of married subjects in the far-western sample was significantly larger (p<0.004) and that in the eastern region less (p<0.03) than in the total sample .The sample from the eastern region had fewer subjects who lived with their families and that from the midwestern region had more. The sample consisted of persons from all the castes and ethnic groups represented in the population of the region concerned. More than one third of the subjects in the sample were unemployed and one fifth were students. Of the total of 520 respondents, 31.7 per cent stated that at least one of their family members had been employed abroad, about one half of them in the army. A large majority (90 per cent) of the drug abusers resided with their families, 65.2 per cent belonging to traditional joint families. A small proportion (0.38 per cent), mostly from the central region, was homeless. Most married respondents (86.6 per cent) lived with their spouses.

Table 2. Socio-demographic characteristics of the interviewed subjects in the sample (n=520), by region

Item

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Mean age (in years)
23.3 24.6 23.2 22.0 25.7 23.8
Proportion of males (%)
97.5 97.3 99.2 96.9 100 98.1
Proportion having studied up to secondary school (%)
31.7 24.7 39.2 44.6 15 31.2
Proportion married (%)
19.2 32.7 25.6 26.2 46.7 28.7
Proportion residing in a joint family (%)
48.3 72.7 60.0 86.2 68.3 65.2
Proportion unemployed (%)
43.3 31.3 42.4 18.5 36.7 35.8
Proportion of students (%)
21.7 16 17.6 32.3 16.7 19.8
Mean age at onset of smoking
16.2 15.4 14.8 15.4 17.7 15.7
tobacco (in years)
(±2.5) (±2.3) (±2.4) (±3.2) (±3.2) (±2.7)
Mean age at onset of drinking
17.8 15.8 15.6 16.5 19.3 16.6
alcohol (in years)
(±2.9) (±3.3) (±2.6) (±3.8) (±3.8) (±3.4)
Mean age at onset of using
18.9 17.5 17.0 17.8 20.1 18.0
first illicit drug (in years)
(±3.5) (±2.4) (±2.1) (±3.4) (±4.0) (±3.1)
Mean age at onset of drug
20.2 21.4 22.0 22.1 24.5 21.5
injecting (in years) among drug injectors/IDUs, n = 204
(±3.8) (±8.7) (±3.2) (±4.8) (±1.4) (±6.4)

Several key informants noted that most drug abusers were young males. A community key informant from the far-western region commented as follows: "The majority ... have been smoking cannabis (ganja) traditionally. The farmers and old people used it to relieve fatigue. But the young have started misusing it, ... although cannabis is not regarded as an illicit drug here." A key informant from the western region (Pokhara) said that drug abusers "are from families where a senior male member has gone abroad for work... (They) send a lot of money ... Unlimited money leads to its misuse." Several qualitative inter-views seem to show that all castes and ethnic groups currently use alcohol following a traditional pattern of alcohol use among a few ethnic groups in Nepal.

Drug abuse pattern of family members and friends

The study revealed that a large majority of respondents had at least one family member who smoked tobacco (81.7 per cent) or drank alcohol (77.7 per cent) and at least one close relative who smoked tobacco (95.6 per cent) or drank alcohol (89.8 per cent). A smaller proportion of respondents had a family member (12.1 per cent) or a close relative (30.8 per cent) who used cannabis or any other illicit drugs (see table 3). An overwhelming majority of respondents had at least one friend who smoked tobacco (98.3 per cent), drank alcohol (96.9 per cent) or used an illicit drug (98.7 per cent). The study clearly showed the influence of kinship and social relationships on patterns of drug abuse. The study also showed the influence of peer group pressure during adolescence and young adulthood in the initiation and continuation of drug abuse. The high proportion of family members and close relatives of respondents using cannabis in the far-western region is primary due to the high prevalence of traditional use of cannabis in the region.

A drug abuser from the far-western region commented: "Ganja and charesh (cannabis) are taken like cigarette(s) ... I take them sitting with my father ... but alcohol is not allowed, so I take it secretly." Another respondent said: "I tasted cigarette(s) for the first time stealing from my father's pocket." A third respondent from Kathmandu said: "What is bad to drink is beer ... Perhaps illicit drugs are bad ... Drinking beer is common in our family."

Many respondents who were drug abusers commented: "Friends make drugs available ... They are considerate about problems ... I love to stay with them ... Every one needs support friends provide support ... I learnt to smoke cannabis from my friends."

Table 3. Drug abuse pattern of family members and friends of subjects in the sample (n=520), by region

(Percentage)

Item

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Proportion with at least one family member who smokes
79.2 86.0 78.4 81.5 83.3 81.7
Proportion with at least one family member who drinks alcohol
76.7 82.0 84.0 72.3 61.7 77.7
Proportion with at least one family member who abuses cannabis
5.0 11.3 11.1 7.8 35.0 12.1
Proportion with at least one close relative (outside the immediate family) who smokes
97.5 98.0 92.8 93.8 93.3 95.6
Proportion with at least one close relative (outside the immediate family) who drinks alcohol
90.8 92.0 92.0 80.0 88.3 89.8
Proportion with at least one close relative (outside the immediate family) who uses cannabis or other illicit drugs
20.8 21.3 32.8 24.6 76.7 30.8
Proportion with at least one close friend who smokes
95.8 99.3 99.2 98.5 98.3 98.3
Proportion with at least one close friend who drinks alcohol
93.3 98.7 97.6 98.5 96.7 96.9
Proportion with at least one close friend who abuses cannabis or other illicit drugs
100 99.3 96.8 98.5 98.3 98.7
Proportion of respondents who smoke
82.5 98.7 99.2 98.5 95.0 94.6
Proportion of respondents who drink alcohol
70.0 95.3 95.2 95.4 93.3 89.2
First drug of abuse

Of the total of 520 respondents in the sample, 56 per cent stated that cannabis was their first illicit drug of abuse, followed by codeine-containing cough syrups (28 per cent). Cannabis as the first illicit drug of abuse was again more common in the far- western region and codeine-containing cough syrups were more common in the eastern region (see table 4). A smaller proportion also reported having started to abuse illicit drugs with heroin-smoking (more common in the central region) or sedative-hypnotic tablets (niftrazepam, diazepam, lorazepam). The perceptions of the drug abusers about the factors that led them into drug abuse were curiosity, peer influence, family quarrels, unemployment or easy availability of drugs. A drug abuser in an in-depth interview said: "For the first time I used cannabis mixed with tobacco in a cigarette when I was 13 year old... Now I take Phensedyl (codeine-containing cough syrup) regularly." A second drug abuser commented: "It depends on what you get in the market and the money you have ... You cannot choose always."

Major drugs of abuse

depth interview said: "For the first time I used cannabis mixed with tobacco in a cigarette when I was 13 years old A large majority of the respondents reported the following lifetime patterns of abuse: cannabis (88 per cent), codeine-containing cough syrup (89.7 per cent), nitrazepam tablets (80 per cent), buprenorphine injections (46 per cent), heroin-smoking (rarely injecting) (45.3 per cent) and opium ingestion (10 per cent) (see table 5). Other lifetime drugs of abuse were: injectable opiates (pentazocine, morphine and pethidine); sedative-hypnotic tablets (diazepam, lorazepam, oxazepam and rarely methaqualone); and other injectables, used generally with injectable synthetic opiates (promethazine or chlorpheniramine). Very rarely Dhaturo (datura),other major tranquillizers, cocaine or lysergic acid diethylamide (LSD) have also been used. Most respondents smoked tobacco (94.6 per cent) or drank alcohol (89.2 per cent) in addition to their illicit drug habit. The current pattern of drug abuse (during the month preceding the study) is also reflected in table 5. When their primary drug of abuse was not available, a small proportion (10 per cent) of drug abusing respondents used various substitutes, common ones being alcohol or various painkillers such as aspirin or paracetamol. In desperation, 12 respondents reportedly had ingested topical salicylate cream (Iodex) and another 12 had ingested shoe polish to relieve craving and withdrawal symptoms.

A drug abusing respondent said: "I started smoking at 14, drinking also at the same age,... (and) cannabis at 15 ... Then to satisfy curiosity I took Phensedyl (codeine-containing cough syrup) and brown sugar (heroin) ... From the last year I have started injecting Tidigesic (buprenorphine)... There is no real substitute when you don't get your stuff... Alcohol helps to some extent." Another respondent in a focus group said: "Tidigesic, Phensedyl and Nitrosun (nitrazepam) are imported from India ... I started with drug-using friends ... I have used smack (heroin), ganja, Phensedyl ... Now I inject Tidigesic once or twice a day ... I want to quit, I cannot." Another respondent from the western region said: "Major drugs of abuse are Tidigesic, Phensedyl, Nitrosun (and) brown sugar, ... but we use whatever is available ... If there is less effect over time, people switch over to other drugs, ... go to Sunaoli (border town of India), fetch drugs and also sell."

Table 4. Pattern of drug abuse, by region

(Percentage)

Item

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Proportion reporting cannabis as the first illicit drug abused
41.7 64 52 53.8 73.3 55.8
Proportion reporting codeine as the first illicit drug abused
46.7 11.3 27.2 38.5 18.3 27.5
Proportion having smoked heroin
6.7 73.3 42.4 32.3 3.3 37.9
Proportion having injected any drug
26.7 60.7 44 30.8 10 39.2
Proportion currently injecting buprenorphine (among IDUs, n=204)
84.4 68.3 89.1 85 83.3 78.4
Proportion having injected heroin (among IDUs, n = 204)
9.4 58.2
--
10
--
28.4

Table 5. Regional distribution of the sample by the types of drug abused (percentage)

(Percentage)

 

Eastern (n=120)

Central (n=150)

Western (n=125)

Mid-western (n=65)

Far-western (n=60)

Total (n=520)

Name of drug

Life-time

Curr-ent

Life-time

Curr-ent

Life-time

Curr-ent

Life-time

Curr-ent

Life-time

Curr-ent

Life-time

Curr-ent

Cannabis
71.7 58.3 94 64 96.8 81.6 76.9 52.3 96.7 91.7 87.7 68.6
Codeine cough syrup
92.3 80.8 78.7 51.3 97.6 51.2 89.2 66.1 86.7 86.7 88.7 64
Heroin
10.6 1.7 81.1 48.7 51.2 7.2 38.9 4.6 4
--
45.3 16.7
Bupre-norphine
46.2 35.8 63.5 47.3 44 39.2 37 26.1 16 11.7 46.3 36
Nitra-zepam
73.1 53.3 66.2 44.7 94.4 89.6 87 46.1 86 65 79.4 60
Dia-zepam
47.1 34.2 37.2 16.7 58.4 24 50 27.7 70 51.7 49.7 27.9
Sources of supply

The commonest reported sources of supply of drugs were friends who also abused drugs, the Indian market across the border and medicine shops (see table 6). Most of the information obtained from the community key informants and from drug abusers in focus groups or in-depth interviews confirmed those reports. Most of the informants from the eastern, midwestern and far-western regions reported the Indian market across the border as the common source of their drug supply. A key informant from the community in the far-western region said: "Tidigesic and Phensedyl are openly sold in Rupedia (Indian border market). Drug users from Nepalgunj go there, buy, use and also sell to their drug-using friends. Some black marketeers also make these medicines available at a higher price." A drug abuser and prison inmate from Biratnagar said: "I bought drugs from medicine shops in Jogbani (Indian border market) ... (and) sometimes from my friends ... When I got sick (withdrawal symptoms) I bought from people with higher prices."

Expenditure on drugs

Of the total of 520 respondents involved in the semi-structured interview, more than one third reported spending less than 500 Nepalese rupees (NRs) a week for their drug habit. More than one third spent NRs 500-1,000 a week. The rest spent more than NRs 1,000 to maintain their drug habit. Families, friends and relatives were the commonest sources of drug money. Average expenditure on drugs was higher among respondents in the central and western regions. One of the drug abusing respondents in an in-depth interview commented. "The same drug costs more here (Kathmandu) than (at) the border side." Another drug abuser said: "My expense depends on my friends ... If I get more supply I tend to spend more ... Otherwise, I spend about 500 rupees a week." A few respondents who were also involved in drug dealing were interviewed. One of them said: "I was used for trafficking drugs from Rupedia when I was young ... I did that for my livelihood ... Rich guys used me and earned a lot." A family member (father of a drug abuser in treatment) commented: "I give him 1,000- 1,500 rupees a month as pocket money ... I do not know how much he gets from his mother ... Sometimes he steals money and household articles."

Drug-injecting

Of the total of 520 respondents who took part in the semi-structured interview, 40 per cent (n=204) had taken drugs by injection, while 14.2 per cent had not injected in the last six moths mainly because of being in treatment. There were more IDUs in the central region (60.7 per cent) and fewer in the far-western region (10 per cent) (see table 4). Of the 204 respondents who had injected drugs, 66.2 per cent had started their injecting habit with buprenorphine and the rest with heroin (20.1 per cent), pentazocine (8.3 per cent) or diazepam (3.4 per cent). The mean age at onset of injecting was typically 21.5 years. A few injectors (n = 6) from the far-western region had a higher age at onset of injecting (24.5 years) (see table 2). Buprenorphine was the most popular drug of injection. There were proportionately fewer injectors of buprenorphine, although still the most popular injectable drug, in the central region, where heroin- injecting is more prevalent than in any other region (see table 7). The sample from the central region included recruits from the methadone programme, which has enrolled former heroin injectors. Most injectors reported having used other drugs, such as codeine-containing cough syrups (83.1 per cent), or having smoked heroin (58.5 per cent), along with cannabis and nitrazepam, before starting to inject. The reasons commonly cited for switching to injecting were the unavailability of the previously used non-injectable drug (34.3 per cent), the rising cost of the non-injectable drug (37.3 per cent) and the relative cheapness of injectable buprenorphine. About two thirds of the sample of injectors felt that injecting gives greater satisfaction, with immediate and more intense effects. More than one half of the injectors reported injecting at least once a day. The frequency of injection varied from once a month to three times a day. A few respondents had injected only a few times and then returned to non-injecting drug use.

Table 6. Regional distribution of the sample by the source of drug supply

 

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Source of drug

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

Medical shop
39 32.5 78 52.0 59 47.2
--
--
25 41.7 201 38.7
Drug-abusing friends
91 75.8 134 89.3 119 95.2 19 29.2 42 70.0 405 77.9
Unknown drug dealer
23 19.2 92 61.3 20 16.0
--
--
16 26.7 151 29.0
Secret selling place
26 21.7 53 35.3 19 15.2 6 9.2 32 53.3 136 26.2
Indian markets across the border
102 85.0 35 23.3 50 40.0 62 95.4 50 83.3 299 57.5
Health workers (doctors, nurses, etc.)
--
--
29 19.3 4 3.2
--
--
1 1.7 34 6.5
Itinerant drug dealer
4 3.3 30 20.0 41 32.8
--
--
4 6.7 79 15.2
Sex partner
1 08 13 8.7 1 0.8
--
--
--
--
15 2.9
Street children
17 14.2 11 7.3
--
--
--
--
--
--
28 5.4
Others
1 0.8 4 2.7
--
--
1 1.5 6 10.0 12 2.3

A community key informant (social worker) commented: "Drug-injecting is increasing rapidly ... Tidigesic-injecting ... (and) certainly heroin has gone down." A drug abusing informant said: "First of all I got injected with the help of a doctor in the .Indian Bazaar at Rupedia ... Now I do (it) myself." It was also revealed in several focus-group discussions with drug abusing participants that the frequency varies over time with the availability of drugs and money and with the street price.

Use of syringes and needles

Plastic disposable syringes and needles, disposed of only after being reused a few times, are typically used. A large proportion of respondents from the eastern region and those from the far-western region reported difficulties in obtaining syringes and needles, usually because of the price of the items and the fear of detection when buying. Common sources of supply of syringes and needles were medicine shops (60.3 per cent), friends (47.5 per cent) or needle exchange centres (30.4 per cent). Most IDU respondents in the central and the western regions knew about the needle exchange centres (see table 7). A significantly larger number of respondents in the western region (76.9 per cent) reported taking part in the needle exchange programme than in the central region (50 per cent).

A drug abuser interviewed in the eastern region (Dharan) said: "It is not difficult to get (a) syringe, ... the difficulty is to buy it." Another drug abuser recruited from the streets of the far-western region commented: "My friend who works in the health (service) provides me (with) syringe(s) ... Sometimes I buy from the medical stores ... It is difficult to buy every time because people may suspect (something)." One participant in the methadone programme said: "only rich men (do) not share needles ... Everyone uses others' needle during sickness (withdrawal)."

Table 7. Drug-injecting pattern by region

(Percentage)

Item

Eastern (n=32)

Central (n=91)

Western (n=55)

Midwestern (n=20)

Far-Western (n=6)

Total (n=204)

Proportion currently injecting buprenorphine
84.4 68.1 89.1 85 83.3 78.4
Proportion having injected heroin
9.4 57.1
--
10
--
27.9
Proportion reporting difficulty obtaining clean needles
34.4 2.2 1.8
--
33.3 7.8
Proportion reporting the sharing of needles generally
62.5 57.1 38.2 55 16.7 51.5
Proportion reporting some kind of cleaning before sharing
62.5 54.9 38.2 55
--
50
Proportion reporting knowledge of a needle exchange programme
--
96.7 90. 9
--
--
67.6
Proportion reporting participation in a needle exchange
--
50 76.9
--
--
--

Most IDUs (over 80 per cent) injceted themselves. About one half of the subjects in the sample reported that they generally shared injecting equipment with their friends (see table 7). A smaller proportion of IDUs from the western region (38.2 per cent), which has a functional needle exchange programme from which the sample was partly drawn, reported the sharing of equipment. The common reasons cited for sharing were the unavailability of syringes and needles, the habit of using drugs and sharing with friends, the cost of needles and the lack of time to buy or collect needles. Of those who generally shared needles, most (96.2 per cent) used some kind of cleaning agent, usually ordinary water (85.3 per cent) or hot water (30.4 per cent), boiling water (11.8 per cent), bleach (9.8 per cent), alcohol (18.6 per cent) and saliva (28.4 per cent) were also used. Bleach was used in the central region where needle exchange programmes and bleach distribution took place. The sharing of other injection paraphernalia was also commonly reported.

Of the total of 138 IDUs who knew about the needle exchange programme, a majority (83.3 per cent) were convinced of its benefits. In contrast, a majority of the non-drug-using key informants from the community were negative or ambivalent towards such a programme. A key informant from the community of Dharan (eastern development region) said: "This type of programme encourages the abusers to inject more drugs ... (The) number of injectors is increasing where such programmes are launched ... (They) should be banned immediately." A key informant associated with one of the needle exchange programmes said: "The programme caters primarily to people who inject drugs. The programme not only distributes needles, but also educates them about HIV and sexually transmitted diseases."

The National Centre for the Control of AIDS and Sexually Transmitted Diseases has furnished data on 10 IDUs infected with HIV/AIDS. Although there has been no systematic surveillance of HIV/AIDS among IDUs in regions other than the central region, the prevalence rate among IDUs studied at a few sites currently appears to be low.

Sexual behaviour

Of the total sample of 520 drug abusing respondents involved in the semi- structured interview, a large proportion (76 per cent) reported having engaged in sexual intercourse, with variations ranging from 45.8 per cent in the eastern region to 93.8 per cent in the Midwestern region (see table 8). The higher proportion of respondents in the Midwestern region having engaged in sexual intercourse could be attributed to the presence of commercial sex workers in the region. Among the total of 389 male respondents who reported such activities, 99.2 per cent had had only partners of the opposite sex. Three male respondents reported having had partners of both sexes and three others had had only male partners.

The last sexual partners reported by the respondents were as follows: Nepalese commercial sex worker (32.9 per cent), wife (32.7 per cent), girlfriend (30.1 per cent), foreign commercial sex worker (2.52 per cent), boyfriend (1.26 per cent) and husband (0.5 per cent). The last sexual encounter reported by about two thirds of the sample was with primary partners (wife or girlfriend), whereas the rest reported encounters with casual partners, mostly sex workers. Of the total of 363 respondents who reported sexual activity, 44 per cent had used a condom most of the time. The rate of condom use by married drug abusers with their spouses was very low (4.7 per cent reporting such use most of the time). More than one half of the respondents who engaged in sexual activity with their girlfriends reported the regular use of a condom. Similarly, 68.4 per cent of the 215 respondents who frequented commercial sex workers generally used condoms. More than 60 per cent of those who failed to use a condom consistently reported the lack of pleasure as the main reason for not doing so. Others reported that they saw no need to use one. Most participants in focus-group or in-depth inter-views reported that they had rarely used condoms with their spouses because they felt no need to do so. Such responses as the following were given: "It costs money"; "It has to be done hurriedly"; "I practice the withdrawal method (coitus interruptus)"; or "I use other methods of contraception." A married drug abuser reported: "During the last six months, I had sex with two prostitutes. Generally, I have sex with my wife twice a week ... (with) no condom use." Another respondent said: "I have sex with my wife, girlfriend and prostitutes. I use (a) condom only with prostitutes. I don't like to use condoms ... (because) pleasure goes down." The third drug-abusing respondent commented: "Most drug users have no desire. ... When I take Nitrosun (nitrazepam), I become sexually excited. ... I use condoms with prostitutes, ... not with my wife." Two thirds of the subjects in the sample who have engaged in sexual activity also reported using alcohol or other drugs before such activity.

Table 8. Regional distribution of subjects in the sample having experienced sexual intercourse

 

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Source of drug

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

Subjects having experienced sexual intercourse
55 45.8 134 89.3 90 72 61 93.8 55 91.7 395 76
Drug use by sex partners

Of the total of 217 drug-abusing respondents, 45.6 per cent reported that their sex partners did not use drugs, while another 36 per cent had no idea whether their sex partners had a drug habit. The drugs commonly reported to have been used by sex partners were cannabis, codeine-containing cough syrup, heroin and nitrazepam. A male drug-abusing respondent in a focus group said: "Prostitutes may use drugs ... They drink and smoke too ... Two of my sex partners use alcohol."

AIDS, penal sanctions and perceived needs

An overwhelming majority (99.4 per cent) of the respondents reported some knowledge of HIV/AIDS. In contrast, only 27 per cent knew about hepatitis. Radio, television or newspapers were the commonest sources of information. About 60 per cent also reported posters or pamphlets, and 45 per cent mentioned drug-using friends, as sources of information.

About 45.6 per cent reported having been taken into police custody, and another 7.69 per cent detained in prison, at least once during their lifetime. The usual reasons for the arrests were taking or dealing in drugs or other petty crimes.

An overwhelming majority of the sample studied (83.5 per cent) felt the need to stop drug abuse. The respondents requested, as part of their treatment of choice, the following: complete treatment with counselling; methadone; treatment of short duration; confidential treatment; and treatment free of cost. About two thirds of the sample knew about the treatment centres, most respondents in the central region being able to pinpoint their location (see table 9). Only one fifth of the sample had ever been in any kind of treatment. A key informant for the community deplored the inadequate treatment facilities in the central region and the even more critical situation elsewhere. A drug-abusing respondent from the eastern region said: "My close friends destroyed me. I want to quit ... but do not know how to give up. ... I do not know of a treatment centre. ... Now I am trying to marry, hoping that it may help me." An official from the Home Ministry commented: "The major responsibility to treat him is ... with the family. Treatment may be provided, ... but rehabilitation depends on the family."

Table 9. Regional distribution of subjects in the sample with knowledge of a drug tratment centre

 

Eastern (n=120)

Central (n=150)

Western (n=125)

Midwestern (n=65)

Far-western (n=60)

Total (n=520)

Item

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

Subjects with knowledge of a treatment centre
67 55.8 140 93.3 93 74.4 48 73.8 15 25 363 69.8

Drug abusers also expressed the need for more support from the family and the community and for an end to the habit of viewing drug abuse as a crime.

Conclusion

The study of the drug-abuse situation in Nepal sheds light on the evolution of the problem in the context of a developing country of south-east Asia. A clear trend towards the abuse of pharmaceuticals, including injectable synthetic opiates and benzodiazepines, has emerged in many population centres of the region, such as Calcutta, [ 5] Delhi, [ 6] Dhaka and Madras. [ 7] The more traditional pattern of drug abuse is reflected in the sample from the far-western region of Nepal, used in the present study, with its higher mean age of the subjects, higher age at the onset of abuse of illicit drugs, and its much greater abuse of cannabis. The diffusion of drug-injecting at all the sites studied should be a matter of serious concern, since IUV prevention programmes are lacking in all but two of them. The focus of interventions should clearly be the family, since most drug abusers are young adult males living with their families. Finally, there is an urgent need to develop the meagre drug treatment facilities of the country, currently concentrated in the central urban area, and to establish cost- effective treatment programmes in each of the other areas.

References

01

United Nations, Treaty Series, vol. 520, No. 7515.

02

Ibid., vol. 976, No. 14152.

03

Official Records of the United Nations Conference for the Adoption of a Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, Vienna, 25 November-20 December 1988, vol. I (United Nations publication, Sales No. E.94.XI.5).

04

A. Peak and others, "Declining risk for HIV among injecting drug users in Kathmandu Nepal: the impact of a harm reduction programme", AIDS, vol. 9 (1995), pp. 1067-1070.

05

S. Panda and others, "Injection drug use in Calcutta: a potential focus for an explosive HIV epidemic", Drug and A1cohol Review, vol. 16 (1997), pp. 17-23.

06

L. Samson and J. Dorabjee, "A community-based intervention for IDUs in New Delhi slums", paper presented at the seventh International Conference on Drug- related Harm held at Hobart, Australia, from 3 to 7 March 1995.

07

G. V. Stimson, "The global diffusion of injecting drug use: implications for human immunodeficiency virus infection", Bulletin on Narcotics, vol. XLV, No. 1 (1993), pp. 3-17.