C I V I L - M I L I T A R Y

F U S I O N

C E N T R E

AFGHANISTAN
March 2012

IN TRANSITION
Comprehensive Information on Complex Crises

Drug Abuse & Treatment Facilities in Afghanistan

Rainer Gonzalez Palau Social & Strategic Infrastructure Desk Officer rainer.gonzalez@cimicweb.org

This report addresses drug abuse in Afghanistan and provides an overview of the number and distribution of drug abuse treatment facilities across the country. The document compares the scale of the drug abuse problem and compares this with the locations of treatment facilities, building upon open source data. Related information is available at www.cimicweb.org. Hyperlinks to source material are highlighted in blue and underlined in the text.

fghanistan cultivates the opium used to produce 92% of the worlds heroin, according to MSNBC. Until the mid-2000s, Afghan opiates were primarily used in Europe and Asia. Drug use in Afghanistan, largely as a result of religious and cultural factors, was relatively rare, reports Time Magazine. However, during the last decade, a growing number of Afghans have reportedly begun using opium as well as heroin, cannabis, painkillers and tranquilizers, according to the United Nations Office on Drugs and Crime (UNODC). The most upto-date estimates, which are included in a UNODC report entitled Drug Use in Afghanistan: 2009 Survey, show that there are around 800,000 illicit drug users in Afghanistan, which is equivalent to approximately 3.3% of population. This amount is several times higher than the rate of opiate use in neighbouring Pakistan, which is 0.7%, according to a separate UNDOC report. Table 1 (next page) shows that the rate of drug use is relatively consistent across Afghanistan. The same UNODC report highlights that opium is used by 60% of drug users but that the use of other drugs, particularly cannabis, has increased significantly during the last decade. Experts have noted several reasons behind the expansion of drug abuse in Afghanistan. Jean-Luc Lemahieu, head of UNODC in Afghanistan, told Time that the recent increase in the number of drug users is related to the Coca Cola effect, which refers to the fact that the mere existence of supply can in some cases foster demand.

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Table 1. Population, Estimated Illicit Drug Users and Prevalence Rate by Region
Region Northern North-Eastern Western Southern Central Eastern Total/Average Population 4,719,400 3,407,200 3,419,600 2,980,100 7,920,500 2,751,400 24,485,600 (Total) Estimated Illicit Drug Users 171,000 82,000 101,000 107,000 253,000 87,000 800,000 (Total) Estimated Prevalence Rate 3.6% 2.4% 3.0% 3.6% 3.2% 3.2% 3.3%1 (Average)

Source: Calculated by the author using data from the Afghan governments Central Statistics Organization and UNODC, 2009.

The Time article suggests that the majority of drug users in Afghanistan were previously perceived as being former refugees or war veterans who became addicted in refugee camps in Iran and Pakistan during the 1980s. More recently, people traumatised by on-going conflict and insurgency in Afghanistan are perceived to comprise a rising number of drug users. Angela Me, head of UNODCs Statistics and Survey Section, told Radio Free Europe/Radio Liberty that, worldwide, people living Figure 1. Percentage of Afghan Drug Users who Give in stressful situations such as wars and natural Opium to Family Members and Children, by Region disasters may attempt to address their pain through the use of narcotics, tranquilizers or alcohol. According to the Time article, entitled A New Afghan Evil: Drug Addiction, stress and war trauma are only two of several factors leading Afghans to take up drug use. The article tells of mothers in northern Afghanistan taking opium to ease muscle pain and, not understanding the health risks, giving opium to their children. In 2005 UNODC estimated that there were approximately 60,000 children using drugs in Afghanistan. The drugs were most commonly provided to the children by drug users. The 2009 drug use survey by UNODC found that drugs, especially Drug Users Giving Opium to Children opiates, were usually given to placate children. The Drug Users Giving Opium to Non-Child Family Members same report highlights that opium was most commonly given to children in southern Afghanistan, where much Source: UNODC, 2009. of the poppy crop is grown, and in north-eastern provinces (Figure 1).

This prevalence rate is presented here as a percentage of the entire population given the prevalence of drug abuse amongst children. The percentage of Afghans aged 15-64 who abuse opium and opiates is 2.92% according to UNODC. Although there are questions concerning the accuracy of these figures and the underlying data sources, UNODC reports that opium/opiate prevalence rate as percentage of population aged 15-64 is 0.25% in China, 2.26% in Iran, 0.54% in Tajikistan and 0.80% in Uzbekistan

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Drug Abuse Treatment Facilities

According to the UNODC, there are 33 drug treatments facilities across Afghanistan (Figure 2). Twelve provinces do not currently have any drug treatment facility, and 20 provinces have one. Only Balkh and Kabul have more than two drug treatment facilities, with three and six, respectively. In addition, UNODC notes that the majority of these facilities are located in the provincial capitals or in urban areas and may not serve the needs of rural communities affected by drug abuse.

Figure 2. Drug Treatment Facilities, Public Health Centres and Levels of Poppy Cultivation, 20102

Poppy Free < 1,000 ha 1,000-10,000 ha 10,000-20,000 ha > 20,000 ha Provincial Boundary Intl Boundary Drug Treatment Facilities

Public Health Centres

Source: Calculated by the author using data from UNODC, 2010.

Based on data provided by the UNODC and the Afghan Central Statistics Organization (CSO), the number of drug users per treatment facility can be calculated for each region (Table 2). On average, there is one drug treatment facility for every 24,485 drug users.

The UNODC definition of Health Centres includes provincial hospitals, district hospitals and comprehensive health centres (CHC), which are the only health facilities required to have at least one doctor. In each province there are additional health posts and basic health centres which are not required to have a doctor and which are not included in the figure above. Health centres have been included in the figure as an implicit measure of additional health resources in the province. In addition, the majority of the drug abusers are initially treated in hospitals and other health centres before being transferred to specialised drug treatment facilities.

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Table 2. Number of Drug Users per Drug Treatment Facility versus Estimated Prevalence Rate by Region
Drug Treatment Facilities 6 4 4 4 13 2 33 (Total) Estimated Prevalence Rate (%) 3.6% 2.4% 3.0% 3.6% 3.2% 3.2% 3.3% (Average) Estimated Drug Users per Treatment Facility3 28,316.40 20,443.20 25,647.00 26,820.90 19,496.62 44,022.40 24,485.60 (Average)

Region

Population

Northern North-Eastern Western Southern Central Eastern Total/Average

4,719,400 3,407,200 3,419,600 2,980,100 7,920,500 2,751,400 24,485,600 (Total)

Source: Calculated by the author using data from the Afghan governments CSO and UNODC, 2009.

Approaches to Drug Abuse Treatment

UNODC reports that of Afghanistans estimated drug users, 780,000 reported a need for treatment in 2009. However, only 86,000 have received or are receiving treatment. This leaves an estimated 694,000 Afghans who wish to receive treatment for drug addiction but who have been unable to access relevant services. The most common treatment for drugs abuse in Afghanistan is detoxification, according to the International Press Service (IPS). However, a drug substitution programme, which provides patients with controlled doses of methadone (an opiate substitute), has been described by non-governmental medical experts in Afghanistan as highly successful. Relapse rates for heroin users who underwent detoxification were reportedly high, around 92%, according to the IPS article. In contrast, only 17-25% of those treated through a drug substitution programme reportedly relapsed. The article says that UNODC has advocated for scaling up of drug substitution programmes urgently in Afghanistan given that it is believed to be more effective in reducing drug addiction and in preventing the spread of diseases, such as HIV/AIDS and Hepatitis C, which are common among drug users. The Ministry of Counter Narcotics (MCN) has called for an independent review and has frozen the acceptance of new patients into the drug substitution programme, according to IPS. The New York Times reports that the MCN officials are sceptical of such programmes and have twice blocked the import of methadone into the country. The same article insists that drug substitution programmes are much more effective than detoxification given that patients who go through detoxification rarely receive follow-on support in Afghanistan.

This statistic does not suggest that this many drug users are actually seeking or receiving treatment from each centre. Rather, this is the ratio of estimated drug users per region to drug treatment facilities.

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Other countries experiences with drug treatment, which are reviewed in a UNODC Study of Drug Treatment Modalities and Approaches in Pakistan, demonstrate the importance of including aftercare and reintegration activities within drug treatment programmes. The study remarks that approaches which address patients needs for community-based aftercare and rehabilitation are the most successful. For instance, one Afghan non-governmental organisation (NGO) engages people recovering from drug Box 1. Rehabilitation through Embroidery abuse in small projects such as embroidery as well as followSanga Amaj Womens Treatment Centre in on counselling in order to help them avoid relapse (see Box 1). Another UNODC report on Reducing Drug Demand and HIV in Afghanistan proposes an integrated intervention framework to tackle drug use in Afghanistan. UNODC proposed eight main areas of intervention, which are outlined in Annex A. These include the following; (i) saving lives by reaching out to drug users; (ii) addressing workplace drug use prevention and treatment for Afghan National Police; (iii) engaging in effective information, education and communication (IEC) activities; (iv) building towards Afghan ownership of addiction problems; (v) targeting HIV prevention; (vi) advocating evidence-based HIV prevention, treatment and care at a provincial level; (vii) conducting research towards an effective response; and (viii) building towards Afghan ownership of HIV/AIDS prevention.
Kabul is the only womens residential drug abuse treatment centre in Afghanistan. Since its opening in 2007, the centre has successfully treated 400 women, only 15 of whom have reportedly relapsed. The centre approaches the drug addiction problem in part through an embroidery programme. The programme helps women to focus on small achievements and to keep their hands and minds busy. The embroidery programme is run by Rubia Handwork, an Afghan non-profit organisation whose mission is to develop economic opportunities for Afghan women and their families. The women produce a variety of traditional products using tools and techniques that Afghan women have used for centuries.

Conclusion
Afghanistan is the worlds largest producer of heroin. Heroin, opiates, raw opium and other illegal drugs are increasingly used not only by citizens of Asia and Europe but also by Afghans themselves. More than 3% of the countrys population use illegal drugs. Meanwhile, the country is home to only one treatment facility for every 24,485 drug users, and debates continue over the adoption of proven treatment methods.

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Annex A.

UNODC Proposed Intervention Framework

This annex outlines the integrated intervention framework proposed by UNODC to tackle drug abuse in Afghanistan. Saving lives by reaching out to drug users (1) Establish residential treatment centres in the five priority provinces; (2) Establish affiliated drop-in-centres/ mobile units to provide brief solution focussed therapy, drug treatment, and aftercare for outpatients including education, training and employment as well as services through an outreach community based model; (3) Capacity building/training for frontline treatment and harm reduction practitioners in evidence based approaches which reflect best practice and yield demonstrable treatment as well as harm minimisation outcomes; (4) Organise training programmes on evidence based drug treatment and harm reduction for service providers at all levels; (5) Conduct sensitisation training for community members and key individuals (teachers, shura members, religious leaders, tribal elders etc) to act as treatment motivators; (6) Advocate to increase awareness on drug misuse and drug-related harm with government counterparts at the central, provincial and district level; (7) Research, monitoring and evaluation of drug use prevalence, drug treatment and harm reduction delivery outcomes, monitoring and gap analysis in order to support effective monitoring of service provision, highlight areas of need and those which require funding and to ensure service providers are meeting targets and working in line with existing policies such as the National Treatment Guidelines; (8) Build the capacity of civil society to conduct research in under evaluated areas of drug demand reduction (DDR) and research on specific target groups or particular trend. Workplace drug use prevention and treatment for Afghan National Police (1) Provide a comprehensive and integrated package of drug treatment and harm reduction services to Police drug users in priority provinces; (2) Capacity building of ANP and MoI medical staff in drug treatment, interventions and harm reduction approaches, reflecting evidence based effectiveness and client led practice; (3) Monitoring and evaluation of treatment and harm reduction outcomes, patterns of use, profiling of at-risk demographics, and recidivism rates in order to regularly inform response planning and management. A follow up evaluation will also be conducted to monitor progress and productivity of treated Police; (4) Support to establish ANP workplace prevention strategy. Effective information, education and communication (IEC) (1) Produce and distribute awareness-raising materials on problem drug use and the risks associated with IDU, overdose, and HIV/AIDS as well as other blood borne viruses etc.; (2) Support the development of a drug use prevention programme in select schools of the five priority provinces, in partnership with the Ministry of Education (MoE) and MCN; (3) Develop and promote media campaigns at the national and provincial level to raise awareness of drug misuse and associated harms (physical/mental health, social functioning, livelihood and crime) targeting specific populations especially for young people in institutional settings and out of school; (4) Support key government partners in improving media and communication outreach strategies to better raise awareness on DDR and prevention.

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Afghanization building towards Afghan ownership of addiction problems (1) Provide technical advisory support to the Government of Afghanistan in treatment effectiveness, coordination, monitoring and evaluation; (2) Facilitate capacity building of MCN and MoPH on developing DDR strategies, policies, coordination and treatment/harm reduction best practices; (3) Assist the MCN through capacity building/training in monitoring and evaluation of DDR activities and establishing a national drug user database; (4) Provide support to MCN and MoPH personnel to build public management and technical skills on DDR issues; (5) Build capacity within the MCN and MoPH to conduct empirical research on drug abusing sub-groups and target populations, in order to appropriately inform DDR treatment delivery and interventions. The research will also serve to equip the DDR section with skills and capacity to measure treatment outcomes and conduct gap needs assessments and rapid assessments. Targeted HIV prevention prohibiting further spread to wider community (1) Identify civil society partners to carry out harm reduction interventions among drug users and in prison settings (male and female) in ten sites to be determined on IBBS results and in consultation with NACP; (2) Initiate demonstration projects of methadone maintenance therapy among drug using women; (3) Provide humanitarian services to injecting drug users (night shelters, nutrition etc) in eight provinces to be determined in consultation with NACP; (4) Document lessons learnt for wider dissemination and advocacy; (5) Carry out interventions among police to increase knowledge and capacity to prevent the transmission of HIV. Advocating evidence-based HIV prevention, treatment and care at a provincial level (1) Prepare evidence based advocacy material at the national and regional level for identified target groups in line with existing strategies; (2) Develop networks of NGOs working with drug users/HIV and networks of people who use drugs to undertake advocacy for a rights based approach; (3) Support other stakeholders, in particular drug user communities and civil society organisations, to undertake advocacy; (4) Identify opportunities for mainstreaming IDU/HIV concerns into existing training for law enforcement officials including judiciary, police and correctional facility staff and develop/adapt and implement training modules as required; (5) Arrange periodic meetings with community opinion leaders and law enforcement officials to enhance support for HIV prevention, care and treatment for IDUs and their sex partners; (6) Monitor the impact of advocacy and review strategy as required. Research towards an effective response - evidenced-based policy (1) Provide training to civil society partners to carry out research studies, including GIS mapping, rapid situation assessments of drug using communities with a focus on female drug use, young drug users (less than 18 years) and traditional drug use; (2) Study the stigma faced by drug users; (3) Study on the vulnerability of police and uniformed services to HIV and AIDS; (4) Vulnerability Study on HIV among prison population.

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Afghanization building towards Afghan ownership of HIV/AIDS prevention (1) Carry out technical needs assessment of NACP and among provincial health directorates (in partnership with UNAIDS, World Bank) and develop a technical assistance strategy; (2) Provide specific technical assistance to strengthen the NACP in areas such as procurement, monitoring and evaluation, analysis, advocacy etc.; (3) Strengthen the provincial health directorates in monitoring and implementing a HIV/AIDS response at the local level (including human resources and training cost in priority provinces); (4) Provide technical assistance (human resources, training, equipment, best practices etc.) and institutional support to the Kabul Medical University and specific agencies at the provincial level to develop them into sustainable National/Regional Learning Centres; (5) Support National/Regional Learning Centres to provide ongoing linkages to intervention sites (1 in Kabul and 2 in the regions); (6) Establish linkages with regional training centres like Iranian National Centre for Addiction Studies (INCAS) to provide training and on-site learning (4 annual trainings); (7) Maintain a roster of regional and national experts on a variety of topics; (8) Establish a training and placement calendar at the national and regional level.
Source: Reducing Drug Demand and HIV in Afghanistan, UNODC, 2010.

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