Afghanistan has a sizeable problem with opioid use
Authors: Wayne D Hall, Louisa Degenhardt
Journal: The Lancet Global Health (2014)

In 2010, opioid use and dependence made the largest contribution to morbidity and mortality from illicit drug use,1Degenhardt L Charlson F Mathers B et al.The global epidemiology and burden of opioid dependence: results from the Global Burden of Disease 2010 study.Addiction. 2014; 109: 1320-1333Crossref PubMed Scopus (222) Google Scholar contributing to premature death from drug overdose and suicide, and in those who inject these drugs, infection with HIV and other blood-borne viruses. Dependence also produced considerable disability.1Degenhardt L Charlson F Mathers B et al.The global epidemiology and burden of opioid dependence: results from the Global Burden of Disease 2010 study.Addiction. 2014; 109: 1320-1333Crossref PubMed Scopus (222) Google Scholar Afghanistan has a tradition of opium smoking, and has long been a major source of illegal opiates for eastern and western Europe.2INCBReport of the International Narcotics Control Board for 2013. United Nations, New York2014http://www.incb.org/documents/Publications/AnnualReports/AR2013/English/AR_2013_E.pdfGoogle Scholar, 3UNODCDrug use in Afghanistan: 2009 survey. UN Office on Drugs and Crime, Vienna2009https://www.unodc.org/documents/data-and-analysis/Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdfGoogle Scholar In the past decade, Afghans have also reportedly begun to inject heroin and use pharmaceutical opioids.4Afghanistan Ministry of Counter NarcoticsAfghanistan Drug Report, 2012. Published with technical support of the United Nations Office for Drugs and Crime. Afghan Ministry of Counter Narcotics, Kabul2013http://mcn.gov.af/Content/files/13_11_07__English%20Afghanistan%20Drug%20Report%202012%281%29.pdfGoogle Scholar These developments have been attributed to increased heroin availability, civil disruption from insurgency, and the crowding of displaced Afghans into urban areas where heroin and pharmaceutical opioids are readily available.5Todd CS Macdonald D Khoshnood K Mansoor GF Eggerman M Panter-Brick C Opiate use, treatment, and harm reduction in Afghanistan: recent changes and future directions.Int J Drug Policy. 2012; 23: 341-345Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar There are major challenges in the estimation of the prevalence of opioid use in Afghanistan. The country has been in a state of war and insurgency for the better part of 40 years; its population is widely dispersed and often very mobile; it has low levels of literacy; and Afghans are not accustomed to answering questions about a prohibited behaviour that are posed by a stranger in a survey interview. In The Lancet Global Health, Linda B Cottler and colleagues6Cottler LB Ajinkya S Goldberger BA Ghani MA Martin DM Gold MS Prevalence of drug and alcohol use in urban Afghanistan: epidemiological data from the Afghanistan National Urban Drug Use Study (ANUDUS).Lancet Glob Health. 2014; 2: e592-e600Summary Full Text Full Text PDF Scopus (16) Google Scholar used innovative methods to estimate the prevalence of recent use of drugs (including opioids, pharmaceutical drugs, and cannabis) in the Afghan population. As part of the Afghanistan National Urban Drug Use Study (ANUDUS), they interviewed the female heads of 2187 Afghan households about the drug use of all household members. The sample came largely from urban areas in more accessible and less dangerous provinces. Biological samples (hair, saliva, and urine) were obtained from three specified members of the household (oldest man, female head of the household, and youngest child aged 4–14 years) to validate the head of household reports of drug use (or its absence). Afghan interviewers were trained to do interviews that had been pretested to ensure cultural acceptability. They achieved an overall survey response rate (81·5%) that was much higher than surveys in countries such as the USA. Importantly, the biological data showed reasonable corroboration of the reported drug use. There was, however, under-reporting of use by women compared with the biological data, and men were less likely than women to provide biological samples. Cottler and colleagues6Cottler LB Ajinkya S Goldberger BA Ghani MA Martin DM Gold MS Prevalence of drug and alcohol use in urban Afghanistan: epidemiological data from the Afghanistan National Urban Drug Use Study (ANUDUS).Lancet Glob Health. 2014; 2: e592-e600Summary Full Text Full Text PDF Scopus (16) Google Scholar estimated that, after direct age standardisation, 5·1% of the Afghan population (7·2% of men and 3·1% of women) either reported use or had biological evidence of recent use of drugs such as opium, heroin, pharmaceutical opioids, and cannabis. Opioids were the drug most often detected in the biological samples (5·6%)—2·5% for opium, 2·0% for codeine, and 1·2% for heroin. Prescription drugs (eg, benzodiazepines and opioids) were the drugs most commonly reported in the past 30 days by heads of households (7·6%). In those who tested positive to drugs, there was more opioid and pharmaceutical drug use in women and more cannabis use in men. The prevalence of drug use was probably underestimated in men because a lower proportion of men compared with women gave biological samples. Notwithstanding these limitations, the survey confirms earlier key informant reports3UNODCDrug use in Afghanistan: 2009 survey. UN Office on Drugs and Crime, Vienna2009https://www.unodc.org/documents/data-and-analysis/Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdfGoogle Scholar of very high rates of the recent use of heroin and other pharmaceutical drugs in people who live in Afghanistan. It is difficult to assess time trends because of the differences in methods between ANUDUS and earlier surveys,3UNODCDrug use in Afghanistan: 2009 survey. UN Office on Drugs and Crime, Vienna2009https://www.unodc.org/documents/data-and-analysis/Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdfGoogle Scholar, 7UNODCAfghanistan drug use survey 2005. United Nations Office on Drugs and Crime, Vienna2005http://www.unodc.org/pdf/afg/2005AfghanistanDrugUseSurvey.pdfGoogle Scholar but the female heads of households reported that opiate and pharmaceutical drug use had increased, and that this had occurred in women and men. Participants were asked about lifetime drug use, but the biological tests measured only recent drug use; problem use is probably high in recent users of opiates and pharmaceutical drugs, especially those who injected heroin. Therefore, the survey results are consistent with key informant surveys in Afghanistan that reported substantial numbers of problem users of opiates and heroin and that this drug use was adversely affecting drug users' families and Afghan society.3UNODCDrug use in Afghanistan: 2009 survey. UN Office on Drugs and Crime, Vienna2009https://www.unodc.org/documents/data-and-analysis/Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdfGoogle Scholar, 4Afghanistan Ministry of Counter NarcoticsAfghanistan Drug Report, 2012. Published with technical support of the United Nations Office for Drugs and Crime. Afghan Ministry of Counter Narcotics, Kabul2013http://mcn.gov.af/Content/files/13_11_07__English%20Afghanistan%20Drug%20Report%202012%281%29.pdfGoogle Scholar Opioid use and dependence clearly constitute a major additional problem for a country damaged by war and that has little health and social infrastructure to prevent drug use or to treat drug dependence. Unsafe heroin injecting and dependent use of opioids need to be urgently addressed by proven effective interventions such as opioid substitution therapy to treat dependence and prevent overdose deaths;8Mattick RP Kimber J Breen C Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.Cochrane Database Syst Rev. 2014; (CD002207.)PubMed Google Scholar needle and syringe programmes to prevent HIV, hepatitis C, and other blood-borne viruses;9Palmateer N Kimber J Hickman M Hutchinson S Rhodes T Goldberg D Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews.Addiction. 2010; 105: 844-859Crossref PubMed Scopus (201) Google Scholar and effective treatment of HIV and hepatitis C to reduce the infection burden and decrease future infections.10Degenhardt L Mathers B Vickerman P Rhodes T Latkin C Hickman M Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed.Lancet. 2010; 376: 28-301Summary Full Text Full Text PDF Scopus (354) Google Scholar The efficient delivery of these interventions urgently needs additional international resources and well coordinated implementation of programmes by the Afghan government and civil society, with the assistance and support of international organisations and non-governmental organisations.5Todd CS Macdonald D Khoshnood K Mansoor GF Eggerman M Panter-Brick C Opiate use, treatment, and harm reduction in Afghanistan: recent changes and future directions.Int J Drug Policy. 2012; 23: 341-345Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar LD is supported by an Australian National Health and Medical Research Council (NHMRC) Principal Research Fellowship (number 1041742). The National Drug and Alcohol Research Centre at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grants Fund. WDH is supported by the University of Queensland. Prevalence of drug and alcohol use in urban Afghanistan: epidemiological data from the Afghanistan National Urban Drug Use Study (ANUDUS)These data suggest the female head of household to be a knowledgeable informant for household substance use. They also might provide insight into new avenues for targeted behavioural interventions and prevention messages. Full-Text PDF Open Access