Substance Abuse in Central Asia: An Old Problem with a New Twist
Nina Kerimi, WHO Regional Office For Europe
Copenhagen, Denmark

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In contrast to the previous images of the addict, during the last Soviet anti-drug media campaign, drug users were depicted as victims rather than sinners. In the old debate on whether addiction is a crime or a disease, the definition of drug dependence as a health disorder had been emphasised; legislation was shifted from criminalisation to medicalisation of drug use. Public demand for effective treatment led to the immense growth of the narcological service, an increased number of specialists and stimulation of research in the field of psychoactive substance use. This also marked the beginning of international cooperation in solving the problem. Compulsory treatment still existed, but discussions began about its necessity. Another option considered at that time was the transformation of the institutions into something similar to the American therapeutic communities.

The campaign resulted in further dramatic reduction of drug availability. Opium became extremely expensive. Fetching opium became an even more risky business. Some drug users stopped. Those heavily dependent found ways to overcome the obstacles. Most rural users substituted analgesic or tranquilliser tablets for opium. In the cities, intravenous drug users, forced to be content with much smaller doses, began to take homemade, chemically processed acethylised opium (heroin predecessor), sometimes mixing it with antihistamines or tranquillisers. A few opium smokers shifted to intravenous use of processed opium .Some substituted cheap ephedrone (processed ephedrine with amphetamine-like short-term effect) taken intravenously for opium. The flow of drug addicts to the narcological dispensaries increased. Meantime, the outcomes of addiction treatment were far from desirable.

Current Picture: Social Contexts, Drug Trends, Consequences

After the collapse of the Soviet Union and gaining independence , the countries of Central Asia opened their borders and migration in and out increased. Heroin of different qualities, along with crude opium, was smuggled from Afghanistan and Pakistan. Heroin use gradually became as prevalent as crude opium use. From 1991 to 1999, indices of incidence of drug dependence increased from up to five fold in Kyrgyzstan, Tajikistan and Uzbekistan to more than eight fold in Turkmenistan, to seventeen fold in Kazakhstan , while prevalence increased eight fold in Kazakhstan and up to three fold in the other republics. They continue to grow. A dramatic shift from cannabis to opiate use was observed in Kyrgyzstan and Kazakhstan , although in the latter cannabis users still comprise a significant proportions of all drug users (Fig.1) [5, 8, 9, 10, 11, 12,13].

Fig 1,
Percentage of registered patients using different drugs in Kyrgyzstan in 1991 and 1997

According to UNDCP data, in 1995, opium from Afghanistan became cheaper and its availability increased in all Central Asian republics [4, 5, 9, 10, 11, 12]. The social structure of drug consumers also changed. Clinicians observed younger drug addicts coming from all social strata, including people from well-off families. Incidence of opiates users has been growing rapidly especially in the cities [4, 5]. It proved anecdotal indications that local heroin dealers promoted the drug to the young (for example, in higher education institutions) [4,11].

The social consequences of drug use were worsening with high levels of unemployment and increasing criminality, even among rural users. Tuberculosis, hepatitis B and sexually transmitted diseases were the most common co-morbidity in this group. Serious family problems, divorce, childlessness, unemployment, and criminality were typical [4,5].

New female "customers", young prostitutes, replaced the elderly women who used to be registered as opium addicts. The involvement of women in the illegal drug trade became common practice [4,8, 14].

Since injecting drug use is a relatively recent social phenomenon in Central Asia and not only illegal but a shameful activity, the extent of the problem is difficult to assess. Nevertheless, due to UNAIDs rapid assessment and response surveys, IDU is much higher than the official statistics suggest. For example, the Ministry of Health and Ministry of Internal Affairs of Uzbekistan estimate that at the beginning of 2001 there were 22,000 registered drug users, UNAIDS gives a conservative estimate of 12,000-15,000 IDUs in Tashkent (the capital city) alone. In Kazakhstan there are 34,000 registered cases of IDU but the authorities estimate it to be 7-8 times higher, about 200,000. In Kyrgyzstan and Tajikistan the expert estimates are 10 times higher than the official statistics [8,9, 10, 11,12,13,14].

Among registered cases of opiates use IDUs account for 15 % in Turkmenistan, 30 % in Tajikistan, 40-60% in Uzbekistan, more than 90% in Kazakhstan and Kyrgyzstan. In all five countries, urban young people (males between 16 and 30 ) comprise a majority of IDUs [5,8,14,15].

To understand the scene evolving, one should consider the social context of current drug use in Central Asia (Table 2). In a way it is a déjà vu picture but with some new features.

As already mentioned, the republics had a lower level of development than other parts of the Soviet Union, but this low level was compensated by subsidised social investment by the central government and, as a consequence, Central Asia enjoyed higher human development than other countries with a similar DGP. Life expectancy, education and health indicators were similar to those of more industrialised countries [14]

After independence the drop in living standards has been substantial and the social costs have been immense, although in the last few years, economic reforms have started to show positive results.

The poverty rates in Central Asia were estimated by UNDP as follows:

Tajikistan – over 80%, Kyrgyzstan - 60-70%, Turkmenistan –50%, Kazakstan - 35% and Uzbekistan - 30% of the population. The most desperate situation is in Tajikistan where 85% of the population has been defined as poor and 5% would be considered destitute. Poverty as a general rule is higher in rural areas [14].

The transition from a centrally planned to a market economy meant the end of the system of guaranteed employment enjoyed throughout Central Asia in Soviet times. Particularly hard-hit by unemployment are young people (15-24) who account, for example for between one-third (Kazakhstan) and two-thirds (Uzbekistan) of all officially registered unemployed people. The actual unemployment levels of young people are probably higher since many do not bother to register as unemployed.

Among other features of the transit period is high levels of migration. The post-independence period is typified by large movements of population across the region. According to the estimates of UNHCR, over 4 million people moved within or from Central Asia since the late 1980s driven by civil strife (civil war in Tajikistan) or environmental reasons (from Aral See Basin and Semipalatinsk). In addition, more than 2 million people returned to their ethnic "homelands" beyond Central Asia. To these figures should be added, massive internal migration mostly from rural to urban areas. These internal migrants are essentially poor people, drawn to the towns and cities in search of employment and a better way of life. Faced with few employment possibilities, such migrants are more likely to join the underground economy and are more at risk of being drawn into commercial sex or even criminal activities such as drug trafficking [14].

In addition to permanent migration, there is increased mobility since independence. Migrant workers travel within the CIS, especially to Russia, seeking temporary or seasonal employment. This phenomenon is particularly important in Tajikistan and is attributed, at least anecdotally, as being a factor in the increase of STI and HIV in this country. Besides, long-distance truck drivers travelling throughout the region and shuttle-traders in the informal import-export business, and who travel abroad mainly to Southeast Asia, the Middle East and Gulf countries are other new groups who can also be seen as quasi-risk groups for STIs and drug use (and trafficking) [14].

Table 2
Background information on Central Asian countries

Along with poverty , there is also deterioration of basic services such as health care, education and sanitation. Public financing for both the education and health sectors has fallen since independence. This is reflected in a decline in education and care access and quality (enrolment rate in secondary education has decreased).

Life expectancy fell between 1991 and 1995 and has only just started to recover. Deterioration of health care service is among factors explaining worsening of the health of the population, which points to a legacy of acute infectious diseases and conditions related to reproduction and childhood together with chronic non-infectious diseases. Moreover, other risk factors affect the health of the population, particularly high rates of fertility, inadequate systems of water supply and sanitation, high rates of smoking and alcohol consumption and poor diet.

Talking about lifestyles, for example, in Kyrgyzstan, regular daily smokers aged 15 and above counted for more than 30% for 1996. In 1991-1999 the death rate from smoking related causes has risen in Kazakhstan, Kyrgyzstan and Uzbekistan ( recent data from Tajikistan and Turkmenistan are not available) and on average there were more than 650 deaths per 100,000 relevant population in 1998-1999 [16]

Although alcohol consumption in Central Asia is much lower than in other NIS (on average not more than 3.0 l of pure alcohol per capita per annum), mortality rate from alcohol related causes is high in Kazakhstan (249 per 100,000) and Kyrgyzstan (152 per 100,000) in 1999 (NIS average 154 per 100,000). It correlates with quite high indicators of death caused by external injury and poisoning (134 and 97 per 100,000 population in Kazakhstan and Kyrgyzstan respectively; 156 per 100,000 in NIS) in 1999 [16]. Demographic compositions and economic conditions of the countries should be taken into account when one interprets alcohol related harm in Central Asia. In sum, it is clear that alcohol related problems in urban areas of the Central Asian republics are very similar to those typical for the European parts of the Former Soviet Union (at least for the adult men).

In connection with substance abuse problems, two groups of diseases are important to look at: tuberculosis and sexually transmitted infections (STIs). Incidence of tuberculosis has grown two fold on average in Central Asia, with the highest 140 per 100,000 new cases of the disease registered in Kazakhstan in 1999 (NIS average is 78 per 100,000). It is well known that alcohol and drug dependent people are over represented among those with tuberculosis (up to 25-30% in Turkmenistan in mid 1990s). Again the mortality rate from tuberculosis has increased in all republics (in Kazakhstan, and Kyrgyzstan more than twice from 1991 to 1999 [16].

The incidence of viral hepatitis in Central Asia although fallen since the early 1990s, is still quite high in comparison with other countries of the European region [10]. In a study of health impacts of drug use conducted in Turkmenistan in the mid-1990s, it was shown that about 80% of IDUs had positive tests for viral hepatitis B [4].

The incidence of syphilis has jumped up 10 fold (in Turkmenistan and Tajikistan) to 100 fold in Kazakhstan with three other republics in between [16]. Official statistics do show some evidence of a slow-down in STI in the past two years. However , this may be attributed more to under-reporting because of the way in which STIs are diagnosed, treated and reported than a genuine reduction in the incidence of STI. Because of fear of registration and of discrimination, patients are turning increasingly to non-specialist medical practitioners for the diagnosis and treatment of STI, and as these practitioners are not licensed to treat STIs, there is virtually no reporting. Moreover, vulnerable groups such as commercial sex workers, homosexual individuals, etc. are more likely to turn to unlicensed practitioners for the same reasons.

As a result, in Kazakhstan, only 25% of all patients treated at STI clinics in 1999 had gone voluntarily to the clinics for treatment. In Kyrgyzstan the real figures are thought 60% higher than the official statistics. The most vulnerable group for STI is the 20-29 age group (53.2%), particularly women. Among urban youth the rate of infection was 173.1 per 100,000 in 1998 Approximately 16.1% commercial sex workers were suffering from STIs. In Uzbekistan STI rates among women started recently to exceed the rates among men. Testing for other STIs (i.e. gonorrhoea and chlamidya) is of poor quality and statistics are not reliable.

In summary: the high level of STIs suggests a high level of usage sex behaviour across the region, a source of concern in the effort to contain the spread of HIV infection [14].

As may be expected the rate of STIs is high among those with problem drinking and drug users. In Turkmenistan, self reports of alcohol and drug dependent persons undergoing treatment (N= 249) showed that on average 18% of them suffered from STIs (9% out of 99 drug addicts have had syphilis) over life time and 2% had some STI at the moment of investigation. At the same time 36% of alcohol dependent and 55% of drug dependent males and 57% of drug dependent women have never used condoms, although most of them reported having sexual partners from risk groups (prostitutes, alcoholics, drug addicts).

Looking at gender differences of the responses in this study one could notice some classical features of female victimisation. Being of the same educational level as men and being even better informed about STD’s and protective means, women drug addicts had the highest level of STD’s , had less stable sexual relations, frequently were forced into sexual intercourse by a male partner ( who often was from the same at-risk group), were terrified to get contaminated with STD’s and had casual sexual relation to earn money. More over, it seems that in this last case women could control situation by using preventive measures but they lost this ability in their stable sexual relations : most of them reported that they became STD infected as a result of sexual contacts with their stable partner. [17].

Drug injecting amplifies the risks of STIs transmission. For example, around 80% of IDUs reported to have shared equipment (needles and syringes, filters and spoons) during the last month as shown in surveys from several Central Asian cities (in Central and Eastern Europe 15-35%, in Russia 40-80%) [15]. In Bishkek, 86% of registered IDUs in the survey reported that they seldom or never used condoms. At the same time, 82% of the same sample had sexual partners who were not injecting drug users.[14].

In NIS (Central Asian republics among them) drug using sex workers are on average younger and less willing or able to use condoms than non-injecting ones, implying a greater risk of sexual transmission to their clients [15].

The dramatic increase in STIs which has been recorded throughout the region over the past decade is a key pointer to a potential increase in HIV/AIDS. The first cases of HIV in Central Asia were detected in the late 1980s/early 1990s. The origin of infection could be traced mainly to sexual contacts with infected persons living outside their region. The incidence of HIV remains very low (Table 3 )

Table 3
Status of reported HIV/AIDS cases in Central Asian republics, November 2000

Sources: UNAIDS-Central Asia, 2001 [14]

In 1996, evidence pointed to an HIV epidemic in Karaganda Oblast of Kazakhstan (mainly in Temirtau city) This was mainly limited to injecting drug users. As a result of concerted interventions by national authorities and international agencies, the percentage of HIV positive persons among recent IDU (i.e. less than one year of injecting drug use) has fallen from 15% in 1997 to 5.1% in 1999. By 2000, however HIV cases had been identified in all the provinces of Kazakhstan. The HIV infected population is characterised by the mode of transmission (82% are IDUs), the young age (69% of all HIV positive persons are aged between 15 and 29) and high levels of unemployment (76.9% are unemployed). In general, in 1999, HIV prevalence among drug users in Kazakhstan and Kyrgyzstan was 0.5%.

In Uzbekistan, HIV prevalence is low (135 persons in July 2000) and the main mode of transmission is through IDUs: 80% of HIV infected people are IDUs. Recently there has been an outbreak in Yangiyil, an industrial city on the outskirts of Tashkent where 35 cases have been reported. In Kyrgyzstan, there are 53 positive cases. Analysis of the age structure shows that 83% of all HIV positive cases are aged between 20-29. In both Tajikistan and Turkmenistan respectively 11 and 4 cases.

In 1999 the incidence of clinically diagnosed AIDS in CAR was 0.01 per 100,000 population [16]. Caution is required in interpreting the official statistics because of testing policies and the conditions under which testing is conducted.

To what extent transmission of HIV will remain restricted to IDU is open to conjecture, especially if one considers that there is a high percentage of IDUs among commercial sex workers. For example, in Almaty city (Kazakhstan), 30% of all commercial sex workers are estimated to be drug users with 15% injecting drug users [14].

Thus the situation is characterized by a dramatically increased number of opiates users, decreased age of on onset, spreading of intravenous drug use ( predominantly heroin) along with more severe consequences and less capacity for society to control the drug related situation.

Political response

Political response to the situation has followed a classical path: from problem denial (the early 90s) to anger at "black sheep" (recriminalization of drug use in the mid-90s) to acknowledgement of the problem and the search for more practical countermeasures [4,5].

All five countries are signatories to the international conventions on drug abuse. There are however, few systematic interventions on demand/harm reduction and rehabilitation and detoxification programmes are insufficient for the number of drug addicts.

Each country has embarked on health care reform. These reforms which are at different stages of implementation, aim to provide access to primary health care in both urban and rural areas, replacing the hierarchical, specialty-driven approach to health care with a primary care model.

The narcological service, a highly developed system with a specialist network of out- and in-patient facilities was reduced in all countries except Uzbekistan. The rationale for the decision to cut down the number of institutions and general capacity of the service was based on the fact of under utilization of the narcological facilities (on average only 70% of all beds were used annually in the 1990s). Disappointment of the general public and the authorities with the results of treatment has also been a significant factor in taking the decision. Indeed, not more than 13% of patients had remission up to two years and only 2.5% had remission of 5 years ( 5 years of total abstinence is the term for an individual to be cleared from the narclogical register). The picture was marred by the fact that 25-30% of all registered patients tried to avoid treatment. More over, voluntary admissions comprised only 10-15% of all patients under treatment, all other cases were brought to narcological institutions by the police [5,18].

The most dramatic cut to the service was made in Tajikistan. At the same time Kazakhstan and Uzbekistan opened new institutions for compulsory treatment of drug addiction under the Ministry of Health. Uzbekistan has also expanded its narcological service in the frame of the penitentiary system. In the situation of rapid spreading of drug use and lost hope in the ability of heath care to surmount the problem, stirring up the police for early detection of drug use and expansion of the network of non-voluntary treatment, was seen as an emergency measure for gaining states control of drugs. The immediate response to this policy was growth of a parallel unofficial network of treatment services where most of the socially adjusted drug addicts prefer to go for treatment. Meantime, 5-10% of registered alcohol dependent and up to 10-20% of drug dependent patients are undergoing non-voluntary treatment in the republics. Estimates are made that many more need compulsory treatment[5,8,9, 10,11,12, 13, 18].

The proportion of drug abusers among prison populations in the republics is also quite significant: in Tajikistan 30% (1996), in Uzbekistan 20% (1998), in Kyrgyzstan 4.8% (1995), in Kazakhstan 4.0%. The proportion of females among drug abusers in prison populations is high:

in Tajikistan 25% (1996), in Uzbekistan 19.8% (1998), in Kazakhstan, 8.7% (1998), in Kyrgyzstan 4.2% (1995) [1]. Understanding the seriousness of the risk that the sexual and drug-consuming behaviour of prisoners could lead to the spread of HIV/AIDS led to pilot implementation of projects in prisons to promote safe sex behaviour and harm reduction in some of the republics [14].

The in-built contradiction between the two pursuits of social policy: the objective of social control and the desire to meet human needs [2,3,4], explains some of the particularities of the treatment system of alcohol and drug dependency and especially existence of its non-voluntary part. Generally speaking, very little treatment is completely voluntary, in the sense that the user just decides by himself or herself to enter the treatment system. Even now, substance abuse is often perceived largely as a crime problem rather than a public health or individual health and welfare issue, and the role of treatment is being justified by the contribution it can make to crime reduction [18].

As the whole health care system is still in serious crisis, whatever types of treatment are judged , their effectiveness is perceived as insufficient. For what is remained of the narcological service, the heavy burden of heroin addicts who now comprise the majority ( up to70-90% ) of patients is unbearable. For example in 2000, in Bishkek, Kyrgyzstan, most patients were discharged from the narcologiocal register because they moved out of the assigned area (about 57% men and 55% women) or died (36% men and about 28% women) out of 788 males and 130 females patients. Remission for 5 years was documented only for 18% men and about 15 % women [8]. Although an increasing body of evidence shows that even treatment programmes with high relapse rates are more cost-effective that just law enforcement measures, still the public and authorities expect more convincing outcomes of treatment of substance abuse [1,18,19].

The mentioned reforms give priority to primary care, leaner and more cost-effective hospital systems, changes in medical education and in the balance of general practitioners, specialists and nurses. To this end it should be noticed that all the countries understand the importance of primary health care participation on substance abuse prevention. However, lack of knowledge of appropriate intervention techniques and some particularities of legislation hamper countries’ efforts for more active involvement of general practitioners and their nurses in preventive work

As for primary prevention, it is mainly considered as provision of information and public education. Policy–relevant research with focus on prevention and treatment does not exist.

Recent international efforts aimed at harm reduction (mostly on prevention of STI and AIDS among IDUs) were quite successful. Their value should be measured not only by the direct outcomes but also in terms of capacity building and diffusion of new approaches to prevention in countries, inclusiveness of target groups in preventive work among them.

In the long-term, besides the right balance between supply reduction and demand reduction policies, the social context of substance use in Central Asia should be addressed. The policies should be extended "beyond the immediate requirements of combating drug abuse and trafficking, to address broader issues of political development, through promotion of social and economic stability and the stimulation of education and employment opportunities"[20].

References:

1. The World Drug Report 2000, Oxford University Press, 2001

2. Booth M.(1996) Opium (A History)(Simon& and Shuster)

3. Kazakhstan Country Profile on Drugs, 1995 (draft) (WHO/EURO, 1995)

4. Kerimi N.(2000) Opium Use in Turkmenistan: a Historical Perspective. Addiction 95 (9), 1319-1333.

5. Керими Н. Наркомания в Средней Азии (отчеты национальных экспертов, 1991-1997), Всемирная организация здравоохранения, Европейское региональное бюро, Копенгаген, 1999 [Kerimi N. Drug Addiction in Central Asia (reports of national experts, 1991-1997), World Health Organization, Regional Office for Europe, Copenhagen, 1999]

6. Harkin A.M. Profiles of Alcohol in the Member States of the European Region of the World Health Organization, WHO Regional Office for Europe, Copenhagen, 1995

7. Rehn N. Alcohol Policy Profiles in the European Region of the World Health Organization, WHO Regional Office for Europe, Copenhagen, 2000

8. Asanov T. Some data on registered alcohol and drug dependent patients in Kyrgyzstan, Personal communication, 2001

9. Тастанова А (2001) Наркологическая ситуация в республике Казахстан. Информационный бюллетень WHO CAR News, No 9 (26) [Tastanova (2001) A. Drug related situation in the republic of Kazakhstan, WHO CAR News, No 9 (26)]

10. Асанов Т. Медицинский аспект проблемы наркотиков в Кыргызстане, Информационный бюллетень WHO CAR News, No 9 (26) [Asanov T. The medical aspect of narcotic drugs in Kyrgyzstan, WHO CAR News, No 9 (26)]

11. Информация о ситуации, связанной с употреблением наркотиков в республике Таджикистан (отдел по контролю за законным оборотом наркотиков Агенства по котролю за наркотиками Республики Таджикистан), Информационный бюллетень WHO CAR News, No 9 (26) [Information on the situation related to narcotic drugs consumption in the republic of Tajikistan (Department for control of legal drug trade of the Drug Control Agency of the republic of Tajikistan), WHO CAR News, No 9 (26)]

12. Умаргалиев Дж. Проблема наркомании в Узбекистане, Информационный бюллетень WHO CAR News, No 9 (26) [Umargaliev Dj. Drug addiction problem in Uzbekistan, WHO CAR News, No 9 (26)]

13. Promotion of Multisectoral Effective Response to HIV/AIDS/STI/Drug Abuse in Uzbekistan,UNDP/UNAIDS/Uzbekistan, Draft Report, 2001

14. UNNAIDS Assisted Response to HIV/AIDS, STIs and Drug Abuse in Central Asian Countries (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan), 1996-2000, UNAIDS- Central Asia, Almaty, 2001

15. Dehne K. L.&Kobyshcha Y.(2000) The HIV Epidemic in Central and Eastern Europe: Update 2000, Draft Report

16. Health for All Statistical Database: www.who.dk

17. Kerimi N., Genefico N, Buravlev V., Khen G., Kasimova A., Annanepesova B., Trapeznikova N. (1998). Sexual Behaviours of Alcohol and Drug Dependent Patients in the Context of AIDS/STD Prevention , Draft report to WHO Regional Office for Europe

18. Kerimi N.&Rehn N. Non-voluntary Treatment of Alcohl and Drug Dependence: A European Perspective (report of the meeting, Moscow, Russia, 22-23 April 1999), World Health Organization, Regional Office for Europe, Copenhagen, pending

19. Peter Reuter (2001) Why Does Research Have So Little Impact on American Drug Policy, Addiction, 96 (3), 373-376

20. The World Drug Report 1999, Oxford University Press, 2000

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