Drug and Alcohol Use in Iraq: Findings of the Inaugural Iraqi Community Epidemiological Workgroup

Abstract

Background

Reports suggest increased use of alcohol, prescription drugs, and illicit drugs in Iraq in the past decade, which may portend an increase in substance use disorders (SUDs) and, thus, an increased need for treatments.

Objectives/Methods

To develop better information on the nature and extent of drug and alcohol use in Iraq, the Iraqi Ministry of Health, with support from the U.S. government and technical assistance from U.S. researchers, held an initial Iraqi Community Epidemiology Work Group meeting in May 2012 in Baghdad. Drug seizure data was the primary data source, provided by Iraqi law enforcement and customs officials. Ministry of Health officials presented data from hospitals (medical and psychiatric), outpatient clinics, and health centers, as well as from surveys of medical patients, pharmacy patients, and prisoners.

Results

The data suggest that the most commonly used substances are alcohol, hashish, and prescription drugs. New drugs in Iraq's drug use scene include the amphetamine-type substances “Captagon” and crystal methamphetamine, and the painkiller tramadol. Seizures of Captagon, methamphetamine, Afghan opium, teriac (a crude form of opium), and heroin at border crossings may indicate that these substances are becoming more popular. A plan for an ongoing program of CEWG meetings was developed.

Conclusions

Drug and alcohol use in Iraq is increasing and new drugs are appearing in the country. An ongoing program for monitoring drug use trends and informing Iraqi policy makers is important for public health planning, including the development of strategies to identify citizens with SUDs and provide them treatment.

Drug and Alcohol Use in Iraq

The Republic of Iraq, with an estimated population of 34 million people, is a country bordered by the Islamic Republic of Iran to the east, Turkey to the north, Syria to the northwest, Jordan to the southwest, and Kuwait and Saudi Arabia to the south. As of 2010, there was no official Iraqi agency or organization conducting country-wide or even regional data collection on substance use (World Health Organization [WHO], 2010). Thus, estimates of the patterns and consequences of drug use must be derived from various official and unofficial sources, none of which fully and accurately depicts the substance use situation in Iraq. Some observations from the WHO Regional Office report (WHO, 2010) on Iraq are that:

• increased drug use has occurred among females and youths; the drugs being used include sedatives, benzhexol (Artane®, an anti-Parkinson drug) and inhalants (e.g., paint thinners, glue);

• adults also use benzodiazepines and benzhexol to deal with stresses caused by conflict and war; in addition, codeine is popular;

• opiate use, primarily as smoked opium or heroin, occurs at unknown levels;

• high (and rising) rates of drug use occur in prisons and in urban areas;

• data about cannabis use are not available, but cannabis is widely used.

A survey conducted in 2009 found that lifetime prevalence of alcohol use in Baghdad was 17.8% and drug use prevalence was 7.02% (Al-Hemiary, Al-Diwan, Hashim, & Abdulghani, 2010). Besides the growing levels of alcohol use, which is occurring along with increasing alcohol availability, especially in Baghdad, commonly used drugs across the country are sedative hypnotics and benzhexol. In an article on Iraqi psychiatrists' perceptions of the drug situation in the country (Al-Hasnawi, Aqrawi, Sadik, & Humphreys, 2009), the authors reported on a survey of psychiatrists (70) working in Iraq. Fifty-eight of the 70 psychiatrists (83%) completed the survey regarding patients seen in private or government clinics for substance use disorders. Responses indicated that diverted medications, which were mostly obtained through the black market and privately owned pharmacies (without a prescription), were the leading drug problem, particularly benzehexol and anxiolytic medications, including benzodiazepines. These increases in the use of alcohol, prescription drugs, and illicit drugs may indicate an increase in substance use disorders in the country and, therefore, an increased need for treatment interventions.

Need for More Current and Comprehensive Information on Alcohol and Drug Use in Iraq

In order to develop a coordinated response to the problems related to the use and abuse of substances in Iraq, the Iraqi Ministry of Health, with funding from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and technical assistance from U.S. researchers, developed a plan for building an ongoing process for obtaining timely and accurate information for Iraqi policy makers on the nature and extent of drug and alcohol use in Iraq. The method chosen for collecting and organizing this information is the Community Epidemiology Work Group (CEWG).

The Community Epidemiology Workgroup Surveillance System

The CEWG is a surveillance system that provides information on changes in illicit drug use, drug supplies, and drug-using populations, as well as the consequences of drug use on users. Data gathered and shared during the CEWG meetings can highlight an emerging problem or show how an existing problem is changing. The CEWG methodology was established in the United States in 1976. Comprising a network of researchers from major metropolitan areas, the U.S. CEWG has been used to provide ongoing community-level surveillance on the nature of emerging trends in substance use in the United States, and this information has been used to directly inform policy makers. Data is gathered from multiple sources, including law enforcement records, hospital emergency department admissions, drug treatment centers, medical examiners' and coroners' offices, public health centers, surveys, and ethnographic research. The objectives of the CEWG are to identify local drug use patterns, monitor drug use trends, and detect emerging substances of abuse. Once this information has been obtained, representatives of the Iraq CEWG will communicate and disseminate the information to appropriate agencies to assist in the development and assessment of policy decisions, prevention strategies, and treatment intervention strategies (National Institute on Drug Abuse [NIDA], 2006).

Iraq Community Epidemiology Work Group

The initial meeting of the Iraq Community Epidemiological Work Group (Iraq CEWG) occurred May 8 and 9, 2012, at the Ishtar Sheraton in Baghdad, Iraq (Al-Hemiary, Al-Diwan, Hasson, & Rawson, 2012). The meeting brought together leaders from the substance use disorders sector, public health sector, and mental health sector; law enforcement representatives; university teachers and researchers; governorate representatives; NGOs; representatives from the Ministries of Health, Interior, Labor & Social Affairs, Youth & Sports, and Justice; and international technical assistance experts. The 2-day meeting reviewed the importance of and methods for developing a capacity in Iraq for better understanding the nature and extent of drug and alcohol use in the country and reviewed some of the existing data on this topic.

During the morning of the first day of the meeting, Iraqi and international speakers provided background and a rationale for using the CEWG methodology as an epidemiological data approach. During the afternoon of the first day and the morning of the second day, a series of 14 reports were given that presented data and information on the current use of drugs and alcohol in Iraq. The primary data source was drug seizure data provided by law enforcement and customs officials from locations around Iraq. In addition, Ministry of Health officials presented data from hospitals (medical and psychiatric), outpatient clinics, and community health centers, as well as from several surveys of medical patients, a survey of pharmacy patients, and three prison surveys. On the afternoon of the second day, a workshop was conducted to discuss ways of improving future CEWG meetings by expanding the types and sources of data that would help meet the CEWG goals.

Data were presented during the Iraq-CEWG meeting by the following speakers:

1. The manager of the National Center for AIDS (Baghdad),

2. A consultant psychiatrist from Basrah Governorate,

3. A specialist psychiatrist from Sulaimani Governorate (Kurdistan region),

4. A specialist psychiatrist from Erbil Governorate (Kurdistan Region),

5. A consultant psychiatrist from the Mosul Governorate,

6. A specialist psychiatrist from the Karbala Governorate,

7. An epidemiologist from Baghdad,

8. A police officer from the Central Office of Narcotics – Ministry of Interior,

9. A representative of juvenile prisons – Ministry of Labour and Social Affairs,

10. A representative of the Prisons Directorate – Ministry of Justice,

11. A representative from Police of Narcotics Control – Najaf Governorate,

12. A representative of Primary Health Care – Wasit Governorate,

13. A representative of the Directorate of Customs – Anbar Governorate,

14. A representative of the Children's Future Organization (NGO from Baghdad).

In addition, even though a representative from the Iraq Forensic Department did not attend the meeting, data regarding drug enforcement, including drug arrests and drug seizures, were provided.

Alcohol/Drug Use Information Presented at the Iraq-CEWG

In previous reports about drug use in Iraq (Aqrawi & Humphreys, 2009), prescription medications were the drugs most widely misused, with benzhexol, benzodiazepines, and codeine being the drugs most commonly reported. The primary source of these drugs was pharmacies in Iraq, many of which provided these medications without the necessary prescriptions. Reports in the Iraq-CEWG suggested that seizures of prescription medications occur throughout Iraq, suggesting that availability is still widespread. In contrast, seizures of illegal drugs are made predominantly in the southern governorates and in Kurdistan, in the north. It appears that Basra (Iraq's major port city) is one of the main entry points for much of the illicit drug supply in the south, and the border of Iran is an entry point in the north.

Reports from law enforcement officials regarding drug seizures indicate that two types of amphetamine-type stimulants (ATS) have made a recent appearance in Iraq: “01 Pills” (Captagon tablets, an amphetamine-type drug, likely containing methamphetamine) and “crystal” (methamphetamine). The seizure reports estimate an expansion of the amphetamine market in Iraq. The first seizure of Captagon tablets (and powder) was made in 2009. Since that time, Captagon seizures have increased substantially. The Captagon is coming into the country via ships traveling to the Gulf and Saudi Arabia, whereas the “crystal” has been seized at border crossings with Iran. With a long and increasingly open border with Iran, it is likely that methamphetamine manufactured in Iran is being transported into Iraq.

Until 2009, hashish dominated non-pharmaceutical drug seizures, with only small quantities of heroin and opium being confiscated. While the absolute amounts of hashish seized by law enforcement has continued to increase, in 2010 and again in 2011, heroin/opium accounted for 15% and 5% of the total seizures, respectively. When evaluated on their own, these numbers may not be startling; however, this trend represents a significant shift from previous years, when hashish accounted for nearly 100% of the national drug seizures (Rawson, 2011). Traditionally, opium is used in the form of “teriac” in Afghanistan, Iran, and some Asian countries. Teriac is a crude form of opiuim sold in digit-sized chunks that is either eaten or smoked in a variety of ways, including using a “shisha” (waterpipe). In 2010 and 2011, there were multiple reports of seizures of teriac close to the border with Iran (Rawson, 2012). At the present time, there is evidence of heroin use in Iraq, which is primarily smoked or snorted. Injection does not appear to be the preferred route of administration by the majority of users.

Significantly increased use of tramadol (a relatively weak mu-opiate agonist) was reported in a number of the regions in Iraq. In Mosul, a city in the north of Iraq, a study was conducted on 122 individuals who were using tramadol. Of those interviewed, 15.6% used tramadol by injection. Regarding people's reasons for using Tramadol, 45.8% reported using for chronic pain, 23.8% for acute pain, and 30.2% for psychological well-being. Of those interviewed, 30.2% reported having a prior addiction to drugs or alcohol, and 18% reported that they had tried to stop using tramadol but had been unsuccessful; 14.7% reported that they sometimes take tramadol to get high, and 46.7% have purchased tramadol from a drug dealer. Tramadol use was reported as the primary substance use disorder of patients admitted for treatment at the Baghdad Medical City Detoxification Unit.

Plans for Future Iraq-CEWG Meetings

Following the data presentations and discussions, the group recognized the following considerations for future meetings:

Geographic representation

Discussion about the most important geographic regions to be represented in future Iraq CEWG meetings centered on cities/regions with high rates of tourism/visitors, including border cities and religious centers. The following cities were identified as the 10 cities with the highest priority: Basrah, Anbar, Najaf, Wasit (Kut), Karbala, Sulaymaniyah, Baghdad, Erbil, Mosul, Muthanna (Samawah).

Types of information to access

At the present time, there is one inpatient treatment center in Baghdad and psychiatric units in Mosul and Basra. The only data available at present concern the type of substance used on admission. For subsequent CEWG meetings in Iraq, attempts will be made to obtain and present the following data:

1. Substance use treatment data (treatment content and length);

2. Substance use information from hospital admissions and emergency department visits;

3. Substance use information from health center admissions;

4. Pharmacy records;

5. Law enforcement data, including

   1. Drug seizure reports, and distribution routes (border crossing, customs),

   2. Price/cost of drugs used,

   3. Police records (arrests and accidents, automobile accidents, falls, sexual harassment related to drug and alcohol use, etc.),

   4. Drug-related court records (including civil and military courts);

6. Drug-related mortality data;

7. Poison control data;

8. Prison records on infectious diseases (hepatitis, HIV/AIDS);

9. Surveys (street surveys, youth risk behavior surveys, school surveys, high-risk population surveys).

Surveys are among the primary sources of data on drug use. Surveys conducted regularly on populations at risk can provide information on attitudes, as well as trends and emerging problems. One specific suggestion was that a national survey on alcohol and drug use be conducted in Iraq to inform future CEWG meetings. A suggested parameter for the survey is to sample approximately 3,000–4000 participants nationally. The survey will be done by local staff who will receive a one-week training course in survey data collection, including training on survey research ethics and confidentiality. Sampling will collect information from a representative segment in each governorate; in addition, the following populations at high risk will be oversampled: sex workers, street vendors, and young adults. Saliva samples will be collected on a subset of participants and tested to assess validity of the self-reports.

Summary

The initial meeting of the Iraq Community Epidemiological Work Group brought together leaders from a broad swath of Iraqi institutions. The 2-day meeting reviewed the importance of and methods for developing a capacity in Iraq to better understand the nature and extent of drug and alcohol use in the country and reviewed some of the existing data on this topic.

The findings from this meeting suggest that since the time of the reports by Aqrawi and Humphreys (2009) and Al-Diwan (2010) on drug use in Iraq, as summarized in Rawson (2011), some aspects of the drug-use situation in Iraq have remained relatively stable, while there have been significant changes in other areas. The psychoactive substances most widely used in Iraq continue to be alcohol and the following prescription drugs: benzodiazepines, benzhexol, codeine, and a variety of psychiatric medications. This set of “primary drugs” is consistent with the earlier reports. However, there was near universal agreement that the use of hashish, tramadol (an opioid-type analgesic), and amphetamine-type substances (ATS) is increasing rapidly in some areas and that drug and alcohol use overall is increasing. Reports from Basrah health officials and police were noteworthy. Two types of ATS have been seized in considerable amounts in Basrah: “01 Pills” (tablets of Captagon, an amphetamine-type drug) and “crystal” (methamphetamine). The 01 Pills appear to be of the same type of ATS that are being used in epidemic amounts in Saudi Arabia, and they appear to be coming into the country via ships traveling to the Gulf and Saudi Arabia. The crystal is likely coming from Iran, since drug seizures have been near the Iranian border and crystal use in Iran is very extensive. In addition, reports from Mosul and from federal drug seizure data suggest that the use of tramadol is also increasing substantially in many parts of Iraq. This drug is available to users from pharmacies and from street drug dealers. At the present time, there is little evidence of increased use of heroin in Iraq, and rates of injection drug use appear to continue to be relatively low.

The practical advantage of CEWG methodology is its use of existing data, prepared in a standard format. The data from existing sources is augmented by research and population surveys, when available. A national survey is currently being planned to provide new information, which will inform future meetings of the Iraqi CEWG and, it is hoped, lead to improved treatment for Iraqis with substance use disorders.