AFGHANISTANDrug Use Survey 2005Drug Use Survey 2005

Government of Afghanistan

Ministry of Counter Narcotics

Government of Afghanistan

Ministry of Counter Narcotics

Acknowledgements The following individuals contributed to this national assessment of drug abuse in Afghanistan and to the preparation of the present survey report: Drug Demand Reduction Section of the Ministry of Counter-Narcotics Mohammad Zafar (Head) Mohammad Raza (Deputy Head) David Macdonald (Consultant) UNODC (Afghanistan)

• Doris Buddenburg (Representative) • Jehanzeb Khan (International Project Coordinator) • Mohammad Naim (National Project Coordinator) • Sayed Hassan (Senior Programme Officer) • Friba Aabidi (National Project Officer) • Mohammad Aqa Stanikzai (National Project Officer) • Patrick Halewood (Consultant) • Hakan Demirbuken (Regional Illicit Crop Monitoring Expert, ICMP) • Nazir Ahmad Shah (National Project Coordinator, ICMP) • Ziuddin Zaki (Data Analyst, ICMP) • Shamsullah Rahman (Database Developer) • Nooria Khairandish (Data Entry Clerk) • Zuhra Saddiqe (Data Entry Clerk) • Zia Ulhaq (Data Entry Clerk) • Mohammad Alam Ghaleb (Regional Coordinator, Nangarhar Zone) • Fazal Mohammad Fazli (Regional Coordinator, Kandarhar Zone) • Lutfurahman Lutfi (Regional Coordinator, Balkh Zone) • Mohammad Alem Yaqubi (Regional Coordinator, Badakhshan Zone) • Altaf Hussain Joya (Regional Coordinator, Herat Zone)

The field interviews were conducted by field workers of the Drug Dependency Treatment Center of the Mental Health Hospital and the Gesellschaft fuer Technische Zusammenarbeit (GTZ) ,Demand Reduction Action Teams (DRATs) comprising staff of the Ministries of Public Health and Education, and UNODC field surveyors. The implementation of UNODC’s Afghanistan Drug Use Survey 2005 was made possible by financial contributions from the Governments of Canada, Italy and Japan. UNODC Country Office for Afghanistan House 49/51, Lane 4, Street 15 Wazir Akbarkhan Kabul, Afghanistan Tel: +93 (0) 20 230.22.33,+93 (0) 70.27.96.98 Fax:+873.763.468.836 / +43.1.260.60.74.743 Email: fo.afghanistan@unodc.org

DRUG ABUSE FACT SHEET................................................................................................... 1

EXECUTIVE SUMMARY........................................................................................................... 2 GLOSSARY............................................................................................................................... 4

1. INTRODUCTION AND BACKGROUND TO THE REPORT ................................................ 5

2. SURVEY METHODOLOGY .................................................................................................. 7 Estimation of the number of drug users........................................................................... 8 Profile of drug users ........................................................................................................... 9

3. RESULTS............................................................................................................................ 10 Opium use .......................................................................................................................... 12 Heroin use .......................................................................................................................... 19 Hashish use ....................................................................................................................... 25 Pharmaceutical use........................................................................................................... 29 Alcohol use ........................................................................................................................ 34 Use of other drugs ............................................................................................................ 38 Trends in drug use in Afghanistan.................................................................................. 42 Urban and rural patterns of drug use.............................................................................. 43 Drug use among females.................................................................................................. 47 Child drug use ................................................................................................................... 49 Drug use among ex-combatants ..................................................................................... 50 Drug use among returned refugees ................................................................................ 51 Injecting drug use ............................................................................................................. 53 Drug treatment facilities and services in Afghanistan .................................................. 54

Estimated number of drug users 920,000 as percent of total population (23,850,000) 3.8%Estimated number of adult male drug users 740,000 as percent of total adult male population (6,062,000) 12.1%Estimated number of adult female drug users 120,000 as percent of total adult female population (5,825,000) 2.1%Estimated number of child drug users 60,000 as percent of total child population (11,963,000) 0.7%

Estimated number of opium users 150,000 as percent of total population 0.6%

Estimated number of heroin users 50,000 as percent of total population 0.2%

Estimated number of hashish users 520,000 as percent of total population 2.2%

Estimated number of pharmaceutical drug users 180,000 as percent of total population 0.8%

Estimated number of alcohol users 160,000 as percent of total population 0.7%

Estimated number of other drug users1 200,000 as percent of total population 0.9%

Note: Estimates of drug use are based on results from 1480 key informant and 1393 drug user interviews1. Other drugs include preparations made from the cannabis plant and opium poppy capsule, as well as solvents

FACT SHEET - AFGHANISTAN DRUG USE SURVEY 2005

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Executive summary

• The Afghanistan Drug Use Survey 2005 was carried out from April to August 2005 in 32 provincial capitals, 30 district centres and 152 villages in Afghanistan.The number of interviews was based on the estimated population in each location.

• A total of 1480 key informants and 1393 drug users were interviewed in provincial

capitals, district centres and villages. People identified as having knowledge of drug use in their communities, such as community leaders, health care workers, police officers and teachers, were selected as key informants. They were asked a series of questions regarding their estimates of the number and demographics of drug users, the types of drugs used and drug use trends in the areas in which they were living. Key informants and other sources introduced the interviewers to problem drug users in their communities. The drug users were asked the same questions, and also further questions regarding their own drug use history.

• The number of drug users in Afghanistan is estimated at nearly 1,000,000 people,

with few areas in the country where drug use does not occur. This figure represents 3.8% of the total population, and includes over 860,000 adults (7% of the population aged 15-64). There are strong indications that the estimates presented in this survey of numbers of drug users are lower than the true figures, particularly the number of women and child drug users, since Afghans are likely for cultural reasons to underestimate the level of drug use in their communities.

• According to key informants and experienced drug demand reduction workers, the

number of drug users in Afghanistan is increasing. This survey estimates that the number of drug users in Kabul in 2005 had doubled since 2003. The level of poly-drug use is also rising.

• The amount and type of drugs consumed and the frequency of use indicate that many

people in Afghanistan are dependent on a range of drugs. At least 200,000 people (1.7% of the population aged 15-64), mostly men, are regular users of opiates in the form of either opium or heroin, accounting for between 5% and 10% of Afghanistan’s opium harvest. An estimated 180,000 people use pharmaceutical drugs illicitly, including 60,000 women and 30,000 children under 15 years of age.

• Injecting drug use occurs in the heroin and pharmaceutical drug user communities

(14% and 16% of each community, respectively), and to a lesser degree among opium users, and needle-sharing is common. Drug demand reduction workers consider injecting drug use to be increasing. An on-going seroprevalence assessment of blood-borne infections among Kabul IDU has detected measurable prevalences of HIV, syphilis, and hepatitis B and C.

• There is a higher rate of drug use among returned refugees than among other

members of Afghan society. Approximately two per cent of Afghans have spent time in Iran as refugees, yet returnees account for nearly one third of heroin users and almost the same proportion of opium users in Afghanistan. Less than half of those Afghans that fled to Iran have returned.

• Current drug treatment services and facilities cannot meet demand. There are no

more than 100 places available in residential treatment facilities in the entire country, and many areas identified as having a large number of drug users have no treatment facilities at all. Such programmes, even when operating at maximum efficiency, can treat less than 0.25% of drug users in Afghanistan each year.

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Glossary Demand reduction: A broad term applied to a range of policies and programmes which seek to reduce desire and preparedness to obtain and use illegal drugs. Demand for drugs may be reduced through prevention and education programmes to dissuade users or potential users from experimenting with illegal drugs and/or continuing to use them; treatment programmes aimed primarily towards facilitating abstinence and reducing the frequency of use or amount consumed; and broad social policies to minimize factors contributing to drug use, such as unemployment, homelessness and truancy. Dependence: As applied to alcohol and other drugs: a need for repeated doses of a given drug, giving the user a continued sense of wellbeing or preventing withdrawal symptoms. Detoxification: The process by which a person who is dependent on a psychoactive substance ceases use in such a way as to minimize withdrawal symptoms and risk of harm. Traditionally, detoxification has been provided on an in-patient basis, either in a specialist treatment facility or on the wards of a general or psychiatric hospital. Drug: A term of varied usage. In the various United Nations Conventions and the Declaration on the Guiding Principles of Drug Demand Reduction, the term refers to substances subject to international control. In common usage, it often refers specifically to psychoactive drugs, and also, within that category, to illicit drugs. Drug use: Current international drug control treaties do not define drug use, but instead employ a variety of terms, including “abuse”, “misuse” and “illicit use”. For the purposes of this report, the term “drug use” means the use of any substance under international control for purposes other than medical use, including use without a doctor’s prescription, in excess, or for an unjustified period of time. Hashish: In Afghanistan, hashish refers to cannabis resin obtained from the flowering tops of the cannabis plant. Heroin: A drug obtained through acetylation of morphine. The most common type of heroin in Afghanistan is so-called “brown heroin” and is not suitable for injection, though it can be converted easily into an injectable form. Home treatment: Home-based detoxification, usually involving home visits by medical staff and informal support provided by family and/or friends. IV: An abbreviation for “intravenous injection route”, i.e., the injection of a substance into a vein in any part of the body. Regular injecting drug users may damage the veins in their arms and consequently inject veins in other parts of their body instead. Opium: The coagulated juice from the unripe capsule of the poppy plant (Papaver somniferum). Contains approximately 10 per cent morphine. Outreach programme: A community-based activity with the overall aim of facilitating improvement in health and reducing drug-related risk or harm to individuals and groups. Peer pressure: This term is applied to drug use to embody the idea of pressure exerted on an individual to conform to the behavioural norms of his or her peers, which may include the illegal consumption of drugs. Such individuals are seen to be easily influenced and passive in the face of such pressure. Pharmaceutical drug: A pharmaceutical drug (pharmaceutical) is a substance manufactured by the pharmaceutical industry or prepared in a pharmacy for medical purposes, or any preparation derived from such substances. The most common pharmaceuticals encountered during this survey were anxiolytic and hypnosedative drugs such as Diazepam, and painkillers such as Pentacozine. Poly-drug use: The use of more than one psychoactive drug either simultaneously or at different times. The term is often used to distinguish persons with a more varied pattern of drug use from those who use only one kind of drug. Relapse: A return to drug use after a period of abstinence. Residential treatment: Treatment programmes which require participants to live in a hostel, home or hospital unit. Self-treatment: Home-based detoxification carried out by a drug user with minimal outside support. Snowballing: A method of recruitment of illicit drug users for research purposes. The method involves the recruitment of a small number of illicit drug users for the purpose of establishing contact with a number of other drug users of their acquaintance.

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1. Introduction and background to the report The Drug Use Survey 2005, conducted jointly by UNODC and the Ministry of Counter-Narcotics (MCN) of the Islamic Republic of Afghanistan, aims to provide the first nationwide profile of drug use in the country. For the survey, 1480 key informants were asked questions regarding the number of drug users in their communities, the drug types that were used and trends in the level of drug use. In addition, 1393 drug users were asked the same questions and also interviewed regarding their own drug use history. The answers given by these two groups provide the core of this report. It is anticipated that the report will provide accurate baseline information enabling relevant government agencies and NGOs to develop rational and realistic strategies for drug demand reduction interventions in Afghanistan. Illicit drug use has long been recognised as a major problem in Afghan communities both within Afghanistan and in neighbouring countries. A report produced by UNODC (formerly UNDCP) in 1995 noted that levels of urban drug use, particularly heroin, were increasing1, and as early as 1998, high levels (20% to 30%) of opium addiction were reported among the local population in areas of Badakhshan province2. In response to the reported escalation of drug use in Afghan communities, in 1998 UNODC launched the first of five studies on problem drug use within those communities. The first report3 set out an initial assessment of the problem within Afghanistan and in Afghan refugee communities in Pakistan, particularly in Peshawar and Quetta. It identified the prevalence of poly-drug use, including the use of 20 different combinations of drugs, and also the health-related, economic, social and legal problems associated with drug use within Afghan communities. It further identified IV use among heroin users and the potential for misuse of pharmaceutical drugs. The report noted that the most commonly used illicit drug was hashish; that alcohol use outside of Kabul and Mazar-e-Sharif was restricted; and that a number of young people had applied to a drug treatment centre for treatment of solvent abuse. Subsequent studies focused on specific groups of drug users or specific areas in Afghanistan. Afghan women living in refugee camps and street heroin users in Pakistan were the subjects of more detailed reports4 5. A report on the former group noted a high prevalence of poly-drug use among female refugees (76%6), particularly the use of opium and pharmaceutical drugs alone or in combination with other drugs (62%). The report indicated low levels of heroin use among women (four per cent), and suggested the relatively high price of heroin and a ready supply of other, cheaper drugs as possible factors influencing the decision by women not to use heroin. The report on street heroin users interviewed 150 male users in Peshawar and Quetta. The average rate of IV use among those populations was 1.3%, though a further 5% of heroin users had injected in the past. At least 43% of IV users shared needles. The fourth report7 focused on drug use in rural areas southeast of Kabul. The study area covered parts of the Logar, Kabul, Nangarhar and Paktya provinces. The report estimated that 4% to 6% of adults used opium; 0.1% to 0.14% heroin; 7% to 11% hashish; and 1.4% to 2% pharmaceutical drugs. It also showed that the distribution of drug users varied widely between districts, and that nearly 40% of drug users first used drugs in either Pakistan or Iran.

1 Ulrich Kohler (1995), Report of a drug demand reduction assessment and strategy formulation mission to Afghanistan,

UNDCP, Islamabad, quoted in UNDCP (1999), Community Drug Profile #1 - Problem Drug Use in Afghan Communities: An Initial Assessment, UNDCP Programme, Islamabad.

2 ORA International Central Asia (1998), Taking up the Challenge: ORA Annual Report 1997/98, ORA, quoted as above. 3 UNDCP (1999), Community Drug Profile #1 - Problem Drug Use in Afghan Communities: An Initial Assessment, UNDCP

Programme, Islamabad. 4 UNDCP (1999), Community Drug Profile #2 – Opium and Other Problem Drug Use in a Group of Afghan Refugee Women,

UNDCP Programme, Islamabad. 5 UNDCP (2000), Community Drug Profile #3 – A Comparative Study of Afghan Street Heroin Addicts in Peshawar and Quetta,

UNDCP Programme, Islamabad. 6 The original report indicated a figure of 92%, but included tobacco use. The present report did not consider tobacco use. 7 UNDCP (2001), Community Drug Profile #4 – An Assessment of Problem Drug Use in Rural Afghanistan: the GAI Target

Districts, UNDCP Programme, Islamabad.

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The final UNODC survey1, carried out in 2003, was designed to assess problem drug use in Kabul itself. The survey interviewed 100 key informants and 200 drug users (25% of the latter were female) in Kabul and estimated the following levels of drug use2: opium 0.4%; heroin 0.3%; hashish 1%; pharmaceuticals 0.6%; and alcohol 0.3%. As in earlier reports, drug users were asked where they first started using drugs, and again it was found that a high percentage (40% of opium users and 50% of heroin users) had first started using drugs in either Iran or Pakistan. The report also examined reasons why individuals began using drugs and the problems associated with drug use, and also identified problems in accurately assessing levels of drug use in Afghanistan, particularly among women. All of the reports found that, whilst the level of drug use in Afghanistan is difficult to estimate, even conservative estimates indicate that drug use is a major problem in Afghanistan and among Afghan communities overseas. They also established that the level of drug use appears to be increasing, particularly heroin use, and that treatment services are not able to meet demand. There have been a number of other studies on drug use in Afghanistan. Such studies often examine use of a specific drug in a particular location3. Whilst these studies have a narrow focus, many of their findings can be applied at the national level, such as the health and social problems experienced by drug users and the level of debt in which many families find themselves as a result of drug use. During the 2005 Annual Opium Poppy Survey 1,900 village headmen were asked to provide an estimate on the number of opium and heroin addicted people in their communities. The survey4 reported that opium addiction affects 0.5% of the rural population (approximately 1% of population aged 15-64), and heroin addiction 0.03% of the rural population. The report further noted that, on average, opium addiction rates were seven times higher in opium poppy growing villages than in other villages. This survey was designed to give indicative figures of the level of opiate addiction in rural Afghanistan. The survey did not conduct interviews in urban centers or in district centres.

1 UNDCP (2003), Community Drug Profile #5 – An Assessment of Problem Drug Use in Kabul City, UNDCP Programme,

Islamabad 2 Lowest estimates, based on an estimate of the population of Kabul at 2.5 million at the time of the survey . 3 For example: Theuss et al, (2005) Addiction in the Border Regions of Badakshan, Afghanistan: Range, Trajectory and Impacts. 4 UNODC (2005), Afghanistan Opium Poppy Survey, November 2005, p85-87

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2. Survey Methodology A total of 1480 key informants and 1393 drug users were interviewed in all 32 provincial capitals, 30 district centres (10% of all district centres) and 152 villages (0.5% of all villages) in Afghanistan1. District centres and villages were chosen at random from the AIMS Geocodes and Settlements Database for Afghanistan2, the number of interviews being based on the estimated population in each location. Interviews were conducted with both male (1250) and female (155) key informants, and likewise with male (1228) and female (122) drug users3. Approximately 150 people in Kabul and other provincial centres were trained in interview skills, ethnography applied to working with drug users, and survey methodology. The survey began in June 2005 and was completed by September of the same year. The surveyors’ first task was to identify key informants in each of the selected communities. Key informants were chosen on the basis of their familiarity with the local drug user population. Female informants were employed primarily as health care workers or teachers, or were not employed outside of the home; male informants were employed in a broader range of jobs, but were often police officers, community leaders or self-employed (Table 2.1).

1 2 3 4 5 6Female 33 4* 7 8 41 62Male 138 86 23 357 441 205Not recorded 12 6 0 18 23 16

* including two judges

1=Healthcare workers, doctors, pharmacists, social workers2=Police3=Government employees4=Religious/ community leaders5=Labourers/ farmers/ self-employed/ tradesmen/ shopkeepers/ students/ housewives/ unemployed6=Teachers

Employment category

Table 2.1 Employment categories of key informants

Over 70% of key informants had lived in their respective communities for more than 10 years, almost 60% having never lived anywhere else. Most informants were aged between 31 and 50, almost all were married and many (40%) had completed high school. Female informants tended to be younger (on average 37 years old) and better educated than their male counterparts, who were older (on average 42 years old) and more likely to have been educated at a madrasa (religious school). Most key informants reported that they were familiar with drug use with respect to at least one of the six categories of drugs that they were asked about (Table 2.2), and more than 90% were personally acquainted with one or more drug users.

Drug type Yes No Don't knowOpium 75 20 5Heroin 39 48 13Hashish 91 6 3Pharmaceuticals 38 34 28Alcohol 36 49 15Other drugs 31 47 22

Drug use within the community (percentage of key informants)

Table 2.2: Key informants’ awareness of drug use

1 See Annex A1. 2 http://www.aims.org.af/services/mapping/shape_files/afghanistan/point/settlements.zip 3 Gender of interviewee was not always recorded.

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The majority of those key informants that reported that they were not acquainted with any drug users were from one of six villages where no drug users were identified, which suggested that those villages were drug-free. The high percentage of key informants who were unaware of any pharmaceutical use may be attributable to the method of use of such drugs, which are commonly consumed in tablet form, and to the fact that pharmaceuticals are generally not consumed when others are present. Each key informant was asked a series of 72 questions regarding their perceptions of drug use in their immediate community. These questions covered not only the types of drugs consumed and the number of drug users, but also the reasons for drug use, problems experienced as a result of drug use and whether more or fewer people were using drugs than in the past1. Key informants were then asked to introduce the surveyors to a number of drug users in the areas in which they were living. On the basis of initial interviews with drug users, further users were identified and questioned. A total of 1393 drug users were identified and interviewed in this way. Drug users were asked the same questions as key informants, but were also asked a further 74 questions regarding their own pattern of drug use2. These questions included the history of their drug use, the amount and types of drugs that they consumed, family drug use, details of problems that they had experienced as a result of drug use and information on any treatment that they had undergone.

Drug Type Yes No Don't KnowOpium 60 16 24Heroin 34 33 33Hashish 81 5 14Pharmaceuticals 18 28 54Alcohol 33 35 32Other Drugs 16 33 51

Drug Use Exists in Community (% of Drug Users)

Table 2.3: Drug users’ awareness of drug use Drug users reported lesser knowledge of drug use in their communities than key informants. This was noted in previous surveys3 and attributed to the fact that the drug user questionnaire was much longer than that given to the informants. Users were more likely to lose concentration, possibly owing inter alia to cold or fatigue, and give vague or misleading answers. It is unlikely that users experienced cold during the survey, since it was carried out during the summer, but other such factors may have come into play. Estimation of the number of drug users Estimates of the number of drug users were calculated using the reports of both key informants and drug users. A simple average of the estimates provided by key informants and drug users was used to minimize the likelihood of over- or underestimation4. Where an informant or user had given a clearly unlikely estimate, then the answer given by that individual would not be used in determining the final estimate for the location in question, for example, if 5 users and 4 informants all estimated the number of opium users in their 1 See Annex A2 for complete questionnaire. 2 See Annex A3 for complete questionnaire. 3 UNDCP (2003), Community Drug Profile #5 – An Assessment of Problem Drug Use in Kabul City, UNDCP Programme,

Islamabad, p. 10. 4 See Annex A4.

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community at between 10 and 15, but a single informant estimated there to be no opium users, or perhaps 50 users. There was a very high correlation between the estimates provided by key informants and drug users (r= 0.90); informants generally estimated numbers of drug users at 20% to 30% higher than drug users themselves1. The high correlation between key informants’ and drug users’ estimates was found in communities irrespective of total population and drug using population. In order to calculate a national estimate of the number of drug users, it was necessary to take into account the sampling method used — only 0.5% of villages and 10% of district centres were sampled2 — and to adjust figures to allow for the level of poly-drug use. It is important to note that the sampling method used was designed to provide an accurate estimate of drug use at the national or regional level at best. Parts of the present report, give estimates of drug users at the provincial level. These estimates must be used with caution, and should be interpreted as indicative only. No estimate of error can be given at the provincial level, as the sample size was too small to give accurate provincial estimates. Profile of drug users The profiles of drug users set out in Section 3 are predominantly based on analysis of the additional questions posed to drug users. Key informants provided useful information on problems experienced by users as a result of drug use and reasons why users cease drug use. Any analysis of these answers must take into account, however, that drug users themselves are likely to give more accurate answers to these questions.

1 See Annex A4 for details. 2 See Annex A5 for details.

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3. Results There are a number of important issues that should be borne in mind when interpreting the findings of this report. Past studies have shown that informants may for cultural reasons underestimate levels of drug use. The stigma commonly associated with drug use may be perceived by informants as reflecting on themselves or their communities; even among drug users there appears to be a reluctance to provide accurate estimates of community drug use or to discuss personal drug use openly. Whilst the surveyors were well trained in techniques to overcome these problems, the estimated numbers of drug users reported in this survey should be treated as minimum estimates. A further problem, identified in previous work, in accurately estimating levels of drug use among women is the difficulty in identifying female drug users who are willing to be interviewed. Due to the nationwide coverage of this survey, interviews were often carried out in areas with poor security. Female surveyors, required to interview female key informants and drug users, were unable to travel to some areas. This was not only the case in isolated, rural areas, but also in a number of urban areas where female surveyors were unable to contact a reasonable sample of female drug users. In discussions with staff at drug treatment centres and other experienced drug demand reduction workers, it was noted that drug use patterns among women are of a less public nature than those among men. Most pharmaceutical and opium use by women occurs in the home, and women typically eat opium rather than smoking it, which makes their drug use less visible to other members of the community. This suggests that those key informants and drug users interviewed may have had less knowledge of drug use among females than of that among males in their respective communities, and that their estimates of drug use among females are lower than the true figures. Since drug use among children is also less visible outside of the family home, this survey probably underestimates the true level of child drug use. Before estimating the total number of illicit drug users in Afghanistan, it was necessary to consider poly-drug use. Drug users were asked a series of questions regarding the combination, if any, of drugs that they were using from among six categories, namely opium, heroin, hashish, pharmaceutical drugs, alcohol and other drugs.

Number of illicit drug types used

Drug users interviewed (%)

1 only 53%2 only 27%3 only 13%4 only 5%5 only 2%All 6 1%

Table 3.1: Poly-drug use, based on individual patterns of use among drug users.

The answers given indicated that poly-drug use was common, particularly among men, and that nearly half of all adult drug users used more than one drug type (Table 3.1). Of 63 possible combinations of two or more drugs from among the six drug categories, male drug users reported using 54 combinations, whilst female drug users reported 21 combinations1. Since no children (under 15 years of age) were interviewed during the survey, it is not possible to estimate the level of poly-drug use among child users separately from that among adults. The estimate of the total number of drug users was reduced by approximately 30% to account for those that had been included in the estimates of numbers of poly-drug users (Table 3.2)2.

1 See Annex B1. 2 See Annex A5 for details.

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90% confidence

interval Drug type Male Female Child1 Total Lower Upper

Opium 132,207 16,528 4,134 150,000 110,000 155,000 Heroin 45,801 3,467 268 50,000 35,000 51,000

Hashish 511,224 8,083 2,778 520,000 430,000 665,000 Pharmaceuticals 91,875 57,444 29,626 180,000 125,000 200,000

Alcohol 143,794 18,599 984 160,000 155,000 200,000 Other drugs 93,135 64,018 46,284 200,000 130,000 230,000

Total 1,018,035 168,138 84,074 1,260,000 980,000 1,500,000

Total, adjusted for poly-drug

use 739,000 121,000 60,000 920,000 710,000 1,090,000

Table 3.2: Estimated number of drug users in Afghanistan in 2005.1

The use of illicit drugs is ubiquitous in Afghanistan. The total number of drug users is estimated at 1.27 million people, on the basis of estimates provided by key informants and drug users. If this figure is adjusted to allow for poly-drug use, i.e., cases in which a user may have been counted twice or more, the estimated number of illicit drug users in Afghanistan is at least 920,000. This figure represents 3.8% of the total population2.

1 Children under 15 years of age. 2 Based on an estimated national population of 23.9 million.

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Opium use It is estimated that there are at least 152,000 opium users in Afghanistan, approximately 86% (132,000) of who are adult males, 11% (16,000) adult females, and 3% (4,000) children. These figures are based on estimates given by both male and female key informants and drug users. Had only those responses given by female interviewees been used, the final estimate of the number of female opium users would have been almost three times higher i.e. more than 45,000 women. Geographically, the highest concentrations of opium users outside of Kabul city are found in provinces along Afghanistan’s northern border (Figure 3.4). Although opium is used in areas along Afghanistan’s border with Pakistan, it is noticeable that levels in those areas are significantly lower than elsewhere in the country. This is even more noteworthy when considering that, in 2005, the Hilmand and Kandarhar provinces accounted for almost 40% of Afghanistan’s total opium production1, and that Nangarhar province has traditionally produced a significant quantity of opium2. The distribution of male and female opium users does not vary significantly from province to province, although there were almost no reports of opium use among females across a broad swath of provinces stretching from Hilmand and Kandarhar through to the Bamyan and Wardak provinces.

Figure 3.1: Estimated number of opium users, by province. The following profile of opium users is based on the answers given by 576 male and 71 female opium users. Approximately 40% of opium users interviewed lived in provincial centres and 60% in rural Afghanistan. Most users were between 30 and 40 years of age and had been using opium for an average of six years. Most opium users were married (75%), and almost 20% of female users were widowed (the corresponding figure for male users was 1%). Whilst 15% of male users were unemployed, nearly 65% of women were not in paid employment. Approximately 15% of opium users reported that they were ex-combatants. Typically, the family income of female opium users was approximately 2,800 Afghanis (AFA) per month, of which those users spent a monthly sum of roughly AFA1,600 on opium, whilst

1 UNODC (2005), Afghanistan Opium Poppy Survey, November 2005. 2 UNODC (2004), Afghanistan Opium Poppy Survey, November 2004.

13 13

the average income of male opium users was AFA3,400 per month, of which approximately AFA2,500 was spent on opium each month1. Roughly 60% of female opium users obtained their opium exclusively from drug dealers, although a further 30% purchased some of their opium from drug dealers; 13% reported that they had obtained opium from their own poppy fields. Approximately 35% of male opium users obtained their opium exclusively from drug dealers. Whilst 20% reported that they obtained opium from their own poppy fields, only 4% reported private cultivation as their sole source. It is estimated that 10% of households in Afghanistan are directly involved in the cultivation of opium poppy2. It is not possible to establish whether poppy farming leads to a higher rate of opium use, or whether opium users grow poppy for their own use, but this survey shows that a greater percentage of opium users than non-users are involved in poppy cultivation. Sixty per cent of female users who purchased opium depended solely on family members as a source of money. Approximately 35% of women used their income from employment to purchase opium. No women reported having to resort to crime to raise money. Ninety-four per cent of male users who purchased opium depended on earned income or money borrowed from family members to finance their purchases. A small number of opium users resorted to crime (three per cent) or begging (four per cent) to raise money. Interviewees tended to be descriptive rather than referring to approximate weights when asked how much opium they used each day, often describing the quantity used as equal to the size of a seed, such as a bean or a pea. In general, female users consumed less opium (1.2g per day) than male users (1.7g), and used opium less frequently, although roughly 90% of both groups consumed opium at least once per day. No attempt was made during this survey to measure the potency or quality of opium used in different areas, the variability of which may partly account for the variation in quantities used. Combined analysis of the data obtained for quantities of opium used and the estimates of the number of opium users indicate that at least 88 metric tonnes of opium are consumed within Afghanistan each year, accounting for just over 2% of opium production of Afghanistan in 20053. There is a general trend of increased opium consumption with length of use among male users (Figure 3.3), with men who had used opium for more than 10 years using 70% more opium than men who had used opium for less than 1 year. There is no clear trend among female opium users. The most common method of opium use among women was to eat the drug, whilst the numbers of male users who ate opium and those that smoked the drug were roughly equal (Figure 3.4). Less than two per cent of male opium users reported that they injected a preparation of the drug, and in no cases was injection reported as the sole method of drug use. Notably, all but one injecting opium user reported sharing needles with other injecting users. There appears to be no correlation between length of use and method of use, or between method of use and quantity used.

1 Estimates of amount spent on drugs each month should be considered indicative only. Often drug users are supported financially by other family members, and this level of support may not have been included in their overall expenditure 2 UNODC (2005), Afghanistan Opium Poppy Survey, November 2005. 3 Ibid.

14 14

0

0.5

1

1.5

2

2.5

< 1 year 1-3 years 4-6 years 7-9 years > 10 years

Aver

age

amou

nt o

f opi

um c

onsu

med

dai

ly (g

)

FEMALE

MALE

Figure 3.3: Average amount of opium used daily compared to length of time using opium

0

10

20

30

40

50

60

70

80

90

eating smoking injecting

% o

f use

rs

FEMALE

MALE

Figure 3.4: Method of opium use.

Very few male users gave a clear, single answer as to why they began using opium. The most common answers given were “recreation” and “peer pressure” (Figure 3.5). Significantly, 42% of male users reported that the medicinal effects of opium were among the reasons why they first took opium. Unlike male users, female users provided reasonably clear answers as to why they first began using opium. More than 85% reported that the medicinal effects of opium were among the reasons why they first took opium, and 70% reported those effects as the only reason.

15 15

0

10

20

30

40

50

60

70

80

90

asmedicine

curiosity easilyavailable

liked theeffects

other peerpressure

recreation

% o

f opi

um u

sers

FEMALE

MALE

Figure 3.5: Reasons given for beginning to use opium.

There was moderate correlation between user age and length of time using opium. All women interviewed were married or widowed; 93% had children; nearly 25% had seven or more children; and 70% gave the sole response “as medicine” when asked why they first began using opium. On that basis it was concluded that the majority of female users first began taking opium to treat medical conditions associated with childbirth. Most male opium users (92%) reported at least one problem associated with their use of opium, and the majority reported multiple problems (Figure 3.6). All female opium users reported at least one problem associated with their use of opium, and again the majority reported multiple problems.

0

10

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40

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60

70

80

90

100

criminalbehaviour

financial health socialrelations

stigma

% o

f opi

um u

sers

FEMALE

MALE

Figure 3.6: Problems associated with opium use.

Except in the case of criminal behaviour, men and women experience the same problems as a result of drug use. It is ironic that health problems are most commonly reported, considering that the use of opium as a medicine is one of the most common reasons given for beginning to use the drug. Nearly 75% of female users reported that they were trying to resolve their problems: 13% were seeking treatment and 62% were trying to give up opium by other methods. The corresponding percentages among male users were more than 90%; 30%; and 60% respectively.

16 16

0

10

20

30

40

50

home jail selfdetoxif ication

treatment centre

% o

f opi

um u

sers

FEMALE

MALE

Figure 3.7: Methods/location used to give up opium.

Nearly 63% (n=361) of male opium users and 70% (n=49) of female opium users reported that they had tried to stop using opium in the past, citing different circumstances in which they had stopped. Just over 40% (n=164) of this group of male and female opium users had stopped at home with some help from health workers. Some of these users had also been taken to a medical clinic by their family for help rather than being helped at home, with a few physically restricted to the home by family members. A further 22% (n=11) of women and 25% (n=90) of men stopped at home by themselves without any medical assistance, going through a process of self-detoxification unaided. Around 20% (n=72) of men who had stopped and 12% (n=9) of women had received specialist help from a drug treatment centre, either residential or community-based. Just under 5% of men had stopped opium use when they had been sent to prison.1.

0

10

20

30

40

50

A few days 1 w eek 1 month 1 year >1 year

% o

f opi

um u

sers

who

had

trie

d st

oppi

ng

Figure 3.8: Period of abstinence from opium among users following stopping.

A variety of reasons were given by male drug users as to why they resumed opium use following stopping (Figure 3.9). By far the most common reason for resuming use was physical or psychological pain, according to nearly 55% of respondents. Female opium users formed the overwhelming majority of those that reported physical or psychological pain as the reason for resuming opium use following stopping. Nearly 55% of all women who had sought treatment cited the same as their sole reason for resuming opium use.

1 Sample size of female users was very small (37).

17 17

0

10

20

30

40

50

60

70

80

90

100

easily andcheaplyavailable

lack of familysupport

no treatmentfacility

pain (physicalor

psychological)

peer pressure unemployment other

FEMALE

MALE

Table 3.9: Reasons given for resuming opium use following stopping.

A comparison of the reasons given by opium users for first beginning to use opium and those given for resuming opium consumption following stopping reveals that female users commonly give a clear single answer: they begin using opium for its medicinal effects, and resume use as a result of pain after giving up. Male users rarely give clear single answers; peer pressure and recreation were more commonly identified as reasons for first using opium than any medicinal effect that the drug may have; and peer pressure was a common reason given for resuming opium use following treatment.

0

5

10

15

20

brotheror sister

father mother spouse childunder 5

childover 5

other

% o

f all o

pium

use

rs

FEMALE

MALE

Figure 3.10: Use of opium by family members of users.

The pattern of opium use among users’ family members varied between male and female users. Slightly less than 18% of male opium users reported that a close family member also used opium, in most cases one or more brothers. Nearly one third of female opium users reported that a close family member also used opium, in most cases their husband. Women were also more likely than men to have a mother or children who used opium. More than 78% of male opium users reported poly-drug use, compared with approximately 55% of female users. By far the most common combination of drugs used by males — reported by 56% of male users — was that of opium and hashish, in combination with or without other drugs. While 28% of men said that they took only opium, 27% reported that they used heroin in combination with opium. The most common drug type used by female users in combination with opium was pharmaceutical drugs (30%). Of the 20% of women who

18 18

reported that they used heroin in combination with opium, all lived in urban areas, particularly Kabul. This report estimates significantly higher figures of opium use, particularly in Kabul, than past surveys1. Earlier reports predicted that opium use in Afghanistan may increase as a result of easy availability and relatively cheap prices, and the present report can confirm that those predictions indeed appear to be coming true. It should be noted that this report does not confirm previous estimates of opium use in Badakshan. This is possibly due to the sampling methodology applied in this study. Opium use in Badakshan appears to be common only in certain areas (particularly the Ishkashim, Shugnan, Wakhan and Zebak districts). One of the consequences of selecting a small number of villages at random was that only one of the surveyed villages was in an area of high opium use, whereas five were in areas where opium use is not considered common.

Figure 3.11: Surveyed villages (Drug Use Survey 2005) in Badakshan and areas previously

identified as having high levels of opium use.

1Theuss et al, (2005) Addiction in the Border Regions of Badakshan, Afghanistan: Range, Trajectory and Impacts.

19 19

Heroin use According to estimates provided by key informants and drug users, there are some 49,500 heroin users in Afghanistan. More than 92% (46,000) of heroin users are men, 7% (3,500) are women, and less than 1% (fewer than 300) are children. These results are based on the estimates given both by male and by female interviewees. Had only the estimates provided by women been used, the final estimate of the number of female heroin users would have been nearly 200% higher, i.e. approximately 10,000 women.

Figure 3.12: Estimated number of heroin users, by province.

The distribution of heroin users in Afghanistan follows a similar pattern to that of opium users, with most rural users living in provinces along Afghanistan’s northern border and urban users concentrated in Kabul. Whilst female users were concentrated particularly in Kabul, there were reported to be no female heroin users in 22 of the total 32 provinces. The stigma associated with drug use, in particular with heroin use among females, must be considered here. It is possible that informants failed to report cases of heroin use by females in those provinces because they were either unwilling to do so or were unaware of such cases. There appears to be little correlation between the location of heroin production facilities1 and the distribution of heroin users. The following profile of heroin users is based on the answers given by 259 men and 19 women who reported that they were using heroin. Of the men, 137 lived in provincial centres, whilst the remainder (122) lived in rural areas; only one woman lived in a rural area. Whilst the responses given by women will be discussed, it is not possible to draw up an accurate profile of female users owing to the very low number of female heroin users interviewed. The responses given by a single rural female heroin user cannot of course be representative of all rural female heroin users. The average age of those interviewed was 32 years for male heroin users and 38 years for female heroin users. The former had been using heroin for an approximate average of 4 years and the latter for an average of 4.8 years. Some 70% of heroin users were married, whilst the remainder were single or, rarely (less than 1% percent), widowed or divorced.

1 UNODC, 2005, p. 89.

20 20

Almost 50% of male and 80% of female users had never attended school; 10% of male users had completed high school, as compared to 0% of female users. Just over 25% of heroin users were unemployed, although the corresponding figure for female users was higher at 80%. Most users (approximately 70%) worked in the private sector or as farmers. Some 16% of male heroin users reported that they were ex-combatants. Most heroin users (70%) had lived in their communities for more than 10 years. Typically, male heroin users earned approximately AFA3,400 per month and spent around AFA2,400 on heroin monthly. Eighty-five per cent of users depended on earned income or money borrowed from family members to purchase heroin. Some male heroin users resorted to crime (ten per cent) or begging (nearly nine per cent) to raise money. Approximately 35% of heroin users obtained the drug exclusively from drug dealers, and all users reported that they obtained all or most of their heroin from drug dealers or friends. Each male user consumed an average of 1.4 g of heroin per day, whilst women consumed 0.9 g. More than 90% of male and female users consumed heroin at least once a day, and nearly two thirds of male users consumed heroin more than once a day. As in the case of Opium there is a general trend of increased heroin consumption with length of use among male users (Figure 3.13), with men who had used opium for more than 10 years using 100% more opium than men who had used opium for less than 1 year. There is no clear trend among female opium users. No users were asked questions relating to the grade or quality of the heroin that they used.

0

0.5

1

1.5

2

2.5

< 1 year 1-3 years 4-6 years 7-9 years > 10 years

Ave

rage

am

ount

of h

eroi

n co

nsum

ed d

aily

(g)

Figure 3.13 Average amount of heroin used daily compared to length of time using heroin.

21 21

0

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30

40

50

60

70

80

90

100

eating injecting smoking

% o

f her

oin

user

s

Figure 3.14: Method of heroin use.

Smoking was the most popular method of heroin use by both male and female users (Figure 3.14). Almost 14% of male users injected heroin, whereas no female users reported using the injection method. Unlike in the case of opium use, few people reported using multiple methods to take heroin. Nearly 70% of men who injected heroin reported sharing needles with other users. Very few users gave a clear single answer as to why they began using heroin, although women tended to give fewer reasons than men. The most common answers given by female users were “as medicine” and “liked the effects”, whilst men selected “peer pressure” and “recreation” (Figure 3.15). A small number of men also reported work pressure as a reason for beginning to use heroin. Unlike opium users, few heroin users first used the drug for any medicinal effects it may have. Recreational use of heroin and peer pressure were significant reasons for first use by both men and women.

0

10

20

30

40

asmedicine

curiosity easilyavailable

liked theeffects

peerpressure

recreation other

% o

f her

oin

user

s

FEMALE

MALE

Figure 3.15: Reasons given for beginning to use heroin.

All heroin users reported at least one problem associated with their use of heroin, with over 98% reporting multiple problems (Figure 3.16).

22 22

0

10

20

30

40

50

60

70

80

90

100

criminalbehaviour

financial health socialrelations

stigma

% o

f her

oin

user

sFEMALEMALE

Figure 3.16: Problems associated with heroin use

Approximately 85% of male users and 90% of female users reported financial problems. Ninety-eight per cent of heroin users reported multiple problems associated with their drug use; eighty per cent reported that they were trying to resolve their problems; twenty per cent of women and thirty per cent of men were seeking treatment. Remarkably, health problems were reported by half as many women as men, and by half as many female heroin users as female opium users. Nearly 80% of female heroin users and 70% of male users reported that they had tried to stop using heroin in the past (Figure 3.17), although only 20% of them had tried multiple methods. With the exception of jail, male and female treatment patterns are very similar.

0

10

20

30

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50

60

70

home jail selfdetoxif ication

treatment centre

% o

f her

oin

user

s

FEMALE

MALE

Figure 3.17: Methods used to give up heroin.

23 23

0

10

20

30

40

50

A few days 1 w eek 1 month 1 year >1 year

% o

f use

rs w

ho h

ad tr

ied

to s

top

Figure 3.18: Period of abstinence from heroin following treatment. This analysis of periods of abstinence was based on answers provided by heroin users who had tried only one method of treatment (140). No women reported being treated in jail. Home-based treatment was the least successful method in treating heroin use, whilst treatment at treatment centres and — to a lesser degree — self-detoxification were most successful. As in the case of opium users, heroin users gave a variety of reasons as to why they resumed heroin use following treatment (Figure 3.19). By far the most common reason for resuming use was physical or psychological pain, as given by over 80% of male respondents and all female respondents, thus revealing close similarity between the responses given by heroin and opium users to this question.

0

10

20

30

40

50

60

70

80

90

easily andcheaplyavailable

lack of familysupport

no t reatmentfacilit ies

pain (physicalor

psychological)

peer pressure unemployment other

% o

f her

oin

user

s w

ho h

ad u

nder

gone

trea

tmen

t

Table 3.19: Reasons given for resuming heroin use following treatment.

Approximately 10% of heroin users reported that a close family member also used heroin, although the corresponding figure among female users only is higher at 30%. The majority of those that reported other family members as using heroin (56%) were men with a brother or

24 24

brothers who also used heroin. Only one man reported multiple close family members as using heroin, namely his mother, wife and brother(s). Just over 80% of male heroin users reported poly-drug use, whilst the corresponding figure among female users was lower at 70%. Almost 53% of male users used hashish in combination with heroin, whilst 52% used opium in combination with heroin. Fifty-six per cent of female users used heroin in combination with opium.

25 25

Hashish use According to the responses of key informants and drug users interviewed for this survey, there are 520,000 hashish users in Afghanistan. Hashish use is almost exclusively a male activity. Slightly more than 98% of hashish users are men; 1.5% women; and the remainder children. Had only the estimates given by female hashish users (n=14) and key informants (n=142) been used to calculate the estimated number of female hashish users in Afghanistan, that number would be approximately 40,000 women rather than 8,000.

Figure 3.20: Estimated number of hashish users, by province. According to both male and female key informants and drug users, there are no female hashish users in 25 of Afghanistan’s 321 provinces. Unlike in the case of the distribution of male opiate users, male hashish users are not concentrated in any particular area in Afghanistan, with the exception of urban users, who are found predominantly in Kabul city. The following profile of hashish users is based on the answers given by 774 men and 14 women who reported that they had used hashish in the past or were using hashish at the time of the survey. Of those users, 287 lived in provincial centres and 501 in rural areas. The average age of hashish users was 34 years, and the average length of time for which respondents had been using hashish was approximately 7 years. Around 75% of hashish users were married, whilst the remainder were single or, rarely (less than one per cent), widowed or divorced. Almost 55% of users had never attended school, although 10% had completed high school. Just over 15% of hashish users were unemployed. Most users (around 75%) worked in the private sector or as farmers. Some 15% of male hashish users reported that they were ex-combatants. Typically, male hashish users earned approximately AFA3,400 per month and spent an approximately monthly sum of AFA1,400 on hashish. Roughly 70% of users relied on their income from employment to purchase hashish. Some hashish users resorted to crime (four per cent) or begging (four per cent) to raise money. Approximately 40% of hashish users obtained their hashish exclusively from drug dealers. All hashish users reported that they obtained all or most of their hashish from drug dealers or friends. Around 15% of users reported that they produced hashish from their own crops.

1 This survey used the 32-province model. Thirty-four provinces are now officially recognized.

26 26

Each hashish user consumed an average of 2.3 g of hashish per day, generally smoking the drug, although 3% said that they ate it. Ninety-three per cent of users consumed hashish at least once a day, and more than two thirds of users consumed hashish more than once a day. There are low correlations between the number of years a user has consumed hashish and user age (r=0.13) or the quantity of hashish consumed (r=0.08). It is estimated that between 400 and 550 metric tonnes of hashish are consumed in Afghanistan each year. No reliable estimate of Afghanistan’s hashish production is available. Very few users gave a clear single answer as to why they began using hashish. The most common answers given were “recreation” and “peer pressure”. A small number of men also cited medicinal effects and family influence as reasons for beginning to use hashish.

0

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50

60

70

80

90

asmedicine

curiosity easilyavailable

liked theeffects

peerpressure

recreation other

% o

f has

hish

use

rs

Figure 3.21: Reasons given for beginning to use hashish.

Despite the fact that almost 80% of respondents reported using hashish for recreation, a high percentage of users (96%) reported at least one problem associated with their use of hashish, with 85% reporting multiple problems (Figure 3.22).

0

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40

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60

70

80

90

criminalbehaviour

financial health social relations stigma

Figure 3.23: Problems associated with hashish use.

27 27

Approximately 78% of users reported financial problems and 75% reported health problems as a result of using hashish. Seventy-five per cent reported that they were trying to resolve their problems; twenty five per cent were seeking treatment. Almost 60% of hashish users reported that they had tried to stop using hashish in the past, although only 15% reported using multiple methods (Figure 3.24).

0

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40

home jail self detoxif ication treatment

% o

f has

hish

use

rs

Figure 3.24: Methods used to give up hashish.

0

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40

50

A few days 1 w eek 1 month 1 year >1 year

% o

f use

rs w

ho h

ad tr

ied

to s

top

Figure 3.25: Period of abstinence from hashish following treatment.

This analysis of periods of abstinence was based on answers provided by hashish users who had tried only one method of treatment. No women reported being treated in jail. Home-based treatment was the least successful method in treating hashish use, whilst treatment at treatment centres was the most successful.

28 28

0

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70

easily andcheaplyavailable

unemployment lack of familysupport

no treatmentfacility

pain (physicalor

psychological)

peer pressure other

% o

f has

hish

use

rs w

ho h

ad s

ough

t tre

atm

ent

Figure 3.26: Reasons given for resuming hashish use following treatment.

A variety of reasons were given by drug users as to why they resumed hashish use following treatment (Figure 3.26). By far the most common reason for resuming use, given by over 60% of respondents, was physical or psychological pain. As in the case of all other drugs, the majority of male users cited peer pressure as a reason for their return to hashish use. Approximately 20% of hashish users reported that a close family member also used hashish. In all cases the family member in question was male (Figure 3.27).

0

5

10

15

20

brother father other

% o

f has

hish

use

rs

Figure 3.27: Hashish users with family members who also use hashish.

Poly-drug use is common among hashish users. Slightly less than 60% of men reported taking another drug in combination with hashish, particularly opium and alcohol.

29 29

Pharmaceutical use (illicit use of pharmaceutical drugs) Pharmaceutical drugs (pharmaceuticals) include a wide variety of anxiolytic drugs, painkillers and hypnosedatives. Specifically, respondents mentioned Atarex, Diazepam, Dolantine, Librium, Mandrax, Pentacozine, and Sosegan. It is estimated that there are 180,000 pharmaceutical drug users in Afghanistan, of whom approximately 50% (90,000) are male, 30% (60,000) are female and 20% (30,000) are children. Pharmaceuticals are the drugs most commonly used by women and children. Had only those estimates by female pharmaceutical users and female key informants been used to calculate the number of female pharmaceutical users in Afghanistan, the figure would be in the region of 180,000 women, i.e. twice the estimated number of male pharmaceutical users.

Figure 3.28: Estimated numbers of pharmaceutical drug users, by province. Whilst pharmaceutical use is widespread across Afghanistan, Kabul and surrounding provinces are home to the highest concentration of drug users. A lower but nonetheless significant concentration of pharmaceutical users is found in the Balkh and Samangan provinces. Those concentrations are accounted for by both male and female users in urban and rural environments. It is suggested that pharmaceutical use is related to access to health care facilities. Anecdotal evidence suggests that many people first take pharmaceutical drugs under medical supervision and subsequently continue to take the same drugs without paying regular visits to doctors and without prescription, even when such use is no longer justified on medical grounds. The following profile of pharmaceutical users is based on the answers given by 231 men and 55 women who reported that they had used pharmaceuticals in the past or were doing so at the time of the survey. Of the total number of users, 118 lived in provincial centres and 168 in rural areas. The average age of female pharmaceutical users was 37 years, and the average length of time for which they had been using pharmaceuticals was 4 years. The corresponding statistics for male users were 34 years of age and 3 years, respectively. Approximately 75% of male pharmaceutical users were married and the remainder single or, rarely (less than 3%), widowed or divorced. Slightly more than 25% of female pharmaceutical users were widows. Almost 80% of female users and 50% of male users had never attended school, although 10% had completed high school. Slightly more than 25% of all

30 30

pharmaceutical users were unemployed. Most users (approximately 66%) worked in the private sector or as farmers. Some 15% of male pharmaceutical users reported that they were ex-combatants. Typically, pharmaceutical users earned approximately AFA3,300 per month, of which they spent approximately AFA1,200 on pharmaceuticals. Roughly 65% of users relied on their income from employment to purchase pharmaceuticals. Some pharmaceutical users resorted to crime (three per cent) or begging (three per cent) to raise money. Almost all pharmaceutical users obtained a proportion of their drugs from pharmacies (Figure 3.29).

0

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40

60

80

100

bazaar family and friends other users pharmacy

% o

f pha

rmac

eutic

al u

sers

Figure 3.29: Source of pharmaceuticals.

Whilst many drug users provided details of the quantities of pharmaceuticals that they used (i.e., number of tablets), they did not provide details of the type or doses of those drugs. It was recorded that 85% of users took pharmaceutical drugs on a daily basis. Nearly 20% of male pharmaceutical users reported injecting pharmaceuticals, and 55% of injecting users shared needles with other injecting drug users. No women reported injecting pharmaceuticals. The answer most commonly given for beginning to use pharmaceuticals was “as medicine” (Figure 3.30).

0

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50

60

70

80

90

100

asmedicine

curiosity easilyavailable

liked theeffects

peerpressure

recreation other

% o

f pha

rmac

eutic

al u

sers

FEMALE

MALE

Figure 3.30: Reasons given for beginning to use pharmaceuticals.

31 31

Men often gave multiple answers as to why they began using pharmaceuticals, but unlike other drug users did not consider peer pressure to be a significant factor. Nearly one third of men began using pharmaceutical drugs partly for recreation or because they liked the effects. Almost 96% of pharmaceutical users reported at least one problem associated with their use of pharmaceuticals, and 85% reported multiple problems (Figure 3.31).

0

10

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30

40

50

60

70

80

90

criminalbehaviour

financial health socialrelations

stigma

% o

f pha

rmac

eutic

al u

sers

FEMALE

MALE

Figure 3.31: Problems associated with pharmaceutical use.

Approximately 72% of users reported financial problems, and 78% reported health problems. As in the case of other drug types, a high percentage of users reported first beginning to use a drug because of its supposed medicinal effects, but the same users subsequently reported health problems as a result of using the drug. Some 75% of users reported that they were trying to resolve their problems; 22% were seeking treatment. Nearly 55% of pharmaceutical users reported that they had tried to stop using pharmaceuticals in the past, though few reported using multiple methods (Figure 3.32).

0

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home jail selfdetoxif ication

treatment centre

% o

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Figure 3.32: Methods used to give up pharmaceuticals.

32 32

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% o

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Figure 3.33: Period of abstinence from pharmaceuticals following treatment.

This analysis of periods of abstinence was based on answers given by pharmaceutical users who had tried only one method of treatment. No women reported stopping pharmaceutical drug use in jail. Home-based treatment was the least successful method in treating pharmaceutical use; treatment centres were the most successful.

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easily andcheaply

available

unemployment lack of f amilysupport

no t reat mentf acilit y

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psychological)

peer pressure ot her

FEM ALEM ALE

Figure 3.34: Reasons given for resuming use of pharmaceutical drugs following treatment.

A variety of reasons were given by drug users as to why they resumed use of pharmaceuticals following treatment (Figure 3.34). By the far the most common reason — given by almost 90% of respondents — was physical or psychological pain. Whilst peer pressure was cited as an influence by male pharmaceutical users, it was not considered as important by male pharmaceutical users as by male users of other drugs. Approximately 18% of pharmaceutical users reported that a close family member also used pharmaceutical drugs. Considering the level of child pharmaceutical use estimated in this report, it was unexpected that only one pharmaceutical user should have reported a child in his family that also used drugs of this type. The family member most commonly identified as using pharmaceuticals was “parent”, mothers and fathers being equally represented in male and female drug user responses.

33 33

0

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15

all family brother orsister

child <5yrs

parent spouse other

% o

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rmac

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al u

sers

FEMALE

MALE

Figure 3.35: Users’ family members who also use pharmaceutical drugs.

Poly-drug use was reported by just over 80% of male pharmaceutical drug users. The most common combination of drugs used was that of opium and hashish, reported by nearly 50% of male users. As in the case of female drug users in general, the level of poly-drug use among female pharmaceutical users (49%) was lower than that among male users. It is important to note that the survey did not ask users about poly-drug use as applicable to the combined use of different types of pharmaceuticals only. The few responses that clearly indicated the types of pharmaceuticals used also indicated that more than one type of pharmaceutical drug were often used].

34 34

Alcohol use It is estimated that there are 160,000 alcohol users in Afghanistan. Of that total, 140,000 (88%) are men, 20,000 (12%) are women and fewer than 1,000 are children. These results are based on all key informant and drug user responses. Unlike in the case of the other drugs studied so far in this report, had only those responses given by women been used to calculate the level of use among females, the estimated number of female users would be lower by around 20%, i.e. approximately 16,000 women.

Figure 3.36: Estimated number of alcohol users, by province. Kabul city and nearby towns and villages account for 70% of alcohol users in Afghanistan. While alcohol users were concentrated to a lesser degree in northern Afghanistan, in a number of provinces — particularly in southern provinces such as Kandarhar, Uruzgan and Zabul — alcohol use was reported as negligible among men and non-existent among women. The following profile of alcohol users is based on the answers given by 262 men and 4 women who reported that they consumed alcohol. Of that total, 142 lived in provincial centres and 224 in rural areas. The average age of alcohol users was approximately 32 years, and the average length of time for which they had been consuming alcohol was 5 years. Some 75% of alcohol users were married; the remainder were single. Almost 33% of users had never attended school, whereas nearly 25% had completed high school. Slightly more than 17% of all alcohol users were unemployed. Nearly 50% of users worked in the private sector, and 13% of male users reported that they were ex-combatants. Typically, alcohol users earned approximately AFA4,000 per month, of which they spent around AFA3,000 on alcohol. Some 75% of users relied on their income from employment to purchase alcohol; 22% borrowed money from family members. Very few alcohol users resorted to crime (3%) or begging (1.5%) to raise money, and all of that number were poly-drug users. Almost 80% of users purchased some of their alcohol from drug dealers; 50% purchased some of their alcohol from shops. It is not known whether those drug dealers who sell alcohol also sell other drugs. Alcohol users commonly gave vague and/or contradictory answers when asked about their consumption of alcohol, typically reporting that they consumed one to three glasses per week

35 35

yet at the same time describing their intake as twice daily. The few clear answers given indicate that 70% of users consume alcohol only once a day or less frequently, generally one or two glasses on each occasion. When questioned regarding the type of alcohol consumed, the answers were more clear (Figure 3.37).

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beer home-brew vodka other

% o

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ohol

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Table 3.37: Type of alcohol consumed in Afghanistan.

Nearly 30% of users reported consuming one type of alcohol only, typically vodka in urban areas and home-made alcoholic beverages in rural areas. The most common reasons given for beginning to consume alcohol were recreation, peer pressure and “liked the effects” (Figure 3.38).

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asmedicine

curiosity easilyavailable

liked theeffects

peerpressure

recreation other

% o

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Figure 3.38: Reasons given for beginning to consume alcohol.

Typically, alcohol users gave multiple answers as to why they began consuming alcohol, and, as in the case of many other drugs, peer pressure played an important role among men. Nearly 86% of alcohol users reported at least one problem associated with their consumption of alcohol; 80% reported multiple problems (Figure 3.39).

36 36

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criminalbehaviour

financial health social relations stigma

% o

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Figure 3.39: Problems associated with alcohol consumption.

Whilst only 54% of users reported health problems associated with their consumption of alcohol as compared to the higher corresponding percentages established for other drug categories, the proportion of users who reported social relationships and stigma as problems (64% and 56%, respectively) did not vary significantly from that of users of other drugs such as opiates. More than half of those users who reported problems associated with their consumption of alcohol said that they were trying to resolve those problems; 17% were seeking treatment. Slightly more than 40% of alcohol users reported that they had tried to give up alcohol in the past, although only 25% reported using multiple methods (Figure 3.40).

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Figure 3.40: Methods used to give up alcohol.

37 37

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Figure 3.41: Period of abstinence from alcohol following treatment.

This analysis of periods of abstinence was based on responses given by alcohol users who had tried only one method of treatment. Home-based treatment and self-detoxification were the most successful methods, although sample sizes were small (only 15 users tried self-detoxification).

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easily available lack of familysupport

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% o

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usin

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Figure 3.42: Reasons given for resuming alcohol consumption following treatment.

A variety of reasons were given by drug users as to why they resumed alcohol consumption following treatment (Figure 3.42). By far the most common reason for resuming consumption was peer pressure, as reported by nearly 70% of respondents, which exceeds the percentage of users who gave peer pressure as a reason for beginning to consume alcohol. Approximately 16% of alcohol users reported that a close family member also used alcohol, in almost all cases a male family member, particularly brother(s) (13%) or father (2%). Poly-drug use was reported by slightly less than 80% of male alcohol users. Alcohol was predominantly combined with hashish — as reported by nearly 65% of male users — and also with opium, as reported by 50% of users. No female alcohol user reported using other drugs.

38 38

Use of other drugs Other drugs most commonly reported were cough medicines; volatile liquids – commonly petrol and glues, which are inhaled and/or consumed; various preparations derived from the cannabis plant and opium poppy capsules, such as barsh, bhangawa and majun; and a variety of locally sourced drugs, including preparations made from dried scorpions, snakes and wasps. It is estimated that there are 200,000 users of such drugs in Afghanistan, of whom 90,000 (45%) are men, 65,000 (33%) are women and 45,000 (22%) are children. These results are based on all key informant and drug user responses. Had only those responses given by female respondents been used to calculate the level of use of other drugs among females, the number of female users would be in the region of 170,000.

Figure 3.43: Estimated number of users of other drugs, by province. The use of other drugs was concentrated in Kabul and surrounding provinces, and in northern and western provinces. The following profile of users of other drugs is based on the answers given by 147 men and 25 women who said that they used other drugs; 56 lived in provincial centres and 119 in rural areas. The average age of users of other drugs was 34 years and the average length of time for which they had been using such drugs was 4.5 years. Approximately 76% of users of other drugs were married; the remainder were single (17%) or divorced (7%). Almost 50% of users had never attended school, although the corresponding figure among female users was 90%. Slightly less than 20% of users were unemployed. Nearly 45% worked in the private sector, and 30% were farmers. Around 13% of male users reported that they were ex-combatants. Typically, users of other drugs earned around AFA3,000 per month, of which they spent approximately AFA850 on such drugs. Almost 75% of those drug users who gave clear answers as to which other drugs they used said that they consumed cough syrup, whilst 20 per cent reported using solvents. Approximately 70% of users relied on their income from employment to purchase drugs; 45 per cent borrowed money from family members. Very few drug users resorted to crime (three per cent) or begging (three per cent) to raise money, and all of these were poly-drug users. Almost 93% of users purchased drugs from their local market; 40% reported that they obtained at least a proportion of their drugs from other users. Less than two per cent of users

39 39

reported purchasing drugs from drug dealers or pharmacies. Other users commonly gave vague answers when asked about their consumption of drugs. Common answers were “whenever I cough” or “a few times a month”. Even when users gave more specific answers, they tended not to specify the type or indicate the potency of the drugs that they were referring to. User responses indicate that some 75% of users consume such drugs at least once a day. The most common answer given for beginning to use other drugs was “as medicine” (Figure 3.44), as reported by 85% of drug users. The overwhelming majority of women gave this as their sole reason for beginning use.

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asmedicine

curiosity easilyavailable

liked theeffects

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Figure 3.44: Reasons given for beginning to use other drugs.

Nearly 84% of users of other drugs reported at least one problem associated with their use of drugs; 55% reported multiple problems (Figure 3.45).

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Figure 3.45: Problems associated with use of other drugs.

More than 78% of users reported financial problems associated with their use of drugs, and almost 73% reported health problems. The proportion of those who reported social relationships and stigma as problems (35% and 24%, respectively) was significantly lower than that of users of drugs in other categories. More than 60% of those who reported problems associated with their use of other drugs said that they were trying to resolve those problems; 20% were seeking treatment.

40 40

Slightly more than 43% of users of other drugs reported that they had tried to stop using drugs in the past; one third reported using multiple methods (Figure 3.46).

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Figure 3.46: Methods used to give up other drugs.

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Figure 3.47: Period of abstinence from other drugs following treatment.

This analysis of periods of abstinence was based on answers given by users of other drugs who had tried only one method of treatment. Home-based treatment and self-detoxification were the most successful methods, although sample sizes were small (eight had tried self-detoxification and six had been treated in treatment centres).

41 41

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easily andcheaplyavailable

lack of familysupport

no treatmentfacility

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Figure 3.48: Reasons given for resuming use of other drugs following treatment. As in the case of all drug types, male users gave a variety of reasons as to why they resumed use of other drugs following treatment (Figure 3.48). By far the most common reason for resuming use was pain relief, as reported by 95% of respondents and given by all female users as the only reason. Almost 42% of users of other drugs reported that a close family member also used drugs, and often entire families used the same drug. This proportion was the highest among all drug categories.

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Figure 3.49: Users’ family members who also use other drugs.

Poly-drug use was reported by 95% of users of other drugs, although poly-drug use among females was slightly lower at 80%. Men combined other drugs predominantly with hashish, as reported by 67% of male users, whilst 44% of women reported using other drugs in combination with opium.

42 42

Trends in drug use in Afghanistan Although there have been no previous nationwide estimates of drug use in Afghanistan, with respect to the number of drug users in Kabul city the results of this survey can be compared to a survey conducted by UNODC in 20031, which used a similar methodology to estimate that number (Table 3.3).

2003 2005 Change Opium 10,800 24,000 +220% Heroin 7,000 16,500 +235% Hashish 24,000 63,500 +265% Pharmaceuticals 14,300 12,000 -16% Alcohol 6,600 81,000 +1200%

Table 3.3: Lowest estimated number of drug users in 2003 and 2005 in Kabul city, and per cent difference (change) shown as percentage. Note: Estimates for 2005 include children under 15 years of age. Except in the case of pharmaceuticals, the percentage change in the number of drug users from 2003 to 2005 concurs with estimates provided by drug treatment workers in Kabul. Earlier in this report it was noted that pharmaceutical use among women is likely to be a significant underestimate. This may explain the decrease in the estimated number of pharmaceutical drug users between 2003 and 2005. The percentage changes seen in Kabul city cannot be applied to other areas in Afghanistan, since regional variations were identified in key informants’ responses during this survey. Key informants were asked whether the number of drug users in their communities had increased or decreased, but drug users themselves were not asked that question. The majority of informants considered numbers to be increasing in all drug categories (Table 3.4).

Number of key

informants Decrease Increase

Opium 951 8% 92% Heroin 487 6% 94% Hashish 1150 7% 93% Pharmaceuticals 387 8% 92% Alcohol 479 3% 97% Other drugs 303 11% 89%

Table 3.4: Trends in drug use as reported by key informants.

There were some regional differences in perceptions among key informants as to the extent of change in drug use levels. Opium use in the Jawzjan and Sari Pul provinces in northern Afghanistan and in Paktika province in southern Afghanistan was considered by the majority of key informants living in those provinces to be decreasing; heroin use was also thought to be decreasing in Paktika; and pharmaceutical use was believed to be decreasing in Samangan province. There were no provinces where the majority of key informants considered hashish, alcohol or other drug use to be decreasing. In some villages within individual provinces, drug use was considered by all key informants to have decreased, and in provincial centres the majority of informants reported that drug use was decreasing in some districts.

1 UNDCP (2003), Community Drug Profile #5 – An Assessment of Problem Drug Use in Kabul City, UNDCP Programme, Islamabad, p. 12.

43 43

Urban and rural patterns of drug use It is estimated that 188,000 drug users live in urban areas in Afghanistan, 87% of whom are men, 1%1 per cent women, and 2% children under 15 years of age. A further 732,000 drug users live in rural areas, of whom 78% are men, 14% women, and 8% children. When considering these figures in conjunction with estimated urban and rural populations (Table 3.7), it becomes clear that men account for the overwhelming majority of the drug user community in Afghanistan. This is true of all categories of drugs, particularly heroin and alcohol in the case of urban male users and opium and hashish in the case of rural male users. Use of alcohol among urban women and use of pharmaceuticals and other drugs among their rural counterparts reflect most closely the overall percentage of female drug users in Afghanistan.

Drug type Male Female Child Male Female Child National totalOpium 27,036 5,847 510 105,172 10,682 ,3,624 152,869Heroin 19,698 1,968 13 26,103 1,500 256 49,536

Hashish 82,930 2,135 41 428,294 5,948 2,738 522,084Pharmaceuticals 9,418 6,140 1,585 82,458 51,304 28,042 178,945

Alcohol 79,940 9,123 984 63,854 9,476 0 163,376Other drugs 6,826 4,015 1,688 86,310 60,003 44,597 203,437

Total 225,846 29,227 4,819 792,189 138,911 79,255 1,270,247Total, adjusted for

poly-drug use 164,000 21,000 3,000 575,000 100,000 57,000 920,000

Urban Rural

Table 3.5: Estimated number of urban and rural drug users.

Drug Type Male Female Child Male Female Child TotalOpium 18% 4% <1% 69% 7% 2% 100%Heroin 40% 4% <1% 53% 3% 1% 100%

Hashish 16% <1% <1% 82% 1% 1% 100%Pharmaceuticals 5% 3% 1% 46% 29% 16% 100%

Alcohol 49% 6% 1% 39% 6% <1% 100%Other Drugs 3% 2% 1% 42% 29% 22% 100%

Urban Rural

Table 3.6: Urban and rural drug users as percentage of users of each drug type.

Urban Rural Male Female Male Female Total Population

(million) 2.7 2.5 9.6 9.1 23.9

% of national

population 11.5% 10.5% 40.0% 38.0% 100%

Table 3.7: Estimated population of Afghanistan in 2005.

In addition to differences in urban and rural patterns of drug use, substantial variation is found in drug use from province to province (Tables 3.8 and 3.9).

44 44

Province Opium Heroin Hashish Ph Alcohol OtherBadakhshan <500 <500 500 <500 500 <500

Badghis <500 <500 <500 <500 <500 <500Baghlan <500 <500 500 <500 <500 <500

Balkh 1500 500 2000 500 4000 <500Bamyan <500 <500 <500 <500 <500 <500Farah <500 <500 <500 <500 <500 <500Faryab 1000 1000 1000 <500 1500 <500Ghazni <500 <500 500 <500 <500 <500Ghor <500 <500 500 <500 500 <500Herat 500 <500 1000 <500 <500 <500

Hilmand 2500 1000 3000 <500 <500 <500Jawzjan <500 <500 <500 <500 500 <500Kabul 24000 16500 63500 12000 81000 10500

Kandarhar 500 500 4500 <500 <500 <500Kapisa <500 <500 <500 500 <500 <500Khost <500 <500 <500 <500 <500 <500Kunar <500 <500 500 <500 <500 <500

Kunduz <500 <500 500 <500 <500 <500Laghman <500 <500 <500 <500 <500 <500

Logar <500 <500 <500 <500 <500 <500Nangarhar <500 <500 500 <500 500 <500

Nimroz <500 <500 <500 <500 <500 500Nuristan <500 <500 <500 <500 <500 <500Paktika <500 <500 <500 <500 <500 <500Paktya <500 1000 1000 2000 <500 500Parwan 1500 500 3500 1500 500 <500

Samangan <500 <500 <500 <500 <500 <500Sari Pul <500 <500 <500 <500 <500 <500Takhar <500 <500 <500 <500 <500 <500

Uruzgan <500 <500 500 <500 <500 <500Wardak <500 <500 <500 <500 <500 <500Zabul <500 <500 <500 <500 <500 <500

Table 3.8. Indicative number of drug users in urban areas, by province.

In terms of absolute numbers, the overwhelming majority of urban drug users live in Kabul (Figure 3.50). Drug users are also concentrated in the cities of Chaharikar in Parwan province, Gardez in Paktya province, Maymana in Fayab province, Lashkar Gah in Hilmand province and Mazar-i-Sharif in Balkh province. The greatest number of rural drug users are found in rural areas of Kabul province. Users are also concentrated in a band of provinces stretching from northwest Kabul to Balkh province, and in a cluster of provinces in northwest Afghanistan, particularly along the country’s borders with Iran and Turkmenistan.

45 45

Province Opium Heroin Hashish Ph Alcohol OtherBadakhshan 3500 <500 9000 <500 1500 <500

Badghis 2000 1500 7500 4500 1500 15000Baghlan 11500 1000 52500 5000 9000 2000

Balkh 20500 2500 31000 12000 4000 8000Bamyan 1500 <500 5500 <500 <500 <500Farah 2000 <500 7000 13000 1500 31000Faryab 11000 5000 30500 3500 8000 1500Ghazni 3500 <500 11500 <500 <500 <500Ghor 8000 500 20000 500 2500 9500Herat 7000 2500 35500 4500 3000 <500

Hilmand 3000 1500 17500 <500 <500 <500Jawzjan 8000 <500 1000 1000 <500 500Kabul 9500 16000 51000 15500 26500 17000

Kandarhar 1000 500 11000 500 <500 500Kapisa 1000 500 9000 13500 1000 11000Khost 500 <500 6000 1000 1000 1000Kunar <500 <500 5500 <500 <500 500

Kunduz 1500 500 5000 1000 1500 500Laghman 4500 <500 18000 18500 <500 22000

Logar 1500 500 6000 <500 <500 <500Nangarhar 500 <500 15000 4500 <500 <500

Nimroz 1000 500 2000 500 <500 5000Nuristan <500 <500 <500 <500 <500 500Paktika 500 <500 13000 <500 <500 <500Paktya <500 <500 6500 4000 <500 2000Parwan 1500 <500 9000 31000 <500 18000

Samangan 4500 500 16500 12000 4000 8500Sari Pul 1500 <500 9000 500 3000 <500Takhar 1000 <500 3000 <500 500 <500

Uruzgan 3500 500 17500 500 <500 <500Wardak 1500 <500 6000 13500 1000 13500Zabul <500 1000 <500 <500 <500 <500

Table 3.9: Indicative number of drug users in rural areas, by province.

47 47

Drug use among females It is estimated that there are 120,000 adult female drug users in Afghanistan, which represents 2.1% of the female population. The drugs by far the most commonly used by women are pharmaceuticals (an estimated 60,000 users) and other drugs (65,000 users) such as cough syrups; poly-drug use is common, particularly the combined use of opium and pharmaceuticals. These figures are considered to be an underestimate of the true level of female drug use in Afghanistan for a number of reasons, most influential of which is the stigma associated with drug use in Afghanistan. This is thought to be the reason for underestimation overall, but appears to influence estimates by key informants and drug users of female drug use in particular. . As noted earlier in this report, patterns of female drug use reflect the fact that female users are able to conceal their use of drugs from the community ― inter alia by eating rather than smoking opium and consuming pharmaceuticals in tablet form rather than injecting them ― thus increasing the likelihood of underestimation. A further reason for underestimation is the difficulty in identifying female drug users; interviews alone may cause such users fear of exposure to family and community members. All interviews with women were carried out by female surveyors, and some areas could not be visited by women due to the poor security situation, particularly in southern Afghanistan. It was noted during the analysis of the survey results that men generally provided much lower estimates of female drug use in their communities than women, whilst male and female estimates of drug use among men did not vary significantly. Were only the responses of female key informants and drug users used to calculate the level of drug use among females in Afghanistan, the resulting estimates would be 45,000 opium users, 10,000 heroin users, 40,000 hashish users, 180,000 pharmaceutical users, 16,000 alcohol users, and 170,000 other drug users. Female informants estimate that 330,000 women in Afghanistan are poly-drug users. Few areas in Afghanistan were identified as having no female drug users (Figure 3.48). The majority of female drug users live in Kabul city and the surrounding rural areas of Kabul province. Most female opium users are found in Kabul, although significant numbers are also found in the northern provinces of Balkh, Faryab, Kunduz and Jawzjan, and smaller numbers in major poppy-growing provinces in western and southern Afghanistan, such as Hilmand, Hirat, Kandarhar and Nimroz. Outside of Kabul, and to a lesser degree in Balkh province, female heroin use is extremely rare; there was reported to be a small number of users located in Nimroz. Kabul and surrounding provinces such as Kapisa, Parwan and Paktya reported the highest levels of pharmaceutical use among women, and lower levels were estimated for Balkh, Jawzjan and Kunduz. Female alcohol and hashish use was rarely reported; Kabul city and province reported the highest levels. The greatest numbers of users of other drugs were reported in Kabul and Nimroz, and to a lesser degree in Kapisa. Quantities of drugs used and frequency of use were consistently lower among women than among men. Except in the case of heroin, the response most commonly given by female drug users to the question as to why they first took drugs was for the medicinal effect of the drug. Unlike male drug users, they rarely cited peer pressure, curiosity, or recreation as reasons for beginning to take drugs. Once women became regular drug users, the range of problems that they faced differed little from those experienced by men. Health and financial problems were common for all drug types, and problems in social relationships and stigma were also typically cited. Very few women reported criminal behaviour as a consequence of their use of drugs. In cases where women had tried to stop using drugs, physical or psychological pain was given by the overwhelming majority as their reason for resuming use. Whilst male drug users generally gave multiple reasons for resuming drug use following treatment, women were consistent in reporting pain as their reason, rarely citing easy availability, lack of treatment services or peer pressure.

48 48

Figure 3.51: Female drug users in Afghanistan, by province.

49 49

Child drug use It is estimated that 60,000 children under 15 years of age use drugs. However, since no children were interviewed during this survey, it is not possible to estimate that number accurately. The above figure is based on the assumption that the level of poly-drug use among children is the same as that among adults. Assuming that poly-drug use is rare among children, however, the number of child drug users is estimated at 85,000, i.e., approximately one third higher. The majority of child drug users use either pharmaceuticals (30,000) or drugs classified in this survey as “other drugs” (45,000). Although absolute figures for child opiate use are low (approximately 5,000), the level is still alarming. It is important to note that whilst estimates by drug users and key informants were used to calculate the number of child drug users, very few drug users reported a child drug user in their family. Some 12% of opium users― mostly women ― and 6% of users of other drugs reported that a child in their family also used such drugs. It is clear from discussions with staff at treatment facilities that in nearly all cases children who use drugs have at least one parent that uses the same drug(s).

Figure 3.52: Child drug users in Afghanistan, by province.

As Figure 3.52 shows, the majority (85%) of child drug users live in Kabul city and surrounding rural areas. Smaller concentrations of child drug users are found in northern Afghanistan, particularly in the Balkh, Faryab and Jawzjan provinces. Child heroin use was not reported outside of Kabul, and hashish use was confined to Nimroz province. Pharmaceutical use was most common in Kabul and neighbouring Kapisa province, although above-average levels were also found in Jawzjan and Paktya provinces. Use of other drugs among children was most common in Nimroz, Kabul and Kapisa provinces.

50 50

Drug use among ex-combatants Drug demand reduction workers in Kabul consider ex-combatants to be particularly susceptible to drug use. This perception, however, was not confirmed in this study. All drug users were asked whether they had been combatants during any of Afghanistan’s conflicts since 1979. Table 3.10 shows the percentage of male drug users who responded affirmatively.

Drug type per cent ex-combatants

Opium 13.4 Heroin 16.1 Hashish 12.5 Pharmaceuticals 14.6 Alcohol 12.5 Other 13.1

Table 3.10: Percentage of drug users who are ex-combatants.

An average 12.9% of male drug users were ex-combatants, although individual percentages ranged from 12.5% (hashish and alcohol users) to 16.1% (heroin users). A range of estimates is given for the number of ex-combatants in Afghanistan. The most common estimate of 100,0001 refers to the estimated number of men in private militias in 2003. Such militias are the focus of disarmament activities by UNDP. The figure does not include men who fought in conflicts from 1979 onwards and may have disarmed before 2003; no estimates of the number of such men could be found.

No of illicit drug types used

% of drug users interviewed

1 only 512 only 253 only 114 only 75 only 4all 6 1

Table 3.11: Levels of poly-drug use among ex-combatants.

The level of poly-drug use among ex-combatants did not differ significantly from that among the overall drug user population. There is no evidence from this survey to suggest that ex-combatants are more likely than other members of the community to be drug users. The pattern of drug use among ex-combatants does not differ from that among other drug users.

1 2003, United Nations General Assembly: Disarmament, demobilization and reintegration.

51 51

Drug use among returned refugees Approximately 7.8 million Afghans have spent some time living as refugees in either Iran (1.7 million) or Pakistan (6.1 million). Of that number, some 800,000 have returned to Afghanistan from Iran and 3.5 million from Pakistan. On the basis of these figures it can be calculated that approximately 0.3% of the population of Afghanistan were formerly refugees in Iran, and 11.3% have lived as refugees in Pakistan. According to experienced demand reduction workers in Kabul, the level of drug use among returned refugees is much higher than that among the general population, and returnees began to use drugs while living as refugees. It would appear that, taken at face value, these statements are likely to be true, given levels of drug use in Iran and Pakistan. However, they should also be reflected in the number of drug users who themselves reported first using a drug while living as a refugee in either Iran or Pakistan. Of the 1393 drug users interviewed for this study, 18.6% (n=259) had spent time as refugees in Iran, and 17.2% (n=239) as refugees in Pakistan (Figures 3.53 and 3.54). These figures are far higher than corresponding percentages for non-drug users who have lived as refugees in either of those two countries. Percentages for men and women varied little. Much higher numbers of opium and heroin users had been refugees in Iran than in Pakistan.

0

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refugee inIran

refugee inPakistan

never left thisarea

other area ofAfghanistan

othercountries

no answer

% o

f dru

g us

ers

FEMALE

MALE

Figure 3.53: Responses to the question: “Where did you live before your current location?”

Drug users were also asked where they had first used specific drugs (Figure 3.55). The responses given indicate that, except in the case of opium and heroin, few drug users first began using drugs in areas other than the location in which they were living at the time of the survey. A high proportion of opium and heroin users first began using those drugs in Iran (approximately 28% of users in both cases). The following may be concluded with regard to refugees only:

• Almost 85% of all opium users who had spent time as refugees in Iran (n=179) first used opium during that period, as compared to only 45% who began using the drug while refugees in Pakistan (n=70).

• Ninety per cent of all heroin users who had spent time as refugees in Iran (n=77) first used heroin during that period, as compared to only fifty per cent who began using the drug while refugees in Pakistan (n=38).

• Nearly 30% of all hashish users who had spent time as refugees in Iran (n=138) first used hashish during that period, as compared to 50% who began using the drug while refugees in Pakistan (n=168).

• Forty-one per cent of all pharmaceutical users who had spent time as refugees in Iran (n=61) or Pakistan (n=51) began using those drugs during that period.

• There were few cases in which users claimed to have begun using different drug types in different areas.

52 52

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refugee in iran refugee inpakistan

never left thisarea

other are inAfghanistan

othercountries

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heroin

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pharmaceuticals

alcohol

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Figure 3.54: Responses to the question: “Where did you live before your current location?”

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Iran Pakistan this area ofAfghanistan

other area ofAfghanistan

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Figure 3.55: Responses to the question: “Where did you first use drugs?”

There is clear evidence to suggest that having been a refugee in either Iran or Pakistan leads to a higher likelihood of being a drug user. This is particularly true in the case of opiate use among those formerly refugees in Iran. Whilst such users represent approximately 2% of the general population, they account for almost 30% of opium and heroin users. The situation regarding those who lived as refugees in Pakistan is more complex. Despite the fact that this group accounts for a large proportion of drug users, particularly hashish users, few reported using drugs for the first time in Pakistan. It would appear that some aspect of having been a refugee in Pakistan leads to an increased level of drug use following return to Afghanistan. There is no evidence from this survey to indicate that levels of drug use were high among those who left Afghanistan to become refugees in Pakistan before they did so. Given that approximately 50% of those who left Afghanistan to live as refugees are yet to return, and that the Office of the United Nations High Commissioner for Refugees (UNHCR) expects the rate of return to increase in the coming years, it can be expected that the level of drug use in Afghanistan will drastically increase during that period. Current treatment services already fall severely short of demand, a situation that is expected to worsen whilst demand reduction activities are not expected to increase sufficiently to address that shortfall effectively.

53 53

Injecting drug use among opium, heroin and pharmaceutical drug users in Afghanistan A total of 1393 drug users were questioned regarding their opium, heroin and pharmaceutical drug use, including the methods that they used to consume those drugs, whether they injected the drug, and whether they shared their needles with other drug users. The responses are shown in Table 3.13.

Number of users interviewed

Number of IDU

Number of IDU sharing needles

Opium 663 9 8Heroin 287 39 28

Pharmaceuticals 292 46 11

Table 3.12: Summary of drug users’ responses to questions regarding injecting drug use (IDU).

Women claimed not to have injected drugs. For a number of injecting drug users, the sex was not recorded, it is likely that they were males. Slightly more than 1% of opium1 users, 14% of heroin users and 16% of pharmaceutical users reported injecting those drugs. Many injecting users also reported also using other methods: for example, all injecting opium users reported that they also smoked the drug. The level of needle-sharing varied across drug types. Among injecting drug users, 90% of opium users, 70% of heroin users and 25% of pharmaceutical users reported sharing needles with other drug users. The combination of these figures with nationwide estimates of numbers of opium, heroin and pharmaceutical drug users and levels of poly-drug use produces an estimate of 19,000 injecting drug users in Afghanistan. This figure includes 2,000 opium users, 7,000 heroin users and 18,000 pharmaceutical users. Assuming that the pattern of drug use among those interviewed accurately represents the overall pattern of drug use, an estimated 8,000 injecting drug users share needles in Afghanistan. An on-going seroprevalence study among injection drug users is being conducted through the Central Polyclinic in Kabul. Preliminary data indicates that measurable prevalence of HIV, syphilis, and hepatitis B and C exist among this group. Due to the cross-sectional nature of this study, the sample may not be representative of all IDU in Kabul. However, when final results are available, the information will provide some indication of existing infection in this environment with high rates of needle-sharing.

1 It was previously thought that it was not possible to produce from raw opium a material suitable for injection without chemical refinement. However, experienced drug demand reduction workers are aware of a simple process used in Afghanistan that does produce a solution suitable for injecting use .

54 54

Drug treatment facilities and services in Afghanistan Although demand for drug treatment facilities in Afghanistan has increased over the last 25 years, the resources and facilities available for such treatment are limited. This survey found that no more than 100 places were available at residential treatment centres throughout the country. Resources currently allocated to drug treatment activities are such that these programmes treat fewer than 0.25% of drug users in Afghanistan each year. The Government of Afghanistan and national and international organizations are implementing projects to address this issue. The Drug Demand Reduction Directorate of the Ministry of Counter-Narcotics is responsible for the overall coordination of demand reduction activities in Afghanistan. At present, treatment facilities and services are offered by the following organizations:

• UNODC Drug Demand Reduction Action Teams (DRATs);

• Ministry of Counter-Narcotics (MCN);

• Gesellschaft für Technische Zusammenarbeit (GTZ);

• Colombo Plan Drug Advisory Programme;

• Mental Health Hospital of the Ministry of Public Health;

• Aga Khan Foundation;

• Khatiz Organization for Rehabilitation (KOR);

• Nejat Centre;

• Welfare Association for the Development of Afghanistan (WADAN);

• Shahmat Centre

55 55

56 56

ANNEX A.1 Number and Location of Interviews

UN Zone Province KIs DUs KIs DUs No of Villages KIs DUs

Kabul 63 81 4 5 4 27 18

Khost 10 10 5 5 5 25 25

Logar 10 10 5 5 5 23 23

Paktya 14 16 4 6 5 25 25

Parwan 25 25 5 5 5 25 25

Wardak 15 8 5 8 4 25 17

Kapisa 9 9 4 2 5 25 31

Kunar 10 10 5 5 5 25 25

Laghman 20 20 5 5 5 25 25

Nangarhar 25 25 5 5 5 25 25

Nuristan 5 5 5 5 4 20 19

Badakhshan 25 25 10 10 5 25 20

Takhar 20 20 10 10 6 30 21

Badghis 5 3 5 4 5 25 19

Baghlan 25 25 5 4 5 27 22

Balkh 15 16 11 11 5 26 26

Bamyan 10 10 5 25 19

Faryab 5 5 10 10 5 25 25

Jawzjan 20 15 5 1 4 20 6

Kunduz 20 20 10 10 5 25 24

Samangan 12 11 9 11 5 24 24

Sari Pul 10 10 5 25 25

Ghazni 15 15 5 5 4 25 19

Hilmand 28 29 10 10 5 25 20

Kandarhar 20 33 5 5 5 25 25

Paktika 10 10 5 5 5 25 25

Uruzgan 15 15 5 5 4 20 19

Zabul 10 10 5 5 3 20 10

Farah 5 5 5 3 5 25 17

Ghor 15 14 5 3 5 25 16

Herat 10 10 10 10 5 25 25

Nimroz 10 10 5 5 4 20 15

Total 511 530 187 183 152 782 680

Wes

tE

ast

Nor

th

Eas

tN

orth

Sou

th

Provincial Capital District Centre Villages

Cen

tral

Table A.1 Number of key informants (KIs) and drug users (DUs) interviewed.

57 57

ANNEX A.2 Key Informants Questionnaire

58 58

59 59

60 60

ANNEX A.3 Drug Users Questionnaire

61 61

62 62

63 63

64 64

65 65

ANNEX A.4 Estimates of the number of drug users

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ANNEX A.5 Estimation of the Number of Drug Users As all 32 province centers were visited by surveyors, no extrapolation is needed for urban figures given by drug users or key informants. For rural areas (districts and villages) drug user estimations were done at UN zone level for each drug type using: DU ( ) ( )iiiii VyDx ** += equation (1) Where

=iDU Estimated number of drug users in zone i

=ix Average number of users of drug i in sampled district centre

=iD Total number of districts in zone i

=iy Average number of users of drug i in sampled villages

=iV Total number of villages in zone i The population of villages and district centers vary across each zone. Therefore a ‘boot strap technique’ was used to calculate the total number of users for each drug category. This means, equation (1) was iterated 10,000 times and the average of all iterations was used to derive the final estimation figures. Adjustment for Poly-Drug Users By simply combining the total number of users of each drug type to arrive at an overall total number of drug users over represents the number of drug users, since an individual drug user may have been counted in the figures for more than one drug type (e.g. an opium user who also uses hashish and alcohol would be included three times in the combined total figure). Based on drug user’s answers regarding their personal drug use patterns it was found that 54% of all drug users take only one drug type, and 27% of all drug users take a combination of 2 drug types. Table A.3 gives the percentage of all drug users that reported using combinations of 1 or more drug types.

No. of illicit drug types used

% of drug users interviewed

1 only 53%2 only 27%3 only 13%4 only 5%5 only 2%all 6 1%

Table A.3 Polydrug use from drug users own patterns of use

Using these percentages, the following formula was applied to the estimated total number of drug users, the estimated total number of male drug users, the estimated total number of female drug users and the estimated total number of child drug users:

AT = 6

01.0*5

02.0*4

05.0*3

13.0*2

27.0*53.0* DUDUDUDUDUDU +++++

= DU*0.727 equation (2) Where AT = adjusted estimate of drug users DU= total estimate of drug users While male and female drug users reported using different combinations of drug types, overall the percentages using one or more drug types were not significantly different.

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ANNEX B.1 Combinations of drugs used in Afghanistan (as reported by drug users).

Combinations Number of users % of users Combinations Number of

users % of users

Op 160 13 Op 33 26He 51 4 He 8 7Ha 319 26 Ph 27 22Ph 43 4 Al 3 2Al 53 4 Ot 5 4Ot 11 1 Op+He 5 4Op+He 23 2 Op+Ha 1 1Op+Ha 118 10 Op+Ph 8 7He+Ha 25 2 Ph+Al 1 1Op+Ph 20 2 Op+Ot 8 7He+Ph 4 <1 He+Ot 2 2Ha+Ph 18 1 Ha+Ot 1 1Op+Al 7 1 Ph+Ot 4 3He+Al 4 <1 Op+He+Ha 1 1Ha+Al 37 3 OP+He+Ph 6 5Ph+Al 3 <1 OP+Ha+Ph 3 2Op+Ot 15 1 Op+Ph+Ot 2 2He+Ot 5 <1 Ha+Ph+Ot 1 1Ha+Ot 22 2 He+Ph+Ot 1 1Ph+Ot 25 2 Op+He+Ha+Ph 1 1Al+Ot 3 <1 Op+He+Ph+Ot 1 1Op+He+Ha 38 3OP+He+Ph 13 1Op+He+Al 5 <1 KeyOp+He+Ot 2 <1 Op = OpiumOP+Ha+Ph 17 1 He = HeroinHe+Ha+Ph 6 <1 Ha = HashishOp+Ha+Al 52 4 Ph = Pharmaceutical drugsHe+Ha+Al 1 <1 Al = AlcoholOp+Ha+Ot 6 <1 Ot = Other drugsOp+Ph+Al 1 <1He+Ph+Al 1 <1Ha+Ph+Al 6 <1Op+Ph+Ot 2 <1Ha+Ph+Ot 5 <1He+Al+Ot 1 <1Ha+Al+Ot 2 <1Op+He+Ha+Ph 12 1Op+He+Ha+Al 23 2Op+He+Ha+Ot 4 <1Op+He+Ph+Ot 2 <1He+Ha+Ph+Al 7 1Op+Ha+Ph+Al 2 <1Op+Ha+Ph+Ot 6 <1Op+Ha+Al+Ot 6 <1He+Ha+Al+Ot 1 <1Ha+Ph+Al+Ot 2 <1Op+He+Ha+Ph+Al 12 1Op+He+Ha+Ph+Ot 8 1Op+He+Ha+Al+Ot 3 <1Op+He+Ph+Al+Ot 1 <1Op+Ha+Ph+Al+Ot 3 <1He+Ha+Ph+Al+Ot 3 <1Op+He+Ha+Ph+Al+Ot 9 1

MALE USERS (n=1228) FEMALE USERS (n=122)

Table B.1 Combinations of drugs used in Afghanistan (as reported by drug users).

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