S. Haroon Ahmad ( Department of Neuropsychiatry, Jinnah Postgraduate Medical Centre, Karachi. )
N.U. Gichki ( Malaria Control Programme, Quetta, Baluchistan. )
M. Husain ( Lasbella, Baluchistan. )
Through epidemiological method, prevalence of drug dependence in the four villages of Panjgur is estimated to be 3.37% of the population.. Cannabis was found to be abused by 1.13%, opium 0.5% and heroin 0.64%. The difference between the estimates of heroin abuse made earlier through information from patients and the current survey is more than five times. It is suggested that currently used estimates may be reviewed critically (JPMA 35: I0,(1985).
Impressed by the number of heroin addicts from Mekran treated in the public and private hospitals of Karachi, we investigated their prevalence at the source. On thq basis of information provided by addicts it was estimated that 3.5% of the population of Panjgur (both rural and urban) was abusing heroin. Among the high risk group in males between 10 - 39 years the prevalence was as high as 13.6%1. It meant that heroin addiction at Panjgur (and may be in Mekran) was highest in Pakistan. During our stay in the region, we were able to plan a low profile epidemiological survey. Considering the sensitivity of the problem it was a unique opportunity to compare the result of the two approaches. Brief review of the drug scene in Pakistan may help to put the present study in its proper perspective.
Drug Scene in Pakistan
Opium (Afim) and Cannabis (Charas) use in the Indo.Pakistan sub-continent has been well known for a long time (Indian Hemp Drugs Commission, 1969)2. The morphine, pethidine and barbiturates appeared in the sixties which was followed by a brief period of stimulants.3It was at the same time that methaqualone and non barbiturate hypnotics also became fashionable in major cities. Since then methaqualone has continued to be abused to a certain extent, but the unnoticed use of benzodiazepines particularly the short acting ones have been added to the list. At. least one dozen different brands of benzodiazepines are marketed in Pakistan and their availability without prescription makes the most easily obtained substance of abuse.
There is considerable variation in the sociomedical literature on drug abuse in Pakistan. Those conducted by individuals or even international agencies are either poor in methodology or population is highly selected while a few suffer from over enthusiasm. In 1972 Husain4 estimated that as many as 4.0% of population of Pakistan is addicted to opium. Another study concluded that 3.42% of the population of North West Frontier Province is dependent on one or the other substance5. Drug use among non-student youth explored by Smart, Arif and others5 in four cities in north of Pakistan found that in a sample of drug dependent persons 84.4% had used cannabis, 13.1% opium and 6.7% barbiturates. Huges et al.7 in collaboration with Pakistan Narcotics Control Board had reported earlier that out of 300 people interviewed 70% were daily users of opium and 17% of cannabis. Other drugs were rarely used. The disparity in these studies is most likely due to differences in selection of the sample.
A nation wide survey conducted by Pakistan Narcotics Control Board is awaiting publication. Preliminary results of the number of addicts in 34 cities and 200 villages have been released recently. The survey estimates 1 .3 million addicts which includes multi-drug users. The break up is cannabis 800.000; opium 320,000; Bhang (a cannabis leaf concoction) 250,000; alcohol, 220,000 and heroin 100,0008.
While Westermer’s maxim of the ‘pro-heroin effects of anti-opium laws in Asia’ (1976) was operating Hadd ordinance in 197910 was enforced and political changes along the northwestern borders of Pakistan stepped up the process. The ‘golden crescent’ eclipsed due to rapid revolutionary changes in Iran and Afghanistan, leaving Pakistan to carry the burden. It has been aptly summarized by Khan11 that there cannot be more ideal place in the world than the tribal areas of Pakistan, with abundant supply of locally grown opium and no government control. Heroin appeared in late 1980.
Gwader, Turbat and Panjgur are three administrative districts of Mekran division the south-western part of Baluchistan. The population of Panjgur is concentrated in coglomeration of villages which are clustered on the two sides of the torential river Rakhshan (Fig).
Malaria control programme in Baluchistan (1982)12 have upto date information on the population and house-hold, which is collected by their local staff through periodic surveys. It was, therefore, decided to collaborate with this department and also with the local staff of Rural Health Centre (RHC), Panjgur.
Four villages in Panjgur district were selected. They were Washbood, Khudabadan, Sardu and Chitkan. The criteria being their easy accessability and familiarity of the field staff with the people.
During routine domiciliary visit between September and December, 1982 the usual respondent from every fifth house-hold was asked additional questions. They were : has any one suffered in the last one year or presently suffering from Gwat*, evil spirit, madness or had taken/ taking an addictive substance as tablets, charas, opium or heroin. No responders to drug related questions were considered as nonabusers. The field staff was directed to stop enumeration in case of frequent unfounded suspicion shown by the respondents or the residents. As expected it has to be stopped after varying numbers of house-holds were visited in each village. The prevalence of drug-dependence was determined on the basis of population calculated from the number of house-hold visited.
Information about heroin dependence was also collected from heroin dependent seeking treatment at RHC Panjgur. The medical officer (Dr. M.H.) recorded them from September to December 1982, on the modified version of the proforma developed by Smart et al.6 (1981).
Results and Discussion
The prevalence of drug taking in the four villages under study averages 3.37% of the population (Washbood 2.5%, Khudabadan 3.45%, Sardu 3.28% and Chitkan 3.81%). Cannabis was found to be more frequently abused. Average percentages of population abusing various compounds were: Cannabis 1.13%, opium 0.5% (none from Washbood) and heroin 0.64%. In ‘others’ are included variety of substances used in the form of pills (tranquilizers), tinctures and alcohol (Washbood sample does not inëlude alcohol in ‘others’). In this survey no female addict was reported although they are known to abuse opium (Table 1).
Certain characteristics of heroin abusers seeking help at Rttral Health Centre, Panjgur is given in Table II.
Average age is 27 years, the first-choice of only two was opium smoking who also used heroin in previous month. All used charas in the past.
Earlier studies in the Punjab and North West Frontier Province heavily depended on the information from patients or heresay. The ‘willing (captive) addict is usually eager to please the highly motivated ‘stranger’ (investigator). The limitations of a survey like this are immense and the field experience clearly indicated that 0.64% prevalence of heroin dependence is on the lower side. But the disparity between the estimates made earlier through informations from patients and the current survey is much more than expected. The difference in the same area, at the same time (within four months) by the same investigators using different methodology is 5.4 times. It is reasonable to state that the addicts tend to exaggerate, not only the frequency and the quantity of the substance abused, as generally accepted, but also the number of people abusing them. It is, therefore, suggested that the currently used estimates or all those calculated from patients may be reviewed critically.
The reasons of such a high prevalence of drug abuse at Panjgur (which could be generalized to Mekran) needs urgent attention. There is no industry or any kind of commercial activity in Mekran. The trading and shop keeping is carried out by the Pathans and cultivation on Carez* irrigated land is limited to dates and fodder only. Apparent affluence is due to remittances from expatriates. On an average two male members from each house-hold are working in Gulf, majority in Muscat army. The young still at home and unemployed having all the time and spare money are potential candidate for drug taking.
Before 1980 the presence of heroin across the border was known but its use was not popular. Once the traffic was reversed heroin was all over. It is too well known that ample supply awaiting illicit transport across the border has stabilized the price at a lower level. The aggressive pushing in the area is indicated by reports from village elders that traditional door to door female cloth vendors are selling heroin as an excellent remedy for all kinds of aches and pain including menstrual disorders.
The number of patients seeking treatment can be an indication of the extent of heroin abuse, but it could also be the scare the substance has created among people unaware of its long and short term effects (as against the use and abuse of charas and opium). It may be a revolving door stage. It is not quite clear if heroin is going to replace cannabis and opium. Many ex-heroin addicts encountered during the survey stated with satisfaction that they have settled down to good old ‘charas’ again. It may be the beginning of realization that this is not the type of ‘relaxant’ they wanted. It is also not compatible with the leisurely life style of a tribal society.
This assumption calls for urgent action now. Sensible intervention can save a large number of young people from becoming part of a future hard core heroin dependent sub-culture.
We are grateful to the field staff of Malaria Control Programme and those from the Department of Health, Baluchistan for their interest and help in collecting the data.
1. Ahmed, S.H. and Hussain, M. Heroin at Panjgur. JPMA., 1984; 34 : 31.
2. Report of Indian Hemp Drugs Commission 1893-1894.Marijuana, Silverspnng, Maryland.1969.
3. Hasan, K.Z. and Ahmed, S.H. Drug addiction; need for effective control. JPMA., 1969; 19:102.
4. Hussein, K. Nature and extent of drug addiction in West Pakistan, Social Science Research Centre, University of the Punjab, Lahore. 1972 (unpublished monograph).
5. Elahi, K. Profile of Drug Abuse in N.W.F.P. in proceedings of International Conference on Demand and Supply of Opiates in Pakistan. Pakistan Narcotics Control Board, Islamabad.
6. World Health Organization Drug use among non-student youth. R.G. Smart, A. Arif, P. Hughes et at., offset publication, No. 60, 1981.
7. World Health Organization, Cure data for epidemiological studies of Non-medical drug use,P.Hughes, J. Venulet, U. Khant, M.E. Medina Mora V. Navaratnam et at., Offset publication No.56, 1980.
8. Askari, M. A drug addict every 15 minutes, Karachi Dawn, 1983.
9. Westermeyer, J. The Pro-heroin effects of anti-opium laws in Asia. Arch, Gen. Psychiatry, 1976; 33 : 1135.
10. Hadd Ordinance. Prohibition Order, Government of Pakistan, 1979.
11. Khan, M.Z. Heroin abuse at Karachi, in proceedings of International Conference on Demand and Supply of Opiates. Pakistan Narcotics Control Board, Islamabad, p. 43-37, 1982.
12. Malaria Control Programme, Baluchistan, 1982 (Personal Communication).