substance abuse treatment and hiv in iran azarakhsh mokri md iranian national center for addiction...

Substance Abuse Substance Abuse Treatment and HIV in IranTreatment and HIV in Iran

Azarakhsh Mokri MDAzarakhsh Mokri MD

Iranian National Center for Addiction Studies Iranian National Center for Addiction Studies (INCAS)(INCAS)Tehran University of Medical SciencesTehran University of Medical SciencesTehran, IranTehran, Iran

IV Heroin Users; 175,000

Heroin Smoking; 250,000

Opium Ingestion

Opium Smoking

I. Iran suffers from an I. Iran suffers from an intriguing duality of narcotic intriguing duality of narcotic

abuse! abuse!

Afghanistan produces 3,200 tons each year!

Results: Heroin vs. Opium Results: Heroin vs. Opium AbusersAbusers

Opium Users (n=215)Opium Users (n=215) Heroin Users (n=158)Heroin Users (n=158)

AgeAge 36.09 ± 11.4936.09 ± 11.49 35.23 ± 9.7335.23 ± 9.73

Duration of addictionDuration of addiction 7.39 ± 6.377.39 ± 6.37 8.81 ± 7.578.81 ± 7.57

Money spent daily on Money spent daily on drugsdrugs

3.6 ± 2.4 $3.6 ± 2.4 $ 9.5 ± 8.4 $*9.5 ± 8.4 $*

Marital statusMarital status 54% married54% married

5.3% divorced5.3% divorced51% married51% married

6% divorced6% divorced

Employment rateEmployment rate 58%58% 62%62%

Years of formal Years of formal educationeducation

9.12 ± 3.589.12 ± 3.58 9.59 ± 3.349.59 ± 3.34

First drug of abuseFirst drug of abuse 97% opium97% opium 95% opium95% opium

History of IDUHistory of IDU 14%14% 71%*71%*

History of incarcerationHistory of incarceration 33%33% 63%*63%*

HIV infection rateHIV infection rate 4% (n=4 /107)4% (n=4 /107) 17%* (n=12/69)17%* (n=12/69)

*P<.01



AgeAge 36.09 ± 11.4936.09 ± 11.49 35.23 ± 9.7335.23 ± 9.73



3.6 ± 2.4 $3.6 ± 2.4 $ 9.5 ± 8.4 $*9.5 ± 8.4 $*






9.12 ± 3.589.12 ± 3.58 9.59 ± 3.349.59 ± 3.34

First drug of abuseFirst drug of abuse 97% opium97% opium 95% opium95% opium

History of IDUHistory of IDU 14%14% 71%*71%*


HIV infection rateHIV infection rate 4% (n=4 /107)4% (n=4 /107) 17%* (n=12/69)17%* (n=12/69)*P<.01



AgeAge 36.09 ± 11.4936.09 ± 11.49 35.23 ± 9.7335.23 ± 9.73



3.6 ± 2.4 $3.6 ± 2.4 $ 9.5 ± 8.4 $*9.5 ± 8.4 $*






9.12 ± 3.589.12 ± 3.58 9.59 ± 3.349.59 ± 3.34

First drug of abuseFirst drug of abuse 97% opium97% opium 95% opium95% opiumHistory of IDUHistory of IDU 14%14% 71%*71%*


HIV infection rateHIV infection rate 4% (n=4 /107)4% (n=4 /107) 17%* (n=12/69)17%* (n=12/69)*P<.01

We know (or think we know) 2 We know (or think we know) 2 other facts about opium versus other facts about opium versus

heroin enigma;heroin enigma; Heroin and opium users show similar Heroin and opium users show similar

relapse rates after detoxificationrelapse rates after detoxification Opium dependence can be Opium dependence can be

pharmacologicallypharmacologically as severe as as severe as heroin dependence!heroin dependence!

Detoxification of opium versus heroin Detoxification of opium versus heroin abusersabusers

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Opium (n=37) Heroin (n=32)

II. HIV is highly related to IDUII. HIV is highly related to IDU

More than 11,200 cases of HIV/AIDS More than 11,200 cases of HIV/AIDS have been registered and estimated have been registered and estimated 30,000-40,000 HIV/AIDS cases are in 30,000-40,000 HIV/AIDS cases are in the country. the country.

Around 60% of the cases are infected Around 60% of the cases are infected through needle sharing in IDUs.through needle sharing in IDUs.

If cases with unknown route are If cases with unknown route are omitted 85% and 10% are through omitted 85% and 10% are through IDU and sexual contact, respectively.IDU and sexual contact, respectively.

HIV knowledgeHIV knowledge

Approximately 97% of drug users (n=61) Approximately 97% of drug users (n=61) stated that HIV could be contracted via stated that HIV could be contracted via sharing needles.sharing needles.

Engaging in unprotected sex was seen as Engaging in unprotected sex was seen as an HIV transmission route by slightly more an HIV transmission route by slightly more than 80% of individuals.than 80% of individuals.

A high percent of opium and heroin users A high percent of opium and heroin users (20%-30%) believed that casual contacts (20%-30%) believed that casual contacts were transmission paths for HIV as well. were transmission paths for HIV as well.

Needle/syringe availabilityNeedle/syringe availability

Syringes have been available at low Syringes have been available at low price (<4 cents!) for many years.price (<4 cents!) for many years.

Pharmacies are local, widespread Pharmacies are local, widespread and cooperative.and cooperative.

No ban on selling or carrying No ban on selling or carrying syringes.syringes.

Zamani et. al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005, 19:709–716

Drug abuse is a crime and drug Drug abuse is a crime and drug abusers are arrested!abusers are arrested!

Total prisoners in Iran; 130,000

65% of prisoners are convicted because of drug related charges!

In some years up to 400,000 people are convicted because of drug related charges.

Most convicts stay 45 days to 6 months in prison.

IV Heroin users

Opium users

Infected with HIV & HCV

IV Heroin users

Opium users


Decriminalizing drug use?!

MeanwhileMeanwhile

Implementing other treatments for IV drug users;

•Need for more than abstinence models•Governmental specialized centers for IDUs•Free of charge MMT for street drug users•NGO based needle exchange and condom distribution programs

Specialized Governmental MMT Specialized Governmental MMT CentersCenters

Governmental MMT center Satellite distribution center

Offer MMT and MH care for high-risk, high comorbidity

clients;PsychiatristsGPPsychologistsSocial workers

Independent funding

Low-risk, low comorbidity High-risk, high comorbidity

MH/SA joint specialized centers

MH/SA/STD/HIV joint specialized centers

???

Patients in MMT and methadone Patients in MMT and methadone consumptionconsumption

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Methadone consumption (in Kg)


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Where is the lost methadone?Where is the lost methadone?

Methadone is consumed by opium Methadone is consumed by opium users for detox and short-term users for detox and short-term replacement.replacement.

Both clients and physicians favor such Both clients and physicians favor such approach.approach.

Such practice has little proven value.Such practice has little proven value. IV heroin users are excluded at IV heroin users are excluded at

expense of opium smokers!!expense of opium smokers!!

The Utmost Critical The Utmost Critical QuestionQuestion

Should opium dependent Should opium dependent individuals receive individuals receive

substitution treatment?substitution treatment?

Methadone: global manufactureMethadone: global manufactureand consumption, 1983-2002and consumption, 1983-2002

Low-risk, low comorbidity High-risk, high comorbidity

X

Office-based MMT

Office basedbuprenorphine

Tincture ofOpium???

PHC abstinence oriented interventions

SR morphine

Starting with office-based MMTStarting with office-based MMT

GP + (social worker+ psychologist + GP + (social worker+ psychologist + nurse)nurse)

Spend 15 days training in academic Spend 15 days training in academic centerscenters

Get certificate and start workGet certificate and start work So far 130 but by end of 2005 So far 130 but by end of 2005

planned 300 and next year 600.planned 300 and next year 600.

For more specialized centersFor more specialized centers

Psychiatrists+ (GP + social worker+ Psychiatrists+ (GP + social worker+ psychologist + nurse)psychologist + nurse)

Psychiatry residents spend 1-3 Psychiatry residents spend 1-3 months rotation at INCAS. Medical months rotation at INCAS. Medical students part time for a month. students part time for a month.

Chance to interact with patients, Chance to interact with patients, other staff, even police and other staff, even police and judiciariesjudiciaries

IV Heroin users

Opium users


MMT Needle

exchange

Condoms

Bleach

Drug courts

Alternates to prison

But the true wonderful But the true wonderful trend!trend!

Massive demand thus Massive demand thus large scalelarge scale supply.supply.

Mobilizing resources and training staffMobilizing resources and training staff Providing Providing diversitydiversity Self-organizationSelf-organization Intelligent decision making and controlIntelligent decision making and control

substance abuse treatment and hiv in iran azarakhsh mokri md iranian national center for addiction...

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