Demand Reduction Program: Afghanistan
Drug consumption represents one of the greatest threats to the future of Afghanistan. Addressing drug use in Afghanistan serves a counter-insurgency mission by denying revenue to the insurgents and safeguarding a vulnerable segment of the population that is prone to exploitation. Drug demand reduction programs also rescue the vital human capital that will be needed to build a self-sustained public and private sector for generations to come.
The alarming prevalence of drug use among adult men and women, adolescents, and children is facilitated through the cheap availability of opium and heroin in a country that produces 94% of the world’s opiates. Traditional usage as medication, lack of public awareness on the harms of opium, and frequent contact with opiates (e.g. during cultivation and trafficking) are some of the factors that contribute to high addiction rates. Hashish and the misuse of prescription drugs are other substances commonly abused in Afghanistan.
The United States’ Department of State, through the Bureau for International Narcotics and Law Enforcement Affairs (INL) recognizes the critical role of demand reduction as part of a comprehensive strategy to reduce both supply and demand of illicit drugs in Afghanistan. As the largest supporter of demand reduction programs in Afghanistan, INL works closely with the Ministry of Counternarcotics to implement a comprehensive program of prevention, treatment, and aftercare; technical assistance; and capacity building.
The purpose of this factsheet is to provide background for the public and media on the nature of the drug use problem in Afghanistan and the U.S. Government’s response, as well as answering some common questions and misperceptions on this issue.
Drug Use in Afghanistan
How many Afghans use opium or heroin in Afghanistan?
Survey data is critical in identifying the magnitude of the problem and which provinces and cities have a more acute addiction problem. To date, no science-based national drug use survey using drug testing has been conducted for Afghanistan.
The UNODC’s 2005 national drug use survey estimated nearly one million drug users in Afghanistan (approximately 4% of the population). The figure represented a conservative estimate as the survey teams had limited access to women and children. The UNODC’s 2009 national drug use survey (not yet released) also relied on questionnaires, but did not take hair, urine, or saliva samples. The UNODC’s efforts in undertaking these two surveys are commendable, considering the difficulty of conducting a survey due to the stigma related to drug use and the challenging security environment.
INL plans to conduct the first scientific study in 2010 using hair, urine, and saliva samples to determine drug use on a national level which will be subjected to peer review upon completion. The national survey will help uncover the extent and severity of drug addiction, which INL believes is under-reported (i.e., current surveys document drug use, but not the toxic level of drugs in the systems of Afghan users that have severe implications for treatment assistance). These figures, in turn, will help the governments of Afghanistan, United States, and other stakeholders to improve planning for the drug treatment centers.
How can effective demand reduction programs be implemented in the absence of survey data?
Traveling through the streets of Afghanistan, it is not difficult to find drug addicts on the streets. Surveys are not needed to identify the problem when the population is not hidden. INL staff have personally witnessed 1,000+ drug addicts actively smoking opium and injecting heroin at the former Russian Cultural Center in Kabul. Some tribal elders have reported that half of the members of their villages are addicted.
How is the drug treatment infrastructure organized?
The Government of the Islamic Republic of Afghanistan (GIROA) is responsible for the administration of the national drug treatment and prevention system. Specifically, the Ministries of Counternarcotics and Public Health have a lead role in the implementation of demand reduction programs. The U.S. Department of State’s Bureau for International Narcotics and Law Enforcement is the primary and largest donor for drug treatment programs in Afghanistan. Two public international organizations (PIO), the Colombo Plan and the United Nations Office on Drugs and Crime (UNODC) provide monitoring, oversight, and training. Six Afghan NGOs provide drug treatment services:
- Khatiez Organization for Rehabilitation (KOR)
- Shahamat Health and Rehabilitation Organization (SHRO)
- Social Services for Afghan Women Organization (SSAWO),
- Voice of Women Organization (VWO)
- Welfare Association for the Development of Afghanistan (WADAN).
How many residential drug treatment centers operate in Afghanistan?
The Ministries of Counternarcotics and Public Health have identified 40 residential drug treatment centers in Afghanistan. The last pages of this factsheet include the complete list of treatment centers, their characteristics, and maximum annual client capacity information. Other privately-run treatment centers operate in some provinces, but these do not utilize minimum treatment standards and are therefore not regarded as viable treatment centers.
In addition, to treatment centers, seven drop-in (outreach) centers operate throughout the country. (Logar, Nangarhar, Badakhshan, and four in Kabul). The Ministry of Public Health also administers ten community centers which are funded by the Counter Narcotics Trust Fund. Eight of these centers provide home-based treatment and two provide in-patient residential treatment (Nangarhar and Balkh).
How can you make a significant different in the problem of addiction if the current drug treatment system is only capable of accommodating a small fraction of the population, with a capacity of 10,216 users per year?
If one takes the population of 1,000,000 drug users cited by the 2005 UNODC survey, only 1% of the population has access to treatment per year. Still, this figure is generally consistent with demand for treatment services in the United States. In the U.S., only 1.8% of the population who need treatment for substance abuse make an effort to receive services (SAMHSA, 2007 National Survey on Drug Use). Nonetheless, INL is exploring options for large-scale village-based treatment in communities where over 50% of the population are estimated to consumes opiates by tribal leaders.
What types of treatment programs does the U.S. support in Afghanistan?
INL Support for Demand Reduction Programs in Afghanistan Treatment Protocol Development Training Prevention Evaluation, Testing, and Surveying Administration
INL Support for Demand Reduction Programs in Afghanistan
Evaluation, Testing, and Surveying
In 2010, the United States will support 30 residential drug treatment centers, making it the largest contributor to drug treatment services in Afghanistan (75% of all centers). Of the 30 centers, 16 centers provide residential treatment for men and outpatient services for women. Six centers provide residential treatment and outpatient services for women, and each one has an adjacent center that provides services to the children of the female clients. Two centers provide drug treatment services for adolescents.
How do you know if treatment is being implemented well in Afghanistan? How are you evaluating success?
A random sample of Afghan treatment programs are currently involved in an INL-funded three-year outcome/impact evaluation to measure long-term treatment success (i.e., reduction in drug use/relapse rates, reduction in criminal activity and recidivism rates, reduction in intravenous drug use that leads to HIV/AIDS, and increase in employment and mental health status). Clients are pre-tested before entering treatment and post-tested six-months after leaving treatment. Post-treatment drug use will be measured by urine screening/hair follicle analysis of all clients. In addition, periodic surprise monitoring visits are conducted on all treatment clinics to ensure they are following required treatment protocols and to verify that all treatment slots/beds are occupied.
What is your experience with child addiction? How is the U.S. helping address the problem of child addiction in Afghanistan?
The Ministry of Public Health and NGO treatment providers are anecdotally reporting an ever-increasing addictions problem among adolescents aged 6 to 16, particularly in Hirat province. Furthermore, heroin and opium-addicted toddlers (aged 2 to 4) and children (aged 6) have been medically documented in INL-funded treatment programs for women and children in Kabul and Balkh provinces. The children arriving with their mothers in the INL-funded women and children’s treatment centers represent the youngest drug addict sub-population ever identified worldwide. As such, no clinical or treatment protocols have ever been developed for this age group.
In response to this unique problem, INL is working with the United Nations Office on Drugs and Crime (UNODC), the National Institute on Drug Abuse (NIDA), World Health Organization (WHO), and international university researchers to develop, validate, refine, and deliver new treatment options for drug addicted children that can be used in the six women and children’s treatment centers and future centers for homeless addicted street children.
Can children exposed to second-hand opium smoke become addicted?
The health effects of second-hand opium smoke exposure to children are not well understood. Second-hand tobacco smoke is an environmental toxin that is directly linked to cancer, bronchitis, ear infections, and many childhood diseases. No level of tobacco smoke is safe for consumption. Similarly, no levels of opium can be qualified as safe for children to breathe.
INL funded a three-year project to collect air and surface samples within residences in Kabul, Kandahar, and Badakhshan provinces, where children are present during opium use. The study is important for three reasons:
- to better understand the health effects of children exposed to both second-hand smoke from opium use within the home
- to determine the toxic effects on a child’s system from skin contact with surfaces within the home that are contaminated with residues from second-hand smoke which can be easily absorbed through the skin to exert its toxic effects, and
- to identify and target for treatment a hidden addiction population that traditional drug use surveys fail to identify (i.e., unintended drug addiction among children via second-hand exposure).
Results: All households where opium smoking was suspected tested positive for high concentrations of opium smoke in the air and opium residue in all carpets. At least one child in each household (some as young as 4 months to 4 years of age) tested positive for high concentrations of opium and heroin metabolites. This special testing will continue for the children whose mothers are admitted into drug treatment centers in order to provide tailored services.
Drug Prevention in Afghanistan
What kind of drug prevention messages are you communicating to the youth?
The Colombo Plan, with INL support, is expanding their pilot school-based drug prevention program in Kabul to boys and girls schools. The Life Skills Prevention model is a science-based program in elementary and middle schools designed to address a wide range of risk and protective factors by teaching social skills in combination with drug resistance, decision-making, and conflict resolution skills, guiding youth toward healthy choices and a drug and violence-free lifestyle.
In addition this Colombo Plan program, the INL-funded Counter Narcotics Advisory Teams (CNAT) located in seven provinces of Afghanistan actively disseminate messages on the harms of narcotics and engage in community in activities that incorporate messaging against consumption and cultivation of drugs.
How are you involving religious leaders in Afghanistan to address drug use?
INL has conducted drug awareness seminars for religious leaders (e.g., mullahs) since 2003. Over 500 mullahs have been trained at one time on the problems of drug addiction and how to conduct community shuras on the dangers of drug consumption, including drug production and trafficking. Mullahs have also been assisted in opening outreach/drop-in centers in their mosques to provide brief intervention services for addiction, referral to treatment, and aftercare services for ex-addicts who have completed treatment. Religious leaders are now a major source of referral of addicts into treatment.
Other Frequently Asked Questions
How does drug use in Afghanistan affect the U.S. and international community? How are U.S. demand reduction programs addressing these issues?
Drug use in Afghanistan affects the U.S. and international community in three respects:
- Counter-insurgency: Insurgents partly fund their activities with funds earned from the drug trade, including consumption by the Afghan populace. Demand reduction activities serve a counterinsurgency mission by enlisting the support of religious leaders in educating their communities about the dangers of narcotics. Drug addicts also represent a vulnerable population that insurgents can exploit for advancement of the insurgency.
- Safeguarding Human Capital which is Needed to Build Afghan Society: Considering the significant amount of drug addicts, including children, demand reduction activities serve a vital role in preserving human capital and rehabilitating members of Afghan society. Rehabilitated from drug addiction, Afghan citizens will more capably assume leadership positions in society and build self-sustained public and private sector institutions. Less drug use will also mean less violence and related criminal activities, less funding from illicit sources (drug use) for insurgent organizations, and less illicit money available for corruption.
- Afghanization: Supporting the Government of the Islamic Republic of Afghanistan (GIROA) to address Afghanistan’s drug addiction also promotes Afghanization by building the capacity and human capital of the local communities to deliver drug treatment services. U.S. support to drug treatment also strengthens the central government’s capacity to administer and monitor a national drug treatment infrastructure.
What is the end goal of U.S. support for drug treatment centers in Afghanistan? The U.S. cannot fund these indefinitely. How will drug treatment become self-sustainable in the medium- to long-term?
Short Term (2 years)
- By 2012, we will have the results of our independent, science-based evaluation of drug treatment effectiveness (e.g., reductions in drug use and related criminal behavior pre- and post-treatment).
- Since relapse back to drug use prior to INL-funding of treatment centers was close to 100%, the major goal of our INL-funded treatment centers is to initially cut relapse in half (i.e., 50% of all clients will be drug free).
Medium Term (3-4 years)
- Following further refinements to the treatment centers, our goal for drug free-clients is 70%, on par with the evaluation results from our other INL-funded treatment initiatives in Asia and Latin America.
- Afghanistan is a special case as we are working with the GIROA to build the beginnings of a national drug treatment system, as opposed to other countries which already had functioning infrastructure prior to INL assistance.
Long Term (5-7 years)
- Treatment programs will become self-sufficient, following the model currently used by our treatment center in Dai Kundi, where the local community contributes to the operational cost. Using this model, the GIROA’s national and provincial funding should be able to make up the difference.
- Intensive training of trainers in the short- and medium- term will result in a self-sustained Afghan addictions training capacity.
Afghanistan’s National Drug Treatment System Treatment Center Characteristics and Maximum Annual Client Capacity
Source: Ministries of Counternarcotics and Public Health
Updated April 6, 2010
|No||Province||Operating Agency||Donor and Monitoring Organization||Number of Beds at the Center||Annual Residential and Outpatient||Annual Home-Based||Length of Tx in Days|
|1||Kabul||WADAN (male)||INL/Colombo Plan||40||320 males||160 females||45|
|WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|SSAWO (female)||INL/Colombo Plan||20||160 females||160 females||45|
|SSAWO (children)||INL/Colombo Plan||15||120 children||None||45|
|WADAN Janglakak (male)||INL/UNODC||50||400 males||None||45|
|Nejat Janglakak (male)||INL/UNODC||50||400 males||None||45|
|Nejat (male)||German Caritas||10||120 males||240 males and females||30|
|2||Khost||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|4||Paktya||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|6||Parwan||MOPH (male) – Located in MOPH building.||Red Crescent – Funding ended on Jan 2010, but staff continue to work||10||120 males||120 males||30|
|7||Wardak||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|8||Ghazni||MOPH – Both Independent building with sufficient space for residential treatment. Only provides community-based treatment, not residential.||CNTF||0||0||120 males and females||30|
|13||Nangarhar||WADAN (female)||INL/Colombo Plan||20||160 females||160 females||45|
|WADAN (children)||INL/Colombo Plan||15||120 children||None||45|
|MOPH (male) through March 21, 2010||CNTF – Funding ended on March 21, 2010; MOPH is seeking additional funding.||20||160 males||160 females||45|
|15||Badakhshan||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|SHRO (female)||INL/Colombo Plan||20||160 females||160 females||45|
|SHRO (children)||INL/Colombo Plan||15||120 children||None||45|
|16||Takhar||SHRO (male)||INL/Colombo Plan||40||320 males||160 females||45|
|17||Kunduz||MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment. Currently has 10 beds.||CNTF – Funding ended on Dec 31, 2010, but the staff is still working.||10||120||120 males and females||30|
|19||Balkh||SHRO (female)||INL/Colombo Plan||20||160 females||160 females||45|
|SHRO (children)||INL/Colombo Plan||15||120 children||None||45|
|MOPH (male) through March 21, 2010 –Independent building. Center provides residential and home-based treatment.||CNTF – Funding ended on March 21, 2010; MOPH is seeking additional funding.||20||240 males||120 males||30|
|20||Bamyan||SHRO (male)||INL/Colombo Plan||20||160 males||160 females||45|
|MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staff is still working.||0||0||120 males||30|
|21||Faryab||MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staffs is still working.||0||0||120 males||30|
|Nejat||Norwegian Church Aid (NCA)||10||120 males||240 males and females||30|
|22||Jowzjan||SHRO (adolescent)||INL/Colombo Plan||50||100 adolescents||None||180|
|MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staffs is still working.||0||0||120 males and females||30|
|25||Helmand||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|26||Kandahar||WADAN (male)||INL/Colombo Plan||20||160 males||160 females||45|
|29||Dai Kundi||KOR (male)||INL/Colombo Plan||20||160 males||48 females||45|
|KOR (male)||INL/Colombo Plan||10||80 males||48 females||45|
|31||Farah||VWO (female)||INL/Colombo Plan||20||160 females||160 females||45|
|VWO (children)||INL/Colombo Plan||15||120 children||None||45|
|MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staffs is still working.||0||0||120 males||30|
|32||Ghor||MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staffs is still working.||0||0||120 males||30|
|33||Hirat||SHRO (female)||INL/Colombo Plan||20||160 females||160 females||45|
|SHRO (children)||INL/Colombo Plan||15||120 children||None||45|
|VWO (adolescent)||INL/Colombo Plan||50||100 adolescents||None||180|
|34||Nimroz||MOPH (male) – Only provides community-based treatment, not residential. Building has sufficient space for residential treatment.||CNTF – Funding ended on Dec 31, 2010, but the staffs is still working.||0||0||120||30|
1 Red Crescent
1 German Caritas
|760 beds at the centers||5,720 ||4,496 ||30d = 12|
45d = 27
180d = 2
|40 Centers Total||10,216 = Maximum Annual Client Capacity|
CNTF - Counter Narcotics Trust Fund
CP - Colombo Plan
GIROA - Government of the Islamic Republic of Afghanistan
INL - U.S. Department of State’s Bureau for International Narcotics and Law Enforcement
KOR - Khatiez Organization for Rehabilitation
MCN - Afghanistan Ministry of Counter Narcotics
MOPH - Afghanistan Ministry of Public Health
NAS - Narcotics Affairs Section
SHRO - Shahamat Health and Rehabilitation Organization
SSAWO - Social Services for Afghan Women Organization
VWO - Voice of Women Organization
WADAN - The Welfare Association for the Development of Afghanistan