Working Group on the Prevention and Control of Drug Dependence, Manila, Philippines, 28 June - 4 July 1983 : report

(WP)MNH/ICP/MNH/OOl

21 November 1983 ENGLISH ONLY

WORKING GROUP ON THE PREVENTION AND CONTROL OF DRUG DEPENDENCE Convened by the WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 28 June - 4 July 1983

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines

NOTE

The views expressed in this report are those of the members of the Working Group on the Prevention and Control of Drug Dependence and do not necessarily reflect the policies of the Organization.

•

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for the Governments of Member States in the Region and for those who participated in the Working Group on the Prevention and Control of Drug Dependence, held in Manila, Philippines, on 28 June - 4 July 1983.

CONTENTS ;

1.

INTRODUCTION

.......................................................................................... ..

1 1

2.

OBJECTIVES AND GUIDELINES 2.1 2.2 2.3 2.4

..

.............................................................. .

Objectives of the meeting ••••••••••.••••••••••••••••• Continuity of WHO's activities in relation to the programmes on prevention and control of drug dependence ................................................ IO.. .. .. .. .... .... .. .... .. .. .. .. .. .. ..

1 2

Seventh general programme of work •••••••••••.••.••••• Regional targets for the prevention and control of drug dependence ......................................................

2 3

3.

OUTLINE OF WHO ACTIVITIES

.................................................................. ............................................ ................

3 4

4. 5.

SUMMARY OF COUNTRY AND AREA PROFILES

HEALTH PERSPECTIVE ON DRl1G-RELATED HEALTH PROBLEMS S.l 5.2 5.3

6 6

I 6.

Area of interest and terminology Relations with other disciplines

•••••••••••••••.••••• •••••••••••••••••••••

Target for action .................................... .. Health perspective .••.•.•..••••••••••••••••••••••••••

6 7 7

5.4

ASSESSMENT, INFORMATION AND MONITORING 6.1 6.2

.. .. .. .. .. .. . .. .. .. .. . . .. .. .. .. .. . ..

8. 8 8 9

Assessment rationale ................................................................. 'I'ypes of data ...........................................

6.3 6.4

Monitoring systems ••.••.••.•.••••.•••••.•••.•..•••••. Regional data bank on drug dependence and related health and social problems ....................

10

7.

PREVENTION AND CONTROL OF DRUG DEPENDENCE IN PRIMARY HEALTH CARE ...................................................... ..

11 11 11

7.1 7.2 7.3 8.

Rationale Prevention ..•••..•...•.•..••..••••.•••.....••.•••••.• Management of dependent persons ••••••••••••••••••••••

..............................................

12 13 13

ROLE OF COORDINATION AND COLLABORATION AT GLOBAL, REGIONAL AND NATIONAL LEVELS ..••.•..•••..••••..•••.•••.... 8.1 8.2 8.3 Collaboration with countries or areas to promote policy and programme development •••••••••••••••••••.••••••.•

Collaboration with other United Nations agencies and non-governmental organizations

Collaboration at national level

.............................

14 14

, , ii j

, ,

.,1 I

1 1

\i 9.

OONCLUSIONS 9.1

..............................................................................................

15 15 15 16 16 16 17 17 18

i

i

I I

9.2 9.3 9.4 9.5

9.6 9.7

Evaluation of the meeting •..•.••••••.•.••..•.•.•••.•• Goals and strategies ................................................................ .. Recent trends .............................................................................. .. Data collection and monitoring •••••.••••••••••••..••• Prevention and management ...................................................... .. Collaboration and coordination ••.••••..••••..•.•..•.• Regional targets

10.

RECOMMENDATIONS

.............. " .................................................................... . ..................................................................

ANNEX 1 - LIST OF MEMBERS

19 23

"

ANNEX 2 - OPENING SPEECH OF THE REGIONAL DIRECTOR ANNEX 3 - AGENDA

..................

....................................................................................

25 27

II

ANNEX 4 - PROFORMA AND SUMMARY OF COUNTRY AND AREA PROFILES ...................................................................... ANNEX 5 - LIST OF PAPERS PRESENTED AND BACKGROUND DOCUMENTS ••••••••••••••••••••••••••••

43

,

1.

INTRODUCTION

The Working Group on the Prevention and Control of Drug Dependence was held at the World Health Organization Regional Office for the Western Pacific, Manila, from 28 June to 4 July 1983. Dr S.T. Han, Acting Regional Director, opened the meeting and welcomed the participants on behalf of Dr Hiroshi Nakajima, who was absent on a mission and unable to attend. In his message, the Regional Director recalled that drug dependence had been a serious and long-standing problem in many countries or areas of the Western pacific Region and that the situation had recently deteriorated, reflecting the rapid socioeconomic and cultural changes in Member States. Prevention and control of drug dependence should be conceived as forming an essential component of primary health care activities and should thus be integrated within the overall efforts of the Organization to achieve health for all by the year 2000. The Working Group was attended by ten temporary advisers from nine countries or areas and two observers a

Dr l~s nrew, Australia, and Dr viz Navaratnam, Malaysia, provided support in the preparation and conduct of this meeting as consultants. Dr Awni Arif, Senior Medical Officer in-charge, Drug Dependence Programme, Division of Mental Health, Geneva, and Dr Helmut Sell, Regional Adviser in Mental Health, WHO Regional Office for South-East Asia, participated as members of the secretariat. The members concurred unanimously with the nomination of Dr Chi-yan Sam (Hong Kong) as Chairman, Dr Takemitsu Hemmi (Japan) as Vice-Chairman, and Dr Rey San Pedro (Philippines) as Rapporteur. The list of members, observers, consultants and secretariat is attached as Annex 1.

2.

OBJECTIVES AND GUIDELINES

2.1

Objectives of the meeting The objectives of the Working r.roup were as follows: (1)

to review the nature, extent and trends of the major problems related to narcotics and psychotropic drugs; to examine the reporting systems, restrictive measures and monitoring systems in use for cases of drug abuse;

(2) (3) (4)

to discuss the management and treatment techniques 1n use for acute and chronic diseases;

to formulate ways and means of improving the exchange of information and experience on drug abuse control.

- 2 -

. ~e meeting considered objective (1) under agenda items 3 and 4 ob~ect~ve (2) under agenda item 5, objective (3) under agenda item ob]ect1ve (4) under agenda items 7 and 8, respectively. 2.2

6:

and

Continuity of WHO's activities in relation to programmes on prevention and control of drug dependence

I

I

The WHO Regional Office for the Western Pacific, recognizing the seriousness of drug related health problems, has undertaken several activities on the prevention and control of drug dependence since 1974. The Operational Officer described the flow of activities and stressed the continuity and consistency of WHO policies in its collaboration with Member States. He drew attention to the various suggestions for action made at the most recent Regional Workshop on Psychotropic Drugs, held in Manila, in August 1980. 2.3 Seventh General Programme of Work

The Group reviewed the targets and approaches to the prevention and control of drug dependence described under the Seventh General Programme of Work. The targets of the Seventh General Programme of Work covering the period 1984-1989 are that by 1989: (1)

the results of the evaluation of national policies and programmes for the prevention and control of drug abuse problems in at least five countries that have adopted such measures will be disseminated to all Member States; technologies for the prevention and management of alcohol and drug abuse problems will have been identified and the effects of their application in at least one country in each region will have been documented and evaluated. II

(2)

With regard to the approach to achieving these targets, the following points were stressed: (1)

Emphasis will be given to the development of treatments that are effective in developing countries and to their possible integration into general health care. Operational research will be promoted into optimiZing the use of resources and evaluating the impact of intervention programmes.

(2) (3)

In support of country programmes, appropriate technologies for the prevention and control of drug abuse will be identified, adapted and tested, mainly using WHO collaborating centres, and in collaboration with the United Nations Division on Narcotic Drugs and such agencies as the United Nations Fund for Drug Abuse Control.

- 3 -

(4)

Appropriate information about existing methods for diagnosis, prevention and treatment will be incorporated in training curricula and learning materials for various categories of health worker.

2.4

Regional targets for the prevention and control of drug dependence

The Working Group was to review the feasibility of the regional targets and to assess whether these targets were in accordance with the targets and plan of action of each country/area in the Region. The Operational Officer introduced the regional targets for the prevention and control of drug dependence under the regional medium-term programmes for the period 1984-1989, as follows: (1) (2) (3) (4) Most of the countries or areas will have ratified the international legislation on narcotic and psychotropic drugs. Most countries or areas will be in a position to provide information on drug abuse. A network for information exchange and research on drug abuse will have been established. Community-based programmes for the prevention and control of drug abuse, involving various sectors, such as those concerned with

education, social welfare and law enforcement, as well as health services, will have been developed or strengthened. It was noted that some of the countries or areas have already achieved several of these regional targets.

3.

OUTLINE OF WHO ACTIVITIES

The Senior Medical Officer, Division of Mental Health, WHO Headquarters, introduced the global WHO programme on drug dependence, which has been developed in response to resolutions WHA26.S2, WHA28.80 and WHA33.27, United Nations General Assembly resolutions 32/124 and 34/177 and the WHO strategy of health for all by the year 2000, and in recognition of the seriousness of the problem of drug abuse both in developing and developed countries and its socioeconomic and health consequences. Implementation of the programme requires the simultaneous use of three complementary approaches: (1) cooperation with countries to assess the extent and nature of their problems and to formulate policies for their resolution; (2) development of the technologies necessary for programme implementation; and (3) the application of such technology, accompanied by appropriate evaluation so that it can be further developed when necessary.

- 4 -

The programme involves the integration of multidisciplinary action. Its objectives are: (1) to prevent or reduce problems related to drug abuse and drug dependence; (2) to increase effectiveness of the general health ~ervices through development of skills, knowledge and technology; (3) to integrate these activities in the general health services, including primary health care. In the area of assessment, several epidemiological studies have been completed. In the programme area concerning promotion of policy development and awareness of drug abuse problems, six WHO interregional workshops have been implemented. In the area of development of technology, many studies have been completed or are ongoing. Several interregional training courses for physicians on prevention and treatment as well as training courses on assessment and epidemiology are being conducted. WHO is also collaborating with nine countries to develop country programmes on prevention and treatment, with financial support from the Un ited Na tions Fund for Drug Abuse Control (UNFDAC).

4.

SUMMARY OF COUNTRY AND AREA PROFILES

Profiles were prepared in line with a proforma developed by the Secretariat. National control structures

In all countries or areas which are experiencing significant problems, special coordinating mechanisms have been established. In many cases, there is still room for improvement to facilitate exchange of information between the agencies involved and to reduce duplication and conflict. As sessment It was reported that there are, currently, no significant problems in China or the Republic of Korea (apart from the smuggling out from the Republic of Korea of amphetamines), and that the problem with narcotics in Viet Nam has been contained. In other countries or areas, there has been little recent change, apart from some trend towards polydrug abuse. The drugs of major concern vary as between amphetamines (Japan), heroin (Macao), heroin and opium (Hong Kong, Malaysia and Singapore), opium (Viet Nam) , psychotropic and heroin (Australia), and psychotropics (Philippines). Use of inhalants by the very young is emerging as, at least. a potential problem in a number of countries.

- 5 -

In Australia, Hong Kong, Malaysia, the Philippines and Singapore, formal data collection systems are well established. In other countries or areas, less formal systems are used to assess the situation. In every country or area, a need was identified for further improvements in data collection and monitoring. Some specific suggestions were made about information requirements. It was reported that very rarely were assessment studies made on drug related health problems. All countries or areas indicated that available information is used for purposes of developing and reviewing policies, strategies and programmes. Prevention and control programmes In all countries or areas, activities include control of trafficking, treatment and rehabilitation of drug users, and education programmes. The extent and form of treatment and rehabilitation programmes vary considerably, particularly in the balance between the involvement of law enforcement agencies with compulsory detention and treatment, and the emphasis on voluntary participation snd outpatient care. In most countries or areas education is focused on enhancing awareness of the dangers associated with the non-medical use of drugs, but there is also emphasis on alternatives to drugs and community development in a number of countries or areas. Nowhere or was there satisfaction with the level of involvement of medical practitioners, or even of paramedical workers. Similarly, although a start has been made in developing training programmes, tra1n1ng programmes are seen to be very inadequate everywhere for all levels of workers. General Although at national level a number of specific priorities were mentioned, it was indicated that there is a need for better information to be available and that, for one purpose or another, more resources are required. For the Western Pacific Region, there was general agreement that assistance with the development of data bases, and the promotion of exchange of information between countries, are priority requirements.

Most countries/areas appear to have nothing but very general goals. Some have specified strategies, or identified targets to be addressed e.g. Hong Kong: intensive treatment and rehabilitation of young addicts but only Viet Nam has a quantified target - to eliminate drug dependence by 1990. saw them

All countries or areas agreed with the proposed regional targets and Most agreed 8S consonant with their own policies and priorities. that the targets would be totally achievable by 1989.

- 6 -

5.

HEALTH PERSPECTIVE ON DRUG-RELATED HEALTH PROBLEMS

5.1

Area of interest and terminology

In dealing with the topic, it was found that a clarification of the areas of interest of the Working Group was required. The drugs of concern include, potentially, all psychoactive substances, including alcohol and tobacco, but particularly those substances which are being used illegally and are currently causing concern in the countries or areas represented: heroin, psychotropics generally, cough preparations, amphetamines, cannabis, inhalants, etc. Drug dependence was prescribed as the focus for attention. However, it was found that this term is used differently by different people and not in strict accord with the WHO definition (e.g. ICD9-304). In a number of countries or areas, use of certain drugs is considered sufficient cause for intervention without requiring that the criteria of the definition of drug dependence (e.g. the presence of compulsion) be fulfilled. It was also proposed that drug dependence may be considered a pattern of behaviour (a behavioural syndrome) rather than being a health problem in its own right; drug dependence is not always accompanied by significant impairment of wellbeing; on the other hand many drug users who are not drug dependent experience significant impairment of health, particularly in the form of specific health problems. It is clear that, by comparison with sporadic or infrequent use, frequent or regular use of drugs is more likely to be associated with both drug dependence and the risk of experiencing drug-related health problems. Some of the specific drug-related problems to which reference was made are deaths from drug overdose (accidental or suicidal), sudden death from sniffing, respiratory problems from chronic cannabis smoking, hepatitis and septicaemia (infections through injections). The group remained divided on the matter of terminology, although it was clear that there is a need for clarification of the issues highlighted. 5.2 Target for action

The need for targets for action to be identified and measured, if relevant policies and programmes are to be developed and evaluated, was highlighted. However, after considerable discussion, a division of opinion still remained as to whether prevention of drug dependence should be the only goal or whether minimizing of drug-related problems (perhaps including drug dependence as one of those problems) was a more appropriate health goal. It was agreed by most participants that the prevention or reduction of drug abuse (i.e. illegal drug use), the minimization of drug-related problems, and the treatment and rehabilitation of drug dependent persons are each relevant if the goal is to promote the greatest possible well-being of the individual and the community.

- 7 -

5.3

Health perspective

The need to clearly differentiate the health perspective from the perspective of other sectors was also generally acknowledged, it being acknowledged that there will be an overlap and that the development of linkages between the different perspectives is essential. A complexity of factors was seen to be involved in determining non-medical use of drugs and in linking drug abuse to drug problems in individuals and societies. The necessity to differentiate between

association and cause-effect relationships was also emphasized. It W8S agreed that drug abuse is often a symptom of more serious, or more general, problems. In developing policies and programmes, it was seen to be important to know what level of risk of harm is associated with specific patterns of drug use and to take into account both positive and negative effects of interventions. "It was proposed that it is the responsibility of health workers to make residual drug use (i.e. that which is left after attempting to prevent drug abuse) as safe as possible. This was not strongly supported by all participants. It was, however, agreed that it is essential, regardless of terminology or goals, that efforts be taken to ensure that psychotropic drugs are used wisely, and that general health workers should become more sensitive to human problems and less reliant on offering chemical answers to such problems. Limiting the use of pharmaceuticals will contribute in many ways to reducing drug problems. 5.4 Relations with other disciplines

On the basis of these considerations, the value of cooperation and coordination of health and other disciplines (e.g. law enforcement, education, social welfare) was reviewed. It was concluded that there is considerable scope for beneficial collaboration. Much is to be gained by pooling information. At the working level, cooperative efforts will almost always improve results, in terms of better outcome for the drug user as well as in minimization of drug-related health problems. However, caution needs to be exercised by health workers to ensure that their identified goal is not compromised by such activity. In particular, there was discussion about whether, and with what justification, drug dependent persons might be forcefully detained or treated. Opposing views were expressed invoking, on the one hand, the concept of drug epidemic and comparisons with quarantine procedures and contrasting, on the other hand, the general principles governing compulsory treatment of persons with mental illness and the rights of individuals to pursue destructive life styles. No conclusion was reached. The implications of international treaties and of national laws relating to drugs of dependence were reviewed. Laws vary with the country but, inevitably, they have a vital place in the prevention and control of drug dependence.

- 8 -

6.

ASSESSMENT, INFORMATION AND MONITORING

6.1

Assessment rationale

In planning prevention and control programmes in drug dependence, there is a need to assess the nature and extent of drug dependence (and drug-related health and social problems) as well as the available resources to cope with it. This information will enable planners to develop adequate and appropriate responses and strategies. The Group noted that several countries or areas in the Region have initiated data gathering (assessment) activities. However, more often than not, they are not pursued systematically. The importance of gathering reliable data was emphasized, as only valid assessment information will be beneficial to planners. 6.2 Types of data

The Group reviewed the various categories of data that need to be collected. It was pointed out that information regarding the use, the drug, the ill-effects of its use, the problems encountered by the user as a consequence of use, as well as psychosocial and environmental interrelationships, need to be ascertained. 6.2.1 Information on the user

The Group considered information on incidence and prevalence rates as well as characteristics of the users to be essential information. 6.2.2 Information on the drug

The Group considered information on the types of drugs used and their patterns of use as well as data on availability to be essential information. It was recognized that information on composition (particularly of illicit "street" drugs) and bioavailability data are useful though not essential information. 6.2.3 Information on ill-effects and health-related consequences

The Group expressed concern that at present, very little, if any, emphasis is being given to collecting data on drug-related health problems and on wellbeing. It was acknowledged that, to date, data collection efforts have emphasized the identification of the user and the drug, rather than health-related issues (some of which are difficult to assess). The Group urged that efforts be made to develop appropriate assessment technologies for the identification and analysis of drug-related health and social consequences.

6.2.4

Information on environmental factors

The Group felt that this is useful information. However, only particular data (e.g. family, living conditions) which have been demonstrated to have implications in the causation of drug dependence or in the outcome of interventions should be collected.

- 9 -

6.2.5

Laboratory analytical data

The Group recognized that modern laboratory methods allow the generation of valuable information about drug use and should, whenever possible, be collected. It was emphasized that laboratory assessment techniques are only tools which generate information on use. They should not be considered on their own, but be seen within the context of a total data gathering system. The Group reviewed the various laboratory techniques available, including recent developments in the analytical field. It was felt that, within the context of the Western Pacific Region, it is more important to ensure the development of reliable and reproducible techniques than sophisticated procedures except for those laboratories which have high levels of technology. It was emphasized that laboratories conducting forensic analytical functions must take measures to ensure

quality control. 6.2.6 Information on resources and their utilization

The Group considered that these are useful data, but the consensus was that this information should be considered optional data. 6.3 Monitoring systems

It was noted that the development of monitoring systems, the systematic collection of data relating to drug dependence and drug-related health and social problems at different points of time, adds the dimension of time to the informative system (which is missing from less systematic efforts at data collection). This allows the rates and direction of change to be determined and provides the basis for estimating the nature and extent of future problems. The Group discussed various approaches to monitoring drug dependence. It was recognized that repeated surveys constitute one approach, though it is difficult to implement and is not cost-effective. However, indepth surveys permit the ascertainment of discrete data which cannot be obtained by other approaches. The Group examined the various types of monitoring system that have been developed. Discussion focused on the system of four: event monitoring systems; case monitoring systems; case register systems; and

integrated data monitoring systems. The Group concluded that the types of systems to be developed at the country level should be decided upon by the national authorities, based on their own needs, resources and level of technology. Irrespective of the type of system developed it should be able to fulfil the following functions: (1) (2) (3) determine the incidence, prevalence and characteristics of drug users in the community; measure continuously the trends and the serious consequences of drug use; determine and describe groups at risk of those consequences;

- 10 -

(4) (5)

determine how and to what extent community agencies are used to deal with problems associated with drug dependence; assess existing efforts and evaluate their impact in the prevention and control of drug dependence.

The Group emphasized that information on drug dependence is of value to both health and enforcement authorities. For this reason, it is essential to remove as far as possible any obstacles to the free flow of information between them. Every effort should be made to integrate both data sets. 6.4 Regional data bank on drug dependence and related health and social problems

The Group noted that in 1980, the Regional Workshop on Psychotropic Drugs had suggested that countries in the Region should cooperate to the fullest possible extent in eXChanging information on psychoactive drugs. The Group reviewed the paper prepared for the Regional Office entitled "Establishment of a regional data centre on drug dependence for the Western Pacific".

The Group stated that data obtained from various countries constitutes a valuable public resource that cannot easily be duplicated. As such, it is essential that the data be used to the fullest extent. Furthermore, national data sets are available to form a regional data bank, and this will greatly expand the types and numbers of observations covering a wide array of social conditions, and hence allow the conduct of a more comprehensive and definitive analysis of drug dependence and related health and social problems. It was pointed out that secondary analysis of a series of comparable data sets from different points in time provides one of the rare opportunities for the empirical description of long-term change. Such an analysis would allow not only researchers but also regional policy and programme planners to gain a more objective and wider perspective of drug related health and social problems. The regional data centre would also be in a position to stimulate and support the refinement of national data gathering and analytical activities as well as act as an "early warning system" for countries or areas. After extensive discussion, the Group strongly recommended that, in the near future, the WHO Regional Office for the Western Pacific should establish a regional data centre in conjunction with the WHO Collaborating Centre for Research and Training, University of Science, Penang, Malaysia.

- 11 -

7.

PREVENTION AND CONTROL OF DRUG DEPENDENCE IN PRIMARY HEALTH CARE

7. I

Rat ionale

The concept of primary health care has been shown to playa positive role in countries or areas where it has been applied. Comprehensive primary health care, which normally has community participation, should include not only maternal and child health, control of communicable diseases, nutrition, etc. but also mental health. It is felt that to achieve the ultimate goal of health for all by the year 2000, the concept of primary health care needs to be applied in the management and prevention of drug dependence, accepting the situation as a public health problem. WHO has already developed a manual on primary health care in the prevention and management of drug dependence. It needs to be evaluated and then applied on a wide scale, to COver many member countries. It is hoped that, in the application of this concept, primary health care workers (PHCWs) would be involved in the following activities: (1)

preventive health education in areas of drugs and drug dependence; early identification of cases of drug dependence; identification of groups at risk; treatment of uncomplicated cases; management and follow-up of certain cases.

(2) (3) (4) (5)

There is no doubt that, with community participation, the above list of activities can be integrated into the present system of comprehensive health care. It has to be acknowledged that the tra1n1ng of the primary health care workers would vary from country to country depending on the different situations and should be developed according to the various local needs. 7.2 Prevention

Little evidence is available which would indicate that the prevention of drug abuse merely through information on drugs is useful, especially in the setting where it is most commonly undertaken, namely, the classroom. In fact, some evidence even suggest that such education effectively increases the risk of experimentation with drugs since risk-seeking

behaviour, which is characteristic of adolescents in many societies, would be specifically directed towards experimenting with drugs once the risks involved are pointed out.

- 12 -

However, there are sOme preliminary data that education on drugs may have a positive effect when done in the framework of education towards responsible decision-making. This approach will need careful development, implementation, strengthening and evaluation. Hence, the simple passing on of knowledge on the dangers of drugs, especially in the classroom, cannot be advocated. However, preventive education efforts in settings other than the school may need special attention, as pointed out by a recent WHO Advisory r,roup.l The primary health care setting may be one such setting for such intervention. 7.3 Management of dependent persons

From the point of view of health care, the factors needed for the care of dependent persons are identical with factors which are known to have a positive influence on outcome in other diseases. It is noteworthy in this context that most of the studies on which the following list of needs is based did not employ measures of health (i.e. wellbeing according to WHO's Constitution) but mainly involved the use of abuse patterns as outcome criteria. The following were identified as health needs of dependent persons: (1) (2) The availability of the drug should be low (and the cost high). There should be a strong community pressure upon him (by relatives, elders, other ex-addicts, police, etc.) to give up or reduce drug intake. His family cohesion should be maintained. His family should be given education on drugs and dependence. Long-term support by staff should be given to his family. He should be employed or in school. He should be detected and an intervention should be undertaken early. He should be treated by optimistic staff and respected by the staff. Treatment should be available as close to his home as possible. Contingency contracting should be part of the intervention (patient-staff, patient-relatives, patient-employer). Long-term outpatient follow-up should be organized.

(3) (4) (5) (6) (7) (8) (9) (10) (11)

lWHO Project on the Development of Strategies and Guidelines for the Prevention of Drug Dependence, MNH82.53.

- 13 -

(12)

As many dependent persons as possible in his community should undergo detoxification and treatment together with him or within less than six months. Family therapy sessions should be organized for his family. He should be offered methadone maintenance (under certain conditions in heroin dependence).

(13) (14)

It is obvious that, with the exception perhaps of the last two, all the needs of dependent persons can be met by primary health care staff. Most of those needs are social in nature and at least require intensive and maintained social contact with the dependent person and his family. Primary health care, whenever it has the social connotation implied in its philosophy, would therefore appear to be in an ideal position to fulfil the health needs of the dependent persons and improve the outcome. At the same time, work in the field of dependence may help to develop in the primary workers the sense of social responsibility and the communication skills necessary to fulfil the social role envisaged by the primary health care philosophy.

B.

ROLE OF COORDINATION AND COLLABORATION AT GLOBAL, REGIONAL AND NATIONAL LEVELS

One of the important areas of activities of the WHO global drug dependence programme is collaboration with countries Or areas to promote policy formulation and to strengthen collaboration and coordination between countries through implementing a series of interregional programmes. B.l Collaboration with countries or areas to promote policy and programme development

Six regional and interregional workshops have been held with the objective of bringing awareness concerning the problem of drug dependence to decision-makers and to people working in this field. Representatives of the countries who participated have discussed the major issues concerning drug abuse in their countries, its assessment, the nature and extent of the

problem, treatment and also policy formulation and coordination and collaboration between neighbouring countries or areas. National coordination groups or committees on drug dependence have been established in a large number of countries. These groups sometimes report to ministers of health, or in some instances, prime ministers, and

deal specifically with drug dependence. It was noted that a wide variety of groups and diverse variety of mechanisms have been used. WHO has provided support towards the development or strengthening of coordinating activities.

- 14 -

The collaboration and coordination between WHO, other specialized agencies and United Nations agencies concerned with drug abuse is an important component in developing international strategies for prevention

and control of the problem. 8.2 Co llaborat ion with organlzatlons 0

ther United Na tions agenc ies and non-govermenta 1

Close collaboration and coordination has been established over the

years between WHO and the United Nations Division of Narcotic Drugs, International Narcotics Control Board, ILO, UNESCO, FAD and also with Non-Governmental Organizations, particularly International Council on

Alcohol and Addictions. aspects in this field.

WHO has contributed to the United Nations Narcotic

Commission meeting each year, including an annual report and to the International Narcotics Control Board as a technical adviser on health

Ad hoc interagency coordinating meetings have been held regularly, twice a year: one in February during the United Nations Narcotic August~

Commission Meeting, and the other in

To enhance collaboration at the international level in the field of research and training on drug abuse and dependence, WHO has designated centres of expertise as WHO cOllaborating centres at the global level. They serve as active repositories of skills and develop methods for use in national and international programmes. They also assume an important role in research, based on individual country and regional needs.

Five WHO collaborating centres have been designated, specifically in the area of research and training on drug dependence and alcohol-related problems. These are the National Institute of Drug Abuse, USA, Addiction Research Foundation, Canada, Institute of Psychiatry, Mexico, National Drug Research Centre, universiti Sains Malaysia, Penang, Malaysia, and

Chulalongkorn University, Thailand. Two other centres are under consideration for possible deSignation. In addition, there are other WHO designated Collaborating Centres which deal with the overall field of mental health, including activities in the field of drug dependence and alcohol-related problems. 8.3 Collaboration at national level Alcohol and drug problems are multifaceted and require a government response involving the participation of many agencies and sectors. Government policies and programme implementation in drug and alcohol areas need to be coordinated to promote interagency cooperation and efficacy. The suitable means of coordination and interagency cooperation

may vary depending on the legislative or administrative basis.

They may

take the form of either a drug or alcohol commission, a narcotic board, an interministerial or interdepartmental committee, or a section in the ministry or department of health. Factors contributing towards the

usefulness and effectiveness of such coordinating mechanisms are: level government recognition; the government. strong political support;

high

adequate funding

to carry out the mission; high level and respected memberShip; public awareness and support; and prominent public visibility and priority within

- IS -

The country's legislative or administrative basis for the

establishment of coordinating bodies may include any of the following, singly or in combination: legislation for control of drug abuse; specified comprehensive drug abuse programme goals; specified

comprehensive alcohol programmes goals; international drug control treaties.

and laws implementing the

A variety of coordinating mechanisms have been developed in the participating countries (see country profiles - Annex 4) and have been found useful although, in some casps, in need of further development.

9.

CONCLUSIONS

9.1

Evaluation of the meeting

It was felt that the meetings of the Working Group have achieved the objectives outlined to the Group at its commencement of its session. 9.2 Goals and strategies There was considerable discussion on the nature of the major problems

related to narcotic and psychotropic drugs. The present terminologies used in the field were discussed. Some participants felt that the use of the concept, or the phrase, "prevention of drug dependence", did not identify accurately the targets for action by health workers, the setting of goals, the development of programmes or the evaluation of success. The alternative offered was "minimizing drug-related health problems". Several other participants felt that the existing terminology was acceptable. The Group deliberated on the possible goals of health intervention. It was emphasized that health intervention formed one element of the broader approach directed towards the stated goal of the prevention of drug dependence. It was felt that the goal of health action should emphasize the reduction of drug use and the minimization of drug-related health problems. It was noted that three main strategies for achieving this goal would be: (1) (2) (3) the prevention of illicit drug use and the reduction of licit drug use; the treatment and management of drug dependent persons; intervention to reduce specific drug related health problems.

The Group discussed whether the principal goal of health activities should be the prevention (or reduction and control) of drug dependence or the minimizing of drug-related health problems. It was apparent that the use of the term "drug dependence" is still variable. However, it was

opined that to date countries or areas have focused more on preventing drug dependence than on minimizing drug-related health and social problems. The current approach of most intervention programmes pursues the strategy of

- 16 -

prevention and control of drug dependence, and does not address the issues pertaining to the ill-effects of the drug on the uSer and his environment. It was suggested that studies should be undertaken to correlate patterns and amounts of drugs used with the frequency and severity of various types of health and social consequences. It was further suggested that the terminology used should be reviewed, based on the outcome of such studies. 9.3 Recent trends

It was reported that in those countries where there is significant use of narcotics and psychotropic drugs, there is little recent change in the level of use or, so far as can be assessed, of drug-related health problems. If anything, there are indications in some countries, of some changes with the major drug - i.e heroin - with a trend towards an increased level of use of other drugs.

9.4

Data collection and monitoring

Although a variety of reporting systems are already in use in a number of countries or areas represented, there was general agreement, both in the country/area profiles and in discussions, that there is a need to improve the data base concerning both the use of narcotic and psychotropic drugs and the health problems associated with that use. It was appreciated that, without adequate data, it is impossible to develop appropriate policies and programmes, or to monitor their effectiveness. In particular, the need for and lack of data concerning the incidence and severity of specific drug-related health and social problems were noted together with indicators of the quality of interventions and outcome.

It was suggested that WHO should support countries or areas in their attempt to increase their capacity to monitor trends. There is also a need to develop a regional data base to obtain the total picture in the Region. This would have value for the evaluation of different approaches as well as being an incentive to each country to develop an effective reporting system. In particular, there would be value in annual reporting of data to the WHO Regional Office for the Western Pacific, on a uniform basis as far as possible. The Group recommended the establishment of a regional data centre and suggested that, in the development of a uniform reporting procedure, the data items and areas of information identified during the discussions should be taken into consideration. In this activity, future collaboration with other regional offices and Headquarters should be considered. 9.5 Prevention and management

A variety of treatment modalities were reviewed. In addition, it was reported that different overall approaches are used in different countries or areas. Nevertheless, it was appreciated that there is always a need for specialist services to deal with serious and difficult cases, and for some people to be especially equipped to act as trainers of health workers and as consultants, offering supervision and support to other workers. However, there will never be enough of such specialists or enough special

- 17 -

services to deal with all the problems or to do all the prevention. In fact, general health workers and primary health care workers especially are in many ways much more appropriate people to undertake both of these tasks. Special facilities suffer many limitations. To date, training, both for specialists and for primary health care workers, has been inadequate in this field. Training which is appropriate to the field of drug dependence will equip health workers with the basic knowledge and experience in behavioural science required to respond more effectively to other programmes. Training at all levels needs to be given high priority. with adequate tra1n1ng and support, primary health care workers should be able to undertake most preventive and management activities. It was agreed that every effort should be made to encourage primary health care workers to contribute towards the prevention or minimization of

drug-related problems. However, for primary health care workers and all other workers, targets for prevention and the goals of management need to be clearly specified through a process of task-oriented training.

In all interventions, the need to improve the overall wellbeing of individuals should be uppermost. 9.6 Collaboration and coordination

The complexity of factors influencing drug use and the linkages between drug use and drug-related health problems were appreciated, together with the implications that prevention and intervention both need to take this complexity into account. Multifaceted, broad-based approaches are required. Taking these considerations into account, it was emphasized that there is a place for regulatory activity, e.g. restrictions on the availability of specific drugs. Both international treaties and local laws are of importance in this respect. Also, various United Nations and WHO initiatives have been of considerable value in clarifying preventive and management responses, often across disciplinary boundaries.

It was agreed that considerable advantage could often result from collaboration with law enforcement, education and other sectors. The importance of a national coordinating body in the prevention of drug dependence was stressed. 9.7 Regional targets

It was agreed that the aims for most countries or areas should be to ratify the international treaties, to develop information-gathering systems on drug-related health problems so as to identify and develop information and research centre(s), as well as to implement and strengthen communitybased programmes. These aims were considered to be both feasible and achievable.

- 18 -

10.

RECOMMENDATIONS

(1)

It is recommended that WHO should urge Member States to implement

assessment activities to monitor on a continuous basis problems associated with drug dependence in order to provide information as a basis for

developing and evaluating programmes. (2) It is recommended that WHO should urge Member States to develop the systematic collection of information on specific drug-related health problems. (3) It is recommended that WHO should urge Member States to ensure information exchange on a continuous basis between the health, education, law enforcement and other relevant sectors in order to obtain a comprehensive picture of the implications of the use of drugs of dependence. (4) It is recommended that WHO should urge Member States to develop a comprehensive approach to the prevention and management of the drug dependence through primary health care. (5) It is recommended that WHO should urge Member States to initiate or

strengthen training in the prevention and management of drug dependence for

all levels of health workers. (6) It is recommended that WHO should develop programmes for the exchange of information on drug dependence and drug-related health problems, including the establishment of a regional data centre. (7) It is recommended that WHO should initiate and promote programmes to collaborate with countries or areas in their efforts aimed at minimizing drug-related health problems through primary health care as mentioned in recommendations 4 and 5.

(R) It is recommended that WHO should develop and adapt training materials on drug-related health problems for primary health workers. (9) It is recommended that, in view of the constantly changing pattern of drug dependence and the development of new intervention strategies,

follow-up meetings should be convened to assess the implementation of recommendations 6, 7 and 8.

- 19 -

ANNEX 1

LIST OF MEMBERS 1. CHINA MEMBERS Dr Jiang Zuoning Consultant Psychiatrist Deputy Director of An Ding Hospital Beijing Dr Chi-yan Sam Assistant Director of Medical and Health Services Medical and Health Services Department Sunning Plaza 6/F., 10 Hysan Avenue Hong Kong Dr Takemitsu Hemmi Professor School of Health Sciences University of Tokyo 7-3-1, Hongo, Bunkyo-ku Tokyo Dr Maria Manuel Pais Rodrigues c/o The Director Medical and Health Services Caixa Postal 473 Macao

HONG KONG

JAPAN

MACAO

MALAYSIA

Dr Abdul Aziz Abdullah Consultant Psychiatrist General Hospital Kuala Lumpur Dr Rey M. San Pedro Chief Treatment and Rehabilitation Division Dangerous Drugs Board 6th Floor Tuazon-Gonzales Bldg. 356 Solana Stree t Intramuros

PHILIPPINES

Manila

- 20 -

Annex 1 PHILIPPINES (cont.) Mr Romeo J. Sanga Chief Control Regulation and Intelligence Division Dangerous Drugs Board 6th Floor Tuazon-Gonzales Bldg. 356 Solana Street Intramuros

Manila REPUBLIC OF KOREA Dr Kang-Kyu Park Head Department of Special Therapy National Mental Hospital No. 20-1, Junggog-dong Seongdong-k u Seoul Dr Teo Seng Hock Director Woodbridge Hospital yio Chu Kang Road Singapore 1954 Mr Ngo Gia Truc Director

SINGAPORE

VIET NAM

Depa rtmen t 0 f Pha rmac y Ministry of Health Hanoi

2.

OBSERVERS Colonel Franklin Z. Littaua Chief Drug Intelligence Group and Secretary-General Drugs Intelligence Coordinating Comnittee Fort Bonifacio Metro Manila Dr Jose Monteiro Jr. c/o The Director Medical and Health Services Caixa Postal 473 Macao

- 21/22 -

Annex 1 3.

CONSULTANTS Dr L.R.H. Drew Senior Adviser Alcohol and Drug Dependence Department of Health Canberra Australia Dr viz Navaratnam Associate Professor and Director National Drug Research Centre Universiti Sains Malaysia Minden, Pulau Pinang Malaysia

4.

SECRETARIAT Dr A. Arif Senior Medical Officer Division of Mental Health World Health Organization Ceneva Dr H. Sell Regional Adviser in Mental Health WHO Regional Office for South-East Asia New Delhi Mr H.S. Dhillon Chief Human Resource Development WHO Regional Office for the Western Pacific Manila Dr 1. Ceizer Regional Adviser Heal th Laboratory Services WHO Regional Office for the Western Pacific Manila Dr T. Morioka Scientist Pharmaceutical Drug Policy WHO Regional Office for the Western Pacific Manila Dr N. Shinfuku (Operational Officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila

- 23 -

ANNEX 2

OPENING SPEECH OF THE REGIONAL DIRECTOR FOR THE WORKING GROUP ON THE PREVENTION AND

CONTROL OF DRUG DEPENDENCE MANILA, 28 JUNE TO 4 JULY 1983

Distinguished participants, Ladies and C,entlemen,

It gives me great pleasure to welcome you today to the WHO Regional Office for the Western Pacific to take part in this Working Group on the Prevention and Control of Drug Dependence. As you know, drug dependence has been a serious and long standing problem in many countries of the Western Pacific Region. Recently, however, the situation has deteriorated, reflecting the rapid socioeconomic and cultural changes that are taking place in Member States. There has been a further spread in the use of psychotropic drugs as well as opiate derivatives and also an increasing tendency towards multi-drug abuse. Drug abuse among adolescents is posing a particularly alarming problem in many countries. The Regional Office has, for many years, recognized the importance of the health implications of drug addiction and has undertaken several activities in relation to prevention and control of drug dependence. The Working Group on the Application of Laboratory Methods in the Surveillance/Epidemiology of Drug Dependence, held in Manila in 1978, recommended that a working group be held every two years to review the progress achieved and the difficulties encountered in the management and control of drug dependence in countries of the Region. The Regional Workshop on Psychotropic Drugs, held in Manila in 1980, assessed the consumption and abuse of psychotropic drugs, reviewed measures taken by countries in the management, manufacture, distribution and sale of

psychotropic drugs, and called for the continued monitoring of the situation. The Working Group which i" starting today is thus a continuation of our past efforts in the field of drugs and will provide a basis for our future activities.

I should like to express a few ideas in connexion with some of the salient points you will be discussing during this meeting.

- 24 -

Annex 2 First, as you know, WHO is now focusing all its efforts on the achievement of the goal of "health for all" and it has decided that primary health care will be an essential vehicle in the attainment of that goal. The prevention and control of drug dependence should be conceived as forming an essential component of primary health care activities and should thus be integrated within the overall efforts of the Organization. Consideration must be given to such issues as early intervention, community

participation and the involvement of other sectors and disciplines in activities directed towards the prevention and control of drug dependence. After all, the problem of drug addiction is much more than the medical problem of a drug-dependent individual. Various socioeconomic and cultural factors are also involved, and the health sector must therefore act in close coordination with other related sectors at national, district and community level if its drug policies are to be successfully implemented.

Second, implementation of a realistic and successful programme will require a thorough evaluation of the situation. An up-to-date review of the nature, extent and trend of the problems in countries of the Region would provide a sound basis for future action. Such a review should take into account any constraints encountered" with regard to report'ing systems,

and the restrictive measures and monitoring system·s applicable to cases of drug abuse. Third, effective measures for the prevention and control of drug abuse will require the close collaboration of neighbouring countries. One of tbe Objectives of this Working Group will be the formulation of ways and means of improving the exchange of information and experience in drug abuse control among the various experts in countries of the Region.

The establishment of some kind of mechanism will be of great benefit to Member States. I am gratified to note that the agenda for this Working Group includes all these important areas and no doubt in the course of your deliberations you will be formulating guidelines on the necessary action to be taken by Member States as well as by WHO for the prevention and control of drug dependence. All the members of this Working Group are distinguished experts in this field and I look forward, therefore, with keen interest to receiving the results of the deliberations and the recommendations of this Working Group. Allow me in conclusion to express my gratitude to Dr Les Drew, Dr Viz Navaratnam, WHO consultants, Dr Awni Arif, Senior Medical Officer from the Division of Mental Health, Headquarters, and to Dr Helmut Sell, Regional Adviser in Mental Health from the WHO Regional Office for South-East Asia, for their assistance in the preparation and conduct of

this meeting. I wish you all an enjoyable stay in Manila. Thank you.

- 25/26 -

ANNEX 3

AGENDA 1. 2. 3. 4. 5.

Opening ceremony Objectives of the Working Group and adoption of agenda Presentation of country profiles Health perspectives of drug-related problems Assessment, information and monitoring system

6. 7. 8. 9. 10. 11. 12.

Prevention And management of drug-related problems by health workers Coordination and collaboration Health for all by the year 2000, realistic goals concerning drug-related health problems Other issues Formulation of recommendations and adoption of the report Feedback and evaluation Closing ceremony

- 27 -

ANNEX 4

PROFORMA FOR SUMMARY OF NATIONAL PROFILE ON PREVENTION AND CONTROL OF DRUG DEPENDENCE

A.

Background (1) (2) Name of country Give a brief description of your national drug control structure.

B.

Assessment (1) Briefly describe the nature and extent of drug abuse and related problems. (please provide information on the trends noted over the last few years in respect to rate of abuse. substances being abused, types of persons involved, consequent health and social problems noted) How is information on drug abuse and related problems generated and is there any attempt to continually assess the situation? What kinds of assessment studies on drug-related health problems are being carried out in your country? Are there a national/state/city monitoring system(s) for drug-related problems? (Please describe the system)

(2) (3) (4) (5)

IS this information utilized in the development of strategies, policies and programmes for the prevention and control of drug dependence and how? How can the present system be strengthened/improved?

(6)

c.

Prevention and control programmes

(1)

Describe your country activities in the prevention and control of drug dependence. (Please give information on types of treatment/rehabilitation programmes; approximate capacity, early intervention programmes, community education programmes, etc.) Are medically qualified persons working in health care setting involved in the prevention and control of drug dependence?

(2)

.•• if "yes" please describe their activities • •• • if "no" please indicate whether it is feasible to get them involved and describe what.you envisage their roles to be.

, - 28 -

,

J I

Annex 4

(3)

Are paramedical primary health workers (or Basic Health Workers) involved in the prevention and control of drug dependence? ••• if '~es"

please describe their activities •

•• • if ''no'' indicate whether it is feasible to get them involved and describe what you envisage their roles to be. (4) Briefly describe the types of training programmes that exist in your country for personnel involved in the prevention and control of drug dependence.

D.

Genera 1 (1) What do you see as priority needs for the future for ••• your country .•• the Western Pacific Region (2) (3)

What are the current problems and constraints in the implementation of prevention and control programmes? What "new" social and health drug-related problems do you see emerging in your country?

(4)

Are there any national targets established for the prevention and control of drug dependence. If '~es"

- briefly describe them.

(5) (6)

Do you consider it feasible for the regional targets outlined in the working paper for item 8 as achievable? (Please comment) Do you consider that the regional targets are in consonance with your national targets or in cases where there are no national targets, can these regional targets form the basis of developing national targets?

- 29 -

Annex 4

PROFORMA AND SUMMARY OF COUNTRY AND AREA PROFILES

AUSTRALIA National drug control structure A National Committee of Ministers and National Committees on Health and Law Enforcement, and other Advisory Bodies. Assessment

Drug abuse and related problems: These mostly relate to psychotropic drugs and older adults. Illegal drug use by the young, of opiates and psychotropics, is also of COncern. Cannabis use is common. Use and problems are not, now, increasing. Causes of concern are death from overdose, hepatitis and criminality. Information is derived from: population and school surveys, reports from police and other officials, and special data collection. Collections are ongoing. Assessment studies on health problems: ad hoc basis. are only occasional and on an

Monitoring systems: treatment services.

as above, and data on people attending government

The data collected is used: for policy development and programme review. Further data system need to be developed. Prevention and control programmes Supply control is through customs, police and monitoring systems. Demand control is through a National Drug Education Programme and community development. Treatment is provided by government and voluntary agencies. Compulsory treatment is not favoured. Medical practitioners are only rarely involved. Most ignore the problems. Better training in pharmacology and behavioural science would help. Paramedics are slightly more likely to get involved. Training is mostly "in-service", with some short courses through government services and at tertiary institutions.

- 30 -

Annex 4

General Priority needs for Australia - more and better trained trainers for health workers, and for the Western Pacific Region - better information system focusing on health problems. Difficulties. relate to the fact that drug use depends on many factors which defy change. General reliance on chemicals and technology needs to be reduced. Regional targets are feasible but unlikely to be fully achieved. have already been achieved for Australia. They

CHINA National drug control structure Bureau of Drug Control in the Ministry of Health with Sections (or Division) of Drug Control in each Province or City, and Law Enforcement Departments (nationwide). Assessment Drug abuse and related problems. there is no narcotic drug abuse, but over prescription of psychotropic drugs leads to abuse. Information is derived from every health unit and sent to health administration. A central board of psychotropic substances is to be set up. Assessment studies on health studies have not yet been conducted. A monitoring system is soon to be set up. Reporting and monitoring with needs to be integrated with primary health care. Prevention and control programmes Ir. 15-19 August 1983, there will be a workshop regarding drug problems, then a nationwide research unit will be formed and be an advisory body to the Ministry of Public Health. Medical Practitioners. only physicians and psychiatrists are involved now. Later, doctors working in the grassroot level should be involved. This is feasible. A training course for physicians is to be tried. Later, such training will be popularized throughout the country.

- 31 -

Annex 4

General Priority needs, for China, the proper or rational use of hypnotics or psychotropic drugs; for the Western Pacific Region, narcotic drugs as well as some other dangerous drugs. Overuse of minor tranquilizers may become a

problem.

Regional targets are considered to be feasible and consonant with

national targets.

HONG KONG

Area drug control structure, Action Committee Against Narcotics (NARCAN) a policy decision body with appointed members and representatives of government departments. Commission for narcotics - coordinates actlvltles for government

departments and directs day-to-day activities. Assessment

Drug abuse and related problems, By end of 1982 - 41 906 drug addicts· recorded; 3464 new addicts in 1982. 95% - primary drug heroin; 6.7% female, but this is increasing; and most are prostitutes, hostesses or bar

girls. Persons under 21 have increased at a rapid rate in recent years and use heroin by injection. Information derived from~

Registry on Drug Abuse (CRDA).

reports from 40 institutions to the Central An ongoing collection.

Assessment studies' CRDA issues reports every six months. Special studies are made to meet requests. eRDA has a national monitoring system. The data is used in developing strategies, policies and programmes. A system to record movements of addicts (e.g. migration and deaths) needs to be devised. Prevention and control programmes

There are three treatment progra~es catering for 13 000 addicts daily - Compulsory Programme of Correctional Services Department; voluntary inpatient programme of SARDA and voluntary outpatient methadone programme (medical and health department). There is also a community education programme. Medical practitioners work in methadone clinics and as senior medical

officers in charge of regions. Numbers of the Auxiliary Medical Services (AMS) are front line staff with addicts. Training of AMS is provided by doctors and through refresher courses.

- 32 -

Annex 4

General Priority needs for Hong Kong - control of multi-drug use; for the Western Pacific Region - coordination and information. More information and research studies are required to improve programmes. New problems may develop among younger age groups, and there may also be new health problems. The target for special effort is intensive treatment and rehabilitation of youth. Regional targets are considered to be feasible, achievable and consonant with area targets.

JAPAN National drug control structure National and Local Centres for the Control of Stimulant Drugs under the Minister of Health and Welfare. Assessment Drug abuse and related problems: lacquer thinner sniffing in low teens (starting in 1968) and methamphetamine injection by persons in 20s and 30s noted since 1969. 5-10% never recover from toxic psychoses. Information is derived from all ministries and gathered by the Prime Minister's Office. The Ministry of Health and Welfare organizes study groups. The data are used in policy formulation, etc., but are inadequate due to budgetary constraints. Prevention and control programmes Treatment is mainly provided through the correctional system. Probation officers are active on this issue. Education is mainly through mass media. Probation officers have regular training programmes. General educat~on)

A priority need is for drug education (in combination with alcohol in and out of schools.

- 33 -

Annex 4

MACAO National drug control structure The Police Corporation is responsible for apprehension and control. Judiciary police are responsible for investigation. The Health Department only controls drugs for therapeutic and research use. A Tribunal is responsible to determine punishment for traffickers. Assessment

The average drug abuser is 30 years old; heroin is most commonly used, sometimes in association with psycho tropics or LSD. Most addicts belong to the lower socia-economic level, generally among delinquents, unemployed. Information Centre (CRS). 1S

derived from reports from the Social Recuperation There is no effective monitoring

Epidemiological data is lacking. system.

Prevention and control programmes The CRS, for treatment and rehabilitation of drug addicts, has 50 beds (male) for voluntary admissions and persons committed by the Tribunal (traffickers who are also addicts). Admission is for a fixed term of six months, but volunteers are discharged on request. Treatment is detoxication followed by occupational therapy. There is no other prevention and control programme, nor any training programme, because of the absence of persons equipped to implement them.

Ceneral Priority needs for Macao are primary health care with technical support; control of import, prescription and trade on drugs; linkages between departments involved with drugs and drug problems. Priority needs for the Western Pacific Region' exchange of information, technical support, dissemination of information about new advances. An area target is to establish an epidemiological reporting which enable priorities to be set for intervention.

Regional targets are feasible and achievable and consonant with territorial goals.

- 34 -

Annex 4

MALAYSIA National drug control ~tructure

Cabinet Committee chaired by the Deputy Premier assisted by a National Coordinating Committee for the Prevention of Drug Abuse (Chairman Secretary-General of the Department of Home Affairs). Assessment

Previously (early 1960s) the problem was opium abuse by the elderly population (Chinese). Now the problem is use of heroin by people under 30 years of age, by "chasing the dragon", with consequent social and economic problems. Information is obtained from records of hospitals, treatment and rehabilitation centres, and police. This is supplied to the National Drug Research Centre, Universiti Sains Penang. There have been no systematic assessment studies thus far. In addition to the National Drug Research Centre, there is a National Operation Centre which updates on a variety of data on a 24 hourly basis. (There are similar centres at State level.) Information has been used to develop policies and programmes in terms of trends revealed - e.g. increased efforts in schools if drug abuse among school children is being shown. An evaluation system is required to assess the objectives and effectiveness of the current system. Prevention and control programmes Preventive drug education programmes, focusing on creating an awareness of 'problem', dangers, etc. have been developed for schools (pupils, teachers and parents) and the community through - National Association for the Prevention of Drug Abuse (PEMADAM). Law enforcement activities to prevent smuggling, trafficking, pushing (with seminar and workshops for staff). Treatment and rehabilitation is offered through four government centres (600 beds), and gazetted detection and detoxication centres in hospitals. PEMADAM provides another 300 beds, and a 3Q-bed day centre. There is mandatory two-year follow-up. Medically qualified people are involved in health education with community and in training of health professionals. Paramedics are also used in these tasks. Many medical officers have received special (four weeks) training, and paramedics and welfare officers receive on-job training (some also get formal training). Enforcement unit has its own training programme.

- 35 -

Annex 4

General Malaysia requires a more coordinated approach, more preventive educstion, evaluation and assessment of poor programmes and mOre flexibility in programmes. Current efforts are hampered by limitations of trained personnel and manpower resources and inflexibility.

PHILIPPINES National drug control structure The Dangerous Drugs Board (DDB) has ultimate policy making, coordinating and implementation responsibilities. The Minister of Health is Chairman, with six other ministerial members and the Director-General of the National Intelligence and security Authority as special adviser. Assessment Since 1974, heroin has been hard to obtain and little used. The drugs of abuse are marijuana, cough preparations, tranquilizer, analgesics and glue, in that order. There has been a fluctuating trend in treatment centre admissions over the last five years but there has been a spread of drug abuse to the country beyond Metro Manila. Most drug abusers are aged 15-21 years (15 males to 1 female). A number of physical, psychological and social effects are associated with drug abuse. Information is obtained by receipt of monthly reports from rehabilitation centres, the Central Screening and Referral Unit (CSRU), and regional coordinators of the nationwide drug abuse assessment programme. Assessment studies are undertaken by the Research Statistics Division of the Dangerous Drugs Board, directed at answering questions of importance for policies and programmes. There is a national monitoring system based on the reports mentioned above, together with monthly reports on drug-related hospital admissions and reports on the illicit drug scene from the control, regulation and intelligence division of the DDB. This information is used for the development, planning and implementation of programmes and projects. The present system could be improved by more adequate funding, and by smoother coordination and collaboration among all the involved agencies.

- 36 -

Annex 4

Prevention and control programmes The DDB has formulated a National Treatment and Rehabilitation Programme for Drug Dependence, focusing on a multidisciplinary team approach, although other modalities (therapeutic community and formal therapy) are also used. There are five residential centres (580 beds, but there is currently much overcrowding). Outpatient programmes are integrated into health centres.

The National Drug Abuse Prevention Programme utilizes mUlti-agency coordination, multidisciplinary cooperation, and community participation in demand reduction programmes - e.g. close collaboration between schools and community. A wide range of activities is promoted. The DDB has a preventive education, training and information division. Doctors and paramedics are used in health centres. They provide assessment and emergency treatment, early identification and case finding, guidance and counselling, and act as resource speakers in panels and discussions. Training is provided by DDB for all personnel contributing to programmes - extending from doctors to Barangay Captains, youth leaders, teachers, school security guards, Vice-Mayors of Metro Manila, middle management, media. forest rangers. General In the Philippines, more funding, more intensive multisectoral efforts, more cooperation with the media, mOre facilities and services, special provisions for drug-related psychoses, training for more health personnel, more research and more evaluation studies; moves towards outpatient treatment and a computerized information system are required. Current problems include absence of penalties for non-compliance with directives of DDB; sporadic application of programmes; drug abuse is not a reportable disease; inadequate funding, etc. New problems could include increased mental disorders, respiratory disease, neglect of personal hygiene, drug-related crimes against property, school dropouts, family rifts and reduced employability due to drugs.

- 37 -

Annex 4

REPUBLIC OF KOREA National drug control structure The Ministry of Health and Social Affairs maintains close links with other government departments and local services. Its Narcotic Division has a Narcotic Section and an Investigation Section. Assessment

There is no current problem with use of narcotics but illegal traffic (international smuggling) of amphetamine has increased recently. Cannabis use increased amongst youth until 1975. Glue inhalation and tobacco smoking, by young males, are new trends.

Information is gathered by local agents of the narcotics division and local health centres, and from special research projects. There have been no specific assessment studies of health problems but, recently, special studies of substance use patterns amongst juveniles have been made. There is no systematized monitoring system. Reliance is placed

on reports from officers and institutions together with obligatory reports from drug dealers (including retail pharmacies). Information is utilized as feedback to workers. More systematized reporting and monitoring systems are required.

Prevention and control programmes Publicity campaigns showing dangers of drug use; rewards for persons reporting illegal drug traffic; education on dangers of drug use for the young. Enforcement of legal controls through the Korea-U.S. Mobile Narcotic Squad. Follow-up of ex-convict •• Doctors and nurses are involved through local health centres and schools. Investigators of Narcotic Division are highly qualified in pharmacy or law. Professional training of narcotic investigators - twice a year. Yearly, special education for school counsellors, school nurses, and local

health centre workers.

- 38 -

Annex 4

General In Korea, there is need for improvement of reporting and research

systems. Currently, there are no special problems but finance restricts the

data system. No new problems are anticipated but, if there adolescent group. IS

one, it will be of

There are no national targets. Regional targets are feasible and achievable and can form the basis for national targets.

SINGAPORE National drug control structure The Department of Home Affairs coordinates all programmes through: the Central Narcotics Bureau (CNB), Police and Customs Division - arrests of drug abusers and pushers and the control of smuggling; the Prisons Department - treatment programmes CNB - compulsory supervision of rehabilitated addicts. Other ministries and voluntary agencies compliment these activities. Assessment

Heroin use has escalated dramatically since 1972 and is now the main problem. The annual number of heroin arrests has dropped from 5682 in 1976 to 2008 in 1982, and only 1 or 5 are now new cases. Most drug offenders are aged 20-24 years, 95% male; most 'chased the dragon'. Almost 50% have records of petty crimes. Inhalant abuse has appeared since 1981. Information is obtained as follows: Ministries of Pome Affairs and Health secure regular returns from their

agencies.

Addiction is a reportable condition.

There is a national computerized monitoring system which, although not comprehensive and fully integrated, gives necessary information. Information is regularly reviewed and is used in development of strategies) policies and programmes.

The system could be upgraded to a fully integrated drug monitoring system.

- 39 -

Annex 4

Prevention and control programmes The Misuse of Drugs Act (1973) provides for action against drug traffickers and for heroin and opium addicts to be compulsorily treated and rehabilitated in Drug Rehabilitation Centre run by the Prisons Department. Admission does not constitute a criminal record. Detoxication is carried

out without replacement therapy. The main stress in the programme is rehabilitation through industrial works. A Day Release Scheme (1979) bridges the gap between control in the centre and complete freedom. Discharge is followed by two years of compulsory supervision. Aftercare is provided by voluntary workers. The Singapore Anti-Narcotic Association (SANA) conducts an intensive community education programme. The Ministry of Education also has an early intervention and prevention programme. There is an anti-drug abuse '~adge

award" campaign for uniformed youth groups. Medical practitioners supervise detoxication and special cases are referred to specialists (including psychiatrists). Doctors are encouraged to prescribe judiciously to notify cases of drug abuse and educate the community. Their contribution is limited by the limitations of their training. Paramedical involvement is mainly in after-care, and preventive

education through SANA. SANA organizes training for its own workers and other interested groups - films and lectures, workshops and role plays, practical assignments and written tests are used. General Priority needs: Singapore requires improved treatment programmes for recidivist addicts; to be alert to any new trends (e.g. use of alcohol and psychotropic drugs) in drug abuse and take corrective action.

Di fficulties:

Financial restraints and shortage of trained manpower; lack of knowledge of causative factors in drug abuse.

Alcohol abuse (with social and health-related problem) may emerge as a new cha llenge. Singapore target is "Health Living Without Drugs". The best strategy is prevention through minimizing involvement of the young in drug abuse. Regional targets are realistic and should be achievable. consonant with Singapore's target. They are

- 40 -

SOCIALIST REPUBLIC OF VIET NAM National drug control structure Ministry of Health controls treatment and drugs used for medical and scientific purposes. Ministry of Interior is responsible for minimizing illicit drug traffic. Ministry of War Invalids and Social Affairs controls rehabilitation and prevention.

In 1975, South Viet Nam had 500 000 addicts. mainly using opium. 85% are 16-35 years old.

Now there are 70 000

Current data is not exact as it relies on health workers in communes whose training and skills are limited (re: records).

Assessment studies rely on data from treatment centres, schools of youth re-education, hospitals, polyclinics and the interior services. The monitoring system depends on coordination and communication up and down the chain of services and across communities - e.g. health stations,

communes and the mass (youth) organizations. Information gained is essential to the implementation of strategy and achievement of our goal. The present system could be improved by strengthening information and monitoring system and improving coordination

between the three involved ministries. Prevention and control programme Education and surveys are carried out widely and are effective in prevention and in case finding. Treatment methods - acupuncture, traditional breathing exercises, gymnastics and medicaments and education

and sctivity - followed by learning handicraft and then working in collectivity. Doctors are involved in hospitals and the special treatment centres. There is no involvement of paramedical primary health care workers. Provincial health schools organize training courses for physicians on prevention and control of drug~, and diagnosis and treatment of mental diseases.

- 41/42 Annex 4

General In Viet Nam, there is a need to strengthen treatment and prevention activities. At regional level, there is need to eliminate illicit traffic in drugs. Currently, there are problems in record-keeping and development of statistical systems. No new problems are anticipated. The national target is to eliminate drug dependence in 1990 (wipe out old addicts, no new addicts). The Regional targets are feasible and achievable. We must have coordinated activity for illicit traffic to be eliminated. The Regional target is consonant with Viet Nam's target.

-

- 43 -

ANNEX 5

LIST OF PAPERS PRESENTED AND BACKGROUND DOCUMENTS

Presented papers' Guidelines for the Working Group Summary of WHO projects and activities in the field of prevention and treatment of drug dependence Classification of drug-related health problems Health issues in socio-environmental context Relationships with other disciplines A review of International Treaties National laws promulgated in relation to International Treaties and their Implications Assessment, Information and Monitoring Systems Laboratory Detection Techniques Establishment of a Regional Data Bank on Drug Abuse in the Western Pacific Region The psychological process of drug dependence, selected cases Towards a public health and comprehensive approach in drug dependency Treatment and rehabilitation of drug dependent persons - an overview Primary health care in substance abuse control Professional training for the minimization of drug-related health problems The role of national advisory, coordinating bodies Health for all by the year 2000 realistic goals covering drug related health problems Aspects of well-being in the treatment of substances abuse Dr N. Shinfuku

Dr A. Arif Dr L. Drew Dr L. Drew Dr L. Drew Dr A. Arif Mr R.J. Sanga

Dr V. Navaratnam Dr V. Navaratnam Dr V. Navaratnam Dr T. Hemmi Dr A. Aziz Abdullah Dr R. San Pedro

Dr H. Sell Dr L. Drew Dr A. Arif Dr N. Shinfuku Dr H. Sell

- 44 -

Annex 5

Background documents Nomenclature and classification of drug and alcohol-related problems: A WHO Memorandum Bull. WHO 59 (2) 225-242 (1981) By: Edwards, G.; Arif A.; and Hodgson, R. Outline for Country Descriptions: Document for the project of Strategies and Guidelines for Prevention of Drug Abuse By: Arif, A. Reports of Advisory Group Meetings - 23-27 February 1981, and 20-24 April 1982 - WHO Project on the Development of Strategies and Guidelines for the Prevention of Drug Dependence. Guidelines for the Assessment of the Treatment and Management of Drug Dependence (Draft) By: Arif, A.; Navaratnam, V.; Klett, J.; and Westermayer, J.

II