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(WP)MNH/ICP/ADA/OOl
ENGLISH ONLY
REPORT WORKING GROUP ON DRUG-RELATED PROBLEMS IN ADOLESCENTS
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION
Tokyo, Japan 25-28 February 1986
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Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines May 1986
NOTE
The views expressed in this report are those of the members of the Working Group on Drug-Related Problems in Adolescents and do not necessarily reflect the policies of the World Health Organization.
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This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the members of the Working Group on Drug-Related Problems in Adolescents, held in Tokyo, from 25 to 28 February 1986.
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CONTENTS
1.
INTRODUCTION " ................ " .................................................................. " .. SUMMARY OF COUNTRY PROFILES ................................................ 10 . . . . . . . . ..
1 2
2.
2.1
Regional perspective •••••••••••••••••••.••••.•••••••
2
2.2 3.
Individual countries/areas
....................................................
3 8
PREVENTION/EDUCATION 3.1 3.2
.. .............. ,. ................ " .................................... .
Situation analysis Guiding principles
....................................................................
8 9
....................................................................
4.
MANAGEMENT/TREATMENT OF DRUG-RELATED PROBLEMS .. .................... .. 4.1
10 10
Situation analysis Guiding principles
.................................................................... ....................................................................
4.2 5.
10 12 12 14 16 16
RESEARCH ................................................................................................ ..
5.1
Current status
............................................................................ ..................................................
5.2 6.
Areas of interest and needs
REGIONAL COLLABORATION 6.1 6.2 Current status possible areas
.......... ,. .................................. .
...................................... for collaboration ....................
16 17
7.
RECOt1M.ENDATIONS •••••••••••••••••••••••••••••••••••••••••••
ANNEX 1 - OPENING SPEECH OF DR H. NAKAJIMA REGIONAL DIRECTOR, WHO WESTERN PACIFIC REGION ••••••• ANNEX 2 - LIST OF MEMBERS, RESOURCE PERSONS, REPRESENTATIVES/ OBSERVERS AND SECRETARIAT
19 21 27
...........................
ANNEX 3 - AGENDA ••••••••••••••••••••••••••••••••••••••••••••••
1.
INTRODUCTION
The Regional Working Group on Drug-Related Problems in Adolescents was held at the Sasakawa Memorial Hall in Tokyo, Japan, from 25 to 28 February 1986. The objectives of the Working Group were as follows: (1) to update and exchange information on drug-related problems in the Region, with particular emphasis on drug-related problems in adolescents; to examine the measures used for the management and treatment of drug-related problems in the Region and to evaluate the effectiveness of those measures; to review the present research activities and determine possible new areas for research on drug-related problems in the Region; to develop guiding principles on measures for preventing drug-rela~ed problems in the Region, focusing on health education and community involvement; to recommend ways and means of developing international collaboration in dealing with drug-related problems, including intercountry training and research in the Region.
(2)
(3)
(4)
(5)
Dr Hiroshi Nakajima, Regional Director of the Regional Office for the Western Pacific of the World Health Organization, opened the meeting. Mr Yoshinori Kobayashi, Director-General, Pharmaceutical Affairs Bureau, Ministry of Health and Welfare, Japan, welcomed the participants on behalf of the host country. The Working Group was attended by nineteen members from twelve countries or areas in the Region, three resource persons from Japan, the
United Kingdom and the United States of America, representatives from the Ministry of Health and Welfare, Ministry of Foreign Affairs, Ministry of Education, Ministry of Justice, National Police Agency, and a number of experts from the host country as observers. Dr Marcus Grant, Senior Scientist, Division of Mental Health, WHO Headquarters, Geneva, participated as a member of the Secretariat. The following nominations were unanimously approved by the participants: Chairman Vice-Chairman Rapporteurs Dr Tomoji Yanagita (Japan) - Dr Douglas Rankin (Australia) - Dr Robert Fisher (New Zealand) Dr Marcus Grant (WHO/Geneva)
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The opening address of the Regional Director, the list of participants and the agenda of the Working Group are attached as Annexes 1, 2 and 3, respectively.
2.
SUMMARY OF COUNTRY PROFILES
2.1
Regional perspectives
The considerable diversity of approaches and experiences among countries/areas in the Region was acknowledged by all participants. The types of drugs causing abuse are different in every country/area. In several contingency countries, heroin is the drug of most concern. In one
country, cannabis, cough preparations containing 10-20% of alcohol solution and some anxiolytic drugs are used. In another, cannabis remains the most widely used, while in yet another, amphetamine continues to constitute a
significant abuse problem. Treatment services and administration of drug control also vary
greatly. Comprehensive drug education programmes for occasional users are actively promoted in many countries and there is cooperation among different agencies and nongovernmental societies. Drug-dependent persons in some countries are compulsorily confined in private or government facilities for treatment. Individuals who request treatment voluntarily may obtain assistance from these facilities. Countries/areas have developed specific programmes responsive to their particular problems. In addition to the fact that each country/area in this Region has its own historical background of drug abuse, it is particularly noted that most of them are composed of various ethnic groups.
Despite all those differences, SOme themes emerged from the country reports which were relevant to the Region as a whole. Many of these are reflected in later sections of this report and in the recommendations of the Working Group. Some countries/areas in the Region have already experienced
considerable success in dealing with drug-related health problems. These include those in which the range of severity of such problems was very considerable. It therefore proved possible during the meeting to identify protective factors which would support the efforts of countries to combat drug problems, as well as risk factors which might make some popUlations more vulnerable. These factors could facilitate planning of the development of future strategies. Administrative bodies for the prevention and treatment of drug addicts are well organized in the Region. The next step could involve facilitating community-based rehabilitation services. Social workers or counsellors for this purpose may need to be trained because community-based treatment
skills are different from the skills required for in-patient treatment.
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Many countries also recognized that drug-related problem can not be viewed in isolation. Not only are they related to problems such as those caused by alcohol and tobacco use, but also to wider health and social problems, particularly those with a behavioural component. In this context, drug problems should be recognized as an aspect of a complicated psychosocial phenomena, in which different substances might become more prominent at different times. The current concern about organic solvents and stimulant abuse was an example of this changing pattern.
It should be noted that tobacco smoking is frequently the first step of drug use/abuse. In some countries, the second step seems to be the sniffing or organic solvents, including petrol. Later in adolescence, many of these young people switch to alcohol or other dangerous drugs. It was therefore suggested by various countries that drug education concerning tobacco and alcohol should also be emphasized. There was ~n emphasis in all countries/areas on the need to take a broad view of prevention and treatment. Different approaches are more appropriate for different circumstances, but the need to establish strong links between prevention and treatment was acknowledged. The role of the health sector has been under-emphasized in the past and was recognized as an essential component in national and international responses to drug-related problems.
All countries/areas indicated the importance of using social and cultural norms to support prevention and treatment efforts. The traditional belief in the supremacy of the family and the cultural group in Asian countries/areas was pointed out as an important protective factor which may not exist in western societies with their strong belief in individualism. Finally, there was a consensus that drug abuse must be seen as a multidimensional dynamic problem that calls for broad community participation and support for its control. 2.2 2.2.1 Individual countries/areas Australia
On 2 April 1985, all Australian governments launched a well funded cooperative and coordinated National Campaign Against Drug Abuse, directed primarily against problems of illegal drug use in the young but including an emphasis on alcohol, tobacco and other legal drugs, and all age groups. Adult drug use and drug problems are diminishing but those of adolescents, although perhaps reaching a plateau, are not yet declining significantly. The major problems, even in adolescents, relate to alcohol and rn1suse of legal drugs. Cannabis use is common and is a cause of concern and contention. Heroin use and use of volatile substances are also of concern, particularly in some cities and among some subgroups. Methadone maintenance programmes are expanding but are a cause of concern because national guidelines are not being followed.
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Australia is emphasizing, as never before, a denland reduction approach and seeking to involve all sectors of the community In a wide range of initiatives designed to minimize drug use.
2.2.2
China
The opium scourge 1n old China (about 10 000 000 addicts) was eliminated in 1952 and narcotic drugs were put under strict and effective control by the Government; at present there are only few cases of drug abuse of sedative-hypnotics, mainly of methaqualone due to inappropriately prolonged use. Among adolescents there is no evidence indicating the abuse
of drugs except cigarette smoking, which is increasing. In recent years China has taken effective steps to contact and collaborate with the international drug control bodies, as a result of which China ratified the two conventions concerning narcotic and psychotropic substances in 1985 and
became a member of the Commission on Narcotic Drugs and International Narcotics Control Board. A Drug Dependence Research Centre was set up by the State Council in 1984 with a view to the study and prevention of drug abuse and the tasks of the Centre assigned by the Government are being implemented.
2.2.3
Hong Kong
There is little recent change in the trends regarding the drug problem; heroin continues to be the most popular drug of abuse involving over 98% of all individuals reported. A well established information and monitoring system is in existence to guide policy decisions and there is a centralized advisory and
coordinating body to deal with all matters relating to drug problems. A multi-modality approach in the treatment of drug addiction has been adopted providing a range of treatment programmes available to those in need. Preventive education and pUblicity programmes are being implemented energetically and have attracted the support of community leaders. Drug abuse among adolescents remains a problem and intensive treatment, rehabilitation and aftercare of young addicts are among the identified goals.
2.2.4
Japan
Abuse of methamphetamine after the Second World War was the first experience of drug abuse in Japan and was followed by abuse of heroin in the 1950s. These epidemics were rapidly halted by comprehensive action, including amendment of legislation, treatment of addicts and information campalgns. However, since the 1970s, the abuse of stimulants has become epidemic again. Abuse of heroin and cocaine is rarely observed In Japan. Abuse of organic solvents among adolescents has been reported Slnce the 1960s. To coordinate the various elements involved in drug control, the Government has centralized countermeasures against drug abuse in the Prime Minister's Office since 1970.
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The Government's action programme emphasizes the importance of preventive education and information activities, and promotion of research on the management and treatment of drug addicts, in conjunction with strict law enforcement.
2.2.5
Macau
Macau presents a major heroin problem among adolescents and young adults that needs to be dealt with in a more appropriate and realistic way.
The need for legislation and law enforcement in this area is recognized. There is a need to open in-patient and out-patient facilities for the treatment of voluntary drug addicts; now under the care of the Health Services. There is a need for more effective prevention and education activities as well as training of skilled staff. The major problems include the lack of facilities for prevention, treatment and after-care of the voluntary drug addict; the lack of legislation concerning drug addiction; and the negative attitudes to drug addiction on the part of an important part of the community. This calls for information education and discussion, as well as collaboration without interference. j
The first priority is legislation. Facilities for the voluntary and mandatory treatment of addicts need to be established, as do programmes of education and prevention in the community (parents, teachers, magistrates, police forces, etc). Training of skilled health and community workers should be initiated. International cooperation and exchange of information and experiences need to be developed, mainly with Hong Kong health workers in the drug addiction area, other countries in the Western Pacific, as well as international organizations like WHO, UNESCO, etc.
2.2.6
Malaysia
The majority of adolescent drug abusers are from urban areas, namely, males between the ages 15-18, who are either unemployed or unskilled workers and have completed lower secondary or at least primary education. The majority (87%) begin drug use between the ages of 15-18 and are heroin abusers (78%). Poly-drug abuse is common. Malaysia has stringent laws on the prevention and control of drug abuse and national law enforcement efforts have been reasonably successful in reducing illicit drug trafficking and availability. Drug dependent persons undergo institutional rehabilitation or non-institutional supervision; an after-care programme is incorporated as part of the programme. The national objective is to provide a comprehensive treatment J rehabilitation and after-care programme to persons afflicted by drug abuse. Drug abusers who have criminal records are managed under a programme run by the correctional services.
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Malaysia places special emphasis on preventive efforts. A preventive education programme has been initiated, using health education and school counselling services as the vehicles for intervention. Community information/prevention efforts have also been initiated ~ith the objective of increasing public awareness. Research has also been given an important priority and is perceived as a support component of policy and programme development. A comprehensive programme of research has been developed and the work has been spearheaded by the Drug Research Centre, University of Science, Penang. Malaysia is committed to regional and international collaboration In drug abuse control efforts and continues to work towards a harmonization of efforts in this field. 2.2.7 New Zealand
New Zealand is a pluralistic society with Maori, European, Polynesian and Chinese composing most of its ethnic peoples. Alcohol, tobacco, cannabis, sedative-hypnotic drugs and heroin, in that order, are the most common drugs of abuse in New Zealand. Adolescents are involved in approximately 27% of all drug offences (excluding cannabis) and 40% of cannabis offences. Solvent abuse, although numerically probably not large, remains a concern because its target population is often most vulnerable to its socially disruptive effects. A developing concern is the illegal manufacture of both morphine and heroin from cocaine in small clandestine laboratories, and the increase in prescription drug abuse. Important strategies focused on both supply and demand reduction include the development of an integrated, interdepartmental national policy for alcohol and drug abuse; development of guidelines for the provision of health care; and targeting of prevention and treatment programmes to specific groups with special programmes. Most importantly, the Government believes that truly effective prevention must begin with children and their families, particularly children at special risk. Similarly, important affiliate persons and groups to the drug abuser - families, ethnic, cultural and religious groups - must be included in all treatment planning. Innovative efforts include therapeutically constructed outdoor programmes, health (including drug) educational programmes in schools, and increasingly specific resources directed to important and relevant sociocultural groups. Resource provision is increasingly through "users pay levies", such as those already in place through New Zealand's Alcoholic Liquor Advisory Council (which is funded by a tax on alcohol beverages). Finally, New Zealand recognizes the great importance of both accurate and appropriate, socio-demographic and clinical information for all prevention and treatment activities, and in this regard is making fundamental changes in its mental health information system. 2.2.7 Philippines
The Philippines is not an opium or cocaine-producing country. Marijuana grows in great abundance in the countryside. There are no heroin addicts but there are other drug abusers. The drugs commonly abused are cough syrup preparations, marijuana and tranquillizers, in that order.
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The Government has a very strong drug prevention and control programme. Vigorous and intensified efforts pursued along this line, both by the government and nongovernmental sectors, have led to the curtailment of heroin abuse. However, because of its geographical location, the country remains a transit point for illicit drug trafficking. The national thrust is to update the Dangerous Drugs Act of 1972 to keep pace with the changing patterns of the drug problem, and further promote and strengthen international cooperation and understanding. 2.2.8 Republic of Korea
According to an epidemiological study, the lifetime prevalence of drug abuse/dependence is low in the Republic of Korea: 0.88% in Seoul and 0.49% in rural areas. This is due to the strict narcotic law and to effective law enforcement by narcotic teams. However, drug abuse among adolescents is a serious social problem. According to a study with middle school and high school students, 16.3% of them have had experiences with drugs. Stimulants, minor tranquillizers and organic solvents are the main substances used. In spite of the Government's policy to ban the sale of these substances, abused drugs are still available. The public needs to be alerted through a nationwide educational campaign, and the school system must develop effective counselling facilities. There is an urgent need for treatment centres for drug abuse. 2.2.9 Republic of Palau
Drug abuse is becoming a problem in Palau. A typical drug abuser is male, 18-30 years old, a school drop out, single, a poly-drug abuser, and usually comes from a disrupted family. He often has been involved with the law and is a potential suicide. Treatment and follow-up rehabilitation programmes need improvement. Increased preventive and promotive health education is also of great importance. 2.2.10 Singapore
Heroin abuse, which was a problem of epidemic proportions in 1977 and 1978, has been brought under control through the collaborative efforts of both the Government and people of Singapore. A network of community-based infrastructure has been established and successfully utilized for the dissemination of preventive education programmes, provision of counselling and aftercare, and the collection of useful feedback data at grassroot levels by the Singapore Anti-Narcotics Association (SANA) - a nongovernmental organization. This complements the Government's mandatory institutional treatment, rehabilitation and statutory supervision of drug addicts. Inhalent abuse or glue-sniffing among children of schoolgoing age is becoming a major problem. Pending the announcement by the Government of suitable treatment and rehabilitation programmes, SANA in 1985 mounted a national campaign against glue-sniffing with the participation of government ministries and nongovernmental organizations, to create awareness among parents and to mobilize community support to curb the spread of inhalent abuse.
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The growing awareness that drug abuse is not an isolated condition but one manifestation among many others of personal and family problems, has prompted both the Government and SANA to place emphasis on the education of parents about the dangers of drug abuse and the importance of proper moral and spiritual values among the young. 2.2.11 Viet Nam
After the liberation of north Viet Nam in 1954, opium addiction was eradicated in the cities and rural areas. But in the mountainous regions the minority peoples continue to grow and eat opium. In south Viet Nam from 1965 to 1975 heroin use among adolescents was widespread. There were about 500 000 drug addicts in the country, of which 150 000 were in Ho Chi Minh City. According to surveys, 0.35% to 1% of drug addicts are aged under 17 and 0.85% are aged from 18-35. After Liberation in 1975, a rehabilitation centre for drug addicts was established in Ho Chi Minh City. In 10 years the centre has received 17 000 persons. Treatment consists of acupuncture associated with cool baths, breathing and relaxing exercises. According to more follow ups, 50% of drug addicts discharged from the centre have been successfully treated. From 1955 to 1975, the Government Council adopted a number of resolutions to eradicate drug addiction and to persuade the mountain inhabitants to stop producing and eating opium. Drug addiction, illegal traffic and opium growing are regarded as crimes but total rehabilitation is implemented for drug addicts. The State controls the importation of narcotic and psychotropic drugs. Only State pharmacies can sell these drugs under a physician's prescription. Drug addiction is now declining in Viet Nam. prevent drug addiction among adolescents. International cooperation between countries having similar economic and social problems including assistance from United Nations organizations, is necessary to
3.
PREVENTION/EDUCATION
3.1
Situation analysis
With the exception of a few countries where drug abuse by adolescents is not yet considered a problem, countries in the Region are conducting drug education programmes, which they consider to be helpful. In those countries which consider that they do not have an adolescent drug problem, it is felt that drug education programmes might be counterproductive. In China, preventive education is being carried out by administrative directives to professionals through a three-level built-in communication system where feedback is obtained.
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Drug education for adolescents is generally integrated into primary and secondary school health education programmes, the curricula of which are appropriately planned by each country. While these curricula may be designed to improve life-styles, due recognition is given to the fact that an adequate knowledge about drugs, properly given, may help adolescents to make mature decisions which will lead them into life-styles that do not require the illicit use of drugs. In addition to students and out-of-school adolescents, important target groups for education have been found to be teachers, health professionals, law enforcement personnel, parents, the media, the judiciary, religious organizations and community service groups. All of these have been found to have an influence on the behaviour of adolescents, either directly or indirectly. Generally, drug education programmes are being appropriately designed to meet the needs of specific target groups. This has been shown to be particularly relevant to those countries whose population is multiracial and composed of diverse religious groups. Other factors include the population and the physical characteristics of the country. In some countries with a smaller population, particularly if they are also geographically small, it has proved possible to saturate the whole community using the media and other communication approaches. In many countries, physical activities as alternatives to drug-related behaviour have been designed for out-of-school adolescents, whether these have been "drop outs", unemployed, or just school children after school hours.
It is recognized that no preventive measure will stand alone, and that concurrent, multidisciplinary activities are essential. Important tools include education and legislation to control advertising. In addition, law enforcement can be used to prevent the illicit entry of drugs into a country, as well as illicit manufacture and diversion of drugs from legal channels. 3.2 Guiding principles
In order to obtain uniformity of programmes within each country and to avoid contradictory approaches to drug abuse prevention, some "umbrella" national body that would coordinate all preventive activities (education, law enforcement and legislation) is considered to be essential. While it is acknowledged that, in order to be able to define the problem of drug abuse among adolescents in a particular country, adequate epidemiological studies must be carried out, very few countries have done this, and without knowledge about the true nature and extent of the problem among adolescents, it is difficult to develop appropriate strategies to cope with it. Few countries have realistic evaluation techniques that are based on the pre-determined goals of prevention programmes. It was considered by the Group that future action in the area of prevention of drug abuse by adolescents could be based on what is known about protective factors and risk factors, as they are perceived among the countries of the Region.
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Different protective and risk factors exist for different countries, and in determining these, one is conscious of the fact that within the Region, there is an immense diversity in terms of size, ranging from the world's largest to one of the smallest, maturity, from one of the world's oldest to the newest, economy, from highly industrialized countries to those that are dependent largely on a rural economy, and other factors. Many factors will influence vulnerability. Some of these are generally more likely to exert a protective influence. These include religion, norms, cultural traditions, the historical background of a country, community and family ties. On the other hand, some factors may increase the risk of problems. These include rapid socioeconomic change, unemployment, unscheduled leisure, educational and social competitiveness, and rapid communication.
4.
MANAGEMENT/TREATMENT OF DRUG-RELATED PROBLEMS
4.1
Situation analysis
From the country profiles of participating countries/areas, it seems that the main drugs of abuse are opiates (7 countries/areas), stimulants (2), cannabis (3), solvents, benzodiazepines and cough syrups. The range of treatment services available differs widely between different countries or areas in the Region with Australia, Hong Kong and New Zealand providing a relatively wide range of facilities. In most but not all countries or areas there is provision for hospital-based specialist services. There are therapeutic communities available in six countries and other community-based services in seven countries/areas. Self-help groups have started in four and after-care provisions in seven countries/areas. Provision is made for the treatment of drug abusers in prison in eight countries/areas and there are special corrective services under the penal system in seven countries/areas. Detoxification and pharmacotherapy is done in nine countries/areas; however, opiate (methadone) is provided for detoxification and maintenance in only three. Primary health care workers are involved in the treatment of drug abusers in only four countries/areas but all participants believed that this group of workers should playa much greater role. This belief was linked to the recognition that the outcome of treatment for drug abuse problems is more frequently positive than is widely recognized. Drug abuse does, of course, have a serious impact on social and physical functioning. Nevertheless, with appropriate treatment, many of those afflicted can attain a rewarding life-style. 4.2 (1) Guiding principles Community and individual level
At the community level, drug abuse is a health issue which warrants intervention from a health perspective. It is equally important to define
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the areas of concern and the goals of intervention, and to be able to assesS progress towards achieving such goals. At the individual level, the essential basis for health interventions is an adequate assessment of the person in his/her total context, the identification of threats to health or impairment of health, and a programme formulated to achieving specific changes in the direction of maintenance or restoration of health. There are ethical perspectives and responsibilities for all those helping drug abusers. Those working in the health field are bound by well understood standards of medical ethics, which are based on respect for the dignity of the patient. It is also acknowledged, however, that certain factors in a therapeutic relationship are best determined within a cultural framework. Although in some instances it may be difficult to make the distinction between medical and corrective interventions, it is important that the general principles underlying such distinctions should be defined and that the roles of health workers and the health system should be clarified in relation to drug abusers. (b) National level
National policies on drug abuse should ensure that a comprehensive coordinated, multidisciplinary approach is adopted and that guidelines for good treatment and effective rehabilitation are available and followed. Services should be humanized and geared to solving common problems. It is appropriate, in developing programmes for adolescents, to offer a wide range of treatment options, recognizing that flexibility will allow specific approaches to the needs of particular groups. Ideally treatment will occur at every level in an extensive integrated system of services, extending from the efforts of ordinary citizens to help each other, supported by informed primary health and welfare workers, through members of expert resource groups. Interdisciplinary relations should be such that, in each case, the lead is taken by the profession or discipline most appropriate to the particular issues and problems presented. There may be Borne special programmes for treatment of drug users, their range and balance depending on local circumstances and policy decisions.
Distinctions between treatment, rehabilitation and after-care are often arbitrary. A long-term response is usually required, related to the learning and application of new skills in living without drugs. A comprehensive model of drug use needs to include not only the physical and psychosocial dimensions, but also attention to issues such as personal values and meanings of life, the contribution of collective values, and the sense of demoralization and hopelessness of drug abusers who are in difficulties.
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In general, the need for the pattern of drug use to be interrupted (at least ~emporarily), so that a normal life-style can be reinstated, must be emphasized regardless of any model of drug use that may be adopted. Similarly, there is generally a need for a long-term involvement bet~een the person ~ith the drug problem and those with key responsibilities for treatment. All drug-abuse treatment programmes should be kept under regular by those directly responsible for them and periodically by those responsible for regional and national pOlicies. revie~
5.
RESEARCH
5.1
Current status
Research in the drug abuse area is derived from and must support prevention and treatment activities. Research can be considered both as a philosophy of investigation and a process of technique. Such a philosophy ackno~ledges the importance of rigorous investigation in determining both clinical and prevention activities. Similarly, the importance of research into the process and outcome of drug abuse treatment and rehabilitation services is emphasized. Research conceptualized as a process or technique demands a scientifically constructed approach to all clinical activities, as well as experimental efforts. This section considers in turn the follo~ing
aspects:
analytical/chemical studies; animal studies; clinical and human experimental studies; epidemiological and psychosocial studies; 5.1.1 Analytical/chemical studies
Methods to detect amphetamine in biological samples are being studied in Japan, and several new methods for detecting amphetamine from urine, saliva, and hair have been established. A research effort at the Malaysia Drug Research Centre is aimed at the development of simple new analytical techniques for drug detection both in confiscated and biological samples. Studies are also being carried out on the chemistry of smoking and also on the effects of drug combinations. Similar types of studies are also being developed at the Institute of Medical Research. In Viet Nam, analytical research into narcotics and psychotropic drugs is being carried out.
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5.1.2
Animal studies
A number of animal studies have been conducted concerning the pharmacological, toxicological and dependence-producing properties of drugs of abuse in Japan. Because of the widespread abuse of amphetamines and the serious problem of amphetamine psychosis, the mechanisms of development of such phenomena as the enhancement and recurrence of psychotoxic manifestation have been intensively studied. In China, among other projects, studies are being carried out on dependence potential in rodents. In some countries such as Australia, Republic of Korea, Singapore and Viet Nam, studies are being carried Qut in universities. Studies at
the Drug Research Centre in Malaysia have focused on the neuropsycho-pharmacological, biochemical and toxicological aspects of drug abuse in small animals.
5.1.3
Clinical and human experimental studies
In Australia, studies on the effects of cannabis on humans, alone and in combination with alcohol, have been carried out. A prospective study on the children of heroin-dependent mothers is also being undertaken. Recent clinical studies on amphetamine abuse in Japan have clarified the phenomenon of reemergence of paranoid symptoms by a small dose of the drug, by drinking alcohol, or even by psychological cues. The focus of attention is now on whether there exists a common underlying mechanism for this phenomenon. It has been demonstrated that glue-sniffers tend to shift to amphetamine around the age of 18-20 years. A high degree of competitiveness in school is facilitating the engagement by school and social drop outs in delinquent group activity. In the Republic of Korea, clinical studies on drug-related problems have not been active. However, there are reports on psychological issues But these studies were done in
related to the abuse of minor tranquillizers among drug addicts and case reports on organic solvent inhalation, etc. a non-systematic manner.
A large number of studies have been carried out at the Drug Research Centre in Malaysia, particularly on pharmaco-kinetic and pharmacodynamic aspects of drugs of abuse. Tolerance, preference and efficacy studies on selected drugs, such as delta nine THe sedative-hypnotics are being carried out.
In New Zealand, clinical studies are currently under way to assess the cost-effectiveness of drug abuse treatment, problems, strategies of matching patients and appropriate treatment, and the use of various agents in opiate withdrawal. 5.1.4 Epidemiological and psychosocial studies In Australia, a national survey of attitudes to drugs has recently been undertaken. In addition, a study is proceeding on cocaine use and its illicit promotion.
A nationwide network is currently being organized in China for an
epidemiological survey on drug abuse.
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In Hong Kong, a study had been carried out to find the association between tetanus infection and drug addiction. Regular studies are also being underta~en to ~dentify the characteristics of the addict population and to determine their drug of abuse. The results show that heroin is still the most popular drug, used by over 98% of the addict population. A prospective study is going on to identify the possible causes of sustained abstinence in some addicts while others relapse in drug use. Epidemiological studies on drug abuse in Japan so far have shown that glue-sniffing and methamphetamine abuse are mostly circumscribed within delinquent and criminal groups. Currently there is a research team in epidemiology in the Republic of Korea, who are undertaking studies on drug-related problems. A wide range of epidemiological, social and psychological studies have been carried out at the Drug Research Centre in Malaysia. A current study includes identification of IJrisk" indicators, adjunctive drug uSe and abuse
patterns. Evaluation studies on efficacy of treatment as well as prevention efforts are being carried out. Similar studies on the social and health consequences of drug abuse are being carried out. Epidemiological studies of morbidity and mortality, incidence and prevalence are being carried out in New Zealand. Palau has undertaken epidemiological studies on drug and alcohol abuse as they relate to suicide among adolescents. 5.2 5.2.1 (1) Areas of interest and needs Analytical chemical studies Development of sensitive, but simple and reliable methods of detection of abused substances in body fluids. Priority should be given to cannabis, amphetamine, cocaine and inhalants.
(2) 5.2.2 (1) (2) (3) (4)
Development of chemical screening techniques for assessment of drugs of abuse on selected at-risk population. Animal studies The assessment of dependence liability of drugs Pharmacotherapy and behavioural studies in animals related to reduction of craving for drugs Psycho-toxicity of drugs Organ toxicity studies with particular reference to neurotoxicity Clinical and human experimental studies
5.2.3 (1)
The development of differential diagnostic procedures to improve diagnosis.
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(2) (3)
Development of clinical methods for assessment of dependence-potential. Development and application of new and innovative techniques, viz. nuclear magnetic resonance (NMR), positron emission tomography (PET) scan and computerized electro-encephalography (EEG). Studies in pharmaco-kinetics in relation to the behavioural effects of drugs in humans with emphasis on substances such as inhalants, cannabis, stimulants and drug combinations. Establishment of predictive methods of ill-effects, both physical and behavioural, due to drugs. New approaches for treatment of drug dependence and related problems. Prospective studies of children born of drug-dependent mothers. Development of more sophisticated assessment strategies which differentiate the psychological, physical, socio-cultural and exogenous factors (e.g. drug type and route of ingestion). Epidemiological and psychosocial studies
(4)
(5) (6) (7) (8)
5.2.4 (1)
Multivariate, multidisciplinary prospective studies on selected cohorts in areas with significant drug abuse among adolescents are needed. The cohort should be selected at the pre-adolescent period and should encompass the totality of physical and environmental factors. Some of the areas that should be included are listed below: Objectives: (a) Determine vulnerability (b) Determine resistance (c) Influence of family (d) Influence of peers - and friendship patterns
(e) Other environmental factors, including the media (f) Pathways of drug use - poly-drugs Alternative or simultaneous poly-drug abuse. (g) Cultural/historical/national ethnic factors (h) Youth culture - interrelationship with adult culture (i) Genetic influences (j) Physical consequences to the drug abuser (2) Comparative studies on various adolescent populations (e.g. users Vs non-users; young adolescents vs old adolescents etc.) are urgently needed.
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(3)
Development of national epidemiological monitoring schemes for drug abuse.
5.2.5
Policy and programme evaluation
Studies of the relative effectiveness of different policies and their implementation through national and local programmes. This will include the assessment of the process of policy and programme development.
6.
REGIONAL COLLABORATION
6.1
Current status
Over the past few years, there have been concerted efforts through health and other authorities to coordinate drug abuse prevention and control efforts by countries/areas in the Region. These efforts have primarily been directed to the areas of legislation, law enforcement, research and manpower development. WHO has coordinated the implementation of epidemiological studies, training and exchange of expertise between countries of the Region. Other organizations/agencies such as the United Nations and ASEAN have played important complementary functions. ASEAN, in particular, has attempted to develop close collaboration among the five-member association in order to enhance drug abuse control efforts. In spite of the existing efforts, it was noted that such collaboration is still marginal and there exist tremendous opportunities to improve and increase intercountry and regional collaboration, particularly in relation to the problems of adolescents. 6.2 possible areas for collaboration
The existence of several groups, in many Member States, who are actively involved in prevention, treatment and research activities was
noted. The linking of these groups either by formal or informal mechanisms would obviously facilitate the exchange of information, enhance the quality of activities as well as maximize these efforts. Cooperation in this area
was regarded as providing potential for collaborative projects among countries/areas in the Region. (1) Epidemiological studies aimed at the quantification of problems of drug abuse among adolescents as well as the identification of possible risk and protective factors.
(2)
Development and utilization of evaluative procedures for assessing the cost-effectiveness of prevention, education and treatment programmes, taking into account standards for diagnosis and treatment. Studies on the psychosocial and health consequences of drug use and abuse.
(3)
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(4) (5)
The exchange between countries of personnel, experiences and information in relation to prevention and treatment efforts. Collaboration among health care workers within and between countries whether their involvement is in prevention, treatment, rehabilitation
or child and adolescent mental health, is considered essential. (6) The standardization of research methods for determining abuse potential in humans. Efforts must be made to determine the abuse potential in all central nervous sytem therapeutic agents prior to their introduction on the market in all countries. Research studies are urgently needed in the area of inhalant abuse, particularly among adolescents, since these problems appear to be rapidly escalating. There was appreciation of the existence of varying degrees of developmental problems in adolescents. Studies are required to identify the features of healthy and impaired relationships between adolescents, their families and their immediate social environment.
(7)
(8)
7.
RECOMMENDATIONS
A. (1)
To Member States A national policy and guidelines on prevention, treatment and rehabilitation of drug abusers, with special emphasis on adolescents should be developed by all countries/areas in accordance with their own needs.
(2)
There is clearly a need for trained personnel to implement prevention, treatment and research programmes. Consideration should be given to initiating national training courses for all personnel involved. Outcome and process research is essential for determining the efficacy of various treatment and prevention programmes on drug-related problems in adolescents. Such evaluative efforts should be incorporated as a requirement in all programmes. Information and experiences, including educational materials, should be shared by countries/areas within the Region in regard to drugs, abuse, treatment, prevention and research, with a view to establishing a clearing house for such material. The development of drug abuse information systems should be given urgent priority. Core data, whenever possible, should be collected in a uniform manner utilizing WHO guidelines. These data should be related to health information systems or be part of the social and demographic system.
(3)
(4)
(5)
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B. (1)
To the World Health Organization Countries/areas of the Region are experiencing severe problems due to lack of trained personnel. Urgent consideration should be given to the initiation and conduct of training courses, seminars and workshops for those involved in prevention, treatment/management and research on a national and regional level. Priority should be given to the training of trainers. A regional network of collaborating research groups, with a focus on identified national priorities in the area of drug abuse, should be considered. To facilitate the formation of the network, WHO should collaborate with such research groups and, where no such groups exist in a country, their development should be encouraged. Special emphasis should be placed on prevention and treatment research on drug-related problems in adolescents. Continuing attention should be given to the classification, nomenclature and diagnosis of drug abuse, with particular attention to
(2)
(3) (4)
the relationship between drug abuse and other disabilities.
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ANNEX 1
OPENING SPEECH OF DR H. NAKAJIMA REGIONAL DIRECTOR, WHO WESTERN PACIFIC REGION
Distinguished Guests, Participants, Colleagues, Friends, Ladies and Gentlemen,
It gives me great pleasure to welcome you on the occasion of the opening of the WHO Working Group on Drug-Related Problems in Adolescents, which is being held here at the Sasakawa Memorial Hall, from 25 to 28 February 1986. I am very pleased to note that this Working Group has brought together a large number of distinguished experts on drug-related problems in the Western Pacific Region, representing disciplines as varied as health administration, health education, pharmacology, psychiatry, law enforcement and rehabilitation. In addition, we can happily count on the services of three resource persona from Japan, the United Kingdom and the United States of America, as well as representatives from the United Nations Asia and Far East Institute for the Prevention of Crime and the Treatment of Offenders (UNAFEI). We also have a number of observers from the host country. To begin with, I would like to express my sincere gratitude to the Government of Japan for kindly agreeing to hold this meeting in Japan. This Working Group is of particular importance for the development of programmes for the prevention and control of drug-related problems in adolescents both at regional and global level. As you know, drug-related proble~s have been a long-~tanding social and health concern in many CQUntr1es and have become lncreasingly serious in recent years. Recognizing the above situation, both the United Nations and the World Health Organizati?n, as one of its specialized agencies, have adopted a number of resolutIons and developed various programmes in this problem area. 11 .As an international public health organization WHO is now focusing Its efforts on the achievement of the goal of h~alth for sll b th ~~~;i~OOOj the preve~tion and co~trol of drug-related problems sho~ld :e ere an essentIal element In the strategy for achieving this goal. a the in his address to United Nations to undertake a bo~~Cla~ CouncIl, B~reBsed the need for the trafficking and abuse and dan new offensIve to combat drug '. ,propose that a world conf b t h e mlnlsterial level in 1987 t d 1 . erence e convened at his statement, he declared that o"d ea w~th all aspects of drug abuse. In to this and coming generations lik:u~h: u~e presen~s a destructive threat the world in earlier centuries" T . P agues WhICh swept many parts of most seriously affected are you~g rag~CallY'hhe pointed out, many of those peop e on w om OUr future depends.
U~:t=:YN~:~~~st~;o~~~~da~:tion~ Secreta~y-General,
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Annex 1
At the World Health Assembly in May 1985, concern was expressed about the urgent need for international agreement on action by health authorities for the prevention, care, and rehabilitation of drug-related problems. The Regional Committee for the Western Pacific has also manifested its concern with the present situation. During its thirty-sixth session last September, the Committee adopted a resolution on alcohol and drug abuse, requesting the Regional Director to intensify collaboration with Member States in implementing regional and national activities related to alcohol and drug abuse and to promote health research in these areas. In January this year, the seventy-seventh session of the Executive Board of the World Health Organization held a special session which discussed the problems of "Abuse of narcotic and psychotropic substances" and highlighted the importance of WHO's role with respect to drug-abuse problems. During the Executive Board meeting, I particularly referred to the complexity of drug-related problems which need to be solved at a higher political level, both the economic and social factors as well as the fundamental health aspects being identified. Soon after this Working Group has completed its work, a Conference of Ministers of Health will be convened in London from 18 to 20 March 1986. The outcome of the present Working Group will be directly reported to the Conference of Ministers of Health in London next month. One of the objectives of the Working Group is to recommend ways and means of developing international collaboration in dealing with drug-related problems, including intercountry training and research in the Region. Apart from being distinguished experts in this field, many of you have been involved in various international programmes on drug prevention
and control. I look forward therefore with keen interest to receiving your suggestions on how WHO can effectively collaborate with Member States in alleviating and minimizing these problems.
You may rest assured that WHO will continue to collaborate with you in the fight against this scourge. In conclusion, I would like to express my gratitude for the contribution made by the various persons involved in the preparations for this meeting. Special thanks are due to the Ministry of Health and Welfare, particularly the staff members of the Division of Narcotic Affairs, Bureau of Pharmaceuticals, and also Dr Nobukatsu Kato, Chairman of the National Organizing Committee, for their tireless efforts. I would also like to thank the three resource persons, Dr Alfred Freedman (U.S.A.), Dr Hamid A. Ghodse (U.K.) and Dr Takemitsu Hemmi (Japan), for their excellent technical contributions. My thanks also go to Dr Marcus Grant, Senior Scientist, Division of Mental Health, WHO/Headquarters, who, I am sure, will be very helpful in conveying to you the global perspective of the WHO programme on drug abuse. I wish you all a successful and fruitful meeting and a pleasant stay in Tokyo. Thank you.
- 21 ANNEX 2
LIST OF MEMBERS, RESOURCE PERSONS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT 1. MEMBERS
Dr Abdul Aziz Abdullah General Hospital Kuala Lumpur Malaysia Dr Cai Zhi-Ji Professor Institute of Clinical Pharmacology Beijing Medical College Beijin~
People s Republic of China Dr Artur Jorge Neves Marinha de Campos Department of Psychiatry Hospital Central C.S. JanuArio Macau
Dr Chan Sik-lam Assistant Director (Narcotics) Narcotics and Drug Administration Division Medical and Health Department Hong Kong Dr Les 1 ie Drew Senior Medical Services Adviser Drug of Dependence Commonwealth Department of Health P.O. Box 100 Woden, A.C.T. 2606 Australia Dr Robert Fisher Assistant Director of Mental Health Department of Health P.O. Box 5013 Wellington New Zealand Atty Leonardo Gonzales, Jr. Administrator Treatment and Rehabilitation Centre for Drug Addicts National Bureau of Investigation Tagayta~ City PhHipp.nes
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Annex 2
Dr Nguyen Quy Hung Director Department of Rehabilitation Ministry of Social Welfare and Invalid Hanoi Socialist Republic of Viet Nam Dr Nobukatsu Kato Director Tokyo Metropolitan Matsuzawa Hospital Setagaya-ku, Kamikitazawa 2-1-1 Tokyo 156 Japan Dr Ho Young Lee
Chairman and Professor Psychiatry Department Yonsei University College of Medicine Seoul Republic of Korea Dr Viz Navaratnam Director National Drug Dependence Research Centre Universiti Sains Malaysia Minden, Pulau Penang Malaysia Dr Tran Van Nhiem Director
Rehabilitation Centre for Drug Abuse Ho Chi Minh City Socialist Republic of Viet Nam Mr Baey Lian Peck President Singapore Anti-Narcotics Associstion and Chairman of the Advisory Committee on Treatment and Rehabilitation of Drug Addicts SANA- 2 Orchard Blvd. Singapore 0922 Dr Anthony Polloi Acting Chief, Public Health and Chief, Mental Health Bureau of Health Services P.O. Box 100 Koror Republic of Palau 96940
- 23 Annex 2
Dr Douglas Rankin Epidemiologist Public Health Division Health Department Victoria 555 Collins Street Melbourne, Victoria Australia 3000 Atty Manuel Supnet Executive Director
Dangerous Drugs Board P.O. Box 3682 Intramuros
Manila Philippines Dr Kiyoshi Suzuki Director
National Shimofusa Ryoyosho 578, Henda-cho Chiba-ken Japan Dr Tomoji Yanagita Director Preclinical Research Laboratories Central Institute for Experimental Animals 1433 Nogawa Kawasaki Japan 213 Dr Xia Zheny i Professor and Chairman Shanghai Psychiatric Hospital 600 Wan Ping Nan Lu Shanghai People's Republic of China 2. RESOURCE PERSONS
Dr Alfred Freedman Chairman and Professor
Department of Psychiatry and Behavioural Sciences New York Medical College Valhalla, New York 10595 U.S.A.
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Annex 2
Dr A.H. Ghodse Consultant Psychiatrist and Director St George's, St Thomas' and Tooting Bec Hospitals Blackshaw Road London, SW17 OQT England Dr Takemitsu Hemmi Nakaochiai-3-23-5 Shinjuku-ku Tokyo 161 Japan
3. UNITED NATIONS ASIA AND FAR EAST FOR THE PREVENTION OF CRIME AND THE TREATMENT OF OFFENDERS (UNAFEI) MINISTRY OF HEALTH AND WELFARE
REPRESENTATIVES/OBSERVERS
Dr Masaharu HinD Director, UNAFEI Mr HideD Utsuro Deputy Director, UNAFEI Dr Koichi Watanabe Facul ty, UNAFE I Dr Kazutaka Ichikawa Director
Division of Narcotic Affairs Pharmaceutical Affairs Bureau Dr Akira Yamamoto Deputy Director Division of Narcotic Affairs Pharmaceutical Affairs Bureau Dr Tetsuo Kurokawa Depu ty Direc tor Division of International Affairs Minister's Cabinet Dr Takefumi Fukuhara Deputy Director Division of Mental Health Public Health and Medical Service Bureau
OBSERVERS
Dr Susumu Fuku i National Kohnodai Hospital 1-7-1 Kohnodai, Ichikawa Chiba 272 Japan
- 25/26 Annex 2
Dr Hiroshi Kaneto Professor School of Pharmacy Nagasaki Universtiy 1-14, Bunkyocho, Nagasaki Nagasaki 852 Japan Dr Kyohei Konuma National Psychiatric Institute of Shimofusa 578 Henda-cho, Chiba 280-02 Japan Dr Motoi Ogata
Professor School of Allied Health Professions Sapporo Medical College Nishi 17, Minami 3, Chuo-ku, Sapporo Hokkaido 060 Japan Dr Satoru Saito
Psychiatric Research Institute of Tokyo 2-1-8, Kamikitazawa, Setagaya-ku Tokyo 156 Japan Dr Hiroshi Suwaki Assistant Professor Kochi Medical School Kohasu, Okatoyocho, Nangoku Kohoni 781-51 Japan
4.
SECRETARIAT
Dr Marcus Grant Senior Scientist Division of Mental Health World Health Organization Geneva, Switzerland Dr Naotaka Shinfuku (Operational Officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila
J
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AGENDA
i 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Opening ceremony Guidelines of the meeting Country reports Education and other preventive measures Management and treatment Research - present and future International collaboration Formulation of recommendations Review and adoption of the report Closing ceremony