Out of the Shadows: Iran’s Evolving Approach to Drug Addiction

By Basoodler · Nov 7, 2014 ·
  1. Basoodler
    Iran has long had one of the world’s biggest drug addiction problems, but the government’s attitude toward the drug war remains rife with contradiction. Iran has taken drug addiction very seriously, as evidenced both by its extensive and heavy-handed law enforcement efforts and by the resources it puts toward prevention, treatment and harm-reduction programs. However, officials have at times downplayed the extent of the problem, as politicians have sought to paint a positive picture of the state of drug addiction in Iran.

    In a June speech, Interior Minister Abdolreza Rahmani Fazli said that Iran was home to 1.35 million addicts, adding that this number put Iran below the overall world addiction rate. By most accounts, however, the levels of addiction in the Islamic Republic are among the highest in the world. Former UNODC head Antonio Maria Costa has said, “Addiction in Iran is ten times what is known in other countries,” that actual Iranian addiction rates are likely much higher than those reported by the government and that drug addiction rates are actually closer to 6 percent. The last comprehensive survey, according to some scientists, was done in 2004, the year before Mahmoud Ahmadinejad was elected president, and it put Iran’s number of addicts at 3.7 million.

    The demographics of Iran’s addiction problem are wide-ranging. Government-sponsored drug abuse surveys indicate that while addiction is primarily a male problem—nine out of 10 addicts are male—there are men of all backgrounds among the drug-using population. Many are highly educated; in fact, more than 21 percent of drug addicts in the country have at least a bachelor’s degree. Increasingly, drug users are young adults. Chronic youth unemployment, including among recent university graduates, has contributed significantly to this phenomenon.

    As times and governments have changed, so have the opiates of choice in Iran. Opium has been a commonly used drug in Iran for hundreds if not thousands of years. Traditionally used by older men in particular, it did not carry a great deal of stigma. In the 1960s and 1970s, however, heroin began showing up in Iranian cities, first attracting a young subsection of urban artists and intellectuals who wanted to differentiate themselves from their opium-smoking peers. Overall drug use increased significantly in the years following the 1979 revolution, alongside a switch among many opium users to heroin and a switch from smoking to injection; an estimated 10-20 percent of drug users are injectors. Government-sponsored surveys from the turn of the millennium showed that despite 40 percent of drug users reporting having recently used heroin, only 5.6 percent had taken heroin as their first drug, while about 60 percent had started as opium users.

    Supply and Demand

    Iran’s heroin problem begins in Afghanistan, the primary source of Iran’s opiates since domestic cultivation was nearly eradicated during the Pahlavi dynasty. Afghanistan’s opium production has recently reached record-high levels. In 2013, it produced more than 6,000 tons of opium, a 49 percent increase over 2012. This increase contributed to a 17 percent increase in drug seizures in Iran from March 2013 to March 2014. Land devoted to opium cultivation in Afghanistan, meanwhile, also spiked 36 percent from 2012 to 2013, according to the United Nations Office on Drugs and Crime (UNODC). With more than half of Afghanistan’s total production coming from the southern provinces of Kandahar and Helmand, where coalition forces have long struggled to gain control and defeat the Taliban, fears are high that the departure of coalition forces at the end of 2014 will result in unchecked growth in poppy cultivation, leading to supplies flooding Iran on their way to markets in the West.

    Until the middle of the past decade, heroin users in Iran were largely limited to basic brown heroin, which officials judged to be generally of relatively low purity. Then, however, two new forms began surfacing in the cities of Iran. One was a counterfeit version of the opiate buprenorphine, which was largely made of heroin. Produced in Pakistan and smuggled to Iran, it also contained a corticosteroid—often dexamethasone—which presented its own health risks but added a side effect: that of changing users’ facial appearance so they could avoid standing out as likely heroin addicts.* This effect made it popular among young people in more affluent parts of cities like Tehran, Shiraz and Isfahan, many of whom were previously addicted to heroin. However, its use has largely disappeared by now.

    The second new form was a street drug in the form of white rocks locally known as crack, also referred to as “Iranian crack” or “Afghan crack.” Unlike crack cocaine, it is made primarily of concentrated heroin extract. It attained widespread use in Iran in the past decade, due in part to eventual price decreases making its ultra-concentrated effects appealing to addicts. In addition, dealers would often tout it as a cure for opium addiction, “which was in fact true,” an Iranian source explains, but “drug users [who] abandoned using opium after starting with ‘crack’ could, however, not stop using the latter itself.”

    This latter form rapidly spiked in popularity, and one 2007 assessment suggested that one-third of opiate users in Iran were using “crack.” Predominantly inhaled, it became increasingly injected—after being easily dissolved in water—as users’ tolerance built up and purity likely decreased. Officials reported that “crack” seemed to spark much stronger cravings than opium and brown heroin and also more drastically affected users’ ability to function. High levels of processing impurities and adulteration—acetylcodeine was cited as the most common added substance found in a 2012 study by Tehran-based scientists—coupled with treatment progress provoked a brief dip in its consumption.

    Since 2012, however, there has been a resurgence in traditional heroin consumption, although this has been coupled with reports of high-purity heroin—reportedly stronger even than “crack”—in cities like Mashhad, not far from the border with Afghanistan. Resurgent heroin consumption has, in turn, reportedly turned more addicts back to “crack” after a dip in consumption.

    “The peak of Afghan crack consumption in our country was a few years back, but then because of the high level of imperfection in derivative products and awareness raising, addicts’ demand for it decreased and drug gangs lost interest in it,” said Farid Barati, the director of addiction prevention and treatment at the Iranian Welfare Organization, in an interview with the reformist daily Shargh last year. “But now, due to the increase in heroin consumption in the country, Afghan crack has once again found prevalence, and it must be noted that an increase in heroin consumption means an increase in sharing of needles, and the return of a second wave of HIV.”

    Iran’s National AIDS Committee Secretariat, made up of numerous government health officials, has also expressed concern that HIV could see a new wave of increase in the country. In a report to UNAIDS earlier this year, it noted that a decrease in the intensity of harm-reduction programs “in recent years” could leave Iran vulnerable for further spread of the disease via intravenous drug use. HIV has long been a problem associated with heroin in Iran; a recent report prepared by Iranian officials for UNAIDS tallied the infection rate among intravenous drug users at 15.07 percent.

    Even if Iran succeeds in its battle with heroin, however, it is far from the only drug plaguing the country now. In addition to the opium that has addicted Iranians for centuries and the cocaine that has attracted many users among the wealthy, crystal meth—locally known as sheesheh, or glass—has spread rapidly throughout Iran in the past decade, reportedly surpassing heroin in its number of users, although both remain less used than opium. Part of its appeal to dealers is its reduced risk with respect to opiates—because it can be produced locally, there is no need to deal with traffickers or middlemen to get product from Afghanistan—and its low production cost. In fact, Iran has become a major exporter of meth to regions such as Southeast Asia, although authorities have reported progress both in cracking down on its export and production in Tehran and the neighboring Alborz province. Iranian public health authorities have also associated rising crystal meth use among young people with risky sexual behaviors, raising concern that amphetamines could contribute to the spread of HIV in Iran.

    Iran’s Strategy to Combat Drug Addiction

    Iran’s drug treatment program has seen some setbacks in recent years, yet remains relatively thorough and multifaceted. To understand its current state properly, one must look at decades of shifting priorities, policies and ideologies, as the Iranian government’s approach to drug addiction has seen many phases.

    When the Pahlavi-era authorities found that crop destruction and border enforcement weren’t doing enough, they embarked on prevention and treatment-based programs that showed some promise. However, the immediate aftermath of the Islamic Revolution of 1979 saw a turn to a strict categorization of addiction as a criminal moral failing, as drug users were routinely sentenced to substantial prison terms or detention in labor camps where they were expected to overcome their addiction through abstinence.

    To try to dry up the supply of illegal drugs, the government turned to harsh penalties for traffickers and dealers, with lengthy jail terms, corporal punishment and execution being common sentences. Under a law codified in 1989, Iranians could be executed for being caught carrying little more than an ounce of heroin, codeine, morphine or methadone. Around that time, authorities began sending around 200,000 heroin and opium addicts to mandatory rehab camps, where the emphasis was on detoxification through complete abstinence from drugs. While the stress of detention and the mandatory work at the camps were difficult for addicts, the withdrawal symptoms were often truly unbearable. Upon being discharged after sentences that averaged two months, many addicts were desperate to resume drug use, making them prone to repeat arrests and camp detentions.

    Worse than having a low success rate, the abstinence-only camps were often counterproductive. Desperate to calm their cravings, inmates were known to smuggle in drugs. While the majority of addicts in these camps had been opium smokers, once faced with the limited availability of drugs and syringes, many turned to sharing needles to inject smuggled heroin. Not only were opium smokers transformed into heroin addicts, many also contracted hepatitis C and HIV during their time in camps or the prison system. A prison study in the major provincial cities of Kerman, Shiraz and Kermanshah in 1995 found HIV rates of 5-8 percent among drug-using inmates. Meanwhile, the system of more than 160 miles of border defenses that Iran had put in place throughout the 1990s at costs exceeding $800 million had failed to catch the majority of drug smuggling from Afghanistan and Pakistan, while 2,800 security officers had been killed in clashes with smugglers.

    Over time, the need for a new approach became clear. However, public stigma toward drug users was high. When a member of parliament from Kermanshah reacted to the 1995 study with a plan to create a national HIV hospital in his city, the public outcry derailed the project and contributed to the failure of his re-election bid. While prevention education programs began to spread in the intervening years, the end of the 1990s represented a turning point. The mandatory rehab camps were closed, and the National Welfare Organization and the Ministry of Health conducted clinic-based surveys in conjunction with U.N. agencies, which pointed out stark statistics including an annual growth rate in the number of addicts around 8 percent.

    Given the stigma, heroin users—many of whom had been in and out of jail and rehab camps, and a growing number of whom had HIV—remained in the shadows and refrained from seeking proper treatment. With an era of greater openness unfolding in Iran under the presidency of reformist cleric Mohammad Khatami, a new generation of doctors and scientists sought to reorient Iran’s drug response to one of harm reduction from one of stigmatization and punishment, and they received government support to this end.

    In one notable example, 2000 saw the creation of the first Triangular Clinic in Kermanshah. The Triangular Clinic model provided a three-pronged approach, enabling walk-in and referred drug abusers to receive treatment for addiction, with an emphasis on destigmatization and harm reduction, alongside HIV testing, treatment and counseling, including for STDs. The approach gained popularity with addicts seeking treatment due to its emphasis on total physical, mental and social health, even offering group activities like mountain hikes.

    “We realized that even more than treatment, they needed somebody to talk to,” says Kamiar Alaei, currently the director of the Global Institute for Health and Human Rights at the University at Albany, who co-founded the first Triangular Clinic with his older brother Arash. The clinics soon gained the attention of provincial and national authorities, who expanded the model across the country and brought elements of it into the prison system. Government officials brought it to the attention of the World Health Organization, who praised it as a best-practice model for the region.

    The clinics are highly progressive by American standards, providing critical elements of harm reduction such as methadone, condoms and clean syringes. In addition, they provide drug treatment not only for HIV and STDs, but also for other diseases that are highly prevelant among drug users, such as tuberculosis. By showing positive results for family health and cohesion coming from the clinics, doctors were able to gain support from open-minded religious leaders. Demonstrable decreases in mother-to-child transmission of HIV were one uncontroversial selling point. “We started by talking about saving babies,” says Alaei. “Who could be against that?”

    With the support of much of the clergy in place, public awareness campaigns about drug use and even condom use became permissible; in January 2005, Justice Minister Esmail Shooshtari, himself a cleric, issued an order for prosecutors to refrain from punishing drug users to the full extent of the law, and instead to defer to guidance from the Health Ministry on referring addicts to treatment programs. Iran’s Majlis, or parliament, despite then being led by a conservative majority, followed by acceding to health practitioners’ request to allow any family doctor to prescribe methadone to patients.

    Law enforcement officials saw the need for change as well. During his time as chief of the Iranian Police Forces, current Tehran Mayor Mohammad Bagher Ghalibaf met regularly with Ministry of Health officials to coordinate drug policy. “There was a broad understanding from folks in the security apparatus that you needed to have change,” says Amir Afkhami, assistant professor of psychiatry and global health at George Washington University. “You couldn’t stop it by interdiction alone.”

    The Backlash to the Reforms

    With the election of Mahmoud Ahmadinejad as president later in 2005, however, morality politics began to roll back the changes of the Khatami years. Education programs about drug use and HIV, which had been prepared for schools and Red Crescent programs, were abruptly shelved by incoming officials. While drop-in clinics had become entrenched enough to remain operational, government support waned, and stigma toward drug users and other high-risk populations began to increase. Some point to official statistics showing the number of new HIV cases among intravenous drug users dropping each year from 2004 to 2010, from 3,111 to 1,585 per year, as a sign of progress, while others think these statistics are simply the result of at-risk heroin users returning to the shadows. “The patients who were at risk did not trust the clinics enough to come in for testing,” suggests Alaei.

    Further, doctors who worked to publicize and regularize at-risk populations who engaged in behavior that clashed with Ahmadinejad’s idealized view of a pious Iran felt new pressure. This was particularly true if they also worked with Western entities, which were once again heavily demonized as threats to Iran’s security after years of relative detente under Khatami. Most notably, the Alaei brothers—who had worked on grants that brought in millions of dollars in international funding, and who had also arranged numerous exchange trips for Iranian and American doctors—found themselves in prison on charges of plotting to overthrow the Islamic Republic. After their exchange programs were declared to be a cover for international training by the West to foment revolution, Arash spent three years in prison and Kamiar two and a half.

    With harm reduction less of a government priority at a time of budget difficulties caused in part by international sanctions, spending on clinics and related services hasn’t kept up with Iran’s rampant inflation. Between 2010 and 2012, nearly a third of Iran’s needle exchange centers closed. However, the strong progress made in the preceding years insulated the harm-reduction program from being seriously dismantled. As of 2011, UNAIDS reported that Iran had 600 dedicated drug rehabilitation centers and 1,250 additional centers offering harm reduction services. In addition, needle exchange programs dispensed more than 12 million syringes for drug users in the year ending September 2013.

    While a lack of comprehensive data collection on drug use has led to confusion over the effects of the policy shifts of the Ahmadinejad years, there is some evidence that there has been a negative impact on Iran’s HIV situation. Before, HIV was mostly a disease of intravenous drug users. Of all registered HIV cases in Iran’s history, those who contracted the virus from intravenous drug use outnumbered those who contracted it through sexual intercourse by a ratio of 4-to-1. In 2010-2011, however, this ratio was only 1.6-to-1. Surveys indicate condom use among injectors hovers well below 50 percent on average. Increased stigma likely harmed the ability of health care providers to reach drug users and raise awareness of methods to prevent spreading HIV via intercourse.

    This aspect of Iran’s drug problem is seeing more attention and publicity since the election of President Hassan Rouhani in June 2013. Last year, the new president’s health minister, Hassan Hashemi, gave a high-profile speech on World AIDS Day—which the Ahmadinejad administration had stopped officially observing in 2011—on Iran’s rising HIV rate and its shift from being a mostly syringe-spread disease to a largely sexually spread phenomenon. “Today people in Iran are frightened of AIDS because of misinformation and unscientific claims,” he said, urging Iran to make up for lost time in combatting the disease, which has seen an estimated 80 percent annual increase in cases in the past 11 years. “That is why it remains a taboo.” This taboo is blamed for the fact that while an estimated 100,000 or more Iranians are living with HIV, only 27,000 cases have been confirmed by medical clinics.

    Despite shifts away from criminalizing drug consumption, the sale and trafficking of drugs remains heavily punished in the Islamic Republic, and penalties can include execution. Iran executed at least 369 people in 2013, more than any other nation that released records. Fazli, the interior minister, said earlier this year that four out of every five prisoners executed in Iran are put to death for trafficking-related offenses.

    Today, approximately half of all prisoners in Iran are in jail on drug-related charges. Prisons also continue to be a locus of drug use, and reports in the Iranian media suggest an estimated 80 percent of Iranian prisoners are addicted to drugs. Fortunately, in light of these staggering figures, harm-reduction programs, including many of the elements of the Triangular Clinic system, are offered in 165 prisons and detention centers across the country. Roughly 41,000 prisoners receive methadone therapy on-site.

    There is an ongoing effort to try to further remove drug users from the general criminal justice system, and the creation of a new system of compulsory work camps for drug addicts as an alternative to regular prison is a central element. These camps have been operating in the provinces of Isfahan and Khorasan—home to Mashhad, Iran’s second-largest city—with a Tehran camp reportedly preparing to open within the next few months pending the solution of budget problems. If provided funding from the judiciary, camps would then open in the southern province of Kerman, the poor province of Sistan and Baluchistan, just to its east on the Afghan border.

    The goal, according to Gholamhossein Ismaili, who served as head of Iran’s prison system until earlier this year, is to move 30,000 individuals—a number equal to approximately one-third of Iran’s total inmate population—into the work camps, allowing for treatment for low-level criminals addicted to drugs and saving Iran’s prison system money at the same time. Anecdotal reports suggest the camps, while not as pleasant or as safe as walk-in centers, do often have access to methadone treatment facilities, unlike the abstinence-only camps of the late 20th century.

    Conclusion: Can the U.S. and Iran Work Together Against Drugs?

    Despite the political sensitivity of collaboration with the West on demand and harm reduction, some doctors remain hopeful that medical and scientific exchanges will enable the U.S. and Iran to share best practices. Some call for greater efforts to build what would need to be a two-way relationship that treats Iran with respect: a mutually beneficial exchange, with Iranian clinic experiences being shared with American practitioners and American treatment methods shared with Iranian doctors. Even those Iranians with first-hand knowledge of the political and legal risks of such exchanges of expertise are hopeful that collaboration will be helpful for Iran. Kamiar Alaei believes that his arrest was largely due to timing and circumstances that have now changed. “That was not the right time, with Bush here and Ahmadinejad there,” he says, “But now we have Obama here and Rouhani there, and it is the best time to do health diplomacy and science diplomacy.”

    As for direct support from the U.S. government, this will also remain a sensitive issue. During the Khatami administration, Washington took steps to encourage such practices—the Treasury Department granted sanctions waivers for the National Institute of Health to work in Iran in the late 1990s and early 2000s, for example—and could work to support cooperation again. However, while the UNODC for the most part enjoys the Islamic Republic’s support for its significant advisory and operational presence in Iran, it has faced some limitations, such as an inability to incorporate American officials and experts into its activities. Furthermore, distrust is high enough that the UNODC office in Tehran receives no funding from the U.S., Canada or the U.K.

    Some remain skeptical that this distrust will dissipate, even under the more open Rouhani government. While negotiations with the U.S. have brought Tehran and Washington into more direct contact than at any time since the founding of the Islamic Republic, Iran’s constitution gives the most authority to Supreme Leader Ali Khamenei, who has maintained a deep skepticism of American motives throughout his tenure. In addition, since the time of greater cooperation during the Khatami era, the Majlis has grown significantly more conservative, and the political power of the Islamic Revolutionary Guard Corps has increased substantially, leading to a strengthened security apparatus that remains wary of Tehran’s adversaries. Asked about the potential for American cooperation with Iranian authorities, Afkhami says, “I don’t see anything happening under Rouhani, even in the case of an entente on the nuclear issue.”

    However, Tehran and Washington share common goals. Stopping the flow of drugs into Iran—an Afghan official recently suggested that 40 percent of the opium that crosses into Iran is consumed there—will reduce the ease with which drugs can reach the U.S. via Europe. Trust is low not only due to decades of enmity, but also due to U.S. assertions that elements of Iran’s Revolutionary Guards are involved in heroin smuggling across the Afghan border. Still, American organizations like the RAND Corporation have suggested creating a joint U.S.-Iranian-Afghan counternarcotics program. This could perhaps come in the form of U.S. support for the Triangular Initiative, which sees Iranian, Pakistani and Afghan authorities share intelligence on trafficking activities along their shared borders, and could be feasible due to the convergence of interests, if relations could progress to the point where Iran felt comfortable collaborating with the U.S. in its own backyard.

    False dawns in U.S.-Iran relations have been abundant over the years; in fact, cooperation over Afghanistan briefly looked set to be the thread to bind the two old enemies following the 9/11 attacks. But depending on the future of the always volatile relationship and the outcome of the ongoing nuclear negotiations, the wall of mistrust stands a chance of giving way just enough for Tehran and Washington to take steps, however modest, to tackle the twin problems of drug addiction at home and instability in Afghanistan.

    *This sentence was revised for clarity.

    By Mehrun Etebari, Oct. 28, 2014, Feature

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