Patterns of Drug Use in Developing Countries

Geographical Prevalence of Injecting Drug Use. Injecting drug use exists in over 50 developing countries, and HIV has been identified in this population in over half of these countries. Table 2 lists the countries where both injecting drug use and HIV among IDUs have been found (WHO, 1994; Stimson and Choopanya 1996).

Table 2. Developing Countries Reporting Injecting Drug Use and HIV among IDUs (in bold).

Source: Stimson and Choopanya, 1996.

High prevalence of injecting drug use exists in countries in both Asia and South America, and is beginning to be seen in some countries in Africa. Table 3 provides estimates of the number of injecting drug users for selected countries. Estimates of the number of injecting drug users usually come from treatment facilities, and may understate the prevalence of injecting drug use. Prevalence of IDUs is very high in Thailand, Argentina, Puerto Rico, Hong Kong, and Malaysia, and in some areas in India. Heroin is the main drug injected in countries in Asia, while in South America drug users inject primarily cocaine (Mann, et al, 1992).

Table 3. Estimates of Number of IDUs for Selected Countries

In Asia, heroin injecting has been practiced in Hong Kong since the 1950s and in Thailand since the 1960s, however, drug injecting is a recent phenomenon in many countries, having been identified only in the 1980s in China, India, Lao People’s Democratic Republic, Myanmar, Nepal, Sri Lanka, and Viet Nam (Stimson, 1993; Poshyachinda, 1993; Suwanwela and Poshyachinda, 1986). India has also experienced a dramatic increase in injecting drug use in some areas, including Manipur, Madras, Mizoram, and Nagaland states. The highest rates of injecting drug use occur in the cities, but in certain areas, including Thailand and Yunnan province in China, many IDUs are found in the rural areas and hill tribes as well (Weniger et al. 1991).

In the regions of South and Central America and the Caribbean, high prevalence of injecting drug use is found mainly in Brazil, Argentina, and Puerto Rico, but some level of injecting has also been identified in other countries in these regions (see Table 2). In South America, cocaine, rather than heroin, is injected by most IDUs.

Global Spread of Injecting Drug Use. Injecting drug use has been spreading internationally in both developed and developing countries due to political, economic, and social conditions and changes, drug control strategies, law enforcement, and local culture and tradition (Stimson, 1993, 1996; Des Jarlais, 1992). In the 1970s and 1980s, injection of illicit drugs began to increase in countries in Asia and South America. As yet there is no definitive explanation for the increase in injecting drug use in these countries, but three hypotheses have been suggested as important components. (Des Jarlais, et al. 1992; Stimson 1993; Inciardi, 1992).

First, illicit drug use occurs along drug production and drug trafficking routes (Des Jarlais, et al. 1992; Stimson, 1993; Inciardi, 1992; Sarkar, et al 1993). Particularly relevant are the areas referred to as the "Golden Triangle" and the "Golden Crescent." The Golden Triangle is a major heroin producing region which comprises the area in Southeast Asia where the Lao People’s Democratic Republic, Myanmar, and Thailand meet. (Inciardi, 1992; McCoy and Inciardi, 1995). The Golden Crescent is the second major heroin producing region, and includes districts in the Northwest Frontier Province of Pakistan, the adjacent Badakhshan area of Afghanistan and the Baluchistan area of Iran. (Poshyachinda, 1993; Inciardi, 1992).

The increase of injecting drug use in some countries in Asia, including Thailand, Myanmar, the Lao People’s Democratic Republic, Yunnan Province in China, Viet Nam, and also the northeastern states of India (including Manipur, Mizoram and Nagaland) has been attributed to the availability of inexpensive heroin, grown (from poppies) and produced in the Golden Triangle and distributed along drug trafficking routes in these countries (Stimson 1993, 1994). For example, until the 1960s, opium was produced in the Golden Triangle region for export for refining in the Mediterranean basin. As heroin was refined elsewhere, it was not available for local consumption, and opium was the drug most commonly used in Southeast Asia. However, from the late 1960s onward, the Golden Triangle region experienced an expansion of the refining of opium into heroin. The development of heroin refining was influenced by successful law enforcement against production in the Mediterranean countries and later in Mexico, as well as lower production costs and the growth of the world market (Stimson 1996). Markets for heroin emerged due to the refining and distribution of heroin in the Golden Triangle region, and resulted in availability of the drug at low cost. In addition, enforcement and government activity against dissident groups in Myanmar and the development of new transport networks caused drug trade routes to shift from Myanmar to a route that went through Shan State to Yunnan Province, China and on to Hong Kong (Stimson 1996). Yunnan Province has experienced a corresponding increase in heroin abuse.

Availability of inexpensive heroin is not relegated to countries surrounding the drug producing regions. Countries in Africa, particularly Nigeria, Cote d’Ivoire and South Africa, have become part of the international heroin and cocaine trafficking route, and have experienced increases in injecting drug use in the last 5-10 years. (Stimson, 1993; Mann, et al. 1992; Adelekan, 1995; Adelekan and Stimson 1996).

It is also important to note that there are temporal and regional variations in patterns of heroin use that seem to be influenced by drug production and trafficking routes. Many countries have experienced a shift from predominantly opium smoking, to smoking of heroin ("chasing the dragon"), to injection of heroin, and these shifts correspond with availability of injectable grade heroin (Stimson and Choopanya 1996). For instance, in Madras, India, injection as a route of administration of heroin was uncommon, with most drug users smoking brown sugar heroin (unrefined heroin) until the mid-to late-1980s. Injecting was not reported until 1987. Several factors seem to be related to the shift to injection, including the increased availability of injectable-quality heroin from young people who migrated from Manipur and brought in heroin from South-east Asia. By 1990, injecting was increasingly found in many areas of Madras (Stimson and Choopanya 1996). Similarly, Thailand experienced a shift in the pattern of drug administration which coincided with increased drug production and trade in the Golden Triangle. Within a period of 25 years many drug users Thailand switched from smoking to injecting heroin (Stimson and Choopanya 1996). Other countries, including China (Yunnan Province), Myanmar and Viet Nam have had similar experiences. While the mechanisms of this transition are somewhat unclear, it is accurate to state that where injectable-quality drugs are available, injecting drug use occurs.

Regional variations in the prevalence of smoking versus injecting heroin also exist, and these again correspond to drug production and trade routes. For example, in Myanmar, the areas close to the heart of the poppy growing regions tend to have higher prevalence rates of opium smoking than heroin injecting. However, in areas further from the growing regions and closer to the heroin distribution routes, injecting is more common than smoking (Stimson and Choopanya 1996). Similarly, in certain regions in China along the drug trade route (Yunnan, Guangxi, Guangdong and Sichuan provinces), heroin injecting is common. Drug users in provinces remote from the drug trade routes tend to use less injectable drugs such as "yellow crust" (heroin and opium) and opium (Zheng et al. 1995).

The spread of drug use and injecting can also be examined in terms of innovation and diffusion from upper and middle-classes to poorer classes. In Western Europe, heroin injecting was initially adopted by small groups of individuals, such as jazz musicians, bohemians, and students (Stimson and Choopanya 1996). However, with the increase in heroin produced in South-east Asia in the 1970s and distributed in Europe, injecting spread rapidly to new groups, and subsequently became associated with poor and disadvantaged social groups. The same pattern can be seen in Nigeria. Over the past 15 years there as been an increase in the use of heroin and cocaine as a result of increased trafficking through this area. While consumption of these drugs initially occurred among middle class elites, heroin and cocaine are now used by all classes (Adelekan 1995). Increased availability and decreased prices afford poor individuals greater access to drugs previously limited to wealthier groups.

At the individual level, there are differences in the timing of transition from snorting or inhaling ("chasing the dragon") to injecting, and whether that transition is made at all. Some drug users move from snorting or sniffing to injecting within 6 to 12 months, while others remain dependent on inhaling for over a decade (Strang, et al. 1992). There are several explanations and theoretical perspectives that contribute to understanding this shift in behavior; however, no one model of transition can be specified. Transition at the individual level depends both on contextual factors, including economic, political, and normative influences, as well as individual behavioral factors and individual relationships (see Strang, et al. 1992 for a review of relevant perspectives). Understanding changes in route of drug administration is important for considering HIV prevention programs. Interventions may need to be tailored to specific types of drug users in different stages of their drug careers.

The second hypothesis explaining increased prevalence of injecting drug use is related to law enforcement and drug-related policies. Efforts by law enforcement to control drug use have the effect of increasing drug prices and decreasing availability, thereby creating a need for efficient distribution and consumption of drugs (Des Jarlais, et al. 1992; Inciardi, 1992; Stimson, 1993). Highly processed drugs, such as heroin and cocaine, are more compact and, therefore, more easily transported and distributed than other forms of drugs, such as opium. In addition, injection is a more efficient route of drug administration because none of the drug is lost as it is when smoked. Injection provides a rapid delivery of drug to the brain and a reportedly more intense drug effect (Des Jarlais et al, 1992; Inciardi, 1992, McCoy and Inciardi, 1995; Auerbach 1994). These factors become important to the drug user when drugs are expensive and not readily available. A pilot study of IDUs in Malaysia found that one of the primary reasons cited for administering the drug by injection was to economize on expenses of drugs (Kin 1995). There is also evidence of a temporal relationship between law enforcement efforts to control opium smoking in cities such as Bangkok, Calcutta, and other areas in India, and a subsequent increase in heroin injection (Des Jarlais, et al. 1992; Sarkar, 1995).

In addition, the experience of Southeast Asia discussed above indicates that national drug enforcement policies can result in re-routing of drug transportation, which in turn influences drug consumption patterns. Successful law enforcement efforts against heroin refining in the Mediterranean were partly responsible for the expansion of heroin refining in the Golden Triangle, resulting in increased availability and use of heroin in this area (Stimson, 1996). Also, in the mid- to late 1980s, Thailand began to vigorously pursue law enforcement efforts against opium and heroin production, and implemented crop-replacement programs in opium growing regions in the northern hill areas (Tullis 1995; Stares 1996). These policies have resulted in decreased production of heroin in this country (though not decreased trafficking), with cultivated hectares of opium poppy cut in half (United States, Department of State 1993). However, these drug control efforts also resulted in the displacement of production of opium and heroin into the neighboring country of Laos (Stares 1996; Tullis 1995). Since then, illicit heroin production and trafficking have increased in this country.

Third, increased injecting drug use can be seen as part of modernization of some developing countries (Des Jarlais, et al. 1992; Inciardi, 1992). Improved transportation routes and infrastructure and the availability of industrial chemicals facilitate processing and transportation of illicit drugs (Inciardi, 1992). For example, in India, the prevalence of IDUs corresponds with the path of national highway 39, which originates from a town bordering Myanmar, and cuts across urban areas of Manipur state to reach Nagaland (Sarkar, et al. 1993). IDU prevalence is lower in areas further from this highway.

Demographic characteristics of IDUs. Data indicate that worldwide, the majority of injecting drug users are men (usually upward of 75 percent), and are relatively young, typically in their early twenties to late-30s. Many IDUs are married to non-injecting partners, and education levels vary depending on the country. However, most of what is known about IDUs comes from samples of IDUs in urban areas, and information on IDUs in rural areas comes mostly from small samples from a limited number of regions or villages in a limited number of countries. This makes it difficult to generalize about socioeconomic characteristics of all IDUs. Table 4 presents demographic characteristics of samples of IDUs from selected countries and regions within those countries. Socioeconomic status of IDUs varies across countries. In some areas, such as Bangkok, IDUs seem better off (e.g., have higher education and higher rates of employment). While in others, including Yunnan Province, China, IDUs have very low levels of education. In Yunnan Province in China, IDUs living in rural areas have low levels of education, with one estimate of an average of 2.7 years, and another with about 27 percent receiving no formal education (Xia et al. 1994; Zheng, et al. 1994). A high percentage of IDUs here are married (83 percent in one sample from Longdao village in Ruili county) (Xia, et al. 1994). Characteristics of IDUs in urban areas differ a bit, with higher education levels found in the city. Of IDUs in treatment in a facility in the city of Kunming (Ruili County), over half were employed, 64 percent had at least middle school training, with a median education of 9 years (McCoy, et al. 1996b).

The samples of IDUs in Manipur, India, are also fairly well-educated and tend to be employed, with 78 percent in Manipur able to read up to high school or college levels, and 53 percent employed (Sarkar et al. 1996). In Thailand, as in many other developing countries, IDUs are mainly economically deprived, although they tend to be employed as unskilled workers (Des Jarlais, et al. 1992). Among IDUs in Bangkok, 70 percent are employed. Rio de Janeiro and Santos, Brazil, also have relatively high rates of employment among IDUs (about 55 percent and 50 percent, respectively).

Demographic characteristics may differ between drug users who inject heroin and those who use heroin through other routes of administration. For example, in the study of drug users in villages in Yunnan Province, injectors were more likely to be young (20-39), ethnic minorities, and unmarried, compared to non-injecting drug users who inhaled opium and heroin (Zheng et al. 1994).

Table 4. Demographic Characteristics of Injecting Drug Users in Selected Areas.

a. Computed by taking the midpoint value of age ranges, grouped as follows: <20, 20-24 years, 25-34 years, 35-44 years, 44+ years (20 and 44 used as value from lowest and highest categories, respectively).

b. Computed by taking the midpoint value of ranges, group as follows: 0-4 years, 5-9 years, 10-14 years, 15+ years (15 used as value from highest category).

Mobility of IDUs. IDUs travel extensively both abroad and in their own countries, and inject drugs in these other areas. The WHO Multi-City study (1994) found that substantial proportions of IDUs from all cities in the study, including Bangkok (78 percent), Rio de Janeiro (62 percent) and Santos (53 percent) reported having injected outside their home city within the previous two years. Some of this travel is due to "drug tourism" - where IDUs go to areas where drugs are less expansive to buy them (Simons, 1994). Travel is also due to the drug trade, with IDUs traveling to transport drugs, and to search for employment. When IDUs travel between cities, they are unlikely to carry drugs and injecting equipment with them, for fear of being caught by customs officials or other law enforcement personnel. In this case, traveling drug users may be more likely to share equipment with IDUs from other cities (WHO 1994). In Bangkok and Rio de Janeiro, about 72 percent of IDUs shared needles outside the city in the last two years, and in Santos, about 48 percent reported sharing outside their city. Also, a survey done in Malaysia found that those who traveled to Thailand in the last 5 years were more likely to be infected with HIV than those who had not traveled there (76 v. 26 percent) (Singh, et al. 1993).

Drug Use among Youths. There is a sizable population of youths in developing countries who use illicit drugs. In the Republic of Korea, a survey conducted in 1987 revealed that 1.4 percent of working adolescents reported drug use, and prevalence among institutionalized youths was even higher, at 9.6 percent. About 90 percent of these youths injected drugs (Poshyachinda 1993). High school students in Rio de Janeiro also report injecting drug use. One survey of students from private and public high schools schools found that 0.7 percent of the students reported injecting drug use at some time in their life (Lima et al. 1992).

Drug use among "street youths" (homeless, orphans, or delinquents) is prevalent in a number of areas, including Brazil, Nigeria and South Africa. In Brazil, it is estimated that from 7 to 8 million children live and/or work on the streets. One survey of street children in Sao Paulo, found that 45 percent were heavy drug users (Dimenstein, 1992). Another study in Belo Horizonte (a large city northeast of Rio de Janeiro) revealed that 84 percent of children living full-time on the streets had histories of illicit drug use, and 10.6 percent reported injecting drug use (Campos, et al. 1994). Drug use among street children in Rio de Janeiro is also a problem. One review cites a study where 39 percent of youths interviewed reported drug use to be a problem for them (Surratt and Inciardi 1996). In Nigeria, heroin and cocaine are increasingly being used by young people. In a sample of 217 street youths in a rehabilitation camp in 1993, 87 percent were using cocaine and 89 percent were using heroin, compared to 47 percent and 51 percent using cannabis and alcohol, respectively (Adelekan 1995).