CDF 58/2 SA - Lebanese Medical Journal

ARTICLE ORIGINAL / ORIGINAL ARTICLE A RAPID SITUATION ASSESSMENT (RSA) STUDY OF ALCOHOL AND DRUG USE IN LEBANON http://www.lebanesemedicaljournal.org/articles/58-2/original3.pdf

Elie G. KARAM1,2,3, Lilian A. GHANDOUR3,4, Wadih E. MAALOUF3, Karim YAMOUT.3,5, Mariana M. SALAMOUN3. Karam EG, Ghandour LA, Maalouf WE, Yamout K, Salamoun MM. A rapid situation assessment (RSA) study of alcohol and drug use in Lebanon. J Med Liban 2010 ; 58 (2) : 76-85.

Karam EG, Ghandour LA, Maalouf WE, Yamout K, Salamoun MM. Consommation d’alcool et abus de substances au Liban : Etude RSA (Rapid Situation Assessment). J Med Liban 2010 ; 58 (2) : 76-85.

ABSTRACT • BACKGROUND : Research on substance use and misuse in Lebanon is scarce and, when available, focuses on a specific substance or a limited segment of the population. The objective of this Rapid Situation Assessment (RAS) study was to survey the use of multiple substances in diverse segments of the Lebanese population. METHODS : A multi-method and multi-sample survey was conducted to collect quantitative and qualitative data from the academic sector (high school and university students), substance users in treatment or under arrest (prison, detention), and non-institutionalized “street” users. RESULTS : Age of first use of substances started as early as 9 years in the youth sample. Moreover, 12% of the high school students reported smoking one or more packs of cigarettes per day and 9% of the university students met criteria for DSM-IV alcohol abuse. Cannabis represented the most commonly used illicit drug in both high school and university students, and tranquilizers were the most frequently misused medicinal substance. Heroin was responsible for 50% of the treatment admissions, followed by cocaine (20%), and alcohol (20%) ; heroin was also the most common substance of arrest. Recidivism was almost the rule for heroin users across all treatment settings. Unperceived need for treatment was the most common reason for not seeking treatment in non-institutionalized drug users (47.6%). Injecting drug use was a common behavior noted within substance using populations, in treatment and non-institutionalized (about 50% of them), with a high rate of needle sharing practices. About half of all patients in treatment had a history of police arrests, and about one-third of those in prison ever received prior treatment for substance use. CONCLUSION : The study points towards a growing trend for substance use problems in early adolescence that warrants close monitoring. Further investigation of these patterns is needed since the Lebanese population might have specific pathways of abuse. There is a need to bring together various health, legislative, and academic stakeholders for a continuous appraisal of data from substance abuse studies as evidenced by the recent, although slow, progress in the fields of legislation and treatment that follow such concerted efforts.

RÉSUMÉ • CONTEXTE : Les recherches sur la consommation et l’abus de substances sont peu nombreuses et souvent limitées à certaines substances ou à des échantillons réduits. L’objectif de cette étude RSA (Rapid Situation Assessment) est d’examiner la consommation et l’abus de substances au Liban. MÉTHODE : Des données quantitatives et qualitatives ont été recueillies dans plusieurs secteurs : académique (lycées et universités), médical (centres de réhabilitation et hôpitaux), sujets en captivité (prisons et centres de détention) ainsi que les consommateurs « non institutionnalisés » ou consommateurs « de rue ». RÉSULTATS : La consommation de substances parmi la jeunesse libanaise débute à un âge précoce, dès l’âge de 9 ans pour certains. 12% des étudiants au lycée fument au moins un paquet de cigarettes par jour et 9% des étudiants à l’université remplissent les critères d’abus d’alcool du DSM IV. L’usage de cannabis figure en tête de liste des substances illicites consommées et les tranquillisants sont les substances les plus fréquemment utilisées parmi les jeunes au lycée et à l’université. L’héroïne est responsable de 50% des admissions en traitement, suivie par la cocaïne (20%) et l’alcool (20%). Les causes d’arrestations de la population en détention durant l’étude sont principalement liées à la consommation d’héroïne. La majorité des consommateurs d’héroïne rechutent après le traitement ; 47,6% des consommateurs de drogues « non institutionnalisés » n’éprouvent aucun besoin d’être traités. L’injection de drogues est fréquente parmi les consommateurs en traitement et ceux « non institutionnalisés » (environ 50%), avec une récurrence de la pratique des seringues partagées. Environ la moitié des patients sous traitement ont été victimes d’arrestations durant la période de consommation de drogues et environ le tiers des consommateurs en prison n’ont jamais reçu de traitement pour abus de substances. CONCLUSION : Les résultats de l’étude confirment l’expansion de la consommation et de l’abus de substances parmi les préadolescents et les adolescents libanais. Il est nécessaire de mener de nombreuses investigations afin d’en déterminer les spécificités. Ces résultats viennent s’ajouter à ceux d’autres recherches et permettent de préconiser et d’orienter une politique d’action dans les secteurs de la santé, législatif et académique, afin d’établir les fondements d’un système de bases de données concernant la consommation et l’abus de substances.

1

Department of Psychiatry and Clinical Psychology, School of Medicine, Balamand University, Lebanon. Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon. Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), Lebanon. 4 Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon. 5 Georgia School of Professional Psychology, Argosy University, USA. Corresponding author : Dr. Elie G. Karam, MD. Institute for Development, Research, Advocacy and Applied Care (IDRAAC). St. George Hospital University Medical Center. P.O. Box 166227 Ashrafieh. Beirut 1100-2110. Lebanon. Tel / Fax : +961 1 583 583 e-mail : [email protected] 2 3

INTRODUCTION

Research on the use and misuse of substances in Lebanon is scarce, and the available studies mainly focus on either specific substances (e.g. nicotine, alcohol) [1-5] or specific populations, namely students [6-7, 3]. The existing literature indicates that alcohol is the substance of choice among sampled school [8] and university students [3, 9] in Lebanon, whereas heroin is the substance accountable for most substance use-related treatment and rehab admissions [10-12]. Findings from a study that monitored substance use among university students in 1991, predicted a probable increase in the use of licit and illicit substances due to a noticeably earlier age of onset of substance use reported by consecutively younger age cohorts [7]. Other studies [1-7], mainly surveying nicotine use, provide supporting evidence that the proportion of cigarette use among youth may potentially be increasing and that substance use in general warrants closer monitoring. Nonetheless, all available studies fail to draw a comprehensive sketch (within the same timeframe) on the use of various substances in multiple segments of the population. National drug control strategies do best when based on a reliable, up-to-date and comprehensive understanding of national patterns of drug use and their relation to other risky behaviors. Globally, and as part of the United Nations General Assembly Special Session, the year 1998 witnessed the adoption of the political declaration that committed governments to substantially reduce illicit drug demand and supply by 2008 [13]. Local governments were incited to collect epidemiologically sound and comprehensive data to ensure future evidence-based policy-making and resource allocation. In cooperation with the government of Lebanon, and in an effort to ratify this political declaration, the United Nations Office on Drugs and Crime (UNODC) commissioned IDRAAC (Institute for Development Research Advocacy and Applied Care) in 2001, in association with the Department of Psychiatry and Clinical Psychology at Saint George Hospital University Medical Center and Balamand University, to assess the substance use situation in Lebanon based on the United Nations Guidelines on Drug Abuse Rapid Situation Assessment and Response [14] (referred to here on as such). The Lebanon RSA study (in line with the RSA guidelines) aimed at understanding the nature and extent of drug and alcohol misuse, the availability (or lack of) resources needed to address prevailing related issues, and ultimately developing evidence-based recommendations and appropriate responses [14]. This paper summarizes the key findings and mainly focuses on the extent and patterns of use and misuse of alcohol and drugs among high school and university students. In addition, it provides a focused evaluation, in a cross sectional paradigm, of substance users in several settings : hospitals, rehabilitation centers, street, and detention centers (including prison). The paper also highlights some of the main data-oriented recommendations that were generated (and discussed among several local and

international stakeholders). The extensive RSA findings and a comprehensive list of recommendations that emanated can be found in the full report [14]. METHODS

Procedures This study was conducted with the use of the Drug Abuse Rapid Situation Assessment and Responses methodology developed by the United Nations Office for Drug Control and Crime Prevention (UNODCCP at the time, UNODC at present). The RSA is a research modality that relies on a combination of qualitative and quantitative data collection techniques through a variety of data sources. The methodology was approved by the Institution Review Board (IRB) of Balamand University School of Medicine and all study participants were insured confidentiality and anonymity. Samples Several surveys were conducted to collect quantitative data from diverse segments of the population : youth at the high school and university level were surveyed, as well as institutionalized and non-institutionalized substance users. The study also included a qualitative component which was derived from focus group discussions and key informant interviews with several health professionals and other experts in the field of substance use prevention, treatment, and policy-making. Findings from the qualitative part of the Lebanon RSA study are published in the full report [14]. The following is a brief description of the methods used in each of the surveys (described in more detail elsewhere) [14]. High School Survey : A cross-sectional study was conducted on 1307 high school students (i.e. eleventh and twelfth graders) recruited from ten private schools selected from the four largest cities in Lebanon (Beirut, Tripoli, Sidon and Zahle). All students in the participating schools completed an anonymous self-filled questionnaire that assessed a number of demographic characteristics, cigarette use, and the patterns of use and misuse of various other licit (e.g. alcohol, stimulants/amphetamines, tranquilizers/barbiturates, and medicinal opiates) and illicit (i.e. hashish/marijuana, cocaine, ecstasy, and heroin) substances. Questions on several correlates of substance use (e.g. availability and attitude towards use) were also included. The instrument was developed by IDRAAC with the expertise of other institutions including the National Institute for Drug Abuse (NIDA), European Monitoring Center for Drugs and Drug Addiction [15], Institute for Social Research at the University of Michigan (which is responsible for the annual Monitoring the Future Surveys), and the Pompidou Group (who conduct the yearly European School Survey Project on Alcohol and Other Drugs). University Survey : In 1999, IDRAAC completed Phase II of the Substance Use University Monitoring Study which surveyed 1837 students who were enrolled in

E. G. KARAM et al. – Rapid Situation Assessment of substance use in Lebanon

Lebanese Medical Journal 2010 • Volume 58 (2) 77

two of the largest private universities in Lebanon [3, 16] and represented 25% of the student population in each university. Students were sampled using a stratified cluster sampling (cluster = major of study). The Phase II data were analyzed as a source of primary data for the present RSA study. Substance abuse and dependence were examined using questions from the Diagnostic Interview Schedule version IV (DIS-IV) [17] based on the Diagnostic Statistical Manual criteria (DSM-IV). Similar to the high school survey instrument, this questionnaire included additional sections on availability of substances, attitude towards substance use, and other potential environmental and individual risk and protective factors. Treatment Survey : A cross-sectional survey was conducted sampling all 162 consecutive substance-related inpatient admissions and outpatient visits over a three-month period (April-June 2001) (except for one center where the data collection period lasted up to six months). Six hospitals renowned for their substance use treatment services have been contacted but only five (American University of Beirut Medical Center, Cross Hospital, Serhal Hospital, St. George Hospital University Medical Center, and St. Charles Hospital), as well as the most established substance use rehabilitation center (Oum el Nour) participated in various capacities to the study. The treatment sample (n = 162) is comprised of three sub-samples : substance users awaiting to be screened for admission to the rehab center (referred to as “accueil” sample, n = 57), substance users in rehab at the time of the survey (rehab sample, n = 33), and substance users who were in a hospital or made an outpatient visit to a hospital-affiliated clinic at the time of the survey (hospital sample, n = 72). Data was collected using a face-to-face structured interview developed by IDRAAC that included sections similar to that in the ISF survey questionnaire (described below) and adapted to their treatment status. All the interviewers from the respective treatment centers were trained by IDRAAC members, specifically the co-authors who are epidemiologists (LG, WM). Internal Security Forces Survey : A cross-sectional survey was conducted on all those arrested (n = 52) over a period of two months (April 15-June 30) in 2001 for drug related offences (e.g. possession, use, facilitation) in all four branches of the Internal Security Forces (ISF) Drug Enforcement Offices in Lebanon. IDRAAC, in coordination with the ISF team, and in consultation with the European Monitoring Centre for Drugs and Drug Addiction [15], developed a questionnaire to specifically collect treatment and rehabilitation history, legal history (e.g. arrests and/or imprisonment), and other factors in this subpopulation. About 14% of the ISF sample was arrested for drug dealing, which in the context of this study includes only the small-scale facilitators. Interviewers were trained by the same IDRAAC trainers. Prison Survey : This survey included all those incarcerated (n = 64) at the time of the study (July-September 2001) in Roumieh prison for primary or secondary drugrelated offences or those detained in prison for drug-relat78 Lebanese Medical Journal 2010 • Volume 58 (2)

ed offences awaiting the judiciary verdict. All prisoners were interviewed face-to-face, in private, and using the ISF survey questionnaire. Interviewers were also trained by the same IDRAAC trainers. Street Users Survey : Field workers were trained by IDRAAC to identify, using the “snowballing technique,” drug users “on the street” (substance users who are not in treatment or under arrest or in prison at the time of the survey). Over a period of three months (April-June 2001), substance users who were mainly using hard drugs (i.e. excluding marijuana only users) were interviewed (n = 103). Recruitment first took place from areas with known “hotspots” for drug use and dealing. Consequently, identified users then led the field workers to other drug users [18]. Data was collected through face-to-face interviewing using an instrument similar to that of the ISF and treatment surveys. Analyses All quantitative data was entered into the computer using the Fox Pro statistical software. Analysis was conducted using SPSS. The appropriate statistical analyses were carried depending on the nature of the outcome variable (e.g. binary, categorical, continuous), mainly, Pearson’s chisquare tests and logistic regression analysis (α was set at the 0.05 level). RESULTS

The results will be presented by survey, beginning with the youth in the academic sector, and then followed by findings on substance users institutionalized in their respective settings at the time of the survey. Academic sector High School Survey : The mean age of the surveyed students, 17.1 (± 0.9) years was composed of slightly more males (51.8%) than females. More than two thirds (70%) were lifetime alcohol drinkers, the majority (96.4%) of whom had had at least one drink in the preceding year. About one in four high school students (26.7%) reported ever getting drunk, and 7.4% (11.4% of the lifetime drinkers) were diagnosed with DSM-IV defined lifetime alcohol abuse (i.e. reported at least one alcohol-related problem at the health, social and/or legal level). About 17% reported smoking cigarettes daily for a period of one month or more in their lifetime (from hereon referred to as ever regular smokers). Moreover, 12.1% reported smoking one pack or more per day during the time period they defined as the one during which they had smoked the most (Table I). Regarding the use of illicit substances, about 9% of the sample reported ever trying any illegal drug once or more. Slightly more than half of the lifetime users of any illicit substance had tried hashish/marijuana only, rendering cannabis the most commonly tried illicit substance. About 3% of the high school students also reported having ever taken tranquilizers for non-medical reasons or without a


TABLE I DEMOGRAPHIC CHARACTERISTICS OF THE ACADEMIC (HIGH SCHOOL AND UNIVERSITY) RSA SAMPLES AND EVER USE OF SUBSTANCES HIGH SCHOOL SAMPLE 2001

N Ever use : N (%) Cigarettes Alcohol Hashish/Marijuana Heroin Cocaine XTC* Amphetamines/Stimulants Tranquilizers MO/Barbiturates* a

UNIVERSITY SAMPLE 1999

Total

Female

Male

Total

Female

Male

1303

628

675

1837

967

870

225 898 88 10 22 36 15 43 16

(17.3%) (69.1%) (6.8%) (0.8%) (1.7%) (2.8%) (1.2%) (3.3%) (1.2%)

89 392 27 1 9 9 7 27 8

(14.2%) (62.9%) (4.3%) (0.2%) (1.4%) (1.4%) (1.1%) (4.3%) (1.3%)

Difference between genders is statistically significant, p < 0.005.

136 504 61 9 13 27 7 15 8

(20.2%)a (74.9%)a (9.1%)a (1.3%)b (1.9%) (4.0%)a (1.0%) (2.2%)b (1.2%) b

402 1295 155 15 22

(21.9%) (70.8%) (8.8%) (0.8%) (1.2%)

181 649 58 3 9

(18.9%) (67.7%) (6.3%) (0.3%) (1.0%)

76 (4.3%) 54 (5.9%) 231 (13.1%)138(15.0%) 92 (5.2%) 50 (5.5%)

221 645 97 12 13

(25.4%)a (74.3%)a 11.4%)a (1.4%)b (1.5%)

22 (2.6%)b 93 (10.9%)b 42 (4.9%)

Difference between genders is statistically significant, p < 0.05.

* XTC : ecstasy ; MO : medicinal opiates doctor’s prescription or recommendation. The proportion of lifetime use of other substances was less than 2% (Table I). Significant gender differences were observed (Table I). Lifetime use of alcohol, hashish/marijuana, heroin, and ecstasy (XTC) was higher in males (ratio : 2:1 for any illicit substance) whereas females were more likely to report ever having taken a licit substance for non-medical purposes (ratio : 3:2). Upon examining the age of onset of substances in this sample, we found that high school students tend to first use alcohol (around age 13), then cigarettes (around age 14), followed by no clear chronological order of other substances (around age 15-16 years) (Table II). Students’ attitude towards substance use and their perception of its harmfulness was also assessed. Only 10.1% of the students thought cocaine was as “bad” as heroin. Slightly more than half of the students thought that the use

of ecstasy or hashish/marijuana (57.7% and 57.3%, respectively) was a crime ; about three-fourth (75.7%) thought the same of cocaine or heroin. Only 8.6% thought that the use of hashish/marijuana would lead to the use of “harder” drugs and 26.6% thought that ecstasy or hashish/ marijuana was as bad as cocaine/heroin. With respect to the perceived availability of substances, slightly less than half of the sample (44.2%) reported that it was easy/very easy to obtain tranquilizers and more than one in ten students (15.5%) thought heroin was easily/very easily available. High school students in this sample were also asked about whether they have ever sought help due to their substance use, and only 2.8% of the sample reported ever receiving any kind of professional help for substance use problems. University Student Survey : The mean age of the university sample (47.4% males) was 20.2 (± 1.6) years. Similar to the high school students, about 70% of the uni-

TABLE II AGE-OF-ONSET OF EVER-USE OF SUBSTANCES IN THE ACADEMIC (HIGH SCHOOL AND UNIVERSITY) RSA SAMPLES HIGH SCHOOL SAMPLE 2001 Mean (± SD) years Cigarettes Alcohol Hashish/Marijuana Heroin Cocaine XTC* Amphetamines/Stimulants Tranquilizers MO/Barbiturates*

14.8 13.3 16.1 15.2 15.0 16.0 15.6 15.7 15.7

(2.0) (2.8) (1.5) (1.7) (2.6) (1.7) (1.3) (1.3) (1.3)

UNIVERSITY SAMPLE 1999

Min-Max

Mean (± SD) years

7-19 2-20 9-19 13-17 10-19 9-18 13-17 13-19 13-17

Min-Max

17.5 16.1 17.7 17.9 18.1

(2.1) (2.6) (1.8) (2.0) (2.0)

9-23 5-30 14-23 16-22 15-22

17.0 17.5 15.9

(2.1) (2.7) (3.7)

12-22 7-27 5-22

* XTC : ecstasy ; MO : medicinal opiates.



versity students had tried alcohol, with almost all of the lifetime users (97%) having had at least one drink in the preceding year. About one-fourth of the sample reported ever getting drunk (23.7%), and 9.1% (12.9% of the lifetime drinkers) were diagnosed with DSM-IV lifetime alcohol abuse. About 12% of the student sample (57.7% of the ever-regular smokers) reported smoking cigarettes daily during the preceding month. A third (31.4%) of the current smokers were light smokers (i.e. less than 10 cigarettes/ day), 44.1% were moderate smokers (10-20 cigarettes/ day) and the remaining quarter (24.5%) were heavy smokers (more than 20 cigarettes/day) during the period they had smoked the most. The proportion of lifetime use of marijuana/hashish, cocaine and heroin among this university sample was 8.8%, 1.7%, and 0.8% respectively. About 13.0%, of the students reported ever taking tranquilizers (e.g., Valium®, Lexotanil®, Ativan®, Xanax®, etc.) for non-medical reasons. Similar to the high school sample, university-level males reported a higher percentage of lifetime use of alcohol, hashish/marijuana, and heroin while females were more likely to have had ever taken tranquilizers for nonmedical reasons. A comparable proportion of males and females reported lifetime use of cocaine (1.5% and 1.0% respectively) and barbiturates (4.9% and 5.5% respectively) (Table I). The age of onset for using substances, other than cigarettes and alcohol, ranged from 15.9 years (barbiturates) to 18.1 years (cocaine) (Table II). The majority of the university sample (95.3%) perceived drugs as harmful, but still 15.6% and 6.7% of the students were for the legalization of hashish/marijuana and cocaine or heroin, respectively. Only 2.1% of the sample reported ever seeking professional help for substance use problems (excluding alcohol). Institutionalized substance users Substance users institutionalized either in a treatment/ rehab setting, or prison or by the security forces during the time of data collection (April-June 2001) were surveyed on a number of factors related to their current/past treatment and current/past arrest, as well as other risky behaviors. Institutionalized substance users are users who were either at a treatment (hospital/rehab) setting or seeking one (acceuil sample), arrested (ISF survey), or in prison (prison survey). Given the particularity of those surveyed, it is important to interpret the findings in light of their demographic distribution. Demographic characteristics : Institutionalized users were predominantly male (> 80%), with the majority between 20-40 years of age (65-76%). The proportion of illiterates (defined as neither reads nor writes) was relatively low in the treatment samples (range : 0%-7%) and higher in the ISF and prison samples (15% and 11% respectively). The large majority (50%-87%) of all samples, excluding notably the accueil (18%), were employed (incidentally reflecting the selection process from accueil to the rehabilitation treatment of the same center). Almost two thirds of all the substance using samples reported 80 Lebanese Medical Journal 2010 • Volume 58 (2)

never being married, less so among the prison sample (45.3%) and more so among those in rehab (81.8%), which requires one year full time residency program, potentially causing disruptions of financial responsibilities for applicants who are married. The living arrangement of all the users followed the typical Lebanese culture (i.e. living with family, either parents or spouse). The following paragraphs highlight the main findings pertaining to each of the institutionalized substance using samples. 1. Treatment Survey (accueil, hospital & rehab samples) The following paragraph describes the users’ substance use profile, keeping in mind that all were either seeking or in treatment/rehab for their alcohol and/or drug use. The most commonly reported substance as the “substance of admission” to accueil rehab was heroin (70%). About a third of the users in rehab reported having sought treatment for cocaine (30.1%), keeping in mind that respondents may have reported more than one substance. For the hospital sample, slightly less than half (47.5%) reported heroin as being the substance responsible for their hospitalization ; 20%, 20%, and 15% reported alcohol, cocaine, and tranquilizers, respectively. Regarding the sources of referral to treatment, the most commonly reported ones were personal willingness and family pressure, and the least reported source was the ISF (1.7%) (Table III). About 40% (n = 63) of the treatment sample was seeking treatment for the very first time. Reasons for not seeking prior treatment for their substance use included embarrassment (5%), cost (3.6%), and most commonly not perceiving the need to (47.6%). Among the remaining 60% who had sought prior treatment (n = 95), approximately one-third were non-compliant (35.6%), the highest non-compliance rate being among those who had last received outpatient treatment (50%). The most common reasons reported for non-compliance were : “to resume use” (36.4%) and “disliking the treatment center” (31.8%) ; cost was not reported as a reason. Quite importantly, the majority (75%) of those who were in treatment or seeking treatment at the time of the survey had their previous admission a year or less earlier. Recidivism was common among heroin users whereby 96% of those who were admitted for heroin had had a previous admission for heroin. The same was true for alcohol users (83.3%). Inpatient treatment was the main mode of previous treatment, among those who were previously treated ; this was true for substance users in all treatment modalities at the time of the survey. Almost a quarter of those who were in the accueil or rehab center had been in rehab before (data not shown). Other risky behaviors among the treatment sample were also examined. Injection drug use was reported by about half of the substance users in accueil and the rehab center and was lowest in hospital treatment cases (25.4%). Among the IV drug users, 1 in 4 at least additionally reported ever having shared needles. Sex under the influence of drugs was quite common among those who were in and/or seeking treatment or rehab (78-90%). Unpro-


TABLE III MODE OF TREATMENT AND SOURCE OF REFERRAL AMONG THE SUBSTANCE USING SAMPLES SUBSTANCE USING SAMPLES Treatment Sample

N Age (yrs), Mean ± SD Ever admitted N (%) Mode of treatment Outpatient Inpatient (hospitals) Rehabilitation centre Source of Referral Personal determination Family pressure Peer pressure ISF referral Escaping ISF Overdose Others

ISF

Street

Prison

Accueil

Rehab

Hospital

57 30.4 ± 9.6 39 (69.6%)

33 28.1 ± 9.8 17 (51.5%)

72 31.1 ± 11.9 39 (56.5%)

52 33.8 ± 12.4 17 (34.7%)

103 33.8 ± 11.1 37 (35.9%)

64 33.3 ± 8.2 20 (31.3%)

2 (5.1%) 26 (66.7%) 11 (28.2%)

2 (11.8%) 11 (64.7%) 4 (23.5%)

4 (11.1%) 31 (86.1%) 1 (2.8%)

1 (7.1%) 9 (64.3%) 4 (28.5%)

6 (16.2%) 31 (83.8%)

0 (0.0%) 17 (85.0%) 5 (25.0%)

43 19 2 2 1

17 (51.5%) 19 (57.6%) 3 (9.1%)

34 29 3 1 7 1

(81.1%) (35.8%) (3.8%) (3.8%) (1.9%)

4 (12.1%) 1 (3.0%)

(57.6%) (49.2%) (5.1%) (1.7%) (11.9%) (1.7%)

12 (85.7%) 1 (7.14%) 1 (7.14%)

7 24 10 1 1

(19.4%) (66.7%) (27.8%) (2.8%) (2.8%)

15 (75.0%) 4 (20.0%) 2 (10.0%)

2 (5.6%)*

* Travel temptation tected sex under the influence of drugs was most commonly reported among drug users in accueil and in hospitals (Table IV). Reports of antisocial behavior during the 12 months prior to the survey were more common among users in rehab than accueil or hospitals (Table IV). The arrest history of the substance users who were seeking or in treatment at the time of the survey was also examined. Approximately half of those in rehab (45.5%), accueil (49.1%), and a third of the hospital sample (32.4%) had been arrested, two thirds or more for drugrelated reasons. Heroin was the main substance of arrest

(46.2% hospitals, 76.2% accueil, and 81.8% rehab). A considerable portion of the arrests (more than 60%) had taken place more than two years prior to the time of survey. The most common verdict for arrest as reported by those in accueil and rehab samples was imprisonment (65% and 45.5%, respectively) ; as for those who reported ever being arrested among the hospital sample, 30.8% had been imprisoned, and more than 53.8% were released without paying a fine. Quite importantly, only 10% or less of the arrested ever users (majority being arrested for drug use) had been sent to rehab for treatment.

TABLE IV DEMOGRAPHIC PROFILE, RISKY BEHAVIORS AMONG THE SUBSTANCE USING POPULATION SUBSTANCE USING SAMPLES Treatment Sample

N Risky behavior IV use Sharing needlesa Sexb Use of protectionc Antisocial behavior Frequent fights with family* with non-family** Ever shoplifting a

Among IV users

b

Accueil

Rehab

Hospital

57

33

72

28 7 51 29

(50.0%) (25.0%) (89.5%) (24.1%)

11 (19.3%) 5 (8.8%) 18 (32.7%)

17 6 30 29

(51.5%) (35.3%) (90.9%) (58%)

14 (42.4%) 15 (45.5%) 29 (87.9%)

Sex under the influence of substances.

c

18 6 52 11

(25.4%) (33.3%) (78.8%) (36.7%)

17 (25.4%) 16 (24.2%) 9 (13.6%)

21 7 25 17

ISF

Street

Prison

52

103

64

(43.8%) (33.3%) (67.6%) (70.8%)

5 (10.9%) 5 (10.2%) 2 (4.4%)

27 17 90 21

(26.7%) (63.0%) (90.9%) (24.1%)

39 (38.3%) 63 (61.8%) 47 (45.6%)

23 2 57 26

(35.9%) (8.7%) (89.1%) (45.6%)

11 (17.2%) 10 (15.6%) 19 (30.2%)

Among those who reported ever having had sex under the influence of substances

* Daily fights or several times per week within the past 12 months preceding the survey. ** Three or more times within the past 12 months preceding the survey.



2. ISF Survey While 73% of the ISF sample reported lifetime alcohol use and 54% had had a drink at least once in the preceding 12 months, none of those in the ISF sample endorsed any of the symptoms of alcohol abuse and only 4.3% were diagnosed with alcohol dependence. All those arrested were detained for a drug use related reasons, and the most common substance behind their arrest was heroin (75%) followed by hashish/marijuana (35%) then cocaine (15%), keeping in mind that each of these substances may have been reported alone or in combination. Slightly more than half (55.1%) of those currently under arrest were “recidivists” (i.e. were arrested once before for drug or nondrug related reasons) and half of the previous arrests had occurred two or more years prior to this survey. The most frequently reported reason for a prior arrest was drug use (85.7%), followed by drug dealing (9.6%), bearing in mind that each respondent may have reported more than one reason for arrest. The ISF sample’s treatment history was also examined. The majority had sought treatment at least once for the use of heroin (alone or in combination with another substance, 63.6%). The most commonly reported mode of treatment was inpatient (i.e. hospitalization) (64.3%), the majority having done so out of personal determination (85.7%) (Table III). The most commonly reported reason for noncompliance to previous treatment in this sample was cost (40%). With regards to their other risky behaviors, more than one-third reported injection drug use (43.8%). Slightly more than two-thirds of the sample reported having had sexual intercourse under the influence of drugs (67.6%), a majority (70.8%) of which had had unprotected sex under the influence of drugs. Antisocial behaviors during the year preceding the survey was reported by 4 to 11% of the sample (Table IV). 3. Prison Survey Among the prison sample, 94% reported lifetime use of alcohol and 67% had had a drink in the 12 months preceding imprisonment. About a third of the prison sample was diagnosed with lifetime alcohol abuse or dependence (33.4% and 34.4%, respectively). Lifetime abuse and dependence of other substances was 62.9% and 65.1%, respectively. Approximately a third of the prison sample had ever sought treatment (31.3%), mainly for heroin use (84.2 %). The majority of those who reported never having had sought treatment for their substance use reported “not perceiving the need to” as the main reason (61.4%), while “personal determination” was the main impetus among those who had sought care (Table III). Slightly less than half (45.1%) of those who reported not complying with previous treatment reported having done so “to resume use”. The proportions of risky and antisocial behaviors associated with substance use in this sample are shown in Table IV. Two thirds of the prison sample (68.8%) had been previously arrested, mostly for drug-related reasons (70.5%). 82 Lebanese Medical Journal 2010 • Volume 58 (2)

The most common substance of past and current arrest at the time of the survey was heroin (61.3% and 47.5% respectively). A considerable portion of the arrests took place more than two years prior to the survey, with the most common outcome being imprisonment. Non institutionalized substance users Street Survey The mean age of the street sample was 33.83 ± 11.13 years. The majority were males (82.5%), 60.4% were single, 24.5% were unemployed and none reported being illiterate. Almost all the street sample (99%) was diagnosed with lifetime DSM-IV defined alcohol abuse and about a third (32%) with alcohol dependence. The majority (89.2%) of the sample had been abusing and 80.6% were DSM-IV dependent on their primary drug (identified by the respondent as the drug used most within the preceding year). However, slightly more than half (58.2%) of the street users reported never receiving any type of treatment for their substance use. Among those who had been treated, only 9% reported having received any treatment in the preceding 18 months. Heroin was the main substance for their treatment (alone or in combination with another substance, 83.8%), followed by cocaine (10.8%). The most common mode of previous treatment was rehabilitation (83.8%), the majority having had chosen to receive care due to personal determination (Table III). However, 71% of those previously treated reported noncompliance to treatment because they “disliked the center” (71%). Risky and antisocial behaviors among street users included mainly sex under the influence of drugs and frequent fights with non-family members (Table IV). Additionally, approximately one-third (35.9%) had had been ever arrested ; two thirds (65.7%) of the previous and/or current arrests were for drug-related reasons, especially heroin (85.7%). Slightly more than half of the arrests (55%) had occurred at least in the preceding two years. DISCUSSION

The purpose of this assessment modality (RSA) is to provide policy makers and health officials with an overview of key epidemiological findings for the problem under consideration from multiple different angles and in different settings. This was not meant to be and is not a nationally representative sample and thus carries with it all the important limitations that are embedded within such a survey methodology. The latter focuses at one point in time at several subgroups of the Lebanese population in an attempt to draw a sketch of the prevailing conditions in the country, and suggest accordingly future steps at the level of research, local resources, policy, and intervention. To help draw that preliminary picture, the present study examined the use and misuse of alcohol and drugs not only among youth in high schools and universities but also in settings where substance users gravitate : among


their friends (“street”), in inpatient and rehabilitation treatment centers, as well as detention centers (under arrest and jail), to furthermore gather more details about their experiences in those settings. Given the findings from the youth samples, substance use tends to initiate during the early teenage years (14-15 years), with alcohol and nicotine being the first substances that young people tend to experiment with, followed by cannabis (hashish/marijuana) and the other drugs but not necessarily with cannabis first thus frequently violating the “gateway theory” [19]. These findings from the present Lebanon RSA study corroborate those of international studies on youth, more so in the Western world [15, 20-21] and far Eastern [22] than those from the Arab world [23]. Correlates of violators of the gateway theory, in its second part (cannabis following other drug use) will need a more focused study. Reports from the NCS-R study in the US points to the probable effect of early onset mental disorders on the violation of the gateway theory [24]. Alcohol is a less socially stigmatized substance in Lebanon relative to the other substances, and can be legally purchased from most stores. Alcohol-related findings in the present study warrant close attention and further monitoring, particularly that a substantial portion of the youth samples reported alcohol-related problems. Although many of the young alcohol users might later on reduce their consumption, early initiation of alcohol has been linked to a greater risk for alcohol use disorders [2527], and an increased likelihood of experimenting with a variety of illicit substances [27-28]. Tobacco is another substance which is readily available to the Lebanese youth ; for example in year 2008 Lebanon consumed about 8 billion cigarettes/year which is about 2000 cigarettes per year per capita (personal communication with Mr. W. Bizri, President of International Chamber of Commerce, Vice-President of the Association of Lebanese Industrialists, June 2009). Experimentation with illicit drugs, not only for cannabis but also for cocaine, was also noted (as elsewhere in the world) to begin quite early in youth (1.7% and 1.2% of the high school and university sample reporting lifetime cocaine use). Examining the substance using samples yielded more in-depth findings regarding their current or past treatment and arrest history, although the methodology of this study was not meant to accurately represent the total population of substance users in Lebanon. Heroin was the most commonly reported substance in demand for treatment, followed by cocaine and alcohol. The most commonly reported reason, by far, for not seeking treatment was “not having perceived the need do so.” On a parallel level, personal willingness and/or family pressure were the main impetus for substance users to seek help, and quite importantly, more than a quarter of the treatment samples reported positive peer pressure as a reason. These findings highlight the importance of the collective effort needed to encourage drug users to seek help. Quite importantly, non-compliance to treatment and recidivism rates were high, pointing not only to the known difficulties gen-

erally inherent in the treatment of substance dependence, but also to the need for availability of additional variety of drug treatment services integrated in a recovery oriented continuum of care. Incarceration was quite a common outcome for drugrelated arrests, and more than half (55.1%) of those under arrest at the time of the study were “recidivists”, the most frequently (85.7%) reported reason for previous arrest being drug use. Quite interestingly, about half of those in treatment at the time of the study had previously been arrested, and a third of those under arrest at the time of the study had ever been treated. This highlights the impressive record of the Lebanese Internal Security Forces, but nevertheless and more importantly underlines the importance of initiating and sustaining a collaborative effort between the legal and the health sectors on multiple levels including (but not limited to) : regular updating of the legislative process on the use and misuse of substances and related offenses, availability of adequate care and referral in the detention centers, legal representation and counseling in the treatment institutions, and above all the need to activate the existing interagency bodies that deal with the different facets of this significant health problem. Although they cannot be generalized, our findings pertaining to high risk drug use, particularly in terms of IV use, needle sharing and unprotected sex, are indicative of some of the negative health and social consequences associated with drug use. This is namely with regards to sexually transmitted diseases, HIV Hepatitis B and C risk, stressing the importance of adopting harm reduction strategies (e.g. reducing risky behaviors among existing users) to complement the available drug demand reduction services. Prevention should begin at an early stage to include at-risk populations such as students in schools and universities, and extend to substance using populations via outreach and drop-in programs, providing harm reduction services. Our findings have shed some light on the drug and alcohol use conditions in two different segments of the Lebanese population : those who are still at-risk of use or more frequent and harmful use (i.e. high school and university students), and those who are already under arrest, in prison, or in treatment or rehab for their substance use. The goal of the RSA methodology is not to unfold representative national findings but more to try and “solve a puzzle by bringing in as many pieces as possible together” for the purpose of alerting national stakeholders such as researchers and policy makers to undertake further action. Given that both general youth and substance users were examined, this study carries many significant implications on the primary as well as secondary and tertiary prevention levels. Several recommendations based on the present RSA findings were drafted, discussed and revised among international and national substance use experts to address issues on the prevention, treatment, and legal levels, for the ultimate development of a national action plan for drug demand reduction in Lebanon [14]. The recommendations were categorized under four themes : the role of the Leba-



nese ministries, substance use prevention and awareness, substance use health care services, and substance use legal and judicial system. Across all four themes, recommendations addressed topics such as general directions for substance use prevention and awareness, action assignments to parents and school administrators, promotion of demand reduction services, establishment of treatment or rehab centers, relapse and aftercare, the need for research, prisons and correctional facilities, provision of alternatives to conviction and punishment, and control over the availability of licit substances. The full set of recommendations are available in the report [14], while the process of drafting a national action plan for drug demand reduction has been slow given the political upheavals and other health priorities. The Lebanon RSA study, nonetheless, has thus far helped bring together several pieces of the puzzle in order to draw a more comprehensive picture of the drug situation in Lebanon at the level of use, as well as treatment and incarceration. A limitation inherent to the methodology is our inability to generalize the current findings to the entire Lebanese population, or to students of a lower socio-economic status or enrolled in public schools. Still, deriving national estimates was not the main purpose of the RSA study, but rather the goal of another nationally representative mental health survey undertaken by our group [29]. Nonetheless, the significance of the current Lebanon RSA findings lies in their role in alerting policymakers, legislators, health professionals in particular, and the Lebanese government for the ultimate goal of modifying existing or adopting new policies and/or developing new strategies to help address existing substance-related problems under the UN 1998 political declaration. Another possible limitation is the validity of the answers endorsed by substance users who are known to be notoriously imprecise in giving accurate data in specific settings (ISF, prison, etc.). Yet, self-report remains the most commonly used data collection method in drug use surveys [30]. Substance users may also have been reluctant to admit their substance use, despite the confidentiality assurance. Notwithstanding these limitations, the study has several offsetting strengths, namely its ultimate goal, which is to use the findings generated from this quick “screening” (rather than a full-fledged “diagnosis”) of the drug use situation for the purpose of advocating and orienting policy action. Consequently, future steps ensuing from this assessment would help form the basis upon which a programme of technical assistance to Lebanon could be developed, and a strategic national action plan (NAP) could be implemented. Thus far, new approaches for treatment such as substitution therapy and new day care centers followed and the law for substance use is in the process of being revised. All these endeavors were major improvements in this field but a lot remains to be done. The unstable political situation in Lebanon had prevented long-term action by the government, which is essential to stabilize rules and develop solid permanent structures. Meanwhile, a multi84 Lebanese Medical Journal 2010 • Volume 58 (2)

tude of individual institutions in Lebanon is already very active in the field of substance use on the preventive as well as treatment levels, applying state of the art knowledge in partnership with well established international organizations. ACKNOWLEDGMENT

We would like to thank Miss Ranya Hajjar for helping in the editing of the manuscript. Also, we would like to thank our partners from the United Nations Office on Drugs and Crime (UNODC), Lebanese Ministries of Education, Justice, Public Health, Social Affairs, and Parliament of Education. Also we would like to thank all those who have participated in the RSA study : Internal Security Forces, NGOs, Treatment/Rehabilitation Centers, and High Schools and Universities. For more details please consult www.unodc.org and www.idraac.org. This study was supported by the UNODC and IDRAAC (Lebanon). REFERENCES 1. Baddoura R, Wehbeh-Chidiac C. Prevalence of tobacco use among the adult Lebanese population. East Mediterr Health J 2001 ; 7 (4-5) : 819-28. 2. Chaaya M, Jabbour S, El-Roueiheb Z, Chemaitelly H. Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon. Addict Behav 2004a ; 29 (9) : 1821-31. 3. Karam EG, Maalouf WE, Ghandour LA. Alcohol use among university students in Lebanon : prevalence, trends and covariates. The IDRAAC University Substance Use Monitoring Study (1991 and 1999). Drug Alcohol Depend 2004 ; 76 (3) : 273-86. 4. Naja WJ, Pelissolo A, Haddad R, Baddoura R, Baadoura C. A general population survey on patterns of benzodiazepine use and dependence in Lebanon. Acta Psychiatrica Scandinavica 2000 ; 102 : 429-31. 5. Tamim H, Terro A, Kassem H et al. Tobacco use by university students, Lebanon, 2001. Addiction 2003 ; 98 (7) : 933-9. 6. Chaaya M, El-Roueiheb Z, Chemaitelly H, Azar G, Nasr J, Al-Sahab B. Argileh smoking among university students : a new tobacco epidemic. Nicotine Tob Res 2004b ; 6 (3) : 457-63. 7. Karam E, Melhem N, Mansour C, Maalouf W, Saliba S, Chami A. Use and abuse of licit and illicit substances : prevalence and risk factors among students in Lebanon. Eur Addict Res 2000 ; 6 (4) : 189-97. 8. Sibai A, Kanaan N. Youth health risk behavior survey among secondary school students in Lebanon : Prevalence and clustering of risk behaviours. 1997. Unpublished report presented to the WHO/UNICEF, 1999. 9. Shediac-Rizkallah M, Afifi-Soweid R, Farhat T, Yeretzian J. Health practices of older adolescents in postwar Lebanon : Results from a university survey and comparison with Western findings : Reports presented at the First Mediterranean Social and Political Research, Florence, Italy, 2000. 10. Abdel-Malak N : Evolution de la toxicomanie à travers les années de la guerre [The evolution of drug addiction throughout the years of war], Unpublished thesis, St.


11. 12.

13. 14.

15.

16.

17. 18.

19. 20.

21. 22.

Joseph University, Beirut, Lebanon, 1989. Baddoura C. Toxicomanie au Liban [Drug addiction on Lebanon] Bull Acad Natle Med 1992 ; 176 (9) : 1505-15. Zaarour R : La toxicomanie au Liban : Etude et enquête. [The drug addict in Lebanon : study and research], Unpublished thesis, St. Joseph University, Beirut, Lebanon, 1994. UNODC : http://www.unodc.org/adhoc/gass/content.htm Karam EG, Ghandour L, Maalouf W, Yamout K. Substance Use and Misuse in Lebanon : The Lebanon Rapid Situation Assessment & Responses Study. Technical Reports on Drugs and Crime in North Africa and the Middle East, United Nations Office on Drugs and Crime (UNODC), 2003. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Annual report on the state of the drugs problem in the European Union. Lisbon, Portugal : EMCDDA, 2000. Ghandour LA, Karam EG, Maalouf WE. Lifetime alcohol use, abuse, and dependence among university students in Lebanon : Exploring the role of religiosity in different religious faiths. Addiction 2009 ; 104 (6) : 940-8. American Psychiatric Association (APA) : Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Washington, DC : American Psychiatric Association, 1994. Technical Working Group on Snowball Sampling and Other Methods. Handbook on Snowball Sampling. Council of Europe. Cooperation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group). Coordinator of report : Richard Hartnoll, P-PG/Epid (97) 6, 1997. Kandel D, Yamaguchi K. Testing the gateway hypothesis. Addiction 2006 ; 101 : 470-2. Johnston LD, O’Malley PM, Bachman JG. National survey results on drug use from the monitoring the future study, 1975-2000. Volume I : Secondary school students. Michigan, the University of Michigan, Institute for Social Research, 2000. Kandel D, Davies M. High school students who use crack an other drugs. Arch Gen Psychiatry 1996 ; 53 : 71-80. Yang MS, Yang MJ, Liu Y, Ko Y. Prevalence and relat-

23.

24.

25. 26.

27.

28.

29.

30.


ed risk factors of licit and illicit substances use by adolescent students in southern Taiwan. Public Health 1998 ; 112 : 347-52. Shareif M, Kharabsheh S, Abu Danon M, Abu Hejleh N, Sallaj A, Belbisi A, Abu Sleeih N, Saleh S, Al Moaquat M, Khattab K. Rapid Situation Assessment for Drug Abuse and Dependence in the H.K. of Jordan. United Nations Office on Drugs and Crime. Regional Office for the Middle East and North Africa, 2001. Degenhardt L, Chiu WT, Conway K et al. Does the ‘gateway’ matter ? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication. Psychological Medicine 2009 ; 39 : 157-67. Dewit D, Adlaf E, Offord D, Ogborne A. Age at first alcohol use : a risk factor for development of alcohol disorders. Am J Psychiatry 2000 ; 157 (5) : 745-50. National Institute of Health (NIH). Age of drinking onset predicts future alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism. Press Release, 1998. Rhodes T, Lilly R, Fernandez C, Giorgino E, Kemmesis U, Ossebaard H, Lalam N, Faasen I, Spannow K. Risk factors associated with drug use : the importance of “risk environment”. Unpublished review paper, 1997. Grant BF, Dawson DA. Age of onset of drug use and its association with DSM-IV drug abuse and dependence : Results from the national longitudinal alcohol epidemiologic survey. Journal of Substance Abuse 1998 ; 10 (2) : 163-73. Karam EG, Mneimneh ZN, Fayyad JA et al. Lifetime prevalence of mental health disorders : First onset, treatment and exposure to war. PLoS Medicine 2008 ; 5 (4) : e61. Harrison L, Hughes A. Introduction. The validity of selfreported drug use in survey research : Improving the accuracy of research estimates. In : Harrison L, Hughes A, editors. The Validity of Self-reported Drug Use : Improving the Accuracy of Survey Estimates. NIDA Research Monograph Series (167). Publication No 974147. Rockville, MD : NIDA, 1997 : 1-16.
