Commentaries 15

vation was successful.' The main cause of theheroin epidemic was most probably the estab-lishment of an illicit drug distribution network.Few cases of heroin-dependent hill tribes and thepattern of heroin spread have been reportedsince 1978.'' Perhaps because of the small num-ber, no preventive action against heroin epidemicin this minority group has ever been attempted.Heroin use and clandestine production were notnew phenomena in India;'' ' heroin use was cur-rently growing in some urban areas, such asBombay. High prevalence of heroin use andintravenous administration were reported in Ma-nipur and Nagaland in the northwest near theMyanmar border.^ In indigenous opium use ar-eas a heroin epidemic apparently hinges on thedecision of ruthless illicit traffickers and localentrepreneurs to market their deadly product.Given the time taken to control indigenousopium use effectively, early intervention beforeheroin use starts is worth consideration. How-ever, it is always an imposing task to convincepolicy-makers of the need to intervene whenthere is no apparent problem.

ViCHAI POSHYACHINDADrug Dependence Research Center,

Institute of Health Research,Chulalongkom University,

Bangkok,Thailand

1. SUWANWELA, C , POSHYACHINDA, V., T A S A N A -PRADIT, P. et al. (1978) The hill tribes of Thailand,their opium use and addiction. Bulletin on Nar-cotics, 30, pp. 1-19.

2. SUWANWELA, C , POSHYACHINDA, V., T A S A N A -PRADIT, P. et al (1980) Opium use among the hilltribes of Thailand, 1980, Journal of Drug Issues,Spring, pp. 215-220.

3. MCGLOTHLIN, W . H. , MUBBASHAR, M . ,SHAFIQUE, M . et al. (1978) Opium use in twocommunities of Pakistan—a preliminary compari-son of rural and urban patterns. Bulletin onNarcotics, 30, pp. 1-15.

4. SUWANWELA, C , K A N C H A N A H U T A , S . &ONTHUAM, Y. (1979) Hill tribe opium addicts: aretrospective study of 1,382 patients. Bulletin onNarcotics, 31, pp. 2?>-A0.

5. VISUDHIMARK, A. (1991) HIV infection amonghill tribal drug dependents in northern drugdependence treatment center. Bulletin of Depart-ment of Medical Services (Depanment of MedicalServices, Ministry of Public Health, Thailand), 16,pp. 290-295.

6. MOHAN, D . ADITYANJEE, SAXENA, S. et al. (1985)

Changing trends in heroin abuse in India: andassessment based on treatment records. Bulletin onNarcotics, 37, pp. 19-24.

7. UNrrED NATIONS (1985) Situation and trends indrug abuse and the illicit traffic, including reports ofsubsidiary bodies concern with the illicit traffic indrugs. Report submitted to the Commission onNarcotic Drugs at its thirty-first session (E/CN.7/1985/9), p. 7.

8. PAL, S. C . etal. (1990) Explosive epidemic of HIVinfection in north-eastern states of India, Manipurand Nagaland, Centre of AIDS Research Calling(New Delhi, Indian Council of Medical Research),3, pp. 2-6.

How about a harm reduction trial?Reginald G. Smart

The paper by Ganguly et al. sets out a movingdescription of rural opium use in a poor country.It recalls the reports of traditional opiumsmoking in the highlands of Thailand and Laosin the 1970s and 1980s. The Rajasthan opiumsituation presents many of the same problemsand cries out for the same solutions as did SouthEast Asia's drug problem. Whether we havethose solutions in crop replacement pro-grammes, barefoot doctor schemes and othercommunity development works is still debated.As I read this paper I was struck by the generalacceptance of opium smoking in Rajasthan andthe impact it must have on everyday life. It alsooccurred to me that finding a solution for theopium problem will be difficult and probablyexpensive.

It is interesting to see how heavily embeddedin Rajasthan society opium smoking has become.Probably few activities ignore so many tra-ditional barriers but are so well accepted. Opiumuse appears to cross caste and religious lines andis engaged in by Muslims as well as Hindus. Itappears in most social gatherings and is used bymales and females as well as given to children.Both young people and older people seem to useit. Because opium is useful in treating illnesssuch as coughs, aches and pains and diarrhoea itmust have an important place in the family phar-macopoeia; with so many users it is not surpris-ing that there is general acceptance of users asnormal, non-deviant people.

It would be interesting to know more abouthow opium affects day to day activities in Ra-jasthan societies. If there were 250 addicts from1800 households that means that about 14% ofhouseholds have an opium addict (assuming one

16 Commentaries

per household). To put it another way; if weassume there are five or six people per house-hold, then about 2-3% of the population areopium addicts. We are told that long-term usersdo nothing but smoke opium or look for ways toget it. This leaves many questions unanswered,perhaps for the next ethnographic study. Someof them are as follows: how can a society copewith so many opium users? How does it affectproductivity and family fiinctioning if 14% offamilies have one member who has an expensivehabit and does not work? Does it lower overallstandards of living? Do addicts steal or engage inany crime to support their habits?

Probably radical solutions to the Rajasthanopium problem will be needed. There seemslittle to work with by way of community supportfor prevention. Also, the health care system isnot developed so major treatment or educationprogrammes may not be practical, without fur-ther programme development. It is interestingthat no opium users are taken to the policebecause of their use. Because the opium is notgrown locally but imported by pedlars someaction against traffickers could be taken. Therisks are that opium prices would be raised andthat traffickers would become more sophisticatedor more violent to protect their markets. Clearly,there is a need for primary health care facilitiesthat would treat the illnesses now medicatedwith opium. Also, treatment of large numbers ofopium users may have to be done on a village byvillage basis. It is probably more effective to treatall opium users in the same village at the sametime, as was done in Thailand and Laos.

A better approach would be to create a con-vincing harm reduction trial in several villages.Rajasthan might be an ideal place to try severaldifferent harm reduction strategies in some vil-lages and not others. Punitive measures againstusers have not been taken, so a health-basedmodel could be unfettered. Communicationbetween villages is probably poor, thus limitingcross-village infiuences and allowing quasi-experimental conditions. Also, the villages aresmall enough to infiuence everyone in a harmreduction approach involving better healtheducation, improved primary care and treatmentfor opium addicts. International support for thistype of trial should be possible through theUnited Nations Drug Control Programme, theWorld Health Organization and other agencies.Probably some donor nations in Europe and

North America would contribute to the costs.Harm reduction seems to be the wave of thefuture in drug abuse prevention. It deserves agood trial in a place where it probably would behelpful.

REGINALD G. SMARTAddiction Research Foundation,

33 Russell Street, Toronto,Ontario, Canada MS8 2S1

Counting the costs as well as the henefits ofdrug control lawsMichael Gossop

It is disappointing that so little is known aboutthe use of drugs in producer countries. Thesecountries are confronted by many special sorts ofproblems related to the use and abuse of drugs.For this reason alone, it is interesting to learnabout the consumption of opium in the austerebut beautiful state of Rajasthan. As in manyother Asian countries, in India there is an estab-lished cultural tradition surrounding the use ofthe drug, and patterns of use differ substantiallyfrom those in Western countries. Many opiumsmokers are farmers or live in rural areas; usersare often middle-aged or elderly; and many userscan be described as 'stable' addicts in so far asthey lead relatively normal and productive livesdespite their regular use of largish amounts ofthe drug. Similar observations have been madeabout the consumption of coca leaves in theAndean countries. It would be foolish andarrogant of addiction researchers in Westerncountries to dismiss these traditional patterns ofdrug use as no more than a cultural curiosity. Abetter understanding of such habits may teach usa good deal about the nature of drug taking andaddictive behaviour. A clearer view of the waysin which such patterns of drug use respond tocontrol measures could teach us much that isrelevant to prevention in our own societies.

The existence of traditional patterns of drugconsumption may sometimes offer protection tousers against the attractions of new drugs; but itmay also make users vulnerable to transferringfrom the old to the new. The Indian sub-continent and the Andean cocaine-producingcountries have both experienced radical changesin patterns of drug use within the last 10 or 20years. New preparations of traditional drugs have