Chris Beyrer Shruti Mehta and Stefan David Baral

How opium came to humans: A myth of the Akha people in northern Laos.

Seven men court a local beauty. She dies after making love to all of them - rather than having to choose only one suitor thereby avoiding bitterness and conflict. She promised a beautiful flower would emerge from her grave and those tasting its fruit would be compelled to do so again and again. She warned it would bring both good and evil...

This story from one of the ethnic minority peoples who grow opium in the Golden Triangle region of Southeast Asia captures some core truths of the ambivalent nature of opiates - their seductive power, attraction to men, addictive capacity, and potential for both good and evil. As with opiates, still the most important class of drugs for severe pain across medicine, so too with alcohol. Wine has been called the nectar of the Gods, and is indeed essential to religious rituals, from the Catholic mass to shamanic rituals, among traditional peoples across Southeast Asia. But it is also a major source of morbidity and mortality, and is implicated as a lethal factor in threats as varied as motor vehicle accident fatalities, domestic violence, liver disease, and birth defects. These ambivalent features of psychoactive substances are as old as mankind, if not older, and they have generated a wide array of cultural, social, legal, political, and medical responses. Responses to the use of psychoactive agents range from attempts to control their use, tax them, restrict them to adults or to special populations (like some opiates reserved for the terminally ill), or ban them outright. Social responses have included tolerance to incarceration, legalization to aggressive promotion. There is perhaps no more compelling an example of the paradoxes in social responses to opiates than the First and Second Opium Wars of the nineteenth century. In these conflicts the British Empire, under the ostensibly conservative Queen Victoria,

Cohen and Lyttleton, 2002

attempted to redress a grave trade imbalance by forcing opium sales on the Qing Dynasty of China. Opium grown in British-controlled India was forced on China at gunpoint, and the losses of the Qing in both wars led to the British right to sell opium throughout China, and to a colonial concession only recently returned to the Chinese - the opium port of Hong Kong (Waley, 1958). These complex responses to psychoactive substances have continued to have diverse downstream effects - some of profound social and public health import. Thus the now infamous "Rockefeller" era drug laws, harsh and mandatory sentences for possession and sale of cocaine, have been implicated in the disastrously high incarceration rates among the African-American poor in the United States (Correctional Association of New York, 2001). One global downstream effect of social ambiguity regarding substance use has been the widespread limits on safe and effective technologies for the prevention of HIV and HCV infections among injecting drug users. Restrictions such as the still active US Federal ban on funding for needle and syringe exchange have helped drive epidemics of life-threatening viral infections around the world (Beyrer, 2005).

Most striking, perhaps, of the varied social responses and subsequent health outcomes are the divergences in the cultivation of licit and illicit opium poppies - the beautiful flowers of the Akha. Licit poppy cultivation occurs primarily in controlled agricultural areas in Australia (on the island of Tasmania), India, and Turkey (Senlis Council, 2006). Australia supplies the raw material for most of the world's pharmaceutical-grade codeine, that balm for dental patients. Illicit poppy cultivation, principally in Afghanistan, Burma, and Laos, is at the center of an opiate addiction epidemic which stretches from Western Europe to the South China Sea and from Siberia to Indonesia, and which has had enormous health and social impacts, from burgeoning AIDS epidemics to the undermining of civil society in the production states (Beyrer, 2002). While the agent in question (opium in this case) is the same, the outcomes could hardly differ more sharply. And so, in trying to understand how these agents affect health and disease, we must explore not only the agents themselves but also our responses to them at community and societal levels. This approach is essential if we are to understand the interaction of one key mode of substance use, injection drug use (IDU), and the diseases with which it is associated.

HIV/AIDS is now the most severe infectious-disease threat to mankind. In 2005, a record 3.1 million people died of AIDS, and over 5 million became newly infected (UNAIDS, 2005). While sexual spread predominates in the most affected region in the world, sub-Saharan Africa, spread attributed to injection drug use accounted for an estimated 10 percent of all new infections in 2005, and 30 percent of all infections excluding those in sub-Saharan Africa (Beyrer, 2005). In the fastest-growing epidemic regions of Central Asia, the Russian Federation, and the former Soviet Union, spread by IDU was the predominate mode across this vast region (Aceijas et al., 2004). And further east, in China, Indonesia, Vietnam, Malaysia and Burma, IDU spread was also the predominant mode of

Emergent Epidemics

Established Epidemics

• Belarus

• Burma

• India

• Kazakhstan

• Russia

• Malaysia

• Ukraine

• Italy

• Serbia & Montenegro

• Iran

• Netherlands

• Portugal

• Nepal

• Spain

• Brazil

• Libya

• Uruguay

• Puerto Rico

• Kenya, Tanzania, Ghana,

• USA

Nigeria**

"African States with at least one published report of IDU risks

Figure 3.1 States with at least one site with HIV prevalence >20 percent in IDU in 2006. Adapted from Aceijas etal. (2004).

Figure 3.1 States with at least one site with HIV prevalence >20 percent in IDU in 2006. Adapted from Aceijas etal. (2004).

transmission. IDU epidemics continue to emerge, with some of the most recently reported outbreaks in settings previously spared HIV spread - such as Iran and the Balkans. States with at least one outbreak with greater than 20 percent of injection drug users infected in 2004 include Iran, Libya, Serbia and Montenegro, Nepal, Tajikistan, Kazakhstan, and Belarus (Aceijas et al, 2004; see also Figure 3.1). What so many of these states have in common, in addition to surges in narcotic availability and epidemics of injection use of drugs and of HIV infection among those injectors, are markedly limited HIV-prevention efforts to address emerging epidemics. The availability of narcotics and the addictive nature of opiates, and these limited prevention efforts, have led us in country after country to the same difficult reality - human behaviors are driving HIV epidemics at the individual level, and government responses are aiding and abetting these epidemics at community and population levels. We will explore this difficult reality, and attempt to propose ways forward that might both mitigate the devastating impacts of addiction and help control HIV spread.

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