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AM. J. DRUG ALCOHOL ABUSE, 4(1), pp. 1- 1 1 (1977)
A Heroin “Epidemic” in Asia
JOSEPH WESTERMEYER, M.D., M.P.H., Ph.D. Associate Professor Department of Psychiatry University of Minnesota Minneapolis, Minnesota 55455
PETER BOURNE, M.D., M.A. Drug Abuse Council, lnc. 1828 L Street N.W. Washington, D. C. 20036
ABSTRACT Heroin “epidemics” have been reported in North America but not in Asia. Following passage of an anti-opium law in Laos,heroin use suddenly began in one area during 1972. Initially heroin use prevailed among indigenous Asian addicts, mostly older addicts who gradually switched from opium to heroin. In addition, there evolved a new group of indigenous addicts: young, single, unemployed males in urban areas whose Fist narcotic drug was heroin. After the appearance of heroin in Laos, increasing numbers of younger Americans and Europeans were soon attracted to heroin use in Laos.
INTRODUCTION Heroin “epidemics” have been reported among several American populations. These have included Washington, D.C. [ 1 ] , Chicago [2] , New Haven [3], 1
WESTERMEYER AND BOURNE
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various other American cities, and American military forces in southeast Asia [4]. While reports from Asia have documented the replacement of opium by heroin [5, 61, the term “epidemic” has not been applied in describing the appearance of heroin addiction in Asia. Instead, chronic opium addiction has been seen there as an endemic phenomenon in areas such as Laos, with a prevalence rate of about 2 to 3% [7]. We had the opportunity to observe the sudden appearance and rapid spread of heroin addiction in Laos, a country that has produced both opium and opium addicts for centuries [8, 91. Each of us made annual trips t o Asia during the period 1971-1975 as consultants to the Ministry of Health in Laos, and to the U.S. Agency for International Development (Public Health Division) in Laos. One of us (J.W.) had studied opium use in Laos since 1965 [7, 10-131. The other of us (P.B.) was deputy chief of the Special Action Office of the President on Drug Abuse and had done both clinical work and research in the drug abuse field [ 141 . Our roles in Laos enabled us to collect data on this heroin “epidemic” phenomenon as it was developing. Based on the estimated addict population in Vientiane city (2,000 to 3,000) and the proportion of Vientiane addicts using heroin, it is estimated that there were 1,000 to 1,500 heroin addicts in Laos at the time of this study.
METHOD In part this study is based on earlier work on addiction in Laos. This includes a field survey of opium use and addiction [ l o ] , an intensive case study of 40 addicts [ 7 ] , observations on three opium dens [ 111 , and folk treatments for addiction [12]. In the course of this work it was possible to ascertain the times and places that heroin use first appeared in Laos. Specific data about the prevalence of heroin use, its spread, and the people who used it were obtained from the National Detoxification Center in Laos. Located in Vientiane, it was established in September 1972 to treat refugee opium addicts. During the first year of operation, 503 Asian addicts were treated at this facility. In addition, 56 European, American, and Australian addicts came to the center for treatment; they were treated during the 28 months between September 1972 and December 1974. Information was collected on all 559 subjects using a research questionnaire devised from previous studies. This was supplemented by selected use of in-depth interviews. Access to these patients and their charts was provided by Dr. Chomchan Soudlay, Director of the National Detoxification Center.
3
A HEROIN “EPIDEMIC” IN ASIA
FINDINGS
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Appearance of Heroin No reports on heroin addiction were obtained during 1965-1967 despite extensive clinical experience with addicts and a field survey of addicts [ l o , 131. During an intensive case study of 40 addicts in Febraury and March 1971 [7] and a public health consultation regarding addicted refugees in November 1971, again there was no evidence of heroin addiction. However, by March of 1972 several opium addicts had reported hearing of heroin use in Vientiane. One addict stated that a few addicted friends had begun using heroin in lieu of opium, and that he had visited a place where heroin was sold in Vientiane. By late 1972, heroin had become more widely available. Heroin addicts appeared among the first group admitted to the National Detoxification Center in September 1972. Most heroin addicts had previously been addicted to opium. Initially they continued using opium, but supplemented it with heroin; eventually most later switched completely to heroin. Among the 503 Asian addicts in the 1972-1973 sample, 65 (13%) were using heroin at the time of being admitted for treatment. What accounted for the sudden appearance of heroin among Laotian addicts? Elsewhere one of us (J.W.)has made the argument that the passage of an anti-opium law in November 1971 gave rise to the appearance of heroin in Laos (as it had previously done elsewhere in Asia) [6]. Vigorous law enforcement effectively cut down on the flow of bulky, odoriferous, and readily detectable opium into the capital city of Vientiane. In its place, compact, odor-free heroin appeared in order to meet the need of narcotic drug users. Did “world travelers” from Europe or American introduce heroin into Laos? After all, of the 56 admitted for treatment in Laos, 82% were using heroin part-time (with opium) or all of the time. However, the evidence suggests they were not responsible for its introduction. Prior to the 1973 Peace Accords in Laos, few tourists came to Laos due to the military insecurity, difficulty in travel, and the high mortality among adventurers who chose to disregard the political and military realities. Indeed, the few addicted Caucasians in Laos prior to this time used opium. By 1974 this had changed. Young, Caucasian tourists were coming to Laos by the thousands. Data from the National Detoxification Center indicated their latter-day arrival in Laos. During the 16 months between September 1972 and December 1973, only 13 Caucasian addicts were admitted for treatment (i.e., 0.75 addicts per month). In the subsequent 12 months of 1974, 44 were admitted (i.e., 3.67 addicts per
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WESTERMEYER AND BOURNE
month), an increase of 490%. The rate was still rising during our last visit in early 1975. This suggested that “world travelers” took advantage of a situation that was already present rather than introducing heroin into Laos themselves. Was heroin ever manufactured in Laos? During 1973 the Ministry of the Interior did find a heroin factory in Laos, located close to Burma and Thailand (i.e., in the “Golden Triangle”), but hundreds of kilometers away from any population centers in Laos. Since access from this area into Thailand was good, but difficult through Laos to Vientiane, it was not likely that this installation supplied Laos. Data in the next section from addicted patients further suggested that Laos’ heroin came from (or through) Thailand.
Geographic Spread of Heroin
Asian addicts. Of the 65 Asian addicts using heroin, 62 were currently living in the city of Vientiane (the capital and largest city in Laos). Those initially addicted to heroin came primarily from two districts in Vientiane: See Khay and Mixay. All three addicts not from Vientiane came from Tha Deua, a town about 20 miles east of Vientiane. Though the remaining 438 Asian addicts came from every province and every large town in Laos, not one reported the use of heroin. Both Vientiane and Tha Deua are located on the Mekong River across from Thailand. Since the Mekong is more navigable at Tha Deua than at Vientiane, most transport between Laos and Thailand took place at Tha Deua. Across from Tha Deua was Nong Khai, a major town in northern Thailand. Legal importation and exportation, transport of people, and even smuggling between the two countries took place at the Tha Deua-Nong Khai area. Cuucasian addicts. All of the Caucasian addicts were currently residing in Vientiane when they came for treatment. Most were “world travelers” who had been in Laos less than a year. Those using opium along with heroin had generally lived in Laos for over a year and had originally been addicted to opium. Two opium-and-heroin users had recently arrived but were in poor financial straits, and thus were using opium as an inexpensive substitute for heroin. Most Caucasian addicts had originally started using heroin in other countries. Only six addicts who were first addicted to heroin had been introduced to heroin in Laos. All six of them had started using heroin in Vientiane, and all
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A HEROIN “EPIDEMIC” IN ASIA
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within 1 year or less of seeking treatment (i.e., between 1972 and 1974). A seventh person had started addiction with opium 3 years previously in another Laotian town (Luang Prabang); he had subsequently begun using both opium and heroin when he moved to Vientiane. Among the “world traveler” addicts, most were currently living at one of four hotels in Vientiane where rooms could be had for U.S. $0.50 to 0.75 per day (Bungalow Hotel, Lido Hotel, Saylom Villa, Vieng Vilay Hotel). Those who had been living in Laos for more than a year came from several different districts in Vientiane (i.e., Wattay, Phone Keng, Dong Phalane, Nai Muong, Mixay) but visited the downtown district regularly for work, meals, mail, newspapers, or social contacts.
The Heroin Addicts
Asian addicts (see Table 1). Heroin users ranged from age 1 8 years to 60 years, with the greatest number in their thirties. Only one out of the entire 65 people was female; she was a 26 year old Vietnamese woman whose husband was addicted to heroin. Their ethnic affiliation included Lao, Thai, Chinese, Vietnamese, and an Indian. As was also generally true of Asian opium addicts, most of this group were married, living with their families, and employed. However, a significant subgroup (not present among opium smokers) included several single, unemployed, unskilled men in their late teens and early twenties. Unlike most Asian addicts, this group had recently started narcotic usage with heroin, rather than with opium. Of the total 65 heroin-using addicts, 51 (78%) were using heroin or morphine exclusively at the time of admission and the remainder were using both heroin and opium. Most were smoking their narcotic drug. A few were eating their doses of opium (heroin is destroyed by the gastrointestinal tract if eaten). The three addicts injecting their drug were using primarily morphine which they obtained from military or pharmaceutical sources. Most addicts came for treatment after having been addicted between a few years and a few decades, though several were addicted only a year or less. Caucasian addicts (see Table 2). This group ranged in age from 18 years to 48 years, with most in their twenties. Of the total 46 addicts, 9 (20%) were female. The nationality most represented was France (n = 19)-an expected finding since many French people lived in Laos, a former French colony.
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WESTERMEYER AND BOURNE
TABLE 1. Asian Heroin Addicts, 12-Month Period
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Characteristic Age Less than 20 years 20-29 years 30-39 years 40-49 years Over 5 0 years Sex Male Female
Number of addicts 2 11 33 16 3
63 64 1
63
( 3%) ( 17%) ( 51%) ( 25%)
0 (101%) ( 98%) (2%)
(100%)
Ethnicity La0
Thai Chinese Vietnamese Indian Marital status Single Married Divorced, separated Unknown Residence With family With relatives With friends Alone Unknown Employed Yes No Unknown
41 12 6 5 1
z i 14 40 4 7
65
53 1 3 4 4
B
45 15 5
w
( 63%) ( 18%) ( 9%) ( 8%) (2%)
(100%) ( 22%) ( 62%) ( 6%)
U) (101%)
( 82%) ( 2%) ( 5%) ( 6%) (6%)
(101%) ( 69%) ( 23%) (8%)
(100%)
Type of narcotic drug Heroin only Heroin + opium
51 14
6%
( 78%) (22%) (100%)
Mode of use Smoke Smoke + eat Inject
58 4 3
( 89%) ( 6%) %)5(
Duration of addiction Less than 1 year 1-5 years 6-10 years 11-15 Years Over IS years
z i 7 34 11 8 5
FX
(100%) ( 11%) ( 52%) ( 17%)
12%)
TABLE 2. Caucasian Heroin Addicts, 28-Month Period Characteristic
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Age Less than 20 years 20-29 years 30-39 years 40-49 years Over 50 years
Number of addicts 1 41 3 1 0
w
( 2%) ( 89%) ( 7%) ( 2%)
0 (100%)
sex
Male Female Ethnicity French American English Australian Italian German Canadian Marital status Single Married Divorced Unknown Residence With family With relatives With friends Alone Unknown Employment Yes No Unknown Type of narcotic drug Heroin only Heroin + opium Mode of use Smoke Smoke + eat Inject Inject + smoke Sniff Duration of addiction Less than 1 year 1-5 years 6-10 years Over 10 years
37 9
( 80%)
19
( ( ( ( ( (
w 8
7 7 3 1 1
(20%) (100%) 41%) 17%) 15%) 15%) 7%) 2%)
w
(2%) ( 99%)
32 8 5 1
( 70%) ( 17%) ( 11%) ( 2%)
w
7 0 11 27 1
(100%) ( 15%) ( 0%) ( 24%) ( 59%)
w
2(%)
11 34 1
( 24%) ( 74%)
39 7
( 85%)
w w
10 1 24 3 8
w 21 23 2 0 46
(100%)
L w (lOW0) 0 (100%) ( 22%) ( 2%) ( 52%) ( 7%) ( 17%)
(100%) ( 46%) ( 50%) ( 4%)
(0%)
(lOWo’1
WSTERMEYER A N D BOURNE
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Another 11 came from elsewhere in Europe; 9 from North American; and 7 from Australia. Unlike the Asian group, these Caucasian addicts were primarily single, living or traveling alone, and currently unemployed. Half of them had become addicted to heroin elsewhere in Asia (Thailand, Malaysia, Vietnam, Indonesia, Afghanistan, Pakistan, and India). Almost a third had first become addicted in their country-of-origin. And the remaining six addicts were originally addicted in Laos as described earlier. In this group of 46 addicts, 39 of them (85%) were using only heroin and 7 (15%) were using both opium and heroin. Unlike the Asians, these people were primarily injecting heroin. A small proportion (all with marked physiologic addiction) were sniffing or “snorting” their heroin. Most patients came for treatment within a year or two of becoming addicted; none had been addicted for more than 10 years.
DISCUSSION Though the technology for producing heroin had been available for almost a century, widespread heroin use did not appear in Laos until 1972. This was so despite the fact that a heroin factory had been present for some time within the Laotian portion of the Golden Triangle. If small amounts of heroin did occasionally come into Laos prior to 1972, this presence alone was not sufficient t o induce prevalent or persistent heroin use. As has been argued elsewhere [6], the passage of an anti-opium law accomplished what a heroin factory alone could not accomplish. Heroin use began in the capital city of Vientiane soon after the passage of an anti-opium law. Police power was strongest in the capital city; thus enforcement of the law was effectively implemented there. This soon led to a decrease in the opium supply and the subsequent creation of a market for illicit narcotic drugs. The geographic distribution of heroin addicts in Laos suggested that heroin was brought from Thailand into Laos at Tha Deua in early 1972. In Vientiane heroin was probably first distributed to Asian addicts in the See Khay and Mixay districts of Vientiane. Within a short time heroin then became available to Caucasian addicts, probably in the downtown area. During the first year that heroin was introduced into Vientiane, most heroin users were Asian. Only 10 Caucasian heroin addicts were treated during the 12 months of 1972-1973, at the same time that 65 Asian heroin addicts were treated.
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A HEROIN “EPIDEMIC” IN ASIA
Once introduced into Vientiane, the use of heroin spread rapidly among the Lao and expatriate Asians. Many former opium addicts tried heroin, used both narcotic drugs for a time, and then switched entirely to heroin. They were virtually all male and employed at wage or salaried jobs. In addition, a new group of Asian addicts appeared: addicts whose first narcotic usage involved heroin. They were exclusively male, young, single, literate but unemployed and unskilled, and often from upwardly mobile urban families. Often they were alienated from their families. This latter group comprised a new subpopulation of addicts for Laos, though they were much like the “modern” urban post-World War I1 addicts in Bangkok, Hong Kong, or New York City. Caucasian heroin addicts soon became involved with heroin after it had appeared in Laos. Caucasian heroin users who had become addicted elsewhere began to descend on Laos. Some “world travelers” first became addicted to heroin in Laos. While these numbers remained small during the first year of heroin use in Laos, the 490% increase of Caucasian addicts at the National Detoxification Center between the first and second year (at a time when the number of Asian addicts admitted for treatment remained fairly stable) indicated a marked increase in the number of Caucasian heroin addicts in Laos. So also did the simple presence of many more Caucasian addicts “on the nod” in Vientiane during 1974 and 1975. The development of a pattern of progressive heroin use in Laos is mirrored in other Southeast Asian Nations. A combination of repressive laws geared toward suppressing traditional and often socially constrained opium use, urbanization and industrialization, the alienation of youth with progressive identification with western life-styles, and the availability of heroin as a new and profitable commodity for domestic and export use, all have favored the development of epidemics of heroin use. Thailand, Burma, Indonesia, and Malaysia all face problems of major proportions which they have had little success controlling with limited trained personnel for the treatment of any medical condition let alone drug addiction. Failure to control the problem or limit its spread is likely to result in the creation of a serious undermining of the attempt to stabilize the economies and enhance the development of these nations. As such, heroin addiction in Asia currently represents a much more serious problem than is generally recognized.
CONCLUSIONS 1. Widespread heroin use suddenly began in a localized area of Laos during 1972.
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WESTERMEYER AND BOURNE
2. Careful analysis of the heroin outbreak suggested that Caucasian “world travelers” did not cause the introduction of heroin into Laos, but that the anti-opium law was the prime causal factor. 3. Vientiane had been widely considered a “sleepy”-if somewhat overgrown -riverside town not heir to the problems of modern urban centers. The sudden appearance of young, single, male unemployed addicts (often from “good” middle class families) provided a warning that traditional social institutions were no longer meeting the needs of urban society, its families, and its youth in Laos.
ACKNOWLEDGMENTS Acknowledgment is expressed to Chomchan Soudaly, M.D., of Laos; Charles Weldon, M.D., M.P.H., of U.S. Agency for International Development; Grace Peng, M.S., Department of Biometry, University of Minnesota; Beth Stone, M.A., Department of Psychiatry, University of Minnesota, for their assistance. The study was supported in part by the Minnesota Medical Foundation, International Programs Office at the University of Minnesota, and the National Institute of Drug Abuse (grant no. 5 TO1 DA00023-02).
REFERENCES DuPont, R., and Greene, M. H., The dynamics of a heroin addiction epidemic, Science 181~716-722(1973). Hughes, P. H., Senay, E. C., and Parker, R., The medical management of a heroin epidemic, Arch. Gem Psychiatry 27~585-592(1972). Hunt, L. G., Recent spread of heroin use in the United States, Am. J. Public Health SUPPI.64~16-23(1974). Siegel, A. J., The heroin crisis among U.S. forces in southeast Asia: An overview, J. Am. Med. Assoc. 223:1258-1261 (1973). Way, E. L., Control and treatment of drug addiction in Hong Kong, in Narcotics (D.M. W h e r and G . G. Kasselbaum, eds.), McGraw-Hill, New York, 1965, pp. 278289. Westermeyer, J., The pro-heroin effects of anti-opium laws, Arch. Gen. Psychiatry 33:1135-1139 (1976). Westermeyer, J., Use of alcohol and opium by the Meo in Laos, Am. J. Psychiatry 127: 1019-1023 (1971). LeBar, F., and Suddard, A., Laos: Its People, Its Society, Its Culture, New Haven, Connecticut. Osborne, M., River Road to China; The Mekong River Expedition, 1866-73, Liveright, New York, 1975. Westermeyer, J., Opium smoking in Laos: A survey of 40 addicts, Am. J. Psychiatry 131: 165-170 (1974). Westermeyer, J., Opium dens: A social resource for addicts in Laos,Arch. Gen. Psychiatry 31:237-40 (1974).
A HEROIN “EPIDEMIC” IN ASIA
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[ 121 Westermeyer, I., Folk treatment for opium addiction in Laos, Br. J. Addict., 68: 345-349 (1973). (131 Westermeyer, J., The use of alcohol and opium among two ethnic groups in Laos, Panscultural Psychiatr. Res. 6:148-151 (1969). [ 141 Bourne, P., Issues in addiction, in Addiction, Academic, New York, 1974, pp. 1-19.
AM. J. DRUG ALCOHOL ABUSE, 4(1), pp. 1- 1 1 (1977)
A Heroin “Epidemic” in Asia
JOSEPH WESTERMEYER, M.D., M.P.H., Ph.D. Associate Professor Department of Psychiatry University of Minnesota Minneapolis, Minnesota 55455
PETER BOURNE, M.D., M.A. Drug Abuse Council, lnc. 1828 L Street N.W. Washington, D. C. 20036
ABSTRACT Heroin “epidemics” have been reported in North America but not in Asia. Following passage of an anti-opium law in Laos,heroin use suddenly began in one area during 1972. Initially heroin use prevailed among indigenous Asian addicts, mostly older addicts who gradually switched from opium to heroin. In addition, there evolved a new group of indigenous addicts: young, single, unemployed males in urban areas whose Fist narcotic drug was heroin. After the appearance of heroin in Laos, increasing numbers of younger Americans and Europeans were soon attracted to heroin use in Laos.
INTRODUCTION Heroin “epidemics” have been reported among several American populations. These have included Washington, D.C. [ 1 ] , Chicago [2] , New Haven [3], 1
WESTERMEYER AND BOURNE
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various other American cities, and American military forces in southeast Asia [4]. While reports from Asia have documented the replacement of opium by heroin [5, 61, the term “epidemic” has not been applied in describing the appearance of heroin addiction in Asia. Instead, chronic opium addiction has been seen there as an endemic phenomenon in areas such as Laos, with a prevalence rate of about 2 to 3% [7]. We had the opportunity to observe the sudden appearance and rapid spread of heroin addiction in Laos, a country that has produced both opium and opium addicts for centuries [8, 91. Each of us made annual trips t o Asia during the period 1971-1975 as consultants to the Ministry of Health in Laos, and to the U.S. Agency for International Development (Public Health Division) in Laos. One of us (J.W.) had studied opium use in Laos since 1965 [7, 10-131. The other of us (P.B.) was deputy chief of the Special Action Office of the President on Drug Abuse and had done both clinical work and research in the drug abuse field [ 141 . Our roles in Laos enabled us to collect data on this heroin “epidemic” phenomenon as it was developing. Based on the estimated addict population in Vientiane city (2,000 to 3,000) and the proportion of Vientiane addicts using heroin, it is estimated that there were 1,000 to 1,500 heroin addicts in Laos at the time of this study.
METHOD In part this study is based on earlier work on addiction in Laos. This includes a field survey of opium use and addiction [ l o ] , an intensive case study of 40 addicts [ 7 ] , observations on three opium dens [ 111 , and folk treatments for addiction [12]. In the course of this work it was possible to ascertain the times and places that heroin use first appeared in Laos. Specific data about the prevalence of heroin use, its spread, and the people who used it were obtained from the National Detoxification Center in Laos. Located in Vientiane, it was established in September 1972 to treat refugee opium addicts. During the first year of operation, 503 Asian addicts were treated at this facility. In addition, 56 European, American, and Australian addicts came to the center for treatment; they were treated during the 28 months between September 1972 and December 1974. Information was collected on all 559 subjects using a research questionnaire devised from previous studies. This was supplemented by selected use of in-depth interviews. Access to these patients and their charts was provided by Dr. Chomchan Soudlay, Director of the National Detoxification Center.
3
A HEROIN “EPIDEMIC” IN ASIA
FINDINGS
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Appearance of Heroin No reports on heroin addiction were obtained during 1965-1967 despite extensive clinical experience with addicts and a field survey of addicts [ l o , 131. During an intensive case study of 40 addicts in Febraury and March 1971 [7] and a public health consultation regarding addicted refugees in November 1971, again there was no evidence of heroin addiction. However, by March of 1972 several opium addicts had reported hearing of heroin use in Vientiane. One addict stated that a few addicted friends had begun using heroin in lieu of opium, and that he had visited a place where heroin was sold in Vientiane. By late 1972, heroin had become more widely available. Heroin addicts appeared among the first group admitted to the National Detoxification Center in September 1972. Most heroin addicts had previously been addicted to opium. Initially they continued using opium, but supplemented it with heroin; eventually most later switched completely to heroin. Among the 503 Asian addicts in the 1972-1973 sample, 65 (13%) were using heroin at the time of being admitted for treatment. What accounted for the sudden appearance of heroin among Laotian addicts? Elsewhere one of us (J.W.)has made the argument that the passage of an anti-opium law in November 1971 gave rise to the appearance of heroin in Laos (as it had previously done elsewhere in Asia) [6]. Vigorous law enforcement effectively cut down on the flow of bulky, odoriferous, and readily detectable opium into the capital city of Vientiane. In its place, compact, odor-free heroin appeared in order to meet the need of narcotic drug users. Did “world travelers” from Europe or American introduce heroin into Laos? After all, of the 56 admitted for treatment in Laos, 82% were using heroin part-time (with opium) or all of the time. However, the evidence suggests they were not responsible for its introduction. Prior to the 1973 Peace Accords in Laos, few tourists came to Laos due to the military insecurity, difficulty in travel, and the high mortality among adventurers who chose to disregard the political and military realities. Indeed, the few addicted Caucasians in Laos prior to this time used opium. By 1974 this had changed. Young, Caucasian tourists were coming to Laos by the thousands. Data from the National Detoxification Center indicated their latter-day arrival in Laos. During the 16 months between September 1972 and December 1973, only 13 Caucasian addicts were admitted for treatment (i.e., 0.75 addicts per month). In the subsequent 12 months of 1974, 44 were admitted (i.e., 3.67 addicts per
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WESTERMEYER AND BOURNE
month), an increase of 490%. The rate was still rising during our last visit in early 1975. This suggested that “world travelers” took advantage of a situation that was already present rather than introducing heroin into Laos themselves. Was heroin ever manufactured in Laos? During 1973 the Ministry of the Interior did find a heroin factory in Laos, located close to Burma and Thailand (i.e., in the “Golden Triangle”), but hundreds of kilometers away from any population centers in Laos. Since access from this area into Thailand was good, but difficult through Laos to Vientiane, it was not likely that this installation supplied Laos. Data in the next section from addicted patients further suggested that Laos’ heroin came from (or through) Thailand.
Geographic Spread of Heroin
Asian addicts. Of the 65 Asian addicts using heroin, 62 were currently living in the city of Vientiane (the capital and largest city in Laos). Those initially addicted to heroin came primarily from two districts in Vientiane: See Khay and Mixay. All three addicts not from Vientiane came from Tha Deua, a town about 20 miles east of Vientiane. Though the remaining 438 Asian addicts came from every province and every large town in Laos, not one reported the use of heroin. Both Vientiane and Tha Deua are located on the Mekong River across from Thailand. Since the Mekong is more navigable at Tha Deua than at Vientiane, most transport between Laos and Thailand took place at Tha Deua. Across from Tha Deua was Nong Khai, a major town in northern Thailand. Legal importation and exportation, transport of people, and even smuggling between the two countries took place at the Tha Deua-Nong Khai area. Cuucasian addicts. All of the Caucasian addicts were currently residing in Vientiane when they came for treatment. Most were “world travelers” who had been in Laos less than a year. Those using opium along with heroin had generally lived in Laos for over a year and had originally been addicted to opium. Two opium-and-heroin users had recently arrived but were in poor financial straits, and thus were using opium as an inexpensive substitute for heroin. Most Caucasian addicts had originally started using heroin in other countries. Only six addicts who were first addicted to heroin had been introduced to heroin in Laos. All six of them had started using heroin in Vientiane, and all
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A HEROIN “EPIDEMIC” IN ASIA
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within 1 year or less of seeking treatment (i.e., between 1972 and 1974). A seventh person had started addiction with opium 3 years previously in another Laotian town (Luang Prabang); he had subsequently begun using both opium and heroin when he moved to Vientiane. Among the “world traveler” addicts, most were currently living at one of four hotels in Vientiane where rooms could be had for U.S. $0.50 to 0.75 per day (Bungalow Hotel, Lido Hotel, Saylom Villa, Vieng Vilay Hotel). Those who had been living in Laos for more than a year came from several different districts in Vientiane (i.e., Wattay, Phone Keng, Dong Phalane, Nai Muong, Mixay) but visited the downtown district regularly for work, meals, mail, newspapers, or social contacts.
The Heroin Addicts
Asian addicts (see Table 1). Heroin users ranged from age 1 8 years to 60 years, with the greatest number in their thirties. Only one out of the entire 65 people was female; she was a 26 year old Vietnamese woman whose husband was addicted to heroin. Their ethnic affiliation included Lao, Thai, Chinese, Vietnamese, and an Indian. As was also generally true of Asian opium addicts, most of this group were married, living with their families, and employed. However, a significant subgroup (not present among opium smokers) included several single, unemployed, unskilled men in their late teens and early twenties. Unlike most Asian addicts, this group had recently started narcotic usage with heroin, rather than with opium. Of the total 65 heroin-using addicts, 51 (78%) were using heroin or morphine exclusively at the time of admission and the remainder were using both heroin and opium. Most were smoking their narcotic drug. A few were eating their doses of opium (heroin is destroyed by the gastrointestinal tract if eaten). The three addicts injecting their drug were using primarily morphine which they obtained from military or pharmaceutical sources. Most addicts came for treatment after having been addicted between a few years and a few decades, though several were addicted only a year or less. Caucasian addicts (see Table 2). This group ranged in age from 18 years to 48 years, with most in their twenties. Of the total 46 addicts, 9 (20%) were female. The nationality most represented was France (n = 19)-an expected finding since many French people lived in Laos, a former French colony.
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WESTERMEYER AND BOURNE
TABLE 1. Asian Heroin Addicts, 12-Month Period
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Characteristic Age Less than 20 years 20-29 years 30-39 years 40-49 years Over 5 0 years Sex Male Female
Number of addicts 2 11 33 16 3
63 64 1
63
( 3%) ( 17%) ( 51%) ( 25%)
0 (101%) ( 98%) (2%)
(100%)
Ethnicity La0
Thai Chinese Vietnamese Indian Marital status Single Married Divorced, separated Unknown Residence With family With relatives With friends Alone Unknown Employed Yes No Unknown
41 12 6 5 1
z i 14 40 4 7
65
53 1 3 4 4
B
45 15 5
w
( 63%) ( 18%) ( 9%) ( 8%) (2%)
(100%) ( 22%) ( 62%) ( 6%)
U) (101%)
( 82%) ( 2%) ( 5%) ( 6%) (6%)
(101%) ( 69%) ( 23%) (8%)
(100%)
Type of narcotic drug Heroin only Heroin + opium
51 14
6%
( 78%) (22%) (100%)
Mode of use Smoke Smoke + eat Inject
58 4 3
( 89%) ( 6%) %)5(
Duration of addiction Less than 1 year 1-5 years 6-10 years 11-15 Years Over IS years
z i 7 34 11 8 5
FX
(100%) ( 11%) ( 52%) ( 17%)
12%)
TABLE 2. Caucasian Heroin Addicts, 28-Month Period Characteristic
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Age Less than 20 years 20-29 years 30-39 years 40-49 years Over 50 years
Number of addicts 1 41 3 1 0
w
( 2%) ( 89%) ( 7%) ( 2%)
0 (100%)
sex
Male Female Ethnicity French American English Australian Italian German Canadian Marital status Single Married Divorced Unknown Residence With family With relatives With friends Alone Unknown Employment Yes No Unknown Type of narcotic drug Heroin only Heroin + opium Mode of use Smoke Smoke + eat Inject Inject + smoke Sniff Duration of addiction Less than 1 year 1-5 years 6-10 years Over 10 years
37 9
( 80%)
19
( ( ( ( ( (
w 8
7 7 3 1 1
(20%) (100%) 41%) 17%) 15%) 15%) 7%) 2%)
w
(2%) ( 99%)
32 8 5 1
( 70%) ( 17%) ( 11%) ( 2%)
w
7 0 11 27 1
(100%) ( 15%) ( 0%) ( 24%) ( 59%)
w
2(%)
11 34 1
( 24%) ( 74%)
39 7
( 85%)
w w
10 1 24 3 8
w 21 23 2 0 46
(100%)
L w (lOW0) 0 (100%) ( 22%) ( 2%) ( 52%) ( 7%) ( 17%)
(100%) ( 46%) ( 50%) ( 4%)
(0%)
(lOWo’1
WSTERMEYER A N D BOURNE
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8
Another 11 came from elsewhere in Europe; 9 from North American; and 7 from Australia. Unlike the Asian group, these Caucasian addicts were primarily single, living or traveling alone, and currently unemployed. Half of them had become addicted to heroin elsewhere in Asia (Thailand, Malaysia, Vietnam, Indonesia, Afghanistan, Pakistan, and India). Almost a third had first become addicted in their country-of-origin. And the remaining six addicts were originally addicted in Laos as described earlier. In this group of 46 addicts, 39 of them (85%) were using only heroin and 7 (15%) were using both opium and heroin. Unlike the Asians, these people were primarily injecting heroin. A small proportion (all with marked physiologic addiction) were sniffing or “snorting” their heroin. Most patients came for treatment within a year or two of becoming addicted; none had been addicted for more than 10 years.
DISCUSSION Though the technology for producing heroin had been available for almost a century, widespread heroin use did not appear in Laos until 1972. This was so despite the fact that a heroin factory had been present for some time within the Laotian portion of the Golden Triangle. If small amounts of heroin did occasionally come into Laos prior to 1972, this presence alone was not sufficient t o induce prevalent or persistent heroin use. As has been argued elsewhere [6], the passage of an anti-opium law accomplished what a heroin factory alone could not accomplish. Heroin use began in the capital city of Vientiane soon after the passage of an anti-opium law. Police power was strongest in the capital city; thus enforcement of the law was effectively implemented there. This soon led to a decrease in the opium supply and the subsequent creation of a market for illicit narcotic drugs. The geographic distribution of heroin addicts in Laos suggested that heroin was brought from Thailand into Laos at Tha Deua in early 1972. In Vientiane heroin was probably first distributed to Asian addicts in the See Khay and Mixay districts of Vientiane. Within a short time heroin then became available to Caucasian addicts, probably in the downtown area. During the first year that heroin was introduced into Vientiane, most heroin users were Asian. Only 10 Caucasian heroin addicts were treated during the 12 months of 1972-1973, at the same time that 65 Asian heroin addicts were treated.
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A HEROIN “EPIDEMIC” IN ASIA
Once introduced into Vientiane, the use of heroin spread rapidly among the Lao and expatriate Asians. Many former opium addicts tried heroin, used both narcotic drugs for a time, and then switched entirely to heroin. They were virtually all male and employed at wage or salaried jobs. In addition, a new group of Asian addicts appeared: addicts whose first narcotic usage involved heroin. They were exclusively male, young, single, literate but unemployed and unskilled, and often from upwardly mobile urban families. Often they were alienated from their families. This latter group comprised a new subpopulation of addicts for Laos, though they were much like the “modern” urban post-World War I1 addicts in Bangkok, Hong Kong, or New York City. Caucasian heroin addicts soon became involved with heroin after it had appeared in Laos. Caucasian heroin users who had become addicted elsewhere began to descend on Laos. Some “world travelers” first became addicted to heroin in Laos. While these numbers remained small during the first year of heroin use in Laos, the 490% increase of Caucasian addicts at the National Detoxification Center between the first and second year (at a time when the number of Asian addicts admitted for treatment remained fairly stable) indicated a marked increase in the number of Caucasian heroin addicts in Laos. So also did the simple presence of many more Caucasian addicts “on the nod” in Vientiane during 1974 and 1975. The development of a pattern of progressive heroin use in Laos is mirrored in other Southeast Asian Nations. A combination of repressive laws geared toward suppressing traditional and often socially constrained opium use, urbanization and industrialization, the alienation of youth with progressive identification with western life-styles, and the availability of heroin as a new and profitable commodity for domestic and export use, all have favored the development of epidemics of heroin use. Thailand, Burma, Indonesia, and Malaysia all face problems of major proportions which they have had little success controlling with limited trained personnel for the treatment of any medical condition let alone drug addiction. Failure to control the problem or limit its spread is likely to result in the creation of a serious undermining of the attempt to stabilize the economies and enhance the development of these nations. As such, heroin addiction in Asia currently represents a much more serious problem than is generally recognized.
CONCLUSIONS 1. Widespread heroin use suddenly began in a localized area of Laos during 1972.
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WESTERMEYER AND BOURNE
2. Careful analysis of the heroin outbreak suggested that Caucasian “world travelers” did not cause the introduction of heroin into Laos, but that the anti-opium law was the prime causal factor. 3. Vientiane had been widely considered a “sleepy”-if somewhat overgrown -riverside town not heir to the problems of modern urban centers. The sudden appearance of young, single, male unemployed addicts (often from “good” middle class families) provided a warning that traditional social institutions were no longer meeting the needs of urban society, its families, and its youth in Laos.
ACKNOWLEDGMENTS Acknowledgment is expressed to Chomchan Soudaly, M.D., of Laos; Charles Weldon, M.D., M.P.H., of U.S. Agency for International Development; Grace Peng, M.S., Department of Biometry, University of Minnesota; Beth Stone, M.A., Department of Psychiatry, University of Minnesota, for their assistance. The study was supported in part by the Minnesota Medical Foundation, International Programs Office at the University of Minnesota, and the National Institute of Drug Abuse (grant no. 5 TO1 DA00023-02).
REFERENCES DuPont, R., and Greene, M. H., The dynamics of a heroin addiction epidemic, Science 181~716-722(1973). Hughes, P. H., Senay, E. C., and Parker, R., The medical management of a heroin epidemic, Arch. Gem Psychiatry 27~585-592(1972). Hunt, L. G., Recent spread of heroin use in the United States, Am. J. Public Health SUPPI.64~16-23(1974). Siegel, A. J., The heroin crisis among U.S. forces in southeast Asia: An overview, J. Am. Med. Assoc. 223:1258-1261 (1973). Way, E. L., Control and treatment of drug addiction in Hong Kong, in Narcotics (D.M. W h e r and G . G. Kasselbaum, eds.), McGraw-Hill, New York, 1965, pp. 278289. Westermeyer, J., The pro-heroin effects of anti-opium laws, Arch. Gen. Psychiatry 33:1135-1139 (1976). Westermeyer, J., Use of alcohol and opium by the Meo in Laos, Am. J. Psychiatry 127: 1019-1023 (1971). LeBar, F., and Suddard, A., Laos: Its People, Its Society, Its Culture, New Haven, Connecticut. Osborne, M., River Road to China; The Mekong River Expedition, 1866-73, Liveright, New York, 1975. Westermeyer, J., Opium smoking in Laos: A survey of 40 addicts, Am. J. Psychiatry 131: 165-170 (1974). Westermeyer, J., Opium dens: A social resource for addicts in Laos,Arch. Gen. Psychiatry 31:237-40 (1974).
A HEROIN “EPIDEMIC” IN ASIA
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[ 121 Westermeyer, I., Folk treatment for opium addiction in Laos, Br. J. Addict., 68: 345-349 (1973). (131 Westermeyer, J., The use of alcohol and opium among two ethnic groups in Laos, Panscultural Psychiatr. Res. 6:148-151 (1969). [ 141 Bourne, P., Issues in addiction, in Addiction, Academic, New York, 1974, pp. 1-19.
