British Journal of Addiction (1992) 87, 1241-1248
INTERNATIONAL REVIEW SERIES—18
Alcohol and drug abuse in Nepal NIRAKAR MAN SHRESTHA Mental Hospital, Lagankhel, Kathmandu, Nepal
Abstract Alcohol use has been in Nepal since time immemorial. Social tolerance to alcohol use is quite high and so far alcohol has not been taken seriously either by the Government or by any social organization. Production, sale, and consumption of alcohol is ever on the increase and it could be taken as the number one problem drug in the country. Cannabis and opium use has been in Nepal for centuries and in the past they did not pose much of a problem. Drug use began to be seen as a problem since only the mid-1960s and early-1970s with the influx of large numbers of hippies. Presently, the drug scene in Nepal is dominated by heroin and it has affected youths, mainly in the urban areas. A number of measures, both on supply reduction and demand reduction, have been taken by the Government together with non-Governmental organizations. However, the number of drug users is on the increase. Relapse rate following detoxification treatment is quite high. After-care and rehabilitative measures are lacking. Many drug users become involved in high-risk behaviours in spite of their knowledge of the dangers. Therefore, it calls for the change in our strategies which must be based on the thorough understanding of human nature and its behaviour.
Nepal is a land-locked country nestled in the midst of the world's highest mountains, strategically situated between the vast plains of the Indian subcontinent to the south, east and west and the high Tibetan plateau of China to the north. The total land area is 147,181 square kilometers. The population is estimated at about 20 million; about 90% are Hindus, and more than 90% live in rural areas. Topographically, the country can be divided into three well-defined physio-geographical belts running from east to west. The Terai contains 23% of the land area and 45% of the population; it is 200-1000 feet above sea level. The hills contain 42% of the land area and 47% of the population; this area is 1000-16,000 feet above sea level. The mountains, with 35% of the land area and the remaining 8% of the population, lies above 16,000 feet.
Administratively, the country is divided into five development regions and 75 districts. The economy of Nepal depends heavily on agriculture, which provides employment for more than 91% of the economically active population and accounts for about 60% of export earnings. Tourism plays an active part in foreign exchange earnings. In 1986, of 233,331 tourist arrivals, 25% came from India, 38% from Western Europe and 37% from the rest of the world. The average stay was 11.2 days. Many Nepalese also have relatives in adjacent states of India and both sides move freely across the border.
Alcohol Use Alcohol has always been used in Nepal. Alcoholic beverages are culturally accepted and social tolerance for alcohol use and alcohol dependence is quite high, so alcohol has not been considered a drug for
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1242
Alcohol and drug abuse in Nepal Table 1. Sales of alcohol (litre)
High quality liquor Low quality liquor Beer Annual revenue (NRs)
1988-89
1989-90
1990-91
1,533,085 1,533,085 6,300,175 211,371,785
1,909,816 7,858,588 7,307,044 242,580,356
1,767,304 7,148,000 10,288,429 234,317,532
serious concern either by the Government or by any social organization. Alcohol could be the number one problem drug if we seriously consider the magnitude and extent of the problem it has created in Nepal. For example, in just one of the 75 districts, in one month in 1989,46 men and 4 women were arrested for being rowdy under the influence of alcohol (T/ie Rising Nepal, 28 March 1989). Such arrests are mentioned almost every day in the national daily newspapers. Alcoholic drinks in various forms have long been consumed in Nepal. Alcohol is necessary on most occasions among many ethnic groups. Drunkenness among men is relatively frequent and is well tolerated by many communities, but there is strong social disapproval of female drunkenness, though it is not uncommon to see female alcoholics in the country, especially in the mountainous and hilly regions. A 'Matwali' is a person who is allowed to drink alcoholic beverages by virtue of his birth. A high percentage of the Nepalese population belong to this category and many of them take alcoholic beverages either on social occasions or on a regular basis. People who do not belong to this category are not supposed to consume alcoholic beverages even on social occasions. But there seems to be a steady rise in the number of people belonging to this category who consume alcoholic beverages. People in Nepal generally believe that alcohol is a remedy for cold, pain, physical tiredness, mental tension, sleeplessness, social inhibitions, and so on. In fact, alcohol is extensively used for many ailments, especially in the rural areas. Most of the unskilled and semi-skilled workers in Nepal believe that they can function better if they take small amounts of alcohol from time to time. Moreover, alcohol has become a status symbol for many people. Parties, get-togethers or festivities are considered incomplete if alcoholic beverages are not served. According to the 1991 figures from the Department of Excise, the sale of alcoholic beverages seems to be increasing rapidly (Table 1). Since
there is no export of alcoholic beverages from Nepal, all beverages are sold and consumed within the country. If we take into account home production, under-reporting of commercial production, liquor brought in from duty free shops and liquor imports, even more alcoholic beverages are consumed in Nepal. The number of distilleries and breweries is also increasing. It is a paradox to see an increase in the production and consumption of alcoholic beverages in the country when the Nepalese are striving very hard to have their bare minimum needs fulfilled by the year 2000. We are seeing benefits in terms of increased excise revenue but we seem to ignore the physical, mental, social and economic damage that alcohol use has done to the community in general and to alcoholics and their families in particular.
Drug Use Drug use is not entirely a new phenomenon in Nepal, but the type and magnitude of the problem today is much different from before. Cannabis, in the form of bhang, ganja and charas, has been used for centuries. This drug is particularly accepted in Nepal. It is not uncommon to see groups of elderly people enjoying puffs of cannabis, especially in rural areas. It has been said that 'sadhu' and 'jogi' (saints and hermits) who routinely take these preparations are responsible for introducing this habit to others to a great extent. Quite a few elderly people in Nepal want to associate with these socalled holy people in order to get spiritual knowledge and attainment of 'mokshya' (going to heaven after death). Cannabis preparations are considered as holy 'prashad' of Lord Shiva; so when these holy people offer this 'prashad' to others, they cannot say no. Gradually, they get psychologically dependent on cannabis and offer it to others and so the cycle goes on. The pre-existing mood of these elderly people, the expectations they have from the puffs and the social setting where they smoke all make the experience enjoyable.
Nirakar Man Shrestha Cannabis is freely distributed every year by the Government to all 'sadhus' and 'jogis' on 'Maha Shivaratri', the night when Lord Shiva was born. It is also taken in groups at the time of Holi, the festival that is celebrated every year to rejoice over the death of Holika. Opium has also been used in Nepal for many years. It is either ingested as a pill or smoked in a clay pipe. It is usually crude and samples vary in strength. It has been used for many purposes, such as treating various ailments. Drug use began to be seen as a problem in only the mid-1960s and early 1970s. During the mid1960s, many hippies entered Nepal as tourists and stayed on. They got good quality cannabis easily and cheaply; many cheap restaurants became available; and they were impressed by the natural beauty of Nepal and by the hospitality of Nepalese people. Frustrated young Nepalese seem to have been impressed by their lifestyle and philosophy and started associating with them. These hippies first started smoking ganja and hashish, which had been limited to a few elderly people and saints and hermits, but soon it was replaced by opiates, mainly heroin. Young Nepalese followed these hippies blindly, to such an extent that the Government had to do something to stop it. By that time, most of the youths who had taken up the drug habit were dependent on heroin. The hippies were mainly confined to the Kathmandu valley and Pokhara, which had more than 90% of drug dependents in the country. Then the vicious cycle of 'drug use—drug dependence— drug withdrawal—withdrawal symptoms—drug use' started. Drug traders kept supplying the drug through complex channels, and later the drug dependents started pushing drugs to their friends, mainly to support their own habits. This acted as a catalyst in the spread of drug dependence among youths. Many studies have reported that peer group pressure is the main cause for initiation of drug use in youths (Bhandari, 1988; Roche, Kohler & Pandey, 1988; Shrestha, 1989). One could argue that ultimately the pusher is the one who compels an addict to introduce it to his friends. This too is a possibility, but peer pressure is what is seen directly. The first case of a heroin addict coming for treatment was in December 1976 when a patient was referred from a medical ward for psychiatric opinion (Kunwar, 1981). On detailed psychiatric examination, he was found to be a poly-drug user of two years' duration but lately to be dependent on heroin.
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His severe withdrawal symptoms were treated with symptomatic drugs. According to Gafney (1985), heroin use was in epidemic proportions in Nepal from 1980 to 1985. Case records of drug dependents admitted to Nava Jeevan Ashram, the treatment centre of DAPAN, show that heroin use began in the country in 1972 and reached epidemic proportions in 1982-83. During this period, groups of youths could be seen 'chasing the dragon' in corners of street restaurants (Subba, 1988). There has not yet been any systemic large-scale study of the type and prevalence of drug dependence in Nepal. It has been estimated that the number of people dependent on drugs (excluding tobacco, alcohol and cannabis) in the country at present is more than 25,000, mostly in the Kathmandu valley (Nepal National Committee Against Drug Abuse and Drug Trafficking, 1989) though drug use has spread to other towns and some rural areas. The drug scene in Nepal is largely dominated by heroin (Shrestha, 1986, 1989; Bhandari, 1988; Roche, Kohler & Pandey, 1988; Subba, 1990). Nearly 6 kg of brown heroin is consumed daily in the kingdom—which, at the current market price, costs NRs 2.5 million (Nepal National Committee Against Drug Abuse and Drug Trafficking, 1989). Other drugs being used include benzodiazepines, amphetamines and barbiturates. Steroid use and solvent abuse have not been seen so far. About 11% of drug dependents start taking drugs before the age of 15 years, 61% between 15 and 20 years, 19% between 21 and 25 years, and only 9% after the age of 25 years (Shrestha, 1989; Subba, 1990). Only 5.5% of drug dependents are reported to be female (Shrestha, 1986), but the percentage of female drug dependents might be higher as they usually do not report or are not brought for treatment to hospitals or treatment centres because of social reasons. Until a few years ago, heroin users were not using the intravenous method (Shrestha, 1986) but now 37% of heroin dependents are using this (Shrestha, 1989). The number of intravenous drug users is increasing rapidly; it is not uncommon to find drug dependents lying unconscious in the public toilets following intravenous administration of the drug {The Rising Nepal, 16 October 1989). Shrestha (1989) reported that 60% of those admitted to a residential treatment centre were unmarried and 84% belonged to the 'Matwali' community, which accepts the consumption of
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Alcohol and drug abuse in Nepal
alcoholic drinks; 99% were dependent on heroin only and only 1% on alcohol. Almost all of them needed to take other drugs as substitutes whenever the drug of their choice was not available to them—mainly other opiates, alcohol, benzodiazepines, methaqualone, amphetamines, pentazocine and barbiturates. Fifty-one per cent took only about 0.5 g of brown heroin per day and only 11% took more than 1 g per day. This study also showed that most patients relapsed within three months of discharge from the treatment centre, as many as 90% of those treated had relapsed. This shows virtual absence of followup and rehabilitative measures in the country at the moment and the need for the successful management of drug dependence. Shrestha (1986) reported that 10% of drug dependents admitted to a mental hospital had preexisting serious psychopathology before initiating a drug and 1-2% developed psychosis after starting. The development of psychosis after the initiation of a drug might be just coincidence rather than the result of the drug, but this study tells us that mental illness could both be the cause and effect of drug dependence. The same study found that 86% of cases were brought for treatment by their close family members, which shows a good and supportive family system in Nepalese society. Therefore, what the family needs most is proper and timely information, knowledge and guidance so that they can be actively engaged in preventing drug dependence in the community. Heroin is not produced in Nepal; it comes exclusively from outside. White heroin is uncommon because of the price and is rarely used. Brown heroin is used after some purification. Morphine, pethidine, pentazocine and benzodiazepines are also used. Cocaine was seized in Nepal, once in 1982 and once in 1984 (Subba, 1988). According to the Ministry of Home Affairs (1987), about 18 kg of cocaine was seized in Nepal from two foreigners and one Nepalese person in 1987, However, cocaine use has not been reported. Nepal is already plagued by a massive tobacco smoking problem. With 87% of men and 72% of women consuming tobacco in Nepal (WHO, 1988), there is considerable morbidity and mortality from this habit.
are brought for treatment by family members, who also give good support during their stay in hospital (Shrestha, 1986). The vast majority of drug dependents are staying with their parents and/or wife at the time of reporting for treatment (Subba, 1990), It has been observed that drug use and drug trafficking are closely allied activities. Many drug dependents eventually turn to selling drugs and help in trafficking for a number of reasons, most importantly to procure a steady supply of their daily drugs. Most of the drug traffickers use drugs because of their personality, their lifestyle, the type of people they associate with, and the philosophy of life they believe in. Involvement in drugs, therefore, usually means both using and trafficking. Two types of crimes are usually committed by drug dependents: non-violent and money-making and violent and serious, A simple drug dependent who had a normal pre-morbid personality and no criminal record and who started taking drugs because of peer pressure, curiosity or stress usually commits only non-violent and money-making type of crimes, such as pick-pocketing, theft or lying. On the other hand, violent and serious crimes are usually committed by those drug dependents with psychopathic or antisocial personalities and who had criminal records before starting taking drugs. In Nepal, many crimes are committed under the infiuence of alcohol. Much violence both outside and inside the home has taken place under its infiuence, and it has been the root cause or precipitant in many antisocial and criminal acts. Alcohol has been the starting drug for many, and it has also been freely available whenever the drug of choice is not available. Many crimes have been committed by drug dependents in Nepal. Although some are violent and serious, most are petty crimes, committed for money to support the drug habit (Shrestha, 1989; Subba, 1990). The mental tension and mental torture that a drug dependent or a drug dealer causes to the family and in the community is quite serious. Loss of money, loss of social prestige, fear of arrest, fear of contracting various diseases including AIDS and fear of so many other things makes the lives of family members disorganized, insecure, unpredictable and unproductive.
Drug Use and Social Problems
Controlling Measures
Less than 10% of drug dependents give family problems as a reason for drug use and 86% of them
In talking about drug use and drug trafficking, three things are to be considered: the individual, the
Nirakar Man Shrestha environment and the drug. All three are important in the origin, progression and maintenance of drug use in the society. When attacking drug use we have to attack all three fronts simultaneously. Drug use is a big challenge: neither Governments nor non-Governmental organizations can face it alone; they should move forward jointly. In order to attack on all the three fronts simultaneously, two basic strategies have been adopted: demand reduction and supply reduction.
Demand reduction Non-Governmental organizations are playing a leading part in reducing the demand for drugs in Nepal, One significant landmark was the establishment of the Social Services National Co-ordination Council (SSNCC) in February 1977, Many organizations have the sole objective of preventing drug use; their main role is in primary prevention and to some extent in secondary and tertiary prevention as well, DAP AN (Drug Abuse Prevention Association of Nepal) carries out several activities, Nava Jeevan Ashram is the intervention programme centre, located in Kumari Pati in Lalitpur, This residential treatment centre was inaugurated in 1987. It offers specialized services with accommodation facilities for 20 inmates at a time. Patients are treated in the centre for two weeks for a nominal charge. This two-week intervention programme is not adequate for the final recovery of drug dependents, A day-care centre was started therefore in Kathmandu in 1988 with the main aim of preventing relapse of patients from detoxification and intervention programmes in Nava Jeevan Ashram and other therapeutic centres. It carries out various activities in order to keep drug-free individuals away from drugs as long as possible and help to reintegrate them in the mainstream of society, DAP AN also has had a counselling centre for drug dependents and their families in Baghbazar, Kathmandu, since 1986, published a book on drug abuse in Nepal and produced a telefilm, a documentary film, leafiets, posters, pamphlets, advertisements, etc. conveying the anti-drug message in plain and simple language. It runs an orientation programme on countering drug use for different target groups and supplies drug education to schoolchildren, has organized a national seminar on drug use prevention, and participates in other national, regional and international meetings, conferences and workshops related to drug use and illicit drug
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trafficking. DAP AN also brings out a news bulletin, Pratikar, every month, St. Xavier's Social Service Centres have been running a Freedom Centre in Lalitpur for about 15 years with the aim of providing treatment and rehabilitation services for drug dependents, Neuroleptic and other drugs were being used for detoxification until the end of 1986, but since then the acupuncture detoxification technique has been used. Its non-medical personnel have been certified by the National Acupuncture Detoxification Association in New York as Acupuncture Detoxification specialists (Gafney, 1989), UMN—DAPP (United Mission to Nepal—Drug Abuse Prevention Programme) was started in 1985 and since then it has launched various activities with the active involvement and co-operation of various organizations. It has been a catalyst and a motivating force in sensitizing people against drugs. Its activities include posters, pamphlets, leafiets, stickers, video films, anti-drug spots on Nepal Television and a drug education programme in some schools and colleges. Many other social organizations have carried out activities in the country: a 'youth forum' to discuss drug use; seminars; workshops; talk programmes and panel discussions on radio and television; antidrug rallies; poster competitions; T-shirts carrying the anti-drug message; home visits; articles on drugs in national dailies and so on. The first seminar on drug abuse and addiction in Nepal was organized by the Nepal Medical Association in 1977. The Governmental Mental Hospital and Tribhuvan University Teaching Hospital provides treatment services to drug dependents and experts from these hospitals have been helping various organizations in their drive against drug use.
Supply reduction There is no doubt that problem of drug dependence is the problem of the whole world and of the entire human population. But it is too costly a problem for the least developed countries like Nepal, which is striving to provide basic minimum needs to its people by the turn of the century. Nepal is fully committed to facing the challenge of drug use, at the national as well as regional and international levels. The Government has taken some important steps in this direction. First, in June 1987, it signed the UN Single Convention on Narcotic Drugs of 1961 as amended by 1972 protocol. It made a second amendment to the Narcotic Control Act of 1976 in
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Alcohol and drug abuse in Nepal
1987. The salient features of this amended act are as follows: (a) Drug dependents are considered sick persons and not offenders provided they are under treatment from a qualified physician or from a recognized treatment centre. (b) Cultivation, production, processing, purchase, sale, distribution, export, import, trafficking, storage or consumption of hemp is banned all over the country. (c) The cultivation and production of opium, coca leaf and other narcotics are illegal. (d) Manufacture, processing, sale, distribution, export, import, purchase, storage, possession and trafficking of narcotic drugs have been banned. (e) Seized drugs are to be publicly destroyed. (f) Provision is made to reward informers. (g) Provision is made to confiscate property, movable or immovable, gained illegally from the drug business. (h) A maximum fine of up to NRs.2 million and imprisonment of up to 20 years. (Previously, the maximum punishment for drug offences was an imprisonment of up to 14 years and a fine of up to NRs. 100,000.) (i) Physicians and other medical practitioners have been cautioned against indiscriminate prescriptions of dependence-producing drugs. For this offence, they could be penalized with a fine of up to NRs. 1000 and/or an imprisonment of up to one month. (j) Chemists and druggists have been cautioned not to sell dependence-producing drugs without a prescription from a registered medical
practitioner and they are required to maintain a register for this. Violation could lead to imprisonment of up to one month and/or a fine of up to NRs. 1000. One unique feature of this amendment is that if somebody is caught in possession of drugs, then it becomes the responsibility of that person to furnish evidence to the contrary or to prove that he/she got the drugs by legal means. The Customs Department, Police Force, Revenue Research Division and Local Administration have been strengthened and made more efficient to keep strict vigilance on drug crimes in the country. A Narcotic Control Administration Unit has been set up under the Ministry of Home Affairs. An additional Secretary of Home Affairs has been designated as the Chief Narcotics Control Officer at the central level, and 75 District Officers have been designated as District Narcotics Control Officers in their respective districts. Drugs seized and the number of people arrested for drug offences in 1989, 1990, and the first six months of 1991 are given in Tables 2-4. There are some legal restrictions on the production, sale and consumption of alcoholic beverages. For example, in Madira Niyamharu (2033), legal provision has been made for the sale of alcoholic beverages only by persons possessing a valid licence, and the production and sale of alcoholic beverages within 200 yards of temples and educational boundaries has been prohibited. Alcoholic drinks can be sold only from 10.00 am to 10.00 pm. The sale or offering of alcoholic drinks to persons below 18 years of age is illegal. Production
Table 2. Dmg offences in Nepal in 1989
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Non-medical purposes (kg) Stock (kg)
Cannabis Sativa (Ganja) 52 72
Cannabis Resin (Hashish) 61 98
24 —
12 1
46 2 1194.5 8955.9 40 —
Heroin 93 179
Opium 4 5
Total 210 354
11 1
2 —
49 2
82 3
166 1
3 —
297 6
188.5 375.8 10 —
7.6 0.05
0.22 0.66
7.606.5
—
* Nationality of Foreigners: Indian, 40; Australian, 1; American, 3; Japanese, 1; Irish, 2; Spanish, 2; Canadian, 1.
Nirakar Man Shrestha
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Table 3. Drug offences in Nepal in 1990
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Stock (kg)
Cannabis Sativa (Ganja)
Cannabis Resin (Hashish)
Heroin
42 59
46 66
34 66
2 2
124 193
14 —
8
4 —
— 1
26 1
41 4
53 5
57 5
1 —
152 14
623.6 2401.29 —
349 173 175.5
3.5 — 3.5
0.53 0.83 —
Opium
Total
* Nationality of Foreigners: Indian—27. Table 4. Drug offences in Nepal in the first half of 1991
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Stock (kg)
Cannabis Sativa (Ganja)
Cannabis Resin (Hashish)
Heroin
17 28
19 31
10 21
1 1
47 81
13 1
2
1 —
—
16 1
14 —
35 —
20 —
1 —
70 —
329.85 148.45 1751.76
620.8 — 762.2
2.3 — 3.5
0.11 — 5.8
Opium
Total
*Nationality of Foreigners: Indian—17.
of 'raksi' (liquors) up to 5 litres and 'jand' (homemade beer) up to 10 litres at a time for domstic use is allowed without a licence, but only 6 times a year, and the quantities thus produced must be reported to the authorities. However, these rules do not seem to have been implemented and open violations can be seen even in the heart of the capital. No legal measures yet exist in Nepal to control or to minimize tobacco consumption.
Drugs and AIDS Intravenous drug use is increasing in Nepal (Shrestha, 1989). None of the local drug dependents tested so far has been seropositive. Although most of the heroin dependents complain of a loss of interest in sex and homosexuality and unnatural sex are not
common in Nepal, there is every chance that use of intravenous drug use may become the major source of HIV transmission in the country. Female drug dependents are frequently involved in prostitution to support their drug habit. Most Intravenous Drug Users (IVDUs) share syringes, needles and other paraphernalia. They give financial, technical, legal and other reasons for this sharing, but, above all, they give the reason of companionship and trust. Anyone in the group not sharing the paraphernalia is not welcome and is excluded. Almost all IVDUs in Nepal know that this could be the source of HIV infection, but even then they continue this needle sharing behaviour. Therefore information and education alone will not be sufficient to change the behaviour of IVDUs.
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Alcohol and drug abuse in Nepal
To be effective, preventive intervention must also include behaviour-change strategies. The first case of AIDS in Nepal was diagnosed in July 1988. As of June 1990,13,623 persons had been tested for HIV antibodies, 3146 of whom were patients with sexuality transmitted diseases (STDs), 446 were drug dependents, 318 were prisoners, 4134 were blood donors, and 2681 were pregnant women; 2898 were tested for other reasons. Nine were found to be seropositive; 6 from STDs group (4 Nepalese women and 2 foreigners), 1 (foreigner) who was drug dependent, and 2 prisoners (foreigners). Six were in the carrier stage, 1 had AIDS-related complex, and 2 were in the final stage of full-blown AIDS (AIDS Prevention and Control Programme, 1990).
References AIDS PREVENTION AND CONTROL PROGRAMME (1990)
AIDS Newsletter, June/July 1991, Ministry of Health, Kathmandu. BHANDAW, B. (1988) Drug abuse in Nepal: a case study of the Kathmandu Valley, Pratikar, The Official News Bulletin of DAP AN, Kathmandu, 4, pp. 1-2. DEPARTMENT
OF
ExasE,
MINISTRY
OF
FINANCE,
HMG/NEPAL (1991) Personal communication with Mr Bimal Prasad Adhikaii, Under Secretary. GAFNEY, T . E. (1985) Statement of St Xavier's Social Service Centres, in: BHANDARI, B. & SARMAH, H. P.
(Eds) Drug Abuse in Nepal, DAP AN, Kathmandu, p. 59. GAFNEY, T . E . (1989) Personal communication on 26 March 1989, St Xavier's Social Service Centres, Lalitpur, Nepal. KtJNWAR, D. R. B. (1981) Treatment techniques of drug dependents in Nepal, The First National Seminar and Workshop on Drug Abuse and Addiction, 20-22 September 1981, NMA/HMG/WHO/Colombo Plan Bureau, Kathmandu, p. 1. Conclusions MADIRA, NIYAMHARU (2033) Neptd Niyam Sangraha, Although alcohol, tobacco and cannabis use has Khanda-4(KA) 2040, Ministry of Law and Justice, HMG/Nepal, pp. 132-138. always taken place in Nepal, the use of opiates,
especially heroin, and other psychotropic drugs, has been a relatively recent phenomenon. Alcohol has not been taken seriously in spite of the fact that it is the number one problem drug in the country. Tobacco use is so extensive in Nepal that it has become part of Nepalese life; the Government has not even thought of reducing its use in the community. The word 'drug' has been equated with 'brown sugar', and for most people, a drug dependent means a person who is dependent on heroin. The number of drug dependents and of drug crimes is on the increase despite the Government's commitment to control drug use and drug trafficking. This indicates that there is definitely something wrong somewhere. Certainly, many people use drugs in spite of their knowledge that drug use is illegal and potentially dangerous and harmful. More than 90% of drug dependents relapse within three months of detoxification treatment. Therefore, information, education and simple detoxification treatment alone will not be enough to solve the problem. In order to tackle this problem, we need to change our strategies: they must be based on the good understanding of human nature in general and addiction behaviour in particular.
MINISTRY OF HOME AFFAIRS (1987) Drug Offences in
Nepal, HMG/Nepal, Kathmandu. NEPAL NATIONAL CoMMnTEE AGAINST DRUG ABUSE AND
DRUG TRAFFICKING (1989) The Rising Nepal, 10 December. ROCHE, P., KOHLER, P. & PANDEY, G . R. (1988) UMN
Report on Drug Use among Nepalese Youths, Pratikar, The Official News Bulletin of DAP AN, 4, pp. 2-3. SHRESTHA, N . M . (1986) A Retrospective Study of Drug Dependent cases admitted in Mental Hospital. Paper presented at the National Workshop on Prevention, Treatment and Management of Drug Dependence, Kathmandu, 20-25 October, HMG/WHO. SHRESTHA, N . M . (1989) A study of drug dependent cases admitted to the treatment centre of DAPAN, Paper prepared for SAARC Meeting of NGOs on Drug Abuse Prevention, Islamabad, 2-4 April. SUBBA, C. (1988) Drug and drug addiction in Nepal, in: BHANDARI, B. & SAKMAH, H . P. (Eds) Drug Abuse in
Nepal, DAPAN, Kathmandu, pp. 47-72. SUBBA, C. (1990) Treatment of Drug Dependence in Nepal: Approaches and Experiences of Nava Jeevan Ashram (a treatment centre), DAPAN, Kathmandu. WORLD HEALTH ORGANIZATION (1988) Collaboration in
health development in South-East Asia, 40th Anniversary Vol., Regional Office for South-East Asia, New Delhi, p. 271.
INTERNATIONAL REVIEW SERIES—18
Alcohol and drug abuse in Nepal NIRAKAR MAN SHRESTHA Mental Hospital, Lagankhel, Kathmandu, Nepal
Abstract Alcohol use has been in Nepal since time immemorial. Social tolerance to alcohol use is quite high and so far alcohol has not been taken seriously either by the Government or by any social organization. Production, sale, and consumption of alcohol is ever on the increase and it could be taken as the number one problem drug in the country. Cannabis and opium use has been in Nepal for centuries and in the past they did not pose much of a problem. Drug use began to be seen as a problem since only the mid-1960s and early-1970s with the influx of large numbers of hippies. Presently, the drug scene in Nepal is dominated by heroin and it has affected youths, mainly in the urban areas. A number of measures, both on supply reduction and demand reduction, have been taken by the Government together with non-Governmental organizations. However, the number of drug users is on the increase. Relapse rate following detoxification treatment is quite high. After-care and rehabilitative measures are lacking. Many drug users become involved in high-risk behaviours in spite of their knowledge of the dangers. Therefore, it calls for the change in our strategies which must be based on the thorough understanding of human nature and its behaviour.
Nepal is a land-locked country nestled in the midst of the world's highest mountains, strategically situated between the vast plains of the Indian subcontinent to the south, east and west and the high Tibetan plateau of China to the north. The total land area is 147,181 square kilometers. The population is estimated at about 20 million; about 90% are Hindus, and more than 90% live in rural areas. Topographically, the country can be divided into three well-defined physio-geographical belts running from east to west. The Terai contains 23% of the land area and 45% of the population; it is 200-1000 feet above sea level. The hills contain 42% of the land area and 47% of the population; this area is 1000-16,000 feet above sea level. The mountains, with 35% of the land area and the remaining 8% of the population, lies above 16,000 feet.
Administratively, the country is divided into five development regions and 75 districts. The economy of Nepal depends heavily on agriculture, which provides employment for more than 91% of the economically active population and accounts for about 60% of export earnings. Tourism plays an active part in foreign exchange earnings. In 1986, of 233,331 tourist arrivals, 25% came from India, 38% from Western Europe and 37% from the rest of the world. The average stay was 11.2 days. Many Nepalese also have relatives in adjacent states of India and both sides move freely across the border.
Alcohol Use Alcohol has always been used in Nepal. Alcoholic beverages are culturally accepted and social tolerance for alcohol use and alcohol dependence is quite high, so alcohol has not been considered a drug for
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Alcohol and drug abuse in Nepal Table 1. Sales of alcohol (litre)
High quality liquor Low quality liquor Beer Annual revenue (NRs)
1988-89
1989-90
1990-91
1,533,085 1,533,085 6,300,175 211,371,785
1,909,816 7,858,588 7,307,044 242,580,356
1,767,304 7,148,000 10,288,429 234,317,532
serious concern either by the Government or by any social organization. Alcohol could be the number one problem drug if we seriously consider the magnitude and extent of the problem it has created in Nepal. For example, in just one of the 75 districts, in one month in 1989,46 men and 4 women were arrested for being rowdy under the influence of alcohol (T/ie Rising Nepal, 28 March 1989). Such arrests are mentioned almost every day in the national daily newspapers. Alcoholic drinks in various forms have long been consumed in Nepal. Alcohol is necessary on most occasions among many ethnic groups. Drunkenness among men is relatively frequent and is well tolerated by many communities, but there is strong social disapproval of female drunkenness, though it is not uncommon to see female alcoholics in the country, especially in the mountainous and hilly regions. A 'Matwali' is a person who is allowed to drink alcoholic beverages by virtue of his birth. A high percentage of the Nepalese population belong to this category and many of them take alcoholic beverages either on social occasions or on a regular basis. People who do not belong to this category are not supposed to consume alcoholic beverages even on social occasions. But there seems to be a steady rise in the number of people belonging to this category who consume alcoholic beverages. People in Nepal generally believe that alcohol is a remedy for cold, pain, physical tiredness, mental tension, sleeplessness, social inhibitions, and so on. In fact, alcohol is extensively used for many ailments, especially in the rural areas. Most of the unskilled and semi-skilled workers in Nepal believe that they can function better if they take small amounts of alcohol from time to time. Moreover, alcohol has become a status symbol for many people. Parties, get-togethers or festivities are considered incomplete if alcoholic beverages are not served. According to the 1991 figures from the Department of Excise, the sale of alcoholic beverages seems to be increasing rapidly (Table 1). Since
there is no export of alcoholic beverages from Nepal, all beverages are sold and consumed within the country. If we take into account home production, under-reporting of commercial production, liquor brought in from duty free shops and liquor imports, even more alcoholic beverages are consumed in Nepal. The number of distilleries and breweries is also increasing. It is a paradox to see an increase in the production and consumption of alcoholic beverages in the country when the Nepalese are striving very hard to have their bare minimum needs fulfilled by the year 2000. We are seeing benefits in terms of increased excise revenue but we seem to ignore the physical, mental, social and economic damage that alcohol use has done to the community in general and to alcoholics and their families in particular.
Drug Use Drug use is not entirely a new phenomenon in Nepal, but the type and magnitude of the problem today is much different from before. Cannabis, in the form of bhang, ganja and charas, has been used for centuries. This drug is particularly accepted in Nepal. It is not uncommon to see groups of elderly people enjoying puffs of cannabis, especially in rural areas. It has been said that 'sadhu' and 'jogi' (saints and hermits) who routinely take these preparations are responsible for introducing this habit to others to a great extent. Quite a few elderly people in Nepal want to associate with these socalled holy people in order to get spiritual knowledge and attainment of 'mokshya' (going to heaven after death). Cannabis preparations are considered as holy 'prashad' of Lord Shiva; so when these holy people offer this 'prashad' to others, they cannot say no. Gradually, they get psychologically dependent on cannabis and offer it to others and so the cycle goes on. The pre-existing mood of these elderly people, the expectations they have from the puffs and the social setting where they smoke all make the experience enjoyable.
Nirakar Man Shrestha Cannabis is freely distributed every year by the Government to all 'sadhus' and 'jogis' on 'Maha Shivaratri', the night when Lord Shiva was born. It is also taken in groups at the time of Holi, the festival that is celebrated every year to rejoice over the death of Holika. Opium has also been used in Nepal for many years. It is either ingested as a pill or smoked in a clay pipe. It is usually crude and samples vary in strength. It has been used for many purposes, such as treating various ailments. Drug use began to be seen as a problem in only the mid-1960s and early 1970s. During the mid1960s, many hippies entered Nepal as tourists and stayed on. They got good quality cannabis easily and cheaply; many cheap restaurants became available; and they were impressed by the natural beauty of Nepal and by the hospitality of Nepalese people. Frustrated young Nepalese seem to have been impressed by their lifestyle and philosophy and started associating with them. These hippies first started smoking ganja and hashish, which had been limited to a few elderly people and saints and hermits, but soon it was replaced by opiates, mainly heroin. Young Nepalese followed these hippies blindly, to such an extent that the Government had to do something to stop it. By that time, most of the youths who had taken up the drug habit were dependent on heroin. The hippies were mainly confined to the Kathmandu valley and Pokhara, which had more than 90% of drug dependents in the country. Then the vicious cycle of 'drug use—drug dependence— drug withdrawal—withdrawal symptoms—drug use' started. Drug traders kept supplying the drug through complex channels, and later the drug dependents started pushing drugs to their friends, mainly to support their own habits. This acted as a catalyst in the spread of drug dependence among youths. Many studies have reported that peer group pressure is the main cause for initiation of drug use in youths (Bhandari, 1988; Roche, Kohler & Pandey, 1988; Shrestha, 1989). One could argue that ultimately the pusher is the one who compels an addict to introduce it to his friends. This too is a possibility, but peer pressure is what is seen directly. The first case of a heroin addict coming for treatment was in December 1976 when a patient was referred from a medical ward for psychiatric opinion (Kunwar, 1981). On detailed psychiatric examination, he was found to be a poly-drug user of two years' duration but lately to be dependent on heroin.
1243
His severe withdrawal symptoms were treated with symptomatic drugs. According to Gafney (1985), heroin use was in epidemic proportions in Nepal from 1980 to 1985. Case records of drug dependents admitted to Nava Jeevan Ashram, the treatment centre of DAPAN, show that heroin use began in the country in 1972 and reached epidemic proportions in 1982-83. During this period, groups of youths could be seen 'chasing the dragon' in corners of street restaurants (Subba, 1988). There has not yet been any systemic large-scale study of the type and prevalence of drug dependence in Nepal. It has been estimated that the number of people dependent on drugs (excluding tobacco, alcohol and cannabis) in the country at present is more than 25,000, mostly in the Kathmandu valley (Nepal National Committee Against Drug Abuse and Drug Trafficking, 1989) though drug use has spread to other towns and some rural areas. The drug scene in Nepal is largely dominated by heroin (Shrestha, 1986, 1989; Bhandari, 1988; Roche, Kohler & Pandey, 1988; Subba, 1990). Nearly 6 kg of brown heroin is consumed daily in the kingdom—which, at the current market price, costs NRs 2.5 million (Nepal National Committee Against Drug Abuse and Drug Trafficking, 1989). Other drugs being used include benzodiazepines, amphetamines and barbiturates. Steroid use and solvent abuse have not been seen so far. About 11% of drug dependents start taking drugs before the age of 15 years, 61% between 15 and 20 years, 19% between 21 and 25 years, and only 9% after the age of 25 years (Shrestha, 1989; Subba, 1990). Only 5.5% of drug dependents are reported to be female (Shrestha, 1986), but the percentage of female drug dependents might be higher as they usually do not report or are not brought for treatment to hospitals or treatment centres because of social reasons. Until a few years ago, heroin users were not using the intravenous method (Shrestha, 1986) but now 37% of heroin dependents are using this (Shrestha, 1989). The number of intravenous drug users is increasing rapidly; it is not uncommon to find drug dependents lying unconscious in the public toilets following intravenous administration of the drug {The Rising Nepal, 16 October 1989). Shrestha (1989) reported that 60% of those admitted to a residential treatment centre were unmarried and 84% belonged to the 'Matwali' community, which accepts the consumption of
1244
Alcohol and drug abuse in Nepal
alcoholic drinks; 99% were dependent on heroin only and only 1% on alcohol. Almost all of them needed to take other drugs as substitutes whenever the drug of their choice was not available to them—mainly other opiates, alcohol, benzodiazepines, methaqualone, amphetamines, pentazocine and barbiturates. Fifty-one per cent took only about 0.5 g of brown heroin per day and only 11% took more than 1 g per day. This study also showed that most patients relapsed within three months of discharge from the treatment centre, as many as 90% of those treated had relapsed. This shows virtual absence of followup and rehabilitative measures in the country at the moment and the need for the successful management of drug dependence. Shrestha (1986) reported that 10% of drug dependents admitted to a mental hospital had preexisting serious psychopathology before initiating a drug and 1-2% developed psychosis after starting. The development of psychosis after the initiation of a drug might be just coincidence rather than the result of the drug, but this study tells us that mental illness could both be the cause and effect of drug dependence. The same study found that 86% of cases were brought for treatment by their close family members, which shows a good and supportive family system in Nepalese society. Therefore, what the family needs most is proper and timely information, knowledge and guidance so that they can be actively engaged in preventing drug dependence in the community. Heroin is not produced in Nepal; it comes exclusively from outside. White heroin is uncommon because of the price and is rarely used. Brown heroin is used after some purification. Morphine, pethidine, pentazocine and benzodiazepines are also used. Cocaine was seized in Nepal, once in 1982 and once in 1984 (Subba, 1988). According to the Ministry of Home Affairs (1987), about 18 kg of cocaine was seized in Nepal from two foreigners and one Nepalese person in 1987, However, cocaine use has not been reported. Nepal is already plagued by a massive tobacco smoking problem. With 87% of men and 72% of women consuming tobacco in Nepal (WHO, 1988), there is considerable morbidity and mortality from this habit.
are brought for treatment by family members, who also give good support during their stay in hospital (Shrestha, 1986). The vast majority of drug dependents are staying with their parents and/or wife at the time of reporting for treatment (Subba, 1990), It has been observed that drug use and drug trafficking are closely allied activities. Many drug dependents eventually turn to selling drugs and help in trafficking for a number of reasons, most importantly to procure a steady supply of their daily drugs. Most of the drug traffickers use drugs because of their personality, their lifestyle, the type of people they associate with, and the philosophy of life they believe in. Involvement in drugs, therefore, usually means both using and trafficking. Two types of crimes are usually committed by drug dependents: non-violent and money-making and violent and serious, A simple drug dependent who had a normal pre-morbid personality and no criminal record and who started taking drugs because of peer pressure, curiosity or stress usually commits only non-violent and money-making type of crimes, such as pick-pocketing, theft or lying. On the other hand, violent and serious crimes are usually committed by those drug dependents with psychopathic or antisocial personalities and who had criminal records before starting taking drugs. In Nepal, many crimes are committed under the infiuence of alcohol. Much violence both outside and inside the home has taken place under its infiuence, and it has been the root cause or precipitant in many antisocial and criminal acts. Alcohol has been the starting drug for many, and it has also been freely available whenever the drug of choice is not available. Many crimes have been committed by drug dependents in Nepal. Although some are violent and serious, most are petty crimes, committed for money to support the drug habit (Shrestha, 1989; Subba, 1990). The mental tension and mental torture that a drug dependent or a drug dealer causes to the family and in the community is quite serious. Loss of money, loss of social prestige, fear of arrest, fear of contracting various diseases including AIDS and fear of so many other things makes the lives of family members disorganized, insecure, unpredictable and unproductive.
Drug Use and Social Problems
Controlling Measures
Less than 10% of drug dependents give family problems as a reason for drug use and 86% of them
In talking about drug use and drug trafficking, three things are to be considered: the individual, the
Nirakar Man Shrestha environment and the drug. All three are important in the origin, progression and maintenance of drug use in the society. When attacking drug use we have to attack all three fronts simultaneously. Drug use is a big challenge: neither Governments nor non-Governmental organizations can face it alone; they should move forward jointly. In order to attack on all the three fronts simultaneously, two basic strategies have been adopted: demand reduction and supply reduction.
Demand reduction Non-Governmental organizations are playing a leading part in reducing the demand for drugs in Nepal, One significant landmark was the establishment of the Social Services National Co-ordination Council (SSNCC) in February 1977, Many organizations have the sole objective of preventing drug use; their main role is in primary prevention and to some extent in secondary and tertiary prevention as well, DAP AN (Drug Abuse Prevention Association of Nepal) carries out several activities, Nava Jeevan Ashram is the intervention programme centre, located in Kumari Pati in Lalitpur, This residential treatment centre was inaugurated in 1987. It offers specialized services with accommodation facilities for 20 inmates at a time. Patients are treated in the centre for two weeks for a nominal charge. This two-week intervention programme is not adequate for the final recovery of drug dependents, A day-care centre was started therefore in Kathmandu in 1988 with the main aim of preventing relapse of patients from detoxification and intervention programmes in Nava Jeevan Ashram and other therapeutic centres. It carries out various activities in order to keep drug-free individuals away from drugs as long as possible and help to reintegrate them in the mainstream of society, DAP AN also has had a counselling centre for drug dependents and their families in Baghbazar, Kathmandu, since 1986, published a book on drug abuse in Nepal and produced a telefilm, a documentary film, leafiets, posters, pamphlets, advertisements, etc. conveying the anti-drug message in plain and simple language. It runs an orientation programme on countering drug use for different target groups and supplies drug education to schoolchildren, has organized a national seminar on drug use prevention, and participates in other national, regional and international meetings, conferences and workshops related to drug use and illicit drug
1245
trafficking. DAP AN also brings out a news bulletin, Pratikar, every month, St. Xavier's Social Service Centres have been running a Freedom Centre in Lalitpur for about 15 years with the aim of providing treatment and rehabilitation services for drug dependents, Neuroleptic and other drugs were being used for detoxification until the end of 1986, but since then the acupuncture detoxification technique has been used. Its non-medical personnel have been certified by the National Acupuncture Detoxification Association in New York as Acupuncture Detoxification specialists (Gafney, 1989), UMN—DAPP (United Mission to Nepal—Drug Abuse Prevention Programme) was started in 1985 and since then it has launched various activities with the active involvement and co-operation of various organizations. It has been a catalyst and a motivating force in sensitizing people against drugs. Its activities include posters, pamphlets, leafiets, stickers, video films, anti-drug spots on Nepal Television and a drug education programme in some schools and colleges. Many other social organizations have carried out activities in the country: a 'youth forum' to discuss drug use; seminars; workshops; talk programmes and panel discussions on radio and television; antidrug rallies; poster competitions; T-shirts carrying the anti-drug message; home visits; articles on drugs in national dailies and so on. The first seminar on drug abuse and addiction in Nepal was organized by the Nepal Medical Association in 1977. The Governmental Mental Hospital and Tribhuvan University Teaching Hospital provides treatment services to drug dependents and experts from these hospitals have been helping various organizations in their drive against drug use.
Supply reduction There is no doubt that problem of drug dependence is the problem of the whole world and of the entire human population. But it is too costly a problem for the least developed countries like Nepal, which is striving to provide basic minimum needs to its people by the turn of the century. Nepal is fully committed to facing the challenge of drug use, at the national as well as regional and international levels. The Government has taken some important steps in this direction. First, in June 1987, it signed the UN Single Convention on Narcotic Drugs of 1961 as amended by 1972 protocol. It made a second amendment to the Narcotic Control Act of 1976 in
1246
Alcohol and drug abuse in Nepal
1987. The salient features of this amended act are as follows: (a) Drug dependents are considered sick persons and not offenders provided they are under treatment from a qualified physician or from a recognized treatment centre. (b) Cultivation, production, processing, purchase, sale, distribution, export, import, trafficking, storage or consumption of hemp is banned all over the country. (c) The cultivation and production of opium, coca leaf and other narcotics are illegal. (d) Manufacture, processing, sale, distribution, export, import, purchase, storage, possession and trafficking of narcotic drugs have been banned. (e) Seized drugs are to be publicly destroyed. (f) Provision is made to reward informers. (g) Provision is made to confiscate property, movable or immovable, gained illegally from the drug business. (h) A maximum fine of up to NRs.2 million and imprisonment of up to 20 years. (Previously, the maximum punishment for drug offences was an imprisonment of up to 14 years and a fine of up to NRs. 100,000.) (i) Physicians and other medical practitioners have been cautioned against indiscriminate prescriptions of dependence-producing drugs. For this offence, they could be penalized with a fine of up to NRs. 1000 and/or an imprisonment of up to one month. (j) Chemists and druggists have been cautioned not to sell dependence-producing drugs without a prescription from a registered medical
practitioner and they are required to maintain a register for this. Violation could lead to imprisonment of up to one month and/or a fine of up to NRs. 1000. One unique feature of this amendment is that if somebody is caught in possession of drugs, then it becomes the responsibility of that person to furnish evidence to the contrary or to prove that he/she got the drugs by legal means. The Customs Department, Police Force, Revenue Research Division and Local Administration have been strengthened and made more efficient to keep strict vigilance on drug crimes in the country. A Narcotic Control Administration Unit has been set up under the Ministry of Home Affairs. An additional Secretary of Home Affairs has been designated as the Chief Narcotics Control Officer at the central level, and 75 District Officers have been designated as District Narcotics Control Officers in their respective districts. Drugs seized and the number of people arrested for drug offences in 1989, 1990, and the first six months of 1991 are given in Tables 2-4. There are some legal restrictions on the production, sale and consumption of alcoholic beverages. For example, in Madira Niyamharu (2033), legal provision has been made for the sale of alcoholic beverages only by persons possessing a valid licence, and the production and sale of alcoholic beverages within 200 yards of temples and educational boundaries has been prohibited. Alcoholic drinks can be sold only from 10.00 am to 10.00 pm. The sale or offering of alcoholic drinks to persons below 18 years of age is illegal. Production
Table 2. Dmg offences in Nepal in 1989
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Non-medical purposes (kg) Stock (kg)
Cannabis Sativa (Ganja) 52 72
Cannabis Resin (Hashish) 61 98
24 —
12 1
46 2 1194.5 8955.9 40 —
Heroin 93 179
Opium 4 5
Total 210 354
11 1
2 —
49 2
82 3
166 1
3 —
297 6
188.5 375.8 10 —
7.6 0.05
0.22 0.66
7.606.5
—
* Nationality of Foreigners: Indian, 40; Australian, 1; American, 3; Japanese, 1; Irish, 2; Spanish, 2; Canadian, 1.
Nirakar Man Shrestha
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Table 3. Drug offences in Nepal in 1990
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Stock (kg)
Cannabis Sativa (Ganja)
Cannabis Resin (Hashish)
Heroin
42 59
46 66
34 66
2 2
124 193
14 —
8
4 —
— 1
26 1
41 4
53 5
57 5
1 —
152 14
623.6 2401.29 —
349 173 175.5
3.5 — 3.5
0.53 0.83 —
Opium
Total
* Nationality of Foreigners: Indian—27. Table 4. Drug offences in Nepal in the first half of 1991
Drugs Number of cases Number of persons arrested Foreigners* Male Female Nepalese Male Female Quantities seized (kg) Drugs destroyed (kg) Stock (kg)
Cannabis Sativa (Ganja)
Cannabis Resin (Hashish)
Heroin
17 28
19 31
10 21
1 1
47 81
13 1
2
1 —
—
16 1
14 —
35 —
20 —
1 —
70 —
329.85 148.45 1751.76
620.8 — 762.2
2.3 — 3.5
0.11 — 5.8
Opium
Total
*Nationality of Foreigners: Indian—17.
of 'raksi' (liquors) up to 5 litres and 'jand' (homemade beer) up to 10 litres at a time for domstic use is allowed without a licence, but only 6 times a year, and the quantities thus produced must be reported to the authorities. However, these rules do not seem to have been implemented and open violations can be seen even in the heart of the capital. No legal measures yet exist in Nepal to control or to minimize tobacco consumption.
Drugs and AIDS Intravenous drug use is increasing in Nepal (Shrestha, 1989). None of the local drug dependents tested so far has been seropositive. Although most of the heroin dependents complain of a loss of interest in sex and homosexuality and unnatural sex are not
common in Nepal, there is every chance that use of intravenous drug use may become the major source of HIV transmission in the country. Female drug dependents are frequently involved in prostitution to support their drug habit. Most Intravenous Drug Users (IVDUs) share syringes, needles and other paraphernalia. They give financial, technical, legal and other reasons for this sharing, but, above all, they give the reason of companionship and trust. Anyone in the group not sharing the paraphernalia is not welcome and is excluded. Almost all IVDUs in Nepal know that this could be the source of HIV infection, but even then they continue this needle sharing behaviour. Therefore information and education alone will not be sufficient to change the behaviour of IVDUs.
1248
Alcohol and drug abuse in Nepal
To be effective, preventive intervention must also include behaviour-change strategies. The first case of AIDS in Nepal was diagnosed in July 1988. As of June 1990,13,623 persons had been tested for HIV antibodies, 3146 of whom were patients with sexuality transmitted diseases (STDs), 446 were drug dependents, 318 were prisoners, 4134 were blood donors, and 2681 were pregnant women; 2898 were tested for other reasons. Nine were found to be seropositive; 6 from STDs group (4 Nepalese women and 2 foreigners), 1 (foreigner) who was drug dependent, and 2 prisoners (foreigners). Six were in the carrier stage, 1 had AIDS-related complex, and 2 were in the final stage of full-blown AIDS (AIDS Prevention and Control Programme, 1990).
References AIDS PREVENTION AND CONTROL PROGRAMME (1990)
AIDS Newsletter, June/July 1991, Ministry of Health, Kathmandu. BHANDAW, B. (1988) Drug abuse in Nepal: a case study of the Kathmandu Valley, Pratikar, The Official News Bulletin of DAP AN, Kathmandu, 4, pp. 1-2. DEPARTMENT
OF
ExasE,
MINISTRY
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FINANCE,
HMG/NEPAL (1991) Personal communication with Mr Bimal Prasad Adhikaii, Under Secretary. GAFNEY, T . E. (1985) Statement of St Xavier's Social Service Centres, in: BHANDARI, B. & SARMAH, H. P.
(Eds) Drug Abuse in Nepal, DAP AN, Kathmandu, p. 59. GAFNEY, T . E . (1989) Personal communication on 26 March 1989, St Xavier's Social Service Centres, Lalitpur, Nepal. KtJNWAR, D. R. B. (1981) Treatment techniques of drug dependents in Nepal, The First National Seminar and Workshop on Drug Abuse and Addiction, 20-22 September 1981, NMA/HMG/WHO/Colombo Plan Bureau, Kathmandu, p. 1. Conclusions MADIRA, NIYAMHARU (2033) Neptd Niyam Sangraha, Although alcohol, tobacco and cannabis use has Khanda-4(KA) 2040, Ministry of Law and Justice, HMG/Nepal, pp. 132-138. always taken place in Nepal, the use of opiates,
especially heroin, and other psychotropic drugs, has been a relatively recent phenomenon. Alcohol has not been taken seriously in spite of the fact that it is the number one problem drug in the country. Tobacco use is so extensive in Nepal that it has become part of Nepalese life; the Government has not even thought of reducing its use in the community. The word 'drug' has been equated with 'brown sugar', and for most people, a drug dependent means a person who is dependent on heroin. The number of drug dependents and of drug crimes is on the increase despite the Government's commitment to control drug use and drug trafficking. This indicates that there is definitely something wrong somewhere. Certainly, many people use drugs in spite of their knowledge that drug use is illegal and potentially dangerous and harmful. More than 90% of drug dependents relapse within three months of detoxification treatment. Therefore, information, education and simple detoxification treatment alone will not be enough to solve the problem. In order to tackle this problem, we need to change our strategies: they must be based on the good understanding of human nature in general and addiction behaviour in particular.
MINISTRY OF HOME AFFAIRS (1987) Drug Offences in
Nepal, HMG/Nepal, Kathmandu. NEPAL NATIONAL CoMMnTEE AGAINST DRUG ABUSE AND
DRUG TRAFFICKING (1989) The Rising Nepal, 10 December. ROCHE, P., KOHLER, P. & PANDEY, G . R. (1988) UMN
Report on Drug Use among Nepalese Youths, Pratikar, The Official News Bulletin of DAP AN, 4, pp. 2-3. SHRESTHA, N . M . (1986) A Retrospective Study of Drug Dependent cases admitted in Mental Hospital. Paper presented at the National Workshop on Prevention, Treatment and Management of Drug Dependence, Kathmandu, 20-25 October, HMG/WHO. SHRESTHA, N . M . (1989) A study of drug dependent cases admitted to the treatment centre of DAPAN, Paper prepared for SAARC Meeting of NGOs on Drug Abuse Prevention, Islamabad, 2-4 April. SUBBA, C. (1988) Drug and drug addiction in Nepal, in: BHANDARI, B. & SAKMAH, H . P. (Eds) Drug Abuse in
Nepal, DAPAN, Kathmandu, pp. 47-72. SUBBA, C. (1990) Treatment of Drug Dependence in Nepal: Approaches and Experiences of Nava Jeevan Ashram (a treatment centre), DAPAN, Kathmandu. WORLD HEALTH ORGANIZATION (1988) Collaboration in
health development in South-East Asia, 40th Anniversary Vol., Regional Office for South-East Asia, New Delhi, p. 271.
