Substance Use & Misuse
ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20
Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study Abbas Deilamizade & Sara Esmizade To cite this article: Abbas Deilamizade & Sara Esmizade (2015) Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study, Substance Use & Misuse, 50:7, 859-868, DOI: 10.3109/10826084.2015.978673 To link to this article: http://dx.doi.org/10.3109/10826084.2015.978673
Published online: 27 Feb 2015.
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Substance Use & Misuse, 50:859–868, 2015 C 2015 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.978673
ORIGINAL ARTICLE
Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study Abbas Deilamizade and Sara Esmizade
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Department of Research, Rebirth Society, Tehran, Iran expansive ones, which encouraged large families (AbbasiShavazi, 2002). These policies led to an increase in the population, mainly youth population, during the 1990s and 2000s. According to 2006 and 2011 population census, more than 60% of Iran’s population is aged under 35 years (Table 1; Statistical Center of Iran, 2014). A significant number of these young Iranians, even those who have high level of education, are still dealing with big challenges such as unemployment, inequality, and poverty as well as depression, stress, and other psychological and social problems because of Iran’s difficult socioeconomic conditions (Salehi-Isfahani, 2010). In 2006, the International Monetary Fund (IMF) ranked Iran as highest in brain drain among 90 countries (both developed and less developed), with over 180,000 people leaving annually the country due to poor job market. In fact, it is estimated that over 25% of Iranians with postsecondary degrees live and work abroad. (Online Universities, 2011) Besides, Iran had a substantial drain of highly educated individuals (15%) in the early 1990s (Carrington & Detragiache, 1999). Being geographically vulnerable to drug trafficking, and having a large youth population, Iran has become the destination and transit country for drug trafficking for the past few decades, and consequently drugs are now easily available in Iran (Haghdoost, Mirzadeh, Shokohi, Sedaghat, & Gouya, 2013). In spite of substantial interdiction efforts and considerable control measures along the border with Afghanistan, Iran remains one of the primary transshipment routes for heroin from Southwest Asia to Europe, and has one of the highest opiate addiction rates in the world (Central Intelligence Agency, 2014). Although According to unofficial statistics, the number of people involved in drug abuse1 accounts to 5.5 million, but the officially declared number is about 1.5 million (Rahmani-Fazli, 2014).
This qualitative study was conducted in 2013 among male drug user patients referred to Drop-In Centers (n = 23) and Residential Treatment Centers (n = 25) in Tehran. The results show that when the price of drugs increases, some drug users tend to use cheaper drugs, which are more harmful, use more harmful routes of administration, such as injecting drugs, sharing needles, and make money illegally. Economic sanctions have threatened Iranian people’s economic status since 2006 and have become more intense in 2010 and 2011. As an important consequence of these economic sanctions, the price of drugs, as well as other goods and services, have increased in Iran in recent years. Given these “big economic events,” big changes in the patterns of drug use, and an increase in drug use-related harms, can be expected to occur in the near future. Keywords sanctions, drug users, homeless, injection, sharing needle and syringe
BACKGROUND
The Islamic Republic of Iran is an Islamic-Shiite Middle Eastern country, with Afghanistan–the world’s largest opium producer–on its eastern borders. Although smoking opium and tobacco had been a part of traditional customs in Iran, drug trafficking and using drugs have been legally condemned since 1910 (Azimiyan Bajestani, Miniee, Imaniyan, Jafari, & Sepehri, 2008), and dealing with its damaging effects on the population has been one of the most important concerns of the government. After the Islamic Revolution in 1979, Iran was involved in eight years of unwanted war against Iraq, while being under economic sanctions from the United States and some other western countries (Feyazmanesh, 2003). Experiencing these difficult conditions, in the 1980s the government replaced restrictive population policies with
1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. Address correspondence to Abbas Deilamizade, Department of Research, Rebirth Society, No.17, Cheraghali Alley, Jenah Exp. Way, Tehran, Iran. E-mail: [email protected].
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TABLE 1. Selected results of 2006 and 2011 census Age (years)
2006 (%)
2011 (%)
0–14 15–34 35 and more
25.08 43.29 31.63
23.37 40.81 35.82
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Source: Statistical Center of Iran (2014).
A gradually policy shift from strict supply-reduction to progressive harm-reduction during the last two decades led to several harm-reduction programs that provided services such as needle exchange, free condom distribution, methadone maintenance treatment, general medical care, and referral for voluntary counseling and testing (Razzaghi et al., 2006). One of these programs—triangular clinics–has been recognized as the best practice (Razzaghi et al., 2006). The innovative triangular clinic was first established and implemented in Kermanshah province to provide comprehensive HIV/AIDS prevention, and care for injecting drug users. The clinic seeks to address injecting drug use through a harm-reduction approach, while also providing services for the treatment of sexually transmitted diseases (STDs), and treatment, care and support for People Living With HIV/AIDS (PLWHA). Prevention and care are integrated across these services and the clinic has sought to incorporate many of the key elements that underpin successful HIV prevention approaches. This innovative model is being replicated elsewhere in the Islamic Republic of Iran, including the establishment of triangular clinics in 21 provinces as well as prisons (World Health Organization, 2004). In Iran, harm reduction activities are currently being implemented by governmental and non-governmental organizations (Razzaghi et al., 2006). Some international organizations and programs, such as The Global Fund,2 are co-funding the above-mentioned harm-reduction programs. INTRODUCTION
During the early months of 2012, the unpredictable and uncontrollable impacts of global, formal economic sanctions against Iran–a Big Event3 –began to manifest in the 2
The Global Fund is an international financing institution that fights AIDS, tuberculosis, and malaria with a 21st century approach: partnership, transparency, constant learning, and results-based funding. The Global Fund to fight AIDS, tuberculosis, and malaria was created in 2002 to dramatically increase resources for the fight against the three pandemics. The Global Fund does not manage or implement programs on the ground, relying instead on local experts. It works with partners to ensure that funding serves the men, women, and children affected by these diseases in the most effective way (The Global Fund, 2014). 3 This relatively new term, introduced into the intervention literature by Friedman, Rossi and Flom (2006), refers to major events, such as megadisasters, natural as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc., which effect adaptation, functioning, and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions, and loss of control over one’s life is experienced.
devaluation of the Iranian Real (IRR) against the US dollar. As a consequence, the price of goods and services in Iran increased several-fold. In February 2012, one US dollar was exchanged for 12,253 IRRs; but one and a half years later, in July 2013, one US dollar was worth 35,000 IRRs, and at some points it even registered a record of 40,000 IRRs. (Khabaronline, 2013) During the same period, the prices of basic goods, such as bread, rice, chicken, and meat, which constitute Iranians’ staple diet, multiplied by a factor of two or three. This process has continued while the income of a great majority of the population hasn’t experienced much change, and nor has kept pace with inflation. According to the labor laws in Iran, the minimum wage in 2011 was 110,100 IRRs a day, which according to the then exchange rates amounted to around US$9 a day. This minimum wage has been increased to 162,375 IRRs a day in 2013, which according to the current exchange rates amount to US$4.6 a day (Ministry of Cooperatives, Labor and Social Welfare, 2013). Parallel to these developments, the price of various types of illegal drugs available in Iran’s drug markets has also increased. Drug traffickers pay more dollars to buy drugs from abroad and then supply those drugs at a higher price. The price of constituent parts of stimulants has also increased, which has led to an increase in the price of such drugs (Bagheri, 2013). Our observations on the below-mentioned four points across Tehran have documented that over the last two years, i.e., 2012 and 2013,:
• the price of opium has more than doubled, ranging from 23,000 to 40,000 IRRs per gram based on the purity of the drug; • the price of methamphetamine has increased from 60,000 to 170,000–300,000 IRRs per gram; • the price of heroin has risen from 130,000 IRRs per gram to 230,000–250,000 IRRs per gram, and • heroin krack4 was sold for 250,000 IRRs per gram in the markets. Studies have documented that when a certain type of drug becomes scarce or its price rises considerably, its users tend to resort to cheaper and more accessible alternatives. A study performed in Australia in 2004 showed that when heroin became extremely scarce during 1999–2001, the demand for cocaine and methamphetamines increased and the pattern of drug consumption changed, so that the number of injecting drug users increased (Donnelly, Weatherburn, & Chilvers, 2004). The authors of the referred study have cited a probability of an increase in the prevalence of hepatitis C as one of the consequences of this change of pattern, because according to research the prevalence of hepatitis C among cocaine users was much higher than that in heroin users. When the present study began in 2012, heroin had become scarce in Iran and its price increased. During the 4
Heroin krack refers to a high purity street-level heroin and is an opioid (Alam Mehrjerdi, 2013) Iranian crack or crack (as Iranians call it) is a heroin-based narcotic which is basically different from cocaine-based crack used in western countries (Farhodian et al., 2014).
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same period, the price of methamphetamines dropped and their use became widespread, so much so that these were said to have become dominant drugs in Iran. The society’s lack of information about this type of drug and its effects, and also lack of preparedness of rehabilitation centers to offer services5 to its users added to the severity of change in the pattern of this drug’s usage. This change in consumption pattern from opiates to stimulants had many harmful effects such as high-risk sexual practices among youth that contribute to HIV prevalence (National AIDS Committee Secretariat, Ministry of Health and Medical Education, 2012). Since the methamphetamine used in Iran is not injectable, its widespread use led to a relative decrease in the number of injecting drug users. However, although it has not been documented, recently drug use(r) researchers and harm reduction activists have announced that the consumption of heroin is again rising (Bagheri, 2013; Dejakam, 2013; Mohrez, 2014); and one of the consequences of this development may be a rise in the number of injecting drug users because heroin, unlike methamphetamine, is injectable. With the increase in injectable drug use, the prevalence of HIV and hepatitis will probably also rise (Bagheri, 2013; Jemalpoor, 2013). This has led some specialists to warn about the return of the second wave of HIV/AIDS pandemic in Iran (Sedaghat, 2012, 2013). However, the national budget for social problems, including harm-reduction programs, has decreased in recent years and led to serious financial problems for DICs and other harm-reduction programs (Aqtar, 2010; Barati Sade, 2014; Deilamizade, 2014; Mosavi Chalak, 2013; Samgis, 2012). In this study, during a two-year period, novel aspects of the impact of increase in drug prices are investigated through individuals’ personal experiences. Issues such as higher economic pressure on the families of drug users, decrease in the amount of foodstuff bought by the family, increasing violence between the family members of drug user, and loss of decision-making about the type and amount of drugs used and routes of administration, are among the issues that our case studies explored from drug users’ anecdotes. These aspects might have been ignored in a more general approach.
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actions and reactions of drug users as a result of change in Iran’s economic conditions due to economic sanctions. Questionnaires, participants’ observations, and statistical analysis of the existing data were used to complete the data collected through interviews. Participant Recruitment The study’s 48 participants were chosen gradually and in several phases. Initially, the study focused on homeless drug users who did not have financial resources and did not benefit from a social support network to understand changes that might had occurred in the living conditions and were more likely to be vulnerable6 to recent economic changes. Several male and female individuals who came to DICs were interviewed for this purpose. Question about new economic conditions was posed to drug users belonging to the middle of the income ladder. Then male and female participants were chosen from residential treatment centers. Also, snowball sampling was used to recruit some male and female university students using drugs. Analyzing the interviews, it was realized that the interview samples could be divided into two groups by a fundamental criteria—being financially dependent or independent. Based on the results of analysis, 70% (n = 25) of male homeless drug users of residential treatment centers were classified as being financially independent, while the other group of samples were identified as being financially dependent on their parents, spouses, sexual partners, or relatives. Being financially independent (as applied in this study) did not necessarily mean that they had legitimate jobs or were able to pay for their living expenses thru legal sources of income; it just meant that they did not expect any kind of financial support from others. On the other hand, being financially dependent did not mean that they were entirely dependent on others for financial support. Some of the study’s participants identified as being financially dependent had small source of income but they were not forced to pay for their expenses, and hence remained dependent financially. Regarding this newly emerged criteria and due to difficulty of analyzing and integrating results of a wide range
METHODS 6
Design
A combination of several methodologies has been utilized in this study. One part of the study is a qualitative, exploratory research using personal anecdotes to study the 5
A significant number of scientific studies during recent decades have documented the effects of stimulants on human and animal brains and behavior (Substance Abuse and Mental Health Services Administration, 1999). Amphetamine use causes serious damages to brain cells. It has been posited that effective treatment for amphetamine dependency as well as amphetamine-related psychiatric disorders have to include much more psychiatric and psychological services than treatment programs for opioids (Substance Abuse and Mental Health Services Administration, 1999). In Iran, the MATRIX model is currently the most used treatment method for methamphetamine (Alam Mehrjardi, 2013).
The reader is reminded that the concepts of “risk factors,” “vulnerability,” and “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development and decay; anchoring or integration; cessation; etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level), which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to operate, and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon the “principles of faith,” doctrinaire positions, “personal truths,” historical observation, precedents and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, or “transient public opinion.” This is necessary to consider and to clarify whether these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith,” and stakeholder objectives. Editor’s note.
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of data that were obtained from six different groups of samples (male and female homeless drug users, male and female patients, and male and female student drug users), only the results of the interviews of financially independent drug users (male homeless drug users from DICs and 25 male patients from residential treatment centers) were discussed in this paper. Data Collection Questionnaires were used to collect participants’ selected data. The main aim of the questionnaires was to obtain a brief description of interview samples. The 10 questions included basic socio-demographic data such as age, gender, literacy, employment, marital status, and some information about issues such as the type of drugs used, the method of drug use, the number of years that they have been using drugs, source and the amount paid for drugs, and high-risk sexual behavior. Psychologists, social workers, and counselors working in the centers, who were in daily contact of drug users and had their trust, filled these questionnaires. Three drug users in DICs and eight patients in residential treatment centers refused to enter the study because they found it difficult and painful to talk about their personal lives. The questionnaires were not given to the participants; they were questioned and their answers were written down. An oral informed consent was obtained from all the participants prior to their enrollment in the study. A psychologist, counselor, or social worker who used the questionnaire explained to each participant that “the researcher needs to know how increasing prices of drugs have influenced your life, so some questions could be very personal and you can refuse to answer them.” Also, before starting the interview, the interviewer once again explained the process. The oral informed consents are available for the taped interviews. All participants were interviewed extensively to collect their stories about prevalent economic and social conditions that they faced and their reactions to such conditions. Data collected through observation of petty drug dealers in four neighborhoods in Tehran–North, South, East, and West Tehran7 –were added to the data gathered through questionnaires and interviews. The observations were performed in the course of a day by four drug users, and the needed data regarding the type of drugs available in the market and their prices were collected. In the next phase, in order to complement the data collected through interviews and questionnaires, statistics from residential centers and DICs for the last several years were analyzed separately. 7
These four neighborhoods are different in some ways. North Tehran is a wealthy neighborhood and its rich people enjoy a very different lifestyle from others. East and West Tehran are middle-class neighborhoods. Although East Tehran is more crowded and the average age of its residents is higher than west, West Tehran is a destination for middleclass immigrants from other cities. South Tehran is a poor, crowded neighborhood that is the first destination for poor immigrants.
Questionnaires were filled and interviews were conducted in DICs and the drug user treatment centers. Completing each questionnaire took 15 to 20 minutes, and each interview lasted about an hour. Data Analysis The data collected through questionnaires were analyzed with SPSS software. The interview-based data were analyzed by the Grounded Theory (GT) coding methods. Understanding the implications of global economic sanctions against Iran and their potential consequences on drug users as “big events” necessitated exploratory research that allowed more flexibility and freedom because no relevant studies currently exist on this issue. Such research can engage the needed attention of policy makers and harm-reduction activists toward current processes occurring in the society, which can lead to serious social consequences in the near future. Among interpretive and qualitative research methods, grounded theory offers unique benefits to “big events”related research, providing a detailed, rigorous, and systematic method of analysis. This advantage provides the researcher with greater freedom to explore the research area and allows issues to emerge (Bryant, 2002). As a consequence, grounded theory is useful in providing rigorous insight into the areas that are relatively unknown to the researcher (Martin & Turner, 1986, p. 141). Focus of the methodology is toward uncovering basic social processes. Grounded theory is “ideal for exploring integral social relationships and the behavior of groups where there has been little exploration of the contextual factors that affect individuals’ lives (Crooks, 2001). Due to difference between the two groups of interviewees—the state of their being homeless and its related consequences versus their more acceptable social and economic conditions–the data relevant to each group were analyzed separately and the results were also presented separately. Although the aim of this study has not been a comparison between the two groups, a separate analysis of this pilot study’s data provides an opportunity for comparing the two groups. Sample Description Selected demographics of both samples are presented in Table 2. Data representing a drug user’s resources (“capital”, skills, abilities, etc) as well as limitations, as he adapts and functions daily, in a range of roles, contexts, situations, networks and environments, manifesting levels and qualities of awareness, expectations, judgments, problemsolving, decision-making which is or isn’t implemented, learned from or not, were not collected. The sample’s 23 homeless drug users (DICs) were males, aged 25 to 55 years (average age 39 years). Of these, 52% reported being homeless, 22% reported living in a friend’s house, and 26% reported living at their workplace, where actually a stash of recyclable goods was kept; 65.2% reported having a job and were living through picking trash for recyclable materials. On average, they
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TABLE 2. Selected demographics of samples
Frequency Minimum age (years) Maximum age (years) Average age (years) Homeless (%) Living in workplace (%) Living with friends (%) Living with family (%) Having a job (%) Average years of using drugs Illegal acts to acquire drugs (%) Having dependents (%) Spending more than half of monthly expenses on drugs (%) Those with dependents who spend more than half of monthly expenses on drugs (%) Average daily Income Average daily drug expenses
Patients in DICs
Residential centers
23 25 55 39 52 26 22
25 26 58 38
65.2 12.5 53 60
87 100 15.3 46 60 48 52
80,000 IRRs 400,000 IRRs 116,000 IRRs 230,000 IRRs
have been using drugs for 12.5 years, and more than 50% have admitted that when they are short of money or drugs, they attempt anything to acquire the drugs they need, including begging, stealing, working as drug mules, and extortion. Sixty percent of them reported that more than half of their monthly expenses were used to procure drugs, and they had paid on average 116,000 IRRs per day for drugs, while their average daily income was 80,000 IRRs. A statistical study performed in early 2012 based on the existing files in several DICs (including centers in which the interviews for this study were conducted) documented that the patients who have been frequently referred to DICs at least for six months received the necessary education and services related to mitigation of harmful effects, and that they tend to use less dangerous drugs and adopt less dangerous methods of drug use. At the time of their initial referral to DICs, the main drugs used by such patients were methamphetamine and heroin, most of them using both drugs simultaneously. But at the time of this file-based study (March 2012), their main drug of choice was opium followed by heroin and cannabis. Injecting drug users who had the experience of using shared or used needles announced that after being referred to the center they started using sterile needles. Data from this pilot study carried out more than one and a half years after the March 2012 study document that the consumption of methamphetamine, crack heroin, and heroin has increased. It should be noted that 21 of the 23 interviewees had been referred to outpatient drug user treatment centers weekly or daily for the last two years. The 25 residential center drug users were aged from 26 to 58 years (average age being 38 years). Of these, 87% live with their families, either with their spouses and children or with their parents. All of them reported being currently employed. More than 46% of these participants
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reported of having committed illegal acts to acquire drugs. Sixty percent of the participants had dependents and pay for their expenses, while 52% of these participants with dependents used more than half of their monthly income for the procurement of drugs. Findings
Data from four interviews were omitted from the final analysis because the interviewees had been ill and were unable to continue with the interview. The following information is based on data from 23 interviews. The participants in this group have been, on average, homeless for three years and for most of the nights go to shelters. During spring and summer, when it was not cold, they sometimes spent their nights in parks, on streets, under bridges, or in other similar places. Some of them who have kept their contacts with their families (five individuals; 20%) had the opportunity to spend some nights at their relatives’ homes. A majority of them picked trash of recyclable materials as a way of earning to survive and procure their daily dosage of drugs. They searched urban trash bins for various materials, including metals, plastic, and paper to sell these for a pittance. DIC3 describes a typical work day as follows: “We get up and get out in the morning, search among the trash—there are these huge trash bins which the city workers empty at nights—for plastic, metal objects, and paper to sell. Right now soft drink cans are in demand and sell for 20,000–30,000 IRRs a kilo. But there is too much competition. All the people you see around here have the same job. We sell our goods, get some money, buy dope and use it in a corner. If there is some money left, we spend it on a piece of bread or cookie in order to survive. We have lunch and a cup of tea here, that’s all.”
Most participants said that up to one and a half to two years ago, they were able to earn enough money for their daily drug dosage and one or two meals a day by working three to four hours each day. But recently, with the increase in the price of drugs and food, they had to work for longer hours, usually seven or eight hours a day. DIC8 says: “In the past we worked three–four hours and we could both pay for our drugs and cigarettes and also some food. But now some days we work till dark without even making enough money for drugs. I walk for seven or eight hours a day without earning much. At nights, I go begging to my dealer but he only gives me as much drugs as I have money for, for the rest I take pills to avoid withdrawal symptoms. If it weren’t for the free lunch given here, I wouldn’t find anything to eat.”
DIC9 says: “I work long enough to earn money for my daily dosage, I never ask whether I have food or not, or whether I’m hungry or not, I straight go to the dealer, and then collapse at some corner till it is time to go to the shelter for a meal.”
DIC19 has been a heroin user for several years, but with the increase in prices he tried to find cheaper alternatives. He says:
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“After the prices shot up, I quit heroin and tried to replace it with methadone. But after five days I had taken so much methadone without getting a high that I overdosed. At that time methamphetamine was very cheap and I turned to it because nothing else answered my needs. Now that the prices of methamphetamine, heroin, and crack are the same, I use anything that comes my way.”
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“I was afraid of injecting. But I saw nothing satisfies me, and I heard, it [is] said that injection is both easier and less expensive. So I began injecting. Now I both smoke and inject, and when I can find nothing else, I take some pills, which I buy myself. I drink cough syrups and like 60 diphenoxylate pills a day. I know they are bad for me.”
DIC19’s story documents that in order to satisfy his drug use, he tried various ways, including using more dangerous drugs, such as methamphetamine, and using more dangerous routes, such as injections. Those who are older and incapable of physical activity, are not able to pick trash, or do another manual jobs, they usually make a living through begging. But it barely covers increasing drug costs. Those who are able to work, have the option of working for longer hours and making more money, they have found a different solution and have resorted to taking pills. For a small amount of money, they can buy quite a good number of expired pills from gray market. DIC1 says: “In the past I had some money and used it as capital. I would make a stand in the street and sell second-hand bags. A couple of times when I was high I was robbed. The other guys go on their rounds but I can’t do it. I cannot even stand on my legs, let alone going on rounds. Now I’m popping pills, 90 or 100 of them a day. If I find drugs or if other guys offer me a free fix, I don’t say no.”
Later, he explains that becoming a pill addict is the last step that an addict might be forced to take, it is the time when the addict is utterly incapable of procuring drugs: “Here anyone who is a pill popper will not admit it. They are embarrassed to admit that they are so desperate as to take pills. In fact it’s an insult if you call someone pill-popper.”
DIC4, who has been taking pills for some time, says: “When the prices go up, those who can steal; those who can’t steal, beg or use less. And since they suffer when they use less, they turn to clonazepam and sleeping pills and such like. They reach a point when they see pills are cheaper, so they quit drugs and only use pills, like 50 or 60 pills at one go.”
Lack of enough money for drugs in some instances is associated with losing control over the type of drug that is taken by drug users, how much they use, or how they use. Such drug users are incapable of earning daily income to pay for their drugs to be smoked, taken orally, or injected. Therefore, they go for partners with others and pay money to a dealer for a certain number of fixes, and at regular intervals during the day they go to a particular dealer and drink or inject the solution prepared in advance by that dealer.
DIC 17 says: –“I’m in a hurry; I have to go [to] get my dope.” –“From where?” –“Right behind here, the guys are waiting for me, I’ve just come to have lunch here and go [to] join them. I’ve given them money to buy the stuff by the time I get back.” –“Do you use drugs together?” –“We all chipped in and gave the money to the dealer. I don’t earn enough to buy for myself and smoke it in a corner. We take one fix at noon and another at night. By the time we arrive, the dealer himself has prepared the fix; he dissolves the dope in a cup of tea or sugared water and gives it to us. We don’t know what it is, or how much it is. We don’t know what kind of trash is in the cup. I swear to God, it is all pills. And at last he says our money was enough for this much dope.” During their addiction period, these individuals have had the experience of using drugs with their friends, but what they are experiencing now is fundamentally different from their previous experiences. Previously the user himself or his friend bought the drugs, so even if he went partners with others or used in a group, he at least had the chance to take a look at the drug when buying it, and to some degree had a control over the type and amount of drug he wanted to use. But now such users barely have control over the quality of the drug they use. They can’t even be sure what kind of drug they are using. DIC17 has quit injecting drugs for some years, but some of the guys he goes with on his trash picking rounds still inject. He says that these friends are currently getting their fixes in a similar way: “We don’t hang out with shooters, but for them too, the dealer prepares the fixes in a bowl and whoever arrives takes a fix from the bowl and injects right there.”
DIC23, who for the last year has been injecting drugs, says: “I used to sell things on the streets, tissue boxes and such like. Sometimes I carried drugs as a favor and at the side also dealt. Later on, the prices went up and . . . Then the market went south and my income wasn’t enough. My brother and I had a new idea. When we bought the dope, we didn’t smoke it all, we mixed part of the dope with pills and such like and sold it. One night I was suffering badly from withdrawal symptom. My brother had been caught with dope and was in jail. I tried everywhere but I didn’t find anything. I went to some of the guys and found them injecting. At first I was afraid. I’d seen in the past how they injected dope, but I hadn’t tried it up till then. I was desperate for drugs and they told me: “We have just this; you are welcome if you want it.” At last one of them injected me for the first time. Later on I saw it’s a more fun, and also cheaper, so by the time my brother was out from jail I’d become a shooter. My brother is now a shooter too.”
DIC23 and his brother, as a result of their frequent visits to DIC, have become aware of how HIV and hepatitis are transmitted, and especially of the issues associated with injecting drugs and sexual contacts. They receive free
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needles, syringes, and condoms on a regular basis. However, he says:
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“When you have no money and no dope, you have no other way. I always have new needles with me, I get them from DIC but they say you will catch the disease even if you take the dope out of a common ontainer, but when you don’t have the dope, you have to go sponging on someone else. You have no options; you have to take the dope he has prepared. Well, I can’t help using.”
DIC3 used to work for a drug dealer to get his own drugs and have a place to sleep. He used to carry drugs for the dealer. But when he fell out with the dealer, he was forced to start working for another drug dealer, and since the new dealer dealt in methamphetamine, DIC3 began using methamphetamine instead of heroin. Iran’s drug user residential treatment centers (RC) are the settings that offer abstinence-based treatment for drug dependency. The participants interviewed in these centers were chosen from the individuals who had been using drugs for several years, and had entered the treatment program at least 10 days before the interview. There are two outstanding themes about this group of addicts: 1. Increasing economic pressure on family members. 2. Tendency to buy cheaper drugs, using dangerous methods of drug use, and common drug use with friends. For drug users, drugs are considered to be a basic commodity and are a staple in their families’ daily expenses. Increase in daily expenses, including cost of drugs on the one hand, and scant increase in family income on the other, have added to the economic pressure afflicting the families of drug users. This is felt even more dearly when the drug user is family’s bread winner or provides part of family income. Under such circumstances, family’s spending priorities change and get more directed toward basic needs such as food, clothing, shelter, and also drugs. Under such circumstances, education, sports, health care, and entertainment receive less attention. RC12, who lives with his wife and two children and works in an auto company, explains the process thus: “In the past we got by. We ate and dressed like others. My kids went to school and language class like other kids. My wife had even put them in a swimming class. It’s true that I wasn’t myself and made them suffer, but on the surface we lacked nothing. But gradually our expenses went up. The price of meat, chicken, and other stuff shot up several times, so did the price of drugs. At the same time, my consumption went up too. 100,000 IRRs a day became 200,000; and 200,000 IRRs a day became 300,000. How much can one earn? After a while I had no money for kids’ schools. I had to find an excuse to change their schools. I couldn’t pay the rent, let alone for things such as language school, swimming school, or similar stuff. Every day there was money for water, electricity, and telephone. We just managed to survive without losing face among others. . .”
Those with very low income, and others who earned enough to get by, had tried other drugs and methods of use
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due to rising drug prices; some of them in search of a way to lower their drug expenses, and others by force when they hadn’t been able to procure their drug of choice. RC16 say: “Heroin was scarce, and even if you found some, it was very pricey. My friends several times suggested that I use methamphetamine, which was at that time very cheap and also highly admired by others. At first I resisted; for a time I was able to find heroin; but later on I was forced into smoking methamphetamine.”
RC32 also says: “I started by injecting, but I was alone and always used my own needle. I was desperately looking for drugs. Either there were no drugs or it was very expensive. A couple of times I bought a cheap variety, but it made me sick. It was obvious that it was full of junk. Once I went to the house of a dealer with some money that was not enough. He took my money and said, “‘Some guys are inside, come in and get a fix.”’ From that time on whenever I couldn’t find drugs or didn’t have enough money I went there.”
Similar to the reports of some homeless drug users, some residential treatment drug users reported that as a result of rising prices they concluded that they could earn money by adding impurities to the drugs they buy, and then sell. RC5 lives alone. He was a university student until several months ago and used to work as a private teacher to cover his living expenses, including drugs. But recently it was not enough. He said: “It became my job to add pills, flour, and any other junk I found to the drugs and sell them in the university to my friends, especially to the beginners. Once, I and my friends thought of stealing stuff belonging to the university. One night three of us stole three printers from the university. But the next day there was a great row. Later on, we thought of pilfering expensive books from the university library and selling them.”
DISCUSSION
This paper, and the pilot study, documents that Iranian urban drug users and their families are among the vulnerable groups who have been deeply affected by the economic crises that have worsened as a result of increasing economic sanctions against Iran. Homeless drug users were the most vulnerable group. Their reported history documents that under such circumstances different individuals resort to different ways in line with their resources:
• Some of them resort to shared buying and using of drugs. Shared use can be associated with shared injections. Generally, the individual resorts to this when he hasn’t been able to acquire drugs he needs and is at the most vulnerable point, so he joins the crowd. Some interviews documented that even awareness of the dangers of shared injections is not necessarily an obstacle to using drugs under high risk conditions. • A study performed in 2001 deals with the issue that the use of shared needles, and also high-risk sexual behavior, among addicts can be explained by the concept of “discounting of delayed rewards” (Bickel & Marsch, 2001) Discounting of delayed rewards means that the
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reward which is expected in the future will have a lesser value compared with an immediate reward. The results of this study show that the discounting of delayed reward can provide an explanation for both drug use and high risk behavior related with injecting drug. (Bickel & Marsch, 2001). Shared drug use can and does occur in cases in which the individual loses his control over the type of drug used, the amount of drug used, the pattern of use, and the method of drug use. In order to earn money that they need, some drug users join drug distribution network, or mix some of the drugs they buy with impurities and sell them to others. Some of them steal from their place of work, homes, or family members, or they look for other illegal ways to earn money to pay for their drug habits. A common experience under such circumstances is resorting to alternate drugs or methods of use which provide the much needed fix at a lower cost. Another undesirable consequence associated with rising drug prices and simultaneous rising of daily expenses is the lowering of quality of life of drug users and their families. Families with low incomes can change their economic priorities, judgments, and decisions, and neglect some less priory expenses from their economic basket. Under such circumstances, the first choices to exclude are generally entertainment, education, books, sports, and health care.
had access to HIV/AIDS information as well as harmreduction tools. These results are to some extent supported by statistical analysis of existing documents. The abovementioned results had been also experienced to some degree by the clients of residential centers. The findings documented that rising prices of drugs–a basic commodity for drug users–had brought more economic pressure on their families. There is a need for further quantitative and qualitative investigation of broader consequences and implications of big events on increased drug prices, manner, and pattern of drug use in Iran as well as elsewhere. Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper. There is no Ethics Committee or Institutional Review Board in Iran for such a research. There is just an ethics committee for medical research. This study did not need or have IRB approval or permission. THE AUTHORS Abbas Deilamizade is the chairman of a regional network of NGOs (ADNA) working on drug demand reduction and harm reduction in Central and West Asia. His research interests are drug demand reduction, harm reduction, drug economy and drug control policies.
Study’s Limitations
This pilot study’s limitations include its small convenience samples, which may or may not be the representative of Iran’s urban as well as rural drug users; some confounders, such as occasional police interventions, that could not be controlled, and the statements of participating drug users, which cannot be completely trusted. The study design does not permit for “cause and effect” conclusions to be drawn, nor is sufficiently sensitive to the nonlinear, dynamic, and multi-dimensional processes associated with the measurable and non-measurable operations of “big events.” The findings do enable and merit deriving hypotheses for the future research in this relatively new research area.
Sara Esmizade has a master’s degree in sociology from the Faculty of Social Sciences, University of Tehran, Tehran (Iran). Her research interests are homelessness, drug abuse, harm reduction, and drug control policies.
CONCLUSIONS
One of the important factors that are associated with a sharp and continuous rise in Iran’s street drug prices and the price of other goods and services is the devaluation of IRR against US dollar–an outcome of recent economic sanctions against Iran. Our interviews with 48 male drug users in Tehran documented that all of them had been affected in different ways by the recent economic changes, especially by rise in drug prices as well as other daily expenses. Homeless drug users experienced this maximum in the form of limited access to drugs whose pharmacological actions are relatively less harmful. This change was associated with the use of cheaper and more harmful drugs and adopting high-risk methods of use, such as injectables, as well as losing control over routes of administration and type of drugs. It has to be mentioned that rise in high risk behaviors had occurred among DIC clients who
GLOSSARY
Drop-in Center (DIC): It is a non-profit center serving homeless drug users, and offers lunch and learning sessions on HIV/AIDS, hepatitis, and high risk behaviors. Also, it provides them with clothes, needles, syringes, and condoms. Currently, in Iran most DICs are run by NGOs and co-funded by governmental organizations such as Ministry of Health or State Welfare Organization as well as some international organizations and programs such as the Global Fund.
SANCTIONS AGAINST IRAN, AND DRUG USE IN TEHRAN
Residential treatment center: It provides a multidisciplinary approach to facilitate recovery from substance use. Comprehensive chemical dependency treatment services offered by peer counselors–ex-addicts who are trained in chemical dependency counseling–provide a structured therapeutic environment. The services provided often include individual and group counseling, structured physical activities, stress reduction, holistic approaches such as yoga, vocational training, relapse prevention support, social skills training, educational services, and 12-step substance user programs.
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Farhodian, A., Sadeghi, M., Khodami Vishte, H., Moazen, B., Fekri, M., & Rahimi Movaghar, A. (2014). Component analysis of Iranian crack; a newly abused narcotic substance in Iran. Iranian Journal of Pharmaceutical Research, 13(1), 337–344. Feyazmanesh, S. (2003). The politics of the US economic sanctions against Iran. Review of Radical Political Economics, 35(3), 221–240. Friedman, S. R., Rossi, D., & Flom, P. L. (2006). “Big events” and networks: Thoughts on what could be going on. Connections, 27(1): 9–14. Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press. Haghdoost, A., Mirzadeh, A., Shokohi, M., Sedaghat, A., & Gouya, M. (2013). HIV trend among Iranian prisoners in 1990s and 2000s; analysis of aggregated data from HIV sentinel seroserveys. Harm Reduction Journal, 10, 32. Jemalpoor, F. (2013). A 500% increase in price of crystal in one year. Retrived April 11, 2013, from Magiran website: http://www.magiran.com/npview.asp?ID = 2707219. Khabaronline. (2013). Price of dollar came to 3415 Tomans. Retrieved July 1, 2013, from http://khabaronline.ir/detail/ 301370/Economy/financial-market:[farsi]. Martin, P. Y., & Turner, B. A. (1986). Grounded theory and organizational research. The Journal of Applied Behavioral Science, 22(2), 141–157. Ministry of Cooperatives, Labor and Social Welfare. (2013). Minimum wage rate in Iran. Retrieved January 5, 2014, from http://hormozgan.mcls.gov.ir/fa/hoghogh: [farsi]. Mohrez, M. (2014). Concerns about increasing sexual transmission of HIV. Retrieved May 18, 2014, from National Center of HIV/AIDS Prevention website: http://aids.ir/news531-.html. Mosavi Chalak, H. (2013). The national budget for social problems has decreased. Retrieved October 1, 2013, from SalamatNews website: http://tnews.ir/%D8%B3%D9%84%D8%A7%D9% 85%D8%AA-%D9%86%DB%8C%D9%88%D8%B2/584017792863.html National AIDS Committee Secretariat, Ministry of Health and Medical Education. (2012). Islamic Republic of Iran; AIDS progress report, March 2012. Iran: National AIDS Committee Secretariat, Ministry of Health and Medical Educatio. Online Universities. (2011). 10 countries facing the biggest brain drain. Retrieved October 21, 2013, from http://www.onlineuniversities.com/blog/2011/07/10-countriesfacing-the-biggest-brain-drain/ Rahmani-Fazli, M. R. (2014). Officially declared number of drug users amounts to 1.5 million. Young Journalist Club. Retrieved May 26, 2014, from http://khabarfarsi.com/ext/ 9324662 Razzaghi, E., Ohiri, k., Claeson, M., Nassirmanesh, B., Afshar, P., & Power, R. (2006). HIV/AIDS harm reduction in Iran. The Lancet, 368(9534), 434–435. Salehi-Isfahani, D. (2010). Iranian youth in times of economic crisis. Working paper No. 3, The Dubai Initiative, Harvard University, MA. Samgis, B. (2012). No more budget for methadone maintenance in harm reduction settings. Retrieved July 28, 2012, from Magiran website: http://www.magiran.com/npview.asp?ID = 2550202. Sedaghat, A. (2012). Decrease in budget and return of the second wave of the HIV/AIDS in prisons. Retrieved March 3, 2012, from HRANA website: https://hra-news.org/fa/prisoners/ 1-10331.
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Sedaght, A. (2013). Ministry of health is worried about return of the second wave of HIV/AIDS. Retrieved June 17, 2013, from ISNA website: http://www.isna.ir/fa/news/92032716093/. Statistical Center of Iran. (2014). The 2011 census data. Retrieved May 26, 2014, from http://www.amar.org.ir/ Default.aspx?tabid=1485 Substance Abuse and Mental Health Services Administration. (1999). Treatment for stimulant use disorders: Treatment improvement protocol (TIP), series No. 33. Substance Abuse and Mental Health Services Administration.
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Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study Abbas Deilamizade & Sara Esmizade To cite this article: Abbas Deilamizade & Sara Esmizade (2015) Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study, Substance Use & Misuse, 50:7, 859-868, DOI: 10.3109/10826084.2015.978673 To link to this article: http://dx.doi.org/10.3109/10826084.2015.978673
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Substance Use & Misuse, 50:859–868, 2015 C 2015 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.978673
ORIGINAL ARTICLE
Economic Sanctions Against Iran, and Drug Use in Tehran, Iran: A 2013 Pilot Study Abbas Deilamizade and Sara Esmizade
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Department of Research, Rebirth Society, Tehran, Iran expansive ones, which encouraged large families (AbbasiShavazi, 2002). These policies led to an increase in the population, mainly youth population, during the 1990s and 2000s. According to 2006 and 2011 population census, more than 60% of Iran’s population is aged under 35 years (Table 1; Statistical Center of Iran, 2014). A significant number of these young Iranians, even those who have high level of education, are still dealing with big challenges such as unemployment, inequality, and poverty as well as depression, stress, and other psychological and social problems because of Iran’s difficult socioeconomic conditions (Salehi-Isfahani, 2010). In 2006, the International Monetary Fund (IMF) ranked Iran as highest in brain drain among 90 countries (both developed and less developed), with over 180,000 people leaving annually the country due to poor job market. In fact, it is estimated that over 25% of Iranians with postsecondary degrees live and work abroad. (Online Universities, 2011) Besides, Iran had a substantial drain of highly educated individuals (15%) in the early 1990s (Carrington & Detragiache, 1999). Being geographically vulnerable to drug trafficking, and having a large youth population, Iran has become the destination and transit country for drug trafficking for the past few decades, and consequently drugs are now easily available in Iran (Haghdoost, Mirzadeh, Shokohi, Sedaghat, & Gouya, 2013). In spite of substantial interdiction efforts and considerable control measures along the border with Afghanistan, Iran remains one of the primary transshipment routes for heroin from Southwest Asia to Europe, and has one of the highest opiate addiction rates in the world (Central Intelligence Agency, 2014). Although According to unofficial statistics, the number of people involved in drug abuse1 accounts to 5.5 million, but the officially declared number is about 1.5 million (Rahmani-Fazli, 2014).
This qualitative study was conducted in 2013 among male drug user patients referred to Drop-In Centers (n = 23) and Residential Treatment Centers (n = 25) in Tehran. The results show that when the price of drugs increases, some drug users tend to use cheaper drugs, which are more harmful, use more harmful routes of administration, such as injecting drugs, sharing needles, and make money illegally. Economic sanctions have threatened Iranian people’s economic status since 2006 and have become more intense in 2010 and 2011. As an important consequence of these economic sanctions, the price of drugs, as well as other goods and services, have increased in Iran in recent years. Given these “big economic events,” big changes in the patterns of drug use, and an increase in drug use-related harms, can be expected to occur in the near future. Keywords sanctions, drug users, homeless, injection, sharing needle and syringe
BACKGROUND
The Islamic Republic of Iran is an Islamic-Shiite Middle Eastern country, with Afghanistan–the world’s largest opium producer–on its eastern borders. Although smoking opium and tobacco had been a part of traditional customs in Iran, drug trafficking and using drugs have been legally condemned since 1910 (Azimiyan Bajestani, Miniee, Imaniyan, Jafari, & Sepehri, 2008), and dealing with its damaging effects on the population has been one of the most important concerns of the government. After the Islamic Revolution in 1979, Iran was involved in eight years of unwanted war against Iraq, while being under economic sanctions from the United States and some other western countries (Feyazmanesh, 2003). Experiencing these difficult conditions, in the 1980s the government replaced restrictive population policies with
1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. Address correspondence to Abbas Deilamizade, Department of Research, Rebirth Society, No.17, Cheraghali Alley, Jenah Exp. Way, Tehran, Iran. E-mail: [email protected].
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TABLE 1. Selected results of 2006 and 2011 census Age (years)
2006 (%)
2011 (%)
0–14 15–34 35 and more
25.08 43.29 31.63
23.37 40.81 35.82
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Source: Statistical Center of Iran (2014).
A gradually policy shift from strict supply-reduction to progressive harm-reduction during the last two decades led to several harm-reduction programs that provided services such as needle exchange, free condom distribution, methadone maintenance treatment, general medical care, and referral for voluntary counseling and testing (Razzaghi et al., 2006). One of these programs—triangular clinics–has been recognized as the best practice (Razzaghi et al., 2006). The innovative triangular clinic was first established and implemented in Kermanshah province to provide comprehensive HIV/AIDS prevention, and care for injecting drug users. The clinic seeks to address injecting drug use through a harm-reduction approach, while also providing services for the treatment of sexually transmitted diseases (STDs), and treatment, care and support for People Living With HIV/AIDS (PLWHA). Prevention and care are integrated across these services and the clinic has sought to incorporate many of the key elements that underpin successful HIV prevention approaches. This innovative model is being replicated elsewhere in the Islamic Republic of Iran, including the establishment of triangular clinics in 21 provinces as well as prisons (World Health Organization, 2004). In Iran, harm reduction activities are currently being implemented by governmental and non-governmental organizations (Razzaghi et al., 2006). Some international organizations and programs, such as The Global Fund,2 are co-funding the above-mentioned harm-reduction programs. INTRODUCTION
During the early months of 2012, the unpredictable and uncontrollable impacts of global, formal economic sanctions against Iran–a Big Event3 –began to manifest in the 2
The Global Fund is an international financing institution that fights AIDS, tuberculosis, and malaria with a 21st century approach: partnership, transparency, constant learning, and results-based funding. The Global Fund to fight AIDS, tuberculosis, and malaria was created in 2002 to dramatically increase resources for the fight against the three pandemics. The Global Fund does not manage or implement programs on the ground, relying instead on local experts. It works with partners to ensure that funding serves the men, women, and children affected by these diseases in the most effective way (The Global Fund, 2014). 3 This relatively new term, introduced into the intervention literature by Friedman, Rossi and Flom (2006), refers to major events, such as megadisasters, natural as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc., which effect adaptation, functioning, and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions, and loss of control over one’s life is experienced.
devaluation of the Iranian Real (IRR) against the US dollar. As a consequence, the price of goods and services in Iran increased several-fold. In February 2012, one US dollar was exchanged for 12,253 IRRs; but one and a half years later, in July 2013, one US dollar was worth 35,000 IRRs, and at some points it even registered a record of 40,000 IRRs. (Khabaronline, 2013) During the same period, the prices of basic goods, such as bread, rice, chicken, and meat, which constitute Iranians’ staple diet, multiplied by a factor of two or three. This process has continued while the income of a great majority of the population hasn’t experienced much change, and nor has kept pace with inflation. According to the labor laws in Iran, the minimum wage in 2011 was 110,100 IRRs a day, which according to the then exchange rates amounted to around US$9 a day. This minimum wage has been increased to 162,375 IRRs a day in 2013, which according to the current exchange rates amount to US$4.6 a day (Ministry of Cooperatives, Labor and Social Welfare, 2013). Parallel to these developments, the price of various types of illegal drugs available in Iran’s drug markets has also increased. Drug traffickers pay more dollars to buy drugs from abroad and then supply those drugs at a higher price. The price of constituent parts of stimulants has also increased, which has led to an increase in the price of such drugs (Bagheri, 2013). Our observations on the below-mentioned four points across Tehran have documented that over the last two years, i.e., 2012 and 2013,:
• the price of opium has more than doubled, ranging from 23,000 to 40,000 IRRs per gram based on the purity of the drug; • the price of methamphetamine has increased from 60,000 to 170,000–300,000 IRRs per gram; • the price of heroin has risen from 130,000 IRRs per gram to 230,000–250,000 IRRs per gram, and • heroin krack4 was sold for 250,000 IRRs per gram in the markets. Studies have documented that when a certain type of drug becomes scarce or its price rises considerably, its users tend to resort to cheaper and more accessible alternatives. A study performed in Australia in 2004 showed that when heroin became extremely scarce during 1999–2001, the demand for cocaine and methamphetamines increased and the pattern of drug consumption changed, so that the number of injecting drug users increased (Donnelly, Weatherburn, & Chilvers, 2004). The authors of the referred study have cited a probability of an increase in the prevalence of hepatitis C as one of the consequences of this change of pattern, because according to research the prevalence of hepatitis C among cocaine users was much higher than that in heroin users. When the present study began in 2012, heroin had become scarce in Iran and its price increased. During the 4
Heroin krack refers to a high purity street-level heroin and is an opioid (Alam Mehrjerdi, 2013) Iranian crack or crack (as Iranians call it) is a heroin-based narcotic which is basically different from cocaine-based crack used in western countries (Farhodian et al., 2014).
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same period, the price of methamphetamines dropped and their use became widespread, so much so that these were said to have become dominant drugs in Iran. The society’s lack of information about this type of drug and its effects, and also lack of preparedness of rehabilitation centers to offer services5 to its users added to the severity of change in the pattern of this drug’s usage. This change in consumption pattern from opiates to stimulants had many harmful effects such as high-risk sexual practices among youth that contribute to HIV prevalence (National AIDS Committee Secretariat, Ministry of Health and Medical Education, 2012). Since the methamphetamine used in Iran is not injectable, its widespread use led to a relative decrease in the number of injecting drug users. However, although it has not been documented, recently drug use(r) researchers and harm reduction activists have announced that the consumption of heroin is again rising (Bagheri, 2013; Dejakam, 2013; Mohrez, 2014); and one of the consequences of this development may be a rise in the number of injecting drug users because heroin, unlike methamphetamine, is injectable. With the increase in injectable drug use, the prevalence of HIV and hepatitis will probably also rise (Bagheri, 2013; Jemalpoor, 2013). This has led some specialists to warn about the return of the second wave of HIV/AIDS pandemic in Iran (Sedaghat, 2012, 2013). However, the national budget for social problems, including harm-reduction programs, has decreased in recent years and led to serious financial problems for DICs and other harm-reduction programs (Aqtar, 2010; Barati Sade, 2014; Deilamizade, 2014; Mosavi Chalak, 2013; Samgis, 2012). In this study, during a two-year period, novel aspects of the impact of increase in drug prices are investigated through individuals’ personal experiences. Issues such as higher economic pressure on the families of drug users, decrease in the amount of foodstuff bought by the family, increasing violence between the family members of drug user, and loss of decision-making about the type and amount of drugs used and routes of administration, are among the issues that our case studies explored from drug users’ anecdotes. These aspects might have been ignored in a more general approach.
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actions and reactions of drug users as a result of change in Iran’s economic conditions due to economic sanctions. Questionnaires, participants’ observations, and statistical analysis of the existing data were used to complete the data collected through interviews. Participant Recruitment The study’s 48 participants were chosen gradually and in several phases. Initially, the study focused on homeless drug users who did not have financial resources and did not benefit from a social support network to understand changes that might had occurred in the living conditions and were more likely to be vulnerable6 to recent economic changes. Several male and female individuals who came to DICs were interviewed for this purpose. Question about new economic conditions was posed to drug users belonging to the middle of the income ladder. Then male and female participants were chosen from residential treatment centers. Also, snowball sampling was used to recruit some male and female university students using drugs. Analyzing the interviews, it was realized that the interview samples could be divided into two groups by a fundamental criteria—being financially dependent or independent. Based on the results of analysis, 70% (n = 25) of male homeless drug users of residential treatment centers were classified as being financially independent, while the other group of samples were identified as being financially dependent on their parents, spouses, sexual partners, or relatives. Being financially independent (as applied in this study) did not necessarily mean that they had legitimate jobs or were able to pay for their living expenses thru legal sources of income; it just meant that they did not expect any kind of financial support from others. On the other hand, being financially dependent did not mean that they were entirely dependent on others for financial support. Some of the study’s participants identified as being financially dependent had small source of income but they were not forced to pay for their expenses, and hence remained dependent financially. Regarding this newly emerged criteria and due to difficulty of analyzing and integrating results of a wide range
METHODS 6
Design
A combination of several methodologies has been utilized in this study. One part of the study is a qualitative, exploratory research using personal anecdotes to study the 5
A significant number of scientific studies during recent decades have documented the effects of stimulants on human and animal brains and behavior (Substance Abuse and Mental Health Services Administration, 1999). Amphetamine use causes serious damages to brain cells. It has been posited that effective treatment for amphetamine dependency as well as amphetamine-related psychiatric disorders have to include much more psychiatric and psychological services than treatment programs for opioids (Substance Abuse and Mental Health Services Administration, 1999). In Iran, the MATRIX model is currently the most used treatment method for methamphetamine (Alam Mehrjardi, 2013).
The reader is reminded that the concepts of “risk factors,” “vulnerability,” and “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development and decay; anchoring or integration; cessation; etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level), which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to operate, and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon the “principles of faith,” doctrinaire positions, “personal truths,” historical observation, precedents and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, or “transient public opinion.” This is necessary to consider and to clarify whether these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith,” and stakeholder objectives. Editor’s note.
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of data that were obtained from six different groups of samples (male and female homeless drug users, male and female patients, and male and female student drug users), only the results of the interviews of financially independent drug users (male homeless drug users from DICs and 25 male patients from residential treatment centers) were discussed in this paper. Data Collection Questionnaires were used to collect participants’ selected data. The main aim of the questionnaires was to obtain a brief description of interview samples. The 10 questions included basic socio-demographic data such as age, gender, literacy, employment, marital status, and some information about issues such as the type of drugs used, the method of drug use, the number of years that they have been using drugs, source and the amount paid for drugs, and high-risk sexual behavior. Psychologists, social workers, and counselors working in the centers, who were in daily contact of drug users and had their trust, filled these questionnaires. Three drug users in DICs and eight patients in residential treatment centers refused to enter the study because they found it difficult and painful to talk about their personal lives. The questionnaires were not given to the participants; they were questioned and their answers were written down. An oral informed consent was obtained from all the participants prior to their enrollment in the study. A psychologist, counselor, or social worker who used the questionnaire explained to each participant that “the researcher needs to know how increasing prices of drugs have influenced your life, so some questions could be very personal and you can refuse to answer them.” Also, before starting the interview, the interviewer once again explained the process. The oral informed consents are available for the taped interviews. All participants were interviewed extensively to collect their stories about prevalent economic and social conditions that they faced and their reactions to such conditions. Data collected through observation of petty drug dealers in four neighborhoods in Tehran–North, South, East, and West Tehran7 –were added to the data gathered through questionnaires and interviews. The observations were performed in the course of a day by four drug users, and the needed data regarding the type of drugs available in the market and their prices were collected. In the next phase, in order to complement the data collected through interviews and questionnaires, statistics from residential centers and DICs for the last several years were analyzed separately. 7
These four neighborhoods are different in some ways. North Tehran is a wealthy neighborhood and its rich people enjoy a very different lifestyle from others. East and West Tehran are middle-class neighborhoods. Although East Tehran is more crowded and the average age of its residents is higher than west, West Tehran is a destination for middleclass immigrants from other cities. South Tehran is a poor, crowded neighborhood that is the first destination for poor immigrants.
Questionnaires were filled and interviews were conducted in DICs and the drug user treatment centers. Completing each questionnaire took 15 to 20 minutes, and each interview lasted about an hour. Data Analysis The data collected through questionnaires were analyzed with SPSS software. The interview-based data were analyzed by the Grounded Theory (GT) coding methods. Understanding the implications of global economic sanctions against Iran and their potential consequences on drug users as “big events” necessitated exploratory research that allowed more flexibility and freedom because no relevant studies currently exist on this issue. Such research can engage the needed attention of policy makers and harm-reduction activists toward current processes occurring in the society, which can lead to serious social consequences in the near future. Among interpretive and qualitative research methods, grounded theory offers unique benefits to “big events”related research, providing a detailed, rigorous, and systematic method of analysis. This advantage provides the researcher with greater freedom to explore the research area and allows issues to emerge (Bryant, 2002). As a consequence, grounded theory is useful in providing rigorous insight into the areas that are relatively unknown to the researcher (Martin & Turner, 1986, p. 141). Focus of the methodology is toward uncovering basic social processes. Grounded theory is “ideal for exploring integral social relationships and the behavior of groups where there has been little exploration of the contextual factors that affect individuals’ lives (Crooks, 2001). Due to difference between the two groups of interviewees—the state of their being homeless and its related consequences versus their more acceptable social and economic conditions–the data relevant to each group were analyzed separately and the results were also presented separately. Although the aim of this study has not been a comparison between the two groups, a separate analysis of this pilot study’s data provides an opportunity for comparing the two groups. Sample Description Selected demographics of both samples are presented in Table 2. Data representing a drug user’s resources (“capital”, skills, abilities, etc) as well as limitations, as he adapts and functions daily, in a range of roles, contexts, situations, networks and environments, manifesting levels and qualities of awareness, expectations, judgments, problemsolving, decision-making which is or isn’t implemented, learned from or not, were not collected. The sample’s 23 homeless drug users (DICs) were males, aged 25 to 55 years (average age 39 years). Of these, 52% reported being homeless, 22% reported living in a friend’s house, and 26% reported living at their workplace, where actually a stash of recyclable goods was kept; 65.2% reported having a job and were living through picking trash for recyclable materials. On average, they
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TABLE 2. Selected demographics of samples
Frequency Minimum age (years) Maximum age (years) Average age (years) Homeless (%) Living in workplace (%) Living with friends (%) Living with family (%) Having a job (%) Average years of using drugs Illegal acts to acquire drugs (%) Having dependents (%) Spending more than half of monthly expenses on drugs (%) Those with dependents who spend more than half of monthly expenses on drugs (%) Average daily Income Average daily drug expenses
Patients in DICs
Residential centers
23 25 55 39 52 26 22
25 26 58 38
65.2 12.5 53 60
87 100 15.3 46 60 48 52
80,000 IRRs 400,000 IRRs 116,000 IRRs 230,000 IRRs
have been using drugs for 12.5 years, and more than 50% have admitted that when they are short of money or drugs, they attempt anything to acquire the drugs they need, including begging, stealing, working as drug mules, and extortion. Sixty percent of them reported that more than half of their monthly expenses were used to procure drugs, and they had paid on average 116,000 IRRs per day for drugs, while their average daily income was 80,000 IRRs. A statistical study performed in early 2012 based on the existing files in several DICs (including centers in which the interviews for this study were conducted) documented that the patients who have been frequently referred to DICs at least for six months received the necessary education and services related to mitigation of harmful effects, and that they tend to use less dangerous drugs and adopt less dangerous methods of drug use. At the time of their initial referral to DICs, the main drugs used by such patients were methamphetamine and heroin, most of them using both drugs simultaneously. But at the time of this file-based study (March 2012), their main drug of choice was opium followed by heroin and cannabis. Injecting drug users who had the experience of using shared or used needles announced that after being referred to the center they started using sterile needles. Data from this pilot study carried out more than one and a half years after the March 2012 study document that the consumption of methamphetamine, crack heroin, and heroin has increased. It should be noted that 21 of the 23 interviewees had been referred to outpatient drug user treatment centers weekly or daily for the last two years. The 25 residential center drug users were aged from 26 to 58 years (average age being 38 years). Of these, 87% live with their families, either with their spouses and children or with their parents. All of them reported being currently employed. More than 46% of these participants
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reported of having committed illegal acts to acquire drugs. Sixty percent of the participants had dependents and pay for their expenses, while 52% of these participants with dependents used more than half of their monthly income for the procurement of drugs. Findings
Data from four interviews were omitted from the final analysis because the interviewees had been ill and were unable to continue with the interview. The following information is based on data from 23 interviews. The participants in this group have been, on average, homeless for three years and for most of the nights go to shelters. During spring and summer, when it was not cold, they sometimes spent their nights in parks, on streets, under bridges, or in other similar places. Some of them who have kept their contacts with their families (five individuals; 20%) had the opportunity to spend some nights at their relatives’ homes. A majority of them picked trash of recyclable materials as a way of earning to survive and procure their daily dosage of drugs. They searched urban trash bins for various materials, including metals, plastic, and paper to sell these for a pittance. DIC3 describes a typical work day as follows: “We get up and get out in the morning, search among the trash—there are these huge trash bins which the city workers empty at nights—for plastic, metal objects, and paper to sell. Right now soft drink cans are in demand and sell for 20,000–30,000 IRRs a kilo. But there is too much competition. All the people you see around here have the same job. We sell our goods, get some money, buy dope and use it in a corner. If there is some money left, we spend it on a piece of bread or cookie in order to survive. We have lunch and a cup of tea here, that’s all.”
Most participants said that up to one and a half to two years ago, they were able to earn enough money for their daily drug dosage and one or two meals a day by working three to four hours each day. But recently, with the increase in the price of drugs and food, they had to work for longer hours, usually seven or eight hours a day. DIC8 says: “In the past we worked three–four hours and we could both pay for our drugs and cigarettes and also some food. But now some days we work till dark without even making enough money for drugs. I walk for seven or eight hours a day without earning much. At nights, I go begging to my dealer but he only gives me as much drugs as I have money for, for the rest I take pills to avoid withdrawal symptoms. If it weren’t for the free lunch given here, I wouldn’t find anything to eat.”
DIC9 says: “I work long enough to earn money for my daily dosage, I never ask whether I have food or not, or whether I’m hungry or not, I straight go to the dealer, and then collapse at some corner till it is time to go to the shelter for a meal.”
DIC19 has been a heroin user for several years, but with the increase in prices he tried to find cheaper alternatives. He says:
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“After the prices shot up, I quit heroin and tried to replace it with methadone. But after five days I had taken so much methadone without getting a high that I overdosed. At that time methamphetamine was very cheap and I turned to it because nothing else answered my needs. Now that the prices of methamphetamine, heroin, and crack are the same, I use anything that comes my way.”
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“I was afraid of injecting. But I saw nothing satisfies me, and I heard, it [is] said that injection is both easier and less expensive. So I began injecting. Now I both smoke and inject, and when I can find nothing else, I take some pills, which I buy myself. I drink cough syrups and like 60 diphenoxylate pills a day. I know they are bad for me.”
DIC19’s story documents that in order to satisfy his drug use, he tried various ways, including using more dangerous drugs, such as methamphetamine, and using more dangerous routes, such as injections. Those who are older and incapable of physical activity, are not able to pick trash, or do another manual jobs, they usually make a living through begging. But it barely covers increasing drug costs. Those who are able to work, have the option of working for longer hours and making more money, they have found a different solution and have resorted to taking pills. For a small amount of money, they can buy quite a good number of expired pills from gray market. DIC1 says: “In the past I had some money and used it as capital. I would make a stand in the street and sell second-hand bags. A couple of times when I was high I was robbed. The other guys go on their rounds but I can’t do it. I cannot even stand on my legs, let alone going on rounds. Now I’m popping pills, 90 or 100 of them a day. If I find drugs or if other guys offer me a free fix, I don’t say no.”
Later, he explains that becoming a pill addict is the last step that an addict might be forced to take, it is the time when the addict is utterly incapable of procuring drugs: “Here anyone who is a pill popper will not admit it. They are embarrassed to admit that they are so desperate as to take pills. In fact it’s an insult if you call someone pill-popper.”
DIC4, who has been taking pills for some time, says: “When the prices go up, those who can steal; those who can’t steal, beg or use less. And since they suffer when they use less, they turn to clonazepam and sleeping pills and such like. They reach a point when they see pills are cheaper, so they quit drugs and only use pills, like 50 or 60 pills at one go.”
Lack of enough money for drugs in some instances is associated with losing control over the type of drug that is taken by drug users, how much they use, or how they use. Such drug users are incapable of earning daily income to pay for their drugs to be smoked, taken orally, or injected. Therefore, they go for partners with others and pay money to a dealer for a certain number of fixes, and at regular intervals during the day they go to a particular dealer and drink or inject the solution prepared in advance by that dealer.
DIC 17 says: –“I’m in a hurry; I have to go [to] get my dope.” –“From where?” –“Right behind here, the guys are waiting for me, I’ve just come to have lunch here and go [to] join them. I’ve given them money to buy the stuff by the time I get back.” –“Do you use drugs together?” –“We all chipped in and gave the money to the dealer. I don’t earn enough to buy for myself and smoke it in a corner. We take one fix at noon and another at night. By the time we arrive, the dealer himself has prepared the fix; he dissolves the dope in a cup of tea or sugared water and gives it to us. We don’t know what it is, or how much it is. We don’t know what kind of trash is in the cup. I swear to God, it is all pills. And at last he says our money was enough for this much dope.” During their addiction period, these individuals have had the experience of using drugs with their friends, but what they are experiencing now is fundamentally different from their previous experiences. Previously the user himself or his friend bought the drugs, so even if he went partners with others or used in a group, he at least had the chance to take a look at the drug when buying it, and to some degree had a control over the type and amount of drug he wanted to use. But now such users barely have control over the quality of the drug they use. They can’t even be sure what kind of drug they are using. DIC17 has quit injecting drugs for some years, but some of the guys he goes with on his trash picking rounds still inject. He says that these friends are currently getting their fixes in a similar way: “We don’t hang out with shooters, but for them too, the dealer prepares the fixes in a bowl and whoever arrives takes a fix from the bowl and injects right there.”
DIC23, who for the last year has been injecting drugs, says: “I used to sell things on the streets, tissue boxes and such like. Sometimes I carried drugs as a favor and at the side also dealt. Later on, the prices went up and . . . Then the market went south and my income wasn’t enough. My brother and I had a new idea. When we bought the dope, we didn’t smoke it all, we mixed part of the dope with pills and such like and sold it. One night I was suffering badly from withdrawal symptom. My brother had been caught with dope and was in jail. I tried everywhere but I didn’t find anything. I went to some of the guys and found them injecting. At first I was afraid. I’d seen in the past how they injected dope, but I hadn’t tried it up till then. I was desperate for drugs and they told me: “We have just this; you are welcome if you want it.” At last one of them injected me for the first time. Later on I saw it’s a more fun, and also cheaper, so by the time my brother was out from jail I’d become a shooter. My brother is now a shooter too.”
DIC23 and his brother, as a result of their frequent visits to DIC, have become aware of how HIV and hepatitis are transmitted, and especially of the issues associated with injecting drugs and sexual contacts. They receive free
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needles, syringes, and condoms on a regular basis. However, he says:
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“When you have no money and no dope, you have no other way. I always have new needles with me, I get them from DIC but they say you will catch the disease even if you take the dope out of a common ontainer, but when you don’t have the dope, you have to go sponging on someone else. You have no options; you have to take the dope he has prepared. Well, I can’t help using.”
DIC3 used to work for a drug dealer to get his own drugs and have a place to sleep. He used to carry drugs for the dealer. But when he fell out with the dealer, he was forced to start working for another drug dealer, and since the new dealer dealt in methamphetamine, DIC3 began using methamphetamine instead of heroin. Iran’s drug user residential treatment centers (RC) are the settings that offer abstinence-based treatment for drug dependency. The participants interviewed in these centers were chosen from the individuals who had been using drugs for several years, and had entered the treatment program at least 10 days before the interview. There are two outstanding themes about this group of addicts: 1. Increasing economic pressure on family members. 2. Tendency to buy cheaper drugs, using dangerous methods of drug use, and common drug use with friends. For drug users, drugs are considered to be a basic commodity and are a staple in their families’ daily expenses. Increase in daily expenses, including cost of drugs on the one hand, and scant increase in family income on the other, have added to the economic pressure afflicting the families of drug users. This is felt even more dearly when the drug user is family’s bread winner or provides part of family income. Under such circumstances, family’s spending priorities change and get more directed toward basic needs such as food, clothing, shelter, and also drugs. Under such circumstances, education, sports, health care, and entertainment receive less attention. RC12, who lives with his wife and two children and works in an auto company, explains the process thus: “In the past we got by. We ate and dressed like others. My kids went to school and language class like other kids. My wife had even put them in a swimming class. It’s true that I wasn’t myself and made them suffer, but on the surface we lacked nothing. But gradually our expenses went up. The price of meat, chicken, and other stuff shot up several times, so did the price of drugs. At the same time, my consumption went up too. 100,000 IRRs a day became 200,000; and 200,000 IRRs a day became 300,000. How much can one earn? After a while I had no money for kids’ schools. I had to find an excuse to change their schools. I couldn’t pay the rent, let alone for things such as language school, swimming school, or similar stuff. Every day there was money for water, electricity, and telephone. We just managed to survive without losing face among others. . .”
Those with very low income, and others who earned enough to get by, had tried other drugs and methods of use
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due to rising drug prices; some of them in search of a way to lower their drug expenses, and others by force when they hadn’t been able to procure their drug of choice. RC16 say: “Heroin was scarce, and even if you found some, it was very pricey. My friends several times suggested that I use methamphetamine, which was at that time very cheap and also highly admired by others. At first I resisted; for a time I was able to find heroin; but later on I was forced into smoking methamphetamine.”
RC32 also says: “I started by injecting, but I was alone and always used my own needle. I was desperately looking for drugs. Either there were no drugs or it was very expensive. A couple of times I bought a cheap variety, but it made me sick. It was obvious that it was full of junk. Once I went to the house of a dealer with some money that was not enough. He took my money and said, “‘Some guys are inside, come in and get a fix.”’ From that time on whenever I couldn’t find drugs or didn’t have enough money I went there.”
Similar to the reports of some homeless drug users, some residential treatment drug users reported that as a result of rising prices they concluded that they could earn money by adding impurities to the drugs they buy, and then sell. RC5 lives alone. He was a university student until several months ago and used to work as a private teacher to cover his living expenses, including drugs. But recently it was not enough. He said: “It became my job to add pills, flour, and any other junk I found to the drugs and sell them in the university to my friends, especially to the beginners. Once, I and my friends thought of stealing stuff belonging to the university. One night three of us stole three printers from the university. But the next day there was a great row. Later on, we thought of pilfering expensive books from the university library and selling them.”
DISCUSSION
This paper, and the pilot study, documents that Iranian urban drug users and their families are among the vulnerable groups who have been deeply affected by the economic crises that have worsened as a result of increasing economic sanctions against Iran. Homeless drug users were the most vulnerable group. Their reported history documents that under such circumstances different individuals resort to different ways in line with their resources:
• Some of them resort to shared buying and using of drugs. Shared use can be associated with shared injections. Generally, the individual resorts to this when he hasn’t been able to acquire drugs he needs and is at the most vulnerable point, so he joins the crowd. Some interviews documented that even awareness of the dangers of shared injections is not necessarily an obstacle to using drugs under high risk conditions. • A study performed in 2001 deals with the issue that the use of shared needles, and also high-risk sexual behavior, among addicts can be explained by the concept of “discounting of delayed rewards” (Bickel & Marsch, 2001) Discounting of delayed rewards means that the
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reward which is expected in the future will have a lesser value compared with an immediate reward. The results of this study show that the discounting of delayed reward can provide an explanation for both drug use and high risk behavior related with injecting drug. (Bickel & Marsch, 2001). Shared drug use can and does occur in cases in which the individual loses his control over the type of drug used, the amount of drug used, the pattern of use, and the method of drug use. In order to earn money that they need, some drug users join drug distribution network, or mix some of the drugs they buy with impurities and sell them to others. Some of them steal from their place of work, homes, or family members, or they look for other illegal ways to earn money to pay for their drug habits. A common experience under such circumstances is resorting to alternate drugs or methods of use which provide the much needed fix at a lower cost. Another undesirable consequence associated with rising drug prices and simultaneous rising of daily expenses is the lowering of quality of life of drug users and their families. Families with low incomes can change their economic priorities, judgments, and decisions, and neglect some less priory expenses from their economic basket. Under such circumstances, the first choices to exclude are generally entertainment, education, books, sports, and health care.
had access to HIV/AIDS information as well as harmreduction tools. These results are to some extent supported by statistical analysis of existing documents. The abovementioned results had been also experienced to some degree by the clients of residential centers. The findings documented that rising prices of drugs–a basic commodity for drug users–had brought more economic pressure on their families. There is a need for further quantitative and qualitative investigation of broader consequences and implications of big events on increased drug prices, manner, and pattern of drug use in Iran as well as elsewhere. Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper. There is no Ethics Committee or Institutional Review Board in Iran for such a research. There is just an ethics committee for medical research. This study did not need or have IRB approval or permission. THE AUTHORS Abbas Deilamizade is the chairman of a regional network of NGOs (ADNA) working on drug demand reduction and harm reduction in Central and West Asia. His research interests are drug demand reduction, harm reduction, drug economy and drug control policies.
Study’s Limitations
This pilot study’s limitations include its small convenience samples, which may or may not be the representative of Iran’s urban as well as rural drug users; some confounders, such as occasional police interventions, that could not be controlled, and the statements of participating drug users, which cannot be completely trusted. The study design does not permit for “cause and effect” conclusions to be drawn, nor is sufficiently sensitive to the nonlinear, dynamic, and multi-dimensional processes associated with the measurable and non-measurable operations of “big events.” The findings do enable and merit deriving hypotheses for the future research in this relatively new research area.
Sara Esmizade has a master’s degree in sociology from the Faculty of Social Sciences, University of Tehran, Tehran (Iran). Her research interests are homelessness, drug abuse, harm reduction, and drug control policies.
CONCLUSIONS
One of the important factors that are associated with a sharp and continuous rise in Iran’s street drug prices and the price of other goods and services is the devaluation of IRR against US dollar–an outcome of recent economic sanctions against Iran. Our interviews with 48 male drug users in Tehran documented that all of them had been affected in different ways by the recent economic changes, especially by rise in drug prices as well as other daily expenses. Homeless drug users experienced this maximum in the form of limited access to drugs whose pharmacological actions are relatively less harmful. This change was associated with the use of cheaper and more harmful drugs and adopting high-risk methods of use, such as injectables, as well as losing control over routes of administration and type of drugs. It has to be mentioned that rise in high risk behaviors had occurred among DIC clients who
GLOSSARY
Drop-in Center (DIC): It is a non-profit center serving homeless drug users, and offers lunch and learning sessions on HIV/AIDS, hepatitis, and high risk behaviors. Also, it provides them with clothes, needles, syringes, and condoms. Currently, in Iran most DICs are run by NGOs and co-funded by governmental organizations such as Ministry of Health or State Welfare Organization as well as some international organizations and programs such as the Global Fund.
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Residential treatment center: It provides a multidisciplinary approach to facilitate recovery from substance use. Comprehensive chemical dependency treatment services offered by peer counselors–ex-addicts who are trained in chemical dependency counseling–provide a structured therapeutic environment. The services provided often include individual and group counseling, structured physical activities, stress reduction, holistic approaches such as yoga, vocational training, relapse prevention support, social skills training, educational services, and 12-step substance user programs.
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