Side event: Africa; strategic findings to understand and address a multi-faceted drug problem

Organized by the UNODC Regional Section for Africa and the Middle East with the support of the UNODC Research and Trend Analysis Branch

Alexia Taveau, Programme Coordinator, Regional Section for Africa and the Middle East, UNODC: What we are addressing in this event is particularly timely as UNODC recently launched its strategic vision for Africa 2030. This innovative document represent a transformative approach to our work in Africa for the next 10 years. It aims to adopt an integrated, people centred and human rights based approach to empower African societies against drugs and crime. At the heart of the strategic vision for Africa and in line with the UNODC corporate strategy which was also launched this year and the corporate strategies for 2021-2025 there are three value propositions; alongside to normative and technical assistance our work on analysis, research and evidence is central. Our aim is to strengthen member states on data analysis, research and statistics in order to generate evidence based legislative policy and operational responses as well as research products. Our work is ever timely as we advance towards the achievement of the SDGs and the African Union aspirations 2063. Research colleagues in the field and headquarters have spearheaded numerous such initiatives and our goal is that the strategic vision for Africa 2030 will be a catalyst for a better understanding of the causes and drivers of criminality, including drug trafficking and drug abuse. We will also work to strengthen the research capacities of African institutions and support the establishment of data and analysis hubs. The long research promoting people’s health through balanced drug control is one of the five investment areas of the strategic vision, and improving data collection and analysis is the first objective under this investment area. Thus, showcasing our deep commitment to research and analysis as the basis on which we can build a people centred and balanced approach to [tackle] the world and Africa’s drug problem. The strategic vision for Africa also includes 6 change enablers, including building partnerships especially through South-South cooperation, the empowerment of women and youth, as well as the importance of prevention. These will influence our implementation in the years to come. I would like to invite you to visit the UNODC website to read the document in full, so that you will have our whole vision for Africa.

Angela Me, Chief, Research and Trend Analysis Branch, UNODC: I will be discussing four main challenges that Africa is facing: 1) the issue of the increased complexity of drug use, 2) the issue related to the lower accessibility to treatment and care, 3) the one regarding lower accessibility on pain medication, and what is related is the issue of transit routes for both heroin and cocaine and 4) the issue of data gaps. My colleague will focus on one of the main challenges in the continent relating to the trafficking and the non medical use of Tramadol. 

Regarding complexity between 2008 and 2019 the global number of people who use drugs has increased by 36%. This clearly indicates that globally drug markets have expanded. This is particular important for Africa. The increase and all the people using drugs is particularly acute in developing countries as compared to developed countries. Looking at population dynamics, we know that the higher prevalence of drug use is among the young population and in developing countries youth population is growing higher; for example the population between 18-25 grew by 80% in developing countries and in developed countries actually decreased by 10%. We can expect this trend to continue. In the next WDR in June you will see the implication of these demographic dynamics in terms of the number of drug users in Africa. The percentage of people seeking treatment related to cannabis is increasing as well as for other types of drugs. In the last decade Africa has become more and more a transit continent for cocaine affecting regional drug use and dependence. I also want to highlight the non medical use of all the pharmaceuticals and particularly in North and West Africa and the issue of Tramadol. Also from a population survey in Nigeria we found that 2,5 million people are misusing cough syrup. Globally, we see that 1 out of every 8 received treatment but in Africa this is lower.  On a study conducted in Nigeria we saw an instability on treatment coverage that is relevant to the various type of drugs used; for instance only 20-30% of those dependent on heroin actively get treatment. This really highlights the challenge the whole of the continent is facing: the low accessibility to treatment. Asking about the reasons for that we found un-affordability and stigma. Not only in Nigeria but in general stigmatising drugs may protect people by not entering into risk behaviours but stigmatising drug users prevents them from seeking treatment. The other challenge that I just wanted to highlight is the very low accessibility to pain medication, particularly to control substances in the region. Evidence emphasises on the incredible disparity found between people living in North America and in Africa, with the first receiving 35,000 doses [of pain medication] per million inhabitants when for people living in Africa is close to 0. The fact that Africa is a transit route for drugs exacerbates insecurity, violence crime and increases the risk for [some] of the drugs to stay in Africa increasing therefore regional consumption. We have the eastern route (the heroin route) coming from Afghanistan through eastern and northern Africa reaching Europe and the western route (the cocaine route) coming from Latin America through western and northern Africa to reach Europe. Seizures remained significant even during COVID-19 pandemic where much of the trade of illicit trade has been challenged actually drug trafficking has not fallen and is very high. Lastly I wish to emphasise on the data gaps and on the many things that we still don’t know about Africa that actually prevent us from improving policies. Countries may not have the capacity to report data to the UNODC but also what is demonstrated is a chronicle lack of data in general. Without data we cannot for instance find out about the exact impact of the increase trafficking of cocaine and heroin in Africa since we cannot quantify trends. Besides South Africa and Nigeria where we had population surveys, in the rest of Africa we really have a challenge in quantifying drug use, or OD deaths or other drug use disorders. Currently member states at the CND are negotiating a resolution to improve data collection on the harm caused by the non medical use of pharmaceuticals. UNODC prioritises drug use population surveys to understand the magnitude [of the phenomenon] but also high risk surveys to understand the harm caused by drug use, and also to improve the treatment information system making sure these are comprehensive and they provide quality information. Also to experiment with wastewater analysis; is something that has been done in some region, and maybe could expand in other parts since this is a cost effective solution. Also to think about big data solutions and to improve the supply information system in terms of price and purity [of seized drugs], and to support countries to establish their national observatories.

Francois Andre Emile Patuel, Head of Research, Regional Office Central and West Africa, UNODC: I’m going to talk to you today about the pharmaceutical opioid crisis in West Africa. This is a research project that really aimed at debunking the cliche that Africa is simply a place of transit for drugs. It is indeed a place of transit since we know that they are heroin and cocaine flows in the region and there is a large amount of resources dedicated to understanding these flows. But there is far less resources being invested in trying to understand the problem of drug use and the harm that it creates in the region. We decided to focus on pharmaceutical opioids in West Africa and we did a research between 09/2018 and 07/2019. We used official data and reports from the West African epidemiological network, desk reviews and interviews. We also did two regional workshops inviting national drug enforcement agencies to share their experiences of having to deal with Tramadol or other pharmaceuticals. What is the challenge for them to seizing Tramadol and apprehending traffickers.

Between 2011 and 2019 there were 569 tonnes of pharmaceutical opioids that were seized in West Africa, mostly Tramadol. In 2017, West Africa accounted for 77% of all Tramadol seizes globally. This gives you a sense of the scale of the trafficking. With this there is the question of how much of it is misused in Africa. In Nigeria alone around 4.6 million people were misusing pharmaceutical in 2017. In Niger is more prevalent that cannabis and in Togo an estimated 37% of people aged 12 to 24 had used Tramadol at least once in their life. What is not really understood is the tolerance/dependence Tramadol misuse brings by time and the risks of an opioid overdose. But we are lacking of data reports to monitor the effects on health. Also one of the effects of Tramadol is to alter your perception of risks and this can have a detrimental effect on crime. People are more likely to commit crimes if they are not aware of the risks. Also, in terms of political violence Tramadol is found to be distributed -in Guinea for instance- prior to public demonstrations that included violent clashes between demonstrators and law enforcement. Regarding trafficking most of Tramadol originates from South Asia, although states in West Africa are increasing their production capacities. In Ghana it’s estimated that about half of what has been circulating was actually produced locally. The main point of entry to West Africa tend to be Nigeria where there were high levels of seizures, particularly from from 2016 and onwards. But also, Benin, and Guinea and from then on by land spreads to North. It is difficult to control pharmaceutical opioids in Africa since you cannot just cut access to painkillers in the region; painkillers are an important part of the medical response. The diversion is facilitated by the loosely regulated export laws and poorly supply control in the region. You can buy Tramadol in a pharmacy with prescription but it’s far easier to buy it in local markets. On top there is the issue of rebranding as traffickers are adapting. So, we need 1) to improve awareness about the risks that it creates including in health and crime, 2) to improve data collection, 3) to enhance the oversight role of law enforcement agencies, 4) to enforce and harmonise medicine regulations, 5) control supply chains and 6) [improve] international cooperation. 

Abel Basutu, African Union Commission: I am merely going to amplify what Francois and Angela said, from a continental perspective. In the area of drug control we have an action plan for the period 2019 – 2023 that promotes a multi sectoral balanced and integrated approach to drug control, cognizant of global challenges including current socio economic well being as well as security. The continent is transformed from being a trafficking hub into being a major destination; along with domestic consumption rising there is regional production on the rise. We know about the growing nexus between drugs and organised crime, including complex and shifting nexus of insurgency, local and regional politics including corruption, and terrorism. This shows the evolution of organised crime; for instance cybercrime, piracy, small arms trafficking, money laundering and so on. These are pretty formidable challenge in terms of addressing drug control architecture on the continent. [ ] There is an estimate of 9 million people that were using illicit drugs in 2019 and the modelling predictions are not encouraging showing a 150% increase to 40 million by 2050. In 2016, the African Union [initiated] a project to operationalize a continental drug surveillance system which we call the Pan African epidemiological network on drug use, by facilitating the creation and capacity building of sustainable national drug epidemiological networks. These data help our policymakers in terms of legislative and policy review. However of course we do acknowledge that some of them [data points] are still developing. Data showing an increase on admissions in accordance with what was reported. [ ]

Cannabis remains the major drug for which people undergo treatment; in West Africa this accounts for over 55% of all treatment admissions in 2018 and 2019 followed by alcohol. Then of course there is the issue of opioids in particular the non medical use of pharmaceuticals which in our view presents the biggest concern for public health, safety, as well as law enforcement. We also have the issue the NPS that are on the rise. Every day, people are inventing something so it makes it a problem, worsened by the fact that most of our member states do not have forensic labs in order to determine the composition of those NPS. The biggest challenge remains the huge unmet demand for treatments [services]. We know of course that globally 1 in 6 problem drug users receive treatment for substance use dependence but in Africa is 1 in 18. Data reveal that only 53 per million have access to treatment. We have a young continent and as a result many of them are prone to trafficking but also to using drugs; data confirm that. An enabling environment for young people to prosper needs to be put in place together with a comprehensive package of drug dependence treatment services. The other challenge that we face is, of course, conflict which mainly causes displacements. Substance use amongst the populations has been documented and this is an emerging area that needs to be looked at. Last, I just want to highlight the proliferation of substandard and falsified medicines and consumables which was apparent mainly after COVID-19. So that’s, that’s an issue that needs to be to be addressed. 

Charles Parry, South African Medical Research Council: We set up the South African epidemiology network on drug use 25 years ago; we collect data from five regions in South Africa. For the first half of last year I have done the ranking of the primary drugs that bring people into treatment under 20. Except for the Western Cape cannabis is the drug that is primarily is bringing people into treatment. Cannabis does cause problems despite the fact that many people said it’s fairly harmless. There are people experiencing problems that need attention. Heroin follows. Heroin is smoked together with cannabis otherwise it is used through injection or “chasing the dragon”. After heroin is pretty much methamphetamine and then cocaine. What follows is a fairly unique problem with Methaqualone which is a sedative. Regarding cannabis, it is highly reported as a primary or secondary drug abuse and since now it is legal for adults to have in private spaces is going to be interesting to see how that changes; does it become less for adults does it increase by adolescence? We will be watching it carefully. Heroin use is very problematic and the demand for treatment is increasing over time. [ ] We are talking about treatment demands and the access isn’t always available; between 20% to 30% are under 20 years of age. Unfortunately we don’t have a strong burden of disease data on cannabis use but there is substantial data on the link between drug use and mental health problems, TB, HIV, risk adverse outcomes and some data on violence/injury related to drug use.

Regarding health impacts many people are obtaining cannabis for medicinal purposes from the illegal markets where there is no quality control and potency can be either too high or too low for it to be effective, and sometimes is mixed with other products or harmful contaminants. We are likely to experience an increase the number of people experiencing problems especially with cannabis cause; more people are using it because it is now legal for private use. There is likely to have greater problems with vaping and edibles because you can’t really control as easily the potency, and particular concern about cannabis use amongst adolescents. Regarding public health responses we are particularly concerned to reduce second hand smoking and about medicinal cannabis we really need to better inform people. We need to ensure that there are quality affordable medicinal cannabis products out there. We need to prevent spillover from medicinal to recreational use. We need to be careful about how cannabis products are marketed, needing some controls in that area.

Bronwyn Myers, South African Medical Research Council: Access to substance use disorder treatment is scarce including South Africa which still has a relatively well resource treatment system compared to other parts of Africa. But we have been advocating not only for access to treatments for people with moderate to severe substance use disorders but also earlier interventions that can prevent progression to more chronic problems.

One of the areas that we could really see the impact of substance use disorders in a country is through integrative screening brief intervention and referrals to treatment services into our primary health care services. There has been a large body of research that has been looking at how we can integrate the screening and evidence based brief interventions into services. Although we have very large shortages of healthcare professionals that have capacity to deliver these interventions we have demonstrated through various implementation projects that the ability and sort of the acceptability of task-sharing these interventions within HIV care force workers, community health workers, as well as peers who have histories of lived experience with substances themselves. Stigma is an issue that need to be addressed. Introducing stigma reduction interventions into these clinics and into health services is certainly something that would be a barrier to the scale of the services and particularly in the disclosure of substance use in the context of healthcare. But one of the issues that I guess obstacle to the integration of these kinds of services into primary health services has been the referral to treatment for those individuals who have more moderate than severe problems that require specialist substance use disorder treatment services. Sometimes primary services is not a place to refer these individuals. We not only need to improve access to substance use treatment but also to improve the quality of services. In South Africa only about less than 3% of adults with drug use disorder that are interested in treatment are able to access adequate treatment; defined as 2-3 counselling sessions. We need data on the quality of services that are provided so that we can drive service quality improvement efforts. South Africa has fought since 2008, developed, and in the last five years implemented a service quality measures initiative where we routinely collect data on various aspects or domains for treatment quality. These domains look at the effectiveness of services, efficiency, perceived access to services and perceived quality to services. [ ] The system is also able to look at the performance on these indicators which is useful for developing interventions that target these factors and can lead to system improvements. [ ] We found that people who had comorbid mental health disorders, who had long histories of substance use and who are of black African ethnicity, which reflects racial disparities and in quality of care were more likely to perceive the treatment that they received to be of a sub optimal quality. The main driver of unsatisfactory treatment quality outcomes was perceptions of sub optimal treatment quality just really underscoring the importance of ensuring that the treatment that is provided is person centred and directed towards the needs of patients. There is also just major gaps in our treatment system that are important to consider: 1) the lack of medication assisted treatment is especially important given the issue around opiates; 2) also the lack of trauma informed services and the integration of mental health services; and 3) stigma.

Alexia Taveau: I will turn to Angela on the question of cannabis to maybe just provide a quick overview of the framework that the United Nations has in how we operate within that.

Angela Me: In many parts of the world you have referrals from the criminal justice system to treatment. Even if it is an alternative to punishment we always encourage people who use drugs to seek for treatment and not the criminal justice. In Africa there is a high percentage of people in treatment for cannabis demonstrating that cannabis is harmful; having all of the scientific evidence today to actually prove this. Without demonising cannabis, irregular and heavy use of cannabis has serious health consequences and I think treatment data also showed this.

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