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Introduction
Heroin abuse became a major concern in China in the
19th century, when western colonialists forcibly imported
opium into the country. Before the establishment of the
People¡¯s Republic of China in 1949, approximately 5% of the
entire population of mainland of China (approximately 20
million people) were addicted to opium. Following a 1949
national anti-drug campaign, China became "a country free
from drugs"[1,2]. However, China has been facing the
recurrence of pandemic drug abuse, especially heroin abuse, again
since the late 1980s[3,4]. Drug trafficking and production have
been increasing in China.
3,4-methylenedioxymetham-pheta-mine (MDMA; also known as ecstasy), which emerged
recently and is popular among young people, is the most abused
drug, followed by opiates[4-6]. The aim of this review is to
give a perspective of the current situation of drug abuse, the
problems associated with it, especially HIV, and the strategy
to control it in China.
Drug abuse sweeps across the country
Beginning in the early 1990s, drug abuse spread quickly
across China. The number of registered drug users increased
from 70 000 in 1990 to more than one million by the end of
2004[7_9] (Figure 1). Most coastal cities in the country are
affected, and the actual number of drug users is probably
much higher than the official estimates. The drug abuse
problem has spread to 2148 counties/cities, representing
72.7% of the total counties (or cities or districts) in
China[7-9]. Furthermore, in recent times drug abuse has spread to
undeveloped areas, especially in the northwest and central
regions of the country (Figure 2). A 2003 survey shows that
heroin is the most abused drug in China (89.34% of total abused
drugs), followed by MDMA (5.37%) and other opiate
substances such as morphine and methadone
(2.25%)[3,8,9]. Most heroin abusers are male (M:F=1:0.22), young (55.7% are
26_35 years old, and 86.4% are 21-41 years old), unmarried
(54.7%), and unemployed (64.5%), with a low educational
level (81% have only a junior education or
lower)[8,9]. For new drug abusers (who first used drugs in the past year),
nasal inhalation is the main route of administration, whereas
for experienced drug abusers, injection is the main method
of delivery. According to surveys, most new drug abusers
spend less than 2000 RMB (Chinese yuan) per month on
drugs, whereas most experienced drug abusers spend more
than 2000 RMB per month[8_10].
Illicit drug trafficking
In the early 1980s, international drug traffickers took
advantage of the reforms and more open policies in China
to smuggle drugs into the country, which resulted in drug
abuse occurring in many southern cities. As the number of
drug abusers increases, consumption and production also
increase. Many drug producers have been captured in
coastal cities since 2000, some of whom are immigrants from
South Korea and Japan[5,6]. The main sources of opium
smuggled into China were Afghanistan, Myanmar and Laos,
and cannabis and synthetic drugs, such as
methampheta-mine, have tended to be imported from Cambodia and North
Korea, respectively[5,10,11]. In 2004, 98 000 drug-related cases
were brought before the authorities (an increase of 61.4%
compared with 1999), and 10 800 kg of heroin, 12 000 kg of
opium, 2700 kg of methamphetamine, 3 000 000 tablets of
ecstasy, 186 000 kg of opium poppies and 408 000 kg of
precursor or raw materials for manufacturing drugs were
confiscated by security staff[5,12].
A spokesman from the National Anti-drug Committee
noted in 2004 that drugs have entered China from various
sources, and that internal trafficking activities have become
increasingly widespread[10,13]. Many Chinese provinces lie
along the so-called "China Channel" of drug smuggling,
which leads from the Golden Triangle (an area near the
borders of Myanmar, Thailand and Laos) to Chinese cities and
abroad, and passes through the provinces of Yunnan,
Gui-zhou, Shanxi, Gansu and
Guangzhou[9,13]. The China Channel became a drug trafficking route at the end of the 1980s.
International drug smugglers used China¡¯s reputation as a
drug-free country to institute this new trafficking route from
the Golden Triangle, the largest opiate processing centre in
the world, to areas in Yunnan province, then to Sichuan,
Guizhou, Hong Kong and Macao. Wenshan in Yunnan
Province lies directly next to the Golden Triangle, and there is no
physical barrier between the 2 areas. Guangzhou city,
adjacent to Hong Kong, was the first place in China to be opened
to the world and is now one of the centers for trafficking
drugs to other Chinese cities and
abroad[14,15]. The cities of Anshun, Chongqing, Xi¡¯an and Lanzhou had long histories
of opium use and production before the foundation of the
People¡¯s Republic of China in
1949[2,3,5]. According to a police report, approximately 90 000 suspected drug dealers were
caught in 2003 and approximately 9290 kg of heroin and 3190
kg of methamphetamine were
seized[8,9,13].
Now, in order to prevent illicit drug trafficking, the
Chinese Department of States has founded a commission to
battle drug production and distribution in cooperation with
the police, the intelligence service, the health sector and the
government¡¯s legislative branch.
MDMA as an emerging drug
As the number of drug addicts increases and the drug
abuse problem spreads, consumption of traditional drugs
grows alongside increasing use of new kinds of drugs. It has
been reported that although opiates, especially heroin, remain
the most commonly used drugs, MDMA and methamphetamine have recently become popular "recreational" drugs in
large or medium-sized Chinese
cities[8,9]. MDMA belongs to the class of amphetamine-type stimulants (ATS), and is a
synthetic drug that can be manufactured in 2 ways: from benzyl
methyl ketone, or from ephedrine extracted from the medicinal
herb ephedra[16_18]. The increasing illicit manufacture of ATS,
particularly methamphetamine, in East and South-East Asia is
a major concern. It has been estimated that more than 70% of
all seizures of amphetamine in the world took place in East and
South-East Asia, mainly in South Korea, Japan, China and
Thailand[5,19,20]. A dramatic increase in MDMA trafficking has
occurred throughout the region, and illegal MDMA
laboratories have been discovered in mainland China, Hong Kong,
Taiwan, Malaysia, and most notably
Indonesia[5]. The increased demand for ecstasy and the ready availability of
precursor chemicals from China and Vietnam make South-East
Asian nations increasingly vulnerable to becoming havens
for large-scale MDMA manufacture[5,20]. In China, the
countryside also faces a growing problem of ATS
abuse[7,21]. In addition to its use in mainland China, ecstasy has become
especially widely used in Macao and Hong Kong, the 2
Special Administrative Zones of
China[13,14].
Drug use at "rave" parties has been growing in China,
and the drugs most frequently encountered at raves are
phenethylamine type stimulants (PTS) including ecstasy,
methamphetamine, and ketamine[8,9]. According to the 2003
report of the Chinese Drug Surveillance Center, MDMA,
methamphetamine and ketamine account for 5.6% of drugs
used by new drug abusers, second only to
opiates[8]. A comparison between experienced drug abusers and new drug
abusers with respect to the most abused stimulants reveals
that experienced drug abusers use more MDMA (0.13% for
new drug abusers, versus 5.37% for experienced drug
abusers) and methamphetamine (0.05% for new drug abusers,
versus 0.19% for experienced drug abusers). MDMA is the
most abused drug among young people. First-time MDMA
users are getting younger, but the number of adults abusing
ecstasy is also on the rise.
HIV among drug users
Drug abuse has led to many problems, in particular
HIV/AIDS. In Asia and the Pacific, more than one million people
acquired HIV in 2003, bringing the total to 7.2 million
infected people in the region[6,13]. The growth of the epidemic
in this area is largely due to the growing epidemic in China,
in which a million people are living with HIV. China¡¯s AIDS
epidemic began in the early 1990s among injecting heroin
users[22,23]. Injecting drug users account for more than half
of China¡¯s HIV infections. In addition, many of China¡¯s sex
workers inject drugs, and thus provide a bridge for HIV
transmission to the general
population[24_26]. As the commercial sex industry has exploded in China over the past 2 decades,
HIV infection rates have also increased
dramatically[22,26]. By the end of 2003, the number of registered HIV infections was
62 159 (including 2693 cases of AIDS, from which 1047 people
died). An estimated 106 990 Chinese people were HIV
positive by the end of 2004 (Figure 3). HIV infections have been
reported in 31 provinces, autonomous regions, and
municipa-lities, and the actual number of cases and spread of infection
is likely much greater[22,23]. Drug abusers accounted for
63.7% of HIV cases. China is now one of the 6 South-East
Asian countries in which there is growing ATS use, and
vulnerability to HIV/AIDS appears to have
increased[15,22].
It is well known that AIDS affects not only patients, but
their families, society, and the economy. China¡¯s first law
targeting the disease was passed by the Standing
Committee of the National People¡¯s Congress in 2004.
Discriminating against the victims of infectious diseases has also been
outlawed. Many efforts and measures have been adopted
by the Central Government to help patients obtain effective
treatment. As for preventing HIV spread among drug addicts,
some places in China, such as Guangzhou province, are
instituting needle exchange programs among drug abusers in
order to break the HIV-heroin connection. Some areas are
also advocating 100% condom use among sex workers.
Comments and recommendations
In recent years, China¡¯s government has paid a great
deal of attention to drug abuse, and has implemented
strategies to control it, especially in terms of drug prevention and
intervention. For instance, in 2002 the Chinese NNCC,
together with 3 other Ministries, issued an important
announcement about the strengthening of drug prevention work.
Newspapers such as the People¡¯s Daily, Fazhi Daily, and
China¡¯s Youth, set up special pages for drug
education[11,12]. Organizations such as the culture, health, civil administration,
youth, women and workers¡¯ unions all joined in this work.
Because most drug abusers are young people, the Ministry
of Education now requires students from the fifth grade of
primary school to the second grade of senior middle school
to attend classes on drug
prevention[6,12]. Intervention work has also begun in regions where the drug abuse and
HIV/AIDS problems are serious. Drug abusers are given help in
remaining drug free by their communities after being released
from detoxification settings. Programs such as the
China_UK HIV/STD Prevention Project are helping to carry out harm
reduction programs among drug abusers and sex workers in
Sichuan and Yunnan provinces[12]. More than 252 000 people
were sent to drug rehabilitation programs last year,
according to police statistics[8,9]. Chinese law stipulates that people
found using drugs must be detained for up to 15 days, and
that those found to be addicted to drugs be sent for
rehabilita-tion. Strict law enforcement and intensive public
awareness and prevention activities are indispensable in protecting
young people from drug abuse.
Drug addiction is characterized by high rates of relapse
and long-lasting vulnerability to drug-taking
behaviors[27_29]. Relapse can be induced by environmental cues, stress and
the drug itself [29_31]. The main challenge for addiction
treatment is the prevention of
relapse[32,33]. Many measures for the maintenance of drug-free states in addicts who abstain
from drug abuse have been instituted in China; however,
effective strategies are still
lacking[3,6]. Strong measures are necessary, but alone these are insufficient to control drug
abuse; changing public attitudes is also very
important[34,35]. Drug abusers are often deserted by their families and friends.
Even after ending their drug use, they are still rejected and
looked down upon by the community: a situation which
might lead to relapse. For drug abusers, psychological help
is necessary, especially support from relatives, friends and
colleagues. Therefore, the public must change its attitudes
towards drug abusers, and accept them and help them
instead of abandoning them[34,35]. In Hong Kong, some
institutes for drug abstinence have set up a psychological
treatment center to accelerate recovery; in addition, some
workshops have also been set up to provide recovering addicts
with employment[13,14]. In some areas, social workers offer
recovering drug abusers job training. This kind of help is of
great value to drug abusers.
In 2004, NNCC Director and Public Security Minister
Yong-kang Zhou stated that the situation was very serious,
and that there was much work to be done on narcotics
control in China[7,10]. According to Minister Zhou, the
government will intensify its struggle to stop drugs entering China,
especially in Southwest China¡¯s Yunnan Province and South
China¡¯s Guangxi Zhuang Autonomous Region, and step up
efforts to control chemicals used in the production of illegal
drugs, such as ephedrine. Moreover, new technologies such
as drug detectors will be given to police and intelligence
networks to assist in the fight against drug importation.
As for the dramatic increase in HIV/AIDS infections
among drug abusers, the government should implement a
program of action that would follow international "best
practice"[6,13,15]. First, the government should mount a multisector
response and employ social science methods and approaches
to the design and evaluation of anti-drug policies and
pro-grams. Second, legislation is needed to support clean
syringe exchange, methadone replacement and voluntary HIV
tests among the public and to protect the rights and privacy
of HIV-infected people. Third, a national HIV/AIDS and drug
abuse public education program should be delivered to
every Chinese citizen, especially those at highest risk. For
example, among young people (high school students,
unemployed young people, migrant workers, and teenagers and
those aged in their 20s in less developed areas) the drug
abuse situation is even worse. Fourth, HIV prevention
efforts for drug users and sex workers will also require
partnership with China¡¯s Public Security Bureau and police at all
levels, as will a major attitude change in the population.
Finally, health services and workers should be deployed to
mitigate the HIV epidemic, and the required drugs for HIV
treatment should be added to formularies and essential drug
lists and made available at reasonable prices.
In summary, drug abuse and HIV infection are increasing
in China at an alarming rate, and require strong, effective,
and immediate interventions.
Acknowledgements
We would like to thank Emily Wentzell (National
Institute on Drug Abuse, NIH, USA) and the NCI, CCR
Editorial Board of the National Institutes of Health for editorial
assistance.
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