วารสารสมาคมจิตแพทย์แห่งประเทศไทย
Journal of the Psychiatrist Association of Thailand
ISSN: 0125-6985
บรรณาธิการ มาโนช หล่อตระกูล
Editor: Manote Lotrakul, M.D.

วิชัย โปษยะจินดา, พ.บ.**
วิภา ด่านธำรงกุล, พบ.ม. (สถิติประยุกต์)**
อุษณีย์ พึ่งปาน, M.A.**

 บทคัดย่อ การเปลี่ยนแปลงการใช้สารเสพย์ติดประเภทเฮโรอีนและยากระตุ้นประสาทที่นำเสนอในบทความนี้จะใช้สารนิเทศ และข้อมูลจากการประชุมเจ้าหน้าที่อาวุโสด้านยาเสพติดแห่งอาเซียนและสถิติมหาภาคของกระทรวงสาธารณสุขในกลุ่มประชากรผู้เข้ารับการรักษาสารเสพย์ติดในสถานพยาบาลทั่วประเทศ สถิติการจับกุมฝิ่นและเฮโรอีนจากสามเหลี่ยมทองคำยืนยันว่าอุปทานยังคงที่ สถิติผู้เข้ารับการรักษาเฮโรอีนรายใหม่ในประเทศไทยมีแนวโน้มลดลง สัดส่วนของนักเรียนและคนว่างงานคงเป็นเช่นเดิม น่าสังเกตว่าจำนวนผู้เข้ารับการรักษาเฮโรอีนรายใหม่เพิ่มขึ้นเรื่อยๆ ในเขตการพัฒนาอุตสาหกรรมและการท่องเที่ยว ซึ่งเป็นสัญญาณเตือนถึงผลกระทบในเชิงลบของการพัฒนาเศรษฐกิจและสังคมของประเทศ การเปลี่ยนแปลงที่สำคัญอีกประการหนึ่งคือ การเพิ่มจำนวนโรงงานการผลิตสารกระตุ้นประสาทอย่างรวดเร็วในประเทศฟิลิปปินส์และไทย อุปทานที่ผิดกฎหมายนี้ไม่เพียงแต่สนับสนุนให้เกิดการขยายจำนวนผู้เสพสารเสพย์ติด แต่ยังทำให้เกิดการขยายอุปทานของสารนี้ในระดับโลกอย่างรวดเร็ว การใช้สารเสพย์ติดในกลุ่มสารกระตุ้นประสาทแอมเฟตามีนและยาอีเป็นที่แพร่หลายในกลุ่มประเทศอาเซียนและใน 2-3 ประเทศก็มีรายงานการใช้ยาแก้ไอในทางที่ผิด แม้ว่ายังไม่มีรายงานที่ชัดเจนถึงการใช้ยาประเภทออกฤทธิ์ต่อจิตประสาทในทางที่ผิด แต่ดูเหมือนจะเป็นอีกภาพหนึ่งซึ่งต้องการความสนใจและการเข้าไปแทรกแซงที่ถูกต้อง

วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2541; 43(2):

คำสำคัญ เฮโรอีน, แอมเฟตามีน, อาเซียน

 * บทความในการประชุม The International Seminar on Drug Addiction Organized by the University Libre de Bruxelles as part of the scientific cooperation with Universities of the Mekong Region with the support of the Belgian Federal Agency of Cooperation to the Development, 10-20 มีนาคม 2541 . กรุงเทพฯ.

** ศูนย์วิจัยยาเสพติด สถาบันวิจัยวิทยาศาสตร์การแพทย์ จุฬาลงกรณ์มหาวิทยาลัย กรุงเทพ 10 330

 The Major Changes in The 1990s Substance Abuse Scenario in Asean Countries*

Vichai Poshyachinda, M.D.**
Vipa Danthamrongkul. M.S.**
Usaneya Perngparn, M.A.**

 Abstract

 Information and data from Meetings of Asean Senior Officials on Drug Matters and the macro statistics of the drug dependence treatment population database of the Ministry of Public Health, Thailand in the 1990s were used to illustrate the major changes of opiate and stimulant abuse scenarios. Statistics of confiscated opium and heroin from the Golden Triangle indicated that the supply most likely remained stable. While statistics of new heroin user treatment cases in Thailand declined, the proportion of students and the unemployed persisted. A gradual increased density of new heroin user treatment cases in industrialized and tourism development zones was observed. The pattern provided a warning of the negative impact from socio-economic strategies. The critical changes which will most likely generate the greatest deleterious impact to the region is the rapid growth of clandestine stimulant production observed mainly in the Philippines and Thailand. The illicit supply not only fostered dramatic expansion of the user population in the country of production but also contributed substantially to the rapid increase in global supply. Consumption of illcit methamphetamine and the Ecstacy group of stimulant increased in practically all countries in the Asean region. Illicit diversion of cough mixture seemed substantial with corresponding evidence of an increased abuser population in some countries. Even though the abuse of medicinal psychotropic drugs do not yet warrant any alarm, they seem to be another persistent scenario which requires attention and appropriate intervention.

J Psychiatr Assoc Thailand 1998; 43(2):

Key word : Heroin, Amphetamine, Demand, Supply, Asean

 * Prepared for the opening session of the International Seminar on Drug addiction Organized by the Universite Libre de Bruxelles as part of the scientific cooperation with Universities of the Mekong Region with the support of the Belgian Federal Agency of Cooperation to the Development, 10^th-20^th March 1998, Bangkok, Thailand.

** Drug Dependence Research Center, Institute of Health Research, Chulalongkorn University, Institute II Building, Chula Soi 62, Phyathai road, Bangkok 10330.

 The Southeast Asia region is quite unique in its historical experience on substance abuse. Opium was extensively abused in the distant past. At the end of the 19th century, opium trade was franchised leading to evermore wide spread use and abuse (1). By the middle of the 20th century, the Golden Triangle area became infamously known as the major seat of opium and heroin production supplying the escalated global demand especially from western countries. The first heroin epidemic also occurred in many countries in the region during the same period (2,3).

In the 1990s, substance abuse in Southeast Asia changes dramatically in both supply and demand aspects. This communication presents selected scenarios of the major change in opiates, stimulants and medicinal drugs abuse. The discussions are made mainly under considerations for future interventions. The materials do not comprehensively cover the overall status of substance abuse in Southeast Asia. Certain changes not included may very well be of equal if not of greater importance for the future. A significant proportion of the materials are extracts from the annual report of the Meeting of ASEAN Senior Officials on Drug Matters and the databases of the Office of Narcotics Control Board, Office of the Prime Minister (ONCB), the Department of Medical Services, Ministry of Public Health (DMS/MPH) and the Drug Dependence Research C4enter, Institute of Health Research, Chulalongkorn University (DDRC/CU).

 A. THE OPIATES

 In 1989, the Government of Myanmar could successfully solicit peace accord from many groups of insurgent in the Shan State and liberated the area that has been the seat of opiates production from their control. The break through became even more meaningful when finally in 1996, Khun Sa, the key controller of the illicit production and traffic, and his followers unconditionally surrendered to the central government (4). This major change opens for the first time the full opportunity to control the opiates supply from the Golden Triangle area and also raises an expectation on significant reduction of the global illicit opiate supply. However, the official reports from ASEAN countries on opiate seizures so far did not yet corroborate with the expectation. Between 1990 and 1996, the annual amount of opium seized by the Myanmar law enforcement remains at the same level, ranging from about 1 to 2.5 tons. Moreover, the amount of confiscated opium during the first 6 months of 1997 reached an all time high of 5.39 tons of opium and 480.99 kg. of heroin (Table 1). 75% of the seizures reported by Myanmar were made in the Shan State. The Myanmar government also remarked that these opiates were mostly meant for domestic market. Between 1991 and the first half of 1997, 45 refineries were seized in Myanmar. Twelve of which were seized in the first half of 1997 (4). While an additional 5 were destroyed in Thailand by local law enforcement (5)

 Table 1 Opium and heroin seizures in ASEAN countries between 1987 and 1996.

______________________________________________________________________________

 Substance/ Amount of drug seized (kg)

_______________________________________________________

Country 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

______________________________________________________________________________

 Opium

Malaysia 217.4 237.0 736.6 658.0 85.6 270.6 349.5 69.1 155.9 2.6

Singapore 452.1 70.8 139.7 43.8 61.2 150.3 7.4 n.r n.r n.r

Thailand 1141.1 1906.2 174.6 813.7 1493.9 1297.3 2149.0 609.3 928.2 619.1

Myanmar - 1510.0 920.0 2300.0 1500.0 2260.0 2490.01760.0 1060.0 1300.0

 Heroin

Malaysia 40.2 307.9 297.8 189.1 263.9 112.8 263.4 212.4 119.6 240.7

Singapore 10.4 52.4 45.9 35.5 56.8 60.5 71.7 67.8 50.2 121.3

Philippines 4.0 1.0 0.8 29.4 15.6 35.0 17.4 23.0 - n.r.

Thailand 1233.0 2081.7 744.4 1159.3 1685.9 1052.3 2416.9 1321.1 697.2 395.2

Myanmar - 119.0 219.7 220.1 186.2 388.2 358.3 304.8 72.6 504.6

______________________________________________________________________________

n.r. = No quantity reported

Source :Country reports of the ASEAN Annual Meeting of Senior Officials on Drug Matters.

 These statistics indicated that the close circuit of demand and supply within Myanmar is still of phenomenal amount. Such situation will most likely exert a strong local motivation for the production in addition to the already enormous incentive from lucrative global demand. The supply from the Golden Triangle area is probably not going to decrease any time soon. More significantly, the situation pose a serious question on the mechanism that run this enormous illicit trade if the insurgent groups are in collaboration with the officials in developing the area in order to reduce the opiate production. The remarkable increase seizure amount in 1997 could be an indication of improvement if they are the direct result of improved law enforcement control of the area due to the elimination of insurgency. In this case, we could remain optimistic that the reduction of opiate supply from the Golden Triangle can still be realized although at another distant future.

 The first heroin epidemic in Thailand started in 1960 (2,3). Since then, heroin dependence had grown into a wide spread unabated endemic problem. Through the 1990s, indications from statistics on the total drug dependence treatment population revealed no substantive trend of decrease population size until the last two years. The total heroin treatment population reported from about 200 drug dependence treatment units distributed over the whole country showed gradual increase from 58,327 cases in 1990 to 101,145 cases in 1995, then dramatically drop to 81,050 and 62,215 cases in 1996 and 1997 respectively (6). Furthermore, the percentages of new cases of heroin users which varied between about 65-85% between 1981 and 1995 also rapidly decreased to 40⁺% in 1997 (Figure 1). However, the percentages of student and the unemployed among these new case of treatment population stratified by age groups remained stable through the 1990s (Figure 2). This fairly encouraging trend of decrease new case percentages is offset by the long standing statistics that demonstrated concentration and rapid increase new cases in provincial areas that had intensive social and economic development through either industrialization or tourism in comparison to adjacent provinces that carried regular development programme, Figure 3 and 4 respectively (7).

 Figure 1 Percentage of new case classified by type of principle drug used during the last 30 days

  Figure 2 Percentage of student and the unemployed among new case heroin users classified by age group.

  Figure 3 Number of new heroin user treatment population per 100,000 in provinces with and without industrial development

 A. Province with industrial development. B. Adjacent province without industrial development.

  Figure 4 Number of new heroin user treatment population per 100,000 in provinces with and without tourism development.

 A. Province with tourism development B. Adjacent province without tourism development

  Accelerated industrial and tourism development often lead to population migration from rural to urban area and the inevitable changes in family relationship and social environment. Increase economic gain open up opportunities for improvement of quality of life as well as opportunities for experimentation with the hedonistic pleasure temptingly accessible in urban area. Substance abuse could drain most benefit from development unnoticed if attention is preoccupied over individual reasons for abuse while the broader and significant influence from social and economic environment are overlooked.

 B. THE STIMULANTS

 In the 1990s stimulant abuse emerged in many ASEAN countries. This major change in pattern of substance abuse can perhaps be considered as the first stimulant epidemic of the region. The Philippines is probably the first ASEAN country that faced severe stimulant abuse. The abuse of methamphetamine was noted in 1986 among the affluents, entertainment and artist population. The status of methamphetamine or "shabu" abuse at that time seemed well confined. However in 1987, the abuse spreaded to the general population. The large users population superseded the cannabis and multiple drug users population which had dominate the substance abuse scene through out the past (8). Clandestine production of methamphetamine was also discovered in 1989 with evidence of relationship with foreign national. The description of one clandestine laboratory stated that

The report certainly implied that the local production had some collaborative input from outside the country. At present, the situation of methamphetamine supply in the Philippines seems to gain additional dimension. Government reports indicated that supply came from both local manufacturing and importation. The illicit trade had grown into a multinational network with transhipment to other country as evident from the following official statement.

The large production of illicit methamphetmine was also reported from Loa People Democratic Republic (11) and Myanmar (4) in 1997 as follows.

Illicit stimulant tablet had been confiscated in Thailand since the early 1960s. The rapid increase number of amphetamine indictment in the early 1970s indicated of rapid increase demand then. In 1979 follow immediately after a major seizure of large quantity of illicit stimulant of nearly 300 kg. look alike tablet containing ephedrine or combination of ephedrine with caffeine and finally methamphetamine in combination with ephedrine and caffeine were discovered in the illicit drug market. Since then, the illicit stimulant tablet in Thailand remains as products from multiple recipes of combination between few common active ingredients, methamphetamine, ephedrine and caffeine (12). The supply of the amphetamines in Thailand was believed to be of foreign source until 1986 when the first clandestine laboratory producing methamphetamine was found in the suburb of Bangkok (7). Report from the Philippines and Thailand on law enforcement seizures through the 1990s demonstrated the persistent large supply of methamphetamine (Table 2). The massive manufacturing of methamphetamine in Thailand is reflected in the number of methamphetamine refineries destroyed in the 1996 and the first half of 1997, 13 and 14 laboratories respectively (5).

 Table 2 Methylamphetamine seized in the Philippines and Thailand between 1987-1996.

______________________________________________________________________________

 Substance/ Amount of methylamethylamphetamine seized (kg.)

____________________________________________________________

country 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

______________________________________________________________________________

 Philippines n.r. 9.5 73.2 51.6 150.3 129.5 160.7 114.6 230.4 989.1

Thailand 511.4 42.7 54.5 75.9 508.0 64.9 626.0 444.0 538.2 757.2

______________________________________________________________________________

 n.r. = No quantity reported

Source :Country reports of the ASEAN Annual Meeting of Senior Officials on Drug Matters.

 The information and statistics reported from ASEAN countries in 1990s leave no doubt that illicit methamphetamine manufacturing has became fairly wide spread. The Golden Triangle area production instead of decreasing is actually expanding from the opiates to include large supply of methamphetamine in a very short time. The involvement of multinational network extending over the whole far east in the illicit trade is equally evident. Such a rapid development strongly indicates that a significant proportion of the supply of illicit methamphetamine is most likely fostered by the age old infrastructure of the opiate supply network. Addition of new groups of operators is also inevitable.

 Although there was no direct evidence on the size of stimulant abuse population the implication from the confiscated quantities again leave little doubt that the number is most likely quite large especially in the Philippines and Thailand. There are however, many indirect indicators of the recent change of situation among many countries in ASEAN region. The official reports of Brunei Darussalam (13), Indonesia (14) the Philippines (10), Singapore (15) and Thailand (5) referred to the increasing trend of illicit stimulant abuse as demonstrated in the following extracts.

In Thailand the rapid expansion of methamphetamine user population was revealed by the increase number of new case of stimulant users among the total treatment population. The trend of increase started in 1991 and became very rapid from 1994 onward (Figure 5). Student constituted 41.4 and 42.8% of the new stimulant users in 1996 and 1997 respectively. Over 75% of student case were between 15 and 19 years old (16). However, the increase did not accurately reflect amphetamine dependence among student. Students suspected of amphetamine use were often sent to the treatment units for dependency diagnosis. They were frequently added to the dependent case by mistake. Hence, the statistics demonstrated inclusively cases of ever use, occasional use and dependence. The common reasons for stimulant use were for recreation and enhancing work performance such as night work and hard labour.

 Figure 5 Percentage of amphetamine use daily during the last 30 days before admission : 1980-1996.

Eventhough the manufacturing of illicit stimulant in the ASEAN countries evidently confined to methamphetamine, the abuse of illicit stimulant included other stimulant such as the ecstacy group of amphetamine derivatives and cocaine as well. It is clear that the abuse of stimulant was fostered simultaneously by intra and extra regional supply. There seems to be differences in the proportion of demographics and pattern and reasons of use between the "old" opiate and "new" stimulant user population. In fact, the situation indicates the grave danger from expansion of substance abuse into a broader demographics and diverse illicit substances availability. Population at risk on using these two groups of substances are not completely overlapped. The extent to which they do not overlap is actually the extent of the future threat for the expansion of future substance abuse population.

C. THE MEDICINAL DRUGS

The abuse of tranquilizers in the benzodiazepines group by the opiate dependents is well known and very common. In the 1990s law enforcement seizures of the tranquilizers appeared from all ASEAN countries. However, persistent yearly seizure were reported from Brunei Darussalam, Malaysia and Thailand. Malaysia reported large quantities of psychotropic pill, 709,865 tablets, in 1996. Cough mixture had been commonly abused in combination with cannabis in the Philippines for many years. Yearly or almost seizures of illicit diversion were reported from Brunei Darussalam, Myanmar, Philippines and Singapore. The largest quantitites of illicit traffic on cough mixture were actually reported from Myanmar. Between 1988 and 1996 the annual confiscated amount varied between 1,789.9 to 10,253.1 litres (Figure 6)(4). Corroborative illicit export of cough mixture from the southern region of Thailand to Myanmar was reported by the Food and Drug Agency of the Ministry of Public Health.

 Figure 6 Phensedyl seizures in Myanmar between 1988 and 1997. (Jan. - Jun.)

 The abuse of medicinal drug and illicit diversion had apparently been observed in ASEAN countries for quite a time. There as yet is no clear evidence of real awareness that the situation constitute a part of the national substance abuse problem. The situation can hardly be overlook since they pose a different threat from the cycle of supply and demand that involved different target groups from those related with the narcotics. Abuse and illicit diversion of essential drugs required quite different interventions from the illicit substance and certainly not more simple to resolve. They may in fact be even more difficult to define and intervene.

 D. THE POINTS OF CONCERN

The selected facets of changes in the substance abuse situation so far presented are probably adequate to express deep concern over the rapidity which these major changes had evolved. The tip of the ice berg is frequently compared with the knowledge on the current situation. Is this the question of learning too late? In consideration is the insensitive monitoring of the situation in nature, extent and timeliness. The complex nature and extent of substance abuse need good monitoring system which required technical expertise as well as effective and sustainable operation. The challenge on monitoring is the that no one really know the depth or the size and shape of the iceberg underneath the surface. Yet how can the problem be solve if the situation remains obscure

 The fragmentary knowledge on substance abuse situation and the rapid change pose unique problem on intervention. The need for flexible policy, strong commitment of government and intervention implementor, effective coordination and collaboration and appropriate intervention measures had often been identified as key elements for successful control. However, real evidence on actual effective operation of these elements are rarely available on hand anywhere. In consideration is the availability of ready made and reliable solution much sought after by all party concern. If there is no solution in this respect what can we learn from past experience and proven knowledge. Keeping in mind that past achievement and success are clearly inadequate to keep substance abuse under control not having to consider irradication.

 CONCLUSION

 The growing problem, the inadequate interventions and the sense of inevitable defeat because of the complexity of the roots of the problems and the phenomenal efforts required to intervene are probably repetitive rhetorics heard in substance abuse discussion. They deserve reiteration under more critical appraisal and strong action programme that is effective and sustainable.

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16 Anonymous. Statistical Report FY 1997, Drug Dependence Information System Treatment Population, Department of Medical Services, Ministry of Public Health and the Institute of Health Research, Chulalongkorn University ISSN 0125-8761 TT. (in press)