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Survey of Substance Abuse in Iraq
Background and Objectives
The Iraq National Household Survey on Alcohol and Drug Use (INHSAD) provides previously unavailable population-based information collected from 18 governorates in Iraq and from several selected subgroups. The overall objective for the INHSAD was to understand the extent of tobacco, alcohol and drug use in Iraq. There were four specific aims: (1) to compile data on self-reported prevalence of tobacco and alcohol use, and licit and illicit drug misuse; (2) to identify trends and patterns of substance use in the Iraqi population; (3) to identify specific factors that may be associated with substance use; and (4) to identify reasons for use, substance availability and consequences of use.
Survey Team and Method
The survey project was a cooperative project, funded by DOS/INL, and implemented by a U.S.- based international health organization (CHS) in partnership with a U.S. university (UCLA) and an Iraqi team with leaders from Iraqi universities (Universities of Baghdad and Kerbala), an Iraqi professional society (IRSAM), and the Iraqi Ministry of Health. A team of Iraqi surveyors were trained to administer the survey and collect saliva samples for drug analysis. Another Iraqi data management team compiled the data in Kerbala and sent it to the UCLA data center for processing and analysis. The UCLA team conducted the data analysis and prepared the report draft.
The participant sample for the household survey consisted of one individual from 3200 randomly selected households; a minimum of 100 households to be selected from each of the 18 governorates and more households were added in approximate proportion to the governorate population, for a total of 3200 individuals/households. In the analysis of substance use rates, an adjustment by gender for substance use prevalence were computed and applied to provide an estimate for the Iraq adult population, since the sample was 72% male/28% female and the general population is approximately 50% male/female.
In addition, 464 individuals (14.5%) were randomly selected to provide a saliva sample for analysis for 5 illicit drugs. 395 saliva tests (12.3%) were completed and valid for analysis. An additional 100 participants from 3 selected subgroups completed the survey, of which 58 were randomly selected to provide a saliva sample. 52 saliva tests (17.3%) were completed and valid for analysis. The project was conducted in the midst of extreme violence and political, social, and military turmoil and chaos of Iraq in 2014. The accomplishment of the survey under these very challenging circumstances is an extraordinary accomplishment by the Iraqi team.
Overall self-reported "lifetime" (any use during lifetime) tobacco use was 29.0% and "current" (past 12 months) use was 23.4% in the household survey sample. Self-reported "lifetime" and "current" alcohol use was 8.6% and 3.4%, respectively. Alcohol and tobacco use differed significantly across regions, population groups, and genders. "Lifetime" and "current" licit drug misuse (cough syrup, tramadol, Somadril, benzodiazepines, benzhexol, anabolic steroids, other pills) was reported at 2.5% and 1.2%, respectively. The most misused licit drugs were steroids and benzodiazepines in the household survey sample. "Lifetime" and "current" illicit drug use (cannabis, Captagon/amphetamine-type stimulants (ATS), opium/heroin, and inhalants) were reported at 0.4% and 0.2%, respectively. Summaries of self-reported total "lifetime" and "current" substance use (adjusted for gender) in totals in the household survey sample are: Lifetime Use of Any Substance (Alcohol, Licit or Illicit Drugs) 10.3%, Current Use of Any Substance 4.1%, Lifetime Use of Any Drug (Licit or Illicit) 2.7%, Current Use of Any Drug 1.3%, * Estimates presented here are adjusted for unequal gender distribution.
Of the 3200 participants in the household survey, only one individual reported a history of drug injection; 7 of 395 (1.8%) of the randomly selected participants who provided a saliva test had a positive result for any drug use. Approximately 19.5% of the participants in the household survey reported that they knew someone who misused licit drugs and 11.0% knew someone who used illicit substances. The rates of knowing someone was very low in the governorates in the middle and Baghdad regions and much higher in the Southern region, where more than a third of the region reported knowing others who used licit or illicit drugs. Responses to "reasons for drug and alcohol use" suggested that the most widely cited reasons were for coping with the negative conditions and negative emotional status associated with life in 21st century Iraq.
Three subpopulations were selected for closer examination. The groups included internally displaced persons (IDPs), Hawasim, and individuals recently released from prison (another group from the military was planned, but was cancelled due to security issues). One hundred individuals were surveyed from each subpopulation. Results from these analyses indicated that rates for IDPs were comparable with the household survey sample. "Lifetime" and current tobacco use was reported at higher rates for the Hawasim group, as compared to the household survey. "Lifetime" use rates of tobacco, alcohol, and drugs among the group recently released from prison (who were all males) were higher than that of males from the household survey sample.
In focus groups with the surveyors it was estimated that 3-20% of participants may not have accurately reported their drug use. Focus groups with military and police personnel reported that they saw alcohol as a problem in the police and military and that drug use was increasing in these groups.
The successful completion of this survey under the violent and politically contentious circumstances of 2014 Iraq was a very impressive accomplishment. The survey design, plan, and oversight, along with the data management plan for the survey data were appropriate and successfully carried out. There was minimal missing data, and the refusal rate was not excessive. Results of this survey indicate that tobacco use is a significant public health problem in Iraq. Current alcohol use is reported in 6.7% of males, and the average number of drinks on a day of drinking was reported at 6 drinks per day. Drug use is reported at low levels, and saliva test results generally support this finding. However, the self-report data in this survey likely suffers from under-reporting concerning the licit and illicit drug categories, particularly in highly religious areas and in areas with serious security problems. The fact that the vast majority of saliva tests were negative for illicit drugs supports the perception from the self-reports that the use of illicit drugs in Iraq is much lower than in other countries in the region, such as Iran and Afghanistan. However, since the saliva tests do not test for alcohol or licit drugs, the self-reported low rates of alcohol use and licit drug misuse was not assessed with a biological measure.
Conclusions and Recommendations
The information collected in the first Iraq National Household Survey of Alcohol and Drug Use (INHSAD) suggests that the drug problem in Iraq is still in a gestational phase. With the conditions of economic distress, social chaos, violence, and generally stressful environment, as well as escalating drug trafficking and availability (reported in the 2012 and 2014 CEWG meetings); it is highly probable that Iraq is at very high risk for the emergence of a substantial societal problem with licit and illicit drugs. A set of recommendations are given in areas of policy development, future alcohol and drug monitoring activities, capacity-building and practice development.