In 2010, opioid use and dependence made the largest contribution to morbidity and mortality from illicit drug use, contributing to premature death from drug overdose and suicide, and in those who inject these drugs, infection with HIV and other blood-borne viruses. Dependence also produced considerable disability.1 Afghanistan has a tradition of opium smoking, and has long been a major source of illegal opiates for eastern and western Europe. In the past decade, Afghans have also reportedly begun to inject heroin and use pharmaceutical opioids

Degenhardt, Louisa

Hall, Wayne D.

The Lancet Global Health

Hall, Wayne D

Elsevier - Publisher Connector 

Afghanistan has a sizeable problem with opioid use 

Wayne D Hall

Louisa Degenhardt

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Afghanistan has a sizeable problem with opioid use

Comment
www.thelancet.com/lancetgh   Vol 2   October 2014 e557
Afghanistan has a sizeable problem with opioid use 
In 2010, opioid use and dependence made the largest 
contribution to morbidity and mortality from illicit 
drug use,1 contributing to premature death from drug 
overdose and suicide, and in those who inject these 
drugs, infection with HIV and other blood-borne viruses. 
Dependence also produced considerable disability.1 
Afghanistan has a tradition of opium smoking, and has 
long been a major source of illegal opiates for eastern 
and western Europe.2,3 In the past decade, Afghans 
have also reportedly begun to inject heroin and use 
pharmaceutical opioids.4 These developments have been 
attributed to increased heroin availability, civil disruption 
from insurgency, and the crowding of displaced Afghans 
into urban areas where heroin and pharmaceutical 
opioids are readily available.5 
There are major challenges in the estimation of the 
prevalence of opioid use in Afghanistan. The country has 
been in a state of war and insurgency for the better part of 
40 years; its population is widely dispersed and often very 
mobile; it has low levels of literacy; and Afghans are not 
accustomed to answering questions about a prohibited 
behaviour that are posed by a stranger in a survey 
interview. In The Lancet Global Health, Linda B Cottler 
and colleagues6 used innovative methods to estimate 
the prevalence of recent use of drugs (including opioids, 
pharmaceutical drugs, and cannabis) in the Afghan 
population. As part of the Afghanistan National Urban 
Drug Use Study (ANUDUS), they interviewed the female 
heads of 2187 Afghan households about the drug use 
of all household members. The sample came largely 
from urban areas in more accessible and less dangerous 
provinces. Biological samples (hair, saliva, and urine) 
were obtained from three speciﬁ ed members of the 
household (oldest man, female head of the household, 
and youngest child aged 4–14 years) to validate the head 
of household reports of drug use (or its absence). 
Afghan interviewers were trained to do interviews that 
had been pretested to ensure cultural acceptability. They 
achieved an overall survey response rate (81·5%) that 
was much higher than surveys in countries such as the 
USA. Importantly, the biological data showed reasonable 
corroboration of the reported drug use. There was, 
however, under-reporting of use by women compared 
with the biological data, and men were less likely than 
women to provide biological samples.
Cottler and colleagues6 estimated that, after direct age 
standardisation, 5·1% of the Afghan population (7·2% 
of men and 3·1% of women) either reported use or had 
biological evidence of recent use of drugs such as opium, 
heroin, pharmaceutical opioids, and cannabis. Opioids 
were the drug most often detected in the biological 
samples (5·6%)—2·5% for opium, 2·0% for codeine, and 
1·2% for heroin. Prescription drugs (eg, benzodiazepines 
and opioids) were the drugs most commonly reported in 
the past 30 days by heads of households (7·6%). In those 
who tested positive to drugs, there was more opioid and 
pharmaceutical drug use in women and more cannabis 
use in men. The prevalence of drug use was probably 
underestimated in men because a lower proportion of 
men compared with women gave biological samples. 
Notwithstanding these limitations, the survey 
conﬁ rms earlier key informant reports3 of very high rates 
of the recent use of heroin and other pharmaceutical 
drugs in people who live in Afghanistan. It is diﬃ  cult 
to assess time trends because of the diﬀ erences in 
methods between ANUDUS and earlier surveys,3,7 but 
the female heads of households reported that opiate 
and pharmaceutical drug use had increased, and that 
this had occurred in women and men. 
Participants were asked about lifetime drug use, but 
the biological tests measured only recent drug use; 
problem use is probably high in recent users of opiates 
and pharmaceutical drugs, especially those who injected 
heroin. Therefore, the survey results are consistent with 
key informant surveys in Afghanistan that reported 
substantial numbers of problem users of opiates and 
heroin and that this drug use was adversely aﬀ ecting 
drug users’ families and Afghan society.3,4
Opioid use and dependence clearly constitute a major 
additional problem for a country damaged by war and 
that has little health and social infrastructure to prevent 
drug use or to treat drug dependence. Unsafe heroin 
injecting and dependent use of opioids need to be 
urgently addressed by proven eﬀ ective interventions 
such as opioid substitution therapy to treat dependence 
and prevent overdose deaths;8 needle and syringe 
programmes to prevent HIV, hepatitis C, and other 
blood-borne viruses;9 and eﬀ ective treatment of HIV and 
hepatitis C to reduce the infection burden and decrease 
future infections.10 The eﬃ  cient delivery of these 
See Articles page e592 
Comment
e558 www.thelancet.com/lancetgh   Vol 2   October 2014
interventions urgently needs additional international 
resources and well coordinated implementation of 
programmes by the Afghan government and civil 
society, with the assistance and support of international 
organisations and non-governmental organisations.5
*Wayne D Hall, Louisa Degenhardt
Centre for Youth Substance Abuse, University of Queensland, 
Brisbane, QLD, Australia (WDH); National Addiction Centre, King’s 
College London, London, UK (WDH); National Drug and Alcohol 
Research Centre, University of New South Wales, Sydney, NSW, 
Australia (LD); School of Population and Global Health, University 
of Melbourne, Melbourne, VIC, Australia (LD); Department of 
Global Health, School of Public Health, University of Washington, 
Seattle, WA, USA (LD); and Centre for Adolescent Health, 
Murdoch Children’s Research Institute, Melbourne, VIC, Australia
w.hall@uq.edu.au
LD is supported by an Australian National Health and Medical Research Council 
(NHMRC) Principal Research Fellowship (number 1041742). The National Drug 
and Alcohol Research Centre at the University of New South Wales is supported 
by funding from the Australian Government under the Substance Misuse 
Prevention and Service Improvements Grants Fund. WDH is supported by the 
University of Queensland.
Copyright © Hall et al. Open access article published under the terms of CC BY-NC-SA
1 Degenhardt L, Charlson F, Mathers B, et al. The global epidemiology and 
burden of opioid dependence: results from the Global Burden of Disease 
2010 study. Addiction 2014; 109: 1320–33.
2 INCB. Report of the International Narcotics Control Board for 2013. 
New York: United Nations, 2014. http://www.incb.org/documents/
Publications/AnnualReports/AR2013/English/AR_2013_E.pdf (accessed 
Aug 14, 2014).
3 UNODC. Drug use in Afghanistan: 2009 survey. Vienna: UN Oﬃ  ce on Drugs 
and Crime, 2009. https://www.unodc.org/documents/data-and-analysis/
Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdf 
(accessed July 17, 2014).
4 Afghanistan Ministry of Counter Narcotics. Afghanistan Drug Report, 2012. 
Published with technical support of the United Nations Oﬃ  ce for Drugs 
and Crime. Kabul: Afghan Ministry of Counter Narcotics, 2013. http://mcn.
gov.af/Content/ﬁ les/13_11_07__English%20Afghanistan%20Drug%20
Report%202012%281%29.pdf (accessed Aug 14, 2014).
5 Todd CS, Macdonald D, Khoshnood K, Mansoor GF, Eggerman M, 
Panter-Brick C. Opiate use, treatment, and harm reduction in Afghanistan: 
recent changes and future directions. Int J Drug Policy 2012; 23: 341–45.
6 Cottler LB, Ajinkya S, Goldberger BA, Ghani MA, Martin DM, Gold MS. 
Prevalence of drug and alcohol use in urban Afghanistan: epidemiological 
data from the Afghanistan National Urban Drug Use Study (ANUDUS). 
Lancet Glob Health 2014; 2: e592–600.
7 UNODC. Afghanistan drug use survey 2005. Vienna: United Nations Oﬃ  ce 
on Drugs and Crime, 2005. http://www.unodc.org/pdf/afg/2005Afghanist
anDrugUseSurvey.pdf (accessed July 17, 2014).
8 Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance 
versus placebo or methadone maintenance for opioid dependence. 
Cochrane Database Syst Rev 2014: CD002207.
9 Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. 
Evidence for the eﬀ ectiveness of sterile injecting equipment provision in 
preventing hepatitis C and human immunodeﬁ ciency virus transmission 
among injecting drug users: a review of reviews. Addiction 2010; 
105: 844–59.
10 Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. 
Prevention of HIV infection for people who inject drugs: why individual, 
structural, and combination approaches are needed. Lancet 2010; 
376: 28–301.


University of Queensland eSpace

Comment
www.thelancet.com/lancetgh   Vol 2   October 2014 e557
Afghanistan has a sizeable problem with opioid use 
In 2010, opioid use and dependence made the largest 
contribution to morbidity and mortality from illicit 
drug use,1 contributing to premature death from drug 
overdose and suicide, and in those who inject these 
drugs, infection with HIV and other blood-borne viruses. 
Dependence also produced considerable disability.1 
Afghanistan has a tradition of opium smoking, and has 
long been a major source of illegal opiates for eastern 
and western Europe.2,3 In the past decade, Afghans 
have also reportedly begun to inject heroin and use 
pharmaceutical opioids.4 These developments have been 
attributed to increased heroin availability, civil disruption 
from insurgency, and the crowding of displaced Afghans 
into urban areas where heroin and pharmaceutical 
opioids are readily available.5 
There are major challenges in the estimation of the 
prevalence of opioid use in Afghanistan. The country has 
been in a state of war and insurgency for the better part of 
40 years; its population is widely dispersed and often very 
mobile; it has low levels of literacy; and Afghans are not 
accustomed to answering questions about a prohibited 
behaviour that are posed by a stranger in a survey 
interview. In The Lancet Global Health, Linda B Cottler 
and colleagues6 used innovative methods to estimate 
the prevalence of recent use of drugs (including opioids, 
pharmaceutical drugs, and cannabis) in the Afghan 
population. As part of the Afghanistan National Urban 
Drug Use Study (ANUDUS), they interviewed the female 
heads of 2187 Afghan households about the drug use 
of all household members. The sample came largely 
from urban areas in more accessible and less dangerous 
provinces. Biological samples (hair, saliva, and urine) 
were obtained from three specifi ed members of the 
household (oldest man, female head of the household, 
and youngest child aged 4–14 years) to validate the head 
of household reports of drug use (or its absence). 
Afghan interviewers were trained to do interviews that 
had been pretested to ensure cultural acceptability. They 
achieved an overall survey response rate (81·5%) that 
was much higher than surveys in countries such as the 
USA. Importantly, the biological data showed reasonable 
corroboration of the reported drug use. There was, 
however, under-reporting of use by women compared 
with the biological data, and men were less likely than 
women to provide biological samples.
Cottler and colleagues6 estimated that, after direct age 
standardisation, 5·1% of the Afghan population (7·2% 
of men and 3·1% of women) either reported use or had 
biological evidence of recent use of drugs such as opium, 
heroin, pharmaceutical opioids, and cannabis. Opioids 
were the drug most often detected in the biological 
samples (5·6%)—2·5% for opium, 2·0% for codeine, and 
1·2% for heroin. Prescription drugs (eg, benzodiazepines 
and opioids) were the drugs most commonly reported in 
the past 30 days by heads of households (7·6%). In those 
who tested positive to drugs, there was more opioid and 
pharmaceutical drug use in women and more cannabis 
use in men. The prevalence of drug use was probably 
underestimated in men because a lower proportion of 
men compared with women gave biological samples. 
Notwithstanding these limitations, the survey 
confi rms earlier key informant reports3 of very high rates 
of the recent use of heroin and other pharmaceutical 
drugs in people who live in Afghanistan. It is diffi  cult 
to assess time trends because of the diff erences in 
methods between ANUDUS and earlier surveys,3,7 but 
the female heads of households reported that opiate 
and pharmaceutical drug use had increased, and that 
this had occurred in women and men. 
Participants were asked about lifetime drug use, but 
the biological tests measured only recent drug use; 
problem use is probably high in recent users of opiates 
and pharmaceutical drugs, especially those who injected 
heroin. Therefore, the survey results are consistent with 
key informant surveys in Afghanistan that reported 
substantial numbers of problem users of opiates and 
heroin and that this drug use was adversely aff ecting 
drug users’ families and Afghan society.3,4
Opioid use and dependence clearly constitute a major 
additional problem for a country damaged by war and 
that has little health and social infrastructure to prevent 
drug use or to treat drug dependence. Unsafe heroin 
injecting and dependent use of opioids need to be 
urgently addressed by proven eff ective interventions 
such as opioid substitution therapy to treat dependence 
and prevent overdose deaths;8 needle and syringe 
programmes to prevent HIV, hepatitis C, and other 
blood-borne viruses;9 and eff ective treatment of HIV and 
hepatitis C to reduce the infection burden and decrease 
future infections.10 The effi  cient delivery of these 
See Articles page e592 
Comment
e558 www.thelancet.com/lancetgh   Vol 2   October 2014
interventions urgently needs additional international 
resources and well coordinated implementation of 
programmes by the Afghan government and civil 
society, with the assistance and support of international 
organisations and non-governmental organisations.5
*Wayne D Hall, Louisa Degenhardt
Centre for Youth Substance Abuse, University of Queensland, 
Brisbane, QLD, Australia (WDH); National Addiction Centre, King’s 
College London, London, UK (WDH); National Drug and Alcohol 
Research Centre, University of New South Wales, Sydney, NSW, 
Australia (LD); School of Population and Global Health, University 
of Melbourne, Melbourne, VIC, Australia (LD); Department of 
Global Health, School of Public Health, University of Washington, 
Seattle, WA, USA (LD); and Centre for Adolescent Health, 
Murdoch Children’s Research Institute, Melbourne, VIC, Australia
w.hall@uq.edu.au
LD is supported by an Australian National Health and Medical Research Council 
(NHMRC) Principal Research Fellowship (number 1041742). The National Drug 
and Alcohol Research Centre at the University of New South Wales is supported 
by funding from the Australian Government under the Substance Misuse 
Prevention and Service Improvements Grants Fund. WDH is supported by the 
University of Queensland.
Copyright © Hall et al. Open access article published under the terms of CC BY-NC-SA
1 Degenhardt L, Charlson F, Mathers B, et al. The global epidemiology and 
burden of opioid dependence: results from the Global Burden of Disease 
2010 study. Addiction 2014; 109: 1320–33.
2 INCB. Report of the International Narcotics Control Board for 2013. 
New York: United Nations, 2014. http://www.incb.org/documents/
Publications/AnnualReports/AR2013/English/AR_2013_E.pdf (accessed 
Aug 14, 2014).
3 UNODC. Drug use in Afghanistan: 2009 survey. Vienna: UN Offi  ce on Drugs 
and Crime, 2009. https://www.unodc.org/documents/data-and-analysis/
Studies/Afghan-Drug-Survey-2009-Executive-Summary-web.pdf 
(accessed July 17, 2014).
4 Afghanistan Ministry of Counter Narcotics. Afghanistan Drug Report, 2012. 
Published with technical support of the United Nations Offi  ce for Drugs 
and Crime. Kabul: Afghan Ministry of Counter Narcotics, 2013. http://mcn.
gov.af/Content/fi les/13_11_07__English%20Afghanistan%20Drug%20
Report%202012%281%29.pdf (accessed Aug 14, 2014).
5 Todd CS, Macdonald D, Khoshnood K, Mansoor GF, Eggerman M, 
Panter-Brick C. Opiate use, treatment, and harm reduction in Afghanistan: 
recent changes and future directions. Int J Drug Policy 2012; 23: 341–45.
6 Cottler LB, Ajinkya S, Goldberger BA, Ghani MA, Martin DM, Gold MS. 
Prevalence of drug and alcohol use in urban Afghanistan: epidemiological 
data from the Afghanistan National Urban Drug Use Study (ANUDUS). 
Lancet Glob Health 2014; 2: e592–600.
7 UNODC. Afghanistan drug use survey 2005. Vienna: United Nations Offi  ce 
on Drugs and Crime, 2005. http://www.unodc.org/pdf/afg/2005Afghanist
anDrugUseSurvey.pdf (accessed July 17, 2014).
8 Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance 
versus placebo or methadone maintenance for opioid dependence. 
Cochrane Database Syst Rev 2014: CD002207.
9 Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. 
Evidence for the eff ectiveness of sterile injecting equipment provision in 
preventing hepatitis C and human immunodefi ciency virus transmission 
among injecting drug users: a review of reviews. Addiction 2010; 
105: 844–59.
10 Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. 
Prevention of HIV infection for people who inject drugs: why individual, 
structural, and combination approaches are needed. Lancet 2010; 
376: 28–301.


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Afghanistan has a sizeable problem with opioid use

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