Drug Abuse Research in the Middle East: An Exercise in Cooperation Richard Rawson, Ph.D. UCLA ISAP Los Angeles, California USA

Drug Abuse Research In the Middle East: Acknowledgements Colleagues Palestine: Mohamed Afifi, MD Substance Abuse Research and Addiction Center (SARC), Gaza City, Gaza Israel: Richard Isralowitz, Ph.D. Ben Gurion University Beersheva, Israel Egypt: Nasser Loza, MD, and Ahmed El Dosoky, MD, Behman Hospital Cairo, Egypt Project funded by the Middle East Regional Cooperation Program, USAID

Brief History UN creates Commission on Narcotics after WW2. UN creates Commission on Narcotics after WW2.  In 1959 the Middle East Narcotics Survey Mission concludes: agreements between neighboring countries are essential should be liaison among gov’t agencies including health, education and social welfare ministries as well as NGO’s – No major evidence of cooperation and coordination until this experience

Oslo Accord Oslo Accord – Sept, 1993 Oslo Accord – Sept, 1993 People to People (P2P) provisions set in place (Sept. 28, 1995) based on the guiding principle that political leaders cannot do it alone, social networks need to be built. People to People (P2P) provisions set in place (Sept. 28, 1995) based on the guiding principle that political leaders cannot do it alone, social networks need to be built.

Peace Process The aim of P2P was to create strong relations The aim of P2P was to create strong relations across broad networks of dedicated non- across broad networks of dedicated non- government individuals and institutions, thereby government individuals and institutions, thereby establishing a basis for the Palestinian-Israeli establishing a basis for the Palestinian-Israeli peace process. Key elements include: peace process. Key elements include: – promote short & long term transition efforts including cease fires, amnesty and mutual recognition – establish an infrastructure for communications and interaction – building a peace constituency

Drugs & Peace Aims Develop a network of key contacts and relations among US Embassy/State Dept. and peace organization personnel Develop a network of key contacts and relations among US Embassy/State Dept. and peace organization personnel Promote organization factors among the key participants in terms of 5 C’s: Promote organization factors among the key participants in terms of 5 C’s: improve communications, cooperation and coordination of activities;improve communications, cooperation and coordination of activities; minimize the conflict of negative national and regional issues and competition over scarce resourcesminimize the conflict of negative national and regional issues and competition over scarce resources Build a bond between US/UCLA and Middle East drug experts Build a bond between US/UCLA and Middle East drug experts Generate short and long term drug related activities geared to addressing individual country/people needs leading to a platform of regional cooperation. Generate short and long term drug related activities geared to addressing individual country/people needs leading to a platform of regional cooperation.

Drug & Peace Activities Regional Alcohol and Drug Abuse Resources center development (RADAR-SAMHSA) Regional Alcohol and Drug Abuse Resources center development (RADAR-SAMHSA) Workshop training Workshop training – Pre-workshop training in Gaza and the West Bank in case borders are closed Beer Sheva workshop (1997) Beer Sheva workshop (1997) – border problems – finger pointing (addicts, informers, prostitutes, dealers being released, etc) Beer Sheva training (and threatened walkout but … 1998) Beer Sheva training (and threatened walkout but … 1998) Bethlehem workshop (Israeli security personnel stonewalled participation – however … 1998) Bethlehem workshop (Israeli security personnel stonewalled participation – however … 1998) Matrix/UCLA Manualized Treatment Protocols (in Hebrew and Arabic with MASHAV/PIN support) ( ) Matrix/UCLA Manualized Treatment Protocols (in Hebrew and Arabic with MASHAV/PIN support) ( )

Activities Palestinian/Al Quds University workshop Palestinian/Al Quds University workshop manualized treatment training (supported by the manualized treatment training (supported by the Israel Foreign Ministry – 1998) Israel Foreign Ministry – 1998) Beer Sheva follow up meeting with World Health Organization representation (1998) Beer Sheva follow up meeting with World Health Organization representation (1998) RADAR meeting in Irvine California (June 1999) RADAR meeting in Irvine California (June 1999) UCLA/Friends Research Institute, Inc., US Agency for International Development/MERC proposal development meeting (June 1999) UCLA/Friends Research Institute, Inc., US Agency for International Development/MERC proposal development meeting (June 1999) Publications:Isralowitz, R., Sussman, G., Afifi, M. Rawson, R. Babor, T. and Monteiro, M. (2001) Substance Abuse Policy and Peace in the Middle East: A Palestinian and Israeli Partnership. Addiction, 96, Publications:Isralowitz, R., Sussman, G., Afifi, M. Rawson, R. Babor, T. and Monteiro, M. (2001) Substance Abuse Policy and Peace in the Middle East: A Palestinian and Israeli Partnership. Addiction, 96, Isralowitz, R. Afifi,M.and Rawson, R., Editors. (2002) Drug Problems: Cross-Cultural Policy and Program Development. Greenwood Publishing, Westport, Conn. Isralowitz, R. Afifi,M.and Rawson, R., Editors. (2002) Drug Problems: Cross-Cultural Policy and Program Development. Greenwood Publishing, Westport, Conn.

Activities (con’t) MERC related R & D activities MERC related R & D activities MERC 1 – Youth at-risk and drug use assessment MERC 1 – Youth at-risk and drug use assessment NIDA Community Epidemiology Work Group participation (3 partners: Israel/Palestine/US) MERC 2 – Addiction Severity Index development MERC 2 – Addiction Severity Index development (3 partners: Egypt/Israel/US) MERC 3 – Lebanon (3 partners: Israel/Lebanon/US) pending MERC 3 – Lebanon (3 partners: Israel/Lebanon/US) pending

Joint Project: SARC-Palestine, FRI Research Center, BGU University Financed by USAID Agency M.Afifi, S.Sousi, Z.AbuRsas

Purpose Promote cooperation Promote cooperation Generate information transfer Generate information transfer Monitor drug use problems among youth in the region Monitor drug use problems among youth in the region

Introduction: Gaza Strip - Geography Area = 362 sq.km Area = 362 sq.km Located in South West of Palestine (Israel) at the Mediterranean Located in South West of Palestine (Israel) at the Mediterranean 50 km long and (5-12 km width. 50 km long and (5-12 km width. Borders: West (Sea), North and East (Israel), and South (Egypt) Borders: West (Sea), North and East (Israel), and South (Egypt) 25% occupied by Israeli settlements. 25% occupied by Israeli settlements.

Introduction: Gaza Strip – Population Total = 1.3 Millions, Total = 1.3 Millions, Adolescents and young adults (more than 50%.) Adolescents and young adults (more than 50%.) Population Growth rate 3.5% per year Population Growth rate 3.5% per year Un employment is over 60% Un employment is over 60% More than 80% of families under poverty line More than 80% of families under poverty line The general economic situation is very bad (in the last 3 years due to Intifada, violence, closures and restrictions by the Israeli army. The general economic situation is very bad (in the last 3 years due to Intifada, violence, closures and restrictions by the Israeli army.

Elementary schools (age 6-12 years) Elementary schools (age 6-12 years) Preparatory schools (age years) Preparatory schools (age years) Secondary (high) schools (16-18 years) Secondary (high) schools (16-18 years) There are 70 high schools in Gaza Strip (33 schools for boys, 37 for girls), with total of students. (27015 boys, and girls). There are 70 high schools in Gaza Strip (33 schools for boys, 37 for girls), with total of students. (27015 boys, and girls). Introduction: School System and High Schools Distribution

Data Collection Instrument SUSI Substance Use Survey Instrument Substance Use Survey Instrument (Modified version) (28 simple questions about drug and problem behaviors)

Study Population (Gaza Strip) Students (Boys and Girls) TotalGirlsBoysRegion North Reg Gaza Reg Khanyonis Rafah Reg Total

Study Cohort (N=1,034) The students sample consisted of class units (one randomly selected class of grade 11). 26 high schools were chosen (14 boys schools and 12 girls schools). The total is 1034 students. The students sample consisted of class units (one randomly selected class of grade 11). 26 high schools were chosen (14 boys schools and 12 girls schools). The total is 1034 students.

Some Data Collection pictures

Tobacco 17.2% of the boys 17.2% of the boys 7.9% of the girls 7.9% of the girls Observed smoking in schools:34.2% Observed smoking in schools:34.2% Observed smoking in districts:46.7% Observed smoking in districts:46.7% Age of first use (years): 13 for boys and 15 for girls. Age of first use (years): 13 for boys and 15 for girls.

Prescribed medicines 2.5% of the boys 2.5% of the boys 5.6% of the girls 5.6% of the girls Observed using in schools:3.2% Observed using in schools:3.2% Observed using in districts:5.2% Observed using in districts:5.2% Age of first use (years): 14 for boys and 15 for girls Age of first use (years): 14 for boys and 15 for girls

Beer 1.6% of the boys 1.6% of the boys 0.3% of the girls 0.3% of the girls Observed using in schools:0.6% Observed using in schools:0.6% Observed using in districts:4.5% Observed using in districts:4.5% Age of first use (years): 14 for boys and 15 for girls Age of first use (years): 14 for boys and 15 for girls

Inhalants 6.4% of the boys 6.4% of the boys 2.6% of the girls 2.6% of the girls Observed using in schools:% Observed using in schools:% Observed using in districts:% Observed using in districts:% Age of first use (years): 13 for boys and girls Age of first use (years): 13 for boys and girls

Cannabis/Bango 3% of the boys 3% of the boys 1.1% of the girls 1.1% of the girls Observed using in schools:1.1% Observed using in schools:1.1% Observed using in districts:3.5% Observed using in districts:3.5% Age of first use (years): 13 for boys, and 15 for girls Age of first use (years): 13 for boys, and 15 for girls

Cocaine/Heroin 1.7% of the boys 1.7% of the boys 0.8% of the girls 0.8% of the girls Observed using in schools:% Observed using in schools:% Observed using in districts:% Observed using in districts:% Age of first use (years): 14 for boys, 16 for girls Age of first use (years): 14 for boys, 16 for girls

Problem Behavior (users and non-users boys) (last 12 months) Victimization (stolen/or spoiled objects, injured, threatened): Victimization (stolen/or spoiled objects, injured, threatened):  12.3%-90% of users  2.1%-9.1% of non-users Desire to carry weapons for self defense: Desire to carry weapons for self defense:  28.1%-54.2% of users  17.30%-21% of non-users Absence from schools being afraid (one day or more): Absence from schools being afraid (one day or more):  22.4%-50% of users  15.9%-19.6% of non-users Spending evenings hanging in streets and coffees: Spending evenings hanging in streets and coffees:  19%-45.6% of users  6.3%-19.6% of non-users

Results: Life Use of Drugs By Boys & Girls

Age of first use

Results: Summery of How Easy to Get Drugs

Additional Monitoring Suggestions patterns of drug use and spending patterns of drug use and spending patterns of ‘hard drugs’ and accessibility patterns of ‘hard drugs’ and accessibility patterns of obtaining drugs patterns of obtaining drugs percentage of money owed for drugs percentage of money owed for drugs

Conclusions The study shows that Gaza Strip is vulnerable to drug use and that starts as early as years. The study shows that Gaza Strip is vulnerable to drug use and that starts as early as years. The most common drugs used are tobacco (cigarettes), the prescription drugs, inhalants and marijuana (known as Bango). The most common drugs used are tobacco (cigarettes), the prescription drugs, inhalants and marijuana (known as Bango). warning indicators: warning indicators:  age of first use  poly-drug use fire wall prevention development: fire wall prevention development:  monitoring  low-cost intervention strategies - priority on tobacco & alcohol  treatment programs

Conclusions (con’t) There is need for effective low cost intervention strategies with priority attention given to the ‘gateway’ drugs (cigarettes and alcohol) There is need for effective low cost intervention strategies with priority attention given to the ‘gateway’ drugs (cigarettes and alcohol) There is need for treatment programs for youth with problem behavior associated with drug use There is need for treatment programs for youth with problem behavior associated with drug use There is need for effective education and training of drug service personnel. There is need for effective education and training of drug service personnel. additional research: additional research:  youth workers  underserved groups: females, Youth

High-Risk Youth and Drug Use Toward an Early Warning System of Problem Behaviors Richard Isralowitz, Ph.D. Director Regional Alcohol and Drug Abuse Resources Center

 Population 6.5 million ( about 10% living abroad; 18% of the immigrants are from the FSU since 1989; 18% are Israeli Arab citizens….)  Geographic Area The size of New Jersey (20,770 sq/km) Borders Egypt, Jordan, Syria, Lebanon, Gaza, West Bank Israel

Purpose Promote cooperation Promote cooperation Generate information transfer Generate information transfer Monitor drug use problems among Monitor drug use problems among high risk youth among in the region high risk youth among in the region

Data Collection Instrument SUSI Substance Use Survey Instrument Substance Use Survey Instrument (28 simple questions about drug and problem behaviors)

Study Cohort (N=1,019) Probation Youth (102) Other High Risk Youth (917) (immigrants, youth in alternative special education/training programs, street youth, and those from low-income neighborhoods) (immigrants, youth in alternative special education/training programs, street youth, and those from low-income neighborhoods)

Results 26% - no connection with school 26% - no connection with school  33% - probation youth  24% - other high risk youth 28% - hang out in streets at night 28% - hang out in streets at night school youth, on average, come late about 7 times each month school youth, on average, come late about 7 times each month those that come to school, on average, are absent about 4 days each month those that come to school, on average, are absent about 4 days each month

TOBACCO 30% report smoking cigarettes 30% report smoking cigarettes (67% of probation youth are cigarette users) age of first use – 13 years age of first use – 13 years most smoke cigarettes per day most smoke cigarettes per day on average, $11/week is spent for cigarettes on average, $11/week is spent for cigarettes

ALCOHOL age of first use – 13 years age of first use – 13 years last 30 day use: last 30 day use: - beer 53% - wine 42% - hard liquor 37% 28% binge drink ( 5 or more drinks/occasion) 28% binge drink ( 5 or more drinks/occasion)

Drinking & Driving (last 30 days) 13% (23% probation youth) were in a car with a driver who had been drinking 13% (23% probation youth) were in a car with a driver who had been drinking 6% (14% probation youth) were driving a car when they had been drinking 6% (14% probation youth) were driving a car when they had been drinking

Cannabis (marijuana and hashish) age of first use - 15 years age of first use - 15 years life time use (at least once) - 13% life time use (at least once) - 13% last 30 days use: last 30 days use: 15% probation youth 15% probation youth 5% other high risk youth 5% other high risk youth 72% had no problem obtaining the substance 72% had no problem obtaining the substance spending/week: spending/week: marijuana users - $11 hashish users - $21

Prescription Drugs age of first use - 11 years age of first use - 11 years life time use (at least once) - 11% life time use (at least once) - 11% last 30 day use - 8% last 30 day use - 8%

Ecstasy age of first use - 16 years age of first use - 16 years life time use (at least once): life time use (at least once): 13% - probation youth 13% - probation youth 4% - high risk youth 4% - high risk youth last 30 day use: last 30 day use: 5% - probation youth 5% - probation youth 2% - high risk youth 2% - high risk youth 67% had no problem obtaining the substance 67% had no problem obtaining the substance

Inhalants age of first use - 12 years age of first use - 12 years life time use (at least once) - 7% life time use (at least once) - 7% last 30 day use - 4% last 30 day use - 4% spending/week - $5 spending/week - $5

Problem Behavior (last 12 months) serious fighting - 27% serious fighting - 27% 54% - probation youth 54% - probation youth 24% - other high-risk youth 24% - other high-risk youth carried a weapon - 10% carried a weapon - 10% 19% - probation youth 19% - probation youth 9% - other high-risk youth 9% - other high-risk youth selling drugs - 3% selling drugs - 3% 8% - probation youth 8% - probation youth 2% - other high risk youth 2% - other high risk youth stealing - 15% stealing - 15% 27% - probation youth 27% - probation youth 14% - other high risk youth 14% - other high risk youth

Age at First Use

Youth Drug Use: Last 30 Days

Problem Behavior Last Year

Additional Monitoring Suggestions patterns of drug use and spending patterns of drug use and spending patterns of ‘hard drugs’ and accessibility patterns of ‘hard drugs’ and accessibility patterns of obtaining drugs patterns of obtaining drugs percentage of money owed for drugs percentage of money owed for drugs

Conclusions warning indicators: warning indicators:  age of first use  daily or weekly drug use  poly-drug use fire wall prevention development: fire wall prevention development:  monitoring  low-cost intervention strategies - priority on tobacco & alcohol  treatment programs

Conclusions (con’t) training/education for personnel training/education for personnel additional research: additional research:  youth workers  underserved groups:  females  immigrants

Conclusions This process has demonstrated the importance of NGO’s in terms of stimulating and providing a safety net as well as an island of sanity and interaction in rough political seas. This process has demonstrated the importance of NGO’s in terms of stimulating and providing a safety net as well as an island of sanity and interaction in rough political seas. Current hostilities offer a stark contrast to the possibilities created Current hostilities offer a stark contrast to the possibilities created The hostilities underscore the fragility of the peace process, its shallowness and the extent to which careful planning and painstaking efforts can be underscored. The hostilities underscore the fragility of the peace process, its shallowness and the extent to which careful planning and painstaking efforts can be underscored. Perhaps, when enough loss of life occurs, people will go back to examine and implement steps necessary to create co-existence – for there is no alternative. Perhaps, when enough loss of life occurs, people will go back to examine and implement steps necessary to create co-existence – for there is no alternative.

Conclusions (con’t) Accomplishments have been made and are still being generated. These small steps lead to an important whole. Accomplishments have been made and are still being generated. These small steps lead to an important whole. In retrospect, our ability to move forward has been limited by the lack of permanent funding, administrative support, and our lack of utilizing a meta-analysis approach to evaluate what has been accomplished. In retrospect, our ability to move forward has been limited by the lack of permanent funding, administrative support, and our lack of utilizing a meta-analysis approach to evaluate what has been accomplished. Finally, the question that arises – can the effort be replicated. The answer, in our opinion, is yes; however, such in roads are limited if peace cannot be secured and maintained Finally, the question that arises – can the effort be replicated. The answer, in our opinion, is yes; however, such in roads are limited if peace cannot be secured and maintained