2. DRUG USE IN THE POPULATION

2.1. Drug Use in Turkey

A survey was done in 2002 (TPA 2002) (n=7681), where the sample was drawn in stratified multistage method. Point prevalence of substance use other than alcohol and nicotine in cigarette form was 0.3% (n=25); prevalence of substance use at least once in life-time was 1.2% (n=97). Me-an age of first drug use was 16.6 ± 3.0. Cannabis was the most frequently used substance (60%); oral nicotine use (20`)/0), antidepressant abuse (12%) and unidentified drug use (8`)/0) followed can-nabis.

The above mentioned survey had been carried on a contract basis between state and Turkish Association of Psycgologists (a non-govermental organisation) and realized on home basis. This survey is also the first one covering the country.

Another study — "National Study on Assessment of the Nature and Extent of Drug Abuse in Turkey" — in this field has been completed in 2003 under the coordination of UNODC and with the cooperation of related public institutions in 6 large provinces of Turkey, namely, Adana, Ankara, Di-yarbakir, Izmir, Istanbul and Samsun. The aim of the Study in question is to provide complete in-formation on drug use in Turkey through a comprehensive analysis of different geographical regi-ons of the country. The sub studies conducted in line with the National Study are as follows: (a) Key Person Survey (b) Drug User Survey (c) Alcohol, Tobacco and Substance Use Student Survey (d) Ecstasy and Other Rave Party Substances Focus Groups (e) Information Need and Resource Analysis.

According to the date and information collected during the assessments the ratio of the opia-tes users among the Turkish population between the ages 15 and 64 varies between 0.03 % and 0.07 % (average 0.05%); and the ratio of the volatile substance users among the same section of the population varies between 0.03°/o and 0.09% (average 0.06`)/0). It is estimated that more than two thirds of the opiates addicts use heroin. Besides the notified illicit substances, there are data showing that other types of substances are also used in the different regions of Turkey. Furthermo-re the figures mentioned are not exact figures, but estimates and do not reflect the general situati-on in Turkey, but mirror the drug use in large provinces of Turkey.

The key persons and drug users surveyed have stated that hashish and volatile substances are the most prevalent substances in Turkey. In accordance with the information supplied by the key persons the volatile substance and hashish use in provinces are very similar, however the use of ecstasy, benzodiazepines, barbiturates, heroin and opiates is lower in Turkey. Diyarbakir being one of the provinces of the National Study has ranked the first in terms of hashish, heroin, opium, bar-biturates and volatile substance use. Diyarbakir is followed by Istanbul in terms of the use of substances stated above. Moreover Istanbul has ranked the first in terms of cocaine and ecstasy use. The highest figures in terms of benzodiazepine use have been recorded in Izmir. Moreover Izmir fol-lows Diyarbakir in terms of hashish use. On the other hand Ankara has scored the lowest figures in most of these substances except for the volatile substances.

Hashish, heroine and ecstasy use is prevalent mainly among men and young individuals, whe-reas volatile substance use is mostly prevalent among adolescents and particularly street children. Women mainly misuse over the counter benzodiazepines (off-the shelf). The age of first volatile substance use is 11. It is 16 and 17 for hashish and ecstasy. In general the age of first drug use is below the age of 25.

There is an increasing trend in drug use in all the provinces. Therefore it is not wrong to say that there is also an increasing trend in the use of volatiles, hashish and ecstasy. Furthermore it has been reported that there is an increase in the use of benzodiazepines in Izmir and an increase in heroin and by injecting drug use in Istanbul. In Diyarbakir by injecting use shows also an increasing trend; and this trend may be deemed as a risk. In Adana it has been detected that drug use has be-en increased in all types of drugs mainly in volatile substances, hashish, benzodiazepines, ecstasy, heroin and cocaine.

The results of assessment indicate that mainly the young population in Turkey use drugs. The mean age of the drug users has been estimated as 24. And it has been reported that more than half of the drug users are between the ages of 15 and 24.
In general the drug users have got 6 years of education. One third of the users have been pro-vided with 7-12 years of education. The vast majority of the drug users are single (never married) and more than one forth of them are married. Two third of the drug users live in houses or flats. Most of the users live by their parents, spouses or friends. However a considerable number of users live alone and on the streets, which is mainly a dominant factor in the sample community.

Some of the drug users have stated that they are unemployed. And some others have stated that they are employed as unqualified or qualified workers. Most of the drug users have said that they are unemployed for twelve months before the survey. However they stated that they earn the-ir living from daily jobs or they are financially supported by their families or lovers. Moreover many of the drug users have admitted that they commit crimes for their living such as burglary, drugs dea-ling, pick pocketing and begging.

The drug users nearly in all the provinces have mentioned that they have injected drugs in the-ir lives. The most prevalent injected drug is heroin. There are some users who have stated that they have injected opiates and benzodiazepines as well.

More than the one third of the drug users has told that they have received treatment. It has been found out that the drug users mainly request for treatment against opiates, hashish and vola-tile substances. The drug users have mentioned that they have received treatment more than thre-e times (averagely) in their lives and they have received the first treatment when they were around 23 years old. There is nearly more than 5 years between the first use of opiates and the first treat-ment. However this period has been declared as 2 years by the users of the volatile substances. More than two thirds of the drug users from the sample of community and more than half of the drug users from the sample of convicts have admitted that they need treatment. This is an indicator that the drug users living among the community want to be treated voluntarily.

Most of the drug users from the samples of community and convicts have stated that they ha-ve been arrested for drug related crimes in their lives. And more than one thirds of them have ad-mitted that they have been arrested for any other crime in their lives. The mean age for arrest among the drug users is 26. The users have stated that they have been arrested three times averagely du-ring the period they were using drugs. The most frequent crimes that these individuals are charged with are possession, use and selling of drugs. Moreover more than half of the users have stated that they have been arrested for burglary, theft and traffic rules violations.

2.2. Drug Use Habits

All drug users interviewed were requested to provide information regarding their past of drug use. Those taking part in the survey were requested to state whether they used any of the drugs in-dicated in each index drug group or not, how old they were when they first used it, whether they used it in the last 12 months or not, (if they did) the frequency in a period of 30 days and the met-hod by which they generally use this drug.

It is possible to conclude from the data collected that drug use habit among the drug users has a rather variable and hybrid structure. Generally there is no great difference in terms of drug use re-lated information among the three samples of community, however there are certain differences ob-served among different cities.

Most of those taking part in the survey stated they had a past experience of heroin use. This rate was the highest in Izmir (>80°/0 of those taking part in the survey) and lowest in Ankara (50`)/0). The mean age of initial drug use was stated to be 17, which is similar to the age identified by key persons. Furthermore, around half of them admitted to using heroin in the last 12 months. Most of those who used heroin in the 30 day period before the interview or entry into a treatment centre or prison stated they used it on a daily basis. The general method for using heroin is reported to be smoking.

More than half of the drug users stated they had a past experience of volatile substance use, whereas two thirds of them said they used drugs in the last 12 month period. Use of volatile subs-tances is the lowest (28`)/0) among the sample of convicts and highest among the treatment samp-les in which two thirds of them stated they had a past experience of volatile substance use. Expe-rience of volatile substance use was found to be highest in Izmir (3`)/0) among the different provin-ces in which the study was conducted. The mean age of initial drug use was stated to be 14, due to the common use of these drugs among teenagers and young people. Nearly one third of those who stated they used volatile substances in the last 30 day period said they used these drugs on a daily basis.

Over one fourth of all the samples stated they had an experience of heroin use. Among those having an experience of heroin use; the lowest rate was estimated to be in Ankara (8°/0) and the hig-hest rates were found to be in Diyarbakir and Istanbul (>40% each) provinces. Around two thirds of these also stated they used heroin in the last 12 month period. The mean age of initial heroin use is 24 (between the age ranges 12-54). Most of the drug users who used heroin in the last 30 days said they used this drug on a daily basis. Most of the heroin users (>50%) said they used this drug by "snif-fing", inhaling or by "chasing the dragon". The interesting point here is that one fourth of the heroin users stated they used this drug by intravenous method. This rate was reported to be higher in the Is-tanbul sample, where one third of the heroin users used the intravenous method. A small number of those taking part in the survey (6`)/0 each) stated they had experience of opiates use. Most of those ta-king part in the survey said the most common method for opiates use was the intravenous method.

13% of the drug users said they had an experience of cocaine use and most of these users stated they used cocaine in the last 12 month period. The provinces with the highest rate of cocai-ne users are Istanbul and Izmir. The mean age of initial cocaine use is reported to be 26. Around one third of the sample community stated they had an experience of Ecstasy use. Two thirds of the-se people stated they used Ecstasy in the last 12 month period. The rate of ecstasy users are aga-in the highest in Istanbul and Izmir provinces. Around one third of the drug users in these provinces stated they tried Ecstasy. The mean age of initial Ecstasy use is 22. This rate is the highest in Izmir among other provinces and in the treatment sample among other samples. Less than half of the drug users in Izmir and one fourth of the drug users in the treatment sample interviewed admitted to having an experience of benzodiazepine use. Furthermore, nearly half of these users stated they used benzodiazepine in the last 12 month period (before the interview or entry into the treatment centre or prison). The mean age for initial use of benzodiazepine is 19.

2.3. Drug Use at School and Among the Young Population

In the Europan School Survey Projecton Alcohol and Other Drugs (ESPAD) based survey do-ne by UNODC Turkey Country representative in 6 metropols (Adana, Ankara, Diyarbakir, Istanbul, Izmir, Samsun) in 2003 (The same survey with general population survey), 88 schools were visited.

In this part, where the drug use among the youth is indicated, the data regarding the use of drugs, alcohol and smoking life-long, in the last 12 month period and in the last 30 days, as stated by those taking part in the survey, are examined.

More than half of the students answering the questions about the use of alcohol, tobacco and other substances stated they had an experience of smoking. Two end results were obtained in terms of the experience of smoking: 18% of the students stated they tried smoking once or twice, whereas 13% stated they had an experience of smoking over 40 cigarettes. Less than half of the students stated they had an experience of drinking alcoholic beverages.

Most of the students admitted to having experiences of alcohol use and a group of 20% said they got drunk once or twice. Data regarding life-long use of various substances, use in the last 12 month period and last 30 days are given in the table below.

The most commonly used drugs in order of prevalence are hashish and volatile substances among students. These are followed by (over the counter) anabolic steroids, tranquilizers or sedatives and ecstasy. More than 5°/0 of the students stated they used tranquilizers under supervision of the doc-tor. All the same, most of the students said they used these drugs for a period less than three weeks.

The alcohol use rates in the last twelve months are around 35% among all students. The ra-te is again higher among boys in comparison with girls. Similarly, 16°/0 of the students stated they got drunk once or twice in the last 12 month period. Among the drugs reported to have been used in the last 12 month period, over 3% of the students stated they used hashish whereas over 2°/o sta-ted they used volatile substances. The rates are again higher among boys than girls. With regards use of drugs other than hashish and volatile substances; less than 1`)/0 of the students stated they used these drugs in the last 12 month period.

Rates regarding those who used alcohol, tobacco or drugs once and those using these subs-tances on continuous basis may be included into the rates regarding those who used such substan-ces in the last 30 days. According to the information provided by the answers given to the part re-garding the use of alcohol in the last 30 days in the last survey; nearly 20% (%10 in total) stated they used alcohol once or twice during this period. More than 15% of the students stated they had more than five drinks in a row (for example in a party, etc.), whereas 8°/0 stated they got drunk on-ce or twice in the 30 day period before the interview. Most students stated they smoked 1,5 cigaret-tes in answer to the question about smoking in the last 30 day period. They are followed by those who said they smoked 6-10 cigarettes in answer to the question. With regards hashish and volatile substances use; more than 2°/0 of the students stated they used these drugs during this 30 day pe-riod. The rate related to use of other drugs during the last 30 day period is around 1%.

2.4. Drug Use in Specific Groups

In preparation for developing surveillance activities in line with recommendations for 2nd ge-neration surveillance in Turkey being a low level epidemic country, a situation analysis on surveil-lance of STIs and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) has been conducted in 2005 by Ministry of Health. This analysis highlighted the need to increase the depth of knowledge related to populations at risk in order to provide more concrete re-commendations for inclusion in the National Surveillance Plan. Following this analysis a rapid as-sessment study has been carry out to synthese and analyse risky behaviour within sub-populations like commercial sex workers and IDUs, anticipated to be more at risk, in order to recommend their inclusion in surveillance activities.

Actual data from IDUs demonstrates that participants have some accurate knowledge, but al-so wrong-information about transmission of and protection from STI/HIV/AIDS. Although they have knowledge about them and are afraid of these diseases, during times of intensive drug usage they expressed that neither needle and syringe sharing nor unsafe sex are important at "that vety mo-ment', this is a striking feature of the information obtained from this population.

The decision to implement the Second Generation Declaration System was taken in the Na-tional HIV/AIDS Consensus Conference organized in 2005 by the Ministry of Health in considerati-on of these results reached. In line with the decision in question; "STD/HIV Operational Project has been put into implementation under the "Strengthening the STD/HIV Notification System" in Turkey Reproductive Health Program initiated in 2003 by way of the cooperation between the Ministry of Health and the European Commission. The aim of this project is to strengthen the STD/HIV/AIDS notification system, make current mechanisms more prevalent to enable the monitoring of STD/HIV/AIDS and to measure the changes in behaviours as a result of the policies implemented. This project aims to determine the current dissemination of the sexually transmitted diseases among high HIV risk groups (commercial sex workers, intravenous drug users and homosexuals) in metro-politans like Ankara, Istanbul, Izmir.

Under the framework of the "Turkey HIV/AIDS Prevention and Support Program" undertaken by the Ministry of Health, the ultimate goal is to enable broader access of vulnerable groups like commercial sex workers, homosexual men, convicted people and intravenous drug users to HIV/AIDS preventive health services. Non-governmental organizations in Ankara, Istanbul, Izmir and Gaziantep have commenced activities to realize the goals towards intravenous drug users. Wit-hin the scope of the same program; training modules and educative visual materials aimed at field workers are prepared and peer trainings on HIV/AIDS are delivered to field workers who are intra-venous drug users and the relevant public officials. Furthermore, behaviour surveys have also be-en planned in order to measure the influence of the program on knowledge, behaviour and attitude and they are expected to be finalized in the year 2007. Another activity falling under the scope of the program and expected to be realized in 2007 is the improvement of advocacy against intrave-nous drug use among the decision makers.

Moreover, another aim is to send the doctors specified in the field of "substance misuse" by AMATEM (Research, Treatment and Training Center for Alcohol and Drug Addiction) abroad to par-ticipate in trainings in centres where such treatment is provided.