For the purposes of IDPC’s regional work, the Middle East / North Africa (MENA) region is composed of the following countries: Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, the United Arab Emirates (UAE), the West Bank & Gaza, and Yemen.
There is limited data and information on illicit drug production, trafficking, and consumption in MENA. This can be attributed to the lack of capacities for data collection and analysis. Such information is essential, however, for the development of effective drug policies.
Although MENA is primarily a drug trafficking and consumption region, there are also notable production trends in cannabis, amphetamine-type stimulants (ATS) and Khat. North Africa has the greatest number of cannabis resin seizures on the continent. This is largely attributable to Morocco, which has historically been the world’s leading global supplier of cannabis resin. However, although Morocco remains a prominent producer, there are indications that cannabis resin production is declining. This can be attributed to increased enforcement efforts, as well as a shift in production trends in Western and Central Europe allowing demand for cannabis herb to be satisfied by local production. In the Middle East, Lebanon is a noteworthy supplier of cannabis resin. Cannabis herb is also cultivated in nearly all North African countries, with Egypt as the greatest supplier in the region. High seizures have occurred in the Middle Eastern countries of Lebanon, Bahrain, Kuwait and Israel, although the latter is primarily a result of trafficking from Egypt. ATS in the form of Captagon tablets is produced in Lebanon. Egypt appears to be the most significant source of tramadol, an opioid painkiller increasingly used throughout MENA (World Drug Report, 2013). Tramadol is not under international control, however, it has been placed under national control in most MENA countries and is therefore only legally accessible by prescription (INCB 2013, Asia). Concerns have been expressed that the control of tramadol may inhibit its medical uses, which are important in a number of developing countries where other opioids are less available owing to regulatory obstructions. Khat, a mild plant-based stimulant, is legally cultivated and used in Yemen and Djibouti, although it is much more prominent in the former (World Drug Report, 2013).
MENA countries are strategically positioned for trafficking substances to Western Europe and the Russian Federation. The Balkan route, which goes through Iran, is a main heroin (and recently cocaine) trafficking route linking Afghanistan to these markets. Since 2010, heroin and opium seizures have declined in Iran, seemingly as a result of enforcement efforts. However, alternative trafficking routes seem to have emerged in the region (although data on the proliferation of trafficking routes in North Africa continue to be very limited). For example, several countries in the Middle East, including Saudi Arabia, Syria and the UAE, have reported increases in opiate and cocaine seizures. Methamphetamine trafficking tends to originate in Benin and Nigeria, and the substance is then trafficked through MENA countries including Libya, Egypt, Qatar, and the UAE, on route to East and South East Asia. Cannabis resin originating in Morocco travels through Algeria before reaching Europe via Spain (World Drug Report, 2013).
Political instability has increased the vulnerability of MENA to illicit drug trafficking. In addition to Egypt and Syria, which have become characterised by political and social unrest, this region has several conflict, post-conflict, and fragile states, notably Israel and Iraq (read more). Increases in seizures of methamphetamines, prescription medicines, and new psychoactive substances (NPS) throughout the Middle East suggest that trafficking and consumption are on the rise. Importantly, 64% of global amphetamine seizures take place in the Middle East in the form of Captagon tablets (World Drug Report, 2013). North Africa has observed increases in seizures of cannabis herb and cocaine. Egypt has seen a steady increase in heroin seizures, although this is largely attributed to a rise in Egyptian consumption (INCB 2013, Africa).
In North Africa, the consumption of opioids, cannabis, ATS, and cocaine have been increasing since 2012 (INCB 2013, Africa). Similar trends are apparent in the Middle East, as the use of opioids, ATS, methamphetamines, cocaine, stimulants, and prescription medicines (notably tramadol) are on the rise (INCB 2013, Asia). Opium smoking is a traditional practice in some Middle Eastern countries, including Iran and Iraq. Iran’s especially high consumption of heroin can be attributed to its position on the Balkan route (World Drug Report, 2013). Egypt now has the highest consumption of heroin in North Africa, as well as a high demand for cannabis, although the consumption of this substance is prominent throughout all of North Africa (INCB 2013, Africa). Recent information on drug use in Algeria shows that there has been an increase in the use of cocaine, cannabis, tranquilizers, and sedatives, while Morocco has seen an increased consumption of cocaine and opiates. The illicit use of other substances has remained stable in these countries (World Drug Report, 2013). Methamphetamine consumption has risen in Iran and Israel, with the latter country primarily consuming such substances in the form of “yaba” tablets from South-East Asia (INCB 2013, Asia). In the Middle East, there is a high demand for Captagon tablets, especially in Saudi Arabia, Jordan, and Syria (World Drug Report, 2013).
The emergence of NPS use, particularly synthetic cannabinoids, has been reported in the Middle East and in Egypt. However, apart from Egypt, NPS use is relatively low in the region. Increased seizures and smuggling has led to the emergency scheduling of some NPS in Bahrain and Saudi Arabia, and Table I banning of synthetic cannabinoids in the UAE. Similar efforts to ban NPS have been undertaken in Israel, in particular for synthetic cannabinoids (INCB 2013, Asia). Nevertheless, it is expected that NPS will continue to be supplied and consumed, as bans in other parts of the world have proven ineffective in tackling the rapidly evolving field of NPS – as has also been the case for more traditional substances.
National reports of drug use throughout the MENA region, particularly the Middle East, rarely account for women who use drugs. This is mainly due to the stigma attached to drug use – and especially drug injection – among women. In Iran, recent data showed that about 700,000 of the 3 million people who use drugs are women. Elsewhere in MENA, reports on drug use among women are generally rare, often incomplete or inaccurate.
Alcohol consumption is permissible in all MENA countries except Iran, Libya, Saudi Arabia and Yemen. Consumption is forbidden by Islam, the predominant religion in the region. Patterns of consumption in MENA have remained stable, with the exception of Qatar and the UAE, where consumption has risen, and Bahrain, Djibouti, and Syria, where consumption has fallen (WHO Global status report on alcohol and health 2014, Individual country profiles). Although MENA has the lowest consumption levels of alcohol in the world, in some MENA countries between 50% and 100% of consumption involves home-made or informally produced alcohol, smuggled alcohol, alcohol intended for industrial or medical uses, and alcohol obtained through cross-border shopping (WHO Global status report on alcohol and health 2014, Status report without country profiles). Many of these sources of unrecorded alcohol can have significant health harms, as consumers are unable to assess the quality and quantity of alcohol they are drinking.
Regional Drug Policies
Drug policies in most MENA countries focus on strong law enforcement, rather than a balanced approach between supply and demand, with little space given to health protection and social inclusion. Nevertheless, some countries have recently responded to the increased demand for treatment and rehabilitation with some level of healthcare services.
Strong law enforcement efforts have been the customary approach to drug production, trafficking and consumption in MENA. To date, MENA countries have focused their drug policies on the criminalisation of drug possession and use (including alcohol, which is illegal in some countries in the region). In Bahrain, for example, people who use opioids can be arrested for the simple possession of syringes, leading to increased risky behaviours among people who inject drugs. Operations to arrest dealers and intercept drug shipments have also been a core focus of drug policies in MENA. Iran has received extensive support from UNODC to implement measures aimed at interdicting supplies of drugs entering its territory (Technical Cooperation on Drugs and Crime in the Islamic Republic of Iran), with the government recently announcing that it would intensify interdiction efforts at its border with Afghanistan and Pakistan. However, the continuing prevalence of drug trafficking and consumption in Iran, and the displacement of trafficking routes, indicates that such efforts are ineffective in reducing the scale of the drug market in the region and worldwide. In North Africa, weak and under-resourced criminal justice systems, as well as corrupt institutional structures, have hampered efforts to curtail the illicit drug trade.
These policies have resulted in a situation where drug offenders and people accused of drug offences (mostly for minor infractions) represent a disproportionately high percentage of people held in pre-trial detention or prison (African Union Plan of Action on Drug Control). In Tunisia, for example, people caught for the production, possession and distribution of drugs can be imprisoned for 6 to 10 years. Drug control policies have therefore placed a significant burden on the country’s criminal justice system (IDPC report: First IDPC seminar on drug policy in the Middle East and North Africa).
Corporal punishment and the death penalty
The use of corporal and capital punishment for drug offences is a troubling feature of the region’s criminal justice system. Iran, Libya, Qatar, Saudi Arabia, the UAE and Yemen use judicial corporal punishment (i.e. state-sanctioned beating, caning, or whipping of a person) for drug use, purchase or possession. This is a clear violation of international human rights law (Inflicting Harm: Judicial Corporal Punishment for Drug and Alcohol Offences in Selected Countries). The death penalty for drug offences continues to be prescribed in the law of numerous MENA countries, including Bahrain, Egypt, Iran, Iraq, Kuwait, Libya, Oman, Qatar, Saudi Arabia, Syria, the UAE, Gaza and Yemen. With the exception of Iran and Saudi Arabia, the majority of these states do not regularly sentence those convicted of drug offences to death. In Iran, the imposition of the death penalty is mandatory for trafficking and/or possessing more than 30 grams of specified synthetic, non-medical psychotropic drugs. Between 1979 and 2011, more than 10,000 people were executed for drug offences (Death Penalty for Drug Offences: Global Overview 2012).
At the High-Level Segment of the 57th session of the Commission on Narcotic Drugs in March 2014, Iran made a statement about the death penalty on behalf of itself and sixteen other states, including Bahrain, Egypt, Kuwait, Libya, Oman, Qatar, Saudi Arabia, Syria, the UAE and Yemen. Iran asserted that the death penalty was not prohibited under international law (including the UN drug conventions), that every state had the sovereign right to apply the death penalty as they saw fit, and that capital punishment served as a deterrent for the most serious crimes, including drug trafficking (CND Report on the 57th Session). In contrast, statements made during the High-Level Segment by the European Union and its member states, as well as 31 other nations, indicate that there is widespread belief that capital punishment for drug offences violates international law and is incompatible with human rights principles. The UNODC’s position is that “the application of the death penalty has never been in the spirit of the conventions” (UNODC Report for the High-Level Review), while the INCB issued a press release in early March 2014 to encourage UN member states to “consider abolishing the death penalty for drug-related offences” (INCB Press Release). The use of the death penalty for drugs offences has also been condemned by a number of UN human rights bodies.
HIV among people who inject drugs
Together with South-West Asia, the Near and Middle East has the highest prevalence of HIV among people who inject drugs worldwide (World Drug Report, 2013). Among this key population, HIV prevalence is 10% or higher in Iran, Libya and Morocco, 5% to 9.9% in Egypt and Tunisia, and between 1% and 4.9% in Bahrain, Oman and Saudi Arabia (HIV and AIDS in the Middle East and North Africa).
In Iran, the HIV epidemic among people who inject drugs is established at national concentrated levels of about 15%. Emerging concentrated epidemics (in which HIV prevalence among people who inject drugs has been increasing and is projected to continue doing so) can be observed in parts of Egypt and Morocco. HIV prevalence among people who inject drugs is also troubling in parts of Libya, where the nation’s capital, Tripoli, has the highest reported prevalence of HIV among people who inject drugs in MENA at 87.1%. Although the quality of evidence is insufficient to determine if there is a concentrated epidemic, data from Bahrain and Oman indicates at least an outbreak of HIV infection among people who inject drugs, with reported prevalence up to 21.1% and 27% respectively. Many of the remaining MENA nations lack evidence to determine the level of HIV prevalence. Hence, the possibility of hidden HIV epidemics in other parts of MENA remains (HIV among people who inject drugs in the Middle East and North Africa).
Research on injecting risk behavior has found that people who inject drugs in MENA face a high injecting risk environment. For example, about a quarter of people who inject drugs shared a needle or syringe in their most recent injection (HIV among people who inject drugs in the Middle East and North Africa). The high rates of HIV prevalence among people who inject drugs in several MENA countries is a predictable outcome of the lack of adequate harm reduction services and comprehensive and confidential HIV prevention and treatment services, limited access to existing services due to widespread stigma, and increased injecting drug use (most notably heroin). Such an environment creates a high potential for further HIV spread. An additional cause of increasing HIV prevalence is the low rate of HIV testing, which suggests that more people may be living with HIV than has been currently measured and may therefore not take necessary precautions to avoid new HIV transmissions. Better data collection and surveillance is needed in most MENA countries to inform effective HIV policy and programming.
Harm reduction services
The policies of several MENA countries, including Iran, Israel, Jordan, Lebanon, Morocco, Syria and Tunisia, explicitly refer to harm reduction, indicating government commitment to tackling drug-related harms. Although coverage of opioid substitution treatment (OST) and needle and syringe programmes (NSPs) is generally limited, some MENA countries have been gradually increasing the availability of these services. NSPs are currently available in Egypt, Iran, Israel, Lebanon, Morocco, Oman, Tunisia and West Bank & Gaza. OST is available in Iran, Israel, Lebanon, Morocco and the UAE. Tunisian NGOs are currently working on the introduction of methadone maintenance treatment in the country. Iran is the only country in the region that provides NSPs and OST in prison (Harm Reduction International – MENA Regional Overview).
Throughout the region, however, coverage is largely insufficient to meet the demand, and repressive legal and policy frameworks, as well as high levels of stigma, pose substantial barriers to successful implementation. Iran, for example, has been expanding harm reduction services since the late 1990s and continues to be the regional leader in harm reduction services. Nevertheless, injecting drug use remains the main mode of HIV transmission in the country, highlighting the need for increased and sustained harm reduction services (UNAIDS 2013 Regional Report for the Middle East and North Africa), as well as the creation of a political and legal environment that removes barriers for access to these life-saving services.
Furthermore, harm reduction services throughout MENA are rarely gender-specific and therefore do not take into account the unique vulnerabilities of women who use drugs (Women Injecting Drug Users in MENA). Harm reduction programmes in MENA must be targeted to address the unique demographics of vulnerable groups, such as women and youth. They must aim to reduce the physical harms associated with drug use, the social stigma around drug use, as well as the harms associated with the criminalisation of people who use drugs.
Access to drug dependence treatment
Drug laws in a small number of MENA countries have been slowly advancing towards a public health approach. In 2005, the UAE law on the control of narcotic drugs was amended to classify people who use drugs as “patients”, rather than as “criminals”. As a result of this change, the National Rehabilitation Centre of Abu Dhabi (NRC) was established to provide drug dependence treatment (including methadone maintenance therapy), rehabilitation, and post-treatment follow-up services. In Egypt, the 2009 Mental Health Act classified people dependent on drugs as mental health patients, which led to the development of rules on voluntary access to drug dependence treatment – a substantial step forward from compulsory rehabilitation centres. Drug treatment and rehabilitation centres have also been established in other MENA countries, including Gaza & the West Bank and Saudi Arabia (IDPC report: First IDPC seminar on drug policy in the Middle East and North Africa).
Although this is a positive trend, many of these centres do not abide by international quality standards. Challenges with treatment programmes in MENA include: the lack of distinction between occasional and dependent drug use, the use of coercion to force people who use drugs into treatment facilities, and the absence of tailored treatment services to patients’ needs, as well as to the specific needs of women, youth, and other minority groups.
Another challenge is the fact that some drug laws are not adequately implemented. In Lebanon, for instance, drug laws theoretically give people who use drugs a choice between treatment and prison. However, the law also establishes that treatment centres must be affiliated with the Health Ministry. In practice, none of the existing treatment centres are affiliated with the Ministry, meaning that people charged with drug use are in fact sent to prison (read more).
Access to treatment services is also hampered by the social stigma associated with drug dependence, especially for women. In Iran, for example, although the harm reduction policy adopted in 2002 included women as a target group, efforts to target females who use drugs have been unsuccessful. This is largely because women are reluctant to access services as a result of widespread stigmatisation. Recognising that women-only drug treatment clinics attract females who use drugs that would not normally enter treatment, Iran established the Persepolis clinic for women who use drugs in 2007 in south Tehran (Six-month follow-up of Iranian women in methadone treatment). The clinic provided both treatment and harm reduction services (including methadone maintenance treatment and a needle and syringe programme). The uptake of services at the clinic was enormous, with nearly one hundred clients in the first year of operations. As of 2010, five of the 173 drug treatment clinics operating in Iran were for women only. In order to effectively target females who use drugs and the female partners of men who use drugs, more women-only drug services should be established. The need for gender-specific services is prevalent throughout MENA. Until services can be expanded, existing centres should allocate specific daily times for women only in order to increase their accessibility to treatment (The establishment of a methadone treatment clinic for women in Tehran, Iran).
Finally, in most of the region there are not enough treatment centres to meet the demand. For example, in Tunisia there is only one dependence treatment centre in Sfax operated by the NGO ATUPRET, and there is therefore a long waiting list of people who use intravenous drugs waiting to access treatment (IDPC report: First IDPC seminar on drug policy in the Middle East and North Africa). This is partly due to the fact that national health-care systems in North Africa often lack the financial resources necessary to establish comprehensive drug treatment programmes (African Union Plan of Action on Drug Control), but also because offering health services to people who use drugs is rarely considered as a political priority in the region.
Access to medical cannabis
There is limited information about the use of marijuana for medical purposes in MENA. Israel has a sophisticated and developed medical marijuana scheme and has funded and supported substantial research on the medical properties of cannabis. The number of cannabis patients in the country increased from 1,800 in 2008-2009 to 12,000 in 2013 (read more), indicating the success of the regulatory framework. To gain access to medical marijuana, patients must obtain a cannabis license from the Ministry of Health (after receiving a prescription from one of 20 doctors) and receive training from experts familiar with different strains (read more).
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