Background and aims
Drug abuse is a significant social and public health problem in Iran. The present study aimed to provide prevalence estimates and information on correlates of illicit drug use ...disorder and opioid dependence, as well as service use for these disorders in Iran.
Design, setting and participants
This report is based on the Iranian household Mental Health Survey (IranMHS) conducted in 2011. A three‐stage probability sampling was employed. Face‐to‐face interviews by trained psychologists were carried out with a nationally representative sample of 7841 individuals (3366 men and 4475 women) aged 15–64 years.
Measurements
The Composite International Diagnostic Interview and questionnaires for socio‐demographic correlates and service use.
Findings
The prevalence of 12‐month use disorders for any illicit drug according to DSM‐IV and DSM‐5 criteria were 2.09% 95% confidence interval (CI) = 1.70–2.47% and 2.44% (95% CI = 2.03–2.85%), respectively. Opioid use disorders, and opium in particular, were the most common use disorder. The odds of drug use disorders were greater in men than in women, in previously married participants than in currently or never married participants, and in participants with lower socio‐economic status than in those with higher socio‐economic status (all P‐values <0.05). Approximately half of those with drug use disorders and 40% with opioid dependence had a 12‐month unmet need for treatment. Self‐help groups were the most common type of service used, followed by obtaining medication from pharmacies directly and outpatient treatment services.
Conclusions
Opioid use disorders are the most common type of drug use disorders in Iran, setting Iran apart from many other countries. Patterns of service use suggest a large unmet need for drug use disorder treatment in Iran.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background and Aims
Misuse of tramadol, an opioid prescription analgesic, is known as a public health challenge globally. We aimed to systematically review studies on the prevalence of non‐prescribed ...use, regular tramadol use and dependence, tramadol‐induced poisoning and mortality in Iran.
Methods
Consistent with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, international (Medline, Scopus, Web of Science) and Persian (SID) databases were systematically searched up to June 2019. Other relevant data were collected through personal contacts and review of reference lists. Pooled estimates of prevalence of tramadol use in subgroups of males and females, percentage of tramadol poisoning among admitted poisoning cases, tramadol‐associated seizures and mortality among tramadol poisonings and percentage of tramadol as a cause of death among fatal drug‐poisoning records were estimated through a random‐effects model.
Results
A total of 84 records were included. Pooled estimates of last 12‐month use of tramadol in the Iranian general population were 4.9% 95% confidence interval (CI) = 4.1–5.9 and 0.8% (95% CI = 0.2–1.8) among males and females, respectively. The estimates for last 12‐month use among Iranian male and female university students were 4.8% (95% CI = 1.9–8.9) and 0.7% (95% CI = 0.3–1.1), respectively. Six heterogeneous reports indicated the existence of regular use of tramadol and dependence in Iran. Sixty‐two studies provided data on tramadol‐induced poisoning, seizures and mortality. The pooled estimate of the percentage of tramadol poisoning among all drug‐poisoning patients was 13.1% (95% CI = 5.7–22.9). The overall estimates of seizures and mortality among tramadol‐poisoning patients were 34.6% (95% CI = 29.6–39.8) and 0.7% (95% CI = 0.0–1.9), respectively. The pooled percentage of tramadol‐related fatalities among drug‐poisoned cases was 5.7% (95% CI = 0.5–15.4).
Conclusion
Despite control policies, tramadol use is as prevalent as the use of illicit opioids in Iran. Numerous cases of tramadol abuse, dependence, poisonings, seizures and hundreds of tramadol‐related deaths have been reported in recent years.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Aims
In Iran, injecting drug use has been the major route of human immunodeficiency virus (HIV) transmission. In order to control the HIV epidemic, a harm reduction program was initiated and has been ...expanded in recent years. The aim of this study was to provide an updated estimate of HIV prevalence among people who inject drugs (PWID) in Iran, investigate prevalence differences over time and assess prevalence correlates.
Design
A comprehensive systematic review was undertaken in the international, regional and national bibliographic databases in November 2018 and extensive contacts with authors were made. For studies conducted before 2005, we used data from a previous published systematic review.
Setting
All studies conducted in Iran were included. Recruitment settings included anywhere except studies conducted in infectious diseases wards or HIV counseling centers.
Participants
PWID with any definition utilized in the studies. Thirty‐six studies were included, which were conducted in 24 of 31 provinces with a sample size of 22 160 PWID.
Measurements
We included studies that had performed HIV testing and had a confirmed diagnosis of HIV through repeating the enzyme‐linked immunosorbent assay (ELISA) or Western immunoblot assay (WB). Pooled prevalence of HIV was calculated for the total sample and for different subgroups, by available socio‐demographic and behavioral factors. For assessing the trend of HIV prevalence over time, a linear meta‐regression model was fitted separately for before 2007 and during 2007 and afterwards.
Findings
The pooled prevalences of HIV before 2007 and in 2007 and afterwards were 14.3% 95% confidence interval (CI) = 9.8–18.9 and 9.7% (95% CI = 7.6–11.9), respectively. HIV prevalence increased until 2005–06 and then slowly declined until 2009–10, which was not significant. Prevalence of HIV was significantly higher in PWID above age 25 years, and in those with history of imprisonment and history of needle/syringe‐sharing. HIV prevalence was higher in men than in women, but the difference was insignificant.
Conclusion
The prevalence of HIV among people who inject drugs in Iran decreased after 2006 which could, at least in part, be attributed to the development of extensive harm reduction programs in the country.
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Backgrounds and aims
Iran has 2.1 and 1.8% of its 15–64‐year‐old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a ...large and multi‐modality addiction treatment system, spanning the time before and after the Islamic Revolution.
Methods
Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop‐in centers providing low‐threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence‐based residential centers. We will review the evolution of this system in four phases.
Results
In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non‐agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid‐maintenance programs has been implemented to reduce HIV‐related high‐risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court‐based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization.
Conclusion
Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Following approval of the ICD‐11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD‐10 to the ICD‐11, with reporting of health ...statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders following ICD‐11’s approval. The development of the ICD‐11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD‐11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture‐related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery‐based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD‐11 classification of mental disorders as compared to the ICD‐10, and the development of two new ICD‐11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD‐11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD‐11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD‐11 and in preparing for implementation in their own professional contexts.
Background and Aims
There is a paucity of data on outcomes of opioid use disorder (OUD) from low‐ and middle‐income countries. We aimed to investigate the mortality as well as negative social and ...health outcomes in a 6‐year follow‐up study of a cohort of individuals with opioid use, including those with OUD, in Iran.
Design and setting
Participants with opioid use initially interviewed in late 2011 in the Iranian National Mental Health Survey (IranMHS)—a household survey of 15–64‐year‐old population—were followed‐up in early 2018.
Participants
All respondents (n = 236) who had reported use of any opioids at least five times during the 12‐month period prior to the index interview were included in the study.
Measurements
Composite International Diagnostic Interview (CIDI) version 2.1 was used for assessment of opioid use and OUD at baseline. Vital status in the follow‐up was ascertained through contact with participants/informants, primarily via telephone calls and also through the death registration systems. Weighted incidence rates of negative consequences of opioid use (e.g. incarceration, suicide attempts, violent behavior) were estimated for those who were interviewed.
Findings
Seven (3.3%) of the 236 participants with opioid use including four (3.1%) of the 136 with OUD had died by the time of the follow‐up interview, resulting in death rates of 0.49 95% confidence interval (CI) = 0.21–1.38 and 0.53 (95% CI = 0.16–2.62) per 100 person‐years, respectively. Overall, 35.0% of participants with opioid use and 44.0% of those with OUD among the 145 individuals interviewed at follow‐up experienced non‐fatal serious adverse outcomes.
Conclusions
In Iran, opioid use and opioid use disorder are associated with increased mortality and other adverse outcomes.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background and ams
Despite the evident public health impact, the extent and patterns of alcohol use in the Eastern Mediterranean countries remain understudied. The latest estimation for the last ...12‐month use of alcohol in the region was 2.9% in 2016 by the World Health Organization. We reviewed the main indicators for alcohol consumption in the region since 2010.
Methods
We systematically searched on‐line databases until September 2023, together with other global and regional sources for studies on the adult general population (aged ≥ 15 years) and young general populations (aged < 18 years) and studies on the treatment‐seeking individuals with substance use in Eastern Mediterranean countries. Studies were included from 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen.
Results
A total of 148 were included (n = 95 on the prevalence of alcohol use, n = 46 on the prevalence of alcohol use disorder, regular use and heavy episodic drinking, n = 35 on alcohol use pattern among people who use substances and one report on alcohol per capita consumption, n = 29 had data for more than one category). The pooled prevalence of the last 12‐month alcohol use in the adult general population was 9.5% 95% confidence interval (CI) = 6.4–13.7 among males, 2.8% (95% CI = 1.3–5.5\) among females and 6.2% (95% CI = 3.9–9.6) in both sexes in the region, with notable subregional variations. Data on the prevalence of alcohol use disorder and heavy drinking were limited to several countries, with heterogeneous indicators. The pooled estimate of alcohol as the primary substance of use among treatment‐seeking people who used substances was 16.9% (95% CI = 8.8–26.9).
Conclusions
More than 30 million adults in the Eastern Mediterranean region used alcohol in the last 12 months, with a prevalence of 6.2%. This is far fewer than the global estimate of 43% of the population aged 15 years and above, but is approximately two times more than the previous estimate (2.9%), reported by the World Health Organization in 2016, which might show an increasing trend.
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We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The ...Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3–47·9 million) and 109 500 people (105 800–113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes—eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background and aims
Following the recognition of ‘internet gaming disorder’ (IGD) as a condition requiring further study by the DSM‐5, ‘gaming disorder’ (GD) was officially included as a diagnostic ...entity by the World Health Organization (WHO) in the 11th revision of the International Classification of Diseases (ICD‐11). However, the proposed diagnostic criteria for gaming disorder remain the subject of debate, and there has been no systematic attempt to integrate the views of different groups of experts. To achieve a more systematic agreement on this new disorder, this study employed the Delphi expert consensus method to obtain expert agreement on the diagnostic validity, clinical utility and prognostic value of the DSM‐5 criteria and ICD‐11 clinical guidelines for GD.
Methods
A total of 29 international experts with clinical and/or research experience in GD completed three iterative rounds of a Delphi survey. Experts rated proposed criteria in progressive rounds until a pre‐determined level of agreement was achieved.
Results
For DSM‐5 IGD criteria, there was an agreement both that a subset had high diagnostic validity, clinical utility and prognostic value and that some (e.g. tolerance, deception) had low diagnostic validity, clinical utility and prognostic value. Crucially, some DSM‐5 criteria (e.g. escapism/mood regulation, tolerance) were regarded as incapable of distinguishing between problematic and non‐problematic gaming. In contrast, ICD‐11 diagnostic guidelines for GD (except for the criterion relating to diminished non‐gaming interests) were judged as presenting high diagnostic validity, clinical utility and prognostic value.
Conclusions
This Delphi survey provides a foundation for identifying the most diagnostically valid and clinically useful criteria for GD. There was expert agreement that some DSM‐5 criteria were not clinically relevant and may pathologize non‐problematic patterns of gaming, whereas ICD‐11 diagnostic guidelines are likely to diagnose GD adequately and avoid pathologizing.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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