Drug abuse in Pakistan - United Nations Office on Drugs and Crime

ANNEX I. METHODOLOGICAL DISCUSSION
In addition, appropriate key <strong>in</strong>formants were also asked
these questions dur<strong>in</strong>g the national contour mapp<strong>in</strong>g part
of this study (component study 1). In this manner the
study team were confident that the national coverage of
this exercise was acceptably good and was estimated by
a local treatment expert at 90% or better.
Mak<strong>in</strong>g use of the component studies:
estimat<strong>in</strong>g the scale of hero<strong>in</strong> <strong>abuse</strong>
<strong>in</strong> <strong>Pakistan</strong>
In mak<strong>in</strong>g a practical and policy-relevant assessment of
the country's drug-<strong>abuse</strong> situation the first concern must
be the impact of illicit drug use on society with respect
to the problems caused and the social resources necessary
to remedy them. Some of these issues are addressed
<strong>in</strong> the component studies of the national assessment exercise
as discussed above. In many respects the critical policy-relevant
questions are “how does the drug <strong>abuse</strong> problem
make it self felt?” (i.e. problems) and “do current
responses address these problems?” Ly<strong>in</strong>g beh<strong>in</strong>d these
different aspects is the question of the current overall
prevalence of drug use, which is a useful summary guide
to and non-specific <strong>in</strong>dicator of the overall problem.
This importance of the value of prevalence estimates <strong>in</strong>
themselves should not be overstated. The development of
sound policy need not be reliant on an exact measure of
the current size of the abus<strong>in</strong>g population. Nonetheless,
hav<strong>in</strong>g a reasonable estimate of the size of different
aspects of the drug abus<strong>in</strong>g population is useful. It was
decided that this analysis should be <strong>in</strong>cluded <strong>in</strong> addition
to the other aspects of the study, rather than constitute
the only objective of the assessment exercise.
In <strong>Pakistan</strong>, <strong>in</strong> common with most countries <strong>in</strong> the world,
the prevalence figure for drug <strong>abuse</strong> is difficult to estimate
with any degree of accuracy. This difficulty underl<strong>in</strong>es the
need to focus on obta<strong>in</strong><strong>in</strong>g good data directly from the primary
problem areas, such as those <strong>in</strong>dividuals need<strong>in</strong>g
treatment. For example, <strong>in</strong>dicators such as the level of firsttime
demands for drug treatment are often <strong>in</strong> practice better
than overall prevalence estimates as a tool for monitor<strong>in</strong>g
drug <strong>abuse</strong> trends over time. This is <strong>in</strong> part because
they can be measured more accurately and more cost effectively
than actual prevalence can be estimated, <strong>in</strong> part
because they often serve as a better <strong>in</strong>dicator of <strong>in</strong>cidence
(new cases), and <strong>in</strong> part because they are a measure of
direct imp<strong>in</strong>gement of the drug problem on national
resources. It is important therefore that these po<strong>in</strong>ts of
contact, where the drug problem imp<strong>in</strong>ges directly on social
resources, are monitored as systematically as possible.
Ideally this should be done on a cont<strong>in</strong>uous basis, to provide
a future steady flow of <strong>in</strong>formation on trends <strong>in</strong> the
drug <strong>abuse</strong> situation. This is a topic we return to <strong>in</strong> this
report's conclud<strong>in</strong>g section where some of the options for
the ongo<strong>in</strong>g monitor<strong>in</strong>g of the drug <strong>abuse</strong> situation are
considered.
It was considered important <strong>in</strong> this study, however, to produce
a prevalence estimate for hero<strong>in</strong> <strong>abuse</strong> and drug
<strong>in</strong>ject<strong>in</strong>g. One reason for this was that current estimates
varied greatly and therefore there was considerable benefit
<strong>in</strong> generat<strong>in</strong>g a more reliable basel<strong>in</strong>e figure. The methods
used <strong>in</strong> this study to generate a prevalence estimate
for hard-core hero<strong>in</strong> use <strong>in</strong> <strong>Pakistan</strong> is described <strong>in</strong> detail
<strong>in</strong> the section of this report that conta<strong>in</strong>s the estimates
themselves. Here we provide a more general overview of
the pr<strong>in</strong>ciples beh<strong>in</strong>d the exercise.
In simple terms, two approaches are available to those who
wish to generate drug prevalence estimates for the general
population. The first is to conduct some form of conventional
household survey us<strong>in</strong>g established survey methods
and probability sampl<strong>in</strong>g. This approach has a number of
problems. Most importantly, household surveys are costly,
and as drug use is a stigmatized and low frequency behaviour,
surveys do not always produce conv<strong>in</strong>c<strong>in</strong>g estimates
even when considerable resources are <strong>in</strong>vested. This is
especially a problem for drugs like hero<strong>in</strong>, whose use is
often particularly stigmatised. A pilot household survey
approach was tested <strong>in</strong> the 1986, national assessment study
<strong>in</strong> <strong>Pakistan</strong>. The results were extremely disappo<strong>in</strong>t<strong>in</strong>g at it
was concluded that this method was not appropriate to
record<strong>in</strong>g drug <strong>abuse</strong> <strong>in</strong> <strong>Pakistan</strong>. Among the reasons for
this were the difficulties <strong>in</strong> generat<strong>in</strong>g an appropriate sampl<strong>in</strong>g
frame and the simple fact that is was not considered
likely that respondents would admit to drug use <strong>in</strong> the
household sett<strong>in</strong>g. These problems are not specific to
<strong>Pakistan</strong> and, arguably, household survey work never performs
well for the measurement of hard-core drug <strong>abuse</strong>.
These problems lead the research team <strong>in</strong> discussions with
<strong>Pakistan</strong> Government to rule out this approach as a sensible
option for this study.
The second approach to prevalence estimation rests on
more recent work to develop <strong>in</strong>direct statistical techniques
for this purpose. These “benchmark/multiplier” methods
rema<strong>in</strong> relatively new but are now seen as hav<strong>in</strong>g merit for
estimat<strong>in</strong>g the prevalence of the use of drugs like hero<strong>in</strong>,
even <strong>in</strong> countries with a long tradition of conduct<strong>in</strong>g household
surveys.
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