TRAPPED IN A NARCOTIC HAZE

Few Treatment Options for Afghans As Drug Use Rises

KABUL, Afghanistan -- Once a river flowed under the low Pul-i-Sokhta
bridge here, but now the thin stream is clotted with garbage, the
banks are piled with refuse and crowds of heroin and opium addicts
huddle in the shadows, some hanging like moths near the bridge's
supports, then slumping in the haze of narcotic smoke.

When outsiders venture in, dozens of the addicts -- there are 200 or
300 here on any given day -- drift over to see the newcomers. Most of
the visitors are health care workers trying to persuade the addicts
to visit their clinic for a shower and a medical screening.

"Are you taking names for treatment?" one man asks, his soiled salwar
kameez hanging loosely around his thin body. "Put me down, my name is
Zainullah."

This is another of Afghanistan's afflictions: a growing drug
addiction problem and all the ills that come with that, not least
H.I.V., the virus that causes AIDS, which can be transmitted when
addicts share needles. There were about 900,000 drug users in
Afghanistan in 2010, according to the United Nations Office on Drugs
and Crime, a marked increase from previous years. That means about 7
percent of the adult population of 14 million is using narcotics.

A vast majority take opium-based drugs, which are extraordinarily
pure here and very cheap -- about $3.50 for enough to get high,
addicts say. Afghanistan is the world's leading producer of opium
poppy, and the opium produced and sold here and its derivatives,
including heroin, are among the most potent on earth. About 150,000
of those using opium-based drugs are injecting heroin, according to
the World Health Organization.

A measure of the problem is that surveys show that 12 to 41 percent
of police recruits test positive for some form of narcotic -- most
are hashish smokers -- according to a recent report by the Government
Accountability Office. Another indicator of the problem is a recent
report by the Ministry of Public Health in partnership with Johns
Hopkins University that found H.I.V. present in about 7 percent of
drug users, double the figure just three years ago, said Dr. Fahim
Paigham, who until recently directed the Ministry of Public Health's
AIDS control program.

Unlike the situation in many countries, where H.I.V. is transmitted
primarily through sexual contact, in Afghanistan the primary
transmission is through shared needles.

The Pul-i-Sokhta bridge -- the name means "burned bridge" -- and
another bridge nearby are the most recent refuges for many of Kabul's
heroin and opium addicts who used to gather in the ruins of the
Russian cultural center on the east side of the city. They were
forced out in late 2010; although some remained in the neighborhood,
many came to the bridges.

Some come here every day to buy and use narcotics, crouching in the
dark corners to shoot up or gathering in small groups to heat the
opium powder until it melts into a black liquid and gives off smoke to inhale.

The ground under the bridge is thick with discarded syringes. Six
mornings a week a team of former addicts, nurses and a couple of
social workers from the French group Medecins du Monde (Doctors of
the World), a nonprofit health care organization, forge ahead into
this particular circle of hell, with large plastic disposal jugs in
one hand and long-handled pincers in the other to pluck needles from
the garbage. It is not uncommon to pick up 160 or 170 needles in a
morning. They hand out fresh needles and alcohol swabs, and the
nurses treats the addicts' seeping wounds where they have injected
themselves too many times.

Not all the addicts are sure they can tolerate treatment, and some
are so high they often make little sense. "I am the Bobby Devil of
this town," said a tall, bony young man in aviator glasses, cargo
pants and a plaid cotton shirt, who was sprawled next to a small
group smoking heroin, but had propped himself up on his elbows to
talk. Bobby Devil is the stage name of an Indian actor well known
here for his action movies.

"I've been using for four years," he added. "Last night I went home
with money and fresh fruit, and my wife and children told me to go
away. They said, 'You are a drug addict, you are a dog.' "

Could he quit? "Well, I can't decide; both my wife and the drug are
strong," he said and lay back down.

Many of the addicts say they want to stop using, but treatment
options are woefully few. The government, through some Afghan
nonprofit groups, runs several detoxification centers and is building
seven more, but the facilities offer almost no post-detoxification
support and have a 92 percent relapse rate, according to the Ministry
of Counternarcotics, which is involved in running them. The most
efficacious treatment -- opiate substitution therapy -- has been all
but blocked by the ministry despite pleas from the Ministry of Public
Health, whose doctors are worried about the rising incidence of H.I.V.

"The results from opiate substitutes like methadone are very
positive," Dr. Paigham said.

"If you stop using heroin, you stop using the needles, and if you
stop using the needles there is much less risk of spreading H.I.V."

Methadone is typically given in syrup form here. However, officials
at the Ministry of Counternarcotics are leery of it, perhaps because
they have the most experience with detoxification, but also, they
say, because the opiate substitutes do not cure addiction.

"It is the view in Afghanistan it is just substituting one addiction
for another," said Mohammed Ibrahim, the deputy minister of counternarcotics.

The ministry undermined the country's sole opiate substitution
effort, a pilot program run by Medecins du Monde that administers
methadone to 70 addicts. The program has been strongly endorsed by
the World Health Organization as well as by participants, and it has
a waiting list. However, the ministry twice blocked the import of the
methadone, making it all but impossible for the heavily addicted
participants to stick with the program.

For now the pilot program is running, but it has not been permitted to expand.

This year the number of drug addicts is expected to rise. Many
Afghans start using narcotics when they seek work in Iran, which has
one of the worst drug problems in the region. Increasingly, Iran is
expelling addicted Afghans, shipping them back across the border. A
few Afghan addicts say they were trying to quit while in Iran, which
has a comprehensive system of methadone clinics that provide the
drug, but most cannot imagine a way out.

"I started using in Iran from depression and sadness," said
Zainullah, 19, a Hazara man from Ghazni Province. "I was alone. There
was no one in Iran from my family. I went there to find work, and I
started smoking heroin."

He returned to his farming village and his nine siblings six months
ago, but a month later came to Kabul.

"Nobody likes a drug addict, so my family sent me here to quit," he
said, speaking softly. "Instead, here I am under the bridge, and I
have increased my dose since I came.

"If you could help me, please," he said, raising his thin arms as if
beseeching the aid workers. "I don't know how to stop."

Sangar Rahimi contributed reporting.