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Opium use in Turkmenistan: a historical perspective

      By Nina Kerimi, Department of Psychiatry, The Turkmen StateMedical Institute, Ashgabat, Turkmenistan Addiction, Sep 2000, Vol. 95 Issue 9, p1319, 15p
      Abstract
      This paper presents a picture of how the patterns of opium use have changed in Turkmenistan over more than 100 years and the relationship between these transformations and formal and informal social controls of drug use.
      >From the late 18th century, when opium use began to become a social problem, informal control weakened. Eventually, in the late 19th century, formal control was introduced, aimed at the prohibition of drug trade and use.
      >From that time, the intended and unintended outcomes of implemented policies led to changes in the demographic patterns of users and the social-medical consequences of opiate use. The anti-drug policies, where criminal prohibition coexisted with strategies aimed at raising the population's general living standards and at providing free access to health care, were effective up to the early 1980s.
      New political and social-economic realities in the 1980-90s have radically changed the drug scene in the country, with heroin trade and use as the main concerns. The government's reaction, while following the old paths, has included new elements, based mainly on ideas of national consolidation.

      Introduction
      The natural properties of opium have determined its primary role as a popular medicine since ancient times. With the development of modern societies, opium's repertoire of use has changed and broadened.
      This paper describes how patterns of opium use in Turkmenistan have changed over more than 100 years and how these changes relate to formal and informal social controls on drug use. It is based on data from the National Archives of

      Turkmenistan and on previous research.
      The analysis focuses on the use of opium, taken separately from other psychoactive substances such as alcohol and cannabis, which have also played their role in shaping the contemporary drug related situation in Turkmenistan. The paper presents a generalized picture of how the patterns of opium use have changed, leaving unanswered questions about why.

      The deep background
      One of the frequent (if arguable) citations regarding drug use in Central Asia is Herodotus' (5th century BC mention of the Massagets' custom of inhaling smoke from burnt poppy heads, for the purpose of inducing euphoria.(n1) Massagets are an ancient people who inhabited the Northern coast of the Caspian sea and one of the supposed ancestors of Turkmens.
      Some authors claim that the soldiers of Alexander the Great: carried both opium and poppy seeds with them on their way to conquer the known world, thus introducing opium to the countries lying east from Asia Minor.(n2)
      Another view is that opium was imported to the region as a trade commodity (pharmaceuticals) from the countries where it was widely used as a medicine (Egypt, Greece, Rome, Byzantium.(n1, n3 ,n4)
      The Greek word theriaka, meaning "opium remedy" (invented by Andromachus, physician to the Emperor Nero (1st century AD) and described by Galen (2nd-3rd century AD),(n1, n3) has remained practically unchanged in the Turkmen word ter'iak for crude opium (as well as in the language's predecessors--Dari and Farsi). Another synonym of the word, nasha, brought supposedly by Arab merchants (who dominated the Silk Road trade from the 8th to 14th centuries,(n1, n2, n4) has been used by Turkmens for stupefying substances in general (more often for cannabis).
      One more name for crude opium used in the current colloquial Turkmen language is gara derman (of Turkic roots) translated as "black medicine". These names reflect the two primary functions of opium since ancient times: a panacea in illness and a means of pleasure in recreation.
      The ancient and medieval medicines containing opium were generally prescribed as solutions or in a paste. Slow absorption of the drug when ingested in these forms and the presence of opium's "inactive" gum-like substances and other ingredients modified and attenuated its psychoactive effects.(n4, n5) In fact, the best-appreciated risk of extensive medicinal opium use at that time was accidental or intentional overdose.(n1, n2, n4) Opium dependence as a result of treatment was generally accepted as the price one paid for the relief of disease symptoms.(n1, n2, n4)
      More serious problems, such as epidemics of infectious diseases, malnutrition, endless wars and intertribal skirmishes, were causes of a high mortality rate and short life expectancy. Those factors outweighed the negative consequences of opium use.
      Although recreational opium use had become common in the Muslim world from the Middle Ages onward, there were unwritten rules on the quantities used and modes of behaviour under its influence that held socially unacceptable consequences of opium consumption in check.(n2, n4) Indications of opium addiction as an emerging social problem in the Orient during the 18th century came from reports by Europeans who travelled to the East.(n1, n4)
      The surge in opium use among the peoples of the Near and Middle East and Indo-China was made possible by increased availability of opium in social conditions, boosting its demand.(n4)
      In the 16-19th centuries Egypt, Turkey, India and Persia became the world's main exporters of opium.(n1, n2, n4) From the late 18th century, "opium growing and production became in places a highly organized, efficient and lucrative industry". Development of means of communication and transport in the region and expansion of international trade made even imported opium cheaper.(n4)
      Another important factor that had an impact on the drug situation was the spread of a new mode of opium use: smoking, in addition to the existing practice of opium eating. This new fashion most probably came from China where, since the late 17th century, opium smoking had been seen as a social disaster.(n1, n2, n4)
      The shift to smoking played a major role in emphasizing the pleasure-giving property of opium, with subsequent use beyond the medicinal and increased risk of developing dependency. Cases of opium addiction became common.(n4, n6)

      Thus, two factors, increasing availability of opium and a new method of consumption (smoking), gave a momentum to the metamorphosis of opium from panacea to evil. The underlying cause of this conversion was the profit gained from the opium trade.(n1, n4)
      The appointment of special inspectors for finding and destroying opium dens in Central Asia came at the time of emirates and khanates in the late 18th century.(n7) These were buffer states governed by Emir or Khan, respectively, and existed in Central Asia in the 18-19th centuries. This was a sign of a new social problem arising and an indicator of the first efforts, albeit unsuccessful, to establish formal control of the drug situation.

      Turkmen folk tales and the works of poets and writers from the 18th to the early 20th century depict a wide variety of circumstances of opium use, as well as the medical and social consequences.(n8-n11) Opium smoking was described as a pernicious passion and a sin; it was a great shame for the user's family (no one would marry the son or daughter of a ter'iaktchy, scornful names for a social maladjusted opium addict). The attitude to the dependent person, especially in a case of overt social maladjustment, was absolutely negative. He was treated with contempt and repudiated by all.(n8-n12)       Beginning of the struggle (the late 19th-the early 20th century)
      Joining the territory of Turkmenistan to Russia in 1881 became an important historical point marking the beginning of transactions between two mainly distinct cultures. It also determined the specific development of the drug-related situation in Turkmenistan in the forthcoming epoch. Surveys (1882-1911) by the Russian administration of the Trans-Caspian District, as this territory was called, show the situation through the eyes of newcomers The surveys and other archive documents are invaluable evidence of the social context of opium use in Turkmenistan at the end of the 19th and beginning of the 20th century. They reflect how the new rulers perceived the Turkmen culture as a whole; how they dealt with the problem of opium use, and how this shaped the anti-drug policy of Russia.
     At the time of joining, the Turkmen nation consisted of nomadic (cattle breeding) and settled (peasant) tribes. The living standards of the population were very low. The Russians, while acknowledging such positive features of Turkmen as honesty, respect for the elderly and the existence of a system of informal social control, pointed to the peoples' extreme ignorance, superstition and illiteracy:
     A Turkmen who can read is rare, but the one, who besides reading, can write is an exception.(n13)
     Strangers also had an impression that Turkmens were not religious and that there was no fanaticism of any kind. Most of the local people did not follow religious rituals and had no clear understanding of Muslim holidays.(n13)

      This notion is concordant with the known particularities of the spread of Islam in Central Asia (the religion only for a few selected nobles.(n14) It also supports the assumption of the absence of any religious use of opium by Turkmens. With regard to folk holidays and celebrations, reporters assessed them with the words: "entertainment and amusement of Turkmen are extremely plain".(n13)
      One more observation is important when analysing opium use in the Trans-Caspian District at that time; namely, the Turkmens' attitudes to disease and treatment. Turkmens called for tabibs (local healers) or physicians (Russians) only if they suffered severe and chronic diseases:
     ... most of them persistently demanded medicines as an inalienable part of the treatment. They ignored the advice of sanitary and hygienic character.(n13)
     The czarist analysts did not connect opium use by Turkmen with these social-cultural features. However, the Russian administration was concerned with the drug-related situation in the province; opium use was thought to be the main cause of inability to pay taxes and of the population's poor health. Opium consumption was seen as a predominantly Persian custom, especially widespread in the areas close to the border with Persia.(n13)

      Opium addiction was considered ambivalently as a sin and at the same time as a disease:
     ... public health is being badly affected by Turkmens' opium smoking. The passion for opium had already taken roots among Turkmens, before the Russians came to the territory. Nowadays, ter'iaktchy-Turkmens are far from rare in the Trans-Caspian District. The predilection for opium had passed to Turkmens from Persians. Opium was obtained in Persia and transferred [to the District] under the name of "teriak".(n15)
     The idea that opium was brought to the District and was being sold to Turkmens exclusively by the "Persians" ran through all the czarist administration's documents related to opium in the Trans-Caspian area.(n13, n15-n18)
     This conclusion was valid since the main trade route to the new Russian province lay from Persia. The agricultural crisis in Persia in the middle of the 19th century influenced immensely the speed of the diffusion of opium addiction throughout the territory: After 1860, when silk-worm disease had undermined sericulture, the area under opium poppy crops began to advance rapidly in Persia.(n19)
     Since the 1860s, because of its high profitability, the opium poppy had become widely cultivated in Persia: 18 out of 30 Persian provinces grew opium poppy. Export was allowed and opium smuggling was also flourishing.(n19)

      Russian agricultural surveys of that time say nothing about opium poppy growth in the Trans-Caspian District, although there is a mention of cultivation of the plant in Semirech'ie, another Central Asian province of the Empire (territory of modern Kyrgyzstan).(n13, n15, n20-n22)
     Attempts to decrease the prevalence of opium smoking and reduce the harm to Turkmens led to the Decree on the Prohibition of Opium Import to the Trans-Caspian District issued by the Emperor of Russia in 1891.(n16a)
     The edict forbade opium import to the province (even for further transition to Europe), trade and consumption of the drug (strictly speaking, only opium smoking was forbidden.(n16a, n16b, n17) Repressive measures were directed at opium dealers and consumers. An effort was made to engage Turkmen communities in solving opium use problems. As the District Governor's order stated:
     If taxes are not paid by an opium smoker, the whole arrears will be taken from the community at large." ... the most stubborn smokers ... have to be arrested, while the cost of their accommodation [in custody] should be put on the relatives' account.(n16a)
     According to the order, the Turkmen senior representatives (village foremen) had to carry out a search for opium in the homes of known opium smokers and seize the drug and paraphernalia for smoking. The Governor, General Kuropatkin, gave the foremen a mandate for surveillance of the drug-related situation and demanded regular information on the process of implementation of the order.(n16a) At the same time, the administration noticed that the Turkmen communities themselves regulated their relations with drug addicts:
     There is a moral retribution of opium consumers, arisen spontaneously, in Tekke [implying the Turkmen people] midst. Those people [addicts], according to Adat [court based on Adat, previously only a court of appeal], are not allowed to participate in the community's assemblies, they do not have a right to vote, and are not eligible to be subpoenaed as witnesses in whatever case.(n16b)

      In addition, The natives, being completely conscientious about harms done by opium smoking, have submitted a petition to the Chief of the District asking about permission to prosecute opium smokers and indigenous opium dealers by the People's Court.(n15)
     There is no record of whether all these measures were ever implemented and if so, of the outcome. Given the poverty of the population, drug addicts' relatives are unlikely to have paid for involuntary custody. However, there are documents on solitary drug-related trials.(n18, n20-n22) Turkmens also volunteered to help capture opium smugglers although there was a hint of suspicion that the volunteers had misappropriated some part of the confiscated opium.(n18)
     Evaluation of the success of the prohibitive measures was contradictory. One of the Russian surveys stated:
     The struggle gave good results: recently there were not more than two or three law suits involving opium smokers, that, in comparison with previous years, comprised a very insignificant percentage [of all cases].(n15)
     Nevertheless, other data from the archives provide evidence that opium smuggling from Persia to the Trans-Caspian District and further to the East was going on and that Turkmens themselves were involved in the smuggling.
     Moreover, armed groups of contrabandists had emerged.(n23, n24) It became clear that opium came to the Trans-Caspian area not only directly from Persia; but also from Afghanistan, India and Semirech'ye.(n17, n19)
     The Russian public also expressed worry over the drug-related situation in Central Asia. In 1908, the Novoye Vremya (New Time) magazine published a notice about opium import and use in Turkestan (the territory of Central Asia being, in the 19th century, under Russian rule), pointing out the extreme harm produced and blaming the local administration for an inadequate response to the situation.(n22) The reaction to this notice, presented in the memorandum from the Office of the Turkestan governorship "On Measures Taken Against Diffusion of the Narcotic Substances Among the Population", was sanguine:
     Although, opium and hashish are used in the District, but ... in such a subtle size, that this does not evoke any apprehension about the health of the population at large and even about the health of its [at-risk] groups; besides, the struggle against this evil has been carried on quite satisfactorily by the available personnel of the local police.(n22) However, the Chief Administrator of the Turkestan territory, General Samsonov, appends his instructions which were less dismissive of the problem:
     I can not agree [with the assessment]; comforting information from Mr.'s Military Governors does not reassure me, therefore, order them to strengthen surveillance of opium smokers and narcotic drugs dealers.(n22)
     The issue of treatment of drug addiction was not even raised. A psychiatric unit in affiliation with a general hospital for the Russian military and administrative personnel in Ashgabat was organized in 1915, but its capacity was very limited and, in addition, alcohol and drug dependence were not considered psychiatric disorders.(n25)

      New power--new policy
      The First World War and a series of revolutions changed the political and social system of all Russia. In 1924 the Turkestan territory was divided into new administrative regions, and the Turkmen republic was created as a sovereign state subject of the USSR. What did the new power encounter in Turkmenistan?
     There were problems everywhere. Poverty was rife. Tuberculosis, syphilis, trachoma and other infectious diseases were raging.(n26-n28) The mortality rate was high in all age groups, but especially appalling among babies and women. Public health and education systems were non-existent. Only 1% of Turkmen men (to say nothing of women) were literate.(n26-n28)

      Information collected by soviet ethnographers, historians and medical professionals in the 1920s-30s showed that the most common use of opium by Turkmens was as a remedy:(n27-n29) "opium and uy-ley root (liquorice) are considered the best medicines ...".(n29)
     Physicians observed that Turkmens appealing for medical aid expected to recover instantly just by one intervention.(n27) Opium was not only taken orally (eating opium gum or drinking opium solution were the most frequent modes) or by smoking, but also was used for eye-drops and external compresses.(n29) Babies could be given a decoction of poppy straw (ghok-nar) or thin ter'iak solution in cases of diarrhea, cough and restlessness; women used opium (as a rule orally) to control acute and chronic pain and to treat "the blues"; old people drank poppy straw "tea" more or less regularly for alleviation of minor chronic health disorders.

      The mild stimulatory effect of raw opium taken orally (due to the presence of alkaloids with strychnine-like effect and slow absorption(n5) also allowed its use as a means for better adjustment during hard physical labour or in a difficult psychological situation.(n11) In this role ter'iak or ghok-nar were used by shepherds who stayed at remote pastures in the mountains and by crop-collectors working in the cotton fields. Dosage and duration of drug-taking were regulated by healers or by "patients" themselves. As a treat, opium was offered to the (mature) male guests at a wedding or other parties; the drug could also be used by an individual in private, as an indulgence after the working day or during leisure time.(n26-n29)

      The investigators concluded that opium use was prevalent, the doses used were high, habituation was quick and eventually the addiction ruined the life of ter'iakkesh: "... the smoker of ter'iak is considered ill and peoples' attitudes to him are based on this assumption".(n27)
     The folk methods of dependence treatment varied from a "cold turkey" approach to virtual detoxification of the patient by gradually lowering the concentration of the opium solution taken (eventually it became just water), until signs of withdrawal were gone. Visits to sacred places and magic amulets were also in use.(n26, n27, n29, n30) As for the dosage, there are indications that daily doses of ter'iak varied from 10 to 100 g depending on how the drug was used (larger doses when eaten).(n27, n28) At that time, smuggled Persian ter'iak sold retail in black markets contained not more than 1-4% of morphine,(n16c, n17) thus 100 g of ter'iak was equivalent to 1.0-4.0 g of morphine.
     Addiction was perceived as a male problem; a special report described a woman addict with a feeling of surprise.(n30) Women's addiction was invisible because women were socially invisible. Norms and traditions limited the sphere of their activities to "the porch of the yurt".(n31) Being the main housekeeper, a woman was absolutely dependent on her husband or older male relatives. Her husband could give her ter'iak as a mercy in illness or as a reward. It was not uncommon for a ter'iaktchy husband to deliberately accustom his wife to the drug to avoid her discontent.(n28)
     Women usually started using opium in middle and old age (after accomplishing their generative functions). The proportion of women addicts had always been significantly less then men (for more on women, see).(n33, n34)
     Officially, opium addiction was defined as a "social disease", determined by poor social conditions and superstitions which were deemed to be "vestiges of the past".(n27, n28) In the 1926 Annual Report of the Commissar of Public Health on the public health status in Turkmen SSR, a special chapter was devoted to the problem of opium use. The report stated: "Opium smoking, highly prevalent in the Republic, necessitated organization of a special unit for treatment of drug addicts".(n27) This explains the opening of a 30-bed unit in the neuropsychiatric hospital in Ashgabat in 1925.
     The unit organization was a first step in creating a specialist service for the treatment of substance use disorders (narcological service) in Turkmenistan. It gave physicians an opportunity to start registration and clinical observation of opium dependence in Turkmenistan.
     The first, very brief, clinical descriptions were made in the late 1920s.(n28) The effectiveness of the treatment of the first 238 patients was assessed very optimistically: "50% of those who had undergone the treatment, got rid of their disease forever".(28) After the late 1920s the treatment of drug addiction became routine.(n32)
     During the 1920s opium continued to be smuggled across the border with Iran. Experts assessed the size of illegal opium sales inside Iran, together with its contraband flow to other countries, as coming up to 100 tons a year.(n19) The Soviet authorities reacted to the severe drug-related situation in the country (not only in Turkmenistan) by issuing a series of laws aimed at decreasing opium availability.
     The laws declared a State monopoly for the trade and processing of opium (1926), the prohibition of unauthorized circulation of opium and other narcotic drugs on USSR territory (1928) and prohibition of opium poppy cultivation by individuals (1934).(n27)
     Another judicial measure included limiting the civil rights of opium smokers. To increase peoples' awareness of the consequences of violating the law, public trials of opium den landlords were organized.(n27) In 1928, the voluntary Society for Fighting Alcoholism and Drug Addiction was created in the Republic. The society began anti-alcohol and anti-drug education campaigns. Educational material covered the medical-social consequences of substance abuse, with a strong emphasis on the moral side of the problem.(n35a, n35b) The struggle against opium abuse was but a small piece of the huge picture of radical social change. The foundations of public education, health care and women's emancipation were laid. Immigration of the intelligentsia (teachers, doctors, engineers, etc.), mainly from Russia but also from other republics of the Soviet Union, altered the traditional culture and shaped a new morality and a new identity for the people of Turkmenistan. The immigration flow continued until the 1960s. Since that time Turkmenistan's population balance (around 45% of urban and 55% of rural dwellers) has been stable. Non-Turkmen immigrants settled mostly in the cities, especially in Ashgabat (at different times Ashgabat hosted 30-50% of non-Turkmen dwellers). In rural areas, more than 98% of residents were Turkmens.(n36, n37)

      Statistical data or documents about the severity of the problem from the late 1930s to the late 1950s are missing. Many documents (including hospital reports and other sources of statistics) were lost during the devastating earthquake in Ashgabat in 1948. Despite lack of documentation, it is believed that there was no surge in opium use during the Second World War and after the earthquake.(n12, n32) After the war, narcotic drug abuse was not a social problem for the major part of the Soviet Union and drug dependence became a less common diagnosis. However, Turkmenistan was first among the 15 republics of the Soviet Union in incidence and prevalence indices of narcotic drug use. A wide variety of situations, reasons, dosages and modes of opium use had brought diverse outcomes: from occasional use without increased tolerance for a score of years to severe dependence with devastating medical-social consequences.(n7, n33)
     Specific forms of mitigated opium dependence, so-called latent and passive dependencies, were described.(n32, n33) There were also a few published(n7) and unpublished descriptions of alleged "opium psychoses" in the 1950-60s seen mainly in forensic practice). Early clinical descriptions gave "the opium addict's typical habitus".(n28, n32) However, over time, when the problems of malnutrition were solved and the general health of the population became better (and opium doses smaller), specific health disorders resulting from opium use were not mentioned.(n33) Typically, development of opium dependence took months, tolerance grew slowly, drug users were socially adjusted for a long time and criminality among them was low.(n12, n32,n36,n38,n39)
     The main source of ter'iak or ghok-nar for this type of user was illegal opium poppy cultivation on small patches of land in hidden places. The harvest, usually small, was used by the grower himself and could also be sold secretly in the neighbourhood or transported to the city. This traditional model of opium use (with all its variations) was the only one that existed in Turkmenistan until the late 1960s.
     At that time, living standards in the Soviet Union improved gradually. Although Turkmenistan had always been behind the other Soviet republics with regard to social-economic indicators, positive social changes obviously influenced the drug-related scene. Among them were the increased level of population education (almost total literacy) and development of public health care, with universal coverage and free access to treatment. One more important factor was consistency in the anti-drug policies. The clear official message that opium use was illegal and punishable, plus effective availability control, made the drug more expensive and its use more perilous.
     Intercultural influences and the official ideology strengthening formation of a new supernational, Soviet identity, that rejected "old superstitions", also played a role.(n33, n36, n39, n40) All these factors made opium use in many instances an unnecessary and risky venture. Meanwhile, another problem overtook the USSR government's attention: the growth of alcoholism. To increase the effectiveness of the alcohol policy, several decrees and laws were issued in the 1960s-70s. Among these were the decrees on compulsory treatment of alcoholism and drug dependence. Under the laws individuals with antisocial behaviour who were avoiding voluntary treatment had to be sent to court (after medical examination and resolution of the medical commission). The court then decided whether compulsory treatment was necessary. It was an attempt by central government to tackle the large problem of alcoholism and the minor one of drug addiction in concert. The anti-drug policies, while not publicly discussed, were designed, implemented and enforced in parallel with anti-alcohol measures. Widening the network for voluntary treatment of alcoholism and drug addiction was paralleled by the creation of institutions for coercive treatment within the penitentiary system.
     Notification to the police of illegal drug users detected by the medical profession, mandatory medical examination of those under suspicion and the treatment course, if drug dependence was confirmed, became obligatory. Patients with medically confirmed drug dependence (later on, also drug abusers without signs of dependence) were double-registered: at the psychoneurological dispensary and at the local police station. Illegal drug use was criminalized; censorship was introduced for publications on drug use; anti-drug public education faded. Research was scarcely performed.
      Statistics and epidemiological data on narcotic drugs were categorized as classified data and could not be published in regular scientific journals but only as documents for in-service use. Also, there were too many permissions to be obtained before starting research. In some instances, the researcher had to sign an undertaking not to divulge the results. All this shifted research to the clinical-biological side where there were fewer restrictions.
     The main changes in opium use observed through the 1960s-80s related mainly to situations of opium use and the demographics of drug consumers. Children and women became even more rare consumers. Rural men, middle-aged and especially the elderly, represented the largest category of opium users. The former were using opium mainly for recreation or as a means for better adaptation, the latter continued with opium use to "maintain health". The average daily doses of crude opium ranged from 0.5 to 4.0 g. The number of registered cases dropped almost twofold in the period 1971 to 1988 (from more than 6000 to about 4000 while the population grew from 2.3 million to 3.5 million). It should be noted that 1988 saw the peak of the anti-drug activities, meaning that detection and registration of drug users were carried out with great zeal.(n33, n36, n38)
     However, after the early 1970s cases of intravenous use of crude opium solution (boiled and filtered) became increasingly frequent among drug-dependent patients undergoing treatment. Practically all intravenous drug users were socially maladjusted young urban men. Their proportion among all registered opium users in Turkmenistan was growing. In the mid 1980s it became possible to distinguish two patterns of opium use in Turkmenistan. One classical pattern, described above, with relatively mild medical-social consequences, prevailed in rural areas and was still common in the cities. The new pattern, characterized by intravenous opium use, early age of onset (before 30 years of age) and quick and serious medical and social consequences of drug use, was observed predominantly among young urban men and, to a small extent, women. Tuberculosis, hepatitis B and sexually transmitted disease (not AIDS) were the most common co-morbidity in this group.(n33)
     Serious family problems, divorce, childlessness, unemployment and criminality were typical.(n41, n42) This group of opium users consumed not only opium supplied domestically but also smuggled from other parts of the Soviet Union. In 1988 the proportion of intravenous opium users constituted more than 40% of all registered cases of opium use in the urban areas, 32% of urban dwellers used opium orally and 25% by smoking. In the villages, these indicators were 2%, 62% and about 46%, respectively.(n34)
     Several factors played a role in this particular distribution of the methods of opium use in Turkmenistan. As mentioned, the largest number of opium consumers were older people who mainly ingested opium; a significant proportion of these people were recent urban residents, taken to the cities by their children, who stayed there after graduating from college or university. The connections between relatives in villages and cities were very close; this allowed urban residents to obtain raw opium from rural places and maintain their old-fashioned habit. Indeed, chronological analysis of the years of drug use onset showed that there were "traditional" opium users who had started opium consumption in the 1930-40s with a majority commencing in the 1950-60s.
     Intravenous drug users, being younger, began to use opium in the 1970-80s, years when intravenous infusions were widespread in medical practice in Turkmenistan and were considered a safe and effective cure for any disease from infancy to old age.(n38, n39)
     Another factor possibly influenced the change in the methods of opium use in Turkmenistan. The republic had several prisons that served the whole country. This meant that people of different origins, life experience and habits were kept together during imprisonment. Some of them were left in the republic on probation for years. Drug use was not uncommon in the republic's penitentiaries. Twenty-five per cent of the registered drug users with criminal records reported that they had started drug use while incarcerated. Most of them were intravenous opium users.(n43)

      This combination of the peoples' perceptions of the old (mild) drug and new (more effective in reaching euphoria) methods of its use along with the reshaped national identity and specific micro-social environment, could facilitate the initiation of opium use, with preference for injections, among young people. The question has been raised whether the involvement of the USSR in the Afghan war played a major role in spreading drug addiction in the country in the 1980s. The war definitely had a negative impact on the political climate and economic conditions in the USSR, thus facilitating illegal drug trade within the country. "Opium leakage" through the border with Afghanistan was first flagged in the 1980s. However, in the author's experience, few opium-dependent patients identified the war with Afghanistan as a starting point of their drug use.
     The two groups of drug users reacted differently to the last Soviet anti-narcotic campaign that begun in 1986 and faded at the time of the USSR's collapse in 1991. This campaign was a reflection of the spirit of perestroika, and grew from the preceding anti-alcohol campaign of 1985.
     It started with the mass media highlighting the drug-related situation in the country and the overt statement that illegal drug use was a serious problem. Among new features of this campaign was an unexpected presentation of the image of a drug user. Earlier visions of drug addicts were as miserable and worthless creatures, "wreckage of the past". This evolved in the 1970s to repugnant images of the "junkie", "offender", "public enemy", ready to commit any crime to get "the dose". While the first image aroused disgust and irritation, the second evoked fear, aggression and hostility.
     Both led to the social isolation of the addict.
     Indeed, sociological surveys of the late 1980s showed that public opinion toward drug users was extremely negative in practically all social groups and especially among urban youngsters. At the same time, a significant number of rural teenagers thought it acceptable for adults to use opium in some situations; moreover, even urban adults pointed out some admissible reasons for opium eating or smoking; such as disease and celebration parties.(n33, n44-n46)
     Simultaneously, there were two types of attitudes: one, negative, toward the symbolic drug addict-criminal presented by mass media and the other, ambivalent or rather multi-dimensional, based on the historic memory of opium's social functions and on the peoples' own experience of taking opium or encountering opium users (for example, observing what calamities the neighbour ter'iakkesh brought to his family or, on the contrary, having a deeply loved grandfather who drinks his ghoknar tea, while remaining the hero of World War Two and the respectable senior of the village). A similar duality existed in the drug addicts' own perception: intravenous drug use was itself a sign of extreme depravity, and "pure" opium smokers did not identify themselves with intravenous drug users; the latter shared global feelings of guilt and despair.
     In contrast to the previous images of the addict, during the last Soviet anti-drug media campaign drug users were depicted as victims rather than sinners. In the old debate on whether addiction is a crime or a disease, the definition of drug dependence as a health disorder had been emphasized; the legislation was shifted from criminalization to medicalization of drug use. Public demand for effective treatment led to the immense growth of the narcological service, an increased number of specialists and stimulation of research in the field of psychoactive substance use. This also marked the beginning of international co-operation in solving the problem. Compulsory treatment still existed, but discussions began about its necessity. Another option considered at that time was the transformation of the institutions into something similar to the American therapeutic communities.
     In Turkmenistan, the campaign resulted in further dramatic reduction of drug availability. Ter'iak became extremely expensive. Fetching opium became an even more risky business. Some drug users stopped. Those heavily dependent found ways to overcome the obstacles. Most rural users substituted analgesic or tranquillizer tablets for opium.(n33) In the cities intravenous drug users, forced to be content with much smaller doses, began to take home-made, chemically processed opium, sometimes mixing it with antihistamines or tranquillizers.
     A few opium smokers shifted to intravenous use of processed opium.(n33) Some substituted cheap ephedron (processed ephedrine with an amphetamine-like short-term effect) taken intravenously for opium.(n33) The flow of drug addicts to the narcological dispensaries increased. Meantime, the outcomes of addiction treatment were far from desirable.
     Soviet psychiatry, and narcology as a branch of it, had a very clear biomedical orientation. Most investigations into substance abuse (mainly alcohol dependence) were searching for the "magic bullet", effective pharmaceuticals or other means, that would eliminate pathological craving for the drug and thus terminate the problem. New knowledge brought by the opporunities for international professional exchange raised interest in the psychological approaches used in the western treatment programmes. Strong criticism of the existing treatment protocols came from abroad and within the country; it was the beginning of the crisis in narcology. The old approaches were discredited. New ones, advocated with enthusiasm by those who had the chance to learn them, could not be implemented because of lack of knowledge and skills among the whole profession and, very often, because of cultural inappropriateness of the western techniques. The specialists were confused and unsure; the public was also disappointed: hope for the "quick fix" was left unrealized.
     Turkmenistan had a specific problem in the treatment of drug addiction: the treatment of older addicts (65-80 years of age). They were forced into mandatory inpatient treatment with universally used detoxification. Given their long duration of opium use (up to 45 years) and the age-related co-morbidity, the standard detoxification led to deterioration of their health. More intensive interventions were invoked to cope with the emerging complications.
     The folk method of gradually diluting the opium solution could not be used in medical settings, as opium was an illegal drug. Medical failure, the Turkmens' traditional respect for the aged and the necessity to persuade the elderly to undergo treatment against their will were a source of growing discomfort among doctors and police as well. Yet the desire to let these elderly users alone could not be followed as their activity (opium use) was illegal; another concern was the facilitating effect that their example (if left not targeted at all) could have on future generations.
     After the fall of the Soviet Union in the early 1990s the search for alternatives vanished as drug addiction was removed from the list of the government's priorities and the narcological service became increasingly disorganized. At that time, police anti-drug activity decreased radically and a significant decline in voluntary admittance to the narcological facilities led to their under utilization.(n34)

      Time of independence
     In 1991, the status of independence set a new agenda for political and economic development for the Turkmen republic. The issue of drug addiction was dealt with mainly from the perspective of updating national legislation to match international anti-drug laws. A series of reforms, including one of public health care, was started. The idea of the rebirth of the Turkmen nation was diffused constantly through the mass media by support for restoration of old customs, traditions and arts. Religious practices as means of building new spiritual values were welcomed. Turkmen, with its new Latin-character alphabet, was declared the only official language. At the same time the republic tried to enter the mainstream of the world community. Political stability and the country's status of neutrality gained in 1995 attracted foreign businesses to Turkmenistan. Still, there were many difficulties, due to the disruption of traditional economic and cultural "space".
     The narcological service experienced the same shortages in medical supplies as other health care services. Short supply of pharmaceuticals, the cornerstone of the medically centred treatment of drug addiction and lack of clear treatment protocols led to poor results. This, in addition to the legislative swings to and from restrictive measures toward drug use and increased sense of ambiguity of the anti-drug policies, deflated the prestige of the service both among patients and in official circles. Eventually, the dissatisfaction resulted in cutting beds and staff of the narcological service and its facilities were merged with psychiatric institutions.(n34)
     Meanwhile, the country's borders were opened and migration in and out increased. Heroin of different qualities, along with crude opium, was smuggled from Afghanistan and Pakistan.(n48-n50)
     Heroin use gradually became as prevalent as crude opium use.(n12, n51) From 1991 to 1997 indices of incidence of drug dependence increased about eight-fold, while prevalence increased two-fold. It corresponds with UNDCP data that in 1995 opium from Afghanistan became cheaper.(n48, n49) Incidence of opiates users has been growing rapidly, especially in the cities.(n34) The urban/rural ratio of registered opiate users was 0.4 in 1988 and 0.8 in 1996 (the latter reflected the general population urban/rural ratio: 0.8). It proved anecdotal indications that local heroin dealers promoted the drug to the young (for example, in higher education institutions).(n51)

      The social structure of drug consumers also changed. Clinicians observed younger drug addicts coming from all social strata, including people from well-off families. The social consequences of drug use were worsening with high levels of unemployment and increasing criminality, even among rural users.(n34) New female "customers", young prostitutes, replaced the elderly women who used to be registered as opium addicts.(n33, n34) The involvement of women in the illegal drug trade became common practice.(n12, n51) Smoking heroin, rather than intravenous injection, has been a predominant pattern of its use by people of different demographic features. In 1996 the proportion of registered intravenous drug users in urban areas dropped to 29%; remaining low (about 3%) in rural areas.(n34) This is a quite different picture from that in such Central Asian republics as Kazakhstan and Kyrgyzstan where, in the late 1990s, the absolute majority of drug addicts used heroin intravenously.(n34)
     Preference for smoking could imply an attempt by users to avoid the additional hassles linked with drug injection and the stigma of being "lost" if known as an intravenous user. It is not likely that education in relation to blood-borne diseases (e.g. HIV/AIDS) influenced the choice of drug use pattern (smoking). In this connection it should be noticed that no case of HIV/AIDS has been registered in Turkmenistan (1998 last data available), although incidence of other STDs has increased significantly over the last 5 years. Generally speaking, the Turkmen population assessed the risk of HIV contamination as low. Nevertheless, some virtual understanding that drug smoking is not so dangerous, in comparison with injections, played a part.
     Other mechanisms could influence the visible drug-related landscape. The shame and fear of registration as a drug addict in the official system could lead to avoidance of the service, with a resulting general underestimation of drug users, and especially of intravenous (yet socially adjusted) users. If drug addicts call for the treatment voluntarily they are registered only in the narcological dispensary, but if they then avoid treatment and surveillance the dispensary has to inform a local police station, seeking assistance in returning the patient to "voluntary" treatment or raising questions about need for compulsory treatment. Thus, even voluntary admittance to the official narcological setting increases the risk of police registration. The existence of a parallel hidden medical service for drug users supports the assumption.(n34) Although heroin smoking is considered less harmful than intravenous opiates use from the medical-social perspective, the criminal activity related to illegal drugs has been growing in the republic. The profile has changed toward more serious and dangerous crime, such as large-scale illegal drug trade and money laundering.(n52)
     Political response to the situation has followed a classical path: from the problem denial (the early 1990s) to anger at "black sheep" (recriminalization of drug use in the mid-1990s) to acknowledgement of the problem and the search for more practical countermeasures.(n51)
     While supply reduction is still a priority goal of all the efforts, the social mobilization campaign initiated by the government and aimed at the "demand side" of the problem started in 1998. The motto of the campaign "To the 21st Century--Drug-Free" is based on the concept of national consolidation. The message infers that drug consumption is alien to Turkmens and that, being a virtuous nation, they should purge themselves of the evil in order to enter the next millennium "clean". Accountability of the province authorities for the prevention of drug use in their territories was demanded by the government. A series of amnesties were effected, with a view to giving the opportunity to start a new life to those convicted of drug-related offences. Senior people were asked to meet regularly with youth in their local communities, with the aim of giving advice and education on moral values. There were other emotionally charged and highly publicized anti-drug activities nation-wide.(n51)
      Certainly, one can argue about the effectiveness of all these interventions in the existing socio-economic conditions with deteriorating living standards, unemployment, corruption, lack of capacity to deter drug supply through borders and other material shortages. In border regions, the drug trade was often among the very few means of earning money. On the other hand, this policy can be seen as the beginning of a long and persistent way to tackle the old problem appearing in a new guise.

      Conclusion
     As elsewhere in the world, in Central Asia before the late 18th century informal control of opium use could contain it within a socially acceptable frame. Society tolerated the casualties of traditional (ingested) opium use. Introduction of opium smoking and its increased availability shifted the focus of the drug's repertoire to the recreational side (or rather from being the body's remedy to the soul's refuge).
     Subsequent social-economic changes led to the decline of local authority, thus weakening the influence of the system of informal social controls.
     In the 19th century growing drug-related harms led to the introduction of formal control in the form of prohibition of drug trade and use. Users were excluded from the process of solving the emerging conflicts of interest between them and non-users. The main causes that supported demand for drug use were not (and could not be) addressed. The unintended outcomes of these policies led to aggravation of drug-related crimes (opium muggling and, very probably, the beginning of home-grown opium poppy cultivation) in the territory.
     In the 20th century a new definition of addiction emerged as a condition mediated by the social environment. It shaped anti-drug policy where criminal prohibition co-existed with strategies aimed at raising the population's general living standards and providing free access to heath care. This policy was relatively effective, since it eliminated a significant part of the causes sustaining drug demand. Development of technology and communication along with intercultural influences conditioned by the dynamics of the political scene of the 1970-80s (including periods of "stagnation", war in Afghanistan, perestroika) began to play a major role in the transformation of the patterns of opium use. Here again the old scenario of a combination of a traditional drug (raw opium) and a new medium (syringe) brought a new turn to the development of the drug-related situation. More harmful, intravenous, modes of opiates use came into existence. Antagonism between mainstream society and the changed subpopulation of drug users became stronger.
     Inconsistency in anti-drug policy, which followed the major political changes, worsened further the drug-related situation in Turkmenistan. The new combination of the imported "pure" drug (heroin) and the socially quasi-tolerable pattern of its use (smoking) spread quickly and penetrated all strata of society. There were too many users to consider them marginals. Besides the well-known medical and social problems of drug addiction, heroin brought a very new one: economic crime.
     The speed of the transformations of the patterns of opiate use over the last 30 years was rapid in comparison with the rest of the history of drug use in Turkmenistan. It was still governed by the same universal economic rule effective since the drug became a profitable commodity, especially in social conditions where other opportunities for earning were lacking. In turn, the more profit to be gained by its production and trade, the more difficult it became to curb the situation. Taking into account the current socioeconomic situation in Turkmenistan it is clear that, to be effective, drug policies should be extended "beyond the immediate requirements of combating drug abuse and trafficking, to address broader issues of political development, through promotion of social and economic stability and the stimulation of education and employment opportunities".(n53) In this sense, a retrospective analysis of the dynamics of psychoactive drug use might be helpful in designing more comprehensive policies and more effective prevention programmes.

      Acknowledgements
     I am grateful to Dr Merle Meacham, University of Washington (Seattle, WA, USA) for being the first editor of the manuscript, and to Prof. Alan Ducatman, Chair of the Department of Community Medicine, West Virginia University School of Medicine, (Morgantown, WV, USA) for further advice. My deep gratitude goes to Ms Pauline Glover, Programme Assistant, Alcohol, Drugs and Tobacco, WHO/EURO, whose corrections made the language of the article more clear for English-speaking readers. Correspondence to: Dr Nina Kerimi, World Health Organization, Regional Office for Europe, 8 Scherfigsvej 2100 Copenhagen O, Denmark. Submitted 10th September 1999; initial review completed 12th November 1999; Final ersion accepted 21st March 2000.

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