Sustainable Approach to Drug and Substance Abuse Prevention in Nigeria By

Dr. Martin O. Agwogie, Founder/Executive Director Global Initiative

on Substance Abuse (GISA) at a Symposium Organized

by the Nigeria Academy of Pharmacy on the 11th of June, 2019 in Lagos, Nigeria.

Introduction

Drug and substance abuse in Nigeria has become a threat to public health, national stability, peace and security  that  needs  more  than  urgent  attention.  Over  the  years,  the  national  drug  phenomenon  has expanded from the conventional illicit drugs like cannabis, cocaine, heroin, methamphetamine to the non- conventional substances like volatile solvents (inhalants), lizard dung/excretes, bio-generic fumes (soak away/pit toilet gas) to the misuse of synthetic/pharmaceutical opioids and benzodiazepines. This is in addition to the consumption of a wide range of new psychoactive substances.

The Facts

–      Global prevalence of drug use is 5.6% but in Nigeria, it is 14.4% (14.3 million people)

–      1 in 7 persons in Nigeria between the ages of 15 and 64 years use at least one psychoactive substance as against global average of 1 in 20

–      1 in 5 persons who use drugs in Nigeria are suffering from drug use disorders. This is higher than the global average of 1 in 11 persons

–      1 in every 4 drug users in Nigeria is a woman. For cough syrup containing codeine, more women (2.5%) than men (2.3%) are involved. This portend grave danger even to the generation yet unborn. Women involvement in substance abuse has more implications than men, especially considering the critical role of women in child nurturing from the womb

–      1of 5 high risk drug users inject drugs, using needle and syringe. This has its own multiplier health consequences

–      The most common drugs injected are pharmaceutical opioids

–      Nigeria population is about 3% of the world population but 6% of the world population of cannabis users are in Nigeria

–      14% of the world population who misuses pharmaceutical opioids are in Nigeria. Making Nigeria one of the countries in the world with the highest population of people who misuses tramadol and codeine cough syrup

–      Reports recently ranked Nigeria as 5th in the world with the highest suicide rate of an average of 6 suicides per month. As we may all know, factors that put individuals at the risk of substance use are very much related to factors which make people to commit suicide. More so, persons with substance use disorders places less premium on life, therefore at the risk of suicide

–      Beyond suicide, there are increased cases of sudden deaths among youths in the country which may not be unrelated to opioid overdose. Going by the recent trend, and if nothing is urgently done, we stand the risk of losing more than 100 youths daily to opioid overdose. Substance abuse may become one of the leading cause of deaths in Nigeria

–      Also worrisome is the increasing drug supply via the internet including the anonymous online marketplace known as the “dark net”.

S  Y  M  P  O  S  I  U  M

How did we get here?

Let’s examine this from the Federal level with a historical perspective:

The use of mind altering substances of natural origin has been known since the prehistoric times. For centuries,  man  has  tried  to  either  complement  some  pleasant  features  of  life  or  escape  from  the unpleasant features of life, whether real or imaginary, by using fermented liquor and different plant products. For example, drinking of palm wine and locally brewed alcohol such as “ogogoro”, “burukutu” as well as chewing of different stimulating plants and their products in Nigeria have been known for ages. Reports have it that the use of these substances was more of occasional and in moderation with few exceptions. This was the trend of substance use in Nigeria until after the Second World War in the

40s when cannabis (hemp) cultivation was introduced through the war veterans who brought back the cannabis seed from India. Though, some scholars argued that there were small-scale cannabis cultivation and use before the 40s. The 70s and 80s documented the use of other drugs like cocaine, heroin, amphetamines and pharmaceutical opioids (codeine, morphine etc).

Efforts to address the drug problems in Nigeria actually started far back in 1935 with The Dangerous Drugs Ordinance even before evidence of abuse of cannabis, cocaine, heroin and their opium derivatives were documented. To me, this was a proactive step by the then government and must be commended. This was followed by The Indian Hemp Decree No 19 of 1966. Under this decree, cultivation of cannabis could lead to 21 years imprisonment or death penalty. Smoking of it was a mandatory sentence of 10 years imprisonment. Since then, there have been amendments to these laws, such as The Indian Hemp (Amendment) Decree No 34 of 1975. In 1984 The Special Tribunal (Miscellaneous Offences) Decree was promulgated by the then Federal Military Government. The Decree stipulated death penalty by firing squad for any person dealing in, selling, smoking or inhaling cocaine or other similar drugs without lawful authority.

In 1989, The National Drug Law Enforcement Agency (NDLEA) Decree was promulgated by Decree No.

48 (now CAP N 30 L.F.N. 2004). The Act stipulates that the Agency has the responsibility of controlling illicit  drug  cultivation,  abuse,  possession,  manufacturing,  production,  trafficking  in  narcotic  drugs, psychotropic substances and chemical precursors. NDLEA was established as a unique agency saddled with  dual  responsibilities-  drug  supply  suppression  (arrest  of  suspects,  seizure  of  drug  exhibit  and prosecution) and drug demand reduction (prevention, treatment and after care). The establishment of NDLEA was viewed as Nigeria’s most deliberate efforts at evolving an institutional framework for the suppression of the drug problems. Since then, there have been a number of amendments such as the National  Drug  Law  Enforcement  Agency  (Amendment)  Decree  No  33,  1990,  National  Drug  Law Enforcement  Agency  (Amendment)  Decree  No  15,  1992,  The  Money  Laundering  (Miscellaneous Offences) Decree 3, 1995 and The Money Laundering (Prohibition) Act No 7 of 2004.

In quick succession to the establishment of NDLEA, Decree No 15 establishing the National Agency for Food and Drug Administration and Control (NAFDAC) was enacted in 1993 (now CAP N. 1 L.F.N. 2004). NAFDAC is mandated to regulate and control the importation, exportation, manufacture, distribution, advertisement and sale of food, drugs, chemicals, cosmetics, medical devises, detergents and packaged water.

Today, each of these agencies has operational structures across the 36 states of the federation and the

Federal Capital Territory.

The laws establishing these agencies, from the beginning, recognized the need for them to collaborate among relevant stakeholders for effective drug control in Nigeria with NDLEA playing the lead role. This has been the case since early 90s.

2

Is the drug abuse situation in Nigeria today an indictment of these two agencies? “Maybe yes”, “maybe not”

•      NDLEA: Due to neglect by the federal government over the years, among other factors, NDLEA has not been able to respond effectively to drug control in Nigeria. While other countries of the world were moving towards scientific approach in developing sustainable strategies for effective drug control, it was not the same with Nigeria. Don’t get me wrong, no country of the world has overcome the drug problem but it depends on where we are on the ladder.

Today, NDLEA is under the supervision of the Federal Ministry of Justice which aligns it more with the law enforcement mandates of arrest and prosecution of offenders. Yet, NDLEA leads the drug use prevention components under the Drug Demand Reduction pillar of the National Drug Control Master Plan. There have been instances where officials of the Federal Ministry of Justice will represent the Ministry at national and international Drug Demand Reduction Technical Working Group meetings because it is the supervisory ministry.

Since 2012, beyond salaries and allowances, most of NDLEA activities, including capacity building, have been  through  support  from  the  European  Union  funded  project  being  administered  by  the  United Nations Office on Drugs and Crime (UNODC) and support from other international donors.

•      NAFDAC: NAFDAC is under the supervision of the Federal Ministry of Health. Like NDLEA, NAFDAC is not receiving the due attention it deserves. With its mandate and technical competence for drug regulations and control, which to me is one of the bedrock for substance abuse prevention, I am not sure if those who should know better and the public is sensitive to the position of NAFDAC in the lives of everyone. This, among other challenges, I found in an interview with the DG, Prof. Mojisola C. Adeyeye published by The News April 9, 2019.

NDLEA and NAFDAC may not have received adequate technical competence and capacity for effective and sustainable substance abuse prevention in Nigeria, basically due to a number of factors, some I already mentioned. However, both agencies have qualified and committed manpower, despite being poorly remunerated, and they have better spread across the country for substance abuse prevention strategies. What may be required is comprehensive capacity building and overhaul for them to conform to public health approach to substance use prevention and drug demand reduction generally. Going forward! What if NDLEA and NAFDAC are made to operate under the presidency for the next 10 years to drive effective and sustainable national drug prevention strategies? A question we may need to ponder on.

Beside NDLEA and NAFDAC, we have technical competences for treatment of persons with substance use disorders in the Federal Neuropsychiatric Hospitals, Teaching Hospitals, and Federal Medical Centres etc all departments/parastatals under the Federal Ministry of Health. The number of persons with the technical  competence  is  however  few  compared  to  the  demand  for  treatment  for  substance  use disorders. I will not talk more on this since we are dealing with prevention which is the bedrock of our drug control initiative. Once we are able to prevent, we will have fewer people who will go for treatment for substance use disorders.

Generally, the public health dimension to drug control, which of course is based on science, has (and unfortunately) ignited politics and rivalry in our drug control efforts with different agitations including the creation of an agency for drug demand reduction among others. This politics and rivalry is not necessary if Nigeria is to get out of the present drug predicament.

Drug Control at the State Level

The need to involve states in our drug control efforts was documented as far back as 1994; unfortunately our states have not been very committed to drug control. For example, despite efforts by the UNODC with  the  awareness  and  sensitization  programmes/trainings  through  the  European  Union  funded project, only 7 out of the 36 states in Nigeria have functional State Drug Abuse Control Committee (SDCC).

Local Government Level: They don’t see it as their business. If it is not the business of States how will it be that of the local governments?

Communities: They are helpless; unfortunately that is where the major solution to drug problems lies. I

will come to that later.

Families: Families are faced with the sense of hopelessness and despair on one side, ignorance and denial on the other side, thereby serving as enabler to substance use and abuse. There is usually the assumption that peer influence is stronger than family influence. Science has taught us that family, which is the smallest unit of socialization, is the strongest agent of socialization and as such, plays a significant role in substance use prevention. Unfortunately families have abandoned their primary responsibilities.

Our Usual Approach and Focus of Substance Use Prevention

•     Penal Laws: Laws are the foundation for drug control, defining what is acceptable and what is not.

Some people have advocated for stiffer penalty for drug use. Unfortunately, stiffer penalty has never been a deterrent to substance use/abuse. There is ample evidence that drug laws don’t stop lots of people trying drugs. For those who have started, drug control and the fear of arrest or prosecution have little to do with their decisions to stop using drugs. Instead, they improvise or use adulterated/impure substances thereby making their drug use more dangerous and hostile. This we can also see from our historical experience. It is counterproductive, inefficient, and costly. For trafficking, I will say yes. We must not also forget that the Nigeria major drug control efforts started with death penalty. Experience has also shown that even in countries where drug trafficking attracts death penalty, Nigerians still traffic drugs to those countries.

As good as laws may be, it is just inadequate. Drug demand reduction is evolving and dynamic such that before you conclude legislative processes, the trend would have evolved 360 degrees that you would want to start an amendment process immediately. There are close to 800 psychoactive substances of abuse globally. How many can you legislate on? While it takes an average of six (6) years to pass drug related bills in Nigeria, it takes less than 30 days for novel psychoactive substance to evolve. Beyond this, I am not sure of how we will legislate or regulate the possession and use of lizard dung, inhalants of different types or coffee mixed with a brand of soft drink etc.

•      Sensitization, awareness, media campaign and rallies: Studies have shown that these are not very effective in substance use prevention. You spend more for limited impact. Unfortunately, this is what we do most. You can use these to draw support from relevant stakeholders but not enough on its own.

•      Scare tactics: Scare tactics and providing just information about the consequences of substance abuse without commensurate skills is relatively ineffective in substance use prevention. Studies have shown that substance abuse is not all about ignorance. Among those who received treatment for substance use disorders in Nigeria between 2016 and 2017, more than 75% had secondary school education. In fact 53% are graduates. Among those who use or abuse drugs today are medical doctors, psychologists, and lecturers. They are knowledgeable and I am sure they know the

consequences. Part of the scare tactics or fear arousal is the use of persons in recovery (“ex-drug users”) as testimonials. Also not effective is focusing only on self-esteem and emotional education.

•      One size fits all approach: This is where we put both the young and the old together for substance abuse prevention programme. This negates the common knowledge of human physical, cognitive, social and emotional development. This approach does more harm than good. The younger ones

are made to listen to presentations or messages that will arouse their curiosity for drug use. In most cases, it addresses no particular category of prevention (universal, selective or indicated).

•      Spontaneous reaction: There is no magic in substance abuse prevention. In 2016, I published an article titled “Drug Abuse and the Future of Nigerian Youths” and I stated “Today, ingenuity has been introduced into drug abuse with complex mixtures, experimentations and new discoveries. This has resorted to the abuse of lizard dung (especially the whitish part), pit toilet/soak away fumes (bio generic gas) … pharmaceutical products (tramadol, rohypnol) and many more. Codeine containing cough syrup mixed with soft drinks is gradually taking over alcohol in youth parties” (Agwogie, 2016. Vanguard 23rd June). This may not have received attention, but 2 years later, a BBC documentary on similar topic was aired April 29, 2018 and 2 days later, there was a policy statement. This may be by coincidence. It is however better to be late than never as the

documentary among other documented cases and the accompanying policy pronouncements have led to more consultations and pragmatic approach to addressing the drug problems in Nigeria.

Evidence Based Substance Use Prevention

Evidence based prevention, what is it? How does it work?

Evidence Based Practice (EBP) is the use of systematic decision-making processes or provision of services which have been shown, through available scientific evidence, to consistently improve measurable client outcomes. Instead of tradition, gut reaction or single observations as the basis of decision-making, EBP relies on data collected through experimental research and accounts for individual client characteristics and clinician expertise (EBPI, 2012). In evidence based approach, you define the problem, identify risk and  protective  factors,  develop  and  test  prevention  strategies,  then  adopt  for  expanded implementation. That means, substance use prevention interventions meet the same criteria established for other health and social services. Evidence based intervention is a scientific approach. For effective and sustainable substance abuse prevention in Nigeria, there is no short cut.

An important component in evidence based substance abuse prevention intervention is capacity building on the epidemiology and etiology of substance use. This seeks to identify the predictors and processes associated with positive and negative behavioral outcomes as well as their distribution in populations. Through this, interventions are developed to alter trajectories of vulnerable populations by promoting positive developmental outcomes and reducing negative behaviours and outcomes. Evidence based prevention interventions does not emphasis on the consequences of substance abuse and scare tactics but emphasizes on identifying the risk and protective factors. People don’t just use drugs, they use drugs for a purpose, and what are they? Address the causative factors instead of the symptoms. That is the focus of evidence based prevention. Learn about who is vulnerable to abuse psychoactive substances and  get  addicted;  how  micro  and  macro  environments,  personal  characteristics  and  genetics  of individuals put one at risk of substance abuse. Learn different interventions for different age groups, the roles of different socialization agents (family, schools, workplace, religious organizations, community etc) in substance abuse prevention. Learn how to assess the needs and resources of each of these settings for evidence based substance abuse prevention.

Settings under which evidence based substance abuse prevention can be delivered

Different  settings  have  been  identified  through  which  evidence  based  substance  abuse  prevention interventions  can  be  delivered  with  positive  outcomes.  Each  of  these  settings/components  requires different trainings and skills.

Family-based Prevention Interventions

The focus of capacity building under family based prevention intervention is knowledge and skills. It presents overview of the science underlying family-based prevention interventions; and the methods used  to  intervene  effectively  to  prevent  substance  use  in  children  and  adolescents.  It  also  provides experiential learning in some of the skills used in effective family-based intervention methods to prepare prevention practitioners to participate in such programs. Training includes extensive in-class exercises.

School-based Prevention Interventions and Policies

This presents overview of the science underlying school-based prevention interventions and policies; and the methods used to improve school climate, strengthen policies, and intervene directly with classroom prevention  interventions.  Also  provides  administrators  with  effective  planning  and  strategies  for addressing school policy and climate; and teachers primarily on classroom interactive strategies and interventions. School officials are trained to include extensive in-class exercises. It is knowledge and skills- based. School based prevention is critical considering their age bracket. Only trained personnel on school based  substance  use  prevention  should  provide  such  services  for  this  population  (childhood  and adolescent) in educational settings.

Workplace-based Prevention Interventions and Policies

The  focus  of  capacity  building  under  workplace  prevention  intervention  is  knowledge  and  skills.  It presents  the  rationale  for  workplace  substance  use  prevention,  an  overview  of  the  science  behind workplace-based prevention interventions and policies, and the methods and strategies workplace can use to improve the workplace environment and culture. It also provides experiential learning in planning for workplace policy changes and other substance use prevention efforts to empower employees to avoid substance use.

Community-based Prevention Implementation Systems

The focus of capacity building in community based substance abuse prevention is to encourage the concept of shared safety where everyone takes responsibility of fostering public health and safety in their respective communities. In this case, everyone has a defined role within the community. It presents overview of the science underlying systems approaches to prevention interventions; and presents the primary methods for planning community-wide implementation systems, provides experiential learning in planning and working with stakeholders to develop prevention intervention services suitable for their community.

Environment-based Prevention Interventions and Policies

This presents overview of effective environment-based prevention interventions and policies which focus on community-wide strategies to prevent substance abuse including drug cultivation, trafficking and general  protection  of  the  environment.  It  provides  experiential  learning  in  planning  for  and implementing  environmental  policy  changes  and  other  community-wide  substance  use  prevention efforts.

Media-based Prevention Interventions

It is unfortunate that attempt for the media industry to help in substance abuse prevention, more harm are done through media publications which in turn raises curiosity among the young ones. Media-based prevention  intervention  presents  overview  of  the  science  of  effective  media-based  substance  use prevention interventions with a focus on developing successful persuasive communications. It provides experiential learning in planning messages and media for reaching parents and youth in substance use prevention efforts.

Monitoring and Evaluation of Prevention Intervention and Policies

One key component of evidence based prevention interventions is monitoring and evaluation. This is very much lacking in most of our activities in Nigeria. It is difficult to measure the outcome of our present programmes and activities. This presents primary evaluation methods with a focus on monitoring and process evaluation used to measure outcomes of evidence-based substance use prevention interventions and policies. Before you measure an outcome, you must in the first place define what the problems are and strategies to address the problems. It provides experiential learning in planning and monitoring outcomes through exercises and a practicum completed at the end of the training.

You will agree with me that this is a holistic approach to substance use prevention with each sector having their responsibilities and complementing each other.

Who should deliver these interventions?

Substance abuse prevention science is a multidisciplinary field. Many fields of knowledge contribute to our understanding of human development and those factors and processes that lead to positive and negative  health  behaviors  and  outcomes.  These  fields  cut  across  Medicine,  Psychology,  Pharmacy, Teaching,  Guidance  Counselling,  Sociology,  Epidemiology,  and  other  related  professions.  It  also recognizes  the  significant  roles  of  religious  and  traditional  institutions,  parents,  policy  makers, politicians, operators of NGOs/Civil societies, community leaders, students, youths, women groups, law enforcement agents among others.

However,  irrespective  of  professional  background  and  academic  achievements,  to  deliver  evidence based substance abuse prevention intervention requires capacity building in specific area of intervention and understanding of the UNODC International Standards on Drug Use Prevention.

What should be the role of professional bodies, associations and organizations?

It is good to be relevant at the federal level but professional bodies and associations are more required at the  community  levels  for  effective  and  sustainable  substance  abuse  prevention.  Individuals  and organizations have immediate environment and belong to a community. The role of professional bodies and associations is to enforce the code of ethics and rules of its profession and associations in their immediate communities and align with other members of a community coalition, to assess the needs and resources of the community, define community goals and collectively drive the community agenda for the health and safety of members of the community. Professional bodies are to use their professional expertise to guide substance abuse prevention policies within their immediate environment and in line with  national,  state  or  local  government  regulatory  policies.  However,  key  leaders  in  community substance abuse prevention would be required to receive the necessary trainings. Organizations within a defined  community  should  also  identify  with  the  community  and  support  its  activities.  If  every professional  body,  association  and  organization  concentrate  more  on  influencing  their  immediate

S  Y  M  P  O  S  I  U  M

community, it becomes easier to make impact across the length and breadth of the country. Doing this also requires that we put aside our professional ego. This is not the time for ego but to work with the local community towards the future of our people and the nation.

Conclusion

In conclusion and going forward:

i.     Substance abuse prevention is science and should be so treated

ii.     Let us support evidence based substance abuse prevention through capacity building

iii.   Our substance abuse prevention measures should focus on communities and it should be community driven

iv.   To avoid more harm in our drug control efforts, only those who have received adequate training in evidence based substance abuse prevention should provide prevention services

v.     Collaboration across board is required and should be promoted

vi.    Let us support the professionalization of drug demand reduction in Nigeria

vii.   Let us support the introduction of substance addiction as a course of study in Nigeria higher institutions of learning.

Thank you

References

i.     Drug Abuse and Nigerian Youths. Vanguard Newspaper, June 23rd, 2016

ii.     Drug use in Nigeria, 2018

iii.    Evidence Based Practice Institute, 2012; http://depts.washington.edu/ebpi/

iv.    National Drug Control Master Plan (2015-2019)

v.     National Drug Control Master Plan (2008-2011)

vi.    Nigeria’s increasing suicide rate: Which way out? The Nigerian Tribune, May 25, 2019 (36)

vii.   The News April 9, 2019.

https://www.thenewsnigeria.com.ng/2019/04/how-house-of-reps-committee-is-impeding-my- dream-nafdac-dg/

viii.  Universal Prevention Curriculum (UPC) for Substance Use Disorders, Implementers Series, 1st

Edition, 2018.

ix.    UNODC International Standards on Drug Use Prevention (Second Updated Edition), 2018. x.     UNODC World Drug Report, 2016

xi.    UNODC World Drug Report, 2018

8

A D