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Official websites use. Share sensitive information only on official, secure websites. The unique socioeconomic context in Palestine, characterized by political and economic tensions, creates conditions that facilitate the spread of illicit drug use among Palestinians. This paper presents findings from a survey of high-risk drug use HRDU among males in four regions in Palestine: the West Bank north, middle, and south and the Gaza Strip. These findings are essential for developing effective policies to respond to the increasing use of drugs among Palestinians. Eligible participants were males aged 15 years and above who used at least one drug other than non-synthetic hashish or marijuana during the previous week. Participants underwent a face-to-face interview and had their drug use verified by urinalysis. Data were collected using respondent-driven sampling and data were analyzed using the successive sampling estimator. Multivariate regression analysis was conducted to examine factors associated with ever seeking rehabilitation services for illicit drug use in the West Bank and the Gaza Strip. A total of males who use drugs were sampled in Gaza, plus in the south, in the north, and in the middle region of the West Bank. Findings indicate that polydrug use is a serious issue in Palestine, especially in the West Bank, and that synthetic marijuana is prevalent among teenagers and young adults. Palestine must strengthen its national efforts to scale up harm reduction and treatment and care options for people suffering from drug use disorders, especially those involved in polydrug use. Additional measures are needed to prevent substance use among children and youth, support the families of people who use drugs, and ensure the continuity of HRDU services during emergencies. Drug use is criminalized, hidden, and stigmatized in most societies. Worldwide, an estimated The Mediterranean region has been affected by the widespread use of illicit drugs \[ 2 \]. Although the extent of illicit drug use in Arab countries is difficult to estimate due to the limited availability of research and the stigma associated with it \[ 2 \]. Available data indicate abuse of Tramadol the common brand name is Tramal, a drug that affects the central nervous system and used primarily to treat severe pain in Egypt \[ 3 \], heroin in Libya, cannabis and heroin in Morocco and Algeria, and different illicit drugs in Jordan \[ 4 \]. Spice products can have different potency based on number and types of additives which are known to increase the risk of unintentional overdose \[ 6 \]. In Palestine, the unique socioeconomic context characterized by political and economic tensions has created conditions that facilitate the spread of illicit drug use. Some research indicates that Palestinian youth use illicit drugs to cope with the existing harsh conditions, which include political violence, house demolitions, arrests, restrictions on movement, and land encroachments \[ 7 \]. The use of more than one drug simultaneously, or polydrug use, is a serious concern in Palestine. Factors associated with polydrug use include being younger, being younger at first drug use \[ 4 \], and poor mental health \[ 5 \]. Furthermore, despite the rising global incidence of drug addiction, there is still a treatment gap whereby only Factors associated with seeking reahbilitation services for illicit drug use include support from family and friends, plus awareness of the availability of and accessibility to rehabilitative programs \[ 8 \]. Currently, the West Bank has only three government drug treatment centers, including the Methadone Treatment Center, and five private centers, in addition to rehabilitation centers in Israel. In the Gaza Strip, there are four public rehabilitation centers and one newly established private rehabilitation center for women \[ 9 \]. Drug use is exacerbated by the the absence of a unified Palestinian authority and police system, internal Palestinian conflict, weak enforcement of laws, and limited control of borders to combat the trafficking of illicit drugs. UN estimates from official sources indicate that there are about 10, registered drug users in the West Bank and the Gaza Strip, and about 15, in East Jerusalem \[ 10 \]. It is essential to know the extent of HRDU and the pattern of illict drug consumption to allocate funding and develop effective rehabilitation services for people using drugs in Palestine. The aim of the study was to examine the extent and characteristics of HRDU in Palestine to inform the development of rehabilitation services in complex settings like Palestine. In addition, we used demographic data to determine the population size of men 15 years and above for use in gauging the size of the burden. Males aged 15 years and older who had used at least one drug other than non-synthetic hashish or marijuana during the week prior to the study, and living in either the north Nablus , middle Shufat camp and south Hebron of the West Bank, or in Gaza City were sampled using respondent driven sampling in Hashish and marijuana were excluded from the study eligibility given the low morbidity and mortality associated with this drug and to better focus on higher risk drugs in order to inform the development of rehabilitation services in Palestine. Self-reported drug use in the previous week was verified by urinalysis. The West Bank, a large geographical area with long distances and checkpoints between major cities that indicate independent network components, had three distinct survey sites: Nablus in the north, Shufat camp in the middle region, and Hebron in the south. Sample sizes were calculated using a change in proportion in drug use over time 0. The resulting sample sizes were in each of the three West Bank locations and in Gaza City. Given the stigma associated with drug use and findings from formative research that the population is socially networked, this survey used respondent-driven sampling RDS \[ 13 \]. Briefly, RDS is a peer-to-peer recruitment method that optimizes a coupon quota and long recruitment chains to mimic a Markov Chain process \[ 14 , 15 \]. Recruitment began with four seeds initial non-randomly selected participants in Gaza City and Hebron, and three seeds in Shufat and Nablus. Seeds were selected via the Maqdesy Counselling Center in Jerusalem based on their ability to recruit peers who fulfilled a variety of different characteristics, including age, type of drug used, whether they injected drugs or not, and residential location. Seeds and subsequent participants were screened for eligibility, given a description of the survey process, underwent informed consent and had their urine tested with Abon by Alere USA and the Arco Biotech kit to confirm at least one of the following drugs in their system: cocaine, amphetamines, methamphetamines, methadone, morphine, phencyclidine, barbiturates, benzodiazepines, tricyclic anti-depressants or Tramadol. Once enrolled, participants completed face-to-face interviews by trained interviewers in Arabic. Of those, how many are 15 years of age or older? Of those, how many have you met in the last two weeks? Responses to these questions are necessary to weight the data during data analysis. Once the survey steps were complete, each participant received up to three coupons with unique identification numbers to use in recruiting eligible peers. Successive waves of recruitment continued until the sample sizes were achieved \[ 9 \]. This study also used successive sampling population size estimation SSPSE , a Bayesian technique to estimate the sizes of hidden populations using data collected in a RDS survey. This method harnesses information about the network size with prior knowledge about population size and assumptions related to successive sampling to generate a median and mean estimation with probability bounds \[ 16 \]. Participation was anonymous and no personal identifying information was collected. All methods were carried out in accordance with relevant guidelines and regulations. Data for each of the four locations were weighted and analyzed using the Giles successive sampling estimator 20 in RDS Analyst www. Aggregate analysis was conducted on all four locations using SPSS along with exported successive sampling weights and population size weights to examine the prevalence of illicit drug use in combination with alcohol in the West Bank, and factors associated with seeking rehabilitation services. Bivariate and multivariable regression analysis were conducted to examine factors associated with ever seeking rehabilitation services for illicit drug use in the West Bank and in the Gaza Strip. Alcohol problem use was assumed for persons who reported having three or more alcoholic drinks per day \[ 18 \]. Drug combinations with alcohol were calculated for participants who were considered to have an alcohol problem use in addition to two different drug combinations. Population size estimates using SS-PSE were calculated in RDS Analyst using the date of enrollment, personal network size, visibility imputation, and prior size data \[ 16 \]. The final sample sizes were in Gaza, in the north of the West Bank, and in each of the south and middle locations of the West Bank. The maximum number of waves was nine in Gaza, ten in the south, 13 in the north, and 14 in the middle of the West Bank Fig. Almost all illicit drug users Almost all had attended school with the majority having only attended primary and secondary school. While the majority in the West Bank were single and never married, the majority in the Gaza Strip were married. Drug use during the previous week was more frequent in Gaza and the middle region compared with the south and north. Based on urinalysis, HRDU in the north had a maximum number of 12 drugs and HRDUs in the middle and south had a maximum of eight drugs detected in their urine. The maximum number of drugs detected in the Gaza Strip was six. In addition, the most common drug combinations in the West Bank were cannabis and benzodiazepines ; amphetamines and benzodiazepines ; cocaine and amphetamines ; while drug combinations with alcohol included amphetamines and benzodiazepines ; and cannabis and benzodiazepines In the Gaza Strip, the most common drug combinations were cannabis and Tramadol ; benzodiazepines and Tramadol 80 ; and tricyclic anti-depressants and Tramadol 49 Table 2. Few HRDUs ever injected drugs. In the north, almost equal percentages injected heroin and cocaine. The median frequency of trying to stop using non-injection drugs in each of the four areas ranged from two to three times with a maximum range of 17 in the north and 50 in the middle region not in table. Most HRDUs reported receiving no rehabilitation treatment services while in prison. Of the HRDUs who did report receiving rehabilitation treatment while in prison or detention, the majority received only medical rehabilitation treatment. Most HRDUs who had ever been arrested for drug use suffered withdrawal symptoms while in prison or detention. Based on univariate analysis Table 4 , factors associated with seeking rehabilitation services in the West Bank were older age, being married, having children, polydrug use, having been imprisoned, suffering from health conditions, memory loss, and withdrawal symptoms due to drug use. In the Gaza Strip, factors associated with seeking rehabilitation services were older age, having been imprisoned, having children, and suffering from withdrawal symptoms due to drug use. Based on multivariate logistic regression Table 4 , adjusting for confounders being married and have children , factors associated with seeking rehabilitation services in the West Bank were older age, having been imprisoned, and suffering from memory loss due to drug use. In the Gaza Strip, factors associated with seeking rehabilitation services were having been imprisoned and suffering from withdrawal symptoms due to drug use. Factors associated with seeking rehabilitation services in the West Bank and the Gaza Strip, From this information, the estimated number of HRDUs who ever injected drugs is in the Gaza Strip, plus in the north, in the south, and in the middle of the West Bank. Political and economic tension in Palestine has facilitated the spread of illicit drug use among Palestinians. Research on the use of tramadol in the Gaza Strip demonstrates that recurrent attacks and siege related to the Israeli occupation, as well as high unemployment among university graduates are factors associated with the widespread use of tramadol \[ 20 \]. Similarly, violence and traumatic events experienced by children in the Gaza Strip related to the Israeli occupation is linked to increased illicit drug use among children \[ 21 \]. In addition to political, economic, and social factors, regulatory and enforcement issues also contribute to the increase of illicit drug use in Palestine, which includes the absence of unified Palestinian authority and police system, internal political turmoil, weak legal enforcement, and limited border control to combat trafficking \[ 22 \]. Many HRDUs were found to be using drugs, such as Tramadol and sedatives, that should be prescribed by a physician. Based on the UNODC drug report of , there has been a rise in the non-medical use of pharmaceutical drugs between and \[ 1 \]. Although Tramadol and Lyrica are not considered to have the same addiction risk as other narcotics, they are still addictive when used frequently and in high doses \[ 22 \]. Lyrica was only used in the Gaza Strip. As Lyrica was not yet among the the list of controlled drugs at the time of this study, it was being used instead of Tramadol. Tramadol was classified as a controlled drug, its use was crminalized, and offenders were imprisoned and had to pay to large penalties for each arrest related to Tramadol use. Although synthetic marijuana use could not be verified by urinalysis, its use has been increasing rapidly, especially among teenagers and young adults based on survey data and drug seizures since \[ 6 \]. According to a study of drug arrests between and , the most commonly seized and used substances were cannabis, hashish Although synthetic marijuana has been mistakenly linked to cannabis, it is often easier to obtain, less expensive, and far more dangerous, causing more severe adverse health effects and dependence than cannabis \[ 6 \]. In the West Bank, synthetic marijuana is mixed with tobacco and with other more toxic compounds including insecticides, rodenticides, and acetone to make it a more potent substance for a lower price \[ 22 \]. Based on urinalysis, between A comparison of reported drug use in the previous month with drugs detected in urine, other than marijuana and synthetic marijuana, showed differences in consistency by location. Descrepancies between reported use and the results of the urinalysis may be explained by ignorance of the type of drug used, and the interval of screening as many of the listed substances will not appear in urine after 2—4 days. The combination of drugs found in this study can produce additive adverse effects on the respiratory and cardiovascular systems. Benzodiazepines and opioids, including heroin, morphine, methadone, codeine and Tramadol, all have central nervous system CNS depressant effects. Alcohol is another CNS depressant commonly used in combination with these drugs. Yet, Palestinian law allows for its production and sale. Amphetamines, cocaine and tricyclic anti-depressants are also associated with risks to the cardiovascular system, including hypertension, life-threatening arrhythmias, and circulatory collapse. Furthermore, the combination of cocaine with alcohol results in increased cardiotoxicity \[ 24 \]. Studies found that the reason for combining drugs can be intentional for additive recreational effects or can be totally random and unintentional \[ 25 , 26 \]. Regardless of the reason behind it, polydrug use found among the study population is alarming and carries a high risk of additive side effects that could be fatal and can complicate medical interventions in case of toxicity as multiple agents and antidotes could be needed. Our research found that older HRDUs from the West Bank and the Gaza Strip who were imprisoned were more likely to seek assistance for illicit drug use, which is in line with findings from a previous study conducted among Latinos \[ 8 \]. This could be explained by use of the rehabilitation services at prison, which are mostly medical, or could also be explained by individuals seeking rehabilitation services to avoid going to prison again. In the West Bank and the Gaza Strip, suffering from the consequences of drug use, memory loss and withdrawal symptoms, respectively, was also associated with seeking rehabilitation services, which is in line with previous research \[ 8 \], which is comparable to what we observe in the West Bank where individuals who have been imprisoned are more likely to seek such programs. This study has several strengths. First, it is the first study in Palestine to estimate the extent of high-risk drug use in Palestine among males aged 15 and above, including the extent of polydrug use and the prevalence of ever injecting drugs. Our findings provide evidence to inform prevention and treatment services. Second, our data provide more granular insights into the extent of HRDU by sampling three distinct areas in the West Bank North, middle, and south , as well as in Gaza. Third, this is the first study to examine factors associated with seeking rehabilitation services among HRDUs to inform policy. Fourth, drug use was verified based on urine analysis, rather than self-report. However, a major limitation in this study is that females were not included. Females who use illicit drugs are known to be at higher risk than males due to the fact that females have more limited rehabilitation treatment options. Cultural expectations and constraints pose significant barriers to females taking part in any rehabilitation program. In addition, there are inadequate rehabilitation treatment services tailored to the special needs of females who use drugs and who are likely to be more vulnerable to sexual harassment and abuse. Although males who use illicit drugs certainly know females who use illicit drugs, female illicit drug users are normally more hidden and stigmatized than male illicit drug users in Palestine, as in other countries. Nevertheless, it is essential that female illicit drug users are at least qualitatively studied and that appropriate rehabilitation treatment services are available to them. Another potential bias may have been reporting bias due to culture and religion and heightened stigma towards drug and alcohol use. However, we took several precautions to ensure participants felt comfortable, including involving illicit drug users in the planning of the survey, collecting data anonymously, hiring former illicit drug users to screen participants, hiring recruiting trained data collectors, and providing a safe and accepting survey environment. Finally, as participants were not randomly selected, unknown confounders were not adjusted for in the study design. Although sampling begins with non-randomly selected seeds, which introduce a large amount of bias, a goal in RDS is to attain a sufficient number of waves whereby the sample transitions to convergence. Convergence is an indication that the final estimates are no longer impacted by the bias of the seeds and that the final estimates represent the network of the population sampled \[ 15 \]. In our sample, we reached up to 14 waves and attained convergence on all key variables reported in this paper. A high percentage of them are polydrug users and a low percentage of them are injecting drugs. High percentages of HRDUs started using drugs when they were below the ages of 18 years, and most are unaware of existing rehabilitation services. Based on the study findings, a number of policy recommendations regarding illicit drug use in Palestine are evident. These include, educating and providing early interventions to young people who are at higher risk for drug use, developing flexible treatment modalities that involve internationally accepted detoxification and diagnosis, and treatment of co-morbidities such as mental health and drug use related disorders \[ 8 \], providing appropriate treatment to females, creating plans to ensure the continuity drug use services during emergencies, including during epidemics i. Finally, this study should be repeated over time to assess trends and measure improvements and failures. Special thanks are due to Issam Jwehan and Ghassan Awad and their study teams. All authors have read and approved the manuscript. The Korea International Cooperation Agency had no role in the design and data collection, analysis and in writing the manuscript. Informed consent was taken following a description of the study to participants. All the methods were carried out in accordance with relevant guidelines and regulations. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. BMC Psychiatry. Find articles by Salwa Massad. Find articles by Hadil Dalloul. Find articles by Lina Adwan. Find articles by Khalid Abu Saman. Find articles by Rawan Kafri. Find articles by Walaa Abu Alia. Marina Tucktuck 4 School of Medicine, St. Find articles by Marina Tucktuck. Find articles by Lisa G Johnston. Received Mar 17; Accepted Sep 13; Collection date Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Ever sought rehabilitation treatment services for non-injecting drug use. Ever sought rehabilitation treatment services for injection drug use. Experienced withdrawal symptoms while in prison for drug use.
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Alarmingly high prevalence of high-risk drug use among palestinian males: a cross-sectional study
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