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Editorial: Editorials

The Poppies of Afghanistan

Pagel, Paul S. MD, PhD

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doi: 10.1213/ane.0b013e3181b32ce6

Afghanistan produces more than 93% of the world's opium. The poppy (Papaver somniferum) from which this drug is derived is grown on a truly massive scale.1 The United Nations Office on Drugs and Crime estimates that approximately 450 thousand acres (700 square miles or two-thirds the area of Rhode Island) of Afghanistan is dedicated solely to this plant, resulting in the production of nearly 6000 metric tons of raw opium per year.2 The cultivation of opium poppies and the subsequent refinement of heroin generate an estimated revenue of $3–4 billion per year, which represents nearly 50% of Afghanistan's gross domestic product.3 Despite intense efforts by the Karzai government to the contrary, Afghan farmers, supported by drug cartels and powerful tribal chieftains, continue to grow opium poppies because they are capable of earning as much as 12 times more income per acre compared with conventional crops. Before being forced from power in late 2001, the fundamentalist Taliban regime banned and nearly eradicated the opium poppy industry on strict theological grounds, but since that time, the Taliban has relied, ironically, on profits derived from the resurgent opium-heroin trade to partially fund their ongoing paramilitary insurgency in Afghanistan and neighboring Pakistan.4 The immediate threat posed by the Taliban to the region's political stability aside, Afghan opium and heroin have profound socioeconomic consequences on Iran, Pakistan, and the southern republics of the former Soviet Union through which the majority of drug trafficking occurs.

Iran has paid a particularly heavy cost for its geographic proximity to the poppy fields of Afghanistan. Iran has the highest rate of opioid dependence in the world, in large part because of readily available, relatively inexpensive raw Afghan opium and partially refined heroin.5 The incidence of opioid dependence has been conservatively estimated to range between 2.8% and 6% of Iran's population of 70 million people (compared with substantially <1% of the United States population).6 Instead of relying on conventional law enforcement strategies to address this crisis, the Iranian government has responded by instituting a multifaceted, progressive campaign: using the educational system and the news media to widely acknowledge the broad existence and consequences of opioid dependence; vastly expanding the number of drug treatment centers and methadone distribution programs throughout the country; strongly discouraging the long-standing Persian cultural tradition of recreational opium use; and aggressively addressing the medical implications of the disease, including Human Immunodeficiency Virus, from both prevention and treatment perspectives. Over 60% of Afghanistan's total opium production is diverted through its western border with Iran, and in response, the Iranian government constructed a $6 billion wall along this front in an effort to thwart trafficking and also substantially strengthened its police efforts to confiscate and destroy opium and heroin shipments.6 Unfortunately, widespread poverty and unemployment, especially in rural areas of Iran, combined with the pervasive corruption of local officials and the marked increase in opium production in Afghanistan since the Taliban's expulsion, continue to overwhelm the Iranian government's efforts to curb the alarming incidence of opioid abuse in any meaningful way.6

It is within this context that Azarasa et al.7 examined the incidence of substance abuse and dependence in 600 cardiac surgical patients in Tabriz, Iran that appears in the current issue of Anesthesia & Analgesia. Tabriz is located in northwestern Iran near the Turkish border, a region that is a well-known major route of Afghan opium and heroin diversion to Europe.6 Thus, it is perhaps not surprising that the authors reported a staggering 12.0% of their patients met the DSM-IV diagnostic criteria for opioid abuse or dependence.7 Interestingly, the rate of opium “addiction” (using an older definition that incorporated psychological or physical dependence) was 6.9% in northern Iran in 1978,8 suggesting that an increase in this substance abuse disorder had occurred over the intervening 30 yr. The results of the study by Azarasa et al. indicated that opioid abuse and dependence may be more prevalent in northwestern Iran compared with other regions of the country. For example, Ahmadi and Benrazavi9 described a 9.4% prevalence of opium use in 96 patients with cardiovascular disease in their medical center located in the southwestern city of Shiraz. These investigators also noted that 14.1% and 7.3% of patients with chronic renal disease and those undergoing general surgery, respectively, admitted to opium use.10,11 However, Ahmadi and Benrazavi9–11 did not specifically examine opioid abuse or dependence in these studies and instead simply reported previous or current use. More recently, Ahmadi et al.12 observed a 7.2% incidence of opium abuse in medical inpatients using DSM-IV criteria, but the authors did not quantify drug dependence in this latter study. Despite these subtle regional differences in opioid abuse and dependence rates in Iran, the current and previous results serve to underscore the magnitude of this public health crisis for the government and its people. The findings of Azarasa et al. and other investigators further emphasize that Iranian cardiac anesthesiologists are routinely confronted by opioid-dependent patients and therefore must be thoroughly familiar with the wide range of important clinical consequences of this devastating substance abuse disorder13 to safely provide care for this patient population.

As may be expected, the high incidence of opioid abuse and dependence in Iranian cardiac surgical patients reported by Azarasa et al. and other investigators has not been observed in European and American patients in whom abuse of opium-derived drugs is less common. For example, Misra et al.14 described a 6.2% incidence of illicit drug use in 161 patients undergoing coronary artery bypass graft (CABG) surgery in the United States. Marijuana, amphetamines, and cocaine, but not opioids, were identified as the major drugs of abuse in this study.14 In contrast, a history of marijuana or psychostimulant abuse was absent in Iranian patients undergoing cardiac surgical procedures.7 Alcohol is also not a major drug of abuse in Iran because alcohol sales and consumption are legally forbidden in the Islamic republic. Nevertheless, Azarasa et al. reported an 8.1% incidence of alcohol consumption in their cohort of patients undergoing cardiac surgery, supporting the observations in general surgery patients.11 These findings also stand in sharp contrast to those described in CABG patients in the United States, in which the prevalence of daily alcohol consumption exceeds 40%.15 Regardless of the specific drugs of abuse, the results of Azarasa et al. further suggested that a history of an opioid or alcohol abuse disorder did not appear to adversely affect the incidence of perioperative cardiovascular, pulmonary, or neurological complications. Such a conclusion will require additional study to confirm, because the current investigation most likely did not have sufficient statistical power to definitively exclude the null hypothesis. Other studies have also suggested that short-term outcome after cardiac or noncardiac surgery is relatively unaffected by a history of substance abuse. For example, marijuana, amphetamine, or cocaine abuse was a predictor of cardiovascular complications in the first 6 mo after CABG, but not during the immediate postoperative period.14 Patients with a history of opioid use undergoing CABG were less compliant with care after hospital discharge and, as a result, were more likely to require readmission for the treatment of cardiovascular complications.16 Similarly, IV drug abuse was associated with a higher rate of early recurrent infection after valve replacement for endocarditis, but the initial prognosis was unaffected when aggressive surgical treatment was combined with organism-specific antimicrobial therapy.17,18 The short-term cardiovascular, neurological, and infectious outcomes of cocaine-positive trauma patients undergoing surgery during the first 24 h after admission was also not negatively affected compared with those who had not abused the drug.19 Furthermore, noncompliance with long-term treatment protocols increased morbidity and mortality in patients with a history of substance abuse after heart transplantation.20 Taken together, the current and previous data suggest that vigilance during the perioperative care of the patient with a substance abuse disorder may substantially reduce the relative risk of short-term morbidity independent of the specific drug(s) of abuse, but patient noncompliance associated with a return to illicit drug use after surgery most likely contributes to an increased risk of long-term complications. The findings further emphasize that the perioperative period may provide a unique opportunity to arrange drug rehabilitation for the patient with a substance abuse disorder.


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