Opioids

Opioids remain the main cause of mortality related to use of illicit substances in the region. The second- and third-highest global death rates per 100 000 from opioid overdoses occur in Libya and the United Arab Emirates (UAE) respectively.^{Reference Ritchie and Roser11} Also, opium smoking is a traditional practice in countries such as Afghanistan, Iran and Iraq.

Tramadol is an opioid that is widely used to treat moderate to severe pain and has also been used off-label in the treatment of sexual dysfunction such as premature ejaculation. There is growing evidence of non-medical use of tramadol in the EMR, reflected in the number of people in treatment for tramadol-related problems and the number of tramadol overdose deaths reported in some countries, particularly among young people.¹² Different studies have concluded that the high levels of misuse of tramadol are a result of its easy availability in pharmacies (including without medication refills in some of these countries) and illicit markets, low price compared with illicit drugs, perceptions among users that tramadol is safe as it is a prescription medication, and the ease with which it can be hidden. Having in mind that less than 10% of tramadol users have a medical source,^{Reference Abd-Elkader, Kabbash, El-Sallamy, El-Sawy and Gad13} the non-medical use of tramadol has been reported by many countries, including Egypt, Iran, Jordan, Lebanon, Libya, Qatar, Saudi Arabia and the UAE. Among Egyptian adolescents, tramadol use is more prevalent than heroin.^{Reference Rabie, Shaker, Gaber, El-Habiby, Ismail and El-Gaafary14} Tramadol use in the Iranian general population has been estimated at 4.9% among males and 0.8% among females.^{Reference Rostam-Abadi, Gholami, Amin-Esmaeili, Safarcherati, Mojtabai and Ghadirzadeh15} Increasingly, tramadol has been placed under national control in most EMR countries and is therefore only legally accessible by prescription. Such tight control is concerning because it may restrict the medical use of tramadol, particularly in countries of the region where regulatory mechanisms make other opioids (opioid agonist treatments for opiate addiction) less available for medical use.

Amphetamine-type stimulants, including captagon

The increasing trend of clandestine manufacture and use of amphetamine-type stimulants has become a major concern in countries such as Iran, Morocco and Pakistan. There is also a high demand for fenethylline (captagon) tablets in some countries of the region, especially in Syria, Lebanon and countries in the Arabian Peninsula.¹⁶ Captagon^® was first introduced for its beneficial effects on hyperactivity, depression and narcolepsy, but its addictive and hallucinogenic features made it a popular illegal psychoactive substance.^{Reference Wu, Feng, He, Kwon, Wang and Xie17} Captagon^® itself is no longer manufactured and counterfeit captagon tablets are mostly combined with amphetamine, caffeine, ephedrine, quinine, theophylline acetaminophen and diphenhydramine and may cause unpredictable complications.^{Reference Al-Imam, Santacroce, Roman-Urrestarazu, Chilcott, Bersani and Martinotti3} In Saudi Arabia, there are more treatment admissions registered as a result of captagon use than opioid use.^{Reference Shadloo, Amin-Esmaeili, Haft-Baradaran, Noroozi, Ghorban-Jahromi and Rahimi-Movaghar18}

In addition to the established patterns, there have been emerging regional trends of substance use not only related to cultural and geographical expectations in the region but also as a result of the large number of displaced populations. Captagon is an illustration of this trend.^{Reference Crabtree19} A novel concern about captagon use in Syria and neighbouring countries is that soldiers from all parties to the conflict use the drugs as combat stimulants (‘chemical courage’).^{Reference Wu, Feng, He, Kwon, Wang and Xie17} Meantime the current unstable situation in Syria has forced some traffickers to move production of captagon to Libya, Jordan, the UAE, Saudi Arabia and Sudan.^{Reference Crabtree19}

Khat

Catha edulis, commonly known as khat, is a flowering plant growing in the khat belt countries in the Horn of Africa and the Arabian Peninsula. Khat misuse and dependency is still the major illicit substance use-related problem in countries such as Djibouti, Yemen, Somalia and southern provinces of Saudi Arabia.^{Reference Numan20} Most of the effect of chewing khat is thought to come from two chemicals that are structurally related to amphetamine. In Saudi Arabia, khat use is mostly prevalent in the Jazan region in the south of the country on the Yemeni border. A community-based study conducted in the Jazan region reported an overall prevalence of 29% of current khat chewing among respondents. Khat chewing was about four times higher among males than females in both current and lifetime users.^{Reference Mahfouz, Rahim, Solan, Makeen and Alsanosy21} It is reported that nearly 67.9% of adults in Yemen have at least one lifetime episode of khat use.^{Reference Numan20}

People who use khat frequently report increased levels of energy, alertness and self-esteem, better ability for communication, sensations of elation, enhanced imaginative ability and a greater capacity for associating ideas. The literature suggests that khat use is associated with personal/public health and social problems. Khat chewing might reduce productivity considering the large amount of time individuals spend on khat chewing. Additionally, another group of studies suggested a possible association between heavy khat consumption and psychosis.^{Reference Manghi, Broers, Khan, Benguettat, Khazaal and Zullino22}

Multiple substance use

Multiple substance use is a common practice in the EMR and adulterated substances available on the drug market have added to the vulnerability of people with substance use to various health hazards, making the clinical picture of drug intoxication complicated. For example, in some countries of the EMR people have added amphetamine-type stimulant use to opium use – drugs with completely different profiles of intoxication and withdrawal symptoms.^{Reference Alblooshi, Hulse, El Kashef, Al Hashmi, Shawky and Al Ghaferi23} Amphetamine-type stimulant use by patients under methadone maintenance treatment, especially women, is also a potential threat to treatment success.^{Reference Radfar, Cousins, Shariatirad, Noroozi and Rawson24} Lead poisoning among people who use opium has been a problem predominantly observed in Iran due to the impurity of opium products.^{Reference Alinejad, Aaseth, Abdollahi, Hassanian-Moghaddam and Mehrpour25} The impurity of drugs might be due to the addition of heavy metals by local retailers, to produce heavier packages and therefore higher prices.^{Reference Ghane, Zamani, Hassanian-Moghaddam, Beyrami and Noroozi26} The other routine scenario is adding hallucinogens or sedatives or even other pharmacological formulas to improve the experience of the person who uses the drug.^{Reference Akhgari, Etemadi-Aleagha, Jokar and Preedy27} Therefore, many people who have used a single street substance may present with a mixed clinical picture.