Heroin addiction in Saudi Arabia.

To the editor: I read with interest the letter entitled ‘Heroin addiction in Saudi Arabia’ by Osman and Shawoosh published in the Nov/Dec 2003 issue. The authors have omitted some vital information like when the study was done and what route addicts were using. Both facts are quite relevant and would help understand the findings in the right context. I wish to make some comments:

The study does not in any way reflect the status of heroin addiction in the kingdom nor the frequency of medical complications in this group, as the authors seem to imply. The sample is heavily biased. The conclusions were based on a small sample from Jeddah and cannot be generalized to the kingdom. It is already known that the pattern of drug use varies from region to region. For instance, in western region of Saudi Arabia heroin is abused predominantly in the twin cities of Mecca and Jeddah but not in other areas.1 These patients were seen in a general hospital setting where they would only be treated or admitted if they had a significant medical problem. This does not in any way imply that heroin addicts get more medical complications or that medical complications were very common in this group. Medical morbidity in heroin addicts is well recognized and well published. Earlier findings on this subject from our hospital that specializes in addiction treatment are similar to what had been published outside the kingdom.2

Complications in heroin addicts are mostly injection related3 e.g.dirty equipment, unhygienic technique, sharing needles and syringes etc.) and in few instances caused by heroin or contaminants itself. The authors’ assumption that complications were mainly due to contaminants because more complications were seen in those using higher amounts of heroin is erroneous and misleading. Consumption of large amounts per day does not only imply more contaminants but also more heroin. Increased amount of heroin would require more injections thereby increasing the risk of injection related complications. This is the basis of harm reduction strategies like needle exchange programs in the west. If the authors’ assumptions are correct then perhaps heroin exchange programs should replace these.

Interestingly hepatitis was much less common in these subjects compared to the already published data.2,4 The authors must offer some explanation on this important point.

Figures from our hospital seem to indicate that heroin use may be on the decline.1,2 This would imply less heroin related complications as well.

Epidemiological studies are therefore required to substantiate this further. The peak may have passed and future prospects might not be so grim as the authors seem to perceive.

Lastly stigmatization is not the main reason why addicts do not get treatment, as generally believed. Many in the field overemphasize this point. It is lack of information and awareness about addiction treatment and outcome compounded by misconceptions that keeps addicts and their families away particularly in this country. This may be changing. There is more than two-fold increase in the number of outpatient visits and admissions to our hospital in the last five years. The ever-increasing number of addicts coming for treatment reflects this change.

I agree with the authors that a balanced view should be adopted for effective treatment of addicts. However the role of religion in recovery of addicts should not be minimized. Many psychiatrists perceive religion as unscientific and vague. It is true that religion lacks the objectivity of science. This does not imply that it has no or little therapeutic value. Religion is under researched, under utilized and under valued as a treatment modality. Significant evidence currently exists that support the fact that religion does indeed offer protection against both mental illness and addiction.5 There is therefore a need to bring objectivity to religion by developing and researching religious therapies and interventions. There is no better place than Saudi Arabia to do this.