ADDRESSING DRUG ADDICTION PROBLEMS

IN PUTAO TOWNSHIP (ADAPT)

Rapid Assessment Report

Submission Date: [December 23, 2021]

Agreement Number: [72048221FA00001]

Activity Start Date and End Date: [January 08 2021 to January 07 2024]

[COR/AOR] Name: [Myint Myint Kyu]

Submitted by: [ Simon Thaung ], Chief of Party

[Myaw Lint Yar (HOPE)]
[No. 16, Mulashidi Street, Mulashidi Ward, Putao, Kachin State, Burma.]
Tel: [+959250041058]
Email: [hoperays@gmail.com]
 Table of contents

Acronyms 1Executive Summary 2Introduction 3Aims and Objectives of the

study 3Methodology 4For qualitative data collection 4For quantitative data
collection 6Ethical consideration 7Findings 7I. Findings of Focus Group
Discussion with the elders of the target communities 9II. Grids specified for each
Assessment Module and its findings 13III. Findings from the Drug Use Mapping
23IV. Estimation of drug user population size and prevalence of drug use 29V.
Drug Use Screening Inventory survey (DUSI-R) 29Discussion 34Conclusion
40Recommendations: The Operational Plan 40Annex 48
 Acronyms

ADAPT – Addressing Drug Addiction Problems in Putao Township

CAC - Community Advisory Committee
CBO – Community Based Organization
CIDI – Composite international diagnostic interview
CSO – Civil Society Organization
DUSI – Drug Use Screening Inventory Survey
FGD – Focus Group Discussion
GDP – Gross Domestic Product
GHQ – General health questionnaire
HIV – Human Immunodeficiency Virus
IDU – Intravenous Drug User
INGO – International Non-governmental Organization
KII – Key Informant Interview
MoU – Memorandum of understanding
NGO - Non-governmental Organization
PWHUD – People who have used drugs at least once in their lifetime
PWID – People who inject drugs
PWNUD – People who never use drugs
PWUD – People who use drugs
RAR – Rapid Assessment and Response
SARA – Substance Abuse Research Association
SCID - Structured clinical interview for DSM-IV
UNAIDS - United Nations Programme on HIV/AIDS
UNODC - United Nations Office on Drugs and Crime
WHO - World Health Organization

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Executive Summary
Putao township is situated at the northernmost part, Kachin Region in Myanmar where drug
use is highly prevalent and renowned for drug epidemic. The rapid assessment was conducted
to support the Addressing Drug Addiction Problems in Putao Township (ADAPT) activity. The
assessment was aimed to assess the extent, nature and consequences of drug use in Putao. It
used a mixed-method study approach to obtain a “snapshot” of the prevailing drug use
situation. The assessment use both qualitative and quantitative research methods to obtain as
much information within a short period of time. The preliminary assessment interview was
carried out among the local authorities, community leaders, religious group leaders, village
elders, social workers and villagers of different backgrounds. The initial assessment included
key informant interview (KII), focus group discussion (FGD), mapping and estimation. There
were 3 FGDs to People who inject drugs (PWID), spouses of PWID and parents of PWID. The
quantitative assessment was conducted to 152 participants of 15-39 age groups, using a
convenient sampling in 3 wards and 13 villages in the township. The questionnaire was a self-
administered drug use screening inventory (DUSI) survey form with 135 questions.
From the preliminary interview, it was found that the top most demand of the community was
drug use prevention interventions followed by drug treatment and rehabilitation. Putao
township has been an isolated community, left behind in socio-economic and educational
development. The reasons for drug use mainly included the lack of awareness on drug use
prevention, inability to control the urge for drug use due to poor mental health of youths,
unemployment and reduced parental monitoring of their children in relation to being absence
from home to work in the fields or work in the mines. The low level of socio-economic status
in the environment gravitates the drug users towards the use of the most “cost-effective” mode
of drug use i.e., using the method which allows maximum effect with the least cost”, which is
achievable by using the drug via the injecting route. Community resistance to harm reduction
interventions is quite common as they view these interventions are encouraging drug use.
The overall drug user population is estimated at 4,774, and PWID at 4,099 and 675 People who
use drugs (PWUD). The estimated sex and age group specific point prevalence of PWID is 26
per 100 at risk population and PWUD is 4 per 100 at risk population. The estimated sex and
age group specific total all drug use point prevalence for Putao is 30 per 100 at risk population.
The ward with the highest proportion of drug use is in Hokho/Pan Hlaing ward at 67.81%
which is more than one thirds of the males in the 15-19-year-olds age group. Lone Sut is the
second highest at 57.47% which is more than half of the target population. The lowest
proportion of drug use is in Mu La Shi Di at 7.25%, and this shows that one in ten of males in
the 15-19-year-olds age group are using drugs. The findings of DUSI showed that the biological,
psychological and social factors that are influencing an individual to use drugs at least once in
their lifetime, are much more severely affected than those who have never used drugs in their
lifetime.
For recommendations, the basic principles in reducing the drug use problem situation for
Putao needs to be formulated and drafted to be in line with the 2018 National Drug Control
Policy 1 . In terms of technical policies, the guiding principles mentioned in the National

1
National Drug Control Policy, February 2018. Ministry of Home Affairs. 2 National Institute on Drug Abuse: Preventing Drug Use
among Children and Adolescents-A Research-based guide for Parents, Educators and Community Leaders (Second Edition), 2003.

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 Institute for Drug Abuse 2 need to be followed as much as possible. At the local level, reduction
of drug use and its adverse health consequences, need to work in a collaborative approach
with local networks and local stakeholders to provide rehabilitation support to PWUD/PWID,
drug use prevention activities for youths and vocational trainings to increase self-esteem and
occupational skills of youths to increase chances of employment.
Introduction
Putao township is the northernmost township in Myanmar and is situated in the Kachin state.
It borders India in its northern and north-eastern part, and has an area of 1.83 square miles. The
population of Putao is around 64,000 according to the 2019 report by the General
Administration Department of Putao District and is composed mainly (91.2%) of Kachin, Shan
(6.14%) and Bamar (2.22%) 3. There are altogether 10,612 households in the township and the
majority (71%) live in the rural area, while 3074 households (29%) live in the urban areas.
There are altogether 11 wards, 14 village tracts and 101 villages in Putao. The total population
of under 18 years old is 57% of the total population and the population of 18 years and above
is 43% of the total population. This suggests that Putao has more younger age groups. The
male to female ratio is almost equal among the age group of 18 years and younger, and the
same sex ratio is seen in the 18 and older age group. The majority (92%) are Christian and 8%
are Islam, and the main occupation is farming.

The rapid assessments are used to help make decisions about appropriate interventions for
health and social problems. Most of the methods and techniques that are used can be found in
social science and evaluation research textbooks. This method will be used to assess the extent,
nature and consequences of drug use in Putao township, Kachin state.

Since drug use and its associated adverse health problems are diverse and patterns of drug use
and injection and their health consequences vary from country to country, between areas,
between social groups, and can change over time, there is a need to study the extent and pattern
of drug use within a relatively short time period.

The Rapid Assessment utilized a mixed study approach to obtain a “snap shot” of the prevailing
drug use situation and comprises of both qualitative and quantitative research methods which
were combined together to obtain as much information within a short period of time.

Aims and Objectives of the study

Aims: To facilitate the reduction of drug use and its adverse health consequences
Objectives:
(a) to assess the extent, nature and diffusion of Drug Use and drug injecting
(b) to assess the extent of adverse health consequences of Drug Use, especially HIV infection
and also other blood-borne infections and drug overdose
(c) to assess risk behaviors associated with drug use and injection leading to adverse health
consequences

2
3
http://themimu.info/sites/themimu.info/files/documents/TspProfiles_GAD_Puta-O_2019_MMR.pdf

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(d) to identify and initiate effective interventions to reduce the adverse health
consequences associated with drug use and injecting drug
(e) to identify and initiate effective interventions to influence transitions to less harmful routes
of drug administration
Methodology
It was a mixed qualitative and quantitative study in Putao township. The data collection was
conducted from mid-May to early August 2021.
a. For qualitative data collection
The Rapid Assessment and Response (RAR) method was mainly used for conducting
qualitative studies to the extent that local Covid infection and political situation allowed. The
change in the political situation at the national level affected access to data sources more
difficult as a vacuum was created especially in the governmental sector i.e., township
government department operations were essentially shut down with the refusal to work with
the new government data. Uncertainty in how services should be delivered in a specific
delivery framework was not available. This affected the data collection of this Rapid
Assessment Study which relies heavily on gaining access to data/information that is already
available from the various governmental and non-governmental sectors.

The Rapid Assessment Team members in Putao were remarkable in their ability to get access
to the target population as well as in devising innovative approaches to obtain access to data
sources using their personal connections and organizing abilities. This resulted in collecting
data through generation of own data by the Team and which are also recommended by the RAR
guidelines.
1.1 Interviews – Key Informants and In-depth Interviews
1.2. Focus Groups
1.3. Drug Use Mapping and Drug user population size estimates
1.4. Estimation Techniques – Drug Use Survey
b. The approach used to conduct Rapid Assessment and Response
In the early stages of developing the most appropriate approach to formulate the RAR for Putao,
the need to have a general idea of the level of technical expertise and experience of the potential
data collectors in Putao was assessed. In this preliminary assessment, it was found that the
group of potential data collectors needed to have basic training in data collection methods as
well as some training in the theoretical concepts about the RAR methods and also about drug
abuse and its consequences.

c. Trainings on Rapid Assessment

The following training topics were orderly provided to the twelve-member Rapid Assessment
Team in a series of on-line or phone line trainings.
1. Formation of Rapid Assessment Team and Training
2. Introduction to Rapid Assessment and Response
3. Introduction to Stake-holder Analysis
4. Community Participation and Advocacy
5. Organizing the Rapid Assessment and Response

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 6. Training in the Seven Assessment Modules.
7. Process of Conducting the Rapid Assessment

Step 1. Formation of Rapid Assessment Team and Training

HOPE assisted Substance Abuse Research Association (SARA) to select or recruit 12 members
of the Rapid Assessment Team led by a Team Administrator. The team is comprised of one
Team Leader (field operations), one Field Operator, one Data Assistant and eight Data
Collectors. SARA’s Technical Director and Rapid Assessment Officer provided the Rapid
Assessment Methodology training virtually by using audio-visual.

Step 2. Introduction to Rapid Assessment and Response Methodology

This training series introduced the trainees various concepts and approaches which they need
to understand the wider scope of the Rapid assessment process and included the following
topics;
1) Aims of the study
2) Objectives of the Rapid Assessment Methodology
3) Methods
4) Introduction to Seven Assessment Modules
5) Rationale for using Rapid Assessment Methods for assessing drug use/injecting in
a community.
6) Definition and areas of Health Intervention.
7) Relation of Rapid Assessment to the development of interventions.
8) Using Rapid Assessment methods to demonstrate the feasibility of community
interventions
9) The Rapid Assessment Cycle/Process
10) Harms from using drugs

Step 3. Introduction to Stakeholder Analysis

3.1. Different types of Key Stakeholders
3.2. How to do a stakeholder analysis
3.3. Potential list of stakeholders

Step 4. Introduction to Community Participation and Advocacy

4.1. Principles of Community Participation
4.2. Barriers to Community Participation
4.3. Important steps in developing Community Participation
4.4. Basic Principles of Advocacy

Step 5. Organizing Rapid Assessment and Response

5.1. How to organize a Rapid Assessment team
5.2. Guiding Principles in organizing a Rapid Assessment study
5.3. Aspects of organizing rapid assessment and response

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Step 6. Training on seven Rapid Assessment Modules

Training on the seven Rapid Assessment Modules was provided to the ten trainees virtually or
via phone lines (with the trainees having received the training materials beforehand). The
training took more time to complete as phone lines to Putao were cut off and the trainees had
to travel to Myitkyina where phone lines and internet access was available. Internet
accessibility has greatly facilitated the training. The trainers in Yangon were able to conduct
the training by using Power Point presentations to explain each module which included
background knowledge and data collection grids.

The seven Modules of Rapid Assessment which were taught are;

1. Module 1: Initial Consultation
2. Module 2: Country and City Profile
3. Module 3: Contextual Assessment
4. Module 4: Drug Use Assessment
5. Module 5: Health Consequences Assessment
6. Module 6: Risk Behavior Assessment
7. Module 7: Intervention and Policy Assessment
In each Training Module, data collection was done using Grids for each Module. SARA team
translated the Grids into Myanmar language and the team used them during the data collection
process.
d. For quantitative data collection
The Drug Use Screening Inventory II-(Revised questionnaire which has been translated into
Myanmar language since the late 1990s), was used in this survey (Annex 3).
Drug use screening inventory (revised) (DUSI-R)
Brief description
The DUSI-R measures severity of problems in 10 domains: (1) substance abuse, (2)
psychiatric disorder, (3) behavior problems, (4) school adjustment, (5) health status, (6) work
adjustment, (7) peer relations, (8) social competency, (9) family adjustment, and (10)
leisure/recreation. In addition, it contains a lie scale and documents drug and alcohol use,
preferred substance, and substance with which they report the greatest problem. The output
is in the form of two profiles: (1) a profile indexing absolute severity of disorder (0 to 100
percent); and (2) a relative problem index ranking the order of severity in the 10 domains.
An overall problem density score, ranging from 0 to 100 percent, documents severity of
maladjustment.
The DUSI-R is used for measuring current status, identifying areas in need of prevention,
and evaluating the magnitude of change after a treatment intervention

Target population
Adults
Adolescents and children (over 10 years)

Groups for which this instrument might be especially helpful?

Known or suspected alcohol/drug users; matching specific treatments to specific problems;
identifying youth in need of prevention.
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Sampling Procedure
The survey was administered to a convenient sample of the above age group across 13 out of
15 rural villages in the township and 3 out of 10 wards in the city.
Selection of villages and wards were made depending on the acceptance of the local
administrative authorities, local elders, faith-based organizations, and community-based
organizations (CBOs).
Although the sample size was targeted at 200 individuals in the 15-39 age group, only 152
participants questionnaires were found to be completed upon data entry, and 48 questions had
to be discarded. Out of 152 participants, there were 65 female participants and 87 male
participants who took part in the study.
Data Collection Procedure
Six sub-groups of the Rapid Assessment Team were each allocated villages/wards to conduct
the survey, while the Team Leader and Data Coordinator visited the selected sites ahead of the
survey date to advocate for the smooth conduct, completion of the survey and to ensure upon
data entry, the community takes an active participation in the survey.
The actual data collection sites were conducted in various settings e.g., participants’ homes,
churches, religious centers etc., anyplace where the participants felt comfortable answering the
questionnaire.
The participants were explained about their rights and after which they were required to read
the participant Informed Consent Form (which was read out to the participants by the Rapid
Assessment Team member) and to sign on it if they agreed to participate in the assessment.
Once the data has been collected, all the forms were compiled by the Data Coordinator in
Myitkyina and scanned for any blanks or wrong answers. The completed questionnaires were
then sent to SARA Yangon Office.
Data entry and analysis
At SARA Yangon Office, a database was created in Excel to enter the data of each
questionnaire. Descriptive analysis of relevant variables was conducted and Student’s t- test
was used to conduct comparison of Means of the relevant variables.
Differences in the domain scores between the people who have never used drugs in their
lifetime and those who have used drugs at least once in their lifetime (Lifetime drug use) were
compared with the aim of identifying any specific domains that are affected in the two groups
and whether they are different across the two groups.
Ethical consideration
The participants were informed of the strict confidentiality of their answers and the
questionnaires themselves do not include any self-identification questions that could be used
to trace the participants.

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Findings
Data collection for RAR started with formation of a Community Advisory Committee (CAC)
to oversee and guide the data collection process, while at the same time encourage their buy-in
to the data collection efforts as well as to keep them informed of the findings and garner future
support for the interventions.
The RAR Field Team was able to form this Advisory Committee, with the members agreeing
to take part in the RAR process. However, the Initial Consultation could not be conducted in
a single meeting due to Covid restrictions. So, the RAR Field Team Leader visited each
member in their homes and explained about the process and obtained valuable insights from
each of the members. Consensus on each issue presented to the CAC was obtained.
The information was gathered through conducting in-depth interview sessions and focus group
discussions via phone and on-line interviews.
The Initial Consultation with CAC members was able to gather the information. The four
members of the CAC were involved in the Key Informant Interviewing process with members
from various religious groups and elders from the village communities.
The themes that were discussed with them were;
1. Opinion on Drug use situation in their communities in general
Community elders think that drug use situation has increased in recent times and there
is also changing trends in the type and mode of drug use which has shifted from the use
of opium by smoking to the use of heroin by injecting. Amphetamine use has also
emerged.
They estimated that out of 32 youths in the village, 27 youths (two thirds) are injecting
drugs while one third smoke heroin or opium.
All four participants reported that “drug use in their communities seem to be on the
increase during recent times (during 2021).”

2. Changing trends in the type and mode of drug use

The four participants all reported that
“Previously, the use of opium by smoking with bamboo or opium pots were
common. At that time, heroin did not arrive in these parts. However, after 2016,
maybe for 3-4 years back, heroin appeared.”
Community elder, Putao city

3. Current drug use situation

The participants agreed that the current drug use situation has worsened in recent years.
“If there were around 32 youths in a village, 27 would be using drugs and the
majority of them injected the drug. Out of the total number of drug users, one third
of drug users smoke while the rest (two thirds) inject heroin.”
Religious group leader, Putao

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 I. Findings of Focus Group Discussion with the elders of the target communities
Three FGDs were conducted with a range of participants from three to five participants in the
various villages and wards.
Themes
1. Health Consequences of drug use
The participants agreed that drug use has a severe impact on the health of drug users and also
affects socio-economic status of the user as well as the family. They also see that drug use
eventually leads to destroy the development of their community as a whole.

“Drug users health status is severely affected, together with his socio-economic status
because of his drug use. My family members’ basic eating, earning a living became
very difficult and the family cannot progress any further because of him. We cannot go
and work in the fields because we cannot leave our homes. Our son (who is using
drugs) will sell any household item that he can sell, when we go to the fields, to get
money to buy drugs. So, it is very difficult for us (the family) to work and earn a living.”

A father (also a village elder) of a drug user, Mun Se village, Putao Township

2. Disease specific health consequences of drug use

The participants were also aware of the spread of infectious diseases associated with
injecting drug use. They mentioned all the infections that can occur with injecting drug use
e.g., HIV, Hepatitis B and also other infections which are associated with the use of drugs
(non-injecting as well as injecting) e.g., tuberculosis and sexually transmitted infection.
They also recognize the disease transmission risk increases if the drug user uses within a
group of friends.

“If the drug users use drugs in a group of friends, they can catch TB, B, C and
HIV….. plus, STDs…. there are a lot of them having these infections…. I am seeing
some of them having TB treatment.”
A Ward elder in Putao Township

3. The presence of sub-groups of injecting drug users

Several types of drug users were identified in Putao Township, based on their job
characteristics, education background etc.
Several jobs seem to expose more risk to drug use i.e., highway car drivers, farmers, gold
and amber mine workers, high school students and school drop-outs.

“It’s difficult to say which group has the greatest number of drug use since there is
a mix of these groups that are affected. There are students, highway car drivers,
farmers who use drugs casually.”
FGD session among village elders

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4. Drug use in gold mines
Drug use is as high as 70% among workers in the gold mines. People who have worked
for several years in these gold mines believe that drug use can prevent themselves from
malaria and also enables them to dive underwater longer which they believe, will increase
their chances of finding more gold. For those workers who need to work without sleeping
at night, the use of “yarma” is more common. Even government staff who work in these
regions use drugs.

“In the gold mines, at least 70% of the workers use drugs, especially those who
have worked there for several years. With bad conditions in these mines, they
take drugs to prevent them from malaria, allows them to stay longer underwater
when diving for gold and also allows them to be able to work without sleeping
during the night. Even the government staff are also using drugs.”

A member of the FGD session who lives in the gold mining area

With regards to the site of these gold and amber mines, they report that the mines are
located along the Malikha river between Putao and Sumprabum Townships. They are
about 20-30 miles away from their villages. However, for those who go to faraway
Townships e.g., Pharkant and Tanai, the proportion of drug use among these mine workers
are much higher, at around 75%. Very few people who return from these sites return
without using drugs.
The majority of mine workers who return from Tanai prospect for amber and gold while
those workers from Hpakant prospect for small jade debris “ye ma say kyauk”, that can be
found among discarded excavated earth.Some mine workers go there in a seasonal manner
(when farming season is over) while some go there for several years.There are farmers
who do not travel to these mines but 40-50% of these farmers in Putao need to travel to
these mines as the money they earn are not sufficient enough to meet their annual income
needs.

“There are farmers who do not go and work in the mines because the money
they earn from farming is enough for them, but “single season farmers” are
farmers who do not earn enough to last a year…. need to go to these mines.
Approximately, 40-50% of the farmers are single season farmers.

A member of the FGD group who is also a single season farmer

5. Women drug users in the mines

Women who use drugs are also seen in the mining areas. Approximately 13-16% of the
women in the mines use drugs. The most common scenario is when the husband uses
drugs, the drug is mixed with alcohol or beer and taken by both couples. In these scenarios,
both the husband and wife become addicted to drugs.
In some cases, some young women in the mines become promiscuous when they travel to
these mines and use drugs for sexual pleasure with their male youth in their group of
friends. This may point out to the use of drugs for “chem-sex”.

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6. Unofficial naming of certain village tracts or wards depending on drug use levels.
Drug use in the various wards and village tracts in Putao Township are not the same. The
level of drug use can be categorized as “high, medium and low”, and some areas, it is
“minimal.”
Among the “high” drug use villages are Lan Taung, Lan Nung. Lone Shar Yan, Sun Tarran,
and in the cities, Law Sawt (Hokho) and Man Pan wards.

The main reason behind the “high” level of drug use in these villages/wards is that they
have a “traditional trend” of being involved in opiate business since many years ago. With
the declining supply of opium and increasing availability of heroin, druguse changed to
heroin. The farmers mainly live in these villages and wards.

7. The need for drug demand reduction services

Preference for Drug Use Prevention interventions appear as the top most need by the
community, followed by drug treatment and rehabilitation. The stated reason for this
choice is that the community are not aware that drug use can be prevented since the level
of education, awareness of the drug use prevention measures is low and inability to control
the urge for drug use due to the poor mental health of the youths.
In addition, youth unemployment, reduced parental monitoring of their children in relation
to being absent from home to work in the fields or to find supplemental income in the
mines are also factors to be considered to be taken into account to prevent drug use.
As Putao Township has been an isolated community for decades, the drug demand
reduction efforts are not heard of and the community members do not have the capacity to
seek information in this regard. They have been left far behind in socio-economic
development, educational development and overall development visions for their
communities.

“Here, we are not developing in socio-economic status, educational status and

new community development visions since we are living in remote mountainous
regions. Thus, we cannot envision the future and the way out of this sad
situation and cannot afford to have visions and goals for developing our
community.”

A religious leader from a ward in Putao

The magnitude of the drug use problem in their villages and wards were also expressed,
along with the mortality rate of youths due to heroin overdose by a local administrative
authority.

“In our ward, drug use is a very significant problem as the majority (70%) of
youths use drugs and most of them inject (80%) while only 20% smoke it. We
have lost a lot of youths to drug overdoses and I think 20% of those who inject
have died of overdosing on heroin.

A local administrative authority of a ward

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8. Parental monitoring of drug use among their children
Parents have to leave home to supplement their annual income to make ends meet, which
meant being away from home for several months to years. This resulted in poor parental
monitoring of the children and late recognition of their children who have started
experimenting with drugs.

“…some parents need to go and work in the mines and their children are left at
home unattended. It is during these times that children start experimenting with
drugs and when the parents return back home, they realize that their children
are already hooked on drugs.

A religious leader in Myitkyina helping drug users access drug treatment services

There are also instances in which parents do not travel away from the family but their sons
become drug users. While the parents notice that their son(s) are getting involved with
drugs, they detect it very late and their son has become already addicted.

“Yes, there are families who do not need to travel to the mines for supplemental
income but can stay at home. Since they detect the drug use of their sons only
when he becomes addicted, it becomes difficult to give discipline or persuade
their son not to use drugs.

A parent of a village in which drug use levels are high.

9. The need for access to drug treatment services

While the need for access to drug treatment services are high, there are considerable
barriers for parents to overcome, and they are;
(1) priority given to earning money to put food on the table instead of using hard-earned
money to pay for drug treatment costs.
(2) while there are facilities for providing drug treatment and dispensing services for
methadone is present, they are out of reach in terms of actual cost of these services as
well as indirect costs related to accompanying family members (this applies especially
to drug users from the villages who need board and lodging costs which can be not
affordable by the family.
“It is difficult for the families of drug users to get access to drug treatment
services as most of us are daily wagers…..and have to save the money to spend
on food for the family…. if we should send our drug using son to a drug
treatment facility…we would need money to spend on food, boarding and
lodging…. this cost is something which we cannot afford or give priority…”

A parent from a village who has a son using drugs

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 “We would like to request drug use prevention services and drug treatment
assistance for our village as there are quite a lot of youths using drugs and they
cannot get treatment…please help us…”

A parent from Mulashidi village who has a son using drugs.

“We feel really sad to see a lot of youths using drugs… and just like what the
previous friends here have just mentioned, previously, there was very little
problem with heroin, but now, the use of heroin by the youths have become very
widespread… so, we need a lot of people to help our community tackle this
problem. Upon hearing that you would help us in treating drug users while at
the same time provide trainings in preventing drug use and educating the
parents on how to handle drug use problems, we are really happy to hear about
this.”
A pastor from Putao Township

Another pastor from a different denomination also said;

“Regarding youths who use drugs, our churches also provide encouragement
through prayers, teaching the Bible etc. Before these approaches come into
effect, we feel that the youths who use drugs need really some form of
medications to help them. In addition, they would also need medicines to treat
infectious diseases that can accompany drug use”.

10. Opportunities for alternate lifestyle for youths.

There are very little facilities for youths to be engaged in self-development activities. At
most, they can play football or attend bible study classes. There seems to be a lack of
understanding the importance of putting in place a wide range of activities e.g., a variety
of sports, music, performing arts etc. for youths to be actively engaged during their leisure
hours and to keep them away from experimenting with drugs.

11. Opportunities for learning vocational skills for youths

There are no opportunities for youths to learn vocational skills in Putao which makes it
difficult to learn vocational skills to help the youths to secure a job in Putao or even in
Myitkyina.

“There are no vocational skills training schools and no classes for youths to learn
a skill that will give him a job. All we have are apprenticeship in motorcycle
workshops, brick baking and farming”.
A volunteer youth social worker.

II. Grids specified for each Assessment Module and its findings
Upon completion of the Trainings in Assessment Modules, the Rapid Assessment Team were
divided into four subgroups with the Data Collection Supervisor and the Team Leader who
divided themselves to implement the Assessment Modules in each of the four selected project
village tracts and wards.

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The subgroups visited the project sites over the course of two weeks to collect the data using
the Grids for guidance and return back to the HOPE office in Myitkyina to collate the data with
the help of the Data Collection Supervisor and Team Leader. The data was collected in
Myanmar language and sent to Yangon Office.
The Rapid Assessment Officer in Yangon summarized the data/information in a separate file
digitally and emailed it to the Rapid Assessment Officer who analyzed and did the write-up of
the study paper while doing the translation into English language simultaneously.
The summary of the findings that were derived from the Assessment Grids are mentioned
below.

Assessment Module 1: Initial Consultation

The following information with regards to drug use in Putao was collected during the Initial
Consultation with members of the Community Advisory Committee.
a. They noted that in Putao Townships, infectious diseases such as HIV, Hepatitis B,
Hepatitis C and Tuberculosis cases were rising.
b. They also noted that there was an increase in heroin injecting more than opium smoking,
with increase in the above infectious diseases.
c. They also thought that the RAR process should also include village authorities, community
elders, youths, women and drug users (both injectors and smokers).
d. In terms of groups of people who could contribute information regarding drug use in Putao
are government departments, especially health sector, INGOs/NGO. They also advised
on providing parenting education to prevent drug use, monitoring the spread of drug use
in the villages and also on the type and method of drug being abused.
e. They also expressed their wish to see the community members from the village level to
the Township level, join in the effort to tackle the drug use problem, and believe that at
least 80% of the community in Putao will join in this effort.

Assessment Module 2: Ward/Village Tract Grids

Key geo-environmental features
Among the four project sites, Man Pan village tract is the largest with 15,047 square miles
acreage, followed by Long Shar Yan village with 9437 square miles, Mulashidi with 3289
square miles and Pan Hlaing ward at 3199 square miles.
The yearly weather is the same across these sites with temperatures ranging from 20.6 degrees
to 12.8 degrees Centigrade.
The wards and villages are governed by Putao Township Administrative Office.

The population structure and characteristics

The Long Shar Yan village has the largest population at 5152 persons, followed by Man Pan
village at 4858, Mulashidi at 2115 and Pan Hlaing at 618 persons.
The population estimated to be vulnerable to drug injecting (both males and females) within
the age of 19-24 is 90% (the highest) in Long Shar Yan village, at 80% in Mulashidi and 70%
in Man Pan and 60% in Pan Hlaing.
The main nationalities, ethnic and racial groups in Long Shan village is 35% Jing Hpaw,
30% Li Su, 30% Rawang and 5% Shan. In Man Pan, 92% are Shan, and 8% are Li Su. In
Mulashidi, 70% are Li Su, 30% are Rawang. In Pan Hlaing ward, 60% are Shan, 20% are Lisu
and 10% are Rawang, 10% are Chinese.

14
This reflects a wide range of ethnic composition in the project sites.
The written language is the same across all four villages and it is Myanmar language.
The spoken language is Myanmar and also reflects the various ethnic nationalities mentioned
above for each village/ward.

The levels of education and literacy

The education level is the highest in Pan Hlaing ward having around 59 graduates and 100
students who have passed the matriculation level. It is followed by Long Shar Yan village
which has 10 graduates and 36 students who have passed matriculation level. This is followed
by Mulashidi village having 10 graduates and 31 students who have passed matriculation. Man
Pan village only has 9 graduates and 20 students who have passed matriculation.
In terms of Literacy rate, two thirds of the people living in Pan Hlaing ward and Mulashidi are
literate and one third of the people living in Long Shan Yan and Man Pan are literate.

The main religions and belief systems

The main religions in Long Shan Yan and Pan Hlaing are Christian and Buddhists, while
Mulashidi is composed of all Christians and Man Pan village is composed of all Buddhists.

The main causes of ill-health and mortality

The life expectancy across the four project sites is the same at 65 years, but the infant mortality
rate is not available due to the closure of Township Health Department.
Key health problems apart from drug use, are also the same across the four project sites and
they are diarrhea, high blood pressure, malaria and influenza.

The characteristics of the local economy

While the GDP figures for the project villages (as well as for the Township) are not available,
the goods produced include rice and vegetables.
The private business sector is mainly opening of shops, farming and vegetable gardening only.
Prospecting of gold and amber is very common among the project population and the people
depend on this mining “industry” to a large extent.
The unemployment rates range from 50% to 70%, with the highest rate in Man Pan and Pan
Hlaing at 70%, followed by 60% in Long Shar Yan and 50% in Mulashidi.

The main communication channels and access to the media

There are no local newspapers and the highest proportion of the population with access to radio
is highest (50%) in Long Shar Yan village and the lowest (20%) in Mulashidi.
The presence of Television sets is highest in terms of proportion is 40% in Mulashidi and lowest
(30%) in Long Shar Yan and Man Pan villages.
Access to Telephone services is highest in Mulashidi at 40% and lowest in Long Shar Yan
village at 20%.
The main means of transport is by roads with cars and motorcycle, while there is an airfield in
Putao Township with flights two or three times a week to Myitkyina-Mandalay-Yangon.

The levels of access to basic services

Long Sha Yan is the only village without electricity, while access to water is present in all four
villages.

15
As for sewage services, all four sites do not have sewage systems but some have outhouses.

The system of government and political structure

At the time of the data collection during April, 2021, the system of government was undergoing
a change from a democratic government to a military government.
The level of decision making
In the field of Health, the decision making is the same across all village sites at the Station
Health Department level.
In the field of Social Welfare, the decision making is also the same across all village sites at
the village level.
In the field of Law, the decision making across all sites is at the Township level, which is the
same in the case of decision making in the Law Enforcement field.

Health services provision and coverage

Health services are mainly provided by the government Health Departments. They are financed
by the government. The organization of the Health Department is placing a Township Hospital
together with Township Health and from this, there are Station Hospital, Rural Health Centers
and Rural Health Sub-Centers. The health care service is usually free of charge. However, the
coverage of health services is low which is mainly due to poor filling of the health posts by
health personnel as Putao is a very remote part of the country (in fact, it is the northern-most
Township in the country) and health staff find it difficult to travel and work in these posts.
In addition to the government health service, several INGOs and NGOs are also working in
Putao to provide health care services (details mentioned in Policy Assessment Module grid)

Education facilities
All project sites have State Primary, Middle and High Schools as the highest level of education
and are financed by the government. The level of schools set up usually follow the
administrative hierarchy within the Township.

The legislation regarding drug use and law enforcement

The legislation regarding drug use has been abolished since 2019 February but possession of
drugs is still an offence. These laws apply to the whole country, but due to the remoteness of
Putao, the new law may have not come into effect as yet.
The number of convictions under the drugs legislation could not be obtained along with the
number of prisoners sentenced under drugs legislation.

Non-governmental organizations (NGOs)

All INGOs have to sign MoUs with the central line ministries and all NGOs have to register at
the Central government level. There is an INGO (Medical Action Myanmar) working in the
field of PWID and HOPE is working in the field of Drug Use Prevention, Treatment and
Rehabilitation.

Assessment Module 3: Contextual Assessment

1. Factors that encourage or discourage the spread of drug injecting/use

16
 The need to find supplemental income is high since farming alone is not sufficient to meet
the basic food needs for a year, and the mining work is physically very demanding. Drug
use/injecting helps relieve the pain and stress of working in these gold and amber mines.
Access to jobs apart from farming, that will provide additional income to provide basic
food needs can discourage the spread of drug use/injecting.
2. Factors that exacerbate or ameliorate the consequences of injecting
Poverty seems to be the basic factor that exacerbates the consequences of injecting drug
use since oftentimes, the drug users do not have enough money to buy a single “packing”
(single penicillin vial or a single “pipe” of plastic straw) of the drug and need to pool money
among themselves to buy them. This “cost sharing” in buying drugs usually leads to
sharing of the “drug solution” using a single needle and syringe or sharing of the drug
solution through a cotton filter that is placed on the spoon that contains the solution.
Sometimes, when a person has started suffering from withdrawal symptoms, there is an
urgency to use drugs. In these instances, the drug user cannot pay attention to using drugs
safely, but get the drug into his veins as soon as possible. These situations also encourage
the spread of infectious diseases.
Although there is needle exchange program, the easy availability of used needles and
syringes that have been discarded in the “shooting sites” also unintentionally encourages
the use of used needles and syringes, especially when sterile injecting needles and syringes
are not available nearby.
To avoid the use of discarded or used syringes in these circumstances, harm reduction
activities need to be expanded so that high coverage of needle and syringe distribution is
obtained. In addition, proper disposal of used needle and syringes should be put in place
in these shooting sites so that used needle and syringes cannot be available easily.
3. Factors that hinder or enable the development of interventions.
The enthusiasm and commitment to improve the development of health status of the
community is seen as a major factor that enables the development of interventions.
The Assessment Module study has not revealed any factor that hinders the development of
interventions to improve the health of communities.

Assessment Module 4: Drug Use Assessment

1. Knowledge and perceptions about different kinds of drug use.
Not only drug users but the community have heard about injecting drug use.
The majority of drug users (non-injecting) have not encountered injecting drug use.
The majority of drug users who do not inject think that drug injection is bad.

2. Availability of drugs, including those that can be injected.

Drugs that are usually seen in other rural regions of the country are available e.g., alcohol,
amphetamine-type stimulants, methadone, opium, heroin and diazepam.
Drugs that can be injected and mainly available are diazepam and heroin, but heroin is the
drug that is mainly being injected.

17
 Methadone is the licit substance that is mainly available in the hospital and from an INGO
and drug production (heroin) are not produced locally. There is misuse of methadone by
PWUD who takes treatment shares with others. However, there are some reports that “yar
ma” is produced locally but cannot be confirmed.
These drugs are illegally transported mainly through roads with cars and motorcycles.

3. Views of injectors about the use and injection of different drugs

The PWID mainly prefer to inject heroin and do not like to inject opium and methadone.
Sometimes, heroin injectors would like to change to smoke heroin but cannot afford to
change as this mode of use is more costly.

4. Extent of drug use

These estimates on various prevalence rates (lifetime use, use in last year, use in last month
etc.) of drug use are not available and the information that is obtained using the
Assessment grids could only provide information from the observation from the local
population. These estimates are 70% of people between the age of 16 and 40 use drugs
and 80% of adults (age 18 years and above) use drugs at any time, and also 80% of adults
use drugs in the last year and 80% of adults use drugs during the last month.
Since the reliability of these figures is low, there is a need to conduct the Drug Use
Screening Inventory survey to provide these prevalence estimates.

5. Extent of injecting drug use

These estimates, like the above estimates, are also community reports, which essentially
is of low validity. The lifetime prevalence of injecting drug use is estimated at 10%, for
injecting drug use during the past year is 30% and 40% in the past year.
The injecting drug use among adults during the lifetime, past year and past month are 40%,
45% and 45% respectively.

6. Trends in the injection of drugs over time

Injection of drugs was introduced since the early ‘70s during which only the rich and a
small group of artists started using heroin through injecting. In the 1960s, youth who
displayed defiance against the authorities, started injecting heroin. During these years, the
cheap heroin came in from Pakistan which ignited the heroin epidemic even among youths
who are not financially well off. Since these years, the heroin epidemic spread rapidly
within the youth community.
In terms of geographical spread of injecting drug use, the western and central parts of
Putao are more involved with injecting drug use.
The general sense of the trend of drug injecting is that it is increasing in nature, based on
discussions with religious leaders, community elders, cultural development organizations
etc.

7. Characteristics of drug users who do not inject

The social groups who do not inject are the average laymen who are males in their middle-
ages (around 40 years) and they have only Middle School education, unemployed, earn
money for a living through farming and without a distinct ethnic group.

18
8. Characteristics of drug injectors
The social groups who inject, in the early years of drug use are those who are well off in
financial terms, as well as by artists in the entertainment business. Later on, even people
who are financially well-off also started injecting heroin. 75% of drug users are males and
their age groups are mainly in the 17–18-year age bracket and less than 25 years. A small
group whose age is around 60 years are also injecting drugs.
Their average educational standard is Middle School and majority of them are unemployed
or do some farming. Their income is below average from regular jobs, side business which
may include selling drugs themselves. There is no distinct ethnic group that inject drugs.

9. The drug using career of the injector

The youngest age at which drug use started, is commonly at 16 years but occasionally, 14-
year-olds are seen starting to inject heroin. The eldest age in which drug injecting occurs
is 25 years.
Drug injecting occurs usually as early as 18 years of age, and drug injecting is usually
continuous and those who stop on their own is rarely seen. They usually seek drug
treatment services only after at least 5 years of injecting drugs. People who inject drugs for
more than 26 years can also be found.

10. Geographical location of injectors

The drug injectors live all over the urban and rural areas with no specific and clearly defined
area. They obtain drugs from villages that deal in black market goods and inject in nearby
villages. Some inject within their homes, outhouses, bushes but openly in the gold, amber
and jade mines.

Assessment Module 5: Health Consequences Assessment

These data for the Health Consequences Assessment using the respective grid could not be
obtained from the Township Health Department since the head(s) of these department were not
attending their duty stations
The data from INGO working in the field of harm reduction was also unable to provide any
information that they had.
Some data on Health Consequences of drug use can be obtained from Drug Use Screening
Inventory and the findings form this survey is presented in the respective section.
Since the data that was required to fill in the Assessment grid was mainly focused on
epidemiological data regarding the infectious diseases associated with injecting drug use, these
data are not expected to be available in a remote Township where the health system is not
strong enough to collect this information e.g., prevalence of injecting drug use, prevalence and
incidence of HIV infection among PWID etc. These data can only be obtained through ad hoc
and longitudinal studies.

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 Assessment Module 6: Risk Behavior Assessment

1. What injecting behaviors among PWID increase the risk of infectious diseases?
Needle and syringe sharing with re-use of used syringes have now become decreased with
the introduction of harm reduction interventions in Putao city by an INGO, the Medical
Action Myanmar, sharing of used syringes are still occurring in the rural areas of Putao and
this behavior is expected to increase the risk of transmission of infectious diseases,
especially in the gold and amber mining areas.

Contaminated drug solution pooling of money to buy drugs (since the drug users do not
have enough money to buy a “single packing unit” that is sold and lack of sterilization of
the “pooled” drug solution, may also increase the infectious disease risk.
Drugs are usually sold in small pre-filled bottles and bags and buying ready-filled syringes
are not seen.
Dividing drug solution between syringes was present but not commonly seen. There was a
possibility of sharing filters but is uncommon. Sharing of drug solution was practiced due
to pooling of funds to buy drugs, but some PWID are aware of the risks involved. Sharing
of rinse water practice was seen and some were not aware that this was a risky behavior to
become infected with diseases.

2. How high are levels of injecting risk behaviors among PWID?

Needle sharing risks is higher among PWID who just started injecting, compared to
PIWDs who have injected for a long time.
It was estimated that about 20% of new IDU could have risk behavior of sharing needles
and syringes.
Estimates the number of PWID: this information is not available.
Estimate the key differences: this information is not available.

3. What sexual risk behaviors among PWID increase the risk of infectious diseases?
Unprotected penetrative sex and having multiple sexual partners increase the risk of
infectious diseases.
Casual partners: not available

4. How high are levels of sexual risk behaviors among PWID?

The overall assessment of the level of sexual risk behaviors among PWID are high.
Estimated proportion of PWID who practice risky sexual behaviors: 25-40% of PWID
have unprotected sex with regular partners and casual partners.
The frequency of high-risk sexual behavior is estimated as being frequent.
The estimated number of PWID who practice high risk behavior is about 2 casual partners
per month.
The key differences among PWID and PWUD is that drug users who use heroin heavily
(about 7-8 times a day, spending 50,000MMK to 100,000MMK per day) were less likely
to engage in sexual activity.

5. What behaviors among PWID increase the risk of overdose and other health conditions?

20
 Poly drug use (heroin and alcohol) is most common behavior among those who overdose,
and those who usually inject with friends also tend to overdose.
The purity of drugs is relatively constant and they are not “tested” before use e.g., tasting
the powder before using.

6. How high are levels of overdose risk behaviors among PWID?

Overall, the level of overdose among PWID is not high and usually when strong home-
made alcohol is used together with heroin, then overdose occurs.
Estimated proportion of overdose: not available
Estimated frequency of overdose: not available maybe due to a stable purity of heroin.
Estimated number of people who overdose: 2-3 reported fatal overdose each year (less
than 10 PWID have non-fatal overdose).
Key difference among PWID who overdose and those who do not overdose: The use of
alcohol together with heroin is the key difference. PWID who drink alcohol and inject
heroin tend to overdose more.

7. What are PWID levels of knowledge and their perception of the risks associated with drug
injecting and sexual behavior?
PWID know that they should not share needles and syringe and knowledge about
transmission of HIV and Hepatitis B is high.

Sharing drug solutions by dividing between syringes (“front-loading” and “back-loading”)

is not as frequent due to most PWID not using sterile water (distributed by harm reduction
organization) to mix with heroin, but those who share solutions are unaware that they
could get infected because of this risk behavior.

Unprotected sex: Most PWID focus on not sharing needles and do not think unprotected
sex is important as much.

8. How do social norms influence injecting risk behaviors among PWID?

There is a general frustration among the community members on injecting drug use, which
they do not like but at the same time, do not know what should be done or how this problem
should be tackled. On the part of PWID, the negative pressure from the community on
their drug use prods them into avoiding their “eyes”, and inject drugs out of sight from
them as well as from the law enforcement personnel. Thus, there is a resultant negative
influence on the PWID to inject secretly and quickly, which encourages risky drug use.

9. How do social norms influence sexual risk behaviors among PWID?

Most of the youths use condoms for casual sexual encounters but middle-aged men are
more likely not to use condoms.
When a woman gets married to a PWID, she is left alone to handle her husband’s injecting
drug use and the prospect of getting HIV infected from her husband. There are also low
levels of condom use within marriage context. So, the wife usually has to face these
problems of preventing herself from becoming HIV positive.
Youths who are single, engage in casual encounters and majority have primary sexual
partners.

21
 Women who use drugs engage in sex for money/drugs but male drug users rarely engage
in sex for money/drugs.
Anal sex between men is not prevalent currently.

10. How do social norms influence the risk of overdose and other health conditions?
The negative pressure from the community and law enforcement personnel creates a
“pressure” situation where PWID need to inject their drugs as quick and as undetectable
as can be made. This “encourages” the PWID to inject as quickly as possible and inject
in “out of sight” places, thus increasing the chances of overdose and at the same time,
reducing the chances of being detected by the community that a PWID is overdosing
himself and results in not being taken to a hospital for reversal of overdose.
Before the presence of harm reduction organizations came into operations in Putao, skin
infection among PWID were very common and treatment access was avoided by them
with the fear of being “stigmatized” as well as being arrested for drug use.

11. How do the social settings in which injecting and sexual behaviors occur, influence risk
behavior among PWID?
Prisons: Prison offenders in Putao are most drug offenders who were arrested on drug
charges, unlike the prisons of the rest of the country where more than 50% of inmates are
drug users. Thus, drug usage in Putao prisons is almost non-existent.

Shooting galleries: There are no overt shooting galleries in Putao. People use drugs in
quiet places, near the river banks which are mostly out of sight from the public, places
away from roads and near dealer’s houses.

These suggest that there are negative perceptions on injecting drug users by the community
as well as law enforcement personnel.

Injecting in friend’s homes: This is not uncommonly seen and suggests that parents are
mostly not at home and is regularly away at certain times of the day or even away for
months at a time.

Area X: Drug injecting in gold and amber mines are areas in which law enforcement is
lax or not accessible, and this allows a certain level of independence to indulge in vices to
occur without being hampered by society or law enforcement.

12. Do particular social groups of PWID have higher levels of injecting risk behavior?
Sharing of needles and syringes: newly-initiated PWID are more likely to share needles
and syringes than PWID who have injected for a long time.

PWID living in the mining areas also have higher levels of injecting behavior as their jobs
demand severe levels of physical endurance, resulting in the need to take something that
will give pain relief as well as help them sleep so that they wake up with enough energy
to work for another day.

22
 Unprotected sex: Most PWID living in the city are proper how to use condoms and thus
have low sexual risk for HIV but PWIs who live in gold and amber mines have higher
levels of injecting risk behavior since there is less social pressure on the use of drugs.

Overdose: There is a general sense that overdose is more prevalent among PWID living
in the gold and amber mines and these incidences are under-reported when compared to
overdoses among PWID living in the city.

13. What impact do local and national policies have on PWID risk behavior?
Sharing of needles and syringes: Communities in Putao city area accept harm reduction
practices but there was resistance to these interventions, particularly from the religious
sector in remote urban areas. This could be related to the higher level of exposure to newly
updated National Drug Control Policy by the city communities or due to the lower
educational levels in the urban areas.
The updated National Drug Control Policy has changed its policy towards drug use more
from the health point of view, rather than from the old policy which has Law Enforcement
point of view. Back then, drug use per se is considered an offence and thus, legal action
can be taken for drug use alone.

Unprotected sex: Previous national policies have the provision to consider “condoms’ as
(exhibits)proof of illegal sex work. However, this policy has been abolished in recent
years but still in remote parts of the country like urban Putao, condom use is at low levels
which may be the result of old laws or the new policy has not reached them.

14. What impact does the social and economic environment have on PWID’s risk behavior?
The high level of unemployment among the male population and low prospects of job
opportunities observed in previous Assessment grids and qualitative interviews reveal that
the low level of socio-economic status in the environment gravitates the drug users
towards the use of the most “cost-effective” mode of drug use i.e., using the method which
allows maximum effect with the least cost”, which is achievable by using the drug via the
injecting route.
This progresses to PWID suffering from drug addiction, poor health consequences,
inability to work, reduced income, no money to obtain treatment, continue using drugs,
which is a vicious cycle that is occurring repeatedly and there is no way visible in the near
future to break this vicious cycle.

Unprotected sex: The social and economic environment impacts on the risky sexual
behavior among PWID in that they cannot afford to spend more money (which they need
to buy drugs) to buy condoms, resulting in practicing “unprotected sex”.

Women who use or inject drugs need money to obtain drugs and they also would not like
to spend money which has been “hard-earned” by selling sex, would rather spend whatever
they earn on drugs.

III. Findings from the Drug Use Mapping

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In order to complement the findings from the qualitative data collection, as well as from the
Assessment Module, the Rapid Assessment Team conducted a drug use Mapping exercise
whereby, all sub-groups went to all villages and wards and met with the village tract and ward
authorities. They took with them a 5 by 8-feet map of Putao Township that was printed on a
vinyl sheet.
The village tract and ward authorities were first informed about the aims and objectives of the
Rapid Assessment study to secure their participation in the Assessment effort as well as to
increase their “ownership” of the assessment and future interventions.
Then they were requested to provide their perception of the number of drug users, drug injectors
in their villages and then were asked to provide the total population of their villages and wards.
The Rapid Assessment Team managed to visit 13 villages out of 14 and 3 wards out of 10
wards, depending on the availability of the respective village elders and ward authorities and
also on the general security of the locality
In line with their perception of drug use in their respective village and ward, they placed one
red colored paper sticker (circle in shape) for at least 10 drug injectors and one yellow colored
sticker (also circle in shape) for at least 10 non-injecting drug users on their respective village
tract/ward on the vinyl map.
In this way, a general idea of the geographical spread of drug use within Putao can be obtained
and visualized within a short period of time. Since this mapping exercise of drug use was based
on the perception of local authorities and local elders of the community and not a scientific
study, the number of drug users which they perceived to be present in their communities
represent only “guess work”. However, the advantage of this method, in terms of assessment
of the spread of drug use, was very useful. A bird’s eye view of the geographical spread of
drug use, and the presence of “pockets” of high levels of drug use, can be obtained.
These findings were not a complete picture, but should be seen as complementing the
information that is being gathered by other means to assess the drug use situation in Putao.
Drug use was seen in all village tracts and wards in Putao township (see Putao Map showing
the village tracts and wards that have drug use and pointed out by the small colored circular
stickers) but was not a homogenous spread. The geographical presence of drug use in the Map
shows that it was not confined to the city alone but extends to all rural village tracts, and this
had to be kept in mind when interventions to prevent drug use was made i.e., the whole
township area needed to be taken into consideration when planning for drug use prevention and
drug treatment, rehabilitation etc., which were essentially Drug Demand Reduction activities.
However, areas with high proportion of drug use (drug use clusters) need to be given more
priorities than those with low proportion.
In general, the overall finding was that drug use proportions seem to be higher in the rural areas
than the urban areas of Putao (see Graph No.1 below).
The differences in the proportion of PWUD were much higher in the rural areas as compared
with the urban area and suggest that there was a higher potential number of non-injecting drug
users to “transit” to risky mode of drug injecting in the rural areas. If these rural PWUD were
not well versed with the dire consequences associated with injecting drug use, there was a high

24
chance that they would become infected with HIV, Hepatitis B and Hepatitis C in the upcoming
months or years and the incidence of HIV among PWID would increase dramatically.

25
 Urban Drug
Use clusters

PUTAO City

The presence of pink colored circles that could be envisioned in the above Map suggests that
drug users tend to “cluster” in certain groups of villages, which leads to an indication that drug
selling was not only confined to the city area, but extended to the rural areas. Rural drug users

26
cannot travel frequently to the cities to get their drugs as the roads are very poor, so, they need
to buy drugs as close as possible to their villages.

Comparison of proportion of modes of drug use in selected villages/wards

Graph No.1: Comparison of proportion of various modes

of drug use between selected villages/wards, Putao
Township

39.2
PWUD
7.2

39.2
PWID
38.16

49.6
All drug users
44.2

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Rural Urban

In the Graph 1, the overall drug use (both PWID and PWUD) proportions is higher in the rural
areas than the urban areas. However, the differences in proportions are very marked for the
PWUD category, but in the PWID category the difference is of a lesser degree.
The proportion of drug use per each rural village is shown in the Graph 2. In this graph, Mansay
and Long Sha Yang seem to overshoot more than 100% of the target age group. This is
probably due to the village elder’s personal perception that includes male drug users who are
more than 40 years of age, but at the same time, they reflect the highest proportion of drug
users in these two villages.
Lang Taung village follows in the third place with 76.63%, which is more than three thirds
of the targeted sex and age group i.e., males aged 15-39 years age group.
Mu La Shi Di village and PuTaung villages take fourth and sixth place with 43.23% and 41.95%
respectively, which essentially is almost half of the target population.
Pu Taung and Mansaykhun take seventh and eighth places with 33.91% and 24.1% respectively,
which is essentially around one third of the targeted sex and age group.
Ma Lu Leit village shows 24.1% which is almost one quarter of the targeted sex and age group.
Zi Aun, Ma Kat Mon, Hpat Mar,Sar Hkam Dam have 12.77%, 10.92%, 9.58% and 9.46%
respectively and are one tenth of the targeted sex and age group.

27
Nam Ton Khu and Panmatee villages share the lowest proportion of drug users at 6.16% and
5.31% respectively, which suggests that even in the villages that have the lowest involvement
of drug use, one in twenty of males in the 15–39-year age group are using drugs.
Distribution of drug users in rural villages

Graph Number 2. Proportion of all drug users in the rural

villages, Putao 2021
250 223.99

200

150
103.95
100 76.63
43.23 41.95 33.91
50 24.10 12.77 10.92 9.58 9.46 6.16 5.31
0

Proportion of all drug users in the village %

Distribution of drug use in the city area

The Graph number 3 shows the proportion of male drug users who are in the 15–39-year age
group in the sampled three wards.

Graph No 3. Proportion of drug users in the sampled wards, Putao City,

2021
80

70 67.81

60 57.47

50

40

30

20

10 7.25

0
Hokho/Pan Hlaing Lone Sut Mu La Shi Di

The ward with the highest proportion of drug use is in Hokho/Pan Hlaing ward at 67.81%
which is more than one thirds of the males in the 15–19-year age group. Lone Sut is the second
highest at 57.47% which is more than half of the target population. The lowest proportion of

28
drug use is in Mu La Shi Di at 7.25%, and this shows that one in ten of males in the 15–19-
year age group are using drugs.

IV. Estimation of drug user population size and prevalence of drug use
Based on the above findings, a drug user estimation exercise was made to extrapolate these
findings from the village and ward level to the Township level.
Details of the calculation are mentioned in the Annex 1, but essentially the average proportion
of drug use in the target village/ward population is calculated by dividing the estimated number
(by observation method) by the target population of each village which is given by the
administrative authority of that village.
These village proportions are then averaged, to get the average proportion of drug users all the
sampled villages and wards.
Extrapolation of these averaged sampled proportions are then applied to the Township sample
population to obtain estimated number of PWID, PWUD in Putao Township as well as the
Township level proportion of PWUD, PWID and all drug use proportion. These figures may
represent the point prevalence of PWUD, PWID and all drug use in Putao since the “at risk”
population of the whole township is used as the denominator.
In the absence of any scientific epidemiologic studies, these figures may be assumed as proxy
figures for point prevalence of drug use in Putao and also proxy figures for drug user size
estimation.
The overall drug user population is estimated at 4774, and PWID at 4099 and 675 PWUD.
The estimated sex and age group specific point prevalence of PWID is 26 per 100 at risk
population and PWUD is 4 per 100 at risk population. The estimated sex and age group
specific total all drug use point prevalence for Putao is 30 per 100 at risk population.

V. Drug Use Screening Inventory survey (DUSI-R)

The Drug Use Screening Survey was conducted with the aim of obtaining the biological,
psychological and social risk factors which influence the use of drugs (risk factors for drug use)
and also factors which protect an individual from drug use (protective factors for drug use).
In this way, drug use prevention activities could be accurately formulated and at the same time,
provide deeper insights to the bio-psycho-social factors that are influencing people who are
using drugs. This provides a useful tool for service providers in developing treatment
approaches and design rehabilitation interventions which accurately tackle the most pressing
issues that are acting on the individual, families and communities.
The target group of the survey was between the age of 15 to 39 years age group living in the
project ward and villages. They were given a self-administered DUSI-Revised form, that has
been translated into the Myanmar language. The questionnaire is a self-administered
questionnaire form and has 135 questions in which the participant has to choose one from the
two answers provided. Additional questions on their socio-demographics, without including
any questions that can be used to identify the participant were included.

29
Socio-demographics of the sample population (see Table below)
The mean age of the study sample is 23.3 years with a standard deviation of 6.26 years, and
57%(n=87) of the sample are males and 43%(n=65) are females. In terms of marital status, the
majority (59.2%, n=90) are single, 2.6% (n=53) are married, while another 2.6% (n=4) are
either divorced or separated.
The majority (89.5%, n=136) are not employed, while on 7.9% (n=12) are employed and 2.6%
did not respond to this question.
Socio-demographic characteristics of the study sample

Differences in the two groups

In order to find if there are any differences in the bio-psycho-social factors between the rural
and urban people who have never used drugs(PWNUD) in their lifetime and those who have
used drugs (PWHUD)at least once in their lifetime, a descriptive analysis of the DUSI-R scores
between these two groups were made and the mean differences between the two scores showed
that the mean scores of 37.90 of people who have never used drugs in their lifetime and the
differences in the mean scores of 50.27 people who have used drugs in their lifetime, were
statistically significant with p-value less than 0.05.
This shows that the biological, psychological and social factors that are influencing an
individual to use drugs at least once in their lifetime is much more severe than those who have
never used drugs in their lifetime.

30
It is also important to note that the means DUSI-R score 37.9 for people who have never used
drugs is also at a very high level as compared with other countries e.g., people who have never
used drugs in Brazil 4 have a mean score of 1.9 which is very much lower than the mean scores
that the study found in Putao. This suggests that people who have never used drugs in Putao
are also suffering from at least a form of distress which is high and fortunately, have not turned
to drugs. This implies that drug use prevention interventions need to target non-drug using
populations too and address the domains of the DUSI-R which are more affected, as the people
are almost on the “verge” of falling into the drug use trap.

p value is less than 0.05

e. Comparison of DUSI-R across various domains between people who never use drugs
(PWNUD) and people who have used drugs at least once in their lifetime (PWHUD)
With the aim of obtaining a deeper understanding of the risk and protective factors associated
with using drugs for the first time in their lifetime among people aged between 15-39 years, a
comparison study of people who have never used drugs in their lifetime and people who have
used drugs at least once in their lifetime was made.
The comparison was made to identify the differences in the domain scores of the DUSI-R
questionnaire achieved by the two groups mentioned above and also to prioritize the most
affected domain that is associated with drug use.
The domains that were compared included
1. Substance Abuse
2. Mental Health
3. Behavior Problems
4. Health Status
5. Job Relationships
6. Friend (Peer) relations

4
Validation of a Short Version of the Revised Drug Use Screening Inventory (DUSI-R) in a Brazilian Sample of Adolescents
Thiago Marques Fidalgo, MD, PhD, Ralph Tarter, PhD, Evelyn Doering da Silveira, Levent Kirisci, PhD and Dartiu Xavier da Silveira, MD, PhD
Am J Addict. 2010; 19(4): 364–367. doi:10.1111/j.1521-0391.2010.00058.x.

31
 7. Social Relationships
8. Family Relationships
9. Leisure/Recreation
Analysis of School Adjustment was not carried out since only ten participants were
attending school and this number was too low to conduct a meaningful analysis. In the
Substance Abuse domain, Lifetime use of a drug at least once variable, was used as the
outcome variable to divide the survey sample into a dichotomous category.

Results of the Analysis.

Comparison of DUSI Percentage Scores across domains between those

who have Used drugs at least once in their lifetime and those who
have never Used drugs in their lifetime, Putao Township, August 2021.

Leisure time Usage 4.12

6.01

Friend Relationships 3.31

5.57

Job Relationships 1.88

3.24

Family Relationships 3.2

4.98

Social Relationship 5.91

6.78

Mental Health 6.47

7.32

Health 1.95
3.56

Behavior 5.87
7.44
0 1 2 3 4 5 6 7 8

Lifetime Never used drugs Lifetime ever Used drugs +

The above Graph shows the comparison of different domains of the DUSI-R test scores across
the two groups, PWNUD and PWHUD.
The analysis showed that the scores of the two groups are different across all domains, with the
PWNUD group showing less scores in all domains than the PWHUD. This finding implies
that the problem severity of all the assessment domains for PWHUD is higher than PWNUD.
Prioritizing the severity of the problem for people who have used drugs (PWHUD) at least
once in their lifetime.
In terms of severity of the domain that is affected in people who have used drugs, the most
severely affected domain to the least affected domain is mentioned as:
1. Behavior Adjustment
2. Mental Health
3. Social Relationships

32
 4. Leisure Time Usage
5. Friend (Peer) relationships
6. Family Relationships
7. Health status
8. Job relationships

The above prioritization indicates that the Behavior of the PWHUD is the most severely
affected domain and points out to the need for treatment service providers to pay full attention
to tackle this problem during the treatment and recovery processes.
Behavior change interventions need to be at the core of the treatment and recovery process.
The second-most affected domain is the Mental Health domain of the PWHUD. This also
throws light on the drug users’ mental health. Interventions to treat drug users also need to
take this factor into account and the treatment processes should include assessment of the
mental health of drug users who come into their treatment and recovery process.

The third most affected domain is the Social Relationships domain. This also points out the
need to tackle the social relationships issue when by teaching of social relationship skills to
drug users in treatment and recovery.

The fourth most affected domain is the Leisure time usage of drug users. This is an important
discovery for the parents as well as the community members who need to play an active part
in the recovery of the drug user.

The fifth most affected domain is the Peer relationship domain. This is also another domain
which the drug treatment service providers as well as the parents need to give priority as this
usually leads to relapse to drug use for the treated drug user.
Prioritizing the severity of the problem for people who have never used drugs (PWNUD) at
least once in their lifetime.
In terms of severity of the domain that is affected in people who never used drugs (PWNUD),
the most severely affected domain to the least affected domain is mentioned as follows;
1. Mental Health
2. Social Relationships
3. Behavior Adjustment
4. Leisure Time usage
5. Friend Relationships
6. Family Relationships
7. Health
8. Job relationships

The first five domains associated with “never using drugs in their lifetime” also points out to
the importance of keeping these domains at low levels at all times. If should these levels
increase, there is a possibility that the individual can start experimenting with drugs. This is
an important observation for Drug Use prevention providers since they can develop programs
that aim to reduce or at least maintain these five domains at this level.

33
Family Relationships, Health and Job relationships domain may be providing a clue to
preventing drug experimentation as these three domains have the lowest problem levels. This
seems to indicate that good family relationships, good health in general and good relations
within the workplace environment act as “protective factors” for drug experimentation. Drug
use prevention providers may formulate preventive programs based on conducting activities
that focus on improving these domains among the families, workplace and physical health
issues.

Discussion
Drug use situation, the extent and health consequences of drug use was explored by in-depth
interviews and focus group discussion via phone and on-line interviews from Yangon.
Community elders think that drug use situation has increased in recent times and there was also
changing trends in the type and mode of drug use which has shifted from the use of opium by
smoking to the use of heroin by injecting. Amphetamine use has also emerged. They estimated
that out of 32 youths in the village, 27 youths (two thirds) were injecting drugs while one third
smoked heroin or opium.
Drug use had a severe impact, not only on the health of the users but also the socio-economic
impact on the individual as well as the family and extending to the community. Infectious
diseases such as HIV, Hepatitis B and C, and Tuberculosis were also seen among the drug users.
Several sub-groups of drug users were identified in Putao, such as highway car drivers, farmers,
gold and amber mine workers, high school students and school drop-outs. The context of drug
use in the gold, amber and jade mines were rather dire in the sense that 70% of the workers
there use drugs and was facilitated by false beliefs that using heroin prevents them from
contracting local infectious diseases and also enables them to work without sleeping at night.
Workers who work in jade mines had been working there for quite a long time so much so that
they had concocted a name “Yay Ma Say Kyauk” workers which in the literal sense means that
workers who work with jade that were not washed with water.
Farmers who needed supplemental income need to travel to these mines when farming season
was over and this practice exposes them to high risk of drug use. Women were also seen
travelling to these mines for various reasons e.g., working in the sex trade, recreational
purposes, earning money for drug use.
There was a common knowledge among the villagers that Lan Taung, Lan Nung, Lon Shar
Yan, Sun Tarran villages had high levels of drug use, and Hokho and Man Pan wards in the
city were also notorious for high levels of drug use which the community assumes that it was
due to the presence of drug sellers in these villages and wards.
There was a high level of expressed need for Drug Demand Reduction services that borders on
desperation and helplessness. The communities want urgent help in assisting them on technical
expertise on these issues so that they will be able to tackle this prevailing drug use problem in
their communities.

34
In terms of drug use prevention, there was little knowledge about how to prevent drug use
although they were aware that use prevention, treatment and recovery efforts were in urgent
need.
Access to drug demand reduction services by the people affected by drug use was a big obstacle
since travel to the city by road is physically demanding due to poor roads and long distances.
The cost of accessing treatment services was also a financial barrier since the family of the
drug user who need to accompany him for drug treatment makes it unaffordable.
There were few opportunities for youths to be engaged in self-development activities e.g.,
sports, arts, music etc., and the youths end up using their leisure time experimenting with drugs.
There were also no vocational skills training facilities and youths grow up without having
learned employable skills, which results in frustration and loss of hope for their future.
From initial consultation, it was reported that there was an increase in heroin injection
accompanied with increase in infectious diseases and that intervention efforts need to be
include all sectors of the community to make it successful.
Vulnerabilities to drug use and injecting were not homogenous across the various village tracts
and wards and some have higher proportion of drug use, especially in Long Shar Yang village.
The composition of the ethnic nationalities is also different across the various wards and village
tracts. However, Burmese language was the most commonly used written language in Putao
Township.
There was a very low level of education and literacy in Putao Township and they differ across
different wards and village tracts, depending on the remoteness of them. The people worship
Christianity and Buddhism but the Christians seem to be the majority.
The life expectancy was lower than the national figure at 65 years while key health problems,
apart from drug use are infectious diseases. In terms of health services, the main provider is the
Health Department of the government, and the health care services were free of charge.
However, due to the remoteness and difficult travel conditions, health care service stations are
frequently understaffed. There is some presence of INGOs and NGOs that provide various
health care services in recent years.
The local economy is mainly the small business in the private sector, while supplemental
income is obtained from working in the gold and amber mines. Thus, the unemployment rate
is very high, ranging from 50-70% in certain village tracts.
There is no access to the local media and the main communication channel is radio at 50% and
TV at 40% in certain villages. Access to mobile phones is highest in Mulashidi at 40% of the
population. The main means of transport is by roads with cars and motorcycles and twice a
week flight to Myitkyina.
The decision-making in the field of Law is the same across all sites and is done at the Township
level. The legislation regarding drug use per se has been abolished since February 2019, but
possession of drugs is still an offence.
It was also found that the need to find supplemental income is high for the average farmer,
which is the main driver of the need to work in “high-drug use risk” jobs e.g., working in the

35
mines. Poverty is also a major factor that results in the practice of harmful drug use practices
e.g., sharing of needles and sharing of drug solutions.
The people who use drugs have considerable knowledge and perceptions of different kinds of
drug use as well as the availability of drugs that can be injected with heroin topping the list.
Methadone dispensing services are available in the Township hospitals in recent years, while
amphetamine-type stimulants are emerging drug of abuse. Estimates of drug use in the
township varies significantly across wards and village tracts. The lifetime prevalence of drug
use was estimated at 40% which is based on the observation of the local authorities and elders
and the validity of these estimates are low.
There is a change of modes of drug use from smoking opium to injecting heroin over time, and
in recent years, heroin injecting has become dominant. This was seen especially in the western
and central parts of Putao. Youths who inject drugs early on in their injecting career were those
who were well-off financially, and the majority of them were males in the late teens.
Remarkably, there was a subgroup of heroin injectors who are in the 60s. The youngest age at
which drug use started is commonly at 16 years but occasionally, 14-year-olds could be seen
injecting heroin. Injecting drug users usually seek drug treatment services only after at least 5
years of drug use.
In terms of geographical spread of drug use, drug injectors were spread all over the township
areas and not confined to the city. More details of this geographical spread were obtained from
the drug use Mapping exercise.
Sharing of needles and syringes was common even in the rural areas while it was reduced in
the city in which an INGO is implementing harm reduction activities. Needle sharing was seen
among 20% of new IDUs.
HIV risk behavior through the pooling of the heroin solution was one of the major high-risk
practices that result from the poverty of the drug injectors, especially in the mining areas.
Sexual risk behavior of PWID was found to be as high as 25-40% among PWID and there was
a tendency for drug users who use more frequently or inject more frequently, to be less involved
in high-risk sexual behavior.
Heroin overdose among injectors was observed to be not so high, but were seen among those
who mix heroin injecting with alcohol. Despite the remoteness of the city, knowledge about
the consequences of drug use and transmission of infectious diseases was high.
The level of frustration felt by the community members on how to tackle the problem of drug
use was very high as there was a vast need for technical expertise in this regard. This had
resulted in development of negative reaction to the drug users and an inclination to take more
drastic measures which had the effect of driving the drug users “underground” with subsequent
rise of high-risk behavior.
The spouses of drug users were especially in need of help to prevent them from being infected
with HIV from their PWID husbands, since the social stigma surrounding drug users tend to
extend towards their spouses.
Drug use in prison settings was not seen as a problem since drug users were not arrested for
drug use per se.

36
Injecting drug use was mainly occurred in a friend’s home and there are no overt “shooting
galleries” like elsewhere in the Kachin region. However, drug use was more in the “open” in
the amber and gold mines.
The low level of socio-economic status in the environment gravitated the drug users towards
the use of the most “cost-effective” mode of drug use i.e., using the method which allows
maximum effect with the least cost”, which was achievable by using the drug via the injecting
route.
Community resistance to harm reduction interventions was quite common as they view these
interventions were being encouraging drug use. Population estimates of drug users cannot be
obtained but was mentioned in the drug use Mapping exercise section.
From mapping, the overall finding of drug use proportions was higher in the rural areas than
the urban areas of Putao. The differences in the proportion of PWUD were much higher in the
rural areas as compared with the urban area and suggested that there was a higher potential
number of non-injecting drug users to “transit” to risky mode of drug injecting in the rural areas.
Drug users tend to “cluster” in certain groups of villages, which leads to an indication that drug
selling is not only confined to the city area, but extends to the rural areas. The overall drug use
(both PWID and PWUD) proportions was higher in the rural areas than the urban areas.
Mansay and Long Sha Yang seem to overshoot more than 100% of the target age group. This
was probably due to the village elders’ personal perception that includes male drug users who
are more than 40 years of age, but at the same time, they reflected the highest proportion of
drug users in these two villages.
Lang Taung village follows in the third place with 76.63%, which was more than three thirds
of the targeted sex and age group i.e., males aged 15-39 years age group. Mu La Shi Di village
and PuTaung villages took fourth and sixth place with 43.23% and 41.95% respectively, which
essentially was almost half of the target population.
In terms of the lowest proportion of drug use, one in twenty of males in the 15–39-year age
group in Nam Ton Khu and Panmatee village are affected by drug use.
The ward with the highest proportion of drug use was Hokho/Pan Hlaing ward at 67.81% which
was more than one thirds of the males in the 15–19-year age group. Lone Sut is the second
highest at 57.47% which is more than half of the target population. The lowest proportion of
drug use is in Mu La Shi Di at 7.25%, and this shows that one in ten of males in the 15–19-
year age group are using drugs.
From estimation, the overall drug user population is estimated at 4774, and PWID at 4099 and
675 PWUD. The estimated sex and age group specific point prevalence of PWID is 26 per 100
at risk population and PWUD is 4 per 100 at risk population. The estimated sex and age group
specific total all drug use point prevalence for Putao is 30 per 100 at risk population.
The DUSI showed that the biological, psychological and social factors that are influencing an
individual to use drugs at least once in their lifetime were much more severely affected than
those who have never used drugs in their lifetime.
The findings also showed that people who had never used drugs in Putao were also suffering
from at least a form of psychological distress which was high but fortunately, had not turned

37
to drugs. This implied that drug use prevention interventions were needed to target non-drug
using populations too and address the domains of the DUSI-R which were more affected, as
the people are almost on the “verge” of falling into the drug use trap.
The analysis showed that the scores of the two groups are different across all individual
domains, with the PWNUD group showing less scores in all individual domains than the
PWHUD. This finding implied that the problem severity of all the individual domains for
PWHUD is higher than PWNUD.
The Behavioral Problems of the PWHUD was the most severely affected domain and points
out to the need for treatment service providers to pay full attention to tackle this problem during
the treatment and recovery processes.
The second-most affected domain was the Mental Health domain of the PWHUD. This also
throws light on the high level of association of the mental health of drug users and their
addiction problem. Interventions to treat drug users also need to take this factor into account
and the treatment processes should include assessment of the mental health of drug users who
come into their treatment and recovery process.
The third most affected domain was the Social Relationships domain of the PWHUD. Drug
treatment providers need to include life skills training for treated drug addicts to enable drug
users develop the social skills that are needed to face life in general, e.g., the Enhancing Life
Skills in Drug Treatment and Rehabilitation. 5
The fourth most affected domain was the Leisure time usage of drug users. This was an
important discovery for the parents as well as the community members who need to play an
active part in the recovery of the drug user.
Parents need to monitor their child’s leisure time activities to see if he/she is spending his/her
leisure time that contributes towards their personal development, rather than spending time
with youths who they themselves are not spending their leisure time in activities that do not
contribute towards their all-round development activities. Experimentation with drugs and
other addictive substances usually occur during their leisure time, and boredom is also closely
associated with use of drugs. Thus, parents and communities need to create opportunities for
their children to get them engaged in sports activities, music, arts and crafts and introduce them
to the basic skills of gaining employment, e.g., teaching of the use of computer word processing
skills, English language skills, and vocational skills which are relevant and applicable in the
local context.
The fifth most affected domain was the peer relationship domain. This is also another domain
which the drug treatment service providers as well as the parents need to give priority with
regards to the friends of the drug user, as this usually leads to relapse to drug use for the treated
drug user.
The high level of severity of problems in different domains suggested that these domains
provide some idea of the underlying psychological disturbances that were associated with drug
use. Thus, these domains can be used as proxy measures to assume that they are “risk factors”

5
Enhancing Life Skills in Drug Treatment and Rehabilitation: A Manual for Practitioners and Trainers. Drug
Advisory Program, Colombo Plan. October 2009.

38
for drug use and or experimentation in this study sample. While “risk” concept in public health
was established by scientific cohort or longitudinal studies, the present study was not purely
scientific in this sense, but at the same time, identifies certain problematic psychological
domains which are highlighted for future scientific studies.
Teaching of drug refusal skills, Assertiveness skills and Decision-making skills while in
treatment and rehabilitation can play an important part in preventing relapse of drug use
initiated by return to the “old crowd” of friends.
Salient biological, psychological and social characteristics of the people who have never used
drugs in their lifetime (in order of severity from the highest to the lowest)
1. Mental Health
2. Social Relationships
3. Behavior Adjustment
4. Leisure Time usage
5. Friend Relationships
The first five domains associated with “never using drugs in their lifetime” also pointed out to
the importance of keeping these domains at low levels at all times. If should these levels
increase, there was a possibility that the individual can start experimenting with drugs. This
was an important observation for Drug Use prevention providers since they can develop
programs that aim to reduce or at least maintain these five domains at this level.
Family Relationships, Health and Job relationships domain may be providing a clue to
preventing drug experimentation as these three domains have the lowest problem levels.
This seems to indicate that good family relationships, good health in general and good relations
within the workplace environment act as “protective factors” for drug experimentation.
Drug use prevention providers may need to formulate preventive programs based on
conducting activities that focus on improving these domains among the families, workplace
and physical health issues.
Limitations of the Study
f. During the study, access to available information from the governmental sector was very
much limited as the key persons were not available. To compound this problem, non-
governmental organizations were also reluctant to provide some information regarding the
consequences of drug use.
g. On-line communications: Frequent disruptions in the Internet communications between
Yangon and Putao was the major factor that limited the Trainings of the Rapid Assessment
Teams. The Rapid Assessment Methodology intended to conduct these trainings to the
whole group using Zoom group meetings for the Rapid Assessment Team training
sessions, but this could not be done for only a few sessions due to frequent breakdowns or
irregular connectivity.
h. On-line communications also posed some challenges during the qualitative data collection
process for which the Yangon Team was assigned to do, since frequent disruptions in
internet connectivity reduced the depth and intensity of Focus Group Discussions with
various targeted groups e.g., PWID, PWUD, local authorities.

39
 i. Access to available data on drug use situation: Since the Rapid Assessment Methodology
relied heavily on collecting information that is already available in the government
departments handling drug use issues, the Rapid Assessment study happened to fall within
the early months of the political changes when there was a vacuum in the operational
aspects of the local authorities. This resulted in almost a total lack of information
gathering from these sectors.
j. However, the Yangon Team and the field Rapid Assessment Team overcame this
limitation to a certain extent by arranging access to the local authorities on a personal level
and also chose to conduct several contingency approaches to obtain data e.g., conducting
drug use mapping exercise and a community-based survey using the Drug Use Screening
Inventory II-Revised questionnaire. This approach, while managing to gather invaluable
information related to drug use, required more time for data collection, data entry, data
cleaning and data analysis.
k. Access to the Law Enforcement and Judiciary records could not be done, and this reduces
the scope of the study, as this information will complete the drug use situation assessment.
Conclusion
The above study has been able to gather considerable amount of in-depth knowledge regarding
the drug use situation, the context in which it is occurring and the socio-economic factors which
are in play. The information gained, despite very difficult conditions, will be very useful in the
drafting of the Operational Plan for Drug Use Prevention interventions for Putao Township.

Recommendations: The Operational Plan

While the information collected by the study above has provided a vast amount of data
regarding drug use, the following Responses have become essential if preventive interventions
are to be formulated.
Since the findings of the study have displayed that drug use is widespread across the whole
township area of Putao Township and that the scope of the drug use problem is very wide which
encompasses Supply reduction and Drug Demand Reduction issues, the basic principles in
reducing the drug use problem situation for Putao needs to be formulated and drafted in line
with the 2018 National Drug Control Policy 6 as well as follow the Drug Use Prevention
Strategic Plan for the Kachin Region 7.
In terms of technical policies, the guiding principles mentioned in National Institute for Drug
Abuse 8 need to be followed as much as possible.
During the drafting of specific Drug Demand Reduction interventions in Putao Township, it is
very important to stay within the 2018 National Drug Control Policy which was developed by
a wide range of stakeholders, right from the grass-roots level from all Regions and Divisions

6
National Drug Control Policy, February 2018. Ministry of Home Affairs.
7
Drug Use Prevention Strategic Plan for the Kachin Region, 2019-2022.
8
National Institute on Drug Abuse: Preventing Drug Use among Children and Adolescents-A Research-based
guide for Parents, Educators and Community Leaders (Second Edition), 2003.

40
of the country and UNODC Regional Office for Southeast Asia and the Pacific, UNODC’s
Myanmar Office and CCDAC and its various sectors of the Ministry of Home Affairs.
Priority areas of the Drug Control Policy were identified and they are
1. Supply Reduction and Alternative Development
2. Demand and Harm Reduction
3. International Cooperation
4. Research and Analysis (to develop a strong evidence-base)
5. Compliance with Human Rights
Since the current Rapid Assessment Study has the main aim of obtaining a better understanding
of drug use situation in Putao Township, the essential areas in the study were related to the
Demand and Harm Reduction priority area mentioned above.
The 2018 National Drug Control Policy’s priority area for the Drug Demand Reduction and
Harm reduction sector recommends the following interventional framework to be implemented
within the whole country, and they recommend the following policy, principles, objectives and
guidelines
Policy for Drug Demand and Harm Reduction
1. To reduce the potential drug-related risks to individuals and society and a new drug
control policy should take a health-based approach with a focus on prevention to deter
the initiation of drug use.
2. To target individuals at the highest risk of drug use
3. To reduce harm to individuals, families and the community from drug use.
Policy for drug use prevention
Educating the public against the use of illicit drugs, which is essential in deterring drug use.
This requires strengthening the capacity of stakeholders, including community-based
organizations to deliver preventive interventions and promoting an enabling environment
for implementation of related activities.
Primary Prevention measures envisaged to implement interventions that reflect this policy
are
● Awareness-raising evidence-based prevention measures that target vulnerable
groups
● promoting alternative lifestyles including improving recreational facilities and
activities
● Coordination between governmental and non-governmental stakeholders with
specific emphasis on Civil Society.
The Primary Prevention activities that have been identified as priorities include;
● Interventions at the school and community level to educate against the use of illicit
drugs
● Health-related approaches making mental health services available to youth
● Social Approach: to change perceptions of drug use at the community and
workplace and to reach other vulnerable groups

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 ● Develop Alternative lifestyles through developing and promoting social
alternatives to drug use through school. family and in the community
● Conduct Awareness raising preventive drug education, awareness raising
including through utilization of social-media, journals and newspapers.
● Promoting an enabling environment through a favorable legal environment for
implementation of activities
● Provision of funds to promote prevention activities
Policy for Harm Reduction
Harm reduction refers to policies, programs and practices that aim primarily to reduce the
adverse health, social and economic consequences of the use of illicit drugs, and focuses on
reducing the harm to people who use drugs, their families and the community.

Harm reduction approaches start with the principle that drug dependence is a health disorder
with social causes and consequences. The problem of illicit drug use cannot be solved
through law enforcement measures alone, and structural reform is required to reduce the
negative consequences associated with drug use and to promote alternatives to imprisonment
for drug offenses.

The following interventions were suggested to materialize the harm reduction policy
● Decriminalize drug use.
● Promote and expand a comprehensive package of harm reduction including overdose
prevention and treatment, according to WHO, UNODC and UNAIDS technical
guidelines.
● Capacity building for frontline providers including law enforcement officers and health
care providers on harm reduction.
● Promoting an enabling environment: i.e., a favorable legal environment for
implementation activities, availability of funds to promote the activities.

Policy for drug Treatment, Rehabilitation and Reintegration

Reducing the limitations of accessing and receiving treatment is important for rehabilitating
and reintegrating drug users into society.

This includes removing unnecessary registration requirements, ensuring the right to choose
a treatment option, reducing the legal implications associated with treatment, and reducing
the social stigma associated with drug use, both for individuals and their families.

An increase in the availability and affordability of treatment options that address both mental
and physical health would benefit the treatment of drug disorders, including the community-
based services for treatment, care and rehabilitation programs for drug users.

This requires investment in the capacity of health social and law enforcement and other
criminal justice authorities, not just in-service delivery, but in the implementation of
comprehensive, integrated and balanced responses to drug abuse and drug use disorders

The following interventions were suggested to materialize the drug treatment policy.

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● Transform compulsory treatment systems to voluntary drug treatment systems.
● Ensure adequate access to treatment, rehabilitation and reintegration services.
● Provide skill and capacity development for service providers in delivering treatment
and rehabilitation services.
● Promote subsidies to reduce the cost of treatment at treatment centers and hospitals.
● Promote and incentivize investment in drug treatment.
● Develop processes to facilitate the successful reintegration into society for drug users,
specifically youth and vulnerable groups.
● Establish screening, assessment and referral to various treatment options.
● Promote community-based service delivery programs.
● Enable private sector involvement in prevention, drug treatment and rehabilitation
services.
● Strengthen and upgrade the public sector facilities for treatment and rehab.
● Involve peers in drug treatment and rehabilitation services.

Coordination of Operational Mechanisms

A demand and harm reduction approach particularly requires coordination between
government and nongovernment stakeholders to deliver a social economic and health-based
response.

Define clear role and responsibilities in implementation and promotion of interventions.

Strengthen effective coordination mechanisms among respective ministries.

Invest in prison reform to address prison management and improve access to health services,
including drug treatment services.

Provide training and legislative support to law enforcement and judges to promote
alternatives to imprisonment of drug users.

Promote comprehensive service delivery approaches (prevention, harm reduction, treatment,

reintegration available in one location).

Establish coordination structure with meaningful involvement of other stakeholders such as

CSOs.

The above Drug Control Policy guidelines deal with the Drug Demand Reduction sector at
the national level only. This should be followed by regional level Strategic Plan for all
Regions and Divisions, as recommended in the Drug Control Policy mentioned above.

The Kachin Region was the first Region in the country to have drafted a regional level
Strategic Plan to prevent drug use. This Strategic Plan was drafted and adopted by the
Regional Committee for Drug Abuse Control, Kachin Region, with the Technical Support
of SARA and funding support from the Bureau of International Narcotics and Law
Enforcement Affairs, US Department of State.

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This Regional Strategic Plan for Drug Use Prevention in Kachin State was approved, adopted
and launched on 28th of September, 2018 in a launching ceremony in Myitkyina. Heads of
Regional Government of relevant Government Ministries, Faith-based organizations, CBOs,
NGOs attended the ceremony.

This Strategic Plan to Prevent of Drug Use in Kachin Region was launched after a series of
Workshops in which Faith-based organizations, CBOs, Civil Society and relevant
government organizations from the various districts of Kachin Region took part.

The finalized Strategic Plan was passed after obtaining approval from the Central Committee
for Drug Abuse, Regional Committee for Drug Abuse. This document is available on request
from SARA.

In line with the format of various National Policy Guidelines, the Kachin Workshop agreed
to choose the following Strategies for Kachin Region to prevent drug use.

Strategic Objective (1): To conduct Drug Use Prevention Interventions

Strategic Objective (2): To develop Alternative Social Models

Strategic Objective (3): To develop Monitoring Systems and Research

Strategic Objective (4): To strengthen Collaboration and Coordination mechanisms

Strategic Objective (5): To ensure sustainability of drug use prevention interventions

With the passing of the above Strategic Plan for Drug Use Prevention in the Kachin Region,
the various townships were given the task of developing Township-level Operational Plans,
based on the extent and patterns of drug use in each respective township.

In terms of the findings of the Rapid Assessment that provided vast information on the extent
and patterns of drug use as well as the psychological risk factors associated with drug use
aggregated on rural/urban residences of the people who have never used drugs as opposed
who have used drugs at least once in their life time.

The first step towards drafting the Drug Use Prevention Operational Plan for Putao is to
decide plans and activities based on the Core elements of Research-based Drug Use
Prevention interventions:

Structure: A broad-based coordination structure that will include all relevant community
sectors, non-governmental as well as governmental sectors need to be included and a
coordination structure that will oversee all the Drug Demand and Supply reduction issues
need to be set up.

This is in line with the Regional Strategic Objective Plan to increase Collaboration and
Coordination mechanisms.

However, for Putao Township, the Community Advisory Committee (CAC) could be a
starting point to put in place a coordination mechanism to conduct drug use prevention
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interventions. If and when the Township-level Committee for Drug Abuse Control of Putao
becomes active again, they may take the leading role in the future.

The various local non-governmental organizations and international non-governmental

organizations could take an active position in this coordination mechanisms through
providing technical, financial and human resource inputs to bring this mechanism become
operational.

Based on the findings of the Rapid Assessment in which drug use is seen to be widespread
all over the Putao township proper and which is even higher in the rural areas, the
Coordination structure should be wide and inclusive enough to be able to reach right into the
rural communities and not only focusing on the city population and sub-urban population.

Content: In tackling the drug abuse problem in Putao, the approach that will be used to
raise the awareness of the community members on drug use prevention, drug treatment and
recovery will form a major part in the Operational Plan.

Based on the Epidemiological Triad of Agent, Host and Environment interaction factors, the
following activities are warranted taking into consideration the findings of the Rapid
Assessment.

a. Agent factors: Since the above Assessment Study is focused mainly on the Demand
Reduction strategies, some information regarding Supply Reduction strategies were
obtained.
Since drug use was found to be widely available, especially at street-level suppliers,
interventions that can reduce the accessibility of the drugs through community
‘policing’ in which parents, community members accompany their children when the
children have to pass through these “high availability” areas.
In addition, accessibility to drugs in or near schools need to be monitored closely to
set up “barriers” to prevent the drug pusher from reaching the children.
b. Host factors: There is a vast number of factors influencing the clients which push an
individual to use drugs. In the above study, biological-psychological and social
factors that are in play was studied using the DUSI-R instrument.
For the major risk factors identified, interventions targeting maladaptive Behavior of
the “at risk” youths for preventive interventions as well as for those who have already
started their drug use career, will need to be developed.
In response to the second highest risk factor i.e., Mental Health problems,
interventions to improve the mental well-being of the youths and also for the youths
who have already become drug users.
In response to finding that Social Relationship problems are also a high-risk factor
that needs to be addressed, interventions that strive to improve the Social Skills of at-
risk youths as well as those who are in drug treatment programs should be developed
and implemented.
In terms of drug use prevention interventions, priority should be given to
interventions that seek to improve Family Relationships. physical health and job
prospects/relationships, as they are found to provide “protective” influence for youths
not to start experimenting with drugs.

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 c. Environment factors: There are several levels involved in dealing with the
environmental factors that are in play.
1. Family Environment
2. Peer Environment
3. Community Environment

The widespread nature of drug use in Putao which was found in the present Rapid
Assessment study strongly suggests developing drug use prevention interventions that
involves participation of the whole Putao community.
In addition, since Peer relationship problems are also identified as risk factors for drug
use, drug use prevention interventions targeting the Peers of drug users are also
warranted. For youths, Life skills for preventing drug use through teaching of drug
refusal skills, Peer relationship skills, Communication Skills, Assertiveness Skills,
and Coping Skills should be included in the preventive interventions.

1. Delivery: Once the above two aspects have been decided, this section involves
addressing the “How, who, when, and where” aspects of the Operational Plan.
The “Delivery” aspects of the Operational Plan to prevent drug use in Putao needs to be
formulated for Putao Township together with the collaboration of the various
stakeholders in the township. Several workshops will be needed to decide in specific
terms, who? how? when? where? and what? will conduct the specific drug use prevention
interventions. These interventions need to be developed along the framework of the
Regional Drug Use Prevention Strategic Plan for Kachin Region.
The coordination effort needed to achieve this fall upon the CAC or T-CDAC (Township
Committee for Drug Abuse Control) and an Putao Township Operational Plan for Drug
Use Prevention should be drafted in which all stakeholders e.g., CBOs, Faith-based
organizations, NGOs (both local and international) and relevant government line
ministries at the township level etc., should all take part in the drafting effort.
The Operational Plan needs to be presented to all participants, organizations, community
members etc., and the Plan adopted after their approval.
In drafting of the Program “Delivery” aspects of the Operational Plan, decision regarding
the “level” of interventions, also need to be considered to enable that the Operational Plan
is efficient enough to produce positive outcomes in the short-term and tangible impact in
the long term.
Levels of intervention
Based on the findings of the current Rapid Assessment, there is a need to conduct drug
use preventions almost township-wide. In this sense, Universal intervention programs
are recommended especially for programs that aim to increase awareness of the dangers
of drug use.
Selective programs need to be drafted also for the drug users who work in the gold and
jade mines, drivers of highway cars and school drop-outs. Vocational skills training
programs need to be drafted for youths who do not have the skills for gainful employment.

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 Indicated programs need to be drafted for youths who are displaying high levels of
physical and psychological problems and also for youths who have problems in
maladaptive leisure-time activities.
Development of programs that address the “Alternative Social Models” e.g., provision of
activities and facilities which can encourage youths to become engaged in self-
development, leadership skills, confidence building activities etc., need to be formulated
in the drafting of the Operational Plan. This is to prevent youths from spending their
leisure time on maladaptive behaviors like experimenting with drugs, hanging out with
friends and getting involved in petty crimes and drug use.
Overall, “tiered” programs need to be drafted for Putao because of the widespread
prevalence, low levels of job opportunities and also for teaching employable skills.

Delivery Approaches: Program types of Interventions

Out of the three program types in the delivery approaches i.e., Community, School and
Family, Putao needs all three program approaches. However, based on the current on
ground situation where schools are not opening regularly, youths attending churches,
monasteries, working in tea shops etc., can be reached instead.
This requirement is necessary due to the widespread use of drugs in the whole township
and the need for high coverage of drug use prevention interventions is high.
Sustainability of Intervention Programs
Special attention should also be paid to the long-term sustainability of the interventions
in accordance with the Kachin Regional Strategic Plan, especially at the start of the
interventions. Judging from the findings of the Rapid Assessment study, objectives of
drug use prevention interventions can only be achieved with long term planning with
sustained funding sources, which can be local as well as from international donor funding.
In addition, income generation activities that produce enough funding to meet the
requirements of the various interventions need to be brainstormed during the drafting of
the Putao Drug Use Operational Plan. The income generation could be tied with
Recovery Programs which can be designed in conjunction with vocational trainings for
drug users who have completed drug detoxification.
2. Monitoring systems
Setting up of Monitoring systems is also important since this system performs as a
tracking system to monitor drug use patterns as well as the impact of drug use
interventions project in Putao Township.
These systems also need to be developed to provide valuable information and data which
could be incorporated in future Operational Plans. The monitoring system will also
provide information on “emergent psychoactive substances” and also inform any
emergency conditions which need rapid responses to prevent mortality and/or morbidity
e.g., sudden availability of high-grade heroin which increases the risk of heroin overdoses
among PWID.

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 This monitoring system can also provide data for evaluation of drug use programs at the
Township level, as it affords opportunities to conduct impact evaluation of the
interventions.
3. Levels of intervention
During the drafting of the Operational Plan, a decision should be made by the project
operators on which “level” to aim their interventions.

Annex
Population Estimates Exercise: Population of PWID and PWUD in Putao, July, 2021

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