Keywords

Substance abuse, Legislation, Gondar, Ethiopia.

List of Abbreviations

FCTC– Framework Convention on Tobacco Control

FDRE- Federal Democratic Republic of Ethiopia

FMHACA –Food, Medicine and Health Care Administration and Authority

HSTP- Health Sector Transformation Plan

HIV/AIDS- Human Immune Viruses and Acquired Immune Deficiency Syndrome

USA $ - United states America dollar

WHO- World Health Organization

Introduction

According to World Health Organization (WHO), substance abuse can be defined as the illicit consumption of any substance to change the way, in which a person thinks, feels, or behaves without considering the adverse outcomes on physical and mental health [1].

Ethiopia is a developing nation with a demographic profile dominated by a young population. Adolescents are the most exposed age group for use of different substances. Being males are at high risk of using substances than females. The substances such as khat, tobacco, and alcohol are the most commonly misused substances among users. Cannabis is becoming more public in the urban area and at-risk populations like street children engage in inhalant use such as glue sniffing and benzene [2].

Substance abuse and related adverse social and health outcomes are worldwide problems touching humanity. Furthermore, substance abuse has a serious health-threatening behavior, which is related to negative consequences and causes certain worries for not only the substance users, but also their families, peers, school, and parents, society as a whole [3].

Ethiopia is placed amongst the least industrialized countries in the world facing recurrent drought, poor living standards, high unemployment rate, widespread HIV/AIDS, and many other socioeconomic problems. The hardly recognized social problem, drug abuse attributes to these problems [4].

Realizing the fact that drugs impose huge health, economic and social problems to individual users, families, the community, and the nation as a whole, the Ethiopian government has ratified international conventions to control drug abuse and has also established organizational structures such as the Ethiopian Drug Administration and Control Authority, the Illicit drug control units in the Federal and Regional police commissions and drug treatment centers to deal with drug issues [5].

As the prevalence of use of substance abuse continues to increase, educating and taking preventive measures will be an increasingly important method to reduce the consequence of substance abuse. Recently, the use of substances is becoming high regardless of the country's and university's policies, rules, and regulations to avoid substance abuse. This literature review identifies the most commonly used substance abuse in Ethiopia and assessing their hazardous effects and reviews laws that are applied in Ethiopia to control these problems and identifying their limitation that challenge the implementation of existing regulations. Therefore, the objective of this review is to assess the use of the most common substance abuse and legal consideration in Ethiopia.

Hazardous Effects of Substance

Hazardous Effects of Substance Abuse

Substances produce alterations in behavior characteristics by changing brain chemistry. Once brain feature is changed, a man or woman experiences behavioral, physical, and psychological changes. Changes in psychological and physical functioning are reason to harm the body, mind, behavior, and social relationship. The degree to which these consequences can also rely upon the drug used, the individual using the drug, and instances below which the drug is used [6].

The United Nations Office reported that the use of substance abuses and its problem grew to be worsening through difficult psycho-social challenges such as crime, poverty, unwanted pregnancy, sexual assault, and unemployment. Despite the challenges, substance sellers have applied a deep impact on young men and women to take substances so that once they emerge as addicted, they similarly affect their friends into taking substances. These issues have been devastating many communities and families throughout nations [7].

The accelerated exposure of younger people to western lifestyles through films and direct contact with young humans from those cultures who travel to their world nations has influenced the demand for items of conspicuous consumption like quick music, alcohol, and drugs. Substance abuse produces grave consequences, which are large and multi-sectoral; consists of HIV/AIDS, health, financial and social problems. Drug abuse doesn’t only affect precise individual users, however, can also have a significant effect on families, friends, and subsequently the whole community of the country [8].

Hazardous Effects of Substance Abuse on Social Aspect

A social difficulty is a hassle that influences many citizens inside a society. It is frequent trouble in present-day society and one that many human beings attempt to solve. It is often the outcome of factors extending beyond an individual's control. Some of them are divorced, unemployment crime (hijacking, forgery, rape, theft, e.t.c.), accidents (road traffic accidents), violence, and prostitution [9].

Most of the contributors agreed that the majority of the students were intoxicated following alcohol drink. The situation leads to violent behaviors, not able to attend lessons and lab demonstrations due to overnight chewing, scoring low grades, and dismissal. Similarly, violence, damage to property, suspension from campus, household relation difficulties, accidents, and different related problems are faced [10].

A previous study revealed that the occurrence of sexually violent behavior among male undergraduate students was accelerated by 67%, 67%, and 33% due to khat, cigarette, and alcohol, consumption, respectively [11].

Alcohol consumption is a robust contributing component to the behavioral and mental conditions among students. It is attributable to expanded depressive symptoms accompanied by drinking as a coping mechanism for suicidal behaviors, improve delinquent behavior, and deliberate self-harm [12].

Hazardous Effects of Substance of Abuse on Health

Depending on the real compound, drug abuse such as alcohol may additionally lead to health problems, morbidity, injuries, homicides, suicides, physical dependence, and psychological addiction. Some of the mental disorders experienced by substance users showed violent behavior, loneliness, risk of suicidal ideation, depression, and different related psychopath that suggest the importance of imposing anti-drug and alcohol approaches [13].

Some studies stated concerning physical health, participants responded that those who chaw khat skip breakfast and lunch. As a result, they experience weight loss, poor personal hygiene, and physical illnesses. Besides, some participants honestly indicated that they had been admitted to a medical institution after having to experience and intoxicated sustained damage. A previous study conducted in Butajira showed that substance misuse is related to suicide tries, psychological distress, functional impairment, hazardous or risk-taking behavior, and physical illnesses [14].

A study conducted in Jiga high school students revealed that 16% of participants stated that they had sexual intercourse. Among those who had started sex, 14.7% of them were practiced in risky sexual behavior that exposes them to different health problems. About 56.3% of the respondent’s first sexual intercourse was before their eighteenth years of age. Factors associated with risky sexual behavior consist of participant’s age between 20- 23, drinking alcohol, and having poor know-how closer to HIV/ AIDS [15]. Besides, a study observed that despite the scientific evidence that cigarette smoking used to be a dominant factor for lung cancer, people who smoke continue to expand the possibility of dependence and other health risks [16].

In the previous study, about 74% of HIV seropositive has stated that alcohol drinking increases their sex desire, which could be accountable for their exposure to HIV/AIDS. Drug use and alcohol among populations may also lead to unprotected sexual intercourse, sexually transmitted diseases, acquiring HIV/ AIDS, sexual violence, earlier sexual initiation, and unintended pregnancy. A find out in Ethiopia has proven a widespread association of sexual dysfunction with the intensity of khat chewing with the risk of being higher amongst early day users.

A study conducted in Amanuel Psychiatric Hospital revealed that khat chewing is part of the culture in some parts of the country. The findings showed that about 41.86% of schizophrenic patients have chawed khat [17].

In Ethiopia, 85.29% of street homeless people had psychotic disorders. Among this 77.40% of them were found with schizophrenia. Almost all (93.20%) of the respondents had records of substance use. Most of the substance users had comorbid conditions other than neurologic and mental disorders [18].

Hazardous Effects of Substance of Abuse on Economy

Since substance dependence needs regular taking of a high amount of substances to prevent withdrawal symptoms, the undesirable economic effects are also apparent. Moreover, the substance users devote much of their time by searching and then consuming the substances [19].

The economic consequences include increased expenditure for health-related issues, unemployment, the expanded value of violence, proliferation of criminal networks, increased expenditure by drug abusers, property crimes associated with drug abuse and dependence, accidents, increasing producers of substance abuse, and transfer of illicitly obtained assets to different countries [20].

While the apparent advantage of consumption for substance abusers has a tendency to be temporary and are quickly outdated by way of tremendous financial and health burden on communities, there are possible great incomes for traffickers and suppliers of illegal substances. This is without a doubt printed through the readiness of traffickers and suppliers to function in the illicit markets. Trafficking and producer countries, however, tend to pay a high political and social value for short-term financial advantages [21].

Drug abuse occurs most frequently amongst young people in the 18-25 age groups. It hence consists of those who are simply about to enter or who have entered the workforce. Given the excessive joblessness rates in various nations, admission into the workforce is frequently a most important problem. Taking of illegal substances confines the possibilities of remaining or entering the workforce, whilst frustration induced by failure to locate sufficient employment favors substance use, as a result growing a vicious circle. The hyperlinks between accidents, drug-taking behavior, and low productivity are courteously established. Substance users in the workforce enforce goodsized more fees on the enterprise sector, accordingly reducing its competitiveness.

Substances Misuse and Legal Considerations in Ethiopia

Substance misuse is the use of hazardous or harmful psychoactive substances by peoples. These substances include over-thecounter, illicit drugs, prescription medications, and alcohol. Recently, substance misuse is becoming an unhealthy way to respond to anxiety and stress, mostly when treating chronic disease. Likewise, substance use can lead to dependency associated with behavioral, cognitive, and physiological problems develops which consequences in difficulties in controlling use, a persisting in its use despite harmful consequences, increased tolerance, strong desire to take the drug, sometimes a physical withdrawal state, and a higher priority is given to drug use than to other activities and obligations [22].

It is crucial to restrict the numbers of psychotropic and narcotic drugs to be used nationwide. This would warrant that only psychotropic and narcotic drugs, which are needed for the medical care of the population and research, are put on the market. Hence, Ethiopia has comprised an essential psychotropic and narcotic drugs in the national drug list of Ethiopia. Globally controlled psychotropic and narcotic drugs that are accepted for use in Ethiopia include narcotic include codeine, fentanyl, methadone, morphine, pethidine, and psychotropic substance include Bromazepam Pentobarbital, Chlordiazepoxide, Phenobarbital, Methadone, Clonazepam, Temazepam, Diazepam, Medazepam, Oxazepam, Pentazocine [23].

Realizing the fact that drugs impose huge health, economic and social problems to families, the community, individual users, and the nation as a whole, the Ethiopian government has ratified international conventions adopted by the UN to control drug abuse include; the 1961 Single convention on narcotic drugs is the first complete international legal instrument that combined earlier conventions and treaties on narcotics their possibilities of application. The 1971 Convention on psychotropic substances launches a system for psychotropic substances and the 1988 convention against illicit traffic in psychotropic and narcotic drugs offers legal apparatuses for implementing the former conventions and has also established organizational structures such as Drug Administration and Control Authority of Ethiopia, the Illicit drug control units in the Federal and Regional police commissions, drug treatment centers to deal with drug issues [24].

Most Commonly Used Substance and Legal Consideration in Ethiopia

Khat, Hashish (Itse-fars), Alcohol, Benzene sniffing/Inhalation, Benzodiazepines, Tobacco, and Pethidine are substances that are commonly abused in Ethiopia.

Alcohol

Alcohol is a central nervous system intoxicant and depressant; it is also the most frequently used psychoactive substance by both mentally ill and mentally healthy people. Alcoholism is the extreme use of ethanol-containing beverages. The exact nature of alcohol dependency and alcoholism remains debatable, this is due to socio-cultural inconsistency in the use of alcohol and the apparent overlap between alcohol abuse and normal drinking behavior [25].

Regulation on Alcohol Users in Ethiopia

Ethiopia has barred all promotion of alcoholic drinks, as part of efforts to promote healthy living in African. Furthermore, banning lottery prizes connected with alcoholic drinks, alcoholic drinks advertisements, and billboards promoting alcoholic drinks are forbidden in the new proclamation. Under the new law, any promotion of alcoholic product shall hold a warning, as proper in sound or writing that it is prohibited to sell for those who are less than 18 years of age. Similarly, the law bans the selling of any alcoholic drink in cinema houses, education facilities, health institutions, government institutions, places of worship, universities and colleges, and sporting places [26].

Khat

Khat is an extensively used and grown green leafy plant, its fresh leaves are chewed for brain stimulation. Several historians trust that khat is a green leafy plant that is indigenous to Ethiopia. The use is deeply rooted in the regional traditions and customs. University and college students consume khat to get work hard and mental alertness in their academic endeavors. The prevalence of khat chewing is diverse in different parts of Ethiopia. A study conducted in Jimma revealed that the prevalence of khat chewing was 30.6% out of which Muslims constituted 77.1%. and twothirds of the khat chewers were males [27].

Regulation on khat Users in Ethiopia

The approach of the Government of Ethiopia to the regulation of khat is characterized by a policy dilemma. On the one hand, the Government includes khat in its annual earnings plan as one of its sources of foreign exchange earnings and source of taxbased revenue. On the other hand, the government exhibits disapproval towards the cultivation and consumption of khat that it has not addressed khat in its agriculture sector policy and strategy documents. It is not covered by the agricultural extension services package. The Health Sector Transformation Plan (HSTP) aims at reducing the number of khat consumers by 35% at the national level [28].

Further, the Educational Management Organization prohibits teachers and students from using, among other things, khat on school premises. Similarly, the Road Traffic Control Regulation issued by the FDRE Council of Ministers provides that no driver may drive a vehicle while chewing or after chewing khat. Else, there is no comprehensive policy or legal instrument that pertains to or regulates the production, distribution, and consumption of khat in Ethiopia. Chat locally produced and supplied khat shall be charged at a tax rate of Birr 5 per kg. The exporters of khat shall be liable to pay the tax and 25% of the tax as a penalty if they fail to export the khat [29].

Tobacco/cigarettes

The use of tobacco to satisfy and create nicotine dependence was make known to Columbus by Native Americans and spread quickly to Europe. The use of tobacco in the form of cigarettes, though, is mainly a 20th phenomenon. Nicotine is the main component of tobacco accountable for its addictive effect. Most addicted cigarette smokers control their blood levels and nicotine intake by regulating the intensity and frequency of their tobacco use to avoid withdrawal symptoms and gain the desired psychoactive effects.

Mortality because of the use of Tobacco is predicted to rise from 14% in 1990 to 23% in 2020. In a study done in Ethiopia in 1983, a lifetime prevalence rate of cigarette smoking among college students was 31.9%. Likewise, in 2001, the lifetime prevalence among college students was 13.1%. A study conducted among Ethiopian university teachers in 2001 showed a lifetime prevalence of 28.2% and a current prevalence of 13.3% [30].

Regulation on Tobacco Users in Ethiopia

The direct or indirect dissemination of the advertisement of cigarette or other tobacco products and advertisement of a narcotic drug or psychotropic substance Article 25 (1) of this Proclamation shall be punishable with a fine not less than USA $1000 and not exceeding $ 8334. The Mekele city make known smoke-free laws in public spaces with measures and became the first to ban smoking in public spaces. It is provided that anyone who trespasses the ban will be subject to a fine of USA $34 and tobacco taxation prices of the most sold brand, pack of 20 cigarettes is USA $0.5 [31]. The regulation on tobacco users in Ethiopia are listed below:

A. Smoking and the use of any tobacco product are prohibited in any part of all indoor public places, workplaces, and on all means of public transport. Smoking is also prohibited in outdoor areas of schools and universities, government facilities, youth centers, amusement parks, among other places. Subnational jurisdictions may enact smoke-free laws that are more stringent than the national law.

B. All indirect or direct forms of tobacco advertising and promotion are prohibited. However, the law excludes legitimate forms of expression recognized by the FCTC Art.13. Guidelines that could be construed as advertising such as trade newsletters, legitimate journalist or artistic expression among other things. All forms of financial or other tobacco sponsorship are prohibited.

C. Rotating text and pictorial health warnings are required to cover 70 percent of the front and the back of tobacco product packaging. Misleading packaging and labeling, including terms such as “light” and “low tar” and other signs, is prohibited.

D. The law regulates specified contents of cigarettes, including banning characterizing flavors; ingredients that create the impression of health benefits; and ingredients that are associated with energy and vitality. The law requires that manufacturers and importers disclose to government authority information on the contents and emissions of their products.

E. The law prohibits the sale of tobacco products via the internet and within 100 meters of schools, health institutions, and youth centers. In addition, the law prohibits the sale of shisha, single cigarettes, and small packets of cigarettes. The sale of tobacco products is prohibited to persons under the age of 21.

F. The law bans the manufacture, wholesale, distribution, sale, or offer for sale, and import to the trade of any e-cigarette or “other related cigarette resembling technology product.” There are no restrictions on the use or advertising, promotion, and sponsorship of e-cigarettes.

G. Price and tax measures are an important and effective means of reducing tobacco consumption, especially among young people. Raising taxes and hence the price of cigarettes and other tobacco products has a double advantage: it not only generates revenue for the government but also produces a prompt decline in tobacco use, particularly among young people and low-income groups. For example, there are case studies of well-implemented price and tax measures from Norway, South Africa among others [32].

Psychotropic

A psychotropic drug is any substance their main effects are on the central nervous system. Cannabis (Marijuana or Hashish) is one of the psychotropic drugs, it is more commonly known as hashish in Ethiopia, referring to marijuana. Unlike tobacco and alcohol products, Cannabis is prohibited in Ethiopia. The cannabis plant is cultivated in different parts of the country, but more widely in western, central, and northwestern parts of the country. Shashemenee which is located in southern Ethiopia is a well-known area for the cultivation of cannabis. Cannabis is used up as marijuana smoke, even though it is not locally known by this name [33].

Regulation on Cannabis Users in Ethiopian

Cannabis use is forbidden by law. If you’re found in possession of it, you could be given a six-month prison sentence and a fine. However, it’s not widely used in the country, only 2.6% of Ethiopians use cannabis. If you are arrested for cannabis possession in the country, you are meant to be brought to court within 48 hours. It is also illegal to sell cannabis in Ethiopia and penalties are more severe for this type of offense. They range from five to ten years’ imprisonment plus a fine of USA $3334. The authorities regularly conduct checks at border crossings and ports of entry. The law does not permit you to buy or sell cannabis seeds in Ethiopia. This means you can’t mail them through the post. The regulations on narcotic drugs and psychotropic substances in Ethiopia are listed below:

A. A special license issued by the Authority shall be required to import, export, manufacture, or distribute narcotic drugs and a person’s having drug trade license shall be issued only to persons having drug trade license organizations.

B. Any person having a permanent special license to import or export narcotic drugs or psychotropic substances shall apply for a special import or export permit for each consignment; such special permit shall be valid only for ninety (90) days. No person shall import or export narcotic drugs or psychotropic substances through the post office or by ship and packing them with other drugs or articles.

C. Only a medical practitioner who is registered and has a special license shall prescribe narcotic drugs. No medical practitioner shall prescribe narcotic drugs and psychotropic substances for himself. It is only being prescribed on a special prescription paper. The management of and standard that any prescription for narcotic drugs or psychotropic substances shall fulfill would be outlined in the regulation to be issued according to this proclamation.

D. Storage Narcotic drugs and psychotropic substances and invoices, registers, and prescriptions shall be stored in a lockable metal cupboard or in a special room the key of which shall at all times remain in the hands of the authorized professional.

E. Any person shall keep damaged, expired, or seized narcotic drugs or psychotropic substances in a separate place and shall dispose of them as per the directive to be issued by the Authority according to this Proclamation.

F. Any person who is licensed according to this Proclamation and who ceases to operate his business shall deal with the stocks of narcotic drugs, psychotropic substances, invoices, other documents, and prescriptions related to same as directed by the Authority.

G. Any person who is licensed according to this Proclamation shall keep records and send reports about narcotic drugs or psychotropic substances as per a directive that shall be issued by the Authority.

Proclamation No 414/2004 the criminal code of the FDRE Article 525, trafficking in or using Narcotic, Psychotropic, and poisonous agents is an intensify offense the provision whoever without special authorization and intent of trafficking produces, cultivates, manufactures poisons or makes transforms psychotropic substances and narcotic drugs or possesses, or plants, offers for sell, distributes, dispatch, or procures for another any of those substance listed under can be punishable with rigorous imprisonment for not less than 5-15 year and fine not exceeding USA $3334.

Other sub-articles of this provision stated that every offender is punished with rigorous imprisonment not exceeding five years-seven years with USA $1667. Even if 1957 penal code Art 510 revised the provision stated that who so ever, without lawful authority, produce or makes, transform, imports or transport, stores, a receives or quires, offers for distributes or sale, or procures for another, narcotic substances or drugs or is punishable simple imprisonment of not less than three months to a rigorous imprisonment not exceeding 5 years as well as a fine of USA $667 up to $100, respectively. The regulations on the illegal drug trade are listed below.

A. Any licensed person who impedes the work of inspector assigned according to Article 14 of this Proclamation shall be punishable with imprisonment for not more than six months or with a fine not exceeding USA $ 300 or with both [34].

B. Transfers the licenses issued to him to any person by way of any means shall be punishable with imprisonment of not less than one year and not more than three years and a fine of not less than USA $167 and not exceeding USA $667.

C. Any licensed drug manufacturer, importer, exporter, or wholesaler who sales drug to a person without a license shall be punishable with imprisonment of not less than two years and not exceeding five years and with a fine of not less than USA $167 and not exceeding USA $667.

D. Any person who trades drugs without a certificate of competence shall be punishable with imprisonment for not less than five years and not exceeding seven years and with a fine of not less than USA $ 667 and not exceeding USA $1667.

E. Any licensed drug retailer who wholesales, or dispenses drugs in excess or less quantity than that justified by a medical practice or purchase drugs from a person who is not licensed according to this proclamation shall be punishable with imprisonment of not less than two years and not exceeding five years and with a fine of not less than USA $167 and not exceeding USA $667.

F. Any person exercising unfair trade practice by counterfeiting, or adulterating or affixing or enclosing mislabel to packaging material, or buying or selling substandard or expired drugs shall be punishable with imprisonment of not less than 10 years and not exceeding 20 years and with a fine of not less than USA $667 and not exceeding USA $1667.

G. Any person, who fails to comply with the provisions of this Proclamation, or regulations and directives issued according to this Proclamation, shall be punishable with imprisonment of not exceeding two years and with a fine of not exceeding USA $300. For the execution of this article, the drug shall mean any substance excluding narcotic drugs and psychotropic substances.

H. Sells or supplies narcotic drugs or psychotropic substances on presentation of a prescription, where he knows that the presentation is forged, unlawfully altered, canceled, or expired, shall be punishable with imprisonment of not less than 7 years and not exceeding 15 years and with a fine of not less than USA $1000 and not exceeding USA $1667.

Control Methods

Substance abuse control comprises control of supply, production, availability, crop eradication, provision of suitable alternative sources of income, crop substitution, control of access, and distribution. Demand reduction, reducing consumption, increase prices, control of advertising and promotion, and increase individual resistance from social pressure through health education are among the possible control methods. Ethiopia is a party to the single convention on narcotic drugs of 1961 and the 1971 convention on psychotropic substances. As per the stipulations of the conventions, the Ministry of Health, Pharmacy Department is the central body to exercise all control actions to decrease the demand and supply of drugs and thereby limit the use of drugs to entirely scientific and medical purposes.

The principal laws under which psychotropic and narcotics drugs are controlled in Ethiopia are the Pharmacy Regulation of 1964 and the penal code of 1956. The basis of drug control legislation is the pharmacy regulation of 1964, which controls the supply of pharmaceutical products at all stages such as manufacture, registration, quality control, export, import, distribution, and store.

Conclusions

Presently, substance abuse is one of the hottest public health issues in Ethiopia. Even though, it has been known that this public health problem is a persistent issue, the real extent, and magnitude of drug abuse are not yet appropriately discovered. Alcohol, tobacco/cigarettes, and khat were identified as the most commonly used substances. The adverse impact of substance use like chat, smoking on academic performance has been reported by some studies, although its impact on mental health, physical health, and social wellbeing of students was also stated but, not well reported. After realizing the consequence of substance abuse, we overviewed their legal consideration from the Ethiopian proclamation and policies but still, there are no clear and enough laws regarding drug abuse like khat. Lack of discussion on substance abuse by concerning bodies is perhaps determined by silent contentment over rising tax revenues as well as concerns over the sensitivities of regulating a substance grown by millions of farmers and consumed by millions of citizens.

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