Introduction

While many nations face epidemic levels of illegal drug use, the nature of each nation’s drug problem and the historical circumstances that have shaped it vary widely. These differences translate to differences in the intervention and drug treatment. In the case of China, the problem of drug abuse first emerged several centuries ago, and has been a social and political issue that has both directly and indirectly influenced the country’s development.

The advent of widespread use of addictive drugs in China was related to illegal opium trafficking into China from British India in the 1760s (Fang et al. 2006; Lowinger 1973, 1977). The influx of a great deal of opium led to the use of the drug to become prevalent across the country. While this opium use threatened millions of people’s health, it also underlays social problems such as increased crime rate and loss of workforce. These social conflicts caused by opium abuse played an important role in China’s transition from a feudalist society to a semi-feudalist and semi-colonial society (Fang et al. 2006; Lowinger 1973, 1977). Although two Opium Wars and other efforts were carried out against importation of opium, the lack of effective treatments for drug abuse eventually led to the decreased production and financial failure in Qing Empire.

Following the establishment of the People’s Republic of China, the new Chinese government made an announcement in 1952 that the demon of drug abuse had been eliminated in the nation (Lowinger 1973, 1977; Michels et al. 2007). This success was linked to strict law enforcement and government policy separating China from western countries. With the recent re-establishment of the open-door policy toward western nations, the problem of drug abuse has re-emerged and spread in China again (Fang et al. 2006; Michels et al. 2007). To control the harm induced by drugs, such as the spread of HIV/AIDS and social crime, the Chinese government sought to implement multiple levels of intervention into the problem of widespread drug use. Instead of focusing only on punishment, government agencies have also carried out medical treatments including methadone maintenance treatment (MMT) and using traditional Chinese medicine (TCM).

Here, we seek to discuss the unique characteristics of China’s drug problem by grounding it in historical context, specifically by detailing the history of drug abuse in China from the later stage of Qing dynasty (Table 1) to 1980s. Building on this historical background, we then discuss the current state of the drug problem in China, the particular challenges that the nation must face, and some of the specific interventions developed to control the drug problem.

Table 1 The history of China (list of dynasty)
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The History of Drug Abuse in China (From the 1st Opium War to the 1980s)

Opiate abuse in China can be traced back several centuries (Table 1). In the 16th century, the British introduced Indian opium into China (McCoy et al. 1997). This opium trade flourished because of its great profitability; it has been reported that England imported 4,000 boxes (of 50–60 kg opium per box) of opium from India to China every year in the first two decades in the 19th century (Poroy 1981). More severely, the total number of opium smuggled to China was 420,000 boxes from 1800 to 1840, which directly cost China at least 300,000,000 silvers (approximately 200 million US dollars). The British opium trade was thus a financial drain and public health hazard for the Qing dynasty.

The Qing dynasty quickly recognized the harm done by opium and outlawed its importation and use nationally. Public confiscation and burning of opium in 1839 reduced opium smuggling, but threatened British interests in the drug trade, which led to the first Opium War in 1840. The British defeated the Qing government in this war and forced the government to sign the Nanjing Treaty, legalizing opium importation to China (Fang et al. 2006; Lowinger 1973, 1977). In an attempt to further open the Chinese market, England and France started the second Opium War in 1856, leading to the further importation of opium into Qing dynasty.

In addition to Opium importation and smuggling, local cultivation of narcotics in China was also an important contributor to the epidemic of opium abuse. Opium is the oldest and the most broadly used narcotic in the history of China. In the1860s, the Qing government began to allow the cultivation of opium poppies, and homegrown opium gradually supplanted imported opium. Despite the subsequent outlawing of opium cultivation, farmers continued to grow opium poppies for their high profits. This abundance of opium also supplied the raw materials for making other kinds of opioid drugs, such as heroin.

By 1906, China had 13.5 million opioid addicts, who accounted for 27% of the adult male population, and had consumed some 39,000 tons of opium (Fang et al. 2006; Lowinger 1973, 1977). This astounding prevalence of opioid addiction was probably the largest in the world history (Bureau for International Narcotics and Law Enforcement Affairs 2003). The Republic of China, in power from 1912 to 1949, launched a massive but ultimately unsuccessful anti-opium movement (Lowinger 1973, 1977). Just before the founding of the People’s Republic of China in 1949, there were over 20 million opium abusers (5% of the population, see Table 2) in the country and 25% of the population in Yunnan province abused the drug (Bai 2001). In the early 1950s, the new Chinese government began a strict nationwide campaign against opium abuse (McCoy et al. 2001). During this campaign, people involved in growing, transporting, and/or trafficking illegal drugs were rounded up and punished with detention in labor camps or execution. By 1952, drug trafficking and abuse had nearly disappeared (Fang et al. 2006). However, with government reform and open-door policies implemented in China since the early 1980s, the problem of drug abuse has re-emerged.

Table 2 Estimated registered drug abusers in China over different historical periods
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The Present Epidemic of Drug Abuse in China (from the 1980s to 2007)

With the establishment of closer ties with the West in the 1980s, the illicit drug traffic re-emerged in China, mainly through the “tunnel” from the Golden Triangle region (Myanmar, Yunnan, and Guizhou Provinces) to Canton (Guangzhou) and Hong Kong (Naik et al. 1991). Illicit drug abuse, particularly heroin abuse, has quickly spread and has reached epidemic levels in the last 10 years. The number of registered drug users increased from 70,000 in 1990 to 1.16 million at the end of 2005 (Fig. 1); whereas in 2004 the estimated number of actual users was 3.5 million (China National Narcotics Control Commission 2002). Currently, 72.7% of Chinese counties (cities or districts) report problems with drug addiction. In the past decade, drug abuse has also become evident in rural areas, especially in the northwest and central regions of the country (Fig. 2).

Fig. 1
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Registered drug abusers in China (1991–2005)

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Fig. 2
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Distribution of new drug abusers in different areas of China (2006)

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The specifics of China’s drug problem have been thoroughly documented by Hao et al. who described the prevalence and patterns of illicit drug use in the heavily populated areas of Yunnan, Sichuan, Gansu, and Gungdong provinces between 1993 and 2000 (Hao et al. 1998, 2002; Wolf et al. 2004). Hao and colleagues screened more than 50,000 individuals aged 15 or above in these communities and interviewed possible abusers. The data from these subjects showed that the prevalence of lifetime illicit drug use was 1.08, 1.60, and 1.52% in 1993, 1996, and 2000 respectively. Prevalence of use in the past year was 0.91, 1.11, and 1.17% in 1993, 1996, and 2000 respectively. Heroin was by far the most abused drug: 51.8% of drug abusers had used the heroin in 1993, 83.4% in 1996, and 95.9% in 2000. The two most frequent routes of heroin administration were inhalation (89.2% in 1993, 60.1% in 1996, and 93.5% in 2000) and intravenous injection (27.2% in 1993, 31.0% in 1996, and 25.7% in 2000). Other studies conducted after 2000 showed that intravenous injection accounted for 50–70% and ‘chasing the dragon’ (zhuilong: ingestion of the drug by inhaling the vapor produced when the drug is heated to a level at which it sublimates) accounted for 25–50% of heroin administration.

Key trends in Chinese drug abuse include the ever-increasing popularity of intravenous administration of heroin, fueled by the switch many users make from “chasing the dragon” to intravenous injection. Another trend, provoked by consumption of traditional drugs of abuse, is the increasing use of newer drugs of abuse. While opiates, especially heroin, remain the most commonly abused drugs in China, MDMA (methylenedioxymethamphetamine or ecstasy) and methamphetamine have recently gained popularity in large and medium-sized Chinese cities (Xue et al. 2002; National Institute on Drug Dependence and Drug Abuse Surveillance Center 2003, 2004).

With increasing drug abuse have come increases in related health problems, especially the spread of HIV/AIDS. Almost one million people are currently living with HIV in China (Fig. 3), and drug abusers account for 63.7% of this population (Fang et al. 2006). The Chinese AIDS epidemic dates back to the early 1990s, when the disease spread through needle sharing among injection heroin users. In addition, many prostitutes also inject drugs, providing a bridge for HIV transmission to their clients and the general population (Kerr 2005; Lau et al. 2005; Yang et al. 2005; Qian et al. 2006). In general, the explosive growth of the commercial sex industry in China over the past two decades has caused the HIV infection rate to increase dramatically.

Fig. 3
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Registered HIV-infected individuals in China (1986–2005)

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By the end of 2003, the registered number of HIV infections in China was 62,159, including 2,693 cases of AIDS, which claimed 1,047 people’s lives. An estimated 840,000 Chinese people are HIV positive (range, 650,000–1,020,000) (Fig. 3). HIV infections have been found in 31 provinces, autonomous regions, and municipalities (Kerr 2005). China is one of the six Southeast Asian countries in which there is a growing concern of vulnerability to HIV/AIDS (Aceijas et al. 2004; Kerr 2005).

Crime is another serious drug-related problem. Drug abuse in many nations links to both organized crimes such as increased gang violence, and to theft, violence, and prostitution committed by addicts seeking to obtain drugs. In some areas of China, drug-related crime represents 70–80% of all crime. In LanZhou city, a larger city in northwest China, approximately 70% of drug abusers were found to have committed related crimes, and 70% of criminals reported using drugs. Drug-related crime thus threatens the stability of Chinese society broadly (Fang et al. 2006; Shi et al. 2007).

To check the spread of HIV/AIDS and reduce drug-related crime, the Chinese government has taken several steps to control drug abuse, and has made anti-drug work a priority (Kaufman and Jing 2002). On October 23, 2003 Chinese president Jiang announced the beginning of a government war on drugs; this project was broadened in 2005. In 2006, Chinese National Narcotics Control Commission (NNCC) promoted this anti-drug war to a national level, which has included multi-faceted efforts involving the media, police, department of education, and justice department. The police, custom immigration quarantine (CIQ), national security, and justice department were also called on to coordinate to control drug-related crime. For example, from January to April 2005, 24,000 drug-related crimes were solved, 19,000 suspects were arrested, and 3859 kg of heroin, 1005 kg of methamphetamine, and 198,000 tablets of ecstasy were captured (Fang et al. 2006).

The Chinese government has also become more involved in raising awareness about drug abuse and taking steps to prevent and control it. First, the government presents nationwide educational programs that disseminate scientific knowledge about illicit drugs to the general public. Newspapers have set up special pages for drug abuse prevention education. Organizations such as the culture, health, civil administration, youth, women, and workers’ unions have all joined in these educational efforts (Zhao et al. 2004). Secondly, the Chinese government has developed educational programs focusing on preventing HIV/AIDS transmission. Given that so many drug abusers are young people, the Ministry of Education has decided to offer drug prevention courses, beginning in the fifth grade of primary school and continuing through the second grade of senior middle school (Krishnan-Sarin et al. 1995; Maas et al. 1998). Thirdly, intervention work has begun in the regions that are most vulnerable to drug abuse and the spread of HIV/AIDS (Zhao et al. 2004).

These government efforts have been supported by firm policy. In 2002, China’s NNCC, together with three other Ministries, announced the strengthening of drug abuse prevention work. Chinese law now stipulates that people found using drugs must be detained for up to 15 days and that those found to be addicted to drugs must be sent to rehab centers. Over 252,000 people were sent to drug rehabilitation programs in 2002, according to police statistics. Further, drug abusers who complete rehabilitation programs are subsequently given community help in remaining drug free, including education, problem solving, surveillance, and re-entry community plan, which prevents them from relapse to substance abuse.

Finally, the Chinese government has sought to cooperate with western countries that are experienced in treatment of drug addiction and HIV/AIDS prevention (Krishnan-Sarin et al. 1995). Programs such as China-UK HIV/STD Prevention Project are helping Sichuan and Yunnan provinces to conduct harm reduction programs among drug abusers and sex workers 2006 (China-UK Workshop on HIV/AIDS, 2002 ). In March 2004, the Methadone Maintenance Treatment (MMT) and Needle Syringe Program (NSP) were also set up nationwide. Evaluations of these programs indicated a statistically significant decrease in drug abuse and drug-related crime. While China and western countries may find somewhat different approaches appropriate to their historically and culturally different drug abuse epidemics, it is to all nations’ benefit to continue sharing successful models of drug abuse prevention and treatment (Michels et al. 2007).

The future of drug abuse in China

Although drug abuse is a serious problem in China, we expect that concentrated government efforts like those discussed above will help to win our anti-drug war. In recent years, the Chinese government has adopted new measures to combat the illegal trafficking and abuse of drugs, and has sought to be both open-minded and flexible in its drug control strategy. In this spirit, China continues to work through challenges that impede three aspects of its anti-drug campaign.

Firstly, consumption of new types of addictive drugs has made the drug addition landscape more complex, requiring the government to retool its drug control strategies. With the increasing manufacture of ATS, particularly methamphetamine, in East and South-East Asia, an increasing number of young people in China have begun to take these synthetic drugs (Qian et al., 2006). In recent years, large amounts of the precursor chemicals used to make these drugs have been illegally sold within China or exported to overseas markets.

According to the 2003 report of the Chinese Drug Surveillance Center, MDMA, methamphetamine, and ketamine account for 5.6% of the drugs taken by new drug abusers, following opiates (National Institute on Drug Dependence and Drug Abuse Surveillance Center 2003, 2004). A comparison between experienced drug abusers and new drug abusers with respect to the most abused stimulants reveals that new drug abusers use more MDMA and methamphetamine. MDMA is thus the most abused drug among young people, and even as first-time MDMA users are getting younger, the number of adults abusing ecstasy is also on the rise. To address these problems, China needs to further strengthen controls over the sale of precursor chemicals and combat the domestic production of the synthetic drugs. We must also focus on preventing the illicit export of precursor chemicals to overseas markets, particularly, the Golden Triangle, which is likely to turn from a “heroin empire” into an “ice empire”(Lintzeris et al. 2006).

Another challenge relates to the legal treatment of drug abuse. China’s anti-drug legislation must be strengthened, as well as updated to keep up with the current drug abuse situation. Laws are needed that can resolve jurisdictional confusion between anti-drug law enforcement and the justice department. In June 2006, the draft of mainland China’s first anti-drug law was presented to the National People’s Congress for consideration; this legislation is expected to specify whether taking banned drugs is a criminal act and what punishment should be meted out to abusers (Fang et al. 2006).

Last but not least, a great challenge lies in the change in the government policy and public attitude toward drug addicts in order to make constructive changes. Strict laws alone cannot solve the country’s drug abuse problem, since drug addiction is characterized by high rates of relapse and long-lasting vulnerability to drug-taking. Relapse can be induced by environmental cues and stress as well as exposure to the drug itself. The main medical challenge for addiction treatment is thus the prevention of relapse (Fang et al. 2006). Although forceful measures are necessary, shifting government policy and public attitude in order to gain support for medical intervention into relapse is also essential (Fok and Tsang 2005; Tang et al. 2005).

As mentioned earlier, some local governments have begun to introduce new drug control measures, including the Pilot Needle Exchange Program and the Methadone Maintenance Therapy Program. However, the high cost of methadone is a huge financial burden for both the government and addicts. In addition, although the government has gradually adjusted its drug control policy and changed its attitude toward addicts, now regarding them as both victims and patients, it is likely to take both time and educational efforts for the general public to accept this view. As long as the public continues to discriminate against addicts and rehabilitated former users, and are reluctant to help them reintegrate back into mainstream society, China’s drug control work will ultimately not be successful.

The MMT in China

In recent years, the People’s Republic of China has seen an expansion of harm reduction oriented programs intended to cope with the drug addiction and HIV/AIDS problem. In Methadone maintenance treatment, drug takers eventually reduce dependence on heroin by taking methadone under doctor’s instructions. The treatment can also prevent the spread of AIDS, since MMT patients ideally stop sharing drug injection equipment. Methadone-based withdrawal regimens have been performed in China since 1993. At the beginning, methadone was difficult to manufacture and only a few clinics had staff trained to administer the treatment. While Chinese MMT has proven to be safe and effective, long-term treatment regimens are still being piloted (Yu et al. 2007; Shi et al. 2007, in press; Michels et al. 2007). The nation’s first eight dedicated MMT clinics were set up in early 2004 and another 26 were completed later that year. Additionally 300 clinics were established by June 2006 and the number of clinics has now reached 500 (Sullivan and Wu 2007). To date, more than 10,000 opioid-dependent patients have received MMT in China (Michels et al. 2007). In order to control the spread of AIDS among drug takers, China plans to set up 1,000 clinics to offer methadone maintenance treatment in the next five years. It is estimated that approximately 200,000 drug takers will benefit from this project.

Considering the severe drug abuse problem in China, it is necessary to adopt an effective therapy to reduce the impact of drug dependence. Currently, the main treatment for heroin abusers is short-term detoxification with opiate agonists (methadone or buprenorphine) or non-opiate agents at compulsory rehabilitation centers and re-education-through-labor centers. Unfortunately, patients who have undergone short-term treatment have shown low rates of recovery and high rates of relapse. This state of affairs has led the government to introduce longer-term maintenance treatment, which has been suggested to be the most effective treatment for heroin withdrawal and relapse (Lintzeris et al., 2006).

Although the MMT programs have shown promise in China, the programs face many difficulties. First, the programs’ dropout rate is rather high (at 30–40%), mainly due to the relapse of drug use in patients and the following forced detoxification, which suggested that the experience of MMT in China is limited (Yu et al. 2007; Shi et al. 2007). Greater retention in treatment has been found to result in greater decrease in drug use, criminal activity, and unemployment (Simpson et al. 1997). Thus, extending treatment duration can effectively improve post-treatment outcomes. Also, there is an urgent need to give patients easy access to both the MMT clinic and additional psychosocial interventions, such as motivational interviewing (Bureau for International Narcotics and Law Enforcement Affairs and State, 2003). These complimentary approaches hold great promise for enhancing MMT treatment initiation, retention, and outcomes (Carroll et al. 2006). Adding behavioral intervention components into the MMT programs can also help to increase abstinence and reduce HIV risk behavior.

Secondly, the financial resources currently available for MMT treatment are not sufficient. The ministry of health has ambitious plans to expand the MMT program. However, given that many drug users in China are living in rural areas and have limited access to treatment facilities, it is impractical to center treatment in large-scale methadone programs that addicts cannot attend daily. It is important to raise awareness among the political leadership in order to obtain sufficient financial support. With consistent economic development and grant support from Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as other international donor organizations, there is hope that the budgets for the MMT program will be expanded.

Thirdly, conflicts internal to the policy and law landscape have lead to difficulties in implementing the MMT program. For example, drug users may be reluctant to participate in MMT programs due to the fear of being arrested (Thompson 2005). Unfortunately, there is a lack of any definite laws or regulations to address this dilemma. The ministry of public security seems to approach drug abuse with zero tolerance, while the central government supports the “harm reduction” policy via MMT or needle syringe program (NSP). Inconsistent interpretations of “harm reduction” by public health officials and the ministry of public security present a barrier to effective nationwide implementation of MMT (Qian et al. 2006).

In conclusion, in order to be successful, the MMT program in China must be supported financially, by all government agencies, and by clear law and policy. Cooperation with other countries and international organizations that have had success with MMT may also be helpful (Tang and Hao 2007; Michels et al. 2007).

Traditional Chinese medicine (TCM) in the Treatment of Drug Abuse

Traditional Chinese medicine (TCM) includes Chinese herbal medicine and acupuncture. TCM has been practiced in China for more than 2000 years and has been used for treatment of drug addiction for the past 200 years. Chinese herbal medicine consists of natural products including plants, animals, and minerals. Ten Chinese herbal medicines for the treatment of opiate addiction have been approved by the Chinese State Food and Drug Administration (SFDA) and at least six are in clinical trials.

The effects of these herbal medicines includes: (1) sedation, pain relief, local anesthesia, hypnosis, and anti-convulsion; (2) stabilization of blood sugar, improvement of protein metabolism, protection of liver, blood pressure control, and anti-hypoxemia; (3) anti-fatigue, anti-stress, and anti-shock; and (4) cardiovascular system protection and modulation of immune function (Fang et al., 2006; Shi et al., 2006). Generally, the efficacy of Chinese herbal medicine in controlling opiate withdrawal symptoms has been found to be less than narcotic detoxification agents, but similar to or better than non-narcotic detoxification agents (e.g., clonidine, lofexidine hydrochloride) (Fang et al. 2006; Tang et al. 2007).

Acupuncture, another essential part of TCM, is performed by inserting thin needles in specific bodily points that are believed to center the flow of bodily energy. In some cases, a small electrical impulse is added to the needles. According to the theory of acupuncture, the functions of the human body are controlled by systems of ‘Jingluo’ and ‘Qi-xue’ (they are both abstract notions in TCM, Qi-xue is a collective name for all the body fluid and Jingluo is the channel for them, like the circulatory systems); acupuncture improves the functions of the human body by controlling these systems (Fang et al. 2006; Shi et al. 2006). Acupuncture or electroacupuncture (EA) have been used very successfully to attenuate behavioral signs of opiate withdrawal in addicts (Clement et al. 1979; Shwartz et al. 1999; Montazeri et al. 2002).

Acupuncture has many advantages for the treatment of drug addiction. It is an effective treatment for the prevention of relapse to opiate use that is inexpensive, easy to perform, and has little side effects. It is also safe for pregnant women and parturients (Clement et al. 1979; Ou et al. 1998).

Acupuncture can also be use in concert with pharmacotherapy to increase rates of drug abstinence (Washburn et al. 1993; Konefal et al. 1994; Nu et al. 2000; Fang et al. 2006). This combination of therapies is especially promising since acupuncture would not negatively interact with, and would add no side effects to, methadone or benzodiazepine and phenoziazine treatment (Zhuang et al. 1995; Zhang et al. 1998; Fang et al. 2006).

Since TCM works by targeting multiple systems and mechanisms, it has been suggested that this therapeutic approach may be particularly suited to attenuating withdrawal symptoms and preventing relapse to opiate addiction (Wen et al. 1995; Li et al. 2001). Since it has fewer side effects, Chinese medicines can also be used as an alternative and complimentary approach (Yang and Kwok 1986; Zhuang et al. 1995). Furthermore, Chinese medicine can improve immune functions following opiate withdrawal; this treatment may thus enhance recovery of normal immune functions depleted by chronic opiate use in addition to decreasing opiate withdrawal symptoms (Shibata et al. 1994; Zhuang et al. 1995; Watanabe 1997).

Concluding Remarks

In summary, drug abuse is a serious social problem in China. It has had both historical and present-day impacts on China’s public health, economy, and social stability. Different Chinese governments have attempted to solve this problem many times in the past, succeeding only with authoritarian measures in the 1950s. Unfortunately, drug abuse re-emerged as a national problem with the adoption of the open-policy in the 1980s. Currently, drug abuse and related HIV infection and crime are increasing in China at an alarming rate. This circumstance requires the Chinese government to implement strong, effective, and immediate intervention; appropriate new government and legal policy, cooperation with other countries and non-governmental organizations, and MMT and TCM therapies may help to achieve this goal.

Cumulative number of HIV infections reported, China, 1984–2005 from sentinel surveillance (government of China) (Source: China UN Theme Group on HIV/AIDS, 2005)