In the last half-century, Iran has experienced five different areas of dealing with the addiction problem. About one decade before the 1979 revolution in Iran, when heroin use, like in many other parts of the world, had become a health and social problem , law enforcement focused on implementing rules enacted based on the international drug control conventions that highlighted supply reduction .
Decades ago (in the 1930s), the regime, like the hijab and other traditional clothing, recognized narcotic use as an obstacle to authoritarian development. The regime forced drug users to cease, made women remove their hijab (unveiling) and men wear clothes according to Western fashion . In line with the latest scientific findings, addiction was gradually accepted as a disease that needed to be treated by specialists. Although those who had not quit using drugs were subject to social penalties, the law had not criminalized drug use, and, as a medically harmful condition, the authority and responsibility for managing the "problem of addicts" had been delegated to the Ministry of Health and Medical Education (MOHME). However, this policy did not provide adequate addiction treatment coverage in Iran .
With no harm reduction approach but to decrease smuggled drugs, the government in pre-revolutionary Iran started to locate opium rations for the elderly dependent users in 1956 . This measure did not solve the problems induced by the rising trend of heroin use among the youth and caused the leak of government opium to the black market for the consumption of other people. It was not law enforcement, but health professionals who criticized this policy, perhaps because this approach's legal and security consequences were lesser than illegal drug trafficking by violent criminals, and the police prefered to focus on drug supply reduction. As a result, there was no significant challenge between the health system and law enforcement. However, the imbalance of supply and demand reduction policies and ignoring the dynamics of these two areas was one of the critical reasons for the failure of efforts for the first maintenance program in Iran .
Almost all anti-monarchist revolutionaries, regardless of their ideology and slogans, raised this policy as a sign of the regime's deliberate attempt to narcotize the masses and normalize Western-style liberalism. They saw the prevalence of drug use as one of the imperialist tricks to weaken independent societies and defeat the revolution's ideals. Hence, it was no surprise that shortly after the 1979 Islamic revolution, the new Islamic government cut opium quotas, criminalized drug use, and mandated addicts to quit drug use within six months .
Afterward, the Revolutionary Courts became responsible for dealing with drug-related crimes . Prosecuting perpetrators of imprisonment, torture, and murder of revolutionaries in the former regime, as well as prosecuting acts such as assassination, sabotage, espionage, and economic conspiracy against the Islamic Republic regime, are these courts' duties. Also, they deal with drug-related crimes, and within a week, they must issue a sentence that is not appealable .
Central law enforcement of these courts was the Islamic Revolutionary Committees, one of the first institutions established after the revolution, to obtain security and discipline in the country to protect the achievements of the Islamic Revolution of Iran . In addition to intelligence and security missions and fighting against the counter-revolutionaries, the committees were responsible for maintaining the moral security of society against depravities, including drinking, and non-observances of the Hijab law, illegitimate relations between men and women, supply and the consumption of alcohol and drugs . Nearly twelve years later, these committees merged with two different institutions in terms of organizational structure and objectives, namely the civilian police and the gendarmerie, to form the police force of today, with committees playing a fundamental role, especially in its command ranks.
The main idea at that time was to quickly and decisively eliminate all the problems and deprivations attributed to the former regime by using the revolutionary will in the direction of the revolution's ideals. In an endeavor to fight against drugs, the revolutionary courts and committees carried out this determination to “eradicate drugs” and “eliminate drug users” from society through two principal measures: The imposition of severe punishments, such as execution and long-term imprisonment for both drug dealing and trafficking; and, collecting drug users and keeping them in compulsory camps to the forced cessation of drug use . Despite the efforts of the health care system to develop addiction treatment in the country, the nature of the addiction disease did not allow most consumers to permanently quit drug use within the six months prescribed by the law. However, due to ideological beliefs, law enforcement had no restrictions on performing “the sacred duty of cleansing society of the contamination of addicts.” Thus, they started mass arresting drug users and imprisoning them before the end of the six-month legal deadline for quitting addiction . It is the route of deep conflict between the health and judicial systems.
The concept of addiction as a chronic, recurrent, and treatable disease; and the notion of substance use as a perverted, sinful, criminal, and counter-revolutionary conduct, which must be repented of or punished, are in contrast. Naturally, forming a harm reduction approach to substance use in such an environment was impossible. The law, which originated from a jurisprudential-revolutionary ideology, obliged drug users to quit drug use and law enforcement to purge society of addicts; then, dissidents could not raise other diverse approaches, such as harm reduction.
This situation continued until the pragmatic government came to power after the devastating eight-year Iran–Iraq war (1980–1988). The effects of the war and the consequences of socioeconomic transformations changed the patterns of drug use, drug users, and the harms of addiction in Iran. The harm could not be controlled by gathering arrested addicts to force them to quit drug use in compulsory camps and forsaken islands of the Persian Gulf. Then, it allowed the government to raise reconsideration of counter-narcotics policies at the highest levels of authority, the Expediency Discernment Council.
The new 1997 amendment still criminalized drug use and forced addicts to quit to avoid punishment. However, two decades after the revolution, drug users with no deadline were allowed to take addiction treatment and rehabilitation at medical centers licensed by the MOHME . Nevertheless, treatment in government facilities was inadequate and limited to detoxification. In this period, harm reduction still had no place inlaws or scientific societies, and even some experts were skeptical about it.
What changed the scene was the prevalence of HIV infection among people who inject drugs (PWID), particularly in prisons . The danger of HIV was previously ignored by the Islamic Republic of Iran and attributed to unrestrained sexual relationships in Western countries. However, it finally emerged through the gates of addiction.
Health care system technocrats, first in the field of infectious diseases, then mental health and addiction, turned this threat into an opportunity to build the foundations of addiction harm reduction programs in Iran. Their advocacy efforts were fantastic, and they could get the judiciary's support at the highest level. The health care system developed NSP, VCT, then MMT programs in prisons and high-risk areas [13, 14]. Despite legal requirements, judicial authorities prohibited the imprisonment of individuals solely on charges of addiction . Shortly after, the words "harm reduction" entered the Iranian legal literature through the Anti-Narcotics Law adopted in 2010 .
Although in the beginning, even some judicial authorities persecuted harm reduction activists and even the IMOH officials on charges such as abetment in the crime of drug use, with the emergence of harm reduction benefits, their views on these programs changed.Footnote 1 The MMT program has reduced everyday struggles over drug possession in prisons as much as it is impossible to imagine a prison without the MMT program. Also, social support and harm reduction programs have decreased drug-seeking conduct and illegal behaviors to get drugs. Furthermore, thousands of people covered by agonist drugs, especially MMT, have been removed from the criminal population and returned to ordinary life for not committing drug offenses. Finally, the decline in the incidence of HIV/AIDS among injecting drug users in Iran presents the world as a successful example of the health and judicial systems' participation in harm reduction programs .
All of these took place in the context of socio-political changes in which reformism, tolerance, and civil society were the main keywords. That is everything necessary for the harm reduction movement in Iran. Under these circumstances, not only did the NGOs take a humane approach to modify strict policies in dealing with drug users, but also the police, who were trying to show a changed face in line with the new social atmosphere associated with this movement .
The police carried out the orders of the judicial authorities regarding harm reduction activities and dealing with their clients. However, the Iran Drug Control Headquarters (DCHQ), the highest executive authority in this field, played an essential role in bringing together the government bodies with different opinions and interests, including the police and health system . At the time, balancing the measures of reduction of drug supply and demand was the central approach in global drug policy . Then, the DCHQ sought to lead the activities of various organizations in these areas in a direction that met the goals of the general policies of the system in drug control. Although the general drug policy still criminalizes drug use, it excludes the use of psychotropic medications (such as opioid agonists) for drug treatment and harm reduction. In particular, it considers preventing the change of consumption patterns from low-risk to high-risk substances as one of the main goals .
The honeymoon was short for Iran's drug use harm reduction. With the entry of stimulants (in the mid-2000s) into the Iran drug market, a new pattern of consumers appeared with distinct demographic and socioeconomic characteristics from usual opioid users . This pattern of use caused unprecedented problems of drug addiction. The media exaggerated the noisy consequences of stimulant use , including aggressive behaviors, domestic violations, violent crimes, and its rapidly destructive effects, and panicked the community; the harm reduction managers were also surprised by the new situation . Before these problems were associated with the intrinsic properties of stimulants, they were the result of marginal factors such as the impurity of drugs available in the market and consumers' unfamiliarity with new substances to control consumption to reduce its side effects. Over time, users of stimulants have become aware of how to manage the use of these substances, and harm reduction infrastructures have significantly impacted creating this awareness; stimulants are no longer an exciting subject for the media!
Reducing the risk of HIV transmission through injecting drugs has been the central goal of addiction harm reduction programs in Iran for two decades, and the health administration has focused on achieving this goal. Therefore, the "addiction harm reduction approach" in Iran has been reduced to interventions to "reduce the risk of HIV transmission through injecting drug use." For many reasons, including the training provided through harm reduction programs, the prevalence and incidence of injecting drug use are much lower today than in the past . However, in the harm reduction package, the necessary interventions have not been prepared for other consequences of drug use, especially at the social level. As the social effects of stimulant use were greater than those of narcotics, the weakness of harm reduction programs in dealing with these substances became more apparent.
The burden of these social consequences on the judiciary and law enforcement increased even more. They directly faced considerable people committing crimes under the psychotic effects of drug use that the health system had no plan to manage. This unexpected situation made doubt the potential of harm reduction programs. Gradually, the police, who were at the forefront of dealing with new challenges, reduced their vital involvement with the health system for harm reduction programs.
These changes coincided with the end of the work of the reformist government in 2005, which advocated harm reduction, and the emergence of a government with reactionary ideas and a revolutionary manner that sought to solve social, economic, and other problems by instant plans. The changes were not only at the political level but also altered the social and economic situation of the country, which directly or indirectly affected the quantity and quality of government health and support services and the participation of non-governmental sectors in providing them . Similarly, policies on dealing with drug users, especially street addicts, the target group of harm reduction interventions, changed. According to the Anti-Narcotics Law, they are taken to compulsory camps and even to jails by police on charges of exposing manifestations of drug use and addiction in society .