Khat: A literature review
Khat is a plant whose leaves are sometimes chewed for their stimulant properties, especially among some members of East African communities.
The Centre for Culture, Ethnicity and Health (CEH) has undertaken a review of the health and social effects of khat use. This review will assist affected communities to acquire up-to date evidence on the health and social impacts of khat use, and legal and social responses to khat use in other comparable countries, to assist in developing informed local debate.
Associate Professor John Fitzgerald was engaged to undertake the work, with the support of a specially-formed advisory group made up of representatives from a number of East African community organisations, the Ethnic Communities' Council of Victoria, the Australian Drug Foundation and the Victorian Multicultural Commission.
The report focussed on human studies and included peer and non-peer reviewed literature. It concluded that:
"An emerging consensus among international health authorities [indicates] that khat has a low abuse potential ... Whilst the scientific literature suggests that the social and physical impact of khat is also low there is still concern from elements of the East African communities regarding khat use. This review suggests that while importation has increased, evidence of harm is minimal.
"Most importantly, this review suggests that the social and structural settings in which khat is used may provide opportunities for individual, community and regulatory responses to khat use. The review suggests that whilst education campaigns to reduce harmful consumption may be beneficial for some targeted communities, changes to the processes of social marginalisation (i.e. changing the setting of use) among African Diaspora communities in Australia may have greater impact in reducing the harms associated with khat consumption."
From Fitzgerald, John (2009) Khat: A literature review, Centre for Culture, Ethnicity and Health, 2009.
Download the complete report.
Khat is a plant whose leaves are sometimes chewed for their stimulant properties, especially among some members of East African communities.
The Centre for Culture, Ethnicity and Health (CEH) has undertaken a review of the health and social effects of khat use. This review will assist affected communities to acquire up-to date evidence on the health and social impacts of khat use, and legal and social responses to khat use in other comparable countries, to assist in developing informed local debate.
Associate Professor John Fitzgerald was engaged to undertake the work, with the support of a specially-formed advisory group made up of representatives from a number of East African community organisations, the Ethnic Communities' Council of Victoria, the Australian Drug Foundation and the Victorian Multicultural Commission.
The report focussed on human studies and included peer and non-peer reviewed literature. It concluded that:
"An emerging consensus among international health authorities [indicates] that khat has a low abuse potential ... Whilst the scientific literature suggests that the social and physical impact of khat is also low there is still concern from elements of the East African communities regarding khat use. This review suggests that while importation has increased, evidence of harm is minimal.
"Most importantly, this review suggests that the social and structural settings in which khat is used may provide opportunities for individual, community and regulatory responses to khat use. The review suggests that whilst education campaigns to reduce harmful consumption may be beneficial for some targeted communities, changes to the processes of social marginalisation (i.e. changing the setting of use) among African Diaspora communities in Australia may have greater impact in reducing the harms associated with khat consumption."
From Fitzgerald, John (2009) Khat: A literature review, Centre for Culture, Ethnicity and Health, 2009.
Download the complete report.
"Khat goes by numerous names: Khat, qat , chat, qaadka, kus-es-salahin miraa, tohai, tschat,Abyssinian tea, African tea, African salad, and brown cows (in tablet form).
Qat leaves are crimson-brown and glossy but become yellow-green and leathery as they age. The leaves are up to 5 cm wide and up to 10 cm long and emit a strong aromatic smell and have astringent and slightly sweet taste (Sawair et al., 2007).
The stimulant effect of Khat is related to the cathinone content of the leaves (Kalix, 1990).
Cathinone is metabolized rapidly to cathine (norpseudoephedrine) and norephedrine, which possess weak central stimulant properties because of their less lipophilic character (Geisshüsler and Brenneisen, 1987).
Khat is of interest as it one of a few plants that are legally consumed for their
ethnopharmacological properties.
Debates over the legal status and health effects related to consumption of this plant are currently underway in many parts of the world on account of the spread of consumption from eastern Africa resulting from migration among East African communities (Klein, 200
Current Australian regulatory considerations
The current guidelines for important khat are clearly set out.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ocs-tc-guidance-imp-khat.htm
Control status
In 1965, the World Health Organization Expert Committee on Dependence-producing Drugs' Fourteenth Report noted, "The Committee was pleased to note the resolution of the Economic and Social Council with respect to khat, confirming the view that the abuse of this substance is a regional problem and may best be controlled at that level" [1]. For this reason, khat was not Scheduled under the Single Convention on Narcotic Drugs. In 1980 the World Health Organization classified khat as a drug of abuse that can produce mild to moderate psychic dependence.
Cathine is in Schedule IV and cathinone is in Schedule I of the U.S. Controlled Substance Act. The 1993 DEA rule placing cathinone in Schedule I noted that it was effectively also banning khat:
Cathinone is the major psychoactive component of the plant Catha edulis (khat). The young leaves of khat are chewed for a stimulant effect. Enactment of this rule results in the placement of any material which contains cathinone into Schedule I.
In the UK, Cathine and Cathinone are Class C drugs. The plant Catha edulis is uncontrolled. In Germany, Cathine is a controlled substance, and ownership and sale of the plant is illegal. Similar levels of control exist throughout most other European countries.
In Australia, the importation of khat is controlled under the Customs (Prohibited Imports) Regulations. Individual users may apply for several required licenses to import up to 5kgs per month for personal use
In 2003, the total number of khat annual permits was 294 and the total number of individual khat permits was 202."
"There are two types of import permits. The single use Permit to Import can only be used once and you must request a new permit for each time you wish to import khat.
Annual Permits are labelled as such and consist of two pages. Annual Permits allow you to import up to 5 kilograms once a month for up to twelve months."
In Australia, the importation of khat is subject to regulation 5 of the Customs (Prohibited Imports)Regulations 1956 and is prohibited unless the importer holds a licence and permit issued by the Office of Chemical Safety (OCS).
A request to AQIS for data on khat license permits resulted in the release of aggregate data for license permits for the period 2003-2008. Unfortunately these permits do not contain data on the volume of khat imported.
Permits are needed for importation and a licence/permit is required for the importation of khat for personal use. Khat import permits require details on whether the permit is for fresh or dried khat.
The current licensing arrangements allow for the importation of 5kg of khat under one permit each month.
Using the 2007 data, it is estimated that an average of 33 kg was imported per permit in 2007
It is possible that if permits were renewed each month, on average it suggests that each permit could be responsible for 2.8 kg of imported khat each month in 2007.
As a projection of what could have been imported using the current licensing arrangements, it is possible that the market could have risen to 33,180 kg in 2007 if every permit was used to import 5 kg each month.
The expansion of the marketplace is substantial in the Australian community.
On the basis of this evidence, if there were significant harms (eg mental health, crime and acute health) associated with khat it certainly would have become evident in health and criminological data in this time period.
For example, a rudimentary analysis of the import data suggests that in 2007, the importation of khat supported a retail market of around $2.2 million (18,380 kg producing 73,520 two hundred and fifty gram bundles at $35 a bundle).
This estimate is based on an average import weight per permit per month of 2.8 kg. The market could expand under the current regulatory regime to $3.9 million annually, if every permit was used to import the maximum amount allowed under federal regulations.
Compared to other psychoactive drug markets, this is a very small marketplace. As a comparison, the retail heroin market in Smith Street Fitzroy alone was estimated in 2000 to be 10 Khat: a literature review worth approximately $10 million annually (Fitzgerald unpublished data).
Pharmacology
This review of the pharmacology of khat is limited to human studies. There is a substantial literature from animal studies on khat and cathinone, which have been recently reviewed (Feyissa & Kelly, 200.
Khat Catha edulis; Chaat; Gat; Kat; Miraa; Qat; Tschat
Catha edulis
Scientific classification
Kingdom: Plantae
Division: Magnoliophyta
Class: Magnoliopsida
Order: Celastrales
Family: Celastraceae
Genus: Catha
Species: C. edulis
Binomial name
Catha edulis
(Vahl) Forssk. ex Endl.
Khat (Catha edulis, family Celastraceae), pronounced "cot" and also known as qat, gat, chat, and miraa, is a flowering plant native to tropical East Africa. Believed to originate in Ethiopia, it is a shrub or small tree growing to 5–8 m tall, with evergreen leaves 5–10 cm long and 1–4 cm broad. The flowers are produced on short axillary cymes 4–8 cm long, each flower small, with five white petals. The fruit is an oblong three-valved capsule containing 1–3 seeds.
Cultivation and uses
Khat has been grown for use as a stimulant for centuries in the Horn of Africa and the Arabian Peninsula. There, chewing khat predates the use of coffee and is used in a similar social context. Its fresh leaves and tops are chewed or, less frequently, dried and consumed as tea, in order to achieve a state of euphoria and stimulation. Due to the availability of rapid, inexpensive air transportation, the drug has been reported in London, Rome, Amsterdam, Canada, Australia and the United States. The public has become more aware of this exotic drug through media reports pertaining to the United Nations mission in Somalia, where khat use is endemic, and its role in the Persian Gulf. The khat plant is known by a variety of names, such as qat in Yemen, chat in Ethiopia, jaad in Somalia and miraa in Kenya.
Khat use has traditionally been confined to the regions where khat is grown, because only the fresh leaves have the desired stimulating effects. In recent years improved roads, off-road motor vehicles and air transport have increased the global distribution of this perishable commodity. Traditionally, khat has been used as a socializing drug, and this is still very much the case in Yemen where khat-chewing is a predominantly male habit. In other countries, khat is consumed largely by single individuals and at parties. It is mainly a recreational drug in the countries which grow khat, though it may also be used by farmers and laborers for reducing physical fatigue, and by drivers and students for improving attention. This is similar to the use of the coca leaf in South America.
Khat is used for its mild euphoric and stimulating effects. Because of its anorectic effects, khat is used by some members of the Islamic faith during Ramadan, the ninth month of the Muslim year, which is spent in fasting from sunrise to sunset. It was previously only used by Muslims in Ethiopia, forbidden to those of the Orthodox faith, though today it is gaining popularity among Christians as well.
Chemistry/pharmacology
The stimulant effect of the plant was originally attributed to cathine, a phenethylamine-type substance isolated from the plant. However, the attribution was disputed by reports showing the plant extracts from fresh leaves contained another substance more behaviorally active than cathine. In 1975, the related alkaloid cathinone was isolated, and its absolute configuration was established in 1978. Cathinone is not very stable and breaks down to produce cathine and norephedrine. These chemicals belong to the PPA (phenylpropanolamine) family, a subset of the phenethylamines related to amphetamines and the catecholamines epinephrine and norepinephrine.
Pharmacokinetics
According to several early studies, on average around 100–300g of khat can be chewed in a 3-4 hour khat session (Nencini & Ahmed 1989; Kalix ,1990; 1994).
The most detailed account of Khat pharmacokinetics is reported by Toennes et al., (2003). In that study, Toennes et al., (2003) conducted a pharmacokinetic study following administration of 36–59 g of khat or approximately 0.5 mg/kg body weight.
The mucosa of the mouth is thought to be the first absorption segment, where most of the active constituents are absorbed (mean ± SD 59 ± 21% for cathinone and 84 ± 6% for cathine). The extraction of the active constituents from the leaves by chewing is very effective with only 9.1 ± 4.2% remaining as a residue after chewing (Toennes et al., 2003). Similar findings were reported in Brenneisen et al (1990) who examined the pharmacokinetics of cathinone (0.6 mg/kg body weight). The second adsorptive segment is the stomach and small intestine.
Peak plasma levels of cathinone are obtained 1.5–3.5 h after the onset of chewing khat (Feyissa & Kelly, 200. After 1-hour of chewing, plasma levels range from 40 to 140 ng/ml (mean 83 ng/ml).,
Cathinone is detectable in plasma for up to 24 hours after khat consumption. The elimination half-life is 260 min (Widler et al., 1994). Metabolism of cathinone is rapid. Only 2% of administered cathinone was found unchanged in the urine (Brenneisen et al., 1986; Nencini & Ahmed, 1989).
Blood pressures are elevated for about 3 hours after 1 hour of chewing of 0.6 g/kg, about one quarter of the amount consumed in a traditional khat session (Toennes et al., 2003). This dose is comparable with a mean oral dose of 45 mg cathinone.
Cathamines are excreted in breast milk and detected in the urine of breast-fed babies 2-4 hours after ingestion (Graziani, et al., 200.
Cardiovascular effects Khat has direct effects on the cardiovascular system causing clear increases in heart rate and blood pressure in humans (Brenneisen et al., 1990).
Brenneisen et al (1990) examined the effects of cathinone (0.6 mg/kg body weight). This dose is equivalent to approximately 25% of a normal dose.
This dose produced pressor effects (increased blood pressure) over a 2-hour period consistent with the pharmacokinetic profile for cathinone. At this dose level the pressor effects whilst statistically significant are relatively mild. It is unclear to what extent these changes are dose dependent.
These findings have been reproduced in other pharmacokinetic studies that also monitored cardiovascular changes. Significant increases in systolic and diastolic blood pressures persist for between 3 and 4 hours after the onset of chewing
khat (Toennes et al 2003; Widler et al 1994).
There is evidence of increased risk of myocardial infarction among khat users (Al-Motarreb et al., 2005), however other studies show less convincing evidence
of the links between cardiac dysfunction and khat use (Al-Hebshi & Skaug 2005: p304).
Abuse potential Using a systematic framework to assess the harm of current and future drugs of abuse, Nutt et al., (2007) ranked a range of 20 psychoactive substances in terms of social harm, physical harm and dependence potential.
The ranking system positioned khat as the least harmful substance in the group of substances evaluated in the United Kingdom by a panel of experts.
Khat is not a scheduled drug in the United Kingdom. Following from the recommendation of the Advisory Council on the Misuse Of Drugs (ACMD, 2005) khat remains a nonscheduled substance in the United Kingdom.
Although the ACMD (2005) suggested that dependence on khat was likely, the nature of this dependence was compared to a dependence on caffeine. The ACMD noted that:
“ the vast majority of people who use khat do not use in a dependent fashion and there is no evidence of more widespread drug misuse amongst khat users”.
(ACMD, 2005: p22)
Qat leaves are crimson-brown and glossy but become yellow-green and leathery as they age. The leaves are up to 5 cm wide and up to 10 cm long and emit a strong aromatic smell and have astringent and slightly sweet taste (Sawair et al., 2007).
The stimulant effect of Khat is related to the cathinone content of the leaves (Kalix, 1990).
Cathinone is metabolized rapidly to cathine (norpseudoephedrine) and norephedrine, which possess weak central stimulant properties because of their less lipophilic character (Geisshüsler and Brenneisen, 1987).
Khat is of interest as it one of a few plants that are legally consumed for their
ethnopharmacological properties.
Debates over the legal status and health effects related to consumption of this plant are currently underway in many parts of the world on account of the spread of consumption from eastern Africa resulting from migration among East African communities (Klein, 200
Current Australian regulatory considerations
The current guidelines for important khat are clearly set out.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ocs-tc-guidance-imp-khat.htm
Control status
In 1965, the World Health Organization Expert Committee on Dependence-producing Drugs' Fourteenth Report noted, "The Committee was pleased to note the resolution of the Economic and Social Council with respect to khat, confirming the view that the abuse of this substance is a regional problem and may best be controlled at that level" [1]. For this reason, khat was not Scheduled under the Single Convention on Narcotic Drugs. In 1980 the World Health Organization classified khat as a drug of abuse that can produce mild to moderate psychic dependence.
Cathine is in Schedule IV and cathinone is in Schedule I of the U.S. Controlled Substance Act. The 1993 DEA rule placing cathinone in Schedule I noted that it was effectively also banning khat:
Cathinone is the major psychoactive component of the plant Catha edulis (khat). The young leaves of khat are chewed for a stimulant effect. Enactment of this rule results in the placement of any material which contains cathinone into Schedule I.
In the UK, Cathine and Cathinone are Class C drugs. The plant Catha edulis is uncontrolled. In Germany, Cathine is a controlled substance, and ownership and sale of the plant is illegal. Similar levels of control exist throughout most other European countries.
In Australia, the importation of khat is controlled under the Customs (Prohibited Imports) Regulations. Individual users may apply for several required licenses to import up to 5kgs per month for personal use
In 2003, the total number of khat annual permits was 294 and the total number of individual khat permits was 202."
"There are two types of import permits. The single use Permit to Import can only be used once and you must request a new permit for each time you wish to import khat.
Annual Permits are labelled as such and consist of two pages. Annual Permits allow you to import up to 5 kilograms once a month for up to twelve months."
In Australia, the importation of khat is subject to regulation 5 of the Customs (Prohibited Imports)Regulations 1956 and is prohibited unless the importer holds a licence and permit issued by the Office of Chemical Safety (OCS).
A request to AQIS for data on khat license permits resulted in the release of aggregate data for license permits for the period 2003-2008. Unfortunately these permits do not contain data on the volume of khat imported.
Permits are needed for importation and a licence/permit is required for the importation of khat for personal use. Khat import permits require details on whether the permit is for fresh or dried khat.
The current licensing arrangements allow for the importation of 5kg of khat under one permit each month.
Using the 2007 data, it is estimated that an average of 33 kg was imported per permit in 2007
It is possible that if permits were renewed each month, on average it suggests that each permit could be responsible for 2.8 kg of imported khat each month in 2007.
As a projection of what could have been imported using the current licensing arrangements, it is possible that the market could have risen to 33,180 kg in 2007 if every permit was used to import 5 kg each month.
The expansion of the marketplace is substantial in the Australian community.
On the basis of this evidence, if there were significant harms (eg mental health, crime and acute health) associated with khat it certainly would have become evident in health and criminological data in this time period.
For example, a rudimentary analysis of the import data suggests that in 2007, the importation of khat supported a retail market of around $2.2 million (18,380 kg producing 73,520 two hundred and fifty gram bundles at $35 a bundle).
This estimate is based on an average import weight per permit per month of 2.8 kg. The market could expand under the current regulatory regime to $3.9 million annually, if every permit was used to import the maximum amount allowed under federal regulations.
Compared to other psychoactive drug markets, this is a very small marketplace. As a comparison, the retail heroin market in Smith Street Fitzroy alone was estimated in 2000 to be 10 Khat: a literature review worth approximately $10 million annually (Fitzgerald unpublished data).
Pharmacology
This review of the pharmacology of khat is limited to human studies. There is a substantial literature from animal studies on khat and cathinone, which have been recently reviewed (Feyissa & Kelly, 200.
Khat Catha edulis; Chaat; Gat; Kat; Miraa; Qat; Tschat
Catha edulis
Scientific classification
Kingdom: Plantae
Division: Magnoliophyta
Class: Magnoliopsida
Order: Celastrales
Family: Celastraceae
Genus: Catha
Species: C. edulis
Binomial name
Catha edulis
(Vahl) Forssk. ex Endl.
Khat (Catha edulis, family Celastraceae), pronounced "cot" and also known as qat, gat, chat, and miraa, is a flowering plant native to tropical East Africa. Believed to originate in Ethiopia, it is a shrub or small tree growing to 5–8 m tall, with evergreen leaves 5–10 cm long and 1–4 cm broad. The flowers are produced on short axillary cymes 4–8 cm long, each flower small, with five white petals. The fruit is an oblong three-valved capsule containing 1–3 seeds.
Cultivation and uses
Khat has been grown for use as a stimulant for centuries in the Horn of Africa and the Arabian Peninsula. There, chewing khat predates the use of coffee and is used in a similar social context. Its fresh leaves and tops are chewed or, less frequently, dried and consumed as tea, in order to achieve a state of euphoria and stimulation. Due to the availability of rapid, inexpensive air transportation, the drug has been reported in London, Rome, Amsterdam, Canada, Australia and the United States. The public has become more aware of this exotic drug through media reports pertaining to the United Nations mission in Somalia, where khat use is endemic, and its role in the Persian Gulf. The khat plant is known by a variety of names, such as qat in Yemen, chat in Ethiopia, jaad in Somalia and miraa in Kenya.
Khat use has traditionally been confined to the regions where khat is grown, because only the fresh leaves have the desired stimulating effects. In recent years improved roads, off-road motor vehicles and air transport have increased the global distribution of this perishable commodity. Traditionally, khat has been used as a socializing drug, and this is still very much the case in Yemen where khat-chewing is a predominantly male habit. In other countries, khat is consumed largely by single individuals and at parties. It is mainly a recreational drug in the countries which grow khat, though it may also be used by farmers and laborers for reducing physical fatigue, and by drivers and students for improving attention. This is similar to the use of the coca leaf in South America.
Khat is used for its mild euphoric and stimulating effects. Because of its anorectic effects, khat is used by some members of the Islamic faith during Ramadan, the ninth month of the Muslim year, which is spent in fasting from sunrise to sunset. It was previously only used by Muslims in Ethiopia, forbidden to those of the Orthodox faith, though today it is gaining popularity among Christians as well.
Chemistry/pharmacology
The stimulant effect of the plant was originally attributed to cathine, a phenethylamine-type substance isolated from the plant. However, the attribution was disputed by reports showing the plant extracts from fresh leaves contained another substance more behaviorally active than cathine. In 1975, the related alkaloid cathinone was isolated, and its absolute configuration was established in 1978. Cathinone is not very stable and breaks down to produce cathine and norephedrine. These chemicals belong to the PPA (phenylpropanolamine) family, a subset of the phenethylamines related to amphetamines and the catecholamines epinephrine and norepinephrine.
Pharmacokinetics
According to several early studies, on average around 100–300g of khat can be chewed in a 3-4 hour khat session (Nencini & Ahmed 1989; Kalix ,1990; 1994).
The most detailed account of Khat pharmacokinetics is reported by Toennes et al., (2003). In that study, Toennes et al., (2003) conducted a pharmacokinetic study following administration of 36–59 g of khat or approximately 0.5 mg/kg body weight.
The mucosa of the mouth is thought to be the first absorption segment, where most of the active constituents are absorbed (mean ± SD 59 ± 21% for cathinone and 84 ± 6% for cathine). The extraction of the active constituents from the leaves by chewing is very effective with only 9.1 ± 4.2% remaining as a residue after chewing (Toennes et al., 2003). Similar findings were reported in Brenneisen et al (1990) who examined the pharmacokinetics of cathinone (0.6 mg/kg body weight). The second adsorptive segment is the stomach and small intestine.
Peak plasma levels of cathinone are obtained 1.5–3.5 h after the onset of chewing khat (Feyissa & Kelly, 200. After 1-hour of chewing, plasma levels range from 40 to 140 ng/ml (mean 83 ng/ml).,
Cathinone is detectable in plasma for up to 24 hours after khat consumption. The elimination half-life is 260 min (Widler et al., 1994). Metabolism of cathinone is rapid. Only 2% of administered cathinone was found unchanged in the urine (Brenneisen et al., 1986; Nencini & Ahmed, 1989).
Blood pressures are elevated for about 3 hours after 1 hour of chewing of 0.6 g/kg, about one quarter of the amount consumed in a traditional khat session (Toennes et al., 2003). This dose is comparable with a mean oral dose of 45 mg cathinone.
Cathamines are excreted in breast milk and detected in the urine of breast-fed babies 2-4 hours after ingestion (Graziani, et al., 200.
Cardiovascular effects Khat has direct effects on the cardiovascular system causing clear increases in heart rate and blood pressure in humans (Brenneisen et al., 1990).
Brenneisen et al (1990) examined the effects of cathinone (0.6 mg/kg body weight). This dose is equivalent to approximately 25% of a normal dose.
This dose produced pressor effects (increased blood pressure) over a 2-hour period consistent with the pharmacokinetic profile for cathinone. At this dose level the pressor effects whilst statistically significant are relatively mild. It is unclear to what extent these changes are dose dependent.
These findings have been reproduced in other pharmacokinetic studies that also monitored cardiovascular changes. Significant increases in systolic and diastolic blood pressures persist for between 3 and 4 hours after the onset of chewing
khat (Toennes et al 2003; Widler et al 1994).
There is evidence of increased risk of myocardial infarction among khat users (Al-Motarreb et al., 2005), however other studies show less convincing evidence
of the links between cardiac dysfunction and khat use (Al-Hebshi & Skaug 2005: p304).
Abuse potential Using a systematic framework to assess the harm of current and future drugs of abuse, Nutt et al., (2007) ranked a range of 20 psychoactive substances in terms of social harm, physical harm and dependence potential.
The ranking system positioned khat as the least harmful substance in the group of substances evaluated in the United Kingdom by a panel of experts.
Khat is not a scheduled drug in the United Kingdom. Following from the recommendation of the Advisory Council on the Misuse Of Drugs (ACMD, 2005) khat remains a nonscheduled substance in the United Kingdom.
Although the ACMD (2005) suggested that dependence on khat was likely, the nature of this dependence was compared to a dependence on caffeine. The ACMD noted that:
“ the vast majority of people who use khat do not use in a dependent fashion and there is no evidence of more widespread drug misuse amongst khat users”.
(ACMD, 2005: p22)
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