Drug addiction

A 'Drug' is defined by the World Health Organization (WHO) as any substance that, when introduced into a living organism may alter or modify one or more of its functions. This definition conceptualizes 'drug' in a very board way, including not only the prescribed medications but also all other pharmacologically actives substances.

A 'psychoactive substance' is a substance that is capable of altering the mental functioning of an individual. Such substance when used brings changes in individual's consciousness, behavior, thinking, mood, perception, judgment and insight. The terms 'drug addiction' and 'drug addict' have been dropped from scientific use due to their derogatory connotation. Instead terminologies like 'substance abuse', 'substance dependence', 'harmful use' and ' psychoactive substance use disorder' are used now a days. Licit drug are legal and easily available in the market and their use per se is not legally prohibited, e.g. different medications, tobacco, alcohol, coffee, tea, and solvent. Illicit drug are illegal and not available in the local market. Production, procession, trafficking, buying, selling and use of these drug is illegal, e.g. heroin, cocaine, buprenorphine, cannabis etc

Many mental and behavioral disorders can be cause due to use of one or more psychoactive substances.

·      Substance (Drug) Abuse is a serious public health problem in Nepal.

·      It is estimated that there are about 70,000-drug user in Nepal and about 35,000 of the total estimated drug are IDUs (Inject able Drug User). 40% of the IDUs are said to be infected with HIV. 90% of the using substances are under the age of 30(population under risk)

Important clinical conditions associated with psychoactive substance use

i.                Acute intoxication: It is the condition following administration of any psychoactive substance, resulting in disturbances in level of consciousness, thinking, perception, mood, behavior or other psycho-physiological function and responses. It may be uncomplicated with bodily injuries, delirium, convulsion or coma.

ii.              Harmful use: It is a pattern as psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis) or (e.g. depression).

iii.             Dependence syndrome: This is the state also commonly know as "drug addiction". It is a condition in which the use of substance taken on a much higher priority for a given individual than all other he/she used to value more. The key feature is a compulsion to use substances. Other features are tolerance; withdrawal and uses of substance to received or avoid withdrawal symptoms. A dependent individual's increasing focus on seeking behavior leads to progressive loss of other interests, focus on drug seeking behavior leads to progressive loss of other interests, neglect of self care and social relationship and disregard for harmful consequences.

iv.            Withdrawal syndrome: Its is a group of symptoms occurring on absolute or relatives withdrawal of a substance after repeated and usually prolonged use in usually high doses. It is time limited, and requires medical treatment. It is one of the indicators of the presence of dependence syndrome.

v.              Substance induced psychiatric disorders: Substance can lead to many of psychiatric disorder including psychosis, depression, anxiety, sleep disturbance, sexual dysfunctions etc.

Types of abused substances

·      Depressants: These substances slow down the activity of the brain. E.g. Alcohol, Barbiturates, Benzodiazepines - diazepam (Valium), nitrazepam etc.

·      Stimulant: They increase the activity of the brain / CNS. E.g. Cocaine, Amphetamine, Tobacco (the active substance in tobacco is nicotine)

·      Narcotic analgesics: These are substances obtained from opium or synthetic (artificial) opium substitute that has opium like effects. E.g.-Opium (ckmLd_, Morphine, Codeine (active component in Phencidyl), Pethidine, Heroin (Brown sugar / white sugar / smack), Pentazocine (Fortwin), Buprenorphin (Tidigesic), Proxyvon etc.

·      Hallucinogens: These substances predominantly produce perceptual disturbances including hallucinations. E.g. LSD, Cannabis - Bhaang (efË), Gaanja (ufFhf), Hashish, Chares (r/];)

·      Volatile inhalants: These substances are inhaled to produce the desired effects. E.g. Adhesive glues (dendrite), paint thinners, correcting fluid, shoe police etc.

Commonly abused substances in Nepal are Alcohol, Nicotine, cannabis, narcotics and benzodiazepines

Few users of any substance become dependent. The estimated proportions of exposed individuals who become dependent on substances are:

·      Nicotine> 30%

·      Opioids --25%

·      Alcohol -- 10-15%

Major risk factors for substance abuse

·      Family disorganization

·      Parental Neglect

·      Parent child conflict

·      Poor discipline

·      Peer group pressure / influence

·      Isolation - lack of emotional support

·      Over protection by parents

·      Repeated failures

·      Personality problems

Why people take psychoactive substances?

·      For excitement and pleasure

·      When in depression

·      To be 'fashionable" / be one among the crowd

·      To be different

·      To escape form problems

·      To see what it is like / curiosity

·      When bored

·      As a break from work

Causes of substance dependence (Drug addiction): Substance dependence is a multifactor and complex phenomenon. Different pharmacological, environmental, social and psychological factors play an important role in one or the other way in the initiation and maintenance of drug seeking behavior:

a.              Pharmacological factors: pain relief, relief from cough, fatigue, obtaining highly pleasurable effects, obtaining intensive sensory and perceptual experiences, enhancing self esteem through "highs" produced y some substances are some of such factors leading to substance seeking behavior and dependence.

b.             Environmental factors: These include-

          Easy availability of substance - Easy availability leads to more frequent use of substances and dependence

             Inverse relationship of price and rate of use -Thus, if the prices of substances are low, the rte of use will be more. Effects of mass media

c.              Social factors:

i.           Home and family environment — Interpersonal or parent child conflicts, parental neglect resulting from large families and (or extensive employment or overtime work of parents), poor parenting skills and family disorganization are of some of the factors which lead to two important weaknesses in the family system:

a)         The unhappy life experiences of the individual, and

b)        Lack of care and supervision for the young ones

          The results in individuals felling dissatisfied, frustrated, anxious, insecure, fearful and even hostile in the home or family.

ii.         Peer group pressure: This is an importance social factoring the beginning of substance use. It initiates substance use because of:

-       Social acceptance

-       Encouragement of friends

-       With friends

-       The desire to go along with crowd

-       Peer values

iii.        Sub-cultural factors: These include characteristics of modern living, integration into the student subculture and "pop culture" of loose morals and declining social values.

D.        Psychological factors:

i.  Personality disturbances - certain personally make ups or traits predispose an individual to develop substance dependence. E.g.Anxious, always stressed, depressive, fearful of competition, antisocial, always in despair, low self esteem, inability to face the reality of life

ii.Escape mechanism - Substance may be used by an individual as a means of escaping from frustration, problems, from reality and something undesirable

iii.        Satisfying curiosity or becoming adventurous

iv.       Hedonism - using drugs for fun, "kick" or "high"

v.         Symbol of rejection- Substance may be used as a means of rebellion against conventional, social and traditional values, or as a means of expressing hostility against authority and parental figures, instauration or society.

vi.       Substance may be used to achieve a sense of belongingness or to express independence.

Commonly used substances

Opioids

Opium is derived from the Opium poppy plant (Papaver somniferous), containing more than 20 alkaloids. In use for more than 3500 years in the forms of crude opium and alcoholic solutions of opium. Major opioids in use include Morphine, Codeine (active ingredient in phencidyl), Heroin (Brown Sugar/ Smack), Buprenophin (Norphin/ Tidigesic), Pentazocin (Fortwin) and Dextropropoxyphene (Proxyvon)

The most commonly abused opioids is Heroin.

Routes of ingestion:   

·      Oral

·       Chasing (Intranasally)/sniffing

·      Intravenous injections

·      Subcutaneous injections

Effect on use

·      Euphoric rush

·      Feeling of warmth / facial flushing

·      Dry mouth / Heaviness of extremities following by sedation (also called Nodding off)

·      Occasional low mood / Nausea and vomiting

·      Decreased respiratory rate

·      Change in blood pressure and heart rate

Effects of acute opoid withdrawal

·      All opioids have following withdrawal symptoms in common:

·      Pin& muscle cramps, dysphoria, restlessness, craving for opioids, insomnia, papillary dilatation, anxiety, irritation, yawing

·      Nausea, Vomiting, diarrhea, bowel cramps, bone pain

·      Sweating, piloerection (goose flesh), running nose, excessive lacrimation

·      Raised blood pressure, increased heart rate

Withdrawal symptoms usually being within 12 hours of last does, peak in 24-36 hours, subside in 72 hours and disappear in 1-2 weeks, but this may differ according to the type of opioids used.

 Adverse affects of opioids use

·      Potential transmission of hepatitis B and C / HIV

·      Idiosyncratic allergic reactions — anaphylactic shocks, pulmonary edema

·      Skin popper- lesions in skin consisting of circular depressed scars and underlying chronic abscesses

·      Cellulites

·      Thrombophlebitis

·      Endocarditic

·      Septicemia

·      Gangrene

·      Nutritional

·      Overdose (intentional / accidental)

·      Accident / Death

Treatment of opioids use

1.         Detoxification: Medical detoxification deals with withdrawing a patient safely from physical dependence on substances. It takes nearly 10-15 days for a person t recovers physically from the discomfort of substance withdrawal.

2.         Replace prevention: Replace is a process that begins long before a person reuses substances. Relapse shows some failure to develop defective's ways of dealing with daily stress. Majority of substance of substance users go into relapse. Relapse can be prevented by:

·      Understanding and anticipating the possibility of relapse

·      By recognizing and handing risk situations

3.         After Care:             This is designed to maintain the gains, which the patient has made in treatment and rehabilitation. This offers safe environment for continued support until no longer required.

Different means of aftercare include:

·      Counseling

·      Self help group for abstinence - Alcohol anonymous (AA), Narcotic Anonymous (NA)

Recovery in a patient with substance abuse means signification behavioral change, which include:

·      Change in habits

·      New skills are learnt

·      New social, family and work expectations are defined and met

·      Responsibility taken for change oneself

·      Relapse prevention strategies are developed.

Cannabis

   It is the generic name given to the drugs containing plant product of hemp (Cannabis sativa). Bhaang -efË_, Gaanja-ufFhf_, Hashish, Chares-r/];_ are the derivatives of the same plant.

Psychiatric consequences of cannabis use

i)          Acute intoxication: The features include-

·      Euphoria or apathy

·      Perceptual distortion, illusions hallucination

·      Suspiciousness

·      Increased appetite

·       Dry mouth, red eyes

·      Increased heart rat

ii)              Flashback phenomena:

             Re- experiencing the perceptual symptoms that occurred during acute intoxications even when the person is not using cannabis

iii)            Cannabis induced psychotic disorder

iv)            Cannabis induced anxiety disorder

Benzodiazepines

These include medications like Alprazolam, Lorazepam, Nitrazepam, Which are abused. Tolerance Occurs after a minimum of 3-4 weeks of daily use. The features of benzodiazepine withdrawn are similar to alcohol withdrawal. Treatment is gradual Withdrawal of the drug and counseling

 

Evaluation of substance use disorder:

Objectives when taking a history of substance use:

Its is necessary to determine:

·      What substance a patient currently use

·      What substance a patient has used in the past

·      How the patient has used these substances

·      If this patient is dependent upon these substances

·      If the substance use is causing problems (Medical, Family, social relationship, employment, financial)

·      How to patient feels about their substances use

How t identify a person abusing substances

·      Physical evidence:

·      Order of marijuana (like burnt rope) in room

·      Use of room deodorizers

·       Marijuana cigarettes (rolled and twisted at each end)

·      Butt or "roach" (end of marijuana cigarettes)

·      Power, seeds, leaves, plants

·      Capsules or tables

·      Cigarette rolling paper

·      Small spoons, razor blades

·      Unfamiliar small containers or locked boxes

·      Small glass vials

·      Used syringes / needles

Physical symptoms:  

·      Acting intoxicated

·      "Blood shade" or red eyes

·      Drooping eyelids

·      Imprecise eye movement

·      Wearing sunglasses at inappropriate times

·      Abnormally pale complexion

·      Frequent persisting illnesses, sniffles, and cough

·      Change in sleep pattern such as insomnia, napping or sleeping at inappropriate times

·      Neglect of personal appearance and grooming

Behavioral changes;

·      Unexplained periods of moodiness, depression, anxiety, irritability, hypersensitivity or hostility

·      Strongly inappropriate over reaction to mild criticism or simple requests

·      Decreased interaction and communication with other

·      Loss of interest in previously important things such as hobbies or sports

·      Loss of motivation and enthusiasm

·      Lethargy and lack of energy

·      Lose of ability to assume responsibility

·      Need for instant to gratification

·      Change in value, ideas and beliefs

·      Change in friends, unwillingness to introduce friends

·      Withdrawal from family and social isolation

·      Spending long times in bathroom

·      Persistent lying and stealing

Change in relation to students:

·      Decrease in academic performance, decline in grades

·      Decreased short term memory, concentration and attention

·      Loss of motivation and interest for participation in activities

·      Frequent absenteeism

·      Less interest in participating in classes and meetings

·      Untidy appearing, dress, personal hygiene

·      Slow to respond, forgetful and apathetic

·      Increased disciplinary and behavioral problems

·      Change the peer group

·      Disappearance of money and other items of value from home.

Tips to parents for preventing substance use:

·      Do not quarrel in front of children

·      Spend more times with children

·      Make your children feel that you are their parents and as wells as a friends

·      Try to know the friends of your children

·      Encourage your children to practice moral values

·      Try to practice what you teach to them

                                                                           Dr C P Sedain,Neuropsychiatrist,

                                                                            Chitwan med college

,                                                                Bharatpur,Nepal