Substance abuse

Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. The use of psychoactive substances causes significant health and social problems for the people who use them, and also for others in their families and communities. Substances of abuse include alcohol, opiates, cocaine, amphetamines, hallucinogens, prescription and over-the-counter drug abuse. (Psychoactive substances are substances that, when taken in or administered into one's system, affect mental processes).

Psychoactive substance use poses a significant threat to the health, social and economic aspects of families, communities and nations.  Globally, the prevalence of alcohol use disorders is significantly higher than the prevalence of drug use disorders. Generally, alcohol and drug use disorders are more common among males than among females. According to the World Health Organisation Report 2002 (WHO),  8.9% of the total burden of disease  is due to use of psychoactive substances; tobacco accounted for 4.1%, alcohol 4%, and illicit drugs 0.8% of the burden of disease .There are  2 billion alcohol users, 1.3 billion smokers and 185 million drug users globally (WHO 2002). These three psychoactive substances have different disease burden on different age groups. Illicit drug use causes mortality earliest in life, alcohol also mainly (65%) before the age of 60, while 70% of the tobacco deaths occur after the age of 60.

The use of different substances varies in different WHO regions as in Europe and South-East Asia tobacco use is the largest burden while alcohol is the largest burden in Africa, the Americas, and Western Pacific.

155 to 250 million people, or 3.5% to 5.7% of world’s population aged 15-64 used other psychoactive substances, such as cannabis, amphetamines, cocaine, opioids, and non-prescribed psychoactive prescription medication (WHO-2008). Globally, cannabis is the most commonly used substance (129-190 million people), followed by amphetamine type stimulants, then cocaine and opioids.

People who inject drugs (psychoactive drugs for non medical purposes) are at increased risk of HIV, hepatitis B and hepatitis C. Around 13 million people inject drugs globally and 1.7 million of them are living with HIV; injecting drug user accounts for approximately 10% of HIV infections. The estimated global prevalence of hepatitis C in people who inject drugs is 67%.

In India opioids are commonly used by IDUs. These opioids include heroin (‘smack’ / ‘brown sugar’) as well as pharmaceutical opioids (such as buprenorphine, pentazocine and dextro-propoxyphene). In the north-eastern region, heroin and dextropropoxyphene are the most commonly used opioids; impure heroin (smack), and buprenorphine are the most commonly used opioids in metropolitan cities such as Delhi, Mumbai, Chennai and Kolkata. Pentazocine is the most commonly injected opioid in Karnataka, Andhra Pradesh, Chattisgarh. In the states of Punjab and Haryana, buprenorphine is commonly used by injectors. As per the HIV sentinel surveillance report, HIV prevalence among IDUs in India is 7.2%. However, some states have much higher HIV rates among IDUs such as HIV prevalence among IDUs is 21% in Punjab, 18% in Delhi and around 12% in Manipur and Mizoram.

Psychoactive substance use by drivers has been associated with impaired driving and increased accidents risk.

Health and social problems associated with use of and dependence on tobacco, alcohol and illicit substances can be prevented by greater awareness by individuals, families and societies to use appropriate public health actions.

References-

www.who.int/topics/substance_abuse/en/

www.who.int/substance_abuse/activities/msbatlasexecsum.pdf?ua=1

www.who.int/substance_abuse/facts/en/

www.who.int/substance_abuse/facts/psychoactives/en/

www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction

www.who.int/substance_abuse/activities/en/

www.who.int/substance_abuse/ungass-leaflet.pdf?ua=1

www.who.int/substance_abuse/facts/global_burden/en/

www.who.int/substance_abuse/publications/en/Neuroscience.pdf

naco.gov.in/sites/default/files/Opiod%20Substitution%20Therapy%20Guideline.pdf

www.who.int/hiv/topics/idu/en/

http://link.springer.com/chapter/10.1007%2F978-3-7643-9923-8_10#page-2

Substance use problems can arise as a result of acute intoxication, regular use or dependence, and from the way in which substances are used. It is possible for a person to have problems from all of these.

Acute intoxication can occur as a result of a single episode of drug use. Intoxication is highly dependent on the type and dose of drug and is influenced by an individual's level of tolerance and other factors. Problems may be-

• Ataxia, vomiting, fever and confusion
• overdose and loss of consciousness
•  prone to accidents and injury
• aggressive, unpredictable behavior and violence
• unintended sex and unsafe sexual practices

The term acute intoxication is most commonly used with regard to alcohol use and in everyday speech it is called as “drunkenness". Alcohol intoxication is manifested by such signs as facial flushing, slurred speech, unsteady gait, euphoria, increased activity, talkativeness, disorderly conduct, slowed reactions, impaired judgment and motor incoordination, insensibility.

Regular use- A variety of different problems can occur from using the psychoactive substances regularly ranging from physical, mental and social problems:

• specific physical and mental health problems,
• tolerance (person no longer responds to the drug in the way that person initially responded),
• anxiety, depression, mood swings, irritability,
• criminal offences,
• relationship problems,
• cognitive problems relating to memory or attention,
• difficulties with regular job or study.

Dependent use: Dependence is usually associated with more frequent use of a substance, and at higher doses than used previously. The problems arising from dependent use of a substance can be similar to those observed with regular use, but are more severe:

• craving and increased desire to use,
• anxiety, irritability, gastrointestinal upsets and sleep problems,
• increasingly dysfunctional in daily life,
• marked tolerance,
• criminal behavior,
• relationship breakdowns,
• difficulty stopping in spite of problems,
• possible withdrawal symptoms on abstinence,
• continued use despite evidence the use is causing harms to the individual.

Injecting of any drug is associated with following risks-

• Dependence
• Overdose
• Psyscosis
• Vein collapse
•  Infection
• Local: abscesses and ulcers
• Systemic-HIV, Hepatitis C

Specific health and other problems due to individual substances

Smoking/chewing of tobacco products

• It is a risk factor for a number of serious long term health problems and increases the severity of diseases such as high blood pressure, diabetes and asthma, chronic obstructive pulmonary diseases.
• Children exposed to second-hand tobacco smoke are at increased risk of health problems such as respiratory infections, allergies and asthma.
• Pregnant women who smoke are at higher risk of miscarriage, premature labour and having a low birth weight baby.
• Tobacco use is risk factor for cancers of lung, bladder, breast, mouth, throat and oesophagus.

Alcohol consumption alcohol use contributes to a wide range of diseases, health conditions and high-risk behaviours, from mental disorders and road traffic injuries, to liver diseases and unsafe sexual behaviour.     

• Alcohol consumption at unsafe levels is a major cause of premature illness, disability and death and wide range of social problems.
• Women who consume alcohol during pregnancy are at risk of having babies with birth defects, learning and behavioural difficulties and impaired brain development.
• Liver and pancreas diseases.
• Cancers of the mouth, throat and breast.

Cannabis-The likelihood of death due to cannabis intoxication alone is very low, although combination with other drugs can result in overdose and death. Cannabis use is associated with numerous negative health consequences.

Cocaine-Cocaine is a stimulant drug. There is a significant risk of toxic complications and sudden death, usually due to cocaine’s effect on the cardiovascular system.

Amphetamine-type stimulants (ATS) can lead to a wide range of physical and mental health problems.

Inhalants cover all volatile solvents that can be inhaled or breathed in. The most commonly used volatile substances include petrol, solvents, glues, sprays, lacquers containing benzene and glues or paint thinners containing toluene. The most common way they are used is to sniff them from a container, although some may breathe them through a plastic bag. The short term effects include nausea, vomiting, headaches, and diarrhoea. Higher doses can cause slurred speech, disorientation, confusion, delusions, weakness, tremor, headaches, and visual hallucinations. Ultimately use can cause coma or death from a heart failure.

Sedatives and sleeping pills: Tolerance and dependence on sedatives or sleeping pills can develop after a short period of use, and withdrawal from these drugs can be extremely unpleasant. Withdrawal symptoms include severe anxiety and panic, insomnia, depression, headache, sweating and fever, nausea and vomiting and convulsions.

Hallucinogens: These are the group of drugs that affect the user’s perceptions of reality by distortion of one or several of the five senses (vision, hearing, smell, taste, touch) resulting in hallucinations.

Opioids: Use of street or non-prescribed opioids (heroin and opium) can cause many problems for users, particularly as they are generally injected or smoked which can create further problems for the user.

References-

apps.who.int/iris/bitstream/10665/44320/1/9789241599382_eng.pdf?ua=1

Risk factors-

Some risk factors that can influence a child for later substance abuse and other problems have their presence during different developmental periods of life. Many risk factors are related and tend to cluster together. Following are the various risk factors:

Prenatal period:

Smoking and drinking alcohol during pregnancy can affect a developing fetus with altered growth and physical development and cognitive impairments in the child.

Infancy and childhood:

Insecure attachment during the child’s first year of life can cause a child to be aggressive or withdrawn and have difficulty interacting with other children or adults. Uncontrolled aggression during early childhood can lead to poor social skills and problems during preschool period.

Lack of classroom structure in the school environment can lead to additional social and behavioral problems in children and academic failure. At the same time, they may be exposed to greater availability of drugs, drug abusers, and social activities involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other substances.

Parental abuse and neglect are commonly seen as part of the cause of drug abuse. An adolescent or pre-adolescent may be trying to gain attention from an inattentive parent or escape an abusive one by using drugs; prolonged attempts through drug use can be a cause of drug abuse.

Parental substance use can also affect child both directly and indirectly by disturbing family environment and poor parenting. There are increased chances of child abuse and neglect in such families.

Parental smoking in home can also expose children to secondhand smoke; putting them risk for health and behavioral problems as well as increasing children’s likelihood of smoking when they grow older.

Association with drug abusing peers is often the most immediate risk for exposing adolescent.

Mental illnesses can increase risk for drug abuse.

Genetic factors also influence the person’s vulnerability to addiction.

Many people use substances because they have pleasurable or desirable effects, while others may use them to block out physical or psychological pain. Some people use these substances to increase their performance, to stay awake or lose weight.

Methods of substance use-

• Injected with a needle under the skin, into a vein or muscle
• Smoked or inhaled through the mouth or nose, or inhaled by placing a bag over the head (bagging)
• Placed on a mucus membrane (such as inside the anus or vagina, the nose or under the eyelid)
• Chewed, swallowed or dissolved slowly in the mouth
• Rubbed in to the skin

References-

www.drugabuse.gov/publications/principles-substance-abuse-prevention-early-childhood/chapter-2

www.drugabuse.gov/publications/preventing-drug-abuse-among-children-adolescents/chapter-1

apps.who.int/iris/bitstream/10665/44320/1/9789241599382_eng.pdf?ua=1

www.emedicinehealth.com/substance_abuse/page3_em.htm

www.unodc.org/pdf/globalinitiative/initiative_activities_workbook.pdf

www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

In response to the overwhelming public health burden associated with psychoactive substance use worldwide, WHO experts developed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

• The ASSIST can be completed in about five to ten minutes and can be incorporated into the normal consultation at primary health care services.
• A list of substances such as tobacco products, alcohol, cannabis, cocaine, amphetamine-type stimulants (ATS), sedatives and sleeping pills (benzodiazepines), hallucinogens, inhalants, opioids, ‘other’ drugs are included in the screening test.
• The ASSIST obtains information from persons about lifetime use of substances, and use of substances and associated problems over the last 3 months.
•  It can identify a range of problems associated with substance use including acute intoxication, regular use, dependent or ‘high risk’ use and injecting behaviour.
• The ASSIST determines a risk score for each substance.
• The score obtained for each substance falls into a ‘lower‘, ‘moderate’ or ‘high’ risk category which determines the most appropriate intervention for that level of use (‘no treatment’, ‘brief intervention’ or ‘referral to specialist assessment and treatment’ respectively).

In brief the ASSIST comprises the following questions:

• Question 1 (Q1) asks about which substances have ever been used in the person’s lifetime.
• (Q2) asks about the frequency of substance use in the past three months, which gives an indication of the substances which are most relevant to current health status.
• (Q3) asks about the frequency of experiencing a strong desire or urge to use each substance in the last three months.
• (Q4) asks about the frequency of health, social, legal or financial problems related to substance use in the last three months.
• (Q5) asks about the frequency with which use of each substance has interfered with role responsibilities in the past three months.
• (Q6) asks if anyone else has ever expressed concern about the person’s use of each substance and how recently that occurred.
• (Q7) asks whether the person has ever tried to cut down or stop use of a substance, and failed in that attempt, and how recently that occurred.
• (Q8) asks whether the client has ever injected any substance and how recently that occurred.

Screening aims to detect health problems or risk factors at an early stage before they have caused serious disease or other problems, and is part of maintaining prevention practice activities in health care settings.

Reference-

apps.who.int/iris/bitstream/10665/44320/1/9789241599382_eng.pdf?ua=1

Management of substance abuse incorporates many components as it disrupts several aspects of an individual’s life. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Patients require long-term and repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery.

Principles of effective treatment should be:

• Substance abuse is treatable.
• Treatment varies depending on the type of drug and the characteristics of the patients
• Treatment needs to be readily available.
• Effective treatment must address the individual drug abuse and any associated medical, psychological, social, vocational and legal problems.
• Behavioral therapies including individual, family, or group counseling are the most commonly used forms of drug abuse treatment.
• Medications are an important element of treatment for many patients (such as alcohol, nicotine, heroin or other opioids), especially when combined with counseling and other behavioral therapies.
• An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
• The appropriate duration of treatment for an individual depends on the type and degree of the patient’s problems and needs. Usually recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment.
• Several sub groups within the larger population of individuals affected by drug use disorders such as adolescents, women, pregnant women, people with medical and psychiatric co-morbidities, sex workers, and socially marginalized individuals, prisoners often require targeted and specialized care.
• Target populations, their families, community members and local organization should be actively involved in the planning, implementation and monitoring of drug dependence treatment services.
• As drug related crimes are highly prevalent, there should be coordination between drug dependence treatment and criminal justice system for such individuals.

References-

www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/preface

apps.who.int/iris/bitstream/10665/44320/1/9789241599382_eng.pdf?ua=1

www.unodc.org/documents/drug-treatment/UNODC-WHO-Principles-of-Drug-Dependence-Treatment-March08.pdf

The damage caused by substance abuse depends on the type of drug abused and the duration of abuse. The following factors also influence the severity of the problems that follow drug abuse:

Age: The damage is greater among adolescents as well those who are above 50 years of age.

Nutrition status and living conditions: Poor quality and inadequate quantity of food, unhygienic living conditions and poor access to health care increase the problems caused by drug abuse.

Health condition prior to abuse: The damage is less among individuals whose physical condition is good, as compared to individuals whose health was poor even before the onset of addiction.

Genetic loading factor: A family history of a specific medical or psychiatric problem makes the individual more susceptible to the same problems in comparison to another drug abuser who is not genetically prone to the disorder.

Medical and psychiatric complications due to substance abuse:

a)Problems due to intoxication

• Trauma or other physical injury: Mood changes caused by drugs reduce inhibitions as well as increase negative feelings leading to violence.
• Driving vehicles or operating machinery under the influence of alcohol/ drugs causes accidents and injury.
• Poor judgment and poor coordination can cause physical injury or even death.
• Perceptual distortions can also result in accidents.
•  Acute intoxication reaction.
• Coma and overdose deaths.

b) Problems due to withdrawal-Physical withdrawal symptoms of varying intensity occur as part of withdrawal.

c) Psychiatric disorders associated with substance abuse-Psychoactive substances can induce psychotic disorders during or immediately after use such as cannabis.

d) Systemic disorders associated with substance abuse

Dermatological complications-

• When the same vein is used to inject the drug, repeated injections leave marks on the vein. The discoloration along the vein leaves dark lines called needle tracks.
• Tattooing and scarring in IV drug users at injecting site.
• Use of infected needles can cause infection at the injection site.
• Pruritis and dermatitis

Cardio-vascular complications-

• Infection in the heart
• Blocking circulation: Repeated injections at the same site can cause blood clots or air bubbles (emboli) that can block the blood supply in the veins.
• Ventricular fibrillation: This may lead to hemorrhage and sudden death.

Pulmonary complications

• Embolus formation
• Pulmonary oedema
• Aspiration pneumonia
• Pharyngitis, bronchitis, pneumonia and tuberculosis are common infective respiratory diseases among drug abusers.

Hepatic complications

• Hepatitis: Hepatitis B, C & D are blood borne infections that can be transmitted through sharing of needles.
• Alcoholic hepatitis
• Fatty liver
• Alcoholic cirrhosis
• Hepatic trauma

Complications in the reproductive system

• The incidence of sexually transmitted diseases is higher among drug abusers.
• Drug abuse can reduce sex drive and cause impotence.
• Reduced ovulation and menstrual abnormality are seen among female drug abusers.
• Children born to mothers who abuse drugs and alcohol during their pregnancy usually have low birth weight and other problems in their physical and mental development.

Neuromuscular complications

• Cerebrovascular accidents
• Dementia
• Neuritis
• Bacterial meningitis

Haematopoietic complications

• Reduced count of platelets in the blood may lead to bleeding disorders.
• Bone marrow depression: The count of both white and red blood corpuscles may fall.
• Poor nutritional status can cause anemia, especially among alcoholics.

Endocrine system disorders

• Ganja, opiate and alcohol abuse lowers the testosterone levels in the body,
• Incidence of diabetes mellitus increases among alcoholics.

Renal function disorders:

• Damage to renal cells cause nephropathy.

Gastro-intestinal disorders

• Gastritis (inflammation of the lining of the stomach) and peptic ulcers can develop due to poor food habits as well as due to the effect of the drugs abused.
• Acute and chronic pancreatitis.
• The incidence of cancer all along the gastro intestinal tract from the mouth to the anus is higher among alcoholics.

Cancer-

As most drug and alcohol abusers also abuse tobacco products, the risk of cancer is high.

References-

www.unodc.org/pdf/india/publications/DAIIM_Manual_

www.who.int/substance_abuse/facts/alcohol/en/

WHO has recommended the prevention of substance abuse as primary prevention, early intervention, treatment, care, recovery, rehabilitation and social reintegration measures, along with measures aimed at minimizing the adverse public health and social consequences of drug abuse.

• Successful prevention of substance use and risk reduction is thus an essential approach to achieve better public health outcomes in following disorders:
• The prevention of substance-induced mental disorders and
• reductions in injuries and violence (traffic and domestic injuries, child abuse, and gender-based, sexual and other violence),
• reduction in  communicable diseases such as HIV, viral hepatitis and tuberculosis, sexual and reproductive health problems (sexually transmitted infections, unplanned pregnancies and complicated pregnancies) and
• reduction in noncommunicable diseases (such as cancer, cardiovascular diseases and liver diseases).

Prevention of drug abuse can be achieved by-

i) To take effective and practical primary prevention measures that protect people, in particular children and youth, from drug use initiation:

• by providing them with accurate information about the risks of drug abuse,
• by developing supportive parenting and healthy social environments and
• by promoting skills and opportunities to choose healthy lifestyles and
• by ensuring equal access to education and vocational training;

The family is the strongest factor in protecting children from drug use and other risky behaviour. Families that are happy communicate openly and provide a healthy environment and a positive future for their children.

Schools can cultivate sound values in their students in relation to health and drug use through the development of knowledge and providing them with coping skills to face situations which can lead to drug abuse. It is also necessary to target those who are not in school. Therefore, outreach efforts on the streets are often helpful.  

Workplace: Employers can promote the health of employees by preventing substance abuse and assisting those with a drug dependence problem.

ii) To take effective measures to prevent progression to severe drug use disorders through targeted interventions for people at risk for such progression.

iii) Raising awareness of drug-driving and its impact on road safety including deaths, injuries, property damage and harm to other road users among the general public. Policy-makers can reduce drug-driving by enforcing drug driving laws. It is important not only to enforce drug driving laws but also to counsel and, when appropriate, treat drivers found to be impaired by drugs; especially those who are repeat offenders or those with drug-use disorders.

iv) Mass media can play an important role in substance abuse prevention. They can be used to raise awareness concerning not only the dangers of drug abuse but also the dangers of specific practices such as injecting drugs.

National Programmes related to prevention of substance abuse:

Ministry of Health and Family Welfare (MoHFW) and Ministry of Social Justice and Empowerment (MSJE), Government of India are involved with alcohol and drug demand reduction policies and drug de-addiction programme (DDAP) in the country. Under the DDAP de-addiction centres have been established in association with various District Hospitals and psychiatry departments of Medical Colleges. The centre at All India Institute of Medical Sciences, Delhi (AIIMS) has been designated as the “National Drug Dependence Treatment Centre” (NDDTC) and functions as a resource centre for the DDAP of MoHFW, GoI.

Various E- Health web based programmes related to prevention of substance abuse such as alcohol e-Help (alcoholwebindia.in/intervention) operated by NDDTC,AIIMS, Delhi (alcoholwebindia.in/) and m-Cessation programme (nhp.gov.in/quit-tobacco) for tobacco cessation have been initiated by MoHFW, GoI.

National AIDS Control Programme (NACP),MoHFW, GoI has implemented various targeted interventions programme for IDUs such as Needle syringe programme, Opioid substitution therapy.

The MSJE, GoI, has formulated the central sector scheme of assistance for prevention of alcoholism and substance (drugs) abuse and social defence services which has been updated in 2015.

The Department of Revenue, Central government acts as administrator of the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985 and the Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act, 1988;

The Narcotics Control Bureau, Ministry of Home Affairs, GoI functions as an enforcement agency for NDPS Act.

Tips for prevention of substance abuse: youth

• Don’t be afraid to say no.
• Connect with your friends and avoid negative peer pressure.
•  Make connections with your parents or other adults.
• Get educated about alcohol and drugs.

References-

apps.who.int/gb/ebwha/pdf_files/WHA69/A69_12-en.pdf?ua=1

www.who.int/substance_abuse/activities/global_initiative/en/

www.unodc.org/docs/youthnet/Brochures/Families_First_Brochure.pdf

www.unodc.org/pdf/youthnet/handbook_school_english.pdf

www.unodc.org/unodc/en/prevention/workplaceprevention.html

apps.who.int/iris/bitstream/10665/249533/1/WHO-MSD-NVI-2016.01-eng.pdf?ua=1

mohfw.nic.in/index1.php?lang=1&level=0&linkid=229&lid=1353

www.dtc-scheme.in/pdf/scheme-document.pdf

naco.gov.in/sites/default/files/Opiod%20Substitution%20Therapy%20Guideline.pdf

socialjustice.nic.in/writereaddata/UploadFile/sch-drug-1115635790509608217343.pdf

dor.gov.in/sites/upload_files/revenue/files/NationalPolicyonNDPS.pdf

www.unodc.org/documents/drug-prevention-and-treatment/UNODC_2016_

www.ncadd.org/about-addiction/underage-issues/ten-tips-for-prevention-for-youth