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.
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-
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:
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:
Injecting of any drug is associated with following risks-
Specific health and other problems due to individual substances
Smoking/chewing of tobacco products
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.
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.
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:
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-
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).
In brief the ASSIST comprises the following questions:
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.
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:
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
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
Complications in the reproductive system
Endocrine system disorders
Renal function disorders:
As most drug and alcohol abusers also abuse tobacco products, the risk of cancer is high.
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.
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:
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