Drug Deaddiction

Contents

Preface
Foreword Acknowledgements

1. Drug De-addiction Programmes in India

2. Assessment and Diagnosis in Substance Use
Disorder

3. Epidemiology of Substance Use

4. Acute Effects of Alcohol, Opioid and
Cannabis Use

5. HealthHazardsofLongTermAlcohol,Opioid
and Cannabis Use

6. Treatment Principles and Issues in Manage-
ment of Substance Use Disorder
– An Overview

7. Pharmacotherapy of Substance Use Disorder

8. Long-Term Treatment of Opioid Dependence
Syndrome

9. Psychosocial Treatment in Substance Use

10. Community-based Treatment of Substance Use Disorder

11. Nicotine Dependence
12. InterventionwithTreatmentNonSeekers 13. Role of Laboratory Services in Substance

Use Disorder
14. Prevention of Substance Abuse in India 15. Management of Substance Use Disorder in

Primary Care
16. Comorbidity in Substance Use Disorder 17. Substance use disorder in Women
18. Adolescent Substance Abuse
19. Legal Aspects of Drug Abuse in India

List of Contributors Disorder Glossary

Appendix 1 Appendix 2 Appendix 3 Appendix 4

Appendix 5 Appendix 6 Appendix 7 Appendix 8

We look forward to any suggestions for improvement and changes.

Preface

It is indeed a pleasure to be associated with the task of compiling the manual for the World Health Organization (India) and the Ministry of Health and Family Welfare (Government of India). This manual is a product of intense deliberations and the felt need to revise the course materials for training of General Duty Medical Officers being conducted as a part of training programmes undertaken by the Ministry of Health and Family Welfare (Government of India) at various apex institutes across the country. It is intended to cover as many areas as can be envisaged. There may be some degree of overlap in the information given between chapters, which the editors have not deleted in order to maintain the coherence of individual chapters. Any suggestions for topics that have not been covered and are important may be informed so that they may be addressed in the revised version.

Though intended to be used primarily by the GDMO’s, this manual may also be useful for others who are involved in the care of patients with substance use disorders.

Rakesh Lal Ravindra Rao Indra Mohan

October 2005

Foreword

Substance Abuse is a complex problem having medical and social ramifications which impacts all social strata. It affects not only the user and their families but all sections of the society. Controlling substance abuse by way of demand reduction, provision of treatment services etc. has been a matter of priority for the Ministry of Health and Family Welfare for many years now.

Recognizing that there is a paucity of experts in this field, the Ministry has made efforts so that in each State and Central Government Health Institutions, General Physicians are sensitized and trained to combat the problem. The task of managing this training was entrusted to the National Drug Dependence Treatment Centre, AIIMS which has been conducting regular courses for medical officers on the subject of Substance Abuse for the past 15 years. A Manual had been developed to assist the GDMO’s undergoing training in 1999.

Due to the rapid advancements in this field, a need to revise the existing manual became neces- sary. I congratulate the National Drud Dependence Treatment Centre, AIIMS for bringing out this new edition of the training manual. I am sure it will be a useful tool for all persons con- cerned with the treatment and care of patients of Substance Use Disorder.

Rita Teaotia

Joint Secretary
Ministry of Health and Family Welfare

Acknowledgements

In the road to putting this manual together there were a number of persons and agencies that helped. At the outset I would like to gratefully acknowledge the funds provided by the World Health Organization (India). I would like to especially thank Dr Cherian Varghese at the WHO (I) who has been a guiding force all through. Thanks are also due to the Drug Abuse Cell at the Ministry of Health and Family Welfare (Government of India) for the support and encourage- ment. Special mention must be made of the Joint Secretary, Ms. Rita Teaotia and Director, Mr Rajesh Bhushan.

Acknowledgemnts are due to the Director as well as to the Dean, All India Institute of Medical Sciences for permission to carry out the work.

Professor Rajat Ray, Chief, National Drug Dependence Treatment Centre deserves special grati- tude for being the constant guide and critic and without his tireless assistance this work would not have been possible.

Acknowledgements are also due to the participants of the National Workshop where the course materials revision was discussed and finalized.

This work would just not have been possible without the timely help of the contributors and special thanks are due to each and every one of them.

My associate editors, Dr. Ravindra Rao and Dr. Indra Mohan deserve special mention of grati- tude for their tireless support and help in putting this case-book together.

Rakesh Lal

Drug De-addiction Programmes in India

Rajesh Bhushan

I. The context

. 1.1 The constitution of India under Article 47, enjoins that the state shall endeavor to bring about prohibition of the con- sumption, except for medical purposes, of intoxicating drinks and of drugs which are injurious to health. The various drug de-addiction programmes of Government of India have to be seen in this light. The Government of India, Ministry of Health and Family Welfare in 1976 appointed a high powered committee to examine the problem of Drug De-Addiction and sug- gest future guidelines. The report of this high powered committee was submitted in 1977 and was laid on the floor of the Parliament. The Planning Commission and the Central Council of Health Min- isters reviewed this report in 1979. The recommendations of the report empha- sized the need to evolve appropriate strat- egies and to bring about better coordina- tion among different Ministries and De- partments working in this area. The Plan- ning Commission and the Central Coun- cil of Health Ministers accepted this.

. 1.2 Drug addiction entails high cost to hu- man health, social fabric and economy. In addition, Drug addiction has come to represent yet another danger over the past decades. This comes from the role which drug use plays in the spread of HIV/AIDS. It was in this context that the Drug De- addiction Programme in the Ministry of Health & Family Welfare was started in the year 1987-88.

. 1.3 In the area of Drug De-addiction and drug trafficking, the control on illicit drug trafficking and its production in India as well as coordination with international agencies is the responsibility of Ministry of Home Affairs. Rehabilitation of addicts as well as their counseling is the responsi- bility of Ministry of Social Justice & Em- powerment. Demand reduction by way of treatment and after care is the concern of Ministry of Health & Family Welfare. The Drug De-addiction Programme of the Ministry of Health & Family Welfare was started in 1987-88, which was modified in 1992-93 as a scheme under Central sector assistance to States.

. 1.4 The role of Ministry of Health & Family Welfare in the area of Drug De-addiction is demand reduction by way of providing treatment services. Under the scheme a one time grant in aid of Rs. 8.00 lakhs is given for construction of Drug De-addic- tion Centres and a recurring grant of Rs. 2.00 lakhs is given to Drug De-addiction Centres established in North Eastern Regions. At present 122 such Centres have been established across the country including centres in Central Government hospitals and institutions. 43 such Cen- tres have been established in the North Eastern Region. The six Drug-addiction Centres established in Central Govern- ment hospitals and institutions are at All India Institute of Medical Sciences, New Delhi, Dr. RML Hospital, New Delhi, Lady Hardinge Medical College, New

Delhi, PGI, Chandigarh, JIPMER, Pondicherry and NIMHANS, Bangalore. A national nodal centre has been estab- lished under the All India Institute of Medical Sciences (AIIMS), New Delhi. This is located in Ghaziabad and has been designated as “National Drug Dependence Treatment Centre.”

II. National Drug Dependence Treatment Centre, AIIMS

2.1 National Drug Dependence Treatment Centre, AIIMS was established during the year 1987-88 and was functioning at Deen Dayal Upadhyay Hospital, Hari Nagar.This has subsequently been shifted to its own building constructed at CGO Complex, Kamala Nehru Nagar, Ghaziabad. It started outdoor facilities from 14.04.03 and indoor facilities on 2.12.03. A Community Clinic was estab- lished at Trilokpuri and this started func- tioning from 1.8.2003. Apart from ren- dering patient-care services, the centre is engaged in a number of research projects.

III. Drug De-addiction Centre, PGI Chandigarh:

3.1 Drug De-Addiction Centre, PGI Chandigarh was established during 1988- 89. The Centre has facilities for both out- door and inpatient services. Additionally, it conducts drug-de-addiction awareness programmes, treatment camps, counsel- ing and provides free medication.

IV. Drug De-addiction Centre, National In- stitute of Mental Health & Neuro Sciences, Bangalore

4.1 Drug De-addiction Centre at NIMHANS, Bangalore was established during the year 1991. This Centre is func- tioning as a Regional Centre. A separate building has been constructed with a cost

of Rs. 5.10 crores and currently houses 30 in patient beds. The centre conducts therapeutic group sessions for both inpa- tients and outpatients.

4.2 The De-addiction Centre caters to more than 50% of the patients seeking treat- ment for substance abuse problems in the city of Bangalore. The Centre also treats patients from different parts of Karnataka, Andhra Pradesh, Tamil Nadu and Kerala. Referrals are also received from other states of the country including the North-East- ern States. Recently there have been sev- eral referrals from countries in the SAARC region and other countries as well.

V. Convergence:

. 5.1 In a meeting held on 6.10.04 in the chamber of Joint Secretary, Ministry of Social Justice & Empowerment, it was decided that an effective linkage between the rehabilitation centres managed by NGOs funded by the Ministry of Social Justice could be established with the treat- ment centres supported by the Ministry of Health. The collaboration would be through the following modalities:-

. 5.2 Identification of NGOs to be linked with Drug De-addiction Centres would be done, Drug De-addition Centre wise. This action would be initiated and completed by Ministry of Social Justice and Empowerment.

. 5.3 NGOs would recommend cases requiring treatment for Drug De-addiction to the Drug De-addiction Centres. The Drug De-addiction Centres in turn would re- fer patients after completion of treatment to identified NGOs for rehabilitation and monitoring.

. 5.4 Apart from detoxification services, which are provided by the Drug De-Addiction

Drug De-addiction Programmes in India

Centres run by Ministry of Health and Family Welfare, the counseling of patients and their families would commence along with the treatment. Ministry of Social Justice and Empowerment would consider funding one counselor in each Drug De- Addiction Centre run by the Ministry of Health and Family Welfare.

5.5 All Health Secretaries of State Govern- ments have been requested for issuing necessary directions to the Drug De-ad- diction Centres in this regard.

VI. Evaluation

6.1 Under the Drug De-addiction Programme, so far 114 Drug De-addic- tion Centres have been established in vari- ous States. On the request of the Minis- try, WHO has provided funds for the evaluation of centres. Evaluation of these Centres have been done by National Drug Dependence Treatment Centre, AIIMS on the following parameters

. (a) to assess the status of functioning of Gov- ernment De-addiction centres by assess- ing the patient load

. (b) treatment being provided

. (c) availability and utilization of

equipment
(d) staffing in terms of posts available and filled
(e) on-site interview and
(f) review of records of de-addiction centres.
The evaluation had focussed on the states of Manipur, Nagaland and Rajasthan. The evaluation findings have served as a valu- able input into the reformulation of the National Drug De-addiction Programme which is under consideration of the Min- istry.

VII. Five Year Plan Outlay

7.1 Approved outlay for 10th Five Year Plan in respect of this programme is Rs. 33.00 crores, the break-up of which is given below:-

Rs. in crores

Drug De-addiction Programmes in India

Year

Outlay

2002-03 2003-04 2004-05 2005-06 2006-07

7.00 6.50 6.50 6.50 6.50

Total

33.00

Assessment and Diagnosis in 2 Substance Use Disorder

Ravindra Rao, Indra Mohan, Rakesh Lal

Summary

Assessment forms the cornerstone in diagnosis and management of substance use disorder. The chapter is divided into two parts – assessment and diagnosis. The assessment part begins with the discussion on necessity of assessment fol- lowed by stages, settings and levels of assess- ment. Finally it is described how the assess- ment is carried out (tools of assessment). In this chapter emphasis is given on the clinical tool(history and examination), as the labora- tory investigation to aid in assessment is dealt with elsewhere.

The diagnosis section begins with the mean- ing of some commonly employed terms, fol- lowed by description of the criteria for ‘depen- dence’ and ‘harmful use’.

Assessment

Substance use disorder (SUD) affects individu- als across various strata of society. The preva- lence of SUD including alcohol, tobacco is high in general population across the world includ- ing India.

Though there are experts in deaddiction cen- tres to treat such patients, the fact remains that only a handful of patients are treated in these centres. Often deaddiction centres are the last point of contact in the patients’ chain of treat- ment seeking. In contrast, primary care physi- cians are often contacted initially for a number of physical problems associated with drug use. Thus physicians should have knowledge of

treating patients in their setup.

A proper assessment is necessary for treatment. It is also helpful in numerous other ways including:

b ) c) d) e)

Screening of patients who may present only with physical problems but do not reveal drug use by themselves.

Establishing a diagnosis
Planning treatment
Referral to a specialist for further treatment

Assessment also serves to establish rapport and motivate client towards seeking treat- ment/ reduce harmful use/ abstinence.

Assessment is not a one time phenomenon. This is carried out at various stages. Thus, the stages of assessment include

. a) Preintervention: where the purpose of assessment is to define the problem, formulate treatment, select an appropriate treatment from various modalities and motivate clients for treatment.

. b) Intervention: here assessment is done to monitor progress

. c) Post intervention: assess maintenance and abstinence status.

Depending on the reasons for assessment and the settings in which the assessment is being carried out (inpatient v/s outpatient), there can

be various levels of assessment. This can range clinical decision regarding treatment and reas- from brief screening and basic assessment for sessment for continuing care.
diagnosis to specialized assessment for taking

Stages of Assessment 1. Preintervention 2. Intervention
3. Post intervention

Screening:

An initial function of assessment is identifying individuals who may either have a substance use problem or is at risk of developing one. Screening is usually applied to a large group of individuals and is brief by nature. It is usually applicable in those settings where the individu- als are encountered for problems that may not appear to be related to substance use, yet the association of the problem with substance use may be strong. Such settings may include a general medical setup, emergency rooms, trauma centres, psychiatric setting, and ante- natal checkup or in a legal setup (e.g. prison wards, individuals caught for drunken driving). These settings usually encounter individuals who may have a substance use problem but are not actively seeking treatment for the same.

Efforts have been made to develop brief ques- tionnaires and interviews so that many indi- viduals with drug abuse problem may be iden- tified in a relatively short period. Consequently a number of instruments have been developed towards this end. These instruments comprise of simple questions that have a ‘yes/no’ or a ‘most true/ not true’ answers. These instru- ments have been designed to have a high degree of sensitivity at the cost of specificity (thereby increasing false negativity). Some

Levels of Assessment
1. Brief Screening
2. Basic Assessment
3. Specialized Assessment

Specificity/ Cost

Broad focus/ Inexpensive

Narrow focus/ Costly

Assessment and Diagnosis in Substance Use Disorder

frequently used instruments are

1. CAGE: an acronym for 4 questions used to assess those with alcohol problem

2. MAST: Michigan Alcohol Screening Test

3. DAST: Drug Abuse Screening Test

4. AUDIT: Alcohol Use Disorder Identifica- tion Test

The usefulness of these instruments depends on the setting and the type of population in which these instruments are used.

Tools of assessment

Assessment can be carried out by various means. These are

A) Clinical:

Here, assessment is carried out by eliciting information as well as carrying out a detailed examination of the patient. The relevant infor- mation can be gathered from patient as well as persons associated with patients who are willing to be involved in the treatment and care of the patient. It has been observed that, at times, informants tend to under/over report the patient’s drug abuse. However, informants can be a good source for corroborating other aspects of patients drug use with regards to

various complications (physical, social, famil- ial, occupational) as well as patients’ attempts to leave the drug (abstinence).

ing team, areas to be focused during reha- bilitation. The areas probed are

1. physical: long term health hazards asso- ciated with drug use

2. psychological: chronic mental effects of continuous use of drug
financial: losses suffered/debts incurred

SUD has been considered as biopsychosocial problem. Hence assessment should be carried
out in multiple domains focusing on physi- ological, behavioral, psychological and social 3. factors associated with drug use.

Clinically, assessment may be carried out in the following manner:

History

Assessment begins with collection of

a. Patient’s sociodemographic profile i.e. name, age, sex, marital status, qualification, occupation, type of family and place of resi- dence.

b. Details of drug use are then inquired into. This include

1. age of initiation

2. various drugs used

3. frequency of drugs used

4. the quantity of drug taken usually (usual
dose)

5. the time lag since the dose last used

6. need to increase the quantity of drug
consumed in order to produce the same
effect (tolerance)

7. the effect of the use of a particular drug
and signs and symptoms of intoxication

8. presence/ absence of physiological/psy- chological symptoms and signs when the particular drug is not taken/ less than the usual amount of drug is being taken
(withdrawls)

9. compelling need/ urge to take the sub-
stance

c. Complications associated with drug use

should be inquired. This can be in various spheres of patients’ life and gives the treat-

4. occupational: frequent absenteeism at work, constant change of job, memos issued, periods of unemployment

5. familial – social: frequent fight with spouse/ other family members, neglect of responsibility at home, social outcast

6. Legal: involvement in illegal activities to sustain drug use, arrests/ charges on ac- count of drug use, caught driving under intoxicated state, drinking brawl.

High risk behaviors: presence of injection use with needle sharing and unsafe sexual practices

Past abstinence attempts: herein inquiry should be made regarding

1. number of attempts made

2. duration of each attempt

3. reason for abstinence

4. whether treatment sought

5. nature of treatment sought: pharmaco-
logical, psychological or combined

6. reason for relapse

The information collected would be very helpful in deciding further treatment plan and measures to be taken to prevent relapses

Reason for seeking treatment and motiva- tion level of individual: whether seeking treatment by self or brought forcibly by family member. Assessing level of motiva- tion would help the clinician decide the type of intervention needed.

Psychiatric illnesses such as a mood disor- der, psychotic disorder and personality dis-

Assessment and Diagnosis in Substance Use Disorder

order/ traits are common comorbid conditions accompanying substance use disorder. Presence of comorbid psychiatric illness should be specifically inquired and intervention modified accordingly.

h. Presence of family history of SUD, psychi- atric illness and the current living arrange- ments. Extent of social support should be assessed.

i. Premorbid personality: especially presence/ absence of Antosocial personality disorder.

Physical examination

1. Evidence of drug use with respect to

a) Intoxication,
b) Withdrawals and
c) Route of drug use as evidenced by burn

marks/ nicotine stains on fingers in cigarette use and heroin by inhalational route; injection marks in case of injec- tion drug use (IDU).

2. Evidence of physical damage due to drug use: a systemic examination should be con- ducted for every drug user to rule out physi- cal damage associated with drug use. This would provide an excellent opportunity to treat comorbid physical problem and also use this evidence to enhance motivation towards abstinence

Mental status examination

Though a detailed description is outside the purview of the current chapter, in mental sta- tus examination, attention is given to the gen- eral appearance and behavior of the patient (dressing, grooming, mannerism, motor activ- ity, and eye contact), the nature of his affect (mood: happy, sad, anxious), speech (rate, vol- ume, pitch, coherence, relevance), the content of the patient’s thought (delusions, obsessions, depressive thought, suicidal ideas), perceptual disturbances (illusions, hallucinations) and

cognitive functions of the patient.

Finally, the motivation level of the patient is assessed.This can be assessed by inquiring into the reasons for seeking treatment.

B) Investigations:

While the details of laboratory measures in drug abuse settings in discussed elsewhere in the manual, it serves two purposes.

1. confirming presence/ absence of drugs of abuse

2 . investigations for physical damage caused by these drugs

Similar to examination, investigation provides an objective measure of the drug used and the extent to which drug use has caused damage to the body. This can be used effectively to enhance motivation of individuals who are in the state of denial with regards to their drug use.

C) Instruments:

These tools consist of a set of questions designed to assess one or more domains associ- ated with drug abuse. This provides a more structured way of assessment of an individual. Several rating scales and instruments exist to assess different domains. Some of these instru- ments have high sensitivity so that they can be used for screening purpose. Instruments with high degrees of specificity confirm the diagno- sis of SUD. Some instruments may require training to enable the individual to administer the particular instrument.

Thus, it can be seen that assessment can be carried out using several sources of informa- tion as well as using different measures. Though investigations and rating scales can aid in as- sessment, a thorough clinical assessment serves a number of additional purposes including es- tablishing rapport as well as increasing moti- vation of the individual.

Assessment and Diagnosis in Substance Use Disorder

Validity of self reports

Many clinicians are of the impression that self report, especially in the area of substance use, may not be reliable because of a perceived notion that the substance user does not accu- rately report the extent of his substance use. However, research suggests that the possible distortion in self report is less problematic than it is feared to be. Self reports can be made more reliable by enhancing motivation and devel- oping an empathic and non judgemental atti- tude towards drug user.

Several factors have been suggested that increase the validity of self reports.

1. the patient is alcohol and drug free when interviewed

2. sufficient time has passed since last drink/ drug use to allow clear responses

3. confidentiality is assured.

4. the setting is non threatening and non judgemental.

5. the patient does not feel pressured to respond in a particular way.

6. the patient has no reason to distort reports (e.g. abstinence being a condition of pa- role).

7. the patient is aware that corroborating in- formation is available and will be collected (e.g. breath test, report of spouse), and that this information from other sources will be used to confirm what he or she reports.

8. the questions are clearly worded and valid measurement approaches are used.

9. the assessment worker or therapist has a good rapport with the patient.

10.the person administering the measures should be able to communicate clearly with the patient.

DIAGNOSIS

Before looking into features that make a diag- nosis of SUD, it would be beneficial to see what constitutes a disease.

A cluster of signs and symptoms occurring more than due to chance factor

Syndrome

Disease

SUD, like most other psychiatric disorders, is still at the syndromal level. This is because there is no definite etiology to explain SUD. In the absence of a definite etiology, the diag- nosis of SUD is based on a cluster of signs and symptom. Many hypothetical constructs or models exist to explain the occurrence of a par- ticular syndrome. Some of these, for SUD, are moral model (use seen as sin, crime), charac- terological (use seen as a defect in personality), conditioning model (use as a result of classical and operant conditioning) and biomedical model (genetic and physiological/biological cause of SUD). However, it is not possible to explain the phenomenon of SUD based on one model exclusively. In the face of this, people of different schools of thought would diagnose SUD differently. Thus, a clinician ascribing to the biological model would place more impor- tance to the biological changes caused by sub- stance, while another of psychological school would place importance on the psychological factors to make a diagnosis of SUD. This natu- rally would lead to a variable diagnosis of SUD.

To this effect the World Health Organization (WHO) and the American Psychiatric Associa- tion have independently proposed a cluster of factors to make a uniform diagnosis of SUD. These classificatory systems aim to be atheoretical. The current versions are polythetical, meaning that no single criterion

Assessment and Diagnosis in Substance Use Disorder

An etiology associated with occurrence of syndrome

is necessary or sufficient to make a diagnosis. Rather, the diagnosis is made by the presence of a fixed number of criteria out of the larger group. The most commonly followed diagnos- tic system is that published by WHO, the ICD 10 (International Classification of Diseases). ICD 10 classifies SUD into intoxication, harm- ful use, dependence syndrome, withdrawal state, psychotic disorder and amnestic syndrome. This chapter deals with the ‘depen- dence syndrome’ and ‘harmful use’.

Dependence syndrome

Dependence syndrome has been defined in ICD 10 as “A cluster of physiological, behavioural and cognitive phenomena in which use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value”

The criteria for substance dependence syn- drome has been influenced by the criteria laid down by Edwards and Gross (1976) for the diagnosis of Alcohol dependence syndrome. Though Edwards and Gross laid down the cri- teria particularly for alcohol dependence, this has been used uniformly to diagnose all classes of substance dependence. The ICD 10 criteria specifies dependence as three or more experi- ences exhibited at some time during a one year period

. a) Tolerance: there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with contin- ued use of the same amount of the substance.
For e.g., an individual would have started with 60ml of whisky to obtain pleasure, however with continuous use, he has to con- sume 180 ml of the same to obtain the same amount of high.

. b) Physiological withdrawal state: character- istic symptoms experienced on stoppage/ reduction of a substace after prolonged use. The patient uses the same (or closely re- lated) substance to relieve or avoid with-

drawal symptoms.

Every class of substance produces its own set of signs/ symptoms of withdrawal. For e.g. alcohol withdrawal would produce tremors, sweating, nausea/ retching/ vom- iting, insomnia, palpitations with tachy- cardia, hypertension, headache, psychomo- tor agitation and in severe cases, hallucina- tion, disorientation and grand mal seizures.

c) Impaired capacity to control substance use behavior in terms of its onset, termination or level of use as evidenced by the substance being often taken in larger amounts or over a longer period than intended; or by a per- sistent desire or unsuccessful efforts to re- duce or control substance use.

Thus, an individual may find it difficult to avoid using substances at particular place or time or also to limit himself to a par- ticular predetermined amount. Some re- searchers are of the view that loss of control is the most important criterion determin- ing substance use.

. d) Preoccupation with substance use, as mani- fested by important alternative pleasures or interests being given up or reduced because of substance use; or a great deal of time spent in activities necessary to obtain, take or recover from the effects of the substance.

. e) Continued use inspite of clear evidence of harmful consequences, as evidenced by con- tinued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm.

. f) Strong desire to use substance (craving).
This craving may occur spontaneously or induced by the presence of particular stimuli. Exposure to stimuli where or with whom the individual would have used the substance would lead to a strong desire to consume the substance. This is termed ‘cue induced’ craving.

Criteria (a) and (b) are physiological, while criteria (c), (d) and (f) are psychological in

Assessment and Diagnosis in Substance Use Disorder

nature. Thus, not one domain is sufficient to diagnose dependence. For e.g. cancer patients who are given opioid as analgesics may have tol- erance and withdrawal. However they may not be diagnosed as having dependence syndrome unless they fulfill other criteria. The dependence syndrome criteria are not an all or none state, rather one that exists in degrees of severity.

Harmful use

ICD 10 uses the category of harmful use as a state that constitutes

. a) A pattern of substance use that is causing damage to health. The damage may be physical or mental. The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.

. b) No concurrent diagnosis of the substance dependence syndrome for the same class of the substance.

The DSM IV equivalent of this category is ‘abuse’. This includes social, legal and occupa- tional consequence of drug use in addition to physical and mental harm. Because there may be cultural difference that may result in differ- ent impact on the social, legal and occupational front, ICD 10 has intently omitted these and stuck to the health damage only.

Technique and style in assessment and diagnosis

The traditional view regarding substance abus- ing population is that drug abusers are to a large extent unmotivated, are in a state of de- nial and resistant to change/ stop their drug

Suggested Reading

1. Galanter M, Kleber HD, eds. The American Psychi- atric Press Textbook of Substance Abuse Treatment, American Psychiatric Press, Washington D.C.; 1999.

2. LowinsonJ,RuizP,MillmanR,LangrodJ,eds.Sub- stance abuse, A comprehensive textbook, 4th ed. Bal- timore: Lippincott Williams and Wilkins; 2005.

using behavior. Thus, because of this view cli- nicians often assume a confrontational style and much of the efforts goes into making the pa- tient accept/realize his drug use i.e. ‘addict/ alcoholic’ label. However, such an approach would make the drug user move away from the treatment rather than towards it. Research has found that these labels and opinions regarding drug user is falsely based. Denial is not a per- sonality of drug abuser, but a modifiable state. Treatment works, but the clinician should

a. not insist that the individual accept the la- bel of ‘addict/ alcoholic’

b. express a warm and affective concern about the problem

c. be non directive, non judgemental and sup- portive

Such an approach goes a long way in effectively engaging a drug abuser in treatment process.

Conclusion

The magnitude of SUD is enormous. How- ever the experts to treat such patients are few. The primary physicians are better suited to form a cost effective alternative to this. While a comprehensive treatment requires a compre- hensive evaluation, the assessment done is guided by a number of factors. Apart from diagnosing substance related problems, assess- ment provides a very good opportunity to develop rapport with patients. This goes a long way in management of SUD.

3. McCrady, B.S. & Epstein, E. eds. Addictions: A Comprehensive Guidebook. New York: Oxford Uni- versity Press; 1999: 477-498.

4. Mood Disorders. In: Diagnostic and Statistical Manual of M e n t a l D i s o r d e r s , F o u r t h E d i t i o n , ( D S M – I V ) , Te x t R e v i – sion (2000), American Psychiatric Association: 297-343.

Assessment and Diagnosis in Substance Use Disorder

Suggested slides for OHP

Slide 1

SUD is common among general population

Specialised Deaddiction centres are able to treat only few patients and are often last point of contact

Primary care physicians are often considered initially for problems other than SUD

appendix)

Investigations – for confirming substance use & estab- lishing physical damage caused by substance use

Questionnaires – provides for structured assessment Self reports – largely found to be reliable

Slide 7

Diagnosis

Syndrome = signs + symptoms, Disease = etiology ascribed to syndrome
Psychiatric disorders, including SUD, are at syn- drome level

Uniform Criteria for diagnosis of SUD, proposed by WHO (ICD) and APA (DSM)
Both criteria are polythetic in nature
No single criterion necessary or sufficient

Slide 8

ICD 10 criteria for dependence Tolerance

Withdrawl
Craving
Difficulty in controlling substance use Continued use despite knowledge of harm Neglect of all pleasures or great deal of time spent on substance use

Slide 9

Harmful use

Substance use causing damage to physical or mental health
Doesn’t fulfill criteria of diagnosis anytime

‘Abuse’ term used by DSM IV to describe legal, social, occupational and physical damage by substance use

Slide 2

Reasons to assess patients
Diagnosis and treatment
Screening
Referral to a specialist
Establish rapport and increase motivation

Slide 3

Stages of assessment
Preintervention – define problem and formulate a treatment plan
Intervention – monitor program
Post intervention – assess maintenance

Setting – inpatient v/s outpatient

Slide 4

Levels of assessment Brief screening

Basic assessment to diagnosis
Specialised assessment to treat individuals Reassessment for continuing care

Slide 5

Screening
Applied to a large group
Brief in duration
Usually applied in high risk non treatment seeking individuals
Questionnaires with a high degree of sensitivity available which are easy to apply

Slide 6

Tools of assessment Clinical

Investigations Questionnaires

Clinical – history & examination (points provided in

Assessment and Diagnosis in Substance Use Disorder

Epidemiology
of Substance Use

Hem Raj Pal, Amardeep Kumar

Summary

Data on substance use is required from differ- ent regions in the country as the likelihood of regional disparity in substance use is high. The recently completed project “The extent, pat- tern and trends of drug abuse in India” pro- vides nationwide data of substance use among general population (NHS), treatment seeking substance using population (DAMS), hidden substance using population not seeking treat- ment (RAS) and certain special groups (FTS). The finding refutes certain previously held notions about substance use in India; e.g. IDU use being found all over India as opposed to previously held belief that only North- East- ern states are affected. Similarly picture from rural India is a worrying finding as it reflects heroin use and injection opioid use. Indulgence in unsafe sexual and injection drug use prac- tices by a substantial proportion of our drug using population along with limited number of functional specialized drug dependence treatment centre is another cause of concern. Among licit drug use, doubling of per capita alcohol consumption over past two decades is another worrying finding. However, the find- ings of the project provide only baseline infor- mation for further study. It gives a wakeup call to policy makers as well as treating clinician to tackle the problem more effectively. Cost-ef- fective screening instruments and intervention need to be developed to tackle the problem. There is a need to continuously monitor chang- ing trends in substance abuse.

Introduction

Epidemiology is defined as the study of distri- bution and determinants of disease frequency

in humans. This definition as applicable to substance use would be “the study of distribu- tion and determinants of substance use in humans”.

Information obtained from the epidemiology of substance use is as follows –

1. Extent of substance use problem.

2. Nature and pattern of substance abusing behaviour.

3. Characteristics of persons abusing the sub- stances.

4. Change in the trend of substance use over time.

5. Factors that may be associated with or etio- logically related to substance use.

The information obtained from the epidemio- logical studies helps in understanding the sub- stance use problem in two ways –

1. At a macro level – for a policy maker whereby treatment and prevention related policy issues can be planned.

2. At a micro level – for a clinician whereby information about risk factors and outcome can be obtained leading to effective treat- ment of substance use problem.

Indicators of Substance Use Problem

There are number of indicators pointing to- wards extent and magnitude of substance use problems in a population. Arbitrarily they can be divided into direct indicators and indirect indicators.

Direct indicators
Surveys – In direct epidemiological studies or

surveys researchers go into a community and

collect information about substance use pat- tern. This approach gives a reasonably accu- rate picture of extent of substance related problems.Additionally,this approach has the advantage of finding out about substance us- ers who are not seeking treatment.

Surveys also obtain information about demo- graphic variables, pattern of drug use, percep- tion of risk associated with drug use, health and adverse psychological consequences and treatment history (if any).

In India, the National Household Survey of Drug and Alcohol Abuse (NHS) sponsored by Ministry of Social Justice and Empowerment, Government of India (MSJE, GOI) and United Nations Office on Drugs and Crime, Regional Office for South Asia (UNODC, ROSA) has recently been completed. This survey was a part of larger project- the ‘National Survey on Ex- tent, Pattern and Trend of Drug abuse in In- dia’. This is the first study that aimed to gen- erate national level prevalence estimates of drugs of abuse in India.

Issues that need to be addressed while conduct- ing a survey include:

Where to conduct a study? A preliminary study needs to be carried out to identify high prevalence areas. Thereafter surveys focus on these areas.

How to select a sample? For licit substances, surveys which select a sample representa- tive of general population, generates most generalisable result and has usefulness in planning policies related to prevention and therapeutic intervention strategies. For illicit substances whose use are more preva- lent in certain high-risk population such as students, slum-dwellers, drivers trans- portation workers and commercial sex- workers. Sample representative of general population has limited usefulness in terms

of planning, focused preventive and thera- peutic intervention strategies. For these groups of substances, a sample of high-risk population is more appropriate.

How to obtain information? Most of the stud- ies obtain information regarding substance use from the subjects. However due to cer- tain limitations posed by this approach such as feasibility, misinformation, ‘hidden’ phenomenon of illicit drug use, alternative techniques to obtain the information have also been developed. Two such techniques are:

. (a) “Key information technique”: This tech- nique elicits information on substance use and its profile in the persons under survey from key informant. ‘Key infor- mant’ is usually person with respectabil- ity, knowledge and wisdom, and they are considered to be quite reliable source of information. Examples of key informants are Head of the Household (HOH), teachers, local community leaders, etc.

. (b) “Snowball” technique: This technique makes use of few identified substance users, who provide information about other users. The newly identified users are contacted to obtain information about other users and so on. This technique is particularly effective in surveys and stud- ies looking for illicit substance use.

What information is to be obtained? Depend- ing upon the objectives of study and re- sources available, a variety of information could be obtained including nature of the substance being used, its pattern, adverse consequences, treatment history and per- ception of risk. Normally surveys do not generate a diagnosis of abuse and depen- dence. They focus on information such as ‘ever use’ (any time in the past), ‘recent use’ (past 1 year), and ‘current use’ (past 1 month) of the substance

Epidemiology of Substance Use

Whereas survey is a cross sectional study, sur- veillance is defined as “the continuous scrutiny of the factors that determine the occurrence and dis- tribution of disease and other conditions of ill- health i.e. use of substance”. The main purpose of surveillance is to detect changes and iden- tify trends.

Indirect indicators

Indirect indicators are those which do not di- rectly provide information regarding substance use in a population, but they are elicited from the data already available somewhere. This data is then secondarily analyzed to gauge the ex- tent of substance use problems. Some such in- dicators can be –

1. Production and consumption of substances

2. Seizure of illicit drugs.

3. Drug related illness.

4. Reporting systems: Data obtained from persons attending heath services notably drug dependence treatment services can provide valuable indirect information re- garding substance use problems in the com- munity.

India has no national system to monitor drug abuse currently. An attempt was made to de- velop and establish a National Drug Abuse Monitoring System (DAMS) as a part of larger project- the ‘National Survey on Extent, Pat- tern and Trends of Drug Abuse in India’. The study obtained data from 203 agencies across India.

The major limitation of this approach is that it touches only the tip of the iceberg since not all substance users come for treatment. In or- der to assess the extent and magnitude of sub- stance use in a community the best way is a direct epidemiological study or survey.

GLOBAL SCENARIO

Licit substances

Alcohol

Alcohol consumption has numerous health and social consequences and is an important con- tributor to death and disability. Alcohol is es- timated to cause about 20-30% of oesophageal cancer, liver cancer, and cirrhosis of the liver, homicide, epilepsy, and motor vehicle acci- dents. Worldwide, alcohol causes 1.8 million deaths each year

Globally alcohol consumption has increased in recent decades, with all or most of that increase being in developing countries

Tobacco

Tobacco continues to be the substance causing the maximum health damage globally. Accord- ing to WHO estimates, there are around 1.1 thousand million smokers in the world; about one-third of the population aged 15 and over. While consumption is levelling off and even decreasing in some countries, worldwide more people are smoking, and smokers are smoking more cigarettes. Substantially fewer cigarettes are smoked per day per smoker in developing countries than in developed countries. How- ever, this gap is fast narrowing and unless ef- fective tobacco control measures take place, daily cigarette consumption in developing countries is expected to increase as economic development results in increased real dispos- able income.

According to the World Health Report 2002, among industrialized countries where smok- ing has been common, smoking is estimated to cause over 90% of lung cancer in men and about 70% of lung cancer among women. In addition, in these countries, the attributable fractions are 56-80% for chronic respiratory disease and 22% for cardiovascular disease.

Epidemiology of Substance Use

Worldwide, it is estimated that tobacco cause about 4.9 million deaths each year and unless current trends are reversed, that figure is ex- pected to rise to 10 million deaths per year in another 20 years, 70% of those deaths occur- ring in developing countries.

Illicit substances

Opiates–

Reports by the UNDCP have shown that there has been a global increase in the production, transportation and consumption of opioids, mainly heroin. The worldwide production of heroin has almost tripled since 1985. Glo- bally, it is estimated that 13.5 million people take opioids, including 9.2 million who use heroin.

Although in recent time the production of heroin in 2002 was more or less at the same level as in 1998, regional shift has markedly reshaped the patterns of heroin abuse in the world. The rapid growth of opium production in Afghanistan has fuelled the development of a large heroin market in the region and, fur- ther, in Central Asia, the Russian Federation and East Europe. An increase in intravenous heroin abuse has led to an increased prevalence of HIV/AIDS.

Cannabis –

Cannabis is by far the most widely cultivated, trafficked and abused illicit drug. Half of all drug seizures worldwide are cannabis seizures. The geographical spread of those seizures is also global, covering practically every country of the world. About 147 million people, 2.5% of the world population, consume cannabis (annual prevalence) compared with 0.2% consuming cocaine and 0.2% consuming opiates. In the present decade, cannabis abuse has grown more rapidly than cocaine and opiate abuse. Can- nabis has become more closely linked to youth

culture and the age of initiation is usually lower than for other drugs.

Amphetamine–type stimulants (ATS)-

Amphetamine-type stimulants (ATS) refer to a group of drugs whose principal members in- clude amphetamine and methamphetamine. However, a range of other substances also fall into this group, such as methcathinone, fenetylline, ephedrine, pseudoephedrine, me- thylphenidate and MDMA or ‘Ecstasy’ – an amphetamine-type derivative with hallucino- genic properties.

The use of ATS is a global and growing phe- nomenon and in recent years, there has been a pronounced increase in the production and use of ATS worldwide. Over the past decade, abuse of amphetamine-type stimulants (ATS) has infiltrated its way into the mainstream culture in certain countries. Younger people in par- ticular seem to possess a skewed sense of safety about the substances believing rather errone- ously that the substances are safe and benign.

For many countries, the problem of ATS is rela- tively new, but is rapidly growing and unlikely to go away. The geographical spread is widen- ing, but awareness is limited and responses are neither integrated nor consistent. Recent data has shown a decline in ATS use in the regions of the Americas and Europe, while the highest levels of abuse worldwide have emerged in East Asia and Oceania. According to a review of ATS by UNDCP in 1996, there are about 20 coun- tries in which the abuse of ATS is more wide- spread than that of heroin and cocaine com- bined. Japan, Korea and the Philippines all register 5-7 times the rate of ATS use com- pared with heroin and cocaine use.

Smoking, sniffing and inhaling are the most popular methods of ATS use, but ways to take the drug vary widely across the region. In coun- tries like Australia, where over 90 per cent of

Epidemiology of Substance Use

those who report using ATS (mostly metham- phetamine) inject, the drug represents a significant risk factor in the transmission of blood-borne viruses. Philippines and Viet Nam are also reporting signs that injecting meth- amphetamine is increasing while in Thailand the number of methamphetamine users now represents the majority of all new drug treat- ment cases.

Cocaine –

Cocaine and its derivative ‘crack’ provide an example of both the globalization of substance use and the cyclical nature of drug epidemics. Traditionally coca leaves have been chewed by people in the Andean countries of South America for thousands of years. Cocaine be- came widely available in North America in the 1970s and Europe in the 1980s.

Prevalence rates for lifetime use of cocaine are typically 1-3% in developed countries, with higher rates in the United States and in the producer countries. Cocaine dependence has become a major public health problem, result- ing in a significant number of medical, psy- chological and social problems, including the spread of infectious diseases (e.g. AIDS, hepa- titis and tuberculosis), crime, violence and neo- natal drug exposure.

Box 1 :

INDIAN SCENARIO

In 1999, the Ministry of Social Justice and Empowerment, Government of India (MSJE, GOI) and the United Nations International Drug Control Programme, Regional Office for South Asia (UNIDCP, ROSA) decided to un- dertake a large-scale national survey to obtain information on extent, pattern and magnitude of substance abuse in the country. The study had several components, which could be called “……carried out first time in India”. For this purpose multiple indicators and several meth- ods to assess the situation were chosen.

The major components of this survey were National Household Survey (NHS), Drug Abuse Monitoring System (DAMS) and Rapid Assessment Survey (RAS). Additionally, focused studies on special populations like women, rural subjects, people living in border towns and prison population have also been carried out. Finally, burden as perceived by women due to drug abuse in the family has also been enquired into.

National Household Survey (NHS) is one of the first nationwide surveys which aimed at determining prevalence of the use of licit (to- bacco, alcohol and prescription medications) drugs & illicit (opiates and cannabis) drugs, studying some socio-demographic correlates of drug abuse and estimating the extent of drug dependence for alcohol and opiates for coun- try as a whole.The survey was conducted to provide estimates of the prevalence at the na- tional level drawing a sample of 40,000 males from 25 states of the country. The data was collected between March 2000 and Novem- ber 2001 through face to face interviews with the respondents by trained interviewers. The diagnosis of dependence was arrived using WHO (ICD-10) criteria.

The data for Drug Abuse Monitoring Survey (DAMS) component was obtained from con-

Epidemiology of Substance Use

Licit substances (alcohol and tobacco) are the most commonly used substances.

Among illicit substances, heroin and cocaine have most serious health related effects.

Heroin abuse is increasing in Central Asia, the Russian Federation and East Europe.

Largely caused by IDU, HIV/AIDS epi- demic has been expanding at an alarming rate in South-East Asia.

ATS abuse is clearly shifting towards East and South-East Asia in recent years.

secutive new patients contacting various treat- ment centres. In addition, information on the drug abusing population was also obtained from prisons, NGOs working with children, NGOs working with HIV/ AIDS affected per- sons, youth organizations (Nehru Yuva Kendras) and psychiatric hospitals.

The Rapid Assessment Survey (RAS) collected information on drug use through in-depth in- terviews of identified drug users (non-random sample), key informants and focus group dis- cussion from 14 urban sites.

The five focused thematic studies (FTS) were designed to capture information in the follow- ing areas: drug abuse among women, the bur- den on women due to drug abuse by family members, drug abuse among the rural popu- lation, the availability and consumption of drugs in border areas.

A comprehensive picture of a country can only be obtained through multiple data sources us- ing multiple methodologies, as has been car- ried out in the current survey. Each element supplements another.

Table 1- Objectives of major components of National Survey

Epidemiology of Substance Use

NHS

DAMS

RAS

Prevalence of lifetime and current use of various substances

Estimate the extent of substance dependence

Socio-demographic correlates

Develop a monitoring system for the country

Collection of data from people seeking treatment

Develop a format for collecting information on a regular basis

Study the extent and nature of drug use in the identified urban sites

Study the demographic char- acteristics, drug use patterns, risk behaviors, adverse health and social consequences of drug users

Study the service demand of drug users and the existing treatment responses

Recommend an action plan to reduce the adverse conse- quences of drug abuse

Table 2: Major Drugs of Abuse in India

Source : National Survey, 2004

Drug Type

NHS (current prevalence, %)

DAMS (% among treatment seekers)

Alcohol Cannabis Heroin Opium
Other Opiates

21.4% 3.0% 0.2% 0.4% 0.1%

43.9% 11.6% 11.1%

8.6% 6.3%

Source : National Survey, 2004

– Alcohol, cannabis, opium and heroin are the major drugs of abuse in the country as shown in the table.

– Relative importance of the drugs as seen in the general population (NHS) and among treatment seekers (DAMS) is different.

– Alcohol is the most frequently used sub- stance as seen in the NHS and the DAMS.

– The relative proportion of opiate users is high in the treatment centres (26%) though their prevalence is low in general population (0.7%).
Table 3- Estimates of Number of Users of Select
1991 census male population stratified for age (15-60 years) adjusted for ten-year growth in males)

Epidemiology of Substance Use

– Very few cannabis users reported for treat- ment.

It was observed that between 17 and 26 per- cent of current users of various substances were dependent users. Thus, the proportion of de- pendent users would be around one quarter of the total population shown in table 3 requir- ing immediate treatment for substance use problem. An attempt has been made to project the total number of males abusing various drugs for the nation as a whole based on the preva- lence figures is depicted in the table below-

Drug Type (approximate, in millions Based on

Drug Type

Ever Use

Current Use

Tobacco
Alcohol
Cannabis
Opiates
Sedative/ Hypnotics

168.99 75.59 11.96

2.92 0.58

162.86 62.46 8.75 2.04 0.29

Source : NHS

It can be interpreted from the above table that a large number of current users would require help so that they do not progress to regular or dependent use. It is useful to know about the consumption of major substances of abuse in India as compared with the consumption in other countries.

Table 4 – Comparison of Annual Prevalence of major substances of abuse

Annual Prevalence (%) of alcohol use among adult males

Annual Prevalence (%)
of Opiate Abuse among those 15 years and older

Annual Prevalence (%) of cannabis abuse among those 15 years and older

. India (2001, past month use)- 21.4.
Canada ( 1997)- 78.1. Finland (1995)- 90. Sweden (1997)-90. Poland (1997)-93.8. Australia (1996)-80. China (1997)-87.3

India (NHS, 2001 past month use)- 0.7. Canada-0.2.
Russian federation-0.9. U.K-0.6.

Australia (1998)-0.7. Pakistan (1997)-1.7. Bangladesh-0.6 Nepal (1996)- 0.3. Sri Lanka (1997)-0.3

India (NHS, 2001 past month use)- 3.0. Canada- 7.4.
Russian Federation-0.9. U.K-9.0.

Australia (1998)-17.9. Pakistan (1998)- 1.2. Bangladesh- 3.2. Nepal (1996)-2.8.

Sri Lanka ( 1999)-1.4

Source : National Survey, 2004

– Annual prevalence of drinking among adult males in India is low. However, the worry- ing development is that over two decades the consumption of alcohol in India has increased by 106 percent as against many countries where the consumption of alco- hol declined.

– Annual prevalence of opiates in other coun- tries is relatively low.

– The current prevalence of cannabis use in India is relatively low when compared to other countries.

The high prevalence of opiate use in the coun- try is a worrying phenomenon. The number of persons requiring help is deemed enormous when projecting the prevalence data on to a male population that stood at 531 million as per the 2001 census.

Regional variation of substance of abuse in India

The variation of different substance use region wise is as follows-
Table 5: Regional variation of Alcohol abuse in India (high use regions)

Source: National Survey, 2004 Table 6: Regional variation of Cannabis abuse in India (high use regions)

Source: National Survey, 2004 Table 7: Regional variation of Opiate abuse in India (high use regions)

Epidemiology of Substance Use

Region

NHS

DAMS

North-East North West South

Nagaland, Arunachal Pradesh, Manipur Himachal Pradesh, Haryana
……….
………..

……..
Uttar Pradesh Maharashtra Kerala

Region

NHS

DAMS

North- East North
East

Manipur ……….. Bihar

………
Uttar Pradesh Bihar

Region

NHS

DAMS

North- East North
East
West

Mizoram, Nagaland, Arunachal Pradesh Haryana, Himachal Pradesh, Punjab ………..
Rajsthan

……….
Punjab, Uttar Pradesh West Bengal
Rajsthan

Source: National Survey, 2004 The RAS component of the study provided certain indicators, which suggest emerging trends.

These can be summarized as in the next table-

Changing Trends of substance use in India

Table 9: New emerging trend of substance use in India

Epidemiology of Substance Use

Substance

Region

LSD
Methaquolone
Inhalants
Inj. Propoxyphene Pharmaceutical products

Goa, Ahmedabad
Bangalore, Ahmedabad
Delhi, Bangalore, Thiruvananthapuram
Imphal, Dimapur
Amritsar, Ahmedabad, Imphal, Dimapur, Mumbai and Kolkata

Hazards and High-Risk Behaviour

Substance use causes various health and psychosocial hazards. Along with these, high risk behaviours are associated with injecting drug use thereby increasing the possibility of transmis- sion of HIV, HBV and HCV infection. Table 10 reflects the study findings of high-risk behaviours associated with injecting drug use.

Table 10: High-Risk Behaviour among Current Users

Source: National Survey, 2004

Items

NHS (National) Drug users

DAMS

RAS All 14 sites (States)

RAS Non-metros 9 sites (States)

IDU (%) Lifetime Current

Sharing of needles/ syringes (%)

Sex with CSWs (%)

Practice of safe sex (%)

0.1 ….

97.0

…. ….

14.3 9.4

7.7

4.4 38.5

43.0 ….

….

…. 41-64

33.4 ….

57.9

24.4 35.9

– Sharing of needles is extremely common in the sample studied in NHS as well as RAS and overall varied between 58 and 97 %.

– Other high-risk behaviour i.e. unsafe sex and sex with CSWs was also seen.
Concerns of Special Populations
The study also provides information on special population such as women, rural

Source: National Survey, 2004 population, border areas and prison popula-

tion. The summarized study findings are-

– Women are sufferers either directly due to substance use by themselves or indirectly as a consequence of substance use by spouse or another family member.

– The data from women drug users showed that opiates (heroin and propoxyphene),

alcohol and minor tranquillizers were be- ing abused. This contradicts a prevalent myth about drug use by women, that tran- quillizers are the exclusive drugs of choice.

– Abuse of heroin and IDUs were reported in rural settings too.

– Drug abuse is prominent in rural India but with inadequate service delivery for the

–

population.

Youth and very young drug users were in- dulging in several high-risk behaviours like IDU, needle sharing and unsafe sex practices.

Fig 3: Percentage of Subjects reporting ever having Taken Treatment by Various Components

2 0

Epidemiology of Substance Use

Treatment seeking

The figure below give an account of treatment seeking (ever) for substance use problems as found by the various survey components.

18.7 4

24.4 26.9

DAMS RAS

1.4

Rural

33.3

Border

(Alcohol) (Cannabis) Opiates IDU NHS NHS NHS NHS

Needs of Users and Service Requirements

Focussed Group Discussions with Drug Users Revealed –

– Treatment should be free and available to all.

– Identity of the person seeking treatment should not be revealed.

– Proper medication and counseling should be available.

– Some requested for drug substitution.

Service requirements reveal that modification is needed in data collection due to the chang- ing need of drug using population. These re- quirements include –

. Low cost surveillance

. Improve data collection on drug related mor- bidity and mortality

. Surveillance of IDU and linkages with HIV/ AIDS

The overall findings can be summarized as thus:

Alcohol, cannabis, opium and heroin are the major drugs of abuse.

The number of persons requiring treat- ment is large.

IDUs. In tribal areas, consumption of home brewed alcoholic beverages occurs among both the sexes. Raw opium consumption for thera- peutic and other traditional purpose is preva- lent in women in Rajasthan.

Age:

The age group of 15-24 years has emerged as critical period for the initiation of substance use habit and more than half of the abusers of all substances use the substance for the first time at this age. Tobacco use starts at an even earlier age. Among college students, the boys are initiated to drug use a year or two before entering college and among girls, it is two-three years after entering college. Most of the opiate dependent individuals are in the age group of 21 to 30 years and there is a decline in opiate use in those above 40 years of age.

Occupation:

Substance abuse has been reported from dif- ferent occupational categories such as students, factory employees, auto rickshaw drivers, sex- workers, professionals and businessmen. About one- third to half the drug dependent indi- viduals were either currently unemployed or had never been employed.

Other Determinants

Genetic:

Family studies from West have demonstrated that the risk of alcoholism was much higher among the first- degree family members of an alcoholic. On an average, the risk was increased seven times. Studies of twin pairs also demon- strated a genetic influence. There is also a high correlation between smoking by parents and child’s substance use.

Co-morbidity:

The diagnosis of other substance abuse, anti- social personality, mania, schizophrenia, de- pression and anxiety disorders are also associ- ated with alcoholism and drug dependence.

Drug abuse is seen in both rural and ur- ban India which is against the previously held belief that it is mostly found in ur- ban population.

IDUs have been reported from various sites, including rural India as opposed to previously held belief that IDU is mainly limited to North-Eastern states.

One study reported IDU among women.

A large number of drug users engage in
unsafe sex practices.

Multiple other high-risk behaviours were reported.

Several common variables associated with drug abuse were identified across various survey components and thematic studies.

Congruence between treatment seeking and the extent of the problem in a given state was lacking.
One of the important use of epidemiological studies is to give some information on aetiological factors (risk factors) associated with substance use. Some information about risk factors for substance dependence can help to target strategies to prevent dependence. Most of the data available is related to demographic factors associated with substance dependence.
FACTORS ASSOCIATED WITH SUB- STANCE DEPENDENCE
Sex:
Substance abuse is primarily a phenomenon occurring among the males in India but women also indulge in abuse of a few drugs like alco- hol, tobacco, minor tranquillizers, heroin and

Epidemiology of Substance Use

Attitude towards Substance Abuse Personal

Perceived positive effects, harmful effects, whether own abuse perceived as a problem, sources of help perceived as available/useful are important determinants.

Societal

Tolerance/ ambivalence towards substance abuse amongst specified groups (e.g., age, sex, occupation) and situational context are impor- tant determinants.

Personality variables

Self-esteem, sense of personal control, anxiety, depression and disturbed mood states influ- ence drug use.

Interpreting Epidemiologic Research Methodological Issues

1. Concepts and definitions – Although there is consensus about the concept of the term dependence, certain terms like disorder, problematic or morbid pattern of use and what constitutes a case are subject to individual interpretations.

2. Reliability of information – The major source of information in epidemiological studies is the individual himself. The ac- curacy and reliability of information remain questionable due to factors such as social- stigma and denial.

3. Geographical variations – The pattern of substance use and frequency of substance related disorders varies across geographical areas. This limits the generalization of re- sults obtained from one area or community.

Population Screening Instruments

These are the instruments which help in the early detection of substance use problem. They are very useful in general population settings.

Population screening instruments for substance abuse need to be highly sensitive, easy to ad- minister and brief. It also needs to be validated on the population to be used.

Screening instruments available for alcohol use disorders are CAGE, MAST and AUDIT. (Appendix).

The AUDIT has been validated for use in In- dian population through a study co-coordi- nated at National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi.

Interventional epidemiology

To be useful for public health, data obtained from epidemiological studies need to provide effective methods of early interventions so that the problem can be tackled at an early stage in a cost-effective manner. Interventional epide- miology deals with generation of such inter- ventions.

Linking screening and intervention

Screening instruments and interventional methods are closely linked. For example, by using AUDIT as a screening instrument for alcohol use disorder one can roughly estimate the number of alcohol using problematic pa- tients. Depending upon the cut-off score, vari- ous level of severity of alcohol problem can be estimated i.e. mild, moderate and severe. De- pending upon the degree of severity, specific intervention that is cost-effective can be used. For example, in mild degree of severity of alco- hol use problem, community based Brief In- tervention strategies have been found to be very useful and cost-effective.

Suggested guidelines for getting familiar with local epidemiology

It is important to follow certain guidelines if one wishes to be familiar with epidemiology of substance use in your area. Some suggestions are-

Epidemiology of Substance Use

1. To have a clearly stated aim and objective of the study.

2. To decide the study design- To study the prevalence of substance use in a locality survey is preferred. However, other indi- rect indicators can also be studied, such as studying drug-related illness from hospi- tal emergency room data.

3. To decide the universe of study- depend- ing on how the results are going to be used. For policy issues general community is pre- ferred universe but for treatment planning specific areas such as slums, college cam- pus/university area may be preferred.

4. To decide from whom to obtain informa- tion: person using the substance is pre-

Suggested Reading

1. Kumar S M (2002). Rapid Assessment Survey of Drug Abuse in India. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Of- fice for South Asia.

2. Murthy P (2002). Women and Drug Abuse: The Problem in India. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Of- fice for South Asia.

3. Ray R (2004). The Extent, Pattern and Trends of Drug Abuse in India, National Survey.

4. Sethi H S (2002). Drug Abuse among Prison Popu- lation: A case study of Tihar Jail. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Office for South Asia.

5. Siddiqui H Y (2002). Drug Abuse Monitoring Sys- tem-AProfileofTreatmentSeekers.

6. Srivastava A, Pal H, Dwivedi S N, Pandey A (2002).
National Household Survey of Drug Abuse in India.
Report submitted to Ministry of Social Justice and Empowerment, Government of India and United

ferred source of information but in some cases key informants and snowballing may be the preferred approaches.

What information to obtain: Depends on the aim and objective of the study. Com- monly, following information is obtained-

Socio-demographic information- Age, Sex, Social class, Occupation, Education Drug use information- Type of drugs used, amount and frequency of use Treatment history and Complications- Medical, Psycho-social

For IDU- H/o needle sharing, unsafe

· · · ·

Epidemiology of Substance Use

sexual practices 7. Analysis of the data.

Nations Office on Drugs and Crime, Regional Of- fice for South Asia.

7. UNODCCP (United Nations Office for Drug Control and Crime Prevention) (2000). World Drug Report. United Nations Office for Drug and Crime Prevention, Vienna.

8. UNODCCP (United Nations Office for Drug Control and Crime Prevention) (2001). Global Il- licit Drug Trends 2001. United Nations Office for Drug and Crime Prevention, Vienna.

9. Saxena S, Pal HR, Ambekar A (2003). Alcohol and drug abuse, New Age International Publishers, New Delhi.

10. The Centre for Harm Reduction (2002). Revisit- ing ‘The Hidden Epidemic’- A situation Assess- ment of Drug Use in Asia in the context of HIV/ AIDS. The Burnet Institute, Australia.

11. Ministry of Social Justice and Empowerment, Gov- ernment of India and United Nations Office on Drugs and Crime, Regional Office for South Asia.

12. MinistryofSocialJusticeandEmpowerment,Gov- ernment of India and United Nations Office on Drugs and Crime, Regional Office for South Asia.

Suggested slides for OHP

Slide 1

Epidemiology of drug abuse is the study of distribution of drug abuse in a population and factors associated with it.
Indicators of substance use problem

Direct indicators – Surveys Indirect indicators

. a) Production and consumption of substances

. b) Seizure of illicit drugs

. c) Drug-related illness

. d) Reporting systems

Slide 2

Global Burden of Substance use

Slide 4

Indian Scene
o% National Survey (2004) – First nationwide survey done for substance use
o% Components-

NHS RAS DAMS FTS

o% Major findings-
· Alcohol, cannabis, opium and heroin – major drugs of

abuse.
· The number of persons requiring treatment – large.
· Drug abuse is seen in both rural and urban India.
· IDUs have been reported from various sites, including

rural India.
· A large number of drug users engage in unsafe sex

practices.
· Multiple other high-risk behaviours were reported.
· Congruence between treatment seeking and the ex-

tent of the problem in a given state was lacking.
· Enrollment in treatment is low.
· The duration of drug abuse is long.
· The time gap between onset of drug use and treatment

seeking is significant.

Slide 5

Factors Associated with Drug Dependence

. A) Sex- male more common

. B) Age-onset in adolescent or early adulthood

. C) Occupation varies

. D) Pattern of use in rural/urban areas

. E) Others- Genetic factors important in alcoholism

Slide 6

Methodological issues

. A) concepts and definitions

. B) Reliability of information

. C) Geographical variations

Substance Alcohol Tobacco smoker Illicit drug

Number of users 2 billion
1.3 billion
185 million

Epidemiology of Substance Use

Death and Disability
Death- 12.4% of all deaths

DALYs- 8.9% of DALYs lost Regional distribution of Burden

Overall- DALYs lost higher in EURO and WPRO regions

Tobacco- Largest burden in EURO and SEARO re- gions

Alcohol- Largest burden in AFRO, AMRO and WPRO regions

Slide 3

Global trends

‘“Licit substances (alcohol and tobacco) – most com- monly used substances.’”Among illicit substances, heroin and cocaine – most serious health related ef- fects. ‘“Heroin abuse – increasing in Central Asia, the Russian Federation and East Europe.’”Largely caused by IDU, HIV/AIDS epidemic expanding at an alarming rate in South-East Asia.’”ATS abuse shifting towards East and South-East Asia in recent years.

Acute Effects of Alcohol, 4 Opioid and Cannabis Use

Kul Bhushan, BN Gangadhar.

Summary

The acute effects of psychotropic substances are determined by a number of factors. The knowledge of acute effects of commonly used psychotropic substances is necessary to the pri- mary care physician for accurate diagnosis and management. Along with the acute effects on various body systems as well as psychological effects, mention is also made of the pharmaco- kinetics of the substances as well as the signs/ symptoms of acute intoxications. This chapter deals with the commonly abused substances viz. alcohol, opioid and cannabis

Introduction

The acute effects of psychotropic substances are determined broadly by 4 groups of factors:

1. Levels of use: Based on quantity used and consequences, the use of psychoactive sub- stances can be at one of two levels.

a) Social use, with no apparent harm and includes experimentation, group activ- ity, dietary practice and religious ritual. Once initiated, susceptible individuals graduate to abuse and even dependence.

b) Pathological use, which includes abuse and dependence characterised by crav- ing, compulsive use, tolerance and the withdrawal syndrome.

2. Patterns of use: Includes the routes of ad- ministration, quantity and frequency of use, route of administration and variations in preparations.

3. Individual factors: Besides differences be- tween naive and experienced users, geneti- cally determined susceptibility accounts for the occasional psychotic reactions. Men- tal set and expectations too are important.

4. Social factors: Group influence, social am- bience and shared values are a potent in- fluence in shaping the subjective experience both in content and magnitude.

ALCOHOL

Ethyl alcohol (ethanol) is the active ingredi- ent. Concentration of ethyl alcohol differs across preparations:

Drinks prepared by using yeast to ferment vari- ous sugar containing plant products have a low concentration as yeast ceases to grow when the concentration of ethanol reaches about 15%. Stronger liquors, however, have become avail- able in modern times through distillation. Whisky, brandy, rum and gin contain 35% to 50% alcohol whereas beers ordinarily contain 4 to 5%.Wines contain approximately 12% alcohol. However, fortified wines (prepared by adding brandy to wine) may contain about 20% of alcohol.

Table 1: Alcohol Preparations

Acute Effects of Alcohol, Opioid and Cannabis Use

Preparation of Alcohol

Concentration of alcohol by volume (%ABV)

Absolute alcohol (gms/100ml)

Standard Drink

Beer (standard)
Beer (strong)
Wines
Fortified Wines
Spirits (Whiskey, Rum, Gin, Vodka, Brandy etc) Arrack

3-4 8-11 5-13 14-20 40

2.3-3.1

6.2-8.6 3.9-10.1 10.9-15.9 31.2

25.7

300-400 ml. 100-150 ml. 100-250 ml. 60-90 ml. 30 ml.

40 ml.

The standard drink or a unit of alcohol corresponds to 10 ml of absolute alcohol.

One Standard Drink = 1⁄2 bottle of Standard Beer = 1⁄4 bottle of Strong Beer = 1 peg (30 ml.) Spirits = 1⁄2 packet of Arrack = 1 glass (125 ml.) of table wine = 1 glass (60 ml.) fortified wine

Absorption

Alcohol is rapidly absorbed from upper gas- trointestinal tract. Peak blood alcohol concen- tration (BAC) is reached in 30 to 60 minutes after consuming alcohol on an empty stom- ach. A number of variables influence the BAC attained. It rises slowly if the drink is sipped over a period but rapidly if it is gulped. The larger the quantity of absolute alcohol, the higher the peak BAC. Alcohol absorption may increase by as much as 20% as concentration rises. Carbonated beverages (e.g. soda) increase the rate of absorption of alcohol. Conversely, food in the stomach, especially carbohydrates, delays the absorption and peak BAC. There is no sex difference in the time to reach peak BAC though in women the peak BAC is 20% higher than in men since body water is only 50% of body weight compared to 60% in men. For the average person of 70 kg body weight, one drink (one standard unit of alcohol is 10ml of absolute alcohol, i.e. 7.87g) is likely to raise the BAC to approximately 15 to 20 mg/dl. Consumed over a period of an hour, 60ml and 90 ml of whisky produce BAC of 50mg/dl and 80mg/dl respectively.

Metabolism

Alcohol is eliminated from body at a rate of 7- 10 gm (1 standard drink) an hour. So, BAC may remain elevated for considerable periods following ingestion. If an individual drinks 9 large drinks (60 ml.) of whisky (18 units) dur- ing an evening, then alcohol will still be present in his blood at noon the following day.

Most of the alcohol in blood is metabolised in liver by oxidation. Small amounts of alcohol (2-4% of the total dose) are lost into the urine and into the alveolar air by diffusion. The al- cohol in alveolar air is in equilibrium with the alcohol in the blood passing through the lungs; a determination of the alcohol concentration in respiratory air by a breath analyzer can there- fore be used and estimate blood concentration for medico-legal purposes. The concentration of alcohol in the urine is less precisely corre- lated with the average blood concentration.

Alcohol is converted by the activity of enzyme Alcohol dehydrogenase (ADH) to acetalde- hyde, which is oxidized to acetate by the en- zyme Aldehyde Dehydrogenase (ALDH). Ac- etate thus produced is rapidly converted to

carbon dioxide and water. A variant of enzyme Aldehyde Dehydrogenase is found in some 40% oriental people. The individuals carrying this variant have a remarkably reduced capac- ity to metabolize acetaldehyde and thus in- crease in circulating acetaldehyde produces general vasodilatation with distinctive flushing response.

Acute Effects of Alcohol

Psychological Effects:

The effects of alcohol begin within about 15 minutes and last for several hours. Alcohol is a depressant of the central nervous system (CNS). In small amounts it sedates and relieves anxi- ety. Paradoxically, it may also give a sense of strength and result in boisterous behaviour. These latter effects seen as ‘drunkenness’ are mistaken to be different from the effects of other CNS-depressing sedatives. The excitement that some times follows drinking is a manifestation of CNS depression, not stimulation. Alcohol is generally taken not at bedtime as a hypnotic but as a social drug. This explains the more common occurrence of paradoxical excitement and accounts for the commission of crimes as well as the consequences of drunken driving. The behavioural manifestations of CNS-depres- sion by alcohol vary with the individual and with the setting. It heightens the mood prior to intake, be it sadness or happiness.

Despite being suitable and generally accepted as a social or recreational drug (relieves anxiety and promotes social behaviour), alcohol impairs judgement by reducing conscious self control during the period of intoxication. Coupled with a lack of insight into the impairment, the individual undertakes activities that can be risky – driving cars, operating machinery, besides indulging in social indiscretions such as unsafe sex.

Impairment of performance of real or simulated driving provides a generally accepted index to define drunken driving: blood alcohol concen- tration of 80mg/dl or more. This is achieved in the majority of persons after drinking 3 or more of 30 ml (1-oz) whisky within an hour.

The unpleasant effects that follow a drinking bout, usually the morning after, is at least partly a manifestation of withdrawal. For example, the first half of a night’s sleep after alcohol may be deeper than usual but is followed by a dis- turbed sleep pattern reflecting increased excit- ability. Also, other factors like keeping awake till late in the night, unaccustomed activity, anxiety and remorse besides certain trace in- gredients in the drink contribute to hangover. The manifestations of hangover include throb- bing headache, vertigo, tremors, weakness, fa- tigue, gastritis with nausea and vomiting and dehydration with persistent acidosis and labile blood pressure. It is self-limiting and subsides

Table 2: The acute effects that commonly occur at increasing blood alcohol concentrations (BAC)

Acute Effects of Alcohol, Opioid and Cannabis Use

BAC mg/dl

Effects

< 80

>80 100-200

200-300 300-350 355-600

Euphoria, feeling of relaxation and talking freely, clumsy movements of hands and legs, reduced alertness but believes himself to be alert.
Noisy, moody, impaired judgement, impaired driving ability Electroencephalographic changes begin to appear, Blurred vision, unsteady gait, gross motor in-coordination, slurred speech, aggressive, quarrelsome, talking loudly.

Amnesia for the experience – blackout. Coma
May cause or contribute to death

with fluids, but aspirin, antacid and sodium bicarbonate may be tried for early relief.

Physical effects:

Gastrointestinal effects: Alcohol in modera- tion is an appetizer and gastric acid secretion is increased. Alcohol irritates the gastric mu- cosa and therefore should be avoided by pa- tients with acid peptic disease. Alcohol ingested in a concentrated form even in the presence of food will cause gastritis with hyperaemia. This also leads to prolonged emptying time due to pylorospasm and decreased gastric motility, increased mucous and decreased acid secretion. Eventually, vomiting as well as gastric bleed- ing may occur. Alcohol also reduces the sphinc- ter pressure at both ends of oesophagus and impedes oesophageal peristalsis. It may lead to gastro-oesophageal reflux and oesophagitis. Vomiting occurs after a drinking bout and may result in a Mallory-Weiss tear in the mucosa of the cardio-oesophageal junction, leading to profuse gastrointestinal bleeding.

Cardiovascular effects: Acute alcohol intake may lead to depression of left ventricular function and may cause ventricular premature beats even in individual with no history of heart disease. The blood pressure usually decreases with small or extremely large doses, but actually increases with moderate doses. Vasodilatation is the primary cardiovascular effect of alcohol as well as its active metabolite acetaldehyde. It causes a warm, flushed skin and a subjective feeling of warmth. Loss of heat from the body is in- creased, raising the risk of hypothermia. Heart rate and stroke volume may increase, but brady- cardia may be seen with a very large intake. Anginal pain is sometimes relieved. This may be explained as analgesia due to central depres- sion but it may be due to reduced cardiac work consequent to generalised vasodilatation.

Respiratory effects: Small or moderate doses

cause stimulation of respiratory centre conse- quent to accumulation of acetaldehyde. Very large doses of alcohol cause the respiratory de- pression as part of the CNS depressant effect. Vomiting occurring in intoxicated individuals may lead to aspiration pneumonia.

Musculoskeletal System: Acute heavy intake of alcohol may lead to alcoholic myopathy. The spectrum of this disorder is wide; some indi- viduals may be asymptomatic and may be de- tected only because of increased serum creati- nine kinase levels, while others may develop acute rhabdomyolyis with myoglobinuria, acute tubular necrosis and fatal renal failure. However, most individuals present with muscle pain, mainly around shoulder and hip. This is often accompanied by muscular swelling and progressive weakness of lower limb muscles.

Diuresis: Initially, alcohol suppresses the ac- tion of antidiuretic hormone (ADH) and causes diuresis independent of the volume of fluid taken as a beverage. Later, urine volume gener- ally reflects fluid intake, but some sodium re- tention occurs.

Diagnosis of Alcohol intoxication

Clinically, a person can be said to be intoxi- cated if he exhibits significant maladaptive behavioural or psychological changes (e.g., in- appropriate sexual or aggressive behaviour, mood lability, impaired judgement, impaired social or occupational functioning) that devel- oped during, or shortly after alcohol ingestion. This is accompanied by one (or more) of the following signs: slurred speech, motor incoor- dination, unsteady gait, nystagmus, impair- ment in attention or memory, and stupor or coma.

By definition, such intoxication is due to the recent ingestion of alcohol and is reversible over a relatively short period of time (hours). In- toxication is readily recognized by eliciting his-

Acute Effects of Alcohol, Opioid and Cannabis Use

tory, examining the individual and conduct- ing blood examination for BAC. Breath ana- lyzers can satisfactorily discern intoxication too. Some breath analysers can give actual alcohol concentration but others only indicate whether it is above a preset threshold, (e.g. 60 mg/dl).

Table 3: Summary of acute effects of alcohol

done that are not produced from opium and may have very different chemical struc- tures than the opium alkaloids.

All these drugs produce a similar profile of acute effects and carry the risk of addiction. Mor- phine, pethidine, codeine and pentazocine are in medical use whereas methadone is used for maintenance of opioid addicts. The highly potent heroin has largely replaced morphine among illicit users in most countries. The term opiate is limited to the natural opium alka- loids and the semi-synthetics derived from them.

In India, apart from heroin, several opioids that are used as medications are also abused. Com- mon among these are codeine cough syrups, morphine and pentazocine injections, dextropropoxyphene capsules and buprenorphine tablets. Several abusers use them to tide over periods of non availability of heroin, but many individuals use them as pri- mary substance of abuse.

Route of administration

Heroin may be smoked, chased (inhaled) or injected (intramuscular or intravenous) and morphine is usually injected intravenously. When suitable vessels become unavailable, sub- cutaneous administration or “skin-popping” may be substitutes. Oral ingestion of opium as well as smoking through a special wooden pipe has been the traditional Indian method. Buprenorphine is either taken sublingually or dissolved in water and injected.

Absorption and metabolism

Opioids are less potent when taken by mouth than when injected, as they are readily metabolised in liver (first-pass metabolism). Opioids display “multi-compartmental” distri- bution : re-distribution occurs firstly into muscle, and then into poorly perfused tissues (e.g. fat). Their accumulation in body and satu- ration of tissue binding leads to prolonged ef- fects with chronic use. They generally have low plasma protein binding (e.g. Morphine 20- 30%, Methadone 60-90%)

Acute Effects of Alcohol, Opioid and Cannabis Use

Summary of acute effects of alcohol

Mental & Behavioural Effects

Physical Effects

Drowsiness

Impaired attention

Impaired memory

Impaired judgement

Impulsive behaviour

Inappropriate sexual behaviour

Aggressive behaviour

Inappropriate social conduct

Impaired occupational performance

Mood lability (rapid changes)

Stupor/Coma

Flushed face Rapid pulse Headache Stomach ache Diarrhoea Sweating

Slurred speech

Motor
in coordination

Unsteady gait

Nystagmus

Respiratory depression

OPIOIDS Pharmacological aspects

Opium and morphine occur naturally, and are the principal constituents of the poppy plant (Papaver somniferum). An opioid is any drug that activates the opioid receptors found in the brain, spinal cord and gut. There are three broad classes of opioids:

1. Naturally occurring opium alkaloids, such as morphine and codeine;

2. Semi-synthetics such as heroin, oxycodone and hydrocodone that are produced by modifying natural opium alkaloids.

3. Pure synthetics such as fentanyl and metha-

Table 4: Hepatic clearance of various opioids

Acute Effects of Alcohol, Opioid and Cannabis Use

Drug

Hepatic Clearance

Oral Bioavailability (approx.)

Morphine Pentazocine Buprenorphine Fentanyl

High

20-40% (variable)

Codeine Pethidine

Intermediate

50%

Methadone

Low

90%

Opioids undergo extensive metabolism. Me- tabolites may be active/toxic, e.g. Heroin, Co- deine, Pethidine. Renal excretion is a minor route of elimination, but may be very impor- tant in the excretion of active metabolites, e.g. Pethidine, Morphine. There is considerable inter-patient variability in the metabolism of

Table 5: Doses and duration of action of various

opioids. Heroin is metabolised to morphine in the body (liver and brain) and is rapidly ex- creted in the urine after conjugation with glu- curonic acid. Nearly 90 percent of the total urinary excretion of morphine occurs within 24 hours. The duration of action of heroin and morphine is about 4 hours.

opioids

Compound

Dose (mg)

Duration of Action (hr.)

Injected

Oral

Morphine
Heroin
Methadone Pethidine
Codeine Dextropropoxyphene Dihydrocodeine Buprenorphine Pentazocine

10 4 10 100 30 — 15 60 0.3

60
30
20
300
90
200
45
180
0.8 (sublingual)

4 3-4 6-24 3
4
8
4
3
7

Psychological effects:

Due to marked tolerance, the acute effects dif- fer widely between naive and chronic users. Dependent users injecting heroin or morphine describe short lived (less than a minute) in- tense experience -”rush”. It is described as a state of profound euphoria. There is also pain relief due to analgesia and a dreamlike state characterized by decreased responsiveness to the environment. These analgesic and sedative ef-

fects usually persist for hours outlasting the initial intense euphoria. It should be noted, however, that the euphoria is probably not an intrinsic property of the opiates. When given to a subject who has not previously experienced the effects of the drugs and who is not in pain, morphine and codeine will more commonly produce a subjectively unpleasant reaction. In the presence of pain or fear, the reaction of a patient to an opiate may be much less dyspho- ric, and in some people, the relief from anxiety

may be pleasurable enough to provoke a desire for repetition of the experience. Sedation is due to action in the brain stem. Reduced pain per- ception, is due to suppression of the spinal cord, mid brain and thalamus whereas euphoria is due to limbic system stimulation. Excitation with convulsions may occur at higher doses.

Physical effects

Gastrointestinal effects: Nausea and vomiting (stimulation of the chemoreceptor zone in the medulla), anorexia and constipation (decreased gastrointestinal motility).

Respiratory and cardiovascular effects: Respi- ratory depression and suppression of cough reflex. At higher doses, bradycardia and pos- tural hypotension may occur. Pulmonary oedema (with intravenous use) cyanosis and hy- pothermia are also seen. Skin may be warm and flushed due to peripheral vasodilatation.

Other effects: Itching may occur due to hista- mine release. Users experience a delay in ejacu- lation (and may take it to treat premature ejacu- lation) but prolonged use may lead to impo- tence.

OPIOID INTOXICATION

Opiate intoxication is classically characterized by the triad of pinpoint pupils, depressed res- piration and coma. The syndromic criteria for the diagnosis of opioid intoxication (DSM IV) are: Clinically significant maladaptive behavioural or psychological changes (initial euphoria followed by apathy, dysphoria, psy- chomotor agitation or retardation, impaired judgement or impaired social or occupation functioning) that develops during or shortly af- ter opioid use. This is accompanied by pupil- lary constriction (or pupillary dilatation due to anoxia from serve overdose), slurred speech, and impairment in attention or memory and either

drowsiness or coma. Illusions may occur in the absence of delirium as also hallucinations with intact reality testing (the person knows that the hallucinations are induced by the substance and do not represent external reality).

A suicidal or accidental overdose of opioids is an emergency. If opioid overdose is suspected, nalox- one must be immediately administered intrave- nously (0.4 mg).This is both diagnostic and therapeutic. If sensorium improves and pupils dilate it confirms the diagnosis of opioid intoxi- cation. Such timely intervention can sometimes be life-saving.

Table 6: Summary of acute effects of opiates

Acute Effects of Alcohol, Opioid and Cannabis Use

Summary of acute effects of opiates

Mental & Behavioural Effects

Physical Effects

Drowsiness Initial euphoria

Apathy or dysphoria Impaired judgement Impaired performance Psychomotor agitation or retardation Impaired attention and memory

Illusions or Hallucinations with insight

Pupillary constriction Slurred speech Slow respiration Slow pulse Stupor/coma

Pupillary dilation (anoxic)

CANNABIS

Cannabis is derived from the plant cannabis sativa, which grows in the wild all around the world. It is used in various forms such as Bhang- paste of leaves of the plant or dried leaves

Ganja – dried flowering stem of the plant Charas or hashish is extracted from the resin covering the plant.
Hash oil is made by extracting Cannabinoids from the resin by using organic solvents.

The active compounds in cannabis products are called Cannabinoids. Most potent among them is tetrahydrocannabinol (THC). The concentration of THC varies in different forms of cannabis products. Wild cannabis products have lower concentration whereas commercially produced cannabis products have higher con- centration of THC. Marijuana cigarette is a relatively mild preparation from various parts of uncultivated plants and delivers, on an aver- age, 2 to 5 mg of delta THC. Other prepara- tions used for smoking are ganja, which is ap- proximately three times more potent than marijuana, and charas, the pure resin (ten times stronger than marijuana). Liquid cannabis (hashish oil) is syrup extracted from cannabis resin with a non-aqueous solvent and is five times stronger than charas.

Table 7: THC concentration of Cannabis Products

In West, cannabis is also cooked in form of cakes and biscuits etc.

Forms

THC content (extremely variable)

Marijuana Ganja(cultivated) Hashish (charas) Hashish oil

1 – 3 % THC
6 – 20 % THC 10 – 20 % THC 15-30% THC (may be more)

Mode of use

Cannabis is used in several ways 1. Orally as:

(a) Milk based drink called Thandai is commonly used in North India especially on ceremonial occasions (Holi & Shivratri).

(b) Sweets

(c) Manoka, a dry slightly sweetish prepa- ration consisting of bhang paste and other materials. This is also sold as Ayurvedic medicinal preparation in certain parts of North India.

(d) Bhang is also mixed with flour to make ‘pakodas’ or ‘bhajji’.

Cannabis is unsuitable for intravenous use as it is relatively water insoluble and can lead to anaphylaxis due to undissolved particulate matter.

Cannabis is smoked in rural India, with social sanction, often in a group for relaxation and fellow feeling. Some smoke it in a religious context whereas others use it as an aphrodi- siac. Like alcohol, cannabis too reduces inhi- bition and increases desire but does not en- hance performance. Some users, nevertheless, claim to use it for the enhancement of sexual pleasure.

Absorption

In smoking, up to half of the active ingredi- ents are absorbed rapidly into the blood across the alveoli exerting their full effects in a few minutes. This occurs only if it is smoked with deep inhalations and retention in the lungs for some time period. Smoked (inhaled) cannabis is about three times more potent than when ingested orally due to more rapid absorption from the lungs, avoidance of hepatic first-pass metabolism and the enhanced release of delta THC from the pyrolysis of THC acids. Blood

2 .

Smoking:
(a) In cigarettes

Dried bhang leaves, ganja or charas can be mixed with tobacco in cigarettes and smoked.

(b) Clay pipes

Ganja is filled in clay pipes and smoked. This is the most common method in reli- gious settings and rural areas.

Traditional hookah or modern ‘bong’. In this, smoke passes through water before being inhaled.

Acute Effects of Alcohol, Opioid and Cannabis Use

levels of THC peak within minutes though sub- jective intoxication peaks only by about half an hour. Acute effects persist for a couple of hours. THC concentration in blood is a poor guide to level of intoxication as it correlates only moderately with cannabis intoxication partly because of its lipid solubility. Additionally tol- erance develops to many of the effects of can- nabis. The pharmacological effects of orally ingested cannabis occur after 30 minutes, peak in 2-3 hours and last 3 to 6 hours.

THC is highly protein bound and less than one percent of the absorbed drug enters the brain. It crosses the placenta, enters breast milk and induces hepatic enzymes. The plasma half- life in naive subjects is twice (50 to 60 hrs) that of a habitual user. The more active me- tabolites of THC (e.g. 11- hydroxy THC) have half-lives much longer than 50 hours. Follow- ing a single smoke of cannabis, therefore, THC and its metabolites remain in the body up to a month. Persistent activity in the blood can cause long term adverse effects on cognitive functioning of habitual users even when they are not apparently intoxicated. Likewise, the residual effects of intoxication may continue for several days. The hangover from acute in- toxication is demonstrable with impairment on neuropsychological and driving/flight simula- tor tests up to even 48 hours after intoxica- tion.

Psychological effects

Cannabis exerts the same diffuse depression of the CNS as alcohol and barbiturates. Besides sedation, it can also cause a paradoxical excite- ment due to disinhibition. A distinction must therefore be made between the pharmacologic effect of CNS depression and the manifest behaviour of excitement. The manifest behaviour in the individual, sedation or excite- ment, depends upon his personality, mental set and the setting. There may be a dreamy state with an increased tendency to fantasize and to accept suggestions. Large enough doses

cause a loss of consciousness (general anaesthe- sia). Animals when given lethal doses die of respiratory depression.

As the blood level of THC rises, there may be a state of euphoria and well being (high) and a dreamy, hypnogogic (hallucinations just prior to falling asleep) state of enjoyment. This is generally followed by a period of drowsiness. It is accompanied by ataxia and impaired per- formance. Even relatively modest amounts of cannabis can prolong reaction time and im- pair coordination and make the operation of heavy machinery hazardous. Dexterity and hand steadiness are both adversely affected. Alcohol, which is often concomitantly used, aggravates these adverse effects. Increased sen- sory acuity, which is largely subjective, does not compensate for the impaired psychomotor performance that places the cannabis user at risk. The tolerance developed by regular users to the adverse effect on psychomotor perfor- mance cannot be regarded as protective enough. The recognition and acquisition pro- cesses involved in the storages of short-term (hours to days) memory are the most affected, whereas long-term (months to years) memory is largely unaffected. The preferential concen- tration and action of THC in the hippocam- pus accords with and explains these effects. The EEG effects are similar to that seen with seda- tives – slowing of frequency, increased alpha and decreased beta electrical activity.

Other psychological effects include perceptual and sensory distortions. Capacity for depth perception declines and scenes appear to have greater depth. Sounds and colours may become more intense alongwith derealization (what is seen or heard has an air of unreality) and dep- ersonalization (ones own body feels unreal). Subjective sense of time seems to be much slower than it actually is. Dysphoria, restless- ness, fear and even panic may spoil the experi- ence (“bad trip”). Delirium occurs as a com- plication only rarely in neurologically intact

Acute Effects of Alcohol, Opioid and Cannabis Use

individuals. In such cases, symptoms of de- lirium, psychosis, or anxiety seldom persist be- yond 48 hrs after acute cannabis intoxication. If they do so, the probability is high that they are a continuation of pre-existing psychopathol- ogy. The acute psychotic reaction is self-limit- ing, generally polymorphous and stormy. An acute organic state, phenomenologically indis- tinguishable from delirium, may follow cannabis use (generally at a high dose – 250 micrograms/ kg of THC). Altered brain amine levels and/or inhibition of cholinergic transmission may be responsible for the same. Emotional turmoil, excitement, paranoid (unwarranted suspicion) or hypomanic symptoms and hallucinations may predominate. There may be driven activ- ity (subject knows that one’s activities are mean- ingless, yet is unable to control them). Halluci- nations are vivid, well formed and commonly visual.

Physical effects: Gastrointestinal Effects

Physical effects of acute low dose cannabis (50 micrograms/kg of delta-9-THC) include dry mouth, thirst, increased appetite and consti- pation.

Cardiovascular effects

Cardiovascular effects include rise in blood pres- sure and tachycardia. The increase in heart rate of upto 50 percent over baseline occurs within a few minutes and persists for a few hours. It also causes vasodilatation and red- dening of conjunctivae which is a characteris- tic sign of cannabis use. Vasodilatation may lead to postural hypotension and fainting. The ear- liest indication of intoxication in naive users is a feeling of “light-headedness.” Most of these cardiovascular changes are clinically inconse- quential except that they can magnify anxiety and contribute to the panic (sudden, intense fear) attacks sometimes experienced by them. However these effects may lead to serious car- diac complications in individuals with pre ex-

Acute Effects of Alcohol, Opioid and Cannabis Use isting heart disease.

Respiratory system

Cannabis smoke contains carbon monoxide and carcinogens similar to those in cigarette smoke. Smoking a cannabis cigarette leads to about five fold increase in carboxy-hemoglobin con- centration and three fold greater inhalation of tar and retention of tar in respiratory tract. This happens mainly because cannabis is smoked with deep and prolonged inhalation. Cannabis leads to irritation of the bronchial mucosa from smoking and a mild bronchoconstriction followed by bronchodilation.

Ophthalmic effects

Decreased intraocular pressure, and rarely pho- tophobia, nystagmus and conjunctival injec- tion are acute effects of low dose of cannabis on eyes. Higher doses (250 microgram/kg of THC) produce ptosis and miosis.

Diagnosis of cannabis intoxication

The syndrome criteria for the diagnosis of can- nabis intoxication (DSM IV) are:

Clinically significant maladaptive behavioural or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgement, social with- drawal) that developing during or shortly after cannabis intake and two (or more) of character- istic signs (conjunctival injection, increased appetite, dry mouth, tachycardia) developing within two hours of cannabis use. Illusions may occur in the absence of delirium as also halluci- nations with intact reality testing.

Usually mood alterations and perceptual distor- tions are inconsequential and do not require any- thing more than reassurance. However, in a “bad trip” with psychotic excitement, prompt relief may be obtained with parenteral haloperidol (5- 10mg). If psychotic disturbance persists beyond 1 or 2 hours referral to a psychiatrist is advised.

Table 8: Summary of acute effects of cannabis

To recapitulate, this chapter helps the medical officer to perform his role as an educator, as a medical expert in medico-legal cases, as a diag- nostician and as a therapist. Alcohol, opiates and cannabis exert profound mental and physi- cal effects. These effects are influenced by prior experience, pattern of use, physiological, psy- chological and psychosocial factors. The medi- cal officer should consciously include these as- pects while taking history and examining the patients. Whenever intoxication is suspected, suitable action will aid accurate diagnosis and prompt treatment. Taking care of the unwanted acute effects is an important task in the overall care of drug and alcohol dependent individuals.

Acute Effects of Alcohol, Opioid and Cannabis Use

Mental & Behavioural Effects

Physical Effects

Drowsiness
(at high doses) Euphoria
Anxiety Suspiciousness Expectations of harm Sensation of slowed time
Social withdrawal Impaired judgement Illusions & halluc- inations with insight

Red eyes
Dry mouth Thirst
Increased appetite Tachycardia (or Bradycardia at high doses)
Light headedness (Postural hypotension)

Suggested Reading:

1. Adams IB and Martin BR. Cannabis: phar- macology and toxicology in animals and hu- mans. Addiction, 1996; 91:1585-1614.

2. American Psychiatric Association (1994) Di- agnostic and Statistical Manual of Mental Disorders (fourth edition). APA: Washing- ton, DC.

3. Frances, RJ, Mille SI (1998): Clinical Text-

book of Addictive Disorders. Guilford Press.

4. Lowinson JH, Ruiz P, Millman RB, Langrod JG (1997). Substance Abuse: A compre- hensive text book Lippincott Williams & Wilkins.

5. Miller, NS (1991): The Pharmacology of Alcohol and Drugs of Abuse and Addiction. Springer-Verlag: New York.

Suggested slides for OHP

Slide 1

Factors influencing Acute Effects of Alcohol, Opioids and Cannabis

Prior Experience (Occasional/Regular/Dependent) Pattern of use (Oral/injected/inhaled) Physiological (Genetic Predisposition) Psychosocial (Mental Set/Social Ambience)

Moody
Impaired judgement Poor driving skills EEG slowing

Slide 6

Blood Alcohol Level 100-200 mg/dl Blurred vision

Unsteady gait Incoordination Slurred speech Aggressive Quarrelsome

Slide 7

Very High Blood Alcohol Levels

Slide 8

Alcohol: Pharmacokinetics
Onset of Effects <15 Minutes

Diffusion into alveolar air (proportional to blood levels)
Major metabolism in liver
Urine excretion 2-4%

Slide 9

Alcohol: CVS Effects
Smaller dose decreased BP

Larger dose increased BP
Initial vasodilatation (relieves anginal pain and feel- ing of warmth)
Tachycardia

Slide 10

Alcohol: GIT & Other Effects Increased gastric acidity

Slide 2

Determinants of Blood Alcohol Concentration Quantity

Concentration (Window Effect) Body Fat (Women)
Addition of carbonated beverages Empty stomach

Body weight (Men) Carbohydrate food

Slide 3

Alcohol Concentration & Drinks Beers 4-8%
Wines 12%
Whisky 40%

Illicit 35-50%

Acute Effects of Alcohol, Opioid and Cannabis Use

Level (mg/dl)

Effect

200-300 300-350 >350

Amnesia / Blackout Coma
May lead to death

I Unit= 10gm Absolute alcohol
In 70kg person 1 Unit gives blood levels of 15-20 mg/dl

Slide 4

Blood Alcohol Level <80mg/dl Euphoria

Relaxed feeling
Talks freely
Clumsy movements
Decreased alertness but unaware Normal speech

Slide 5

Blood Alcohol Level 80-100mg/dl Noisy and loud speech

Increased acid peptic disease Hemetemesis
Low doses increased respiratory rate Large dose depressant
Facilitates diuresis.

Slide 11

Diagnosing Alcohol Intoxication Inappropriate behaviour

Impaired Judgement Labile Mood

Slurred speech, incoordination, Ataxia, Nystagmus, Lowered sensorium on examination
h/o recent alcohol ingestion

Breath Analyzer/Blood Alcohol Level

Slide 12

Opiates & their use
Natural – Opium, Morphine

Synthetic – Heroin, Methadone Medical Use & Non medical abuse Oral, injectable, inhaled (chasing)

Slide 13

Opiates: Absorption and elimination
Absorption through stomach/duodenum/lungs

Hepatic Glucuronidation Urinary excretion
Most elimination in < 24 hours

Slide 14

Diagnosing Opiate Intoxication

Symptoms

Euphoria, Apathy, dysphoria Psychomotor changes Impaired judgement

Signs

Miosis, drowsiness Slurred speech Lowered sensorium

Naltrexone 0.4 mg Intravenous; Diagnostic and thera- peutic effect

Slide 15

Cannabis Preparations

Plant – Cannabis Sativa
Marijuana Cigarette – 2-5 mg of THC
Ganja – Flowering tops of female plant Charas/hashish – Pure resin (10 times more potent)
Hash oil – extract of Cannabinoids in organic solvents (50 times more potent)
Bhang – orally consumed

Slide 16

Cannabis:
Rapid absorption after smoking

Crosses placenta, present in milk Long half life – upto 50 hours

Impaired neuropsychological performance upto 48 hours after last smoke

Slide 17

Diagnosing Cannabis Intoxication

Symptoms

Impaired motor coordination Euphoria/anxiety/dysphoria Sensation of slowed time Poor judgement

Social withdrawal

Signs

Conjunctival injection Dry mouth & appetite Tachycardia

H/O Recent (2-3Hrs) Cannabis Use Symptomatic Relief-Haloperidol Use

Acute Effects of Alcohol, Opioid and Cannabis Use

Health Hazards of Long Term 5 Alcohol, Opioid and Cannabis Use

K Srinivasan, KS Chandramauli

Summary

Alcohol abuse and abuse of illicit drugs are a major health problem and its management calls for a concerted effort from all sections of the medical community. An effort has been made in this chapter to familiarize the clinician with the possible medical complications of alcohol and drug abuse. A drug abuser’s first contact with the health system might be because of a physical complication and the general practi- tioner is at a vantage position to identify the problem early and offer help to the individual and his family. In order to provide compre- hensive health care, a practitioner might have to liaise with other medical experts and he will need to establish contact with local drug treat- ment centres and non – governmental organi- zations, which offer rehabilitation and long term help to drug abusers. Most patients who present to a primary health centre do so with a relatively minor complication or early in the course of a chronic medical complication re- sulting from drug abuse. The physical compli- cations in majority of these patients improve with abstinence from alcohol or drug use.

Table –1 Diseases Associated with Alcohol Use

Introduction

Community surveys, hospital based studies and mortality indices all suggest an increased preva- lence of alcohol and drug abuse in contempo- rary society. People who abuse alcohol are fre- quent users of the health care system. It is esti- mated that alcoholism is about 1.5 times more prevalent than diabetes in the community. Unfortunately, less than 20 % of such patients are identified and offered treatment.

A similar trend is seen in the increased preva- lence of abuse of drugs, such as heroin, with its attendant health risks. Thus, it is clear that alcohol and drug abuse related problems are major national health concerns. General prac- titioners and primary health care givers have a key role to play in the early identification and treatment of such problems.

Health Hazards of Long Term Alcohol Use

(Table 1)

Daily drinking of alcohol is associated with a wide range of medical complications.

Organ System

Disease

Gastrointestinal
system
Nutritional deficiencies Haematological disorders Cardiovascular system Central nervous

system
Metabolic disorders Miscellaneous

Cancers

Fatty liver, Alcoholic Hepatitis, Cirrhosis, Esophagitis, Acute gastritis, Pancreatitis, Malabsorption
Thiamine, Pyridoxine, Vitamin A, Folic acid, Ascorbic acid
Anaemia, Leucopenia, Thrombocytopenia

Cardiomyopathy, Hypertension
Wernicke- Korsakoffs syndrome, Dementia, Cerebellar degeneration, Peripheral neuropathy, Myopathy, Head injury
Ketoacidosis, Hypoglycaemia, Hypocalcemia, Hypomagnesemia Fetal alcohol syndrome, Osteoporosis, Tuberculosis, Psoriasis, Domestic & traffic accidents
Oral, Esophagus, Colon, Hepatocellular, Breast (women)

GASTROINTESTINAL SYSTEM 1. Alcoholic Liver Disease

Alcoholic liver disease refers to a spectrum of clinical conditions: Fatty liver, Alcoholic hepa- titis and Cirrhosis. Fatty liver is often associ- ated with moderate consumption of alcohol, while alcoholic hepatitis and cirrhosis are usu- ally seen in heavy drinkers. Daily heavy drink- ing places most individuals at a great risk to develop liver disease. Women who drink daily develop cirrhosis much earlier than men. Con- tinuous daily drinking is more likely to lead to liver damage than intermittent drinking. It must be stressed that a person need not be physically dependent on alcohol to develop liver disease.

Fatty Liver

Patients with fatty liver are usually asymptom- atic. The clinical features and investigations necessary to diagnose fatty liver are given be- low (Table 2). On abstaining from alcohol, clinical symptoms and liver function tests be- come normal. Complete abstinence from alco- hol must be emphasised as the condition is totally reversible.

Table 2: Fatty Liver

Most patients with alcoholic hepatitis improve with abstinence and require minimal medical intervention. However, in some, the onset may be fulminant and in such cases the short term mortality may be as high as 20-60 %. The clini- cal picture in these patients is one of florid hepatic failure and they should be referred to a hospital for further treatment. Treatment is generally supportive. An adequate nutrition and fluid electrolyte balance needs to be main- tained. Nasogastric feeding becomes necessary only in severally ill patients. Treatment of com- plications necessitates referral to a hospital. Glucocorticoids are useful in patients with se- vere disease. Following abstinence, the clinical symptoms resolve in about six weeks time. However, in those individuals who continue to drink, alcoholic hepatitis may progress to cirrhosis. Poor prognostic factors are

. a) very high levels of bilirubin

. b) prolonged prothrombin time that is unre- sponsive to Vitamin K and

. c) presence of encephalopathy.

Table – 3: Alcoholic hepatitis

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Symptoms

Signs Investigations

Complications

Treatment Prognosis

Anorexia, nausea, vomiting, pain abdomen, fever

Icterus, tender hepatomegaly

Elevated AST, ALT & bilirubin, prolonged prothombin time

Fulminant hepatic failure, ascites, encephalopathy, gastrointestinal bleed, coagulopathy

Supportive, Glucocorticoids

In the absence of complications reversible with abstinence

Fatty Liver

Clinical Features

Symptoms Signs Investigations

Treatment Prognosis

Often asymptomatic Hepatomegaly

Elevated AST, ALT, Bilirubin

Abstinence

Completely reversible with abstinence

Alcoholic hepatitis

Patients with alcohol induced hepatitis can mani- fest a wide range of clinical features (Table–3).

Presence of complications would require refer- ral to a hospital.

Cirrhosis (Table 4, 5)

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis Table – 5 Cirrhosis : Investigations

Liver function tests

Liver biopsy

Abdominal ultrasound

Endoscopy

Ascitic fluid analysis

Serum bilirubin, AST, ALT, (not diagnostic) may be elevated, prothrombin time prolonged, serum al- bumin low

Diagnostic

Useful non – invasive test for evaluation of cirrhosis

Diagnosis of varices and evaluation of hematemesis

Diagnosis of ascites and bacterial peritonitis

About 8-39% of subjects who abuse alcohol daily develop cirrhosis. Onset of the clinical syndrome of cirrhosis is often insidious. The clinical signs and symptoms of cirrhosis are presented in Table – 4. As cirrhosis of liver is often accompanied by various complications (Table – 4), patients suspected of cirrhosis should be referred to a hospital for an initial evaluation and subsequent treatment can be carried out in a primary health care setting based on the advise of the specialist.

Table – 4 Liver Cirrhosis : Features

Symptoms

Signs

Complications

Anorexia, weight loss, ab- dominal discomfort, dis- tension of abdomen

Jaundice, spider naevi, clubbing, parotid enlarge- ment, palmar erythema, gynaecomastia, testicular atrophy, Dupyutren’s con- tracture, distended veins over abdomen, hepatome- galy or shrunken liver, sple- nomegaly, ascites

Ascites, variceal bleed, he- patic encephalopathy, spontaneous bacterial peritionitis, hepatic failure, renal failure

Treatment of cirrhosis includes a complete ab- stinence from alcohol with good nutritional and vitamin supplementation.

Table 6 – Cirrhosis: Treatment

Abstinence from alcohol

Good nutrition : 2000 – 3000 calories / day

Protein: 1 gm/kg, if no encephalopathy

Vitamin supplementation particularly thia- mine and folate

Treatment of associated complications in a hospital setting

Initial assessment and treatment in a hospi- tal setting

Patients to be referred to hospital for initial evaluation when cirrhosis is suspected.

The investigations that are necessary in cirrho- sis are dictated by the presence of associated complications and are listed in Table – 5

The management of associated complications would require referral to a hospital and such patients can later be followed up in a primary health centre based on the advice of a specialist.

Hepatic Encephalopathy

Hepatic encephalopathy can occur in patients with alcoholic hepatitis and /or cirrhosis. Table – 7 lists the clinical features and the abnormal

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

If facilities available

Ryles tube – Continuous aspiration
Refer to tertiary care centre

Vasopressors for hypoten- sion, Blood transfusion Vasopressin, somatostatin infusions Sengstaken tube

findings on laboratory investigations in cases of acute hepatic encephalopathy. Treatment of acute hepatic encephalopathy must be carried out in an inpatient hospital setting under the care of a specialist.

Table – 7 Hepatic Encephalopathy: Clinical features

Symptoms

Signs

Precipitating factors

Investigations

Immediate measures

Agitation, mood swings, confusion, disorientation, disturbed sleep, altered sensorium, coma

Flapping tremor, Hyperre- flexia, coma

G.I. bleed, infection, increased protein intake, use of sedatives, Electrolyte imbalance

Elevated levels of serum ammonia, abnormal liver function tests, prolonged PT, abnormal EEG

Low protein diet / supplement carbohydrates, Bowel wash, syrup lactulose, Antibiotics : Amoxycillin; Later referral to a specialist care in a hos- pital setup

Variceal Bleed

Clinical manifestations and management of variceal bleed are listed in Table –8

Table – 8 Variceal bleed: Clinical features and management

In summary, the management of alcohol liver disease is directed towards the treatment of the associated complications. However, the most important element in the treatment process is to help the patient to stop drinking.

2. Oesophagus

Alcohol alters the oesophageal motility result- ing in defective oesophageal clearance. What is more important, however, is that chronic alco- hol use reduces the oespohageal sphincter pres- sure leading to reflux oesophagitis. These pa- tients improve with symptomatic treatment and abstinence. Occasionally, due to severe retching following an alcoholic binge, an indi- vidual might develop a tear in the lower end of the oesophagus resulting in haematemesis (Mallory – Weiss Syndrome) and such patients would require referral to a hospital for further management.

3. Stomach

Alcohol delays gastric empting and disrupts the mucosal barrier resulting in gastritis. Its role in the development of chronic gastritis, how- ever, remains doubtful. Following a bout of heavy drinking, haemorrhagic gastritis might develop resulting in gastrointestinal bleeding.

4 . Small Intestine

Contrary to its effect on the oesophagus and stomach, alcohol increases the intestinal mo- tility leading to diarrhoea. This effect, com- bined with derangement of the villous archi-

Symptoms of signs

Immediate measures

Hematemesis, malena, worsening ascites, encepha- lopathy, hypotension

Vital signs record
IV fluids : Normal saline, Hemmaccel if hypotension

tecture, results in decreased absorption of wa- ter, sodium, glucose, aminoacids, folic acid and thiamine. Among these, folate deficiency is the most common clinical manifestation.

5. Pancreas

The association between alcohol use and pan- creatitis is well known. The clinical signs and symptoms of acute pancreatitis are listed in Table – 9. Pain in pancreatitis can be acutely brought on by a drinking binge. Patients sus- pected of pancreatitis should be referred to a specialist for evaluation and treatment.

Table – 9 Acute Pancreatitis: features

these symptoms is a state of protein calorie malnutrition. Multiple vitamin deficiencies are frequently associated with chronic alcohol use (Table – 10). After initial treatment and cor- rection of the depleted body stores of various vitamins, it is essential to continue the patients on a maintenance dose till the patient starts taking a normal diet.

Table 10. Alcohol Abuse: Nutritional Deficiencies

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Substance

Signs and Symptoms

Protein calorie malnutrition

Vit B1 deficiency

Vit B2 deficiency Vit B6 deficiency Vit A deficiency

Vit C deficiency

Weight loss, lethargy, fatigue

Beriberi, Wernicke – Korsakoff syndrome

Pellagra
Peripheral neuropathy

Night blindness, keratomalacia

Scurvy

Symptoms Signs Investigations

Complications

Treatment

Abdominal pain radiating to back, nausea, vomiting

Tenderness in upper abdo- men

Elevated serum amylase, X- Ray abdomen,Ultra sound abdomen

Coagulopathy, shock, pan- creatic abscess, pancreatic pseudocyst

Supportive, IV fluids, NPO, NG aspiration, re- ferral for complication

Features of chronic pancreatitis include recur- rent pain abdomen, diabetes mellitus and mal- absorption

NUTRITONAL DEFICIENCIES

Alcohol has a direct appetite suppressant ef- fect. In addition, because of its high caloric content, it is often substituted for food. Alco- hol also interferes with the absorption of vari- ous nutrients. As a result, individuals who drink large amounts daily present with easy fatiga- bility, lethargy and weight loss. Underlying

Treatment comprises of high calorie, high pro- tein diet and vitamin supplements.

HAEMATOLOGICAL DISORDERS

Apart from the effects of associated nutritional deficiencies, alcohol, due to a direct depres- sant action on the bone marrow, can cause anaemia, leucopenia and thrombocytopenia. Anemia can also be secondary to an acute or chronic blood loss from the gastrointestinal tract and hypersplenism. Coagulopathies due to diminished production of vitamin K depen- dent factors might complicate the picture in chronic liver disease and such cases would need detailed evaluation and treatment in a hospi- tal setting.

CARDIOVASCULAR SYSTEM

Alcohol directly affects the heart musculature

resulting in the development of alcoholic car- diomyopathy. This condition is seen after many years of heavy drinking (>10 yrs). Alco- holic cardiomyopathy may present with car- diac failure and arrhythmias. Mural thrombi may be present in patients with chronic con- gestive failure. There is a strong association between moderate to heavy consumption of alcohol and hypertension. This association is clinically relevant in middle aged hypertensives. Eliciting history of alcohol abuse is important when treating a hypertensive patient. Alcohol interferes with antihypertensive therapy and heavy drinkers may fail to respond to standard medical treatment. Alcoholic hypertensive may become normotensive following abstinence.

Table 11 – Alcohol Abuse: Cardiovascular Com- plications

Will need specialist evaluation for initiation of treatment.

NERVOUS SYSTEM

Chronic alcohol use can produce a significant alteration in the functioning of both central and peripheral nervous system (Table 12). Some of the complications are due to a coexist- ing thiamine deficiency, while a direct neuro- toxic effect is also responsible for many of the manifestations.

Table 12 – Alcohol Abuse: Neurological Mani- festation

Will need specialist evaluation and treatment.

Wernicke – Korsakoff Syndrome

Alcohol associated thiamine deficiency is re- sponsible for Wernicke – Korsakoff syndrome (Table 13). Thiamine deficiency in alcoholism results from inadequate intake of thiamine, interference with its absorption from the gas- trointestinal tract and impairment of its stor- age in the liver. The clinical presentation of Wernicke’s encephalopathy and its treatment are presented in Table – 13. With therapy, ocular signs usually resolve quite rapidly. The psychological symptoms take a longer time to recede. In spite of treatment, the gait difficulty may persist in up to 50% of patients. If prompt treatment is not instituted, mortality occurs in about 20% of cases of Wernicke’s encephal- opathy. With treatment, as the acute neuro- logical symptoms subside, the memory diffi- culties may become apparent. This picture, referred to as Korsakoff syndrome, often fol- lows the acute Wernicke’s syndrome. It is char- acterized by an inability to remember imme- diate past events and also difficulty in retain- ing newly learnt material. Studies have shown that only about 25% of patients with Korsakoff syndrome respond to treatment with thiamine. Among the rest, the memory deficits tend to persist.

Table – 13 Wernicke – Korsakoff Syndrome : Clinical features and Therapy

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Hypertension

Cardiomyopathy – chronic congestive failure, mural thrombi, arrhythmias

Clinical features

Ocular muscle paralysis Strabismus, gaze paralysis, Nystagmus
Ataxia, confusion, drowsiness

Therapy: Thiamine 50mg i.v. + 50mg i.m stat and 50 mg i.m. daily till patient recov- ers followed by oral supplementation.

Sequelae: Deficit in recent memory and learning, Psychosis, Persisting memory defi- cits in spite of treatment with thiamine. (may be permanent)

Peripheral neuropathy
Wernicke – Korsakoff syndrome Cerebellar degeneration
Dementia
Myopathy
Cerebro-Vascular accidents

Treatment of Wernicke’s encephalopathy is a medical emergency and involves prompt cor- rection of thiamine deficiency. Initially parenteral administration of thiamine is nec- essary. This is to be followed by oral supple- mentation of thiamine for several weeks. Acute glucose load, in the form of an intravenous glu- cose drip, must be avoided in alcoholic patients as the glucose load can precipitate a Wernicke’s encephalopathy. When glucose infusion be- comes a necessity, it must be preceded by ad- equate thiamine supplementation.

Alcoholic Dementia

Memory difficulties, inattentiveness and an inability to maintain concentration are com- monly seen in chronic alcoholics. Occasionally, these might progress on to frank dementia characterised by personal and social deteriora- tion, memory lapses and difficulty in carrying out every day tasks. There is a decline in intel- lectual ability. Alcoholic dementia generally appears after many years of heavy drinking. CT scan may reveal cerebral atrophy. Abstinence from alcohol leads to a reversal of both, the cognitive deficit and the radiological abnormal- ity. It is important to remember that cognitive impairment in chronic alcoholics might inter- fere with their ability to comply with treat- ment regimens.

Alcoholic Cerebellar Degeneration

Alcoholic cerebellar degeneration is characterised by ataxia affecting the trunk and lower limbs. The upper extermities are affected less often than the lower limbs. Patients present with a broad based stance and gait difficulty. These symptoms become more prominent during acute binges or alcohol withdrawal states. The progression of the disease process is slow. The etiology is still largely unknown. Abstinence from alcohol and nutritional supplementation might result in some im- provement over many months.

Peripheral Neuropathy

Peripheral neuropathy seen among alcoholics results from vitamin deficiencies, especially, thiamine, pyridoxine and pantothenic acid. The onset of the symptoms is insidious and the progress is slow. Typically, patients com- plain of pain, paraesthesias and weakness, with symptoms being generally more prominent in the lower extremities. Paraesthesias are particu- larly distressing. Symptoms are more striking in the distal part of the limbs (glove and stock- ing distribution) and progress proximally as the disease advances. On physical examination, there is loss or diminution of ankle jerks. Sen- sory examination reveals loss of superficial touch, position sense and vibratory sensation. These changes are usually symmetric. Treat- ment involves vitamin supplementation, along with physical therapy to preserve muscle strength. Recovery is slow. Tricyclic antidepres- sants and carbamazepine have been used to al- leviate pain. Alcoholism might affect the auto- nomic nerves resulting in impotence, postural hypotension and bladder or bowel dysfunction.

Alcoholic Myopathy

Chronic use of alcohol is sometimes associated with progressive muscle weakness. Character- istically, the proximal group of muscles of the lower limbs is involved. Patients usually com- plain of difficulty in climbing staircases or walk- ing on an uneven ground. On physical exami- nation, subjects have difficulty in getting up from squatting position without support. Di- agnosis is confirmed by muscle biopsy. Treat- ment consists of abstinence & physiotherapy.

Alcohol and Accidents

There is a three- fold increase in accident rate among alcoholics. Besides road traffic accidents, alcoholics are at a greater risk to be involved in accidents at home and at the work place. Head injury in an alcoholic is particularly common. It has been reported that more than 20% of accident related head injury is associated with

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

recent alcohol consumption in our country. An alcoholic who has had a head injury is a diffi- cult patient to manage. Treatment of alcohol withdrawal syndrome with sedatives may in- terfere with the assessment of head injury. A closed head injury sustained during an intoxi- cated state may not be reported to a clinician and thus, a potentially treatable condition such as a subdural haematoma might be missed with disastrous consequences for the patient. Often alcoholic patients with head injury behave aggressively and this interferes with the evalu- ation and treatment process. Thus, a high in- dex of suspicion is necessary in diagnosing head injury among alcoholics and, when in doubt, a CT scan must be ordered to rule out signifi- cant head injury. The presence of an altered level of sensorium, headache accompanied by vomiting, epileptic fits or the appearance of neurological signs such as papilloedema, hemi- paresis and extensor plantar response are some of the obvious pointers to the presence of head injury. Patients with head injury must be re- ferred to a neurosurgeon for proper assessment and treatment. It is important to remember that an altered state of sensorium in an alco- holic patient could be due to various other causes and thus calls for a detailed evaluation (Table – 14).

Table –14 Altered Sensorium in Alcoholics Differential diagnosis and Treatment

MISCELLANEOUS CLINICAL CONDI- TIONS:

Foetal alcohol syndrome

About one third of children born to mothers who continue to drink during pregnancy show features of foetal alcohol syndrome. Typically, these children have reduced body weight and height, are hyperactive and have subnormal intelligence. Their faces may be recognized by short palpebral fissures, short upturned noses, mid facial hypoplasia, low nasal bridge and a thin upper lip. Hence, it is advisable that preg- nant women should abstain from alcohol.

Alcohol and Metabolic Effects

Alcohol can cause a wide variety of metabolic disturbances including ketoacidosis, hypo- magnesemia, hypocalcemia, hypophos- phatemia and hypoglycemia. Among these, ketoacidosis and hypoglycemia are frequently encountered during clinical practice.

Others

Alcohol can accelerate the development of os- teoporosis, especially in women drinkers. Al- cohol reduces bone mass. Recent studies have suggested a link between alcohol abuse and psoriasis. Finally, alcohol affects the immune system and lowers resistance to infection. Tu- berculosis is frequently seen amongst alcohol- ics.

Health Hazards of Long Term Opiate and Multi Drug Abuse (Table – 15)

Opiates refer to a group of drugs derived from the poppy plant Papaver somniferum and to their synthetic and semisynthetic derivatives. The naturally occurring opiate plant alkaloids include morphine, thebaine and codeine. How- ever, it is the synthetic and semi-synthetic de- rivatives of opiates such as heroin, pethidine, buprenorphine, pentazocine and methadone, which have attained notoriety because of their abuse potential. Among these, the abuse of

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Clinical condition

Treatment

Alcohol intoxication Coma due to heavy alcohol ingestion

Hypoglycaemia

Alcohol withdrawal Delirium tremens

Head injury Post –ictal state

Wernicke’s Encephalopathy

No specific treatment Dialysis is life saving

I.V. glucose infusion with I.V. thiamine

Benzodiazepine (diazepam)

CT scan and referral to a neurosurgeon

Anticonvulsants and referral to a physician

Thiamine supplementation

heroin (di-acetyl morphine) has assumed epi- demic proportions in recent times. The vari- ous medical complications that arise due to long term use of heroin are related to the mode of administration rather than the direct effect of these drugs. Besides, the presence of impuri- ties in the street sample of heroin might lead to additional medical problems. Regular use of drugs like heroin often results in social dete- rioration, neglect of personal hygiene and a decline in living standards. Consequently, they suffer from various nutritional deficiencies and are more prone to develop infections. Studies have shown that mortality rates are high among regular drug users with death resulting from overdose, complications due to the use of non- sterile injecting procedures, serious accidents due to falls and Human – Immuno Deficiency Virus infection.

Table – 15 Opiate abuse: Medical complica- tions

Cellulitis

Cellulitis refers to a spreading infection of the subcutaneous tissue. In an intravenous drug user, cellulitis results from the use of contami- nated needles and this can develop into an ab- scess. Occasionally, sterile abscesses can occur as a result of the irritant effects of the impuri- ties present in the injected drug. Swabs from the wound should be taken (if possible) for bac- teriological culture. Appropriate antibiotic therapy should be initiated. Abscess needs to be drained and in cellulitis, the affected part must be rested in an elevated position, if pos- sible.

Thrombophlebitis

The irritant effect of the additives in the in- jectable drug can cause thrombophlebitis. Se- vere thrombophlebitis leads to venous obstruc- tion with consequent edema of the affected limb. Treatment involves resting the affected limb in an elevated position. Anticoagulants are useful if venous thrombosis is present. Crepe bandage and elastic stockings help to alleviate oedema after the acute stage is controlled.

Endocarditis

In endocarditis, the heart valves get infected. The masses of blood clot and bacteria might then embolize to other organs where they act as septic foci of infection. In general, endocardi- tis develops on damaged heart valve, but among parenteral drug abusers, it can develop in a healthy heart. The major source of infection is the contaminated needle which introduces the bacteria directly into the venous blood. These reach the right side of the heart. Consequently, tricuspid valves are commonly affected in in- travenous drug abusers. The presence of high grade fever with cardiac murmurs should alert the clinician to a possible diagnosis of en- docarditis. It must be remembered that right sided endocarditis may present without mur- murs as the infection can develop even with a

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Mechanism

Medical complication

Related to mode
of self administration of drug – parenteral

Related to mode of self administration of drug –
inhalation (chasing)

Socio – economic decline in living standards

Poor immune status Miscellaneous

Cellulitus, thrombo- phlebitis, endocarditis, septicaemia, hepatitis B and C, AIDS, pulmo- nary hypertension

Chronic bronchitis, respiratory infections

Nutritional deficiencies, multiple vitamin deficiencies

Recurrent infections, pulmonary tuberculosis

Overdose (accidental, deliberate) accidental injury during intoxicated state

normal valve. Among patients with right sided endocarditis, pulmonary complications (pneu- monia, embolism) because of septic emboli into the lungs are commonly seen. Patients sus- pected of endocarditis must be initially evalu- ated by a specialist but can be followed up in primary health care centre once the acute phase is over.

Septicaemia

Septicaemia should be considered in any intra- venous drug abuser who presents in a toxic con- dition with high grade fever. A localized infec- tion due to non-sterile injection technique may develop into septicaemia with widespread or- gan damage and multiorgan failure. Patients with septicaemia are very ill with fever, hypotension, mental confusion and impaired sensorium. Sep- ticaemia is a serious medical event and prompt intervention is necessary. Diagnosis is confirmed by blood culture and the patient is best treated under the care of a specialist.

Hepatitis

Hepatitis is commonly encountered in parentral drug abusers as they often share needles and thus spread infection from one to another. Amongst the various subtypes of in- fective hepatitis, Hepatitis B and Hepatitis C are more likely to be associated with parenteral drug abuse. Patients with acute hepatitis present with malaise, loss of appetite, nausea and low grade fever. On physical examination of the patient, icterus is usually seen and may be accompanied by an enlarged, tender liver. The liver function tests are abnormal with raised serum bilirubin, AST and ALT.

Hepatitis B is associated with a long incuba- tion period (2-6 months) and during this as- ymptomatic stage the individual is capable of infecting others. Hepatitis B infection is con- firmed by the presence of HBsAg in the blood. Treatment is mainly supportive. Majority of patients recover completely. Some patients

might develop complications such as hepatic encephalopathy and or coagulopathy which will necessitate referral to a hospital. Some patients remain as carriers (HBsAg +ve with normal LFT). Some patients develop chronic active hepatitis (HBsAg +ve and abnormal LFT per- sisting for more than 6 months) which may progress to cirrhosis or hepatocellular carci- noma.

Hepatitis C virus infection usually occurs fol- lowing blood transfusion but has also been re- ported in intravenous drug abusers. Hepatitis C can manifest either as an acute hepatitis (un- common) which resolves over 5-12 weeks or can go on to a chronic stage directly resulting in some cases in the development of cirrhosis. The diagnosis of hepatitis C rests on a positive anti HCV test. No specific treatment is neces- sary in the acute phase.

Acquired Immune Deficiency Syndrome (AIDS)

Intravenous drug abusers (IDUS) are a high risk group to develop AIDS. They often share infected needles and acquire the infection. In various treatment centers about 10 –560 per thousand samples are positive for HIV and in Manipur, 50 percent of IDUS are HIV posi- tive. Nationally, it has been estimated that about 8 percent acquire the infection through injecting drug use and sexual contact accounted for nearly 75 per cent infections. Patients with HIV infection at the stage of seroconversion, might develop flu like symptoms. After a vari- able period, usually around 10 years, patients become symptomatic. Persistent lymphadenapathy, weight loss, fever and diar- rhea may be the initial symptoms. As immu- nosuppression progresses, opportunistic infec- tions appear. Candidiasis, Tuberculosis, Pneumocystis carinii pneumonia & cryptococceal meningitis are the common sec- ondary infections seen in out patients. Treat- ment is available for most of the opportunistic

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

infections.However, HIV infection is not cur- able currently. Prevention remains the best strategy.

Preventive measures begin with HIV testing of drug abusers. These include education regard- ing transmission, manifestation of HIV infec- tion and the implication of a positive and nega- tive test result. The patient must be assured of complete confidentiality regarding all aspects of the HIV test during pre-test counseling. During post-test counselling, results of the test are discussed with the patient. Even in the face of a negative test result reduction of risk fac- tors should be emphasized. Psychological im- pact of a positive result should not be underes- timated and patients must be given time to express their feelings adequately and precau- tion against infecting others emphasized dur- ing counselling.

Pulmonary Complications

Occasionally an intravenous drug user may present to a physician with features of pulmo- nary hypertension. Particulate matters in the drug get trapped in the pulmonary circulation leading to formation granulomas and inflam- matory exudates which might occlude pulmo- nary arterioles and result in the development of pulmonary hypertension. Chronic bronchi- tis may result from regular use of heroin when it is inhaled (chased) or smoked. There is also an increased risk of pulmonary tuberculosis among regular users of heroin due to altered immune status and poor living conditions as- sociated with social deterioration. Various toxic substances such as arsenic and rat poison are often found in street samples of heroin and when inhaled might lead to medical compli- cations.

Overdose

Drug abusers may inject themselves with large doses of opiates either accidentally or as an at-

tempt to commit suicide. They are brought to the emergency service in an unresponsive state. Naloxone given intravenously (0.4mg) serves both a diagnostic and a therapeutic purpose in suspected cases of opiate overdose. Patients with opiate overdose respond quickly to naloxone and the dose can be repeated till the level of sensorium improves or pupils dilate. Blood pressure and respiratory rate must be closely monitored during the treatment of opiate poi- soning. It must be remembered that naloxone is a short acting opiate antagonist and the pa- tient may slip back into unconsciousness once the drug effect wears off. In a regular drug user withdrawal syndrome may be precipitated by naloxone.

In conclusion, patients who are regular intra- venous drug abusers run the risk of developing multiple infections due to unhygienic inject- ing practice. To get the patient to give up in- travenous drug use should be the therapeutic endeavour. Harm reduction programmes aimed at decreasing the chances of medical complica- tions like HIV have encouraged various alter- natives such as the needle exchange program, where in the addicts are provided with clean sterile needles.

Health Hazards of Long Term Cannabis use

Cannabis is derived from the Indian hemp plant cannabis sativa. The plant grows in many parts of the country and is used widely as an intoxi- cant. Various forms of Cannabis are available and their potency is related to the content of the active ingredient ‘Tetrahydrocannabinol’ (THC). Chronic cannabis use is not associated with any significant medical complications. However, regular use of cannabis must be dis- couraged, as there is greater likelihood that the individual might come into contact with drugs with far greater health consequences such as heroin.

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Table 16 – Reversible Medical Condition fol- lowing Abstinence from Alcohol and Drug Use

Many such patients are helped by simple ad- vice focusing on the need to abstain from alco- hol and drug use. However, clinicians often have a pessimistic and cynical attitude towards these individuals because of their life styles and frequent relapses into earlier patterns of drink- ing and drug taking. This negative concern must be removed by the fact that even a brief period of abstinence gives damaged tissues time to heal and a chance for recovery. Further, treat- ment offers a drug free life to the individual.

Suggested Reading

Alcohol

1. Barnes HN, Aronson MD and Delbanco TL, eds. Alcoholism: A Guide for the Pri- mary Care Physician. Springar Verlag, New York, 1987.

2. Edwards G, Peters TJ, eds. British Medical Bulletin; Alcohol and Alcohol Problems. 1994;50:1-234

3. Sherlock S. Alcohol and the Liver. In: Dis- eases of the Liver and Biliary System. Eighth ed; Blackwell Scientific Publications, Ox- ford, 1989;425-448.

4. Victor M, Adams RD and Collins GH. The Wernicke-korsakoff Syndrome. Blackwell Scientific Publications, Oxford, 1971.

Opiate Abuse

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Fatty liver

Uncomplicated alcoholic hepatitis

Nutrition deficiencies

Vitamin deficiencies (except Korsakoff ’s
syndrome)

Hypertension (some patients become nor-
motensive following abstinence from
alcohol)

Peripheral neuropathy (subjective symp-
toms with no objective loss of sensation )

Alcoholic dementia (early stages)

Metabolic abnormalities

Infections, local and systemic (except
AIDS & Hepatitis B and C)

Banks A and Waller, TAN. Drug Misuse: A Practical Handdook for General Practioners. Blackwell Scientific Publica- tions, Oxford, 1988:103-143.

Ghodse H. Drug and Addictive Behaviour: A Guide to Treatment. Blackwell

Scientific Publications, Oxford, 1989.

Suggested slides for OHP

Slide 1

Individuals who abuse alcohol and drugs are frequent users of health care system

Less than 20 % of such patients are identified and of- fered treatment.

Slide 5

Medical complications associated with opiate abuse

Slide 2

Diseases associated with alcohol abuse

Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis

Mechanism

Medical complications

Related to mode of self administration of drug : parenteral

Related to mode of self administration of drug : smoking\chasing

Decline in living standards

Miscellaneous

Cellulitis,Thrombophlebitis, Endocarditis,Septicaemia, Hepatitis B and C, AIDS, Pulmonary hypertension

Chronic bronchitis, Respiratory infections

Nutritional deficiencies, Multiple vitamin deficiencies
Poor immune status, Recurrent infections, Pulmonary tuberculosis

Drug overdose, Accidental injury while intoxicated

Organ system

Diseases

Gastrointestinal system

Cardiovascular system

Central nervous system

Nutritional deficiencies

Haematological disorders Metabolic

Miscellaneous

Fatty liver, Alcohol Hepatitis, Cirrhosis,Oesophagitis, Acute Gastritis, Malabsorption Pancre- atitis, Hepatocellular carcinoma

Cardiomyopathy, Hypertension

Wernicke- Korsakoff ’s syndrome, Dementia, Cerebellar Degeneration, Peripheral Neuropathy, Myopathy

Thiamine, Pyridoxine, Folic acid, Ascorbic Acid deficiency

Anaemia, Leucopenia, Thrombocytopenia Ketoacidosis, Hypogly- caemia, Hypocalcaemia, Hypomagnesemia

Fetal alcohol syndrome, Osteoporosis, psoriasis, Tuberculosis

Slide 4

Slide 6

Reversible medical conditions following abstinence from alcohol and drug abuse

• Fatty liver

• Uncomplicated alcoholic hepatitis

• Nutrition deficiencies

• Vitamin deficiencies (except Korsakoffs syndrome)

• Hypertension (normotensive following abstinence
is some cases)

• Peripheral neuritis (subjective symptoms with no
objective loss of sensation)

• Alcohol dementia (early stages)

• Metabolic abnormalities
Slide 7
Close interaction among GDMOs, staff of department of medicine and other specialists.
Linkages with NGOs and de- addiction centers neces- sary for optimal health care.

Treatment has two components.
Treatment of the associated medical complications

Simple advice regarding complete abstinence from alcohol is useful in most patients

Some individuals require referral to a specialized de-ad- diction service.

Treatment Principles and Issues in Management 6 of Substance Use Disorder – An Overview

Rajat Ray, Arindam Mondal

Summary:

Treatment for substance use disorder can be done in a variety of settings with a variety of clinical modalities. A combination of pharma- cological and non-pharmacological (psychoso- cial) interventions yields most favourable treat- ment outcome. The treatment process is en- hanced when clinicians match clinical inter- ventions with patients’ motivation for change and other factors. Treatment of such patients requires well-planned strategy and co-ordinated effort. The treatment goal could either be ab- stinence or harm reduction.

In the national context, it is important to inte- grate the treatment of these patients with the general health care. Thus, general duty medi- cal officers and para-medical staff have a very significant role to play. The majority of patients can be treated at the primary care level and do not require hospitalisation or intensive treat- ment. Treatment in the OPD, community clinic and general medical setting is possible and cost-effective. Some may require complex and multiple interventions. They are best re- ferred to specialised de-addiction centres.

Introduction

The general principles of treatment for all drugs including alcohol are similar. However, treat- ments for specific substances may differ as the problems associated with drug abuse and medi- cines needed are different. Further pre-treat- ment variables and severity of addiction vary significantly from person to person and from one substance to another. Drug and alcohol

abuse are complex problems and have impact on the occupational, health, or social spheres of individuals. This has an important bearing on the treatment process.

There are several approaches to treat drug ad- diction. These include medications, psychoso- cial therapy (behaviour therapy, counselling, cognitive therapy, psychotherapy) or their com- bination. Behaviour therapies offer people strat- egies to cope with craving, prevent relapse, and help them deal with relapse, if it occurs. The most effective treatment combines therapies and other services for comprehensive management.

Treatment involves several categories of profes- sionals. They are most commonly general phy- sicians and psychiatrists, and often psycholo- gists, counsellors and social workers. Commu- nity leaders, spiritual leaders and even lay vol- unteers and patients (ex-addicts) have an im- portant role to play in the treatment process.

The present chapter discusses various treatment issues, treatment as a process and generalities from a medical perspective. Specific treatment issues are discussed in the subsequent chap- ters.

The current chapter discusses various issues as applicable to the medical model. According to this model, drug dependence is understood as a bio-behavioural condition and manifests as a chronic non-communicable disease, with spe- cific symptoms and signs. Thus, affected indi- viduals are considered to be medically ill. Hence, as with many diseases of the above na-

ture (viz. diabetes mellitus, arthritis and asthma), treatment can only modify and alter the course. Use of the term “cure” following treatment, as understood in traditional medi- cal parlance and as applicable to infective dis- eases, is inappropriate. Many professionals, notably health specialists, accept the above concept.

Goals of Treatment

Treatment goals differ from patient to patient and over time and may need to be reframed as the treatment progresses. Traditionally, the primary goal of treatment was to achieve per- manent abstinence. However, this goal may remain elusive and alternate goals have to be pursued for some. In this sub-group, interven- tion is directed towards decreasing the harm- ful consequences of continued drug use. Such an effort is practical and attainable, and is called “harm minimisation”. Strategies for harm minimisation are discussed later. The other goal pursues improvement of physical, psychosocial and occupational functioning.

Goals may also be classified as immediate, short-term and long-term goals. Immediate goals may be completion of detoxification, in- tervention of psychosocial and medical crisis. Short-term goals may include management of medical and psychiatric co-morbidity and re- integration with family. Long-term goals con- sist of prevention of relapse, re-integration into the society, occupational rehabilitation and improvement in overall quality of life.

Assessment

Treatment planning and appropriate interven- tions follow assessment. Assessment helps in developing a therapeutic relationship with the patient. This relationship is based on trust, empathy and a non-judgmental attitude.

Issues to consider in assessment:

Drug Use and Treatment – Quantity and pattern of use of licit and illicit drugs; pre- vious treatment, complications and sever- ity of dependence.

Medical & Psychiatric Problems – Medical and psychiatric problems related to drug use.

Psychosocial Factors – Support; barriers, expectations & goals.

Physical Assessment – Effects of drug, in- toxication and withdrawal, general physi- cal assessment.

LaboratoryTests-Confirmationofdruguse, screening for illnesses predisposed by the drug used; Investigation of abnormalities uncovered in assessment.

Opportunities for Harm Reduction: Inject- ing behaviour; sexual behaviour and high- risk behaviour.

Treatment Principles and Issues in Management of Substance Use Disorder

Issues In Assessment

Drug use and treatment Medical & psychiatric Problems

Psychosocial factors responsible for contin- ued drug use

Physical assessment Laboratory tests

Opportunities for pursuing various treat- ment goals

Treatment Goals

Abstinence
Harm minimisation

Improvement of health, social, occupa- tional functions

Improved quality of life.

Treatment Settings

Currently, most countries including India have established specialised treatment facilities to treat drug dependence disorder run by either government (GOs) or non-government organisations (NGOs). Most government treat- ment centres are part of a medical college/gen- eral hospital. However, many patients report to other settings including general medical OPD with ailments directly attributable to excess drug and alcohol consumption. Often they go undetected. It is important to identify these patients in the non-specialised settings and offer prompt treatment. The above arrange- ment is convenient to patients and cost effec- tive too.

Most patients and their families including many professionals think that for treatment of drug dependence, one needs inpatient care. In fact, majority do not require admission. They do well on OPD treatment and through do- miciliary care.

Inpatient care provides obvious advantages of restrictive care, more intensive patient contact, closer monitoring and usually enforces absti- nence. Guidelines for OPD or in-patient treat- ment as practiced in our centre are provided (Annexure). Care can also be rendered through community clinics, psychiatric hospitals and prisons. Each of these has specific purpose to serve. Treatment from community clinic and exclusive OPD treatment needs a fair clinical trial before inpatient treatment is considered. Inpatient treatment is usually not the first line treatment.

Levels of Care

There are various levels of care, from the least complex to the most comprehensive interven- tion. Complex interventions need not neces- sarily be the most desirable. Often, brief and simple intervention would suffice. Various lev- els of care can be categorised as:

Level 1: Acute intoxication, overdose and with- drawal symptoms are treated

Level 2: Short term pharmacotherapy, brief interventions, community care and general measures of rehabilitation are rendered

Level 3: This comprises multiple psychosocial interventions with or without pharma- cotherapy. Treatment is often deter- mined by individual’s need.

Progress and outcome are closely monitored.

Treatment Principles and Issues in Management of Substance Use Disorder

Levels of Care

Level 1: Management of acute intoxication, overdose and withdrawal

Level 2: Brief therapy and short term phar- macotherapy

Level 3: Complex psychosocial therapy, long term pharmacotherapy and monitored fol- low-up

Treatment Settings

Community clinic
Specialised De-addiction centre

Non-specialised settings viz. Medical OPD, Dispensary

Government & Non-Government centres Psychiatric hospital
Prisons
OPD vs. Ward

Personnel required at various levels

The treatment team consists of various catego- ries of staff and is multidisciplinary in nature. The team comprises of doctors, nurses, psy- chologists, social workers, pre-clinical scientists, laboratory staff and others for support services.

The role of each team members is distinct and complementary. However, there are grey areas. Certain duties can be performed by more than one category of staff, especially after (in-ser- vice) training. To illustrate, a nurse can carry

ing a drug free status and initiates the process of reintegration into the society. It may last for 3-6 months. During the late phase, a healthy life style and alternate coping strategies are taught. Usually treatment is multi-modal, which includes pharmacological and non-phar- macological therapy.

out the nursing

b) c) d)

following activities besides providing care and dispensing medicines:

Obtaining drug use history from patients

Assessment of patients
Counselling the patient
Counselling the relatives of the patient

These should be reinforced and opportunities should be provided for in-service training so as to encourage broader participation of various activities. These are even more evident in a com- munity clinic where strict division of role should be discouraged.

Treatment Modalities

Certain basic principles of management are common, irrespective of the nature of substance being abused. In this chapter the focus is on commonalties and general principles of man- agement rather than issues that are specific to a particular substance.

Broadly speaking, there are two modalities: pharmacotherapy and psychosocial therapy. Goals of pharmacotherapy are reversal of acute effects (intoxication and overdose), ameliora- tion of withdrawal symptoms, decline of crav- ing, prevention of relapse and restoration of normal physiological functions. Currently, vari- ous pharmacological agents are available for the above purposes.

Treatment Principles and Issues in Management of Substance Use Disorder

Treatment Phases

Initial Middle Phase Late Phase

2 to 4 weeks 3 to 6 months >6 months

Personnel

Multidisciplinary

Traditional hospital setting – Clarity of role, division of work

Community Clinic – Multiplicity of role

Phases/ Stages of Treatment

Comprehensive treatment of drug abuse com- prises initial, middle and late phases. Phases of treatment are linked with the issue of levels of care (above). In the pre-treatment period ac- ceptance of the problem by the patient occurs and the patient prepares himself for treatment. The peer group and family members play a significant role.

The initial phase is of detoxification, which usually lasts for 2-4 weeks. Here efforts are made to free the person of all intoxicants and attend to the immediate medical consequences of drug abuse. The middle phase is aimed at maintain-

General physicians or specialists from other disciplines are more often engaged in provid- ing treatment for toxicity and organ damage.

Treatment Modalities- 1

Medicines (Agonist, Antagonist, Deterrents & Others)

Reversal of acute effects, overdose & toxicity Detoxification
Decline of craving Prevent relapse Restoration of health damage

Specialists from addiction medicine provide long-term care. Both can carry out detoxifica- tion.

Detoxification is the initial step in drug abuse intervention. Various long-term medications like agonist, antagonist and deterrents are used subsequently. These compounds promote ab- stinence and minimise relapse. However, a simple pharmacological answer to treat sub- stance use disorder is still elusive. Thus they have to be supplemented with various forms of psychological and social interventions. These include single session counselling and brief therapies. In tertiary care settings, more com- plex therapies are carried out to promote so- briety and drug free healthy life style. These are adjuncts to pharmacotherapy and impor- tant for aftercare and rehabilitation.

Other common tasks are building an improved doctor-patient relationship, therapeutic alliance and improved communication with the patient and his/her relatives. Negotiated treatment to enhance motivation is very effective to improve treatment compliance. Treatment efforts, progress, adherence to treatment need to be assessed. Sometimes, treatment failure requires alternate treatment strategies.

stinence and a reduction in drug consumption before becoming totally drug free. Consider- able patience is required on part of the patient, family members and the treating team in the process of treatment.

Following improvement, treatment is termi- nated in a phased fashion. It is important to decide about the length of treatment. Obvi- ously, treatment cannot go on indefinitely. Treatment should be terminated in a planned manner.

Relapse Prevention

This involves strategies, which help the patient to maintain the necessary changes in their drug taking behaviour over time. These strategies are used in the middle and late stages of treatment. Family support is encouraged. The basic aim in Relapse Prevention is helping patients to:

Identify high-risk relapse factors and develop strategies to deal with them

Understand relapse as a process

Understand and deal with cues related to
drug and alcohol use and craving

Deal with social pressure to use drugs and alcohol

Develop and enhance a supportive social network

Develop methods of coping with negative emotional states

Learn methods to cope with cognitive dis- tortion

Work towards a balanced lifestyle
In addition, the patients should be assessed for presence of psychiatric disorder and the need for regular follow-up is emphasised.
Treatment Resistance
Resistance to treatment is a barrier one has to overcome fairly often. This may happen in the initial phase of substance abuse when patients

Treatment Principles and Issues in Management of Substance Use Disorder

Treatment Modalities- 2

Psychological & Single session Social Therapy Brief Counselling

Other complex therapies

Treatment Modalities – 3

Doctor-patient relationship Therapeutic alliance Enhancement of motivation Improved treatment compliance

Achieving permanent abstinence is a slow pro- cess. Patients go through short periods of ab-

deny or minimise their substance use and its consequences. Among patients receiving treat- ment, patient with additional psychiatric ill- nesses such as personality disorders and those with minimal socio-occupational dysfunction offer the maximum resistance to treatment.

Though many alcohol and drug dependent individuals ultimately reach formal treatment settings, many remain untreated. Such patients can be helped by “concerned others” such as a family member, friend, co-worker, religious or community leaders to initiate contact with a treatment agency for help. When such a pa- tient does contact the treatment provider, Motivational interviewing is the single most important step in breaking the resistance to treatment.

Network Therapy

Network therapy is a multi-modal approach to office-based rehabilitation in which specific family members and friends are enlisted to pro- vide ongoing support and promote attitude change. It is complementary to other thera- pies. It has 3 critical tasks:

. a) Maintaining abstinence: The network of- fers a safe place with trusted family and friends who help the patient stay in therapy and avoid cues that can lead to relapse,

. b) Caring for the network: An unique thera- peutic instrument, the network stays in- volved in enhacing the patient’s coping skills, offering common sense and a posi- tive team attitude,

. c) Securing future behaviour: It structures the clinical situation to limit the possibility of relapse.

Other Approaches to Treatment

Self Help Approach: In this approach, people with similar problems unite to form a group for mutual help. These groups are called ‘self- help’ groups. These groups are voluntary and self-sufficient and provide mutual assistance to

all its members. Self-help groups like “Alco- holic Anonymous” (AA) and “Narcotic Anony- mous” (NA) have congregations in most cities. Additionally, ‘self-help’ groups for family mem- bers, friends and children of drug and alcohol abusers have been developed, viz. Al Anon, Al Teen etc.

Social Correctional Approach: According to this approach, drug and alcohol abuse is seen as a social deviance and residential programmes are offered as a correctional method. Therapeutic Community (TC) is the most well known of the facilities offered under this concept.

Workplace based Intervention: Substance abuse problems in the workplace and their cost to the industry are difficult to estimate and is usually underestimated. Also, the ultimate goal in the treatment of substance abuse is employ- ment. Of late, Governments have acknowl- edged these issues and are adopting corrective measures. Though the main focus is on alco- hol and nicotine dependence, use of other drugs is also addressed. Employee’s Assistance Programme (EAP) identifies and resolves pro- ductivity problems associated with employees impaired by personal problems, including al- cohol and drug abuse. It offers assessment, re- ferral and follow-up services for mental health, alcohol and other drug related problems.

Integration with General Health Care: For many patients, the general medical setting is the first point of contact in the treatment of drug de- pendence. A proportion of these patients can be effectively treated in these settings, e.g. dis- pensary, medical and surgical outpatient ser- vices. Treatment in such settings has several advantages,

a) Being cost-effective,
b ) Increased convenience for patients,
c) Less stigma and
d) Medical infrastructure already in place.

General duty medical officers can treat these

Treatment Principles and Issues in Management of Substance Use Disorder

patients adequately provided they have received training and have liaison with specialised (de- addiction) treatment centres.

In India, treatment facilities have been estab- lished at medical colleges, district level hospi- tals and community health centres. Training of staff of these centres has led to increase in knowledge, skill to treat and change in atti- tude among various health personnel.

Services possible in these settings are:

Emergency care for toxicity, overdose

Management of withdrawal

Treatment of associated health damage

Linkages with other programme viz. con-
trol of Tuberculosis, HIV/AIDS etc

Referral to specialised treatment centres
following detoxification

Laboratory Services

Laboratory tests have an important role to play in assessment and treatment. Confirmation of use of particular drugs, detection of sporadic use and relapse, assessment for co-morbid in- fectious diseases, assessment of physical com- plications and monitoring of blood parameters as prerequisite for medical therapy are the com- mon situations where laboratory services are required. Detection of substances being abused is important even from the legal aspect.

In most instances, self-report and collateral re- port by family members about extent and na- ture of current drug use pattern would suffice. However, when in doubt, monitoring is called for. Commonly qualitative methods like Thin Layer Chromatography (TLC) or Enzyme Multiplied Immunoassay Test (EMIT) are used, and can be confirmed by Gas Liquid Chromatography (GLC). These methods can detect common drugs like opiates, cannabis, benzodiazepines and anti-histaminics in bio- logical samples like urine and blood. Alcohol can be estimated quantitatively in blood and breath. Breath-analysers are now commercially available.

Other laboratory tests are required in the as- sessment of the effects of drugs on various organ systems, e.g. altered liver function in chronic alcohol use; in acute management, e.g. Delirium tremens or in monitoring of treatment programmes, e.g. Liver function before and dur- ing therapy with medications like Disulfiram and Naltrexone. Additional tests include haemogram, blood counts, urine examination, Chest X-Ray, tests for Hepatitis B virus and HIV, and sputum for Acid Fast Bacillus (AFB) to as- sess the health status of the patient.

Outcome Measures

Traditionally treatment success was measured by abstinence. Today most clinicians feel that drug use/ abstinence should not be the sole

Treatment Principles and Issues in Management of Substance Use Disorder

Integration with General Health Care

Setting Services Integration

Medical College, district hos- pital, CHC

Emergency care, detoxifica- tion, referral to other centres

Other health programmes e.g. Tuberculosis, HIV/AIDS con- trol

Training of several categories of staff

From a public health perspective, effective treat- ment strategies are:

Facilities for treatment in various settings

Energetic and vigorous outpatient treat-
ment

Establishment of a referral system from primary care to tertiary care hospital

Integration with other health programmes as discussed earlier

Interaction with community leaders and utilisation of community resources for ef- fective drug abuse control

criteria to assess outcome. Hence there is more emphasis on the patient’s well being, beliefs about drinking and drug use, readiness to change, social functioning and social support. Improvement should be seen in total function- ing of the person. Thus, any after-care programme should attend to these areas as well. Current approaches to treatment of alcohol and drug-related problems reflect a continuum of treatment.

Various measures to achieve this are:

Determination of targeted prioritisation and limit setting

harm,

Outcome

Chronic relapsing disorder: frequent relapse – up to 80% within three months

Harm reduction:

Reduce adverse health, social and eco- nomic consequences without necessarily eliminating drug use

Shift from more harmful to less harmful substance

Shift from more harmful to less harmful route of intake eg. Injection to Oral

Harm Minimisation

Harm minimisation is an important principle in the management and intervention of sub- stance use disorder. Here, abstinence is not the highest or most immediate priority. Emphasis is placed on reducing many of the problems associated with alcohol and drug use, and not just focusing on substance use per se. Harm minimisation strategies address the overall health and well being of the individual and the community at large.

The central idea in the concept of harm minimisation is to reduce adverse health, so- cial and economic consequences of drug use without necessarily eliminating drug use. The principle of such a strategy acknowledges that there is a broad spectrum of damage and the risks are hierarchical (less severe to most severe). Thus the most damaging consequences should be given priority in management.

Imparting knowledge regarding adverse health consequences

Decrease transmission of communicable diseases related to drug use

Minimisation of hazardous drug taking situations

Alternate substitute (agonist) medicines Many strategies can be initiated. These include:

Comprehensive drug education programme for high risk behaviour

Easy accessibility to substance abuse man- agement services

Reduction of hazardous drinking and drug taking

Education regarding impairment of perfor- mance following drug use

Clarification of doubts and myths regard- ing substance abuse

Establishment of fixed point of services

Specific steps to minimise adverse health consequences viz. avoidance of needle shar- ing, use of bleach to clean syringes, etc.

Treatment Principles and Issues in Management of Substance Use Disorder

Harm Minimisation

Determination of priority
Reduce adverse health consequences Decrease transmission of communicable diseases Education about adverse effects.
Avoiding hazardous drug taking situation Substitution of illicit substances with licit medicines to prevent relapse

Successful programmes need active community participation. Another essential component of such an activity is the partnership with other agencies involved in control of drug abuse viz. NGO, Police, Judiciary, Social Welfare.

Treatment Principles and Issues in Management of Substance Use Disorder

The following flow chart explains the range of issues and suggests steps to decide upon the various treatment options.

Patient seeking treatment

Treatment Decision Tree

Motivational interview

Unmotivated Patient

Referral from specialist Referral from Police

Outpatient/clinic/dispensary

No mediation (Drug free)

Relapse

Special needs Resistance Complications

Assessment
Testing
Detoxification Counselling

Agonist (Buprenorphine)

Antagonist (Naltrexone)

Deterrents (Disulfiram)

Anti-craving (Acamprosate)

Functioning well Continue & monitor up to 2 yrs.

Referral to specialised centre/TC

Other issues

Treatment Principles and Issues in Management of Substance Use Disorder cacy of medicines in the management of sub-

Even though we have useful medicines, clini- cians have used these only sparingly. Many are sceptical about use of medications to treat sub- stance dependence. This is more so as the field is crowded with non-medical experts viz. so- cial activists, lay volunteers and ex-addicts, who perceive drug dependence as a moral problem. Medicines are used sparingly and even when used, the dose/duration is inadequate. There is a need to make clinicians aware of the effi-

stance abuse.

It is not the intention of this chapter to sug- gest a simple pharmacological answer to treat substance dependence. Medications must be combined with psychosocial therapies. Simple steps like supervised and contractual pharma- cotherapy can enhance efficacy of medicines. These will ensure treatment adherence and minimise dropouts.

Suggested Reading

1. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Substance Abuse Disorders: Alcohol, Cocaine, Opioids. American Journal of Psy- chiatry, 1995, 152 (Suppl.): 1-59

2. Galanter M and Kleber HD, eds. The American Psychiatric Publishing Textbook of Substance Abuse Treatment. 3rd ed. American Psychiatric Publishing Inc. Wash- ington, DC, 2004.

3. Lowinson JH, Ruiz P, Millman RB and Langrod JG – eds. Substance Abuse-A Comprehensive Textbook. 3rd edition. Wil- liams & Wilkins, Baltimore, 1997.

4. Miller NS and Gold MS. Pharmacological Therapies for Drugs and Alcohol Addic- tions. Marcel Dekker Inc. New York, 1995.

5. Shuckit MA. Drug and Alcohol Abuse: Clinical Guide to Diagnosis and Treatment. Plenum Press. New York, 1995.

Annexure

Guidelines for Treatment Environments

A. Indications for In-Patient Treatment

1. Severe withdrawal states e.g. delirium tre- mens,

2. Injecting Drug Users with complications and multiple drug use.

3. Serious health damage related to drug/ al- cohol use e.g. multiple abscesses, overdose, Wernicke’s encephalopathy, dementia symptom complex, liver cirrhosis, and car- diovascular system involvement.

4. Obvious psychopathology that can possi- bly be managed in drug/alcohol treatment unit e.g. affective disorder, psychosis.

5. Geographical distance from the centre.

6. Failure of outpatient treatment.

7. Definite possibility of a relapse.

8. Crisis in “Social support” system, patient or family member(s) asking for “restrictive care”.

9. Intoxicated states (not overdose or suicidal

Treatment Principles and Issues in Management of Substance Use Disorder attempts).

10. Academic and Research reasons.

(Florid psychosis and active suicidal intent are more suitable for management in a general psy- chiatry ward/ hospital).

B. Relative Contraindications for Inpatient Treatment

1. Obvious Antisocial personality disorder or behaviour likely to cause major interper- sonal problems on the ward.

2. Significant criminal record.

3. Two or more instances of premature dis- charge from the “treatment units”.

4. Several unsuccessful/ aborted treatment attempts at various other “treatment units”.

C. Indications for Intensive Outpatient Treat- ment:

1. Mild or moderate dependence.

2. No previous treatment attempt.

3. Good social support system.

4. Absence of significant health damage.

5. Geographical proximity (within 5 km).

Suggested slides for OHP Slide 1 Treatment goals

Abstinence
Harm minimisation
Improvement of health, social, occupational functions Improvement of quality of life

Slide 2 Issues in assessment

Drug use and treatment
Medical & psychiatric problems Psychosocial factors
Physical assessment
Laboratory tests
Opportunities for harm reduction

Slide 3 Treatment settings

Community clinic
Specialised de-addiction centre
Non-specialised settings viz. Medical OPD, dispensary Government & non-government centres
Psychiatric hospital
Prisons
OPD vs. Ward

Slide 4 Levels of care

Level 1: management of acute intoxication, overdose and withdrawal
Level 2: brief therapy and short-term pharmacotherapy Level 3: complex psychosocial therapy, long term phar- macotherapy and monitored follow-up

Slide 5 Personnel

Multidisciplinary
Traditional hospital setting – clarity of role, division of work
Community clinic – multiplicity of role

Medicines

Long-term medication

Reversal of acute effects Detoxification
Decline of craving Prevent relapse Restoration of health damage

Agonist, antagonist, deterrents & others.

Slide 6 Treatment phases

Initial & middle phases Late phase

Mostly medical, pharmacotherapy Mostly psychosocial

Training of several categories of staff

Slide 12 Outcome after treatment

Frequent relapse – up to 80% within three months Chronic relapsing disorder

Slide 7. Standard Treatment – 1

Treatment Principles and Issues in Management of Substance Use Disorder

Slide 8 Standard Treatment – 2

Psychological & Social Therapy

Single session
Brief Counselling
Other complex therapies

Slide 9 Standard Treatment – 3

Doctor-patient relationship Therapeutic alliance Enhancement of motivation Improved treatment compliance

Slide 10 Harm Minimisation

Determination of priority
Reduce adverse health consequences
Decrease transmission of communicable diseases Education on drug taking and impairment of perfor- mance
Avoiding hazardous drug taking situation
Substitute long-term medicines

Slide 11 Integration with General Health Care

Setting

Services

Integration

Medical College, district hospital, CHC
Emergency care, detoxification, refer- ral to other centres

Other health programmes e.g. Tuber- culosis, HIV/AIDS control

Harm reduction:

Reduce adverse health, social and economic conse-
quences without necessarily eliminating drug use

More harmful to less harmful substance use

More harmful to less harmful route of intake Eg.
Injection to Oral
Slide 13 Strategies for harm reduction
Comprehensive drug education Wide-ranging services
Early identification and intervention Community support
Decrease transmission of communicable disease (drug related)
Minimise harmful drug taking situations
Substitute medication
Target, priority, limit setting, public policy

Slide 14 Action plan for harm reduction

Knowledge on minimising health damage Responsible drinking
Education-performance following drug taking Clarify doubts & myths

Establish fixed point of service
Encourage people to come forward for treatment (hid- den phenomena).

Slide 15 Public health model

Multi level treatment (primary-tertiary care) Rigorous OPD treatment
Early identification
Establish referral system

Manpower development
Integration with general health care Integration with other parallel programme I.E.C.
Monitoring

Treatment Principles and Issues in Management of Substance Use Disorder

Pharmacotherapy of 7 Substance Use Disorder

Rakesh Lal

Summary

Pharmacotherapeutic intervention has an im- portant role to play in the management of sub- stance abuse. It is important not only in the acute phase (detoxification), but also in the long term management (relapse prevention). Fur- ther, pharmacotherapeutic intervention is im- portant for management of psychiatric and medical comorbidity and sequelae.

This chapter provides details of medicines used for detoxification of various substances (alco- hol, opioid, sedative-hypnotic medications and nicotine) and also long term management strat- egies (deterrent, substitution, antagonist and anticraving agents). Merits and demerits of each of these methods are also discussed.

Introduction

The primary goal of treatment in substance abuse disorders is to help the patient achieve and maintain abstinence and the management of complications. Along with various psycho- social interventions, pharmacotherapy has an important role to play in the prevention of re- lapse.

Development of an effective treatment is based on assessment findings. The selection of treat- ment setting will depend on the treatment goals in the immediate, short-term and long term frames. These treatment goals would be determined by severity of disorders, the patient’s current condition and motivation, as well as the presence of physical and/or psychi- atric comorbidity.

The primary goal of treatment in substance

abuse disorders is to help the patient achieve and maintain abstinence and the management of complications. Along with various psycho- social interventions, pharmacotherapy has an important role to play in the prevention of re- lapse.

Treatment Settings

Pharmacotherapeutic intervention may be car- ried out in a wide variety of hospital and non- hospital residential and community settings. The hospital settings include specialized treat- ment centres for substance use disorders, psy- chiatric hospitals or centres, and psychiatric medical services in general hospitals

There is a widespread belief that treatment of a substance abuse patient can only be carried out in an in-patient setting. Though in-patient care has the advantage of ‘restrictive care’, con- tinuous monitoring and a more intensive con- tact with the treating team, the outpatient treatment has the merits of being closer to natu- ral settings, an increased family involvement and is more cost-effective. Research data does not support the belief about the superiority of inpatient treatment over outpatient treatment.

Goals of Treatment

Immediate goals can be detoxification, treat- ment of acute medical sequelae and crisis in- terventions; short term goals usually target treatment of comorbid medical or psychiatric conditions, maintaining abstinence, family re- integration and vocational placement; the long term goals focus on the larger issues of relapse prevention, occupational rehabilitation, social

reintegration, abstinent life style and improve- ment of quality of life. Pharmacotherapy plays an important role in all phases of treatment.

Phase of Treatment

The detoxification phase being considered as treatment is in itself a common misconception, not only in the patients and their families but also in health professionals. Detoxification is merely the first phase of treatment. The detoxi- fication phase usually runs from 2-4 weeks, followed by the active treatment phase during which the short-term goals are focused upon and the plan for the long-term goals are made. This phase runs from 3-12 months or more, and involves the process of choosing from amongst the many pharmacological and psy- chosocial modalities of treatment. The post- treatment or after-care phase focuses on the long-term objectives being realized and can be seen to continue for 3-5 years or even longer. In this phase too, pharmacotherapy has proved to be beneficial.

Detoxification

This is the initial phase of treatment of sub- stance dependence and includes treatment of withdrawal symptoms, assessment of health and psychosocial complications with treatment of those requiring acute intervention, and build- ing up of a therapeutic relationship between the patient and treating team. Pharmaco- therapy has a primary role in this phase of treat- ment.

Detoxification is done by abrupt cessation of the substance and prescription of specific agents to reduce withdrawal symptoms or by gradu- ally tapering off the substance being abused. The purpose is to minimize subjective and objective discomfort as this is an important reason for relapse.

Methods of detoxification

The methods of detoxification include:

1. Gradual reduction of the substance in de- creasing amounts, and

2. Abrupt cessation of the substance of abuse and administration of specific medication which,

a. have cross tolerance to the substance of use: e.g. benzodiazepine for alcohol and, buprenorphine for opioid withdrawal,

b. have some specific pharmacological prop- erties to suppress withdrawal, e.g. carbamazepine for alcohol withdrawal, clonidine for opiate withdrawal.

c. Provide general symptomatic relief, e.g. hypnotics (benzodiazepine as well as non-benzodiazepines, anti-emetics, antidiarrheals etc).

By and large, abrupt total cessation of the pri- mary drug of dependence and control of with- drawal syndrome to a tolerable level by suit- able medication is the widely accepted method.

Use of antipsychotic or antiepileptic agents is not recommended to control withdrawal, though they may be required to treat comorbid psychiatric seizure disorders. Similarly use of IV fluids and parenteral drugs to control with- drawal is not recommended, until there are specific indications, e.g. presence of severe de- hydration, delirium tremens.

Doses of medicines for detoxification

Doses of medicines should be decided accord- ing to the expected severity of withdrawal syndrome, which will vary according to the sub- stance abused (its potency, half life), the time elapsed since the last dose, severity of depen- dence (duration, consumption, route of admin- istration etc) the concomitant use of other drugs, the presence of general medical or psy- chiatric disorder and individual biological and psychological variables.

Pharmacotherapy of Substance Use Disorder

The aim is to make the experience of withdrawal state tolerable rather than to suppress all symp- toms of withdrawal. The principle ‘least pos- sible amount of medicines for the shortest pos- sible time’ should be followed as majority of the drugs used for detoxification themselves have moderate to high abuse liability. One may need to modify the dosage schedule according to the withdrawal symptoms which need to be as- sessed continuously during detoxification.

Duration of detoxification

Usually alcohol detoxification can be com- pleted in 7-10 days and opioid detoxification requires 2-3 weeks. However, the duration will depend on severity of dependence, drugs of dependence (its half life), drugs used for detoxi- fication (their half life). This will be longer in elderly patients, and debilitated and medically or surgically ill patients. Management of pro- tracted withdrawal takes longer duration (week or months, even up to 6 months) and various non pharmacological methods like cognitive behavior therapy, relaxation therapy may need to be used.

Detoxification of individual substances A. Alcohol withdrawal

Benzodiazepines are the drugs of choice in management of alcohol withdrawal. Usually daily doses of 20-60 mg of diazepam or 40- 120 mg of chlordiazepoxide are required. The use of antipsychotic or antiepileptic, except carbamazepine, has no role. Patients with any of the clinical features of Wernicke’s syndrome must be treated immediately with intravenous thiamine HCl, 100 mg twice in a day, for the first five days. Parenteral administration of thiamine in every patient is not necessary, but oral administration of thiamine in all the pa- tients for prevention of Wernicke’s syndrome is justified. Carbamazepine has been found to be effective in place of benzodiazepines. Load- ing dose of diazepam has occasionally been

used, but has not proven to be more effective.

Delirium tremens (DT) or impending DT should be treated as an emergency (20-25% mortality in untreated cases and 5-10% mor- tality even with treatment). Immediate hos- pitalization is indicated. Treatment of choice is intravenous diazepam, which needs to be given in doses of 10 mg every 20 minutes till patient is sedated or signs and symptoms of withdrawal subside significantly. Patient may require further doses of diazepam (oral or in- travenous), depending upon the withdrawal symptoms that may reappear subsequently up to two weeks. Supportive treatment comprises of parenteral thiamine in all patients, and cor- rection of fluid depletion and electrolyte im- balances. The environment needs to be pro- tective and an effort should be made to orient the patient. Sensory stimuli should be minimised in case of a delirious patient. With treatment, the features of DT are usually con- trolled within 2-3 days, though patient usu- ally requires inpatient treatment for another week.

B. Opioid withdrawal

The starting dose of medication needs to be decided according to amount of opioid con- sumed by a patient in the 24 hour period, con- verted into equivalent doses of compound used for detoxification. Subsequent doses needs to be adjusted according to the severity of with- drawal symptoms which peak during 3rd to 7th day in case of heroin. Usually the doses re- quired are 1.2-4.0 mg buprenorphine or 6-12 capsules of dextropropoxyphene initially and tapered off after the third day. Usually, detoxi- fication medicines are required for 2-3 weeks. Certain withdrawal symptoms like insomnia, restlessness and mild body aches persist even after 3 weeks, and can be managed symptom- atically by sedatives and non-narcotic analge- sics as well as non-pharmacological treatments like relaxation therapy etc.

Pharmacotherapy of Substance Use Disorder

In accelerated detoxification, low doses of naltrexone are given to precipitate withdrawal symptoms and clonidine in usual or higher doses than those used in hypertension is used to control symptoms. This method reduces the detoxification period to 4-5 days.

C. Sedative-hypnotic withdrawal

Sedative hypnotic withdrawal is managed by gradual tapering of the substance of depen- dence. In cases of mild to moderate depen- dence, an outpatient detoxification by taper- ing of the drug, with weekly reduction in doses can be carried out in well motivated patients. In patients with severe dependence, particu- larly with dependence on short acting benzo- diazepines, indoor detoxification is preferred. In indoor setting, the drugs can be tapered off at a rate of 10% a day. In patients dependent on short or intermediately acting benzodiaz- epine (oxazepam, alprazolam etc), risk of with- drawal seizures should be kept in mind and to prevent the seizures, detoxification is started with equivalent doses of long acting benzodi- azepines, which then should be tapered off as

usual. Usually, detoxification in indoor set- ting is over within 2 weeks; however, some- times, protracted withdrawal requires longer detoxification medication. In cases where only insomnia persists, non-benzodiazepine hypnotics like zopiclone alone or with relax- ation exercises, should be tried.

D. Nicotine withdrawal

There is no specific medication for nicotine withdrawal symptoms. It is possible to tide over this period with psychological interven- tion, with or without benzodiazepines for a period of week or so. Use of nicotine chewing gum makes the detoxification easier and this may be used for long as a maintenance agent.

E. Multiple substance withdrawal

In patients, where dependence to more than one substance has been clearly identified, the specific medication for each category of the substance of dependence should be given. Fre- quently, patient requires inpatient treatment and the period of detoxification is longer than in patients with single substance dependence.

Pharmacotherapy of Substance Use Disorder

Summary of Detoxification Agents

Category of medication

Opiate withdrawal

Alcohol withdrawal

BDZ withdrawal

Nicotine withdrawal

1. Medicines which exhibit cross tolerant

2. Medicines having no cross tolerance but suppresses specific withdrawal syndromes

3. General symptom- atic medications

4. Medicines for complicated withdrawal

Tincture opium Morphine Dextropropoxyphene Buprenorphine

Alpha – 2 adrenergic agonists e.g. clonidine

Antidiarrheals Hypnotics
–

Oral benzodiazepines (Diazepam Chlordiazepoxide Oxazepam ) Carbamazepine Beta -Blockers

–

Injection benzodiazepines in DT, seizures

Long acting benzodiazepines

–

– –

Nicotine gum, Nicotine transdermal patches

–

– –

Long-term Pharmacological Treatment

This is intended to help patients maintain ab- stinence after completion of detoxification, with the use of medically prescribed drugs.

Based on the mechanism which operates for maintenance of abstinence, the pharmacologi- cal agents used in long term treatment can be classified in four categories;

Pharmacological Agents for Long-term Treat- ment

enzyme that metabolizes acetaldehyde, the first metabolic breakdown product of alcohol. In the presence of disulfiram, alcohol use results in the accumulation of toxic levels of acetalde- hyde in liver and systemic blood circulation, which causes a host of unpleasant signs and symptoms which are potentially fatal. The acetaldehyde syndrome, as a result of the ef- fect of disulfiram treated individuals when they consume alcohol, has been termed as disulfiram ethanol reaction (DER).

It should be remembered that disulfiram does not reduce craving primarily.

Side effects and adverse reactions: The com- monly experienced side effects are of drowsi- ness and gastric irritation. The adverse effects which occur most commonly with use of dis- ulfiram are hepatotoxicity, peripheral neuropa- thy, skin reactions and psychosis. The safety of disulfiram, estimated on the number of reac- tions reported, corresponds to an intermediate rate of adverse reaction (1 per 200-2000 treat- ment year). The death rate with disulfiram is estimated at 1 per 25,000 treatment years.

Contraindications: Many of the adverse reac- tions of disulfiram therapy are also long term health complications of alcohol use and must be considered as contraindications for disul- firam therapy. Hepatic dysfunction, periph- eral neuropathy, and psychosis are the com- mon relative contraindications. The other rela- tive contraindication includes presence of cog- nitive deficits because of the inability to un- derstand and remember the consequences of alcohol use while on disulfiram. Use in first trimester of pregnancy is the only absolute con- traindication.

Clinical regimen: Disulfiram should always be given after obtaining informed consent and after baseline investigations for monitoring the

Pharmacotherapy of Substance Use Disorder

A.Deterrent agents:

Disulfiram, citrated calcium carbimide, metronidazole, and compounds like nitrefezole

B.Substitution agents:

Methadone, LAAM, buprenorphine, morphine, nicotine replacement (nasal solution, gum, dermal patch).

C.Antagonist agents:

Naltrexone

D.Anticraving agents:

Fluoxetine, Acamprosate

A. Deterrent agents

Alcohol sensitizing drugs act through definite chemical mechanisms to deter the person from drinking and cause an unpleasant reaction if the patient does take alcohol in any form while he is taking the deterrent agent.

The most prominent example in this category is disulfiram (tetraethyl thiuram disulfide). The other agents have been used in some geo- graphical regions at times, but have not gained wider acceptance.

Disulfiram

Mechanism of action: Disulfiram and its ac- tive metabolites irreversibly inhibit the activ- ity of aldehyde dehydrogenase (ALDH), the

side effects. The usual dose is 250 mg/day; however due to metabolic differences, some patients may require a higher dose of 500-750 mg/day to experience DER. It is generally dis- pensed in a single daily dose in the morning but may be given in divided doses to avoid unpleasant gastrointestinal side effects.

Supervised disulfiram therapy: Disulfiram works well when its use is supervised as it en- sures better compliance. Supervision also en- sures that the possibility of DER is reduced. Unsupervised use in well motivated patients is also in practice widely, but several randomized controlled trials have shown that disulfiram can make clinically significant contribution to treat- ment outcome only if its administration is care- fully supervised.

Education of the patient and supervisor: Dis- ulfiram therapy should be initiated only after the patient and the supervisor has been in- formed about the rationale for its use as well as the necessary precautions with disulfiram use. An informed consent of patient is a necessary prerequisite. Patient and family members should be educated about the signs and symp- toms of DER, and the actions required to be taken if they notice these signs or symptoms.

It should be explained that DER can occur with alcohol intake even in small doses. It is a good practice that the patients be provided small cards containing the sign and symptoms of DER and necessary first aid methods in case of occurrence of DER. Generally, DER does not occur in the first week of disulfiram use and if alcohol is consumed after 5-7 days of stopping disulfiram, but can occur even up to two weeks after stopping disulfiram.

Ethanol challenge test: A challenge test by administering a small dose of ethyl alcohol to the patient in controlled conditions in hospi- tal setting, has been recommended by some

clinicians based on the premise that actual ex- perience of the DER is likely to be more effec- tive than the mere cognitive awareness of DER. The clinical opinion varies considerably about the usefulness of such an ethanol challenge and definitive research information is lacking. It is recommended that the option of undergoing a challenge test should be with the patient.

For the ethanol challenge test, alcohol is ad- ministered, generally in the form of spirits (like whisky or rum) which have approximately 40% volume by volume content of absolute ethyl alcohol, starting with 15 ml and further supplements of 15 ml every 15 minutes up to a maximum of 90 ml. The patient’s vital signs should be closely monitored all through the test. An intravenous line should be maintained for vasopressor administration consequent to a precipitous fall in the blood pressure. If it is not possible to achieve a significant DER with 250 mg of disulfiram, the dose can be increased to 500 mg and the challenge test be repeated. The dose may be required to be increased to 750 mg in some cases to obtain a good DER.

Treatment of DER:

The fall in blood pressure should be controlled on a priority basis. If DER is mild, assurance and oral fluids suffice. In patients with mod- erate or severe DER, intravenous fluids and, in some patients, dopamine infusion is necessary to control the severe hypotension.

The use of 4-methyl-pyrazole, which blocks formation at acetaldehyde, has been found to be successful but is still not common in clini- cal practice.

B. Substitution agents

Substitution maintenance programs derive their philosophy from the methadone mainte- nance program, initiated by Dole and Nyswander in 1964, as an experiment with six

Pharmacotherapy of Substance Use Disorder

heroin addicts. It was suggested that high fre- quency of relapse in heroin addicts is due to intense craving for narcotic and it might be appropriate to target at rehabilitation rather than abstinence in these patients. It was rec- ommended that narcotic medication, if used in these patients to satisfy their craving, will help in controlling illicit drug use and related behavior thereby making them accessible to rehabilitation. Methadone is the most com- monly used substitution agent for opioid de- pendent patients in the US and Europe

In India, substitution maintenance program had been practiced through the opium regis- try, wherein registered opium addicts were dis- bursed a certain amount of tincture opium till it was discontinued in 1959. In the period of heroin dependence in India, there has been no officially approved substitution maintenance program and the treatment has mainly focused on the goal of total abstinence and helping the patients achieve a life style free of any substance use.

However, in spite of the recognition of sub- stance dependence as a chronic disease which is not amenable to ‘cure’, many people, includ- ing psychiatrists and physicians, do not feel comfortable with the idea of maintenance therapy with substitution agents even though substitution with morphine, raw opium or bupenorphine which is prescribed medically, has been practiced in one or other form in vari- ous centres in this country

The reservations have been about the moral and ethical issues involved in such a treatment strategy and about the sociopolitical consider- ations of the expense involved in making the lifestyle of these addicts more comfortable by providing another addictive drug.

It is important that the merits and demerits of

the substitution maintenance programs be understood for making appropriate choices in individual patients as well as for larger policy decisions in the context of each region or coun- try.

The merits of and arguments in support of substitution maintenance treatment are:

i. Reduction in illicit drug consumption.

ii. Avoidance of medical complications of im- purities in street preparations, and the com- plications of parenteral administration and overdose.

iii. Better nutritional and health status.

iv. Decrease in criminal behavior.

v. Improvement in social behavior and psy- chological well being.

vi. Increased productivity

vii. Cost effectiveness.

When using substitution agents, care should be exercised to prevent illicit diversion and con- comitant use of illicit substances.

Criteria for patient selection

i. Severe dependence of long duration, with significant psychosocial disability.

ii. Past record of unsuccessful treatment at- tempts (at least three).

iii. High risk of relapse

iv. Preferably older than 25 years.

v. Minimal criminal involvement

Substance used for long term maintenance therapy

1 . a.

Opioid agonists

Methadone and LAAM (Levo-alpha-acetyl- methadol) are the two compounds most

Pharmacotherapy of Substance Use Disorder

commonly used abroad but are not avail- able in our country. Both have a long half life and are medically safe

b. Morphine: This has been found to be most effective in doses of 60mg daily. A higher dose is needed sometimes to control crav- ing and withdrawal symptoms. A dose of upto 180mg – 240 mg can be adminis- tered and the effects last for upto 12 – 24 hours. Strict monitoring is required as morphine produces chemical dependence and the patient may try to escalate the dose, use other narcotics concomitantly or even divert the prescribed morphine to the il- licit market.

2. Opiate partial agonists

Buprenorphine, a partial receptor agonist pro- duces sub-maximal effect in maximally effec- tive doses. It also has Kappa opioid receptor antagonistic properties. Although it has a short plasma half life of three hours, its duration of action has been longer, due to its slow disso- ciation from opioid receptors. This prolonged action of buprenorphine makes it effective when dispensed in once daily dosage or even on alternate days. Side effects of buprenophine are sedation, drowsiness and constipation. Tolerance to these effects can be expected to develop during continued buprenorphine therapy. No apparent health risk has been re- ported in studies involving long term buprenorphine therapy. Due to partial ago- nist property, there is a ceiling effect on the side effects, reducing the risk of severe drug induced respiratory depression.

Due to all these properties and evidence from clinical trials, there has been a strong recom- mendation about the use of buprenorphine as a maintenance agent in case of opioid depen- dence. The dosage schedule is 2-8 mg/day. There has been a concern about increasing sub-

lingual and parenteral use of buprenorphine which enhances the risk of illicit channelisation of buprenorphine dispensed as a maintenance agent. A combination product containing buprenorphine and naloxone for sublingual use is in the experimental stages and may become a promising agent for opioid substitution therapy.

Maintenance therapy in other substance use disorders

Nicotine replacement: Use of nicotine re- placement with gums or patches, is based essentially on the principle of substitution therapy and has been found to be useful.

Oral substitution in parenteral substance users: In broader terms, the substitution of a more harmful route by a less harmful route (e.g. oral) without changing the sub- stance of abuse can be termed as substitu- tion therapy. It will minimize the harmful consequences of use.

Pharmacotherapy of Substance Use Disorder

C Antagonist agents

Opioid antagonists are substances that bind to opioid receptors but do not produce mor- phine like effects. If an individual stabilized on opiate antagonist consumes an opiate ago- nist like heroin, he will not experience the eu- phoric effects as the opioid receptors are already occupied and hence not available for the opi- ate agonist. In this manner, over time, drug seeking behavior becomes extinct. This phe- nomenon helps the patient in achieving a drug free life style.

Various antagonists (naloxone, cyclazocine and nalorphine) had been tried but were not found suitable due to their short half life, severe side effects or lack of effectiveness through oral ad- ministration. However, the introduction of naltrexone in the early 1980s, which is effective orally, with long duration of action and mini-

mal side effects, has revolutionized this approach.

Naltrexone, available as 50 mg tablets, is well absorbed from the GI tract. Although its plasma half life is about 6-8 hours, effective receptor blockade is sustained for 48-72 hours. There are three common schedules for admin- istration: daily (50 mg/day), thrice a week (100 mg on Mondays and Wednesdays, and 150 mg on Fridays) and twice a week (150 mg on Mon- days and 200 mg on Thursdays).

The daily dose regimen is generally preferred over the other regimens. Naltrexone therapy should be started, only after detoxification has been completed, which can be confirmed by naloxone challenge test in case of doubt. This is necessary as there is a risk of precipitation of severe withdrawal features if the patient has consumed an opioid in the past 2-3 days. The common side effects of naltrexone are mild opiate withdrawal like symptoms (nausea, ab- dominal pain, dyspepsia), skin rash and de- rangement in liver function test in obese per- sons. The only important contraindication of naltrexone therapy is the presence of hepatic failure; minor degree of liver dysfunction is not a contraindication. Base line liver function tests are mandatory before starting naltrexone therapy. The duration of naltrexone therapy has been recommended to be at least 6-12 months, but longer duration may often be nec- essary.

Since naltrexone does not give a ‘high’ and is devoid of reinforcing properties, there is a high dropout rate. Naltrexone therapy is beneficial in patients with a high level of motivation.

D. Anticraving agents

Certain classes of medicines have been found to be useful in reducing craving, an important reason for relapse. They do not have a signifi-

Pharmacotherapy of Substance Use Disorder cant effect in reducing withdrawal symptoms.

Naltrexone

There is some evidence that naltrexone re- duces craving and enhances abstinence in alcohol-dependent subjects.

There is good evidence that naltrexone re- duces relapse and number of drinking days in alcohol-dependent subjects.

Naltrexone was found to be most efficacious with a daily dosing of 50mg. If logistics do not permit then 100mg on alternate days or 150mg every third day has also ben used.
Acamprosate

Trials of acamprosate in alcohol dependence are large but limited to Western popula- tions, primarily European.

There is good evidence that acamprosate enhances abstinence and reduces drinking days in alcohol-dependent subjects.

There is good evidence that acamprosate is reasonably well tolerated and without any serious harmful effects.

Depending on the body weight , 4-6 tab- lets a day in three divided doses has been found to be therapeutic.
Serotonergic Agents

There are several controlled clinical trials of serotonergic agents in primary alcohol- ics without comorbid mood or anxiety dis- orders.

There is minimal evidence on the efficacy of serotonergic agents for treatment of the core symptoms of alcohol dependence.

There is some evidence on the efficacy of serotonergic agents for the treatment of al- cohol-dependent symptoms in patients

with comorbid mood or anxiety disorders, although the data are limited.

Lithium

There are limited studies on the effects of lithium in primary alcoholics without comorbid mood disorders.

There is evidence that lithium is not effi- cacious in the treatment of the core symp- toms of alcohol dependence.

There is minimal evidence for efficacy of lithium for the treatment of alcohol-depen- dent symptoms in patients with comorbid depression.

Suggested Reading

1. Galanter M, Kleber HD, eds. The Ameri- can Psychiatric Press Textbook of Substance Abuse Treatment, American Psychiatric Press, Washington D.C., 1999.

2. Lowinson J, Ruiz P, Millman R, Langrod J, eds. Substance abuse: A Comprehensive Textbook, 4th edn. Baltimore, Lippincott Williams and Wilkins, 2005.

3. McGrady BS. & Epstein E, eds. Addictions: A Comprehensive Guidebook. New York: Oxford University Press, 1999:477-498.

4. Mood Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fourth edn, (DSM-IV), Text Revision. American Psychi- atric Association, 2000: 297-343.

Pharmacotherapy of Substance Use Disorder

Suggested slides for OHP

Slide 1:

Goals of treatment Immediate

Detoxification
Acute psychiatric and medical complications Crisis intervention

Long term
Co morbidity

Relapse prevention Rehabilitation

Slide 2:

Pharmacological Psychological Sociological

Treatment settings

Hospital Specialized

Psychiatric

General hospital Non-hospital

Residential Community Inpatient

Restrictive care Continuous monitoring Intensive contact Emergency

Outpatient
Cost effective

Natural surrounding Family involvement

Slide 3:

Detoxification
Gradual reduction Abrupt cessation using

Cross-tolerant medicines Withdrawl suppressant Symptomatic relief

Dosing of medicines depends on Potency and half-life of substance used Time since last intake
Severity of dependence
Presence of co morbidity

Slide 4: Alcohol

Benzodiazepines (diazepam: 20 – 60 mg; chlordiazep- oxide: 40 – 120 mg)
Thiamine 100 mg bid
Carbamazepine

Delirium tremens
10 – 25 % mortality
Intravenous diazepam 10 mg every 20 minutes till se- dated
Thiamine 100 mg
Minimize sensory stimuli

Slide 5: Opioids

1.2 to 2.4 mg of buprenorphine
6 to 12 capsules of dextropropoxyphene Taper after 3rd day
Sedative – hypnotic
Gradual tapering (10% daily)
Nicotine
Non-specific, symptomatic

Pharmacotherapy of Substance Use Disorder

Slide 6:

Pharmacotherapy of Substance Use Disorder

Summary of Detoxification Agents

Category of medication

Opiate withdrawal

Alcohol withdrawal

BDZ withdrawal

Nicotine withdrawal

1. Medicines which exhibit cross tolerant

2. Medicines having no cross tolerance but suppresses specific withdrawal syndromes

3. General symptom- atic medications

4. Medicines for complicated withdrawal

Tincture opium Morphine Dextropropoxyphene Buprenorphine

Alpha – 2 adrenergic agonists e.g. clonidine

Antidiarrheals Hypnotics
–

Oral benzodiazepines (Diazepam Chlordiazepoxide Oxazepam ) Carbamazepine Beta -Blockers

–

Injection benzodiazepines in DT, seizures

Long acting benzodiazepines

–

– –

Nicotine gum, Nicotine transdermal patches

–

– –

Slide 7:

Slide 8:

Disulfiram
Dose: 250 – 750 mg/day
Inhibits aldehyde dehydrogenase (increase aldehyde level)
Contraindications

Refusal of consent Hepatic dysfunction Peripheral neuropathy Psychosis

Cognitive deficits Pregnancy

ministration and overdose.
Better nutritional and health status, with regular monitoring. Decrease in criminal behavior.
Improvement in social behavior and psychological well being. Increased productivity

Slide 10: Long-term maintenance

A. Deterrent agents:

Disulfiram, citrated calcium carbimide, metronidazole, and compounds like nitrefezole

B. Substitution agents:

Methadone, LAAM, buprenorphine, morphine, nicotine replacement (nasal solution, gum, dermal patch).

C.Antagonist agents:

Naltrexone

D.Anticraving agents:

Fluoxetine, Acamprosate

Slide 9:

Opioids Agonists

Methadone LAAM Morphine

Partial agonist Buprenorphine

Antagonist Naltrexone

Alcohol Anticraving

Naltrexone Acamprosate Serotonergicagents Lithium

Deterrent Disulfiram

Merits of substitution
Reduction in illicit drug consumption.
Avoidance of medical complications of impurities in street preparations, and the complications of parenteral ad-

Nicotine
Substitution with nicotine chewing gum

Long-Term Treatment of Opioid 8 Dependence Syndrome

Anju Dhawan, Amardeep Kumar

Summary

Opiate dependence is a chronic, relapsing dis- order and requires multiple treatment episodes. Moreover many drug users do not seek treat- ment until they are into a lifestyle committed to drug use and criminal activity. Thus, though complete abstinence is the ultimate treatment goal, it is difficult for many patients. The al- ternative goal of harm minimization is achiev- able and desirable for many patients. The goals of treatment require the patients to be on long- term pharmacological treatment. This is an integral part of a comprehensive treatment plan which also includes psychosocial and medical interventions to reduce the use of other drugs, to decrease the transmission of HIV, Hepatitis B, C and other sexually transmitted diseases. One also needs to impart necessary support to the patients and skills for better integration in the society. The long-term pharmacological treatment is of two types- antagonist treatment and agonist maintenance. Antagonist treatment follows the complete abstinence approach while agonist maintenance follows the harm mini- mization approach. The long-term antagonist treatment helps in maintaining complete ab- stinence by extinction of drug seeking behaviour by blocking the effects of opioid over a signifi- cant period of time. The basic principle in ago- nist maintenance treatment is to substitute il- licit, medically unsafe and short-acting opiate with a medically safer, long-acting agonist of known potency, purity and dosage. The ap- proved antagonist agent is naltrexone while the agonist agents approved for treatment are methadone, LAAM and buprenorphine. Both

type of treatments have limitations. Thus ef- forts are being made to develop newer modes of delivery of medications so that compliance can be improved and illicit diversion can be reduced. To reduce the risk of illicit diversion (misuse), combination tablets of buprenorphine and naloxone has been devel- oped which will soon be available in India. Simi- larly to enhance the compliance with naltrexone, depot preparation has been devel- oped which are in phase III clinical trials. Bet- ter modes of psychosocial interventions are also being developed to improve the treatment out- come. There is no fixed optimal duration of long-term pharmacological treatment. The decision to terminate the pharmacological treat- ment should based on the treatment goals and should be a joint decision of treating team, patients and their family members.

Introduction

Opiate dependence is a chronic relapsing dis- order and single episode of treatment seldom leads to long term abstinence from drugs. Majority of heroin addicts relapse within the first year of treatment; mostly within the first three months. Numerous studies conducted during the past 35 years have demonstrated that, once initiated, drug use often escalates to more severe levels, with repeated cycles of ces- sation and resumption. Thus, long-term treat- ment is needed for opiate dependent individu- als. Though complete abstinence is the ulti- mate goal of the long-term treatment, it may be a difficult option for many patients in whom the alternative goal of harm minimization is

achievable and desirable. Depending upon the goals of the treatment, various long-term treat- ment strategies have been developed. These strategies include various pharmacological, psychosocial and medical interventions.

Pharmacological interventions are an integral part of long-term treatment. To be effective, an ideal long-term pharmacological agent should be able to produce blockade of exter- nally administered opioids, reduce craving, should not be liable to abuse and be safe, non- toxic and free of side-effects. Along with these, its acceptability among patients should be good and its duration of action should be long so that multiple administrations are not required. Two kinds of pharmacological agents for long- term treatment are:

. a) opioid antagonist treatment – naltrexone and

. b) opioid agonist maintenance treatment such as methadone, LAAM (levo- acetyl methadol), buprenorphine.

Studies have shown that the effectiveness of long-term pharmacological treatment is pow- erfully influenced by the quality of additional services provided. Thus, psychosocial and medi- cal intervention remains an important part of adjunctive treatment along with pharmacologi- cal interventions.

A) Antagonist therapy

The underlying principle of antagonist treat- ment in opioid dependent individuals is that it blocks the euphoric effects of opioids. Naltrexone is an opioid antagonist which is safe, non-toxic, has no abuse liability, no depen- dence potential, a long duration of action (24 hours) and does not produce withdrawal symp- toms on cessation. Thus it promises to be an effective agent for maintaining complete absti- nence. This gradually leads to the extinction

of drug seeking behaviour and prevents the re- establishment of physical dependence. Patients taking naltrexone experience less craving in the presence of opioid-related cues, presumably because on a cognitive basis they are aware that they will be unable to experience the effects of opioids. The limitation of long-term naltrexone treatment is low compliance and a high drop- out rate. Since it does not produce euphoria, a high level of motivation is required for compli- ance with naltrexone. Available studies have found that 30 to 40 percent patients maintain abstinence at 1-year follow up if there is a good social support and active involvement of im- mediate family.

B) Opiate agonist therapy

Opiate substitution or maintenance on an ago- nist drug is well accepted as an effective harm minimization treatment strategy. The basic principle of agonist maintainence treatment is to substitute an illicit, medically unsafe, short acting opiate with a medically safe, long act- ing agonist of known potency, purity and dos- age. Agonist maintenance eliminates drug hun- ger and produces cross-tolerance so that the person does not experience any withdrawal symptoms and there is no craving for the drug he was abusing. When combined with psycho- social interventions it minimizes dysfunction, helps the patient become productive and im- proves self-esteem and personal dignity.

Specific primary and secondary goals of long- acting opioid agonist pharmacotherapy are-

Primary goal is “significant reduction or cessa- tion of illicit opiate use” with “a related goal of voluntary retention in treatment for an ad- equate duration”.

The secondary goals include:
Reduction or cessation of alcohol and

polydrug abuse.

Long-Term Treatment of Opioid Dependence Syndrome

Reduction of exposure to diseases transmit- ted by unsterile injection equipment (in parenteral drug abusers) such as hepatitis B, C, and HIV infection.

Reduced criminality and antisocial behav- iors.

Improvement in socio-occupational func- tioning.
Achievement of these goals was correlated with the duration of retention in treatment. Treat- ment lasting less than 90 days usually had little or no impact in behavioral change. A 6-month retention rate with an agonist was correlated with long term improvement.
Harm minimization approach using opiate agonists has its own drawbacks. These include the risk of abuse (including toxicity) and de- pendence on opiate agonist medications, di- version of medications for illicit use and emer- gence of opioid withdrawal symptoms when these medications are stopped.
Experience in some treatment centres has also suggested that in some patients it has been possible to shift a patient from opiate agonist maintenance to an antagonist drug at a suit- able time in the course of treatment.
Comprehensive treatment
Patients with opiate dependence usually have concomitant psychological, social and health problems. An essential component of long- term maintenance treatment is the availability and inclusion of a comprehensive range of ser- vices to assist individuals to reduce their con- comitant health and psychological problems. These would include pharmacological and psy- chosocial interventions to reduce use of other drugs (including alcohol and tobacco); inter- ventions to reduce risks associated with hepa- titis A, B and C and HIV viruses; medical, psy-

chiatric and psychological assessment and care; crisis intervention; social and economic assis- tance; vocational and family assistance. Brief, supportive and problem-oriented counselling can add to the effectiveness of treatment for patients with current life problems. Cognitive- behavioural therapy, motivational interviewing, relapse prevention counselling and social skills training are some approaches that can be em- ployed.

A comprehensive treatment plan should be for- mulated early in treatment. The treatment plan should set out the services to be provided. Ser- vices should include dose review and adjust- ments (for long-term agonist maintenance treatment), setting and reviewing treatment goals, monitoring of progress and harm reduc- tion interventions (e.g. advice on reducing risks of contracting or spreading hepatitis and HIV infection). Supportive or social skills training, focussed counselling, assistance with vocational difficulties (e.g. linking with training or em- ployment services), assistance in reducing con- current drug use and assessment of suitability for gradual withdrawal from treatment is also given. The nursing staff or a social scientist can be trained to conduct several of these assess- ments.

Such a treatment plan should be reviewed every three months with the patient. Completion of ac- tivities and progress against goals should be noted. All members of the treating team should be in- volved in the decision making process and subse- quent review. Based on the progress of the pa- tient, treatment plans and objectives may need to be revised more than once.

Long-term pharmacological treatment agents

Various agents have been used for the long- term pharmacological treatment of opioid de- pendent individuals. These include both ago- nist and antagonistic medicines.

Long-Term Treatment of Opioid Dependence Syndrome

Antagonist agents–

Naltrexone- It is an opioid antagonist synthe- sized in 1965 and approved in USA for long- term treatment of detoxified opioid dependent patients in 1984. Naltrexone selectively com- petes with exogenously ingested opioids for central nervous system (CNS) and non-CNS opioid receptors and blocks their activity. This blockade lasts for up to 72 hours after naltrexone administration and prevents reinforcement from opioid use. This blockade can have posi- tive psychological consequences including re- duced craving related to reduced immediate effects of opioid (cognitive basis of action) and deconditioning/extinction of cue-related crav- ing as patients are exposed to several cues for- merly associated with opioid use while being protected from opioid effects (classical and operant learning basis of action). It is orally effective and when given three times a week (100mg on 1st and 3rd day and 150mg on 5th day), it completely blocks the effects of sub- stantial doses of heroin. The opioid antagonist properties of naltrexone do not appear to be subject to development of tolerance, as potency has been demonstrated even after maintenance for 1 year or more. Naltrexone does not have opioid agonist properties, and thus patients neither obtain a high after use nor is it associ- ated with significant withdrawal symptoms if use is discontinued. However, some patients continue to complain of adverse effects or opioid withdrawal effects for several weeks. Another issue of concern is that patients may be more sensitive to lower doses of opioids once naltrexone is discontinued, because of the loss

of tolerance to exogenous opioids, thus increas- ing the risk of overdosage and related compli- cations.

In carefully selected patients who are well mo- tivated, naltrexone can be used as a mainte- nance medication. The followings are useful guidelines for selecting the patients suitable for long-term treatment with naltrexone as fol- lowed in western countries –

Clinical experience at NDDTC, AIIMS sug- gests that it can probably be used in a wider subgroup of opioid dependent patients.

As a nonscheduled medication without psy- choactive or addictive properties, naltrexone can be administered as a maintenance treat- ment in a range of medical settings without any governmental regulations. Since diversion is not an issue, take-home medications can be provided with no special precautions. However, lack of initial patient acceptance and subsequent medication noncompliance limits the utility of naltrexone for opioid dependence. Naltrexone should be administered only after complete abstinence from opioids for a suffi- ciently long duration that ensures complete washout of the illicit as well as prescribed opio- ids. Hence, patients must start treatment with a goal of achieving total opioid abstinence and a willingness to undergo detoxification. Stud- ies have shown that most patients from unselected populations drop out within first three months of treatment. Greater success has been achieved with patients motivated for ad- herence to treatment with individual counsel- ling and involvement of family members.

Long-Term Treatment of Opioid Dependence Syndrome

Long-term pharmacological agents for opioid dependence.

Opioid antagonist– Naltrexone.

Agonist opioids– Methadone, LAAM, Buprenorphine, Sustained release morphine

High motivation
Short duration of opioid use
Professionals like doctors, dentists etc. No co-morbid psychopathology
Good social support

Depot preparation of naltrexone is currently in phase-III clinical trials and have shown ad- equate blockade of externally administered opioids for 30 days with a single injection. This will be helpful in ensuring compliance in near future.

be a favorable drug as it has a long duration of action (24 hours) requiring once daily admin- istration, is safe and non-toxic with minimal side effects. Individuals need to attend specialty clinics (methadone clinics) daily where they receive their dose in a supervised manner to prevent the misuse of the medication. Studies have shown that as part of a broader programme of support and rehabilitation, methadone maintenance treatment reduces illicit opiate use, criminal activity, mortality and morbid- ity (including HIV infection) and improves psychosocial functioning. The major factor known to be involved with better outcome is the duration of treatment (retention in treat- ment). Retention in treatment in turn is re- lated to factors such as adequate dose, flexibil- ity of dosing, well-trained staff, positive rela- tionships between staff and patients and there- fore these factors are associated with a favourable outcome.

Methadone maintenance still has some limita- tions. Opioid dependent individuals need to attend the methadone clinics daily leading to significant inconvenience. Apart from this, the stigma attached to attending such speciality clinics is another cause of concern. The risk of abuse and dependence also exists. Patients re- lapse soon after leaving treatment and use of other drugs may continue even on methadone. Studies have shown that after leaving the treat- ment programme, significant numbers relapse (70 percent at 1 year) and indulge in various criminal activities.

LAAM

LAAM is a derivative of methadone developed in the 1940s in Germany as an analgesic. It was approved as a maintenance treatment agent for opioid dependence in USA in 1993. LAAM has a long duration of action and can be given once every 2-3 days. It has been found to be safe and efficacious. Some studies have shown

Agonist Maintenance Agents–
Agonist agents for the maintenance treatment

of opioid dependence are-

Methadone

Methadone is the most extensively used and studied agent for maintenance treatment in many countries. It was introduced in mid 1960s by Dole and Nyswander at the Rockfeller Institute, USA. They found metha- done to be effective in producing cross-toler- ance and blockade of the effect of externally administered narcotic. In other words, a per- son stabilized on methadone would not expe- rience the acute effects, including euphoria fol- lowing the use of heroin. To date there have been over 500 research trials looking at various aspects of methadone treatment. Together they form a large body of evidence in favour of the effectiveness of methadone maintenance. It has been shown that 60mg of methadone is the lowest effective dose. Methadone was found to

Long-Term Treatment of Opioid Dependence Syndrome

NALTREXONE

Opioid antagonist

Goal of treatment- complete abstinence

Daily dose – 50mg/day

Thrice/week dispensing (100 mg each on 1st and 3rd day and 150 mg on 5th day)

No tolerance, no abuse and dependence potential.

Poor compliance and high drop-out from treatment

Enhanced compliance – Depot naltrexone (phase III clinical trials)

it to be equivalent to methadone in suppress- ing illicit opioid use and encouraging produc- tive activity. The drawback however, is related to the cumulative toxicity of LAAM and its metabolites. There are reports of arrhythmias (Torsades de Pointes) in some patients. LAAM is more complex pharmacologically than methadone and its use demands a more skilled clinician than methadone.

Buprenorphine

The search for a better alternative to above mentioned agents lead to use of buprenorphine for the long-term treatment of opioid depen- dent individuals. Buprenorphine is a semi-syn- thetic opium alkaloid derivative of thebaine. It is a long acting, highly lipophilic opiate. It is generally administered as sublingual tablet (S.L) or as a liquid. Bio-availability after sub- lingual administration is approximately 50%. Peak concentration occurs within 2 hours of sublingual administration. Elimination half-life of sublingual buprenorphine is approximately 27 hours. It is 25-30 times more potent than morphine (in analgesic action). About 0.4-0.6 mg S.L is equi-analgesic to 10 mg morphine given intravenously. It is a partial mu agonist and antagonist of kappa. It produces analgesia and other central nervous system effects that are qualitatively similar to those of morphine. Buprenorphine can be substituted for morphine or heroin and suppresses symptoms of mu agonist withdrawal. The effects are slower in onset and longer lasting than morphine. It dissociates slowly from the opiate receptors thus having a long duration of action. Some studies have shown that it can be used every alternate day or once in three days. Buprenorphine exhibits a ceiling effect, most noticeably in its respiratory depression and euphoriant effect which accords the medication a high degree of clinical safety. It has found high acceptability amongst patients. The above mentioned prop- erties (frequency of dosing, safety, acceptabil-

ity) generally suggest it to be a safe and effec- tive medication.

The efficacy of buprenorphine has been com- pared with methadone. Several studies have compared different doses of buprenorphine to methadone. These have confirmed that buprenorphine produces an opiate agonist ef- fect similar to methadone. Many have recom- mended 8 mg of buprenorphine per day, how- ever, it has been also reported that the differ- ence between efficacy of 4 mg and 8 mg daily dose of buprenorphine is marginal.

It has been suggested from the clinical experi- ence at the NDDTC, AIIMS that opiate de- pendent individuals who may be suitable for buprenorphine are a subgroup of opiate de- pendent patients who fulfil the following re- quirements-

Long-Term Treatment of Opioid Dependence Syndrome

Suitability

Above 21 years of age

Regular opiate use for at least 3 years

Proof of at least 2 unsuccessful attempts to achieve abstinence following treatment from recognised treatment centres

Certification by a Medical Officer

Willingness to give body fluids to check il- licit drug consumption on demand

However, long-term maintenance treatment with buprenorphine has got its own drawbacks. Withdrawal symptoms do occur following the abrupt withdrawal of this medication, but the symptoms are milder than those of methadone. The risk of abuse and dependence does exist, although lower than methadone. There have also been reports of injecting the tablets of buprenorphine through intravenous or intra- muscular route by dissolving the tablets. To reduce this serious risk, supervised dispensing has been advocated. Along with this, to com- bat the problem, a buprenorphine-naloxone

combination tablet has been developed. The rational has been that when used by opiate addicts by the intended route (sublingual), the buprenorphine-naloxone tablet would yield desirable effects; i.e. buprenorphine would be adequately absorbed and act as a maintenance drug, while naloxone would not be absorbed adequately by the sublingual or oral routes. However, if the buprenorphine-naloxone tab- lets were diverted for misuse and dissolved for use by the i.m/i.v route, naloxone would be- come active and produce/precipitate opiate withdrawal symptoms, which are distressful to the patient and hence would discourage such use. Studies have also tried to arrive at the best dosing ratios of such a combination tablet. Some earlier studies suggested that dose combina- tions at 2:1 and 4:1 ratios may be useful in treating opiate dependence (Buprenorphine: Naloxone). Later studies suggest a ratio of 4:1. Such a tablet is also likely provide for greater patient autonomy in the form of weekly or fort- nightly (as opposed to daily or alternate-daily) visits to the treatment centre and make a pro- vision for ‘take-home’ medications, thus pro- viding patients with more time for vocational/ rehabilitative activities. Buprenorphine-nalox- one combination tablet would soon be avail- able in India.

and poor availability in all parts of country, some other agonist medications are also being tried for these patients.

Sustained release Morphine (MS CONTIN)

This medication is being routinely used in the treatment of cancer pain. Compared with short acting, immediate release morphine, MS Contin has the advantage of 12-hour dosage, decreased sleep disturbance and increased medication compliance. MS Contin has been recently tried for opioid dependent patients for maintenance programme at the NDDTC, AIIMS. However, the risk of abuse and depen- dence exists as with other agonist drugs. Clini- cal experience with sustained release morphine as opioid agonist maintenance agent is limited.

To summarize, all the agonist agents help the opioid-dependent individuals by minimizing the harm (physical, psychosocial) caused by the use of illicit opioids while the individuals are still on an opioid agonist drug that has abuse and dependence potential.

Termination of long-term pharmacological treatment

Patients should remain in treatment for the minimum time it takes to achieve their agreed treatment goals. The length of time required for treatment will vary amongst individuals. Regular reviews will assist in determining need for continued treatment. There is no fixed op- timal duration of pharmacological treatment and removing people from treatment too early may result in very poor outcomes, including high rates of relapse into illicit opiate use and a consequent increased risk of overdose. Set- ting an arbitrary duration of treatment and withdrawing treatment at that endpoint is not recommended. The treatment approach should include working towards goals which prepare a patient to live well without pharmacological

Long-Term Treatment of Opioid Dependence Syndrome

BUPRENORPHINE

Partial opioid agonist

Clinically safe

Dose – 4-8 mg/day

Frequency – Every 3rd day possible

Dependence potential – less than metha-
done. Abuse potential present

Possible safeguard from abuse – Combi- nation buprenorphine and naloxone tablets

Due to the high treatment cost with the abovementioned medications (buprenorphine and naltrexone which are available in India)

treatment. An important objective of mainte- nance treatment is the successful withdrawal from maintenance agent combined with con- tinued good functioning, including good health and social functioning. Planning for successful withdrawal from maintenance treat- ment should commence from the initiation of treatment. The decision to withdraw voluntar- ily from long-term pharmacological treatment should be a joint decision of the patient and the prescribing doctor, with information con- tributed by the social worker or nursing staff who may be evaluating the psychosocial func- tioning of the patient. When all agree about the timing and method of withdrawal, patients tend to be more successful in continuing abstinence.

The elements of treatment that assist patients to complete withdrawal from an agonist drug successfully include a flexible approach to dose reduction and individualizing reduction of

Suggested Reading

1. Blaine JD, ed. Buprenorphine, Alternative Treatment for Opioid Dependence. NIDA Research Monograph 121. US Department of Health and Human Services Washington D.C, 1992.

2. Effective Medical Treatment of Heroin Ad- diction- Program and Abstracts. Office of the Director, National Institute of Health, 1997.

3. Ray R, Dhawan A. Oral Buprenorphine Substitution Therapy. Report submitted to UNODC, ROSA, 2004.

4. Reisine T, Pasternak G. Opioid Analgesics and Antagonists. In: Goodman & Gillman’s, The Pharmacological basis of Therapeutics

medication. A slower rate of reduction would be desirable if relapse is likely After withdrawal from agonist maintenance, patient may require more frequent supportive, skill oriented and relapse prevention counseling, more frequent monitoring and review, access to residential programme if necessary (residential withdrawal or rehabilitation programme) and increased involvement of significant others (including family).

Counseling, continuing case management and structured group programme are all likely to assist outcome after completion of pharmaco- logical treatment. The staff should remain in- volved in the care of patients who have volun- tarily withdrawn from pharmacological treat- ment for up to a few months after completion of treatment. In case of relapse, the patient should have easy access back into treatment. Treatment should be offered expeditiously and without recrimination.

9th edn. (Harman JG and Leemboid LE, Eds in chief). Mc Graw-Hill, New York, 1996, 521-556.

5. Lowinson J H, Payte J T, Salsitz E, Joseph H, Marion I J, Dole V P Methadone Main- tenance. In: JH Lowinson, P Ruiz, RB Millman, JG Langrod (eds.) Substance Abuse- A Comprehensive Textbook- third edition, Williams and Wilkins, USA, Mary- land, 1997.

6. Jaffe JH, Jaffe AB. Opioid related disorders. In: BJ Sadock, VA Sadock (eds.) Compre- hensive Textbook of Psychiatry- seventh edi- tion, Lippincott Williams & Wilkins, 2000.

Long-Term Treatment of Opioid Dependence Syndrome

Suggested slides for OHP Slide 1

– Opioid dependence- Chronic relapsing disorder

– Risk of relapse high within the 1st year of t/t

– Long-term t/t needed for majority of opiate depen-
dent individuals

– Various strategies for long-term t/t has been devel-
oped in the form of comprehensive t/t plan
Slide 2

– Comprehensive t/t plan- various pharmacological, psychosocial and medical interventions

– Concept of long-term t/t

– complete abstinence using opiate antagonist

– Harm minimization using opiate agonist

– Pharmacological agents for long-term t/t-
Opioid antagonist- Naltrexone
Opioid agonist- Methadone, LAAM, Buprenorphine, Sustained release Morphine
Slide 3
NALTREXONE

Slide 4

• • • •

• • •

• • • • •

Opioid antagonist
Goal of treatment- complete abstinence
Daily dose- 50mg/day
Thrice/week dispensing (100 mg each on week- days and 150 mg on weekends)
No tolerance, No abuse and dependence potential. Poor compliance and high drop-out from treatment. Enhanced compliance- Depot naltrexone (phase III clinical trials)
Suitability for long-term treatment with naltrexone

High motivation
Short duration of opioid use Professionals like doctors, dentists etc. No co-morbid psychopathology Good social support

Slide 5

–

– –

BUPRENORPHINE

• Partial opioid agonist

• Clinically safe

• Dose- 4-8 mg/day

• Frequency- Every 3rd day possible

• Dependence potential- less than methadone

• Abuse potential present
Possible safeguards from abuse- Combination buprenorphine and naloxone tablets
Suitability for long-term treatment with buprenorphine
Above 21 years of age
Regular opiate use for at least 3 years
Proof of at least 2 unsuccessful attempts to achieve abstinence following treatment from recognised treat- ment centres
Certification by a Medical Officer
Willingness to give body fluids to check illicit drug consumption on demand

– – –

Termination of long-term t/t
No fixed optimal duration of long-term t/t Decision to terminate t/t

Based on agreed t/t goals
Joint decision of treating team, patients and their family members

• •

Long-Term Treatment of Opioid Dependence Syndrome

Psychosocial Treatment in 9 Substance Use Disorder

Renuka Jena

Summary

The management of substance use goes beyond pharmacology. Clinical and academic experi- ence reflects the significance of psychosocial interventions in addition to the pharmacologi- cal treatment. Motivational interviewing, mo- tivation enhancement, counseling and relapse prevention have been used with success in short and long term management of substance use. Brief intervention has shown significant results in alcohol and nicotine abuse in busy outpa- tient and primary care settings. The chapter focuses on various psychosocial modalities use- ful in substance use.

Introduction

The use of substances that alter mood, behav- ior, or cognition has been a part of human life across numerous social contexts throughout history. Invariably, there are some individuals whose use of such substances may lead to abuse and eventual psychological, social or physical harm. Although some people use drugs safely, most encounter problems.

Assessment

Before embarking on a treatment program, a sound assessment is required that will deter- mine the choice of treatment – goal and con- tent. Information should be attained on the evolution of drug/alcohol intake, family his- tory, patterns of current use, degree of depen- dency, the extent of drug and alcohol related problems, reinforcement parameters maintain- ing the behavior, and the opportunities within

the client’s environment for developing more adaptive responses. It is also important to as- sess the extent of any co-existing psychopathol- ogy.

There are numerous scales that have been de- veloped for the assessment of various aspects of drug and alcohol abuse. These instruments are very general and assess a number of variables from a conceptually distinct area e.g., craving, outcome and efficacy expectations.

The assessment process will assist the thera- pist in tailoring a treatment program to the needs of the individual as well as elucidating on the most appropriate treatment goal. Gossop (1996) has provided examples of treatment goals which include:

. (i) Reduction of psychosocial or physical prob- lems either directly or indirectly related to the drug problem.

. (ii) Reduction of risky behavior associated with the use of the drug.

(iii)Attainment of controlled or nondependent use.

(iv) Attainment of abstinence from the prob- lem drug.

(v) Attainment of abstinence from all drugs.

The issue of controlled use rather than absti- nence has been debated at length for many years. Whatever the treatment goal, a key issue is the client’s commitment to implementing real and permanent change in his pattern of drug or alcohol use. The following section will

review some models that assist in this decision- making process.

The stages of change

Psychotherapists have long been interested in the process of change. Pettony (1981) noted that most therapeutically induced change in cognition, affect, or behavior involves an ini- tial destructuring with resistance being a cen- tral feature, an intermediate stage of conver- sion and a final stage of restructuring.

The idea of transitional stages or dispositional states within addiction literature has been de- veloped by various authors. Tuchfeld (1976) proposed a two stage model of change. The first is when defensive avoidance becomes unten- able and a commitment to change is made. The second is one of maintenance of a new behav- ioral repertoire, which is characterized by per- sonal vigilance and during which time the in- dividual develops coping strategies to attenu- ate the possibility of relapse.

The most influential model of change has been the transtheoretical model of Prochaska and Di Clemente (1984). This has helped rationalize the diversity of psychological interventions and place them in the context of the evolution of personal change.

The stages proposed are precontemplation, contemplation, preparation, action and main- tenance along with the issue of relapse or re- currence. Essentially during precontemplation individuals do not feel impelled to do anything about their behavior, perhaps as a result of de- nial or selective exposure to information. As they become aware a problem exists, they en- ter the contemplation stage which is charac- terized by conflict and dissonance. Preparation is defined as a time when the individual drug user formulates action plans and is serious about his or her intention to alter behavior. Action is a period when overt changes are made, after

which successful individuals enter the mainte- nance stage when new behaviors are strength- ened and consolidated. The individual who does not relapse during this stage eventually exits the change system to termination, or in other words favorable long-term outcome. Most people do not immediately sustain the new changes they are attempting to make, and a return to substance use occurs known as re- lapse.

It has been observed that progression through the stages follow a cyclical pattern. People may move back from action to contemplation and precontemplation before eventually achieving long-term resolution of the problem. Stages of Change questionnaire and the 12 item Readi- ness to Change scale have been developed to assess the stages of change for drug abusers.

The model of change does provide a structure to help us match different interventions with albeit, the arbitrarily, defined stages. Miller (1983) suggested that motivational interview- ing is most useful for individuals in the con- templation stage, although it can prove ben- eficial for individuals in all stages of change. Behavioral and cognitive interventions can be optimally applied in the preparation and main- tenance stages.

Psychologically based treatment methods

Motivational Interviewing

Motivational interviewing (MI) originally ac- counted by Miller (1983) saw motivational problems as a result of the therapist/client dia- logue, with the behavior of the therapist influ- encing the expectations, attributions, and be- havior of the client. During MI the individual is encouraged to reach his or her own decision about change, while the role of the therapist is simply to facilitate this process through clari- fication, advice when appropriate, accurate feed- back, and empathy. The aim of the therapy is

Psychosocial Treatment in Substance Use Disorder

to increase cognitive dissonance until a critical mass of motivation has been achieved and the individual is ready to move from pre-contem- plation to action. At this point commitment to real behavior change is a likely outcome. Motivational interviewers operationally define motivation as the probability that a person will enter into, continue, and adhere to a specific change strategy and there is a strong emphasis on ambivalence resolution and the decisional balance. Essentially the client begins to present his or her own argument for change rather than being directed by a coercive therapist, while it is the therapist’s role to set in place the opti- mum conditions for change.

Motivational enhancement

The multidimensional nature of motivation is highlighted by the three critical elements that a person is ready, willing and able to change. One can be able to change, but not willing. The willing component involves the importance a person places on changing and the ready com- ponent represents the final step in which the person finally decides to change a particular behavior. To instill motivation for change is to help the client become ready, willing and able. The motivational style of counseling is useful not only to instill motivation initially, but throughout the process of treatment in the preparation, action, and maintenance stages as well.

Appropriate motivational strategies for each stage of change (Miller 1999) could be as fol- lows:

Precontemplation: Establish rapport, build trust. Raise doubts or concerns in the person about substance using pattern. Explore the meaning of vents that brought the patient to treatment or the results of previous treatment. Elicit the patient’s perception of the problem. Give factual information about the risk of sub-

stance use. Provide personalized feedback about assessment findings. Explore the pros and cons of substance use. Examine the discrepancies between the patient and others perception of the problem behavior. Express concern and keep the door open.

Contemplation: Normalize ambivalence; help the patient tip the decisional balance scale to- wards change by eliciting and weighing pros and cons of substance use and change. Change extrinsic and intrinsic motivation. Examine the patient’s personal values in relation to change. Emphasize the choice of responsibility and self- efficacy. Elicit self motivational statements of intent and commitment. Elicit ideas regard- ing perceived self efficacy and expectations to- wards treatment. Summarize self motivational statements.

Preparation: Clarify the patient’s own goal and strategies for change. Offer a menu of options. With permission, offer advice. Negotiate a change or treatment plan and behavior con- tract. Counter and lower barriers to change. Help the patient enlist social support. Explore treatment expectancies and the patient’s role. Elicit what has worked in the past for him or others whom he knows. Assist the patient to negotiate finances, child care, work or other barriers. Have the person publicly announce plans to change.

Action: Engage the patient in treatment and reinforce the importance of remaining in re- covery. Support a realistic view of change through small steps. Acknowledge difficulties for the person in early stages of change. Help in identifying high risk situation and develop appropriate coping strategies to overcome them. Assist in finding new reinforcers of the change. Help in assessing whether the person has strong family and social support.

Maintenance: Help in identifying and sample

Psychosocial Treatment in Substance Use Disorder

drug free sources of pleasure. Support life style change. Affirm person’s resolve and self efficacy. Assist in practicing the use of new coping strat- egies to avoid return to drug use. Maintain supportive contact. Develop a ‘fire-escape’ plan if the patient resumes substance use. Review long term goals.

In summary, motivational enhancement is a client centred, directive therapeutic style to resolve ambivalence and promote greater com- mitment to change.

Relapse Prevention

Substance abuse has long been seen as a chronic, relapsing condition hence relapse management is an important issue in the treat- ment of addictive behaviors. Relapse preven- tion is a generic term for a variety of approaches to the treatment of drug and alcohol abuse, primarily aimed at those in the maintenance stage of change.

Though relapse has been viewed differently by various authors, the most common view is that while a lapse is an occasional slip, a relapse is a return to the original pattern of intake. Re- lapse has also been systematically approached from what has been called a psychobiological perspective. Central to these models is the idea that relapse is precipitated by craving, which results in loss of control. Craving can be seen as a cognitive interpretation of the feelings of arousal associated with drug-related stimuli. Researchers have also found that relapse is more likely in individuals who had few coping re- sources and who have encountered a relatively large number of risk situations.

The model by Marlatt and Gordon presented relapse prevention as a set of principles broadly based on social learning theory. In this pro- gram, individuals are taught to recognize the possibility of relapse. Essentially the client con-

structs a personal behavioral analysis and re- ceives training in specific coping strategies. These can include broad-based skills training (behavioral rehearsal, assertiveness training), cognitive reframing (coping imaginary, reframing reactions to lapse), and lifestyle in- terventions (relaxation and exercise enhance- ment). Clients are taught to recognize early warning signals and made aware of apparently irrelevant decisions that can increase the possi- bility of relapse. Emphasis is placed on the modification of cognitive distortions and the challenging of faulty beliefs or dysfunctional assumptions. The abstinence violation effect is a distorted redefinition of lapse as relapse, so undermining the effectiveness of future cop- ing behavior. The Marlatt and Gordon relapse prevention program is therefore a combination of skills training, self-management, and cogni- tive interventions and the client is encouraged to practice these strategies using rehearsal, role- play and homework tasks.

The relapse prevention model of Annis and Davis(1989) draws more explicitly on self-ef- ficacy theory. The emphasis of this approach is on performance based methods, notably the exposure to increasingly high-risk situations with continuing self-monitoring of efficacy ex- pectations. In guiding the client through the high- risk situations four factors are taken into account. First, the situation is challenging; second, to succeed in mastering the situation a moderate degree of effort is needed; third, the client is responsible and external help is kept to a minimum; and fourth, the success is de- scribed as part of improved performance.

Moser and Annis (!995) have emphasized the role of coping strategies in their cognitive be- havioral model of relapse. They demonstrate that the survival of relapse is strongly related to the number and type of coping strategies employed. Avoidance strategies are less effec- tive in preventing relapse than active strategies,

Psychosocial Treatment in Substance Use Disorder

such as carrying out alternative activities, seek- ing support from others, positive self-talk, and cognitive problem-solving.

In summary self-efficacy expectation, or the belief that addictive behavior can be changed by mobilizing personal resources, is the most powerful predictor of intention and subsequent behavioral control. Training in coping skills is not enough, people must use the skills at the right time for them to be effective. As the prac- tice of these coping skills improves self-efficacy so they are utilized effectively in real-life risk situation.

12 step facilitation therapy

Among the contemporary multimodal treat- ment packages for alcohol abuse, Alcoholics Anonymous is a community self-help group founded by Bill Wilson and Dr. Bob Smith in 1935. The principles of change described by AA are based on a religious organization in the Protestant tradition which emphasized self-ex- amination, the public admission of character deficits, restitution, pledge taking and bible reading. The AA belief system is articulated in the 12 steps mediated by fellowship meetings conducted by formerly drug-dependent per- sons, which include the requirement of a search- ing personal inventory, commitment to a greater power, making amends to other people, and carrying the message to other alcoholics. It also takes in to account motivation enhance- ment by proximal goals, role modeling, relapse management in terms of alternative activity and new social networks. AA emphasizes that help- ing other members is an essential component of one’s own recovery. With about 9000 AA groups across 134 countries including India, the AA is the world’s largest self-help group. Depending upon the type of drug abuse, there are other self-help groups like the Narcotics Anonymous (NA), Cocaine Anonymous.

Therapeutic community

Therapeutic communities (TCs) and social model recovery programs emphasize on giving back to the community a way to facilitate one’s own and others’ recovery. Experienced residents help orient new residents, take on job respon- sibilities to maintain the facility, and volun- teer to participate in a residents’ council or cli- ent government that helps manage program operations. Descriptions of social model recov- ery homes have described an ethic of volunteerism as a hallmark of that modality. In TC treatment, the role modeling for other clients during daily activities and treatment groups is an essential component of one’s treat- ment.

Network Therapy

Three key elements are introduced into the Network Therapy technique. The first is cog- nitive behavioral approach to relapse preven- tion. Emphasis in this approach is placed on triggers to relapse and behavioral techniques for avoiding them. Second, support of the patient’s natural social network is engaged in treatment e.g., peer support, family, friends and spouses. Third, drug-free rehabilitation is pro- vided by mobilization of resources.

Family and Marital Therapy

Family therapy is appropriate and helpful throughout the process of recovery. The model follows different stages. One generally starts by working with the most motivated family mem- ber or members, convening other family mem- bers when needed. The problem is defined and a contract negotiated. The case for a chemical- free life, with the involvement of family mem- bers is then established. The crisis faced by fam- ily members when they go through the change is managed and help given in stabilizing the family. Family reorganization and recovery is

Psychosocial Treatment in Substance Use Disorder

the next stage where the roles are balanced and assistance is given in couple or family issues of power and control. The family unit is helped to achieve closeness and intimacy. Treatment comes to an end when client and therapist(s) mutually agree to stop meeting regularly.

Brief Intervention

Brief intervention is a short counseling session focused on helping a person change a specific behavior. BI has proven to be effective in the management of individual with hazardous and harmful drug or alcohol use. The consistent features in BI have been summarized by Miller and Sanchez (1993) using the acronym FRAMES: Feedback, Responsibility, Advice, Menu of options, Empathy and Self-efficacy (confidence for change). The provision of giv- ing personally relevant feedback after assessment such as individual’s drug use and problems and associated personal risks is a key component of brief intervention. Personal responsibility is emphasized so as to bring about change in be- havior. Advice about changing the drug taking behavior is given in a nonjudgemental man- ner. Alternative strategies to cut down or stop their substance use are given. Empathic coun- seling and understanding approach to encour- age the patient’s confidence so as to promote self- efficacy in their behavior is used.

Efficacy of different therapies

There is good evidence on the effectiveness of psychological approaches for addictive behav- ior. Moos, Finney and Crankie (1990) in their review concluded that treatment leads to sub- stantial improvement in drinking behavior while acknowledging the importance of indi- vidual and social factors in the determination of outcome. Bien, Miller and Torigan (1993) in their review concluded that there are remark- ably few differences between brief and extended interventions for treatment-seeking alcoholics.

Most treatment reviews discuss treatment in- tensity and the need for treatment matching. The interventions planned for all types of drug problems need to be tailored to the individu- als’ needs and circumstances. Project MATCH Research group (1997) was the largest treat- ment trial on alcoholics randomly assigned to one of the three treatment modalities namely 12-step facilitation (TSF), cognitive behavioral coping skills and motivation enhancement therapy. The results indicated significant and sustained improvement in all three types of interventions.

Extensive studies have documented the efficacy of Brief Interventions by physicians and other health care providers for substance users. In their studies, Edwards et al (1977) and Wallace et al (1988) show that alcohol use decreased with BI. The studies conducted by Senft et al (1977) and Wilk et al (1997) also supported the efficacy of BI among alcohol users. Apart from playing a major role in reducing alcohol consumption, BI also helps the cigarette users as shown in a number of studies.

Research supports the integration of motiva- tional interviewing modules into programs to reduce attrition, enhance patients’ participa- tion in treatment and to increase the achieve- ment and maintenance of positive behavioral outcomes.

In 1974 the National Institute on Alcohol Abuse and Alcoholism recognized family therapy as “one of the outstanding current ad- vances in the area of psychotherapy” for alco- holism (Stanton & Heath).The most updated reviews of the research on marital and family treatment for alcoholism (Farrell, 1992) have concluded that family and marital treatment produces better marital and drinking outcomes than non-family methods.

Psychosocial Treatment in Substance Use Disorder

Conclusion

Most of the interventions described in the chapter have been offered to users of a range of substances. It is important to understand that the main component of any intervention is the cognitive and behavioral changes that accrue irrespective of the preferred drug of abuse. Re- search shows relapse prevention procedures are clearly useful for smokers, moderately effective for alcohol abusers, and have some variable ef- fect, as a treatment for cocaine abuse. While treatment based on psychological approaches have been shown to be effective, no specific treatment approach has emerged as being con-

Suggested Reading:

1. Annis HM. and Davis CS. Relapse preven- tion. In: RK Hester and WR Miller (Eds), Handbook of Alcoholism Treatment Ap- proaches: Effective alternatives. New York: Pergamon, 1989: 137-148.

2. Bien TH, Miller WR, Tonigan JS. Brief in- terventions for alcohol problems. A review. Addictions; 1993,88:315-33.

3. Davidson R, Rollnick S, and MacEwan I. Counselling Problem Drinkers, London: Routledge, 1991.

4. Davidson RJ. The Treatment of Substance Abuse and Dependence. In: A Bellack & M.Hersen, eds, Comprehensive Clinical Psy- chology. Elsevier Science, Oxford, 1998, 567-585

5. Gossop M. Cognitive and Behavioral Treat- ments for The Substance Misuse. In: G Edwards & C Dare, eds., Psychotherapy, Psychological Treatments and Addiction. Cambridge, UK: Cambridge University Press, 1996, 139-157.

6. Marlatt GA and Gordon JR. Relapse pre-

sistently superior to the others.

In the primary care setting the need for brief interventions and motivational interviewing would be a useful technique since many patients enter these programs unwillingly or at best with motivation to deal with the immediate crisis and placate those responsible for getting them into treatment. The issue of cost effectiveness of treat- ment is discussed at length rather than the need of the individual. Thus it has been emphasized that it would be best to remind the treatment providers that it would be justified to work on the need for caring of this population rather than cost-benefit analysis.

vention: Maintenance strategies in the treat- ment of addiction behaviour. New York: Guilford, 1985.

7. Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psycho- therapy, 1983,11:147-172.

8. O’Farrell TJ. Families and Alcohol Problems: An Overview of Treatment Research. J Fam Psychol; 1992,5:339-359.

9. Rollnick S, Heather N, and Bell A. Negoti- ating Behaviour Change in Medical Setting. The development of brief motivation inter- viewing. Journal of Mental Health, 1992,1:25-27.

10. Stanton MD & Heath W. Family and Marital Therapy. In: Lowinson JH, Ruiz P, Millman RB & Langrod JG., eds. Substance Abuse: A Comprehensive Textbook. Mary- land USA: Williams & Wilkins, 1992.

11. Tuchfeld B. Changes in the pattern of al- cohol use without the aid of formal treat- ment. Research Triangle Park, NC; Research Triangle Institute, 1976.

Psychosocial Treatment in Substance Use Disorder

Suggested slides for OHP

Slide 1: Substance use alters mood, cognition, behaviour
Assessment essential prior to psychosocial treatment

Slide 2: Psychotherapists work to influence the pro- cess of change

Involves- destructuring with resistance -conversion

-restructuring

Slide 3: Transtheoretical model most acceptable and widely used
Various psychosocial interventions affect these stages

Contemplation-Motivational Interviewing

Preparation & Maintenance- Behavioural & cogni- tive techniques

Slide 4: Motivational interviewing- influences behaviour & expectation

-client reaches his/her own decision -therapist facilitates the transition -eventually enhances motivation to change

Slide 5: Motivational Enhancement
Sets the process of change at various stages Resolves ambivalence
Requires-rapport, empathy, nonjudgmental attitudes

-feedback, facilitation
-emphasis on responsibility & action -identification of high risk situations -developing coping skills
-enlisting social & family support

Slide 6: Relapse Prevention Essential for long term abstinence

Involves-lapse
-transitional process

-occasional slip -relapse

-loss of control

-return to original pattern of intake Requires client –to understand the risk of relapse

-identify high risk situations

-use cognitive, behavioural techniques & life style modification

Slide 7: Self help groups (e.g. NA, AA)
Involves- self examination, restitution, pledge taking

-role modeling, relapse prevention, new social net- works

Slide 8: Therapeutic Community
Emphasizes one’s own & others recovery
Role modeling for other clients influences change

Slide 9: Family & Marital Therapy
Help in the process of recovery
One family member takes control Establishes the need for substance free life

Psychosocial Treatment in Substance Use Disorder

Community-based Treatment of Substance Use Disorder

HK Sharma

Summary

The drug scenario in the country has changed significantly in the last few decades. This has necessitated redefining and broadening of goals along with innovation in drug treatment and settings. Community based treatment and emphasis on a preventive approach are impor- tant measures to reach various vulnerable groups These individuals often do not seek help due to financial constraints and social stigma. In this approach, treatment is made available to alcohol/drug affected individuals and af- flicted families closer to their homes. This chap- ter discusses the rationale, approaches, strate- gies and interventions that can be applied in the context of community based treatment.

Need and rationale for Community-based treatment:

The drug scenario in the country has changed rapidly in the last few decades. There has been a gradual shift from plant products to alien and potent drugs, a change in the route of intake, early age of initiation and a diminishing of urban and rural differences in drug preferences. Consequently, drug abuse related complications have also shown a change. These developments call for redefining and broadening of goals and innovation in drug treatment and settings. Community based treatment and prevention approach emerged as a key strategy to reach vulnerable groups. The rationale behind the approach is that treatment process is brought closer to alcohol/drug affected individuals and afflicted families, who may not be able to avail these facilities on account of social stigma and

host of other factors. The outsourcing of ser- vices can foster community development and broader responses at the grass-root level. It also facilitates family and community participation and identification of multi-stake holders who can address larger issues related to availability and control of substance abuse.

The advantage of community-based treatment is that flexibility can be maintained in delivery of services. It addresses both the individual’s behavior as well as the socio-cultural context that define norms relating to a particular be- havior. These services are proving useful as an instrument for behavior change and assists the community to cope with harmful behaviors or situations. These services help in focusing on personal health (drug affected individuals), improve social function and reduce threat to public health (HIV/AIDS) and public safety (drunken driving, violence, crime etc.). There is a significant improvement in the treatment outcome when social and environmental fac- tors are taken into consideration, and social sup- port mechanisms enlisted in after care and so- cial reintegration of patients.

In the West, the community-based treatment has assumed a great significance in the crimi- nal justice system for drug related offences in- cluding drunken driving and serious felonies. Correctional measures are being provided in the prison or Drug Treatment Alternatives to prison programme. After the release, they are facilitated to join treatment/rehabilitation ser- vices at community to be part of mainstream life. The modality is being implemented at

small scale in the prison setting in our country and there is a need for widening of these ser- vices at district level as the number of drug offenders are increasing.

The community-based treatment/intervention has another distinct advantage. The use of ex- isting community infrastructure and mobili- zation of resources and manpower on volun- tary basis makes these services less costly vis-à- vis institutional services. The health care prac- titioner plays a key role in the treatment pro- cess.

The present chapter covers some of the salient features of community based treatment, ap- proaches and strategies, establishment of these services in different settings, concept of com- munity mobilization and intervention programme at grass-root level.

(2) Treatment goals

The National Institute on Drug Abuse (NIDA, USA) stresses that while the ultimate goal of all drug abuse treatment is to enable the abuser or addict to achieve lasting abstinence, there are important immediate goals as well. These are:

To reduce drug use,

Improve the patient’s ability to function,
and

To minimize the medical and social com- plications of drug abuse.
The envisaged goals of community-based treat- ment remain the same but the emphasis is on:

Detoxification of a selected group of alco- hol and drug dependents in a locality/catch- ment area.

Re-establishment of family bonds and re- integration of detoxified persons with their community.

Creation of awareness in the community of the existence of alcohol and other prob- lems in their environment.

Development of a sense of responsibility on the part of the public and voluntary organizations in supporting the process of treatment and rehabilitation.

Encouragement to the clients to commence rehabilitation with confidence

(3) Approaches:

Different approaches can be visualized in the context of community-based treatment in the field of substance abuse. These include both non-participatory (concerned authorities deliv- ering services to the community) to participa- tory (grass-root involvement for appropriate action). Community-based treatment ap- proaches seek to mobilize the elements of mu- tual support and common interest that char- acterize a natural community.

The main approaches to community mobili- zation are “bottom-up” and “top-down”. The former includes grass-root strategies, developed and implemented by community members. In the top-down approach, outside experts and/ or self-selected community leaders formulate strategies in delivering services. Each approach has its own strength and weakness. Under grass- roots approach, a wide spectrum of commu- nity members and institutions are involved to increase a sense of ownership but they may not have experience or expertise to design and implement effective intervention strategies. In the top-down approach outside experience and expertise play a vital role but may not reflect the community’s true concerns, interests and socio-cultural sensitivity. A comprehensive com- munity-based is more appropriate where es- sential elements of both the approaches are incorporated. The essential elements are expe-

Community-Based Treatment of Substance Use Disorder

rience and expertise of the former and multi- sectoral inclusion, organizational linkages and mechanisms of enabling and support. The multi-sectoral approach reflects level of com- munity involvement, organizational linkages denotes collaboration of different agencies and institutions; while enabling and support give leverage to access and control of resources.

(4) Organizations/ Resources that can be mobilized:

Community mobilization is an important pro- cess where members of a community identify a need, garner support and bring people to- gether to facilitate a programme. It brings con- cerned individuals, institutions, non-govern- ment organizations, government bodies, and media outlets behind the development and implementation of a programme. When com- munity mobilization works it is a very empow- ering exercise.

The following steps are suggested:

(i) Formation of core group: The first step in this direction is formation of a core group of representatives from different walk of life, including health/welfare personnel, reli- gious leaders, parent’s groups, business and trade group, educators, trade unions, women/youth groups, enforcement person- nel and local officials. The group helps in assessment of problems, need assessment and formulation of local action plan.

(ii) Community support: After detoxification and stabilization phase, the community resources are required in after care and re- habilitation of treated patients. The activi- ties may range from creating drug free zones for marginalized groups, social acceptance and reintegration. The community volun- teers, ex-users and family members and core group and community based organizations (CBOs) play a significant role.

(iii) Larger community: The continuum care needs support from larger community both financially and for provision of manpower. A cadre of community level workers or vol- unteers would be ideally placed to help individuals and families in distress. The ‘naturally occurring” support network of volunteers and CBO’s and neighborhood families can be an asset in identifying sec- ondary signs of alcohol/drug abuse like child abuse, domestic violence and eco- nomic hardships in affected families and in initiating remedial steps. Likewise, these groups also help in building social pres- sure against undesirable and anti-social el- ements.

(iv)Institutional network: Government agen- cies: In a given community, a large num- ber of central and state agencies operate in different spheres and their available re- sources can provide a big platform for com- munity intervention. Institutions like school, colleges and vocational training, and health and welfare care units may be iden- tified in the community and also outside the boundaries of the community. A num- ber of welfare agencies focusing on prob- lems of child, youth and women, environ- mental and economic development can become part of community network and support to deal with substance abuse prob- lem.

(5) Strategies to be adopted:

The intervention/ treatment strategies are worked out at various levels. These are:

(i) Organized treatment, rehabilitation and reintegration for physical/psychological de- pendence on drugs. (Continuum treatment services in community set up.) These in- clude:

Detoxificationisa5to30daytreatment 3

Community-Based Treatment of Substance Use Disorder

intended to wean the user from his or her substance. This can be done in a hospital-like setting or in a community- based program. Residential settings usu- ally treat patients for 14 to 28 days.

Outpatient. Frequently alcohol/drug dependence is treated in an outpatient setting. Some people receive care in day treatment programs, where they attend treatment for part of the day but spend the night at home.

Self-Help Groups are another form of outpatient treatment. Twelve-step pro- grams are available at some places and are run by group members. Popular among these are Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

Group treatment has been identified by some clinicians as the treatment of choice. This method tends to be effec- tive because it uses peer feedback, mod- eling, confrontation, and support. Group treatment can also be used to teach cop- ing and interpersonal skills.

Maintainence treatment, has been used on an outpatient basis. This involves us-

ing medicines (e.g., antabuse, naltrexone,buprenorphine,morphine) to reduce a person’s physical need for sub- stances or create an unpleasant effect if he uses it.

Family treatment focuses on stabilizing the family and helping them set bound- aries with the substance user.

Outpatientcounseling/therapy:Thegoal is to help the patient gain insight into their substance-using behaviors, address problem behaviors, teach social skills, and provide support.

Brief Intervention: Brief intervention by primary care providers is helpful to prob- lematic alcohol users/ heavy drinkers. The brief intervention consists of brief

advice sessions by physicians/ therapist focusing on harmful aspect, recognition of problems/ risk situations and manage- ment.

(ii) Preventive/protective measures: Along with secondary/tertiary preventions, the commu- nity based treatment services also emerge as a viable platform for primary prevention measures for school/ college youth through institutional network. Issues such as drunken driving, accidents/injury and availability of illicit drugs become part of community intervention and social action.

6. Treatment Settings:

Various settings have been adopted in treat- ment of substance abuse at community level. These include delivery of services from a hos- pital (Civil/District or specialized institute/ de- addiction center), establishment of community clinic/drop-in-center, field post and mobile clinic.

(a) Centre Based Treatment extending to com- munity: A drug affected community/spe- cific groups are adopted by De-Addiction Centre/ Medical Institute/ College and substance abusers are referred to these ser- vices for detoxification and management of concurrent illness. After completion of a treatment regime and psychosocial treat- ment, the patients are sent back to their community and a community team moni- tors, involves the family to prevent relapse and manages other problems including any crisis.

(b)Community Based Treatment at District Level

In this regard Civil/District hospital pro- vides treatment services and medical col- leges/ institutions and the Ministry of Health act as agencies for execution, advice and monitoring. The district bodies do the

Community-Based Treatment of Substance Use Disorder

actual implementation. Each district can have a local coordination committee to carry out various activities. By and large, the dis- trict committees are headed by District Magistrates. The various activities being carried out are

. a) survey to assess the magnitude of the problem

. b) delivery of treatment and aftercare ser- vices

. c) community awareness building

. d) health education

. e) integration with other parallel
programmes of the government and

. f) integration with supply reduction activi-
ties.

Another feature of district level programme can be formulation of district coordination committee, which suggests the action plan/ programme activities.

(C) Community Clinic/Outreach Services:

The outreach services are set up in the natu- ral milieu. Its broad objectives are:

To identify majority of drug dependents in main catchment areas and adjoining localities and to initiate the process of pre-treatment counseling (clarify myths and misconceptions associated with drug abuse.

To focus on health and social conse- quences of socially sanctioned drugs like alcohol and tobacco as well as illicit drugs such as heroin and psychotropic drugs in their environment and suggest possible remedial steps.

To provide low-cost treatment services within community.

To facilitate formation of local support groups (youth, women, etc.) as well as self-help groups (AA, NA, etc.)
The physical infrastructure is provided by

the community or organized by the com- munity and the core team for treatment is provided by the service delivery team of De- Addiction Center/ Institutions or hospitals.

(d) Camp Approach : Camp approach emerged as a key approach in the context of opium and alcohol treatment, especially in the rural areas. It involves identification of all drug dependent persons living in a local- ity, mobilization of ex-users and volunteers for assistance in the detoxification camp, use of premise (community center, empty schools or other institutional premises) for 10-14days. Even after detoxification pro- cess, care providers maintain contact fairly over a long period of time to assure that momentum is not lost and community continues its vigilance and helps in relapse prevention.

(e) Field Post: The field post approach is gen- erally used to make an access to hard-to reach populations – truck drivers, migrants, sex workers, street children and homeless people. It is also an useful tool for target- ing risk behavior- ID use practices, unpro- tected sex and HIV/AIDS. The outreach team gains alliance with key people. After gaining access to hidden population, risk reduction interventions can be carried out to target their risky behavior. The approach helps in making regular and close contact with at risk population and helps in iden- tifying drug users, who can be trained as peer counselors and help in implementing harm reduction activities.

Community-Based Treatment of Substance Use Disorder

Essential Elements:

Identification of drug dependent persons through social network and multiple en- try points.

Rehabilitation before detoxification: The social fabrics in developing countries facilitate process of rehabilitation before

Community-Based Treatment of Substance Use Disorder

detoxification through spreading message of optimism and de-mystification of drugs.

Involvement of family, ex-users and vol- unteers

Detoxification in natural setting/ group detoxification

Vigilant Groups

(7) Intervention, mobilization and education of appropriate individuals

workers, homeless, sex workers etc.)

Underprivileged/ slum population

High rate of consumption of legal drugs (alcohol, pharmaceutical products)

Drug trafficking routes/networks

Diversion from legal opium cultivation

International border areas/points
Treatment package:
The treatment package comprises of outpatient/ home detoxification, free distribution of medi- cines and psychosocial intervention. The func- tioning of the staff at these services is generally participatory to perform a wide range of activi- ties. The medical staff provides medical assess- ment, physical examination, pharmacothera- peutic services and clinical supervision. The other staff (social workers, nursing staff etc.) carries out assessments, individual, group and family counseling, education of patients and their families. They make periodic home visits for the registered patients and also motivate others to seek assistance at the clinic. They also help in community mobilization, linkages with other prograamme developers and other resource persons. The core staff can be further strengthened by community volunteers and ex- addicts in carrying out various intervention programmes.
Awareness/education/mass campaign:
Education plays a significant role in creating awareness about treatment services, clarifying myths and misconceptions about substance abuse.These can be disseminated through for- mal and informal channels involving family, peers, social organizations and interest groups. At an individual level, simple handouts, pam- phlets or set of booklets can be developed or procured. The patient related information on ‘treatment compliance’, detoxification and “short and long term maintenance” steps in ‘recovery’ and ‘social integration’ in simple

Broad- based steps:

Identification of people who have risk
factors

Build protective factors by giving healthy prevention messages;

Participation in community and other activities;

Home visits and follow-up;

Social reintegration of cured drug addicts

Advocacy with government officials on policy matters

Promotion on healthy lifestyle

Establishment/running of CBT services:

Selection of community (ies):

The problem of substance abuse may not be evenly distributed in a given population. In this regard, needs and resources assessment is one of the important steps in planning of ac- tivities ranging from early intervention, treat- ment/rehabilitation or specific target oriented programmes. The target groups in a commu- nity is selected on various indicators, viz.

Severity of drug problems

Drug related health and social problems

Concentration of vulnerable groups in a given population (school dropouts, migrant

terms should be made freely available. The sec- ond set of material can be developed for af- fected families and resource persons.

Community mobilization:

Important steps:

To form a core group/ team: It is impor- tant to form a group that is representative of community (geographic community or a community of like-minded people or people joined by a common interest).

Establishment of action plan: According to the need and resources to achieve goals. This step helps in developing some structure to meet the objectives.

Spread the message to reach as many mem- bers of the community as possible about available/future services.

A strong media campaign aimed at getting ongoing coverage about an issue/group, radio programs, offering a spokesperson to be a guest and addressing other groups.

The resources available to the community to achieve these goals should be identified and assessed. Goals should be modified and clarified as these services progresses and gains more information about the substance abuse problem.

To sustain momentum, keep the public informed and continue to gather informa- tion to ensure community members are in- volved in the problem-solving process.

Continue to expand group/coalition/part- nerships.
(8) Cost effectiveness
One of the main advantages of the commu- nity-based treatment is a low cost strategy in comparison to hospital or specialized services. The experiences of establishing and running

these services both in India and abroad has shown that the cost of medicine dispensed, core staff salary and infrastructure cost of running community clinic/out reach services is almost one-third to that of hospital based or special- ized services. The cost borne by the alcohol/ drug dependent and his family on procurement of substances, transportation scale down con- siderably when a person get registered for de- addiction services and continue to follow-up for a reasonable period. This helps in reduc- tion of internal (private) cost on the part of individual and his family.

The community-based treatment run over a long period of time helps in reduction of in- tangible cost borne by the society in terms of crime, road traffic accidents, worksite mishaps, injury and loss of productivity. There is a cor- responding decrease in family burden and dis- organization when community takes collective decisions and social action. These services gal- vanize the concerned people to stem undesir- able behavior.

(9) Integration of services with existing services:

The inter-sectoral partnership between differ- ent organizations dealing with health, social welfare, education has led to a forward move- ment in the management of substance abuse in community setting. The collation can take place and the manpower of these services can be utilized through various mechanisms. The information dissemination, training and short term orientation courses can help in pre-treat- ment process as well as in recovery, after care and social reintegration of treated patients.

The service delivery network can involve local NGOs, self- government bodies (Panchayat, Zila Parishad), office of the district adminis- tration, District Magistrate (DM), Sub-Divi- sional Officer (SDO), Block Development Of-

Community-Based Treatment of Substance Use Disorder

fices (BDO), Community Development Of- ficer (CDO) and personnel engaged in agri- culture extension and rural development. In urban areas state/central government agencies like urban basic service, ICDS, municipal bod- ies and health and welfare care network and resources can be tapped to strengthen the ser-

vices at community level. The enforcement of- ficials, (Superintendent of Police), office of the Deputy Narcotics Commissioner (DNC) can be part of community based intervention treat- ment. The emphasis is to involve officials from both demand and supply reduction activities at the district level.

Suggested Reading:

1. Galanter M, Kleber HD, eds. Textbook of Substance Abuse Treatment. American Psy- chiatric Publishing, Inc. Washington, DC, 2004.

2. Community Action to Prevent Alcohol Prob- lems. WHO Regional Office for Europe, Copenhegen, 1999.

3. A community Prevention Trial to Reduce Alcohol-Involved Trauma. Addiction, 92, Supplement 2, June, 1997.

4. Economic and Social Commission for Asia

and Pacific. Approaches to community- based HIV/AIDS prevention in ESCAP re- gion. United Nations, New York, 1998.

5. Economic and Social Commission for Asia and Pacific. Community-Based Drug De- mand Reduction and HIV/AIDS Preven- tion, A manual for planners, practioners, trainers and evaluators. United Nations, New York, 1995.

6. Nadkarni VV, ed. Drug Abuse Demand Re- duction: Focus on Community Based Ap- proaches. Bombay, 1992.

Community-Based Treatment of Substance Use Disorder

Suggested slides for OHP Slide : 1

Need and rationale for Community-based treatment (CBT):

· Changing drug scenario- broadening of goals/ meth- ods of drug treatment.

· CBT approach emerged key strategy

· Reaching to un reached and other vulnerable groups

· Helps to overcome stigma and isolation of alcohol/

Community Mobilization Key points:

· Core group: representative of community (geo-
graphic community/ like minded people or people.

· Establishment of action plan:

· Spread the message and reach as many members of
the community.

· Staging a public event, function or a meeting.

· Advertising in local papers

· Utilizing free community announcements through
media outlets

· To sustain momentum, keep the public informed
and continue to gather information.

· Continue to expand group/coalition/partnerships
alcohol/ drug sellers or their patrons.
Slide: 5
Strategies to be adopted

(i) Organized treatment, rehabilitation and reintegra-

tion for physical/psychological dependence on drugs. (Continuum treatment services in commu- nity set up.) These include:

· Out patient:

· Day care treatment

· Self-Help Groups outpatient treatment (Twelve-
step programs):Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA).

· Group treatment

· Maintenance programme

· Family treatment

· Outpatient counseling/therapy:

· Brief Intervention.
(iii) Preventive/protectivemeasures:
Slide: 6
Treatment Settings:
Centre Based Treatment extending to community:

drug affected individuals/ families

· The outsourcing foster community development

· Broader responses at the grass-root level.

· Cost effective and economic
Slide 2

Advantages:

· Flexibility in delivery of services.

· Addresses individual’s behavior and the socio-cul-
tural context.

· Other community infrastructure/ manpower costly

· Health care practitioner( government/ private sec-
tors) play a key role

· CBT useful skill for behavior change

· Enables the community to cope with harmful be-
haviors/ situations.
Slide: 3
Approaches:

· Non-participatory (concerned authorities deliver-
ing services to the community)

· Participatory (grass-root involvement for appropri-
ate action).

· Seek to mobilize the elements of mutual support

· Common interest that characterize natural commu-
nity.

· Bottom-up: grass-root strategies developed and
implemented by community members.

· Top-down approach: outside experts/self-selected
community leaders formulate strategies
Slide: 4

· ·

De-Addiction Centre/ Medical Institute/ College adopt drug affected community/groups.

Substance abusers identified and referred Detoxification and management of concurrent ill- ness.

Community-Based Treatment of Substance Use Disorder

· Psycho-social treatment with treatment regime,

· Patients are sent back to their community to moni-
tor

· Crisis management

· Family members help in relapse prevention and
manage other problems.
Slide: 7
Community Clinic/outreach services:
The outreach services are set up in the natural milieu

o identify majority of drug dependents in main

catchments area
o initiate process of pre-treatment counseling, moti-

vation
o to focus on health and social consequences of so-

cially sanctioned drugs like alcohol and tobacco and

illicit use of heroin
o to provide low-cost treatment services within com-

munity.
o to facilitate formation of local support groups

(youth, women etc.)
o to establish self-help groups( AA, NA etc.)

Slide:8

Camp Approach:

· Key approach opium/ alcohol treatment, in the ru-
ral areas.

· It involves identification of all drug dependent per-
sons living in a locality.

· Ex-users, volunteers for assistance in the detoxifica-
tion camp

· Parents/ families and community leaders remains
important partners

· Physical facility of the locality to be utilized

· Care providers maintain contact fairly over a long
period.

· Helps in relapse prevention.
Slide :9
Broad-based steps:

· Identification of people who have risk factors;

· Build protective factors by giving healthy preven-
tion messages;

· Participation in community and other activities;

· Home visits and follow-up;

· Social reintegration of cured drug addicts

· Advocacy with government officials on all levels to
change laws/ policies;

· Promotion of healthy life style.
Slide: 10
Collaboration:

· CBT: Comprehensive services at the community
level,

· Involving government medical institutions/health
infrastructure

· NGOs, local self government bodies (Panchayat,
Zila Parishad),

· Enforcement officials, Deputy Narcotics Commis-
sioner (DNC).

· Involving officials from both demand and supply
reduction activities at the district level.

· The district committees are headed by District
Magistrates.
Slide 11:
Conclusion:
Community based treatment

· Key strategy in present circumstances

· Cost effective measures

· Key role of health providers

· Flexibility in delivery of services

· Community participation- a cardinal principle in
delivery of services

· Integration of services

· Sustainable programme

Community-Based Treatment of Substance Use Disorder

Nicotine Dependence

Vivek Benegal

Summary

Tobacco use is common amongst men and women worldwide. Tobacco dependence is in- variably present in all substance users. The need to abstain and understand its harmful conse- quences remains unrealized in large populace. It is also considered to be difficult to manage. This chapter highlights the major issues related to nicotine dependence and effective ways to manage in primary care settings.

1. Tobacco use in India

1.1 Types of tobacco used

In India, tobacco is used in a wide variety of ways including smoking, chewing, applying, sucking and gargling. Beedi smoking is the most popular form of smoking, while cigarettes form the second most popular form of tobacco smoking.

Chewing paan (betel leaf) with tobacco is the major form of smokeless-tobacco (SMT) use. Dry tobacco and areca nut preparations such as paan masala, gutka and mawa are also popu- lar and highly addictive.

1.2 Prevalence of use

Tobacco use among men and women is wide- spread in all regions of India and among all sections of society. It has been estimated that 55.8% of males in the age range of 12 – 60 years currently use tobacco. Among men the prevalence of smoking and the use of smoke- less tobacco is roughly similar. Among women, the prevalence of smoking is low in most areas

due to social unacceptability, but is somewhat common in parts of the north, east, northeast and Andhra Pradesh. Overall, 2.4% of women smoke and 12% chew tobacco. Tobacco use prevalence is higher among older age groups compared to the younger age groups. None- theless, it is estimated that two in every ten boys and one in every ten girls use a tobacco product and initiation to tobacco products before the age of 10 years is increasing. Cur- rent non-cigarette tobacco use (13.6%) was three times more common than current ciga- rette smoking (4.2%)among the young.

2. Why do people need to be helped to stop?

2.1 Consequences of Tobacco use

In the year 2000, an estimated 4.83 million premature deaths in the world were attribut- able to smoking alone; 2.41 million in devel- oping countries and 2.43 million in industrialised countries. The region with the highest number of deaths attributable to smok- ing (0.68 million) was the developing region of South-East Asia (SEAR-D; dominated by India in terms of population).

Tobacco-related cancers constitute 56.4% and 44.9% of all cancers in males and females in India, respectively. Tobacco chewing in its vari- ous forms is directly responsible for cancers of the oral cavity, oesophagus, pharynx, cervix and penis. Beedi and cigarette smoking cause oral, pharyngeal, oesophageal, laryngeal, lung, stom- ach, gallbladder, urinary bladder and penile cancers.

Tobacco use, especially smoking, is associated with vascular diseases. The major constituents of tobacco smoke which are responsible for the cardiovascular effects are nicotine and carbon monoxide. Tobacco use is associated with ear- lier myocardial infarction (heart attacks) and coronary heart disease-related deaths at an early age. Many of the deaths due to cardiovascular diseases occur at a younger age in India com- pared to other countries. In India, 42% of the total deaths by 2020 are projected to be due to cardiovascular causes.

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling lung disease, which leads to respiratory crippling and premature death. In India, it affects over 5% of males and 2.7% of females who are over 30 years of age. Tobacco smoking is responsible for over 82% of COPD, which accounts for about 12 million adults suffering from smok- ing-attributed COPD in India.

Exposure of non-smokers, especially children and women, to second-hand smoke from oth- ers is an important cause of respiratory infec- tions, worsening of asthma and poor lung func- tions.

Tobacco use in any form has marked effects upon the soft tissues of the oral cavity. Tobacco use is associated with oral precancerous lesions such as leucoplakia and erythroplakia. Leucoplakia is the most common precancer- ous lesion associated with smoking and/or chewing tobacco. Oral submucous fibrosis (OSMF) is emerging as a new epidemic, espe- cially among the youth. In this disease, fibrous bands develop in the mouth, mucosa looses its elasticity and the ability to open the mouth reduces progressively. In extreme cases, victims may be only able to open their mouths enough to pass through a drinking straw. This disease does not regress, has no known cure and has a very high potential for cancer development. The relative risk is almost 400 times that of a non- user. The dramatic increase in OSMF among young people in India has been attributed to chewing gutka and paan masala.

Tobacco use has an adverse effect on the sexual and reproductive health of both men and women. Men who smoke have a lower sperm count and poorer sperm quality than non- smokers. The effects of maternal tobacco use (smoked and smokeless) during pregnancy in- clude decreased foetal growth, spontaneous abortions, foetal deaths, pregnancy complica- tions including those that predispose to preterm delivery and long term effects on the surviving children. Exposure to second-hand smoke during pregnancy has been associated with lower infant birth weight.

It is estimated that the total cost entailed by the major tobacco-related diseases in India, was about Rs 30,833 crores for the year 2001- 2002.

Nicotine Dependence

ALL-CAUSE MORTALITY DUE TO TOBACCO

The relative risk for death due to tobacco use in cohort studies from rural India is 40% to 80% higher for any type of tobacco use; 50 to 60% higher for smoking; 90% higher for reverse smoking; 15% and 30% higher for tobacco chewing in men and women, re- spectively; 40% higher for chewing and smoking combined.

An urban cohort study in Mumbai found that the relative risk of dying was more than 50% higher for smokers and about 15% higher for smokeless tobacco users.

Overall, smoking currently causes about 700,000 deaths per year in India.

From Report on Tobacco Control in India (2004)

2.2 What are the Benefits Of Tobacco Cessa- tion?

Tobacco cessation is an essential component for reducing the mortality and morbidity related to tobacco use. Continuing use may lead to an additional 160 million global deaths among smokers alone by 2050.

However, for the individual user, personalized reasons for quitting tobacco use (stated in posi- tive terms) is likely to be a more compelling source of motivation [see Box]. Professionals involved in helping people through tobacco cessation need to be able to discuss these ben- efits with their clients.

For Any User

· Feel better and less tired; improve ability to exercise; perform better at work in sports

· Live a healthier life, have fewer illnesses – and more likely to live long enough to enjoy retirement years, grandchildren

· Eliminate smell of cigarettes on body and clothes

· Decrease the following: Chronic sore mouth/sore throat; Hacking cough ; Rough, deepened voice; Shortness of breath; White patches in the mouth, which may be precancerous; Bad breath; Stained, hairy tongue; Stained teeth; Eroded teeth and cavities or gum recession (for users of SMT)

· Improve ability to taste, smell, and feel well

· Save money — money not spent on tobacco products and health services will be avail- able for personal benefit
For Pregnant Women

· Lower the rate of spontaneous abortion and fetal death

· Decrease the risk of having a low birth weight baby

· Decrease the risk of maternal complications
For Parents

· Lower the risk of sudden infant death syn- drome

· Decrease coughing and incidence of respi- ratory illnesses in children

· Decrease ear infections in children

· Become a better role model for children

For Teenage Users

· Show that you are not easily manipulated by misleading advertising

· Feel free of fear of being caught by par- ents

· Independence; behavior not controlled by nicotine

· Improve appearance, which may make it easier to get a job and/or become more attractive to potential romantic partners

· Money for fun things; doesn’t burn money
For New Users

· Quit while it is easier, before habit be- comes stronger

· Be more socially acceptable

· Make life less complicated without the dis- traction and mess
For Asymptomatic Adults

· Cut the risk of heart disease in half; re- duce the risk of getting emphysema as much as 6 times; reduce the risk of lung cancer by 90%; have a longer lifespan

· Save cost of tobacco products

· Save cost of health services

· Reduce bad breath; become more socially acceptable

· Have fewer wrinkles and avoid looking older than you are

· Reduce health risks to family, friends, and coworkers
Adapted from Mecklenburg et al., 1998

Box: Reasons for Quitting

Nicotine Dependence

3.1 Cause of Addiction

Nearly 3000 chemical constituents have been identified in smokeless tobacco (SMT), while close to 4000 are present in tobacco smoke, most of them harmful. Of these, Nicotine is the chemical that makes addicts out of tobacco users. It is a stimulant with properties similar to those of cocaine and amphetamines. Nico- tine is 1000 times more potent than alcohol, 10-100 times more potent than barbiturates and 5-10 times more potent than cocaine or morphine in its addictive potential. The ad- dictive effect of nicotine is linked to its capac- ity to trigger the release of dopamine – a chemi- cal in the brain that is associated with feelings of pleasure. However, recent research has sug- gested that in the long term, nicotine depresses the ability of the brain to experience pleasure. So, smokers and chewers need greater amounts of the drug to achieve the same levels of satis- faction. Tobacco use is therefore a form of self- medication: further use relieves the withdrawal symptoms, which set in soon after the effects of nicotine wear off.

Nicotine also combines with a number of other neurotransmitters in the brain and may con- tribute to the following effects: Acetylcholine (Arousal, cognitive enhancement), Serotonin (Mood modulation, suppression of appetite), Norepinephrine (Arousal, appetite suppres- sant), Vasopressin(Memory improvement), Beta-endorphin(Reduction of anxiety / ten- sion).

A key factor is the compulsion to take the drug experienced by the user. Most tobacco users smoke or use smokeless tobacco on a daily ba- sis. Other indicators of dependence include the time from waking to first use. Among smokers of all ages, 15 per cent light up within five minutes of waking, while almost half of all smokers (46 per cent) smoke within the first half hour of the day. More than eighty per-

cent of smokers who smoke 20 or more ciga- rettes a day say that they find it difficult to go a whole day without smoking.

Another marker for addiction is the occurrence of withdrawal symptoms following cessation of drug use. Typical physical symptoms follow- ing cessation or reduction of nicotine intake include craving for nicotine, irritability, anxi- ety, difficulty concentrating, restlessness, sleep disturbances, decreased heart rate, and increased appetite or weight gain.

Genetic Influence: Recent research suggests that certain smokers may be predisposed to nico- tine addiction through the effects of a gene re- sponsible for metabolising nicotine. Non- smokers are twice as likely to carry a mutation in a gene that helps to rid the body of nico- tine. In addition, smokers who carry muta- tions in the gene, (known as CYP2A6) are likely to smoke less because nicotine is not rapidly removed from the brain and bloodstream. By contrast, smokers with the efficient version of the gene will tend to smoke more heavily to compensate for nicotine being removed more rapidly.

Other factors to consider besides nicotine’s addictive properties include its high level of availability, the small number of legal and so- cial consequences of tobacco use, and the so- phisticated marketing and advertising meth- ods used by tobacco companies. These factors, combined with nicotine’s addictive properties, often serve as determinants for first use and, ultimately, addiction.

3.2 Behavioral and Psychological factors

The second reason why people find it difficult to stop is the psychological dependence upon tobacco use as a means of handling stress or reducing other unpleasant emotions.

The third reason is a learned response to cer- tain environmental/social cues (such as finish-

Nicotine Dependence

ing a meal or smoking by others), This can be thought of as an addiction triangle.

Helping people to quit tobacco must therefore address all three arms of this addiction triangle in order to be successful.

Difficulty in quitting: Surveys have shown that the majority of smokers (around 70 per cent) want to stop smoking yet the successful quit

rate remains very low. As little as 3 per cent of those who try to quit succeed in abstaining for as long as a year, using willpower alone. Twenty per cent or less of those who embark on a course of treatment succeed in abstaining for as long as a year. The power of addiction is also demon- strated by the fact that some smokers are reluc- tant to stop smoking even after undergoing sur- gery for smoking-induced diseases.

Nicotine Dependence

Clinical intervention goals for tobacco users according to degree of dependence and motivation to quit

Motivation

Low

High

Dependence

Low

• Unlikely to stop but could do so without help

• Primary goal is to increase motivation

• Likely to stop with minimal help

• Primary goal is to trigger a quit attempt

High

• Unlikely to stop
• Primary goal is to initially increase

motivation to make the user receptive to treatments for dependence

• Unlikely to stop without help but would benefit by treatment

• Primary goal is to engage in more intensive treatment

3.3 Who is likely to change? Assessment of people with tobacco abuse.

Whether a user succeeds in stopping depends on the balance between that individual’s moti- vation to stop tobacco use and his/her degree of dependence on tobacco. Clinicians must be able to assess both of these characteristics. Motivation is important because “treatments” to support cessation will not work in those who are not highly motivated. Dependence is espe- cially important in those who do want to stop, as it influences the choice of intervention. It is also important to bear in mind that motiva- tion to stop and dependence are often related to each other. For example heavy users may show low motivation because they lack confidence in their ability to quit; lighter users may show

low motivation because they believe they can stop in the future if they wish. Also, the moti- vation to stop fluctuates and can vary consid- erably with time and is strongly influenced by the immediate environment.

Measuring dependence in tobacco users

The simplest approach to measuring depen- dence is to ask whether the user has difficulty in refraining from smoking or using SMT in circumstances when he or she would normally use or whether the user has made a serious at- tempt to stop in the past but failed.

Another approach is to use a quantitative mea- sure of dependence like the Fagerstrom test for nicotine dependence (appendix 2), which has proved successful in predicting the outcome of

attempts to stop. Patients who quit smoking and relapse within two or three weeks usually do so to relieve withdrawal symptoms second- ary to their physical dependence on nicotine. The Fagerström Test for Nicotine Dependence is a standard instrument for assessing the in- tensity of this physical addiction (1). The higher the score on this questionnaire, the higher the level of dependence. The Fagerström test helps physicians document the indications for pre- scribing medication for nicotine withdrawal and craving. While this scale was originally con- structed for smokers, a modified version for SMT users also exists.

The main value of measuring dependence in tailoring cessation interventions to individual smokers is in the choice of pharmacotherapy. Smokers of 10 or more cigarettes a day show significantly better results with smoking ces- sation drug products (principally nicotine re- placement therapy and bupropion). However, some experts feel this cut off is arbitrary and all persons who have no specific contra-indication should be given the benefit of pharmaco- therapy.

Objective methods such as measurements of the concentration of nicotine or its metabo- lite, cotinine, in blood, urine, or saliva is often used in research as an objective index of depen- dence because it provides an accurate measure of the quantity of nicotine consumed, which is itself a marker of dependence. Carbon monox- ide concentration of expired air is a measure of smoke intake over preceding hours; it is not as accurate an intake measure as nicotine based measures, but it is much less expensive and gives immediate feedback to the smoker.

Measuring motivation to stop tobacco use

Direct questioning : Motivation to stop can be assessed qualitatively by means of simple direct questions about their interest and in- tentions to quit. This simple approach is prob-

ably sufficient for most clinical practice, although slightly more complex, semiquan- titative measures (asking the smoker to rate degree of desire to stop on a scale from “not at all” to “very much”) can also be used.

Simple qualitative test of motivation to stop

Do you want to stop smoking (using SMT) for good ?
Are you interested in making a serious attempt to stop in the near future?

Are you interested in receiving help with your quit attempt?

No/Yes No/Yes

No/Yes

A “yes” response to all questions suggests that behavioural support and/or medication should be offered

Stages of change:

Another approach, which utilizes the under- standing of the process of behaviour change, has become popular: the “transtheoretical model.” In this model, users are assigned to one of five stages of motivation.

Stages of change in process of stopping smoking.

Nicotine Dependence

Adapted from Prochaska et al. Clin Chest Med 1991;12: 727-35

This model has been widely adopted, though no evidence exists that the rather elaborate ques- tionnaires for assigning smokers to particular stages predict smoking cessation better than

the simple direct questions outlined above.

Some clinicians use a smoker’s degree of motivation to stop as a prognostic indicator of likely success once the quit attempt has been decided. In fact, degree of motivation seems to play a fairly small role in success; once a quit attempt is made, markers of dependence are far stronger determinants of success. The ultimate practical objective of assessing motivation is therefore to identify tobacco users who are ready to make a quit attempt. After that, it is the success of the intervention in overcoming dependence that matters.

4. What has been shown to help users quit?

Tobacco-cessation counseling provided by phy- sicians and other health care professionals have proved to be effective. The key elements of ef- fective intervention include identifying tobacco users, offering consistent and repeated advice to stop in a way that is of personal medical relevance, use of pharmacological adjuncts such as anti-craving medication and nicotine re- placement therapy (NRT), follow-up contact, and advice regarding intensive cessation therapy when necessary.

For patients who are unwilling to quit, moti- vational interventions, including information regarding personal risks associated with smok- ing and chewing and rewards resulting from cessation are useful. Counseling can be offered at all patient encounters, to both outpatients and hospitalized patients. Similar strategies are used in both smoking and smokeless tobacco- cessation interventions.

There are two broad strategies: One involves focused treatment for tobacco cessation to people seeking to stop or referred from other sources. Trained personnel in specialized ces- sation clinics usually offer this. The other in- volves detecting tobacco users opportunistically when they come to the attention of doctors

and health care workers having come for con- sultation for some other illness. The interven- tion is typically brief, as it needs to be carried out along with the original treatment sought. But the opportunity to motivate a person to change is high as the concern about his or her health provides the clinician with an excellent “teachable moment”. Less intensive interven- tions, as simple as physicians advising their patients to quit smoking, can produce cessa- tion rates of 5% to 10% per year. More inten- sive interventions, combining behavioral coun- seling and pharmacologic treatment, can pro- duce 20% to 25% quit rates in one year.

4.1 Brief interventions in the non-treatment – seeking population

There is good evidence that brief tobacco ces- sation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the propor- tion of users who successfully quit and remain abstinent after 1 year. Minimal clinical inter- vention consists of brief cessation advice from health care providers delivered opportunisti- cally during routine consultations to smokers whether or not they are seeking help with stop- ping smoking. Physicians, especially general practitioners (GPs), are in a unique position to influence the many smokers who are not ready to quit as well as to aid the ones who are ready. GPs see patients who smoke at many oppor- tune moments when they are concerned about their health. A GP may see the same patient who smokes over decades.

The components of physicians’ clinical inter- vention in tobacco use in broad terms are pro- vided in the adjoining box.

Knowing the user’s stage of readiness to change allows messages to be tailored to the appropri- ate goal for that patient’s condition and facili-

Nicotine Dependence

tate patient movement from the current stage to the next, with the eventual goal being long- term tobacco cessation. This approach has been described as the 5As interventions. The dura- tion of each session of minimal intervention is usually three to five minutes, and certainly less than ten minutes

4.2 Medications and Nicotine replacement

Numerous effective pharmacotherapies for smoking cessation now exist. Except in the pres- ence of contraindications, these should be used

with all patients attempting to quit smoking or smokeless tobacco use:

A. First-line pharmacotherapies that reliably increase long-term smoking abstinence rates are sustained release bupropion, nicotine gum, nicotine inhaler, nicotine nasal spray and nicotine patch.

B. Second-line pharmacotherapies including clonidine and nortriptyline, have been iden- tified as efficacious and may be considered by physicians if first-line pharmacothera- pies are not effective.

Special consideration, however, is required for certain patient groups among whom one or more of the drugs may have deleterious effects:

· Pregnant/breast-feeding women. No agents are approved for these patients, but phar- macotherapy is less harmful than tobacco use itself.

· Quit attempts without pharmacotherapy — especially in light tobacco users (<10 cigarettes/day or <1 sachet of SMT /day) — are initially preferred.

· Smokers with cardiovascular or pulmonary disease. Although all agents are generally safe, patients with these conditions should be specially cautioned not to use tobacco while using nicotine replacement. Care should be exercised with use of nicotine with patients who have had a recent myo- cardial infarction, experience severe or wors- ening angina, or have serious arrhythmias.
4.2.1 Use of Nicotine replacement therapy
Nicotine Replacement Therapy (NRT) is used to relieve withdrawal symptoms in tobacco users when trying to quit by substituting the nicotine in tobacco with nicotine in relatively safer form as they do not contain all the dan- gerous chemicals present in tobacco. However, it must be made very clear that NRT alone is

Nicotine Dependence

The 5 A’s of smoking cessation

Ask every patient on every visit about his or her use status and systematically identify all users. Record tobacco use status promi- nently, along with vital signs.

Advise strongly all users to quit. Tailor the advice toward the patients’ current medical problems and concerns.

Assess the patient’s willingness to quit. Ask every user if he or she is willing to make a quit attempt. If the patient is not yet ready to make a quit attempt, provide motivational intervention to promote future quit at- tempts.

Assist patients in their efforts to quit. Pro- vide nicotine replacement and/or pharma- cotherapy as well as teach behavioral strate- gies to quit, deal with withdrawal and pre- vent relapse.

Arrange a follow-up close around the quit date to assure the patient that assistance and counseling are available.Arrange subsequent follow-ups to provide support.

Adapted from The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA. 1996.

not the answer. Behavior modification is an important aspect of any behavior change, es- pecially tobacco cessation. The use of NRT al- lows individuals to focus on the behavioral as- pects of quitting without experiencing severe withdrawal symptoms. After the acute with- drawal period, nicotine replacement therapy is gradually reduced.

Use of Nicotine Gum

Nicotine gum, which is currently available in India, is available in strengths of 1, 2 and 4 mg of nicotine that can be released from a resin by chewing. The gum manufactured in India comes in two varieties a guthka flavored one for pan paraag and guthka users and a mint flavored one for smokers.

Dosage: Scheduled dosing (e.g., one piece of 2-mg gum/hour for light smokers, and 4-mg gum for highly nicotine-dependent smokers is recommended.

It is recommended that the gum be started on the quit date when the user is advised to abso- lutely stop all tobacco products and use the gum instead. Duration of treatment is 4-6 weeks. The gum is weaned off subsequently by tapering the frequency and strength of the gum over 2-3 months or less.

At present, other Nicotine replacement thera- pies such as Nicotine patches and Nicotine inhalers are not freely available.

4.2.2 Use of Bupropion Hydrochloride Sus- tained Release tablets

Bupropion (an antidepressant agent) has been used along with NRT as first-line therapy for treating tobacco dependence. It is presumed to reduce cravings associated with nicotine dep- rivation by affecting noradrenaline and dopam- ine. These two chemicals have been identified as the key components of the nicotine addic- tion pathway. Taking the drug alone produces higher cessation rates than placebo. In actual practice settings, the combination of bupropion and minimal or moderate counseling has been associated with 1-year quit rates of 23.6% to 33.2%.

Taking it along with nicotine replacement is even more successful.

Dosage : Bupropion treatment is begun 1-2 weeks before the set quit date. The usual adult target dose for bupropion sustained release tab- lets is 300 mg/day, given as 150 mg, twice daily. There should be an interval of at least 8 hours between successive doses. Dosing with bupropion sustained release tablets should be- gin at 150 mg/day given as a single daily dose in the morning. If the 150 mg initial dose is adequately tolerated, an increase to the 300- mg/day-target dose, given as 150 mg twice daily, may be made as early as day 4 of dosing. Doses above 300 mg/day should not be used.

Nicotine Dependence

Patient Instructions for Nicotine Gum

1. Do not smoke while using the gum.

2. Use one piece of gum at a time and use on a fixed schedule (1 piece/hour).

3. Chew gum slowly until a peppery taste or tingling of the gums occurs. Then, stop chewing and park the gum in between the gums and cheek until tingling stops. Start chewing gum again and repeat the parking and chewing process for about 30 minutes.

4. Do not eat or drink anything 15 minutes prior to and during the use of the gum. Absorption of nicotine in the buccal mucosa is decreased by an acidic environ- ment; thus, patients should not use beverages (e.g., coffee, soda, juice) immediately before, during, or after nico- tine gum use.

The 150 mg twice-daily dosage is continued for 7-12 weeks after quit date and maintenance therapy may go on for 6 months. It is impor- tant that patients continue to receive counsel- ing and support throughout treatment with bupropion, and for a period of time thereafter.

Adverse Effects: The medicine may result in an activating effect with feelings of agitation or restlessness that however decreases in 1-2 weeks after starting medication. Insomnia, gas- trointestinal upset, appetite suppression and weight loss, headache and lowering of seizure threshold have been reported. (Seizure inci- dence is 1 in 4000, but incidence is rare with sustained release preparations below 400 mg / day). If insomnia is marked, the night dose should be taken in the late afternoon.

Drug Interactions: It may interact with other antidepressants like Fluoxetine – causing panic and Psychosis. Carbamezapine may increase its breakdown and reduce its efficacy.

Contraindications: The medication is not rec- ommended in people with epilepsy, those tak- ing concurrent psychiatric medications, those with eating disorders like Anorexia Nervosa and Bulimia and in Pregnancy.

4.3 Behavioral methods: Problem-solving and skills training.

The ideal strategy combines pharmacological treatment and behavioral treatment. All users wishing to quit must be provided with practi- cal counseling. Some of the main problems to be addressed and skills that need to be devel- oped include the following:

1. Skills to assist users to make the quit at- tempt: Review of the participant’s tobacco use history and motivation to quit; setting a specific quit date; learning to interrupt the conditioned responses that support to- bacco use by self-monitoring and making

plans for coping with temptations to smoke or use SMT following cessation.

2. Skills to deal with problems that may oc- cur immediately after stopping or with- drawal from the effects of nicotine

3. Skills to avoid a lapse or relapse to earlier tobacco using patterns: Help in identifica- tion of high-risk situations and cues which lead to tobacco use, and generation of prob- lem-solving strategies to deal with high-risk situations.

These behavioral methods can be taught as part of a brief intervention programme. However, with patients who have very heavy use or have made multiple unsuccessful attempts at quit- ting, a range of more intensive behavioural methods is often used as part of

a] Individual counseling or through

b] Supportive group sessions.

4.3.1 Skills to assist users to make the quit attempt

A. Setting a quit date.

Help the patient set a quit date, preferably within 2 weeks, but not immediately, un- less there is an immediate health crisis. Al- low the patient at least a few days to plan for it and tell others about it. The patient should also be helped to draw up a list of personalized reasons for wanting to stop.

Prompt the patient by suggesting a signifi- cant date, for example, a birthday, an an- niversary, a holiday, the first of the month, or something else that would keep the date in mind.

Recommend that they not quit during an anticipated high-stress time. Acknowledge that no time is ideal but that sooner is bet- ter than later.

If a patient’s spouse, significant other, or close friend uses tobacco, recommend that

Nicotine Dependence

the other person and the patient quit to- gether. If the spouse is not interested in quitting, suggest that the patient arrange to have the spouse help by not using to- bacco in the patient’s presence.

Nicotine fading techniques may be recom- mended so that patient is able to achieve a reduction of more than 50% of initial use by the quit date. This involves progressively lowering the number of cigarettes or SMT sachets daily, so that nicotine intake is at the lowest possible level just before the quit date. This is best done after recording when and the way one tends to use tobacco by maintaining a tobacco use diary. The alter- native is the cold turkey method of giving up all of a sudden on the quit date.

Advise clients to throw away all tobacco and other items such as ashtrays etc. the night before the quit day dawns, preferably in a ceremonial gesture.

Advise the patient that starting on the quit date, total abstinence is essential. Discuss the possibility of using Nicotine gum as a substitute from that date.

Note the date selected in the clinic progress record.

If there are no contra-indications, prescribe Bupropion and build up to the required dosage by the time of the quit date.
B. Overcoming psychological dependence.
Years of conditioning have created habits that cannot be erased easily or quickly. Neurons and neural circuits have adapted to the presence of nicotine over several years of use. Years of regu- lar use have created finely developed behavior patterns and in effect, the individual has be- come conditioned to use tobacco in certain social settings. It is essential to help the pa- tient identify each of the environmental con- ditions that most likely lead to tobacco use and then develop a course of behavior that avoids

those conditions or prevents them from occur- ring. Suggest that the patient develop an alter- nate plan to having a cigarette during the morn- ing toilet, smoking after a meal, smoking to manage stress at work or in traffic, being in an argument, and so on.

Patients should be encouraged to anticipate when they will be most vulnerable and have a coping response planned and rehearsed. The therapist needs to help the patient draw up a list of such daily circumstances and triggers, which are cued, to tobacco use. The patient is then encouraged to make small changes in his daily habitual activities in order to break the automatic link between these and the cued tobacco use. These can be as simple as doing something different, say drinking two glasses of water before going for the morning toilet. Doing something different forces the person to think and not carry out the usual chain of activity automatically.

Additionally, patients can be advised to make longer term changes in their lifestyle like tak- ing up yoga or an exercise routine.

C. Using past quit experience.

Since most users have tried to quit before, the patient can draw on those experiences. Many times relapse is not due to physical withdrawal. Identify what helped and what hindered pre- vious quit attempts. Was it physical withdrawal symptoms? Feeling sad, bored or upset? A so- cial situation? Help the patient plan how to handle the type of situation that led to the re- lapse.

D. Anticipating triggers or challenges. [see Box].

Encourage the patient to imagine situations that might lead to relapse. Discuss how the patient might successfully manage each. En- courage practicing responses to feeling, places, and social situations.

Nicotine Dependence

E. Avoiding alcohol.

Drinking is one of the most common causes of relapse. Alcohol impairs judgment and will- power. This subject should be raised even if the patient doesn’t bring it up. Suggest that alcohol be avoided during the quitting process, especially during the first weeks of abstinence, and used with caution later, especially if the patient drinks where others are smoking.

G. Reviewing and retaining information.

Providing self-help literature allows patients to review what they learned and to learn more as questions arise.

H. Extratreatment social support.

Patients should be encouraged to obtain social support for their treatment from family, co- workers, friends, and others. They will find that reinforcement is usually frequent and positive when such people understand what the patient is trying to do. Conversely, having other smok- ers in the household is a strong risk factor and

common cause for relapse. Patients should en- courage spouses to quit with them or not smoke in their presence.

4.3.2 Skills to deal with withdrawal

Physical withdrawal from nicotine is a tempo- rary condition, but it can cause a fair amount of discomfort while it lasts. Commonly reported symptoms include: Cravings (irresistible urges for tobacco), feeling irritable or cranky, insom- nia and fatigue, inability to concentrate, head- ache, increased cough with postnasal drip and sore throat, constipation, gas, stomach pain, dry mouth and sore tongue or gums and tight- ness in the chest.

Most people have some of these, but rarely all of them and these discomforts are short-lived.

It is essential to teach the patient coping skills to deal with the irresistible urge to smoke or use SMT [see Box] and the other problems which may be encountered.

Nicotine Dependence

Withdrawal Problems
Cravings
Strongest in the first week. Experienced in waves, individual “cravings” last 30-90 seconds. Begin 6-12 hours after stopping, peak for 1-3 days, and may last 3-4 weeks. As the days pass, the cravings get farther and farther apart. Mild occasional cravings may last for 6 months.

Suggested coping skills

The five D’s to handle Urges·

• Delay until the urge passes—usually within
3-5 minutes

• Distract yourself

• Call a friend or go for a walk

• Drink water to fight off cravings

• Deep Breaths—Relax! Close your eyes and
take 10 slow, deep breaths

• Discuss your feelings with someone close
to you.

Difficulty in concentrating usually begins within the first 24 hours, peak for the first 1-2 weeks, and disappears within a month.

Taking a break: gazing into a photo or looking out a window; closing eyes and relaxing for ten minutes.
Doing different tasks instead of focusing on any one activity for too long. Temporarily putting off work when feeling unable to do it.

Insomnia

Trouble falling asleep or disturbed sleep and daytime drowsiness. Troublesome for the first

Avoiding coffee, tea, caffeinated drinks after 6 pm. Drinking lots of fruit juices, and

Nicotine Dependence

1-2 weeks, and disappear within a month.

water. Learning relaxation/meditation techniques. Avoiding changes in sleep routine: always getting up at the same time every morning.

Depression and tiredness

Mild feelings of depression may occur usually within the first 24 hours, continue in the first 1-2 weeks, and go away within a month

Identifying specific feelings. Is one actually feeling tired, lonely, bored or hungry? Focus on and address these specific needs.
Add up how much money you have saved already by not purchasing cigarettes and imagine (in detail) how you will spend your savings in six months.

Call a friend and plan to have lunch, go to a movie. Make a list of things that are upsetting to you and write down solutions for them.

Irritability, Restlessness, Anger and Frustration

Feeling more “edgy” and short-tempered is common. These peak (stay high) the first 1-2 weeks, and disappear within a month.

Taking short walks or exercising. Having a hot bath, using relaxation techniques. Taking regular 10 minute mental and physical breaks from whatever work one is doing to …walk, stretch, run.

Keeping hands busy, like playing with a rubber band or squeezing a rubber ball.

Increased Appetite and Weight Gain

Stronger and more frequent hunger pangs are experienced, and the sense of taste also improves. Weight gain most often due to eating more after is a common but temporary phenomenon.

More physical activities (e.g. take the stairs instead of a lift, park further away from the door to the office/shop etc.). Drinking more water—especially before meals. Eating

plenty of fresh fruit—carrying it to work!

4.3.3 Skills to avoid a lapse or relapse to ear- lier tobacco using patterns:

These interventions should be part of every encoun- ter with patient who has recently quit.

Every ex-tobacco user should receive congratu- lations on any success and strong encourage- ment to remain tobacco free. Use open ended questions designed to initiate patient problem solving. “How has stopping tobacco use helped you?” Encourage patients’ active discussion of the following topics:

• Benefits, including potential health ben- efits, of cessation

• Success the patient has had in quitting,

duration, reduction of withdrawal, etc.

• Problemsencounteredoranticipatedthreats to maintaining abstinence eg. weight gain, depression, alcohol, other tobacco users in house

Prescriptive Relapse Prevention: based on in- formation obtained about specific problems the patient has encountered or likely to, should be de- livered during follow-up contact or through a spe- cialized clinic or program.

High Risk Situations

1. First step: identify high-risk situations. Where they’ve relapsed in past. How would

you answer this question: “If I were to start smoking again on the spur of the mo- ment…” Be specific: where? When? With whom? How you are feeling? Thinking? Doing?

2. Next, plan in advance, responses or solu- tions to cope with these triggers.

before they finally succeeded.

Encourage the person to recognize that a slip is merely a small setback. One slip need not mean a failure of the attempt or the person’s inability to be a non-user. But it is important to get back on the abstinence track immedi- ately.

Help the person identify the trigger: Exactly what was it that prompted him/her to smoke or use SMT? Once aware of the trigger, help the person plan how to cope with it when it comes up again.

Marking Progress

Each month, on the anniversary of the quit date, advise the patient to plan a special cel- ebration or purchase with the money saved. Encourage the quitter to periodically write down new reasons why he/she is glad to have quit, and post these reasons where they will be sure to be seen.

Follow-Up: After the Patient’s Quit Date

Frequent follow-up of the patient is an impor- tant predictor of success. Approximately 40% of smokers who quit relapse after the first year of abstinence. Reinforcement should be pro- vided at every visit because tobacco use is a chronic disease. Steps to take at follow-up ap- pointments after the patient quits include the following:

Data Gathering – Ask patients if they have re- mained abstinent. Ask patients about problems encountered and how they are managing them. Discussing problems helps identify solutions and makes living with a problem more man- ageable. Ask about other problems that might be encountered and how the patient might deal with them. This encourages patients’ thinking through circumstances and coping strategies. Invite discussion of benefits and success mile- stones.

Nicotine Dependence

Anticipating triggers or challenges

The urge to smoke after quitting often hits at predictable times. The trick is to antici- pate those times and find ways to cope with them–without smoking. Look at the follow- ing list of typical triggers. Does any of them ring a bell with you? Check off those that might trigger and urge to smoke, and add any others you can think of:

• Watching someone else smoke

• Working under pressure

• Feeling bored, angry or sad

• Finishing a task

• Before starting task

• To relax/take a break

• To concentrate

• While Studying

• Talking on the
telephone

• Having a drink

• Watching television

• Morning toilet

• Finishing a meal

• Playing cards

• Drinking coffee

• Driving your car

USE THE 4 “A’S”

Avoid. Certain people and places can tempt you to smoke.
Stay away for now. Alter. Switch to soft drinks or water instead of alcohol or coffee. Take a different route to school or work. Take a walk when you used to take a smoke break. Alternatives. Use oral substitutes like gum, cloves or saunf. Activities. Exercise or do hobbies that keep your hands busy can help distract the urge to smoke.

Relapse: If one slips!

Do not be discouraged if your patient slips and starts using again. Remind the person that many former users tried to stop several times

Intervention – Reinforce behaviors that are used to remain abstinent and be positive. Continue to build patients’ confidence in themselves as ex-tobacco users. Ask again about their reasons for quitting and continue to reinforce their motives. Determine if the drug therapy selected, if any, is being used correctly and if there are any related problems. Ask how family, friends, and associates are helping or not helping. Rec- ognize if your patient has had any slips or short- term lapses. Assure the patient that he or she has only experienced a small setback and that does not automatically make him or her smoker again. Urge the patient to get back on track as a nonuser as soon as possible to avoid further lapses. Help him or her to identify what trig- gered the lapse so that he or she will recognize the signs next time and know how to cope.

5. A suggested clinical protocol

During the first visit:

Ask for tobacco use, assess and record levels of dependence and motivation to stop. Advise the patient to take up a programme of tobacco ces- sation, tying in the advice with his/her current medical problems or other relevant tobacco related concerns.

If the patient is currently unwilling, discuss the roadblocks and prepare to discuss the issue on further visits.

If the patient is willing:

1. Plan a Designated Quit Date [DQD] within the next 2 weeks

2. Start the patient on increasing doses of Bupropion and discuss the use of Nicotine chewing gum or other NRT following the DQD.

3. Outline the steps to be taken to decrease

tobacco (nicotine dosage) to less than 50% of current usage before the DQD.

4. Detail the changes in daily habits and in general lifestyle that the patient is advised to start before the DQD.

5. Explain the likely withdrawal symptoms and strategies to cope with them. Persuade the patient to agree on implementing one or more of these.

6. Advise about getting support from persons close to the patient. If possible the patient could be asked to get in touch telephoni- cally whenever his abstinence is threatened.

7. Schedule the next follow-up visit, close to the DQD.

During the second visit:

1. Check on usage of medications and side effects if any. Start the patient on NRT giv- ing written details regarding use.

2. Review information on withdrawal symp- toms and coping strategies.

3. Educate about relapse triggers and skills to deal with them

4. Reinforce the patient’s motivation to con- tinue with the cessation plan

5. Schedule the next follow-up visit, prefer- ably after a week.

During subsequent visits (preferably weekly for the next one month and then at increasing in- tervals):

Check on medication and NRT. Review prob- lems faced regarding relapse triggers or slips and advise accordingly. Always reinforce the patient’s continuing in his cessation attempt and deal with any lapses or slips in a positive and empathic manner.

Nicotine Dependence

Suggested Reading

1. Ray R, Mondal AB, Gupta K, Chatterjee A, Bajaj P (2004) The Extent, Pattern and Trends of Drug Abuse in India: National Survey.New Delhi. United Nations Office on Drugs and Crimes & Ministry of Social Justice and Empowerment, Government of India.

2. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L.(2003) Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional house- hold survey. Tobacco Control. 2003 Dec;12(4):e4. Available at: http:// tc.bmjjournals.com/cgi/content/full/12/4/ e4. Accessed on 14 May 2005.

3. Global Youth Tobacco Survey (GYTS) Country Factsheets, India (by year of completion and state). Centers for Disease Control and Prevention, Atlanta.Available

from URL: http://www.cdc.gov/tobacco/ global/GYTS.htm (GYTS/factsheets/ pdf_files/india)(accessed on 30 September 2004).

4. Ezzati M & Lopez AD (2004) Regional, disease specific patterns of smoking-attrib- utable mortality in 2000. Tobacco Con- trol;13:388-395.

5. National Cancer Registry Programme (NCRP). Two year report of the population- based cancer registries, 1997.98. Bangalore: Indian Council of Medical Research, Coor- dinating Unit, NCRP; 2004a.

6. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.

Nicotine Dependence

Suggested slides for OHP

Smoking- beedi & cigarette smoking common Smokeless- chewing, gargling (paan masala,

gutka)

Prevalence- 55.5% males (age 12-60 years) use to- bacco

2.4% women smoke: 12% chew tobacco prevalence low in women- social unacceptability

– Relieves withdrawal symptoms

– Safe & behaviour modification also required Bupropion hydrochloride SR tablets

– reduces craving
– Begin 1-2 weeks before the set quit date
-150 mg single dose
– to continue for 7-12 weeks after quit date -maintenance therapy for 6 months
-seizures at very high doses only
-if tolerated, increased to 150mg b.i.d after 4 days

Behavioural methods
Learning skills like self monitoring & coping with craving
Skills to deal with withdrawals
Skills to avoid a lapse /relapse
Individual/group sessions also useful

8. Avoiding alcohol use

Regular follow up and marking progress Enhance motivation & confidence

– –

3. Consequences of tobacco use
– Relative risk of death due to tobacco use is high
– Smoking causes more than 700,000 deaths/year in
India -Tobaccorelatedcancersconstitutemorethanhalfof
all cancers in India
– Cardiovascular, cerebrovascular and respiratory af-
flictions common with tobacco use
– Oral Submucous fibrosis common with chewing
tobacco

4. Nicotine dependence
Nicotine release dopamine- reinforces its use Release other neurotransmitters- reinforces its use
Behavioural & psychological factors contribute to dependence

5. Measuring dependence

Fagerstrom test for nicotine dependence
– Available for smokers & smokeless tobacco – Higher scores- greater dependence

6. Measuring motivation

– Direct questioning
– Assessing the stage of change

7. Management

Brief Intervention
– Useful in non treatment seekers – Can be practiced in short time
– Useful for motivated individuals

Nicotine Replacement (Nicotine gum, patches, inhalers)

Nicotine Dependence

Intervention with Treatment Non Seekers

Manoj Kumar Sharma, Deepak Yadav

Summary

Treatment non-seekers constitute a large num- ber of the substance using population. Rea- sons for not seeking treatment are multiple and vary from individual to individual. Numerous studies have focused on the socio-demographic profile of these individuals and reasons for not seeking treatment. The process of bringing this population into the treatment program is of paramount importance as they form a large number in the community. This chapter high- lights their characteristics and ways to engage in the treatment process.

Introduction

Treatment refers to a variety of activities and processes that aim at helping individuals with drug related problems. Various characteristics have been associated with treatment seeking individuals. It includes stable socioeconomic status, married, 30-44 year age group, religious affiliation and history of abstinence in past. Self- recognition of substance related problems, oc- currence of negative events and conscious and informal advice or suggestion by others are other reasons cited by treatment seekers. However, treatment seekers do not constitute a signifi- cant proportion of alcohol users. Available re- ports suggest that only 2% of total alcohol users report to treatment as late as five years after the onset of use and only 27% had ever reported to any organization for help.

Trends of non-treatment seeking alcohol users

Studies suggests that the lifetime prevalence of at-risk drinking and alcohol abuse may be as high as 35% and the frequency of problem drinking as high as 10% in primary care set- tings. The estimated ratio of untreated to treated individuals’ ranges from 3:1 to 13:1. Even among the patients seen by the primary care physician, less than half were recognized as alcohol abusers. The majority of individuals with alcohol use / abuse do not enter treat- ment and there exists a pressing need to un- derstand factors that people perceive as barri- ers to seek help.

In general population surveys, respondents who had ever had an alcohol problem reported several reasons for not seeking treatment: 96% thought they could handle it on their own, 84% did not think their problem was serious enough and 56% said they did not want help. Alcohol abusers in treatment or who sought advice about their drinking have also reported delaying seeking treatment because they felt their drinking was not a problem or was not serious enough to warrant attention. The stigma associated with the alcoholism or ad- mitting to being an alcoholic has been another reason they gave for not wanting to enter treat- ment. Patient report feeling of being ashamed and a belief that treatment does not help as reasons for not seeking treatment. Denial may be prevalent among persons with alcohol use disorders and it is the most commonly cited reason for failure to seek treatment. The Rapid Assessment Survey (2004) cited difficulty in

Definition of Treatment Characteristic of Treatment Seekers

obtaining help from a treatment centre, not being aware of treatment facility, not needing treatment and a belief that treatment was not possible as reasons for not seeking treatment.

These barriers have also been linked to various socio-demographic characteristics. It includes lack of a stable job and having no issue or fam- ily responsibility and a low socioeconomic sta- tus (inability to afford transport expense or buy prescription drugs). Women (less likely to be referred by conventional routes, not being able to arrange for care of child, stigma, drink- ing as a manifestation of other interpersonal problem), youth (denial, fear of losing a job, not wanting to go for treatment, not having time for treatment) and being homeless are the other groups who do not seek treatment.

Identification of treatment non-seekers

Identification of treatment non-seeking persons with alcohol use / abuse is especially impor- tant in developing countries.

Intervention in Primary Health Care

Primary care physician are in a unique posi- tion to identify and treat patients with ‘at risk drinking’ and alcohol related problems. Pro- viding treatment – either directly or by refer- ral to specialized services logically follows the process of screening and diagnosis of alcohol problems. Counseling is one of the approaches to prevent relapse.

Counseling based nonpharmacological treat- ment strategies have been studied extensively for the care of patients who are ‘at risk’ for al- cohol problems. These approaches are based on the principle and process of behavioral change and typically involve the type of coun-

seling that can be used by the primary care physician. The important components of in- terventions are:

Identification / Screening Interventions

– Brief intervention

– Community Reinforcement Approach

– Contingency Management Intervention

– Specialized Group
• Women
• Adolescent
• Homeless Addict
Identification / Screening: Primary care phy- sicians need to ask all patients about current and past alcohol use “Do you currently or have you ever used alcohol?” quickly identifies those patients who are not lifetime abstainers and who require further screening. In addition, given the importance of family history as a risk fac- tor for alcohol problems, it is important to ask all patients about alcohol use in their families. Among patients who use alcohol, the next step is to obtain a detailed history regarding quan- tity and frequency of current and past alcohol use. Screening instruments in the form of AU- DIT, SMAST and CAGE could be adminis- tered to detect alcohol abuse and dependence. (Appendix 3, 4, 5)
Treatment Approaches :
Education Programme: Group or street meet- ings and pamphlet distribution help to re- duce stigma, enhance awareness about alcohol abuse, treatment approaches, cost and its avail- ability.
Brief Intervention: It is most intensively stud- ied in primary care setting. These counseling sessions are short (5-20 minutes) and focused.

Intervention with Treatment Non Seekers

Identification and Screening Treatment Characteristics

Primary Care setting
Characteristic of Treatment Non-Seekers Barriers to treatment

They incorporate four components namely motivational techniques, feedback about the problems associated with alcohol abuse, dis- cussion of adverse effects of alcohol and setting drinking limits. These interventions have been found to be effective in motivating the treat- ment non-seekers into treatment.

Community Reinforcement Approach (CRA)

The over reaching goal of CRA is to rearrange and improve the quality of the reinforcers ob- tained by patients through social, recreational, vocational and family activities. Community Reinforcement approach has been adopted to assist the significant others of treatment resis- tant problem drinkers by encouraging the drinkers to enter treatment. The CRA inter- vention includes education about alcohol prob- lems, information and discussion of the posi- tive consequences of abstinence from alcohol, assistance involving the designated client in healthy activities, increasing the involvement of the significant other in social and recreational activities and training the significant others in how to respond to drinking episodes. Several studies on this topic suggest greater efficacy of the CRA approach compared with more tradi- tional approach involving confrontation. The majority of designated clients whose families received the CRA intervention entered treat- ment and decreased their problem drinking.

Contingency Management Intervention: It involves the explicit and direct application of the conditioning principle of reinforcement and punishment to increase desired behaviour or to decrease problematic ones. It has three com- ponents: an objective, an observable target mode of behaviour that must be increased or decreased and tangible consequences that can be delivered promptly and reliably by a treat- ment provider upon display of the target re- sponse. Research has shown that contingency management intervention can be used to mo-

tivate or increase the participation of treatment non-seekers into treatment.

Specialized Group

Besides using the above-mentioned component of intervention, specific guidelines can be used for women, adolescent / children and the home- less addict.

Women:

Women are more likely to seek treatment ini- tially from medical doctors or from psychiatric facilities for alcohol related problems or psy- chological difficulties associated with drinking. Further, there is evidence that physicians are less effective in identifying alcohol abuse in women. There is a need to sensitize the pri- mary physician to diagnose, refer and treat women with alcohol problems.

The main component of intervention

Education material targeting stigma, social support and health consequences.

Educating Primary care physician on screening and detection of alcohol prob- lems.

Screening and referral information should be provided in women’s health clinic, preg- nancy and family planning clinics.

Improve the availability of services for chil- dren

Availability of childcare services while women participate in treatment.

Provide assessment, referral and treatment of behavioral problems in children.

Outreach services to women at risk for drinking should be improved and out reach workers specially educated on screening and treatment referrals for alcohol problems in women.

Intervention with Treatment Non Seekers

Children and Adolescents:

Alcohol consumption is a major contributor to adolescent morbidity and mortality. Forty to fifty percent of adolescents who died as a result of violent event (i.e. traffic accidents and homicides) were found in post mortem inves- tigation to have drunk alcohol. Children and adolescents who use substances often show high risk behaviours.

Intervention
Education about the health hazards of sub- stance use. It may include conducting school program or sensitizing the parents about the risk factors for substance use in parent teacher meeting.

Proceed according to the severity of prob- lem

– Substance use once or twice in a year: focus should be on awareness build- ing about drugs.

– Consumption has been frequently re- ported: There should be regular visit and therapeutic intervention.

Individual Therapy
Children and adolescents with co morbid psychiatric disorder should be taken for individual therapy. Therapy can focus on improving social skill training, coping behaviour and communication training.

Family involvement
It involves the family for motivating the patient to seek treatment, planning reha- bilitation and compliance to treatment.
Homeless Addicts
The problem of homelessness has worsened markedly in recent years. The main compo- nents of interventions are

Enhancing awareness about substances among homeless addicts / in shelter homes.

Community Reinforcement Approach

Brief Intervention.
National Drug Dependence Treatment

Centre (NDDTC, AIIMS) experience

A group using alcohol is identified through patients / family members attending commu- nity clinic or by social scientist visiting the community. A group generally constitutes 20- 25 members comprising mostly women and older age group. They act as catalysts in moti- vating the treatment non-seekers. Psychiatrist, psychologist, social scientist and psychiatric nurses conduct group sessions. A session in- cludes identification of senior members as group leader to mobilize interaction and dis- cussion focused on characteristics of alcohol abuse, psychosocial problems, benefits of treat- ment, pamphlet distribution, clarifying their misapprehension and sharing of experiences for alcohol free life style. These sessions have a positive impact on treatment seeking behaviours. Every meeting is being able to motivate 3-4 alcohol abusers into treatment.

Conclusion

Barriers to treatment must be addressed if we want to encourage the greater population of untreated substance user to enter treatment. These barriers might be reduced by a change in public perception of problem, the role of treatment, family role, and community in- volvement to motivate substance users or by how and where treatment is being offered. Al- though this chapter deals largely with work done with the alcohol abuser, the principles of treatment remain the same for all categories of substance abusers.

Intervention with Treatment Non Seekers

Suggested Reading

1. Fergusson DM and Horwood LJ (1998). Psychiatric disorder and treatment seeking in a birth cohort of young adult. Report prepared for Ministry of Health from the Christchurch Health and Development study. Department of Psychological Medi- cine, Christchurch School of Medicine, New Zealand.

2. Fiellin DA, Reid MC and O’connor PG (2000): New therapies for alcohal problems : application to primary care. Am J. Med. 108, 227-237).

3. Heather N (1990). Brief intervention strat- egies. In RK Hester and WR Miller (Eds.) Handbook of alcoholism treatment ap- proach. Effective alternatives, New York, Pergamun Press pp. 93-116.

4. Higgins ST and Silverman K. (1999): Mo- tivating Behaviour Changes among illicit drug abusers: Research on contingency Management Interventions. Washington, D.C., American Psychological Association.

5. Meyers RJ and Miller WR (2001): A Com- munity Reinforcement Approach to Addic- tion treatment. Cambridge, UK: Cambridge University Press 40-45.

6. Miller WR, Sovereign RG and Krege B (1988). Motivational interviewing with problem drinkers. The drinker’s checkup as a preventive intervention. Behavioural Psy- chotherapy, 16 : 251-268.

7. Moos RH, Finney JW and Crunkite RC (1990). Alcoholism treatment context, pro-

cess and outcome. New York Oxford Uni- versity Press.

8. Pal H, Jena R and Yadav D (2004). Valida- tion of alcohol use disorder identification in urban community outreach and de-ad- diction. Center samples in North India Jour- nal of studies on Alcohol, 40; 794-800.

9. Roizen R (1977). Barriers to alcoholism treatment. Berkdey CA. Alcohol Research Group, pp. 30-34.

10. Sobell LC, Sobell MB and Toneatto T (1991). Recovery from alcohol problems without treatment. In: Heather N, Miller WR, Greeley J (Eds). Self control and ad- dictive behaviours. New York, Maxwell Macmillan, pp. 198-242.

11. Sobell MB and Sobell LC (1993). Treat- ment for problem drinkers- A public health priority. In JS Boer, GA Morlatt and RJ McMohan (Eds). Additive behaviorus across the life span: Prevention, treatment and policy issues. Beverly Hills CA, Sage Publi- cation, pp. 34-36.

12. The Extent, Pattern and Trends of Drug Abuse in India. National Survey (2004). Sponsored by Ministry of Social Justice and Empowerment, Government of India and United National office on Drug and Crime. Regional Office for South Asia, pp. 19-36.

13. Thomas B (1986;). Sex difference in help seek- ing for alcohol problems. The barriers to help seeking. British Journal of Addiction, 81: 777- 788.

Intervention with Treatment Non Seekers

Suggested slides for OHP Slide 1 Definition

Treatment refers to a variety of activities and process that aim at helping individuals with alcohol related prob- lems.

Slide 2 Characteristics of treatment seekers

– Selfrecognitionofsubstancerelatedproblems – Occurrenceofnegativeevents
– Coercion
– Informaladviceorsuggestionbyother

– GoodSocio-economicstatus – Married
– Agegroup30-44years.
– PastH/oofabstinence

– Religionaffiliation

Slide 3 National survey

– Treatment seekers constitute 2% of the total alcohol abusers

– Reported for treatment as late as five years after onset of alcohol/drug user

– 27%hadeverreportedtoanyorganizationforhelps
Slide 4 Treatment nonseekers

– Ratio of untreated to treated individual- 3:1 to 13:1

– Frequently seen in hospital emergency/crisis
center / medical practitioner.

– Asmanyas12%ofpatientsseenbyprimarycare
physician

– Fewerthanhalfoftheserecognizedasalcoholic
Slide 5 Sociodemographic characteristics of non-seek- ers

– Stablejob

– Havingnoissues/lackoffamilyresponsibility

– Lowsocioeconomicstatus

– Women

– Youth

Slide 6 Reasons for not seeking treatment

– Stigma

– Did not think their problem was serious

– Thought they could handle it on their own
– Didnotwanttoadmitthattheyneededhelp
– Drinkingwasnotaproblem.
– Ididnotthinktoseekhelp.
– Problemwouldgetbetterbyitself.
– Ashamedtoadmitproblem
– Treatmentdoesnothelp
– Difficultyinobtaininghelpfromtreatmentcenter – Notawareoftreatmentfacility
– Treatmentwasnotpossible
Slide 7 Intervention
– Identification/Screening
– Intervention
– BriefIntervention
– CommunityReinforcementApproach – ContingencyManagementIntervention – SpecializedGroup
– Women
– Adolescent

– Homeless Addict

Slide 8 NDDTC experience

– Identificationofgroupsabusingalcohol(through patient, family member or visit by social scientist).

– Visitbyconsultant,Psychologist,SocialScientist and Psychiatric nurse to community.

– Groupconstitute20-30persons

– Identificationofseniormemberofgroupasleader
(village pradhan)

– Groupsessionfocusonalcoholuse,psychosocial
problem and benefits of treatment)

– Pamphletsdistributions/sharingofexperiencesen-
tertained,

– Positivelycorrelatedwithtreatmententry.

Intervention with Treatment Non Seekers

Role of Laboratory Services in Substance Use Disorder

Raka Jain

Summary

While clinical assessment forms the cornerstone of diagnosis and management of substance use disorders, laboratory investigations can aid in helping the clinician in this endeavor. Labora- tory provides an objective way of assessing drug use and monitoring progress, treatment com- pliance, as well as assisting law enforcement agency.

While the availability of newer techniques have definitely benefited this field, the older tech- niques are relevant on account of their low cost and easy applicability, especially in the con- text of primary care. The present chapter gives an overview dealing with the need for labora- tory testing, the type of samples and techniques used and their application in clinical field.

Introduction

The abuse of psychotropic substances and nar- cotics has become a major problem of our times, with high economic and social costs. The pat- tern of drug use varies from time to time de- pending on the availability of new illicit drugs. The problem of drug abuse is of concern to health professionals, clinical chemists, toxicolo- gists and regulatory authorities.

WHY TO TEST

A valid assessment of drug consumption is criti- cal for evaluating substance abuse treatment programs and treatment outcome data. Self- reported drug use is a principle measure in the evaluation of treatment outcome. Drug depen- dent subjects tend to falsify their pattern of

drug use. Deception, denial and minimizing the extent of drug use are common practices seen among drug addicts. They often fear that reporting their activities correctly may result in legal sanctions or denial of treatment. There have been concerns about the accuracy of self- reporting. It is therefore necessary to establish its validity by an independent objective method.

Currently, drug testing in body fluids has gained popularity for validating self-reported drug use. Such analysis helps to diagnose, plan intervention, and monitor progress following treatment and also provides an epidemiologi- cal data in studying patterns of drug abuse. Thus, laboratory has a very important role in substance abuse testing program.

WHEN TO SCREEN FOR DRUG ABUSE

Determining when to suggest the need for a drug screening is a difficult matter. Several physical, behavioral or emotional patterns in the patient may suggest the need for screen- ing. For instance, deterioration in academic performance, conduct or antisocial disorders such as repetitive lying, stealing, recurrent violence towards people, may suggest the need for screening. Serious depressive or biphasic mood disorders, unexplained fatigue in a per- son where life is deteriorating, chronic vaso- motor rhinitis, seizure disorder or coma of un- explained etiology are also indications of drug use. Periodic urine testing for drugs of abuse is often recommended for drug addicts who are under treatment or in maintenance program. In recent years, substance abuse testing

programme have also been extended outside the De-addiction Treatment Centres and is currently used as a part of pre – employment physicals and for monitoring drug in employ- ees in a variety of industries and government agencies.

ANALYTICAL ISSUES

Biological Specimens

Many biological specimens can be used for drug abuse testing. Among all the biological samples, urinalysis is a favored method for self- reported drug use in a clinical setting, although alternative specimens such as blood, oral fluid (saliva), sweat and hair and fingernails have also been used. Each specimen has its own advan- tages and limitations.

Urine specimens are preferred for mass screen- ing as large sample volumes can be collected non-invasively. Drugs and their metabolites generally remain detectable in urine from sev- eral hours to several days especially in chronic users. The concentration of a drug in urine depends on a number of factors. In general, drug concentrations in urine vary with dose, route of administration, time elapsed since administration, and the individual’s physiologi- cal status, which influences urine flow, urine pH and metabolism. Moreover, urine has a sim- pler matrix than other biological specimens, which simplifies its sample preparation and analysis. Before carrying out a urine test, it is essential to ensure that urine specimen being tested is actually from the patient who is be- ing assessed as urine specimens can easily be tampered with by substitution, dilution or adulteration.

Blood samples can be used alternatively to de- tect drugs or their metabolites. The half-life of drugs in blood is short, making blood speci- mens less useful for routine drug screening (though a high concentration of active drug will suggest recent usage). The major concern

is the invasive nature of the collection process. Also the cost of collection and analysis is greater.

Saliva analysis is a developing technology, par- ticularly the sample collection is relatively quick, noninvasive and the matrix has the po- tential to provide both qualitative and quanti- tative information. It is less prone to adultera- tion than urine but drug concentrations are lower as compared to urine, and require more- sensitive test methods. A major disadvantage of saliva drug testing is the high risk of con- tamination and false positives by oral and na- sal routes. Also, drugs are only detectable for one to two days. It is not considered eco- nomically viable or practical for continuous drug use monitoring.

The sweat patch, although accurate in the test- ing for drug use, has one major flaw. The col- lection process is quite lengthy, in that the donor must have the patch applied, wear the patch for 10 days to two weeks, and then have the patch removed and sent to a laboratory for analysis. Sweat patches are being considered for use in drug-compliance programs.

Unlike urine testing, hair testing can detect drug use for a much longer period. The stan- dard hair test will detect drug use for up to three months. The greatest advantage of hair testing is the ability to create a permanent record of drug use in the strand (shaft) of the hair. No convenient screening procedures for the measurement of drugs in hair exist, and hair tests lack the sensitivity of urine tests for occasional or single-time drug use.

Fingernail specimens can also accurately detect drugs of abuse. The overwhelming disadvan- tage is the inability to detect recent drug use. Most fingernail clippings are between five and six months old by the time they can be ob- tained and would give very little insight as to recent use of drugs. Fingernail use is, however, gaining acceptance in the postmortem setting.

Role of Laboratory Services in Substance Use Disorder

Table I. A comparison of the types of samples that can be used in drugs-of-abuse testing.

Role of Laboratory Services in Substance Use Disorder

Sample

Advantages

Disadvantages

Blood

• Difficult to adulterate

• Short half-life of drugs
• Low drug concentrations

Hair

• Potential for long-term assessment of drug use

• Requires difficult analytical procedures • Drug deposition not uniform among

hair types
• Testing is expensive

Saliva

• Difficult to adulterate

• Low drug concentrations
• Difficult to get large volumes for

confirmation

Sweat patch

• Can monitor accumulated drug use for 3–7 days

• Requires difficult analytical procedures • Difficult to get large volumes for

confirmation
• Environmental contamination possible

Urine

· Noninvasive
· Available in large volumes · Remains positive 2–3 days

• High adulteration potential when collection not witnessed

Specimen Collection and Transportation

A major issue in the drug abuse testing programmes is proper sampling, as the valid- ity of test results is dependent on the integrity of the specimen being collected. Adulterating or diluting the specimens is a common prac- tice by patients attending the de-addiction ser- vices. Common contaminants include sodium hypochloride, table salts, lemon juice, vinegar, ammonia water, soap solutions or caustic com- pounds, eye drops and all of these may inter- fere in testing. It is therefore very important to take the following precautions at the collec- tion site, before the sample is sent for testing to the laboratory:

. i) Container or specimen bottle must be clean, dry, unbreakable and leak proof.

. ii) Urine sample should be collected under close supervision of trained personnel who have a clear understanding of the

collection process and its significance for the laboratory results.

. iii) There should not be any be any provision of sink or hot water in the toilet. If pos- sible, a toilet bluing agent should be placed in the toilet bowl to deter specimen dilu- tion.

. iv) The staff at the collection site should check the temperature of the urine sample im- mediately after voiding. A freshly voided urine should have a temperature close to body temperature i.e 330 C- 360 C and the urinary pH should range between 4.6 and 8.0. If adulteration is suspected the labo- ratory should be notified.

. v) Minimum volume of urine to be collected should be 30-60 ml.

. vi) Each specimen must be clearly labeled with patient’s name, date, time, and identifica- tion number to prevent intentional or in- advertent confusion.

vii) The person supervising the collection site should notify the date, time of collection of the specimen on the drug screening req- uisition form. It is also important for the personnel at the collection site to sign on the drug requisition form to ensure the in- tegrity of the specimen.

viii)Each specimen should be properly sealed and transported to the laboratory to avoid pilferage. Each sample should be accom- panied with the drug abuse requisition forms containing the details of investiga- tions required with adequate clinical his- tory.

Sample Storage

Proper storage of samples is also important in drug abuse testing programs. If the samples are left at room temperature for long before analysis, their pH value get altered. It changes from acidic to basic and bacterial decomposi- tion occurs, which increases the chances of false negatives. In general, sample should be refrig- erated within 12hrs of their collection prefer- ably at -200 C. Barbiturates, amphetamines and cocaine are unstable at room temperature. Samples brought from offsite laboratories should be transported in an ice bath. Ideally, quick transport and short period of storage can significantly contribute to the quality of results.

Methodology for Detection

Analytical Techniques

Large selection of procedures are available for analysis of drugs of abuse. The specific method chosen by a laboratory will depend upon many factors that include nature and quantity of specimen, turnaround time, sensitivity re- quired, existing facilities, available manpower, workload, program needs and economic con- siderations.

Drug abuse testing is a two-step process; pre-

liminary screening followed by confirmatory analysis of the prescriptive positive and doubt- ful results. Analytical methods used in most laboratories for the detection of drugs are so selected as to meet the requirements for screen- ing and confirmation. A screening test should be able to identify potential positives and should be sensitive, rapid and inexpensive whereas the confirmatory tests should be more specific than screening test. Screening test gen- erally involves immunoassays and thin layer chromatography (TLC). Confirmation testing is the second step of testing following the de- tection of a positive result on the preliminary or screening test. The purpose of confirmation is to eliminate any false positive results or false negative results that may have originated from an initial screening process. More specific con- firmation tests used to identify drugs of abuse are chromatographic techniques like gas liquid chromatography (GLC), high-pressure liquid chromatography (HPLC) and gas chromatog- raphy-mass spectrometry (GC-MS). A detailed description of each technique is beyond the scope of this chapter.

i) Competitive Immunoassays:

The most common analytical approach to urine drug screening is the use of competitive im- munoassays, in which specific antibodies bind to targeted chemical atoms and functional groups. A fixed amount of labeled drug mate- rial from the test kit (marked with a radioac- tive substance, enzyme, fluorescent tag, or col- ored particle) competes for antibody binding sites with the variable amount of unlabeled drug in the urine sample. When the binding sites are saturated, the amount of either free or bound labeled drug is measured. For a bound-labeled drug, low sample-drug concentration will pro- duce a high analytical signal; high concentra- tion will produce a low analytical signal.

Role of Laboratory Services in Substance Use Disorder

The most commonly employed immunoassays used for urine screening include methods such as radioimmunoassay (RIA), enzyme immu- noassay (EIA), and fluorescence polarization immunoassay (FPIA). Each method has its own advantages and limitations. The principal advantages of the immunological assays are ease of sample handling, rapidity of analysis and high sensitivity. These techniques do not re- quire preliminary sample processing. Technolo- gists can also be trained easily. Radioimmu- noassays can detect very small concentration of drugs. Its sensitivity ranges between 1-5 nanogram per ml. Disadvantages include the use of radioactive substances, separation of free and bound fractions, high cost of reagent , high cost of equipment, relatively slow turn around time, linearity of response and cross-reactivity with other drugs which may produce both false positive and false negative results.

The enzyme immunoassay has a short analysis time and has an additional advantage of being a homogenous assay, requiring no separation step for free and bound fractions. It is less sen- sitive than RIA but has moderate to good sen- sitivity. The disadvantage of this technique is the cost of the reagents. Other problems in- clude difficulty with linearity of response and cross reactivity with other drugs.

FPIA is also a homogenous assay technique. It does not require physical separation step. Ad- vantages of this technique are its ease of opera- tion, speed and high sensitivity. The limita- tions of this technique are its expensive reagent costs and the limited sources from which they are available.

The most serious limitations of all immunoas- says are that specificity for a drug is not abso- lute. Drugs of similar chemical structure may cross-react. For this reason, all negative results may be considered reliable and all the positive results may be considered ambiguous and must

be confirmed by another non-immunological method such as TLC, GLC or HPLC etc. Also these assays do not differentiate between drugs in these classes and may cross-react with re- lated therapeutic substances. For example co- deine and poppy seeds may lead to false-posi- tive opiate results and decongestants such as pseudoephedrine and phenylpropanolamine may lead to false-positive test for amphetamine.

The interferents do not produce a false-posi- tive result with the chromatographic assays now employed for confirmation—a justification of the two-tiered approach to drug testing.

ii) Chromatographic Technique

All chromatographic methods in use today are based on a common principle. There are in the system two phases. One of them is stationary which may be solid or liquid on an inert sup- port having a large surface area and other a mobile (moving) phase which may be a liquid or a gas. The compounds to be separated are differentially attracted to the stationary phase because of variation of their physiochemical properties. This distinctive influence is mani- fested by different distance migrated. The com- pounds which are less strongly held by the sta- tionary phase would tend to move faster in mobile phase and vice-versa. Identification of a compound is achieved by comparing the dis- tance traveled by the pure known standard against the distance traveled by the unknown compounds from the biological samples (Rf) or by comparing the time taken to migrate a specified time (retention time) of pure known standard with that of unknown sample. There are various types of chromatography depend- ing upon the stationary and mobile phase.

Thin Layer Chromatography (TLC)

It is widely used for multiple drug screening programs. It requires pH dependent extraction

Role of Laboratory Services in Substance Use Disorder

followed by purification and concentration of the drug from a biological sample. We found TLC to be very effective for preliminary screen- ing of opiates and other drugs. It offers the advantages of low start up cost, relatively rapid analysis, and simultaneous determination of multiple drugs and metabolites. Identification of drug is based on Rf values in various sol- vents and color reaction following specific spray- ing reagents. Drug concentrations as low as 0.3- 1.0 microgram per ml can be detected with proper sample preparation, which may require hydrolysis of conjugated drugs and metabolites. The technical staff can be trained in two months time. A single technician can handle 30-40 samples per day in 8 hours. TLC has a fair degree of specificity and sensitivity; hence drugs having identical Rf values overlap and obscure one another resulting in false posi- tives. In such circumstances, use of multiple solvent systems aid in the differentiation and confirmation by an alternative technique such as HPLC or GLC is recommended. Some dis- advantages of TLC are that it is labor intensive and results are highly dependent on the technician’s skill as interpretation of results is subjective.

Gas Liquid Chromatography (GLC) and High Pressure Liquid Chromatography (HPLC)

GLC and HPLC are widely used for confirma- tion of presumptive positive and doubtful re- sults in screening assays. Both techniques are highly sensitive and specific and are used for qualitative and quantitative purposes. Identi- fication is based on the retention time (Rt). Detection limit is about 0.1 μg/ml. The main limitations of these techniques are intensive sample preparation, the capacity to analyze a single sample at a time, the expense of the equip- ment and highly trained personnel to operate and interpret the data.

Gas Chromatography-Mass Spectometry (GC-MS)

In recent years, the most sophisticated drug testing approaches is gas chromatography coupled with mass-spectrometry (GC-MS). This technique combines the efficient separat- ing power of gas chromatography with the high sensitivity and specificity of mass spectromet- ric detection. It can detect nano to pico grams of drugs, per milliliter concentration of samples. It offers an insight into molecular structure and makes unequivocal identification possible. It is most sensitive, specific of all the methods available for confirmation and quantitation of drugs and their metabolites in biological samples. It is considered as the “gold stan- dard” test. It is the method least likely to be challenged in court and should be considered essential in national program at the nodal De- addiction centres. Components are chromato- graphically well resolved and are quickly iden- tified using retention time and mass spectral information.

The use of GC-MS or LC-MS is limited by virtue of being an expensive equipment to buy and maintain, lack of technical expertise needed for operation and interpretation of the data and complex sample preparation.

Detection Periods

The length of time that the presence of drugs of abuse in the body can be detected is an im- portant factor in drug screening. Table II out- lines approximate time of detection of drugs in different body fluids. This time duration depends on several variables including amount and frequency of usage, drug tolerance, age, body mass, the body’s metabolism, the subject’s physical condition, urine pH and state of hy- dration. Moreover, the detection of the drug would also depend on the type of technique adopted by the laboratory.

Role of Laboratory Services in Substance Use Disorder

Table II. Detection of drugs in biological specimens

Role of Laboratory Services in Substance Use Disorder

Substance

Urine

Hair

Blood

Alcohol
Amphetamine Barbiturates Benzodiazepines Cannabis (single use) Cannabis (habitual use) Cocaine Codeine/Morphine Heroin Methamphetamine PCP

6-24 hrs
1-4 days 1-21 days 1-42 days 48-72 hrs
up to 12 wks 4-5 days

2-4 days 8 hrs 3-5 days 3-7 days

n/a
up to 90 days Unknown Unknown
up to 90 days up to 90 days up to 90 days up to 90 days up to 90 days up to 90 days up to 90 days

Unknown Unknown Unknown Unknown 2-3 days 2 weeks Unknown Unknown Unknown 1-3 days 1-3 days

Recommended Frequency of urine testing is every third day for Inpatients and during ev- ery follow up for Outpatient.

In order to keep a check on the reliability, va- lidity, sensitivity and reproducibility of the test results, Quality Control (QC) of a drug abuse- testing laboratory should be maintained. These laboratories should maintain their internal QC by carrying out blind exercises periodically. A satisfactory performance of the laboratory would be if the false positive and false negative results do not exceed more than 10 percent.

Safety Guidelines

Safety measures of a drug abuse testing labora- tory are no different from a routine clinical labo- ratory such as wearing of gloves and masks, washing of hands with disinfectant or antisep- tic solution, use of rubber bulbs or dispenser for pipetting acids\ bases\ chemicals and re- agents, and provision of exhaust fan and fume hood in the laboratory. For HIV screening, the used needles, syringes and gloves should be destroyed immediately in incinerator or by burning them. Blood samples should be care- fully handled. Moreover, never leave a discarded

tube or infected material unattended or unla- beled. Furthermore, eating, drinking and smoking in work area should be strictly pro- hibited.

Communication with the laboratory

Regular interaction of laboratory personnel and clinical staff is essential so that lacunae on ei- ther side are minimized in the interest of pa- tient care. Clinicians should be familiar with the strength and limitations of the drug screen- ing techniques and programs. For meaningful interpretation of test results, particulars of drug use are important. Hence clinicians should fur- nish adequate clinical history regarding sus- pected drug use, route of administration, quan- tity of consumption, frequency of use in last 72 hrs, time of last intake of drug before sample collection and medicines being pre- scribed to the patients. Knowing which spe- cific substances are suspected on clinical grounds helps the laboratory to tell the clini- cians whether or not the laboratory can iden- tify such substances, for how long they can be detected after ingestion and whether serum or urine is preferred. The laboratory may also al- ter the methods used to prepare the sample to

maximize the sensitivity of the testing for those substances. Moreover, this would also minimize the false positive results, for example, in pa- tients who are being prescribed with cough syrup containing codeine.

Limitations of Drug Testing

Inadvertent positive results have been an issue for drug testing programs. Some drugs are con- sumed as food like dietary poppy seeds can give a strong positive results for urinary opiates for several days. Some consumer medications con- tain drugs of abuse (Tylenol 3 contains codeine as well as acetaminophen). In such cases, ana- lytically true-positive test results are false-posi- tive indicators of drug abuse by the individual.

Some individuals resort to diluting, substitut- ing, or adulterating urine samples to avoid the consequences of a positive drug test result. The object of dilution is to reduce the concentra- tion of illicit substance in urine to below the cutoff level, either in vitro, by adding water, saline, or other fluid after collection, or in vivo, by consuming diuretics or plasma volume ex- panders to stimulate excess water excretion. A urine sample is considered dilute when creati- nine is below 20 mg/dl and specific gravity is less than 1.003.

Replacement of donor urine with non-urine fluid is substitution. To succeed as a ruse, the substituted fluid must be warm, as the collec- tor is instructed to check specimen tempera- ture within 3 minutes of collection. A sample is deemed substituted if creatinine is less than

5 mg/dl and the specific gravity is 1.000 or 1.001.

Since most immunoassays are designed to be performed under narrow pH and ionic strength ranges, the addition of acids, bases, salts, or detergents will invalidate them. However, these adulterants generally do not affect GC/MS test results.

Health Damage

Apart from drug abuse testing, De-addiction laboratories should also have facilities for as- sessment of health damage in drug addicts. With increasing intravenous drug use, testing for HIV and Hepatitis B is also considered es- sential. As majority of the patients attending de-addiction clinics are from lower socio- eco- nomic status, some general health investiga- tions such, as haemogram, X-ray chest, rou- tine urine examination etc. are also necessary. On occasions, biochemical investigations like (LFT) are also undertaken to ascertain the con- dition of organ damage.

Experience indicates that the establishment of a well-equipped laboratory is a prerequisite re- quirement for any hospital-offering Drug – Dependence Treatment services as it plays an important role in the assessment and clinical management of patient’s drug problem. More De-addiction laboratories should be estab- lished and upgraded. Such up gradation and infrastructural development will ultimately improve the quality of care given by the Health care delivery system.

Role of Laboratory Services in Substance Use Disorder

Suggested Reading

1. Braithwaite RA, Jarvie DR, Minty PS, Simpson D, Widdop B. Screening for drugs of abuse. I: Opiates, amphetamines and cocaine. Annals of Clinical Biochemistry 32, 1995:123-153.

2. Eskridge KD and Guthrie SK. Clinical is- sues associated with urine testing of sub- stances of abuse. Pharmacotherapy, 1997, 17:497-510.

3. Fraser AD and Zamecnik J. Impact of low- ering the screening and confirmation cutoff values for urine drug testing based on dilu- tion indicators.

trol Programme, Regional Office of South Asia, New Delhi, India, 1998:214-221.

8. Katz N, Fanciicullo GJ. Role of urine toxi- cology testing in the management of chronic opioid therapy. Clinical Journal of Pain, 2002, 18(Suppl 4):S76-82.

9. Report of the substance abuse testing com- mittee. Critical issues in urinalysis and abused substances. Clinical Chemistry, 1988, 605-632.

10. Samyn N, van Haeren C. On-site testing of saliva and sweat with Drugwipe and de- termination of concentrations of drugs of abuse in saliva, plasma and urine of sus- pected users. 2000. International Journal of Legal Medicine, 113, 150-154.

11. Simpson D, Braithwaite RA, Jarvie DR, Stewart MJ, Walker S, Watson IW and Widdop B. Screening for drugs of abuse (II): Cannabinoids, lysergic acid diethyl amide, buprenorphine, methadone, barbiturates, benzodiazepines and other drugs. Annals of Clinical Biochemistry, 1997, 34:460-510.

12. Wu AHB. Integrity of Urine Specimens Submitted for Toxicologic Analysis: Adul- teration, Mechanisms of Action, and Labo- ratory Detection. Forensic Science Review, 1998,10:47–65.

4. Therapeutic Drug 2003,25:723-727.

Monitoring,

5. Jain R and Ray R. Detection of drugs of abuse and its relevance to clinical practice. Indian Journal of Pharmacology, 1995,27:1-6.

6. Jain R. (ed). Detection of Drugs of Abuse in Body Fluids: A Manual for Laboratory Personnel. Drug Dependence Treatment Centre, All India Institute of Medical Sci- ences, N. Delhi, India, 1998.

7. Jain R. The relevance of laboratory Services in South Asia. In: South Asia Drug De- mand Reduction Report, Ray R (ed), United Nations International Drug Con-

Role of Laboratory Services in Substance Use Disorder

Suggested slides for OHP Slide1:

Why laboratory services in a drug dependence treat- ment programme

• Confirmclinicalhistoryofdrugintake

• Monitorprogressfollowingtreatment

• Treatmentcompliance

• Assessmentofoverallhealthstatusofdrugdepen-

• Removeparticulates
• Concentratesoluteofinterest • Enhancesensitivity

Selection of analytical methodology • Cost

• Workload
• Turnaroundtime • Senstivityrequired • Reliability

Slide 5:

Screening techniques
• Immunoassays:RIA,EMIT,FPIA • Chromatography-TLC

Confirmatory techniques
• Gasliquidchromatography(GLC)
• Highpressureliquidchromatography(HPLC)
• Gaschromatography-massspectrometry(GC-MS)

Principle of immunoassays
Competition between the labeled drug and unlabeled drug to bind to its binding sites

AB+D*+DÞABD*+ABD AB= antibody, D* = labeled drug D= unlabeled drug

Slide 6:

Advantages of immunological assays • Nosamplepreparation
• Easeofoperation
• Rapidanalysis

• Highlysensitive
• Detectionlimit:0.001-0.1μg/ml
• Qualitativeandquantitativeestimation

Limitations of immunological assays
• Highreagentcosts
• Specificityforadrugisnotabsolute • Moderatetohighequipmentcost

Slide 7:

Advantages of TLC techniques

dents

• Clarificationofmedico-legalproblems

• Toassistlawenforcement

• Promotepharmacokineticandmetabolicresearch
Slide 2:
Biological samples
• Biologicalfluids:blood,urine,saliva,sweat • Tissues: hair,fingernail
Why urine is preferred for screening

• Non invasive procedure

• Easy collection

• Largervolumeavailable

• Drugsandmetabolitescanbedetectedinhigher concentration for a longer period of time

• Easierprocessing

Slide 3:

Precautions in sample collection

• Closesupervision

• Properlabelling

• Hotwatershouldnotbeavailableatcollectionsite

• Urinarytemperatureshouldapproximatenormal
body temperature

• Propersealing

• Transportationundercustody
Storage of samples
• Storageunder-20°ctemperatureisrecommended

Slide 4:

Why do sample preparation
• Removeinterferingmaterial

Role of Laboratory Services in Substance Use Disorder

• Simple
• Comprehensive
• Inexpensive
• Fairlyrapid
• Fairdegreeofspecificity
• Detectionlimit0.5μg/ml
• IdentificationbasedonRfvalue

Slide 8:

Features of GC
• Moderateequipmentcost
• Lowreagentcost
• Onesampleatatime
• Identificationbasedonretentiontime • Detectionlimit:0.01-0.1μg/ml
• Confirmationtechnique
• Quantitationtechnique
• Hightechnologistskillrequired

Slide 9:

Features of HPLC
• Moderateequipmentcost
• Moderatereagentcost
• Onesampleatatime
• Multipledrugssimultaneously
• Identificationbasedonretentiontime
• Analysistimeislessthananhour
• Resolutionishigh
• Confirmation&quantizationtechnique • Detectionlimit:0.01-0.1μg/ml
• Hightechnologistskillrequired

Slide 10:

GLC-mass spectrometry (GC-MS) • Rapid,sensitive&specific
• Unknownsamples
• Drug&theirmetabolites

• Diagnosisofoverdose
• Lowreagentcost
• Veryhighequipmentcost
• Onesampleatatime
• Multipledrugssimultaneously
• Detectionlimit:0.0001-0.1μg/ml

• Veryhightechnologistskillneeded • Confirmationneeded

Slide 11:

Pertinentclinicalinformationrequiredfordrugabuse screening

• Suspecteddrugabused
• Routeofadministration
• Quantityofconsumption
• Frequencyofuseinlast72hr.
• Timeofcollectionfromlastintake • Medicationprescribed

Slide 12:

Assessmentofgeneralhealthstatus • Biochemicalprofile

– Liverfunctiontest – Lipidprofile
– Renalfunctiontest

• Haematologicalprofile
– Completehaemogram

Role of Laboratory Services in Substance Use Disorder

Prevention of Substance Abuse in India

Parmanand Kulhara, Debashish Basu

Summary

The problem of substance abuse continues and will continue, at least in the foreseeable future, driven both by large-scale vested interests at a macro-level as well as man’s inherent pleasure- seeking propensity and psychobiological vul- nerabilities at a micro-level. However, with a combined multi-pronged effort at multiple lev- els, aimed not just at supply reduction but also at demand and harm reduction, countries and their people can potentially contain the prob- lem at a manageable level.

Introduction

Misuse of alcohol and other drugs (collectively referred to as ‘psychoactive substances’) is a problem not only for the abuser but also for the caregiver, family, workplace, neighbourhood, and indeed, for the society at large. It can affect anybody regardless of age, sex and socio-occupational status. No geo- graphical location, race, or religion is exempt.

The growing menace of alcohol and drug abuse at both international and national levels is of great concern today. It has been continuously challenging the existing resources to combat the problem. For such a multifaceted complex problem, the interventional strategies also need to be multidimensional in nature.

Before considering the various ways in which a multi-level preventive approach can be taken up, it is first important to understand the com- mon but often confusing terms such as ‘drug’ and ‘abuse’.

Basic concepts

Broadly speaking, a drug is defined as any chemical which, when administered, alters the functioning of one or more systems of the or- ganism. However, this definition is too general and would include virtually all medicines rang- ing from antacids to vitamins and antibiotics. A more narrowly defined term is a ‘psychotro- pic’ drug, which induces change primarily in some aspect(s) of mental functioning; for ex- ample, an anti-depressant is meant to relieve mental depression.

When we refer to ‘drugs’ we mean agents such as alcohol, cannabis, heroin or morphine. Al- though they are all psychotropic agents, they are rarely taken for a particular illness. Rather, they are consumed voluntarily to alter one’s mood, thinking, perception or other mental functions so as to induce pleasure in an artificial manner. Further, these drugs can cause addic- tion when taken repeatedly so that, at a later stage, these are consumed not so much to in- duce pleasure as to avoid or reduce the dis- comfort resulting from their absence in the body (in other words, to avoid or decrease the ‘withdrawal’ of the drugs). In this sense, alco- hol is also a ‘drug’. In order to differentiate them from other, more generally defined, me- dicinal drugs, these are now called ‘psychoac- tive substances’ or simply ‘substances’. Of course, there are several medicinal drugs that can also be misused as drugs of abuse, e.g., codeine- containing cough syrups, several painkillers containing opium-like substances, etc. When used in this context (for non-medical uses such as inducing pleasure), these are also referred as

‘substances’.

nabis, tranquillisers, and recently, volatile sol-

vents. The disorders resulting from pathological (ex-

cessive, compulsive, uncontrolled, or non- medical) use of these substances are grouped as “Psychoactive substance use disorders”. The common terms such as ‘abuse’ and ‘depen- dence’ come under this umbrella.

‘Addiction’ is a much older term than both ‘abuse’ and ‘dependence’. It is now omitted from technical language because of its pejora- tive connotation. However, the term still is re- tained in popular usage. It denotes either abuse or dependence. Also, the word ‘abuse’ when used non-specifically may cover both abuse and dependence phenomena. Thus, used loosely, a drug ‘abuser’ (earlier called ‘addict’) is a per- son who uses drug(s) in a pathological fashion and may meet the technical definition of ei- ther ‘abuse’ or ‘dependence’. This clarification of terminology was felt necessary because of- ten these various terms create confusion in our mind.

The World Health Organization in 1992 has enlisted the following categories of psychoac- tive substances:

1. Alcohol

2. Opioids (opium, heroin, morphine, pethi-
dine, buprenorphine, codeine, etc.)

3. Cannabis (‘ganja’, ‘bhang’, ‘charas’)

4. Sedative-hypnotics (‘tranquillisers’)

5. Cocaine

6. Other stimulants, including amphet-
amines and caffeine

7. Hallucinogens (e.g., LSD, ‘acid’)

8. Tobacco

9. Volatile solvents (typewriter correction and
dilution fluids, kerosene, gasoline, petrol, paint-thinners, nail-polish removers, etc.) and other organic hydrocarbons (e.g., those in shoe-polish, Iodex, etc.)

Of these, the common and major substances used in India are alcohol, tobacco, opioids, can-

Levels of substance abuse prevention Traditionally, the two major strategies at the

level of primary prevention are:

. (i) supply reduction (policies and activities aimed at minimizing the availability of al- cohol and drugs to people); and

. (ii) demand reduction (aimed at decreasing the internal need or demand for the substances by the people).

A third strategy is harm reduction, which tends to minimize the harm resulting due to sub- stance use, and thus acts at the levels of second- ary and tertiary prevention.

Both international and national-level active responses have been mounted to take the drug menace in its stride. International Treaties and various International Agencies or Drug Con- trol Programmes (most notably the United Nations Office for Drugs and Crime, UNODC, formerly United Nations Drug Control Programme, UNDCP) are in force, trying to plan, implement and monitor many aspects of the drug control programme, in terms of both the reduction in supply of, and the demand for drugs.

India is a signatory to the following interna- tional conventions:

a) Single convention on Narcotic Drugs, 1961, as amended by the 1972 Protocol;

b) Convention on Psychotropic Substances, 1971;

c) U.N. Convention against Illicit Trafficking in Narcotic Drugs and Psychotropic Sub- stances, 1988.

In addition, India has enacted her own com- prehensive legislation in this matter in the form

Prevention of Substance Abuse in India

of Narcotic Drugs and psychotropic Substance Act (NDPS) in 1985, amended in 1988. Vari- ous Ministries/Departments are given respon- sibility for tackling different aspects of the problem. The supply reduction aspects are largely the responsibility of the Ministry of Home Affairs (along with the Narcotics Con- trol Bureau) and the Ministry of Finance (De- partment of Revenue). Prevention and reha- bilitation are primarily responsibilities of the Ministry of Social Justice and Empowerment, formerly known as the Ministry of Welfare, and the Ministry of Health and Family Welfare (Department of Health, Drug De-addiction Programme). Thus, a multi-pronged approach has been adopted.

Section 4(d) of the NDPS Act provides for identification, treatment, education, aftercare, rehabilitation and social reintegration of drug abusers. For this purpose the Act also empow- ers the Government, under section 71(1), to establish as many centres as it thinks fit and frame appropriate rules for their functioning.

Following this mandate, a number of de-ad- diction centres have been established at both Central and State levels with the assistance and under the auspices of Ministry of Health and Family Welfare. Most of these are directly funded and monitored by the Ministry of Health and some are directly funded by the UNODC. Other than the above, there are a number of counselling and rehabilitation cen- tres operating through the Ministry of Social Justice and Empowerment. Still other, volun- tary, non-government organizations (NGOs) are actively pursuing the common goal of drug abuse control.

The focus of all these activities is threefold: the drug abuser, his family, and the society at large. The drug abuser is first motivated and engaged in treatment. He is then detoxified in an out- patient and/or inpatient set-up depending upon the needs and priorities. This part of the

treatment is essentially pharmacological (i.e., through medicines given to counteract the withdrawals of drugs of abuse). Side by side, a comprehensive assessment is made of the patient’s biological, psychological and socio- environmental aspects. Guided by the assess- ment, a longer-term treatment plan is formu- lated which may include both pharmacologi- cal aspects (e.g., giving disulfiram, naltrexone or acamprosate to alcohol-dependent persons and naltrexone to opioid-dependent persons) and non-pharmacological aspects. The latter may comprise of individual counselling, cog- nitive or behavioural therapies, Yoga therapy and meditation, and group work including participation in self-help groups like the Alco- holics or Narcotics Anonymous (AA and NA). The AA and NA groups are especially useful for maintenance of sobriety for many millions of former substance abusers all over the world. A final long-term plan is then drawn up for occupational rehabilitation and social re-inte- gration.

The family of the drug abuser similarly un- dergoes thorough assessment and counselling. The latter is aimed at providing emotional sup- port, psycho-education, defusing family con- flicts and guiding the family through the dif- ferent phases of treatment and rehabilitation. At times a formal family therapy or couples therapy is undertaken. More usually, family groups are formed where various related and common issues are discussed and mutual sup- port is generated. Various practical day-to-day tips for management of the patients at home are also given, often in the form of Dos and Don’ts for the family members. The family groups have especially been found to the help- ful.

The society of the drug abuser is tapped in more indirect ways. It is at this focus that prin- ciples of demand reduction really come into action. One of the most vital components of demand reduction is raising awareness – aware-

Prevention of Substance Abuse in India

ness about both the evils of drug abuse as also about the availability of help for treatment should the need occur. The modalities of achieving this end are manifold: campaigns through the press, television and radio; public meetings, workshops, poster and painting com- petitions; disseminating information through books, pamphlets, posters and stickers; orga- nizing and popularising ‘drug free’ music and other cultural events; networking with various NGOs, clubs, hotels and other areas of social intercourse; and promoting in general a healthy drug-free but full-of-fun lifestyle. Ex-abusers and their family members take an active part in this social focus on demand reduction.

Supply reduction

Supply reduction has to be conceptualised dif- ferently for licit (alcohol and tobacco) and il- licit drugs. For illicit drugs, supply reduction strategies remain an important issue at inter- national, national and local levels. However, alcohol and tobacco control pose dilemmatic questions for the policy makers, because al- though they are responsible for immense harm at personal, familial and societal level, they generate handsome revenue for the government. Further, it has been seen repeatedly that a su- perimposed complete prohibition of supply for alcohol and tobacco does not work. All it does is to create an artificial illegal market for these substances and to encourage corrupt practices at various levels, causing further expenditure for an already impoverished state exchequer for law enforcement. On the other hand, unre- stricted easy availability of alcohol and tobacco have been seen to correspond with increasing use, which in turn results in a commensurate increase in substance-related morbidity (lung cancer, cirrhosis of liver), mortality and social harm such as violence and accidents (especially for alcohol). An attempt to contro supply is akin to tightrope walking. The following mea- sures have been suggested:

1. 2.

Price controls.

Controls on availability:

a. Minimum age limits for sale.

b. Limiting the hours and days of sale.

c. Licensing and restricting the number and
location of outlets.

d. Prohibition on selling to intoxicated per-
sons (for alcohol).

e. Public monopolies of retail sale.

f. Enforcement of retail controls.

g. Restrictions on import.

Controls on the use of alcohol and tobacco:

a. At specified places (e.g., public offices,
schools, etc.).

b. At specified times.

c. During specified activities (e.g., driving,
operating heavy machinery).

Product safety standards:

a. Alcohol and tar content specification and restriction.

b. Display of warning statements on health hazards on the packages.

Controls on marketing:

a. Controls on advertisements of alcohol
and tobacco in print or electronic media

b. Controls on ‘surrogate’ advertising (e.g., advertising ‘apple juice’ or other innocu- ous products by a particular industry which also produces alcoholic drinks, and indirectly but clearly advertising the alcohol product under the garb of ad- vertisement of the innocuous product).

c. Controls on sponsorship of cultural,
sports or other events.

d. Taxing marketing costs.

e. Controls on the mass media of the por-
trayal of alcohol and tobacco use.

Prevention of Substance Abuse in India

Combating the abuse of both licit and illicit substances is a tall order. Nonetheless, the cur- rent data suggests that some strategies are bet- ter than others. Though supply reduction mea- sures for alcohol and tobacco as outlined above have been shown to be modestly successful if implemented properly, interventions aimed at

reducing the supply of illicit drugs rarely works effectively. These measures are expensive both in terms of resources, infrastructure and man- power, and tend not to significantly curb the supply of illicit drugs, the number of users, or the amounts they consume. Governments must therefore develop stronger parallel strategies to reduce the demand for drugs if the problem is to be meaningfully addressed. This requires en- hanced public education that includes messages on prevention that are meaningful to the youth and that note the dangers associated with the more casually accepted use of tobacco and ap- parently less potent liquors. The most success- ful educational campaigns tend to be locally administered, culturally meaningful, and rel- evant for all youths. Governments should also develop and support culturally relevant pre- vention efforts.

Demand reduction

The major role of demand reduction activities in India lies with the Ministry of Social Justice and Empowerment and also with the Minis- try of Health and Family Welfare. Other min- istries involved in demand reduction activities in the country are the Ministry of Human Resource Development (Department of Youth Affairs and Education) and the Ministry of Broadcasting. In the federal system of India, health is an issue dealt with by individual states in which the federal (Central) Government has a policy making, coordinating, and assisting role. So the relevant Ministries of the states also deal with drug issues. NGOs too have played a key role in all aspects of drug demand reduc- tion.

Under the NDPS Act, several high level com- mittees were formed in the past. Ministry of Health and Family Welfare appointed an ex- pert committee in 1986. An advisory commit- tee was constituted in 1988. The Central Gov- ernment directly constituted a Cabinet Sub- committee in April 1988 (upon whose recom-

mendation the national-level Drug De-addic- tion Programme was launched) and also in August 1993. A Narcotics Coordination Com- mittee of secretaries (from the Ministries of Health, Welfare, Home, Revenue and Direc- tor-General of Narcotics Control Bureau) was also constituted in March 1994. Since 1988, specific project documents were also developed in collaboration with UNODC (then UNDCP).

In 1994, a national Master Plan for Drug Abuse Control (1994-2003) was submitted. The Master Plan had proposals for both demand and supply reduction and had outlined over- lapping responsibilities for the Ministry of So- cial Justice and Empowerment and the Minis- try of Health and Family Welfare in demand reduction.

The Ministry of Social Justice and Empower- ment currently funds more than 400 counsel- ling and rehabilitation centres throughout the country (December 2002: 462 centres; 318 are De-addiction-cum-rehabilitation centres and 144 are Counselling and Awareness cen- tres). Funding for NGOs working in the field of drug abuse is also available from several bi- lateral agencies. The strategy of this Ministry in demand reduction can be summarized as follows:

1. Building awareness and educating people about ill effects of drug abuse.

2. Dealing with the abusers through a well rounded-up programme of motivation, counselling, treatment, follow-up and so- cial integration of cured persons.

3. To impart drug abuse prevention and re- habilitation training to volunteers and gen- erate an educated cadre of demand reduc- tion workers.

The Ministry of Health and Family Welfare has funded more than 100 drug de-addiction centres in the country (December 2003: 122).

Prevention of Substance Abuse in India

These are located in the hospitals and medical institutes. Although mainly concerned with treatment and rehabilitation of alcohol and drug abusers (i.e., working at the secondary and ter- tiary levels of prevention), these drug de-ad- diction centres are involved in several demand reduction (primary prevention) activities as well. These include:

1. Generating trained manpower by training doctors, nurses, social workers, counsellors, other health professionals.

2. Development and dissemination of health education materials relevant to demand reduction themes as well as need for early detection and treatment.

3. Community-based research in several ar- eas related to substance abuse, including demand reduction.

4. Information, Education and Communica- tion (IEC) activities at the local levels (schools, colleges, public offices, factories and industries, etc.) as also via mass me- dia.

5. Establishing a data collection and moni- toring system for drug abuse.

6. Establishment of drug abuse screening services.

Demand reduction and other preventive activities

Governmental as well as non-governmental voluntary agencies (NGOs) are currently car- rying out several activities in demand reduc- tion and other preventive activities. These in- clude:

A. Primary Prevention:

1. Audio-visual publicity

2. Development and distribution of print
materials

3. Press advertisements

4. Out door publicity

5. Anti-drug awareness campaigns

6. Awareness programmes in schools and

7. Workplace prevention

8. Drug abuse prevention for street chil-
dren.

B. Drug Treatment and Rehabilitation:

1. Medical detoxification

2. Treatment with antagonists such as
naltrexone

3. Treatment with pharmacological agents
such as deterrents (disulfiram) or anti-
craving agents (acamprosate)

4. Pilot treatment programmes for opiate
abusers

5. Utilizing twelve-step programmes

6. Therapeutic communities

7. Long-term rehabilitation programmes

8. Drug treatment programmes in jails

9. Detoxification camps in villages

10.Community based case detection and

treatment programmes.

In spite of this impressive array of activities and programmes, evaluation of these programmes has been minimal. An earlier evaluation of the national demand reduction activities in the country observed that the budgetary utiliza- tion was low, the pace of the implementation of the programmes have been slow, and the quality and range of services were limited. The need for broadening of primary prevention ser- vices was also emphasized in the evaluation. The latest formal evaluation of the drug de- addiction centres funded by Ministry of Health & Family Welfare has depicted a rather dismal picture: about 60% of the centres were non- functional (though some of them have been maintaining a degree of low-key service), nearly one-fourth of the centres were not providing any de-addiction services at all, and only about 13% of the evaluated centres were optimally functional. Almost all the functioning centres kept their activities limited to providing out- patient and/or inpatient services; only a mi- nority of the centres were providing commu- nity-based services as well.

There are numerous factors contributing to a

colleges

Prevention of Substance Abuse in India

lack of progress in these demand reduction programmes. These include a host of adminis- trative factors including improper coordination between the various Ministries and agencies involved in this work. This leads to a neglect of some areas and duplication of others. A with- ering political and administrative will is an- other factor. In spite of having been formulated a decade back, the National Master Plan for Drug Abuse Control was never published offi- cially, let alone being put into action. This might have to do with yet another factor: the gradual drying up of funds. Since 1987-88, when UNDCP and other agencies were heavily funding the drug de-addiction and demand reduction programmes, that was the time when a lot of activities took place. Since 1994-95, the activities and initiatives on the part of the government have tended to become half- hearted. A parallel decline of interest was evi- dent at the level of the funded agencies as well. As mentioned in World Mental Health, it is an irony that “despite the inadequacy of supply- reduction policies, efforts to decrease the de- mand for substances of abuse remain almost universally under-funded and under-sup- ported. Although treatment and prevention services are offered, and sizable amounts of money are spent on demand-reduction programmes, the comparatively small amounts

Suggested Reading

1. Galanter M, Kleber HD, Eds.The Ameri- can Psychiatric Press Textbook of Substance Abuse Treatment. American Psychiatric Press, Washington D.C. 1999

2. Lowinson J, Ruiz P, Millman R, Langrod J. Substance abuse, a comprehensive textbook, 4th edn. Baltimore: Lippincott Williams and Wilkins, 2005.

3. McGrady BS. & Epstein E, eds. Addictions: A Comprehensive Guidebook. New York:

of resources allocated reflect a lack of priority given to demand reduction in almost countries, including India. This relative imbalance speaks of a lack of knowledge about the potential ef- fectiveness of demand-reduction strategies, the conflicting political forces that reign in the area of substance-abuse control, and the quasi-mili- tary approach that sees substance abuse as un- related to health and human services.”

On a much smaller but equally important level, all of us can render valuable preventive services to our community if we follow these simple ten steps while dealing with our younger gen- eration, as mentioned by the U.S. Department of Health and Human Services:

2. 3.

4. 5.

6. 7.

8. 9. 10.

Talk with your child about alcohol and other drugs.
Learn to listen to your child.
Help your child feel good about himself or herself.

Help your child develop strong values.
Be a good role model or example in your own use of alcohol, other drugs or tobacco. Help your child deal with peer pressure. Set firm no use rules about drinking and other drug use by your children. Encourage healthy, creative activities. Team up with other parents.
Know what to do if you suspect a problem.

Prevention of Substance Abuse in India

Oxford University Press, 477-498.

4. Diagnostic and Statistical Manual of Men- tal Disorders, Fourth Edition, (DSM-IV), Text Revision, American Psychiatric Asso- ciation, 2000.

5. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Substance Abuse Disorders: Alcohol, Co- caine, Opioids. American Journal of Psy- chiatry, 1995, 152 (Suppl.): 1-59

Suggested slides for OHP Slide 1:

Misuse of alcohol & drugs, a worldwide problem Affects all ages, gender & geographical locations

Slide 2:

Prevention involves 3 strategies – Primary
– Secondary
– Tertiary

Slide 3:

Primary Prevention involves – Supplyreduction
– Demandreduction

Secondary & tertiary prevention involves – Harmreduction

Supply reduction seen by

– Ministry of Home Affairs

– Narcotics Control Bureau

– Ministry of Finance
Prevention & rehabilitation seen by

– Ministry of Social Justice and Empowerment

– Ministry of Health & Family Welfare
Slide 4:
Supply reduction different for licit & illicit substances For licit substances measures include
– Price controls
– Controls on availability
– Controls on the use of alcohol and tobacco – Product safety standards
– Controls on marketing

Slide 5:

Demand Reduction
– Master plan for Drug Abuse Control (1994-2003)-

proposed for demand & supply reduction

Funding for counseling & rehabilitation centres Strategies- awareness & education about ill effects of drug use

– coordinated treatment plan of drug abuser
– prevention & rehabilitation training to volunteers

Funding for deaddiction centres
Strategies- Generating trained manpower by train- ing doctors, nurses etc

– Development and dissemination of health edu- cation materials

– Community-based research

– Information,EducationandCommunication

– Datacollectionandmonitoringsystemfordrug
abuse

– Establishment of drug abuse screening ser-
vices
Slide 6:
Other preventive activities
– Publicity
– Awarenessforstreetchildren
Failure in prevention
– Lackofpolitical&administrativewill
– Lackoffundsindemandreductionprogrammes – Failuretoprovidecommunityservices

For illicit substances measures include
– Public education
– Awareness
– Information culturally meaningful & relevant for youths

Prevention of Substance Abuse in India

Management of Substance Use Disorder in Primary Care

Prabhat K Chand, Mohan K Isaac

Summary

The primary care physician is best placed to treat substance abuser at an early stage. Alco- hol and tobacco are the drugs most commonly encountered by the physician. It has been shown that disorders related to these substances can be easily diagnosed in primary care set- tings. Therapies such as brief intervention and motivational enhancement has been found to be effective in these settings too. Safe medi- cines are currently available and the physician can familiarise himself with these easily. This chapter deals with assessment and management of alcohol and tobacco use in primary care set- tings.

Introduction

Management of substance abuse is usually easier in the early stages of the disorder. At an early stage, the substance abusing person is most likely to present to the primary care phy- sician with a variety of non-specific problems. The physician who is unaware may treat the physical symptoms without attending the un- derlying substance problem and its other con- sequences.

For effective management the physician needs to be competent in

This chapter explores ways of management of substance abuse from a primary care physician’s perspective and discusses its key elements. In India, Alcohol and tobacco are the major sub- stances of abuse and will be the primary focus of this chapter.

ALCOHOL

“Does your heart sometimes sink when you find one of your patients has an alcohol problem? If so, you are not alone, many doctors rate this as a difficult area.”

General physician are in an ideal position to detect heavy drinking and to advise patients, as they are likely to present with various physi- cal problems. Simply spending 5-15 minutes on a brief intervention can be highly effective in reducing the level of problem drinking.

Broadly alcohol misuse can be classified as follows:

Heavy drinking: Currently not experienc- ing any problem but if continued, at risk for liver damage, neuropathy, pancreatitis, and addiction to it

Problem drinking: Evidence of deterioration of physical, psychological or social condition i.e. not able to drive properly or absence from duty, or fighting, inappropriate behaviour under influence.

Male: >4 units/day or >14 units/week

Female: >2units/day or > 7units/week Addiction/dependence: Evidence of tolerance, withdrawal, craving, physical/social/ psycho- logical damage, impaired control over drink

Screening patients for substance use

Assessment of problems related to substance use

Treatment

Timely referral to specialized services

The majority of people presenting to general practitioner clinic belong to the first two cat- egories. Research has consistently shown the effectiveness of intervention in this population.

Screening

The symptoms with which the patient presents often gives clues to underlying alcohol misuse (box). Even directly asking about drinking is a part of life style assessment and routine health examination. This should be done irrespective of gender and type of presentation.

As the patient may deny or under-estimate the amount he drinks, the physician should estab- lish a good therapeutic relationship with the patient. Showing empathy, understanding and being non-judgemental is the key to establish- ing a good therapeutic rapport. Wherever pos- sible one should seek corroborative informa- tion from family members and involve them in treatment.

Detection and Intervention

Step I: Ask
In all: Do you use alcohol? In current drinkers:

Frequency-How often do you drink?

Quantity-How much do you drink?

Duration-How long are you drinking?

Abstinence-How many days in past have you not drunk alcohol at a stretch?

Also assess associated withdrawal symptoms and high-risk behaviours i.e. repeated intoxi- cations, drinking and driving. Some people may minimise the severity of problems and would say that they drink ‘occasionally’ or ‘only at weekends’ or ‘only after work’. These need further exploration about actual drinking pat- terns and problems.

Step II: Assess

In a patient who reports regular drinking, assess:

Physical damage: a small list is provided in the box. But a good physical examination may give evidence of early physical damage in problem drinkers.

Psychological: stress, depression or anxiety

Occupational: Monday morning blues, going late to work, frequent absenteeism, accidents, inter personal problems etc

Legal: arrest or reprimanded for drunken driv- ing, fights or brawls

Management of Substance Use Disorder in Primary Care

Clues

Symptoms

Gastrointestinal: poor appetite, indigestion, heart burn, dyspepsia, diarrhoea

Neurological:tremors,sweating, headaches, insomnia, burning legs

Cardiorespiratory: palpitations, chest pain, pneumonia

Musculosketal: backache, repeated injuries, rheumatism

Gynecological: menstrual problems, pre-menstrual disturbances etc.

Skin: bruises, flushing, rashes Endocrinology: reduced libido, obesity

On examination

Conjunctiva injection Bloated face
Periorbital puffiness Parotid swelling
Smell of alcohol on breath Flushing

Hepatomegaly etc.

Screening questionnaires

These help the physician in detection of prob- lem drinking in patients with history of regu- lar intake of alcohol. One or more positive responses on the CAGE questionnaire indicate problem drinking and more than three points suggest dependence.

Another widely used scale is the Alcohol use disorders identification test (AUDIT). An AUDIT score of more than eight indicates prob- lem drinking and the need for intervention.

In depth assessment in persons

• Drinking
• >2-3 times/wk
• >2units/day in male />one unit/day in

female
• Heavy episodic drinking

Laboratory investigations

Laboratory investigations assist in the detec- tion of problem and heavy drinking and are outlined in the accompanying table.

When alcohol problems are identified, it is important to evaluate patient’s perception about the problems and the need for reducing or stopping alcohol. As shown below the person’s response may vary from not willing to very well motivated for reduction in drinking.

Stages of change
Not ready Unsure Ready Changing Changed

(Pre-contemplation) (Contemplation) (Preparation) (Action) (Maintenance)

Management of Substance Use Disorder in Primary Care

Laboratory test

MCV (Mean corpuscular volume)

GGT (Gamma glutamyl transferase)

AST/ALT (Aspartate transferase/Alanine Transferase)

Abnormal values Macrocytosis (>100 fL)

Elevated GGT (>55 U/L)

>1.5

Interpretation

Detects approximately 20–30% of problem drinkers in general practice

Detects approximately 30% of problem drinkers in a general practice setting and 70–75% in a hospital setting

Alcoholic liver damage

In pre-contemplation stage, patients are not even considering change. As they become aware of reasons to alter behavior, they think about it, weigh pros and cons of changing- the con- templation stage. When the argument for change wins through, a decision point is reached. They are now ready to change and move into stage of action.

These changes involve alteration of life style, handling stress and successful coping. Stage changes occur slowly with time and may have repeated setbacks. The goal of each visit should be to help the person move along the con- tinuum of change towards the reduction of al- cohol use.

Step III: Advice

Many people are sensitive about their drink- ing and the offer of help will be more readily accepted if it is given in a spirit of concern for health and family well being. There should be mutual trust and respect.Dire warnings and judgemental statements do not work. Most physicians are pessimistic about being able to help excessive drinkers yet there is good evi- dence that as many as 75% respond well to brief intervention.

The steps of brief intervention are:

Feedback of personal risk

Be clear in informing the patient about how drinking is going to worsen his condition fur- ther. At the same time state your concern on the prescribed medicine and its interaction with alcohol. Focussing on physical problems and correlating with drinking reduces the patient’s defensiveness.

E.g. “your drinking is going to worsen your stomach pain” // “I am concerned that your drinking is contributing to your easy tiredness and sleeping problem”

At the same time just treating the physical ali- ment without discussing about drinking, may be counterproductive and undermine the seri- ousness of problem drinking.

Similarly statements may help for minor prob- lems i.e. sleep disturbance.

E.g. I am prescribing some medicines for symp- tomatic relief of your stomach pain but you will need to completely stop your drinking for some time to allow healing. Why don’t you give up for two weeks and see the difference?

It is important to involve the spouse or an im- portant family member and educate them re- garding ill effects of alcohol on the patient’s current health.

Responsibility

Emphasise that the decision about drinking is

the patient’s responsibility and choice. No one else can make the change or decide for them.

E.g. “Now it is up to you to take a decision on drinking”

Advice

Give clear advice as a doctor to reduce drink- ing. The person can also make a balance sheet as shown and discuss about future plan with the doctor.

Management of Substance Use Disorder in Primary Care

Balance sheet

Drinking Continue

Reduce Stop

Advantage

Forget worries Escape responsibility

Be like others Prestige

Health better Money save

Disadvantage

Family fights Health problems Cost

Pass time Gives kick

Loss friends

Menu

Discuss variety of strategies for the patient to choose to achieve the goal. It is worth clarify- ing initially about patient’s goal i.e. no change, cut down or stop. The impediments for the desired goal will be obvious from the interview or from the balance sheet. The common strat- egies are shown in box.

Keeping a diary of drinking occasions, amount of drink per week is helpful in keeping track of drink.

Menu (Alternate strategies)
Recognising and avoiding trigger situations

• Planning ahead to limit drinking

• Pacing one’s drinking

• Learning to cope with everyday
problems that encourage drinking

• Finding alternate sources of enjoyment

Self-efficacy

Patient needs to be encouraged to be optimis- tic and to bring about the changes in drinking behaviour. It is best to aim for specific short- term goals at first so that the patient gets a sense of control or achievement.

E.g. A person who is able to abstain for 2-3 weeks should be encouraged to continue it.

Step IV: Agree

The final choice for future alcohol intake is best left to the person. The low risk or moderate drinking option is advisable if person wants to continue drinking. The moderate drinking needs to be carefully planned and discussed and is best preceded by period of abstinence. Abstinence is strongly advised in certain con- ditions.

that he or she returns for the next appoint- ment. At this time, the short-term achievements and problems can be reviewed and further goals agreed. Supportive laboratory test i.e. GGT, MCV, AST, ALT are useful objective means of monitoring progress and results and their im- plication should be discussed with patient.

Progress should be reviewed regularly over a year. The first six months of progression often gives good impression of longer-term prognosis.

Relapse

Most patients will drink again whatever the original goal of treatment, but this need not be a catastrophic relapse involving the loss of all that has been achieved. It is to be viewed as an opportunity for the patient to learn from. The important issues to be addressed are men- tioned in the box. Relapse is not the end of the road. One common cause of relapse is compla- cency and overconfidence that this problem is in the past and drinking will be now safe.

Late stage alcohol problems

Persons, who drink regularly, having developed tolerance, craving, or significant problems, are considered to be addicted or dependent. This group of patients need detoxification and more intensive counselling for management. Absti- nence is the goal in these groups. They need pharmacological intervention to handle with- drawal symptoms and future abstinence.

Detoxification/ management of withdrawal symptoms

It is a process that provides safe withdrawal from alcohol. The common withdrawal

Management of Substance Use Disorder in Primary Care

Low risk or moderate drinking

• Men: # 2 units/day, # 4 units/ occasion

• Women: # 1unit/day, # 3 units/ occasion

• Over 65 yr: # 1unit/day, #3 units/ occasion

• No drinking at least 3 days/week

Relapse
• When?
• Where?
• What preceded?

How is he going to handle it in future?

Abstinence
• Addicted/dependence
• Significant physical damage
• Failed in moderate/controlled drinking Family h/o of alcohol dependence

Step V: Monitor (Follow up)

Whatever the agreed goal, it is essential that the doctor regularly review the patient’s progress. The most important task at the first interview is to gain the patient’s interest in tack- ling his or her drinking problem and to ensure

symptoms like insomnia, tremors, irritability, restlessness, sweating, increase pulse rate usu- ally begins 6-8 hr of last drink, reaches its peak at 24-48 hr and subside in next 7days.

Mainstay of management is pharmacotherapy and most of cases can be managed on an out- door basis. Roughly for one unit of alcohol, 1mg of diazepam, 5mg of chlordiazepoxide needed.

Management of Substance Use Disorder in Primary Care

Drug

Dose

Trade name

Interval

Comments

Diazepam Chlordiazepoxide Lorazepam

10-40mg 50-120mg 4-12mg

Calmpose Librium Ativan

6hr-8hr 6hr-8hr 6hr-8hr

Safe
Safe
Safe even in liver disease

Additionally, intramuscular injection thiamine 100mg/day for five days should be given fol- lowed by oral vitamin B complex orally for two weeks.

In a few patients, the withdrawal becomes se- vere and can present as confusion, disorienta- tion, seizure and generalised tremors. This con- dition is known as delirium tremens and re- quires inpatient intensive treatment.

Pharmacotherapies for alcohol dependence

Pharmacotherapeutic agents may be prescribed for alcohol dependent individuals generally af- ter the phase of acute alcohol withdrawal is over. This coupled with a comprehensive rehabili- tation program with individual and family counselling, relapse prevention, coping skills and is essential for a successful treatment out- come.

Disulfiram (Antabuse, deaddict, esperal, dis- ulfiram)

Disulfiram was the mainstay of pharmacologi- cal treatment for alcohol dependence for a long time. It acts by irreversibly inhibiting aldehyde dehydrogenase and leading to accumulation of acetaldehyde. This triggers an unpleasant re- action when alcohol is ingested and this acts as a psychological deterrent to drinking alcohol. This form of aversive therapy is effective in motivated and reliable patients who have good

social support who can monitor its intake.

Disulfiram alcohol reaction: flushing, headache, palpitations, dyspnoea, nausea, hypotension, and prostration when alcohol is ingested. It varies in intensity between individuals and usu- ally occurs within 10 minutes of taking alco- hol and reaches a peak at 20–30 minutes and last for 1–2 hours.

Contraindications: psychosis, ischaemic heart disease, severe hepatic or renal disease.

Dose: It is to be administered only after pa- tient understands disulfiram alcohol interac- tion and informed written consent is taken. Patients need to abstain from alcohol for at least one day before administration of disulfiram and for at least one week after cessation of treat- ment. Disulfiram is available as 250 mg tab- lets, and is commonly prescribed once daily

Naltrexone (Naltima, Nodict)

Alcohol consumption is thought to produce a feeling of well being brought about by the re- lease of endorphins in the brain and stimula- tion of opiate receptors. This reinforces drink- ing of alcohol and ultimately leads to relapse. Naltrexone competitively blocks opioid recep- tors and reduces the reinforcing and reward- ing effects of alcohol. Naltrexone at 50 mg/ day significantly reduces the risk of relapse to heavy drinking and the frequency of drinking.

Management of Substance Use Disorder in Primary Care

Drug

Trade name

Dose

Comments

Disulfiram

Naltrexone Acamprosate Topiramate

Disulfiram, deaddict, esperal

Naltima, Nodict

Acamprol 333mg/tablet

Topmac, Topaz

250mg/day

50mg/day once day

4-6 tablets thrice day

200-300 mg/day

Work best if patient is motivated, good social support

Anticraving agent, work with positive family history of addiction

Can be started during detoxification, least side effects

Latest agent, needs slow building
of dose (25’!200mg/day),c/i in renal stone

Acamprosate (Acamprol)

It predominantly suppresses excitatory glutaminergic neurotransmitters and decreases craving.

Side effects: mild and transient. Diarrhoea oc- curs in few patients but is reduced by taking medication with a meal

Contraindications: renal insufficiency, hepatic failure

Dose and duration: available as 333mg/tablet. <50kg=4tablets in three divided dose, >50kg =6tablets in three divided dose

Conclusion

tobacco in some form. At the same time about one fifth of tobacco used in India is as smoke- less type i.e. guthka, tooth paste etc. The pro- cess of stopping smoking is often a cyclical one, with the smoker sometimes making multiple attempts to quit and failing before finally be- ing successful. Approximately 70 to 80% of smokers would like to quit smoking and ap- proximately one-third of current smokers at- tempt to quit each year. 90% of these unas- sisted quit attempts fail.

MANAGEMENT

The 5 A’s is a brief intervention method used to guide the clinician in tobacco cessation Counseling. This method is found to be effec- tive and takes only 5-15 minutes.

ASK

Ask all the patients about tobacco use at the time of history taking

“Do you smoke or chew tobacco?”/Have you ever used tobacco ? Are you using now?”

Also enquire about amount and type of tobacco used by the patient. It is important to check about the duration and any associated complications.

Alcohol is second only to tobacco as a cause of substance induced morbidity and mortality. It is a risk factor for many cancers, liver disease, road fatalities, homicides and suicides. As one in five patients who visit a primary care physi- cian drink alcohol at hazardous levels, physi- cians play a unique and vital role in early iden- tification and prevention of alcohol related harm.

Tobacco

Tobacco is a major cause of morbidity and mortality all over world. In India, it is esti- mated that 65% of men and 33% women use

5 A’s of Intervention • ASK

• ADVISE
• ASSESS
• ASSIST
• ARRANGE

Screening

One of the easy ways to assess whether the per- son needs help is by asking the two questions given in the box. A “yes” response to either of these questions would suggest that the person need help in stopping tobacco.

ADVISE

In a clear, strong and personalized manner, urge every tobacco user to quit. It is important for the person to be aware of the complications of tobacco use.

tion to stop can be assessed by means of simple direct questions about their interest and in- tentions to quit. Past attempts of quitting if present can be used to encourage further and longer abstinence.

Management of Substance Use Disorder in Primary Care

Motivational enhancement

Nicotine gum + Bupropion

Initial Contact

Motivation Assessment

Willing

1.Do you find it difficult not to smoke/chew in situations where you would normally do so?

2.Have you tried to stop smoking for good in the past but found that you could not?

Not willint

Willing

<10 cigarette or < 5 packets no physical or psychological problem

>10 cigarette or > 5 packets physical or psychological problem

If you smoke, have no problems yet You have
Twice the risk of heart attack

Six times the risk of emphysema
Ten times the risk of lung cancer Increased risk of colorectal cancer, skin cancer

And
Life span 5-8year shorter

If chewing tobacco, you have high risk for Increased risk of leukoplakia

5 times increased risk of oral cancer Stained and abraded teeth

Gingivitis, dental caries, bad breath Poor wound healing

It is useful to tie tobacco use to current health and its social, economical costs as well as its impact on children and other house hold mem- bers.

ASSESS

During initial contact with the patient assess his motivation to quit smoking or chewing. Usually very few people think of cessation of smoking at any given point of time. Motiva-

Simple advice
Reinforce commitment to change

Help in making a plan

Follow up

ASSIST
1. Patients willing to change

Physician should discuss with them the benefits of stopping tobacco use and at the same time encourage them to do so. Another impor- tant thing is to make a plan on how to stop use. The important points while making plan are:

a) Identify what works and what does not work i.e. “What worked well last time when you stopped using tobacco?” What did not work? What were the problems?”

b) Triggers: These are situations or thoughts that initiates tobacco use and can be the reason for restarting tobacco use after a few days/weeks of abstinence. It is important to identify these and developing strategies to handle them.

Management of Substance Use Disorder in Primary Care

Common triggers

Boredom/ Stress/anxiety smoke

Mood (positive or negative)

Party

Handling

Spend time which person enjoy like listening songs, exercise etc.

Spend time with friends/family member who do not tobacco or smoke.

Substitute with other behaviors i.e. playing games, creative pursuits.

Craving:

This is one of common impediments in tobacco cessation. Generally, craving is strongest in the first week and lasts for 30-90 seconds each time. As the days pass, the intensity of cravings re- duces.

Most withdrawal symptoms are self limiting and are not very disabling.

decrease craving after quitting smoking or chewing tobacco. One can use an average of 10 to 15 gums per day but most patients in India do not require such high doses.

Duration of treatment: 6- 12 weeks. Bupropion

Bupropion, an antidepressant also helps in to- bacco cessation and taking it along with nico- tine gum increases the chance of success.

Dose: Patient should first set a QUIT DATE (no tobacco) after discussion with physician. Bupropion sustained release (150 mg) should be started two weeks prior to this and patient should be advised to progressively decrease to- bacco consumption.

Duration: for 7-12 weeks. If no significant progress toward abstinence by the 7th week , it is unlikely he will quit during that attempt and treatment can be discontinued.

Contraindication: seizure disorder ARRANGE Follow up

Set a follow up date about 2 weeks after quit- ting and reassess the situation. There is every likelihood that patient may slip back to earlier pattern. If so, be accepting and empathetic, reassess the situation and may plan accordingly.

Patient unwilling to change

Patients unwilling to make a quit attempt dur- ing a visit may lack information about the harmful effect of tobacco, may have fears or con- cerns about quitting or may be demoralized because of previous

relapse. Such patients may respond to moti- vational intervention that provides the clini- cian an opportunity to educate, reassure and motivate the person.

Handling Craving

• Avoid smoking situation

• Drink 2 glass of water

• Think again reason for quitting

• Exercise or take bath

• Eat sugar rich food

• Deep breathing

c) Explore use of medications i.e. nicotine gum, patch or Bupropion tablets

Nicotine gum

It is now available in India. Each chewing gum contains 2mg of nicotine and is to be chewed like any other chewing gum. It is to be chewed slowly and should remain in mouth for at least 30 minutes for effective absorption. It is more effective in heavy smok- ers but can be used as and when required to

Increase motivation to quit(5 R’s)

• Relevance • Risks
• Rewards
• Road block • Repetition

Relevance: Encourage the patient to indicate why quitting is important for him and his cur- rent health. It works best when the issue is rel- evant to patient’s disease status risk, family or social situations, health concerns etc.

Risks: Discuss with the patient about short and long term risk of continued tobacco use. High- light the conditions that are most relevant for the patient. Also emphasize that smoking fil- tered cigarette, low tar or smokeless tobacco will not eliminate these risks.

Rewards: Ask the patient to identify potential benefits of stopping tobacco use.

Roadblocks : Ask the patient to identify barriers or impediments to quitting and reassure that these can be handled if he would try quitting.

Repetitions : The motivational intervention should be repeated every time an unmotivated patient visits the clinic. Tobacco user who has failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

Conclusion :

Tobacco dependence is a chronic disease that needs treatment. Effective treatment methods are now available and should be used with ev- ery current and former tobacco user.

5. Molyneux A. ABC of smoking cessation: Nicotine replacement therapy. British Medical Journal, 2004,328:454-456.

6. Patton A. ABC of alcohol. British Medical Jour- nal publishing group, Tavistok Square, London, 1994.

7. Ray R. Treatment principles and issues in management of addictive behavior. In: Sub- stance use disorder: a manual for physician (ed by) Rajat Ray, Drug Deaddiction Treat- ment Center, Department of Psychiatry, AIIMS New Delhi, 2002, 85-97.

8. West R. ABC of smoking cessation: Assess- ment of dependence and motivation of quit. British Medical Journal, 2004,328, 338- 339.

Management of Substance Use Disorder in Primary Care

Roadblocks (Barriers)

• Fear of failures

• Withdrawal symptoms

• Loss of pleasure

• Constipation

• Depression

Rewards

• Improved health

• Dental hygiene

• Feel better physically and psychologically

• Good example for children

• Reduced wrinkling and aging

Suggested Reading

1. Benegal V, Murthy P, Shantala A, Janakiramaiah N. Alcohol related problems : a manual for medical officers. Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore, India, 2002.

2. Coleman T. ABC of smoking cessation: Use of simple advice and behavioral support. British Medical Journal, 2004, 328:397- 399.

3. Johnstone C. Effective brief interventions in problem drinking. The Practitioner, 243, 1999:614-618.

4. Latt N, Saunders JB. Alcohol misuse and dependence: assessment and management. Australian Family Physician, 2002,31:1079-1085

Suggested slides for OHP Slide 1: Introduction

Intervention is easy in the early stage of the disorder Physician should be competent in:

• Screeningpatientsforsubstanceuse
• Assessmentofproblemsrelatedtosubstanceuse • Treatment
• Timelyreferraltospecializedservices

Slide 2: Alcohol

Problem patterns of drinking include:

• Heavydrinking:atriskfordamagei.e.hepatitis,
neuropathy, gastritis & addiction

• Problemdrinking:evidenceofdamageinphysical/
psychological/social

• Addiction:developmentoftolerance,craving,with-
drawal symptoms, morning drinking, impaired con- trol over drink
Slide 3: Screening
Physician should have a high index of suspiciousn and pick of clues
Pay attention to non specific symptoms i.e.tiredness, insomnia, weight loss, indigestion etc which may indi- cate an underlying alcohol problem
Routinely enquire about alcohol as a regular part of his- tory taking
Slide 4: Detection and Intervention
Step I: ASK:
Do you drink alcohol?

Yes
Frequency- quantity-duration-type
Check withdrawal symptoms, high risk behaviors i.e. drink driving, fights &physical damage, unprotected Sex under intoxication
Slide 5: Step II:Assess
Detailed assessment required in persons Drinking
>2-3 times/wk

>2units/d in male />one unit/d in female Heavy episodic drinking
On screening questionnaire

Yes on any one item of CAGE Score of > 8 on AUDIT

Slide 6: Assess

With the help of laboratory investigations:
Raised MCV, GGT, AST/ALT ratio
Stage of motivation
Not ready unsure ready changing changed

Slide 7: Step III: Advice

Be non judgmental, express concern regarding health Feedback personal risk
Stress on personal responsibility
Advice specifically and clearly regarding desirable change Provide a Menu /future plan

Indicate Optimism

Slide 8: Step IV: Agree

Final choice on drinking left to the patient
Agree on low risk or moderate drinking if abstinence not being considered by patient
On the need for regular monitoring
Involve the family member i.e. spouse

Slide 9: Agree…

Strongly advice Abstinence in patients with: Dependence

Significant physical damage
Failed attempts at moderate drinking Familyhistoryofalcoholdependenceand related complications

Regular follow up is essential

Slide 10: Alcohol dependence

Considered late stage alcohol problem
Detoxification essential
Benzodiazepine mainstay for detoxification Additional specific pharmacotherapy along with coun- seling helps

Abstinence is the goal

Management of Substance Use Disorder in Primary Care

Slide 11: Relapse

Slide 14: Assess

Does the patient now use tobacco

Most patient do restart drinking
Do not panic as relapse is natural in the course of alcohol use
Assess: When, Where, Preceding event for relapse Advise: How is patient going to handle relapses in fu- ture?

Slide 12: Tobacco

ASK
Do you find it difficult not to smoke in certain situa- tions?
Have you tried to quit smoking in the past but could not?
“Yes” to either of these questions-person need help Advise

Strongly urge all users to quit in a clear, strong, and personalized manner.
CLEAR- “Quit now, not just when you are ill”. STRONG- “Quit now and protect health PERSONALISED- Tie use to adverse impact.

Slide 13: Advise…

Benefits of quitting
20 MINS – B.P, Pulse & Body Temperature returns to normal
8 HRS – CO level in blood & O2 level becomes normal 24 HRS – Chances of heart attack decrease
72 HRS- Bronchial trees relax, lung capacity, breathing easier
2 WKS- 3 MONTHS – Circulation improves, walking easier
5 YRS – Lung cancer death risk decreases by 50%
10 YRS – Lung cancer death risk drops to the level of a non-smoker.

Yes
now willing to quit

Yes No

Slide 15: ASSIST

No
Did he once use tobacco

Yes No

Management of Substance Use Disorder in Primary Care

Provide appropriate treatment

Provide information to quit

Help with a quit plan:
Set a quit date
Tell family, friends/request help
Avoid, Remove tobacco
Relapse Prevention
Discuss triggers/challenges
Review past experience and lessons learnt
Help the user to obtain extra-treatment social support from workmates, family and friends
Recommend use of approved pharmacotherapy.

Prevent relapse

No interv- ention required, encourage abstinence

Comorbidity in Substance Use Disorder

S Parker

Summary

The coexistence of substance use with mental health problems is a rule rather than an excep- tion. It has also been established beyond doubt that comorbid conditions have severe clinical presentations. Till date, there are no uniformly accepted, comprehensive and coherent guide- lines for the care of patients with coexisting substance use and mental health problems. Management is mostly opinion-led and this area of substance use disorders continues to remain a poor neglected step-child.

Patients with comorbid disorders irrespective of temporality and cause-effect relationship pose a great burden on health care services. However, the significance of this condition is almost always disregarded. A dire consequence of this is that these patients and their families experience tremendous distress. It is of signifi- cant mental health importance that this cat- egory of patients be identified and treated ap- propriately – in a manner dissimilar from the solitary diagnosis of a substance use disorder or a mental illness.

Introduction

Comorbidity is defined as the presence, either simultaneously or in succession, of two or more specific disorders in an individual within a speci- fied period.

Comorbidity can be used to describe the pres- ence of a comorbid physical condition (gen- eral medical condition) or psychiatric disorder. However, in most systems of psychiatric classi-

fication, general medical condition is coded separately. Comorbidity in psychiatric terms and in the context of substance use disorders usually refers to the co-occurrence of psycho- active substance use and other mental disor- ders.

Two terminologies often used include:

. 1) Mentally Ill Chemical Abuser (MICA)/ Mentally Ill Substance Abuser (MISA)/ Chemical Abusing Mentally Ill (CAMI): These terms have been used to describe patients with a psychiatric disorder having a comorbid substance use disorder.

. 2) Dual Diagnosis: Patients with a substance use disorder and comorbid psychiatric manifestation are referred to as dual diag- nosis patients.

The distinction between the two categories is very thin and it may not always be possible to establish a primary-secondary relationship be- tween the two.

Irrespective of the type, comorbidity has been shown to have major consequences. Three ma- jor epidemiological surveys, the Epidemiologi- cal Catchment Area study (ECA), National Comorbidity Study (NCS) which were con- ducted in USA and Netherlands Mental Health Survey and Incidence Study showed that sub- jects with comorbid disorders had higher ser- vice utilization rates than those with psychiat- ric illness alone. Studies have also linked comorbidity with a more severe symptom pro- file, greater functional disability and a longer illness course.

Prevalence

In the ECA study, an estimated 45% of indi- viduals with alcohol use disorders and 72% of individuals with a drug use disorder had at least one co-occurring psychiatric disorder. In the NCS, approximately 78% of alcohol-depen- dent men and 86% of alcohol-dependent women met lifetime criteria for another psy- chiatric disorder, including drug dependence.

Correspondingly, 65% women with other sub- stance abuse or dependence received at least one additional diagnosis. Conversely among psychiatrically ill patients, substance use dis- order was found to be 15.7% in the past month with a lifetime prevalence of 32.7%.

Indian studies are available only on psychiat- ric conditions comorbid with alcohol. The prevalence of comorbid psychiatric disorders in alcohol ranges from 12.5%-46.0%, depres- sive symptoms from 27.5%- 48.6%, depres- sive disorder from 8.8%- 23.6%, and psycho- sis from 10.0%-29.2%.

The most common psychiatric disorders seen with substance use disorders are:

. 1) Antisocial personality disorder (prevalence rate of 35-60%)

. 2) Depression. One-third to one-half of opioid abuse or dependence and about 40% of those with alcohol meet criteria for major depressive disorder sometime during their lives. Studies have also shown substance abuse to be a major precipitating factor for suicide. Persons abusing substances are 20 times more likely to die by suicide as com- pared to the general population.

. 3) Panic and other anxiety disorders (In pa- tients with alcohol dependence-Panic dis- order – 5 to 42%, Generalized anxiety dis- order-8.3 and 52.6%, social anxiety disor- der- 8 to 56%, Obsessive-compulsive dis- order –3-12%).

. 4) Schizophrenia: 10.1% prevalence.

Classification

Comorbid disorders can be classified as follows:

. a) Depending on the drug of abuse like alco- hol-induced psychosis or schizophrenia with comorbid alcohol dependence.

. b) On the pharmacological action of the drug e.g. stimulant induced psychosis.

. c) Type of psychiatric disorder such as schizo- phrenia, depression.

. d) Etiological significance.

The routinely followed classification is based on etiological significance. In order to estab- lish a cause –effect relationship, it is essential to understand

. 1) The chronological order of appearance:

. 2) Influence of remission in one of the disor- ders on severity of the other: This usually confirms the diagnosis. Often in substance- induced cases, there is an attenuation of the comorbid psychiatric disturbance as- sociated with abstinence from the substance.

. 3) Certain other paradigms that can be used in diagnosing substance-induced disorders including absence of any other condition that could result in the psychiatric distur- bance and the severity of mental illness as- sociated with the substance use.

Accordingly, Comorbid conditions in sub- stance use disorders can be classified thus:

a) Classification based on etiology

1) Primary substance use disorder with sec- ondary psychiatric disorder.
These include substance-induced con- ditions such as alcohol-induced psycho- sis probably caused by organic changes in the brain. In some cases, the psychi- atric disorder can be a secondary condi- tion caused by the psychological and

Comorbidity in Substance Use Disorder

b )

2) Secondary substance use disorder Model :

Among secondary substance use disorder model, there is support for the supersensi- tivity model, which posits that biological vulnerability of psychiatric disorders results in sensitivity to small amounts of alcohol leading to substance use disorders. This models implies a selective matching of spe- cific substances (and their subjective effects) with specific symptoms. The self medica- tion hypothesis links substance use to the patients’ wish to improve psychopathologi- cal symptoms such as anhedonia or side effects of neuroleptic treatment.

3) Secondary Psychiatric disorder model :

Secondary psychiatric disorder model re- mains controversial till date. This model focusses on vulnerability and hypothesizes that drug abuse may cause psychiatric ill- nesses and vice versa in a vulnerable indi- vidual.

social effects of the substance use.

. 2) Primary psychiatric disorder with sec- ondary substance use disorder.
In some psychiatric disorders, it is seen that the patients consume the substance as a form of self-medication to obtain relief from the disorder. e.g. alcohol con- sumption secondary to panic attacks. Patients with schizophrenia very com- monly abuse nicotine to decrease the in- tensity of hallucinations and thus im- prove alertness.

. 3) Primary psychiatric disorder with sub- stance use disorder as part of the clinical syndrome.
In some patients, the substance disor- der can be a part of the clinical syndrome of the psychiatric illness. e.g. alcohol consumption increases during the manic phase of bipolar disorder.

. 4) Two coexisting independent disorders. Initially considered improbable, the con- cept of co-existence of two independent psychiatric disorders is now accepted.

Classification Based on Severity :

This approach based on severity considers a mix of substance abuse and mental health disorders in the categorization scheme, and uses categories that reflect the relative se- verity of each set of problems. It has been adapted from Weiss et al. whereby catego- ries based on low/high severity of psychi- atric and substance use disorders are de- scribed.

. 1) Substance abuse and non-severe psycho- pathology (Psych-low, Substance-low).

. 2) Complicated chemical dependency (Psych-low, Substance-high).

. 3) Substance abusing mentally ill. (Psych- high, Substance low).

. 4) Substance dependent mentally ill. (Psych-high, Substance-high).

c) Approach Based on existing classificatory systems

The third approach is to form sub-catego- ries based on a broad DSM-IV classifica- tion of mental health disorders.DSM-IV provides the option of indicating that the disorder is “substance induced” .

Etiology

The etiology of the high prevalence of substance use disorders in patients with mental illness is unclear. The evidence of different theories of increased comorbidity can be organized accord- ing to four General Models.

1 )

Common factor model :

Among common factor models, evidence suggests that anti-social personality disor- ders accounts for some increased comorbidity.

Comorbidity in Substance Use Disorder

Various other models like the bidirectional model have been proposed but these have not been adequately substantiated. No single model has unequivocal support and can claim to ex- plain all cases of comorbidity between substance abuse and psychiatric illnesses and it is pos- sible that all models contribute in the expla- nation.

Management

It is of importance to realize that treatment of comorbid conditions cannot be generalized. Treatment has to be tailored according to the specific needs of each individual patient. This will vary according to

to be most efficacious when the psychiat- ric symptoms are not very severe.

3) Integrated treatment :

A third model, called integrated treatment, an approach that combines elements of both mental health and addiction treat- ment into unified and comprehensive treat- ment program for patients with co-mor- bid disorders. Integrated treatment involves clinicians cross trained in both mental health and addiction who use a unified case management approach, making it possible to monitor and treat patients through vari- ous periods of crisis related to either sub- stance abuse or the psychiatric illness.

Management of comorbid conditions essen- tially includes:

. 1) Establishing a diagnosis

. 2) Management of substance withdrawal

. 3) Short-term management of the psychiatric disorder

. 4) Maintenance of abstinence and long-term management of psychiatric disorder

. 5) Rehabilitation

. 6) Caregiver psychoeducation

1) Establishment of diagnosis:

Substance intoxication may resemble a psychi- atric disorder (for e.g. patients under the in- fluence of alcohol often talk irrelevantly) and protracted substance withdrawal can compli- cate psychiatric presentation (for e.g. opium withdrawal can mimic depressive disorder). Inadequate history may give rise to further con- fusion about the cause-effect relationship. Hence, it is advisable to treat the substance withdrawal and wait for a minimum of 2-4 weeks before confirming the diagnosis of the psychiatric disorder.

2 )

Nature of drug abused like stimulant, seda- tive

Type of psychiatric disorder.

Models of Treatment :

As mental health professionals have become increasingly aware of the existence of patients with co-morbid disorders, various attempts have been made to adapt treatment to the spe- cial needs of these patients. These attempts reflect philosophical differences about the na- ture of comorbid disorders, as well as differing opinion regarding the best way to treat them. There are three approaches to treatment.

1) Sequential treatment :

This is the first and (historically) most com- mon model of dual disorder treatment. The term sequential treatment describes the serial involvement of both mental health and addiction treatment teams. The se- verity of the disorder determines the prior- ity – substance abuse or Psychiatric illness.

2) Parallel treatment :

In this model the mental health and ad- diction treatment teams work simulta- neously, but seperately. This has been found

Comorbidity in Substance Use Disorder

2) Management of substance withdrawal:

Adequate management of the substance with- drawal (detoxification) must be done for an adequate duration. Substance-induced psychi- atric disturbances remit with adequate and rig- orous management of withdrawal. However, in some conditions like alcoholic hallucinosis, the condition can become chronic. It forms good clinical practice to consider substance induced psychotic disorders as a variant of brief psy- chotic disorder and treat the patient accord- ingly.

3) Short-term management of the psychiatric disorder:

If the patient continues to manifest the psy- chiatric disturbance, it is recommended that the patient receive treatment appropriate to the disorder.

anti-craving agent. Long-acting depot antipsychotics have been shown to be effica- cious in patients with alcohol dependence and comorbid psychosis. It is advisable to avoid the use of long-term benzodiazepines in patients due to their addictive potential.

Psychotherapy: Patients with comorbid disor- ders are difficult to engage in any kind of psy- chotherapeutic relationship. However, these patients can benefit from psychoeducational programmes, group therapy, and individual psychotherapy.

5) Rehabilitation:
It is essential to ensure that patients are ad-

equately rehabilitated to prevent relapses.

6) Caregiver psychoeducation:

Caregivers need to be educated about the spe- cial nature of comorbidity, i.e., the co-exist- ence of two disorders and should be forewarned about the problems and prognosis. They should be adequately prepared to spot the early warn- ing signs of relapse. This can be done either individually or in groups. Adequate support to the caregiver and encouraging healthy cop- ing patterns to deal with perceived burden is essential.

Problems in management:

. 1) Difficulties in establishing the diagnosis. (Discussed in the earlier section)

. 2) Difficulties in treatment: Patients with comorbid substance use disorder are often non-compliant to the medications. They are more prone to the side-effects of the various psychotropics used for treatment.

. 3) Presence of additional organic brain dam- age may complicate management.

. 4) Long-term rehabilitation is often difficult, as most substance-use rehabilitation cen- tres do not attend to patients with

4 )

Maintenance of abstinence and long-term management of psychiatric disorder:

Both steps are to be treated hand-in-hand. Comorbidity forms a vicious cycle with both disorders contributing to each other. Hence it becomes essential to attain long-term remis- sion in both. If any one condition is neglected, the comorbid condition can get exacerbated. The following paradigms can be helpful in management.

Long-term management of psychiatric disor- der involves

Pharmacotherapy: The patient should be treated for the psychiatric disorder with ad- equate doses for an adequate time period. Anticraving agents can help in abstinence. However, the anticraving agent has to be se- lected appropriately. SSRIs can help in comorbid depression. Disulfiram can precipi- tate psychosis and hence should be used cau- tiously in comorbid schizophrenia. Topiramate as a mood-stabilizer has also been used as an

Comorbidity in Substance Use Disorder

comorbid psychiatric disorders leading to poorer prognosis characterized by an unpatterned behaviour pattern and frequent relapses.

Mental Health Significance:

Even relatively minor use of a substance by a person experiencing mental health difficulties may lead to worsening of this condition and may have significant health implications. The coexistence of substance use and mental health problems has been linked to increase in im- pulsive, aggressive and disinhibited behaviors, as well as an increase in anxiety, depression and self-harm.

Comorbidity also leads to social problems, dif- ficulties with activities of daily living, worsen- ing of physical health and significant legal and financial problems. In extreme situations a per- son may end up behaving in self-destructive and antisocial ways. They may become home- less, be disengaged from their family and com- munity, and have a higher chance of exhibit- ing high-risk behaviors such as indulging in criminal activities, intravenous drug use, needle sharing, suicide attempts, unsafe sex, and binge consumption.

Overall, the presence of comorbidity increases the incidence of relapse and the need for acute intervention for both the substance use and the mental health problem.

Impact on caregivers and health providers:

As discussed earlier, comorbidity in substance use disorder is characterized by frequent re- lapses. This poses tremendous burden on the caregivers emotionally and financially and can lead to caregiver burden and depression. These in turn lead to increased expressed emotions that further aggravate the patient’s illness. Of- ten it is seen that because of the frequent re- lapses, the caregiver loses interest in the pa- tient and the treatment process. The patients

are then brought to the treatment facilities only in dire emergencies.

Frequent relapses, difficulty in establishing and maintaining therapeutic relationship, poor compliance and a non-committal attitude of the caregiver has a negative impact on the treat- ment provider occasionally leading to a nega- tive counter-transference.

An ideal situation for management of these patients is a specialized set-up with physicians trained in all aspects of management of patients with dual disorders.

Impact on health care utilization:

Studies have shown that comorbidity increases health care service utilization. It has also been shown that 50% patients attending the emer- gency room are patients with dual disorders. Thus these patients account for a significant proportion of health care costs.

Role of the General Practitioner:

Majority of patients suffering from comorbid conditions are never seen by a specialist.The general practitioners (GPs) is often the first and only contact. Damien McCabe and Chris Holmwood (Australian Resource Centre, Pri- mary Mental Health Care) have suggested the following possible role of GPs in management:

• Early detection and accurate diagnosis of
comorbidity

• Provision of information on the patients’
condition and treatment approaches

• Brief interventions for people with lower
levels of disability

• Referral and co-ordination of care for more
severely affected people

• Medical treatment for physical health com-
plications

• Provision of a high level of support to the
patient and their family

• Long term monitoring and follow-up

Comorbidity in Substance Use Disorder

Suggested Reading

1. Nimesh G Desai, Dhanesh K Gupta, KA Khurshid. Substance use disorders. In: Text- book of postgraduate psychiatry. JN Vyas and Niraj Ahuja (Eds). New Delhi. Jaypee Brothers Medical Publishers (P) Ltd, 1999, 76-150.

2. Ron de Graaf, Rob V. Bijl, Filip Smit, Wilma A.M. Vollebergh, and J. Spijker. Risk Fac- tors for 12-Month Comorbidity of Mood, Anxiety, and Substance Use Disorders: Findings from the Netherlands Mental Health Survey and Incidence Study. Am J Psychiatry 2002; 159:620-629.

3. Li-Tzy Wu, Anthony C. Kouzis, and Philip J. Leaf. Influence of Comorbid Alcohol and Psychiatric Disorders on Utilization of Men- tal Health Services in the National Comorbidity Survey. Am J Psychiatry 1999; 156:1230-1236.

4. Substance-related disorders. In: Synopsis of psychiatry. Harold I Kaplan and Benjamin J Sadock (Eds) 8th edition 1998.Maryland. Williams and Wilkins: 375-455.

5. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-

U, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disor- ders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8-19.

6. Robins LN, Locke BZ, Regier DA: An over- view of psychiatric disorders in America, in Psychiatric Disorders in America: The Epi- demiologic Catchment Area Study. Edited by Robins LN, Regier DA. New York, Free Press, 1991,328-366.

7. Hugh Myrick, Kathleen Brady. Review of Comorbidity of Affective, Anxiety, and Sub- stance Use. Current Opinion in Psychiatry, 2003; 16(3): 261-270.

8. Reiger DA, Farmer ME, Rae DS, et al Comorbidity of mental disorders with alco- hol and other drug abuse. JAMA 1990; 264:2511-2518.

9. Damian McCabe & Dr Chris Holmwood. What is comorbidity and why do general practitioners need to know about it? -The Comorbidity Problem. Primary Mental Health Care Australian Resource Centre. (PARC project-2001).

Comorbidity in Substance Use Disorder

Suggested slides for OHP
Slide 1: Comorbidity and substance use disorders:

Concept: Co-occurrence or presence, either simulta- neously or in succession, of two or more specific disor- ders in an individual within a specified period. Terminologies:

• MICA(MentallyIllChemicalAbuser),MISA(Men- tally Ill Substance Abuser), CAMI (Chemical abus- ing Mentally Ill)

• Dual Diagnosis
Slide 2: Basis of classification:

. 1) Drug of abuse like alcohol, opium, cannabis.

. 2) Purpose the drug serves such as stimulants, seda-
tives.

. 3) Type of psychiatric disorder like depression, psy-
chosis.

. 4) Etiological significance

Slide 3: Criteria for establishing cause-effect relationship:

• Chronologicalorderofappearanceofsymptoms

• Influenceofremissionononeofthedisorderson
severity of the other.
Classification (etiological significance)

• Primarysubstanceusedisorderwithsecondarypsy-
chiatric disorder

• Primarypsychiatricdisorderwithsecondarysub-
stance use disorder

• Primarypsychiatricdisorderwithsubstanceusedis-
order as part of the clinical syndrome

• Two coexisting independent disorders.
Slide 4: Etiological Models
Common Factor Model
Secondary substance use disorder Model
Secondary psychiatric disorder Model :
Bidirectional Model
Prevalence
ECA study: Comorbidity of mental illness in substance use disorder
Men – 76% Women – 65%

Slide 5: Most common comorbidity in substance use disorders

1. Antisocial Personality Disorder
2. Depression
3. Panic disorder and other anxiety disorders 4. Schizophrenia

Slide 6: Significance

Comorbidity in Substance Use Disorder

Difficulties in diagnosis: –

a. Substance intoxication can resemble psychiatric
disorder

b. Protracted substance withdrawal complicates
psychiatric presentation.

c. Establishment of a cause-effect relationship

Difficulties in management

a. Problems in establishing therapeutic relationship

b. Poor compliance to medications

c. Increased side-effects with medications

Increased chances of organic brain damage due to substance use disorder

Slide 7: Management: Salient features

. 1) Adequate and appropriate management of with- drawal phase

. 2) Diagnosis of psychiatric disorder to be established only after end of withdrawal phase.

. 3) Appropriate and rigorous management of psychi- atric disorder

. 4) Anticraving drugs for substance use disorder can be used

. 5) Disulfiram contraindicated in comorbid psychosis

. 6) SSRIs preferred as anticraving in comorbid depres-
sion

. 7) Long-acting depot preparations like Flupenthixol

. 8) Avoid long-term use of benzodiazepines

. 9) Long term rehabilitation with regular follow-up

. 10) Caregiver psychoeducation.

Slide 8: Role of GPs.

• Earlydetectionandaccuratediagnosis

• Provisionofinformationonconditionandtreat-
ment approaches

• Briefinterventionsforlowerlevelsofdisability

• Referralandco-ordinationofcareforhigherlevels
of disability

• Medicaltreatmentforphysicalhealthcomplications

• Provisionofsupporttothepatientandtheirfamily

• Longtermmonitoringandfollow-up

Psychiatric Illness

Substance Abuse

Comorbidity

Substance use disorder in Women

Pratima Murthy, Prabhat Chand

Summary

Substance abuse in women is a growing con- cern in India. While traditional surveys have been unable to provide insights into this hid- den problem, recent studies of special popula- tion and qualitative research suggests that al- cohol, tobacco, opiates and sedatives are drugs that are commonly abused by women from diverse backgrounds. Patterns of use across the country vary.However, some common themes appear to be an early onset, use in the context of a heterosexual relationship, greater emotional problems and poor social support. Women are more vulnerable to the adverse physical conse- quences of substance use. The environment plays a significant role in development of sub- stance abuse in addition to genetic vulnerabil- ity. There are specific issues with regard to treat- ment of substance use in women, which in- clude delay in recognition of the problem, as- sociated stigma, lack of support systems for treatment and follow-up and other social and psychological issues.

Introduction

Substance abuse has traditionally been consid- ered a disease of men. Women were believed to have some kind of immunity in terms of “so- cial inoculation”. However it is now being seen that women are also susceptible to substance use and related problems. Historically, the understanding of substance use is based on male consumption patterns. Though earlier believed that these patterns are equally applicable to women, recent research has shown important gender differences in biology, epidemiology,

socio-cultural factors and psychological comorbidity.

In many developing countries substance abuse is no longer an exclusive or predominantly male activity. However there is hardly any informa- tion on substance abuse among women from developing countries.

Epidemiology

Epidemiological surveys from the United States show one-month prevalence rates of alcohol use disorders in men as being five times more com- mon than in women. The prevalence of alco- hol dependence was twice in men as compared to women. The rates of tobacco dependence are almost the same in both groups (men: 31%, women: 27%). Evidence from U.K, Australia and Switzerland point towards increasing sub- stance abuse in women.

In India, traditional use of various substances by women during religious festivals is not un- known. Chewing tobacco is a common prac- tice among many women across the country. Cultural use of alcohol has been known in some tribal populations. National multi-centered studies in early 80’s reported negligible drug use rates among women. The findings in the 1990s also indicated that drug abuse was a predominantly male phenomenon and that 92 to 94 percent of women had never used drugs in their lifetime.

The low numbers of women substance users in traditional surveys is probably reflective of the unsuitability of existing epidemiological

surveys in identifying substance use among women. However, recent data from treatment centers shows that 1 to 3 percent of treatment seekers are female. Therefore, more recent stud- ies have shifted from traditional surveys to stud- ies of specific groups of women with respect to their substance use. A study carried out in 2002 in three cities i.e. Delhi, Mumbai and Aizwal examined substance abuse patterns in women, characteristics of women users and gender issues in treatment. The predominant drugs of abuse were heroin, propoxyphene, al- cohol and minor tranquilizers. Injecting drug use was reported especially from Mumbai and Aizawl. About half the women substance us- ers were between twenty to thirty years and majority were employed. Engaging in unsafe sexual practice was observed among many sub- stance abusing women.

In a rapid assessment study of 4648 substance users in the community, it was possible to iden- tify 371 women substance users (7.9%), which may suggest that substance use among women is becoming more visible. The trends from this study appear to suggest that substance use oc- curs more commonly in single, educated women. Currently, women appear to have an early onset of substance use, have high level of substance use in families and also have an early initiation into sexual activity. In comparison to male coun- terparts, there appear to be increasing numbers of single, better-educated women initiating sub- stance use in urban areas.

Studies from western countries show that men smokers are twice that of women smokers. Al- though smoking among women is not com- mon in our culture, chewing of tobacco is quite high. Among 39,840 women in Mumbai, 58% were chewing tobacco. In rural Karnataka, 7- 9% of 467 women reported chewing tobacco. In a survey of 500 pregnant women, 33% re- ported tobacco use, mainly as tooth powder.

Etiology

Genetic factors

Twin and adoption studies in males have sug- gested the robust association of genetic factors in the cause of alcoholism. In female alcohol abusers there is evidence that inherited factors are strongly influenced by the environment. One recent study from Australia involving 2000 female twin pairs have showed the risk of ge- netic factors for drinking falling from 60 to 40 percent following marriage or cohabitation. Across all studies, one of the most important factors influencing drinking in women was found to be alcohol use or abuse by spouse. Stud- ies from India also suggest that a large number of women alcohol dependents started drinking to keep their spouses company. These evidences imply the important role of environmental in- fluences in association with genetic factors in development of alcohol abuse in females

Studies on genetic markers showed that com- pared to non-alcoholic women without first- degree relatives suffering from alcohol depen- dence, those with first-degree relatives suffer- ing from alcohol dependence showed fewer er- rors for the same Blood alcohol level.

Psychological factors

The few studies examining psychological pre- dictors of alcohol use in women all emphasize the strong association of co-morbid psychologi- cal factors in this group in comparison with males. Low self esteem and impaired ability to cope at the high school level in girls was found to predispose to future problem drinking in an Australian study. Childhood sexual abuse increased the risk for both substance abuse and dependence in women. There is a significant association between substance use and major depression in women, with studies suggesting an odds ratio for developing alcohol abuse or dependence of 4.10 for depressed female com- pared to 2.67 for a male with major depres-

Substance use disorder in Women

sion. Studies from India report association of depression (62.7%) and anxiety (53.3%) in the women using substances.

Sociocultural factors

Research in developed countries suggests that a number of social factors differentiate women and men substance users. Women experience more social disapproval of substance use. Simi- larly women are more likely to have role mod- els in their families and have an alcohol-using spouse. More female substance users are likely to get separated or divorced. In males, the sub- stance abuse is more likely to affect jobs or ca- reer. Women are less likely to be involved in criminal acts or social deviance and have higher internalizing problems than males. Other fac- tors like poor education status, lack of job, young age at work, early marriage and lack of social support increase vulnerability to sub- stance use in female.

Biological responses

Gender differences in the physiological effects contribute to the increased harmful effects of

alcohol in women than in men. Women be- come intoxicated after drinking smaller quan- tities of alcohol than do men. This may be due to less body water in comparison to size, which means they achieve higher blood concentrations than do men after drinking an equivalent amount of alcohol. Additionally, lower levels of alcohol dehydrogenase enzymes in the stom- ach results in a higher amount of alcohol in the systemic circulation. Women develop al- cohol liver disease with comparatively shorter and less intense drinking than men. More women die from cirrhosis than men. Heavy alcohol consumption may also be associated with increased risk of menstrual disturbances, infertility and breast cancer.

Substance use disorder in Women

Aetiology

• High family loading

• Greater psychiatric symptoms and dual
diagnosis, especially depression

• Greater likelihood of living with an sub-
stance using partner

• Greater marital disruption

Interacting factors leading to substance use among women

Adapted from Murthy P (2002): Women and drug abuse : the problem in India

Social Disadvantage and Social isolation

Predisposition Modelling

Role Transition and lifestyle changes

Drug Use

Stigma, lack of support

Drug Availability

Physical and emotional problems and ignorance about treatment

Lack of knowledge of harm

Pregnancy and lactation

Teratogenic effects of alcohol consumption are well known. Fetal alcohol syndrome (FAS) and fetal alcohol effects of alcohol have been iden- tified as among the leading cause of mental retardation in the western world. FAS is diag- nosed by presence of craniofacial anomalies, central nervous system dysfunction, and ma- jor organ system malformation. Children born with less than the full constellations are termed as FAE (Fetal alcohol effects), a continuum of fetal alcohol syndrome. The incidence of FAE is found to be 1.9 per 1000 live birth in west- ern studies. In case of heavy alcohol drinking, the incidence increased up to 25 per1000 live births. Under reporting of the alcohol use in women poses difficulty in actual estimation of harmful effects on the fetus. Prenatal alcohol exposure is related significantly to persistent problems with attention, distractibility and slower reaction times.

Use of other substances like cocaine and nico- tine showed significant impairment of orien- tation, motor and intrauterine growth retar- dation. Term infants born to these mothers had lower mean birth weights, lengths, and head circumferences. Apart from this, the risk of adolescent pregnancy and its complication goes together with increased risk of substance use.

Alcohol and Sex

Traditionally, alcohol is believed to increase sexual power and enjoyment. Studies have shown that it is not alcohol itself, but the be- lief that alcohol improves sex, which is respon- sible for increased sexual enjoyment. However, heavy drinking actually inhibits sexual enjoy- ment. Women who drink heavily have been shown to be more likely to have early sexual experiences, to have a greater number of sexual partners, and to have unprotected sex. This exposes them to the problem of unwanted

pregnancies and sexually transmitted diseases. Drinking to intoxication also makes a woman less able to defend herself, and more vulner- able to sexual abuse and rape.

Course of Illness

Initiation

The reasons for initiation of substance particu- larly alcohol among adolescent girls have been studied predominantly in American situations. Common reasons cited include adolescent de- pression and problems in adjustment, hang- ing out with older male friends, peer pressure, feeling of a sense of glamour and power, and disappearing stereotypes about feminity. These reasons are likely to be universal, and equally applicable in India. Adolescence is a time when there is a constant struggle between dependence and autonomy, and all adolescents are extremely vulnerable to psychological pressures includ- ing drinking as a way of creating an image or dealing with the pressures.

Research suggests that while many of the rea- sons why adolescent’s drink are gender blind, some factors may affect girls more than boys.

• Puberty tends to bring a higher incidence of depression among teenage girls, which can trigger alcohol use. One study found symptoms of depression in one in four girls – a rate that is 50 percent higher than in boys.

• Adolescent girls who are heavy drinkers (drink five or more drinks in a row on at least 5 different days in the past month) are more likely than boys to say that they drink to escape problems or because of frus- tration or anger.

• Friends have a big influence on teenagers overall, but girls are particularly susceptible to peer pressure when it comes to drink- ing. Adolescent girls are more likely than

Substance use disorder in Women

boys to drink to fit in with their friends, while boys drink largely for other reasons and then join a group that also drinks.

Course

The course of substance use disorders, particu- larly alcohol, seems to be different for women than for men. The interval between the age of first drinking and treatment seeking seems to be shorter for women than for men. As men- tioned previously, studies suggest that women experience greater medical, physiological and psychological impairment earlier in their drink- ing career. In addition, women seem to progress between landmarks associated with the devel- opmental course of alcoholism (e.g. regular drink- ing or loss of control) sooner than men. This accelerated progression of alcoholism in women is commonly referred to as “telescoping.”

Assessment and treatment

Once a female patient begins treatment, she should be carefully evaluated for additional psychiatric and substance use disorders. The first step involves building rapport with the patient. It is important to educate them about the substance and its ill effects. It works well when the physician can personalize the harm suffered by the index patient. For example, for a patient having alcohol induce hepatitis, discuss- ing about the physical effects of alcohol is more useful. Linking the medical problem with the substance and recommend reduction or absti- nence is the next most important step in the management. Also emphasize patient’s respon- sibility in helping herself out of the problem.

Decisions about in-patient admission need to take into consideration not just clinical issues, but also social issues, especially the care of young children that the patient may have. The need for separate services for women with substance use to address their special social and emotional needs is increasingly being recognized.

Girls often are introduced to alcohol by their boyfriends, who may be older and more likely to drink.

It is shown from Indian studies that positive expectancies regarding benefits of alcohol use were cited as the most common reason for initially starting to drink. Also, the positive expectancies cited by men and women differ significantly (Table 1).

Table 1: Positive expectancies regarding effects of alcohol use

Substance use disorder in Women

of drinking was in order to keep company with their husbands.

Females*

Males**

· Elevates mood

· Provides strength
after childbirth

· Improves health
and relieves tiredness

·Improves sleep ·Improves sleep ·Relieves tiredness,

fatigue and worry ·Prevents colds,

coughs and breathing problems, helps in asthma and paralysis

·Increases joy and cements friendship

·Improves sexual desire and performance

*Murthy et al (1995) **Chandrasekhar (1994)

Women attributed mood elevating and antidepressant properties to alcohol, and in the light of the prominent pre-existing depression reported by many of them, might have started alcohol as a form of self-medication. Men on the other hand used it to improve sleep or decrease tiredness. The second most common attribution among women was that alcohol had major restorative properties after childbirth. The next most common reason for initiation

Then physician helps the patient in ways to maintain abstinence from substance like rec- ognizing risky situations, coping with negative emotions, handling friends etc. Even if you feel that the patient is not motivated or not sure regarding the treatment, it is very impor- tant to keep her in therapeutic net. It helps the person to think and reconsider his views in next follow up. It is helpful to involve the fam- ily members, particularly spouse in the treat- ment plan and long term rehabilitation. Clinical experience suggests that social supports for women substance users are often lacking, and this increases their chances of dropping out of treatment. Enchancing support as part of after-care is very important to maintain recov- ery among women.

Treatment approaches to substance dependence in women

Establishing confidentiality and rapport, being non judgmental

Assessment of severity of the problem Comorbid depression, anxiety, and inter

personal problem need attention Educate ill effects of substance to her and family and fetus if she is of reproductive

age
Feed back of the damage due to substance Help in reduction or abstinence and in

handling high risk situations Increase self esteem
Use pharmacotherapy also where

indicated

In a woman who is dependent or having a co-morbid psychiatric problem, it is advisable to refer her to the specialist.

When co-morbid psychiatric disorders are discovered, it is helpful to determine whether

the disorder preceded the addiction or had its onset during a prolonged period of abstinence and therefore may be regarded as primary. In the latter condition, the patient should be pre- pared to recognize early indication of recur- rence of the psychiatric disorder during her recovery from addiction.

Pharmacotherapy

In the initial visits the symptomatic treatment of substance withdrawal symptoms is essential. Unless the withdrawal is complicated by con- ditions like delirium tremens or seizures, most cases can be treated as outdoor basis. This is especially important in social situations when admission may not be feasible.

Conclusion

Under recognition of substance abuse and bar- riers to accessing services often prevent women from benefiting from treatment. First, identi- fication of women substance abusers by health care professionals can be hindered because of stereotypic views of women and of substance abusers. Second, women often have basic needs such as food, economic constraints, housing, and safety from battering or assault. Further- more women, more often than men are pri- mary care givers for their children and that may hinder from entering into treatment due to lack of social support.

Summarising, women need some of the same treatment services as men, such as detoxification, education, support, and treatment of comorbid physical and psychiatric disorders. Women, how- ever, require more attention for childcare, associ- ated psychiatric and medical disorders, building self-esteem, supportive therapy from therapist, care from spouses, and other possible sources of support in the community.

Substance use disorder in Women

Suggested Reading

1. Blume SB. Alcohol and other drug prob- lems in women. In: Substance abuse :a com- prehensive text book (eds.) J.H. Lowinson, P. Ruiz & R.B. Willman. Maryland. Will- iams & Wilkins. 1992, 794-807.

2. Blume SB. Addiction in women. In: Text book of Substance use (eds.) M Galanter & HD Kleber Washington. American Psychiatry Press, 1999.

3. Brady KT & Randall CL. Gender differences in substance use disorders. Psychiatric Clinic of North America 1999,22:241-252.

Alcohol. In Manual on Women’s Counsel- ling. (eds) C.R.Chandrashekar . NIMHANS, Bangalore, 2002:33-36.

7. Murthy NV, Benegal V, Murthy P. Alcohol Dependent Females: A clinical profile. Ab- stracts of scientific papers presented at the 47th Annual National Conference of the Indian Psychiatric Society. Indian Journal of Psychiatry (Supplement); 1995, 37:2.

8. Murthy P. Women and drug abuse: the prob- lem in India. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Office for South Asia, 2002.

9. Murthy P. Alcohol consumption and its conse- quences for women. In Young Ladies (ed) A. Khwaja. Banjara academy, Bangalore, 2003: 31- 36.

10. Prasad S, Murthy P, Verma V,Mallika R and Gopinath P S. Alcohol dependence in women: a preliminary profile. NIMHANS Journal 1998, 2:87-91.

Closser MH & Blow FC. Special populations:women,ethnic minorities and the elderly. Psychiatric Clinic of North America 1993,16:199-209.

5. Gupta PC. Survey of Socio demographic characterstics of tobacco use among 99598 individuals in Bombay, India using handheld computers. Tobacco Control, Summer, 1996, 5(2): P 114-120.

6. Kewalramani M, Murthy P. Women and

Substance use disorder in Women

Suggested slides for OHP Slide1

• Substanceusetraditionallyadiseaseofmen

• Recentresearchshowsignificantdifferencesinbiol- ogy, sociocultural factors and psychological morbid-
ity in women and men

• Veryfewstudiesexistonsubstanceabuseandwomen
Slide2: Epidemiology

quantities
Develop alcohol liver disease earlier with shorter duration of alcohol use Increased risk of menstrual disturbance, infertility and breast ca

Slide 5: Pregnancy and Lactation

US–

India –

Prevalence of alcohol use disorders in women 1/5 as compared to men
Alcohol dependence 1⁄2 compared to men Tobacco dependence: 27% in females Traditional and cultural use permissible in certain sections of society

Treatment seekers: 1 – 3% of treatment seekers are females
Study in 3 cities in 2002:

Heroin, Propoxyphene, Alcohol, and Minor Tranquilisers Majority in 20s – 30s, employed

Rapid assessment survey: 7.9% female users Most common:

Single uneducated females Early onset of drug use Family history positive Early initiation into sexual life

Tobacco use: 3.7% of females in India smoke

Other substances: IUGR, impairment of orientation, motor abnormalities

Slide 6: Course of illness

Initiation:
Common reasons – adolescent depression, adjustment problems, hanging out with older male friends, peer pressure, glamour
Increased expectancies regarding effect of alcohol use Course:
Interval between age of initiation and treatment seeking shorter for females compared to males
Greater psychological and physiological impairment Faster telescoping

Slide 7: Assessment and Treatment

• Establishingconfidentialityandrapport,beingnon judgmental

• Assessmentofseverityoftheproblem

• Comorbiddepression,anxiety,andinterpersonal
problem need attention

• Educate ill effects of substance to her and family
and fetus if she is of reproductive age

• Feedbackofthedamageduetosubstance

• Helpinreductionorabstinenceandinhandling
high risk situations

• Increaseselfesteem

• Usepharmacotherapyalsowhereindicated

Slide 3: Etiology

A) Geneticfactors:Robustassociationwithalcoholism Both state and trait markers seen

B) Psychological:

Strong association compared to males Low self esteem, impaired ability to cope Increased association of depression (odds ratio of 4.10 for alcohol) Indian studies: Depression – 62.7%

Anxiety – 53.3%

Slide 4: Etiology contd…

C) Sociocultural:

Role models present
Increased likelihood to have a drug using spouse
Increased social disapproval Decreased likelihood of legal problems

D) Biologicalresponses:genderdifferencespresent Females intoxicated with smaller

Alcohol:

Teratogenic effect present
Fetal alcohol syndrome: craniofacial anomaly, CNS malfunction, major organ malformation
Fetal alcohol effects: 1.9/ 1000 live birth (western studies)

Substance use disorder in Women

Adolescent Substance Abuse

Anju Dhawan, Yatan Pal Singh Balhara, Indra

Summary

Majority of drug users start drug use in ado- lescence with use of licit substances such as tobacco and alcohol. Some of them subse- quently graduate to use of harder/illicit sub- stances. Drug abuse among adolescents is a cause of concern because use in this age group is associated with increased risk of accidents, violence and high-risk sexual behaviour. The profile of drugs used in adolescence may also be different from the drugs used in adulthood. Co-morbid psychiatric disorders are also more common in adolescents who have substance use disorder. The intervention in substance using adolescents requires involvement of parents as well as teachers. The family needs to be coun- seled about nature of treatment and the pro- cess of recovery.

Less intensive intervention may be required for those with structured lifestyle, absence of psy- chopathology, and those who have not yet be- come dependent on the substance.

Introduction

Majority of substance users start use in adoles- cence with use of licit substances such as to- bacco and alcohol. However, most adolescents who use substances give it up subsequently and do not go on to develop abuse/dependence.

Substance use during adolescence is associated with high-risk behaviour, increased risk of in- fections such as HIV, interpersonal problems, decline in academic performance and failure to complete education.. Co-morbid psychiat- ric disorders are also more common in adoles- cents who have substance use disorder as com- pared to their non- substance using counter-

parts and the substance using adult popula- tion.

Adolescence: A Transition Phase

Adolescence is one of the least understood phases of human development. It heralds bio- logical and psychological changes for the indi- vidual. Considered to begin usually from the 10th to 12th year of life, the period lasts till 18 years or up to 20 years as considered by some researchers.

Adolescence is associated with experimentation in the realms of social relationships, diet, rest/ activity cycles, ideas, dating, and roles. Even though for many teenagers drug use is just another form of experimentation, society still has a legitimate concern. The reason is that the residual number of children who do not spon- taneously stop but go on to have drug-using lifestyles is significant and growing.

Epidemiological Data-International

The incidence estimates based on data from the National Survey on Drug Use and Health (NSDUH), United States, show a period of increase for initiation of most drugs in 1990s (marijuana, cocaine, hallucinogen, prescription medication, tobacco). Some of the drugs have shown stabilization in incidence estimates thereafter (marijuana, prescription drugs) while others have shown a decrease in incidence (LSD, ecstasy, tobacco), although incidence may still be very high.

In 2001, an estimated 2.7 million Americans used cigarettes for the first time. About three quarters (76 percent) of these initiates were under age 18, and about half (51 percent) were

Mohan

males. In 2001, an estimated 5.3 million took alcohol for the first time. Most of these new alcohol users were under the legal drinking age of 21. There were an estimated 2.6 million new marijuana users and a million new cocaine us- ers in 2002. About two thirds (69 percent) of these new marijuana users were under age 18. The number of new inhalant users was about 1 million in 2002. As in prior years, these new users were predominately under age 18 (78 percent). New initiates of pain relieving medi- cation were 2.5 million. More than half (55 percent) of the new users in 2002 were females, and more than half (56 percent) were aged 18 or less.

Age of Initiation: Data indicates that three sub- stances were initiated by more than 50% of users in sixth grade or earlier. These “gateway drugs” were alcohol, tobacco, and inhalants.

EPIDEMIOLOGICAL DATA-INDIA

In India, adolescent drug use has been studied in the general population as well as special populations such as school and university stu- dents. Since most of the data is cross-sectional, it is not possible to discuss change in trends over time. Studies on substance use among adolescents were first carried out in 1970s. A multi- centred study on the prevalence and pattern of drug abuse among the university students concluded that alcohol was the most commonly used drug in both the sexes in all the centres (10- 15%), which was followed by tobacco (8- 15%) and tranquilizers (1- 2.5%). The study did not report any opiate and stimu- lant use (Mohan et al, 1976- 77). The survey was repeated after ten years and found similar figures of licit substance use although 0.02 to 0.04 % students reported heroin abuse, which had not been present in 1976. Another study on drug abuse among senior high school stu- dents in Delhi on a sample of 2032 students reported use of alcohol by 13%, tobacco by 6% and tranquilizers by 4%. There was no re- port of cannabis and opiate use (Mohan and Sundaram, 1977-78). More recent data from

reanalysis of the data from National Sample Survey Organization (1995-1996) gave figures based on a sample that is representative for the country. It reported current regular use of to- bacco by 8% males and 2% females in the age group of 10-20 years in the country. In the same age group alcohol use was reported by 1.3% females and 0.5% females respectively. The prevalence was comparatively higher in rural areas (Mohan et al, 2002). The National Household Survey (NHS) is the first survey in the country carried out specifically to provide figures of prevalence for drug use in the coun- try using a representative sample. In this sample, 21% of the respondents were 12 to 18 years old and 19% were students. It found that 21% of current users of alcohol, 3% of current users of cannabis and 0.1% current users of opiates were below 18 years of age and 10% opiate users and 2.5% of current alcohol and cannabis users were students (UNODC, 2004).

Drug Abuse Monitoring System (DAMS) pro- vided data from treatment seekers from 203 centres providing services to drug users in In- dia. It reported that 0.4% of treatment seekers in de-addiction centres in various states were less than 15 years of age and 4.6% of the sub- stance users were between 16-20 years of age. Among users of heroin, cannabis and propoxyphene, 0.5 to 0.8% were in the age group below 15 years. The proportion of opium and alcohol users in this age group was com- paratively low. The proportion of users of vari- ous drugs belonging to the age group 16-20 years varied between 2.7 and 18.8 percent. The percentage of users of propoxyphene was the highest. Adolescent treatment seekers were more often users of propoxyphene, heroin and cannabis. There was a regional variation in the drug of use. Adolescent propoxyphene users were mostly from Mizoram and Manipur; heroin users were more often reported from Punjab, Haryana, Bihar and Orissa and Chandigarh had the highest proportion of young cannabis users. Some data on drug use

Adolescent Substance Abuse

was also reported from 11 NGOs catering to children and 30 Nehru Yuva Kendras (NYKs). Most of the children from NGOs reported being introduced to drugs at a young age (be- low 15 years) and injecting drug use was quite common by them (13.8% in NGO-children and 20.1% in NYKs). Only 20% had tried to give up drug use in the past. High-risk sexual behaviour was reported by 5% (NYKs) to19% (NGO-children). The Rapid Assessment Sur- vey (RAS) provided data on inaccessible drug users in the community using a purposive sample. About 13% of substance users from this sample were below 20 years of age.

A study of profile of 52 subjects seen in the Drug Dependence Treatment Centre of AIIMS in the year 1999-2003 (Malhotra, personal communication) and 21 subjects seen in 2004 and 2005 (Dhawan, personal communication) found that all were male in the age range of 13-18 years with most initiating substance use at or below 15 years of age. About half of them were currently neither studying nor working, while some were students. They were living with the family and many of them were ac- companied to the treatment centre by family members. Family history of alcohol abuse or dependence was present in the fathers in one- third cases. History of conduct disorders was present in about one-fourth and 10% reported antisocial behaviour secondary to drug use as well as 10% had history of some legal prob- lems. Tobacco was the most commonly used substance with a lifetime use in 76.0% of ado- lescent treatment seekers. Lifetime use of Can- nabis and the inhalants were the second most common, (38% each) and 33.0% of the re- spondents had life time use of opioids. 29.0 % reported use of alcohol and 5.0% had used benzodiazepines and methaqualone each. Out of the treatment seekers, 29.0% did not meet the criteria for dependence but were in the cat- egory of drug abuse. Most common primary substance of use was inhalants (33.0%), fol- lowed by opioids (29%), tobacco (14%), can- nabis (10.0%), alcohol (5%), benzodiazepines

(5%) and methaqualone (5.0%).

Etiology

A number of behavioral characteristics and en- vironmental influences are associated with age of initiation of substance use, substance use intensity and the related negative consequences during adolescence. These risk factors deter- mine the risk of substance use. It has been shown that as the number of risk factors increases, the likelihood of adolescent substance use greatly increases. Early age of onset of drug use in- creases risk of drug related problems in future.

Behavioral characteristics- Impulsivity, Aggres- sion, Sensation seeking, Low harm Avoidance, Inability to delay gratification, Low achievement striving, Lack of religiosity, Psychopathology

Environmental factors include- peer pressure, absence of normative peers, affiliation with deviant or delinquent peers, easy drug avail- ability, social norms facilitating drug use, and relaxed laws and regulatory policies.

Familial factors include- stressful life events, deficient parental support or supervision, poor discipline, ambiguous parental attitude to- wards substance use, parental and sibling sub- stance use.

Co-morbidity

Psychiatric comorbidity is commonly seen in the substance using adolescents and is more than in the non-users. The largest subpopula- tion of adolescents with Substance Use Disor- der (SUD) includes those who are dually diag- nosed. A number of psychiatric disorders are commonly associated with SUD in youth. The most common are conduct (50 to 80%) and mood disorders, including major depression and bipolar disorder. The prevalence of depres- sive disorders ranges from 24% to 50%. Sui- cidal behavior, especially while being under the influence of the substance is commonly re- ported in adolescents following substance use or those diagnosed as SUD. Attention Deficit Hyperactivity Disorder (ADHD) is another

Adolescent Substance Abuse

disruptive disorder that is observed in substance abusing youth, however, this association is likely due to the high level of co morbidity between conduct disorder and ADHD. Anxiety disor- ders are another commonly diagnosed group of disorders in substance using adolescents with prevalence ranging from 7% to 40%. Social phobia usually precedes substance abuse while panic and generalized anxiety disorder more often follow the onset of SUD. Adolescents with SUD often have a history of Post Trau- matic Stress Disorder (PTSD) consequent to a history of physical or sexual abuse. Bulimia nervosa and gambling behavior are also com- monly found in adolescents having SUD. Sub- stance use disorders were seen in 26.6% of adolescents suffering from major depression. Cigarette smoking was seen in 16.6%, alcohol abuse in 6.6% and inhalant abuse in 3.3% of adolescents (Garg et al 2004 unpublished).

Management

a) Assessment

Assessment of the adolescents with substance use problems would include a detailed and comprehensive work up including the identi- fication of substance use, psychiatric status, physical health status, school adjustment, vo- cational status, family function, peer relation- ship, leisure and recreation activity, and legal situation. Assessment should include interviews with both the adolescent and the parents, first separately and then together.

There now exists several interview protocols for adolescents (or children) that address DSM- III criteria for mental disorders, including those for substance use disorder diagnoses. Some of the important interview schedules include the Diagnostic Interview Schedule for Children and Adolescents (Reich et al. 1982), the Kiddies Schedule for Affective Disorders and Schizo- phrenia (Chambers et al., in press), the Na- tional Institute of Mental Health Diagnostic Interview Schedule for Children (Costello et al. 1984), and the Child Assessment Schedule (Hodges et al. 1982). The other instruments

used in India are Achenbach’s behavioural checklist, Youth self reporting form, childhood psychopathology measurement schedule and developmental psychopathology schedule.

Other severity oriented rating scales available include Teen Addiction Severity Index (T- ASI), Adolescent Drug and Alcohol Diagnos- tic Assessment (ADAD) and Adolescent Prob- lem Severity Index (APSI). These scales help in quantifying the problem severity in adolescents.

b) Treatment

Compared to the adult literature, studies on treatment effectiveness in adolescent drug us- ers are limited although they do show clearly that some treatment is better than no treat- ment. However, there is considerable variabil- ity with respect to the effect of treatment. Pre- treatment characteristics of adolescents have not consistently been found to be associated with outcome except psychopathology, which is as- sociated with non-completion of treatment and relapse. The available literature suggests that the relapse rate is in the range of 35 to 85 per- cent among various treatment studies. Out- come predictors are time spent in treatment, staff characteristics, program environment, and treatment services.

Treatment setting (e.g., inpatient, residential treatment, and outpatient) is less important for outcome than the modality of treatment. Family therapy and cognitive-behavioral therapy have demonstrated enhanced clinical utility in the treatment of adolescents with SUD. The Multi-systemic Therapy (MST) model is a highly successful approach in which interventions simultaneously target family func- tioning and communication, school and peer functioning and adjustment in the community. Behavioral treatment, manual guided therapy (including drug refusal skills, problem-solving, and social skills), group treatment, role-play- ing are the available modalities of intervention. Brief therapy and contingency measures pro- vide the treating team effective and time bound interventions.

Adolescent Substance Abuse

It has been observed that the best predictors of specific post treatment outcomes are pretreat- ment measures of functioning (e.g. pretreat- ment alcohol problems predicted heavier con- sumption after treatment). Continued time in treatment, completion of treatment, and favor- able behavior during treatment are other posi- tive prognostic indicators of outcome. Low in- tensity of drug and solvent abuse has been found to be positive prognostic factors.

Pharmacotherapeutic agents like disulfiram, naltrexone, sedatives, clonidine are being used as an adjunct in the multidisciplinary approach for this specific group of substance users, al- though these interventions are still in their early stages. One should also be cautious while us- ing these agents in adolescents since the phar- macokinetic and pharmacodynamic profile of medications differs in certain aspects from the adult population. Adolescents are rapid metabolizers. Naltrexone has been shown to alter some endocrinal activity in adolescents. However, the issues related to medium and long term use remains unaddressed. The grow- ing use of medications will provide more in- formation regarding the efficacy and safety of these agents in adolescent population.

Family based approaches

Some believe that adolescent problems can best be understood by studying the characteristics of the family system. To reduce adolescent problems, family systems therapists attempt to change some of the above family characteris- tics through:

(a) gaining access and influence in the system,

(b) interrupting the reciprocal relationships between the dysfunctional family characteris- tics and the adolescent problems,

(c) establishing new family characteristics to interact with new adolescent behaviors and (d) home detoxification, probation, and the com- munity network approach.

Brief strategic family therapy is a structured

intervention based on the principle of this ap- proach and deals with individualized but well defined treatment goals specifically in the realm of family dynamics.

It seems very likely that parents will prove to be the most effective agents for changing the behavior of their preadolescent or adolescent children. Obtaining parent cooperation in any kind of intervention, and ensuring their com- pliance needs to be addressed in order to en- sure the effectiveness of the intervention programme.

The effects of treatment are not uniform. Sub- stantial variability is observed with respect to outcome status post-treatment.

Management of Co morbidity

The co morbid psychiatric conditions should be adequately managed. This would include a detailed assessment and a comprehensive man- agement plan keeping in mind the possibility of drug interactions between the various com- pounds and the increased potential of certain group of the drugs being abused by this popu- lation sub- group. There are several issues spe- cific to teenagers that need attention in prescrib- ing psychotropic drugs. One of these is the ad- ditive effects of marijuana and tricyclic antide- pressants on heart rate. There is a question of neuroleptic impairment of cognition due to se- dation. There are reports that chlorpromazine administered for over 6 months reduces plasma testosterone and luteinizing hormone response to luteinizing releasing hormone in adolescents.

These issues need to be kept in mind while formulating a plan for the adolescents using substances.

Prevention

Efforts for preventive services concentrate on activities designed for supply/demand reduc- tion. The goal of primary prevention among children and adolescents is to defer or mini- mize the risk of initiation of gateway-substances such as cigarettes, alcohol, and marijuana (can-

Adolescent Substance Abuse

nabis). The strategy used is to increase knowl- edge of the consequences of drug use. Psychoso- cially based approach aiming at enhancing so- cial skills and specific drug refusal skills is an important adjunct. The first step in this regard includes the identification of the potential ben- eficiaries and the intervention groups. They may include the general population or specific group based interventions like children of substance users. The programme developed for a particu- lar group must address the needs of the group and should have active participation of the local community to add to the acceptability and effi- cacy. These approaches should involve individu- als from various spheres of the society and may include the parents, teachers, community lead- ers and policy makers. Interventions aimed at imparting life skills training, counseling and providing newer opportunities to the adolescents so that their energy can be channelised in a

Suggested Reading

1.DrugAbuse:AnalysesofTreatmentResearchNIDA Research Monograph 77 (1988). Eds: Elizabeth R. Rahdert & John Grabowski.

2. Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions NIDA Research Monograph 156 (1995). Eds: Elizabeth Rahdert & Dorynne Czechowicz.

3. Brook, D. W., Brook, J. S., Zhang, C., Cohen, P., & Whiteman, M. (2002). Drug Use and the Risk of Ma- jor Depressive Disorder, Alcohol Dependence, and Sub- stance Use Disorders. Archives of General Psychiatry, 59, 1039-1044.

4. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D. & Cunningham, P. B. (1998). Multisystemic Treatment of Antisocial Behavior in Chil- dren and Adolescents. New York: Guilford Publications.

5. McGillicuddy, N.B., Rychtarik, R.G., Duquette, J.A., & Morsheimer, E.T. (2001). Development of a skill train-

proper direction should be included as apart of the broader strategy.

Future Research

Gaps in our knowledge persist despite the emer- gence of more and more information on the number of unanswered questions. The future research must concentrate on these issues for better understanding of the problem. The va- lidity of adult criteria for adolescents needs to be studied. In India, studies on prevalence of drug use in school children are required. Data to document trends or change in prevalence is also required. Studies to validate the instruments in local languages are needed. Manuals on in- terventions need to be developed for used in drug abuse treatment settings. Further research is needed to evaluate the efficacy of various in- terventions in adolescent populations.

ingprogramforparentsofsubstance-abusingadolescents. Journal of Substance Abuse Treatment, 20(1), 59.

6. Bastiaens, L., Francis, G., & Lewis, K. (1999). The RAFFT as a screening tool for adolescent substance use disorders. American Journal on Addictions, 9(1), 10-16.

7. Martino, S., Grilo, C.M., & Fehon, D.C. (2000). The development of the drug abuse screening test for adolescents (DAST-A). Addictive Behaviors, 25,57-70.

8. Estroff, T.W. (2001). Manual of adolescent substance abuse treatment. Washington, D.C.: American Psychi- atric Press.

9. Winters, K. (1999). Treatment of adolescents with sub- stance abuse. Rockville, MD: U.S. Department of Health and Human Services.

10. Garg, R., Mehta, M., Sagar, R. (2004 unpublished). Clinical study of psychosocial factors and comorbidity in Major Depressive Disorder in adolescents

Adolescent Substance Abuse

Suggested slides for OHP

Slide 1. ADOLESCENCE: A TRASITION PHASE

Relatively less understood phases of human develop- ment
Presence of both biological and psychological changes Tendency to experiment in various realms of life Emotional and physical stressors of transition

New responsibilities and new opportunities

Slide 2. EPIDEMIOLOGICAL DATA

Role of gateway drugs
Age of initiation in a substantial proportion of substance users
Community based surveys- 3- 10% lifetime prevalence National Household Survey (NHS)-20% users less than 18 years old

Slide 3. AETIOLOGY

Behavioral characteristics- Impulsivity, Aggression, Sen- sation seeking, Low harm Avoidance, Inability to delay gratification, Low achievement striving, Lack of religios- ity, Psychopathology

Environmental factors include- peer pressure, absence of normative peers, affiliation with deviant or delinquent peers, perception of high drug availability, social norms facilitating drug use, and relaxed laws and regulatory policies. Familial factors include- stressful life events, deficient parental support or supervision, poor disci- pline practices, ambiguous parental attitude towards substance use, parental and sibling substance use.

Slide 4. NOSOSLOGICAL STATUS

ICD- 10 classificatory system Harmful use

Dependent use
DSM IV classificatory system

Abuse

Dependent use
Criteria for adult population being used for adolescents

Slide 5. CO MORBIDITY

Conduct disorder Mood disorders

Major depression Bipolar disorder Dysthymia in adulthood

Anxiety disorders Social phobia

Panic disorder
Generalized anxiety disorder
Post Traumatic Stress Disorder (PTSD)

Bulimia nervosa Gambling behavior

Slide 6. ASSESSMENT

Identification of substance use Psychiatric status
Physical health status
School adjustment

Vocational status
Family function
Peer relationship
Leisure and recreation activity
Legal situation depending on the need

Slide 7. TREATMENT

Treatment setting Inpatient

Residential treatment

Outpatient Modality of treatment

Family therapy
Cognitive-behavioral therapy
The Multi-systemic Therapy (MST) Behavioral therapy
Manual guided therapy Group treatment Brief therapy
Contingency measures

Adolescent Substance Abuse

Legal Aspects of Drug Abuse in India

S Lalwani, TD Dogra

CURRENT LEGISLATIVE CONTROL

Drug abuse is a major public health problem with extensive legal ramifications. In India, le- gal aspects of drug abuse involves two main areas,

(a) Licensing laws regulating production and retail supply,

(b) Legislation for offences committed under intoxication circumstances

THE DRUGS AND COSMETICS ACT, 1940–

This enactment was legislated to regulate the import, manufacture, distribution and sale of drugs and cosmetics. The act contains two schedules. The first deals with Ayurvedic and Siddha systems of drugs and second schedule deals with standards to be complied with im- ported drugs and drugs manufactured for sale, sold and stocked and exhibited for sale or dis- tributed.

The act improvised the constitution of

1. Drugs Technical Advisory Board, to advise the Central and State Government on techni- cal matters arising out of administration of this act,

2. Central Drugs Laboratory and its functions along with prescribing the procedure of submission of samples of drugs for analysis or test, forms of laboratory report and fees payable in respect of such reports and

3. Drugs Consultative Committee to advise the Central and State Government and Drug

Technical Advisory Board on any matter tending to secure uniformity throughout in the administration of this act.

The quality and purity of drugs are the main objectives of the act. Standard of quality of drug is to be maintained. This act prohibits import, manufacture and sale of certain drugs which is not of standard quality, misbranded and spu- rious drugs, propriety medicines lacking list of ingredients including quantity or formula on label and drugs which claims to cure or miti- gate any such disease or ailments. This act also empowers Central Government to prohibit import of drugs which are likely to involve any risk to human beings or animals and drugs which are of no therapeutic value in public in- terest. This act provides stringent punishment for contravention of provisions of act and rules made thereof.

THE NARCOTIC DRUGS AND PSYCHO- TROPIC SUBSTANCES (NDPS) ACT, 1985-

This act consolidates and amends the existing laws related to narcotic drugs. Stringent provi- sions are made for the control and regulation of operations relating to narcotic drugs and psychotropic substances and for matters con- nected therewith. The act empowers Central government to take measures for preventing and combating abuse of and illicit traffic of nar- cotic drugs etc. Salient features of this act are as under

1. Some of the important definitions under this act includes

1. “Addict” as a person who has dependence on any narcotic drugs or psychotropic substance.

2. “Narcotic drug” as coca leaf, cannabis (hemp), opium, poppy straw and in- cludes all manufactured goods and

3. “Psychotropic substance” as any sub- stance, natural or synthetic, or any natu- ral material or any salt or preparation of such substance or material included in the list of psychotropic substances (n=110).

4. “Cannabis (hemp)” means-
(a) charas, that is the separated resin, in whatever form, whether crude or puri- fied, obtained from the cannabis plant and also includes concentrated prepara- tion and resin known as Hashish oil or liquid Hashish
(b) ganja, that is the flowering or fruit- ing top of the cannabis plant

5. ‘Coca derivatives’ means-
(a) Crude cocaine (Any extract of cocaine leaf )
(b) Ecgonine and all the derivatives of ecgonine from which it can be recovered. (c) All preparations containing more that 0.1% of cocaine

6. ‘Opium’ means
(a) the coagulated juice of opium poppy; and
(b) any mixture, with or without any neutral material, of the coagulated juice of the opium poppy.
It does not include any preparation con- taining more than 0.2% of morphine.

7. ‘Opium derivatives’ means-
(a) Medicinal opium
(b) Prepared opium used for smoking (c) Diacetylmorphine or heroin
(d) any preparation containing more than 0.2% of morphine

(e) Phenanthrene alkaloids- Morphine,

codeine, thebaine and their salts

2. Central Government may, constitute a fund to be called the National Fund for Control of Drug Abuse which shall be applied to meet the expenditure incurred in connec-
tion with the measures taken for-

3. a) Combating illicit traffic in narcotic drugs, psychotropic substances or con- trolled substances, b) controlling the abuse of narcotic drugs and psychotropic sub- stances, c) identifying, treating and reha- bilitating addicts d) preventing drug abuse, e) educating public against drug abuse and f) supplying drugs to addicts where such supply is medical necessity.

4. This act prohibits cultivation of any coca plant, opium plant or any cannabis plant or gather any portion of coca plant or pro- duce, manufacture, possess, sell, purchase, transport, warehouse, use, consume, import inter-State, export inter State, import into India, export from India or transship any narcotic drug or psychotropic substance except for medical or scientific purposes and in manner and to the extent provided by the provisions of this act

5. The act empowers Central Government to permit and regulate by rules i) The culti- vation, or gathering of any portion of coca plant, or the production, possession, sale, purchase, transport, import inter-State, ex- port inter-State, use or consumption of coca leaves; ii) the cultivation of opium poppy; iii) the production and manufacture of opium and production of poppy straw; iv) the sale of opium and opium derivatives from the Central Government Factories for export from India or sale to State Govern- ment or manufacturing chemists v) the manufacture of manufactured drugs, not including manufacture of medicinal opium or any other preparation containing manu-

Legal Aspects of Drug Abuse in India

factured drug from materials which the maker is lawfully entitled to possess; vi) the manufacture, possession, transport, import inter-State, export inter-State, sale pur- chase, consumption or use of psychotropic substances and vii) the import into India and export from India and transhipment of narcotic drugs and psychotropic sub- stances.

6. The State Government may by rules per- mit and regulate i) the possession, sale, warehousing, purchase, transport, import inter-State, export inter-State, use and con- sumption of poppy straw; ii) the posses- sion, transport, import inter-State, export inter-State, purchase and consumption of opium iii) the cultivation of canabis plant, production , manufacture, possession, transport, import inter-State, export inter- State, sale, purchase and consumption of cannabis(Except Charas); iv) The manufac- ture of medicinal opium or any prepara- tion containing the manufactured drug from materials which the maker is lawfully entitled to process; (v) the production and manufacture of opium and production of poppy straw; iv) the sale of opium and opium derivatives from the Central Gov- ernment Factories for export from India or sale to State Government or manufactur- ing chemists v) the possession, transport, import inter-State, export inter-State, pur- chase, use or consumption of manufactured drugs other than prepared opium and of coca leaf and any preparation containing any manufactured drugs. vi) the manufac- ture and possession, of prepared opium from opium lawfully possessed by an addict reg- istered with the State Government on medical advice for his personal consump- tion.

7. Punishment for contravention involving small quantity in relation to poppy straw,

prepared opium, cannabis plant & can- nabis, manufactured drugs & preparations, psychotropic substances, and for illegal import into India, export from India or transhipment of narcotic drugs and psy- chotropic substances, is rigorous imprison- ment for a term up to six months or with fine up to 10,000 rupees or both. For con- travention involving quantity lesser than commercial quantity but greater than small quantity, punishment is rigorous impris- onment for a term up to ten years and with fine up to 1,00,000 rupees. For contraven- tion involving commercial quantity pun- ishment is rigorous imprisonment for a term up to ten years, which may extend up to 20 years and fine up to 1,00,000 rupees, which can be extended up to 2,00,000 rupees. Court has to record rea- sons in the judgement, for imposing a fine exceeding 2,00,000 rupees. Punishment for cultivation of any cannabis plant is rigor- ous imprisonment up to ten years and also fine up to 1,00,000 rupees.

8. Punishment for contravention in relation to coca plant and coca leaves is rigorous imprisonment for a term up to ten years or fine up to 1.00,000 rupees .

9. Punishment for contravention in relation to opium poppy and poppy involving small quantity, is rigorous imprisonment for a term up to six months or with fine up to 10,000 rupees or both. For contravention involving commercial quantity punishment is rigorous imprisonment for a term up to ten years, which may extend up to 20 years and fine up to 1,00,000 rupees, which can be extended up to 2,00,000 rupees. Court has to record reasons in the judgement, for imposing a fine exceeding 2,00,000 rupees. In any other case, the punishment is rig- orous imprisonment up to ten years and fine up to 1,00,000 rupees

Legal Aspects of Drug Abuse in India

10. Punishment for consumption of any nar- cotic drug or psychotropic substance like cocaine, morphine, diacetyl-morphine or any other narcotic drug or any psychotro- pic substance specified by Central Govern- ment by Gazette Notification is rigorous imprisonment for a term up to one year or fine up to 20,000 rupees or both. Punish- ment for consumption of any narcotic drug or psychotropic substance other than men- tioned is rigorous imprisonment for a term up to six months or fine up to 10,000 ru- pees or both. For second and each subse- quent offence, punishment is rigorous im- prisonment for a term, which may extend to one half of the maximum term of im- prisonment and also fine up to one half of the maximum amount of fine. If person is liable to punished with a minimum term of imprisonment and minimum amount of fine, the minimum punishment for such a person will be one half of the minimum term of imprisonment and one half of the minimum amount of fine.

11. Under section 31 A, Chapter IV of this act, (1) If any person who has been convicted for offences punishable under section 19( punishment for embezzlement of opium cultivator), section 24 (Punishment for ex- ternal dealings(outside India) of narcotic drugs and psychotropic substances), sec- tion 27 A(Punishment for financing illicit traffic and harbouring offenders) and for offences involving commercial quantity of any narcotic drugs or psychotropic sub- stance, is subsequently convicted of the commission of, or attempt to commit, or abetment of, or criminal conspiracy to com- mit an offence relating to a) engaged in the production, manufacture, possession, trans- portation, import to India, export from India or transhipment, of the narcotic drugs or psychotropic substances and quantity

exceeding to those specified in the clause b) financing directly or indirectly or any of the activities specified in clause (a), shall be punishable with death, (2) where any person convicted by a competent court of criminal jurisdiction outside India under any law corresponding to the provisions of subsection 1, such person in respect of such conviction shall be dealt with for the pur- pose of sub section 1 as if he has been con- victed by a court in India.

12.Under section 64 A, any addict, who is charged with an offence punishable under section 27 or with offences involving small quantity of narcotic drugs or psychotropic substances, who voluntarily seeks to un- dergo medical treatment for de-addiction from a hospital or an institution maintained or recognized by the Government or a lo- cal authority and undergoes such treatment shall not be liable to prosecution under section 27 or any other section for offences involving small quantity of narcotic drugs and psychotropic substances. This immu- nity may be withdrawn if the addict does not undergo the complete treatment for de- addiction.

13.Section 71 of this act, empowers govern- ment to establish centers for identification, treatment, education, after care, rehabili- tation, social reintegration of addicts and for supply, of any narcotic drugs and psy- chotropic substance (as prescribed by con- cerned Government) to the addicts regis- tered with government and to others where such supply is a medical necessity.

14. Small quantity of drugs defined under this act are

Hashish or Charas- 5gm Opium-5gm
Cocaine-125mg
Ganja-500gm
Heroin/Smack/Brown Sugar-250mg.

Legal Aspects of Drug Abuse in India

THE DRUGS (CONTROL) ACT, 1950 –

This act provide for the control of the sale, sup- ply and distribution of drugs. This act regu- lates maximum prices and maximum quanti- ties which may be held or sold and also involve restrictions on sale of drugs. The act provides limitation on quantity which may be possessed at any one time. Issue of cash memorandum on certain sales marking of prices and exhibit- ing list of prices and stocks is mandatory un- der this act. Whoever contravenes any of the provisions of this Act or fails to comply with any direction made under authority conferred by this Act shall be punishable with imprison- ment for a term which may extend to three years, or with fine, or with both.

LAWS PERTAINING TO CRIMINAL OF- FENCES & DRUG ABUSE

The nature of association between drug use and crime is complex. Besides commonest offences such as possession and trafficking and ‘drug related crime’ or ‘street crime’ an offence may be committed during an abnormal mental state related to drug use. However, most drugs of abuse do not cause violent criminal behavior, and personality, circumstances and cultural background remain critical determinants.

As per section 85 of Indian Penal Code, “Noth- ing is an offence which is done by a person who, at the time of doing it, is, by reason of intoxication, incapable of knowing the nature of the act, or that he is doing what is either wrong, or contrary to law; provided that the thing which intoxicated him was administered to him without his knowledge or against his will.

Under Section 86 of Indian Penal Code, In cases where act done is not an offence unless done with a particular knowledge or intent, a per- son who does the act in a state of intoxication shall be liable to be dealt with as if he had the

same knowledge as he would have had if he had not been intoxicated, unless the thing which intoxicated him was administered to him without his knowledge or against his will.

However, if the intoxication is induced volun- tarily, the act done is an offence even if the person is incapable of knowing the nature of the act or that what he is doing is either wrong or contrary to law.

LAWS RELATED TO ALCOHOL

Alcohol is one of the commonly consumed in- toxicating substances all over the world. Legal aspects of alcohol involves three main areas, (a) Licensing laws regulating retail supply, (b) leg- islation on drunkenness defining intoxication as an offence under certain circumstances and (c) road traffic legislation makes driving an of- fence when blood alcohol level exceeds a cer- tain value.

LICENSING LAWS

‘World Health Organization’ recommends that member governments should begin to reduce per capita consumption by reducing the avail- ability of alcoholic beverages. Prohibition is incorporated in the Constitution of India among the directive principles of state policy. Article 47 says: “The state shall regard the rais- ing of the level of nutrition and standard of living of its people as among its primary duties and in particular, the state shall endeavor to bring about prohibition of the use except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health.” Alco- hol policy is under the legislative power of in- dividual states. Prohibition, enshrined as an aspiration in the Constitution, was introduced and then withdrawn in Haryana and Andhra Pradesh in the midi-1990s, although it con- tinues in Gujarat, with partial restrictions in other states – Delhi, for example, has dry days. There was an earlier failure of prohibition in Tamil Nadu.

Legal Aspects of Drug Abuse in India

Excise department regulate and control the sale of liquor in the NCT of Delhi. Retail supply of alcohol is regulated by Delhi Liquor License Rules, 1976. It prohibits consumption and service of liquor at public places. This also pro- hibits employment to any person (male under the age of 25 years or any female) at any li- censed premises either with or without remu- neration in part of such premises in which li- quor or intoxicating drug is consumed by the public. Similarly no individual should possess liquor at one time more than the prescribed limit without special permit. As per excise rules in Rajasthan, a person can posses maximum 3liters of Country Liquor, 6 Liter of IMFL and 12 Bottles of Beer.

The Bombay Prohibition Act, 1949, prohib- its the production, manufacture, possession, exportation, importation, transportation, pur- chase, sale, consumption and use of all intoxi- cants.

The Cable Television Network (Regulation) Amendment Bill, in force September 8, 2000, completely prohibits cigarette and alcohol ad- vertisements. The government controlled chan- nel, Doordarshan, does not broadcast such advertisements but satellite channels however are replete with them.

Drunkenness

Drunkenness is defined as the condition pro- duced in a person who has taken alcohol in a quantity sufficient to cause him to lose control of his faculties to such an extent that he is un- able to execute the occupation on which he is engaged at the material time.

Section 84 of the Bombay Prohibition Act 1949 provides that any person, who is found drunk or drinking in a common drinking house or is found there present for the purpose of drinking, shall on conviction, be punished with fine which may extend to five hundred rupees.

Section 85 provides that any person found drunk and incapable of controlling himself or behaves in a disorderly manner under the in- fluence of drink in any street or thoroughfare or public place or in any place to which public have or permitted to have access, shall on con- viction, be punished with imprisonment for a term which may extend to one to three months and with fine which may extend to two hun- dred to five hundred rupees.

Drunken Driving

Across the world, governments have defined different acceptable blood alcohol levels. How- ever, there is no minimum threshold below which alcohol can be consumed without risk. With rise in blood alcohol concentration, there is progressive loss of driving ability due to in- creased reaction time, over confidence, im- paired concentration, degraded muscle coor- dination and decreased visual and auditory acu- ity. Though the laws to check the drunken driv- ing do exist in India but there is need to effec- tively impose the same on the alcohol impaired drivers.

As per section 185 (Chapter XIII) of the Mo- tor Vehicle Act(India) 1988, as amended in November 1994, driving by a drunken person or by a person under the influence of drugs.- Whoever, while driving, or attempting to drive, a motor vehicle,-

(a) has, in his blood, alcohol exceeding 30 mg per 100 ml of blood detected in a test by a breath analyser, or

(b) is under the influence of a drug to such an extent as to be incapable of exercising proper control over the vehicle,

shall be punishable for the first offence with imprisonment for a term which may extend to six months, or with fine which may extend to two thousand rupees, or with both; and for a

Legal Aspects of Drug Abuse in India

second or subsequent offence, if committed within three years of the commission of the previous similar offence, with imprisonment for a term which may extend to two years, or with fine which may extend to three thousand ru- pees, or with both.

LAWS PERTAINING TO TOBACCO AND SMOKING

1. The cigarettes and other Tobacco products (Prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) act, 2003- It has been uni- versally regarded that tobacco is one of the major public health hazards. The previously existing legislation, The Cigarettes Act, 1975, merely stipulates the statutory warning on ciga- rette packets. The 39th World Health assem- bly in its fourteenth plenary meeting on 15th May 1986 urged the member states to imple- ment the measures to ensure that effective pro- tection is provided to non smokers from invol- untary exposure to tobacco smoke and to pro- tection of children and young people from be- ing addicted to use of tobacco. Similarly in 43rd World Health assembly in its fourteenth Ple- nary meeting on 17th May 1990 urged mem- ber states to consider their tobacco control strat- egies plans for legislation and other effective measures for protecting their citizens with spe- cial attention to risk groups such as pregnant women and children from involuntary expo- sure to tobacco smoke, discourage the use of tobacco and impose progressive restrictions and take concerted action to eventually eliminate all direct and indirect advertising, promotion and sponsorship concerning tobacco.

To prohibit the consumption of cigarettes and other tobacco products which are injurious to health and in view of article 47 of the consti- tution of India for protection of public health, The cigarettes and other Tobacco products (Pro- hibition of advertisement and regulation of

trade and commerce, production, supply and distribution) act, 2003 came into existence on 18th May 2003, which extends to whole of India. As per this act

1. Smoking in public places is prohibited. “Public places means any place in which the public have access and includes auditoria, hospital buildings, railway wait- ing room, amusement centers, restaurants, public offices court buildings, educational institutions, libraries, public conveyance and the like which are visited by general public but does not include any open apace.”

2. No person engaged in the production, sup- ply or distribution of cigarettes or any other tobacco products is allowed to advertise and no person is allowed to take part in any advertisement which directly or indirectly suggests or promotes the use or consump- tion of cigarettes or any other tobacco prod- ucts.

3. No person shall sell, offer for sale, or per- mit sale of, cigarette or any other tobacco product-(a) to any person who is under eighteen years of age and (b) in an area within radius of 100 yards of any educa- tional institution.

4. No person is allowed, directly or indirectly to produce, supply or distribute cigarettes or any other tobacco products unless every package of cigarettes or any other tobacco products bears thereon, or on its label, the specified warning including a pictorial de- piction of skull and cross bones and the prescribed warning.

5. For the purpose of testing nicotine and tar contents in cigarettes and any other tobacco products the Central Government shall by notification in the official gazette grant rec- ognition to such testing laboratory as the Government may deem necessary.

Legal Aspects of Drug Abuse in India

6. Any person who produces or manufactures cigarettes or tobacco products, which do not contain, either on the package or on their label, the specified warning and the nicotine and tar contents, shall in the case of first conviction be punishable with im- prisonment up to two years, or with fine up to five thousand rupees, or with both, second and subsequent conviction is pun- ishable with imprisonment up to five years and with fine up to ten thousand rupees.

7. Punishment for smoking in public place is fine up to two hundred rupees and it is a compoundable offence.

8. Whoever violates the Section of prohibition of advertisement of cigarettes and other tobacco products, shall be punished (1) in the case of first conviction, with imprison- ment up to two years, or with fine up to one thousand rupees, or with both, and (2) in the case of second and subsequent con- viction, with imprisonment up to five years and with fine up to five thousand rupees.

9. Punishment for sale of cigarettes or any other tobacco products in certain places or to persons below the age of eighteen years is fine up to two hundred rupees. All of- fences under this section are compound- able and are to be tried summarily.

This act empowers central Government to make rules to carry out provisions of this act called “The cigarettes and other Tobacco products (Prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) Rules, 2004. According to these rules

1. The owner or the manager or in charge of the affairs of a public place shall cause to be displayed prominently a board, of a minimum size of 60cmx30cm in the In- dian languages(s) as applicable, at least one

at the entrance of the public place and one at conspicuous place(s) inside, containing the warning “No Smoking area-Smoking here is an offence”.

2. The owner or the manager or in charge of the affairs of a hotel having thirty rooms or restaurant having seating capacity of thirty persons or more and the manager of the air port shall ensure that (i) the smoking and nonsmoking areas are physically segregated;(ii) the smoking area shall be located in such manner that the public is not required to pass through it in order to reach the nonsmoking area and (iii) each area shall contain boards indicating “Smok- ing Area/Non-Smoking Area”.

3. The size of board used for advertisements for cigarettes and any other tobacco prod- ucts displayed at the entrance or inside a warehouse or a shop where cigarettes and any other such tobacco products are offered for distribution or sale shall not exceed 90 cm x 60cm and number of such board shall not exceed two. Each board shall contain in the Indian language as applicable, one of the following warnings occupying 255 of the top area of the board namely (I) To- bacco causes cancer or (ii) Tobacco Kills,. Board shall contain the brand name or pic- ture of tobacco product and no other pro- motional message and picture.

4. The owner or the manager or the in-charge of the affairs of a place where cigarettes and other tobacco products are sold shall dis- play a board of minimum size of 60cmx 30cm at conspicuous place(s) containing the warning “Sale of tobacco products to a person under the age of eighteen years is a punishable offence”, in Indian language(s) as applicable. The onus of the proof that the buyer is not a minor lies with the seller of the tobacco products.

Legal Aspects of Drug Abuse in India

2. The Delhi Prohibition of smoking and non-smokers health protection act 1996- prohibits smoking in places of public work or use and in service vehicles in National capital territory of Delhi. “Place of public work or use” means a place such as auditoria, hospital buildings, health institutions, amusement centers, restaurants, public of- fices, court buildings, educational institu- tions, libraries and the like which are vis- ited by general public but does not include any open place and Banquet halls, monu- ments and stadia (Closed area only), cinema halls, hotels and restaurants (Provided there is separate place for smokers and nonsmok- ers in hotels and restaurants). “Public Ser- vice vehicle” means any motor vehicle used or adapted to be used for the carriage of pas- sengers for hire or reward, and includes the maxicab, a motor cab, contract carriage and stage carriage (Under Section 2 of Section 35 of Motor Vehicles Act, 1988). This acts also prohibits advertisement, sale to minors and storage and distribution (in the vicinity

Suggested Reading

1. Gunn J, Taylor PJ, eds. Forensic Psychiatry- Clini- cal, Legal and Ethical issues. Butterworth- Heinemann, Oxford 1999, 435-480.

2. Drugs and Cosmetcis Act with Rules. Universal Law Publishing Company Pvt. Ltd., Delhi, 2005

3. The Narcotic Drugs and Psychotropic Substances Act, 1985, Universal Law Publishing Company Pvt. Ltd., Delhi, 2005

4. The cigarettes and other Tobacco products (Prohi- bition of advertisement and regulation of trade and commerce, production, supply and distribution)

of educational institutions-Within 100 meters)) of cigarettes and beedis etc.

Punishment for smoking in place of public work or use and in public service vehicles is punishable with fine up to 100 rupees and in subsequent offence, with fine up to 200 ru- pees, but may extend up to 500 rupees. Pun- ishment for advertising, selling cigarettes etc to minors and distributing it in the vicinity of educational institutions is fine up to 500 ru- pees and with subsequent offences imprison- ment up to three months, or fine minimum up to 500 rupees but may extend up to 1000 rupees or both.

3. The Cable Television Networks (Amend- ment) Act, 2000– prohibits direct and indi- rect tobacco advertising on Cable Channels.

4. As per the bill passed by Parliament of In- dia, from 2ndOctober 2005, exhibition of smoking in cinemas has been prohibited by the Government.

Legal Aspects of Drug Abuse in India

act, 2003 Universal Law Publishing Company Pvt. Ltd., Delhi, 2005.

5. The Delhi Prohibition of smoking and non-smok- ers health protection act 1996- Universal Law Pub- lishing Company Pvt. Ltd., Delhi, 2005.

6. Subramanyam BV, ed. Modi’s Medical Jurisprundence and Toxicology. Butterworths In- dia, New Delhi, 317-319, 1999.

7. Reddy KSN. The essentials of Forensic Medicine & Toxicology, 19th ed. 2000, K.Saguna Devi Pub- lication, Hyderabad.

Appendix 1:

Suggested Performa for Clinical Assessment in Substance Use Disorder

A. Sociodemographic profile

Name, age, sex, marital status, qualification, occupation, type of family and place of resi- dence.

B.Details of drug use

1. Age of initiation

2. Various drugs abused

3. Frequency of drugs used

4. The quantity of drug taken usually (usual dose)

5. The time lag since the dose last used (last dose)

6. Whether need to increase the quantity of drug consumed in order to produce the same effect (tolerance)

7. The effect of the use of a particular drug and signs and symptoms of intoxication

8. Presence/ absence of physiological/psycho- logical symptoms and signs when the par- ticular drug is not taken/ less than the usual amount of drug is being taken (withdrawls)

9. Compelling need/ urge to take the sub- stance

C. Complications associated with drug use

1. Physical: long term health hazards associ- ated with drug use

2. Psychological: chronic mental effects of con- tinuous use of drug

3. Financial: losses suffered/debts incurred

4. Occupational: frequent absenteeism at work, constant change of job, memos is- sued, periods of unemployment

5. Familial – social: frequent fight with spouse/ other family members, neglect of responsi- bility at home, social outcast

6. Legal: involvement in illegal activities to sustain drug use, arrests/ charges on ac- count of drug use, caught driving under intoxicated state, drinking brawl.

D. High risk behaviors: presence of injection use/ unsafe sexual practices

1) injection risk: sharing of needles/ sharing syringes/ water used for rinsing; reuse of needles, syringes, unhealthy practice of in- jecting

2) sexual risk: contact with commercial sex workers, unprotected sexual intercourse

E. Past abstinence attempts:

1. number of attempts made

2. duration of each attempt

3. reason for abstinence

4. whether treatment sought

5. nature of treatment sought: pharmacologi- cal, psychological or combined

6. reason for relapse

F.Reason for seeking treatment and motivation level of individual: whether seeking treatment by self or brought forcibly by family member;

G. Presence of comorbid psychiatric illness such as affective disorder, psychotic disorder and personality disorder/ traits.

H. Presence of family history of SUD, psychi- atric illness, current living arrangements

I. Premorbid personality: especially presence/ absence of ASPD

J. Physical examination

Vital signs – Pulse, Blood pressure, Respi- ratory rate

Systemic examination – Cardiovascular, Res- piratory, Abdominal and Nervous system

K. Mental status examination

General appearance and behavior of the patient (dressing, grooming, mannerism, motor activ- ity, and eye contact); Affect (mood) (does he appear happy, sad, anxious? Is it sustained throughout the interview?); Speech (rate, vol- ume, pitch, coherence, relevance); The content of the patient’s thought (delusions, obsessions, depressive thought, suicidal ideas); Perceptual disturbances (illusions, hallucinations) and Cognitive functions of the patient.

Appendix 2

Fagerstrom’s Test for Nicotine Dependence

1. How soon after you wake up do you smoke your first cigarette?
After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Within 5 minutes (3)

2. Do you find it difficult to refrain from smoking in places where it is forbidden?
No (0) Yes (1)

3. Which cigarette would you hate most to give up?
The first in the morning (1) Any other (0)

4. How many cigarettes per day do you smoke?
10 or less (0) 11-20 (1) 21-30 (2)
31 or more (3)

5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?

No (0) Yes (1)

6. Do you smoke even if you are so ill that you are in bed most of the day?

No (0) Yes (1)

Interpretation of the scores –

• 0-2 –Very low dependence
• 3-4 – Low dependence
• 5 – Medium dependence
• 8-10 – Very high dependence

Heatherton TF, Kozlowski LT, Frecker RC et al. The Fagerstrom Test for Nicotine Dependence : a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 1991;86(9):119-127.

Appendix 3

CAGE

CAGE is a mnemonic for the following ques- tions:

1. Have you ever felt that you should cut down on your drinking?

2. Have people annoyed you by criticizing your drinking?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Interpretation of CAGE questions

Answering Yes to 2 questions – Strong Indica- tion for alcohol dependence

Answering Yes to 3 questions – Confirms alco- hol dependence

Mayfield D, McLoed G and Hall P. The CAGE Questionnaire : Validation of a new alcoholism instrument. American Journal of Psychiatry, 1974;131:1121-23.

Appendix 4

The Alcohol Use Disorders Identification Test

Read questions as written. Record answers care- fully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. Place the correct answer number in the box at the right.

1. How often do you have a drink containing alcohol?

(0) Never [Skip to Qs 9-10] (1) Monthly or less
(2) 2 to 4 times a month (3) 2 to 3 times a week

(4) 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9 (4) 10 or more

3. How often do you have six or more drinks on one occasion?

(0) Never
(1) Less than monthly (2) Monthly
(3) Weekly
(4) Daily or almost daily

4. How often during the last year have you found that you were not able to stop drink- ing once you had started?

(0) Never
(1) Less than monthly (2) Monthly
(3) Weekly
(4) Daily or almost daily

5. How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never
(1) Less than monthly (2) Monthly
(3) Weekly
(4) Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking ses- sion?

(0) Never
(1) Less than monthly (2) Monthly
(3) Weekly
(4) Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

(0) Never
(1) Less than monthly (2) Monthly

(3) Weekly
(4) Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never
(1) Less than monthly (2) Monthly
(3) Weekly
(4) Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?

(0) No
(2) Yes, but not in the last year (4) Yes, during the last year

10. Has a relative or friend or a doctor or an- other health worker been concerned about your drinking or suggested you cut down?

(0) No
(2) Yes, but not in the last year (4) Yes, during the last year

Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0

Interpretation of AUDIT scores:

Total scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. AU- DIT scores in the range of 8-15 represent a medium level of alcohol problems whereas scores of 16 and above represented a high level of alcohol problems.

Saunders JB, Aasland OG, Babor TF, DeLaFuente JR and Grant M. Development of the Alcohol Use Disorder Identifi- cation Test (AUDIT) : WHO collaborative project on early detection of persons with harmful alcohol consumption. Addiction, 1993;88:791-804.

Appendix 5

Michigan Alcohol Screening Test

Please answer YES or NO to the following questions:

1. Do you feel you are a normal drinker? (“nor- mal” – drink as much or less than most other people)
YES or NO

2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
YES or NO

3. Does any near relative or close friend ever worry or complain about your drinking?
YES or NO

4. Can you stop drinking without difficulty after one or two drinks?
YES or NO

5. Do you ever feel guilty about your drink- ing?
YES or NO

6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?
YES or NO

7. Have you ever gotten into physical fights when drinking?
YES or NO

8. Has drinking ever created problems between you and a near relative or close friend?

9. Has any family member or close friend gone to anyone for help about your drinking?

YES or NO

10. Have you ever lost friends because of your drinking?

YES or NO

11. Have you ever gotten into trouble at work because of drinking?

YES or NO

12. Have you ever lost a job because of drink- ing?

YES or NO

13. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?

YES or NO
14. Do you drink before noon fairly often?

YES or NO

15.Have you ever been told you have liver trouble such as cirrhosis?

YES or NO

16.After heavy drinking have you ever had delirium tremens (D.T.’s), severe shaking, visual or auditory (hearing) hallucinations?

YES or NO

17. Have you ever gone to anyone for help about your drinking?

YES or NO

18. Have you ever been hospitalized because of drinking?

YES or NO

19.Has your drinking ever resulted in your being hospitalized in a psychiatric ward?

YES or NO

20.Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?

YES or NO

21. Have you been arrested more than once for driving under the influence of alcohol?
YES or NO

22. Have you ever been arrested, even for a few hours because of other behavior while drinking?
(If Yes, how many times ________ ) YES or NO

Scoring

Please score one point if you answered the fol- lowing:

1. No
2. Yes
3. Yes
4. No
5. Yes
6. Yes
7 through 22: Yes

Interpretation of the scores:

0 – 2 No apparent problem
3 – 5 Early or middle problem drinker 6 or more Problem drinker

Selzer ML. The Michigan Alcoholism Screening Test : The quest for a new diagnostic instrument. American Journal of Psychiatry, 1971;127:1653-58.

Appendix 6

Drug Abuse Screening Test (DAST)

The following questions concern information about your involvement and abuse of drugs. Drug abuse refers to

(1) the use of prescribed or “over the counter” drugs in excess of the directions

(2) any non-medical use of drugs

The questions DO NOT include alcoholic beverages. The DAST does not include alco- hol use.

The questions refer to the past 12 months. Carefully read each statement and decide whether your answer is yes or no. Please give the best answer or the answer that is right most of the time. Click on the box for Yes or No.

1. Have you used drugs other than those re- quired for medical reasons?
Yes No

2. Have you abused prescription drugs?
Yes No

3. Do you abuse more than one drug at a
time?
Yes No

4. Can you get through the week without us-
ing drugs?
Yes No

5. Are you always able to stop using drugs
when you want to?
Yes No

6. Have you had “blackouts” or “flashbacks”
as a result of drug use? Yes No

7. Do you ever feel bad or guilty about your drug use?

Yes No
8. Does your spouse (or parents) ever com-

plain about your involvement with drugs?

Yes No
9. Has drug abuse created problems between

you and your spouse or your parents?

Yes No
10.Have you lost friends because of your use

11.

12.

1 3 .

of drugs? Yes No

Have you neglected your family because of your use of drugs?

Yes No
Have you been in trouble at work because

of your use of drugs?
Yes No
Have you lost a job because of drug abuse? Yes No

14.Have you gotten into fights when under the influence of drugs?

Yes No
15. Have you engaged in illegal activities in

order to obtain drugs?

Yes No
16.Have you been arrested for possession of

illegal drugs?

Yes No

17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes No

18. Have you had medical problems as a result
of your drug use (e.g., memory loss, hepa- titis, convulsions, bleeding, etc.)?
Yes No

19. Have you gone to anyone for help for a drug
problem?
Yes No

20. Have you been involved in a treatment pro-
gram especially related to drug use? Yes No

Interpretation of Scores

Skinner HA. The Drug Abuse Screening Test. Addictive Behaviours, 1982;7:363-71.

0
1 – 5 6-10 11-15 16-20

none reported low level moderate level substantial level severe level

Appendix 7

Reference for ‘Addiction Severity Index’ Scale: http://www.tresearch.org/resources/instruments/ASI_5th_Ed.pdf

Appendix 8

List of Drug De-addiction Centres

Central Institute/Hospitals

1. All India Institute of Medical Sciences, New Delhi

2. Dr.R.M.L.Hospital, New Delhi

Chandigarh Administration

22. Govt. Medical College, Chandigarh

Delhi

23. Central Jail, Tihar, New Delhi

24. Institute of Human Behaviour & Al- lied Sciences, Delhi

Gujarat

25. Medical College, Baroda
26. Medical College, Ahmedabad

Goa

27. Asilo Hospital, Mapusa (Goa)

Haryana

28. Medical College Rohtak 29. District Hospital, Ambala

Himachal Pradesh

30. Indira Gandhi Medical College, Shimla 31. District Hospital, Mandi
32. District Hospital, Dharamshala

Jammu & Kashmir

33. Medical College, Jammu 34. Medical College, Srinagar 35. District Hospital, Baramulla 36. District Hospital, Kathua

Karnataka

37. Govt. Medical College, Bangalore

Kerala

38. Govt. Medical College, Trivandrum

39. General Hospital, Erankulam

3. Lady Hardinge Medical College & Hospital, New Delhi

4. P.G.I.M.E.R., Chandigarh

5. J.I.P.M.E.R., Pondicherry

6. NIMHANS, Bangalore

Centres of Excellence (Funded by UNDCP)

7. K.E.M. Hospital, Bombay

8. I.P.G.M.E.R., Calcutta

Andhra Pradesh

9. Osmania General Hospital (Shifted to Institute of mental health, Hyderabad), Hyderabad

10. SVRRGG Hospital, Tirupati

11. Govt. General Hospital, Warangal

Assam

12. Guwahati Medical College, Guwahati

13. Assam Medical College, Dibrugarh

14. Silchar Medical College, Silchar

15. District Hospital, Johrat

16. Civil Hospital, Dhubri

17. Civil Hospital, Diphu

18. Civil Hospital, Tejpur

19. Civil Hospital, Karimganj

20. Civil Hospital, Nalbari

21. Civil Hospital, Nagaon

40. Medical Collge, Kottayam

41. Medical Collge, Kozhikode

42. Medical College, Trissur

43. Academy of medical Pariyaram, Kannur, Kerala

Madhya Pradesh

Sciences,

67. District Hospital, Saiha
68. District Hospital, Champhai 69. District Hospital, Serchhip 70. District Hospital, Lawngtlai

Nagaland

71. Naga Hospital, Kohima

72. District Hospital, Mukokchung

73. District Hospital, Tuensang

74. Civil Hospital, Dimapur

75. Civil Hospital, Wokha

76. Civil Hospital, Mon

77. District Hospital, Zunheboto

78. District Hospital, Phek

Orissa

79. S.C.B.Medical College, Cuttack

Pondicherry

80. General Hospital, Karaikal
81. Govt. General Hospital, Pondicherry

Punjab

82. Medical College, Patiala 83. Medical College, Amritsar 84. District Hospital, Bhatinda 85. Medical College, Faridkot

Rajasthan

86. SMS Medical College, Jaipur 87. Medical College, Udaipur 88. Medical College, Jodhpur 89. Medical College, Kota

90. Medical College, Ajmer 91. Medical College, Bikaner

Sikkim

92. STNM Hospital, Gangtok

93. District Hospital, Namchi

94. District Hospital, Gyalshing (W.Sikkim)

44. District Hospital, Mandsaur 45. District Hospital, Ratlam 46. District Hospital, Ujjain 47. District Hospital, Indore 48. District Hospital, Gwalior 49. District Hospital, Jabalpur

Chattisgarh

50. District Hospital, Raipur

Maharashtra

51. Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardhi

52. District Hospital, Nasik

Manipur

53. Regional Institute of Medical Sciences, Imphal

54. District

55. District

56. District

57. District

58. District

59. District

60. District

61. District

62. District

63. District

Meghalaya

64. District

Mizoram

65. District 66. District

Hospital, Imphal Hospital, Sajiva
Hospital, Chandel Hospital, Churachandpur Hospital, Ukhrul Hospital, Moreh Hospital, Thoubal Hospital, Bishnupur Hospital, Senapati Hospital, Tamenglong

Hospital, shillong

Hospital, Aizawal Hospital, Lunglei

Tamil Nadu

95. Madras Medical College, Madras

96. Medical College, Madurai

97. Govt. Headquarters Hospital, Nagercoil

98. Govt. Stanley medical College and Hos- pital, Chennai

99. Govt. Medical College and Hospital, Coimbatore

100. Govt. Medical College and Hospital, Tirunelveli

101. Govt Mohan Kumaramangalalm Medi- cal College and Hospital, Salem

102. Govt. Medical College and Hospital, Thanjavur

103. Govt. Medical College and Hospital, Tuticorin

104. Govt. Kilpauk Medical College and Hospital, Chennai

105. Govt. Chengaipattu Medical College and Hospital, Chengaipattu

106. Govt. KAP Viswanathan Medical Col- lege Hospiatl, Tirichirapalli

Tripura

107. Kumarghar Rural Hospital, Darchai

Uttar Pradesh

108. Institute of medical Sciences, Banaras Hindu University, Varanasi

109. Gorakhpur Medical College, Gorakhpur

110. King George Medical College, Lucknow

111. Medical College, Meerut

Uttranchal

112. Base Hospital Sringar, Garhwal

West Bengal

113. North Bengal Medical College, Siliguri 114. Burdwan Medical College, Burdwan 115. Bankura Medical College, Bankura

Arunachal Pradesh

116. District Hospital, Tezu

117. District Hospital Changlang

118. District Hospital, Khonsa

Bihar

119. Jawaharlal Nehru Medical College, Bhagalpur,

120. Shri Krishna Medical College, Muzaffarpur

121. Anurag Narayan Medical College, Gaya

122. Sadar Hospital, Munger

List of Contributors

Amardeep Kumar

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Anju Dhawan

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Arindam Mondal

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

BN Gangadhar

Department of Psychiatry
National Institute of Mental Health and Neu- rosciences
Bangalore – 560 029.

Debasish Basu

Department of Psychiatry
Postgraduate Institute of Medical Education & Research
Chandigarh

Deepak Yadav

National Drug Dependence Treatment Centre All India Institute of Medical Sciences
New Delhi – 110029

HK Sharma

National Drug Dependence Treatment Centre All India Institute of Medical Sciences
New Delhi – 110029

Hem Raj Pal

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Indra Mohan

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

K Srinivasan

Department of Psychiatry
St. John’s Medical College Hospital Bangalore

K S Chandramouli

Department of Medicine
St. John’s Medical College Hospital Bangalore

Kul Bhushan

Department of Psychiatry
National Institute of Mental Health and Neurosciences
Bangalore – 560 029.

Manoj Kumar Sharma

National Drug Dependence Treatment Centre All India Institute of Medical Sciences
New Delhi – 110029

Mohan Isaac

Department of Psychiatry
National Institute of Mental Health and Neurosciences
Bangalore – 560 029

Parmanand Kulhara

Department of Psychiatry
Postgraduate Institute of Medical Education & Research
Chandigarh

Prabhat K Chand

Department of Psychiatry
National Institute of Mental Health and Neurosciences
Bangalore – 560029

Pratima Murthy

Department of Psychiatry
National Institute of Mental Health and Neurosciences
Bangalore – 560029

Rajat Ray

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Rajesh Bhushan

Director, Deaddiction Services Ministry of Health and Family Welfare New Delhi

Raka Jain

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Rakesh Lal

Department of Psychiatry and National Drug

Dependence Treatment Centre
All India Institute of Medical Sciences New Delhi – 110029

Ravindra V Rao

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Renuka Jena

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

S Lalwani

Department of Forensic Medicine
All India Institute of Medical Sciences New Delhi – 110029

Shubhangi Parker

Department of Psychiatry K E M Hospital
Mumbai

T D Dogra

Department of Forensic Medicine
All India Institute of Medical Sciences New Delhi – 110029

Vivek Benegal

Department of Psychiatry
National Institute of Mental Health and Neurosciences
Bangalore – 560 029.

Yatan Pal Singh Balhara

Department of Psychiatry and National Drug Dependence Treatment Centre
All India Institute of Medical Sciences
New Delhi – 110029

Glossary

Abuse: This term essentially connotes a pat- tern of unhealthy, prolonged consumption of drug, which interferes with social, occupa- tional, or personal functioning of an individual. (N.B: The word ‘abuse’ when used non-spe- cifically may cover both abuse and dependence phenomena. Thus, used loosely, a drug ‘abuser’ (earlier called ‘addict’) is a person who uses drug(s) in a pathological fashion and may meet the technical definition of either ‘abuse’ or ‘de- pendence’).

Attributable risk: Proportion of new cases aris- ing in a population that are attributable to ex- posure under study.

Case control study: It involves two populations- cases and controls. In case control studies, the unit is the individual rather than the group. The focus is on a disease or some other health problem that has already developed. Case con- trol studies are basically comparison studies.

Cohort study: It is a type of observational study which is usually undertaken to refute or sup- port the existence of an association between suspected cause and disease.

Cohort: It is defined as a group of people who share a common characteristic or experience within a defined time period ( e.g., age, occu- pation etc)

Community: Social structural aspect: As a “so- cial organism” comprises of rural helmets/ vil- lages to urban neighborhood. The focus is on people living in the community, the social net- works and institutions located in the commu- nity.

Comorbidity: Comorbidity is defined as the presence, either simultaneously or in succes- sion, of two or more specific disorders in an

individual within a specified period.

Consciousness: Our own awareness of ourselves and the world; the mental processes that we can perceive; our thoughts and feelings.

Craving: A powerful, intense, often uncontrol- lable, desire for drugs.

Cross-sectional study: These studies are per- formed in a defined ‘target population’ with clearly defined ‘cases’. The subjects need to be assessed only once. These studies are especially useful for defining the health care needs of a given population.

Delirium: an etiologically non-specific syn- drome characterised by concurrent distur- bances of consciousness and attention, percep- tion, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle.

Dementia: a syndrome due to the disease of the brain, usually of a chronic or progressive nature, in which there is a disturbance of mul- tiple higher cortical functions, including memory, thinking, concentration, orientation, comprehension, calculation, learning capacity, language and judgement. However, the con- sciousness is not clouded.

Denial Unconsciously refusing to admit that someone is addicted.

Dependence: A cluster of physiological, behavioural and cognitive phenomena in which use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. (N.B: Addiction is a much older term than both ‘abuse’ and ‘dependence’. It is now omitted from technical language because of its pejorative connotation. However, the term still

is retained in popular usage. It denotes either abuse or dependence).

Descriptive study: Distribution of persons who abuse various kinds of substances according to various socio-demographic variables is assessed. This can give information about regional varia- tion and change in trends over time.

Detoxification. A process of withdrawing a person from a specific psychoactive substance in a safe and effective manner.

Drug: any chemical which, when administered, alters the functioning of one or more systems of the organism.

Dual Diagnosis: Patients with a substance use disorder with a comorbid psychiatric manifes- tation.

Hallucination: false sensory perception not as- sociated with any real, external stimuli.

Illusions: misperception or misinterpretation of real external sensory stimuli.

Incidence: Occurrence of new cases in mem- bers of a target population over time.

Insight: ability of the patient to understand the true cause and meaning of a situation.

Intoxication: a transient condition following the administration of a psychoactive substance, resulting in disturbances in level of conscious- ness, cognition, perception, behaviour or af- fect, or other psychophysiological functions and responses.

Judgement: ability to assess a situation correctly and to act appropriately within that situation

Lapse: the initial (single) episode of drug use following a period of abstinence, synonymous with “slip.”

Mentally Ill Chemical Abuser (MICA)/ Men- tally Ill Substance Abuser (MISA)/ Chemical Abusing Mentally Ill (CAMI): Terms used to

describe patients with a psychiatric disorder having a comorbid substance use disorder.

Motivation: The internally generated state that stimulates us to act.

Narcotics: morphine and related group of drugs.

Opiates: Any of the psychoactive drugs that originate from the opium poppy or that have a chemical structure like the drugs derived from opium.

Opioid: Any chemical that has opiate-like ef- fects.

Prevalence: Proportion of a population that has a particular occurrence at a point or period in time. The former definition refers to as point prevalence and letter as period prevalence.

Problem Drinking. An informal term describ- ing a pattern of drinking associated with life problems prior to establishing a definitive di- agnosis of alcoholism. Also, an umbrella term for any harmful use of alcohol, including alco- holism.

Psychosis: inability to distinguish reality from fantasy; impaired reality testing.

Psychotropic drug: chemical which induces change primarily in some aspect(s) of mental functioning; for example, an anti-depressant is meant to relieve mental depression. (N.B: when we refer to ‘drugs’ in the manual we mean al- cohol, cannabis, heroin or morphine. Although they are all psychotropic agents, they are rarely taken for a particular effect or illness. Rather, they are consumed voluntarily to alter one’s mood, thinking, perception or other mental functions so as to induce pleasure in an artificial manner. In order to differentiate them from other, more generally defined, medicinal drugs, these are now called ‘psychoactive substances’ or simply ‘substances’).

Relapse: the failure to maintain abstinence;

resumption of a pattern of substance abuse or dependency

Relative risk: The chance of occurrence of event in the population exposed to risk factor as com- pared to those not exposed.

Stimulants: A class of drugs that elevates mood, increases feelings of well-being, and increases energy and alertness.

Withdrawal Syndrome. The onset of a predict- able constellation of signs and symptoms fol- lowing the abrupt discontinuation of, or rapid decrease in dosage of a psychoactive substance.