Drug and Substance Abuse

What is a drug?

According to the World Health Organization (W.H.O), a drug is defined as a substance that, when taken into the living organism, may modify one or more of its functions (W.H.O. 1969).

Definitions of drug/substance abuse

• Drug use without a doctor’s prescription
• Excessive use of a socially acceptable drug
• Use of a legally banned drug

According to ICD-10, substance abuse is characterized by a pattern of psychoactive substance use that is causing damage due to physical or mental ill-health.

According to DSM-IV, substance abuse refers to a maladaptive pattern of substance use leading to significant impairment or distress or mental ill-health in the last 12 months, resulting in clinical, social, legal, or occupational distress (must not meet criteria for dependence).

Valuable points

• Youths, especially males, predominate in the drug abuse scene, with the involvement of more females in the last two decades.
• Alcohol use and cigarette smoking tend to start in early adolescence (ages 11-13 years) prior to the use of illegal drugs.
• Cannabis remains the most common illicit drug of abuse.
• The use of psycho-stimulants is on the increase.
• The abuse of drugs cuts across different social classes.
• Adolescents and young adults, both in and out of school, constitute the high-risk group for substance use.
• Easy availability of substances increases the chance of substance abuse by adolescents.

• Total abstinence
• Experimental use – there may be no outward behavioral change.
• Occasional/recreational use: the individual seeks the euphoric effects of the drug, establishes a reliable drug source, etc.
• Harmful use
• Dependence: has symptoms of withdrawal

• Intoxication
• Harmful use
• Dependence syndrome
• Withdrawal state with or without delirium
• Psychotic disorders
• Amnesic syndrome
• Residual and late-onset psychotic disorder
• Other mental and behavioral disorders

DSM-IV (above plus dementia, sexual dysfunction, sleep disorder)

DSM-IV	ICD-10
Alcohol	Alcohol
Amphetamine	Other substances including caffeine
Caffeine	-
Cannabis	Cannabinoids
Cocaine	Cocaine
Hallucinogen	Hallucinogen
Inhalant	volatile solvent
Nicotine	tobacco
Opioids	Opioids
Phencyclidine	-
Sedatives/hypnotics/anxiolytics	Sedatives/hypnotics
Polysubstance use	multiple drug use

• Age range 15-24 years
• Male gender
• Peer pressure – influence of friends.
• Desire to experiment.
• Personality defects.
• Notion of machismo – risk-taking to prove oneself to friends.
• Siblings exposure.
• Employment outside the home for adolescents.
• Social pathologies such as unemployment and underemployment.
• Parental deprivations – separation, divorce, death of spouse, etc.
• Rapid urbanization – breakdown of family social support.
• Exposure to high-risk jobs – working in breweries, tobacco companies, bar attendants, etc.
• Drug availability e.g. fallout effects of drug trafficking, ineffective drug control policies.
• Advertising

Social consequences

• Loss of sense of responsibility.
• Loss of job creating financial problems for self and family.
• Family disruption.
• Criminal behavior such as stealing, armed robbery, murder, etc.
• Delinquent acts among the youths e.g. truancy from school, rape, violence, etc.
• Lack of achievement of life purpose e.g. dropping out of school.
• Road Traffic Accidents causing harm to self or to others.
• Attempted suicide and suicide.
• Unprotected sexual behavior and promiscuity under the influence of habit-forming substances.

Physical/Medical Complications:

• Physical dependence leading to withdrawal reactions as in alcohol dependence.
• Stimulation of the central nervous system (CNS) giving rise to restlessness, insomnia, tremors, disturbance of thinking, etc.
• Depression of the CNS resulting in drowsiness, incoherent speech, coma, death.
• Damage to body organ structures such as liver, pancreas, nerves, and brain.
• Home accidents and road traffic accidents.
• Damage to unborn babies as in chronic alcoholism during pregnancy (foetal alcohol syndrome).
• Human immunodeficiency virus infection (HIV), and Acquired Immune Deficiency Syndrome (AIDS).
• Physical damage to several organ structures in acquired immune deficiency syndrome (AIDS).

Psychological Complications:

• Psychological dependence leading to craving desire.
• Alteration of mood (elevation or depression).
• Psychological symptoms of withdrawal e.g. severe anxiety, perception of non-existing stimuli (hallucinations), etc.
• Impairment of memory (dementia) as in chronic alcohol use.
• Personality disintegration and loss of self-esteem.
• Impairment of motivation as seen in chronic cannabis.
• Sexual disorders such as impotence, delayed ejaculation, and infertility.
• Psychological damage (cognitive impairment) to unborn babies.

• Alcohol abuse has a long history, dating back to the beginning of human existence.
• Alcohol encompasses various related compounds, such as isopropyl alcohol (rubbing alcohol), methyl alcohol (wood alcohol), butyl alcohol, and ethyl alcohol. However, the term "alcohol" typically refers to ethyl alcohol, also known as ethanol or beverage alcohol.
• Ethanol is the only alcohol suitable for consumption. Other types of alcohol are toxic substances that can be fatal when ingested. For instance, methanol, when consumed, binds to the optic nerves and can lead to blindness.
• Alcoholic beverages have varying alcohol content:
• Local gin (20-80%)
• Beer (4%)
• Stout (6%)
• Wine (11-18%)
• Dry gin (40-50%)
• Fresh palm wine (4% or less)
• Alcohol content is measured in units, with 1 unit of alcohol equaling 8 grams of alcohol.
• In most countries, legal intoxication is defined as having a blood alcohol concentration (BAC) of 0.1%.
• Blood alcohol concentration decreases by 0.01% per hour after drinking ceases.
• Alcohol abuse contributes significantly to the global health burden, accounting for 4% of the total burden and 3.2% of yearly deaths.

Signs and Symptoms of Alcohol Use

• Affects all systems e.g., nervous system, endocrine system, and can result in a variety of physical and mental health problems.
• Initially serves as a stimulant and then induces a feeling of relaxation and reduces anxiety.
• Impair judgment, lower inhibitions, and induce euphoria.
• Signs of use and intoxication:
• Smell of alcohol breath
• Irritability
• Euphoria
• Loss of physical coordination
• Inappropriate or violent behavior
• Loss of balance
• Unsteady gait
• Slurred and/or incoherent speech
• Loss of consciousness
• Slowed thinking
• Depression
• Impaired short-term memory
• Blackouts

Symptoms of Withdrawal

• Tremors
• Agitation
• Anxiety
• Confusion
• Hallucination
• Delusions
• Nausea and vomiting
• Tachycardia
• Sweating
• Seizures

Chronic abuse of alcohol can lead to dependence. The behavior of abusers and the consequences of that behavior are better indicators of dependence than quantity and frequency of use.

• The traditional cigarette and smoking method are associated with health hazards such as carcinoma of the lung, chronic bronchitis, etc. There are up to 3000 poisonous chemicals released when a cigarette is lit.
• Every effort is being made to exert pressure against tobacco manufacturing, but the manufacturers are also putting up resistance.

E-cigarette

• Electronic cigarettes are now being manufactured.
• Models of e-cigarettes include V2 cig, Eversmoke, Green smoke, White cloud, Blue cigs, etc.
• A starter pack contains the battery, e-liquid, atomizer, and charger.
• Mechanism: E-liquid contains nicotine and some flavors e.g., coffee, cherry, cola, mint, vanilla, etc.
• When the battery is turned on, it activates the inbuilt nebulizer which heats up the e-liquid and thereby releases vapor of nicotine and flavors to be inhaled by the user.
• The strength of nicotine bought can vary from 4.4%, 1.8%, 1.2%, 0.6% to 0%.

Advantages:

• Smokeless
• Nicotine concentration can be adjusted downwards
• Good for smokers who want to quit as there could be gradual withdrawal from nicotine to 0%

Note: Though most states in the U.S allow for e-cigs to be smoked in public, a lot of explanation must be made to avoid protest from others.

• Most common illicit drug (used by 2.8% of world population).
• Discovered around 2800BC in China, then spread to India, Middle East, North Africa, Europe/America, Nigeria.
• Its potent form is the female plant.
• Exists in the form of:
• Bhang: Cheapest, flowering tops and subtending leaves.
• Ganja: Dried flowers.
• Hashish: 7-14% THC, concentrated resins.
• Hashish oil: 20% THC, most potent, also called butane honey oil.
• Most active ingredient is d-9 tetrahydrocannabinol.
• Other compounds include cannabinoids, cannabinol, cannabidiol, THCcannabivarin.
• Acts through CB1 and CB2 receptors which increase DA and modulates opioids.
• It is lipophilic hence lasts for weeks after intake.
• Other plant varieties apart from C. sativa are C. Indica and C. Ruderalis.
• Medicinal uses of cannabis include antiemetic in terminally ill patients, treatment of glaucoma, multiple sclerosis, depression (sold as Marinol).
• Detection/screening – in urine, blood, oral fluids, sweat, hair using chromatographic technique. Urine contains THC-cooH, other fluids contain THC while blood contains both.
• Duquenois-Levine test used as screening test but it is prone to false positives.
• Gas chromatography is the confirmation test.

Signs and Symptoms of Cannabis Use

• Binds to cannabinoid receptors.
• Causes sudden mood changes.
• Memory impairment.
• Perceptual distortions - liliputian hallucination.
• Impaired judgment ability.
• Diminished motor skills.
• Increased apathy, loss of ambition.
• Decline in school or work performance.
• Impairment of driving skills for at least 4-6 hours after smoking cannabis.
• Accelerated heartbeat.
• Redness of the eyes.
• Diminished immunity to diseases.
• Chronic lung diseases.
• May precipitate psychotic illnesses e.g., schizophrenia, mania, and acute organic brain syndrome.

Cannabis and Schizophrenia

• There is a lot of debate on this.
• Some claim no association.
• Others claim there is, suggesting it increases the chance of developing schizophrenia about 2.5 times and in heavy users to about 6 times (Andreasson et al, 1997).
• They suggested that removing cannabis from society will prevent about 8% of schizophrenia (Arsenault et al, 2004).

• 80% of world food contains some form of caffeine.
• Mild use poses no danger.
• The content of caffeine in brewed coffee ranges from 90-125mg per 5oz, tea contains about 30-70mg, Coca-Cola 45mg, and decaffeinated coffee 1-6mg per 5oz.
• Single low to moderate doses of caffeine (i.e., 20 to 200mg) can produce subjective effects generally identified as pleasurable and increased ratings on measures such as well-being, energy and concentration, and motivation to work.
• High doses of caffeine, more than 250mg a day, may exacerbate existing conditions in the cardiovascular system (e.g., raised blood pressure), gastrointestinal system (e.g., ulcer).
• It may also lead to a syndrome known as caffeinism or caffeine intoxication, and a mild form of dependence on the substance.
• Symptoms of caffeinism include nervousness, irritability, restlessness, insomnia, tremors, headache, tachycardia or disturbances of heart rhythm, ringing sensation in the ears.
• Doses of caffeine higher than 10g may produce respiratory failure, seizures, and eventually death (Obot, 1999).
• Long-term use of high doses of caffeine may lead to withdrawal state (headache, nervousness, depression, nausea or vomiting, and a sense of lethargy if the drug is stopped).

• Crystalline alkaloid from leaves of coca plant (Erythroxylon coca).
• It is a serotonin-norepinephrine-dopamine reuptake inhibitor (triple reuptake inhibitor).
• It affects the mesolimbic reward center.
• Its various forms include coca paste, cocaine hydrochloride (90-100% pure), free base cocaine, and crack cocaine which is the cheapest and most popular form.

Effects of Cocaine

• It is a short-acting but potent CNS stimulant and a topical anesthetic.
• It produces euphoria, excitement, increased energy, grandiose ideation, impaired judgment, sexual disinhibition, visual and auditory hallucinations, paranoid ideation, aggression, formication (cocaine bug).
• Physical effects include constriction of blood vessels, increased vital signs, subarachnoid hemorrhage, TIA (transient ischemic attack), seizures, respiratory failure, nasal septal perforation.

• Heroin (diacetylmorphine, diamorphine) belongs to the class of drugs known as narcotic analgesics.
• It is an opioid analgesic synthesized from morphine, a derivative of the plant opium poppy (Papaver somniferum).
• Heroin is made in the laboratory by boiling equal quantities of morphine with acetic anhydride.
• Heroin is the most well-known opiate of abuse today as it has largely replaced morphine as a drug of abuse.
• It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as “black tar heroin”.
• Most street heroin is cut with other drugs or with substances such as sugar, starch, powdered milk, or quinine.
• Street names associated with heroin include smack, junk, horse, gbana, brown, sugar.
• It is estimated that the purity of heroin decreases from 95% to about 5% by the time it is sold to users because of adulteration by dealers.

Symptoms of Opioids

• Short-term effects of heroin use appear soon after a single dose and disappear in a few hours.
• There is a feeling of a surge of pleasurable sensation (a “rush”). This is usually accompanied by nausea, vomiting, and severe itching. Other effects include drowsiness, respiratory depression, constricted pupils, and constipation.
• Overdose can lead to unconsciousness, convulsion, coma, and death.
• Long-term use can lead to tolerance.
• Withdrawal symptoms include:
• Intense craving
• Restlessness
• Muscle and bone pain
• Insomnia
• Diarrhea and vomiting
• Cold flashes with goosebumps (“cold turkey”)
• Kicking movements (“kicking the habit”)
• Other symptoms

These features usually begin about 6 hours after the last dose, reach a peak after 36-48 hours, and then wane.

• HIV, hepatitis B and C, and tetanus are common complications.

What is Drug Dependence?

• Substance dependence is a continuum in the substance abuse spectrum.
• DSM-IV defines it as:
• A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following occurring at any time in the same 12-month period:
• Tolerance
• Primacy
• Withdrawal
• Harmful use
• Inability to cut down

Neurobiological Basis of Dependence

• Not all persons that experiment with drugs develop dependence.
• Dependence results from:
• Complex interaction of the physiological effects of substances on brain areas associated with motivation and emotion, combined with 'learning' about the relationship between substances and substance-related cues.
• Dependence is a product of the complex relationship between genetics and environment.
• The neuromechanism varies with the drug, for example:
• Alcohol and benzodiazepines potentiate GABA.
• Amphetamine and cocaine block reuptake of noradrenaline and dopamine.
• Cannabis possibly acts through the μ-cannabinoid receptors in the limbic systems.

‘Incentive Sensitization’ Theory of Dependence as Proposed by Robinson et al (2000)

• Psychoactive substances repeatedly activate the motivational systems of the brain that are normally activated by such important stimuli as food, water, danger, and mates.
• The brain is ‘‘tricked’’ by the substances into responding as if the substances and their associated stimuli are biologically needed.
• With repeated exposure, the association becomes stronger and stronger, evoking a larger behavioral and neuro-chemical response.

Anatomical Areas Involved in Drug Dependence

Nucleus Accumbens

• This is part of a large group of subcortical nuclei collectively called the basal ganglia.
• It lies in the rostral cerebral hemisphere, in the ventral forebrain.
• The nucleus accumbens can be divided into two components: the outer portion (shell) and the central portion (core).
• The shell typically builds strong connections with the limbic system, while the core is usually associated with the motor system.

Mesolimbic Pathway

• This is a dopaminergic pathway in the brain that connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain.
• The ventral striatum includes the nucleus accumbens and the olfactory tubercle.

Ventral Tegmental Area (VTA)

• This is a group of neurons located close to the midline on the floor of the midbrain.
• The VTA is the origin of the dopaminergic cell bodies of the mesocorticolimbic dopamine system and other dopamine pathways.
• It plays an important role in a number of processes, including reward cognition (motivational salience, associative learning, and positively-valenced emotions) and orgasm.

Features of Drug Dependence

• Primacy Effect
• Tolerance
• Persistent use in spite of evidence of overtly harmful consequences
• Strong desire or compulsion to take drug
• Difficulty in controlling substance use
• Withdrawal symptoms e.g. tremors, pains, running nose, formication

Management of Substance Abuse and Drug Dependence

• Primary
• Secondary
• Tertiary

Primary Prevention

• Public enlightenment activities to increase general awareness of the society to the problem. Mass media, seminars, workshops, etc. are tools to accomplish this goal.
• Preventive education for targeted audiences such as families, schools, workers, religious organizations, out-of-school youths, etc.
• Strategies focused on individuals and peer groups – provision of recreational facilities for youths in rural and urban areas, moral rearmament that de-emphasizes materialism, improved employment opportunities, and effective control of drug availability.
• Educational approaches targeting parents – improving family lifestyle.
• Drug education as part of the school curriculum.
• Legislation and enforcement.
• Screening (CAGE, AUDIT, ASSIST, etc.).
\
• CAGE:
• Cut: Have you ever felt you needed to cut down on your drinking?
• Annoyed: Have people annoyed you by criticizing your drinking?
• Guilty: Have you ever felt guilty or bad about your drinking?
• Eye-opener: Do you ever drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
• AUDIT:
• Alcohol Use Disorders Identification Test
• ASSIST:
• Alcohol, Smoking, and Substance Involvement Screening Test

Secondary Treatment

• Detoxification
• Cold turkey
• Assisted/gradual
• Treatment of associated physical and mental disorders
• Psychotherapy
• Individual (motivational interview using principles of behavior change and FRAMES)
• Group
• AA (Alcoholics Anonymous)
• Alanon
• Al-teen

• Laboratory Tests
• Alcohol:
  • Gamma Glutamyl Transpeptidase (GGT) increased in 70% of abusers
  • MCV raised above normal in 60% of abusers
  • Increased level of carbohydrate-deficient transferrin (more specific than GGT)
  • Increased Blood Alcohol Concentration (BAC)
• Cannabis:
  • Detection of hydrocannabinol in urine
• Maintenance of Drug-Free Behavior
• Alcohol:
  • Disulfiram (Antabuse) – prevents oxidation of alcohol leading to accumulation of acetaldehyde resulting in nausea, vomiting, throbbing headache, flushing, tachycardia, etc.
  • Naltrexone
  • Acamprosate (Calcium Acetyl Homotaurinate)
• Opioids:
  • Methadone
  • Naltrexone (a long-acting opioid antagonist)

Tertiary Treatment

• Occupational rehabilitation
• Educational rehabilitation/counselling
• Social rehabilitation
• Legal assistance/intervention
• Continuation of Self-help group programs

Treatment Facilities

• Clinics
• Hospitals
• NGO centers
• Therapeutic communities
• Drop-in centers (not in Nigeria)
• Help lines
• Schools
• Religious houses
• Traditional healers' homes