Substance Use Disorder in 4

Home , Alcohol and sex, Macrocytosis, Paan, Skin popping, Substance intoxication

Contents

Preface 10. Community-based Treatment of Substance Foreword Use Disorder Acknowledgements 11. Nicotine Dependence 12. Intervention with Treatment Non Seekers 1. Drug De-addiction Programmes in India 13. Role of Laboratory Services in Substance 2. Assessment and Diagnosis in Substance Use Use Disorder Disorder 14. Prevention of Substance Abuse in India 3. Epidemiology of Substance Use 15. Management of Substance Use Disorder in 4. Acute Effects of Alcohol, Opioid and Primary Care Cannabis Use 16. Comorbidity in Substance Use Disorder 5. Health Hazards of Long Term Alcohol, Opioid 17. Substance use disorder in Women and Cannabis Use 18. Adolescent Substance Abuse 6. Treatment Principles and Issues in Manage- 19. Legal Aspects of Drug Abuse in India ment of Substance Use Disorder – An Overview Appendix 1 Appendix 5 7. Pharmacotherapy of Substance Use Disorder Appendix 2 Appendix 6 8. Long-Term Treatment of Opioid Dependence Appendix 3 Appendix 7 Syndrome Appendix 4 Appendix 8 9. Psychosocial Treatment in Substance Use List of Contributors Disorder Glossary 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. We look forward to any suggestions for improvement and changes. 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 necessary. 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 concerned 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 1

Rajesh Bhushan

I. The context 1.3 In the area of Drug De-addiction and drug trafficking, the control on illicit drug 1.1 The constitution of India under Article trafficking and its production in India as 47, enjoins that the state shall endeavor well as coordination with international to bring about prohibition of the con- agencies is the responsibility of Ministry sumption, except for medical purposes, of Home Affairs. Rehabilitation of addicts of intoxicating drinks and of drugs which as well as their counseling is the responsi- are injurious to health. The various drug bility of Ministry of Social Justice & Em- de-addiction programmes of Government powerment. Demand reduction by way of India have to be seen in this light. The of treatment and after care is the concern Government of India, Ministry of Health of Ministry of Health & Family Welfare. and Family Welfare in 1976 appointed a The Drug De-addiction Programme of the high powered committee to examine the Ministry of Health & Family Welfare was problem of Drug De-Addiction and sug- started in 1987-88, which was modified gest future guidelines. The report of this in 1992-93 as a scheme under Central high powered committee was submitted sector assistance to States. in 1977 and was laid on the floor of the Parliament. The Planning Commission 1.4 The role of Ministry of Health & Family and the Central Council of Health Min- Welfare in the area of Drug De-addiction isters reviewed this report in 1979. The is demand reduction by way of providing recommendations of the report empha- treatment services. Under the scheme a sized the need to evolve appropriate strat- one time grant in aid of Rs. 8.00 lakhs is egies and to bring about better coordina- given for construction of Drug De-addiction among different Ministries and De- tion Centres and a recurring grant of Rs. partments working in this area. The Plan- 2.00 lakhs is given to Drug De-addiction ning Commission and the Central Coun- Centres established in North Eastern cil of Health Ministers accepted this. Regions. At present 122 such Centres have 1.2 Drug addiction entails high cost to hu- been established across the country man health, social fabric and economy. including centres in Central Government In addition, Drug addiction has come to hospitals and institutions. 43 such Cen- represent yet another danger over the past tres have been established in the North decades. This comes from the role which Eastern Region. The six Drug-addiction drug use plays in the spread of HIV/AIDS. Centres established in Central Govern- It was in this context that the Drug De- ment hospitals and institutions are at All addiction Programme in the Ministry of India Institute of Medical Sciences, New Health & Family Welfare was started in Delhi, Dr. RML Hospital, New Delhi, the year 1987-88. Lady Hardinge Medical College, New

1 Drug De-addiction Programmes in India Delhi, PGI, Chandigarh, JIPMER, of Rs. 5.10 crores and currently houses Pondicherry and NIMHANS, Bangalore. 30 in patient beds. The centre conducts A national nodal centre has been estab- therapeutic group sessions for both inpa- lished under the All India Institute of tients and outpatients. Medical Sciences (AIIMS), New Delhi. 4.2 The De-addiction Centre caters to more This is located in Ghaziabad and has been than 50% of the patients seeking treat- designated as “National Drug Dependence ment for substance abuse problems in the Treatment Centre.” city of Bangalore. The Centre also treats II. National Drug Dependence Treatment patients from different parts of Karnataka, Centre, AIIMS Andhra Pradesh, Tamil Nadu and Kerala. Referrals are also received from other states 2.1 National Drug Dependence Treatment of the country including the North-East- Centre, AIIMS was established during ern States. Recently there have been sev- the year 1987-88 and was functioning at eral referrals from countries in the SAARC Deen Dayal Upadhyay Hospital, Hari region and other countries as well. Nagar.This has subsequently been shifted to its own building constructed at CGO V. Convergence: Complex, Kamala Nehru Nagar, 5.1 In a meeting held on 6.10.04 in the Ghaziabad. It started outdoor facilities chamber of Joint Secretary, Ministry of from 14.04.03 and indoor facilities on Social Justice & Empowerment, it was 2.12.03. A Community Clinic was estab- decided that an effective linkage between lished at Trilokpuri and this started func- the rehabilitation centres managed by tioning from 1.8.2003. Apart from ren- NGOs funded by the Ministry of Social dering patient-care services, the centre is Justice could be established with the treat- engaged in a number of research projects. ment centres supported by the Ministry III. Drug De-addiction Centre, PGI of Health. The collaboration would be Chandigarh: through the following modalities:- 3.1 Drug De-Addiction Centre, PGI 5.2 Identification of NGOs to be linked with Chandigarh was established during 1988- Drug De-addiction Centres would be 89. The Centre has facilities for both out- done, Drug De-addition Centre wise. door and inpatient services. Additionally, This action would be initiated and it conducts drug-de-addiction awareness completed by Ministry of Social Justice programmes, treatment camps, counsel- and Empowerment. ing and provides free medication. 5.3 NGOs would recommend cases requiring IV. Drug De-addiction Centre, National In- treatment for Drug De-addiction to the stitute of Mental Health & Neuro Sciences, Drug De-addiction Centres. The Drug Bangalore De-addiction Centres in turn would refer patients after completion of treatment 4.1 Drug De-addiction Centre at to identified NGOs for rehabilitation and NIMHANS, Bangalore was established monitoring. during the year 1991. This Centre is func- 5.4 Apart from detoxification services, which tioning as a Regional Centre. A separate are provided by the Drug De-Addiction building has been constructed with a cost

2 Drug De-addiction Programmes in India Centres run by Ministry of Health and equipment Family Welfare, the counseling of patients (d) staffing in terms of posts available and and their families would commence along filled with the treatment. Ministry of Social (e) on-site interview and Justice and Empowerment would consider (f) review of records of de-addiction funding one counselor in each Drug De- centres. Addiction Centre run by the Ministry of The evaluation had focussed on the states Health and Family Welfare. of Manipur, Nagaland and Rajasthan. The 5.5 All Health Secretaries of State Govern- evaluation findings have served as a valu- ments have been requested for issuing able input into the reformulation of the necessary directions to the Drug De-ad- National Drug De-addiction Programme diction Centres in this regard. which is under consideration of the Min- VI. Evaluation istry. VII. Five Year Plan Outlay 6.1 Under the Drug De-addiction Programme, so far 114 Drug De-addic- 7.1 Approved outlay for 10th Five Year Plan in tion Centres have been established in vari- respect of this programme is Rs. 33.00 crores, ous States. On the request of the Minis- the break-up of which is given below:- try, WHO has provided funds for the evaluation of centres. Evaluation of these Rs. in crores Centres have been done by National Year Outlay Drug Dependence Treatment Centre, 2002-03 7.00 AIIMS on the following parameters 2003-04 6.50 (a) to assess the status of functioning of Gov- 2004-05 6.50 ernment De-addiction centres by assess- 2005-06 6.50 ing the patient load (b) treatment being provided 2006-07 6.50 (c) availability and utilization of Total 33.00

3 Assessment and Diagnosis in Substance Use Disorder 2

Ravindra Rao, Indra Mohan, Rakesh Lal

Summary treating patients in their setup.

Assessment forms the cornerstone in diagnosis A proper assessment is necessary for treatment. and management of substance use disorder. The It is also helpful in numerous other ways chapter is divided into two parts – assessment including: and diagnosis. The assessment part begins with the discussion on necessity of assessment fol- a) Screening of patients who may present only lowed by stages, settings and levels of assess- with physical problems but do not reveal ment. Finally it is described how the assess- drug use by themselves. ment is carried out (tools of assessment). In b) Establishing a diagnosis this chapter emphasis is given on the clinical tool(history and examination), as the labora- c) Planning treatment tory investigation to aid in assessment is dealt d) Referral to a specialist for further treatment with elsewhere. e) Assessment also serves to establish rapport The diagnosis section begins with the mean- and motivate client towards seeking treating of some commonly employed terms, fol- ment/ reduce harmful use/ abstinence. lowed by description of the criteria for ‘dependence’ and ‘harmful use’. Assessment is not a one time phenomenon. This is carried out at various stages. Thus, the stages Assessment of assessment include Substance use disorder (SUD) affects individu- a) Preintervention: where the purpose of als across various strata of society. The preva- assessment is to define the problem, lence of SUD including alcohol, tobacco is high formulate treatment, select an appropriate in general population across the world includ- treatment from various modalities and ing India. motivate clients for treatment. Though there are experts in deaddiction cen- b) Intervention: here assessment is done to tres to treat such patients, the fact remains that monitor progress only a handful of patients are treated in these centres. Often deaddiction centres are the last c) Post intervention: assess maintenance and point of contact in the patients’ chain of treat- abstinence status. ment seeking. In contrast, primary care physi- Depending on the reasons for assessment and cians are often contacted initially for a number the settings in which the assessment is being of physical problems associated with drug use. carried out (inpatient v/s outpatient), there can Thus physicians should have knowledge of

1 Assessment and Diagnosis in Substance Use Disorder 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

Specificity/ Cost Stages of Assessment Levels of Assessment Broad focus/ 1. Preintervention Inexpensive 1. Brief Screening 2. Intervention 2. Basic Assessment Narrow focus/ 3. Post intervention Costly 3. Specialized Assessment

Screening: frequently used instruments are An initial function of assessment is identifying 1. CAGE: an acronym for 4 questions used to individuals who may either have a substance assess those with alcohol problem use problem or is at risk of developing one. 2. MAST: Michigan Alcohol Screening Test Screening is usually applied to a large group of individuals and is brief by nature. It is usually 3. DAST: Drug Abuse Screening Test applicable in those settings where the individu- 4. AUDIT: Alcohol Use Disorder Identifica- als are encountered for problems that may not tion Test appear to be related to substance use, yet the association of the problem with substance use The usefulness of these instruments depends may be strong. Such settings may include a on the setting and the type of population in general medical setup, emergency rooms, which these instruments are used. trauma centres, psychiatric setting, and ante- Tools of assessment natal checkup or in a legal setup (e.g. prison wards, individuals caught for drunken driving). Assessment can be carried out by various These settings usually encounter individuals means. These are who may have a substance use problem but are not actively seeking treatment for the same. A) Clinical: Efforts have been made to develop brief ques- Here, assessment is carried out by eliciting tionnaires and interviews so that many indi- information as well as carrying out a detailed viduals with drug abuse problem may be iden- examination of the patient. The relevant infor- tified in a relatively short period. Consequently mation can be gathered from patient as well as a number of instruments have been developed persons associated with patients who are towards this end. These instruments comprise willing to be involved in the treatment and care of simple questions that have a ‘yes/no’ or a of the patient. It has been observed that, at ‘most true/ not true’ answers. These instru- times, informants tend to under/over report the ments have been designed to have a high patient’s drug abuse. However, informants can degree of sensitivity at the cost of specificity be a good source for corroborating other (thereby increasing false negativity). Some aspects of patients drug use with regards to

2 Assessment and Diagnosis in Substance Use Disorder various complications (physical, social, famil- ing team, areas to be focused during reha- ial, occupational) as well as patients’ attempts bilitation. The areas probed are to leave the drug (abstinence). 1. physical: long term health hazards asso- SUD has been considered as biopsychosocial ciated with drug use problem. Hence assessment should be carried 2. psychological: chronic mental effects of out in multiple domains focusing on physi- continuous use of drug ological, behavioral, psychological and social 3. financial: losses suffered/debts incurred factors associated with drug use. 4. occupational: frequent absenteeism at work, constant change of job, memos Clinically, assessment may be carried out in issued, periods of unemployment the following manner: 5. familial – social: frequent fight with History spouse/ other family members, neglect of responsibility at home, social outcast Assessment begins with collection of 6. Legal: involvement in illegal activities to a. Patient’s sociodemographic profile i.e. sustain drug use, arrests/ charges on ac- name, age, sex, marital status, qualification, count of drug use, caught driving under occupation, type of family and place of resi- intoxicated state, drinking brawl. dence. d. High risk behaviors: presence of injection use with needle sharing and unsafe sexual b. Details of drug use are then inquired into. practices This include e. Past abstinence attempts: herein inquiry 1. age of initiation should be made regarding 2. various drugs used 3. frequency of drugs used 1. number of attempts made 4. the quantity of drug taken usually (usual 2. duration of each attempt dose) 3. reason for abstinence 5. the time lag since the dose last used 4. whether treatment sought 6. need to increase the quantity of drug 5. nature of treatment sought: pharmaco- consumed in order to produce the same logical, psychological or combined effect (tolerance) 6. reason for relapse 7. the effect of the use of a particular drug The information collected would be very and signs and symptoms of intoxication helpful in deciding further treatment plan 8. presence/ absence of physiological/psy- and measures to be taken to prevent relapses chological symptoms and signs when the f. Reason for seeking treatment and motiva- particular drug is not taken/ less than tion level of individual: whether seeking the usual amount of drug is being taken treatment by self or brought forcibly by (withdrawls) family member. Assessing level of motiva- 9. compelling need/ urge to take the sub- tion would help the clinician decide the stance type of intervention needed. c. Complications associated with drug use g. Psychiatric illnesses such as a mood disor- should be inquired. This can be in various der, psychotic disorder and personality dis- spheres of patients’ life and gives the treat-

3 Assessment and Diagnosis in Substance Use Disorder order/ traits are common comorbid cognitive functions of the patient. conditions accompanying substance use Finally, the motivation level of the patient is disorder. Presence of comorbid psychiatric assessed.This can be assessed by inquiring into illness should be specifically inquired and the reasons for seeking treatment. intervention modified accordingly. h. Presence of family history of SUD, psychi- B) Investigations: atric illness and the current living arrange- While the details of laboratory measures in ments. Extent of social support should be drug abuse settings in discussed elsewhere in assessed. the manual, it serves two purposes. i. Premorbid personality: especially presence/ 1. confirming presence/ absence of drugs of absence of Antosocial personality disorder. abuse Physical examination 2. investigations for physical damage caused by these drugs 1. Evidence of drug use with respect to Similar to examination, investigation provides a) Intoxication, an objective measure of the drug used and the b) Withdrawals and extent to which drug use has caused damage c) Route of drug use as evidenced by burn to the body. This can be used effectively to marks/ nicotine stains on fingers in enhance motivation of individuals who are in cigarette use and heroin by inhalational the state of denial with regards to their drug route; injection marks in case of injec- use. tion drug use (IDU). C) Instruments: 2. Evidence of physical damage due to drug use: a systemic examination should be con- These tools consist of a set of questions ducted for every drug user to rule out physi- designed to assess one or more domains associ- cal damage associated with drug use. This ated with drug abuse. This provides a more would provide an excellent opportunity to structured way of assessment of an individual. treat comorbid physical problem and also Several rating scales and instruments exist to use this evidence to enhance motivation assess different domains. Some of these instru- towards abstinence ments have high sensitivity so that they can be used for screening purpose. Instruments with Mental status examination high degrees of specificity confirm the diagnosis of SUD. Some instruments may require Though a detailed description is outside the training to enable the individual to administer purview of the current chapter, in mental sta- the particular instrument. tus examination, attention is given to the general appearance and behavior of the patient Thus, it can be seen that assessment can be (dressing, grooming, mannerism, motor activ- carried out using several sources of informa- ity, and eye contact), the nature of his affect tion as well as using different measures. Though (mood: happy, sad, anxious), speech (rate, vol- investigations and rating scales can aid in as- ume, pitch, coherence, relevance), the content sessment, a thorough clinical assessment serves of the patient’s thought (delusions, obsessions, a number of additional purposes including es- depressive thought, suicidal ideas), perceptual tablishing rapport as well as increasing moti- disturbances (illusions, hallucinations) and vation of the individual.

4 Assessment and Diagnosis in Substance Use Disorder Validity of self reports DIAGNOSIS Many clinicians are of the impression that self Before looking into features that make a diag- report, especially in the area of substance use, nosis of SUD, it would be beneficial to see what may not be reliable because of a perceived constitutes a disease. notion that the substance user does not accu- A cluster of signs and symptoms rately report the extent of his substance use. occurring more than due to chance factor 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 Syndrome reliable by enhancing motivation and devel- An etiology associated with oping an empathic and non judgemental atti- occurrence of syndrome tude towards drug user. Disease Several factors have been suggested that increase SUD, like most other psychiatric disorders, is the validity of self reports. still at the syndromal level. This is because 1. the patient is alcohol and drug free when there is no definite etiology to explain SUD. interviewed In the absence of a definite etiology, the diagnosis of SUD is based on a cluster of signs and 2. sufficient time has passed since last drink/ symptom. Many hypothetical constructs or drug use to allow clear responses models exist to explain the occurrence of a par- 3. confidentiality is assured. ticular syndrome. Some of these, for SUD, are moral model (use seen as sin, crime), charac- 4. the setting is non threatening and non terological (use seen as a defect in personality), judgemental. conditioning model (use as a result of classical 5. the patient does not feel pressured to and operant conditioning) and biomedical respond in a particular way. model (genetic and physiological/biological cause of SUD). However, it is not possible to 6. the patient has no reason to distort reports explain the phenomenon of SUD based on one (e.g. abstinence being a condition of pa- model exclusively. In the face of this, people of role). different schools of thought would diagnose 7. the patient is aware that corroborating in- SUD differently. Thus, a clinician ascribing to formation is available and will be collected the biological model would place more impor- (e.g. breath test, report of spouse), and that tance to the biological changes caused by substance, while another of psychological school this information from other sources will be would place importance on the psychological used to confirm what he or she reports. factors to make a diagnosis of SUD. This natu- 8. the questions are clearly worded and valid rally would lead to a variable diagnosis of SUD. measurement approaches are used. To this effect the World Health Organization 9. the assessment worker or therapist has a (WHO) and the American Psychiatric Associa- good rapport with the patient. tion have independently proposed a cluster of 10. the person administering the measures factors to make a uniform diagnosis of SUD. These classificatory systems aim to be should be able to communicate clearly with atheoretical. The current versions are the patient. polythetical, meaning that no single criterion

5 Assessment and Diagnosis in Substance Use Disorder is necessary or sufficient to make a diagnosis. drawal symptoms. Rather, the diagnosis is made by the presence Every class of substance produces its own of a fixed number of criteria out of the larger set of signs/ symptoms of withdrawal. For group. The most commonly followed diagnos- e.g. alcohol withdrawal would produce tic system is that published by WHO, the ICD tremors, sweating, nausea/ retching/ vom- 10 (International Classification of Diseases). iting, insomnia, palpitations with tachy- ICD 10 classifies SUD into intoxication, harm- cardia, hypertension, headache, psychomo- ful use, dependence syndrome, withdrawal tor agitation and in severe cases, hallucina- state, psychotic disorder and amnestic tion, disorientation and grand mal seizures. syndrome. This chapter deals with the ‘depen- c) Impaired capacity to control substance use dence syndrome’ and ‘harmful use’. behavior in terms of its onset, termination Dependence syndrome or level of use as evidenced by the substance being often taken in larger amounts or over Dependence syndrome has been defined in ICD a longer period than intended; or by a per- 10 as “A cluster of physiological, behavioural sistent desire or unsuccessful efforts to re- and cognitive phenomena in which use of a duce or control substance use. substance or a class of substances takes on a much higher priority for a given individual than Thus, an individual may find it difficult to other behaviours that once had greater value” avoid using substances at particular place or time or also to limit himself to a par- The criteria for substance dependence syn- ticular predetermined amount. Some re- drome has been influenced by the criteria laid searchers are of the view that loss of control down by Edwards and Gross (1976) for the is the most important criterion determin- diagnosis of Alcohol dependence syndrome. ing substance use. Though Edwards and Gross laid down the cri- d) Preoccupation with substance use, as mani- teria particularly for alcohol dependence, this fested by important alternative pleasures or has been used uniformly to diagnose all classes interests being given up or reduced because of substance dependence. The ICD 10 criteria of substance use; or a great deal of time specifies dependence as three or more experi- spent in activities necessary to obtain, take ences exhibited at some time during a one year or recover from the effects of the substance. period e) Continued use inspite of clear evidence of a) Tolerance: there is a need for significantly harmful consequences, as evidenced by con- increased amounts of the substance to tinued use when the individual is actually achieve intoxication or the desired effect, or aware, or may be expected to be aware, of a markedly diminished effect with contin- the nature and extent of harm. ued use of the same amount of the substance. f ) Strong desire to use substance (craving). For e.g., an individual would have started with 60ml of whisky to obtain pleasure, This craving may occur spontaneously or however with continuous use, he has to con- induced by the presence of particular sume 180 ml of the same to obtain the same stimuli. Exposure to stimuli where or with amount of high. whom the individual would have used the substance would lead to a strong desire to b) Physiological withdrawal state: character- consume the substance. This is termed ‘cue istic symptoms experienced on stoppage/ induced’ craving. reduction of a substace after prolonged use. The patient uses the same (or closely re- Criteria (a) and (b) are physiological, while lated) substance to relieve or avoid with- criteria (c), (d) and (f) are psychological in

6 Assessment and Diagnosis in Substance Use Disorder nature. Thus, not one domain is sufficient to using behavior. Thus, because of this view cli- diagnose dependence. For e.g. cancer patients nicians often assume a confrontational style and who are given opioid as analgesics may have tol- much of the efforts goes into making the pa- erance and withdrawal. However they may not tient accept/realize his drug use i.e. ‘addict/ be diagnosed as having dependence syndrome alcoholic’ label. However, such an approach unless they fulfill other criteria. The dependence would make the drug user move away from the syndrome criteria are not an all or none state, treatment rather than towards it. Research has rather one that exists in degrees of severity. found that these labels and opinions regarding Harmful use drug user is falsely based. Denial is not a personality of drug abuser, but a modifiable state. ICD 10 uses the category of harmful use as a Treatment works, but the clinician should state that constitutes a. not insist that the individual accept the la- a) A pattern of substance use that is causing bel of ‘addict/ alcoholic’ damage to health. The damage may be b. express a warm and affective concern about physical or mental. The diagnosis requires the problem that actual damage should have been caused to the mental or physical health of the user. c. be non directive, non judgemental and supportive b) No concurrent diagnosis of the substance dependence syndrome for the same class of Such an approach goes a long way in effectively the substance. engaging a drug abuser in treatment process. The DSM IV equivalent of this category is Conclusion ‘abuse’. This includes social, legal and occupa- The magnitude of SUD is enormous. How- tional consequence of drug use in addition to ever the experts to treat such patients are few. physical and mental harm. Because there may The primary physicians are better suited to form be cultural difference that may result in different impact on the social, legal and occupational a cost effective alternative to this. While a front, ICD 10 has intently omitted these and comprehensive treatment requires a compre- stuck to the health damage only. hensive evaluation, the assessment done is guided by a number of factors. Apart from Technique and style in assessment and diagnosis diagnosing substance related problems, assess- The traditional view regarding substance abus- ment provides a very good opportunity to ing population is that drug abusers are to a develop rapport with patients. This goes a long large extent unmotivated, are in a state of de- way in management of SUD. nial and resistant to change/ stop their drug

Suggested Reading

1. Galanter M, Kleber HD, eds. The American Psychi- 3. McCrady, B.S. & Epstein, E. eds. Addictions: A atric Press Textbook of Substance Abuse Treatment, Comprehensive Guidebook. New York: Oxford Uni- American Psychiatric Press, Washington D.C.; 1999. versity Press; 1999: 477-498. 2. Lowinson J, Ruiz P, Millman R, Langrod J, eds. Sub- 4. Mood Disorders. In: Diagnostic and Statistical Manual of stance abuse, A comprehensive textbook, 4th ed. Bal- Mental Disorders, Fourth Edition, (DSM-IV), Text Revi- timore: Lippincott Williams and Wilkins; 2005. sion (2000), American Psychiatric Association: 297-343.

7 Assessment and Diagnosis in Substance Use Disorder Suggested slides for OHP

Slide 1 appendix) SUD is common among general population Investigations – for confirming substance use & estab- Specialised Deaddiction centres are able to treat only lishing physical damage caused by substance use few patients and are often last point of contact Questionnaires – provides for structured assessment Primary care physicians are often considered initially for Self reports – largely found to be reliable problems other than SUD Slide 7 Slide 2 Reasons to assess patients Diagnosis Diagnosis and treatment Syndrome = signs + symptoms, Disease = etiology Screening ascribed to syndrome Referral to a specialist Psychiatric disorders, including SUD, are at syn- Establish rapport and increase motivation drome level Uniform Criteria for diagnosis of SUD, proposed Slide 3 by WHO (ICD) and APA (DSM) Stages of assessment Both criteria are polythetic in nature Preintervention – define problem and formulate a No single criterion necessary or sufficient treatment plan Intervention – monitor program Slide 8 Post intervention – assess maintenance ICD 10 criteria for dependence Setting – inpatient v/s outpatient Tolerance Slide 4 Withdrawl Craving Levels of assessment Brief screening Difficulty in controlling substance use Basic assessment to diagnosis Continued use despite knowledge of harm Specialised assessment to treat individuals Neglect of all pleasures or great deal of time spent Reassessment for continuing care on substance use

Slide 5 Slide 9 Screening Harmful use Applied to a large group Substance use causing damage to physical Brief in duration or mental health Usually applied in high risk non treatment seeking Doesn’t fulfill criteria of diagnosis anytime individuals Questionnaires with a high degree of sensitivity ‘Abuse’ term used by DSM IV to describe legal, social, available which are easy to apply occupational and physical damage by substance use Slide 6 Tools of assessment Clinical Investigations Questionnaires Clinical – history & examination (points provided in

8 Epidemiology of Substance Use 3

Hem Raj Pal, Amardeep Kumar

Summary in humans. This definition as applicable to substance use would be “the study of distribu- Data on substance use is required from differ- tion and determinants of substance use in humans”. ent regions in the country as the likelihood of regional disparity in substance use is high. The Information obtained from the epidemiology recently completed project “The extent, pat- of substance use is as follows – tern and trends of drug abuse in India” pro- 1. Extent of substance use problem. vides nationwide data of substance use among general population (NHS), treatment seeking 2. Nature and pattern of substance abusing substance using population (DAMS), hidden behaviour. substance using population not seeking treat- 3. Characteristics of persons abusing the sub- ment (RAS) and certain special groups (FTS). stances. The finding refutes certain previously held 4. Change in the trend of substance use over notions about substance use in India; e.g. IDU time. use being found all over India as opposed to 5. Factors that may be associated with or etio- previously held belief that only North- East- logically related to substance use. ern states are affected. Similarly picture from rural India is a worrying finding as it reflects The information obtained from the epidemio- heroin use and injection opioid use. Indulgence logical studies helps in understanding the sub- in unsafe sexual and injection drug use prac- stance use problem in two ways – tices by a substantial proportion of our drug using population along with limited number 1. At a macro level – for a policy maker of functional specialized drug dependence whereby treatment and prevention related treatment centre is another cause of concern. policy issues can be planned. Among licit drug use, doubling of per capita 2. At a micro level – for a clinician whereby alcohol consumption over past two decades is information about risk factors and outcome another worrying finding. However, the find- can be obtained leading to effective treat- ings of the project provide only baseline infor- ment of substance use problem. mation for further study. It gives a wakeup call to policy makers as well as treating clinician to Indicators of Substance Use Problem tackle the problem more effectively. Cost-ef- There are number of indicators pointing to- fective screening instruments and intervention wards extent and magnitude of substance use need to be developed to tackle the problem. problems in a population. Arbitrarily they can There is a need to continuously monitor chang- be divided into direct indicators and indirect ing trends in substance abuse. indicators. Introduction Direct indicators Epidemiology is defined as the study of distri- Surveys – In direct epidemiological studies or bution and determinants of disease frequency surveys researchers go into a community and 1 Epidemiology of Substance Use collect information about substance use pat- of planning, focused preventive and thera- tern. This approach gives a reasonably accu- peutic intervention strategies. For these rate picture of extent of substance related groups of substances, a sample of high-risk problems.Additionally,this approach has the population is more appropriate. advantage of finding out about substance us- z How to obtain information? Most of the stud- ers who are not seeking treatment. ies obtain information regarding substance Surveys also obtain information about demo- use from the subjects. However due to cer- graphic variables, pattern of drug use, percep- tain limitations posed by this approach tion of risk associated with drug use, health such as feasibility, misinformation, ‘hidden’ and adverse psychological consequences and phenomenon of illicit drug use, alternative treatment history (if any). techniques to obtain the information have also been developed. Two such techniques In India, the National Household Survey of are: Drug and Alcohol Abuse (NHS) sponsored by Ministry of Social Justice and Empowerment, (a) “Key information technique”: This tech- Government of India (MSJE, GOI) and United nique elicits information on substance Nations Office on Drugs and Crime, Regional use and its profile in the persons under Office for South Asia (UNODC, ROSA) has survey from key informant. ‘Key infor- recently been completed. This survey was a part mant’ is usually person with respectabil- of larger project- the ‘National Survey on Ex- ity, knowledge and wisdom, and they are tent, Pattern and Trend of Drug abuse in In- considered to be quite reliable source of dia’. This is the first study that aimed to gen- information. Examples of key informants erate national level prevalence estimates of drugs are Head of the Household (HOH), of abuse in India. teachers, local community leaders, etc. (b) “Snowball” technique: This technique Issues that need to be addressed while conduct- makes use of few identified substance ing a survey include: users, who provide information about other users. The newly identified users z Where to conduct a study? A preliminary are contacted to obtain information about study needs to be carried out to identify other users and so on. This technique is high prevalence areas. Thereafter surveys particularly effective in surveys and stud- focus on these areas. ies looking for illicit substance use. z How to select a sample? For licit substances, z What information is to be obtained? Depend- surveys which select a sample representa- ing upon the objectives of study and re- tive of general population, generates most sources available, a variety of information generalisable result and has usefulness in could be obtained including nature of the planning policies related to prevention and substance being used, its pattern, adverse therapeutic intervention strategies. For consequences, treatment history and per- illicit substances whose use are more preva- ception of risk. Normally surveys do not lent in certain high-risk population such generate a diagnosis of abuse and depen- as students, slum-dwellers, drivers trans- dence. They focus on information such as portation workers and commercial sex- ‘ever use’ (any time in the past), ‘recent workers. Sample representative of general use’ (past 1 year), and ‘current use’ (past 1 population has limited usefulness in terms month) of the substance

2 Epidemiology of Substance Use Whereas survey is a cross sectional study, sur- GLOBAL SCENARIO veillance is defined as “the continuous scrutiny of Licit substances the factors that determine the occurrence and distribution of disease and other conditions of ill- Alcohol health i.e. use of substance”. The main purpose of surveillance is to detect changes and iden- Alcohol consumption has numerous health and tify trends. social consequences and is an important contributor to death and disability. Alcohol is es- Indirect indicators timated to cause about 20-30% of oesophageal cancer, liver cancer, and cirrhosis of the liver, Indirect indicators are those which do not di- homicide, epilepsy, and motor vehicle acci- rectly provide information regarding substance dents. Worldwide, alcohol causes 1.8 million use in a population, but they are elicited from deaths each year the data already available somewhere. This data is then secondarily analyzed to gauge the ex- Globally alcohol consumption has increased in tent of substance use problems. Some such in- recent decades, with all or most of that increase dicators can be – being in developing countries 1. Production and consumption of substances Tobacco

2. Seizure of illicit drugs. Tobacco continues to be the substance causing the maximum health damage globally. Accord- 3. Drug related illness. ing to WHO estimates, there are around 1.1 thousand million smokers in the world; about 4. Reporting systems: Data obtained from one-third of the population aged 15 and over. persons attending heath services notably While consumption is levelling off and even drug dependence treatment services can decreasing in some countries, worldwide more provide valuable indirect information re- people are smoking, and smokers are smoking garding substance use problems in the com- more cigarettes. Substantially fewer cigarettes munity. are smoked per day per smoker in developing India has no national system to monitor drug countries than in developed countries. How- abuse currently. An attempt was made to de- ever, this gap is fast narrowing and unless ef- velop and establish a National Drug Abuse fective tobacco control measures take place, Monitoring System (DAMS) as a part of larger daily cigarette consumption in developing project- the ‘National Survey on Extent, Pat- countries is expected to increase as economic tern and Trends of Drug Abuse in India’. The development results in increased real dispos- study obtained data from 203 agencies across able income. India. According to the World Health Report 2002, The major limitation of this approach is that among industrialized countries where smok- it touches only the tip of the iceberg since not ing has been common, smoking is estimated all substance users come for treatment. In or- to cause over 90% of lung cancer in men and der to assess the extent and magnitude of sub- about 70% of lung cancer among women. In stance use in a community the best way is a addition, in these countries, the attributable direct epidemiological study or survey. fractions are 56-80% for chronic respiratory disease and 22% for cardiovascular disease.

3 Epidemiology of Substance Use Worldwide, it is estimated that tobacco cause culture and the age of initiation is usually lower about 4.9 million deaths each year and unless than for other drugs. current trends are reversed, that figure is expected to rise to 10 million deaths per year in Amphetamine–type stimulants (ATS)- another 20 years, 70% of those deaths occur- Amphetamine-type stimulants (ATS) refer to ring in developing countries. a group of drugs whose principal members in- Illicit substances clude amphetamine and methamphetamine. However, a range of other substances also fall Opiates– into this group, such as methcathinone, fenetylline, ephedrine, pseudoephedrine, me- Reports by the UNDCP have shown that there thylphenidate and MDMA or ‘Ecstasy’ – an has been a global increase in the production, amphetamine-type derivative with hallucino- transportation and consumption of opioids, genic properties. mainly heroin. The worldwide production of heroin has almost tripled since 1985. Glo- The use of ATS is a global and growing phe- bally, it is estimated that 13.5 million people nomenon and in recent years, there has been a take opioids, including 9.2 million who use pronounced increase in the production and use heroin. of ATS worldwide. Over the past decade, abuse of amphetamine-type stimulants (ATS) has Although in recent time the production of infiltrated its way into the mainstream culture heroin in 2002 was more or less at the same in certain countries. Younger people in par- level as in 1998, regional shift has markedly ticular seem to possess a skewed sense of safety reshaped the patterns of heroin abuse in the about the substances believing rather errone- world. The rapid growth of opium production ously that the substances are safe and benign. in Afghanistan has fuelled the development of a large heroin market in the region and, fur- For many countries, the problem of ATS is rela- ther, in Central Asia, the Russian Federation tively new, but is rapidly growing and unlikely and East Europe. An increase in intravenous to go away. The geographical spread is widen- heroin abuse has led to an increased prevalence ing, but awareness is limited and responses are of HIV/AIDS. neither integrated nor consistent. Recent data has shown a decline in ATS use in the regions Cannabis – of the Americas and Europe, while the highest Cannabis is by far the most widely cultivated, levels of abuse worldwide have emerged in East trafficked and abused illicit drug. Half of all Asia and Oceania. According to a review of ATS drug seizures worldwide are cannabis seizures. by UNDCP in 1996, there are about 20 coun- The geographical spread of those seizures is also tries in which the abuse of ATS is more wide- global, covering practically every country of the spread than that of heroin and cocaine com- world. About 147 million people, 2.5% of the bined. Japan, Korea and the Philippines all world population, consume cannabis (annual register 5-7 times the rate of ATS use com- prevalence) compared with 0.2% consuming pared with heroin and cocaine use. cocaine and 0.2% consuming opiates. In the Smoking, sniffing and inhaling are the most present decade, cannabis abuse has grown more popular methods of ATS use, but ways to take rapidly than cocaine and opiate abuse. Can- the drug vary widely across the region. In coun- nabis has become more closely linked to youth tries like Australia, where over 90 per cent of

4 Epidemiology of Substance Use those who report using ATS (mostly metham- INDIAN SCENARIO phetamine) inject, the drug represents a In 1999, the Ministry of Social Justice and significant risk factor in the transmission of Empowerment, Government of India (MSJE, blood-borne viruses. Philippines and Viet Nam GOI) and the United Nations International are also reporting signs that injecting meth- Drug Control Programme, Regional Office for amphetamine is increasing while in Thailand South Asia (UNIDCP, ROSA) decided to un- the number of methamphetamine users now dertake a large-scale national survey to obtain represents the majority of all new drug treat- information on extent, pattern and magnitude ment cases. of substance abuse in the country. The study Cocaine – had several components, which could be called “……carried out first time in India”. For this Cocaine and its derivative ‘crack’ provide an purpose multiple indicators and several meth- example of both the globalization of substance ods to assess the situation were chosen. use and the cyclical nature of drug epidemics. Traditionally coca leaves have been chewed by The major components of this survey were people in the Andean countries of South National Household Survey (NHS), Drug America for thousands of years. Cocaine be- Abuse Monitoring System (DAMS) and Rapid came widely available in North America in the Assessment Survey (RAS). Additionally, focused 1970s and Europe in the 1980s. studies on special populations like women, rural subjects, people living in border towns Prevalence rates for lifetime use of cocaine are and prison population have also been carried typically 1-3% in developed countries, with out. Finally, burden as perceived by women higher rates in the United States and in the due to drug abuse in the family has also been producer countries. Cocaine dependence has enquired into. become a major public health problem, resulting in a significant number of medical, psy- National Household Survey (NHS) is one of chological and social problems, including the the first nationwide surveys which aimed at spread of infectious diseases (e.g. AIDS, hepa- determining prevalence of the use of licit (to- titis and tuberculosis), crime, violence and neo- bacco, alcohol and prescription medications) natal drug exposure. drugs & illicit (opiates and cannabis) drugs, studying some socio-demographic correlates of Box 1 : drug abuse and estimating the extent of drug dependence for alcohol and opiates for coun- zzz Licit substances (alcohol and tobacco) are try as a whole.The survey was conducted to the most commonly used substances. provide estimates of the prevalence at the na- zzz Among illicit substances, heroin and cocaine tional level drawing a sample of 40,000 males have most serious health related effects. from 25 states of the country. The data was zzz Heroin abuse is increasing in Central Asia, collected between March 2000 and Novem- the Russian Federation and East Europe. ber 2001 through face to face interviews with zzz Largely caused by IDU, HIV/AIDS epi- the respondents by trained interviewers. The demic has been expanding at an alarming diagnosis of dependence was arrived using rate in South-East Asia. WHO (ICD-10) criteria. zzz ATS abuse is clearly shifting towards East The data for Drug Abuse Monitoring Survey and South-East Asia in recent years. (DAMS) component was obtained from con-

5 Epidemiology of Substance Use secutive new patients contacting various treat- The five focused thematic studies (FTS) were ment centres. In addition, information on the designed to capture information in the follow- drug abusing population was also obtained ing areas: drug abuse among women, the bur- from prisons, NGOs working with children, den on women due to drug abuse by family NGOs working with HIV/ AIDS affected per- members, drug abuse among the rural popu- sons, youth organizations (Nehru Yuva lation, the availability and consumption of Kendras) and psychiatric hospitals. drugs in border areas. The Rapid Assessment Survey (RAS) collected A comprehensive picture of a country can only information on drug use through in-depth in- be obtained through multiple data sources us- terviews of identified drug users (non-random ing multiple methodologies, as has been car- sample), key informants and focus group dis- ried out in the current survey. Each element cussion from 14 urban sites. supplements another. Table 1- Objectives of major components of National Survey NHS DAMS RAS Prevalence of lifetime and Develop a monitoring system Study the extent and nature current use of various for the country of drug use in the identified substances urban sites Estimate the extent of Collection of data from Study the demographic char- substance dependence people seeking treatment acteristics, drug use patterns, risk behaviors, adverse health and social consequences of drug users Socio-demographic correlates Develop a format for Study the service demand of collecting information on a drug users and the existing regular basis treatment responses Recommend an action plan to reduce the adverse consequences of drug abuse Source : National Survey, 2004 Table 2: Major Drugs of Abuse in India Drug Type NHS (current prevalence, %) DAMS (% among treatment seekers) Alcohol 21.4% 43.9% Cannabis 3.0% 11.6% Heroin 0.2% 11.1% Opium 0.4% 8.6% Other Opiates 0.1% 6.3% Source : National Survey, 2004

6 Epidemiology of Substance Use - Alcohol, cannabis, opium and heroin are - Very few cannabis users reported for treat- the major drugs of abuse in the country as ment. shown in the table. It was observed that between 17 and 26 per- - Relative importance of the drugs as seen in cent of current users of various substances were the general population (NHS) and among dependent users. Thus, the proportion of de- treatment seekers (DAMS) is different. pendent users would be around one quarter of - Alcohol is the most frequently used sub- the total population shown in table 3 requir- stance as seen in the NHS and the DAMS. ing immediate treatment for substance use problem. An attempt has been made to project - The relative proportion of opiate users is the total number of males abusing various drugs high in the treatment centres (26%) for the nation as a whole based on the preva- though their prevalence is low in general lence figures is depicted in the table below- population (0.7%). Table 3- Estimates of Number of Users of Select Drug Type (approximate, in millions Based on 1991 census male population stratified for age (15-60 years) adjusted for ten-year growth in males) Drug Type Ever Use Current Use Tobacco 168.99 162.86 Alcohol 75.59 62.46 Cannabis 11.96 8.75 Opiates 2.92 2.04 Sedative/ Hypnotics 0.58 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 (%) Annual Prevalence (%) Annual Prevalence (%) of alcohol use among of Opiate Abuse among those of cannabis abuse among adult males 15 years and older those 15 years and older . India (2001, past month India (NHS, 2001 past India (NHS, 2001 past use)- 21.4. month use)- 0.7. month use)- 3.0. Canada ( 1997)- 78.1. Canada-0.2. Canada- 7.4. Finland (1995)- 90. Russian federation-0.9. Russian Federation-0.9. Sweden (1997)-90. U.K-0.6. U.K-9.0. Poland (1997)-93.8. Australia (1998)-0.7. Australia (1998)-17.9. Australia (1996)-80. Pakistan (1997)-1.7. Pakistan (1998)- 1.2. China (1997)-87.3 Bangladesh-0.6 Bangladesh- 3.2. Nepal (1996)- 0.3. Nepal (1996)-2.8. Sri Lanka (1997)-0.3 Sri Lanka ( 1999)-1.4 Source : National Survey, 2004

7 Epidemiology of Substance Use - Annual prevalence of drinking among adult - The current prevalence of cannabis use in males in India is low. However, the worry- India is relatively low when compared to ing development is that over two decades other countries. the consumption of alcohol in India has The high prevalence of opiate use in the coun- increased by 106 percent as against many try is a worrying phenomenon. The number of countries where the consumption of alco- persons requiring help is deemed enormous hol declined. when projecting the prevalence data on to a - Annual prevalence of opiates in other coun- male population that stood at 531 million as tries is relatively low. 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) Region NHS DAMS North-East Nagaland, Arunachal Pradesh, Manipur …….. North Himachal Pradesh, Haryana Uttar Pradesh West ………. Maharashtra South ……….. Kerala Source: National Survey, 2004

Table 6: Regional variation of Cannabis abuse in India (high use regions) Region NHS DAMS North- East Manipur ……… North ……….. Uttar Pradesh East Bihar Bihar Source: National Survey, 2004

Table 7: Regional variation of Opiate abuse in India (high use regions) Region NHS DAMS North- East Mizoram, Nagaland, Arunachal Pradesh ………. North Haryana, Himachal Pradesh, Punjab Punjab, Uttar Pradesh East ……….. West Bengal West Rajsthan Rajsthan Source: National Survey, 2004 Changing Trends of substance use in India The RAS component of the study provided certain indicators, which suggest emerging trends. These can be summarized as in the next table-

8 Epidemiology of Substance Use Table 9: New emerging trend of substance use in India Substance Region LSD Goa, Ahmedabad Methaquolone Bangalore, Ahmedabad Inhalants Delhi, Bangalore, Thiruvananthapuram Inj. Propoxyphene Imphal, Dimapur Pharmaceutical products Amritsar, Ahmedabad, Imphal, Dimapur, Mumbai and Kolkata Source: National Survey, 2004 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 transmission 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 Items NHS DAMS RAS RAS (National) All 14 sites Non-metros Drug users (States) 9 sites (States) IDU (%) Lifetime 0.1 14.3 43.0 33.4 Current …. 9.4 …. …. Sharing of 97.0 7.7 …. 57.9 needles/ syringes (%) Sex with …. 4.4 …. 24.4 CSWs (%) Practice of …. 38.5 41-64 35.9 safe sex (%) Source: National Survey, 2004 - Sharing of needles is extremely common in population, border areas and prison popula- the sample studied in NHS as well as RAS tion. The summarized study findings are- and overall varied between 58 and 97 %. - Women are sufferers either directly due to - Other high-risk behaviour i.e. unsafe sex substance use by themselves or indirectly and sex with CSWs was also seen. as a consequence of substance use by spouse Concerns of Special Populations or another family member. - The data from women drug users showed The study also provides information that opiates (heroin and propoxyphene), on special population such as women, rural

9 Epidemiology of Substance Use alcohol and minor tranquillizers were be- population. ing abused. This contradicts a prevalent - Youth and very young drug users were in- myth about drug use by women, that tran- dulging in several high-risk behaviours like quillizers are the exclusive drugs of choice. IDU, needle sharing and unsafe sex practices. - Abuse of heroin and IDUs were reported Treatment seeking in rural settings too. The figure below give an account of treatment - Drug abuse is prominent in rural India but seeking (ever) for substance use problems as with inadequate service delivery for the found by the various survey components.

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

80 73 70

40 33.3 30 24.4 26.9

20 18.7 1.4 10 2 4 0 (Alcohol) (Cannabis) Opiates IDU DAMS RAS Rural Border NHS NHS NHS NHS

Needs of Users and Service Requirements Service requirements reveal that modification is needed in data collection due to the chang- Focussed Group Discussions with Drug Users ing need of drug using population. These re- Revealed – quirements include – - Treatment should be free and available to all. . Low cost surveillance - Identity of the person seeking treatment . Improve data collection on drug related mor- should not be revealed. bidity and mortality - Proper medication and counseling should be available. . Surveillance of IDU and linkages with HIV/ AIDS - Some requested for drug substitution.

10 Epidemiology of Substance Use The overall findings can be summarized as thus: IDUs. In tribal areas, consumption of home brewed alcoholic beverages occurs among both zzz Alcohol, cannabis, opium and heroin are the sexes. Raw opium consumption for thera- the major drugs of abuse. peutic and other traditional purpose is preva- zzz The number of persons requiring treat- lent in women in Rajasthan. ment is large. Age: zzz Drug abuse is seen in both rural and ur- The age group of 15-24 years has emerged as ban India which is against the previously critical period for the initiation of substance held belief that it is mostly found in ur- use habit and more than half of the abusers of ban population. all substances use the substance for the first zzz IDUs have been reported from various time at this age. Tobacco use starts at an even sites, including rural India as opposed to earlier age. Among college students, the boys previously held belief that IDU is mainly are initiated to drug use a year or two before limited to North-Eastern states. entering college and among girls, it is two-three years after entering college. Most of the opiate zzz One study reported IDU among women. dependent individuals are in the age group of zzz A large number of drug users engage in 21 to 30 years and there is a decline in opiate unsafe sex practices. use in those above 40 years of age. zzz Multiple other high-risk behaviours were Occupation: reported. Substance abuse has been reported from dif- zzz Several common variables associated with ferent occupational categories such as students, drug abuse were identified across various factory employees, auto rickshaw drivers, sex- survey components and thematic studies. workers, professionals and businessmen. About zzz Congruence between treatment seeking one- third to half the drug dependent indi- and the extent of the problem in a given viduals were either currently unemployed or state was lacking. had never been employed. One of the important use of epidemiological Other Determinants studies is to give some information on Genetic: aetiological factors (risk factors) associated with substance use. Some information about risk Family studies from West have demonstrated factors for substance dependence can help to that the risk of alcoholism was much higher target strategies to prevent dependence. Most among the first- degree family members of an of the data available is related to demographic alcoholic. On an average, the risk was increased factors associated with substance dependence. seven times. Studies of twin pairs also demonstrated a genetic influence. There is also a high FACTORS ASSOCIATED WITH SUB- correlation between smoking by parents and STANCE DEPENDENCE child’s substance use. Sex: Co-morbidity: Substance abuse is primarily a phenomenon The diagnosis of other substance abuse, anti- occurring among the males in India but women social personality, mania, schizophrenia, de- also indulge in abuse of a few drugs like alco- pression and anxiety disorders are also associ- hol, tobacco, minor tranquillizers, heroin and ated with alcoholism and drug dependence.

11 Epidemiology of Substance Use Attitude towards Substance Abuse Population screening instruments for substance abuse need to be highly sensitive, easy to ad- Personal minister and brief. It also needs to be validated Perceived positive effects, harmful effects, on the population to be used. whether own abuse perceived as a problem, sources of help perceived as available/useful are Screening instruments available for alcohol use important determinants. disorders are CAGE, MAST and AUDIT. (Appendix). Societal The AUDIT has been validated for use in In- Tolerance/ ambivalence towards substance dian population through a study co-coordi- abuse amongst specified groups (e.g., age, sex, nated at National Drug Dependence Treatment occupation) and situational context are impor- Centre (NDDTC), AIIMS, New Delhi. tant determinants. Interventional epidemiology Personality variables To be useful for public health, data obtained Self-esteem, sense of personal control, anxiety, from epidemiological studies need to provide depression and disturbed mood states influ- effective methods of early interventions so that ence drug use. the problem can be tackled at an early stage in Interpreting Epidemiologic Research a cost-effective manner. Interventional epidemiology deals with generation of such inter- Methodological Issues ventions. 1. Concepts and definitions – Although there Linking screening and intervention is consensus about the concept of the term dependence, certain terms like disorder, Screening instruments and interventional problematic or morbid pattern of use methods are closely linked. For example, by and what constitutes a case are subject to using AUDIT as a screening instrument for individual interpretations. alcohol use disorder one can roughly estimate the number of alcohol using problematic pa- 2. Reliability of information – The major tients. Depending upon the cut-off score, vari- source of information in epidemiological ous level of severity of alcohol problem can be studies is the individual himself. The ac- estimated i.e. mild, moderate and severe. De- curacy and reliability of information remain pending upon the degree of severity, specific questionable due to factors such as social- intervention that is cost-effective can be used. stigma and denial. For example, in mild degree of severity of alco- 3. Geographical variations – The pattern of hol use problem, community based Brief In- substance use and frequency of substance tervention strategies have been found to be very related disorders varies across geographical useful and cost-effective. areas. This limits the generalization of re- Suggested guidelines for getting familiar with sults obtained from one area or community. local epidemiology Population Screening Instruments It is important to follow certain guidelines if These are the instruments which help in the one wishes to be familiar with epidemiology of early detection of substance use problem. They substance use in your area. Some suggestions are very useful in general population settings. are-

12 Epidemiology of Substance Use 1. To have a clearly stated aim and objective ferred source of information but in some of the study. cases key informants and snowballing may be the preferred approaches. 2. To decide the study design- To study the prevalence of substance use in a locality 5. What information to obtain: Depends on survey is preferred. However, other indi- the aim and objective of the study. Com- rect indicators can also be studied, such as monly, following information is obtained- studying drug-related illness from hospi- · Socio-demographic information- Age, tal emergency room data. Sex, Social class, Occupation, Education 3. To decide the universe of study- depend- · Drug use information- Type of drugs ing on how the results are going to be used. used, amount and frequency of use For policy issues general community is pre- · Treatment history and Complications- ferred universe but for treatment planning Medical, Psycho-social specific areas such as slums, college cam- · For IDU- H/o needle sharing, unsafe pus/university area may be preferred. sexual practices 4. To decide from whom to obtain informa- 7. Analysis of the data. tion: person using the substance is pre-

Suggested Reading

1. Kumar S M (2002). Rapid Assessment Survey of Nations Office on Drugs and Crime, Regional Of- Drug Abuse in India. Ministry of Social Justice and fice for South Asia. Empowerment, Government of India and United 7. UNODCCP (United Nations Office for Drug Nations Office on Drugs and Crime, Regional Of- Control and Crime Prevention) (2000). World fice for South Asia. Drug Report. United Nations Office for Drug and 2. Murthy P (2002). Women and Drug Abuse: The Crime Prevention, Vienna. Problem in India. Ministry of Social Justice and 8. UNODCCP (United Nations Office for Drug Empowerment, Government of India and United Control and Crime Prevention) (2001). Global Il- Nations Office on Drugs and Crime, Regional Of- licit Drug Trends 2001. United Nations Office for fice for South Asia. Drug and Crime Prevention, Vienna. 3. Ray R (2004). The Extent, Pattern and Trends of 9. Saxena S, Pal HR, Ambekar A (2003). Alcohol and Drug Abuse in India, National Survey. drug abuse, New Age International Publishers, New 4. Sethi H S (2002). Drug Abuse among Prison Popu- Delhi. lation: A case study of Tihar Jail. Ministry of Social 10. The Centre for Harm Reduction (2002). Revisit- Justice and Empowerment, Government of India ing ‘The Hidden Epidemic’- A situation Assess- and United Nations Office on Drugs and Crime, ment of Drug Use in Asia in the context of HIV/ Regional Office for South Asia. AIDS. The Burnet Institute, Australia. 5. Siddiqui H Y (2002). Drug Abuse Monitoring Sys- 11. Ministry of Social Justice and Empowerment, Gov- tem- A Profile of Treatment Seekers. ernment of India and United Nations Office on 6. Srivastava A, Pal H, Dwivedi S N, Pandey A (2002). Drugs and Crime, Regional Office for South Asia. National Household Survey of Drug Abuse in India. 12. Ministry of Social Justice and Empowerment, Gov- Report submitted to Ministry of Social Justice and ernment of India and United Nations Office on Empowerment, Government of India and United Drugs and Crime, Regional Office for South Asia.

13 Epidemiology of Substance Use Suggested slides for OHP

Slide 1 Slide 4

Epidemiology of drug abuse is the study of distribution Indian Scene of drug abuse in a population and factors associated º% National Survey (2004) - First nationwide survey with it. done for substance use Indicators of substance use problem º% Components- Direct indicators – Surveys NHS Indirect indicators RAS a) Production and consumption of substances DAMS b) Seizure of illicit drugs FTS c) Drug-related illness º% Major findings- d) Reporting systems · Alcohol, cannabis, opium and heroin - major drugs of abuse. Slide 2 · The number of persons requiring treatment - large. Global Burden of Substance use · Drug abuse is seen in both rural and urban India. Substance Number of users · IDUs have been reported from various sites, including Alcohol 2 billion rural India. Tobacco smoker 1.3 billion · A large number of drug users engage in unsafe sex Illicit drug 185 million practices. Death and Disability · Multiple other high-risk behaviours were reported. Death- 12.4% of all deaths · Congruence between treatment seeking and the ex- DALYs- 8.9% of DALYs lost tent of the problem in a given state was lacking. Regional distribution of Burden · Enrollment in treatment is low. Overall- DALYs lost higher in EURO and WPRO · The duration of drug abuse is long. regions · The time gap between onset of drug use and treatment Tobacco- Largest burden in EURO and SEARO re- seeking is significant. gions Slide 5 Alcohol- Largest burden in AFRO, AMRO and WPRO regions Factors Associated with Drug Dependence A) Sex- male more common Slide 3 B) Age-onset in adolescent or early adulthood Global trends C) Occupation varies D) Pattern of use in rural/urban areas ‘“Licit substances (alcohol and tobacco) - most com- E) Others- Genetic factors important in alcoholism monly used substances.’”Among illicit substances, heroin and cocaine - most serious health related ef- Slide 6 fects. ‘“Heroin abuse - increasing in Central Asia, Methodological issues the Russian Federation and East Europe.’”Largely A) concepts and definitions caused by IDU, HIV/AIDS epidemic expanding at B) Reliability of information an alarming rate in South-East Asia.’”ATS abuse shifting towards East and South-East Asia in recent C) Geographical variations years.

14 Acute Effects of Alcohol, Opioid and Cannabis Use 4

Kul Bhushan, BN Gangadhar.

Summary 2. Patterns of use: Includes the routes of administration, quantity and frequency of The acute effects of psychotropic substances use, route of administration and variations are determined by a number of factors. The in preparations. knowledge of acute effects of commonly used psychotropic substances is necessary to the pri- 3. Individual factors: Besides differences be- mary care physician for accurate diagnosis and tween naive and experienced users, geneti- management. Along with the acute effects on cally determined susceptibility accounts for various body systems as well as psychological the occasional psychotic reactions. Men- effects, mention is also made of the pharmaco- tal set and expectations too are important. kinetics of the substances as well as the signs/ symptoms of acute intoxications. This chapter 4. Social factors: Group influence, social am- deals with the commonly abused substances bience and shared values are a potent in- viz. alcohol, opioid and cannabis fluence in shaping the subjective experience both in content and magnitude. Introduction ALCOHOL The acute effects of psychotropic substances are determined broadly by 4 groups of factors: Ethyl alcohol (ethanol) is the active ingredient. Concentration of ethyl alcohol differs 1. Levels of use: Based on quantity used and across preparations: consequences, the use of psychoactive substances can be at one of two levels. Drinks prepared by using yeast to ferment various sugar containing plant products have a low a) Social use, with no apparent harm and concentration as yeast ceases to grow when the includes experimentation, group activ- concentration of ethanol reaches about 15%. ity, dietary practice and religious ritual. Stronger liquors, however, have become avail- Once initiated, susceptible individuals able in modern times through distillation. graduate to abuse and even dependence. Whisky, brandy, rum and gin contain 35% to 50% alcohol whereas beers ordinarily contain b) Pathological use, which includes abuse 4 to 5%.Wines contain approximately 12% and dependence characterised by crav- alcohol. However, fortified wines (prepared by ing, compulsive use, tolerance and the adding brandy to wine) may contain about withdrawal syndrome. 20% of alcohol.

1 Acute Effects of Alcohol, Opioid and Cannabis Use Table 1: Alcohol Preparations Preparation of Alcohol Concentration of Absolute alcohol Standard Drink alcohol by volume (gms/100ml) (%ABV) Beer (standard) 3-4 2.3-3.1 300-400 ml. Beer (strong) 8-11 6.2-8.6 100-150 ml. Wines 5-13 3.9-10.1 100-250 ml. Fortified Wines 14-20 10.9-15.9 60-90 ml. Spirits (Whiskey, Rum, 40 31.2 30 ml. Gin, Vodka, Brandy etc) Arrack 33 25.7 40 ml. The standard drink or a unit of alcohol corresponds to 10 ml of absolute alcohol. One Standard Drink = ½ bottle of Standard Beer = ¼ bottle of Strong Beer = 1 peg (30 ml.) Spirits = ½ packet of Arrack = 1 glass (125 ml.) of table wine = 1 glass (60 ml.) fortified wine

Absorption Metabolism Alcohol is rapidly absorbed from upper gas- Alcohol is eliminated from body at a rate of 7- trointestinal tract. Peak blood alcohol concen- 10 gm (1 standard drink) an hour. So, BAC tration (BAC) is reached in 30 to 60 minutes may remain elevated for considerable periods after consuming alcohol on an empty stom- following ingestion. If an individual drinks 9 ach. A number of variables influence the BAC large drinks (60 ml.) of whisky (18 units) dur- attained. It rises slowly if the drink is sipped ing an evening, then alcohol will still be present over a period but rapidly if it is gulped. The in his blood at noon the following day. larger the quantity of absolute alcohol, the higher the peak BAC. Alcohol absorption may Most of the alcohol in blood is metabolised in increase by as much as 20% as concentration liver by oxidation. Small amounts of alcohol rises. Carbonated beverages (e.g. soda) increase (2-4% of the total dose) are lost into the urine the rate of absorption of alcohol. Conversely, and into the alveolar air by diffusion. The al- food in the stomach, especially carbohydrates, cohol in alveolar air is in equilibrium with the delays the absorption and peak BAC. There is alcohol in the blood passing through the lungs; no sex difference in the time to reach peak BAC a determination of the alcohol concentration though in women the peak BAC is 20% higher in respiratory air by a breath analyzer can there- than in men since body water is only 50% of fore be used and estimate blood concentration body weight compared to 60% in men. For for medico-legal purposes. The concentration the average person of 70 kg body weight, one of alcohol in the urine is less precisely corre- drink (one standard unit of alcohol is 10ml of lated with the average blood concentration. absolute alcohol, i.e. 7.87g) is likely to raise Alcohol is converted by the activity of enzyme the BAC to approximately 15 to 20 mg/dl. Alcohol dehydrogenase (ADH) to acetalde- Consumed over a period of an hour, 60ml and hyde, which is oxidized to acetate by the en- 90 ml of whisky produce BAC of 50mg/dl and zyme Aldehyde Dehydrogenase (ALDH). Ac- 80mg/dl respectively. etate thus produced is rapidly converted to

2 Acute Effects of Alcohol, Opioid and Cannabis Use carbon dioxide and water. A variant of enzyme Despite being suitable and generally accepted Aldehyde Dehydrogenase is found in some as a social or recreational drug (relieves anxiety 40% oriental people. The individuals carrying and promotes social behaviour), alcohol impairs this variant have a remarkably reduced capac- judgement by reducing conscious self control ity to metabolize acetaldehyde and thus in- during the period of intoxication. Coupled crease in circulating acetaldehyde produces with a lack of insight into the impairment, the general vasodilatation with distinctive flushing individual undertakes activities that can be response. risky - driving cars, operating machinery, besides indulging in social indiscretions such Acute Effects of Alcohol as unsafe sex. Psychological Effects: Impairment of performance of real or simulated The effects of alcohol begin within about 15 driving provides a generally accepted index to minutes and last for several hours. Alcohol is a define drunken driving: blood alcohol concen- depressant of the central nervous system (CNS). tration of 80mg/dl or more. This is achieved In small amounts it sedates and relieves anxi- in the majority of persons after drinking 3 or ety. Paradoxically, it may also give a sense of more of 30 ml (1-oz) whisky within an hour. strength and result in boisterous behaviour. The unpleasant effects that follow a drinking These latter effects seen as ‘drunkenness’ are bout, usually the morning after, is at least partly mistaken to be different from the effects of other a manifestation of withdrawal. For example, CNS-depressing sedatives. The excitement that the first half of a night’s sleep after alcohol may some times follows drinking is a manifestation be deeper than usual but is followed by a dis- of CNS depression, not stimulation. Alcohol turbed sleep pattern reflecting increased excit- is generally taken not at bedtime as a hypnotic ability. Also, other factors like keeping awake but as a social drug. This explains the more till late in the night, unaccustomed activity, common occurrence of paradoxical excitement anxiety and remorse besides certain trace in- and accounts for the commission of crimes as gredients in the drink contribute to hangover. well as the consequences of drunken driving. The manifestations of hangover include throb- The behavioural manifestations of CNS-depres- bing headache, vertigo, tremors, weakness, fa- sion by alcohol vary with the individual and tigue, gastritis with nausea and vomiting and with the setting. It heightens the mood prior dehydration with persistent acidosis and labile to intake, be it sadness or happiness. blood pressure. It is self-limiting and subsides Table 2: The acute effects that commonly occur at increasing blood alcohol concentrations (BAC) BAC mg/dl Effects < 80 Euphoria, feeling of relaxation and talking freely, clumsy movements of hands and legs, reduced alertness but believes himself to be alert. >80 Noisy, moody, impaired judgement, impaired driving ability 100-200 Electroencephalographic changes begin to appear, Blurred vision, unsteady gait, gross motor in-coordination, slurred speech, aggressive, quarrelsome, talking loudly. 200-300 Amnesia for the experience – blackout. 300-350 Coma 355-600 May cause or contribute to death

3 Acute Effects of Alcohol, Opioid and Cannabis Use with fluids, but aspirin, antacid and sodium cause stimulation of respiratory centre conse- bicarbonate may be tried for early relief. quent to accumulation of acetaldehyde. Very large doses of alcohol cause the respiratory de- Physical effects: pression as part of the CNS depressant effect. Gastrointestinal effects: Alcohol in modera- Vomiting occurring in intoxicated individuals tion is an appetizer and gastric acid secretion may lead to aspiration pneumonia. is increased. Alcohol irritates the gastric mu- Musculoskeletal System: Acute heavy intake of cosa and therefore should be avoided by pa- alcohol may lead to alcoholic myopathy. The tients with acid peptic disease. Alcohol ingested spectrum of this disorder is wide; some indi- in a concentrated form even in the presence of viduals may be asymptomatic and may be de- food will cause gastritis with hyperaemia. This tected only because of increased serum creati- also leads to prolonged emptying time due to nine kinase levels, while others may develop pylorospasm and decreased gastric motility, acute rhabdomyolyis with myoglobinuria, increased mucous and decreased acid secretion. acute tubular necrosis and fatal renal failure. Eventually, vomiting as well as gastric bleed- However, most individuals present with muscle ing may occur. Alcohol also reduces the sphinc- pain, mainly around shoulder and hip. This is ter pressure at both ends of oesophagus and often accompanied by muscular swelling and impedes oesophageal peristalsis. It may lead to progressive weakness of lower limb muscles. gastro-oesophageal reflux and oesophagitis. Vomiting occurs after a drinking bout and may Diuresis: Initially, alcohol suppresses the ac- result in a Mallory-Weiss tear in the mucosa of tion of antidiuretic hormone (ADH) and causes the cardio-oesophageal junction, leading to diuresis independent of the volume of fluid profuse gastrointestinal bleeding. taken as a beverage. Later, urine volume generally reflects fluid intake, but some sodium re- Cardiovascular effects: Acute alcohol intake may tention occurs. lead to depression of left ventricular function and may cause ventricular premature beats even Diagnosis of Alcohol intoxication in individual with no history of heart disease. The blood pressure usually decreases with small Clinically, a person can be said to be intoxi- or extremely large doses, but actually increases cated if he exhibits significant maladaptive with moderate doses. Vasodilatation is the behavioural or psychological changes (e.g., in- primary cardiovascular effect of alcohol as well appropriate sexual or aggressive behaviour, as its active metabolite acetaldehyde. It causes mood lability, impaired judgement, impaired a warm, flushed skin and a subjective feeling social or occupational functioning) that devel- of warmth. Loss of heat from the body is in- oped during, or shortly after alcohol ingestion. creased, raising the risk of hypothermia. Heart This is accompanied by one (or more) of the rate and stroke volume may increase, but brady- following signs: slurred speech, motor incoor- cardia may be seen with a very large intake. dination, unsteady gait, nystagmus, impair- Anginal pain is sometimes relieved. This may ment in attention or memory, and stupor or be explained as analgesia due to central depres- coma. sion but it may be due to reduced cardiac work By definition, such intoxication is due to the consequent to generalised vasodilatation. recent ingestion of alcohol and is reversible over Respiratory effects: Small or moderate doses a relatively short period of time (hours). In- toxication is readily recognized by eliciting his-

4 Acute Effects of Alcohol, Opioid and Cannabis Use tory, examining the individual and conduct- done that are not produced from opium ing blood examination for BAC. Breath ana- and may have very different chemical struc- lyzers can satisfactorily discern intoxication too. tures than the opium alkaloids. Some breath analysers can give actual alcohol All these drugs produce a similar profile of acute concentration but others only indicate whether effects and carry the risk of addiction. Mor- it is above a preset threshold, (e.g. 60 mg/dl). phine, pethidine, codeine and pentazocine are in medical use whereas methadone is used for Table 3: Summary of acute effects of alcohol maintenance of opioid addicts. The highly Summary of acute effects of alcohol potent heroin has largely replaced morphine among illicit users in most countries. The term Mental & Behavioural Physical Effects opiate is limited to the natural opium alka- Effects loids and the semi-synthetics derived from them. Drowsiness Flushed face Impaired attention Rapid pulse In India, apart from heroin, several opioids that are used as medications are also abused. Com- Impaired memory Headache mon among these are codeine cough syrups, Impaired judgement Stomach ache morphine and pentazocine injections, Impulsive behaviour Diarrhoea dextropropoxyphene capsules and buprenorphine tablets. Several abusers use Inappropriate sexual Sweating them to tide over periods of non availability of behaviour heroin, but many individuals use them as pri- Aggressive behaviour Slurred speech mary substance of abuse. Inappropriate social Motor Route of administration conduct in coordination Heroin may be smoked, chased (inhaled) or Impaired occupational Unsteady gait injected (intramuscular or intravenous) and performance morphine is usually injected intravenously. When suitable vessels become unavailable, sub- Mood lability Nystagmus cutaneous administration or “skin-popping” (rapid changes) may be substitutes. Oral ingestion of opium Stupor/Coma Respiratory as well as smoking through a special wooden depression pipe has been the traditional Indian method. Buprenorphine is either taken sublingually or OPIOIDS dissolved in water and injected. Pharmacological aspects Absorption and metabolism Opium and morphine occur naturally, and are Opioids are less potent when taken by mouth the principal constituents of the poppy plant than when injected, as they are readily (Papaver somniferum). An opioid is any drug metabolised in liver (first-pass metabolism). that activates the opioid receptors found in the Opioids display “multi-compartmental” distri- brain, spinal cord and gut. There are three bution : re-distribution occurs firstly into broad classes of opioids: muscle, and then into poorly perfused tissues (e.g. fat). Their accumulation in body and satu- 1. Naturally occurring opium alkaloids, such ration of tissue binding leads to prolonged ef- as morphine and codeine; fects with chronic use. They generally have low 2. Semi-synthetics such as heroin, oxycodone plasma protein binding (e.g. Morphine 20- and hydrocodone that are produced by 30%, Methadone 60-90%) modifying natural opium alkaloids. 3. Pure synthetics such as fentanyl and metha-

5 Acute Effects of Alcohol, Opioid and Cannabis Use Table 4: Hepatic clearance of various opioids Drug Hepatic Clearance Oral Bioavailability (approx.) Morphine High 20-40% (variable) Pentazocine Buprenorphine Fentanyl Codeine Pethidine Intermediate 50% Methadone Low 90%

Opioids undergo extensive metabolism. Me- opioids. Heroin is metabolised to morphine in tabolites may be active/toxic, e.g. Heroin, Co- the body (liver and brain) and is rapidly ex- deine, Pethidine. Renal excretion is a minor creted in the urine after conjugation with glu- route of elimination, but may be very impor- curonic acid. Nearly 90 percent of the total tant in the excretion of active metabolites, e.g. urinary excretion of morphine occurs within Pethidine, Morphine. There is considerable 24 hours. The duration of action of heroin inter-patient variability in the metabolism of and morphine is about 4 hours. Table 5: Doses and duration of action of various opioids Compound Dose (mg) Duration of Action Injected Oral (hr.) Morphine 10 60 4 Heroin 4 30 3-4 Methadone 10 20 6-24 Pethidine 100 300 3 Codeine 30 90 4 Dextropropoxyphene — 200 8 Dihydrocodeine 15 45 4 Buprenorphine 60 180 3 Pentazocine 0.3 0.8 (sublingual) 7

Psychological effects: fects usually persist for hours outlasting the initial intense euphoria. It should be noted, Due to marked tolerance, the acute effects dif- however, that the euphoria is probably not an fer widely between naive and chronic users. intrinsic property of the opiates. When given Dependent users injecting heroin or morphine to a subject who has not previously experienced describe short lived (less than a minute) in- the effects of the drugs and who is not in pain, tense experience -”rush”. It is described as a morphine and codeine will more commonly state of profound euphoria. There is also pain produce a subjectively unpleasant reaction. In relief due to analgesia and a dreamlike state the presence of pain or fear, the reaction of a characterized by decreased responsiveness to the patient to an opiate may be much less dyspho- environment. These analgesic and sedative ef- ric, and in some people, the relief from anxiety 6 Acute Effects of Alcohol, Opioid and Cannabis Use may be pleasurable enough to provoke a desire drowsiness or coma. Illusions may occur in the for repetition of the experience. Sedation is due absence of delirium as also hallucinations with to action in the brain stem. Reduced pain per- intact reality testing (the person knows that the ception, is due to suppression of the spinal cord, hallucinations are induced by the substance and mid brain and thalamus whereas euphoria is do not represent external reality). due to limbic system stimulation. A suicidal or accidental overdose of opioids is an Excitation with convulsions may occur at emergency. If opioid overdose is suspected, nalox- higher doses. one must be immediately administered intrave- Physical effects nously (0.4 mg).This is both diagnostic and therapeutic. If sensorium improves and pupils Gastrointestinal effects: Nausea and vomiting dilate it confirms the diagnosis of opioid intoxi- (stimulation of the chemoreceptor zone in the cation. Such timely intervention can sometimes medulla), anorexia and constipation (decreased be life-saving. gastrointestinal motility). Table 6: Summary of acute effects of opiates Respiratory and cardiovascular effects: Respi- ratory depression and suppression of cough Summary of acute effects of opiates reflex. At higher doses, bradycardia and pos- Mental & Behavioural Physical Effects tural hypotension may occur. Pulmonary Effects oedema (with intravenous use) cyanosis and hy- Drowsiness pothermia are also seen. Skin may be warm and Initial euphoria Pupillary flushed due to peripheral vasodilatation. constriction Apathy or dysphoria Slurred speech Other effects: Itching may occur due to hista- Impaired judgement Slow respiration mine release. Users experience a delay in ejacu- Impaired performance Slow pulse lation (and may take it to treat premature ejacu- Psychomotor agitation Stupor/coma lation) but prolonged use may lead to impo- or retardation tence. Impaired attention Pupillary OPIOID INTOXICATION and memory dilation (anoxic) Illusions or Hallucinations Opiate intoxication is classically characterized with insight by the triad of pinpoint pupils, depressed respiration and coma. The syndromic criteria for CANNABIS the diagnosis of opioid intoxication (DSM IV) are: Clinically significant maladaptive Cannabis is derived from the plant cannabis behavioural or psychological changes (initial sativa, which grows in the wild all around the euphoria followed by apathy, dysphoria, psy- world. It is used in various forms such as chomotor agitation or retardation, impaired Bhang- paste of leaves of the plant or dried judgement or impaired social or occupation leaves functioning) that develops during or shortly af- Ganja – dried flowering stem of the plant ter opioid use. This is accompanied by pupil- Charas or hashish is extracted from the resin lary constriction (or pupillary dilatation due to covering the plant. anoxia from serve overdose), slurred speech, and Hash oil is made by extracting Cannabinoids impairment in attention or memory and either from the resin by using organic solvents.

7 Acute Effects of Alcohol, Opioid and Cannabis Use The active compounds in cannabis products In West, cannabis is also cooked in form of cakes are called Cannabinoids. Most potent among and biscuits etc. them is tetrahydrocannabinol (THC). The 2. Smoking: concentration of THC varies in different forms (a) In cigarettes of cannabis products. Wild cannabis products have lower concentration whereas commercially Dried bhang leaves, ganja or charas can be produced cannabis products have higher con- mixed with tobacco in cigarettes and centration of THC. Marijuana cigarette is a smoked. relatively mild preparation from various parts (b) Clay pipes of uncultivated plants and delivers, on an aver- Ganja is filled in clay pipes and smoked. age, 2 to 5 mg of delta THC. Other prepara- This is the most common method in reli- tions used for smoking are ganja, which is ap- gious settings and rural areas. proximately three times more potent than marijuana, and charas, the pure resin (ten times (c) Water pipes stronger than marijuana). Liquid cannabis Traditional hookah or modern ‘bong’. In (hashish oil) is syrup extracted from cannabis this, smoke passes through water before resin with a non-aqueous solvent and is five being inhaled. times stronger than charas. Cannabis is unsuitable for intravenous use as Table 7: THC concentration of Cannabis it is relatively water insoluble and can lead to Products anaphylaxis due to undissolved particulate matter. Forms THC content (extremely variable) Cannabis is smoked in rural India, with social sanction, often in a group for relaxation and Marijuana 1 – 3 % THC fellow feeling. Some smoke it in a religious Ganja(cultivated) 6 – 20 % THC context whereas others use it as an aphrodi- Hashish (charas) 10 – 20 % THC siac. Like alcohol, cannabis too reduces inhi- Hashish oil 15-30% THC bition and increases desire but does not en- (may be more) hance performance. Some users, nevertheless, claim to use it for the enhancement of sexual Mode of use pleasure. Cannabis is used in several ways 1. Orally as: Absorption (a) Milk based drink called Thandai is In smoking, up to half of the active ingredi- commonly used in North India especially ents are absorbed rapidly into the blood across on ceremonial occasions (Holi & Shivratri). the alveoli exerting their full effects in a few (b) Sweets minutes. This occurs only if it is smoked with deep inhalations and retention in the lungs for (c) Manoka, a dry slightly sweetish prepa- some time period. Smoked (inhaled) cannabis ration consisting of bhang paste and other is about three times more potent than when materials. This is also sold as Ayurvedic ingested orally due to more rapid absorption medicinal preparation in certain parts of from the lungs, avoidance of hepatic first-pass North India. metabolism and the enhanced release of delta (d) Bhang is also mixed with flour to make THC from the pyrolysis of THC acids. Blood ‘pakodas’ or ‘bhajji’.

8 Acute Effects of Alcohol, Opioid and Cannabis Use levels of THC peak within minutes though sub- cause a loss of consciousness (general anaesthe- jective intoxication peaks only by about half sia). Animals when given lethal doses die of an hour. Acute effects persist for a couple of respiratory depression. hours. THC concentration in blood is a poor guide to level of intoxication as it correlates only As the blood level of THC rises, there may be moderately with cannabis intoxication partly a state of euphoria and well being (high) and a because of its lipid solubility. Additionally tol- dreamy, hypnogogic (hallucinations just prior erance develops to many of the effects of can- to falling asleep) state of enjoyment. This is nabis. The pharmacological effects of orally generally followed by a period of drowsiness. ingested cannabis occur after 30 minutes, peak It is accompanied by ataxia and impaired per- in 2-3 hours and last 3 to 6 hours. formance. Even relatively modest amounts of cannabis can prolong reaction time and im- THC is highly protein bound and less than pair coordination and make the operation of one percent of the absorbed drug enters the heavy machinery hazardous. Dexterity and brain. It crosses the placenta, enters breast milk hand steadiness are both adversely affected. and induces hepatic enzymes. The plasma half- Alcohol, which is often concomitantly used, life in naive subjects is twice (50 to 60 hrs) aggravates these adverse effects. Increased sen- that of a habitual user. The more active me- sory acuity, which is largely subjective, does tabolites of THC (e.g. 11- hydroxy THC) have not compensate for the impaired psychomotor half-lives much longer than 50 hours. Follow- performance that places the cannabis user at ing a single smoke of cannabis, therefore, THC risk. The tolerance developed by regular users and its metabolites remain in the body up to a to the adverse effect on psychomotor perfor- month. Persistent activity in the blood can mance cannot be regarded as protective cause long term adverse effects on cognitive enough. The recognition and acquisition pro- functioning of habitual users even when they cesses involved in the storages of short-term are not apparently intoxicated. Likewise, the (hours to days) memory are the most affected, residual effects of intoxication may continue whereas long-term (months to years) memory for several days. The hangover from acute in- is largely unaffected. The preferential concen- toxication is demonstrable with impairment on tration and action of THC in the hippocam- neuropsychological and driving/flight simula- pus accords with and explains these effects. The tor tests up to even 48 hours after intoxica- EEG effects are similar to that seen with sedation. tives – slowing of frequency, increased alpha and decreased beta electrical activity. Psychological effects Cannabis exerts the same diffuse depression of Other psychological effects include perceptual the CNS as alcohol and barbiturates. Besides and sensory distortions. Capacity for depth sedation, it can also cause a paradoxical excite- perception declines and scenes appear to have ment due to disinhibition. A distinction must greater depth. Sounds and colours may become therefore be made between the pharmacologic more intense alongwith derealization (what is effect of CNS depression and the manifest seen or heard has an air of unreality) and dep- behaviour of excitement. The manifest ersonalization (ones own body feels unreal). behaviour in the individual, sedation or excite- Subjective sense of time seems to be much ment, depends upon his personality, mental slower than it actually is. Dysphoria, restless- set and the setting. There may be a dreamy ness, fear and even panic may spoil the experi- state with an increased tendency to fantasize ence (“bad trip”). Delirium occurs as a com- and to accept suggestions. Large enough doses plication only rarely in neurologically intact

9 Acute Effects of Alcohol, Opioid and Cannabis Use individuals. In such cases, symptoms of de- isting heart disease. lirium, psychosis, or anxiety seldom persist beyond 48 hrs after acute cannabis intoxication. Respiratory system If they do so, the probability is high that they Cannabis smoke contains carbon monoxide and are a continuation of pre-existing psychopathol- carcinogens similar to those in cigarette smoke. ogy. The acute psychotic reaction is self-limit- Smoking a cannabis cigarette leads to about ing, generally polymorphous and stormy. An five fold increase in carboxy-hemoglobin con- acute organic state, phenomenologically indis- centration and three fold greater inhalation of tinguishable from delirium, may follow cannabis tar and retention of tar in respiratory tract. use (generally at a high dose - 250 micrograms/ This happens mainly because cannabis is kg of THC). Altered brain amine levels and/or smoked with deep and prolonged inhalation. inhibition of cholinergic transmission may be Cannabis leads to irritation of the bronchial responsible for the same. Emotional turmoil, mucosa from smoking and a mild excitement, paranoid (unwarranted suspicion) bronchoconstriction followed by or hypomanic symptoms and hallucinations bronchodilation. may predominate. There may be driven activity (subject knows that one’s activities are mean- Ophthalmic effects ingless, yet is unable to control them). Halluci- Decreased intraocular pressure, and rarely pho- nations are vivid, well formed and commonly tophobia, nystagmus and conjunctival injec- visual. tion are acute effects of low dose of cannabis Physical effects: on eyes. Higher doses (250 microgram/kg of THC) produce ptosis and miosis. Gastrointestinal Effects Diagnosis of cannabis intoxication Physical effects of acute low dose cannabis (50 micrograms/kg of delta-9-THC) include dry The syndrome criteria for the diagnosis of can- mouth, thirst, increased appetite and consti- nabis intoxication (DSM IV) are: pation. Clinically significant maladaptive behavioural or Cardiovascular effects psychological changes (e.g., impaired motor Cardiovascular effects include rise in blood pres- coordination, euphoria, anxiety, sensation of sure and tachycardia. The increase in heart slowed time, impaired judgement, social with- rate of upto 50 percent over baseline occurs drawal) that developing during or shortly after within a few minutes and persists for a few cannabis intake and two (or more) of character- hours. It also causes vasodilatation and red- istic signs (conjunctival injection, increased dening of conjunctivae which is a characteris- appetite, dry mouth, tachycardia) developing tic sign of cannabis use. Vasodilatation may lead within two hours of cannabis use. Illusions may to postural hypotension and fainting. The ear- occur in the absence of delirium as also halluci- liest indication of intoxication in naive users is nations with intact reality testing. a feeling of “light-headedness.” Most of these Usually mood alterations and perceptual distor- cardiovascular changes are clinically inconse- tions are inconsequential and do not require any- quential except that they can magnify anxiety thing more than reassurance. However, in a “bad and contribute to the panic (sudden, intense trip” with psychotic excitement, prompt relief fear) attacks sometimes experienced by them. However these effects may lead to serious car- may be obtained with parenteral haloperidol (5- diac complications in individuals with pre ex- 10mg). If psychotic disturbance persists beyond 1 or 2 hours referral to a psychiatrist is advised.

10 Acute Effects of Alcohol, Opioid and Cannabis Use 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 Mental & Behavioural Physical Effects medical expert in medico-legal cases, as a diag- Effects nostician and as a therapist. Alcohol, opiates Drowsiness Red eyes and cannabis exert profound mental and physi- (at high doses) Dry mouth cal effects. These effects are influenced by prior Euphoria Thirst experience, pattern of use, physiological, psy- Anxiety Increased appetite chological and psychosocial factors. The medi- Suspiciousness Tachycardia (or cal officer should consciously include these as- Expectations of harm Bradycardia at pects while taking history and examining the Sensation of slowed high doses) patients. Whenever intoxication is suspected, time Light headedness suitable action will aid accurate diagnosis and Social withdrawal (Postural prompt treatment. Taking care of the unwanted Impaired judgement hypotension) acute effects is an important task in the overall Illusions & halluc- care of drug and alcohol dependent individuals. inations with insight

Suggested Reading:

1. Adams IB and Martin BR. Cannabis: phar- book of Addictive Disorders. Guilford Press. macology and toxicology in animals and humans. Addiction, 1996; 91:1585-1614. 4. Lowinson JH, Ruiz P, Millman RB, Langrod JG (1997). Substance Abuse: A compre- 2. American Psychiatric Association (1994) Di- hensive text book Lippincott Williams & agnostic and Statistical Manual of Mental Wilkins. Disorders (fourth edition). APA: Washing- ton, DC. 5. Miller, NS (1991): The Pharmacology of Alcohol and Drugs of Abuse and Addiction. 3. Frances, RJ, Mille SI (1998): Clinical Text- Springer-Verlag: New York.

11 Acute Effects of Alcohol, Opioid and Cannabis Use Suggested slides for OHP

Slide 1 Moody Impaired judgement Factors influencing Acute Effects of Alcohol, Opioids Poor driving skills and Cannabis EEG slowing Prior Experience (Occasional/Regular/Dependent) Pattern of use (Oral/injected/inhaled) Slide 6 Physiological (Genetic Predisposition) Psychosocial (Mental Set/Social Ambience) Blood Alcohol Level 100-200 mg/dl Blurred vision Slide 2 Unsteady gait Determinants of Blood Alcohol Concentration Incoordination Slurred speech Quantity Aggressive Concentration (Window Effect) Quarrelsome Body Fat (Women) Addition of carbonated beverages Slide 7 Empty stomach Body weight (Men) Very High Blood Alcohol Levels Carbohydrate food Level (mg/dl) Effect 200-300 Amnesia / Blackout Slide 3 300-350 Coma Alcohol Concentration & Drinks >350 May lead to death Beers 4-8% Slide 8 Wines 12% Whisky 40% Alcohol: Pharmacokinetics Illicit 35-50% Onset of Effects <15 Minutes Diffusion into alveolar air (proportional to blood I Unit= 10gm Absolute alcohol levels) In 70kg person 1 Unit gives blood levels of 15-20 mg/dl Major metabolism in liver Slide 4 Urine excretion 2-4%

Blood Alcohol Level <80mg/dl Slide 9 Euphoria Alcohol: CVS Effects Relaxed feeling Smaller dose decreased BP Talks freely Larger dose increased BP Clumsy movements Initial vasodilatation (relieves anginal pain and feel- Decreased alertness but unaware ing of warmth) Normal speech Tachycardia

Slide 5 Slide 10

Blood Alcohol Level 80-100mg/dl Alcohol: GIT & Other Effects Noisy and loud speech Increased gastric acidity

12 Acute Effects of Alcohol, Opioid and Cannabis Use Increased acid peptic disease Slide 15 Hemetemesis Cannabis Preparations Low doses increased respiratory rate Large dose depressant Plant - Cannabis Sativa Facilitates diuresis. Marijuana Cigarette – 2-5 mg of THC Ganja – Flowering tops of female plant Slide 11 Charas/hashish – Pure resin (10 times more Diagnosing Alcohol Intoxication potent) Inappropriate behaviour Hash oil - extract of Cannabinoids in organic Impaired Judgement solvents (50 times more potent) Labile Mood Bhang – orally consumed Slurred speech, incoordination, Ataxia, Nystagmus, Slide 16 Lowered sensorium on examination h/o recent alcohol ingestion Cannabis: Breath Analyzer/Blood Alcohol Level Rapid absorption after smoking Crosses placenta, present in milk Slide 12 Long half life – upto 50 hours Opiates & their use Impaired neuropsychological performance upto 48 Natural – Opium, Morphine hours after last smoke Synthetic – Heroin, Methadone Medical Use & Non medical abuse Slide 17 Oral, injectable, inhaled (chasing) Diagnosing Cannabis Intoxication Slide 13 Symptoms Opiates: Absorption and elimination Impaired motor coordination Absorption through stomach/duodenum/lungs Euphoria/anxiety/dysphoria Hepatic Glucuronidation Sensation of slowed time Urinary excretion Poor judgement Most elimination in < 24 hours Social withdrawal Slide 14 Signs Diagnosing Opiate Intoxication Conjunctival injection Dry mouth & appetite Symptoms Tachycardia Euphoria, Apathy, dysphoria Psychomotor changes H/O Recent (2-3Hrs) Cannabis Use Impaired judgement Symptomatic Relief-Haloperidol Use Signs Miosis, drowsiness Slurred speech Lowered sensorium Naltrexone 0.4 mg Intravenous; Diagnostic and therapeutic effect

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

K Srinivasan, KS Chandramauli

Summary Introduction Alcohol abuse and abuse of illicit drugs are a Community surveys, hospital based studies and major health problem and its management calls mortality indices all suggest an increased preva- for a concerted effort from all sections of the lence of alcohol and drug abuse in contempo- medical community. An effort has been made rary society. People who abuse alcohol are fre- in this chapter to familiarize the clinician with quent users of the health care system. It is esti- the possible medical complications of alcohol mated that alcoholism is about 1.5 times more and drug abuse. A drug abuser’s first contact prevalent than diabetes in the community. with the health system might be because of a Unfortunately, less than 20 % of such patients physical complication and the general practi- are identified and offered treatment. tioner is at a vantage position to identify the A similar trend is seen in the increased preva- problem early and offer help to the individual lence of abuse of drugs, such as heroin, with and his family. In order to provide compre- its attendant health risks. Thus, it is clear that hensive health care, a practitioner might have alcohol and drug abuse related problems are to liaise with other medical experts and he will major national health concerns. General prac- need to establish contact with local drug treat- titioners and primary health care givers have a ment centres and non – governmental organi- key role to play in the early identification and zations, which offer rehabilitation and long treatment of such problems. term help to drug abusers. Most patients who present to a primary health centre do so with a Health Hazards of Long Term Alcohol Use relatively minor complication or early in the (Table 1) course of a chronic medical complication resulting from drug abuse. The physical compli- Daily drinking of alcohol is associated with a cations in majority of these patients improve wide range of medical complications. with abstinence from alcohol or drug use.

Table –1 Diseases Associated with Alcohol Use Organ System Disease Gastrointestinal Fatty liver, Alcoholic Hepatitis, Cirrhosis, Esophagitis, Acute gastritis, system Pancreatitis, Malabsorption Nutritional deficiencies Thiamine, Pyridoxine, Vitamin A, Folic acid, Ascorbic acid Haematological disorders Anaemia, Leucopenia, Thrombocytopenia Cardiovascular system Cardiomyopathy, Hypertension Central nervous Wernicke- Korsakoffs syndrome, Dementia, Cerebellar degeneration, system Peripheral neuropathy, Myopathy, Head injury Metabolic disorders Ketoacidosis, Hypoglycaemia, Hypocalcemia, Hypomagnesemia Miscellaneous Fetal alcohol syndrome, Osteoporosis, Tuberculosis, Psoriasis, Domestic & traffic accidents Cancers Oral, Esophagus, Colon, Hepatocellular, Breast (women)

1 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis GASTROINTESTINAL SYSTEM Most patients with alcoholic hepatitis improve with abstinence and require minimal medical 1. Alcoholic Liver Disease intervention. However, in some, the onset may Alcoholic liver disease refers to a spectrum of be fulminant and in such cases the short term clinical conditions: Fatty liver, Alcoholic hepa- mortality may be as high as 20-60 %. The clini- titis and Cirrhosis. Fatty liver is often associ- cal picture in these patients is one of florid ated with moderate consumption of alcohol, hepatic failure and they should be referred to a while alcoholic hepatitis and cirrhosis are usu- hospital for further treatment. Treatment is ally seen in heavy drinkers. Daily heavy drink- generally supportive. An adequate nutrition and ing places most individuals at a great risk to fluid electrolyte balance needs to be main- develop liver disease. Women who drink daily tained. Nasogastric feeding becomes necessary develop cirrhosis much earlier than men. Con- only in severally ill patients. Treatment of com- tinuous daily drinking is more likely to lead to plications necessitates referral to a hospital. liver damage than intermittent drinking. It Glucocorticoids are useful in patients with se- must be stressed that a person need not be vere disease. Following abstinence, the clinical physically dependent on alcohol to develop liver symptoms resolve in about six weeks time. disease. However, in those individuals who continue to drink, alcoholic hepatitis may progress to Fatty Liver cirrhosis. Poor prognostic factors are Patients with fatty liver are usually asymptomatic. The clinical features and investigations a) very high levels of bilirubin necessary to diagnose fatty liver are given be- b) prolonged prothrombin time that is unre- low (Table 2). On abstaining from alcohol, sponsive to Vitamin K and clinical symptoms and liver function tests become normal. Complete abstinence from alco- c) presence of encephalopathy. hol must be emphasised as the condition is Table – 3: Alcoholic hepatitis totally reversible. Symptoms Anorexia, nausea, vomiting, Table 2: Fatty Liver pain abdomen, fever Fatty Liver Clinical Features Signs Icterus, tender hepatomegaly Symptoms Often asymptomatic Investigations Elevated AST, ALT & bilirubin, prolonged prothombin time Signs Hepatomegaly Complications Fulminant hepatic failure, Investigations Elevated AST, ALT, ascites, encephalopathy, Bilirubin gastrointestinal bleed, Treatment Abstinence coagulopathy Prognosis Completely reversible with Treatment Supportive, Glucocorticoids abstinence Prognosis In the absence of complications reversible Alcoholic hepatitis with abstinence Patients with alcohol induced hepatitis can mani- Presence of complications would require refer- fest a wide range of clinical features (Table–3). ral to a hospital.

2 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis Cirrhosis (Table 4, 5) Table – 5 Cirrhosis : Investigations

About 8-39% of subjects who abuse alcohol Liver function Serum bilirubin, AST, daily develop cirrhosis. Onset of the clinical tests ALT, (not diagnostic) may syndrome of cirrhosis is often insidious. The be elevated, prothrombin time prolonged, serum al- clinical signs and symptoms of cirrhosis are bumin low presented in Table – 4. As cirrhosis of liver is often accompanied by various complications Liver biopsy Diagnostic (Table – 4), patients suspected of cirrhosis Abdominal Useful non – invasive test should be referred to a hospital for an initial ultrasound for evaluation of cirrhosis evaluation and subsequent treatment can be carried out in a primary health care setting Endoscopy Diagnosis of varices and based on the advise of the specialist. evaluation of hematemesis

Table – 4 Liver Cirrhosis : Features Ascitic fluid Diagnosis of ascites and analysis bacterial peritonitis Symptoms Anorexia, weight loss, ab- Treatment of cirrhosis includes a complete abdominal discomfort, dis- stinence from alcohol with good nutritional and tension of abdomen vitamin supplementation. Signs Jaundice, spider naevi, Table 6 – Cirrhosis: Treatment clubbing, parotid enlarge- Abstinence from alcohol ment, palmar erythema, gynaecomastia, testicular Good nutrition : 2000 – 3000 calories / day atrophy, Dupyutren’s con- Protein: 1 gm/kg, if no encephalopathy tracture, distended veins Vitamin supplementation particularly thia- over abdomen, hepatome- mine and folate galy or shrunken liver, sple- nomegaly, ascites Treatment of associated complications in a hospital setting Complications Ascites, variceal bleed, he- Initial assessment and treatment in a hospi- patic encephalopathy, tal setting spontaneous bacterial peritionitis, hepatic failure, The management of associated complications renal failure would require referral to a hospital and such patients can later be followed up in a primary Patients to be referred to hospital for initial health centre based on the advice of a specialist. evaluation when cirrhosis is suspected. Hepatic Encephalopathy The investigations that are necessary in cirrho- Hepatic encephalopathy can occur in patients sis are dictated by the presence of associated with alcoholic hepatitis and /or cirrhosis. Table complications and are listed in Table – 5 – 7 lists the clinical features and the abnormal

3 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis findings on laboratory investigations in cases Ryles tube – Continuous of acute hepatic encephalopathy. Treatment of aspiration acute hepatic encephalopathy must be carried Refer to tertiary care out in an inpatient hospital setting under the centre care of a specialist. If facilities Vasopressors for hypoten- Table – 7 Hepatic Encephalopathy: Clinical available sion, Blood transfusion features Vasopressin, somatostatin Symptoms Agitation, mood swings, infusions Sengstaken tube confusion, disorientation, disturbed sleep, altered In summary, the management of alcohol liver sensorium, coma disease is directed towards the treatment of the associated complications. However, the most Signs Flapping tremor, Hyperre- important element in the treatment process is flexia, coma to help the patient to stop drinking. Precipitating G.I. bleed, infection, factors increased protein intake, 2. Oesophagus use of sedatives, Electrolyte Alcohol alters the oesophageal motility result- imbalance ing in defective oesophageal clearance. What is Investigations Elevated levels of serum more important, however, is that chronic alco- ammonia, abnormal liver hol use reduces the oespohageal sphincter pres- function tests, prolonged sure leading to reflux oesophagitis. These pa- PT, abnormal EEG tients improve with symptomatic treatment Immediate Low protein diet / and abstinence. Occasionally, due to severe measures supplement carbohydrates, retching following an alcoholic binge, an indi- Bowel wash, syrup vidual might develop a tear in the lower end of lactulose, Antibiotics : the oesophagus resulting in haematemesis Amoxycillin; Later referral (Mallory – Weiss Syndrome) and such patients to a specialist care in a hos- would require referral to a hospital for further pital setup management. Variceal Bleed 3. Stomach Alcohol delays gastric empting and disrupts the Clinical manifestations and management of mucosal barrier resulting in gastritis. Its role variceal bleed are listed in Table –8 in the development of chronic gastritis, how- Table – 8 Variceal bleed: Clinical features and ever, remains doubtful. Following a bout of management heavy drinking, haemorrhagic gastritis might develop resulting in gastrointestinal bleeding. Symptoms of Hematemesis, malena, signs worsening ascites, encepha- 4. Small Intestine lopathy, hypotension Contrary to its effect on the oesophagus and Immediate Vital signs record stomach, alcohol increases the intestinal mo- measures IV fluids : Normal saline, tility leading to diarrhoea. This effect, com- Hemmaccel if hypotension bined with derangement of the villous archi-

4 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis tecture, results in decreased absorption of wa- these symptoms is a state of protein calorie ter, sodium, glucose, aminoacids, folic acid and malnutrition. Multiple vitamin deficiencies are thiamine. Among these, folate deficiency is the frequently associated with chronic alcohol use most common clinical manifestation. (Table – 10). After initial treatment and correction of the depleted body stores of various 5. Pancreas vitamins, it is essential to continue the patients The association between alcohol use and pan- on a maintenance dose till the patient starts creatitis is well known. The clinical signs and taking a normal diet. symptoms of acute pancreatitis are listed in Table 10. Alcohol Abuse: Nutritional Deficiencies Table – 9. Pain in pancreatitis can be acutely brought on by a drinking binge. Patients sus- Substance Signs and Symptoms pected of pancreatitis should be referred to a specialist for evaluation and treatment. Protein calorie Weight loss, lethargy, malnutrition fatigue Table – 9 Acute Pancreatitis: features Vit B1 deficiency Beriberi, Wernicke – Symptoms Abdominal pain radiating Korsakoff syndrome to back, nausea, vomiting Vit B2 deficiency Pellagra Signs Tenderness in upper abdomen Vit B6 deficiency Peripheral neuropathy Investigations Elevated serum amylase, X- Vit A deficiency Night blindness, Ray abdomen,Ultra sound keratomalacia abdomen Vit C deficiency Scurvy Complications Coagulopathy, shock, pan- Treatment comprises of high calorie, high pro- creatic abscess, pancreatic tein diet and vitamin supplements. pseudocyst HAEMATOLOGICAL DISORDERS Treatment Supportive, IV fluids, NPO, NG aspiration, re- Apart from the effects of associated nutritional ferral for complication deficiencies, alcohol, due to a direct depressant action on the bone marrow, can cause Features of chronic pancreatitis include recur- anaemia, leucopenia and thrombocytopenia. rent pain abdomen, diabetes mellitus and mal- Anemia can also be secondary to an acute or absorption chronic blood loss from the gastrointestinal tract and hypersplenism. Coagulopathies due NUTRITONAL DEFICIENCIES to diminished production of vitamin K depen- Alcohol has a direct appetite suppressant ef- dent factors might complicate the picture in fect. In addition, because of its high caloric chronic liver disease and such cases would need content, it is often substituted for food. Alco- detailed evaluation and treatment in a hospi- hol also interferes with the absorption of vari- tal setting. ous nutrients. As a result, individuals who drink CARDIOVASCULAR SYSTEM large amounts daily present with easy fatiga- bility, lethargy and weight loss. Underlying Alcohol directly affects the heart musculature

5 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis resulting in the development of alcoholic car- Wernicke – Korsakoff Syndrome diomyopathy. This condition is seen after many years of heavy drinking (>10 yrs). Alco- Alcohol associated thiamine deficiency is re- holic cardiomyopathy may present with car- sponsible for Wernicke – Korsakoff syndrome diac failure and arrhythmias. Mural thrombi (Table 13). Thiamine deficiency in alcoholism may be present in patients with chronic con- results from inadequate intake of thiamine, gestive failure. There is a strong association interference with its absorption from the gas- between moderate to heavy consumption of trointestinal tract and impairment of its stor- alcohol and hypertension. This association is age in the liver. The clinical presentation of clinically relevant in middle aged hypertensives. Wernicke’s encephalopathy and its treatment Eliciting history of alcohol abuse is important are presented in Table – 13. With therapy, when treating a hypertensive patient. Alcohol ocular signs usually resolve quite rapidly. The interferes with antihypertensive therapy and psychological symptoms take a longer time to heavy drinkers may fail to respond to standard recede. In spite of treatment, the gait difficulty medical treatment. Alcoholic hypertensive may may persist in up to 50% of patients. If prompt become normotensive following abstinence. treatment is not instituted, mortality occurs in about 20% of cases of Wernicke’s encephal- Table 11 – Alcohol Abuse: Cardiovascular Com- opathy. With treatment, as the acute neuro- plications logical symptoms subside, the memory difficulties may become apparent. This picture, zzz Hypertension referred to as Korsakoff syndrome, often fol- zzz Cardiomyopathy – chronic congestive lows the acute Wernicke’s syndrome. It is char- failure, mural thrombi, arrhythmias acterized by an inability to remember imme- Will need specialist evaluation for initiation of diate past events and also difficulty in retain- treatment. ing newly learnt material. Studies have shown that only about 25% of patients with Korsakoff NERVOUS SYSTEM syndrome respond to treatment with thiamine. Chronic alcohol use can produce a significant Among the rest, the memory deficits tend to alteration in the functioning of both central persist. and peripheral nervous system (Table 12). Table – 13 Wernicke – Korsakoff Syndrome : Some of the complications are due to a coexist- Clinical features and Therapy ing thiamine deficiency, while a direct neuro- Clinical features toxic effect is also responsible for many of the Ocular muscle paralysis manifestations. Strabismus, gaze paralysis, Table 12 – Alcohol Abuse: Neurological Mani- Nystagmus festation Ataxia, confusion, drowsiness zzz Peripheral neuropathy Therapy: Thiamine 50mg i.v. + 50mg i.m zzz Wernicke – Korsakoff syndrome stat and 50 mg i.m. daily till patient recov- zzz Cerebellar degeneration ers followed by oral supplementation. zzz Dementia Sequelae: Deficit in recent memory and zzz Myopathy learning, Psychosis, Persisting memory defi- zzz Cerebro-Vascular accidents cits in spite of treatment with thiamine. (may be permanent) Will need specialist evaluation and treatment.

6 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis Treatment of Wernicke’s encephalopathy is a Peripheral Neuropathy medical emergency and involves prompt correction of thiamine deficiency. Initially Peripheral neuropathy seen among alcoholics results from vitamin deficiencies, especially, parenteral administration of thiamine is nec- thiamine, pyridoxine and pantothenic acid. essary. This is to be followed by oral supple- The onset of the symptoms is insidious and mentation of thiamine for several weeks. Acute the progress is slow. Typically, patients com- glucose load, in the form of an intravenous glu- plain of pain, paraesthesias and weakness, with cose drip, must be avoided in alcoholic patients symptoms being generally more prominent in as the glucose load can precipitate a Wernicke’s the lower extremities. Paraesthesias are particu- encephalopathy. When glucose infusion be- larly distressing. Symptoms are more striking comes a necessity, it must be preceded by ad- in the distal part of the limbs (glove and stock- equate thiamine supplementation. ing distribution) and progress proximally as the disease advances. On physical examination, Alcoholic Dementia there is loss or diminution of ankle jerks. Sen- Memory difficulties, inattentiveness and an sory examination reveals loss of superficial inability to maintain concentration are com- touch, position sense and vibratory sensation. monly seen in chronic alcoholics. Occasionally, These changes are usually symmetric. Treat- these might progress on to frank dementia ment involves vitamin supplementation, along characterised by personal and social deteriora- with physical therapy to preserve muscle tion, memory lapses and difficulty in carrying strength. Recovery is slow. Tricyclic antidepres- sants and carbamazepine have been used to al- out every day tasks. There is a decline in intel- leviate pain. Alcoholism might affect the auto- lectual ability. Alcoholic dementia generally nomic nerves resulting in impotence, postural appears after many years of heavy drinking. CT hypotension and bladder or bowel dysfunction. scan may reveal cerebral atrophy. Abstinence from alcohol leads to a reversal of both, the Alcoholic Myopathy cognitive deficit and the radiological abnormal- ity. It is important to remember that cognitive Chronic use of alcohol is sometimes associated impairment in chronic alcoholics might inter- with progressive muscle weakness. Character- fere with their ability to comply with treat- istically, the proximal group of muscles of the lower limbs is involved. Patients usually com- ment regimens. plain of difficulty in climbing staircases or walk- Alcoholic Cerebellar Degeneration ing on an uneven ground. On physical examination, subjects have difficulty in getting up Alcoholic cerebellar degeneration is from squatting position without support. Di- characterised by ataxia affecting the trunk and agnosis is confirmed by muscle biopsy. Treat- lower limbs. The upper extermities are affected ment consists of abstinence & physiotherapy. less often than the lower limbs. Patients present with a broad based stance and gait difficulty. Alcohol and Accidents These symptoms become more prominent There is a threefold increase in accident rate during acute binges or alcohol withdrawal among alcoholics. Besides road traffic accidents, states. The progression of the disease process is alcoholics are at a greater risk to be involved in slow. The etiology is still largely unknown. accidents at home and at the work place. Head Abstinence from alcohol and nutritional injury in an alcoholic is particularly common. supplementation might result in some im- It has been reported that more than 20% of provement over many months. accident related head injury is associated with

7 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis recent alcohol consumption in our country. An MISCELLANEOUS CLINICAL CONDI- alcoholic who has had a head injury is a diffi- TIONS: cult patient to manage. Treatment of alcohol withdrawal syndrome with sedatives may in- Foetal alcohol syndrome terfere with the assessment of head injury. A About one third of children born to mothers closed head injury sustained during an intoxi- who continue to drink during pregnancy show cated state may not be reported to a clinician features of foetal alcohol syndrome. Typically, and thus, a potentially treatable condition such these children have reduced body weight and as a subdural haematoma might be missed with disastrous consequences for the patient. Often height, are hyperactive and have subnormal alcoholic patients with head injury behave intelligence. Their faces may be recognized by aggressively and this interferes with the evalu- short palpebral fissures, short upturned noses, ation and treatment process. Thus, a high in- mid facial hypoplasia, low nasal bridge and a dex of suspicion is necessary in diagnosing head thin upper lip. Hence, it is advisable that preg- injury among alcoholics and, when in doubt, nant women should abstain from alcohol. a CT scan must be ordered to rule out significant head injury. The presence of an altered Alcohol and Metabolic Effects level of sensorium, headache accompanied by Alcohol can cause a wide variety of metabolic vomiting, epileptic fits or the appearance of disturbances including ketoacidosis, hypo- neurological signs such as papilloedema, hemi- magnesemia, hypocalcemia, hypophos- paresis and extensor plantar response are some phatemia and hypoglycemia. Among these, of the obvious pointers to the presence of head ketoacidosis and hypoglycemia are frequently injury. Patients with head injury must be re- encountered during clinical practice. ferred to a neurosurgeon for proper assessment and treatment. It is important to remember Others that an altered state of sensorium in an alcoholic patient could be due to various other Alcohol can accelerate the development of os- causes and thus calls for a detailed evaluation teoporosis, especially in women drinkers. Al- (Table – 14). cohol reduces bone mass. Recent studies have suggested a link between alcohol abuse and Table –14 Altered Sensorium in Alcoholics psoriasis. Finally, alcohol affects the immune Differential diagnosis and Treatment system and lowers resistance to infection. Tu- Clinical condition Treatment berculosis is frequently seen amongst alcohol- Alcohol intoxication No specific treatment ics. Coma due to heavy Dialysis is life saving alcohol ingestion Health Hazards of Long Term Opiate and Multi Drug Abuse (Table – 15) Hypoglycaemia I.V. glucose infusion with I.V. thiamine Opiates refer to a group of drugs derived from Alcohol withdrawal Benzodiazepine the poppy plant Papaver somniferum and to Delirium tremens (diazepam) their synthetic and semisynthetic derivatives. Head injury CT scan and referral The naturally occurring opiate plant alkaloids to a neurosurgeon include morphine, thebaine and codeine. How- ever, it is the synthetic and semi-synthetic de- Post –ictal state Anticonvulsants and rivatives of opiates such as heroin, pethidine, referral to a physician buprenorphine, pentazocine and methadone, Wernicke’s Thiamine which have attained notoriety because of their Encephalopathy supplementation abuse potential. Among these, the abuse of

8 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis heroin (di-acetyl morphine) has assumed epi- Cellulitis demic proportions in recent times. The various medical complications that arise due to long Cellulitis refers to a spreading infection of the term use of heroin are related to the mode of subcutaneous tissue. In an intravenous drug user, cellulitis results from the use of contami- administration rather than the direct effect of nated needles and this can develop into an ab- these drugs. Besides, the presence of impuri- scess. Occasionally, sterile abscesses can occur ties in the street sample of heroin might lead as a result of the irritant effects of the impuri- to additional medical problems. Regular use ties present in the injected drug. Swabs from of drugs like heroin often results in social dete- the wound should be taken (if possible) for bac- rioration, neglect of personal hygiene and a teriological culture. Appropriate antibiotic decline in living standards. Consequently, they therapy should be initiated. Abscess needs to suffer from various nutritional deficiencies and be drained and in cellulitis, the affected part are more prone to develop infections. Studies must be rested in an elevated position, if pos- have shown that mortality rates are high among sible. regular drug users with death resulting from overdose, complications due to the use of non- Thrombophlebitis sterile injecting procedures, serious accidents The irritant effect of the additives in the in- due to falls and Human – Immuno Deficiency jectable drug can cause thrombophlebitis. Se- Virus infection. vere thrombophlebitis leads to venous obstruc- Table – 15 Opiate abuse: Medical complication with consequent edema of the affected tions limb. Treatment involves resting the affected limb in an elevated position. Anticoagulants Mechanism Medical complication are useful if venous thrombosis is present. Crepe bandage and elastic stockings help to alleviate Related to mode Cellulitus, thrombo- oedema after the acute stage is controlled. of self administration phlebitis, endocarditis, of drug – parenteral septicaemia, hepatitis B Endocarditis and C, AIDS, pulmonary hypertension In endocarditis, the heart valves get infected. The masses of blood clot and bacteria might Related to mode of Chronic bronchitis, then embolize to other organs where they act self administration of respiratory infections as septic foci of infection. In general, endocardi- drug – tis develops on damaged heart valve, but among inhalation (chasing) parenteral drug abusers, it can develop in a healthy heart. The major source of infection is Socio – economic Nutritional deficiencies, the contaminated needle which introduces the decline in living multiple vitamin bacteria directly into the venous blood. These standards deficiencies reach the right side of the heart. Consequently, Poor immune status Recurrent infections, tricuspid valves are commonly affected in intravenous drug abusers. The presence of high pulmonary tuberculosis grade fever with cardiac murmurs should alert Miscellaneous Overdose (accidental, the clinician to a possible diagnosis of en- deliberate) accidental docarditis. It must be remembered that right injury during sided endocarditis may present without mur- intoxicated state murs as the infection can develop even with a

9 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis normal valve. Among patients with right sided might develop complications such as hepatic endocarditis, pulmonary complications (pneu- encephalopathy and or coagulopathy which will monia, embolism) because of septic emboli into necessitate referral to a hospital. Some patients the lungs are commonly seen. Patients sus- remain as carriers (HBsAg +ve with normal pected of endocarditis must be initially evalu- LFT). Some patients develop chronic active ated by a specialist but can be followed up in hepatitis (HBsAg +ve and abnormal LFT per- primary health care centre once the acute phase sisting for more than 6 months) which may is over. progress to cirrhosis or hepatocellular carcinoma. Septicaemia Hepatitis C virus infection usually occurs fol- Septicaemia should be considered in any intra- lowing blood transfusion but has also been re- venous drug abuser who presents in a toxic con- ported in intravenous drug abusers. Hepatitis dition with high grade fever. A localized infec- C can manifest either as an acute hepatitis (un- tion due to non-sterile injection technique may common) which resolves over 5-12 weeks or develop into septicaemia with widespread or- can go on to a chronic stage directly resulting gan damage and multiorgan failure. Patients with in some cases in the development of cirrhosis. septicaemia are very ill with fever, hypotension, The diagnosis of hepatitis C rests on a positive mental confusion and impaired sensorium. Sep- anti HCV test. No specific treatment is neces- ticaemia is a serious medical event and prompt sary in the acute phase. intervention is necessary. Diagnosis is confirmed by blood culture and the patient is best treated Acquired Immune Deficiency Syndrome under the care of a specialist. (AIDS) Hepatitis Intravenous drug abusers (IDUS) are a high risk group to develop AIDS. They often share Hepatitis is commonly encountered in infected needles and acquire the infection. In parentral drug abusers as they often share various treatment centers about 10 –560 per needles and thus spread infection from one to thousand samples are positive for HIV and in another. Amongst the various subtypes of in- Manipur, 50 percent of IDUS are HIV posi- fective hepatitis, Hepatitis B and Hepatitis C tive. Nationally, it has been estimated that are more likely to be associated with parenteral about 8 percent acquire the infection through drug abuse. Patients with acute hepatitis injecting drug use and sexual contact accounted present with malaise, loss of appetite, nausea for nearly 75 per cent infections. Patients with and low grade fever. On physical examination HIV infection at the stage of seroconversion, of the patient, icterus is usually seen and may might develop flu like symptoms. After a vari- be accompanied by an enlarged, tender liver. able period, usually around 10 years, patients The liver function tests are abnormal with raised become symptomatic. Persistent serum bilirubin, AST and ALT. lymphadenapathy, weight loss, fever and diar- Hepatitis B is associated with a long incuba- rhea may be the initial symptoms. As immu- tion period (2-6 months) and during this as- nosuppression progresses, opportunistic infec- ymptomatic stage the individual is capable of tions appear. Candidiasis, Tuberculosis, infecting others. Hepatitis B infection is con- Pneumocystis carinii pneumonia & firmed by the presence of HBsAg in the blood. cryptococceal meningitis are the common sec- Treatment is mainly supportive. Majority of ondary infections seen in out patients. Treat- patients recover completely. Some patients ment is available for most of the opportunistic

10 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis infections.However, HIV infection is not cur- tempt to commit suicide. They are brought to able currently. Prevention remains the best the emergency service in an unresponsive state. strategy. Naloxone given intravenously (0.4mg) serves both a diagnostic and a therapeutic purpose in Preventive measures begin with HIV testing of suspected cases of opiate overdose. Patients with drug abusers. These include education regard- opiate overdose respond quickly to naloxone ing transmission, manifestation of HIV infec- and the dose can be repeated till the level of tion and the implication of a positive and nega- sensorium improves or pupils dilate. Blood tive test result. The patient must be assured of pressure and respiratory rate must be closely complete confidentiality regarding all aspects monitored during the treatment of opiate poi- of the HIV test during pre-test counseling. soning. It must be remembered that naloxone During post-test counselling, results of the test is a short acting opiate antagonist and the pa- are discussed with the patient. Even in the face tient may slip back into unconsciousness once of a negative test result reduction of risk fac- the drug effect wears off. In a regular drug user tors should be emphasized. Psychological im- withdrawal syndrome may be precipitated by pact of a positive result should not be underes- naloxone. timated and patients must be given time to express their feelings adequately and precau- In conclusion, patients who are regular intra- tion against infecting others emphasized dur- venous drug abusers run the risk of developing ing counselling. multiple infections due to unhygienic injecting practice. To get the patient to give up in- Pulmonary Complications travenous drug use should be the therapeutic Occasionally an intravenous drug user may endeavour. Harm reduction programmes aimed present to a physician with features of pulmo- at decreasing the chances of medical complica- nary hypertension. Particulate matters in the tions like HIV have encouraged various alter- drug get trapped in the pulmonary circulation natives such as the needle exchange program, leading to formation granulomas and inflam- where in the addicts are provided with clean matory exudates which might occlude pulmo- sterile needles. nary arterioles and result in the development of pulmonary hypertension. Chronic bronchi- Health Hazards of Long Term Cannabis use tis may result from regular use of heroin when Cannabis is derived from the Indian hemp plant it is inhaled (chased) or smoked. There is also cannabis sativa. The plant grows in many parts an increased risk of pulmonary tuberculosis of the country and is used widely as an intoxi- among regular users of heroin due to altered cant. Various forms of Cannabis are available immune status and poor living conditions as- and their potency is related to the content of sociated with social deterioration. Various toxic the active ingredient ‘Tetrahydrocannabinol’ substances such as arsenic and rat poison are (THC). Chronic cannabis use is not associated often found in street samples of heroin and with any significant medical complications. when inhaled might lead to medical compli- However, regular use of cannabis must be dis- cations. couraged, as there is greater likelihood that the Overdose individual might come into contact with drugs Drug abusers may inject themselves with large with far greater health consequences such as doses of opiates either accidentally or as an at- heroin.

11 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis Table 16 – Reversible Medical Condition fol- Many such patients are helped by simple ad- lowing Abstinence from Alcohol and Drug Use vice focusing on the need to abstain from alcohol and drug use. However, clinicians often zzz Fatty liver zzz Uncomplicated alcoholic hepatitis have a pessimistic and cynical attitude towards zzz Nutrition deficiencies these individuals because of their life styles and zzz Vitamin deficiencies (except Korsakoff’s frequent relapses into earlier patterns of drink- syndrome) ing and drug taking. This negative concern zzz Hypertension (some patients become nor- must be removed by the fact that even a brief motensive following abstinence from period of abstinence gives damaged tissues time alcohol) to heal and a chance for recovery. Further, treat- zzz Peripheral neuropathy (subjective symp- ment offers a drug free life to the individual. toms with no objective loss of sensation ) zzz Alcoholic dementia (early stages) zzz Metabolic abnormalities zzz Infections, local and systemic (except AIDS & Hepatitis B and C)

Suggested Reading Alcohol 4. Victor M, Adams RD and Collins GH. The 1. Barnes HN, Aronson MD and Delbanco Wernicke-korsakoff Syndrome. Blackwell TL, eds. Alcoholism: A Guide for the Pri- Scientific Publications, Oxford, 1971. mary Care Physician. Springar Verlag, New Opiate Abuse York, 1987. 1. Banks A and Waller, TAN. Drug Misuse: 2. Edwards G, Peters TJ, eds. British Medical A Practical Handdook for General Bulletin; Alcohol and Alcohol Problems. Practioners. Blackwell Scientific Publica- 1994;50:1-234 tions, Oxford, 1988:103-143. 3. Sherlock S. Alcohol and the Liver. In: Dis- eases of the Liver and Biliary System. Eighth 2. Ghodse H. Drug and Addictive Behaviour: ed; Blackwell Scientific Publications, Ox- A Guide to Treatment. Blackwell ford, 1989;425-448. Scientific Publications, Oxford, 1989.

12 Health Hazards of Long Term Use of Alcohol, Opioid and Cannabis Suggested slides for OHP

Slide 1 Slide 5

Individuals who abuse alcohol and drugs are frequent Medical complications associated with opiate abuse users of health care system Mechanism Medical complications Less than 20 % of such patients are identified and of- Related to mode of self Cellulitis, Thrombophlebitis, fered treatment. administration of drug : Endocarditis,Septicaemia, Slide 2 parenteral Hepatitis B and C, AIDS, Pulmonary Diseases associated with alcohol abuse hypertension Related to mode of self Chronic bronchitis, Organ system Diseases administration of drug : Respiratory infections Gastrointestinal Fatty liver, Alcohol Hepatitis, smoking\chasing system Cirrhosis,Oesophagitis, Acute Decline in living Nutritional deficiencies, Gastritis, Malabsorption Pancre- standards Multiple vitamin atitis, Hepatocellular carcinoma deficiencies Cardiovascular Cardiomyopathy, Poor immune status, system Hypertension Recurrent infections, Central nervous Wernicke- Korsakoff’s Pulmonary tuberculosis system syndrome, Dementia, Miscellaneous Drug overdose, Cerebellar Degeneration, Accidental injury while Peripheral Neuropathy, intoxicated Myopathy Nutritional Thiamine, Pyridoxine, Slide 6 deficiencies Folic acid, Ascorbic Acid Reversible medical conditions following abstinence from deficiency alcohol and drug abuse Haematological Anaemia, Leucopenia, disorders Thrombocytopenia • Fatty liver Metabolic Ketoacidosis, Hypogly- • Uncomplicated alcoholic hepatitis caemia, Hypocalcaemia, • Nutrition deficiencies Hypomagnesemia • Vitamin deficiencies (except Korsakoffs syndrome) • Hypertension (normotensive following abstinence Miscellaneous Fetal alcohol syndrome, is some cases) Osteoporosis, psoriasis, • Peripheral neuritis (subjective symptoms with no Tuberculosis objective loss of sensation) • Alcohol dementia (early stages) Slide 4 • Metabolic abnormalities

Treatment has two components. Slide 7 Treatment of the associated medical complications Close interaction among GDMOs, staff of department Simple advice regarding complete abstinence from of medicine and other specialists. alcohol is useful in most patients Some individuals require referral to a specialized de-ad- Linkages with NGOs and de- addiction centers neces- diction service. sary for optimal health care.

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

Rajat Ray, Arindam Mondal

Summary: abuse are complex problems and have impact on the occupational, health, or social spheres Treatment for substance use disorder can be of individuals. This has an important bearing done in a variety of settings with a variety of on the treatment process. clinical modalities. A combination of pharmacological and non-pharmacological (psychoso- There are several approaches to treat drug ad- cial) interventions yields most favourable treat- diction. These include medications, psychoso- ment outcome. The treatment process is en- cial therapy (behaviour therapy, counselling, hanced when clinicians match clinical inter- cognitive therapy, psychotherapy) or their com- ventions with patients’ motivation for change bination. Behaviour therapies offer people strat- and other factors. Treatment of such patients egies to cope with craving, prevent relapse, and requires well-planned strategy and co-ordinated help them deal with relapse, if it occurs. The effort. The treatment goal could either be ab- most effective treatment combines therapies and stinence or harm reduction. other services for comprehensive management. In the national context, it is important to inte- Treatment involves several categories of profes- grate the treatment of these patients with the sionals. They are most commonly general phy- general health care. Thus, general duty medi- sicians and psychiatrists, and often psycholo- cal officers and para-medical staff have a very gists, counsellors and social workers. Commu- significant role to play. The majority of patients nity leaders, spiritual leaders and even lay vol- can be treated at the primary care level and do unteers and patients (ex-addicts) have an im- not require hospitalisation or intensive treat- portant role to play in the treatment process. ment. Treatment in the OPD, community clinic and general medical setting is possible The present chapter discusses various treatment and cost-effective. Some may require complex issues, treatment as a process and generalities and multiple interventions. They are best re- from a medical perspective. Specific treatment ferred to specialised de-addiction centres. issues are discussed in the subsequent chapters. Introduction The current chapter discusses various issues as The general principles of treatment for all drugs applicable to the medical model. According to including alcohol are similar. However, treat- this model, drug dependence is understood as ments for specific substances may differ as the a bio-behavioural condition and manifests as a problems associated with drug abuse and medi- chronic non-communicable disease, with spe- cines needed are different. Further pre-treat- cific symptoms and signs. Thus, affected indi- ment variables and severity of addiction vary viduals are considered to be medically ill. significantly from person to person and from Hence, as with many diseases of the above na- one substance to another. Drug and alcohol

1 Treatment Principles and Issues in Management of Substance Use Disorder ture (viz. diabetes mellitus, arthritis and Assessment asthma), treatment can only modify and alter the course. Use of the term “cure” following Treatment planning and appropriate interventions follow assessment. Assessment helps in treatment, as understood in traditional medi- developing a therapeutic relationship with the cal parlance and as applicable to infective dis- patient. This relationship is based on trust, eases, is inappropriate. Many professionals, empathy and a non-judgmental attitude. notably health specialists, accept the above concept. Issues to consider in assessment:

Goals of Treatment zzz Drug Use and Treatment - Quantity and pattern of use of licit and illicit drugs; pre- Treatment goals differ from patient to patient vious treatment, complications and sever- and over time and may need to be reframed as ity of dependence. the treatment progresses. Traditionally, the primary goal of treatment was to achieve per- zzz Medical & Psychiatric Problems - Medical manent abstinence. However, this goal may and psychiatric problems related to drug remain elusive and alternate goals have to be use. pursued for some. In this sub-group, intervention is directed towards decreasing the harm- zzz Psychosocial Factors - Support; barriers, ful consequences of continued drug use. Such expectations & goals. an effort is practical and attainable, and is zzz Physical Assessment - Effects of drug, in- called “harm minimisation”. Strategies for toxication and withdrawal, general physi- harm minimisation are discussed later. The cal assessment. other goal pursues improvement of physical, psychosocial and occupational functioning. zzz Laboratory Tests - Confirmation of drug use, screening for illnesses predisposed by the Goals may also be classified as immediate, drug used; Investigation of abnormalities short-term and long-term goals. Immediate uncovered in assessment. goals may be completion of detoxification, intervention of psychosocial and medical crisis. zzz Opportunities for Harm Reduction: Inject- Short-term goals may include management of ing behaviour; sexual behaviour and high- medical and psychiatric co-morbidity and re- risk behaviour. integration with family. Long-term goals consist of prevention of relapse, re-integration into Issues In Assessment the society, occupational rehabilitation and Drug use and treatment improvement in overall quality of life. Medical & psychiatric Problems Treatment Goals Psychosocial factors responsible for contin- Abstinence ued drug use Harm minimisation Physical assessment Improvement of health, social, occupa- Laboratory tests tional functions Opportunities for pursuing various treat- Improved quality of life. ment goals

2 Treatment Principles and Issues in Management of Substance Use Disorder

Treatment Settings Government & Non-Government centres Currently, most countries including India have Psychiatric hospital established specialised treatment facilities to Prisons treat drug dependence disorder run by either OPD vs. Ward government (GOs) or non-government organisations (NGOs). Most government treat- Levels of Care ment centres are part of a medical college/gen- There are various levels of care, from the least eral hospital. However, many patients report complex to the most comprehensive interven- to other settings including general medical tion. Complex interventions need not neces- OPD with ailments directly attributable to sarily be the most desirable. Often, brief and excess drug and alcohol consumption. Often simple intervention would suffice. Various lev- they go undetected. It is important to identify els of care can be categorised as: these patients in the non-specialised settings and offer prompt treatment. The above arrange- Level 1: Acute intoxication, overdose and with- ment is convenient to patients and cost effec- drawal symptoms are treated tive too. Level 2: Short term pharmacotherapy, brief Most patients and their families including interventions, community care and many professionals think that for treatment of general measures of rehabilitation are drug dependence, one needs inpatient care. In rendered fact, majority do not require admission. They Level 3: This comprises multiple psychosocial do well on OPD treatment and through do- interventions with or without pharma- miciliary care. cotherapy. Treatment is often deter- Inpatient care provides obvious advantages of mined by individual’s need. restrictive care, more intensive patient contact, Progress and outcome are closely monitored. closer monitoring and usually enforces abstinence. Guidelines for OPD or in-patient treat- Levels of Care ment as practiced in our centre are provided Level 1: Management of acute intoxication, (Annexure). Care can also be rendered through overdose and withdrawal community clinics, psychiatric hospitals and prisons. Each of these has specific purpose to Level 2: Brief therapy and short term phar- serve. Treatment from community clinic and macotherapy exclusive OPD treatment needs a fair clinical trial before inpatient treatment is considered. Level 3: Complex psychosocial therapy, long Inpatient treatment is usually not the first line term pharmacotherapy and monitored fol- treatment. low-up Treatment Settings Personnel required at various levels Community clinic The treatment team consists of various categories of staff and is multidisciplinary in nature. Specialised De-addiction centre The team comprises of doctors, nurses, psy- Non-specialised settings viz. Medical OPD, chologists, social workers, pre-clinical scientists, Dispensary laboratory staff and others for support services.

3 Treatment Principles and Issues in Management of Substance Use Disorder The role of each team members is distinct and ing a drug free status and initiates the process complementary. However, there are grey areas. of reintegration into the society. It may last for Certain duties can be performed by more than 3-6 months. During the late phase, a healthy one category of staff, especially after (in-ser- life style and alternate coping strategies are vice) training. To illustrate, a nurse can carry taught. Usually treatment is multi-modal, out the following activities besides providing which includes pharmacological and non-phar- nursing care and dispensing medicines: macological therapy. a) Obtaining drug use history from Treatment Phases patients Initial 2 to 4 weeks b) Assessment of patients Middle Phase 3 to 6 months c) Counselling the patient d) Counselling the relatives of the patient Late Phase >6 months

These should be reinforced and opportunities Treatment Modalities should be provided for in-service training so as to encourage broader participation of various Certain basic principles of management are activities. These are even more evident in a com- common, irrespective of the nature of substance munity clinic where strict division of role should being abused. In this chapter the focus is on be discouraged. commonalties and general principles of management rather than issues that are specific to Personnel a particular substance. Multidisciplinary Broadly speaking, there are two modalities: Traditional hospital setting - Clarity of role, pharmacotherapy and psychosocial therapy. division of work Goals of pharmacotherapy are reversal of acute effects (intoxication and overdose), ameliora- Community Clinic - Multiplicity of role tion of withdrawal symptoms, decline of craving, prevention of relapse and restoration of Phases/ Stages of Treatment normal physiological functions. Currently, various pharmacological agents are available for the Comprehensive treatment of drug abuse com- above purposes. prises initial, middle and late phases. Phases of treatment are linked with the issue of levels of Treatment Modalities- 1 care (above). In the pre-treatment period ac- Medicines Reversal of acute effects, ceptance of the problem by the patient occurs (Agonist, overdose & toxicity and the patient prepares himself for treatment. Antagonist, Detoxification The peer group and family members play a Deterrents & Decline of craving significant role. Others) Prevent relapse Restoration of health The initial phase is of detoxification, which damage usually lasts for 2-4 weeks. Here efforts are made to free the person of all intoxicants and attend General physicians or specialists from other to the immediate medical consequences of drug disciplines are more often engaged in provid- abuse. The middle phase is aimed at maintaining treatment for toxicity and organ damage.

4 Treatment Principles and Issues in Management of Substance Use Disorder Specialists from addiction medicine provide stinence and a reduction in drug consumption long-term care. Both can carry out detoxifica- before becoming totally drug free. Consider- tion. able patience is required on part of the patient, family members and the treating team in the Detoxification is the initial step in drug abuse process of treatment. intervention. Various long-term medications like agonist, antagonist and deterrents are used Following improvement, treatment is termi- subsequently. These compounds promote ab- nated in a phased fashion. It is important to stinence and minimise relapse. However, a decide about the length of treatment. Obvi- simple pharmacological answer to treat sub- ously, treatment cannot go on indefinitely. stance use disorder is still elusive. Thus they Treatment should be terminated in a planned have to be supplemented with various forms of manner. psychological and social interventions. These include single session counselling and brief Relapse Prevention therapies. In tertiary care settings, more com- This involves strategies, which help the patient plex therapies are carried out to promote so- to maintain the necessary changes in their drug briety and drug free healthy life style. These taking behaviour over time. These strategies are are adjuncts to pharmacotherapy and impor- used in the middle and late stages of treatment. tant for aftercare and rehabilitation. Family support is encouraged. The basic aim in Relapse Prevention is helping patients to: Treatment Modalities- 2 zzz Identify high-risk relapse factors and Psychological & Single session develop strategies to deal with them Social Therapy Brief Counselling zzz Understand relapse as a process Other complex therapies zzz Understand and deal with cues related to Other common tasks are building an improved drug and alcohol use and craving doctor-patient relationship, therapeutic alliance zzz Deal with social pressure to use drugs and and improved communication with the patient alcohol and his/her relatives. Negotiated treatment to zzz Develop and enhance a supportive social enhance motivation is very effective to improve network treatment compliance. Treatment efforts, zzz Develop methods of coping with negative progress, adherence to treatment need to be emotional states assessed. Sometimes, treatment failure requires zzz Learn methods to cope with cognitive dis- alternate treatment strategies. tortion Treatment Modalities - 3 zzz Work towards a balanced lifestyle In addition, the patients should be assessed for Doctor-patient relationship presence of psychiatric disorder and the need Therapeutic alliance for regular follow-up is emphasised. Enhancement of motivation Treatment Resistance Improved treatment compliance Resistance to treatment is a barrier one has to Achieving permanent abstinence is a slow pro- overcome fairly often. This may happen in the cess. Patients go through short periods of ab- initial phase of substance abuse when patients

5 Treatment Principles and Issues in Management of Substance Use Disorder deny or minimise their substance use and its all its members. Self-help groups like “Alco- consequences. Among patients receiving treat- holic Anonymous” (AA) and “Narcotic Anony- ment, patient with additional psychiatric ill- mous” (NA) have congregations in most cities. nesses such as personality disorders and those Additionally, ‘self-help’ groups for family mem- with minimal socio-occupational dysfunction bers, friends and children of drug and alcohol offer the maximum resistance to treatment. abusers have been developed, viz. Al Anon, Al Teen etc. Though many alcohol and drug dependent individuals ultimately reach formal treatment Social Correctional Approach: According to this settings, many remain untreated. Such patients approach, drug and alcohol abuse is seen as a can be helped by “concerned others” such as a social deviance and residential programmes are family member, friend, co-worker, religious or offered as a correctional method. Therapeutic community leaders to initiate contact with a Community (TC) is the most well known of treatment agency for help. When such a pa- the facilities offered under this concept. tient does contact the treatment provider, Motivational interviewing is the single most Workplace based Intervention: Substance abuse important step in breaking the resistance to problems in the workplace and their cost to treatment. the industry are difficult to estimate and is usually underestimated. Also, the ultimate goal Network Therapy in the treatment of substance abuse is employ- Network therapy is a multi-modal approach ment. Of late, Governments have acknowl- to office-based rehabilitation in which specific edged these issues and are adopting corrective family members and friends are enlisted to pro- measures. Though the main focus is on alco- vide ongoing support and promote attitude hol and nicotine dependence, use of other drugs change. It is complementary to other thera- is also addressed. Employee’s Assistance pies. It has 3 critical tasks: Programme (EAP) identifies and resolves productivity problems associated with employees a) Maintaining abstinence: The network of- impaired by personal problems, including al- fers a safe place with trusted family and cohol and drug abuse. It offers assessment, re- friends who help the patient stay in therapy ferral and follow-up services for mental health, and avoid cues that can lead to relapse, alcohol and other drug related problems. b) Caring for the network: An unique therapeutic instrument, the network stays in- Integration with General Health Care: For many volved in enhacing the patient’s coping patients, the general medical setting is the first skills, offering common sense and a posi- point of contact in the treatment of drug de- tive team attitude, pendence. A proportion of these patients can be effectively treated in these settings, e.g. dis- c) Securing future behaviour: It structures the pensary, medical and surgical outpatient ser- clinical situation to limit the possibility of vices. Treatment in such settings has several relapse. advantages, Other Approaches to Treatment a) Being cost-effective, Self Help Approach: In this approach, people b) Increased convenience for patients, with similar problems unite to form a group c) Less stigma and for mutual help. These groups are called ‘self- d) Medical infrastructure already in place. help’ groups. These groups are voluntary and self-sufficient and provide mutual assistance to General duty medical officers can treat these

6 Treatment Principles and Issues in Management of Substance Use Disorder patients adequately provided they have received Laboratory Services training and have liaison with specialised (de- addiction) treatment centres. Laboratory tests have an important role to play in assessment and treatment. Confirmation of In India, treatment facilities have been estab- use of particular drugs, detection of sporadic lished at medical colleges, district level hospi- use and relapse, assessment for co-morbid in- tals and community health centres. Training fectious diseases, assessment of physical com- of staff of these centres has led to increase in plications and monitoring of blood parameters knowledge, skill to treat and change in atti- as prerequisite for medical therapy are the com- tude among various health personnel. mon situations where laboratory services are required. Detection of substances being abused Services possible in these settings are: is important even from the legal aspect.

zzz Emergency care for toxicity, overdose In most instances, self-report and collateral re- zzz Management of withdrawal port by family members about extent and na- zzz Treatment of associated health damage ture of current drug use pattern would suffice. zzz Linkages with other programme viz. con- However, when in doubt, monitoring is called trol of Tuberculosis, HIV/AIDS etc for. Commonly qualitative methods like Thin zzz Referral to specialised treatment centres Layer Chromatography (TLC) or Enzyme following detoxification Multiplied Immunoassay Test (EMIT) are used, and can be confirmed by Gas Liquid Integration with General Health Care Chromatography (GLC). These methods can Setting Medical College, district hos- detect common drugs like opiates, cannabis, pital, CHC benzodiazepines and anti-histaminics in biological samples like urine and blood. Alcohol Services Emergency care, detoxifica- can be estimated quantitatively in blood and tion, referral to other centres breath. Breath-analysers are now commercially Integration Other health programmes e.g. available. Tuberculosis, HIV/AIDS control Other laboratory tests are required in the assessment of the effects of drugs on various organ Training of several categories of staff systems, e.g. altered liver function in chronic alcohol use; in acute management, e.g. Delirium From a public health perspective, effective treat- tremens or in monitoring of treatment ment strategies are: programmes, e.g. Liver function before and during therapy with medications like Disulfiram zzz Facilities for treatment in various settings and Naltrexone. Additional tests include zzz Energetic and vigorous outpatient treat- haemogram, blood counts, urine examination, ment Chest X-Ray, tests for Hepatitis B virus and HIV, zzz Establishment of a referral system from and sputum for Acid Fast Bacillus (AFB) to as- primary care to tertiary care hospital sess the health status of the patient. zzz Integration with other health programmes Outcome Measures as discussed earlier zzz Interaction with community leaders and Traditionally treatment success was measured utilisation of community resources for ef- by abstinence. Today most clinicians feel that fective drug abuse control drug use/ abstinence should not be the sole

7 Treatment Principles and Issues in Management of Substance Use Disorder criteria to assess outcome. Hence there is more Various measures to achieve this are: emphasis on the patient’s well being, beliefs zzz Determination of targeted harm, about drinking and drug use, readiness to prioritisation and limit setting change, social functioning and social support. Improvement should be seen in total function- zzz Imparting knowledge regarding adverse ing of the person. Thus, any after-care health consequences programme should attend to these areas as well. zzz Decrease transmission of communicable Current approaches to treatment of alcohol and diseases related to drug use drug-related problems reflect a continuum of zzz Minimisation of hazardous drug taking treatment. situations Outcome zzz Alternate substitute (agonist) medicines Chronic relapsing disorder: frequent relapse Many strategies can be initiated. These include: - up to 80% within three months zzz Comprehensive drug education programme Harm reduction: for high risk behaviour zzz Reduce adverse health, social and eco- zzz Easy accessibility to substance abuse man- nomic consequences without necessarily agement services eliminating drug use zzz Reduction of hazardous drinking and drug zzz Shift from more harmful to less harmful taking substance zzz Education regarding impairment of perfor- zzz Shift from more harmful to less harmful mance following drug use route of intake eg. Injection to Oral zzz Clarification of doubts and myths regard- Harm Minimisation ing substance abuse Harm minimisation is an important principle zzz Establishment of fixed point of services in the management and intervention of sub- zzz Specific steps to minimise adverse health stance use disorder. Here, abstinence is not the consequences viz. avoidance of needle shar- highest or most immediate priority. Emphasis ing, use of bleach to clean syringes, etc. is placed on reducing many of the problems Harm Minimisation associated with alcohol and drug use, and not just focusing on substance use per se. Harm Determination of priority minimisation strategies address the overall Reduce adverse health consequences health and well being of the individual and Decrease transmission of communicable diseases the community at large. Education about adverse effects. The central idea in the concept of harm Avoiding hazardous drug taking situation minimisation is to reduce adverse health, so- Substitution of illicit substances with licit cial and economic consequences of drug use medicines to prevent relapse without necessarily eliminating drug use. The principle of such a strategy acknowledges that Successful programmes need active community there is a broad spectrum of damage and the participation. Another essential component of risks are hierarchical (less severe to most severe). such an activity is the partnership with other Thus the most damaging consequences should agencies involved in control of drug abuse viz. be given priority in management. NGO, Police, Judiciary, Social Welfare.

8 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.

Treatment Decision Tree

Patient seeking treatment Unmotivated Patient

Motivational interview

Referral from specialist

Referral from Police

Outpatient/clinic/dispensary

zzz Assessment zzz Testing zzz Detoxification zzz Counselling

No mediation Agonist Antagonist Deterrents Anti-craving (Drug free) (Buprenorphine) (Naltrexone) (Disulfiram) (Acamprosate)

Relapse Functioning well

Continue & monitor up to 2 yrs.

Special needs Resistance Complications

Referral to specialised centre/TC

9 Treatment Principles and Issues in Management of Substance Use Disorder Other issues cacy of medicines in the management of substance abuse. Even though we have useful medicines, clinicians have used these only sparingly. Many are It is not the intention of this chapter to sug- sceptical about use of medications to treat sub- gest a simple pharmacological answer to treat stance dependence. This is more so as the field substance dependence. Medications must be is crowded with non-medical experts viz. so- combined with psychosocial therapies. Simple cial activists, lay volunteers and ex-addicts, who steps like supervised and contractual pharma- perceive drug dependence as a moral problem. cotherapy can enhance efficacy of medicines. Medicines are used sparingly and even when These will ensure treatment adherence and used, the dose/duration is inadequate. There minimise dropouts. is a need to make clinicians aware of the effi-

Suggested Reading 1. American Psychiatric Association. Practice 3. Lowinson JH, Ruiz P, Millman RB and Guidelines for the Treatment of Patients Langrod JG - eds. Substance Abuse-A with Substance Abuse Disorders: Alcohol, Comprehensive Textbook. 3rd edition. Wil- Cocaine, Opioids. American Journal of Psy- liams & Wilkins, Baltimore, 1997. chiatry, 1995, 152 (Suppl.): 1-59 4. Miller NS and Gold MS. Pharmacological 2. Galanter M and Kleber HD, eds. The Therapies for Drugs and Alcohol Addic- American Psychiatric Publishing Textbook tions. Marcel Dekker Inc. New York, 1995. of Substance Abuse Treatment. 3rd ed. 5. Shuckit MA. Drug and Alcohol Abuse: American Psychiatric Publishing Inc. Wash- Clinical Guide to Diagnosis and Treatment. ington, DC, 2004. Plenum Press. New York, 1995.

10 Treatment Principles and Issues in Management of Substance Use Disorder Annexure attempts). Guidelines for Treatment Environments 10. Academic and Research reasons. (Florid psychosis and active suicidal intent are A. Indications for In-Patient Treatment more suitable for management in a general psy- 1. Severe withdrawal states e.g. delirium tre- chiatry ward/ hospital). mens, B. Relative Contraindications for Inpatient 2. Injecting Drug Users with complications Treatment and multiple drug use. 1. Obvious Antisocial personality disorder or 3. Serious health damage related to drug/ al- behaviour likely to cause major interper- cohol use e.g. multiple abscesses, overdose, sonal problems on the ward. Wernicke’s encephalopathy, dementia 2. Significant criminal record. symptom complex, liver cirrhosis, and cardiovascular system involvement. 3. Two or more instances of premature dis- charge from the “treatment units”. 4. Obvious psychopathology that can possi- bly be managed in drug/alcohol treatment 4. Several unsuccessful/ aborted treatment unit e.g. affective disorder, psychosis. attempts at various other “treatment units”. 5. Geographical distance from the centre. C. Indications for Intensive Outpatient Treat- ment: 6. Failure of outpatient treatment. 1. Mild or moderate dependence. 7. Definite possibility of a relapse. 2. No previous treatment attempt. 8. Crisis in “Social support” system, patient or family member(s) asking for “restrictive 3. Good social support system. care”. 4. Absence of significant health damage. 9. Intoxicated states (not overdose or suicidal 5. Geographical proximity (within 5 km).

11 Treatment Principles and Issues in Management of Substance Use Disorder Suggested slides for OHP

Slide 1 Treatment goals Medicines Reversal of acute effects Detoxification Abstinence Decline of craving Harm minimisation Prevent relapse Improvement of health, social, occupational functions Restoration of health Improvement of quality of life damage Slide 2 Issues in assessment Long-term Agonist, antagonist, medication deterrents & others. Drug use and treatment Medical & psychiatric problems Slide 8 Standard Treatment - 2 Psychosocial factors Physical assessment Psychological & Single session Laboratory tests Social Therapy Brief Counselling Opportunities for harm reduction Other complex therapies

Slide 3 Treatment settings Slide 9 Standard Treatment - 3

Community clinic Doctor-patient relationship Specialised de-addiction centre Therapeutic alliance Non-specialised settings viz. Medical OPD, dispensary Enhancement of motivation Government & non-government centres Improved treatment compliance Psychiatric hospital Prisons Slide 10 Harm Minimisation OPD vs. Ward Determination of priority Slide 4 Levels of care Reduce adverse health consequences Decrease transmission of communicable diseases Level 1: management of acute intoxication, overdose Education on drug taking and impairment of perfor- and withdrawal mance Level 2: brief therapy and short-term pharmacotherapy Avoiding hazardous drug taking situation Level 3: complex psychosocial therapy, long term phar- Substitute long-term medicines macotherapy and monitored follow-up Slide 11 Integration with General Health Care Slide 5 Personnel

Multidisciplinary Setting Medical College, district hospital, Traditional hospital setting - clarity of role, division of CHC work Services Emergency care, detoxification, refer- Community clinic - multiplicity of role ral to other centres Integration Other health programmes e.g. Tuber- Slide 6 Treatment phases culosis, HIV/AIDS control Training of several categories of staff Initial & middle phases Mostly medical, pharmacotherapy Slide 12 Outcome after treatment Late phase Mostly psychosocial Frequent relapse - up to 80% within three months Slide 7. Standard Treatment - 1 Chronic relapsing disorder

12 Treatment Principles and Issues in Management of Substance Use Disorder Harm reduction: Slide 14 Action plan for harm reduction zzz Reduce adverse health, social and economic conse- Knowledge on minimising health damage quences without necessarily eliminating drug use Responsible drinking zzz More harmful to less harmful substance use Education-performance following drug taking zzz More harmful to less harmful route of intake Eg. Clarify doubts & myths Injection to Oral Establish fixed point of service Slide 13 Strategies for harm reduction Encourage people to come forward for treatment (hidden phenomena). Comprehensive drug education Wide-ranging services Slide 15 Public health model Early identification and intervention Multi level treatment (primary-tertiary care) Community support Rigorous OPD treatment Decrease transmission of communicable disease (drug Early identification related) Establish referral system Minimise harmful drug taking situations Manpower development Substitute medication Integration with general health care Target, priority, limit setting, public policy Integration with other parallel programme I.E.C. Monitoring

13 Pharmacotherapy of Substance Use Disorder 7

Rakesh Lal

Summary abuse disorders is to help the patient achieve and maintain abstinence and the management Pharmacotherapeutic intervention has an im- of complications. Along with various psycho- portant role to play in the management of sub- social interventions, pharmacotherapy has an stance abuse. It is important not only in the important role to play in the prevention of re- acute phase (detoxification), but also in the long lapse. term management (relapse prevention). Fur- ther, pharmacotherapeutic intervention is im- Treatment Settings portant for management of psychiatric and medical comorbidity and sequelae. Pharmacotherapeutic intervention may be carried out in a wide variety of hospital and non- This chapter provides details of medicines used hospital residential and community settings. for detoxification of various substances (alco- The hospital settings include specialized treat- hol, opioid, sedative-hypnotic medications and ment centres for substance use disorders, psy- nicotine) and also long term management strat- chiatric hospitals or centres, and psychiatric egies (deterrent, substitution, antagonist and medical services in general hospitals anticraving agents). Merits and demerits of each of these methods are also discussed. There is a widespread belief that treatment of a substance abuse patient can only be carried Introduction out in an in-patient setting. Though in-patient The primary goal of treatment in substance care has the advantage of ‘restrictive care’, con- abuse disorders is to help the patient achieve tinuous monitoring and a more intensive con- and maintain abstinence and the management tact with the treating team, the outpatient of complications. Along with various psycho- treatment has the merits of being closer to natu- social interventions, pharmacotherapy has an ral settings, an increased family involvement important role to play in the prevention of re- and is more cost-effective. Research data does lapse. not support the belief about the superiority of inpatient treatment over outpatient treatment. Development of an effective treatment is based on assessment findings. The selection of treat- Goals of Treatment ment setting will depend on the treatment Immediate goals can be detoxification, treat- goals in the immediate, short-term and long ment of acute medical sequelae and crisis in- term frames. These treatment goals would be terventions; short term goals usually target determined by severity of disorders, the treatment of comorbid medical or psychiatric patient’s current condition and motivation, as conditions, maintaining abstinence, family re- well as the presence of physical and/or psychi- integration and vocational placement; the long atric comorbidity. term goals focus on the larger issues of relapse The primary goal of treatment in substance prevention, occupational rehabilitation, social

1 Pharmacotherapy of Substance Use Disorder reintegration, abstinent life style and improve- Methods of detoxification ment of quality of life. Pharmacotherapy plays The methods of detoxification include: an important role in all phases of treatment. 1. Gradual reduction of the substance in de- Phase of Treatment creasing amounts, and The detoxification phase being considered as 2. Abrupt cessation of the substance of abuse treatment is in itself a common misconception, and administration of specific medication not only in the patients and their families but which, also in health professionals. Detoxification is a. have cross tolerance to the substance of merely the first phase of treatment. The detoxi- use: e.g. benzodiazepine for alcohol and, fication phase usually runs from 2-4 weeks, buprenorphine for opioid withdrawal, followed by the active treatment phase during b. have some specific pharmacological prop- which the short-term goals are focused upon erties to suppress withdrawal, e.g. and the plan for the long-term goals are made. carbamazepine for alcohol withdrawal, This phase runs from 3-12 months or more, clonidine for opiate withdrawal. and involves the process of choosing from c. Provide general symptomatic relief, e.g. amongst the many pharmacological and psy- hypnotics (benzodiazepine as well as chosocial modalities of treatment. The post- non-benzodiazepines, anti-emetics, treatment or after-care phase focuses on the antidiarrheals etc). long-term objectives being realized and can be By and large, abrupt total cessation of the pri- seen to continue for 3-5 years or even longer. mary drug of dependence and control of with- In this phase too, pharmacotherapy has proved drawal syndrome to a tolerable level by suit- to be beneficial. able medication is the widely accepted method. Detoxification Use of antipsychotic or antiepileptic agents is not recommended to control withdrawal, This is the initial phase of treatment of sub- though they may be required to treat comorbid stance dependence and includes treatment of psychiatric seizure disorders. Similarly use of withdrawal symptoms, assessment of health IV fluids and parenteral drugs to control with- and psychosocial complications with treatment drawal is not recommended, until there are of those requiring acute intervention, and build- specific indications, e.g. presence of severe de- ing up of a therapeutic relationship between hydration, delirium tremens. the patient and treating team. Pharmaco- Doses of medicines for detoxification therapy has a primary role in this phase of treatment. Doses of medicines should be decided according to the expected severity of withdrawal Detoxification is done by abrupt cessation of syndrome, which will vary according to the sub- the substance and prescription of specific agents stance abused (its potency, half life), the time to reduce withdrawal symptoms or by gradu- elapsed since the last dose, severity of depen- ally tapering off the substance being abused. dence (duration, consumption, route of admin- The purpose is to minimize subjective and istration etc) the concomitant use of other objective discomfort as this is an important drugs, the presence of general medical or psy- reason for relapse. chiatric disorder and individual biological and psychological variables.

2 Pharmacotherapy of Substance Use Disorder The aim is to make the experience of withdrawal used, but has not proven to be more effective. state tolerable rather than to suppress all symptoms of withdrawal. The principle ‘least pos- Delirium tremens (DT) or impending DT sible amount of medicines for the shortest pos- should be treated as an emergency (20-25% sible time’ should be followed as majority of mortality in untreated cases and 5-10% mor- the drugs used for detoxification themselves have tality even with treatment). Immediate hos- moderate to high abuse liability. One may need pitalization is indicated. Treatment of choice to modify the dosage schedule according to the is intravenous diazepam, which needs to be withdrawal symptoms which need to be as- given in doses of 10 mg every 20 minutes till sessed continuously during detoxification. patient is sedated or signs and symptoms of withdrawal subside significantly. Patient may Duration of detoxification require further doses of diazepam (oral or intravenous), depending upon the withdrawal Usually alcohol detoxification can be com- symptoms that may reappear subsequently up pleted in 7-10 days and opioid detoxification to two weeks. Supportive treatment comprises requires 2-3 weeks. However, the duration will of parenteral thiamine in all patients, and cor- depend on severity of dependence, drugs of rection of fluid depletion and electrolyte im- dependence (its half life), drugs used for detoxi- balances. The environment needs to be pro- fication (their half life). This will be longer in tective and an effort should be made to orient elderly patients, and debilitated and medically the patient. Sensory stimuli should be or surgically ill patients. Management of pro- minimised in case of a delirious patient. With tracted withdrawal takes longer duration (week treatment, the features of DT are usually con- or months, even up to 6 months) and various trolled within 2-3 days, though patient usu- non pharmacological methods like cognitive ally requires inpatient treatment for another behavior therapy, relaxation therapy may need week. to be used. B. Opioid withdrawal Detoxification of individual substances The starting dose of medication needs to be A. Alcohol withdrawal decided according to amount of opioid con- Benzodiazepines are the drugs of choice in sumed by a patient in the 24 hour period, con- management of alcohol withdrawal. Usually verted into equivalent doses of compound used daily doses of 20-60 mg of diazepam or 40- for detoxification. Subsequent doses needs to 120 mg of chlordiazepoxide are required. The be adjusted according to the severity of with- rd th use of antipsychotic or antiepileptic, except drawal symptoms which peak during 3 to 7 carbamazepine, has no role. Patients with any day in case of heroin. Usually the doses re- of the clinical features of Wernicke’s syndrome quired are 1.2-4.0 mg buprenorphine or 6-12 must be treated immediately with intravenous capsules of dextropropoxyphene initially and thiamine HCl, 100 mg twice in a day, for the tapered off after the third day. Usually, detoxi- first five days. Parenteral administration of fication medicines are required for 2-3 weeks. thiamine in every patient is not necessary, but Certain withdrawal symptoms like insomnia, oral administration of thiamine in all the pa- restlessness and mild body aches persist even tients for prevention of Wernicke’s syndrome after 3 weeks, and can be managed symptom- is justified. Carbamazepine has been found to atically by sedatives and non-narcotic analge- be effective in place of benzodiazepines. Load- sics as well as non-pharmacological treatments ing dose of diazepam has occasionally been like relaxation therapy etc.

3 Pharmacotherapy of Substance Use Disorder In accelerated detoxification, low doses of usual. Usually, detoxification in indoor set- naltrexone are given to precipitate withdrawal ting is over within 2 weeks; however, some- symptoms and clonidine in usual or higher times, protracted withdrawal requires longer doses than those used in hypertension is used detoxification medication. In cases where only to control symptoms. This method reduces insomnia persists, non-benzodiazepine the detoxification period to 4-5 days. hypnotics like zopiclone alone or with relaxation exercises, should be tried. C. Sedative-hypnotic withdrawal D. Nicotine withdrawal Sedative hypnotic withdrawal is managed by gradual tapering of the substance of depen- There is no specific medication for nicotine dence. In cases of mild to moderate depen- withdrawal symptoms. It is possible to tide dence, an outpatient detoxification by taper- over this period with psychological interven- ing of the drug, with weekly reduction in doses tion, with or without benzodiazepines for a can be carried out in well motivated patients. period of week or so. Use of nicotine chewing In patients with severe dependence, particu- gum makes the detoxification easier and this larly with dependence on short acting benzo- may be used for long as a maintenance agent. diazepines, indoor detoxification is preferred. In indoor setting, the drugs can be tapered off E. Multiple substance withdrawal at a rate of 10% a day. In patients dependent In patients, where dependence to more than on short or intermediately acting benzodiaz- one substance has been clearly identified, the epine (oxazepam, alprazolam etc), risk of with- specific medication for each category of the drawal seizures should be kept in mind and to substance of dependence should be given. Fre- prevent the seizures, detoxification is started quently, patient requires inpatient treatment with equivalent doses of long acting benzodi- and the period of detoxification is longer than azepines, which then should be tapered off as in patients with single substance dependence. Summary of Detoxification Agents Category of Opiate Alcohol BDZ Nicotine medication withdrawal withdrawal withdrawal withdrawal 1. Medicines which Tincture opium Oral Long acting Nicotine gum, exhibit cross Morphine benzodiazepines benzodiazepines Nicotine tolerant Dextropropoxyphene (Diazepam transdermal Buprenorphine Chlordiazepoxide patches Oxazepam ) 2. Medicines having Alpha – 2 Carbamazepine -- no cross tolerance adrenergic agonists Beta -Blockers but suppresses e.g. clonidine specific withdrawal syndromes 3. General symptom- Antidiarrheals - - - atic medications Hypnotics 4. Medicines for - Injection - - complicated benzodiazepines withdrawal in DT, seizures

4 Pharmacotherapy of Substance Use Disorder Long-term Pharmacological Treatment enzyme that metabolizes acetaldehyde, the first metabolic breakdown product of alcohol. In This is intended to help patients maintain ab- the presence of disulfiram, alcohol use results stinence after completion of detoxification, with in the accumulation of toxic levels of acetalde- the use of medically prescribed drugs. hyde in liver and systemic blood circulation, Based on the mechanism which operates for which causes a host of unpleasant signs and maintenance of abstinence, the pharmacologi- symptoms which are potentially fatal. The cal agents used in long term treatment can be acetaldehyde syndrome, as a result of the ef- classified in four categories; fect of disulfiram treated individuals when they consume alcohol, has been termed as disulfiram Pharmacological Agents for Long-term Treat- ethanol reaction (DER). ment It should be remembered that disulfiram does A.Deterrent Disulfiram, citrated calcium not reduce craving primarily. agents: carbimide, metronidazole, and compounds like Side effects and adverse reactions: The com- nitrefezole monly experienced side effects are of drowsi- B.Substitution Methadone, LAAM, ness and gastric irritation. The adverse effects agents: buprenorphine, morphine, which occur most commonly with use of dis- nicotine replacement ulfiram are hepatotoxicity, peripheral neuropa- (nasal solution, gum, thy, skin reactions and psychosis. The safety of dermal patch). disulfiram, estimated on the number of reac- C.Antagonist Naltrexone tions reported, corresponds to an intermediate agents: rate of adverse reaction (1 per 200-2000 treat- D.Anticraving Fluoxetine, ment year). The death rate with disulfiram is agents: Acamprosate estimated at 1 per 25,000 treatment years. Contraindications: Many of the adverse reac- A. Deterrent agents tions of disulfiram therapy are also long term Alcohol sensitizing drugs act through definite health complications of alcohol use and must chemical mechanisms to deter the person from be considered as contraindications for disul- drinking and cause an unpleasant reaction if firam therapy. Hepatic dysfunction, periph- the patient does take alcohol in any form while eral neuropathy, and psychosis are the com- he is taking the deterrent agent. mon relative contraindications. The other relative contraindication includes presence of cog- The most prominent example in this category nitive deficits because of the inability to un- is disulfiram (tetraethyl thiuram disulfide). The derstand and remember the consequences of other agents have been used in some geo- alcohol use while on disulfiram. Use in first graphical regions at times, but have not gained trimester of pregnancy is the only absolute con- wider acceptance. traindication. Disulfiram Clinical regimen: Disulfiram should always Mechanism of action: Disulfiram and its ac- be given after obtaining informed consent and tive metabolites irreversibly inhibit the activ- after baseline investigations for monitoring the ity of aldehyde dehydrogenase (ALDH), the 5 Pharmacotherapy of Substance Use Disorder side effects. The usual dose is 250 mg/day; clinicians based on the premise that actual ex- however due to metabolic differences, some perience of the DER is likely to be more effec- patients may require a higher dose of 500-750 tive than the mere cognitive awareness of DER. mg/day to experience DER. It is generally dis- The clinical opinion varies considerably about pensed in a single daily dose in the morning the usefulness of such an ethanol challenge and but may be given in divided doses to avoid definitive research information is lacking. It is unpleasant gastrointestinal side effects. recommended that the option of undergoing a challenge test should be with the patient. Supervised disulfiram therapy: Disulfiram works well when its use is supervised as it en- For the ethanol challenge test, alcohol is ad- sures better compliance. Supervision also en- ministered, generally in the form of spirits (like sures that the possibility of DER is reduced. whisky or rum) which have approximately 40% Unsupervised use in well motivated patients is volume by volume content of absolute ethyl also in practice widely, but several randomized alcohol, starting with 15 ml and further controlled trials have shown that disulfiram can supplements of 15 ml every 15 minutes up to make clinically significant contribution to treat- a maximum of 90 ml. The patient’s vital signs ment outcome only if its administration is care- should be closely monitored all through the fully supervised. test. An intravenous line should be maintained for vasopressor administration consequent to a Education of the patient and supervisor: Dis- precipitous fall in the blood pressure. If it is ulfiram therapy should be initiated only after not possible to achieve a significant DER with the patient and the supervisor has been in- 250 mg of disulfiram, the dose can be increased formed about the rationale for its use as well as to 500 mg and the challenge test be repeated. the necessary precautions with disulfiram use. The dose may be required to be increased to An informed consent of patient is a necessary 750 mg in some cases to obtain a good DER. prerequisite. Patient and family members should be educated about the signs and symp- Treatment of DER: toms of DER, and the actions required to be The fall in blood pressure should be controlled taken if they notice these signs or symptoms. on a priority basis. If DER is mild, assurance It should be explained that DER can occur and oral fluids suffice. In patients with mod- with alcohol intake even in small doses. It is a erate or severe DER, intravenous fluids and, in good practice that the patients be provided some patients, dopamine infusion is necessary small cards containing the sign and symptoms to control the severe hypotension. of DER and necessary first aid methods in case The use of 4-methyl-pyrazole, which blocks of occurrence of DER. Generally, DER does formation at acetaldehyde, has been found to not occur in the first week of disulfiram use be successful but is still not common in clini- and if alcohol is consumed after 5-7 days of cal practice. stopping disulfiram, but can occur even up to two weeks after stopping disulfiram. B. Substitution agents Ethanol challenge test: A challenge test by Substitution maintenance programs derive administering a small dose of ethyl alcohol to their philosophy from the methadone mainte- the patient in controlled conditions in hospi- nance program, initiated by Dole and tal setting, has been recommended by some Nyswander in 1964, as an experiment with six

6 Pharmacotherapy of Substance Use Disorder heroin addicts. It was suggested that high fre- the substitution maintenance programs be quency of relapse in heroin addicts is due to understood for making appropriate choices in intense craving for narcotic and it might be individual patients as well as for larger policy appropriate to target at rehabilitation rather decisions in the context of each region or coun- than abstinence in these patients. It was rec- try. ommended that narcotic medication, if used in these patients to satisfy their craving, will The merits of and arguments in support of help in controlling illicit drug use and related substitution maintenance treatment are: behavior thereby making them accessible to i. Reduction in illicit drug consumption. rehabilitation. Methadone is the most commonly used substitution agent for opioid de- ii. Avoidance of medical complications of im- pendent patients in the US and Europe purities in street preparations, and the complications of parenteral administration and In India, substitution maintenance program overdose. had been practiced through the opium regis- iii. Better nutritional and health status. try, wherein registered opium addicts were dis- bursed a certain amount of tincture opium till iv. Decrease in criminal behavior. it was discontinued in 1959. In the period of v. Improvement in social behavior and psy- heroin dependence in India, there has been no chological well being. officially approved substitution maintenance program and the treatment has mainly focused vi. Increased productivity on the goal of total abstinence and helping the vii. Cost effectiveness. patients achieve a life style free of any substance When using substitution agents, care should use. be exercised to prevent illicit diversion and con- However, in spite of the recognition of sub- comitant use of illicit substances. stance dependence as a chronic disease which Criteria for patient selection is not amenable to ‘cure’, many people, including psychiatrists and physicians, do not feel i. Severe dependence of long duration, with comfortable with the idea of maintenance significant psychosocial disability. therapy with substitution agents even though ii. Past record of unsuccessful treatment at- substitution with morphine, raw opium or tempts (at least three). bupenorphine which is prescribed medically, has been practiced in one or other form in vari- iii. High risk of relapse ous centres in this country iv. Preferably older than 25 years. The reservations have been about the moral v. Minimal criminal involvement and ethical issues involved in such a treatment strategy and about the sociopolitical consider- Substance used for long term maintenance ations of the expense involved in making the therapy lifestyle of these addicts more comfortable by 1. Opioid agonists providing another addictive drug. a. Methadone and LAAM (Levo-alpha-acetyl- It is important that the merits and demerits of methadol) are the two compounds most

7 Pharmacotherapy of Substance Use Disorder commonly used abroad but are not avail- lingual and parenteral use of buprenorphine able in our country. Both have a long half which enhances the risk of illicit channelisation life and are medically safe of buprenorphine dispensed as a maintenance agent. A combination product containing b. Morphine: This has been found to be most buprenorphine and naloxone for sublingual use effective in doses of 60mg daily. A higher is in the experimental stages and may become dose is needed sometimes to control crav- a promising agent for opioid substitution ing and withdrawal symptoms. A dose of therapy. upto 180mg – 240 mg can be administered and the effects last for upto 12 – 24 Maintenance therapy in other substance use hours. Strict monitoring is required as disorders morphine produces chemical dependence and the patient may try to escalate the dose, 1. Nicotine replacement: Use of nicotine reuse other narcotics concomitantly or even placement with gums or patches, is based divert the prescribed morphine to the il- essentially on the principle of substitution licit market. therapy and has been found to be useful. 2. Opiate partial agonists 2. Oral substitution in parenteral substance users: In broader terms, the substitution Buprenorphine, a partial receptor agonist proof a more harmful route by a less harmful duces sub-maximal effect in maximally effec- route (e.g. oral) without changing the sub- tive doses. It also has Kappa opioid receptor stance of abuse can be termed as substitu- antagonistic properties. Although it has a short tion therapy. It will minimize the harmful plasma half life of three hours, its duration of consequences of use. action has been longer, due to its slow disso- C Antagonist agents ciation from opioid receptors. This prolonged action of buprenorphine makes it effective Opioid antagonists are substances that bind when dispensed in once daily dosage or even to opioid receptors but do not produce mor- on alternate days. Side effects of buprenophine phine like effects. If an individual stabilized are sedation, drowsiness and constipation. on opiate antagonist consumes an opiate ago- Tolerance to these effects can be expected to nist like heroin, he will not experience the eu- develop during continued buprenorphine phoric effects as the opioid receptors are already therapy. No apparent health risk has been re- occupied and hence not available for the opi- ported in studies involving long term ate agonist. In this manner, over time, drug buprenorphine therapy. Due to partial ago- seeking behavior becomes extinct. This phe- nist property, there is a ceiling effect on the nomenon helps the patient in achieving a drug side effects, reducing the risk of severe drug free life style. induced respiratory depression. Various antagonists (naloxone, cyclazocine and Due to all these properties and evidence from nalorphine) had been tried but were not found clinical trials, there has been a strong recom- suitable due to their short half life, severe side mendation about the use of buprenorphine as effects or lack of effectiveness through oral ad- a maintenance agent in case of opioid depen- ministration. However, the introduction of dence. The dosage schedule is 2-8 mg/day. naltrexone in the early 1980s, which is effective There has been a concern about increasing sub- orally, with long duration of action and mini-

8 Pharmacotherapy of Substance Use Disorder mal side effects, has revolutionized this approach. cant effect in reducing withdrawal symptoms.

Naltrexone, available as 50 mg tablets, is well Naltrexone absorbed from the GI tract. Although its zzz There is some evidence that naltrexone re- plasma half life is about 6-8 hours, effective duces craving and enhances abstinence in receptor blockade is sustained for 48-72 hours. alcohol-dependent subjects. There are three common schedules for administration: daily (50 mg/day), thrice a week (100 zzz There is good evidence that naltrexone re- mg on Mondays and Wednesdays, and 150 mg duces relapse and number of drinking days on Fridays) and twice a week (150 mg on Mon- in alcohol-dependent subjects. days and 200 mg on Thursdays). zzz Naltrexone was found to be most efficacious with a daily dosing of 50mg. If logistics do The daily dose regimen is generally preferred not permit then 100mg on alternate days over the other regimens. Naltrexone therapy or 150mg every third day has also ben used. should be started, only after detoxification has been completed, which can be confirmed by Acamprosate naloxone challenge test in case of doubt. This zzz Trials of acamprosate in alcohol dependence is necessary as there is a risk of precipitation of are large but limited to Western popula- severe withdrawal features if the patient has tions, primarily European. consumed an opioid in the past 2-3 days. The common side effects of naltrexone are mild zzz There is good evidence that acamprosate opiate withdrawal like symptoms (nausea, ab- enhances abstinence and reduces drinking dominal pain, dyspepsia), skin rash and de- days in alcohol-dependent subjects. rangement in liver function test in obese per- zzz There is good evidence that acamprosate is sons. The only important contraindication of reasonably well tolerated and without any naltrexone therapy is the presence of hepatic serious harmful effects. failure; minor degree of liver dysfunction is not a contraindication. Base line liver function tests zzz Depending on the body weight , 4-6 tab- are mandatory before starting naltrexone lets a day in three divided doses has been therapy. The duration of naltrexone therapy found to be therapeutic. has been recommended to be at least 6-12 Serotonergic Agents months, but longer duration may often be necessary. zzz There are several controlled clinical trials of serotonergic agents in primary alcohol- Since naltrexone does not give a ‘high’ and is ics without comorbid mood or anxiety dis- devoid of reinforcing properties, there is a high orders. dropout rate. Naltrexone therapy is beneficial zzz There is minimal evidence on the efficacy in patients with a high level of motivation. of serotonergic agents for treatment of the D. Anticraving agents core symptoms of alcohol dependence.

Certain classes of medicines have been found zzz There is some evidence on the efficacy of to be useful in reducing craving, an important serotonergic agents for the treatment of al- reason for relapse. They do not have a signifi- cohol-dependent symptoms in patients

9 Pharmacotherapy of Substance Use Disorder

with comorbid mood or anxiety disorders, zzz There is evidence that lithium is not effi- although the data are limited. cacious in the treatment of the core symptoms of alcohol dependence. Lithium zzz There are limited studies on the effects of zzz There is minimal evidence for efficacy of lithium in primary alcoholics without lithium for the treatment of alcohol-depen- comorbid mood disorders. dent symptoms in patients with comorbid depression.

Suggested Reading 1. Galanter M, Kleber HD, eds. The Ameri- 3. McGrady BS. & Epstein E, eds. Addictions: can Psychiatric Press Textbook of Substance A Comprehensive Guidebook. New York: Abuse Treatment, American Psychiatric Oxford University Press, 1999:477-498. Press, Washington D.C., 1999. 4. Mood Disorders. Diagnostic and Statistical 2. Lowinson J, Ruiz P, Millman R, Langrod J, Manual of Mental Disorders, Fourth edn, eds. Substance abuse: A Comprehensive (DSM-IV), Text Revision. American Psychi- Textbook, 4th edn. Baltimore, Lippincott atric Association, 2000: 297-343. Williams and Wilkins, 2005.

10 Pharmacotherapy of Substance Use Disorder Suggested slides for OHP

Slide 1: Slide 3: Detoxification Goals of treatment Gradual reduction Immediate Abrupt cessation using Detoxification Cross-tolerant medicines Acute psychiatric and medical complications Withdrawl suppressant Crisis intervention Symptomatic relief Long term Dosing of medicines depends on Co morbidity Potency and half-life of substance used Relapse prevention Time since last intake Rehabilitation Severity of dependence Presence of co morbidity Slide 2:

Pharmacological Slide 4: Alcohol Psychological Benzodiazepines (diazepam: 20 – 60 mg; chlordiazep- Sociological oxide: 40 – 120 mg) Treatment settings Thiamine 100 mg bid Hospital Carbamazepine Specialized Delirium tremens Psychiatric 10 – 25 % mortality General hospital Intravenous diazepam 10 mg every 20 minutes till se- Non-hospital dated Residential Thiamine 100 mg Community Minimize sensory stimuli Inpatient Restrictive care Slide 5: Opioids Continuous monitoring 1.2 to 2.4 mg of buprenorphine Intensive contact 6 to 12 capsules of dextropropoxyphene Emergency Taper after 3rd day Outpatient Sedative – hypnotic Cost effective Gradual tapering (10% daily) Natural surrounding Nicotine Family involvement Non-specific, symptomatic

11 Pharmacotherapy of Substance Use Disorder Slide 6:

Summary of Detoxification Agents Category of Opiate Alcohol BDZ Nicotine medication withdrawal withdrawal withdrawal withdrawal 1. Medicines which Tincture opium Oral Long acting Nicotine gum, exhibit cross Morphine benzodiazepines benzodiazepines Nicotine tolerant Dextropropoxyphene (Diazepam transdermal Buprenorphine Chlordiazepoxide patches Oxazepam ) 2. Medicines having Alpha – 2 Carbamazepine -- no cross tolerance adrenergic agonists Beta -Blockers but suppresses e.g. clonidine specific withdrawal syndromes 3. General symptom- Antidiarrheals - - - atic medications Hypnotics 4. Medicines for - Injection - - complicated benzodiazepines withdrawal in DT, seizures

Slide 7:

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 8: ministration and overdose. Better nutritional and health status, with regular monitoring. Disulfiram Decrease in criminal behavior. Dose: 250 – 750 mg/day Improvement in social behavior and psychological well being. Inhibits aldehyde dehydrogenase (increase aldehyde Increased productivity level) Contraindications Slide 10: Long-term maintenance Refusal of consent Opioids Alcohol Hepatic dysfunction Agonists Anticraving Peripheral neuropathy Methadone Naltrexone Psychosis LAAM Acamprosate Cognitive deficits Morphine Serotonergic agents Pregnancy Partial agonist Lithium Slide 9: Buprenorphine Deterrent Merits of substitution Antagonist Disulfiram Reduction in illicit drug consumption. Naltrexone Avoidance of medical complications of impurities in street Nicotine preparations, and the complications of parenteral ad- Substitution with nicotine chewing gum

12 Long-Term Treatment of Opioid Dependence Syndrome 8

Anju Dhawan, Amardeep Kumar

Summary type of treatments have limitations. Thus efforts are being made to develop newer modes Opiate dependence is a chronic, relapsing dis- of delivery of medications so that compliance order and requires multiple treatment episodes. can be improved and illicit diversion can be Moreover many drug users do not seek treat- reduced. To reduce the risk of illicit diversion ment until they are into a lifestyle committed (misuse), combination tablets of to drug use and criminal activity. Thus, though buprenorphine and naloxone has been devel- complete abstinence is the ultimate treatment oped which will soon be available in India. Simi- goal, it is difficult for many patients. The al- larly to enhance the compliance with ternative goal of harm minimization is achiev- naltrexone, depot preparation has been devel- able and desirable for many patients. The goals oped which are in phase III clinical trials. Bet- of treatment require the patients to be on long- ter modes of psychosocial interventions are also term pharmacological treatment. This is an being developed to improve the treatment out- integral part of a comprehensive treatment plan come. There is no fixed optimal duration of which also includes psychosocial and medical long-term pharmacological treatment. The interventions to reduce the use of other drugs, decision to terminate the pharmacological treat- to decrease the transmission of HIV, Hepatitis ment should based on the treatment goals and B, C and other sexually transmitted diseases. should be a joint decision of treating team, One also needs to impart necessary support to patients and their family members. the patients and skills for better integration in the society. The long-term pharmacological Introduction treatment is of two types- antagonist treatment and agonist maintenance. Antagonist treatment Opiate dependence is a chronic relapsing dis- follows the complete abstinence approach while order and single episode of treatment seldom agonist maintenance follows the harm mini- leads to long term abstinence from drugs. mization approach. The long-term antagonist Majority of heroin addicts relapse within the treatment helps in maintaining complete ab- first year of treatment; mostly within the first stinence by extinction of drug seeking behaviour three months. Numerous studies conducted by blocking the effects of opioid over a signifi- during the past 35 years have demonstrated cant period of time. The basic principle in ago- that, once initiated, drug use often escalates to nist maintenance treatment is to substitute il- more severe levels, with repeated cycles of ces- licit, medically unsafe and short-acting opiate sation and resumption. Thus, long-term treat- with a medically safer, long-acting agonist of ment is needed for opiate dependent individu- known potency, purity and dosage. The ap- als. Though complete abstinence is the ulti- proved antagonist agent is naltrexone while the mate goal of the long-term treatment, it may agonist agents approved for treatment are be a difficult option for many patients in whom methadone, LAAM and buprenorphine. Both the alternative goal of harm minimization is

1 Long-Term Treatment of Opioid Dependence Syndrome achievable and desirable. Depending upon the of drug seeking behaviour and prevents the re- goals of the treatment, various long-term treat- establishment of physical dependence. Patients ment strategies have been developed. These taking naltrexone experience less craving in the strategies include various pharmacological, presence of opioid-related cues, presumably psychosocial and medical interventions. because on a cognitive basis they are aware that they will be unable to experience the effects of Pharmacological interventions are an integral opioids. The limitation of long-term naltrexone part of long-term treatment. To be effective, treatment is low compliance and a high drop- an ideal long-term pharmacological agent out rate. Since it does not produce euphoria, a should be able to produce blockade of exter- high level of motivation is required for compli- nally administered opioids, reduce craving, ance with naltrexone. Available studies have should not be liable to abuse and be safe, non- found that 30 to 40 percent patients maintain toxic and free of side-effects. Along with these, abstinence at 1-year follow up if there is a good its acceptability among patients should be good social support and active involvement of im- and its duration of action should be long so mediate family. that multiple administrations are not required. Two kinds of pharmacological agents for long- B) Opiate agonist therapy term treatment are: Opiate substitution or maintenance on an ago- a) opioid antagonist treatment - naltrexone nist drug is well accepted as an effective harm and minimization treatment strategy. The basic b) opioid agonist maintenance treatment such principle of agonist maintainence treatment is as methadone, LAAM (levo- acetyl to substitute an illicit, medically unsafe, short methadol), buprenorphine. acting opiate with a medically safe, long acting agonist of known potency, purity and dos- Studies have shown that the effectiveness of age. Agonist maintenance eliminates drug hun- long-term pharmacological treatment is pow- ger and produces cross-tolerance so that the erfully influenced by the quality of additional person does not experience any withdrawal services provided. Thus, psychosocial and medi- symptoms and there is no craving for the drug cal intervention remains an important part of he was abusing. When combined with psycho- adjunctive treatment along with pharmacologi- social interventions it minimizes dysfunction, cal interventions. helps the patient become productive and im- A) Antagonist therapy proves self-esteem and personal dignity. The underlying principle of antagonist treat- Specific primary and secondary goals of long- ment in opioid dependent individuals is that acting opioid agonist pharmacotherapy are- it blocks the euphoric effects of opioids. Primary goal is “significant reduction or cessa- Naltrexone is an opioid antagonist which is safe, tion of illicit opiate use” with “a related goal of non-toxic, has no abuse liability, no depen- voluntary retention in treatment for an ad- dence potential, a long duration of action (24 equate duration”. hours) and does not produce withdrawal symptoms on cessation. Thus it promises to be an The secondary goals include: effective agent for maintaining complete absti- zzz Reduction or cessation of alcohol and nence. This gradually leads to the extinction polydrug abuse.

2 Long-Term Treatment of Opioid Dependence Syndrome

zzz Reduction of exposure to diseases transmit- chiatric and psychological assessment and care; ted by unsterile injection equipment (in crisis intervention; social and economic assis- parenteral drug abusers) such as hepatitis tance; vocational and family assistance. Brief, B, C, and HIV infection. supportive and problem-oriented counselling can add to the effectiveness of treatment for zzz Reduced criminality and antisocial behav- patients with current life problems. Cognitive- iors. behavioural therapy, motivational interviewing, zzz Improvement in socio-occupational func- relapse prevention counselling and social skills tioning. training are some approaches that can be em- Achievement of these goals was correlated with ployed. the duration of retention in treatment. Treat- A comprehensive treatment plan should be for- ment lasting less than 90 days usually had little mulated early in treatment. The treatment plan or no impact in behavioral change. A 6-month should set out the services to be provided. Ser- retention rate with an agonist was correlated vices should include dose review and adjust- with long term improvement. ments (for long-term agonist maintenance Harm minimization approach using opiate treatment), setting and reviewing treatment agonists has its own drawbacks. These include goals, monitoring of progress and harm reduc- the risk of abuse (including toxicity) and de- tion interventions (e.g. advice on reducing risks pendence on opiate agonist medications, di- of contracting or spreading hepatitis and HIV version of medications for illicit use and emer- infection). Supportive or social skills training, gence of opioid withdrawal symptoms when focussed counselling, assistance with vocational these medications are stopped. difficulties (e.g. linking with training or employment services), assistance in reducing con- Experience in some treatment centres has also current drug use and assessment of suitability suggested that in some patients it has been for gradual withdrawal from treatment is also possible to shift a patient from opiate agonist given. The nursing staff or a social scientist can maintenance to an antagonist drug at a suit- be trained to conduct several of these assess- able time in the course of treatment. ments. Comprehensive treatment Such a treatment plan should be reviewed every three months with the patient. Completion of ac- Patients with opiate dependence usually have tivities and progress against goals should be noted. concomitant psychological, social and health All members of the treating team should be in- problems. An essential component of long- volved in the decision making process and subse- term maintenance treatment is the availability quent review. Based on the progress of the pa- and inclusion of a comprehensive range of ser- tient, treatment plans and objectives may need to vices to assist individuals to reduce their con- be revised more than once. comitant health and psychological problems. These would include pharmacological and psy- Long-term pharmacological treatment agents chosocial interventions to reduce use of other drugs (including alcohol and tobacco); inter- Various agents have been used for the long- ventions to reduce risks associated with hepa- term pharmacological treatment of opioid de- titis A, B and C and HIV viruses; medical, psy- pendent individuals. These include both agonist and antagonistic medicines.

3 Long-Term Treatment of Opioid Dependence Syndrome

Long-term pharmacological agents for of tolerance to exogenous opioids, thus increas- opioid dependence. ing the risk of overdosage and related complications. Opioid antagonist- Naltrexone. In carefully selected patients who are well mo- Agonist opioids- Methadone, LAAM, tivated, naltrexone can be used as a mainte- Buprenorphine, Sustained release nance medication. The followings are useful morphine guidelines for selecting the patients suitable for Antagonist agents- long-term treatment with naltrexone as followed in western countries – Naltrexone- It is an opioid antagonist synthe- sized in 1965 and approved in USA for long- zzz High motivation term treatment of detoxified opioid dependent zzz Short duration of opioid use patients in 1984. Naltrexone selectively com- zzz Professionals like doctors, dentists etc. petes with exogenously ingested opioids for central nervous system (CNS) and non-CNS zzz No co-morbid psychopathology opioid receptors and blocks their activity. This zzz Good social support blockade lasts for up to 72 hours after naltrexone Clinical experience at NDDTC, AIIMS sug- administration and prevents reinforcement gests that it can probably be used in a wider from opioid use. This blockade can have posi- subgroup of opioid dependent patients. tive psychological consequences including reduced craving related to reduced immediate As a nonscheduled medication without psy- effects of opioid (cognitive basis of action) and choactive or addictive properties, naltrexone deconditioning/extinction of cue-related crav- can be administered as a maintenance treating as patients are exposed to several cues for- ment in a range of medical settings without merly associated with opioid use while being any governmental regulations. Since diversion protected from opioid effects (classical and is not an issue, take-home medications can be operant learning basis of action). It is orally provided with no special precautions. However, effective and when given three times a week lack of initial patient acceptance and subsequent (100mg on 1st and 3rd day and 150mg on 5th medication noncompliance limits the utility day), it completely blocks the effects of sub- of naltrexone for opioid dependence. stantial doses of heroin. The opioid antagonist Naltrexone should be administered only after properties of naltrexone do not appear to be complete abstinence from opioids for a suffi- subject to development of tolerance, as potency ciently long duration that ensures complete has been demonstrated even after maintenance washout of the illicit as well as prescribed opio- for 1 year or more. Naltrexone does not have ids. Hence, patients must start treatment with opioid agonist properties, and thus patients a goal of achieving total opioid abstinence and neither obtain a high after use nor is it associ- a willingness to undergo detoxification. Stud- ated with significant withdrawal symptoms if ies have shown that most patients from use is discontinued. However, some patients unselected populations drop out within first continue to complain of adverse effects or opioid three months of treatment. Greater success has withdrawal effects for several weeks. Another been achieved with patients motivated for ad- issue of concern is that patients may be more herence to treatment with individual counsel- sensitive to lower doses of opioids once ling and involvement of family members. naltrexone is discontinued, because of the loss

4 Long-Term Treatment of Opioid Dependence Syndrome Depot preparation of naltrexone is currently be a favorable drug as it has a long duration of in phase-III clinical trials and have shown ad- action (24 hours) requiring once daily admin- equate blockade of externally administered istration, is safe and non-toxic with minimal opioids for 30 days with a single injection. This side effects. Individuals need to attend specialty will be helpful in ensuring compliance in near clinics (methadone clinics) daily where they future. receive their dose in a supervised manner to prevent the misuse of the medication. Studies NALTREXONE have shown that as part of a broader programme zzz Opioid antagonist of support and rehabilitation, methadone maintenance treatment reduces illicit opiate zzz Goal of treatment- complete abstinence use, criminal activity, mortality and morbid- zzz Daily dose - 50mg/day ity (including HIV infection) and improves zzz Thrice/week dispensing (100 mg each on psychosocial functioning. The major factor 1st and 3rd day and 150 mg on 5th day) known to be involved with better outcome is zzz No tolerance, no abuse and dependence the duration of treatment (retention in treat- potential. ment). Retention in treatment in turn is related to factors such as adequate dose, flexibil- zzz Poor compliance and high drop-out from ity of dosing, well-trained staff, positive rela- treatment tionships between staff and patients and there- zzz Enhanced compliance - Depot naltrexone fore these factors are associated with a favourable (phase III clinical trials) outcome. Agonist Maintenance Agents- Methadone maintenance still has some limita- Agonist agents for the maintenance treatment tions. Opioid dependent individuals need to of opioid dependence are- attend the methadone clinics daily leading to significant inconvenience. Apart from this, the Methadone stigma attached to attending such speciality Methadone is the most extensively used and clinics is another cause of concern. The risk of studied agent for maintenance treatment in abuse and dependence also exists. Patients re- many countries. It was introduced in mid lapse soon after leaving treatment and use of 1960s by Dole and Nyswander at the other drugs may continue even on methadone. Rockfeller Institute, USA. They found metha- Studies have shown that after leaving the treat- done to be effective in producing cross-toler- ment programme, significant numbers relapse ance and blockade of the effect of externally (70 percent at 1 year) and indulge in various administered narcotic. In other words, a per- criminal activities. son stabilized on methadone would not expe- LAAM rience the acute effects, including euphoria following the use of heroin. To date there have LAAM is a derivative of methadone developed been over 500 research trials looking at various in the 1940s in Germany as an analgesic. It aspects of methadone treatment. Together they was approved as a maintenance treatment agent form a large body of evidence in favour of the for opioid dependence in USA in 1993. LAAM effectiveness of methadone maintenance. It has has a long duration of action and can be given been shown that 60mg of methadone is the once every 2-3 days. It has been found to be lowest effective dose. Methadone was found to safe and efficacious. Some studies have shown

5 Long-Term Treatment of Opioid Dependence Syndrome it to be equivalent to methadone in suppress- ity) generally suggest it to be a safe and effec- ing illicit opioid use and encouraging productive medication. tive activity. The drawback however, is related to the cumulative toxicity of LAAM and its The efficacy of buprenorphine has been com- metabolites. There are reports of arrhythmias pared with methadone. Several studies have (Torsades de Pointes) in some patients. LAAM compared different doses of buprenorphine to is more complex pharmacologically than methadone. These have confirmed that methadone and its use demands a more skilled buprenorphine produces an opiate agonist ef- clinician than methadone. fect similar to methadone. Many have recommended 8 mg of buprenorphine per day, how- Buprenorphine ever, it has been also reported that the difference between efficacy of 4 mg and 8 mg daily The search for a better alternative to above dose of buprenorphine is marginal. mentioned agents lead to use of buprenorphine for the long-term treatment of opioid depen- It has been suggested from the clinical experi- dent individuals. Buprenorphine is a semi-syn- ence at the NDDTC, AIIMS that opiate de- thetic opium alkaloid derivative of thebaine. It pendent individuals who may be suitable for is a long acting, highly lipophilic opiate. It is buprenorphine are a subgroup of opiate de- generally administered as sublingual tablet pendent patients who fulfil the following re- (S.L) or as a liquid. Bio-availability after sub- quirements- lingual administration is approximately 50%. Peak concentration occurs within 2 hours of Suitability sublingual administration. Elimination half-life Above 21 years of age of sublingual buprenorphine is approximately Regular opiate use for at least 3 years 27 hours. It is 25-30 times more potent than Proof of at least 2 unsuccessful attempts to morphine (in analgesic action). About 0.4-0.6 achieve abstinence following treatment from mg S.L is equi-analgesic to 10 mg morphine recognised treatment centres given intravenously. It is a partial mu agonist Certification by a Medical Officer and antagonist of kappa. It produces analgesia and other central nervous system effects that Willingness to give body fluids to check il- are qualitatively similar to those of morphine. licit drug consumption on demand Buprenorphine can be substituted for However, long-term maintenance treatment morphine or heroin and suppresses symptoms with buprenorphine has got its own drawbacks. of mu agonist withdrawal. The effects are slower Withdrawal symptoms do occur following the in onset and longer lasting than morphine. It abrupt withdrawal of this medication, but the dissociates slowly from the opiate receptors thus symptoms are milder than those of methadone. having a long duration of action. Some studies The risk of abuse and dependence does exist, have shown that it can be used every alternate day or once in three days. Buprenorphine although lower than methadone. There have exhibits a ceiling effect, most noticeably in its also been reports of injecting the tablets of respiratory depression and euphoriant effect buprenorphine through intravenous or intra- which accords the medication a high degree of muscular route by dissolving the tablets. To clinical safety. It has found high acceptability reduce this serious risk, supervised dispensing amongst patients. The above mentioned prop- has been advocated. Along with this, to com- erties (frequency of dosing, safety, acceptabil- bat the problem, a buprenorphine-naloxone

6 Long-Term Treatment of Opioid Dependence Syndrome combination tablet has been developed. The and poor availability in all parts of country, rational has been that when used by opiate some other agonist medications are also being addicts by the intended route (sublingual), the tried for these patients. buprenorphine-naloxone tablet would yield desirable effects; i.e. buprenorphine would be Sustained release Morphine (MS CONTIN) adequately absorbed and act as a maintenance This medication is being routinely used in the drug, while naloxone would not be absorbed treatment of cancer pain. Compared with short adequately by the sublingual or oral routes. acting, immediate release morphine, MS However, if the buprenorphine-naloxone tab- Contin has the advantage of 12-hour dosage, lets were diverted for misuse and dissolved for decreased sleep disturbance and increased use by the i.m/i.v route, naloxone would be- medication compliance. MS Contin has been come active and produce/precipitate opiate recently tried for opioid dependent patients for withdrawal symptoms, which are distressful to maintenance programme at the NDDTC, the patient and hence would discourage such AIIMS. However, the risk of abuse and depen- use. Studies have also tried to arrive at the best dence exists as with other agonist drugs. Clini- dosing ratios of such a combination tablet. Some cal experience with sustained release morphine earlier studies suggested that dose combina- as opioid agonist maintenance agent is limited. tions at 2:1 and 4:1 ratios may be useful in To summarize, all the agonist agents help the treating opiate dependence (Buprenorphine: opioid-dependent individuals by minimizing Naloxone). Later studies suggest a ratio of 4:1. the harm (physical, psychosocial) caused by the Such a tablet is also likely provide for greater use of illicit opioids while the individuals are patient autonomy in the form of weekly or fort- still on an opioid agonist drug that has abuse nightly (as opposed to daily or alternate-daily) and dependence potential. visits to the treatment centre and make a provision for ‘take-home’ medications, thus pro- Termination of long-term pharmacological viding patients with more time for vocational/ treatment rehabilitative activities. Buprenorphine-nalox- Patients should remain in treatment for the one combination tablet would soon be avail- minimum time it takes to achieve their agreed able in India. treatment goals. The length of time required BUPRENORPHINE for treatment will vary amongst individuals. Regular reviews will assist in determining need zzz Partial opioid agonist for continued treatment. There is no fixed op- zzz Clinically safe timal duration of pharmacological treatment zzz Dose - 4-8 mg/day and removing people from treatment too early rd zzz Frequency - Every 3 day possible may result in very poor outcomes, including zzz Dependence potential - less than metha- high rates of relapse into illicit opiate use and done. Abuse potential present a consequent increased risk of overdose. Set- zzz Possible safeguard from abuse - Combi- ting an arbitrary duration of treatment and nation buprenorphine and naloxone tablets withdrawing treatment at that endpoint is not recommended. The treatment approach should Due to the high treatment cost with the include working towards goals which prepare abovementioned medications (buprenorphine a patient to live well without pharmacological and naltrexone which are available in India)

7 Long-Term Treatment of Opioid Dependence Syndrome treatment. An important objective of mainte- medication. A slower rate of reduction would nance treatment is the successful withdrawal be desirable if relapse is likely After withdrawal from maintenance agent combined with con- from agonist maintenance, patient may require tinued good functioning, including good more frequent supportive, skill oriented and health and social functioning. Planning for relapse prevention counseling, more frequent successful withdrawal from maintenance treat- monitoring and review, access to residential ment should commence from the initiation of programme if necessary (residential withdrawal treatment. The decision to withdraw voluntar- or rehabilitation programme) and increased ily from long-term pharmacological treatment involvement of significant others (including should be a joint decision of the patient and family). the prescribing doctor, with information con- tributed by the social worker or nursing staff Counseling, continuing case management and who may be evaluating the psychosocial func- structured group programme are all likely to tioning of the patient. When all agree about assist outcome after completion of pharmaco- the timing and method of withdrawal, patients logical treatment. The staff should remain in- tend to be more successful in continuing volved in the care of patients who have volun- abstinence. tarily withdrawn from pharmacological treatment for up to a few months after completion The elements of treatment that assist patients of treatment. In case of relapse, the patient to complete withdrawal from an agonist drug should have easy access back into treatment. successfully include a flexible approach to dose Treatment should be offered expeditiously and reduction and individualizing reduction of without recrimination.

Suggested Reading

1. Blaine JD, ed. Buprenorphine, Alternative 9th edn. (Harman JG and Leemboid LE, Eds Treatment for Opioid Dependence. NIDA in chief). Mc Graw-Hill, New York, 1996, Research Monograph 121. US Department 521-556. of Health and Human Services Washington 5. Lowinson J H, Payte J T, Salsitz E, Joseph D.C, 1992. H, Marion I J, Dole V P Methadone Main- 2. Effective Medical Treatment of Heroin Ad- tenance. In: JH Lowinson, P Ruiz, RB diction- Program and Abstracts. Office of Millman, JG Langrod (eds.) Substance the Director, National Institute of Health, Abuse- A Comprehensive Textbook- third 1997. edition, Williams and Wilkins, USA, Mary- 3. Ray R, Dhawan A. Oral Buprenorphine land, 1997. Substitution Therapy. Report submitted to 6. Jaffe JH, Jaffe AB. Opioid related disorders. UNODC, ROSA, 2004. In: BJ Sadock, VA Sadock (eds.) Compre- 4. Reisine T, Pasternak G. Opioid Analgesics hensive Textbook of Psychiatry- seventh edi- and Antagonists. In: Goodman & Gillman’s, tion, Lippincott Williams & Wilkins, 2000. The Pharmacological basis of Therapeutics

8 Long-Term Treatment of Opioid Dependence Syndrome Suggested slides for OHP

Slide 1 Slide 4

– Opioid dependence- Chronic relapsing disorder – BUPRENORPHINE – Risk of relapse high within the 1st year of t/t – Long-term t/t needed for majority of opiate depen- • Partial opioid agonist dent individuals • Clinically safe – Various strategies for long-term t/t has been devel- • Dose- 4-8 mg/day oped in the form of comprehensive t/t plan • Frequency- Every 3rd day possible Slide 2 • Dependence potential- less than methadone • Abuse potential present – Comprehensive t/t plan- various pharmacological, – Possible safeguards from abuse- Combination psychosocial and medical interventions buprenorphine and naloxone tablets – Concept of long-term t/t – complete abstinence using opiate antagonist – Suitability for long-term treatment with – Harm minimization using opiate agonist buprenorphine – Pharmacological agents for long-term t/t- Above 21 years of age Opioid antagonist- Naltrexone Regular opiate use for at least 3 years Opioid agonist- Methadone, LAAM, Proof of at least 2 unsuccessful attempts to achieve Buprenorphine, Sustained release Morphine abstinence following treatment from recognised treat- Slide 3 ment centres Certification by a Medical Officer NALTREXONE Willingness to give body fluids to check illicit drug • Opioid antagonist consumption on demand • Goal of treatment- complete abstinence • Daily dose- 50mg/day Slide 5 • Thrice/week dispensing (100 mg each on week- days and 150 mg on weekends) – Termination of long-term t/t • No tolerance, No abuse and dependence potential. – No fixed optimal duration of long-term t/t • Poor compliance and high drop-out from treatment. – Decision to terminate t/t • Enhanced compliance- Depot naltrexone (phase III • Based on agreed t/t goals clinical trials) • Joint decision of treating team, patients and their Suitability for long-term treatment with naltrexone family members • High motivation • Short duration of opioid use • Professionals like doctors, dentists etc. • No co-morbid psychopathology • Good social support

9 Psychosocial Treatment in Substance Use Disorder 9

Renuka Jena

Summary the client’s environment for developing more adaptive responses. It is also important to as- The management of substance use goes beyond sess the extent of any co-existing psychopathol- pharmacology. Clinical and academic experi- ogy. ence reflects the significance of psychosocial interventions in addition to the pharmacologi- There are numerous scales that have been de- cal treatment. Motivational interviewing, mo- veloped for the assessment of various aspects of tivation enhancement, counseling and relapse drug and alcohol abuse. These instruments are prevention have been used with success in short very general and assess a number of variables and long term management of substance use. from a conceptually distinct area e.g., craving, Brief intervention has shown significant results outcome and efficacy expectations. in alcohol and nicotine abuse in busy outpatient and primary care settings. The chapter The assessment process will assist the thera- focuses on various psychosocial modalities use- pist in tailoring a treatment program to the ful in substance use. needs of the individual as well as elucidating on the most appropriate treatment goal. Gossop Introduction (1996) has provided examples of treatment goals which include: The use of substances that alter mood, behavior, or cognition has been a part of human life (i) Reduction of psychosocial or physical prob- across numerous social contexts throughout lems either directly or indirectly related to history. Invariably, there are some individuals the drug problem. whose use of such substances may lead to abuse (ii) Reduction of risky behavior associated with and eventual psychological, social or physical the use of the drug. harm. Although some people use drugs safely, most encounter problems. (iii)Attainment of controlled or nondependent use. Assessment (iv) Attainment of abstinence from the prob- Before embarking on a treatment program, a lem drug. sound assessment is required that will deter- (v) Attainment of abstinence from all drugs. mine the choice of treatment - goal and content. Information should be attained on the The issue of controlled use rather than absti- evolution of drug/alcohol intake, family his- nence has been debated at length for many tory, patterns of current use, degree of depen- years. Whatever the treatment goal, a key issue dency, the extent of drug and alcohol related is the client’s commitment to implementing problems, reinforcement parameters maintain- real and permanent change in his pattern of ing the behavior, and the opportunities within drug or alcohol use. The following section will

1 Psychosocial Treatment in Substance Use Disorder review some models that assist in this decision- which successful individuals enter the mainte- making process. nance stage when new behaviors are strength- ened and consolidated. The individual who The stages of change does not relapse during this stage eventually Psychotherapists have long been interested in exits the change system to termination, or in the process of change. Pettony (1981) noted other words favorable long-term outcome. Most that most therapeutically induced change in people do not immediately sustain the new cognition, affect, or behavior involves an ini- changes they are attempting to make, and a tial destructuring with resistance being a cen- return to substance use occurs known as re- tral feature, an intermediate stage of conver- lapse. sion and a final stage of restructuring. It has been observed that progression through The idea of transitional stages or dispositional the stages follow a cyclical pattern. People may states within addiction literature has been de- move back from action to contemplation and veloped by various authors. Tuchfeld (1976) precontemplation before eventually achieving proposed a two stage model of change. The first long-term resolution of the problem. Stages of is when defensive avoidance becomes unten- Change questionnaire and the 12 item Readi- able and a commitment to change is made. The ness to Change scale have been developed to second is one of maintenance of a new behav- assess the stages of change for drug abusers. ioral repertoire, which is characterized by per- The model of change does provide a structure sonal vigilance and during which time the in- to help us match different interventions with dividual develops coping strategies to attenu- albeit, the arbitrarily, defined stages. Miller ate the possibility of relapse. (1983) suggested that motivational interview- The most influential model of change has been ing is most useful for individuals in the con- the transtheoretical model of Prochaska and Di templation stage, although it can prove ben- Clemente (1984). This has helped rationalize eficial for individuals in all stages of change. the diversity of psychological interventions and Behavioral and cognitive interventions can be place them in the context of the evolution of optimally applied in the preparation and main- personal change. tenance stages. The stages proposed are precontemplation, Psychologically based treatment methods contemplation, preparation, action and main- Motivational Interviewing tenance along with the issue of relapse or re- currence. Essentially during precontemplation Motivational interviewing (MI) originally ac- individuals do not feel impelled to do anything counted by Miller (1983) saw motivational about their behavior, perhaps as a result of de- problems as a result of the therapist/client dia- nial or selective exposure to information. As logue, with the behavior of the therapist influ- they become aware a problem exists, they en- encing the expectations, attributions, and be- ter the contemplation stage which is charac- havior of the client. During MI the individual terized by conflict and dissonance. Preparation is encouraged to reach his or her own decision is defined as a time when the individual drug about change, while the role of the therapist is user formulates action plans and is serious about simply to facilitate this process through clari- his or her intention to alter behavior. Action is fication, advice when appropriate, accurate feed- a period when overt changes are made, after back, and empathy. The aim of the therapy is

2 Psychosocial Treatment in Substance Use Disorder to increase cognitive dissonance until a critical stance use. Provide personalized feedback about mass of motivation has been achieved and the assessment findings. Explore the pros and cons individual is ready to move from pre-contem- of substance use. Examine the discrepancies plation to action. At this point commitment between the patient and others perception of to real behavior change is a likely outcome. the problem behavior. Express concern and Motivational interviewers operationally define keep the door open. motivation as the probability that a person will enter into, continue, and adhere to a specific Contemplation: Normalize ambivalence; help change strategy and there is a strong emphasis the patient tip the decisional balance scale to- on ambivalence resolution and the decisional wards change by eliciting and weighing pros balance. Essentially the client begins to present and cons of substance use and change. Change his or her own argument for change rather than extrinsic and intrinsic motivation. Examine the being directed by a coercive therapist, while it patient’s personal values in relation to change. is the therapist’s role to set in place the opti- Emphasize the choice of responsibility and self- mum conditions for change. efficacy. Elicit self motivational statements of intent and commitment. Elicit ideas regard- Motivational enhancement ing perceived self efficacy and expectations towards treatment. Summarize self motivational The multidimensional nature of motivation is statements. highlighted by the three critical elements that a person is ready, willing and able to change. Preparation: Clarify the patient’s own goal and One can be able to change, but not willing. strategies for change. Offer a menu of options. The willing component involves the importance With permission, offer advice. Negotiate a a person places on changing and the ready com- change or treatment plan and behavior con- ponent represents the final step in which the tract. Counter and lower barriers to change. person finally decides to change a particular Help the patient enlist social support. Explore behavior. To instill motivation for change is to treatment expectancies and the patient’s role. help the client become ready, willing and able. Elicit what has worked in the past for him or The motivational style of counseling is useful others whom he knows. Assist the patient to not only to instill motivation initially, but negotiate finances, child care, work or other throughout the process of treatment in the barriers. Have the person publicly announce preparation, action, and maintenance stages as plans to change. well. Action: Engage the patient in treatment and Appropriate motivational strategies for each reinforce the importance of remaining in re- stage of change (Miller 1999) could be as fol- covery. Support a realistic view of change lows: through small steps. Acknowledge difficulties for the person in early stages of change. Help Precontemplation: Establish rapport, build in identifying high risk situation and develop trust. Raise doubts or concerns in the person appropriate coping strategies to overcome about substance using pattern. Explore the them. Assist in finding new reinforcers of the meaning of vents that brought the patient to change. Help in assessing whether the person treatment or the results of previous treatment. has strong family and social support. Elicit the patient’s perception of the problem. Give factual information about the risk of sub- Maintenance: Help in identifying and sample

3 Psychosocial Treatment in Substance Use Disorder drug free sources of pleasure. Support life style structs a personal behavioral analysis and re- change. Affirm person’s resolve and self efficacy. ceives training in specific coping strategies. Assist in practicing the use of new coping strat- These can include broad-based skills training egies to avoid return to drug use. Maintain (behavioral rehearsal, assertiveness training), supportive contact. Develop a ‘fire-escape’ plan cognitive reframing (coping imaginary, if the patient resumes substance use. Review reframing reactions to lapse), and lifestyle in- long term goals. terventions (relaxation and exercise enhancement). Clients are taught to recognize early In summary, motivational enhancement is a warning signals and made aware of apparently client centred, directive therapeutic style to irrelevant decisions that can increase the possi- resolve ambivalence and promote greater com- bility of relapse. Emphasis is placed on the mitment to change. modification of cognitive distortions and the Relapse Prevention challenging of faulty beliefs or dysfunctional assumptions. The abstinence violation effect is Substance abuse has long been seen as a a distorted redefinition of lapse as relapse, so chronic, relapsing condition hence relapse undermining the effectiveness of future cop- management is an important issue in the treating behavior. The Marlatt and Gordon relapse ment of addictive behaviors. Relapse preven- prevention program is therefore a combination tion is a generic term for a variety of approaches of skills training, self-management, and cogni- to the treatment of drug and alcohol abuse, tive interventions and the client is encouraged primarily aimed at those in the maintenance to practice these strategies using rehearsal, role- stage of change. play and homework tasks. Though relapse has been viewed differently by The relapse prevention model of Annis and various authors, the most common view is that Davis(1989) draws more explicitly on self-ef- while a lapse is an occasional slip, a relapse is a ficacy theory. The emphasis of this approach is return to the original pattern of intake. Re- on performance based methods, notably the lapse has also been systematically approached exposure to increasingly high-risk situations from what has been called a psychobiological with continuing self-monitoring of efficacy ex- perspective. Central to these models is the idea pectations. In guiding the client through the that relapse is precipitated by craving, which high- risk situations four factors are taken into results in loss of control. Craving can be seen account. First, the situation is challenging; as a cognitive interpretation of the feelings of second, to succeed in mastering the situation a arousal associated with drug-related stimuli. moderate degree of effort is needed; third, the Researchers have also found that relapse is more client is responsible and external help is kept likely in individuals who had few coping re- to a minimum; and fourth, the success is de- sources and who have encountered a relatively scribed as part of improved performance. large number of risk situations. Moser and Annis (!995) have emphasized the The model by Marlatt and Gordon presented role of coping strategies in their cognitive be- relapse prevention as a set of principles broadly havioral model of relapse. They demonstrate based on social learning theory. In this pro- that the survival of relapse is strongly related gram, individuals are taught to recognize the to the number and type of coping strategies possibility of relapse. Essentially the client con- employed. Avoidance strategies are less effective in preventing relapse than active strategies,

4 Psychosocial Treatment in Substance Use Disorder such as carrying out alternative activities, seek- Therapeutic community ing support from others, positive self-talk, and cognitive problem-solving. Therapeutic communities (TCs) and social model recovery programs emphasize on giving In summary self-efficacy expectation, or the back to the community a way to facilitate one’s belief that addictive behavior can be changed own and others’ recovery. Experienced residents by mobilizing personal resources, is the most help orient new residents, take on job respon- powerful predictor of intention and subsequent sibilities to maintain the facility, and volun- behavioral control. Training in coping skills is teer to participate in a residents’ council or cli- not enough, people must use the skills at the ent government that helps manage program right time for them to be effective. As the prac- operations. Descriptions of social model recov- tice of these coping skills improves self-efficacy ery homes have described an ethic of so they are utilized effectively in real-life risk volunteerism as a hallmark of that modality. situation. In TC treatment, the role modeling for other clients during daily activities and treatment 12 step facilitation therapy groups is an essential component of one’s treat- Among the contemporary multimodal treatment. ment packages for alcohol abuse, Alcoholics Network Therapy Anonymous is a community self-help group founded by Bill Wilson and Dr. Bob Smith in Three key elements are introduced into the 1935. The principles of change described by Network Therapy technique. The first is cog- AA are based on a religious organization in the nitive behavioral approach to relapse preven- Protestant tradition which emphasized self-ex- tion. Emphasis in this approach is placed on amination, the public admission of character triggers to relapse and behavioral techniques deficits, restitution, pledge taking and bible for avoiding them. Second, support of the reading. The AA belief system is articulated in patient’s natural social network is engaged in the 12 steps mediated by fellowship meetings treatment e.g., peer support, family, friends and conducted by formerly drug-dependent per- spouses. Third, drug-free rehabilitation is pro- sons, which include the requirement of a search- vided by mobilization of resources. ing personal inventory, commitment to a greater power, making amends to other people, Family and Marital Therapy and carrying the message to other alcoholics. Family therapy is appropriate and helpful It also takes in to account motivation enhance- throughout the process of recovery. The model ment by proximal goals, role modeling, relapse follows different stages. One generally starts by management in terms of alternative activity and working with the most motivated family mem- new social networks. AA emphasizes that help- ber or members, convening other family mem- ing other members is an essential component bers when needed. The problem is defined and of one’s own recovery. With about 9000 AA a contract negotiated. The case for a chemical- groups across 134 countries including India, free life, with the involvement of family mem- the AA is the world’s largest self-help group. bers is then established. The crisis faced by fam- Depending upon the type of drug abuse, there ily members when they go through the change are other self-help groups like the Narcotics is managed and help given in stabilizing the Anonymous (NA), Cocaine Anonymous. family. Family reorganization and recovery is

5 Psychosocial Treatment in Substance Use Disorder the next stage where the roles are balanced and Most treatment reviews discuss treatment in- assistance is given in couple or family issues of tensity and the need for treatment matching. power and control. The family unit is helped The interventions planned for all types of drug to achieve closeness and intimacy. Treatment problems need to be tailored to the individu- comes to an end when client and therapist(s) als’ needs and circumstances. Project MATCH mutually agree to stop meeting regularly. Research group (1997) was the largest treatment trial on alcoholics randomly assigned to Brief Intervention one of the three treatment modalities namely Brief intervention is a short counseling session 12-step facilitation (TSF), cognitive behavioral focused on helping a person change a specific coping skills and motivation enhancement behavior. BI has proven to be effective in the therapy. The results indicated significant and management of individual with hazardous and sustained improvement in all three types of harmful drug or alcohol use. The consistent interventions. features in BI have been summarized by Miller and Sanchez (1993) using the acronym Extensive studies have documented the efficacy FRAMES: Feedback, Responsibility, Advice, of Brief Interventions by physicians and other Menu of options, Empathy and Self-efficacy health care providers for substance users. In (confidence for change). The provision of giv- their studies, Edwards et al (1977) and Wallace ing personally relevant feedback after assessment et al (1988) show that alcohol use decreased such as individual’s drug use and problems and with BI. The studies conducted by Senft et al associated personal risks is a key component of (1977) and Wilk et al (1997) also supported brief intervention. Personal responsibility is the efficacy of BI among alcohol users. Apart emphasized so as to bring about change in be- from playing a major role in reducing alcohol havior. Advice about changing the drug taking consumption, BI also helps the cigarette users behavior is given in a nonjudgemental man- as shown in a number of studies. ner. Alternative strategies to cut down or stop Research supports the integration of motiva- their substance use are given. Empathic coun- tional interviewing modules into programs to seling and understanding approach to encourage the patient’s confidence so as to promote reduce attrition, enhance patients’ participa- self- efficacy in their behavior is used. tion in treatment and to increase the achievement and maintenance of positive behavioral Efficacy of different therapies outcomes.

There is good evidence on the effectiveness of In 1974 the National Institute on Alcohol psychological approaches for addictive behav- Abuse and Alcoholism recognized family ior. Moos, Finney and Crankie (1990) in their therapy as “one of the outstanding current ad- review concluded that treatment leads to sub- vances in the area of psychotherapy” for alco- stantial improvement in drinking behavior holism (Stanton & Heath).The most updated while acknowledging the importance of indi- reviews of the research on marital and family vidual and social factors in the determination treatment for alcoholism (Farrell, 1992) have of outcome. Bien, Miller and Torigan (1993) concluded that family and marital treatment in their review concluded that there are remark- produces better marital and drinking outcomes ably few differences between brief and extended than non-family methods. interventions for treatment-seeking alcoholics.

6 Psychosocial Treatment in Substance Use Disorder Conclusion sistently superior to the others. Most of the interventions described in the In the primary care setting the need for brief chapter have been offered to users of a range of interventions and motivational interviewing substances. It is important to understand that would be a useful technique since many patients the main component of any intervention is the enter these programs unwillingly or at best with cognitive and behavioral changes that accrue motivation to deal with the immediate crisis and irrespective of the preferred drug of abuse. Re- placate those responsible for getting them into search shows relapse prevention procedures are treatment. The issue of cost effectiveness of treat- clearly useful for smokers, moderately effective ment is discussed at length rather than the need for alcohol abusers, and have some variable ef- of the individual. Thus it has been emphasized fect, as a treatment for cocaine abuse. While that it would be best to remind the treatment treatment based on psychological approaches providers that it would be justified to work on have been shown to be effective, no specific the need for caring of this population rather than treatment approach has emerged as being con- cost-benefit analysis.

Suggested Reading

1. Ray R, Mondal AB, Gupta K, Chatterjee A, from URL: http://www.cdc.gov/tobacco/ Bajaj P (2004) The Extent, Pattern and global/GYTS.htm (GYTS/factsheets/ Trends of Drug Abuse in India: National pdf_files/india)(accessed on 30 September Survey.New Delhi. United Nations Office 2004). on Drugs and Crimes & Ministry of Social 4. Ezzati M & Lopez AD (2004) Regional, Justice and Empowerment, Government of disease specific patterns of smoking-attrib- India. utable mortality in 2000. Tobacco Con- 2. Rani M, Bonu S, Jha P, Nguyen SN, trol;13:388-395. Jamjoum L.(2003) Tobacco use in India: 5. National Cancer Registry Programme prevalence and predictors of smoking and (NCRP). Two year report of the population- chewing in a national cross sectional house- based cancer registries, 1997.98. Bangalore: hold survey. Tobacco Control. 2003 Indian Council of Medical Research, Coor- Dec;12(4):e4. Available at: http:// dinating Unit, NCRP; 2004a. tc.bmjjournals.com/cgi/content/full/12/4/ 6. Heatherton TF, Kozlowski LT, Frecker RC, e4. Accessed on 14 May 2005. Fagerström KO. The Fagerström Test for 3. Global Youth Tobacco Survey (GYTS) Nicotine Dependence: a revision of the Country Factsheets, India (by year of Fagerström Tolerance Questionnaire. Br J completion and state). Centers for Disease Addict 1991;86:1119-27. Control and Prevention, Atlanta.Available

16 Nicotine Dependence Suggested slides for OHP

1. Smoking- beedi & cigarette smoking common - Relieves withdrawal symptoms Smokeless- chewing, gargling (paan masala, - Safe & behaviour modification also required gutka) Bupropion hydrochloride SR tablets - reduces craving 2. Prevalence- 55.5% males (age 12-60 years) use to- - Begin 1-2 weeks before the set quit date bacco -150 mg single dose - 2.4% women smoke: 12% chew tobacco - to continue for 7-12 weeks after quit date - prevalence low in women- social unacceptability -maintenance therapy for 6 months -seizures at very high doses only 3. Consequences of tobacco use -if tolerated, increased to 150mg b.i.d after 4 days - Relative risk of death due to tobacco use is high Behavioural methods - Smoking causes more than 700,000 deaths/year in Learning skills like self monitoring & coping with India craving - Tobacco related cancers constitute more than half of Skills to deal with withdrawals all cancers in India Skills to avoid a lapse /relapse - Cardiovascular, cerebrovascular and respiratory af- Individual/group sessions also useful flictions common with tobacco use 8. Avoiding alcohol use - Oral Submucous fibrosis common with chewing tobacco Regular follow up and marking progress Enhance motivation & confidence 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)

17 Intervention with Treatment Non Seekers 12

Manoj Kumar Sharma, Deepak Yadav

Summary Trends of non-treatment seeking alcohol users Treatment non-seekers constitute a large num- Studies suggests that the lifetime prevalence of ber of the substance using population. Rea- at-risk drinking and alcohol abuse may be as sons for not seeking treatment are multiple and high as 35% and the frequency of problem vary from individual to individual. Numerous drinking as high as 10% in primary care set- studies have focused on the socio-demographic tings. The estimated ratio of untreated to profile of these individuals and reasons for not treated individuals’ ranges from 3:1 to 13:1. seeking treatment. The process of bringing this Even among the patients seen by the primary population into the treatment program is of care physician, less than half were recognized paramount importance as they form a large as alcohol abusers. The majority of individuals number in the community. This chapter high- with alcohol use / abuse do not enter treat- lights their characteristics and ways to engage ment and there exists a pressing need to un- in the treatment process. derstand factors that people perceive as barriers to seek help. Introduction In general population surveys, respondents Treatment refers to a variety of activities and who had ever had an alcohol problem reported processes that aim at helping individuals with several reasons for not seeking treatment: 96% drug related problems. Various characteristics thought they could handle it on their own, have been associated with treatment seeking 84% did not think their problem was serious individuals. It includes stable socioeconomic enough and 56% said they did not want help. status, married, 30-44 year age group, religious Alcohol abusers in treatment or who sought affiliation and history of abstinence in past. Self- advice about their drinking have also reported recognition of substance related problems, oc- delaying seeking treatment because they felt currence of negative events and conscious and their drinking was not a problem or was not informal advice or suggestion by others are other serious enough to warrant attention. The reasons cited by treatment seekers. However, stigma associated with the alcoholism or ad- treatment seekers do not constitute a signifi- mitting to being an alcoholic has been another cant proportion of alcohol users. Available re- reason they gave for not wanting to enter treat- ports suggest that only 2% of total alcohol ment. Patient report feeling of being ashamed users report to treatment as late as five years and a belief that treatment does not help as after the onset of use and only 27% had ever reasons for not seeking treatment. Denial may reported to any organization for help. be prevalent among persons with alcohol use disorders and it is the most commonly cited Definition of Treatment reason for failure to seek treatment. The Rapid Characteristic of Treatment Seekers Assessment Survey (2004) cited difficulty in

1 Intervention with Treatment Non Seekers obtaining help from a treatment centre, not seling that can be used by the primary care being aware of treatment facility, not needing physician. The important components of in- treatment and a belief that treatment was not terventions are: possible as reasons for not seeking treatment. zzz Identification / Screening These barriers have also been linked to various zzz Interventions socio-demographic characteristics. It includes lack of a stable job and having no issue or fam- – Brief intervention ily responsibility and a low socioeconomic sta- – Community Reinforcement Approach tus (inability to afford transport expense or – Contingency Management Intervention buy prescription drugs). Women (less likely to – Specialized Group be referred by conventional routes, not being • Women able to arrange for care of child, stigma, drink- • Adolescent ing as a manifestation of other interpersonal • Homeless Addict problem), youth (denial, fear of losing a job, not wanting to go for treatment, not having Identification and Screening time for treatment) and being homeless are the Treatment Characteristics other groups who do not seek treatment. Identification / Screening: Primary care phy- Identification of treatment non-seekers sicians need to ask all patients about current and past alcohol use “Do you currently or have Identification of treatment non-seeking persons you ever used alcohol?” quickly identifies those with alcohol use / abuse is especially impor- patients who are not lifetime abstainers and tant in developing countries. who require further screening. In addition, given Primary Care setting the importance of family history as a risk fac- Characteristic of Treatment Non-Seekers tor for alcohol problems, it is important to ask Barriers to treatment all patients about alcohol use in their families. Among patients who use alcohol, the next step Intervention in Primary Health Care is to obtain a detailed history regarding quan- Primary care physician are in a unique posi- tity and frequency of current and past alcohol tion to identify and treat patients with ‘at risk use. Screening instruments in the form of AU- drinking’ and alcohol related problems. Pro- DIT, SMAST and CAGE could be adminis- viding treatment – either directly or by refer- tered to detect alcohol abuse and dependence. ral to specialized services logically follows the (Appendix 3, 4, 5) process of screening and diagnosis of alcohol Treatment Approaches : problems. Counseling is one of the approaches to prevent relapse. Education Programme: Group or street meetings and pamphlet distribution help to re- Counseling based nonpharmacological treat- duce stigma, enhance awareness about alcohol ment strategies have been studied extensively abuse, treatment approaches, cost and its avail- for the care of patients who are ‘at risk’ for al- ability. cohol problems. These approaches are based on the principle and process of behavioral Brief Intervention: It is most intensively stud- change and typically involve the type of coun- ied in primary care setting. These counseling sessions are short (5-20 minutes) and focused.

2 Intervention with Treatment Non Seekers They incorporate four components namely tivate or increase the participation of treatment motivational techniques, feedback about the non-seekers into treatment. problems associated with alcohol abuse, discussion of adverse effects of alcohol and setting Specialized Group drinking limits. These interventions have been Besides using the above-mentioned component found to be effective in motivating the treat- of intervention, specific guidelines can be used ment non-seekers into treatment. for women, adolescent / children and the home- Community Reinforcement Approach (CRA) less addict. The over reaching goal of CRA is to rearrange Women: and improve the quality of the reinforcers ob- Women are more likely to seek treatment ini- tained by patients through social, recreational, tially from medical doctors or from psychiatric vocational and family activities. Community facilities for alcohol related problems or psy- Reinforcement approach has been adopted to chological difficulties associated with drinking. assist the significant others of treatment resis- Further, there is evidence that physicians are tant problem drinkers by encouraging the less effective in identifying alcohol abuse in drinkers to enter treatment. The CRA inter- women. There is a need to sensitize the pri- vention includes education about alcohol prob- mary physician to diagnose, refer and treat lems, information and discussion of the posi- women with alcohol problems. tive consequences of abstinence from alcohol, assistance involving the designated client in The main component of intervention healthy activities, increasing the involvement of the significant other in social and recreational zzz Education material targeting stigma, social activities and training the significant others in support and health consequences. how to respond to drinking episodes. Several zzz Educating Primary care physician on studies on this topic suggest greater efficacy of screening and detection of alcohol prob- the CRA approach compared with more tradi- lems. tional approach involving confrontation. The zzz Screening and referral information should majority of designated clients whose families be provided in women’s health clinic, preg- received the CRA intervention entered treat- nancy and family planning clinics. ment and decreased their problem drinking. zzz Improve the availability of services for chil- Contingency Management Intervention: It dren involves the explicit and direct application of the conditioning principle of reinforcement and zzz Availability of childcare services while punishment to increase desired behaviour or women participate in treatment. to decrease problematic ones. It has three com- zzz Provide assessment, referral and treatment ponents: an objective, an observable target of behavioral problems in children. mode of behaviour that must be increased or decreased and tangible consequences that can zzz Outreach services to women at risk for be delivered promptly and reliably by a treat- drinking should be improved and out reach ment provider upon display of the target re- workers specially educated on screening sponse. Research has shown that contingency and treatment referrals for alcohol problems management intervention can be used to mo- in women.

3 Intervention with Treatment Non Seekers

Children and Adolescents: zzz Enhancing awareness about substances among homeless addicts / in shelter homes. Alcohol consumption is a major contributor to adolescent morbidity and mortality. Forty zzz Community Reinforcement Approach to fifty percent of adolescents who died as a zzz Brief Intervention. result of violent event (i.e. traffic accidents and homicides) were found in post mortem inves- National Drug Dependence Treatment tigation to have drunk alcohol. Children and Centre (NDDTC, AIIMS) experience adolescents who use substances often show high A group using alcohol is identified through risk behaviours. patients / family members attending commu- zzz Intervention nity clinic or by social scientist visiting the community. A group generally constitutes 20- Education about the health hazards of sub- 25 members comprising mostly women and stance use. It may include conducting older age group. They act as catalysts in moti- school program or sensitizing the parents vating the treatment non-seekers. Psychiatrist, about the risk factors for substance use in psychologist, social scientist and psychiatric parent teacher meeting. nurses conduct group sessions. A session in- zzz Proceed according to the severity of prob- cludes identification of senior members as lem group leader to mobilize interaction and discussion focused on characteristics of alcohol - Substance use once or twice in a year: abuse, psychosocial problems, benefits of treat- focus should be on awareness build- ment, pamphlet distribution, clarifying their ing about drugs. misapprehension and sharing of experiences for - Consumption has been frequently re- alcohol free life style. These sessions have a ported: There should be regular visit positive impact on treatment seeking and therapeutic intervention. behaviours. Every meeting is being able to zzz Individual Therapy motivate 3-4 alcohol abusers into treatment. Children and adolescents with co morbid psychiatric disorder should be taken for Conclusion individual therapy. Therapy can focus on Barriers to treatment must be addressed if we improving social skill training, coping want to encourage the greater population of behaviour and communication training. untreated substance user to enter treatment. zzz Family involvement These barriers might be reduced by a change It involves the family for motivating the in public perception of problem, the role of patient to seek treatment, planning reha- treatment, family role, and community in- bilitation and compliance to treatment. volvement to motivate substance users or by how and where treatment is being offered. Al- Homeless Addicts though this chapter deals largely with work The problem of homelessness has worsened done with the alcohol abuser, the principles of markedly in recent years. The main compo- treatment remain the same for all categories of nents of interventions are substance abusers.

4 Intervention with Treatment Non Seekers

Suggested Reading

1. Fergusson DM and Horwood LJ (1998). cess and outcome. New York Oxford Uni- Psychiatric disorder and treatment seeking versity Press. in a birth cohort of young adult. Report 8. Pal H, Jena R and Yadav D (2004). Valida- prepared for Ministry of Health from the tion of alcohol use disorder identification Christchurch Health and Development in urban community outreach and de-ad- study. Department of Psychological Medi- diction. Center samples in North India Jour- cine, Christchurch School of Medicine, New nal of studies on Alcohol, 40; 794-800. Zealand. 9. Roizen R (1977). Barriers to alcoholism 2. Fiellin DA, Reid MC and O’connor PG treatment. Berkdey CA. Alcohol Research (2000): New therapies for alcohal problems Group, pp. 30-34. : application to primary care. Am J. Med. 10. Sobell LC, Sobell MB and Toneatto T 108, 227-237). (1991). Recovery from alcohol problems 3. Heather N (1990). Brief intervention strat- without treatment. In: Heather N, Miller egies. In RK Hester and WR Miller (Eds.) WR, Greeley J (Eds). Self control and ad- Handbook of alcoholism treatment ap- dictive behaviours. New York, Maxwell proach. Effective alternatives, New York, Macmillan, pp. 198-242. Pergamun Press pp. 93-116. 11. Sobell MB and Sobell LC (1993). Treat- 4. Higgins ST and Silverman K. (1999): Mo- ment for problem drinkers- A public health tivating Behaviour Changes among illicit priority. In JS Boer, GA Morlatt and RJ drug abusers: Research on contingency McMohan (Eds). Additive behaviorus across Management Interventions. Washington, the life span: Prevention, treatment and D.C., American Psychological Association. policy issues. Beverly Hills CA, Sage Publi- 5. Meyers RJ and Miller WR (2001): A Com- cation, pp. 34-36. munity Reinforcement Approach to Addic- 12. The Extent, Pattern and Trends of Drug tion treatment. Cambridge, UK: Cambridge Abuse in India. National Survey (2004). University Press 40-45. Sponsored by Ministry of Social Justice and 6. Miller WR, Sovereign RG and Krege B Empowerment, Government of India and (1988). Motivational interviewing with United National office on Drug and Crime. problem drinkers. The drinker’s checkup as Regional Office for South Asia, pp. 19-36. a preventive intervention. Behavioural Psy- 13. Thomas B (1986;). Sex difference in help seek- chotherapy, 16 : 251-268. ing for alcohol problems. The barriers to help 7. Moos RH, Finney JW and Crunkite RC seeking. British Journal of Addiction, 81: 777- (1990). Alcoholism treatment context, pro- 788.

5 Intervention with Treatment Non Seekers Suggested slides for OHP

Slide 1 Definition Slide 6 Reasons for not seeking treatment

Treatment refers to a variety of activities and process that – Stigma aim at helping individuals with alcohol related prob- – Did not think their problem was serious lems. – Thought they could handle it on their own – Did not want to admit that they needed help Slide 2 Characteristics of treatment seekers – Drinking was not a problem. – Self recognition of substance related problems – I did not think to seek help. – Occurrence of negative events – Problem would get better by itself. – Coercion – Ashamed to admit problem – Informal advice or suggestion by other – Treatment does not help – Good Socio-economic status – Difficulty in obtaining help from treatment center – Married – Not aware of treatment facility – Age group 30-44 years. – Treatment was not possible – Past H/o of abstinence Slide 7 Intervention – Religion affiliation – Identification/Screening Slide 3 National survey – Intervention – Brief Intervention – Treatment seekers constitute 2% of the total – Community Reinforcement Approach alcohol abusers – Contingency Management Intervention – Reported for treatment as late as five years after – Specialized Group onset of alcohol/drug user – Women – 27% had ever reported to any organization for helps – Adolescent Slide 4 Treatment nonseekers – Homeless Addict

– Ratio of untreated to treated individual- 3:1 to 13:1 Slide 8 NDDTC experience – Frequently seen in hospital emergency/crisis center / medical practitioner. – Identification of groups abusing alcohol (through – As many as 12% of patients seen by primary care patient, familymember or visit by social scientist). physician – Visit by consultant, Psychologist, Social Scientist – Fewer than half of these recognized as alcoholic and Psychiatric nurse to community. – Group constitute 20-30 persons Slide 5 Sociodemographic characteristics of non-seek- – Identification of senior member of group as leader ers (village pradhan) – Group session focus on alcohol use, psychosocial – Stable job problem and benefits of treatment) – Having no issues / lack of family responsibility – Pamphlets distributions/sharing of experiences en- – Low socioeconomic status tertained, – Women – Positively correlated with treatment entry. – Youth

6 Role of Laboratory Services in Substance Use Disorder 13

Raka Jain

Summary drug use. Deception, denial and minimizing the extent of drug use are common practices While clinical assessment forms the cornerstone seen among drug addicts. They often fear that of diagnosis and management of substance use reporting their activities correctly may result disorders, laboratory investigations can aid in in legal sanctions or denial of treatment. There helping the clinician in this endeavor. Labora- have been concerns about the accuracy of self- tory provides an objective way of assessing drug reporting. It is therefore necessary to establish use and monitoring progress, treatment com- its validity by an independent objective pliance, as well as assisting law enforcement method. agency. Currently, drug testing in body fluids has While the availability of newer techniques have gained popularity for validating self-reported definitely benefited this field, the older tech- drug use. Such analysis helps to diagnose, plan niques are relevant on account of their low cost intervention, and monitor progress following and easy applicability, especially in the con- treatment and also provides an epidemiologi- text of primary care. The present chapter gives cal data in studying patterns of drug abuse. an overview dealing with the need for labora- Thus, laboratory has a very important role in tory testing, the type of samples and techniques substance abuse testing program. used and their application in clinical field. WHEN TO SCREEN FOR DRUG ABUSE Introduction Determining when to suggest the need for a The abuse of psychotropic substances and nar- drug screening is a difficult matter. Several cotics has become a major problem of our times, physical, behavioral or emotional patterns in with high economic and social costs. The pat- the patient may suggest the need for screen- tern of drug use varies from time to time de- ing. For instance, deterioration in academic pending on the availability of new illicit drugs. performance, conduct or antisocial disorders The problem of drug abuse is of concern to such as repetitive lying, stealing, recurrent health professionals, clinical chemists, toxicolo- violence towards people, may suggest the need gists and regulatory authorities. for screening. Serious depressive or biphasic WHY TO TEST mood disorders, unexplained fatigue in a person where life is deteriorating, chronic vaso- A valid assessment of drug consumption is criti- motor rhinitis, seizure disorder or coma of un- cal for evaluating substance abuse treatment explained etiology are also indications of drug programs and treatment outcome data. Self- use. Periodic urine testing for drugs of abuse is reported drug use is a principle measure in the often recommended for drug addicts who are evaluation of treatment outcome. Drug depen- under treatment or in maintenance program. dent subjects tend to falsify their pattern of In recent years, substance abuse testing

1 Role of Laboratory Services in Substance Use Disorder programme have also been extended outside is the invasive nature of the collection process. the De-addiction Treatment Centres and is Also the cost of collection and analysis is greater. currently used as a part of pre - employment physicals and for monitoring drug in employ- Saliva analysis is a developing technology, par- ees in a variety of industries and government ticularly the sample collection is relatively agencies. quick, noninvasive and the matrix has the potential to provide both qualitative and quanti- ANALYTICAL ISSUES tative information. It is less prone to adulteration than urine but drug concentrations are Biological Specimens lower as compared to urine, and require more- Many biological specimens can be used for sensitive test methods. A major disadvantage drug abuse testing. Among all the biological of saliva drug testing is the high risk of con- samples, urinalysis is a favored method for self- tamination and false positives by oral and na- reported drug use in a clinical setting, although sal routes. Also, drugs are only detectable for alternative specimens such as blood, oral fluid one to two days. It is not considered eco- (saliva), sweat and hair and fingernails have also nomically viable or practical for continuous been used. Each specimen has its own advan- drug use monitoring. tages and limitations. The sweat patch, although accurate in the test- Urine specimens are preferred for mass screening for drug use, has one major flaw. The col- ing as large sample volumes can be collected lection process is quite lengthy, in that the non-invasively. Drugs and their metabolites donor must have the patch applied, wear the generally remain detectable in urine from sev- patch for 10 days to two weeks, and then have eral hours to several days especially in chronic the patch removed and sent to a laboratory for users. The concentration of a drug in urine analysis. Sweat patches are being considered depends on a number of factors. In general, for use in drug-compliance programs. drug concentrations in urine vary with dose, route of administration, time elapsed since Unlike urine testing, hair testing can detect administration, and the individual’s physiologi- drug use for a much longer period. The stan- cal status, which influences urine flow, urine dard hair test will detect drug use for up to pH and metabolism. Moreover, urine has a sim- three months. The greatest advantage of hair pler matrix than other biological specimens, testing is the ability to create a permanent which simplifies its sample preparation and record of drug use in the strand (shaft) of the analysis. Before carrying out a urine test, it is hair. No convenient screening procedures for essential to ensure that urine specimen being the measurement of drugs in hair exist, and tested is actually from the patient who is be- hair tests lack the sensitivity of urine tests for ing assessed as urine specimens can easily be occasional or single-time drug use. tampered with by substitution, dilution or Fingernail specimens can also accurately detect adulteration. drugs of abuse. The overwhelming disadvan- Blood samples can be used alternatively to de- tage is the inability to detect recent drug use. tect drugs or their metabolites. The half-life of Most fingernail clippings are between five and drugs in blood is short, making blood speci- six months old by the time they can be ob- mens less useful for routine drug screening tained and would give very little insight as to (though a high concentration of active drug recent use of drugs. Fingernail use is, however, will suggest recent usage). The major concern gaining acceptance in the postmortem setting.

2 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. Sample Advantages Disadvantages Blood • Difficult to adulterate • Short half-life of drugs • Low drug concentrations Hair • Potential for long-term assessment • Requires difficult analytical procedures of drug use • 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 • Can monitor accumulated • Requires difficult analytical procedures patch drug use for 3–7 days • Difficult to get large volumes for confirmation • Environmental contamination possible Urine · Noninvasive • High adulteration potential when · Available in large volumes collection not witnessed · Remains positive 2–3 days

Specimen Collection and Transportation collection process and its significance for the laboratory results. A major issue in the drug abuse testing programmes is proper sampling, as the valid- iii) There should not be any be any provision ity of test results is dependent on the integrity of sink or hot water in the toilet. If pos- of the specimen being collected. Adulterating sible, a toilet bluing agent should be placed in the toilet bowl to deter specimen dilu- or diluting the specimens is a common prac- tion. tice by patients attending the de-addiction services. Common contaminants include sodium iv) The staff at the collection site should check hypochloride, table salts, lemon juice, vinegar, the temperature of the urine sample im- ammonia water, soap solutions or caustic com- mediately after voiding. A freshly voided pounds, eye drops and all of these may inter- urine should have a temperature close to 0 0 fere in testing. It is therefore very important body temperature i.e 33 C- 36 C and the to take the following precautions at the collec- urinary pH should range between 4.6 and tion site, before the sample is sent for testing 8.0. If adulteration is suspected the labo- to the laboratory: ratory should be notified. v) Minimum volume of urine to be collected i) Container or specimen bottle must be clean, should be 30-60 ml. dry, unbreakable and leak proof. vi) Each specimen must be clearly labeled with ii) Urine sample should be collected under patient’s name, date, time, and identifica- close supervision of trained personnel who tion number to prevent intentional or in- have a clear understanding of the advertent confusion.

3 Role of Laboratory Services in Substance Use Disorder vii) The person supervising the collection site liminary screening followed by confirmatory should notify the date, time of collection analysis of the prescriptive positive and doubt- of the specimen on the drug screening req- ful results. Analytical methods used in most uisition form. It is also important for the laboratories for the detection of drugs are so personnel at the collection site to sign on selected as to meet the requirements for screen- the drug requisition form to ensure the in- ing and confirmation. A screening test should tegrity of the specimen. be able to identify potential positives and should be sensitive, rapid and inexpensive viii)Each specimen should be properly sealed whereas the confirmatory tests should be more and transported to the laboratory to avoid specific than screening test. Screening test gen- pilferage. Each sample should be accom- erally involves immunoassays and thin layer panied with the drug abuse requisition chromatography (TLC). Confirmation testing forms containing the details of investiga- is the second step of testing following the de- tions required with adequate clinical his- tection of a positive result on the preliminary tory. or screening test. The purpose of confirmation Sample Storage is to eliminate any false positive results or false negative results that may have originated from Proper storage of samples is also important in an initial screening process. More specific con- drug abuse testing programs. If the samples firmation tests used to identify drugs of abuse are left at room temperature for long before are chromatographic techniques like gas liquid analysis, their pH value get altered. It changes chromatography (GLC), high-pressure liquid from acidic to basic and bacterial decomposi- chromatography (HPLC) and gas chromatog- tion occurs, which increases the chances of false raphy-mass spectrometry (GC-MS). A detailed negatives. In general, sample should be refrig- description of each technique is beyond the erated within 12hrs of their collection prefer- scope of this chapter. ably at -200 C. Barbiturates, amphetamines and cocaine are unstable at room temperature. i) Competitive Immunoassays: Samples brought from offsite laboratories should be transported in an ice bath. Ideally, The most common analytical approach to urine quick transport and short period of storage can drug screening is the use of competitive im- significantly contribute to the quality of results. munoassays, in which specific antibodies bind to targeted chemical atoms and functional Methodology for Detection groups. A fixed amount of labeled drug mate- Analytical Techniques rial from the test kit (marked with a radioactive substance, enzyme, fluorescent tag, or col- Large selection of procedures are available for ored particle) competes for antibody binding analysis of drugs of abuse. The specific method sites with the variable amount of unlabeled drug chosen by a laboratory will depend upon many in the urine sample. When the binding sites factors that include nature and quantity of are saturated, the amount of either free or bound specimen, turnaround time, sensitivity re- labeled drug is measured. For a bound-labeled quired, existing facilities, available manpower, drug, low sample-drug concentration will pro- workload, program needs and economic con- duce a high analytical signal; high concentra- siderations. tion will produce a low analytical signal. Drug abuse testing is a two-step process; pre-

4 Role of Laboratory Services in Substance Use Disorder The most commonly employed immunoassays be confirmed by another non-immunological used for urine screening include methods such method such as TLC, GLC or HPLC etc. Also as radioimmunoassay (RIA), enzyme immu- these assays do not differentiate between drugs noassay (EIA), and fluorescence polarization in these classes and may cross-react with re- immunoassay (FPIA). Each method has its lated therapeutic substances. For example co- own advantages and limitations. The principal deine and poppy seeds may lead to false-posi- advantages of the immunological assays are ease tive opiate results and decongestants such as of sample handling, rapidity of analysis and pseudoephedrine and phenylpropanolamine high sensitivity. These techniques do not re- may lead to false-positive test for amphetamine. quire preliminary sample processing. Technolo- The interferents do not produce a false-posi- gists can also be trained easily. Radioimmu- tive result with the chromatographic assays now noassays can detect very small concentration employed for confirmation—a justification of of drugs. Its sensitivity ranges between 1-5 the two-tiered approach to drug testing. nanogram per ml. Disadvantages include the use of radioactive substances, separation of free ii) Chromatographic Technique and bound fractions, high cost of reagent , high cost of equipment, relatively slow turn around All chromatographic methods in use today are time, linearity of response and cross-reactivity based on a common principle. There are in the with other drugs which may produce both false system two phases. One of them is stationary positive and false negative results. which may be solid or liquid on an inert support having a large surface area and other a The enzyme immunoassay has a short analysis mobile (moving) phase which may be a liquid time and has an additional advantage of being or a gas. The compounds to be separated are a homogenous assay, requiring no separation differentially attracted to the stationary phase step for free and bound fractions. It is less sen- because of variation of their physiochemical sitive than RIA but has moderate to good sen- properties. This distinctive influence is mani- sitivity. The disadvantage of this technique is fested by different distance migrated. The com- the cost of the reagents. Other problems in- pounds which are less strongly held by the sta- clude difficulty with linearity of response and tionary phase would tend to move faster in cross reactivity with other drugs. mobile phase and vice-versa. Identification of FPIA is also a homogenous assay technique. It a compound is achieved by comparing the dis- does not require physical separation step. Ad- tance traveled by the pure known standard vantages of this technique are its ease of opera- against the distance traveled by the unknown tion, speed and high sensitivity. The limita- compounds from the biological samples (Rf) tions of this technique are its expensive reagent or by comparing the time taken to migrate a costs and the limited sources from which they specified time (retention time) of pure known are available. standard with that of unknown sample. There are various types of chromatography depend- The most serious limitations of all immunoas- ing upon the stationary and mobile phase. says are that specificity for a drug is not absolute. Drugs of similar chemical structure may Thin Layer Chromatography (TLC) cross-react. For this reason, all negative results It is widely used for multiple drug screening may be considered reliable and all the positive programs. It requires pH dependent extraction results may be considered ambiguous and must 5 Role of Laboratory Services in Substance Use Disorder followed by purification and concentration of Gas Chromatography-Mass Spectometry the drug from a biological sample. We found (GC-MS) TLC to be very effective for preliminary screen- In recent years, the most sophisticated drug ing of opiates and other drugs. It offers the testing approaches is gas chromatography advantages of low start up cost, relatively rapid coupled with mass-spectrometry (GC-MS). analysis, and simultaneous determination of This technique combines the efficient separat- multiple drugs and metabolites. Identification ing power of gas chromatography with the high of drug is based on Rf values in various sol- sensitivity and specificity of mass spectromet- vents and color reaction following specific spray- ric detection. It can detect nano to pico grams ing reagents. Drug concentrations as low as of drugs, per milliliter concentration of samples. 0.3- 1.0 microgram per ml can be detected It offers an insight into molecular structure and with proper sample preparation, which may makes unequivocal identification possible. It require hydrolysis of conjugated drugs and is most sensitive, specific of all the methods metabolites. The technical staff can be trained available for confirmation and quantitation of in two months time. A single technician can drugs and their metabolites in biological handle 30-40 samples per day in 8 hours. TLC samples. It is considered as the “gold stan- has a fair degree of specificity and sensitivity; dard” test. It is the method least likely to be hence drugs having identical Rf values overlap challenged in court and should be considered and obscure one another resulting in false posi- essential in national program at the nodal De- tives. In such circumstances, use of multiple addiction centres. Components are chromato- solvent systems aid in the differentiation and graphically well resolved and are quickly iden- confirmation by an alternative technique such tified using retention time and mass spectral as HPLC or GLC is recommended. Some dis- information. advantages of TLC are that it is labor intensive The use of GC-MS or LC-MS is limited by and results are highly dependent on the virtue of being an expensive equipment to buy technician’s skill as interpretation of results is and maintain, lack of technical expertise needed subjective. for operation and interpretation of the data and Gas Liquid Chromatography (GLC) and High complex sample preparation. Pressure Liquid Chromatography (HPLC) Detection Periods GLC and HPLC are widely used for confirma- The length of time that the presence of drugs tion of presumptive positive and doubtful re- of abuse in the body can be detected is an im- sults in screening assays. Both techniques are portant factor in drug screening. Table II out- highly sensitive and specific and are used for lines approximate time of detection of drugs qualitative and quantitative purposes. Identi- in different body fluids. This time duration fication is based on the retention time (Rt). depends on several variables including amount Detection limit is about 0.1 µg/ml. The main and frequency of usage, drug tolerance, age, limitations of these techniques are intensive body mass, the body’s metabolism, the subject’s sample preparation, the capacity to analyze a physical condition, urine pH and state of hy- single sample at a time, the expense of the equip- dration. Moreover, the detection of the drug ment and highly trained personnel to operate would also depend on the type of technique and interpret the data. adopted by the laboratory.

6 Role of Laboratory Services in Substance Use Disorder Table II. Detection of drugs in biological specimens Substance Urine Hair Blood Alcohol 6-24 hrs n/a Unknown Amphetamine 1-4 days up to 90 days Unknown Barbiturates 1-21 days Unknown Unknown Benzodiazepines 1-42 days Unknown Unknown Cannabis (single use) 48-72 hrs up to 90 days 2-3 days Cannabis (habitual use) up to 12 wks up to 90 days 2 weeks Cocaine 4-5 days up to 90 days Unknown Codeine/Morphine 2-4 days up to 90 days Unknown Heroin 8 hrs up to 90 days Unknown Methamphetamine 3-5 days up to 90 days 1-3 days PCP 3-7 days up to 90 days 1-3 days

Recommended Frequency of urine testing is tube or infected material unattended or unla- every third day for Inpatients and during ev- beled. Furthermore, eating, drinking and ery follow up for Outpatient. smoking in work area should be strictly prohibited. In order to keep a check on the reliability, validity, sensitivity and reproducibility of the test Communication with the laboratory results, Quality Control (QC) of a drug abuse- testing laboratory should be maintained. These Regular interaction of laboratory personnel and laboratories should maintain their internal QC clinical staff is essential so that lacunae on ei- by carrying out blind exercises periodically. A ther side are minimized in the interest of pa- satisfactory performance of the laboratory tient care. Clinicians should be familiar with would be if the false positive and false negative the strength and limitations of the drug screen- results do not exceed more than 10 percent. ing techniques and programs. For meaningful interpretation of test results, particulars of drug Safety Guidelines use are important. Hence clinicians should fur- nish adequate clinical history regarding sus- Safety measures of a drug abuse testing labora- pected drug use, route of administration, quan- tory are no different from a routine clinical labo- tity of consumption, frequency of use in last ratory such as wearing of gloves and masks, 72 hrs, time of last intake of drug before washing of hands with disinfectant or antisep- sample collection and medicines being pre- tic solution, use of rubber bulbs or dispenser scribed to the patients. Knowing which spe- for pipetting acids\ bases\ chemicals and re- cific substances are suspected on clinical agents, and provision of exhaust fan and fume grounds helps the laboratory to tell the clini- hood in the laboratory. For HIV screening, the cians whether or not the laboratory can iden- used needles, syringes and gloves should be tify such substances, for how long they can be destroyed immediately in incinerator or by detected after ingestion and whether serum or burning them. Blood samples should be care- urine is preferred. The laboratory may also al- fully handled. Moreover, never leave a discarded ter the methods used to prepare the sample to

7 Role of Laboratory Services in Substance Use Disorder maximize the sensitivity of the testing for those 5 mg/dl and the specific gravity is 1.000 or substances. Moreover, this would also minimize 1.001. the false positive results, for example, in patients who are being prescribed with cough Since most immunoassays are designed to be syrup containing codeine. performed under narrow pH and ionic strength ranges, the addition of acids, bases, salts, or Limitations of Drug Testing detergents will invalidate them. However, these adulterants generally do not affect GC/MS test Inadvertent positive results have been an issue results. for drug testing programs. Some drugs are consumed as food like dietary poppy seeds can give Health Damage a strong positive results for urinary opiates for several days. Some consumer medications con- Apart from drug abuse testing, De-addiction tain drugs of abuse (Tylenol 3 contains codeine laboratories should also have facilities for as- as well as acetaminophen). In such cases, ana- sessment of health damage in drug addicts. lytically true-positive test results are false-posi- With increasing intravenous drug use, testing tive indicators of drug abuse by the individual. for HIV and Hepatitis B is also considered essential. As majority of the patients attending Some individuals resort to diluting, substitut- de-addiction clinics are from lower socio- eco- ing, or adulterating urine samples to avoid the nomic status, some general health investiga- consequences of a positive drug test result. The tions such, as haemogram, X-ray chest, rou- object of dilution is to reduce the concentra- tine urine examination etc. are also necessary. tion of illicit substance in urine to below the On occasions, biochemical investigations like cutoff level, either in vitro, by adding water, (LFT) are also undertaken to ascertain the con- saline, or other fluid after collection, or in vivo, dition of organ damage. by consuming diuretics or plasma volume ex- panders to stimulate excess water excretion. A Experience indicates that the establishment of urine sample is considered dilute when creati- a well-equipped laboratory is a prerequisite re- nine is below 20 mg/dl and specific gravity is quirement for any hospital-offering Drug - less than 1.003. Dependence Treatment services as it plays an important role in the assessment and clinical Replacement of donor urine with non-urine management of patient’s drug problem. More fluid is substitution. To succeed as a ruse, the De-addiction laboratories should be estab- substituted fluid must be warm, as the collec- lished and upgraded. Such up gradation and tor is instructed to check specimen tempera- infrastructural development will ultimately ture within 3 minutes of collection. A sample improve the quality of care given by the Health is deemed substituted if creatinine is less than care delivery system.

8 Role of Laboratory Services in Substance Use Disorder

Suggested Reading 1. Braithwaite RA, Jarvie DR, Minty PS, trol Programme, Regional Office of South Simpson D, Widdop B. Screening for drugs Asia, New Delhi, India, 1998:214-221. of abuse. I: Opiates, amphetamines and 8. Katz N, Fanciicullo GJ. Role of urine toxi- cocaine. Annals of Clinical Biochemistry 32, cology testing in the management of 1995:123-153. chronic opioid therapy. Clinical Journal of 2. Eskridge KD and Guthrie SK. Clinical is- Pain, 2002, 18(Suppl 4):S76-82. sues associated with urine testing of sub- 9. Report of the substance abuse testing com- stances of abuse. Pharmacotherapy, 1997, mittee. Critical issues in urinalysis and 17:497-510. abused substances. Clinical Chemistry, 1988, 3. Fraser AD and Zamecnik J. Impact of low- 605-632. ering the screening and confirmation cutoff 10. Samyn N, van Haeren C. On-site testing values for urine drug testing based on dilu- of saliva and sweat with Drugwipe and de- tion indicators. termination of concentrations of drugs of 4. Therapeutic Drug Monitoring, abuse in saliva, plasma and urine of suspected users. 2000. International Journal 2003,25:723-727. of Legal Medicine, 113, 150-154. 5. Jain R and Ray R. Detection of drugs of 11. Simpson D, Braithwaite RA, Jarvie DR, abuse and its relevance to clinical practice. Stewart MJ, Walker S, Watson IW and Indian Journal of Pharmacology, Widdop B. Screening for drugs of abuse (II): 1995,27:1-6. Cannabinoids, lysergic acid diethyl amide, 6. Jain R. (ed). Detection of Drugs of Abuse buprenorphine, methadone, barbiturates, in Body Fluids: A Manual for Laboratory benzodiazepines and other drugs. Annals of Personnel. Drug Dependence Treatment Clinical Biochemistry, 1997, 34:460-510. Centre, All India Institute of Medical Sci- 12. Wu AHB. Integrity of Urine Specimens ences, N. Delhi, India, 1998. Submitted for Toxicologic Analysis: Adul- 7. Jain R. The relevance of laboratory Services teration, Mechanisms of Action, and Labo- in South Asia. In: South Asia Drug De- ratory Detection. Forensic Science Review, mand Reduction Report, Ray R (ed), 1998,10:47–65. United Nations International Drug Con-

9 Role of Laboratory Services in Substance Use Disorder Suggested slides for OHP

Slide 1: • Remove particulates • Concentrate solute of interest Why laboratory services in a drug dependence treat- • Enhance sensitivity ment programme Selection of analytical methodology • Confirm clinical history of drug intake • Cost • Monitor progress following treatment • Workload • Treatment compliance • Turn around time • Assessment of overall health status of drug depen- • Senstivity required dents • Reliability • Clarification of medico-legal problems • To assist law enforcement Slide 5: • Promote pharmacokinetic and metabolic research Screening techniques Slide 2: • Immunoassays: RIA, EMIT, FPIA • Chromatography-TLC Biological samples Confirmatory techniques • Biological fluids: blood, urine, saliva, sweat • Gas liquid chromatography (GLC) • Tissues: hair, finger nail • High pressure liquid chromatography (HPLC) Why urine is preferred for screening • Gas chromatography-mass spectrometry (GC-MS) • Non invasive procedure Principle of immunoassays • Easy collection Competition between the labeled drug and unlabeled • Larger volume available drug to bind to its binding sites • Drugs and metabolites can be detected in higher AB + D* + D Þ ABD* + ABD concentration for a longer period of time AB= antibody, D* = labeled drug • Easier processing D= unlabeled drug

Slide 3: Slide 6:

Precautions in sample collection Advantages of immunological assays • Close supervision • No sample preparation • Proper labelling • Ease of operation • Rapid analysis • Hot water should not be available at collection site • Highly sensitive • Urinary temperature should approximate normal • Detection limit: 0.001-0.1 µg/ml body temperature • Qualitative and quantitative estimation • Proper sealing Limitations of immunological assays • Transportation under custody • High reagent costs Storage of samples • Specificity for a drug is not absolute • Storage under -20° c temperature is recommended • Moderate to high equipment cost Slide 4: Slide 7: Why do sample preparation Advantages of TLC techniques • Remove interfering material

10 Role of Laboratory Services in Substance Use Disorder • Simple • Very high technologist skill needed • Comprehensive • Confirmation needed • Inexpensive Slide 11: • Fairly rapid • Fair degree of specificity Pertinent clinical information required for drug abuse • Detection limit 0.5 µg/ml screening

• Identification based on Rf value • Suspected drug abused • Route of administration Slide 8: • Quantity of consumption Features of GC • Frequency of use in last 72 hr. • Moderate equipment cost • Time of collection from last intake • Low reagent cost • Medication prescribed • One sample at a time Slide 12: • Identification based on retention time • Detection limit: 0.01- 0.1µg/ml Assessment of general health status • Confirmation technique • Biochemical profile • Quantitation technique - Liver function test • High technologist skill required - Lipid profile - Renal function test Slide 9: • Haematological profile Features of HPLC - Complete haemogram • Moderate equipment cost • Moderate reagent cost • One sample at a time • Multiple drugs simultaneously • Identification based on retention time • Analysis time is less than an hour • Resolution is high • Confirmation & quantization technique • Detection limit: 0.01- 0.1µg/ml • High technologist skill required

Slide 10:

GLC-mass spectrometry (GC-MS) • Rapid, sensitive & specific • Unknown samples • Drug & their metabolites • Diagnosis of overdose • Low reagent cost • Very high equipment cost • One sample at a time • Multiple drugs simultaneously • Detection limit: 0.0001-0.1 µg/ml

11 Prevention of Substance Abuse in India 14

Parmanand Kulhara, Debashish Basu

Summary Basic concepts The problem of substance abuse continues and Broadly speaking, a drug is defined as any will continue, at least in the foreseeable future, chemical which, when administered, alters the driven both by large-scale vested interests at a functioning of one or more systems of the or- macro-level as well as man’s inherent pleasure- ganism. However, this definition is too general seeking propensity and psychobiological vul- and would include virtually all medicines rang- nerabilities at a micro-level. However, with a ing from antacids to vitamins and antibiotics. combined multi-pronged effort at multiple lev- A more narrowly defined term is a ‘psychotro- els, aimed not just at supply reduction but also pic’ drug, which induces change primarily in at demand and harm reduction, countries and some aspect(s) of mental functioning; for ex- their people can potentially contain the prob- ample, an anti-depressant is meant to relieve lem at a manageable level. mental depression. Introduction When we refer to ‘drugs’ we mean agents such as alcohol, cannabis, heroin or morphine. Al- Misuse of alcohol and other drugs (collectively though they are all psychotropic agents, they referred to as ‘psychoactive substances’) is a are rarely taken for a particular illness. Rather, problem not only for the abuser but also for they are consumed voluntarily to alter one’s the caregiver, family, workplace, mood, thinking, perception or other mental neighbourhood, and indeed, for the society at functions so as to induce pleasure in an artificial large. It can affect anybody regardless of age, manner. Further, these drugs can cause addic- sex and socio-occupational status. No geo- tion when taken repeatedly so that, at a later graphical location, race, or religion is exempt. stage, these are consumed not so much to in- The growing menace of alcohol and drug abuse duce pleasure as to avoid or reduce the dis- at both international and national levels is of comfort resulting from their absence in the great concern today. It has been continuously body (in other words, to avoid or decrease the challenging the existing resources to combat ‘withdrawal’ of the drugs). In this sense, alco- the problem. For such a multifaceted complex hol is also a ‘drug’. In order to differentiate problem, the interventional strategies also need them from other, more generally defined, me- to be multidimensional in nature. dicinal drugs, these are now called ‘psychoactive substances’ or simply ‘substances’. Of course, Before considering the various ways in which a there are several medicinal drugs that can also multi-level preventive approach can be taken be misused as drugs of abuse, e.g., codeine- up, it is first important to understand the com- containing cough syrups, several painkillers mon but often confusing terms such as ‘drug’ containing opium-like substances, etc. When and ‘abuse’. used in this context (for non-medical uses such as inducing pleasure), these are also referred as

1 Prevention of Substance Abuse in India ‘substances’. nabis, tranquillisers, and recently, volatile solvents. The disorders resulting from pathological (excessive, compulsive, uncontrolled, or non- Levels of substance abuse prevention medical) use of these substances are grouped as “Psychoactive substance use disorders”. The Traditionally, the two major strategies at the common terms such as ‘abuse’ and ‘depen- level of primary prevention are: dence’ come under this umbrella. (i) supply reduction (policies and activities ‘Addiction’ is a much older term than both aimed at minimizing the availability of al- ‘abuse’ and ‘dependence’. It is now omitted cohol and drugs to people); and from technical language because of its pejora- (ii) demand reduction (aimed at decreasing the tive connotation. However, the term still is re- internal need or demand for the substances tained in popular usage. It denotes either abuse by the people). or dependence. Also, the word ‘abuse’ when A third strategy is harm reduction, which tends used non-specifically may cover both abuse and to minimize the harm resulting due to sub- dependence phenomena. Thus, used loosely, a stance use, and thus acts at the levels of second- drug ‘abuser’ (earlier called ‘addict’) is a per- ary and tertiary prevention. son who uses drug(s) in a pathological fashion and may meet the technical definition of ei- Both international and national-level active ther ‘abuse’ or ‘dependence’. This clarification responses have been mounted to take the drug of terminology was felt necessary because of- menace in its stride. International Treaties and ten these various terms create confusion in our various International Agencies or Drug Con- mind. trol Programmes (most notably the United Nations Office for Drugs and Crime, UNODC, The World Health Organization in 1992 has formerly United Nations Drug Control enlisted the following categories of psychoac- Programme, UNDCP) are in force, trying to tive substances: plan, implement and monitor many aspects of 1. Alcohol the drug control programme, in terms of both 2. Opioids (opium, heroin, morphine, pethi- the reduction in supply of, and the demand dine, buprenorphine, codeine, etc.) for drugs. 3. Cannabis (‘ganja’, ‘bhang’, ‘charas’) India is a signatory to the following interna- 4. Sedative-hypnotics (‘tranquillisers’) tional conventions: 5. Cocaine 6. Other stimulants, including amphet- a) Single convention on Narcotic Drugs, 1961, amines and caffeine as amended by the 1972 Protocol; 7. Hallucinogens (e.g., LSD, ‘acid’) 8. Tobacco b) Convention on Psychotropic Substances, 9. Volatile solvents (typewriter correction and 1971; dilution fluids, kerosene, gasoline, petrol, c) U.N. Convention against Illicit Trafficking paint-thinners, nail-polish removers, etc.) in Narcotic Drugs and Psychotropic Sub- and other organic hydrocarbons (e.g., those stances, 1988. in shoe-polish, Iodex, etc.) In addition, India has enacted her own com- Of these, the common and major substances prehensive legislation in this matter in the form used in India are alcohol, tobacco, opioids, can-

2 Prevention of Substance Abuse in India of Narcotic Drugs and psychotropic Substance treatment is essentially pharmacological (i.e., Act (NDPS) in 1985, amended in 1988. Vari- through medicines given to counteract the ous Ministries/Departments are given respon- withdrawals of drugs of abuse). Side by side, a sibility for tackling different aspects of the comprehensive assessment is made of the problem. The supply reduction aspects are patient’s biological, psychological and socio- largely the responsibility of the Ministry of environmental aspects. Guided by the assess- Home Affairs (along with the Narcotics Con- ment, a longer-term treatment plan is formu- trol Bureau) and the Ministry of Finance (De- lated which may include both pharmacologi- partment of Revenue). Prevention and reha- cal aspects (e.g., giving disulfiram, naltrexone bilitation are primarily responsibilities of the or acamprosate to alcohol-dependent persons Ministry of Social Justice and Empowerment, and naltrexone to opioid-dependent persons) formerly known as the Ministry of Welfare, and and non-pharmacological aspects. The latter the Ministry of Health and Family Welfare may comprise of individual counselling, cog- (Department of Health, Drug De-addiction nitive or behavioural therapies, Yoga therapy Programme). Thus, a multi-pronged approach and meditation, and group work including has been adopted. participation in self-help groups like the Alco- holics or Narcotics Anonymous (AA and NA). Section 4(d) of the NDPS Act provides for The AA and NA groups are especially useful identification, treatment, education, aftercare, for maintenance of sobriety for many millions rehabilitation and social reintegration of drug of former substance abusers all over the world. abusers. For this purpose the Act also empow- A final long-term plan is then drawn up for ers the Government, under section 71(1), to occupational rehabilitation and social re-inte- establish as many centres as it thinks fit and gration. frame appropriate rules for their functioning. The family of the drug abuser similarly un- Following this mandate, a number of de-ad- dergoes thorough assessment and counselling. diction centres have been established at both The latter is aimed at providing emotional sup- Central and State levels with the assistance and port, psycho-education, defusing family con- under the auspices of Ministry of Health and flicts and guiding the family through the dif- Family Welfare. Most of these are directly ferent phases of treatment and rehabilitation. funded and monitored by the Ministry of At times a formal family therapy or couples Health and some are directly funded by the therapy is undertaken. More usually, family UNODC. Other than the above, there are a groups are formed where various related and number of counselling and rehabilitation cen- common issues are discussed and mutual sup- tres operating through the Ministry of Social port is generated. Various practical day-to-day Justice and Empowerment. Still other, volun- tips for management of the patients at home tary, non-government organizations (NGOs) are also given, often in the form of Dos and are actively pursuing the common goal of drug Don’ts for the family members. The family abuse control. groups have especially been found to the help- The focus of all these activities is threefold: the ful. drug abuser, his family, and the society at large. The society of the drug abuser is tapped in The drug abuser is first motivated and engaged more indirect ways. It is at this focus that prin- in treatment. He is then detoxified in an out- ciples of demand reduction really come into patient and/or inpatient set-up depending action. One of the most vital components of upon the needs and priorities. This part of the demand reduction is raising awareness – aware-

3 Prevention of Substance Abuse in India ness about both the evils of drug abuse as also 1. Price controls. about the availability of help for treatment 2. Controls on availability: should the need occur. The modalities of a. Minimum age limits for sale. achieving this end are manifold: campaigns b. Limiting the hours and days of sale. through the press, television and radio; public c. Licensing and restricting the number and meetings, workshops, poster and painting com- location of outlets. petitions; disseminating information through d. Prohibition on selling to intoxicated per- books, pamphlets, posters and stickers; orga- sons (for alcohol). nizing and popularising ‘drug free’ music and e. Public monopolies of retail sale. other cultural events; networking with various f. Enforcement of retail controls. NGOs, clubs, hotels and other areas of social g. Restrictions on import. intercourse; and promoting in general a healthy 3. Controls on the use of alcohol and tobacco: drug-free but full-of-fun lifestyle. Ex-abusers a. At specified places (e.g., public offices, and their family members take an active part schools, etc.). in this social focus on demand reduction. b. At specified times. c. During specified activities (e.g., driving, Supply reduction operating heavy machinery). Supply reduction has to be conceptualised dif- 4. Product safety standards: ferently for licit (alcohol and tobacco) and il- a. Alcohol and tar content specification and licit drugs. For illicit drugs, supply reduction restriction. strategies remain an important issue at inter- b. Display of warning statements on health national, national and local levels. However, hazards on the packages. alcohol and tobacco control pose dilemmatic 5. Controls on marketing: questions for the policy makers, because al- a. Controls on advertisements of alcohol though they are responsible for immense harm and tobacco in print or electronic media at personal, familial and societal level, they b. Controls on ‘surrogate’ advertising (e.g., generate handsome revenue for the government. advertising ‘apple juice’ or other innocu- Further, it has been seen repeatedly that a su- ous products by a particular industry perimposed complete prohibition of supply for which also produces alcoholic drinks, alcohol and tobacco does not work. All it does and indirectly but clearly advertising the is to create an artificial illegal market for these alcohol product under the garb of ad- substances and to encourage corrupt practices vertisement of the innocuous product). at various levels, causing further expenditure c. Controls on sponsorship of cultural, for an already impoverished state exchequer for sports or other events. law enforcement. On the other hand, unre- d. Taxing marketing costs. stricted easy availability of alcohol and tobacco e. Controls on the mass media of the por- have been seen to correspond with increasing trayal of alcohol and tobacco use. use, which in turn results in a commensurate Combating the abuse of both licit and illicit increase in substance-related morbidity (lung substances is a tall order. Nonetheless, the cur- cancer, cirrhosis of liver), mortality and social rent data suggests that some strategies are bet- harm such as violence and accidents (especially ter than others. Though supply reduction mea- for alcohol). An attempt to contro supply is sures for alcohol and tobacco as outlined above akin to tightrope walking. The following mea- have been shown to be modestly successful if sures have been suggested: implemented properly, interventions aimed at

4 Prevention of Substance Abuse in India reducing the supply of illicit drugs rarely works mendation the national-level Drug De-addic- effectively. These measures are expensive both tion Programme was launched) and also in in terms of resources, infrastructure and man- August 1993. A Narcotics Coordination Com- power, and tend not to significantly curb the mittee of secretaries (from the Ministries of supply of illicit drugs, the number of users, or Health, Welfare, Home, Revenue and Direc- the amounts they consume. Governments must tor-General of Narcotics Control Bureau) was therefore develop stronger parallel strategies to also constituted in March 1994. Since 1988, reduce the demand for drugs if the problem is to specific project documents were also developed be meaningfully addressed. This requires en- in collaboration with UNODC (then hanced public education that includes messages UNDCP). on prevention that are meaningful to the youth and that note the dangers associated with the In 1994, a national Master Plan for Drug Abuse more casually accepted use of tobacco and ap- Control (1994-2003) was submitted. The parently less potent liquors. The most success- Master Plan had proposals for both demand ful educational campaigns tend to be locally and supply reduction and had outlined over- administered, culturally meaningful, and rel- lapping responsibilities for the Ministry of So- evant for all youths. Governments should also cial Justice and Empowerment and the Minis- develop and support culturally relevant pre- try of Health and Family Welfare in demand vention efforts. reduction. Demand reduction The Ministry of Social Justice and Empower- ment currently funds more than 400 counsel- The major role of demand reduction activities ling and rehabilitation centres throughout the in India lies with the Ministry of Social Justice country (December 2002: 462 centres; 318 and Empowerment and also with the Minis- are De-addiction-cum-rehabilitation centres try of Health and Family Welfare. Other min- and 144 are Counselling and Awareness cen- istries involved in demand reduction activities tres). Funding for NGOs working in the field in the country are the Ministry of Human of drug abuse is also available from several bi- Resource Development (Department of Youth lateral agencies. The strategy of this Ministry Affairs and Education) and the Ministry of in demand reduction can be summarized as Broadcasting. In the federal system of India, follows: health is an issue dealt with by individual states in which the federal (Central) Government has 1. Building awareness and educating people a policy making, coordinating, and assisting about ill effects of drug abuse. role. So the relevant Ministries of the states also 2. Dealing with the abusers through a well deal with drug issues. NGOs too have played rounded-up programme of motivation, a key role in all aspects of drug demand reduc- counselling, treatment, follow-up and so- tion. cial integration of cured persons. Under the NDPS Act, several high level com- 3. To impart drug abuse prevention and re- mittees were formed in the past. Ministry of habilitation training to volunteers and gen- Health and Family Welfare appointed an ex- erate an educated cadre of demand reduc- pert committee in 1986. An advisory commit- tion workers. tee was constituted in 1988. The Central Gov- The Ministry of Health and Family Welfare ernment directly constituted a Cabinet Sub- has funded more than 100 drug de-addiction committee in April 1988 (upon whose recom- centres in the country (December 2003: 122).

5 Prevention of Substance Abuse in India These are located in the hospitals and medical 7. Workplace prevention institutes. Although mainly concerned with 8. Drug abuse prevention for street chil- treatment and rehabilitation of alcohol and drug dren. abusers (i.e., working at the secondary and ter- B. Drug Treatment and Rehabilitation: tiary levels of prevention), these drug de-ad- 1. Medical detoxification diction centres are involved in several demand 2. Treatment with antagonists such as reduction (primary prevention) activities as naltrexone well. These include: 3. Treatment with pharmacological agents such as deterrents (disulfiram) or anti- 1. Generating trained manpower by training craving agents (acamprosate) doctors, nurses, social workers, counsellors, 4. Pilot treatment programmes for opiate other health professionals. abusers 2. Development and dissemination of health 5. Utilizing twelve-step programmes education materials relevant to demand 6. Therapeutic communities reduction themes as well as need for early 7. Long-term rehabilitation programmes detection and treatment. 8. Drug treatment programmes in jails 3. Community-based research in several ar- 9. Detoxification camps in villages eas related to substance abuse, including 10. Community based case detection and demand reduction. treatment programmes. 4. Information, Education and Communica- In spite of this impressive array of activities and tion (IEC) activities at the local levels programmes, evaluation of these programmes (schools, colleges, public offices, factories has been minimal. An earlier evaluation of the and industries, etc.) as also via mass me- national demand reduction activities in the dia. country observed that the budgetary utiliza- 5. Establishing a data collection and moni- tion was low, the pace of the implementation toring system for drug abuse. of the programmes have been slow, and the quality and range of services were limited. The 6. Establishment of drug abuse screening services. need for broadening of primary prevention ser- Demand reduction and other preventive vices was also emphasized in the evaluation. activities The latest formal evaluation of the drug de- addiction centres funded by Ministry of Health Governmental as well as non-governmental & Family Welfare has depicted a rather dismal voluntary agencies (NGOs) are currently car- picture: about 60% of the centres were non- rying out several activities in demand reduc- functional (though some of them have been tion and other preventive activities. These in- maintaining a degree of low-key service), nearly clude: one-fourth of the centres were not providing any de-addiction services at all, and only about A. Primary Prevention: 13% of the evaluated centres were optimally 1. Audio-visual publicity functional. Almost all the functioning centres 2. Development and distribution of print kept their activities limited to providing out- materials patient and/or inpatient services; only a mi- 3. Press advertisements nority of the centres were providing commu- 4. Out door publicity nity-based services as well. 5. Anti-drug awareness campaigns 6. Awareness programmes in schools and There are numerous factors contributing to a colleges

6 Prevention of Substance Abuse in India lack of progress in these demand reduction of resources allocated reflect a lack of priority programmes. These include a host of adminis- given to demand reduction in almost countries, trative factors including improper coordination including India. This relative imbalance speaks between the various Ministries and agencies of a lack of knowledge about the potential ef- involved in this work. This leads to a neglect of fectiveness of demand-reduction strategies, the some areas and duplication of others. A with- conflicting political forces that reign in the area ering political and administrative will is an- of substance-abuse control, and the quasi-mili- other factor. In spite of having been formulated tary approach that sees substance abuse as un- a decade back, the National Master Plan for related to health and human services.” Drug Abuse Control was never published offi- On a much smaller but equally important level, cially, let alone being put into action. This all of us can render valuable preventive services might have to do with yet another factor: the to our community if we follow these simple gradual drying up of funds. Since 1987-88, ten steps while dealing with our younger gen- when UNDCP and other agencies were heavily eration, as mentioned by the U.S. Department funding the drug de-addiction and demand of Health and Human Services: reduction programmes, that was the time when a lot of activities took place. Since 1994-95, 1. Talk with your child about alcohol and the activities and initiatives on the part of the other drugs. government have tended to become half- 2. Learn to listen to your child. hearted. A parallel decline of interest was evi- 3. Help your child feel good about himself or dent at the level of the funded agencies as well. herself. As mentioned in World Mental Health, it is an 4. Help your child develop strong values. irony that “despite the inadequacy of supply- 5. Be a good role model or example in your reduction policies, efforts to decrease the de- own use of alcohol, other drugs or tobacco. mand for substances of abuse remain almost 6. Help your child deal with peer pressure. universally under-funded and under-sup- 7. Set firm no use rules about drinking and ported. Although treatment and prevention other drug use by your children. services are offered, and sizable amounts of 8. Encourage healthy, creative activities. money are spent on demand-reduction 9. Team up with other parents. programmes, the comparatively small amounts 10. Know what to do if you suspect a problem.

Suggested Reading 1. Galanter M, Kleber HD, Eds.The Ameri- Oxford University Press, 477-498. can Psychiatric Press Textbook of Substance Abuse Treatment. American Psychiatric 4. Diagnostic and Statistical Manual of Men- Press, Washington D.C. 1999 tal Disorders, Fourth Edition, (DSM-IV), Text Revision, American Psychiatric Asso- 2. Lowinson J, Ruiz P, Millman R, Langrod J. ciation, 2000. Substance abuse, a comprehensive textbook, 4th edn. Baltimore: Lippincott Williams and 5. American Psychiatric Association. Practice Wilkins, 2005. Guidelines for the Treatment of Patients with Substance Abuse Disorders: Alcohol, Co- 3. McGrady BS. & Epstein E, eds. Addictions: caine, Opioids. American Journal of Psy- A Comprehensive Guidebook. New York: chiatry, 1995, 152 (Suppl.): 1-59

7 Prevention of Substance Abuse in India Suggested slides for OHP

Slide 1: Slide 5:

Misuse of alcohol & drugs, a worldwide problem Demand Reduction Affects all ages, gender & geographical locations - Master plan for Drug Abuse Control (1994-2003)- proposed for demand & supply reduction Slide 2: Funding for counseling & rehabilitation centres Prevention involves 3 strategies Strategies- awareness & education about ill effects of – Primary drug use – Secondary - coordinated treatment plan of drug abuser – Tertiary - prevention & rehabilitation training to volunteers Funding for deaddiction centres Slide 3: Strategies- Generating trained manpower by train- Primary Prevention involves ing doctors, nurses etc – Supply reduction - Development and dissemination of health edu- – Demand reduction cation materials - Community-based research Secondary & tertiary prevention involves - Information, Education and Communication – Harm reduction - Data collection and monitoring system for drug Supply reduction seen by abuse – Ministry of Home Affairs - Establishment of drug abuse screening ser- – Narcotics Control Bureau vices – Ministry of Finance Prevention & rehabilitation seen by Slide 6: – Ministry of Social Justice and Empowerment Other preventive activities – Ministry of Health & Family Welfare – Publicity Slide 4: – Awareness for street children Failure in prevention Supply reduction different for licit & illicit substances – Lack of political & administrative will For licit substances measures include – Lack of funds in demand reduction programmes - Price controls – Failure to provide community services - Controls on availability - Controls on the use of alcohol and tobacco - Product safety standards - Controls on marketing For illicit substances measures include - Public education - Awareness - Information culturally meaningful & relevant for youths

8 Management of Substance Use Disorder in Primary Care 15

Prabhat K Chand, Mohan K Isaac

Summary This chapter explores ways of management of substance abuse from a primary care physician’s The primary care physician is best placed to perspective and discusses its key elements. In treat substance abuser at an early stage. Alco- India, Alcohol and tobacco are the major sub- hol and tobacco are the drugs most commonly stances of abuse and will be the primary focus encountered by the physician. It has been of this chapter. shown that disorders related to these substances can be easily diagnosed in primary care set- ALCOHOL tings. Therapies such as brief intervention and “Does your heart sometimes sink when you find motivational enhancement has been found to one of your patients has an alcohol problem? If be effective in these settings too. Safe medi- so, you are not alone, many doctors rate this as cines are currently available and the physician a difficult area.” can familiarise himself with these easily. This chapter deals with assessment and management General physician are in an ideal position to of alcohol and tobacco use in primary care set- detect heavy drinking and to advise patients, tings. as they are likely to present with various physical problems. Simply spending 5-15 minutes Introduction on a brief intervention can be highly effective in reducing the level of problem drinking. Management of substance abuse is usually easier in the early stages of the disorder. At an Broadly alcohol misuse can be classified as early stage, the substance abusing person is follows: most likely to present to the primary care physician with a variety of non-specific problems. Heavy drinking: Currently not experienc- The physician who is unaware may treat the ing any problem but if continued, at risk physical symptoms without attending the un- for liver damage, neuropathy, pancreatitis, derlying substance problem and its other con- and addiction to it sequences. Problem drinking: Evidence of deterioration of physical, psychological or social condition For effective management the physician needs i.e. not able to drive properly or absence from to be competent in duty, or fighting, inappropriate behaviour under influence. ¾¾¾ Screening patients for substance use Male: >4 units/day or >14 units/week ¾¾¾ Assessment of problems related to Female: >2units/day or > 7units/week substance use Addiction/dependence: Evidence of tolerance, ¾¾¾ Treatment withdrawal, craving, physical/social/ psycho- ¾¾¾ Timely referral to specialized services logical damage, impaired control over drink

1 Management of Substance Use Disorder in Primary Care

The majority of people presenting to general Clues practitioner clinic belong to the first two categories. Research has consistently shown the Symptoms effectiveness of intervention in this population. Gastrointestinal: poor appetite, indigestion, Screening heart burn, dyspepsia, diarrhoea Neurological:tremors,sweating, headaches, The symptoms with which the patient presents insomnia, burning legs often gives clues to underlying alcohol misuse Cardiorespiratory: palpitations, chest pain, (box). Even directly asking about drinking is a pneumonia part of life style assessment and routine health examination. This should be done irrespective Musculosketal: backache, repeated injuries, of gender and type of presentation. rheumatism Gynecological: menstrual problems, As the patient may deny or under-estimate the pre-menstrual disturbances etc. amount he drinks, the physician should estab- Skin: bruises, flushing, rashes lish a good therapeutic relationship with the patient. Showing empathy, understanding and Endocrinology: reduced libido, obesity being non-judgemental is the key to establish- On examination ing a good therapeutic rapport. Wherever possible one should seek corroborative informa- Conjunctiva injection tion from family members and involve them Bloated face in treatment. Periorbital puffiness Detection and Intervention Parotid swelling Smell of alcohol on breath Step I: Ask Flushing In all: Do you use alcohol? Hepatomegaly etc. In current drinkers: Step II: Assess Frequency-How often do you drink? Quantity-How much do you drink? In a patient who reports regular drinking, assess: Duration-How long are you drinking? Physical damage: a small list is provided in the Abstinence-How many days in past have box. But a good physical examination may give you not drunk alcohol at a stretch? evidence of early physical damage in problem Also assess associated withdrawal symptoms drinkers. and high-risk behaviours i.e. repeated intoxi- Psychological: stress, depression or anxiety cations, drinking and driving. Some people may minimise the severity of problems and Occupational: Monday morning blues, going would say that they drink ‘occasionally’ or ‘only late to work, frequent absenteeism, accidents, at weekends’ or ‘only after work’. These need inter personal problems etc further exploration about actual drinking patterns and problems. Legal: arrest or reprimanded for drunken driving, fights or brawls

2 Management of Substance Use Disorder in Primary Care Screening questionnaires In depth assessment in persons These help the physician in detection of prob- • Drinking lem drinking in patients with history of regu- • >2-3 times/wk lar intake of alcohol. One or more positive • >2units/day in male />one unit/day in responses on the CAGE questionnaire indicate female problem drinking and more than three points • Heavy episodic drinking suggest dependence. Laboratory investigations Another widely used scale is the Alcohol use disorders identification test (AUDIT). An Laboratory investigations assist in the detec- AUDIT score of more than eight indicates prob- tion of problem and heavy drinking and are lem drinking and the need for intervention. outlined in the accompanying table.

Laboratory test Abnormal values Interpretation MCV (Mean Macrocytosis (>100 fL) Detects approximately 20–30% of corpuscular volume) problem drinkers in general practice GGT (Gamma Elevated GGT Detects approximately 30% of problem glutamyl transferase) (>55 U/L) drinkers in a general practice setting and 70–75% in a hospital setting AST/ALT (Aspartate >1.5 Alcoholic liver damage transferase/Alanine Transferase)

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)

In pre-contemplation stage, patients are not These changes involve alteration of life style, even considering change. As they become aware handling stress and successful coping. Stage of reasons to alter behavior, they think about changes occur slowly with time and may have it, weigh pros and cons of changing- the con- repeated setbacks. The goal of each visit should templation stage. When the argument for be to help the person move along the con- change wins through, a decision point is tinuum of change towards the reduction of al- reached. They are now ready to change and move into stage of action. cohol use.

3 Management of Substance Use Disorder in Primary Care Step III: Advice the patient’s responsibility and choice. No one Many people are sensitive about their drink- else can make the change or decide for them. ing and the offer of help will be more readily E.g. “Now it is up to you to take a decision on accepted if it is given in a spirit of concern for drinking” health and family well being. There should be mutual trust and respect.Dire warnings and Advice judgemental statements do not work. Most Give clear advice as a doctor to reduce drink- physicians are pessimistic about being able to ing. The person can also make a balance sheet help excessive drinkers yet there is good evi- as shown and discuss about future plan with dence that as many as 75% respond well to the doctor. brief intervention. Balance sheet The steps of brief intervention are: Drinking Advantage Disadvantage Feedback of personal risk Be clear in informing the patient about how Continue Forget worries Family fights drinking is going to worsen his condition fur- Escape Health ther. At the same time state your concern on responsibility problems the prescribed medicine and its interaction with Cost alcohol. Focussing on physical problems and Reduce Be like others Pass time correlating with drinking reduces the patient’s Prestige Gives kick defensiveness. Stop Health better Loss friends E.g. “your drinking is going to worsen your Money save stomach pain” // “I am concerned that your drinking is contributing to your easy tiredness Menu and sleeping problem” Discuss variety of strategies for the patient to At the same time just treating the physical ali- choose to achieve the goal. It is worth clarify- ment without discussing about drinking, may ing initially about patient’s goal i.e. no change, be counterproductive and undermine the seri- cut down or stop. The impediments for the ousness of problem drinking. desired goal will be obvious from the interview Similarly statements may help for minor prob- or from the balance sheet. The common strat- lems i.e. sleep disturbance. egies are shown in box. E.g. I am prescribing some medicines for symptomatic relief of your stomach pain but you Keeping a diary of drinking occasions, amount will need to completely stop your drinking for of drink per week is helpful in keeping track of some time to allow healing. Why don’t you drink. give up for two weeks and see the difference? Menu (Alternate strategies) It is important to involve the spouse or an im- Recognising and avoiding trigger situations portant family member and educate them regarding ill effects of alcohol on the patient’s • Planning ahead to limit drinking current health. • Pacing one’s drinking • Learning to cope with everyday Responsibility problems that encourage drinking Emphasise that the decision about drinking is • Finding alternate sources of enjoyment

4 Management of Substance Use Disorder in Primary Care Self-efficacy that he or she returns for the next appoint- Patient needs to be encouraged to be optimis- ment. At this time, the short-term achievements tic and to bring about the changes in drinking and problems can be reviewed and further goals behaviour. It is best to aim for specific short- agreed. Supportive laboratory test i.e. GGT, term goals at first so that the patient gets a MCV, AST, ALT are useful objective means of sense of control or achievement. monitoring progress and results and their implication should be discussed with patient. E.g. A person who is able to abstain for 2-3 Progress should be reviewed regularly over a year. weeks should be encouraged to continue it. The first six months of progression often gives Step IV: Agree good impression of longer-term prognosis. The final choice for future alcohol intake is best Relapse left to the person. The low risk or moderate Most patients will drink again whatever the drinking option is advisable if person wants to original goal of treatment, but this need not continue drinking. The moderate drinking be a catastrophic relapse involving the loss of needs to be carefully planned and discussed all that has been achieved. It is to be viewed as and is best preceded by period of abstinence. an opportunity for the patient to learn from. Abstinence is strongly advised in certain con- The important issues to be addressed are men- ditions. tioned in the box. Relapse is not the end of the Low risk or moderate drinking road. One common cause of relapse is compla- cency and overconfidence that this problem is • Men: # 2 units/day, # 4 units/ occasion in the past and drinking will be now safe. • Women: # 1unit/day, # 3 units/ occasion Relapse • Over 65 yr: # 1unit/day, #3 units/ • When? occasion • Where? • No drinking at least 3 days/week • What preceded? How is he going to handle it in future? Abstinence Late stage alcohol problems • Addicted/dependence Persons, who drink regularly, having developed • Significant physical damage tolerance, craving, or significant problems, are • Failed in moderate/controlled drinking considered to be addicted or dependent. This Family h/o of alcohol dependence group of patients need detoxification and more intensive counselling for management. Absti- nence is the goal in these groups. They need Step V: Monitor (Follow up) pharmacological intervention to handle withdrawal symptoms and future abstinence. Whatever the agreed goal, it is essential that the doctor regularly review the patient’s Detoxification/ management of withdrawal progress. The most important task at the first symptoms interview is to gain the patient’s interest in tack- It is a process that provides safe withdrawal ling his or her drinking problem and to ensure from alcohol. The common withdrawal

5 Management of Substance Use Disorder in Primary Care symptoms like insomnia, tremors, irritability, Mainstay of management is pharmacotherapy restlessness, sweating, increase pulse rate usu- and most of cases can be managed on an out- ally begins 6-8 hr of last drink, reaches its peak door basis. Roughly for one unit of alcohol, 1mg at 24-48 hr and subside in next 7days. of diazepam, 5mg of chlordiazepoxide needed.

Drug Dose Trade name Interval Comments Diazepam 10-40mg Calmpose 6hr-8hr Safe Chlordiazepoxide 50-120mg Librium 6hr-8hr Safe Lorazepam 4-12mg Ativan 6hr-8hr Safe even in liver disease

Additionally, intramuscular injection thiamine social support who can monitor its intake. 100mg/day for five days should be given followed by oral vitamin B complex orally for two Disulfiram alcohol reaction: flushing, headache, weeks. palpitations, dyspnoea, nausea, hypotension, and prostration when alcohol is ingested. It In a few patients, the withdrawal becomes se- varies in intensity between individuals and usu- vere and can present as confusion, disorienta- ally occurs within 10 minutes of taking alco- tion, seizure and generalised tremors. This con- hol and reaches a peak at 20–30 minutes and dition is known as delirium tremens and re- last for 1–2 hours. quires inpatient intensive treatment. Contraindications: psychosis, ischaemic heart Pharmacotherapies for alcohol dependence disease, severe hepatic or renal disease. Pharmacotherapeutic agents may be prescribed Dose: It is to be administered only after pa- for alcohol dependent individuals generally af- tient understands disulfiram alcohol interac- ter the phase of acute alcohol withdrawal is over. tion and informed written consent is taken. This coupled with a comprehensive rehabili- Patients need to abstain from alcohol for at least tation program with individual and family one day before administration of disulfiram and counselling, relapse prevention, coping skills for at least one week after cessation of treat- and is essential for a successful treatment out- ment. Disulfiram is available as 250 mg tab- come. lets, and is commonly prescribed once daily Disulfiram (Antabuse, deaddict, esperal, dis- Naltrexone (Naltima, Nodict) ulfiram) Alcohol consumption is thought to produce a Disulfiram was the mainstay of pharmacologi- feeling of well being brought about by the re- cal treatment for alcohol dependence for a long lease of endorphins in the brain and stimula- time. It acts by irreversibly inhibiting aldehyde tion of opiate receptors. This reinforces drink- dehydrogenase and leading to accumulation of ing of alcohol and ultimately leads to relapse. acetaldehyde. This triggers an unpleasant re- Naltrexone competitively blocks opioid recep- action when alcohol is ingested and this acts as tors and reduces the reinforcing and reward- a psychological deterrent to drinking alcohol. ing effects of alcohol. Naltrexone at 50 mg/ This form of aversive therapy is effective in day significantly reduces the risk of relapse to motivated and reliable patients who have good heavy drinking and the frequency of drinking.

6 Management of Substance Use Disorder in Primary Care

Drug Trade name Dose Comments Disulfiram Disulfiram, 250mg/day Work best if patient is deaddict, motivated, good social support esperal Naltrexone Naltima, 50mg/day Anticraving agent, work with Nodict once day positive family history of addiction Acamprosate Acamprol 4-6 tablets Can be started during detoxification, 333mg/tablet thrice day least side effects Topiramate Topmac, 200-300 Latest agent, needs slow building Topaz mg/day of dose (25’!200mg/day),c/i in renal stone

Acamprosate (Acamprol) tobacco in some form. At the same time about one fifth of tobacco used in India is as smoke- It predominantly suppresses excitatory less type i.e. guthka, tooth paste etc. The pro- glutaminergic neurotransmitters and decreases cess of stopping smoking is often a cyclical one, craving. with the smoker sometimes making multiple Side effects: mild and transient. Diarrhoea oc- attempts to quit and failing before finally be- curs in few patients but is reduced by taking ing successful. Approximately 70 to 80% of medication with a meal smokers would like to quit smoking and ap- Contraindications: renal insufficiency, hepatic proximately one-third of current smokers at- failure tempt to quit each year. 90% of these unas- sisted quit attempts fail. Dose and duration: available as 333mg/tablet. <50kg=4tablets in three divided dose, >50kg MANAGEMENT =6tablets in three divided dose The 5 A’s is a brief intervention method used Conclusion to guide the clinician in tobacco cessation Alcohol is second only to tobacco as a cause of Counseling. This method is found to be effec- substance induced morbidity and mortality. It tive and takes only 5-15 minutes. is a risk factor for many cancers, liver disease, ASK 5 A’s of Intervention road fatalities, homicides and suicides. As one • ASK in five patients who visit a primary care physi- Ask all the patients • ADVISE cian drink alcohol at hazardous levels, physi- about tobacco use at • ASSESS cians play a unique and vital role in early iden- the time of history • ASSIST tification and prevention of alcohol related taking • ARRANGE harm. “Do you smoke or chew tobacco?”/Have you Tobacco ever used tobacco ? Are you using now?” Tobacco is a major cause of morbidity and Also enquire about amount and type of tobacco mortality all over world. In India, it is esti- used by the patient. It is important to check about mated that 65% of men and 33% women use the duration and any associated complications.

7 Management of Substance Use Disorder in Primary Care Screening tion to stop can be assessed by means of simple direct questions about their interest and in- One of the easy ways to assess whether the per- tentions to quit. Past attempts of quitting if son needs help is by asking the two questions present can be used to encourage further and given in the box. A “yes” response to either of longer abstinence. these questions would suggest that the person need help in stopping tobacco. Initial Contact r 1.Do you find it difficult not to smoke/chew in Motivation Assessment situations where you would normally do so? r 2.Have you tried to stop smoking for good Not willint Willing Willing in the past but found that you could not? rr <10 cigarette >10 cigarette ADVISE or < 5 packets or > 5 packets no physical or physical or In a clear, strong and personalized manner, urge psychological psychological every tobacco user to quit. It is important for problem problem r the person to be aware of the complications of tobacco use. Motivational r enhancement Nicotine gum + If you smoke, have If chewing tobacco, Bupropion no problems yet you have high risk for r r You have Increased risk of Simple advice Twice the risk of leukoplakia Reinforce commitment to change heart attack 5 times increased Help in making a plan r Six times the risk of risk of oral cancer Follow up emphysema Stained and abraded Ten times the risk of teeth ASSIST lung cancer Gingivitis, dental Increased risk of caries, bad breath 1. Patients willing to change colorectal cancer, Poor wound healing Physician should discuss with them the skin cancer benefits of stopping tobacco use and at the same And time encourage them to do so. Another impor- Life span 5-8year shorter tant thing is to make a plan on how to stop use. The important points while making plan are: It is useful to tie tobacco use to current health and its social, economical costs as well as its a) Identify what works and what does not work impact on children and other house hold mem- i.e. “What worked well last time when you bers. stopped using tobacco?” What did not work? What were the problems?” ASSESS b) Triggers: These are situations or thoughts that During initial contact with the patient assess initiates tobacco use and can be the reason for his motivation to quit smoking or chewing. restarting tobacco use after a few days/weeks of Usually very few people think of cessation of abstinence. It is important to identify these and smoking at any given point of time. Motiva- developing strategies to handle them.

8 Management of Substance Use Disorder in Primary Care

Common triggers Handling decrease craving after quitting smoking or chewing tobacco. One can use an average of Boredom/ Spend time which 10 to 15 gums per day but most patients in Stress/anxiety smoke person enjoy like India do not require such high doses. listening songs, Duration of treatment: 6- 12 weeks. exercise etc. Bupropion Mood (positive or Spend time with Bupropion, an antidepressant also helps in to- negative) friends/family member bacco cessation and taking it along with nico- who do not tobacco tine gum increases the chance of success. or smoke. Dose: Patient should first set a QUIT DATE Party Substitute with other (no tobacco) after discussion with physician. behaviors i.e. playing Bupropion sustained release (150 mg) should games, creative pursuits. be started two weeks prior to this and patient should be advised to progressively decrease to- Craving: bacco consumption. This is one of common impediments in tobacco Duration: for 7-12 weeks. If no significant cessation. Generally, craving is strongest in the progress toward abstinence by the 7th week , first week and lasts for 30-90 seconds each time. it is unlikely he will quit during that attempt As the days pass, the intensity of cravings re- and treatment can be discontinued. duces. Contraindication: seizure disorder Most withdrawal symptoms are self limiting ARRANGE Follow up and are not very disabling. Set a follow up date about 2 weeks after quit- Handling Craving ting and reassess the situation. There is every • Avoid smoking situation likelihood that patient may slip back to earlier • Drink 2 glass of water pattern. If so, be accepting and empathetic, • Think again reason for quitting reassess the situation and may plan accordingly. • Exercise or take bath Patient unwilling to change • Eat sugar rich food • Deep breathing Patients unwilling to make a quit attempt during a visit may lack information about the c) Explore use of medications i.e. nicotine gum, harmful effect of tobacco, may have fears or con- patch or Bupropion tablets cerns about quitting or may be demoralized because of previous Nicotine gum Increase motivation relapse. Such patients to quit(5 R’s) It is now available in India. Each chewing gum may respond to moti- contains 2mg of nicotine and is to be chewed vational intervention • Relevance like any other chewing gum. It is to be chewed that provides the clini- • Risks slowly and should remain in mouth for at least cian an opportunity to • Rewards 30 minutes for effective educate, reassure and absorption. It is more effective in heavy smok- • Road block motivate the person. ers but can be used as and when required to • Repetition

9 Management of Substance Use Disorder in Primary Care Relevance: Encourage the patient to indicate Roadblocks : Ask the patient to identify why quitting is important for him and his cur- barriers or impediments to quitting and rent health. It works best when the issue is rel- reassure that these can be handled if he would evant to patient’s disease status risk, family or try quitting. social situations, health concerns etc. Roadblocks (Barriers) • Fear of failures Risks: Discuss with the patient about short and • Withdrawal symptoms long term risk of continued tobacco use. High- • Loss of pleasure light the conditions that are most relevant for • Constipation the patient. Also emphasize that smoking fil- tered cigarette, low tar or smokeless tobacco • Depression will not eliminate these risks. Repetitions : The motivational intervention Rewards: Ask the patient to identify potential should be repeated every time an unmotivated benefits of stopping tobacco use. patient visits the clinic. Tobacco user who has failed in previous quit attempts should be told Rewards that most people make repeated quit attempts • Improved health before they are successful. • Dental hygiene Conclusion : • Feel better physically and Tobacco dependence is a chronic disease that psychologically needs treatment. Effective treatment methods • Good example for children are now available and should be used with ev- • Reduced wrinkling and aging ery current and former tobacco user.

Suggested Reading 1. Benegal V, Murthy P, Shantala A, 5. Molyneux A. ABC of smoking cessation: Janakiramaiah N. Alcohol related problems Nicotine replacement therapy. British : a manual for medical officers. Deaddiction Medical Journal, 2004,328:454-456. Centre, National Institute of Mental Health 6. Patton A. ABC of alcohol. British Medical Jour- and Neurosciences, Bangalore, India, 2002. nal publishing group, Tavistok Square, London, 2. Coleman T. ABC of smoking cessation: Use 1994. of simple advice and behavioral support. 7. Ray R. Treatment principles and issues in British Medical Journal, 2004, 328:397- management of addictive behavior. In: Sub- 399. stance use disorder: a manual for physician 3. Johnstone C. Effective brief interventions in (ed by) Rajat Ray, Drug Deaddiction Treat- problem drinking. The Practitioner, 243, ment Center, Department of Psychiatry, 1999:614-618. AIIMS New Delhi, 2002, 85-97. 4. Latt N, Saunders JB. Alcohol misuse and 8. West R. ABC of smoking cessation: Assess- dependence: assessment and management. ment of dependence and motivation of quit. Australian Family Physician, British Medical Journal, 2004,328, 338- 2002,31:1079-1085 339.

10 Management of Substance Use Disorder in Primary Care Suggested slides for OHP

Slide 1: Introduction >2units/d in male />one unit/d in female Heavy episodic drinking Intervention is easy in the early stage of the disorder On screening questionnaire Physician should be competent in: Yes on any one item of CAGE • Screening patients for substance use Score of > 8 on AUDIT • Assessment of problems related to substance use • Treatment Slide 6: Assess • Timely referral to specialized services With the help of laboratory investigations: Slide 2: Alcohol Raised MCV, GGT, AST/ALT ratio Stage of motivation Problem patterns of drinking include: Not ready p unsure p ready p changing p changed • Heavy drinking: at risk for damage i.e. hepatitis, Slide 7: Step III: Advice neuropathy, gastritis & addiction • Problem drinking: evidence of damage in physical/ Be non judgmental, express concern regarding health psychological/social Feedback personal risk • Addiction: development of tolerance, craving, with- Stress on personal responsibility drawal symptoms, morning drinking, impaired con- Advice specifically and clearly regarding desirable change trol over drink Provide a Menu /future plan Indicate Optimism Slide 3: Screening Slide 8: Step IV: Agree Physician should have a high index of suspiciousn and pick of clues Final choice on drinking left to the patient Pay attention to non specific symptoms i.e.tiredness, Agree on low risk or moderate drinking if abstinence not insomnia, weight loss, indigestion etc which may indi- being considered by patient cate an underlying alcohol problem On the need for regular monitoring Routinely enquire about alcohol as a regular part of his- Involve the family member i.e. spouse tory taking Slide 9: Agree…

Slide 4: Detection and Intervention Strongly advice Abstinence in patients with: Step I: ASK: Dependence Do you drink alcohol? Significant physical damage L Failed attempts at moderate drinking Family history of alcohol dependence and related Yes complications Frequency- quantity-duration-type Regular follow up is essential Check withdrawal symptoms, high risk behaviors i.e. drink driving, fights &physical damage, unprotected Slide 10: Alcohol dependence Sex under intoxication Considered late stage alcohol problem Slide 5: Step II:Assess Detoxification essential Benzodiazepine mainstay for detoxification Detailed assessment required in persons Additional specific pharmacotherapy along with coun- Drinking seling helps >2-3 times/wk Abstinence is the goal

11 Management of Substance Use Disorder in Primary Care Slide 11: Relapse Slide 14: Assess

Most patient do restart drinking Does the patient now use tobacco Do not panic as relapse is natural in the course of alcohol use Assess: When, Where, Preceding event for relapse Yes No Advise: How is patient going to handle relapses in fu- now willing to quit Did he once use tobacco ture?

Slide 12: Tobacco Yes No Yes No Provide Provide Prevent No interv- ASK appropriate information relapse ention Do you find it difficult not to smoke in certain situa- treatment to quit required, tions? encourage Have you tried to quit smoking in the past but could abstinence not? “Yes” to either of these questions-person need help Advise Slide 15: ASSIST Strongly urge all users to quit in a clear, strong, and Help with a quit plan: personalized manner. Set a quit date CLEAR- “Quit now, not just when you are ill”. Tell family, friends/request help STRONG- “Quit now and protect health Avoid, Remove tobacco PERSONALISED- Tie use to adverse impact. Relapse Prevention Slide 13: Advise… Discuss triggers/challenges Review past experience and lessons learnt Benefits of quitting Help the user to obtain extra-treatment social support 20 MINS - B.P, Pulse & Body Temperature returns to from workmates, family and friends normal Recommend use of approved pharmacotherapy.

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.

12 Comorbidity in Substance Use Disorder 16

S Parker

Summary fication, general medical condition is coded separately. Comorbidity in psychiatric terms The coexistence of substance use with mental and in the context of substance use disorders health problems is a rule rather than an excep- usually refers to the co-occurrence of psycho- tion. It has also been established beyond doubt active substance use and other mental disor- that comorbid conditions have severe clinical ders. presentations. Till date, there are no uniformly accepted, comprehensive and coherent guide- Two terminologies often used include: lines for the care of patients with coexisting substance use and mental health problems. 1) Mentally Ill Chemical Abuser (MICA)/ Management is mostly opinion-led and this Mentally Ill Substance Abuser (MISA)/ area of substance use disorders continues to Chemical Abusing Mentally Ill (CAMI): remain a poor neglected step-child. These terms have been used to describe patients with a psychiatric disorder having Patients with comorbid disorders irrespective a comorbid substance use disorder. of temporality and cause-effect relationship 2) Dual Diagnosis: Patients with a substance pose a great burden on health care services. use disorder and comorbid psychiatric However, the significance of this condition is manifestation are referred to as dual diag- almost always disregarded. A dire consequence nosis patients. of this is that these patients and their families experience tremendous distress. It is of signifi- The distinction between the two categories is cant mental health importance that this cat- very thin and it may not always be possible to egory of patients be identified and treated ap- establish a primary-secondary relationship be- propriately – in a manner dissimilar from the tween the two. solitary diagnosis of a substance use disorder Irrespective of the type, comorbidity has been or a mental illness. shown to have major consequences. Three ma- Introduction jor epidemiological surveys, the Epidemiologi- cal Catchment Area study (ECA), National Comorbidity is defined as the presence, either Comorbidity Study (NCS) which were con- simultaneously or in succession, of two or more ducted in USA and Netherlands Mental Health specific disorders in an individual within a speci- Survey and Incidence Study showed that sub- fied period. jects with comorbid disorders had higher service utilization rates than those with psychiat- Comorbidity can be used to describe the pres- ric illness alone. Studies have also linked ence of a comorbid physical condition (gen- comorbidity with a more severe symptom pro- eral medical condition) or psychiatric disorder. file, greater functional disability and a longer However, in most systems of psychiatric classi- illness course.

1 Comorbidity in Substance Use Disorder Prevalence Classification In the ECA study, an estimated 45% of indi- Comorbid disorders can be classified as follows: viduals with alcohol use disorders and 72% of individuals with a drug use disorder had at least a) Depending on the drug of abuse like alco- one co-occurring psychiatric disorder. In the hol-induced psychosis or schizophrenia NCS, approximately 78% of alcohol-depen- with comorbid alcohol dependence. dent men and 86% of alcohol-dependent b) On the pharmacological action of the drug women met lifetime criteria for another psy- e.g. stimulant induced psychosis. chiatric disorder, including drug dependence. c) Type of psychiatric disorder such as schizo- Correspondingly, 65% women with other sub- phrenia, depression. stance abuse or dependence received at least d) Etiological significance. one additional diagnosis. Conversely among psychiatrically ill patients, substance use dis- The routinely followed classification is based order was found to be 15.7% in the past month on etiological significance. In order to estab- with a lifetime prevalence of 32.7%. lish a cause –effect relationship, it is essential to understand Indian studies are available only on psychiatric conditions comorbid with alcohol. The 1) The chronological order of appearance: prevalence of comorbid psychiatric disorders 2) Influence of remission in one of the disor- in alcohol ranges from 12.5%-46.0%, depres- ders on severity of the other: This usually sive symptoms from 27.5%- 48.6%, depres- confirms the diagnosis. Often in substance- sive disorder from 8.8%- 23.6%, and psycho- induced cases, there is an attenuation of sis from 10.0%-29.2%. the comorbid psychiatric disturbance as- The most common psychiatric disorders seen sociated with abstinence from the substance. with substance use disorders are: 3) Certain other paradigms that can be used 1) Antisocial personality disorder (prevalence in diagnosing substance-induced disorders rate of 35-60%) including absence of any other condition 2) Depression. One-third to one-half of opioid that could result in the psychiatric distur- abuse or dependence and about 40% of bance and the severity of mental illness as- those with alcohol meet criteria for major sociated with the substance use. depressive disorder sometime during their lives. Studies have also shown substance Accordingly, Comorbid conditions in sub- abuse to be a major precipitating factor for stance use disorders can be classified thus: suicide. Persons abusing substances are 20 a) Classification based on etiology times more likely to die by suicide as compared to the general population. 1) Primary substance use disorder with sec- 3) Panic and other anxiety disorders (In pa- ondary psychiatric disorder. tients with alcohol dependence-Panic dis- These include substance-induced con- order - 5 to 42%, Generalized anxiety dis- ditions such as alcohol-induced psycho- order-8.3 and 52.6%, social anxiety disor- sis probably caused by organic changes der- 8 to 56%, Obsessive-compulsive dis- in the brain. In some cases, the psychi- order –3-12%). atric disorder can be a secondary condi- 4) Schizophrenia: 10.1% prevalence. tion caused by the psychological and

2 Comorbidity in Substance Use Disorder social effects of the substance use. c) Approach Based on existing classificatory 2) Primary psychiatric disorder with sec- systems ondary substance use disorder. The third approach is to form sub-catego- In some psychiatric disorders, it is seen ries based on a broad DSM-IV classifica- that the patients consume the substance tion of mental health disorders.DSM-IV as a form of self-medication to obtain provides the option of indicating that the relief from the disorder. e.g. alcohol con- disorder is “substance induced” . sumption secondary to panic attacks. Patients with schizophrenia very com- Etiology monly abuse nicotine to decrease the in- The etiology of the high prevalence of substance tensity of hallucinations and thus im- use disorders in patients with mental illness is prove alertness. unclear. The evidence of different theories of 3) Primary psychiatric disorder with sub- increased comorbidity can be organized accord- stance use disorder as part of the clinical ing to four General Models. syndrome. In some patients, the substance disor- 1) Common factor model : der can be a part of the clinical syndrome Among common factor models, evidence of the psychiatric illness. e.g. alcohol suggests that anti-social personality disor- consumption increases during the manic ders accounts for some increased phase of bipolar disorder. comorbidity. 4) Two coexisting independent disorders. 2) Secondary substance use disorder Model : Initially considered improbable, the concept of co-existence of two independent Among secondary substance use disorder psychiatric disorders is now accepted. model, there is support for the supersensi- tivity model, which posits that biological b) Classification Based on Severity : vulnerability of psychiatric disorders results This approach based on severity considers in sensitivity to small amounts of alcohol a mix of substance abuse and mental health leading to substance use disorders. This disorders in the categorization scheme, and models implies a selective matching of spe- uses categories that reflect the relative se- cific substances (and their subjective effects) verity of each set of problems. It has been with specific symptoms. The self medica- adapted from Weiss et al. whereby catego- tion hypothesis links substance use to the ries based on low/high severity of psychi- patients’ wish to improve psychopathologi- atric and substance use disorders are de- cal symptoms such as anhedonia or side scribed. effects of neuroleptic treatment. 1) Substance abuse and non-severe psycho- 3) Secondary Psychiatric disorder model : pathology (Psych-low, Substance-low). Secondary psychiatric disorder model re- 2) Complicated chemical dependency mains controversial till date. This model (Psych-low, Substance-high). focusses on vulnerability and hypothesizes 3) Substance abusing mentally ill. (Psych- that drug abuse may cause psychiatric ill- high, Substance low). nesses and vice versa in a vulnerable indi- 4) Substance dependent mentally ill. vidual. (Psych-high, Substance-high).

3 Comorbidity in Substance Use Disorder Various other models like the bidirectional to be most efficacious when the psychiat- model have been proposed but these have not ric symptoms are not very severe. been adequately substantiated. No single model 3) Integrated treatment : has unequivocal support and can claim to explain all cases of comorbidity between substance A third model, called integrated treatment, abuse and psychiatric illnesses and it is pos- an approach that combines elements of sible that all models contribute in the expla- both mental health and addiction treat- nation. ment into unified and comprehensive treatment program for patients with co-mor- Management bid disorders. Integrated treatment involves It is of importance to realize that treatment of clinicians cross trained in both mental comorbid conditions cannot be generalized. health and addiction who use a unified case Treatment has to be tailored according to the management approach, making it possible specific needs of each individual patient. This to monitor and treat patients through vari- will vary according to ous periods of crisis related to either substance abuse or the psychiatric illness. 1) Nature of drug abused like stimulant, sedative Management of comorbid conditions essentially includes: 2) Type of psychiatric disorder. 1) Establishing a diagnosis Models of Treatment : 2) Management of substance withdrawal As mental health professionals have become increasingly aware of the existence of patients 3) Short-term management of the psychiatric with co-morbid disorders, various attempts disorder have been made to adapt treatment to the spe- 4) Maintenance of abstinence and long-term cial needs of these patients. These attempts management of psychiatric disorder reflect philosophical differences about the nature of comorbid disorders, as well as differing 5) Rehabilitation opinion regarding the best way to treat them. 6) Caregiver psychoeducation There are three approaches to treatment. 1) Establishment of diagnosis: 1) Sequential treatment : Substance intoxication may resemble a psychi- This is the first and (historically) most com- atric disorder (for e.g. patients under the in- mon model of dual disorder treatment. fluence of alcohol often talk irrelevantly) and The term sequential treatment describes the protracted substance withdrawal can compli- serial involvement of both mental health cate psychiatric presentation (for e.g. opium and addiction treatment teams. The se- withdrawal can mimic depressive disorder). verity of the disorder determines the prior- Inadequate history may give rise to further con- ity – substance abuse or Psychiatric illness. fusion about the cause-effect relationship. 2) Parallel treatment : Hence, it is advisable to treat the substance In this model the mental health and ad- withdrawal and wait for a minimum of 2-4 diction treatment teams work simulta- weeks before confirming the diagnosis of the neously, but seperately. This has been found psychiatric disorder.

4 Comorbidity in Substance Use Disorder 2) Management of substance withdrawal: anti-craving agent. Long-acting depot antipsychotics have been shown to be effica- Adequate management of the substance with- cious in patients with alcohol dependence and drawal (detoxification) must be done for an comorbid psychosis. It is advisable to avoid the adequate duration. Substance-induced psychi- use of long-term benzodiazepines in patients atric disturbances remit with adequate and rig- due to their addictive potential. orous management of withdrawal. However, in some conditions like alcoholic hallucinosis, the Psychotherapy: Patients with comorbid disor- condition can become chronic. It forms good ders are difficult to engage in any kind of psy- clinical practice to consider substance induced chotherapeutic relationship. However, these psychotic disorders as a variant of brief psy- patients can benefit from psychoeducational chotic disorder and treat the patient accord- programmes, group therapy, and individual ingly. psychotherapy. 3) Short-term management of the psychiatric 5) Rehabilitation: disorder: It is essential to ensure that patients are ad- If the patient continues to manifest the psy- equately rehabilitated to prevent relapses. chiatric disturbance, it is recommended that the patient receive treatment appropriate to the 6) Caregiver psychoeducation: disorder. Caregivers need to be educated about the spe- 4) Maintenance of abstinence and long-term cial nature of comorbidity, i.e., the co-exist- management of psychiatric disorder: ence of two disorders and should be forewarned about the problems and prognosis. They should Both steps are to be treated hand-in-hand. be adequately prepared to spot the early warn- Comorbidity forms a vicious cycle with both ing signs of relapse. This can be done either disorders contributing to each other. Hence it individually or in groups. Adequate support becomes essential to attain long-term remis- to the caregiver and encouraging healthy cop- sion in both. If any one condition is neglected, ing patterns to deal with perceived burden is the comorbid condition can get exacerbated. essential. The following paradigms can be helpful in management. Problems in management: Long-term management of psychiatric disor- 1) Difficulties in establishing the diagnosis. der involves (Discussed in the earlier section) 2) Difficulties in treatment: Patients with Pharmacotherapy: The patient should be comorbid substance use disorder are often treated for the psychiatric disorder with ad- non-compliant to the medications. They equate doses for an adequate time period. are more prone to the side-effects of the Anticraving agents can help in abstinence. various psychotropics used for treatment. However, the anticraving agent has to be selected appropriately. SSRIs can help in 3) Presence of additional organic brain dam- comorbid depression. Disulfiram can precipi- age may complicate management. tate psychosis and hence should be used cau- 4) Long-term rehabilitation is often difficult, tiously in comorbid schizophrenia. Topiramate as most substance-use rehabilitation cen- as a mood-stabilizer has also been used as an tres do not attend to patients with

5 Comorbidity in Substance Use Disorder comorbid psychiatric disorders leading to are then brought to the treatment facilities only poorer prognosis characterized by an in dire emergencies. unpatterned behaviour pattern and frequent relapses. Frequent relapses, difficulty in establishing and maintaining therapeutic relationship, poor Mental Health Significance: compliance and a non-committal attitude of Even relatively minor use of a substance by a the caregiver has a negative impact on the treat- person experiencing mental health difficulties ment provider occasionally leading to a nega- may lead to worsening of this condition and tive counter-transference. may have significant health implications. The An ideal situation for management of these coexistence of substance use and mental health patients is a specialized set-up with physicians problems has been linked to increase in im- trained in all aspects of management of patients pulsive, aggressive and disinhibited behaviors, with dual disorders. as well as an increase in anxiety, depression and self-harm. Impact on health care utilization: Comorbidity also leads to social problems, dif- Studies have shown that comorbidity increases ficulties with activities of daily living, worsen- health care service utilization. It has also been ing of physical health and significant legal and shown that 50% patients attending the emer- financial problems. In extreme situations a per- gency room are patients with dual disorders. son may end up behaving in self-destructive Thus these patients account for a significant and antisocial ways. They may become home- proportion of health care costs. less, be disengaged from their family and community, and have a higher chance of exhibit- Role of the General Practitioner: ing high-risk behaviors such as indulging in Majority of patients suffering from comorbid criminal activities, intravenous drug use, needle conditions are never seen by a specialist.The sharing, suicide attempts, unsafe sex, and binge general practitioners (GPs) is often the first and consumption. only contact. Damien McCabe and Chris Overall, the presence of comorbidity increases Holmwood (Australian Resource Centre, Pri- the incidence of relapse and the need for acute mary Mental Health Care) have suggested the intervention for both the substance use and the following possible role of GPs in management: mental health problem. • Early detection and accurate diagnosis of comorbidity Impact on caregivers and health providers: • Provision of information on the patients’ As discussed earlier, comorbidity in substance condition and treatment approaches use disorder is characterized by frequent re- • Brief interventions for people with lower lapses. This poses tremendous burden on the levels of disability caregivers emotionally and financially and can • Referral and co-ordination of care for more lead to caregiver burden and depression. These severely affected people in turn lead to increased expressed emotions • Medical treatment for physical health com- that further aggravate the patient’s illness. Of- plications ten it is seen that because of the frequent re- • Provision of a high level of support to the lapses, the caregiver loses interest in the pa- patient and their family tient and the treatment process. The patients • Long term monitoring and follow-up

6 Comorbidity in Substance Use Disorder

Suggested Reading 1. Nimesh G Desai, Dhanesh K Gupta, KA U, Kendler KS: Lifetime and 12-month Khurshid. Substance use disorders. In: Text- prevalence of DSM-III-R psychiatric disor- book of postgraduate psychiatry. JN Vyas ders in the United States: results from the and Niraj Ahuja (Eds). New Delhi. Jaypee National Comorbidity Survey. Arch Gen Brothers Medical Publishers (P) Ltd, 1999, Psychiatry 1994; 51:8-19. 76-150. 6. Robins LN, Locke BZ, Regier DA: An over- 2. Ron de Graaf, Rob V. Bijl, Filip Smit, Wilma view of psychiatric disorders in America, in A.M. Vollebergh, and J. Spijker. Risk Fac- Psychiatric Disorders in America: The Epi- tors for 12-Month Comorbidity of Mood, demiologic Catchment Area Study. Edited Anxiety, and Substance Use Disorders: by Robins LN, Regier DA. New York, Free Findings from the Netherlands Mental Press, 1991,328-366. Health Survey and Incidence Study. Am J Psychiatry 2002; 159:620-629. 7. Hugh Myrick, Kathleen Brady. Review of Comorbidity of Affective, Anxiety, and Sub- 3. Li-Tzy Wu, Anthony C. Kouzis, and Philip stance Use. Current Opinion in Psychiatry, J. Leaf. Influence of Comorbid Alcohol and 2003; 16(3): 261-270. Psychiatric Disorders on Utilization of Men- tal Health Services in the National 8. Reiger DA, Farmer ME, Rae DS, et al Comorbidity Survey. Am J Psychiatry 1999; Comorbidity of mental disorders with alco- 156:1230-1236. hol and other drug abuse. JAMA 1990; 264:2511-2518. 4. Substance-related disorders. In: Synopsis of psychiatry. Harold I Kaplan and Benjamin 9. Damian McCabe & Dr Chris Holmwood. J Sadock (Eds) 8th edition 1998.Maryland. What is comorbidity and why do general Williams and Wilkins: 375-455. practitioners need to know about it? -The Comorbidity Problem. Primary Mental 5. Kessler RC, McGonagle KA, Zhao S, Nelson Health Care Australian Resource Centre. CB, Hughes M, Eshleman S, Wittchen H- (PARC project-2001).

7 Comorbidity in Substance Use Disorder Suggested slides for OHP Slide 5: Most common comorbidity in substance use disorders Slide 1: Comorbidity and substance use disorders: 1. Antisocial Personality Disorder Concept: Co-occurrence or presence, either simulta- 2. Depression neously or in succession, of two or more specific disor- 3. Panic disorder and other anxiety disorders ders in an individual within a specified period. 4. Schizophrenia Terminologies: • MICA (Mentally Ill Chemical Abuser), MISA (Men- Slide 6: Significance tally Ill Substance Abuser), CAMI (Chemical abus- 1. Difficulties in diagnosis: - ing Mentally Ill) a. Substance intoxication can resemble psychiatric • Dual Diagnosis disorder b. Protracted substance withdrawal complicates Slide 2: Basis of classification: psychiatric presentation. 1) Drug of abuse like alcohol, opium, cannabis. c. Establishment of a cause-effect relationship 2) Purpose the drug serves such as stimulants, seda- 2. Difficulties in management tives. a. Problems in establishing therapeutic relationship 3) Type of psychiatric disorder like depression, psy- b. Poor compliance to medications chosis. c. Increased side-effects with medications 4) Etiological significance 3. Increased chances of organic brain damage due to Slide 3: Criteria for establishing cause-effect relationship: substance use disorder • Chronological order of appearance of symptoms Slide 7: Management: Salient features • Influence of remission on one of the disorders on 1) Adequate and appropriate management of with- severity of the other. drawal phase Classification (etiological significance) 2) Diagnosis of psychiatric disorder to be established • Primary substance use disorder with secondary psy- only after end of withdrawal phase. chiatric disorder • Primary psychiatric disorder with secondary sub- 3) Appropriate and rigorous management of psychi- stance use disorder atric disorder • Primary psychiatric disorder with substance use dis- 4) Anticraving drugs for substance use disorder can be order as part of the clinical syndrome used • Two coexisting independent disorders. 5) Disulfiram contraindicated in comorbid psychosis 6) SSRIs preferred as anticraving in comorbid depres- Slide 4: Etiological Models sion Common Factor Model 7) Long-acting depot preparations like Flupenthixol Secondary substance use disorder Model 8) Avoid long-term use of benzodiazepines Secondary psychiatric disorder Model : 9) Long term rehabilitation with regular follow-up Bidirectional Model 10) Caregiver psychoeducation. Prevalence ECA study: Comorbidity of mental illness in substance Slide 8: Role of GPs. use disorder Men – 76% • Early detection and accurate diagnosis Women - 65% • Provision of information on condition and treatment approaches

Psychiatric Illness Substance Abuse • Brief interventions for lower levels of disability • Referral and co-ordination of care for higher levels of disability • Medical treatment for physical health complications • Provision of support to the patient and their family • Long term monitoring and follow-up Comorbidity

8 Substance use disorder in Women 17

Pratima Murthy, Prabhat Chand

Summary socio-cultural factors and psychological comorbidity. Substance abuse in women is a growing concern in India. While traditional surveys have In many developing countries substance abuse been unable to provide insights into this hid- is no longer an exclusive or predominantly male den problem, recent studies of special popula- activity. However there is hardly any information and qualitative research suggests that al- tion on substance abuse among women from cohol, tobacco, opiates and sedatives are drugs developing countries. that are commonly abused by women from diverse backgrounds. Patterns of use across the Epidemiology country vary.However, some common themes Epidemiological surveys from the United States appear to be an early onset, use in the context show one-month prevalence rates of alcohol use of a heterosexual relationship, greater emotional disorders in men as being five times more com- problems and poor social support. Women are mon than in women. The prevalence of alco- more vulnerable to the adverse physical conse- hol dependence was twice in men as compared quences of substance use. The environment to women. The rates of tobacco dependence plays a significant role in development of sub- are almost the same in both groups (men: 31%, stance abuse in addition to genetic vulnerabil- women: 27%). Evidence from U.K, Australia ity. There are specific issues with regard to treat- and Switzerland point towards increasing sub- ment of substance use in women, which instance abuse in women. clude delay in recognition of the problem, associated stigma, lack of support systems for In India, traditional use of various substances treatment and follow-up and other social and by women during religious festivals is not un- psychological issues. known. Chewing tobacco is a common practice among many women across the country. Introduction Cultural use of alcohol has been known in some Substance abuse has traditionally been consid- tribal populations. National multi-centered ered a disease of men. Women were believed to studies in early 80’s reported negligible drug have some kind of immunity in terms of “so- use rates among women. The findings in the cial inoculation”. However it is now being seen 1990s also indicated that drug abuse was a that women are also susceptible to substance predominantly male phenomenon and that 92 use and related problems. Historically, the to 94 percent of women had never used drugs understanding of substance use is based on male in their lifetime. consumption patterns. Though earlier believed The low numbers of women substance users that these patterns are equally applicable to in traditional surveys is probably reflective of women, recent research has shown important the unsuitability of existing epidemiological gender differences in biology, epidemiology,

1 Substance use disorder in Women surveys in identifying substance use among Etiology women. However, recent data from treatment centers shows that 1 to 3 percent of treatment Genetic factors seekers are female. Therefore, more recent stud- Twin and adoption studies in males have sug- ies have shifted from traditional surveys to stud- gested the robust association of genetic factors ies of specific groups of women with respect to in the cause of alcoholism. In female alcohol their substance use. A study carried out in abusers there is evidence that inherited factors 2002 in three cities i.e. Delhi, Mumbai and are strongly influenced by the environment. One Aizwal examined substance abuse patterns in recent study from Australia involving 2000 women, characteristics of women users and female twin pairs have showed the risk of ge- gender issues in treatment. The predominant netic factors for drinking falling from 60 to 40 drugs of abuse were heroin, propoxyphene, al- percent following marriage or cohabitation. cohol and minor tranquilizers. Injecting drug Across all studies, one of the most important use was reported especially from Mumbai and factors influencing drinking in women was Aizawl. About half the women substance us- found to be alcohol use or abuse by spouse. Stud- ers were between twenty to thirty years and ies from India also suggest that a large number majority were employed. Engaging in unsafe of women alcohol dependents started drinking sexual practice was observed among many sub- to keep their spouses company. These evidences stance abusing women. imply the important role of environmental influences in association with genetic factors in In a rapid assessment study of 4648 substance development of alcohol abuse in females users in the community, it was possible to iden- Studies on genetic markers showed that com- tify 371 women substance users (7.9%), which pared to non-alcoholic women without first- may suggest that substance use among women degree relatives suffering from alcohol depen- is becoming more visible. The trends from this dence, those with first-degree relatives suffer- study appear to suggest that substance use oc- ing from alcohol dependence showed fewer er- curs more commonly in single, educated women. rors for the same Blood alcohol level. Currently, women appear to have an early onset of substance use, have high level of substance Psychological factors use in families and also have an early initiation The few studies examining psychological pre- into sexual activity. In comparison to male coun- dictors of alcohol use in women all emphasize terparts, there appear to be increasing numbers the strong association of co-morbid psychologi- of single, better-educated women initiating sub- cal factors in this group in comparison with stance use in urban areas. males. Low self esteem and impaired ability to Studies from western countries show that men cope at the high school level in girls was found smokers are twice that of women smokers. Al- to predispose to future problem drinking in an Australian study. Childhood sexual abuse though smoking among women is not com- increased the risk for both substance abuse and mon in our culture, chewing of tobacco is quite dependence in women. There is a significant high. Among 39,840 women in Mumbai, 58% association between substance use and major were chewing tobacco. In rural Karnataka, 7- depression in women, with studies suggesting 9% of 467 women reported chewing tobacco. an odds ratio for developing alcohol abuse or In a survey of 500 pregnant women, 33% re- dependence of 4.10 for depressed female com- ported tobacco use, mainly as tooth powder. pared to 2.67 for a male with major depres-

2 Substance use disorder in Women sion. Studies from India report association of alcohol in women than in men. Women be- depression (62.7%) and anxiety (53.3%) in come intoxicated after drinking smaller quan- the women using substances. tities of alcohol than do men. This may be due to less body water in comparison to size, which Sociocultural factors means they achieve higher blood concentrations Research in developed countries suggests that than do men after drinking an equivalent a number of social factors differentiate women amount of alcohol. Additionally, lower levels and men substance users. Women experience of alcohol dehydrogenase enzymes in the stom- more social disapproval of substance use. Simi- ach results in a higher amount of alcohol in larly women are more likely to have role mod- the systemic circulation. Women develop al- els in their families and have an alcohol-using cohol liver disease with comparatively shorter spouse. More female substance users are likely and less intense drinking than men. More to get separated or divorced. In males, the sub- women die from cirrhosis than men. Heavy stance abuse is more likely to affect jobs or ca- alcohol consumption may also be associated reer. Women are less likely to be involved in with increased risk of menstrual disturbances, criminal acts or social deviance and have higher infertility and breast cancer. internalizing problems than males. Other factors like poor education status, lack of job, Aetiology young age at work, early marriage and lack of • High family loading social support increase vulnerability to sub- • Greater psychiatric symptoms and dual stance use in female. diagnosis, especially depression Biological responses • Greater likelihood of living with an substance using partner Gender differences in the physiological effects • Greater marital disruption contribute to the increased harmful effects of

Interacting factors leading to substance use among women Adapted from Murthy P (2002): Women and drug abuse : the problem in India

Social Role Disadvantage Predisposition Transition and Social Modelling and lifestyle isolation changes

rrr

Stigma, lack of Physical and emotional support Drug Availability problems and ignorance about treatment rr r r Lack of knowledge of harm p Drug Use

3 Substance use disorder in Women Pregnancy and lactation pregnancies and sexually transmitted diseases. Drinking to intoxication also makes a woman Teratogenic effects of alcohol consumption are less able to defend herself, and more vulner- well known. Fetal alcohol syndrome (FAS) and able to sexual abuse and rape. fetal alcohol effects of alcohol have been identified as among the leading cause of mental Course of Illness retardation in the western world. FAS is diagnosed by presence of craniofacial anomalies, Initiation central nervous system dysfunction, and ma- The reasons for initiation of substance particu- jor organ system malformation. Children born larly alcohol among adolescent girls have been with less than the full constellations are termed studied predominantly in American situations. as FAE (Fetal alcohol effects), a continuum of Common reasons cited include adolescent de- fetal alcohol syndrome. The incidence of FAE pression and problems in adjustment, hang- is found to be 1.9 per 1000 live birth in west- ing out with older male friends, peer pressure, ern studies. In case of heavy alcohol drinking, feeling of a sense of glamour and power, and the incidence increased up to 25 per1000 live disappearing stereotypes about feminity. These births. Under reporting of the alcohol use in reasons are likely to be universal, and equally women poses difficulty in actual estimation of applicable in India. Adolescence is a time when harmful effects on the fetus. Prenatal alcohol there is a constant struggle between dependence exposure is related significantly to persistent and autonomy, and all adolescents are extremely problems with attention, distractibility and vulnerable to psychological pressures includ- slower reaction times. ing drinking as a way of creating an image or Use of other substances like cocaine and nico- dealing with the pressures. tine showed significant impairment of orien- Research suggests that while many of the rea- tation, motor and intrauterine growth retar- sons why adolescent’s drink are gender blind, dation. Term infants born to these mothers had some factors may affect girls more than boys. lower mean birth weights, lengths, and head circumferences. Apart from this, the risk of • Puberty tends to bring a higher incidence adolescent pregnancy and its complication goes of depression among teenage girls, which together with increased risk of substance use. can trigger alcohol use. One study found symptoms of depression in one in four girls Alcohol and Sex – a rate that is 50 percent higher than in Traditionally, alcohol is believed to increase boys. sexual power and enjoyment. Studies have • Adolescent girls who are heavy drinkers shown that it is not alcohol itself, but the be- (drink five or more drinks in a row on at lief that alcohol improves sex, which is respon- least 5 different days in the past month) sible for increased sexual enjoyment. However, are more likely than boys to say that they heavy drinking actually inhibits sexual enjoy- drink to escape problems or because of frus- ment. Women who drink heavily have been tration or anger. shown to be more likely to have early sexual • Friends have a big influence on teenagers experiences, to have a greater number of sexual overall, but girls are particularly susceptible partners, and to have unprotected sex. This to peer pressure when it comes to drink- exposes them to the problem of unwanted ing. Adolescent girls are more likely than

4 Substance use disorder in Women boys to drink to fit in with their friends, of drinking was in order to keep company with while boys drink largely for other reasons their husbands. and then join a group that also drinks. Course Girls often are introduced to alcohol by their boyfriends, who may be older and more likely The course of substance use disorders, particu- to drink. larly alcohol, seems to be different for women than for men. The interval between the age of It is shown from Indian studies that positive first drinking and treatment seeking seems to expectancies regarding benefits of alcohol use be shorter for women than for men. As men- were cited as the most common reason for tioned previously, studies suggest that women initially starting to drink. Also, the positive experience greater medical, physiological and expectancies cited by men and women differ psychological impairment earlier in their drink- significantly (Table 1). ing career. In addition, women seem to progress between landmarks associated with the devel- Table 1: Positive expectancies regarding effects opmental course of alcoholism (e.g. regular drink- of alcohol use ing or loss of control) sooner than men. This Females* Males** accelerated progression of alcoholism in women · Elevates mood ·Improves sleep is commonly referred to as “telescoping.” · Provides strength ·Improves sleep Assessment and treatment after childbirth ·Relieves tiredness, · Improves health fatigue and worry Once a female patient begins treatment, she and relieves tiredness ·Prevents colds, should be carefully evaluated for additional coughs and psychiatric and substance use disorders. The breathing problems, first step involves building rapport with the helps in asthma and patient. It is important to educate them about paralysis the substance and its ill effects. It works well ·Increases joy and when the physician can personalize the harm cements friendship suffered by the index patient. For example, for a ·Improves sexual patient having alcohol induce hepatitis, discuss- desire and ing about the physical effects of alcohol is more performance useful. Linking the medical problem with the substance and recommend reduction or absti- *Murthy et al (1995) **Chandrasekhar (1994) nence is the next most important step in the Women attributed mood elevating and management. Also emphasize patient’s respon- antidepressant properties to alcohol, and in the sibility in helping herself out of the problem. light of the prominent pre-existing depression Decisions about in-patient admission need to reported by many of them, might have started take into consideration not just clinical issues, alcohol as a form of self-medication. Men on but also social issues, especially the care of young the other hand used it to improve sleep or children that the patient may have. The need decrease tiredness. The second most common for separate services for women with substance attribution among women was that alcohol had use to address their special social and emotional major restorative properties after childbirth. needs is increasingly being recognized. The next most common reason for initiation

5 Substance use disorder in Women Then physician helps the patient in ways to the disorder preceded the addiction or had its maintain abstinence from substance like rec- onset during a prolonged period of abstinence ognizing risky situations, coping with negative and therefore may be regarded as primary. In emotions, handling friends etc. Even if you the latter condition, the patient should be pre- feel that the patient is not motivated or not pared to recognize early indication of recur- sure regarding the treatment, it is very impor- rence of the psychiatric disorder during her tant to keep her in therapeutic net. It helps recovery from addiction. the person to think and reconsider his views in next follow up. It is helpful to involve the fam- Pharmacotherapy ily members, particularly spouse in the treat- In the initial visits the symptomatic treatment ment plan and long term rehabilitation. Clinical of substance withdrawal symptoms is essential. experience suggests that social supports for Unless the withdrawal is complicated by con- women substance users are often lacking, and ditions like delirium tremens or seizures, most this increases their chances of dropping out of cases can be treated as outdoor basis. This is treatment. Enchancing support as part of especially important in social situations when after-care is very important to maintain recov- admission may not be feasible. ery among women. Conclusion Treatment approaches to substance dependence in women Under recognition of substance abuse and barriers to accessing services often prevent women ¾ Establishing confidentiality and rapport, from benefiting from treatment. First, identi- being non judgmental fication of women substance abusers by health ¾ Assessment of severity of the problem care professionals can be hindered because of ¾ Comorbid depression, anxiety, and inter stereotypic views of women and of substance personal problem need attention abusers. Second, women often have basic needs ¾ Educate ill effects of substance to her and such as food, economic constraints, housing, family and fetus if she is of reproductive and safety from battering or assault. Further- age more women, more often than men are pri- ¾ Feed back of the damage due to substance mary care givers for their children and that may ¾ Help in reduction or abstinence and in hinder from entering into treatment due to lack handling high risk situations of social support. ¾ Increase self esteem Summarising, women need some of the same ¾ Use pharmacotherapy also where treatment services as men, such as detoxification, indicated education, support, and treatment of comorbid In a woman who is dependent or having a physical and psychiatric disorders. Women, how- co-morbid psychiatric problem, it is advisable ever, require more attention for childcare, associ- to refer her to the specialist. ated psychiatric and medical disorders, building self-esteem, supportive therapy from therapist, When co-morbid psychiatric disorders are care from spouses, and other possible sources of discovered, it is helpful to determine whether support in the community.

6 Substance use disorder in Women

Suggested Reading 1. Blume SB. Alcohol and other drug prob- Alcohol. In Manual on Women’s Counsel- lems in women. In: Substance abuse :a com- ling. (eds) C.R.Chandrashekar . prehensive text book (eds.) J.H. Lowinson, NIMHANS, Bangalore, 2002:33-36. P. Ruiz & R.B. Willman. Maryland. Will- iams & Wilkins. 1992, 794-807. 7. Murthy NV, Benegal V, Murthy P. Alcohol Dependent Females: A clinical profile. Ab- 2. Blume SB. Addiction in women. In: Text book stracts of scientific papers presented at the of Substance use (eds.) M Galanter & HD 47th Annual National Conference of the Kleber Washington. American Psychiatry Indian Psychiatric Society. Indian Journal Press, 1999. of Psychiatry (Supplement); 1995, 37:2. 3. Brady KT & Randall CL. Gender differences 8. Murthy P. Women and drug abuse: the prob- in substance use disorders. Psychiatric lem in India. Ministry of Social Justice and Clinic of North America 1999,22:241-252. Empowerment, Government of India and 4. Closser MH & Blow FC. Special United Nations Office on Drugs and Crime, populations:women,ethnic minorities and Regional Office for South Asia, 2002. the elderly. Psychiatric Clinic of North 9. Murthy P. Alcohol consumption and its conse- America 1993,16:199-209. quences for women. In Young Ladies (ed) A. 5. Gupta PC. Survey of Socio demographic Khwaja. Banjara academy, Bangalore, 2003: 31- characterstics of tobacco use among 99598 36. individuals in Bombay, India using 10. Prasad S, Murthy P, Verma V,Mallika R handheld computers. Tobacco Control, Summer, 1996, 5(2): P 114-120. and Gopinath P S. Alcohol dependence in women: a preliminary profile. NIMHANS 6. Kewalramani M, Murthy P. Women and Journal 1998, 2:87-91.

7 Substance use disorder in Women Suggested slides for OHP

Slide1 quantities Develop alcohol liver disease earlier • Substance use traditionally a disease of men with shorter duration of alcohol use • Recent research show significant differences in biol- Increased risk of menstrual ogy, sociocultural factors and psychological morbid- disturbance, infertility and breast ca ity in women and men • Very few studies exist on substance abuse and women Slide 5: Pregnancy and Lactation Slide2: Epidemiology Alcohol: Teratogenic effect present Fetal alcohol syndrome: craniofacial US – Prevalence of alcohol use disorders in women anomaly, CNS malfunction, major organ 1/5 as compared to men malformation Alcohol dependence ½ compared to men Fetal alcohol effects: 1.9/ 1000 live birth Tobacco dependence: 27% in females (western studies) India – Traditional and cultural use permissible in Other substances: IUGR, impairment of orientation, certain sections of society motor abnormalities Treatment seekers: 1 – 3% of treatment seekers are females Slide 6: Course of illness Study in 3 cities in 2002: Initiation: Heroin, Propoxyphene, Alcohol, Common reasons – adolescent depression, adjustment and Minor Tranquilisers problems, hanging out with older male friends, peer Majority in 20s – 30s, employed pressure, glamour Rapid assessment survey: 7.9% female users Increased expectancies regarding effect of alcohol use Most common: Course: Single uneducated females Interval between age of initiation and treatment seeking Early onset of drug use shorter for females compared to males Family history positive Greater psychological and physiological impairment Early initiation into sexual life Faster telescoping Tobacco use: 3.7% of females in India smoke Slide 7: Assessment and Treatment Slide 3: Etiology • Establishing confidentiality and rapport, being non A) Genetic factors: Robust association with alcoholism judgmental Both state and trait markers seen • Assessment of severity of the problem B) Psychological: Strong association compared to males • Comorbid depression, anxiety, and inter personal Low self esteem, impaired ability to cope problem need attention Increased association of depression • Educate ill effects of substance to her and family (odds ratio of 4.10 for alcohol) and fetus if she is of reproductive age Indian studies: Depression – 62.7% • Feed back of the damage due to substance Anxiety – 53.3% • Help in reduction or abstinence and in handling Slide 4: Etiology contd… high risk situations • Increase self esteem C) Sociocultural: Role models present • Use pharmacotherapy also where indicated Increased likelihood to have a drug using spouse Increased social disapproval Decreased likelihood of legal problems D) Biological responses: gender differences present Females intoxicated with smaller

8 Adolescent Substance Abuse 18

Anju Dhawan, Yatan Pal Singh Balhara, Indra Mohan

Summary parts and the substance using adult population. Majority of drug users start drug use in adolescence with use of licit substances such as Adolescence: A Transition Phase tobacco and alcohol. Some of them subse- Adolescence is one of the least understood quently graduate to use of harder/illicit sub- phases of human development. It heralds bio- stances. Drug abuse among adolescents is a logical and psychological changes for the indi- cause of concern because use in this age group vidual. Considered to begin usually from the is associated with increased risk of accidents, 10th to 12th year of life, the period lasts till violence and high-risk sexual behaviour. The 18 years or up to 20 years as considered by profile of drugs used in adolescence may also some researchers. be different from the drugs used in adulthood. Co-morbid psychiatric disorders are also more Adolescence is associated with experimentation common in adolescents who have substance use in the realms of social relationships, diet, rest/ disorder. The intervention in substance using activity cycles, ideas, dating, and roles. Even adolescents requires involvement of parents as though for many teenagers drug use is just well as teachers. The family needs to be coun- another form of experimentation, society still seled about nature of treatment and the pro- has a legitimate concern. The reason is that the cess of recovery. residual number of children who do not spontaneously stop but go on to have drug-using Less intensive intervention may be required for lifestyles is significant and growing. those with structured lifestyle, absence of psychopathology, and those who have not yet be- Epidemiological Data-International come dependent on the substance. The incidence estimates based on data from Introduction the National Survey on Drug Use and Health (NSDUH), United States, show a period of Majority of substance users start use in adoles- increase for initiation of most drugs in 1990s cence with use of licit substances such as to- (marijuana, cocaine, hallucinogen, prescription bacco and alcohol. However, most adolescents medication, tobacco). Some of the drugs have who use substances give it up subsequently and shown stabilization in incidence estimates do not go on to develop abuse/dependence. thereafter (marijuana, prescription drugs) while Substance use during adolescence is associated others have shown a decrease in incidence with high-risk behaviour, increased risk of in- (LSD, ecstasy, tobacco), although incidence fections such as HIV, interpersonal problems, may still be very high. decline in academic performance and failure In 2001, an estimated 2.7 million Americans to complete education.. Co-morbid psychiat- used cigarettes for the first time. About three ric disorders are also more common in adoles- quarters (76 percent) of these initiates were cents who have substance use disorder as com- under age 18, and about half (51 percent) were pared to their non- substance using counter-

1 Adolescent Substance Abuse males. In 2001, an estimated 5.3 million took reanalysis of the data from National Sample alcohol for the first time. Most of these new Survey Organization (1995-1996) gave figures alcohol users were under the legal drinking age based on a sample that is representative for the of 21. There were an estimated 2.6 million new country. It reported current regular use of to- marijuana users and a million new cocaine us- bacco by 8% males and 2% females in the age ers in 2002. About two thirds (69 percent) of group of 10-20 years in the country. In the these new marijuana users were under age 18. same age group alcohol use was reported by The number of new inhalant users was about 1.3% females and 0.5% females respectively. 1 million in 2002. As in prior years, these new The prevalence was comparatively higher in users were predominately under age 18 (78 rural areas (Mohan et al, 2002). The National percent). New initiates of pain relieving medi- Household Survey (NHS) is the first survey in cation were 2.5 million. More than half (55 the country carried out specifically to provide percent) of the new users in 2002 were females, figures of prevalence for drug use in the coun- and more than half (56 percent) were aged 18 try using a representative sample. In this or less. sample, 21% of the respondents were 12 to 18 years old and 19% were students. It found Age of Initiation: Data indicates that three sub- that 21% of current users of alcohol, 3% of stances were initiated by more than 50% of current users of cannabis and 0.1% current users in sixth grade or earlier. These “gateway users of opiates were below 18 years of age and drugs” were alcohol, tobacco, and inhalants. 10% opiate users and 2.5% of current alcohol EPIDEMIOLOGICAL DATA-INDIA and cannabis users were students (UNODC, In India, adolescent drug use has been studied 2004). in the general population as well as special Drug Abuse Monitoring System (DAMS) pro- populations such as school and university stu- vided data from treatment seekers from 203 dents. Since most of the data is cross-sectional, centres providing services to drug users in In- it is not possible to discuss change in trends dia. It reported that 0.4% of treatment seekers over time. Studies on substance use among in de-addiction centres in various states were adolescents were first carried out in 1970s. A less than 15 years of age and 4.6% of the sub- multi- centred study on the prevalence and stance users were between 16-20 years of age. pattern of drug abuse among the university Among users of heroin, cannabis and students concluded that alcohol was the most propoxyphene, 0.5 to 0.8% were in the age commonly used drug in both the sexes in all group below 15 years. The proportion of opium the centres (10- 15%), which was followed by and alcohol users in this age group was com- tobacco (8- 15%) and tranquilizers (1- 2.5%). paratively low. The proportion of users of vari- The study did not report any opiate and stimu- ous drugs belonging to the age group 16-20 lant use (Mohan et al, 1976- 77). The survey years varied between 2.7 and 18.8 percent. The was repeated after ten years and found similar percentage of users of propoxyphene was the figures of licit substance use although 0.02 to highest. Adolescent treatment seekers were 0.04 % students reported heroin abuse, which more often users of propoxyphene, heroin and had not been present in 1976. Another study cannabis. There was a regional variation in the on drug abuse among senior high school stu- drug of use. Adolescent propoxyphene users dents in Delhi on a sample of 2032 students were mostly from Mizoram and Manipur; reported use of alcohol by 13%, tobacco by heroin users were more often reported from 6% and tranquilizers by 4%. There was no re- Punjab, Haryana, Bihar and Orissa and port of cannabis and opiate use (Mohan and Chandigarh had the highest proportion of Sundaram, 1977-78). More recent data from young cannabis users. Some data on drug use

2 Adolescent Substance Abuse was also reported from 11 NGOs catering to (5%) and methaqualone (5.0%). children and 30 Nehru Yuva Kendras (NYKs). Etiology Most of the children from NGOs reported being introduced to drugs at a young age (be- A number of behavioral characteristics and en- low 15 years) and injecting drug use was quite vironmental influences are associated with age common by them (13.8% in NGO-children of initiation of substance use, substance use and 20.1% in NYKs). Only 20% had tried to intensity and the related negative consequences give up drug use in the past. High-risk sexual during adolescence. These risk factors deter- behaviour was reported by 5% (NYKs) to19% mine the risk of substance use. It has been shown (NGO-children). The Rapid Assessment Sur- that as the number of risk factors increases, the vey (RAS) provided data on inaccessible drug likelihood of adolescent substance use greatly users in the community using a purposive increases. Early age of onset of drug use in- sample. About 13% of substance users from creases risk of drug related problems in future. this sample were below 20 years of age. Behavioral characteristics- Impulsivity, Aggres- A study of profile of 52 subjects seen in the sion, Sensation seeking, Low harm Avoidance, Drug Dependence Treatment Centre of AIIMS Inability to delay gratification, Low achievement in the year 1999-2003 (Malhotra, personal striving, Lack of religiosity, Psychopathology communication) and 21 subjects seen in 2004 Environmental factors include- peer pressure, and 2005 (Dhawan, personal communication) absence of normative peers, affiliation with found that all were male in the age range of deviant or delinquent peers, easy drug avail- 13-18 years with most initiating substance use ability, social norms facilitating drug use, and at or below 15 years of age. About half of them relaxed laws and regulatory policies. were currently neither studying nor working, while some were students. They were living Familial factors include- stressful life events, with the family and many of them were ac- deficient parental support or supervision, poor companied to the treatment centre by family discipline, ambiguous parental attitude to- members. Family history of alcohol abuse or wards substance use, parental and sibling sub- dependence was present in the fathers in one- stance use. third cases. History of conduct disorders was Co-morbidity present in about one-fourth and 10% reported antisocial behaviour secondary to drug use as Psychiatric comorbidity is commonly seen in well as 10% had history of some legal prob- the substance using adolescents and is more lems. Tobacco was the most commonly used than in the non-users. The largest subpopula- substance with a lifetime use in 76.0% of ado- tion of adolescents with Substance Use Disor- lescent treatment seekers. Lifetime use of Can- der (SUD) includes those who are dually diag- nabis and the inhalants were the second most nosed. A number of psychiatric disorders are common, (38% each) and 33.0% of the re- commonly associated with SUD in youth. The spondents had life time use of opioids. 29.0 most common are conduct (50 to 80%) and % reported use of alcohol and 5.0% had used mood disorders, including major depression benzodiazepines and methaqualone each. Out and bipolar disorder. The prevalence of depres- of the treatment seekers, 29.0% did not meet sive disorders ranges from 24% to 50%. Sui- the criteria for dependence but were in the cat- cidal behavior, especially while being under the egory of drug abuse. Most common primary influence of the substance is commonly re- substance of use was inhalants (33.0%), fol- ported in adolescents following substance use lowed by opioids (29%), tobacco (14%), can- or those diagnosed as SUD. Attention Deficit nabis (10.0%), alcohol (5%), benzodiazepines Hyperactivity Disorder (ADHD) is another

3 Adolescent Substance Abuse disruptive disorder that is observed in substance used in India are Achenbach’s behavioural abusing youth, however, this association is likely checklist, Youth self reporting form, childhood due to the high level of co morbidity between psychopathology measurement schedule and conduct disorder and ADHD. Anxiety disor- developmental psychopathology schedule. ders are another commonly diagnosed group Other severity oriented rating scales available of disorders in substance using adolescents with include Teen Addiction Severity Index (T- prevalence ranging from 7% to 40%. Social ASI), Adolescent Drug and Alcohol Diagnos- phobia usually precedes substance abuse while tic Assessment (ADAD) and Adolescent Prob- panic and generalized anxiety disorder more lem Severity Index (APSI). These scales help in often follow the onset of SUD. Adolescents quantifying the problem severity in adolescents. with SUD often have a history of Post Trau- matic Stress Disorder (PTSD) consequent to a b) Treatment history of physical or sexual abuse. Bulimia Compared to the adult literature, studies on nervosa and gambling behavior are also com- treatment effectiveness in adolescent drug us- monly found in adolescents having SUD. Sub- ers are limited although they do show clearly stance use disorders were seen in 26.6% of that some treatment is better than no treat- adolescents suffering from major depression. ment. However, there is considerable variabil- Cigarette smoking was seen in 16.6%, alcohol ity with respect to the effect of treatment. Pre- abuse in 6.6% and inhalant abuse in 3.3% of treatment characteristics of adolescents have not adolescents (Garg et al 2004 unpublished). consistently been found to be associated with Management outcome except psychopathology, which is associated with non-completion of treatment and a) Assessment relapse. The available literature suggests that Assessment of the adolescents with substance the relapse rate is in the range of 35 to 85 per- use problems would include a detailed and cent among various treatment studies. Out- comprehensive work up including the identi- come predictors are time spent in treatment, fication of substance use, psychiatric status, staff characteristics, program environment, and physical health status, school adjustment, vo- treatment services. cational status, family function, peer relation- Treatment setting (e.g., inpatient, residential ship, leisure and recreation activity, and legal treatment, and outpatient) is less important situation. Assessment should include interviews for outcome than the modality of treatment. with both the adolescent and the parents, first Family therapy and cognitive-behavioral separately and then together. therapy have demonstrated enhanced clinical There now exists several interview protocols for utility in the treatment of adolescents with adolescents (or children) that address DSM- SUD. The Multi-systemic Therapy (MST) III criteria for mental disorders, including those model is a highly successful approach in which for substance use disorder diagnoses. Some of interventions simultaneously target family func- the important interview schedules include the tioning and communication, school and peer Diagnostic Interview Schedule for Children and functioning and adjustment in the community. Adolescents (Reich et al. 1982), the Kiddies Behavioral treatment, manual guided therapy Schedule for Affective Disorders and Schizo- (including drug refusal skills, problem-solving, phrenia (Chambers et al., in press), the Na- and social skills), group treatment, role-play- tional Institute of Mental Health Diagnostic ing are the available modalities of intervention. Interview Schedule for Children (Costello et Brief therapy and contingency measures pro- al. 1984), and the Child Assessment Schedule vide the treating team effective and time bound (Hodges et al. 1982). The other instruments interventions.

4 Adolescent Substance Abuse It has been observed that the best predictors of intervention based on the principle of this ap- specific post treatment outcomes are pretreat- proach and deals with individualized but well ment measures of functioning (e.g. pretreat- defined treatment goals specifically in the realm ment alcohol problems predicted heavier con- of family dynamics. sumption after treatment). Continued time in It seems very likely that parents will prove to treatment, completion of treatment, and favor- be the most effective agents for changing the able behavior during treatment are other posi- behavior of their preadolescent or adolescent tive prognostic indicators of outcome. Low in- children. Obtaining parent cooperation in any tensity of drug and solvent abuse has been kind of intervention, and ensuring their com- found to be positive prognostic factors. pliance needs to be addressed in order to en- Pharmacotherapeutic agents like disulfiram, sure the effectiveness of the intervention naltrexone, sedatives, clonidine are being used programme. as an adjunct in the multidisciplinary approach The effects of treatment are not uniform. Sub- for this specific group of substance users, al- stantial variability is observed with respect to though these interventions are still in their early outcome status post-treatment. stages. One should also be cautious while using these agents in adolescents since the phar- Management of Co morbidity macokinetic and pharmacodynamic profile of The co morbid psychiatric conditions should medications differs in certain aspects from the be adequately managed. This would include a adult population. Adolescents are rapid detailed assessment and a comprehensive man- metabolizers. Naltrexone has been shown to agement plan keeping in mind the possibility alter some endocrinal activity in adolescents. of drug interactions between the various com- However, the issues related to medium and pounds and the increased potential of certain long term use remains unaddressed. The grow- group of the drugs being abused by this popu- ing use of medications will provide more in- lation subgroup. There are several issues spe- formation regarding the efficacy and safety of cific to teenagers that need attention in prescrib- these agents in adolescent population. ing psychotropic drugs. One of these is the ad- Family based approaches ditive effects of marijuana and tricyclic antide- pressants on heart rate. There is a question of Some believe that adolescent problems can best neuroleptic impairment of cognition due to se- be understood by studying the characteristics dation. There are reports that chlorpromazine of the family system. To reduce adolescent administered for over 6 months reduces plasma problems, family systems therapists attempt to testosterone and luteinizing hormone response change some of the above family characteris- to luteinizing releasing hormone in adolescents. tics through: These issues need to be kept in mind while (a) gaining access and influence in the system, formulating a plan for the adolescents using (b) interrupting the reciprocal relationships substances. between the dysfunctional family characteris- Prevention tics and the adolescent problems, Efforts for preventive services concentrate on (c) establishing new family characteristics to activities designed for supply/demand reduc- interact with new adolescent behaviors and (d) tion. The goal of primary prevention among home detoxification, probation, and the com- children and adolescents is to defer or mini- munity network approach. mize the risk of initiation of gateway-substances Brief strategic family therapy is a structured such as cigarettes, alcohol, and marijuana (can-

5 Adolescent Substance Abuse nabis). The strategy used is to increase knowl- proper direction should be included as apart of edge of the consequences of drug use. Psychoso- the broader strategy. cially based approach aiming at enhancing so- Future Research cial skills and specific drug refusal skills is an important adjunct. The first step in this regard Gaps in our knowledge persist despite the emer- includes the identification of the potential ben- gence of more and more information on the eficiaries and the intervention groups. They may number of unanswered questions. The future include the general population or specific group research must concentrate on these issues for based interventions like children of substance better understanding of the problem. The va- users. The programme developed for a particu- lidity of adult criteria for adolescents needs to lar group must address the needs of the group be studied. In India, studies on prevalence of and should have active participation of the local drug use in school children are required. Data community to add to the acceptability and effi- to document trends or change in prevalence is cacy. These approaches should involve individu- also required. Studies to validate the instruments als from various spheres of the society and may in local languages are needed. Manuals on in- include the parents, teachers, community lead- terventions need to be developed for used in ers and policy makers. Interventions aimed at drug abuse treatment settings. Further research imparting life skills training, counseling and is needed to evaluate the efficacy of various in- providing newer opportunities to the adolescents terventions in adolescent populations. so that their energy can be channelised in a

Suggested Reading

1. Drug Abuse: Analyses of Treatment Research NIDA ing program for parents of substance-abusing adolescents. Research Monograph 77 (1988). Eds: Elizabeth R. Journal of Substance Abuse Treatment, 20(1), 59. Rahdert & John Grabowski. 6. Bastiaens, L., Francis, G., & Lewis, K. (1999). The 2. Adolescent Drug Abuse: Clinical Assessment and RAFFT as a screening tool for adolescent substance use Therapeutic Interventions NIDA Research Monograph disorders. American Journal on Addictions, 9(1), 10-16. 156 (1995). Eds: Elizabeth Rahdert & Dorynne 7. Martino, S., Grilo, C.M., & Fehon, D.C. (2000). Czechowicz. The development of the drug abuse screening test for 3. Brook, D. W., Brook, J. S., Zhang, C., Cohen, P., & adolescents (DAST-A). Addictive Behaviors, 25,57-70. Whiteman, M. (2002). Drug Use and the Risk of Ma- 8. Estroff, T.W. (2001). Manual of adolescent substance jor Depressive Disorder, Alcohol Dependence, and Sub- abuse treatment. Washington, D.C.: American Psychi- stance Use Disorders. Archives of General Psychiatry, 59, 1039-1044. atric Press. 4. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., 9. Winters, K. (1999). Treatment of adolescents with sub- Rowland, M. D. & Cunningham, P. B. (1998). stance abuse. Rockville, MD: U.S. Department of Health Multisystemic Treatment of Antisocial Behavior in Chil- and Human Services. dren and Adolescents. New York: Guilford Publications. 10. Garg, R., Mehta, M., Sagar, R. (2004 unpublished). 5. McGillicuddy, N.B., Rychtarik, R.G., Duquette, J.A., Clinical study of psychosocial factors and comorbidity & Morsheimer, E.T. (2001). Development of a skill train- in Major Depressive Disorder in adolescents

6 Adolescent Substance Abuse Suggested slides for OHP

Slide 1. ADOLESCENCE: A TRASITION Slide 5. CO MORBIDITY PHASE Conduct disorder Relatively less understood phases of human develop- Mood disorders ment Major depression Presence of both biological and psychological changes Bipolar disorder Tendency to experiment in various realms of life Dysthymia in adulthood Emotional and physical stressors of transition Anxiety disorders New responsibilities and new opportunities Social phobia Panic disorder Slide 2. EPIDEMIOLOGICAL DATA Generalized anxiety disorder Role of gateway drugs Post Traumatic Stress Disorder (PTSD) Age of initiation in a substantial proportion of substance Bulimia nervosa users Gambling behavior Community based surveys- 3- 10% lifetime prevalence Slide 6. ASSESSMENT National Household Survey (NHS)-20% users less than 18 years old Identification of substance use Psychiatric status Slide 3. AETIOLOGY Physical health status School adjustment Behavioral characteristics- Impulsivity, Aggression, Sen- Vocational status sation seeking, Low harm Avoidance, Inability to delay Family function gratification, Low achievement striving, Lack of religios- Peer relationship ity, Psychopathology Leisure and recreation activity Environmental factors include- peer pressure, absence Legal situation depending on the need of normative peers, affiliation with deviant or delinquent peers, perception of high drug availability, social norms Slide 7. TREATMENT facilitating drug use, and relaxed laws and regulatory policies. Familial factors include- stressful life events, Treatment setting deficient parental support or supervision, poor disci- Inpatient pline practices, ambiguous parental attitude towards Residential treatment substance use, parental and sibling substance use. Outpatient Modality of treatment Slide 4. NOSOSLOGICAL STATUS Family therapy ICD- 10 classificatory system Cognitive-behavioral therapy Harmful use The Multi-systemic Therapy (MST) Dependent use Behavioral therapy DSM IV classificatory system Manual guided therapy Group treatment Abuse Brief therapy Dependent use Contingency measures Criteria for adult population being used for adolescents

7 Legal Aspects of Drug Abuse in India 19

S Lalwani, TD Dogra

CURRENT LEGISLATIVE CONTROL Technical Advisory Board on any matter tending to secure uniformity throughout Drug abuse is a major public health problem in the administration of this act. with extensive legal ramifications. In India, legal aspects of drug abuse involves two main The quality and purity of drugs are the main areas, objectives of the act. Standard of quality of drug is to be maintained. This act prohibits import, (a) Licensing laws regulating production and manufacture and sale of certain drugs which is retail supply, not of standard quality, misbranded and spu- (b) Legislation for offences committed under rious drugs, propriety medicines lacking list of intoxication circumstances ingredients including quantity or formula on label and drugs which claims to cure or miti- THE DRUGS AND COSMETICS ACT, gate any such disease or ailments. This act also 1940– empowers Central Government to prohibit This enactment was legislated to regulate the import of drugs which are likely to involve any import, manufacture, distribution and sale of risk to human beings or animals and drugs drugs and cosmetics. The act contains two which are of no therapeutic value in public in- schedules. The first deals with Ayurvedic and terest. This act provides stringent punishment Siddha systems of drugs and second schedule for contravention of provisions of act and rules deals with standards to be complied with im- made thereof. ported drugs and drugs manufactured for sale, THE NARCOTIC DRUGS AND PSYCHO- sold and stocked and exhibited for sale or dis- TROPIC SUBSTANCES (NDPS) ACT, tributed. 1985- The act improvised the constitution of This act consolidates and amends the existing 1. Drugs Technical Advisory Board, to advise the laws related to narcotic drugs. Stringent provi- Central and State Government on techni- sions are made for the control and regulation cal matters arising out of administration of of operations relating to narcotic drugs and this act, psychotropic substances and for matters con- nected therewith. The act empowers Central 2. Central Drugs Laboratory and its functions government to take measures for preventing and along with prescribing the procedure of combating abuse of and illicit traffic of nar- submission of samples of drugs for analysis cotic drugs etc. Salient features of this act are or test, forms of laboratory report and fees as under payable in respect of such reports and 1. Some of the important definitions under 3. Drugs Consultative Committee to advise the this act includes Central and State Government and Drug

1 Legal Aspects of Drug Abuse in India 1. “Addict” as a person who has dependence (e) Phenanthrene alkaloids- Morphine, on any narcotic drugs or psychotropic codeine, thebaine and their salts substance. 2. Central Government may, constitute a fund 2. “Narcotic drug” as coca leaf, cannabis to be called the National Fund for Control (hemp), opium, poppy straw and in- of Drug Abuse which shall be applied to cludes all manufactured goods and meet the expenditure incurred in connec- 3. “Psychotropic substance” as any sub- tion with the measures taken for- stance, natural or synthetic, or any natu- 3. a) Combating illicit traffic in narcotic ral material or any salt or preparation of drugs, psychotropic substances or con- such substance or material included in trolled substances, b) controlling the abuse the list of psychotropic substances of narcotic drugs and psychotropic sub- (n=110). stances, c) identifying, treating and reha- 4. “Cannabis (hemp)” means- bilitating addicts d) preventing drug abuse, (a) charas, that is the separated resin, in e) educating public against drug abuse and whatever form, whether crude or puri- f) supplying drugs to addicts where such fied, obtained from the cannabis plant supply is medical necessity. and also includes concentrated prepara- 4. This act prohibits cultivation of any coca tion and resin known as Hashish oil or plant, opium plant or any cannabis plant liquid Hashish or gather any portion of coca plant or pro- (b) ganja, that is the flowering or fruit- duce, manufacture, possess, sell, purchase, ing top of the cannabis plant transport, warehouse, use, consume, import 5. ‘Coca derivatives’ means- inter-State, export inter State, import into (a) Crude cocaine (Any extract of cocaine India, export from India or transship any leaf) narcotic drug or psychotropic substance (b) Ecgonine and all the derivatives of except for medical or scientific purposes and ecgonine from which it can be recovered. in manner and to the extent provided by (c) All preparations containing more that the provisions of this act 0.1% of cocaine 5. The act empowers Central Government to 6. ‘Opium’ means permit and regulate by rules i) The culti- (a) the coagulated juice of opium poppy; vation, or gathering of any portion of coca and plant, or the production, possession, sale, (b) any mixture, with or without any purchase, transport, import inter-State, ex- neutral material, of the coagulated juice port inter-State, use or consumption of coca of the opium poppy. leaves; ii) the cultivation of opium poppy; It does not include any preparation con- iii) the production and manufacture of taining more than 0.2% of morphine. opium and production of poppy straw; iv) 7. ‘Opium derivatives’ means- the sale of opium and opium derivatives (a) Medicinal opium from the Central Government Factories for (b) Prepared opium used for smoking export from India or sale to State Govern- ment or manufacturing chemists v) the (c) Diacetylmorphine or heroin manufacture of manufactured drugs, not (d) any preparation containing more including manufacture of medicinal opium than 0.2% of morphine or any other preparation containing manu-

2 Legal Aspects of Drug Abuse in India factured drug from materials which the prepared opium, cannabis plant & can- maker is lawfully entitled to possess; vi) the nabis, manufactured drugs & preparations, manufacture, possession, transport, import psychotropic substances, and for illegal inter-State, export inter-State, sale pur- import into India, export from India or chase, consumption or use of psychotropic transhipment of narcotic drugs and psy- substances and vii) the import into India chotropic substances, is rigorous imprison- and export from India and transhipment ment for a term up to six months or with of narcotic drugs and psychotropic sub- fine up to 10,000 rupees or both. For con- stances. travention involving quantity lesser than commercial quantity but greater than small 6. The State Government may by rules per- quantity, punishment is rigorous impris- mit and regulate i) the possession, sale, onment for a term up to ten years and with warehousing, purchase, transport, import fine up to 1,00,000 rupees. For contraven- inter-State, export inter-State, use and con- tion involving commercial quantity pun- sumption of poppy straw; ii) the posses- ishment is rigorous imprisonment for a sion, transport, import inter-State, export term up to ten years, which may extend inter-State, purchase and consumption of up to 20 years and fine up to 1,00,000 opium iii) the cultivation of canabis plant, rupees, which can be extended up to production , manufacture, possession, 2,00,000 rupees. Court has to record rea- transport, import inter-State, export inter- sons in the judgement, for imposing a fine State, sale, purchase and consumption of exceeding 2,00,000 rupees. Punishment for cannabis(Except Charas); iv) The manufac- cultivation of any cannabis plant is rigor- ture of medicinal opium or any prepara- ous imprisonment up to ten years and also tion containing the manufactured drug fine up to 1,00,000 rupees. from materials which the maker is lawfully entitled to process; (v) the production and 8. Punishment for contravention in relation manufacture of opium and production of to coca plant and coca leaves is rigorous poppy straw; iv) the sale of opium and imprisonment for a term up to ten years or opium derivatives from the Central Gov- fine up to 1.00,000 rupees . ernment Factories for export from India or 9. Punishment for contravention in relation sale to State Government or manufactur- to opium poppy and poppy involving small ing chemists v) the possession, transport, quantity, is rigorous imprisonment for a import inter-State, export inter-State, pur- term up to six months or with fine up to chase, use or consumption of manufactured 10,000 rupees or both. For contravention drugs other than prepared opium and of involving commercial quantity punishment coca leaf and any preparation containing is rigorous imprisonment for a term up to any manufactured drugs. vi) the manufac- ten years, which may extend up to 20 years ture and possession, of prepared opium from and fine up to 1,00,000 rupees, which can opium lawfully possessed by an addict reg- be extended up to 2,00,000 rupees. Court istered with the State Government on has to record reasons in the judgement, for medical advice for his personal consump- imposing a fine exceeding 2,00,000 rupees. tion. In any other case, the punishment is rigorous imprisonment up to ten years and 7. Punishment for contravention involving fine up to 1,00,000 rupees small quantity in relation to poppy straw,

3 Legal Aspects of Drug Abuse in India 10. Punishment for consumption of any nar- exceeding to those specified in the clause cotic drug or psychotropic substance like b) financing directly or indirectly or any of cocaine, morphine, diacetyl-morphine or the activities specified in clause (a), shall any other narcotic drug or any psychotro- be punishable with death, (2) where any pic substance specified by Central Govern- person convicted by a competent court of ment by Gazette Notification is rigorous criminal jurisdiction outside India under imprisonment for a term up to one year or any law corresponding to the provisions of fine up to 20,000 rupees or both. Punish- subsection 1, such person in respect of such ment for consumption of any narcotic drug conviction shall be dealt with for the pur- or psychotropic substance other than men- pose of sub section 1 as if he has been con- tioned is rigorous imprisonment for a term victed by a court in India. up to six months or fine up to 10,000 ru- 12. Under section 64 A, any addict, who is pees or both. For second and each subse- charged with an offence punishable under quent offence, punishment is rigorous im- section 27 or with offences involving small prisonment for a term, which may extend quantity of narcotic drugs or psychotropic to one half of the maximum term of im- substances, who voluntarily seeks to un- prisonment and also fine up to one half of dergo medical treatment for de-addiction the maximum amount of fine. If person is from a hospital or an institution maintained liable to punished with a minimum term or recognized by the Government or a lo- of imprisonment and minimum amount of cal authority and undergoes such treatment fine, the minimum punishment for such a shall not be liable to prosecution under person will be one half of the minimum section 27 or any other section for offences term of imprisonment and one half of the involving small quantity of narcotic drugs minimum amount of fine. and psychotropic substances. This immu- 11. Under section 31 A, Chapter IV of this act, nity may be withdrawn if the addict does (1) If any person who has been convicted not undergo the complete treatment for de- for offences punishable under section 19( addiction. punishment for embezzlement of opium 13. Section 71 of this act, empowers govern- cultivator), section 24 (Punishment for ex- ment to establish centers for identification, ternal dealings(outside India) of narcotic treatment, education, after care, rehabili- drugs and psychotropic substances), sec- tation, social reintegration of addicts and tion 27 A(Punishment for financing illicit for supply, of any narcotic drugs and psy- traffic and harbouring offenders) and for chotropic substance (as prescribed by con- offences involving commercial quantity of cerned Government) to the addicts regis- any narcotic drugs or psychotropic sub- tered with government and to others where stance, is subsequently convicted of the such supply is a medical necessity. commission of, or attempt to commit, or abetment of, or criminal conspiracy to com- 14. Small quantity of drugs defined under this mit an offence relating to a) engaged in the act are production, manufacture, possession, trans- Hashish or Charas- 5gm portation, import to India, export from Opium-5gm India or transhipment, of the narcotic drugs Cocaine-125mg or psychotropic substances and quantity Ganja-500gm Heroin/Smack/Brown Sugar-250mg.

4 Legal Aspects of Drug Abuse in India THE DRUGS (CONTROL) ACT, 1950 - same knowledge as he would have had if he had not been intoxicated, unless the thing This act provide for the control of the sale, sup- which intoxicated him was administered to him ply and distribution of drugs. This act regu- without his knowledge or against his will. lates maximum prices and maximum quantities which may be held or sold and also involve However, if the intoxication is induced volun- restrictions on sale of drugs. The act provides tarily, the act done is an offence even if the limitation on quantity which may be possessed person is incapable of knowing the nature of at any one time. Issue of cash memorandum the act or that what he is doing is either wrong on certain sales marking of prices and exhibit- or contrary to law. ing list of prices and stocks is mandatory un- LAWS RELATED TO ALCOHOL der this act. Whoever contravenes any of the provisions of this Act or fails to comply with Alcohol is one of the commonly consumed in- any direction made under authority conferred toxicating substances all over the world. Legal by this Act shall be punishable with imprison- aspects of alcohol involves three main areas, (a) ment for a term which may extend to three Licensing laws regulating retail supply, (b) leg- years, or with fine, or with both. islation on drunkenness defining intoxication as an offence under certain circumstances and LAWS PERTAINING TO CRIMINAL OF- (c) road traffic legislation makes driving an of- FENCES & DRUG ABUSE fence when blood alcohol level exceeds a cer- The nature of association between drug use and tain value. crime is complex. Besides commonest offences LICENSING LAWS such as possession and trafficking and ‘drug related crime’ or ‘street crime’ an offence may ‘World Health Organization’ recommends that be committed during an abnormal mental state member governments should begin to reduce related to drug use. However, most drugs of per capita consumption by reducing the avail- abuse do not cause violent criminal behavior, ability of alcoholic beverages. Prohibition is and personality, circumstances and cultural incorporated in the Constitution of India background remain critical determinants. among the directive principles of state policy. Article 47 says: “The state shall regard the rais- As per section 85 of Indian Penal Code, “Noth- ing of the level of nutrition and standard of ing is an offence which is done by a person living of its people as among its primary duties who, at the time of doing it, is, by reason of and in particular, the state shall endeavor to intoxication, incapable of knowing the nature bring about prohibition of the use except for of the act, or that he is doing what is either medicinal purposes of intoxicating drinks and wrong, or contrary to law; provided that the of drugs which are injurious to health.” Alco- thing which intoxicated him was administered hol policy is under the legislative power of in- to him without his knowledge or against his dividual states. Prohibition, enshrined as an will. aspiration in the Constitution, was introduced Under Section 86 of Indian Penal Code, In cases and then withdrawn in Haryana and Andhra where act done is not an offence unless done Pradesh in the midi-1990s, although it con- with a particular knowledge or intent, a per- tinues in Gujarat, with partial restrictions in son who does the act in a state of intoxication other states – Delhi, for example, has dry days. shall be liable to be dealt with as if he had the There was an earlier failure of prohibition in Tamil Nadu.

5 Legal Aspects of Drug Abuse in India Excise department regulate and control the sale Section 85 provides that any person found of liquor in the NCT of Delhi. Retail supply drunk and incapable of controlling himself or of alcohol is regulated by Delhi Liquor License behaves in a disorderly manner under the in- Rules, 1976. It prohibits consumption and fluence of drink in any street or thoroughfare service of liquor at public places. This also pro- or public place or in any place to which public hibits employment to any person (male under have or permitted to have access, shall on con- the age of 25 years or any female) at any li- viction, be punished with imprisonment for a censed premises either with or without remu- term which may extend to one to three months neration in part of such premises in which li- and with fine which may extend to two hun- quor or intoxicating drug is consumed by the dred to five hundred rupees. public. Similarly no individual should possess liquor at one time more than the prescribed Drunken Driving limit without special permit. As per excise rules Across the world, governments have defined in Rajasthan, a person can posses maximum different acceptable blood alcohol levels. How- 3liters of Country Liquor, 6 Liter of IMFL and ever, there is no minimum threshold below 12 Bottles of Beer. which alcohol can be consumed without risk. The Bombay Prohibition Act, 1949, prohib- With rise in blood alcohol concentration, there its the production, manufacture, possession, is progressive loss of driving ability due to in- exportation, importation, transportation, pur- creased reaction time, over confidence, im- chase, sale, consumption and use of all intoxi- paired concentration, degraded muscle coor- cants. dination and decreased visual and auditory acuity. Though the laws to check the drunken driv- The Cable Television Network (Regulation) ing do exist in India but there is need to effec- Amendment Bill, in force September 8, 2000, tively impose the same on the alcohol impaired completely prohibits cigarette and alcohol ad- drivers. vertisements. The government controlled chan- nel, Doordarshan, does not broadcast such As per section 185 (Chapter XIII) of the Mo- advertisements but satellite channels however tor Vehicle Act(India) 1988, as amended in are replete with them. November 1994, driving by a drunken person or by a person under the influence of drugs.- Drunkenness Whoever, while driving, or attempting to drive, a motor vehicle,- Drunkenness is defined as the condition produced in a person who has taken alcohol in a (a) has, in his blood, alcohol exceeding 30 mg quantity sufficient to cause him to lose control per 100 ml of blood detected in a test by a of his faculties to such an extent that he is un- breath analyser, or able to execute the occupation on which he is engaged at the material time. (b) is under the influence of a drug to such an extent as to be incapable of exercising proper Section 84 of the Bombay Prohibition Act control over the vehicle, 1949 provides that any person, who is found drunk or drinking in a common drinking house shall be punishable for the first offence with or is found there present for the purpose of imprisonment for a term which may extend to drinking, shall on conviction, be punished with six months, or with fine which may extend to fine which may extend to five hundred rupees. two thousand rupees, or with both; and for a

6 Legal Aspects of Drug Abuse in India second or subsequent offence, if committed trade and commerce, production, supply and within three years of the commission of the distribution) act, 2003 came into existence on previous similar offence, with imprisonment for 18th May 2003, which extends to whole of a term which may extend to two years, or with India. As per this act fine which may extend to three thousand rupees, or with both. 1. Smoking in public places is prohibited. “Public places means any place in which LAWS PERTAINING TO TOBACCO AND the public have access and includes SMOKING auditoria, hospital buildings, railway wait- ing room, amusement centers, restaurants, 1. The cigarettes and other Tobacco products public offices court buildings, educational (Prohibition of advertisement and regulation institutions, libraries, public conveyance of trade and commerce, production, supply and the like which are visited by general and distribution) act, 2003- It has been uni- public but does not include any open versally regarded that tobacco is one of the apace.” major public health hazards. The previously existing legislation, The Cigarettes Act, 1975, 2. No person engaged in the production, sup- merely stipulates the statutory warning on ciga- ply or distribution of cigarettes or any other rette packets. The 39th World Health assem- tobacco products is allowed to advertise and bly in its fourteenth plenary meeting on 15th no person is allowed to take part in any May 1986 urged the member states to imple- advertisement which directly or indirectly ment the measures to ensure that effective pro- suggests or promotes the use or consump- tection is provided to non smokers from invol- tion of cigarettes or any other tobacco prod- untary exposure to tobacco smoke and to pro- ucts. tection of children and young people from be- 3. No person shall sell, offer for sale, or per- ing addicted to use of tobacco. Similarly in 43rd mit sale of, cigarette or any other tobacco World Health assembly in its fourteenth Ple- product-(a) to any person who is under nary meeting on 17th May 1990 urged mem- eighteen years of age and (b) in an area ber states to consider their tobacco control strat- within radius of 100 yards of any educa- egies plans for legislation and other effective tional institution. measures for protecting their citizens with special attention to risk groups such as pregnant 4. No person is allowed, directly or indirectly women and children from involuntary expo- to produce, supply or distribute cigarettes sure to tobacco smoke, discourage the use of or any other tobacco products unless every tobacco and impose progressive restrictions and package of cigarettes or any other tobacco take concerted action to eventually eliminate products bears thereon, or on its label, the all direct and indirect advertising, promotion specified warning including a pictorial de- and sponsorship concerning tobacco. piction of skull and cross bones and the prescribed warning. To prohibit the consumption of cigarettes and 5. For the purpose of testing nicotine and tar other tobacco products which are injurious to contents in cigarettes and any other tobacco health and in view of article 47 of the consti- products the Central Government shall by tution of India for protection of public health, notification in the official gazette grant rec- The cigarettes and other Tobacco products (Pro- ognition to such testing laboratory as the hibition of advertisement and regulation of Government may deem necessary.

7 Legal Aspects of Drug Abuse in India 6. Any person who produces or manufactures at the entrance of the public place and one cigarettes or tobacco products, which do at conspicuous place(s) inside, containing not contain, either on the package or on the warning “No Smoking area-Smoking their label, the specified warning and the here is an offence”. nicotine and tar contents, shall in the case 2. The owner or the manager or in charge of of first conviction be punishable with im- the affairs of a hotel having thirty rooms or prisonment up to two years, or with fine restaurant having seating capacity of thirty up to five thousand rupees, or with both, persons or more and the manager of the air second and subsequent conviction is pun- port shall ensure that (i) the smoking and ishable with imprisonment up to five years nonsmoking areas are physically and with fine up to ten thousand rupees. segregated;(ii) the smoking area shall be 7. Punishment for smoking in public place is located in such manner that the public is fine up to two hundred rupees and it is a not required to pass through it in order to compoundable offence. reach the nonsmoking area and (iii) each area shall contain boards indicating “Smok- 8. Whoever violates the Section of prohibition ing Area/Non-Smoking Area”. of advertisement of cigarettes and other tobacco products, shall be punished (1) in 3. The size of board used for advertisements the case of first conviction, with imprison- for cigarettes and any other tobacco prod- ment up to two years, or with fine up to ucts displayed at the entrance or inside a one thousand rupees, or with both, and (2) warehouse or a shop where cigarettes and in the case of second and subsequent con- any other such tobacco products are offered viction, with imprisonment up to five years for distribution or sale shall not exceed 90 and with fine up to five thousand rupees. cm x 60cm and number of such board shall not exceed two. Each board shall contain 9. Punishment for sale of cigarettes or any in the Indian language as applicable, one other tobacco products in certain places or of the following warnings occupying 255 to persons below the age of eighteen years of the top area of the board namely (I) To- is fine up to two hundred rupees. All of- bacco causes cancer or (ii) Tobacco Kills,. fences under this section are compound- Board shall contain the brand name or pic- able and are to be tried summarily. ture of tobacco product and no other pro- This act empowers central Government to make motional message and picture. rules to carry out provisions of this act called 4. The owner or the manager or the in-charge “The cigarettes and other Tobacco products of the affairs of a place where cigarettes and (Prohibition of advertisement and regulation other tobacco products are sold shall dis- of trade and commerce, production, supply play a board of minimum size of 60cmx and distribution) Rules, 2004. According to 30cm at conspicuous place(s) containing these rules the warning “Sale of tobacco products to a 1. The owner or the manager or in charge of person under the age of eighteen years is a the affairs of a public place shall cause to punishable offence”, in Indian language(s) be displayed prominently a board, of a as applicable. The onus of the proof that minimum size of 60cmx30cm in the In- the buyer is not a minor lies with the seller dian languages(s) as applicable, at least one of the tobacco products.

8 Legal Aspects of Drug Abuse in India 2. The Delhi Prohibition of smoking and of educational institutions-Within 100 non-smokers health protection act 1996- meters)) of cigarettes and beedis etc. prohibits smoking in places of public work or use and in service vehicles in National Punishment for smoking in place of public capital territory of Delhi. “Place of public work or use and in public service vehicles is work or use” means a place such as auditoria, punishable with fine up to 100 rupees and in hospital buildings, health institutions, subsequent offence, with fine up to 200 ru- amusement centers, restaurants, public of- pees, but may extend up to 500 rupees. Pun- fices, court buildings, educational institu- ishment for advertising, selling cigarettes etc tions, libraries and the like which are vis- to minors and distributing it in the vicinity of ited by general public but does not include educational institutions is fine up to 500 ru- any open place and Banquet halls, monu- pees and with subsequent offences imprison- ments and stadia (Closed area only), cinema ment up to three months, or fine minimum halls, hotels and restaurants (Provided there up to 500 rupees but may extend up to 1000 is separate place for smokers and nonsmok- rupees or both. ers in hotels and restaurants). “Public Ser- 3. The Cable Television Networks (Amend- vice vehicle” means any motor vehicle used ment) Act, 2000- prohibits direct and indi- or adapted to be used for the carriage of pas- rect tobacco advertising on Cable Channels. sengers for hire or reward, and includes the maxicab, a motor cab, contract carriage and 4. As per the bill passed by Parliament of In- stage carriage (Under Section 2 of Section dia, from 2ndOctober 2005, exhibition of 35 of Motor Vehicles Act, 1988). This acts smoking in cinemas has been prohibited by also prohibits advertisement, sale to minors the Government. and storage and distribution (in the vicinity

Suggested Reading

1. Gunn J, Taylor PJ, eds. Forensic Psychiatry- Clini- act, 2003 Universal Law Publishing Company Pvt. cal, Legal and Ethical issues. Butterworth- Ltd., Delhi, 2005. Heinemann, Oxford 1999, 435-480. 5. The Delhi Prohibition of smoking and non-smok- 2. Drugs and Cosmetcis Act with Rules. Universal Law ers health protection act 1996- Universal Law Pub- Publishing Company Pvt. Ltd., Delhi, 2005 lishing Company Pvt. Ltd., Delhi, 2005. 3. The Narcotic Drugs and Psychotropic Substances 6. Subramanyam BV, ed. Modi’s Medical Act, 1985, Universal Law Publishing Company Jurisprundence and Toxicology. Butterworths In- Pvt. Ltd., Delhi, 2005 dia, New Delhi, 317-319, 1999. 4. The cigarettes and other Tobacco products (Prohi- 7. Reddy KSN. The essentials of Forensic Medicine bition of advertisement and regulation of trade and & Toxicology, 19th ed. 2000, K.Saguna Devi Pub- commerce, production, supply and distribution) lication, Hyderabad.

9 Appendix 1: Suggested Performa for Clinical Assessment in Substance Use Disorder

A. Sociodemographic profile 4. Occupational: frequent absenteeism at work, constant change of job, memos is- Name, age, sex, marital status, qualification, sued, periods of unemployment occupation, type of family and place of resi- dence. 5. Familial – social: frequent fight with spouse/ other family members, neglect of responsi- B.Details of drug use bility at home, social outcast 1. Age of initiation 6. Legal: involvement in illegal activities to sustain drug use, arrests/ charges on ac- 2. Various drugs abused count of drug use, caught driving under 3. Frequency of drugs used intoxicated state, drinking brawl. 4. The quantity of drug taken usually (usual D. High risk behaviors: presence of injection dose) use/ unsafe sexual practices 5. The time lag since the dose last used (last 1) injection risk: sharing of needles/ sharing dose) syringes/ water used for rinsing; reuse of 6. Whether need to increase the quantity of needles, syringes, unhealthy practice of in- drug consumed in order to produce the jecting same effect (tolerance) 2) sexual risk: contact with commercial sex 7. The effect of the use of a particular drug workers, unprotected sexual intercourse and signs and symptoms of intoxication E. Past abstinence attempts: 8. Presence/ absence of physiological/psychological symptoms and signs when the par- 1. number of attempts made ticular drug is not taken/ less than the usual 2. duration of each attempt amount of drug is being taken (withdrawls) 3. reason for abstinence 9. Compelling need/ urge to take the substance 4. whether treatment sought 5. nature of treatment sought: pharmacologi- C. Complications associated with drug use cal, psychological or combined 1. Physical: long term health hazards associ- 6. reason for relapse ated with drug use F.Reason for seeking treatment and motivation 2. Psychological: chronic mental effects of con- level of individual: whether seeking treatment tinuous use of drug by self or brought forcibly by family member; 3. Financial: losses suffered/debts incurred G. Presence of comorbid psychiatric illness such K. Mental status examination as affective disorder, psychotic disorder and General appearance and behavior of the patient personality disorder/ traits. (dressing, grooming, mannerism, motor activ- H. Presence of family history of SUD, psychi- ity, and eye contact); Affect (mood) (does he atric illness, current living arrangements appear happy, sad, anxious? Is it sustained throughout the interview?); Speech (rate, vol- I. Premorbid personality: especially presence/ ume, pitch, coherence, relevance); The content absence of ASPD of the patient’s thought (delusions, obsessions, depressive thought, suicidal ideas); Perceptual J. Physical examination disturbances (illusions, hallucinations) and Vital signs – Pulse, Blood pressure, Respi- Cognitive functions of the patient. ratory rate Systemic examination – Cardiovascular, Res- piratory, Abdominal and Nervous system Appendix 2 Fagerstrom’s Test for Nicotine Dependence

1. How soon after you wake up do you smoke 5. Do you smoke more frequently during the your first cigarette? first hours after awakening than during the rest of the day? After 60 minutes (0) 31-60 minutes (1) No (0) 6-30 minutes (2) Yes (1) Within 5 minutes (3) 6. Do you smoke even if you are so ill that you 2. Do you find it difficult to refrain from are in bed most of the day? smoking in places where it is forbidden? No (0) No (0) Yes (1) Yes (1) 3. Which cigarette would you hate most to give up? The first in the morning (1) Any other (0) Interpretation of the scores – 4. How many cigarettes per day do you smoke? • 0-2 –Very low dependence 10 or less (0) • 3-4 – Low dependence 11-20 (1) 21-30 (2) • 5 – Medium dependence 31 or more (3) • 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- Interpretation of CAGE questions tions: Answering Yes to 2 questions – Strong Indica- 1. Have you ever felt that you should cut down tion for alcohol dependence on your drinking? Answering Yes to 3 questions – Confirms alco- 2. Have people annoyed you by criticizing hol dependence 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)?

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- 4. How often during the last year have you fully. Begin the AUDIT by saying “Now I am found that you were not able to stop drink- going to ask you some questions about your ing once you had started? use of alcoholic beverages during this past year.” (0) Never Explain what is meant by “alcoholic beverages” (1) Less than monthly by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. (2) Monthly Place the correct answer number in the box at (3) Weekly the right. (4) Daily or almost daily 1. How often do you have a drink containing 5. How often during the last year have you alcohol? failed to do what was normally expected from you because of drinking? (0) Never [Skip to Qs 9-10] (1) Monthly or less (0) Never (2) 2 to 4 times a month (1) Less than monthly (2) Monthly (3) 2 to 3 times a week (3) Weekly (4) 4 or more times a week (4) Daily or almost daily 2. How many drinks containing alcohol do you have on a typical day when you are 6. How often during the last year have you drinking? needed a first drink in the morning to get yourself going after a heavy drinking ses- (0) 1 or 2 sion? (1) 3 or 4 (0) Never (2) 5 or 6 (1) Less than monthly (3) 7, 8, or 9 (2) Monthly (4) 10 or more (3) Weekly 3. How often do you have six or more drinks (4) Daily or almost daily on one occasion? 7. How often during the last year have you (0) Never had a feeling of guilt or remorse after (1) Less than monthly drinking? (2) Monthly (0) Never (3) Weekly (1) Less than monthly (4) Daily or almost daily (2) Monthly (3) Weekly 10. Has a relative or friend or a doctor or an- (4) Daily or almost daily other health worker been concerned about your drinking or suggested you cut down? 8. How often during the last year have you been unable to remember what happened (0) No the night before because you had been (2) Yes, but not in the last year drinking? (4) Yes, during the last year (0) Never Skip to Questions 9 and 10 if Total Score for (1) Less than monthly Questions 2 and 3 = 0 (2) Monthly (3) Weekly Interpretation of AUDIT scores: (4) Daily or almost daily Total scores of 8 or more are recommended as 9. Have you or someone else been injured as a indicators of hazardous and harmful alcohol use, result of your drinking? as well as possible alcohol dependence. AU- DIT scores in the range of 8-15 represent a (0) No medium level of alcohol problems whereas (2) Yes, but not in the last year scores of 16 and above represented a high level (4) Yes, during the last year 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 9. Has any family member or close friend gone questions: to anyone for help about your drinking? 1. Do you feel you are a normal drinker? (“nor- YES or NO mal” - drink as much or less than most other 10. Have you ever lost friends because of your people) drinking? YES or NO YES or NO 2. Have you ever awakened the morning after 11. Have you ever gotten into trouble at work some drinking the night before and found because of drinking? that you could not remember a part of the evening? YES or NO YES or NO 12. Have you ever lost a job because of drinking? 3. Does any near relative or close friend ever worry or complain about your drinking? YES or NO YES or NO 13. Have you ever neglected your obligations, your family, or your work for two or more 4. Can you stop drinking without difficulty days in a row because you were drinking? after one or two drinks? YES or NO YES or NO 14. Do you drink before noon fairly often? 5. Do you ever feel guilty about your drinking? YES or NO YES or NO 15. Have you ever been told you have liver trouble such as cirrhosis? 6. Have you ever attended a meeting of Alcoholics Anonymous (AA)? YES or NO YES or NO 16. After heavy drinking have you ever had delirium tremens (D.T.’s), severe shaking, 7. Have you ever gotten into physical fights visual or auditory (hearing) hallucinations? when drinking? YES or NO YES or NO 17. Have you ever gone to anyone for help about 8. Has drinking ever created problems your drinking? between you and a near relative or close friend? YES or NO YES or NO 18. Have you ever been hospitalized because Scoring of drinking? Please score one point if you answered the fol- YES or NO lowing: 19. Has your drinking ever resulted in your 1. No being hospitalized in a psychiatric ward? YES or NO 2. Yes 20. Have you ever gone to any doctor, social 3. Yes worker, clergyman or mental health clinic 4. No for help with any emotional problem in which drinking was part of the problem? 5. Yes YES or NO 6. Yes 21. Have you been arrested more than once for 7 through 22: Yes driving under the influence of alcohol? YES or NO Interpretation of the scores: 22. Have you ever been arrested, even for a few 0 - 2 No apparent problem hours because of other behavior while drinking? 3 - 5 Early or middle problem drinker (If Yes, how many times ______) 6 or more Problem drinker YES or NO

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 7. Do you ever feel bad or guilty about your about your involvement and abuse of drugs. drug use? Drug abuse refers to Yes No (1) the use of prescribed or “over the counter” 8. Does your spouse (or parents) ever com- drugs in excess of the directions plain about your involvement with drugs? Yes No (2) any non-medical use of drugs 9. Has drug abuse created problems between The questions DO NOT include alcoholic you and your spouse or your parents? beverages. The DAST does not include alco- Yes No hol use. 10. Have you lost friends because of your use The questions refer to the past 12 months. of drugs? Carefully read each statement and decide Yes No whether your answer is yes or no. Please give 11. Have you neglected your family because of the best answer or the answer that is right most your use of drugs? of the time. Click on the box for Yes or No. Yes No 1. Have you used drugs other than those re- 12. Have you been in trouble at work because quired for medical reasons? of your use of drugs? Yes No Yes No 2. Have you abused prescription drugs? 13. Have you lost a job because of drug abuse? Yes No Yes No 3. Do you abuse more than one drug at a 14. Have you gotten into fights when under time? the influence of drugs? Yes No Yes No 4. Can you get through the week without us- 15. Have you engaged in illegal activities in ing drugs? order to obtain drugs? Yes No Yes No 5. Are you always able to stop using drugs 16. Have you been arrested for possession of when you want to? illegal drugs? Yes No Yes No 6. Have you had “blackouts” or “flashbacks” 17. Have you ever experienced withdrawal as a result of drug use? symptoms (felt sick) when you stopped Yes No taking drugs? Yes No Interpretation of Scores 18. Have you had medical problems as a result 0 none reported of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 1 - 5 low level Yes No 6-10 moderate level 19. Have you gone to anyone for help for a drug problem? 11-15 substantial level Yes No 16-20 severe level 20. Have you been involved in a treatment program especially related to drug use? Yes No

Skinner HA. The Drug Abuse Screening Test. Addictive Behaviours, 1982;7:363-71. 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 Chandigarh Administration 1. All India Institute of Medical Sciences, 22. Govt. Medical College, Chandigarh New Delhi Delhi 2. Dr.R.M.L.Hospital, New Delhi 23. Central Jail, Tihar, New Delhi 3. Lady Hardinge Medical College & 24. Institute of Human Behaviour & Al- Hospital, New Delhi lied Sciences, Delhi 4. P.G.I.M.E.R., Chandigarh Gujarat 5. J.I.P.M.E.R., Pondicherry 6. NIMHANS, Bangalore 25. Medical College, Baroda 26. Medical College, Ahmedabad Centres of Excellence (Funded by UNDCP) Goa 7. K.E.M. Hospital, Bombay 27. Asilo Hospital, Mapusa (Goa) 8. I.P.G.M.E.R., Calcutta Haryana Andhra Pradesh 28. Medical College Rohtak 9. Osmania General Hospital (Shifted to Institute of mental health, 29. District Hospital, Ambala Hyderabad), Hyderabad Himachal Pradesh 10. SVRRGG Hospital, Tirupati 30. Indira Gandhi Medical College, Shimla 11. Govt. General Hospital, Warangal 31. District Hospital, Mandi Assam 32. District Hospital, Dharamshala 12. Guwahati Medical College, Guwahati Jammu & Kashmir 13. Assam Medical College, Dibrugarh 33. Medical College, Jammu 14. Silchar Medical College, Silchar 34. Medical College, Srinagar 15. District Hospital, Johrat 35. District Hospital, Baramulla 16. Civil Hospital, Dhubri 36. District Hospital, Kathua 17. Civil Hospital, Diphu Karnataka 18. Civil Hospital, Tejpur 37. Govt. Medical College, Bangalore 19. Civil Hospital, Karimganj Kerala 20. Civil Hospital, Nalbari 38. Govt. Medical College, Trivandrum 21. Civil Hospital, Nagaon 39. General Hospital, Erankulam 40. Medical Collge, Kottayam 67. District Hospital, Saiha 41. Medical Collge, Kozhikode 68. District Hospital, Champhai 42. Medical College, Trissur 69. District Hospital, Serchhip 43. Academy of medical Sciences, 70. District Hospital, Lawngtlai Pariyaram, Kannur, Kerala Nagaland Madhya Pradesh 71. Naga Hospital, Kohima 44. District Hospital, Mandsaur 72. District Hospital, Mukokchung 45. District Hospital, Ratlam 73. District Hospital, Tuensang 46. District Hospital, Ujjain 74. Civil Hospital, Dimapur 47. District Hospital, Indore 75. Civil Hospital, Wokha 48. District Hospital, Gwalior 76. Civil Hospital, Mon 49. District Hospital, Jabalpur 77. District Hospital, Zunheboto Chattisgarh 78. District Hospital, Phek 50. District Hospital, Raipur Orissa Maharashtra 79. S.C.B.Medical College, Cuttack 51. Mahatma Gandhi Institute of Medical Pondicherry Sciences, Sevagram, Wardhi 80. General Hospital, Karaikal 52. District Hospital, Nasik 81. Govt. General Hospital, Pondicherry Manipur Punjab 53. Regional Institute of Medical Sciences, Imphal 82. Medical College, Patiala 54. District Hospital, Imphal 83. Medical College, Amritsar 55. District Hospital, Sajiva 84. District Hospital, Bhatinda 56. District Hospital, Chandel 85. Medical College, Faridkot 57. District Hospital, Churachandpur Rajasthan 58. District Hospital, Ukhrul 86. SMS Medical College, Jaipur 59. District Hospital, Moreh 87. Medical College, Udaipur 60. District Hospital, Thoubal 88. Medical College, Jodhpur 61. District Hospital, Bishnupur 89. Medical College, Kota 62. District Hospital, Senapati 90. Medical College, Ajmer 63. District Hospital, Tamenglong 91. Medical College, Bikaner Meghalaya Sikkim 64. District Hospital, shillong 92. STNM Hospital, Gangtok Mizoram 93. District Hospital, Namchi 65. District Hospital, Aizawal 94. District Hospital, Gyalshing 66. District Hospital, Lunglei (W.Sikkim) Tamil Nadu 109. Gorakhpur Medical College, Gorakhpur 95. Madras Medical College, Madras 110. King George Medical College, 96. Medical College, Madurai Lucknow 97. Govt. Headquarters Hospital, Nagercoil 111. Medical College, Meerut 98. Govt. Stanley medical College and Hos- pital, Chennai Uttranchal 99. Govt. Medical College and Hospital, 112. Base Hospital Sringar, Garhwal Coimbatore West Bengal 100. Govt. Medical College and Hospital, Tirunelveli 113. North Bengal Medical College, Siliguri 101. Govt Mohan Kumaramangalalm Medi- 114. Burdwan Medical College, Burdwan cal College and Hospital, Salem 115. Bankura Medical College, Bankura 102. Govt. Medical College and Hospital, Arunachal Pradesh Thanjavur 116. District Hospital, Tezu 103. Govt. Medical College and Hospital, 117. District Hospital Changlang Tuticorin 118. District Hospital, Khonsa 104. Govt. Kilpauk Medical College and Hospital, Chennai Bihar 105. Govt. Chengaipattu Medical College 119. Jawaharlal Nehru Medical College, and Hospital, Chengaipattu Bhagalpur, 106. Govt. KAP Viswanathan Medical Col- 120. Shri Krishna Medical College, lege Hospiatl, Tirichirapalli Muzaffarpur Tripura 121. Anurag Narayan Medical College, Gaya 107. Kumarghar Rural Hospital, Darchai 122. Sadar Hospital, Munger Uttar Pradesh 108. Institute of medical Sciences, Banaras Hindu University, Varanasi List of Contributors

Amardeep Kumar Hem Raj Pal Department of Psychiatry and National Drug Department of Psychiatry and National Drug Dependence Treatment Centre Dependence Treatment Centre All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi – 110029 New Delhi – 110029

Anju Dhawan Indra Mohan Department of Psychiatry and National Drug Department of Psychiatry and National Drug Dependence Treatment Centre Dependence Treatment Centre All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi – 110029 New Delhi – 110029

Arindam Mondal K Srinivasan Department of Psychiatry and National Drug Department of Psychiatry Dependence Treatment Centre St. John’s Medical College Hospital All India Institute of Medical Sciences Bangalore New Delhi – 110029 K S Chandramouli BN Gangadhar Department of Medicine Department of Psychiatry St. John’s Medical College Hospital National Institute of Mental Health and Neu- Bangalore rosciences Bangalore - 560 029. Kul Bhushan Department of Psychiatry Debasish Basu National Institute of Mental Health and Department of Psychiatry Neurosciences Postgraduate Institute of Medical Education Bangalore - 560 029. & Research Chandigarh Manoj Kumar Sharma National Drug Dependence Treatment Centre Deepak Yadav All India Institute of Medical Sciences National Drug Dependence Treatment Centre New Delhi – 110029 All India Institute of Medical Sciences New Delhi – 110029 Mohan Isaac Department of Psychiatry HK Sharma National Institute of Mental Health and National Drug Dependence Treatment Centre Neurosciences All India Institute of Medical Sciences Bangalore - 560 029 New Delhi – 110029 Parmanand Kulhara Dependence Treatment Centre Department of Psychiatry All India Institute of Medical Sciences Postgraduate Institute of Medical Education New Delhi – 110029 & Research Chandigarh Ravindra V Rao Department of Psychiatry and National Drug Prabhat K Chand Dependence Treatment Centre Department of Psychiatry All India Institute of Medical Sciences National Institute of Mental Health and New Delhi – 110029 Neurosciences Renuka Jena Bangalore - 560029 Department of Psychiatry and National Drug Dependence Treatment Centre Pratima Murthy All India Institute of Medical Sciences Department of Psychiatry New Delhi - 110029 National Institute of Mental Health and Neurosciences Bangalore - 560029 S Lalwani Department of Forensic Medicine Rajat Ray All India Institute of Medical Sciences Department of Psychiatry and National Drug New Delhi – 110029 Dependence Treatment Centre All India Institute of Medical Sciences Shubhangi Parker New Delhi - 110029 Department of Psychiatry K E M Hospital Rajesh Bhushan Mumbai Director, Deaddiction Services T D Dogra Ministry of Health and Family Welfare Department of Forensic Medicine New Delhi All India Institute of Medical Sciences New Delhi – 110029 Raka Jain Department of Psychiatry and National Drug Vivek Benegal Dependence Treatment Centre Department of Psychiatry All India Institute of Medical Sciences National Institute of Mental Health and New Delhi – 110029 Neurosciences Bangalore - 560 029. Rakesh Lal Department of Psychiatry and National Drug 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- individual within a specified period. tern of unhealthy, prolonged consumption of Consciousness: Our own awareness of ourselves drug, which interferes with social, occupa- and the world; the mental processes that we tional, or personal functioning of an individual. can perceive; our thoughts and feelings. (N.B: The word ‘abuse’ when used non-specifically may cover both abuse and dependence Craving: A powerful, intense, often uncontrol- phenomena. Thus, used loosely, a drug ‘abuser’ lable, desire for drugs. (earlier called ‘addict’) is a person who uses Cross-sectional study: These studies are per- drug(s) in a pathological fashion and may meet formed in a defined ‘target population’ with the technical definition of either ‘abuse’ or ‘de- clearly defined ‘cases’. The subjects need to be pendence’). assessed only once. These studies are especially Attributable risk: Proportion of new cases aris- useful for defining the health care needs of a ing in a population that are attributable to ex- given population. posure under study. Delirium: an etiologically non-specific syn- Case control study: It involves two populations- drome characterised by concurrent distur- cases and controls. In case control studies, the bances of consciousness and attention, percep- unit is the individual rather than the group. tion, thinking, memory, psychomotor The focus is on a disease or some other health behaviour, emotion and the sleep-wake cycle. problem that has already developed. Case con- Dementia: a syndrome due to the disease of trol studies are basically comparison studies. the brain, usually of a chronic or progressive Cohort study: It is a type of observational study nature, in which there is a disturbance of mul- which is usually undertaken to refute or sup- tiple higher cortical functions, including port the existence of an association between memory, thinking, concentration, orientation, suspected cause and disease. comprehension, calculation, learning capacity, language and judgement. However, the con- Cohort: It is defined as a group of people who sciousness is not clouded. share a common characteristic or experience within a defined time period ( e.g., age, occu- Denial Unconsciously refusing to admit that pation etc) someone is addicted. Community: Social structural aspect: As a “so- Dependence: A cluster of physiological, cial organism” comprises of rural helmets/ vil- behavioural and cognitive phenomena in which lages to urban neighborhood. The focus is on use of a substance or a class of substances takes people living in the community, the social net- on a much higher priority for a given individual works and institutions located in the commu- than other behaviours that once had greater nity. value. (N.B: Addiction is a much older term than both ‘abuse’ and ‘dependence’. It is now Comorbidity: Comorbidity is defined as the omitted from technical language because of its presence, either simultaneously or in succes- pejorative connotation. However, the term still sion, of two or more specific disorders in an is retained in popular usage. It denotes either describe patients with a psychiatric disorder abuse or dependence). having a comorbid substance use disorder. Descriptive study: Distribution of persons who Motivation: The internally generated state that abuse various kinds of substances according to stimulates us to act. various socio-demographic variables is assessed. Narcotics: morphine and related group of This can give information about regional varia- drugs. tion and change in trends over time. Opiates: Any of the psychoactive drugs that Detoxification. A process of withdrawing a originate from the opium poppy or that have a person from a specific psychoactive substance chemical structure like the drugs derived from in a safe and effective manner. opium. Drug: any chemical which, when administered, Opioid: Any chemical that has opiate-like ef- alters the functioning of one or more systems fects. of the organism. Prevalence: Proportion of a population that has Dual Diagnosis: Patients with a substance use a particular occurrence at a point or period in disorder with a comorbid psychiatric manifes- time. The former definition refers to as point tation. prevalence and letter as period prevalence. Hallucination: false sensory perception not as- Problem Drinking. An informal term describ- sociated with any real, external stimuli. ing a pattern of drinking associated with life Illusions: misperception or misinterpretation problems prior to establishing a definitive di- of real external sensory stimuli. agnosis of alcoholism. Also, an umbrella term for any harmful use of alcohol, including alco- Incidence: Occurrence of new cases in mem- holism. bers of a target population over time. Psychosis: inability to distinguish reality from Insight: ability of the patient to understand fantasy; impaired reality testing. the true cause and meaning of a situation. Psychotropic drug: chemical which induces Intoxication: a transient condition following change primarily in some aspect(s) of mental the administration of a psychoactive substance, functioning; for example, an anti-depressant is resulting in disturbances in level of conscious- meant to relieve mental depression. (N.B: when ness, cognition, perception, behaviour or af- we refer to ‘drugs’ in the manual we mean al- fect, or other psychophysiological functions and cohol, cannabis, heroin or morphine. Although responses. they are all psychotropic agents, they are rarely Judgement: ability to assess a situation correctly taken for a particular effect or illness. Rather, and to act appropriately within that situation they are consumed voluntarily to alter one’s Lapse: the initial (single) episode of drug use mood, thinking, perception or other mental following a period of abstinence, synonymous functions so as to induce pleasure in an artificial with “slip.” manner. In order to differentiate them from other, more generally defined, medicinal drugs, Mentally Ill Chemical Abuser (MICA)/ Men- these are now called ‘psychoactive substances’ tally Ill Substance Abuser (MISA)/ Chemical or simply ‘substances’). Abusing Mentally Ill (CAMI): Terms used to 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 compared 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 following the abrupt discontinuation of, or rapid decrease in dosage of a psychoactive substance.