:¿ÉeOE’G á«Ñ£dG OÉ©HC’G á«°ùØædGh á«YɪàL’Gh á«eÓ°SE’G ájDhôdGh

ِ  ِ ِ "... َوﻳُﺤ ﻞ ﻟَُﻬ ُﻢ اﻟﻄﻴﺒَﺎت َوﻳُ َﺤﺮُم َﻋﻠَْﻴِﻬ ُﻢ ا ﻟْ َﺨﺒَﺎﺋ َﺚ ... " ﺳﻮرة اﻷﻋﺮاف:157

“…He (Allah) allows them as lawful what is good (and pure) and prohibits them from what is bad (and impure)…”

The Glorious Qur’an: Al-A’raf:7:157

FIMA Year Book 2014 Federation of Islamic Medical Associations

اﻻﺗﺤﺎد اﻟﻌﺎﻟﻤﻲ ﻟﻠﺠﻤﻌﻴﺎت اﻟﻄﺒﻴﺔ اﻹﺳﻼﻣﻴﺔ

ADDICTION: MEDICAL, PSYCHOSOCIAL AND ISLAMIC PERSPECTIVES

اﻹدﻣﺎن:

اﻷﺑﻌﺎد اﻟﻄﺒﻴﺔ واﻻﺟﺘﻤﺎﻋﻴﺔ واﻟﻨﻔﺴﻴﺔ واﻟﺮؤﻳﺔ اﻹﺳﻼﻣﻴﺔ

Publisher: Jordan Society for Islamic Medical Sciences – Jordan Medical association, Amman-Jordan  ام ا ا -  اطء ارد With special permit from: Federation of Islamic Medical Associations (FIMA)

October, 2014

FIMA YEAR BOOK 2014

Editorial Board

Editor in Chief Hossam E. Fadel Clinical Professor, Obstetrics and Gynecology Maternal Fetal Medicine The Medical College of Georgia, Georgia Regents University Augusta, GA, USA

Aly A. Misha’l Senior Consultant in Endocrinology Chairman-Ethics Committee, and Ex-Chief of Medical Staff Islamic Hospital Amman- Jordan

Abul Fadl Mohsin Ebrahim Professor Emeritus School of Religion, Philosophy and Classics University of KwaZulu-Natal, Durban, South Africa

Musa bin Mohammad Nordin

Consultant Pediatrician – Neonatologist Professor- Cyberjaya University College Of Medical Sciences (CUCMS) Kuala Lumpur – Malaysia TABLE OF CONTENTS

1. Editorial IX Publisher: 2. FIMA: Federation of Islamic Medical Associations: in Brief XIII JORDAN SOCIETY FOR ISLAMIC MEDICAL SCIENCES, In collaboration with, and special 3. BIOLOGICAL MECHANISMS UNDERLYING ADDICTION permit from: FEDERATION OF ISLAMIC MEDICAL ASSOCIATIONS ( FIMA ). Ilhan Yargic ADDICTION: Medical, Psychosocial and Islamic Perspectives 4. USE DISORDERS: SCIENTIFIC HORIZONS AND ISLAMIC PERSPECTIVES ادن: اد ا وا وا واؤ ا Mohammad Ali Albar, and Aly Mishal All rights reserved, No part of this publication may be reproduced, stored in a retrieved system, 5. DEPENDENCE: THE WHOLE STORY or transmitted in any means, electronic, mechanical, photocopying, recording or otherwise Feras Hawari without the prior permission of the publisher. 6. OPIATE ADDICTION M. Basheer Ahmad First Edition: October, 2014 7. ISBN: 969-8695-10 Adnan Takriti 8. QAT ADDICTION IN YEMEN: SOCIO - ECONOMIC PERSPECTIVES ON HEALTH Husni Al-Goshae ا ارد ا BEHAVIORAL ADDICTION .9 ر ااع ى داة Mehmet Dinc ا اط ( ( 2014/10/4934 ) 10. ADDICTION AND SUBSTANCE ABUSE IN PREGNANCY Hassan M. Harirah, and Saher E. Donia 11. MOBILIZATION OF THE PUBLIC AGAINST ADDICTION: Jordan Society for Islamic Medical Sciences THE TURKISH GREEN CRESCENT SOCIETY AS A MODEL INSTITUTION FIMA Year Book 2014: ADDICTION: Medical, Psychosocial and Islamic M. Ihsan Karaman Perspectives / Jordan Society for Islamic Medical Sciences – Amman: JSIMS, 2014. 12. BEWARE OF SPIRITUAL BYPASSING: INTEGRATE PSYCHOTHERAPY ( 180 ) P IN THE ADDICTION RECOVERY PROCESS Deposit No.:2014/10/4934 Ketam Hamdan Descriptors: Addiction// Medical// Psychosocial 13. HARM REDUCTION STRATEGY IN THE TREATMENT OF ADDICTION IN THE CONTEXT OF ISLAMIC JURISPRUDENCE Imthiaz Hoosan and Prof. Yasien Mohamed  14. ISLAMIC PERSPECTIVES ON PROPHYLAXIS AND THERAPY أت داة ا ا ت ا وا او OF ADDICTION Mahmoud Abu Dannoun 15. ISLAMIC RELIGIOUS INPUT IN THE TREATMENT Opinions in the articles are those of their authors. The editorial board does not necessarily AND REHAB OF DRUG ADDICTION: EXPERIENCES FROM MALAYSIA endorse these opinions, nor do these opinions represent the official position of FIMA. Mahmood Nazar Mohamed, and Sabitha Marican 16. ISLAMIC PSYCHO-SPIRITUAL THERAPY (PST): PANACEA FOR THE DRUG ADDICT M. Hatta Shaharom Printed in Amman-Jordan, Al-Dustour Printing. EDITORIAL

TABLE OF CONTENTS

1. Editorial IX 2. FIMA: Federation of Islamic Medical Associations: in Brief XIII 3. BIOLOGICAL MECHANISMS UNDERLYING ADDICTION Ilhan Yargic 4. ALCOHOL USE DISORDERS: SCIENTIFIC HORIZONS AND ISLAMIC PERSPECTIVES Mohammad Ali Albar, and Aly Mishal 5. TOBACCO DEPENDENCE: THE WHOLE STORY Feras Hawari 6. OPIATE ADDICTION M. Basheer Ahmad 7. CANNABIS Adnan Takriti 8. QAT ADDICTION IN YEMEN: SOCIO - ECONOMIC PERSPECTIVES ON HEALTH Husni Al-Goshae 9. BEHAVIORAL ADDICTION Mehmet Dinc 10. ADDICTION AND SUBSTANCE ABUSE IN PREGNANCY Hassan M. Harirah, and Saher E. Donia 11. MOBILIZATION OF THE PUBLIC AGAINST ADDICTION: THE TURKISH GREEN CRESCENT SOCIETY AS A MODEL INSTITUTION M. Ihsan Karaman 12. BEWARE OF SPIRITUAL BYPASSING: INTEGRATE PSYCHOTHERAPY IN THE ADDICTION RECOVERY PROCESS Ketam Hamdan 13. HARM REDUCTION STRATEGY IN THE TREATMENT OF ADDICTION IN THE CONTEXT OF ISLAMIC JURISPRUDENCE Imthiaz Hoosan and Prof. Yasien Mohamed 14. ISLAMIC PERSPECTIVES ON PROPHYLAXIS AND THERAPY OF ADDICTION Mahmoud Abu Dannoun 15. ISLAMIC RELIGIOUS INPUT IN THE TREATMENT AND REHAB OF DRUG ADDICTION: EXPERIENCES FROM MALAYSIA Mahmood Nazar Mohamed, and Sabitha Marican 16. ISLAMIC PSYCHO-SPIRITUAL THERAPY (PST): PANACEA FOR THE DRUG ADDICT M. Hatta Shaharom

FIMA YEAR BOOK 2014 VII

EDITORIAL

EDITORIAL

Dear FIMA members Assalamu Alaykum Bismillah al-Rahman al-Rahim

shower His blessings and (ﷻ) Praise be to Allah the Most Merciful, the Most Beneficent. May Allah .(ﷺ) peace on the Prophet and Messenger Muhammad

I begin by thanking the FIMA Executive Committee for honoring me with the responsibility of being for giving me this opportunity (ﷻ) the Editor-in-Chief again for this year's yearbook. I thank Allah to accept my effort in His way and to (ﷻ) and enabling me to accomplish this task. I pray to Allah reward all who participated in this effort. This year’s yearbook is addressing the worldwide serious problem of addiction. Addiction is a chronic relapsing disease characterized by craving for a drug, compulsive drug use, inability to control intake, and a resultant state of withdrawal with specific features when the drug cannot be accessed. Another type of addiction has been recently described, i.e. behavioral addiction. It is the same condition except that the putative agent is not a drug but a certain behavior.

In the first chapter, Dr Yargic discusses biologic mechanisms underlying addiction. He argues that addiction is a brain disease that starts with drug use that triggers a series of biological cascades. The drugs affect four interrelated biologic systems; brain , autonomic nervous system, prefrontal cortex (PFC), and the brain stress system. Drugs stimulate the mesolimbic dopaminergic system much more than natural stimuli and produce a reward or high. Repetitive stimulation causes that causes craving for the drug. Other neurotransmitters are also involved e.g. serotonin. Dr Yargic describes the brain stress system as an alarm circuit that is triggered by unpleasant stimuli. It is mediated by corticotrophin releasing factor resulting in release of glucocorticoids, norepinephrine and dynorphin. This system aims to neutralize the reward effects of drug use and to decrease dopamine release and restore normal function. This causes tolerance to the drug and dysphonic syndrome when the use stops because the changes in the stress system continue after avoiding the drug. Long term use of drugs leads to adaptation within the autonomic nervous system and target organs. This adaptation is disturbed when the drug is avoided and results in the physical manifestations of withdrawal. The prefrontal cortex is involved in both the limbic reward system and the regulation of the higher order executive functions. In addition PFC dysfunction is related to both compulsive drug use and the dysfunctional behaviors of the addict.

Alcohol is the most widely abused drug worldwide. (Alcohol Use Disorder) is more common than dependence on all other psychoactive drugs combined. This is primarily because of its easy availability in most world communities. Although "social drinking” is acceptable in most nations, no level of alcohol consumption is considered safe. Drs Al-Bar and Mishal describe the of alcohol consumption. They report that the total cost of alcohol consumption and dependence to national USA economy was 185 billion USD in 1998. This excludes the intangible losses that are difficult to quantify, including; domestic violence, child abuse and loss of careers. The authors discuss in detail the medical harmful effects of alcohol. Globally, alcohol is reported to

FIMA YEAR BOOK 2014 IX EDITORIAL

be responsible for 3.2% of all deaths and 4% of disease burden. Excessive alcohol consumption and are the third leading cause of preventable death in USA. The cardiovascular effects have been the subject of several studies. Some observational studies conferred some “beneficial “effects of social drinking primarily cardioprotective effects (decrease in the risk of coronary heart disease). These studies were not replicated in randomized studies and were not endorsed by professional organizations such as the Royal College of Physicians (UK) or by the American Heart Association's Science advisory Council in its 2001 report. Any such possible benefit is outweighed by its harmful effects on almost all organ systems as detailed in the article. Alcohol is a contributing factor in accidents, especially car accidents and in injuries resulting from the use of dangerous equipment. Up to 45% of injured patients reported consuming alcohol before their injuries and more than a third reported that their injury occurred within 30 minutes of their last drink. , homicide, serious assaults and rape are significantly increased in association with alcohol consumption. The authors point out that the main difficulty in the control of alcohol use disorder is that policies are not directed towards limiting the availability of alcohol. They compare this with efforts to curtail the availability of other dependence inducing drugs. They cite the failure of the amendment passed in USA 1919-33 and of similar attempts in Russia. The attempt to only partially limit alcohol consumption, by penalizing driving under the influence of alcohol and the prohibition of sale or service of alcoholic drinks to youngsters has not been successful either. They compare these failed efforts to the successful Islamic approach. Islam aimed at and succeeded almost completely in eliminating alcohol consumption by a gradual approach of its prohibition, simultaneous nurturing of moral values, and inculcation of faith that led people to obey God’s orders.

Dr Hawari discusses tobacco dependence. Smoking is probably as widespread as alcohol intake. is highly addictive. acts on the nucleus accumbens causing release of dopamine similar to other recreational drugs. As other addictive drugs nicotine addiction is characterized by the persistence of drug seeking behavior, and the occurrence of withdrawal symptoms upon abrupt cessation. According to the Diagnostic and Statistical Manual of mental disorders it is ranked third after and and higher than alcohol and cannabis in its ability to cause dependence. It has been documented that smoking is responsible for increased morbidity and mortality due to various diseases directly attributed to smoking and the effects of second hand smoking mostly affecting women and children. It is estimated that more than 5 million persons die annually due to tobacco related diseases. Smoking is associated with increased incidence of cardiovascular diseases, peripheral vascular disease, cerebrovascular diseases, and of sudden death. Smoking also increases the risk of head and neck cancers, lung, urinary bladder, colon, liver, and breast cancers. This increased risk is caused by the presence of at least 69 chemicals in tobacco smoke that are carcinogenic. Smoking causes and affects many respiratory diseases, notably chronic obstructive pulmonary disease (COPD) . Dr Hawari then discusses tobacco dependence treatments. Quitting smoking results in significant and rather quick beneficial effects on health. It reduces premature death by 90% for those who quit before the age of 30 and by 50% for those who quit before the age of 50. The World Health Organization (WHO) has recommended strategies to encourage smoking cessation. These include inclusion of smoking cessation advice in primary healthcare settings, establishing accessible and free quit-lines and ensuring the availability of low cost pharmacotherapy. These include nicotine replacement therapy as well as medications that help suppress the urge to smoke such as Buprion, and varenicline. WHO also developed “The Treaty Framework Convention on Tobacco Control” that

X FIMA YEAR BOOK 2014 EDITORIAL

advocates various strategies to counteract marketing of and smoking culture by the tobacco industry.

Dr Basheer Ahmed discusses opiate addiction. Globally between 24 and 25 million adults aged between 15 and 64 years used an illicit opiate in 2010, 12 million of whom were in the USA. Opiate addiction is the most serious form of drug addiction. In that year, 100 deaths occurred every day from opiate overdose in the USA. A major component of opiate addiction is the abuse of prescription opiates. Prescriptions for opioid analgesics increased from 75.5 million in 1999 to 206.5 million in 2009. Oxycodone, oxycontin, fentanyl and codeine are commonly prescribed for moderate and severe pain, sometimes without proper justification. There are three medications approved by the Federal Drug Administration (FDA) in the USA for long term treatment, the opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid antagonist naltrexone. Along with the medications psychosocial treatment significantly enhances successful results. Dr Ahmed states that the elucidation of the underlying cause(s) of the addictive behavior through psychosocial therapy enhances the motivation to stop drugs, teaches coping with stress, changes reinforcement contingencies, fosters management of pain effects and enhances social support and inter-personal functioning. Dr Ahmed laments the fact that contrary to Islamic teachings, Muslims are heavily involved in planting, harvesting, refinement, smuggling, and distribution of heroin(and Cannabis) to Western countries. Afghanistan is the world's top user of heroin per capita. Iran and Pakistan have a high percentage of heroin addicts. Dr Ahmed emphasizes the responsibility of Muslim communities to support and help to rehabilitate the addicts- rather than stigmatizing them-and to encourage them to seek treatment. He emphasizes that for Muslim patients, psychotherapy should focus on spirituality, strong belief in God, asking for forgiveness, increasing the hope and giving strength to coping mechanisms. This spiritual guidance may affect the brain reward system so the addict recognizes new cues for pleasure redirecting it away from drugs to new religious experiences.

Another commonly used is Cannabis which is discussed by Dr Takriti in another chapter. He reports that the United Nations considered cannabis the most used illicit drug worldwide. Cannabis is produced from dried leaves, flower, stems and seeds of the weed . It contains 460 compounds, at least 80 of which are , the most active of which is tetrahydrocannabinoid (THC). Cannabis can be consumed as the dried herb, resin, or oil. Cannabis can be smoked in cigarettes alone or with tobacco. The resin and oil may be eaten directly or incorporated in foodstuffs. THC binds to receptors. These are two types; CB1 and CB 2 and both are G-protein coupled receptors. TCH via CB1 receptors indirectly increase dopamine release. It also acts as an allosteric modulator of the mu and delta opioid receptors. This results in relaxation, mild euphoria (the "high"), increased appetite, and impairment of short term memory, psychomotor coordination and concentration. Marijuana use has been implicated as a gateway to harder drugs. Dr Takriti presents the various evidence for and against this theory. It is clear that there is no evidence of a specific pharmacologic effect of cannabis priming the brain for cocaine or heroin. It may be that the presumed gateway effect is caused by the common factors involved in using drugs in the first place, and that cannabis users are more likely to be subjected to situations allowing them to get acquainted with individuals using or selling the various other illegal drugs.

FIMA YEAR BOOK 2014 XI EDITORIAL

Most countries have laws against the cultivation and possession or transport of cannabis. In the USA although Federal law still prohibits and penalizes marijuana use, some states have allowed its medicinal uses such as for treating nausea and vomiting associated with chemotherapy. Whilst some states (Colorado and Washington) have already legalized its recreational use. Other countries have lightened penalties for cannabis use, enforcing confiscation and fines rather than imprisonment. Islamically, cannabis is considered an intoxicant, with significant harms on cognitive functions and psychosocial problems, and is prohibited. The author cites early jurists’ opinions and a more recent fatwa by the Grand Mufti of Egypt. The rulings of alcohol apply similarly for cannabis.

Qat was categorized as a drug in 1973. It is primarily consumed in Yemen, and East African countries. According to Dr al-Goshae in his contribution to this yearbook, 70-80% of Yemenis chew qat on a daily basis. Qat plantation occupies 58.5% of the total cultivated land and consumes 60% of the scarcely available water. Two to three billion USD are spent yearly on qat consumption. Almost 20% of Yemen's workforce is involved in qat business. As it is locally produced and locally consumed, qat generates no national income. The main active constituents in qat are cathinone and cathine. They are central nervous system stimulants that induce release of catecholamines. At first they cause alertness, talkativeness, and euphoria but later they cause depression. Excessive and prolonged qat chewing may cause psychosis and schizophrenia. It also affects the cardiovascular system causing hypertension, palpitation, cold extremities, and sweating. Qat also affects the gastro-intestinal system causing hyperacidity and aggravation of duodenal ulceration. Dr al-Goshae then discusses whether qat produces dependence. While it is true that qat induces psychoactive effects that cause individuals to continue using it regularly despite its harmful effects on the family, income and health, but qat chewers do not experience significant withdrawal symptoms on abrupt cessation of its use. Some researchers believe that qat dependence is mainly psychological and chewers can quit the habit easily. Because of the significant harmful socioeconomic effects the Yemeni government had sought to curtail its use. Qat chewing is banned in all government institutions and during work hours. Taxes were levied against various qat businesses. More recently, NGOs are trying to combat qat growing and consumption. To date, these efforts have been ineffective. Religious scholars in Yemen issued opinions declaring the prohibition of qat chewing. However there is no clear official fatwa (religious decree) in that regard In Yemen. In Saudi Arabia, the Fatwa Institution, and the International Islamic Fiqh Academy issued fatwas that qat is a narcotic and thus prohibited.

The other type of addiction i.e. behavioral addiction is discussed by Dr Dinc. It is difficult to draw the line between personal lifestyle and preferences on one hand and psychiatric pathology on the other. Dr Dinc cites the definition by Dr Griffiths as any behavior that fulfils six components, salience, mood modification, tolerance, withdrawal, conflict, and relapse. Gambling has been the best example of behavioral addiction, but at present there are many more examples such as internet, pornography, and shopping. Dr Dinc focuses on internet addiction because of its affordability, accessibility, anonymity, and that it can be used for all causes; sex, gambling, shopping, etc. He recommends paying special attention to children and youngsters to prevent them from developing behavioral addiction. Those who are at special risk are those who have any type of psychopathology and those who suffer from Attention Deficit Disorder. He recommends teaching them to use the internet responsibly and to encourage periodic physical exercise. He recommends

XII FIMA YEAR BOOK 2014 EDITORIAL

encouraging the youngsters to express themselves and to socialize and to participate in group activities to express themselves and have a meaning and fulfillment of their lives. There is no specific treatment for behavioral addiction. However, psychosocial treatment methods like the 12 step approach and pharmacologic treatment such as naltrexone which is a part of opiate addiction treatment may be helpful.

Drs Harirah and Donia discuss substance abuse during pregnancy. It is estimated that about 4% of pregnant women use some type of illicit drugs e.g. cocaine or marijuana, and that many more smoke and drink alcohol. Smoking is relatively common especially in teenagers. Both nicotine and carbon monoxide readily cross the placenta. Their concentration in fetal blood is much higher than in the maternal blood. Smoking increases the risk of abortion, ectopic pregnancy, placental insufficiency, fetal growth restriction (FGR), low birth weight (LBW), and preterm delivery. Marijuana is the most commonly used illicit drug during pregnancy in USA. THC crosses the placenta and has direct toxic effects on the fetus. FGR and preterm delivery are associated with marijuana use but there is no evidence of increased incidence of fetal malformations. Alcohol is still commonly consumed by pregnant women despite all its hazards. According to the 2010 National survey, 18.8% do, and 38% report binge drinking during pregnancy. Alcohol freely crosses the placenta and its level in fetal blood is the same as in the maternal blood. The fetal liver cannot metabolize it as efficiently as the mother’s liver. Alcohol consumption in pregnancy is associated with abortion, and fetal malformation specifically Fetal Alcohol Syndrome, characterized by FGR, decreased head circumference, abnormal facies, cardiac and renal abnormalities. Heroin and methadone are the most common opiates used by the pregnant women with a recent increase in prescription opiate analgesics abuse.Pregnant women who are using heroin should be tested for sexually transmitted diseases (STDs). Intravenous heroin addicts have significantly increased risk of HBV, HCV, and HIV infections. They must be counseled about methadone maintenance treatment which is associated with much better outcome. Heroin readily crosses the placenta. Heroin addicts experience six-fold increase in the risk of maternal complications; FGR, preterm delivery, LBW, stillbirth, depressed Apgar scores, meconium staining of the amniotic fluid, and chorioamnionitis. The judicial use of analgesic opioids has not been associated with increased fetal malformations or other complications. However, if they are used around the time of delivery there will be increased risk of neonatal withdrawal. Neonatal Abstinence Syndrome is the most consistent outcome in neonates delivered of mothers addicted to opioids. The withdrawal symptoms include seizures, breathing complications, tremors, and difficulty in feeding. Another addiction drug used in pregnancy is cocaine. In the USA, a 1995 survey found that the prevalence of cocaine abuse in pregnancy was 4.5%, 0.4%, and 0.7% of Afro-American, white, and Latino women respectively. Cocaine has dopaminergic effects leading to euphoria or “the high”. Cocaine hasalso sympathomimetic effects causing vasoconstriction, hypertension, tachycardia, and possibly arrhythmias. Prenatal use of cocaine is associated with FGR, LBW, and decreased fetal head circumference. Use in the first trimester increases the risk of abortion and fetal malformation.Use later in pregnancy is associated with increased risk of placental abruption, preterm labor, premature rupture of membranes, and stillbirth. Cocaine abusing mothers are prone to infant neglect and abuse. Methamphetamine is becoming a relatively common drug of abuse in young women and thus in pregnancy. As with virtually all other drugs of abuse, amphetamine use is associated with risky sexual behavior, teenage pregnancy, and potential increased risk of STDs. Prenatal exposure to

FIMA YEAR BOOK 2014 XIII EDITORIAL

amphetamine leads to LBW and to neonatal complications such as decreased alertness and poor feeding. Barbiturates and other sedatives such as benzodiazepine are sometimes prescribed to pregnant women. There is no definite evidence of teratogenic effects but their use in the last trimester may be associated with neonatal withdrawal symptoms and with the floppy infant syndrome. Drs Harirah and Donia discuss the general principles of management of pregnant women abusing drugs. Preconception counseling vis a vis cessation of smoking, abstaining from alcohol is very important. Generally, other addicts do not present themselves to prenatal counseling or even for prenatal care, especially in the early part when most of the teratogenic events occur. Screening for fetal malformations should be adequately pursued. Genetic counseling should be offered if a malformation is diagnosed. Serial sonography should be provided for evaluation of fetal growth. Fetal well being testing should be offered in the third trimester. Nutritional counseling by trained nutritionists is to be recommended to mitigate the poor nutritional status of these women. Timing of delivery can be a challenge. The risks of prematurity should be balanced against that of stillbirth. Pain relief management during labor should be discussed in advance.

Dr Karaman relates the experience of the Turkish Green Crescent Society (TGCS) in combating the problem of addiction. He notes the power groups that promote addiction mainly the alcohol and tobacco industries, the "addiction industry". He describes the impact of addiction on global mortality figures as well as the disease burden. Dr Karaman reports that the annual value of the illicit drugs in the world is estimated at 320 billion USD which is beyond governments' control. He gives the history and the programs of TGCS. The society played a major role in the Turkish government adoption and implementation of the WHO 's Framework Convention on Tobacco Control. Although a "National Alcohol Control Action Plan" was introduced in Turkey in May 2013, there is significant opposition from the secularists and the alcohol industry. The Society continues to advocate for the law. TGCS aims to be a part of the international solidarity to fight addiction on a global level. The Society is a member of the European Alcohol Policy Alliance and holds a special consultative status with the Economic and Social Council of the United Nations. The Society serves as a model and helped to form similar societies in Palestine, Bosnia, Malaysia, and Thailand. Eventually they hope to establish the “World Federation of Green Societies"

After elucidating the problem, the next chapters of the yearbook address the different approaches to the treatment of addiction. Dr Hamdan discusses the psychological model of addiction therapy but stresses its possible hindrance by "Spiritual Bypassing". She defines it as a person's utilization of spiritual procedures and beliefs to avoid unresolved psychological issues that may be the trigger for the addiction. There is scarce research about “Spiritual Bypassing” and almost none from the Muslim perspective. Most Muslims believe that addiction is a great sin and the result of weak Iman, and that increasing one's faith and Islamic practices is the way to overcome it. This, however, does not solve the problem. It allows the person to avoid examining or taking responsibility for the issues underlying addiction. Dr Hamdan notes that devout Muslims believe that calamities and illnesses are a means to get closer to Allah so they should embrace their illness because it cleanses and purify them from their sins. So an addict should use the problem as an opportunity to reevaluate his or her life and to increase one’s Islamic practices. Further, Muslims tend not to discuss problems such as addiction with family or friends depriving themselves from the beneficial effect of social support in the addiction recovery process. Instead they tend to seek help from an Imam rather than from a professional. The religious leaders usually have no formal

XIV FIMA YEAR BOOK 2014 EDITORIAL

education or training in these types of issues and Muslims thus forgo proper treatment. Dr Hamdan believes that the Imams should serve as mentors referring these addicts to professional counselors/ mental health professionals rather than just prescribing engaging in more Islamic rituals and practices. This does not mean one should neglect spirituality. In fact many psychology experts recognize its essential role. Studies suggest that early childhood trauma such as abuse or neglect by parents often results in children engaging in addiction behavior later in life. Psychological help will probably unveil issues in the unconscious which are the root cause of the addiction behavior. Muslims in general shun psychological counseling because of cultural taboo. This needs to be corrected. Psychotherapy and Islam combined will allow one to address the root cause of addiction and result in better chance of recovery. Muslim religious leaders and healthcare providers need to make concerted effort to debunk the negative stereotype of psychotherapy, counseling and mental health services. Dr Hamdan stresses the point that while the Quran and Sunnah provide the principles by which one lives his life, "professional counseling could be used to help the person understand why he or she may have difficulty applying these principles”. " In that sense she believes that " Psychotherapy and counseling can serve to enhance a person's spiritual beliefs not taking away from or replacing religion".

In most Muslim majority countries the traditional treatment of drug addiction is based on abstinence. Another strategy i.e. "Harm Reduction" is discussed by Drs Hoosen and Mohamed. This strategy allows substitute drugs such as methadone for heroin addicts and provides syringes, needles and condoms for intravenous drug users as a means to treat the addiction while minimizing the health, social and economic harms to the addicts, their families and community at large. It tends to reduce legal problems, crime, domestic violence and job loss. The permissiveness of this approach is controversial, especially in Muslim countries. The authors opine that this approach is acceptable within Islamic guidelines. Harm reduction is a mainstream in all European Union member countries. The authors cite Spain as an example of the change in drug policy to harm reduction with resultant increase in retention rates in treatment centers and a parallel decrease in morbidity and mortality of the addicts. The authors also cite a similar experience in some Muslim majority countries. In Iran, substance abuse was dealt with primarily by punitive measures. This was associated with high relapse rates and increased risky behavior. Political and religious leaders recognized that incarceration and abstinence were unsuccessful in addressing the continued increase in drug abuse and in rates of HIV infection. This led to a review of the government policies and subsequently the introduction of harm reduction strategies. In Malaysia the zero tolerance approach to drug use failed to curtail the problem. This gradually changed to harm reduction programs with the approval of the "Institute of Islamic Understanding" which declared that the harm reduction approach did not violate Shari’ah (Islamic jurisprudence). Similarly in Afghanistan harm reduction interventions were introduced in 2003. Harm reduction strategies are generally challenged in Muslim countries based on the concept that intoxicants and extramarital sex are forbidden in Islam. Distribution of syringes, condoms and substitute drugs imply approval of the illicit behaviors. The authors, however, point out that the abstinence only approach has been unsuccessful in stemming the spread of HIV and the punitive approach was counterproductive. They propose citing contemporary Muslim scholars who believe that it is not sufficient for verdicts to be passed purely on the basis of classical legal texts but has to employ Ijtihad taking into consideration the objectives of Shari’ah which in essence are meant to

FIMA YEAR BOOK 2014 XV EDITORIAL

bring benefit and ward off harm. According to this school of thought, if harm reduction strategies which involve the use of haram (forbidden) substances, and haram practices are beneficial to the society as a whole, by preventing harm to the general public, then this strategy will be Islamically acceptable. The authors invoke some Qura’nic verses and prophetic Ahadith and fiqh principles that support their view. In "Harm Reduction strategies addicts may not achieve total abstinence and they may still indulge in drug use but they do that in a less risky manner thus minimizing the harms to themselves and others". They will be encouraged to enter into treatment facilities where they will be more likely to engage with health professionals and maybe "more receptive to Islamic psychotherapy which may motivate them towards total abstinence". The authors also point out the similarity of harm reduction strategy to the gradual way Islam adopted for alcohol prohibition. They also point out that addiction is an illness and addicts require treatment and not punishment. Furthermore, the authors remind us that Islam teaches us compassion towards the sick and that it is “not the duty of the health practitioner to pass moral judgment but only to care for the patient."

In another chapter Dr. Abu Dannoun discusses the Islamic perspectives of addiction prophylaxis and therapy. He points out that although the prohibition of Khamr was largely applied to alcohol, the major and may be the only known addictive substance known then, in fact the prohibition is clearly because of its intoxicating effect. On that basis the ruling of prohibition applies to any other intoxicating substance regardless of its chemical structure or other scientific means of characterization. In Islam tahrim (prohibition) is linked to faith and its manifestations such as prayers and fasting. This has more authority on the true Muslim than manmade laws. Tahrim of intoxicants is deeply rooted in the Muslim psyche that even with the current decline of the leadership of Islam in Muslim societies, addiction is a less of a problem than in non-Muslim countries. The individual Muslim avoids alcohol and other intoxicants because it is prohibited and because of his or her desire to please Allah. In addition, the society as a whole exerts pressure on its members to avoid addictive substances. It is ironic that in non-Muslim countries there are serious attempts to curtail the availability of other addictive substances while alcohol is largely accepted as a social drink despite the fact that the former have less deleterious effects than alcohol. Dr Abu Dannoun brings up the question of whether addiction is an illness or a behavioral disorder. Other contributors to this yearbook consider it to be a brain disease but still is it a disease that one has no control on? Dr Ahmed, in his opiate article, states that while genetics and other biologic underlying factors are involved in addiction, it is very possible that one can control it. Contemporary Western oriented approaches are based on the concept that addiction is a disease that needs therapy. Significant concessions are practiced to drug addicts in the harm reduction approach as discussed previously. Dr Abu Dannoun does not approve of this approach while not neglecting the medical, psychosocial and rehabilitation needs of drug addicts. He does consider addiction a devious behavior and ethical-religious disobedience which are self afflicted by the individual. These considerations render them liable to punitive measures. He believes that recognized therapeutic measures should be mandatory. They may be gradual and long-term but should aim at complete abstinence. Clearly Dr Abu Dannoun’s approach is orthodox in nature but I think that harm reduction approach merits consideration and should be subjected to Ijtihad by Muslim scholars alongside medical experts, psychotherapists, social workers, and others directly involved in the care of addicted individuals.

XVI FIMA YEAR BOOK 2014 EDITORIAL

Drs Mohamed and Marican from Malaysia state in their article that there are different methods of addiction treatment and no single treatment is suitable for all. Treatment must be carefully adjusted to ensure that a specific plan meets the person's changing needs. Detoxification maybe the first sep but counseling and behavioral therapy should be applied to minimize the rate of relapse. Recovery can be a lifelong process with multiple treatments. In Malaysia, Compulsory Centers for Drug Users (CCDUs) were established to provide primarily psychosocial treatment. More recently the supply and demand reduction approach was applied and resulted in a decrease in the number of drug addicts. Supply reduction focuses on legislation, and law enforcement. Demand reduction is achieved through several methods including education, increasing public awareness of the dangers of addiction, and the establishment of effective abstinence based treatment programs. Because of the limited success of the supply and demand reduction approach the harm reduction approach was introduced in the first decade of this century. In 2005 MMT was endorsed by the government. Moreover, this approach includes religious teaching conducted by certified religious teachers. The harm reduction approach resulted in further reduction of substance abuse, greater concern for one's own health, decrease in illegal activities, longer retention in treatment centers and increase in gainful employment. There is evidence that by participation in these programs the recovering addicts become more practicing Muslims with less attraction to negative life influences. The authors note that the inclusion of religious teaching in drug treatment does have positive effect onto the lives of the clients, while religious input in isolation is of little value. This supports the importance of avoiding Spiritual Bypass described earlier by Dr Hamdan, and the Harm Reduction approach discussed by Drs Hoosen and Mohamed. The religious input should not be a fixed program but needs to be tailored to each individual needs specifically to their prior religious knowledge.

Dr Shaharom describes a role for Islamic Psycho-Spiritual Therapy (IPST) in the treatment of addiction. He defines it as a healing technique that transfers the individual from the realm of ill health to that of well-being that is Rabbani (Godly). IPST incorporates the different theories of psychotherapy that are not inherently anti-religion, Islamizing them in the process. Dr Shaharom recommends using his designed Islamic Religiosity Scale to evaluate each individual and to design the best combination of modalities for his treatment and to follow his progress. The basic modalities are prayers, meditation, zikr (remembrance of Allah), and Qura’nic reading / recitation. Dr Shaharom stresses that in some cases IPST needs to be coupled with pharmacotherapy. He cites beneficial results for IPST and concludes that it is relevant in the treatment of addiction.

I conclude by thanking all the authors for their contributions to the issue. I especially thank members of the Editorial Board: Drs. Aly Misha’l, Abul Fadl Mohsin Ibrahim, and Musa Mohd Nordin for their valuable input and guidance. I sincerely appreciate the work of Dr. Mishal's staff for copyediting and proofreading of the manuscripts, especially Ms. Elham Mohammad Swaid.

guide us to the (ﷻ) accept and bless our efforts in His service. May Allah (ﷻ) I pray that Allah right path and have mercy on us. Amin. Wassalam Hossam E Fadel, M.D., Ph.D., F.A.C.O.G Clinical professor, Obstetrics and Gynecology. Maternal Fetal Medicine, The Medical College of Georgia Georgia Regents University Augusta, GA, USA

FIMA YEAR BOOK 2014 XVII

EDITORIAL

Federation Of Islamic Medical Associations ( FIMA ) in Brief

 Established at the outset of the 15th Hijrah century, December 1981, in Orlando, Florida, USA, where senior leading medical professionals representing ten Islamic medical organizations, from various parts of the world, convened and laid down the foundation of the Federation.  Subsequently, in March 1999, FIMA was incorporated in the State of Illinois as a non-profit organization, then acquired the special consultative status with the United Nations Economic and Social Council (UN-ECOSOC).  Since that time, FIMA membership progressively expanded to include 29 full members, 13 associate members, and more than 15 prospective and collaborating organizations from all over the world.  Most FIMA activities and achievements are based on the endeavors of its member Islamic Medical Associations (IMAs), in constructive mutual cooperation, and harmonious understanding.  Islamic medical activities of FIMA have a holistic nature. Leadership, mutual cooperation and innovation are prerequisites for the welfare of our communities, our Ummah and humanity at large.  These activities include, but are not limited to: 1. Cooperation in humanitarian medical relief work, where and when needed in disaster stricken countries, regardless of ethnicity, religion or race. The FIMA Save Vision Program was initiated in early 2005. To date more than 100,000 eye surgeries were performed by volunteer ophthalmologists and teams from IMAs in several countries, in Africa, South and Southeast Asia, where visual impairments are rampant. The program included training of local medical professionals to continue and widen this activity by qualified local talents. The program also included establishment of local eye hospitals or eye sections in existing general hospitals, in deprived communities. This activity qualified FIMA for a distinguished award from the American College of Physicians ( ACP ), designated for outstanding humanitarian medical achievements. Over the past five years, two new humanitarian activities were launched: The cleft lip/palate, and the vesico-vaginal fistula projects, both highlighted as significant medical and psychosocial problems in several needy communities.

FIMA YEAR BOOK 2014 XIX EDITORIAL

2. Collaboration with regional and international organizations in areas of preventive medicine and community health education. 3. Scientific, professional and ethical jurisprudence related conferences, seminars and publications. 4. Establishment of the Consortium of Islamic Medical Colleges ( CIMCO ), to foster cooperation in improvement of curriculum, training, research, administration, and up-bringing of model medical practitioners. 5. Establishment of the Islamic Hospitals Consortium ( IHC ), to pursue cooperation and coordination among medical professionals and hospital administrators in areas of experience exchange, benchmarking, improvement of health care delivery, ethical, administrative and operational activities, to meet the most advanced international standards, in the context of Islamic principles. 6. Publication of FIMA Year Books, which address biomedical, ethical, scientific and other related issues that are needed for medical practitioners, educators as well as Jurists. 7. In 2013, FIMA committee on Bioethics embarked on the project of Encyclopedia of Medical and Health Ethics. In view of the extensive effort needed, this project is expected to span over several years. 8. Medical students’ activities, including conferences, seminars, publications, camps, Umrah and Ziarah programs. 9. Collaboration to extend a helping hand to Muslim medical practitioners in underprivileged countries, to work together and organize professional medical societies, to serve their communities. 10. Establishment of resource centers. The HIV/AIDS Resource Center has been functional in prophylactic, social and therapeutic activities in several countries for the past two decades. The Biomedical Ethics Resource Center has been functional for the past decade.

For Correspondence:

 FIMA President: Dr. Tanveer Zubairi- Pakistan E-mail: [email protected]

 FIMA General Secretary: Prof. Abdul Rashid Abdul Rahman- Malaysia E-mail: [email protected], [email protected]

 FIMA Executive Director: Dr. Aly A. Misha’l E-mail: [email protected]

 FIMA Executive Director in USA: Dr. Parvaiz Malik E-mail: [email protected]

FIMA WEBSITE: www.fimaweb.net

XX FIMA YEAR BOOK 2014 BIOLOGICAL MECHANISMS UNDERLYING ADDICTION

Ilhan Yargic*

Abstract:

Addiction is a behavioral disorder related to alterations in neurobiological systems involved in reward system, brain stress response, physical withdrawal, inhibition and executive control. Genetic and epigenetic variations in these neurobiological systems cause individual differences and responses to these substances. The current review summarizes the literature on the biological basis of drug addiction. In addition, this review tries to explain the path from occasional recreational substance use to the compulsive, addicted state. It will help to understand why the absolute avoidance of psychoactive drugs is very crucial.

Keywords: addiction, mechanism, abuse, dependence, neurobiology

Introduction:

Drug addiction is a chronic, relapsing ator systems. Generally, the discussion disorder that is characterized by a craving about the health hazards of alcohol and for drugs, compulsive drug use, loss of drugs has often focused on their control in limiting intake, and emergence deleterious effects on bodily functions and of an aversive state (withdrawal) when the organs like the liver and lungs. However, drug is not accessed1. Although any drug the worst effect of alcohol and drugs is on use has a potential for further abuse or the brain, because they cause long term dependence, clinical experience and neuroadaptive changes in the CNS which animal studies show that neurobiological leads to compulsive drug use with frequent effects of occasional and limited use of a relapses and poor outcomes even after drug, like alcohol, is different from those acute withdrawal symptoms have abated. of a chronic dependent state2. Addiction Modern research on drug abuse has develops as a result of a transition from the demonstrated the biochemical, cellular, first neurobiological state to the second. genetic, epigenetic and circuitry mechan- Drug intake, accompanied by a biological isms that mediate the progression from vulnerability causes some permanent fun- experimentation with a drug to addiction. ctional and structural changes3 in various These changes in the brain have a potential parts of the central nervous system (CNS) to continue for a long time after drug use and several neuro-endocrinological modul- has stopped.

*Prof. Dr. Ilhan Yargic Istanbul University Istanbul Medical Faculty Psychiatry Department, Istanbul, Turkey E-mail: [email protected]

FIMA YEAR BOOK 2014 1 BIOLOGICAL MECHANISMS

These changes in the brain have a potential Through this mechanism, Allah has to continue for a long time after drug use programmed us to want things that we has stopped. Addiction is a biopsycho- need to survive. For example eating food is social disorder similar to other chronic not a burden that we just have to do but it physiological disorders such as diabetes is a pleasure we seek for. Rewards serve as mellitus that are progressive and influe- positive reinforcers because they affect the nced by environmental factors and stress- behavior towards obtaining a goal that ors. A diabetic person cannot claim that he results in pleasure and satisfaction. When will use his will power to keep a normal someone uses a psychoactive drug, he is blood glucose level after he consumes a abusing the reward system outside its large amount of carbohydrate. Likewise, special purpose. Almost all drugs of abuse an addict cannot keep limiting his drug use stimulate mesolimbic dopaminergic system and avoid bad consequences forever. But much stronger than the natural stimuli, like a diabetic person who should avoid thus they produce pleasurable effects food that is rich in carbohydrates, an addict initially. should take every precaution to stay away Repetitive stimulation of this system from drugs for good. causes sensitization that is responsible of Alcohol and drugs have effects on four craving for the specific drug. Drugs act interrelated biological systems in the brain like computer viruses that change the that underlie addiction. original program of a computer (the brain) These are brain reward system, brain stress and reorganize the system to perceive them systems, autonomic nervous system (relat- as a basic need, re-program the system to ed to physical withdrawal) and pre-frontal produce an urge for them (drugs). The drug cortex function (related to cognitive user imagines this strong desire for drugs inhibitory control). as his natural will. Especially in the initial Drug use produces biological changes that phases of addiction, they say “I use it as I ruin the homeostatic operations of the CNS want to use it”. They do not take into and a new state of chronic dysregulation consideration that this urge is not innate (an allostatic state) is shaped4. and it develops after drug use. This strong feeling of desire (impulse) for drug use Brain Reward Systems: that affects decision-making process of the person is one of the key elements of Reward system is the fuel of life. addiction. Most of the drugs of abuse Mesolimbic dopaminergic system that increase dopamine in the mesolimbic connects nucleus accumbens and ventero- system directly or indirectly to produce a tegmental area and gives projections to the reward or a high. For example opiates act prefrontal cortex is the neural structure of on opioid receptors which then stimulate the reward pathway. This brain circuit is dopamine receptors, cocaine competes present in human and all animals and it with dopamine in the synaptic cleft for the gives an appetitive stimulus to obtain dopamine reuptake pump and keeps innate needs (food and sex) that are dopamine in the cleft. necessary for survival of the individual and Activation of dopamine neurons is a moti- continuation of the generations. The vational factor that produces reward- pleasure imbedded in them is like a small anticipation. fee given to the creatures to turn the wheel When a reward is higher than expected, of physical existence. sensitization of dopamine neurons incr-

2 FIMA YEAR BOOK 2014 BIOLOGICAL MECHANISMS eases. This sensitization increases the urge The brain has a plastic property and it or motivation for the reward5. Drugs may rapidly develops an adaptation to the produce different effects on individuals6. effects of drugs. This is called tolerance. For example cocaine or meth-ylphenidate Repetitive use of a drug increases reward use increases dopamine levels in human thresholds (decreases reward). For this brain and this increase is associated with reason, drug use does not produce satiety pleasure. If drug-naïve subjects had low as in natural rewards like food. A person levels of dopamine D2 receptors, they can eat up to a certain amount of his experience pleasure. But if they originally favorite food each time but increases the had high receptor levels, they experience amount of a drug in subsequent uses. The unpleasant feelings. This study explains person cannot get the same high from a the biological mechanism of why drug use drug during chronic use but he still is pleasurable for some people and tends to experiences a high level of urge to use it. be repetitive while it is unpleasant and not In other words, tolerance does not repetitive for others6. extinguish this desire. The brain keeps the Neurotransmitters other than dopamine value of possible actions in memory also play a role in reward system7. according to the amount of reward it Dopamine independent reward mechan- produced in the past5. This stored value is isms have been described for opioids and used to evaluate possible results of future alcohol. actions as reward or punishment. Serotonergic receptors in the nucleus accumbens mediate the reinforcing effects Brain Stress Systems: of psychostimulant drugs. Stimulation of µ-opioid receptors in the nucleus accum- Stress system is the brain alarm circuit that bens and ventral tegmental area are respon- is triggered by danger or unpleasant sible for the reinforcing effects of opioids. stimuli. Some neurochemicals that are Opioid receptors in the ventral striatum activated by acute or chronic stressors and amygdala mediate the reinforcing initiate some typical behavioral responses. effects of . Acute intoxicating doses In animals various behavioral responses of alcohol also increase inhibitory γ- like freezing or flight may be observed1. aminobutyric acid (GABA) in the Brain stress systems include neurocircuitry amygdala. Activation of the mesolimbic mediated by glucocorticoids, corticotropin- dopamine system produces an incentive releasing factor (CRF), norepinephrine, salience linked to the environmental and dynorphin. There are also neuro- stimuli and drives goal-directed behavior1. chemicals like neuro-peptide Y (NPY), Pleasure (hedonic state) provided by the nociceptin, and endo-cannabinoids that reward starts a learning process including oppose the brain stress systems. condi-tioning with cues that are associated Stimulation of nucleus accumbens, the with drug use, assigning value and reward system, also activates brain stress motivational status to the reward. systems that subsequently feedback to dec- Motivational state produced by drug rease dopamine release in the mesolimbic withdrawal is like hunger and sexual dopamine system. Brain stress systems aim arousal that increase the incentive salience to neutralize the effects of the drug and of the reward and related cues8. As the restore normal function despite the hunger or withdrawal rises, struggle to get presence of drug. This causes tolerance to the reward will accelerate. the effects of the drug use and dysphoric

FIMA YEAR BOOK 2014 3 BIOLOGICAL MECHANISMS

syndrome when the use is stopped because higher drug doses to get the same effect, so the change in stress systems continues that the person gets into the vicious cycle although the drug use is avoided1. of tolerance. Acute physical withdrawal is Adrenocorticotropic hormone (ACTH) and related to the somatic effects of drug use. corticosterone are elevated during withdra- Long term use of many drugs leads to wal and this disturbs the hypothalamic- adaptations within the autonomic nervous pituitary-adrenal (HPA) axis and extra- system and its target organs. hypothalamic brain stress system mediated This adaptation is disturbed when drug use by cortisol releasing factor (CRF). is avoided12. For this reason, medications Withdrawal and protracted abstinence from that modulate the autonomic nervous drugs produce anxiety and irritability system, such as clonidine and propranolol mediated by CRF1. Dynorphin activation are effective at reducing acute withdrawal mediates depressive responses to stress and symptoms. Acute somatic symptoms of dysphoric responses during withdrawal withdrawal abate in days to weeks after the from drugs9. Animal studies10 show that drug is discontinued, however, a chronic or when primates were conditioned to asso- protracted withdrawal state, where the ciate a cue with a pleasurable object like patient suffers from unpleasant psycho- food, increased dopaminergic activity was logical symptoms especially triggered by a response to the cue and not to the food. drug cues, lasts for months to years. Absence of food caused a drop in Permanent changes in the brain may dopaminergic function. Reduction in the induce relapses to drug abuse long after dopaminergic activity is considered to be detoxification. associated with negative affect like Gamma-aminobutyric acid (GABA)-ergic dysphoria. So when an addict comes across system and the glutamatergic system play with a cue (e.g. needle, money), and important roles in alcohol withdrawal13. cannot access the drug he may feel Increased glutamatergic NMDA function is dysphoric. This negative feeling will also involved in seizures and cell death. increase the drive to get the drug. Amygdala and hippocampus are critical sites for glutamatergic hyperactivity. Physical Withdrawal: Reduction in dopamine plays a role in both early abstinence and protracted withdrawal Withdrawal is the emergence of specific from many drugs of abuse14. behavioral and physical symptoms Neuroimaging studies have shown reduced following sudden discontinuation of a drug dopaminergic activity in opiate, cocaine in subjects who had been under its chronic and alcohol addictions. Even partial reco- influence. It is the result of reversal of very of this change takes several months6. homeostatic mechanisms which had been Altered reward neurotransmitters increase disturbed by the drug before discon- brain reward thresholds (a higher set point tinuation11. In other words withdrawal is for drug reward) during abstinence. This in the result of sudden backward change of turn produces the negative motivational the homeostatic mechanisms that caused state in withdrawal (psychological symp- tolerance to the drug. Actually in toms of withdrawal) and makes the patient stimulants and heroin, tolerance starts to vulnerable to relapse1. develop very early on and the person Withdrawal symptoms are aversive for the cannot get the same effect from the same drug user; therefore he starts to seek the amount of drug and needs progressively

4 FIMA YEAR BOOK 2014 BIOLOGICAL MECHANISMS drug not for pleasure but to avoid through biologi-cal maturation of the brain withdrawal symptoms. during adoles-cence. Therefore adolescent brain is more vulnerable to the harmful Impulse control effects of drug abuse18. Different parts of And decision making: the PFC are related to distinct features of addiction; for example medial orbitofrontal Inhibitory control and decision making are cortex and ventromedial prefrontal cortex key executive functions for the develop- to craving, orbitofrontal cortex to drug ment of addiction and they are mediated by expectation, anterior cingulate cortex to the forebrain. Prefrontal cortex (PFC) is attention bias and dorsolateral prefrontal involved in regulation of both limbic cortex to drug-related memories15. reward regions and higher-order executive Glutamatergic pathway starting from the functions. Therefore in addiction, PFC PFC and controlling the dopaminergic dysfunction is not only related to neurons in the nucleus accumbens are compulsive drug use but also underlines associated with addiction19. the dysfunctional behavioral pattern of Several other neurotransmitter systems drug addicts. Impairment of the PFC such as endogenous opioid, serotonergic, functions is also related to salience cannabinoid and dopaminergic systems are attribution in addiction. “Salience attribu- also involved in prefrontal impair tion” is ascribing excessive prominence to ment15.Inhibitory control enables to take the drug and drug related cues, decline in appropriate actions to accomplish complex sensitivity to non-drug reinforcers and less tasks and provides adaptation to new ability to inhibit maladaptive behaviors15. environmental conditions by suppressing This impairment makes drug seeking and immediate or habitual responses. drug use the main motivational drive even Impairment in the inhibitory control is a though it leads to long term losses. It leads key element in repetitive substance misuse to neglecting other activities and the and dependence17. Deficit in impulse person can engage in extreme behaviors in control can be demonstrated with neuroco- order to obtain drugs16. The process ends gnitive tests like color word Stroop task, in the weakening of free will. continuous performance test and the stop- Administration of drugs of dependence to signal task. In laboratory gambling task drug naïve laboratory animals produces where risky decision making is accessed, changes in PFC similar to those in human drug addicts tend to take actions associated drug addicts. PFC impairment seen in drug with short-term gains although they can addicts is a result of drug use that enables bring long-term losses17.The individuals further use. However, PFC impairment is with impulsive personality traits are more also present in several other psychiatric prone to try and be addicted to drugs and and neurological conditions such as drug use puts these individuals into a borderline personality disorder, attention vicious cycle of further impulsivity20. deficit and hyperactivity disorder (ADHD), Impairment in impulse control leads to a schizophrenia and bipolar disorder and weakening in self control (the ability to traumatic brain injury17. The presence of postpone or avoid an activity that may not PFC impairment makes those patient be appropriate or is perceived as groups more vulnerable to drug use and incorrect)21. dependence. Executive functions mediated This explains the inability of drug addicts by the pre-frontal cortex are gained to inhibit excessive drug use although they

FIMA YEAR BOOK 2014 5 BIOLOGICAL MECHANISMS

are aware of the destructive consequences. 9. Chartoff E, Sawyer A, Rachlin A, et al. Blockade of kappa opioid receptors attenuates the development Impairment in impulse control and self of depressive-like behaviors induced by cocaine control also underline engagement in withdrawal in rats. Neuropharmacology 2012; criminal activities and aggression. Young 62:1167–1176 10. Schultz W. Reward signaling by dopamine neurons. individuals who already have weak self- Neuroscientist. 2001; 7:293-302. control are more prone to substance 11. Vetulani J. Drug addiction. Part II. Neurobiology of dependence21. addiction. Pol J Pharmacol. 2001; 53:303-317. 12. Naqvi NH, Bechara A. The insula and drug addiction: an interoceptive view of pleasure, urges, Conclusion: and decision-making. Brain Struct Funct. 2010; 214:435-450 13. Roberto M, Gilpin NW, Siggins GR. The central The addicted brain is in a state of chronic amygdala and alcohol: role of γ-aminobutyric acid, dysregulation (allostasis) where function of glutamate, and neuropeptides. Cold Spring Harb reward circuits are impaired and stress Perspect Med. 2012; 2:a012195. 14. Murphy A, Taylor E, Elliott R. The detrimental systems are activated both of which lead to effects of emotional process dysregulation on increased impulses to use drugs. Somatic decision-making in substance dependence. Front withdrawal symptoms as well as emotional Integr Neurosci. 2012; 6:101 15. Goldstein RZ, Volkow ND. Dysfunction of the dysregulation also increase the urge for prefrontal cortex in addiction: neuroimaging drug use. On top of these, dysregulation of findings and clinical implications. Nat Rev the frontal cortex which is supposed to Neurosci. 2011; 12:652-669. 16. Volkow ND, Li TK. Drug addiction: the execute thoughts, impulses and emotions neurobiology of behaviour gone awry. Nat Rev results in compulsive drug seeking and loss Neurosci. 2004; 5:963-970. of control over intake. This is a process 17. Li CS, Sinha R. Inhibitory control and emotional stress regulation: neuroimaging evidence for frontal- initiated by drug use and can be avoided limbic dysfunction in psycho-stimulant addiction. primarily by staying away from drugs. Neurosci Biobehav Rev. 2008; 32:581–597. 18. Selemon LD. A role for synaptic plasticity in the adolescent development of executive function. References: Transl Psychiatry. 2013; 3:e238 19. Lingford-Hughes A, Nutt D. Neurobiology of 1. Koob GF. Addiction is a Reward Deficit and Stress addiction and implications for treatment. Br J Surfeit Disorder. Front Psychiatry. 2013; 4:72. Psychiatry. 2003; 182:97-100. 2. Koob GF. Theoretical Frameworks and Mechanistic 20. Dawe S, Loxton NJ. The role of impulsivity in the Aspects of Alcohol Addiction: Alcohol Addiction as development of substance use and eating disorders. a Reward Deficit Disorder. Curr Top Behav Neurosci Biobehav Rev. 2004; 28:343-351. Neurosci. 2013; 13:3–30. 21. Moffitt TE, Arseneault L, Belsky D, et al. A 3. Denier N, Schmidt A, Gerber H, et al. Association gradient of childhood self-control predicts health, of frontal gray matter volume and cerebral perfusion wealth, and public safety. Proc Natl Acad Sci U S A. in heroin addiction: a multimodal neuroimaging 2011; 108:2693-2698. study. Front Psychiatry. 2013; 4:135. 4. Edwards S, Koob GF. Neurobiology of dysregulated motivational systems in drug addiction. Future Neurol. 2010; 5:393–401. 5. Arias-Carrión O, Pŏppel E. Dopamine, learning, and reward-seeking behavior. Acta Neurobiol Exp (Wars). 2007; 67:481-488. 6. Volkow ND, Fowler JS, Wang GJ. Imaging studies on the role of dopamine in cocaine reinforcement and addiction in humans. J Psychopharmacol. 1999; 13:337-345. 7. Nestler EJ. Is there a common molecular pathway for addiction? Nat Neurosci. 2005; 8:1445-1449. 8. Karoly HC, Harlaar N, Hutchison KE. Substance use disorders: a theory-driven approach to the integration of genetics and neuroimaging. Ann N Y Acad Sci. 2013; 1282:71-91.

6 FIMA YEAR BOOK 2014 ALCOHOL USE DISORDER: SCIENTIFIC HORIZONS AND ISLAMIC PERSPECTIVES

Mohammad Ali Albar*, and Aly A. Misha’l

Abstract:

Alcohol beverages have been used since antiquity. Alcohol dependence is a worldwide problem, more intense and widespread than all other drugs causing dependence combined. The tendency has been to manage the dilemma of alcohol dependence leaving aside the problem of availability and accessibility of alcoholic beverages in most communities around the world. Historically, the USA trial to forcibly prohibit alcohol use by law (1919-1933) had failed miserably. Similar trials in USSR met the same fate. Multiple terms are used to describe the clinical conditions associated with excessive use of alcohol. Over the past few years, the terms of and alcohol dependence were replaced by a single diagnosis: alcohol use disorder, with the term “” reserved for the more severe manifestations of alcohol use disorder, that could be fatal. The diagnostic criteria of alcohol use disorder, its epidemiology, pathogenesis, clinical manifestations, adverse consequences, assessments and management are outlined in this paper, together with the Islamic perspectives and approach in eradication and prophylaxis.

Keywords: Alcohol, dependence, alcohol use disorders, intoxication, Islam.

Introduction:

The terms alcohol abuse and alcohol dep-  Impaired control over drinking. endence were recently replaced by one  Preoccupation with alcohol. diagnosis: alcohol use disorder1. The term  Use of alcohol despite adverse (alcoholism) has been frequently used to consequences. describe the more severe manifestations of  Distortions in thinking, most notably: alcohol use disorder. Alcohol use disorder denial. is a worldwide problem. It is more deleteri- ous and widespread than all other drug Definition of various levels of alcohol dependencies combined 2. Typical intake and the level that is considered characteristics of this disorder include: abuse differs between countries3,4.

*Dr. Mohammad Ali Albar (FRCP London) Director of Medical Ethics International Medical Center Jeddah, Saudi Arabia E-mail: [email protected]

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A “” in the US is 14-15 gm the USA, a trial to forcibly prohibit alcohol of alcohol (0.5-0.6 fl.oz), equivalent to 12 consumption, was implemented between oz of beer, 5 oz of wine, and 1.5 oz of 80 1919 and 1933. The Eighteenth Amend- proof liquor5. ment to the USA constitution that was In UK: 19.75 gm of alcohol2,3. known as the Prohibition Amendment, was In addition to the amount of alcohol in passed on January 16,1919, by the “one drink”, cut points to define Congress, to be fully implemented after ”Moderate” and “Heavy” drinking also one year from its ratification. This varies between countries6: amendment proclaimed that the manufac- In the US the following parameters ture, sale, transportation, importation and generally apply: exportation of “intoxicating liquors” shall “Moderate drinking”: be legally prohibited. The Congress was  Women: < 2 drinks per day. authorized to enforce this amendment by  Men: < 3 drinks per day. appropriate legislation 8. “Heavy drinking”: The alcohol prohibiting legislation did not  Women: > 7 drinks per week or 3 change the public attitudes towards alcohol drinks per occasion. consumption. The majority of US citizens  Men: > 14 drinks per week or 4 were incapable or unwilling to curb their drinks per occasion. drinking habit. Illicit production and illegal “Binge drinking”: smuggling of alcohol continued and there  Women: 4 or more drinks in one was no decrease in the availability of occasion. alcoholic beverages. It became clear that  Men: 5 or more drinks in one the attempt failed and the amendment was occasion. repealed in December, 1933, by Congress. No level of alcohol consumption can The wording of this repeal was very reliably be regarded as safe7. No studies significant in stating: “The prohibition have been published to predict alcohol amendment, known as the Eighteenth abuse, or alcohol use disorder, in individu- Amendment, was not repealed on the basis als who consume “moderate” amounts of of whether alcohol is good or bad, alcohol, or who are described as “social harmless or hazardous. The decision was drinkers”. Any of these individuals, under made on the very realistic and practical certain circumstances, could turn into an basis that prohibition was not working” 8,9. alcohol abuse. Some measures were adopted to curb With the free availability and accessibility excessive harms, including: of alcoholic beverages in most comm-  Legislation prohibiting driving cars unities, people of various ages could easily while intoxicated. start as mild “social” or “moderate”  Prohibition of sale of alcoholic drinkers and later turn into the category of beverages to youngsters. alcohol use disorder and alcoholism.  Limiting the hours during which the sale or serving of alcohol is allowed. Historical trials to curb Unfortunately these measures proved alcohol consumption: fruitless. Even public education about alcohol hazards proved ineffective in the In the 20th century, because of the various face of slick alcohol advertisement, and the hazards of alcohol consumption, there influence of alcohol industry on public life. were trials to ban, or at least to curb it. In This industry generates huge profits

8 FIMA YEAR BOOK 2014 ALCOHOL worldwide, and is ready to fight any real from the year 2001 to 2002. The effort to curb alcohol consumption. prevalence of alcohol abuse and In the former Soviet Union, campaigns to dependence over a life time and over the curb alcohol consumption started at the last 12 months was 17.8% and 3.8%12. time of the first Bolshevik government According to the 2008 National Survey on after the revolution. But by 1921, this Drug Use and Health, 51.6% of Americans policy failed. Alcohol consumption had aged 12 years or older, reported being returned to very high levels, and alcohol- current drinkers of alcohol. This translates related deaths escalated to almost 15-folds to around 129 million people. More than in some cities such as Moscow. 58 million of them reported binge drinking Subsequently, a series of campaigns in the 30 days prior to the survey, and against alcohol abuse were adopted under more than 17 million reported heavy presidents of USSR, Brezhnev, Andropov drinking13.Increased rates of alcohol and Chernenko under the general heading dependence have been found to be of reducing anti-social behavior. By 1984, associated with male sex, younger age, there was some evidence that both alcohol being single, lower income and White or consumption and alcohol-related crimes Native American ethnicity12. Middle-aged were falling. In early 1985, President adults (30-64 years) have been found to be Gorbachev pursued this line, and all organs at the highest risk for alcohol abuse. In of government were exhorted to develop children and adolescents, statistics are very strategies to reduce alcohol consumption. worrisome. According to the "Monitoring The All-Union Voluntary Society for the the Future Study", 16% of eighth graders Struggle for was launched in had consumed five or more drinks at one September 1985. This campaign finally occasion within the last two weeks collapsed in 1988. The collapse was preceding the study14. Alcohol is by far the ascribed to various factors, including major most commonly used drug among high increases in illegal alcohol production and school students. Seventy two percent of the trade, as well as marked reduction of students have consumed alcohol by the end public finances, which dwindled by more of high school, and 39% have done so by than 28 billion roubles between 1985 and the 8th grade. In 2008, 55% of the 12th 1987.This was followed by an increase of graders and 18% of the 8th graders reported alcohol-related mortality and a decline in having been drunk at least once. This life expectancy, especially among the compares with 10- 20% of high school young and middle aged. Changes on this seniors reporting use of cocaine, and 40- scale were unprecedented anywhere in the 50% reporting marijuana use14. world in peacetime 10,11. Statistics from other parts of the world are These alcohol-related deaths were mainly not less alarming. Binge drinking due to injuries and cardiovascular diseases. (consuming five or more drinks in a single occasion) is a significant component of Epidemiology: drinking behaviors in teens and individuals in their twenties. In a cross-sectional study In all countries where the consumption of from Britain, 56% reported binge drinking alcohol is legally permitted, the majority of at least once in a seven day period15. the adult population drink. A National Compared with individuals who begin Epidemiologic Survey on Alcohol and drinking at or after 21 year of age, early Related Conditions was conducted in USA drinkers have been found to be four times

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more likely to develop alcohol dependence Some studies made conclusions dependant and more likely to be involved in alcohol- on self-reported health, sick leave related violence16,17. relationship with alcohol consumption and Evidence suggests that high doses of other parameters. alcohol at an early age may result in lasting In 1987, the Royal College of Physicians effects on neurophysiological function18, (RCP) published a series of seminal reports and addiction. on the topic of UK government policy on alcohol. The main report was significantly Economic costs: titled: “The medical consequences of alcohol abuse, a great and growing evil”22. Literature is full with staggering economic The evidence on the risks of alcohol burdens on the individual, family and state. consumption is complex. Most systems of In the US, the total cost to national the body can be damaged by alcohol con- economy from alcohol abuse and sumption, but the rate at which harm dependence was estimated to be 185 increases in relation to the amount of billion USD for 199819-21. alcohol consumed varies between different This includes costs of treatment, associated systems. For example, liver disease has an diseases, crime, loss of work time and exponential relationship with alcohol other expenses. There are other costs that consumption, whereas the risk of cancers are difficult to quantify including; domes- shows a dose dependent relationship. tic violence, child abuse and loss of a The risk to which an individual is exposed promising future. to is related to both the amount and the Approximately 27% of heavy alcohol frequency of drinking, in addition to drinkers miss one or more days of work genetics and age. every month, 15% due to an injury or All alcohol consumption carries a level of illness. risk. There is no data to indicate how much Alcohol problems in many parts of the alcohol is safe. But, given the fact that world constitute a serious impediment to alcohol consumption is widespread and socio-economic development and threaten enjoyed by many, there was a judgment to overwhelm their healthcare systems. about what an acceptable level of risk was. RCP published certain guidelines, based on Alcohol and overall health: this very difficult judgment. It recommends “sensible limits of Alcohol use represents an unusual drinking”. These limits have been argued challenge for clinicians, social workers and about for years and in different countries. healthcare policy makers. They include variations in the numbers and Medical literature is replete with discuss- amounts of drinks per week, which are ions and debate about risks and benefits, different between males and females. To related to various levels of alcohol consu- minimize hazards of alcohol consumption, mption. There is general agreement that RCP recommended that people should problem drinking reduces the quality of have three alcohol-free days per week. life for individuals, their families and In December 1995 these government- societies. However, only few studies have adopted guidelines were reviewed and properly evaluated how “social” and changed following some circulated “moderate” alcohol consumption affect the evidence indicating that alcohol drinking quality of life, and health parameters. might give protection from coronary heart

10 FIMA YEAR BOOK 2014 ALCOHOL disease. These changes were not  Highlighting the rising levels of recommended by RCP. In fact they were alcohol harm. adopted by an interdepartmental group,  Proposing evidence-based solutions to comprising of civil servants 23. They made reduce this harm. two extremely significant changes to the  Influencing decision makers to take RCP guidelines. positive action to address the damage Firstly, they substituted the weekly limit caused by alcohol abuse. with a daily one. This, in effect appeared to The World Health Organization (WHO) sanction daily drinking, which is coordinated many forums, global and considered one of the key risk factors for regional studies and publications on the alcohol dependency (addiction) and also global alcohol hazards since its inception. for alcohol-related harms. Secondly, the Alcohol consumption was considered daily drink limits led to a 30% increase in among the top ten causes of mortality the RCP’s adopted guidelines. worldwide. In 2002, alcohol was reported These government guidelines were never to be the underlying cause of some two supported by a review of evidence carried million deaths per year in the world27. out by the RCP, Royal College of General Since then this figure has clearly increased. Practitioners and Royal College of The health hazards related to alcohol are Psychiatrists. As a matter of fact, RCP multiple and well documented28. They disputed these guidelines, and reported that come from both acute consequences daily drinking is an important risk factor (accidents, intoxication…), and chronic for the development of alcohol dependence ones (liver disease, cancer, cardiovascular and for alcoholic liver diseases. disease). The harmful effects include RCP also reported that the majority of mortality, morbidity and socioeconomic young people confine their drinking to ills. “binges”, once or twice a week. These WHO repeatedly advocated population- binges are associated with major health based global interventions, alcohol harms, including accidents, violence, self consumption policies and strategies. There harm and suicide, and as a result, alcohol is is consensus about effective interventions the leading cause of death in the 16-24 age reported in the WHO’s “Alcohol and group 24. A very large number of young Policy Group”28 which address reducing people develop alcohol dependence, and availability of alcohol by all possible become on track to develop physical health measures. complications as they move into their 30s Controlling advertising and marketing of and 40s25-26. alcoholic beverages is a popular public On this basis, RCP criticized the UK topic which is attractive to politicians. The governmental guidelines of 1995, and major problem is the ineffectiveness of considered them potentially dangerous. “partial” restrictions, and unfeasibility of One aspect of this criticism is that alcohol total ban. Thus, alcohol-related harm calls dependence is effectively a disease of the for comprehensive measures and princi- young. ples29. In November 2007, RCP in coordination Drinking habits are communicated by with the Alcohol Health Alliance UK global marketing, advertising and media. (AHA), pursued diligent activities to The “westernization” of drinking habits address the escalating harms of alcohol means escalation of alcohol consumption consumption. These activities were: in many parts of the world. The alcohol

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industry is increasingly globalized, and the WHO publications provided significant big multinational companies have consid- information in areas of alcohol drinking- erable lobbying power to protect their adverse effects, , injur- commercial interests. Lobbying by the big ies and the role of alcohol in emergency alcohol industry has deterred the WHO, departments visits / hospitalizations. the specialized health agency of the United Globally, alcohol causes 3.2% of all deaths Nations, from any stronger actions. (1.8 million deaths annually). It is Health-concerned leaders, worldwide, are estimated that about half of the deaths continuously seeking international and attributable to alcohol are from injuries. global effective collaborations to counter- Alcohol also accounts for 4.0% of all act the alcohol-related problems29. disease burden worldwide. The problem of alcohol-related injuries is Medical morbidity: particularly alarming in many low-and middle- income countries, where alcohol Alcohol can be a significant contributing consumption is increasing. Consequently, factor to many illnesses, such as hepatitis, injury rates are extremely high, where hypertension, tuberculosis, pneumonia, there is lack of appropriate public health , and cardiomyopathy30. It is facilities and policies to deal with this known that alcohol abuse exposes people increase. to infections, and hampers their healing. Emergency rooms are the most important One half of all cases of liver in sites to collect information about alcohol the USA have been attributed to alcohol. involvement in injuries. Unfortunately, few Excess alcohol consumption also contrib- hospitals collect this information routine- utes to central nervous system disease and ly35. In view of unlikelihood of majority of severe psychiatric disorders. involved subjects to access health care apart from emergency departments, the Alcohol and specific illnesses: collection of pertinent data from these patients regarding their drinking patterns is  Accidents, trauma and violence: lacking, which significantly hinders proper interventions in this hard-to-reach popula- Alcohol is implicated in the increased tion group. morbidity and mortality from trauma31, Some of the conclusions of the WHO including collisions with greater severity Collaborative Study on Alcohol and of injuries in motor vehicle accidents32. Injuries, a cross-sectional study conducted There is an increased risk of injuries due to in 12 countries from various parts of the falls, burns, and violence. There is also world from December 2000 to February increased risk of drowning. In addition, 2002, revealed a clear relationship between there is an increased incidence of occupa- alcohol consumption and the risk of injury. tional injuries and there is no identified Up to 45% of injured patients reported safe level of alcohol consumption for the consuming alcohol prior to their injuries. use of potentially dangerous equipment. The majority of patients were males, under Suicide, homicide, serious assaults and 35 years of age, with a peak in the late rape are significantly increased with teens and young adults from low to middle alcohol intake33,34. socioeconomic classes. More than a third Alcohol and injury has been addressed of patients reported that their injury extensively in the world literature. occurred within 30 minutes of their last

12 FIMA YEAR BOOK 2014 ALCOHOL drink. The study was a useful tool to drinkers) than in abstainers, and rose inform health policy-makers of the high progressively with heavier consumption36. burden of injuries associated with alcohol The type of alcoholic beverage, by most use. evidence, does not alter this risk41. There are several studies describing Cancer: correlation of GI cancer risk with alcohol intake, with no clear safe threshold of Alcohol use has been associated with consumption identified42. In one of these increased risk for cancers of multiple studies, as an example, a 2013 meta- organs36. The following is a brief review of analysis of 36 epidemiologic studies the literature describing specific cancers: demonstrated that light alcohol intake (< 1 drink per day) was associated with an  Breast Cancer: increase in risk of oropharyngeal cancer 40 There is consistent evidence that breast (RR 1.17, 95% CI 1.06-1.29) . cancer risk is higher for women consuming low (less than one drink /day) to high (3 or Nonmalignant liver disease: more drinks/day) compared with abstainers. There appears to be a A study of 277,000 men revealed elevated significant dose response relationship that risk of death from cirrhosis among mild begins with alcohol intakes as low as 3-6 drinkers as compared to abstainers. The drinks per week37-39. A meta-analysis of relative risk of those who had consumed one or two drinks per day were: 1.21 and 110 epidemiologic studies conducted in 43 2013, showed a small but significant 3.15, respectively . This implies gradually association between female breast cancer increased risk of cirrhosis, with increased and light alcohol intake40. In the largest levels of alcohol consumption. cohort study of 105,986 women in the Many studies revealed more cirrhosis Nurses’ Health Study, from 1980 until prevalence in heavy drinkers. One half of 200839, there was a gradual increase in the all cases of liver cirrhosis in the USA have risk of breast cancer at lower levels of been attributed to alcohol. alcohol intake (3-6 drinks per week), with Some of the increased risk associated with upward increase of cancer of 10% with moderate drinking may be due to alcohol interaction with other hepatotoxic agents, each 10 grams of alcohol intake. Cancer 44 risk was linearly correlated with cumuli- especially hepatitis viruses . It is well tive lifetime alcohol intake. Moreover, established that cirrhosis is associated with there seems to be greater potential for increased risk of hepatocellular cancer. invasiveness of breast cancer cells associated with alcohol intake37. Cholelithiasis:  Gastrointestinal (GI) Cancer: In the Nurses’ Health Study, women who consumed at least 2-3 drinks weekly were Several GI cancers are linked to alcohol 40% less likely to develop symptomatic consumption, even at low levels of intake. gall stones than abstainers45. The In a study of 226,000 men, the combined mechanism of this protective effect may be mortality rate from cancers of the mouth, due to reduction in the biliary cholesterol larynx, pharynx, esophagus, and liver was saturation index46. This benefit is reversed 40% higher in low (less than daily

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in heavier alcohol consumption, especially Heavy drinking is detrimental to the with alcoholic cirrhosis47. management, morbidity and mortality of diabetic subjects. Pancreatitis:  Pregnancy: Heavy alcohol intake predisposes to both acute and chronic pancreatitis. Moreover, Alcohol is known to have teratogenic mild alcohol consumption may increase effects, and alcohol consumption while relative risk of chronic pancreatitis 48. pregnant increases the risk of fetal mal- development59,60. Osteoporosis: A spectrum of birth defects related to alcohol has been described and is called Heavy alcohol use predisposes to hip Fetal Alcohol Syndrome (FAS). It is fractures by causing both osteoporosis and characterized by fetal growth restriction, falls49. Several studies showed mixed central nervous system dysfunction, renal relationship of “moderate” alcohol intake, anomalies and a characteristic facies61. bone mineral density and fractures. No safe level of alcohol intake during pregnancy exists62. A large case-control Diabetes Mellitus (DM): study of more than 4,700 babies with congenital abnormalities found that even The risk of DM was reported as decreased sporadic intake of only 1-2 drinks during in people with moderate alcohol consump- the whole pregnancy was associated with tion50. A meta-analysis of 15 cohort studies higher risks of eye abnormalities, particul- found a decreased risk of diabetes among arly microphthalmia 62. Low birth weight light to moderate, but not heavy may also be a consequence of mild alcohol drinkers51.The validity of these studies is consumption during pregnancy63. questionable because they are observa- Moderate drinking may raise the risk of tional studies. In any case, studies suggest spontaneous abortion64. This risk increases the following mechanisms for the reported with the increased alcohol consumption65. low DM risk: No evidence supports a benefit of alcohol  Improved insulin sensitivity and lower use during pregnancy to the mother or plasma insulin levels52. fetus. There is consensus that women should completely abstain from alcohol  Lower level of oxidative stress and 66 inflammatory markers53. during pregnancy . However, recent data  Potential effect of alcohol on from Australia indicate that up to 65% of postprandial hyperglycemia54. women drink significant amounts of alcohol before and during early  Effects of “moderate” alcohol intake 67 on adiponectin (an adipocyte hor- pregnancy . mone) which improves insulin sensitivity in animal models55. Cardiovascular disease:

On the other hand, alcohol may worsen There are conflicting reports related to diabetic neuropathy56, and my induce “social” or “moderate” alcohol consump- severe hypoglycemia, lactic acidosis, tion and cardiovascular disorders. Our hypertriglyceridemia and fatty liver57,58. knowledge of effects of (moderate) alcohol consumption is derived primarily either

14 FIMA YEAR BOOK 2014 ALCOHOL from short-term trials analyzing effects of cardiovascular disease risk and sudden alcohol on physiological parameters, or cardiac death. from observational studies that compare To date, randomized trials in this area have moderate drinkers with abstainers. Both not been performed. types of studies suffer from limitations68. The risk of heart failure was reportedly Their validity and reliability is less than reduced with light to moderate alcohol cross sectional or cohort studies. They consumption73. could be adversely influenced by various Chronic alcohol consumption on the other factors including the lobbying liquor hand, may lead to alcohol-induced industry. cardiomyopathy. The incidence of atrial Some observational studies in USA fibrillation (AF) was increased by heavy reported that “moderate” alcohol drinking and binge drinking, while moderate may have some cardio protective benefits drinking does not seem to increase AF. particularly in regards to coronary heart The incidence of hypertension was disease (CHD)69. These studies were not increased by 1.5 to 2 folds in those who supported by similar studies in Europe, consume more than two drinks daily Russia or Australia- . In compared to non-drinkiers74. This effect is addition, these observational studies are dose dependent. usually based on comparison of alcohol Problem drinking is clearly related to drinkers with abstainers (non-drinkers). excessive mortality75. It is the third leading The latter group of individuals is very preventable cause of death in the US76. heterogeneous. Some of them avoid Following the publication of these alcohol because of medical conditions, observational studies indicating that family history of alcoholism, past personal drinking alcohol might give some history of alcohol intake, religious or protection from coronary heart disease, the cultural factors. Royal college of Physicians (RCP), A large systematic review and meta- together with other Royal Colleges, analysis of 84 studies, conducted in many published a report in 199577. The report countries from nearly all over the world, reviewed these studies alongside data on reported that light to moderate alcohol all-cause mortality, psychosocial risks and consumption was associated with a 14- the possibility that publicizing these 25% reduction in the risk of multiple recommendations have led to an overall cardiovascular outcomes, compared to increase in alcohol consumption, and an non-drinkers70. Consumption of larger increase of the number of heavy drinkers. amounts of alcohol was associated with The RCP report balanced the potential higher risk of mortality. benefits of alcohol intake against its A meta-analysis of 34 studies (comprising harms/ risks. It could be summarized in the over a million subjects and 94,000 deaths) following points: found that total mortality was reduced by  For young men: The major causes of 18% in women who consumed one drink death due to alcohol consumption are daily, and in men who consumed one to accidents and violent deaths. two drinks daily, compared to non-  For premenopausal women: Any drinkers71. More than the above level of assumed protective effects against alcohol drinking was associated with coronary heart disease are balanced by increased risk for sudden death72. Binge deleterious effects on breast cancer, drinking was associated with increased and on pregnancy

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 For men aged 55 to 60 years, alcohol  Excessive drinking, especially of harms outweigh any coronary heart strong alcoholic drinks, such as disease benefits. “vodka”, was recently reported, by a  Older people are particularly vulner- large prospective study, to be a major able to various harms of alcohol, due to cause of premature death in Russian physiological changes associated with adults81. aging, even at modest levels of alcohol  Moreover, alcohol-related mortality intake. They are prone to have higher increased exponentially with the blood alcohol levels than younger increased amounts of alcohol people on drinking the same amount of consumed. Death at ages 55-74 years alcohol due to lower body mass to ranged from around 50% for those water ratio, reduced hepatic blood flow consuming less than a bottle of vodka and less efficient hepatic metabolism. per week, to as high as 64% for those Moreover, older people are prone to consuming three or more bottles of develop more depression, dementia, falls vodka per week. and physical illness. Recommended limits  Excess mortality in this study was from for “safe” drinking by older people require external causes (accidents, violence, further considerations. Considering the suicide, homicide …) or from eight increasing of aging population, an diseases, including cardiovascular increased alcohol-related morbidity and deaths (acute ischemic heart disease mortality is expected. other than myocardial infarction).  Defining the boundary between Excessive alcohol consumption and binge moderate and hazardous drinking is not drinking are the third leading cause of clear cut. preventable death in the United States82,  The possible protective effects on coro- and most likely in the rest of the Western nary heart disease could be achieved by world. lifestyle changes including diet and From all these studies, including the exercise, as well as the use of statins. observational studies, researchers provide  Individual factors also contribute to the the following general recommendations: risks of alcohol consumption, including (1) The reported cardiovascular benefits of medication use, co-morbidity, frailty social or moderate alcohol drinking were and physiological changes associated not validated by randomized studies. with aging. (2) Social or moderate drinkers could In Russia, there was increased mortality become “problem” drinkers under various from cardiovascular disease linked to pressures and circumstances, and the alcohol consumption, which is contrary to deleterious sequellae on the cardiovascular the view prevailing in some countries in system will escalate. the West, where alcohol, at least in (3) Binge drinking is associated with moderate amounts, is seen by some as serious cardiovascular complications. cardio-protective69. Some of the explana- (4) Any apparent advantage of moderate tions of this discrepancy include: drinking must be balanced against the  Binge drinking has effects on the heart deleterious effects of alcohol on other which are different from those seen in disorders, including cancer, liver disease, regular moderate consumption 79,80. central nervous system and psychological  This pattern leads to a greatly increased derangements, violence, and socioecono- risk of sudden cardiac death80. mic problems.

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(5) The risk-benefit balance may vary in Effects of the (alcohol dehydrogenase different age group and ethnicities. gene) were studied in a case-control study (6) There is no evidence to support of 396 men with myocardial infarction and encouraging people, with or without CHD, 770 men as a control group. This gene has to drink alcohol. two forms (alleles), one of which In 2001, The American Heart Association metabolizes ethanol quickly (reducing the (AHA) Science Advisory Council body’s exposure to alcohol), and the other concluded: allele metabolizes ethanol slowely91. Daily There is little current justification to drinkers with two copies of the faster recommend alcohol (wine specifically) as alleles had a 38% lower risk of myocardial a cardioprotective strategy83. infarction, as compared with non or rare In 2006, AHA recommended: In the drinkers. absence of randomized trials, the consumption of alcohol cannot be Stroke risk: recommended for CVS risk reduction86. Alcohol beverage types were studied in A meta-analysis of 19 cohort, and 16 case- view of reports that French red wine control studies found the following risks of produced lower coronary artery disease stroke in drinkers, compared to non- mortality85. Red wine contains phenolic drinkers92: and flavonoid substances that have anti-  Heavy drinking increases the risk of all thrombotic and antioxidant properties86. strokes. However, small human studies  Moderate drinking: no significant demonstrated similar protective properties reduction in the risk of all strokes. in using de-alcoholized red wine87. This  Light drinking: lower risk of all material is also present in red grapes. strokes. Resveratol (3,5,4’-trihydroxystilbene) is a These observations were in contrast to substance produced by plants in response another meta-analysis93. “The Nurses’ to stress, and is found in grape skin and Health Study” which found that even light also in red wine. This substance was found drinkers had twice the risk of subarachnoid to extend life of non-mammalian hemorrhage compared to nondrinkers. The organisms, and to improve the metabolic study revealed a slightly lower risk of profile and lifespan of mice fed high fat ischemic stroke, but higher risk for diets90. In man, this substance has to be hemorrhagic stroke93. used in large amounts to produce enough Binge drinking was associated with concentrations. increased risk for all strokes94. Genetic factors have significant implica- The effects of alcohol may be modified by tions on alcohol effects on ischemic heart ethnicity. As an example, in Japan, disease. In a study of 3383 Danish men moderate alcohol use may slightly raise the found that alcohol consumption was only risk of dying from stroke95. protective for men with Lewis blood group Le(a-b-) who are particularly prone to Alcohol intoxication: ischemic heart disease89. This observation was also reported from Two-thirds of American adults consume the Framingham Offspring Study in alcoholic beverages. Up to 10% of adults individuals carrying the Lewis gene-3 are alcohol abusers. Acute alcohol (FUT3) gene90. intoxication is estimated to be responsible

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for over 600,000 emergency department The characteristic withdrawal syndrome is visits each year96. manifested within hours or days of Acute alcohol intoxication is associated stopping or reducing alcohol use. Two or with significant increase of traffic more symptoms must be present, such as accidents, domestic violence, homicide and sweating, tachycardia, tremulousness, suicide. In one study, ethanol was detected anxiety, headache, nausea and/or in 15 to 40% of unselected emergency gastrointestinal problems. department patients97. More severe manifestations are generalized Clinical manifestations of intoxication can tonic-clonic seizures100, hallucinations and include slurred speech, nystagmus, disinhi- which could be fatal101. bited behavior, incoordination, unsteady gait, memory impairment, stupor or coma. Alcohol Availability and Accessibility: Acute intoxication can also induce hypotension and tachycardia, secondary to In view of legalization of production, peripheral vasodilatation or to volume loss. import, export and sale of alcoholic Multiple metabolic derangements may beverages in most countries, alcohol is occur, including hypoglycemia, lactic freely available and accessible. The limited acidosis, hypokalemia, hypomagnesemia legal measures to control some of the and hypophosphatemia98. consequences have proved fruitless. This clinical presentation may be The worldwide tendency towards treatment complicated by ingestion of other of alcoholic individuals while ignoring the substances such as opioids, sympatho- problems of availability and accessibility mimetic drugs, benzodiazepines, barbitur- contradicts the diligent global measures to ates, and other drugs. Serum ethanol prevent other dependence-producing drugs, concentration, although helpful in confirm- such as opiate, cannabis…etc. This was ing the diagnosis, and for legal and expressed by the WHO Expert Committee forensic investigations, often does not on Drug Dependence2: correlate closely with the symptom- “In many parts of the world, problems matology of acute intoxication. Taking in associated with the use of alcohol far consideration the possibilities of head exceed those associated with the non- trauma, mental status changes, presence of medical use of less socially accepted other disease entities, consumption of other dependence-producing drugs such as those drugs, the management of moderate to of amphetamine, cannabis and severe alcohol intoxication represents a types" 2. real emergency medical challenge. The worldwide tendency to treat Alcohol withdrawal: alcoholism, while ignoring the problem of availability and accessibility of alcohol has Drinkers with heavy, prolonged alcohol proved largely fruitless. There prevails a use are at increased risk for alcohol use striking disparity between public, disorder, and its consequences. governmental and international attitudes Excessive alcohol drinking for even one towards alcohol vs other addicting drugs. week can lead to some withdrawal The ill effects of alcoholic beverages far symptoms, and excessive drinking for over exceed those of opiates, barbiturates and one month leads to significant withdrawal hallucinogenic drugs, such as cannabis and 99 symptoms . LSD put together2.

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The main factors behind this major suffer unacceptable burdens of harm from imbalance in approach are: alcohol-related problems. (1) Alcohol is deeply integrated in many In the view of Royal College of Physicians cultures, especially in Western cultures. (RCP), evidence suggests that policy Attempts to prohibit its consumption are measures to tackle the price, availability neither desirable nor possible to the and promotion of alcoholic drinks are the majority of the populace. most effective way of dealing with alcohol (2) Licensing laws have been lax102. In abuse 108. Australia and New Zealand, as examples, it has been well established that licensing Alcohol: Remedy or Malady: premises is associated with a significant amount of alcohol-related harm103,104. All From the previous literature review of governmental efforts to control alcoholic scientific evidence related to alcohol beverages have failed to produce the consumption risk, harms and possible desired effects. Alcohol consumption benefits, the following conclusions could continued to increase105. be derived: (3) : This is a global  There are established risks of handicap! The experience from Australia- morbidity and mortality caused by New Zealand may be illustrative. The alcohol consumption, which include Royal Australian College of Physicians increased risk of various cancers, (RACP) and the Royal Australian and New cardiovascular, and neuropsychiatric Zealand College of Psychiatrists diseases and complications, in addition (RANZCP) have worked together to to increased risk of fetal address the problem of the irresponsible malformations. Added to these are the marketing and promotion of alcohol increased incidences of violence, products. Several recommendations were suicide, homicide, family and work adopted to counteract the influences of productivity disorders. There is also alcohol beverage industry and that of the established worsening of many pre- harmful marketing, promotion and existing medical disorders of various advertising. It seems that the efforts by systems. these professional organizations have been  The reported “observational” reports of unsuccessful in curbing these dominant cardiovascular benefits of “social” or influences 106. Although alcohol industry “moderate” alcohol consumption, published its “DrinkWise Australia”, there could not stand in the face of major is pessimism among many clinicians and medical, psychosocial and economic policy makers about the success of this and harms. All these reports were not other current strategies to prevent alcohol- validated by randomized studies. The related harm. It is a fact that there are Royal College of Physicians in 1987 minimal regulations of alcohol advertising submitted to the fact that “alcohol and promotion. Significantly, the bulk of consumption is widespread and advertising is aimed at young people!. enjoyed by many” and that was behind Effective and evidence- based clinical issuing a “judgment about what an practice and prevention strategies accept- acceptable level of risk was”22. able at the government level, often face In addition to this fact, the dominant opposition from the alcohol beverage influences of profiteering alcohol industry, industry107. The community continues to marketing and advertising play major roles

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in curtailing any meaningful measures to motivation / up-brining, in addition to curb the universal alcohol consumption the influences of the profiteering problem. alcohol industry.  There are staggering economic consequences of alcohol consumption. Islamic Perspectives:  Alcohol consumption is frequently Why Islamic guidance succeeded and associated with smoking and other others failed? : addictive substances.  Starting alcohol consumption in Fourteen centuries ago, Islam had younger age groups and frequent binge completely and successfully eradicated drinking are instrumental in increasing alcohol consumption, in a society in which tendency to transit from “moderate” it was deeply entrenched and intertwined and “social” drinking to alcohol abuse with their daily lifestyle, social occasions, disorders or alcoholism under various culture, rituals and rites. A gradual personal or social influences. These are approach together with nurturing of moral all looming dangers of problematic values in Muslim individuals and societies alcohol use. were the reasons for this success. In the  The current tendency to deal with pre-Islamic era, and even during the early alcohol use disorders, while leaving Islamic years, alcohol consumption was a aside the problem of alcohol deeply entrenched, widespread and availability and accessibility, have indispensible tradition. It was considered a proved to be fruitless. source of joy, nutrition and promotion of  Most countries adopt legalization of good health. Islam did not primarily attack alcohol consumption, with certain alcohol intoxication. Islam, rather dealt limitations such as on drinking whilst with the deep-rooted false belief and value driving cars, and sale to younger age system upon which many habits and groups. Such limitations are without behaviors were based. When Islam real effectiveness in the face of alcohol addressed established habits and traditions, availability and accessibility. Islamic guidance tended towards gradual  Currently, the strong and slick approaches that went hand in hand with advertisement, in addition to the nurturing of values and faith of individuals dominant influence of alcohol industry and societies. Over three years, Qura’nic on policy makers, are strong barriers to verses addressed the issue of alcohol, and negate any influence of education on other deep-rooted traditions, by first the various dangers of alcohol outlining risks and dangers that outweigh consumption on the health, welfare and any limited benefits. The first Quranic safety of individuals and societies. verse in this regard was:  Alcohol prohibition by forcible legal ِ ِ ِ ِ ِ ِ measures was historically attempted in "ﻳَ ْﺴﺄَﻟُﻮﻧَ َﻚ َﻋ ِﻦ ا ﻟْ َﺨ ْﻤِﺮ َوا ﻟْ َﻤْﻴﺴِﺮ ﻗُ ْﻞ ﻓ ِﻴﻬَﻤﺎ إﺛْ ٌﻢ َﻛﺒ ٌﻴﺮ َوَﻣﻨَﺎﻓ ُﻊ ﻟ ﻠ ﻨ ﺎ ِس both the USA and in the previous وإِﺛﻤﻬﻤﺎ أَﻛﺒـﺮ ِﻣﻦ ﻧـﻔِﻌِﻬﻤﺎ .. . . " َ ُْ ُ َ َُْ ْ َ Soviet Union, but unfortunately ended up with disastrous failure. A multiplicity of factors were believed "They ask you about khamr (alcohol, to be behind failure of these historical intoxicants) and gambling. Say: In them is a great sin, and benefits for mankind, but attempts. They include lack of proper 109 education, and of moral-religious their sin is greater than their benefits” .

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The verse points out that there are grave made hideous mistakes in reciting the sins and some benefits involved in alcohol Glorious Qur’an in his prayer. consumption, with greater preponderance This restriction was very significant in two of major and versified harms, that exceed ways: their benefits. (1) Alcohol consumption was placed, for This risk-benefit imbalance was later the first time, face to face against the established by contemporary scientific cardinal worship of the 5 ritual prayers evidence as shown in the literature review (salah) that are distributed thoughtout the cited above. Muslim commentators that day, starting with dawn (fajr) prayer and time, at their level of scientific-medical ending with the night (isha) prayer. knowledge, had explanations of the word (2) This partial restriction was very (sins). They defined (sins) as harms and pertinent in the process of breaking the risks including religious wrong- doing, and basis of alcoholism (addiction). The Arabs harmful clouding of thinking that at that time had established drinking precludes proper attention and performa- traditions of morning drinking (Sabouh), as nce of worship and other functions110. well as early evening drinking Another Tafsir (explanation) referred to (Ghabough). The new restriction was the harmful effects of wasting of wealth instrumental in reducing and wide -spacing (mal) and clouding of thinking (aql)111. of drinking episodes. In fact, there would They were not aware of the grave physical be limited time left for drinking, if one has and mental consequences of alcohol to attend to these collective prayers in the consumption, as recently revealed by mosque, or at home, five times a day. scientific evidence. Breaking the habitual drinking for longer Muslim commentators explained the word hours every day is effective in minimizing “benefits” in terms of some general tendency to alcohol addiction. prevailing impressions at that time, such as The final and most decisive step of total improvement of digestion, getting rid of prohibition was delivered in the wake of a excretions, joyous feelings, in addition to major feast that included both Muhajirin sale profiteering110. (from Makkah) and Ansar (from Madinah) This initial Qura’nic verse was enough for at which hard liquour was served. Once many devout Muslims to turn away from intoxicated, there insued a state of tribal khamr and gambling, seeking purity and boasting, shouting and hand fighting. As blessings of their Creator. they were restored to their senses, and the Subsequently, the next Quranic verse was effects of liquor had worn off, they intered revealed: into a state of depression, and deep . feelings of sinfulness and guiltِ "ﻳَﺎ أَﻳـَﻬﺎ اﻟﺬ َﻳﻦ َآﻣﻨُﻮاْ ﻻَ َﺗـْﻘَﺮﺑُﻮاْ اﻟﺼﻼةَ َوأَﻧﺘُ ْﻢ ُﺳ َﻜ َﺎرى َﺣﺘ َﻰ َﺗـْﻌﻠَ ُﻤﻮاْ At this point the decisive Qur’anic verse ﻣﺎ ﺗـﻘﻮﻟُﻮن ..." .was revealed َ َُ َ “O believers, do not perform prayers when you are drunken (intoxicated), so that you "ﻳﺎ أَﻳـﻬﺎ اﻟِﺬﻳﻦ آﻣﻨﻮا ِإﻧﻤ ﺎ ا ﻟْ ﺨﻤﺮ وا ﻟْ ﻤﻴ ِﺴﺮ واﻷَﻧﺼﺎب واﻷَزﻻم َ know (understand) what you are ُ ْ َ ُ َ َ ُ َْ َ ُ ْ َ َ ْ َُ َ َ ِ ِ  ِ ِ .112 ِرْﺟ ٌﺲ ﻣ ْﻦ َﻋ َﻤِﻞ اﻟﺸْﻴﻄَﺎن ﻓَ ْﺎﺟﺘَﻨﺒُﻮﻩُ ﻟََﻌﻠ ُﻜ ْﻢ ُﺗـْﻔﻠ ُﺤ َﻮن ، إﻧَﻤﺎ ﻳُِﺮ ُﻳﺪ ”saying ِ ِ ِ This verse was revealed when a sahabi اﻟﺸْﻴﻄَ ُﺎن أَن ﻳُﻮﻗ َﻊ َﺑـْﻴـﻨَ ُﻜ ُﻢ َاﻟْﻌ َﺪ َاوةَ َو َاﻟْﺒـﻐْ َﻀﺎء ﻓ ﻲ ا ﻟْ َﺨ ْﻤِﺮ َوا ﻟْ َﻤْﻴﺴِﺮ  ِ ِ ِ (ﷺ) companion) of the Prophet) َوﻳَ ُﺼﺪُﻛ ْﻢ َﻋﻦ ذْﻛِﺮ اﻟﻠﻪ َوَﻋ ِﻦ اﻟﺼﻼة َﻓـَﻬ ْﻞ أَﻧﺘُﻢ ﻣ َﻨﺘـُﻬ َﻮن " performed prayer while inebriated, and

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said: “Never. It is a disease (ﷺ) Satan wants only to cast enmity and prophet.…“ hatred among you, by means of khamr and not a cure”118. (alcohol, intoxicants) and Maysir (games In another more comprehensive Hadith, said: “Allah has sent (ﷺ) of chance), and to turn you away from the the Prophet remembrance of Allah and prayer. Will 113 down both the disease and the cure, and He you not then desist?” . has appointed a cure for every ailment. So At the final stage of this historical event, get your cure through lawful medications, 119 . ”proclaimed his and never use prohibited things (ﷺ) Prophet Muhammad famous Hadith, whereby he cursed Khamr (alcohol, intoxicants), the one who drinks Concluding Remarks it, brews, sells or even serves it114. Following this Hadith, in a matter of a day For the past 14 centuries, Muslim or two, the Muslim community in Madinah communities all over the world are either got rid of all their stored alcoholic free or are the least affected by alcohol and beverages, and became abstinent, in the its consequences. The vast majority of most successful campaign that had ever Muslims, from different cultures, ethnicit- been launched by man against alcohol ies and geographic locations, kept their consumption. Ever since these fateful days, abstinence throughout the ages, together Muslims all over the world, from various with dominant and deep-rooted intellectu- ethnicities and cultures, became liberated al, social, moral and ethical conviction. from alcohol, or are the least affected Arnold Toynbee in his book “Civilization among world populations. Islamic spirit on Trial” said: “Islamic spirit… may be and religious conviction were able to expected to manifest itself in … a accomplish what could never be achieved liberation from alcohol which was inspired by external sanctions of man-made laws. by religious conviction and which was therefore able to accomplish what could The use of alcohol as medicine never be enforced by the external sanction of an alien law….Here, then, in the The issue of using alcohol as a medicine in foreground of the future, we can remark certain ailments, was addressed by several …valuable influences which Islam may prophetic Ahadith. exert upon the cosmopolitan proletariat of a Western society that has cast its net was asked: We use 120 (ﷺ) The Prophet khamr (alcohol) as a medicament. His round the world” . answer was: “It is no cure. It is itself a Even in the U.S.A where proscription of disease”115. alcohol failed (1919-1933), Islam has Abdullah bin Masoud narrated: The proved capable of solving this intricate problem. James Baldwin, a well-known said: “ Allah never made (ﷺ) Prophet 116 Afro-American writer, who himself conv- cure in things He prohibited” . erted to Islam, wrote in his book: “The Fire Abu Hurairah narrated that the Prophet Next Time”, the following passage to his :said: “ That who tries to get cure fellow American blacks120 (ﷺ) through drinking khamr (alcohol), Allah 117 “I remembered my buddies of years ago, in will not cure his ailment” . the hallways with their wine and their A Sahabi (companion) asked the Prophet whisky and their tears, in hallways still about wine as a medicament. The frozen on the needle, and my brother (ﷺ) saying to me once, if Harlem didn’t have

22 FIMA YEAR BOOK 2014 ALCOHOL so many churches and junkies, there would alcohol-related problems must be on the be blood flowing in the streets”. area of primary prevention”. “And now suddenly people who have Islam provides such a successful measure. never before been able to hear this Humanity has to study seriously Islam and message (of Islam) hear it, and believe it, how did it manage to solve such a difficult and are changed ….(Islam) has been able and intricate problem both in the past and to do what generations of welfare workers, present. committees, resolutions, reports, housing projects and playgrounds have failed to do: References: to heal and redeem drunkards and junkies, 1.American Psychiatric Association. Diagnostic and to convert people who have come out of Statistical Manual of Mental Disorders, Fifth Edition prisons and keep them out, to make men (DSM-5), American Psychiatric Association, Arlington, chaste and women virtuous, and to invest VA 2013. 2. Report of a WHO Expert Committee: Problems related both male and female with pride and to alcohol, WHO Technical Report Series No. 650, serenity that hang about them like WHO, Geneva, 1980: 7-13. unfailing light”121. 3. Kloner RA, Rezkalla SH. To drink or not to drink? That is the question. Circulation 2007, 116:1306. The miracle had taken place and these 4. Kerr WC, Greenfield TK, Tujague J, Drown SE. A harassed drunkards and junkies were drink is a drink? Variation in the amount of alcohol completely changed by Islamic teachings. contained in beer, wine and spirits drinks in a US methodological sample. Alcohol Clin Exp Res 2005, The emphasis which has so far been laid 29:2015. on tackling the problem of alcoholism on a 5.http://pubs.niaaa.nih.gov/publications/Practitioner/Clini personal level should change, as it has ciansGuide2005/clinicans_guide.htm (accessed on October 10,2011). proved fruitless. The WHO report on the 6. National Institute on Alcohol Abuse and Alcoholism. problem of alcoholism emphasized the The physicians’ guide to helping patients with alcohol failure of the present day approach of problems. Government printing Office, Washington, DC 1995. Western nations towards the problem of 7. United States Department of Agriculture. Dietary alcoholism. The following passage is guidelines for Americans 2005. Available at: quoted from this Technical Report 122: www.health.gov/DIETARYGUIDELINES/dga2005/docu emnt/html/chapter9.htm (Accessed on December “Problems related to alcohol and 12,2006). particularly to its excessive consumption, 8. Miles Samuel: Learning About Alcohol, American rank among the world’s major public Association of Health, Washington, 1974 P. 23. 9. Ibid. health problems and constitute serious 10. Rayan, M. (1995): Alcohol and rising mortality in the hazards for human health, welfare, and Russian Federation. BMJ/310, pp. 646-648. life". 11. Mckee, M. Alcohol in Russia- Invited Commentary (1999). Alcohol and Alcoholism. Vol. 34, No. 6, PP. 824- “With problems of such magnitude, it is 829. clear that even the most effective treatment 12. Hasin DS, Stinson FS, Ogburn E, Grant BF. programs for alcohol dependence cannot Prevalence, correlates, disability, and comorbility of DSM-IV alcohol abuse and dependence in the United possibly constitute an adequate response. States, results from the National Epidemiologic Survey Moreover, treatment approaches have had on Alcohol and Related Conditions. Arch Gen Psychiatry only limited success in this field, and there 2007, 64:830. 13. Substance Abuse and Mental Health Services is much concern at present about their cost Administration, 2009. Results from the 2008 National effectiveness even when they are Survey on Drug Use and Health: National Findings successful. In the light of all these (Office of Applied Studies, Substance NSDUH Series H- 36, HHS Publication No. SMA 09-4434). Rockville, MD. considerations, it appears inescapable that 14. Johnston LD, O’Malley PM, Bachman JG, the major focus of efforts to reduce Schulenburg JE. Monitoring the Future national results on adolescent drug use: Overview of key findings, 2008

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Advisory: Wine and your heart: a science advisory for 66. National Institute of Alcohol Abuse and Alcoholism. healthcare professionals from the Nutrition Committee, Drinking and your pregnancy. National Institute of Council on Epidemiology and Prevention, and Council Health. US Department of Health and Human Services, on Cardiovascular Nursing of the American Heart 1996. Association. Circulation 2001, 103:472. 67. Bower C. Tdethon Institute of Child Health Research. 84. American Heart Association Nutrition Committee, Western Australia. Personal communication, 2005. Lichtenstein AH, Appel LJ, et al. Diet and lifestyle 68. GrØnbaek M, Johansen D, Becker U, et al. Changes recommendations revision 2006: a scientific statement in alcohol intake and mortality: a longitudinal population- from the American Heart Association Nutrition based study. Epidemiology 2004, 15:222. Committee. Circulation 2006, 114:82.

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85. Renaud S, de Lorgeri M. Wine, alcohol, platelets, and 104. Ibid, P. 36 the for coronary heart disease. Lancet 105. Ibid, P. 41. 1992, 339:1523. 106. Royal Australian College of Physicians (2005). 86. Carnacini A, Arfelli g. Selected nutritional www.racp.edu.au/hpu/policy/index.htm components of wine. Alcologia 1994, 6:41. 107. Ref. #102, P. 69-71. 87. Opie LH, Lecour S. The red wine hypothesis: from 108. Babor, T. et al. Alcohol, no ordinary commodity; concepts to protective signaling molecules. Eur Heart J research and public policy, 2nd edition, Oxford: Oxford 2007, 28:1683. University Press. 2010; 243-46. 88. Baur JA, Pearson KJ, Price NL, et al. Resveratrol 109. Glorious Qur’an, Al-Baqara, 2:219. improves health and survival of mice on a high-colorie 110. Al-Sabouni, M.A, Abridged Tafsir-Ibn Kathir,Darul diet. Nature 2006, 444:337. Qur’an Al-Karim, Beirut-Lebanon, 7th Ed, 1981, p 192- 193. 89. Hein HO, SØrensen H, Suadicani P, Gyntelberg F. 111. Hawwa S. Al-Asas fi Al-Tafsir, 1st volume, Dar al- Alcohol consumption, Lewis phyenotyes, and risk of Salam publishing, Cairo-Egypt, 1985, p 507. ischemic heart disease. Lancet 1993, 341:392. 112. Glorious Qur’an, Al-Nisa’a, 4:43. 90. Djoussé L, Karamohamed S, Herbert AG, et al. 113. Glorious Qur’an, Al-Maeda, 5: 90-91 Fucosyltransferase 3 polymorphism and atherothrombotic 114. Abu Daoud, Al-Sunan.,Hadith Darul Risalah Al- disease in the Framingham Offspring Study. Am Heart J Alamiyyah, Damascus 2009 2007, 153:636. 115. Sahih Muslim , kitab al-Salah, Hadith #1984. 91. Hines LM, Stampfer MJ, Ma J, et al. Genetic Publisher: Beirut Afkar Al-Dowliyyah, Riyadh, Saudi variation in alcohol dehydrogenase and the beneficial Arabia, 1998. effect of moderate alcohol consumption on myocardial 116. Sahih Al-Bukhari, Maktabat Al Nahdha Al Haditha; infarction. N Engl J Med 2001, 344:549. Cairo;1957; Kitabul Ashribah. 92. Reynolds K, Lewis b, Nolen JD, et al. Alcohol 117. Abu Na-eem Al Asfahany: Tibbi Nabawi. Dar Ibn consumption and risk of stroke: a meta-analysis. JAMA Hazm, Beirut,2006;commented by Musthafa Khider Al 2003, 289:579. Turkey;Vol 1,page 199-201. 93. Stampfer MJ, Colditz GA, Willett WC, et al. A 118. Narrated by Muslim , kitab al-Salah, Hadith. prospective study of moderate alcohol consumption and Publisher: Beirut Afkar Al-Dowliyyah, Riyadh, Saudi the risk of coronary disease and stroke in women. N Engl Arabia, 1998 J Med 1988. 319:267. 119. Abu Daoud, Al-Sunan, Hadith #3874. Darul Risalah 94. Sundell L, Salomaa V, Vartiainen, et al. Increased Al-Alamiyyah, Damascus 2009. Stroke is related to a binge- 120. Arnold Toynbee: Civilization on Trial; Oxford drinking habit. Stroke 2008, 39:3179. University Press; Newyork; 1948;(out of print) 95. Kono S, Ikeda M, Tokudome S, et al. Alcohol and 121. Baldwin, James: The Fire Next Time, a penguin mortality: a cohort study of male Japanese physicians. Int book, London, 1962, p. 39 and 68, quoted by M. Badri, J Epidemiol 1986, 15:527. Islam and Alcoholism, p. 60-61. 96. Pletcher MJ, Maselli J, Gonzales R. Uncomplicated 122. WHO Technical Report No. 650, P. 13. alcohol intoxication in the emergency department: analysis of the National Hospital Ambulatory Medical Care Survey. Am J Med 2004, 117:863. 97. Cherpitel CJ. Breath analysis and self-reports as measures of alcohol-related emergency room admissions. J Stud Alcohol 1989, 50:155. 98. Vonghia L, Leggio L, Ferruli A, et al. Acute alcohol intoxication. Eur J Intern Med 2008, 19:561. 99. ISBELL H, FRASER HF, WIKLER A, et al. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 1955, 16:1. 100. Roffman JL, Stern TA. Alcohol withdrawal in the setting of elevated blood alcohol levels. Prim Care Companion J Clin Psychiatry 2006, 8:170. 101. Yost DA. Alcohol withdrawal syndrome. Am Fam Physician 1996, 54:657. 102. Stockwell TR. Alcohol misuse and violence: An evaluation of the appropriateness and efficiency of liquor licensing laws across Australia, report No. 5. Australian Government Publishing Service. Canberra 1995. 103. The Royal Australian College of Physicians (RACP) and The Royal Australian and New Zealand College of Psychiatrists (RANZCP). Alcohol Policy: Using evidence for better outcomes. 2005, P 40. Sydney. http://www.racp.edu.au/hpu/policy/index.htm

26 FIMA YEAR BOOK 2014 TOBACCO DEPENDENCE: THE WHOLE STORY

Feras I. Hawari*

Abstract:

The use of tobacco dates back to hundreds of years and is considered highly addictive. Nicotine is the predominant substance that causes tobacco dependence. Nicotine exerts its effect via similar neurological pathways used by other recreational drugs resulting in high level of dependence. All forms of exposure to tobacco including active use of tobacco, second-hand as well as third-hand exposure to tobacco smoke are known to be harmful. Tobacco is the only risk factor that is common between all non-communicable diseases including cardiovascular diseases, respiratory illnesses, cancer and diabetes mellitus. International consensus regarding the harms of tobacco is now evident. Many international organizations are mapping the way for the end of tobacco. Until then, aggressive treatment for those subjects interested in quitting must be provided in order to prevent a significant surge in non-communicable diseases especially in low income countries. Tobacco dependence is a chronic relapsing disorder that requires a multidisciplinary approach using psychological and pharmacological techniques.

Keywords: Tobacco dependence, tobacco harms, tobacco control, tobacco dependence treatment. The history of tobacco1,2: Tobacco is a naturally deadly plant that statement made by Sir Francis Bacon who initially was grown only in North and South noted that ” trying to quit the bad habit was America. It belongs to the same family as really hard”. By mid-1600’s it became morally potatoes and pepper. Following the discovery unacceptable to smoke in certain states of the of America, sailors brought tobacco with them United States of America such as Massa- to Europe and then to the rest of the world. In chusetts due to the fact the tobacco may be the 1500’s it was thought that tobacco can cure harmful. In 1760, Pierre Lorillard established a all diseases and was promoted as such by company in New York City to process physicians and recommended to be taken tobacco, cigars, and snuff and became the daily. Later in the 1600’s, tobacco became so oldest tobacco company. The tobacco industry popular and was used instead of money to became well established since then and played complete business transactions. During those a role in financing governmental actions times the first hints that tobacco might be including military operations. Following that harmful began to surface. and in 1826 specifically, nicotine was isolated In 1610 the first evidence that tobacco might in its pure format and was declared few years be addictive and that smokers might be later poisonous and that it can be used as an interested in quitting was concluded by a insecticide.

*Dr. Feras Hawari, MD, FCCP Consultant Pulmonologist Cancer Control Office King Hussein Cancer Center (KHCC) Amman-Jordan E-mail: [email protected]

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In 1836 the first statement was made regard- inhaling the smoke or as smokeless tobacco ing the lethal effects of nicotine as a chemical which is usually consumed either orally or that might be able to kill a human being. nasally, without burning or combustion. Both Cigarettes were first manufactured in 1847. By forms of tobacco consumption increase the the year 1900 cigarettes be-came the major risk of cancer and lead to nicotine addiction. tobacco product made and sold. In 1901 for Combustion, however, uses heat to create new example, 3.5 billion cigarettes and 6 billion chemicals that are not found in unburned cigars were sold. Cigarettes continued to tobacco such as carbon monoxide, tobacco- spread after that to a point that they were part specific nitrosamines (TSNAs) and benzopy- of soldiers’ rations during World War II. rene, and allows them to be absorbed through Finally, in 1964 the first USA Surgeon Gener- the lungs1. al report came out carrying the title “Smoking Manufactured cigarettes are the most and Health” focusing on health effects of commonly consumed tobacco products tobacco and providing the first document for worldwide. They consist of tobacco that is governments to start regulating and controlling processed with chemicals and flavors such as the spread of tobacco. Later, more Surgeon menthol and rolled into a paper-wrapped General reports began to shed the light on the cylinder. As it burns from one end, smoke is harmful effects of tobacco till the year 1982 inhaled from the other end through a cellulose when second hand smoke exposure was acetate filter. Cigars are made of air-cured and declared a risk factor for the development of fermented tobacco rolled in tobacco-leaf lung cancer resulting in the gradual banning on wrappers. This process of aging and fermenta- smoking in public places. Throughout the tion results in high concentrations of carcino- years, all efforts by governments to curb the genic compounds inhaled by smokers that are spread of tobacco were constantly faced by higher than in cigarettes. Waterpipe, also counter novel and misleading tactics by the known as shisha, hookah, narghile, or hubble- tobacco industry that encouraged the use of bubble constitutes now a world-wide tobacco through marketing to teenagers and epidemic3. The additional use of charcoal in females using products designed specifically waterpipe smoking to indirectly heat and burn to attract such consumers. In addition, they tobacco represents a significant added risk that started diversifying their products to include contributes to the carcinogenicity of this food and clothing. Lately, the tobacco industry method of smoking. When smoking waterpipe, moved into a new line of production, electron- smoke is drawn through the water to be ic cigarettes in order to face global efforts partially cooled and inhaled into the lungs aiming at putting an end to this industry and through a hose. Flavored tobacco maybe used reducing tobacco prevalence to less than 5% too. Kreteks, another form of smoking by 2040. Worldwide, 3.8 million hectares of tobacco, are usually clove-flavored and contain agricultural land are used in tobacco agricul- eugenol which has an anesthetic e ect4. ture distributed over 124 countries. China Flavoring in general usually allows for deeper grows 43% of the world’s tobacco cigarettes and thus more harmful smoke inhalation.ff This accounting for 92% of the value of all tobacco form of smoking tobacco is commonly used in products sold globally. countries in Southeast Asia such as Indonesia. Contrary to the belief of the general public, Forms of tobacco roll-your-own cigarettes which are hand-filled And tobacco smoke exposure: by the smoker using paper and fine- Tobacco is used either by burning dry or cut loose tobacco contain high concentrations processed leaves of the tobacco plant and of tobacco particulates, tar, nicotine, and

28 FIMA YEAR BOOK 2014 TOBACCO

TSNAs resulting in increased risk for smokers to environmental tobacco smoke”. developing cancers of the head and neck, Such conclusion was then the basis for strict lungs, and esophagus. It is most prevalent in implementation of banning the exposure to Europe and New Zealand. Bidis on the other second hand smoke in public places11.Another hand, consist of a small amount of crushed form of exposure to tobacco smoke is the tobacco, hand-wrapped in dried temburni or newly described third-hand smoking. This tendu leaves, and tied with string. Bidis deliver refers to the chemicals and products that more tar and carbon monoxide than manufa- precipitate on the surfaces after second hand ctured cigarettes due to the fact that users need smoke is cleared12. to pu harder to keep them lit. Bidis are most Third-hand smoke contaminate surfaces, prevalent in South Asia and India. Pipes are furniture and clothing with carcinogenic madeff of briar, slate, clay, or other substances. chemicals such as radioactive polonium-210 After placing tobacco in a special bowl, it is and tobacco-specific nitrosamines13,14. burned and smoke is inhaled through the stem. These chemical could potentially pose great Pipes are prevalent worldwide. Sticks are deal of danger to infants and young children made from sun-cured tobacco and wrapped in who are more likely to crawl and eat with their cigarette paper. hands without washing them. Research is Smokeless tobacco forms include chewing underway to expose the real health risks tobacco, moist tobacco and dissolvable associated with third-hand smoking15. tobacco. All these forms deliver nicotine through the buccal mucous membranes. Dry Epidemiology, expected health tolls snuff is inhaled through the nose or taken and finance: orally. Despite efforts to control the spread of Second-hand smoking (passive smoking) is tobacco, currently 20% of the world’s another form of exposure to tobacco smoke. population, that is approximately one billion, This type of exposure does not only contribute are active smokers. Eighty percent of smokers to the initiation of smoking, development of 5 are males. Such large number of smokers is tobacco dependence and significant irritation not only causing a rise in morbidity and to those who are exposed to it, but it also mortality due to various diseases that result contributes to significant mortality and 6 directly from smoking, but also contributing morbidity in the community . Passive smoking significantly to death resulting from second can significantly elevate the level of carbon hand smoking especially in women and monoxide, increase risk of lung cancer, coron- children While current death toll from second ary artery disease and sudden cardiac arrests in 7 hand smoking is estimated to be at 600,000 those expose to it . In the 1960s the adverse individuals annually1, it is also estimated that effects of maternal smoking on the developing 75% of these deaths are among women and fetus and on children exposed to second hand children. More than half the countries of the smoke in smoking households were 8,9 world have a female smoking prevalence rate reported . Those fetuses who were exposed to of less than 10%. Smoking rates among boys environmental tobacco smoke suffered from 10 and girls are more comparable and differ by decreased lung function . All that led to a less than five percentage points in almost half conclusion by the US Department of Health of the world’s countries. Smokers consumed and Human Services (USDHHS) in 1986, that nearly 5.9 trillion cigarettes in 2009. Tobacco “Simple separation of smokers and non- taxation is considered a significant source of smokers within the same air space may reduce, revenue income for most countries. Despite but does not eliminate, exposure of non- the fact that governments collect nearly $133

FIMA YEAR BOOK 2014 29 TOBACCO

billion in tobacco tax revenues each year, they mes have been classified as substance abuse spend less than $1 billion on tobacco control. disorders under WHO International Statistical Further increase in revenue is expected if illicit Classification of Diseases and Related Health trade were to be eliminated with reports Problems (ICD 10)18, an important step in reaching up to USD 31.3 billion in immediate justifying and encouraging governments to gains upon the elimination of such trade16. The offer treatment to smokers. In general, World Health Organization (WHO) recomme- dependence develops when the neurons adapt nds that at least 70% of the retail price of to the repeated drug exposure and only tobacco products come from excise taxes. At function normally in the presence of the least 86% of WHO member states imposed a drug19. Tobacco dependence is driven by the tobacco excise tax, and at least 14% use a highly addictive nature of nicotine. As a portion of tobacco tax revenue for health psychoactive drug, nicotine induces euphoria, purposes. Some countries are now envisioning serves as a reinforcer of its use and acts both an end game for tobacco, with prevalence as a stimulant and a depressant. Strong and targets of under 5%. The WHO Frame Work overwhelming withdrawal symptoms develop Convention on Tobacco Control (FCTC) treaty in its absence. Tobacco dependence fulfils all covers 87.4% of the world population. the criteria for substance abuse as outlined in Approximately 3.8 billion people are covered the ”Diagnostic and Statistical Manual of by at least one of the six MPOWER strategies Mental Disorders, 4th Edition”20. It is ranked that will be discussed below at the highest third after heroin and cocaine and higher than level of achievement. The number of people alcohol and cannabis in its ability to cause protected by comprehensive smoke-free laws dependence21. The combination of its highly has doubled from 2008 to 20101. addictive property as well as the severe adverse effects that it inflicts on its active Tobacco initiation and dependence: users as well as the severe detrimental health Tobacco initiation typically occurs during effects second and third hand smoking have on childhood or adolescence. It is an acquired the population, caused religious Islamic 16 social behavior . Social learning occurs in leaders in many Muslim countries such as children as they adopt behaviors in part Jordan, Egypt, many countries in Gulf through observation of parents, peers, and Cooperation Council as well as Islamic other role models. During the teenage years, countries in southeast Asia to issue a Fatwa peer pressure becomes the dominant social that using tobacco products is forbidden 16 influence . Media plays an important role in according to Islamic rules (Haram)22-25. It is promoting and normalizing the appearance and important to note that nicotine mechanism of the behavior of smokers through projecting action and the targeted areas in the brain are famous figures smoking in public. Initially, similar to other recreational drugs such as initiation is mostly voluntary, however, upon cocaine. The principle mechanism of action is the development of addiction, self-control can thought to be targeting areas in the brain such become seriously difficult and impaired. The as the nucleus accumbens and increasing cycle of nicotine addiction starts when nicotine levels of dopamine which in return result in containing products are used for pleasure and the desirable effects and inhibit the withdrawal for enhancing mood and perform-ance. As symptoms that may result from abstinence tolerance and physical dependence develop from the drug26. Nicotine reaches the brain over time continuous use of nicotine products through either the lungs when smoked or is used to self-medicate withdrawal symptoms mucous membranes when smokeless tobacco 17 in addition to the above sought after effects . forms are used. Although the levels of many Tobacco dependence and withdrawal syndro-

30 FIMA YEAR BOOK 2014 TOBACCO substances are reported to increase in the brain discontinue once the treatment goals are upon exposure to tobacco smoking such as achieved. Although it has been always serotonin and endogenous opiates, dopamine emphasized that nicotine is the most important remains the main chemical involved in the chemical in cigarettes that contributes to its process of positive reinforcing aspects of highly addictive properties, other compounds nicotine addiction and the desired feelings such as acetaldehyde, ammonia compounds, sought by those who use tobacco. As nicotine and menthol also make cigarettes more reaches the brain it binds to a special receptor addictive through increasing free-base known as α4β2 nicotinic acetylcholine receptor nicotine, making it easier to produce larger (nAChR)located in the ventral tegmental puffs (filter-tip ventilation) and other factors region which results in the release of that reduce the concerns for smokers and 27,28 34 dopamine . As nicotine binds to α4β2 increase the attractiveness of the products . nicotinic acetylcholine receptor (nAChR) Nicotine is metabolized primarily by the liver occupancy on glutamatergic terminals, glutam- enzymes CYP2A6, UDP-glucuronosyltrans- ate, an excitatory neurotransmitter, is released fease (UGT), and flavin-containing mono- which results in an increased release of oxygenase (FMO). Many factors influence the dopamine in the nucleus accumbens and the metabolism of nicotine such as genetic factors, frontal cortex29,30. In addition Nicotine binds diet, age, sex, use of estrogen-containing to α4β2 nicotinic acetylcholine receptor hormone preparations, pregnancy, kidney (nAChR) occupancy on gamma-aminobutyric disease, other medications, and smoking acid (GABA)-releasing terminals31. itself35. Nicotine is further metaboli-zed to cotinine, which may be measured in blood, This binding causes an increase in the levels of urine, saliva, hair, or nails. Cotinine levels are GABA, an inhibitory neurotransmitter. used to distinguish smokers from non- Furthermore, nicotine binds to a specific smokers. Levels exceeding 3 ng/ml indicate receptor in regions of the brain such as the active smoking status in countries with low nucleus accumbens and result in the produc- 32 exposure to second hand tobacco smoke. tion of dopamine . These chain reactions start in 10-20 seconds Second hand smoke exposure is believed to after inhalation mainly due to the large surface play an important role in the occupancy of 33 α4β2 nicotinic acetylcholine receptor. Recent area in the lung available for absorption . In 36 general, nicotine dependence follows a similar evidence utilizing Positron emission tomo- pattern that occurs with other substances and graphy scanning measured whether moderate second hand smoke (SHS) exposure results in that is characterized by both the persistence of brain α4β2* nicotinic acetylcholine receptor a drug-seeking behavior and the emergence of occupancy in smokers and non-smokers. The withdrawal symptoms upon the abrupt 32 study concluded that nicotine from SHS cessation of nicotine administration . In the exposure results in substantial brain α4β2* end, chronic nicotine exposure result in a nAChR occupancy in smokers and non- neurobiologic adaptation and desensitization smokers. In addition, the finding suggested of the receptors with the need to increase those that such occupancy would be sufficient to receptors through further increase in the deliver a priming dose of nicotine to the brain quantities of tobacco consumed. However, not that contributes to continued cigarette use in all forms of nicotine delivery pose an equal risk in establishing or maintaining nicotine smokers. It was also important to note that addiction. Nicotine replacement therapy used while moderate exposure tested in this study in treating tobacco dependence for example, is was sufficient to cause an increase in plasma less likely to cause dependence and easier to nicotine concentration of approximately 0.2

FIMA YEAR BOOK 2014 31 TOBACCO

ng/mL and a mean 19% brain α4β2* nAChR pressures on countries with limited resources occupancy in young adults, heavy SHS to enforce their tobacco control regulations41. exposure (in enclosed rooms with multiple NCDs related deaths are expected to increase smokers) demonstrated increases in plasma by more than 25% in low income countries nicotine levels greater than 2 ng/mL and over the next 15 years42. Cardiovascular 37 greater than 70% α4β2* nAChR occupancy . diseases (CVDs) occupy the number one spot These alarming findings have greater among all NCDs that cause death in humans. implications in countries where second hand The relation between tobacco use and exposure control are not implemented result- cardiovascular diseases was recognized in the ing in significant exposure in nonsmokers first US surgeon general report in 196443. especially prepubescent children and infants Cigarette smoking accelerates atherosclerosis who have a 1-minute ventilation per kilogram and contributes to cardiovascular diseases of bodyweight that is approximately 2 to 3 through many mechanisms that precipitate times higher than adults. Because of that thrombosis, hemorrhage, or vasoconstriction increases in plasma nicotine concentration and resulting in the end in vascular occlusion and occupancy of brain α4β2* nAChRs from ischemia. Cigarette smoking affects blood similar levels of SHS exposure may be even lipids profile and hemostasis. Smokers have greater for children than for adults, thus setting lower concentrations of high density lipopro- them up to be dependent on nicotine during teins, a risk factor for coronary artery diseases. early childhood. Such studies that link SHS Carbon monoxide resulting from the exposure and craving in smokers as well as combustion of tobacco is significantly elevated priming nonsmokers especially children is in the blood of smokers. It is known to have highly relevant to public policy and laws that more than 200 times higher affinity for aim at limiting SHS exposure in closed public hemoglobin than that of oxygen, thus directly places38,39. reducing oxygen delivery to the tissues. Overall, smoking causes CVD through Health effects of tobacco: multiple mechanisms including: endothelial Every year more than 5 million people die dysfunction, increasing prothrombotic effect, from tobacco-related diseases. By the year enhanced platelet activation in response to 2030, this number is expected to near 10 different stimuli, inflammation through κ 44 million40. With high income countries making activation of NF- B pathway , altered lipid efforts to limit the spread of tobacco in their metabolism, and increased demand for myocardial oxygen. All these proposed areas and consequently succeeding in mechanisms would result in a decreased decreasing the prevalence of smoking, it is supply of myocardial blood and oxygen either expected that more than 80% of these tobacco- directly through narrowing of the lumen (due related deaths will occur in low income 1 to atherogenesis plaque formation and vasoco- countries . Tobacco is currently the most nstriction) or through the increased demand easily preventable cause of death and is the (due to nicotine mediated sympathetic only risk factor that is common among all non- stimulation and increased heart rate, blood communicable diseases (NCDs), namely pressure and myocardial contractility). The cardiovascular disease, cancer, respiratory 2010 Surgeon General’s report45 reported an illnesses and diabetes mellitus. However, the World Economic Forum estimates that the cost increase in coronary heart disease risk with of these diseases in low income countries is more cigarettes smoked per day only up to expected to exceed USD 20 trillion over the about 25 cigarettes. Others showed such next 15 years, thus exerting enormous relation to continue up to 40 cigarettes per

32 FIMA YEAR BOOK 2014 TOBACCO day46. These effects are not exclusive for smoke might predispose to breast cancer. In active tobacco smoking, In fact, second- hand general, smoking has been associated with smoke is also associated with chronic decreased survival in patients with a variety of inflammation and a non-linear dose-response cancers such as those of the head and neck, relationship between such exposure and breast, colon, rectum, prostate and others58. cardiovascular effects47. Jefferis et al showed This negative effect on survival is that serum cotinine in nonsmokers was multifactorial. For example, smoking has been positively associated with white blood cell associated with poor nutrition, co-morbidities, count and with levels of C-reactive protein impaired immune function and accelerated (CRP), Interleukin-6 (IL-6), fibrinogen, and carcinogenesis and disease progression59,60. matrix metalloproteinase 9. The CRP levels of Second, patients who continue to smoke while nonsmokers were about one-third lower than they are receiving chemo and radiotherapy are the levels of active smokers, but CRP levels at risk of receiving suboptimal therapy for increased more sharply among nonsmokers at their cancer61 and have a higher chance of higher exposure levels48. These findings developing adverse events related to these emphasize again the benefits of banning modalities of treatment62,63. Third, the smoking in public places. In addition to development of a second primary cancer and coronary heart disease, a growing body of the negative impact of smoking on the life of evidence indicates that smoking causes sudden cancer survivors are other significant risks that death49, aortic aneurysms50, and peripheral cancer patients who continue to smoke must vascular disease51,52. There is a dose-response deal with64,65. relationship between smoking and cerebro- Smoking and pulmonary diseases: vascular disease53,54 and a new strong evidence Smoking is known to cause and affect many demonstrates a causal relationship between respiratory illnesses such as Chronic Obstruc- exposure to second hand smoke and increased tive Pulmonary Disease (COPD), asthma, risk of stroke up to 30%55,56. tuberculosis and pulmonary fibrosis. Smoking causes all elements of the COPD phenotypes Smoking and cancer: It has been established that smoking increases including emphysema and damage to the the risk for certain cancers such as those of the airways of the lung. Smoke recruits inflamma- head and neck, lung, urinary bladder and tory cells such as macrophages and liberates leukemia. Tobacco smoke contains more than proteases from viable lung cells which in 7,000 chemicals, and at least 69 of these can return disrupt the function of protease 57 inhibitors like α1-antitrypsin. This results in cause cancer . facilitating the effect of proteases and the Examples of these chemicals include aromatic destruction of extracellular matrix. Evidence is amines, polycyclic aromatic hydrocarbons suggestive that women who smoke are more (PAHs), tobacco-specific nitrosamines; forma- susceptible to develop severe COPD at ldehyde, acetaldehyde, 1,3-butadiene, and younger ages33. benzene. When inhaled, these substances cause DNA damage, inflammation and muta- Similarly, asthma is impacted by smoking tions in oncogenes and tumor suppressor genes through many mechanisms. Chronic airway leading to loss of normal growth controlled inflammation, impaired mucociliary clearance, mechanisms54. Recently, new evidence impaired growth of the lungs during child- concluded a causal relationship between smok- hood, and increased bronchial hyper-respon- ing and colon and liver cancers33. In addition, siveness are all enhanced by smok-ing54,66. evidence is suggestive that both active Immunologic mechanisms include effects on T smoking and exposure to second-hand tobacco cell function and a higher ratio of Th2/Th1,

FIMA YEAR BOOK 2014 33 TOBACCO

increased production of IgE, and greater infertility in both males and females. Maternal allergic sensitization. Cigarette smoke may active smoking might be also linked to increase neurogenic inflammation in the spontaneous abortion and fetal anomalies such bronchial airway67,68 resulting in further as orofacial clefts, clubfoot, gastroschisis, and inflammation of the airway. atrial septal heart defects42. In summary, the evidence is suggestive of a causal relationship between active smoking Tobacco control strategies: and the incidence of asthma in adults as well as exacerbation of asthma among children, The WHO through its international treaty the adolescents, and adults. Serious lung infec- “Frame Work Convention on Tobacco Control tions can also be promoted by smoking. For (FCTC)” lists six evidence-based strategies example, the risk of mycobacterium that aim to address the various articles in this tuberculosis disease, mortality from the treaty including policy, regulatory and disease and disease recurrence are all higher in economic interventions75. Summarized in the smokers69. Lastly, some evidence suggests a word MPOWER, the components stand for the possible relationship between cigarette smok- following: ing and idiopathic pulmonary fibrosis70. Monitor tobacco use and prevention policies: Cigarette smoking and diabetes mellitus: The National data are collected periodically to risk of developing diabetes is 30–40% higher track tobacco use and consumption. The for active smokers than nonsmokers42. There is Global Adult Tobacco and the Global Youth a positive dose-response relationship between Tobacco surveys are examples. Unfortunately, the number of cigarettes smoked and the risk many countries in the world are not capable of of developing diabetes. Furthermore, smoking conducting these surveys due to their high aggravates insulin resistance in persons with cost. diabetes resulting in suboptimal control of the Protect people from tobacco smoke: blood glucose42. Recently, smoking was Implementing bans on smoking in public implicated in the pathogenesis of rheumatoid places is the cornerstone of this strategy. arthritis. The mechanism appears to involve While this has been a very successful strategy both the effects of oxidizing chemicals in the in high-income countries to reduce the spread smoke and the sympathomimetic effects of and harms of tobacco, it has been very nicotine42. The incidence of neovascular and challenging to implement in low income atrophic forms of age-related macular countries due to the significant lack of degeneration are also increased by smoking. governmental commitment and a strong Multiple pathways are likely responsible for tobacco lobby that has been transferring its the degenerative changes in the macula. In markets to those vulnerable regions. genetically susceptible persons, smoking Offer help to quit tobacco use: causes changes in retinal pigment epithelium, This strategy will be discussed in details in the Bruch’s membrane, and choroidal endothelium following section. and generate a local inflammatory response71. Warn about the dangers of tobacco: Oxidative stress and vascular insufficiency are Mass media campaigns as well as the use of proposed mechanisms for smoking-related pictorial warnings are known successful damage to retinal structures72,73. methods to attract public attention, deliver Additional evidence is sufficiently conclusive necessary health messages and drive up the that smoking is associated with many other intention to quit among smokers. Pictorial conditions such as erectile dysfunction, ectopic warnings on cigarette packs are usually pregnancy74 and contributes significantly to graphic and occupy at least 50% of the surface

34 FIMA YEAR BOOK 2014 TOBACCO area of the cigarette pack. In the Eastern phlegm occurs within hours to days from Mediterranean Region (EMR), Jordan, Egypt quitting78. and Iran introduced those warnings and in the In the long-term, quitting tobacco reduces process of upgrading them. premature death by 90% for those who quit Unfortunately, Enforcement is generally before the age of 30 and by 50% for those who lacking in Eastern Mediterranean Region, quit before the age of 5078. In five years, the despite evidence that such intervention would risk of stroke falls to that of a non-smoker, and help in reducing the prevalence of smoking, the risk of head, neck and bladder cancers is tobacco consumption as well as burden and reduced by half79. Better control of respiratory death from various diseases76,77. diseases like asthma and COPD including Raise taxes on tobacco: symptoms, exacerbations of the disease, This strategy is considered by far the most hospital admissions and finally mortality form effective strategy for tobacco control. COPD has been clearly demonstrated in the Typically, national governments would impose literature80. However, despite these high taxes on tobacco products in order to documented short and long-term benefits of increase the price and making cigarettes less quitting smoking, and despite listing O – offer accessible to the public especially children. help to quit as one of the recommended WHO Revenues from these taxes are then invested in strategies for tobacco control, tobacco strengthening tobacco control measures, dependence treatment (TDT) services continue improving customs and border controls, and to be scarce and inconsistent across the world. curbing tobacco illicit trade. Furthermore, such Many factors contribute to this shortage of revenues can be invested in building health TDT, including the lack of training care systems and train health care providers. opportunities for health care providers in basic Currently, worldwide variation in successful skills needed to deliver TDT services. Tobacco implementation of this strategy exists. High dependence treatment is an integral component income countries took steady steps in of any comprehensive tobacco control effort. implementing this strategy while low income Comprehensive TDT services include the countries continue to fall for the tobacco techniques of brief advice, motivational industry promises of guaranteed short term interviewing and counseling, establishing profits and discouraged from taking aggressive effective quit lines, and availing low-cost moves by the misleading evidence provided by pharmacotherapy. In 1999, the World Bank, the tobacco industry to governments that such building on data published by Peto et al. profits might be hindered should higher taxes estimated that if adult consumption of tobacco were implemented due to the increase in is halved by 2020 the world can prevent about smuggled tobacco, an action typically 200 million deaths by 2050. In comparison, promoted and supported by the tobacco the short-term effect on mortality of halving industry. the number of young people who take up smoking was negligible. Accordingly, the Tobacco dependence treatment and the report urged governments seeking health and gains of quitting: economic gain to encourage smokers to quit81. Likewise, WHO -through Article 14 of the The benefits of quitting occur simultaneously FCTC- mandates parties to design and with the cessation of smoking. For example, implement effective programs to promote normalization of the heart rate, blood pressure cessation of tobacco use and provide adequate and decrease in coughing and production of treatment for tobacco dependence82. The WHO recommends inclusion of cessation advice in

FIMA YEAR BOOK 2014 35 TOBACCO

primary healthcare services, establishing use of all these medications. Relapse is very accessible and free quit lines, and availing common in subjects trying to quit smoking and low-cost pharmacotherapy83. Inclusion of must be addressed early on in the course of cessation advice in primary healthcare settings treatment. Behavioral and cognitive techni- proves to be a low-cost strategy where the ques are key in TDT and in preventing relapse. major investment is in training of providers Many challenges face establishing effective and in providing informational materials to tobacco dependence treatment programs. tobacco users83. Tobacco education and training in healthcare disciplines continues to be lacking. A 2009 Pharmacotherapy, while more expensive than survey of 171 countries indicated that only offering cessation advice, has been shown to 83 27% of medical schools taught a specific double or triple quit rates . Overall, TDT module on tobacco88. interventions are extremely cost effective when compared to treatment of other chronic However, progress is being made via diseases such as hypertension. While a international collaborations through training specialist may average two hours for treatment health care providers (HCPs) on delivering of one tobacco dependence case, treatment of effective TDT. The East Mediterranean hypertension over the lifetime of the patient Region (EMR) countries continue to face other 84 challenges that hinder service expansion. King consumes more time . In general the cost- Hussein Cancer Center (KHCC), a compre- effectiveness of TDT exceeds that of other hensive cancer care facility in Jordan that has commonly provided clinical preventive been offering TDT services to cancer patients services, including Pap tests, mammography, and the general public since 2008, recognized colon cancer screening, treatment of mild to early on that such gaps in capacity and moderate hypertension, and treatment of high 85 competence limit the reach of services and levels of serum cholesterol . patients’ access to help. Realizing the The American College of Chest Physicians importance of training HCPs in evidence- recommends dealing with tobacco dependence based treatment, KHCC started in 2011 to as a chronic relapsing condition similar to asthma. Various forms of treatments are used offer TDT training to countries of the EMR in a controller and reliever fashion86. through collaboration with Global Bridges; an In most subjects combination pharmaco- international healthcare alliance for tobacco therapy is used for better outcome. A long dependence treatment that was founded by acting nicotine replacement therapy (NRT) Mayo Clinic, the American Cancer Society, such as the nicotine patch is usually combined and the University of Arizona. Global Bridges with as needed doses of a short acting NRT seeks to create opportunities to share treatment such as nicotine gum, lozenges, inhaler or and advocacy expertise and to provide state- nasal spray. All NRT doses are titrated to of-the-art training to help countries fulfill control subjects’ withdrawal and craving FCTC’s Article 14. While other organizations symptoms. Bupropion, an antidepressant represent Global Bridges throughout Latin America, Africa, and Europe, KHCC is the and/or varenicline (α4β2 nicotinic acetylcholine receptor partial agonist) are combined with regional host and partner for Global Bridges in NRT for better control of symptoms and the EMR. To date, KHCC has trained over enhanced cessation rates87. In both choices, 1500 HCPs and advocates from EMR on doses are titrated up over few days to avoid tobacco control and TDT through more than side effects. Treatment is usually continued for 20 workshops and conferences spanning the at least three months or as long as it is needed. region from Morocco to United Arab Safety data are now available for the chronic Emirates. Political commitment to tobacco

36 FIMA YEAR BOOK 2014 TOBACCO control is not uniform across the region, and 2. History of Tobacco: http://academic.udayton.edu/health/syllabi/tobacco/history. the tobacco industry (TI) has been gaining htm traction in some countries. As developed Eriksen M, Mackay J, Ross H. The Tobacco Atlas. Fourth nations tighten their regulations on the tobacco Ed. Atlanta, GA: American Cancer Society; New York, industry, the developing nations of the EMR - NY: World Lung Foundation; 2012 3. Mackay J, Eriksen M, Shafey O. The tobacco atlas, 2nd with their relaxed tobacco control regulations- ed. Atlanta, GA, American Cancer Society, 2006. present themselves as a safe haven to the TI. 4. Malson JL et al. Clove cigarette smoking: biochemical, While tobacco companies are state-owned in physiological, and subjective effects. Pharmacology, eight EMR countries, multi-nationals are Biochemistry, and Behaviour, 2003,74:739–745. 5. Brody AL, Mandelkern MA, London ED, Khan A, establishing their operations in other countries 89 Kozman D, Costello MR, Vellios EE,Archie MM, Bascom such as in Jordan . R, Mukhin AG. Effect of second hand smoke on Another challenge that may hinder expansion occupancy of nicotinic acetylcholine receptors in brain. of TDT services in the region is tobacco use Arch Gen Psychiatry. 2011 Sep; 68(9):953-60. doi: 10.1001/archgenpsychiatry.2011.51. Epub 2011 May 2. among physicians and other healthcare 6. U.S. Department of Health and Human Services. The workers. The prevalence of ever smoking Health Consequences of Involuntary Exposure to Tobacco cigarettes among medical students in 2010 in Smoke: A Report of the Surgeon General– Executive the region ranged between 24% and 42%90. Summary. Rockville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and This undermines the role that healthcare Prevention, Coordinating Center for Health Promotion, providers should play in reducing the social National Center for Chronic Disease Prevention and Health acceptability of tobacco use and their Promotion, Office on Smoking and Health, 2006 91 7. Hurt RD, Weston SA, Ebbert JO, McNallan SM, credibility in promoting TDT services . It is Croghan IT, Schroeder DR, Roger VL. Myocardial thus imperative that teaching and training infarction and sudden cardiac death in Olmsted County, programs for HCPs address tobacco control Minnesota, before and after smoke-free workplace laws. and TDT early on, and that special attention is Arch Intern Med. 2012 Nov 26;172(21):1635-41. 8. Comstock GW, Lundin FE Jr. Parental smoking and given to helping these professionals quit perinatal mortality. Am J tobacco use as an initial step. Furthermore, the Obstet Gynecol. 1967 Jul 1;98(5):708-18. lack of insurance coverage by national or 9. Colley JR, Holland WW, Corkhill RT. Influence of private health care plans as well as the passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. inconsistency in the availability of necessary Lancet. 1974 Nov 2;2(7888):1031-4. pharmacological drugs used in TDT and the 10. White, J. R. and Froeb, H. F.:Small airways prices of these drugs are all considered real dysfunction in nonsmokers chronically exposed to tobacco obstacles facing smokers who are trying to smoke. N. Eng. J. Med. 302:720-23, 1980. 11. U.S. Department of Health and Human Services. The quit. Health Consequences of Involuntary Smoking. A Report of In conclusion, tobacco is highly addictive and the Surgeon General. Rockville (MD): U.S. Department of poses great danger to those who consume it, Health and Human Services, Public Health Service, and societies at large. Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health, 1986. Dependence and harms of tobacco as well as DHHS Publication No. (CDC) 87-8398. the benefits of quitting are clearly documented 12. Ballantyne C, What is third-hand smoke? Is it in the literature. International strategies for hazardous? Scientific American. January 6, 2009. http://www.scientificamerican.com/article.cfm?id=what-is- tobacco control must be implemented globally third-hand-smoke in an effort to lower the prevalence by the year 13.Sleiman M, Gundel LA, Pankow JF, Jacob P 3rd, 2040 to less than 5% worldwide. Singer BC, Destaillats H. Formation of carcinogens indoors by surface-mediated reactions of nicotine with References: nitrous acid, leading to potential thirdhand smoke hazards. 1. Eriksen M, Mackay J, Ross H. The Tobacco Atlas. Proc Natl Acad Sci U S A. 2010 Apr 13;107(15):6576-81. Fourth Ed. Atlanta, GA: American Cancer Society; New doi: 10.1073/pnas.0912820107. Epub 2010 Feb 8. ) York, NY: World Lung Foundation; 2012 14. Caryn Rabin, R. , A New Cigarette Hazard — 'Third- Hand Smoke. The New York Times. January 2, 2009.

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40 FIMA YEAR BOOK 2014

OPIATE ADDICTION

M. Basheer Ahmed*

Abstract:

Drug addiction is rapidly increasing in most parts of the world resulting in escalating healthcare cost, fatalities and serious negative familial and social consequences. The opiate addiction is the most serious form of drug addiction and it is extremely difficult to treat and keep the patient sober. The article covers the historical perspective, genetic and environmental factors contributing to the addiction behavior and the brain mechanisms for addiction. It will discuss the diagnostic criteria and the current methods of treatment available including use of opiate agonists, opiate partial agonists, opiate antagonists and psychosocial treatments. The article also includes a brief discussion about the current situation related to drug use in the Muslim World and proposes some guidelines for treatment and control of the spread of drug use in the Muslim World.

Keywords: Drug addiction, Opiate use disorders, neurologic mechanisms, causes of addiction, treatment of addiction, history, Islamic perspective.

Introduction:

The death of Philip Seymour Hoffman, the disorder”3. Some of the most common drugs brilliant Oscar winning actor, created headline of abuse are opiates and opioids. news about mortality due to overdosing on Opiates are derived from the poppy seeds and opiates. One of the statements he made created is known as heroin. Opioids are semi synthetic this renewed interest in this subject when he products such as Morphine, Oxycodone, stated, “if one of us dies of an overdose Percocet, Tylox, Oxycontin, Hydrocodone, probably 10 people who were about to 1 Vicodin, Tramadol, Ultram, Pentazocine, won’t” . Opiate dependence is a significant Talwin and Fentanyl. The heroin is used worldwide public health issue. Globally, intravenously, as a smoke or as an inhalant and between 24 and 35 million adults between the all opioids are used orally. ages 15 and 64 years used an illicit opiate in 20102. Alcohol and illicit drugs are harming According to the USA Centers for Disease millions of people in many countries around Control and Prevention (CDC), 12 million the world. Alcohol and drug use account for Americans used opiates in 2010 and that every 5.4% of the world’s annual disease burden. In day 100 people die from drug overdoses, 75% some Eastern European countries, 16% of the of which are caused by prescription opiates. population suffers from “Alcohol use The rate has tripled in the last two decades.

*Dr. Basheer Ahmed MD Professor of Psychiatry (Retired) South Western Medical School, Dallas, Texas, USA Medical Director Texas Treatment Services, Fort Worth, Texas, USA E-mail: [email protected]

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There have been more than 17 deaths linked to gambling, computers and being pre-occupied the possible use of Fentanyl- contaminated with persistent sexual thoughts and heroin in Pittsburgh, Pennsylvania alone from pornography inspite of negative consequences, January 24, till March 23, 2014. In the first which influence health, relationships and two weeks of January, there were 22 such work. In other words, addiction has many deaths reported in the state of Rhode Island forms; some of them are related to substances due to heroin overdose. Heroin is always an while the others are related to psychological extremely intoxicating drug of abuse with a dependence on behaviors. wide array of risks including overdose and The addiction alters the brain’s function and increased exposure to Hepatitis C, HIV/AIDS structures affecting mood, perception and and other infectious diseases. It often contains consciousness leading to physical, other ingredients which render it potentially psychological and psycho-social problems. more harmful or in some cases deadly4. Addiction is a primary, chronic disease of Opiates become more dangerous when mixed brain’s reward, motivation, memory and with benzodiazepines and can be fatal. In related circuitry. Addiction affects neurotrans- 2009, slightly over 120 million visits were mission and interactions within reward made to the emergency departments in general structures of the brain, including the nucleus hospitals in the United States and at least 4.5 accumbens, anterior cingulate cortex, basal million of these visits were drug-related. Drug- forebrain and amygdala, such that motivational related emergency department visits have hierarchies are altered and addictive behaviors, increased by over 80 percent since 2004. This which may or may not include alcohol and increase primarily reflects greater numbers of other drug use, supplant healthy, self-care medical emergencies associated with adverse related behaviors. reactions, accidental drug ingestions, and Addiction also affects neurotransmission and misuse or abuse of prescription drugs and interactions between cortical and hippocampal over-the-counter medications 5. circuits and brain reward structures, such that Countries around the world spend billions of the memory of previous exposures to rewards dollars fighting drugs and treating and (such as food, sex, alcohol and other drugs) rehabilitating those addicted. In addition to leads to biological and behavioral responses personal and social problems, alcohol, drug to external cues, in turn triggering craving use and other addictions lead to criminal and/or engagement in addictive behaviors6. behavior. Hundreds of thousands of individuals are arrested for possession and /or Historical Perspective sales of drugs, or for committing crime to obtain them. Drug intoxication results in Contrary to common belief, the contemporary traffic accidents which may cause fatalities. drug problems are not new. In fact, the use of One-third of AIDS cases occur in IV drug psychotropic substances seems to be an almost users and children are born with AIDS to the universal phenomenon which has long been a female drug users. great social concern. Today, there are only a few isolated societies in which psychoactive What is Addiction? substances are not used. It is stated that the very desire to alter consciousness, whether by Addiction is an obsessive and compulsive drugs or some other means “is an innate, behavior which includes taking drugs (alcohol, normal drive analogous to hunger or the sexual opiates and other drugs), engaging in drive.” Blum identified only four out of 247

42 FIMA YEAR BOOK 2014 OPIATE cultures where people do not use any making it possible to produce more potent substance which alters the mind. The only alcoholic beverages. In the 16th century, people without a traditional intoxicant are the drunkenness was mentioned in England for the Eskimos, “who had the misfortune to be first time as a crime, and laws were passed unable to grow anything and had to wait for against its use. In European colonies, white men to bring them alcohol” 7-9. drunkenness was prominent, but it was not Human beings have always had a desire to considered a major problem or stigmatized consume substances that make them feel behavior. In England, the consumption of relaxed, stimulated, or euphoric. People started beers and wines, particularly home-brews, was chewing leaves, herbs and other natural integrated into every aspect of family life7. products, and they cultivated plants which they In the 12th century the chewing of coca leaves used for food, for alleviating pain or was common in the Inca Empire (South recreational purposes. Some of these America), mostly in religious and special preparations produced euphoria, and many of social functions. The coca plant was also these were used in religious rites. The later viewed as a divine gift of the Sun God giving discovery of fermentation of fruits or juices energy and euphoria. was closely followed by the production of In the 14th century, coffee was initially used in alcohol. One of the oldest drinks was a juice Ethiopia for medicinal purposes. The extracted from Palm trees (Palm toddy) (an technique of roasting made coffee cheaper and incision is made on top of the stem of the tree more pleasant to consume. Cultivation and use during the night and the juice is collected early of coffee expanded into Arabia. morning)10, after being left in the sunshine for In the 15th century, Arabs spread the use of a few hours, it becomes fermented and gives coffee to the Muslim countries. Use of coffee the same effect as alcohol. It is still commonly became predominant because wine is used in South Asia. Initially, these drugs prohibited according to Islamic law. Initially, were used as natural products and were less coffee was prohibited in Turkey (Middle East) harmful. As their potency is increased by and the coffee houses were closed but the ban distillation and other mechanisms, they was lifted some time later when it was realized become more intoxicating and harmful. that people did not stop drinking coffee. In the recorded history from ancient times, Coffee became a popular drink throughout the alcohol was the only drug mentioned causing Middle East. When coffee was introduced in problems in the Greek and Roman periods. I Europe from Muslim Turkey, it was banned on am sure there were other drugs used which religious grounds as it was regarded as alter mental conditions causing stimulation, “infidel’s drink.” Later during the 16th century, relaxation and euphoria but alcohol was its use was sanctioned. mentioned as causing significant social Tobacco chewing and smoking were first problems. The earliest recorded example of observed by Europeans when they landed in concern related to alcohol use is the America. Later, they cultivated and prohibition of its use in the7th century under transported tobacco to Europe due to great the Islamic law based on the commandment of financial rewards. Tobacco seeds were God recorded in the Glorious Qur’an. Muslims transported from Brazil to France and England are strictly forbidden from using alcohol and for cultivation. Within a century, tobacco use other intoxicants which alter consciousness became widespread in most European and from an addictive behavior that is countries7. gambling11. In the 11th century, the technique In 7th century, the opium poppy was of distillation became known in Europe, introduced in India and China by Arabs, and

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its use was limited to medicinal purposes. Unfortunately, underground breweries and However, its use increased significantly distilleries became very popular throughout especially in China. Later, British opium the country to supply the demand for alcohol. traders from India established depots at Canton The sale of alcohol in the and and Macao and its trade became very importation of alcohol from other countries by profitable. As opium smoking spread and the illegal means became widespread. This number of Chinese addicts significantly resulted in forcing Congress to repeal the 18th increased compromising their productivity, the amendment by the 21st amendment (the 18th emperor of China prohibited its sale. The amendment is the only constitutional amend- effort was initially successful with the ment that was repealed by another amendment destruction of all British opium stock in 1839. – the 21st amendment) 7. However, to protect this trade, Britain declared Cannabis, opium, coca, tea, coffee, tobacco, war on China. The first opium war was from and alcohol became the most commonly used 1839 to 1842 and the second opium war was substances in the world. Tobacco, alcohol, and from 1856 to 1860. China was defeated and became the major three drugs of the war ended with the Treaty of Nanking, addiction in Europe and America. There was which protected foreign opium traders from an initial opposition for their use but due to Chinese law. It is ironic to see how far the their widespread use, these substances were imperialist governments will go to destroy not regarded as drugs of addiction. The use of humanity for financial gains. The Maoist alcohol in Western countries is well accepted, revolution ended drug addiction quickly. By and no criminal sanctions are imposed on 1952, there were no more addicts, no more alcohol use. In Muslim countries alcohol is pushers, and no more drugs smuggled. In only prohibited, however its use along with other three short years, China went from 70 million drugs has increased considerably during the drug addicts to none12. last decade. Alcohol and tobacco are now Cocaine and opiate addiction in the United recognized as highly addictive drugs causing States became increasingly identified with the severe detrimental effects on health. underworld and organized crime. In 1914, Congress passed the Harrison Act which What causes addiction? regulated and taxed the production, importation and distribution of opiates and Most addictions with drugs such as alcohol coca products. It required all persons and opiates or pleasurable behaviors such as authorized to handle or manufacture narcotic gambling and pornography start as pleasurable drugs to register, pay a fee, and keep a record or recreational activities, but continued use or of the drugs in their possession. The act did engagement in such behavior results in dire not prohibit the supply of opiates to users by consequences. Many addicts do not recognize registered physicians. Temperance movements this at the early stages. Only when the for alcohol use have been active since 1840s behavior becomes out of control and causes by religious organizations and finally the 18th problems to themselves and others that it is amendment to the USA constitution was recognized. There are some controversies passed as “the national prohibition act of about which of the behavioral addictions are 1919” which required licensures for businesses validated as true addictions. There has been no that brew, distill and wholesale alcoholic agreement among professionals on this beverages. The prohibition act and the controversial issue and more research is religious movement of temperance were hoped needed to have a clear definition and to to curtail the sale and use of alcohol. establish the criteria for diagnosis.

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The gambling disorder is included in the system is activated by drugs, which results in DSM-V, and requires five criteria to diagnose mood-altering behavior. These parts of the patients with clinically significant gambling brain are also responsible for executive related disorders13. functions and decision making.Thus, excessive Most people exhibiting addictive behaviors are drug use influences decision making behavior. emotionally stressed and or unstable and thus Amphetamine and cocaine stimulate the psychologically vulnerable to develop neurons to release large quantities of the dependence on drugs. Research also showed neurotransmitter dopamine, resulting in that there are some genetic predispositions for excessive stimulation leading to excitement, drug dependence. Recent studies of twin pleasurable feelings and euphoria. This families with history of drug abuse indicate pleasurable experience is remembered which that drug abuse is substantially heritable14,15. results in continuous use of drugs and Genes of the dopamine system are likely dependence on drugs. Brain imaging studies candidates to harbor risk variants, as dopamine have provided information on the drugs’ neurotransmission is involved in mediating the neurobiological effects, explained the causes rewarding effects of drugs of abuse. and mechanisms of vulnerability to drug These data demonstrate the importance of abuse, and yielded important insights into dopamine gene variants in the risk for opioid abusers’ subjective experiences and behaviors, dependence and highlight a functional including their struggles in recovery. Recent polymorphism that warrants further study16. neuroimaging studies suggest that people While genetics plays a role in drug addiction, living with a drug addiction have considerable it is important to recognize that environmental decreases in dopamine D2 receptors and in factors also play a significant role in the dopamine release, which may contribute to transmission of this disease. Recent research both the rewarding properties of substances confirms the role of environmental factors and difficulties in abstaining despite adverse such as the influence of parents and siblings on consequences. Brain areas such as the adolescent drug use. When one member of the prefrontal cortex have been identified as being family household is using a drug, it places the directly involved in assessing the reward other members of the family at risk. Socio- potential of decision-making and vulnerability economic conditions of the family, for relapse. Abnormal hippocampus and neighborhood level of social deprivation also anterior cingulate functioning are associated affects the risk for drug abuse, beyond family with challenges in the ability to cope with socio-economic status17,18. stress, in addition to problems in cognition19. Structural MRI provides information on the How drugs influence brain and behavior location, shapes, and sizes of the brain’s various regions. Most drugs of abuse directly or indirectly Sagital sections of human brain showing Orbitofrontal affect the brain’s reward system through the cortex (OFC) and Ventral tegmental area (VTA) neurotransmitter dopamine. The limbic system contains the brain’s reward circuit and through the complex neuronal system links with cerebral cortex and mid brain structures including the hypothalamus, amygdale and other areas which process information resulting in perception of anger, fear, happiness and other emotions. The limbic

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opiates. Prescriptions for opioid analgesics A structural MRI study found that individuals increased from about 75.5 million to 209.5 with a history of abusing drugs have smaller million in 10 years. Admissions for opiate prefrontal lobes. It also showed that chronic drug dependence have increased from substance abusers’ frontal lobe tissues approximately 280,000 to 421,000 during a 10 contained a lower proportion of white matter year period (1999-2009) 23. In a study of than those of matched controls 20. Jordanian opiate dependent patients, the major Researchers have used functional MRI to cause of premature death was accidental obtain detailed information about the roles of overdose, along with infectious disease. different brain areas in producing cocaine- Moreover, a high prevalence of criminal induced euphoria and subsequent craving. An activity and psychosocial difficulties are also influx of cocaine described as a drug rush found among Jordanian heroin users24. occurs during a brief period when a set of Addiction to opiates can be caused either by areas, including the caudate (an area of the the recreational use of opiate based drugs, or it basal ganglia), cingulate, and most of the may be caused by prescribed use of the drugs. lateral prefrontal cortex showed higher levels Opiates create a feeling of euphoria. The initial of activity. The participants’ reports of craving feeling of euphoria wears off in a short period commenced when the euphoria subsided and and a user starts feeling withdrawal symptoms. persisted as long as a different set of brain They then use larger doses to reduce areas-including the nucleus accumbens (NAc)- withdrawal symptoms and experience remained activated. Positron Emission pleasure. Tomography (PET) and single-photon Often times, opiates such as Oxycontin, emission computerized tomography (SPECT) Oxycodone or morphine are prescribed for the have also shown the presence and actions of treatment of chronic pain associated with drugs of abuse in the brain’s reward system degeneration of bones, arthritis, post surgical with their euphoric properties and their ability pain, cancer and other diseases. Unfortunately, to preoccupy addicted individuals. Dopamine many people who are prescribed opiate pain flow in these areas is a main determinant of killers do not realize the risk of opiate how much pleasure is derived. A PET study addiction and believe that they are under no also revealed that while methamphetamine danger if they take the medication as temporarily hyper-activates the dopamine prescribed by their doctor. Seventy five per system, chronic exposure to the drug reduces cent of high school seniors perceive using the availability of dopamine transporters, heroin once or twice as dangerous, but only which may indicate a loss of dopamine cells21 . 40% perceive similar use of prescription opiates as dangerous25. Opiate dependence Unfortunately, indiscriminate use of prescription opiates creates a major problem in Opiate dependence is a major public health the USA. Physicians are prescribing narcotic problem, and the illicit use of opiates analgesics without proper justification. contributes to the global burden of disease and Patients are becoming addicted and in some can result in premature disability and death. cases they sell the drugs on the streets. While Incidence and prevalence of blood borne pain management clinics help patients with viruses (e.g., HIV, hepatitis B, and hepatitis C) chronic pain, they are also the major are higher in injection drug users22. contributors in creating prescription drug The United States has seen a significant dependence. Iatrogenic drug addiction has increase in the illicit use of prescription become a major problem. No strict guidelines

46 FIMA YEAR BOOK 2014 OPIATE have been developed for the use of these elucidated. This interaction forms the highly addictive drugs. Many physicians do hypothesized foundation for the persistence of not have a protocol about stopping drug use addiction vulnerability even in those who have until it is too late. The new regulations and discontinued drug use and indicates that long law enforcement efforts have curtailed the term relapse prevention strategies need to supply of prescription drugs and the cost of include both environmental and these drugs in the open market has increased pharmacological interventions beyond the considerably. This has resulted in many users immediate period of withdrawal. switching to a cheaper drug – heroin. Environmental factors such as availability of Diagnostic criteria opiates, psychosocial stresses and lack of for opioid dependence coping strategies also influence the risk of developing opiate addiction. Traumatic DSM-5 Opioid Use Disorder - Diagnostic lifetime experiences such as post-traumatic Criteria, American Psychiatric Association stress disorder may increase the risk for opiate In the DSM-5, is the addiction. Weak parental bonds also increase singular diagnosis which combines substance the risk for illicit drug use during adulthood26. abuse and substance dependence. It is defined The risk for developing opiate addiction is a as such: complex interaction between genetics, A problematic pattern of opioid use leading to environmental factors, and the pharmaco- clinically significant impairment or distress, as logical effects of opiates. Genetic loci manifested by at least two of the following, associated with opiate self-administration have occurring within a 12-month period: been identified; and selective disruption of the 1) Opioids are often taken in larger amounts or gene encoding the mu opioid receptor, the over a longer period than was intended. principal target of opiates, can eliminate opiate 2) There is a persistent desire or unsuccessful self-administration and conditioned place efforts to cut down or control opioid use. preference27. Prolonged opiate use leads to 3) A great deal of time is spent in activities changes in neuronal connections that result in necessary to obtain the opioid, use the opioid, an inability of the body to cope with or stop or recover from its effects. pain. Once in the brain, the primary target for 4) Craving, or a strong desire or urge to use abused opiates is the mu opioid receptor. opioids. Located throughout the brain, the highest 5) Recurrent opioid use resulting in a failure to density of this receptor occurs in areas fulfill major role obligations at work, school, modulating pain and reward (e.g., thalamus, or home. amygdala, anterior cingulated cortex, and 6) Continued opioid use despite having striatum). Activation of mu opioid receptors persistent or recurrent social or interpersonal inhibits GABA-mediated dopaminergic problems caused or exacerbated by the effects neurons in the ventral tegmental area28. of opioids. Human imaging studies have identified 7) Important social, occupational, or ongoing reductions in dopamine D2 receptor recreational activities are given up or reduced binding potential in opiate addicts and that this because of opioid use. reduction correlates with the duration of opiate 8) Recurrent opioid use in situations in which use29. The details of how the interaction it is physically hazardous. between genes, environment, and drugs 9) Opioid use is continued despite knowledge contributes to the development, persistence, of having a persistent or recurrent physical or and relapse to addiction have yet to be

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psychological problem that is likely to have Initial signs of dependence: Dependence is been caused or exacerbated by the substance. indicated by extreme fatigue, sleeping more 10) Tolerance, as defined by either of the than usual, or episodes of “nodding off” during following: normal activities. Other manifestations a) A need for markedly increased include: pinpoint and fixed pupils that are amounts of opioids to achieve unresponsive to changes of light as well as intoxication or desired effect. changes in appetite and weight (both will often b) A markedly diminished effect with decrease drastically), loss of interest in usual the continued use of the same amount activities, and constipation. of an opioid. Common features of opiate addiction: lack 11) Withdrawal, as manifested by either of the of control over drug consumption, exhausting following: all financial resources, spending more and a) The characteristic opioid withdrawal more time using drugs, denial or thinking that syndrome. there is no problem and lying or hiding the b) Presence of either of the following: drug use, using drugs despite known negative consequences such as financial breakdown,  Cessation of (or reduction in) opioid use effects on physical health, family problems, that has been heavy and prolonged (i.e., occupational and legal problems, inability to several weeks or longer). maintain social relationships, and multiple  Administration of an opioid antagonist failed attempts to quit. after a period of opioid use. Three (or more) of the following developing Withdrawal symptoms: within a minute to several days after the cessation of (or reduction in) opioid use: The main features of opioid withdrawal are Dysphoric mood, nausea or vomiting, muscle nausea, vomiting, diaphoresis, yawning, aches, lacrimation or rhinorrhea, pupillary fatigue, aches and pain, muscle cramps, dilation, piloerection, sweating, diarrhea, diarrhea, mydriasis, and piloerection. Other yawning, fever, and insomnia 30. symptoms include chills, irregular heartbeat, itching, restless leg syndrome, flu-like Side effects of opiates symptoms, diarrhea and weakness. As tolerance goes up, susceptibility to withdrawal Opiate side effects include sedation, dizziness, becomes marked. Withdrawal symptoms can be excruciating and include muscle aches, nausea or vomiting, constipation, and anxiety, sweating and insomnia. Subjective respiratory depression which may lead to death symptoms are much greater than objective in cases of overdose. People receiving signs. Cravings begin 4 to 6 hours after the last prescriptions from several different providers, dose of short-acting opioids, leading to active and take high daily doses of opiates are more drug-seeking behavior. This is followed by prone to have an overdose. anxiety, diaphoresis, and agitation after 8 to 12 hours. Peak withdrawal discomfort is usually Treating opiate intoxication experienced after 36 to 72 hours and decreases Mild to moderate opiate intoxication does not thereafter31. require treatment. Overdose of opioids results Treatment of opiate use disorder in respiratory depression. It requires treatment in an emergency department. Naloxone is The main objective of treatment is to reduce usually used to reverse the respiratory dependence and issues associated with use. It depression. is important to realize that treatment for opiate

48 FIMA YEAR BOOK 2014 OPIATE addiction requires long-term management. term treatment of opiate dependence are: the Discontinuing opiates without medical opioid agonist methadone, the opioid partial supervision is not only difficult but it is also agonist buprenorphine, and the opioid dangerous. Opiates cause physical changes antagonist naltrexone. Oral naltrexone is within the body and the brain that can make effective in treating opiate addiction but recent quitting cold turkey almost impossible except studies using extended release naltrexone in prisons or in hospitals under medical injections have shown good results in patients supervision. Generally, it is not advisable to who lack strong motivation. For many years, quit opiates without at least tapering the drugs methadone, an opioid agonist, was the main off or being under the direct care of a pharmacologic treatment option for opioid healthcare professional because there is a risk dependence, but its availability in the United of opiate withdrawal symptoms leading to States was limited to licensed programs. The deadly consequences. Behavioral interventions introduction of another opioid agonist in the alone have extremely poor outcomes, with form of sublingual bupre-norphine, which can more than 80% of patients returning to drug be prescribed in office-based practices, has use. Most often, a combination of medical greatly expanded access to treatment for intervention and psychological counseling is individuals with opioid dependence. The needed in order to effectively help an individu- opioid antagonist naltrexone has been al overcome opiate addiction. Because this available as a treatment for opioid dependence addiction is medically recognized as a central for many years, but its use has been limited, nervous system disorder, much attention has particularly in countries where agonist been placed on medical intervention and treatment is available. treatment of opiate addiction through Sometimes, opiate addiction treatment takes medication replacement therapies. The place in hospitals or residential treatment cravings and withdrawal symptoms associated centers. Because of the severity of withdrawal with quitting opiate use are very strong and symptoms that are associated with opiate difficult to overcome. It is for this reason that dependence and addiction, opiate addiction medication-assisted treatments are often requires a longer stay in a residential treatment recommended. These therapies address the setting before safely integrating into an changes that drugs have caused in a user’s outpatient treatment setting. brain. The pharmacotherapy with methadone, buprenorphine and naltrexone combined with Methadone and methadone maintenance psycho-social services are effective in clinics: reducing opiate use, dangerous behavior, and Methadone is the oldest of these kinds of criminal activity, while improving the mental 32 treatments and has been used since the 1960s. health of patients . Medication-assisted It must be taken in certified, specialized therapies are safe in that they are administered methadone clinics. Methadone is given each by trained physicians in measured daily doses. day in sufficient quantity to counteract the They are not taken intravenously and thus withdrawal symptoms. eliminate the risk of HIV and other IV-related Methadone is a synthetic mu opioid receptor diseases; when taken correctly they eliminate agonist, administered orally in liquid or tablet the risk of overdose. form. Following oral administration, peak Pharmacological treatments plasma levels are reached within 2–4 hours for opiate disorder and the elimination half-life at the steady state The three medications approved by the USA is approximately 28 hours, allowing for once Federal drug Administration (FDA) for long- daily dosing. Methadone safety is well

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established. Like other opiate agonists, difficulties35,36. Retention in methadone methadone has the potential to induce treatment clinics and adherence to the respiratory suppression. Recent increases in treatment regimen are similar to or exceed methadone-associated deaths are primarily results for other medically managed diseases related to its minimally regulated use in the such as hypertension, dyslipidemia, and treatment of pain and not due to its use in the diabetes mellitus37. When the patient is well treatment of opiate dependence 33, 34. stabilized on a specific dose and does not Methadone response appears to be dose- experience any side effects and shows related with most patients stabilizing at doses improvement in psychosocial functioning, between 60 and 120 mg daily. Response is gradual detoxification can be started. most frequently measured in terms of retention Detoxification period varies from patient to in treatment and discontinuation of opiates, patient depending on the patient's self- other drugs and improvement of psycho-social confidence, social circumstances, marital functioning. At our clinic, all patients with stability, occupational stability and coping opiate dependence are initially evaluated by capabilities. Methadone is an effective means the physician and have a physical examination for an addict to discontinue opiates and move and laboratory work. Once the diagnosis is forward with a more productive life. It is much established, they receive an initial oral dose of safer and cleaner than opiates and allows methadone 20-30 mg daily in either tablet or people to successfully hold a job and manage liquid form. The dose is increased between 5 - other aspects of their lives. A small percentage 10 mg daily until it reaches 50 mg. During the of patients will continue to use opiates. initial evaluation, patients are instructed to stop use of opiates, benzodiazepines, and other Buprenorphine drugs due to serious side effects. Patients who are using benzodiazepines are required to Buprenorphine is a semi-synthetic mu opioid discontinue the benzodiazepines after with weak partial agonist effects. It has less consulting with the prescribing physician or abuse potential than other opioids because the gradually discontinuing them in 4 to 6 weeks. intensity of the rewarding effect is milder and All patients are required to consult with a plateaus at higher doses38. It produces a physician to increase the dose of methadone. normalizing effect in individuals with opioid All patients are seen weekly by a trained addiction already in withdrawal. Sublingual counselor who assesses psycho-social buprenorphine has a long half-life (24 to 60 functioning and develops a treatment plan to hours, mean 37 hours). Suboxone contains 2 help the patient as needed. The treatment active ingredients; buprenorphine and approach is problem-oriented and focuses on naloxone at the ratio of 4:1. Naloxone is achieving well-defined goals. Providing intended to deter individuals from abusing the intensive psychosocial services and counseling medication. Naloxone blocks the effect of may improve treatment outcomes. opiates. While a patient is on Buprenorphine Methadone maintenance for patients with (which contains Naloxone) takes opiates he opiate disorders is effective in decreasing will not feel any euphoric effect of opiates and opiate use, psychological and medical therefore it acts as a deterrent for relapse. The morbidity associated with opiates, improving intravenous use of opiate gives a surge to the social functioning, reducing the spread of HIV individual and he will not experience this infection and decreasing criminal activity. The when taking. Therefore, Suboxone must be most common side effects of methadone are given after the total discontinuation of the constipation, increased sweating and sexual

50 FIMA YEAR BOOK 2014 OPIATE opiate, and the patient is already in substitution treatment, bupreno rphine’s lower withdrawal. abuse potential and good safety profile make it The literature on safety evaluation of particularly appealing for family physicians. buprenorphine maintenance is less developed Those patients that fail to respond are then than that of methadone, but is considered to be referred for methadone maintenance. Moderate quite safe. During maintenance treatment, to high doses (8 to 24 mg) of buprenorphine patients have reduced illicit opiate use but are usually required. Use of buprenorphine- following buprenorphine taper, some patients naloxone in primary care settings is return to illicit opiate use. In one study efficacious, safe, and feasible within reason- comparing heroin addicts to prescription- able time constraints 43. opiate addicts, the heroin addicted patients had Naltrexone: Naltrexone is an opioid receptor more severe addiction and did not do as well antagonist used in treatment of opioid with buprenorphine treatment as the less ill dependence. It helps patients overcome opioid prescription opiate dependents. Buprenorphine addiction by blocking the drug’s euphoric is a safe treatment with expected side effects effects. Naltrexone should not be confused of sedation, constipation, headache, nausea or with Naloxone (which is used in emergency vomiting, and dizziness, and it carries a lower cases of opioid overdose) as it can cause acute risk of respiratory depression than full opioid opioid withdrawal symptoms. Return to opiate agonists. use following detoxification is caused by There are rare reports of hepatoxicity, in negative reinforcement of environmental addition to a few reports of death when stimuli (e.g., cues and social stressors) and if combined with benzodiazepines 39, 40. an antagonist prevented the addict from Buprenorphine, was approved by the FDA in relieving this negative state through opiate use, 2002 and can be prescribed by physicians and then the behavior of turning to opiates in these can be taken in physicians’ offices rather than situations would eventually cease. Naltrexone solely in specialized clinics like methadone. It can block the effect of opiates for is taken as a tablet or sublingually once a day. approximately 24–48 hours after oral dosing. For the induction phase, patients can be started Naltrexone is a useful non-addictive pharma- on buprenorphine (maximum 8 mg on day 1, cotherapy for opioid addiction. Naltrexone is as per the drug monograph, in single or non narcotic and non addictive drug. Therefore divided doses) 12 to 24 hours after the last there is no chance of a patient becoming opioid dose. Dosage can then be adjusted addicted to Naltrexone whereas Methadone based on clinical symptoms. Patients should be and Suboxone contain opiates which are observed medically for at least two hours after narcotics and has potential for abuse. In Russia the initial dose41. It is well established that and some Muslim countries (like Jordan) moderate to high doses (8 to 16 mg) have opiate agonists such as Methadone or significantly higher efficacy. Although the Suboxone are not approved to be used for maximum dose recommended by the treatment of opiate addiction. manufacturer is 24 mg, doses of up to 32 mg While some patients do well with oral have been used in some trials. Naltrexone, it must be taken daily and a Buprenorphine’s long half-life and slow patient whose cravings become overwhelming dissociation from opioid receptors allows for can take opioids simply by skipping the dose the possibility of less-than-daily dosing42. before taking the opioids. A monthly injection Buprenorphine is an effective detoxification of long acting depot naltrexone can be used for agent for opioid dependence. Although patients to motivate themselves to stick to a methadone remains a slightly superior treatment regime which is very useful. The

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plasma levels sufficient to block 25 mg of in the methadone group except for increased heroin are approximately 1–2 ng/ml, a level perspiration with Tramadol47. maintained for 21–28 days following 380 mg of the intramuscular extended release Treatment of opiate dependence formulation 44. In 2010, the FDA approved in pregnant patients extended-release injectable naltrexone for the treatment of opioid dependence. This approval Opioid use may result in poor nourishment, was partly based on the results of a trial general medical complications, miscarriage conducted at 13 addiction treatment centers in and preterm birth. Fifty percent of the infants Russia where opioid agonist treatment is born to women with opiate dependence are prohibited. Extended release naltrexone may physiologically dependent on opioids and may improve treatment outcomes because non- experience withdrawal symptoms. The adherence to daily oral regimens is reduced by placenta is metabolically active and can delivery of a once monthly injection. increase clearance of both methadone and Currently, there is limited data regarding the buprenorphine. Methadone is the standard of extended release intramuscular injection. A care for pregnant women and has been shown larger trial in Russia retained 53% of patients to reduce illicit opioid use, enhance at 6 months compared to 38% for placebo. compliance with obstetric care, and improve Patients receiving extended release naltrexone neonatal outcomes. Since methadone does not also had significantly fewer days of illicit have active metabolites, patients may opiate use45. Naltrexone should be given after experience early withdrawal and may require a week of abstinence from opioids due to risk increases in or splitting of methadone dose of acute withdrawal. Common side effects are during the second and third trimesters. It is diarrhea and abdominal cramps. High doses recommended that neither naloxone nor may cause liver damage. naltrexone be administered during pregnancy, Research studies recently showed that a higher thus buprenorphine should be administered as retention rate can be achieved with Naltrexone the mono product and naltrexone should be implants. The implants are not currently avoided. approved and are not available in USA46. In a small Cochrane meta-analysis of maintenance treatment in pregnancy, there Tramadol versus methadone were no differences in maternal or fetal for treatment of opiate withdrawal outcomes between groups taking buprenor- phine or methadone. Recent trials have Tramadol may be as effective as methadone in suggested buprenorphine to be superior in the control of withdrawal and could be terms of fetal outcomes, with less severe considered as a potential substitute for neonatal abstinence syndrome48-50. methadone to manage opioid withdrawal. Seventy patients randomly assigned to two Psychosocial treatment of opiate groups received either prescribed methadone use disorder (60 mg/day) or tramadol (600 mg/day). The withdrawal symptoms of patients were Individuals with substance use disorder are evaluated before and after rapid opiate often ambivalent about giving up their habit. detoxification. No significant differences They deny and minimize the negative existed between the two groups. Drop out rates consequences of their behavior. They struggle were similar in both groups. Side effects in the with the emergence of cravings and thoughts tramadol group were as or less common than about using the drugs. Other stresses such as

52 FIMA YEAR BOOK 2014 OPIATE influence of friends and family members who for a certain individual may not work for are using drugs, unemployment, hopelessness, another. The main difference in programs is despair and persistent pain make the individual that in some facilities housing is provided. more vulnerable to relapse. They need These facilities are called residential centers, supportive therapy and guidance to strengthen and they provide around the clock care, daily their coping mechanism. Psychosocial counseling in either one-on-one, group settings treatment for opiate use disorder helps in or both. They are usually more costly than the bringing about better patients' behavior, alternative outpatient programs and usually thought process and social functioning. The require people to leave their job, family, and primary goal of this treatment is enhancing other parts of their lives for the duration of motivation to stop drugs, teaching coping with treatment. stress, changing reinforcement contingencies, fostering management of pain effects and Is addiction primarily a brain disease?? enhancing social support and inter-personal functioning. Sustaining motivation is required There is no single theory or approach that can to forgo the rewards of substance use, to offer a complete explanation for the existence tolerate the discomfort of withdrawal of any social problem. The view of addiction symptoms and to cope with the cravings. as primarily a brain disease disregards the Coping skills are required to manage and extensive body of research that suggests avoid situations that place the individual at neurogenetic explanations of mental illness risk of relapse. It is reported that successful contribute to negative perceptions towards improvement occurred in patients receiving people with mental illness, and substance use both opiate agonists (methadone or subsoxone) problems. The brain disease model implies treatments as well as psychosocial treatment that addicted individuals are unable to exercise services35. any degree of control over their substance use. This focus on a biological model may bring : about unintentional consequences on a person’s sense of identity, responsibility, Some people do not want to go with notions of autonomy, illness, and treatment medication-assisted therapy and therefore, do preference. not wish to take part in a methadone Addiction consists of interacting biological maintenance program. For those who decide and psychosocial mechanisms because the not to quit cold turkey but also not to take part mechanism (e.g., the behavior) contributing to in a medication replacement program, drug addiction involves action within a social rehab is an option. Drug rehab involves a system. Every learned action, whether pro- combination of medical intervention, social or anti-social, may be prompted by monitoring, peer support and counseling to social conditions such as a lack of resources, effectively help patients overcome opiate conflicts, social norms, peer pressure, an addiction. Many drug rehabilitation programs underlying drive (cravings similar to hunger do utilize methadone maintenance or and sex drive) or a combination of these Suboxone for a short period but most provide factors. Factors such as drug availability alternatives that are also effective at helping within the environment can increase craving patients get past the strongholds of opiate and consequently, the vulnerability for relapse. addiction and move on with their lives. It is believed that laws and policies that are There are several different kinds of drug lenient to substance use are linked with greater rehabilitation facilities, and the one that works prevalence of use and criminal activity.

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However, research findings have not neurotransmitters which promotes “reward confirmed this claim. In one study comparing behavior”. cannabis use in San Francisco (where cannabis However in my opinion the humans are is criminalized) and Amsterdam (de-facto capable of resisting genetic predispositions decriminalization), there was no evidence to which may lead to negative consequences. Our support claims that criminalization laws experience with treatment of alcohol addiction reduce use or that decriminalization increases shows that psychosocial interventions, use. In fact, San Francisco reported a higher including spirituality, play a significant role in cannabis use rate than Amsterdam51. Similarly overcoming this problem. tobacco smoking has become less acceptable as a normative method of social interaction The current situation of drug use in the due to the medical interventions for smoking Muslim world cessation as well as social and public health efforts to curtail smoking behavior. It shows Alcohol is forbidden in the Muslim world, but that social and public health efforts in the alcohol consumption has nearly doubled curtailing the smoking behavior are more across the Islamic world in the last decade. effective than laws prohibiting the smoking. The French newspaper Le Monde reported that Drug use is a pleasure-oriented desire and between 2005 and 2010, the average continued medicalization of addiction will consumption of alcohol by the French dropped obviate all responsibility for behaviors from 104.2 liters of alcohol per year to 96.7, associated with drug use. The opinion that while in the same period in the Middle East people with addictions lack decision-making and Africa it increased by 25%, In countries capacity is supported by research in both like Iran, Saudi Arabia, Libya and Pakistan addiction neuroscience and the neuroscience where alcohol is legally banned, drinking is of decision-making. Substance use influences still commonplace53, 54. voluntary brain mechanisms and renders Contrary to the Islamic teaching, unfortunately individuals incapable of making rational Muslims are heavily involved in planting, decisions. harvesting, refinement, smuggling and The brain responds to particular social cues distributing heroin and cannabis to the that may provide instant pleasure. Brain Western countries. Morocco is the largest systems that moderate feeling, memory, cannabis exporter to Europe through Spain. cognition, and engage the individual with the Afghanistan, Pakistan and Iran are the major world influence the decision to consume or not producers and exporters of heroin. In 2007, consume a drug, or participate in a specific Afghanistan produced an extraordinary 8,200 behavior or series of actions. The degrees in tons of opium (34% more than in 2006), which self-control is exerted, free choice is becoming practically the exclusive supplier of realized and desired outcomes achieved are the world’s deadliest drug (93% of the global dependent on these complex interacting bio- opiates' market)55. Taliban initially opposed psycho-social systems. The complex the production of heroin, but they realized that combination of biological, psycho-social and these narcotics provided an invaluable source systemic factors may explain why it is so of income, and they supported its production. difficult for some individuals to refuse or stop They argued that it is permissible because it is consuming illicit drugs in the face of consumed by non-believers in the West. Islam increasingly negative consequences52. There is does not permit the production and sale of no question that the addictive behavior is narcotics for Muslims or non-Muslims. genetically determined and mediated by

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According to United Nations Office on Drugs importation and sale (death penalty). However, and Crime (UNODC) in 2009, Afghanistan so far, not enough attention is given to has around one million heroin and opium education or treatment60. The incidence of addicts aged between 15 and 64 years out of a alcohol and drug use among Muslims is population of 30 million, making it the world's gradually increasing in USA, but it has not top user per capita. Sixty thousand women in reached the same level as among non- Afghanistan regularly take illegal drugs. HIV Muslims. Strict religious prohibition against epidemic among injection drug users increased the drugs plays a major role in curtailing the from 3% (2005), to 7% average in three main drug seeking and using behavior. The exact cities (2009). Iran has 1.2 million "drug users," data about the Muslim minorities' drug use is and 2.26 percent of the population aged not available as data is not collected based on between 15 and 64 are addicted to opiate. In religious preferences. The actual incidence 1979, Pakistan has no heroin addicts but 20 may be much higher than observed as there is years later, there were 5 million addicts. In denial by addicts and their family members. 2011, nearly six percent - or 6.4 million adults They tend to minimize the issue until it is too used drugs. Most of the heroin in Europe is late. Even if the family members are aware of transported via Turkey. British Muslims are the problem they do not talk about it. They do also heavily involved in drug use and the sale not seek help due to shame and guilt, and the of the drugs. These young men were seldom fear that the problem will become known in educated in understanding and respecting the the community. Alcohol use is relatively more Islamic values or the dangers of drug use. common than the use of other drugs. In United Arab Emirates, alcohol and prescription-drug use has been on the rise for Islamic Perspective the past 10 years and Tramadol, a painkiller similar to opiates such as morphine, has been a Shari`ah (Islamic Law) was established in the commonly prescribed drug of addiction. 7th century based on Qur’anic commandment. Community surveys conducted in Dubai and The warning against using intoxicants was and was gradually (ﷻ) al-Ain, United Arab Emirates have further revealed by Allah confirmed a high prevalence of drug 56-59 introduced to the people until the total disorders . ,says (ﷻ) In Saudi Arabia, amphetamine abuse is most prohibition was declared. Allah prevalent. Saudi authorities confiscated 12 “They ask you (O’ Muhammad) about khamr metric tons of amphetamine (the world drug (alcohol) and gambling. Say: “In them there is report in 2010 UNODC). Professor Jallal great sin, and some profit, for men, but sin is Toufiq, founder of the Middle East and North greater than the profit”61. said: Every (ﷺ) Africa “Harm Reduction Association," told the The Prophet Muhammad USA Cable News Network (CNN): There is a intoxicant is Khamr and every intoxicant is worsening of the drug situation in the whole forbidden62. region. However, there is a void in terms of Islam stops the wrong behavior before its data and information. In many Muslim inception so that it will not become a major countries, there is a lack of political problem. By declaring that Khamr is willingness to accept that a drug problem prohibited, taking intoxicants became a major exists. People just do not want to deal with this sin and for a strong believer, this problem. Peer pressure is a significant factor commandment serves as a preventive measure. influencing the young people to use the drugs. People who are addicted to alcohol, opioid and Saudi Arabia has strict laws for drug other substances must seek medical and

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psychological treatment, but they can also get and internalized parental and social the benefit from spiritual guidance. It is a (super ego). Super ego is responsibility of the Muslim community to associated with ethics, values and self-critical support and help persons who need treatment assessment. It is influenced by parents, for addiction rather than stigmatizing or teachers and the religious beliefs. This is the outcasting them. These patients also require part of conscience development. The hunger, guidance in improving their social sexual derives, etc. are genetically determined relationships, getting employment and gaining and influenced by id. However, the super ego respect in the community. controls or directs its appropriate expression. As discussed earlier, there are multiple factors, There is no question that the desire to use a which may cause addictive behavior. Current drug is genetically determined and mediated research points out that there is a genetic through the brain’s neuronal system. However, predisposition for addiction. However, an humans have the capacity to control and individual has a capacity to control these restrain its use. This capacity of restraining is tendencies. Sexual desire is genetically influenced by parenting and religious determined and controlled by neuronal and guidance. The Glorious Qur’an has described hormonal discharges. In spite of this, an these psychological interactions in 6th century individual should have full control on the in terms of al-Nafs al- Ammarah, al-Nafs al- expression and fulfillment of the sexual Lawwamah, and al-Nafs al-Mutma’innah. says in the Qur’an: "O you who (ﷻ) desires. Similarly, an individual can control Allah the desire to take drugs, although there may be believe, intoxicants, gambling, the altars of genetic predisposition. idols and game of chance are admonitions of According to Islamic beliefs, the human soul is the devil; you shall avoid, that you may composed of three elements: 11 succeed” . 1) Al-Nafs al-Ammarah (soul commanding of In overcoming addiction, one needs to feel evil or evil-inciting soul) guilty for allowing one self to be controlled by 2) Al-Nafs al-Lawwamah (self–reproaching the lower desires and seek help from Allah soul) to give him strength to overcome the (ﷻ) Al-Nafs al-Mutma’innah (tranquil, peaceful (3 :says (ﷻ) soul) habit. Allah The goal of every Muslim is to be aware of the “And be you not like those who forgot Allah. stage of the development of his or her own He made them forget their own souls. Such are soul and discipline himself in obedience of the rebellious transgressors”64. God. He / She must strive to control al-Nafs The solution to the drug problem is not simple. al-Ammarah and achieve al-Nafs al- 63 It must be recognized that environment plays a Mutma’innah . significant role in causing drug addiction. Freud described human's basic instinctual Affluence, easy access to the drugs, permissive drives (id), human’s perceptual, intellectual- environment, and peer pressure are major cognitive, and executive functions (ego) and contributing factors. The Muslim community human’s capability of controlling self desires, must be educated about the importance of reflecting social standards learned from early upbringing, parental guidance and parents, culture and religion (super ego) as developing strong religious beliefs, which will parts of the personality structure. ‘id’ is help in building a super ego or consciousness primarily an instinctual desire, and the ‘ego’ (al-Nafs al-Lawwamah, the self-reproaching represents the self, and it mediates between the soul). This is necessary to develop a strong demands of primitive instinctual drives (id) ego which will resist temptation (al-Nafs al-

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Ammarah) for drug use and to achieve al-Nafs methadone and buprenorphine have a risk of abuse, dependence and diversion. Many ﷻ() al-Mutma’innah. A strong belief in Allah Muslim governments do consider the use of and the respect for Shari`ah law as well as use opioid agonists as haram (forbidden) and this of consciousness in decision making is must be respected. However, the use of necessary. A Muslim addict must be methadone and buprenorphine for opioid drug encouraged to adopt the Islamic way of life. addiction must be acceptable in Muslim Educational programs must be developed for countries where their dispensing is middle and high school children informing permissible. them about negative consequences of drug use, For Muslim patients, psychotherapy and resisting peer pressure and adopting Islamic counseling should focus on spirituality, strong way of life. The most effective strategy is belief in God, asking for forgiveness and prevention but unfortunately in most countries mercy. These will increase the hope and give of the world this strategy is not implemented. strength to the coping mechanisms. The Islam provides clear direction for every aspect positive affective status of spiritual experience of life. The Qur’anic legislation concerning the may affect the brain reward system, and the prohibition of using intoxicants gives Islam a patient may recognize the new cues for distinct place in comparison to other religions. pleasure, redirecting the pleasure reward The treatment of drug addiction must be 65 system to the new religious experiences . regarded as a medical treatment and all addicts Religious guidance can also direct the patient must be encouraged to seek medical and to adopt a healthy lifestyle. psychosocial treatment. Islam does not Various Islamic countries have instituted "shame" its believers when they seek support groups of Alcoholic Anonymous (AA) forgives the and Narcotic Anonymous (NA) for patients (ﷻ) treatment, and Allah shortcomings. The community has the with addiction. They have modified the responsibility to support and assist in recovery ‘twelve steps’ and replaced the word ‘higher whenever possible. These support groups .( ﷻ power’ with Allah The prescription and the dispensing of the are also helpful in the recovery of Muslim narcotics must be reviewed, as the prescription patients when presented with Islamic spiritual opioid abuse became the most serious problem beliefs. Prayers and Dhikr (remembrance of in the world today. Many young men do not ﷻ realize that prescription opiates are potentially Allah ( ) should be incorporated in the dangerous drugs. treatment regime. Abstinence-oriented treatment programs are Strict control of drug trafficking, and preferable in Muslim majority countries. The manufacturing of narcotics and pharmaceutical recently introduced anti-opiod medication products containing opioids are absolutely naltrexone (by injection and possibly as an necessary. Close monitoring of prescriptions implant) is effective in blocking the euphoric can avoid iatrogenic dependence. Stigma effects of opioid. The effects of long acting should be removed, and addicts should be naltrexone last 3-4 weeks and this will be a treated as victims and patients rather than useful deterrent for opioid use. This criminals. Legal statue should be applied medication along with psychosocial support equally to affluent and non-affluent residents system, guidance to improve the family life of the country. and occupation may be the best options of treatment in Muslim majority countries. There References: is no risk of abuse, dependence and diversion th 1. Time magazine, February 17 2014, P21 of this drug. The opioid agonists such as

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2. UNODC. World drug report 2011. 2011 United Nations 22. World Health Organization. Geneva: WHO Press; 2009. Publication Global health risks: mortality and burden of disease 3. World Health Organization: Atlas on Substance Use attributable to selected major risks. (2010): Resources for the Prevention and Treatment of 23. Substance Abuse and Mental Health Services Substance Use Disorder. Geneva, Switzerland, WHO Press Administration. Treatment episode data set. 2011 2010 24. Hadidi MS, Ibrahim MI, Abdallat IM. Current trends in 4. drug abuse-associated fatalities – Jordan, 2000–2004. Forensic http://www.unodc.org/unodc/en/frontpage/2010/April/unodc- Sci Int. 2009;186:44–47. [PubMed] 2010-annual-report-released.html 25. Monitoring the Future. 2011 data from in-school surveys 5. of 8th- ,10th, and 12th-grade students. [12-21-2011];2011 http://www.samhsa.gov/data/2012BehavioralHealthUS/2012- http://monitoringthefuture.org/data/11data.html#2011data- BHUS.pdf drugs. 6. “Definition of Addiction” Policy Statement adopted by 26. Vazquez V, Giros B, Dauge V. Maternal deprivation American Society of Addictive Medicine April 2011 specifically enhances vulnerability to opiate dependence. Maryland USA Behav Pharmacol. 2006;17:715–724. [PubMed] 7. Gregory A. Austin’s, “Perspectives on the History of 27. Kreek MJ, Bart G, Lilly C, Laforge KS, Nielsen DA. Psychoactive Substance Use” National Institute on Drug Pharmacogenetics and human molecular genetics of opiate and Abuse, 1979 cocaine addictions and their treatments. Pharmacol Rev. (http://babel.hathitrust.org/cgi/pt?id=uc1.32106001081378;vie 2005;57:1–26. [PubMed] w=1up;seq=139) 28. Johnson SW, North RA. Opioids excite dopamine neurons 8. Blum et al (Society and Drugs, San Francisco: Jossey-Bass, by hyperpolarization of local interneurons. 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Medical safety and side effects of methadone in Sundquist J: Genetic and family and community tolerant individuals. JAMA. 1973;223:665–668. [PubMed]53 environmental effects on drug abuse in adolescence: a 34. Center for Substance Abuse Treatment. Methadone Swedish national twin and sibling study. Am J Psychiatry mortality - a reassessment. Division of Pharmacologic 2014; 171: 207-217 Therapies, Center for Substance Abuse Treatment, 15. Rennert L, Denis C, Peer K, Lynch KG, Gelemter J, SAMHSA/DHHS; 2007 Kranzler HR, Prevalence and characteristics in a substance use 35. “Treatment of patients with substance use disorder” disorder. Biol Psychiatry, 2013 Oct 19 Am.Psychiat.Ass.Practice guidelines-Journal of 16. Clarke TK, Weiss AR, et al, “The dopamine receptor D2 Am.Psychiat.Ass 164:4 April 2007. (DRD2) SNP rs 1076560 is associated with opioid addiction”. Ann. Hum. Genet. 2014 Jan; 78(1): 33-9, doi: 36. Mattick, R.,P., Breen,C., etal “Methadone maintenance 10.1111/ahg.12046.Epub 2013 Nov 25 therapy vs no opioid replacement therapy for opioid 17. Brook JS, Whiteman M, et al, “Sibling influence on dependence Cochrane database system review 2003: adolescent drug use: older brothers on younger brother”. J Am CD002209 Acad Child Adolesc Psychiatry 1991; 30:958-966 18. Dohrenwend BP, Levav I,et al, “Socioeconomic status and 37. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug psychiatric disorder: the caution-selection issue”. Science dependence, a chronic medical illness: implications for 1992; 255:946-952. treatment, insurance, and outcomes evaluation. JAMA. 19. Kaufman JN, Ross TJ, et al. “Cingulate hypoactivity in 2000;284:1689–1695. [PubMed cocaine users during a GO-NOGO task as revealed by event- 38. Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. related functional magnetic resonance imaging” J Clinical pharmacology of buprenorphine: ceiling effects at Neurosci. 2003 Aug 27;23(21):7839-43. high doses. Clin Pharmacol Ther. 1994;55(5):569–80. 20. Schlaepfer T.E., et al. “Decreased frontal white-matter [PubMed] volume in chronic substance abuse”. International Journal of 39. Lange WR, Fudala PJ, Dax EM, Johnson RE. Safety and Neuropsychopharmacology. 2006; 9(2):147–153. [PubMed]) side-effects of buprenorphine in the clinical management of 21. Fowler, J.S., Volkow, N.D., et al, “Imaging the Addicted heroin addiction. Drug Alcohol Depend. 1990;26(1):19–28. Human Brain” Sci Pract Perspect. 2007 April; 3(2): 4– [PubMed]32. 16[PubMed])

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40. Reynaud M, Petit G, Potard D, Courty P. Six deaths linked 58. Abou-Saleh, M.,T.,”Substance use disorders: recent to concomitant use of buprenorphine and benzodiazepines. advances in treatment and models of care.”Journal of Addiction. 1998;93(9):1385–92. [PubMed]) Psychosomatic Research Volume 61, Issue 3 , Pages 305-310, 41. Center for Substance Abuse Treatment . Clinical September 2006 guidelines for the use of buprenorphine in the treatment of 59. Samaruddin , Vandecasteele, O., “Opioid Substitution opioid addiction. Treatment Improvement Protocol (TIP) Therapy in the Islamic Republic of Afghanistan” series 40. Rockville, MD: Substance Abuse and Mental Health worldbank.org/SOUTHASIAEXT/Resources/2235461296680 Services Administration; 2004. 097256/7707437-1318366151525/O 42. Ahmadi J. Methadone versus buprenorphine maintenance 60. “Does Saudi Arabia have the world’s biggest amphetamine for the treatment of heroin-dependent outpatients. J Subst habit”? Mark Tutton CNN July 23rd 2010 Abuse Treat. 2003;24(3):217–20. [PubMed] (http://www.cnn.com/2010/WORLD/meast/07/23/middle.east. 43. Simon D.Ronald F.Kathryn G,. “Update on the clinical use drugs.amphetamine) of buprenorphine” Can Fam Physician. 2012 January; 58(1): 61. The Glorious Quran, al-Baqarah (2:229) 37–41 PMCID: PMC3264008 62. Sahih Muslim, Book 36, Hadith 93; 44. Dunbar JL, Turncliff RZ, Dong Q, Silverman BL, Ehrich (http://sunnah.com/muslim/36/93) EW, Lasseter KC. Single- and Multiple-Dose 63. www.whyislam.org/social-values-in- Pharmacokinetics of Long-acting Injectable Naltrexone. islam/self.../addiction-and-islam Alcoholism: Clinical and Experimental Research. 64. The Glorious Quran, al-Hashr (59:19) 2006;30:480–490. 65. Pargament, K. I. “The Psychology of Religion and 45. Krupitsky E, Nunes EV, Ling W, Illeperuma A, Gastfriend Coping”. The Guilford press NY 1997. DR, Silverman BL. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011;377:1506–1513. [PubMed] 46. Reece,A.S.,”Psychosocial and treatment correlate of opiate-free success in a clinical review of a Naltrexone implant program”Substance abuse treatment,prevention and policy 2007 2:35 doi:10.11861747-597x-2-35 http://www.substance abuse policy.com/content/2/1.35 47. Zarghami M, Masoum B, Shiran MR : “Tramadol versus methadone for treatment of opiate withdrawal: a double-blind, randomized, clinical trial.”. J Addict Dis. 2012;31(2):112-7. 48. Fajemirokun-Odudeyi O, Sinha C, Tutty S, Pairaudeau P, Armstrong D, Phillips T, et al. Pregnancy outcome in women who use opiates. Eur J Obstet Gynecol Reprod Biol. 2006;126(2):170–5. Epub 2005 Oct 23. [PubMed]81. 49. Minozzi S, Amato L, Vecchi S, Davoli M. Maintenance agonist treatments for opiate dependent pregnant women. Cochrane Database Syst Rev. 2008;(2):CD006318. [PubMed] 50. Kakko J, Heiling M, Sarman I. Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal and neonatal outcomes in two consecutive case series. Drug Alcohol Depend. 2008;96(1–2):69–78. Epub 2008 Mar 19. [PubMed] 51. Craig Reinarman, Peter D. A. Cohen, and Hendrien L. Kaal “THE LIMITED RELEVANCE OF DRUG POLICY Cannabis in Amsterdam and in San Francisco” American Journal of Public Health, 2004;94:836–842) 52. Buchman D., W.,and J.,” Negotiating the Relationship Between Addiction, Ethics, and Brain Science” AJOB Neurosci. 2010 ) January; 1(1): 36–45. 53. Islam: Survey, Alcohol Use In Mideast-Africa - ANSAmed, February 23, 2011. 54. Muslim Statistics (Alcohol and Drugs) From WikiIslam, the online resource on Islam 55. United Nations Office on Drugs and Crime (UNODC) Afghanistan Opium Survey 2007 56. Muslim Statistics (Alcohol and Drugs) From WikiIslam, the online resource on Islam) 57. Yahya Brit, “Muslims have a problem with drug” http://www.liveleak.com/view?i=402_1211492769#4thCyklU APevXhW0.99

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Adnan Y. Takriti*

Abstract Cannabis, The most commonly used illegal drug, is produced from dried leaves, flowers, stems, and seeds of the weed Cannabis Sativa. Various patterns of usage are explained. The main cannabinoid receptor is anandamide. Cannabis contains at least 60 psychoactive cannabinoids, the most important of which is 9-8 (THC). The drug is metabolized to active and inactive metabolites and their absorption into fat means that urine tests remain positive for up to 4 weeks after regular use has ceased. Acute intoxication, general and chronic ill-health effects including psychiatric and organic syndromes is explored. The immediate effects include mild euphoria, a sense of enhanced well-being, subjective sense of enhanced sensation, relaxation, altered time sense, and increased appetite. Physically there is mild tachycardia, variable dysarthria and . Acute harmful effects include mild paranoia, panic attacks, and accidents associated with delayed reaction time... Chronic harmful effects include dysthymia, anxiety/depressive illnesses, and the disputed amotivational syndrome. Cannabis use can precipitate an episode of or relapse of schizophrenia. In addition, in regular users it is associated with dose-related paranoid ideation and other psychotic features. Historical background, safety, drug testing, gateway theory and legal status are discussed. Keywords: Addiction, cannabis, marijuana.

Introduction: Cannabis is also known as marijuana1, heightened mood or euphoria, relaxation, and by neumerous other names is a and increase in appetite3. Unwanted side preparation of the cannabis plant intended effects can sometimes include a decrease for use as a psychoactive drug and as in short-term memory, dry mouth, medicine. Pharmacologically, the principal impaired motor skills, reddening of the psychoactive constituent of cannabis is eyes, and feelings of paranoia or anxiety4. tetrahydrocannabinol (THC), one of 483 Contemporarily, cannabis is used as known compounds in the plant, including a recreational or medicinal drug, and as at least 84 other cannabinoids, such as part of religious or spiritual rites; the (CBD), Cannabinol (CBN), earliest recorded uses date from the 3rd tetrahydrocanna bivarin (THCV) and millennium BC5. Since the early 20th cannabigerol (CBG)2. Cannabis is often century cannabis has been subject to legal consumed for its psychoactive and restrictions with its possession, use, and physiological effects, which can include sale.

*Dr. Adnan Y. Takriti, MD, FRCP Psych. Consultant Psychiatrist Founder and Editor-in-Chief The Arab Journal of Psychiatry, 1989-2011 Amman- Jordan E-mail: [email protected]

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Preparations containing psychoactive sacrament by ancient Jews and early cannabinoids are currently illegal in most Christians17,18 due to the similarity countries of the world. According to the between the Hebrew word "qannabbos" United Nations cannabis is considered the ("cannabis") and the Hebrew phrase most used illicit drug in the world. In 2004, "qenébósem" ("aromatic cane"). It was the United Nations estimated that global used by Muslims in various Sufi orders as consumption of cannabis indicated that early as the Mamluk period, for example approximately 4% of the adult world by the Qalandars19. population (162 million people) used A study published in the South African cannabis annually, and that approximately Journal of Science showed that "pipes dug 0.6% (22.5 million) of people used up from the garden of Shakespeare's home cannabis daily6. in Stratford-upon-Avon contain traces of cannabis"20. The chemical analysis was History carried out after researchers hypothesized that the "noted weed" mentioned in Sonnet Cannabis is indigenous to Central and 76 and the "journey in my head" South Asia7. Evidence of the inhalation of from Sonnet 27 could be references to cannabis smoke can be found in the 3rd cannabis and the use thereof21. millennium BC, as indicated by charred Cannabis was criminalized in various cannabis seeds found in a ritual brazier at countries beginning in the early 20th an ancient burial site in present day century. In the United States, the first Romania8. restrictions for sale of cannabis came in In 2003, a leather basket filled with 1906 (in District of Columbia)22. It was cannabis leaf fragments and seeds was outlawed in South Africa in 1911, found next to a 2,500 - to 2,800- year old in Jamaica (then a British colony) in 1913, mummified shaman in the northwest- and in the and New ern Xinjiang Uygur Autonomous Region Zealand in the 1920s23. In 1925 a of China9,10. Evidence for the consumption compromise was made at an international of cannabis has also been found in conference in The Hague about the Intern- Egyptian mummies dated about 950 ational Opium Convention that banned BC11,12. exportation of "Indian " to countries Cannabis is also known to have been used that had prohibited its use, and requiring by the ancient Hindus of India and Nepal importing countries to issue certificates thousands of years ago. The herb was approving the importation and stating that called ganjika in Sanskrit (गांजा, ganja in the shipment was required "exclusively for 13,14 medical or scientific purposes". It also modern Indo-Aryan languages) . required parties to "exercise an effective Cannabis was also known to the ancient control of such a nature as to prevent the Assyrians, who discovered its psychoac- 15 illicit international traffic in Indian hemp tive properties through the Aryans . Using and especially in the resin"24,25. In the it in some religious ceremonies, they called United States in 1937, the Marihuana Tax it qunubu (meaning "way to produce Act was passed, and prohibited the smoke"), a probable origin of the modern 16 production of hemp in addition to word "cannabis" . Cannabis has an cannabis. The reasons that hemp was also ancient history of ritual use and is found included in this law are disputed. Several in pharmacological cults around the world. scholars have claimed that the act was Cannabis was used as a religious

62 FIMA YEAR BOOK 2014 CANNABIS passed in order to destroy the US hemp and leaves38. It varies in color from black industry26,27.28. The United Nations' to golden brown depending upon purity 2012 Global Drug Report stated that and variety of cultivar it was obtained cannabis "was the world's most widely from39. It can be consumed orally or produced, trafficked, and consumed drug smked40. in the world in 2010", identifying that between 119 million and 224 million users Tincture existed in the world's adult (18 or older) 29 Cannabinoids can be extracted from population . cannabis plant matter using high- proof spirits (often grain alcohol) to create Preparations a tincture, often referred to as "green dragon"41. Whole flower and leaf Nabiximols is a branded product name from a tincture manufacturing pharma- The terms cannabis and marijuana gener- ceutical company42. ally refer to the dried flowers and subtending leaves and stems of the female cannabis plant30. This is the most widely consumed form, containing 3% to 22% Hash oil is obtained from the cannabis THC31.32. In contrast, cannabis varieties plant by solvent extraction, and contains used to produce industrial hemp contain the cannabinoids present in the natural oils 43 less than 1% THC and are thus not valued of cannabis flowers and leaves . The for recreational use33. solvents are evaporated to leave behind a This is the stock material from which all very concentrated oil. other preparations are derived. It is noted Hemp oil is very different from both hemp 44 that cannabis or its extracts must be seed oil and cannabis flower essential oil . sufficiently heated or dehydrated to Owing to its purity, these products are cause decarboxylation of its most abundant consumed by smoking, vaporizing, eating, cannabinoid, tetrahydrocannabinolic acid or topical application. (THCA), into psychoactive THC34. Infusions Kief There are many varieties of cannabis Kief is a powder, rich in tricho- infusions owing to the variety of non- mes35, which can be shifted from the volatile solvents used. The plant material is leaves and flowers of cannabis plants and mixed with the solvent and then pressed either consumed in powder form or and filtered to express the oils of the plant compressed to produce cakes of hashish36. into the solvent. Examples of solvents used The word "kif" derives from Arabic () in this process are cocoa butter, dairy (Kayf), meaning well-being or pleasure37. butter, cooking oil, glycerine, and skin moisturizers. Depending on the solvent, these may be used in cannabis foods or 45 Hashish (also spelled hasheesh, hashisha, applied topically . or simply hash) is a concentrate- ed resin cake or ball produced from Methods of consumption pressed kief, the detached trichomes and Cannabis is consumed in many different fine material that falls off cannabis flowers ways46: Smoking, which typically involves

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inhaling vaporized cannabinoids ("smoke") cannabichromene (CBC) and cannabigerol from small pipes, bongs (portable versions (CBG), they have less (THC). of hookahs with water chamber), paper- may have a CBD: wrapped joints or tobacco-leaf-wrapp- THC ratio four to five times that ed blunts, clips, and other items47. of Cannabis sativa. Cannabis strains with Vaporizer, which heats herbal cannabis to relatively high CBD: THC ratios are less 165–190 °C (329–374 °F)48, causing the likely to induce anxiety than those with a active ingredients to evaporate into lower ratio. This may be due to a vapor without burning the plant material CBD's antagonistic effects at the cannabin- (the boiling point of THC is 157 °C oid receptors, compared to THC's partial (315 °F) at 760 mmHg pressure)49. agonist effect. CBD is also a 5- Cannabis tea contains relatively small HT1A receptor agonist, which may also concentrations of THC, because THC is an contribute to an anxiolytic effect. This oil (lipophilic) and is only slightly water- likely means the high concentrations of soluble (with a solubility of 2.8 mg per CBD found in Cannabis indica mitigate the liter)50. Cannabis tea is made by first anxiogenic effect of THC significant- adding a saturated fat to hot water (e.g. ly. The effects of sativa are well known for cream or any milk except skim) with a their cerebral high, hence its daytime use small amount of cannabis51. Edibles, where as , while indica is well cannabis is added as an ingredient to one known for its sedative effects and preferred of a variety of foods. Marijuana vending night time use as medical cannabis. machines for selling or dispensing cannabis are in use in the United States and Mechanism of action are planned to be used in Canada52. The high lipid-solubility of cannabinoids Pharmacology53 results in their persisting in the body for long periods of time54. Even after a single The genus Cannabis contains two species administration of THC, detectable levels of which produce useful amounts of psycho- THC can be found in the body for weeks ctive cannabinoids: Cannabis indica and or longer (depending on the amount Cannabis sativa, which are listed as administered and the sensitivity of the Schedule I medicinal plants in the US. A assessment method)54. third species, Cannabis ruderalis, has few A number of investigators have suggested psychogenic properties. Cannabis contains that this is an important factor in more than 460 compounds, at least 80 of marijuana's effects, perhaps because these are cannabinoids– chemical cannabinoids may accumulate in the body, compounds that interact with cannabinoid particularly in the lipid membranes of receptors in the brain. As of 2012, more neurons55. Not until the end of the 20th than 20 cannabinoids were being studied century was the specific mechanisms of by the U.S. FDA. The most psychoactive action of THC at the neuronal level cannabinoid found in the cannabis plant is studied. Researchers have subsequently tetrahydrocannabinol (or delta-9-tetrahydro confirmed that THC exerts its most -cannabinol, commonly known as THC). prominent effects via its actions on two Other cannabinoids include delta-8- types of cannabinoid receptors, tetrahydrocannabinol, cannabidiol (CBD), the CB1 receptor and the CB2 receptor, cannabinol (CBN), cannabicyclol (CBL),

64 FIMA YEAR BOOK 2014 CANNABIS both of which are G-protein coupled associated with the acute effects of receptors56. cannabis ingestion, such as euphoria and The CB1 receptor is found primarily in the anxiety. Some effects may include a brain as well as in some peripheral tissues, general alteration of conscious perception, and the CB2 receptor is found primarily in euphoria, feelings of well-being, relaxation peripheral tissues, but is also expressed or stress reduction, increased appreciation in neuroglial cells57. THC appears to alter of humor, music (especially discerning its mood and cognition through its agonist various components/instruments) or the actions on the CB1 receptors, which inhibit arts, joviality, metacognition and a secondary messenger system (adenylate- introspection, enhanced recollection cyclase) in a dose dependent manner. (episodic memory), increased sensuality, These actions can be blocked by the increased awareness of sensation, 62 selective CB1 receptor antagonist increased libido , and creativity. Abstract SR141716A (rimonabant), which has been or philosophical thinking, disruption of shown in clinical trials to be an effective linear memory and paranoia or anxiety are treatment for smoking cessation, weight also typical. Anxiety is the most loss, and as a means of controlling or commonly reported side effect of smoking reducing metabolic syndrome risk marijuana. Between 20 and 30 percent of factors58. However, due to the dysphoric recreational users experience intense effect of CB1 antagonists, this drug is anxiety and/or panic attacks after smoking often discontinued due to these side cannabis, however, some report anxiety effects59. only after not smoking cannabis for a 63 Via CB1 activation, THC indirectly prolonged period of time . increases dopamine release and produces Cannabis also produces many subjective psychotropic effects. Cannabidiol also acts and highly tangible effects, such as greater as an allosteric modulator of the mu and enjoyment of food taste and aroma, an delta opioid receptors60. THC also enhanced enjoyment of music and comedy, potentiates the effects of the glycine and marked distortions in the perception of receptors61. The role of these interactions time and space (where experiencing a in the "marijuana high" remains elusive. "rush" of ideas from the bank of long-term memory can create the subjective Psychoactive effects impression of long elapsed time, while a clock reveals that only a short time has The psychoactive effects of cannabis, passed). At higher doses, effects can known as a "high", are subjective and can include altered body image, auditory vary based on the person and the method and/or visual illusions, pseudohallucinato- of use. ry, and ataxia from selective impairment of When THC enters the blood stream and polysynaptic reflexes. reaches the brain, it binds to cannabinoid In some cases, cannabis can lead to receptors. The endogenous ligand of these dissociative states such as depersonaliza- receptors is anandamide, the effects of tion64,65 and derealization66, such effects which THC emulates. This agonism of the are most often considered desirable, but cannabinoid receptors results in changes in have the potential to induce panic attacks the levels of various neurotransmitters, and paranoia in some unaccustomed especially dopamine and norepinephrine; users66. Any episode of acute psychosis neurotransmitters which are closely that accompanies cannabis use usually

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abates after 6 hours, but in rare instances Cannabis has been used to reduce nausea heavy users may find the symptoms and vomit-ing in chemotherapy and people continuing for many days67. When the with AIDS, and to treat pain and muscle episode is accompanied by aggression, spasticity76. According to a 2013 review, sedation or physical restraint may be "Safety concerns regarding cannabis necessary67. include the increased risk of developing While many psychoactive drugs clearly schizophrenia with adolescent use, impair- fall into the category of either stimulant, ments in memory and cognition, accidental depressant, or hallucinogen, cannabis pediatric ingestions, and lack of safety exhibits a mix of all properties, perhaps packaging for medical cannabis formula- leaning the most towards hallucinogenic or tions"77. The US Food and Drug Admini- psychedelic properties, though with other stration (FDA) maintains that the herb effects quite pronounced as well. THC is cannabis is associated with numerous typically considered the primary active harmful health effects, and that significant component of the cannabis plant; various aspects such as content, production, and scientific studies have suggested that supply are unregulated. certain other cannabinoids, like CBD, may also play a significant role in its Chronic health effects of cannabis use78 psychoactive effects68,69,70.  Selective impairment of cognitive General Effects functioning which include the organization and integration of Cannabishas psychoactive and physio- complex information involving vari- logical effects when consumed71. The ous mechanisms of attention and immediate desired effects from consuming memory processes. cannabis include relaxation and mild  Prolonged use may lead to greater euphoria (the "high" or "stoned" feeling), impairment, which may not recover while some immediate undesired side- with cessation of use, and which effects include a decrease in short-term could affect daily life functions; memory, dry mouth, impaired motor skills  Development of a cannabis depend- and reddening of the eyes72. Aside from a ence syndrome characterized by a subjective change in perception and mood, loss of control over cannabis use is the most common short-term physical and likely in chronic users. neurological effects include increased heart  Cannabis use can exacerbate rate, increased appetite and consumption of schizophrenia in affected individu- food, lowered blood pressure, impairment als. of short-term and working memory73,74,  Epithelial injury of the trachea and psychomotor coordination, and concentr- major bronchi is caused by long- ation. term . A 2013 literature review reported that  Airway injury, lung inflammation, exposure to marijuana had biologically- and impaired pulmonary defence based physical, mental, behavioral and against infection from persistent social health consequences and was cannabis consumption over prolong- "associated with diseases of the liver ed periods. (particularly with co-existing hepatitisC),  Heavy cannabis consumption is lungs, heart, and vasculature"75. associated with a higher prevalence

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of symptoms of chronic bronchitis more common with new users or in those and a higher incidence of acute who already have a psychiatric disease. bronchitis than in the non-smoking The amount and effect of these side effects cohort. varies from person to person, as well as  Cannabis used during pregnancy is with the amount of marijuana used. associated with impairment in fetal Marijuana is often cut with hallucinogens development leading to a reduction and other, more dangerous drugs that have in birth weight. more serious side effects than marijuana.  Cannabis use during pregnancy may These side effects may include: lead to postnatal risk of rare forms  Sudden high blood pressure with of cancer although more research is headache. needed in this area. The health  Chest pain and heart rhythm disturba- consequences of cannabis use in nces. developing countries are largely  Extreme hyperactivity and physical unknown because of limited and violence. non-systematic research, but there is  Heart attack. no reason a priori to expect that  Seizures. biological effects on individuals in  Stroke. these populations would be  Sudden collapse (cardiac arrest). substantially different to what has been observed in developed count- Treatment ries. However, other consequences might be different given the cultural Treatment and care involves: and social differences between  Preventing injury. countries.  Reassuring those who have panic reactions due to the drug. Marijuana acute intoxication79 Benzodiazepines, such as diazepam (Valium) or lorazepam (Ativan) may be Symptoms: given. Children who have more serious The intoxicating effects of marijuana symptoms or those with serious side include relaxation, sleepiness, and mild effects may need to stay in the hospital for euphoria (getting high). treatment. Treatment may include heart Smoking marijuana leads to fast and and brain monitoring. predictable signs and symptoms. Eating marijuana can cause slower, and Prognosis sometimes less predictable effects. Uncomplicated marijuana intoxication Marijuana can cause undesirable side rarely needs medical advice or treatment. effects, which increase with higher Occasionally, serious symptoms occur. doses. These side effects include: However, these symptoms are rare and  Decreased short-term memory usually associated with other drugs or  Dry mouth compounds mixed in with marijuana.  Impaired perception and motor skills  Red eyes Safety More serious side effects include panic, Fatal overdose associated with cannabis paranoia, or acute psychosis, which may be use have not been reported as of 200880.

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There has been too little research to binoid system and an overall role of determine whether cannabis users die at a cannabis in causing decreased peripheral higher rate as compared to the general resistance and increased cardiac output, population, though some studies suggest which potentially could pose a threat to that fatal motor vehicle accidents and death those with cardiovascular disease86. from respiratory and brain cancers may be more frequent among heavy cannabis Detection of cannabis-consumption drug users. Many studies have looked at testing the effects of smoking cannabis on the respiratory system. Cannabis smoke THC and its major (inactive) metabolite, contains thousands of organic and THC-COOH, can be measured in blood, inorganic chemical compounds. This tar is urine, hair, oral fluid or sweat using chemically similar to that found in tobacco chromato-graphic techniques as part of a smoke81, and over fifty known carcino- drug use testing program or a forensic gens have been identified in cannabis investigation of a traffic or other criminal smoke82, including; nitrosamines, reactive offense87. The concentrations obtained aldehydes, and polycylic hydrocarbons, from such analyses can often be helpful in including benz[a]pyrene83. distinguishing active use from passive There is serious suspicion among cardio- exposure, elapsed time since use, and logists, spurring research but falling short extent or duration of use. These tests of definitive proof, that cannabis use has cannot, however, distinguish authorized the potential to contribute to cardiovascul- cannabis smoking for medical purposes ar disease. Cannabis is believed to be an from unauthorized recreational smoking88. aggravating factor in rare cases of arteritis, Commercial cannabinoid immuno-assays, a serious condition that, in some cases often employed as the initial screening leads to amputation. Because 97% of method when testing physiological subjects in case-reports also smoked specimens for marijuana presence, have tobacco, a formal association with cannab- different degrees of cross-reactivity with is could not be made. THC and its metabolites89. Urine contains If cannabis arteritis turns out to be a pre-dominantly THC-COOH, while hair, distinct clinical entity, it might be the oral fluid and sweat contain primarily consequence of vasoconstrictor activity ob- THC87. Blood may contain both served from delta- 8- THC and delta-9- substances, with the relative amounts THC84. dependent on the recency and extent of Other serious cardiovascular events usage87. including myocardial The Duquenois-Levine test is commonly Infarction, stroke, sudden cardiac death, used as a screening test in the field, but it and cardiomyopathy have been reported to cannot definitively confirm the presence of be temporally associated with cannabis cannabis, as a large range of substances use. Research in these events is have been shown to give false positives. complicated because cannabis is often used Despite this, it is common in the United in conjunction with tobacco, and drugs States for prosecutors to seek plea such as alcohol and cocaine85. bargains on the basis of positive D-L tests, These putative effects can be taken in claiming them definitive, or even to seek context of a wide range of cardiovascular conviction without the use of gas phenomena regulated by the endocanna- chromatography confirmation, which can

68 FIMA YEAR BOOK 2014 CANNABIS only be done in the lab90. In 2011, cannabis (though the reverse may be true researchers at John Jay College of in some areas), thus leading to the Criminal Justice reported that dietary zinc "gateway sequence" in those individuals supplements can mask the presence of since they are most likely to experiment THC and other drugs in urine. Similar with any drug offered63. claims have been made in web forums on "Notice that none of these interpretations that topic91. involves a specific pharmacological effect of the sort drug warriors seem to have in Gateway drug Theory mind when they suggest that pot smoking primes the brain for cocaine or heroin. As Since the 1950s, United States drug policy a National Academy of Sciences panel has been guided by the assertion that observed in a 1999 report, 'There is no cannabis use increases the probability of evidence that marijuana serves as a trying "harder" drugs92. The hypothesis has stepping stone on the basis of its particular endured as one of the central pillars of drug effect.' Last year the Canadian anti-cannabis drug policy in the United Senate's Special Committee on Illegal States93, and as such the validity and Drugs likewise concluded that 'cannabis implications of the hypothesis are hotly itself is not a cause of other drug use. In debated92. Almost two-thirds of the poly- this sense, we reject the gateway theory'101. drug users in the "2009/10 Scottish Crime and Justice Survey" used cannabis94. Legal status Some studies state that while there is no proof for the gateway hypothesis95, young Since the beginning of the 20th century, cannabis users should still be considered as most countries have enacted laws against a risk group for intervention programs96, the cultivation, possession or transfer of while other findings indicate that hard drug cannabis102. users are likely to be poly-drug users, and These laws have impacted adversely on the that interventions must address the use of cannabis plant's cultiva-tion for non- multiple drugs instead of a single hard recreational purposes, but there are many drug97. regions where, under certain circumsta- Another gateway hypothesis covers that a nces, handling of cannabis is legal or gateway effect may be caused by the licensed. Many jurisdictions have lessened "common factors" involved in using any the penalties for possession of small illegal drug. Through the illegal status of quantities of cannabis, so that it is punish- cannabis, users are more likely to be ed by confiscation and sometimes a fine, subjected to situations allowing them to rather than imprisonment, focusing more acquaint with individuals using or selling on those who traffic the drug on the black various illegal drugs98,99. Utilizing this market. In some areas where cannabis use argument some studies have shown that has been historically tolerated, some new alcohol and tobacco may additionally be restrictions have been put in place, such as regarded as gateway drugs100, however, a the closing of cannabis coffee shops near more parsimonious explanation could be the borders of the Netherlands103, closing that cannabis is simply more readily of coffee shops near secondary schools in available (and at an earlier age) than illegal the Netherlands and crackdowns on hard drugs. In turn alcohol and tobacco are “Pusher Street” in Christiania, Copenhagen easier to obtain at an earlier point than is in 2004104,105.

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Some jurisdictions use free voluntary was jurists’ consensus, from all schools of treatment programs and/or mandatory Islamic thought, to classify cannabis as an treatment programs for known frequent intoxicant (khamr)110-113, and to apply the users. Simple possession can carry long rulings of alcohol on cannabis, i.e. prison terms in some countries, particularly prohibition (tahrim), and punishment (by in East Asia, where the sale of cannabis flogging). may lead to a sentence of life in prison or Ibn Taymiyah110, Ibn al-Qayyim111, Badr even execution. More recently however, al- Din al-Zarkashy112 and Imam al- many political parties and non-profit Nawawi113 wrote in detail about the organizations are working on the problem, and its rulings. legalization of medical cannabis and/or Several ahadith were cited, including the legalizing the plant entirely, with some following: "   و  ام" .restrictions have emerged In December 2012, the U.S. state “Every intoxicant is khamr (alcohol-like) of Washington became the first state to and every khamr is haram (prohibited)114. "ا   اofficially legalize cannabis in a state law " (Washington Initiative 502) (but still “Khamr is whatever clouds the mind”115. 106 و أم ": ال (ﷺ) illegal by federal law) , with the state    وof Colorado following close behind " 107 prohibited any (ﷺ) Colorado Amendment 64) . On January The Prophet) 1, 2013, the first marijuana "club" for intoxicant and languid-causing material116. private marijuana smoking (no buying or Al-Sayyid Sabiq, in his book: Fiqh al- selling, however) was allowed for the first 107 Sunnah, elaborated on the opinion of the time in Colorado . The California above scholars, and added a fatwa Supreme Court decided in May 2013 that (religious decree) issued by the Grand local governments can ban medical Mufti of Egypt (Mufti al-Diyar al- marijuana dispensaries despite a state law Misriyyah), Shaikh Abdul Majid Salim, in California that permits the use of that cannabis (hashish) is haram117. cannabis for medical purposes. At least 180 cities across California have enacted References: bans in recent years108. In December 2013, Uruguay became the 1. Mahmoud A. ElSohly (2007). Marijuana and the first country to legalize growing, sale and Cannabinoids. Springer. p. 8. ISBN 978-1-59259- use of cannabis109. 947-9. 2. Ethan B Russo (2013). Cannabis and Cannabinoids: Pharmacology, Toxicology, and Islamic rulings: Therapeutic Potential. Routledge. p. 28. ISBN 978-1-136-61493-4. 3. "Marijuana - Marijuana Use and Effects of Muslim jurists began to deliberate on Marijuana". Webmd.com. 2012-07-23. Retrieved cannabis effects nearly six centuries after 2013-07-12. Hijrah (13th century C.E.) after the Tatars’ 4. Riedel, G.; Davies, S.N. (2005). "Cannabinoid function in learning, memory and invasion on the Muslim countries. Prior to plasticity". HandbExpPharmacol. Handbook of that time, the cannabis problem was not Experimental Pharmacology 168: known to Muslim scholars110. 446.doi:10.1007/3-540-26573-2_15. ISBN 3-540- 22565-X.PMID 16596784. In view of cannabis effects on human mind 5. Martin Booth (2003). Cannabis: A History. and body i.e. clouding of thinking and Transworld. p. 36. ISBN 978-1-4090-8489-1. associated psychosocial problems, there 6. UNODC. World Drug Report 2010. United Nations Publication. p. 198. Retrieved 2010-07-19.

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7. Marijuana and the Cannabinoids", ElSohly (p. 8). Oxford University Press. p. 24. ISBN 978-0-19- 8. Rudgley, Richard (1998). Lost Civilisations of the 513893-1. Stone Age. New York: Free Press. ISBN 0-684- 29. ElianaDockterman (29 June 2012). "Marijuana 85580-1. Now the Most Popular Drug in the World". Time 9. Lab work to identify 2,800-year-old mummy of NewsFeed. Time Inc. Retrieved 16 March 2013. shaman. People's Daily Online. 2006. 30. AnnFowlet Rhoads (2000). The Plants of 10. Hong-En Jiang, et al. (2006). "A new insight Pennsylvnia: an lllustrated Manual. University of intoCannabis sativa (Cannabaceae) utilization Pennsylvania Press. P. 309.ISBA 978-0-8122- from 2500-year-old Yanghai tombs, Xinjiang, 3535-7.Retrived 2013. China". Journal of Ethnopharmacology 108 (3): 31. "High Times in Ag Science: Marijuana More 414– Potent Than Ever". Wired.com. 2008-12-22. 22.doi:10.1016/j.jep.2006.05.034. PMID 16879937 Retrieved 2010-01-02. 11. Parsche, Franz; Nerlich, Andreas (1995). "Presence 32. "Marijuana". dictionary.reference.com. of drugs in different tissues of an 33. "Decarboxylation – Does Marijuana Have to be egyptianmummy".Fresenius' Journal of Analytical Heated to Become Psychoactive?". Cannabis- Chemistry 352 (3-4): 380– culture.com. 2003-01-02. Retrieved 2012-10-09. 384. doi:10.1007/BF00322236. 34. Ed Rosenthal (2002). Ask Ed : Marijuana Gold: 12. Balabanova, S.; Parsche, S.; Pirsig, W. (August Trash to Stash. QUICK AMER Publishing 1992). "First identification of drugs in Egyptian Company. p. 116.ISBN 978-0-932551-52-8. mummies".Naturwissenschaften 79 (8): 358– 35. "Kief". Cannabisculture.com. 2005-03-09. 358.doi:10.1007/BF01140178. Retrieved 2010-01-02. 13. Leary, Timothy (1990). Tarcher& Putnam, 36. David Bukszpan (2012). Is That a Word?: From ed.Flashbacks. New York: GP Putnam's AA to ZZZ, the Weird and Wonderful Language of Sons. ISBN 0-87477-870-0. SCRABBLE. Chronicle Books. p. 94. ISBN 978-1- 14. Miller, Ga (1911). "Encyclopædia Britann- 4521-0824-7. ica". Science34 (883) (11 ed.). pp. 761– 37. "Hashish". dictionary.reference.com. 2.doi:10.1126/science.34.883.761. PMID17759460 38. Castle/Murray/D'Souza (2004). Marijuana and 15. Franck, Mel (1997). Marijuana Grower's Guide. Madness. Cambridge University Press. Red Eye Press. p. 3. ISBN 0-929349-03-2. p. 35. ISBN 978-1-139-50267-2. 16. Rubin, Vera D (1976). Cannabis and Culture. 39. Raymond Goldberg (2012). Drugs Across the Campus Verlag. p. 305. ISBN 3-593-37442-0. Spectrum, 7th ed.. Cengage Learning. 17. Walton, Robert P (1938). Marijuana, America's p. 255. ISBN 978-1-133-59416-1. New Drug Problem. JB Lippincott. p. 6. 40. Leslie L. Iversen (2000). The Science of 18. Matthew J. Atha (Independent Drug Monitoring Marijuana. Oxford University Press. Unit)."Types of Cannabis Available in the United p. 17. ISBN 978-0-19-515110-7. Kingdom (UK)". 41. Jeffrey A. Cohen; Richard A. Rudick (2011). 19. "Cannabis linked to Biblical healing". Multiple Sclerosis Therapeutics. Cambridge News (BBC). 2003-01-06. Retrieved 2009-12-31. University Press. p. 670. ISBN 978-1-139-50237-5. 20. IbnTaymiyya (2001). Le haschichetl'extase (in 42. Leslie A. King (2009). Forensic Chemistry of French). Beyrouth: Albouraq. ISBN 2-84161-174- Substance Misuse: A Guide to Drug Control. Royal 4. Society of Chemistry. p. 78. ISBN 978-0-85404- 21. "Bard 'used drugs for inspiration'". BBC News. 178-7. 2001-03-01. Retrieved 2009-08-07. 43. "Hash Oil Info". a1b2c3.com. 22. "Drugs clue to Shakespeare's genius". CNN (Turner 44. Elise McDonough; Editors of High Times Broadcasting System). 2001-03-01. Retrieved Magazine (2012). The Official High Times 2009-08-07. Cannabis Cookbook: More Than 50 Irresistible 23. Statement of Dr. William C. Woodward. Drug Recipes That Will Get You High. Chronicle Books. library. Retrieved 2010-09-20. p. 17. ISBN 978-1-4521-0133-0. 24. "Debunking the Hemp Conspiracy Theory". 45. Leslie L. Iversen Professor of Pharmacology 25. W. W. Willoughby (1925). Opium as an inter- University of Oxford (2007). The Science of national problem. Baltimore: The Johns Hopkins Marijuana. Oxford University Press. Press. Retrieved 2010-09-20. p. 194. ISBN 978-0-19-979598-7. 26. Opium as an international problem: the Geneva 46. Andrew Golub (2012). The Cultural/Subcultural conferences – Westel Woodbury Willoug- Contexts of Marijuana Use at the Turn of the hby at Google Books Twenty-First Century. Routledge. p. 82. ISBN 978- 27. Laurence Armand French; MagdalenoManzanárez 1-136-44627-6. (2004). Nafta & Neocolonialism: Comparative 47. Allan Tasman; Jerald Kay; Jeffrey A. Lieberman; Criminal, Human & Social Justice. University Michael B. First, Mario Maj (2011). Psychiatry. Press of America. p. 129. ISBN 978-0-7618-2890- John Wiley & Sons. p. 9. ISBN 978-1-119-96540- 7. 4. 28. Mitch Earleywine (2002). Understanding Marijuana: A New Look at the Scientific Evidence.

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48. Ed Rosenthal (2002). Ask Ed: Marijuana Gold: 65. Shufman, E;Lerner, A; Witztum, E (2005). Trash to Stash. Perseus Books Group. Depersonalization after withdrawal from cannabis p. 15. ISBN 978-1-936807-02-4. usage”. Harefuah (in Hebrew) 144 (4): 249–51, 49. "Cannabis and Cannabis Extracts: Greater Than the 303.PMID 15889607. Sum of Their Parts?". Cannabis-med.org. Retrieved 66. Johnson, BA (1990). "Psychopharmacological 2014-04-07. effects of cannabis". 50. in the ChemIDplus database British journal of hospital medicine 43 (2): 114–6, 51. Dale Gieringer, Ph.D.; Ed Rosenthal 118–20, 122. PMID 2178712. (2008). Marijuana medical handbook: practical 67. Barceloux, Donald G (20 March guide to therapeutic uses of marijuana. QUICK 2012). "Chapter 60: Marijuana (Cannabis AMER Publishing Company. p. 182.ISBN 978-0- sativa L.) and synthetic cannabinoids". Medical 932551-86-3. Toxicology of Drug Abuse: Synthesized Chemicals 52. Blackwell, Tom (2013-10-16). "The pot vending and Psychoactive Plants. John Wiley & Sons. machine’s first foreign market? Canada, of course, p. 915. ISBN 978-0-471-72760-6. ‘a seed for the rest of the world’". National Post. 68. Stafford, Peter (1992). Psychedelics Encyclopedia. Retrieved 2013-12-04. Berkeley, California, United States: Ronin 53. H.K. Kalant& W.H.E. Roschlau (1998). Principles Publishing, Inc.ISBN 0-914171-51-8. of Medical Pharmacology (6th ed.). pp. 373–375. 69. McKim, William A (2002). Drugs and Behavior: 54. Wayne Hall; Rosalie LiccardoPacula An Introduction to Behavioral Pharmacology (5 (2003).Cannabis Use and Dependence: Public ed.). Prentice Hall. p. 400. ISBN 0-13-048118-1. Health and Public Policy. Cambridge University 70. "Information on Drugs of Abuse". Commonly Press. p. 15. ISBN 978-0-521-80024-2. Abused Drug Chart. nih.gov. 55. Leo E. Hollister, et al. (March 1986). "Health 71. Nadia Hejazi, Chunyi Zhou, Murat Oz, Hui Sun, aspects of cannabis". Pharma Review (38): 1–20. Jiang Hong Ye, Li Zhang (March 2006). "∆9- Archived from the original on 1986. Retrieved tetrahydrocannabinol and endogenous cannabinoid 2011-02-17. anandamide directly potentiate the function of 56. Juan Iovanna; UktamIsmailov (2009). glycine peceptors". Pancreatology: From Bench to Bedside. Springer. Molecular Pharmacology 69 (3): 991– p. 40. ISBN 978-3-642-00152-9. 7.doi:10.1124/mol.105.019174. PMID 16332990. 57. Wilson, R. &Nicoll, A. (2002). "Endocannabinoid 72. Emmanuel S Onaivi; Takayuki Sugiura; Vincenzo signaling in the brain". Science 296 (5568): 678– Di Marzo (2005). Endocannabinoids: The Brain 682.doi:10.1126/science.1063545. PMID 1197643 and Body's Marijuana and Beyond. Taylor & 7. Francis. p. 58.ISBN 978-0-415-30008-7. 58. Fernandez, J. & Allison, B. (2004). 73. Wayne Hall; Rosalie LiccardoPacula "RimbonabantSanofi-Synthelabo". Current (2003). Cannabis Use and Dependence: Public Opinion in Investigational Drugs (5): 430–435. Health and Public Policy. Cambridge University 59. Atta-ur- Rahman; Allen B. Reitz (2005). Frontiers Press. p. 38. ISBN 978-0-521-80024-2. in Medicinal Chemistry. Bentham Science 74. Mary Lynn Mathre; International Cannabis Publishers. p. 150. ISBN 978-1-60805-205-9. Alliance of Researchers and Educators 60. Kathmann, Markus; Flau, Karsten; Redmer, Agnes; (1997). Cannabis in Medical Practice: A Legal, Tränkle, Christian; Schlicker, Eberhard (2006). Historical, and Pharmacological Overview of the "Cannabidiol is an allosteric modulator at mu- and Therapeutic Use of Marijuana. University of delta-opioid receptors". Naunyn-Schmiedeberg's Virginia Medical Center. pp. 144–. ISBN 978-0- Archives of Pharmacology 372 (5): 354– 7864-8390-7. 361. doi:10.1007/s00210-006-0033- 75. Riedel, G.; Davies, S.N. (2005). "Cannabinoid x. PMID 16489449. edit function in learning, memory and plastic- 61. Nadia Hejazi, Chunyi Zhou, Murat Oz, Hui Sun, ity". HandbExpPharmacol. Jiang Hong Ye, Li Zhang (March 2006). "∆9- Handbook of Experimental Pharmacology 168: tetrahydrocannabinol and endogenous cannabinoid 446.doi:10.1007/3-540-26573-2_15. ISBN 3-540- anandamide directly potentiate the function of 22565-X.PMID 16596784. glycine peceptors". 76. Gordon AJ, Conley JW, Gordon JM (December Molecular Pharmacology 69 (3): 991– 2013). "Medical consequences of marijuana use: a 7.doi:10.1124/mol.105.019174. PMID 16332990. review of current literature". Curr Psychiatry Rep 15 (12): 419.doi:10.1007/s11920-013-0419- 7. PMID 24234874. 62. http://cannabislink.ca/http://cannabislink.ca/info/M 77. Borgelt LM, Franson KL, Nussbaum AM, Wang otivationsforCannabisUsebyCanadianAdults- GS (February 2013). "The pharmacologic and 2008.pdf clinical effects of medical 63. Medical Marijuana and the Mind”. Harvard Mental cannabis". Pharmacotherapy 33 (2): 195– Health Letter. April 2010. Retrieved April 25.2011. 209.doi:10.1002/phar.1187. PMID 23386598. 64. "Medication-Associated Depersonalization Symp- toms" 78. World Health Organization (WHO) www.who.int/substance_abuse/facts/cannabis/en/

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79. Medline, Marijuana intoxication, Medline Medical Alteration. SAGE Publications. p. 18. ISBN 978-0- Encyclopedia NIm.nih.gov.Retrieved 2013-07-12 7619-3007-5. 80. Calabria B, et al. (May 2010). "Does cannabis use 95. Saitz, Richard (2003-02-18). "Is marijuana a increase the risk of death? Systematic review of gateway drug?". Journal Watch 2003 (218): 1. epidemiological evidence on adverse effects of 96. Degenhardt, Louisa et al. (2007). "Who are the cannabis use". Drug Alcohol Rev. 29 (3): 318– new amphetamine users? A 10-year prospective 30. doi:10.1111/j.1465- study of young Australians". Addiction 102 (8): 3362.2009.00149.x. PMID 20565525. 1269–79.doi:10.1111/j.1360- 81. Gumbiner, Jann (2011-02-17). Does Marijuana 0443.2007.01906.x.PMID 17624977. Cause Cancer?. Psychology Today. Retrieved 97. Morral AR, McCaffrey DF, Paddock SM (2002). 2013-01-09. "Reassessing the marijuana gateway 82. Does smoking cannabis cause cancer?. Cancer effect". Addiction 97(12): 1493– Research UK. 2010-09-20. Retrieved 2013-01-09. 504. doi:10.1046/j.1360- 83. Tashkin, Donald (March 1997). Effects of 0443.2002.00280.x.PMID 12472629. marijuana on the lung and its immune defenses. 98. "Marijuana Policy Project- FAQ". Archived UCLA School of Medicine. Retrieved 2012-06-23. from the original on 2008-06-22. 84. Cottencin O. (Dec 2010). "Cannabis arteritis: 99. Torabi MR, Bailey WJ, Majd-Jabbari M (1993). review of the literature". J Addict "Cigarette Smoking as a Predictor of Alcohol and Med (Review) 4 (4): 191– Other Drug Use by Children and Adolescents: 6.doi:10.1097/ADM.0b013e3181beb022.PMID 21 Evidence of the "Gateway Drug Effect"". The 769037. Journal of School Health 63 (7): 302– 85. Thomas G (2014-01-01). "Adverse cardiovascular, 6.doi:10.1111/j.1746- cerebrovascular, and peripheral vascular effects of 1561.1993.tb06150.x.PMID 8246462. marijuana inhalation: what cardiologists need to 100. Sullum, Jacob (24 Jan 2003), Marijuana as a know". Am J Cardiol 113 (1): 187– "gateway" drug, Reason, retrieved 2014-04-01 90.doi:10.1016/j.amjcard.2013.09.042. PMID 2417 101. David Levinson (2002). Encyclopedia of Crime 6069. and Punishment. SAGE Publications. 86. RT Jones (2002-11). "Cardiovascular system p. 572. ISBN 978-0-7619-2258-2. effects of marijuana". 102. "Many Dutch coffee shops close as liberal policies J ClinPharmacol (Review) 42 (11 Suppl): 58S– change, Exaptica". Expatica.com. 2007-11-27. 63S. PMID 12412837. Retrieved 2010-09-20. 87. Donald G. Barceloux (3 February 2012). Medical 103. EMCDDA Cannabis reader: Global issues and Toxicology of Drug Abuse: Synthesized Chemicals local experiences, Perspectives on Cannabis and Psychoactive Plants. John Wiley & Sons. controversies, treatment and regulation in Europe, pp. 910–.ISBN 978-1-118-10605-1. Retrieved 14 2008, p. 157. July 2013. 104. "43 Amsterdam coffee shops to close door", Radio . 88. Randall Clint Baselt (2008). Disposition of Toxic Netherlands, Friday 21 November 2008 Drugs and Chemicals in Man. Biomedical 105. Marijuana goes legal in Washington state amid Publications. pp. 1513–1518. ISBN 978-0- mixed messages. Reuters. Retrieved December 14, 9626523-7-0. 2012. 89. Leslie M. Shaw; Tai C. Kwong (2001). The 106. Alan Duke (2012-11-08). "2 states legalize pot, but Clinical Toxicology Laboratory: Contemporary don't 'break out the Cheetos' yet". CNN.com. Practice of Poisoning Evaluation. Amer. Assoc. Retrieved 2013-01-02. for Clinical Chemistry. p. 51.ISBN 978-1-890883- 107. "Marijuana clubs ring in new year in Colorado as 53-9. legalized pot smoking begins". Abcnews.go.com. 90. John Kelly (2010-06-28). Has the most common 2013-01-01. Retrieved 2013-01-02. marijuana test resulted in tens of thousands of 108. HorwardMintz (2013-05-06). "Medical pot: wrongful convictions?. AlterNet. California Supreme Court allows cities to ban weed 91. RAND study casts doubt on claims that marijuana dispensaries".Marin Independent Journal. acts as "gateway" to the use of cocaine and heroin. 109.http://www.theguardian.com/travel/2013/dec/ RAND Corporation. 2002-12-02. Archived 11/uruguay-marijuana-laws-around-world from the originalon 2006-11-04. 110.Ibnu Taymiyah in his book: Al-Siyasah al- 92. Arthur Benavie (University of North Carolina) Shariyyah. P. 108. And Al-Fatawa al-Kubra (2009).Drugs: America's Holy War. Routledge. 4/263-264 and 4/275-276, Kurdistan pp. 90–.ISBN 978-0-7890-3840-1. Scientific Publishing, Cairo-Egypt, 1329H. 93. "3 The Experience of Drug Users". 2009/10 Scottish Crime and Justice Survey: Drug Use. The 111. Ibnul Qayyim al-Jawziyyah, Zad a Ma’ad, Scottish Government. 21 January 2011. Retrieved vol. 5, pp. 661-662. 5 November 2013. 112. Imam Badr al-Din al-Zarkashi (D.794H): 94. Clayton J. Mosher; Scott Akins (2007). Drugs and Zahr al-Arish fi Tahrim al-Hashish. Dar al Drug Policy: The Control of Consciousness Wafa’a publishing 1987, Cairo-Egypt, pp 89- 121.

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113. Hamid Jami’ and Mohammad Fathi Eid: Al- Mukhaddarat fi Rai al-Islam (Narcotics in the Islamic opinion), Majma’ al-Buhuth al- Islamiyyah-al-Kitab al-Awwal, pp. 12-16 and 56-66. 114. Sahih Muslim, Kitab al-Ashribah # 2003. 115.. Sahih Al-Bukhari, hadith #1/40. 116. Sunan Abi Dawad 2/322, and 6/309-Bab al- Nahiy an al-Muskir. Al-Risalah Printing- Beirut, Lebanon. 117. Al-Sayyid Sabiq. Fiqh al-Sunnah, vol 2. Dar al Kitab al-`Arabi, 6th Edition, 1985, Beirut, Lebanon, pp 385-394.

74 FIMA YEAR BOOK 2014 QAT ABUSE IN YEMEN: SOCIO-ECONOMIC AND HEALTH PERSPECTIVES

Husni Al-Goshae*

Abstract:

Qat (or Khat) is an evergreen shrub named Catha Edulis which belongs to the family: Gelastraceae. The plant grows in Ethiopia, Kenya, Somalia, South Africa, Madagascar, and was imported to Yemen from East Africa approximately 700 years ago. Over the past several decades, the plant became widely grown in Yemen and occupied the fertile land that was traditionally cultivated by life sustaining crops for Yemeni people. Approximately 58.5% of agricultural lands are currently planted by Qat, leaving the rest for grains, vegetables, fruits …etc. What makes the matter more serious is the amount of water needed to grow this plant. In a country with limited water resources, like Yemen, more than 60% of this water is consumed for Qat plantation, drawing the country into major economic and social problems. In this presentation, various Qat-related problems with their pathophysiolgoic basis are discussed, with special attention to the various health hazards that affect many body systems. Available Islamic Jurisprudence opinion will be outlined.

Keywords: Qat, Qat-induced medical problems, Catha Edulis, Yemen, addiction.

Introduction:

Qat (Khat) belongs to the Catha Edulis leaves of the plant, especially when plant family. The active ingredients are consumed within 24 hours after harvesting. three main alkaloids, namely: cathinone, Both cathinone and cathine have strong cathine and ephedrine1. Cathinone is an CNS stimulant affects2. However, cathine amphetamine-like substance that induces has much less stimulant effect on the CNS release of catecholamines in the peripheral than cathinone. The World Health and central nervous systems. The main Organization (WHO) categorized Qat as a metabolites of cathinone are norpseudo- drug in 1973. The concentration of the Qat ephedrine and ephedrine. alkaloids vary according to the region in Both substances have sympathomimetic which Qat is grown. Cathinone concentra- activities, and stimulant properties on the tion is 3.3% in Yemeni Qat, and 14% in central nervous system (CNS), while Kenyan Qat. The effects of cathine on the cathinone has the predominantly peripheral CNS as a stimulant are much less than that effects1. Cathinone is present in the fresh of cathinone.

*Prof. Dr. Husni Ahmed Al-Goshae Ph.D in Neuroscience- Dundee University- UK President of the High Council For Medical Education University of Science and Technology Sana’a- Yemen Ex-Chairman, Consortium of FIMA Islamic Medical Colleges (CIMCO) E-mail: [email protected]

FIMA YEAR BOOK 2014 75 QAT

The Qat shrub is an evergreen plant grown tions and during working hours. Taxes on a wide scale in Yemen, the East African were levied against various Qat-related countries: Kenya, Ethiopia, Somalia and businesses. Unfortunately such measures Djibouti. Qat is primarily consumed in proved ineffective and fruitless to curtail these countries but in addition, Qat is also this deep-rooted social habit and its consumed in some European countries, consequences. such as Britain and some states in USA, where migrants from these countries Medical consequences of Qat: 3,4 reside . Over the years, Qat consumption was In Yemen, Qat plantation occupies 58.5% shown to cause many health problems. of the total cultivated land, which leaves Most body systems are adversely affected, only 41.5% of land to other crops that including the central nervous system represent essential food items such as (CNS), cardiovascular (CVS), gastrointes- grains, vegetables, and fruits. Moreover, tinal (GIT), and genitor-urinary (GUT) Qat consumes around 60% of water, in a systems. As Qat is mostly consumed by country that suffers from scarcity of water. chewing, periodontal health is adversely Almost 70-80% of the Yemeni population affected. of 25 million chew Qat on daily basis, with Moreover, there are added toxic sequelae exacerbation of consumption on holidays of the frequently uncontrolled and unregul- and special occasions. The fresh leaves of ated practices of farmers in using the shrub are usually chewed, especially fertilizers, insecticides and other chemicals during social and cultural gatherings, and to increase Qat production and to hasten held in the lower buccal pouch as a bolus marketing of the fresh plant. Such for long hours, to enjoy its pleasurable practices increase various damaging effects stimulant properties. The majority of Qat on various body systems. chewers are16 to 60 years old but some chewers are as young as 7-15 years. Effects of Qat on the CNS In Yemen, which is considered among the world poorest countries, 2-3 billion dollars These follow 5 stages: are spent yearly on Qat consumption5. Stage 1: Starts within 30 minutes Over the past 2-3 decades, Qat cultivation following chewing Qat leaves. It is escalated exponentially. Almost 20% of characterized by hyperactivity, alertness, the Yemeni work force is involved in the talkativeness, sense of euphoria and Qat business. As a locally produced and wellbeing. This stage lasts 60-90 minutes. consumed crop, Qat generates no national These effects are similar to the effects of 2 income from export, and therefore it amphetamines on the CNS . represents economic waste. Qat consumes Such temporary effects are the cause for most of the families' income, with the prevailing beliefs that Qat improves significant socio-economic consequences, work performance, counteracts fatigue and including, but not limited to family helps students in preparing for 4 fragmentation and devious means to secure examinations . the financial burdens of Qat consumption. Stage 2: Also called: the imagination and The Yemeni government sought to under- problem-solving stage. During this stage take measures to deal with the escalating Qat chewers feel they are able to solve Qat phenomena since 1975. Qat chewing most problems, whether personal, social or was banned in all governmental institu- business-related. This stage lasts about 2-3 hours.

76 FIMA YEAR BOOK 2014 QAT

Stage 3: The stage of silence. This starts 5- neurotransmitter of cathinone, has symp- 6 hours from the beginning of Qat athomimetic effects, with vasoconstriction chewing. Talking stops, silence prevails that is dose-dependent9,10,11. Elevation of with excessive smoking, feelings of lack of blood pressure and palpitation, cold safety, sense of fear, anxiety accompanied extremities and sweating, are frequently by auditory and visual hallucinations. encountered during and after sessions of Frequently, the individual starts talking to Qat chewing, and were ascribed to himself. vasoconstrictive effects of cathinone. Stage 4: Stage of depression. This stage is These effects were documented in animal characterized by headache, feelings of experiments11,12. loneliness, doubt towards surrounding Acute myocardial infarction (MI) was people, aggressiveness and insomnia. This linked to Qat consumption. Qat is stage starts after the Qat chewer throws considered an independent, dose-related away the long-chewed Qat bolus from his risk factor for MI13. mouth. Stage 5: The final stage starts few hours Qat effects on GIT: prior to dawn. It is characterized by generalized weakness, relaxation, laziness, Several effects of Qat were reported on the desire to sleep, which is uncomfortable, GIT. Large doses could cause hyperacid- with bad dreams, morning depression and dity, GI mucosal injuries and aggravation aggressiveness2. of gastric and duodenal ulcerations14. Other GIT complications include esophagi- Qat and psychosis: ititis, , delay of intestinal Excessive and prolonged Qat chewing may absorption, and development of oral cause psychosis and schizophrenia which keratotic white lesions at the site of 6 chewing (tachzeen). Cytotoxic effects on could be severe . 15 Two types of psychosis were described in the hepatic and renal cells were observed . The Advisory Council on the Misuse of the literature: 16 1.Schizophrenic psychosis, described in Drugs (ACMD) report, 2013 revealed heavy Qat chewers, with paranoid delus- proven incidence of acute hepatitis. As ions, sense of fear (phobia), lack of mentioned previously, these complications adaptation to environment, isolation tende- of Qat consumption on GIT and other body ncy, hearing hallucinations, and aggressive systems, are greatly enhanced by the toxic behavior. These symptoms may disappear effects of chemicals used as insecticides on stopping Qat consumption, but tend to and fertilizers to promote Qat productivity 7 as farmers believe. Some of these effects recur if the habit is resumed . 17 2. Manic psychosis, with hyperactivity, may be carcinogenic . loud shouting, speech difficulty, delusions, flight of ideas, euphoria and anger. These Effects of Qat on GUT: symptoms usually subside spontaneously The early stages (1 and 2) of Qat chewing, when Qat is discontinued 7,8. are usually accompanied by great increase in sexual desire. Although this increase in Qat effects on CVS: libido persists to the subsequent stages of Qat chewing (stages 3-5), the feelings of Clinical studies showed cathinone to cause depression, headache and impotence CVS complications. Norepinephrine, the predominate18. The seminal fluid is dis-

FIMA YEAR BOOK 2014 77 QAT

charged of the urethra involuntarily among economy suffers about 2-3 billion USD most Qat chewers. The effect is ascribed to every year. These estimated statistics were inhibitory effects of cathinone on the obtained in 2013 from local NGOs that are sphincters of seminal vesicles18. functional in Yemen to combat Qat There are some reports on the relationship growing and consumption. One of those of Qat chewing to an increase in urinary NGOs is "Erada (willpower) and Yemen bladder dysfunction19. Qat may increase without Qat" Organization. the possibility of urinary tract stone Similar decreases in economic productivity formation, but this needs further were also reported from Ethiopia, Somalia, investigations. Uganda and Kenya23. In some African Periodontitis and oral health: countries it was reported that Qat may push its users to inappropriate behaviors, Heavy, long- term Qat chewing is an such as bribery, cheating, stealing, independent risk factor for periodontal prostitution and other criminal behaviors24. diseases with adverse affects on teeth, The other significant and alarming gums, clinical attachment loss and other economic problem is the increased water 20 aspects of oral hygiene . consumption of Qat agriculture. In Yemen, Is there Qat addiction or dependence? with sparse drinking water supplies, more than 60% of available water, underground Cathinone, one of the main two constitue- or otherwise, is consumed by Qat cultiva- nts of Qat, with its major metabolite: tion. Farmers prefer Qat cultivation over norpseudoephedrine, leads to the 1 other life supporting crops, in view of its dependence effects of Qat . It was, biannual profitable cultivation pattern, and however, observed that Qat chewers ease of marketing in local markets. These experience no significant withdrawal individual benefits are in contrast to the symptoms when they stop Qat. This is major harms on the national Yemeni frequently observed when Qat chewers economy in view of lack of income travel abroad and stay away from the habit. generation of hard currency as Qat is not This observation led some researchers to exported. conclude that dependence on Qat is mainly 21 psychological , and people are able to Islamic perspectives: discontinue the habit easily, if intension and willpower are exercised. Some people, Qat consumption was discussed by in such situations may have minor uncom- Shari’ah scholars and Fatwa forums inside fortable symptoms, such as bad dreams, and outside Yemen. feeling hot sensations in extremities, leth- In view of various significant health, argy and sense of missing Qat chewing. psychosocial and harmful economic Tolerance to the central amphetamine-like consequences of Qat consumption, and in effects have been frequently described22. view of scientific stand-points of the There are no significant withdrawal World Health Organization considering symptoms comparable to those related to Qat as a narcotic and addicting drug, most alcohol or other narcotics. of Yemeni Islamic scholars issued Fatawa that forbid Qat consumption considering it Socio-economic consequences: as (Haram)5. In Yemen, Qat causes approximately 20 These scholars include: million lost hours in work productivity  Sheikh Abdulwahab Al-Dielmy, form- every day. It was estimated the Yemeni er minister of justice.

78 FIMA YEAR BOOK 2014 QAT

 Sheikh Mohammad Al-Sadak- Al- References: Eman University, Sana’a.  Sheikh Mohammad Al-Imam, and 1. Kalix, P. and Braenden, O. (1985), Pharmacological Aspects of the chewing of khat leaves. Pharmacol. Rev., others. 1985;37:149-164. An official standpoint from the Yemeni 2. Kalix, P. Cathinone, a natural amphetamine. government and the official Fatwa Pharmacol. Toxicol. (1992); 70: 77-86. 3. Ethiopia Medical Journal, April 1997, pp 137-139. authorities, however, was not adopted 4. Hassan N. A. G. M., Gunaid A. A. , and Murray-Lyon sofar, in view of lack of determination and I. M. , “Khat (Catha edulis): health aspects of khat resolve. chewing”. Eastern Mediterranean Health Journal, vol. 13, no. 3, pp. 15-24, 2007. In Saudi Arabia, the Fatwa Institution issu- 5. Al-Goshae, et. al, 2003, Book, Khat Between Medicine ed Fatwa number 2159 dated 25/10/1398 and Shari’ah. Hijri (1977), in which the cultivation, 6. Morgan, J. and Perkin, E. 1984, Lancet; Volume 2: p selling, buying and chewing of Qat is 455. 5 7. Drake. P. H. (1988). Khat-Chewing in the near East forbidden (Haram) . (letter). Lancet, I, 532-533. A similar decision was undertaken by the 8. Giannini, A. J., &Castellani, S. (1982). A manic-like psychosis due to Khat (Catha EdulisForsk). Journal of International Islamic Fiqh Academy held Clinical Toxicology, 19: 455-459). in Madina-Saudi Arabia in 1402 Hijri. 9. Brenneisen R, Fish H-U, Koelbing U, Geisshusler S, They recommended to punish Qat chewers Kalix P. Amphetamine-like effects in humans of the khat and traffickers on the same basis adopted alkaloid cathinone. Br. J.Clin. Pharmacol. 1990;30:825- 25 828. by Shari’ah to other narcotics . 10.Kohli JD & Goldberg LI.(1982). Cardiovascular Effect of (-) Cathinone in The Anesthetized Dogs: Concluding remarks: Comparison With (+) Amphetamine. J. Pharma, Pharmacol, 1982, (34):338-340. 11. Al-Motarreb A, and Kenneth, J., Broadley, K. J. Qat in Yemen, represents a major obstacle Coronary and Aortic vasoconstriction by cathinone, the to socio-economic development, in active constituent of khat. Auton. Autacoid Pharmacol. 2003;23(5-6):319-26. addition to its significant health 12. Al-Motarreb, A. Effect of Cathinone on blood consequences. vessels; Proceeding in the 4th Yemeni-Italian conference It affects physical, mental and psycho- 2004;18-20 January, Sana'a, Yemen. 13. Al-Motarreb, A. and George, S. J. B.(2004): Khat logical health of major population strata, Chewing is a risk factor for acute Myocardial Infarction; especially in the age groups that represent Proceedings Second GCC Cardiovascular Conference, the productive work force of the country. 2004;12-15 January; Muscat Oman. 14. Wintana Tadesse, (2011): Addis Ababa University These combined parameters make it Libraries Electronic Thesis and Dissertation: School of prohibited “haram” to be consumed by Pharmacy – Experimental Pharmacology. Item: Muslims. http://hdl.handle.net/123456789/3065. 15. Molham Al-Habori, (2005): Review, The potential To date, the proper constructive response adverse effects of habitual use of Catha Edulis (Khat); from governmental, political, social, religi- November 2005, Vol. 4, No 6, P. 1145-1154 ous and educational leadership has been (doi:10.1517/14740338.4.6. 1145). 16. The Advisory Council on the Misuse of Drugs ineffective, leading to exacerbation of this (ACMD) Report, 2013; Advisory Council on the Misuse multifaceted problem. All concerned of Drugs; Khat: A review of its potential harms to the individuals, societies and organizations, individual and communities in the UK. 17. Al-Goshae, H.A & Al-Karawani, N. (2009), and Al- official or community-based, are called Goshae, H. A., (2012). Book, The Opinion of Scholars in upon to lay down proper and constructive Khat Chewing, medical, economic, and legal study. The planning and collaboration to combat this Universities Publisher House, Sana, Yemen, ISSN 1126/2012. problem by all means. 18. Halbach, H. (1972), Medical aspects of the chewing Khat leaves. Bulletin of the World Health Organzation, 47: 21-29.

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19. Nasher, A. A., Qirbi, A. A., Ghafoor, M. A., Catteral, a., Thompson, A., Ramsay, J. W. A., and Murray-Lyon, I. M., (2008). British Medical Journal of Urology, VGol. 75, Issue 5. DOI: 10.1111/j. 1464-410x. 1995. Tb07415.x. 20. Al-Sharbi AK, Shuga-Aldin H., Ghandour I and Al- Hebshi N. Qat chewing as an Independent Risk Factor for Periodontitis: A cross-sectional study. International Journal of Dentistry, 2013, PP. 1-7. 21. Al-Motarreb, A., Baker, K. and Broadley, K. J.,Khat: Pharmacological and Medical Aspects and its Social Use In Yemen. Phyto-therapy Research 2002;16:403-413. 22. Kassim S., Islam S. and Croucher r. “Validity and reliability of a Severity of Dependence Scale for Khat (SDS-Khat)”. Journal of Ethropharmacology, 2010, vol. 132, No 3, pp 570-577. 23. Giannini, A. J., Burge, H., Shaheen, J. M., (1986), Khat: Another drug of abuse? Journal of Psychoactive Drugs, 8:155-158. 24. Elmi, A. S., (1983). The chewing of Khat in Somalia. Journal of Ethnopharmacology, 8:163-176. 25. The Islamic International Fiqh Academy- Session held in Madina, Saudi Arabia, 27-30 5, 1402 H.

80 FIMA YEAR BOOK 2014 BEHAVIORAL ADDICTION

Mehmet Dinc*

Abstract:

Until recent years, the general public have mostly seen behavioral addictions like innocent habits and mental health professionals have ignored it as they are so focused on substance abuse problems. This fact makes it difficult to find funding sources for research or even to take a class at a university on behavioral addiction. Therefore, behavioral addiction has been underestimated, undertreated and understudied. For example, gambling addiction was first mentioned in the medical literature in the early 1800s but it could not find a place in the Diagnostic and Standardized Manual of Mental Disorders (DSM) until 1980 and still it has been put under impulse control disorder instead of under addiction until DSM-V. However, major changes in all aspects of life, mostly in the fields of scientific research, have resulted in increased awareness of behavioral addiction as an entity and made it more visible now. Such changes have triggered new types of addiction like Internet addiction and new forms of old addictions such as online gambling and Internet pornography. General information about addiction will be presented and then information about what we should know and what we should do about behavioral addiction will be discussed.

Keywords: Addiction, Behavioral Addiction, Gambling Addiction, Sex Addiction, Internet Addiction, Shopping Addiction.

says in the Glorious Quran: Being dependent is not the effect of a (ﷻ) Allah contract. It is not related to any role nor "...Make not your own hands contribute is it the result of one’s social class. to your destruction..."1. Dependency is the consequence of "...nor kill yourselves..."2. lowering your self-esteem, abdicating said: your dignity. It is what happens when (ﷺ) The Prophet Muhammad "There should be neither harming, nor you allow your being to be crushed… reciprocating harm”3. Dependency is a disease of Being! … It “To be dependent, even if involuntarily, is the result of one’s incompleteness…to is always a personal choice. Nothing and be dependent means to cease believing in oneself. To depend means to stop no one can force you into dependency, 4 only you can do that to yourself! … dreaming” .

*Mehmet Dinc Clinical Psychologist MA, M.Ed(Master of Education) Hasan Kalyoncu University Valide-i Atik Mh. Lami Celebi Sk. No:4/2 Uskudar Istanbul- Turkey E-mail: [email protected]

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Definition of Addiction consistent and reliable shift in the mood state. Sometimes, it might be to get high Defining of addiction, especially from or to be aroused but sometimes it might the perspective of behavioral addiction, be the total opposite, i.e. to numb or to is not easy because there is no clear distress. Tolerance means that to get the distinction between use, abuse and same effects on the person's mood addiction. Moreover, the differences modification, he/she needs to use this between addictions, habits, interest, behavior more and more day by day. obsession, dedication and so on are Withdrawal symptoms mean experience- mostly blurred. For this reason, some ing some psychological symptoms, for researchers like Vaillant5 offered that example increased moodiness or instead of searching for a ready storability and physiological problems, definition of addiction, we consider it such as sweaty hands, nausea, stomach like a mountain or season, when cramps, headaches and anxiety attacks, confronted with these situations, we when the addictive behavior is prevented. know these things implicitly. However, Conflict means having repetitive to work on addictions as a doctor, problems in his family life or work life psychiatrist, psychologist, social worker, because of the addictive behavior and or a researcher, we need a functional even though he wants to cut down and definition of addiction. Following are the stop he cannot do it because he lost his three different definitions of addiction. control on the behavior. Relapse means it “Addiction is a brain disease resulting does not matter to give up from any from the interaction among salience/ addiction for some time because as soon reward, learning/ memory/ conditioning as an addictive person starts he does not and a lowering inhibition/control”6. start from the beginning but from the Addiction is a “Behavior that is center of addiction circle. motivated by emotions ranging between the Craving to Compulsion spectrum; Risk Factors Continued use in spite of adverse consequences and Loss of Control” 7. Before pointing out any factors which “All addiction is characterized by a loss may lead to addiction, I would like to of control, preoccupation, compulsivity, share a letter which was written by Carl narrowing of interest, dishonesty, guilt G. Jung to Bill Wilson who is one of the and chronic relapse”8. founders of , just before Jung’s death. In the letter Jung Definition of Behavioral Addiction describes the need for alcohol (or any other addiction) as being similar to According to Griffiths9 who is one of the spiritual thirst. Meanly, if anyone cannot most prominent pioneers in behavioral reach wholeness with spirituality, he addiction, any behavior, which fulfills six may look for other ways to feed his thirst components, is an addictive behavior. and most of the time he uses addiction to The six components are: salience, mood squinch his thirst. Wallace10 explained modification, tolerance, withdrawal spiritual thirst by these concepts; intense symptoms, conflict and relapse. Salience feelings of alienation, apartness, means the behavior becomes the most emptiness, meaninglessness, and lack of important thing in anyone’s life so that purpose in living. Therefore, spirituality the person becomes totally preoccupied might be a prevention and treatment for with the behavior mentally if not any addiction at the same time. Jung physically. Mood modification means stated his ideas with these words in the some specific behaviors are used for a letter:

82 FIMA YEAR BOOK 2014 BEHAVIORAL ADDICTION

“…….. addiction is an issue. Moreover, after His craving for alcohol was the some time of addiction an important equivalent on low level of the spiritual question arises that is whether life thirst of our being for completeness, problems have caused the addiction or expressed in medieval language: the the addiction has caused the life union with God. problems. How could one formulate such an insight Addicted people mostly use two in a language that I misunderstood in our techniques about their addictions to days? persuade themselves. First, they The only right and legitimate way to such underestimate their use even if they an experience is, that it happens to you in experience so many times that their use reality and it can only happen to you causes major problems in their lives, and when you walk on a path, which leads second, they believe that they can stop you to a higher level of understanding. whenever they want. You might be led to that goal by an act of Comparing substance addiction to Grace or through a personal and honest behavioral addiction, substance addiction contact with friends, or through a higher looks more harmful than behavioral education of the mind beyond the addiction. Although substance addiction confines of mere rationalism. I see from has stronger effects on the human brain your letter that Roland H. has chosen the than behavioral addiction, behavioral second way, which was, under the addiction has a big impact on low self- circumstances, obviously the best one. esteem, depression, anxiety, trauma, I am strongly convinced that the evil distress, conflict in marriage and family, principle prevailing in this world, leads poor academic and job performance and the unrecognized spiritual need into it can even lead to suicide and homicide6. perdition, if it is not counteracted either by a real religious insight or by the Common Types of Behavioral protective wall of human community. An Addiction ordinary man, not protected by an action :says (ﷻ) rom above and isolated in society cannot Allahﮏ resist the power of evil, which is called “Say: Not equal are al-Khab'ith (all that very aptly the Devil. But the use of such is evil and bad as regards things, deeds, words arouse so many mistakes that one beliefs, people, food, etc.) and al-Tayiiyib can only keep aloof from them as much (all that is good as regards things, deeds, as possible…….. beliefs, people, food, etc.), even though You see, Alcohol in Latin is “spiritus” the abundance of al-Khabith (evil) may and you use the same word for the please you. So, fear Allah much [(abstain highest religious experience as well as from all kinds of sins and evil deeds for the most depraving poison. The which He has forbidden) and love Allah helpful formula therefore is: spiritus much (perform all kinds of good deeds 11 contra spiritum” . which He has ordained)], O men of Another important reason for being understanding in order that you may be addicted to any behavior is lack of skill successful”12. to cope with life problems. Therefore, There are many types of behavioral most addicted people use the behavior as addiction: From work to exercise and an automatic stress reliever. Surely from love to eating, so many behaviors people show some behaviors to calm have been seen as an addiction. There is down, feel relaxed and add some even an alphabetic list in some websites pleasure to their lives. However, when it about types of addiction that name more becomes the only choice to calm down, than 100 different types of addiction.

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However, this kind of categorization than using the Internet. Internet is received many criticisms with exciting for many people because of its accusations of creation of false epidemics affordability, accessibility and and creation of diagnostic inflation. anonymity. It is cheaper than any other Therefore, a line has to be drawn leisure activity, it can be used anytime between a personal lifestyle and a regardless of day or night, and people use psychiatric pathology to understand and it to become or pretend to be who they work on behavioral addiction, even it want to be. Furthermore, whatever they might be so difficult. This paper will want (sex, gambling, shopping etc.), they focus on Internet addiction as the model can have access to it without any of behavioral addiction, because of three limitations. Therefore, Internet usage has reasons: increased enormously in the last years all 1. It is impossible to cover all behavioral around the world. From 1980’s to the addiction that are listed in the literature. year 2000, technology, mostly the 2.The most common types of behavioral Internet, was praised and people were addiction are sub-groups of Internet happy about the change that Internet has addiction . Moreover, so many people made in their lives. However, after 2000, become easily addicted to some behavior people have seen some real and on the Internet and so many behavioral dangerous negative effects of the addicted people use Internet to feed their Internet, mostly on children. Then addiction, whatever they are. researches have started studying Internet 3. Internet addiction has spread like use, abuse and addiction. Statistics about wildfire all around the world regardless Internet addiction can be easily found in of religion, nationality and education and the literature14-17. has brought so many devastating results In the following part, prevention of that have never been seen before. The internet abuse and addiction will be following examples may give some idea discussed and some possible solutions about the results: will be offered. However, before the In 2001, the murder of his own brother prevention part, some short information by a middle school student, mimicking a about treatment will be given. scene from an internet online game. In 2005, a person jumped off from a Treatment building after being forced to exit the league by the game manager. In 2007, a Since behavioral addiction has been person learned how to commit murder ignored for so many years, there are only and conceal the body from computer few specifically designed treatment games. A middle school student programs for behavioral addiction murdered his grandmother in 2010, and relative to the vast number of treatment headed to internet café without a blink, programs for substance addiction. after murdering the mother for being Moreover, there is no medication annoying”13. approved by any official authority around the world for treatment of behavioral Internet Addiction addiction. However, some researches show that psychosocial treatment People use the Internet for a reason or methods, like the twelve steps approach without any reason. They use it for a and pharmacological treatment, such as reason like sex, gambling, game, chat, naltrexone, which are used for substance shopping etc. They use it without any abuse and related disorders works for reason because they might not have behavioral addiction as well6,18. The best something better or more exciting to do

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way to deal with behavioral addiction is spend their physical energy. For surely prevention. children and adolescents, they mostly Because behavioral addiction was mostly sit during the way to their school and neglected until recent years and hence they sit during the class time for 5 to there are no sufficient experts, 8 hours and they sit in front of TV or researches, institutions and treatment their personal computer when they models. Moreover, completion rate of are home until bedtime. However, treatment and treatment success for their bodies need to spend energy in addiction are less than most of the other some way. If they cannot find a psychopathologies. healthy way to spend their physical energy, they spend it by visiting Prevention pornography websites or online sex sites or playing violent video or First of all, it is possible to prevent online games. Therefore, regular people from behaving in a certain way physical activity should be in as long as the reasons of the behavior are everyone’s life especially children understood. For behavioral addiction or and adolescents’ lives. Internet addiction 5 possible reasons 3. Expressing himself: Everyone needs have been seen. to express himself by saying 1. Psychopathology: There is a strong something or doing something. link between psycho-pathology and Sometimes he needs to express his addiction. People who have genetic feelings; sometimes he needs to vulnerability to any addiction can express his thinking. Most people develop behavioral addiction easier cannot motivate themselves by their than those who do not have it. On the jobs and therefore they cannot other hand, people who suffer from express themselves in their works. any psychopathology can develop Moreover, most people prefer to behavioral addiction easier than those watch TV, read newspaper or visit who do not have it. Particularly, websites rather than listen to other children and adolescents who suffer people. For this reason, if anyone from Attention Deficit Hyperactivity needs to express himself by saying or Disorder (ADHD), social anxiety and doing something, it becomes easier to depression are more vulnerable to find a place or person on the virtual addiction than their peers19. life than real life. However, no virtual Therefore, parents and teachers relationship can substitute real life should be aware of symptoms and needs. signs of psycho-pathologies and 4. Socializing: Although the world and should not be reluctant to seek cities have become more crowded assistance from mental health day-by-day, people become lonelier professionals if needed. On the other and socially isolated than ever before. hand, children and adolescents should However, one of the basic needs of be taught to use Internet with time human beings is socializing. Building limit and responsibility. a relationship with others, meeting 2. Physical energy: Everyone, in new people, talking, sharing, smiling particular, children and adolescents etc. is essential for the psychological need to spend their energy into makeup of humans. Un-fortunately, it something. Because of the modern is a fact that many people have lived lifestyle, that was brought by so many years in the same apartment technology (cars, machines,… etc.), house or same neighbourhood but many people, mainly in cities, cannot never know anything more than

FIMA YEAR BOOK 2014 85 BEHAVIORAL ADDICTION

names or sometimes not even the 8.Ashley, Larry & Boehlke, Karmen K. (2013) Gambling Addiction, Behavioral Addiction, An-Pyng names of other residents or Sun, Larry Ashley, Lesley Dickson (ed.) Central neighbours. In recent years, this Recovery Press, U.S.A. became a reality for families as well. 9.Griffiths, Mark (2013) Gambling and Gaming Addictions: A Cause for Concern?, 1st International People have their spouses, children, Congress of Technology Addiction Congress Book, father or mother but they do not KULT Foundation, Istanbul. know about each other more than 10. Wallace, J. (1996) Theory of 12 Step Oriented Treatment. In: Rotgers, F. Keller, D.S. & Morgenstern, anyone else who follows them on J. (eds.) (1996) Treating Substance Abuse: Theory and Facebook or Twitter. Therefore, new Findings. London: Guilford Press ways to build new relationships or 11. Merter, Mustafa (2014) Nefs Psikolojisi, Kaknüs Yayınları, İstanbul. strengthening the existing ones 12.Glorious Qur’an, Al-Ma’idah, 5:100 should be created to prevent online 13. Kim, Daijin (2013) Internet Addictions and st socializing. Cognitive Functions in Korea, 1 International Congress of Technology Addiction Congress Book, 5. Meaning: Most of online users or KULT Foundation, Istanbul. addictive people use the Internet or 14. Choi Y.H., (2007), Advancement of IT and any behavior pathologically because seriousness of youth Internet addiction, International Symposium on the Counseling and Treatment of Youth they do not have anything better to do Internet Addiction. Seoul, Korea. than surfing on the net, chatting, 15. Kelleci, M., (2008), İnternet, Cep Telefonu, gambling, playing games or visiting Bilgisayar Oyunlarının Çocuk ve Gençlerin Ruh Sağlığına Etkileri, TAF Preventive Medicine Bulletin, porn websites. They do not have any 7. good reason to stop behaving in that 16. Yılmaz, M.B., (2010) İlköğretim 6. ve 7. Sınıf way. They are bored with their lives Öğrencilerinin Bilgisayara Yönelik Bağımlılık Gösterme Eğilimlerinin Farklı Değişkenlere Göre and want to do something joyful İncelenmesi, Eğitim Teknolojileri Araştırmaları without any effort or risk. Thus, Dergisi, 1. without meaning in the life or doing 17. Bölükbaş, K., Yıldız, M.C., (2003), İnternet Kullanımında Kadın-Erkek Eşitsizliği, IV. Ulusal something meaningful, there is no Sosyoloji Kongresi, Cumhuriyet Üniversitesi, Sivas, reason not to become addicted to Türkiye, 16-18/10/2003. something. To prevent addiction, a 18.Arısoy, Ö. (2009) İnternet Bağımlılığı ve Tedavisinde Güncel Yaklaşımlar, Current Approaches number of significant organizations, in Psychiatry, 1:55-67. works, gatherings should be 19. Dinç, Mehmet (2014) Internet Addiction: What We increased and people will learn to Should Know, What We Should Do, Yeşilay Yayınları, İ make their lives more meaningful. stanbul. Then they will have an answer for the question why they should not become addicted to something.

References:

1.Glorious Qur’an, Al-Baqarah, 2:195 2.Glorious Qur’an,l Al-Baqarah, 4:29. 3. Ibnu Majah, Hadith #32, Jami’ Al-Ulum wal-Hikam, p 207. 4. D’Anna, Stefano E. (2004) Tanrılar Okulu, Alteo Yayıncılık, Bursa. 5. Vaillant, G.E. (1982). On defining alcoholism. British Journal of Addiction, 77, 143-144. 6. Sun, An-Pyng (2013) Historical Background of Behavioral Addiction and The Trend Today, Behavioral Addiction, An-Pyng Sun, Larry Ashley, Lesley Dickson (ed.) Central Recovery Press, U.S.A. 7. Shaffer, Howard J. (2013) What is Addiction: A Perspective, http://www.divisiononaddiction.org/html/whatisaddicti on.htm#ixzz2tZ4di1J0

86 FIMA YEAR BOOK 2014 ADDICTION AND SUBSTANCE ABUSE IN PREGNANCY

Hassan M. Harirah* and Sahar E. Donia

Abstract:

Prevalence of addiction and substance abuse by women of childbearing age has increased markedly over the past three decades. In the United States, about four percent of women who are pregnant use some type of illicit drugs. Multiple risk factors exist with maternal addiction and substance abuse and the risks to the fetus or neonate vary depending on the type of substance being abused. Prenatal exposure to substances of abuse has been associated with serious harm to the mother and her fetus, and without intervention, the deleterious effects of these substances could persist throughout the child’s life. Although substance abuse treatment during pregnancy improves maternal and neonatal outcomes, identifying addiction and substance abuse in pregnancy can present a significant clinical challenge and often remains under diagnosed. In this article, we discuss the major categories of drugs/substances that are commonly abused in pregnancy and evaluate the adverse effects these substances may have in the preconception time period, during pregnancy, and the postpartum period. Keywords: Addiction, pregnancy, illicit drugs, tobacco, marijuana, alcohol, opioids, cocaine, and amphetamines, barbiturates, benzodiazepines.

Introduction:

The prevalence of addiction and substance effects of these substances could persist abuse by women of childbearing age has throughout a child’s life. Elucidating the increased markedly over the past three individual effects of in-utero exposure to decades1. In the United States, about four substances of abuse during pregnancy is percent of women who are pregnant use some complicated by multidrug use, including type of illicit drugs, like cocaine or marijuana. alcohol and tobacco. Evidently, substance Many more abuse legal intoxicating abuse during pregnancy has been associated substances prior to the birth of the baby, such with low birth weight, preterm birth, smaller as alcohol or tobacco. A recent self-reporting head circumference, shorter birth length, poor survey by the National Survey on Drug Use neuro-developmental outcomes, and lower and Health (NSDUH) from 2002–2010 Apgar scores3-6. Such poor neonatal outcomes reported a substantial increase in substance also lead to increased health care costs for the abuse among pregnant women. The rates in neonate and mother7. In addition, an increased 2010 were 16.2%, 7.4%, and 1.9% in women incidence of developmental, conduct, and aged 15-17, 18-25, and 26-44 respectively2. attention deficit disorders, and predisposition Prenatal exposure to substances of abuse has to use drugs in the offspring has been been associated with serious harm to the fetus, documentted8,9. and without intervention, the deleterious

*Hassan M. Harirah, MD, FRCSC, University of Texas Medical Branch 301 University Boulevard, Galveston, TX 77555 - USA E-mail: [email protected]

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Multiple risk factors are associated with regarding the management of high risk maternal addiction and substance abuse pregnancies in substance abusing mothers. including young age, low socioeconomic These guidelines primarily address the status, lack of prenatal care, history of psycho- identification and management of teratogenic logical or psychotic illness, history of neglect, exposure, poor maternal nutrition, intra-uterine history of sexual or physical abuse, peer growth restriction (IUGR), placental insuff- pressure, easy access, and lack of knowledge iciency, labor management, and maternal/ of the adverse effects abuse substances have neonatal withdrawal symptoms. on fetal development10. Risks to the fetus or neonate vary depending TOBACCO: on the type of substance being abused which can include preterm delivery, low birth weight, Active and passive tobacco smoking presents birth defects, conditions such as fetal alcohol major risks to human health. Smoking syndrome, mental retardation, neonatal contributes to the development of various seizures secondary to substance withdrawal, human cancers, respiratory illnesses, and other and very often death due to premature diseases. In the United States, tobacco delivery. Substance abuse treatment during smoking is the leading preventable cause of pregnancy improves maternal and neonatal death and each year 480,000 deaths (one out of outcomes11,12. Although pregnancy can be a five) are caused by tobacco-related diseases1. motivating factor for entering substance abuse Among child-bearing age women, there is an treatment, pregnant women face barriers both increased prevalence of smoking particularly to treatment initiation and completion13. in the youngest population.2In addition, the Identifying addiction and substance abuse in lower the level of education achieved, the pregnancy can present a significant clinical greater the risk of being a current smoker14. challenge and often remains under diagnosed3. Tobacco users also have shown an increased Pregnant women may be less likely to enter risk for infertility and dysmenorrhea15. substance abuse treatment due to fear of losing Therefore, every effort should be made to custody of their children, prosecution, identify smokers prior to pregnancy and alienation from society or lack of child care, provide intervention to enhance the likelihood insurance, or economic means. of smoking cessation. Pregnancy can be also a Similarly, despite the benefits of treatment significant motivator to stop or reduce during pregnancy, pregnant women may be at smoking. The most recent available statistics a higher risk of attrition compared with the on tobacco use in pregnancy report that 16.4% general population. Similarly, certain factors of pregnant women continue to smoke during among pregnant women have been associated their pregnancy2. The prevalence of tobacco with an even lower likelihood of treatment smoking in pregnant women differs between completion, including age, race, peer deviance, racial and ethnic groups; 19.8% in African lack of employment, and prior experiences Americans, 24.4% in Caucasians, and 5.8% in with child protection services11. Hispanics16. Tobacco is associated with a The goal of this article is to identify the major higher rate of adverse maternal and fetal categories of drugs /substances that are outcomes and has a clearly demons-trated commonly abused in pregnancy and evaluate dose-response relationship10. In the first the adverse effects these substances may have trimester, these risks include an 2-5 fold during the preconception time period, increased risk of spontaneous abortion and an pregnancy, and the postpartum period. In 1.5-2.5 fold increased risk of ectopic addition, we will review general guidelines pregnancy. In the second and third trimesters,

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there is an increased risk of placental reinforcement of the patient’s desire to quit insufficiency, low birth weight, fetal growth smoking21. restriction, and preterm delivery (1.2 to 16 folds)15. When tobacco is smoked, a mixture MARIJUANA: more than 4,000 chemicals are produced and at least 43 of these chemicals are known Marijuana, also known as cannabis, refers to carcinogens17. preparations of the Cannabis plant intended for Nicotine is principally responsible for the use as a psychoactive drug and as a medicine. addiction to tobacco as a result of the Marijuana is the most commonly used illicit interaction between the compound and drug among women of reproductive age, and nicotinic acetylcholine receptors (nAChRs). during pregnancy and lactation22, 23. Like all This interaction activates the reward centers in substances of abuse, the actual rate of the central nervous system. Nicotine receptors marijuana use and the statistics cited depend are distributed in many areas of the brain.18 on voluntary reporting. In the United States, Nicotine readily crosses the placenta, it can 4.6 % of African American, 3.0% of White, reach concentrations in fetal blood and and 1.5% of Hispanic women admit to amniotic fluid that are much higher than marijuana use in pregnancy58, and the number maternal plasma levels, exposing the fetus to of women 26 year or older who recently toxic effects19. Women who smoke are more initiated marijuana use has increased likely to have a low birth weight baby. Infants significantly from 18,000 to 106,000 between born to women who smoke during pregnancy years 2002 to 20102. are 200 to 300 grams lighter15. Furthermore, Tetrahydrocannabinol (THC), is the major nicotine causes impaired fetal oxygen delivery, psychoactive ingredient of marijuana. It binds resulting in abnormal gas exchange within the to cannabinoid (CB) receptors, widely placenta and activation of the sympathetic distributed throughout the nervous system, and nervous system, increasing the fetal heart rate other parts of the body. In the brain, CB and causing a reduction in fetal breathing receptors are found in high concentrations in movements20. Carbon monoxide is a major by- areas that influence pleasure, memory, product of cigarette smoking that can cause thought, concentration, sensory and time harm to the mother and fetus. Carbon perception, appetite, pain, and movement monoxide crosses the placenta and can be coordination. THC is known to pass from the detected in the fetal circulation at a level 15% mother to the developing fetus through the higher than in the maternal circulation21. placenta. In animal research, THC exposure Carbon monoxide diminishes tissue pre- or perinatally, and even during oxygenation via competitive inhibition with adolescence can alter brain development, oxyhemoglobin, causing decreased availability particularly in areas related to mood, reward, of oxygen to the fetus19. Approximately half of and executive function. Therefore, the fetus is women who quit smoking during pregnancy affected by any amount of cannabis taken by resume smoking within 6 months postpartum the pregnant woman, placing it at a greater risk and 50% to 90% have relapsed 1 year post- of complications24. delivery. Smoking during the postpartum The effects of marijuana use on the developing period causes a significant health risk for both fetus in the preconception period and mother and child. To date, there are no proven pregnancy are hard to establish because users effective strategies for preventing relapse of marijuana will frequently use other illicit during the postpartum period. However, close drugs while pregnant, making it difficult to follow-up, and continued counseling help in separate marijuana’s effects from the effects of

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other drugs. Although THC is the active study found that marijuana-exposed children ingredient in marijuana, over 400 compounds have smaller head circumferences at birth, have been identified in marijuana and it is which increase in disparity in adolescence34. difficult to separate out the effects of these Marijuana use in the postpartum period has not chemicals. Studies have determined that the been well studied and there is limited clinical CB1 receptor is present in all layers of human evidence to derive recommendations regarding placental membranes and that stimulation of counseling, intervention, or rehabilitation. these receptors impairs fetal growth by However, social work consultations should be inhibiting cytotrophoblastic proliferation25, 26. used liberally in an attempt to stabilize the To date, there is no known association home environment as much as possible. between marijuana exposure and spontaneous abortions27. However, in a large population- ALCOHOL: based prospective cohort study, maternal marijuana use was associated with fetal growth According to the 2010 National Survey on restriction.28 Therefore, pregnant women who Drug Abuse, 18.8% of pregnant women aged are known to use marijuana during pregnancy 15 to 44 reported current alcohol use2. The should be counseled about the associated risks prevalence of alcohol use in pregnant women and encouraged to abstain of using marijuana varies between racial and ethnic groups, 15.8% and other substances of abuse during among African Americans, 22.7 % among pregnancy. Obstetric care should include Whites, and 8.7% among Hispanics16. Of follow-up ultrasounds at 28 and 36 weeks to these, 3.7% reported binge drinking, which is confirm adequacy of fetal growth. defined by the National Institute for Drug Although some animal studies indicate that Abuse (NIDA) as a pattern of alcohol marijuana may be teratogenic in very high consumption that brings the blood alcohol doses, there is no firm link between maternal concentration to 0.08% or higher. This number use of marijuana and congenital malformations has remained relatively unchanged over the in humans above the background risk of 3%. last 15 years according to a longitudinal study Reports of associations between marijuana use of data collected from the Behavioral Risk in pregnancy and gastroschisis remain unsub- Factor Surveillance System between 1991 and stantiated.29 However, a study of almost 200535. Alcohol is a protoplasmic poison with 420,000 Australian live births over a 5-year a narcotic-like effect on the CNS. Alcohol period found that in utero marijuana exposure consumed in excessive quantities frequently increased the risk of neonatal intensive care causes poisoning because it rapidly enters the unit admissions, predominantly due to bloodstream, which carries it to all bodily prematurity, but there was no relation to any organs. Long-term consumption of excessive increased risk of perinatal death30. amounts of alcohol leads to Of greater concern, however, is the increasing and cirrhosis of the liver, chronic evidence that in utero marijuana exposure may inflammation of the gastrointestinal tract, impair long-term growth and neurodevelop- damage to the gonads and CNS impairment. ment, particularly in terms of cognition and Alcohol is a well-studied teratogen, and its behavior. Evidence from population-based effects on pregnancy can include spontaneous human studies and in vitro animal data indic- abortion, fetal growth restriction, and birth ates that interference with the endocanna- defects. The incidence of alcohol use in non- binoid system disrupts normal neurobiological pregnant women ages 15 to 44 years is 53%. It development, neurotransmitter maturation, and is estimated that as many as 24% of young neuronal survival31–33. A longitudinal cohort women who drink are binge drinking36.

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Oftentimes, conception occurs during times of ranging from 0.2 to 1.5 per 1,000 live births in alcohol use or abuse and women continue different areas of the United States. This drinking, unaware of their pregnancy, into the makes alcohol abuse and misuse in pregnancy first trimester where all fetal organ systems the most common non-genetic cause of mental can be affected at this early stage of retardation. Little data exist regarding the development. Therefore, the preconception postpartum period and alcohol use. There is a period is an important time to identify women reported increased risk of sudden infant death at risk37. In the preconception period, each syndrome and post-partum depression in encounter with patients can be an opportunity women who drink alcohol39. As we become to screen for alcohol use or abuse and more aware of the importance of identifying intervene to reduce or completely stop alcohol women at risk for postpartum depression, it consumption. There are several screening tools may be prudent to include those mothers who available. Questions to ask are detailed in are identified as using alcohol during their mnemonics such as Take, annoyed, cut down, pregnancy as a potential focus. The eye opener (T-ACE) 36. The United States postpartum visit may be a good time to screen Preventative Services Task Force, the women for alcohol abuse. The Healthy Moms American College of Obstetrics and Trial supports the implementation of brief Gynecology, and the American Academy of alcohol intervention during the postpartum Pediatrics suggest using preconception and period40. prenatal visits to discuss the benefits of abstaining from alcohol. There are no OPIOIDS: evidence-based studies to suggest any amount of alcohol use that is safe during pregnancy. The term “opioids” refers to natural, semi- During pregnancy, the fetus that is exposed to synthetic, and synthetic alkaloid derivatives alcohol can be severely affected by fetal either prepared from opium or synthesized alcohol spectrum disorder (FASD). The substances possessing morphine like activity. alcohol level in fetal blood reaches the same Opioids can produce a feeling of euphoria, and level as it does in the mother and fetal liver this effect, coupled with physical dependence, cannot process alcohol as efficiently as the can lead to recreational use of opioids by many mother's liver. Therefore, women who drink individuals. The analgesic effects of opioids alcohol during pregnancy subject their fetuses are due to a decreased perception of pain, to a significant risk. There is strong medical decreased reaction to pain as well as increased evidence to suggest that heavy alcohol use or pain tolerance. The most common opioids are binge drinking can lead to high rates of FASD. heroin, morphine, codeine, oxycodone, However, studies show that even small hydrocodone, and methadone. Heroin and amounts of alcohol used on a daily basis can methadone are the most commonly used be detrimental to the fetus38. FASD opioids by pregnant women. encompasses a wide range of disorders defined Most of the information available regarding as prenatal and postnatal growth restriction, the effects of opioids is derived from studies of central nervous system abnormalities, and patients who have used heroin or methadone. craniofacial abnormalities. The prevalence of opioids use in child-bearing Some common fetal abnormalities associated age women ranges from 1% to 21%14. The with alcohol abuse include facial dysmorpho- higher number reflects use in at-risk genesis, cardiac septal defects, and joint populations and does not represent overall use abnormalities. Centers for Disease Control and in obstetric population. Recently, there has Prevention (CDC) studies show FASD rates been a drastic rise in the use of prescription

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46–48 opioid analgesics, such hydromorphone and dependent mothers . Because of the oxycodone.41 Although there is a paucity of increased risks of stillbirth, growth restriction, data specifically focusing on the pregnant and preterm birth, increased fetal surveillance population, data from substance abuse and serial growth evaluations are literature suggest that women with prescription recommended49. opioid dependence are initiating use on Neonatal abstinence syndrome (NAS) is the average at 26 years of age, coinciding with a most consistent outcome in neonates born to woman’s peak reproductive years42. The extent mothers with opioid addiction. The incidence of maternal risk is greatly dependent upon the of NAS is quite variable, ranging from 55% to predominance of intravenous injection as a 94%50. NAS is the constellation of withdrawal route of opioids administration43. Aside from signs in the neonate including seizures, acute overdose, which carries a clear health breathing problems, tremors and irritability, risk, intravenous injection carries an inherent difficulty of feeding, and dehydration. Many infectious risk, most specifically transmission of affected neonates are hospitalized for of hepatitis B (HBV), hepatitis C virus (HCV), several weeks with methadone or morphine and human immunodeficiency virus (HIV), treatment to gradually wean them from their each of which is associated with long-term dependence on the drugs that their mothers health concerns for the mother. There is also a used47. Multiple regimens have been proposed higher rate of reported unplanned pregnancies to treat NAS, however, the American (70% in women with significant illicit drug Academy of Pediatrics (AAP) recommends history compared with 34.8% in women tincture of opium for replacement without drug dependency) 44. medication51. There are preliminary promising Heroin is the most commonly abused illicit data with the use of buprenorphine as a opioid. It crosses the placenta readily and treatment for NAS.52 enters fetal tissues within 1 hour of maternal Opioid analgesics such as oxycodone and use. Women who use heroin are likely to use hydromorphone can be judiciously used in other harmful substances, such as tobacco, pregnancy with close supervision but are much alcohol, and cocaine, all of which have their more commonly used in the post-partum own potential adverse effects on pregnancy. period for post-delivery pain control. No Therefore, it is difficult to separate the effects congenital anomalies have been reported in of heroin from these other substances45. babies born to mothers who used oxycodone Pregnant women who use heroin experience a or hydromorphone for prolonged periods45. six-fold increase in maternal obstetric However, the use of both substances increases complications including intrauterine growth the risk of neonatal withdrawal, particularly if restriction, third trimester vaginal bleeding, they are used in and around the time of preterm delivery, and puerperal morbidity. In delivery. addition, stillbirth, depressed Apgar score, Prenatal and antepartum care for a pregnant meconium staining of the amniotic fluid, and woman using opioids must be tailored to her chorioamnionits are all increased in heroin special needs. users46–48. The developing fetus and neonate Testing for sexually transmitted infections, also share undue burdens when exposed to such as HIV, hepatitis B and C, syphilis, opioids during pregnancy. Rates of preterm gonorrhea, and chlamydia should be included delivery, very low birth weight (1−1.499 kg), in routine care. Pregnant women need to be low birth weight (1.5−2.499 kg), and stillbirth counseled regarding the effects of opioids on have all been shown to be significantly themselves and their fetuses, and the benefits increased among neonates born to opioid- of methadone maintenance compared to

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continued opioids' use. Pregnant women taking dopamine. The norepinephrine effects lead to methadone demonstrate reduced use of illicit hyper-tension, tachycardia, and possible arrhy- drugs, better compliance with prenatal care, thmias. Within 2 minutes of cocaine use, and improved newborn birth weight53. systolic blood pressure rises 25mm Hg and Opioids are excreted into breast milk in small heart rate increases 20 beats/min55. The quantities and minimal, if any, effect on the dopaminergic effects on the limbic system and newborn is clinically significant. However, the cerebral cortex lead to the ‘‘high’’ or euphoria neonate should be observed for signs of experienced with cocaine use56. Other effects adverse effects, such as gastrointestinal side of acute cocaine use include coronary effects, sedation, and feeding pattern changes. vasospasm, possible ischemia after reduced For heavy narcotic abusers and women in cardiac oxygen delivery, platelet activation, methadone treatment, the postpartum period is increased platelet aggregation, and alteration an excellent time to address the possibility of of the thromboxane production leading to an gradual narcotic withdrawal and continued increased risk of thrombosis. These effects rehabilitation. could place a pregnant woman at an increased risk for adverse outcomes57–59. COCAINE: Prenatal cocaine use is associated with poor fetal and birth outcomes. Cocaine rapidly Cocaine is a crystalline tropane alkaloid that is crosses the placenta and a higher concentration obtained from the leaves of erythroxylon coca occurs in the fetus. L plant54. Its use as a ‘‘recreational drug’’ Intrauterine growth restriction, low birth skyrocketed in the last century. The commonly weight, and decreased head circumference are used form, crack, is almost pure cocaine all noted to be increased in neonates of formed through ‘‘cooking’’ the cocaine rocks mothers who use cocaine in pregnancy. with water and sodium bicarbonate, producing Cocaine abuse is frequently associated with the alkalinized form of cocaine. This form, inadequate prenatal care and concomitant use known as crack from the characteristic noise of tobacco and alcohol60. Moreover, cocaine made during the cooking process, is the most abuse is associated with psychosocial, addictive form. In 2010, there were over 1.5 behavioral, and biomedical risk factors, such million current users of cocaine2. It is difficult as poverty, poor nutrition, stress, depression, to discern the true prevalence of cocaine use physical abuse, lack of social support, and during pregnancy due to the large variations sexually transmitted infections, all of which that exist by reporting method. However, in a can greatly affect pregnancy outcome61. large national survey conducted by National As with any other substance, cocaine exposure institute of Drug addiction (NIDA) in 1995 during the first trimester can affect embryonic utilized the self-report method and found that and fetal development. An increased risk of the prevalence of cocaine abuse in pregnant congenital anomalies especially of the brain women was 4.5% among African Americans, and the cardiovascular system has been 0.4% among Whites, and 0.7% among reported62. Hispanics16. Regardless of the form, cocaine is Owing to the significant vasoconstriction absorbed quickly. Once absorbed, the effects, cocaine users experience a significant physiological hallmark of cocaine is profound increase in first trimester spontaneous abortion vasoconstriction, through its sympathomimetic and up to 38% of early pregnancies may result properties. Cocaine blocks the presynaptic in miscarriage in cocaine-abusing mothers60. reuptake of the sympathomimetic neuro- This increase in incidence of spontaneous transmitter norepi-nephrine, serotonin, and abortion is probably secondary to an increase

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in maternal plasma norepinephrine, which serious public health concern. The latest data increases uterine contractility, constricts from the U.S. National Survey on Drug Use placental vessels, and decreases blood flow to and Health (NSDUH), an ongoing national the fetus. probability survey, estimates that 5.8% of Cocaine use during pregnancy is associated persons ages 12 and older (approximately 14.2 with increased risk of premature preterm million people) used methamphetamine at rupture of membranes, preterm labor, and least once in their lifetime64. Information about preterm delivery. Cocaine stimulates uterine the prevalence of methamphetamine use contractility through β-agonist action on the during pregnancy varies widely. The β2-receptors of the uterus. Placental abruption magnitude of the methamphetamine problem accounts for 2% to 15% of adverse effects of comes from the Treatment Episode Dataset cocaine use during pregnancy. Abruption is (TEDS), which indicated that methampheta- thought to be caused by vasospasm and mine abuse has more than doubled between hypoxia of the placental bed. As a result of 2008 and 2012, from 3.7 to 9.2%2. maternal cocaine use and placental abruption, The effects of amphetamine abuse in the the incidence of stillbirth in cocaine-abusing preconception period are difficult to establish mothers is elevated 8% above the expected because amphetamines abusers commonly use level when compared to the general other illicit drugs while pregnant, making it population60. difficult to separate the effects of Cocaine abuse during pregnancy is considered amphetamines from those of other illicit drugs. a significant risk factor for infant neglect and As with virtually all other drugs of abuse, abuse in the post-partum period, and this often amphetamine use is often associated with risky results in the removal of the infant from sexual behaviors, teenage pregnancy, and maternal custody in the first 18 months of life. potential increased risk of sexually transmitted Prospective studies indicated a strong link infections65. between cocaine-using mothers and child Animal studies showed that in utero metham- maltreatment, with high rates of care-giving phetamine exposure can have a negative disruption (43%) and child maltreatment by 2 influence on the neurodevelopment of years (9% to 23%)63. offspring, an increased risk of cleft palate, retinal defects, delayed physical growth and AMPHETAMINES: motor development68, 69. Human studies found also that prenatally exposed infants to The amphetamine like substances including methamphetamine exhibit poor alertness and amphetamine and methamphe-tamine are feeding, low birth weight, cleft lip, ambiguous powerful CNS stimulants with a profound genitalia, anencephaly, and gastroschisis78–70. ability to increase wakefulness and focus. The Other studies have not shown any association principal mechanism of action is increased with increased risk of fetal malformation release of norepine-phrine, serotonin, and above the background 3% population risk68. dopamine from neurons within the brain. At Preclinical studies have shown that the same time, amphetamines inhibit re-uptake methamphetamine to be neurotoxic to dopami- of these neurotransmitters. Amphetamines are nergic and serotonergic neurons through the commonly used as drugs of abuse, particularly production of reactive oxygen species methamphetamine (also known as resulting in cell death and mitochondrial “crystalmeth”). dysfunction71. Studies on prenatal exposure to Methamphetamines abuse in the U.S. and in methamphetamine showed altered neuroco- other regions of the world remains a very gnitive perform-ance in that methamphetamine

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exposed children had lower verbal memory, barbiturates’ use in pregnancy suggests that long-term spatial memory, sustained attention there is no increased risk of fetal malformation and visual motor integration72. However, a noted above expected levels of occurrence. recent study showed that children exposed However, neonatal withdrawal is a critical prenatally to methamphetamine have poorer consideration if the mother is a heavy gross motor and psychomotor performance barbiturates abuser, particularly close to the scores at 2 years of age compared to non- time of delivery45. exposed children, but there was no effect on Benzodiazepine use in the preconception time cognitive and fine motor performance scores73. period is not uncommon and frequently Fetal growth restriction has also been prescribed for the treatment of anxiety. associated with amphetamine use in Benzodiazepines are also frequently prescribed pregnancy. It is unclear if this is related to a during pregnancy and approximately 3% of all direct effect of the agent on the placenta or pregnant women use this type of medication76. fetus or whether this represents a nutritional Benzodiazepines are generally category D problem in patients due to the anorectic effect drugs, reflecting positive evidence of fetal risk. of amphetamines68. However, there is conflicting evidence Information about the use of amphetamines in regarding the teratogenicity of benzodia- the postpartum period is scant, but abuse of zepines, with the suggestion of an increased amphetamines during lactation is considered likelihood of multiple anomalies, including possibly hazardous. Neonatal withdrawal has cleft lip and palate, fetal growth restriction, been described, including jitteriness, drowsi- and intrauterine fetal death. However, there is ness, and respiratory distress74. no study or meta-analysis that has been able to Maternal methamphetamine use may have definitively link benzodiazepine abuse with a long-term detrimental effects on exposed specific neonatal syndrome or constellation of fetuses, and exposure may result in future anomalies. learning and memory impair-ments75. Exposure to benzodiazepines during the last trimester of pregnancy increases the risk for SEDATIVE-HYPNOTICS development of the floppy infant syndrome. AND ANXIOLYTICS: Since the floppy infant syndrome can cause severe morbidity, prescription of benzodia- Barbiturates and benzodiazepines belong to a zepines in the last trimester of pregnancy is not larger category of medications; sedative- recommended77. hypnotics and anxiolytics, which are frequently abused. MANAGEMENT OF PREGNANCIES Of the barbiturates, butalbital is an active IN SUBSTANCE agent in many medications to treat migraines. ABUSING MOTHERS: Since migraines are more common in reproductive age women, many women General considerations: conceive while using butalbital containing Pregnancy in a substance-abusing mother is medications. Due to the severity of migraine considered high-risk and is associated with and headache during pregnancy, these drugs significant maternal and fetal complications. continue to be appealing to many pregnant Teratogenicity, poor maternal nutrition, IUGR, women and they continue using them in poor placental perfusion and function, and pregnancy. Butalbital is a category C drug and withdrawal syndromes are the most common it should only be used if the benefits outweigh obstetric issues that must be addressed. In the the risks. Review of literature about safety of case of cocaine abuse, placental abruption and

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stillbirth are important additional considera- placental function is an important component tions. of care for substance -abusing mothers. Recommendations involve serial uterine fund- Teratogenic Exposure: al height measurements and ultrasound evaluation of the fetus with attention paid to The possibility of substances of abuse causing fetal head circumference and biparietal fetal anomalies is an overriding concern. diameter, abdominal circumference, amniotic Genetic counseling, particularly in the fluid indices, and Doppler velocimetry. Serial preconception period, about the potential ultrasound surveillance typically begins at teratogenic effects of the abused substances is approximately 24 weeks of gestation and very helpful to the expectant mother so she continues at 4-week intervals thereafter. Fetal may abstain from using these substances. wellbeing testing primarily by non-stress Ultrasound identification of structural testing and the biophysical profile can be used anomalies and addressing them by consulting depending on the clinical situation. They are various pediatric specialists for post-delivery typically performed in the beginning of the management will optimize neonatal and infant third trimester. Timing of delivery can be a outcomes. Serial ultrasonographic surveillance challenge in the growth-restricted fetus. The for fetal growth and frequent fetal well-being risks of prematurity must be weighed against testing will help in monitoring fetal growth the risk of intrauterine fetal death due to and delivery planning. placental insufficiency. In general, signi- ficantly abnormal umbilical artery Doppler Nutritional considerations: velocimetry is usually an indication for delivery. Complete absence of fetal growth Poor maternal nutritional status is often observed in consecutive ultrasound evaluations associated with many substances of abuse as may also provide a strong indication for many of these substances suppress maternal delivery. appetite. A multi-disciplinary approach incorporating Labor management: nutritional counseling by trained dieticians can certainly be valuable. Frequent maternal Management of the substance-abusing patient weight checks and fetal interval growth in labor can present significant challenges to surveillance should be in the routine obstetric the obstetrical team. As a general rule, the care for substance abusing mothers. Nutrition labor and management of the substance- counseling should focus on a well-balanced abusing patient should be based on widely diet, adequate caloric intake (25 to 35 kcal/day accepted obstetric practice and recommenda- of optimal body weight) prenatal vitamins, tions. Establishing healthy and non-threatening folic acid and minerals supplementation. Iron communication with a substance-abusing deficiency anemia is a common problem in the mother in labor is a paramount goal for substance abusing population, and an obstetrical caregivers. additional 60 to 120 mg of iron is Regional analgesia is the preferred method to recommended 78. control pain during labor. However, each Intrauterine growth restriction particular substance of abuse brings its own and placental insufficiency: challenges. Anesthesia consultation and pre- operative evaluation should be obtained to Because of the high correlation between determine the safest and most appropriate substance abuse and intrauterine fetal growth method for pain management during labor and restriction, surveillance for fetal growth and

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delivery especially if cesarean section is neurodevelopmental outcome in 1-month-old infants. 79 Pediatrics 2002; 110: 1182−92. planned or expected . 5. Little B, Snell L, Van Beveren T, Crowell R, Trayler S, Johnston W. Treatment of substance abuse during Management of withdrawal symptoms: pregnancy and infant outcome. Am J Perinatol 2003; 20: 255−62. 6. Scott-Lennox J, Rose R, Bohlig A, Lennox R. The impact Issues arising as a result of maternal and fetal of women's family status on completion of substance withdrawal must be managed on an abuse treatment. J Behav Health Serv Res 2000: 27:366−79. individualized basis, taking into consideration 7. Daley M, Argeriou M, McCarty D, Callahan J J, Shepard the substance of abuse. For example, it is not DS, Williams C N. The costs of crime and the benefits of prudent to withdraw methadone from an substance abuse treatment for pregnant women. J Subst Abuse Treat addicted or abusing mother because this may 2000; 19:445−58. 78 8. DellaGrotta S, LaGasse LL, Arria AM, Derauf C, Grant increase the likelihood of fetal stillbirth . P, Smith L M. Patterns of methamphetamine use during In contrast, the withdrawal of cocaine will pregnancy: Results from the Infant Development, Environment, and Lifestyle (IDEAL) study. MaternChild likely diminish the possibility of catastrophic Health J 2010; 14: 519−27. placental abruption or stillbirth. It is important 9. Knight DK, Logan SM, Simpson DD. Predictors of to adopt a team approach regarding maternal program completion for women in residential substance abuse treatment. Am J Drug & Alcohol Abuse 2001; and neonatal withdrawal, incorporating 27:1−18. neonatologists, psychiatrists, and social 10. U.S. Department of Health and Human Services. Office workers. on Smoking and Health, 2014. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Available at Conclusions: http://www.surgeongeneral.gov/library/reports/50-years- of-progress/exec-summary.pdf Accessed April 2014. 11. Kissin WB, Svikis DS, Moylan P, Haug NA, Stitzer ML. There are many challenges in diagnosing and Identifying pregnant women at risk for early attrition treating maternal addiction and substance from substance abuse treatment. J Subst Abuse Treat abuse during pregnancy. 2004; 27:31−8. 12. Lester B, Andreozzi L, Appiah L. Substance use during As the magnitude of the problem increases, it pregnancy: Time for policy to catch up with research. has become critical to create a model in which Harm Reduct J 2004; 5: 1−44. pregnant women can receive comprehensive 13. Grella C, Joshi V, Hser Y. Program variation in treatment outcomes among women in residential drug treatment. medical care while being treated with Eval Rev 2000; 24: 364−83. compassion and dignity to address the 14. Kandel DB, Griesler PC, Schaffran C. Educational complex physical, emotional, social, and attainment and smoking among women: risk factors and consequences for offspring. Drug Alcohol Depend 2009; environmental characteristics of addiction. 104: S24–33. 15. Einarson A, Riordan S. Smoking in pregnancy and References: lactation: a review of risks and cessation strategies. Eur J Clin Pharmacol 2009; 65:325–30. 1. Kuczkowski KM. The effects of drug abuse on 16. National Institute on Drug Abuse. NIDA Survey Provides pregnancy. Curr Opin Obstet Gynecol 2007; 19:578–85. First National Data on Drug Use During Pregnancy. 2. U.S. Department of Health and Human Services, Office National Institute on Drug Abuse; 1995. Bethesda, MD. of Applied Studies; 2010. SAMHSA Results from the Available at: National Survey on Drug Use and Health: National http://archives.drugabuse.gov/NIDA_Notes/NNVol10N1/ Findings. Rockville, MD. Available at NIDASurvey.html. Accessed April 2014. http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10 17. Thielen A, Klus H, Muller L. Tobacco smoke: unraveling Results.htm. Accessed April 2014. a controversial subject. Exp Toxicol Pathol 2008; 3. Bada H S, Das A, Bauer C R, Shankaran S, Lester B M, 60:141–56. Gard, CC, Wright LL, Lagasse L, Higgins R. Low birth 18. Yildiz D. Nicotine, its metabolism and an overview of its weight and preterm births: Etiologic fraction attributable biological effects. Toxicon 2004; 43:619–32. to prenatal drug exposure. J Perinatol 2005; 25:631−7. 19. Andres RL, Day MC. Perinatal complications associated 4. Lester B, Tronick E, LaGasse L, Seifer R, Bauer C, with maternal tobacco use. Semin Neonatol 2000; 5:231– Shankaran S. The maternal lifestyle study: Effects of 41. substance exposure during pregnancy on 20. Burton GJ, Palmer ME, Dalton KJ. Morphometric differences between the placental vasculature of

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nonsmokers, smokers and ex-smokers. BJOG 1989; 37. Floyd RL, Jack BW, Cefalo R, Atrash H, Mahoney J, 96:907–15. Herron A, Husten C, Sokol RJ. The clinical content of 21. Crawford JT, Tolosa JE, Goldenberg RL. Smoking preconception care: alcohol, tobacco, and illicit drug cessation in pregnancy: why, how, and what next. Clin exposures. Am J Obstet Gynecol 2008; 199:S333–9. Obstet Gynecol 2008; 51:419–35. 38. Creasy RK, Resnik R, Iams JD. Creasy and Resnik’s 22. United Nations Office on Drug and Crime. World Drug maternal-fetal medicine: principles and practice, 7th Ed. Report 2013. Available at Philadelphia, PA: Saunders/Elsevier, 2013. http://www.unodc.org/unodc/secured/wdr/wdr2013/Worl 39. Chambers CD, Kavteladze L, Joutchenko L, Bakhireva d_Drug_Report_2013.pdf. Accessed April 6, 2014. LN, Jones KL. Alcohol consumption patterns among 23. Regional drug strategies across the world. European pregnant women in the Moscow region of the Russian Monitoring Centre for Drugs and Drug Addiction. Federation. Alcohol 2006; 38:133–7. http://www.emcdda.europa.eu/publications/emcdda- 40. Fleming MF, Lund MR, Wilton G, Landry M, Scheets D. papers/regional-drug-strategies. Accessed April 8, 2014 The Healthy Moms Study: the efficacy of brief alcohol 24. NCPIC: National Cannabis Prevention and Information intervention in postpartum women. Alcohol Clin Exp Res Centre. Cannabis use and pregnancy. Available at 2008; 32:1600–6. http://www.cannabisaurus.org/ncpic/publications/factshe 41. Kellogg A, Rose CH, Harms R, et al. Current trends in ets/article/cannabis-use-and-reproduction 2011. Accessed narcotic use in pregnancy and neonatal outcomes. Am J April 5, 2014. Obstet Gynecol 2011; 24:259.e1–4. 25. Park B, Gibbons HM, Mitchell MD, Glass M. 42. Drug and Alcohol Services Information System. Identification of the CB1 cannabinoid receptor and fatty Substance Abuse and Mental Health Services acid amide hydrolase (FAAH) in the human placenta. Administration. Characteristics of Primary Prescription Placenta 2003; 24: 990–5. and OTC Treatment Admissions: 2002. Available at: 26. Khare M, Taylor AH, Konje JC, Bell SC. Delta 9- http://www.samhsa.gov/data/2k4/prescriptionTX/prescrip tetrahydrocannabinol inhibits cytotrophoblast cell tion.pdf. Accessed April 2014. proliferation and modulates gene transcription. Mol Hum 43. Griffith P, Gossop M, Powis B, Strang J. Transitions in Reprod 2006; 12: 321–33. patterns of heroin administration: a study of heroin 27. Kline J, Hutzler M, Levin B, Stein Z, Susser M, chasers and heroin injectors. Addiction 1994; 89:301–9. Warburton D. Marijuana and spontaneous abortion of 44. Cleary BJ. Donnelly JM. Strawbridge JD. Gallagher PJ. known karyotype. Paediatr Perinat Epidemiol 1991; Fahey T. White MJ. Murphy DJ. Methadone and 5:320–32. perinatal outcomes: a retrospective cohort study. Am J 28. El Marroun H, Tiemeier H, Steegers EA, Jaddoe VW, Obstet Gynecol 2011; 204:139.e1–9. Hofman A, Verhulst FC, van den Brink W, Huizink AC. 45. Briggs G, Freeman R, Yaffe J. Drugs in pregnancy and Intrauterine cannabis exposure affects fetal growth lactation 9th Ed. Philadelphia: Lippincott trajectories: the Generation R Study. J Am Acad Child Williams&Wilkins, 2011. Adolesc Psychiatry 2009; 48: 1173–81. 46. Almario CV. Seligman NS. Dysart KC. Berghella V. 29. Forrester MB, Merz RD. Comparison of trends in Baxter JK. Risk factors of preterm birth among opiate- gastroschisis and prenatal illicit drug use rates. J Toxicol addicted gravid women in a methadone treatment Environ Health A 2006; 69: 1253–9. program. Am J Obstet Gynecol 2009; 201:3265.e1–6. 30. Burns L, Mattick RP, Cooke M. The use of record 47. Hulse GK1, Milne E, English DR, Holman CD. The linkage to examine illicit drug use in pregnancy. relationship between maternal use of heroin and Addiction 2006; 101: 873–82. methadone and infant birth weight. Addiction 1997; 31. Pacher P, Ba´tkai S, Kunos G. The endocannabinoid 92:1571–9. system as an emerging target of pharmacotherapy. 48. Mayet S, Groshkova T, Morgan L, MacCormack T, Pharmacol Rev 2006; 58: 389–462. Strang J. Drugs and pregnancy outcomes of women 32. Campolongo P, Trezza V, Ratano P, Palmery M, Cuomo engaged with a perinatal outreach addictions service. V. Developmental consequences of perinatal cannabis Drug Alcohol Rev 2008; 27:497–503. exposure: behavioral and neuroendocrine effects in adult 49. Alto WA, O’Connor AB. Management of women treated rodents. Psychopharmacology (Berl) 2011; 214: 5–15. with buprenorphine during pregnancy. Am J Obstet 33. Downer EJ, Campbell VA. Phytocannabinoids, CNS cells Gynecol 2011; 205:302–8. and development: a dead issue? Drug Alcohol Rev 2010; 50. Jones HE, Kaltenbach K, Heil SH, Stine SM, Coyle MG, 29: 91–8. Arria AM, O’Grady KE, Selby P, Martin PR, Fischer G. 34. Fried PA, Watkinson B, Gray R. Growth from birth to Neonatal abstinence syndrome after methadone or early adolescence in offspring prenatally exposed to buprenorphine exposure. NEJM 2010; 363:2320–31. cigarettes and marijuana. Neurotoxicol Teratol 1999; 21: 51. American Academy of Pediatrics Committee on Drugs. 513–25. Neonatal drug withdrawal. Pediatrics 1998; 101:1079– 35. Centers for Disease Control and Prevention. Drinking 88. While Pregnant Still a Problem. Centers for Disease 52. Kraft WK, Dysart K, Greenspan JS, Gibson E, Control and Prevention; 2011. Atlanta, GA. Available at: Kaltenbach K, Ehrlich Revised dose schema of http://www.cdc.gov/Features/dsAlcoholChildbearingAge sublingual buprenorphine in the treatment of the neonatal Women. Accessed April 2014. opioid abstinence syndrome. Addiction 2010; 106:574– 36. Chang G. Alcohol-screening instruments for pregnant 80. women. Alcohol Res Health 2001; 25:204–9.

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53. Minozzi S, Amato L, Bellisario C, Ferri M, Davoli M. expo-sure, polydrug exposure, and poverty on Maintenance agonist treatments for opiate-dependent intrauterine growth. Pediatrics 2006; 118:1149–56. pregnant women. Cochrane Database Syst Rev 2013. 69. Good MM, Solt I, Acuna JG, Rotmensch S, Kim MJ. Available at Methamphetamineuse during pregnancy: maternal and http://onlinelibrary.wiley.com/doi/10.1002/14651858. neonatal implications. Obstet Gynecol 2010; 116: 330–4. CD006318.pub3/pdf. Accessed April, 2014. 70. Elliott L, Loomis D, Lottritz L, Slotnick RN, Oki E, Todd 54. NIDA Cocaine: abuse and addiction. 2010 Report No.10- R. Case–control study of a gastroschisis cluster in 4166. Rockville, MD: NIDA. Available at Nevada. Arch Pediatr Adolesc Med 2009; 163:1000–6. http://www.drugabuse.gov/sites/default/files/cocainerrs.p 71. Quinton MS, Yamamoto BK. Causes and consequences df. Accessed April 2014. of methamphetamine and MDMS toxicity. AAPS J 2006; 55. Jenkins AJ, Keenan RM, Henningfield JE, Cone EJ. 8:337–47. Correlation between pharmacologic effects and plasma 72. Chang L, Smith LM, Lopresti C, Yonekura ML, Kuo J, cocaine concentrations after smoked administration. J Walot I, Ernst T. Smaller subcortical volumes and Anal Toxicol 2002; 26:82–392. cognitive deficits in children with prenatal 56. Kuczkowski KM. Cardiovascular complications of methamphetamine exposure. Psychiatry Res: recreational cocaine use in pregnancy: myth or reality? Neuroimaging 2004; 132: 95–106. Acta Obstet Gynecol Scand 2005; 84:100–1. 73. Wouldes TA, LaGasse LL, Huestis MA, DellaGrotta S, 57. Tanga G, Tempesta E, Togna AR, Dolci N, Cebo B, Dansereau LM, Lester BM. Prenatal methamphetamine Caprino L. Platelet responsiveness and biosynthesis of exposure and neurodevelopmental outcomes in children thromboxane and prostacyclin in response to in-vitro from 1 to 3 years. Neurotoxicology and Teratology 2014; cocaine treatment. Hemostatis 1985; 15:100–7. 42:77–84. 58. Kugelmass AD, Shannon RP, Yeo EL, Ware JA. 74. Smith L, Yonekura ML, Wallace T, Berman N, Kuo J, Intravenous cocaine induces platelet activation in the Berkowitz C. Effects of prenatal methamphetamine conscious dog. Circulation 1995; 91: 1336–40. exposure on fetal growth and drug withdrawal symptoms 59. Heesch CM, Wilhelm CR, Ristich J, Adnane J, in infants born at term. J Dev Behav Pediatr 2003; Bontempo FA, Wagner WR. Cocaine activates platelets 24:17–23. and increases the formation of circulating platelet 75. Skelton MR, Williams MT, Vorhees CV. Developmental containing microaggregates in humans. Heart 2000; effects of 3,4 methylenedioxy methamphetamine: a 83:688–95. review. Behav Pharmacol 2008; 19:91–111. 60. Schempf AH, Strobino DM. Illicit drug use and adverse 76. Bellantuono C, Bozzi F, Orsolini L, Catena-Dell’Osso M. birth outcomes: is it drugs or context? J Urban Health The safety of escitalopram during pregnancy and 2008; 85:858–73. breastfeeding: a comprehensive review. Hum 61. Muhuri PK, Gfroerer JC. Substance use among women: Psychopharmacol 2012; 27:534–9. associations with pregnancy, parenting, and 77. Krüger S. Psychopharmacological Treatment of Mood race/ethnicity. Matern Child Health J 2009; 13:376–85. and Anxiety Disorders During Pregnancy. In: Handbook 62. Vidaeff AC, Mastrobattista JM. In utero cocaine of Experimental Pharmacology. Handbook of exposure: a thorny mix of science and mythology. Am J Experimental Pharmacology. Berlin, Heidelberg: Perinatol 2003; 20:165–72. Springer Berlin Heidelberg; 2012; 214:279–305. 63. Minnes S, Singer LT, Humphrey-Wall R, Satayathum S. 78. American Academy of Pediatrics and the American Psychosocial and behavioral factors related to the post- College of Obstetricians and Gynecologists. Guidelines partum placements of infants born to cocaine-using for Perinatal Care, Seventh Edition 2012. women. Child Abuse Negl 2008; 32:353–66. 79. Ludlow J, Christmas T, Paech MJ, Orr B. Drug abuse and 64. Maxwell, J. C., & Rutkowski, B. A. The prevalence of dependency during pregnancy: anaesthetic issues. methamphetamine and amphetamine abuse in North Anaesth Intensive Care 2007; 35:881–93. America: A review of the indicators, 1992–2007. Drug & Alcohol Review 2008; 2: 229–35. 65. Zapata LB, Hillis SD, Marchbanks PA, Curtis KM, Lowry R. Methamphetamine use is independently associated with recent risky sexual behaviors and adolescent pregnancy. J Sch Health 2008; 78:641–8. 66. Wouldes T, LaGasse L, Sheridan J, Lester B. Maternal methamphetamine use during pregnancy and child outcome: what do we know? NZMJ 2004; 117: 1–10. 67. McDonnell-Dowling K, Donlon M, Kelly JP. Methamphetamine exposure during pregnancy at pharmacologicaldoses produces neurodevelopmental and behavioural effectsin rat offspring. Int J Devl Neurosci 2014; 35: 42–51. 68. Smith LM, Lagasse LL, Derauf C, Grant P, Shah R, Arria A, Huestis M, Haning W, Strauss A, DellaGrotta S, Liu J, Lester BM. The infant development, environment, and lifestyle study: effects of prenatal methamphetamine

FIMA YEAR BOOK 2014 99 100 FIMA YEAR BOOK 2014 MOBILIZATION OF THE PUBLIC AGAINST ADDICTION: THE TURKISH GREEN CRESCENT SOCIETY AS A MODEL INSTITUTION

M.Ihsan Karaman*

Abstract:

In this article, a general framework on the addiction problem is analyzed by focusing on the works of the Turkish Green Crescent Society. A brief comment on the industries behind alcohol, tobacco, and drugs is given to understand the background of the problem. As a model institution, the history, organizational structure, vision, objectives, and activities of the Turkish Green Crescent Society are summarized in the article. Examples of prevention practices, educational, advocacy and international programs are presented in the tactics for the mobilization of the public against addictions. Then the psychological drive behind being addicted and especially the threat of spread among young generation is presented giving special attention to “peer effect” phenomenon.

Keywords: addiction, public awareness, prevention, advocacy, Turkey, Green Crescent Society

Introduction:

As the President of the Turkish Green history, vision, objectives and activities of Crescent Society, and the Chairman of the the Green Crescent Society; including the Addiction Working Group in the Federation tactics for the mobilization of the public of Islamic Medical associations (FIMA), I against addiction. It is important that we would like to start this article by giving a realize and accept that “Addiction is a type of general framework of the problem of slavery! We, representing humanity, have to addiction. Then, I will summarize the be against all kinds of addiction!”

Background of the Problem

One of the ways to prevent the evils of instruments that we can use is to conduct addiction is to fight through scientific serious scientific studies on how the methods against the power groups that problems emerge and spread, to follow up promote it. We are aware of the fact that the with this scientific data and share them with addiction industry reaches out, and intends to the public and authorities, to research on the reach out even further, to our people and our ways of fighting against addiction and how youth, legally and illegally, through various they can be applied through national as well ways and means that continue to change and as international scientific meetings and develop day by day. It is apparent that our forums. The problems related to addiction do efforts in trying to stop them by using not only derive from our own social, ordinary slogans and methods gets more and administrational and moral structure, but are more difficult. For this reason, the best open to the influence of a broader spectrum.

*Professor Dr. M.Ihsan Karaman President, Turkish Green Crescent Society Professor of Urology, Istanbul Medeniyet University, Medical Faculty Istanbul, Turkey E-mail: [email protected]

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Today, through the tools of mass basis. Between the ages 15 and 29, 320.000 communication and the tools and carriers of individuals lose their lives because of alcohol the global culture, a structure with an related reasons every year in the world. This expanding influence has emerged in our number corresponds to 9% of deaths in this society as in the rest of the world. The Green age group1. Crescent Society cares about the world’s way Apart from being addictive, alcohol is a of fighting against this experience that it is public health problem known as the reason going through, and about the scientific for 60 different diseases and conditions, knowledge accumulated in this field. It is injuries, mental and behavioral disorders necessary to transfer this knowledge into including digestive system diseases, cancers, healthy channels by making use of local cardiovascular diseases, immunity disorders, dynamics as well. We are initiating a more lung diseases, musculoskeletal diseases, active process in the international arena, with gonadal dysfunction, preterm births, and the hope and aim that the whole world will low birth weight2 . act upon conscience. Another important addictive substance is Just as the evil does not emerge only from tobacco. According to World Health Organi- our own internal structure, the solution is not zation (WHO), Tobacco kills nearly 6 a process that we can handle on our own, million people each year. More than five either. We want to speed up the activities million of those deaths are the result of direct carried out in coordination with other tobacco use while more than 600,000 are the organizations working in this field through- result of non-smokers being exposed to out the world, in the name of our goal to second-hand smoke. Nearly 80% of the more prevent the evil and addiction before it even than one billion smokers worldwide live in starts. We believe that there is a lot to do, low- and middle-income countries, where the especially in the countries where addiction burden of tobacco-related illness and death is and the production of addictive substances heaviest. More than 50 illnesses and health are widespread. For this purpose, the Green problems are caused by the direct and Crescent Society, with its experience of indirect effects of cigarettes. Tobacco caused almost a century, will remain determined to 100 million deaths in the 20th century. If carry its knowledge and efforts to the interna- current trends continue, it may cause one tional arena, and to mobilize the collective billion deaths in the 21st century3. In addition conscience of humanity in the fight against to alcohol and tobacco, illicit drugs are also addiction. one of the most serious problems threatening our future generations. Recent estimates Addiction Industry: prove that in 2008, 155 to 250 million people, or 3.5% to 5.7% of the world's popul- It is a well known fact that drugs, tobacco, ation aged 15-64, used psychoactive subst- and alcohol are the primary addictive ances, such as cannabis, amphetamines, substances in the world. They cause millions cocaine, opioids, and non-prescribed of deaths every year. Of the producers of psychoactive prescription medication. these substances, at least two of them, Globally, cannabis is the most commonly namely, the tobacco and alcohol industries used (129-190 million people), followed by are acknowledged as legal industries which amphetamine type stimulants, then cocaine are subject to international trade rules. When and opioids. The use of psychoactive we look at this issue from the public health substances causes significant health and perspective, alcohol consumption results in social problems for the people who use them, 2.5 million deaths each year and it is one of and also for others in their families and three primary public health problems of the communities4. world. Alcohol is the third leading reason of Both alcohol and tobacco industries use preventable deaths and injuries on a global similar tactics to resist public health policies.

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They are very actively lobbying politicians, society status is given by the Turkish mobilizing farmers, retailers and advertising government to the organizations that provide agencies to influence public health legisla- public benefits7. The Green Crescent Society tion. They challenge laws and buy friends is an independent, non-profit and non- from sports and cultural groups, and under- governmental organization that acts accord- mine control policies5. In addition to these ing to rules of the Ministry of Interior legal deadly industries, there is also an illicit Department of Associations. The General drug industry with a massive market. Annual Assembly of the Green Crescent is the value of the illicit drugs in the world is highest and most authoritative decision- estimated at US$320 billion. This industry is making body of the Society. The members of to a large extent outside the governmental the Executive Board and the President are controls. In addition to the significant elected triennially by the delegates in the harmful health effects of the drugs they Assembly. The delegates of the General market, this industry is a major contributor to Assembly are elected by the branches and the crime, violence and corruption6.6From the headquarters of the Green Crescent from information above, it can be deduced that among the Green Crescent members. The addiction is not only a psychological issue General Executive Board is composed of affecting individuals, but it is also a major thirteen administrative board members and problem that is caused by interacting social, seven auditing members. The Green Crescent economic and political factors. To protect Branches have their own General Assemblies humanity from the damages of the addiction and Executive Boards. The Headquarters and industry, public health community and civil Branches are governed according to rules of society should cooperate in the struggle the Green Crescent Constitution. The Green against this huge industry and power groups. Crescent has 37 branches and 101 representation offices in different provinces THE TURKISH GREEN CRESCENT of Turkey and has 30 thousands members SOCIETY: across the country8. Apart from employees in History and the Organizational Structure: the headquarters and branches, the members in General Assembly and Executive Boards The Turkish Green Crescent Society was take part in the struggle voluntarily and this founded with the initial name “Hilal-i make the Green Crescent a voluntary move- Akhdar” on 5 March 1920 at the end of the ment. There are two commissions within the First World War in Istanbul. The society was Society consisting of Green Crescent founded by patriotic intellectuals in 1920 as members and volunteers. The first one is the a response to the British attempts to Green Crescent Youth Commission which distribute alcohol and drugs free of charge in involves hundreds of young people, mostly Istanbul in order to undermine the resistance university students. Universities are the against the occupation. The founders sensed primary working field of the Young Comm- the upcoming dangers of alcohol and drug ission and they work within a partnership addiction that would result in decline of the with the Green Crescent Youth Clubs in the resistance against the occupation. The universities. There are 11 Green Crescent patriotic intellectuals established the “Green University clubs in Turkey. The clubs play Crescent”, “Hilal-i Akhdar” in Istanbul in important role in raising awareness and order to warn Turkish society against keeping the young students away from occupation and harms of alcohol and drugs. harmful habits. They are involved in various The Turkish Green Crescent Society is a activities like “smoke-free campuses”9. non-governmental association was included The second voluntary commission is the among “The Public Beneficial Societies” Green Crescent Women Commission. The upon the decision of the Council of Ministers commission members work voluntarily in the dated 19 September 1934. Public beneficial neighborhoods to educate housewives on

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addictions. Both commissions are leading tion. As a supporter of public authorities for voluntary activities of the Green Crescent. human affairs, the Green Crescent is subject to Any person can become a member of the international agreements duly enacted by State Society if he / she adopts the principles, values, of the Republic of Turkey. In this context, it goals and working ethics of the Green Crescent. has the autonomy to make international He / she should have no record of any illegal agreements and to act accordingly within its activity, not addicted to tobacco, alcohol or any field of activity. drug To be a member one should pledge the As Charity Organization: The Green Crescent following commitment “As long as I stay as a is a voluntary charity organization which does member, I solemnly pledge on my honor and life not seek profit or personal benefit in its not to use any tobacco, alcohol or drug and to activities. propagate Society’s ideals.” A person, who As Public Health: The Green Crescent is a would like to be a member, applies directly voluntary non-governmental organization which to directorate of the branch on the basis his/ builds programs to fight risk factors for all her place of residence. The decision making kinds of addiction, particularly, those related to body for the affiliation is Executive Board of tobacco, alcohol, and drugs. the Green Crescent Branch. Turkish Green Scientific Understanding: The Green Crescent Crescent Society is a member of the National adopts evidence-based research, analysis and Quality Movement, led by the Quality intervention regarding behavior reinforcement Association of Turkey. and /or behavior change during the phase of Quality Association of Turkey provides fighting against addiction, protection and training and direction to develop the Green prevention of addiction, therapy and treatment. Crescent's management structure and human Globalism: Having equal status and sharing resources. EFQM (European Foundation of equal responsibility and duty like other foreign Quality Management) Model is implemented national societies in the field of combating to be a part of the journey on the road to addictions, the Green Crescent adopts the being a Center of Excellence. following principles: creating a global organiza- tion to fight against addictions on a worldwide Core Values and Principles of the Society basis and as a part of such organization, Struggling for Human Dignity: evaluating issues on a global scale and working accordingly, functioning on a global level and The scope of the Green Crescent is to ensure the being influential and highly regarded. protection of human health and respect for Sense of Community: Organizing to create human dignity against risk factors causing awareness for public health at every stage from addiction. In all its activities, the Green Crescent the whole part of society to individual and supports mutual understanding, fellowship, public organizations, carrying out participating friendship, cooperation and permanent peace activities on social-level and permanent among individuals. It endeavors to relieve and to achievement are considered as a necessity by prevent human pain anywhere arising from the Green Crescent10. addictions within national and international capacity. MOBILIZATION OF THE PUBLIC Non-Discrimination: The Green Crescent does AGAINST ADDICTION: not discriminate people based on race, Evidence Based and Scientific Prevention age, religion, ability, marital status, sexual Practices orientation. By prioritizing the most urgent and necessary requirements, it focuses on relieving The Green Crescent Society contributes to human pain arising from addictions within its public health by developing evidence-based capacity. prevention programs and advocating for Independency: The Turkish Green Crescent is legal, social and environmental changes in an independent non-governmental organiza- the fight against addiction.

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The Green Crescent fights against tobacco, (ISTKA). Using the slogan "The Green alcohol, drug, gambling, and technology Crescent is looking for youth leaders", the addiction that destroy the mental and project reached 200,000 students in Istanbul. physical health of the youth in cooperation The project aimed to educate nearly 5,000 with the private sector, governmental bodies secondary school students and 1,000 and international organizations. It works to teachers. The young leaders were trained on develop contemporary strategies for dealing the Green Crescent Club Curriculum and with consumption of addictive substances peer education approach was initiated along and for the prevention of addiction by using with training on leadership and motivation. evidence-based scientific methods. As part of the project, participants were The Green Crescent launces many projects administered pre- and post-tests. Awareness and preventive campaigns every year. The and knowledge level of cigarette and internet activities and programs are based on the addiction were measured in students between guidelines of the prevention programs. There the ages of 11 and 14. All indicators showed are general set of guidelines for prevention a positive effect of the peer education activities which are general considerations amongst children of different age groups, for all addiction prevention activities. genders, and socioeconomic levels. Educated Assessment of the need, assessment of the leader students conducted many activities to capacity and sources, planning with goals attract the attention of their peers at schools. and objectives, implementation, and evalua- Approximately 80% of students who parti- tion are the basic steps in the Green Crescent cipated in the training expressed a desire to preventive programs11. The implementation share the information they learned in the and the findings of three different programs program with their friends and to participate are summarized below. in similar programs in the future13.

Youth Center Project National Water Pipe Campaign: with Ministry of Youth and Sports: The National Water Pipe Campaign was The project's aim was to establish a youth prepared as a nationwide communication center in Istanbul with the cooperation of campaign to prevent the epidemic of water Ministry of Youth and Sport. The project was pipe use across the country. Qualitative and planned according to the needs of the quantitative preliminary surveys were university students in Fatih district. A survey lunched and completed in 2013. 1,200 of five hundred young students was smokers, non-smokers, and water pipe users conducted to understand the needs of young participated in the survey. The habit of use of people and evaluate their perception of water pipe and the perception in the commu- addictive substances like; tobacco, alcohol, nity about its use were analyzed to plan and drugs. As a result of the research the communication campaign in 2014. youth center was designed and established to The contents of the campaign were prepared meet the requirement. The Youth Center and the kick off is planned on 1st April 2014. became operational in 2013 and is still At the end of the year another survey will be providing sporting and artistic activities for launched to analyze the effects of the young students12. campaign14.

The Project on Combating Substance Advocacy: Abuse through Official Primary School Green Crescent Clubs in Istanbul: The Turkish Green Crescent Society plays an important role in policy making, lobbying The project was implemented in cooperation and advocacy issues. The Green Crescent with Istanbul Development Agency efforts are especially focused on carrying out

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preventive social and advocacy activities adoption of “The National Alcohol Control aiming at creating public opinion and raising Action Plan”. Green Crescent organized an awareness of the decision-makers and the international symposium in Istanbul on 25-27 general public. The advocacy activities vary April 2013 and representatives from 60 from legislation on public health to alcohol different countries including Turkish Prime and tobacco control policies. Minister Recep Tayyip Erdogan, and the Article 58 of the current Turkish Constitu- Director-General of the World Health tion, which forces the state to protect youth Organization Dr Margaret Chan participated. from harmful habits was a proposal of the Global Alcohol Policy Symposium provided Green Crescent. important base for the adoption of the new “The State shall take necessary measures to in Turkey. As an advocacy protect youth from addiction to alcohol, drug organization, Green Crescent tried to push addiction, crime, gambling, and similar decision makers to enact this law with the vices, and from ignorance”15. scientific and evidence-based public health The WHO Framework Convention on principals19. Tobacco Control and its guidelines provided The Turkish Green Crescent Society has the foundation for countries to implement adopted a strategy to help the development of and manage tobacco control. WHO the alcohol policy in Turkey. The Turkish developed the MPOWER measures to assist Alcohol Policy Platform was established in in reducing the demand for tobacco products 2013 on a national level under the leadership at country-level16. In recent years Turkey of the Green Crescent. Many organizations became an example of success for the from various sectors came together under the implementation of MPOWER measures in platform and currently 40 different the World. Green Crescent played an organizations are the members of this important role in the Turkish Government’s platform. It was an attempt to organize adoption of the Framework Convention on pressure group to raise public health Tobacco Control and its enactment process in awareness in general and about alcohol Turkey17. policy in particular20. Recently, the Turkish Government has enacted a new law on alcohol control policy The Green Crescent in Educational within the framework “the National Alcohol Institutions: Control Action Plan”. The bill was proposed and prepared by the Ministry of Health and As a public health organization, the Green was approved in the Grand National Crescent mostly cooperates with educational Assembly of Turkey on 24th of May, institutions for preventive activities. The 201318. anniversary of the foundation of the Green Unfortunately, the new alcohol law turned to Crescent Society 1-7 March, is celebrated as be a political instrument between the ruling the Green Crescent Week in Turkey by the and the opposition political parties in Turkey. Council of Ministers’ decision since 1960. The new law faced very strong objections The syllabuses of the secondary and high from the secularist segments of the society schools cover contents on harmful habits, claiming that it deliberately restricts their addictions and the concept of the Green freedom and it is an interference into their Crescent during that week, and great lifestyle. Alcohol Industrial involvement and numbers of activities are carried out in lobbying increased the reaction against the schools across the country during the entire regulations. Alcohol industry propagated the month. The Green Crescent has an official argument that the alcohol regulations are protocol with the Ministry of National religious based and mostly violate secular Education. people’s freedom. The Green Crescent The National Educational Program on conducted advocacy campaigns for the Addictions of the Green Crescent has been

106 FIMA YEAR BOOK 2014 THE TURKISH GREEN CRESCENT developed in cooperation with the Ministry. through many doors and find new spaces and It provides an opportunity to conduct many victims. Beside the causes of addiction, what surveys, projects and activities beginning at we really need to pay attention to is the tools primary and including secondary and high of addiction, namely, the means that schools. In every secondary and high school influence and push individuals, the youth, across the country, there is a Green Crescent into addiction. When individuals step out of Club. These clubs are conducted according to didactic education processes in their families the rules of the Club Regulation of Ministry and schools, they become less shielded from of National Education. The regulation the marketing strategies of the media and the obligates schools to constitute the Green addiction industry, and become easier targets Crescent clubs under the leadership of the prone to influence, under the so-called trainers. Although they are compulsory for “freedom”. This opening that comes along the teachers, students participate in the clubs with getting out of teachings and restrictions voluntarily. The Green Crescent clubs follow of their families and schools that interfere in, the curriculum of Ministry of Education and and limit their participation in what they they mostly conduct their activities in March. consider pleasant activities, makes the The Green Crescent club members conduct children/youth open to ideas of “being free” their activities under the guidance of their and “realizing oneself”. This pursuit of teachers. The Green Crescent branches and independence of becomes a tool for headquarters provide the required documents addiction. This concept of freedom combined for the teachers and launch some programs to with the pressure of two other elements. train club trainers in the provinces. Peer One, is the idealized and marketed world; education activities are mostly implemented and two, the acknowledgement of the peers through these clubs to keep children away sharing the same interests and expectations. from harmful habits. According to this Peers are the only place where the method students work to protect their friends individuals who turn their backs to the from harmful habits and they inform their difficulties of being good and responsible, friends periodically at schools. find acknowledgement and appreciation. This Leader students in the clubs reflect and share situation that we can call “the peer effect” their experience in the Green Crescent Club provides two benefits to individuals. First, Periodical published monthly. finding an authority that likes and appreciates Since the Republic of Turkey is a secular the situations and tendencies that are not country, the laws and the rules of the approved by authorities such as the family educational institutions cannot be religious and school. Second, the psychological based. The philosophy of the Green Crescent confidence resulting from seeing the peers clubs is based on the educational rules of sharing the same evil by doing things Ministry of National Education and universal considered bad. As a result of that, the moral values21. individuals isolated by the increasing Peer Effect: criticism and pressure of the families and schools, are left even weaker in their peer There are many causes of addiction. It is groups. At that point, these individuals are impossible to focus on just one single cause now forced to behave according to the and achieve results from methods based on interests and tendencies of their peers, and only that specific cause, whereas many making the expected sacrifices and attempts psychological, physiological, cultural and to get accepted by and belong to the group. environmental factors exist. Taking such an And then it is difficult to predict where these easy way out is no different than what an individuals will stop. On the other hand, we ostrich does when it sees its hunter. cannot undervalue the number of young Addiction of smoking, alcohol, drugs and the people who have received good family recently developed technology can pass discipline, good education and who have

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made healthy progress, and have strong International scope: personalities and characters. What needs to be done and what the Green Crescent has Alongside national affords, the Green adopted is to encourage the youth in the right Crescent targets to be part of international direction. The youth constitutes the most solidarity to fight against addictions on a global important part of the purest and cleanest level. The Turkish Green Crescent Society is times in terms of emotions and thoughts, an organization who has a Special because the demand for justice and tendency Consultative Status within the Economic and to sacrifice oneself in the name of what is Social Council of the United Nations22. The right, and of their ideals, exist intensively in Green Crescent is also a member of the young people. And that is why we have the European Alcohol Policy Alliance, opportunity to educate our youth and make EUROCARE23. Turkish Green Crescent them volunteer to fight against the addictions Society has “EFQM Committed to of their peers by setting good role models. Excellence” certificate of the European Young people diverted to quests outside of Foundation for Quality Management. Green the teachings and ideas of families and Crescent also cooperates with a great number schools, will easily accept their peers who of organizations in the world. are mentally and physically healthy, and who The Society aims to transfer its experience and look to life and the future with confidence. values to other organizations. It helps the This way, peer groups will move from being foundation of new Green Crescents in different a tool of the evil and addiction to leading the countries, namely; Palestinian, Bosnia and way for raising educated generations who Herzegovinian, Malaysian, Thai, Lebanese will look to the future with confidence. Also, and Montenegrin Country Green Crescents. generations who have chosen this path of A major objective of the Turkish Green commitment to benefit and their human- Crescent Society is to launch the World oriented thinking will safeguard the future of Federation of Green Crescent Societies for a our nations. better future of our next generations. It must be our primary goal to expose the The Turkish Green Crescent Society is dangers of the concepts, which are presented always ready to share its expertise, know- to our youth under the name of freedom, and how and documents to help the foundation of which trap them in the web of addiction Green Crescent Societies in other countries industry, and to raise our youth as in order to make our world smoke-free, responsible individuals with strong minds, alcohol-free, drug-free and to protect our morals and personalities of the future. next generations from all kinds of addictions For our social values and healthy family that are the evils of the modern world. structure to be carried into the future in the hands of mentally and physically healthy References: generations, we have adopted an 1. World Health Organization Management of Substance understanding and determination beyond Abuse daily philosophical and political debates. We http://www.who.int/substance_abuse/facts/alcohol/en/. aim to transform the Turkish Green Crescent 2. For further information on alcohol harms see http://www.yesilay.org.tr/en/news/item/207-global- Society into a structure that is more efficient alcohol-policies-symposium-final-declaration.html. and more active both in the service of our 3. World Health Organization Tobacco Free Initiative nation and of humanity, through ideals and http://www.who.int/mediacentre/factsheets/fs339/en/. 4. World Health Organization Management of Substance ideas that we have preserved since the first Abuse day of our foundation, by opposing the http://www.who.int/substance_abuse/facts/psychoactiv misinterpretation of the definition and es/en/. 5. WHO Bulletin, Tobacco Industry Tactics for Resisting requirements of freedom as well as some Public Policy on Health, negative mentalities that stand out as the http://www.who.int/bulletin/archives/78(7)902.pdf. values of our era. 6. Vienna Declaration http://www.viennadeclaration.com/the-declaration/.

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7. For further information on the Turkish Green Crescent Society see the official web site http://www.yesilay.org.tr/en/. 8. Constitution of the Turkish Green Crescent Society http://www.yesilay.org.tr/en/about/constitution.html. 9. For Smoke Free Campus Activity see http://www.yesilay.org.tr/tr/haber/item/20- bezmialemde-sigarasiz-kampus.html. 10. Turkish Green Crescent Society http://www.yesilay.org.tr/en/. 11. For the guidelines of preventive programs see Substance Abuse & Mental Health Services Administration http://www.samhsa.gov/prevention/spfcomponents.asp x. 12. Green Crescent Youth Center http://www.yesilay.org.tr/genclikmerkezi/. 13. For the details of the Green Crescent is Looking for Young Leaders Project see http://www.yesilay.org.tr/en/news/item/375-200,000- students-receive-addiction-resistance-education.html. 14. For further information on Water Pipe Campaign see http://www.nargilegercekleri.com/, the page will be activated as from 1st April 2014. 15. For 58. Article in the Turkish Constitution see http://www.anayasa.gen.tr/1982Constitution-1995- 2.pdf. 16. Framework Convention on Tobacco Control http://www.who.int/fctc/en/. 17. For Turkey’s FCTC success and MPOWER story see http://www.who.int/tobacco/mpower/publications/mpo wer_2013.pdf?ua=1. 18. For an evaluation on the Turkish Alcohol Control Law 2013 see http://www.todayszaman.com/news-316734- erdogan-defends-alcohol-law-not-imposition- protecting-youth.html; http://www.todayszaman.com/news-316365- parliament-passes-bill-limiting-sale-of-alcohol- banning-ads.html. 19. Global Alcohol Policy Symposium 26-27 April 2013 http://gaps-istanbul.com/eng/news.aspx. 20. Turkish Alcohol Policy Platform http://www.tapp.org.tr/. 21. Club Regulation of Ministry of National Education (Turkish) http://mevzuat.meb.gov.tr/html/25699_0.html; Green Crescent Official Page for the Green Crescent Clubs http://www.yesilay.org.tr/yesilaykulubu/. 22. For Consultative Status with the United Nations Economic and Social Council (ECOSOC) see http://csonet.org/; For the Green Crescent Consultative Status see http://www.yesilay.org.tr/en/news/item/337- the-green-crescent,-member-of-the-un-economic-and- social-council.html. 23. European Alcohol Policy Alliance http://www.eurocare.org/.

FIMA YEAR BOOK 2014 109 110 FIMA YEAR BOOK 2014 BEWARE OF SPIRITUAL BYPASSING: INTEGRATE PSYCHOTHERAPY IN THE ADDICTION RECOVERY PROCESS

Ketam Hamdan*

Abstract:

This chapter discusses the phenomenon of spiritual bypassing, generally defined as a person’s utilization of spiritual practices and beliefs to avoid unresolved psychological issues that may have triggered the addiction. As a result, those on the path of addiction recovery will most likely not heal properly and will continue to struggle with their addiction issues. To elaborate on this topic further, this chapter contains four sections. First, a brief discussion of the definitions of key terms used throughout the chapter. Second, a summary of the characteristics of spiritual bypassing and how it may manifest on the path to recovery. Third, a psychological model for holistic development is offered. Finally, this section provides recommendations for using both spiritual and psychological practices for sustainable addiction recovery.

Keywords: Spiritual Bypass, Islam, Addiction Recovery, Therapy, Psychology.

Introduction

In the past decade, there has been a rapid provoke animosity and hatred among you increase in addiction to drugs, alcohol, through intoxicants and gambling, and to gambling, pornography, technology, and distract you from remembering God, and from compulsive eating that have fueled the growth of observing the prayers (Salat). Will you then emotional and behavioral problems in the refrain?”2. American Muslim community1. Most Muslims The above verse directly tells Muslims to abstain hold the worldview that a person with an from harmful things such as alcohol, drugs, and addiction problem is often the result of one’s gambling because these acts are from the devil weak iman (the Arabic word for faith) and that only desires to push people towards faulty increasing one’s faith is the only cure. They things that keep one from the remembrance of believe that addiction violates and disregards the God. Therefore, when a Muslim admits or is basic tenets of Islam. Islamic scriptures provide found to have an addiction problem, his or her Muslims with clear guidelines about what is psychological issues are rarely unearthed and the permissible and what is not. For instance, the underlying reasons for the addiction problem Qur’an informs Muslims: goes unexamined. Instead, one is often preached “ O you who believe, intoxicants, and gambling, at and told to become more religious. and the altars of idols, and the games of chance Unfortunately, this ostrich philosophy that are abominations of the devil; you shall avoid religion is the only remedy to treat an addiction them, that you may succeed. The devil wants to problem is rarely accurate.

*Dr. Ketam Hamdan Ph.D Psychology Master of Theological Studies (M.T.S.) Religion & Psychology, Harvard University Master of Science (M.S.), Social Sciences Columbia University E-mail: [email protected]

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One phenomenon that describes the limitations zed religion, such as Islam. Thus, the words of relying solely on spiritual practices to spirituality, spiritual, religious, and religion are overcome problems such as addiction is known used interchangeably throughout this paper to as spiritual bypassing, which is a phrase that refer to Islam, Islamic rituals, Islamic principles describes a person who avoids dealing with and beliefs. negative emotions and other internal psycho- logical issues. Instead, this person resorts to Definition of spiritual bypassing: healing by using only spiritual practices and beliefs 3,4. Charles Whitefield7, who is a medical doctor Therefore, the objective of this chapter is four that works in the field of trauma and addiction fold. Firstly, it will provide definitions for the recovery, first coined the phrase spiritual bypass. usage of the terms spirituality and spiritual Whitefield noticed that those individuals who bypassing, in relation to how it is used engage in psychological work and development throughout this paper. Secondly, a discussion of were better able to improve and experience true spiritual bypassing traits that Muslims may spirituality. He also noticed that individuals who manifest on the path of addiction recovery. engaged in psychological and spiritual work Thirdly, the paper will share a model of the self together recovered faster from addiction related that helps explain the importance of both issues and were less likely to relapse. Likewise, spiritual and psychological development for John Welwood8, a psychotherapist who holistic addiction recovery. Finally, it will integrates psychological and spiritual therapy, conclude with recommendations of how therapy noticed that many of his clients engaged in can be integrated and used to compliment advanced spiritual practices; however, spiritual growth. their spiritual practices had a tendency to help them avoid facing their wounds, emotional 1.Definition of Terms insecurities, and pains that most likely triggered or influenced one’s addiction problem in the first The usage of the words spirituality and spiritual place. He observed that often times his patients bypassing may have a variety of meanings. were unconsciously using spiritual beliefs to Thus, below are definitions of these words to achieve spiritual maturity while unconsciously clarify what is meant by the use of these terms in overlooking, or bypassing, their personal and the context of this paper. emotional problems. The person is most likely trying to resolve psychological issues at the Definition of spirituality: spiritual level and does not realize that he or she is escaping the work at the other levels, such as The word spirituality has no universal definition the cognitive, emotional, and interpersonal. because the word can be applied to different When this happens, spiritual practice is not contexts. integrated into the real-world state of the psyche For example, one definition of spirituality is “the and, as a result, personal growth is less mature personal quest for understanding answers to than the spiritual practice. ultimate questions about life, about meaning, As a noun, the term bypass means to go around, and about relationship with the sacred or to avoid, or to proceed without reference to transcendent, which may (or may not) lead to or the core or superior issue9. However, for the arise from the development of religious rituals”5. purpose of this paper the term bypassing is Another definition of spirituality is the “human preferred. As a verb, bypassing represents and yearning for divine love”6. For the purpose of implies a developmental process that a person is this paper, spirituality is defined as the perpetual continuously engaged in. Thus, the phrase pain of the soul that craves for a connection with “spiritual bypassing” refers to a person’s a higher power, God, and stems from an organi- unconscious utilization of spiritual beliefs and

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practices to go around psychological issues and There are no quick fixes for fully healing one’s emotional unfinished business, with the hope of repressed issues and childhood wounds. The finding inner peace through one’s faith10. process of transformation takes time and people Moreover, the explosion of New Age fads like need to be educated about the complexity of this think positive, be grateful, and avoid negative process, rather than be given false band-aid fixes people are examples of fast food spiritual that rarely resolve or just scrape the surface of remedies often recommended to people to feel one’s issues. better. Another mainstream fad is the Secret, Furthermore, the literature that discusses spiritu- which is a concept that centers on the attraction al bypassing is scarce. So not only is there principle in New Age spirituality and teaches limited research about spiritual bypassing, but people that whatever one imagines one will also there is no research about this topic from the manifest. The belief is that a person attracts what Muslim perspective. he or she believes. Thus, if an individual The literature also references other phrases that believes he or she is poor then the person will allude to the concept of spiritual bypassing. For most likely live poor. Whereas if a person is instance, Trungpa13 coined the term spiritual content and grateful, the Secret experts suggest materialism, which is the practice of that the person will attract more money and strengthening the ego by accumulating more positive experiences. People are also preached spiritual experiences and by shopping around for catch phrases like “don’t take it personally”, or diverse spiritual practices without commitment “whatever bothers you about someone is really to a specific tradition. Spiritual materialism can about you”11. However, these fads have helped be experienced by both practicing Muslims that to further promote a fast-food spirituality culture understand Islam properly and by Muslims who of drive-through offerings that only temporarily may have had blind faith growing up. Regardless help one feel better. These fads have also if one is applying Islamic practices properly or if misguideda person that becoming more spiritual one is merely implementing what one was taught is the cure to any problem. As a result, the growing up, spiritual materialism most likely individual never seeks help for internal issues occurs when one feels a sense of superiority over that he or she rarely understands. One merely others or holier than others because one is doing escapes internal issues and pain by numbing a lot of spiritual activities. Another phrase is problems with quick fixes like think positive or bullet-proof faith, which suggests that a person avoid negative people. When this happens, an has strong faith in a God that cannot be stirred individual is unable to fully live an authentic and no matter what happens to him or her. Another genuine life because his or her issues are phrase premature transcendence is also known constantly lingering in the background. These to be synonymous with spiritual bypassing, quick fixes and easily blurted expressions which alludes to a person who engages in actually repress one’s painful issues and impact spiritual practices to rise above psychological one’s ability for holistic development that is issues that are internally stored, silent, and necessary for true fulfillment12. Moreover, others remain unresolved14. are told to simply increase their Islamic practices Ultimately, one’s unresolved issues continue to and preached to pray more, to give more charity, haunt them and get acted out, which results in and to read more Qur’an. One’s spiritual immature and half-baked spiritual practices. practices may make one feel better, but often In summary, in the context of this chapter, the times it is only temporary. Individuals will most phrase spiritual bypassing will be used to likely continue to experience frustration and describe Muslims who turn only to their Islamic disappointment because the issues that he or she beliefs and practices to overcome an addiction is trying to escape, via their addiction, still problem. These persons do not address or remains internally and will continue to haunt examine their internal psychological issues that them. One has to first become aware of these most likely contributed to their addiction related issues, and then take steps to overcome them. problems in the first place.

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The next section will discuss in more detail how development. Often religious leaders will spiritual bypassing may manifest. prescribe to someone with an addiction problem the need to engage in more Islamic rituals and 2. Traits of Spiritual Bypass practices. However, recent research suggests a on the Path of Addiction Recovery person’s religious beliefs and practices may hinder sustainable recovery 19. Instead, religious Most Muslims are taught to believe that the leaders could serve as mentors to refer addicts to Qur’an and Sunnah (authentic prophetic professional counselors or mental health traditions) contain the tools and keys for how professionals that are better equipped to help the they should govern their life and enhance their individual. overall character. Many accept that everything Correspondingly, when an addict is in the that happens in one’s life is a direct result of process of recovery and is engaged in spiritual God’s will, especially crises, illnesses, and bypassing, it can manifest itself in different losses. For instance, this verse from the Qur’an ways. For instance, it may appear as an informs Muslims, "Nothing will happen to us obsession with a spiritual leader or religious except what Allah has decreed for us: He is our scholar, which most likely leads to the develop- protector’: and on Allah let the believers put ment of blind faith in spiritual gurus or mystics their trust”15. and social seclusion20. Further, devout Muslims are instructed to trust This unquestioning faith may lead one to renou- that calamities, problems, and illnesses are a nce personal responsibility by passively relying means to get closer to God. As a result, many on religious leaders to resolve psycho-logical Muslims are preached at and told that he or she problems, which can, over the long haul impede should embrace their problems because one’s functioning in the modern world. One may also issues are a means to “cleanse, purify, and demonstrate a zealous preoccupation with balance…on the physical, emotional, mental, reciting the Qur’an, supplications, prophetic and spiritual planes”16. Thus, psychological or sayings, or other Islamic literature that he or she mental health issues such as addiction are rarely did before. In essence, increasing one’s considered a test from God17. For instance, if a religious activities is not wrong and is highly person has feelings of anxiety, depression, and encouraged for every Muslim to do. However, shame that resulted from some type of addiction, the concern is when these Islamic practices are then he or she is often taught to believe that this done in isolation and not complemented with problem should be used as an opportunity to psychotherapy or psychiatric help. It is now reevaluate his or her life and increase their believed that both spiritual and psychological Islamic practices. work are needed for addiction recovery. In addition, for many Muslims, a person’s family In addition to spiritual engagement, Muslims or religious leader (known as an Imam) is often need to gain more knowledge about the seen as the resource to go to when a person complimentary role that therapy can have in experiences a life problem, calamity, or issue. helping them fully recover21. One research study found that Muslim More specifically, Cashwell, Myers, and participants were more likely to consult religious Shurts22 identified three different types of people leaders for help re their mental health issues and that use spiritual beliefs to prevent or avoid that only 11% of participants reported that they facing their psychological issues. These are the would seek treatment from a mental health Good Servant, I Have a Gift, and Turn the Other professional18. However, many religious leaders Cheek. As a Muslim, the Good Servant type may find themselves being consulted about be someone who tries to overcome an addiction psychological issues that they do not have problem by spending a lot of time volunteering formal education or training in. As a result, at the mosque and participating in spiritual Muslims do not get the proper treatment and events and activities. This person most likely guidance needed for healthy recovery or exhibits traits of compulsive goodness and is

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someone who is extremely kind, helpful, person. One should also not talk negatively or considerate of others, and goes out of his or her have negative thoughts about another person. way to do good. The second type, I Have a Gift, This requires one to have a purity of heart and is is most likely a person that believes he or she often difficult for one to achieve without having has been guided by God and is extra special. addressed past pains of not being heard, valued, This person will dismiss their addiction behavior and respected. and pacify the addiction as something that was Furthermore, it is important to note that it is not temporary. As he or she turns to spiritual always easy to detect spiritual bypassing because practices, the persons will rationalize that their it can take the guise of other positive traits, such addiction may be a way to bring them closer to as being extremely polite and nice or being God. Thus, they are special and God is watching overly charitable. At the same time, the person is over them. inconsistent with these extreme positive traits The third type, Turn the Other Cheek, may and will at times demonstrate sudden moments resemble a Muslim who has an addiction issue of frustration, anger, or irritability. These traits because of historical pains and issues associated only further validate the existence of repressed with not being able to express him or herself. and unresolved negative emotions. Thus, the This person internalizes his or her feelings and seemingly more devout Muslim is not congruent negatively acts out feelings, by indulging in drug and does not experience the continuous inner or alcohol abuse. The person generally has an peace of leading a more spiritual life. Instead, addiction problem because the addiction to some the person on the path to recovery and engaged type of substance helped to numb the person’s in spiritual by passing may exhibit traits of being pain. For instance, if while growing up, a person judgmental of others, having a holier than thou did not feel loved by his or her parents, this attitude, critical of those who do not practice, person most likely would have avoided getting morally harsh, and insensitive24. Also, a person close to people and did not feel comfortable may become obsessed with increased religious expressing his or her feelings. If one is unable to activities, which serve as a way for the addict to express him or herself then the person feels feel in control or to contain negative emotions. unimportant and not valued. When one is not The addict in this case is simply replacing a heard, one feels bad and has internal disarray. negative addiction under the guise of a more Thus, instead of confronting his or her pain and positive addiction, a spiritual one. This faulty admitting the need to be valued and heard, the replacement only helps the person further mask person numbs these needs by turning to drugs or his or her historical wounds and issues25. The alcohol as a temporary escape to feel good. following section will elaborate on the concept Thus, on the path to addiction recovery, this of holistic development for sustainable addiction person will rarely be able to express his or her recovery. needs, how he or she feels, and will not confront others when wronged. Instead, he or she may 3. Holistic Development follow Islamic beliefs and teachings, such as this for Addiction Recovery verse, “Those who spend (in Allah’s cause) in prosperity and in adversity, who repress their More and more psychological experts are anger, and who pardon men, verily, Allah loves recognizing that spirituality is essential and can the al-Muhsinun (the good-doers)23” tremendously help one overcome an addiction However, Muslims need to understand the depth problem26. For instance, Carl Jung27, a famed of what is meant by Islamic teachings that psychologist, believed that spirituality might be emphasize forgiveness and pardoning others. the best solution for a person with an addiction The ability to truly forgive someone requires the problem and explained that addiction is most removal of any ill feelings towards a person who likely a sign of a deep spiritual yearning that is has wronged him or her. One should not hold missing in one’s life. Thus, from a deep grudges or have any animosity towards another psychological standpoint, a person’s search for

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spirituality is a sign of seeking completeness of nds and assume that they need to forego any type the soul. Many recovering individuals point to of self-grounding or psychological development their spiritual lives as being central to their of a secure structure. However, spiritual bypass abstinence. Specialists on addiction recovery is more of a false sense of transcendence that describe successful programs, such as the 12- bypasses psychological issues and often entails step addiction recovery plan, as a spiritual avoiding or denying one’s shadowy side. Within revival program that encourages the person to the Muslim community, there is a strong need to return to their faith and find greater meaning in raise awareness of the constructs of the self and their life28. the importance of holistic development. When a Robert Assagioli29, who created the person increases spiritual practices without transpersonal model of psychosynthesis, also examining psychological issues then he or she is agreed with Jung that people experience most likely creating psychic fragmentation, not conflicting impulses on an ongoing basis. They holistic development. In an attempt to explain often fluctuate between the desire for security, more vividly the constructs of the human psyche and the “tendency towards growth, self- and its complex part, Assagioli’s oval model or assertion, and adventure”30. In essence, new “egg diagram33” (Figure I) is illustrated below: drives are continuously being awakened that Figure I. Assagioli’s Structure of the Psyche. challenge previous ones. Assagioli asserts that during adolescence one is likely to awaken new Soul motivations. Then in middle age one is more likely to awaken more spiritual or religious c. Higher aspirations. It is these aspirations that are at the Unconscious heart of spiritual bypass that an addict on the path to recovery may focus on. A person’s spiritual development is not an easy or short Field of b. Middle I process; it is a long and difficult journey that Unconscious Consciousness requires continuous self-awareness, self- & Will regulation, and self-development. If a person neglects psychological growth and focuses only on spiritual amplification, this only makes the a. Lower process more complicated. Unconscious While spiritual practices can help an individual address cognitive and behavioral dissonance, the person must have a secure psychological structure that he or she is grounded in. Welwood assessed that this grounding is: In Figure I: Assagioli’s Structure of the Psyche, Psychological and not spiritual work. Assagioli suggested that the unconscious has It means working with needs, scripts, hunger for three main levels: (a) the lower unconscious, love, fear of love, fear of loss of love, fear of which can be thought of as Jung’s personal receiving love, fear of giving love, and unconscious and Freud’s unconscious area of establishing a sense of self-respect, which is not drives and passions, as well as childhood overwhelmed or crushed by other people’s repressed experiences, anger, and traumas; (b) opinions31. the middle unconscious, similar to everyday Moreover, John Engler coined the phrase “you waking state of consciousness that contains have to be somebody before you can be easily accessible memories and skills, labeled by nobody”32, which emphasizes the need to Freud as the preconscious; (c) the higher strengthen the ego before transcending it. Many unconscious, or super-conscious is the region addicts who are attracted to spiritual practices where more spiritual, mystical, or higher values misguidedly bypass confronting historical wou- reside. For Muslims, the higher unconscious area

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is the area that houses one’s Islamic beliefs and The next section will elaborate in more detail on values. This area also houses creativity, using both spirituality and psychological intuition, and the drive for meaning, and practices for more holistic development. purpose. In the center of the middle layer, signifying the middle unconscious is a circle that 4. Using Both Spiritual Practices and Therapy represents one’s immediate conscious field of awareness that the “I” operates in. Unlike traditional cognitive and behavioral Although the model places the soul on the top of methods, there is a greater need to look at a more the diagram, the soul is an aspect of the self that integrated use of treatment that takes into is “center of the entire psyche. The soul can be account both spiritual and psychological said to pervade all of the oval . . .”34. In this solutions37. Cognitive behavior therapy does not model, the lines are dotted to signify that the necessarily help to diagnose or determine one’s different layers are permeable and can influence unconscious or conscious drivers38. As a result, a the “I”. However, this requires a more conscious person’s problems go undiagnosed and leave understanding of the constructs of the self and wounds pending while allowing one to act in the importance of integrating these parts for ways that may appear to be satisfactory. healthier development. In the case of an addict Essentially, the heart of spiritual bypassing is who has turned to Islamic practices for recovery, predominantly unconscious, or as Assagioli he or she is most likely functioning using two of defined it, the lower unconscious, which the three areas, the upper unconscious and the contains repressed material, developed from middle unconscious. Thus, the person is early childhood experiences, and later covertly engaging in spiritual bypassing because one is affects one’s spiritual intentions and overall most likely unaware of the lower unconscious development. For example, The Adverse area. As mentioned previously, the lower Childhood Experiences (ACE) study suggests unconscious area is the area that stores one’s that early childhood trauma such as abuse or historical issues and wounds that are often continuous neglect by parents often results in repressed and the person is unaware of. In children engaging in addictive behavior during viewing the diagram, one is able to see that in adult life39. Researchers suggest that a child who dismissing or ignoring the lower unconscious suffered abuse will most likely store the abusive altogether the individual is not able to become memories in the lower unconscious. As one whole, which is needed for psychic unity. progresses through life, one never faces the pain Moreover, this thinking is in alignment with and hurt from the abuse. This pain in the lower Freud’s psychological discourse, which emph- part of the unconscious lingers silently and stirs asized the impact of one’s unresolved conflicts internal disarray. To alleviate this disarray, one that are repressed in the unconscious and that turns to drugs or alcohol as an analgesic from there are psychological hazards of not address- reliving, confronting, or acknowledging the pain. ing these past issues35. These unsolved conflicts In most situations, the person is often unaware of cannot remain unknown and over time create the unconscious influence that is fueling his or internal psychic dissonance, which might result her addictive behavior. in serious pathological outcomes. In order to acquire self-awareness of lower Freuddisclosed that the “patient does not unconscious issues, one can begin by seeking remember anything of what he has forgotten and professional help to evaluate their destructive repressed, but acts it out. He reproduces it, not as behavior and learn about unconscious issues that a memory but as an action”36. In essence, Freud is hindering growth. Yet, within the Muslim is telling us that people do not recall the community this poses a challenge because there repressed material; he or she simply repeats it tends to be a general taboo associated with unconsciously and acts its out in unhealthy seeking therapy to examine or understand one’s ways, such as in addiction related behavior. addiction behavior. This attitude is most likely a result of the cultural shame and negative

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stereotypes associated with seeing a therapist or Prophet and said: “O Messenger of Allah! I have getting any type of psychological help. In mingled with a woman in the far side of al- addition, many Muslims simply do not know Medina, and I fulfilled my desire short of what resources to turn to or how to go about actually having sexual intercourse with her. So, dealing with their addiction related issues. There here am I, judge me according to what you is a necessity for Muslims to make a more decide.” Umar Ibn al-Khattab (radiyallahu anhu) conscious effort to understand and resolve their then said: “Allah had kept your secret, why did psychological issues that trigger their addiction not you keep your secret?41. behavior. As a result, most Muslims internalize or Applying religious values and principles, while suppress their issues and do not seek social ignoring necessary psychological development support or professional help for fear of being and work, will most likely continue to create humiliated or scorned. Unfortunately, a person internal disarray and discord40. In addition, that attempts to overcome his or her addiction ignoring psychological work will also result in problem by turning only to spiritual practices incomplete spiritual practices because one’s will still experience challenges because hidden psychological issues will most likely continue to emotions and issues that triggered the addiction blindly impact one’s spiritual practices. For remain unaddressed. example, there are many Muslims who On the surface it will appear to others that the understand Islam properly and are extremely person is getting better, but in reality the devout. However, it is not uncommon to hear person’s psychological wounds that prompted that these very same people are guilty of the addiction are never dealt with. For many domestic violence, drug abuse, or other wrongful individuals who struggle with an addiction acts that go against Islam. These individuals problem, such as substance abuse, alcohol, most likely have undiagnosed or untreated pornography, etc., the addictive behavior often psychological issues that they are unaware of, serves to suppress unwanted issues that the but yet they continue to act out in ways that person is often unaware of. Historically, therapy negate their Islamic beliefs. did not integrate spirituality as part of the Muslims too often approach an addiction healing process. However, the growing practice problem with a nonchalant response that it is a of incorporating spirituality in therapy presents sin and one needs to just obey Islamic teachings. both opportunities for better healing and It is common to hear one say to a person with an potential threats of helping clients bypass addiction problem to fear God (Allah) and the psychological issues. Thus, as stated earlier, problem will go away. Unfortunately, this spiritual bypass happens when a person turns to simplistic attitude is limiting and does not solve his or her religious rituals and dismisses the problem. examining the cause of one’s unhealthy behavior Telling one to just become more religious and or negative emotions. In the short-term, spiritual follow Islamic rules, allows a person to avoid bypass may be beneficial because it provides a examining or taking responsibility for their coping platform for a person to begin the addiction issues. Research also demonstrates that recovery process. However, in the long-term, a social support is instrumental in the addiction person needs to become aware of and face his or recovery process. However, most Muslims are her psychological issues that most likely not comfortable talking about their addiction influenced the addiction to begin with. To do issues with close family or friends for fear of this requires that Muslims embrace professional being reprimanded, ridiculed, or shamed. In fact, counseling and therapy as a formal science that many Muslims are taught to not publicly discuss can help one understand his unconscious drives or disclose their faults. For instance, the and emotional issues. The following are some following prophetic tradition tells Muslims to recommendations for facilitating the integration not disclose your sins. Abdullah Ibn Masoud of spirituality and psychotherapy on the path to (radiyallahu anhu) related, “A man came to the addiction recovery.

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1. Educate: spiritual leaders, educators, medical half-baked spiritual practices because professionals, counseling and mental health psychological issues that triggered the addiction experts need to make a more concentrated problem remain unaddressed. effort to debunk negative stereotypes of The belief is not that one’s religion cannot help, psychotherapy, counseling, and mental but rather the healthiest and most sustainable health services. In addition, there is a need to form of addiction recovery includes using both educate Muslims how psychotherapy spiritual and psychological efforts. For instance, compliments spiritual practices, as well as the Quran and Sunnah (prophetic) are used to how seeking psychotherapy can help provide one with principles and rules to live expedite the recovery process long-term. one’s life by and professional counseling could 2. Motivate: Muslim community leaders and be used to help the person understand why he or professionals need to lead the way and set up she may have difficulty applying these organizations or recommend therapists that principles. Also, a person needs some type of are skilled in helping Muslims get the support to openly discuss their desires, fears, and necessary psychological addiction support emotions, which is often not readily available in and assistance needed. The combination of one’s local community. Thus, the main goal is to psychology and Islam will allow one to educate Muslims that psychotherapy and address the root causes of an addiction counseling can serve to enhance a person’s problem and aid in more holistic spiritual beliefs, not take away or replace development. Failure to do so will often religion. Furthermore, the therapist’s role is result in a relapse and the person returning to instrumental in the healing process, especially the addictive problem or picking up an for Muslims who do not openly feel safe alternative way to act out unresolved discussing their problems with close family and problems. friends. Mental health professionals have the 3. Engage: A skilled therapist can effectively ability to develop secure relationships with work with individuals who demonstrate clients that are essential in helping clients open spiritual bypassing because they can “hold up and tackle difficult emotions repressed in and value both sides of the dilemma”42. The their unconscious mind. Clients advanced in therapist and client dyad can have a powerful their spiritual practices will attempt to bypass effect that facilitates a “flow of energy and emotional discomforts and prefer to work at the information”43 that expedites the healing spiritual level. Historically, therapy did not process, and ultimately transforms the client. integrate spirituality as part of the healing process. However, the growing practice of Conclusions: incorporating spirituality in therapy presents opportunities for better and more sustainable There is a growing phenomenon of people healing. turning to spiritual practices and beliefs to remedy addiction related issues; however, many References: are most likely experiencing spiritual bypassing by avoiding their pains. Islamic scriptures, 1.Basit, A., & Hamid, M. (2010). Mental health issues of Muslim Americans. Journal of the Islamic Medical teachings, and practices serve to provide Association, 42, 106-110. Muslims with clear guidelines and rules to live a 2. The Glorious Qur’an, Al-Ma’ida, 5:90-91. successful and peaceful life. At the same time, to 3. Whitfield, C. L. (1987). Healing the child within. Deerfield resolve an addiction problem properly, one Beach, FL: Health Communications. 4. Welwood, J. (2000). Towards a psychology of awakening: needs to take a holistic development approach Buddhism, psychotherapy, and the path of personal and that includes increasing both spiritual and spiritual transformation. Boston, MA: Shambhala. psychological activities. Failure to understand 5.Koenig, H. G., McCullough, M. E., & Larson, D. B. (2000). one’s psychological issues to address an Handbook of religions and health. New York, NY: Oxford University Press, p. 18. addiction problem will result in immature and

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6.Morgan, O. J. (Ed.). (2007). Counseling and spirituality: psychology (pp. 533-558). Washington, DC: American Views from the profession. Boston, Psychological Association. MA: Lahaska Press. p. 65 27. Jung, C. G. (1959). Conscious, unconscious, and 7.Whitfield, C. L. (1987). Healing the child within. Deerfield individuation. The archetypes and the Beach, FL: Health Communications. collective unconscious (R. F. C. Hull, Trans.). New York, 8. Welwood, J. (2000). Towards a psychology of awakening: NY: Bollingen/Pantheon. (Original Buddhism, psychotherapy, and the path of personal and work published 1939). spiritual transformation. Boston, MA: Shambhala. 28.Galanter, M., Dermatis, H., Bunt, G., Williams, C., 9.Cashwell, C. S., Clarke, P. B., & Graves, E. G. (2009). Step Trujillo, M., & Steinke, P. (2007). Assessment of spirituality by step: Avoiding spiritual bypass in 12-step work. Journal of and its relevance to addiction treatment. Journal of Substance Addictions and Offender Counseling, 30, 37-48. Abuse Treatment, 33, 257-264. 10.Masters, R. A. (2010). Spiritual bypassing: When 29. Assagioli, R. (2000). Psychosynthesis. New York, NY: spirituality disconnects us from what really matters. Berkeley, Viking Press. CA: North Atlantic Books. 30. Assagioli, R. (2000). Psychosynthesis. New York, NY: 11.Masters, R. A. (2010). Spiritual bypassing: When Viking Press. p. 33. spirituality disconnects us from what really matters. Berkeley, 31. Welwood, J. (1984). Principles of inner work: CA: North Atlantic Books. p. 2. Psychological and spiritual. Journal of 12.Cashwell, C. S., & Young, J. S. (2005). (Eds.). Integrating Transpersonal Psychology, 16, p. 64. spirituality and religion into counseling: A guide to 32. Engler, J. (1984). Therapeutic aims in psychotherapy and competent practice. Alexandria, VA: American Counseling meditation: Developmental stages in the representation of Association. self. Journal of Transpersonal Psychology, 16(1), p. 34. 13. Trungpa, C. (1987). Cutting through spiritual materialism. 33. Assagioli, R. (2000). Psychosynthesis. New York, NY: Boston, MA: Shambhala. Viking Press. p. 14. 14.Cortright, B. (1997). Psychotherapy and spirit: Theory and 34. Frager, R. (1999). Heart, self, and soul: The Sufi practice in transpersonal psychology of growth, balance, and harmony.Wheaton, IL: psychotherapy. Albany, NY: State University of New York Quest. p. 65. Press. 35.Jung, C. G. (1938). Psychology & religion. New Haven, 15.The Glorious Qur’an,Al-Tauba 9:51. CT: Yale University Press. 16.Rassool, G. H. (2000). The crescent and Islam: Healing, 36. Freud, S. (1958). Remembering, repeating, and working- nursing, and the spiritual dimension: Some considerations through. In J. Strachey (Ed. & towards an understanding of the Islamic perspectives on Trans.), The standard edition of the complete psychological caring. Journal of Advanced Nursing, 32, 1476-1484. works of Sigmund Freud (Vol. 12, 17.Abu-Ras, W., Gheith, A., & Cournos, F. (2008). The pp. 147-156). London, UK: Hogarth Press. (Original work imam’s role in mental health pro-motion: A study at 22 published 1914) mosques in New York City’s Muslim Community. Journal of 37. Siegel, D. J. (1999). The developing mind. New York, Muslim Mental Health, 3, 155-176. NY: Guilford Press. 18.Aloud, N., & Rathur, A. (2009). Factors affecting attitudes 38. Schore, A. N. (2003). Affect regulation and the repair of towards seeking and using formal mental health and the self. New York, NY: Norton. psychological services among Arab Muslim populations. 39. Felitti, V. J., & Anda, R. F. (1997) .The adverse Journal of Muslim Mental Health, 4, 79-103. childhood experiences (ACE) study. Centers for Disease 19. Cashwell, C. S., Bentley, D. P., & Yarborough, P. (2007). Control and Prevention. Retrieved from The only way out is through: The http://www.cdc.gov/ace/index.htm peril of spiritual bypass. Counseling and Values, 51, 139-148. 40. Schore, A. N. (1994). Affect regulation and the origin of 20. Whitfield, C. L. (1987). Healing the child within. the self. Mahwah, NJ: Erlbaum. Deerfield Beach, FL: Health Communications. 41. Sahih Muslim. Kitab al-tawba. Bab qawlihi ta`ala inna al- 21. Shrikhande, A., Dermatis, H., & Galanter, M. (2008). The hasanati yudhhibna al-sayyi’at. Hadith No. 2763 in need for understanding the role of spirituality in twelve-step http://www.muhaddith.org/cgi-bin/a_optns.exe. programs. Substance Abuse, 29, 1-3. 42. Cortright, B. (1997). Psychotherapy and spirit: Theory 22. Cashwell, C. S., Myers, J. E., & Shurts, M. (2004). Using and practice in transpersonal the Developmental Counseling and psychotherapy. Albany, NY: State University of New York Therapy model to work with a client in spiritual bypass: Press. p. 213. Some preliminary considerations. 43. Siegel, D. J. (2010). The mindful therapist. New York, Journal of Counseling and Development, 82, 403-409. NY: Norton. p. 262. 23. The Glorious Qur’an 3:134. 24. Whitfield, B. H. (1995). Spiritual awakening: Insights of the near death experience. Deerfield Beach, FL: Health Communications. 25. Cashwell, C. S., Glosoff, H. L., & Hammond, C. (2010). Spiritual bypass: A preliminary investigation. Counseling and Values, 54(2), 162-174. 26. Hopson, R. E. (1996). The 12-step program. In E. P. Shafranske (Ed.), Religion and the clinical practice of

120 FIMA YEAR BOOK 2014 HARM REDUCTION STRATEGY IN THE TREATMENT OF ADDICTION IN THE CONTEXT OF ISLAMIC JURISPRUDENCE

Dr Imthiaz Hoosen* and Prof. Yasien Mohamed**

Abstract:

The recreational use of intoxicants in contemporary society is common and widespread and its use is associated with a multitude of harms to the individual and to the wider society. Substance abuse is a public health issue. Some countries treated addicts punitively and advocated an abstinence only approach. This approach is associated with greater harms particularly amongst injection drug users (IDUs). Harm Reduction is an alternative approach that allows addicts to continue using intoxicants, but in a less risky manner. This approach is associated with less harm. Despite its efficacy, there has been opposition to its implementation, particularly in Muslim Countries. To enlighten the Muslim doctor and patient, we discuss the philosophy and higher objectives of the Islamic law and explore how the principles of Islamic law can be applied to the Harm Reduction approach in our contemporary setting. The understanding of maqasid-al- Shari’ah (The Objectives of Islamic Jurisprudence) and proper application of its principles provides an ethical framework through which we can apply the Harm Reduction approach in the treatment of addiction in the Islamic context.

Keywords: Substance abuse, addiction, Islamic jurisprudence, Harm Reduction strategy, addiction treatment.

Introduction: Substance abuse is a complex, multi-faceted individuals would maintain their sobriety. phenomenon. The use of intoxicants is clearly This traditional approach, while being of prohibited in Islam, but in our time the use of benefit to some, has not been universally intoxicants is wide spread and Muslims successful. There are some individuals who do whether living in Muslim-majority or Western not wish to give up their substance abuse, but countries are not immune to the harms of may benefit from using substances in a less substance abuse and drug dependency. risky manner. There are others who have The traditional focus of many countries' drug repeatedly failed to address their substance policies and substance abuse services is to abuse using the traditional approach. There are achieve abstinence. Addicts are encouraged to also those whose substance abuse may be so attend drug rehabilitation centers, enroll in entrenched in their daily lives that abstinence substance abuse programs, attend support may not be a realistic goal. For these groups such as AA (alcoholics anonymous) or individuals a different strategy is needed to NA (narcotics anonymous) or rely on support manage their substance abuse. Harm of family or friends. It is expected that these Reduction is one such strategy.

*Dr. Imtiaz Hoosen ** Professor Yasien Mohamed Consultant Psychiatrist Professor of Arabic Language Lentegeur Psychiatric Hospital And Islamic Philosophy Lecturer, Department of Psychiatry University of the Western Cape - South Africa University of Cape Town - South Africa E-mail: [email protected] E-mail: [email protected]

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This article is not a comprehensive review of the spread of blood-borne viruses, such as the Harm Reduction Strategy, rather it aims to HIV, hepatitis B, hepatitis C, septicemia, raise the issue of Harm Reduction as a public wound and other infections, drug overdose and health intervention within the contemporary unintentional injury, which may lead to Islamic context. We will first briefly discuss premature drug-related deaths. the concept and impact of the Harm Reduction Harm Reduction strategies to reduce the risks strategy and reflect on the changing attitudes associated with injection drug users may and policies of drug treatment in some Muslim include measures such as: countries. Next we will explore the Fiqh  Reducing the sharing of injecting (Islamic jurisprudence) principles that can be equipment by providing clean, sterile applied to this approach. injecting equipment through needle and syringe programs (NSPs) Harm Reduction strategy:  Giving advice about safe injecting methods There is no universal definition of Harm  Providing drug consumption rooms Reduction strategy nor is there a specific (DCRs), methodology for Harm Reduction. Rather,  Providing support for stopping injecting Harm Reduction is a pragmatic approach behavior which encompasses interventions, programs  Distributing free condoms to reduce the and policies that seek to reduce the health, risk of sexually transmitted diseases social and economic harms of drug use to  Providing substitution opioid drugs, such individuals, communities and societies. as methadone and buprenorphine for Substance Abuse is an issue that we cannot heroin users. ignore, nor should we simply condemn  Providing counseling services, peer individuals who engage in this behavior. The education and outreach Harm Reduction approach accepts that  promoting public policies conducive to substance abuse, whether legal or illicit, is a protecting the health of populations at part of contemporary society. This does not risk1. imply that Harm Reduction attempts to minimize or ignores the real dangers Harm Reduction and Public Health: associated with licit and illicit drug use. Rather, it affirms that drug users themselves "Harm Reduction is an exemplar of a are the primary agents for change. It is an mainstream public health intervention"2. approach that seeks to empower users to share Public health is concerned about protecting the information and to support each other in individuals' and populations' health through engaging in strategies to reduce the harms of surveillance, identification and management of their substance abuse. risks to health3,4. Harm Reduction is thus a way of working Contemporary public health views risk and towards minimizing the harmful effects of health decision-making as a responsibility of drugs and improving the quality of lives of health conscious individuals whilst also substance abusers, while acknowledging that emphasizing the significance of the social cessation of all substance abuse is not environment in producing harm and in shaping necessarily the criterion of success. the capacity of individuals and communities to There is a wide range of harms that are avoid risk2,4,5. Mainstream public health associated with licit and illicit substances use approaches thus recognizes the need to create including legal problems, crime, social ‘enabling environments’ to reduce risk and to deprivation, family conflict, abuse and neglect, change behavior, by strengthening community job loss and poor physical and mental health. actions and creating public policies which In addition, there are particular harms support and promote health6. Europe is one of associated with injecting drugs. These include the regions that is most supportive of Harm

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Reduction policies and practices. Harm opioid users and other illicit drug users was Reduction is a mainstream drug policy and the high17. reduction of drug harms is a feature of the The spread of HIV infection promoted a public health objectives of all the European change in legislation in Spain with new laws Union Member States2. introduced in the 1990's changing the drug- In 2003, the European Council adopted a free approach of treatment to one focused on recommendation to prevent and reduce health- Harm Reduction17. This facilitated an related harms associated with drug expansion of opioid agonist maintenance dependence and it provided a framework for treatment (OAMT) in all regions of Spain. action to assist member states to develop Methadone was available in the public health strategies to reduce and prevent drug-related system free of charge, and was also available harms through the implementation of Harm in private practice17. Reduction services for problem drug users. After the change in legislation it was reported The recommendation also sought to reduce the that there was a large increase in the number number of drug-related deaths and extent of of patients receiving metha-done maintenance health damage, including that related to HIV, treatment (MMT), there was a 125% increase hepatitis B (HBV), hepatitis C (HCV) and in methadone centers, and a significant tuberculosis (TB) 7. increase in the availability of MMT in Harm Reduction strategies such as needle and prisons17. Syringe provision started in 1989, syringe distribution and collection programs but it increased consider-ably during 1995– (NSPs) and substitution therapy are associated 1999. By 2012 Spain had seven supervised with reductions in HIV incidence and drug- injection centers. Retroviral treatment was related morbidity. In several settings Harm widely available free of charge for all HIV- Reduction programs have been combined with positive in Spain since 1996 and its use was voluntary counseling, testing services and associated with a reduction in progression to antiretroviral therapy, thus improving access AIDS and a reduction in AIDS-related to medical care for injection drug users (IDUs) mortality17,18. and resulting in reduction in risky behaviors Since 1999, Spain has been one of the 2,8- 13. countries with the highest levels of OAMT Minimizing the risk of drug-related harms is coverage in the world19. By 2010 OAMT thus a key public health issue, both in coverage had reached 60%20. protecting the health of drug users and in The change to a Harm Reduction approach in protecting the wider community. Spain and the expansion of the OAMT coverage was associated with an increase in Lessons from Spain: retention in treatment programs and a parallel reduction in morbidity and mortality. The In the early 1990's Spain had the largest death rate per 1000 person years reduced from number of AIDS (Acquired Immune 59 in 1992 to 16 in 199917,18. In addition, there Deficiency Syndrome) cases related to the was a steady decline in the number of new injection of illicit drugs in Europe14. There HIV cases related to illicit drug injection and were strict laws which limited access to opioid an improvement in health-related quality of agonist maintenance treatments (OAMT), such life for individuals dependent on illicit as methadone maintenance treatment (MMT), heroin17. in Spain during the 1980s. Treatment programs at that time followed a Harm Reduction in Muslim Countries: drug-free approach that promoted abstinence. Residential facilities were managed by people In their paper, "Emerging HIV Epidemics in who were not health professionals, and Muslim Countries", Todd et al, discussed the retention rates in treatment were low15,16. emerging HIV epidemic, the cultural respo- Consequently the mortality among illicit nses and the changing government policies to

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Harm Reduction strategies in three Muslim rapid increase in IDUs through the 1990's with countries, namely Iran, Malaysia and the associated risky behaviors such as sharing Afghanistan8. needles, resulting in an HIV epidemic among It was reported that Iran had a punitive IDUs. approach towards drug use which started in It was estimated that by the early 2000s 75% the Khomeini regime and continued until the of all HIV cases were detected among IDUs26. mid-1990s. The response to drug use and drug The accelerated HIV epidemic and evide-nce trafficking was prison time and corporal of successful Harm Reduction models in other punishment in all cases. countries led to the Malaysia's Ministry of This was accompanied by an increase in the Health investing in Harm Reduction programs overall use of drugs and a shift from opium to such as condom and needle distribution and heroin use and from smoking to injecting methadone main-tenance8,26,27. In their paper drugs. Todd, et al stated that "Afghanistan is at risk Furthermore, the incarceration of large for a concentrated HIV epidemic due to numbers of drug users, resulted in prison multiple factors, including high rates of risky crowding, and created an ideal environment behaviors, low HIV knowledge, abject poverty for injecting and sharing of needles, which and unemployment, large influxes of former facilitated widespread HIV transmission. The refugees and displaced people into urban areas compulsory abstinence-based programs in the with infrastructure unable to support the rehabilitation camps were associated with high population, and psychological changes related relapse rates and risky behavior. By 2001, it to conflict and displacement resulting in was estimated that there were between greater propensity to engage in drug use"8. 200,000 and 300,000 IDUs in Iran, and the The National Drug Control Strategy for estimated prevalence of HIV among the Afghanistan, approved by President Karzai in incarcerated population was 7% to 20%, 2003, endorsed Harm Reduction inter- between 1999 and 20028,21-24. venetions, including needle and syringe Political and religious leaders in Iran exchange and distribution as a means to recognized that incarceration and abstinence prevent transmission of blood-borne infec- only treatment models were not successful in tions among IDUs8,28. addressing the continued increase in the number of drug users and the rise in the rates The challenge of Harm Reduction of HIV among injection drug users. This led to Strategies in Islamic countries: a review of government policy and subseque- ntly various Harm Reduction strategies were The challenge of Harm Reduction in Muslim introduced, including drop-in centers, countries is that the use of intoxicants and triangular clinics, substitution therapy and extramarital relations are clearly forbidden in outreach based needle and syringe distribution Islam and this has been used as a justification and collection programs8,22,25. by some, not to distribute sterile needles and Malaysia previously had a similar punitive condoms, as it implies an approval for this approach to drug use as Iran, with drug illicit behavior. Others believe that infected traffickers receiving mandatory capital IDUs should be punished and isolated from punishment, imposed rehabilitation, imprison- society and that no investment should be made ment and corporal punishment for convicted towards such individuals29. drug users. This led to wide-spread stigma and In Malaysia there was opposition to Harm avoidance of services by drug users due to fear Reduction programs from religious leaders of legal repercussions. Religious and political and the Islamic community. The Prime leaders also initially opposed Harm Reduction Minister of Malaysia, however, supported strate-gies8,25,26. Harm Reduction as did the Institute for Malaysia's zero tolerance approach to drug use Islamic Understanding of Malaysia, which failed to curb the problem, and there was a declared that Harm Reduction was a public

124 FIMA YEAR BOOK 2014 HARM REDUCTION health issue which did not violate shari’ah drug addiction and its related harms, but the law8,30. Islamic prohibitions and the negative beliefs of Similarly, in Afghanistan, religious leaders religious leaders in particular regions make it who are a powerful advocacy group, believe difficult to do so. that abuse of drugs is completely forbidden, In the following section we would like to and that substitution therapy or use of opioids present our understanding of the concept of in the treatment of addiction is not acceptable, Harm Reduction in light of the Islamic as Islam requires total sobriety8,31. jurisprudence. It is not our purpose to delve Police harassment, community disapproval, into the minutiae of Islamic law, nor is it our lack of community support, limited Harm intention to formulate a formal fatwah (Islamic Reduction activities and delays in govern- legal opinion) which for an Islamic Jurist may ments' recognition and response to intravenous be a relatively straightforward matter. drug use have been associated with continued Rather, our aim is to discuss the broad Islamic risky injecting behavior and increasing HIV jurisprudence principles and textual evidences rates8,11,25,32,33. (Quran and Hadith) that could be applied to this issue for the purpose of enlightening the Islamic Jurisprudence Muslim health practitioner who may be And Harm Reduction: delivering such services, and for the Muslim patient who may be a recipient of Harm The abstinence only approach to drug Reduction interventions. addiction has been unsuccessful in stemming Thus, when examining this issue, the Islamic the spread of HIV among injecting drug users legal framework is our main theoretical point (IDUs) and the punitive approach to drug of departure for the justification of using Harm addiction in Muslim countries was counter- Reduction strategies as a public health productive. On the other hand, Harm intervention. Reduction programs have been found to be We shall therefore start by explaining what we efficacious as a public health intervention, in mean by Maqasid al-Shariah (Objectives of both Western and Muslim countries. However, the Islamic jurisprudence) and how scholars social, cultural and religious beliefs have use it as the basis of rulings. This method is adversely affected the implementation of these known as the Maqasid school of thought. programs in certain regions. Harm Reduction strategies include providing The Maqasid School of Thought: the addict with substitute opioid drugs, clean needles and syringes, drug consumption rooms Sheikh Yusuf al-Qaradawi, and Muslim and condoms. Islam however, prohibits the use scholars like Tariq Ramadan and Hashim of intoxicants and premarital and extramarital Kamali are among the contemporary scholars sex. This has been used as a justification that call for the revival of Ijtihad within the against the implementation of Harm Reduction framework of Maqasid al-Shari’ah. Ijtihad strategies by some, because they view this as refers to the use of reason in the application of approving and facilitating practices which are Islamic law in a contemporary social context. prohibited in Islam. Thus, in certain countries These scholars hold the view that it is not and among certain communities a conflict sufficient for verdicts to be passed purely on exists between the need to implement and the basis of classical legal texts, or apply qiyas support Harm Reduction strategies and the (analogical reasoning) only on the basis of the social, religious and cultural inhibitions to its Quran and Hadith. Instead, they postulate that implementation. one has to also take into account the This also presents the Muslim health Objectives of the Islamic Law. This approach practitioner, practicing in these regions, with a is not inconsistent with the approach of the dilemma. The Muslim health practitioner Four Imams; albeit that they applied it in an needs to respond to the growing problem of intuitive way. Imam al-Ghazali (d. 1111) was

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the first to explicitly identify the Objectives of context in which it is considered and the Law, and to place them into five evaluated. This point can be applied to eating categories34. pork, which is normally prohibited, but in the Maslahah (public welfare) refers to anything absence of other food, it is permitted for the that is either useful (manfa’ah) or warding off sake of preserving one’s life35. something harmful (madarrah), and this can It is in this context that we wish to pose the be achieved by preserving the Objectives of following question: Is it permissible to provide the Law, which consists of the following five addicts with substitute drugs which are principles (usul) in order of rank. potentially addictive and intoxicating?. Is it 1. Preserving religion (din). permissible to teach addicts safer ways to 2. Preserving life (nafs). administer drugs, to provide them with clean 3. Preserving intellect or reason (‘aql). syringes and needles, and to provide condoms 4. Preserving progeny (nasl). to unmarried drug users? These are practices 5. Preserving property or wealth (mal). which are not normally permitted in Islam, but they are used in Harm Reduction strategies to What ensures the preservation of these five minimize the risks that addicts pose to principles (usul) is maslahah; what goes themselves and to the wider society. against their preservation is mafsadah34,35. The Objectives of the Law (Maqasid al- Al-Ghazali went beyond the reading of rulings Shari’ah) are meant to promote good and to of the classical scholars, and expected that the prevent harm. These are universal principles to jurists, in providing new rulings to new be shared by all, and so should be considered situations, should constantly keep in mind the when implementing the rulings derived from higher Objectives of the Law. Al-Ghazali’s texts. This school of Maqasid provides an main question is: “how one can remain faithful ethical framework through which we can to the objectives of scriptural sources when approach the question of Harm Reduction. We implementing legal rulings (al-fiqh) in the should therefore distinguish what is beneficial field of social affairs and interpersonal from what is harmful; and if what is beneficial relations (al-mu’amalat)” 35. This fresh requires that we need to use substances that approach enabled the legal scholars to not only are unlawful (haram), or to promote practices be faithful to the texts, but also to be confident that are not usually condoned in Islam, such as and flexible with the new social contexts in providing unmarried drug users with condoms, which they found themselves. then we should be absolutely clear that in The main philosophical point of departure for approving the use of the unlawful substances the maqasid school of thought is that all and practices, it will be beneficial to the commands and prohibitions contained in the society as a whole. If it benefits the society in revealed text and in the sunnah are intended to general, and it prevents harm to the general promote the good and to benefit the human public then we have a clear case of supporting beings, and to protect them from evil, harm such interventions. and suffering. The objectives of the Law The modern approach to Harm Reduction is should be harmonized with their contexts, concerned with the alleviation of suffering of thus, texts should be examined in the light of the patient, and in this respect it is in public interest. Al-Shatibi introduced a sixth consonance with the Objective of the Law, but objective, dignity/honour (al-‘ird). Al-Shatibi Muslim health practitioners have to also know adopted a strict conservative approach with whether what they are doing will earn the or not. It is within this (ﷻ) respect to belief and worship, but adopted a pleasure of Allah flexible approach when it came to human spirit that we want to provide an Islamic relations (mu’amalat). He pointed out that perspective to the issue of Harm Reduction. although an action may be permissible, The Islamic approach is not purely utilitarian, recommended, objectionable or even unlawful but seeks to find biomedical solutions to in itself, its status can change according to the problems that are logically consistent with the

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Objectives of the law and the Islamic "Muslims are bound by their stipulations metaphysical framework. unless it be a condition which turns a halal into haram or a haram into a halaal"42. Maslahah (public welfare): These ahadith provide justification for jurists to consider what is beneficial, provided that it As mentioned, maslahah is achieved when any does not conflict with the Qur’an and Hadith. of the five Objectives of the Law are fulfilled, This permits Muslim jurists to take advantage and in the interest of maslahah one ruling may of the concessions in the law based on the be harmful in one instance and beneficial in following hadith: another. Kamali states: “The masalih (plural "God loves to see His concessions are of maslahah), can neither be enumerated nor observed, just as He loves to see His strict predicted in advance as they change according laws are obeyed" 36,43. to time and circumstances. Thus a law may be The Hadith quoted above, pertaining to the beneficial at one time and harmful at another; easier of the two alternatives, is significant as and even at one and the same time, it may be the immediate and total abstention of beneficial under certain conditions, but prove intoxicants for a number of individuals is far to be harmful in other circumstances”36. more difficult than a gradual reduction. Scholars have quoted the following Qur’anic As pointed out earlier, some Muslim countries verses in support of maslahah: had a punitive approach to drug addiction and they adopted an abstinence only approach, but ِ "َوَﻣ ﺎ أَ ْر َﺳﻠْﻨَ َﺎك إِﻻ َرْﺣ َﻤﺔً ﻟﻠَْﻌﺎﻟَﻤ َﻴﻦ " "And we have not sent you (O Muhammad) this was not effective, particularly in curbing except as a mercy to the worlds"37. the harms associated with injection of drugs, rather it exacerbated the problem. They later "ﻳ ــ ﺎ أَ ﻳ ـﻬــﺎ اﻟﻨــﺎس ﻗَــﺪ ﺟــﺎءﺗﻜﻢ ﻣﻮِﻋﻈَــﺔ ﻣــﻦ رﺑﻜــﻢ وِﺷــﻔﺎء ﻟﻤــﺎ ِﻓــﻲ اﻟﺼــﺪ ِور   ٌ ْ ُ َْ َ ْ ُ َ َ introduced Harm Reduction strategies, such as ُ ْ َ َ َ ُ ِِ providing addicts with substitute drugs and َوُﻫ ًﺪى َوَرْﺣ َﻤﺔٌ ﻟﻠْ ُﻤْﺆﻣﻨﻴﻦ" "O mankind, there has to come to you clean syringes and needles which proved to be instruction from your Lord and healing for more effective. Here the Fiqh principle of the what is in the breasts and guidance and mercy lesser of the two evils (akhaf al-dararayn) for the believers"38. would apply, that is, it is permissible to provide the unlawful substance to the addict in  order to reduce the harms and risks that the ِ ِ "... ﻳُِﺮ ُﻳﺪ اﻟﻠﻪُ ﺑ ُﻜ ُﻢ اﻟْﻴُ ْﺴَﺮ َوﻻَ ﻳُِﺮ ُﻳﺪ ﺑ ُﻜ ُﻢ اﻟْﻌُ ْﺴَﺮ ..." addict poses to him/herself and to the wider "Allah intends for you ease and does not society. Another fiqh principle that can be 39 applied is "necessity makes what is forbidden intend for you hardship" . 35 Thus, one should not stand in the way of permissible" . With the Harm Reduction assisting humanity towards lifting them out of approach, addicts may not achieve total suffering, nor of obstructing their healing. abstinence, and they may still indulge in drug Qualities of mercy and compassion are divine use, but they do so in a less risky manner, thus qualities that we are encouraged to emulate in minimizing the harms to themselves and others. .(ﷻ) order to attain nearness to Allah Furthermore, by utilizing the Harm Reduction Scholars have also quoted the following approach, there is a greater likelihood that the Ahadith or prophetic sayings in support of 36 addict will be retained in treatment; be more maslahah . willing to engage with health professionals "No harm shall be inflicted or reciprocated in 40 and may be more receptive to Islamic Islam" . psychological therapy which may motivate only chose the easier them towards total abstinence. Islamic (ﷺ) He (the Prophet" of two alternatives, so long as it did not 41 psychotherapy requires separate discussion, amount to a sin" . but suffice it to say that ideally it should go hand in hand with medication.

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As mentioned above, Maslahah pertains to the their families, and lose their wealth, property welfare of the society as a whole, and the and dignity. If Harm Reduction strategies can Harm Reduction approach fulfils this prevent such harms to the individual and to the objective. The research evidence has proven society then they can be made permissible on that it reduces the risks and harms to the the grounds that they are fulfilling the individuals, and consequently to the society. Objectives of Islamic Jurisprudence. The risky behavior of the drug addict, if not curbed, can adversely affect the society A Graduated Approach: through crime, loss of employment, increased healthcare costs, breakdown of family During the early period of Islam, there was a relations, and the spread of diseases. When graduated approach to reducing the use of viewed from this perspective, Harm Reduction alcohol amongst the population, rather than an is a better alternative to total and immediate immediate and absolute prohibition. This is abstention. Needless to say, we cannot rule out evidenced by the extended period over which total abstinence as an option. If it works for an the verses which dealt with alcohol individual, it should be applied. (intoxications) were revealed and the content Shifting the focus to the Objectives of the Law of the verses. allows us to view the matter in a broader The first verse coveys the message that there is ethical perspective. more harm than good in alcohol: ِ ِ ِ ِ ِ ِ This would facilitate a more constructive and "ﻳَ ْﺴـــﺄَﻟُﻮﻧَ َﻚ َﻋ ِـــﻦ َاﻟْﺨ ْﻤ ِـــﺮ َوا َﻟْﻤﻴْﺴ ِـــﺮ ﻗُ ْـــﻞ ﻓ ِﻴﻬ َﻤـــﺎ إﺛْ ٌـــﻢ َﻛﺒ ٌﻴـــﺮ َوَﻣﻨَـــﺎﻓ ُﻊ ﻟ ِﻠﻨـــﺎس harmonious understanding between the وإِﺛﻤﻬﻤ ﺎ أَ ْﻛﺒـﺮ ِﻣﻦ ﻧـﻔِﻌِﻬﻤﺎ "... َ ُْ ُ َ َُ ْ َ -Muslim jurists and medical-scientific comm unity and it would allow Muslim jurists to pass "They ask you about wine and gambling. Say, rulings that are more flexible and realistic to in them is great sin and [yet, some] benefit for people. But their sin is greater than their our contemporary context. 44 All legal rulings that are clear and decisive in benefit" . the Qur’an, are applicable for all times.36 The The next verse regarding alcohol warned the prohibition of alcohol falls under this believers not to attend prayers while category, but when it comes to preservation of intoxicated.  ِ "ﻳَـ ـ ﺎ أَ ﻳ ـَﻬــﺎ اﻟــﺬ َﻳﻦ َآﻣﻨُــﻮاْ ﻻَ َﺗـْﻘَﺮﺑُــﻮاْ اﻟﺼــﻼةَ َوأَ ﻧ ـ ـ ﺘُ ْﻢ ُﺳ َــﻜ َﺎرى َﺣﺘ َــﻰ َﺗـْﻌﻠَُﻤــﻮاْ َﻣــﺎ life, when there is no alternative, concessions َﺗـُﻘﻮﻟُ َﻮن ..." have to be made, as in the case of consuming pork when no other food is available. "O you who have believed, do not approach With respect to alcohol, even if permissible prayer while you are intoxicated so that you drinks are available, some jurists have made know what you are saying45. concessions where alcohol is used for medicinal purposes. Drug-abuse, like wine, The believers would thus have had to reduce leads to intoxication, so it is clearly prohibited the frequency and quantity of their alcohol in Islam. This is applicable to the individual, consumption if they wanted to attend prayers but when the use of these substances has without being intoxicated. implications for cure, and for the potential Finally, only during the Medina period was the preservation of human life, or for benefit to conclusive command prohibiting alcohol the society as a whole, then that may be a revealed: different matter. ِ ِ ِ "ﻳَﺎ أَ ﻳ ـَﻬﺎ اﻟﺬ َﻳﻦ َآﻣﻨُﻮاْ إﻧَﻤﺎ َاﻟْﺨ ْﻤُﺮ َوا َﻟْﻤﻴْﺴ ُـﺮ َواﻷَ َﻧﺼ ُـﺎب َواﻷَْز ُﻻم ِرْﺟ ٌـﺲ ﻣ ْـﻦ Substance abuse, can adversely affect the ِ ِ ِ objectives of Islamic Jurisprudence, which are َﻋ َﻤِﻞ اﻟﺸﻴْﻄَﺎن ﻓَ ْﺎﺟﺘَﻨﺒُﻮﻩُ ﻟََﻌﻠ ُﻜ ْﻢ ُﺗـْﻔﻠ ُﺤ َﻮن " there to protect the individual’s life, religion, "O you who have believed, indeed, intoxicants, progeny, wealth, intellect, and even dignity. gambling, [sacrificing on] stone alters [to Addicts are likely to neglect their religious other than Allah], and divining arrows are but practices, place their lives and those of others defilement from the work of Satan, so avoid at risk, compromise their intellect, destroy them that you may be successful"46 .

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Yusuf bin Mahk narrated that Aisha (RA), the intoxicants. There is no dispute in Islam about mother of the believers said:" If the first thing the prohibition of intoxic-ants such as alcohol to be revealed was: "Do not drink alcohol" the or drugs and no Muslim can be excused from people would have said:"We will never leave abusing them, but here again, we have to alcohol", and if it had been revealed, "Do not consider the intentions of the Islamic law commit fornication" they would have said "we which is to protect the individual and the will never give up fornication"47. society. Addicts are responsible for their The consumption of alcohol was widespread actions and the use of intoxicants is prohibited practice amongst the pre-Islamic Arabs and and sinful in Islam, but we also approach the according to the narration from Aysha (RA) matter from the point of view that addiction is had alcohol been prohibited from the outset, an illness, a disease, thus the addict requires the immediate response from the people would treatment and not punishment. Treatment for have been negative, and they would not have addiction can include Harm Reduction desisted from this practice and it may have strategies, thus from a Shari’ah point of view, prevented them from accepting Islam. The this makes the impermissible, permissible. Quranic verses and the narration of Aisha Furthermore, Islam teaches us compassion (RA) indicate that the methodology adopted in towards the sick, no matter the cause of their the early stages of Islam when dealing with the sickness and it is not the duty of the health use of intoxicants was quite similar to the practitioner to pass moral judgments, but only modern day Harm Reduction approach. Both to care for the patient. approaches did not have abstinence as the primary goal and they allowed individuals to Conclusions: continue using intoxicants for a rather long period of time. This facilitates the long-term First we discussed the principles of the Harm engagement of those individuals during which Reduction and presented evidence of its the focus is on motivating them to change, but efficacy as a public health intervention in non- without compelling or imposing changes on Muslim and Muslim countries. We also them from the start. From an Islamic pointed out that a punitive and abstinence only perspective, the gradual prohibition of alcohol approach which was implemented by some allowed people to initially accept Islam countries was not only unsuccessful, but was without having to change their drinking also associated with greater harms. Despite the behavior and it provided the population time efficacy of Harm Reduction strategies, it had to work on strengthening their belief and faith been a challenge to implement it in certain (inner change) so that they were ready to give regions, due to opposition from religious up alcohol when the laws prohibiting its use leaders. We then discussed the Islamic were revealed (external change). theoretical legal framework and the higher In a similar manner contemporary health objectives of the Shari’ah. We explored how professionals who adopt the Harm Reduc-tion this could be applied to the Harm Reduction approach use various Harm Reduction approach and we demonstrated that Harm strategies, motivational interviewing tech- Reduction is consistent with the philo-sophy niques and other psychological techniques to and the higher objectives of Islamic law. The gradually shift the addict from a state of high Muslim doctors and patients should thus have risk use to using substances in a less risky a clear conscience that they are acting within manner, from using substances frequently to the Islamic legal framework. With regards to less frequent use and from having a chaotic the prescribing of such substances, the lifestyle to having more stability. consumption of it and the promotion of It is essential that ordinary people do not practices which reduces harms to the confuse this temporary permissibility to use individual and to the wider society. In an ideal drugs in a specific context with the usual Muslim society, we envisage that addicts Islamic legalization which prohibits the use of should be managed in a comprehensive

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program that integrates medical, psychological Harm Reduction: evidence, impacts and challenges, Ed by Rhodes, T & Hedrich, D. 2010. and spiritual care, with the aim of motivating 3. Ashton, J. and Seymour, H. (1988), The new public health, and supporting individuals to change their Open University Press, behavior and restoring their moral and Milton Keynes 4. Peterson, A. and Lupton, D. (1996), The new public health: spiritual values so that they may ultimately health and self in the age risk, Sage Publications, Newbury achieve complete abstinence. Such programs Park, CA. would need to be accessible, non-judgmental, 5. Rhodes, T. (2002), ‘The “risk environment”: a framework for understanding and reducing drug-related harm’, offer incen-tives, and provide a degree of International Journal of Drug Policy 13, pp. 85–94. supervision to ensure retention in treat-ment, 6. 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19. World Health Organization/United Nations Office on www.quran.com. (accessed 20 February 2014). Drugs and Crime, Joint United Nations Programme on 38. Glorious Qur’an, Surah Younis, 10:57. HIV/AIDS.WHO, UNODC, UNAIDS Technical guide for Translation: Sahih International. Available at: countries to set targets for universal access to HIV prevention, www.quran.com. (accessed 20 February 2014). treatment and care for injecting drug users. Geneva: WHO, 39. Glorious Qur’an surah Al-Baqara 2:185. UNODC, UNAIDS; 2009. Available from: Translation: Sahih International. available at: http://www.unodc.org /documents/hiv- www.quran.com. (Accessed 20 February 2014). aids/idu_target_setting_guide.pdf. 40. IbnMajah, Sunan, hadith 32 www.islaam.net (accessed 7 20. Barrio G, Bravo MJ, Brugal MT, Díez M, Regidor E, July 2014). Belza MJ et al.; Itinere Working Group. Harm Reduction 41. Sahih al-Bukhari, 4.230: 3560. interventions for drug injectors or heroin users in Spain: 42. Abu Dawud, sunan, hadith 3587. expanding coverage as the storm abates. Addiction 43. Narrated by Imam Ahmad , hadith 5839. 2012;107:1111–22. doi:10.1111/j.1360-0443.2011.03759.x 44. Glorious Qur’an Surah Al-Baqara 2:219. PMID:22151686 Translation: Sahih International. Available at: 21. Nassirimanesh B: Drug use and related harms in Iran since www.quran.com. (accessed 20 February 2014). Islamic revolution. Proceedings of the Fourth National 45. Glorious Qur’an, Surah Al-Nissa’a 4: 43. HarmReduction Conference. Seattle, WA; December 1–4, Translation: Sahih International. Available at: 2002. www.quran.com. (accessed 20 February 2014) 22. Nassirimanesh B, Trace M, Roberts M: The Rise of Harm 46. Glorious Qur’an. Surah Al-Maeda’a 5:90. Reduction in the Islamic Republic of Iran. BriefingPaper Translation: Sahih International. Available at: 8.Surrey: The Beckley Foundation Drug Policy Programme; www.quran.com. (accessed 20 February 2014). 2005. 47. Al Bukhari vol 6; hadith 515. 23. Rowhani-Rahbar A, Tabatabee-Yazdi A, Panahi M: Prevalence of common blood-borne infections amongimprisoned injection drug users in Mashhad, North- East Iran. Arch Iran Med 2004, 7:190–194. 24. Dolan K, Kite B, Black E, et al.: HIV in prison in lowincome and middle-income countries. Lancet Infect Dis 2007, 7:32–41 25. Joint United Nations Programme on HIV/AIDS: 2006 Report on the Global AIDS Epidemic. Geneva: Joint UnitedNations Programme on HIV AIDS; 2006. 26. Huang M, Hussein H: The HIV/AIDS epidemic country paper: Malaysia. AIDS EducPrev2004,16 (Suppl A):100–118. 27. TREAT Asia: Confronting HIV/AIDS in Malaysia: An Interview with Marina Mahathir. 1 August, 2007. http://www.amfar.org/cgi- bin/iowa/asia/news/index.html?record=55. 28. MacDonald DS: Drug use in Afghanistan’s history. In Drugs in Afghanistan: Opium, Outlaws, and ScorpionTales. London: Pluto Press; 2007:137–153. 29. Rusli E: In Malaysia, a battle erupts in AIDS fight. International Herald Tribune.July 4, 2005. 30. Ramly R: Distribution of free condoms a health issue, not Syariah-related—IKIM. http://www.malaysia-today.net/Blog- e/2005/07/distribution-of-free-condoms-health. htm#comments. 31. Khatiz Organization for Rehabilitation: Drugs in Islam: Manual on Drug Abuse Prevention for Religious Leadersand Legal Staff. Kabul: Khatiz Organization for Rehabilitation; 2005. 32. Van Ameijden EJ, van den Hoek AR, Coutinho RA: Injecting risk behavior among drug users in Amsterdam, 1986 to 1992, and its relationship to AIDS prevention programs. Am J Public Health, 1994, 84:275–281. 33. Rhodes T, Mikhailova LA, Sarang A, et al.: Situational factors influencing drug injection, risk reduction, and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. SocSci Med 2003, 57:39–54. 34. Al-Ghazali.al-Mustafa min ‘ilm al-usul(The Essentials of the Islamic Legal Theory). Baghdad. Muthanna.1970. 35. Ramadaan T, Radical Reform: Islamic Ethics and Liberation. Oxford University Press. 2009. 36. Kamali, MH. Principles of Islamic Jurisprudence. Islamic Text Society. Cambridge. 1991. 37. Glorious Quran, Surah al-Anbiya’a: 21:107. Translation: Sahih International. available at:

FIMA YEAR BOOK 2014 131 132 FIMA YEAR BOOK 2014 ISLAMIC PERSPECTIVES ON PROPHYLAXIS AND THERAPY OF ADDICTION

Mahmoud Abu Dannoun*

Abstract:

Addiction, or substance dependence, is a global dilemma affecting societies in varying degrees with grave consequences on health, psychosocial and economic aspects. Worldwide programs to prevent or to manage addiction have been, to a large extent, disappointing with no light at the end of the tunnel. In this paper, the salient features of substance abuse, their main underlying causes, as well as the social, medical and governmental responses and attitudes of prophylaxis and management of addiction will be reviewed. The Islamic approach to alcohol, the earliest addictive substance, will be illustrated, as an example of a historical effective success.

Keywords: Addiction, alcohol abuse, Islamic Shari’ah.

Introduction:

created humans in the best of any kind of imbalance, will induce (ﷻ) Allah moulds with perfection of structure and functional derangements of thinking, function of all organs, and delicate balance emotion, memory, concentration, percep- 2 between its various components including tion or hallucination . microconstituents. This perfection includes Proper and balanced nutrition, and vascular brain functions with various intercellular nourishment of the brain, are major factors 3 neurotransmitters1 and other factors. The that maintain normal brain function . Any brain performs various functions utilizing unhealthy addition, such as a medication or an intricate and extensive number of cells a psychotropic substance causes significant and factors, with extremely delicate derangements and deleterious influences 4 systems, the breakdown of any of them, by on brain functions .

*Dr. Mahmoud Abu Dannoun Consultant Psychiatrist Ex-Director of the National Center for Mental Health Amman-Jordan E-mail:[email protected]

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Substance addiction is an outcome of the  CNS depressants, e.g. alcohol, opiates, effects of a certain drug as the body sedatives and hypnotics. systems have to adjust to the substance by  CNS stimulants, e.g. amphetamines. incorporating it into “normal” body  Hallucinogens, e.g. Lysergic acid functioning5. The opioids, as an example, diethylamide (LSD). produce their effects by binding to Addictive substances are also divided into different types of receptors in the central natural substances (alcohol, opiates, nervous system (CNS). cannabis), and synthetic (sedatives and Endogenous opioid peptides (i.e. analgesic medications). enkephalins, endorphins and others) appear to function as natural ligands for opioid An epidemiological overview: receptors. There is evidence that these natural opioid peptides are involved in the Since the dawn of history, man embarked production of euphoria, analgesia and other on consumption of addictive substances, effects of the opioids6. This state creates starting with alcohol. Whenever a new the conditions of tolerance and withdrawal. addictive substance is discovered and used, Tolerance is the process by which the body man diligently propagated it, included it in continually adapts to the substance and industries, marketing and business requires increasingly larger amounts to transactions. Man also surrounded such achieve the original affects. Withdrawal substances with rituals, rites and traditions. refers to physical and psychological In contemporary times, humanity is symptoms experienced upon reducing or witnessing the worst and the largest discontinuing the substance. numbers of addicted individuals and These symptoms generally include, but addictive substances. are not limited to anxiety, irritability, Media, advertisement, feasibility of travel intensive craving for the substance, nausea, and transport and mounting psychological hallucinations, headaches, cold sweats and pressures provide major incentives to tremors. Once physical dependence has addiction. Some individuals with been established, a strong desire emerges psychological and psychiatric disturbances to avoid the negative affective states usually resort to addictive substances in associated with withdrawal. Withdrawal attempts to rid themselves of their symptoms are usually severe and symptoms, such as anxiety9-11, or to avoid intolerable, and manifest the opposite consulting a psychiatrist in order to avoid feelings of the original effects of the stigmatization. addictive drug6. There is ongoing scientific Medical practitioners may also play a debate on biological mechanisms of negative role by over-prescribing of addiction. Genetics, family history, mental sedatives, hypnotics, stimulants and and personality disorders, environmental analgesics. The most significant factor, factors and social interactions are among however, is the abundant availability, as various theories of addiction7, which are well as the accessibility of some major continuously evolving. Several brain addictive substances. Alcohol is one major regions are involved in the biological example. Many societies look upon mechanisms of addiction. Mentally drinking alcoholic beverages as normal effective substances are subdivided into and socially acceptable behavior. Even in three main categories8: many Muslim countries, alcohol factories, sale of these beverages in restaurants and

134 FIMA YEAR BOOK 2014 ISLAMIC PERSPECTIVES cafes is widespread, with nominal and who sold drugs at their school. Asked what ineffective restrictions. Only very few drugs students sold on school grounds, countries have legislations to ban alcohol. 91% said marijuana, 24% said prescription Various types of tobacco smoking are drugs, 9% said cocaine and 7% said alarmingly widespread, even among ecstasy. The survey also revealed that 52% younger age groups and women. of high school students said that there was Qat in Yemen and some other countries, is a place on school grounds or near school widely available, and its use is established where students can go to use drugs, drink as an acceptable and common social habit. or smoke during the school day, and 36% It is disturbing to note the widespread use said it was easy for students to use drugs, of these freely available and accessible drink or smoke during the school day addictive materials to younger age groups, without getting caught. 75% of 12-to-17- even teenagers. This is attributable to the year-olds said that seeing pictures of teens influence of bad company (peer pressure), partying with alcohol or marijuana on and the youngsters' desire of experimenta- Facebook, MySpace or another social tion. networking site encouraged other teens to want to party like that. 45% of teens have In USA, a survey was conducted from seen pictures on social networking sites of Casa, Columbia, by the National Survey on other teens getting drunk, passing out or American Attitudes on Substance Abuse using drugs, and 47% of teens who have XVII: Teens12, published in August 2012. seen these pictures said that it seemed like This survey aimed to identify the the teens in the pictures were having a situations, individual and family good time. characteristics, and social factors that are There is no doubt that legislations and law associated with teen drug abuse and enforcement are instrumental in curbing addiction. Its primary purpose was to track the spread of the addiction phenomenon, attitudes of teens and those, like parents, provided the drugs are legally prohibited who have the greatest influence on whether and their availability and accessibility are teens will smoke, drink, get drunk, use curtailed. Otherwise law enforcement will illegal drugs, or abuse prescription drugs. have limited impact. CASA Columbia’s teen surveys have consistently found that the family is The Islamic Response and Guidance in fundamental to keeping children away Elimination of Addiction: from tobacco, alcohol and illegal drugs. Teen drug abuse plays a major role in In the early days of Islam, addiction was addiction. People who do not use tobacco, rampant in Makkah society and the rest of alcohol or illegal drugs or misuse Arabian Peninsula. At that time the prescription drugs before age 21 are addictive substance was alcohol, which virtually certain never to do so. This report was abundantly available in view of easy outlines several teen drug abuse facts and access, and abundance of natural substrates teen drug abuse statistics. from food materials such as dates, grapes, The survey found that 86% of American barley and others. These easily available high school students said that some and inexpensive materials provided for classmates drink, use drugs and smoke deep rooted traditions of consumption, during the school day. Additionally, 44% enjoyment, rituals and lack of concern to of high school students knew a student the harms alcohol inflicts on the body and

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mind. With the advent of Islam, alcohol This was followed by the Qur’anic consumption was a subject matter of the response to the posed notions of the Islamic guidance for protection and apparently positive or useful benefits of remedy of its various evils, taking in alcohol. These are sedation, relief of consideration the long term rigorous tension, improving sleep, stress traditional endorsement of its use in amelioration, appetite improvement, in society. Alcohol was dealt with as a addition to other materialistic/financial prominent and rampant example of other benefits such as securing jobs in alcohol addictive substances that appeared in preparation and market-ing….etc. The succession in future times. Islamic Glorious Qur’an responds to all of that in a teachings came in a gradual manner with clear and expressive manner: guidance exposing its various vicious side ِ ِ ِ ِ ِ effects in various dimensions. The initial "ﻳَ ْﺴﺄَﻟُﻮﻧَ َﻚ َﻋ ِﻦ ا ﻟْ َﺨ ْﻤِﺮ َوا ﻟْ َﻤْﻴﺴِﺮ ﻗُ ْﻞ ﻓ ِﻴﻬَﻤﺎ إِﺛْ ٌﻢ َﻛﺒ ٌﻴﺮ َوَﻣﻨَﺎﻓ ُﻊ ﻟ ﻠ ﻨ ﺎ ِس step of Islamic guidance was directed وإِﺛﻤﻬﻤﺎ أَﻛﺒـﺮ ِﻣﻦ ﻧـﻔِﻌِﻬﻤﺎ ...." ...." َ ُْ ُ َ َُْ ْ َ towards cognitive understanding of its harmful effects in the face of general and They ask you concerning wine and widespread conviction that alcohol is both gambling. Say: In them is great sin, and some benefits for mankind, but their sin is nutritious, healthy and joyous. The first 14 Qur’anic verse that was revealed on that greater than the benefit…..” . topic classified food materials into those that fall under good subsistence (rizk This Qur’anic verse does not negate the hasan), vs (rizk that is not hasan) to which benefits of alcohol, but it places that in the alcohol belongs. Alcohol was classified as overall balance of minimal positive vs. an intoxicating material. major negative aspects. It asserts that the destructive effects surpass any benefit and confirms its classification as not to be a "وِﻣﻦ ﺛﻤﺮ ِات ا ﻟ ﻨ ِﺨ ِﻴﻞ واﻷَﻋﻨ ِﺎب ﺗـﺘ ِﺨﺬون ِﻣﻨﻪ ﺳ َﻜﺮا وِرزﻗًﺎ ﺣﺴﻨﺎ إِ ن .good subsistence َ َََ َ َْ َ ُ َ ُْ َ ً َ ْ َ ًَ ِ ِ ٍ ِ This balancing is valid at all times, in view ﻓﻲ ذَﻟ َﻚ ﻵﻳَﺔً ﻟَﻘْﻮم َﻳـْﻌﻘﻠُ َﻮن " " “And from the fruits of the date-palm and of proven harmful effects caused by the vine you get out (intoxicating) drink alcohol on the physical, psychological, and good food: behold, in this also is a mental and socio-economic status of the sign for those who are wise addicted and their families.Alcohol abuse (intellectuals)”13. is also responsible for mental breakdown, From this verse, it became clear that the increased crime rates, including rape, and basic effect of alcohol is its intoxicating incest, as well as increased road accidents effect. That was the underlying basis on commonly resulting in fatalities. Human which Muslim jurists established the ruling experience reveals major preponderance of of alcohol prohibition (tahrim). On that economic losses that far exceed any gains basis, the same rulings were applied to any from manufacturing and marketing of this other substance that causes intoxication, substance. disturbance of cognition and conscious- Later on, with the gradual Qur’anic ness. Such ruling is applied to all these approach of eliminating alcohol, and substances based on their effects, with no parallel to building up of the new Muslim regards to their chemical structure, or other personality with new Islamic value system laboratory or scientific means of in faith, commitment and behavior, the characterization. glorious Qur’an provided the next step:

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Eschew (avoid) such (abomination) that "ﻳﺎ أَﻳـﻬﺎ اﻟِﺬﻳﻦ آﻣﻨﻮا ﻻ ﺗـﻘﺮﺑﻮا اﻟﺼﻼة وأَﻧﺘﻢ ﺳﻜﺎرى ﺣﺘﻰ ﺗـﻌﻠَﻤﻮا  َ 17َ َ َُ ْ َ ََُْ ْ َ َ ُ ْ ُ َ َ َ َ َ ْ ُ ْ you may prosper” . َﻣﺎ َﺗـُﻘﻮﻟُ َﻮن ...." “You who believe! Approach not prayers "إِﻧﻤﺎ ﻳِﺮﻳﺪ اﻟﺸﻴﻄﺎن أَن ﻳ ِﻮﻗﻊ ﺑـﻴـﻨﻜﻢ اﻟْﻌﺪاوة واﻟْﺒـﻐﻀﺎء ِﻓ ﻲ ا ﻟْ ﺨﻤِﺮ َ ُ ُ ْ َ ُ ُ َ ََْ ُ ُ َ َ َ َ َ َ ْ َ َ ْ with a mind befogged (intoxicated) so that ِ  ِ ِ ِ َوا ﻟْ َﻤْﻴﺴِﺮ َوﻳَ ُﺼﺪُﻛ ْﻢ َﻋﻦ ذْﻛِﺮ اﻟﻠﻪ َوَﻋ ِﻦ اﻟﺼﻼة َﻓـَﻬ ْﻞ أَﻧﺘُﻢ ﻣ َﻨﺘـُﻬ َﻮن " you can understand (comprehend) all that you say (in prayer)…..” 15 “Satan’s plan is (but) to excite enmity and This new step represented a new stage with hatred between you, with intoxicants significant prophylactic and therapeutic (Khamr, alcohol) and gambling, and dimensions. It is known that alcohol half- hinder you from the remembrance of Allah, and from prayer: Will you not then life in the blood is approximately six 18 hours. For the faithful who wants to abstain?” . perform his regular timed daily prayers, Choosing the word (avoid) has more most of which are approximately 2 to 4 significance than other expressions such hours apart from noon to evening, has not as: (do not drink it), or (stay away from it). to consume alcohol except following Avoidance includes the meanings of Isha’a prayer (late evening) or following avoiding to manufacture, sell, buy, the fajr (dawn) prayer. This means consume, or socialize with individuals elimination of drinking episodes, which while engaged in drinking, or even looking will interrupt the addiction requirements of at the substance. around 4 drinks per day as a minimum These Qur’anic verses associated alcohol down to only two, which may ease the, (Khamr) along with other major vices and transition to abstinence with minimal deviations, such as gambling, stone withdrawal sequelae. In doing so, it casting, hatred, enmity and social becomes easier on individuals to free disruptions, as instigations from Satan. themselves from withdrawal consequences, This concept was deeply established in the as opposed to abrupt cessation which may conscious, mind and conduct of Muslim result in grave consequences, including the individuals and societies ever since. An possibility of lethal delirium tremens 16. “Internal” barrier became deep-rooted at This stage of gradual discontinuation came all times. in parallel with the progress in nurturing This major turn of events was so decisive. and building of the sound Muslim Alcohol was absolutely eliminated from personality with genuine faith (iman), the Muslim society. The faithful sound behavior (suluk), and proper outlook committed early Muslims responded to the paradigm of human life on this earth obediently. Whatever alcoholic beverages and the hereafter. were stored in their homes were disposed The fourth, and final stage came as a of. Whatever jars and various containers distinct and decisive commandment, with that used to be filled with alcohol were the Qur’anic revelation: destroyed. They spilled alcohol in the  roadsides of Medina, while chantingِ ِ ِ "ﻳَﺎ أَﻳـَﻬﺎ اﻟﺬ َﻳﻦ َآﻣﻨُﻮاْ إﻧَﻤﺎ َاﻟْﺨ ْﻤُﺮ َوا ﻟْ َﻤْﻴﺴُﺮ َواﻷَ َﻧﺼ ُﺎب َواﻷَْزﻻمُ prayers and expressions of obedience and 19 ِرﺟﺲ ﻣﻦ ﻋﻤِﻞ اﻟﺸﻴﻄَ ِﺎن ﻓﺎﺟﺘﻨِﺒﻮﻩ ﻟَﻌﻠ ُﻜﻢ ﺗـﻔِﻠﺤﻮن " .  ٌ ْ faith ْ َ َ ْ َ َْ ُ ُ َ ْ ُْ ُ َ “You who believe! intoxicants (Khamr- Islam follows a similar approach towards alcohol) and gambling, dedication of any other addictive substance that impairs stones, and divination by arrows, are brain function, by elimination of their abominations of Satan’s handwork: existence in society, in addition to building

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internal human barrier towards their use. purposes (maqasid) is prohibited (haram) This undertaking contrasts with what we by analogy (qiyas)24. witness nowadays where inefficient and Islam establishes the faith concept as the ineffective policies are based on main prophylaxis against addiction. Faith “limitations” of the substance in certain and religious commitment stand as places and age groups, which does not guardians that links alcohol and other effectively combat the addiction problem. intoxicants to evil behavior, low morality Islam established a road map to deal with and poor manners. addictive substances along the following In a hadith narrated by Uthman ibn A'ffan :said (ﷺ) lines: (RA), the Prophet 1.Alcohol was considered a standard "اا ا  أم ا، أ ن ر    ،ّ  اأة  ر إ رcriterion to judge possible addictive   : إ ك دة،   رsubstances as either permitted (halal) ،   د  أ دو ، ا إ اأة .(prohibited (harm) or abhorred (makruh و ھ م وط ، : إ وﷲ The underlying reason upon which a .2 د دة و د   أو ب  ھه ruling is adopted toward any possible ا ً أو  ھا ام. ل:   ھا addictive substance, is its actual intoxicant ا ،ً ل: زو  :م  و  وinfluence. Any substance that imparts  ا ،ا ا ، وﷲ   ان ,similar effects on man’s mental processes cognition consciousness and ability to وب ا، إ  أن ج أھ ". perform his roles in this life, will acquire “Avoid Khamr (alcohol) because it is the the same ruling as that of alcohol. The mother of all wickedness. In past legal maxims applied in this context are: generations there was a devout man who “Any intoxicant is khamr (alcohol) and any 20. was approached by a seducer woman who khamr is haram (prohibited)" sent her maid to summon him for “Any substance that causes intoxication if testimony. When he responded and entered taken in large quantities is prohibited the woman’s home, the maid led him in (haram) even if consumed in small 21 and locked every door behind him until he quantities" . ended up to a glowing woman, with a boy Intoxication, being a significant cause of and an alcohol container. The woman harm, whether known, unknown, or explained she did not summon him for expected, falls under the broader legal testimony, and instead she gave him the maxim "No harm and no infliction of 22 choice of committing adultery with her, or harm” . to drink the wine, or to kill the boy. He 3.The concept of prohibition (tahrim) in choose drinking wine, cup after cup, and Islam is linked to faith and its ended up in committing adultery with her manifestations, such as the prayers, zakat and killing the boy. Avoid khamr …etc. The faith authority or infleunce is a (alcohol), for faith and drinking alcohol strong basis for the faithful (believer) to will never be combined unless one of them avoid addictive substances. 25 expels the other . Islam established maqasid al-Shari’ah (the Islam imposes a worldly punishment of purposes of Islamic Law). These are: whipping for drinking alcohol. The protection of religion, life, mind, progeny ﷺ 23 and wealth . Any intoxicant substance Prophet ( ) said: which may negatively impact any of these “Flog (punish by whipping) any person who drinks Khamr (alcohol)” 26.

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warned alcohol societies, with negative and condemning (ﷺ) The Prophet drinkers with punishment in the Hereafter, attitudes towards any individual who in the hadith: commits this rejected aberration.   " In the USA, there was a determined trialب ا    ة أر  وإن ت to legally ban alcohol and to impose د ار، ن ب ب ﷲ ..."، و  abstention throughout the country from ا:"وإن د ن  ً ﷲ أن   رد to 1933. Unfortunately this attempt 1919 ال م ا"، و  ال: و رد 30-31 . ended up in disastrous failure ال، ل: "رة أھ ار". “Whoever drinks khamr (alcohol), his Most countries of the world, have “given prayers for 40 nights will not be accepted. up” combating alcohol use and its If he dies, he will enter hell fire, and if he consequences. Alcohol consumption is repents, Allah will accept his legalized, with practically nominal, largely repentance…27. fruitless restrictions, such as avoiding The Hadith ends by:”And if he goes back alcohol while driving, prohibiting the sale to drinking, Allah will make him drink of alcoholic drinks to minors (below from “radghat al khabal” on the day of certain ages)…etc. judgment” 27. Lack of commitment by the governments was asked about and individuals, alcohol industry influence (ﷺ) When the prophet “radghat al-khabal”, the Prophet said: “It and advertisement are among the main is the extract of the people of hell fire”. factors of failure to combat alcohol dependence in the communities. This made it one of his (ﷺ) The Prophet resulted in overwhelming disastrous directives (wassiyyah) to some of his consequences on individuals, societies, companions: national health, socioeconomic and other “Do not make any partners to Allah, even parameters. if you were torn to pieces or burnt, and do 28 It is an irony to note the liberalization and not drink khamr” . legalization of alcohol, while trying to ﷺ In another hadith, the Prophet ( ) combat other addicting substances which responded to an inquiry about whether pose less deleterious consequences than khamr could be used as medicine: “ It is a 29 alcoholic beverages. malady (disease) and not a remedy” . The following may be illustrative of the differences between the Islamic and non- Where Islamic Approach Succeeded and Islamic styles of approach: Others Failed? ( 1 ) Islamic approach prevents the occurrence of addiction by stressing the The success of Islam in eradicating the individual internal motives of faith, and alcohol habit and substance addiction in outlook to a righteous life. Islam aims at general, is manifested by the fact that establishing a sound lifestyle of humans Muslim societies have been largely free and their societies on this earth, to rid them from addiction throughout history. Even at from any behavior, habit or substance that times when Islamic ideology lost its curtail their roles in this life, including any leadership role due to political and material that impairs cognition and socioeconomic deterioration in many hampers humans from performing their countries, most Muslim societies continued sound and constructive roles towards to be relatively safe and immune to the themselves, their societies and humankind various disasters of addiction. Only limited in general. It is noteworthy that, in spite of instances of addiction remain in Muslim

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various current political and socioecono- Building the internal value system, based mic influences, Muslim societies, from on faith, purity, injunction of what is different regions of the world that vary in beneficial and fair, rejecting of all evil, their racial / ethnic backgrounds and have harmful and reprehensible actions, and in all (ﷻ) different cultures, are the least affected by seeking the pleasure of Allah the problem of addiction, among all world endeavors…..are all instrumental in nations. When African American (black nurturing human beings’ immunity to all American) prisoners with various addiction kinds of ill-behaviors. problems embrace Islam there was a remarkable change in their behaviors. The Muslim society, composed of such Many of them turned away from drug individuals, strongly rejects substance addiction and crime, and were resurrected, addiction behaviors. Any individual who as James Baldwin wrote in his book: The has any dealings with addictive substances Fire Next Time32 about his fellow black is looked upon as “anti-society culture” Americans: that is an outcast. This overwhelming “And now, suddenly people who have social factor stands strongly and never before been able to hear this effectively as a guard. And when this is message of Islam, hear it and believe it, combined with the non-availability/ and are changed …. (Islam) has been able accessibility, all bases of success are to do what generations of welfare workers guaranteed. and committees, resolutions and reports This approach is contrasted to and housing projects and playgrounds have contemporary dealings by various failed to do: to heal and redeem drunkards authorities which are based on and junkies, to convert people who have governmental laws and regulations with come out of prisons and keep them out, to various limitations and exceptions in the make them chaste, and women virtuous, context of free availability of substances, and to invest both male and female with such as alcohol, tobacco, and in some pride and serenity that hang about them countries, other addiction substances as like unfailing light” 32. well. One of the main points in Islamic dealing The example of alcohol is more manifest. with substance abuse is the issue of easy With its free availability and accessibility, availability of the substance, within reach current regulations in most countries of people, which represents a formidable around the world, prohibit its sale below obstacle in all efforts to combat the certain age limits, e.g. 18 years of age. problem. Such youngsters could easily obtain it from In this regards, one of the principal pillars their peers who are above that age limit or of the Islamic approach to eradicate from their own homes, and pursue the substance addiction was to prevent the addiction path from that early age. very existence of the substance in society. Taking alcohol as an example, its Moreover, the contemporary ban on most manufacturing, marketing, selling, buying, addictive substances, excluding alcohol, is and any dealings was prohibited and a confusing and inefficient approach that 33 condemned, with no exception. contradicts logic and medical basic facts , The Islamic approach is based on both the in view of the significant and widespread “internal” value-based motives, and the complications of alcohol in all strata of “external” punishment based ones. societies.

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Substance abuse: approaches, is a sign of superficiality A disease or behavioral breakdown? and lack of effective programs.  Liberalization of patients commitment Whether addiction as an illness, or a to anti-addiction programs will behavioral breakdown has significant continue to boost drug trafficking and implications in legal, ethical and social profiteering contexts, but should not have any influence Unlike this approach, the Islamic outlook on medical care and rehabilitation. does not neglect the medical, psychosocial Contemporary western-oriented appro- and rehabilitation needs of drug addicts. It, aches towards substance addiction is however, considers substance abuse- based, to a large extent, on the concept that addiction as a devious behavior and it is a disease that needs therapy. ethical-religious disobedience which is Significant concessions are practiced to self-inflicted by the individuals. The drug addicts including free provision of addictive behavior is a result of their own opiate derivatives, clean syringes to inject decisions and their insistence to pursue it drugs, condoms to minimize HIV/AIDS with disregard to advice, education, and other infections. All such measures are religious and social norms. These provided to the addicts if they demand considerations render them liable for them. They could abandon anti-addiction punitive measures in this life and in the programs as they deem suitable to them, Hereafter. and revert back to the substances of their Recognized Therapeutic measures should choice. Added to the other drawback of be mandatory with the aim at complete availability of alcohol, tobacco and, in abstention. Specialized centers, with some countries, cannabis, is the lack of qualified and dedicated personnel should real effective programs to rehabilitate take proper care to guarantee that therapy, addicts and eradicate addiction. which may be gradual and long-term, All that represents the superficiality and should end up by complete reform. ineffectiveness of this approach, as Punitive measures to deviators and those evidenced by what is manifest in the world who revert back to addiction should be scene. pursued in a dedicated, persistent and The following considerations are controlled manner. illustrative of the implications of looking at Proper punitive measures should be legally the addiction dilemma as merely an applied against traffickers, and distributors. “illness”: In conclusion, the Islamic approach to the  Tolerance and permissiveness towards substance abuse-addiction problem has addicts to pursue and persist in unique features in aspects of prophylaxis obtaining addiction substances to and management. This is manifested by the maintain satisfaction, without fearing recorded historical success of this significant punitive measures. approach in its dealing with alcohol abuse  Minimization of society and state in the early Medina society. This approach responses towards addiction. Addicts is based on both “internal” faith-based are looked upon as victims who are not values, as well as “external” measures, fully responsible for their acts. including health care systems and society-  Lack of legally-binding anti-addiction state punitive-based parameters. The programs, with steady and determined Islamic approach has resulted in the achievement of a society with record

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freedom from addiction and its 31. Albar MA. Contemporary Topics in Islamic Medicine, 1995, Saudi Publishing and Distribution ramifications in Muslim communities, House, Jeddah, Saudi Arabia, pp 13-19. despite many current adverse circumsta- 32: Baldwin J., The Fire Next Time. London: Penguin nces. Books 1962: 39-68. 33. Reference # 10, and Baye I Chodse, Evolution of International drug control, 1999, P 383. References:

1.Kaplan and Sadicks, Synopsies of psychiatry, Williams and Wilkens, 2002-Lippncott, pp 93-94. 2. Ibid, pp 96-97.. 3. Bevridge KC, Food reward- brain substates of wanting and liking, 1996. 4. Ameri A, The effect of Cannanioids on the brain. Progress in Neurology 1999. 5. Torres G, Horowitz TM (1999). “Drugs of abuse and brain gene expression”. Psychosom Med 61 (5): 630-50. PMID 10511013 (www.ncbi.nlm.nih.gov/pubmed/10511013). 6. Reference # 1, pp 1286. 7.http://en.wikipedia.org/wiki/Addiction 8.Diagnostic criteria DSMSTO And: Goodman and Gliman: The Pharmacological Basis of pharmacology, 1992. 9. WHO- Neuroscience psychoactive substance use and dependence. 10. Ali Kamal (Arabic): Al-Idman, Bab al-Abath bil Aql, 1994, Al-Mussasah Al-Arabiyyah Li Al-Dirasat wal- Nashr, pp 115. 11. Hassan Naser Bokely (Arabic): Al-Idman, 1988, Dar al-Maamoon Li al-Turath. P16. 12. National Survey of American Attitudes on Substance Abuse XVI: Teens and Parents. http://www.casacolumbia.org/addiction- research/reports/national-survey-american-attitudes- substance-abuse-teens-2012 13. Glorious Qur’an, Al-Nahl 16:67. 14. Glorious Qur’an, Al-Baqarah 2: 219. 15: Glorious Qur’an: Al-Nisa’a: 4:43 16. Reference #10, p241. 17. The Glorious Qur’an, Al Maedah 5:90. 18. The Glorious Qur’an, Al Maedah 5:91. 19. Sahih Muslim, Narrated by Anas, No. 3669. 20: Sahih Al-Bukhari, Kitab al-Wadu, N. 239. 21: Sunan Ibn Majah, No. 3392. 22: Sunan Ibn Majah, vol. 2, 1953, No. 784 23. Al-Shatibi (d. 790/1388), al-Muwafaqat fi ash- Shariah, 1975, vol. 2: 8-11, P. 10. 24. Abdul Wahab Khallaf, Usul Al-Fiqh (Arabic), Dar al- Kutub al-Ilmiyyah-Beirut-Lebanon, 2006. PP40. 25. Sunan al Nassae, 8/315, Sahih Sunan Al-Nasae 3/46, no. 5236. 26: Abu Dawod, Kitab al Hudud, No. 4485. 27: Sunan Ibn Majah, Kitab al-Ashribah, No. 3377. 28. Ibid, Hadith narrated by Abi al-Dardaa, Bab al-Sabr ala al Bala’a, No. 4034. 29. Abu Dawod, Al-Tib. No. 3873, Tirmidi, No. 2147. 30. Miles S., learning about alcohol. Washington DC: American Association for Health, Physical Education and Recreation- A national affiliate of the National Education Association. 1974:12.

142 FIMA YEAR BOOK 2014 ISLAMIC RELIGIOUS INPUT IN THE TREATMENT AND REHABILITATION OF DRUG ADDICTION: EXPERIENCES FROM MALAYSIA

Mahmood Nazar Mohamed* and Sabitha Marican**

Abstract:

Drug addiction is a chronic relapsing disease which can be treated. Treatment however is dependent on many variables, the drug of choice, degree of drug use, individual and personality characteristics such as religiosity, community and environmental factors, familial and social support, employment and many more. Many countries employ the supply and demand reduction strategies, some of which are successful, and some are not. The advent of HIV-AIDS in the 80’s forced treatment specialists to look at other alternatives. Harm reduction offers a pragmatic approach, however, it remains controversial. Drug Substitution Therapies for people using opioids have proven to be more effective with other non medical approaches such as contingency management, behavioral interventions and spiritual/religious enhancement. This paper reports the experience of Malaysia in providing Islamic religious input to drug treatment and rehabilitation programs in government and non government facilities.

Keywords: Drugs, addiction, treatment, rehabilitation, drug policy, Islam, harm reduction, spiritual therapy, religion.

Introduction:

Treating a chronic relapsing disease is However, all of these illnesses, especially not a simple undertaking. It involves the drug addiction, can be treated with a illness itself, behavioural and psycho- combination of treatment modalities and logical components, belief system and approaches1,3. There are basic principles spirituality1. to drug treatment that healthcare Many treatment providers reported providers must understand in order to significant relapse rates among those provide adequate treatment and rehabilit- undergoing treatment, especially for ation. addiction to psychoactive substances. One important fact is that no single Illnesses like asthma and hypertension treatment is appropriate for all have 50-70% relapse rate, type I Diabetes individuals. Effective treatment attends has 30-50% relapse rate (for example, to multiple needs of the individual, not lack of diabetes control due to lack of just his or her drug use. In addition, compliance with lifestyle modification treatment and service plans must be and proper therapy, leads to relapse of continuously assessed to ensure that the symptoms), whereas drug addiction has a particular plan meets the person’s relapse rate of 40-60%2. changing needs1.

* Mahmood Nazar Mohamed ** Sabitha Marican Professor of Psychology Associate Professor, Public and Social Cyberjaya University College of Medical Policy Sciences (CUCMS) Faculty of Economics and Administration Cyberjaya, Malaysia. University Malaya, Malaysia E-mail: [email protected] E-mail: [email protected]

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When a client is ready for treatment, treatments were given, albeit they were remaining in treatment for an adequate still limited6,7. At that time supply and period of time is critical for treatment demand reduction approach was adopted effectiveness. Many believe that medical as the national anti-drugs strategy. In the detoxification can help, however it is past decade, on the average, the only the first stage of addiction treatment Malaysian authorities arrested around and by itself does little to change long thirty two thousand drug addicts in the term drug use2. Counseling and behavior- country (about 55% - 60% were relapse al therapies are critical components of cases) each year. This number has effective treatment for addiction2,4. significantly decreased in these past Medication is an important element of years to about 22,811 cases in 2006, treatment for many patients. Treatment 14,489 in 2007, 11,194 in 2011, and should provide assessment for HIV, TB 9,015 in 2012. Further reductions in the and other infectious diseases5. It is also numbers of addicts identified every year important to know that recovery can be a demonstrate that the present strategies lifelong process with relapses and require undertaken by the Malaysian government multiple treatments1. has taken effect 6,8.

Drug Addiction in Malaysia: Supply reduction:

The drug problem in Malaysia has been Usually, the first approach to drug recognized since the pre-independence control is supply reduction. Simply put, days. Most of the drug addicts used the supply of the psychoactive substances opiates, specifically opium that was to the affected population must be brought in from China and the Golden intercepted and terminated. Supply Triangle area (Thailand, Myanmar and reduction focuses on law enforcement PR Laos). In the 1960’s, influences from activities to suppress or disrupt produc- the ‘’ Western culture reached the tion and distribution of drugs. Legal shores of Malaysia with marijuana and measures are used by all countries to other psychedelic drugs primarily used control or eliminate the availability of by the American servicemen. The 70’s illicit drugs. Some supply reduction saw the introduction of heroin and strategies employed are6,9: morphine into the country, and drug (i) Source-country control such as crop addiction reached an epidemic destruction and replacement, proportion6. In 1983, drugs and drug (ii) Interdiction of supply into end addiction was declared a national countries, security problem. (iii) Police enforcement of supply and A national drug treatment program was possession, and set up to provide mandatory treatment to (iv) Regulatory policies to restrict drug dependents. Many Compulsory prescription of opioids. Centers for Drug Users (CCDUs) were Efforts on reducing the supply of drugs set up to provide treatment, which was into Malaysia were initiated long before largely based on psychosocial and the independence of the country. These military model, where little focus was efforts were directed to the control of the given to addiction treatment and import, sales and use of opium. Several treatment of other ailments5. It was not laws were enacted with punitive until the 1990’s that drug addiction was consequences and capital punishment for accepted as a chronic relapsing disease. involvement in trafficking, using or Drug addicts were accepted as patients abusing drugs. There are five main Acts that must be treated and alternative that relate to drugs in Malaysia6.

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The first is the "Dangerous Drugs Act", 2004 and several agencies, primarily the 1952. It is the major legislation in Royal Malaysian Police, were given the relation to drug control in Malaysia. This authority and mandate to implement Act is very extensive covering aspects of these laws. It overlaps with the second offences, procedures and evidence. It strategy, which is demand reduction in provides for mandatory death sentence the 80’s to manage and reduce the drug for drug trafficking offences6. The problem in the country. To date, there are second is the "Dangerous Drugs (Special no major changes made to these laws, Preventive Measures) Act", 1985 (The however, there have been evident shifts DDA-SPM) aimed at enhancing the in the policy on treatment and effectiveness of countermeasures taken rehabilitation of drug offenders. by the relevant authorities against those who are involved in drug trafficking. It Demand Reduction: empowers the government to detain anyone suspected of being a trafficker Prior to introducing medications for the without having to bring the suspect to treatment of drug use and abuse in any court of law6. The third is the Malaysia, the authorities placed "Dangerous Drugs (Forfeiture of significant amount of effort to reduce the Property) Act", 1988 (The DDA-FoP) demand towards these illicit substances6. empowers the relevant authorities to Demand reduction refers to efforts aimed trace, freeze and forfeit assets of at reducing public desire for illegal and convicted drug traffickers6. The forth is illicit drugs i.e. to reduce use and abuse the "Poisons Act", 1952. This act of, and demand for, narcotic drugs and controls the import and sale of “poisons” psychotropic substances4,10. which refer to any substance specified in Demand reduction seeks reduction of the Poisons List and includes any abuse directly through prevention and mixture, preparation, solution or natural treatment. substance containing such substance First, demand reduction approach other than an exempted preparation or an provides training and capacity building to article or preparation included for the prevent the onset of substance use and time being in the Second Schedule of the abuse. Act. Many precursors to Amphetamine- Secondly, prevention is achieved by Type-stimulants (ATS) are controlled by intervening at "critical decision points" in this Act6. The fifth Act is the "Drug the lives of vulnerable populations to Dependants (Treatment and Rehabilita- prevent both first use and further use. tion)" Act, 1983 that provides for both Thirdly, it provides effective abstinence- mandatory treatment and rehabilitation of based treatment programs for drug any person who has been certified as dependents. Fourth, it broadens drug dependent as well as for voluntary education and increases public awareness treatment and rehabilitation. The period of the consequences of drug use/abuse. of treatment and rehabilitation at a Fifth, it builds a coalition to mobilize the rehabilitation center is for two (2) years. local and the international community, This institutional treatment and and finally it promotes research on the rehabilitation is followed by after care effectiveness of these and other for another two (2) years6. Finally there programs4,9-12. is the "AADK Act", 2004. This Act In general, the practice of demand specifies the role of the "National Anti reduction includes the school, workplace Drugs Agency (NADA)" in Malaysia. It and the community. Prevention in school empowers NADA for enforcement6. settings consists of introducing basic These laws were enacted from 1952 up to knowledge about, substance use, misuse,

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life skills, and positive relationships. It reduction strategies have contributed also includes early intervention program, significantly to the reduction in numbers and preventive screening13. Prevention at of drug dependents arrested by the the workplace basically includes authorities. programs such as drug-free workplace Figure 1 shows that among the 60% policy and guidelines, employee particip- heroin addicts in the country, the number ation, voluntary and random testing for detained every year has reduced from drugs, drug and addiction counseling, 23,723 in 1995 to 7,963 in 2006, just early intervention, treatment and about one year before Drug Substitution rehabilitation. Continuous or random Therapy (DST) became in full use in monitoring is often built into the human Malaysia8. resource policy of the organization6. Community - based prevention programs Harm reduction: are often the most difficult because they cover a plethora of settings, sub-cultures, The introduction of “Harm Reduction” in ethnic back-grounds and other variables. Malaysia is based on the realization of What is often done is mobilizing the limitations of supply and demand community leaders and members to be reduction approaches that were practiced aware of the drug situation, collaborative between the 1970’s and mid 2010’s15. In effort with enforcement agencies to short, harm reduction is “policies and reduce the demand for drugs, and a programs which attempt primarily to multitude of other drug free community reduce the adverse health, social and efforts6. In Malaysia, several efforts are economic consequences of mood altering being undertaken by both the government substances to individual drug users, their and community to provide institutional families and the communities” 16. There based treatment. The government are many approaches that can be established 12 abstinence-based Cure and included as harm reduction practices Care Clinics that provide voluntary drug such as advocacy and ‘capacity build- treatment and 28 mandatory treatment ing’ which are conducted through centers. In addition, there are 30 forums, seminars, media, training study treatment centers operated by NGOs and tours, research and publication16,17. Most the private sector14. There are also of the services provided under the community-based rehabilitation prog- umbrella of harm reduction are client- rams in 93 districts in the country that friendly. They use the multi-sectoral and focus on individual, group and family community based approach to implement counseling, health and welfare services, harm reduction. They establish Practical Family Association (FA), Narcotic Guidelines and Standard Operating Anonymous (NA), Alcoholic Anonym- Procedures (SOPs) to guide implement- ous (AA) meetings, job placement, tation on the ground. They emphasize religious programs and career ‘evidence-based’ program implement- development of the affected population. tation, effective monitoring and tracking This includes 18 government halfway programs16. There are several outcomes houses and service centers, 4 main drug to harm reduction practices. These are related NGOs providing community- reduction of substance use, not sharing based outreach, relapse prevention and needles specifically for the recipients of career development programs, support Needle Syringe Exchange Program and assistance from more than 50 civil (NSEP), greater concern towards one’s societies to aid in the reentry of health, decrease in illegal activities, recovering drug dependents into longer retention in treatment programs, society6,14. The supply and demand increased gainful employment and

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increase in income. A study by Marsch to follow was the NSEP program. New found that there are significant reduction HIV cases decreased since it was first in the engagement in unlawful activities detected in 1986 (Figure 2)15. after six and 12 months of Opiate Since then, more opiate users and addicts Substitution Therapy (OST)18. Figure 2 have been given the Methadone also shows marked improvement in Maintenance Therapy. Other substitutes reducing drug use, reduction in HIV risk were also provided such is Buphreno- behavior, and reduction in illegal rphine / Subutex and Subutex plus activities from the time of admission to Naloxone (Suboxone). However, these the OST program, six months after the are substitutes for opiates, whereas no program and 12 months after the substitution medications are available for program19. other substances of abuse20. This means that once persons addicted to Many studies found that giving opiates took opiate substitution medica- substitutes together with behavioural and tion such as methadone, they will not psychosocial interventions yielded better look for drugs (heroin or morphine) to results22,23. Harm reduction initiatives satisfy their cravings, thus will not that are supported by counseling, engage in criminal activities in order for especially motivational in nature, can them to obtain these drugs. Harm mould a person’s behavior change to a reduction has helped to curtail the HIV- specific target23. A person on MMT, for AIDS epidemic. Two categories of example, given the proper counseling can affected population were identified and direct his behavior to finding better jobs, focused upon, the sex workers and drug engaging in community activities, taking addicts20. For sex workers, the primary care of his health, and becoming more interventions are preventive education aware of his medications as compared to and condom distribution16. For drug a person that is on MMT alone. addicts, Drug Substitution Therapy Counseling also includes spiritual input, (DST) and Needle Syringe Exchange i.e. encouraging the patient to perform Programs (NSEP) were introduced16,20-22. his religious duties according to his These initiatives were introduced in faith24,25. What is important is that harm Malaysia to curb the HIV epidemic and reduction initiatives can put a user on a drug use15. platform where other services that Medical Treatment of Drug Addiction: enhance abstinence can be provided to him on the long run15. Religiosity seems Harm reduction approaches such as OST to be one of the important factors that is and NSEP were not practiced in present in recovering drug users who have maintained abstinence for a long Malaysia during the supply-demand 25,26 reduction era. However, on 13 Jan 2005, time . the Deputy Prime Minister announced in the National Council for the Eradication Islamic Religious input: of Drugs (MTMD) meeting that the use of Methadone to treat drug dependents It is very clear that many religions of the 6 world oppose the use of intoxicating has been endorsed by the government . 6,26 Methadone Maintenance Therapy substances . Among those which (MMT) programs were started in October clearly declared this opposition is Islam, which prohibits the use of drugs except 2005. For Phase 1, it was conducted in 8 6 hospitals, 2 health clinics, and 8 private those which are medically prescribed . clinics which involved 1,240 opiate The Glorious Quran states dependents in 4 zones (north, south, east “O you who believe! Liquor, gambling, and west) of peninsular Malaysia. Soon idols and divining arrows are but

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abominations and Satanic devices. So perform their 5 times obligatory daily turn wholly away from each of them that prayers in their holding rooms. you may prosper. Satan desires only to Assessments are conducted by JAKIM create enmity and hatred between you by officers on religious understanding, means of liquor and gambling and to knowledge and practice starting from the keep you back from the remembrance of Shahadah and covering all the basics of Allah and from Prayer. Will you then Islam. Following up at the rehabilitation ﷺdesist?” 28. Prophet Muhammad said, 'Every intoxicant is Khamr institution, there are assessments and (alcohol) and all Khamr is Haram evaluations done to match clients’ needs (unlawful or not permitted) ' 29. The very and interests according to the argument that was used against such requirements of the basic knowledge and intoxicating substances is that all drugs values of Islam. Religious practices enable people to escape from real life provided at these centers, among others which would mean that they cannot serve are, mandatory prayers, reading the -As such, people who use any Qur’an, sunnat prayers, zikr (remembra .ﷻ Allah and learning of the (ﷻ type of non-medicinal substance will nce of Allah ,hadith, celebrating Islamic events .6ﷻ have to return to the path of Allah Malaysia, being a Muslim majority religious classes, talks and a choice of country emphasized spiritual rehabilita- careers pertaining to religious practice. tion in most of its social, behavioral and There are several spiritual enhance-ment correctional programs. This can be seen programs at the government drug in all government programs and many treatment institutions that include the others operated by NGOs and private followings: institutions5,30. (i) Spiritual and self-introspection. For government-based programs, most of (ii) Religious educational classes such as the educators, teachers, counselors and tawhid (unity of God), fiqh (Islamic therapists are being provided by the jurisprudence), akhlaq (morals), al- Department of Islamic Development, Qur’an, al-Hadith. Malaysia (JAKIM) and the State (iii) Learning the stories of Prophet the caliphs and ,.(ﷺ) Religious Council / Authorities. Muhammad Thus teachings of Islamic religion and sahabah. good values are done by certified (iv) Subh (morning) and Maghrib religious teachers. Also, drug rehabilita- (evening) religious programs and talks. tion programs obtain assistance from (iv) The religious test (tasmi’) in order to local religious leaders, Ulama, and qualify for advancement to the next Imams of the mosques to interact with phase of treatment. residents in the center to prepare them to There are also annual Islamic programs re-enter society. Drug users from other and celebrations such as, celebration of religious groups also receive inputs from the beginning and year end, du'aa their respective religious personnel. (supplication) at the beginning of Islamic st At the triage department of government calendar year (1 Muharram), Mawlid al treatment centers, drug dependents are Rasul (the Prophet's birthday on 12 detained for 2 weeks following the court Rabi’ul awwal), Isra’and Mi’raj order for assessment, evaluation and (ascension to heaven on 27 Rajab), nisfu relocation. Minimum religious inputs are Sha'ban (15 Sha’ban), Ihya’ (celebrating) provided there because of the short Ramadan (1-30 Ramadan), nuzul al- detainment period. Religious teachers Quran (27 Ramadan), ‘Eidul- Fitr (1 from JAKIM encourage detainees to Shawwal), and ‘Eidul- Adha (10 Zulhijjah). Celebrating these programs

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are often done with family members and in its implementation documents stated significant others in order to facilitate the that the desired outcomes would be family’s involvement in the treatment clients that perform the religious program. practices in their everyday life, clients There are also special programs that are that practice Islam as a way of life. included in the Islamic activities calendar Religion can steer clients away from of the nation. These are Islamic current negative life influences and decisions. issues Forum (with local television There are some improvements of the stations, Janazah (funeral) course, nashid clients’ physical, social and spiritual competition (religious songs), hifz quality of life. The question is how to (memorization) al-Quran program, measure these outcomes in a short time tilawah (proper recitation) of al-Quran frame. program, and Friends of the Mosque A study at 10 community-based Cure and program (a joint program with Care Service Center (CCSC) in 2012 JAKIM)30. showed that there are positive changes perceived by the clients after they Spiritual-based Relapse Prevention undergo at least 12 months of religious Program in Community Settings: programs as part of their rehabilitation23 (Table 2). When recovering drug users leave the In this study, model A is the CCSC institutional drug treatment programs, program operated by government officers most of them will still need guidance to (NADA), CCSC model B is operated be able to re-enter the society1,9,11. Many together by government (NADA) and will use the government facilities, such NGOs, and Model C program is operated as the drop-in and community service- by NGOs. Respondents were interviewed centres (CCSC), community courses and based on a dichotomous rating of ‘Yes’ other community-based programs to and ‘No’ to the items listed in Table 2. regain confidence. Here, there are a They were asked to recall back to the multitude of programs that they can days when they were using drugs, and follow, one of which is the religious compare to the present situation. Almost program as illustrated in Table 1-6. in all models, there have been positive Most of the community-based programs changes on many of the indicators. also contain the following: Specifically, religious indicators such as “perform prayers regularly” and (i) Taqwa (righteousness) enhancement “practice religious teachings” showed the program. largest and more significant perceived (ii) Salat program. change before they enter the rehabilita- (iii)Capacity- building and enhance- tion program and after the program, ment. respectively from 36% to 93% and 29% (iv) Spiritual and religious recovery to 88%. Most of the religious programs mentoring. are being conducted by officers from the (v) Visits of the community religious Department of Islamic Development, leaders. Malaysia (JAKIM) and these positive (vi) Imam and mu'adhin workshop. perceptions among residents can be (vii) Dawah methodology courses. These attributed to its positive outcomes. are often done with collaboration of the local religious heads in the community30. Conclusions:

What is the outcome of these inputs? The inclusion of religion and spirituality National Anti - Drug Agency (NADA)30, into drug treatment has been found to

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have a positive effect onto the lives of Education should start at the appropriate the recovering drug addicts. There has level rather than assuming that they been an increase in church attendance know everything. Inputs that are too that was associated with reduction in demanding or complex would only be cocaine use5, and regular performance of met with rejection22,23. one’s religious obligations22. Thus teaching religion, its values and Such a positive effect, though not practice without proper assessment of the widespread, has helped to improve the client’s needs is counterproductive. The quality of life of recovering drug Alcohol, Smoking and Substance addicts24-26. There are studies that Involvement Screening Test (ASSIST) showed good outcomes to the religious can be used as a guide for placement of programs conducted in Malaysia21-23, clients into specific programs17. Peer- however there are also many studies that educators can be used to guide clients showed little change over a longer period into the programs, and at the same time of time5,11. These studies also pointed out to avoid coercion23. Also the use of those religious inputs must be conducted motivation-enhancement techniques to together with other evidence-based drug move clients up the ladder of religious treatment modalities. When the religious values and practice are more effective program is conducted in isolation it was than following a structured and fixed shown to be of little effect1,11 as program. Guidance and counseling is compared to when it is conducted along necessary to motivate clients towards with other programs such as religion, its values and practices. Clients detoxification, behavioral interventions, who reject religious teachings can and therapeutic communities, and later on will influence others to reject the MMT and other OSTs.. From these program in many ways. studies and a multitude of unrecorded There must be allocations for group experiences of conducting religious discussion sessions on the recovering programs, there are lessons that can be addicts' experience in learning/ learnt from Malaysia. relearning religion, what are the ups and Since many drug users/addicts have downs23. Encourage clients to choose limited knowledge of religion, and are what they want to learn with a given much less practicing it, many treatment menu. Assess their achievements and experts believe that religion is quite give reports /encouragement. ‘alien’ to the lifestyle of a drug addict. Finally, healthcare providers must adhere Relearning religion and religious values to the Principles of Drug Addiction is imperative and it has to be done at a Treatment (PODAT)1. If religious/ slow pace22. spiritual therapy is to be used, medical Treatment providers and specialists also and behavioral therapy must be commented that rejection, lack of integrated to provide a holistic drug commitment, non-adherence to programs treatment strategy. and negative defense mechanisms are common especially among the hardcore References: addicts. Acceptance is much higher with 1. NIDA. Principles of drug addiction treatment: A younger clients and those who do not research-based guide. National Institute on Drug experience severe dependency. This Abuse, National Institutes of Health, U.S. Department would be a good group to start a religious of Health and Human Services, 1999. 22, 25 2. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. program . Drug dependence, a chronic medical illness: Introduction of religious teachings implications for treatment, insurance, and outcomes should be at the level suitable to the evaluation, JAMA, 2000, Oct 4,284(13):1689-95 3. Volkow ND, Chang L. Wang GJ, Fowler JS, subjects’ needs and preparedness. Franceschi D, Sedler M. Gatley M. Miller E.

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Hitzemann R. Ding YS. Logan J. Loss of Dopamine menggunakan methadone di Pusat Khidmat AADK. Transporters in Methamphetamine Abusers Recovers Jurnal Antidadah Malaysia (Malaysian Anti-Drug with Protracted Abstinence, The Journal of Journal), 2009, 5, 79-108. Neuroscience, 2001, December, 21(23): 9414-9418. 18. Marsch, LA. Efficacy of the MMT program. 4. Carroll KM. Onken LS. Behavioral therapies for Addiction, 1998, 93(4), 515-532. drug abuse. The American Journal of Psychiatry, 2005, 19. DASA. Preliminary findings of OST, Washington 168(8):1452–1460. State Outcome Project, 2002. 5. Fu JJ. Bazazi AR. Altice FL. Mohamed MN. 20. Mahmood NM. Hassan A. Faisal HI. Ahamad J. Kamarulzaman A. Absence of Antiretroviral Therapy Estimation of drug users and IDUs in Malaysia, Sintok: and Other Risk Factors for Morbidity and Mortality in Universiti Utara Malaysia Publisher, 2005. Malaysian Compulsory Drug Detention and 21. Mahmood NM. Dzahir K. Drug substitution Rehabilitation Centers. 2012, PLoS ONE 7(9): e44249. therapy: Success and limitations of the methadone and doi:10.1371/journal.pone.0044249. buphrenorphine maintenance program. Jurnal 6. Mahmood NM. Penyalahgunaan dadah: Aspek Antidadah Malaysia (Malaysian Anti-Drug Journal), Undang-undang, Rawatan, Pemulihan dan Pencegahan. 2007, 1: 25-72. Kuala Lumpur: EduSystem Sdn Bhd, 2009. 22. Mahmood NM. MMT and Psychosocial 7. Noor Zurina MR. Rusdi AR. Mohamed MN. Habil Intervention program among drug dependents H. Treating heroin addiction: Bridging the past and undergoing mandatory community supervision: A 12- future. A Malaysian experience, Asia-Pacific months pilot project, Paper presented at 2010 ISAM Psychiatry, 18 APR 2012, DOI: 10.1111/j.1758- Conference, Milan 4-7 October 2010. 5872.2012.00194.x 23. Mahmood NM. Sabitha M. Positive outcomes of 8. National Anti Drugs Agency. 10 years statistics of Cure and Care Service Centers (CCSC): A community- Drug Use in Malaysia: 1995-2006. Putrajaya: NADA, based treatment program in Malaysia, International 2007. Journal of Prevention and Treatment of Substance Use 9. Miller MM. Traditional approaches to the treatment Disorder, March, 2012, 1, 2, 71-83. of addiction. In: A.W. Graham and T.K. Schultz (eds.), 24. Fiellin DA. Pantalon MV. Chawarski MC. Moore Principles of (2nd ed.). BA. Sullivan LE. O’Connor PG. Schottenfeld RS. Washington, D.C.: American Society of Addiction Counseling plus buprenorphine/naloxone maintenance Medicine, 1998. therapy for opioid dependence. The New England 10. Tongue E, Turner D. Treatment options in Journal of Medicine, 2006, 355(4):365–374. responding to drug misuse problems. ONDCP Bull 25. Gorsuch RL. Religious aspects of substance abuse Narcotics Issue 1-001. 1988. and recovery. Journal of Social Issues, 1994, 51, 65– 11. Mahmood NM, Yahya D, Dzahir MK. The practice 83. of TC in 5 ASEAN Countries, Paper presented at the 26. Miller WR. Integrating spirituality into treatment. XXIII World Federation of Therapeutic Community Washington, DC: American Psychological Conference, New York, NY: September 1-5, 2006. Association,1999. 12. McLellan AT. Arndt IO. Metzger D. Woody GE. 27. Pardini DA. Plante TG. Sherman A. Stump JE. O’Brien CP. The effects of psychosocial services in Religious faith and spirituality in substance abuse substance abuse treatment. The Journal of the recovery: Determining the mental health benefits. American Medical Association, 1993, 269(15):1953– Journal of Substance Abuse Treatment, 2000,19, 347– 1959. 354. 13. Simpson DD. Joe GW. Fletcher BW. Hubbard RL. 28. The Glorious Qur’an, Al-Maeda 5: 91-92. Anglin MD. A national evaluation of treatment 29. Sahih Al-Bukhary, Vol 7, Book C9, No, 481-494, outcomes for cocaine dependence. Arch Gen Psych, www.iium.edu.my/deed/hadith/bukhari/069_sbt.html 1999, 56: 507-514. 30. National Anti Drugs Agency, Annual Report 2012, 14. Mahmood NM. Drug situation in Malaysia: Trends, Bangi: NADA, 2012. incidences and anti-drug strategies. Indian J Psychol, January (Special Issue), 2012, 71-82. 15. Ministry of Health, Malaysia, The Global AIDS Response Progress Report 2012, Putrajaya: MoH, 2012. 16. International Harm Reduction Associations (2008). www.ihra.org 17. Sangeeth K. Hafidah M. Mahmood NM. Projek perintis program rawatan terapi gantian (RTG)

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Figure 1: Number of heroin addicts arrested by the authorities from 1995 – 20068

Total number of heroin addicts arrested by the authorities Per Cent of heroin addicts arrested to the total number of drug addict arrested each year (Permission to use obtained from National Anti-Drugs Agency, Malaysia, 2014)

Figure 2: Changing percentages of HIV cases due to intravenous drug use (IDU) and those due to sexual encounters from 1990 to 2010 (Permission to use obtained from Ministry of Health, Malaysia, 2014).

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Table 1: Some of the Community-Based Islamic Programs and Expected Outcomes

No. Program/activities Objective

1 Halaqah Provide continuous religious classes to recovering drug addicts and their families, besides group meetings to enhance recovery 2 Islamic art and culture Provide Islamic entertainment, arts and culture for recovering drug addicts 3 Ibadat camp To provide an intensive program to study fard ‘Ain and fard Kifayah to recovering drug addicts 4 Mosque as foster To aid recovering drug addicts and their families in parents the recovery process by using the spiritual approach 5 Friends of the mosque To encourage recovering drug addicts to be close to the mosque institution. It can act as a temporary shelter for them when they re enter the community 6 Volunteer work in the To encourage recovering drug addicts to contribute community mosque back to the society besides preparing them to be reintegrated back into the community 7 Outreach to other drug Outreach work to recovering or drug addicts and addicts families in the community

Table 2: Measuring outcomes at 10 Cure and Care Community Centers (CCSCs).

Pre-post Interview Model A Model Model at CCSC Pre Post B Post C Post Indicators of Pre Pre Change

Maintain good 95 121 76 92 17 22 relations 63.1% 84.6% 55.9% 70.2% 50.0% 64.7% with parents Maintain good 100 2130 87 108 19 28 relations 48.0% 87.2% 64.0% 79.4% 55.9% 82.4% with siblings & other family member Involved in societal 80 131 65 104 15 25 Voluntary program 53.7% 87.3% 48.1% 76.5% 44.1% 73.5% Perform prayers 55 140 69 121 15 28

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Pre-post Interview Model A Model Model at CCSC Pre Post B Post C Post Indicators of Pre Pre Change

regularly 36.9% 93.3% 51.1% 89.6% 44.1% 82.4% Practice religious 57 118 45 88 10 30 teachings 38.0% 78.7% 33.3% 65.2% 29.4% 88.2% Learn to increase 47 81 38 68 5 18 knowledge 31.3% 54.0% 27.9% 50.0% 14.7% 54.5%

154 FIMA YEAR BOOK 2014 ISLAMIC PSYCHO-SPIRITUAL THERAPY (PST): PANACEA FOR THE DRUG DEPENDENT

Mohamed Hatta Shaharom*

Abstract:

Islamic Psycho-spiritual Therapy (PST) has its roots well embedded in the spiritual Islamic PST .( ﷺ) foundation of the Qur’an and the Sunnah of the Prophet Muhammad is the embodiment of everything that is permissible and potentially possible in the methodologies of the spiritual treatment of the believer, within the confines of the Shari`ah (Divine Law). The upholding of the principle of tawhid (the Oneness of Allah is of prime importance in this therapy. What is basic in Islamic PST is that it is a (ﷻ) healing technique that transfers the individual from the realm of ill health to the realm of wellbeing in a manner that is Godly (Rabbani). It also involves the assessment of the In the .ﷻ patient’s religiosity. In the process, the individual is brought closer to Allah treatment of many who are dependent on alcohol and psychoactive substances, Islamic PST has been proven to be effective. ,Islam, Muslim, , psycho-spiritual, therapy ,( ﷺ) Muhammad ,(ﷻ) Keywords: Allah religiosity, meditation, , addiction. Introduction

From the 1950s to the 1990s, the total Islamic and atheistic influences. number of books, chapters and journal As a methodology, Islamic PST should be articles that included topics on able to incorporate the different theories of psychotherapy, religiosity and religious psychotherapies that are not inherently belief in their titles and abstracts has risen anti-religion and anti-spirituality, Islamiz- from 86 to 330, totaling 774. Of these, five ing them in the process. As the Ummah’s controlled studies examined how religion need for Islamic PST increases, the could be used in psychotherapy to treat training of therapists and counselors in clients1. The Muslim Ummah (nation) of Islamic PST must be enhanced. today is blessed with the presence of In its contemporary forms, Islamic PST Muslim psychotherapists who strive to be has its roots well embedded in the spiritual Shari`ah (Divine Law)-compliant in their foundation of the Glorious Qur’an and the practice. Islamic Psycho-spiritual Therapy .( ﷺ) Sunnah of the Prophet Muhammad (PST) must first of all be free of un-

* Prof. Mohamed Hatta Shaharom Consultant Psychiatrist And Founding Dean- Faculty of Medicine Cyberjaya University College of Medical Sciences, Malaysia And Adjunct Professor of Psychiatry, University Kebangsaan Malaysia (National University of Malaysia). E-mail: [email protected]

FIMA YEAR BOOK 2014 155 ISLAMIC PSYCHO-SPIRITUAL THERAPY

Islamic PST is the embodiment of everyth- confines of the Shari`ah, the sacred law of ing that is permissible and potentially Islam. The upholding of the principle of possible in the methodologies of the tawhid is of prime importance in this spiritual treatment of the believer. therapy, like in any area of the lives of the While approaches of Islamic PST can be Muslim client (patient) and therapist. varied, they must always be within the The five daily compulsory prayers include universal ethics of good practice. prescribed by Islam are adequate spiritual One significant difference between Islamic enforcers for the practicing believer. It is a and non-Islamic ethics is the sitting constant psycho-spiritual reminder, a light arrangement of the therapist and his physical exercise and a social strengthen- patient. When it involves a therapist and a ing effort, all rolled into one. The focusing client of the opposite sex, therapy is best on and mentioning of the name of Allah done in a room with a glass window or a and reciting His beautiful names are glass door so both can be seen from the among the most effective of meditation outside. When there is a chaperone, this techniques to countless Muslims through- requirement does not apply. out the ages. When the need and situation arises, Islamic PST needs to be coupled Measurement of Religiosity: with pharmacotherapy. What is basic in Islamic PST is that it is a Since Islam is a structured religion, it is healing technique that transfers the recommended that the status of the client’s individual from the realm of ill health to religiosity at the commencement and the the realm of wellbeing in a manner that is termination of therapy be recorded. The Godly (Rabbani). In the process, the different levels of religiosity can be individual is brought closer to Allah. measured by a well-structured Islamic This dual function is unique to God- religiosity scale. An example is the consciousness in Islam and Islamic PST. author’s Hatta Islamic Religiosity Scale Thus, while it is health giving to the (HIRS) which measures the religiosity of believer, Islamic PST enhances the the client undergoing therapy. believer’s state of Godliness. It should be This involves the scoring of the client’s: stressed that Islamic PST is part of a ▪ Basic Islamic knowledge, and therapeutic process that is based on a holis- ▪ Practice of basic Islamic rituals. tic paradigm. While the therapist and the Guided by the different scores of the scale, client dwell into the psychological and the the therapist is able to advise the client on spiritual domains of life, the physical and the progress of the therapy and its religio- the social domains must not be neglected. spiritual impact. In brief, a four-domain (bio-physical, During this process of guidance and psychological, social and spiritual) assess- advice, the therapist must not impose his ment of the human being is of great own high standards of Islamic knowledge importance before treatment commences. and practice. He must not be seen as It is only through this approach that one judgmental even though the client is a can identify the diseased or imbalanced sinner according to basic Islamic standards domains2. Islamic ethics in PST must be and a weakling as far as Islamic strictly observed, just as in other forms of commitments are concerned. However, it therapies instituted by any Muslim must be noted that the HIRS does not therapist. Islamic ethics in therapies attempt to measure the faith (iman) of the

156 FIMA YEAR BOOK 2014 ISLAMIC PSYCHO-SPIRITUAL THERAPY client or any Muslim, for the faith of any and let the blessings of Allah be showered Muslim or believer is only known to Allah upon them. He is the one who is in need of It is immeasurable by any human help. The therapist’s appreciation of the .ﷻ inventory or questionnaire. On the other client’s reliance on him must be realized hand the manifestations of an individual’s through an ethical mutual emotional- faith are evident in his daily commitments spiritual relationship that will primarily and undertakings3. benefit the client. If the client is a non- Muslim, the Muslim therapist can still Therapist and Client: Requirements discuss religio-spiritual issues that can help the client's progress towards recovery as a. The Therapist: long as the therapist is not seen as imposing Islamic principles on the client. Since Islamic PST is essentially a psycho- Consent from the client on this technique religious therapy, the therapist must be a must be obtained at the outset. The practicing Muslim. To him, observing the therapist must not be seen as taking basic tenets of Islam is not a problem but a advantage of the therapy to proselytize. pleasure, for he yearns for the pleasure of :through his attitudes and deeds. Therapist and Client: Differences ﷻ Allah He is known as an ethical practitioner who inspires his clients in things spiritual and Being co-religionists, the main similarity moral. He has his clients’ trust as he guides that exists between the therapist and the them with hope and faith on the road client is their religion. In fact, it functions towards health. Therapy is a humbling as the bulwark against further deterioration experience for both therapist and client, of the client’s health while it acts as a regardless of whether it ends in success or savior for the client’s waning spirit, failure. His client’s experiences before and troubled emotion and challenged during therapy remind the therapist that cognition. life is always full of challenges that can Among the characteristics of an efficient devastate or elevate the morale of the therapist is an unwavering belief in good Islamic knowledge and ,(ﷻ)individual. This humility guards the Allah successful healer from the onslaught of practice, and praiseworthy character traits. ostentation and boastful pride. He In contrast, the client may be well constantly reminds himself that in reality, equipped with or deficient in Islamic healing does not come from him but from knowledge and practice. His character can the Almighty, the Ultimate be commendable or otherwise. In brief, it (ﷻ) Allah Healer, according to the following is helpful for the client to feel that the Qur’anic verse: therapist is better than him in terms of “And when I fall ill, He restores me to Islamic knowledge and practice. health”4. Otherwise, he may lack the confidence in his therapist. And this will disrupt the b. The Client: smooth progress of the therapy.

Since Islamic PST involves religious Methods and Contents: principles, the client undergoing it has to be a Muslim. He must be willing to be As the name implies, Islamic PST involves guided psycho-spiritually by the therapist the client’s cognition and emotion (both

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are compositions of human psychology) practicing believer. It is a constant psycho- and his spiritual state. spiritual reminder, a light physical exercise Methods and approaches may vary from and a social strengthening effort, all rolled one therapist to another and from one into one. It is best when done school of PST to another. But the congregationally at any clean place, principles and contents of Islamic PST do outdoors or indoors, and in mosques or in not differ, i.e. they should not conflict with family homes. When any of the daily Islamic principles of human psychology prayers is performed individually, the and spirituality. Forbidden theories of spiritual rewards and blessings are inferior psychology, like the many aspects of as compared to the congregational prayer. Freudian sexual interpretations of human Of course, performing the individual developmental theory, are excluded. The prayer is much better than neglecting it therapist must be aware of anti-religious totally. trends in psychological theories and therapies that, for instance, reduce man to Apart from these compulsory prayers, the level of the mice in the Skinner box or there are supererogatory prayers for special the dog of Pavlov. These non-Islamic occasions that would cleanse and schools of psychology oppose the attempt strengthen the soul of the believer. to find the Godliness in man’s life and efforts. They draw him closer to Allah. These Islamic PST maintains that man is the most include prayers in times of need and supreme of the creatures of Allah. Man hardship and during moments of thanksgiving and joy. Practicing the .(ﷻ) enslaves himself only to Allah Islamic PST is a means to aid the wayward compulsory five daily prayers is extremely slave of Allah. If he deviates from the path important during the duration of Islamic .and falls into the abyss of PST or outside that duration of therapy (ﷻ) of Allah error or even disbelief, Islamic PST offers If the client is not used to perform all the the helping hand. Islamic PST elevates him five daily prayers, he must be encouraged to his former station of fitrah, the original to perform at least one to four of them. It is unblemished state of Godliness of every commendable for the client to perform human being before he becomes corrupted suitable supererogatory prayers to buttress by his own worldly desires and satanic his increasing spiritual strength. It is also influences. appropriate for the therapist to become the imam (prayer leader) of the client should Daily Prayers: they perform the congregational prayer together. In many structured religious traditions, there are prescribed daily prayers to be Meditation: performed by the devout believer. The belief in the hereafter provides an The essence of meditation is the focusing unending hope for salvation. In the of one’s attention on one thing at a time. hereafter is found the eternal reward or Different religious traditions vary in their punishment of all strivings during this approaches to meditation. Often the transitory earthly life. The five daily meditator repeats, either aloud or silently, a compulsory prayers prescribed by Islam syllable, word, or group of words. In the are adequate spiritual enforcers for the Hindu tradition, the Sanskrit term for this

158 FIMA YEAR BOOK 2014 ISLAMIC PSYCHO-SPIRITUAL THERAPY kind of meditation is called mantra. To from the sphere of hopeful determination in (ﷻ) anchor the attention, one gazes at a fixed due to their forgetfulness of Allah object such as a flame or flower. Others the face of intense personal suffering6. find focusing on the rising and falling of In this spirit, even beyond mandatory their own breaths as a convenient and religious rituals, seemingly mundane relaxing point of focus. activities like carrying out a respectable It is the nature of the mind to go astray and job or singing in front of an audience are not stay concentrated. Myriads of thoughts considered Godly. This is as long as they (ﷻ) easily appear and seemingly interfere with are executed out of sincerity to Allah the meditation. By repeating this one and the carrying out of these acts is in moment of awareness (noticing the thought accordance with Islam. The therapist must and then refocusing the attention), be aware that psychotherapy comes in gradually the meditator will realize that: different forms in Islam, and among them  It is impossible to worry, fear, or hate are music and singing therapies. As in when the mind is thinking about other life activities, there must be no free something other than the object of mixing of the sexes. Allah's Beautiful these emotions; Names (Attributes) can be memorized and  The diverse contents of the mind can recited at any time. The therapist should be really fit into a few simple categories, able to choose for the client the appropriate such as grudging thoughts, fearful name(s) to be memorized and recited as thoughts; etc. part of the therapeutic process. For  We act in certain ways due to thoughts instance, the name al-Razzaq (the that have become habitual thought Provider) is appropriate for a client who patterns and perception; experiences mild anxiety and/or mild  Thought and emotion are not depression while he is engrossed with permanent since they pass into and out unnecessary worries about his financial of our body and mind; and needs. Among the assortment of  Life will be lived to its fullest with collections of prayers from the Glorious equanimity and level-headedness when Qur’an and the supplications of the we are awake to what is happening selections ,( ﷺ) Prophet Muhammad right now5. from the following scholar-compilers would be directly relevant for clients c. Invocations and Remembrance: undergoing Islamic PST:  Al-adhkar of al-Nawawi7, and In Islam, the focusing on and mentioning 8  Al-ma’thurat of al-Banna . of the name of Allah (the name of the essence of God) and reciting His beautiful Qur’anic Healing: names [al-asma’ al-husna ( Beautiful Names or Attributes)] are among the most Among the many Qur’anic verses that are effective of meditation techniques to relevant to the healing process are: countless Muslims throughout the ages. “Those who believe (in the Qur’an), those who follow the Jewish scriptures, and the (ﷻ) This act of remembrance of Allah (dhikr Allah) can be practiced anywhere Sabeans and the Christians, whoever and at any time. It has brought solace to believes in Allah and the Last Day and many a troubled soul and offered hope to work righteously, on them shall be no fear, those who had been momentarily displaced nor shall they grieve”9.

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“When My slaves ask you concerning Me, patient suffering from a psychological or I am indeed close to them, I respond to the psychiatric disorder. If the client is prayer of every suppliant when he calls on mentally unfit to pray for himself, his next- Me; let them also listen to My call and of-kin (e.g. parent or sibling) and the believe in Me, that they may walk in the community should pray (supplicate) for right way”10. him/her. Among the common psychiatric The client is also made aware of the fate disorders (DSM-IV-TR criteria)13 that are that befalls unfortunate souls who deny known to afflict patients are: .truth. In reality, the Glorious  Anxiety disorders (ﷻ) Allah’s Qur’an ascertains that they have a disease  Depression. in their hearts. This is essentially a spiritual  Mania. illness that must be prevented from  Schizophrenia. afflicting any believer.  Substance dependence and abuse. “In their hearts is a disease and Allah increases their disease, and grievous Adjunct Therapy: suffering awaits them because they are false (to themselves)”11. There would be situations when Islamic Islamic PST facilitates the introspection PST needs to be coupled with pharmaco- process on the part of the client. If he therapy. Islam, viewing the patient as a discovers that he is suffering from a whole individual, does not negate the role spiritual disease, the therapist would be of other forms of permissible therapy able to help him get through his ordeal and beyond the psycho-spiritual. Adjunct get rid of the illness. Even if he is afflicted therapy that is coupled with Islamic PST is by a mild spiritual discomfort, it would be also permissible in Islam for as long as it helpful if he/she strives to prevent the does not contradict the Shari`ah. occurrence of the illness. Addictive Behaviour: Sickness as Expiation of Sins: Terms related to drug and alcohol Islam has a unique perspective regarding addiction are dependence and misuse. physical and mental illnesses. While Addictive behavior related to the misuse of seeking treatment is a commendable effort, psychoactive substances is associated with the sick person must understand and accept excessive behavioral patterns that are 14 the fact that the expiation of some sins detrimental to the individual’s health . For takes place during illnesses as clearly more than a decade, convincing studies described in the following Hadith: have shown the relationship between Abu Sa‘id al-khudari and Abu Huraira environmental stimuli and the craving for said:"No the drug among drug users as compared to ( ﷺ) narrated that the Prophet fatigue, nor disease, nor sorrow, nor non-users. Neurophysiological responses sadness, nor hurt, nor distress befalls a included elevated heart rate, strong Muslim, even if it were the prick he craving, and Positron Emission Transaxial receives from a thorn, but that Allah Tomography (PET) scans revealing expiates some of his sins for that12". increased activity in the brain’s limbic region. Thus psychological experiences Psychological Disorders: can be associated with brain regions identified by brain imaging techniques15. Relevant prayers must be recited by the

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Comorbidity: its therapeutic domain. Since time immemorial, prayers have been found to It is common for drug users to have be part of the treatment armamentarium of multiple medical problems. For instance, many a civilization and culture. By the end psychiatric comorbidities with attendant of the 20th Common Era century, Western dependency are not infrequent. Coupled researchers have noted the incompleteness with this challenge, the demanding or help- of medical therapy without the prescription rejecting nature of the drug dependent of prayers20. populations may drain staff of clinical The Muslim client has every opportunity to emergency departments16. benefit from Islamic PST. For the non- Non-hospital therapeutic groups whose Muslim believers of God, they can also interest and cooperation can complement gain from a PST that is managed by a well- the services of conventional Western trained Muslim therapist. Meditation and hospital care are welcome to serve and prayers are necessary in the management alleviate the stress on medical services. of the cacophony of post-modern social Looking back at the holistic model of disorder. They are able to help us retain managing the drug abuser, the psycho- our sanity in facing the challenges of life. social aspect must not be overlooked when Without them, we stand to lose our the psychospiritual domain is looked into. psycho-spiritual bearing. Punishment (which is the psychosocial Islamic PST has its relevance in treating aspect of the outcome) must be meted out those who are dependents on and involved to abusers who break the law. But efforts in the misuse of psychoactive substances. to help them overcome their addiction must not be neglected. References:

Concluding Remarks: 1.Stevan Nielsan, W Brad Johnson, Albert Ellis, 2001. Counseling and Psychotherapy with Religious Persons: A Rational Emotive Behaviour Therapy Approach. London: For Muslim drug abusers and addicts, the Lawrence Erlbaum, p ix. psycho-spiritual method has been shown to 2. Mohamed Hatta Shaharom, 2009. Allah: A Psychospiritual Contemplation on His Name. Kuala be helpful in their efforts to overcome the Lumpur: CERT Publications, pp 155-157. problem while they return to the path of a 3. Hanafiah M Salleh, S Mohamed Hatta, et al., 2000. practising Muslim. Whether it is in South Hatta Islamic Religiosity Scale 1996 (HIRS) – A 17 18 19 Reliability and Validity Study. Malaysian Journal of Africa , Malaysia or Indonesia psycho- Psychiatry Vol. 8, No. 1, March 2000: 5-14. spiritual approaches have been successful. 4. The Glorious Qur’an, Ash-Shu‘ara’ (The Poets) 26:80. However two main issues need further 5. Martha Davis, Elizabeth Esheman, Matthew McKay, 1988. The Relaxation & Stress Reduction Workbook. attention: Oakland, CA: New Harbinger, pp 37-38. 1. Empirical studies on the methodologies 6. Mohamed Hatta Shaharom, 2007. 7-Day Stress Relief and outcomes must be enhanced to Plan. Kuala Lumpur: CERT Publications, pp 50-51. 7. Al-Adzkar Imam an-Nawawi (Malay-Indonesian ensure the approaches meet basic Translation with Original Arabic Text) Jakarta, international standards of therapy and Indonesia: Pustaka as-Sunnah, 2006. research. 8. Al-Ma'thurat of Imam Shahid Hasan al-Banna (English Translation with Original Arabic Text) Swansea, UK: 2. It must always be ascertained that Awakening Publications 2nd Edition, 2007. therapies that employ sufi dhikr and 9. The Glorious Qur’an, Al-Ma’idah (The Table Spread) other spiritual techniques must abide 5:69. 10. The Glorious Qur’an, Al-Baqarah (The Heifer) with Islamic Shari`ah principles. 2:186. Prayers are not only confined to Islam and 11. The Glorious Qur’an, Al-Baqarah (The Heifer) 2:10.

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12. Sahih al-Bukhari, Hadith 545 (Vol. 7), Book 70: Patients. Wister Hadith. http://www.gowister.com/sahihbukhari-7-545.html. Retrieved 26 May 2013. 13. American Psychiatric Association’s Diagnostic and Statistical Manual-IV (Text Revision, 2000), cited in Mohamed Hatta Shaharom, 2007. 7-Day Stress Relief Plan. Kuala Lumpur: CERT Publications, pp 38-42. 14. G Hussein Rassool, 2009. Alcohol and Drug Misuse: A Handbook for Students and Health Professionals. London: Routledge, p 7. 15. Stephen A Maisto et al., 2011. Drug Use and Abuse. Belmont: Wadsworth, p 63. 16. Richard Gallagher et al, 2010. Addiction and Emergency Psychiatry. In David Bariser and Ricardo Castaneda. Clinical Addiction Psychiatry. Cambridge: Cambridge University Press, p 228. 17. Selma Cook. The Islamic Approach to Overcoming Addiction. http://www.thekhalids.org/index.php/newsletter- archive/810-islamic-approach-to-overcoming-addiction (Retrieved 25 April 2014). 18. Dini Farhana Baharuddin, Abd. Halim Mohd. Hussin, Melati Sumari et al. Developing A Family Intervention Model For the Treatment and Rehabilitation of Drug Addiction. http://acreda.usim.edu.my/aktiviti-acreda/kajian-acreda; http://www.sinarharian.com.my/rencana/bimbingan- terapi-psikospritual-1.169732; http://www.alhidayah- medic.com/coretan-hj-lokman/rawatan-ketagihan-dadah (Retrieved 28 May 2014). 19. Subandi Taufik, Achmad DP, Fuad Hamsyah. Returning to God: The Role of Dhikr (A Sufi Meditation) Practice in Treating Drug Addicts in Indonesia. http://psikologi.ugm.ac.id/uploads/resources/File/Databas e%20Penelitian%20Dosen/dhikr_drug.pdf (Retrieved 28 May 2014). 20. Dadang Hawari, 2002. Dimensi Religi Dalam Praktek Psikiatri Dan Psikologi (The Religious Dimension in Psychiatric and Psychological Practice). Jakarta: Fakultas Kedokteran Universitas Indonesia (Medical Faculty, University of Indonesia), pp 182-191.

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