Introduction
Contrary to the common ideas prevalent in the public, substance use is extremely widespread. So is substance abuse. It is not a small problem, restricted to the purview of the weak and vile. The usage of drugs transcends race, gender, age, or socioeconomic status. The health burdens as well the economic & legal problems consequent to substance abuse (for the individual as well as to the society) are too high to be ignored by any one of us. Its ramifications in children (secondary to use by parents) & adolescent health as well as subsequent adult health need special attention and parents and adolescents need to play an important role to avoid becoming victims of these difficult problems. Cigarette smoking is responsible for about 80% of deaths from lung cancer and 20% of heart disease deaths each year. About one-third of AIDS cases and the majority of hepatitis C cases can be traced to intravenous drug use. The incidence of HIV & tuberculosis among the drug abusers is very high. Many serious accidents are commonly related to alcohol/drug use. Health care isn’t the only cost involved in substance abuse. Also significant are the consequences of people’s actions while they are involved in drug use. Drug abuse is implicated in about half of all major crimes, and drug-related offenses often land adults in jails. Despite our best efforts, most problems related to substance abuse keep growing with time.
Substances include prescribed medications, alcohol, over-the-counter medications, caffeine, nicotine, steroids, illegal drugs, etc. Substances may be used as mental stimulants, calming agents, energizing, improving memory & concentration, for pain relief, as a hypnotic, and so on.
Presentation
Many substances are accepted by society when used in moderation without significant harm to the individual or society. The usage becomes a problem only when there is persistent inappropriate use despite social, work, and/or legal consequences and despite a potential danger to self or others. Even in the presence of such a situation, the user rarely seeks help directly for his problems. He often denies that he has a serious problem and tends to dismiss it as trivial and avoids facing the issues. He may often have to be forcibly brought by his caring/distraught family members, or the social system.
The signs & symptoms include:
- Resorting to drug use as a maladaptive coping mechanism; heavy, regular, stereotyped consumption of drug;
- Presence of clinically manifest impairment/distress over a significant period of time (in personal life, at work, family, society, economically, spiritually, etc.);
- Using a large amount at high frequency; ability to tolerate higher amounts;
- Intense cravings and compulsive use with a sense of helplessness; episodes of getting drunk/intoxicated; relief drinking to prevent withdrawal discomfort; getting into legal problems;
- Several unsuccessful attempts to cut down on his own; severe withdrawal symptoms may be present on attempting to discontinue; reinstatement of drug use even after achieving abstinence;
- Inordinate time & effort spent in procuring & using the substance often secretively; using the substance assuming a prime salient feature in his life;
- Important activities given up; clear deterioration in performance in several roles;
- Continue despite clear physical/psychological harm being imminent.
Hence the family and the physician will have to use considerable efforts tactfully, in making the substance user aware of the dangerousness of his use and the immediate need to address the problem.
Investigations
For the physical problems associated with usage: Lab tests like Complete blood count, Liver function tests, ECG, Renal function tests, Electrolytes, radiological imaging, etc. are often used routinely. Additional tests may be needed appropriately. (Example: Gamma- Glutamyl-Transferase (GGT), Mean Corpuscular Volume (MCV), Carbohydrate deficient transferrin (% CDT) in the case of alcohol-related problems. Toxicology screens may also be needed (emergencies).
Psychological screening tests & rating scales like CAGE questionnaire, SMAST, AUDIT, Beck’s Depression Inventory (BDI), Hospital Anxiety & Depression Scale (HADS), Rating Scales for Pain, Sleep, and several others to be used appropriately.
Treatment
Instead of seeing drug use as a purely medical problem, it is helpful when a Bio-Psycho-Socio-Spiritual approach is used for understanding drug use and its intervention. Responses to substances can be very individualistic and personalized plan to meet the specific needs of the individual often gives improved results.
The steps include:
- Early identification & education.
- Confidential and non-judgemental approach.
- Evaluate for co-occurring disorders and treat them.
- Evaluate own attitudes about substance use/dependence.
- Hospitalisation whenever indicated.
- Safe Detoxification (use appropriate medications) preferably under specialist care.
- Psychotherapy.
- Behaviour therapy.
- Involvement of family or close relatives in treatment.
- Relapse prevention programs and anti-craving medications.
- 12 step programs - Alcoholics Anonymous (AA).
Complications
Depends on the type of substance use, pattern & chronicity of use, the severity of withdrawal, the patient’s health status, etc. Withdrawal management related to substances like alcohol (Delirium Tremens-DT) can be life-threatening and patients may develop Hepatic encephalopathy, Wernicke’s encephalopathy, Korsakoff- syndrome, Substance-induced Psychosis, Dementia, etc. Hence the need for early identification and expert care. Fetal alcohol syndrome may occur in children of the mother using alcohol during pregnancy.