Drug abuse

DRUG ABUSE
Thursday, June 9, 2016 1

Drug addiction is complex illness characterized by compulsive and uncontrollable drug
craving, seeking and use that persists even in the face of extremely negative
consequences. Drug abuse and its disorders are the result of complex interaction of
sociological, biological and physiological factors. With the easy availability of semi-
synthetic products like heroin the abuse can be associated with more than one factors.
Tolerance means diminishing effect of the same dose of a drug or the need
to increase the dose to get a similar effect.
Habituation is the emotional or psychological need felt for a drug.
Dependence is the physical need to take the drug.

Drugs were use by ancient Muslim and Chinese Physicians to cure diarrhoea, dysentry, cough and similar
other conditions. Gradually people came to know about their side effects like drowsiness, euphoria,
temporary increase in energy etc. and this led to their misuse and addiction.
More than two decades of war an Afghanistan and its consequent socioeconomic devastation has
contributed considerably to increase in drug abuse in Pakistan. Poppy is grown extensively in several areas
of Pakistan whereas heroin laboratories are situated in the tribal areas.
Pakistan is now the transit country in place of Iran for opium and heroin coming from Afghanistan.
According to UNDCCP more than 130 countries are involved in the problem of drug abuse and
it has been increased 3 times than what it was in 1995.
Drug abuse pattern in Pakistan change twice during the previous years. During early 1960’s traditional drug
abuse was present when opium, bhang and to some extent charas was abused by low-income groups. In
late 1960’s charas abuse picked up and it was taken by even educated people. In early 1980’s heroin abuse
started and increased from 20,000 abusers (0.4%) in 1981 to 15,23,864 abusers (50.7% of all) according to
1993 survey.

THE DOPAMINE PATHWAY
MEDIAL FORE BRAIN
NUCLEUS ACCUMBENS reinforcement
VENTRAL TEGMENTAL AREA

GLOBALLY 155-250 million (5.7%) people between the ages of 15-64 have used an illict drug at
least once in the past year.
PROBLEM DRUG users being 16-38 million. Injection Drug Users is the most problematic group
CANNABIS users being 129-190 million (largest group).
ATS being the 2nd most common.
Followed by COCAINE and OPIODS.
WORLD PREVALENCE OF OPIUM USE
IRAN 2.8 AFGHANISTAN 1.4 UK 0.9 PAKISTAN 0.8 USA 0.6
WORLD PREVALENCE OF CANNABIS USE 2008
USA 13.7 UK 6.6 AFGHANISTAN 4.3 PAKISTAN 3.9

DIFFERENT DRUGS USED FOR ADDICTION
Classification given by Lefrancois in 1981
1. CANNABIS
Cannabis is obtained from cannabis sativa and its psychoactive ingredient is
canabinoid. It is used in the form of:
• Bhang: Obtained from the cut tops of uncultivated plants.
• Ganja : Obtained from flower tops and leaves of cultivated
plants
Charas: Obtained from resins covering the leaves and
flower tops.
Charas is 5-8 times more potent than Ganja.
Routes of admission Charas & Ganja are smoked while Bhang is drunk.
Dependence and habituation on cannabis is mild while tolerance is high
Withdrawal symptoms range from insomnia to hyperactivity but there are long run effects on heart, lungs &
brain.Thursday, June 9, 2016 6

2. NARCOTICS
These include Opium and opiates (opium like) drugs like Morphine, Codiene, Pethidine, Heroine, Methodine.
Opium is prepared from thick juice obtained by slicing the poppy bud. This juice is then turned into brownish-
black paste. Two preparations of opium are used:
i. Madak: Mixed with baraley husk and formed into small pellets, the pills of makad are smoked by
water pips.
ii. Chandu: Chandu is prepared by boiling opium to a stage when it turns into concentrated thick
paste. It is then smoked with the help of special pipes. This is much more intoxicating
than madak.
Pethidine and morphine are basically pain killers. Codeine is used in cough syrups. Heroin ( Diacetylmorphine” or
“Diamorphine”. ) is derived from morphine by treating it with acetic anhydride. It is sold in three forms, brown, dark
brown and white. Heroin is administered in various ways such as smoking, sniffing, inhaling and intravenously.
Methodone is used as a substitute in people addicted to heroin. Heroin is most potent opium derivative which acts
quickly and strongly as at crosses the blood brain barrier about 6 to 8 times quicker then morphine.
Routes of admission: Oral smoking & Injection .
Tolerance, dependence & habituation is great for all of them.
Effects: ---
Withdrawal: Watery eyes, runny nose, yawning, loss of apetite, irritability, tremors, panic, cramps,
nausea, chills sweating, insomnia and anxiety.

3. CNS DEPRESSANTS
These include barbiturates, benzodia zapenes, phenothiazenes.
Routes admission Oral, Injection
Tolerance, dependence and habituation is great for all of them.
Effects: Slurred speech, disorientation, drowsiness, drunken behaviour.
Over Dose: Shallow respiration, cold clammy skin, dilated pupil, weak & rapid pulse.
Withdrawal: Anxiety, insomnia, tremors, delirium, convulsions and some times death.

4.CNS STIMULANTS
Nicotine, caffeine, amphetamines.
Routes of admission Oral, Injection
Habituation and tolerance is high while dependence is mild.
Effects: Euphoria, excitation, alertness, insomnia, loss of Appetite, increased blood pressure and pulse.
Over Dose: Agitation, hallucinations, convulsion, increase in temperature & ultimately death
Withdrawal: Apathy, prolonged sleep, irritability, depression and disorientation.
5. HULLUCINOGENS
Lysergic Acid Derivatives, Mescaline, Cocaine
Routes of admission Oral, Injection & Smoking
Tolerance is present while habituation and dependence is not present.
Effects: Illusions, hallucinations, poor perception of time and distance.
Over Dose: More intense episodes, psychosis.
Withdrawal: Irritability, Sleep, Depression.

AETIOLOGY OF DRUG ADDICTION
1. Easy availability and low cost due to local production.
2. Peer pressure (attraction due to the use of friends).
3. Experimental and occasional use leading to addiction.
4. Alcohol or hashish use becomes fashionable.
5. Some take it for allaying anxiety and tension.
6. Some take it for removing depression and frustration of economic
problems, family problems.
7. People sitting idle or at darbars frequently use it
8. Some use it for obtaining mystical state and meditation.
9. Some use it for allaying pain and bringing sleep or for other medical
reasons and then become addicted.

EFFECTS OF DRUG ADDICTION
1. Loss of physical health leading to diseases and early aging
2. Loss of money on drugs.
3. Addicts become economically dependent as they can not perform jobs
4. Loss of sexual energy.
5. Physically handicapped babies are born to addict mothers
6. Addicts are indulged in various crimes.
7. They are responsible for various accidents.
8. Become depressed, frustrated and develop a tendency for suicide,
homicide.

TREATMENT AND REHABILITATION OF ADDICTS
Treatment
1. The addicts should be kept in the hospital or treatment centers for the initial
period where treatment is given.
2. The drug is given in decreasing doses initially and then stopped
3. Other alternative, less dangerous drugs are given initially and then gradually
discontinued.
4. Cold Turkey method
Rehabilitation
4. Contacts with antisocial elements should be stopped
5. Health education should be imparted.
6. Religious education should be imparted.
7. Causes may be removed which cause depression, frustration or family problem.
8. Job opportunity and financial support may be provided where possible.
9. Vocational training be given while in welfare homes. Other activities should be
created for them.Thursday, June 9, 2016 12

BARRIERS
TO TREATMENT
Prior negative interaction
Feelings of shame and guilt
High relapse rate
Lack of access to care giving facilities
IN DATA COLLECTION
Lack of a global defination
Hidden disease
TO OVERCOME
Health education
Provision of health care facilities
Should become a part of our mainstream health care system
Individualized treatment plans
Avoidance of triggers
ORGANIZATIONS WORKING
WHO
UNODC (office on drug and crime)
UNAIDS
NIDA
ACDE (American council foer drug education)
CAMH(centre for addiction and mental health)
CANADIAN CENTRE ON SUBSTANCE ABUSE
DOST
SATSD

LEGISLATION AND STEPS TAKEN BY GOVERNMENT in 8th FIVE YEAR PLAN.
• Creation of a separate ministry of narcotics.
• Creation of anti-narcotics task force.
• Narcotics policy commission.
• Narcotics control, monitoring and evaluation board.
• Pre-trial destruction of seized narcotics and control of acetic anhydride and other
precursors of heroin.
• Elimination of cultivation of plant and heroin laboratories.
• Manufacture, possession, sale and transport of all intoxicating drugs licenced.
• Illegal activities should be checked and punished.
• Health education should be imparted through mass media
• Social welfare agencies and voluntary organization should take part in the
rehabilitation process of the addicts.Thursday, June 9, 2016 14

• Enforcement of coordination programme.
• Control of women folk indulged in addiction.
• Social problems be addressed
• Crimes should be checked
• Foci of addicts should be monitored and those involved in supply be caught and
punished
• Forfeit drug generated money and money laundering.
• Enhanced international cooperation for narcotics control.
• Treatment of addicts by establishing detoxification centers in all districts and teaching
hospitals and providing for their rehabilitation.
The area under illicit poppy cultivation which was 80,500 acers in 1978-79 has been
brought down to 2041 acers in 1997-98. The jurisdiction of anti-narcotics force act 1997
and narcotics substance act has been extended to FATA & PATA. The cabinet in its
meeting in February 1999 approved a Drug Abuse Control Master Plan for Pakistan with
an allocation of Rs. 2832 million, prepared with the assistance of United Nations Drug
Control Programme (UNDCP). The plan encapsules the government policy for narcotics
control between July 1998 to June 2003. This master plan covers the same objectives
as engulfed in 8th five year plan.

DRUG ABUSE SURVEYS
To assess the overall situation of drug abuse in the country the government has decided to carry
out drug abuse surveys after every four years. The salient features of some of them are as follows:
-
1982 SURVEY.
• Total No. of abusers was about 13,01,014 people.
• No. 1 drug of abuse was charas abused by 3.4% of all adult Pakistani males.
• Opium was No. 2 drug of abuse taken by 1.3% of population, alcohol 0.9% and bhang 0.8 %.
• Heroin was abused by 0.4% of all abusers i.e only 20000 people out 13 lacs.
• 48 % of abusers were literate.
• 8.2 lacs of abusers were urban residents and 4.8 lacs were rural (thus abuse was not related
to education,
literacy or socioeconomic status).
• The average age of abuse was 35 years and age of 1st contact was 22 years.
• Average monthly expenditure on drugs was Rs. 300 per person.

1986 SURVEY
• Total No. of abusers increased to 20,66,862.
• 36.8% were urban residents while 63.2% were rural.
• No.1 drug of choice became heroin amounting to 3,65,000 abusers i.e.
31.8% of all addicts.
• Average age of drug abuse was 25 – 30 years.
• Average monthly expenditure on drugs was Rs. 250 - 500 per person.
1988 SURVEY.
Total No. of abusers increased to 22,44,000
• 52 % of drug abusers were literate
• No.1 drug of choice remained heroin amounting to 10,80,000
abusers i.e. 48 % of all addicts.
• Charas remains No.2 drug of choice followed by alcohol and opium.
• Average age of drug abuse was 20 – 25 years.
• First age of contact was 16 – 20 years.
• Average monthly expenditure on drugs was Rs. 1050 per person.

1993 SURVEY
 Total No. of abusers increased to 30,05,649.
 52 % of drug abusers were urban residents while 48 % were rural.
 No.1 drug of choice remained heroin amounting to 15,23,864 abusers i.e. 50.7 % of
all addict
 Charas remained No.2 drug of choice taken by 30.8 % of rural abusers and 28.8 %
of urban.
 Opium was consumed by 5.9% of urban abusers and 5.4% of rural abusers.
 Bhang was consumed by 4.1% of rural abusers and 1.4% of urban abusers.
 Average age of drug abuse was 20 – 25 years.
 First age of contact was 16 – 20 years.
 Average monthly expenditure on drugs was Rs. 1200-1300 per person.
 Most popular drug of Punjab, Sind & Balochistan is Heroin.
 Charas is popular in NWFP.
 Bhang is on the increase in Si
 Opium & Bhang have usually remained low.
 Increase in drug addiction between 1982-1988 was 12.1 % per year and between
1988-1992 it was 6.5% per year. The earlier increase was more in rural areas but
later on both in urban and rural areas and also in literate people.
 Highest No. of drug abuses i.e 2.66 % is in Sind followed by Balochistan 2.52 %,
then Punjab 2.28% and NWFP 2.26%.
 No. of drug abusers in Pakistan is increasing @ 7% per year.

RELATIONSHIP OF DRUG ABUSE WITH SOCIOECONOMIC STATUS ACCORDING TO 1993 SURVEY
Age - 54% are under 30 years, 71.5 % under 35 years
Literacy - In urban areas highest age of abuse is in those educated upto 10 years.
in rural areas highest in those educated upto 5 years.
Occupation - Skilled workers 28%, Unskilled 25 %, Sales workers 17 %.
Income group - 77% have monthly income less then Rs. 3000/month.
Marital Status - 42% unmarried, 54% married, 41% dissolved or separated.
Family Size - 8
Age of First Use – Heroin 3.6 % in children less then 15 years of age
24 % in addicts between 15 – 20 years
Charas 29.4 % in addicts between 20 – 25 years
46 % in addicts between 15 – 20 years
24-.4 % in addicts between 21 – 25 years
Convicted addicts 33%
Residence 82 % have homes – 8.2 % are homeless
Employment 62 % are full time employees, 18 % part time, 20 % unemployed.
In Unemployed Source of Mostly families or charity. Few rely on steeling, gambling
money use for addiction
Reasons for addiction Social Acceptance, Sexual pleasure, Stress, Anxiety, increase in work
performance.
Source of drugs Friends, family members, drug pushers.
Place of abuse Own home, friends home, park,
Intensity 4 times daily 23%, 2 – 3 times daily 41 %, once a week 4 %
Monthly expenditure on drugs Rs. 1200 – 1300

FINDINGS OF DRUG ABUSE SURVEY 2000
Prevalence of drug abuse about 40,00000 people and 1/3rd of this is on charas and hashish
Distribution Largely an urban phenomenon, however rural areas are
also being affected now.
Most commonly abused drug Cannabis with more than 130000 abusers (95% of key
informants reported charas and hashish (cannabinoids) type
of drugs most commonly used ). Annual prevalence of
cannabis abuse between the population aged 15–64 was 3.9%
Heroin and alcohol are on no. 2 & 3 with a rating of 46 %
and 45 % respectively. Besides this 9 % reported for opiates,
20% for psychotropics and 12% were on injectable.
Heroin abuse common in Baluchistan, then Punjab, Sindh while NWFP reported only
12%
Mean age of 1st heroin abuse 22 years.40% of heroin abusers are between 25 to 35 years
while 5% are between 15 to 20 years. As contrast to this in
1993, 25% of heroin abusers were under 20 and 2/3rd were
under 30.
Injectable use of drugs Increasing in urban areas of all provinces except KPK.
In 1993 survey 92.5% smoked the drug and 1.8 % used
injection. In 2000 survey 31% are using injectables.
55% of those surveyed in Karachi are injecting the drug
and only 12% in Peshawar.
Chronic heroin users 500,000 of whom 60 000 inject drugs
Heroin abuse in urban areas or previously high use areas was found to be either stable or
declining in 2000 survey, while its use is defusing to other low use areas.
Overall addicts were more marginalized particularly the street addicts, as compared to 1993
survey while under treatment addicts were usually from affluent class.

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