Introduction

Substance abuse occurs when an individual has been using an habit-forming substance in excess and for a long period of time with detrimental effects on his / her physical health, social life and psychological well-being.

Substance abuse is associated with social, physical and psychological problems.

These substances have psychoactive component; i.e. they affect the thoughts, emotions and behavior.

According to WHO 3% of the general population suffers from substance abuse related mental health problems.

Definition of Terms

• Alcoholism: chronic disease marked by a craving for alcohol. People who suffer from this illness are known as alcoholics. They cannot control their drinking even when it becomes the underlying cause of serious harm, including medical disorders, marital difficulties, job loss, or automobile crashes.
• Tolerance: a form of physical dependence, occurs when the body becomes accustomed to a drug and requires ever-increasing amounts of it to achieve the same pharmacological effects.
• Drug dependency: psychological and sometimes physical state characterized by a compulsion to use a drug to experience psychological or physical effects. Drug dependence takes several forms: tolerance, habituation, and addiction.
• Habituation: a form of psychological dependence, is characterized by the continued desire for a drug, even after physical dependence is gone. A drug often produces an elated emotional state, and a person abusing drugs soon believes the drug is needed to function at work or home.
• Addiction: is a severe craving for the substance and interferes with a person’s ability to function normally. It may also involve physical dependence.

Common Substances Abused in Uganda

• Alcohol (common in self-medication in depression, anxiety and early stages of psychosis, e.g. manic disorder)
• Tobacco
• Diazepam (as sleeping pill, common in self medication for anxiety and depression; may be iatrogenic, i.e. introduced by the doctor in the treatment of anxiety)
• Marijuana (among laborers, students, long distance truck drivers)
• Khat (Mairungi) to dampen hunger
• Pethidine (among health workers or patients who have been exposed to these drugs after major surgery)
• Aviation fuel, petrol, glue, thinner (among street children)
• Cocaine (common among students from rich and/or social prominent families)
• Heroin (as for cocaine)
• Mandrax (Methaqualone) (as for diazepam)
• Amphetamine (students, laborers, long-distance truck drivers to promote alertness and stamina)
• Mogadon (as for diazepam)
• Magic mushroom (youth in dance places, musicians)

Groups Prone to Use Substance of Abuse

• Medical workers (anti-anxiety drugs, hypnotics and sedatives, pethidine)
• Adolescents and children of school going age from rich families (alcohol and stimulants)
• Idle, unemployed youth (cannabis, khat)
• Manual laborers (cannabis, tobacco, khat)
• People who work in breweries (various alcoholic beverages)
• Taxi and long distance drivers (cannabis)
• Students of higher learning institutions (stimulants, cannabis)
• Prostitutes (various alcoholic beverages, heroine, cocaine)
• Music Dance and Drama group (ecstasy, speed)

Factors Predisposing People to Substance Abuse

• Genetic predisposition
• Socio economic stressors
• Cultural practices /influences
• Availability of the drugs of abuse
• Peer pressure
• Pressure to achieve
• Poor school performance
• Frustrations
• Conflict within families and poor relationship between parent and children
• Broken family environment
• Inadequate parental supervision of children
• Underlying mental illness e.g. depression, etc.

Stages of the Process of Substance Abuse

1. Experimentation: try out once or on few occasions-usually in the peer group
2. Social use: this is when the individual uses the drugs regularly
3. Abuse: is irregular intoxication with a substance of abuse, which occurs out of the social context. The individual may be intoxicated during the day, May get problems at work, May have marital discord and may do what is contrary to the law
4. Tolerance: tendency to take increase doses of the substance to get the desired effect
5. Dependence: when the substance is not used at the scheduled time withdrawal symptoms occur (physical dependency). Psychological dependence refers to the repeated psychological need for the effects offered by the substance

Dependence Syndrome

This is a clinical syndrome describing the features of substance dependence.

• Primacy of drug-seeking behaviour Also called ‘salience’ of drug use. The drug and the need to obtain it become the most important things in the person’s life, taking priority over all other activities and interests
• Narrowing of the drug-taking repertoire: The user moves from a range of drugs to a single drug taken in preference to all others. The setting of drug use, the route of use, and the individuals with whom the drug is taken may also become stereotyped.
• Increased tolerance to the effects of the drug: The user finds that more of the drug must be taken to achieve the same effects. They may also attempt to combat increasing tolerance by choosing a more rapidly acting route of administration (e.g. IV rather than smoked), or by choosing a more rapidly acting form (e.g. freebase cocaine rather than cocaine hydrochloride).
• Loss of control of consumption: A subjective sense of inability to restrict further consumption once the drug is taken.
• Signs of withdrawal on attempted abstinence: A withdrawal syndrome, characteristic for each drug, may develop. This may be only regularly experienced in the mornings because at all other times the blood level is kept above the required level.
• Drug taking to avoid development of withdrawal symptoms: The user learns to anticipate and avoid withdrawals (e.g. having the drug available on waking)
• Continued drug use despite negative consequences: The user persists in drug use even when threatened with significant losses as a direct consequence of continued use (e.g. marital break-up, prison term, loss of job).
• Rapid reinstatement of previous pattern of drug use after abstinence: Characteristically, when the user relapses to drug use after a period of abstinence, They are at risk of a return to the dependent pattern in a much shorter period than the time initially taken to reach dependent use.

Effects of Substance Abuse

Substance abuse is associated with health’s, economic and social problems.

• Alcohol for example is the most common cause of liver failure
• Alcohol can also cause Hepatitis, hearth enlargement and cancer of the esophagus, pancreas, and stomach
• Alcohol abuse is also responsible for neuropsychiatric disorders, domestic violent, child abuse and neglect and productivity loss

Substance Abuse and HIV/AIDS

• Injecting drugs involves considerable risk of infections including hepatitis B, C and HIV/AIDS
• The prevalence of HIV infections among injecting drug users has been noted to be increasing all over the world
• Treatment services should therefore provide assessment for HIV/AIDS, Hepatitis B and C, TB etc.
• Treatment of these conditions
• Counseling to help patients stop unsafe injecting practices

Substance Related Psychotic Illness

Although some people can use alcohol and other illicit drugs for long without experiencing serious mental health problems, Use of these substances can cause psychotic disorders in ways:

• The substance may precipitate latent psychotic illness in an individual who may be genetically predisposed
• The substance may themselves induce a psychotic illness in an individual who may not have been genetically predisposed, especially after prolonged used of the substance
• We can have people present with alcohol induced psychosis, cannabis induced psychosis, cocaine induced psychosis, etc.
• Individuals with drug induced psychosis often present with both hallucinations and delusions
• They may present with symptoms similar to those of schizophrenia
• A common distinguishing features is tactile hallucinations, which tend to be more common in such individuals.

Prevention of Substance Abuse

Achieve by the use of support group.

Prevention begins with assessing the pattern and potential magnitude of the use of abuse substance then Followed by the management of the active use of the abused substance (detoxification) before involving the person in the preventive program.

Recognition of Alcohol Abuse (Assessment of Patient Using CAGE)

Doctors and other professionals often do not ask the right questions.

It should be standard practice to ask all patients (medical, surgical and psychiatric) about their alcohol consumption.

The use of four key questions referred to as CAGE will help to identify alcohol abuse.

CAGE is from the initial letters of the following words: Cut, Annoyed, Guilty and Eye-opener. Ask the following.

1. Have you ever felt that you ought to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking habits?
3. Have you ever felt Guilty about your drinking
4. Have you ever had a drink first thing in the morning (an Eye opener) to steady your nerves or get rid of a hang over

Two or more positive replies identify alcohol abuse and one positive reply, possible current use.

Health Education/Harm Reduction

The health care provider should educate the patient with alcohol or substance used disorder at every clinical encounter.

• Advice directed at use of safer drugs or routes of administration.
• Advice regarding safer injecting practice
• Advice regarding safe sex.
• Prescription of maintenance opiates (substitution prescribing) or BDZs.
• Assessment and treatment of comorbid physical or mental illness.
• Engagement with other sources of help (e.g. social work, housing)

Detoxification

Patients should be and helped to appreciate the disadvantages of substance abuse.

The aims of treatment is motivated to put the patient off the substance without the patients developing withdrawal symptoms (detoxification).

It is advisable to carry out detoxification in the hospital because of the dangers of serious withdrawal symptoms.

This is achieved by:

• Giving a patient a drug that has the same properties as the drug of abuse (analogue) and then reducing the dosage
• Incase of alcohol the drug (analogue) is benzodiazepine
• Give also an anticonvulsant drugs in case alcohol used disorder with history of seizure due to withdrawal
• Give vitamins b. complex intra-muscularly followed by oral route after 4-5 days
• Monitor the patients closely and correct any signs of circulatory failure by the use of intravenous fluids therapy in the hospital
• Rehabilitation: the patients is helped to rediscovered his / her lost social and occupational skills
• Support groups: encourage the formation and use of the support groups such as alcohol anonymous groups

Motivational Interviewing (MI)

• Client-centered counseling style for eliciting change
• Clients is help to explore and resolve their ambivalence about behavior change
• The client’s motivation to change is enhance if there is a gentle negotiation process in which he/she articulates the benefits and cost involved
• To achieve and sustain the desired behavior change, The motivation has to come from within the client
• The central principles of this technique is to help the client realize a discrepancy between the client’s most deeply held values and their current behavior (i.e. tease out ways in which the current unhealthy behaviors conflict with client’s wishes)

Ant Abuse

A treatment option whereby the alcoholic who takes a daily ant abuse pill will become very sick whenever he she takes alcohol.

The pill will therefore force the person to give up drinking because of the unpleasant side effects.

However there is no evidence to show that this coercive treatment is effective.

It is unlikely that such treatment will be beneficial.

Alcoholics Anonymous

This is a widespread treatment for alcoholism.

AA is a self-help group of people who are trying to abstain from alcohol use and help others do the same.

They hold meetings regularly to share their experiences and discuss participants’ individual problems.

Treatment within the community is preferable, except those with severe dependence, a history of DT, or withdrawal seizures, an unsupportive home environment or previous failed attempts at detoxification.

Psychosocial support and family intervention are also important esp.in the recovery process, particularly when other problems occur with alcohol dependence.

Therapy for spouses and family members, or simply their involvement has benefits for both initiation and maintenance of alcohol treatment.

Others

Specialized treatment is available at the national referral mental hospital where there is an alcohol and drug unit.

There are also some private facilities in the country offering help to alcoholics and drug addicts.

Stages of Change and Harm Reduction

A model for understanding motivation and action towards change in harmful patterns of drug use was proposed by Prochaska and DiClemente.

Motivation is regarded as a prerequisite for and a precursor to action towards abstinence or more controlled drug use.

This model can be used when trying to tailor treatments to the individual.

• Pre-contemplation: The user does not recognize that the problem of drug use exists, although this may be increasingly obvious to those around them.
• Contemplation: The user may accept that there is a problem and begins to look at both the positive and negative aspects of continued drug use.
• Decision: The point at which the user decides on whether to continue drug use or attempt change.
• Action: The point of motivation, where the user attempts change. A variety of routes exist by which change may be attempted, which may or may not include medical services.
• Maintenance: A stage of maintaining gains made and attempting to improve those areas of life harmed by drug use.
• Relapse: A return to previous behaviour, but with the possibility of gaining useful strategies to extend the maintenance period on the user’s next attempt.