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Drugs and your health

Paper presented by Chairman, National Dangerous Drugs Control Board, Professor Ravindra Fernando at the 4th Global Conference on Drug Abuse Prevention" held recently in Penang, Malaysia.

Non-medical drug use has created many problems world over. Casual or recreational use of moderate amounts of drugs for its pleasurable effects is well known. Non-medical drug use can be for experimental purposes. In certain circumstances, drugs are used for some of their helpful effects. One example is students taking amphetamines.

The types of ill-health or morbidity resulting from the acute or chronic use and misuse of drugs can be classified as follows:

(a) Direct pharmacological effects:

1. Physical: e.g. opiate-induced constipation, phenothiazine-induced extra-pyramidal symptoms.

2. Mental: e.g. psychosis caused by LSD or amphetamines.

(b) Indirect consequences of drug action: e.g. trauma due to a fall caused by unsteadiness in acute or chronic barbiturate poisoning.

(c) Consequences of the method of drug administration: e.g. hepatitis, abscesses.

(d) Dependence and consequences of abstinence syndrome: e.g. convulsions in benzodiazepine and barbiturate withdrawal.

A drug can be defined as any substance that when taken into the living organism, may modify one or more of its functions. Therapeutic drugs, such as aspirin or paracetamol, are taken because they modify bodily functions.

The use of a drug usually by self-administration in a way different from the approved medical or social patterns in a given culture is called "Drug Abuse".

"Drug Addiction" is a state characterised by an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means. It is sometimes accompanied by physical dependence.

The resulting state is detrimental not only to the addict but also to society. Psychic effects

"Drug Dependence" is a state resulting from the interaction between a living organism and a drug, characterised by behavioral and other responses that always include a compulsion to take the drug on a continuous or periodic basis to experience its psychic effects (psychic dependence) and sometimes to avoid the discomfort of its absence (physical dependence). Tolerance may or may not be present. Dependence producing drugs can be classified in different ways. One classification is as follows:

* Alcohol - barbiturate type: alcohol barbiturates and drugs with similar effects

* Amphetamine type stimulate: amphetamine, methylhenidate and anti-obesity drugs

* Cannabis type:

* Cocaine type:

* Hallucinogen type: LSD etc.

* Khat type: preparations of Catha edulis

* Opiate (morphine) type: morphine, heroin, pethidine etc.

* Volatile solvent type: toluene, acetone etc.

* Benzodiazepines and similar drugs:

* Tobacco products:

Drug dependence leads to physical and mental illnesses that shorten the life span. Intravenous drug addicts are known to die prematurely from various kinds of infections that include hepatitis, endocarditis and pneumonia. They are prone to suffer from acute overdose which sometimes causes death. In intravenous heroin addicts, an unexplained fatal acute pulmonary oedema has been documented.

Hallucinations leading to accidental deaths and sudden cardiac deaths following volatile solvent abuse are reported.

As a result of poor nututrition and health status, they develop infections such as tuberculosis easily. HIV/AIDS in intravenous drug addicts include leads to several well-recognised medical complications.

Causes of death in drug addicts inhalation of vomit acute ulcerative endocarditis, bronchopneumonia acute overdosage and hepatitis. They are more prone to accidents including burns and falls from heights victims of murder and suicide. If we consider one drug, cocaine the clinical conditions described in cocaine abusers include perforated nasal septum, keratitis of the eyes, dental erosions crack thumb and hands, seizures, heart muscle disease, coronary artery disease, valvular heart disease liver disease brain haemorrhages, blood and immune system diseases and sudden cardiac death.

Heroin and other opiates are central nervous system depressants. In opiate overdose, respiration slows potentially in hypoxia coma, or death. It is reported that in 1998 alone 140 deaths from unintentional opiate overdoses occurred in King County (which includes Seattle), USA.

The results of this study further indicated that the annual number of opiate overdoses increased by 134% (from 47 to 110) when the county population increased by only 11.3%.

Another group of health problems of drug addicts are related to withdrawal symptoms. For example, withdrawal symptoms and signs for heroin are well documented. They include.

* Anxiety, restlessness

* Sweating, yawning, runny nose and watering of the eyes

* Vomiting

* A goose-flesh appearance of the skin

* Diarrhoea, incontinence of urine and associated abdominal pains

* Muscle cramps

* Loss of appetite, generalized weight loss and dehydration

* Hallucinations and delusions

* Marked chillness alternating with hot flushes when the body temperature rises.

In severe cases of withdrawal, death can occur if medical help is not available. Methadone is used in the management of heroin abuse. However methadone also has caused medical problems.

For example in a study in Hamburg the first methadone-related fatalities were observed three years after methadone maintenance treatment (MMT) was introduced in 1990.

Fatal poisoning

From January 1997 until June 1999, methadone was the predominant cause of death in about 39% of all drug-related fatal poisonings while the proportion of mixed heroin/methadone intoxications was about 10%.

Sixty-five per cent of those who died of fatal methadone-related poisonings had no history of MMT. Since take-home doses for up to 7 days are prescribed to the patient due to a change in the German Narcotics Act in 1998, the diversion of methadone into illegal markets may have been accelerated. This results in rising numbers of non-intentional methadone-related fatalities among addicts who have never been in MMT. Although there was no doubt that the MMT reduced the mortality rate among the great majority of patients in Hamburg, the authors of this study recommended that supreme efforts should be made to prevent or reduce fatal intoxications by methadone in the non-treatment group.

A study performed by the Department of Psychological Medicine and Addiction Sciences of the Institute of Psychiatry, London showed that although the total number of self-poisoning in England and Wales has dropped by 32% the number involving methadone and/or heroin rose by 900% during the period 1974 to 1992.

The proportion of poisoned deaths involving methadone (alone or in combination with heroin) rose by 80% per 3-year period. The proportion of poisoning deaths involving heroin without methadone rose by 76% per 3-year period. The study concluded that the impact of opiate addiction on rates of death by poisoning is rising quickly. This may reflect the growth of the addict population and is an important public health problem.

A study of 2708 heroin-related deaths in north-eastern Italy from 1985 to 1998 to establish the main causes of death showed that overdose was found to be the major cause (37%) followed by HIV/AIDS (32.5%) and road traffic accidents (9.4%). The percentage of deaths due to HIV/AIDS increased steadily from 2.7% in 1985 to 42.2% in 1996, and then decreased to 16.9% in 1998.

The average age of death per year rose from 26 in the mid eighties to 43 in 1998. This study showed that the mortality rate of heroin addicts was 13 times greater than in the general population.

A 33 year follow up study of 581 male heroin addicts, examined longitudinal patterns of heroin use, other substance use, health, mental, health, employment, criminal involvement and mortality. The sample was composed of addicts admitted to the California Civil Addict Program (CAP) during the years 1962 through 1964. At the latest follow-up in 1996-1997, 284 were dead and 242 available for interview.

Mortality

Age, disability, years since first heroin use, and heavy alcohol use were significant correlates of mortality. Of the 242 interviewed subjects, 20.7% tested positive for heroin (with additional 9.5% urine refusal and 14.0% incarceration, for whom urinalyses were unavailable), 66.9% reported tobacco use, 22.1% were daily alcohol drinkers, and many reported illicit drug use.

For example, heroin use was 40.5% marijuana 35.5%, cocaine 19.4%, crack 10.3% and amphetamine 11.6% in the past year. The study also showed high rates of health problems, mental health problems, and criminal justice system involvement. Long-term heroin abstinence was associated with less criminality, morbidity, psychological distress, and higher employment. For some, heroin addiction has been a lifelong condition associated with severe health and social consequences.

There is growing concern about increase in illicit drug use and associated fatalities in young people.

An analysis of successive cohorts of addicts in England and Wales aged 15-19 years were followed up over a 20-year period covering 1974 to 1993. The researchers investigated trends in all-causes mortality, examined teenage-specific mortality, that is deaths during ages 15-19 years, and determined excess teenage-specific death in this population.

Overall mortality rate in the study population of 9491 was 4.7/1000 person-years. The median age at death was 23 years, with the majority (91.3%) of deaths occurring between aged 15 and 29 years. Excess teenage-specific mortality in the population was 10.7 in males and 21.2 in females when the figure for the general population was 1. Increase in excess mortality in both sexes was evident in the last 5-year period of study. The majority of deaths (64.3%) resulted from accidental poisoning.

Methadone and heroine/morphine accounted for about two-thirds of accidental poisoning deaths, while suicide accounted for 11.4% of teenage-specific deaths. It is strongly recommended that treatment services should be more responsive to the need for careful prescribing, dispensing and administration of substitute medication to teenage addicts in their care. The development of needs-led, case-sensitive treatment services for young addicts is indicated.

In the spring of 2000, a series of unexplained deaths was first reported among injection drug users (IDUs) in the United Kingdom and the Republic of Ireland. I also performed a few autopsies of these young addicts in Glasgow, where I was working as a Crown Office Forensic Pathologist. Between 1st April and 12th June 2000, there were about 62 unexplained cases of severe illness, and at least 30 deaths reported among IDUs.

Cases were defined as IDUs who had been admitted to hospital or found dead since 1st April, 2000, with soft-tissue inflammation manifested as abscesses, cellulitis, fascitis or myositis at an injection site and either severe systemic toxicity with high white cell counts and sustained systolic blood pressure less than 90 mm Hg despite fluid resuscitation or evidence at autopsy of a diffuse toxic or infectious process, including pleural effusion and soft-tissue oedema or necrosis at an injection site. The illness was associated with intramuscular or subcutaneous injection, but not with intravenous injection.

The isolation of Clostridium novyi from two cases was reported by a British group of researchers in mid-June of 2000, with further C. novyi and C. perfringens isolations reported in August of the year. There was speculation that the unexplained illnesses and deaths were caused by bacterial contamination of heroin supplies. The most recent update on the epidemic in the UK and Ireland reported that there had been 104 cases, with 35 deaths.

It is believed that contributing risk factors to developing the syndrome include "skin popping" (i.e. injecting into muscle or underneath the skin rather than directly into a vein) and the use of acid to dissolve the heroin, which may contribute to initial skin or muscle damage, or both, leading to ideal growing conditions for Clostridium and other bacteria. These cases serve to remind primary health care providers to be vigilant in cases of soft-tissue infection among IDUs and not to underestimate the potential severity of the situation. Prompt and aggressive treatment may be essential in order to prevent the rapid progression from presenting symptoms to severe illness and death.

Pregnancy

Drug abuse affects foetus in pregnant women. For example, alcohol (ethanol) is the human teratogen that produces the most serious neurobehavioral effects on the fetus. Cocaine is associated with spontaneous abortions, premature labour, precipitous labour, still births and meconium staining.

Heroin use during pregnancy has been associated with low birth weight, miscarriage, prematurity, microcephaly and intrauterine growth retardation. Cigarette smoking has been associated with spontaneous abortions, premature rupture of membranes, preterm delivery, perinatal death, low birth weight infants, and deficits in learning and behaviour. The facts presented here about the health and drug dependent persons paint a grim picture indeed. They are more likely to die young from either natural disease or trauma. The treatment methods utilised can also be as dangerous as the disease itself. The health effects of the drug abusers are a major concern to the family members. The state health services eventually have to bear the cost of treatment spending valuable resources needed for health services, education and poverty alleviation.

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