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xiof traditional treatment with spiritually evolved therapy is aunique approach of The Akal Deaddiction Centers run by TheKalgidhar Trust. Spiritual orientation fosters healthy cognition,positive vibrations which affect the person and the surroundingsThis book will prove to be of immense value tophysician, nursing, paramedical staff, social workers,counselor, psychologists and NGOs involved in themanagement of the addicts.May all those involved in the treatment of the Addictivedisorders be blessed with enthusiasm to rid the Addicts of theiraffliction, and reform these patients so that they can lead ahealthy family life and make the society wholesome.Dr. M.S. AtwalVice ChancellorETERNAL UNIVERSITYBARU SAHIB

DRUG ABUSEDr. (Col.) Rajinder SinghThe serious problem of Drug Addiction and Alcoholismis a global phenomenon of alarming proportions. It is erodingthe very existence of society. The scourge of drug dependencehas deleterious repercussions on the individual’s physical,emotional and socio-cultural spheres.The deaddiction of the drug dependent persons is a timeconsuming and a challenging job. It involves a radical change inthe lifestyle of the individual. The outcome depends on multiplefactors such as personality of the addict, associated emotionalproblems, nature of the drug, duration of abuse etc.IntroductionThe term Drug Addiction does not find mention in thepresent classification of diseases. However, the term addictionis being retained through the current prevalent use of the word“Deaddiction”. As per ICD 10 (International Classification ofDiseases 10th revision), the abuse of drug and alcohol is nowclassified under “Mental and behaviour disorder” due to use ofthe psychoactive substance. Diagnostic and statistical manualof mental disorder fourth edition (DSM - IV) classifies the sameunder “Substance related disorders”.More than 90% of the cases who report to theDeaddiction Centre indulge in opioid and alcohol abuse. Rest of“ When love is your greatest weakness, you will be the greatest person”Anon

13the cases of substance abuse pertain to cannabis,benzodiazepines, antihistamines and nicotine. Various types ofopioids used by the patient, the factors associated with onset ofabuse, modes of drug intake, reasons for seeking treatment andmanagement of the drug abuse are the topics which need theutmost attention of the family physicians.Drug TraffickingIt is fascinating to explore as to how and why anindividual starts taking intoxicating drugs. The various factscame to light while working in a “De-addiction Centre”sponsored by Ministry of Social Welfare, Government of Indiathrough the Punjab Red Cross Society. Most of the patients whoreport to the centre for treatment suffer from abuse of crude/pureopium or its synthetic derivatives. The next common categoryof patients who seek treatment at this “Drug De-addictionCentre” is the alcohol abuse category.Poppy is cultivated in various provinces such asRajasthan, Madhya Pradesh, Uttar Pradesh etc. Because oftrafficking, it is available in every nook and corner of thecountry. Most of the truck transport workers start using opiumderivatives and alcohol soon after joining this trade.The reason given by them is that they have to drive thevehicle during the night and an optimum use of opium or itsderivatives keep them awake and alert. Moreover, manytransport owners give incentives to workers who complete theirjourney in stipulated time. Abuse of opium and alcohol as wellas the incentive for high speed and fast driving are thepredominant factors responsible for high rate of vehicularaccidents. At the same time, truck drivers play an important rolein procuring and distribution of illicit drugs.

14Truck Driver’s SubcultureAny truck driver who takes opium and liquor also takestabacco either in chewable form or by smoking. Taking ofopium and tobacco by the truck transport workers during theprolonged and tiresome driving and to gulp down a quarter of abottle or more to induce sleep may be termed as a part of TruckDrivers Subculture. When asked as to why do the trucktransport workers indulge in intoxicants, their prompt reply was“who would not resort to drugs under such adverse anduncongenial circumstances”. A truck driver who does not usepsychoactive drugs is an exception.ClassificationClassification of psycho-active drugs (substance abuse)as per ICD 10, is as atives and hypnotics?Benzodiazepines?BarbituratesCocaineOther o?Cigarettes?Chewing tobacco?Snuff?Pipes and cigars

159. Volatile solvents?Gasoline?Glue etc.Abuse Of OpioidsDrugs can entrap any member of the society, withoutconsideration of status, education, caste or creed. A commoncategory of people who abuse opium is an uneducated personfrom a rural background coming from lower rungs of societye.g. a farm labourer who allegedly starts taking opium underpeer pressure to raise the work output and to counter the fatigueof strenuous labour. On many occasions, it is the agriculturefarm owner who induces a labourer to take opium for his selfishmotives.Opium SubstitutesWhen an individual is not able to procure opium forhimself, he resorts to other substitutes which are as follows:1. Bhuki (crushed dodas)2. Tablet codeine phosphate3. Tablet Ethyl morphine hydrochloride4. Dextropropoxyphene hydrochloride5. Diphenoxylate hydrochlaride.6. Certain cough syrups containing codeine phosphate.Brown Sugar AddictionBrown sugar is a spurious and cheaper form of Heroin.Smack (Brown Sugar) diacetyl Morphine or synthetic narcoticis a very potent and highly addictive substance used by adultshailing from urban background. Smack is usually used in twoways. A common practice known as “chasing” where the userinhales the smoke of heated ball of brown sugar. The smack is

16heated meticulously over an aluminium foil paper and theindividual follows this moving ball with the pipe in his mouthfor inhaling the smoke. Puffs of cigarettes are smoked by thesmack chaser as the sips of liquor are followed by snacks.The other common method of use of smack is bysniffing. Rarely, ‘smack’ may be taken by intravenous injectionor is mixed with cigarettes and smoked. The smack addict referto the ‘number of lines’ produced by the moving ball of brownsugar (on the aluminum foil paper) to convey the quantum ofbrown sugar chased by him.Factors Associated With Opioid Abuse:Thrill And ExcitementSome of the patients attribute the onset of drug intake toget a thrill or to fulfill the curiosity about the drug. The firstexperience is perceived as exciting and pleasant. Repeatedabuse leads to tolerance and subsequent increase in the dosage.Others have a wish to conform to the norms of the peer group.This peer group who is experimenting with various drugs,generates a similar desire in the persons who succumb to theprevailing pressure. They have difficulty in asserting their viewpoint and the new entrants act in a way approved by the peergroup. The thrill of new, exciting and novel experience is thefirst step towards a very long journey of drug devastation.Domestic stress arising out of the strained interpersonalrelations amongst the members of the family, financialstringency and adjustment problems may contribute to the drugabuse either by precipitating the onset or by perpetuating the useof drug.

17Physiological Actions Of OpioidsThe opioids (opium and synthetic narcotic drugs) causeno alerting or awakening response in the human beings. On thecontrary, the opioids cause sluggishness and induce sleep andproduce a sensation of relaxation. It is the feeling of tranquilityand euphoria caused by opioids which pulls the truck driversand a strenuous laborers through the stress of continuous nightdriving and hard labour which is allegedly interpreted asalerting and increased output of work. Infact, opioids have aravaging effect on the work output and efficiency of anindividual. He has to waste his time in procurement of the illicitdrug and incessant preoccupation with the arrangement of hisfinancial resources for future supply of the drug.The complex of pleasant feeling, tranquility anddecreased concern about anticipated problem after ingestion ofopioids is often referred to as ‘high’. When synthetic opioids areself-administered intravenously or sometimes when brownsugar is smoked, there is a sharp increase in the level of the brainopioids, that produces a distinct, intense and a generallypleasurable sensation, often referred to by these heroin andsmack addicts as ‘flash’ or ‘rush’. Some users liken the feelingto sexual orgasm. Such ‘rush’ is not experienced with a slowonset of opioid action through oral or subcutaneous routes.These experiences may reinforce the use of opioids despite therisks.Adolescence - A Period Of RevoltIt is not uncommon to encounter an adolescentmanifesting his hostility against his family members especiallythe father by resorting to drugs. Adolescence is a period ofprotest against the conventional norms and established values of

18life. Lack of communication between the son and the father andthe maternal overprotection fosters emotional problem in theoffspring which may ultimately be manifested by drug abuse.Use Of Pain Relieving DrugsMajority of the patients who are given pain relievingdrugs during a physical illness do not develop drug addiction.The indiscriminate use of narcotic analgesics by the treatingphysicians and quacks can induce a vulnerable person into drugabuse. Patients suffering from chronic pain due to traumaticinjuries, backache, police tortures and using narcotic analgesicslend to become addicted to opioids.Learning TheoryConditioning factors may play a part in the causation ofaddiction. Feelings of tranquility and peace after intake ofopium narcotic and the relief of the discomfort experiencedthereafter reinforce the individual to continue the use of narcoticdrugs.The basis of this learning theory is the Pavlovianconditioned response. Experience of ‘high’ and ‘rush’ afterintake of opioids encourages the person to repeat the rewardingresponse. There may be interplay of many more factors whichmake an individual dependant on narcotic drugs.If some elder member of the family is addicted to drug,the growing child tends to shape his behavior with the model ofelders. The aspect of behavior which arouses pleasure is easilyadapted by the child.Accessibility Of Drug AndPersonality FactorsEasy availability of the drug may be associated with

19addictive behavior as may be seen amongst professional peoplehandling the drug e.g. doctors, nurses, registered medicalpractitioners, chemists, druggists etc. Many a times, theaddiction of the drugs may be symptom of some deep rootedpersonality disorder in a emotionally immature personality.Arrogant behavior, indifferent attitude towards others, wish forimmediate gratification of one’s desires and tendency to cheatand lie, all these point to a psychopathic personality disorder.Biological ExplanationsIt has been found that human brain produces endogenousmorphine and codeine. Opiates are secreted in excess when aperson is physically hurt and it accounts for the absence of painduring the acute state of traumatic injury. From the biologicalview point, it is postulated that some persons may be deficient inthese endogenously opiate producing site. And this may be thereason for them to resort to external supply of opioids. Becauseof the development of tolerance, these individuals become drugdependent.Role Of EthicsLoosening of the grip on moral and ethical values,especially during the adolescent period, predispose theindividual to drugs. Recent times have witnessed rise ofintolerance, aggression and violent behavior at all levels i.e.social, family and individual. The unethical behavior anddegradation of moral values are closely linked with the abuse ofdrugs.Buperinorphine AddictionAnother hard drug to which the youth gets addicted isBuperinorphine (Injection Tidigesic/ Norphin). In the company

20of other drug dependent persons, the first ‘shot’ is usually givenby someone else intravenously after which a sense ofexhilaration and thrill is experienced soon after the injection.Normally, Inj. Buperinorphine is not taken alone. Other drugswhich are combined along with it are:a)b)c)d)Inj. Pherniramine maleateInj. PromethazineInj. DiazepamInj. Pentazocine lactateThese drugs enhance the feeling of elation whichprompts the abuser to repeat the experience.Those who use Buprenorphine, their legs and arms areswollen due to blockage of the blood flow because of theinflammation of the veins. Their limbs may be covered withmultiple scars due to the ulcers caused by unsterilized andunhygienic syringes used at wrong sites for injecting the drugintravenously. If the same syringe is used, there is possibility oftransmitting HIV/Hepatitis B & C from one addict to another.Because of easy availability of Norphin Injection anddifficulty in procuring ‘smack’, many smack users shift toNorphin. Such persons abusing smack can be identified by thepresence of burn scars on the tips of the fingers and thumbcaused by ‘chasing’ smack during the ‘trip’. Norphin abuse ismore frequently encountered than the ‘smack’ abuse.De -addictionDe-addiction of the drug dependent person is a very timeconsuming and a challenging job. The individual is got rid of thedrug and properly rehabilitated only when the chances ofreverting to the drug are minimum. It involves a radical changein the lifestyle of the individual. The outcome of the de-

21addiction depends on the personality of the addict, associatedemotional problems, nature of the drug and duration of abuse.Hard drug addicts (of ‘Smack’, ‘Heroin’, Inj Norphin’, InjMorphine) tend to have high rate of recurrence and relapses.Seeking TreatmentThe drug abuser gives various reasons for seekingtreatment. There is partial realization that his addictive behavioris causing disruption in the family. Frequent quarrels andskirmishes at home make him feel upset. He realizes that he isnot good model for his growing children and he has followed adeviant path.Financial stringency is another reason put forward. Thedrugs have drained the monetary resources and there is drasticdip in the socioeconomic status. Yet, the addicts maintain ahierarchy in their social standing.Lowering of the social esteem due to the stigmaassociated with drug abuse and poor prospect of finding asuitable marriage proposal for his children, can drive him toseek abstinence from drugs. One of the patients reported that theannoyance shown to his addictive behavior by his young sonaged 4 years was the reason for him to come to the De-addictioncentre for treatment. With passage of time, the person tends tobecome responsible and mature and hence desires to get rid ofdrug seeking behavior.Yet another reason given by the opium dependent personis that he is not able to perform any social obligation in thefamily because of the fear that his addictive behavior willbecome widely known to the relatives. This may havepsychological repercussions on his social esteem.

22Sometimes, the ill effect on the health of an addictedperson may invoke him to seek treatment to get rid of the drugwhich damaged the body organs. This is especially applicable inthe case of alcohol which causes liver disease, gastriculceration, inflammation of the pancreas, polyneuritis,psychiatric illnesses, epilepsy, dementia etc. On the contrary,the narcotic addicts do not appear to be having grave physicalproblems as that of alcohol abuse.ManagementThe treatment of drug addiction may be consideredunder the following heads:1. Pre-hospital PhaseMany of the drug abusers have inadequate motivation toget rid of it. In spite of the devastation caused by the drug, thepatient shows no inclination to get treatment. Thetherapist/counsellor’s job is to solicit cooperation of the patientto seek medical advice. Free and frank discussion may lay baremisconceived notions nurtured by the patient which maydirectly or indirectly prevent him to seek treatment. Motivationof an individual with a drug problem is a vital factor whichdetermines the ultimate outcome of the care. No useful purposeis served in forcing a patient for admission, if he does not desireto be helped and treated.II DetoxificationIt is the management of withdrawal symptoms. Due todevelopment of tolerance, greater quantity of the drug isrequired to produce the same effect. Patients have been treatedfor opium addiction who were consuming more than 20 gm aday and smack, more than 2 gm/day in this De-addiction

23Centre. Sudden withdrawal of the drug is very distressing andpainful. Patient may complain of aches and pains especially ofthe calf muscles, watering of the eyes, running of the nose, hairraising on the body, sweating or feeling of numbness in thelimbs, disturbed sleep, poor appetite, restlessness etc. Thesesymptoms are managed by drugs such as methadone, clonidinefor symptomatic relief. During the detoxification, it is ensuredthat the patient gets proper sleep and rest. At our Centre,buprenorphine which blocks the opioid induced euphorea isused as an agent for detoxification.Cold TurkeyCold Turkey method of treatment consists of suddenwithdrawal of the drug without administrating any medicine.The patient is encouraged to bear the pain and suffering of thewithdrawal. It is postulated that the agony of the patient acts as adeterrent for the addictive person and it is likely that he mayabstain from the drug. This form of treatment is followed as amatter of policy in Singapore.AcupunctureAcupuncture is also one of the methods of treatment. Theskin punctures may cause the endogenous opiate to be secretedin the body and hence the severity of the withdrawal feature maybe reduced considerably.III. RehabilitationThe individual is put on a long-term methadone therapyfor maintenance purposes. Patient is relieved of the incessantpreoccupation with the procurement of the drug and hence canhelp him to be occupied with some constructive employment.Methadone is not available in India. It is pertinent to mention

24that till recently opium was being supplied to the addicts by thePunjab Health Department. Similarly, methadone is suppliednow in western countries. The disadvantage with methadone oropium supply is that the patient continues to use the nar

5. Drug Abuse 12 - 27 6. Drug Addiction in Punjab 28 - 31 7. Alcoholism: Practitioner's Perspective 32 - 47 8. Herion/Smack Addiction 48 - 59 9. Relapse in Drug Abuse treatment 60 - 68 10. Characteristic of a substance Abuser: Causative factors for Drug abuse 69 - 77 11. Incorporating Spiritual Concept in Addiction 78 - 80 12.