Substance Abuse In Nigeria: From Primary Clinical Care Perspective And Suggestions For The Way Forward
Excerpts from a submission on this topic
for the Society Of Family Physicians of Nigeria (SOFPON)
by Dr. Adekunle J. Ariba (MBBS, FMCGP, FWACP)
Chief Consultant Family Physician
Olabisi Onabanjo University Teaching Hospital Sagamu Ogun State
Introduction: The demographic transition in Nigeria and the adoption of Western life style have ushered in a period when the morbidity pattern in primary care is becoming dominated by non-communicable diseases including drug and substance abuse. In a recent scientific descriptive national survey of substance use in the country conducted by prominent Nigerian Psychiatrists and involving all the 6 geo-political zones of the country, it was established that the abuse of both legal and illicit drugs is increasing nationwide.
Hence there is need to design urgent measures to tackle this problem before it overwhelms the already fragile primary care system. Family Physicians are particularly concerned because as doctors of first contact most of the initial consultations and management of affected citizens fall squarely on their shoulders.
Addiction or dependence is a chronic, relapsing brain disorder/ dysfunction characterised by compulsive drug/ substance seeking and use, despite harmful consequences. Certain substances have the tendency to cause dependence/ addictions. This is because they cause structural and/ or functional changes to the brain and these changes lead to the behavioural changes that characterize addiction. The initial decision to use a given substance is usually voluntary. However, with continued use, a person’s ability to exert self-control can become seriously impaired. This impairment is the hallmark of addiction.
Why does Drug Addiction Occur?
The Learning theory of drug abuse: occurs as a result of learning which could be by means of conditioning, instrumental learning or social learning.
The biological theory of drug abuse: determined by the individuals biological or genetic factors which make them vulnerable to drug addiction.
The Personality theory of drug abuse: holds that some personalities are characterised by inability to delay gratification, low tolerance for frustration, poor impulse control, high emotional dependence on other people, poor coping ability and low self-esteem.
Individuals with these personality characteristics find it difficult to abstain from drug abuse.
Socio-cultural theory of drug dependence/abuse: maintains that abuse is determined by socio-cultural values of the people. For instance, while certain cultures permit the consumption of alcohol and marijuana, other cultures do not. Among the Urhobo, Ijaw, Ibibio, Edo, Igbo, Yoruba and Itsekiri, alcohol (Ogogoro) is used in cultural activities. In Northern Nigeria, alcohol is forbidden by the predominant religion which does not forbid cigarette consumption, so that people in that part of the country may be more prone to nicotine dependence.
The fact that no single theory fully explains the aetiology of drug abuse suggests that there are multiple factors involved – most likely a combination of personality, behavioural and environmental factors.
The following are risk factors for drug abuse:
- Aggressive behaviour in childhood.
- 2. Lack of parental supervision, guidance and support.
- 3. Poor social skills.
- Drug experimentation (experimental curiosity).
- Availability of drugs (e.g. at schools).
- Community poverty.
- Poor academic performance.
- Need for energy to work for long hours.
- Emotional and Psychological stresses such as anxiety, frustration.
Signs and Symptoms of Drug Abuse:
According to Adolescents Health Information Project AHIP the following are signs
and symptoms of drug abuse:
- Signs of drug use and drug paraphernalia:
- Possession of drug related paraphernalia such as pipes, rolling paper, small decongestant.
- Possession of drugs, peculiar plants or bolts, seeds of leaves in ashtrays or clothing pockets.
- Odour of drugs, smell of incense or other cover up scents.
- Identification with drug culture:
- Drug related magazines, slogans on clothing.
- Hostility in discussing drugs.
- Signs of physical deterioration:
- Memory lapses, short attention span, difficulty in concentration.
- Poor physical coordination, slurred or incoherent speech; unhealthy appearance, indifference to hygiene and grooming.
- Bloodshot eyes, dilated pupils.
- Changes in behaviour:
- Distinct downward performance in school/place of work.
- Increased absenteeism or tardiness.
- Chronic dishonesty, lying; cheating and stealing.
- Trouble with the police and other law enforcement agencies.
- Change of friends, evasiveness in talking about new ones.
- Increasing and inappropriate anger, hostility, irritability, secretiveness etc.
- Reduced motivation, energy, self-discipline, self-esteem etc.
Types of Drugs Commonly Abused in Nigeria
- Cannabis (Marijuana) contains the psychoactive substance THC (9- delta tetrahydrocannabinol). Although usually grouped with other hallucinogens, marijuana rarely causes hallucinations.
Acute effects from smoking marijuana include an alteration in perception or mood, laughing, increased appetite, conjunctival injection, tachycardia, and mild central nervous system (CNS) depression.
- Rohypnol (flunitrazepam)
Immediate short-term effects include euphoria which is a state of heightened mental alertness (may have an opposite effect for some users), hypersensitivity and irritability, photophobia, paranoia and loss of appetite. When consumed in large quantities, it often leads to bizarre, violent and unpredictable behavior with significant risks of harm to self and others. Mydriasis, flushing, tremors, tachycardia and hyperthermia are some signs of acute intoxication.
Long term effects include malnutrition, Parkinson’s disease and other movement disorders, psychosis, vascular disease and their sequelae, an increased risk HIV infection and faster progression of HIV co-infection.
- Phencyclidine (PCP)
The clinical manifestations of PCP use are extremely variable and unpredictable. The patient may appear calm or wild, disoriented, violent, stuporous, or comatose, depending on the ingested dose. Patients often have a blank stare. Ataxia, grimacing, bruxism, muscle rigidity, and myoclonus are common. Temperature, heart rate, and blood pressure are elevated. Bizarre and psychotic behaviors are often noted. PCP is associated with a much higher morbidity and mortality than other classes of hallucinogens. The dissociative nature of PCP allows users to do tremendous harm to their bodies with little or no perceived pain. Because it is cheap to produce, many street drugs are laced with PCP and sold in the place of more expensive hallucinogens. It is also sold as synthetic marijuana or some other drug and can be sprayed on dried herbs or other medium for smoking
Effects are a decreased sensitivity to pain, a feeling of euphoria, drowsiness and an overall subdued demeanour, as well as slower reaction times and decreased reflexes. Other adverse effects can include nausea and vomiting, headaches and flushing.
When taken orally, the liver metabolizes tramadol into several chemicals including O-desmethyltramadol, which produces much more potent effects than tramadol itself. Taken orally at high doses, tramadol can produce a euphoric high similar to another commonly abused opiate medications such as oxycodone.
- Organic Solvents and other Inhalants.
Inhalants are volatile substances producing vapors that can be inhaled and absorbed by pulmonary mucosa to produce a mind-altering “buzz” or high.
Most inhalants are central nervous system (CNS) depressants, but they also cause adverse medical effects on almost every organ system. Both short- and long-term toxic effects occur. Short-term effects include diplopia, memory impairment, slurred speech, seizure, or death from cardiac arrhythmias. Long-term chronic effects include permanent ataxias or peripheral neuropathies, blindness, cognitive impairment, dementia and renal toxicity.
- 8. Alcohol & Nicotine
Alcohol-related problems includes:
- Physical problems e.g. liver cirrhosis, pancreatic, peptic ulcer, tuberculosis, hypertension, neurological disorder.
- Mental retardation for the foetus in the womb, growth, deficiency, delayed motor development.
- Craniofacial abnormalities, limbs abnormalities and cardiac deficits.
- Psychiatric e.g. pathological drunkenness, suicidal behaviour.
- Socially-broken homes, increased crime rate, sexual offences, homicide and sexually transmitted diseases.
Nicotine (found in Tobacco): Causes stimulation of heart and narrowing of blood vessels, producing hypertension, headache, loss of appetite, nausea and delayed growth of the fetus. It also aggravates or causes sinusitis, bronchitis, cancer, strokes and heart attack.
Drug Abuse Prevention and Control Measures
Robust preventive and control measures against drug abuse must be targeted at every unit of our national life: the individuals, the families, and communities as well as relevant institutions.
Any individual noticed to exhibit clinical features of addiction should be taken to a health facility immediately.
Pre-hospital care providers should attempt to ascertain the type and amount of substance ingested and the presence of any other co-ingested drugs or psychoactive substances.
Physicians and other care providers at the primary level should undergo training and re-training in the recognition and appropriate management of such patients – including early referral when indicated.
Family Oriented Strategies for Prevention of Drug Addiction:
Spiritual Commitment: Parents should be committed in their service to God. They should lead their children to God and make sure that they are committed in their service to God. This gives purpose to life, patience and reason to accept and deal with oppositions and set backs.
Care and Supervising or Monitoring: Parents should care for their children, meet their physical needs as much as they can, while explaining to their children when they cannot.
They should monitor their movements to make sure that they are keeping good company. If they are keeping bad company, this should be corrected immediately.
They should not be over-pampered. Parents should not only educate their children on the dangers of drug abuse, but they should establish and enforce family rules.
They should also create an effective system of monitoring their children’s activities. In the present age this may include installing secret cameras in strategic places in the home to monitor their activities when there is suspicion of drug abuse.
Family Discussion: Family discussion should be done from time to time. It helps in understanding and solving each other’s problem in the family. Family discussion also provides opportunity to share ideas. A problem that may goad a young person into alcoholism could be solved at family discussion time. Meal time or after family prayer. Are good opportunities.
Warm Communication: This is also an important way of preventing or controlling drug abuse in the family. The manner of approach in any situation is important. There is a way parents can talk to a child who is experimenting in illicit drugs that would help them stop but there is also an approach that will worsen the situation. Children should still feel loved even when receiving correction in the family.
Appreciation: There should be genuine appreciation in the family. Parents should always appreciate their children when they do well, and parents should also appreciate one another.
Community-Oriented Strategy for Drug Addiction Prevention:
This refers to a group of people living in a defined area and it has a big role to play in prevention of drug abuse including:
- Creating of awareness in the community on the dangers of drug abuse.
- Provision of alternatives to drug abuse such as recreational activities, etc. alternative entertainment from social media feeds should be offered such as sports, family outings and healthy recreation.
- Provision of job opportunities.
- Organising teachings, seminars, workshops, symposia and conferences to educate the youth on the dangers of drug abuse and how to avoid becoming entangled.
- Control of alcohol sales and consumption especially in motor parks. Breathalysers should be administered on long distance drivers.
- Establishment of drug and alcohol vigilante groups that will monitor and report drug traders, drug addicts and alcoholics to the appropriate authorities.
- Embarking on campaign against drug abuse.
- Interrogating and calling the youths that are loitering in the community in order to know their problems and help provide solutions and providing homes for homeless youths.
Schools– Oriented Strategy for Drug Addiction Prevention.
Drug abuse in tertiary institutions promotes evils such as cultism. Schools have an important role to play in prevention of drug abuse including:
- To teach the students the dangers of drug abuse.
- Monitoring the students’ activities – using CCTV cameras where necessary.
- Organising lecture/seminar for parents and students on the dangers of drug abuse.
- Hosting workshops, conferences and symposia on drug abuse and its effects on students.
Although the problem of drug abuse is not new to Nigeria, the current prevalence and pattern is extremely worrying to Family Physicians and other primary care clinicians who could become overwhelmed.
The widespread involvement of medications commonly prescribed at this level of the health care system (such as Tramadol and Codeine containing cough syrups) calls for an aggressive and multipronged approach to curb the menace.
In addition to the traditional state sponsored control of drugs of abuse by national agencies like the NDLEA and NAFDAC, families, schools and communities must now be actively involved.
In particular, Primary Care Clinicians should be trained and retrained to control the prescription of these drugs and to recognize the early signs of addiction and provide treatment or referral for affected citizens.