Control of Drug Abuse and

Misuse

Mamoona Kokab
Lecturer (Pharmacy Practice), LPC
A Project of LMDC
• Subtopics:
• Definition of rational use
(safety,effectiveness,appropriateness,cost)
• types of drug misuse(wrong, unsafe, unneccessary etc)
• adverse impact of drug misuse
• Factors underlying misuse of drugs (heath system, prescriber,
pateint, industry, dispenser)
• Improving the drug use(educational , managerial)
• Drug dependence, mechanism of dependence
• Tolerance, Substances of abuse, Factors contributing to
addiction(biologicxal, social, pscyhological,others)Harms relating
to drug use and dependence (health,social , crimes, mics)
• Strategies of control of drug use and dependence, Detoxification
and rehabilitation, Needle exchange service, legislation, Practical
management
• Role of community pharmacist.
 Definition of rational use
• 1st Definition: “The rational use of Drug Requires that
patients receive medication appropriate to their own
individual requirement for an adequate period of time
and at lowest cost to tem and their Community”.(WHO
1985)
• More than 50 % of the medication are prescribed,
dispensed, and sold inappropriately and not in accordance
with the standard principles (WHO 1992)
• 2nd Definition: “The Rational use of Medicine has been
defined as The safe, effective, appropriate and economic
use of medicines”
(a) Safety
• Definition of safe, effective, and the other components
needs consideration.
• Safety relates to aspects like relative and absolute safety.
• All medicines have side effects, some less and some more,
such that they may be viewed as more or less safe.
• Safety has to be accessed from many different angles e.g
the severity of the disease, the available treatment
options including medicines and other options, long or
short term treatment, whether the medication is to cure
or control symptoms and over dosage risks.
(b) Effectiveness
• Effectiveness refers to the question of how
well the medicine works in daily practice when
used by unselected population and patients
having co morbidities and other medications.
(c) Appropriateness
• Appropriateness refers to how a medicine is being
prescribed and used in and by patients, including
aspects such as appropriate indication, with no
contraindication, appropriate dosage and
administration. Duration of treatment should be
optimal and the medicine should be correctly
dispensed with appropriate and sufficient
information and counseling. To achieve the intended
effects, the medicine also needs to be correctly
used by the patient.
(d) Economic aspect
• Economic aspect refers to a cost effectiveness
approach which needs to be applied, where all
factors are assessed.
• A somewhat more expensive medicine, for
example, because it has better treatment
outcomes or fewer side effects.
• Additionally, hidden costs, such as a need for
more expensive laboratory tests,, may increase
the total cost of a particular treatment.
 Common terms used
• Drug use: Consumption of Psychoactive
substances without medical or Healthcare
instructions.
• Drug Misuse: Refers to the Drug use that is
problematic and incurs significant risks of harms.
• These two terms are used interchangeably
• “Substance” is sometimes used in place of drug
to include non medical chemicals such as
solvents, alcohol, Nicotine.
• Drug User: is commonly used to refer to some
one who participate in Drug/substance use.
• Drug Misuser refers to someone undertaking
drug use in such a way that it is problematical
and presents significant risk of harms.
• Two terms used interchangeably
 Types of Drug misuse
(1) No drug needed.
• For Example minor respiratory viral infection of the
children are treated with Antibiotics.
• Use of multivitamins when not needed.
(2) Wrong Drug:
• Many children with Streptococcal Pharyngitis are not
properly treated with narrow spectrum penicillin instead
tetracycline (Broad spectrum) is used.
(3) Ineffective Drug:
• Use of anti-motility agents in acute diarrhea.
(4) Unsafe Drug:
• Anabolic steroids for growth and appetite stimulation of children and
athletes.
(5) Incorrect use of Drug:
• One or two day supply of antibiotics rather than the full course of
therapy.
(6) Unnecessary use:
• Unnecessary use of 3rd generation broad spectrum antibiotics when
1st line narrow spectrum is needed.
(7) Unlicensed drug prescribing.
• It includes unregistered unsafe drugs
(8) Sleeping pills
 Adverse impact of drug misuse
 Increased likelihood of ADRs
 Rapid emergence of resistance strains to
chemotherapeutic agents.
 Non Sterile injections are increasing the
transmission of hepatitis and other blood
disorders
 Poor patients outcomes.
 Patient’s inappropriate reliance on drugs.
 Impact of cost.
 Expenditure on non essential pharmaceuticals
like multivitamins products, cough mixtures.
 Inappropriate underdose of a drug at early
stage of disease may produce excess cost by
increasing the probability of prolonged
disease.
 Psychological impact.
 Over use of drugs even essential ones, causes spending of
Pharmaceuticals and wastes of financial resources both by
patients and health care system.
 The concept that there is a pill of every ill is harmful.
Patients comes to rely on drugs and this reliance increases
the demand for them. Patient may demand unnecessary
injections because they have to accustomed to them
 Edema
 Increased LFT.
 Cholesterolemia.
Factors underlying misuse of drugs
(1) Health System Related:
 Unreliable supply.
 Drug shortage.
 Availability of inappropriate drug: such influences results
in lack of confidence of the prescriber in system and also
of the patient
 Expired drugs.
 The patients demands treatment and the prescriber
feels obliged to provide what is available even if the
drug is not correct to treat the conditions
(2) Prescriber Related:
 Inadequate training
 Outdated prescribing practice due to lack of
continuing education
 Lack of objective drug information and the drug
information provided by the medical
representation may be unreliable.
 Profit may affect a prescriber’s choice; if the
prescriber’s income is dependent on the drug sale.
(3) Dispenser Related:
• Substitution of the prescribed drug with
substandard drug.
• Dispensing of drugs without individualized
labels.
• Dispensing without counseling
• Improper storage of drugs
• Drug regulation.
• Availability of non essential drugs.
• Lack of regulation enforcement.
(4) Patient and Community related:
• The individual adherence to treatment
depends upon:
• Cultural believes.
• Communication skills.
• Attitude of prescriber and dispensers
• The shortage of printed material.
• Community’s belief about efficacy of certain
drugs and route of administration.
(5) Industry related:
• Pharmaceutical industries often make
misleading claims about their products:
moreover promotional activities by the
medical representatives also serves as a seed
for irrational prescribing.
• And also the companies succeed to change
the habits of doctors because they understand
what influences these habits.
 Improving the Drug use
(1) Educational Aspects
(A) Patients education
• It is necessary for using various dosage forms:
 Printed materials(leaflets, labels)
 Mass media
 Counseling
 Drug use aids
(B) Prescriber Education

 Prescribing from EDL

 Follow standard treatment guidelines
 Use unbiased information for drug use.
 Monitor patients for ADRs
(2) Managerial aspects
• Define and practice EDL/Formulary system
• Prepare and follow standard treatment
guidelines
• Perform DUR
• Follow GSP and good dispensing practice.
• Practice a public awareness about patient's
rights.
 Drug Dependence
• “Drug Dependence or Addiction refers to the compulsion
to continue administration of Psychoactive substance(s)
in order to avoid Physical and or Psychological
withdrawal effects”
• Dependence syndrome is after defined by Who as:
• “A cluster of behavioral, cognitive and psychological
phenomena that develop after repeated substance use
and that typically include a strong desire to take the drug,
difficulties in controlling its use, persisting in its use
despite harmful consequences, a higher priority given to
drug use than to other priorities and obligations, increased
tolerance, and sometimes a physical withdrawal state”
The dependence syndrome may be present for
a specific psychoactive substances (e.g Tobacco,
alcohol, Diazepam), for a class of
Substances( Opiods drugs) or for wider range of
Pharmacologically different Psychoactive
substances
History of Drug abuse
• History indicate that Psychoactive drug use is
not a new phenomenon in society.
• Psychoactive drug use has been recorded as
part of some societies more than 7000 years
ago.
Mechanism of Dependence
Phases of Drug Addiction
(1) Tolerance: it is the diminishing effect of the
same dose or the need to increase the size of
the dose to get an effect similar to the earliest
one.
(2) Habituation: it is the emotional or
Psychological need felt for a drug.
(3) Dependence: it is the body’s need to get the
drug.
• Drug addiction develops as a process, it is not a sudden
occurrence.
• Increased brain cell tolerance
• Increased metabolic efficiency of the liver
• Consumption of the more of the chemicals to achieve
desired effects
• Physical dependence develop in which body cell cause
withdrawal symptoms to occur in the absence of
chemicals
• Psychological Dependence leading to addiction
Why do people use Psychoactive drugs?
Benefits:
• Attainments of pleasurable feelings(relaxation)
• Increased social interaction
• Alteration of person’s psychological conditions to a more
desirable state(escapism)
• Physical change( Anabolic steroids taken up by builders)
• Avoidance of withdrawal symptoms who is dependent on
drug.
• Opiates use may be commenced to escape from reality or
used as pain killer but then continued to avoid withdrawal
effects.
The Choice of Drug used
• Availability and opportunity to try
• Legal status of the drug
• Perceived desired effects
• Perceived risks
• Desired effects versus the risks
• Availability of the drug and method of
administration.
Weighing up Risks vs benefits

• If the benefits from drugs use are experiences

before the harms, or to a greater extent than
the harm, positive endorsement of drug taking
occurs
Control and Dependence
• When a person loses control over his drug
consumption or Rather consumption Controls
the person, this may be described as
dependence.
• Drug dependence can presents a significant
amount of harms to individual and society.
 Tolerance

• “After repeated administration of

drug, a larger dose is required to
produce the same effect is called
tolerance”
 Substances of abuse
Common Active/Main Most Effect on Examples of Harms from
Name Psychoactive Common CNS desired Use
component Method of effects,
Administrati Reason of
on taking
Acid/LSD Lysergic acid Orally hallucinogen Altered Panic
diethylamid dissolved on ic sensory attacks,
e (LSD) tongue perception fightenning
e.g visual altered
hallucinatio perception,
n, time dysphoria,
distortion, delusion,
detachment psychosis,
from reality tachycardia,
after effects
include
“flashbacks”
Alcohol Ethanol Orallly in CNS Relaxation, Aggressive
drinks, e.g Depressant promote mood,
wines, beers social hypoglycemi
interaction a, sedation,
vomiting,
anxiety, liver
cirrhosis,
acute
hepatitis.

caffeine caffeine Orally in CNS Increased Insomnia,

drinks, tea, stimulants alertness, diuresis,
coffee and combat restlessness
some soft fatigue
drinks

Tobacco nicotine Cigarette CNS Social Various

smoking, Stimulants Activity, cancers,
Chewing mood lung cancer,
tobacco elevation, Cough,
increases COAD
cocaine Cocaine Nasal CNS Euphoria, Hyperthermi
hydrochlorid administrati stimulation alertness, a, Cardiac
e, cocaine on through increase toxicity,
powder, snorting, confidence, tachycardia,
cocaine injecting, excitement, palpitation,
base (crack) smoking Physical hypertensio
stimulation, n, chest
intense pain,
exhilaration sweating,
(injection tremor,
and crack) anxiety
psychosis,
depression,
intense
craving
Speed Amphetami Nasal CNS Physical and Sweating,
ne administrati stimulants mental tachycardia,
on through stimulation, anxiety,
snorting, increased after effects
orally, IV confidence, include
increased fatigue and
energy depression
Heroin diamorphin Inhalation of CNS Increased Nosuea and
e vapours Stimulants Pleasure, vomiting,
when Including constipation
heated on Euphoria, ,
foil, warmth, drowsiness,
intravenous ralxation, dry mouth,
injection detach,ent respiratory
from depression,
emotional pulmonary
stress oedema

Cannabis Tetrahydroc Used with CNS Mood Anxiety,

annabinol tobacco in depressant relaxation panic
hand mille d reaction,
cigarette sedation
Factors contributing to addiction

• Many factors factors generally contribute

to an individual becoming addicted.
(1)Biologically based factors

• Genetic, neurological, biochemical and so on.

• A less subjective feeling of intoxication.

• Easier development of tolerance, liver enzymes adapt to increased use.
• Lack of resilience or fragility of higher( cerebral brain function)
• Difficulty in screening out unwanted or bothersome outside stimuli ( low
stimulus barrier)
• Tendency to amplify outside or internal stimuli (stimulus augmentation)
• Attention deficit hyperactivity disorder and other learning disabilities
• Biologically based mood disorders (depression and bipolar disorder).
(2) Psychological/Personality factors
• Low self esteem
• Depression rooted in learned helplessness and
passivity
• Conflicts
• Repressed and unresolved grief and rage
• Post traumatic stress syndrome ( as abused
victims
(3) Social and cultural environment
• Availability of drugs
• Chemical abusing parental model
• Abusive, neglectful parents; other dysfunctional family
patterns.
• Group norms favoring heavy use and abuse
• Misperception of peer norms( social perception of alcohol use)
• Severe or chronic stressors, as from noise, poverty, racism, or
occupational stress
• Alienation factor: isolation, emptiness
• Difficult migration/acculturation with social disorganization,
gender/generation gaps, or lose of role.
(4)Others
Drinking / as antistress, solitary drinking
Peer norms favoring use
Loss of meaningful role or occupational identity
Loss, grief, or isolation due to loss of parents, divorce
etc
Loss of positive body image
Disappointment when life expectation not met.
• Drinking at times other than at meals
• Drinking alone.
Harms relating to drug use and dependence

• The Risks and harms that drug use and

dependence can present to the individual and
society vary with the drug taken, the
individual and the circumstances in which the
drugs are taken.
• It is not possible to list all possible
consequences from drug use/misuse.
• The risks are categorized as follows:
(1) Health Problems
 Health Problems affect the individual drug user and include
physical and psychological health problems which can be
large and complex.
 Health problems may be relate to the method of
administration e.g injecting drug use is associated damage
to the circulatory system.
 Blood-borne virus infection e.g HIV, Hepatitis B and C is
associated with sharing of injecting equipment.
 Pharmacists are largely involved in preventing or reducing
harms from drug dependence contributes towards
individual and public health and safety.
(2) Social Problems
• Social problems should not be underestimated and often
drive people to seek treatment.
• Social Problems may include:
 Poverty
 Social deprivation
 Exclusion or failure in education
 Inability to obtain or sustain employment
 Spending of income on drugs
 Damage to family relationships,
 Difficulties forming relationships,
 Exclusion from society and homelessness
(3) Drug related crimes

• Drug related crimes includes:

 Criminal activities committed against the misuse of drugs
ACT for which the individual is punished.
 Crimes that impacts on communities and societies i.e
acquisition of drugs or the effects of drugs. For example:
a) Burglary to obtain money to buy drugs
b) Robbery
c) Violence associated with drunkenness
d) Drug driving (Reason of most of the road accidents)
e) Commit suicide
• Drug related crime is one of the reasons why
treatment of drug problems and drug
dependence is a key public health issue
• Treatment of drug dependence contributes
toward mark reduction in drug related
crimes.
• Treatment benefits not only the individual in
terms of improved health but also society by
making communities safer
• Drug users are often at greater risk that non
drug users of being victims of crime e.g:
a) Violence associated with debt to drug dealers
b) Prostitution
c) Robbery
d) Mugging if homeless
e) Intoxicated
(4) Miscellaneous harms
• Physical and sexual energy of the addicts weaken so
rapidly that a young man of thirties looks like an old
man of over sixties
• Economic breakdown of his family
• Physically handicapped babies are born to women
who are addicts or who use them in pregnancy. About
10% of the mentally retarted children are borne to
opium addict mothers
• Addicts lose self confidence and they become burden
for their family
 Strategies of control of drug use and
dependence
• The extent of harm from drug dependence
can be large, hence the need for effective
strategies to support people in changing their
drug use.
• Range of methods used in preventing,
reducing and controlling drug use and
dependence and managing the adverse
consequences are as follows:
(1) Primary Prevention

• Preventing the people from starting the drug use.

• Target groups include vulnerable groups such as
school children, Children in care and young people
who have left education.
(1) Health promotion and education campaigns are used
to warn about the harms that can results from drug use
and dependence.
(2) Primary prevention also include legislation, as the
illegal nature of many drugs may prevent some people
from using them.
• It is difficult to evaluate the impact of primary
prevention activities.
• This does not mean that primary prevention
activities should not be used.
• They are very important for informing children
and young people about drugs and their
effects, in a factually correct and not
scaremongering way.
(2) Secondary Prevention
• Secondary prevention aimed at people who use drugs, by
discouraging further use.
(1) Examples includes:
a) Giving advice to prevent problems such as overheating and
dehydration to ecstasy users.
b) Discouraging heroin smokers from progressing to injecting.
c) Warning of the risks and guiding on the use of CNS
depressant drugs (such as heroin and Methadone) by
stimulants users( such as amphetamine) when depressant
drugs are used to assist with the “come down” following
CNS stimulation.
(3) Drug Education

• Drug Education is a tool used in primary and

secondary prevention campaigns and formats include
leaflets, booklets, films, online information, and
posters.
• Drug users may be benefit from drug education as
they may not be fully informed on the drugs they use
or may consider using. for example long term risks
and overdose prevention.
• Drug education is also a key part of harm reduction
giving people information to assist them in minimizing
risks from drug taking e.g safer injection information.
• Drug education may be provided by : teacher,
youth workers, health promotion workers,
medical and nursing staff and police officers.
• Advice should be appropriate for the target
group e.g advice given to target heroin
smokers should be different would be differ
from aiming to prevent heroin use in school
children.
(4) Social Support
• Social support refers loosely to non
medical/Pharmacological interventions that can be made.
• These may include practical advice and assistance e.g
seeking housing, benefit advice, and provision of hostel
accommodation and use of Psychological tools such as
motivational interviewing.

• Motivational interviewing aims to assist people in

examining their drug use and impact it has on their lives
and those of others to move people towards a
psychological state, where they are motivated to change
their behavior and attempt to change their drug use
• Pharmacist should be aware of the need for a
holistic approach to care, to improve.
• Some Pharmacist with a special interest (PwSI)
who have specialized in drug misuse have
developed skills in motivational interviewing
and other psychological support tools.
(5) Harm reduction
• Harm Reduction includes range of interventions
used to reduce the Adverse consequences of
drug dependence experienced by the both the
individual and the society.
• Harm reduction engages drug users with service
providers, enabling for example, Motivational
interventions.
• Harm reduction is, for most, an important route
to abstinence.
• Examples of harms reductions interventions
include provision of sterile injecting
equipment's and information to drug injectors
to prevent sharing of injecting equipment's ( to
prevent the transmission of HIVE, Hepatitis B and
C). Minimizing the prevalence of such diseases
also protects the non injecting community.
• Harm reduction also includes provision of
substitute therapies with the aim of reducing
illicit drug use and reducing drug related crimes.
Preventive measures against Addiction in
Pakistan
Cultivation of drug plants should be prevented
Manufacture, possession, sale, and transport of
all intoxicating drugs should be checked and
brought under control for appropriate use.
At present, law prohibits the use of alcohol by
local inhabitants but some underground
activities appear to continue the practice.
The use of mass media should be carefully
considered for possible role in prevention.
Smuggling and illicit trafficking of drugs and plants
should be effectively checked.
Legislation for dealing with offenders
Social welfare agencies, voluntary organization,
education and public health institutions should
organize education against drug addiction.
Collection of data regarding addict population,
nature of drug use in the country, attitude of the
people.
Educational curriculum against drug addiction
Unemployment problems should be solved.
Economic worries promote drug addiction.
(6) Detoxification
• Detoxification aims for the person to become
abstinent from the drug on which they are
dependent by:
• (i) The gradual removal of the drug or
• (ii) substitute therapy
• Examples include the use of diazepam at
gradually reducing the doses in benzodiazepine
dependence and use of nicotine replacement
therapy.
(7) Rehabilitation
• Rehabilitation may include a
• (i) Detoxification process followed by
• (ii) A period of social support and
• (iii) Intensive psychotherapy to facilitate sustained change.
• It may comprise the social support and intensive psychotherapy
phase only, with successful detoxification being a requirement for
entry on the program.
• Rehabilitation Center: Rehabilitation is usually provided within a
therapeutic community. Participants live in the environment
where treatment is given, often for several months.
• The outcomes from various drug rehabilitation programs show
improvements in drug use, physical health, psychological health
and involvement in crime.
(8) Legislation.
The purpose of legislation is to define the Penalties imposed
for the illegal undertaking of various activities e.g Possession,
supply, import and export.
• THE Anti Narcotic Force Act, 1997 is An Act to provide for
the constitution of Anti-Narcotics Force.
• The Force shall
• (a) inquire into, investigate and prosecute all offences
relating to, or connected with, preparation, production,
manufacture, transportation, illicit trafficking or smuggling of
intoxicants, narcotics and chemical precursors or reagents
used in the manufacture of narcotics.
(9)Needle exchange service
 Background:
• Needle and Syringe exchange programs (NSPs) began in UK in the mid
1980s in response to the threat from HIV.
• In the early 1990s, the hepatitis C (HCV) was identified. This blood borne
virus is highly transmissible among injectors.
• NSPs were started in many countries in order to enable safe injecting of
drugs.
 Causes of Spread:
• Sharing of injecting paraphernalia, including needles and syringes
• Other items used in the preparation of illicit injections, for example
mixing water, shared makeshift filters used to remove insoluble materials
and contaminated swabs.

 Goal:
• Research projects found that NSPs were effective in reducing the
transmission of HIV without causing an increase in injecting drug use.
Practical management of NSPs

(a) Practical issues in NSP Provision:

 Training:
• Before setting up an NSP service, NSP Pharmacists and their
staff should undertake training on issues relating to needle
exchange.
• Specialist agencies may be able to offer training for
Pharmacists and their staff.
 Hepatitis B Vaccination:
• Although, there is no vaccine for Hepatitis C or HIV, it is a wise
health and safety precaution for all staff involved in NSP to be
vaccinated against hepatitis B (HBV)
• (b) Needle exchange Procedure:
 Supplying clean, sterile injecting equipment in
exchange for used equipment, which is returned in a
sealed sharp container.
 Practitioners should provide advice and check injecting
sites, when problems such as abscesses are identified.
 In order to minimize risk, support and guidance should
be available to the Pharmacist.
 Adequate storage facilities are essential.
 Used equipment returned to the pharmacy in a sharps
bin should be placed in a larger bin by the client, stored
in a separate area from clean equipment and away from
medicines. These bins are sealed when full and
collected for incineration by clinical waste disposal
companies.
 Injecting drug users need to be able to use a clean set of
equipment for each injection and every set of equipment
supplied should be returned for incineration.
 Adequate amount of injecting equipment should be
supplied, bearing in mind that some crack cocaine
injectors may be injecting very frequently (15 times per
day or more)
 A sharp bin should be supplied with every exchange.
 Return of equipment should be strongly encouraged
 Written and oral advise on safe disposal.
 Pharmacy staff should not open disposal bins to count
the number of sets returned.
( c) Record keeping and Audit:
• Record need to be kept in order to audit the Pharmacy
NSP.
• Needle exchange should be provided on an anonymous
basis. Pharmacies issue cards which give the service user
an identification number or code to record service usage.
• The advantage of having a record for each service user is
that it can quickly be seen of someone returns used
equipment or not.
• Disadvantage is that this system can be time consuming.,
some use don’t want to carry card as it identified them as
drug injector..
• Pharmacies with poor return should seek the advice of
specialist drug agencies and scheme coordinators to
increase return rates.
(d) Risk management:
• Written procedure for needle exchange.
• Body fluid spillage kits should be kept in all
pharmacies and staff should be trained in their
use.
• Chain mail gloves should be kept in needle
exchange pharmacies.
 Role of Community Pharmacist

• Community Pharmacist are ideally placed to

contribute to the care of drug users.
• In addition to the health gains for the patient,
there are several advantages for drug users,
the community and pharmacists from
providing care:
 Extended opening hours: The most
Pharmacies are open at least part of the
weekend and some evening when specialist
drug services may be closed.
 Accessibility
 Expert advice
 Discretion: Pharmacies provide a confidential
service exchange
 Network of service
 Job satisfaction: The pharmacist may be the
only healthcare professional with whom some
drug users have regular contact. Over time,
improvement in Health can often be seen in
people receiving substitute therapies, bringing
job satisfaction
 Two most common services provided by
community pharmacist: To prevent and
reduce harm are needle exchange and
dispensing services
 Specialist Pharmacist (PWSI)
• These are Pharmacists who specialize in drug
dependency, come under the umbrella term of
pharmacist with a special interest’(PwSI)
• Some provide services from community
Pharmacies, whereas others may be based in
specialist drug services.
• They may also oversee dispensing and liaise with
(other) community pharmacists. Other undertake
strategic roles such as coordinating local pharmacy
needle exchange services or overseeing the
Pharmacy contribution to shared care.