Rakesh Lal

Substance abuse in children and adolescents

Consumption of licit and illicit substances has increased all over the world and the age of initiation of abuse is progressively falling. The common drugs of abuse amongst children and adolescents in India are tobacco and alcohol. Use of illicit drugs like cannabis and heroin have also been reported. A high prevalence of drug use and even intravenous use among street children and working children is a matter of concern. Although initiation to drug use usually occurs during adolescence, the adolescent drug users are seldom seen in various treatment centres. Thus community based programmes are beneficial for prevention and treatment of substance abuse among children and adolescents.

Sexual Dysfunction among Male Patients Receiving Buprenorphine and Naltrexone Maintenance Therapy for Opioid Dependence

INTRODUCTION Opioid-dependent men suffer from sexual dysfunctions in the short and long term. The medications used for long-term pharmacotherapy of opioid dependence also affect sexual functioning, though this has been a poorly investigated area so far. AIM To study the sexual dysfunction in opioid-dependent men receiving buprenorphine and naltrexone maintenance therapy. METHODS A semistructured questionnaire and Brief Male Sexual Functioning Inventory (BMFSI) was administered to a sample of 60 sexually active men, receiving buprenorphine (n = 30) and naltrexone (n = 30) maintenance therapy for opioid dependence. MAIN OUTCOME MEASURES Prevalence of premature ejaculation, erectile dysfunction, low sexual desire, weakness due to semen loss, and overall satisfaction. RESULTS About 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms. The commonly reported dysfunctions were premature ejaculation (83% in buprenorphine and 87% in naltrexone), erectile dysfunction (43% in buprenorphine and 67% in naltrexone), and loss/reduction in sexual desire (33% in buprenorphine and 47% in naltrexone). On BMSFI however, there were no significant differences among both the groups. CONCLUSIONS Opioid dependence as well as its pharmacological treatment is associated with sexual dysfunctions, which has clinical implication. Future research should explore this further using biochemical analyses.

Volatile Substance Misuse Among Street Children in India: A Preliminary Report

Although substance misuse among children in India has been documented for over a decade, volatile substance misuse (VSM) is a comparatively recent phenomenon there. This paper reviews available Indian studies about VSM among street children and documents the extent of misuse, experienced benefits and harms, and risk factors. Reported perceived benefits include enhanced physical strength, decreased shyness, sleep induction, feeling good, and numbing physical and psychological pain. Identified risk factors include domestic violence, a dictatorial father, presence of stepparents, migrant status, and substance use in the family. Limitations of the current paper and the need for further research are discussed.

Comparison of efficacy between buprenorphine and tramadol in the detoxification of opioid (heroin)-dependent subjects.

AIM/BACKGROUND Tramadol is a synthetic opiate and a centrally acting weak m-opioid receptor agonist. The potential advantages of tramadol include ease of administration, low abuse potential, and being nonscheduled. This study compared tramadol and buprenorphine for controlling withdrawal symptoms in patients with opioid dependence syndrome. METHODS Consenting male subjects between 20 and 45 years of age who fulfilled the ICD-10-DCR criteria for opiate dependence syndrome were randomly assigned in a double-blind, double-dummy placebo-controlled trial for detoxification. Those with multiple drug dependence, abnormal cardiac, renal and hepatic functions, psychosis, or organic mental illness were excluded. Assessments included Subjective Opiate Withdrawal Scale (SOWS), Objective Opiate Withdrawal Scale (OOWS), Visual Analog Scale (VAS), and Side Effect Check List. Subjects were evaluated daily and study duration was 10 days. RESULTS Sixty two subjects were enrolled. The mean SOWS and OOWS and VAS were significantly lower in the buprenorphine group on second and third day of detoxification as compared to the tramadol group. Although the retention rate was higher for buprenorphine group throughout the study, when compared with tramadol the difference was not significant on any day. Three subjects in the tramadol group had seizures. CONCLUSIONS Tramadol was found to have limited detoxification efficacy in moderate to severe opioid withdrawal and substantial risk of seizures as compared to buprenorphine. Further studies are warranted to examine its efficacy in mild opioid withdrawal symptoms and its potential use in outpatient settings where its administration advantages may be valuable.

Problematic Internet Use and Its Correlates Among Students from Three Medical Schools Across Three Countries

ObjectiveThe authors aimed to assess and compare problematic internet use among medical students enrolled in a graduate degree course in one school each from Croatia, India, and Nigeria and to assess correlates of problematic use among these students.MethodsThe questionnaire included a sociodemographic profile of participants and Young’s Internet Addiction Test.ResultsThe final analysis included 842 subjects. Overall, 38.7 and 10.5 % of respondents scored in the mild and moderate categories. Only a small fraction (0.5 %) of students scored in the severe category. Being male and spending more time on the internet were correlated with problematic internet use. Moreover, a significantly higher proportion of participants who scored above the cutoff used the Internet for browsing, social networking, chatting, gaming, shopping, and viewing pornography. However, there was no difference between the two groups with regard to using the internet for e-mailing or academic activities.ConclusionsIt is important to address problematic internet use among medical students. The correlates can help identify those at increased risk.

Brief Interventions for Harmful Alcohol Use in Opioid-dependent Patients on Maintenance Treatment With Buprenorphine: A Prospective Study From India

Introduction:Harmful/hazardous alcohol use is common among individuals receiving opioid substitution therapy (OST). The World Health Organisation (WHO) recommends use of Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)-linked Brief Interventions (BI) for managing harmful alcohol use. However, the feasibility and effectiveness of BI in addressing harmful alcohol use among buprenorphine-maintained OST recipients has not been studied, which was the objective of the present study. Methods:Using a prospective study design, OST recipients were screened with WHO-ASSIST, and those in the harmful/hazardous use category were administered BI sessions. The feasibility of BI was assessed using BI process rating form. Alcohol-related quantitative variables were assessed with WHO-ASSIST and Rutgers Alcohol Problem Index at baseline and 12 weeks post-BI, and compared for measuring BI effectiveness. Results:Thirty-six (of 138 OST recipients screened) had ASSIST scores in the harmful hazardous category at baseline, and underwent 2 BI sessions at 1 to 2 weeks apart. Of these, 35 patients completed all BI sessions, and baseline and end-line assessments. The average time taken for 1 BI session was 26.43 minutes; 54% reported a “significant influence” of BI on alcohol consumption; 88% reported that they attempted to cut down alcohol use; 14% completely stopped drinking; and another 14% reported significant reduction in alcohol consumption. ASSIST and Rutgers Alcohol Problem Index scores were significantly reduced at end-line assessment. Conclusion:BI is a feasible and effective intervention to address harmful/hazardous drinking among buprenorphine-maintained opioid-dependent patients.

Disorders related to use of psychoactive substances in DSM-5: changes and challenges

In the most recent edition of Diagnostic and Statistical Manual (DSM) that is DSM-5 many modifications have been made in substance use disorder section. These include changes in terminology; sections and categories; diagnostic criteria; threshold for diagnosis; severity; and specifier. Additionally, there have been certain additions and omissions from the earlier version. Critical evaluation of the changes made to the section on disorders related to use of psychoactive substances in India context has not been published so far. The current paper presents a critique of the changes made to the substance use disorder section in DSM-5. The rationale for these changes put forth by DSM-5 work group on substance related disorders have been discussed. Additionally, attempt has been made to highlight the possible future challenges consequent to the current nosological revision for substance use disorder category. Overall DSM-5 seems to be promising in fulfilling its goal of DSM-ICD harmonisation and movement towards an internationally compatible and practical diagnostic system for mental health disorders. It has increased the scope of addiction by inclusion of behavioural addiction. It has also tried to balance the categorical and dimensional approach to diagnosis. However, the real test of this newer edition of one of the most commonly used nosological systems will be during clinical care and research. This will help address the debatable issues regarding the changes that DSM-5 brings with it.

Pattern of alcohol use among problem alcohol users in a community-based setting in India: A cross-sectional study

ABSTRACT Introduction: Impact of alcohol on various adverse consequences is also determined by the pattern of consumption. Pattern of drinking from developing countries is an under-researched area. The present study aims to assess the pattern of drinking among nontreatment-seeking problem alcohol users from an urban slum in a metropolitan city of North India. Methodology: Using a cross-sectional study design and employing the snowball method, 75 adult males with problem alcohol use were recruited and interviewed using questionnaire and standard instruments. Results: The median duration of alcohol consumption was 12 (7, 21) years, 90% were drinking daily, 64% were morning drinkers and 92% reported heavy episodic drinking (HED). Three-fourth participants were in the high-risk category of alcohol use as assessed by WHO-ASSIST. One-third were spending 25–50% of their family income on alcohol. The most preferred alcohol beverage was country-made liquor (CML; 54.3%). Most alcohol users preferred drinking at home (58%), alone (67%), in evening or at night (80%). Conclusion: Although many alcohol users consume alcohol in amounts much above the recommended levels, with high rates of HED, they are not on treatment for alcohol-use disorder. Their pattern of alcohol consumption is likely to place them at risk for alcohol-related harmful consequences.

Assessment tools for screening and clinical evaluation of psychosocial aspects in addictive disorders

This article provides an overview of the tools for psychosocial assessment of substance use disorders. Various psychosocial factors need to be assessed for effective management of individuals and to carry out research in the field. These factors include socio-demographic characteristics, neuropsychological functions, psychiatric co-morbidities, psychological vulnerabilities such as personality traits, motivation, and cognitions related to drug use, and the psychosocial functioning of the individual and his family. The various tools used to assess these aspects have been outlined below and the brief descriptions provided can help in choosing the right tool based on the characteristics that need to be measured and logistics.

Maintainence treatment of opioid dependence with tramadol

Background: Although tramadol has been used in the management of acute withdrawal in patients with opioid dependence, its use for maintenance treatment as a harm reduction approach has not been assessed systematically. This case series describes patients with opioid dependence who were treated with tramadol for long-term maintenance. Methods: Patients with opioid dependence who received treatment at the National Drug Dependence Treatment Centre of All India Institute of Medical Sciences, New Delhi, were included in the study. Patients who received at least 6 months of tramadol and had follow-up adherence of more than 80% were included in the case series. Results: A total of 25 cases were included, all of whom were males. The types of opioids being taken at the time of initiation of tramadol were natural opiates (poppy husk and raw opium), followed by heroin. The median dose of tramadol at initiation and maintenance was 300 mg/day. Nineteen patients were able to achieve complete abstinence to other opiates on tramadol. Conclusion: Tramadol may be an effective option in the long-term management of patients with opioid dependence. Further studies are required for establishing the efficacy of tramadol for agonist management of patients with opioid dependence.