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Sociodemographic profile and pattern of substance abusers: A retrospective study to unveil the public health problem of Punjab

Introduction: Substance abuse refers to the harmful or hazardous use of any psychoactive substance including licit and illicit drugs, other than when medically indicated. According to a UN report, 1 million heroin addicts are registered in India, and unofficially, there are as many as 5 million. Among all the states Punjab stood third in substance abuse and also injectable drug use. The present study was thus conducted to assess the sociodemographic profile and pattern of substance abuse among patients attending a Drug de-addiction centre. Material and Methods: A record-based analysis from March 2015 to March 2019 was done. Substance dependence was diagnosed post detailed clinical interview by a consultant psychiatrist at the center using DSM -10. For the 966 registered patients admitted in the last four years, the record was checked for completeness of data and relevant information on socio-demographic profile, substance abused, duration of hospital stays, drop out and relapse rates was extracted. Results: Of the total admitted patients (n= 966) 100% addicts were of male gender and natives of Punjab. 514 (53.21%) were married followed by 434(44.93%) never married. Maximum patients 456(47.20%) were self-employed. Heroin was the most abused drug. The injecting route of drug abuse was used by most of the abusers i.e. 51.66%. Only 173 (17.90%) patients dropped out of the treatment followed by relapse in 192 (19.88%). Conclusion: In this paper we demonstrated the vulnerability of young population towards drug addiction. Easy accessibility of drugs, peer pressure and difficult family circumstances raises the fragility to restore for substance use. However, community-based studies are imperative in order to estimate how big is the problem at the bottom.


Introduction
Substance abuse refers to the harmful or hazardous use of any psychoactive substance including licit and illicit drugs, other than when medically indicated. [1] Presently, every part of the world is entangled in the menace of drug trafficking and drug addiction.
Globally, millions of drug addicts, are leading miserable lives. India too is trapped in the epidemic of substance abuse, and their number is on a rise with every passing day. [2] According to a United Nations report, 1 million heroin addicts are registered in India, and unofficially, there are as many as 5 million. [3] This challenging problem of drug abuse is alarming because of the circumstances associated with it. Changing cultural values, growing economic stress, and weak supportive connections are some of the factors responsible for the initiation of substance use. Among all the states of India, Punjab stood third in substance abuse and also injectable drug use. [4] The situation of substance abuse in Punjab is not only a deep-rooted social problem but also a public health crisis now. Being a complex multifaceted issue tackling the same requires intense collective multisectoral efforts of not just the medics and paramedics but various others such as sociologists, law enforcers, administrators, and legislators.
According to the Punjab Opioid Dependence Survey carried out in 2015 the estimated size of the opioid dependent population in Punjab is 2,32,856. The survey also highlighted that patients with drug addiction problems built up the majority case-attendance of psychiatrists in Punjab. Also, more than half of the substance abuse cases belong to opioid-related disorders. Furthermore, heroin was the most commonly used opioid drug. [5] Drug abuse has emerged as the bane of the state with new patients especially the young getting admitted regularly for deaddiction at various centers throughout the state. [6] Drug abuse requires nipping the bud at the grass-root level with efforts in the practice of primary care physicians, social workers, and grass-root community health workers. The intense social stigma attached to drug abuse makes it all the more important for primary care workers to be aware of various facets of the problem so that the best possible and timely care is provided to the sufferers. This study was conducted to assess the sociodemographic profile and pattern of substance abuse among patients attending a drug deaddiction center. A better understanding of these factors will inform better decision making among the health workers as the political/administrative decision-makers.

Materials and Methods
After prior ethical and institutional permission a record-based analysis from March 2015 to March 2019 was done to study the sociodemographic profile and pattern of abuse of substance-dependent patients undergoing inpatient management at a Red Cross drug deaddiction center in the state of Punjab. Substance dependence was diagnosed post detailed clinical interview by a consultant psychiatrist at the center using the Diagnostic and Statistical Manual of Mental Disorders-10 (DSM-10). Those diagnosed as substance dependent were admitted for pharmacological and nonpharmacological management. Regular follow-up by the psychiatrists was done at the required intervals, followed by home visits for social reform counseling and ensuring maintenance.
The record was checked for completeness for the 966 registered patients for the last 4 years and data were entered in Microsoft Excel. Relevant information on the sociodemographic profile, substance abused, duration of hospital stay, drop out, and relapse rates were extracted and results were presented as mean and simple proportions.

Results
Of the total admitted patients (n = 966), 100% addicts were males and natives of Punjab, with a mean age of 27.25 years at the time of presentation. The 4-year period of analysis revealed a constant decline in the number of addicts seeking treatment at the center with 358, 272, 175 and 161 male addicts being admitted per year [ Figure 1]. Of the total patients (n = 966), 514 (53.21%) were married followed by 434 (44.93%) never married [ Figure 2]. Majority of the patients (456, 47.20%) were self-employed followed by 256 (26.50%) who had left jobs whereas only 14 (1.45%) were students [ Table 1]. Heroin was the most abused drug, used by 653 (67.60%). One hundred and forty-six (15.11%) used other opiates, 82 (8.49%) were alcohol addicts, 73 (7.55%) were poppy husk (bhukki) addicts, and 12 (1.24%) were cannabis addicts [ Table 2]. The injecting route of drug abuse was used by most of the abusers, i.e., 51.66%, while 32.61% of the users used the oral and 15.63% used the sniffing route for abuse [ Figure 3]. Five hundred and ninety-seven (61.80%) of the total addicts were brought to the center by family/friends, 286 (29.61%) were brought by social workers, and 50 (5.18%) were referred by Government hospitals and other agencies. Thirty-three (3.42%) self-reported to the center, while none were brought by law enforcement agencies. The average length of stay among 297 (30.75%) patients was 21-30 days, followed by 281 (29.09%) and 279 (28.88%) admitted for 11-20 and 1-10 days, respectively whereas only 109 (11.28%) required treatment for 31-60 days [ Figure 4]. Home visits for follow-up revealed 317 (32.82%) patients to be sober, 192 (19.88%) had relapsed, 181 (18.74%) were lost to follow-up, 173 (17.90%) patients dropped out of the treatment, and 14 (1.45%) died [ Table 3]. Out of those who dropped out, majority 105 (60.69%) quoted a lack of family support as the reason for drop out [ Table 4].

Discussion
In the current decade, Punjab has encountered a terrific increase in substance abuse. With the introduction of new addictive substances, the condition has further worsened as more and more young population is getting involved. Hence, this study examines the epidemiological profile of drug abuse patients, to get insight into the discrete aspects of this public health problem.
As the deaddiction center under study, catered to a fixed population and only the new patients were being recorded, therefore, the disease trend analysis of past 4 years record showed a decline in the number of clients attending the center. An important finding in our study was nil reporting of women for deaddiction to the center. Substance abuse being a social stigma is hindering female reporting. This reflects the need for focused group discussion in the community to get insight into the various reasons involved in it. In our study, the average age of reporting is 27 years, which indicates that this problem is hitting at the most productive age group. Thus, school and college-based education programs targeting the youth need to be strengthened to raise their awareness levels. In consonance with our findings,      Arora et al. [7] also found all patients reporting to the government hospital settings in Punjab were male and the mean age of reporting was 26.47 ± 5.95 years. In this study, an approximately equal number of patients were either married (53.21%) or single (46.79%). The possible explanation might be that the stress of marriage, carrier, and rearing of children may predispose them to substance abuse although marriage also provides a supportive and supervised environment. Single individuals have to face the stresses of life without the long-term support provided by marriage, which makes them to drug abuse. Majority (47%) of the patients in a study by Prajapati et al. [8] were married whereas Pandey et al. [9] and Kapse et al. [10] reported maximum patients in their study were single. Most of the patients in our study were self-employed (47.2%) followed by unemployed (26.5%), which is in line with the findings of Pande et al. [9] This might be explained by the fact that the individuals engaged in business are at high risk of drug abuse as their occupation demands more socializing as compared to other employments. On the other hand, the unemployed individuals out of frustration get easily persuaded by their peers, thereby gradually getting addicted.
Heroine is the most popular form of opiate consumption especially in Europe and Asia. [11] In this study also, we found that maximum patients were using heroin (67.5%) whereas only (1.24%) were addicted to cannabis. This pattern shows the increased addiction towards synthetic drugs as compared to natural drugs, which reflects the emergence of newer drugs and their easy availability in the market. Similar to our findings, Kaur et al. [12] also found maximum subjects among the opioid users were using heroin (51%) and only 1% were taking cannabis. Whereas in contrast to our findings, Murmu et al. [13] from Kolkata and Kadri et al. [14] noted alcohol was the most prevalent used substance. Most of the abusers (51.66%) were using the injecting route in our study which necessitate human immunodeficiency virus (HIV) testing and treatment to be strictly adhered to all, and spouses to be counseled for HIV testing too. This study finding is in contrast to the finding of Farhat et al., [15] who reported the oral route as a major route for drug administration. Similar to other studies, [16] our study also noted that the average length of stay for maximum patients (88.72%) was less than 30 days and only 17.9% patients dropped out of the treatment. Among those who dropped, majority (60.69%) stated the lack of family support as the reason for drop out. We found a 19.8% relapse rate among the patients attending the deaddiction center. Frequent follow-ups, home visits, psychosocial counseling, and support should be provided to families and the concerned to minimize the relapse rates in those getting sober.

Conclusion
In this paper, we demonstrated the vulnerability of the young population towards drug addiction. Easy accessibility of drugs, peer pressure, and difficult family circumstances raise the vulnerability for substance use. To combat the situation, drives such as each one reach one, wherein each employee of law enforcement agencies is encouraged to convince at least one user/addict to seek care should be started. Accredited social health activists (ASHAs) of the areas are to be trained to get information about drug users in their areas and be provided incentives to ensure counseling and treatment compliance for the vulnerable. Community-based studies are imperative to estimate the magnitude of the problem and its related factors to inform better decision-making.

Limitation
This study has a few important limitations. First, we couldn't precisely define the population at risk as it was a center-based study and secondly, the possibility of duplicate admission could not be ruled out.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.