- Alizah Al-aman
In a course of time the brain has developed in a way to ensure our survival. This survival system incorporates brain’s unique reward system liable for satisfying person’s essential desires (Horvath, n.d.). Unfortunately, substance use is operated within these reward systems that engages an individual in addictive activities. According to Edward (2000) substance use is the hazardous use of psychoactive substances, including alcohol and illicit drugs. It is the dependency that deteriorates individual’s physical and mental health. Consistent with the continuum of chemically mediated responses, substance use is a maladaptive coping manifested by frequent use and dependence of tobacco, alcohol and illicit drugs (APA 2000, p. 198; Stuart, 2009). WHO reported that globally 3.86 billion people are involved in substance abuse in which US has the utmost prevalence whereas in Pakistan it is prevalent among 6.4 million people (Stuart, 2009).
If substance use co-occurs with any mental illness it’s regarded as dual diagnosis. Literature proposes that roughly 50% of the people with psychiatric problems also suffer from substance abuse disorders (chrome et al., 2009). In UK three quarters of drug and 85% of alcohol service users have mood and anxiety disorders (NIDA, 2007). It’s a dilemma that which problem occurred first. However precipitating factors like loneliness, family disturbances, psychological illness, illiteracy trigger substance use in psychiatric clients (Donald & Gail, 2009). In my view to resolve the misery of such pain and mental illness people engage in substance abuse which grants them pleasure as highlighted in the below mentioned scenario.
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On my clinical rotation at C0 ward in AKUH, I encountered a middle aged patient with the dual diagnosis of depression and drug abuse. He was a chain smoker since 30 years and recently had angioplasty. According to the patient he developed gastric ulcers 5 years back for which a local physician prescribed him Inj. Nubain. He wasn’t conversant that the drug should be used till certain time as associated with the risk of addiction. Patient continued taking that medication and developed addiction. The medication not only lessened his pain but made him calm and relieved during his depressive episodes. After angioplasty he was constrained for not using that drug which results intense craving. Patient became unmanageable and restless. Then he was admitted in C0 ward but intense craving made his situation worst resulting in tremors, sweating, insomnia, hypertension and mydriasis. When I visited that patient, he verbalized “I need drug, am very restless, this craving will end my life” so to reroute his mind and lessen his suffering, I along with OT members planned to engage that patient in different activities. We taught him some coping strategies and there was a mild change observed in his performance and condition after psychotherapy and cooping.
Glancing the social context in light of scenario, substance abuse is judged as bad deed because it violets societal norms and values by precipitating ferocious acts, poverty, family disturbances etc. In the above case unmanageable behavior lead the admission of the client in ward. In contrast some communities illustrate acceptability too. Furthermore Canadian mental health association (2006) and Steve & Susan (2003) proposed the comparable fact that patients with dual diagnosis can provoke violence and peace less situation in a community by sevenfold as well as for those who are caring or living with them. Moreover substance use is 65% prevalent in mid adulthood and my patient’s age was in same age group which predisposed him towards this (Stuart, 2009).
Furthermore religion exhibits a fundamental role in an individual’s life. In Islam alcohol is forbidden that’s why researches highlighted less incidence of alcohol abuse in Muslim society whereas higher incidence in western world (Haider & Chaudhry, 2008, p.82). Beside this in Pakistan opioids and marijuana is predominantly abused (UNODC, 2013). Opioid use primarily grants relieve in mental illness but its withdrawal encompasses acute depression, chronic craving, tremors, sleep problems, high BP and dilated pupils as evident in my client’s case (Stuart, 2009). Moreover marijuana also serves as a source for decreasing negative symptoms in schizophrenic clients however in response it exacerbates their suffering (Archives of General Psychiatry, 2011). Survey conducted in Pakistan summarized that 53.6% of the adults smoke shisha (Sameer et al, 2012; Khan, 2010). This percentage illustrates the acceptability of tobacco and shisha in eastern world that results psychosis in individual’s already predisposed for developing it (Archives of General Psychiatry, 2011). Bhang use is also predominately practiced in Indian festivities that generate euphoric and hallucinating effects as encompasses psychotomimetic substances (Thacore, 1977).
In Western world and Roman Catholics drug abuse is more socially acceptable in females but referred unmasculine in males whereas the consumption of alcohol is considered masculine (Donald & Gail, 2009). In US the extreme alcohol use is the 3rd leading cause of death and it also precipitates mental illness by triggering depression, euphoria, mood disorders. Its unavailability would end up leading general depressant withdrawal syndrome. Furthermore 43% of people in US are tobacco abuser however smoking opium is marked deviant (Donald & Gail, 2009). Tobacco smoke is twice more common in depressive clients while thrice in schizophrenic patients. Besides granting pleasure it amplifies the chances of relapse in psychiatric patients (Ash, 2013). So while assessing the client with dual diagnosis HCW’s should take these sociocultural aspects in consideration.
When my client tried to drop the addiction, he felt intense craving. Craving is evidently depicted in the light of neuroadaptive model as prolonged use of drugs induces specific alterations in the brain cell or neurotransmitters which regulate neural drives and grant pleasure. During abstinence neuroadaption consequences in imbalance in brain function which results craving and this craving is accountable for relapse in individuals (Eliason et al., 2007).
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Interventions for such clients could be executed within individual, institutional and community level. In my patient therapeutic interaction assisted me to perform MSE effectively. Dealing with craving was challenging nevertheless I taught him some coping techniques, mind diversional exercises. In addition the intervention that can be carried out is drug testing and if the patient has severe withdrawal history so referral can be made to detoxification program (Stuart, 2009). Furthermore the nurse should develop awareness about the state and feelings of substance abuser in order to eradicate biasness in caring. Assessment of withdrawal symptoms should be carried out every shift.
On institutional level integrated treatment for dual diagnosis verified as evidence based practice (Stuart, 2009). My client was treated simultaneously for both depression and substance abuse. Moreover medicines should be administered to alleviate craving as Methadone was been administered to my patient for plummeting his craving. Moreover individual counseling and CBT prove as a constructive approach for client’s rehabilitation and relapse prevention. Since 2000 AAS is also working for the rehabilitation of substance abusers using the same treatment methodologies such as psychotherapy and drug toxification Besides AAS there should be more rehabilitation centers in those areas where substance abuse is more prevalent in order to restore mental health.
Community level interventions would embraces the conduction of school base awareness programs and workshops for eradicating the risk of substance abuse from initial ages and making individuals realize that substance use is not the accurate coping for alleviating mental illness. Developing religious and social norms would converse an obvious message for drug avoidance in mentally ill clients to whom religion serves as a protective factor. Moreover campaign against substance use on national level would present as example for people in recognizing the harmful effects of it (Reno et al., 2000). Implementation of strict Governmental policies and legislation on consumption and sale of alcohol and illicit drugs can help in reducing the occurrence of dual diagnosis. Detoxification and methadone maintenance programs can be arranged in communities with the assistance of governmental authorities (Stuart, 2009; Reno et al., 2000).
In conclusion, substance abuse can co-occur with mentally illness which impact an individual’s life dreadfully. To get rid of this is difficult but not impractical. Diverse prevention strategies and early detection would assist its control and management. Moreover strong motivation from family, health care providers and especially self can immensely facilitate the individual to cope up and live a healthier life (Harrison, 2006).
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