Year : 2006 | Volume
: 48 | Issue : 4 | Page : 243--247
A profile of substance abusers using the emergency services in a tertiary care hospital in Sikkim
Akhil Bhalla, Sanjiba Dutta, Amit Chakrabarti
Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok 737102, Sikkim, India
Department of Pharmacology, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok 737102, Sikkim
Background: Sikkim, a state in Northeast India with a population of more than 500,000 and inhabited by indigenous population of Lepchas, Bhutias and Nepalis, lies in the foothills of the Himalayas sharing borders with Tibet, Nepal and Bhutan. Northeast India is a major source of injection drug users (IDUs) and associated HIV/AIDS. Alcohol use is traditionally prevalent in Sikkim and recently, IDU behaviour has also been reported, although systematic information on epidemiology and treatment availability of substance abuse in Sikkim is not available.
Aim: To study the sociodemographic and drug use profile of substance abusers using the emergency services in a tertiary care hospital.
Methods: A retrospective chart review was used. Patients with history of current drug use seeking emergency services for any medical or surgical consequence incident to substance abuse from July 2000 to June 2005 (60 months) were included in the study. Data were generated from emergency case register, hospital records and case sheets. SPSS 10.0 was used for data analysis.
Results: Out of 54 patients seeking emergency services with substance abuse (1.16% of all psychiatric consultations), alcohol abusers were 77.8% and other opioid abusers 14.8%. Prevalence of IDU was 16.66%. Common opioids abused were dextrpropoxyphene and pentazocine, both analgesics. A significant number of patients (46.3%) had a history of >20 days/month frequency of abuse. Median of duration of abuse with all drugs was 12 years, while that with IDU population was 3 years. Alcohol withdrawal was the commonest cause (57.4%) of reporting to the emergency. Psychiatric comorbidity was found among 7.4%. Commonest medications used were chlordiazepoxide and clonidine, for withdrawal and naltrexone, for substitution. No standardized treatment protocol for substitution treatment was available.
Conclusions: This is an initial attempt to study the sociodemographic and drug use profile of substance abusers in Sikkim. Demographic and socioeconomic characteristics of substance abusers seeking emergency services are not significantly different from treatment-seeking substance abusers in other parts of India. IDU behaviour has been detected and low median duration of use suggests an emerging problem and need for urgent harm reduction. Alcohol withdrawal was the commonest cause of seeking emergency services, which is related to high prevalence of alcohol abuse in Sikkim. No standardized substitution treatment is available for substance abusers, which may lead to higher rates of relapse.
|How to cite this article:|
Bhalla A, Dutta S, Chakrabarti A. A profile of substance abusers using the emergency services in a tertiary care hospital in Sikkim.Indian J Psychiatry 2006;48:243-247
|How to cite this URL:|
Bhalla A, Dutta S, Chakrabarti A. A profile of substance abusers using the emergency services in a tertiary care hospital in Sikkim. Indian J Psychiatry [serial online] 2006 [cited 2020 Apr 5 ];48:243-247
Available from: http://www.indianjpsychiatry.org/text.asp?2006/48/4/243/31556
Sikkim, a hilly state in Northeast India and the second smallest state of India, is located in the foothills of the Himalayas and shares international borders with Nepal, Bhutan and Tibet. Sikkim is inhabited by indigenous population of Lepchas, Bhutias and Nepalis. Lepchas are traditional inhabitants of Sikkim, whereas Bhutias and Nepalis have migrated from Tibet and Nepal, respectively. Sikkim has an approximate population of 540,493, a literacy rate of 70% and a landscape varying from 300 to 8585 metres in altitude. Sikkim has traditionally been a royal state and was annexed to India in 1975.
From unofficial estimates alcohol use has traditionally been prevalent among Sikkimese population. National Family Health Survey-2, Government of India, has also highlighted a significant prevalence of alcohol use in Sikkim-32% and 17% among above 15 years of age males and females, respectively. From their observations prevalence of alcohol use is more common in rural areas than urban and negatively related to level of education and socioeconomic condition. These rough estimates make it obvious that alcohol use has become an important public health issue in Sikkim. Moreover, since its annexure to Indian state, migration of people from other parts of India has increased and has resulted in introduction of other substance abuse practices in the community, which was so far unexposed to external influences, cultures and practices. As a result, abuse of opioids including heroin and other synthetic opioids have been reported from treatment centers. Similarly injection drug use (IDU) behaviour has also been reported. It is important to note in this context that other Northeast Indian provinces, particularly Manipur, are a significant site of IDU behaviour and resulting blood-borne infections including HIV/AIDS. It is, therefore, obvious that Sikkim is going through a social transition, which is reflected in the changing substance abuse practices in the community. However, to date, any systematic information on epidemiology of drug use behavior in Sikkim is not available.
Emergency services utilization by substance abusers is one of the sources and indicators of assessing problematic substance use. It is an important measure to assess treatment demand from substance abusers and can be an effective tool for a preliminary assessment of magnitude and pattern of substance abuse in the community. Therefore, studying the profile of substance abusers in the emergency services has been conceived as a tool to have an idea about the nature of substance abuse in the community. This may also help to create a baseline data about substance abuse in Gangtok and nearby areas served by the Central Referral Hospital (CRH). The CRH is the teaching hospital of the Sikkim Manipal Institute of Medical Sciences (SMIMS) and is one of the two tertiary care hospitals in Sikkim providing treatment to substance abusers.
Individuals having a history of current substance use and utilizing emergency services at the Central Referral Hospital, SMIMS for any reason related to substance use behaviour were included in the study.
Current substance user: Substance use for more than 10 days in the past 30 daysSeeking treatment for any medical reason related to substance use, as diagnosed by the attending physicianEither sexAny age group
Accidental poisoningSeeking treatment for a medical reason unrelated to substance use, as diagnosed by the attending physician
The study design was a retrospective chart review. Data were collected retrospectively from July 2000 to June 2005 (60 months). Data sources were emergency case register, hospital records and case sheets.
Emergency visit records for all patients from July 2000 were reviewed on a monthly basis from the emergency case register with assistance from the emergency medical officer, in charge. The hospital identification number of patients making emergency visits with possible diagnosis of substance use related medical causes were noted separately. After emergency case register was screened up to July 2005, individual hospital records and case sheets of patients having possible substance use related medical cause were accessed for detailed patient and disease related information. The information, thus accessed, was noted in a pre-devised case record form (CRF). The CRF was devised in partial modification and adaptation of the following.
Pompidou Group: Core Data for Drug Treatment Reporting SystemDrug Abuse Warning Network (DAWN) Medical Examiner ReportGeneral population Survey of Drug Abuse, WHO, 2000
The CRF contained the following information.
Demographic variables, e.g. age, sex, religion, marital status, community, occupation, etc.Socioeconomic variables, e.g. income, education, family information, etc.Drug use variables, e.g. type of drug, duration, route of use, etc.Deviances and high-risk behaviour variables, e.g. property crimes, law infringement, injection sharing, visits to commercial sex workers (CSWs), etc.Reasons for seeking treatment, e.g. overdose, withdrawal, accident, medical consequence, etc.Treatment details and outcome, e.g. diagnosis, medications, previous treatment, complications, disability, death, etc.
The study consisted of only retrospective data analysis from case records and did not involve any patient contact, medical, behavioural, therapeutic or instrumental intervention. The study protocol and CRF were approved by the Institutional Ethical Committee (IEC).
Data was cleaned and initially fed in a MS Excel file and later was analyzed using SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, USA) version 10.0.1 using the chi-square test for non-parametric data. Individual risk factors were described by odds ratio with 95% confidence interval. Level of significance was set at p et al ., where a psychiatric illness was definitely present in 40% of the cases.
This study also highlights the limitation of availability of medications for treatment of substance abuse in this setting. The commonest drug employed for management of alcohol withdrawal had been chlordiazepoxide, a long-acting benzodiazepine. However, there is no standardized protocol of maintenance substitution treatment for alcohol or opioids. Clonidine, an a-2 adrenergic agonist, was employed for opioid withdrawal and naltrexone, an opioid antagonist, was the only drug employed for substitution in four patients with alcohol abuse disorder. Lack of standardized treatment protocol for substance abuse has, thus, resulted in limited follow up visits by the patients and also increases chances of relapse. Adityanjee et al., 1989 has also observed that only 10% of the patients with alcohol related problems were referred for outpatient treatment and 85% were not given any follow up advice.
One of the major limitations of this study is poor quality data availability from hospital case records. However, this is a common problem with retrospective data analysis depending on patient case records. Also, the records of the patients included in the study have been traced from the psychiatry department and thus there is a likelihood of some patients being missed during the process of referral.
In conclusion, this is an early attempt to address the problem of substance abuse in Sikkim and these observations might be helpful in future in designing larger epidemiological investigations.
Conflict Of Interest
The work was supported by a Short Term Research Studentship (STS) by the Indian Council of Medical Research (ICMR), New Delhi given in 2006 to AB.
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