The dilemma of using physical restraint in delirium tremens: a case report

Delirium tremens (DT) is a common presentation in tertiary care hospitals. Refractory DT, though not very common, is a dreaded presentation in any clinical setting. Usually, patients with DT respond to standard doses of benzodiazepines, but sometimes we encounter patients requiring higher than the usual dose. Also, due to the high level of agitation, confusion and hallucinatory behaviour, physical restraint is frequently used in these patients. We hereby report a case of refractory DT in whom the dilemma of using physical restraint and need for higher doses of Benzodiazepine has been highlighted.

Prevalence and pattern of psychoactive substance use among female students aged 18-25 years in universities of North India

Background: Prevalence and underlying reasons of psychoactive substance use vary across different age, gender and societal groups. It is an important concern among females as female physiology and psychology makes them more vulnerable to substance dependence. The primary objective of study was to find prevalence, pattern and factors affecting psychoactive substance use among female students (18-25 years).Methods: In a cross-sectional survey, 250 female students were recruited from a university in Chandigarh using multistage cluster random sampling. Survey tool developed by World Health Organization was used in a self administrated format using paper based survey method. Associations among various factors leading to psychoactive substance use were tested using logistic regression model.Results: Lifetime prevalence of psychoactive substance use was 13.6% [95% CI 9.3-17.8, n=34]. Participants reported their use out of curiosity, for having fun, personal problems, easy availability, familial use, etc. 52.9% (18/250) students reported their use within last 3 months; out of them health problems were faced by two. Association of psychoactive substance use was significant for age, socioeconomic status and family history of psychoactive substance use.Conclusions: Due to sensitive nature of reporting substance use, the lifetime prevalence of 13.6% among female young students may be an underestimation. Familial psychoactive substance use exposes their wards to its use, especially under psychological stress. Qualitative research should be performed to understand why some female students use psychoactive substances while others abstain themselves from using these at all or abstain from their use for a long time after first exposure.

Use of Family CAGE-AID questionnaire to screen the family members for diagnosis of substance dependence.

Background & objectives: CAGE-AID questionnaire is a short, useful screening tool for substance dependence. Assessment of one family member for the screening of substance dependence in the family could be useful in clinical practice and research. In this study, we aimed to assess the validity of the Family CAGE-AID questionnaire for the diagnosis of substance dependence. Methods: Cross-sectional assessments using CAGE-AID and Family CAGE-AID questionnaires were conducted both for the study participants (n = 210) and their family members. The participants were recruited from two different treatment settings: a treatment seeking population from a de-addiction centre, and non-treatment seekers for substance use disorders from the psychiatry outpatient department. ICD-10 criteria and subsequent detailed clinical interview by a trained psychiatrist were used for the final diagnosis of substance dependence. Results: In the psychiatry outpatient group, the scores on CAGE-AID and Family CAGE-AID questionnaires were significantly correlated with the ICD-10 symptom score (r=0.81 and 0.70, respectively). In the same group, inter-rater agreement of the Family CAGE-AID was good with CAGE-AID and moderate with ICD-10 diagnosis of substance dependence (Cohen’s kappa 0.78 and 0.61, respectively). A cut-off score of three on Family CAGE-AID was found to be 95·8 per cent sensitive and 100 per cent specific. Interpretation & conclusions: Family CAGE-AID questionnaire is a valid screening instrument for the diagnosis of substance dependence, with acceptable sensitivity and specificity of a cut-off score of three. The simplicity and the brevity of such an instrument can be valuable in the clinical settings of developing countries and also for epidemiological studies.

Hepatitis C virus (HCV) infection & risk factors for HCV positivity in injecting & non-injecting drug users attending a de-addiction centre in northern India.

Background & objectives: Injecting drug use is a major route of hepatitis C virus (HCV) infection in India, but there may be other risk factors also. this study was carried out to determine the seroprevalence of anti-HCV antibody in injecting drug users (IDUs) vs. non-IDUs (NIDUs), and to study the risk estimates for HCV seropositivity in the total sample of substance users with regard to various demographic, clinical, behavioural and personality factors. Methods: the IDUs (n = 201) and NIDUs (n = 219) were assessed for demographic, clinical and behavioural information, and were rated on instruments for severity of dependence, risk behaviour and personality profiles. Anti-HCV antibody was tested by ELISA and confirmed by recombinant immunoblot assay (RIBA) test. Results: Almost one-third of the IDUs (64 of 201; 31.8%) were positive for anti-HCV antibody, as opposed to only seven (3.2%) of the NIDUs. The four risk factors strongly associated with HCV positivity in multivariate analysis were sharing syringe [Exp(B) 75.04; 95%CI 18.28-307.96; P<0.001], reuse of injection accessories (16.39; 3.51-76.92; P<0.001), blood transfusion (5.88; 1.63-21.23; P=0.007) and IDU status (3.60; 1.26-10.31; P=0.017). Other variables less strongly but significantly associated with HCV positivity were multiple sex partners, opioid dependence, risk behaviour scores, impulsivity, and lower age of onset of drug use. Interpretation & conclusions: Our study showed a high seroprevalence of anti-HCV antibody in IDUs. In the substance users, HCV positivity was significantly and independently associated with several clinical, behavioural, and personality risk factors.

Profile of inhalant users seeking treatment at a de-addiction centre in north India.

Background & objectives: Inhalants are substances whose chemical vapors are inhaled to produce euphoric, disinhibiting, and exciting effects. Data on inhalant abuse in India are relatively scarce. We report the demographic and clinical profile of inhalant users among the treatment seekers at a Drug De-addiction and Treatment Centre in north India. Methods: The records of treatment seekers at the Drug De-addiction and Treatment Centre, over 10 years (2002-2011) were scanned to identify 92 cases reporting inhalant use. Of these 92 cases, the complete record files were available for 87 (94.6%) cases. These case files were reviewed and the relevant data were collected and analyzed. Results: Over the study period of 10 years, the number of cases with inhalant abuse per year rose steadily to peak at 20 cases (4.08% of new cases) in 2006 and then stabilized at 1-3 per cent of new cases annually. Of the 87 cases studied, all were males with a mean age of 18.9±4.12 yr, mean education of 9.8±3.42 yr and mean family income of ` 7676±7343.15 (median: ` 5000). Majority of subjects were unmarried (89.7%), urban resident (79.3%), and from a nuclear family (78.2%). About half of the subjects were students (50.6%). The most common inhalant used was typewriter correction fluid (73.6%) followed by typewriter diluent fluid (19.5%) and glue (6.9%). The most common reason for initiation was curiosity. The mean age of onset of inhalant use was 16.3±4.22 yr. Most subjects fulfilled the criteria for inhalant dependence (85.1%). Psychiatric co-morbidity and the family history of substance dependence were present in 26.4 and 32.9 per cent subjects, respectively. Majority of the subjects reported drug related problems, occupation and finance being the worst affected. Interpretations & conclusions: oOur results showed that the inhalant users were mostly urban youth belonging to middle socio-economic class families. The principal sources of inhalant abuse were the commonly available substances like typewriter correction fluids and majority of the subjects initiated it out of curiosity. Nearly three-fourth of the subjects used some other substance of abuse in addition, tobacco being the most common. In view of associated drug related problems, there is a need for strategies to prevent this emerging health care problem.

Family burden with substance dependence: a study from India.

Background & objectives: A substance dependent person in the family affects almost all aspects of family life. This leads to problems, difficulties or adverse events which impact the lives of family members and causes enormous burden on family caregivers. The present study aimed to assess the pattern of burden borne by the family caregivers of men with alcohol and opioid dependence. Methods: A cross-sectional study was conducted with ICD-10 diagnosed substance dependence subjects and their family caregivers attending a de-addiction centre at a multispecialty teaching hospital in north India. Family Burden Interview Schedule was used to assess the pattern of burden borne by the family caregivers of 120 men with alcohol and/or opioid dependence. Results: Compared to opioid and alcohol+opioid dependence groups, more often the alcohol dependence group was older, married, currently working, having a higher income and with the wife as a caregiver. Family burden was moderate or severe in 95-100 per cent cases in all three groups and more for ‘disruption of family routine’, ‘financial burden’, ‘disruption of family interactions’ and ‘disruption of family leisure’. Family burden was associated with low income and rural location. It was associated neither with age, education or duration of dependence of the patients, nor with family size, type of caregiver or caregiver’s education and occupation. Interpretation & conclusions: Almost all (95-100%) caregivers reported a moderate or severe burden, which indicates the gravity of the situation and the need for further work in this area.

Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978-2008).

Background & objectives: The patterns of abused psychoactive substances change over time, and it is important to document such changes. The present retrospective study was carried out to document these changes in patients registered in a de-addiction centre in north India over three decades. Methods: Case notes of all patients registered in the centre from September 1978 till December 31, 2008 were reviewed. Comparisons were made among three decades (1978-1988, 1989-1998, and 1999-2008). Results: The number of registered subjects increased eight-fold over the decades, and age of the subjects presenting for the treatment decreased. The percentages of subjects presenting for the treatment with opioid dependence were 36.8 per cent (n=204), 42.9 per cent (n=809) and 53.2 per cent (n=2219), respectively for the three decades (P<0.001). The proportion of subjects using natural opioids decreased over the three decades (47.4, 26.5 and 18.3%; P<0.001), with a concomitant emergence and/or increase of newer and prescription opioids such as buprenorphine, codeine and dextropropoxyphene. Dependence on tobacco and sedative-hypnotics also increased, and inhalant abuse was reported especially in the third decade. Polysubstance dependence increased significantly over the decades (P<0.001). Interpretation & conclusions: Our results showed major shifts in the patterns of substance abuse in clinic-attending patients in north India over the three decades from 1978 till 2008. These have important implications for all the stakeholders concerned with combating the challenge of psychoactive substance abuse in our society.

Prevalence & correlates of metabolic syndrome in alcohol & opioid dependent inpatients.

Background & objectives: The research on the association of metabolic syndrome (MS) and substance abuse is scanty. The present research aimed to study the prevalence and correlates of MS among the inpatients at a Drug De-addiction Centre in north India. Methods: Consecutive male subjects (N=110) admitted to a drug de-addiction centre during July to December 2009 with a primary diagnosis of alcohol or opioid dependence were evaluated for the presence of MS as per the International Diabetes Federation (IDF) criteria. Results: The prevalence of MS was 24.6 and 29.3 per cent in alcohol and opioid dependent groups, respectively. MS showed a significant association with the age and body mass index (BMI) in the opioid dependent group. Co-morbid tobacco use was not associated with MS in either group. Interpretation & conclusions: The prevalence of MS in our sample of alcohol and opioid dependent male inpatients was greater than the prevalence of MS in general population, however it was comparable to that reported in physical and other psychiatric disorder populations. Even though the absence of any comparative study limits the generalizability of our findings, results indicate towards a need for screening of the patients with substance dependence especially for those aged above 30 years and/or having a high BMI for MS.

Club drugs: review of the ‘rave’ with a note of concern for the Indian scenario.

'Club drugs’ which include Ecstasy, gamma-hydroxybutyrate (GHB), ketamine, and Rohypnol (flunitrazepam) have become popular with participants in ‘raves’, because they are perceived to enhance energy, endurance, sociability and sexual arousal. These drugs vary in their pharmacologic properties, physiological and psychological effects, and potential consequences. The use of club drugs by young people has increased in the last decade, and continue to get modified and evolve, making them very difficult to monitor. Further, these drugs are not picked up by routine drugs screening procedures, thereby making these popular with the criminals. India, which is in a phase of social transition, also faces this rising menace. Despite the nature and extent of this problem, this area has been under-researched. Data from India are sparse barring a few newspaper and police reports. Keeping abreast of current trends in club drug use prepares the clinician to recognize the clinical effects of club drug use, to manage club drug related emergencies, and to generate social awareness.

Allergic to all medicines and red coloured urine.

Dermatitis artefacta is a disorder in which the skin is the target of self-inflicted injury. We report a case of dermatitis artefacta, in which the patient developed skin lesions, after taking each and every medication. Additionally he also had red coloured urine after taking certain group of medications, which, on further investigations, was found to be associated with glucose 6-phosphate dehydrogenase (G6PD) deficiency. This case illustrates the presence of factitious dermatitis and physical co-morbidity simultaneously, which was missed before psychiatric referral. Every symptom in a patient with a factitious disorder should not be labelled as feigned without a proper workup.

Drug dependence in adolescents 1978-2003: a clinical-based observation from North India.

OBJECTIVE: To study the demographic and clinical profile of adolescent subjects (< or =18 yr) presenting to a state-funded drug de-addiction centre in north India. METHODS: Data on demographic and clinical features were extracted from available case notes of adolescent patients who presented to the centre during 1978-2003 (n=85). RESULTS: Many adolescents came from nuclear family (63.5%), of urban background (83.5%) and were school dropouts (54.1%). Mean age-at-first-use of the primary substance was 14.8 yr and mean age at first presentation was 17 yr. The commonest used primary class of substance was opioids (76.2%) and the commonest used opioid was heroin (36.5%). More than half of the subjects (54.2%) were also nicotine dependent at the time of presentation. The most common reason for starting the use of drugs was curiosity (78.8%). About one-fifth (21.2%) of the subjects indulged in high-risk behaviour such as having sexual intercourse with multiple sexual partners. Nearly half of the subjects had positive family history of either drug dependence (40.2%) or psychiatric disorder (5.5%). CONCLUSION: The results suggest that the development of substance dependence in children and adolescents is a combination of familial and social vulnerability factors, including the drug culture of the social milieu.

Drug and alcohol abuse: general physician's perspective.

Epidemiology, definitions, concepts and various other relevant aspects including management of drug and alcohol abuse are reviewed. The role of general/primary care physicians has been highlited in the persepctive of substance-abuse disorders.

Inhalant abuse by adolescents: a new challenge for Indian physicians.

Inhalant abuse has been commonly reported especially in the young during the last decades globally. The reason for the relative paucity of literature from India may be attributed to a lack of knowledge about this growing problem among health professionals. A series of five cases of inhalant abuse is described in order to understand this growing public health concern. Most of the cases started inhalant abuse during adolescence. All patients except one abused typewriter erasing fluid and thinner which contains toluene. All the patients reported using inhalants as addictive substance because of their easy accessibility, cheap price, their faster onset of action and the regular 'high' that it provided. Whereas several features of inhalant dependence were fulfilled, no physical withdrawal signs were observed. The diagnosis of inhalant abuse can be difficult and relies almost entirely on clinical judgment. Treatment is generally supportive.