SURREPTITIOUS DRUG ABUSE AND THE NEW

 LIBERIAN REALITY: AN OVERVIEW

In 1977 as  the new 9^th grade science reporter for THE SAINTS, the local school newspaper at St. Pat’s in Monrovia , one of my initial assignments was to read up on mental illness and write a report on it. This was welcome news for me since back then as I was interested in everything medical and mental, this was a good opportunity for me to learn as much as I could.  To begin my assignment, I sought an audience with Dr.
Chief Abua Nwaefuna, psychiatrist and then Director of the Catherine Mills Mental Rehab Center . I met him at his Sinkor 9 ^th Street Office at an arranged time.  I introduced myself and said I wanted to interview him about mental illness. I will never forget his intial words. “If you want to learn about mental illness, you have to go to the source. I will not allow you to just interview me like the other fellow from America the other day wanted to do and then you  will go back and say you have all the information on mental illness” he said sternly. That set the pace for our encounter and has shaped my journey since then. I followed and tagged him at Catherine Mills Rehab for the rest of that assignment.

I saw many scary, difficult and interesting things to say the least. He showed me many forms of mental illnesses, many which he said were drug induced. Back then, the main drug of abuse in Liberia was marijuana especially the Cannabis sativa variety as well as its legal counterpart, ethyl alcohol (alcohol for short). I also learned that the drugs of choice of the wives of the Liberian elite and well-to-do (especially those who spent any amount of time in America ) were amphetamine and barbiturates. Cane Juice-C.J. for the poor people and Johnny Walker Red/Black Label Whisky plus or minus some form of cannibis for the mostly male well-to-do. Interestingly, some of these social secrets have been used successfully against several members of the Liberian leadership over the years during the many contract signing ceremonies on the  nation’s behalf. The modern day weapons of choice during these many of these signing/negotiating ceremonies seem to be alcohol plus or minus drugs, illicit and licit, laced coffee/tea/food, and free supply of men and women  as opposed to gunshot , gunpowder and smoke fish of yesteryears. Yet this important detail seem to be lost in translation all the time.  DUI is commonly known as driving under the influence. For Liberians in particular, it is my opinion that it should be known also as “ decision under the influence” and this should be scrutinized seriously in this new light (legally, historically and socially) and remedied as deemed fit if we and our children are to have any glimmer of hope for longevity as a nation.  Stealing, lying, sexual promiscuity(by both men and women) have been aptly pointed out by observational frontline psychological data as covariables that are very much part of substance abuse. (unpublished data, Janet Zumo, 2007). Imagine what substance abuse/dependence with its associated cofactors of lying, stealing, sexual promiscuity in addition to pathologic gambling can do in wrecking havoc on the national coiffers as well as in the propagation/perpetuation of corruption in Liberia .

Now to the main gist of this article. Fast forward 30 years  to 2007. The emerging picture of drug abuse among Liberians is quite different, troubling and worrying as well. More and more men, women and children are using more hard core drugs chronically. The daily revelations of surreptitious and overt drug abuse by Liberians of all walks of life, women, children and men alike make it imperative for us to familiarize ourselves briefly with some of salient features of the main drugs/substances of abuse, psychological and physiologic manifestations,  their systemic effects and how to spot the main signs and symptoms as well as implications for our national life and direction. Additionally, spotting a surreptitious user and nudging him/her to seek real help and counseling could save the life of a mother, father, student, their family members, children, etc or avert a catastrophic national decision that could have lasting negative consequences for all of Liberia . Below will be some salient features  of the frequently encountered drugs, illicit and licit. Some addicts cleverly state that the symptoms they have are from environmental/occupational exposure to  workplace chemical agents like mercury, lead, thallium, organophosphates, ethylene oxide, methyl bromide, organochlorine pesticides which are neurotoxins but the dysfunctions to the central ,peripheral, neuromuscular apparatus and especially the autonomic nervous system are by and large distinct from the features of dependence, tolerance and withdrawal of substance dependence.(eg. Nouri and Zumo, 1998). Hence neurotoxic disorders will be left out of this overview.

All the substances of abuse have potent acute and chronic effects on the nervous system. The effects of the common legal substances of abuse, alcohol and tobacco, are protean and are well known, so will be only  mentioned in passing.

Acute intoxication or overdose of substances of abuse often lead to delirium (confusion with associated autonomic hyperactivity like rapid heart beat, agitation), stupor, or coma, sometimes associated with seizures,  respiratory depression and cardiovascular collapse. Chronic use of most of these agents often leads to drug tolerance or dependence. Abrupt abstinence of a chronically used drug with lead to an acute withdrawal syndrome. Drug abuse may affect the nervous system and human body, indirectly via infectious and embolic consequences of intravenous drug abuse, hypersensitivity or immunologic mechanisms.

On the spot urine drug screening (known as “peeing in a cup” in street parlance)  is widely used in the United States for evaluation of persons for possible job termination, legal action or treatment purposes because the medical and social importance of drug abuse is enormous and rightly recognized so in the USA and other developed countries. Actual offending agents can be determined precisely by  sensitive yet fairly simple chemical methods such as gas liquid  chromatography or mass spectroscopy.

Abuse of opiod analgesics can present in two forms- excessive taking of a prescription opiod analgesic or by street addicts who use the illegal drug, heroin. Heroin crosses the blood brain barrier and its effect on the brain is identical to morphine. When heroin is combined with cocaine, it is called “speedball”. Aside from the pain relieving effects, morphine or heroin can acutely produce a sense of rush, accompanied by euphoria. Hallucinations (seeing or hearing things that are not there) may also occur. Signs to look out for are intense skin scratching, small pupils, constipation and urinary retention. Overdose of heroin leads to coma, respiratory suppression, and pinpoint pupils.

Marijuana, Cannabis sativa, with its primary active ingredient of THC, tetrahydrocannabinol, has effect on mood, memory, judgement, and sense of time. Cannabis sativa has more than 400 compounds in addition to the psychoactive substance, THC.  Often a sense of relaxation, euphoria and depersonalization occurs. High doses of marijuana produce hallucinations, paranoia, or frank panic reaction. Tolerance does develop with chronic use of marijuana, contrary to popular belief. Abrupt stopping of marijuana smoking causes irritability, restlessness, and insomnia. Marijuana cigarettes are prepared from the leaves and flowering tops of the plant. The usual THC concentration varies between 10 and 40 mg/ per marijuana cigarette but concentrations > 100 mg per cigarette have been detected. Hashih is prepared from concentrated resin of Cannabis sativa.  THC is quickly absorbed from the lungs during smoking into the blood and is then rapidly sequestered in the body tissues. Although the effects of acute marijuana intoxication are relatively benign in ‘normal users’, the drug can precipitate severe emotional disorders in individuals who have antecedent psychotic or neurotic problems. Very potent forms of marijuana (sinsemilla) are now available in many communities, and concurrent use of marijuana (considered a gateway drug) with crack/cocaine and phencyclidine is increasing at an alarming rate.

As with the abuse of cocaine, opiods, and alcohol, chronic marijuana abusers may lose interest in common socially desirable goals and steadily devote more and more time to drug acquisition and use. However, THC, in and by itself do not cause a specific and unique “amotivational syndrome”.  Signs to look out for: conjunctival injection (ie. red eyes) and tachycardia (rapid heart beat) are the most frequent immediate physical sings of smoking marijuana. Among regular users, tolerance for marijuana- induced tachycardia develops rapidly. Tolerance to conjunctival injection is the most difficult to develop no matter how long the person has used the drug, and hence the easiest sign to look out for . But mind you, the ever present use of the eye drop, Visine, is used by mask this hard-to get-rid-of physical sign. So if a friend, family member or child is always buying Visine for a supposed chronic eye “infection”, become suspicious. Visine is not an eye antibiotic!!!!!

Medical marijuana tablets, however, are sometimes used in very controlled setting for patients with HIV/AIDS, or multiple sclerosis or as antiemetic in chemotherapy but that is the exception and not the rule.

Cocaine, derived from the leaves of the coca plant, is a stimulant and local anesthetic with potent vascocontrictor properties. The drug can be administered orally, thru the nose, through the vein, or by inhalation after smoking it. Cocaine abuse occurs virtually in all social and economic clases of society. Cocaine produces a brief, dose-related stimulation and enhancement of mood and an increase in cardiac rate and blood pressure.

In addition to generalized seizures, neurologic complications may include headache, ischemic or hemorrhagic stroke or subarachnoid hemorrhage.

Although men and women who abuse cocaine may report that it enhances their libido and sex drive, chronic cocaine use causes significant loss of libido and adversely affect reproductive function; hence the increasing and suprising use of Viagara in this subset of people. Impotence and gynecomastia, persisting for long time even after stopping the drug use, have been reported in male cocaine abusers. Women who abuse cocaine have reported major menstrual cycle dysfunction including galactorrhea, amenorrhea, and infertility. Cocaine abuse by pregnant women, particularly smoking “crack” have been associated with increased fetal congenital malformations, fetal withdrawal syndrome and perinatal maternal cardiac disease and strokes.  Long term use of cocaine may cause paranoid ideation and visual as well as auditory hallucinations, a state resembling alcoholic hallucinosis. Alert: But the characteristic alcoholic breath is absent here. Treatment of cocaine overdose is a medical emergency and must be treated in an intensive care unit. An emerging  pattern called “ crack head” behavior is more and more evident in street addicts, etc  addicted to crack/cocaine. These addicts in part exhibit abnormal thinking, significantly  impaired judgement  and impaired decision making processes that are out of proportion to their physical presentation.

Multiple, concurrent drug use is common among drug abusers. So this fact must be kept in the back of our minds. Drugs have varying effects on different organ systems of the human body. A few examples will illustrate this point.

Drug abuse of almost any form increases the risk of strokes. Drug abuse is the most important risk factor for stroke in people younger than 35 years of age. So if you see a young person in this age group with stroke, don’t leave out drug abuse as a possible cause of stroke. Foreign materials injected during intravenous drug use may cause infective endocarditis, which in turn may cause septic embolic leading to stroke, etc. Vasospasm and vasculitis are frequently associated with the psychostimulants like cocaine,amphetamines.

Anoxic brain damage often follows drug overdose, especially heroin and other opiates.

Cocaine is without doubt the most important cause of drug-related stroke and accounts for approximately 50% of all the cases (esp. in age less than 35).

A rare but acute complication of heroin and cocaine abuse is acute myelopathy, ie. spinal cord syndrome, with flaccid weakness of both legs, urinary retention, etc. This may be due to sudden drop in blood pressure exposing very vulnerable portions of the spinal cord as the usually work up including MRI, spinal taps are all normal.  Sudden bloody urine, kidney failure and muscle weakness can be seen in those who abuse heroin, cocaine, ecstasy, amphetamine (the erstwhile drug of choice of Liberian female elites) and PCP.

Betty Ford-like center for substance abuse in a confidential setting mid or upcountry away from the hustle and bustle environment of Monrovia could go a long way to help us cope with this menace and tragedy.

According to  DSM-IV-TR ,  the diagnosis of substance dependence takes precedence  over substance abuse.  Dependence  is described  as 3 or more  episodes in  a  12  month  period;  abuse as 1or more in  a  12 month period.. Feeding  into dependence is tolerance (marked increase  in amount of substance  with marked decrease  in desired  effect); much time/activity to obtain substance, use  and recover from it.. Abuse is characterized  by recurrent use  which results in failure to fulfill  major  obligations at work, school  or home as  well  as continued  use  despite  persistent or  recurrent  social/interpersonal problems,  etc.

Substance (eg.ethanol, narcotics, opiods  like  prescription pain killers ) dependence is a medical  disease  that  can be  treated most  effectively with a  combination  of  pharmacotherapy  and psychosocial  counseling. Available  pharmacotherapeutics,  in conjunction  with  psychosocial  counseling suppress  withdrawal symptoms  and decrease craving so as to  improve treatment  retention  and reduce illicit substance  use.

It is important to note that certain patients may  be at  a  greater risk  for  substance dependence  than  others; eg. those  with a  family   history of substance  abuse;   co- morbid psychiatric  conditions like depression, mood swings/disorders; chronic  medical  diseases like  hepatitis C, HIV  as  well as  those with  resolved pain but with  lingering  desire for pain medications.

Some questions  that you  may want to ask: (DAST-10, Skinner, 1982;  Yudko, 2007); Are you  unable  to  stop using drugs/alcohol  even  if you want to?;  Do  you  abuse more  than one drug  at the  time?;  Do  you  feel bad or guilty  about  your  drug  use?; Does your  spouses/parents  ever complain about  our  drug/alcohol abuse? Have you  neglected your  family/children because  of  you drug use? Have you  ever had blackouts or flashbacks ass  a result of  drugs/alcohol  abuse?;  Have  you  engaged in illegal/amoral activities  in  order  to obtain drugs?;  Do you  feel  sick/have withdrawal  symptoms  when you  stop  taking  drugs/alcohol?;  Have you  had  medical problems as a result  of  your drug/alcohol use  like memory  loss,  seizures, headaches, bleeding ulcers, etc?  

A higher  degree of ‘yes” answers to this questionnaire susuggests  harmful  behavior and warrants  referral for specialized/intensive  assessment  and treatment. 

During discussion  with people  suspected with substance  abuse/dependence,  it is helpful to  use  a nonjudgmental tone  and   give  reassurance that substance abuse/dependence is a medical condition and not a moral failure.  You  can then suggest referral  for counseling and treatment .  By so doing  you may have helped to save the  life and sanity of a mother , father, promising student,  significant family breadwinner, or  that of a significant political, national or legislative leader.

REFERENCES:

1.So, Y.T. Effects of Drug Abuse on the Nervous system,  in Bradley, W.G et al (eds): Neurology in Clinical Practice, Vol. II, 2000, pp. 1521-1527

2.Mendelson, J.H, Mello, N.K., Cocaine and other commonly abused Drugs, in Kasper, Braunwald et al. (eds), Harrison ’s Internal Medicine Textbook, 2006. 16th ed.ch. 374, pp. 2570-2754. McGraw-Hill.

3.Skinner HA, The drug abuse screening test. Addict Behav. 1982;7:363-371

4.Yudko,E, Lozhkina O,Fouts A: A comprehensive review of the psychometric properties of the Drug Abuse Screening test. J Subst Abuse Treat. 2007;32:189-198.

5.Nouri, S, Zumo Lawrence, Kaufman, H. Autonomic Cardiovascular Reflexes in Chronic Fatigue Syndrome. April 1998. American Academy of Neurology, 50th Anniv. Session Presentation.

6.Zumo, Janet. Unpublished data, 2007. Thanks for many years of  immense continued support and collaboration.

Lawrence A. Zumo, MD
Diplomate, American Board of Psychiatry and Neurology
Member, American Academy of Neurology
Member, European Neurological Society
zumoamos@aol.com