Medical Needs of Different Age Groups of Substance Dependent Subjects: A Cross-sectional Study

Introduction

Substance use disorders have been recognized as a major public health problem globally including India. Substance abuse has emerged as a serious concern, adversely affecting the physical, mental and socio-economic well-being. The processes of industrialization, urbanization and migration have led to change in our social structure and loosening of the traditional methods of social control have rendered individual vulnerable to the stresses and strains of modern life. Substance abuse is a complex medico-social problem, which has various social, cultural, biological, geographical, historical and economic aspects. Psychoactive substance use has typically been associated with onset during late adolescence or early adulthood¹. While adolescents and young adults constitute substantial proportion of the current substance users, the consequences of use during these years continue to impact the middle age and later years of life. Various complications related to use of psychoactive substances are likely to impact individuals in middle years of life². Nation-wide survey on psychoactive substance use in India, has found around 70% of current users to be aged 40 years or less³. Those in middle years of life and elderly population constituted the remainder of 30% of current users. Consequently, adolescents and young adults continue to remain the focus of attention with regards to substance use related problems⁴. There has been a limited focus on illicit substance use among middle aged and elderly population^5,6.

Substance use and mental illness can lead to significant disability adjusted life years (DALY) and the awareness regarding mental illness is also poor in this part of the country; hence for proper management of these disorders, the extent and seriousness of the problem must be assessed. Therefore, to provide comprehensive management, rehabilitation, prevention, and to frame a proper regional health policy such research is required and need to be conducted from time to time reported routinely from different regions of the country. Drug abuse is a complex phenomenon, which has various social, cultural, biological, geographical, historical, and economic aspects. The disintegration of the old joint family system, absence of parental love and care in modern families where both parents are working, decline of old religious and moral values, drug encouraging role of media, role models etc. lead to a rise in the number of drug abuse cases, who take drugs to escape hard realities of life⁷. Different locations play an important role and can influence the pattern and prevalence of substance abuse further various physical, social, economic, factors differ across age groups. Therefore, a proper comparison of comorbid SUD is required, among patients in different age group belonging to similar community. So we conducted this study with aim of comparing sociodemographic characteristics among treatment seeking Substance abusing subjects across different Age groups (Young adult 18–40 years, Middle Age 40–60 years & Elderly > 60 years) as per WHO age classification.

Methodology

The present study was conducted in de-addiction center of Psychiatry Department of Sir Sundar Lal hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, a premier tertiary care hospital situated at northern part of India, covering and serving a large catchment area. The sample was collected from 1 January 2018 to 30 March 2019, both from outdoor and indoor service of department of Psychiatry, IMS, BHU, Varanasi. We took 30 subjects in each age groups of substance use, who were self-reporting, meting the exclusion and inclusion criteria. The sample was determined by convenience method as the study was a part of MD thesis and the time duration for the study was one year, hence the sample size was limited. The study was started after approval from Ethics Committee of our institute.

All subjects were screened as per ICD-10 for substance dependent (all type). There after they were divided into 3 groups (Young adult 18–40 years, Middle Age 40–60 years & Elderly > 60 years) depending upon their age.

Analysis

The data were analyzed using SPSS version 23.0 for window and comparison chi square and p value were used.

Results

Tobacco was most commonly use psychoactive substance in all groups (93.3% in young adult, 96% in middle age and 96% in elderly), followed by alcohol (56.6% in young adult, 76.6% in middle age and 23.6% in elderly, followed by cannabis and opioid (Table 1). Use of cannabis and opioid gradually decrease with increasing age (cannabis & opioid 20% in young adult, 16.6% in middle age). Nobody used cannabis and opioid in elderly treatment seeking subjects. Benzodiazepines are almost equally used by all three groups (6.6% in young adult, 10% in middle age and 6.6% in elderly). Difference between prevalence of alcohol, cannabis and opioid use across different age groups was statistically significant (χ²=17.457; p=0.000, χ² = 6.421; p=0.040, and χ² = 6.421; p=0.040 respectively).

Poly substance use is most commonly use in middle age followed by young adult and least common in elderly (young adult 83.3%, middle age 96.6%, in elderly 23.3%). Difference between prevalence of poly substance use across different age groups was statistically significant (χ² =41.922; p=0.000) (Table 1).

There was statistically significant difference (χ² =15.833; p=0.000) of number of substance users among different age groups with regards to different types of family structure like nuclear and joint family. Nuclear family was more associated with substance use in young and middle age (63.3% and 83.3% respectively) in comparison to elderly age group (33.3%) (Table 2). Most of treatment seeking subjects had been married (young adult 50%, middle age 100% and 93.3% in elderly), and there was statistically significant difference (χ²=28.864; p=0.000) of prevalence of substance abuse among different age groups with regards to marital status of substance use (Table 2). Treatment seeking behavior was significantly more common in young and middle age people belonging to urban background (in young adult 56.6%, middle age 56.6% and in elderly are 16.6%) while elderly people belong to rural background (P=.001), most of young adult were unemployed, mostly students. In middle age mostly self-employed followed by government employee (48.3% self-employed, 33.3% government employee). In elderly mostly, retired people followed by professional (50% retired, 33.3% professional 30% farmer). There was statistically significant difference (χ²= 83.471; p=0.000) of prevalence of substance abuse among different age groups with regards to occupational status of subjects having substance use. majority of participants belonged to upper middle socioeconomic status in all age groups (young adult 56.6%, middle age 53.3%, elderly 50%) followed by lower middle in young and middle age group (young adult 33.3%, middle age 30%) while upper lower in elderly (30%) and least belong to lower socioeconomic status in all age groups. There was statistically significant difference (χ²= 22.804; p=0.004) of prevalence of substance abuse among different age groups with regards to socioeconomic status of subjects having substance use. There was no statistically significant difference of prevalence of substance abuse among different age groups with regards to Gender, Education, and religion of subjects having substance use (Table 2).

Tobacco user had high co-morbidity of other substance use. Majority of young adult tobacco user also used alcohol (53.5%), followed by cannabis (17.8%), opioid (14.2%) and benzodiazepine (7.14%). Majority of middle age tobacco user also used alcohol (75.8%), followed by cannabis (17.2%), opioid (17.2%) and benzodiazepine (10.3%). Only 20.6% of elderly tobacco user used alcohol and 3.4% used benzodiazepine. Difference between prevalence of co-morbidity of alcohol use in tobacco use across different age groups was statistically significant (χ²=3.830; p=0.050).

Discussion

Interestingly, none of the patients in our sample are female which could be due to stigma associated with drug use and hence reluctance to seek treatment. This does not mean females do not use drugs as evident from clinical practice and previous studies. Similar finding has been shown by the previous study conducted by Bashir N et al.¹¹ in Srinagar, Kashmir.

Our study results showed that prevalence of tobacco across different age groups was more than 93% in all age groups. This showed tobacco was most prevalent in our study because tobacco is often considered as a gateway of other drugs¹². Our study result showed that prevalence of alcohol in young adult was 56.6%, in middle age 76.6% and in elderly 23.6%. Similar finding has been shown by previous study conducted by Ashtsnkae HJ et al.¹³ at Nagpur found prevalence of Tobacco was 92.5% and alcohol 70.3%. Our study result showed that prevalence of cannabis and opioid in young adult and in middle age was 20% and 16.6% respectively and none of subjects use these substances in elderly. Similar finding has been shown by previous study conducted by Balhara YP et al.¹⁴ found prevalence of cannabinods 17.3% and opium 15.8%. Our study result showed that prevalence of Benzodiazepine across all age groups ranges 6-10%. Similar finding has been shown by previous study conducted by Roy et al.¹⁵ in Sylhet Bangladesh prevalence of benzodiazepine was 6.5%. Our study result shown that polysubstance use is most commonly use in middle age followed by young adult and least common in elderly (young adult 83.3%, middle age 96.6%, in elderly 23.3%). Similar finding has been shown by previous study conducted by Roy et al.¹⁵ in Sylhet Bangladesh found 61.8% patients abused more than one substance and 32.8% abused multiple substance. Another study by Sau et al.¹⁶ prevalence of polysubstance use 59.1%.

Our study result shown that tobacco user has high co-morbidity of other substance use (Table 3). Our study showed tobacco is most commonly used substance followed by alcohol followed by cannabis and other substances which was similar result shown by Srivastava M et al.¹⁷ probably reflecting true drug use pattern in the community.

Our study result showed that prevalence of alcohol and illicit drugs use decrease with increasing of age. This is due to the general trend among the elderly appears to be a reduction of substance use after the age of 50 years successively. This has been described as a “growing out of ” or “aging out of ” substance use. For example, Indian studies on alcohol use disorders have shown the downward trend of prevalence from 65–69 years to 85 years onward¹⁸.

Our study result showed that majority of subject were married (50% in young adult 100% in middle age 93.3% in elderly. This is due to universality of marriage in Indian culture. The findings of the current study reflect possibility of a relatively less impact of substance use disorder on marital status. However, the observation could simply be a result of more likelihood of those with good marital support to seek treatment. The proportion of married individuals in the current study is like previous studies from another de-addiction centre in India the proportion of married individuals varied from 62.5% to 76.8% across different years in these studies¹⁹.

Our study result showed that majority of subjects (>93%) have family history of substance use (Table 2). This shows that easily availability of substance in home. Similar finding shown by Sarkar et al.²⁰ in West Bengal 83% patients had positive family history for alcoholism. Our study result showed that majority of subjects having substance use in young and middle age came from urban area (56.6%), which may be reflection of the increases of urbanization in our country. Similar, finding by Sau et al.²¹ 73.4% substance users belonging to urban area.

Our study showed that majority of subjects having substance use in young and middle age belonging to nuclear family (60% – 80%). Most of the patients belonged to nuclear families and urban localities, which may reflect the increase in urbanization, accessibility to treatment or a true prevalence of substance abuse in urban population. Moreover, our centre of study was in urban area, so majority of patients belong to the urban area. The findings were in line to other studies^10,21,22. This does not rule out those living in joint family. The various studies in different Indian setting showed that even individuals from joint families are involved in substance abuse.

Our study result shown that majority of subject belonging to Hindu religion (>90%). Similar finding shown by Dadwani²³ 90% substance user in India belong to Hindu by religion. Our study result shown that majority of subjects were educated beyond 10^th class (80-90%) and nearly 40% were graduated in all age groups. Similar finding shown by Kapse et al.²⁴ 65% substance user in Nagpur were educated beyond matric level. Prajapati et al.²⁵ found among literate group of substance user majority (28%) were graduate. It may be explained on the basis that higher educated individuals may be due to more awareness of the harmful effects and inhibitions and came to de-addiction centre.

Our study result shown that most of young adult are self-employed like shopkeeper, businessman followed by unemployed mostly students (33.3% self-employed, 30% unemployed). Similar finding shown by Gul et al.²⁶ study at Jalandhar Punjab that 28.3% self-employed 12.3% were student. In middle age mostly self-employed followed by government employee (48.3% self-employed, 33.3% government employee). Similar finding shown by Prajapati et al.²⁵ majority of the abusers were self-employed (48%) followed by never employed. Businessmen and the service class population carry high risk of drug abuse compared to other occupations. Perhaps persons in these groups need to maintain social relations and drugs act as a media for interaction. In elderly mostly, retired people followed by professional (50% retired, 33.3% professional 30% farmer).

Our study result shown that majority of participants belong to upper middle socioeconomic status in all age groups (young adult 56.6%, middle age 53.3%, elderly 50%) followed by lower middle in young and middle age group (young adult 33.3%, middle age 30%) while upper lower in elderly (30%) and least belong to lower socioeconomic status in all age groups. Similar finding shown by Prajapati et al.²⁵ majority of the abuser (55%) belonged to upper and lower middle socio-economic classes. Very few (19%) of the substance abusers were coming from lower S.E. class. The findings were corroborating with findings of other study Kapse et al.²⁴.

The present study has tried to delineate various psychosocial factors which are important in different age group in term of substance abuse. Thus it can help in an optimal psychosocial intervention which is patient centric⁵. Our study found that tobacco is an important initiative substance and socio-culturally accepted across different age groups, further tobacco became an important gateway substance for triggering further abuse hence multi prong and large scale programs should be undertaken to create awareness and to limit the use of substance. In the present study results are comparable to the studies done before. But various limitations can be highlighted like this study was primarily based on a treatment seeking population which is possibly different from the community-based subjects where substance use is still not thought to be a disease but only a social or legal problem. No women could be registered during the study period. This however reflects the characteristics of the patients attending the de-addiction services in the region. Social stigma dependence on others in the family for treatment seeking and lack of gender-sensitive treatment programs could be postulated as causes of no treatment seeking of women with addiction in our study.

Conclusion

Our study revealed that despite having strict legislation for prohibition of substance abuse. people are still addicted with alcohol cannabis drugs etc. So prohibition has done nothing more than drive liquor underground. There is a need to change behavior of people at large. There is a need for further studies to find the community prevalence of drug use. The service provision is very limited restricted to the capital city and with none in the rural areas. The control of prescription drug use is another major issue which needs to be addressed. It is also worrying that female drug users are not able to seek help due to lack of appropriate facilities.