Substance use: Characterization of patients belonging to the adult mental health unit - Hernán Henríquez Aravena Hospital.
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Introduction: psychoactive substances have been part of the existence of humanity for thousands of years and have been used for different purposes, consolidating its use and abuse in recent years as a highly prevalent condition in our society. They are a large number of substances, and also various forms of classification. In terms of world prevalence, to date, there is no gold standard method that allows the exact measurement of substance consumption to each geographical region, which makes the study difficult and constitutes a challenge when making comparisons between regions. However, in terms of world prevalence, the most consumed substance is alcohol, followed by cannabis, opioids, amphetamines, and cocaine respectively. Objective: characterize adult patients of the mental health polyclinic of the Hernán Henríquez Aravena Hospital with a diagnosis related to substance use and establish the main substances consumed. Material and Method: A cross-sectional descriptive study was carried out in the target population by reviewing the clinical records of adult patients treated at the mental health polyclinic of the Hernán Henríquez Aravena Hospital, during the years 2018, 2019, and 2020. The antecedents collected from the study were analyzed according to the general population and compared according to gender. Results: In the sample studied, 73.2% of the users are male, alcohol being the substance most consumed, followed by cocaine, marijuana, and benzodiazepines
Key words: substance use disorder, adults, hospitals.
Psychoactive Substances have been part of human existence for thousands of years. Throughout history, they have been used for different purposes (religious, analgesic, recreational), developing into use and abuse in recent years and becoming a highly prevalent condition in society.
Every day, new drugs that lead to an increase in the problems related to their use are discovered and designed. Therefore, the approach to this subject is essential within the medical profession.
There are multiple definitions that help us understand patients who suffer from this condition, which is why, it is imperative to be clear about the main concepts related to the matter, in order to define the initial study approach.(1) (Table 1)
Regardless of the substance used or the profile of the patient using, the American Psychiatric Association, through its current classification system (DSM V) has made an effort to unify clinical criteria that allows to define the moment and the characteristics of a maladaptive consumption pattern, that consequently requires treatment and represents what is known as a substance use disorder.(2)
When carrying out bibliographic research related to the matter, it is possible to find that there are a large number of substances and several classification models. However, establishing a difference between classic substances and new substances (also called designer or emerging substances), promotes the understanding and study of the problem.
When defining classic substances, reference is made to all psychoactive substances that include: Alcohol, caffeine, cannabis, hallucinogens, inhalants, opiates, sedatives, hypnotics, anxiolytics, stimulants, and tobacco.
When defining new substances (design or emerging), reference is made to all those substances that are manufactured through chemical processes, and that, unlike other drugs, are not obtained from a natural product, but are synthesized from specific molecular changes in a laboratory, therefore achieving very different effects.
The emerging term not only refers to newly created substances, but also to new consumption environments and new distribution channels (internet). In this context, the indiscriminate use of psychotropic drugs for purely recreational purposes, in parties, by people who do not have a medical prescription, becomes important. So far, 6 groups of psychotropic drugs used within the so-called pill parties have been identified, where opiates, antitutives, anesthetics, 5-phosphodiesterase inhibitors, psychostimulants, Z drugs, GABAergics and hypnotics/sedatives stand out.(3)
In terms of world prevalence, today, there is no gold standard method that allows the exact measurement of substance use for each geographical region. This makes the study difficult and constitutes a challenge when making comparisons worldwide. However, the studies show in terms of prevalence, that the most consumed substance is alcohol, followed in less extent by cannabis, opioids, amphetamines and cocaine.(4)
Moreover, worldwide, the prevalence of substance use disorders is higher in men, while other substance-induced mental disorders are higher in women. Between the years 1990 and 2016, the number of people with substance use disorder has increased exponentially regardless of sex, and this phenomenon has been attributed to the increase and aging of the population
In geographical terms, in Asia and Australia the most used substances are amphetamines. In the case of Eastern Europe, Africa and Latin America it is alcohol and for North America the highest prevalence of consumption is for cannabis, cocaine and opioids.(5)
The use of drugs has negative consequences on health, the economy, productivity and different social aspects, achieving a significant impact that produces a greater burden of disease and consequently justifies research and intervention regarding the matter.
When reviewing national statistics in Chile provided by SENDA institution, in its thirteenth national study of drugs in the general population in 2018, we can see that alcohol and cigarettes are the preferred drugs in the Chilean population, and people are able purchase them close to their homes (liquor stores, supermarkets). From 1994 to date, there has been an increase of 50% in the perceived ease of access to substances. Additionally, the age of substance use onset is close to 12 years old, with a higher prevalence between 19 and 25, and higher consumption rates related to a low socioeconomic
Not all individuals who use substances develop a disorder, which suggests a certain vulnerability in this specific population. People begin using voluntarily, but later certain changes occur in brain circuits, which remain even after detox processes and are combined with other factors such as genetic predisposition, personality traits, environmental associations, social characteristics, and mental state, among others, enable the dynamics of consumption and impede treatment.
The process of creating a drug dependance is a complex, multifactorial process that can happen at any age, however, adolescents are the most vulnerable considering the incomplete development of the circuits involved in emotions, reasoning, and inhibitory capacity of inappropriate responses (mesocorticolimbic-dopaminergic circuit).(7)
The addiction process implies a damage in the interaction of neurobiological functional systems and in the case of psychiatric comorbidity, treatment is even more complicated. The association between both conditions (substance use and psychiatric pathology) is more a rule than an exception, and it is not always easy to determine which one came first.(7,9)
This only confirms the need for research and intervention on this matter and poses challenges in treatment, which requires a complete assessment, involving all the relevant aspects that could affect therapeutic success and allow to sustain a long period of abstinence or the best adaptation possible of the person in society.
The objective of this research is to portray the adult patients treated at the mental health polyclinic of the Hernán Henríquez Aravena Hospital in the city of Temuco, between 2018-2020, with substance use disorder diagnose, to identify the most used substances and to relate sex, age, psychiatric comorbidity and established treatment.
MATERIALS AND METHODOLOGY
A cross-sectional descriptive study was carried out in order to evaluate the characteristics of adult patients diagnosed with substance abuse disorder, as defined by DSM V during 2018, 2019 and 2020 in the health center.
The data of the study participants was obtained by reviewing clinical records, using as a population sample the whole polyclinic record of adult patients, who were classified with diagnoses related to substance use, and were assigned to the mental health unit of the Hernán Henríquez Aravena hospital. Demographic information included: Name, age, sex, diagnosis, prognosis, pharmacological treatment, and also some sensitive clinical variables such as attending psychotherapy, psychiatric comorbidities, kind of substance used and associated medical conditions. The clinical records of patients under 18 years old, clinical records corresponding to deceased patients and clinical records without a diagnosis related to substance use were excluded. Approval was obtained from the scientific ethics committee of the Araucanía Sur health service. Official Letter No.: 75.
The data collected from the study was analyzed according to the general population and compared according to gender.
The variables associated with psychiatric pathologies and medical comorbidities were recategorized according to the International Classification of Diseases, 10th Edition (ICD-10), grouped by type of disorder. Also, the pharmacological treatment received was classified according to pharmacological groups.
Quantitative variables were obtained, presented as mean ± standard deviation, and qualitative variables, were presented as gross figures and percentages related to the study group.
For data analysis, the Kolmogorov-Smirnov normality test was used and in the case of quantitative variables, the unpaired Students t-test or the Mann-Whitney U-test were used. In the comparisons by gender of the qualitative variables, the chi-square test was used. To determine the relative risk and odds ratio of the variables associated with substance abuse, a multivariate analysis was performed with the Koopman and Baptista-Pike tests.
A total of 220 clinical records of adult patients assigned to the mental health unit of the Hernán Henríquez Aravena Hospital in the city of Temuco, treated during the years 2018, 2019 and 2020, of which 3 met exclusion criteria, resulting in a sample size of 217 patients.
Out of the total population (217 participants), 73.2% were male and 27.7% female. With an average age of 44.8 ; out of the whole sample, 61.7% mostly used alcohol, 5% tobacco and 32% used other substances, which is data that is not statistically significant. (Table 2).
In relation to the consumption of other substances other than alcohol, we see that cocaine has the highest prevalence, followed by THC, then benzodiazepines and, to a lesser extent, crack, opiates, inhalants, and hallucinogens. (Graph 1)
In relation to dual pathology, it was observed that, within the population studied, 67% of men presented this condition, while 33% of women presented it. The most frequent psychiatric comorbidity is personality disorder, followed by mood disorders, suicide attempts and psychotic disorders.
At the time of differentiating personality disorders, it was found that 85% belonged to cluster b and 68% of them met criteria for borderline personality disorder and 17% met criteria for antisocial personality disorder.
Regarding mood disorders, 60% met criteria for depression with varying degrees of severity, followed by anxiety disorders in 24.55% of cases and bipolar affective disorder in 15%.
Regarding non-psychiatric medical comorbidities and substance use, it is striking that the majority did not show any signs. Within the group that did present some medical comorbidity, neurological pathology was the most frequent, highlighting that in some cases it presented as a primary pathology mainly with mental retardation and epilepsy. In cases that were secondary to consumption, cognitive deficit and psycho-organic deterioration were presented.
Regarding digestive pathologies, chronic liver damage was found associated with the use of alcohol, liver cirrhosis and variceal hemorrhage, clearly being secondary to the use if this substance.
Regarding non-pharmacological treatment: psychotherapy is the assigned medical treatment with the most evidence. However, of the total sample, only 14 patients complied with it.
This intervention statistically reports a Relative Risk of 4.9%, being able to conclude that those patients who did not attend psychotherapy concomitantly to manage their pathology have a greater risk of remaining in their condition of abuse. (Table 3)
Regarding pharmacological interventions, evidence showed that most patients were treated with independent monotherapy whether or not there was any psychiatric comorbidity. Atypical antipsychotics (Olanzapine, Quetiapine) and benzodiazepines (Clonazepam), were mostly prescribed.
In order to manage other underlying pathologies, the rest of the patients received other drugs such as Disulfiram, anticonvulsants such as Valproic Acid and Phenytoin. A smaller proportion received antidepressants; mainly Serotoninergic (Sertraline), Z drugs (Zolpidem) and to a lesser extent Lithium Carbonate.
When comparing the data obtained from the study with the national and international literature, a trend in a higher prevalence of substance use disorder in males was found, with an approximate ratio of 3:1 which is the same.
Regarding substance abuse, the study shows that alcohol, cocaine, THC and cigarettes were mostly used.
Literature in Chile, shows that alcohol has the highest prevalence of consumption, followed by cigarettes and THC.
On an international level, alcohol remains in first place, followed by substances such as opioid amphetamines, cigarettes, cocaine, and marijuana. Therefore, when comparing the prevalence of national and international substances with the present study, it is noticeable that cigarette consumption falls dramatically, which raises a question regarding the veracity of that data.(5,6)
Regarding dual pathology, it is worth noting that there is unknown information related to the timeline of the conditions. However literature describes the prevalence of dual pathology in countries such as Europe, Australia, Canada, Germany which may vary between 30-50% of substance users. This is data lower than the one obtained in the present study, where a prevalence of 74% of cases was established. This is comparable to the prevalence reported in the United States, where dual pathology prevails up to 78%.(12,13)
Regarding non-pharmacological treatment, evidence supports the use of cognitive behavioral psychotherapy as monotherapy or along with a pharmacological regimen, in which case, literature reports an increase in efficacy, showing better results anger management, craving, stress, sleep quality and assertive behavior. Despite the evidence discussed, in the present study only 14 patients followed this treatment.(14)
Regarding pharmacological treatment, there is little evidence to instruct management and specific schemes. In relation to this variable, it is necessary to carry out a case-by-case evaluation considering the elements that come together in a patient, such as the substance used, comorbid medical or psychiatric pathologies, access to drugs, among others. However, to manage cases of alcohol use disorder associated with monopolar depressive symptoms, the evidence supports the use of combinations of serotonergic + opioid antagonist with results showing longer abstinence time, late relapses and less probability of having permanent depressive symptoms at the end of treatment.(15)
Selection bias by limiting the sample between the years 2018, 2019 and 2020, use of records where the main diagnosis was Substance Use Disorder and a second information bias due to the lack of organization in the clinical records of the mental health unit of the Hernán Henríquez Aravena Hospital.
Substance use disorders are the result of the complex interaction between the effects of the abused drugs, the biological bases of the subjects and the environment. Therefore, although there is no specific management guide, the approach to patients should include different pharmacological and non-pharmacological strategies, on an individual basis, taking into account the specific substance used and the possible comorbidities present in each patient.
Additionally, it is necessary to implement government public policies in each country, to help control substance use and reduce the risk factors related to it.
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