Addiction and its impact on diverse communities Perminder Dhillon MA Chief Executive Officer Drug and Alcohol Action Programme Empowering communities

Addiction and its impact on diverse communities

Perminder Dhillon MA Chief Executive Officer

Drug and Alcohol Action ProgrammeEmpowering communities against addiction

www.daap.org.uk

• A national overview of the extent of drug and alcohol addiction

• Addiction patterns amongst diverse communities (illegal drugs, alcohol and substances like Khat and Pan)

• Key issues for oral hygiene and health related professions


Definition

Substance abuse or misuse is 'the continual misuse of any mind altering substance which severely interferes with an individual's physical and mental health, social situation and responsibilities'.


• Alcohol dependence

• The misuse of illegal drugs like Heroin, Cocaine, Crack and Cannabis

• The misuse of volatile substances such as glue and aerosols

• Includes smoking cigarettes or drinking excessive amounts of coffee

• Use of other substances like Khat and

Paan


Addiction or problematic use is a difficult concept to measure. Those with drug related problems tend to be difficult to find, and addiction is difficult to measure.

The term ‘addict’ has been replaced with the terms ‘Alcohol user, drug user, problematic user’


There are currently 160,450 drug users accessing drug services in England ( 2004/5 National Treatment Agency) and estimates indicate that there are 250, 000 drug users

The BCS 2004/5 estimates:

that almost 11 million people aged 16 to 59 in England and Wales have at some point used illicit drugs and approximately three and a half million have used drugs in the previous year

National Overview

• just under four million people aged 16 to 59 have used Class A drugs in their lifetime with just over 1 million having used them in the past year

• It is estimated that a little over 600 thousand people have taken Cocaine and between 500 and 600 thousand people have taken Ecstasy in the past year

National Overview

National Overview

In Northern Ireland 1746 individuals presented for treatment in 2004/ 05 (Northern Ireland Drug Misuse Database)

There are around 20,000 drug users in Scotland in treatment; and an estimated 56,000 problem drug users in the country (Scottish Drugs Forum 2005)

National OverviewCosts related to use of illegal drugs in

Britain

•Total UK drugs economy is worth around approximately £2 billion a year

•At least £3 billion is spent dealing with social and health costs

•There are more than £6 billion of other costs to society

National Overview•Opiates remain the primary drug of misuse of clients in treatment (75%) With Heroin on the top (67%)

•Cannabis is the main drug for young people under 18 (61%)

•Twenty per cent of under-18s reported Heroin as their main problem drug

•Five per cent use Crack or Cocaine

National Overview

Britain is Europe’s capital in Binge drinking

An alcohol treatment audit published by the government revealed that 1.1 million people in Britain are dependent on alcohol – that is 3.6 per cent of the adult population – and eight million people drink above the recommended limits

• Alcohol abuse costs the British economy £18 billion every year in treatment and loss of earnings

• 17 million working days are lost every year to hangovers and drink-related illnesses

• Alcohol related health costs are estimated by Alcohol Concern to be around £150 million a year or 4.3% of total health spending

National Overview

• If smoking is included, the total could be more than £30 billion a year

• Smoking is estimated to kill around 120,000 people a year in Britain, shortening life on average by at least ten years

• That's 1.2 million years of life lost

National Overview

Costs of drug abuse in Britain

Illegal drugs and crime

• A Department of Health survey of 1,100 drug users found that they had committed more than 70,000 separate crimes in three months before entering treatment. 20% of all those who are convicted of crimes use Heroin and Heroin users are stealing £1.3 billion a year in property to pay for their habit

• The 20% using Heroin are responsible for 80% of all property crime, more than 800,000 burglaries, more than 1.7 million other reported thefts, not including stolen vehicles

Costs of drug abuse in BritainCost to the legal system

• drug-related crime costs £14 billion a year, around 6% of all government spending

• 15% of men in prison are there for drugs offences –trading, buying, selling or stealing

• One in three women prisoners are in prison for drug offences, drug-related theft, burglary or sex work

• 12% of male and 24% of female prisoners are addicted to drugs or alcohol when taken into custody; 10% of prisoners say they were injecting Heroin before going to prison

Costs of drug abuse in BritainIllegal drugs and health costs

• Emergency admissions to hospital include thousands admitted for drug psychosis, Drug dependence and non-dependent use of drugs

• Health issues like HIV/Aids/sex related diseases and hepatitis costs NHS in excess of £210 million

• Hepatitis C has spread rapidly through needle sharing - indeed it is the commonest route of transmission and 60% of drug injectors attending UK drug services are now carrying Hepatitis C

Costs of drug abuse in Britain

Social Costs• The average cost per person using residential

rehabilitation is £390 per week compared to £225 for structured day care

• Also include a proportion of the costs to the voluntary sector, advice centres, child therapy, family support agencies and the rest

• Damage to education – drug use results in suspensions, expulsions and other disciplinary measures

Costs of alcohol abuse in BritainAlcohol

• Alcohol kills 31,000 a year - 28,000 deaths a year are alcohol-related (and a further 3,000 are deaths where alcohol is listed as a cause on a death certificate)

• Deaths from liver disease are ten times the normal rate among heavy drinkers and 3% of all cancers may be linked to alcohol

• 4,500 people are admitted because of mental health problems every year because of alcohol

• 65% of suicide attempts are linked with excessive drinking


Addiction affects individuals,

All communities

and society

“Black people don’t use drugs”

“The few that do will never inject”

“It is a white western disease”

“Religion prohibits drug taking - therefore it is not a problem”

“If there are any Asian drug users they don’t use these services - anyway they look after

themselves”

“Our strong religious and cultural values stop us from this behaviour”

Drug Use and Black and Minority Ethnic Communities

• In England in 2003/4 (NTA), 9% of the total number of 125,545 service users were from Black and minority ethnic communities

• Mixed race• Pakistani/Bangladeshi• Indian• Black• Other


National picture• Greater proportion of younger people in

Black and Minority ethnic communities • Many live in some of the most deprived

areas and are more likely than the rest of the population to be unemployed and to live in poverty

• Members of minority ethnic groups are 50% more likely to suffer from ill health than their white counterparts


• Disproportionately represented amongst those in medium and high security psychiatric care

• Four to six times more likely to be excluded from school than white pupils

• Over-represented at every stage of the Criminal Justice System

• Vulnerable to Homelessness• At least twice as likely to be unemployed• Five-fold increase in Muslim prison

population


• Increasing use of Heroin, Cocaine & Crack Cocaine as first drug of choice

• Increasing use of alcohol among young Muslim men

• Use of steroids and injecting steroids• Increasing experimentation with hallucinogenic

drugs• Increase in use of Class A drugs among young

Asian girls – links to sex work• Khat use amongst Somali and other communities

linked to use of Class A drugs• Increasing drug issues in all communities


• Poor access to services• Service provision not appropriate • Ad-hoc & short term funding for Black and

minority ethnic organisations• Absence of adequate local and national needs

assessments• Poor monitoring especially that of ethnic

monitoring• Lack of strategic planning• Needs of Parents and carers not catered for


Local Picture- Ealing

Identification of ethnic minority groups within caseload

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Primay Substance Misuse in 2003/04

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Ealing England & WalesSource: 2001 Census, ONS

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Some communities use substances which are not illegal but cause health (especially oral health) problems as well as social problems

• Chewing of Paan• Chewing of Khat



PAAN

• Betel pepper leaf (piper chavica betle) The leaf (paan) is used to wrap the fillings to form a quid. The leaf has a minty/menthol taste and is considered a mouth freshener. There is very little evidence to indicate any health implications of the betel leaf

• Areca palm nut (supari) (Areca catechu) It is a small hard nut 20-30mm diameter. It is cured by sun drying, roasting or boiling it. The nut can be used as crushed fragments, sliced slithers or grated strands. Some people add saffron (cheaper versions use yellow food dyes) and sugar syrups to produce sweet supari (sweet nut)


Key compounds in it are tannins (11-26%) considered to be stimulants and alkaloids (0.15-0.67%). The main alkaloid is arecoline. You also find arecaidine, guacine, guvacoline and areaolidine

• Aromatic spices are added to Paans:• Aromatic seeds: Aniseed, Fennel, Coriander, Pods and

buds: Cardamom, Cloves and sweet leaf, Flowers: Gulkhand (rose) and Saffron, Extracts: Rose and Jasmine extract

• Sugar products: Scented sugar syrup, saffron sugar, Fruits: Desiccated coconut shreds, glazed cherries/fruit, Barks-Cinnamon, liquorice and myrrh, Nobel metals- gold or silver leaf

• Studies on the health implications of these aromatic ingredients of Paan have been inconclusive


• Pastes and smears (catalysts) are added or smeared on to the leaf to aid efficacy in the mastication and the release of and absorption of main compounds like the alkaloids from both the leaf and the nut. Two main ingredients used are:

• Slaked lime- Calcium Hydroxide- Ca (OH) Increases the mouth Ph (makes it alkaline) and this aids easier absorption of nicotine via the mouth lining

• Catechu gum (Acacia tree gum or boiled areca extract). This is used to help bind the ingredients in the quid into a consistent paste. It aids in chewing


• Use of Paan - causal link to mouth cancers although there are few large scale UK studies on humans. However, lab tests on rats has shown that the presence of salivary nitrates and the alkaloids in the nut ( Arecoline, arecaidine, guacine, guvacoline and areaolidine) can form nitrosamines that have been shown to be carcinogenic

• Long term use of Areca nut with lime ( a custom in the Pacific Islands and Hunan province China) shows that the chewer suffers from oral submucous fibrosis


• The person with severe oral sub mucous fibrosis cannot open their mouth to the full width as the mouth lining and cheek muscles become hard. Oral hygiene problems can result. Oral sub mucous fibrosis tissue is prone to cancer. Use of tobacco and lime with areca nut has proven to cause cancers

• The abrasive nature of the nut, the increased alkalinity and sugars can result in severe dental problems


Increased Ph and aggressive alkali action have serious oral health implications. Both the lime and the concentrated areca nut extracts can cause oral sub mucous fibrosis and this makes the mouth tissue prone to cancer



Chewing Tobacco

• Tobacco: Tobacco is the most hazardous ingredient added to Paans

• There are a range of tobacco products with some having a very high tar content (over 12mg per cigarette equivalent). The main products added are:

• Semi-cured whole tobacco leaf (common in the Bengali community 8)

• Shredded leaf (Zarda)- Comes as 120 Baba Zarda ® Tins

• Extract of tobacco in glycol gel- sold as Qimam bottles


• Wet snuffs- made from ground tobacco and various other additives

• Dry snuff (masala tobacco)- Gutkas (chewed) and Naswar (snorted)

• The risk of developing oral cancers is very high as tobacco often sits next to the tongue and mouth walls as a masticated paste for up to 1-5 hours. The mouth tissues are vulnerable to cancer as areca nut and lime causes oral submucous fibrosis and the additional exposure to tobacco juices raises the risks


• Gutkas- New developments the 'ready made tobacco masalas'

• Many tobacco companies in South Asia are now making 'ready made' paan mixtures. You can now buy both dry and wet snuff mixtures in easy handy sachets that are sold as "Paan Masalas" or Gutka

• They are prepared by baking and curing a mixture comprising areca nut, lime, spices and tobacco. Artificial flavourings like extract of paan leaf and aromatic esters (to replicate the paan taste) are added. There is evidence that a range of preservatives and other ingredients are added


• The risks attached to the use of these masalas are very high as most of the ingredients are extracts and concentrates

Who chews Gutka?• As the product originated from Indian tobacco

companies, the first outlets were UK Indian Paan houses. Gujarati's from India (Hindu, Muslim and Jains) have been shown to use Gutkas

• Gutkas are now being consumed by a wide range of people and social classes in the wrong belief that they are mouth fresheners



KHAT


• Khat itself is legal in the UK but the two main active ingredients of khat, cathine and cathinone are Class C controlled substances under the 1971 Misuse of Drugs Act

• Khat can stay in the blood for 24 hours


• Khat is a stimulant and chewing it can make people feel more alert and talkative

• It can also suppress appetite • Although it's a stimulant, many users report a

feeling of calm if it is chewed over a few hours• Some describe it as being 'blissed out' Health Risks• Insomnia, heart problems and sexual problems

like impotence • Can give rise to feelings of anxiety and

aggression.


• Some people find it makes them irritable, in some cases very angry and even violent.

• It can make pre-existing mental health problems worse

• Gastro-intestinal tract problems such as anorexia and constipation are linked to Khat use

• There is an increase in Tuberculosis amongst Khat users

• Khat use is also associated with low birth weight in infants, and infant survival rates

• Long-term use of Khat is found to be linked to neck cancer


• Khat is chewed amongst the Somali And the Yemeni communities

• Growing number of women are chewing Khat

• Many social problems particularly family disputes and domestic violence are linked to the habit of chewing Khat


• More young people are Chewing Khat and going on to experiment with illegal drugs

• Young people from other communities particularly South Asian communities are chewing Khat as a ‘cheap alternative’


What are the implications for services

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• Early education and intervention work

• Culturally appropriate Information and education in local languages

• Culturally sensitive support and services

• Specific services for young people

• The need to bring together diverse communities to tackle addiction issues


• National needs assessments for specific communities

• Robust monitoring systems especially on ethnic monitoring

• National strategic planning for commissioning of services Service provision needs to appropriate to the needs of diverse communities

• Needs of parents and carers to be catered for• Community involvement


What are the implications for oral hygiene and health

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Dentists and health professions

COMPETENCIES• Drug and alcohol addiction issues and their

impact on oral hygenience and dental treatment • Addiction to legal substances like Khat and Pan• Issues affecting specific groups• Knowledge of mental health and child protection

issues connected to addiction• Local agencies and services that they offer



IDENTIFICATION AND ASSESSMENT• Patients who have an addiction problem –

alcohol, drugs and other substances• Assess presenting symptoms like physical signs

of drug misuse and related complications• Perform detailed risk assessment for the patient • Refer to other health and support agencies as

appropriate



PATIENT MANAGEMENT • Assess the appropriateness and type of dental

treatment that can be provided• Determine if a referral is required to the GP/other

ADVICE AND EDUCATION• Provide support and advice to those presenting

with addiction problems• Participate in local and national education

campaigns



RESEARCH AND AUDIT

• To be aware of research findings and audits in the dental profession

• To contribute to research and education


Recommendations

• Develop appropriate tools

• Training and teaching

• Service provision and development



If you are interested in participating in a pilot programme, please contact

Drug and Alcohol Action Programme

Empowering communities against addiction

[email protected]

www.daap.org.uk

mailto:[email protected]

That’s how the Dentistry Profession can make a difference to addiction!


Perminder Dhillon MA Chief Executive Officer

Drug and Alcohol Action ProgrammeEmpowering communities against addiction

www.daap.org.uk

Documents

Addiction and its impact on diverse communities Perminder Dhillon MA Chief Executive Officer Drug and Alcohol Action Programme Empowering communities