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June, 2017 >>

Drug addiction and diabetes: South Asian action

Yatan Pal Singh Balhara  ( Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India. )

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )

Abstract

Both diabetes and drug addiction are common phenomena across the world. Drug abuse impacts glycaemic control in multiple ways. It becomes imperative, therefore, to share guidance on drug deaddiction in persons with diabetes. The South Asian subcontinent is home to specific forms and patterns of drug abuse. Detailed study is needed to ensure good clinical practice regarding the same. This communication provides a simple and pragmatic framework to address this issue, while calling for concerted action on drug deaddiction in South Asia.
Keywords: Deaddiction, Diabetes, Nutrition, Psychosocial care, Psychiatry, Tobacco.


Current Recommendations

The American Diabetes Association- Standards of Medical Care 2016 clearly advise all patients not to use cigarettes, other tobacco products, or e-cigarettes.1 Smoking cessation counseling and other forms of treatment are recommended as a routine component of diabetes care. This guidance is based upon epidemiological, case-control and cohort studies, which link smoking with cardiovascular disease premature death, and microvascular disease, including foot ulcers.2 It also notes that smoking may contribute to development of type 2 diabetes, and smoking cessation helps improve metabolic parameters, blood pressure and albuminuria.
Counselling and pharmacological therapy should be combined to achieve best results in smoking cessation. Weight gain may occur after smoking cessation, but this does not antagonize the cardiovascular benefit that accrues from cessation of smoking.1
Guidance on smoking in children asks for direct elicitation of smoking history at initial and follow up visits. Exposure to secondhand smoke should also be enquired into. Youth who do not smoke should be discouraged from beginning, and those who do should be encouraged to quit.3 E-cigarettes are not recommended as an alternative to smoking. Smoking cessation counseling is also indicated as part of preconception care.4
Nutritional therapy recommendation5 propose limits for intake of alcohol. According to these recommendations, adults with diabetes may drink in moderation (one drink/ day for women and 1-2 drinks/day for men). However, alcohol consumption may increase the risk of delayed hypoglycaemia, especially in persons on insulin or insulin secretagogues. It may also precipitate hyperglycaemia, as many 'empty calories' are consumed in the form of alcohol, and as calorie-dense snacks often accompany its use.

The South Asian Scenario

The South Asian subcontinent, however uses (or abuses) tobacco and other drugs (also referred to as psychoactive substances) in a variety of ways.6 Tobacco can be smoked, inhaled, chewed, sniffed or absorbed buccally. The various forms of tobacco include bidis, hookah, khaini, zarda, gul and naswar various unique types of alcohol, including home-distilled spirits, toddy and arak are also consumed in the region. The peninsula, and its surrounding regions, also experiences "socially approved" drug abuse in the form of areca nut (supari), betel quid (paan)- chewing, and even some forms of cannabis (like bhang) and opioids (poppy tea). Hard drug abuse, including that of poppy seeds, opium, heroin, injectable pharmaceutical opioids, marijuana, and stimulants including amphetamine type stimulants (ATS) is also prevalent in the region.7,8

Impact of Drug Abuse on Diabetes

Drug abuse is associated with worsened metabolic control,9,10 and a higher risk of chronic complications as well as acute metabolic decompensation. Drug abusers also have lower self-management skills, and lack motivation to improve their health.11 Injectable drug abusers are at risk of contracting blood- borne infections such as hepatitis B and HIV,12 which may worsen diabetic control. Some drug users may have cognitive impairment and hypoglycaemia unawareness.10 This increases the risk of hypoglycaemia, which can be compounded by erratic dietary habits.

South Asia Centric Guidance

In such a situation, there is an imperative need to create South Asia-centric guidance for prevention and management of drug abuse. It is noteworthy that current guidelines on psychosocial care of diabetes, both from USA and India, do not offer such recommendations.



Such guidance should include detailed steps in history taking, and examination, including symptoms and signs which should prompt detailed questioning about possible drug abuse, the technique of eliciting an accurate history, and the need to perform a 360° assessment (such as enquiries from family members and other care givers). It should also list possible psychological and biomedical investigations and their indications. The frequency of follow up, and its details should be clarified. Non-pharmacological and pharmacological management strategies should be shared, as should strategies to enhance adherence, maximize response, and minimize dropout. Till such consensus is available to help the physician dealing with diabetes, we suggest the following ten point guide (Table-3).




References

1. American Diabetes Association. Comprehensive Medical Evaluation and Assessment of Comorbidities. Diabetes Care. 2017; 40 (Supplement 1): S25-32.
2. American Diabetes Association. Microvascular Complications and Foot Care. Diabetes Care. 2017; 40 (Supplement 1): S88-98.
3. American Diabetes Association. Children and Adolescents. Diabetes Care. 2017; 40 (Supplement 1): S105-13.
4. American Diabetes Association. Management of Diabetes in Pregnancy. Diabetes Care. 2017; 40 (Supplement 1): S114-9.
5. American Diabetes Association. Lifestyle Management. Diabetes Care. 2017; 40 (Supplement 1): S33-43.
6. Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology. 2003; 8: 419-31.
7. Kulsudjarit K. Drug problem in southeast and southwest Asia. Annals of the New York Academy of Sciences. 2004; 1025: 446-57.
8. Mudur G. Abuse of OTC drugs rising in South Asia. BMJ: British Medical Journal. 1999; 318 (7183): 556.
9. Karam GA, Reisi M, Kaseb AA, Khaksari M, Mohammadi A, Mahmoodi M. Effects of opium addiction on some serum factors in addicts with non-insulin-dependent diabetes mellitus. Addiction biology. 2004; 9: 53-8.
10. Howard AA, Arnsten JH, Gourevitch MN. Effect of alcohol consumption on diabetes mellitus: a systematic review. Ann Intern Med 2004; 140: 211-9.
11. Goodall TA, Halford WK. Self-management of diabetes mellitus: a critical review. Health Psychology. 1991; 10: 1.
12. Tandon N, Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, et al. Forum for injection technique (FIT), India: The Indian recommendations 2.0, for best practice in insulin injection technique, 2015. Indian J Endocr Metab 2015; 19: 317.


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