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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 3  |  Page : 230-236

Use of psychoactive substances among patients presenting at the emergency department of a tertiary hospital


1 Department of Psychiatry, College of Health Sciences, Bingham University, Jos, Plateau State, Nigeria
2 Department of Psychiatry, Jos University Teaching Hospital, Jos, Plateau State, Nigeria

Date of Submission07-Jan-2020
Date of Decision01-Jun-2020
Date of Acceptance01-Jun-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Datak Delashik Dapap
Department of Psychiatry, College of Health Sciences, Bingham University, Jos, Plateau State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_5_20

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  Abstract 


Background: Psychoactive substance use is frequently encountered in hospitals' emergency departments (EDs). It accounts for major health-care problems frequently leading to accident and ED admissions, yet it is frequently unidentified. The aim of this study was to determine the prevalence and pattern of psychoactive substance use among patients presenting in the Accident and EDs and to compare the case detection rate of psychoactive substance use between self-report questionnaire and biochemical markers (e.g., urine toxicology). Methods: To achieve this, 200 consenting participants attending the accident and emergency unit of a tertiary hospital were consecutively enlisted into the study within 2 weeks. They were screened for psychoactive substance use with the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the urine drug test (UDT). Results: The lifetime prevalence of psychoactive substance use was 45.5%, while the past 3 months (recent use) prevalence was 27.0%. The pattern of psychoactive substance use revealed that alcohol was the predominant psychoactive substance use with a lifetime prevalence of 13.0% and recent use of 12.0%. The UDT significantly detected more patients who used psychoactive substance compared to self-report (P < 0.001). Conclusion: The prevalence of drug use recorded among attendees of the accident and emergency unit was high in this study. The UDT significantly detected more patients who used psychoactive substances compared to self-report (P < 0.001). Several patients with major health problems as a result of psychoactive substance use were identified with the aid of these screening tools.

Keywords: Accident, emergency hospital, patients, psychoactive substance


How to cite this article:
Dapap DD, Okpataku CI, Audu MD. Use of psychoactive substances among patients presenting at the emergency department of a tertiary hospital. Niger Postgrad Med J 2020;27:230-6

How to cite this URL:
Dapap DD, Okpataku CI, Audu MD. Use of psychoactive substances among patients presenting at the emergency department of a tertiary hospital. Niger Postgrad Med J [serial online] 2020 [cited 2020 Aug 13];27:230-6. Available from: http://www.npmj.org/text.asp?2020/27/3/230/289916




  Introduction Top


The health challenges caused by psychoactive substance misuse have been very disturbing. According to the WHO, the extent of worldwide psychoactive substance use is estimated at 2 billion alcohol users, 1.3 billion smokers and 185 million drug users.[1] Psychoactive substance use cuts across all the geopolitical zones in Nigeria,[2] and is increasing, especially in adolescents.[3] A recent national survey of alcohol and drug use in Nigeria reported a lifetime, 1 year and past 30 days alcohol use prevalence as 39.0%, 30.3% and 24.5%, respectively. Furthermore, the past 30-day prevalence rates of other commonly used drugs are solvent/inhalant (3.2%), Tranquilizer (2.9%), Opiates other than Heroin (2.2%), Heroin (1.8%), Cannabis (1.8%) and Cocaine (1.4%).[4]

Psychoactive substance use is common among patients presenting to hospital emergency departments (EDs), yet it is frequently unidentified.[5] The harmful consequences of psychoactive use are associated with psychiatric disorders, medical conditions and physical injuries.[6] Psychoactive substance use increases the risk of inappropriate treatment and patient management. Issues including postoperative morbidity and behavioural incidents, and higher rates of re-presentation, readmission and re-injury are associated with alcohol and other drug-related presentations.[7]

Global studies have revealed a high proportion of psychoactive substance morbidity among EDs attendees in North America, Europe, Asia and Australia.[8],[9],[10],[11],[12],[13],[14] In Nigeria, there is meagre information regarding the consequences of drug use among accident and emergency unit attendees. A study conducted on injured patients managed in the maxillofacial units of four teaching hospitals in Nigeria among motorcycle riders following accidents revealed that alcohol and or other substances of abuse were implicated in 31.2% of the cases.[15]

Lack of awareness and understanding of alcohol and other drugs among service providers and the reluctance of patients to admit consumption could be barriers to diagnosis, referral and treatment in specialised substance abuse units. The illegal nature of illicit drug use means that users are often hidden due to fear of arrest by law enforcement agencies or because it is not socially acceptable. As a result, research that relies on self-report data may under-report the prevalence of psychoactive substance use and may not succeed in accessing reliable information about alcohol and other drug misuses.[16]

The introduction of biological markers (e.g., urine drug tests [UDTs]) in health-care EDs has facilitated the diagnosis of psychoactive substance consumption in patients treated for other grounds (medical or psychiatric complication).[17] Overall, the rates of self-reported drug use in the ED are estimated to range from 1% to 5%. However, among patients whose biological markers are obtained, the prevalence of illicit drug use ranges from 35% to 40%.[16]

The accident and emergency unit render health-care services to both surgical and medical conditions, including problems associated with psychoactive substance use. Even so, there is compact information about the expansion and gravity of psychoactive substance use among accident and emergency attendees in Nigeria. Therefore, this study is aimed to determine the prevalence and pattern of psychoactive substance use among patients presenting in the Accident and EDs. Having this knowledge would help considerably in the blueprint of intervention programmes to decrease drug misuse among accident and emergency attendees. It will also create an avenue to identify and assist persons with unrecognised and unmet substance use disorders who might otherwise never receive any form of treatment.[18]


  Methods Top


This is a cross-sectional study conducted at the Jos University Teaching Hospital from 5th to 20th June 2016. The hospital located at Lamingo Jos, Nigeria, has 600 beds and it is designed to cater for the health needs of communities within the middle-belt zone of the country and beyond. In addition, teaching and research in health-related matters are among the services undertaken in the hospital. The ED is open 24 h. Ethical clearance was granted on the 20th of August 2015 by the Health Research Ethics Committee of the Jos University Teaching Hospital with reference number JUTH/DCS/ADM/127/XIX/6268.

The study population comprised all consenting patients who were 18 years and above presenting at the ED of the hospital for treatment in June 2016. We excluded patients who could not be interviewed due to the nature or severity of their illness. However, patients that were acutely ill and could not be interviewed at presentation were interviewed after they became stable while still in the emergency room.

The minimum sample size required for the study was calculated using the formula below.[19]



where

n = minimum sample size

z = standard normal variance = 1.96 at 95% confidence interval

d = Absolute standard error = 0.05

p = prevalence.

A prevalence rate of 11.5% was used, based on the findings of the prevalence of psychoactive substance use in an accident and ED in a similar study.[20]





n = 156.4

This figure was rounded up to 200 to obtain more information on the study population and to take care of dropouts. Therefore, 200 participants were recruited into the study.

Following clearance by the Ethical Committee and permission from the Head of the ED, consecutive in and out-patients were approached after the accident and emergency doctors had seen and certified them as emergency cases. All the participants were informed that the study aimed to investigate their alcohol and other drug use and other health-related behaviours and written consents were obtained. The consent form was designed to present the study as psychoactive substance use among patients presenting at the ED.

A socio-demographic questionnaire was employed to acquire particulars of each participant in combination with emergency room data, where patients' case notes were checked to record details of medical illness or injury and the medicines administered. A self-report questionnaire was employed to acquire more detailed particulars of each participant's drug use.[6] There were two versions of this questionnaire and patients not fluent in the English language were administered the Hausa version; Hausa being the commonly spoken language in the community. Attached to the socio-demographic questionnaire was the self-report questionnaire, i.e., Alcohol, smoking and substance involvement screening test (ASSIST) questionnaire,[21] which was administered by a trained interviewer to each participant.

In addition, urine samples were taken from each consenting patient for a multi-drug screening by immune enzymatic technique.[22] The following substances were tested: amphetamines (AMP), Methadone (MTD), Tramadol (TML), Morphine (MOP), opiates (OPT) 3,4-Methylene-Dioxymethamphetamines (MDMA), Tetrahydrocannabinol (THC), Cocaine (COC), Barbiturates (BAR), Alcohol (alc), Nicotine (nct) and Benzodiazepines (BZO). Steps were taken to ensure that drugs detected were not those administered at the Accident and Emergency Unit.

The research team selected two nurses and two doctors from the accident and ED, who had 1 day training on the use of the instruments, i.e., ASSIST and Urine drug screening, to serve as research assistants. The training was facilitated by one of the researchers. The data collection was conducted every day of the week, in 24 h lasting for 2 weeks. The interviewers who were both the researchers and research assistants were always around either at the accident and emergency unit or the hospital premises anticipating patient presentation at the ED.

The data collection was conducted every day of the week, in 24 h lasting for 2 weeks. The interviewers were always around either at the accident and emergency unit or the hospital premises anticipating patient presentation at the ED.

Data analysis

Data were analysed using the Statistical Package for Social Sciences for Windows (SPSS) version 16.0 (SPSS Inc. Chicago, USA). Descriptive statistics such as means and standard deviations were used to summarise continuous variables, while categorical variables were summarised with percentages. Chi-square test was used to test the significant difference between groups or compare two proportions and to investigate the differences between categorical variables and their association. The Student's t-test was used to compare continuous variables. Statistical significance was set at <0.05.


  Results Top


The socio-demographic characteristics of participants in the accident and emergency unit recruited into the study are illustrated in [Table 1].
Table 1: Demographic characteristics of the participants

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A sum of 200 participants were recruited into the study. Males constituted the majority, 111 (55.5%) of the participants compared to 89 (44.5%) of female participants. Participants between the of ages 21 and 30 years, formed the largest 48 (24.0%) age group, while the lowest age group, 18–20 was made up of 15 (7.5%) participants. Majority of the participants 119 (59.5.0%) were married, 68 (34.0%) were still single, while 13 (6.5%) were widowed. Out of the participants, 156 (78.0%) were Christians and 44 (21.5%) were Moslems. The 200 (100%) participants were all Nigerians. Hausas were 38 (19.0%), Igbos 4 (2.0%) and Yorubas 6 (3.0%). There were 31 (15.5%) participants of Berom extraction, while 121 (60.5%) participants were of other indigenous ethnic groups. In terms of education, 50 (24.5%) participants had no formal education, while 3 (1.5%) participants attended school up to Postgraduate level. Most 106 (53.0%) of the participants were employed while Apprentice 3 (1.5%) constituted the lowest number of participants [Table 1].

[Table 2] shows emergency room data of the participants recruited into the study. Seventy-nine (39.5%) participants were recruited into the study between 6 am and 12 pm, while 19 (9.5%) participants were recruited between 12.01 am and 5.59 am. One hundred and thirty-five (67.5%) of the referrals were by self-referrals, while 19 (9.5%) participants were referred directly to the ED from the scene of the accident. Majority of the participants 156 (78.0%) presented with medical illnesses, while 44 (22.0%) presented with an injury. Among those that presented with medical illness, the majority of the participants 151 (75.5%) presented with physical illness, while 5 (2.5%) presented with psychiatric illness [Table 2].
Table 2: Pattern of presentation to the emergency room

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[Table 3] shows the prevalence and pattern of Psychoactive Substance use among patients attending the ED. Eighty-nine (44.5%) participants had used the psychoactive substance at least once in their lifetime, while 54 (27.0%) had used in the past 3 months. Alcohol was the most common drug used by participants; 26 (13.0%) had used alcohol at least once, in their lifetime, 24 (12.0%) had used in the past 3 months. Only 6 (3.0%) participants smoked tobacco in their lifetime, while 2 (1.0%) smoked tobacco in the past 3 months.
Table 3: Prevalence and pattern of psychoactive substances used among patients attending the emergency room

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Lifetime users of amphetamine-like substances or other stimulants, including caffeine, were 13 (6.5%), while 12 (6.0%) had used it in the past 3 months. Eleven (5.5%) had used cannabis at least once in their lifetime, 1 (0.5%) had used in the past 3 months. Five (2.5%) of the respondents reported using sedative (sleeping tablets) in their lifetime, while 1 (0.5%) had used it in the past 3 months. Twelve (6.0%) of the respondents had used opioids in their lifetime, while only 1 (0.5) had used it in the past 3 months. Sixteen (8.0%) of the respondents were involved in polysubstance use in their lifetime and 13 (6.5%) in the past 3 months. Most of these substances are non-prescription drugs [Table 3].

[Table 4] shows a comparison of detection rates of psychoactive substance use between self-report and UDT. The difference in case identification between self-report and UDT revealed that self-report identified 24 (12.0%) of the participants who used alcohol, while only 7 (3.5%) participants tested positive for alcohol by a UDT. Self-report identified 2 (1.0%) participants who used tobacco, while UDT detected 6 (3.0%) of them. The UDT was able to detect 11 (5.5%) participants who used cannabis while self-report identified only 1 (0.5%). 5 (2.5%) respondents who used sedatives (4 used benzodiazepines and1 used barbiturate) were detected by UDT, while self-report identified 1 (0.5%). UDT detected 12 (6.0%) participants who used opioids (8 used TML and 4 used other opioids), while self-report identified only 1 (0.5%). Self-report was able to identify 13 (6.5%) participants who were involved in polysubstance use, while UDT detected 6 (3.0%) participants only [Table 4].
Table 4: The difference in case identification between self-report and urine drug test

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As shown in [Table 5], self-report was able to identify 42 (21.0%) participants who used various psychoactive substances compared to the UDT, which detected 47 (23.5%) participants. Both self-report and UDT agreed on or identified 31 (15.5%) participants who use psychoactive substances, but differ on 16 (8.0%) participants who tested positive for biochemical test only but were not identified by self-report. On the other hand, self-report was able to identify 11 (5.5%) participants who abused substances but were not detected by a UDT. 142 (71.0%) participants were screened negative by both self-report and UDT. UDT significantly detected more patients who used psychoactive substances than self-report, P < 0.001.
Table 5: Comparison of case detection rate of Psychoactive substance use between self-report and biochemical marker (Urine drug test)

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  Discussion Top


We found that the lifetime prevalence of Psychoactive Substance Use was 45.5%, while the prevalence for the past 3 months (recent use) prevalence was 27.0%. The Pattern of Psychoactive Substance Use revealed that alcohol was the predominant psychoactive substance used with a lifetime prevalence of 13.0% and recent use of 12.0%. The difference in detection rates showed that UDT identified participants who use psychoactive substances significantly more than Self report questionnaire, P < 0.001.

The prevalence of psychoactive substance use in this study is lower than that found in the study by Leigh et al.[23] (83.1% for alcohol, 52.7% for tobacco and 55% for illicit drugs). In that study, the apparently higher prevalence might have been due to differences in socio-cultural factors compared to participants of this study. Furthermore, the relatively larger sample size (812) of participants compared to this study with a sample size of 200. The location of the study area could have also contributed to the variation in the prevalence rate. However, Vitale et al. reported a lower prevalence rate of (7.5% for alcohol, 9.0% for illicit drugs) compared to this study, even though they used a larger sample size of 1,398 participants compared to this study.[24] Their low prevalence rate may also be due to the location of the study area. Their study was conducted in the Netherlands while this study was conducted in Nigeria. The difference in prevalence rate could also have been due to variation in methods or measures used.

The pattern of psychoactive substance use found in this study was comparable with similar studies done in other countries.[23],[24] Tobacco accounted for 2.5% in this study, while polysubstance use accounted for 8.0%. This study found a higher prevalence of alcohol use of 13.0% as compared to 7.5% found by Vitale et al.[24] in the Netherlands. This study also recorded a higher prevalence of illicit/non-prescription drugs, which included cannabis 5.5%, sedatives 2.5%, opioids 6.0% and amphetamine-like substances, including caffeine 6.5% compared to study found by Vitale except for cannabis. In their study, cannabis use was reported by 6.9% of the sample, cocaine by 1.9% and opiates by 1.7%. These figures were much lower than those of Quentin et al. where they found a prevalence of alcohol use of 87.7%, tobacco 68.8% and cannabis 60.0%.[25] Less than one-fifth (17.7%) of the samples reported using amphetamines type substances, 6.5% had used inhalants, 22.4% had used benzodiazepine, 22.9% had used cocaine, 4.7% had used barbiturate, 18.8% had used hallucinogen and 11.8% had used opioid. Quentin et al.[25] recorded a higher prevalence rate despite conducting the study 4 days in a week within 12 h/day (11 am to 11 pm), with a small sample size of 170 participants. This may be due to the location of the study area and the period of data collection, which lasted for 7 weeks. It may also be due to differences in the socio-economic status of the participants in the present study compared to the participants in their study.

All these studies show a higher prevalence of alcohol use among respondents attending accident and emergency rooms. This higher prevalence of alcohol compared to other drugs may be because the use of alcohol is legal or socially acceptable. Furthermore, the high prevalence of alcohol use may be because people who use alcohol are more likely to have physical complications or accidents, leading to more presentations at accident and EDs.[17]

Many reasons may be responsible for the higher detection rates by UDT compared to self-report. Individuals may feel intolerable to disclose their alcohol or other drug use, which may be detected by a UDT. Second, socio-cultural and lawful restrictions on the use of psychoactive substances may discourage some participants from disclosing their alcohol and other drug use through self-report, which may easily be detected by biochemical tests (UDT). Apart from this, the stigma associated with drug use may dampen their willingness to disclose their use of psychoactive substances through self-report;[26] however, they may be more willing to consent to biochemical test which may identify the psychoactive substances.

On the other hand, there was poor detection of alcohol by UDT in this study, and this may be due to the period of alcohol use and the small detection period of alcohol (24 h). Therefore, patients who took alcohol about 2 or 3 days before the test may likely show negative results. Another possible reason for the poor detection of alcohol by UDT is that the UDT is an immunoassay, based on the principle of competitive binding, and during testing, a drug, if present in the urine specimen below its cut-off concentration, will not saturate the binding sites of its specific antibody. The antibody will then react with the drug-protein conjugate giving a negative result. It, therefore, means that drugs that have been identified by the self-report but present in the urine below its cut-off concentration will not be detected by the UDT. For instance, there was poor detection of alcohol by UDT compared to self-report.

The case detection rate found in this study is similar to but lower (except for alcohol) than that reported by Vitale et al.,[24] where alcohol use accounts for 7.5% of the respondents for self-report as against 4.7% for a biochemical test (breathalyser). Nine percent (9.0%) of the respondents disclosed using illicit drugs while UDT revealed 30% of the respondents tested positive for illicit drug use. However, in this study, 12.0% of the respondents disclosed using alcohol as against 3.5% detected by the biochemical test. Illicit drug use was reported by 1.5% of the respondents, while UDT reported 14.0% of the respondents positive for illicit/non-prescription drug use.

Similarly, the findings from this study agree with but are lower than that reported by Perrone et al., where self-report alone detected substance use in 70 patients (57%) while urine drug screening-detected substance use in 77 patients (62%).[27] Depending on the drug, there was a wide variation in concordance between self-report and urine drug screen. Self-report was better than urine drug screening for alcohol use (40 versus 10 patients), and cannabis (28 versus 15 patients). The higher prevalence of psychoactive substance use in their study (i.e., both self-report and UDT) compared to this study despite their small sample size of 124 respondents could be because their study was conducted in the psychiatric ED.

Several studies have demonstrated a higher prevalence of psychoactive substance use identified by biochemical tests[24],[26],[28] compared to self-report. However, there is variation in the detection rate of licit drugs by self-report and biochemical test. Cherpitel and Borges[29] deduce that self-disclosure of alcohol use is a more reliable result compared to biochemical test obtain at a presentation at accident and emergency unit. Perrone et al.[27] reported that urine drug testing alone was never significantly better than self-report. Although self-reporting of substance use is not reliable, reliance on urine drug screening alone is also flawed. Therefore, the optimal identification of drug use in the ED requires both self-report and urine drug screening.

There seems to be no previous study in Nigeria comparing detection rate by a self-report and biochemical marker (e.g., UDT) of patients attending accident and EDs with psychoactive substance use. Previous studies had been more concerned with self-report of psychoactive substance use among secondary school students, University students or Household surveys in Nigeria.[3],[30],[31]

Our findings have the following limitations:First, the possibility that the prevalence rates of psychoactive substance use may have been underestimated because self-reporting of substance use is not reliable, while in the UDT, facts specifying the amount, number of times or duration of drug intake is restricted to drug use only over the preceding few days, and also the risk of false-negative and false-positive results. Second, this was a single-centre hospital-based study conducted within 2 weeks with a small sample size of 200 participants looking for emergency care, and it's outcome may not be a true representation of the situation in the community. Third, the self-report questionnaire was interviewer-administered, and this could have introduced bias.


  Conclusion Top


The prevalence of psychoactive substance use recorded among ED attendees was high in our study. The UDT significantly detected more patients who used psychoactive substances compared to self-report. Quite a number of patients with other major health problems and coexisting psychoactive substance use were identified with the aid of these screening tools. This highlights the need to incorporate psychoactive substance use evaluation and management for patients who present to EDs, as part of comprehensive care.

Recommendations

Given the disparity between findings on self-report of drug use and UDTs, routine screening (i.e., both self-report and biochemical tests) should be undertaken in the accident and EDs to identify substance users and to institute early intervention strategies. Furthermore, it is advocated that functional family-based, school-based and community drug use prevention programmes be established to support efforts aimed at primary prevention of psychoactive substance use. Future investigators should consider carrying out multicentre studies using larger sample sizes over an extended period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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