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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 26-29

Poverty, gambling, and illicit drug use perpetuate each other in a bidirectional cycle: An analysis from a case study


1 Independent Public Health Researcher, Dehradun, Uttarakhand, India
2 Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India

Date of Submission17-Nov-2020
Date of Decision07-Dec-2020
Date of Acceptance07-Dec-2020
Date of Web Publication23-Mar-2021

Correspondence Address:
Dr. Sudip Bhattacharya
Jollygrant, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jascp.jascp_3_20

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  Abstract 


Illicit drug use and gambling are global problem, and multiple stakeholders are involved in it. This often leads to devastating physical, mental, and socioeconomic consequences for the family. In this case study, we describe our experience with an urban poor family from north India that was disintegrated by illicit drug and gambling use by one of its members. In this case, the family and school failed to recognize and act on the early warning signs of drug addiction and gambling. Health system failed to retain and follow him up. Law enforcement was also inadequate. It was a multisystem failure. For managing an illicit drug use case, we have also to address the cultural and social complexities that are part of the poverty subculture. Adequate involvement of multiple sectors and optimal follow-up can not only help the patient but also it prevents the collateral damage to a large extent in the affected families.

Keywords: Absolute poverty, mental health, substance-related disorders


How to cite this article:
Bhattacharya S, Singh A. Poverty, gambling, and illicit drug use perpetuate each other in a bidirectional cycle: An analysis from a case study. J Appl Sci Clin Pract 2021;2:26-9

How to cite this URL:
Bhattacharya S, Singh A. Poverty, gambling, and illicit drug use perpetuate each other in a bidirectional cycle: An analysis from a case study. J Appl Sci Clin Pract [serial online] 2021 [cited 2021 Apr 19];2:26-9. Available from: http://www.jascp.com/text.asp?2021/2/1/26/311762




  Introduction Top


According to the World Drug Report by the United Nations Office on Drugs and Crime (2016), the number of people taking illicit drugs has increased from 27 million in 2010–2029 million in 2016.

A person abusing drugs and used to gambling impacts almost all the aspects of the lives of the other family members. This results in serious physical, mental, and socioeconomic consequences for the whole family.[1]

Through a case study, we describe our experience with a poor urban family from northern India that was taken apart by the illicit drug use and gambling of one of its members. Here, our index case was the mother, and not the person – her son – who used to take illicit drugs.


  The Case Top


A 60-year-old female homemaker suffering from chronic hypertension (for the past 7 years) presented with a sudden frontal headache, which radiated down her back, which had lasted for 4 days. The pain was occasionally associated with palpitation, with no diurnal variation, and was aggravated by talking. She reported relief after taking nonsteroidal anti-inflammatory drugs. She had been on a calcium channel blocker, amlodipine 5 mg per day, for the past 7 years. However, she was not adhering to the prescribed medications, even though they were free.

She reported excessive mental stress due to apparent family problems. Her son had been taking illicit drugs for the past 15 years. Her husband had retired from his job 2 years prior but still had to work hard to support his family financially. Her grandchild and daughter-in-law were also living with them, as her son had deserted the family. The family came from a poor socioeconomic background. The mother's headache was not the most important problem this family faced. Informed consent was gained by the family members to be included within this study. Later, it is revealed that the turbulence within the family resulting from the poverty subculture that they lived in emerged as the social diagnosis in this case.[2]

Chain of events

The patient migrated in 1990, from her village, to a city in northern India, where her husband began working a menial, blue-collar job (class four staff). Their only son was 1 year old currently. They have been living in an impoverished area of that city ever since. He used to attend school regularly, was apparently extroverted in nature and generally happy.

At the age of 14 (2003), sudden changes in the son's behavior were observed by his mother. He became disinterested in school activities, his grades dropped, and he was suspended by his teacher after being caught smoking and gambling in class. His teacher at the time warned his parents that their son was in “bad company.” In class eight, he was expelled from school after being caught taking illicit drugs and gambling that were readily available in their area, after which he started working as an apprentice to a car mechanic; however, he continued taking drugs and gambling with his peers. Gradually, he started ignoring his dress and appearance and eventually prohibited his family members from entering his room. He became secretive about where he went with his friends and began to come home late in the evenings with red eyes. He also became progressively weaker over time and frequently demanded money from his parents. If they refused, he would reportedly resort to stealing. The family was aware that their son was taking both oral and intravenous drugs at that time along with addicted to gambling. However, as he was their only son, they believed that, after his marriage, the problem would resolve itself. This is a quite common belief within the Indian culture.[3] However, despite all of this, the drug use and gambling continued. He then, reportedly, began physically abusing his wife whenever she protested his drug use and gambling.

At the age of 24 years, in 2013, he was caught by the railway police for taking drugs on a local train. He was then jailed for 7 days, after which his father bailed him out. He continued working, but eventually became addicted to heroin. A few weeks before the initial seizure episode, the son became increasingly violent when he could not obtain any illicit drugs.

Eventually he also started having seizures within the same year, which a local doctor diagnosed as “drug withdrawal syndrome.” After they stabilized the patient at the local dispensary, he was referred to the Drug De-addiction Treatment Centre (DDTC). He remained there for 1 month, where standard treatment protocol (such as stabilization of the patient) was followed, and substitution therapy was given. He and his family members were duly counseled. At the DDTC, the outpatient department normally follows up on around 90% of cases whereas only 10% require admission to the center. This includes patients who have comorbidities such as hepatitis C, acquired immune deficiency syndrome, and severe withdrawal syndrome, or those who require substitution therapy.

It is quite common within the DDTC for many patients to leave against medical advice.[4] Owing to a shortage of manpower, only telephonic monitoring of these patients is conducted. The patients who cannot afford the treatment cost or do not come for follow-up due to long distances are considered as lost to follow-up.

This is what happened with this family. After being discharged, they discontinued the follow-ups at the DDTC due to the high cost of treatment. The parents also found it difficult to continue the opioid substitution therapy, which required strict supervision and persuasion. The patient was categorized as a serious case (as per the register of the DDTC, usually 10% of admitted cases are labeled as serious case, who require opioid substitution therapy) and was put on a passive monitoring system by phone call. Many phone calls were made from the DDTC for follow-up, but there was no response from the family.

On examination

The mother, our index case, reached menopause at 45 years. Her vitals were good: Heartbeat and lung sound were normal, and her blood pressure was 170/98 mmHg. She was physically active, and there was no significant family history of any systemic disease. However, she could only sleep for around 3–4 h per day. On examination, her Patient Health Questionnaire-9 score was 18, which indicated a moderately severe level of depression.

We examined the husband as well. He also showed signs of being hypertensive, and so we prescribed tablet amlodipine 5 mg/day from our dispensary. The daughter-in-law of our index case also appeared to be under stress. The child of the son was not properly immunized as per her age (evident from their health records) and had not been enrolled in the nearest Anganwadi centre either (a government run playschool for toddlers). This all indicates the severity of the various problems afflicting this family.

The authors diagnosed the index case with a probable case of chronic depression, with hypertension. They counseled her on methods to reduce stress and arranged for free amlodipine tablet (5 mg/day) from the dispensary. Our health workers visited the family home regularly and checked their adherence to the various medications. They were also tasked with helping the daughter-in-law maintain the vaccination schedule of the child and to get her enrolled in the Anganwadi. We also advised her to attend psychiatry and neurology consultations at the tertiary care hospital.


  Discussion Top


Illicit drug dependence directly accounted for 20.0 million disability-adjusted life years (DALYs) in 2010, which account for 0·8% of global all-cause DALYs. Opioid addiction was the highest contributor to DALYs (9.2 million).[5]

While illicit drug use has been shown to contribute to general societal disruption, it is also evident that social deprivation, itself, promotes illicit drug use and gambling as a way of alleviating emotional stress, thus perpetuating a bidirectional cycle.[6]

In the present case study, only the son of that old woman was taking illicit drugs and addicted to gambling. As a result, there were various direct and indirect consequences. Drug use and gambling affected not only him, but also his parents, wife, and child. The father and mother developed hypertension, his child was not immunized adequately for her age, and his wife was under stress. Therefore, a “Domino effect” was observed, with the trigger point being the son's illicit drug use.[7]

Quite commonly, it is difficult for families to distinguish normal teenage mood swings from the signs of illicit drug use.[6] Still, there are some possible indications or signals which are helpful for families to identify possible substance abuse by a member, as witnessed within the current case: (a) problems at school or work, (b) physical health issues, (c) neglect of appearance, (d) Changes in behavior, and (e) monetary issues:

The health system has responded to the problem of illicit drug use by opening drug de-addiction centers.[8] However, as there is a social stigma attached to addiction, patients often do not go to these centers until the problem is aggravated.[9] There are several substantial barriers in linking “patients in medical settings with drug misuse” with “specialty addiction treatment.” These can be classified as those either pertaining to the patient or to the health-care system. Patient-level barriers include not perceiving oneself as needing services, difficulty in accessing treatment, the stigma associated with getting treatment, and limited family budget. There are also false beliefs such as “addiction treatment is not effective.” System-level barriers include long distances, low collaboration between care sites, and little or no availability of services.[9]

In this case report, it was observed, from the family's medical documents, that our health system failed to follow-up on something that was well within its catchment area (the distance of patient's residence and DDTC was around 2 km). This kind of approach by the DDTC can be disastrous.

Drug dependence is a multifactorial health disorder, often following the course of a relapsing and remitting chronic disease. Its effective management is possible through the active involvement of all the stakeholders, i.e., self-control by the addict, and appropriate responses from the family, the health-care system, the social support system, and law enforcement activities.[9],[10],[11],[12],[13]


  Conclusion Top


Illicit drug use and gambling are universal problem. However, its effects are more serious for people living in poverty. Adequate involvement of multiple sectors, namely, family, school, and hospitals, are needed. This will not only help the patients but also will prevent the inevitable disintegration of their families.

Key messages

  1. Illicit drug use is a global health problem and is an aggravating factor of poverty
  2. Taking illicit drugs not only cause harm to the person who is abusing them but also poses health risks to their family members
  3. Illicit drug users display early warning signs, but quite often these are not detected
  4. A huge gap is present between the theoretical and practical approaches for the treatment of illicit drug users
  5. Intersectoral involvement for handling illicit drug use is currently inadequate
  6. Managing health-care provisions for poverty-stricken illicit drug users is a challenging task.


Consent

Consent was taken from the patient and from the family members.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Espada JP, Irles DL. Basic Concepts in Drug Addiction; 176.  Back to cited text no. 1
    
2.
Benson DS. Providing health care to human beings trapped in the poverty culture. Physician Exec 2000;26:28-32.  Back to cited text no. 2
    
3.
Srivastava A. Marriage as a perceived panacea to mental illness in India: Reality check. Indian J Psychiatr 2013;55:239.  Back to cited text no. 3
    
4.
Degenhardt L, Whiteford HA, Ferrari AJ, Baxter AJ, Charlson FJ, Hall WD, et al. Global burden of disease attributable to illicit drug use and dependence: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1564-74.  Back to cited text no. 4
    
5.
Essay on Drugs: Drug Addiction and Domino Effect-1415 Words | Cram. Available from: https://www.cram.com/essay/Drugs-Drug-Addiction-And-Domino-Effect/PKCNHJDK5C. [Last accessed on 2019 Jan 06].  Back to cited text no. 5
    
6.
Ali S, Mouton CP, Jabeen S, Ofoemezie EK, Bailey RK, Shahid M, et al. Early detection of illicit drug use in teenagers. Innov Clin Neurosci 2011;8:24-8.  Back to cited text no. 6
    
7.
Administration (US) SA and MHS, General (US) O of the S. HEALTH CARE SYSTEMS AND SUBSTANCE USE DISORDERS. US Department of Health and Human Services; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424848/. [Last accessed on 2019 Jan 06].  Back to cited text no. 7
    
8.
Rapp RC, Xu J, Carr CA, Lane DT, Wang J, Carlson R. Treatment barriers identified by substance abusers assessed at a centralized intake unit. J Subst Abuse Treat 2006;30:227-35.  Back to cited text no. 8
    
9.
Barman R. Barriers to treatment of substance abuse in a rural population of India. Open Addiction J 2011;4:65-71.  Back to cited text no. 9
    
10.
Dhawan A, Rao R, Ambekar A, Pusp A, Ray R. Treatment of substance use disorders through the government health facilities: Developments in the “Drug De-addiction Programme” of Ministry of Health and Family Welfare, Government of India. Indian J Psychiatr 2017;59:380-4.  Back to cited text no. 10
    
11.
Avasthi A, Basu D, Subodh BN, Gupta PK, Goyal BL, Sidhu BS, et al. Epidemiology of dependence on illicit substances, with a special focus on opioid dependence, in the state of Punjab, India: Results from two different yet complementary survey methods. Asian J Psychiatr 2019;39:70-9.  Back to cited text no. 11
    
12.
Ghosh A, Basu D, Avasthi A. Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions. Indian J Psychiatr 2018;60:361-6.  Back to cited text no. 12
    
13.
Avasthi A, Ghosh A. Drug misuse in India: Where do we stand & where to go from here? Indian J Med Res 2019;149:689-92.  Back to cited text no. 13
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Introduction
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Discussion
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