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Addiction and its impact on
diverse communities
Perminder Dhillon MA
Chief Executive Officer
Drug and Alcohol Action Programme
Empowering communities against addiction
www.daap.org.uk
Addiction and its impact on diverse
communities
• 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
Addiction and its impact on
diverse communities
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'.
Addiction and its impact on
diverse communities
•
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 and its impact on
diverse communities
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’
National Overview
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
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 Overview
Costs 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
National Overview
• 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
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 Britain
Cost 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 Britain
Illegal drugs and health costs
• Emergency admissions to hospital include thousands
admitted for drug psychosis, Drug dependence and nondependent 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 Britain
Alcohol
• 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 and its impact on diverse
communities
Addiction affects individuals,
All communities
and society
Drug Use and Black and Minority
Ethnic Communities
“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”
Addiction and its impact on
diverse 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
Addiction and its impact on
diverse communities
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
Addiction and its impact on
diverse communities
• 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
Addiction and its impact on diverse
communities
• 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
Addiction and its impact on
diverse 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
Blank
White Other
White Irish
White British
Pakistani
Other
Mix white/black Carribean
Mixed white & Asian
Mixed other
Inidan
Black other
Black Carribean
Black African
Bangladeshi
Asian other
Arabic
Local Picture- Ealing
Identification of ethnic minority groups within caseload
600
500
400
300
200
100
0
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s
Bl
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Local Picture- Ealing
Primay Substance Misuse in 2003/04
700
600
500
400
300
No
200
100
0
Local Picture- Ealing
Resident Population by Religious Group
80
70
60
50
% 40
30
20
10
0
Christian Buddhist
Hindu
Source: 2001 Census, ONS
Jew ish
Muslim
Sikh
Ealing
Other
religions
No
religion
Not
stated
England & Wales
Drug Use and Black and Minority
Ethnic Communities
???????
Drug Use and Black and Minority
Ethnic Communities
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
Drug Use and Black and Minority
Ethnic Communities
PAAN
Drug Use and Black and Minority
Ethnic Communities
• 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)
Drug Use and Black and Minority
Ethnic Communities
•
•
•
•
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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
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
Drug Use and Black and Minority Ethnic
Communities
Chewing Tobacco
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority Ethnic
Communities
KHAT
Drug Use and Black and Minority Ethnic
Communities
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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.
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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
Drug Use and Black and Minority
Ethnic Communities
• 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’
Addiction and its impact on diverse
communities
What are the implications for
services
????????????????????????????
Drug Use and Black and Minority
Ethnic Communities
• 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
Addiction and its impact on diverse
communities
• 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
Addiction and its impact on diverse
communities
What are the implications for oral
hygiene and health
????????????????????????????
Addiction and its impact on diverse
communities
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
Addiction and its impact on diverse
communities
Dentists and health professions
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
Addiction and its impact on diverse
communities
Dentists and health professions
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
Addiction and its impact on diverse
communities
Dentists and health professions
RESEARCH AND AUDIT
• To be aware of research findings and audits in the
dental profession
• To contribute to research and education
Addiction and its impact on diverse
communities
Recommendations
• Develop appropriate tools
• Training and teaching
• Service provision and development
Addiction and its impact on
diverse communities
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
That’s how the Dentistry
Profession can make a
difference to addiction!
Addiction and its impact on
diverse communities
Perminder Dhillon MA
Chief Executive Officer
Drug and Alcohol Action Programme
Empowering communities against addiction
www.daap.org.uk