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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 s er o on e an k ia te s Bl /o p O th er N ne in e et ho do H y Ec st as in e ab i oc a an n C C l in e co ho di az ep M nz o O th er Be Al 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