Patterns of drug abuse in Upper Egypt: cause or result of violence?

Drug abuse is a dangerous phenomenon in all countries. According to the World Drug Report (2017), 29.5 million globally suffer from drug use disorders (World drug report 2017). In Egypt, and since 1970s, there was a sudden increase in numbers of abusers (Hamdi et al. 2016). In Egypt, the first report for prevalence of drug abuse was published in Arabic and proved that 6.2% of the population declared the use of these substances at least once (Rakhawy et al. 1996) and this continued to increase as reported in Hamdi et al. (2016).

According to the National Institute of Health (NIH), drug abuse comprises three stages: (1) Drug use refers to taking the drug to distinguish it. (2) Drug abuse refers to any harmful use of drugs. Lastly, (3) dependence, refers to substance dependence as defined by the Diagnostic and Statistical manual of Mental Disorders (DSM) or addiction (Qureshi et al. 2000). Addiction refers to chronic relapsing brain disease that is characterized by drug seeking and re-use even with harmful effects (NIDA 2017). Some researches show that there are some connections between violence, suicidal risk, and substance abuse (Tiet et al. 2006 and Ilgen 2011).

Violence is a complex phenomenon, and WHO has defined it as the intentional use of threatened physical force against oneself, other person, or against a group or community that results in death, injury, maldevelopment, psychological harm, or deprivation (WHO 2002). In 2000, about 1.6 million people worldwide lost their lives due to violence either homicidal or suicidal (WHO 2002). In Egypt, according to the data obtained from the Ministry of Interior, reported homicide cases were 3549 with a rate of 4.34/100,000 in 2011, without causing death and without the suicidal cases (WHO 2014a, b).

According to the media and research studies, violence became a serious problem in most countries (Meyer et al. 2008). Risk factors for violence are complex, and many factors may contribute and interact. Researchers conclude a complex relation between violence and drug abuse where many variables can contribute and are difficult to be measured (Boles and Miotto 2003). The aim of this study is to assess the relationship between use of certain type of drug abuse and the type of violence related to it, as well as the degree of violence, and to clarify the patterns of drug abuse in Upper Egypt.

Table 1 shows the cutoff value used in this study according to the kits used in the study, the Multi-Drug One Step Screen Test Panel. The kits can assess amphetamine, barbiturates, benzodiazepines, cocaine, heroin, marijuana, methadone, methamphetamine, methylenedioxymet-amphetamine, morphine, opiates, phencyclidine, tricyclic Antidepressant, and tramadol.

The aim of this study is to assess the relationship between type of drug abuse and type of violence, to measure the degree of violence related to each type of drug abuse, and to clarify the patterns of drug abuse in Upper Egypt.

The sociodemographic data of abuse in Upper Egypt and its relation with violence shows male abuse was highly significant when compared with the female abuse. Age distribution of abuse was as follow: the most critical age was between 21 to 30 years old followed by 31 to 40 years old. The age of onset of drug abuse is so critical, at young age about 12 years old. There is a highly significant relation between being a previous victim and long period of addiction with occurrence of violence. There is no significant difference between the abuse among those of high education and those illiterate. There was no significant difference among those married, single, or divorced; among those living in rural or urban; and among those with occupation and those without occupation.

One of the main findings in this research is the change of the trends of abuse in Egypt from cannabis and its leaves (bango) to use the tramadol. Trends of drug abuse in Upper Egypt were cannabis mainly and its leaves (Yassa et al. 2009 and Yassa 2012). This is confirmed by Bassiony et al. (2015) who prove the idea that the tramadol began to be the gateway for drug abuse in Egypt. Wide availability of tramadol, its cheap price, and media appearance as a painkiller helped to introduce it widely among Egyptians (Fawzi 2011; Alsirafy et al. 2015; Bassiony et al. 2015).

World Health Organization detects that the number of tramadol abusers is growing especially in some Middle East countries (Zabihi et al. 2011; Taghaddosinejad et al. 2011; and Nazarzadeh et al. 2014). According to the AADIS, the scale of use of tramadol was 40 ± 1, which is a very high scale; this indicates the excessive use of tramadol by addicts in Upper Egypt.

Some studies have confirmed the opioid activity of oral tramadol but conclude that tramadol has a modest abuse liability and also mild withdrawal symptoms which resemble those occurring after cessation of serotonin-specific reuptake inhibitors (Woody et al. 2003; Epstein et al. 2006; and Radbruch et al. 2013). In this study, the abuse liability from the history of the patients is very high, the mostly used method is through oral administration, and the patients were in need to increase the dose, sometimes reaching 10 tablets (225 mg)/day, with severe withdrawal symptoms, which need hospitalization. A study done in China confirmed the result of this study as they concluded that tramadol has a clear risk of producing high abuse potential under the long-term infrequent abuse and high doses (Zhang and Liu 2013). According to the national report in Egypt, cannabis is the mostly misused substance; in this survey, they do not ask about tramadol directly as it is considered by most of adult as an analgesic and to treat the premature ejaculation (Hamdi et al. 2013 and Bassiony et al. 2015). According to the Egyptian law, tramadol is prevented to be sold in the pharmacy by using the common prescription, only by special prescription, as it is an abused drug since 2012, decision no. 125 for 2012 (http://cpegy.blogspot.com/2012/03/125-2012.html).

This study found a correlation between the violence and drug abuse. Violence is a result, and not a causative agent for addiction. The difference among the drug abuse is the type of violence. All types of violence can be found in mixed drugs addiction, self and verbal aggression is common with cannabis abuse, and aggression towards others is common in tramadol, opioids, heroin, and inhalants addiction. Auto-aggression is common in cannabis and barbiturates. Verbal aggression is common in cannabis, tramadol, and inhalants. Aggression towards objects is found in tramadol and inhalants addiction. The aggression towards others and towards objects clarifies the homicidal crimes that are committed against unknown persons.

Harris and Barraclough (1997), Borowsky et al. (2001), and Claro et al. (2015) found that all problems related to alcohol and other drug abuse are associated with psychiatric disorders, such as anxiety disorders, depression, attention deficit, conduct disorders, and hyperactivity disorders. This idea is supported by the finding of Yassa et al. (2010) that abuse of bango (cannabis leaves) affects the brain cells through shrinkage and increases the fatty cell. According to Ghoneim et al. (2014), tramadol affects the brain cells in the form of apoptosis, which can be explained by elevation of lipid peroxidation products with the inhibition of antioxidant enzyme gene. Chronic exposure to thinners or inhalants produces oxidative stress in the brain and increases the free radicals process and the glutathione peroxidase activities, which affect the brain cells (Burmistrov et al. 2001; Martinez-Alfaro et al. 2011 and Martínez-Alfaro et al. 2010).

Chermack et al. (2010) and Paim Kessler et al. (2012) prove the relation between cocaine, either crack or powder, and alcohol with the partner violence.

In contrast to this study, Gorman and White (1995) in their study prove that there are subcultural norms, which increase what is called the street behaviors. These norms lead to the criminal behaviors and addiction. However, in this study, the statistics of crime increase with the same individual after addiction if compared with the period before addiction. Nurco (1998) confirmed that in their study, they noted that the individual crime rates increase six times after addiction.

This study found that there was a significant relation between the history of patients during childhood, either due to abuse or as a stress disorders. This agrees with Swogger et al. (2011); Barrett et al. (2011) and Lev-Ran et al. (2012) who prove that childhood abuse, attention deficiency, and posttraumatic disorders are considered as risk factors for addiction that lead them to violence.

In conclusion, drug abuse is an important risk factor for all types of violence. The risk of inflicted wounds either homicide or suicide was increased in the community due to the increase in the abused drugs. Types and degree of violence differ according to the type of drug abuse.

Good treatment and rehabilitation of the addicts and abusers is a step towards reducing the rate of crimes in our area and also decreasing the number of psychiatric patients. Protection of the public from those addicts can be done only by treating and re-integrating them into the community, not by avoiding them. Forensic psychiatry can develop this balance between those patients and community protection.