A study on socio-medical variables of drug-dependent persons volunteering for treatment in Penang, Malaysia

Sections

Abstract
Historical background
Extent of the problem
Age
Sex
Occupation
Education
Medical History
Drug Use Pattern
Motivation for seeking treatment
Summary
Acknowledgement

Details

Author: V. NAVARATNAM, C.P. SPENCER
Pages: 1 to 7
Creation Date: 1978/01/01

A study on socio-medical variables of drug-dependent persons volunteering for treatment in Penang, Malaysia

V. NAVARATNAM Project Co-ordinator, Drug Dependence Research Project, Centre for Policy Research, Penang University, Malaysia
C.P. SPENCER Research Fellow

Abstract

A series of related studies on drug abuse are being conducted in Malaysia by the Centre for Policy Research at the University of Science in Penang, Malaysia. These are producing data on known hospitalized drug abusers, those before the courts and in prison for drug offences, and on cross-sections of the population; for example, a study has been conducted on school children's knowledge of, attitudes towards and experience of drugs. The first group of studies indicates socio-cultural characteristics of known drug abusers, the common patterns of drug taking etc.; and the second group gives an estimate of the proportions of the general population - or certain population groups experimenting with or regularly abusing drugs. They also compare abusers with control groups in terms of demographic characteristics, life attitudes, values and aspirations, and attitudes towards drugs and drug-taking.

The present report concentrates on the first group of studies. It describes the characteristics of drug-using individuals, who are voluntarily coming for treatment to a major State general hospital; it also describes trends observed in the numbers of users seen by this hospital over the preceeding five years. Before proceding with the study, a brief description of the Malaysian drug situation will be given.

Historical background

Historically, opium consumption has been practised for generations in Malaysia, situated on the major East-West trade routes, the country being close to the main Asian source of the drug. In 1936, there were 60,000 registered opium smokers in a population of just over four million (and it is estimated that an equal number was not registered). During the nineteenth century it was believed that the habit, although common, could be contained and controlled by social custom and by administrative and legislative measures (such as the registration of smokers). Thus, social and legal pressures such as for example licensed opium dens worked together to limit opium use.

Other drugs, especially cannabis (locally called "ganja") have also been well known in the country for a long period of time; and popular views had it that whilst opium was the drug of preference of the older (often Chinese) miners or workers in fisheries, ganja was more in common use among the agricultural population (often Malay or Indian). Until the 1960s drug use, although always of concern, was not the major social problem it is now seen to be: the estimated numbers were smaller, the abuser population generally older. Now, in common with virtually every other country, the picture has become more complex and the situation more acute, as, in addition to what one might call the "traditional" drug abusers, a whole new group - in their teens and twenties - have become drug abusers, and the range of drugs abused extended to include virtually the whole range of substances also abused in other countries. The strain on the country's treatment resources has been severe - as the example of the hospital under study will show. Attempts to estimate the extent of drug abuse face special difficulties here as elsewhere: as in the case of any illegal practice, the figures of drug dependents known to the authorities may well be a poor guide to their occurrence in a community. The aim of the present paper is thus to give a profile of the types of persons who are seeking treatment for drug abuse, their background, drug history and motivations for therapy rather than using the sample to estimate incidence in the general population, or to extrapolate from it a given picture of "the average drug user". (Later papers in the series, using cross-sections of the total population, may make an attempt at attaining the latter goals.)

Extent of the problem

In 1970, a total of 56 cases were admitted to the psychiatric department of the General Hospital, Penang, with a diagnosis of drug dependence. As shown in table 1, new admissions with a diagnosis of drug dependence have since increased annually. By the end of 1975, 372 patients were on the hospital drug register (cumulative since 1972); and during 1975 alone, the department had approximately 1,700 visits from drug dependents seeking treatment for their affliction. Thus, the number of new cases coming for treatment in 1975 has doubled since 1973, and visits have more than trebled in this period. This rapid increase in numbers seeking first-time admission indicates an increase in the awareness of the drug abuse problem, whereas the huge increase one notes in visits is probably more a reflection of the low therapeutic success rate. The therapeutic programme up to 1975 has been straightforward detoxification, and in many instances, out-patient detoxification treatment.

Age

By far the largest group of dependents are those between the age of 21-25, who represented 40 per cent of the 1972-1974 and 37.2 per cent of the 1975 samples, respectively (table 2). Next ranges the 26-30 age group and third the 16-20 age bracket (22.5 per cent for 1975 of the sample). Without doubt the major portion of the problem concerns people between 16-30 years of age. This represents the youth problem which has developed over the last years. It is socially a broader-based group than the traditional drug abusing population, who are probably influenced by the "international youth culture". The disturbing trend is that the lower the age group, the greater the increase of drug abuse; comparing the figures for 1972-1974 with the 1975 hospital population figures one sees a mean increase of 18.5 per cent in the 16-20 year old group, whereas the other age groups hold their position or even show slight decreases.

TABLE 1

Admissions of drug dependants to tile Psychiatric Department, General Hospital, Penang

 

Year

 

Case

1970

1971

1972

1973

1974

1975

Total

New Admissions
56
Unknown
81 166 268 352 923
Old Cases (pre 1969)
Unknown
Unknown
176 50 35 20 281
Visits (total)
Unknown
Unknown
Unknown
342 610 1714  

TABLE 2

The percentage breakdown by age group of drug abusers seen at the General Hospital, Penang (1972/74 and 1975)

 

Age

 

Population

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51 and above

Total

Hospital percentage (mean for 1972-1974)
4 40 27 11.5 7.5 4 2 4 100
Hospital percentage (mean for 1975)
22.5 37.2 25.6 7.0 4.6 2.1 1
Nil
100

The percentage breakdown of the age of initiation to drug abuse for the hospital population are presented in table 3. It shows that 48.4 per cent of them commenced their drug use between the age of 10 and 20; 28.4 per cent were initiated between the ages of 21 and 25. It is obvious that in this population the most vulnerable age in relation to initiation to drug taking has been between 16 and 20 years; surveys of pupils who are now in school suggest that the average age of initiation may now be even lower.

TABLE 3 Age of initiation to drug abuse

Age of Initiation

Percentage

10-15 years
10.9
16-20 years
37.5
21-25 years
28.4
26-30 years
9.4
31-35 years
6.1
36-40 years
2.9
41-45 years
2.6
46-50 years
1.7
51-60 years
0.5
60 + years
Nil
TOTAL
100.0

Sex

Almost all (98 per cent) of the hospital patients interviewed were males. However, the studies on school children indicate that the number of females who are involved in drug abuse is increasing.

Occupation

In the study population 34.6 per cent were manual workers; 21.8 per cent were either shopkeepers or shop assistants who invariably were working in coffee shops (which are known to be a major source of drug supplies). The unemployed formed the third largest category consisting of 19.2 per cent, whilst skilled workers, professional/managerial staff and retired persons made up the balance with 14.5 per cent, 3.2 per cent and 1.9 per cent, respectively.

Unemployment and underemployment may either be seen as cause or as consequence of the use of drugs. Our study showed that nearly 15 per cent of the respondents had been dismissed from previous employment as a result of their drug habit; and 19.2 per cent of the sample were unemployed at the time of the study. There was also a marked instability of employment among the drug dependents who were working. Further, when a comparison was made between the occupational status of the individual with that of his father, it was found that among the study population there were many who were downwardly mobile: again, a striking finding in a country, where continuous economic growth has made inter-generational upward mobility normative.

Education

Only 17.8 per cent of the present study population have had more than a lower secondary education; 4.5 per cent had received no formal schooling and 38.2 per cent did not have more than primary education. However, it was also clear that those interviewed had received more education than their parents had done. The majority of the patients' fathers had received primary education only (38 per cent), or had no formal education (40.7 per cent), and were themselves shopworkers or manual workers; and 58 per cent of mothers of patients had no formal education at all. It has been claimed by American researchers that such discrepancies in educational attainment between generations might engender tension between them; but in relation to Malaysia, this factor should not be overstressed, as generational differences in education are almost the rule in this country. However, it might be a contributory factor.

Medical History

Drug abuse is conventionally seen in a pathological setting; but the hospital study showed only few signs of previous pathologies; and if a drug abuser had ever been hospitalized before, it had been for physical illness; only 8.0 per cent had any history of psychological disorders. Other indicators again showed that clinical signs were rarer than might have been expected. Only 10.8 per cent of drug abusers came from families with a record of mental illness; 8.2 per cent from families with drug abuse history and only 12.7 per cent from families with a known criminal history. However, 39.4 per cent of the drug abusers themselves had a history of criminal involvement. These criminal activities were mainly directed towards maintaining their drug habit. As has already been stated, there were also indicators that they were often underemployed - whether this was a direct result of drug abuse needs further verification.

Drug Use Pattern

The whole hospital population interviewed abused either heroin or morphine, or both. From this study it was further found that heroin was the first drug of choice, ganja (cannabis) the second, opium the third and morphine the fourth. Amphetamines played a smaller role than might be expected in a comparable population in the West.

The daily drug use on admission was analysed; 65.6 per cent of the studied population were using heroin and 37.6 per cent morphine every day. Ganja (cannabis) and opium were used daily by 36.9 per cent and 37.6 per cent of the population, respectively. Other drugs were seldom abused. Mandrax usage in this group amounted to 1.9 per cent of the studied population.

It was found that 63 per cent of the subjects used at least four drugs, 21.7 per cent used at least 6 drug types, 68.6 per cent had been abusing drugs continuously for a period of at least two years, and 28.7 per cent for a period of five years or more.

If one compares the numbers of drugs abused by individuals with the period of drug abuse, one sees a significant correlation between the two. It was found that the 63.0 per cent of the subjects who used at least four drugs had abused drugs for a period of at least two years. Similarly, the 21.7 per cent of the subjects who abused at least six drugs were without exception part of the population who admitted to have taken drugs for a period of five years or more. This significant correlation between the number of drugs abused with the length of drug abuse made it especially relevant to analyse the nature of drug progression in our study population.

Amongst this group of drug abusers, 84 per cent started with cigarettes; a high percentage of these drug abusers moved straight on to heroin smoking, without the intermediate use of ganja (cannabis). A combination of market forces and cultural traditions helps to explain why early drug use in Malaysia frequently involves opiates. It was also found that 6.4. per cent of the studied sample smoked ganja (cannabis) and 2.5 per cent heroin, respectively, without prior initiation to cigarettes. Fifty per cent of the sample went on to using morphine, either for increased effect or because of better utilization of the drug - thus lowering their daily expenditure. Morphine is injected and thus a more intense pharmacological effect is obtained.

Relating the age of the drug abuser with the type of drug abused, it was found that ganja (cannabis) was the drug of choice amongst the 14-16 year age group. Heroin was the main drug of choice amongst the 17-year age group. Morphine and opium were equally used by 12 per cent of this group. A similar pattern existed for the 20-29 year age group, except that here there was a higher percentage of morphine and opium users. With the older age group there was a change in pattern: as the age of the user increased, the percentage of heroin and ganja use declined, whilst that of morphine and opium use predominated.

A similar picture is seen when one compares the age of the abuser with the drug type used daily. Ganja (cannabis) was the drug of choice amongst the 14-16 year olds; and daily heroin use was the norm for 62 per cent of the 17-19 age group. Daily use of morphine increased amongst the 20-29 year age group (20 per cent), although heroin still predominated in 40 per cent of this age group. Opium, heroin and morphine were in equal daily use amongst the 30-39 year old age group. Those above the age of 40 years seem to use exclusively opium or morphine as their daily drug of abuse.

The reasons given by the patients for their initial use of drugs were (i) influence of friends who were already using drugs (47 per cent); (ii) financial or unemployment worries (19.8 per cent); (iii) pleasure obtained from drugs (17.2 per cent) and (iv) stress (16.2 per cent). Clearly, the peer group influence is a major factor with this group of drug dependents, as it has been shown in many other studies of the modern drug problem.

The reasons for inception of drug use were not, however, the same, in order of predominance, as those given for continuing to use drugs. Experience or fear of experience of withdrawal symptoms was the most important reason in 35 per cent of the cases, while continuation for pleasure was given as a reason by 23.2 per cent of individuals. Only 15.7 per cent continued to use drugs as an attempt to alleviate mental stress and 18 per cent financial or unemployment problems, respectively. Whereas influence by friends was important in initiating drug use, only 8 per cent of the individuals reported that they had continued with the drug for this reason. This reduction of peer pressure is not surprising, because other researchers have also shown that many long-term drug dependents prefer to indulge in the drugs alone rather than in a group.

Sources of drug supply were usually coffee shops and other shops known to drug dependents. A quarter of the supply came from other drug dependents who sold drugs to raise money for their own habit.

When asked, most drug dependents said that 9 or 10 of their acquaintances were also drug dependents, who had not sought treatment. If this figure can be relied upon, it gives an estimate of the population of drug dependents and a clear indication of the sub-cultural influence which involves and maintains each individual in this habit, thus making relapse after treatment a very likely possibility. The treated drug dependent, after hospitalization, is returned to a social system where drug abuse persists unchanged, and he must be strongly motivated to remain uninvolved.

Motivation for seeking treatment

Strong motivation, however, was lacking in most of the respondents. When asked why they sought treatment, only 10 per cent gave health reasons. Family pressure (7.7 per cent) and family needs (20 per cent) were some of the other reasons given, but 40 per cent gave as their sole reason the increasing cost of the drugs. This finding is particularly disillusioning, for therapy is not likely to bring about a true change of attitude; furthermore for every group of drug dependents who wish to quit their habit, there is a larger group who will not seek therapy. Unavailability ofthe drug was never mentioned as a reasons for seeking treatment, indicating that in spite of all the concerted efforts by the different agencies to suppress the trafficking of drugs, there still appears to be an abundant supply in the country.

One expects that "volunteers" would have a higher - than average concern than that found in the total drug dependent population. However, since the absolute level of motivation among the volunteers was found to be low, the motivation of those not seeking treatment is probably non-existent However, more dependents may seek treatment (for whatever motive) as they get deeper into their habit, as it was found that a high percentage (40 per cent) of the present study group have used drugs for five years or more before seeking treatment, and have settled into a pattern of 3 or 4 fixes of either heroin or morphine a day (equivalent to 1-1½ tubes costing about $6 to $9 per day). * The prevalence of highly addicted drug dependents may be attributed to the relatively high purity of the street drug which is around 60 per cent.

Summary

There has been a rapid increase in the past five years in the numbers of hospitalized drug dependents. While the studied population was clearly unrepresentative of the country-wide drug using population, it illustrates how the problem is neither limited to one particular stratum of society, nor to the few "traditional" drugs. Indeed, an increasingly youthful group of individuals drawn from all backgrounds is not only becoming dependent upon opiates, but is also using a range of other drugs, all of which are available on the market at relatively low cost. The market prices of drugs have an effect on the pattern of drug use; and many individuals move directly from tobacco to heroin smoking. Drug abuse continues to be a considerable public and governmental concern, and enforcement and treatment programmes are rapidly expanding in attempts to resolve this problem.

Acknowledgement

The authors wish to acknowledge the advice received from Prof. K. J. Ratnam of C.P.R., Dr. G.M. Ling and Dr. M. Kilibarda of UNDND during this study.

*The term "tube" used in the article denotes a small plastic packet or vial containing heroin or morphine. The weight of the content varies from 30 to 50 mg/tube. Chemical analysis showed approximately 60 per cent heroin, 30 per cent caffeine and 10 per cent miscellaneous adulterants. The "street" pure heroin again fluctuates from 45 per cent to 60 per cent. A tube is adequate for 3 "fixes".