Military Academy Saudi Arabias Changing Trends in Substance Addiction Analysis

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MOJ Addiction Medicine & Therapy
Research Article
Open Access
Changing trends of substance addiction in Saudi
Arabia between 1993 and 2013
Abstract
Volume 6 Issue 1 – 2019
Background: Prevalence rates of substance dependency in Saudi Arabia have risen
over the last twenty years. Although there is substantial research on alcohol and
substance abuse in the Arab region, only a few papers give detailed review of the
rising concern
Turki Alahmari,1 Fiona Ashworth,2 Ahmed
Alkhalaf3
Aim: The present study aimed at comparing data of admitted hospital cases between
1993 and 2013. It was expected that changes will be observed in substance abuse and
dependence in hospital admissions between 1993 and 2013. It was also expected that
these changes will be associated to certain demographics and frequency of admissions.
Method: Records from a total of 2,048 admitted cases were obtained from the Al
Amal Hospital of Dammam. Type of addiction, demographics, frequency of hospital
admissions and number of substances abused were compared between 1993 and 2013.
Findings: The data was subjected to quantitative analysis and findings showed
significant differences in type of addiction and sociodemographics between 1993 and
2013.
Al-Amal Complex for Mental Health, Dammam, Saudi Arabia
Department of Psychology, Anglia Ruskin University, United
Kingdom
3
Consultant Clinical Health Psychologist, Neuroscience Institute,
Saudi Arabia
1
2
Correspondence: Ahmed Alkhalaf, Consultant Clinical Health
Psychologist, Clinical Psychology Unit, Psychiatry& Mental
Health Services , Neuroscience Institute, Johns Hopkins Aramco
Healthcare, Dhahran 31311, Saudi Arabia,
Email
Received: February 21, 2018 | Published: February 07, 2019
Conclusion: These changing trends suggest that there is a growing need to review data
in order to implement new strategies, policies and interventions for positive outcomes
in populations affected by substance addiction
Keywords: substance addiction, changing trends, epidemiological studies, alcohol,
drug abuse, psychiatric
Introduction
The prevalence of addiction has changed drastically in the last
decade in the Arabian Gulf and a number of studies are attempting
to grasp its magnitude in order to make services more accessible to
individuals with addictions.1 In Islamic countries, where alcohol and
drug use are legally forbidden, the stigmatization of addiction can
make epidemiological studies far more challenging.2 Research on
addiction in Arab countries began in the early 1980s. Between 1981
and 1982, there was a 50% increase in admissions for alcohol and
drug abuse in Kuwait hospitals, of which 11% were psychiatric.3
Recent empirical evidence, indicates that the prevalence of substance
abuse is rising.1,4,5 This is evident by the growing number of treatment
centers for drug and alcohol abuse such as “Al-Amal” hospitals in
Saudi Arabia.6 A number of factors may have changed in Saudi Arabia
to cause the rise in substance abuse prevalence rates over the last 20
years.3,4,6 The aim of the current study was to explore the links between
addiction prevalence in Saudi Arabia, diagnosis, age, employment
status, relapse, and criminal history.
Background
A number of studies have indicated that there is an increasing
prevalence in substance abuse in Arabic countries. 1,2,7,8,9 The typical
profile of a substance abuser is the young unemployed male of low
educational status.6,10 A few early studies conducted in Saudi Arabia
reported that the mean age of substance abusers was 29 years with
those who abuse heroin being younger than those who abuse only
alcohol.3,4,6,11,12 A few studies have also reported low prevalence
rates among women13–15 which may be due to specific treatment
protocols currently utilized for females. For example, in Kuwait
women are treated either in general psychiatric units or prisons,13 not
in specialized rehabilitation centers. However, the stigma attached to
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MOJ Addict Med Ther. 2019;6(1):39‒47.
substance use and fear of disclosure often makes it challenging for
researchers to obtain data from men, let alone from Arab women.1
Although there is substantial research on alcohol and substance
abuse in the Arab region, only a few papers give a detailed review
of the rising concern.1,5,16 Specifically, the authors of an early study7
argued that the problem of drug abuse in Arab countries is multidimensional and treating the problem is rather challenging as there
is currently no program in the region that can be universally efficient
in reducing drug dependence. In their review,7 the acknowledge the
fact that both criminalization and decriminalization have no apparent
effect in reducing addiction. Similarly, another study1 emphasized the
complexity of treating addiction in Arab countries and the challenges
to research due to stigma and fear of disclosure imposed either by
the culture or the law. A 10-year review17 of 591 patients who had
been admitted to a drug rehabilitation center showed that all admitted
cases were males between 16 and 66 years of age, 42% were married,
60% were unemployed, 51% were educated below secondary school
level, 77% had been admitted voluntarily, and 23% were brought to
the clinic by family members. In addition, 41% were admitted due
to alcohol problems, 20% for prescription drugs, and 16% for heroin
use. Other researchers18 have stressed the importance of more research
on substance abuse in Arab countries, as currently the majority
of research employs measurements that have been developed and
validated either in the United States or Europe. Establishing a nonWestern journal is of paramount importance for validating effectively
appropriate interventions in the Arab region without having to rely
on measurements and prevention programs imported from the West.18
The prevalence rates are different for each drug and for certain
socio-demographic variables.2 For example, 30% of first admission
patients are from families with a history of alcohol abuse and 16%
are from families with a history of drug abuse.17 In addition, the
main reported substance of abuse is alcohol (41.3%). Drugs such as
39
©2019 Alahmari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work non-commercially.
Copyright:
©2019 Alahmari et al.
Changing trends of substance addiction in Saudi Arabia between 1993 and 2013
tetrahydrocannabinol (THC), benzodiazepines, amphetamines, and
inhalants are reported by 22.5% of patients, and heroin is reported
by 16.3%. The remaining drugs include prescription drugs, such as
pain killers including tramadol, methadone, and codeine; sedatives
including Xanax and valium; and other psychoactive substances
including kemadrine, artane, and khat. Since 2009, there has been
a drastic increase in the use of prescription drugs and abuse of
psychoactive polysubstances other than alcohol, heroin, and THC.17 In
the decade from 1986 to 1996, there was a 25% increase in the mean
number of drugs abused per individual.2 There was also a shift from
alcohol as the sole substance of abuse to amphetamine-type stimulants
in the form of fenethylline (captagon), with increasing numbers of
instances of confiscations by enforcement authorities being reported
by the United Nations Office on Drugs and Crime (UNODC). The
number of patients admitted for addiction treatment in Kuwait rose
from 386 in 1997 to 779 in 1999.14
AbuMadini and colleagues2 reviewed the records of 12,743
patients who were admitted to a specialized addiction unit in Saudi
Arabia between 1986 and 2006. In the first decade, the majority (83%)
were aged 20-39 years, never married (60%), and with low educational
status (81%). In the second decade, subjects were significantly older
and had a higher rate of employment than in the first decade (28.9
years versus 30.2 years; 27% versus 19%). The mean annual inception
number (AIN) rose from 509 in the first decade to 765 in the second
decade. In the same periods, the relative frequency of substances
(RFS) increased for amphetamines and cannabis (from 12.1% and
17.5% to 48.1% and 46.5%, respectively), decreased for heroin,
sedatives, and volatile substances (from 51.1%, 15.1%, and 6.1% to
22.5%, 7.3%, and 2.5%, respectively), and remained stable for alcohol
(27.1% and 26.7%). These findings show that over the past 20 years
there has been a shift in the socio-demographic factors that relate to
addiction in Saudi Arabia. One possible explanation of the changes
in socio-demographics is that younger users have now become older
and addicted to other substances such as heroin14,15,19 or prescription
medications.13,20 Evidence from research in Saudi Arabia shows that
addiction is related to a number of other factors, such as age,2 marital
status, employment status, mental health 1,3,7,21, 22 level of education,
and occupation.5,6,10,11,23–26 It may be that these trends have changed as
more men are now unmarried and unemployment rates in Saudi Arabia
have risen over the last 10 years. 27–30 Older age for example has now
been found to be correlated with the use of harder drugs.8,31 With regard
to occupation, evidence suggests that in the Arabian Gulf many drug
addicts are unemployed. For example,17 found that 60% of patients
were unemployed and 33% were either employed or students. Similar
levels of unemployment have also been reported by other authors.2
Moreover, AbuMadini and colleagues (2008) also stated that 80.8% of
users had completed less than a secondary education, a rate similar to
the figures17 reported about socio-demographics of substance abusers
in the Arabian Gulf, as 51% did not have a secondary education, 33%
had secondary education, and 16% had a post-secondary education.
Other research evidence also suggests strong correlations between
low educational status and rise in addiction in both the Arabian Gulf
and Saudi Arabia.11,17,23 found that heroin and other drugs were the
preferred choices for younger patients aged 16 to 26 years, but alcohol
was favoured among those aged 37 to 66 years. Polysubstance use
(abuse of three or more substances simultaneously) has steadily
increased over time with a drastic increase since 2009.17 Furthermore,
evidence suggests that this pattern is also prevalent in Saudi Arabia,
where 57.1% of all patients were young adults under the age of 30 and
77.8% were younger than 40 years.2 Thus, not just younger addicts
40
but also those that are older are taking drugs. This shows how the age
of onset of substance abuse has also changed over time, as initially
primarily younger patients were taking drugs.2 Perceptions about
who uses drugs are also inaccurate. For example, a study of medical
students’ beliefs about substance misuse revealed that 75% believed
that alcohol use and substance abuse is a real problem in the Saudi
community, but the majority believed that substance abuse is primarily
a problem for young males aged 15 to 30 years, and approximately
one-third of the medical students indicated they believed that use of
alcohol and other substances could have some beneficial effect in the
form of alleviation of stress.32 Relatedly, the majority of the medical
students perceived alcohol to be the most commonly abused drug in
the community, followed by amphetamines, heroin, cannabis, and
cocaine. Participants also believed that friends’ influence is the most
important predisposing factor leading to abuse of alcohol and other
substances, followed by life stressors, tobacco smoking, and curiosity
related to experimentation. Of those factors considered, the factors
medical student participants believed contribute least to substance
abuse were physical illnesses and inadequate recreational facilities.32
Aims and objectives
The evidence presented above shows there is a gap in knowledge
of the current trends of alcohol and substance addiction in Saudi
Arabia, as most studies were conducted in the 1980s and 1990s and
captured only a glimpse of the picture by looking at abuse at one
point in time. There have been longitudinal studies in the area, but
to date even the longitudinal studies examined relatively short time
periods. The present study aimed to add to the data available and
provide a more accurate picture of the longer-term trends in Saudi
Arabia. Specifically, this study aimed to look at changing trends
in substance addiction in Saudi Arabia over the last 20 years by
comparing data from two points in time 20 years apart. In order to
meet the above objectives, secondary data were obtained from Al
Amal Hospital in Damman in Saudi Arabia and a systematic analysis
was used to compare factors (e.g., criminal record, educational status,
social status, relapse rates, number of substances abused) associated
with substance abuse of admitted patients between 1993 and 2013.
In addition, the study also aimed to look at the inter correlations
between different types of substances. For example, which substances
are more likely to be abused together? If there are factors that differ
between recent years and approximately 20 years ago, then treatment
programs must be adjusted to better suit the needs of the patients. The
present study aimed to investigate the following questions: Are there
changes between 1993 and 2013 in terms of the factors associated
with substance abuse? What are the most significant factors associated
with substance abuse in 2013?
Methods
Design
The variables examined in this study were substance(s) of addiction
(alcohol, opium, cannabis, hypnotics/sedatives, stimulants, and
volatile solvents), demographics (age, criminal history, educational
level, employment, and social status), number of admissions, and
number of substances abused.
Materials
Medical records were obtained from the Al Amal Hospital in
Damman in Saudi Arabia. Each admitted case was assigned a record
number that included information on relapse frequency (number of
Citation: Alahmari T, Ashworth F, Alkhalaf A. Changing trends of substance addiction in Saudi Arabia between 1993 and 2013. MOJ Addict Med Ther.
2019;6(1):39‒47. DOI: 10.15406/mojamt.2019.06.00145
Copyright:
©2019 Alahmari et al.
Changing trends of substance addiction in Saudi Arabia between 1993 and 2013
admissions), number and types of substances abused (alcohol, opioids,
cannabis, sedatives/hypnotics, volatile solvents, and stimulants),
criminal record (yes or no), social status, educational status, and age.
Procedure and ethics
The first author was granted permission from the authorities of Al
Amal Hospital in Damman, where he is currently employed, to have
access to data files of two cohorts (all admitted cases from 1993 and
all admitted cases from 2013). The current study was also ethically
approved by the psychology department of Anglia Ruskin University
and complied with the ethical guidelines dictated by the British
Psychological Society.
Participants
Records from a total of 2,048 admitted cases (720 from 1993
and 1,328 from 2013) were obtained from the Al Amal Hospital of
Dammam in Saudi Arabia. The minimum age of all admitted cases
in 1993 was 15 and the maximum age was 62 (M=29, SD=7.19). The
minimum age of all admitted cases in 2013 was 17 and the maximum
age 70 (M=33, SD=9.39).
Analysis
Chi-square was used to test for associations between types of
substance abuse/dependence separately, between demographics
and types of substance abuse/dependence, and between number
of admissions and substance abuse/dependence separately in data
sets from both 1993 and 2013. Findings were compared across the
two cohorts (1993 and 2013) and all data was subjected to post hoc
analysis by checking the standardized residuals.
41
age and addiction to opioids and opium was found, Fisher exact test
(N=677), p=.00; Cramer’s V=.16. Post hoc analysis showed that the
standardised residual (SR) for opium abuse in the age group 15-25
(n=177) was -2.0, which indicates that there were fewer cases in this
age group that were abusing opioids and opium (1.7%). In the age
group 26-35 (n=392) there were significantly fewer cases (30.9%)
with no addiction to opioids and opium (SR=-2.5). In the age group
46-55 (n=19) there were significantly more cases (78.9%, SR=2.8)
with no addiction to opioids and opium and significantly fewer
cases that were dependent on opioids and opium (15.8%, SR=-2.4).
In 2013, there was also a significant association between age and
opioids and opium abuse, Fisher exact test, p=.00, Cramer’s V=.26.
Post hoc analysis showed that there were significantly more cases
(90.6%) in the age group of 15-25 (n=320) that were not addicted to
opioids and opium (SR=2.3) and significantly fewer cases (9.4%) that
were dependant on opioids and opium (SR=-4.5). In the age group
26-35 (n=579) there were significantly more cases (88.1%) that were
abusing opioids and opium (SR=2.5) but significantly fewer cases
(11.9%) that were dependant on opioids and opium (SR=-4.7). In the
age group 36-45 (n=283) there were significantly more cases (66.8%)
with no addiction to opioids and opium (SR=-2.3) and significantly
more cases (33.9%) with opioids and opium dependence (SR=4.4).
In the age group of 45-56 (n=153) there were significantly more cases
(48.4%) who were not addicted to opioids and opium (SR=-4.3) and
this was significantly different from those who were dependant on
opioids and opium (51.6%, SR=8.3). Finally, in the age group 56 and
over (n=19) there were significantly more cases (n=7) who were not
addicted to opioids and opium (SR=-2.1) and significantly more cases
(n=12) that were dependant on opioids and opium (SR=4.0) (Figure
1& Figure 2).
Results
Main differences in addiction between 1993 and 2013
(Table 1)
Table 1 Demographic characteristic in the admitted cases between 1993 and
2013
1993 (n=720)
2013 (n=1364)
Criminal record
29.90%
27.30%
Number of
substances abused
71.60%
70.70%
Educational status
97.1% no education
33.9% higher education
Unemployment
63.80%
59.50%
Relationship status
56.5% single
62.9% single
36.4% married
31.7% married
Figure 1 Age and opium dependence.
Number of substances abused and substance addiction
Table 2 shows the significant associations between number of
substances abused and addiction for all cases admitted in 1993
and 2013 respectively. Empty columns indicate no significant post
hoc associations. In the admitted cases from 1993, no significant
associations were found for stimulants, Fisher exact test (N=703),
p=.46, or volatile solvents, Fisher exact test (N=703), p=.29.
Age and addiction
As can be seen in Figure 1, in 1993 individuals in younger age
groups were more likely to be dependent on opioids and opium,
whereas in 2013 (Figure 2) older age was associated with opioids
and opium dependence. In 1993 a significant association between
Figure 2 Age and opium dependence.
Criminal record and addiction
In 1993 criminal record was not associated with alcohol, opium, or
stimulant addiction, whereas in 2013 it was associated with all three.
Figure 3–5 shows the findings for 2013 for different substances.
Citation: Alahmari T, Ashworth F, Alkhalaf A. Changing trends of substance addiction in Saudi Arabia between 1993 and 2013. MOJ Addict Med Ther.
2019;6(1):39‒47. DOI: 10.15406/mojamt.2019.06.00145
Copyright:
©2019 Alahmari et al.
Changing trends of substance addiction in Saudi Arabia between 1993 and 2013
42
Table 2 Significant associations between number of other substances abused and substance addiction
1993
1(N=503)
2 (N=152)
3 (N=37)
Alcohol
A 42%
A 7%
A 26.3%
Opium
NA 44.3%
D 80.9%
D94.6%
Fisher exact test (N=703): p=.00, Cramer’s V=.24
D48.7%
Cannabis
NA 97.2%
D 15.1%
A 35.1%,
Fisher exact test (N=703): p=.00, Cramer’s V=.44
D48.6%,
Sedatives/hypnotics
NA 96.8%
NA54.6%
NA24.3%
A 7.2%)
A13.5%
D 38.2%,
D62.2%
Fisher exact test (N=703): p=.00,
Cramer’s V=.20
Fisher exact test (N=703): p=.00, Cramer’s V=.45
2003
1st time(N=359)
2nd time (N=495)
3rd time (N=403)
Alcohol
NA 89.7%
A16.2%
A67.7%
χ² (5, N=1270)=543.01, p