PREVALENCE OF DRUG ABUSE IN CHILDREN IN DAMIETTA GOVERNORATE FROM THE 1^st OF MAY 2015 TO 1^st OF JANUARY 2017

By

Mostafa A. Mohamed, Mahamoud H. El Saeid,

Waleed E. Abo Baraka, Sanad Foad Mahros, ^*Gamal El-deen I.A. Biomy

Departments of Forensic Medicine and Clinical Toxicology (Damietta - Cairo^*)

Al-Azhar University

ABSTRACT

Background: The direct and indirect effects of substance of abuse on children lead to many adverse health and safety risks for the child, family and community. Patterns of drug abuse in children are determined not only by the availability and cost of different substances, but also by the dynamics and differences within groups, cultures and age groups. There is increasing awareness that the abuse of drugs by parents and other caregivers can have a good impact on the safety, permanence and well-being of children.

Objective: The purpose of this study was to shed light on the prevalence of drug of abuse in children in toxicology unit in Damietta governorate from the 1st of May 2015 to 1st of January 2017.

Subjects and Methods: A total of 100 abused child were detected to estimate the prevalence of drug abuse in children in Toxicology unit Al-Azhar University Hospital (New Damietta) from the 1st of May 2015 to 1st of  January 2017, in addition to 20 healthy volunteers as a control group. Within one hour after arrival to emergency room, blood samples were drawn in sodium fluoride (NaF) contained tubes. Then, it was kept at 4-8 ^oC for subsequent test, using radioimmunoassay strips as a preliminary test, and a high performance liquid chromatography (HPLC) as a confirmatory test. The status of electrolytes, hemoglobin (Hb), liver and renal function tests, and alkaline phosphatase level were evaluated at the same time of screening the substance abuse. Cases and controls were subjected to full medical history with stressing on age, sex, smoking, behaviors, difficult temperament and the psychoactive drugs used during the previous month. This was in addition to  clinical examination with special attention to neurological examination and Glasgow Coma Scale (GCS).

Results: The most common drugs abuse in children were tramadol (90.0%) followed by both cannabis and drugs- co-administration (50.0%), anti-psychotic drugs (30.0%), benzodiazepines (26.0%), antihistamines (13.0%), amphetamine (10.0%), then antidepressants and cough suppressants (5.0%). In control group, tramadol was also the most common drugs abuse (35.0%) followed by cough suppressants (30.0%), cannabis (25.0%), anti-psychotic drugs, benzodiazepines and drugs- co-administration (20.0% for each one), then followed by antihistamines and antidepressants (10.0% for each one). There was a significant difference in tramadol, cannabis, cough suppressants, and drugs-co administration in the study group in comparison to control group.

Conclusion: Tramadol is the most common drug abuse in children in Toxicology Unit in Damietta Governorate, followed by both cannabis and drugs- co-administration, anti-psychotic drugs benzodiazepines, antihistamines, amphetamine, then both antidepressants and cough suppressants respectively.

Keywords: Drug abuse, tramadol, cannabis, amphetamine, antidepressants, coughs suppressants.

INTRODUCTION

    Substance abuse is a common problem in families involved with the child welfare system. (Ragab et al., 2014).

     Substance of abuse in the adolescent population carries a higher risk for school underachievement, delinquency, teenage pregnancy, and depression (Heyman et al., 2015). 

    The younger a child initiates alcohol and other drug use, the higher is the risk for serious health consequences and adult substance abuse (Berman et al., 2014).

    Fatalities, accidental and intentional, that are associated with alcohol and other drug use, in the adolescent population represent one of the leading preventable causes of death for the 15- to 24-year-old population (Spadari et al.,  2009).

   Clinical signs of amphetamines toxicity especially in pediatric population include hyperthermia, tachycardia, tachypnea, mydriasis, tremors, and seizures. In addition, amphetamine intoxication has been reported to cause hyperthermia, hypoglycemia and mild thrombocytopenia (Berman et al., 2014).

     Regarding cannabis intoxication, the main psychoactive metabolite is delta-9-tetrahydrocannabinol (THC) (Schwartz, 2012).

    In parallel to this high prevalence of cannabis consumption, there has been an increase in the number of cases of accidental poisoning by this substance in the pediatric population (Spadari et al., 2009).

      Tramadol poisoning can occur at any time from birth to terminal care. The outcome can range from discomfort, such as constipation, to death from respiratory depression (Ragab et al., 2014).

    Inadvertent passive drug exposure in infants   and toddlers has resulted in multiple medical complications including respiratory illnesses, seizures, altered mental status, and death (Aligne and Stoddard 2007; Bateman and Heagarty, 2009 and Chaney et al., 2011).    

     Illicit drug use is associated with an increased risk of contracting human immunodeficiency virus (HIV). The sharp rise in pediatric HIV infection from 1985 to 1990 paralleled the occurrence of the crack cocaine epidemic. In 1990, 68% of perinatally acquired HIV infection was attributable to intravenous drug abuse in one or both of the child's parents (Stall et al., 2010).

    Even without a history of intravenous drug use, an alcohol- and drug-abusing lifestyle places the abuser, partners, and unborn children at risk for HIV infection due to impaired judgment, reduction of inhibitions and sex-for-drugs (Fergusson and Lynskey, 2011).

     The present work targeted to evaluate the prevalence of drug abuse in children in the Toxicology Unit in Damietta Governorate From the 1st of May 2015 to 1st of  January 2017.

PATIENTS AND METHODS

     A total number of 100 children; suspected for substances abuse toxicity was detected to estimate the prevalence of drug of abuse in children in Toxicology Unit, Al-Azhar University Hospital (New Damietta) from the 1st of May 2015 to 1st of  January 2017 in addition to 20 healthy volunteers as a control group.

All the studied subjects were submitted to the following:

I. Full medical history to all the participants regarding age, sex, smoking, behaviors (such as stealing, aggression, and substance abuse used during the previous month), and difficult temperament such as moodiness, poor compliance, and provocativeness (Smith et al., 2009).

II. Laboratory investigation:Within one hour after arrival to emergency room, blood samples were drawn in sodium fluoride (NaF) contained tubes. Then, it was kept at 4-8 ^oC for subsequent test, using radioimmunoassay strips as a preliminary test, and a high performance liquid chromatography (HPLC) as a confirmatory test. The status of electrolytes, hemoglobin level (Hb), renal function tests, i.e. blood urea nitrogen and serum creatinine concentration, liver function tests, i.e. serum alanine transaminase  “ALT” and aspartate transaminase  “AST” levels, and alkaline phosphatase level were evaluated at the same time of screening the substance abuse (Fidler et al., 2015).

III. Clinical examination with special attention to neurological symptoms and Glasgow Coma Scale (Hogstedt et al., 2011).

STATISTICAL ANALYSIS:

     The collected data was organized, tabulated and statistically analyzed using SPSS 13.0 software. For quantitative data, all the values were expressed as mean± standard deviation. For comparison between the two groups, the students (t) test was used. For qualitative data, number and percent distribution were calculated and chi square test was used for comparison between two groups. The value of P< 0.05 is considered to denote significance.

RESULTS

     The studied groups were matched as regard mean age ±SD being 10±5 in study group, and 9±2 in control group. There was no statistically significant difference in age between different groups.

    In the study group, 70% were males, and 30 % were females, and in control group, 50% were males and the other 50% were females. There was no statistically significant difference in sex distribution between the studied and control groups.

    The prevalence of smokers was 80.0% in study group and 45.0% in control group. There was a significant difference between the studied groups.

       Behavioral changes in the study group; stealing was 40.0%, aggression was 50.0%, and previous exposure to substance of abuse was 90.0%. In control groups, stealing was 5.0%, aggression was 25.0% and previous exposure to substance of abuse was 5.0%. There was a significant difference between the studied and control groups.

       As regards difficult temperament in the study group, moodiness was 35.0%, poor compliance was 70.0%, and provocativeness was 95.0%. In control groups, moodiness was 5.0%, poor com-pliance was 10.0%, and provocativeness was 55.0%. There was no statistically significant difference between the studied and control groups (Table 1).

    For neurotoxic symptoms in the studied groups, tiredness was 30.0%, dizziness was 60.0%, troubles in concentration was 80.0%, confusion was 65.0%, troubles in remembering was 70.0%, relatives notice trouble remembering was 70.0%, have to make notes was 50.0%, difficulty on understanding meaning was 70.0%, irritability was 30.0%, palpitations was 39.0%, troubles in sleep was 80.0%, headache was 40.0% and  nausea was 60.0%. In control group, tiredness was 5.0%, dizziness was 10.0%, trouble in remembering was 15.0%, relatives notice trouble remembering was 15.0%, have to make notes was 15.0%, troubles in sleep was 5.0%, headache was 5.0%, nausea was 10.0%.

     There was a statistically significant difference between both groups (Table 2). ­­­

    As regards the neurotoxic symptoms in the studied groups, depression was 30.0%,  incoordination was 30.0%, decreased leg strength was 5.0%, decreased arm strength was 3.0%, numbness of  fingers was 4.0%, numbness in toes was 6.0%,  sweating was 30.0%, rash was 20.0%,  dryness of skin was 20.0%, and regularity in school was 60.0%. In control group; depression was 15.0%, rash was 5.0%, dryness of skin was 10.0%, sweat was 5.0%, and regularity in school was 45.0%. There was no statistically significant difference between both groups (Table 2).

     There was a highly significant difference between the studied groups as regarding GCS (P=0.02) (Table 2).

     There was no statistically significant difference between the study and control groups as regards positive results of routine laboratory investigation in disturbed serum electrolyte either (increased or decreased), hemoglobin (Hb) level and elevated renal function tests, while its was statistically significant between both groups as regards liver function tests and elevated serum alkaline phosphatase level (Table 3).

     Also, There was no statistically significant difference between the study and control groups as regards comparison of routine laboratory data in study group versus control group in serum potassium, hemoglobin (Hb) level and renal function tests, while its was statistically significant between both groups as regards serum (sodium, chloride and biocarbonate), liver function tests and serum alkaline phosphatase level (Table 4).

    As regards positive results of drug abuse in the study group, tramadol was the most common (90.0%), followed by both cannabis and drugs- co-administration (50.0%), anti-psychotic drugs (30.0%), benzodiazepines (26.0%), antihistamines (13.0%), amphetamine (10.0%), then both antidepressants and cough suppressants were (5.0%). In control group, tramadol was also the most common drug abuse (35.0%) followed by cough suppressants (30.0%), cannabis (25.0%), anti-psychotic drugs, benzodiazepines and drugs- co-administration (20.0% for each one), then antihistamines and antidepressants (10.0% for each one).

      There was a highly significant difference in tramadol, cannabis, cough suppressants, and drugs-co administration in the studied groups, while anti-psychotic drugs, benzodiazepines, amphetamine, antihistamines and antidepressants were statistically insignificant as a compared with control group (Table 5).

Table (1): Comparison between cases and controls as regards demographic data.

Table (2): Comparison between cases and controls as regards neurotoxic symptom.

16 cases from 100 children in the study did not respond to this question.   

Table (3): Comparison of positive results of routine laboratory data between different groups.

Table (4): Comparison of routine laboratory data in study group versus control group.

Table (5): The results of laboratory data (regarding drug abuse).

DISCUSSION

    Substance of abuse intoxication in children is a rare form of acute poisoning. Increasing number of cases have been reported (Ragab et al., 2014).

     The mean age in years was 10.0±5 in study group and (9.0±2) in control group. These finds signified an alarming trend in the prevalence of drug use in such age. Similar result was obtained by Abd EL-Gawad (2014) and Harolyn et al. (2016) who reported that risk factors for the development of an externalized disorder are found in the preschool years. 

     Sex incidences were males 70%, and 30% females in study group, while 50% were males, and 50% were females in control group. The majority of male cases was due to that males were more likely to report the use of psychoactive substance and still be accepted in the society (Robinson et al., 2011).  On the other hand, the intense stigma linked to dependent women is attributed to the society view of drug dependence in women as one of moral and sexual degradation, i.e. the behavior that is tolerated in men is considered scandalous for women (Blume, 2010). Male dominance in drug dependence was also recorded by Amin and Ahmad (2010).

    Smoking was demonstrated in 80.0% of study group, and 45.0% of control group. There was an extremely significant difference in smoking of all study and control groups.  This observation was recorded by Andersson (2009). 

       There was a significant difference between the studied and control groups as regarding behavioral changes. These results were in agreement with Harolyn et al. (2016) who reported that the disorders may initially present with relatively mild behavior problems and progress to severe symptoms such as stealing, aggression, and substance abuse.

    There were no significant difference between the studied and control groups in difficult temperament. These results did not in agree with McMahon (2010) who reported that thetemperament difficulties may exacerbate childhood troublesome behaviors and result in an insecure attachment with the child's primary caregiver.

     There was a significant difference between the studied and control groups as comparison some of neurotoxic symptom in tiredness, dizziness, trouble in concentration, confusion, trouble remembering, relatives notice trouble remembering, have to make notes, difficulty understanding meaning, irritability, palpitations, troubles in  sleep, headache and nausea. Statistically insignificantly differences was found between the study and control groups as regarding depression, incoordination, decreased leg strength, decreased arm strength, numbness in fingers, numbness in toes, sweating, rash, dryness of skin and regularity in school. These results were not in accordance with Anne et al. (2012) who reported that few significant positive associations were found between exposure and the neurobehavioral tests, and each exposure measure was related to a variety of individual symptoms including dizziness, nausea, fatigue and problems associated with arm strength. There was a highly significant difference between the studied and control groups as regards GCS.  These results were in agreement with Tokdemir et al. (2009) who reported that the majority of included cases in their study were mild according to Glasgow Coma Scale. 

     There was no statistically significant difference between the study and control groups as regards positive results of routine laboratory investigation in disturbed serum electrolyte either (increased or decreased), hemoglobin (Hb) level and elevated renal function tests, while its was statistically significant between both groups as regards liver function tests and elevated serum alkaline phosphatase level. These results were reported by Hepler et al. (2010) who reported that the toxicology laboratory plays an important role in ensuring optimum and effective patient care and follow up, and still minimal role in diagnosis.

     There was a highly significant difference in tramadol, cannabis, cough suppressants, and drugs-co administration between the studied and control groups. Anti-psychotic drugs, benzodiazepines, amphetamine, antihistamines and anti-depressants were statistically insignificant as a compared with control group. Woratanarat et al. (2009) reported that amphetamine was found in 16% in cases and 2% in controls resulting in 8.9 times increased crash risk. These results are less than those reported in the present study, and this may be attributed to the different pattern of the drug abuse between both countries, and it may be attributed to the small sample size included in the present study. 

    The cannabis metabolites were found in the study group double the control group. This was in contrary to Woratanarat et al. (2009) who reported that the cannabis was found in the control group more than cases. This may be attributed to the different inclusion criteria.

    Benzodiazepine increased in the study group than the control group. This was in agreement with Engeland et al. (2010) and Movig et al. (2015) who reported that the benzodiazepine increases the crash risk up to 100 times.

    Antihistaminic was detected in 13.0% in study group, and 10.0% in the control group. These results were in agreement with Woratanarat et al. (2009) who reported that antihistamines is found in 2-4% of the studied subjects. This could be due to intermittent use, short duration of use, avoidance prior to driving, or use in a low dosage.

     The prevalence of drugs co-administra-tion were 50.0% in study group, and 20.0% in control group. These results were in agreement with Carmen del Rio and Alvarez (2010) and Movig et al. (2015). Multiple drug dependence continued to be markedly observed in clinical practice and documented in research studied, and the majority of cases were dependent on more than one drug either simultaneously within the same week or concurrently within the last year De Wet et al. (2014).

CONCLUSION

     The most common drugs abuse in children in Toxicology Unit in Damietta governorate were tramadol followed by both cannabis and drugs- co-administra-tion, anti-psychotic drugs benzodiaze-pines, antihistamines, amphetamine, then both antidepressants and cough suppressants respectively.

RECOMMENDATION

    Poisoning by this various substances of abuse is, in itself, an alarm signal on the attitude of parents in caring for their children, and  these families deserve special monitoring by social services for early discovered,  diagnosed and  treat  the abused child to decreased or prevent deleterious effects on healthy of child. Pediatricians must have to detect drug abused-related problems in their patients and their patients' family members and are knowledgeable about the extent of drug abused and availability of drug treatment resources (especially those for  tramadol, cannabis,  amphetamine, cough suppres-sants and  drugs- co administration) in their community.

REFERENCES

1. Abd EL-Gawad, L. (2014): “Drug abuse among youth in sequestrated areas”. A study in Sharabia. The National Review of Criminal Sciences., 45: 116-118.

2. Aligne, C.A. and Stoddard.  J.J. (2007): Tobacco and children. Arch Pediatr Adolesc Med., 154: 648-653.

3. Amin, S.A. and Ahmed, A.M. (2010): Evaluation of pattern of abused medicinal drug in Menoufiya governorate with special emphasis on the sensitivity of screening and confirmatory tests used in detection.  MD thesis (Clin. Toxicology), Faculty of Medicine, Menoufiya University.

4. Andersson, K. (2009):  Effects of cigarette smoking on learning and retention. Psychopharmacologia (Berlin)., 41:1-5.

5. Anne, T., Fidler, E. L. and Baker, R.E. (2012): Neuro-behavioural effects of occupa-tional exposure to organic solvents among construction painters hazard evaluation and technical assistance branch. British Journal of Industrial Medicine., 44:292-308.

6. Bateman, D.A. and Heagarty, M.C. (2009):   Passive freebase cocaine ("crack") inhalation by infants and toddlers. AJDC, 143: 25-27.

7. Berman, S.M., Kaczynski, R.W., McCracken, J.T. and London, E.D. (2014): Potential adverse effects of amphetamine treatment on brain and behavior: a review. Mol Psychiatry, 14: 123-142.

8. Blume, S.B. (2010): Sexuality and stigma: The alcoholic women. Alcohol and Research World., 15: 139-146. 

9. Carmen del Rio, M. and Alvarez, F.J. (2010): Presence of illegal drugs in drivers involved in fatal road traffic accidents in Spain, Drug Alcohol Depend., 57: 177–182.

10. Chaney, N.E. Frank,  J.W. and Adlington,  W.B. (2011): Cocaine convulsions in a breast-fed baby. J Pediatr., 112; 134-135.

11. De Wet, C., Reed, L., Glasper, A., Moran, P. and Grssop, M. (2014): Benzodiazepine co-dependence exacerbates the tramadol withdrawal syndrome. Drug Alcohol Depend., 5: 3-5. 

12. Engeland, A., Skurtveit, S. and Morland, J. (2010): Risk of road traffic accidents associated with the prescription of drugs. a registry-based cohort study. Ann. Epidemiol., 17: 597– 602.

13. Fantegrossi, W.E., Godlewski, T., Karabenick, R.L., Stephens, J.M. and Ullrich, T. (2011): Pharmacological charac-terization of the effects of 3,4- methyl-enedioxy- methamphetamine ("ecstasy") and its enantiomers on lethality, core temperature, and locomotor activity in singly housed and crowded mice. Psychopharmacology (Berl)., 166: 202-211.

14. Fergusson, D.M. and Lynskey, M.T.  (2011):  Alcohol misuse and adolescent sexual behaviors and risk taking. Pediatrics., 98: 91- 96.

15. Fidler, A.T., Baker. E.L. and Letz, R.E. (2015): Estimation of long-term exposure to substance of abuse from questionnaire data: a tool for epidemiologic investigations. Br J Ind Med., 44:133-41.

16. Harolyn, M.E., Belcher, M.D., Harold, E. and Shinitzky, D. (2016): Substance Abuse in Children Prediction, Protection and Prevention Arch Pediatr Adolesc Med., 152: (10):952-960.

17. Hepler, B., Sutheimer, C. and Sunshine, I. (2010): Diagnosis, assessment and treatment of externalizing problems in children: the role of longitudinal data. J Consult Clin Psychol., 33 (2): 245-260.

18. Heyman, R.B., Anglin, T.M., Copperman, S.M., Joffe, A. and McDonald, C.A. (2015): American Academy of Pediatrics. Committee on Substance Abuse. Marijuana: A continuing concern for pediatricians. Pediatrics., 104: 982-985.

19. Hogstedt, C., Hane, M. and Axelson, O. (2011): Diagnostic and health care aspects of workers exposed to substance of abuse. In: Zenz C, ed. Developments in occupational medicine. Chicago: Year Book Medical Publishers., PP. 249-258.

20. McMahon,  R.L. (2010):  Diagnosis, assessment and treatment of externalizing problems in children: the role of longitudinal data. J Consult Clin Psychol., 62: 901- 917.

21. Movig, K.L., Mathijssen., M.P.,Nagel, P.H., Van Egmond, T., De Gier, J.J., Leufkens, H.G. and Egberts, AC. (2015): Psychoactive substance use and the risk of motor vehicle accidents. Accid. Anal. Prev., 36: 631–636.

22. Ragab, A.R., Al-Mazroua, M.K. and Mahmoud, N.F. (2014): Accidental Substance Abuse Poisoning In Children: Experience of the Dammam Poison Control Center. J Clin Toxicol., 4: 204-205.

23. Robinson, G.M., Sellers, E.M. and Janecek, E. (2011): Barbiturate and hypno-sedative withdrawal by a multiple oral phenobarbital loading dose technique. Clinical Pharmacology Therapeutic., 30:71-72.

24. Schwartz, R.H. (2012): Marijuana: a decade and a half later, still a crudedrug with underappreciated toxicity. Pediatrics., 109: 284-289.

25. Smith, D.R., Ilustre, R.P. and Osterloh, J.D. (2009): Methodological considerations for the accurate determination of lead in human plasma and serum Am J Ind Med., 33(5):430-438.

26. Spadari, M., Glaizal, M., Tichadou, L., Blanc, I. and Drouet G. (2009): Accidental cannabis poisoning in children: experience of the Marseille poison center]. Presse Med., 38: 1563-1567.

27. Stall, R.M., Kusick, L and Wiley, J.  (2010): Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: the AIDS Behavioral Research Project. Health Educ Q., 13; 359- 371.

28. Tokdemir, M., Kafadar, H., Deveci, S.E. and  Cemil, C. (2009): Comparison of the severity of traumatic brain injuries in pedestrians and occupants of motor vehicles admitted to the rat health center: A five-year series in an Eastern Turkish city. Med. Sci. Monit., 15: I1-14.

29. Woratanarat, P., Ingsathit, A. and Suriyawongpaisal, P. (2009): Alcohol, illicit and non-illicit psychoactive drug use and road traffic injury in Thailand: A case-control study. Accident, Analysis and Prevention., 41: 651-665.