Subash Subedi
It should come as no surprise that the vast majority of medical students are prone to substance use and its abuse considering the stress and anxiety they face in medical school.Amongst the array of substance misused, tobacco, alcohol, cannabis, and opioids are the most prevalent. Overall, the prevalence of substance use among Nepalese medical students ranges from 49% to 60% and is escalating year over year. Most of the students start with alcohol or smoking either tobacco or Marijuana and push themselves into the world of addiction.
Triggers
Most of the students joining the medical school are just in their late adolescent years which makes them more vulnerable. During this phase of life, there is constant sensation and reward-seeking behavior as well as an increase in activity and sensitivity of the brain reward system. Thus there is a higher chance of risk-taking behavior one of which is substance use. The cumulative effect of stressful life experiences, academic pressure, sudden loss of parental supervision, curiosity to experiment, and peer pressure over time can lead to a steeper escalation of substance use. These circumstances and multiple negative influences have myriad impacts on human behavior and one of which is thetendency to push ourselves towards substance use to mitigate those problems without much thought of the afterward consequences.
Effect
Health effects are tremendous, to name a few lung cancers due to smoking and liver diseases due to alcohol are just the tip of the iceberg. Substance use and its abuse affect interpersonal relationships and may cause a gradual decline in the social ladder and career graph of an individual.There is so much to lose just for the sake of temporary pleasure.
Drugs over-activate Brain reward circuit with a massive surge of dopamine release producing the euphoria of the mental high “feeling good sensation” which leads to addiction. Once a person is addicted he or she not only developsthe habit, it also leads to the development of a network of strong neuro-associationwithin the nervous system and it strengthens with time. So more the year spent on substance abuse the harder to overcome it. But the good news is that these neuro-associations eventually wane away if the person quits for long enough.
Am I Addicted?
Most of the time we consume multiple substances for recreational purposes and during occasional meetup but we may be completely unaware ofthe addiction. So, how can we know if we are addicted? Addiction is a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. The initial decision to take drugs is typically voluntary. But with continued use, a person's ability to exert self-control can become seriously impaired; this impairment in self-control is the hallmark of addiction.The desire to cut down, tolerance (requiring a higher dose to achieve similar “high”), withdrawal symptoms (symptoms that occur on cessation of repeated use), physical and psychological dependence, seeking and craving for greater pleasure are some of the signs of addiction. There may be subtle changes like unusual impulsive reckless behavior and external consequences likeneglecting responsibilities related to career and relationships.
Marijuana Madness
There are several myths and misconceptions about marijuana that persist among medical students and the potential marijuana abusers. The anecdotal evidence suggests that cannabis use for recreational purposes enhances human creativity but some evidence reported impaired divergent thinking and no impact on creativity. Long-term cannabis use impairs memory and neurocognitive function and also increases the risk of developing earlier onset of psychotic disorders. The possible beneficial effects of using cannabis, if any, might not outweigh the potential risks associated with its abuse.
Some research suggests that Marijuana is a gateway drug for multiple substance abuse as it increases vulnerability for addiction to other substances of misuse later in life. For instance, a three-year prospective study found that adults who reported marijuana use were more likely to develop an alcohol use disorder within 3 years than adults who did not use marijuana. This does not mean that everyone who uses marijuana will enter into the phase of transition and use alcohol or other drugs, but it does mean that there is a greater possibility for marijuana users to consume multiple substances in the near future. Further research is needed to understand the relationship between cannabis use and subsequent increased risk of multiple substance abuse.
Solutions
Personal Effort
The most critical step towards quitting addiction is to develop a Personal Belief System i.e. This habit must be changed and I can change it. Addiction is a full-time commitment and it’s not an easy job so unless the person is not determined to quit no one can help.If someone hasn’t started using any form of substance or is already addicted to some substance,experimentation of new substancesshould be avoided inthe first place. It istremendously challenging to get out of the addiction cycle, so once an individual enters into this loophole,reverting is very difficult. Therefore, we must refrain ourselves from using these substances in the first place.
Individuals are most likely to use different substanceswhen coping with triggers and urge to use either in the presence or absence of cues. So, identification of the triggers (maybe anger, stress, rejection, etc.) and the use of the Urge Surfing Technique to refrain oneself is the most essential part. This technique is very practical which includes 4 “Ds”. Delay- refrainingoneself and delaying the urge to use (for instance smoking) for a few hours. This will help to smoke fewer cigarettes at the end of the day. Drinking plenty of water has a calming effect on cravings for many people. Distractingoneself by doing other things one enjoys doing the most (could be hobbies, music, or playing with a pet, etc.) and Deep breathing techniques to help calm the body and mind reducing the stress thereby eliminating urge and trigger.
Setting up a series of short term goals (quitting for a day or a week) and rewarding oneself immediately after achieving the milestone can also help a lot as it activatesthe brain reward circuit and thus the tendency to frequently use addictive substances will be under check.Constant exposure and addiction memory can lead to relapse to addiction and thus it requires multipleefforts before we actually quit. So we have toself-restrain ourselvesby avoiding parties and events where weare more likelyto consume these substances.
Isn’t there a less harmful way of achieving mental high“feeling good sensation”? There sure is. There are ample of evidences that suggestwe get the feeling of being ‘high’ naturally with the help of Yoga and Meditation which drive us away from the urge to use these substancesby pullingour mind away from thoughts that may distract us, upset us, or cause any anxietyand therefore it helpsa person to reach a state of inner peace and calmness, a much healthier way to feel good!
Early self-realization of addiction and early intervention is one of the best thingsany self-loving person would do for themselves.
Medical School
Medical Schools can play a vital role to reduce this escalating trend of substance use and abuse among medical students. Strict monitoring programs within the hostel and college premises can decrease the incidence of substance use in the first place. Creating a support system like establishing a De-Addiction Unit with dedicated psychological counseling by Psychiatrist, referral mechanism ensuring confidentiality will encourage the addicted student to seek help as there is no health-seeking behavior among medical studentsdue to absence of any dedicated area to get help and the prime reason being thefear of defamation and breach of confidentiality.
Professionals Help
To overcome ambivalence behavior of wanting to quit but beingunable to quit on any form of addiction, professional help is the best idea as it is the most effective and time-efficient way to treat an addiction. In Nepal, Psychiatrists are the most trained professionals and are readily willing to treat an addiction in a systematic professional manner.Working with a professional can help to easily find the areas of difficulty in quitting and applying a proven method to eliminate such obstacles which helps to counterturn the negative situation because this unique treatment plan developeddepending upon the specific problem faced by the person will help navigate the path to recovery. Treatment options from addiction professionals include initial detox, least restrictive treatment like outpatient rehabilitation, cognitive behavioral therapy, motivational interviewing,pharmacotherapy, and withdrawal management.Underlying mood and anxiety disorder are treated as well if present.These can help the individual from being ambivalent about giving up their addiction to being determined to quit.
Lockdown due to COVID-19 pandemic can be a great opportunity for all of us to quit our addiction as there is limited accessibility to addictive substances which already hadled to its reduced consumption and thus there is a great chance to cut it down if one puts some effort into it.
Let’squit on our addiction to create SAFE (Substance Abuse Free Environment), productiveenvironment andmove towards a much better health care system for us and our people.
This article is written inreference to an in-depth discussion with Addiction Psychiatrist Dr. Jagadamba Pandit, Adult Psychiatrist Dr. Sagun Pant, and Child Psychiatrist Dr. Sharad Koirala.
(Subedi is currently a medical student at Chitwan Medical College Teaching Hospital).
