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Indian Journal of Forensic Medicine & Toxicology

Substance abuse and its medico-legal implications: An overview

Author(s): Harish D, Sharma BR, Chavali KH

Vol. 2, No. 2 (2008-07 - 2008-12)

Harish D٭, Sharma BR٭٭, Chavali KH٭٭٭

٭Reader, ٭٭Professor, ٭٭٭Senior lecturer, Department of Forensic Medicine, Govt. Medical College, Chandigarh

Abstract

Drug abuse has, of late, spread round the globe like a pandemic. ‘Drugs’ have become “the in thing” and using drugs, a “fashion statement.” They are mostly experimented with, initially – out of curiosity / peer pressure/ to be “with the crowd.” However, these occasional users get entangled in the web of drug abuse, without any way out of its strangle hold. This scourge not only ruins the addict physically and mentally, but also his family and friends – physiologically, socially and financially; as well as, the society at large. Tolerance to the various drugs of abuse in turn leads to either increased dose or the use of multiple drugs – poly drug abuse. This paper outlines, the epidemiology of drug abuse, the factors affecting it, the main points of treatment, and the medico-legal issues arising out of such abuse, with respect to civil and criminal matters.

Key words: Drugs, Drug abuse, Substance abuse, Drug dependence, Medico legal implications

Introduction

The World Health Organization (WHO)1 defines ‘drugs’ as any substances, other than those required for the maintenance of normal health, that when taken in to the living organism, may modify one or more of its functions. The Drugs and Cosmetics Act2 defines drugs as all medicines for internal or external use of human beings or animals and all substances intended to be used for/or in the diagnosis, treatment, mitigation or prevention of any disease or disorder in human beings or animals. Hence, drugs by definition are substances having physiological and psychological effects on human beings and other higher animals. However, these drugs are often misused for their non-therapeutic properties – to cause a change in mood, get away from the real world, and many a times, even to end one’s life.

Moreover, the discovery of certain psychedelic (drugs producing hallucinations) drugs has shaken the very root of social structure, at all levels. These drugs are often misused to get relief from tension, to pass ‘undisturbed peaceful’ time, to be out of touch from practical aspects of personal, familial and social problems and to be in an imaginary state of mental happiness and well-being by being carefree from the influence of the environmental odds. Some of the drugs act as stimulants which give a sense of well-being, hilarity, expansiveness, while the others are depressant in nature which sedate a person. But, finally all these reduce the users to non-productive creatures whose only purpose remains limited to procuring the next dose.

According to the WHO,1 ‘substance abuse’ is a state, psychic and, sometimes also physical, resulting from the interaction between a living organism and a drug, characterized by behavioral and other responses that always include a compulsion to take the drug on a continuous or a periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present.

Substance/ Drug abuse involves the use of a substance despite persistent social, interpersonal or other problems caused by the use of the substance. Substance/ drug dependence is a more severe disorder, which entails signs of physical or psychological tolerance or dependence3. Drug abuse and dependence cause major deleterious psychological and social problems, including family dysfunction, domestic and criminal violence, child abuse, etc4. The essential characteristic of substance abuse is a maladaptive pattern of use resulting in harm caused by repeated use. Substance dependence also involves a harmful maladaptive pattern of substance abuse, which may or may not include physical dependence, but it is the compulsive use and the loss of control over the use of the substance that is at the heart of the concept5.

Generally speaking, “dependence” includes both the terms—addiction and habituation; while “abuse” implies improper or excessive use of therapeutic drugs or the use of non-medically useful or illegal drugs, even in moderate amounts and in the absence of addiction1. The World Health Organization Expert Committee on Addiction Producing Drugs coined a new term “drug dependence” to cover both psychological dependence as well as physiological dependence. However, the older terminology, especially ‘drug addiction’ is still in use and is virtually used to label a person as drug addict6.

Addict, as per the Narcotics Drugs and Psychotropic Substances Act:7 —is a person who has dependence on any narcotic drug or psychotropic substance.

Types of abused drugs

  1. Those causing psychological dependence: Such drugs, if discontinued, do not affect the physiological activities of a person. The user only apprehends or experiences mental distress in the absence of the drug (habit formation). Tobacco, cannabis, LSD, cocaine, etc. are in this group.
  2. Those causing physiological dependence along with psychological dependence (addiction): A person used to any of these drugs will not have the normal physiological functioning capacity of his body in absence of the drug. Morphine and other opiates like heroin and pethidine, barbiturates, alcohol, diazepam, chlordiazepoxide and methaquilone are in this group.

The commonly abused drugs are

Stimulants: Amphétamine derivatives, Cocaine, Phencyclidine (Angel dust), Methylphenidate, Phenmetrazine, etc.
Hallucinogens: Cannabis preparations, Lysergic Acid Diethylamide (LSD), and ergot derivatives, Solvents, Mescaline, Ecstasy, etc.
Narcotics: Morphine, Heroin/Dope/Junk/Smack, Codeine, Pethidine, Methadone, etc.
Hypnotics: Barbiturates, Benzodiazepines, etc. Factors responsible for drug dependence
Personal factors: These are physical and mental illness, user’s personality, tolerance, threshold to different odds of life, e.g., failure in achievements, love affairs, stressful events, sense of responsibility to himself, his family and the society, his emotional trends, habits, liking-ness, mental makeup, compulsive psycho educational status, working engagements, etc.
Social and environmental factors: These include family status, family environment, happenings in the family, family liability, attachment with the family, social and mental status of his friends and associates, environment in school/college, hostel, his capacity to meet social bindings and obligations, residential and working environment, etc.
Drug factors: These determine whether the person develops only habituation or addiction.

Factors leading to drug dependence

  1. Therapeutic use of some drugs like morphine, pethidine, may lead to addiction.
  2. When used for recreational purposes too frequently, the user may find difficulty in leaving the drugs.
  3. From repeated use to get relief from physical and mental exhaustion.
  4. When frequently used with the desire to be freed from mental worries or distress.
  5. Social structure and culture and the influence of one’s social environment.
  6. Conditions prevailing among the co-workers.
  7. Economic factors.
  8. Family structure, cohesion, environment, relationship, culture and status.
  9. Influence of friends (peer pressure).
  10. Environment in school, college or hostel, etc.
  11. Sources and availability of the agents of addiction.
  12. Knowledge about the immediate action of the drug and the cost of the drug.

Some salient features

  • Usually addicts are self-absorbed, non-interfering, noncommittal, and somewhat passive, remaining conscious only of the need to procure the drug by any means.
  • Drug abuse should be suspected in young and adolescents, if there is history of school absenteeism, falling performance in the class, temper tantrums, puffiness of face, slurring of speech, decreasing interest in day to day school and extra-curricular activities, etc.
  • Drugs, which cause psychological dependence, can be discontinued with relative ease as compared to drugs which cause physical dependence. However, some of such drugs, which cause psychological dependence like LSD, are so strong in their action that, they are often equated with drugs which cause physical dependence. Withdrawal of these drugs may seem difficult, though they do not cause physical dependence. But dependence with heroin is very strong and occurs very easily whereas that with diazepam is not so and does not also occur so easily.
  • It is very difficult to recognize when the drug habituation upgrades into drug addiction.

Prevalence

The United States has been called the most drug-abusing industrialized nation in the world, but illegal drugs are a growing problem in other industrialized countries as well. Drug abuse is a major problem for young adults between the ages of 18 and 25 in the United States, with 15 percent of this age group using illegal drugs at least monthly. Of the adolescents aged 12 to 17 years, one out of 14 uses illegal drugs at least monthly, 4 percent regularly use marijuana and 1.5 percent have tried cocaine within the past year8. The incidence of smoking has increased tremendously over the years, throughout the world. In the US alone, tobacco use causes more than 400,000 deaths, annually9. It is more common in poly-drug abusers, the less educated and those with mental illness10.

Similarly, alcohol consumption has become increasingly common in the general population11. In Slovenia, alcohol consumption has increased by 24% per capita in the last decade12. Half of all traffic deaths are linked to alcohol and drug abuse. Two out of three murders, half of all fire fatalities, and eight of 10 suicides involve drugs and alcohol. More than 70 percent of individuals arrested in the 20 largest US cities had been using illegal drugs13.

Inhalants and volatile substances are one of the most commonly abused substances by the adolescents,14 and it is also becoming a major public health problem in India15. Marijuana is the most widely used illicit drug throughout the world16. Many people using marijuana are poly-drug abusers, particularly of alcohol and cigarettes. The exact incidence in India is not known but it is the most commonly used in hilly regions of the Northern part of the country17. The most commonly abused drugs, apart from alcohol and tobacco, in India, appear to be cannabis, opiates, and sedatives and tranquillizers. Indications of significant abuse of cocaine and hallucinogens among the upper echelons of the society are also in abundance18.

Effects of drug abuse

Drug abuse is a major medical problem with extensive legal, social, moral, ethical and even political conations. It is fraught with many ill-effects involving the individual concerned, his family, friends, and the society at large. Many medico-legal and legal implications, both civil and criminal, are also involved. The country stands to lose numerous productive man-hours, besides incurring huge expenses in treating and caring for these individuals.

It impairs alertness and achievement by distorting sensory perception, interfering with memory, and causing a loss of self-control. Many abused drugs can cause long lasting physical and psychological problems. Marijuana smoke, which contains more cancer-causing agents than tobacco smoke, damages the lungs and pulmonary system. When smoked by pregnant women, marijuana also can create genetic problems leading to birth defects.

The liver damage, neurological problems and other dangers of alcohol abuse are well known. Cocaine not only affects the emotions, but also disrupts the brain’s control of heartbeat and breathing and causes high blood pressure. Single or multiple uses have resulted in fatal seizures. PCP (phencyclidine) can produce convulsions, coma and severe psychological disorders. Using PCP also can lead to heart and lung failure or ruptured blood vessels in the brain, any of which may be fatal.

Drugs can destroy an individual’s ability to think and act responsibly and to perform well at school, at work or at home. The continued drug abuse can destroy family relationships, friendships, outside interests, values and goals. Many substances cause physical and psychological dependence.

Regular drug abusers find they need to take larger doses to get the same effect. PCP, heroin and other drugs can alter the body’s chemistry. When the user stops taking the drug, the body rebels with unpleasant and often painful symptoms of withdrawal. There is no such thing as safe and responsible use of an illegal drug or harmless misuse of alcohol or prescription medications. Abusing drugs can lead to lifelong consequences such as loss of memory, high blood pressure, mental illness, heart failure, stroke, lung damage and coma, and may often lead to death of the user.

Identification and treatment

Signs of possible drug use include excessive absenteeism or tardiness, unusual irritability, sharply limited attention span, sleeping on the job, deterioration of work quality, unpredictable and unsafe behavior and mood swings. However, some of these behavior characteristics can be caused by other factors as well.

Substance abuse is a diagnosable and treatable illness, but helping affected individuals can be both complicated and delicate. Not all drug-dependent individuals will seek help on their own. In fact, many drug and alcohol abusers do not realize they have a problem with chemical dependency and cannot stop their self-destructive behavior. Drug-abusing individuals can be helped if they can be provided with intervention, education, counseling, a treatment program and other assistance. Such programs represent an important step toward preventing and alleviating the problems drug and alcohol abuse can create.

Appropriate treatment only should be provided and consideration given to the future management of any clinical problems, including those arising in relation to the substance abuse: harm reduction, brief intervention and appropriate onward referral19.

Active Treatment

Active treatment essentially involves the following principles:

  1. Treatment for ill-health resulting from chronic use of a drug.
  2. Antidote for prevention of re-use of the drug (deaddiction).
  3. Stoppage of supply of drugs of addiction.
  4. Treatment of withdrawal symptoms.
  5. Constant surveillance (a) to assure non-use of the drug, (b) to pay attention towards possible dangerous withdrawal symptoms, (c) to prevent doing any harm to himself and (d) to ensure prevention of escape.
  6. Proper nursing care
  7. Maintenance of adequate food, vitamins, electrolytes, etc.
  8. Giving proper education (mostly psychological and supportive)
  9. Helping to develop his personality and self-respect.

Follow-up of the patients discharged from de-addiction centers is of utmost significance to prevent recurrence. The psychologist can play a key role for in-depth study of the addict and in successfully imparting educational therapy for future rehabilitation and development of personality and subsequent adjustment in the society, family, place of work, etc. For successful drive against drug abuse, though mass education is an effective step, but there must be some legislation of suitable acts and their implementation. There should be effort to identify the abusers and potential abusers, the factors influencing the abuse and effective methods to stop drug trafficking/peddling.

Adequate number of laboratories for drug testing and treatment centers for the drug dependents is the need of the hour. For meaningful rehabilitation programs for the deaddicted persons, the NGOs should come forward.

Any substance has the potential for misuse and new substances are constantly coming to the illicit market. It is therefore important to be aware of the drug trends of the area and update ourselves regarding the newer treatment regimens.

Medico-legal implications

Courts have yet been unable to decide whether drug dependence is a disease of the mind or not. Recent judgments in the US have shown that this debate is still alive in the various courts and the legal circles3. However, they are also adapting themselves in tune with the changes in the society through enactment and implementation of various laws, passing judgments, etc.

The Narcotic Drugs and Psychotropic Substances Act7 is an important step in this direction. It was passed to consolidate and amend the laws relating to narcotic drugs, to make stringent provisions for the control and regulation of operations relating to narcotic drugs and psychotropic substances. The major strengths of this Act are that “No sentence awarded under the Act shall be suspended, remitted, or commuted; Death penalty is awarded for the second conviction; All offences are cognizable and non-bailable; Most of the offences under the Act invite uniform punishment of a minimum of 10 years rigorous imprisonment, which may extend up to 20 years.” The Act also envisages severe punishment for traffickers, but reformative approach for addicts.

Civil matters

The (dependent) person’s competency to take decisions or understand and manage financial matters, etc may become impaired. He may not be able to give a legally valid consent in the stage of intoxication/ withdrawal; or when his mental faculties have been affected by the chronic and constant use of the substance of abuse. The validity of the contracts entered in to and the will(s) made by such a person may be open to question. In fact, everything with any social/ legal or financial implications that is taken up by an addict, may invite censure, depending upon the extent to which his cognitive/ affective or volitional faculties have been affected.

The treating physician has an added responsibility towards these individuals. Failure to accurately assess and diagnose the substance of abuse and the extent of abuse may lead to inappropriate prescription or monitoring of various medications; which may lead to the deterioration of the addict’s condition and even death. Malpractice litigations may also arise due to the degree of confidentiality that has to be maintained in cases of referrals, third-party consultations, and giving information to the authorities, etc.

Criminal matters

From the medico legal stand point, there is perhaps no other chemical compound more frequently encountered as a contributing or causative factor in violent or natural deaths, than alcohol. It is also involved in many non-fatal incidents that ultimately come under the scrutiny of the law enforcement agencies20. It figures prominently in adolescent fatalities arising from motor vehicle collisions.21

The ability of a person to drive a vehicle is greatly affected by alcohol as it causes a drop in the reaction time, impairs concentration, dulls judgment, reduces visual acuity and peripheral vision and gives rise to a feeling of over-confidence. The legally permissible limit of blood alcohol concentration in India is 30mg%.22 The statutory limits in some other countries are: 20mg% in Poland and Sweden; 50 mg% in Finland, Norway and Netherlands; 80 mg% in Denmark, Germany, UK, France and Switzerland; 100 mg% in Ireland and 80-150 mg% in the different states of the USA23. Smoking in public places and while driving has also been made punishable in India.

Substance abuse and dependence have been known to be responsible for or their presence established in an appreciable percentage of crimes. Many such crimes are committed with the sole purpose of getting the requisite money to procure the future doses of the substance(s). Differences between the peddler and the addict over the purity of the drug/ cost of the dose/ credit limits, etc have led to death of either party in a number of instances.

‘Battered Baby Syndrome’ is common in the children of the addict mothers, usually prostitutes. Such children are poorly nourished and will show multiple injuries of various durations along with fractures. The incidence of intra-uterine death is also high in this population24.

Section 85, IPC25 absolves a man from an offence committed by him in such a state of intoxication as to render him incapable of judging the nature of the act or that he is doing what was either wrong or contrary to the law, provided that the thing which intoxicated him was administered to him without his knowledge or against his will.

Voluntary drunkenness is no excuse for the commission of a crime26. However, it becomes relevant in at least two situations: i) Where a specific intent is an essential element of an offence charged and the state of intoxication of the accused is such that he is incapable of forming the specific intent essential to constitute the crime, as in clauses 1, 2 and 3 of Section 300 IPC (murder).27 However, even in such cases, where in the accused fails to actually form the specific intent, Section 86 IPC would impute the necessary knowledge to him and he would therefore, be liable for culpable homicide not amounting to murder, though not for murder28. Therefore, voluntary intoxication would only be a limited defense to reduce an offence of murder (S.302 IPC) to one of culpable homicide not amounting to murder (S.304 IPC)29. ii) Where habitual drunkenness has resulted in such a diseased condition of mind that the accused is incapable of knowing the nature of the act or that he is doing what was wrong or contrary to the law. In other words, “Insanity, whether produced by drunkenness or otherwise, is a defense to the crime charged”30.

Conclusion

Drug abuse, nowadays, is assuming the proportions of ‘a wild forest fire’, spreading through all age groups and breaking out cultural, ethnic and socioeconomic barriers. Hence, its prevention has also become a holistic process aimed at promoting health-enhancing behavior and reducing healthcompromising behaviors. Strategies are becoming more comprehensive and inclusive, incorporating the preventive strategies: Information dissemination, prevention education, alternatives, problem identification and referral, communitybased processes, and environmental approaches. Etiological work has been crucial in shaping current prevention efforts. However, governments have an important role, not only in enacting laws and statutes but also in implementing them in letter and spirit while having good and proven welfare programs side by side. In the mean time, the specification of environments at home, at school, or in the community could lend insight to methods or strategies to change those environments.

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Corresponding address:
Dr. Dasari Harish

#1151, Sec. 32-B, Chandigarh
dasariharish (at) gmail.com

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