5/28/2015. Medhat Bassiony Samar Abdelgayed Usama M. Youssef

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1 Medhat Bassiony Samar Abdelgayed Usama M. Youssef The adolescent is biased by functionally mature subcortical relative to less mature cortical circuitry. With development, the functional connectivity between these regions is strengthened and provides a mechanism for top down modulation of the subcortical systems. 1

2 Two key regions implicated in cognitive and motivational behavior are the prefrontal cortex, known to be important for cognitive control (the part of the brain that enables us to assess situations and make sound decisions) and the striatum (critical in detecting and learning about novel and rewarding cues in the environment). Frontostriatal circuits undergo considerable elaboration during adolescence that are particularly dramatic in the dopamine system. Peaks in the density of dopamine receptors, D1 and D2 in the striatum occur early in adolescence, followed by a loss of these receptors by young adulthood. 2

3 In contrast, the prefrontal cortex does not show peaks in D1 and D2 receptor density until late adolescence and young adulthood. Although DA appears to be the primary mechanism of the initiation of drug reinforcement, opioid and serotonin have also been implicated indirectly (Koob, 2008). Tramadol is a centrally acting analgesic with weak opioid agonist properties and serotonin/ norepinephrine reuptake inhibition. The evidence that tramadol can lead to abuse, dependence, seizures and death continues to emerge. Deaths due to tramadol rose from 83 in 2008 to 154 in 2011 in the UK (Mayor S., 2013). 3

4 A 2007 National Survey report stated that 8.5 percent of Egyptians - or six million people - are addicted to drugs, the majority of them are between 15 and 25 years of age and that the addicts are considered as criminals rather than patients in need for treatment (Khoweiled et al., 2012). In Egypt, Soueif et al., (1986) found that 20% of male students have used drugs at some time in their lives and among them, approximately 25% have continued to do so. Girls did not start experimentation with narcotics before the age of 16, whereas boys began such experimentation before reaching 12 years of age (Soueif et al., 1987). 4

5 Tramadol abuse has dramatically increased in the Middle East region, especially in Iran and Egypt. The lifetime prevalence of tramadol misuse among Iranian adolescents was 4.8% (7.6% for males and 1.8% for females). Egypt has one of the highest death rates due to road accidents and tramadol abuse is associated with 18.7% of these accidents. Adolescent substance abuse is a significant public health issue in the world today (Clark et al., 2001; Sekulic and Tocilj, 2006). Tramadol abuse in Egypt has led to many admissions to addiction treatment centers (Abolmaged et al., 2013). Our study is the first one (to our knowledge) to investigate tramadol use among adolescents in Egypt. 5

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7 Our study was carried out in Zagazig center, Sharkia governorate in the year of 2013 (September October). Center Zagazig Administrations West East Schools 2 preparatory 1 secondary 1 preparatory 2 secondary Students 204 students 204 students ( years old) (13-18 old) Data collection and measures Drug Use Disorders Identification Test (DUDIT) Drug Use Disorders Identification Test- Extended (DUDIT-E) Urine screening 7

8 Participants were assessed for substance abuse using The Drug Use Disorders Identification Test (DUDIT) and The Drug Use Disorders Identification Test- Extended (DUDIT-E). The Drug Use Disorders Identification Test (DUDIT, Berman et al., 2005) was developed to facilitate screening for drug use problems. DUDIT serves as a valuable instrument that will identify individuals who appear to have a drug problem or drug dependence. The questionnaire contains 11 items mapping frequency of drug use, harmful consequences of drug use, and symptoms of dependence. 8

9 The maximum score is 44 points. If a male shows a score of 6 or more, or a woman with a score of 2 or more, he/she probably has drug-related problems either substance abuse/harmful use or dependence. If a client shows a score of 25 points or more, it is highly probable that he or she is dependent on one or more drugs. It was developed to elicit detailed information about patients' views of the pros and cons of their drug use. The rationale for focusing on patients perceptions of positive and negative aspects of drug use is that these perceptions are assumed to be critical to patient s motivation to either continue or cease using drugs. 9

10 The DUDIT-E is used after identification of a drug problem by DUDIT. The first section of DUDIT-E is a 17-item investigating the positive incentives for drug use. It is labeled the P (positive) section. The second section explores negative aspects of drug use and is labeled the N section. The final section contains ten items on treatment readiness and is labeled the T section. Separate scores can be calculated for each section of the DUDIT-E. By multiplying the negative (N) and treatment readiness (T) scores and dividing by the positive (P) score, the motivational index is obtained. The assumption behind the motivational index is that a relatively negative view of the consequences of drug use will potentiate treatment readiness whereas a positive view will diminish it. 10

11 The Drug Use Disorders Identification Test-Extended (DUDIT-E) Positive (p) section Negative (N) Section Treatment readiness (T) section 11

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13 Figures(1-2-3) show Demographic characteristics of participants. Gender Education male Female 52% 48% Preparatory Secondary 27.5% 72.5% 55.9% 44.1% Urban Rural Residence Among school students, 8.8% were using tramadol as shown by urine screen. Among those who were using tramadol, 83.3% were using tramadol alone while 16.7% were using more than one drug. Tow-thirds of school students started with tramadol as the first drug after tobacco smoking. 13

14 Figure (4) shows frequency of using tramadol among tramadol abusers 80% 75% 70% 60% 50% 40% 30% 20% 10% 8.30% 16.70% 0% Once / month 2-4 times/ month 4 times / wk Figure (5) shows the mean age of onset of smoking and tramadol abuse. Age of onset of smoking 16.06±1.39 Age of onset of tramadol abuse 16.5±

15 Table (1) shows Relation between tramadole abuse and demographic characteristics of participants. Variable Substance abused (N.=18) Non substance abused (N.=186) χ 2 p value Gender - Male (N.=148) - Female(N.=56) N. % N. % ** Education - Preparatory (N.=98) - Secondary (N.=106) ** Residence - Urban (N.=90) - Rural(N.=114) Age - X±SD - Range 16.5±1.098 (15 18) 15.14±1.59 ( 13 18) t=3.56 <0.0001** Figure (6) shows the prevalence of drug related problems and dependence among tramadol abusers % 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.60% 5.00% 0.00% Drug related problems Dependence 15

16 Figure (7) shows correlation between DUDIT and age of onset of tramadol abuse. Figure (8) shows the most Positive and Negative thoughts for participants about using tramadol 16

17 1) Tramadol use is common in Egyptian adolescents and consequently tramadol should be added to toxicological screening, especially in adolescents and young adults. 2) Public awareness and prevention programs for school students should be initiated to point out the health problems associated with tramadol use. 3) Legislation authority should place more restrictions on tramadol use especially for adolescents. 4) Egypt is the largest country in the region, so the results of this study could benefit other countries in the middle east region. 17

18 1) The study is cross sectional so causality between tramadol use and correlates can not be inferred. 2) All selected schools were public and many students were absent in 9 th and 12 th grades which might lead to selection bias. 3) Small sample size might limit the generalizability of the findings. 1) Tramadol use was common in adolescents. 2) More than one third of tramadol users had drug- related problems which were negatively correlated with age at onset of tramadol use. 3) There was an association between older age, male gender, smoking and tramadol use. 4) Adolescents used tramadol to become happy, but they did not like its negative impact on concentration. 18

19 1) Large population-based longitudinal studies in adolescents are needed to estimate the prevalence, risk factors and consequences of tramadol use in Egypt. 2) The possible role of tramadol as a gateway drug in the development of substance abuse in Egypt should be investigated. YOU 19