Ministry of Health Vanuatu
July 2019 Mental Health Newsletter
Why do people use substances?
We are not entirely sure, but we do know that mind and mood-altering substances have been used for thousands of years and are present to some degree in every society throughout the world. Some researchers say that it comes from an inbuilt desire to escape the monotony of everyday life. Other substances are used for medicinal purposes, from alleviating pain to relieving fatigue to deliberately altering the way people think and feel about things.
What are the most common substances used in Vanuatu?
The primary substances used in Vanuatu, in order of prevalence, is kava, alcohol, and then cannabis or marijuana. There is less of an issue with other illicit substances in Vanuatu, such as cocaine, heroin, ecstasy and crystal methamphetamine. Let’s have a look at the main two substances in more detail: alcohol and kava.
Throughout history, people have viewed alcohol as a substance that nourishes and gives comfort. According to the Bible, one of the first things Noah did after the great flood was to plant a vineyard (Genesis 9:21). Many myths and religious beliefs reflect the importance of alcohol.
The religious practices of many societies saw alcohol as something to be consumed at special rituals: weddings, births, funerals and other special events. The overall emphasis of most religions and cultures was on temperance or drinking in only moderate amounts and at certain times. Drunkenness was generally condemned.
Alcohol consumption is one of the most significant risks to health. It causes more 3.8% of all deaths worldwide and 4.5% of the burden of injury worldwide from all the non-death related complications that it can also create. Transport-related injuries are closely linked to excessive alcohol use, as is domestic violence and other violent crime.
The ten best ways to tackle alcohol problems worldwide, according to research by the World Health Organisation (WHO), includes:
- Ensuring there is a minimum legal age to buy alcohol
- Having a government monopoly of retail sales of alcohol
- Restrictions on hours or days of sale of alcohol
- Restrictions on the density of alcohol sales outlets
- Taxes on alcohol by volume, not by type of alcoholic drink
- Sobriety checks
- Lowered limits for blood alcohol concentration
- Suspension of licences for driving a vehicle under the influence of alcohol
- Probationary licences for young and new drivers including a zero limit for blood alcohol concentration
- Brief (and potentially mandated) interventions for hazardous drinkers.
Prevention strategies such as education and persuasion, even though they are frequently used to try to tackle the issue, are not as effective at reducing hazardous alcohol consumption! Therefore more needs to be done at a Government level, and new alcohol legislation that incorporates the ten above strategies is currently being drafted in Vanuatu.
No level of alcohol consumption is considered “completely safe”. For women who are pregnant or breastfeeding, not drinking any alcohol is the safest option.
The maximum amount of alcohol recommended on any one occasion to reduce the risk of short-term alcohol related injury is four standard drinks. Short-term risks include accidents, falls, injuries and other risks associated with binge drinking.
The maximum amount of alcohol recommended to avoid long-term health risks is drinking no more than two standard drinks of alcohol each day. Long-term health risks of alcohol include potential brain damage, as well as cancer of the mouth, throat, oesophagus, liver, bowel, breast and prostate.
Kava, also known as Piper Methysticum, is a small shrub native to the islands in the South Pacific. The root and stems are made into a non-alcoholic, psychoactive beverage. It has been used socially and ceremonially for hundreds of years in Hawaii, Fiji, Vanuatu and Tonga.
After drinking a shell or two, a feeling of heightened attention combined with relaxation begins to come on. Although it is soothing, it is unlike alcohol in that thoughts remain clear.
Kava has been marketed since the early 1990s as a herbal remedy for stress and anxiety and insomnia; its popularity has grown ever since. While there is some clinical evidence supporting its use, Kava contains compounds known as kavalactones, which are responsible for its psychoactive qualities. In the brain, they operate on non-opiate pathways to offer a natural and non-narcotic action against anxiety.
According to Duke University Medical Centre, kava is beneficial for anxiety and doesn’t produce dependency or negatively affect heart rate, blood pressure, or sexual function. In a six week study conducted by the University of Melbourne, kava was found to reduce anxiety and was generally well tolerated.
Menopausal women may also find kava to be an excellent option, as it helps their psychological status without affecting estrogen levels – this is especially important when osteoporosis and cardiovascular disease are a concern. In 2003, a clinical study reported that kava encouraged a healthier, pleasant mood among menopausal women.
There are concerns surrounding Kava and liver health
While some suggest it is toxic to the liver, the verdict from scientific research is unclear. One of the primary arguments is that liver damage from kava is unpredictable, dose-independent, and not reproducible. Thus, individual metabolic differences are more likely and excessive consumption of kava should be avoided if possible. The Vanuatu NCD booklet recommends consuming no more than two shells of kava per night.
One common side effect of long term use of Kava consumption is development of a scaly skin rash known as dermopathy. There are several hypotheses concerning its cause. Some speculate it may be the result of interference with cholesterol metabolism. Another idea is that certain metabolites bind to skin proteins and cause an immune response. Regardless, it is often only associated with heavy, prolonged use and is reversible when consumption stops.
Kava Shouldn’t Be Mixed with Prescription Drugs
This is not exclusive to kava; it applies to all herbal therapies. Your body is an ongoing chemistry experiment, and everything you consume can affect it. The metabolizing enzymes that process food and nutritional supplements are the same that metabolize prescription drugs and interactions can occur. If you are taking prescriptions, talk to your prescribing doctor before starting supplemental therapies, including kava.
What about driving after consuming kava?
Concerns have been raised over the effect of sedatives — prescription and herbal — on driving motorized vehicles. It is a valid concern. Safety is extremely important and kava does elicit a certain physically tranquilizing effect. To assess the situation, researchers at the University of Melbourne conducted a driving simulation experiment with 22 adults who were given a “small” serving of kava. The results were inconclusive as the traditional production and making of Kava is not exactly scientific compared to pharmaceutical products. The researchers suggested that additional research is required before an all-out safety rating can be assessed. The best advice is to play it safe, and do not drive after you have consumed kava!
The Nature of Addiction and Abuse
Many people do not understand why or how other people become addicted to drugs. They mistakenly think that those who use drugs lack moral principles or willpower and that they could stop their drug use simply by choosing to. In reality, drug addiction is a complex disease, and quitting usually takes more than good intentions or a strong will. Drugs change the brain in ways that make quitting hard, even for those who want to.
Impact on the brain
Most drugs affect the brain’s “reward circuit” by flooding it with the chemical dopamine. Dopamine is part of our brain’s reward system, and it controls the body’s ability to feel pleasure and desire. It also motivates a person to repeat behaviors needed to thrive, such as eating, drinking and spending time with loved ones. The overstimulation of the reward circuit that drugs can create causes the intensely pleasurable “high” that can lead people wanting to take a drug repeatedly.
As a person continues to use drugs, the brain adjusts to the excess dopamine by making less of it and/or reducing the ability of cells in the reward circuit to respond to it. This reduces the high that the person feels compared to the high they felt when first taking the drug—an effect known as tolerance. They might take more of the drug, trying to achieve the same dopamine high. It can also cause them to get less pleasure from other things they once enjoyed. Learning, judgement, decision-making, stress management, memory and behaviour are all affected in people with an addiction. Despite being aware of these harmful outcomes, many people who use drugs continue to take them, which is the nature of addiction.
Why do some people become addicted and others do not?
People are often surprised to find how easy it is to become addicted to something. Some things people become addicted to include:
- Not only drugs or alcohol but to coffee or sweets or certain foods that dominate their lives.
- Some people become addicted to objects, art, cars, technology like phones and computers or games or other things they believe they cannot do without.
- Some people are addicted to activities such as exercise, sport, watching TV, eating, sex or socialising.
- Some people become fixated or addicted to certain types of people or a person and they feel that they cannot live without them.
When it comes to substances, addiction is complex and hard to predict. It may be related to biology, gender, ethnicity, or personality. The presence of other mental disorders may also influence the risk for drug use and addiction.
It may also be related to environment. A person’s environment includes many different influences, from family and friends to economic status and general quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress, and parental guidance can greatly affect a person’s likelihood of drug use and addiction.
A person’s stage of maturity and development, family values, education and culture may also add to the risk of developing an addiction to substances. These same factors may be protective.
Can Drug addiction can be managed, cured or prevented?
Addiction is treatable and can be successfully managed. People who are recovering from an addiction will be at risk of relapse for years and possibly for their whole lives. Research shows that combining addiction treatment medicines with cognitive and behavioural therapy ensures the best chance of success for most patients.
Treatment approaches tailored to each patient’s drug use patterns and any co-occurring medical, mental, and social problems can lead to continued recovery.
Perhaps the most powerful tool societies have to combat substance abuse is to develop an understanding of the complex issues and possible causes. Education of parents and children from a very early age can make a great deal of difference.
Simply ignoring or banning the discussion on substance use does not work. Children and young adults are very curious and are subjected to many forces outside their homes and communities. Providing information and guidance means that they will be better informed and will then make up their own mind when they are exposed to the temptation of trying a substance.
The American National Institute of Health suggests a number of strategies to combat substance abuse, including:
- Prevention programs such as education and management of early risky behaviour such as school difficulties, deviant behaviours, management of aggression and treatment for abuse. Family education.
- Drug and alcohol education through schools, media other mediums such as churches and community groups with appropriate laws to regulate availability of not only illegal substances but also of over the counter medications.
- Targeted education programs particularly in secondary schools, colleges and universities.
- Media campaigns that provide realistic and appropriate information to the public.
- Training programs that address substance abuse in schools, industry and sports.
- Funding for research in local areas to address emerging substance abuse issues.
- The development of appropriate services both government and non-government to deal with substance abuse. This includes the provision of information and training and services to those seeking help. These services could also provide education and support for family members or others affected by drug abuse.
Substance abuse can be managed and most persons affected will recover from drug addiction and lead productive lives in their community. Society attitudes need to reflect both understanding and support.
For more information or advice, please contact:
Mind Care Clinic
VILA CENTRAL HOSPITAL
Mental Health Clinic
NORTHERN PROVINCIAL HOSPITAL
Mental Health Clinic
Mental Health Clinic
Dr Damon Ashworth
Ministry of Health and Mind Care Clinic, Port Vila Central Hospital