J ournal of Punjab Academy of Forensic Medicine & Toxicology 10 (2010)

37

MEDICO LEGAL ASPECT OF DRUG ABUSE AND DEPENDENCE

Dr Putul Mahanta, Assistant Professor, Gauhati Medical College and Hospital, Gauhati

Article history
Received 3 January, 2010
Received in revised form1 March, 2010
Accepted on 15 May, 2010
Available online June 25, 2010
Abstract

Drug abuse is an intense desire to obtain
increasing amounts of a particular drug or
substance to the exclusion of all other activities
[1]. Dependence is the body's physical need, or
addiction to a specific agent. The misuse of drugs
is not limited to therapeutic purposes but also to
terminate the frustrated lives. A physical
dependence on a substance (needing the drug to
function) is not always part of the definition of
addiction. Some drugs like blood pressure
medications don't cause addiction but do cause
physical dependence. This paper will explore its
different definitions and related issues with
extensive legal, social, moral and ethical problem.
Correspondingauthor

Dr Putul Mahanta
House No 1; Karmabir Bordoloi Path, Wireless, Rukmini-
nagor, Dispur, Guwahati, Assam, India, 781006.

Phone: 00913612222108(R)
Email: drpmahanta@gmail.com

Keyword: Drug abuse; dependence; global problems 2010 JPAFMAT. All rights reserved


Introduction

Drug dependence and drug abuse is a disease
and not a character defect. It represents different ends of
the same disease process. Over the long term, it results in
physical harm, behavioral problems, and association with
people who also abuse drugs. During the past few years
dramatic changes have occurred in drugs abuse vs. crime.
Magnificent increas is everywhere in the number of drug
users who are the member of dominant culture. These
users turn to some form of crude amateur crime like
burglary, robbery and even the prostitution to support
their habits. Juveniles addiction in the larger cities has
become a major problemcausing substantial harm to the
society in every field.

Different terminology

Drug dependence is a condition results from repeated
consumption of a drug characterized by increased desire
to take the drug and that also in an increasing dose to get
the desired effect or an increasing effort to collect it and
thereby causing physical and psychological dependence
[2]. It includes both the terms addiction and
habituation.

Addiction is a state of periodic or chronic intoxication,
produced by the repeated consumption of a drug, which is
harmful to the individual and to the society. Alcohol,
cannabis and heroin are the most commonly abused
substances in the world [3].

Physical dependence is a biological phenomenon which
depends on the type, dose, and duration of drug use
irrespective of the personnel factors and associated with
withdrawal syndrome where as psychological dependence
(drug habituation) is a condition resulting from the
repeated consumption of a drug, in which there is a
psychological or emotional dependency. Caffeine and
nicotine are most common habit forming drugs.[3]

Drug abuse (substance abuse) can lead to drug
dependence or addiction. People who use drugs for pain
relief may become dependent, although this is rare in
those who don't have a history of addiction. The use of
none medically useful or illegal drugs is usually called drug
abuse; even the use is moderate and leads to no harm.
Substance abuse will be more accurate which includes:
non narcotic drugs like hypnotic, stimulants like
amphetamines, cocaine etc, non narcotic analgesics,
tranquilizers and hallucinogens.[3] Solvent abusers are
usually the young male teenagers. It is the deliberate
inhalation of substances like toluene (glue-sniffing),
gasoline (petrol), Xylene etc. Effects resemble like
alcoholism, behaves totally irrationally and may injure or
kill self.[3]
The WHO has established the following types of
drug dependence.[3, 2, 4, 5]

Morphine type: There is over powering desire to continue
the drug and to collect it by any means and tends to
increase the dose due to development of tolerance. The
withdrawal effects start (particularly of heroine) within 8
hours and slowly subsides by 48 to 72hours.

J ournal of Punjab Academy of Forensic Medicine & Toxicology 10 (2010)
38

Barbiturate type: Desire to continue the drug is strong and
the dose also, partly due to tolerance. Cross tolerance to
alcohol present. Withdrawal effect becomes maximumby
2 to 3 days and subsides slowly.



Fig.1. Unripe poppy capsule from where opiumis
extracted.

Cocaine type: Desire to procure the drug is overpowering,
but there develops no tolerance.

Fig.2. Cocaine powder.

Cannabis type: Desire is present with no tolerance or no
tendency to increase the dose. Develop psycho
dependence. There is a danger of addiction to other and
more dangerous drugs. Under its influence the addict may
injure himself or cause harmto others.

Amphetamine type: Desire is present, develops tendency
to increase the dose and tolerance.

Three types of drugs producingaddiction [2]
Stimulants: sympathomimetics like ephedrine and
amphetamines. Some common names are Black bombers,
Purple Heart, French blue and black Beauties.
Depressants: hypnotics like barbiturates and mandrex. The
chief narcotic are opium and its derivatives, especially
morphine or its synthetic substitutes.
Drugs used for distorting senses: Inebriants like alcohol
and its beverages; deliriants like cocaine, cannabis,
hallucinogens like LSD.



Fig.3. Cannabis plant



Causes, incidence and risk factors
The majority of drug victims are neurotic
individuals who are mentally unbalanced. A normal person
has no tendency to become a drug addict and is most
unlikely to become one, even when all the facilities are
available [3]. However, hereditary factors, peer pressure,
anxiety, emotional disturbances, environmental stress,
depression, unstable personality, recreation, too much
gain, adverse social reactions, physical inability to do a job,
curiosity, chronic pain from cancer etc. are some of the
causes. Peer pressure can lead to drug use or abuse, but at
least half of those who become addicted have depression,
post-traumatic stress disorder, ADD (attention deficit
disorder). Those children who grow up in a society of illicit-
drugs use first see their parents using drugs. This may put
them at a higher risk for developing an addiction later in
life for both environmental and genetic reasons.
Children who take drugs may show following
signs. A change in the friends, withdrawn behavior, long
unexplained periods away from home, lying, stealing,
involvement with law, problems with family relations
acting drunk or high, confused, impossible to understand,
distinct changes in behavior and normal attitude and
decreased school performance. [1,2,3,6]

Demographic distribution of addicts
Age group: More vulnerable age group is
between 16 to 35 years. Juvenile delinquents and
economically unsound adults are the more vulnerable
J ournal of Punjab Academy of Forensic Medicine & Toxicology 10 (2010)
39

group. Sex: Male predominates over female. Area
preponderance: Urban people predominate over rural
people. Educational status: More amongst bright boys,
scholars. Social status: Common amongst one child of
parents, Childs of broken home families, pampered child,
slum dwellers, drug traffickers, ganja smoking and
alcoholism. [2]

The problem: Global challenges
Route of drugtrafficking
Transit of traffic of drugs is still significant
through the Golden Triangle which includes Myanmar
(Burma), Thailand, Laos and adjoining part of china and
through the Golden Crescent which include Pakistan,
Afghanistan and Iran. Golden Quadrangle is also an
important part in drug trafficking in India which includes
Varanasi, Lucknow, Bareilly, Barabanki and Badaawn
districts of UP and adjoining parts of Rajasthan, M.P.
including parts of southern, eastern and north-east zone of
India. About 10kg of raw opium will produce 1kg crude
morphine base which then can be converted into NO-4
Chinese heroin(95%pure), or No-3 heroin (60%pure). No-
3 heroin as available in Indian market is commonly


Fig. 4. Showing Brown sugar.

known as Brown Sugar or smack[Fig.4].
Two methods Body stuffer (act of swallowing of
a container such as balloon, plastic bag, and condom etc.
while arrested during smuggling to conceal the material
evidences from the authorities) and Body packer (act of
swallowing containers like balloons, plastic bags or
condoms filled up with illegal drugs for the purpose of
smuggling from one country to the other and after
reaching the destination the smugglers usually defecate
the containers using laxative or rectal suppositories or
enema) are very much in use to conceal the process of
trafficking. But toxicity in such persons may occur from
rupture of the container inside the intestine like the case
of the famous condomof time bomb in Pakistan. [2]

Discussion

Most persons use drug of dependence with
certain discrimination, and in such cases little harm result.
Indiscriminate use of any of these drugs becomes
dangerous, and produces a gradual mental, physical, and
moral deterioration of the individual and sometimes also
sexual perversions or crime. To obtain money for the drug,
the addict often turns to prostitution or crime. [3]
A strong relationship exists between the abuses
of drugs and occurrence of various accidents and the acts
of criminal behavior. Schizophrenia is associated with an
increased risk of violent crime. This association was
attenuated by adjustment for substance abuse, suggesting
a mediating effect. [14]
SAMHSA's DAWN [16] reported that an
estimated 7,873 drug related emergency department visits
in USA involved methylphenidate or amphetamine,
dextroamphetamine, two medications used to treat ADHD
(attention deficit hyperactivity disorder). The most
frequent reason for these ADHD stimulant medication
related visits was nonmedical uses (48%), followed by
adverse reactions associated with medical uses (34%),
accidental ingestions (10%), and suicide attempts (8%) [7].
Data on suicidal attempts, suicidal thought and
related behaviors were also available in SAMHSA's
National Survey on Drug Use and Health and in
SAMHSA's DAWN report. Among adults who experienced a
major depressive episode in the year 2003, 56.3%thought
during their worst or most recent episode that it would be
better if they were dead, 40.3%thought about committing
suicide, 14.5%made a suicide plan, and 10.4%made a
suicide attempt. In 2004, an estimated 106,079 emergency
department visits were the result of drug related suicide
attempts by persons aged 18 or older. A psychiatric
condition was diagnosed in 41% (43,176) of the drug
related suicide attempts treated in the emergency
departments. The most frequent psychiatric diagnosis was
depression. According to SAMHSA's DAWN, in the year
2004 there were over 15,000 emergency department visits
by adolescents aged 12 to 17 whose suicide attempts
involved drugs. Pain medications were involved in about
half of the suicide attempts. Almost three quarters of the
drug related suicide attempts were serious enough to
merit the patient's admission to the same hospital or
transfer to another healthcare facility. Antidepressants or
other psychotherapeutic medications were involved in
over 40%of the suicide attempts by adolescents who were
admitted to the hospital. [8]
The violence of youth is very much related to the
use of illicit drug was reported in USA [16]. An estimated
14%of youths aged 12 to 17 year, approximately 3.5
million youths, had experienced at least one major
depressive episode in their lifetime. Over 7%, an estimated
1.8 million youths, had lifetime major depressive episode
and thought about killing themselves at the time of their
worst or most recent episode. An estimated 712,000
youths had tried to kill themselves during their worst or
most recent major depressive episode; this represents
2.9%of those aged 12 to 17 [9].
The use of Marijuana and its relation with
delinquency among the young group was also reported in
UK [9]. Hispanic females aged 12 to 17 were at higher risk
for suicide than other youths. Hispanic female youths
J ournal of Punjab Academy of Forensic Medicine & Toxicology 10 (2010)
40

born in the United States were at higher risk than Hispanic
female youths born outside the United States. But rates of
suicide risk were similar among Hispanic female youths
across regions and ethnic subgroups e.g., Mexican, Puerto
Rican, Central or South American and Cuban [9]
.

Although not all abnormal people are criminals,
habitual criminals are demonstrably abnormal. A
professional criminal shows strong psychopathic
tendencies. All addicts are not criminal, though legally they
are, for violating narcotics laws whenever they possess
drugs. Cocaine does not arouse criminal impulses in
anyone, but it enhances that criminals mental and
physical impulses into action. Beyond this he becomes
suspicious and fearful. They run away from imagined
enemies, usually the police. They are in a paranoid state
and commit act of violence. Such person would be
incapable of planning and committing a deliberate murder
or bank robbery. Regardless of the legal implications, a
drug addict who is otherwise a respectable member of the
dominant culture cannot be regarded as a criminal, simply
because he uses drugs. He has an unfortunate personality
defect.
Investigation of a drug abuse death [3, 6]

is a
difficult task for a medical person whenever he or she gets
the opportunity to investigate a case of addicted death.
Addicts often die from complication like accidents while
under the influence of drugs; or may commit suicide or
homicide or other sexual offences which may result death
needing the help of professional expert in the field of
investigation.
Investigation of a drug abuse death (at the scene of
crime)
Dead persons clothes and the belongings, to check
for needle, syringe and tourniquet, photographs of the
scene are to be taken and to search for any drugs etc,
should preserve if found.
Specific precautions are to be taken for prevention of
infectious diseases like HIV, Hepatitis B etc during the
conduct of autopsy. Body is to look for any caches of drugs
that may be in orifices etc. The autopsy proper includes
both external and internal examination.
External: Wasting and signs of self neglect, body may be
tattooed to hide scars (railroad tracks), stains at tips of
fingers, needle track scars, fibrosed veins, recent injection
sites may show zones of inflammation. Regional lymph
nodes may be enlarged. Look for the perforation of nasal
septum. Froth may be at mouth nose. Vaginal swabs are to
be taken for laboratory examination.
Internal: Diffuse subcutaneous scaring in the skin; G.I.T.
may contain pills/capsules like that of the condom of time
bomb [16], enlarged lymph nodes, signs of congestion of
visceras, hepato-spleenomagaly, valvular heart diseases
and brain may show edema and focal areas of necrosis due
to hypoxia. Viscera blood, urine etc are mandatory to
preserve for chemical analysis.



Treatment cumrehabilitation

Treatment cant take place unless the individual
attends for treatment. He must come to learn with the
possibility of a life without drug. Unfortunately drug
takers, as a rule, have little or no motivation to undergo
treatment. Alcoholics tend to deny that their consumption
is abnormal; others openly defend their habits. Long term
treatment is not only a medical problem, but needs the
cooperation of psychologists and sociologists. There is a
high relapse rate with all treatment methods. [10]
Though drug addiction may be considered as a
social problem, the first step in its management is medical
care, which includes: (a) identification of drug addicts and
their motivation for detoxication, (b) detoxication
(requires hospitalization), (c) Post-detoxication, counseling
and follow-up (based on clinic and home visits), and (d)
rehabilitation.
Simultaneously with medical treatment, changes
in environment (home, school, college, social circles) are
also important. The patient must affect a complete break
with his group; otherwise the chances of relapse are 100%.
Psychotherapy has a valuable place in the management of
the addict [10]
.
A person being treated for this condition
requires the same respect as a person with any other
medical condition. We all to work comprehensively for
successful drive against illegal drug trafficking. Motivation
can be made by mass people education through television,
radio, news papers etc. Strict legislation and its
implementation, effective state administration are also
important in controlling illegal drug trafficking.
The rehabilitation of former drug user,
regardless of age, is in most cases a long and difficult
process. Relapses are very frequent. Success of the
treatment necessitates the adoption of mature and
realistic attitude by the local community and the
avoidance of panic, moral condemnation and
discrimination. Facilities for vocational training and
sometimes the provision of sheltered work opportunities
are useful in rehabilitation and help to prevent relapse.
Generally speaking, facilities for the registration, diagnosis,
treatment, after-care, etc., of drug dependence individuals
and groups should be regarded as indispensable
integrated parts of the health and social services structure
of any community in which drug dependence exists. It is
suggested that when there is evidence of significant
alienation among a group, especially of younger persons,
it should be regarded as indication of possible presence of
actual or potential drug takers, and should lead to an
analysis of the situation and to such preventive or
remedial action as may be indicated [12]. Strong family
support, social rehabilitation and training for gainful
employment are the most important components after
weaning addicts away from drug dependency to prevent
relapses [3].



J ournal of Punjab Academy of Forensic Medicine & Toxicology 10 (2010)
41

Conclusion

Drug abuse is not a matter of moral weakness or
faulty willpower. It is a vicious cycle that actually causes
changes in the brain, leading to stronger and impulses to
use. Without help, drug abuse destroys families and takes
lives. With the right support and treatment, the road to
recovery is possible.

Acknowledgements

Thanks to my wife MANMI who have helped me
by providing related information. My son Jacinth and
daughter Adriana, deserves special thanks from whose
childhood I borrowed time to pursue my work etc.

Conflict of interest

None declared.


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