Substance Use Disorder (SUD) are patterns of maladaptive use of psychoactive drugs that lead to significant levels of impaired functioning or personal distress. SUD often result in not only serious harm to the health of the individuals, but also enormous financial and social consequences that go beyond the health care system such as loss of economic productivity due to withdrawal from the workplace and increased rates of crime, injury, disability and death. Individuals who experience a Substance Use Disorder (SUD) may also experience a dual diagnosis or co-occurring mental disorder such as anxiety, psychosis, depression and others. A dual diagnosis presents a challenging problem to mental health workers and service planners as Substance Use Disorders (SUD) occurring together with mental health disorders represent a major health problem. SUD is also a heavy burden for the government because it needs a lot of enforcement from the authorities and drains available health care resources. Moreover, the intervention and treatment of SUD is a complex, multidimensional, and long-term endeavor that often requires specialized care tailored to the substance and the severity of the pattern of use. Therefore this paper aims to discuss an overview of SUD and it also cover the contributory factors of SUD and intervention or treatment modalities available for its management in Malaysia.
Drugs; Intervention; Substance use disorder
Drug use disorder, commonly called drug addiction in many countries, has become a prevalent global public health concern and serious social problem. DSM-5 defines Substance Use Disorder (SUD) in terms of maladaptive patterns of behaviours that are related to the continued use of drugs, even though their use creates a set of significant problems for individuals . In addition, it leads to social, academic, economic, and occupational impairment and daily activities. Other social problems associated with substance use disorder are housing instability, homelessness, criminal behaviour, the transmission of Human Immunfidency Virus (HIV) or high-risk behaviour and unemployment . Drug use disorder can range from mild and temporary to severe and chronic.
The DSM-5-TR recognizes substance use disorders resulting from using 10 classes of drugs such as alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, or anxiolytics, stimulants (including amphetamine-type substances, cocaine and other stimulants) and tobacco . These drugs were also known as psychoactive drugs. Using psychoactive drugs without medical supervision is associated with significant health risks and mental health problems. High intake of psychoactive drugs can affect the body and mind function. It also can change how someone's mood and behavior. They also account for more health problems and greater mortality. Physiological features are indicative of neuroadaptation to the substance, including tolerance following the need for increased amounts of the drugs to achieve the same effect and withdrawal following the unpleasant physical and psychological impact that the person experiences when the person tries to stop consuming the drug .
In 2019, 35 million people are estimated to suffer from drug use disorders and require treatment services . Meanwhile, data has shown that around 284 million people aged 15-64 used drugs worldwide in 2020, a 26 per cent increase over the previous decade. Young people are using more drugs, with use levels today in many countries higher than with the previous generation . There are various methods how individuals consume the drugs, such as by injection, swallowing, inhalation, or absorption through their skin. Globally, the report estimates that 11.2 million people worldwide are injecting drugs. Around half of this number was living with hepatitis C, 1.4 million were living with HIV, and 1.2 million were living with both . Additionally, the world sees rising of drug use and abuse as the COVID-19 pandemic drags on. Overdoses have spiked since the onset of the Covid -19.
Malaysia also is known to have the toughest laws in dealing with drug misuse as well as drug trafficking. Drug abuse remains the nation’s number one enemy as the drug problem has become increasingly dangerous and constitute a threat to Malaysian national security. The most common drugs used in Malaysia are methamphetamine (crystalline), followed by opiate and amphetamine-type stimulants (ATS) . In 2020, during the COVID-19 pandemic, National Anti-Drugs Agency recorded 13,879 new cases of drugs addiction and 6764 relapse cases .
Malaysia’s Government has shown their efforts by establishing the National Anti-Drugs Agency (NADA) under the Ministry of Home Affairs. NADA is given the mandate and the main function to prevent, detect, arrest, enforce, investigate and prosecute in terms of prevention, detecting, arrest, enforcement, investigation and prosecution offenders involved in drug offences, as well as to provide treatment and rehabilitation of drug addicts. Indeed, the seriousness shown by the Malaysian Government illustrates how much government very seriously want to help an individual stuck with these symptoms to recover as a normal individual and return to their society.
Many people diagnosed with a SUD also suffer from a co-occurring mental health condition. This is also known as a dual diagnosis which a person has a diagnosis of both a substance use disorder and a mental health disorder. Individuals with psychiatric disorders are at an increased risk of having a comorbid substance abuse disorder and vice versa . Individuals abusing or dependent on drugs can develop symptoms similar to those seen in many psychiatric disorders, including psychotic symptoms, depression, anxiety, mood swings and criminal behavior [9,10]. The most frequent comorbid psychiatric diagnoses were affective and anxiety disorders . It has been shown in multiple studies that drug addiction can lead to psychosis without the involvement of genetic factors. For example, the representative drugs that can cause psychosis are amphetamine, scopolamine, ketamine, Phencyclidine (PCP) and Lysergic Acid Diethylamide (LSD) .
Research through Mycite, My journal Medline, PsycINFO, and PsyArticles showed that there were few studies about dual diagnosis in substance use disorder or drug addiction in Malaysia. One study showed that methamphetamine drug abuse, such as syabu and ecstasy had negative effects on user’s mental health women in Malaysia. Methamphetamine is used to develop depression among women. Therefore, serious attention should be given to the female drug users who are suffering from dual diagnosis . Meanwhile, another study conducted by a Malaysian researcher in one of the mental hospitals showed that males of Kadazan ethnicity with severe mental illness and alcohol use disorder had a higher risk of having comorbid non-alcohol substance use disorder. In addition, male Kadazan patients with severe mental illness and non-alcohol substance use disorder had a higher risk of comorbid alcohol use disorder. Dual-diagnosis patients with alcohol and non-alcohol substance use disorder had higher rates of hospitalizations. Suicidality was higher among patients with alcohol use disorder and severe mental illness. The prevalence of severe mental illness dual diagnosis was high in this study, with poorer outcomes, higher rates of admissions and risk of suicidality .
Patients with SUD and comorbid psychiatric conditions also have a high level of treatment discontinuation. [15,16], with many withdrawal therapies within the first few weeks of inpatient treatment . Treating patients with psychiatric and SUD comorbidities requires a more complex service with psychiatric, substance dependence and medical treatments. However, a global overview of these treatment modalities is frequently left out [17,18]. Apart from that, accurate assessment and diagnosis related to SUD and dual diagnosis were also not given much attention by a healthcare professional. Maybe this is due to lacking of competency and limited skills. In the end it is difficult to find out the appropriate treatment for them. Therefore, this issue needs to be addressed so that a more specific treatment and intervention mechanism can be given to individuals who suffer from it. This highlights the importance of provisions for a more holistic treatment approach among patients with dual diagnosis.
There are several factors that contribute to drug abuse, such as family economic problem, influence by peers, the curiosity of the individual and other factors. A study conducted in Malaysia showed that school environment factors are the main factor in substance use behavior compared to the individual’s family and internal factors among the youth. The researchers stated that when parents spend less time monitoring children, their children tend to develop friendships with peers who support drug use . Most studies have shown that a person who takes a drug at a young age has a high risk of becoming addicted , and an increased risk of substance abuse problems in the future .
Meanwhile, one findings suggest that both parents and peers have significant impacts on substance use, but that the most salient aspects of parenting are subject to change during the transition to high school, monitoring appears to be more central in early adolescence, while family relationship quality appears to be more central in middle and late adolescence. These aspects of the family context demonstrated direct effects on substance use and some indirect effects on later use by way of deviant peer association, suggesting that parental monitoring and parent-youth relationships may play a role in an adolescent's choice of peers, which in turn can influence later substance use .
A study in Malaysia also revealed that family factors (family economic) and peer influence played an important role in an individual's drug abuse habits. The researchers qualitative study shown that three out of the seven participants mentioned that reasons of drug abuse were related to family poverty, meanwhile, four participants stated peer influence be one of the factors causing their drug abuse. Other factors such as curiosity, tension release and betrayal of the spouse also contributed to participant's drug abuse. The study also found that a person's drug abuse is usually caused by a combination of several factors instead of just one sole factor . Another study also indicated that peer influence and curiosity were the top two significant factors contributing to drugs abuse among drugs addiction in a rehabilitation centre. It shows the impact peers could impose on an individual . This study also was supported by NADA Statistic, which revealed that 8,893 case of drugs addicts involvement were due to influence by their peers, followed by curiosity factor with 4723 cases and depression with 2764 cases . This proved that environmental factors play an important causal factor in the development of SUD or drugs addiction later.
Many interventions and treatments have been proposed to reduce SUD or addiction since it became a global issue. The intervention and treatment is a process of helping drugs addicts to stop searching, compulsive drug use and subsequently abandoning drug addiction habits. This process is implemented in different settings, approaches and timeframes. It enables individuals to deal with their addiction problems, make the right decisions in relation to the life and integrate themselves in family and community or societies. Many interventions and treatments have been implemented decades ago by the Malaysian Government through NADA and the collaboration with non-governmental organizations such as Drug Prevention Association of Malaysia (PEMADAM) and PENGASIH Malaysia Association in order to restraint the drugs problem. Psychosocial, psychological and pharmacological interventions can be used in a variety of treatment settings either as stand-alone treatments or in combination with the other interventions. Acknowledging the importance of drug abuse and relapse as a public health issue, the Malaysian Government has implemented a number of programs aimed at restricting drug distribution as well as improving drug treatment programs. Previously, as we discussed on how NADA was responsible for managing the drugs addiction in Malaysia, NADA also has shifted from the 'tough and rugged' approach to a more holistic and caring method involving the biological, psychological, social and spiritual aspects of the clients and their families. NADA has increased access to treatment, rehabilitation and aftercare services to drug users, by scaling up treatment coverage and widen the social net for drug users and addiction in order to facilitate accessibility to treatment services. This agency has provided and supported a range of treatment and rehabilitation modalities for specific groups of drug users by adopting evidence-based treatment protocols based on international standards in treatment.
NADA also had conducted prevention services to educate people about the risk of drugs beside to conducted anti-drugs campaign. The target is to give an awareness of drugs in a family, organization, schools, workplace, and media or in high risk locations. It may prevent or reduce drug use and addiction. These programs include education and outreach to help societies and communities understand the risks and dangers of drugs. Other than spreading awareness and conducting drug prevention programs, NADA is also responsible for curing the drug addicts. Many integrated approaches that have been conducted to the drug addiction to reduce or stop taking the drugs. Treatment and rehabilitation services are carried out through institutional-based treatment and Community-Based Treatments (CBT). A number of rehabilitation centers are established to treat drug addiction problems among drug addicts. It is one of the initiatives the Malaysian Government has implemented to combat the issues of drug misuse and drug addiction. Individual who has been identified as drugs addict, will be recommended by drugs officer to undergo treatment and rehabilitation under Cure and Care Rehabilitation Centre (CCRC) either voluntarary under section 8 (3) (a) of drug dependent (treatment and rehabilitation) Act 1983 or by court orders under section 6 (1) (a) of drugs dependent (treatment and rehabilitation) Act 1983. The services that provided by CCRC are based on the recovery needs of each client. The module treatment in CCRC includes guidance and counselling, psychospiritual, psychosocial, skills and vocational training, and others .
Meanwhile, the treatment and rehabilitation services through community-based to provided in community are based on the rehabilitation needs of each client with various backgrounds, history of addiction and types of drugs. It is an aftercare program for clients who have completed their treatment in the Cure and Care Rehabilitation Centre (CCRC) . The first Malaysian Community-based treatment is the Cure and Care Service Centre (CCSC), which was established in the drug-stricken area of Chow Kit, in the city of Kuala Lumpur, Malaysia. CCSC also function as an outreach centre, providing counseling, medical check-ups, psychosocial programs, methadone maintenance therapy, spiritual and moral education, and support for integration . In addition, CCSC also conducted activities for the community such as a parent, family members and students .
The outcome of the CCSC program was found to be successful. One study conducted a total of 10 CCSCs were randomly chosen with reference to its location in the 4 zones (North, South, East & Central) of Peninsular Malaysia. A total of 232 clients responded to the outcome study. The study found that the outcome of the drug rehabilitation program at CCSC is generally positive. The main outcome is that clients’ involvement in criminal activities has significantly reduced after completing their program at CCSC. The consumption of ketum leaves extracts, alcohol, drugs and even drug injecting behavior have also reduced significantly. Almost 20%of the clients gained employment after their discharge from the program. Also, abouta third of the clients have changed their lifestyle such as they took care of their health, engaged in physical activities and exercises, played sports, took their medicine and maintained their leisure time. Some are involved in religious activities, and almost half of the clients have been seen to have made that change. Furthermore, around 20% have started to renew relationships with their parents, siblings and other family members. A smaller number got involved in intimate relationships and marriage. Many clients also managed to obtain more permanent jobs, engaged in recreational, sports activities and enhanced their relationships with family .
As we discussed earlier, one of the intervention that has been included in the module by NADA were counselling and psychotherapy. The psychological treatment can be implemented individually or in a group therapy and delivered by a counsellors or psychologists. The psychotherapy approach such as behavioral, cognitive behavioral therapy, reality therapy or motivational interviewing also had been showing the effectiveness among drugs use disorder [30-32]. Thus, Government also realizes that drug rehabilitation programs are based on spiritual and religious therapy effective in the prevention and treatment of drug addiction. Religion is one of the protective factors identified as facilitating positive outcome . Psycho spiritually based drug addiction therapy can strengthen internal drug addicts. Thus, it is able to provide effective treatment to drug addicts . The treatment process will be effective if it involves spiritual healing by counselling and therapy .
The Islamic psycho-spiritual therapy has shown effective results in treatment holistic drug rehabilitation. A strong spiritual life is one of the essential elements in treating drug addiction effectively . This is supported by one study that has proposed and formulated the concept of integration therapy between Islamic psychospiritual therapy and the Therapeutic Community (TC) approach. The proposed Islamic psychospiritual includes several spiritual aspects, namely (i) application guided repentance, (ii) application of soul and lust purification, (iii) application of self-surrender to God, (iv) the application of knowing the essence of oneself and the meaning of life and (v) the application of doing charity with values honorable . The appropriate Quran verses are also to be used in spiritual psychotherapy of drug addiction and Quran recitation has been identified as a cure of physical or mental illnesses among drug addiction issue . Another study also showed that respondents’ psychospiritual level and the locus control upon going through the Integrative Psychosocial Module intervention were positively increasing among the drugs addiction .
In addition, the i-DEEN program, a new approach introduced by NADA that emphasizes psychospiritual elements, is seen to be effective and successful in helping the NADA improve the client's self-potential in undergoing the recovery process. Besides focusing on skills and abilities in the rehabilitation process, the i-DEEN program also helps encourage client involvement through religious programs, specifically in understanding and practicing al-Quran. In addition, besides the psychological and psychosocial that have been implemented, healthcare was also very important and being provided to SUD. Health approach policy that accomplished by the Government through NADA is very crucial in the effort to eradicate drug issues in Malaysia. NADA also develop a cohesive collaboration with Ministry of Health in countering drug addicts with psychosis disorder co-occurrence with drug use problems. Patients are transferred to General Hospital for further treatment. A psychiatrist or psychologist is placed in drug treatment center once in every week to provide regular mental health checkup to drug addicts and those at early recovery phase or at abstinence stage that demonstrate psychosis symptoms .
Additionally, the implementation of Cure and Care One Malaysia (CC&1M) clinic is to ensure the treatment and rehabilitation delivery is felt by the people, especially drug addict as the main target group. The center also has specifically designed to be more approachable by reducing the waiting time and less treatment duration. There are wider scopes of service provided to the clients such as inpatient, outpatient, clinical treatment, methadone substitution therapy and advocacy. Thus, the concept applied in C&C1M Clinic is aligned with the health approach recommended by the World Health Organization (WHO). A study by Malaysia researchers shows that methadone are effective to reduce the drug craving, eliminate mood swing as well as increase the employability of the drug addict as they able to substitute their craving towards drug to methadone. In addition, the concept of open access and voluntary treatment, especially in outpatient service, showed that the respondents life and behavior had changed. Therefore, the respondents were able to executed their daily activity such as working. This study concluded that the health approach in C&C1 clinic gives huge impact towards the life of drugs addict .
There are several obstacles in the effort to recover drug addicts. Stigma is one of the obstacles faced by SUD in the effort towards healing. Negative views from society and rejection from society cause them to refuse treatment and go back to use a drugs. This stigma is fueled by ignorance and false beliefs regarding drug substance use disorder. The rejection from family and societies contributes to feelings of disappointment and despair among them. Besides, most employers refuse to hire former drug addicts as their employees. Difficulty getting legitimate employment causes the former drugs addicts to have no choice but to use and sell the drug, and this causes relapse to occur. Moreover, self-motivation to change remains a significant challenge. Lack of self-confidence also is a high tendency for a drug addict to re-involve in drug abuse even after a treatment. This situation describes permanent relapse behavior occurs and is difficult to eliminate.
Substance use disorders are difficult to overcome without support and treatment options. Thus, constant support with adequately planned treatment therapy can help a person lead a better life. The family and society also plays an important role in helping and supporting the SUD. Besides, the employer also needs to support and give a second chance for former SUD or drugs addiction to prove that there will change and being an excellent employees. While treatments exist, the need for more effective treatments is clear, especially those focused on decreasing relapse rates. The mental health professional must also be trained very well in conducting accurate assessment and diagnosis of drug use disorder and dual diagnosis, besides improving skills and competency in drugs specialized intervention or therapy to ensure the appropriate treatment and intervention being given to patients. Models of integration of SUD treatment into existing platforms of medical and mental healthcare can be culturally adapted and expanded through primary training care and mental health professional, including lay health workers. Anyhow, efforts in combating drug addiction problems, especially by the Malaysian Government will never end as to protect the safety of the country and the future generation.
The author does not have conflicts of interest to declare.