Substance addiction is a neuropsychiatric disorder characterized by a recurring desire to continue taking the drug despite harmful consequences. WHO defines substance addiction as – The repeated use of a psychoactive substance or substances, to the extent that the user (addict) is periodically or chronically intoxicated , shows a compulsion to take the preferred substance, has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substance by almost any means. The term addiction also conveys the sense that such substance use has a detrimental effect on society, as well as on the individual. In India, substance use disorders (SUDs) are the most prevalent mental health morbidity observed in data compiled by the National Mental Health Survey of India, 2015-16 [1], as well as it is one of the most worrisome public health concerns. According to the 2019 survey on substance use in India, over 57 million of the population in India require professional assistance for alcohol use disorders and around 7.7 million for opioid use disorders [2]. Tobacco use is one of the major causes of death and disease in India and accounts for nearly 1.35 million deaths every year. India is also the second largest consumer and producer of tobacco. A variety of tobacco products are available at very low prices in the country. Nearly 267 million adults (15 years and above) in India (29% of all adults) are users of tobacco, according to the Global Adult Tobacco Survey India, 2016-17 [3]. Caffeine is an active and addictive constituent found in tea, coffee, soft drinks and energy drinks. Caffeine addiction, although not stigmatized, is an issue that plagues a majority of people. People have reported being unable to function without their morning dose of caffeine. Hospitalization, fatal conditions or even mortality arising from large amounts of caffeine intake are not reported as much as other substance addictions, albeit it does cause dependence and tolerance like any other addictive substance. It can also lead to withdrawal symptoms if stopped abruptly and can exacerbate other underlying conditions such as hypertension, diabetes, COPD, Ischemia and arrhythmias [4,5,6]. The active addictive substance in tobacco is nicotine, a natural alkaloid. The most common forms of tobacco that are consumed are cigarettes and smokeless tobacco (chewing). They are also growing in popularity as e-cigarettes. Tobacco addiction is maintained in the user by nicotine dependence, as nicotine can easily cross the blood-brain barrier and exerts its pharmacological effects via the CNS nicotinic receptors and induces the secretion of neurotransmitters [7]. Other recreational drugs that we found to be commonly used by students are ganjaa /weed scientifically known as cannabis, and rarely cocaine.The active constituents in cannabis are cannabinoids; mainly THC and cannabidiol, which are psychoactive substances. Cannabis can be consumed by smoking it in joints or via inhaling the vapour. Cannabis is also termed as a gateway drug to opioid use and cocaine use as they have a similar pharmacologic interaction with the receptors in the human body, and secrete endogenous opioids in the body [8].

MATERIALS AND METHODS:

The study was an observational Study, conducted via online self-filled survey form. A predesigned and pretested questionnaire was prepared with questions relating to addiction and its pharmacoeconomics. The form was distributed amongst university students and staff in and around Waghodia. Patients in the age group of less than 18 years were excluded from this study. The online survey form generated an Excel sheet composed of all the data filled in by the users. The data was further sorted and filtered out for subjects who left the survey incomplete or denied consent for the survey. The data was summarised in an Excel sheet and the data was run through various Excel programs and summarised tables and charts were generated. Statistical analysis methods were calculated. The results were represented pictorially and theoretically.

OBSERVATION & RESULTS:

A total of 209 subjects filled out the form, of which 164, (76.63%) reported consuming caffeine. 31 subjects (14.48%) reportedly consumed alcohol, 26 subjects (12.14%) smoked cigarettes, 13 subjects (6.07%) chewed tobacco, 7 subjects (3.27%) reported to have consumed recreational drugs which were cannabis, and 1 subject (0.46%) reported to have consumed sopari/ areca nut. The average annual income of each family was found to be 9.6lacs per annum, which bore the cost of substance-seeking behaviours of the addict.

Table 1:  Pharmaco-economics and demographic characteristics of subjects who consumed caffeinated drinks

Table 1 shows information about participants who had consumed caffeine, amongst other addictive substances, such as duration of consumption, annual income of participants and their families, cost of hospital visits, overdose, clinical difficulties, and drug usage cessation.  From 30 subjects, a majority (70%, n=21) of subjects who consumed alcohol belonged to 20-25 years of age. The other participants who consumed alcohol belonged to the age group of 35-40 years (n=4, 13%), 25-30 years (n=2, 6.6%), 30-35 years age (n=2, 6.6%) and 45-50 years of age (n=1, 3.3%). The mean age of male participants who reported consuming alcohol is 24.6 years which is nearly the mean of female age which is 24.5 years of age. The subjects were segregated based on their annual income. A majority of subjects (n=107) earned an average of 2.5 lacs to 10 lacs per year. 29 subjects reported to have an income of 10 lacs to 25 lacs per annum, 6 subjects earned more than 25 lacs per annum and one subject reported to earn less than 2.5 lacs per year. According to the findings of this study, most of the subjects who consume caffeinated drinks were from families that earned 2.5 lacs to 10 lacs per year. Each hospital visit cost is assessed for influencing the cost of caffeine consumption to the subject. We factor in hospital visit costs ranging from 0 to 50,000 rupees. 11 subjects reported having visited clinics seeking medical help. 4 subjects spent between INR 0 to 1,000 on each of the hospital visits, 3 subjects spent INR 1,000-5,000 and another 3 spent in the range of INR 20,000-50,000. One subject spent between 5000-10000 rupees. These subjects spent an average of INR 11,227.00 for hospital visits regarding caffeine overdose or for other caffeine-associated symptoms, which are the direct costs incurred by the patient. These are in addition to caffeine procurement costs which range from INR 10 and can range up to INR 100 per 150ml of caffeinated drinks for each subject.  9 of the 164 participants reported to have overdosed on caffeine at least once. 31 subjects attempted de-addiction of caffeine usage of which a majority (n=25) were successful in doing so. 6 subjects experienced withdrawal symptoms and had relapsed.

The above table shows the comparison of alcohol consumption between males and females. A total of 30 subjects responded to this question.  From 30 subjects, a majority (70%, n=21) of subjects who consumed alcohol belonged to 20-25 years of age. The other participants who consumed alcohol belonged to the age group of 35-40 years (n=4, 13%), 25-30 years (n=2, 6.6%), 30-35 years age (n=2, 6.6%) and 45-50 years of age (n=1, 3.3%). The mean age of male participants who reported consuming alcohol is 24.6 years which is nearly the mean of female age which is 24.5 years of age. Subjects were segregated based on their annual income.  The majority of subjects (n=16) earned an average of 2.5 lacs to 10 lacs per year. 8 subjects 10 lacs to 25 lacs per annum, 6 subjects earned more than 25 lacs per annum and one subject reported to earn less than 2.5 lacs per year.  According to the findings of this study, most of the subjects who consume alcohol were from families that earned 2.5 lacs to 10 lacs per year.  Each hospital visit cost is assessed for influencing the cost of alcohol consumption to the subject. We factor in hospital visit costs ranging from 0 to 50,000 rupees. 8 subjects reported to have visited clinics seeking medical help. 3 subjects spent between INR 0 to 1000 on each of the hospital visits, and another 3 spent in the range of INR 20,000-50,000. One subject spent INR 1,000-5,000 and similarly, another subject spent between 5,000-10,000 rupees. The subjects spent an average of INR 14,625.00 for hospital visits regarding alcohol-associated diseases, which are the direct costs. These are in addition to alcohol procurement costs which range from INR 100.00 and can range up to INR 10,000.00 per bottle of 500ml for each subject. Seven of the 53 participants reported to have overdosed on alcohol at least once

Table 4:  Pharmaco-economics and demographic characteristics of subjects who chew on tobacco.

The above Table-4 contains information about participants who had chewed nicotine as tobacco, such as duration of consumption, annual income of subjects and their families, cost of hospital visits, overdose, clinical difficulties, and drug usage cessation. Of 13 subjects who reported chewing tobacco, a majority (n=8, 61%) of subjects belonged to 20-25 years of age. The other participants who chewed tobacco belonged to the age group of 25-30 years (n=3, 23%), 30-35 years (n=1, 7.69%), and 35-40 years (n=1, 7.69%,).  The mean age of male participants who reported to consume tobacco is 25 years as compared to the mean of female age which is 26.5 years of age. The subjects were segregated based on their annual income.  A majority of subjects (n=8) earned an average of 2.5 lacs to 10 lacs per year. 4 subjects reported to have an income of more than 25 lacs per annum and one subject reported to earn less than 2.5 lacs per year.  According to the findings of this study, most of the subjects who chew tobacco were from families that earned 2.5 lacs to 10 lacs per year.  Each hospital visit cost is assessed for influencing the cost of tobacco consumption to the subject. We factor in hospital visit costs ranging from 0 to 50,000 rupees.3 subjects reported to have visited clinics seeking medical help. 1 subject spent between INR 0 to 1,000 on each of the hospital visits, 1 subject spent INR 1,000-5,000 and another 1 spent in the range of INR 20,000-50,000. These subjects spent an average of INR 12,833.00 for hospital visits regarding nicotine overdose or for other nicotine-associated symptoms, which are the direct costs incurred by the patient. These are in addition to tobacco procurement costs which range from INR 8.00 and can range up to INR 50.00 per 10gm of tobacco for each subject. 3 of the 13 subjects reported to have overdosed on nicotine at least once. 4 subjects attempted de-addiction of which a majority (n=3) were unsuccessful in doing so, and experienced withdrawal symptoms and had relapsed. Only one subject reported to have successfully quit tobacco consumption.

Table 5:  Pharmaco-economics and demographic characteristics of subjects who consume cannabis.

From 7 subjects who responded to the questionnaire, a majority (n=5, 71.42%) of subjects who consumed cannabis belonged to 20-25 years of age of which, males were the predominant majority (n= 4 of 5) The mean age of male participants who reported to consume cannabis is 22.5 years as compared to the mean of female age which is 29.1 years of age. The subjects were segregated based on their annual income.  A majority of subjects (n=4) earned an average of 2.5 lacs to 10 lacs per year. 2 subjects reported to have an income of more than 25 lacs per annum and one subject reported to earn 10 lacs to 25 lacs per year.  According to the findings of this study, most of the subjects who consume cannabis were from families that earned 2.5 lacs to 10 lacs per year.  Each hospital visit cost is assessed for influencing the cost of cannabis consumption to the subject. We factor in hospital visit costs ranging from 0 to 50,000 rupees. 2 subjects reported to have visited clinics seeking medical help. Both of the subjects reported to have spent between INR 20,000 to 50,000 on each of the hospital visits. These subjects spent an average of INR 35,000.00 for hospital visits regarding cannabinoid overdose or for other cannabinoid-associated symptoms, which are the direct costs incurred by the patient. These are in addition to cannabis procurement costs which range from INR 500.00 and can range up to INR 5,000.00 per 1gm of cannabis for each subject. 2 of the 7 subjects reported to have overdosed on nicotine at least once. 2 subjects attempted de-addiction, but both reported to be unsuccessful in doing so and experienced withdrawal symptoms and relapsed.

Out of the total 209 subjects who consume addictive substances, 23 reported having had visits to medical professionals regarding their addictive behaviours. This table represents the medical problems of the addicted subject. A total of 21 participants responded to this question.Of the total 209 respondents, 21 subjects (10%) reported to have diagnosed with a medical condition. 2% of patients (n=5) reported were diagnosed and treated for stomach disorders (peptic ulcers, gastric bleeding), tremors (convulsions due to withdrawal) and liver diseases (cirrhosis, fatty liver and alcoholic liver disease), respectively. 2% (n=4) of patients reportedly were diagnosed with breathing disorders (COPD, asthma). 1% (n=2) of the patients reported to have been treated for heart-related disorders (CHF, Arrhythmia).