By Prof. Adrian Kennedy

DEPENDENCY MANAGEMENT

Alcohol Smoking

Drugs

Paan, etc.

DEPENDENCY MANAGEMENT

Ezzati M, et al. Lancet 2002;360:1347–60

Attributable Mortality (in thousands; total 55,861,000)

0 8000 7000 6000 5000 4000 3000 2000 1000

LIFESTYLE RELATED MORTALITY FACTORS

Total Usage - 35 % Rural Usage - 38 % Urban Usage - 25 % Male - 48 % Female - 20 % Paan, Gutka - 21 % Cigarette, beedi - 09 %

TOBACCO PRODUCTS

Smoking Tobacco Cigars, Cigarettes

Non Smoking Tobacco Paan, Gutka etc

More than 2000 Chemicals including

Acids, Alcohol,

Aromatic Hydrocarbons, Benzene,

Carbon Monoxide, Glycol, Nitric Oxide,Nicotine,Tar,

Cyanide, etc.

Trace Analysis of “Nicotiana Tabacum”

CIGARETTES, CIGARS, PIPE, BEEDI, SHEESH

Carbon Monoxide - Destroys Oxygen

Acids - Destroys Lung Tissue

Alcohol - Cauterizes the Brain

Glycol - Sedative/Tranquilizer

Nitric Oxide - Anesthetic, Pain Reducer

Benzene - Coke Oven Gas/Leukemia

Tar – Cancer

Arsenic – Chemical Warfare

Hydrocarbons - Used for killing Insects

Cyanide - 100 mg causes Death

Nicotine - Highly Addictive

TRACE CHEMICALS IN SMOKING

Brain Stroke

Lungs Cancer Bronchitis

Stomach Ulcer Intestines

Pregnancy Abortion Small/Malformed Congenital

Mouth/Throat

Trachea/Gullet Cancer

Heart HBP Heart Rate Heart Attack

Blood Cancer

Hereditary Passive Smoking

EFFECT OF SMOKING ON THE BODY

Top 3 Smoking-Attributable Causes of Death Lung cancer

Ischemic heart disease COPD

Cancer Lung (#1)* Leukemia (AML, ALL, CLL)2-

4 Oral cavity/pharynx Laryngeal Esophageal Stomach Pancreatic Kidney Bladder Cervical

Cardiovascular Ischemic heart disease (#2)* Stroke – Vascular dementia5 Peripheral vascular disease6

Abdominal aortic aneurysm

Respiratory COPD (#3)* Pneumonia Poor asthma control

Reproductive Low birth weight Pregnancy complications Reduced fertility SIDS

Other Adverse surgical outcomes/wound healing Hip fractures Low bone density Cataract Peptic ulcer disease†

*Top 3 smoking-attributable causes of death. †In patients who are Helicobacter pylori positive. AML = Acute myeloid leukemia; ALL = acute lymphocytic leukemia; CLL = chronic lymphocytic leukemia; COPD = chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome. 1. Surgeon General’s Report. The Health Consequences of Smoking; 2004. 2. Sandler DP et al. J Natl Cancer Inst. 1993;85(24):1994-2003. 3. Crane MM et al. Cancer Epidemiol Biomarkers Prev. 1996;5(8):639-644. 4. Miligi L et al. Am J Ind Med. 1999;36(1):60-69. 5. Roman GC. Cerebrovasc Dis. 2005;20(Suppl 2):91-100. 6. Willigendael EM et al. J Vasc Surg. 2004;40:1158-1165.

SMOKING:LEADING PREVENTABLE CAUSE OF DISEASE AND DEATH

Doll R et al. BMJ. 2004;328:1519–1527.

4

26

59

81

94

100

80

60

40

20

0

40 50 60 70 80 90 100

Physicians Who Smoked Cigarettes

Physicians Who Did Not Smoke

Cigarettes

10 years

97 91

81

59

24

2

Years

% Survival From Age 35

SMOKERS DIE AN AVERAGE OF 10 YEARS YOUNGER

OTHER REASONS NOT TO SMOKE

Social outcast

Smokers Cough

Breathlessness

Fatigue

Ageing

Skin

Bad Breath

Body odour

Disease Risk

Cost Factor

Loss of Taste

Early Demise

Tea/Coffee

Concentration

Reward

Driving

(Time) Habit

Daily Event After a meal

Telephone

Stress

Boredom

Alcohol

Doll R et al. BMJ. 2004;328:1519–1527

Social (peer

pressure)

CUES OR “TRIGGERS” TO SMOKE

Relaxation

Stimulation

Craving

Habit

REASONS FOR SMOKING

Cutting Down Method

Quitting Cold

Aversion Therapy

Alternate Therapy

Nicotine Substitutes

Healthy Substitutes

Hypnosis

Counseling

Group Support

QUIT SMOKING METHODS

Smoke Half only.

Smoke Filter/Mild/Low Tar.

Do not Inhale.

Avoid Dangling Cigarettes.

Do not Smoke in Office /

Home.

Do not Smoke in Public Places.

Resist Passive Smoking.

CUTTING DOWN METHOD

Set a Date To Stop

Find Your Substitute

Group Support System/Advice

Family Support

Abstain ( 3 Weeks)

QUITTING COLD

Relaxation - After Meals, Etc. Music-meditation Yoga Stimulation - Perks Me Up, Help Me Concentrate. Deep Breathing, Exercise Craving - Desperate Urge Aversion, Nicotine Therapy Group Support Habit - Fixed Times, Automatic, Never Buy, Keep/Avoid

HEALTH SUBSTITUTES

Nicotine Replacement treatment

(NRT)

Bupropion (Zyban)

Varenicline (Champix)

MEDICAL METHODS

In smokers, abrupt cessation of Nicotine intake causes Withdrawal Discomfort

Access to Nicotine via alternative routes provides relief and assists with transition to complete abstinence

Slower Nicotine absorption, from source other than cigarettes, helps to combat dependence on Smoking

Harmless as compared to Nicotine combustion in Cigarette

NICOTINE REPLACEMENT TREATMENTS RATIONALE

Gum

Patch

Nasal Spray

Lozenge

NRT PRODUCTS

NRT

Reduces severity of Withdrawal Symptoms

Reduces Urges to Smoke

Delays Weight Gain

Reduces Relapse

Doubles Success Rates

DO THEY WORK?

0

5

10

15

20

0 10 30 50 70 90110

Time (min)

Ven

ou

s N

ico

tin

e (

ng

/ml)

Cigarette

Nasal spray

Nicotine gum etc.

Patch

NICOTINE DELIVERY BY CIGARETTES & NRT PRODUCTS

NRT have been used worldwide for over 25 years by many million of smokers

No alarming side effects or any other danger signal have emerged

NRT is safe, particularly compared with smoking

IS NRT SAFE?

All Smokers

Only 5–10% Succeed each

Year3

70% Want to Stop1

30-40% Try each Year2

1. Bridgwood et al, General Household Survey 1998. West, Getting serious about stopping smoking 1997. 3. Arnsten, Prim Psychiatry 1996.

NICOTINE DEPENDENCE

Smoker

Contemplation (usually lasts 6 months)

Preparation (date is set to quit)

Action (lasts from 1 – 6 months)

Maintenance (may last for years)

Termination (10-15 %)

Relapse (70-85 %)

STAGES OF QUITTING

Restlessness or impatience

(<4 weeks)2

Increased appetite or weight gain (>10 weeks)2

Withdrawal Syndrome

Anxiety (may increase or

decrease with quitting)1,2

Dysphoric or depressed mood

(<4 weeks)2

Irritability, frustration, or

anger (<4 weeks)2

Difficulty concentrating (<4 weeks)2

Insomnia/sleep disturbance (<4 weeks)2

1. Diagnostic and Statistical Manual of Mental Disorders, IV-TR. Washington, DC: APA; 2006: Available at http://psychiatryonline.com. Accessed November 7, 2006. 2. West RW, et al. Fast Facts: Smoking Cessation. 1st ed. Oxford, United Kingdom. Health Press Limited. 2004.

WITHDRAWAL SYNDROME: A COMBINATION OF PHYSICAL & PSYCHOLOGICAL CONDITIONS,

MAKING SMOKING HARD TO TREAT

Night-time Awakening Constipation (17%, 9% Severe)

Mouth Ulcers (40%, 8% Severe), Respiratory Tract Infections

Productive Cough Coughing And Breathlessness Improve Within A Month

LESS FREQUENT WITHDRAWAL SYMPTOMS

1. CDC. Surgeon General Report 2004: http://www.cdc.gov/tobacco/sgr/sgr_2004/sgranimation/flash/index.html. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 2. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 3.US Department of Health & Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1990. Available at: http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed July 2006.

Lung function may start to improve with decreased cough, sinus

congestion, fatigue, and shortness of breath

3 m

on

ths

Lung cancer risk is 30-50% that of continuing smokers

Ce

ssa

tio

n

CHD: excess risk is reduced by 50% among ex-smokers

Cardiovascular heart disease (CHD) risk is similar to never smokers

Stroke risk returns to the level of people who have never smoked at 5-15 years post-cessation

1 y

ea

r

5 y

ea

rs

10

ye

ars

15

ye

ars

WHY QUIT? POTENTIAL LIFETIME HEALTH BENEFITS OF QUITTING SMOKING

0

10

20

30

40

50

60

70

80

90

100

40 50 60 70 80 90 100

Doll R et al. BMJ. 2004;328:1519–1527.

Years

% Survival

From Age 40

Stopped Age 35-44 Nonsmokers Cigarette Smokers

QUITTING AT ANY AGE INCREASES LIFE EXPECTANCY

Beer Wine Cocktails Spirits Liquors

Beer : Ale, Stout, Cider, Lager, Sake Wine : Red, White, Sparkling, Champagne Cocktails : Gimlet, Tom Collins, Manhattan, Martini Spirits : Rum, Whisky, Vodka, Gin, Tequila Liquors : Amaratto, Bendictine, Contreau, Drambue Local : Toddy (Palm), Handiya (Rice) Fenny (Cashew), Arrack (Chemical)

Local

ALCOHOL

Ingredients : Barley, Wheat, Yeast, Water, Apples (Cider) Method : Fermentation Of Grains / Apples For 4- 5 Days Types : Draught, Ale, Lager, Cider Bitter Alcohol Content : 5-10% Serving : Chilled & Straight

BEER

Ingredients : Grapes

Method : Fermentation from 1-5 years

Types : Red, White, Sparkling

Alcohol

content : 10-24%

French wines : Burguindy or Bordeoux and

Don perignon (Champagne)

Portuguese : Port wine

United States : California Red wine (German, Australian and Goan

wines)

Serving : Chilled or room temperate

WINE

Gin : Origin : French and British Distilled : From Barley and Corn with Sugar Fruit and Berries to Taste Not aged : Colourless Famous brand : London Dry Gin

DISTILLED SPIRITS (40-55% ALCOHOL)

Vodka : Origin : Russian and Polish Distilled : From Potatoes, Molasses and Rye Not aged : Colourless and odourless Famous brand : Smirnoff

Tequila : Origin : Mexican Distilled : From Agave Plant Aged : 6 months to a Year Usually Colourless

Serving : Vodka with orange juice Gin with Lime / tonic Tequila shots

Serving : Rum with Coke Brandy, neat at room

temperature

DISTILLED SPIRITS (40-55% ALCOHOL)

Rum : Origin : Carribean - Distilled & Fermented From sugarcane &

Molasses - Aged : 6 months to a year - Colour : Golden, Dark & Colourless - Famous brand : Bacardi, Old Monk

Brandy : Origin : French (Cognac) - Distilled : From wine in a - Ratio of 10 Gallons of Wine gets One

Gallon of Brandy - Aged : 2-5 years in Cask (Naepolean = 4 years & VSOP = 5

years)

Whisky : Scotland Whiskey : Ireland Bourbon : USA - Distilled from a Mash of Grains (barley, wheat, Corn & Rye) - Ageing, 8-24 years in an Oak Cask - Types; Single Malt & Blended - Famous brands: Scotch, Irish & Jack

Daniell

DISTILLED SPIRITS (40-55% ALCOHOL)

Serving : On the rocks with water, soda (and coke)

Cocktails : Bloody Mary, Gimlet,

Screwdriver, Martini,

Tom collins, Diaquiri, Pina

Colada Manhattan, Rattlesnake,

Mahjong

Liquors : Amaretto, Benedictine, Contreau,

Drambue Kahlua, Tia Maria Irish

Cream

COCKTAILS & LIQUORS

1. PEG

30 ML SPIRITS.

1 GLASS WINE

2 GLASS BEER

1

2

3

4

5

1 2 3 4 5

METABOLIZATION RATE

= 1 Peg / Hour.

PEGS Body weight

Food in Stomach

% of Alcohol

Psychological factors

Tolerance levels

METABOLIZATION

1 Peg 3 Pegs 5 Pegs 10 Pegs 13 Pegs

Cheerful Accident Prone Loss of Control Sleep/ Mem Loss Coma/Death

QUANTUM EFFECT

Social Phase (Early) Not Drinking Every Day. Not Exceeding Three Pegs. Not Worried about Non availability.

Risk Phase (Middle) Drinking Alone. Drinking More under Pressure Unable to Quit Easily.

Critical Phase (Chronic) Feeling of Confidence. Frequently Exceeds Three Pegs. Frequently Loses Control.

PHASES IN ALCOHOLISM

Increased Tolerance

Denial Intellectualism

Decreased Tolerance Ethical Breakdown Mental/Physical Malfunction

Drink Slowly - 1 peg/hour

Dilute With Water

Eat Before/During Drinking

Never Exceed Two Pegs

Avoid Drinking Daily

Avoid Drinking Alone

Avoid Drinking Mornings

Avoid Drinking Under Pressure

Do not Drive/Work after Drinking

SAFE DRINKING FOR SOCIAL DRINKERS

Observe or Quit

Alcohol vs. Mortality

1 Peg a Day - Same as Non Drinkers

3 Pegs a Day or More - 60 - 100%

Higher Mortality

AVOIDING A HANGOVER Eat Before / During

Drinking

Avoid More than 3 Drinks

Do not Mix Drinks

Have Sufficient Water

Sleep it Off

Lemon Juice (vit C) is Good

Eat Bananas & Bread

Avoid Coffee / another Drink

Brain & Nervous System Coord/Memory

Eyes. Loss Of Vision Visual Disturbance

Heart & Myopathy Blood

Stomach & Intestines Ulcer

Vitamin Loss Muscle Nerves Brain Heart Blood Skin Liver

Sexual Urge

Liver Cirrhosis Cancer

Muscles & Coordination

Personality Shy/Bold Repressed / Sexual Calm / Disruptive

Foetus Malformation Accidents Violence

EFFECT OF ALCOHOLISM

Loss of work, Finance Loss of Prestige, Shame Guilt, Anger, Fear Desperation, Illness Family Breakdown.

Children Lack of Role Model Loss of self esteem. Confusion & Deception Fear, Insecurity etc.

EFFECT ON FAMILY

Parents Spouse

Medical : Withdrawal, Overdose, Chemical, Tablets, Injections. Psychological : Counseling (Individual and Family) Social : Alcoholics anon, Self - Group Therapy by Ex-alcoholics Behavioral : Avoid Pubs, Parties, Diet, Exercise, Relaxation etc.

QUITTING ALCOHOL

Alcohol is a Disease

An alcoholic loses all Controls after Drinking

An alcoholic can Never Have a Drink

Only an alcoholic can Counsel Another

AA is a World wide Non Professional, Non

Profit Body & has Weekly Meetings

Success Rate 50 %

ALCOHOLICS ANONYMOUS

Accept Personal Powerlessness over Alcohol

Accept that a Power greater than You can help

Make an Honest & Fearless Inventory of Wrong

Doings

Admit to Another Your Wrong Doings & Take Steps

to Remedy them

Pray to God (as you know him) for Daily Help

Help other Alcoholics

A. A. THE 12 STEPS

Prescribed (Medical)

Non Prescribed (Non Medical)

Stimulants Depressants Hallucinogens

Infection Non Infection

CLASSIFICATION OF DRUGS

Infection Antibiotic Antiviral Anti fungal Antiseptic

Non Infection

Systemic Digestive Cardiac Neurology Skeletal Endocrine Reproductive ENT/Eye Skin etc.

General Pain Fever Metabolism Allergies Poison Surgical Cancer Diagnostic

PRESCRIBED DRUGS

Too Much : Increased Dosage. Too Often : Increased Frequency. Too Long : Extended Periods. Wrong Usage : Stimulants & Depressants. Wrong Combinations : Depressants & Alcohol.

General Consequences of Drug Abuse. Tolerance : Higher Doses for Same Effect. Dependence : Psychological, Physical. Withdrawal : Nausea, Vomiting, Watery Discharge Perspiration, Sneezing, Restlessness, Pain, Spasms, Cramps, Insomnia, Delirium, Convulsions.

MEDICATION ABUSE

Stimulants

Amphetamines : Speed, Meth, Dexies, Uppers Cocaine : Coke, Crack

Depressants

Tranquilizers : Downers, Barbs (Valium) Heroin : Junk, Smack, Brown Sugar, Crap Inhalants : Sniffing

Hallucinogens

LSD : Acid, Paper Acid Marihuana : Grass, Pot, Dope, Weed PCP : Angel Dust, Crystal Party Drugs Mind Erasers, Easy Lay, GBH (Great Body Harm)

Street Names NARCOTICS

Amphetamines: capsules, pills ecstasy(Oral). Cocaine (Cocoa Plant Leaves), : Powder (Chewed, sniffed, injected). Effects : Short term : Euphoria, self confidence, increased wakefullness. Long term : Sleep problems, HBP, Tachycardia, mood swings violence. Tolerance, Dependence Withdrawal

Ampetamines (Synthetic)

Cocaine (Natural)

Preferred by Socially elite, students, Executives

STIMULANTS

Effects : Short term: Relaxation, Sedation, Relief of Anxieties : Long term : Depression, Fatigue, Impaired Attention, Reduced Libido

Tolerance Dependence Withdrawal

Tranquilizers (Synthetic)

Heroin (Semi Synthetic)

Opium (Natural)

Inhalents (Synthetic)

DEPRESSANTS

Tranquilizers (Barbiturates, Sleeping pills) : Tablets, Pills, Injection, Anasthesia Inhalents : Solvents (gasoline, paint) ,Aerosol (hair spray) Heroin (Brown sugar) (Morphine) : Powder, Injection, Smoked, Chased, : Injected. Opium (Poppy Plant pods) : Chewed, Smoked, Drunk.

Preferred by Housewives

Lysergic acid diethylamide (LSD) : Derived from Ergot Fungus from Rye, or Morning Glory seeds. (Orally, LSD blotter, tablets, injected). - Mescaline, from The Peyote Cactus (oral route). - Pilocybin, from Mushroom (smoked, chewed). Cannabis (hemp plant): - Ganja / Marijuana (from the Leaf & Flower) smoked - Hashish / Charas (from the Stem) smoked. - Bhang (from Dried Leaves & Stem) drunk. Effects: Short term : Dreamy State, Increased Sensations (light, sound, sight), Altered Perception of Time, Space Capability. Long term : Tachycardia, Dilation of Vessels, Bronchitis, Asthma, Reduced Immunity Tolerance Dependence Withdrawal

LSD (Semi Synthetic)

Cannabis (Natural)

Preferred by Socially Deprived

HALLUCINOGENS

Colourless, Odourless, Fast Acting, Tasteless

Loss of Consciousness, Confusion, Loss of Memory, Lack of Coordination

Street Names : Mind eraser, Easy Lay. (GBH) Great Boday Harm

Safety : Don’t Share, Don’t accept drinks from strangers. Buddy System

STIMULANTS - Ecstacy - Cocaine

ANAESTHETICS - Rohypnon

- Ketamine

PARTY DRUGS

Medical Detoxification

Social Group Therapy Family Therapy Behavior Therapy Self-Help Groups

Alternative Relaxation Therapy Acupuncture Exercise Therapy

TREATMENT METHODS

PROF. ADRIAN KENNEDY

(Chief Wellness Officer)

Arabian Wellness & Life Style Management

(Arabian Healthcare Group Initiative) (RAK Hospital)

Ras al Khaimah, UAE Mob: 0502215234

Email: prof.kennedy.aj@gmail.com