Harm Reduction Strategy PDF

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..."

" ...
157:
He (Allah) allows them as lawful what

is good (and pure) and prohibits them
from what is bad (and impure)
The Glorious Quran: Al-Araf:7:157
FIMA
Year Book 2014
Federation of Islamic Medical Associations
ADDICTION:
MEDICAL, PSYCHOSOCIAL AND ISLAMIC PERSPECTIVES
Publisher:
Jordan Society for Islamic Medical Sciences Jordan Medical
association, Amman-Jordan
-
With special permit from:
Federation of Islamic Medical Associations (FIMA)
October, 2014
FIMA
YEAR BOOK 2014
Editorial Board
Editor in Chief
Hossam E. Fadel
Clinical Professor, Obstetrics and Gynecology
Maternal Fetal Medicine
The Medical College of Georgia,
Georgia Regents University
Augusta, GA, USA
Aly A. Mishal
Senior Consultant in Endocrinology
Chairman-Ethics Committee, and
Ex-Chief of Medical Staff
Islamic Hospital
Amman- Jordan
Abul Fadl Mohsin Ebrahim

Professor Emeritus
School of Religion, Philosophy and Classics
University of KwaZulu-Natal, Durban, South Africa
Musa bin Mohammad Nordin

Consultant Pediatrician Neonatologist
Professor- Cyberjaya University College
Of Medical Sciences (CUCMS)
Kuala Lumpur Malaysia
Publisher:
JORDAN SOCIETY FOR ISLAMIC MEDICAL SCIENCES, In collaboration with, and special
permit from: FEDERATION OF ISLAMIC MEDICAL ASSOCIATIONS ( FIMA ).
ADDICTION: Medical, Psychosocial and Islamic Perspectives

:
All rights reserved, No part of this publication may be reproduced, stored in a retrieved system,
or transmitted in any means, electronic, mechanical, photocopying, recording or otherwise
without the prior permission of the publisher.
First Edition: October, 2014
ISBN: 969-8695-10

( 2014/10/4934 )
Jordan Society for Islamic Medical Sciences

FIMA Year Book 2014: ADDICTION: Medical, Psychosocial and Islamic
Perspectives / Jordan Society for Islamic Medical Sciences Amman:
JSIMS, 2014.
( 180 ) P
Deposit No.:2014/10/4934
Descriptors: Addiction// Medical// Psychosocial
Opinions in the articles are those of their authors. The editorial board does not necessarily
endorse these opinions, nor do these opinions represent the official position of FIMA.
Printed in Amman-Jordan, Al-Dustour Printing.

EDITORIAL
TABLE OF CONTENTS
1. Editorial IX
2. FIMA: Federation of Islamic Medical Associations: in Brief XIII
3. BIOLOGICAL MECHANISMS UNDERLYING ADDICTION
Ilhan Yargic
4. ALCOHOL USE DISORDERS: SCIENTIFIC HORIZONS
AND ISLAMIC PERSPECTIVES
Mohammad Ali Albar, and Aly Mishal
5. TOBACCO DEPENDENCE: THE WHOLE STORY
Feras Hawari
6. OPIATE ADDICTION
M. Basheer Ahmad
7. CANNABIS
Adnan Takriti
8. QAT ADDICTION IN YEMEN: SOCIO - ECONOMIC PERSPECTIVES
ON HEALTH
Husni Al-Goshae
9. BEHAVIORAL ADDICTION
Mehmet Dinc
10. ADDICTION AND SUBSTANCE ABUSE IN PREGNANCY
Hassan M. Harirah, and Saher E. Donia
11. MOBILIZATION OF THE PUBLIC AGAINST ADDICTION:
THE TURKISH GREEN CRESCENT SOCIETY AS A MODEL INSTITUTION
M. Ihsan Karaman
12. BEWARE OF SPIRITUAL BYPASSING: INTEGRATE PSYCHOTHERAPY
IN THE ADDICTION RECOVERY PROCESS
Ketam Hamdan
13. HARM REDUCTION STRATEGY IN THE TREATMENT OF ADDICTION
IN THE CONTEXT OF ISLAMIC JURISPRUDENCE
Imthiaz Hoosan and Prof. Yasien Mohamed
14. ISLAMIC PERSPECTIVES ON PROPHYLAXIS AND THERAPY
OF ADDICTION
Mahmoud Abu Dannoun
15. ISLAMIC RELIGIOUS INPUT IN THE TREATMENT
AND REHAB OF DRUG ADDICTION: EXPERIENCES FROM MALAYSIA
Mahmood Nazar Mohamed, and Sabitha Marican
16. ISLAMIC PSYCHO-SPIRITUAL THERAPY (PST):
PANACEA FOR THE DRUG ADDICT
M. Hatta Shaharom
FIMA YEAR BOOK 2014 VII

EDITORIAL
EDITORIAL
Dear FIMA members
Assalamu Alaykum
Bismillah al-Rahman al-Rahim
Praise be to Allah the Most Merciful, the Most Beneficent. May Allah ( )shower His blessings and
peace on the Prophet and Messenger Muhammad ().
I begin by thanking the FIMA Executive Committee for honoring me with the responsibility of being
the Editor-in-Chief again for this year's yearbook. I thank Allah ( )for giving me this opportunity
and enabling me to accomplish this task. I pray to Allah ( )to accept my effort in His way and to
reward all who participated in this effort.
This years yearbook is addressing the worldwide serious problem of addiction. Addiction is a
chronic relapsing disease characterized by craving for a drug, compulsive drug use, inability to
control intake, and a resultant state of withdrawal with specific features when the drug cannot be
accessed. Another type of addiction has been recently described, i.e. behavioral addiction. It is the
same condition except that the putative agent is not a drug but a certain behavior.
In the first chapter, Dr Yargic discusses biologic mechanisms underlying addiction. He argues that
addiction is a brain disease that starts with drug use that triggers a series of biological cascades.
The drugs affect four interrelated biologic systems; brain reward system, autonomic nervous
system, prefrontal cortex (PFC), and the brain stress system. Drugs stimulate the mesolimbic
dopaminergic system much more than natural stimuli and produce a reward or high. Repetitive
stimulation causes sensitization that causes craving for the drug. Other neurotransmitters are also
involved e.g. serotonin. Dr Yargic describes the brain stress system as an alarm circuit that is
triggered by unpleasant stimuli. It is mediated by corticotrophin releasing factor resulting in
release of glucocorticoids, norepinephrine and dynorphin. This system aims to neutralize the reward
effects of drug use and to decrease dopamine release and restore normal function. This causes
tolerance to the drug and dysphonic syndrome when the use stops because the changes in the
stress system continue after avoiding the drug. Long term use of drugs leads to adaptation within
the autonomic nervous system and target organs. This adaptation is disturbed when the drug is
avoided and results in the physical manifestations of withdrawal. The prefrontal cortex is involved
in both the limbic reward system and the regulation of the higher order executive functions. In
addition PFC dysfunction is related to both compulsive drug use and the dysfunctional behaviors of
the addict.
Alcohol is the most widely abused drug worldwide. Alcohol dependence (Alcohol Use Disorder) is
more common than dependence on all other psychoactive drugs combined. This is primarily because
of its easy availability in most world communities. Although "social drinking is acceptable in most
nations, no level of alcohol consumption is considered safe. Drs Al-Bar and Mishal describe the
epidemiology of alcohol consumption. They report that the total cost of alcohol consumption and
dependence to national USA economy was 185 billion USD in 1998. This excludes the intangible
losses that are difficult to quantify, including; domestic violence, child abuse and loss of careers.
The authors discuss in detail the medical harmful effects of alcohol. Globally, alcohol is reported to
FIMA YEAR BOOK 2014 IX

EDITORIAL
be responsible for 3.2% of all deaths and 4% of disease burden. Excessive alcohol consumption and
binge drinking are the third leading cause of preventable death in USA.
The cardiovascular effects have been the subject of several studies. Some observational studies
conferred some beneficial effects of social drinking primarily cardioprotective effects (decrease
in the risk of coronary heart disease). These studies were not replicated in randomized studies and
were not endorsed by professional organizations such as the Royal College of Physicians (UK) or by
the American Heart Association's Science advisory Council in its 2001 report. Any such possible
benefit is outweighed by its harmful effects on almost all organ systems as detailed in the article.
Alcohol is a contributing factor in accidents, especially car accidents and in injuries resulting from
the use of dangerous equipment. Up to 45% of injured patients reported consuming alcohol before
their injuries and more than a third reported that their injury occurred within 30 minutes of their
last drink. Suicide, homicide, serious assaults and rape are significantly increased in association with
alcohol consumption.
The authors point out that the main difficulty in the control of alcohol use disorder is that policies
are not directed towards limiting the availability of alcohol. They compare this with efforts to
curtail the availability of other dependence inducing drugs. They cite the failure of the prohibition
amendment passed in USA 1919-33 and of similar attempts in Russia. The attempt to only partially
limit alcohol consumption, by penalizing driving under the influence of alcohol and the prohibition of
sale or service of alcoholic drinks to youngsters has not been successful either. They compare
these failed efforts to the successful Islamic approach. Islam aimed at and succeeded almost
completely in eliminating alcohol consumption by a gradual approach of its prohibition, simultaneous
nurturing of moral values, and inculcation of faith that led people to obey Gods orders.
Dr Hawari discusses tobacco dependence. Smoking is probably as widespread as alcohol intake.

Tobacco smoking is highly addictive. Nicotine acts on the nucleus accumbens causing release of
dopamine similar to other recreational drugs. As other addictive drugs nicotine addiction is
characterized by the persistence of drug seeking behavior, and the occurrence of withdrawal
symptoms upon abrupt cessation. According to the Diagnostic and Statistical Manual of mental
disorders it is ranked third after heroin and cocaine and higher than alcohol and cannabis in its
ability to cause dependence. It has been documented that smoking is responsible for increased
morbidity and mortality due to various diseases directly attributed to smoking and the effects of
second hand smoking mostly affecting women and children.
It is estimated that more than 5 million persons die annually due to tobacco related diseases.
Smoking is associated with increased incidence of cardiovascular diseases, peripheral vascular
disease, cerebrovascular diseases, and of sudden death. Smoking also increases the risk of head and
neck cancers, lung, urinary bladder, colon, liver, and breast cancers. This increased risk is caused by
the presence of at least 69 chemicals in tobacco smoke that are carcinogenic. Smoking causes and
affects many respiratory diseases, notably chronic obstructive pulmonary disease (COPD) .
Dr Hawari then discusses tobacco dependence treatments. Quitting smoking results in significant
and rather quick beneficial effects on health. It reduces premature death by 90% for those who
quit before the age of 30 and by 50% for those who quit before the age of 50. The World Health
Organization (WHO) has recommended strategies to encourage smoking cessation. These include
inclusion of smoking cessation advice in primary healthcare settings, establishing accessible and
free quit-lines and ensuring the availability of low cost pharmacotherapy. These include nicotine
replacement therapy as well as medications that help suppress the urge to smoke such as Buprion,
and varenicline. WHO also developed The Treaty Framework Convention on Tobacco Control that
X FIMA YEAR BOOK 2014

EDITORIAL
advocates various strategies to counteract marketing of cigarettes and smoking culture by the
tobacco industry.
Dr Basheer Ahmed discusses opiate addiction. Globally between 24 and 25 million adults aged
between 15 and 64 years used an illicit opiate in 2010, 12 million of whom were in the USA. Opiate
addiction is the most serious form of drug addiction. In that year, 100 deaths occurred every day
from opiate overdose in the USA.
A major component of opiate addiction is the abuse of prescription opiates. Prescriptions for opioid
analgesics increased from 75.5 million in 1999 to 206.5 million in 2009. Oxycodone, oxycontin,
fentanyl and codeine are commonly prescribed for moderate and severe pain, sometimes without
proper justification.
There are three medications approved by the Federal Drug Administration (FDA) in the USA for
long term treatment, the opioid agonist methadone, the opioid partial agonist buprenorphine, and
the opioid antagonist naltrexone. Along with the medications psychosocial treatment significantly
enhances successful results. Dr Ahmed states that the elucidation of the underlying cause(s) of the
addictive behavior through psychosocial therapy enhances the motivation to stop drugs, teaches
coping with stress, changes reinforcement contingencies, fosters management of pain effects and
enhances social support and inter-personal functioning. Dr Ahmed laments the fact that contrary to
Islamic teachings, Muslims are heavily involved in planting, harvesting, refinement, smuggling, and
distribution of heroin(and Cannabis) to Western countries. Afghanistan is the world's top user of
heroin per capita. Iran and Pakistan have a high percentage of heroin addicts.
Dr Ahmed emphasizes the responsibility of Muslim communities to support and help to rehabilitate
the addicts- rather than stigmatizing them-and to encourage them to seek treatment. He
emphasizes that for Muslim patients, psychotherapy should focus on spirituality, strong belief in
God, asking for forgiveness, increasing the hope and giving strength to coping mechanisms. This
spiritual guidance may affect the brain reward system so the addict recognizes new cues for
pleasure redirecting it away from drugs to new religious experiences.
Another commonly used psychoactive drug is Cannabis which is discussed by Dr Takriti in another
chapter. He reports that the United Nations considered cannabis the most used illicit drug
worldwide.
Cannabis is produced from dried leaves, flower, stems and seeds of the weed Cannabis Sativa. It
contains 460 compounds, at least 80 of which are cannabinoids, the most active of which is
tetrahydrocannabinoid (THC). Cannabis can be consumed as the dried herb, resin, or oil. Cannabis
can be smoked in cigarettes alone or with tobacco. The resin and oil may be eaten directly or
incorporated in foodstuffs. THC binds to cannabinoid receptors. These are two types; CB1 and CB 2
and both are G-protein coupled receptors. TCH via CB1 receptors indirectly increase dopamine
release. It also acts as an allosteric modulator of the mu and delta opioid receptors. This results in
relaxation, mild euphoria (the "high"), increased appetite, and impairment of short term memory,
psychomotor coordination and concentration. Marijuana use has been implicated as a gateway to
harder drugs. Dr Takriti presents the various evidence for and against this theory. It is clear that
there is no evidence of a specific pharmacologic effect of cannabis priming the brain for cocaine or
heroin. It may be that the presumed gateway effect is caused by the common factors involved in
using drugs in the first place, and that cannabis users are more likely to be subjected to situations
allowing them to get acquainted with individuals using or selling the various other illegal drugs.
FIMA YEAR BOOK 2014 XI

EDITORIAL
Most countries have laws against the cultivation and possession or transport of cannabis. In the
USA although Federal law still prohibits and penalizes marijuana use, some states have allowed its
medicinal uses such as for treating nausea and vomiting associated with chemotherapy. Whilst some
states (Colorado and Washington) have already legalized its recreational use. Other countries have
lightened penalties for cannabis use, enforcing confiscation and fines rather than imprisonment.
Islamically, cannabis is considered an intoxicant, with significant harms on cognitive functions and
psychosocial problems, and is prohibited. The author cites early jurists opinions and a more recent
fatwa by the Grand Mufti of Egypt. The rulings of alcohol apply similarly for cannabis.
Qat was categorized as a drug in 1973. It is primarily consumed in Yemen, and East African
countries. According to Dr al-Goshae in his contribution to this yearbook, 70-80% of Yemenis chew
qat on a daily basis. Qat plantation occupies 58.5% of the total cultivated land and consumes 60% of
the scarcely available water. Two to three billion USD are spent yearly on qat consumption. Almost
20% of Yemen's workforce is involved in qat business. As it is locally produced and locally consumed,
qat generates no national income.
The main active constituents in qat are cathinone and cathine. They are central nervous system
stimulants that induce release of catecholamines. At first they cause alertness, talkativeness, and
euphoria but later they cause depression. Excessive and prolonged qat chewing may cause psychosis
and schizophrenia. It also affects the cardiovascular system causing hypertension, palpitation, cold
extremities, and sweating. Qat also affects the gastro-intestinal system causing hyperacidity and
aggravation of duodenal ulceration.
Dr al-Goshae then discusses whether qat produces dependence. While it is true that qat induces
psychoactive effects that cause individuals to continue using it regularly despite its harmful
effects on the family, income and health, but qat chewers do not experience significant withdrawal
symptoms on abrupt cessation of its use. Some researchers believe that qat dependence is mainly
psychological and chewers can quit the habit easily.
Because of the significant harmful socioeconomic effects the Yemeni government had sought to
curtail its use. Qat chewing is banned in all government institutions and during work hours. Taxes
were levied against various qat businesses. More recently, NGOs are trying to combat qat growing
and consumption. To date, these efforts have been ineffective. Religious scholars in Yemen issued
opinions declaring the prohibition of qat chewing. However there is no clear official fatwa (religious
decree) in that regard In Yemen. In Saudi Arabia, the Fatwa Institution, and the International
Islamic Fiqh Academy issued fatwas that qat is a narcotic and thus prohibited.
The other type of addiction i.e. behavioral addiction is discussed by Dr Dinc. It is difficult to draw
the line between personal lifestyle and preferences on one hand and psychiatric pathology on the
other. Dr Dinc cites the definition by Dr Griffiths as any behavior that fulfils six components,
salience, mood modification, tolerance, withdrawal, conflict, and relapse. Gambling has been the
best example of behavioral addiction, but at present there are many more examples such as
internet, pornography, and shopping. Dr Dinc focuses on internet addiction because of its
affordability, accessibility, anonymity, and that it can be used for all causes; sex, gambling,
shopping, etc. He recommends paying special attention to children and youngsters to prevent them
from developing behavioral addiction. Those who are at special risk are those who have any type of
psychopathology and those who suffer from Attention Deficit Disorder. He recommends teaching
them to use the internet responsibly and to encourage periodic physical exercise. He recommends
XII FIMA YEAR BOOK 2014

EDITORIAL
encouraging the youngsters to express themselves and to socialize and to participate in group
activities to express themselves and have a meaning and fulfillment of their lives.
There is no specific treatment for behavioral addiction. However, psychosocial treatment methods
like the 12 step approach and pharmacologic treatment such as naltrexone which is a part of opiate
addiction treatment may be helpful.
Drs Harirah and Donia discuss substance abuse during pregnancy. It is estimated that about 4% of
pregnant women use some type of illicit drugs e.g. cocaine or marijuana, and that many more smoke
and drink alcohol. Smoking is relatively common especially in teenagers. Both nicotine and carbon
monoxide readily cross the placenta. Their concentration in fetal blood is much higher than in the
maternal blood. Smoking increases the risk of abortion, ectopic pregnancy, placental insufficiency,
fetal growth restriction (FGR), low birth weight (LBW), and preterm delivery.
Marijuana is the most commonly used illicit drug during pregnancy in USA. THC crosses the placenta
and has direct toxic effects on the fetus. FGR and preterm delivery are associated with marijuana
use but there is no evidence of increased incidence of fetal malformations.
Alcohol is still commonly consumed by pregnant women despite all its hazards. According to the
2010 National survey, 18.8% do, and 38% report binge drinking during pregnancy. Alcohol freely
crosses the placenta and its level in fetal blood is the same as in the maternal blood. The fetal liver
cannot metabolize it as efficiently as the mothers liver. Alcohol consumption in pregnancy is
associated with abortion, and fetal malformation specifically Fetal Alcohol Syndrome, characterized
by FGR, decreased head circumference, abnormal facies, cardiac and renal abnormalities.
Heroin and methadone are the most common opiates used by the pregnant women with a recent
increase in prescription opiate analgesics abuse.Pregnant women who are using heroin should be
tested for sexually transmitted diseases (STDs). Intravenous heroin addicts have significantly
increased risk of HBV, HCV, and HIV infections. They must be counseled about methadone
maintenance treatment which is associated with much better outcome. Heroin readily crosses the
placenta. Heroin addicts experience six-fold increase in the risk of maternal complications; FGR,
preterm delivery, LBW, stillbirth, depressed Apgar scores, meconium staining of the amniotic fluid,
and chorioamnionitis. The judicial use of analgesic opioids has not been associated with increased
fetal malformations or other complications. However, if they are used around the time of delivery
there will be increased risk of neonatal withdrawal. Neonatal Abstinence Syndrome is the most
consistent outcome in neonates delivered of mothers addicted to opioids. The withdrawal symptoms
include seizures, breathing complications, tremors, and difficulty in feeding.
Another addiction drug used in pregnancy is cocaine. In the USA, a 1995 survey found that the
prevalence of cocaine abuse in pregnancy was 4.5%, 0.4%, and 0.7% of Afro-American, white, and
Latino women respectively. Cocaine has dopaminergic effects leading to euphoria or the high.
Cocaine hasalso sympathomimetic effects causing vasoconstriction, hypertension, tachycardia, and
possibly arrhythmias. Prenatal use of cocaine is associated with FGR, LBW, and decreased fetal
head circumference. Use in the first trimester increases the risk of abortion and fetal
malformation.Use later in pregnancy is associated with increased risk of placental abruption,
preterm labor, premature rupture of membranes, and stillbirth. Cocaine abusing mothers are prone
to infant neglect and abuse.
Methamphetamine is becoming a relatively common drug of abuse in young women and thus in
pregnancy. As with virtually all other drugs of abuse, amphetamine use is associated with risky
sexual behavior, teenage pregnancy, and potential increased risk of STDs. Prenatal exposure to
FIMA YEAR BOOK 2014 XIII

EDITORIAL
amphetamine leads to LBW and to neonatal complications such as decreased alertness and poor
feeding.
Barbiturates and other sedatives such as benzodiazepine are sometimes prescribed to pregnant
women. There is no definite evidence of teratogenic effects but their use in the last trimester may
be associated with neonatal withdrawal symptoms and with the floppy infant syndrome.
Drs Harirah and Donia discuss the general principles of management of pregnant women abusing
drugs. Preconception counseling vis a vis cessation of smoking, abstaining from alcohol is very
important. Generally, other addicts do not present themselves to prenatal counseling or even for
prenatal care, especially in the early part when most of the teratogenic events occur. Screening for
fetal malformations should be adequately pursued. Genetic counseling should be offered if a
malformation is diagnosed. Serial sonography should be provided for evaluation of fetal growth.
Fetal well being testing should be offered in the third trimester. Nutritional counseling by trained
nutritionists is to be recommended to mitigate the poor nutritional status of these women. Timing
of delivery can be a challenge. The risks of prematurity should be balanced against that of
stillbirth. Pain relief management during labor should be discussed in advance.
Dr Karaman relates the experience of the Turkish Green Crescent Society (TGCS) in combating the
problem of addiction. He notes the power groups that promote addiction mainly the alcohol and
tobacco industries, the "addiction industry". He describes the impact of addiction on global
mortality figures as well as the disease burden. Dr Karaman reports that the annual value of the
illicit drugs in the world is estimated at 320 billion USD which is beyond governments' control. He
gives the history and the programs of TGCS. The society played a major role in the Turkish
government adoption and implementation of the WHO 's Framework Convention on Tobacco Control.
Although a "National Alcohol Control Action Plan" was introduced in Turkey in May 2013, there is
significant opposition from the secularists and the alcohol industry. The Society continues to
advocate for the law. TGCS aims to be a part of the international solidarity to fight addiction on a
global level. The Society is a member of the European Alcohol Policy Alliance and holds a special
consultative status with the Economic and Social Council of the United Nations. The Society serves
as a model and helped to form similar societies in Palestine, Bosnia, Malaysia, and Thailand.
Eventually they hope to establish the World Federation of Green Societies"
After elucidating the problem, the next chapters of the yearbook address the different
approaches to the treatment of addiction. Dr Hamdan discusses the psychological model of
addiction therapy but stresses its possible hindrance by "Spiritual Bypassing". She defines it as a
person's utilization of spiritual procedures and beliefs to avoid unresolved psychological issues that
may be the trigger for the addiction. There is scarce research about Spiritual Bypassing and
almost none from the Muslim perspective. Most Muslims believe that addiction is a great sin and the
result of weak Iman, and that increasing one's faith and Islamic practices is the way to overcome
it. This, however, does not solve the problem. It allows the person to avoid examining or taking
responsibility for the issues underlying addiction. Dr Hamdan notes that devout Muslims believe
that calamities and illnesses are a means to get closer to Allah so they should embrace their illness
because it cleanses and purify them from their sins. So an addict should use the problem as an
opportunity to reevaluate his or her life and to increase ones Islamic practices. Further, Muslims
tend not to discuss problems such as addiction with family or friends depriving themselves from the
beneficial effect of social support in the addiction recovery process. Instead they tend to seek
help from an Imam rather than from a professional. The religious leaders usually have no formal
XIV FIMA YEAR BOOK 2014

EDITORIAL
education or training in these types of issues and Muslims thus forgo proper treatment. Dr Hamdan
believes that the Imams should serve as mentors referring these addicts to professional
counselors/ mental health professionals rather than just prescribing engaging in more Islamic
rituals and practices. This does not mean one should neglect spirituality. In fact many psychology
experts recognize its essential role. Studies suggest that early childhood trauma such as abuse or
neglect by parents often results in children engaging in addiction behavior later in life. Psychological
help will probably unveil issues in the unconscious which are the root cause of the addiction
behavior. Muslims in general shun psychological counseling because of cultural taboo. This needs to
be corrected.
Psychotherapy and Islam combined will allow one to address the root cause of addiction and result
in better chance of recovery. Muslim religious leaders and healthcare providers need to make
concerted effort to debunk the negative stereotype of psychotherapy, counseling and mental
health services. Dr Hamdan stresses the point that while the Quran and Sunnah provide the
principles by which one lives his life, "professional counseling could be used to help the person
understand why he or she may have difficulty applying these principles. " In that sense she
believes that " Psychotherapy and counseling can serve to enhance a person's spiritual beliefs not
taking away from or replacing religion".
In most Muslim majority countries the traditional treatment of drug addiction is based on
abstinence. Another strategy i.e. "Harm Reduction" is discussed by Drs Hoosen and Mohamed. This
strategy allows substitute drugs such as methadone for heroin addicts and provides syringes,
needles and condoms for intravenous drug users as a means to treat the addiction while minimizing
the health, social and economic harms to the addicts, their families and community at large. It
tends to reduce legal problems, crime, domestic violence and job loss. The permissiveness of this
approach is controversial, especially in Muslim countries. The authors opine that this approach is
acceptable within Islamic guidelines.
Harm reduction is a mainstream drug policy in all European Union member countries. The authors
cite Spain as an example of the change in drug policy to harm reduction with resultant increase in
retention rates in treatment centers and a parallel decrease in morbidity and mortality of the
addicts. The authors also cite a similar experience in some Muslim majority countries. In Iran,
substance abuse was dealt with primarily by punitive measures. This was associated with high
relapse rates and increased risky behavior. Political and religious leaders recognized that
incarceration and abstinence were unsuccessful in addressing the continued increase in drug abuse
and in rates of HIV infection. This led to a review of the government policies and subsequently the
introduction of harm reduction strategies. In Malaysia the zero tolerance approach to drug use
failed to curtail the problem. This gradually changed to harm reduction programs with the approval
of the "Institute of Islamic Understanding" which declared that the harm reduction approach did
not violate Shariah (Islamic jurisprudence). Similarly in Afghanistan harm reduction interventions
were introduced in 2003.
Harm reduction strategies are generally challenged in Muslim countries based on the concept that
intoxicants and extramarital sex are forbidden in Islam. Distribution of syringes, condoms and
substitute drugs imply approval of the illicit behaviors. The authors, however, point out that the
abstinence only approach has been unsuccessful in stemming the spread of HIV and the punitive
approach was counterproductive. They propose citing contemporary Muslim scholars who believe
that it is not sufficient for verdicts to be passed purely on the basis of classical legal texts but has
to employ Ijtihad taking into consideration the objectives of Shariah which in essence are meant to
FIMA YEAR BOOK 2014 XV

EDITORIAL
bring benefit and ward off harm. According to this school of thought, if harm reduction strategies
which involve the use of haram (forbidden) substances, and haram practices are beneficial to the
society as a whole, by preventing harm to the general public, then this strategy will be Islamically
acceptable. The authors invoke some Quranic verses and prophetic Ahadith and fiqh principles that
support their view. In "Harm Reduction strategies addicts may not achieve total abstinence and
they may still indulge in drug use but they do that in a less risky manner thus minimizing the harms
to themselves and others". They will be encouraged to enter into treatment facilities where they
will be more likely to engage with health professionals and maybe "more receptive to Islamic
psychotherapy which may motivate them towards total abstinence". The authors also point out the
similarity of harm reduction strategy to the gradual way Islam adopted for alcohol prohibition.
They also point out that addiction is an illness and addicts require treatment and not punishment.
Furthermore, the authors remind us that Islam teaches us compassion towards the sick and that it
is not the duty of the health practitioner to pass moral judgment but only to care for the patient."
In another chapter Dr. Abu Dannoun discusses the Islamic perspectives of addiction prophylaxis
and therapy. He points out that although the prohibition of Khamr was largely applied to alcohol, the
major and may be the only known addictive substance known then, in fact the prohibition is clearly
because of its intoxicating effect. On that basis the ruling of prohibition applies to any other
intoxicating substance regardless of its chemical structure or other scientific means of
characterization. In Islam tahrim (prohibition) is linked to faith and its manifestations such as
prayers and fasting. This has more authority on the true Muslim than manmade laws. Tahrim of
intoxicants is deeply rooted in the Muslim psyche that even with the current decline of the
leadership of Islam in Muslim societies, addiction is a less of a problem than in non-Muslim
countries. The individual Muslim avoids alcohol and other intoxicants because it is prohibited and
because of his or her desire to please Allah. In addition, the society as a whole exerts pressure on
its members to avoid addictive substances. It is ironic that in non-Muslim countries there are
serious attempts to curtail the availability of other addictive substances while alcohol is largely
accepted as a social drink despite the fact that the former have less deleterious effects than
alcohol.
Dr Abu Dannoun brings up the question of whether addiction is an illness or a behavioral disorder.
Other contributors to this yearbook consider it to be a brain disease but still is it a disease that
one has no control on? Dr Ahmed, in his opiate article, states that while genetics and other biologic
underlying factors are involved in addiction, it is very possible that one can control it. Contemporary
Western oriented approaches are based on the concept that addiction is a disease that needs
therapy. Significant concessions are practiced to drug addicts in the harm reduction approach as
discussed previously. Dr Abu Dannoun does not approve of this approach while not neglecting the
medical, psychosocial and rehabilitation needs of drug addicts. He does consider addiction a devious
behavior and ethical-religious disobedience which are self afflicted by the individual. These
considerations render them liable to punitive measures. He believes that recognized therapeutic
measures should be mandatory. They may be gradual and long-term but should aim at complete
abstinence. Clearly Dr Abu Dannouns approach is orthodox in nature but I think that harm
reduction approach merits consideration and should be subjected to Ijtihad by Muslim scholars
alongside medical experts, psychotherapists, social workers, and others directly involved in the care
of addicted individuals.
XVI FIMA YEAR BOOK 2014

EDITORIAL
Drs Mohamed and Marican from Malaysia state in their article that there are different methods of
addiction treatment and no single treatment is suitable for all. Treatment must be carefully
adjusted to ensure that a specific plan meets the person's changing needs. Detoxification maybe
the first sep but counseling and behavioral therapy should be applied to minimize the rate of
relapse. Recovery can be a lifelong process with multiple treatments. In Malaysia, Compulsory
Centers for Drug Users (CCDUs) were established to provide primarily psychosocial treatment.
More recently the supply and demand reduction approach was applied and resulted in a decrease in
the number of drug addicts. Supply reduction focuses on legislation, and law enforcement. Demand
reduction is achieved through several methods including education, increasing public awareness of
the dangers of addiction, and the establishment of effective abstinence based treatment programs.
Because of the limited success of the supply and demand reduction approach the harm reduction
approach was introduced in the first decade of this century. In 2005 MMT was endorsed by the
government. Moreover, this approach includes religious teaching conducted by certified religious
teachers. The harm reduction approach resulted in further reduction of substance abuse, greater
concern for one's own health, decrease in illegal activities, longer retention in treatment centers
and increase in gainful employment. There is evidence that by participation in these programs the
recovering addicts become more practicing Muslims with less attraction to negative life influences.
The authors note that the inclusion of religious teaching in drug treatment does have positive
effect onto the lives of the clients, while religious input in isolation is of little value. This supports
the importance of avoiding Spiritual Bypass described earlier by Dr Hamdan, and the Harm
Reduction approach discussed by Drs Hoosen and Mohamed.
The religious input should not be a fixed program but needs to be tailored to each individual needs
specifically to their prior religious knowledge.
Dr Shaharom describes a role for Islamic Psycho-Spiritual Therapy (IPST) in the treatment of
addiction. He defines it as a healing technique that transfers the individual from the realm of ill
health to that of well-being that is Rabbani (Godly). IPST incorporates the different theories of
psychotherapy that are not inherently anti-religion, Islamizing them in the process. Dr Shaharom
recommends using his designed Islamic Religiosity Scale to evaluate each individual and to design
the best combination of modalities for his treatment and to follow his progress. The basic
modalities are prayers, meditation, zikr (remembrance of Allah), and Quranic reading / recitation.
Dr Shaharom stresses that in some cases IPST needs to be coupled with pharmacotherapy. He
cites beneficial results for IPST and concludes that it is relevant in the treatment of addiction.
I conclude by thanking all the authors for their contributions to the issue. I especially thank
members of the Editorial Board: Drs. Aly Mishal, Abul Fadl Mohsin Ibrahim, and Musa Mohd Nordin
for their valuable input and guidance. I sincerely appreciate the work of Dr. Mishal's staff for
copyediting and proofreading of the manuscripts, especially Ms. Elham Mohammad Swaid.
I pray that Allah ( )accept and bless our efforts in His service. May Allah ( )guide us to the
right path and have mercy on us. Amin.
Wassalam
Hossam E Fadel, M.D., Ph.D., F.A.C.O.G
Clinical professor, Obstetrics and Gynecology.
Maternal Fetal Medicine, The Medical College of Georgia
Georgia Regents University
Augusta, GA, USA
FIMA YEAR BOOK 2014 XVII

EDITORIAL
Federation Of Islamic Medical

Associations ( FIMA ) in Brief
Established at the outset of the 15th Hijrah century, December 1981, in

Orlando, Florida, USA, where senior leading medical professionals
representing ten Islamic medical organizations, from various parts of the
world, convened and laid down the foundation of the Federation.
Subsequently, in March 1999, FIMA was incorporated in the State of
Illinois as a non-profit organization, then acquired the special consultative
status with the United Nations Economic and Social Council
(UN-ECOSOC).
Since that time, FIMA membership progressively expanded to include 29
full members, 13 associate members, and more than 15 prospective and
collaborating organizations from all over the world.
Most FIMA activities and achievements are based on the endeavors of its
member Islamic Medical Associations (IMAs), in constructive mutual
cooperation, and harmonious understanding.
Islamic medical activities of FIMA have a holistic nature. Leadership,
mutual cooperation and innovation are prerequisites for the welfare of our
communities, our Ummah and humanity at large.
These activities include, but are not limited to:
1. Cooperation in humanitarian medical relief work, where and when needed
in disaster stricken countries, regardless of ethnicity, religion or race. The
FIMA Save Vision Program was initiated in early 2005. To date more than
100,000 eye surgeries were performed by volunteer ophthalmologists and
teams from IMAs in several countries, in Africa, South and Southeast Asia,
where visual impairments are rampant. The program included training of
local medical professionals to continue and widen this activity by qualified
local talents. The program also included establishment of local eye
hospitals or eye sections in existing general hospitals, in deprived
communities.
This activity qualified FIMA for a distinguished award from the American
College of Physicians ( ACP ), designated for outstanding humanitarian
medical achievements.
Over the past five years, two new humanitarian activities were launched:
The cleft lip/palate, and the vesico-vaginal fistula projects, both highlighted
as significant medical and psychosocial problems in several needy
communities.
FIMA YEAR BOOK 2014 XIX

EDITORIAL
2. Collaboration with regional and international organizations in areas of

preventive medicine and community health education.
3. Scientific, professional and ethical jurisprudence related conferences,
seminars and publications.
4. Establishment of the Consortium of Islamic Medical Colleges ( CIMCO ),
to foster cooperation in improvement of curriculum, training, research,
administration, and up-bringing of model medical practitioners.
5. Establishment of the Islamic Hospitals Consortium ( IHC ), to pursue
cooperation and coordination among medical professionals and hospital
administrators in areas of experience exchange, benchmarking,
improvement of health care delivery, ethical, administrative and operational
activities, to meet the most advanced international standards, in the context
of Islamic principles.
6. Publication of FIMA Year Books, which address biomedical, ethical,
scientific and other related issues that are needed for medical practitioners,
educators as well as Jurists.
7. In 2013, FIMA committee on Bioethics embarked on the project of
Encyclopedia of Medical and Health Ethics. In view of the extensive effort
needed, this project is expected to span over several years.
8. Medical students activities, including conferences, seminars, publications,
camps, Umrah and Ziarah programs.
9. Collaboration to extend a helping hand to Muslim medical practitioners in
underprivileged countries, to work together and organize professional
medical societies, to serve their communities.
10. Establishment of resource centers. The HIV/AIDS Resource Center has
been functional in prophylactic, social and therapeutic activities in several
countries for the past two decades. The Biomedical Ethics Resource Center
has been functional for the past decade.
For Correspondence:
FIMA President: Dr. Tanveer Zubairi- Pakistan

E-mail: [email protected]
FIMA General Secretary: Prof. Abdul Rashid Abdul Rahman- Malaysia

E-mail: [email protected], [email protected]
FIMA Executive Director: Dr. Aly A. Mishal

FIMA Executive Director in USA: Dr. Parvaiz Malik

FIMA WEBSITE: www.fimaweb.net
XX FIMA YEAR BOOK 2014

BIOLOGICAL MECHANISMS UNDERLYING ADDICTION
Ilhan Yargic*
Abstract:
Addiction is a behavioral disorder related to alterations in neurobiological systems

involved in reward system, brain stress response, physical withdrawal, inhibition and
executive control. Genetic and epigenetic variations in these neurobiological systems
cause individual differences and responses to these substances. The current review
summarizes the literature on the biological basis of drug addiction. In addition, this
review tries to explain the path from occasional recreational substance use to the
compulsive, addicted state. It will help to understand why the absolute avoidance of
psychoactive drugs is very crucial.
Keywords: addiction, mechanism, abuse, dependence, neurobiology
Introduction:
Drug addiction is a chronic, relapsing ator systems. Generally, the discussion

disorder that is characterized by a craving about the health hazards of alcohol and
for drugs, compulsive drug use, loss of drugs has often focused on their
control in limiting intake, and emergence deleterious effects on bodily functions and
of an aversive state (withdrawal) when the organs like the liver and lungs. However,
drug is not accessed1. Although any drug the worst effect of alcohol and drugs is on
use has a potential for further abuse or the brain, because they cause long term
dependence, clinical experience and neuroadaptive changes in the CNS which
animal studies show that neurobiological leads to compulsive drug use with frequent
effects of occasional and limited use of a relapses and poor outcomes even after
drug, like alcohol, is different from those acute withdrawal symptoms have abated.
of a chronic dependent state2. Addiction Modern research on drug abuse has
develops as a result of a transition from the demonstrated the biochemical, cellular,
first neurobiological state to the second. genetic, epigenetic and circuitry mechan-
Drug intake, accompanied by a biological isms that mediate the progression from
vulnerability causes some permanent fun- experimentation with a drug to addiction.
ctional and structural changes3 in various These changes in the brain have a potential
parts of the central nervous system (CNS) to continue for a long time after drug use
and several neuro-endocrinological modul- has stopped.
*Prof. Dr. Ilhan Yargic

Istanbul University Istanbul Medical Faculty
Psychiatry Department, Istanbul, Turkey
FIMA YEAR BOOK 2014 1

BIOLOGICAL MECHANISMS
These changes in the brain have a potential Through this mechanism, Allah has
to continue for a long time after drug use programmed us to want things that we
has stopped. Addiction is a biopsycho- need to survive. For example eating food is
social disorder similar to other chronic not a burden that we just have to do but it
physiological disorders such as diabetes is a pleasure we seek for. Rewards serve as
mellitus that are progressive and influe- positive reinforcers because they affect the
nced by environmental factors and stress- behavior towards obtaining a goal that
ors. A diabetic person cannot claim that he results in pleasure and satisfaction. When
will use his will power to keep a normal someone uses a psychoactive drug, he is
blood glucose level after he consumes a abusing the reward system outside its
large amount of carbohydrate. Likewise, special purpose. Almost all drugs of abuse
an addict cannot keep limiting his drug use stimulate mesolimbic dopaminergic system
and avoid bad consequences forever. But much stronger than the natural stimuli,
like a diabetic person who should avoid thus they produce pleasurable effects
food that is rich in carbohydrates, an addict initially.
should take every precaution to stay away Repetitive stimulation of this system
from drugs for good. causes sensitization that is responsible of
Alcohol and drugs have effects on four craving for the specific drug. Drugs act
interrelated biological systems in the brain like computer viruses that change the
that underlie addiction. original program of a computer (the brain)
These are brain reward system, brain stress and reorganize the system to perceive them
systems, autonomic nervous system (relat- as a basic need, re-program the system to
ed to physical withdrawal) and pre-frontal produce an urge for them (drugs). The drug
cortex function (related to cognitive user imagines this strong desire for drugs
inhibitory control). as his natural will. Especially in the initial
Drug use produces biological changes that phases of addiction, they say I use it as I
ruin the homeostatic operations of the CNS want to use it. They do not take into
and a new state of chronic dysregulation consideration that this urge is not innate
(an allostatic state) is shaped4. and it develops after drug use. This strong
feeling of desire (impulse) for drug use
Brain Reward Systems: that affects decision-making process of the
person is one of the key elements of
Reward system is the fuel of life. addiction. Most of the drugs of abuse
Mesolimbic dopaminergic system that increase dopamine in the mesolimbic
connects nucleus accumbens and ventero- system directly or indirectly to produce a
tegmental area and gives projections to the reward or a high. For example opiates act
prefrontal cortex is the neural structure of on opioid receptors which then stimulate
the reward pathway. This brain circuit is dopamine receptors, cocaine competes
present in human and all animals and it with dopamine in the synaptic cleft for the
gives an appetitive stimulus to obtain dopamine reuptake pump and keeps
innate needs (food and sex) that are dopamine in the cleft.
necessary for survival of the individual and Activation of dopamine neurons is a moti-
continuation of the generations. The vational factor that produces reward-
pleasure imbedded in them is like a small anticipation.
fee given to the creatures to turn the wheel When a reward is higher than expected,
of physical existence. sensitization of dopamine neurons incr-
2 FIMA YEAR BOOK 2014

eases. This sensitization increases the urge The brain has a plastic property and it
or motivation for the reward5. Drugs may rapidly develops an adaptation to the
produce different effects on individuals6. effects of drugs. This is called tolerance.
For example cocaine or meth-ylphenidate Repetitive use of a drug increases reward
use increases dopamine levels in human thresholds (decreases reward). For this
brain and this increase is associated with reason, drug use does not produce satiety
pleasure. If drug-nave subjects had low as in natural rewards like food. A person
levels of dopamine D2 receptors, they can eat up to a certain amount of his
experience pleasure. But if they originally favorite food each time but increases the
had high receptor levels, they experience amount of a drug in subsequent uses. The
unpleasant feelings. This study explains person cannot get the same high from a
the biological mechanism of why drug use drug during chronic use but he still
is pleasurable for some people and tends to experiences a high level of urge to use it.
be repetitive while it is unpleasant and not In other words, tolerance does not
repetitive for others6. extinguish this desire. The brain keeps the
Neurotransmitters other than dopamine value of possible actions in memory
also play a role in reward system7. according to the amount of reward it
Dopamine independent reward mechan- produced in the past5. This stored value is
isms have been described for opioids and used to evaluate possible results of future
alcohol. actions as reward or punishment.
Serotonergic receptors in the nucleus
accumbens mediate the reinforcing effects Brain Stress Systems:
of psychostimulant drugs. Stimulation of
-opioid receptors in the nucleus accum- Stress system is the brain alarm circuit that
bens and ventral tegmental area are respon- is triggered by danger or unpleasant
sible for the reinforcing effects of opioids. stimuli. Some neurochemicals that are
Opioid receptors in the ventral striatum activated by acute or chronic stressors
and amygdala mediate the reinforcing initiate some typical behavioral responses.
effects of ethanol. Acute intoxicating doses In animals various behavioral responses
of alcohol also increase inhibitory - like freezing or flight may be observed1.
aminobutyric acid (GABA) in the Brain stress systems include neurocircuitry
amygdala. Activation of the mesolimbic mediated by glucocorticoids, corticotropin-
dopamine system produces an incentive releasing factor (CRF), norepinephrine,
salience linked to the environmental and dynorphin. There are also neuro-
stimuli and drives goal-directed behavior1. chemicals like neuro-peptide Y (NPY),
Pleasure (hedonic state) provided by the nociceptin, and endo-cannabinoids that
reward starts a learning process including oppose the brain stress systems.
condi-tioning with cues that are associated Stimulation of nucleus accumbens, the
with drug use, assigning value and reward system, also activates brain stress
motivational status to the reward. systems that subsequently feedback to dec-
Motivational state produced by drug rease dopamine release in the mesolimbic
withdrawal is like hunger and sexual dopamine system. Brain stress systems aim
arousal that increase the incentive salience to neutralize the effects of the drug and
of the reward and related cues8. As the restore normal function despite the
hunger or withdrawal rises, struggle to get presence of drug. This causes tolerance to
the reward will accelerate. the effects of the drug use and dysphoric

syndrome when the use is stopped because higher drug doses to get the same effect, so
the change in stress systems continues that the person gets into the vicious cycle
although the drug use is avoided1. of tolerance. Acute physical withdrawal is
Adrenocorticotropic hormone (ACTH) and related to the somatic effects of drug use.
corticosterone are elevated during withdra- Long term use of many drugs leads to
wal and this disturbs the hypothalamic- adaptations within the autonomic nervous
pituitary-adrenal (HPA) axis and extra- system and its target organs.
hypothalamic brain stress system mediated This adaptation is disturbed when drug use
by cortisol releasing factor (CRF). is avoided12. For this reason, medications
Withdrawal and protracted abstinence from that modulate the autonomic nervous
drugs produce anxiety and irritability system, such as clonidine and propranolol
mediated by CRF1. Dynorphin activation are effective at reducing acute withdrawal
mediates depressive responses to stress and symptoms. Acute somatic symptoms of
dysphoric responses during withdrawal withdrawal abate in days to weeks after the
from drugs9. Animal studies10 show that drug is discontinued, however, a chronic or
when primates were conditioned to asso- protracted withdrawal state, where the
ciate a cue with a pleasurable object like patient suffers from unpleasant psycho-
food, increased dopaminergic activity was logical symptoms especially triggered by
a response to the cue and not to the food. drug cues, lasts for months to years.
Absence of food caused a drop in Permanent changes in the brain may
dopaminergic function. Reduction in the induce relapses to drug abuse long after
dopaminergic activity is considered to be detoxification.
associated with negative affect like Gamma-aminobutyric acid (GABA)-ergic
dysphoria. So when an addict comes across system and the glutamatergic system play
with a cue (e.g. needle, money), and important roles in alcohol withdrawal13.
cannot access the drug he may feel Increased glutamatergic NMDA function is
dysphoric. This negative feeling will also involved in seizures and cell death.
increase the drive to get the drug. Amygdala and hippocampus are critical
sites for glutamatergic hyperactivity.
Physical Withdrawal: Reduction in dopamine plays a role in both
early abstinence and protracted withdrawal
Withdrawal is the emergence of specific from many drugs of abuse14.
behavioral and physical symptoms Neuroimaging studies have shown reduced
following sudden discontinuation of a drug dopaminergic activity in opiate, cocaine
in subjects who had been under its chronic and alcohol addictions. Even partial reco-
influence. It is the result of reversal of very of this change takes several months6.
homeostatic mechanisms which had been Altered reward neurotransmitters increase
disturbed by the drug before discon- brain reward thresholds (a higher set point
tinuation11. In other words withdrawal is for drug reward) during abstinence. This in
the result of sudden backward change of turn produces the negative motivational
the homeostatic mechanisms that caused state in withdrawal (psychological symp-
tolerance to the drug. Actually in toms of withdrawal) and makes the patient
stimulants and heroin, tolerance starts to vulnerable to relapse1.
develop very early on and the person Withdrawal symptoms are aversive for the
cannot get the same effect from the same drug user; therefore he starts to seek the
amount of drug and needs progressively

drug not for pleasure but to avoid through biologi-cal maturation of the brain
withdrawal symptoms. during adoles-cence. Therefore adolescent
brain is more vulnerable to the harmful
Impulse control effects of drug abuse18. Different parts of
And decision making: the PFC are related to distinct features of
addiction; for example medial orbitofrontal
Inhibitory control and decision making are cortex and ventromedial prefrontal cortex
key executive functions for the develop- to craving, orbitofrontal cortex to drug
ment of addiction and they are mediated by expectation, anterior cingulate cortex to
the forebrain. Prefrontal cortex (PFC) is attention bias and dorsolateral prefrontal
involved in regulation of both limbic cortex to drug-related memories15.
reward regions and higher-order executive Glutamatergic pathway starting from the
functions. Therefore in addiction, PFC PFC and controlling the dopaminergic
dysfunction is not only related to neurons in the nucleus accumbens are
compulsive drug use but also underlines associated with addiction19.
the dysfunctional behavioral pattern of Several other neurotransmitter systems
drug addicts. Impairment of the PFC such as endogenous opioid, serotonergic,
functions is also related to salience cannabinoid and dopaminergic systems are
attribution in addiction. Salience attribu- also involved in prefrontal impair
tion is ascribing excessive prominence to ment15.Inhibitory control enables to take
the drug and drug related cues, decline in appropriate actions to accomplish complex
sensitivity to non-drug reinforcers and less tasks and provides adaptation to new
ability to inhibit maladaptive behaviors15. environmental conditions by suppressing
This impairment makes drug seeking and immediate or habitual responses.
drug use the main motivational drive even Impairment in the inhibitory control is a
though it leads to long term losses. It leads key element in repetitive substance misuse
to neglecting other activities and the and dependence17. Deficit in impulse
person can engage in extreme behaviors in control can be demonstrated with neuroco-
order to obtain drugs16. The process ends gnitive tests like color word Stroop task,
in the weakening of free will. continuous performance test and the stop-
Administration of drugs of dependence to signal task. In laboratory gambling task
drug nave laboratory animals produces where risky decision making is accessed,
changes in PFC similar to those in human drug addicts tend to take actions associated
drug addicts. PFC impairment seen in drug with short-term gains although they can
addicts is a result of drug use that enables bring long-term losses17.The individuals
further use. However, PFC impairment is with impulsive personality traits are more
also present in several other psychiatric prone to try and be addicted to drugs and
and neurological conditions such as drug use puts these individuals into a
borderline personality disorder, attention vicious cycle of further impulsivity20.
deficit and hyperactivity disorder (ADHD), Impairment in impulse control leads to a
schizophrenia and bipolar disorder and weakening in self control (the ability to
traumatic brain injury17. The presence of postpone or avoid an activity that may not
PFC impairment makes those patient be appropriate or is perceived as
groups more vulnerable to drug use and incorrect)21.
dependence. Executive functions mediated This explains the inability of drug addicts
by the pre-frontal cortex are gained to inhibit excessive drug use although they

are aware of the destructive consequences. 9. Chartoff E, Sawyer A, Rachlin A, et al. Blockade of
kappa opioid receptors attenuates the development
Impairment in impulse control and self of depressive-like behaviors induced by cocaine
control also underline engagement in withdrawal in rats. Neuropharmacology 2012;
criminal activities and aggression. Young 62:11671176
10. Schultz W. Reward signaling by dopamine neurons.
individuals who already have weak self- Neuroscientist. 2001; 7:293-302.
control are more prone to substance 11. Vetulani J. Drug addiction. Part II. Neurobiology of
dependence21. addiction. Pol J Pharmacol. 2001; 53:303-317.
12. Naqvi NH, Bechara A. The insula and drug
addiction: an interoceptive view of pleasure, urges,
Conclusion: and decision-making. Brain Struct Funct. 2010;
214:435-450
13. Roberto M, Gilpin NW, Siggins GR. The central
The addicted brain is in a state of chronic amygdala and alcohol: role of -aminobutyric acid,
dysregulation (allostasis) where function of glutamate, and neuropeptides. Cold Spring Harb
reward circuits are impaired and stress Perspect Med. 2012; 2:a012195.
14. Murphy A, Taylor E, Elliott R. The detrimental
systems are activated both of which lead to effects of emotional process dysregulation on
increased impulses to use drugs. Somatic decision-making in substance dependence. Front
withdrawal symptoms as well as emotional Integr Neurosci. 2012; 6:101
15. Goldstein RZ, Volkow ND. Dysfunction of the
dysregulation also increase the urge for prefrontal cortex in addiction: neuroimaging
drug use. On top of these, dysregulation of findings and clinical implications. Nat Rev
the frontal cortex which is supposed to Neurosci. 2011; 12:652-669.
16. Volkow ND, Li TK. Drug addiction: the
execute thoughts, impulses and emotions neurobiology of behaviour gone awry. Nat Rev
results in compulsive drug seeking and loss Neurosci. 2004; 5:963-970.
of control over intake. This is a process 17. Li CS, Sinha R. Inhibitory control and emotional
stress regulation: neuroimaging evidence for frontal-
initiated by drug use and can be avoided limbic dysfunction in psycho-stimulant addiction.
primarily by staying away from drugs. Neurosci Biobehav Rev. 2008; 32:581597.
18. Selemon LD. A role for synaptic plasticity in the
adolescent development of executive function.
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19. Lingford-Hughes A, Nutt D. Neurobiology of
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2. Koob GF. Theoretical Frameworks and Mechanistic 20. Dawe S, Loxton NJ. The role of impulsivity in the
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Neurosci. 2013; 13:330. 21. Moffitt TE, Arseneault L, Belsky D, et al. A
3. Denier N, Schmidt A, Gerber H, et al. Association gradient of childhood self-control predicts health,
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Acad Sci. 2013; 1282:71-91.

ALCOHOL USE DISORDER:
SCIENTIFIC HORIZONS AND ISLAMIC PERSPECTIVES
Mohammad Ali Albar*, and Aly A. Mishal
Abstract:
Alcohol beverages have been used since antiquity. Alcohol dependence is a worldwide
problem, more intense and widespread than all other drugs causing dependence
combined. The tendency has been to manage the dilemma of alcohol dependence leaving
aside the problem of availability and accessibility of alcoholic beverages in most
communities around the world.
Historically, the USA trial to forcibly prohibit alcohol use by law (1919-1933) had failed
miserably. Similar trials in USSR met the same fate.
Multiple terms are used to describe the clinical conditions associated with excessive use
of alcohol. Over the past few years, the terms of alcohol abuse and alcohol dependence
were replaced by a single diagnosis: alcohol use disorder, with the term alcoholism
reserved for the more severe manifestations of alcohol use disorder, that could be fatal.
The diagnostic criteria of alcohol use disorder, its epidemiology, pathogenesis, clinical
manifestations, adverse consequences, assessments and management are outlined in this
paper, together with the Islamic perspectives and approach in eradication and
prophylaxis.
Keywords: Alcohol, dependence, alcohol use disorders, intoxication, Islam.
Introduction:
The terms alcohol abuse and alcohol dep- Impaired control over drinking.
endence were recently replaced by one Preoccupation with alcohol.
diagnosis: alcohol use disorder1. The term Use of alcohol despite adverse
(alcoholism) has been frequently used to consequences.
describe the more severe manifestations of Distortions in thinking, most notably:
alcohol use disorder. Alcohol use disorder denial.
is a worldwide problem. It is more deleteri-
ous and widespread than all other drug Definition of various levels of alcohol
dependencies combined 2. Typical intake and the level that is considered
characteristics of this disorder include: abuse differs between countries3,4.
*Dr. Mohammad Ali Albar (FRCP London)

Director of Medical Ethics
International Medical Center
Jeddah, Saudi Arabia

ALCOHOL
A standard drink in the US is 14-15 gm the USA, a trial to forcibly prohibit alcohol
of alcohol (0.5-0.6 fl.oz), equivalent to 12 consumption, was implemented between
oz of beer, 5 oz of wine, and 1.5 oz of 80 1919 and 1933. The Eighteenth Amend-
proof liquor5. ment to the USA constitution that was
In UK: 19.75 gm of alcohol2,3. known as the Prohibition Amendment, was
In addition to the amount of alcohol in passed on January 16,1919, by the
one drink, cut points to define Congress, to be fully implemented after
Moderate and Heavy drinking also one year from its ratification. This
varies between countries6: amendment proclaimed that the manufac-
In the US the following parameters ture, sale, transportation, importation and
generally apply: exportation of intoxicating liquors shall
Moderate drinking: be legally prohibited. The Congress was
Women: < 2 drinks per day. authorized to enforce this amendment by
Men: < 3 drinks per day. appropriate legislation 8.
Heavy drinking: The alcohol prohibiting legislation did not
Women: > 7 drinks per week or 3 change the public attitudes towards alcohol
drinks per occasion. consumption. The majority of US citizens
Men: > 14 drinks per week or 4 were incapable or unwilling to curb their
drinks per occasion. drinking habit. Illicit production and illegal
Binge drinking: smuggling of alcohol continued and there
Women: 4 or more drinks in one was no decrease in the availability of
occasion. alcoholic beverages. It became clear that
Men: 5 or more drinks in one the attempt failed and the amendment was
occasion. repealed in December, 1933, by Congress.
No level of alcohol consumption can The wording of this repeal was very
reliably be regarded as safe7. No studies significant in stating: The prohibition
have been published to predict alcohol amendment, known as the Eighteenth
abuse, or alcohol use disorder, in individu- Amendment, was not repealed on the basis
als who consume moderate amounts of of whether alcohol is good or bad,
alcohol, or who are described as social harmless or hazardous. The decision was
drinkers. Any of these individuals, under made on the very realistic and practical
certain circumstances, could turn into an basis that prohibition was not working 8,9.
alcohol abuse. Some measures were adopted to curb
With the free availability and accessibility excessive harms, including:
of alcoholic beverages in most comm- Legislation prohibiting driving cars
unities, people of various ages could easily while intoxicated.
start as mild social or moderate Prohibition of sale of alcoholic
drinkers and later turn into the category of beverages to youngsters.
alcohol use disorder and alcoholism. Limiting the hours during which the
sale or serving of alcohol is allowed.
Historical trials to curb Unfortunately these measures proved
alcohol consumption: fruitless. Even public education about
alcohol hazards proved ineffective in the
In the 20th century, because of the various face of slick alcohol advertisement, and the
hazards of alcohol consumption, there influence of alcohol industry on public life.
were trials to ban, or at least to curb it. In This industry generates huge profits

ALCOHOL
worldwide, and is ready to fight any real from the year 2001 to 2002. The
effort to curb alcohol consumption. prevalence of alcohol abuse and
In the former Soviet Union, campaigns to dependence over a life time and over the
curb alcohol consumption started at the last 12 months was 17.8% and 3.8%12.
time of the first Bolshevik government According to the 2008 National Survey on
after the revolution. But by 1921, this Drug Use and Health, 51.6% of Americans
policy failed. Alcohol consumption had aged 12 years or older, reported being
returned to very high levels, and alcohol- current drinkers of alcohol. This translates
related deaths escalated to almost 15-folds to around 129 million people. More than
in some cities such as Moscow. 58 million of them reported binge drinking
Subsequently, a series of campaigns in the 30 days prior to the survey, and
against alcohol abuse were adopted under more than 17 million reported heavy
presidents of USSR, Brezhnev, Andropov drinking13.Increased rates of alcohol
and Chernenko under the general heading dependence have been found to be
of reducing anti-social behavior. By 1984, associated with male sex, younger age,
there was some evidence that both alcohol being single, lower income and White or
consumption and alcohol-related crimes Native American ethnicity12. Middle-aged
were falling. In early 1985, President adults (30-64 years) have been found to be
Gorbachev pursued this line, and all organs at the highest risk for alcohol abuse. In
of government were exhorted to develop children and adolescents, statistics are very
strategies to reduce alcohol consumption. worrisome. According to the "Monitoring
The All-Union Voluntary Society for the the Future Study", 16% of eighth graders
Struggle for Sobriety was launched in had consumed five or more drinks at one
September 1985. This campaign finally occasion within the last two weeks
collapsed in 1988. The collapse was preceding the study14. Alcohol is by far the
ascribed to various factors, including major most commonly used drug among high
increases in illegal alcohol production and school students. Seventy two percent of the
trade, as well as marked reduction of students have consumed alcohol by the end
public finances, which dwindled by more of high school, and 39% have done so by
than 28 billion roubles between 1985 and the 8th grade. In 2008, 55% of the 12th
1987.This was followed by an increase of graders and 18% of the 8th graders reported
alcohol-related mortality and a decline in having been drunk at least once. This
life expectancy, especially among the compares with 10- 20% of high school
young and middle aged. Changes on this seniors reporting use of cocaine, and 40-
scale were unprecedented anywhere in the 50% reporting marijuana use14.
world in peacetime 10,11. Statistics from other parts of the world are
These alcohol-related deaths were mainly not less alarming. Binge drinking
due to injuries and cardiovascular diseases. (consuming five or more drinks in a single
occasion) is a significant component of
Epidemiology: drinking behaviors in teens and individuals
in their twenties. In a cross-sectional study
In all countries where the consumption of from Britain, 56% reported binge drinking
alcohol is legally permitted, the majority of at least once in a seven day period15.
the adult population drink. A National Compared with individuals who begin
Epidemiologic Survey on Alcohol and drinking at or after 21 year of age, early
Related Conditions was conducted in USA drinkers have been found to be four times

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more likely to develop alcohol dependence Some studies made conclusions dependant
and more likely to be involved in alcohol- on self-reported health, sick leave
related violence16,17. relationship with alcohol consumption and
Evidence suggests that high doses of other parameters.
alcohol at an early age may result in lasting In 1987, the Royal College of Physicians
effects on neurophysiological function18, (RCP) published a series of seminal reports
and addiction. on the topic of UK government policy on
alcohol. The main report was significantly
Economic costs: titled: The medical consequences of
alcohol abuse, a great and growing evil22.
Literature is full with staggering economic The evidence on the risks of alcohol
burdens on the individual, family and state. consumption is complex. Most systems of
In the US, the total cost to national the body can be damaged by alcohol con-
economy from alcohol abuse and sumption, but the rate at which harm
dependence was estimated to be 185 increases in relation to the amount of
billion USD for 199819-21. alcohol consumed varies between different
This includes costs of treatment, associated systems. For example, liver disease has an
diseases, crime, loss of work time and exponential relationship with alcohol
other expenses. There are other costs that consumption, whereas the risk of cancers
are difficult to quantify including; domes- shows a dose dependent relationship.
tic violence, child abuse and loss of a The risk to which an individual is exposed
promising future. to is related to both the amount and the
Approximately 27% of heavy alcohol frequency of drinking, in addition to
drinkers miss one or more days of work genetics and age.
every month, 15% due to an injury or All alcohol consumption carries a level of
illness. risk. There is no data to indicate how much
Alcohol problems in many parts of the alcohol is safe. But, given the fact that
world constitute a serious impediment to alcohol consumption is widespread and
socio-economic development and threaten enjoyed by many, there was a judgment
to overwhelm their healthcare systems. about what an acceptable level of risk was.
RCP published certain guidelines, based on
Alcohol and overall health: this very difficult judgment.
It recommends sensible limits of
Alcohol use represents an unusual drinking. These limits have been argued
challenge for clinicians, social workers and about for years and in different countries.
healthcare policy makers. They include variations in the numbers and
Medical literature is replete with discuss- amounts of drinks per week, which are
ions and debate about risks and benefits, different between males and females. To
related to various levels of alcohol consu- minimize hazards of alcohol consumption,
mption. There is general agreement that RCP recommended that people should
problem drinking reduces the quality of have three alcohol-free days per week.
life for individuals, their families and In December 1995 these government-
societies. However, only few studies have adopted guidelines were reviewed and
properly evaluated how social and changed following some circulated
moderate alcohol consumption affect the evidence indicating that alcohol drinking
quality of life, and health parameters. might give protection from coronary heart

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disease. These changes were not Highlighting the rising levels of

recommended by RCP. In fact they were alcohol harm.
adopted by an interdepartmental group, Proposing evidence-based solutions to
comprising of civil servants 23. They made reduce this harm.
two extremely significant changes to the Influencing decision makers to take
RCP guidelines. positive action to address the damage
Firstly, they substituted the weekly limit caused by alcohol abuse.
with a daily one. This, in effect appeared to The World Health Organization (WHO)
sanction daily drinking, which is coordinated many forums, global and
considered one of the key risk factors for regional studies and publications on the
alcohol dependency (addiction) and also global alcohol hazards since its inception.
for alcohol-related harms. Secondly, the Alcohol consumption was considered
daily drink limits led to a 30% increase in among the top ten causes of mortality
the RCPs adopted guidelines. worldwide. In 2002, alcohol was reported
These government guidelines were never to be the underlying cause of some two
supported by a review of evidence carried million deaths per year in the world27.
out by the RCP, Royal College of General Since then this figure has clearly increased.
Practitioners and Royal College of The health hazards related to alcohol are
Psychiatrists. As a matter of fact, RCP multiple and well documented28. They
disputed these guidelines, and reported that come from both acute consequences
daily drinking is an important risk factor (accidents, intoxication), and chronic
for the development of alcohol dependence ones (liver disease, cancer, cardiovascular
and for alcoholic liver diseases. disease). The harmful effects include
RCP also reported that the majority of mortality, morbidity and socioeconomic
young people confine their drinking to ills.
binges, once or twice a week. These WHO repeatedly advocated population-
binges are associated with major health based global interventions, alcohol
harms, including accidents, violence, self consumption policies and strategies. There
harm and suicide, and as a result, alcohol is is consensus about effective interventions
the leading cause of death in the 16-24 age reported in the WHOs Alcohol and
group 24. A very large number of young Policy Group28 which address reducing
people develop alcohol dependence, and availability of alcohol by all possible
become on track to develop physical health measures.
complications as they move into their 30s Controlling advertising and marketing of
and 40s25-26. alcoholic beverages is a popular public
On this basis, RCP criticized the UK topic which is attractive to politicians. The
governmental guidelines of 1995, and major problem is the ineffectiveness of
considered them potentially dangerous. partial restrictions, and unfeasibility of
One aspect of this criticism is that alcohol total ban. Thus, alcohol-related harm calls
dependence is effectively a disease of the for comprehensive measures and princi-
young. ples29.
In November 2007, RCP in coordination Drinking habits are communicated by
with the Alcohol Health Alliance UK global marketing, advertising and media.
(AHA), pursued diligent activities to The westernization of drinking habits
address the escalating harms of alcohol means escalation of alcohol consumption
consumption. These activities were: in many parts of the world. The alcohol

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industry is increasingly globalized, and the WHO publications provided significant

big multinational companies have consid- information in areas of alcohol drinking-
erable lobbying power to protect their adverse effects, alcohol intoxication, injur-
commercial interests. Lobbying by the big ies and the role of alcohol in emergency
alcohol industry has deterred the WHO, departments visits / hospitalizations.
the specialized health agency of the United Globally, alcohol causes 3.2% of all deaths
Nations, from any stronger actions. (1.8 million deaths annually). It is
Health-concerned leaders, worldwide, are estimated that about half of the deaths
continuously seeking international and attributable to alcohol are from injuries.
global effective collaborations to counter- Alcohol also accounts for 4.0% of all
act the alcohol-related problems29. disease burden worldwide.
The problem of alcohol-related injuries is
Medical morbidity: particularly alarming in many low-and
middle- income countries, where alcohol
Alcohol can be a significant contributing consumption is increasing. Consequently,
factor to many illnesses, such as hepatitis, injury rates are extremely high, where
hypertension, tuberculosis, pneumonia, there is lack of appropriate public health
pancreatitis, and cardiomyopathy30. It is facilities and policies to deal with this
known that alcohol abuse exposes people increase.
to infections, and hampers their healing. Emergency rooms are the most important
One half of all cases of liver cirrhosis in sites to collect information about alcohol
the USA have been attributed to alcohol. involvement in injuries. Unfortunately, few
Excess alcohol consumption also contrib- hospitals collect this information routine-
utes to central nervous system disease and ly35. In view of unlikelihood of majority of
severe psychiatric disorders. involved subjects to access health care
apart from emergency departments, the
Alcohol and specific illnesses: collection of pertinent data from these
patients regarding their drinking patterns is
Accidents, trauma and violence: lacking, which significantly hinders proper
interventions in this hard-to-reach popula-
Alcohol is implicated in the increased tion group.
morbidity and mortality from trauma31, Some of the conclusions of the WHO
including collisions with greater severity Collaborative Study on Alcohol and
of injuries in motor vehicle accidents32. Injuries, a cross-sectional study conducted
There is an increased risk of injuries due to in 12 countries from various parts of the
falls, burns, and violence. There is also world from December 2000 to February
increased risk of drowning. In addition, 2002, revealed a clear relationship between
there is an increased incidence of occupa- alcohol consumption and the risk of injury.
tional injuries and there is no identified Up to 45% of injured patients reported
safe level of alcohol consumption for the consuming alcohol prior to their injuries.
use of potentially dangerous equipment. The majority of patients were males, under
Suicide, homicide, serious assaults and 35 years of age, with a peak in the late
rape are significantly increased with teens and young adults from low to middle
alcohol intake33,34. socioeconomic classes. More than a third
Alcohol and injury has been addressed of patients reported that their injury
extensively in the world literature. occurred within 30 minutes of their last

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drink. The study was a useful tool to drinkers) than in abstainers, and rose
inform health policy-makers of the high progressively with heavier consumption36.
burden of injuries associated with alcohol The type of alcoholic beverage, by most
use. evidence, does not alter this risk41.
There are several studies describing
Cancer: correlation of GI cancer risk with alcohol
intake, with no clear safe threshold of
Alcohol use has been associated with consumption identified42. In one of these
increased risk for cancers of multiple studies, as an example, a 2013 meta-
organs36. The following is a brief review of analysis of 36 epidemiologic studies
the literature describing specific cancers: demonstrated that light alcohol intake (< 1
drink per day) was associated with an
Breast Cancer: increase in risk of oropharyngeal cancer
There is consistent evidence that breast (RR 1.17, 95% CI 1.06-1.29)40.
cancer risk is higher for women consuming
low (less than one drink /day) to high (3 or Nonmalignant liver disease:
more drinks/day) compared with
abstainers. There appears to be a A study of 277,000 men revealed elevated
significant dose response relationship that risk of death from cirrhosis among mild
begins with alcohol intakes as low as 3-6 drinkers as compared to abstainers. The
drinks per week37-39. A meta-analysis of relative risk of those who had consumed
110 epidemiologic studies conducted in one or two drinks per day were: 1.21 and
2013, showed a small but significant 3.15, respectively43. This implies gradually
association between female breast cancer increased risk of cirrhosis, with increased
and light alcohol intake40. In the largest levels of alcohol consumption.
cohort study of 105,986 women in the Many studies revealed more cirrhosis
Nurses Health Study, from 1980 until prevalence in heavy drinkers. One half of
200839, there was a gradual increase in the all cases of liver cirrhosis in the USA have
risk of breast cancer at lower levels of been attributed to alcohol.
alcohol intake (3-6 drinks per week), with Some of the increased risk associated with
upward increase of cancer of 10% with moderate drinking may be due to alcohol
each 10 grams of alcohol intake. Cancer interaction with other hepatotoxic agents,
risk was linearly correlated with cumuli- especially hepatitis viruses44. It is well
tive lifetime alcohol intake. Moreover, established that cirrhosis is associated with
there seems to be greater potential for increased risk of hepatocellular cancer.
invasiveness of breast cancer cells
associated with alcohol intake37. Cholelithiasis:
Gastrointestinal (GI) Cancer: In the Nurses Health Study, women who

consumed at least 2-3 drinks weekly were
Several GI cancers are linked to alcohol 40% less likely to develop symptomatic
consumption, even at low levels of intake. gall stones than abstainers45. The
In a study of 226,000 men, the combined mechanism of this protective effect may be
mortality rate from cancers of the mouth, due to reduction in the biliary cholesterol
larynx, pharynx, esophagus, and liver was saturation index46. This benefit is reversed
40% higher in low (less than daily

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in heavier alcohol consumption, especially Heavy drinking is detrimental to the

with alcoholic cirrhosis47. management, morbidity and mortality of
diabetic subjects.
Pancreatitis:
Pregnancy:
Heavy alcohol intake predisposes to both
acute and chronic pancreatitis. Moreover, Alcohol is known to have teratogenic
mild alcohol consumption may increase effects, and alcohol consumption while
relative risk of chronic pancreatitis 48. pregnant increases the risk of fetal mal-
development59,60.
Osteoporosis: A spectrum of birth defects related to
alcohol has been described and is called
Heavy alcohol use predisposes to hip Fetal Alcohol Syndrome (FAS). It is
fractures by causing both osteoporosis and characterized by fetal growth restriction,
falls49. Several studies showed mixed central nervous system dysfunction, renal
relationship of moderate alcohol intake, anomalies and a characteristic facies61.
bone mineral density and fractures. No safe level of alcohol intake during
pregnancy exists62. A large case-control
Diabetes Mellitus (DM): study of more than 4,700 babies with
congenital abnormalities found that even
The risk of DM was reported as decreased sporadic intake of only 1-2 drinks during
in people with moderate alcohol consump- the whole pregnancy was associated with
tion50. A meta-analysis of 15 cohort studies higher risks of eye abnormalities, particul-
found a decreased risk of diabetes among arly microphthalmia 62. Low birth weight
light to moderate, but not heavy may also be a consequence of mild alcohol
drinkers51.The validity of these studies is consumption during pregnancy63.
questionable because they are observa- Moderate drinking may raise the risk of
tional studies. In any case, studies suggest spontaneous abortion64. This risk increases
the following mechanisms for the reported with the increased alcohol consumption65.
low DM risk: No evidence supports a benefit of alcohol
Improved insulin sensitivity and lower use during pregnancy to the mother or
plasma insulin levels52. fetus. There is consensus that women
Lower level of oxidative stress and should completely abstain from alcohol
inflammatory markers53. during pregnancy66. However, recent data
Potential effect of alcohol on from Australia indicate that up to 65% of
postprandial hyperglycemia54. women drink significant amounts of
Effects of moderate alcohol intake alcohol before and during early
on adiponectin (an adipocyte hor- pregnancy67.
mone) which improves insulin
sensitivity in animal models55. Cardiovascular disease:
On the other hand, alcohol may worsen There are conflicting reports related to
diabetic neuropathy56, and my induce social or moderate alcohol consump-
severe hypoglycemia, lactic acidosis, tion and cardiovascular disorders. Our
hypertriglyceridemia and fatty liver57,58. knowledge of effects of (moderate) alcohol
consumption is derived primarily either

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from short-term trials analyzing effects of cardiovascular disease risk and sudden
alcohol on physiological parameters, or cardiac death.
from observational studies that compare To date, randomized trials in this area have
moderate drinkers with abstainers. Both not been performed.
types of studies suffer from limitations68. The risk of heart failure was reportedly
Their validity and reliability is less than reduced with light to moderate alcohol
cross sectional or cohort studies. They consumption73.
could be adversely influenced by various Chronic alcohol consumption on the other
factors including the lobbying liquor hand, may lead to alcohol-induced
industry. cardiomyopathy. The incidence of atrial
Some observational studies in USA fibrillation (AF) was increased by heavy
reported that moderate alcohol drinking and binge drinking, while moderate
may have some cardio protective benefits drinking does not seem to increase AF.
particularly in regards to coronary heart The incidence of hypertension was
disease (CHD)69. These studies were not increased by 1.5 to 2 folds in those who
supported by similar studies in Europe, consume more than two drinks daily
Russia or Australia- New Zealand. In compared to non-drinkiers74. This effect is
addition, these observational studies are dose dependent.
usually based on comparison of alcohol Problem drinking is clearly related to
drinkers with abstainers (non-drinkers). excessive mortality75. It is the third leading
The latter group of individuals is very preventable cause of death in the US76.
heterogeneous. Some of them avoid Following the publication of these
alcohol because of medical conditions, observational studies indicating that
family history of alcoholism, past personal drinking alcohol might give some
history of alcohol intake, religious or protection from coronary heart disease, the
cultural factors. Royal college of Physicians (RCP),
A large systematic review and meta- together with other Royal Colleges,
analysis of 84 studies, conducted in many published a report in 199577. The report
countries from nearly all over the world, reviewed these studies alongside data on
reported that light to moderate alcohol all-cause mortality, psychosocial risks and
consumption was associated with a 14- the possibility that publicizing these
25% reduction in the risk of multiple recommendations have led to an overall
cardiovascular outcomes, compared to increase in alcohol consumption, and an
non-drinkers70. Consumption of larger increase of the number of heavy drinkers.
amounts of alcohol was associated with The RCP report balanced the potential
higher risk of mortality. benefits of alcohol intake against its
A meta-analysis of 34 studies (comprising harms/ risks. It could be summarized in the
over a million subjects and 94,000 deaths) following points:
found that total mortality was reduced by For young men: The major causes of
18% in women who consumed one drink death due to alcohol consumption are
daily, and in men who consumed one to accidents and violent deaths.
two drinks daily, compared to non- For premenopausal women: Any
drinkers71. More than the above level of assumed protective effects against
alcohol drinking was associated with coronary heart disease are balanced by
increased risk for sudden death72. Binge deleterious effects on breast cancer,
drinking was associated with increased and on pregnancy

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For men aged 55 to 60 years, alcohol Excessive drinking, especially of

harms outweigh any coronary heart strong alcoholic drinks, such as
disease benefits. vodka, was recently reported, by a
Older people are particularly vulner- large prospective study, to be a major
able to various harms of alcohol, due to cause of premature death in Russian
physiological changes associated with adults81.
aging, even at modest levels of alcohol Moreover, alcohol-related mortality
intake. They are prone to have higher increased exponentially with the
blood alcohol levels than younger increased amounts of alcohol
people on drinking the same amount of consumed. Death at ages 55-74 years
alcohol due to lower body mass to ranged from around 50% for those
water ratio, reduced hepatic blood flow consuming less than a bottle of vodka
and less efficient hepatic metabolism. per week, to as high as 64% for those
Moreover, older people are prone to consuming three or more bottles of
develop more depression, dementia, falls vodka per week.
and physical illness. Recommended limits Excess mortality in this study was from
for safe drinking by older people require external causes (accidents, violence,
further considerations. Considering the suicide, homicide ) or from eight
increasing of aging population, an diseases, including cardiovascular
increased alcohol-related morbidity and deaths (acute ischemic heart disease
mortality is expected. other than myocardial infarction).
Defining the boundary between Excessive alcohol consumption and binge
moderate and hazardous drinking is not drinking are the third leading cause of
clear cut. preventable death in the United States82,
The possible protective effects on coro- and most likely in the rest of the Western
nary heart disease could be achieved by world.
lifestyle changes including diet and From all these studies, including the
exercise, as well as the use of statins. observational studies, researchers provide
Individual factors also contribute to the the following general recommendations:
risks of alcohol consumption, including (1) The reported cardiovascular benefits of
medication use, co-morbidity, frailty social or moderate alcohol drinking were
and physiological changes associated not validated by randomized studies.
with aging. (2) Social or moderate drinkers could
In Russia, there was increased mortality become problem drinkers under various
from cardiovascular disease linked to pressures and circumstances, and the
alcohol consumption, which is contrary to deleterious sequellae on the cardiovascular
the view prevailing in some countries in system will escalate.
the West, where alcohol, at least in (3) Binge drinking is associated with
moderate amounts, is seen by some as serious cardiovascular complications.
cardio-protective69. Some of the explana- (4) Any apparent advantage of moderate
tions of this discrepancy include: drinking must be balanced against the
Binge drinking has effects on the heart deleterious effects of alcohol on other
which are different from those seen in disorders, including cancer, liver disease,
regular moderate consumption 79,80. central nervous system and psychological
This pattern leads to a greatly increased derangements, violence, and socioecono-
risk of sudden cardiac death80. mic problems.

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(5) The risk-benefit balance may vary in Effects of the (alcohol dehydrogenase
different age group and ethnicities. gene) were studied in a case-control study
(6) There is no evidence to support of 396 men with myocardial infarction and
encouraging people, with or without CHD, 770 men as a control group. This gene has
to drink alcohol. two forms (alleles), one of which
In 2001, The American Heart Association metabolizes ethanol quickly (reducing the
(AHA) Science Advisory Council bodys exposure to alcohol), and the other
concluded: allele metabolizes ethanol slowely91. Daily
There is little current justification to drinkers with two copies of the faster
recommend alcohol (wine specifically) as alleles had a 38% lower risk of myocardial
a cardioprotective strategy83. infarction, as compared with non or rare
In 2006, AHA recommended: In the drinkers.
absence of randomized trials, the
consumption of alcohol cannot be Stroke risk:
recommended for CVS risk reduction86.
Alcohol beverage types were studied in A meta-analysis of 19 cohort, and 16 case-
view of reports that French red wine control studies found the following risks of
produced lower coronary artery disease stroke in drinkers, compared to non-
mortality85. Red wine contains phenolic drinkers92:
and flavonoid substances that have anti- Heavy drinking increases the risk of all
thrombotic and antioxidant properties86. strokes.
However, small human studies Moderate drinking: no significant
demonstrated similar protective properties reduction in the risk of all strokes.
in using de-alcoholized red wine87. This Light drinking: lower risk of all
material is also present in red grapes. strokes.
Resveratol (3,5,4-trihydroxystilbene) is a These observations were in contrast to
substance produced by plants in response another meta-analysis93. The Nurses
to stress, and is found in grape skin and Health Study which found that even light
also in red wine. This substance was found drinkers had twice the risk of subarachnoid
to extend life of non-mammalian hemorrhage compared to nondrinkers. The
organisms, and to improve the metabolic study revealed a slightly lower risk of
profile and lifespan of mice fed high fat ischemic stroke, but higher risk for
diets90. In man, this substance has to be hemorrhagic stroke93.
used in large amounts to produce enough Binge drinking was associated with
concentrations. increased risk for all strokes94.
Genetic factors have significant implica- The effects of alcohol may be modified by
tions on alcohol effects on ischemic heart ethnicity. As an example, in Japan,
disease. In a study of 3383 Danish men moderate alcohol use may slightly raise the
found that alcohol consumption was only risk of dying from stroke95.
protective for men with Lewis blood group
Le(a-b-) who are particularly prone to Alcohol intoxication:
ischemic heart disease89.
This observation was also reported from Two-thirds of American adults consume
the Framingham Offspring Study in alcoholic beverages. Up to 10% of adults
individuals carrying the Lewis gene-3 are alcohol abusers. Acute alcohol
(FUT3) gene90. intoxication is estimated to be responsible

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for over 600,000 emergency department The characteristic withdrawal syndrome is

visits each year96. manifested within hours or days of
Acute alcohol intoxication is associated stopping or reducing alcohol use. Two or
with significant increase of traffic more symptoms must be present, such as
accidents, domestic violence, homicide and sweating, tachycardia, tremulousness,
suicide. In one study, ethanol was detected anxiety, headache, nausea and/or
in 15 to 40% of unselected emergency gastrointestinal problems.
department patients97. More severe manifestations are generalized
Clinical manifestations of intoxication can tonic-clonic seizures100, hallucinations and
include slurred speech, nystagmus, disinhi- delirium tremens which could be fatal101.
bited behavior, incoordination, unsteady
gait, memory impairment, stupor or coma. Alcohol Availability and Accessibility:
Acute intoxication can also induce
hypotension and tachycardia, secondary to In view of legalization of production,
peripheral vasodilatation or to volume loss. import, export and sale of alcoholic
Multiple metabolic derangements may beverages in most countries, alcohol is
occur, including hypoglycemia, lactic freely available and accessible. The limited
acidosis, hypokalemia, hypomagnesemia legal measures to control some of the
and hypophosphatemia98. consequences have proved fruitless.
This clinical presentation may be The worldwide tendency towards treatment
complicated by ingestion of other of alcoholic individuals while ignoring the
substances such as opioids, sympatho- problems of availability and accessibility
mimetic drugs, benzodiazepines, barbitur- contradicts the diligent global measures to
ates, and other drugs. Serum ethanol prevent other dependence-producing drugs,
concentration, although helpful in confirm- such as opiate, cannabisetc. This was
ing the diagnosis, and for legal and expressed by the WHO Expert Committee
forensic investigations, often does not on Drug Dependence2:
correlate closely with the symptom- In many parts of the world, problems
matology of acute intoxication. Taking in associated with the use of alcohol far
consideration the possibilities of head exceed those associated with the non-
trauma, mental status changes, presence of medical use of less socially accepted
other disease entities, consumption of other dependence-producing drugs such as those
drugs, the management of moderate to of amphetamine, cannabis and morphine
severe alcohol intoxication represents a types" 2.
real emergency medical challenge.
The worldwide tendency to treat
Alcohol withdrawal: alcoholism, while ignoring the problem of
availability and accessibility of alcohol has
Drinkers with heavy, prolonged alcohol proved largely fruitless. There prevails a
use are at increased risk for alcohol use striking disparity between public,
disorder, and its consequences. governmental and international attitudes
Excessive alcohol drinking for even one towards alcohol vs other addicting drugs.
week can lead to some withdrawal The ill effects of alcoholic beverages far
symptoms, and excessive drinking for over exceed those of opiates, barbiturates and
one month leads to significant withdrawal hallucinogenic drugs, such as cannabis and
symptoms99. LSD put together2.

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The main factors behind this major suffer unacceptable burdens of harm from
imbalance in approach are: alcohol-related problems.
(1) Alcohol is deeply integrated in many In the view of Royal College of Physicians
cultures, especially in Western cultures. (RCP), evidence suggests that policy
Attempts to prohibit its consumption are measures to tackle the price, availability
neither desirable nor possible to the and promotion of alcoholic drinks are the
majority of the populace. most effective way of dealing with alcohol
(2) Licensing laws have been lax102. In abuse 108.
Australia and New Zealand, as examples, it
has been well established that licensing Alcohol: Remedy or Malady:
premises is associated with a significant
amount of alcohol-related harm103,104. All From the previous literature review of
governmental efforts to control alcoholic scientific evidence related to alcohol
beverages have failed to produce the consumption risk, harms and possible
desired effects. Alcohol consumption benefits, the following conclusions could
continued to increase105. be derived:
(3) Alcohol advertising: This is a global There are established risks of
handicap! The experience from Australia- morbidity and mortality caused by
New Zealand may be illustrative. The alcohol consumption, which include
Royal Australian College of Physicians increased risk of various cancers,
(RACP) and the Royal Australian and New cardiovascular, and neuropsychiatric
Zealand College of Psychiatrists diseases and complications, in addition
(RANZCP) have worked together to to increased risk of fetal
address the problem of the irresponsible malformations. Added to these are the
marketing and promotion of alcohol increased incidences of violence,
products. Several recommendations were suicide, homicide, family and work
adopted to counteract the influences of productivity disorders. There is also
alcohol beverage industry and that of the established worsening of many pre-
harmful marketing, promotion and existing medical disorders of various
advertising. It seems that the efforts by systems.
these professional organizations have been The reported observational reports of
unsuccessful in curbing these dominant cardiovascular benefits of social or
influences 106. Although alcohol industry moderate alcohol consumption,
published its DrinkWise Australia, there could not stand in the face of major
is pessimism among many clinicians and medical, psychosocial and economic
policy makers about the success of this and harms. All these reports were not
other current strategies to prevent alcohol- validated by randomized studies. The
related harm. It is a fact that there are Royal College of Physicians in 1987
minimal regulations of alcohol advertising submitted to the fact that alcohol
and promotion. Significantly, the bulk of consumption is widespread and
advertising is aimed at young people!. enjoyed by many and that was behind
Effective and evidence- based clinical issuing a judgment about what an
practice and prevention strategies accept- acceptable level of risk was22.
able at the government level, often face In addition to this fact, the dominant
opposition from the alcohol beverage influences of profiteering alcohol industry,
industry107. The community continues to marketing and advertising play major roles

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in curtailing any meaningful measures to motivation / up-brining, in addition to

curb the universal alcohol consumption the influences of the profiteering
problem. alcohol industry.
There are staggering economic
consequences of alcohol consumption. Islamic Perspectives:
Alcohol consumption is frequently Why Islamic guidance succeeded and
associated with smoking and other others failed? :
addictive substances.
Starting alcohol consumption in Fourteen centuries ago, Islam had
younger age groups and frequent binge completely and successfully eradicated
drinking are instrumental in increasing alcohol consumption, in a society in which
tendency to transit from moderate it was deeply entrenched and intertwined
and social drinking to alcohol abuse with their daily lifestyle, social occasions,
disorders or alcoholism under various culture, rituals and rites. A gradual
personal or social influences. These are approach together with nurturing of moral
all looming dangers of problematic values in Muslim individuals and societies
alcohol use. were the reasons for this success. In the
The current tendency to deal with pre-Islamic era, and even during the early
alcohol use disorders, while leaving Islamic years, alcohol consumption was a
aside the problem of alcohol deeply entrenched, widespread and
availability and accessibility, have indispensible tradition. It was considered a
proved to be fruitless. source of joy, nutrition and promotion of
Most countries adopt legalization of good health. Islam did not primarily attack
alcohol consumption, with certain alcohol intoxication. Islam, rather dealt
limitations such as on drinking whilst with the deep-rooted false belief and value
driving cars, and sale to younger age system upon which many habits and
groups. Such limitations are without behaviors were based. When Islam
real effectiveness in the face of alcohol addressed established habits and traditions,
availability and accessibility. Islamic guidance tended towards gradual
Currently, the strong and slick approaches that went hand in hand with
advertisement, in addition to the nurturing of values and faith of individuals
dominant influence of alcohol industry and societies. Over three years, Quranic
on policy makers, are strong barriers to verses addressed the issue of alcohol, and
negate any influence of education on other deep-rooted traditions, by first
the various dangers of alcohol outlining risks and dangers that outweigh
consumption on the health, welfare and any limited benefits. The first Quranic
safety of individuals and societies. verse in this regard was:
Alcohol prohibition by forcible legal
measures was historically attempted in
"
both the USA and in the previous
."...
Soviet Union, but unfortunately ended
up with disastrous failure.
A multiplicity of factors were believed "They ask you about khamr (alcohol,
to be behind failure of these historical intoxicants) and gambling. Say: In them is
attempts. They include lack of proper a great sin, and benefits for mankind, but
education, and of moral-religious their sin is greater than their benefits 109.

ALCOHOL
The verse points out that there are grave made hideous mistakes in reciting the
sins and some benefits involved in alcohol Glorious Quran in his prayer.
consumption, with greater preponderance This restriction was very significant in two
of major and versified harms, that exceed ways:
their benefits. (1) Alcohol consumption was placed, for
This risk-benefit imbalance was later the first time, face to face against the
established by contemporary scientific cardinal worship of the 5 ritual prayers
evidence as shown in the literature review (salah) that are distributed thoughtout the
cited above. Muslim commentators that day, starting with dawn (fajr) prayer and
time, at their level of scientific-medical ending with the night (isha) prayer.
knowledge, had explanations of the word (2) This partial restriction was very
(sins). They defined (sins) as harms and pertinent in the process of breaking the
risks including religious wrong- doing, and basis of alcoholism (addiction). The Arabs
harmful clouding of thinking that at that time had established drinking
precludes proper attention and performa- traditions of morning drinking (Sabouh), as
nce of worship and other functions110. well as early evening drinking
Another Tafsir (explanation) referred to (Ghabough). The new restriction was
the harmful effects of wasting of wealth instrumental in reducing and wide -spacing
(mal) and clouding of thinking (aql)111. of drinking episodes. In fact, there would
They were not aware of the grave physical be limited time left for drinking, if one has
and mental consequences of alcohol to attend to these collective prayers in the
consumption, as recently revealed by mosque, or at home, five times a day.
scientific evidence. Breaking the habitual drinking for longer
Muslim commentators explained the word hours every day is effective in minimizing
benefits in terms of some general tendency to alcohol addiction.
prevailing impressions at that time, such as The final and most decisive step of total
improvement of digestion, getting rid of prohibition was delivered in the wake of a
excretions, joyous feelings, in addition to major feast that included both Muhajirin
sale profiteering110. (from Makkah) and Ansar (from Madinah)
This initial Quranic verse was enough for at which hard liquour was served. Once
many devout Muslims to turn away from intoxicated, there insued a state of tribal
khamr and gambling, seeking purity and boasting, shouting and hand fighting. As
blessings of their Creator. they were restored to their senses, and the
Subsequently, the next Quranic verse was effects of liquor had worn off, they intered
revealed: into a state of depression, and deep

" feelings of sinfulness and guilt.

At this point the decisive Quranic verse
"...
was revealed.
O believers, do not perform prayers when
you are drunken (intoxicated), so that you
know (understand) what you are

"
saying112.

This verse was revealed when a sahabi

(companion) of the Prophet ()
"
performed prayer while inebriated, and

ALCOHOL
.Satan wants only to cast enmity and prophet ( )said: Never. It is a disease
hatred among you, by means of khamr and not a cure118.
(alcohol, intoxicants) and Maysir (games In another more comprehensive Hadith,
of chance), and to turn you away from the the Prophet ( )said: Allah has sent
remembrance of Allah and prayer. Will down both the disease and the cure, and He
you not then desist?113. has appointed a cure for every ailment. So
At the final stage of this historical event, get your cure through lawful medications,
Prophet Muhammad ( )proclaimed his and never use prohibited things119.
famous Hadith, whereby he cursed Khamr
(alcohol, intoxicants), the one who drinks Concluding Remarks
it, brews, sells or even serves it114.
Following this Hadith, in a matter of a day For the past 14 centuries, Muslim
or two, the Muslim community in Madinah communities all over the world are either
got rid of all their stored alcoholic free or are the least affected by alcohol and
beverages, and became abstinent, in the its consequences. The vast majority of
most successful campaign that had ever Muslims, from different cultures, ethnicit-
been launched by man against alcohol ies and geographic locations, kept their
consumption. Ever since these fateful days, abstinence throughout the ages, together
Muslims all over the world, from various with dominant and deep-rooted intellectu-
ethnicities and cultures, became liberated al, social, moral and ethical conviction.
from alcohol, or are the least affected Arnold Toynbee in his book Civilization
among world populations. Islamic spirit on Trial said: Islamic spirit may be
and religious conviction were able to expected to manifest itself in a
accomplish what could never be achieved liberation from alcohol which was inspired
by external sanctions of man-made laws. by religious conviction and which was
therefore able to accomplish what could
The use of alcohol as medicine never be enforced by the external sanction
of an alien law.Here, then, in the
The issue of using alcohol as a medicine in foreground of the future, we can remark
certain ailments, was addressed by several valuable influences which Islam may
prophetic Ahadith. exert upon the cosmopolitan proletariat of
The Prophet ( )was asked: We use a Western society that has cast its net
khamr (alcohol) as a medicament. His round the world120.
answer was: It is no cure. It is itself a Even in the U.S.A where proscription of
disease115. alcohol failed (1919-1933), Islam has
Abdullah bin Masoud narrated: The proved capable of solving this intricate
problem. James Baldwin, a well-known
Prophet ( )said: Allah never made
Afro-American writer, who himself conv-
cure in things He prohibited116. erted to Islam, wrote in his book: The Fire
Abu Hurairah narrated that the Prophet Next Time, the following passage to his
( )said: That who tries to get cure fellow American blacks120:
through drinking khamr (alcohol), Allah I remembered my buddies of years ago, in
will not cure his ailment117. the hallways with their wine and their
A Sahabi (companion) asked the Prophet whisky and their tears, in hallways still
( )about wine as a medicament. The frozen on the needle, and my brother
saying to me once, if Harlem didnt have

ALCOHOL
so many churches and junkies, there would alcohol-related problems must be on the
be blood flowing in the streets. area of primary prevention.
And now suddenly people who have Islam provides such a successful measure.
never before been able to hear this Humanity has to study seriously Islam and
message (of Islam) hear it, and believe it, how did it manage to solve such a difficult
and are changed .(Islam) has been able and intricate problem both in the past and
to do what generations of welfare workers, present.
committees, resolutions, reports, housing
projects and playgrounds have failed to do: References:
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TOBACCO DEPENDENCE:
THE WHOLE STORY
Feras I. Hawari*
Abstract:
The use of tobacco dates back to hundreds of years and is considered highly addictive. Nicotine
is the predominant substance that causes tobacco dependence. Nicotine exerts its effect via
similar neurological pathways used by other recreational drugs resulting in high level of
dependence. All forms of exposure to tobacco including active use of tobacco, second-hand as
well as third-hand exposure to tobacco smoke are known to be harmful. Tobacco is the only risk
factor that is common between all non-communicable diseases including cardiovascular diseases,
respiratory illnesses, cancer and diabetes mellitus. International consensus regarding the harms
of tobacco is now evident. Many international organizations are mapping the way for the end of
tobacco. Until then, aggressive treatment for those subjects interested in quitting must be
provided in order to prevent a significant surge in non-communicable diseases especially in low
income countries. Tobacco dependence is a chronic relapsing disorder that requires a
multidisciplinary approach using psychological and pharmacological techniques.
Keywords: Tobacco dependence, tobacco harms, tobacco control, tobacco dependence

treatment.
The history of tobacco1,2:
Tobacco is a naturally deadly plant that statement made by Sir Francis Bacon who
initially was grown only in North and South noted that trying to quit the bad habit was
America. It belongs to the same family as really hard. By mid-1600s it became morally
potatoes and pepper. Following the discovery unacceptable to smoke in certain states of the
of America, sailors brought tobacco with them United States of America such as Massa-
to Europe and then to the rest of the world. In chusetts due to the fact the tobacco may be
the 1500s it was thought that tobacco can cure harmful. In 1760, Pierre Lorillard established a
all diseases and was promoted as such by company in New York City to process
physicians and recommended to be taken tobacco, cigars, and snuff and became the
daily. Later in the 1600s, tobacco became so oldest tobacco company. The tobacco industry
popular and was used instead of money to became well established since then and played
complete business transactions. During those a role in financing governmental actions
times the first hints that tobacco might be including military operations. Following that
harmful began to surface. and in 1826 specifically, nicotine was isolated
In 1610 the first evidence that tobacco might in its pure format and was declared few years
be addictive and that smokers might be later poisonous and that it can be used as an
interested in quitting was concluded by a insecticide.
*Dr. Feras Hawari, MD, FCCP

Consultant Pulmonologist
Cancer Control Office
King Hussein Cancer Center (KHCC)
Amman-Jordan

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In 1836 the first statement was made regard- inhaling the smoke or as smokeless tobacco
ing the lethal effects of nicotine as a chemical which is usually consumed either orally or
that might be able to kill a human being. nasally, without burning or combustion. Both
Cigarettes were first manufactured in 1847. By forms of tobacco consumption increase the
the year 1900 cigarettes be-came the major risk of cancer and lead to nicotine addiction.
tobacco product made and sold. In 1901 for Combustion, however, uses heat to create new
example, 3.5 billion cigarettes and 6 billion chemicals that are not found in unburned
cigars were sold. Cigarettes continued to tobacco such as carbon monoxide, tobacco-
spread after that to a point that they were part specific nitrosamines (TSNAs) and benzopy-
of soldiers rations during World War II. rene, and allows them to be absorbed through
Finally, in 1964 the first USA Surgeon Gener- the lungs1.
al report came out carrying the title Smoking Manufactured cigarettes are the most
and Health focusing on health effects of commonly consumed tobacco products
tobacco and providing the first document for worldwide. They consist of tobacco that is
governments to start regulating and controlling processed with chemicals and flavors such as
the spread of tobacco. Later, more Surgeon menthol and rolled into a paper-wrapped
General reports began to shed the light on the cylinder. As it burns from one end, smoke is
harmful effects of tobacco till the year 1982 inhaled from the other end through a cellulose
when second hand smoke exposure was acetate lter. Cigars are made of air-cured and
declared a risk factor for the development of fermented tobacco rolled in tobacco-leaf
lung cancer resulting in the gradual banning on wrappers. This process of aging and fermenta-
smoking in public places. Throughout the tion results in high concentrations of carcino-
years, all efforts by governments to curb the genic compounds inhaled by smokers that are
spread of tobacco were constantly faced by higher than in cigarettes. Waterpipe, also
counter novel and misleading tactics by the known as shisha, hookah, narghile, or hubble-
tobacco industry that encouraged the use of bubble constitutes now a world-wide
tobacco through marketing to teenagers and epidemic3. The additional use of charcoal in
females using products designed specifically waterpipe smoking to indirectly heat and burn
to attract such consumers. In addition, they tobacco represents a significant added risk that
started diversifying their products to include contributes to the carcinogenicity of this
food and clothing. Lately, the tobacco industry method of smoking. When smoking waterpipe,
moved into a new line of production, electron- smoke is drawn through the water to be
ic cigarettes in order to face global efforts partially cooled and inhaled into the lungs
aiming at putting an end to this industry and through a hose. Flavored tobacco maybe used
reducing tobacco prevalence to less than 5% too. Kreteks, another form of smoking
by 2040. Worldwide, 3.8 million hectares of tobacco, are usually clove-avored and contain
agricultural land are used in tobacco agricul- eugenol which has an anesthetic eect4.
ture distributed over 124 countries. China Flavoring in general usually allows for deeper
grows 43% of the worlds tobacco cigarettes and thus more harmful smoke inhalation. This
accounting for 92% of the value of all tobacco form of smoking tobacco is commonly used in
products sold globally. countries in Southeast Asia such as Indonesia.
Contrary to the belief of the general public,
Forms of tobacco roll-your-own cigarettes which are hand-lled
And tobacco smoke exposure: by the smoker using cigarette paper and ne-
Tobacco is used either by burning dry or cut loose tobacco contain high concentrations
processed leaves of the tobacco plant and of tobacco particulates, tar, nicotine, and

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TSNAs resulting in increased risk for smokers to environmental tobacco smoke.

developing cancers of the head and neck, Such conclusion was then the basis for strict
lungs, and esophagus. It is most prevalent in implementation of banning the exposure to
Europe and New Zealand. Bidis on the other second hand smoke in public places11.Another
hand, consist of a small amount of crushed form of exposure to tobacco smoke is the
tobacco, hand-wrapped in dried temburni or newly described third-hand smoking. This
tendu leaves, and tied with string. Bidis deliver refers to the chemicals and products that
more tar and carbon monoxide than manufa- precipitate on the surfaces after second hand
ctured cigarettes due to the fact that users need smoke is cleared12.
to pu harder to keep them lit. Bidis are most Third-hand smoke contaminate surfaces,
prevalent in South Asia and India. Pipes are furniture and clothing with carcinogenic
made of briar, slate, clay, or other substances. chemicals such as radioactive polonium-210
After placing tobacco in a special bowl, it is and tobacco-specific nitrosamines13,14.
burned and smoke is inhaled through the stem. These chemical could potentially pose great
Pipes are prevalent worldwide. Sticks are deal of danger to infants and young children
made from sun-cured tobacco and wrapped in who are more likely to crawl and eat with their
cigarette paper. hands without washing them. Research is
Smokeless tobacco forms include chewing underway to expose the real health risks
tobacco, moist tobacco and dissolvable associated with third-hand smoking15.
tobacco. All these forms deliver nicotine
through the buccal mucous membranes. Dry Epidemiology, expected health tolls
snuff is inhaled through the nose or taken and finance:
orally. Despite efforts to control the spread of
Second-hand smoking (passive smoking) is tobacco, currently 20% of the worlds
another form of exposure to tobacco smoke. population, that is approximately one billion,
This type of exposure does not only contribute are active smokers. Eighty percent of smokers
to the initiation of smoking, development of are males. Such large number of smokers is
tobacco dependence5 and significant irritation not only causing a rise in morbidity and
to those who are exposed to it, but it also mortality due to various diseases that result
contributes to significant mortality and directly from smoking, but also contributing
morbidity in the community6. Passive smoking significantly to death resulting from second
can significantly elevate the level of carbon hand smoking especially in women and
monoxide, increase risk of lung cancer, coron- children While current death toll from second
ary artery disease and sudden cardiac arrests in hand smoking is estimated to be at 600,000
those expose to it7. In the 1960s the adverse individuals annually1, it is also estimated that
effects of maternal smoking on the developing 75% of these deaths are among women and
fetus and on children exposed to second hand children. More than half the countries of the
smoke in smoking households were world have a female smoking prevalence rate
reported8,9. Those fetuses who were exposed to of less than 10%. Smoking rates among boys
environmental tobacco smoke suffered from and girls are more comparable and differ by
decreased lung function10. All that led to a less than five percentage points in almost half
conclusion by the US Department of Health of the worlds countries. Smokers consumed
and Human Services (USDHHS) in 1986, that nearly 5.9 trillion cigarettes in 2009. Tobacco
Simple separation of smokers and non- taxation is considered a significant source of
smokers within the same air space may reduce, revenue income for most countries. Despite
but does not eliminate, exposure of non- the fact that governments collect nearly $133

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billion in tobacco tax revenues each year, they mes have been classified as substance abuse
spend less than $1 billion on tobacco control. disorders under WHO International Statistical
Further increase in revenue is expected if illicit Classification of Diseases and Related Health
trade were to be eliminated with reports Problems (ICD 10)18, an important step in
reaching up to USD 31.3 billion in immediate justifying and encouraging governments to
gains upon the elimination of such trade16. The offer treatment to smokers. In general,
World Health Organization (WHO) recomme- dependence develops when the neurons adapt
nds that at least 70% of the retail price of to the repeated drug exposure and only
tobacco products come from excise taxes. At function normally in the presence of the
least 86% of WHO member states imposed a drug19. Tobacco dependence is driven by the
tobacco excise tax, and at least 14% use a highly addictive nature of nicotine. As a
portion of tobacco tax revenue for health psychoactive drug, nicotine induces euphoria,
purposes. Some countries are now envisioning serves as a reinforcer of its use and acts both
an end game for tobacco, with prevalence as a stimulant and a depressant. Strong and
targets of under 5%. The WHO Frame Work overwhelming withdrawal symptoms develop
Convention on Tobacco Control (FCTC) treaty in its absence. Tobacco dependence fulfils all
covers 87.4% of the world population. the criteria for substance abuse as outlined in
Approximately 3.8 billion people are covered the Diagnostic and Statistical Manual of
by at least one of the six MPOWER strategies Mental Disorders, 4th Edition20. It is ranked
that will be discussed below at the highest third after heroin and cocaine and higher than
level of achievement. The number of people alcohol and cannabis in its ability to cause
protected by comprehensive smoke-free laws dependence21. The combination of its highly
has doubled from 2008 to 20101. addictive property as well as the severe
adverse effects that it inflicts on its active
Tobacco initiation and dependence:
users as well as the severe detrimental health
Tobacco initiation typically occurs during effects second and third hand smoking have on
childhood or adolescence. It is an acquired the population, caused religious Islamic
social behavior16. Social learning occurs in leaders in many Muslim countries such as
children as they adopt behaviors in part Jordan, Egypt, many countries in Gulf
through observation of parents, peers, and Cooperation Council as well as Islamic
other role models. During the teenage years, countries in southeast Asia to issue a Fatwa
peer pressure becomes the dominant social that using tobacco products is forbidden
influence16. Media plays an important role in according to Islamic rules (Haram)22-25. It is
promoting and normalizing the appearance and important to note that nicotine mechanism of
the behavior of smokers through projecting action and the targeted areas in the brain are
famous figures smoking in public. Initially, similar to other recreational drugs such as
initiation is mostly voluntary, however, upon cocaine. The principle mechanism of action is
the development of addiction, self-control can thought to be targeting areas in the brain such
become seriously difficult and impaired. The as the nucleus accumbens and increasing
cycle of nicotine addiction starts when nicotine levels of dopamine which in return result in
containing products are used for pleasure and the desirable effects and inhibit the withdrawal
for enhancing mood and perform-ance. As symptoms that may result from abstinence
tolerance and physical dependence develop from the drug26. Nicotine reaches the brain
over time continuous use of nicotine products through either the lungs when smoked or
is used to self-medicate withdrawal symptoms mucous membranes when smokeless tobacco
in addition to the above sought after effects17. forms are used. Although the levels of many
Tobacco dependence and withdrawal syndro-

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substances are reported to increase in the brain discontinue once the treatment goals are
upon exposure to tobacco smoking such as achieved. Although it has been always
serotonin and endogenous opiates, dopamine emphasized that nicotine is the most important
remains the main chemical involved in the chemical in cigarettes that contributes to its
process of positive reinforcing aspects of highly addictive properties, other compounds
nicotine addiction and the desired feelings such as acetaldehyde, ammonia compounds,
sought by those who use tobacco. As nicotine and menthol also make cigarettes more
reaches the brain it binds to a special receptor addictive through increasing free-base
known as 42 nicotinic acetylcholine receptor nicotine, making it easier to produce larger
(nAChR)located in the ventral tegmental puffs (filter-tip ventilation) and other factors
region which results in the release of that reduce the concerns for smokers and
dopamine27,28. As nicotine binds to 42 increase the attractiveness of the products34.
nicotinic acetylcholine receptor (nAChR) Nicotine is metabolized primarily by the liver
occupancy on glutamatergic terminals, glutam- enzymes CYP2A6, UDP-glucuronosyltrans-
ate, an excitatory neurotransmitter, is released fease (UGT), and flavin-containing mono-
which results in an increased release of oxygenase (FMO). Many factors influence the
dopamine in the nucleus accumbens and the metabolism of nicotine such as genetic factors,
frontal cortex29,30. In addition Nicotine binds diet, age, sex, use of estrogen-containing
to 42 nicotinic acetylcholine receptor hormone preparations, pregnancy, kidney
(nAChR) occupancy on gamma-aminobutyric disease, other medications, and smoking
acid (GABA)-releasing terminals31. itself35. Nicotine is further metaboli-zed to
cotinine, which may be measured in blood,
This binding causes an increase in the levels of
urine, saliva, hair, or nails. Cotinine levels are
GABA, an inhibitory neurotransmitter.
used to distinguish smokers from non-
Furthermore, nicotine binds to a specific
smokers. Levels exceeding 3 ng/ml indicate
receptor in regions of the brain such as the
active smoking status in countries with low
nucleus accumbens and result in the produc-
exposure to second hand tobacco smoke.
tion of dopamine32.
These chain reactions start in 10-20 seconds Second hand smoke exposure is believed to
after inhalation mainly due to the large surface play an important role in the occupancy of
area in the lung available for absorption33. In 42 nicotinic acetylcholine receptor. Recent
general, nicotine dependence follows a similar evidence36 utilizing Positron emission tomo-
pattern that occurs with other substances and graphy scanning measured whether moderate
second hand smoke (SHS) exposure results in
that is characterized by both the persistence of
brain 42* nicotinic acetylcholine receptor
a drug-seeking behavior and the emergence of
occupancy in smokers and non-smokers. The
withdrawal symptoms upon the abrupt
study concluded that nicotine from SHS
cessation of nicotine administration32. In the
exposure results in substantial brain 42*
end, chronic nicotine exposure result in a
nAChR occupancy in smokers and non-
neurobiologic adaptation and desensitization
smokers. In addition, the finding suggested
of the receptors with the need to increase those
that such occupancy would be sufficient to
receptors through further increase in the
deliver a priming dose of nicotine to the brain
quantities of tobacco consumed. However, not
that contributes to continued cigarette use in
all forms of nicotine delivery pose an equal
risk in establishing or maintaining nicotine smokers. It was also important to note that
addiction. Nicotine replacement therapy used while moderate exposure tested in this study
in treating tobacco dependence for example, is was sufficient to cause an increase in plasma
less likely to cause dependence and easier to nicotine concentration of approximately 0.2

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ng/mL and a mean 19% brain 42* nAChR pressures on countries with limited resources
occupancy in young adults, heavy SHS to enforce their tobacco control regulations41.
exposure (in enclosed rooms with multiple NCDs related deaths are expected to increase
smokers) demonstrated increases in plasma by more than 25% in low income countries
nicotine levels greater than 2 ng/mL and over the next 15 years42. Cardiovascular
greater than 70% 42* nAChR occupancy37. diseases (CVDs) occupy the number one spot
These alarming findings have greater among all NCDs that cause death in humans.
implications in countries where second hand The relation between tobacco use and
exposure control are not implemented result- cardiovascular diseases was recognized in the
ing in significant exposure in nonsmokers first US surgeon general report in 196443.
especially prepubescent children and infants Cigarette smoking accelerates atherosclerosis
who have a 1-minute ventilation per kilogram and contributes to cardiovascular diseases
of bodyweight that is approximately 2 to 3 through many mechanisms that precipitate
times higher than adults. Because of that thrombosis, hemorrhage, or vasoconstriction
increases in plasma nicotine concentration and resulting in the end in vascular occlusion and
occupancy of brain 42* nAChRs from ischemia. Cigarette smoking affects blood
similar levels of SHS exposure may be even lipids profile and hemostasis. Smokers have
greater for children than for adults, thus setting lower concentrations of high density lipopro-
them up to be dependent on nicotine during teins, a risk factor for coronary artery diseases.
early childhood. Such studies that link SHS Carbon monoxide resulting from the
exposure and craving in smokers as well as combustion of tobacco is significantly elevated
priming nonsmokers especially children is in the blood of smokers. It is known to have
highly relevant to public policy and laws that more than 200 times higher affinity for
aim at limiting SHS exposure in closed public hemoglobin than that of oxygen, thus directly
places38,39. reducing oxygen delivery to the tissues.
Overall, smoking causes CVD through
Health effects of tobacco: multiple mechanisms including: endothelial
Every year more than 5 million people die dysfunction, increasing prothrombotic effect,
from tobacco-related diseases. By the year enhanced platelet activation in response to
2030, this number is expected to near 10 different stimuli, inflammation through
million40. With high income countries making activation of NF-B pathway44, altered lipid
efforts to limit the spread of tobacco in their metabolism, and increased demand for
myocardial oxygen. All these proposed
areas and consequently succeeding in
mechanisms would result in a decreased
decreasing the prevalence of smoking, it is
supply of myocardial blood and oxygen either
expected that more than 80% of these tobacco-
directly through narrowing of the lumen (due
related deaths will occur in low income
to atherogenesis plaque formation and vasoco-
countries1. Tobacco is currently the most
nstriction) or through the increased demand
easily preventable cause of death and is the
(due to nicotine mediated sympathetic
only risk factor that is common among all non-
stimulation and increased heart rate, blood
communicable diseases (NCDs), namely
pressure and myocardial contractility). The
cardiovascular disease, cancer, respiratory
2010 Surgeon Generals report45 reported an
illnesses and diabetes mellitus. However, the
World Economic Forum estimates that the cost increase in coronary heart disease risk with
of these diseases in low income countries is more cigarettes smoked per day only up to
expected to exceed USD 20 trillion over the about 25 cigarettes. Others showed such
next 15 years, thus exerting enormous relation to continue up to 40 cigarettes per

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day46. These effects are not exclusive for smoke might predispose to breast cancer. In
active tobacco smoking, In fact, secondhand general, smoking has been associated with
smoke is also associated with chronic decreased survival in patients with a variety of
inflammation and a non-linear dose-response cancers such as those of the head and neck,
relationship between such exposure and breast, colon, rectum, prostate and others58.
cardiovascular effects47. Jefferis et al showed This negative effect on survival is
that serum cotinine in nonsmokers was multifactorial. For example, smoking has been
positively associated with white blood cell associated with poor nutrition, co-morbidities,
count and with levels of C-reactive protein impaired immune function and accelerated
(CRP), Interleukin-6 (IL-6), fibrinogen, and carcinogenesis and disease progression59,60.
matrix metalloproteinase 9. The CRP levels of Second, patients who continue to smoke while
nonsmokers were about one-third lower than they are receiving chemo and radiotherapy are
the levels of active smokers, but CRP levels at risk of receiving suboptimal therapy for
increased more sharply among nonsmokers at their cancer61 and have a higher chance of
higher exposure levels48. These findings developing adverse events related to these
emphasize again the benefits of banning modalities of treatment62,63. Third, the
smoking in public places. In addition to development of a second primary cancer and
coronary heart disease, a growing body of the negative impact of smoking on the life of
evidence indicates that smoking causes sudden cancer survivors are other significant risks that
death49, aortic aneurysms50, and peripheral cancer patients who continue to smoke must
vascular disease51,52. There is a dose-response deal with64,65.
relationship between smoking and cerebro- Smoking and pulmonary diseases:
vascular disease53,54 and a new strong evidence Smoking is known to cause and affect many
demonstrates a causal relationship between respiratory illnesses such as Chronic Obstruc-
exposure to second hand smoke and increased tive Pulmonary Disease (COPD), asthma,
risk of stroke up to 30%55,56. tuberculosis and pulmonary fibrosis. Smoking
causes all elements of the COPD phenotypes
Smoking and cancer:
It has been established that smoking increases including emphysema and damage to the
the risk for certain cancers such as those of the airways of the lung. Smoke recruits inflamma-
head and neck, lung, urinary bladder and tory cells such as macrophages and liberates
leukemia. Tobacco smoke contains more than proteases from viable lung cells which in
7,000 chemicals, and at least 69 of these can return disrupt the function of protease
inhibitors like 1-antitrypsin. This results in
cause cancer57.
facilitating the effect of proteases and the
Examples of these chemicals include aromatic
destruction of extracellular matrix. Evidence is
amines, polycyclic aromatic hydrocarbons
suggestive that women who smoke are more
(PAHs), tobacco-specific nitrosamines; forma-
susceptible to develop severe COPD at
ldehyde, acetaldehyde, 1,3-butadiene, and
younger ages33.
benzene. When inhaled, these substances
cause DNA damage, inflammation and muta- Similarly, asthma is impacted by smoking
tions in oncogenes and tumor suppressor genes through many mechanisms. Chronic airway
leading to loss of normal growth controlled inflammation, impaired mucociliary clearance,
mechanisms54. Recently, new evidence impaired growth of the lungs during child-
concluded a causal relationship between smok- hood, and increased bronchial hyper-respon-
ing and colon and liver cancers33. In addition, siveness are all enhanced by smok-ing54,66.
evidence is suggestive that both active Immunologic mechanisms include effects on T
smoking and exposure to second-hand tobacco cell function and a higher ratio of Th2/Th1,

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increased production of IgE, and greater infertility in both males and females. Maternal
allergic sensitization. Cigarette smoke may active smoking might be also linked to
increase neurogenic inflammation in the spontaneous abortion and fetal anomalies such
bronchial airway67,68 resulting in further as orofacial clefts, clubfoot, gastroschisis, and
inflammation of the airway. atrial septal heart defects42.
In summary, the evidence is suggestive of a
causal relationship between active smoking Tobacco control strategies:
and the incidence of asthma in adults as well
as exacerbation of asthma among children, The WHO through its international treaty the
adolescents, and adults. Serious lung infec- Frame Work Convention on Tobacco Control
tions can also be promoted by smoking. For (FCTC) lists six evidence-based strategies
example, the risk of mycobacterium that aim to address the various articles in this
tuberculosis disease, mortality from the treaty including policy, regulatory and
disease and disease recurrence are all higher in economic interventions75. Summarized in the
smokers69. Lastly, some evidence suggests a word MPOWER, the components stand for the
possible relationship between cigarette smok- following:
ing and idiopathic pulmonary fibrosis70. Monitor tobacco use and prevention policies:
Cigarette smoking and diabetes mellitus: The National data are collected periodically to
risk of developing diabetes is 3040% higher track tobacco use and consumption. The
for active smokers than nonsmokers42. There is Global Adult Tobacco and the Global Youth
a positive dose-response relationship between Tobacco surveys are examples. Unfortunately,
the number of cigarettes smoked and the risk many countries in the world are not capable of
of developing diabetes. Furthermore, smoking conducting these surveys due to their high
aggravates insulin resistance in persons with cost.
diabetes resulting in suboptimal control of the Protect people from tobacco smoke:
blood glucose42. Recently, smoking was Implementing bans on smoking in public
implicated in the pathogenesis of rheumatoid places is the cornerstone of this strategy.
arthritis. The mechanism appears to involve While this has been a very successful strategy
both the effects of oxidizing chemicals in the in high-income countries to reduce the spread
smoke and the sympathomimetic effects of and harms of tobacco, it has been very
nicotine42. The incidence of neovascular and challenging to implement in low income
atrophic forms of age-related macular countries due to the significant lack of
degeneration are also increased by smoking. governmental commitment and a strong
Multiple pathways are likely responsible for tobacco lobby that has been transferring its
the degenerative changes in the macula. In markets to those vulnerable regions.
genetically susceptible persons, smoking Offer help to quit tobacco use:
causes changes in retinal pigment epithelium, This strategy will be discussed in details in the
Bruchs membrane, and choroidal endothelium following section.
and generate a local inflammatory response71. Warn about the dangers of tobacco:
Oxidative stress and vascular insufficiency are Mass media campaigns as well as the use of
proposed mechanisms for smoking-related pictorial warnings are known successful
damage to retinal structures72,73. methods to attract public attention, deliver
Additional evidence is sufficiently conclusive necessary health messages and drive up the
that smoking is associated with many other intention to quit among smokers. Pictorial
conditions such as erectile dysfunction, ectopic warnings on cigarette packs are usually
pregnancy74 and contributes significantly to graphic and occupy at least 50% of the surface

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area of the cigarette pack. In the Eastern phlegm occurs within hours to days from
Mediterranean Region (EMR), Jordan, Egypt quitting78.
and Iran introduced those warnings and in the In the long-term, quitting tobacco reduces
process of upgrading them. premature death by 90% for those who quit
Unfortunately, Enforcement is generally before the age of 30 and by 50% for those who
lacking in Eastern Mediterranean Region, quit before the age of 5078. In five years, the
despite evidence that such intervention would risk of stroke falls to that of a non-smoker, and
help in reducing the prevalence of smoking, the risk of head, neck and bladder cancers is
tobacco consumption as well as burden and reduced by half79. Better control of respiratory
death from various diseases76,77. diseases like asthma and COPD including
Raise taxes on tobacco: symptoms, exacerbations of the disease,
This strategy is considered by far the most hospital admissions and finally mortality form
effective strategy for tobacco control. COPD has been clearly demonstrated in the
Typically, national governments would impose literature80. However, despite these
high taxes on tobacco products in order to documented short and long-term benefits of
increase the price and making cigarettes less quitting smoking, and despite listing O offer
accessible to the public especially children. help to quit as one of the recommended WHO
Revenues from these taxes are then invested in strategies for tobacco control, tobacco
strengthening tobacco control measures, dependence treatment (TDT) services continue
improving customs and border controls, and to be scarce and inconsistent across the world.
curbing tobacco illicit trade. Furthermore, such Many factors contribute to this shortage of
revenues can be invested in building health TDT, including the lack of training
care systems and train health care providers. opportunities for health care providers in basic
Currently, worldwide variation in successful skills needed to deliver TDT services. Tobacco
implementation of this strategy exists. High dependence treatment is an integral component
income countries took steady steps in of any comprehensive tobacco control effort.
implementing this strategy while low income Comprehensive TDT services include the
countries continue to fall for the tobacco techniques of brief advice, motivational
industry promises of guaranteed short term interviewing and counseling, establishing
profits and discouraged from taking aggressive effective quit lines, and availing low-cost
moves by the misleading evidence provided by pharmacotherapy. In 1999, the World Bank,
the tobacco industry to governments that such building on data published by Peto et al.
profits might be hindered should higher taxes estimated that if adult consumption of tobacco
were implemented due to the increase in is halved by 2020 the world can prevent about
smuggled tobacco, an action typically 200 million deaths by 2050. In comparison,
promoted and supported by the tobacco the short-term effect on mortality of halving
industry. the number of young people who take up
smoking was negligible. Accordingly, the
Tobacco dependence treatment and the report urged governments seeking health and
gains of quitting: economic gain to encourage smokers to quit81.
Likewise, WHO -through Article 14 of the
The benefits of quitting occur simultaneously FCTC- mandates parties to design and
with the cessation of smoking. For example, implement effective programs to promote
normalization of the heart rate, blood pressure cessation of tobacco use and provide adequate
and decrease in coughing and production of treatment for tobacco dependence82. The WHO
recommends inclusion of cessation advice in

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primary healthcare services, establishing use of all these medications. Relapse is very
accessible and free quit lines, and availing common in subjects trying to quit smoking and
low-cost pharmacotherapy83. Inclusion of must be addressed early on in the course of
cessation advice in primary healthcare settings treatment. Behavioral and cognitive techni-
proves to be a low-cost strategy where the ques are key in TDT and in preventing relapse.
major investment is in training of providers Many challenges face establishing effective
and in providing informational materials to tobacco dependence treatment programs.
tobacco users83. Tobacco education and training in healthcare
disciplines continues to be lacking. A 2009
Pharmacotherapy, while more expensive than
survey of 171 countries indicated that only
offering cessation advice, has been shown to
27% of medical schools taught a specific
double or triple quit rates83. Overall, TDT
module on tobacco88.
interventions are extremely cost effective
when compared to treatment of other chronic However, progress is being made via
diseases such as hypertension. While a international collaborations through training
specialist may average two hours for treatment health care providers (HCPs) on delivering
of one tobacco dependence case, treatment of effective TDT. The East Mediterranean
hypertension over the lifetime of the patient Region (EMR) countries continue to face other
challenges that hinder service expansion. King
consumes more time84. In general the cost-
Hussein Cancer Center (KHCC), a compre-
effectiveness of TDT exceeds that of other
hensive cancer care facility in Jordan that has
commonly provided clinical preventive
been offering TDT services to cancer patients
services, including Pap tests, mammography,
and the general public since 2008, recognized
colon cancer screening, treatment of mild to
early on that such gaps in capacity and
moderate hypertension, and treatment of high
competence limit the reach of services and
levels of serum cholesterol85.
patients access to help. Realizing the
The American College of Chest Physicians
importance of training HCPs in evidence-
recommends dealing with tobacco dependence
based treatment, KHCC started in 2011 to
as a chronic relapsing condition similar to
asthma. Various forms of treatments are used offer TDT training to countries of the EMR
in a controller and reliever fashion86. through collaboration with Global Bridges; an
In most subjects combination pharmaco- international healthcare alliance for tobacco
therapy is used for better outcome. A long dependence treatment that was founded by
acting nicotine replacement therapy (NRT) Mayo Clinic, the American Cancer Society,
such as the nicotine patch is usually combined and the University of Arizona. Global Bridges
with as needed doses of a short acting NRT seeks to create opportunities to share treatment
such as nicotine gum, lozenges, inhaler or and advocacy expertise and to provide state-
nasal spray. All NRT doses are titrated to of-the-art training to help countries fulfill
control subjects withdrawal and craving FCTCs Article 14. While other organizations
symptoms. Bupropion, an antidepressant represent Global Bridges throughout Latin
and/or varenicline (42 nicotinic acetylcholine America, Africa, and Europe, KHCC is the
receptor partial agonist) are combined with regional host and partner for Global Bridges in
NRT for better control of symptoms and the EMR. To date, KHCC has trained over
enhanced cessation rates87. In both choices, 1500 HCPs and advocates from EMR on
doses are titrated up over few days to avoid tobacco control and TDT through more than
side effects. Treatment is usually continued for 20 workshops and conferences spanning the
at least three months or as long as it is needed. region from Morocco to United Arab
Safety data are now available for the chronic Emirates. Political commitment to tobacco

TOBACCO
control is not uniform across the region, and 2. History of Tobacco:

http://academic.udayton.edu/health/syllabi/tobacco/history.
the tobacco industry (TI) has been gaining htm
traction in some countries. As developed Eriksen M, Mackay J, Ross H. The Tobacco Atlas. Fourth
nations tighten their regulations on the tobacco Ed. Atlanta, GA: American Cancer Society; New York,
industry, the developing nations of the EMR - NY: World Lung Foundation; 2012
3. Mackay J, Eriksen M, Shafey O. The tobacco atlas, 2nd
with their relaxed tobacco control regulations- ed. Atlanta, GA, American Cancer Society, 2006.
present themselves as a safe haven to the TI. 4. Malson JL et al. Clove cigarette smoking: biochemical,
While tobacco companies are state-owned in physiological, and subjective effects. Pharmacology,
eight EMR countries, multi-nationals are Biochemistry, and Behaviour, 2003,74:739745.
5. Brody AL, Mandelkern MA, London ED, Khan A,
establishing their operations in other countries Kozman D, Costello MR, Vellios EE,Archie MM, Bascom
such as in Jordan89. R, Mukhin AG. Effect of second hand smoke on
Another challenge that may hinder expansion occupancy of nicotinic acetylcholine receptors in brain.
of TDT services in the region is tobacco use Arch Gen Psychiatry. 2011 Sep; 68(9):953-60. doi:
10.1001/archgenpsychiatry.2011.51. Epub 2011 May 2.
among physicians and other healthcare 6. U.S. Department of Health and Human Services. The
workers. The prevalence of ever smoking Health Consequences of Involuntary Exposure to Tobacco
cigarettes among medical students in 2010 in Smoke: A Report of the Surgeon General Executive
the region ranged between 24% and 42%90. Summary. Rockville, MD: U.S. Department of Health and
Human Services, Centers for Disease Control and
This undermines the role that healthcare Prevention, Coordinating Center for Health Promotion,
providers should play in reducing the social National Center for Chronic Disease Prevention and Health
acceptability of tobacco use and their Promotion, Office on Smoking and Health, 2006
7. Hurt RD, Weston SA, Ebbert JO, McNallan SM,
credibility in promoting TDT services91. It is Croghan IT, Schroeder DR, Roger VL. Myocardial
thus imperative that teaching and training infarction and sudden cardiac death in Olmsted County,
programs for HCPs address tobacco control Minnesota, before and after smoke-free workplace laws.
and TDT early on, and that special attention is Arch Intern Med. 2012 Nov 26;172(21):1635-41.
8. Comstock GW, Lundin FE Jr. Parental smoking and
given to helping these professionals quit perinatal mortality. Am J
tobacco use as an initial step. Furthermore, the Obstet Gynecol. 1967 Jul 1;98(5):708-18.
lack of insurance coverage by national or 9. Colley JR, Holland WW, Corkhill RT. Influence of
private health care plans as well as the passive smoking and parental
phlegm on pneumonia and bronchitis in early childhood.
inconsistency in the availability of necessary Lancet. 1974 Nov 2;2(7888):1031-4.
pharmacological drugs used in TDT and the 10. White, J. R. and Froeb, H. F.:Small airways
prices of these drugs are all considered real dysfunction in nonsmokers chronically exposed to tobacco
obstacles facing smokers who are trying to smoke. N. Eng. J. Med. 302:720-23, 1980.
11. U.S. Department of Health and Human Services. The
quit. Health Consequences of Involuntary Smoking. A Report of
In conclusion, tobacco is highly addictive and the Surgeon General. Rockville (MD): U.S. Department of
poses great danger to those who consume it, Health and Human Services, Public Health Service,
Centers for Disease Control, Center for Health Promotion
and societies at large.
and Education, Office on Smoking and Health, 1986.
Dependence and harms of tobacco as well as DHHS Publication No. (CDC) 87-8398.
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in the literature. International strategies for hazardous? Scientific American. January 6, 2009.
http://www.scientificamerican.com/article.cfm?id=what-is-
tobacco control must be implemented globally third-hand-smoke
in an effort to lower the prevalence by the year 13.Sleiman M, Gundel LA, Pankow JF, Jacob P 3rd,
2040 to less than 5% worldwide. Singer BC, Destaillats H. Formation of carcinogens
indoors by surface-mediated reactions of nicotine with
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OPIATE ADDICTION
M. Basheer Ahmed*
Abstract:
Drug addiction is rapidly increasing in most parts of the world resulting in escalating healthcare
cost, fatalities and serious negative familial and social consequences. The opiate addiction is the
most serious form of drug addiction and it is extremely difficult to treat and keep the patient
sober.
The article covers the historical perspective, genetic and environmental factors contributing to
the addiction behavior and the brain mechanisms for addiction. It will discuss the diagnostic
criteria and the current methods of treatment available including use of opiate agonists, opiate
partial agonists, opiate antagonists and psychosocial treatments.
The article also includes a brief discussion about the current situation related to drug use in the
Muslim World and proposes some guidelines for treatment and control of the spread of drug use
in the Muslim World.
Keywords: Drug addiction, Opiate use disorders, neurologic mechanisms, causes of addiction,
treatment of addiction, history, Islamic perspective.
Introduction:
The death of Philip Seymour Hoffman, the disorder3. Some of the most common drugs
brilliant Oscar winning actor, created headline of abuse are opiates and opioids.
news about mortality due to overdosing on Opiates are derived from the poppy seeds and
opiates. One of the statements he made created is known as heroin. Opioids are semi synthetic
this renewed interest in this subject when he products such as Morphine, Oxycodone,
stated, if one of us dies of an overdose Percocet, Tylox, Oxycontin, Hydrocodone,
probably 10 people who were about to Vicodin, Tramadol, Ultram, Pentazocine,
wont1. Opiate dependence is a significant Talwin and Fentanyl. The heroin is used
worldwide public health issue. Globally, intravenously, as a smoke or as an inhalant and
between 24 and 35 million adults between the all opioids are used orally.
ages 15 and 64 years used an illicit opiate in
20102. Alcohol and illicit drugs are harming According to the USA Centers for Disease
millions of people in many countries around Control and Prevention (CDC), 12 million
the world. Alcohol and drug use account for Americans used opiates in 2010 and that every
5.4% of the worlds annual disease burden. In day 100 people die from drug overdoses, 75%
some Eastern European countries, 16% of the of which are caused by prescription opiates.
population suffers from Alcohol use The rate has tripled in the last two decades.
*Dr. Basheer Ahmed MD

Professor of Psychiatry (Retired)
South Western Medical School, Dallas, Texas, USA
Medical Director Texas Treatment Services, Fort Worth, Texas, USA

OPIATE
There have been more than 17 deaths linked to gambling, computers and being pre-occupied
the possible use of Fentanyl- contaminated with persistent sexual thoughts and
heroin in Pittsburgh, Pennsylvania alone from pornography inspite of negative consequences,
January 24, till March 23, 2014. In the first which influence health, relationships and
two weeks of January, there were 22 such work. In other words, addiction has many
deaths reported in the state of Rhode Island forms; some of them are related to substances
due to heroin overdose. Heroin is always an while the others are related to psychological
extremely intoxicating drug of abuse with a dependence on behaviors.
wide array of risks including overdose and The addiction alters the brains function and
increased exposure to Hepatitis C, HIV/AIDS structures affecting mood, perception and
and other infectious diseases. It often contains consciousness leading to physical,
other ingredients which render it potentially psychological and psycho-social problems.
more harmful or in some cases deadly4. Addiction is a primary, chronic disease of
Opiates become more dangerous when mixed brains reward, motivation, memory and
with benzodiazepines and can be fatal. In related circuitry. Addiction affects neurotrans-
2009, slightly over 120 million visits were mission and interactions within reward
made to the emergency departments in general structures of the brain, including the nucleus
hospitals in the United States and at least 4.5 accumbens, anterior cingulate cortex, basal
million of these visits were drug-related. Drug- forebrain and amygdala, such that motivational
related emergency department visits have hierarchies are altered and addictive behaviors,
increased by over 80 percent since 2004. This which may or may not include alcohol and
increase primarily reflects greater numbers of other drug use, supplant healthy, self-care
medical emergencies associated with adverse related behaviors.
reactions, accidental drug ingestions, and Addiction also affects neurotransmission and
misuse or abuse of prescription drugs and interactions between cortical and hippocampal
over-the-counter medications 5. circuits and brain reward structures, such that
Countries around the world spend billions of the memory of previous exposures to rewards
dollars fighting drugs and treating and (such as food, sex, alcohol and other drugs)
rehabilitating those addicted. In addition to leads to biological and behavioral responses
personal and social problems, alcohol, drug to external cues, in turn triggering craving
use and other addictions lead to criminal and/or engagement in addictive behaviors6.
behavior. Hundreds of thousands of
individuals are arrested for possession and /or Historical Perspective
sales of drugs, or for committing crime to
obtain them. Drug intoxication results in Contrary to common belief, the contemporary
traffic accidents which may cause fatalities. drug problems are not new. In fact, the use of
One-third of AIDS cases occur in IV drug psychotropic substances seems to be an almost
users and children are born with AIDS to the universal phenomenon which has long been a
female drug users. great social concern. Today, there are only a
few isolated societies in which psychoactive
What is Addiction? substances are not used. It is stated that the
very desire to alter consciousness, whether by
Addiction is an obsessive and compulsive drugs or some other means is an innate,
behavior which includes taking drugs (alcohol, normal drive analogous to hunger or the sexual
opiates and other drugs), engaging in drive. Blum identified only four out of 247

OPIATE
cultures where people do not use any making it possible to produce more potent
substance which alters the mind. The only alcoholic beverages. In the 16th century,
people without a traditional intoxicant are the drunkenness was mentioned in England for the
Eskimos, who had the misfortune to be first time as a crime, and laws were passed
unable to grow anything and had to wait for against its use. In European colonies,
white men to bring them alcohol 7-9. drunkenness was prominent, but it was not
Human beings have always had a desire to considered a major problem or stigmatized
consume substances that make them feel behavior. In England, the consumption of
relaxed, stimulated, or euphoric. People started beers and wines, particularly home-brews, was
chewing leaves, herbs and other natural integrated into every aspect of family life7.
products, and they cultivated plants which they In the 12th century the chewing of coca leaves
used for food, for alleviating pain or was common in the Inca Empire (South
recreational purposes. Some of these America), mostly in religious and special
preparations produced euphoria, and many of social functions. The coca plant was also
these were used in religious rites. The later viewed as a divine gift of the Sun God giving
discovery of fermentation of fruits or juices energy and euphoria.
was closely followed by the production of In the 14th century, coffee was initially used in
alcohol. One of the oldest drinks was a juice Ethiopia for medicinal purposes. The
extracted from Palm trees (Palm toddy) (an technique of roasting made coffee cheaper and
incision is made on top of the stem of the tree more pleasant to consume. Cultivation and use
during the night and the juice is collected early of coffee expanded into Arabia.
morning)10, after being left in the sunshine for In the 15th century, Arabs spread the use of
a few hours, it becomes fermented and gives coffee to the Muslim countries. Use of coffee
the same effect as alcohol. It is still commonly became predominant because wine is
used in South Asia. Initially, these drugs prohibited according to Islamic law. Initially,
were used as natural products and were less coffee was prohibited in Turkey (Middle East)
harmful. As their potency is increased by and the coffee houses were closed but the ban
distillation and other mechanisms, they was lifted some time later when it was realized
become more intoxicating and harmful. that people did not stop drinking coffee.
In the recorded history from ancient times, Coffee became a popular drink throughout the
alcohol was the only drug mentioned causing Middle East. When coffee was introduced in
problems in the Greek and Roman periods. I Europe from Muslim Turkey, it was banned on
am sure there were other drugs used which religious grounds as it was regarded as
alter mental conditions causing stimulation, infidels drink. Later during the 16th century,
relaxation and euphoria but alcohol was its use was sanctioned.
mentioned as causing significant social Tobacco chewing and smoking were first
problems. The earliest recorded example of observed by Europeans when they landed in
concern related to alcohol use is the America. Later, they cultivated and
prohibition of its use in the7th century under transported tobacco to Europe due to great
the Islamic law based on the commandment of financial rewards. Tobacco seeds were
God recorded in the Glorious Quran. Muslims transported from Brazil to France and England
are strictly forbidden from using alcohol and for cultivation. Within a century, tobacco use
other intoxicants which alter consciousness became widespread in most European
and from an addictive behavior that is countries7.
gambling11. In the 11th century, the technique In 7th century, the opium poppy was
of distillation became known in Europe, introduced in India and China by Arabs, and

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its use was limited to medicinal purposes. Unfortunately, underground breweries and
However, its use increased significantly distilleries became very popular throughout
especially in China. Later, British opium the country to supply the demand for alcohol.
traders from India established depots at Canton The sale of alcohol in the black market and
and Macao and its trade became very importation of alcohol from other countries by
profitable. As opium smoking spread and the illegal means became widespread. This
number of Chinese addicts significantly resulted in forcing Congress to repeal the 18th
increased compromising their productivity, the amendment by the 21st amendment (the 18th
emperor of China prohibited its sale. The amendment is the only constitutional amend-
effort was initially successful with the ment that was repealed by another amendment
destruction of all British opium stock in 1839. the 21st amendment) 7.
However, to protect this trade, Britain declared Cannabis, opium, coca, tea, coffee, tobacco,
war on China. The first opium war was from and alcohol became the most commonly used
1839 to 1842 and the second opium war was substances in the world. Tobacco, alcohol, and
from 1856 to 1860. China was defeated and caffeine became the major three drugs of
the war ended with the Treaty of Nanking, addiction in Europe and America. There was
which protected foreign opium traders from an initial opposition for their use but due to
Chinese law. It is ironic to see how far the their widespread use, these substances were
imperialist governments will go to destroy not regarded as drugs of addiction. The use of
humanity for financial gains. The Maoist alcohol in Western countries is well accepted,
revolution ended drug addiction quickly. By and no criminal sanctions are imposed on
1952, there were no more addicts, no more alcohol use. In Muslim countries alcohol is
pushers, and no more drugs smuggled. In only prohibited, however its use along with other
three short years, China went from 70 million drugs has increased considerably during the
drug addicts to none12. last decade. Alcohol and tobacco are now
Cocaine and opiate addiction in the United recognized as highly addictive drugs causing
States became increasingly identified with the severe detrimental effects on health.
underworld and organized crime. In 1914,
Congress passed the Harrison Act which What causes addiction?
regulated and taxed the production,
importation and distribution of opiates and Most addictions with drugs such as alcohol
coca products. It required all persons and opiates or pleasurable behaviors such as
authorized to handle or manufacture narcotic gambling and pornography start as pleasurable
drugs to register, pay a fee, and keep a record or recreational activities, but continued use or
of the drugs in their possession. The act did engagement in such behavior results in dire
not prohibit the supply of opiates to users by consequences. Many addicts do not recognize
registered physicians. Temperance movements this at the early stages. Only when the
for alcohol use have been active since 1840s behavior becomes out of control and causes
by religious organizations and finally the 18th problems to themselves and others that it is
amendment to the USA constitution was recognized. There are some controversies
passed as the national prohibition act of about which of the behavioral addictions are
1919 which required licensures for businesses validated as true addictions. There has been no
that brew, distill and wholesale alcoholic agreement among professionals on this
beverages. The prohibition act and the controversial issue and more research is
religious movement of temperance were hoped needed to have a clear definition and to
to curtail the sale and use of alcohol. establish the criteria for diagnosis.

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The gambling disorder is included in the system is activated by drugs, which results in
DSM-V, and requires five criteria to diagnose mood-altering behavior. These parts of the
patients with clinically significant gambling brain are also responsible for executive
related disorders13. functions and decision making.Thus, excessive
Most people exhibiting addictive behaviors are drug use influences decision making behavior.
emotionally stressed and or unstable and thus Amphetamine and cocaine stimulate the
psychologically vulnerable to develop neurons to release large quantities of the
dependence on drugs. Research also showed neurotransmitter dopamine, resulting in
that there are some genetic predispositions for excessive stimulation leading to excitement,
drug dependence. Recent studies of twin pleasurable feelings and euphoria. This
families with history of drug abuse indicate pleasurable experience is remembered which
that drug abuse is substantially heritable14,15. results in continuous use of drugs and
Genes of the dopamine system are likely dependence on drugs. Brain imaging studies
candidates to harbor risk variants, as dopamine have provided information on the drugs
neurotransmission is involved in mediating the neurobiological effects, explained the causes
rewarding effects of drugs of abuse. and mechanisms of vulnerability to drug
These data demonstrate the importance of abuse, and yielded important insights into
dopamine gene variants in the risk for opioid abusers subjective experiences and behaviors,
dependence and highlight a functional including their struggles in recovery. Recent
polymorphism that warrants further study16. neuroimaging studies suggest that people
While genetics plays a role in drug addiction, living with a drug addiction have considerable
it is important to recognize that environmental decreases in dopamine D2 receptors and in
factors also play a significant role in the dopamine release, which may contribute to
transmission of this disease. Recent research both the rewarding properties of substances
confirms the role of environmental factors and difficulties in abstaining despite adverse
such as the influence of parents and siblings on consequences. Brain areas such as the
adolescent drug use. When one member of the prefrontal cortex have been identified as being
family household is using a drug, it places the directly involved in assessing the reward
other members of the family at risk. Socio- potential of decision-making and vulnerability
economic conditions of the family, for relapse. Abnormal hippocampus and
neighborhood level of social deprivation also anterior cingulate functioning are associated
affects the risk for drug abuse, beyond family with challenges in the ability to cope with
socio-economic status17,18. stress, in addition to problems in cognition19.
Structural MRI provides information on the
How drugs influence brain and behavior location, shapes, and sizes of the brains
various regions.
Most drugs of abuse directly or indirectly Sagital sections of human brain showing Orbitofrontal
affect the brains reward system through the cortex (OFC) and Ventral tegmental area (VTA)
neurotransmitter dopamine. The limbic system
contains the brains reward circuit and through
the complex neuronal system links with
cerebral cortex and mid brain structures
including the hypothalamus, amygdale and
other areas which process information
resulting in perception of anger, fear,
happiness and other emotions. The limbic

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opiates. Prescriptions for opioid analgesics

A structural MRI study found that individuals increased from about 75.5 million to 209.5
with a history of abusing drugs have smaller million in 10 years. Admissions for opiate
prefrontal lobes. It also showed that chronic drug dependence have increased from
substance abusers frontal lobe tissues approximately 280,000 to 421,000 during a 10
contained a lower proportion of white matter year period (1999-2009) 23. In a study of
than those of matched controls 20. Jordanian opiate dependent patients, the major
Researchers have used functional MRI to cause of premature death was accidental
obtain detailed information about the roles of overdose, along with infectious disease.
different brain areas in producing cocaine- Moreover, a high prevalence of criminal
induced euphoria and subsequent craving. An activity and psychosocial difficulties are also
influx of cocaine described as a drug rush found among Jordanian heroin users24.
occurs during a brief period when a set of Addiction to opiates can be caused either by
areas, including the caudate (an area of the the recreational use of opiate based drugs, or it
basal ganglia), cingulate, and most of the may be caused by prescribed use of the drugs.
lateral prefrontal cortex showed higher levels Opiates create a feeling of euphoria. The initial
of activity. The participants reports of craving feeling of euphoria wears off in a short period
commenced when the euphoria subsided and and a user starts feeling withdrawal symptoms.
persisted as long as a different set of brain They then use larger doses to reduce
areas-including the nucleus accumbens (NAc)- withdrawal symptoms and experience
remained activated. Positron Emission pleasure.
Tomography (PET) and single-photon Often times, opiates such as Oxycontin,
emission computerized tomography (SPECT) Oxycodone or morphine are prescribed for the
have also shown the presence and actions of treatment of chronic pain associated with
drugs of abuse in the brains reward system degeneration of bones, arthritis, post surgical
with their euphoric properties and their ability pain, cancer and other diseases. Unfortunately,
to preoccupy addicted individuals. Dopamine many people who are prescribed opiate pain
flow in these areas is a main determinant of killers do not realize the risk of opiate
how much pleasure is derived. A PET study addiction and believe that they are under no
also revealed that while methamphetamine danger if they take the medication as
temporarily hyper-activates the dopamine prescribed by their doctor. Seventy five per
system, chronic exposure to the drug reduces cent of high school seniors perceive using
the availability of dopamine transporters, heroin once or twice as dangerous, but only
which may indicate a loss of dopamine cells21 . 40% perceive similar use of prescription
opiates as dangerous25.
Opiate dependence Unfortunately, indiscriminate use of
prescription opiates creates a major problem in
Opiate dependence is a major public health the USA. Physicians are prescribing narcotic
problem, and the illicit use of opiates analgesics without proper justification.
contributes to the global burden of disease and Patients are becoming addicted and in some
can result in premature disability and death. cases they sell the drugs on the streets. While
Incidence and prevalence of blood borne pain management clinics help patients with
viruses (e.g., HIV, hepatitis B, and hepatitis C) chronic pain, they are also the major
are higher in injection drug users22. contributors in creating prescription drug
The United States has seen a significant dependence. Iatrogenic drug addiction has
increase in the illicit use of prescription become a major problem. No strict guidelines

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have been developed for the use of these elucidated. This interaction forms the
highly addictive drugs. Many physicians do hypothesized foundation for the persistence of
not have a protocol about stopping drug use addiction vulnerability even in those who have
until it is too late. The new regulations and discontinued drug use and indicates that long
law enforcement efforts have curtailed the term relapse prevention strategies need to
supply of prescription drugs and the cost of include both environmental and
these drugs in the open market has increased pharmacological interventions beyond the
considerably. This has resulted in many users immediate period of withdrawal.
switching to a cheaper drug heroin.
Environmental factors such as availability of Diagnostic criteria
opiates, psychosocial stresses and lack of for opioid dependence
coping strategies also influence the risk of
developing opiate addiction. Traumatic DSM-5 Opioid Use Disorder - Diagnostic
lifetime experiences such as post-traumatic Criteria, American Psychiatric Association
stress disorder may increase the risk for opiate In the DSM-5, Substance Use Disorder is the
addiction. Weak parental bonds also increase singular diagnosis which combines substance
the risk for illicit drug use during adulthood26. abuse and substance dependence. It is defined
The risk for developing opiate addiction is a as such:
complex interaction between genetics, A problematic pattern of opioid use leading to
environmental factors, and the pharmaco- clinically significant impairment or distress, as
logical effects of opiates. Genetic loci manifested by at least two of the following,
associated with opiate self-administration have occurring within a 12-month period:
been identified; and selective disruption of the 1) Opioids are often taken in larger amounts or
gene encoding the mu opioid receptor, the over a longer period than was intended.
principal target of opiates, can eliminate opiate 2) There is a persistent desire or unsuccessful
self-administration and conditioned place efforts to cut down or control opioid use.
preference27. Prolonged opiate use leads to 3) A great deal of time is spent in activities
changes in neuronal connections that result in necessary to obtain the opioid, use the opioid,
an inability of the body to cope with or stop or recover from its effects.
pain. Once in the brain, the primary target for 4) Craving, or a strong desire or urge to use
abused opiates is the mu opioid receptor. opioids.
Located throughout the brain, the highest 5) Recurrent opioid use resulting in a failure to
density of this receptor occurs in areas fulfill major role obligations at work, school,
modulating pain and reward (e.g., thalamus, or home.
amygdala, anterior cingulated cortex, and 6) Continued opioid use despite having
striatum). Activation of mu opioid receptors persistent or recurrent social or interpersonal
inhibits GABA-mediated dopaminergic problems caused or exacerbated by the effects
neurons in the ventral tegmental area28. of opioids.
Human imaging studies have identified 7) Important social, occupational, or
ongoing reductions in dopamine D2 receptor recreational activities are given up or reduced
binding potential in opiate addicts and that this because of opioid use.
reduction correlates with the duration of opiate 8) Recurrent opioid use in situations in which
use29. The details of how the interaction it is physically hazardous.
between genes, environment, and drugs 9) Opioid use is continued despite knowledge
contributes to the development, persistence, of having a persistent or recurrent physical or
and relapse to addiction have yet to be

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psychological problem that is likely to have Initial signs of dependence: Dependence is

been caused or exacerbated by the substance. indicated by extreme fatigue, sleeping more
10) Tolerance, as defined by either of the than usual, or episodes of nodding off during
following: normal activities. Other manifestations
a) A need for markedly increased include: pinpoint and fixed pupils that are
amounts of opioids to achieve unresponsive to changes of light as well as
intoxication or desired effect. changes in appetite and weight (both will often
b) A markedly diminished effect with decrease drastically), loss of interest in usual
the continued use of the same amount activities, and constipation.
of an opioid. Common features of opiate addiction: lack
11) Withdrawal, as manifested by either of the of control over drug consumption, exhausting
following: all financial resources, spending more and
a) The characteristic opioid withdrawal more time using drugs, denial or thinking that
syndrome. there is no problem and lying or hiding the
b) Presence of either of the following: drug use, using drugs despite known negative
consequences such as financial breakdown,
Cessation of (or reduction in) opioid use effects on physical health, family problems,
that has been heavy and prolonged (i.e., occupational and legal problems, inability to
several weeks or longer). maintain social relationships, and multiple
Administration of an opioid antagonist failed attempts to quit.
after a period of opioid use.
Three (or more) of the following developing Withdrawal symptoms:
within a minute to several days after the
cessation of (or reduction in) opioid use: The main features of opioid withdrawal are
Dysphoric mood, nausea or vomiting, muscle nausea, vomiting, diaphoresis, yawning,
aches, lacrimation or rhinorrhea, pupillary fatigue, aches and pain, muscle cramps,
dilation, piloerection, sweating, diarrhea, diarrhea, mydriasis, and piloerection. Other
yawning, fever, and insomnia 30. symptoms include chills, irregular heartbeat,
itching, restless leg syndrome, flu-like
symptoms, diarrhea and weakness. As
Side effects of opiates
tolerance goes up, susceptibility to withdrawal
Opiate side effects include sedation, dizziness, becomes marked. Withdrawal symptoms can
be excruciating and include muscle aches,
nausea or vomiting, constipation, and
anxiety, sweating and insomnia. Subjective
respiratory depression which may lead to death
symptoms are much greater than objective
in cases of overdose. People receiving
signs. Cravings begin 4 to 6 hours after the last
prescriptions from several different providers,
dose of short-acting opioids, leading to active
and take high daily doses of opiates are more
drug-seeking behavior. This is followed by
prone to have an overdose.
anxiety, diaphoresis, and agitation after 8 to 12
hours. Peak withdrawal discomfort is usually
Treating opiate intoxication
experienced after 36 to 72 hours and decreases
Mild to moderate opiate intoxication does not thereafter31.
require treatment. Overdose of opioids results
in respiratory depression. It requires treatment Treatment of opiate use disorder
in an emergency department. Naloxone is The main objective of treatment is to reduce
usually used to reverse the respiratory dependence and issues associated with use. It
depression. is important to realize that treatment for opiate

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addiction requires long-term management. term treatment of opiate dependence are: the
Discontinuing opiates without medical opioid agonist methadone, the opioid partial
supervision is not only difficult but it is also agonist buprenorphine, and the opioid
dangerous. Opiates cause physical changes antagonist naltrexone. Oral naltrexone is
within the body and the brain that can make effective in treating opiate addiction but recent
quitting cold turkey almost impossible except studies using extended release naltrexone
in prisons or in hospitals under medical injections have shown good results in patients
supervision. Generally, it is not advisable to who lack strong motivation. For many years,
quit opiates without at least tapering the drugs methadone, an opioid agonist, was the main
off or being under the direct care of a pharmacologic treatment option for opioid
healthcare professional because there is a risk dependence, but its availability in the United
of opiate withdrawal symptoms leading to States was limited to licensed programs. The
deadly consequences. Behavioral interventions introduction of another opioid agonist in the
alone have extremely poor outcomes, with form of sublingual bupre-norphine, which can
more than 80% of patients returning to drug be prescribed in office-based practices, has
use. Most often, a combination of medical greatly expanded access to treatment for
intervention and psychological counseling is individuals with opioid dependence. The
needed in order to effectively help an individu- opioid antagonist naltrexone has been
al overcome opiate addiction. Because this available as a treatment for opioid dependence
addiction is medically recognized as a central for many years, but its use has been limited,
nervous system disorder, much attention has particularly in countries where agonist
been placed on medical intervention and treatment is available.
treatment of opiate addiction through Sometimes, opiate addiction treatment takes
medication replacement therapies. The place in hospitals or residential treatment
cravings and withdrawal symptoms associated centers. Because of the severity of withdrawal
with quitting opiate use are very strong and symptoms that are associated with opiate
difficult to overcome. It is for this reason that dependence and addiction, opiate addiction
medication-assisted treatments are often requires a longer stay in a residential treatment
recommended. These therapies address the setting before safely integrating into an
changes that drugs have caused in a users outpatient treatment setting.
brain. The pharmacotherapy with methadone,
buprenorphine and naltrexone combined with Methadone and methadone maintenance
psycho-social services are effective in clinics:
reducing opiate use, dangerous behavior, and Methadone is the oldest of these kinds of
criminal activity, while improving the mental treatments and has been used since the 1960s.
health of patients32. Medication-assisted It must be taken in certified, specialized
therapies are safe in that they are administered methadone clinics. Methadone is given each
by trained physicians in measured daily doses. day in sufficient quantity to counteract the
They are not taken intravenously and thus withdrawal symptoms.
eliminate the risk of HIV and other IV-related Methadone is a synthetic mu opioid receptor
diseases; when taken correctly they eliminate agonist, administered orally in liquid or tablet
the risk of overdose. form. Following oral administration, peak
Pharmacological treatments plasma levels are reached within 24 hours
for opiate disorder and the elimination half-life at the steady state
The three medications approved by the USA is approximately 28 hours, allowing for once
Federal drug Administration (FDA) for long- daily dosing. Methadone safety is well

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established. Like other opiate agonists, difficulties35,36. Retention in methadone

methadone has the potential to induce treatment clinics and adherence to the
respiratory suppression. Recent increases in treatment regimen are similar to or exceed
methadone-associated deaths are primarily results for other medically managed diseases
related to its minimally regulated use in the such as hypertension, dyslipidemia, and
treatment of pain and not due to its use in the diabetes mellitus37. When the patient is well
treatment of opiate dependence 33, 34. stabilized on a specific dose and does not
Methadone response appears to be dose- experience any side effects and shows
related with most patients stabilizing at doses improvement in psychosocial functioning,
between 60 and 120 mg daily. Response is gradual detoxification can be started.
most frequently measured in terms of retention Detoxification period varies from patient to
in treatment and discontinuation of opiates, patient depending on the patient's self-
other drugs and improvement of psycho-social confidence, social circumstances, marital
functioning. At our clinic, all patients with stability, occupational stability and coping
opiate dependence are initially evaluated by capabilities. Methadone is an effective means
the physician and have a physical examination for an addict to discontinue opiates and move
and laboratory work. Once the diagnosis is forward with a more productive life. It is much
established, they receive an initial oral dose of safer and cleaner than opiates and allows
methadone 20-30 mg daily in either tablet or people to successfully hold a job and manage
liquid form. The dose is increased between 5 - other aspects of their lives. A small percentage
10 mg daily until it reaches 50 mg. During the of patients will continue to use opiates.
initial evaluation, patients are instructed to
stop use of opiates, benzodiazepines, and other Buprenorphine
drugs due to serious side effects. Patients who
are using benzodiazepines are required to Buprenorphine is a semi-synthetic mu opioid
discontinue the benzodiazepines after with weak partial agonist effects. It has less
consulting with the prescribing physician or abuse potential than other opioids because the
gradually discontinuing them in 4 to 6 weeks. intensity of the rewarding effect is milder and
All patients are required to consult with a plateaus at higher doses38. It produces a
physician to increase the dose of methadone. normalizing effect in individuals with opioid
All patients are seen weekly by a trained addiction already in withdrawal. Sublingual
counselor who assesses psycho-social buprenorphine has a long half-life (24 to 60
functioning and develops a treatment plan to hours, mean 37 hours). Suboxone contains 2
help the patient as needed. The treatment active ingredients; buprenorphine and
approach is problem-oriented and focuses on naloxone at the ratio of 4:1. Naloxone is
achieving well-defined goals. Providing intended to deter individuals from abusing the
intensive psychosocial services and counseling medication. Naloxone blocks the effect of
may improve treatment outcomes. opiates. While a patient is on Buprenorphine
Methadone maintenance for patients with (which contains Naloxone) takes opiates he
opiate disorders is effective in decreasing will not feel any euphoric effect of opiates and
opiate use, psychological and medical therefore it acts as a deterrent for relapse. The
morbidity associated with opiates, improving intravenous use of opiate gives a surge to the
social functioning, reducing the spread of HIV individual and he will not experience this
infection and decreasing criminal activity. The when taking. Therefore, Suboxone must be
most common side effects of methadone are given after the total discontinuation of the
constipation, increased sweating and sexual

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opiate, and the patient is already in substitution treatment, bupreno rphines lower
withdrawal. abuse potential and good safety profile make it
The literature on safety evaluation of particularly appealing for family physicians.
buprenorphine maintenance is less developed Those patients that fail to respond are then
than that of methadone, but is considered to be referred for methadone maintenance. Moderate
quite safe. During maintenance treatment, to high doses (8 to 24 mg) of buprenorphine
patients have reduced illicit opiate use but are usually required. Use of buprenorphine-
following buprenorphine taper, some patients naloxone in primary care settings is
return to illicit opiate use. In one study efficacious, safe, and feasible within reason-
comparing heroin addicts to prescription- able time constraints 43.
opiate addicts, the heroin addicted patients had Naltrexone: Naltrexone is an opioid receptor
more severe addiction and did not do as well antagonist used in treatment of opioid
with buprenorphine treatment as the less ill dependence. It helps patients overcome opioid
prescription opiate dependents. Buprenorphine addiction by blocking the drugs euphoric
is a safe treatment with expected side effects effects. Naltrexone should not be confused
of sedation, constipation, headache, nausea or with Naloxone (which is used in emergency
vomiting, and dizziness, and it carries a lower cases of opioid overdose) as it can cause acute
risk of respiratory depression than full opioid opioid withdrawal symptoms. Return to opiate
agonists. use following detoxification is caused by
There are rare reports of hepatoxicity, in negative reinforcement of environmental
addition to a few reports of death when stimuli (e.g., cues and social stressors) and if
combined with benzodiazepines 39, 40. an antagonist prevented the addict from
Buprenorphine, was approved by the FDA in relieving this negative state through opiate use,
2002 and can be prescribed by physicians and then the behavior of turning to opiates in these
can be taken in physicians offices rather than situations would eventually cease. Naltrexone
solely in specialized clinics like methadone. It can block the effect of opiates for
is taken as a tablet or sublingually once a day. approximately 2448 hours after oral dosing.
For the induction phase, patients can be started Naltrexone is a useful non-addictive pharma-
on buprenorphine (maximum 8 mg on day 1, cotherapy for opioid addiction. Naltrexone is
as per the drug monograph, in single or non narcotic and non addictive drug. Therefore
divided doses) 12 to 24 hours after the last there is no chance of a patient becoming
opioid dose. Dosage can then be adjusted addicted to Naltrexone whereas Methadone
based on clinical symptoms. Patients should be and Suboxone contain opiates which are
observed medically for at least two hours after narcotics and has potential for abuse. In Russia
the initial dose41. It is well established that and some Muslim countries (like Jordan)
moderate to high doses (8 to 16 mg) have opiate agonists such as Methadone or
significantly higher efficacy. Although the Suboxone are not approved to be used for
maximum dose recommended by the treatment of opiate addiction.
manufacturer is 24 mg, doses of up to 32 mg While some patients do well with oral
have been used in some trials. Naltrexone, it must be taken daily and a
Buprenorphines long half-life and slow patient whose cravings become overwhelming
dissociation from opioid receptors allows for can take opioids simply by skipping the dose
the possibility of less-than-daily dosing42. before taking the opioids. A monthly injection
Buprenorphine is an effective detoxification of long acting depot naltrexone can be used for
agent for opioid dependence. Although patients to motivate themselves to stick to a
methadone remains a slightly superior treatment regime which is very useful. The

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plasma levels sufficient to block 25 mg of in the methadone group except for increased
heroin are approximately 12 ng/ml, a level perspiration with Tramadol47.
maintained for 2128 days following 380 mg
of the intramuscular extended release Treatment of opiate dependence
formulation 44. In 2010, the FDA approved in pregnant patients
extended-release injectable naltrexone for the
treatment of opioid dependence. This approval Opioid use may result in poor nourishment,
was partly based on the results of a trial general medical complications, miscarriage
conducted at 13 addiction treatment centers in and preterm birth. Fifty percent of the infants
Russia where opioid agonist treatment is born to women with opiate dependence are
prohibited. Extended release naltrexone may physiologically dependent on opioids and may
improve treatment outcomes because non- experience withdrawal symptoms. The
adherence to daily oral regimens is reduced by placenta is metabolically active and can
delivery of a once monthly injection. increase clearance of both methadone and
Currently, there is limited data regarding the buprenorphine. Methadone is the standard of
extended release intramuscular injection. A care for pregnant women and has been shown
larger trial in Russia retained 53% of patients to reduce illicit opioid use, enhance
at 6 months compared to 38% for placebo. compliance with obstetric care, and improve
Patients receiving extended release naltrexone neonatal outcomes. Since methadone does not
also had significantly fewer days of illicit have active metabolites, patients may
opiate use45. Naltrexone should be given after experience early withdrawal and may require
a week of abstinence from opioids due to risk increases in or splitting of methadone dose
of acute withdrawal. Common side effects are during the second and third trimesters. It is
diarrhea and abdominal cramps. High doses recommended that neither naloxone nor
may cause liver damage. naltrexone be administered during pregnancy,
Research studies recently showed that a higher thus buprenorphine should be administered as
retention rate can be achieved with Naltrexone the mono product and naltrexone should be
implants. The implants are not currently avoided.
approved and are not available in USA46. In a small Cochrane meta-analysis of
maintenance treatment in pregnancy, there
Tramadol versus methadone were no differences in maternal or fetal
for treatment of opiate withdrawal outcomes between groups taking buprenor-
phine or methadone. Recent trials have
Tramadol may be as effective as methadone in suggested buprenorphine to be superior in
the control of withdrawal and could be terms of fetal outcomes, with less severe
considered as a potential substitute for neonatal abstinence syndrome48-50.
methadone to manage opioid withdrawal.
Seventy patients randomly assigned to two Psychosocial treatment of opiate
groups received either prescribed methadone use disorder
(60 mg/day) or tramadol (600 mg/day). The
withdrawal symptoms of patients were Individuals with substance use disorder are
evaluated before and after rapid opiate often ambivalent about giving up their habit.
detoxification. No significant differences They deny and minimize the negative
existed between the two groups. Drop out rates consequences of their behavior. They struggle
were similar in both groups. Side effects in the with the emergence of cravings and thoughts
tramadol group were as or less common than about using the drugs. Other stresses such as

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influence of friends and family members who for a certain individual may not work for
are using drugs, unemployment, hopelessness, another. The main difference in programs is
despair and persistent pain make the individual that in some facilities housing is provided.
more vulnerable to relapse. They need These facilities are called residential centers,
supportive therapy and guidance to strengthen and they provide around the clock care, daily
their coping mechanism. Psychosocial counseling in either one-on-one, group settings
treatment for opiate use disorder helps in or both. They are usually more costly than the
bringing about better patients' behavior, alternative outpatient programs and usually
thought process and social functioning. The require people to leave their job, family, and
primary goal of this treatment is enhancing other parts of their lives for the duration of
motivation to stop drugs, teaching coping with treatment.
stress, changing reinforcement contingencies,
fostering management of pain effects and Is addiction primarily a brain disease??
enhancing social support and inter-personal
functioning. Sustaining motivation is required There is no single theory or approach that can
to forgo the rewards of substance use, to offer a complete explanation for the existence
tolerate the discomfort of withdrawal of any social problem. The view of addiction
symptoms and to cope with the cravings. as primarily a brain disease disregards the
Coping skills are required to manage and extensive body of research that suggests
avoid situations that place the individual at neurogenetic explanations of mental illness
risk of relapse. It is reported that successful contribute to negative perceptions towards
improvement occurred in patients receiving people with mental illness, and substance use
both opiate agonists (methadone or subsoxone) problems. The brain disease model implies
treatments as well as psychosocial treatment that addicted individuals are unable to exercise
services35. any degree of control over their substance use.
This focus on a biological model may bring
Drug rehabilitation: about unintentional consequences on a
persons sense of identity, responsibility,
Some people do not want to go with notions of autonomy, illness, and treatment
medication-assisted therapy and therefore, do preference.
not wish to take part in a methadone Addiction consists of interacting biological
maintenance program. For those who decide and psychosocial mechanisms because the
not to quit cold turkey but also not to take part mechanism (e.g., the behavior) contributing to
in a medication replacement program, drug addiction involves action within a social
rehab is an option. Drug rehab involves a system. Every learned action, whether pro-
combination of medical intervention, social or anti-social, may be prompted by
monitoring, peer support and counseling to social conditions such as a lack of resources,
effectively help patients overcome opiate conflicts, social norms, peer pressure, an
addiction. Many drug rehabilitation programs underlying drive (cravings similar to hunger
do utilize methadone maintenance or and sex drive) or a combination of these
Suboxone for a short period but most provide factors. Factors such as drug availability
alternatives that are also effective at helping within the environment can increase craving
patients get past the strongholds of opiate and consequently, the vulnerability for relapse.
addiction and move on with their lives. It is believed that laws and policies that are
There are several different kinds of drug lenient to substance use are linked with greater
rehabilitation facilities, and the one that works prevalence of use and criminal activity.

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However, research findings have not neurotransmitters which promotes reward

confirmed this claim. In one study comparing behavior.
cannabis use in San Francisco (where cannabis However in my opinion the humans are
is criminalized) and Amsterdam (de-facto capable of resisting genetic predispositions
decriminalization), there was no evidence to which may lead to negative consequences. Our
support claims that criminalization laws experience with treatment of alcohol addiction
reduce use or that decriminalization increases shows that psychosocial interventions,
use. In fact, San Francisco reported a higher including spirituality, play a significant role in
cannabis use rate than Amsterdam51. Similarly overcoming this problem.
tobacco smoking has become less acceptable
as a normative method of social interaction The current situation of drug use in the
due to the medical interventions for smoking Muslim world
cessation as well as social and public health
efforts to curtail smoking behavior. It shows Alcohol is forbidden in the Muslim world, but
that social and public health efforts in the alcohol consumption has nearly doubled
curtailing the smoking behavior are more across the Islamic world in the last decade.
effective than laws prohibiting the smoking. The French newspaper Le Monde reported that
Drug use is a pleasure-oriented desire and between 2005 and 2010, the average
continued medicalization of addiction will consumption of alcohol by the French dropped
obviate all responsibility for behaviors from 104.2 liters of alcohol per year to 96.7,
associated with drug use. The opinion that while in the same period in the Middle East
people with addictions lack decision-making and Africa it increased by 25%, In countries
capacity is supported by research in both like Iran, Saudi Arabia, Libya and Pakistan
addiction neuroscience and the neuroscience where alcohol is legally banned, drinking is
of decision-making. Substance use influences still commonplace53, 54.
voluntary brain mechanisms and renders Contrary to the Islamic teaching, unfortunately
individuals incapable of making rational Muslims are heavily involved in planting,
decisions. harvesting, refinement, smuggling and
The brain responds to particular social cues distributing heroin and cannabis to the
that may provide instant pleasure. Brain Western countries. Morocco is the largest
systems that moderate feeling, memory, cannabis exporter to Europe through Spain.
cognition, and engage the individual with the Afghanistan, Pakistan and Iran are the major
world influence the decision to consume or not producers and exporters of heroin. In 2007,
consume a drug, or participate in a specific Afghanistan produced an extraordinary 8,200
behavior or series of actions. The degrees in tons of opium (34% more than in 2006),
which self-control is exerted, free choice is becoming practically the exclusive supplier of
realized and desired outcomes achieved are the worlds deadliest drug (93% of the global
dependent on these complex interacting bio- opiates' market)55. Taliban initially opposed
psycho-social systems. The complex the production of heroin, but they realized that
combination of biological, psycho-social and these narcotics provided an invaluable source
systemic factors may explain why it is so of income, and they supported its production.
difficult for some individuals to refuse or stop They argued that it is permissible because it is
consuming illicit drugs in the face of consumed by non-believers in the West. Islam
increasingly negative consequences52. There is does not permit the production and sale of
no question that the addictive behavior is narcotics for Muslims or non-Muslims.
genetically determined and mediated by

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According to United Nations Office on Drugs importation and sale (death penalty). However,
and Crime (UNODC) in 2009, Afghanistan so far, not enough attention is given to
has around one million heroin and opium education or treatment60. The incidence of
addicts aged between 15 and 64 years out of a alcohol and drug use among Muslims is
population of 30 million, making it the world's gradually increasing in USA, but it has not
top user per capita. Sixty thousand women in reached the same level as among non-
Afghanistan regularly take illegal drugs. HIV Muslims. Strict religious prohibition against
epidemic among injection drug users increased the drugs plays a major role in curtailing the
from 3% (2005), to 7% average in three main drug seeking and using behavior. The exact
cities (2009). Iran has 1.2 million "drug users," data about the Muslim minorities' drug use is
and 2.26 percent of the population aged not available as data is not collected based on
between 15 and 64 are addicted to opiate. In religious preferences. The actual incidence
1979, Pakistan has no heroin addicts but 20 may be much higher than observed as there is
years later, there were 5 million addicts. In denial by addicts and their family members.
2011, nearly six percent - or 6.4 million adults They tend to minimize the issue until it is too
used drugs. Most of the heroin in Europe is late. Even if the family members are aware of
transported via Turkey. British Muslims are the problem they do not talk about it. They do
also heavily involved in drug use and the sale not seek help due to shame and guilt, and the
of the drugs. These young men were seldom fear that the problem will become known in
educated in understanding and respecting the the community. Alcohol use is relatively more
Islamic values or the dangers of drug use. common than the use of other drugs.
In United Arab Emirates, alcohol and
prescription-drug use has been on the rise for Islamic Perspective
the past 10 years and Tramadol, a painkiller
similar to opiates such as morphine, has been a Shariàh (Islamic Law) was established in the
commonly prescribed drug of addiction. 7th century based on Quranic commandment.
Community surveys conducted in Dubai and The warning against using intoxicants was
al-Ain, United Arab Emirates have further revealed by Allah ( )and was gradually
confirmed a high prevalence of drug
introduced to the people until the total
disorders56-59.
In Saudi Arabia, amphetamine abuse is most prohibition was declared. Allah ( )says,
prevalent. Saudi authorities confiscated 12 They ask you (O Muhammad) about khamr
metric tons of amphetamine (the world drug (alcohol) and gambling. Say: In them there is
report in 2010 UNODC). Professor Jallal great sin, and some profit, for men, but sin is
Toufiq, founder of the Middle East and North greater than the profit61.
Africa Harm Reduction Association," told the The Prophet Muhammad ( )said: Every
USA Cable News Network (CNN): There is a
intoxicant is Khamr and every intoxicant is
worsening of the drug situation in the whole
forbidden62.
region. However, there is a void in terms of
Islam stops the wrong behavior before its
data and information. In many Muslim
inception so that it will not become a major
countries, there is a lack of political
problem. By declaring that Khamr is
willingness to accept that a drug problem
prohibited, taking intoxicants became a major
exists. People just do not want to deal with this
sin and for a strong believer, this
problem. Peer pressure is a significant factor
commandment serves as a preventive measure.
influencing the young people to use the drugs.
People who are addicted to alcohol, opioid and
Saudi Arabia has strict laws for drug
other substances must seek medical and

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psychological treatment, but they can also get and internalized parental and social
the benefit from spiritual guidance. It is a prohibitions (super ego). Super ego is
responsibility of the Muslim community to associated with ethics, values and self-critical
support and help persons who need treatment assessment. It is influenced by parents,
for addiction rather than stigmatizing or teachers and the religious beliefs. This is the
outcasting them. These patients also require part of conscience development. The hunger,
guidance in improving their social sexual derives, etc. are genetically determined
relationships, getting employment and gaining and influenced by id. However, the super ego
respect in the community. controls or directs its appropriate expression.
As discussed earlier, there are multiple factors, There is no question that the desire to use a
which may cause addictive behavior. Current drug is genetically determined and mediated
research points out that there is a genetic through the brains neuronal system. However,
predisposition for addiction. However, an humans have the capacity to control and
individual has a capacity to control these restrain its use. This capacity of restraining is
tendencies. Sexual desire is genetically influenced by parenting and religious
determined and controlled by neuronal and guidance. The Glorious Quran has described
hormonal discharges. In spite of this, an these psychological interactions in 6th century
individual should have full control on the in terms of al-Nafs al- Ammarah, al-Nafs al-
expression and fulfillment of the sexual Lawwamah, and al-Nafs al-Mutmainnah.
desires. Similarly, an individual can control Allah ( )says in the Quran: "O you who
the desire to take drugs, although there may be
believe, intoxicants, gambling, the altars of
genetic predisposition.
idols and game of chance are admonitions of
According to Islamic beliefs, the human soul is
the devil; you shall avoid, that you may
composed of three elements:
succeed11.
1) Al-Nafs al-Ammarah (soul commanding of
In overcoming addiction, one needs to feel
evil or evil-inciting soul)
guilty for allowing one self to be controlled by
2) Al-Nafs al-Lawwamah (selfreproaching
the lower desires and seek help from Allah
soul)
3) Al-Nafs al-Mutmainnah (tranquil, peaceful ( )to give him strength to overcome the
soul) habit. Allah ( )says:
The goal of every Muslim is to be aware of the And be you not like those who forgot Allah.
stage of the development of his or her own He made them forget their own souls. Such are
soul and discipline himself in obedience of the rebellious transgressors64.
God. He / She must strive to control al-Nafs The solution to the drug problem is not simple.
al-Ammarah and achieve al-Nafs al- It must be recognized that environment plays a
Mutmainnah63. significant role in causing drug addiction.
Freud described human's basic instinctual Affluence, easy access to the drugs, permissive
drives (id), humans perceptual, intellectual- environment, and peer pressure are major
cognitive, and executive functions (ego) and contributing factors. The Muslim community
humans capability of controlling self desires, must be educated about the importance of
reflecting social standards learned from early upbringing, parental guidance and
parents, culture and religion (super ego) as developing strong religious beliefs, which will
parts of the personality structure. id is help in building a super ego or consciousness
primarily an instinctual desire, and the ego (al-Nafs al-Lawwamah, the self-reproaching
represents the self, and it mediates between the soul). This is necessary to develop a strong
demands of primitive instinctual drives (id) ego which will resist temptation (al-Nafs al-

OPIATE
Ammarah) for drug use and to achieve al-Nafs methadone and buprenorphine have a risk of
al-Mutmainnah. A strong belief in Allah () abuse, dependence and diversion. Many
Muslim governments do consider the use of
and the respect for Shariàh law as well as use
opioid agonists as haram (forbidden) and this
of consciousness in decision making is
must be respected. However, the use of
necessary. A Muslim addict must be
methadone and buprenorphine for opioid drug
encouraged to adopt the Islamic way of life.
addiction must be acceptable in Muslim
Educational programs must be developed for
countries where their dispensing is
middle and high school children informing
permissible.
them about negative consequences of drug use,
For Muslim patients, psychotherapy and
resisting peer pressure and adopting Islamic
counseling should focus on spirituality, strong
way of life. The most effective strategy is
belief in God, asking for forgiveness and
prevention but unfortunately in most countries
mercy. These will increase the hope and give
of the world this strategy is not implemented.
strength to the coping mechanisms. The
Islam provides clear direction for every aspect
positive affective status of spiritual experience
of life. The Quranic legislation concerning the
may affect the brain reward system, and the
prohibition of using intoxicants gives Islam a
patient may recognize the new cues for
distinct place in comparison to other religions.
pleasure, redirecting the pleasure reward
The treatment of drug addiction must be
system to the new religious experiences65.
regarded as a medical treatment and all addicts
Religious guidance can also direct the patient
must be encouraged to seek medical and
to adopt a healthy lifestyle.
psychosocial treatment. Islam does not
Various Islamic countries have instituted
"shame" its believers when they seek
support groups of Alcoholic Anonymous (AA)
treatment, and Allah ( )forgives the and Narcotic Anonymous (NA) for patients
shortcomings. The community has the with addiction. They have modified the
responsibility to support and assist in recovery twelve steps and replaced the word higher
whenever possible.
power with Allah ). These support groups
The prescription and the dispensing of the
are also helpful in the recovery of Muslim
narcotics must be reviewed, as the prescription
patients when presented with Islamic spiritual
opioid abuse became the most serious problem
beliefs. Prayers and Dhikr (remembrance of
in the world today. Many young men do not
realize that prescription opiates are potentially Allah ( )should be incorporated in the
dangerous drugs. treatment regime.
Abstinence-oriented treatment programs are Strict control of drug trafficking, and
preferable in Muslim majority countries. The manufacturing of narcotics and pharmaceutical
recently introduced anti-opiod medication products containing opioids are absolutely
naltrexone (by injection and possibly as an necessary. Close monitoring of prescriptions
implant) is effective in blocking the euphoric can avoid iatrogenic dependence. Stigma
effects of opioid. The effects of long acting should be removed, and addicts should be
naltrexone last 3-4 weeks and this will be a treated as victims and patients rather than
useful deterrent for opioid use. This criminals. Legal statue should be applied
medication along with psychosocial support equally to affluent and non-affluent residents
system, guidance to improve the family life of the country.
and occupation may be the best options of
treatment in Muslim majority countries. There References:
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APevXhW0.99

CANNABIS
Adnan Y. Takriti*
Abstract
Cannabis, The most commonly used illegal drug, is produced from dried leaves, flowers,
stems, and seeds of the weed Cannabis Sativa. Various patterns of usage are explained.
The main cannabinoid receptor is anandamide. Cannabis contains at least 60
psychoactive cannabinoids, the most important of which is 9-8 tetrahydrocannabinol
(THC). The drug is metabolized to active and inactive metabolites and their absorption
into fat means that urine tests remain positive for up to 4 weeks after regular use has
ceased. Acute intoxication, general and chronic ill-health effects including psychiatric
and organic syndromes is explored. The immediate effects include mild euphoria, a
sense of enhanced well-being, subjective sense of enhanced sensation, relaxation, altered
time sense, and increased appetite. Physically there is mild tachycardia, variable
dysarthria and ataxia. Acute harmful effects include mild paranoia, panic attacks, and
accidents associated with delayed reaction time... Chronic harmful effects include
dysthymia, anxiety/depressive illnesses, and the disputed amotivational syndrome.
Cannabis use can precipitate an episode of or relapse of schizophrenia. In addition, in
regular users it is associated with dose-related paranoid ideation and other psychotic
features. Historical background, safety, drug testing, gateway theory and legal status are
discussed.
Keywords: Addiction, cannabis, marijuana.
Introduction:
Cannabis is also known as marijuana1, heightened mood or euphoria, relaxation,
and by neumerous other names is a and increase in appetite3. Unwanted side
preparation of the cannabis plant intended effects can sometimes include a decrease
for use as a psychoactive drug and as in short-term memory, dry mouth,
medicine. Pharmacologically, the principal impaired motor skills, reddening of the
psychoactive constituent of cannabis is eyes, and feelings of paranoia or anxiety4.
tetrahydrocannabinol (THC), one of 483 Contemporarily, cannabis is used as
known compounds in the plant, including a recreational or medicinal drug, and as
at least 84 other cannabinoids, such as part of religious or spiritual rites; the
cannabidiol (CBD), Cannabinol (CBN), earliest recorded uses date from the 3rd
tetrahydrocanna bivarin (THCV) and millennium BC5. Since the early 20th
cannabigerol (CBG)2. Cannabis is often century cannabis has been subject to legal
consumed for its psychoactive and restrictions with its possession, use, and
physiological effects, which can include sale.
*Dr. Adnan Y. Takriti, MD, FRCP Psych.

Consultant Psychiatrist
Founder and Editor-in-Chief
The Arab Journal of Psychiatry, 1989-2011
Amman- Jordan

CANNABIS
Preparations containing psychoactive sacrament by ancient Jews and early

cannabinoids are currently illegal in most Christians17,18 due to the similarity
countries of the world. According to the between the Hebrew word "qannabbos"
United Nations cannabis is considered the ("cannabis") and the Hebrew phrase
most used illicit drug in the world. In 2004, "qenbsem" ("aromatic cane"). It was
the United Nations estimated that global used by Muslims in various Sufi orders as
consumption of cannabis indicated that early as the Mamluk period, for example
approximately 4% of the adult world by the Qalandars19.
population (162 million people) used A study published in the South African
cannabis annually, and that approximately Journal of Science showed that "pipes dug
0.6% (22.5 million) of people used up from the garden of Shakespeare's home
cannabis daily6. in Stratford-upon-Avon contain traces of
cannabis"20. The chemical analysis was
History carried out after researchers hypothesized
that the "noted weed" mentioned in Sonnet
Cannabis is indigenous to Central and 76 and the "journey in my head"
South Asia7. Evidence of the inhalation of from Sonnet 27 could be references to
cannabis smoke can be found in the 3rd cannabis and the use thereof21.
millennium BC, as indicated by charred Cannabis was criminalized in various
cannabis seeds found in a ritual brazier at countries beginning in the early 20th
an ancient burial site in present day century. In the United States, the first
Romania8. restrictions for sale of cannabis came in
In 2003, a leather basket filled with 1906 (in District of Columbia)22. It was
cannabis leaf fragments and seeds was outlawed in South Africa in 1911,
found next to a 2,500 - to 2,800- year old in Jamaica (then a British colony) in 1913,
mummified shaman in the northwest- and in the United Kingdom and New
ern Xinjiang Uygur Autonomous Region Zealand in the 1920s23. In 1925 a
of China9,10. Evidence for the consumption compromise was made at an international
of cannabis has also been found in conference in The Hague about the Intern-
Egyptian mummies dated about 950 ational Opium Convention that banned
BC11,12. exportation of "Indian hemp" to countries
Cannabis is also known to have been used that had prohibited its use, and requiring
by the ancient Hindus of India and Nepal importing countries to issue certificates
thousands of years ago. The herb was approving the importation and stating that
called ganjika in Sanskrit (, ganja in the shipment was required "exclusively for
medical or scientific purposes". It also
modern Indo-Aryan languages)13,14.
required parties to "exercise an effective
Cannabis was also known to the ancient
control of such a nature as to prevent the
Assyrians, who discovered its psychoac-
illicit international traffic in Indian hemp
tive properties through the Aryans15. Using
and especially in the resin"24,25. In the
it in some religious ceremonies, they called
United States in 1937, the Marihuana Tax
it qunubu (meaning "way to produce
Act was passed, and prohibited the
smoke"), a probable origin of the modern
production of hemp in addition to
word "cannabis"16. Cannabis has an
cannabis. The reasons that hemp was also
ancient history of ritual use and is found
included in this law are disputed. Several
in pharmacological cults around the world.
scholars have claimed that the act was
Cannabis was used as a religious

CANNABIS
passed in order to destroy the US hemp and leaves38. It varies in color from black
industry26,27.28. The United Nations' to golden brown depending upon purity
2012 Global Drug Report stated that and variety of cultivar it was obtained
cannabis "was the world's most widely from39. It can be consumed orally or
produced, trafficked, and consumed drug smked40.
in the world in 2010", identifying that
between 119 million and 224 million users Tincture
existed in the world's adult (18 or older) Cannabinoids can be extracted from
population29. cannabis plant matter using high-
proof spirits (often grain alcohol) to create
Preparations a tincture, often referred to as "green
dragon"41.
Whole flower and leaf Nabiximols is a branded product name
from a tincture manufacturing pharma-
The terms cannabis and marijuana gener- ceutical company42.
ally refer to the dried flowers and
subtending leaves and stems of the female Hash oil
cannabis plant30. This is the most widely
consumed form, containing 3% to 22% Hash oil is obtained from the cannabis
THC31.32. In contrast, cannabis varieties plant by solvent extraction, and contains
used to produce industrial hemp contain the cannabinoids present in the natural oils
less than 1% THC and are thus not valued of cannabis flowers and leaves43. The
for recreational use33. solvents are evaporated to leave behind a
This is the stock material from which all very concentrated oil.
other preparations are derived. It is noted Hemp oil is very different from both hemp
that cannabis or its extracts must be seed oil and cannabis flower essential oil44.
sufficiently heated or dehydrated to Owing to its purity, these products are
cause decarboxylation of its most abundant consumed by smoking, vaporizing, eating,
cannabinoid, tetrahydrocannabinolic acid or topical application.
(THCA), into psychoactive THC34.
Infusions
Kief There are many varieties of cannabis
Kief is a powder, rich in tricho- infusions owing to the variety of non-
mes35, which can be shifted from the volatile solvents used. The plant material is
leaves and flowers of cannabis plants and mixed with the solvent and then pressed
either consumed in powder form or and filtered to express the oils of the plant
compressed to produce cakes of hashish36. into the solvent. Examples of solvents used
The word "kif" derives from Arabic () in this process are cocoa butter, dairy
(Kayf), meaning well-being or pleasure37. butter, cooking oil, glycerine, and skin
moisturizers. Depending on the solvent,
Hashish these may be used in cannabis foods or
Hashish (also spelled hasheesh, hashisha, applied topically45.
or simply hash) is a concentrate-
ed resin cake or ball produced from Methods of consumption
pressed kief, the detached trichomes and Cannabis is consumed in many different
fine material that falls off cannabis flowers ways46: Smoking, which typically involves

CANNABIS
inhaling vaporized cannabinoids ("smoke") cannabichromene (CBC) and cannabigerol

from small pipes, bongs (portable versions (CBG), they have less (THC).
of hookahs with water chamber), paper- Cannabis indica may have a CBD:
wrapped joints or tobacco-leaf-wrapp- THC ratio four to five times that
ed blunts, roach clips, and other items47. of Cannabis sativa. Cannabis strains with
Vaporizer, which heats herbal cannabis to relatively high CBD: THC ratios are less
165190 C (329374 F)48, causing the likely to induce anxiety than those with a
active ingredients to evaporate into lower ratio. This may be due to
a vapor without burning the plant material CBD's antagonistic effects at the cannabin-
(the boiling point of THC is 157 C oid receptors, compared to THC's partial
(315 F) at 760 mmHg pressure)49. agonist effect. CBD is also a 5-
Cannabis tea contains relatively small HT1A receptor agonist, which may also
concentrations of THC, because THC is an contribute to an anxiolytic effect. This
oil (lipophilic) and is only slightly water- likely means the high concentrations of
soluble (with a solubility of 2.8 mg per CBD found in Cannabis indica mitigate the
liter)50. Cannabis tea is made by first anxiogenic effect of THC significant-
adding a saturated fat to hot water (e.g. ly. The effects of sativa are well known for
cream or any milk except skim) with a their cerebral high, hence its daytime use
small amount of cannabis51. Edibles, where as medical cannabis, while indica is well
cannabis is added as an ingredient to one known for its sedative effects and preferred
of a variety of foods. Marijuana vending night time use as medical cannabis.
machines for selling or dispensing
cannabis are in use in the United States and Mechanism of action
are planned to be used in Canada52.
The high lipid-solubility of cannabinoids
53
Pharmacology results in their persisting in the body for
long periods of time54. Even after a single
The genus Cannabis contains two species administration of THC, detectable levels of
which produce useful amounts of psycho- THC can be found in the body for weeks
ctive cannabinoids: Cannabis indica and or longer (depending on the amount
Cannabis sativa, which are listed as administered and the sensitivity of the
Schedule I medicinal plants in the US. A assessment method)54.
third species, Cannabis ruderalis, has few A number of investigators have suggested
psychogenic properties. Cannabis contains that this is an important factor in
more than 460 compounds, at least 80 of marijuana's effects, perhaps because
these are cannabinoids chemical cannabinoids may accumulate in the body,
compounds that interact with cannabinoid particularly in the lipid membranes of
receptors in the brain. As of 2012, more neurons55. Not until the end of the 20th
than 20 cannabinoids were being studied century was the specific mechanisms of
by the U.S. FDA. The most psychoactive action of THC at the neuronal level
cannabinoid found in the cannabis plant is studied. Researchers have subsequently
tetrahydrocannabinol (or delta-9-tetrahydro confirmed that THC exerts its most
-cannabinol, commonly known as THC). prominent effects via its actions on two
Other cannabinoids include delta-8- types of cannabinoid receptors,
tetrahydrocannabinol, cannabidiol (CBD), the CB1 receptor and the CB2 receptor,
cannabinol (CBN), cannabicyclol (CBL),

CANNABIS
both of which are G-protein coupled associated with the acute effects of
receptors56. cannabis ingestion, such as euphoria and
The CB1 receptor is found primarily in the anxiety. Some effects may include a
brain as well as in some peripheral tissues, general alteration of conscious perception,
and the CB2 receptor is found primarily in euphoria, feelings of well-being, relaxation
peripheral tissues, but is also expressed or stress reduction, increased appreciation
in neuroglial cells57. THC appears to alter of humor, music (especially discerning its
mood and cognition through its agonist various components/instruments) or the
actions on the CB1 receptors, which inhibit arts, joviality, metacognition and
a secondary messenger system (adenylate- introspection, enhanced recollection
cyclase) in a dose dependent manner. (episodic memory), increased sensuality,
These actions can be blocked by the increased awareness of sensation,
selective CB1 receptor antagonist increased libido62, and creativity. Abstract
SR141716A (rimonabant), which has been or philosophical thinking, disruption of
shown in clinical trials to be an effective linear memory and paranoia or anxiety are
treatment for smoking cessation, weight also typical. Anxiety is the most
loss, and as a means of controlling or commonly reported side effect of smoking
reducing metabolic syndrome risk marijuana. Between 20 and 30 percent of
factors58. However, due to the dysphoric recreational users experience intense
effect of CB1 antagonists, this drug is anxiety and/or panic attacks after smoking
often discontinued due to these side cannabis, however, some report anxiety
effects59. only after not smoking cannabis for a
Via CB1 activation, THC indirectly prolonged period of time63.
increases dopamine release and produces Cannabis also produces many subjective
psychotropic effects. Cannabidiol also acts and highly tangible effects, such as greater
as an allosteric modulator of the mu and enjoyment of food taste and aroma, an
delta opioid receptors60. THC also enhanced enjoyment of music and comedy,
potentiates the effects of the glycine and marked distortions in the perception of
receptors61. The role of these interactions time and space (where experiencing a
in the "marijuana high" remains elusive. "rush" of ideas from the bank of long-term
memory can create the subjective
Psychoactive effects impression of long elapsed time, while a
clock reveals that only a short time has
The psychoactive effects of cannabis, passed). At higher doses, effects can
known as a "high", are subjective and can include altered body image, auditory
vary based on the person and the method and/or visual illusions, pseudohallucinato-
of use. ry, and ataxia from selective impairment of
When THC enters the blood stream and polysynaptic reflexes.
reaches the brain, it binds to cannabinoid In some cases, cannabis can lead to
receptors. The endogenous ligand of these dissociative states such as depersonaliza-
receptors is anandamide, the effects of tion64,65 and derealization66, such effects
which THC emulates. This agonism of the are most often considered desirable, but
cannabinoid receptors results in changes in have the potential to induce panic attacks
the levels of various neurotransmitters, and paranoia in some unaccustomed
especially dopamine and norepinephrine; users66. Any episode of acute psychosis
neurotransmitters which are closely that accompanies cannabis use usually

CANNABIS
abates after 6 hours, but in rare instances Cannabis has been used to reduce nausea
heavy users may find the symptoms and vomit-ing in chemotherapy and people
continuing for many days67. When the with AIDS, and to treat pain and muscle
episode is accompanied by aggression, spasticity76. According to a 2013 review,
sedation or physical restraint may be "Safety concerns regarding cannabis
necessary67. include the increased risk of developing
While many psychoactive drugs clearly schizophrenia with adolescent use, impair-
fall into the category of either stimulant, ments in memory and cognition, accidental
depressant, or hallucinogen, cannabis pediatric ingestions, and lack of safety
exhibits a mix of all properties, perhaps packaging for medical cannabis formula-
leaning the most towards hallucinogenic or tions"77. The US Food and Drug Admini-
psychedelic properties, though with other stration (FDA) maintains that the herb
effects quite pronounced as well. THC is cannabis is associated with numerous
typically considered the primary active harmful health effects, and that significant
component of the cannabis plant; various aspects such as content, production, and
scientific studies have suggested that supply are unregulated.
certain other cannabinoids, like CBD, may
also play a significant role in its Chronic health effects of cannabis use78
psychoactive effects68,69,70.
Selective impairment of cognitive
General Effects functioning which include the
organization and integration of
Cannabishas psychoactive and physio- complex information involving vari-
logical effects when consumed71. The ous mechanisms of attention and
immediate desired effects from consuming memory processes.
cannabis include relaxation and mild Prolonged use may lead to greater
euphoria (the "high" or "stoned" feeling), impairment, which may not recover
while some immediate undesired side- with cessation of use, and which
effects include a decrease in short-term could affect daily life functions;
memory, dry mouth, impaired motor skills Development of a cannabis depend-
and reddening of the eyes72. Aside from a ence syndrome characterized by a
subjective change in perception and mood, loss of control over cannabis use is
the most common short-term physical and likely in chronic users.
neurological effects include increased heart Cannabis use can exacerbate
rate, increased appetite and consumption of schizophrenia in affected individu-
food, lowered blood pressure, impairment als.
of short-term and working memory73,74, Epithelial injury of the trachea and
psychomotor coordination, and concentr- major bronchi is caused by long-
ation. term cannabis smoking.
A 2013 literature review reported that Airway injury, lung inflammation,
exposure to marijuana had biologically- and impaired pulmonary defence
based physical, mental, behavioral and against infection from persistent
social health consequences and was cannabis consumption over prolong-
"associated with diseases of the liver ed periods.
(particularly with co-existing hepatitisC), Heavy cannabis consumption is
lungs, heart, and vasculature"75. associated with a higher prevalence

CANNABIS
of symptoms of chronic bronchitis more common with new users or in those

and a higher incidence of acute who already have a psychiatric disease.
bronchitis than in the non-smoking The amount and effect of these side effects
cohort. varies from person to person, as well as
Cannabis used during pregnancy is with the amount of marijuana used.
associated with impairment in fetal Marijuana is often cut with hallucinogens
development leading to a reduction and other, more dangerous drugs that have
in birth weight. more serious side effects than marijuana.
Cannabis use during pregnancy may These side effects may include:
lead to postnatal risk of rare forms Sudden high blood pressure with
of cancer although more research is headache.
needed in this area. The health Chest pain and heart rhythm disturba-
consequences of cannabis use in nces.
developing countries are largely Extreme hyperactivity and physical
unknown because of limited and violence.
non-systematic research, but there is Heart attack.
no reason a priori to expect that Seizures.
biological effects on individuals in Stroke.
these populations would be Sudden collapse (cardiac arrest).
substantially different to what has
been observed in developed count- Treatment
ries. However, other consequences
might be different given the cultural Treatment and care involves:
and social differences between Preventing injury.
countries. Reassuring those who have panic
reactions due to the drug.
Marijuana acute intoxication79 Benzodiazepines, such as diazepam
(Valium) or lorazepam (Ativan) may be
Symptoms: given. Children who have more serious
The intoxicating effects of marijuana symptoms or those with serious side
include relaxation, sleepiness, and mild effects may need to stay in the hospital for
euphoria (getting high). treatment. Treatment may include heart
Smoking marijuana leads to fast and and brain monitoring.
predictable signs and symptoms. Eating
marijuana can cause slower, and Prognosis
sometimes less predictable effects. Uncomplicated marijuana intoxication
Marijuana can cause undesirable side rarely needs medical advice or treatment.
effects, which increase with higher Occasionally, serious symptoms occur.
doses. These side effects include: However, these symptoms are rare and
Decreased short-term memory usually associated with other drugs or
Dry mouth compounds mixed in with marijuana.
Impaired perception and motor skills
Red eyes Safety
More serious side effects include panic, Fatal overdose associated with cannabis
paranoia, or acute psychosis, which may be use have not been reported as of 200880.

CANNABIS
There has been too little research to binoid system and an overall role of
determine whether cannabis users die at a cannabis in causing decreased peripheral
higher rate as compared to the general resistance and increased cardiac output,
population, though some studies suggest which potentially could pose a threat to
that fatal motor vehicle accidents and death those with cardiovascular disease86.
from respiratory and brain cancers may be
more frequent among heavy cannabis Detection of cannabis-consumption drug
users. Many studies have looked at testing
the effects of smoking cannabis on the
respiratory system. Cannabis smoke THC and its major (inactive) metabolite,
contains thousands of organic and THC-COOH, can be measured in blood,
inorganic chemical compounds. This tar is urine, hair, oral fluid or sweat using
chemically similar to that found in tobacco chromato-graphic techniques as part of a
smoke81, and over fifty known carcino- drug use testing program or a forensic
gens have been identified in cannabis investigation of a traffic or other criminal
smoke82, including; nitrosamines, reactive offense87. The concentrations obtained
aldehydes, and polycylic hydrocarbons, from such analyses can often be helpful in
including benz[a]pyrene83. distinguishing active use from passive
There is serious suspicion among cardio- exposure, elapsed time since use, and
logists, spurring research but falling short extent or duration of use. These tests
of definitive proof, that cannabis use has cannot, however, distinguish authorized
the potential to contribute to cardiovascul- cannabis smoking for medical purposes
ar disease. Cannabis is believed to be an from unauthorized recreational smoking88.
aggravating factor in rare cases of arteritis, Commercial cannabinoid immuno-assays,
a serious condition that, in some cases often employed as the initial screening
leads to amputation. Because 97% of method when testing physiological
subjects in case-reports also smoked specimens for marijuana presence, have
tobacco, a formal association with cannab- different degrees of cross-reactivity with
is could not be made. THC and its metabolites89. Urine contains
If cannabis arteritis turns out to be a pre-dominantly THC-COOH, while hair,
distinct clinical entity, it might be the oral fluid and sweat contain primarily
consequence of vasoconstrictor activity ob- THC87. Blood may contain both
served from delta- 8- THC and delta-9- substances, with the relative amounts
THC84. dependent on the recency and extent of
Other serious cardiovascular events usage87.
including myocardial The Duquenois-Levine test is commonly
Infarction, stroke, sudden cardiac death, used as a screening test in the field, but it
and cardiomyopathy have been reported to cannot definitively confirm the presence of
be temporally associated with cannabis cannabis, as a large range of substances
use. Research in these events is have been shown to give false positives.
complicated because cannabis is often used Despite this, it is common in the United
in conjunction with tobacco, and drugs States for prosecutors to seek plea
such as alcohol and cocaine85. bargains on the basis of positive D-L tests,
These putative effects can be taken in claiming them definitive, or even to seek
context of a wide range of cardiovascular conviction without the use of gas
phenomena regulated by the endocanna- chromatography confirmation, which can

CANNABIS
only be done in the lab90. In 2011, cannabis (though the reverse may be true
researchers at John Jay College of in some areas), thus leading to the
Criminal Justice reported that dietary zinc "gateway sequence" in those individuals
supplements can mask the presence of since they are most likely to experiment
THC and other drugs in urine. Similar with any drug offered63.
claims have been made in web forums on "Notice that none of these interpretations
that topic91. involves a specific pharmacological effect
of the sort drug warriors seem to have in
Gateway drug Theory mind when they suggest that pot smoking
primes the brain for cocaine or heroin. As
Since the 1950s, United States drug policy a National Academy of Sciences panel
has been guided by the assertion that observed in a 1999 report, 'There is no
cannabis use increases the probability of evidence that marijuana serves as a
trying "harder" drugs92. The hypothesis has stepping stone on the basis of its particular
endured as one of the central pillars of drug effect.' Last year the Canadian
anti-cannabis drug policy in the United Senate's Special Committee on Illegal
States93, and as such the validity and Drugs likewise concluded that 'cannabis
implications of the hypothesis are hotly itself is not a cause of other drug use. In
debated92. Almost two-thirds of the poly- this sense, we reject the gateway theory'101.
drug users in the "2009/10 Scottish Crime
and Justice Survey" used cannabis94. Legal status
Some studies state that while there is no
proof for the gateway hypothesis95, young Since the beginning of the 20th century,
cannabis users should still be considered as most countries have enacted laws against
a risk group for intervention programs96, the cultivation, possession or transfer of
while other findings indicate that hard drug cannabis102.
users are likely to be poly-drug users, and These laws have impacted adversely on the
that interventions must address the use of cannabis plant's cultiva-tion for non-
multiple drugs instead of a single hard recreational purposes, but there are many
drug97. regions where, under certain circumsta-
Another gateway hypothesis covers that a nces, handling of cannabis is legal or
gateway effect may be caused by the licensed. Many jurisdictions have lessened
"common factors" involved in using any the penalties for possession of small
illegal drug. Through the illegal status of quantities of cannabis, so that it is punish-
cannabis, users are more likely to be ed by confiscation and sometimes a fine,
subjected to situations allowing them to rather than imprisonment, focusing more
acquaint with individuals using or selling on those who traffic the drug on the black
various illegal drugs98,99. Utilizing this market. In some areas where cannabis use
argument some studies have shown that has been historically tolerated, some new
alcohol and tobacco may additionally be restrictions have been put in place, such as
regarded as gateway drugs100, however, a the closing of cannabis coffee shops near
more parsimonious explanation could be the borders of the Netherlands103, closing
that cannabis is simply more readily of coffee shops near secondary schools in
available (and at an earlier age) than illegal the Netherlands and crackdowns on
hard drugs. In turn alcohol and tobacco are Pusher Street in Christiania, Copenhagen
easier to obtain at an earlier point than is in 2004104,105.

CANNABIS
Some jurisdictions use free voluntary was jurists consensus, from all schools of
treatment programs and/or mandatory Islamic thought, to classify cannabis as an
treatment programs for known frequent intoxicant (khamr)110-113, and to apply the
users. Simple possession can carry long rulings of alcohol on cannabis, i.e.
prison terms in some countries, particularly prohibition (tahrim), and punishment (by
in East Asia, where the sale of cannabis flogging).
may lead to a sentence of life in prison or Ibn Taymiyah110, Ibn al-Qayyim111, Badr
even execution. More recently however, al- Din al-Zarkashy112 and Imam al-
many political parties and non-profit Nawawi113 wrote in detail about the
organizations are working on the problem, and its rulings.
legalization of medical cannabis and/or Several ahadith were cited, including the
legalizing the plant entirely, with some following:
restrictions have emerged. " "
In December 2012, the U.S. state Every intoxicant is khamr (alcohol-like)
of Washington became the first state to and every khamr is haram (prohibited)114.
officially legalize cannabis in a state law " "
(Washington Initiative 502) (but still Khamr is whatever clouds the mind115.
illegal by federal law)106, with the state ( ) ":
of Colorado following close behind "
107
(Colorado Amendment 64) . On January The Prophet ( )prohibited any
1, 2013, the first marijuana "club" for intoxicant and languid-causing material116.
private marijuana smoking (no buying or Al-Sayyid Sabiq, in his book: Fiqh al-
selling, however) was allowed for the first Sunnah, elaborated on the opinion of the
time in Colorado107. The California above scholars, and added a fatwa
Supreme Court decided in May 2013 that (religious decree) issued by the Grand
local governments can ban medical Mufti of Egypt (Mufti al-Diyar al-
marijuana dispensaries despite a state law Misriyyah), Shaikh Abdul Majid Salim,
in California that permits the use of that cannabis (hashish) is haram117.
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QAT ABUSE IN YEMEN:
SOCIO-ECONOMIC AND HEALTH PERSPECTIVES
Husni Al-Goshae*
Abstract:
Qat (or Khat) is an evergreen shrub named Catha Edulis which belongs to the family:
Gelastraceae. The plant grows in Ethiopia, Kenya, Somalia, South Africa, Madagascar,
and was imported to Yemen from East Africa approximately 700 years ago. Over the past
several decades, the plant became widely grown in Yemen and occupied the fertile land
that was traditionally cultivated by life sustaining crops for Yemeni people.
Approximately 58.5% of agricultural lands are currently planted by Qat, leaving the rest
for grains, vegetables, fruits etc. What makes the matter more serious is the amount of
water needed to grow this plant. In a country with limited water resources, like Yemen,
more than 60% of this water is consumed for Qat plantation, drawing the country into
major economic and social problems.
In this presentation, various Qat-related problems with their pathophysiolgoic basis are
discussed, with special attention to the various health hazards that affect many body
systems. Available Islamic Jurisprudence opinion will be outlined.
Keywords: Qat, Qat-induced medical problems, Catha Edulis, Yemen, addiction.
Introduction:
Qat (Khat) belongs to the Catha Edulis leaves of the plant, especially when
plant family. The active ingredients are consumed within 24 hours after harvesting.
three main alkaloids, namely: cathinone, Both cathinone and cathine have strong
cathine and ephedrine1. Cathinone is an CNS stimulant affects2. However, cathine
amphetamine-like substance that induces has much less stimulant effect on the CNS
release of catecholamines in the peripheral than cathinone. The World Health
and central nervous systems. The main Organization (WHO) categorized Qat as a
metabolites of cathinone are norpseudo- drug in 1973. The concentration of the Qat
ephedrine and ephedrine. alkaloids vary according to the region in
Both substances have sympathomimetic which Qat is grown. Cathinone concentra-
activities, and stimulant properties on the tion is 3.3% in Yemeni Qat, and 14% in
central nervous system (CNS), while Kenyan Qat. The effects of cathine on the
cathinone has the predominantly peripheral CNS as a stimulant are much less than that
effects1. Cathinone is present in the fresh of cathinone.
*Prof. Dr. Husni Ahmed Al-Goshae
Ph.D in Neuroscience- Dundee University- UK
President of the High Council For Medical Education
University of Science and Technology
Sanaa- Yemen
Ex-Chairman, Consortium of FIMA Islamic Medical Colleges (CIMCO)

QAT
The Qat shrub is an evergreen plant grown tions and during working hours. Taxes
on a wide scale in Yemen, the East African were levied against various Qat-related
countries: Kenya, Ethiopia, Somalia and businesses. Unfortunately such measures
Djibouti. Qat is primarily consumed in proved ineffective and fruitless to curtail
these countries but in addition, Qat is also this deep-rooted social habit and its
consumed in some European countries, consequences.
such as Britain and some states in USA,
where migrants from these countries Medical consequences of Qat:
reside3,4. Over the years, Qat consumption was
In Yemen, Qat plantation occupies 58.5% shown to cause many health problems.
of the total cultivated land, which leaves Most body systems are adversely affected,
only 41.5% of land to other crops that including the central nervous system
represent essential food items such as (CNS), cardiovascular (CVS), gastrointes-
grains, vegetables, and fruits. Moreover, tinal (GIT), and genitor-urinary (GUT)
Qat consumes around 60% of water, in a systems. As Qat is mostly consumed by
country that suffers from scarcity of water. chewing, periodontal health is adversely
Almost 70-80% of the Yemeni population affected.
of 25 million chew Qat on daily basis, with Moreover, there are added toxic sequelae
exacerbation of consumption on holidays of the frequently uncontrolled and unregul-
and special occasions. The fresh leaves of ated practices of farmers in using
the shrub are usually chewed, especially fertilizers, insecticides and other chemicals
during social and cultural gatherings, and to increase Qat production and to hasten
held in the lower buccal pouch as a bolus marketing of the fresh plant. Such
for long hours, to enjoy its pleasurable practices increase various damaging effects
stimulant properties. The majority of Qat on various body systems.
chewers are16 to 60 years old but some
chewers are as young as 7-15 years.
Effects of Qat on the CNS
In Yemen, which is considered among the
world poorest countries, 2-3 billion dollars These follow 5 stages:
are spent yearly on Qat consumption5. Stage 1: Starts within 30 minutes
Over the past 2-3 decades, Qat cultivation following chewing Qat leaves. It is
escalated exponentially. Almost 20% of characterized by hyperactivity, alertness,
the Yemeni work force is involved in the talkativeness, sense of euphoria and
Qat business. As a locally produced and wellbeing. This stage lasts 60-90 minutes.
consumed crop, Qat generates no national These effects are similar to the effects of
income from export, and therefore it amphetamines on the CNS2.
represents economic waste. Qat consumes Such temporary effects are the cause for
most of the families' income, with the prevailing beliefs that Qat improves
significant socio-economic consequences, work performance, counteracts fatigue and
including, but not limited to family helps students in preparing for
fragmentation and devious means to secure examinations4.
the financial burdens of Qat consumption. Stage 2: Also called: the imagination and
The Yemeni government sought to under- problem-solving stage. During this stage
take measures to deal with the escalating Qat chewers feel they are able to solve
Qat phenomena since 1975. Qat chewing most problems, whether personal, social or
was banned in all governmental institu- business-related. This stage lasts about 2-3
hours.

QAT
Stage 3: The stage of silence. This starts 5- neurotransmitter of cathinone, has symp-
6 hours from the beginning of Qat athomimetic effects, with vasoconstriction
chewing. Talking stops, silence prevails that is dose-dependent9,10,11. Elevation of
with excessive smoking, feelings of lack of blood pressure and palpitation, cold
safety, sense of fear, anxiety accompanied extremities and sweating, are frequently
by auditory and visual hallucinations. encountered during and after sessions of
Frequently, the individual starts talking to Qat chewing, and were ascribed to
himself. vasoconstrictive effects of cathinone.
Stage 4: Stage of depression. This stage is These effects were documented in animal
characterized by headache, feelings of experiments11,12.
loneliness, doubt towards surrounding Acute myocardial infarction (MI) was
people, aggressiveness and insomnia. This linked to Qat consumption. Qat is
stage starts after the Qat chewer throws considered an independent, dose-related
away the long-chewed Qat bolus from his risk factor for MI13.
mouth.
Stage 5: The final stage starts few hours Qat effects on GIT:
prior to dawn. It is characterized by
generalized weakness, relaxation, laziness, Several effects of Qat were reported on the
desire to sleep, which is uncomfortable, GIT. Large doses could cause hyperacid-
with bad dreams, morning depression and dity, GI mucosal injuries and aggravation
aggressiveness2. of gastric and duodenal ulcerations14.
Other GIT complications include esophagi-
Qat and psychosis: ititis, gastritis, delay of intestinal
Excessive and prolonged Qat chewing may absorption, and development of oral
cause psychosis and schizophrenia which keratotic white lesions at the site of
could be severe6. chewing (tachzeen). Cytotoxic effects on
Two types of psychosis were described in the hepatic and renal cells were observed15.
the literature: The Advisory Council on the Misuse of
1.Schizophrenic psychosis, described in Drugs (ACMD) report, 201316 revealed
heavy Qat chewers, with paranoid delus- proven incidence of acute hepatitis. As
ions, sense of fear (phobia), lack of mentioned previously, these complications
adaptation to environment, isolation tende- of Qat consumption on GIT and other body
ncy, hearing hallucinations, and aggressive systems, are greatly enhanced by the toxic
behavior. These symptoms may disappear effects of chemicals used as insecticides
on stopping Qat consumption, but tend to and fertilizers to promote Qat productivity
recur if the habit is resumed7. as farmers believe. Some of these effects
2. Manic psychosis, with hyperactivity, may be carcinogenic17.
loud shouting, speech difficulty, delusions,
flight of ideas, euphoria and anger. These Effects of Qat on GUT:
symptoms usually subside spontaneously The early stages (1 and 2) of Qat chewing,
when Qat is discontinued 7,8. are usually accompanied by great increase
in sexual desire. Although this increase in
Qat effects on CVS: libido persists to the subsequent stages of
Qat chewing (stages 3-5), the feelings of
Clinical studies showed cathinone to cause depression, headache and impotence
CVS complications. Norepinephrine, the predominate18. The seminal fluid is dis-

QAT
charged of the urethra involuntarily among economy suffers about 2-3 billion USD
most Qat chewers. The effect is ascribed to every year. These estimated statistics were
inhibitory effects of cathinone on the obtained in 2013 from local NGOs that are
sphincters of seminal vesicles18. functional in Yemen to combat Qat
There are some reports on the relationship growing and consumption. One of those
of Qat chewing to an increase in urinary NGOs is "Erada (willpower) and Yemen
bladder dysfunction19. Qat may increase without Qat" Organization.
the possibility of urinary tract stone Similar decreases in economic productivity
formation, but this needs further were also reported from Ethiopia, Somalia,
investigations. Uganda and Kenya23. In some African
countries it was reported that Qat may
Periodontitis and oral health:
push its users to inappropriate behaviors,
Heavy, long- term Qat chewing is an such as bribery, cheating, stealing,
independent risk factor for periodontal prostitution and other criminal behaviors24.
diseases with adverse affects on teeth, The other significant and alarming
gums, clinical attachment loss and other economic problem is the increased water
aspects of oral hygiene20. consumption of Qat agriculture. In Yemen,
Is there Qat addiction or dependence? with sparse drinking water supplies, more
than 60% of available water, underground
Cathinone, one of the main two constitue- or otherwise, is consumed by Qat cultiva-
nts of Qat, with its major metabolite: tion. Farmers prefer Qat cultivation over
norpseudoephedrine, leads to the other life supporting crops, in view of its
1
dependence effects of Qat . It was, biannual profitable cultivation pattern, and
however, observed that Qat chewers ease of marketing in local markets. These
experience no significant withdrawal individual benefits are in contrast to the
symptoms when they stop Qat. This is major harms on the national Yemeni
frequently observed when Qat chewers economy in view of lack of income
travel abroad and stay away from the habit. generation of hard currency as Qat is not
This observation led some researchers to exported.
conclude that dependence on Qat is mainly
psychological21, and people are able to Islamic perspectives:
discontinue the habit easily, if intension
and willpower are exercised. Some people, Qat consumption was discussed by
in such situations may have minor uncom- Shariah scholars and Fatwa forums inside
fortable symptoms, such as bad dreams, and outside Yemen.
feeling hot sensations in extremities, leth- In view of various significant health,
argy and sense of missing Qat chewing. psychosocial and harmful economic
Tolerance to the central amphetamine-like consequences of Qat consumption, and in
effects have been frequently described22. view of scientific stand-points of the
There are no significant withdrawal World Health Organization considering
symptoms comparable to those related to Qat as a narcotic and addicting drug, most
alcohol or other narcotics. of Yemeni Islamic scholars issued Fatawa
that forbid Qat consumption considering it
Socio-economic consequences: as (Haram)5.
In Yemen, Qat causes approximately 20 These scholars include:
million lost hours in work productivity Sheikh Abdulwahab Al-Dielmy, form-
every day. It was estimated the Yemeni er minister of justice.

QAT
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official or community-based, are called Goshae, H. A., (2012). Book, The Opinion of Scholars in
upon to lay down proper and constructive Khat Chewing, medical, economic, and legal study. The
planning and collaboration to combat this Universities Publisher House, Sana, Yemen, ISSN
1126/2012.
problem by all means. 18. Halbach, H. (1972), Medical aspects of the chewing
Khat leaves. Bulletin of the World Health Organzation,
47: 21-29.

QAT
19. Nasher, A. A., Qirbi, A. A., Ghafoor, M. A., Catteral,

a., Thompson, A., Ramsay, J. W. A., and Murray-Lyon, I.
M., (2008). British Medical Journal of Urology, VGol.
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Tb07415.x.
20. Al-Sharbi AK, Shuga-Aldin H., Ghandour I and Al-
Hebshi N. Qat chewing as an Independent Risk Factor for
Periodontitis: A cross-sectional study. International
Journal of Dentistry, 2013, PP. 1-7.
21. Al-Motarreb, A., Baker, K. and Broadley, K. J.,Khat:
Pharmacological and Medical Aspects and its Social Use
In Yemen. Phyto-therapy Research 2002;16:403-413.
22. Kassim S., Islam S. and Croucher r. Validity and
reliability of a Severity of Dependence Scale for Khat
(SDS-Khat). Journal of Ethropharmacology, 2010, vol.
132, No 3, pp 570-577.
23. Giannini, A. J., Burge, H., Shaheen, J. M., (1986),
Khat: Another drug of abuse? Journal of Psychoactive
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25. The Islamic International Fiqh Academy- Session
held in Madina, Saudi Arabia, 27-30 5, 1402 H.

BEHAVIORAL ADDICTION
Mehmet Dinc*
Abstract:
Until recent years, the general public have mostly seen behavioral addictions like
innocent habits and mental health professionals have ignored it as they are so focused
on substance abuse problems. This fact makes it difficult to find funding sources for
research or even to take a class at a university on behavioral addiction. Therefore,
behavioral addiction has been underestimated, undertreated and understudied. For
example, gambling addiction was first mentioned in the medical literature in the early
1800s but it could not find a place in the Diagnostic and Standardized Manual of
Mental Disorders (DSM) until 1980 and still it has been put under impulse control
disorder instead of under addiction until DSM-V. However, major changes in all
aspects of life, mostly in the fields of scientific research, have resulted in increased
awareness of behavioral addiction as an entity and made it more visible now. Such
changes have triggered new types of addiction like Internet addiction and new forms
of old addictions such as online gambling and Internet pornography.
General information about addiction will be presented and then information about
what we should know and what we should do about behavioral addiction will be
discussed.
Keywords: Addiction, Behavioral Addiction, Gambling Addiction, Sex Addiction,

Internet Addiction, Shopping Addiction.
Allah ( )says in the Glorious Quran: Being dependent is not the effect of a
contract. It is not related to any role nor
"...Make not your own hands contribute is it the result of ones social class.
to your destruction..."1. Dependency is the consequence of
"...nor kill yourselves..."2. lowering your self-esteem, abdicating
The Prophet Muhammad ( )said: your dignity. It is what happens when
"There should be neither harming, nor you allow your being to be crushed
reciprocating harm3. Dependency is a disease of Being! It
To be dependent, even if involuntarily, is the result of ones incompletenessto
is always a personal choice. Nothing and be dependent means to cease believing in
no one can force you into dependency, oneself. To depend means to stop
only you can do that to yourself! dreaming4.
*Mehmet Dinc
Clinical Psychologist
MA, M.Ed(Master of Education)
Hasan Kalyoncu University
Valide-i Atik Mh. Lami Celebi Sk. No:4/2 Uskudar
Istanbul- Turkey

Definition of Addiction consistent and reliable shift in the mood

state. Sometimes, it might be to get high
Defining of addiction, especially from or to be aroused but sometimes it might
the perspective of behavioral addiction, be the total opposite, i.e. to numb or to
is not easy because there is no clear distress. Tolerance means that to get the
distinction between use, abuse and same effects on the person's mood
addiction. Moreover, the differences modification, he/she needs to use this
between addictions, habits, interest, behavior more and more day by day.
obsession, dedication and so on are Withdrawal symptoms mean experience-
mostly blurred. For this reason, some ing some psychological symptoms, for
researchers like Vaillant5 offered that example increased moodiness or
instead of searching for a ready storability and physiological problems,
definition of addiction, we consider it such as sweaty hands, nausea, stomach
like a mountain or season, when cramps, headaches and anxiety attacks,
confronted with these situations, we when the addictive behavior is prevented.
know these things implicitly. However, Conflict means having repetitive
to work on addictions as a doctor, problems in his family life or work life
psychiatrist, psychologist, social worker, because of the addictive behavior and
or a researcher, we need a functional even though he wants to cut down and
definition of addiction. Following are the stop he cannot do it because he lost his
three different definitions of addiction. control on the behavior. Relapse means it
Addiction is a brain disease resulting does not matter to give up from any
from the interaction among salience/ addiction for some time because as soon
reward, learning/ memory/ conditioning as an addictive person starts he does not
and a lowering inhibition/control6. start from the beginning but from the
Addiction is a Behavior that is center of addiction circle.
motivated by emotions ranging between
the Craving to Compulsion spectrum; Risk Factors
Continued use in spite of adverse
consequences and Loss of Control 7. Before pointing out any factors which
All addiction is characterized by a loss may lead to addiction, I would like to
of control, preoccupation, compulsivity, share a letter which was written by Carl
narrowing of interest, dishonesty, guilt G. Jung to Bill Wilson who is one of the
and chronic relapse8. founders of Alcoholics Anonymous, just
before Jungs death. In the letter Jung
Definition of Behavioral Addiction describes the need for alcohol (or any
other addiction) as being similar to
According to Griffiths9 who is one of the spiritual thirst. Meanly, if anyone cannot
most prominent pioneers in behavioral reach wholeness with spirituality, he
addiction, any behavior, which fulfills six may look for other ways to feed his thirst
components, is an addictive behavior. and most of the time he uses addiction to
The six components are: salience, mood squinch his thirst. Wallace10 explained
modification, tolerance, withdrawal spiritual thirst by these concepts; intense
symptoms, conflict and relapse. Salience feelings of alienation, apartness,
means the behavior becomes the most emptiness, meaninglessness, and lack of
important thing in anyones life so that purpose in living. Therefore, spirituality
the person becomes totally preoccupied might be a prevention and treatment for
with the behavior mentally if not any addiction at the same time. Jung
physically. Mood modification means stated his ideas with these words in the
some specific behaviors are used for a letter:

.. addiction is an issue. Moreover, after

His craving for alcohol was the some time of addiction an important
equivalent on low level of the spiritual question arises that is whether life
thirst of our being for completeness, problems have caused the addiction or
expressed in medieval language: the the addiction has caused the life
union with God. problems.
How could one formulate such an insight Addicted people mostly use two
in a language that I misunderstood in our techniques about their addictions to
days? persuade themselves. First, they
The only right and legitimate way to such underestimate their use even if they
an experience is, that it happens to you in experience so many times that their use
reality and it can only happen to you causes major problems in their lives, and
when you walk on a path, which leads second, they believe that they can stop
you to a higher level of understanding. whenever they want.
You might be led to that goal by an act of Comparing substance addiction to
Grace or through a personal and honest behavioral addiction, substance addiction
contact with friends, or through a higher looks more harmful than behavioral
education of the mind beyond the addiction. Although substance addiction
confines of mere rationalism. I see from has stronger effects on the human brain
your letter that Roland H. has chosen the than behavioral addiction, behavioral
second way, which was, under the addiction has a big impact on low self-
circumstances, obviously the best one. esteem, depression, anxiety, trauma,
I am strongly convinced that the evil distress, conflict in marriage and family,
principle prevailing in this world, leads poor academic and job performance and
the unrecognized spiritual need into it can even lead to suicide and homicide6.
perdition, if it is not counteracted either
by a real religious insight or by the Common Types of Behavioral
protective wall of human community. An Addiction
ordinary man, not protected by an action
from above and isolated in society cannot Allah ( )says:
resist the power of evil, which is called Say: Not equal are al-Khab'ith (all that
very aptly the Devil. But the use of such is evil and bad as regards things, deeds,
words arouse so many mistakes that one beliefs, people, food, etc.) and al-Tayiiyib
can only keep aloof from them as much (all that is good as regards things, deeds,
as possible.. beliefs, people, food, etc.), even though
You see, Alcohol in Latin is spiritus the abundance of al-Khabith (evil) may
and you use the same word for the please you. So, fear Allah much [(abstain
highest religious experience as well as from all kinds of sins and evil deeds
for the most depraving poison. The which He has forbidden) and love Allah
helpful formula therefore is: spiritus much (perform all kinds of good deeds
contra spiritum11. which He has ordained)], O men of
Another important reason for being understanding in order that you may be
addicted to any behavior is lack of skill successful12.
to cope with life problems. Therefore, There are many types of behavioral
most addicted people use the behavior as addiction: From work to exercise and
an automatic stress reliever. Surely from love to eating, so many behaviors
people show some behaviors to calm have been seen as an addiction. There is
down, feel relaxed and add some even an alphabetic list in some websites
pleasure to their lives. However, when it about types of addiction that name more
becomes the only choice to calm down, than 100 different types of addiction.

However, this kind of categorization than using the Internet. Internet is

received many criticisms with exciting for many people because of its
accusations of creation of false epidemics affordability, accessibility and
and creation of diagnostic inflation. anonymity. It is cheaper than any other
Therefore, a line has to be drawn leisure activity, it can be used anytime
between a personal lifestyle and a regardless of day or night, and people use
psychiatric pathology to understand and it to become or pretend to be who they
work on behavioral addiction, even it want to be. Furthermore, whatever they
might be so difficult. This paper will want (sex, gambling, shopping etc.), they
focus on Internet addiction as the model can have access to it without any
of behavioral addiction, because of three limitations. Therefore, Internet usage has
reasons: increased enormously in the last years all
1. It is impossible to cover all behavioral around the world. From 1980s to the
addiction that are listed in the literature. year 2000, technology, mostly the
2.The most common types of behavioral Internet, was praised and people were
addiction are sub-groups of Internet happy about the change that Internet has
addiction . Moreover, so many people made in their lives. However, after 2000,
become easily addicted to some behavior people have seen some real and
on the Internet and so many behavioral dangerous negative effects of the
addicted people use Internet to feed their Internet, mostly on children. Then
addiction, whatever they are. researches have started studying Internet
3. Internet addiction has spread like use, abuse and addiction. Statistics about
wildfire all around the world regardless Internet addiction can be easily found in
of religion, nationality and education and the literature14-17.
has brought so many devastating results In the following part, prevention of
that have never been seen before. The internet abuse and addiction will be
following examples may give some idea discussed and some possible solutions
about the results: will be offered. However, before the
In 2001, the murder of his own brother prevention part, some short information
by a middle school student, mimicking a about treatment will be given.
scene from an internet online game. In
2005, a person jumped off from a Treatment
building after being forced to exit the
league by the game manager. In 2007, a Since behavioral addiction has been
person learned how to commit murder ignored for so many years, there are only
and conceal the body from computer few specifically designed treatment
games. A middle school student programs for behavioral addiction
murdered his grandmother in 2010, and relative to the vast number of treatment
headed to internet caf without a blink, programs for substance addiction.
after murdering the mother for being Moreover, there is no medication
annoying13. approved by any official authority around
the world for treatment of behavioral
Internet Addiction addiction. However, some researches
show that psychosocial treatment
People use the Internet for a reason or methods, like the twelve steps approach
without any reason. They use it for a and pharmacological treatment, such as
reason like sex, gambling, game, chat, naltrexone, which are used for substance
shopping etc. They use it without any abuse and related disorders works for
reason because they might not have behavioral addiction as well6,18. The best
something better or more exciting to do

way to deal with behavioral addiction is spend their physical energy. For
surely prevention. children and adolescents, they mostly
Because behavioral addiction was mostly sit during the way to their school and
neglected until recent years and hence they sit during the class time for 5 to
there are no sufficient experts, 8 hours and they sit in front of TV or
researches, institutions and treatment their personal computer when they
models. Moreover, completion rate of are home until bedtime. However,
treatment and treatment success for their bodies need to spend energy in
addiction are less than most of the other some way. If they cannot find a
psychopathologies. healthy way to spend their physical
energy, they spend it by visiting
Prevention pornography websites or online sex
sites or playing violent video or
First of all, it is possible to prevent online games. Therefore, regular
people from behaving in a certain way physical activity should be in
as long as the reasons of the behavior are everyones life especially children
understood. For behavioral addiction or and adolescents lives.
Internet addiction 5 possible reasons 3. Expressing himself: Everyone needs
have been seen. to express himself by saying
1. Psychopathology: There is a strong something or doing something.
link between psycho-pathology and Sometimes he needs to express his
addiction. People who have genetic feelings; sometimes he needs to
vulnerability to any addiction can express his thinking. Most people
develop behavioral addiction easier cannot motivate themselves by their
than those who do not have it. On the jobs and therefore they cannot
other hand, people who suffer from express themselves in their works.
any psychopathology can develop Moreover, most people prefer to
behavioral addiction easier than those watch TV, read newspaper or visit
who do not have it. Particularly, websites rather than listen to other
children and adolescents who suffer people. For this reason, if anyone
from Attention Deficit Hyperactivity needs to express himself by saying or
Disorder (ADHD), social anxiety and doing something, it becomes easier to
depression are more vulnerable to find a place or person on the virtual
addiction than their peers19. life than real life. However, no virtual
Therefore, parents and teachers relationship can substitute real life
should be aware of symptoms and needs.
signs of psycho-pathologies and 4. Socializing: Although the world and
should not be reluctant to seek cities have become more crowded
assistance from mental health day-by-day, people become lonelier
professionals if needed. On the other and socially isolated than ever before.
hand, children and adolescents should However, one of the basic needs of
be taught to use Internet with time human beings is socializing. Building
limit and responsibility. a relationship with others, meeting
2. Physical energy: Everyone, in new people, talking, sharing, smiling
particular, children and adolescents etc. is essential for the psychological
need to spend their energy into makeup of humans. Un-fortunately, it
something. Because of the modern is a fact that many people have lived
lifestyle, that was brought by so many years in the same apartment
technology (cars, machines, etc.), house or same neighbourhood but
many people, mainly in cities, cannot never know anything more than

names or sometimes not even the 8.Ashley, Larry & Boehlke, Karmen K. (2013)
Gambling Addiction, Behavioral Addiction, An-Pyng
names of other residents or Sun, Larry Ashley, Lesley Dickson (ed.) Central
neighbours. In recent years, this Recovery Press, U.S.A.
became a reality for families as well. 9.Griffiths, Mark (2013) Gambling and Gaming
Addictions: A Cause for Concern?, 1st International
People have their spouses, children, Congress of Technology Addiction Congress Book,
father or mother but they do not KULT Foundation, Istanbul.
know about each other more than 10. Wallace, J. (1996) Theory of 12 Step Oriented
Treatment. In: Rotgers, F. Keller, D.S. & Morgenstern,
anyone else who follows them on J. (eds.) (1996) Treating Substance Abuse: Theory and
Facebook or Twitter. Therefore, new Findings. London: Guilford Press
ways to build new relationships or 11. Merter, Mustafa (2014) Nefs Psikolojisi, Kakns
Yaynlar, stanbul.
strengthening the existing ones 12.Glorious Quran, Al-Maidah, 5:100
should be created to prevent online 13. Kim, Daijin (2013) Internet Addictions and
socializing. Cognitive Functions in Korea, 1st International
Congress of Technology Addiction Congress Book,
5. Meaning: Most of online users or KULT Foundation, Istanbul.
addictive people use the Internet or 14. Choi Y.H., (2007), Advancement of IT and
any behavior pathologically because seriousness of youth Internet addiction, International
Symposium on the Counseling and Treatment of Youth
they do not have anything better to do Internet Addiction. Seoul, Korea.
than surfing on the net, chatting, 15. Kelleci, M., (2008), nternet, Cep Telefonu,
gambling, playing games or visiting Bilgisayar Oyunlarnn ocuk ve Genlerin Ruh
Salna Etkileri, TAF Preventive Medicine Bulletin,
porn websites. They do not have any 7.
good reason to stop behaving in that 16. Ylmaz, M.B., (2010) lkretim 6. ve 7. Snf
way. They are bored with their lives rencilerinin Bilgisayara Ynelik Bamllk
Gsterme Eilimlerinin Farkl Deikenlere Gre
and want to do something joyful ncelenmesi, Eitim Teknolojileri Aratrmalar
without any effort or risk. Thus, Dergisi, 1.
without meaning in the life or doing 17. Blkba, K., Yldz, M.C., (2003), nternet
Kullanmnda Kadn-Erkek Eitsizlii, IV. Ulusal
something meaningful, there is no Sosyoloji Kongresi, Cumhuriyet niversitesi, Sivas,
reason not to become addicted to Trkiye, 16-18/10/2003.
something. To prevent addiction, a 18.Arsoy, . (2009) nternet Bamll ve
Tedavisinde Gncel Yaklamlar, Current Approaches
number of significant organizations, in Psychiatry, 1:55-67.
works, gatherings should be 19. Din, Mehmet (2014) Internet Addiction: What We
increased and people will learn to Should Know, What We Should Do, Yeilay Yaynlar,
make their lives more meaningful.
stanbul.
Then they will have an answer for the

question why they should not become
addicted to something.
References:
1.Glorious Quran, Al-Baqarah, 2:195

2.Glorious Quran,l Al-Baqarah, 4:29.
3. Ibnu Majah, Hadith #32, Jami Al-Ulum wal-Hikam,
p 207.
4. DAnna, Stefano E. (2004) Tanrlar Okulu, Alteo
Yaynclk, Bursa.
5. Vaillant, G.E. (1982). On defining alcoholism.
British Journal of Addiction, 77, 143-144.
6. Sun, An-Pyng (2013) Historical Background of
Behavioral Addiction and The Trend Today,
Behavioral Addiction, An-Pyng Sun, Larry Ashley,
Lesley Dickson (ed.) Central Recovery Press, U.S.A.
7. Shaffer, Howard J. (2013) What is Addiction: A
Perspective,
http://www.divisiononaddiction.org/html/whatisaddicti
on.htm#ixzz2tZ4di1J0

ADDICTION AND SUBSTANCE ABUSE IN PREGNANCY
Hassan M. Harirah* and Sahar E. Donia
Abstract:
Prevalence of addiction and substance abuse by women of childbearing age has increased
markedly over the past three decades. In the United States, about four percent of women who are
pregnant use some type of illicit drugs. Multiple risk factors exist with maternal addiction and
substance abuse and the risks to the fetus or neonate vary depending on the type of substance
being abused. Prenatal exposure to substances of abuse has been associated with serious harm to
the mother and her fetus, and without intervention, the deleterious effects of these substances
could persist throughout the childs life. Although substance abuse treatment during pregnancy
improves maternal and neonatal outcomes, identifying addiction and substance abuse in
pregnancy can present a significant clinical challenge and often remains under diagnosed. In this
article, we discuss the major categories of drugs/substances that are commonly abused in
pregnancy and evaluate the adverse effects these substances may have in the preconception time
period, during pregnancy, and the postpartum period.
Keywords: Addiction, pregnancy, illicit drugs, tobacco, marijuana, alcohol, opioids, cocaine,
and amphetamines, barbiturates, benzodiazepines.
Introduction:
The prevalence of addiction and substance effects of these substances could persist
abuse by women of childbearing age has throughout a childs life. Elucidating the
increased markedly over the past three individual effects of in-utero exposure to
decades1. In the United States, about four substances of abuse during pregnancy is
percent of women who are pregnant use some complicated by multidrug use, including
type of illicit drugs, like cocaine or marijuana. alcohol and tobacco. Evidently, substance
Many more abuse legal intoxicating abuse during pregnancy has been associated
substances prior to the birth of the baby, such with low birth weight, preterm birth, smaller
as alcohol or tobacco. A recent self-reporting head circumference, shorter birth length, poor
survey by the National Survey on Drug Use neuro-developmental outcomes, and lower
and Health (NSDUH) from 20022010 Apgar scores3-6. Such poor neonatal outcomes
reported a substantial increase in substance also lead to increased health care costs for the
abuse among pregnant women. The rates in neonate and mother7. In addition, an increased
2010 were 16.2%, 7.4%, and 1.9% in women incidence of developmental, conduct, and
aged 15-17, 18-25, and 26-44 respectively2. attention deficit disorders, and predisposition
Prenatal exposure to substances of abuse has to use drugs in the offspring has been
been associated with serious harm to the fetus, documentted8,9.
and without intervention, the deleterious
*Hassan M. Harirah, MD, FRCSC,
University of Texas Medical Branch
301 University Boulevard, Galveston, TX 77555 - USA

ADDICTION IN PREGNANCY
Multiple risk factors are associated with regarding the management of high risk
maternal addiction and substance abuse pregnancies in substance abusing mothers.
including young age, low socioeconomic These guidelines primarily address the
status, lack of prenatal care, history of psycho- identification and management of teratogenic
logical or psychotic illness, history of neglect, exposure, poor maternal nutrition, intra-uterine
history of sexual or physical abuse, peer growth restriction (IUGR), placental insuff-
pressure, easy access, and lack of knowledge iciency, labor management, and maternal/
of the adverse effects abuse substances have neonatal withdrawal symptoms.
on fetal development10.
Risks to the fetus or neonate vary depending TOBACCO:
on the type of substance being abused which
can include preterm delivery, low birth weight, Active and passive tobacco smoking presents
birth defects, conditions such as fetal alcohol major risks to human health. Smoking
syndrome, mental retardation, neonatal contributes to the development of various
seizures secondary to substance withdrawal, human cancers, respiratory illnesses, and other
and very often death due to premature diseases. In the United States, tobacco
delivery. Substance abuse treatment during smoking is the leading preventable cause of
pregnancy improves maternal and neonatal death and each year 480,000 deaths (one out of
outcomes11,12. Although pregnancy can be a five) are caused by tobacco-related diseases1.
motivating factor for entering substance abuse Among child-bearing age women, there is an
treatment, pregnant women face barriers both increased prevalence of smoking particularly
to treatment initiation and completion13. in the youngest population.2In addition, the
Identifying addiction and substance abuse in lower the level of education achieved, the
pregnancy can present a significant clinical greater the risk of being a current smoker14.
challenge and often remains under diagnosed3. Tobacco users also have shown an increased
Pregnant women may be less likely to enter risk for infertility and dysmenorrhea15.
substance abuse treatment due to fear of losing Therefore, every effort should be made to
custody of their children, prosecution, identify smokers prior to pregnancy and
alienation from society or lack of child care, provide intervention to enhance the likelihood
insurance, or economic means. of smoking cessation. Pregnancy can be also a
Similarly, despite the benefits of treatment significant motivator to stop or reduce
during pregnancy, pregnant women may be at smoking. The most recent available statistics
a higher risk of attrition compared with the on tobacco use in pregnancy report that 16.4%
general population. Similarly, certain factors of pregnant women continue to smoke during
among pregnant women have been associated their pregnancy2. The prevalence of tobacco
with an even lower likelihood of treatment smoking in pregnant women differs between
completion, including age, race, peer deviance, racial and ethnic groups; 19.8% in African
lack of employment, and prior experiences Americans, 24.4% in Caucasians, and 5.8% in
with child protection services11. Hispanics16. Tobacco is associated with a
The goal of this article is to identify the major higher rate of adverse maternal and fetal
categories of drugs /substances that are outcomes and has a clearly demons-trated
commonly abused in pregnancy and evaluate dose-response relationship10. In the first
the adverse effects these substances may have trimester, these risks include an 2-5 fold
during the preconception time period, increased risk of spontaneous abortion and an
pregnancy, and the postpartum period. In 1.5-2.5 fold increased risk of ectopic
addition, we will review general guidelines pregnancy. In the second and third trimesters,

there is an increased risk of placental reinforcement of the patients desire to quit

insufficiency, low birth weight, fetal growth smoking21.
restriction, and preterm delivery (1.2 to 16
folds)15. When tobacco is smoked, a mixture MARIJUANA:
more than 4,000 chemicals are produced and at
least 43 of these chemicals are known Marijuana, also known as cannabis, refers to
carcinogens17. preparations of the Cannabis plant intended for
Nicotine is principally responsible for the use as a psychoactive drug and as a medicine.
addiction to tobacco as a result of the Marijuana is the most commonly used illicit
interaction between the compound and drug among women of reproductive age, and
nicotinic acetylcholine receptors (nAChRs). during pregnancy and lactation22, 23. Like all
This interaction activates the reward centers in substances of abuse, the actual rate of
the central nervous system. Nicotine receptors marijuana use and the statistics cited depend
are distributed in many areas of the brain.18 on voluntary reporting. In the United States,
Nicotine readily crosses the placenta, it can 4.6 % of African American, 3.0% of White,
reach concentrations in fetal blood and and 1.5% of Hispanic women admit to
amniotic fluid that are much higher than marijuana use in pregnancy58, and the number
maternal plasma levels, exposing the fetus to of women 26 year or older who recently
toxic effects19. Women who smoke are more initiated marijuana use has increased
likely to have a low birth weight baby. Infants significantly from 18,000 to 106,000 between
born to women who smoke during pregnancy years 2002 to 20102.
are 200 to 300 grams lighter15. Furthermore, Tetrahydrocannabinol (THC), is the major
nicotine causes impaired fetal oxygen delivery, psychoactive ingredient of marijuana. It binds
resulting in abnormal gas exchange within the to cannabinoid (CB) receptors, widely
placenta and activation of the sympathetic distributed throughout the nervous system, and
nervous system, increasing the fetal heart rate other parts of the body. In the brain, CB
and causing a reduction in fetal breathing receptors are found in high concentrations in
movements20. Carbon monoxide is a major by- areas that influence pleasure, memory,
product of cigarette smoking that can cause thought, concentration, sensory and time
harm to the mother and fetus. Carbon perception, appetite, pain, and movement
monoxide crosses the placenta and can be coordination. THC is known to pass from the
detected in the fetal circulation at a level 15% mother to the developing fetus through the
higher than in the maternal circulation21. placenta. In animal research, THC exposure
Carbon monoxide diminishes tissue pre- or perinatally, and even during
oxygenation via competitive inhibition with adolescence can alter brain development,
oxyhemoglobin, causing decreased availability particularly in areas related to mood, reward,
of oxygen to the fetus19. Approximately half of and executive function. Therefore, the fetus is
women who quit smoking during pregnancy affected by any amount of cannabis taken by
resume smoking within 6 months postpartum the pregnant woman, placing it at a greater risk
and 50% to 90% have relapsed 1 year post- of complications24.
delivery. Smoking during the postpartum The effects of marijuana use on the developing
period causes a significant health risk for both fetus in the preconception period and
mother and child. To date, there are no proven pregnancy are hard to establish because users
effective strategies for preventing relapse of marijuana will frequently use other illicit
during the postpartum period. However, close drugs while pregnant, making it difficult to
follow-up, and continued counseling help in separate marijuanas effects from the effects of

other drugs. Although THC is the active study found that marijuana-exposed children
ingredient in marijuana, over 400 compounds have smaller head circumferences at birth,
have been identified in marijuana and it is which increase in disparity in adolescence34.
difficult to separate out the effects of these Marijuana use in the postpartum period has not
chemicals. Studies have determined that the been well studied and there is limited clinical
CB1 receptor is present in all layers of human evidence to derive recommendations regarding
placental membranes and that stimulation of counseling, intervention, or rehabilitation.
these receptors impairs fetal growth by However, social work consultations should be
inhibiting cytotrophoblastic proliferation25, 26. used liberally in an attempt to stabilize the
To date, there is no known association home environment as much as possible.
between marijuana exposure and spontaneous
abortions27. However, in a large population- ALCOHOL:
based prospective cohort study, maternal
marijuana use was associated with fetal growth According to the 2010 National Survey on
restriction.28 Therefore, pregnant women who Drug Abuse, 18.8% of pregnant women aged
are known to use marijuana during pregnancy 15 to 44 reported current alcohol use2. The
should be counseled about the associated risks prevalence of alcohol use in pregnant women
and encouraged to abstain of using marijuana varies between racial and ethnic groups, 15.8%
and other substances of abuse during among African Americans, 22.7 % among
pregnancy. Obstetric care should include Whites, and 8.7% among Hispanics16. Of
follow-up ultrasounds at 28 and 36 weeks to these, 3.7% reported binge drinking, which is
confirm adequacy of fetal growth. defined by the National Institute for Drug
Although some animal studies indicate that Abuse (NIDA) as a pattern of alcohol
marijuana may be teratogenic in very high consumption that brings the blood alcohol
doses, there is no firm link between maternal concentration to 0.08% or higher. This number
use of marijuana and congenital malformations has remained relatively unchanged over the
in humans above the background risk of 3%. last 15 years according to a longitudinal study
Reports of associations between marijuana use of data collected from the Behavioral Risk
in pregnancy and gastroschisis remain unsub- Factor Surveillance System between 1991 and
stantiated.29 However, a study of almost 200535. Alcohol is a protoplasmic poison with
420,000 Australian live births over a 5-year a narcotic-like effect on the CNS. Alcohol
period found that in utero marijuana exposure consumed in excessive quantities frequently
increased the risk of neonatal intensive care causes poisoning because it rapidly enters the
unit admissions, predominantly due to bloodstream, which carries it to all bodily
prematurity, but there was no relation to any organs. Long-term consumption of excessive
increased risk of perinatal death30. amounts of alcohol leads to fatty liver disease
Of greater concern, however, is the increasing and cirrhosis of the liver, chronic
evidence that in utero marijuana exposure may inflammation of the gastrointestinal tract,
impair long-term growth and neurodevelop- damage to the gonads and CNS impairment.
ment, particularly in terms of cognition and Alcohol is a well-studied teratogen, and its
behavior. Evidence from population-based effects on pregnancy can include spontaneous
human studies and in vitro animal data indic- abortion, fetal growth restriction, and birth
ates that interference with the endocanna- defects. The incidence of alcohol use in non-
binoid system disrupts normal neurobiological pregnant women ages 15 to 44 years is 53%. It
development, neurotransmitter maturation, and is estimated that as many as 24% of young
neuronal survival3133. A longitudinal cohort women who drink are binge drinking36.

Oftentimes, conception occurs during times of ranging from 0.2 to 1.5 per 1,000 live births in
alcohol use or abuse and women continue different areas of the United States. This
drinking, unaware of their pregnancy, into the makes alcohol abuse and misuse in pregnancy
first trimester where all fetal organ systems the most common non-genetic cause of mental
can be affected at this early stage of retardation. Little data exist regarding the
development. Therefore, the preconception postpartum period and alcohol use. There is a
period is an important time to identify women reported increased risk of sudden infant death
at risk37. In the preconception period, each syndrome and post-partum depression in
encounter with patients can be an opportunity women who drink alcohol39. As we become
to screen for alcohol use or abuse and more aware of the importance of identifying
intervene to reduce or completely stop alcohol women at risk for postpartum depression, it
consumption. There are several screening tools may be prudent to include those mothers who
available. Questions to ask are detailed in are identified as using alcohol during their
mnemonics such as Take, annoyed, cut down, pregnancy as a potential focus. The
eye opener (T-ACE) 36. The United States postpartum visit may be a good time to screen
Preventative Services Task Force, the women for alcohol abuse. The Healthy Moms
American College of Obstetrics and Trial supports the implementation of brief
Gynecology, and the American Academy of alcohol intervention during the postpartum
Pediatrics suggest using preconception and period40.
prenatal visits to discuss the benefits of
abstaining from alcohol. There are no OPIOIDS:
evidence-based studies to suggest any amount
of alcohol use that is safe during pregnancy. The term opioids refers to natural, semi-
During pregnancy, the fetus that is exposed to synthetic, and synthetic alkaloid derivatives
alcohol can be severely affected by fetal either prepared from opium or synthesized
alcohol spectrum disorder (FASD). The substances possessing morphine like activity.
alcohol level in fetal blood reaches the same Opioids can produce a feeling of euphoria, and
level as it does in the mother and fetal liver this effect, coupled with physical dependence,
cannot process alcohol as efficiently as the can lead to recreational use of opioids by many
mother's liver. Therefore, women who drink individuals. The analgesic effects of opioids
alcohol during pregnancy subject their fetuses are due to a decreased perception of pain,
to a significant risk. There is strong medical decreased reaction to pain as well as increased
evidence to suggest that heavy alcohol use or pain tolerance. The most common opioids are
binge drinking can lead to high rates of FASD. heroin, morphine, codeine, oxycodone,
However, studies show that even small hydrocodone, and methadone. Heroin and
amounts of alcohol used on a daily basis can methadone are the most commonly used
be detrimental to the fetus38. FASD opioids by pregnant women.
encompasses a wide range of disorders defined Most of the information available regarding
as prenatal and postnatal growth restriction, the effects of opioids is derived from studies of
central nervous system abnormalities, and patients who have used heroin or methadone.
craniofacial abnormalities. The prevalence of opioids use in child-bearing
Some common fetal abnormalities associated age women ranges from 1% to 21%14. The
with alcohol abuse include facial dysmorpho- higher number reflects use in at-risk
genesis, cardiac septal defects, and joint populations and does not represent overall use
abnormalities. Centers for Disease Control and in obstetric population. Recently, there has
Prevention (CDC) studies show FASD rates been a drastic rise in the use of prescription

opioid analgesics, such hydromorphone and dependent mothers4648. Because of the

oxycodone.41 Although there is a paucity of increased risks of stillbirth, growth restriction,
data specifically focusing on the pregnant and preterm birth, increased fetal surveillance
population, data from substance abuse and serial growth evaluations are
49
literature suggest that women with prescription recommended .
opioid dependence are initiating use on Neonatal abstinence syndrome (NAS) is the
average at 26 years of age, coinciding with a most consistent outcome in neonates born to
womans peak reproductive years42. The extent mothers with opioid addiction. The incidence
of maternal risk is greatly dependent upon the of NAS is quite variable, ranging from 55% to
predominance of intravenous injection as a 94%50. NAS is the constellation of withdrawal
route of opioids administration43. Aside from signs in the neonate including seizures,
acute overdose, which carries a clear health breathing problems, tremors and irritability,
risk, intravenous injection carries an inherent difficulty of feeding, and dehydration. Many
infectious risk, most specifically transmission of affected neonates are hospitalized for
of hepatitis B (HBV), hepatitis C virus (HCV), several weeks with methadone or morphine
and human immunodeficiency virus (HIV), treatment to gradually wean them from their
each of which is associated with long-term dependence on the drugs that their mothers
health concerns for the mother. There is also a used47. Multiple regimens have been proposed
higher rate of reported unplanned pregnancies to treat NAS, however, the American
(70% in women with significant illicit drug Academy of Pediatrics (AAP) recommends
history compared with 34.8% in women tincture of opium for replacement
without drug dependency) 44. 51
medication . There are preliminary promising
Heroin is the most commonly abused illicit data with the use of buprenorphine as a
opioid. It crosses the placenta readily and treatment for NAS.52
enters fetal tissues within 1 hour of maternal Opioid analgesics such as oxycodone and
use. Women who use heroin are likely to use hydromorphone can be judiciously used in
other harmful substances, such as tobacco, pregnancy with close supervision but are much
alcohol, and cocaine, all of which have their more commonly used in the post-partum
own potential adverse effects on pregnancy. period for post-delivery pain control. No
Therefore, it is difficult to separate the effects congenital anomalies have been reported in
of heroin from these other substances45. babies born to mothers who used oxycodone
Pregnant women who use heroin experience a or hydromorphone for prolonged periods45.
six-fold increase in maternal obstetric However, the use of both substances increases
complications including intrauterine growth the risk of neonatal withdrawal, particularly if
restriction, third trimester vaginal bleeding, they are used in and around the time of
preterm delivery, and puerperal morbidity. In delivery.
addition, stillbirth, depressed Apgar score, Prenatal and antepartum care for a pregnant
meconium staining of the amniotic fluid, and woman using opioids must be tailored to her
chorioamnionits are all increased in heroin special needs.
users4648. The developing fetus and neonate Testing for sexually transmitted infections,
also share undue burdens when exposed to such as HIV, hepatitis B and C, syphilis,
opioids during pregnancy. Rates of preterm gonorrhea, and chlamydia should be included
delivery, very low birth weight (11.499 kg), in routine care. Pregnant women need to be
low birth weight (1.52.499 kg), and stillbirth counseled regarding the effects of opioids on
have all been shown to be significantly themselves and their fetuses, and the benefits
increased among neonates born to opioid- of methadone maintenance compared to

continued opioids' use. Pregnant women taking dopamine. The norepinephrine effects lead to
methadone demonstrate reduced use of illicit hyper-tension, tachycardia, and possible arrhy-
drugs, better compliance with prenatal care, thmias. Within 2 minutes of cocaine use,
and improved newborn birth weight53. systolic blood pressure rises 25mm Hg and
Opioids are excreted into breast milk in small heart rate increases 20 beats/min55. The
quantities and minimal, if any, effect on the dopaminergic effects on the limbic system and
newborn is clinically significant. However, the cerebral cortex lead to the high or euphoria
neonate should be observed for signs of experienced with cocaine use56. Other effects
adverse effects, such as gastrointestinal side of acute cocaine use include coronary
effects, sedation, and feeding pattern changes. vasospasm, possible ischemia after reduced
For heavy narcotic abusers and women in cardiac oxygen delivery, platelet activation,
methadone treatment, the postpartum period is increased platelet aggregation, and alteration
an excellent time to address the possibility of of the thromboxane production leading to an
gradual narcotic withdrawal and continued increased risk of thrombosis. These effects
rehabilitation. could place a pregnant woman at an increased
risk for adverse outcomes5759.
COCAINE: Prenatal cocaine use is associated with poor
fetal and birth outcomes. Cocaine rapidly
Cocaine is a crystalline tropane alkaloid that is crosses the placenta and a higher concentration
obtained from the leaves of erythroxylon coca occurs in the fetus.
L plant54. Its use as a recreational drug Intrauterine growth restriction, low birth
skyrocketed in the last century. The commonly weight, and decreased head circumference are
used form, crack, is almost pure cocaine all noted to be increased in neonates of
formed through cooking the cocaine rocks mothers who use cocaine in pregnancy.
with water and sodium bicarbonate, producing Cocaine abuse is frequently associated with
the alkalinized form of cocaine. This form, inadequate prenatal care and concomitant use
known as crack from the characteristic noise of tobacco and alcohol60. Moreover, cocaine
made during the cooking process, is the most abuse is associated with psychosocial,
addictive form. In 2010, there were over 1.5 behavioral, and biomedical risk factors, such
million current users of cocaine2. It is difficult as poverty, poor nutrition, stress, depression,
to discern the true prevalence of cocaine use physical abuse, lack of social support, and
during pregnancy due to the large variations sexually transmitted infections, all of which
that exist by reporting method. However, in a can greatly affect pregnancy outcome61.
large national survey conducted by National As with any other substance, cocaine exposure
institute of Drug addiction (NIDA) in 1995 during the first trimester can affect embryonic
utilized the self-report method and found that and fetal development. An increased risk of
the prevalence of cocaine abuse in pregnant congenital anomalies especially of the brain
women was 4.5% among African Americans, and the cardiovascular system has been
0.4% among Whites, and 0.7% among reported62.
Hispanics16. Regardless of the form, cocaine is Owing to the significant vasoconstriction
absorbed quickly. Once absorbed, the effects, cocaine users experience a significant
physiological hallmark of cocaine is profound increase in first trimester spontaneous abortion
vasoconstriction, through its sympathomimetic and up to 38% of early pregnancies may result
properties. Cocaine blocks the presynaptic in miscarriage in cocaine-abusing mothers60.
reuptake of the sympathomimetic neuro- This increase in incidence of spontaneous
transmitter norepi-nephrine, serotonin, and abortion is probably secondary to an increase

in maternal plasma norepinephrine, which serious public health concern. The latest data
increases uterine contractility, constricts from the U.S. National Survey on Drug Use
placental vessels, and decreases blood flow to and Health (NSDUH), an ongoing national
the fetus. probability survey, estimates that 5.8% of
Cocaine use during pregnancy is associated persons ages 12 and older (approximately 14.2
with increased risk of premature preterm million people) used methamphetamine at
rupture of membranes, preterm labor, and least once in their lifetime64. Information about
preterm delivery. Cocaine stimulates uterine the prevalence of methamphetamine use
contractility through -agonist action on the during pregnancy varies widely. The
2-receptors of the uterus. Placental abruption magnitude of the methamphetamine problem
accounts for 2% to 15% of adverse effects of comes from the Treatment Episode Dataset
cocaine use during pregnancy. Abruption is (TEDS), which indicated that methampheta-
thought to be caused by vasospasm and mine abuse has more than doubled between
hypoxia of the placental bed. As a result of 2008 and 2012, from 3.7 to 9.2%2.
maternal cocaine use and placental abruption, The effects of amphetamine abuse in the
the incidence of stillbirth in cocaine-abusing preconception period are difficult to establish
mothers is elevated 8% above the expected because amphetamines abusers commonly use
level when compared to the general other illicit drugs while pregnant, making it
population60. difficult to separate the effects of
Cocaine abuse during pregnancy is considered amphetamines from those of other illicit drugs.
a significant risk factor for infant neglect and As with virtually all other drugs of abuse,
abuse in the post-partum period, and this often amphetamine use is often associated with risky
results in the removal of the infant from sexual behaviors, teenage pregnancy, and
maternal custody in the first 18 months of life. potential increased risk of sexually transmitted
Prospective studies indicated a strong link infections65.
between cocaine-using mothers and child Animal studies showed that in utero metham-
maltreatment, with high rates of care-giving phetamine exposure can have a negative
disruption (43%) and child maltreatment by 2 influence on the neurodevelopment of
years (9% to 23%)63. offspring, an increased risk of cleft palate,
retinal defects, delayed physical growth and
AMPHETAMINES: motor development68, 69. Human studies found
also that prenatally exposed infants to
The amphetamine like substances including methamphetamine exhibit poor alertness and
amphetamine and methamphe-tamine are feeding, low birth weight, cleft lip, ambiguous
powerful CNS stimulants with a profound genitalia, anencephaly, and gastroschisis7870.
ability to increase wakefulness and focus. The Other studies have not shown any association
principal mechanism of action is increased with increased risk of fetal malformation
release of norepine-phrine, serotonin, and above the background 3% population risk68.
dopamine from neurons within the brain. At Preclinical studies have shown that
the same time, amphetamines inhibit re-uptake methamphetamine to be neurotoxic to dopami-
of these neurotransmitters. Amphetamines are nergic and serotonergic neurons through the
commonly used as drugs of abuse, particularly production of reactive oxygen species
methamphetamine (also known as resulting in cell death and mitochondrial
crystalmeth). dysfunction71. Studies on prenatal exposure to
Methamphetamines abuse in the U.S. and in methamphetamine showed altered neuroco-
other regions of the world remains a very gnitive perform-ance in that methamphetamine

exposed children had lower verbal memory, barbiturates use in pregnancy suggests that
long-term spatial memory, sustained attention there is no increased risk of fetal malformation
and visual motor integration72. However, a noted above expected levels of occurrence.
recent study showed that children exposed However, neonatal withdrawal is a critical
prenatally to methamphetamine have poorer consideration if the mother is a heavy
gross motor and psychomotor performance barbiturates abuser, particularly close to the
scores at 2 years of age compared to non- time of delivery45.
exposed children, but there was no effect on Benzodiazepine use in the preconception time
cognitive and fine motor performance scores73. period is not uncommon and frequently
Fetal growth restriction has also been prescribed for the treatment of anxiety.
associated with amphetamine use in Benzodiazepines are also frequently prescribed
pregnancy. It is unclear if this is related to a during pregnancy and approximately 3% of all
direct effect of the agent on the placenta or pregnant women use this type of medication76.
fetus or whether this represents a nutritional Benzodiazepines are generally category D
problem in patients due to the anorectic effect drugs, reflecting positive evidence of fetal risk.
of amphetamines68. However, there is conflicting evidence
Information about the use of amphetamines in regarding the teratogenicity of benzodia-
the postpartum period is scant, but abuse of zepines, with the suggestion of an increased
amphetamines during lactation is considered likelihood of multiple anomalies, including
possibly hazardous. Neonatal withdrawal has cleft lip and palate, fetal growth restriction,
been described, including jitteriness, drowsi- and intrauterine fetal death. However, there is
ness, and respiratory distress74. no study or meta-analysis that has been able to
Maternal methamphetamine use may have definitively link benzodiazepine abuse with a
long-term detrimental effects on exposed specific neonatal syndrome or constellation of
fetuses, and exposure may result in future anomalies.
learning and memory impair-ments75. Exposure to benzodiazepines during the last
trimester of pregnancy increases the risk for
SEDATIVE-HYPNOTICS development of the floppy infant syndrome.
AND ANXIOLYTICS: Since the floppy infant syndrome can cause
severe morbidity, prescription of benzodia-
Barbiturates and benzodiazepines belong to a zepines in the last trimester of pregnancy is not
larger category of medications; sedative- recommended77.
hypnotics and anxiolytics, which are
frequently abused. MANAGEMENT OF PREGNANCIES
Of the barbiturates, butalbital is an active IN SUBSTANCE
agent in many medications to treat migraines. ABUSING MOTHERS:
Since migraines are more common in
reproductive age women, many women General considerations:
conceive while using butalbital containing Pregnancy in a substance-abusing mother is
medications. Due to the severity of migraine considered high-risk and is associated with
and headache during pregnancy, these drugs significant maternal and fetal complications.
continue to be appealing to many pregnant Teratogenicity, poor maternal nutrition, IUGR,
women and they continue using them in poor placental perfusion and function, and
pregnancy. Butalbital is a category C drug and withdrawal syndromes are the most common
it should only be used if the benefits outweigh obstetric issues that must be addressed. In the
the risks. Review of literature about safety of case of cocaine abuse, placental abruption and

stillbirth are important additional considera- placental function is an important component

tions. of care for substance -abusing mothers.
Recommendations involve serial uterine fund-
Teratogenic Exposure: al height measurements and ultrasound
evaluation of the fetus with attention paid to
The possibility of substances of abuse causing fetal head circumference and biparietal
fetal anomalies is an overriding concern. diameter, abdominal circumference, amniotic
Genetic counseling, particularly in the fluid indices, and Doppler velocimetry. Serial
preconception period, about the potential ultrasound surveillance typically begins at
teratogenic effects of the abused substances is approximately 24 weeks of gestation and
very helpful to the expectant mother so she continues at 4-week intervals thereafter. Fetal
may abstain from using these substances. wellbeing testing primarily by non-stress
Ultrasound identification of structural testing and the biophysical profile can be used
anomalies and addressing them by consulting depending on the clinical situation. They are
various pediatric specialists for post-delivery typically performed in the beginning of the
management will optimize neonatal and infant third trimester. Timing of delivery can be a
outcomes. Serial ultrasonographic surveillance challenge in the growth-restricted fetus. The
for fetal growth and frequent fetal well-being risks of prematurity must be weighed against
testing will help in monitoring fetal growth the risk of intrauterine fetal death due to
and delivery planning. placental insufficiency. In general, signi-
ficantly abnormal umbilical artery Doppler
Nutritional considerations: velocimetry is usually an indication for
delivery. Complete absence of fetal growth
Poor maternal nutritional status is often observed in consecutive ultrasound evaluations
associated with many substances of abuse as may also provide a strong indication for
many of these substances suppress maternal delivery.
appetite.
A multi-disciplinary approach incorporating Labor management:
nutritional counseling by trained dieticians can
certainly be valuable. Frequent maternal Management of the substance-abusing patient
weight checks and fetal interval growth in labor can present significant challenges to
surveillance should be in the routine obstetric the obstetrical team. As a general rule, the
care for substance abusing mothers. Nutrition labor and management of the substance-
counseling should focus on a well-balanced abusing patient should be based on widely
diet, adequate caloric intake (25 to 35 kcal/day accepted obstetric practice and recommenda-
of optimal body weight) prenatal vitamins, tions. Establishing healthy and non-threatening
folic acid and minerals supplementation. Iron communication with a substance-abusing
deficiency anemia is a common problem in the mother in labor is a paramount goal for
substance abusing population, and an obstetrical caregivers.
additional 60 to 120 mg of iron is Regional analgesia is the preferred method to
recommended 78. control pain during labor. However, each
Intrauterine growth restriction particular substance of abuse brings its own
and placental insufficiency: challenges. Anesthesia consultation and pre-
operative evaluation should be obtained to
Because of the high correlation between determine the safest and most appropriate
substance abuse and intrauterine fetal growth method for pain management during labor and
restriction, surveillance for fetal growth and

delivery especially if cesarean section is neurodevelopmental outcome in 1-month-old infants.

Pediatrics 2002; 110: 118292.
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MOBILIZATION OF THE PUBLIC AGAINST ADDICTION:
THE TURKISH GREEN CRESCENT SOCIETY AS A MODEL INSTITUTION
M.Ihsan Karaman*
Abstract:
In this article, a general framework on the addiction problem is analyzed by focusing on the
works of the Turkish Green Crescent Society. A brief comment on the industries behind
alcohol, tobacco, and drugs is given to understand the background of the problem. As a model
institution, the history, organizational structure, vision, objectives, and activities of the
Turkish Green Crescent Society are summarized in the article. Examples of prevention
practices, educational, advocacy and international programs are presented in the tactics for the
mobilization of the public against addictions. Then the psychological drive behind being
addicted and especially the threat of spread among young generation is presented giving
special attention to peer effect phenomenon.
Keywords: addiction, public awareness, prevention, advocacy, Turkey, Green Crescent

Society
Introduction:
As the President of the Turkish Green history, vision, objectives and activities of
Crescent Society, and the Chairman of the the Green Crescent Society; including the
Addiction Working Group in the Federation tactics for the mobilization of the public
of Islamic Medical associations (FIMA), I against addiction. It is important that we
would like to start this article by giving a realize and accept that Addiction is a type of
general framework of the problem of slavery! We, representing humanity, have to
addiction. Then, I will summarize the be against all kinds of addiction!
Background of the Problem
One of the ways to prevent the evils of instruments that we can use is to conduct
addiction is to fight through scientific serious scientific studies on how the
methods against the power groups that problems emerge and spread, to follow up
promote it. We are aware of the fact that the with this scientific data and share them with
addiction industry reaches out, and intends to the public and authorities, to research on the
reach out even further, to our people and our ways of fighting against addiction and how
youth, legally and illegally, through various they can be applied through national as well
ways and means that continue to change and as international scientific meetings and
develop day by day. It is apparent that our forums. The problems related to addiction do
efforts in trying to stop them by using not only derive from our own social,
ordinary slogans and methods gets more and administrational and moral structure, but are
more difficult. For this reason, the best open to the influence of a broader spectrum.
*Professor Dr. M.Ihsan Karaman
President, Turkish Green Crescent Society
Professor of Urology, Istanbul Medeniyet University, Medical Faculty
Istanbul, Turkey

THE TURKISH GREEN CRESCENT
Today, through the tools of mass basis. Between the ages 15 and 29, 320.000
communication and the tools and carriers of individuals lose their lives because of alcohol
the global culture, a structure with an related reasons every year in the world. This
expanding influence has emerged in our number corresponds to 9% of deaths in this
society as in the rest of the world. The Green age group1.
Crescent Society cares about the worlds way Apart from being addictive, alcohol is a
of fighting against this experience that it is public health problem known as the reason
going through, and about the scientific for 60 different diseases and conditions,
knowledge accumulated in this field. It is injuries, mental and behavioral disorders
necessary to transfer this knowledge into including digestive system diseases, cancers,
healthy channels by making use of local cardiovascular diseases, immunity disorders,
dynamics as well. We are initiating a more lung diseases, musculoskeletal diseases,
active process in the international arena, with gonadal dysfunction, preterm births, and
the hope and aim that the whole world will low birth weight2 .
act upon conscience. Another important addictive substance is
Just as the evil does not emerge only from tobacco. According to World Health Organi-
our own internal structure, the solution is not zation (WHO), Tobacco kills nearly 6
a process that we can handle on our own, million people each year. More than five
either. We want to speed up the activities million of those deaths are the result of direct
carried out in coordination with other tobacco use while more than 600,000 are the
organizations working in this field through- result of non-smokers being exposed to
out the world, in the name of our goal to second-hand smoke. Nearly 80% of the more
prevent the evil and addiction before it even than one billion smokers worldwide live in
starts. We believe that there is a lot to do, low- and middle-income countries, where the
especially in the countries where addiction burden of tobacco-related illness and death is
and the production of addictive substances heaviest. More than 50 illnesses and health
are widespread. For this purpose, the Green problems are caused by the direct and
Crescent Society, with its experience of indirect effects of cigarettes. Tobacco caused
almost a century, will remain determined to 100 million deaths in the 20th century. If
carry its knowledge and efforts to the interna- current trends continue, it may cause one
tional arena, and to mobilize the collective billion deaths in the 21st century3. In addition
conscience of humanity in the fight against to alcohol and tobacco, illicit drugs are also
addiction. one of the most serious problems threatening
our future generations. Recent estimates
Addiction Industry: prove that in 2008, 155 to 250 million
people, or 3.5% to 5.7% of the world's popul-
It is a well known fact that drugs, tobacco, ation aged 15-64, used psychoactive subst-
and alcohol are the primary addictive ances, such as cannabis, amphetamines,
substances in the world. They cause millions cocaine, opioids, and non-prescribed
of deaths every year. Of the producers of psychoactive prescription medication.
these substances, at least two of them, Globally, cannabis is the most commonly
namely, the tobacco and alcohol industries used (129-190 million people), followed by
are acknowledged as legal industries which amphetamine type stimulants, then cocaine
are subject to international trade rules. When and opioids. The use of psychoactive
we look at this issue from the public health substances causes significant health and
perspective, alcohol consumption results in social problems for the people who use them,
2.5 million deaths each year and it is one of and also for others in their families and
three primary public health problems of the communities4.
world. Alcohol is the third leading reason of Both alcohol and tobacco industries use
preventable deaths and injuries on a global similar tactics to resist public health policies.

They are very actively lobbying politicians, society status is given by the Turkish
mobilizing farmers, retailers and advertising government to the organizations that provide
agencies to influence public health legisla- public benefits7. The Green Crescent Society
tion. They challenge laws and buy friends is an independent, non-profit and non-
from sports and cultural groups, and under- governmental organization that acts accord-
mine control policies5. In addition to these ing to rules of the Ministry of Interior
legal deadly industries, there is also an illicit Department of Associations. The General
drug industry with a massive market. Annual Assembly of the Green Crescent is the
value of the illicit drugs in the world is highest and most authoritative decision-
estimated at US$320 billion. This industry is making body of the Society. The members of
to a large extent outside the governmental the Executive Board and the President are
controls. In addition to the significant elected triennially by the delegates in the
harmful health effects of the drugs they Assembly. The delegates of the General
market, this industry is a major contributor to Assembly are elected by the branches and the
crime, violence and corruption6.6From the headquarters of the Green Crescent from
information above, it can be deduced that among the Green Crescent members. The
addiction is not only a psychological issue General Executive Board is composed of
affecting individuals, but it is also a major thirteen administrative board members and
problem that is caused by interacting social, seven auditing members. The Green Crescent
economic and political factors. To protect Branches have their own General Assemblies
humanity from the damages of the addiction and Executive Boards. The Headquarters and
industry, public health community and civil Branches are governed according to rules of
society should cooperate in the struggle the Green Crescent Constitution. The Green
against this huge industry and power groups. Crescent has 37 branches and 101
representation offices in different provinces
THE TURKISH GREEN CRESCENT of Turkey and has 30 thousands members
SOCIETY: across the country8. Apart from employees in
History and the Organizational Structure: the headquarters and branches, the members
in General Assembly and Executive Boards
The Turkish Green Crescent Society was take part in the struggle voluntarily and this
founded with the initial name Hilal-i make the Green Crescent a voluntary move-
Akhdar on 5 March 1920 at the end of the ment. There are two commissions within the
First World War in Istanbul. The society was Society consisting of Green Crescent
founded by patriotic intellectuals in 1920 as members and volunteers. The first one is the
a response to the British attempts to Green Crescent Youth Commission which
distribute alcohol and drugs free of charge in involves hundreds of young people, mostly
Istanbul in order to undermine the resistance university students. Universities are the
against the occupation. The founders sensed primary working field of the Young Comm-
the upcoming dangers of alcohol and drug ission and they work within a partnership
addiction that would result in decline of the with the Green Crescent Youth Clubs in the
resistance against the occupation. The universities. There are 11 Green Crescent
patriotic intellectuals established the Green University clubs in Turkey. The clubs play
Crescent, Hilal-i Akhdar in Istanbul in important role in raising awareness and
order to warn Turkish society against keeping the young students away from
occupation and harms of alcohol and drugs. harmful habits. They are involved in various
The Turkish Green Crescent Society is a activities like smoke-free campuses9.
non-governmental association was included The second voluntary commission is the
among The Public Beneficial Societies Green Crescent Women Commission. The
upon the decision of the Council of Ministers commission members work voluntarily in the
dated 19 September 1934. Public beneficial neighborhoods to educate housewives on

addictions. Both commissions are leading tion. As a supporter of public authorities for
voluntary activities of the Green Crescent. human affairs, the Green Crescent is subject to
Any person can become a member of the international agreements duly enacted by State
Society if he / she adopts the principles, values, of the Republic of Turkey. In this context, it
goals and working ethics of the Green Crescent. has the autonomy to make international
He / she should have no record of any illegal agreements and to act accordingly within its
activity, not addicted to tobacco, alcohol or any field of activity.
drug To be a member one should pledge the As Charity Organization: The Green Crescent
following commitment As long as I stay as a is a voluntary charity organization which does
member, I solemnly pledge on my honor and life not seek profit or personal benefit in its
not to use any tobacco, alcohol or drug and to activities.
propagate Societys ideals. A person, who As Public Health: The Green Crescent is a
would like to be a member, applies directly voluntary non-governmental organization which
to directorate of the branch on the basis his/ builds programs to fight risk factors for all
her place of residence. The decision making kinds of addiction, particularly, those related to
body for the affiliation is Executive Board of tobacco, alcohol, and drugs.
the Green Crescent Branch. Turkish Green Scientific Understanding: The Green Crescent
Crescent Society is a member of the National adopts evidence-based research, analysis and
Quality Movement, led by the Quality intervention regarding behavior reinforcement
Association of Turkey. and /or behavior change during the phase of
Quality Association of Turkey provides fighting against addiction, protection and
training and direction to develop the Green prevention of addiction, therapy and treatment.
Crescent's management structure and human Globalism: Having equal status and sharing
resources. EFQM (European Foundation of equal responsibility and duty like other foreign
Quality Management) Model is implemented national societies in the field of combating
to be a part of the journey on the road to addictions, the Green Crescent adopts the
being a Center of Excellence. following principles: creating a global organiza-
tion to fight against addictions on a worldwide
Core Values and Principles of the Society basis and as a part of such organization,
Struggling for Human Dignity: evaluating issues on a global scale and working
accordingly, functioning on a global level and
The scope of the Green Crescent is to ensure the being influential and highly regarded.
protection of human health and respect for Sense of Community: Organizing to create
human dignity against risk factors causing awareness for public health at every stage from
addiction. In all its activities, the Green Crescent the whole part of society to individual and
supports mutual understanding, fellowship, public organizations, carrying out participating
friendship, cooperation and permanent peace activities on social-level and permanent
among individuals. It endeavors to relieve and to achievement are considered as a necessity by
prevent human pain anywhere arising from the Green Crescent10.
addictions within national and international
capacity. MOBILIZATION OF THE PUBLIC
Non-Discrimination: The Green Crescent does AGAINST ADDICTION:
not discriminate people based on race, Evidence Based and Scientific Prevention
age, religion, ability, marital status, sexual Practices
orientation. By prioritizing the most urgent and
necessary requirements, it focuses on relieving The Green Crescent Society contributes to
human pain arising from addictions within its public health by developing evidence-based
capacity. prevention programs and advocating for
Independency: The Turkish Green Crescent is legal, social and environmental changes in
an independent non-governmental organiza- the fight against addiction.

The Green Crescent fights against tobacco, (ISTKA). Using the slogan "The Green
alcohol, drug, gambling, and technology Crescent is looking for youth leaders", the
addiction that destroy the mental and project reached 200,000 students in Istanbul.
physical health of the youth in cooperation The project aimed to educate nearly 5,000
with the private sector, governmental bodies secondary school students and 1,000
and international organizations. It works to teachers. The young leaders were trained on
develop contemporary strategies for dealing the Green Crescent Club Curriculum and
with consumption of addictive substances peer education approach was initiated along
and for the prevention of addiction by using with training on leadership and motivation.
evidence-based scientific methods. As part of the project, participants were
The Green Crescent launces many projects administered pre- and post-tests. Awareness
and preventive campaigns every year. The and knowledge level of cigarette and internet
activities and programs are based on the addiction were measured in students between
guidelines of the prevention programs. There the ages of 11 and 14. All indicators showed
are general set of guidelines for prevention a positive effect of the peer education
activities which are general considerations amongst children of different age groups,
for all addiction prevention activities. genders, and socioeconomic levels. Educated
Assessment of the need, assessment of the leader students conducted many activities to
capacity and sources, planning with goals attract the attention of their peers at schools.
and objectives, implementation, and evalua- Approximately 80% of students who parti-
tion are the basic steps in the Green Crescent cipated in the training expressed a desire to
preventive programs11. The implementation share the information they learned in the
and the findings of three different programs program with their friends and to participate
are summarized below. in similar programs in the future13.
Youth Center Project National Water Pipe Campaign:

with Ministry of Youth and Sports:
The National Water Pipe Campaign was
The project's aim was to establish a youth prepared as a nationwide communication
center in Istanbul with the cooperation of campaign to prevent the epidemic of water
Ministry of Youth and Sport. The project was pipe use across the country. Qualitative and
planned according to the needs of the quantitative preliminary surveys were
university students in Fatih district. A survey lunched and completed in 2013. 1,200
of five hundred young students was smokers, non-smokers, and water pipe users
conducted to understand the needs of young participated in the survey. The habit of use of
people and evaluate their perception of water pipe and the perception in the commu-
addictive substances like; tobacco, alcohol, nity about its use were analyzed to plan
and drugs. As a result of the research the communication campaign in 2014.
youth center was designed and established to The contents of the campaign were prepared
meet the requirement. The Youth Center and the kick off is planned on 1st April 2014.
became operational in 2013 and is still At the end of the year another survey will be
providing sporting and artistic activities for launched to analyze the effects of the
young students12. campaign14.
The Project on Combating Substance Advocacy:

Abuse through Official Primary School
Green Crescent Clubs in Istanbul: The Turkish Green Crescent Society plays an
important role in policy making, lobbying
The project was implemented in cooperation and advocacy issues. The Green Crescent
with Istanbul Development Agency efforts are especially focused on carrying out

preventive social and advocacy activities adoption of The National Alcohol Control
aiming at creating public opinion and raising Action Plan. Green Crescent organized an
awareness of the decision-makers and the international symposium in Istanbul on 25-27
general public. The advocacy activities vary April 2013 and representatives from 60
from legislation on public health to alcohol different countries including Turkish Prime
and tobacco control policies. Minister Recep Tayyip Erdogan, and the
Article 58 of the current Turkish Constitu- Director-General of the World Health
tion, which forces the state to protect youth Organization Dr Margaret Chan participated.
from harmful habits was a proposal of the Global Alcohol Policy Symposium provided
Green Crescent. important base for the adoption of the new
The State shall take necessary measures to alcohol law in Turkey. As an advocacy
protect youth from addiction to alcohol, drug organization, Green Crescent tried to push
addiction, crime, gambling, and similar decision makers to enact this law with the
vices, and from ignorance15. scientific and evidence-based public health
The WHO Framework Convention on principals19.
Tobacco Control and its guidelines provided The Turkish Green Crescent Society has
the foundation for countries to implement adopted a strategy to help the development of
and manage tobacco control. WHO the alcohol policy in Turkey. The Turkish
developed the MPOWER measures to assist Alcohol Policy Platform was established in
in reducing the demand for tobacco products 2013 on a national level under the leadership
at country-level16. In recent years Turkey of the Green Crescent. Many organizations
became an example of success for the from various sectors came together under the
implementation of MPOWER measures in platform and currently 40 different
the World. Green Crescent played an organizations are the members of this
important role in the Turkish Governments platform. It was an attempt to organize
adoption of the Framework Convention on pressure group to raise public health
Tobacco Control and its enactment process in awareness in general and about alcohol
Turkey17. policy in particular20.
Recently, the Turkish Government has
enacted a new law on alcohol control policy The Green Crescent in Educational
within the framework the National Alcohol Institutions:
Control Action Plan. The bill was proposed
and prepared by the Ministry of Health and As a public health organization, the Green
was approved in the Grand National Crescent mostly cooperates with educational
Assembly of Turkey on 24th of May, institutions for preventive activities. The
201318. anniversary of the foundation of the Green
Unfortunately, the new alcohol law turned to Crescent Society 1-7 March, is celebrated as
be a political instrument between the ruling the Green Crescent Week in Turkey by the
and the opposition political parties in Turkey. Council of Ministers decision since 1960.
The new law faced very strong objections The syllabuses of the secondary and high
from the secularist segments of the society schools cover contents on harmful habits,
claiming that it deliberately restricts their addictions and the concept of the Green
freedom and it is an interference into their Crescent during that week, and great
lifestyle. Alcohol Industrial involvement and numbers of activities are carried out in
lobbying increased the reaction against the schools across the country during the entire
regulations. Alcohol industry propagated the month. The Green Crescent has an official
argument that the alcohol regulations are protocol with the Ministry of National
religious based and mostly violate secular Education.
peoples freedom. The Green Crescent The National Educational Program on
conducted advocacy campaigns for the Addictions of the Green Crescent has been

developed in cooperation with the Ministry. through many doors and find new spaces and
It provides an opportunity to conduct many victims. Beside the causes of addiction, what
surveys, projects and activities beginning at we really need to pay attention to is the tools
primary and including secondary and high of addiction, namely, the means that
schools. In every secondary and high school influence and push individuals, the youth,
across the country, there is a Green Crescent into addiction. When individuals step out of
Club. These clubs are conducted according to didactic education processes in their families
the rules of the Club Regulation of Ministry and schools, they become less shielded from
of National Education. The regulation the marketing strategies of the media and the
obligates schools to constitute the Green addiction industry, and become easier targets
Crescent clubs under the leadership of the prone to influence, under the so-called
trainers. Although they are compulsory for freedom. This opening that comes along
the teachers, students participate in the clubs with getting out of teachings and restrictions
voluntarily. The Green Crescent clubs follow of their families and schools that interfere in,
the curriculum of Ministry of Education and and limit their participation in what they
they mostly conduct their activities in March. consider pleasant activities, makes the
The Green Crescent club members conduct children/youth open to ideas of being free
their activities under the guidance of their and realizing oneself. This pursuit of
teachers. The Green Crescent branches and independence of becomes a tool for
headquarters provide the required documents addiction. This concept of freedom combined
for the teachers and launch some programs to with the pressure of two other elements.
train club trainers in the provinces. Peer One, is the idealized and marketed world;
education activities are mostly implemented and two, the acknowledgement of the peers
through these clubs to keep children away sharing the same interests and expectations.
from harmful habits. According to this Peers are the only place where the
method students work to protect their friends individuals who turn their backs to the
from harmful habits and they inform their difficulties of being good and responsible,
friends periodically at schools. find acknowledgement and appreciation. This
Leader students in the clubs reflect and share situation that we can call the peer effect
their experience in the Green Crescent Club provides two benefits to individuals. First,
Periodical published monthly. finding an authority that likes and appreciates
Since the Republic of Turkey is a secular the situations and tendencies that are not
country, the laws and the rules of the approved by authorities such as the family
educational institutions cannot be religious and school. Second, the psychological
based. The philosophy of the Green Crescent confidence resulting from seeing the peers
clubs is based on the educational rules of sharing the same evil by doing things
Ministry of National Education and universal considered bad. As a result of that, the
moral values21. individuals isolated by the increasing
criticism and pressure of the families and
Peer Effect:
schools, are left even weaker in their peer
There are many causes of addiction. It is groups. At that point, these individuals are
impossible to focus on just one single cause now forced to behave according to the
and achieve results from methods based on interests and tendencies of their peers, and
only that specific cause, whereas many making the expected sacrifices and attempts
psychological, physiological, cultural and to get accepted by and belong to the group.
environmental factors exist. Taking such an And then it is difficult to predict where these
easy way out is no different than what an individuals will stop. On the other hand, we
ostrich does when it sees its hunter. cannot undervalue the number of young
Addiction of smoking, alcohol, drugs and the people who have received good family
recently developed technology can pass discipline, good education and who have

made healthy progress, and have strong International scope:

personalities and characters. What needs to
be done and what the Green Crescent has Alongside national affords, the Green
adopted is to encourage the youth in the right Crescent targets to be part of international
direction. The youth constitutes the most solidarity to fight against addictions on a global
important part of the purest and cleanest level. The Turkish Green Crescent Society is
times in terms of emotions and thoughts, an organization who has a Special
because the demand for justice and tendency Consultative Status within the Economic and
to sacrifice oneself in the name of what is Social Council of the United Nations22. The
right, and of their ideals, exist intensively in Green Crescent is also a member of the
young people. And that is why we have the European Alcohol Policy Alliance,
opportunity to educate our youth and make EUROCARE23. Turkish Green Crescent
them volunteer to fight against the addictions Society has EFQM Committed to
of their peers by setting good role models. Excellence certificate of the European
Young people diverted to quests outside of Foundation for Quality Management. Green
the teachings and ideas of families and Crescent also cooperates with a great number
schools, will easily accept their peers who of organizations in the world.
are mentally and physically healthy, and who The Society aims to transfer its experience and
look to life and the future with confidence. values to other organizations. It helps the
This way, peer groups will move from being foundation of new Green Crescents in different
a tool of the evil and addiction to leading the countries, namely; Palestinian, Bosnia and
way for raising educated generations who Herzegovinian, Malaysian, Thai, Lebanese
will look to the future with confidence. Also, and Montenegrin Country Green Crescents.
generations who have chosen this path of A major objective of the Turkish Green
commitment to benefit and their human- Crescent Society is to launch the World
oriented thinking will safeguard the future of Federation of Green Crescent Societies for a
our nations. better future of our next generations.
It must be our primary goal to expose the The Turkish Green Crescent Society is
dangers of the concepts, which are presented always ready to share its expertise, know-
to our youth under the name of freedom, and how and documents to help the foundation of
which trap them in the web of addiction Green Crescent Societies in other countries
industry, and to raise our youth as in order to make our world smoke-free,
responsible individuals with strong minds, alcohol-free, drug-free and to protect our
morals and personalities of the future. next generations from all kinds of addictions
For our social values and healthy family that are the evils of the modern world.
structure to be carried into the future in the
hands of mentally and physically healthy References:
generations, we have adopted an
1. World Health Organization Management of Substance
understanding and determination beyond Abuse
daily philosophical and political debates. We http://www.who.int/substance_abuse/facts/alcohol/en/.
aim to transform the Turkish Green Crescent 2. For further information on alcohol harms see
http://www.yesilay.org.tr/en/news/item/207-global-
Society into a structure that is more efficient alcohol-policies-symposium-final-declaration.html.
and more active both in the service of our 3. World Health Organization Tobacco Free Initiative
nation and of humanity, through ideals and http://www.who.int/mediacentre/factsheets/fs339/en/.
4. World Health Organization Management of Substance
ideas that we have preserved since the first Abuse
day of our foundation, by opposing the http://www.who.int/substance_abuse/facts/psychoactiv
misinterpretation of the definition and es/en/.
5. WHO Bulletin, Tobacco Industry Tactics for Resisting
requirements of freedom as well as some Public Policy on Health,
negative mentalities that stand out as the http://www.who.int/bulletin/archives/78(7)902.pdf.
values of our era. 6. Vienna Declaration
http://www.viennadeclaration.com/the-declaration/.

7. For further information on the Turkish Green Crescent

Society see the official web site
http://www.yesilay.org.tr/en/.
8. Constitution of the Turkish Green Crescent Society
http://www.yesilay.org.tr/en/about/constitution.html.
9. For Smoke Free Campus Activity see
http://www.yesilay.org.tr/tr/haber/item/20-
bezmialemde-sigarasiz-kampus.html.
10. Turkish Green Crescent Society
http://www.yesilay.org.tr/en/.
11. For the guidelines of preventive programs see
Substance Abuse & Mental Health Services
Administration
http://www.samhsa.gov/prevention/spfcomponents.asp
x.
12. Green Crescent Youth Center
http://www.yesilay.org.tr/genclikmerkezi/.
13. For the details of the Green Crescent is Looking for
Young Leaders Project see
http://www.yesilay.org.tr/en/news/item/375-200,000-
students-receive-addiction-resistance-education.html.
14. For further information on Water Pipe Campaign see
http://www.nargilegercekleri.com/, the page will be
activated as from 1st April 2014.
15. For 58. Article in the Turkish Constitution see
http://www.anayasa.gen.tr/1982Constitution-1995-
2.pdf.
16. Framework Convention on Tobacco Control
http://www.who.int/fctc/en/.
17. For Turkeys FCTC success and MPOWER story see
http://www.who.int/tobacco/mpower/publications/mpo
wer_2013.pdf?ua=1.
18. For an evaluation on the Turkish Alcohol Control Law
2013 see http://www.todayszaman.com/news-316734-
erdogan-defends-alcohol-law-not-imposition-
protecting-youth.html;
http://www.todayszaman.com/news-316365-
parliament-passes-bill-limiting-sale-of-alcohol-
banning-ads.html.
19. Global Alcohol Policy Symposium 26-27 April 2013
http://gaps-istanbul.com/eng/news.aspx.
20. Turkish Alcohol Policy Platform
http://www.tapp.org.tr/.
21. Club Regulation of Ministry of National Education
(Turkish)
http://mevzuat.meb.gov.tr/html/25699_0.html; Green
Crescent Official Page for the Green Crescent Clubs
http://www.yesilay.org.tr/yesilaykulubu/.
22. For Consultative Status with the United Nations
Economic and Social Council (ECOSOC) see
http://csonet.org/; For the Green Crescent Consultative
Status see http://www.yesilay.org.tr/en/news/item/337-
the-green-crescent,-member-of-the-un-economic-and-
social-council.html.
23. European Alcohol Policy Alliance
http://www.eurocare.org/.

BEWARE OF SPIRITUAL BYPASSING:
INTEGRATE PSYCHOTHERAPY
IN THE ADDICTION RECOVERY PROCESS
Ketam Hamdan*
Abstract:
This chapter discusses the phenomenon of spiritual bypassing, generally defined as a persons
utilization of spiritual practices and beliefs to avoid unresolved psychological issues that may have
triggered the addiction. As a result, those on the path of addiction recovery will most likely not heal
properly and will continue to struggle with their addiction issues. To elaborate on this topic further,
this chapter contains four sections.
First, a brief discussion of the definitions of key terms used throughout the chapter. Second, a
summary of the characteristics of spiritual bypassing and how it may manifest on the path to
recovery. Third, a psychological model for holistic development is offered. Finally, this section
provides recommendations for using both spiritual and psychological practices for sustainable
addiction recovery.
Keywords: Spiritual Bypass, Islam, Addiction Recovery, Therapy, Psychology.
Introduction
In the past decade, there has been a rapid provoke animosity and hatred among you
increase in addiction to drugs, alcohol, through intoxicants and gambling, and to
gambling, pornography, technology, and distract you from remembering God, and from
compulsive eating that have fueled the growth of observing the prayers (Salat). Will you then
emotional and behavioral problems in the refrain?2.
American Muslim community1. Most Muslims The above verse directly tells Muslims to abstain
hold the worldview that a person with an from harmful things such as alcohol, drugs, and
addiction problem is often the result of ones gambling because these acts are from the devil
weak iman (the Arabic word for faith) and that only desires to push people towards faulty
increasing ones faith is the only cure. They things that keep one from the remembrance of
believe that addiction violates and disregards the God. Therefore, when a Muslim admits or is
basic tenets of Islam. Islamic scriptures provide found to have an addiction problem, his or her
Muslims with clear guidelines about what is psychological issues are rarely unearthed and the
permissible and what is not. For instance, the underlying reasons for the addiction problem
Quran informs Muslims: goes unexamined. Instead, one is often preached
O you who believe, intoxicants, and gambling, at and told to become more religious.
and the altars of idols, and the games of chance Unfortunately, this ostrich philosophy that
are abominations of the devil; you shall avoid religion is the only remedy to treat an addiction
them, that you may succeed. The devil wants to problem is rarely accurate.
*Dr. Ketam Hamdan

Ph.D Psychology
Master of Theological Studies (M.T.S.)
Religion & Psychology, Harvard University
Master of Science (M.S.), Social Sciences
Columbia University

BEWARE OF SPIRITUAL BYPASSING
One phenomenon that describes the limitations zed religion, such as Islam. Thus, the words
of relying solely on spiritual practices to spirituality, spiritual, religious, and religion are
overcome problems such as addiction is known used interchangeably throughout this paper to
as spiritual bypassing, which is a phrase that refer to Islam, Islamic rituals, Islamic principles
describes a person who avoids dealing with and beliefs.
negative emotions and other internal psycho-
logical issues. Instead, this person resorts to Definition of spiritual bypassing:
healing by using only spiritual practices and
beliefs 3,4. Charles Whitefield7, who is a medical doctor
Therefore, the objective of this chapter is four that works in the field of trauma and addiction
fold. Firstly, it will provide definitions for the recovery, first coined the phrase spiritual bypass.
usage of the terms spirituality and spiritual Whitefield noticed that those individuals who
bypassing, in relation to how it is used engage in psychological work and development
throughout this paper. Secondly, a discussion of were better able to improve and experience true
spiritual bypassing traits that Muslims may spirituality. He also noticed that individuals who
manifest on the path of addiction recovery. engaged in psychological and spiritual work
Thirdly, the paper will share a model of the self together recovered faster from addiction related
that helps explain the importance of both issues and were less likely to relapse. Likewise,
spiritual and psychological development for John Welwood8, a psychotherapist who
holistic addiction recovery. Finally, it will integrates psychological and spiritual therapy,
conclude with recommendations of how therapy noticed that many of his clients engaged in
can be integrated and used to compliment advanced spiritual practices; however,
spiritual growth. their spiritual practices had a tendency to help
them avoid facing their wounds, emotional
1.Definition of Terms insecurities, and pains that most likely triggered
or influenced ones addiction problem in the first
The usage of the words spirituality and spiritual place. He observed that often times his patients
bypassing may have a variety of meanings. were unconsciously using spiritual beliefs to
Thus, below are definitions of these words to achieve spiritual maturity while unconsciously
clarify what is meant by the use of these terms in overlooking, or bypassing, their personal and
the context of this paper. emotional problems. The person is most likely
trying to resolve psychological issues at the
Definition of spirituality: spiritual level and does not realize that he or she
is escaping the work at the other levels, such as
The word spirituality has no universal definition the cognitive, emotional, and interpersonal.
because the word can be applied to different When this happens, spiritual practice is not
contexts. integrated into the real-world state of the psyche
For example, one definition of spirituality is the and, as a result, personal growth is less mature
personal quest for understanding answers to than the spiritual practice.
ultimate questions about life, about meaning, As a noun, the term bypass means to go around,
and about relationship with the sacred or to avoid, or to proceed without reference to
transcendent, which may (or may not) lead to or the core or superior issue9. However, for the
arise from the development of religious rituals5. purpose of this paper the term bypassing is
Another definition of spirituality is the human preferred. As a verb, bypassing represents and
yearning for divine love6. For the purpose of implies a developmental process that a person is
this paper, spirituality is defined as the perpetual continuously engaged in. Thus, the phrase
pain of the soul that craves for a connection with spiritual bypassing refers to a persons
a higher power, God, and stems from an organi- unconscious utilization of spiritual beliefs and

practices to go around psychological issues and There are no quick fixes for fully healing ones
emotional unfinished business, with the hope of repressed issues and childhood wounds. The
finding inner peace through ones faith10. process of transformation takes time and people
Moreover, the explosion of New Age fads like need to be educated about the complexity of this
think positive, be grateful, and avoid negative process, rather than be given false band-aid fixes
people are examples of fast food spiritual that rarely resolve or just scrape the surface of
remedies often recommended to people to feel ones issues.
better. Another mainstream fad is the Secret, Furthermore, the literature that discusses spiritu-
which is a concept that centers on the attraction al bypassing is scarce. So not only is there
principle in New Age spirituality and teaches limited research about spiritual bypassing, but
people that whatever one imagines one will also there is no research about this topic from the
manifest. The belief is that a person attracts what Muslim perspective.
he or she believes. Thus, if an individual The literature also references other phrases that
believes he or she is poor then the person will allude to the concept of spiritual bypassing. For
most likely live poor. Whereas if a person is instance, Trungpa13 coined the term spiritual
content and grateful, the Secret experts suggest materialism, which is the practice of
that the person will attract more money and strengthening the ego by accumulating more
positive experiences. People are also preached spiritual experiences and by shopping around for
catch phrases like dont take it personally, or diverse spiritual practices without commitment
whatever bothers you about someone is really to a specific tradition. Spiritual materialism can
about you11. However, these fads have helped be experienced by both practicing Muslims that
to further promote a fast-food spirituality culture understand Islam properly and by Muslims who
of drive-through offerings that only temporarily may have had blind faith growing up. Regardless
help one feel better. These fads have also if one is applying Islamic practices properly or if
misguideda person that becoming more spiritual one is merely implementing what one was taught
is the cure to any problem. As a result, the growing up, spiritual materialism most likely
individual never seeks help for internal issues occurs when one feels a sense of superiority over
that he or she rarely understands. One merely others or holier than others because one is doing
escapes internal issues and pain by numbing a lot of spiritual activities. Another phrase is
problems with quick fixes like think positive or bullet-proof faith, which suggests that a person
avoid negative people. When this happens, an has strong faith in a God that cannot be stirred
individual is unable to fully live an authentic and no matter what happens to him or her. Another
genuine life because his or her issues are phrase premature transcendence is also known
constantly lingering in the background. These to be synonymous with spiritual bypassing,
quick fixes and easily blurted expressions which alludes to a person who engages in
actually repress ones painful issues and impact spiritual practices to rise above psychological
ones ability for holistic development that is issues that are internally stored, silent, and
necessary for true fulfillment12. Moreover, others remain unresolved14.
are told to simply increase their Islamic practices Ultimately, ones unresolved issues continue to
and preached to pray more, to give more charity, haunt them and get acted out, which results in
and to read more Quran. Ones spiritual immature and half-baked spiritual practices.
practices may make one feel better, but often In summary, in the context of this chapter, the
times it is only temporary. Individuals will most phrase spiritual bypassing will be used to
likely continue to experience frustration and describe Muslims who turn only to their Islamic
disappointment because the issues that he or she beliefs and practices to overcome an addiction
is trying to escape, via their addiction, still problem. These persons do not address or
remains internally and will continue to haunt examine their internal psychological issues that
them. One has to first become aware of these most likely contributed to their addiction related
issues, and then take steps to overcome them. problems in the first place.

The next section will discuss in more detail how development. Often religious leaders will
spiritual bypassing may manifest. prescribe to someone with an addiction problem
the need to engage in more Islamic rituals and
2. Traits of Spiritual Bypass practices. However, recent research suggests a
on the Path of Addiction Recovery persons religious beliefs and practices may
hinder sustainable recovery 19. Instead, religious
Most Muslims are taught to believe that the leaders could serve as mentors to refer addicts to
Quran and Sunnah (authentic prophetic professional counselors or mental health
traditions) contain the tools and keys for how professionals that are better equipped to help the
they should govern their life and enhance their individual.
overall character. Many accept that everything Correspondingly, when an addict is in the
that happens in ones life is a direct result of process of recovery and is engaged in spiritual
Gods will, especially crises, illnesses, and bypassing, it can manifest itself in different
losses. For instance, this verse from the Quran ways. For instance, it may appear as an
informs Muslims, "Nothing will happen to us obsession with a spiritual leader or religious
except what Allah has decreed for us: He is our scholar, which most likely leads to the develop-
protector: and on Allah let the believers put ment of blind faith in spiritual gurus or mystics
their trust15. and social seclusion20.
Further, devout Muslims are instructed to trust This unquestioning faith may lead one to renou-
that calamities, problems, and illnesses are a nce personal responsibility by passively relying
means to get closer to God. As a result, many on religious leaders to resolve psycho-logical
Muslims are preached at and told that he or she problems, which can, over the long haul impede
should embrace their problems because ones functioning in the modern world. One may also
issues are a means to cleanse, purify, and demonstrate a zealous preoccupation with
balanceon the physical, emotional, mental, reciting the Quran, supplications, prophetic
and spiritual planes16. Thus, psychological or sayings, or other Islamic literature that he or she
mental health issues such as addiction are rarely did before. In essence, increasing ones
considered a test from God17. For instance, if a religious activities is not wrong and is highly
person has feelings of anxiety, depression, and encouraged for every Muslim to do. However,
shame that resulted from some type of addiction, the concern is when these Islamic practices are
then he or she is often taught to believe that this done in isolation and not complemented with
problem should be used as an opportunity to psychotherapy or psychiatric help. It is now
reevaluate his or her life and increase their believed that both spiritual and psychological
Islamic practices. work are needed for addiction recovery.
In addition, for many Muslims, a persons family In addition to spiritual engagement, Muslims
or religious leader (known as an Imam) is often need to gain more knowledge about the
seen as the resource to go to when a person complimentary role that therapy can have in
experiences a life problem, calamity, or issue. helping them fully recover21.
One research study found that Muslim More specifically, Cashwell, Myers, and
participants were more likely to consult religious Shurts22 identified three different types of people
leaders for help re their mental health issues and that use spiritual beliefs to prevent or avoid
that only 11% of participants reported that they facing their psychological issues. These are the
would seek treatment from a mental health Good Servant, I Have a Gift, and Turn the Other
professional18. However, many religious leaders Cheek. As a Muslim, the Good Servant type may
find themselves being consulted about be someone who tries to overcome an addiction
psychological issues that they do not have problem by spending a lot of time volunteering
formal education or training in. As a result, at the mosque and participating in spiritual
Muslims do not get the proper treatment and events and activities. This person most likely
guidance needed for healthy recovery or exhibits traits of compulsive goodness and is

someone who is extremely kind, helpful, person. One should also not talk negatively or
considerate of others, and goes out of his or her have negative thoughts about another person.
way to do good. The second type, I Have a Gift, This requires one to have a purity of heart and is
is most likely a person that believes he or she often difficult for one to achieve without having
has been guided by God and is extra special. addressed past pains of not being heard, valued,
This person will dismiss their addiction behavior and respected.
and pacify the addiction as something that was Furthermore, it is important to note that it is not
temporary. As he or she turns to spiritual always easy to detect spiritual bypassing because
practices, the persons will rationalize that their it can take the guise of other positive traits, such
addiction may be a way to bring them closer to as being extremely polite and nice or being
God. Thus, they are special and God is watching overly charitable. At the same time, the person is
over them. inconsistent with these extreme positive traits
The third type, Turn the Other Cheek, may and will at times demonstrate sudden moments
resemble a Muslim who has an addiction issue of frustration, anger, or irritability. These traits
because of historical pains and issues associated only further validate the existence of repressed
with not being able to express him or herself. and unresolved negative emotions. Thus, the
This person internalizes his or her feelings and seemingly more devout Muslim is not congruent
negatively acts out feelings, by indulging in drug and does not experience the continuous inner
or alcohol abuse. The person generally has an peace of leading a more spiritual life. Instead,
addiction problem because the addiction to some the person on the path to recovery and engaged
type of substance helped to numb the persons in spiritual by passing may exhibit traits of being
pain. For instance, if while growing up, a person judgmental of others, having a holier than thou
did not feel loved by his or her parents, this attitude, critical of those who do not practice,
person most likely would have avoided getting morally harsh, and insensitive24. Also, a person
close to people and did not feel comfortable may become obsessed with increased religious
expressing his or her feelings. If one is unable to activities, which serve as a way for the addict to
express him or herself then the person feels feel in control or to contain negative emotions.
unimportant and not valued. When one is not The addict in this case is simply replacing a
heard, one feels bad and has internal disarray. negative addiction under the guise of a more
Thus, instead of confronting his or her pain and positive addiction, a spiritual one. This faulty
admitting the need to be valued and heard, the replacement only helps the person further mask
person numbs these needs by turning to drugs or his or her historical wounds and issues25. The
alcohol as a temporary escape to feel good. following section will elaborate on the concept
Thus, on the path to addiction recovery, this of holistic development for sustainable addiction
person will rarely be able to express his or her recovery.
needs, how he or she feels, and will not confront
others when wronged. Instead, he or she may 3. Holistic Development
follow Islamic beliefs and teachings, such as this for Addiction Recovery
verse, Those who spend (in Allahs cause) in
prosperity and in adversity, who repress their More and more psychological experts are
anger, and who pardon men, verily, Allah loves recognizing that spirituality is essential and can
the al-Muhsinun (the good-doers)23 tremendously help one overcome an addiction
However, Muslims need to understand the depth problem26. For instance, Carl Jung27, a famed
of what is meant by Islamic teachings that psychologist, believed that spirituality might be
emphasize forgiveness and pardoning others. the best solution for a person with an addiction
The ability to truly forgive someone requires the problem and explained that addiction is most
removal of any ill feelings towards a person who likely a sign of a deep spiritual yearning that is
has wronged him or her. One should not hold missing in ones life. Thus, from a deep
grudges or have any animosity towards another psychological standpoint, a persons search for

spirituality is a sign of seeking completeness of nds and assume that they need to forego any type
the soul. Many recovering individuals point to of self-grounding or psychological development
their spiritual lives as being central to their of a secure structure. However, spiritual bypass
abstinence. Specialists on addiction recovery is more of a false sense of transcendence that
describe successful programs, such as the 12- bypasses psychological issues and often entails
step addiction recovery plan, as a spiritual avoiding or denying ones shadowy side. Within
revival program that encourages the person to the Muslim community, there is a strong need to
return to their faith and find greater meaning in raise awareness of the constructs of the self and
their life28. the importance of holistic development. When a
Robert Assagioli29, who created the person increases spiritual practices without
transpersonal model of psychosynthesis, also examining psychological issues then he or she is
agreed with Jung that people experience most likely creating psychic fragmentation, not
conflicting impulses on an ongoing basis. They holistic development. In an attempt to explain
often fluctuate between the desire for security, more vividly the constructs of the human psyche
and the tendency towards growth, self- and its complex part, Assagiolis oval model or
assertion, and adventure30. In essence, new egg diagram33 (Figure I) is illustrated below:
drives are continuously being awakened that
Figure I. Assagiolis Structure of the Psyche.
challenge previous ones. Assagioli asserts that
during adolescence one is likely to awaken new Soul
motivations. Then in middle age one is more
likely to awaken more spiritual or religious
c. Higher
aspirations. It is these aspirations that are at the Unconscious
heart of spiritual bypass that an addict on the
path to recovery may focus on. A persons
spiritual development is not an easy or short Field of
b. Middle I
process; it is a long and difficult journey that Unconscious Consciousness
requires continuous self-awareness, self- & Will
regulation, and self-development. If a person
neglects psychological growth and focuses only
on spiritual amplification, this only makes the a. Lower
process more complicated. Unconscious
While spiritual practices can help an individual
address cognitive and behavioral dissonance, the
person must have a secure psychological
structure that he or she is grounded in. Welwood
assessed that this grounding is: In Figure I: Assagiolis Structure of the Psyche,
Psychological and not spiritual work. Assagioli suggested that the unconscious has
It means working with needs, scripts, hunger for three main levels: (a) the lower unconscious,
love, fear of love, fear of loss of love, fear of which can be thought of as Jungs personal
receiving love, fear of giving love, and unconscious and Freuds unconscious area of
establishing a sense of self-respect, which is not drives and passions, as well as childhood
overwhelmed or crushed by other peoples repressed experiences, anger, and traumas; (b)
opinions31. the middle unconscious, similar to everyday
Moreover, John Engler coined the phrase you waking state of consciousness that contains
have to be somebody before you can be easily accessible memories and skills, labeled by
nobody32, which emphasizes the need to Freud as the preconscious; (c) the higher
strengthen the ego before transcending it. Many unconscious, or super-conscious is the region
addicts who are attracted to spiritual practices where more spiritual, mystical, or higher values
misguidedly bypass confronting historical wou- reside. For Muslims, the higher unconscious area

is the area that houses ones Islamic beliefs and The next section will elaborate in more detail on
values. This area also houses creativity, using both spirituality and psychological
intuition, and the drive for meaning, and practices for more holistic development.
purpose. In the center of the middle layer,
signifying the middle unconscious is a circle that 4. Using Both Spiritual Practices and Therapy
represents ones immediate conscious field of
awareness that the I operates in. Unlike traditional cognitive and behavioral
Although the model places the soul on the top of methods, there is a greater need to look at a more
the diagram, the soul is an aspect of the self that integrated use of treatment that takes into
is center of the entire psyche. The soul can be account both spiritual and psychological
said to pervade all of the oval . . .34. In this solutions37. Cognitive behavior therapy does not
model, the lines are dotted to signify that the necessarily help to diagnose or determine ones
different layers are permeable and can influence unconscious or conscious drivers38. As a result, a
the I. However, this requires a more conscious persons problems go undiagnosed and leave
understanding of the constructs of the self and wounds pending while allowing one to act in
the importance of integrating these parts for ways that may appear to be satisfactory.
healthier development. In the case of an addict Essentially, the heart of spiritual bypassing is
who has turned to Islamic practices for recovery, predominantly unconscious, or as Assagioli
he or she is most likely functioning using two of defined it, the lower unconscious, which
the three areas, the upper unconscious and the contains repressed material, developed from
middle unconscious. Thus, the person is early childhood experiences, and later covertly
engaging in spiritual bypassing because one is affects ones spiritual intentions and overall
most likely unaware of the lower unconscious development. For example, The Adverse
area. As mentioned previously, the lower Childhood Experiences (ACE) study suggests
unconscious area is the area that stores ones that early childhood trauma such as abuse or
historical issues and wounds that are often continuous neglect by parents often results in
repressed and the person is unaware of. In children engaging in addictive behavior during
viewing the diagram, one is able to see that in adult life39. Researchers suggest that a child who
dismissing or ignoring the lower unconscious suffered abuse will most likely store the abusive
altogether the individual is not able to become memories in the lower unconscious. As one
whole, which is needed for psychic unity. progresses through life, one never faces the pain
Moreover, this thinking is in alignment with and hurt from the abuse. This pain in the lower
Freuds psychological discourse, which emph- part of the unconscious lingers silently and stirs
asized the impact of ones unresolved conflicts internal disarray. To alleviate this disarray, one
that are repressed in the unconscious and that turns to drugs or alcohol as an analgesic from
there are psychological hazards of not address- reliving, confronting, or acknowledging the pain.
ing these past issues35. These unsolved conflicts In most situations, the person is often unaware of
cannot remain unknown and over time create the unconscious influence that is fueling his or
internal psychic dissonance, which might result her addictive behavior.
in serious pathological outcomes. In order to acquire self-awareness of lower
Freuddisclosed that the patient does not unconscious issues, one can begin by seeking
remember anything of what he has forgotten and professional help to evaluate their destructive
repressed, but acts it out. He reproduces it, not as behavior and learn about unconscious issues that
a memory but as an action36. In essence, Freud is hindering growth. Yet, within the Muslim
is telling us that people do not recall the community this poses a challenge because there
repressed material; he or she simply repeats it tends to be a general taboo associated with
unconsciously and acts its out in unhealthy seeking therapy to examine or understand ones
ways, such as in addiction related behavior. addiction behavior. This attitude is most likely a
result of the cultural shame and negative

stereotypes associated with seeing a therapist or Prophet and said: O Messenger of Allah! I have
getting any type of psychological help. In mingled with a woman in the far side of al-
addition, many Muslims simply do not know Medina, and I fulfilled my desire short of
what resources to turn to or how to go about actually having sexual intercourse with her. So,
dealing with their addiction related issues. There here am I, judge me according to what you
is a necessity for Muslims to make a more decide. Umar Ibn al-Khattab (radiyallahu anhu)
conscious effort to understand and resolve their then said: Allah had kept your secret, why did
psychological issues that trigger their addiction not you keep your secret?41.
behavior. As a result, most Muslims internalize or
Applying religious values and principles, while suppress their issues and do not seek social
ignoring necessary psychological development support or professional help for fear of being
and work, will most likely continue to create humiliated or scorned. Unfortunately, a person
internal disarray and discord40. In addition, that attempts to overcome his or her addiction
ignoring psychological work will also result in problem by turning only to spiritual practices
incomplete spiritual practices because ones will still experience challenges because hidden
psychological issues will most likely continue to emotions and issues that triggered the addiction
blindly impact ones spiritual practices. For remain unaddressed.
example, there are many Muslims who On the surface it will appear to others that the
understand Islam properly and are extremely person is getting better, but in reality the
devout. However, it is not uncommon to hear persons psychological wounds that prompted
that these very same people are guilty of the addiction are never dealt with. For many
domestic violence, drug abuse, or other wrongful individuals who struggle with an addiction
acts that go against Islam. These individuals problem, such as substance abuse, alcohol,
most likely have undiagnosed or untreated pornography, etc., the addictive behavior often
psychological issues that they are unaware of, serves to suppress unwanted issues that the
but yet they continue to act out in ways that person is often unaware of. Historically, therapy
negate their Islamic beliefs. did not integrate spirituality as part of the
Muslims too often approach an addiction healing process. However, the growing practice
problem with a nonchalant response that it is a of incorporating spirituality in therapy presents
sin and one needs to just obey Islamic teachings. both opportunities for better healing and
It is common to hear one say to a person with an potential threats of helping clients bypass
addiction problem to fear God (Allah) and the psychological issues. Thus, as stated earlier,
problem will go away. Unfortunately, this spiritual bypass happens when a person turns to
simplistic attitude is limiting and does not solve his or her religious rituals and dismisses
the problem. examining the cause of ones unhealthy behavior
Telling one to just become more religious and or negative emotions. In the short-term, spiritual
follow Islamic rules, allows a person to avoid bypass may be beneficial because it provides a
examining or taking responsibility for their coping platform for a person to begin the
addiction issues. Research also demonstrates that recovery process. However, in the long-term, a
social support is instrumental in the addiction person needs to become aware of and face his or
recovery process. However, most Muslims are her psychological issues that most likely
not comfortable talking about their addiction influenced the addiction to begin with. To do
issues with close family or friends for fear of this requires that Muslims embrace professional
being reprimanded, ridiculed, or shamed. In fact, counseling and therapy as a formal science that
many Muslims are taught to not publicly discuss can help one understand his unconscious drives
or disclose their faults. For instance, the and emotional issues. The following are some
following prophetic tradition tells Muslims to recommendations for facilitating the integration
not disclose your sins. Abdullah Ibn Masoud of spirituality and psychotherapy on the path to
(radiyallahu anhu) related, A man came to the addiction recovery.

1. Educate: spiritual leaders, educators, medical half-baked spiritual practices because

professionals, counseling and mental health psychological issues that triggered the addiction
experts need to make a more concentrated problem remain unaddressed.
effort to debunk negative stereotypes of The belief is not that ones religion cannot help,
psychotherapy, counseling, and mental but rather the healthiest and most sustainable
health services. In addition, there is a need to form of addiction recovery includes using both
educate Muslims how psychotherapy spiritual and psychological efforts. For instance,
compliments spiritual practices, as well as the Quran and Sunnah (prophetic) are used to
how seeking psychotherapy can help provide one with principles and rules to live
expedite the recovery process long-term. ones life by and professional counseling could
2. Motivate: Muslim community leaders and be used to help the person understand why he or
professionals need to lead the way and set up she may have difficulty applying these
organizations or recommend therapists that principles. Also, a person needs some type of
are skilled in helping Muslims get the support to openly discuss their desires, fears, and
necessary psychological addiction support emotions, which is often not readily available in
and assistance needed. The combination of ones local community. Thus, the main goal is to
psychology and Islam will allow one to educate Muslims that psychotherapy and
address the root causes of an addiction counseling can serve to enhance a persons
problem and aid in more holistic spiritual beliefs, not take away or replace
development. Failure to do so will often religion. Furthermore, the therapists role is
result in a relapse and the person returning to instrumental in the healing process, especially
the addictive problem or picking up an for Muslims who do not openly feel safe
alternative way to act out unresolved discussing their problems with close family and
problems. friends. Mental health professionals have the
3. Engage: A skilled therapist can effectively ability to develop secure relationships with
work with individuals who demonstrate clients that are essential in helping clients open
spiritual bypassing because they can hold up and tackle difficult emotions repressed in
and value both sides of the dilemma42. The their unconscious mind. Clients advanced in
therapist and client dyad can have a powerful their spiritual practices will attempt to bypass
effect that facilitates a flow of energy and emotional discomforts and prefer to work at the
information43 that expedites the healing spiritual level. Historically, therapy did not
process, and ultimately transforms the client. integrate spirituality as part of the healing
process. However, the growing practice of
Conclusions: incorporating spirituality in therapy presents
opportunities for better and more sustainable
There is a growing phenomenon of people healing.
turning to spiritual practices and beliefs to
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Shafranske (Ed.), Religion and the clinical practice of

HARM REDUCTION STRATEGY IN THE TREATMENT OF ADDICTION
IN THE CONTEXT OF ISLAMIC JURISPRUDENCE
Dr Imthiaz Hoosen* and Prof. Yasien Mohamed**
Abstract:
The recreational use of intoxicants in contemporary society is common and widespread and its
use is associated with a multitude of harms to the individual and to the wider society. Substance
abuse is a public health issue. Some countries treated addicts punitively and advocated an
abstinence only approach. This approach is associated with greater harms particularly amongst
injection drug users (IDUs). Harm Reduction is an alternative approach that allows addicts to
continue using intoxicants, but in a less risky manner. This approach is associated with less
harm. Despite its efficacy, there has been opposition to its implementation, particularly in
Muslim Countries. To enlighten the Muslim doctor and patient, we discuss the philosophy and
higher objectives of the Islamic law and explore how the principles of Islamic law can be applied
to the Harm Reduction approach in our contemporary setting. The understanding of maqasid-al-
Shariah (The Objectives of Islamic Jurisprudence) and proper application of its principles
provides an ethical framework through which we can apply the Harm Reduction approach in the
treatment of addiction in the Islamic context.
Keywords: Substance abuse, addiction, Islamic jurisprudence, Harm Reduction strategy,

addiction treatment.
Introduction:
Substance abuse is a complex, multi-faceted individuals would maintain their sobriety.
phenomenon. The use of intoxicants is clearly This traditional approach, while being of
prohibited in Islam, but in our time the use of benefit to some, has not been universally
intoxicants is wide spread and Muslims successful. There are some individuals who do
whether living in Muslim-majority or Western not wish to give up their substance abuse, but
countries are not immune to the harms of may benefit from using substances in a less
substance abuse and drug dependency. risky manner. There are others who have
The traditional focus of many countries' drug repeatedly failed to address their substance
policies and substance abuse services is to abuse using the traditional approach. There are
achieve abstinence. Addicts are encouraged to also those whose substance abuse may be so
attend drug rehabilitation centers, enroll in entrenched in their daily lives that abstinence
substance abuse programs, attend support may not be a realistic goal. For these
groups such as AA (alcoholics anonymous) or individuals a different strategy is needed to
NA (narcotics anonymous) or rely on support manage their substance abuse. Harm
of family or friends. It is expected that these Reduction is one such strategy.
*Dr. Imtiaz Hoosen ** Professor Yasien Mohamed

Consultant Psychiatrist Professor of Arabic Language
Lentegeur Psychiatric Hospital And Islamic Philosophy
Lecturer, Department of Psychiatry University of the Western Cape - South Africa
University of Cape Town - South Africa E-mail: [email protected]

HARM REDUCTION
This article is not a comprehensive review of the spread of blood-borne viruses, such as
the Harm Reduction Strategy, rather it aims to HIV, hepatitis B, hepatitis C, septicemia,
raise the issue of Harm Reduction as a public wound and other infections, drug overdose and
health intervention within the contemporary unintentional injury, which may lead to
Islamic context. We will first briefly discuss premature drug-related deaths.
the concept and impact of the Harm Reduction Harm Reduction strategies to reduce the risks
strategy and reflect on the changing attitudes associated with injection drug users may
and policies of drug treatment in some Muslim include measures such as:
countries. Next we will explore the Fiqh Reducing the sharing of injecting
(Islamic jurisprudence) principles that can be equipment by providing clean, sterile
applied to this approach. injecting equipment through needle and
syringe programs (NSPs)
Harm Reduction strategy: Giving advice about safe injecting
methods
There is no universal definition of Harm Providing drug consumption rooms
Reduction strategy nor is there a specific (DCRs),
methodology for Harm Reduction. Rather, Providing support for stopping injecting
Harm Reduction is a pragmatic approach behavior
which encompasses interventions, programs Distributing free condoms to reduce the
and policies that seek to reduce the health, risk of sexually transmitted diseases
social and economic harms of drug use to Providing substitution opioid drugs, such
individuals, communities and societies. as methadone and buprenorphine for
Substance Abuse is an issue that we cannot heroin users.
ignore, nor should we simply condemn Providing counseling services, peer
individuals who engage in this behavior. The education and outreach
Harm Reduction approach accepts that promoting public policies conducive to
substance abuse, whether legal or illicit, is a protecting the health of populations at
part of contemporary society. This does not risk1.
imply that Harm Reduction attempts to
minimize or ignores the real dangers Harm Reduction and Public Health:
associated with licit and illicit drug use.
Rather, it affirms that drug users themselves "Harm Reduction is an exemplar of a
are the primary agents for change. It is an mainstream public health intervention"2.
approach that seeks to empower users to share Public health is concerned about protecting the
information and to support each other in individuals' and populations' health through
engaging in strategies to reduce the harms of surveillance, identification and management of
their substance abuse. risks to health3,4.
Harm Reduction is thus a way of working Contemporary public health views risk and
towards minimizing the harmful effects of health decision-making as a responsibility of
drugs and improving the quality of lives of health conscious individuals whilst also
substance abusers, while acknowledging that emphasizing the significance of the social
cessation of all substance abuse is not environment in producing harm and in shaping
necessarily the criterion of success. the capacity of individuals and communities to
There is a wide range of harms that are avoid risk2,4,5. Mainstream public health
associated with licit and illicit substances use approaches thus recognizes the need to create
including legal problems, crime, social enabling environments to reduce risk and to
deprivation, family conflict, abuse and neglect, change behavior, by strengthening community
job loss and poor physical and mental health. actions and creating public policies which
In addition, there are particular harms support and promote health6. Europe is one of
associated with injecting drugs. These include the regions that is most supportive of Harm

HARM REDUCTION
Reduction policies and practices. Harm opioid users and other illicit drug users was
Reduction is a mainstream drug policy and the high17.
reduction of drug harms is a feature of the The spread of HIV infection promoted a
public health objectives of all the European change in legislation in Spain with new laws
Union Member States2. introduced in the 1990's changing the drug-
In 2003, the European Council adopted a free approach of treatment to one focused on
recommendation to prevent and reduce health- Harm Reduction17. This facilitated an
related harms associated with drug expansion of opioid agonist maintenance
dependence and it provided a framework for treatment (OAMT) in all regions of Spain.
action to assist member states to develop Methadone was available in the public health
strategies to reduce and prevent drug-related system free of charge, and was also available
harms through the implementation of Harm in private practice17.
Reduction services for problem drug users. After the change in legislation it was reported
The recommendation also sought to reduce the that there was a large increase in the number
number of drug-related deaths and extent of of patients receiving metha-done maintenance
health damage, including that related to HIV, treatment (MMT), there was a 125% increase
hepatitis B (HBV), hepatitis C (HCV) and in methadone centers, and a significant
tuberculosis (TB) 7. increase in the availability of MMT in
Harm Reduction strategies such as needle and prisons17. Syringe provision started in 1989,
syringe distribution and collection programs but it increased consider-ably during 1995
(NSPs) and substitution therapy are associated 1999. By 2012 Spain had seven supervised
with reductions in HIV incidence and drug- injection centers. Retroviral treatment was
related morbidity. In several settings Harm widely available free of charge for all HIV-
Reduction programs have been combined with positive in Spain since 1996 and its use was
voluntary counseling, testing services and associated with a reduction in progression to
antiretroviral therapy, thus improving access AIDS and a reduction in AIDS-related
to medical care for injection drug users (IDUs) mortality17,18.
and resulting in reduction in risky behaviors Since 1999, Spain has been one of the
2,8- 13
. countries with the highest levels of OAMT
Minimizing the risk of drug-related harms is coverage in the world19. By 2010 OAMT
thus a key public health issue, both in coverage had reached 60%20.
protecting the health of drug users and in The change to a Harm Reduction approach in
protecting the wider community. Spain and the expansion of the OAMT
coverage was associated with an increase in
Lessons from Spain: retention in treatment programs and a parallel
reduction in morbidity and mortality. The
In the early 1990's Spain had the largest death rate per 1000 person years reduced from
number of AIDS (Acquired Immune 59 in 1992 to 16 in 199917,18. In addition, there
Deficiency Syndrome) cases related to the was a steady decline in the number of new
injection of illicit drugs in Europe14. There HIV cases related to illicit drug injection and
were strict laws which limited access to opioid an improvement in health-related quality of
agonist maintenance treatments (OAMT), such life for individuals dependent on illicit
as methadone maintenance treatment (MMT), heroin17.
in Spain during the 1980s.
Treatment programs at that time followed a Harm Reduction in Muslim Countries:
drug-free approach that promoted abstinence.
Residential facilities were managed by people In their paper, "Emerging HIV Epidemics in
who were not health professionals, and Muslim Countries", Todd et al, discussed the
retention rates in treatment were low15,16. emerging HIV epidemic, the cultural respo-
Consequently the mortality among illicit nses and the changing government policies to

HARM REDUCTION
Harm Reduction strategies in three Muslim rapid increase in IDUs through the 1990's with
countries, namely Iran, Malaysia and the associated risky behaviors such as sharing
Afghanistan8. needles, resulting in an HIV epidemic among
It was reported that Iran had a punitive IDUs.
approach towards drug use which started in It was estimated that by the early 2000s 75%
the Khomeini regime and continued until the of all HIV cases were detected among IDUs26.
mid-1990s. The response to drug use and drug The accelerated HIV epidemic and evide-nce
trafficking was prison time and corporal of successful Harm Reduction models in other
punishment in all cases. countries led to the Malaysia's Ministry of
This was accompanied by an increase in the Health investing in Harm Reduction programs
overall use of drugs and a shift from opium to such as condom and needle distribution and
heroin use and from smoking to injecting methadone main-tenance8,26,27. In their paper
drugs. Todd, et al stated that "Afghanistan is at risk
Furthermore, the incarceration of large for a concentrated HIV epidemic due to
numbers of drug users, resulted in prison multiple factors, including high rates of risky
crowding, and created an ideal environment behaviors, low HIV knowledge, abject poverty
for injecting and sharing of needles, which and unemployment, large influxes of former
facilitated widespread HIV transmission. The refugees and displaced people into urban areas
compulsory abstinence-based programs in the with infrastructure unable to support the
rehabilitation camps were associated with high population, and psychological changes related
relapse rates and risky behavior. By 2001, it to conflict and displacement resulting in
was estimated that there were between greater propensity to engage in drug use"8.
200,000 and 300,000 IDUs in Iran, and the The National Drug Control Strategy for
estimated prevalence of HIV among the Afghanistan, approved by President Karzai in
incarcerated population was 7% to 20%, 2003, endorsed Harm Reduction inter-
between 1999 and 20028,21-24. venetions, including needle and syringe
Political and religious leaders in Iran exchange and distribution as a means to
recognized that incarceration and abstinence prevent transmission of blood-borne infec-
only treatment models were not successful in tions among IDUs8,28.
addressing the continued increase in the
number of drug users and the rise in the rates The challenge of Harm Reduction
of HIV among injection drug users. This led to Strategies in Islamic countries:
a review of government policy and subseque-
ntly various Harm Reduction strategies were The challenge of Harm Reduction in Muslim
introduced, including drop-in centers, countries is that the use of intoxicants and
triangular clinics, substitution therapy and extramarital relations are clearly forbidden in
outreach based needle and syringe distribution Islam and this has been used as a justification
and collection programs8,22,25. by some, not to distribute sterile needles and
Malaysia previously had a similar punitive condoms, as it implies an approval for this
approach to drug use as Iran, with drug illicit behavior. Others believe that infected
traffickers receiving mandatory capital IDUs should be punished and isolated from
punishment, imposed rehabilitation, imprison- society and that no investment should be made
ment and corporal punishment for convicted towards such individuals29.
drug users. This led to wide-spread stigma and In Malaysia there was opposition to Harm
avoidance of services by drug users due to fear Reduction programs from religious leaders
of legal repercussions. Religious and political and the Islamic community. The Prime
leaders also initially opposed Harm Reduction Minister of Malaysia, however, supported
strate-gies8,25,26. Harm Reduction as did the Institute for
Malaysia's zero tolerance approach to drug use Islamic Understanding of Malaysia, which
failed to curb the problem, and there was a declared that Harm Reduction was a public

HARM REDUCTION
health issue which did not violate shariah drug addiction and its related harms, but the
law8,30. Islamic prohibitions and the negative beliefs of
Similarly, in Afghanistan, religious leaders religious leaders in particular regions make it
who are a powerful advocacy group, believe difficult to do so.
that abuse of drugs is completely forbidden, In the following section we would like to
and that substitution therapy or use of opioids present our understanding of the concept of
in the treatment of addiction is not acceptable, Harm Reduction in light of the Islamic
as Islam requires total sobriety8,31. jurisprudence. It is not our purpose to delve
Police harassment, community disapproval, into the minutiae of Islamic law, nor is it our
lack of community support, limited Harm intention to formulate a formal fatwah (Islamic
Reduction activities and delays in govern- legal opinion) which for an Islamic Jurist may
ments' recognition and response to intravenous be a relatively straightforward matter.
drug use have been associated with continued Rather, our aim is to discuss the broad Islamic
risky injecting behavior and increasing HIV jurisprudence principles and textual evidences
rates8,11,25,32,33. (Quran and Hadith) that could be applied to
this issue for the purpose of enlightening the
Islamic Jurisprudence Muslim health practitioner who may be
And Harm Reduction: delivering such services, and for the Muslim
patient who may be a recipient of Harm
The abstinence only approach to drug Reduction interventions.
addiction has been unsuccessful in stemming Thus, when examining this issue, the Islamic
the spread of HIV among injecting drug users legal framework is our main theoretical point
(IDUs) and the punitive approach to drug of departure for the justification of using Harm
addiction in Muslim countries was counter- Reduction strategies as a public health
productive. On the other hand, Harm intervention.
Reduction programs have been found to be We shall therefore start by explaining what we
efficacious as a public health intervention, in mean by Maqasid al-Shariah (Objectives of
both Western and Muslim countries. However, the Islamic jurisprudence) and how scholars
social, cultural and religious beliefs have use it as the basis of rulings. This method is
adversely affected the implementation of these known as the Maqasid school of thought.
programs in certain regions.
Harm Reduction strategies include providing The Maqasid School of Thought:
the addict with substitute opioid drugs, clean
needles and syringes, drug consumption rooms Sheikh Yusuf al-Qaradawi, and Muslim
and condoms. Islam however, prohibits the use scholars like Tariq Ramadan and Hashim
of intoxicants and premarital and extramarital Kamali are among the contemporary scholars
sex. This has been used as a justification that call for the revival of Ijtihad within the
against the implementation of Harm Reduction framework of Maqasid al-Shariah. Ijtihad
strategies by some, because they view this as refers to the use of reason in the application of
approving and facilitating practices which are Islamic law in a contemporary social context.
prohibited in Islam. Thus, in certain countries These scholars hold the view that it is not
and among certain communities a conflict sufficient for verdicts to be passed purely on
exists between the need to implement and the basis of classical legal texts, or apply qiyas
support Harm Reduction strategies and the (analogical reasoning) only on the basis of the
social, religious and cultural inhibitions to its Quran and Hadith. Instead, they postulate that
implementation. one has to also take into account the
This also presents the Muslim health Objectives of the Islamic Law. This approach
practitioner, practicing in these regions, with a is not inconsistent with the approach of the
dilemma. The Muslim health practitioner Four Imams; albeit that they applied it in an
needs to respond to the growing problem of intuitive way. Imam al-Ghazali (d. 1111) was

HARM REDUCTION
the first to explicitly identify the Objectives of context in which it is considered and
the Law, and to place them into five evaluated. This point can be applied to eating
categories34. pork, which is normally prohibited, but in the
Maslahah (public welfare) refers to anything absence of other food, it is permitted for the
that is either useful (manfaah) or warding off sake of preserving ones life35.
something harmful (madarrah), and this can It is in this context that we wish to pose the
be achieved by preserving the Objectives of following question: Is it permissible to provide
the Law, which consists of the following five addicts with substitute drugs which are
principles (usul) in order of rank. potentially addictive and intoxicating?. Is it
1. Preserving religion (din). permissible to teach addicts safer ways to
2. Preserving life (nafs). administer drugs, to provide them with clean
3. Preserving intellect or reason (aql). syringes and needles, and to provide condoms
4. Preserving progeny (nasl). to unmarried drug users? These are practices
5. Preserving property or wealth (mal). which are not normally permitted in Islam, but
they are used in Harm Reduction strategies to
What ensures the preservation of these five minimize the risks that addicts pose to
principles (usul) is maslahah; what goes themselves and to the wider society.
against their preservation is mafsadah34,35. The Objectives of the Law (Maqasid al-
Al-Ghazali went beyond the reading of rulings Shariah) are meant to promote good and to
of the classical scholars, and expected that the prevent harm. These are universal principles to
jurists, in providing new rulings to new be shared by all, and so should be considered
situations, should constantly keep in mind the when implementing the rulings derived from
higher Objectives of the Law. Al-Ghazalis texts. This school of Maqasid provides an
main question is: how one can remain faithful ethical framework through which we can
to the objectives of scriptural sources when approach the question of Harm Reduction. We
implementing legal rulings (al-fiqh) in the should therefore distinguish what is beneficial
field of social affairs and interpersonal from what is harmful; and if what is beneficial
relations (al-muamalat) 35. This fresh requires that we need to use substances that
approach enabled the legal scholars to not only are unlawful (haram), or to promote practices
be faithful to the texts, but also to be confident that are not usually condoned in Islam, such as
and flexible with the new social contexts in providing unmarried drug users with condoms,
which they found themselves. then we should be absolutely clear that in
The main philosophical point of departure for approving the use of the unlawful substances
the maqasid school of thought is that all and practices, it will be beneficial to the
commands and prohibitions contained in the society as a whole. If it benefits the society in
revealed text and in the sunnah are intended to general, and it prevents harm to the general
promote the good and to benefit the human public then we have a clear case of supporting
beings, and to protect them from evil, harm such interventions.
and suffering. The objectives of the Law The modern approach to Harm Reduction is
should be harmonized with their contexts, concerned with the alleviation of suffering of
thus, texts should be examined in the light of the patient, and in this respect it is in
public interest. Al-Shatibi introduced a sixth consonance with the Objective of the Law, but
objective, dignity/honour (al-ird). Al-Shatibi Muslim health practitioners have to also know
adopted a strict conservative approach with whether what they are doing will earn the
respect to belief and worship, but adopted a pleasure of Allah ( )or not. It is within this
flexible approach when it came to human spirit that we want to provide an Islamic
relations (muamalat). He pointed out that perspective to the issue of Harm Reduction.
although an action may be permissible, The Islamic approach is not purely utilitarian,
recommended, objectionable or even unlawful but seeks to find biomedical solutions to
in itself, its status can change according to the problems that are logically consistent with the

HARM REDUCTION
Objectives of the law and the Islamic "Muslims are bound by their stipulations
metaphysical framework. unless it be a condition which turns a halal
into haram or a haram into a halaal"42.
Maslahah (public welfare): These ahadith provide justification for jurists
to consider what is beneficial, provided that it
As mentioned, maslahah is achieved when any does not conflict with the Quran and Hadith.
of the five Objectives of the Law are fulfilled, This permits Muslim jurists to take advantage
and in the interest of maslahah one ruling may of the concessions in the law based on the
be harmful in one instance and beneficial in following hadith:
another. Kamali states: The masalih (plural "God loves to see His concessions are
of maslahah), can neither be enumerated nor observed, just as He loves to see His strict
predicted in advance as they change according laws are obeyed" 36,43.
to time and circumstances. Thus a law may be The Hadith quoted above, pertaining to the
beneficial at one time and harmful at another; easier of the two alternatives, is significant as
and even at one and the same time, it may be the immediate and total abstention of
beneficial under certain conditions, but prove intoxicants for a number of individuals is far
to be harmful in other circumstances36. more difficult than a gradual reduction.
Scholars have quoted the following Quranic As pointed out earlier, some Muslim countries
verses in support of maslahah: had a punitive approach to drug addiction and
" "
they adopted an abstinence only approach, but
"And we have not sent you (O Muhammad) this was not effective, particularly in curbing
except as a mercy to the worlds"37. the harms associated with injection of drugs,
rather it exacerbated the problem. They later

" introduced Harm Reduction strategies, such as

" providing addicts with substitute drugs and
"O mankind, there has to come to you clean syringes and needles which proved to be
instruction from your Lord and healing for more effective. Here the Fiqh principle of the
what is in the breasts and guidance and mercy lesser of the two evils (akhaf al-dararayn)
for the believers"38. would apply, that is, it is permissible to
provide the unlawful substance to the addict in

..."

"... order to reduce the harms and risks that the
addict poses to him/herself and to the wider
"Allah intends for you ease and does not society. Another fiqh principle that can be
intend for you hardship"39. applied is "necessity makes what is forbidden
Thus, one should not stand in the way of permissible"35. With the Harm Reduction
assisting humanity towards lifting them out of approach, addicts may not achieve total
suffering, nor of obstructing their healing. abstinence, and they may still indulge in drug
Qualities of mercy and compassion are divine use, but they do so in a less risky manner, thus
qualities that we are encouraged to emulate in minimizing the harms to themselves and
others.
order to attain nearness to Allah ().
Furthermore, by utilizing the Harm Reduction
Scholars have also quoted the following
approach, there is a greater likelihood that the
Ahadith or prophetic sayings in support of
addict will be retained in treatment; be more
maslahah36.
willing to engage with health professionals
"No harm shall be inflicted or reciprocated in
and may be more receptive to Islamic
Islam"40.
psychological therapy which may motivate
"He (the Prophet ( )only chose the easier them towards total abstinence. Islamic
of two alternatives, so long as it did not psychotherapy requires separate discussion,
amount to a sin" 41. but suffice it to say that ideally it should go
hand in hand with medication.

HARM REDUCTION
As mentioned above, Maslahah pertains to the their families, and lose their wealth, property
welfare of the society as a whole, and the and dignity. If Harm Reduction strategies can
Harm Reduction approach fulfils this prevent such harms to the individual and to the
objective. The research evidence has proven society then they can be made permissible on
that it reduces the risks and harms to the the grounds that they are fulfilling the
individuals, and consequently to the society. Objectives of Islamic Jurisprudence.
The risky behavior of the drug addict, if not
curbed, can adversely affect the society A Graduated Approach:
through crime, loss of employment, increased
healthcare costs, breakdown of family During the early period of Islam, there was a
relations, and the spread of diseases. When graduated approach to reducing the use of
viewed from this perspective, Harm Reduction alcohol amongst the population, rather than an
is a better alternative to total and immediate immediate and absolute prohibition. This is
abstention. Needless to say, we cannot rule out evidenced by the extended period over which
total abstinence as an option. If it works for an the verses which dealt with alcohol
individual, it should be applied. (intoxications) were revealed and the content
Shifting the focus to the Objectives of the Law of the verses.
allows us to view the matter in a broader The first verse coveys the message that there is
ethical perspective. more harm than good in alcohol:
This would facilitate a more constructive and

"
harmonious understanding between the
"...
Muslim jurists and medical-scientific comm-
unity and it would allow Muslim jurists to pass "They ask you about wine and gambling. Say,
rulings that are more flexible and realistic to in them is great sin and [yet, some] benefit for
our contemporary context. people. But their sin is greater than their
All legal rulings that are clear and decisive in benefit"44.
the Quran, are applicable for all times.36 The The next verse regarding alcohol warned the
prohibition of alcohol falls under this believers not to attend prayers while
category, but when it comes to preservation of intoxicated.

life, when there is no alternative, concessions
"
have to be made, as in the case of consuming "...
pork when no other food is available. "O you who have believed, do not approach
With respect to alcohol, even if permissible prayer while you are intoxicated so that you
drinks are available, some jurists have made know what you are saying45.
concessions where alcohol is used for
medicinal purposes. Drug-abuse, like wine, The believers would thus have had to reduce
leads to intoxication, so it is clearly prohibited the frequency and quantity of their alcohol
in Islam. This is applicable to the individual, consumption if they wanted to attend prayers
but when the use of these substances has without being intoxicated.
implications for cure, and for the potential Finally, only during the Medina period was the
preservation of human life, or for benefit to conclusive command prohibiting alcohol
the society as a whole, then that may be a revealed:
different matter.

Substance abuse, can adversely affect the

"
objectives of Islamic Jurisprudence, which are
"
there to protect the individuals life, religion, "O you who have believed, indeed, intoxicants,
progeny, wealth, intellect, and even dignity. gambling, [sacrificing on] stone alters [to
Addicts are likely to neglect their religious other than Allah], and divining arrows are but
practices, place their lives and those of others defilement from the work of Satan, so avoid
at risk, compromise their intellect, destroy them that you may be successful" 46 .

HARM REDUCTION
Yusuf bin Mahk narrated that Aisha (RA), the intoxicants. There is no dispute in Islam about
mother of the believers said:" If the first thing the prohibition of intoxic-ants such as alcohol
to be revealed was: "Do not drink alcohol" the or drugs and no Muslim can be excused from
people would have said:"We will never leave abusing them, but here again, we have to
alcohol", and if it had been revealed, "Do not consider the intentions of the Islamic law
commit fornication" they would have said "we which is to protect the individual and the
will never give up fornication"47. society. Addicts are responsible for their
The consumption of alcohol was widespread actions and the use of intoxicants is prohibited
practice amongst the pre-Islamic Arabs and and sinful in Islam, but we also approach the
according to the narration from Aysha (RA) matter from the point of view that addiction is
had alcohol been prohibited from the outset, an illness, a disease, thus the addict requires
the immediate response from the people would treatment and not punishment. Treatment for
have been negative, and they would not have addiction can include Harm Reduction
desisted from this practice and it may have strategies, thus from a Shariah point of view,
prevented them from accepting Islam. The this makes the impermissible, permissible.
Quranic verses and the narration of Aisha Furthermore, Islam teaches us compassion
(RA) indicate that the methodology adopted in towards the sick, no matter the cause of their
the early stages of Islam when dealing with the sickness and it is not the duty of the health
use of intoxicants was quite similar to the practitioner to pass moral judgments, but only
modern day Harm Reduction approach. Both to care for the patient.
approaches did not have abstinence as the
primary goal and they allowed individuals to Conclusions:
continue using intoxicants for a rather long
period of time. This facilitates the long-term First we discussed the principles of the Harm
engagement of those individuals during which Reduction and presented evidence of its
the focus is on motivating them to change, but efficacy as a public health intervention in non-
without compelling or imposing changes on Muslim and Muslim countries. We also
them from the start. From an Islamic pointed out that a punitive and abstinence only
perspective, the gradual prohibition of alcohol approach which was implemented by some
allowed people to initially accept Islam countries was not only unsuccessful, but was
without having to change their drinking also associated with greater harms. Despite the
behavior and it provided the population time efficacy of Harm Reduction strategies, it had
to work on strengthening their belief and faith been a challenge to implement it in certain
(inner change) so that they were ready to give regions, due to opposition from religious
up alcohol when the laws prohibiting its use leaders. We then discussed the Islamic
were revealed (external change). theoretical legal framework and the higher
In a similar manner contemporary health objectives of the Shariah. We explored how
professionals who adopt the Harm Reduc-tion this could be applied to the Harm Reduction
approach use various Harm Reduction approach and we demonstrated that Harm
strategies, motivational interviewing tech- Reduction is consistent with the philo-sophy
niques and other psychological techniques to and the higher objectives of Islamic law. The
gradually shift the addict from a state of high Muslim doctors and patients should thus have
risk use to using substances in a less risky a clear conscience that they are acting within
manner, from using substances frequently to the Islamic legal framework. With regards to
less frequent use and from having a chaotic the prescribing of such substances, the
lifestyle to having more stability. consumption of it and the promotion of
It is essential that ordinary people do not practices which reduces harms to the
confuse this temporary permissibility to use individual and to the wider society. In an ideal
drugs in a specific context with the usual Muslim society, we envisage that addicts
Islamic legalization which prohibits the use of should be managed in a comprehensive

HARM REDUCTION
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ISLAMIC PERSPECTIVES ON PROPHYLAXIS
AND THERAPY OF ADDICTION
Mahmoud Abu Dannoun*
Abstract:
Addiction, or substance dependence, is a global dilemma affecting societies in varying

degrees with grave consequences on health, psychosocial and economic aspects.
Worldwide programs to prevent or to manage addiction have been, to a large extent,
disappointing with no light at the end of the tunnel.
In this paper, the salient features of substance abuse, their main underlying causes, as
well as the social, medical and governmental responses and attitudes of prophylaxis and
management of addiction will be reviewed.
The Islamic approach to alcohol, the earliest addictive substance, will be illustrated, as an
example of a historical effective success.
Keywords: Addiction, alcohol abuse, Islamic Shariah.
Introduction:
Allah ( )created humans in the best of any kind of imbalance, will induce
moulds with perfection of structure and functional derangements of thinking,
function of all organs, and delicate balance emotion, memory, concentration, percep-
between its various components including tion or hallucination2.
microconstituents. This perfection includes Proper and balanced nutrition, and vascular
brain functions with various intercellular nourishment of the brain, are major factors
neurotransmitters1 and other factors. The that maintain normal brain function3. Any
brain performs various functions utilizing unhealthy addition, such as a medication or
an intricate and extensive number of cells a psychotropic substance causes significant
and factors, with extremely delicate derangements and deleterious influences
systems, the breakdown of any of them, by on brain functions4.
*Dr. Mahmoud Abu Dannoun

Consultant Psychiatrist
Ex-Director of the National Center for Mental Health
Amman-Jordan
E-mail:[email protected]

ISLAMIC PERSPECTIVES
Substance addiction is an outcome of the CNS depressants, e.g. alcohol, opiates,

effects of a certain drug as the body sedatives and hypnotics.
systems have to adjust to the substance by CNS stimulants, e.g. amphetamines.
incorporating it into normal body Hallucinogens, e.g. Lysergic acid
functioning5. The opioids, as an example, diethylamide (LSD).
produce their effects by binding to Addictive substances are also divided into
different types of receptors in the central natural substances (alcohol, opiates,
nervous system (CNS). cannabis), and synthetic (sedatives and
Endogenous opioid peptides (i.e. analgesic medications).
enkephalins, endorphins and others) appear
to function as natural ligands for opioid An epidemiological overview:
receptors. There is evidence that these
natural opioid peptides are involved in the Since the dawn of history, man embarked
production of euphoria, analgesia and other on consumption of addictive substances,
effects of the opioids6. This state creates starting with alcohol. Whenever a new
the conditions of tolerance and withdrawal. addictive substance is discovered and used,
Tolerance is the process by which the body man diligently propagated it, included it in
continually adapts to the substance and industries, marketing and business
requires increasingly larger amounts to transactions. Man also surrounded such
achieve the original affects. Withdrawal substances with rituals, rites and traditions.
refers to physical and psychological In contemporary times, humanity is
symptoms experienced upon reducing or witnessing the worst and the largest
discontinuing the substance. numbers of addicted individuals and
These symptoms generally include, but addictive substances.
are not limited to anxiety, irritability, Media, advertisement, feasibility of travel
intensive craving for the substance, nausea, and transport and mounting psychological
hallucinations, headaches, cold sweats and pressures provide major incentives to
tremors. Once physical dependence has addiction. Some individuals with
been established, a strong desire emerges psychological and psychiatric disturbances
to avoid the negative affective states usually resort to addictive substances in
associated with withdrawal. Withdrawal attempts to rid themselves of their
symptoms are usually severe and symptoms, such as anxiety9-11, or to avoid
intolerable, and manifest the opposite consulting a psychiatrist in order to avoid
feelings of the original effects of the stigmatization.
addictive drug6. There is ongoing scientific Medical practitioners may also play a
debate on biological mechanisms of negative role by over-prescribing of
addiction. Genetics, family history, mental sedatives, hypnotics, stimulants and
and personality disorders, environmental analgesics. The most significant factor,
factors and social interactions are among however, is the abundant availability, as
various theories of addiction7, which are well as the accessibility of some major
continuously evolving. Several brain addictive substances. Alcohol is one major
regions are involved in the biological example. Many societies look upon
mechanisms of addiction. Mentally drinking alcoholic beverages as normal
effective substances are subdivided into and socially acceptable behavior. Even in
three main categories8: many Muslim countries, alcohol factories,
sale of these beverages in restaurants and

cafes is widespread, with nominal and who sold drugs at their school. Asked what
ineffective restrictions. Only very few drugs students sold on school grounds,
countries have legislations to ban alcohol. 91% said marijuana, 24% said prescription
Various types of tobacco smoking are drugs, 9% said cocaine and 7% said
alarmingly widespread, even among ecstasy. The survey also revealed that 52%
younger age groups and women. of high school students said that there was
Qat in Yemen and some other countries, is a place on school grounds or near school
widely available, and its use is established where students can go to use drugs, drink
as an acceptable and common social habit. or smoke during the school day, and 36%
It is disturbing to note the widespread use said it was easy for students to use drugs,
of these freely available and accessible drink or smoke during the school day
addictive materials to younger age groups, without getting caught. 75% of 12-to-17-
even teenagers. This is attributable to the year-olds said that seeing pictures of teens
influence of bad company (peer pressure), partying with alcohol or marijuana on
and the youngsters' desire of experimenta- Facebook, MySpace or another social
tion. networking site encouraged other teens to
want to party like that. 45% of teens have
In USA, a survey was conducted from seen pictures on social networking sites of
Casa, Columbia, by the National Survey on other teens getting drunk, passing out or
American Attitudes on Substance Abuse using drugs, and 47% of teens who have
XVII: Teens12, published in August 2012. seen these pictures said that it seemed like
This survey aimed to identify the the teens in the pictures were having a
situations, individual and family good time.
characteristics, and social factors that are There is no doubt that legislations and law
associated with teen drug abuse and enforcement are instrumental in curbing
addiction. Its primary purpose was to track the spread of the addiction phenomenon,
attitudes of teens and those, like parents, provided the drugs are legally prohibited
who have the greatest influence on whether and their availability and accessibility are
teens will smoke, drink, get drunk, use curtailed. Otherwise law enforcement will
illegal drugs, or abuse prescription drugs. have limited impact.
CASA Columbias teen surveys have
consistently found that the family is The Islamic Response and Guidance in
fundamental to keeping children away Elimination of Addiction:
from tobacco, alcohol and illegal drugs.
Teen drug abuse plays a major role in In the early days of Islam, addiction was
addiction. People who do not use tobacco, rampant in Makkah society and the rest of
alcohol or illegal drugs or misuse Arabian Peninsula. At that time the
prescription drugs before age 21 are addictive substance was alcohol, which
virtually certain never to do so. This report was abundantly available in view of easy
outlines several teen drug abuse facts and access, and abundance of natural substrates
teen drug abuse statistics. from food materials such as dates, grapes,
The survey found that 86% of American barley and others. These easily available
high school students said that some and inexpensive materials provided for
classmates drink, use drugs and smoke deep rooted traditions of consumption,
during the school day. Additionally, 44% enjoyment, rituals and lack of concern to
of high school students knew a student the harms alcohol inflicts on the body and

mind. With the advent of Islam, alcohol This was followed by the Quranic
consumption was a subject matter of the response to the posed notions of the
Islamic guidance for protection and apparently positive or useful benefits of
remedy of its various evils, taking in alcohol. These are sedation, relief of
consideration the long term rigorous tension, improving sleep, stress
traditional endorsement of its use in amelioration, appetite improvement, in
society. Alcohol was dealt with as a addition to other materialistic/financial
prominent and rampant example of other benefits such as securing jobs in alcohol
addictive substances that appeared in preparation and market-ing.etc. The
succession in future times. Islamic Glorious Quran responds to all of that in a
teachings came in a gradual manner with clear and expressive manner:
guidance exposing its various vicious side
effects in various dimensions. The initial
"
step of Islamic guidance was directed
"....
towards cognitive understanding of its
harmful effects in the face of general and They ask you concerning wine and
widespread conviction that alcohol is both gambling. Say: In them is great sin, and
nutritious, healthy and joyous. The first some benefits for mankind, but their sin is
Quranic verse that was revealed on that greater than the benefit..14.
topic classified food materials into those
that fall under good subsistence (rizk This Quranic verse does not negate the
hasan), vs (rizk that is not hasan) to which benefits of alcohol, but it places that in the
alcohol belongs. Alcohol was classified as overall balance of minimal positive vs.
an intoxicating material. major negative aspects. It asserts that the
destructive effects surpass any benefit and
" confirms its classification as not to be a

good subsistence.

" This balancing is valid at all times, in view
And from the fruits of the date-palm and of proven harmful effects caused by
the vine you get out (intoxicating) drink alcohol on the physical, psychological,
and good food: behold, in this also is a mental and socio-economic status of the
sign for those who are wise addicted and their families.Alcohol abuse
13
(intellectuals) . is also responsible for mental breakdown,
From this verse, it became clear that the increased crime rates, including rape, and
basic effect of alcohol is its intoxicating incest, as well as increased road accidents
effect. That was the underlying basis on commonly resulting in fatalities. Human
which Muslim jurists established the ruling experience reveals major preponderance of
of alcohol prohibition (tahrim). On that economic losses that far exceed any gains
basis, the same rulings were applied to any from manufacturing and marketing of this
other substance that causes intoxication, substance.
disturbance of cognition and conscious- Later on, with the gradual Quranic
ness. Such ruling is applied to all these approach of eliminating alcohol, and
substances based on their effects, with no parallel to building up of the new Muslim
regards to their chemical structure, or other personality with new Islamic value system
laboratory or scientific means of in faith, commitment and behavior, the
characterization. glorious Quran provided the next step:


" Eschew (avoid) such (abomination) that

you may prosper17.
"....
You who believe! Approach not prayers
with a mind befogged (intoxicated) so that

"

you can understand (comprehend) all that "
you say (in prayer).. 15 Satans plan is (but) to excite enmity and
This new step represented a new stage with hatred between you, with intoxicants
significant prophylactic and therapeutic (Khamr, alcohol) and gambling, and
dimensions. It is known that alcohol half- hinder you from the remembrance of Allah,
life in the blood is approximately six and from prayer: Will you not then
hours. For the faithful who wants to abstain?18.
perform his regular timed daily prayers, Choosing the word (avoid) has more
most of which are approximately 2 to 4 significance than other expressions such
hours apart from noon to evening, has not as: (do not drink it), or (stay away from it).
to consume alcohol except following Avoidance includes the meanings of
Ishaa prayer (late evening) or following avoiding to manufacture, sell, buy,
the fajr (dawn) prayer. This means consume, or socialize with individuals
elimination of drinking episodes, which while engaged in drinking, or even looking
will interrupt the addiction requirements of at the substance.
around 4 drinks per day as a minimum These Quranic verses associated alcohol
down to only two, which may ease the, (Khamr) along with other major vices and
transition to abstinence with minimal deviations, such as gambling, stone
withdrawal sequelae. In doing so, it casting, hatred, enmity and social
becomes easier on individuals to free disruptions, as instigations from Satan.
themselves from withdrawal consequences, This concept was deeply established in the
as opposed to abrupt cessation which may conscious, mind and conduct of Muslim
result in grave consequences, including the individuals and societies ever since. An
possibility of lethal delirium tremens 16. Internal barrier became deep-rooted at
This stage of gradual discontinuation came all times.
in parallel with the progress in nurturing This major turn of events was so decisive.
and building of the sound Muslim Alcohol was absolutely eliminated from
personality with genuine faith (iman), the Muslim society. The faithful
sound behavior (suluk), and proper outlook committed early Muslims responded
to the paradigm of human life on this earth obediently. Whatever alcoholic beverages
and the hereafter. were stored in their homes were disposed
The fourth, and final stage came as a of. Whatever jars and various containers
distinct and decisive commandment, with that used to be filled with alcohol were
the Quranic revelation: destroyed. They spilled alcohol in the

" roadsides of Medina, while chanting

prayers and expressions of obedience and
"
faith19.
You who believe! intoxicants (Khamr- Islam follows a similar approach towards
alcohol) and gambling, dedication of any other addictive substance that impairs
stones, and divination by arrows, are brain function, by elimination of their
abominations of Satans handwork: existence in society, in addition to building

internal human barrier towards their use. purposes (maqasid) is prohibited (haram)
This undertaking contrasts with what we by analogy (qiyas)24.
witness nowadays where inefficient and Islam establishes the faith concept as the
ineffective policies are based on main prophylaxis against addiction. Faith
limitations of the substance in certain and religious commitment stand as
places and age groups, which does not guardians that links alcohol and other
effectively combat the addiction problem. intoxicants to evil behavior, low morality
Islam established a road map to deal with and poor manners.
addictive substances along the following In a hadith narrated by Uthman ibn A'ffan
lines: (RA), the Prophet ( )said:
1.Alcohol was considered a standard
"
criterion to judge possible addictive

substances as either permitted (halal)
:
prohibited (harm) or abhorred (makruh).

2.The underlying reason upon which a
:
ruling is adopted toward any possible

addictive substance, is its actual intoxicant
: .
influence. Any substance that imparts
: :
similar effects on mans mental processes,

cognition consciousness and ability to
."
perform his roles in this life, will acquire
Avoid Khamr (alcohol) because it is the
the same ruling as that of alcohol. The
mother of all wickedness. In past
legal maxims applied in this context are:
generations there was a devout man who
Any intoxicant is khamr (alcohol) and any
was approached by a seducer woman who
khamr is haram (prohibited)"20.
sent her maid to summon him for
Any substance that causes intoxication if
testimony. When he responded and entered
taken in large quantities is prohibited
the womans home, the maid led him in
(haram) even if consumed in small
and locked every door behind him until he
quantities" 21.
ended up to a glowing woman, with a boy
Intoxication, being a significant cause of
and an alcohol container. The woman
harm, whether known, unknown, or
explained she did not summon him for
expected, falls under the broader legal
testimony, and instead she gave him the
maxim "No harm and no infliction of
choice of committing adultery with her, or
harm22.
to drink the wine, or to kill the boy. He
3.The concept of prohibition (tahrim) in
choose drinking wine, cup after cup, and
Islam is linked to faith and its
ended up in committing adultery with her
manifestations, such as the prayers, zakat
and killing the boy. Avoid khamr
etc. The faith authority or infleunce is a
(alcohol), for faith and drinking alcohol
strong basis for the faithful (believer) to
will never be combined unless one of them
avoid addictive substances.
expels the other 25.
Islam established maqasid al-Shariah (the
Islam imposes a worldly punishment of
purposes of Islamic Law). These are:
whipping for drinking alcohol. The
protection of religion, life, mind, progeny
and wealth23. Any intoxicant substance Prophet ( )said:
which may negatively impact any of these Flog (punish by whipping) any person
who drinks Khamr (alcohol) 26.

The Prophet ( )warned alcohol societies, with negative and condemning

drinkers with punishment in the Hereafter, attitudes towards any individual who
in the hadith: commits this rejected aberration.
" In the USA, there was a determined trial
"... to legally ban alcohol and to impose
": abstention throughout the country from
: " 1919 to 1933. Unfortunately this attempt
." " : ended up in disastrous failure 30-31.
Whoever drinks khamr (alcohol), his Most countries of the world, have given
prayers for 40 nights will not be accepted. up combating alcohol use and its
If he dies, he will enter hell fire, and if he consequences. Alcohol consumption is
repents, Allah will accept his legalized, with practically nominal, largely
repentance . 27 fruitless restrictions, such as avoiding
The Hadith ends by:And if he goes back alcohol while driving, prohibiting the sale
to drinking, Allah will make him drink of alcoholic drinks to minors (below
from radghat al khabal on the day of certain ages)etc.
judgment 27. Lack of commitment by the governments
When the prophet ( )was asked about and individuals, alcohol industry influence
radghat al-khabal, the Prophet said: It and advertisement are among the main
is the extract of the people of hell fire. factors of failure to combat alcohol
dependence in the communities. This
The Prophet ( )made it one of his
resulted in overwhelming disastrous
directives (wassiyyah) to some of his
consequences on individuals, societies,
companions:
national health, socioeconomic and other
Do not make any partners to Allah, even
parameters.
if you were torn to pieces or burnt, and do
It is an irony to note the liberalization and
not drink khamr28.
legalization of alcohol, while trying to
In another hadith, the Prophet () combat other addicting substances which
responded to an inquiry about whether pose less deleterious consequences than
khamr could be used as medicine: It is a alcoholic beverages.
malady (disease) and not a remedy29. The following may be illustrative of the
differences between the Islamic and non-
Where Islamic Approach Succeeded and Islamic styles of approach:
Others Failed? ( 1 ) Islamic approach prevents the
occurrence of addiction by stressing the
The success of Islam in eradicating the individual internal motives of faith, and
alcohol habit and substance addiction in outlook to a righteous life. Islam aims at
general, is manifested by the fact that establishing a sound lifestyle of humans
Muslim societies have been largely free and their societies on this earth, to rid them
from addiction throughout history. Even at from any behavior, habit or substance that
times when Islamic ideology lost its curtail their roles in this life, including any
leadership role due to political and material that impairs cognition and
socioeconomic deterioration in many hampers humans from performing their
countries, most Muslim societies continued sound and constructive roles towards
to be relatively safe and immune to the themselves, their societies and humankind
various disasters of addiction. Only limited in general. It is noteworthy that, in spite of
instances of addiction remain in Muslim

various current political and socioecono- Building the internal value system, based
mic influences, Muslim societies, from on faith, purity, injunction of what is
different regions of the world that vary in beneficial and fair, rejecting of all evil,
their racial / ethnic backgrounds and have harmful and reprehensible actions, and
different cultures, are the least affected by seeking the pleasure of Allah ( )in all
the problem of addiction, among all world endeavors..are all instrumental in
nations. When African American (black nurturing human beings immunity to all
American) prisoners with various addiction kinds of ill-behaviors.
problems embrace Islam there was a
remarkable change in their behaviors. The Muslim society, composed of such
Many of them turned away from drug individuals, strongly rejects substance
addiction and crime, and were resurrected, addiction behaviors. Any individual who
as James Baldwin wrote in his book: The has any dealings with addictive substances
Fire Next Time32 about his fellow black is looked upon as anti-society culture
Americans: that is an outcast. This overwhelming
And now, suddenly people who have social factor stands strongly and
never before been able to hear this effectively as a guard. And when this is
message of Islam, hear it and believe it, combined with the non-availability/
and are changed . (Islam) has been able accessibility, all bases of success are
to do what generations of welfare workers guaranteed.
and committees, resolutions and reports This approach is contrasted to
and housing projects and playgrounds have contemporary dealings by various
failed to do: to heal and redeem drunkards authorities which are based on
and junkies, to convert people who have governmental laws and regulations with
come out of prisons and keep them out, to various limitations and exceptions in the
make them chaste, and women virtuous, context of free availability of substances,
and to invest both male and female with such as alcohol, tobacco, and in some
pride and serenity that hang about them countries, other addiction substances as
like unfailing light 32. well.
One of the main points in Islamic dealing The example of alcohol is more manifest.
with substance abuse is the issue of easy With its free availability and accessibility,
availability of the substance, within reach current regulations in most countries
of people, which represents a formidable around the world, prohibit its sale below
obstacle in all efforts to combat the certain age limits, e.g. 18 years of age.
problem. Such youngsters could easily obtain it from
In this regards, one of the principal pillars their peers who are above that age limit or
of the Islamic approach to eradicate from their own homes, and pursue the
substance addiction was to prevent the addiction path from that early age.
very existence of the substance in society.
Taking alcohol as an example, its Moreover, the contemporary ban on most
manufacturing, marketing, selling, buying, addictive substances, excluding alcohol, is
and any dealings was prohibited and a confusing and inefficient approach that
condemned, with no exception. contradicts logic and medical basic facts33,
The Islamic approach is based on both the in view of the significant and widespread
internal value-based motives, and the complications of alcohol in all strata of
external punishment based ones. societies.

Substance abuse: approaches, is a sign of superficiality

A disease or behavioral breakdown? and lack of effective programs.
Liberalization of patients commitment
Whether addiction as an illness, or a to anti-addiction programs will
behavioral breakdown has significant continue to boost drug trafficking and
implications in legal, ethical and social profiteering
contexts, but should not have any influence Unlike this approach, the Islamic outlook
on medical care and rehabilitation. does not neglect the medical, psychosocial
Contemporary western-oriented appro- and rehabilitation needs of drug addicts. It,
aches towards substance addiction is however, considers substance abuse-
based, to a large extent, on the concept that addiction as a devious behavior and
it is a disease that needs therapy. ethical-religious disobedience which is
Significant concessions are practiced to self-inflicted by the individuals. The
drug addicts including free provision of addictive behavior is a result of their own
opiate derivatives, clean syringes to inject decisions and their insistence to pursue it
drugs, condoms to minimize HIV/AIDS with disregard to advice, education,
and other infections. All such measures are religious and social norms. These
provided to the addicts if they demand considerations render them liable for
them. They could abandon anti-addiction punitive measures in this life and in the
programs as they deem suitable to them, Hereafter.
and revert back to the substances of their Recognized Therapeutic measures should
choice. Added to the other drawback of be mandatory with the aim at complete
availability of alcohol, tobacco and, in abstention. Specialized centers, with
some countries, cannabis, is the lack of qualified and dedicated personnel should
real effective programs to rehabilitate take proper care to guarantee that therapy,
addicts and eradicate addiction. which may be gradual and long-term,
All that represents the superficiality and should end up by complete reform.
ineffectiveness of this approach, as Punitive measures to deviators and those
evidenced by what is manifest in the world who revert back to addiction should be
scene. pursued in a dedicated, persistent and
The following considerations are controlled manner.
illustrative of the implications of looking at Proper punitive measures should be legally
the addiction dilemma as merely an applied against traffickers, and distributors.
illness: In conclusion, the Islamic approach to the
Tolerance and permissiveness towards substance abuse-addiction problem has
addicts to pursue and persist in unique features in aspects of prophylaxis
obtaining addiction substances to and management. This is manifested by the
maintain satisfaction, without fearing recorded historical success of this
significant punitive measures. approach in its dealing with alcohol abuse
Minimization of society and state in the early Medina society. This approach
responses towards addiction. Addicts is based on both internal faith-based
are looked upon as victims who are not values, as well as external measures,
fully responsible for their acts. including health care systems and society-
Lack of legally-binding anti-addiction state punitive-based parameters. The
programs, with steady and determined Islamic approach has resulted in the
achievement of a society with record

freedom from addiction and its 31. Albar MA. Contemporary Topics in Islamic
Medicine, 1995, Saudi Publishing and Distribution
ramifications in Muslim communities, House, Jeddah, Saudi Arabia, pp 13-19.
despite many current adverse circumsta- 32: Baldwin J., The Fire Next Time. London: Penguin
nces. Books 1962: 39-68.
33. Reference # 10, and Baye I Chodse, Evolution of
International drug control, 1999, P 383.
References:
1.Kaplan and Sadicks, Synopsies of psychiatry, Williams

and Wilkens, 2002-Lippncott, pp 93-94.
2. Ibid, pp 96-97..
3. Bevridge KC, Food reward- brain substates of wanting
and liking, 1996.
4. Ameri A, The effect of Cannanioids on the brain.
Progress in Neurology 1999.
5. Torres G, Horowitz TM (1999). Drugs of abuse and
brain gene expression. Psychosom Med 61 (5): 630-50.
PMID 10511013
(www.ncbi.nlm.nih.gov/pubmed/10511013).
6. Reference # 1, pp 1286.
7.http://en.wikipedia.org/wiki/Addiction
8.Diagnostic criteria DSMSTO
And: Goodman and Gliman: The Pharmacological Basis
of pharmacology, 1992.
9. WHO- Neuroscience psychoactive substance use and
dependence.
10. Ali Kamal (Arabic): Al-Idman, Bab al-Abath bil Aql,
1994, Al-Mussasah Al-Arabiyyah Li Al-Dirasat wal-
Nashr, pp 115.
11. Hassan Naser Bokely (Arabic): Al-Idman, 1988, Dar
al-Maamoon Li al-Turath. P16.
12. National Survey of American Attitudes on Substance
Abuse XVI: Teens and Parents.
http://www.casacolumbia.org/addiction-
research/reports/national-survey-american-attitudes-
substance-abuse-teens-2012
13. Glorious Quran, Al-Nahl 16:67.
14. Glorious Quran, Al-Baqarah 2: 219.
15: Glorious Quran: Al-Nisaa: 4:43
16. Reference #10, p241.
17. The Glorious Quran, Al Maedah 5:90.
18. The Glorious Quran, Al Maedah 5:91.
19. Sahih Muslim, Narrated by Anas, No. 3669.
20: Sahih Al-Bukhari, Kitab al-Wadu, N. 239.
21: Sunan Ibn Majah, No. 3392.
22: Sunan Ibn Majah, vol. 2, 1953, No. 784
23. Al-Shatibi (d. 790/1388), al-Muwafaqat fi ash-
Shariah, 1975, vol. 2: 8-11, P. 10.
24. Abdul Wahab Khallaf, Usul Al-Fiqh (Arabic), Dar al-
Kutub al-Ilmiyyah-Beirut-Lebanon, 2006. PP40.
25. Sunan al Nassae, 8/315, Sahih Sunan Al-Nasae 3/46,
no. 5236.
26: Abu Dawod, Kitab al Hudud, No. 4485.
27: Sunan Ibn Majah, Kitab al-Ashribah, No. 3377.
28. Ibid, Hadith narrated by Abi al-Dardaa, Bab al-Sabr
ala al Balaa, No. 4034.
29. Abu Dawod, Al-Tib. No. 3873, Tirmidi, No. 2147.
30. Miles S., learning about alcohol. Washington DC:
American Association for Health, Physical Education and
Recreation- A national affiliate of the National Education
Association. 1974:12.

ISLAMIC RELIGIOUS INPUT IN THE TREATMENT
AND REHABILITATION OF DRUG ADDICTION:
EXPERIENCES FROM MALAYSIA
Mahmood Nazar Mohamed* and Sabitha Marican**
Abstract:
Drug addiction is a chronic relapsing disease which can be treated. Treatment

however is dependent on many variables, the drug of choice, degree of drug use,
individual and personality characteristics such as religiosity, community and
environmental factors, familial and social support, employment and many more.
Many countries employ the supply and demand reduction strategies, some of which
are successful, and some are not. The advent of HIV-AIDS in the 80s forced
treatment specialists to look at other alternatives. Harm reduction offers a pragmatic
approach, however, it remains controversial. Drug Substitution Therapies for people
using opioids have proven to be more effective with other non medical approaches
such as contingency management, behavioral interventions and spiritual/religious
enhancement. This paper reports the experience of Malaysia in providing Islamic
religious input to drug treatment and rehabilitation programs in government and non
government facilities.
Keywords: Drugs, addiction, treatment, rehabilitation, drug policy, Islam, harm

reduction, spiritual therapy, religion.
Introduction:
Treating a chronic relapsing disease is However, all of these illnesses, especially

not a simple undertaking. It involves the drug addiction, can be treated with a
illness itself, behavioural and psycho- combination of treatment modalities and
logical components, belief system and approaches1,3. There are basic principles
spirituality1. to drug treatment that healthcare
Many treatment providers reported providers must understand in order to
significant relapse rates among those provide adequate treatment and rehabilit-
undergoing treatment, especially for ation.
addiction to psychoactive substances. One important fact is that no single
Illnesses like asthma and hypertension treatment is appropriate for all
have 50-70% relapse rate, type I Diabetes individuals. Effective treatment attends
has 30-50% relapse rate (for example, to multiple needs of the individual, not
lack of diabetes control due to lack of just his or her drug use. In addition,
compliance with lifestyle modification treatment and service plans must be
and proper therapy, leads to relapse of continuously assessed to ensure that the
symptoms), whereas drug addiction has a particular plan meets the persons
relapse rate of 40-60%2. changing needs1.
* Mahmood Nazar Mohamed ** Sabitha Marican

Professor of Psychology Associate Professor, Public and Social
Cyberjaya University College of Medical Policy
Sciences (CUCMS) Faculty of Economics and Administration
Cyberjaya, Malaysia. University Malaya, Malaysia
E-mail: [email protected] E-mail: [email protected]

ISLAMIC RELIGIOUS INPUT - MALAYSIA
When a client is ready for treatment, treatments were given, albeit they were
remaining in treatment for an adequate still limited6,7. At that time supply and
period of time is critical for treatment demand reduction approach was adopted
effectiveness. Many believe that medical as the national anti-drugs strategy. In the
detoxification can help, however it is past decade, on the average, the
only the first stage of addiction treatment Malaysian authorities arrested around
and by itself does little to change long thirty two thousand drug addicts in the
term drug use2. Counseling and behavior- country (about 55% - 60% were relapse
al therapies are critical components of cases) each year. This number has
effective treatment for addiction2,4. significantly decreased in these past
Medication is an important element of years to about 22,811 cases in 2006,
treatment for many patients. Treatment 14,489 in 2007, 11,194 in 2011, and
should provide assessment for HIV, TB 9,015 in 2012. Further reductions in the
and other infectious diseases5. It is also numbers of addicts identified every year
important to know that recovery can be a demonstrate that the present strategies
lifelong process with relapses and require undertaken by the Malaysian government
multiple treatments1. has taken effect 6,8.
Drug Addiction in Malaysia: Supply reduction:
The drug problem in Malaysia has been Usually, the first approach to drug
recognized since the pre-independence control is supply reduction. Simply put,
days. Most of the drug addicts used the supply of the psychoactive substances
opiates, specifically opium that was to the affected population must be
brought in from China and the Golden intercepted and terminated. Supply
Triangle area (Thailand, Myanmar and reduction focuses on law enforcement
PR Laos). In the 1960s, influences from activities to suppress or disrupt produc-
the hippie Western culture reached the tion and distribution of drugs. Legal
shores of Malaysia with marijuana and measures are used by all countries to
other psychedelic drugs primarily used control or eliminate the availability of
by the American servicemen. The 70s illicit drugs. Some supply reduction
saw the introduction of heroin and strategies employed are6,9:
morphine into the country, and drug (i) Source-country control such as crop
addiction reached an epidemic destruction and replacement,
proportion6. In 1983, drugs and drug (ii) Interdiction of supply into end
addiction was declared a national countries,
security problem. (iii) Police enforcement of supply and
A national drug treatment program was possession, and
set up to provide mandatory treatment to (iv) Regulatory policies to restrict
drug dependents. Many Compulsory prescription of opioids.
Centers for Drug Users (CCDUs) were Efforts on reducing the supply of drugs
set up to provide treatment, which was into Malaysia were initiated long before
largely based on psychosocial and the independence of the country. These
military model, where little focus was efforts were directed to the control of the
given to addiction treatment and import, sales and use of opium. Several
treatment of other ailments5. It was not laws were enacted with punitive
until the 1990s that drug addiction was consequences and capital punishment for
accepted as a chronic relapsing disease. involvement in trafficking, using or
Drug addicts were accepted as patients abusing drugs. There are five main Acts
that must be treated and alternative that relate to drugs in Malaysia6.

The first is the "Dangerous Drugs Act", 2004 and several agencies, primarily the
1952. It is the major legislation in Royal Malaysian Police, were given the
relation to drug control in Malaysia. This authority and mandate to implement
Act is very extensive covering aspects of these laws. It overlaps with the second
offences, procedures and evidence. It strategy, which is demand reduction in
provides for mandatory death sentence the 80s to manage and reduce the drug
for drug trafficking offences6. The problem in the country. To date, there are
second is the "Dangerous Drugs (Special no major changes made to these laws,
Preventive Measures) Act", 1985 (The however, there have been evident shifts
DDA-SPM) aimed at enhancing the in the policy on treatment and
effectiveness of countermeasures taken rehabilitation of drug offenders.
by the relevant authorities against those
who are involved in drug trafficking. It Demand Reduction:
empowers the government to detain
anyone suspected of being a trafficker Prior to introducing medications for the
without having to bring the suspect to treatment of drug use and abuse in
any court of law6. The third is the Malaysia, the authorities placed
"Dangerous Drugs (Forfeiture of significant amount of effort to reduce the
Property) Act", 1988 (The DDA-FoP) demand towards these illicit substances6.
empowers the relevant authorities to Demand reduction refers to efforts aimed
trace, freeze and forfeit assets of at reducing public desire for illegal and
convicted drug traffickers6. The forth is illicit drugs i.e. to reduce use and abuse
the "Poisons Act", 1952. This act of, and demand for, narcotic drugs and
controls the import and sale of poisons psychotropic substances4,10.
which refer to any substance specified in Demand reduction seeks reduction of
the Poisons List and includes any abuse directly through prevention and
mixture, preparation, solution or natural treatment.
substance containing such substance First, demand reduction approach
other than an exempted preparation or an provides training and capacity building to
article or preparation included for the prevent the onset of substance use and
time being in the Second Schedule of the abuse.
Act. Many precursors to Amphetamine- Secondly, prevention is achieved by
Type-stimulants (ATS) are controlled by intervening at "critical decision points" in
this Act6. The fifth Act is the "Drug the lives of vulnerable populations to
Dependants (Treatment and Rehabilita- prevent both first use and further use.
tion)" Act, 1983 that provides for both Thirdly, it provides effective abstinence-
mandatory treatment and rehabilitation of based treatment programs for drug
any person who has been certified as dependents. Fourth, it broadens
drug dependent as well as for voluntary education and increases public awareness
treatment and rehabilitation. The period of the consequences of drug use/abuse.
of treatment and rehabilitation at a Fifth, it builds a coalition to mobilize the
rehabilitation center is for two (2) years. local and the international community,
This institutional treatment and and finally it promotes research on the
rehabilitation is followed by after care effectiveness of these and other
for another two (2) years6. Finally there programs4,9-12.
is the "AADK Act", 2004. This Act In general, the practice of demand
specifies the role of the "National Anti reduction includes the school, workplace
Drugs Agency (NADA)" in Malaysia. It and the community. Prevention in school
empowers NADA for enforcement6. settings consists of introducing basic
These laws were enacted from 1952 up to knowledge about, substance use, misuse,

life skills, and positive relationships. It reduction strategies have contributed

also includes early intervention program, significantly to the reduction in numbers
and preventive screening13. Prevention at of drug dependents arrested by the
the workplace basically includes authorities.
programs such as drug-free workplace Figure 1 shows that among the 60%
policy and guidelines, employee particip- heroin addicts in the country, the number
ation, voluntary and random testing for detained every year has reduced from
drugs, drug and addiction counseling, 23,723 in 1995 to 7,963 in 2006, just
early intervention, treatment and about one year before Drug Substitution
rehabilitation. Continuous or random Therapy (DST) became in full use in
monitoring is often built into the human Malaysia8.
resource policy of the organization6.
Community - based prevention programs Harm reduction:
are often the most difficult because they
cover a plethora of settings, sub-cultures, The introduction of Harm Reduction in
ethnic back-grounds and other variables. Malaysia is based on the realization of
What is often done is mobilizing the limitations of supply and demand
community leaders and members to be reduction approaches that were practiced
aware of the drug situation, collaborative between the 1970s and mid 2010s15. In
effort with enforcement agencies to short, harm reduction is policies and
reduce the demand for drugs, and a programs which attempt primarily to
multitude of other drug free community reduce the adverse health, social and
efforts6. In Malaysia, several efforts are economic consequences of mood altering
being undertaken by both the government substances to individual drug users, their
and community to provide institutional families and the communities 16. There
based treatment. The government are many approaches that can be
established 12 abstinence-based Cure and included as harm reduction practices
Care Clinics that provide voluntary drug such as advocacy and capacity build-
treatment and 28 mandatory treatment ing which are conducted through
centers. In addition, there are 30 forums, seminars, media, training study
treatment centers operated by NGOs and tours, research and publication16,17. Most
the private sector14. There are also of the services provided under the
community-based rehabilitation prog- umbrella of harm reduction are client-
rams in 93 districts in the country that friendly. They use the multi-sectoral and
focus on individual, group and family community based approach to implement
counseling, health and welfare services, harm reduction. They establish Practical
Family Association (FA), Narcotic Guidelines and Standard Operating
Anonymous (NA), Alcoholic Anonym- Procedures (SOPs) to guide implement-
ous (AA) meetings, job placement, tation on the ground. They emphasize
religious programs and career evidence-based program implement-
development of the affected population. tation, effective monitoring and tracking
This includes 18 government halfway programs16. There are several outcomes
houses and service centers, 4 main drug to harm reduction practices. These are
related NGOs providing community- reduction of substance use, not sharing
based outreach, relapse prevention and needles specifically for the recipients of
career development programs, support Needle Syringe Exchange Program
and assistance from more than 50 civil (NSEP), greater concern towards ones
societies to aid in the reentry of health, decrease in illegal activities,
recovering drug dependents into longer retention in treatment programs,
6,14
society . The supply and demand increased gainful employment and

increase in income. A study by Marsch to follow was the NSEP program. New
found that there are significant reduction HIV cases decreased since it was first
in the engagement in unlawful activities detected in 1986 (Figure 2)15.
after six and 12 months of Opiate Since then, more opiate users and addicts
Substitution Therapy (OST)18. Figure 2 have been given the Methadone
also shows marked improvement in Maintenance Therapy. Other substitutes
reducing drug use, reduction in HIV risk were also provided such is Buphreno-
behavior, and reduction in illegal rphine / Subutex and Subutex plus
activities from the time of admission to Naloxone (Suboxone). However, these
the OST program, six months after the are substitutes for opiates, whereas no
program and 12 months after the substitution medications are available for
program19. other substances of abuse20.
This means that once persons addicted to Many studies found that giving
opiates took opiate substitution medica- substitutes together with behavioural and
tion such as methadone, they will not psychosocial interventions yielded better
look for drugs (heroin or morphine) to results22,23. Harm reduction initiatives
satisfy their cravings, thus will not that are supported by counseling,
engage in criminal activities in order for especially motivational in nature, can
them to obtain these drugs. Harm mould a persons behavior change to a
reduction has helped to curtail the HIV- specific target23. A person on MMT, for
AIDS epidemic. Two categories of example, given the proper counseling can
affected population were identified and direct his behavior to finding better jobs,
focused upon, the sex workers and drug engaging in community activities, taking
addicts20. For sex workers, the primary care of his health, and becoming more
interventions are preventive education aware of his medications as compared to
and condom distribution16. For drug a person that is on MMT alone.
addicts, Drug Substitution Therapy Counseling also includes spiritual input,
(DST) and Needle Syringe Exchange i.e. encouraging the patient to perform
Programs (NSEP) were introduced16,20-22. his religious duties according to his
These initiatives were introduced in faith24,25. What is important is that harm
Malaysia to curb the HIV epidemic and reduction initiatives can put a user on a
drug use15. platform where other services that
Medical Treatment of Drug Addiction: enhance abstinence can be provided to
him on the long run15. Religiosity seems
Harm reduction approaches such as OST to be one of the important factors that is
and NSEP were not practiced in present in recovering drug users who
Malaysia during the supply-demand have maintained abstinence for a long
reduction era. However, on 13 Jan 2005, time25,26.
the Deputy Prime Minister announced in
the National Council for the Eradication Islamic Religious input:
of Drugs (MTMD) meeting that the use
of Methadone to treat drug dependents It is very clear that many religions of the
has been endorsed by the government6. world oppose the use of intoxicating
Methadone Maintenance Therapy substances6,26. Among those which
(MMT) programs were started in October clearly declared this opposition is Islam,
2005. For Phase 1, it was conducted in 8 which prohibits the use of drugs except
hospitals, 2 health clinics, and 8 private those which are medically prescribed6.
clinics which involved 1,240 opiate The Glorious Quran states
dependents in 4 zones (north, south, east O you who believe! Liquor, gambling,
and west) of peninsular Malaysia. Soon idols and divining arrows are but

abominations and Satanic devices. So perform their 5 times obligatory daily

turn wholly away from each of them that prayers in their holding rooms.
you may prosper. Satan desires only to Assessments are conducted by JAKIM
create enmity and hatred between you by officers on religious understanding,
means of liquor and gambling and to knowledge and practice starting from the
keep you back from the remembrance of Shahadah and covering all the basics of
Allah and from Prayer. Will you then Islam.
desist? 28. Prophet Muhammad Following up at the rehabilitation
said, 'Every intoxicant is Khamr institution, there are assessments and
(alcohol) and all Khamr is Haram evaluations done to match clients needs
(unlawful or not permitted) ' 29. The very and interests according to the
argument that was used against such requirements of the basic knowledge and
intoxicating substances is that all drugs values of Islam. Religious practices
enable people to escape from real life provided at these centers, among others
which would mean that they cannot serve are, mandatory prayers, reading the
Allah . As such, people who use any Quran, sunnat prayers, zikr (remembra-
type of non-medicinal substance will nce of Allah )and learning of the
have to return to the path of Allah 6. hadith, celebrating Islamic events,
Malaysia, being a Muslim majority religious classes, talks and a choice of
country emphasized spiritual rehabilita- careers pertaining to religious practice.
tion in most of its social, behavioral and There are several spiritual enhance-ment
correctional programs. This can be seen programs at the government drug
in all government programs and many treatment institutions that include the
others operated by NGOs and private followings:
institutions5,30. (i) Spiritual and self-introspection.
For government-based programs, most of (ii) Religious educational classes such as
the educators, teachers, counselors and tawhid (unity of God), fiqh (Islamic
therapists are being provided by the jurisprudence), akhlaq (morals), al-
Department of Islamic Development, Quran, al-Hadith.
Malaysia (JAKIM) and the State (iii) Learning the stories of Prophet
Religious Council / Authorities. Muhammad ()., the caliphs and
Thus teachings of Islamic religion and sahabah.
good values are done by certified (iv) Subh (morning) and Maghrib
religious teachers. Also, drug rehabilita- (evening) religious programs and talks.
tion programs obtain assistance from (iv) The religious test (tasmi) in order to
local religious leaders, Ulama, and qualify for advancement to the next
Imams of the mosques to interact with phase of treatment.
residents in the center to prepare them to There are also annual Islamic programs
re-enter society. Drug users from other and celebrations such as, celebration of
religious groups also receive inputs from the beginning and year end, du'aa
their respective religious personnel. (supplication) at the beginning of Islamic
At the triage department of government calendar year (1st Muharram), Mawlid al
treatment centers, drug dependents are Rasul (the Prophet's birthday on 12
detained for 2 weeks following the court Rabiul awwal), Israand Miraj
order for assessment, evaluation and (ascension to heaven on 27 Rajab), nisfu
relocation. Minimum religious inputs are Sha'ban (15 Shaban), Ihya (celebrating)
provided there because of the short Ramadan (1-30 Ramadan), nuzul al-
detainment period. Religious teachers Quran (27 Ramadan), Eidul- Fitr (1
from JAKIM encourage detainees to Shawwal), and Eidul- Adha (10
Zulhijjah). Celebrating these programs

are often done with family members and in its implementation documents stated
significant others in order to facilitate the that the desired outcomes would be
familys involvement in the treatment clients that perform the religious
program. practices in their everyday life, clients
There are also special programs that are that practice Islam as a way of life.
included in the Islamic activities calendar Religion can steer clients away from
of the nation. These are Islamic current negative life influences and decisions.
issues Forum (with local television There are some improvements of the
stations, Janazah (funeral) course, nashid clients physical, social and spiritual
competition (religious songs), hifz quality of life. The question is how to
(memorization) al-Quran program, measure these outcomes in a short time
tilawah (proper recitation) of al-Quran frame.
program, and Friends of the Mosque A study at 10 community-based Cure and
program (a joint program with Care Service Center (CCSC) in 2012
JAKIM)30. showed that there are positive changes
perceived by the clients after they
Spiritual-based Relapse Prevention undergo at least 12 months of religious
Program in Community Settings: programs as part of their rehabilitation23
(Table 2).
When recovering drug users leave the In this study, model A is the CCSC
institutional drug treatment programs, program operated by government officers
most of them will still need guidance to (NADA), CCSC model B is operated
be able to re-enter the society1,9,11. Many together by government (NADA) and
will use the government facilities, such NGOs, and Model C program is operated
as the drop-in and community service- by NGOs. Respondents were interviewed
centres (CCSC), community courses and based on a dichotomous rating of Yes
other community-based programs to and No to the items listed in Table 2.
regain confidence. Here, there are a They were asked to recall back to the
multitude of programs that they can days when they were using drugs, and
follow, one of which is the religious compare to the present situation. Almost
program as illustrated in Table 1-6. in all models, there have been positive
Most of the community-based programs changes on many of the indicators.
also contain the following: Specifically, religious indicators such as
perform prayers regularly and
(i) Taqwa (righteousness) enhancement practice religious teachings showed the
program. largest and more significant perceived
(ii) Salat program. change before they enter the rehabilita-
(iii)Capacity- building and enhance- tion program and after the program,
ment. respectively from 36% to 93% and 29%
(iv) Spiritual and religious recovery to 88%. Most of the religious programs
mentoring. are being conducted by officers from the
(v) Visits of the community religious Department of Islamic Development,
leaders. Malaysia (JAKIM) and these positive
(vi) Imam and mu'adhin workshop. perceptions among residents can be
(vii) Dawah methodology courses. These attributed to its positive outcomes.
are often done with collaboration of the
local religious heads in the community30. Conclusions:
What is the outcome of these inputs? The inclusion of religion and spirituality
National Anti - Drug Agency (NADA)30, into drug treatment has been found to

have a positive effect onto the lives of Education should start at the appropriate
the recovering drug addicts. There has level rather than assuming that they
been an increase in church attendance know everything. Inputs that are too
that was associated with reduction in demanding or complex would only be
cocaine use5, and regular performance of met with rejection22,23.
ones religious obligations22. Thus teaching religion, its values and
Such a positive effect, though not practice without proper assessment of the
widespread, has helped to improve the clients needs is counterproductive. The
quality of life of recovering drug Alcohol, Smoking and Substance
addicts24-26. There are studies that Involvement Screening Test (ASSIST)
showed good outcomes to the religious can be used as a guide for placement of
programs conducted in Malaysia21-23, clients into specific programs17. Peer-
however there are also many studies that educators can be used to guide clients
showed little change over a longer period into the programs, and at the same time
of time5,11. These studies also pointed out to avoid coercion23. Also the use of
those religious inputs must be conducted motivation-enhancement techniques to
together with other evidence-based drug move clients up the ladder of religious
treatment modalities. When the religious values and practice are more effective
program is conducted in isolation it was than following a structured and fixed
shown to be of little effect1,11 as program. Guidance and counseling is
compared to when it is conducted along necessary to motivate clients towards
with other programs such as religion, its values and practices. Clients
detoxification, behavioral interventions, who reject religious teachings can and
therapeutic communities, and later on will influence others to reject the
MMT and other OSTs.. From these program in many ways.
studies and a multitude of unrecorded There must be allocations for group
experiences of conducting religious discussion sessions on the recovering
programs, there are lessons that can be addicts' experience in learning/
learnt from Malaysia. relearning religion, what are the ups and
Since many drug users/addicts have downs23. Encourage clients to choose
limited knowledge of religion, and are what they want to learn with a given
much less practicing it, many treatment menu. Assess their achievements and
experts believe that religion is quite give reports /encouragement.
alien to the lifestyle of a drug addict. Finally, healthcare providers must adhere
Relearning religion and religious values to the Principles of Drug Addiction
is imperative and it has to be done at a Treatment (PODAT)1. If religious/
slow pace22. spiritual therapy is to be used, medical
Treatment providers and specialists also and behavioral therapy must be
commented that rejection, lack of integrated to provide a holistic drug
commitment, non-adherence to programs treatment strategy.
and negative defense mechanisms are
common especially among the hardcore References:
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1. NIDA. Principles of drug addiction treatment: A
younger clients and those who do not research-based guide. National Institute on Drug
experience severe dependency. This Abuse, National Institutes of Health, U.S. Department
would be a good group to start a religious of Health and Human Services, 1999.
2. McLellan AT, Lewis DC, O'Brien CP, Kleber HD.
program22, 25. Drug dependence, a chronic medical illness:
Introduction of religious teachings implications for treatment, insurance, and outcomes
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3. Volkow ND, Chang L. Wang GJ, Fowler JS,
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Hitzemann R. Ding YS. Logan J. Loss of Dopamine menggunakan methadone di Pusat Khidmat AADK.
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with Protracted Abstinence, The Journal of Journal), 2009, 5, 79-108.
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Undang-undang, Rawatan, Pemulihan dan Pencegahan. 2007, 1: 25-72.
Kuala Lumpur: EduSystem Sdn Bhd, 2009. 22. Mahmood NM. MMT and Psychosocial
7. Noor Zurina MR. Rusdi AR. Mohamed MN. Habil Intervention program among drug dependents
H. Treating heroin addiction: Bridging the past and undergoing mandatory community supervision: A 12-
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5872.2012.00194.x 23. Mahmood NM. Sabitha M. Positive outcomes of
8. National Anti Drugs Agency. 10 years statistics of Cure and Care Service Centers (CCSC): A community-
Drug Use in Malaysia: 1995-2006. Putrajaya: NADA, based treatment program in Malaysia, International
2007. Journal of Prevention and Treatment of Substance Use
9. Miller MM. Traditional approaches to the treatment Disorder, March, 2012, 1, 2, 71-83.
of addiction. In: A.W. Graham and T.K. Schultz (eds.), 24. Fiellin DA. Pantalon MV. Chawarski MC. Moore
Principles of Addiction Medicine (2nd ed.). BA. Sullivan LE. OConnor PG. Schottenfeld RS.
Washington, D.C.: American Society of Addiction Counseling plus buprenorphine/naloxone maintenance
Medicine, 1998. therapy for opioid dependence. The New England
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OBrien CP. The effects of psychosocial services in Religious faith and spirituality in substance abuse
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Anglin MD. A national evaluation of treatment 29. Sahih Al-Bukhary, Vol 7, Book C9, No, 481-494,
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16. International Harm Reduction Associations (2008).
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17. Sangeeth K. Hafidah M. Mahmood NM. Projek
perintis program rawatan terapi gantian (RTG)

Figure 1: Number of heroin addicts arrested by the authorities from 1995

20068
Total number of heroin addicts arrested by the authorities

Per Cent of heroin addicts arrested to the total number of drug addict arrested
each year
(Permission to use obtained from National Anti-Drugs Agency, Malaysia, 2014)
Figure 2: Changing percentages of HIV cases due to intravenous drug use (IDU)
and those due to sexual encounters from 1990 to 2010
(Permission to use obtained from Ministry of Health, Malaysia, 2014).

Table 1: Some of the Community-Based Islamic Programs and Expected

Outcomes
No. Program/activities Objective
1 Halaqah Provide continuous religious classes to recovering

drug addicts and their families, besides group
meetings to enhance recovery
2 Islamic art and culture Provide Islamic entertainment, arts and culture for
recovering drug addicts
3 Ibadat camp To provide an intensive program to study fard Ain
and fard Kifayah to recovering drug addicts
4 Mosque as foster To aid recovering drug addicts and their families in
parents the recovery process by using the spiritual approach
5 Friends of the mosque To encourage recovering drug addicts to be close to
the mosque institution. It can act as a temporary
shelter for them when they re enter the community
6 Volunteer work in the To encourage recovering drug addicts to contribute
community mosque back to the society besides preparing them to be
reintegrated back into the community
7 Outreach to other drug Outreach work to recovering or drug addicts and
addicts families in the community
Table 2: Measuring outcomes at 10 Cure and Care Community Centers

(CCSCs).
Pre-post Interview Model A Model Model

at CCSC Pre Post B Post C Post
Indicators of Pre Pre
Change
Maintain good 95 121 76 92 17 22

relations 63.1% 84.6% 55.9% 70.2% 50.0% 64.7%
with parents
Maintain good 100 2130 87 108 19 28
relations 48.0% 87.2% 64.0% 79.4% 55.9% 82.4%
with siblings & other
family member
Involved in societal 80 131 65 104 15 25
Voluntary program 53.7% 87.3% 48.1% 76.5% 44.1% 73.5%
Perform prayers 55 140 69 121 15 28

Pre-post Interview Model A Model Model

at CCSC Pre Post B Post C Post
Indicators of Pre Pre
Change
regularly 36.9% 93.3% 51.1% 89.6% 44.1% 82.4%

Practice religious 57 118 45 88 10 30
teachings 38.0% 78.7% 33.3% 65.2% 29.4% 88.2%
Learn to increase 47 81 38 68 5 18
knowledge 31.3% 54.0% 27.9% 50.0% 14.7% 54.5%

ISLAMIC PSYCHO-SPIRITUAL THERAPY (PST):
PANACEA FOR THE DRUG DEPENDENT
Mohamed Hatta Shaharom*
Abstract:
Islamic Psycho-spiritual Therapy (PST) has its roots well embedded in the spiritual
foundation of the Quran and the Sunnah of the Prophet Muhammad (). Islamic PST
is the embodiment of everything that is permissible and potentially possible in the
methodologies of the spiritual treatment of the believer, within the confines of the
Shariàh (Divine Law). The upholding of the principle of tawhid (the Oneness of Allah
( )is of prime importance in this therapy. What is basic in Islamic PST is that it is a
healing technique that transfers the individual from the realm of ill health to the realm of
wellbeing in a manner that is Godly (Rabbani). It also involves the assessment of the
patients religiosity. In the process, the individual is brought closer to Allah . In the
treatment of many who are dependent on alcohol and psychoactive substances, Islamic
PST has been proven to be effective.
Keywords: Allah (), Muhammad (), Islam, Muslim, , psycho-spiritual, therapy,
religiosity, meditation, , addiction.
Introduction
From the 1950s to the 1990s, the total Islamic and atheistic influences.
number of books, chapters and journal As a methodology, Islamic PST should be
articles that included topics on able to incorporate the different theories of
psychotherapy, religiosity and religious psychotherapies that are not inherently
belief in their titles and abstracts has risen anti-religion and anti-spirituality, Islamiz-
from 86 to 330, totaling 774. Of these, five ing them in the process. As the Ummahs
controlled studies examined how religion need for Islamic PST increases, the
could be used in psychotherapy to treat training of therapists and counselors in
clients1. The Muslim Ummah (nation) of Islamic PST must be enhanced.
today is blessed with the presence of In its contemporary forms, Islamic PST
Muslim psychotherapists who strive to be has its roots well embedded in the spiritual
Shariàh (Divine Law)-compliant in their foundation of the Glorious Quran and the
practice. Islamic Psycho-spiritual Therapy
Sunnah of the Prophet Muhammad ().
(PST) must first of all be free of un-
* Prof. Mohamed Hatta Shaharom

Consultant Psychiatrist And Founding Dean- Faculty of Medicine
Cyberjaya University College of Medical Sciences, Malaysia
And Adjunct Professor of Psychiatry,
University Kebangsaan Malaysia (National University of Malaysia).

ISLAMIC PSYCHO-SPIRITUAL THERAPY
Islamic PST is the embodiment of everyth- confines of the Shariàh, the sacred law of
ing that is permissible and potentially Islam. The upholding of the principle of
possible in the methodologies of the tawhid is of prime importance in this
spiritual treatment of the believer. therapy, like in any area of the lives of the
While approaches of Islamic PST can be Muslim client (patient) and therapist.
varied, they must always be within the
The five daily compulsory prayers include universal ethics of good practice.
prescribed by Islam are adequate spiritual One significant difference between Islamic
enforcers for the practicing believer. It is a and non-Islamic ethics is the sitting
constant psycho-spiritual reminder, a light arrangement of the therapist and his
physical exercise and a social strengthen- patient. When it involves a therapist and a
ing effort, all rolled into one. The focusing client of the opposite sex, therapy is best
on and mentioning of the name of Allah done in a room with a glass window or a
and reciting His beautiful names are glass door so both can be seen from the
among the most effective of meditation outside. When there is a chaperone, this
techniques to countless Muslims through- requirement does not apply.
out the ages. When the need and situation
arises, Islamic PST needs to be coupled Measurement of Religiosity:
with pharmacotherapy.
What is basic in Islamic PST is that it is a Since Islam is a structured religion, it is
healing technique that transfers the recommended that the status of the clients
individual from the realm of ill health to religiosity at the commencement and the
the realm of wellbeing in a manner that is termination of therapy be recorded. The
Godly (Rabbani). In the process, the different levels of religiosity can be
individual is brought closer to Allah. measured by a well-structured Islamic
This dual function is unique to God- religiosity scale. An example is the
consciousness in Islam and Islamic PST. authors Hatta Islamic Religiosity Scale
Thus, while it is health giving to the (HIRS) which measures the religiosity of
believer, Islamic PST enhances the the client undergoing therapy.
believers state of Godliness. It should be This involves the scoring of the clients:
stressed that Islamic PST is part of a Basic Islamic knowledge, and
therapeutic process that is based on a holis- Practice of basic Islamic rituals.
tic paradigm. While the therapist and the Guided by the different scores of the scale,
client dwell into the psychological and the the therapist is able to advise the client on
spiritual domains of life, the physical and the progress of the therapy and its religio-
the social domains must not be neglected. spiritual impact.
In brief, a four-domain (bio-physical, During this process of guidance and
psychological, social and spiritual) assess- advice, the therapist must not impose his
ment of the human being is of great own high standards of Islamic knowledge
importance before treatment commences. and practice. He must not be seen as
It is only through this approach that one judgmental even though the client is a
can identify the diseased or imbalanced sinner according to basic Islamic standards
domains2. Islamic ethics in PST must be and a weakling as far as Islamic
strictly observed, just as in other forms of commitments are concerned. However, it
therapies instituted by any Muslim must be noted that the HIRS does not
therapist. Islamic ethics in therapies attempt to measure the faith (iman) of the

client or any Muslim, for the faith of any and let the blessings of Allah be showered
Muslim or believer is only known to Allah upon them. He is the one who is in need of
. It is immeasurable by any human help. The therapists appreciation of the
inventory or questionnaire. On the other clients reliance on him must be realized
hand the manifestations of an individuals through an ethical mutual emotional-
faith are evident in his daily commitments spiritual relationship that will primarily
and undertakings3. benefit the client. If the client is a non-
Muslim, the Muslim therapist can still
Therapist and Client: Requirements discuss religio-spiritual issues that can help
the client's progress towards recovery as
a. The Therapist: long as the therapist is not seen as
imposing Islamic principles on the client.
Since Islamic PST is essentially a psycho- Consent from the client on this technique
religious therapy, the therapist must be a must be obtained at the outset. The
practicing Muslim. To him, observing the therapist must not be seen as taking
basic tenets of Islam is not a problem but a advantage of the therapy to proselytize.
pleasure, for he yearns for the pleasure of
Allah through his attitudes and deeds. Therapist and Client: Differences:
He is known as an ethical practitioner who
inspires his clients in things spiritual and Being co-religionists, the main similarity
moral. He has his clients trust as he guides that exists between the therapist and the
them with hope and faith on the road client is their religion. In fact, it functions
towards health. Therapy is a humbling as the bulwark against further deterioration
experience for both therapist and client, of the clients health while it acts as a
regardless of whether it ends in success or savior for the clients waning spirit,
failure. His clients experiences before and troubled emotion and challenged
during therapy remind the therapist that cognition.
life is always full of challenges that can Among the characteristics of an efficient
devastate or elevate the morale of the therapist is an unwavering belief in
individual. This humility guards the Allah(), good Islamic knowledge and
successful healer from the onslaught of practice, and praiseworthy character traits.
ostentation and boastful pride. He In contrast, the client may be well
constantly reminds himself that in reality, equipped with or deficient in Islamic
healing does not come from him but from knowledge and practice. His character can
Allah ( )the Almighty, the Ultimate be commendable or otherwise. In brief, it
Healer, according to the following is helpful for the client to feel that the
Quranic verse: therapist is better than him in terms of
And when I fall ill, He restores me to Islamic knowledge and practice.
health4. Otherwise, he may lack the confidence in
his therapist. And this will disrupt the
b. The Client: smooth progress of the therapy.
Since Islamic PST involves religious Methods and Contents:

principles, the client undergoing it has to
be a Muslim. He must be willing to be As the name implies, Islamic PST involves
guided psycho-spiritually by the therapist the clients cognition and emotion (both

are compositions of human psychology) practicing believer. It is a constant psycho-

and his spiritual state. spiritual reminder, a light physical exercise
Methods and approaches may vary from and a social strengthening effort, all rolled
one therapist to another and from one into one. It is best when done
school of PST to another. But the congregationally at any clean place,
principles and contents of Islamic PST do outdoors or indoors, and in mosques or in
not differ, i.e. they should not conflict with family homes. When any of the daily
Islamic principles of human psychology prayers is performed individually, the
and spirituality. Forbidden theories of spiritual rewards and blessings are inferior
psychology, like the many aspects of as compared to the congregational prayer.
Freudian sexual interpretations of human Of course, performing the individual
developmental theory, are excluded. The prayer is much better than neglecting it
therapist must be aware of anti-religious totally.
trends in psychological theories and
therapies that, for instance, reduce man to Apart from these compulsory prayers,
the level of the mice in the Skinner box or there are supererogatory prayers for special
the dog of Pavlov. These non-Islamic occasions that would cleanse and
schools of psychology oppose the attempt strengthen the soul of the believer.
to find the Godliness in mans life and
efforts. They draw him closer to Allah. These
Islamic PST maintains that man is the most include prayers in times of need and
supreme of the creatures of Allah. Man hardship and during moments of
enslaves himself only to Allah (). thanksgiving and joy. Practicing the
Islamic PST is a means to aid the wayward compulsory five daily prayers is extremely
slave of Allah. If he deviates from the path important during the duration of Islamic
of Allah ( )and falls into the abyss of PST or outside that duration of therapy.
error or even disbelief, Islamic PST offers If the client is not used to perform all the
the helping hand. Islamic PST elevates him five daily prayers, he must be encouraged
to his former station of fitrah, the original to perform at least one to four of them. It is
unblemished state of Godliness of every commendable for the client to perform
human being before he becomes corrupted suitable supererogatory prayers to buttress
by his own worldly desires and satanic his increasing spiritual strength. It is also
influences. appropriate for the therapist to become the
imam (prayer leader) of the client should
Daily Prayers: they perform the congregational prayer
together.
In many structured religious traditions,
there are prescribed daily prayers to be Meditation:
performed by the devout believer. The
belief in the hereafter provides an The essence of meditation is the focusing
unending hope for salvation. In the of ones attention on one thing at a time.
hereafter is found the eternal reward or Different religious traditions vary in their
punishment of all strivings during this approaches to meditation. Often the
transitory earthly life. The five daily meditator repeats, either aloud or silently, a
compulsory prayers prescribed by Islam syllable, word, or group of words. In the
are adequate spiritual enforcers for the Hindu tradition, the Sanskrit term for this

kind of meditation is called mantra. To from the sphere of hopeful determination

anchor the attention, one gazes at a fixed due to their forgetfulness of Allah ( )in
object such as a flame or flower. Others the face of intense personal suffering6.
find focusing on the rising and falling of In this spirit, even beyond mandatory
their own breaths as a convenient and religious rituals, seemingly mundane
relaxing point of focus. activities like carrying out a respectable
It is the nature of the mind to go astray and job or singing in front of an audience are
not stay concentrated. Myriads of thoughts considered Godly. This is as long as they
easily appear and seemingly interfere with are executed out of sincerity to Allah ()
the meditation. By repeating this one and the carrying out of these acts is in
moment of awareness (noticing the thought accordance with Islam. The therapist must
and then refocusing the attention), be aware that psychotherapy comes in
gradually the meditator will realize that: different forms in Islam, and among them
It is impossible to worry, fear, or hate are music and singing therapies. As in
when the mind is thinking about other life activities, there must be no free
something other than the object of mixing of the sexes. Allah's Beautiful
these emotions; Names (Attributes) can be memorized and
The diverse contents of the mind can recited at any time. The therapist should be
really fit into a few simple categories, able to choose for the client the appropriate
such as grudging thoughts, fearful name(s) to be memorized and recited as
thoughts; etc. part of the therapeutic process. For
We act in certain ways due to thoughts instance, the name al-Razzaq (the
that have become habitual thought Provider) is appropriate for a client who
patterns and perception; experiences mild anxiety and/or mild
Thought and emotion are not depression while he is engrossed with
permanent since they pass into and out unnecessary worries about his financial
of our body and mind; and needs. Among the assortment of
Life will be lived to its fullest with collections of prayers from the Glorious
equanimity and level-headedness when Quran and the supplications of the
we are awake to what is happening
Prophet Muhammad (), selections
right now5.
from the following scholar-compilers
would be directly relevant for clients
c. Invocations and Remembrance:
undergoing Islamic PST:
Al-adhkar of al-Nawawi7, and
In Islam, the focusing on and mentioning
Al-mathurat of al-Banna8.
of the name of Allah (the name of the
essence of God) and reciting His beautiful
Quranic Healing:
names [al-asma al-husna ( Beautiful
Names or Attributes)] are among the most
Among the many Quranic verses that are
effective of meditation techniques to
relevant to the healing process are:
countless Muslims throughout the ages.
Those who believe (in the Quran), those
This act of remembrance of Allah () who follow the Jewish scriptures, and the
(dhikr Allah) can be practiced anywhere Sabeans and the Christians, whoever
and at any time. It has brought solace to believes in Allah and the Last Day and
many a troubled soul and offered hope to work righteously, on them shall be no fear,
those who had been momentarily displaced nor shall they grieve9.

When My slaves ask you concerning Me, patient suffering from a psychological or
I am indeed close to them, I respond to the psychiatric disorder. If the client is
prayer of every suppliant when he calls on mentally unfit to pray for himself, his next-
Me; let them also listen to My call and of-kin (e.g. parent or sibling) and the
believe in Me, that they may walk in the community should pray (supplicate) for
right way10. him/her. Among the common psychiatric
The client is also made aware of the fate disorders (DSM-IV-TR criteria)13 that are
that befalls unfortunate souls who deny known to afflict patients are:
Allahs ( )truth. In reality, the Glorious Anxiety disorders.
Quran ascertains that they have a disease Depression.
in their hearts. This is essentially a spiritual Mania.
illness that must be prevented from Schizophrenia.
afflicting any believer. Substance dependence and abuse.
In their hearts is a disease and Allah
increases their disease, and grievous Adjunct Therapy:
suffering awaits them because they are
false (to themselves)11. There would be situations when Islamic
Islamic PST facilitates the introspection PST needs to be coupled with pharmaco-
process on the part of the client. If he therapy. Islam, viewing the patient as a
discovers that he is suffering from a whole individual, does not negate the role
spiritual disease, the therapist would be of other forms of permissible therapy
able to help him get through his ordeal and beyond the psycho-spiritual. Adjunct
get rid of the illness. Even if he is afflicted therapy that is coupled with Islamic PST is
by a mild spiritual discomfort, it would be also permissible in Islam for as long as it
helpful if he/she strives to prevent the does not contradict the Shariàh.
occurrence of the illness.
Addictive Behaviour:
Sickness as Expiation of Sins:
Terms related to drug and alcohol
Islam has a unique perspective regarding addiction are dependence and misuse.
physical and mental illnesses. While Addictive behavior related to the misuse of
seeking treatment is a commendable effort, psychoactive substances is associated with
the sick person must understand and accept excessive behavioral patterns that are
the fact that the expiation of some sins detrimental to the individuals health14. For
takes place during illnesses as clearly more than a decade, convincing studies
described in the following Hadith: have shown the relationship between
Abu Said al-khudari and Abu Huraira environmental stimuli and the craving for
narrated that the Prophet ( )said:"No the drug among drug users as compared to
fatigue, nor disease, nor sorrow, nor non-users. Neurophysiological responses
sadness, nor hurt, nor distress befalls a included elevated heart rate, strong
Muslim, even if it were the prick he craving, and Positron Emission Transaxial
receives from a thorn, but that Allah Tomography (PET) scans revealing
expiates some of his sins for that12". increased activity in the brains limbic
region. Thus psychological experiences
Psychological Disorders: can be associated with brain regions
identified by brain imaging techniques15.
Relevant prayers must be recited by the

Comorbidity: its therapeutic domain. Since time

immemorial, prayers have been found to
It is common for drug users to have be part of the treatment armamentarium of
multiple medical problems. For instance, many a civilization and culture. By the end
psychiatric comorbidities with attendant of the 20th Common Era century, Western
dependency are not infrequent. Coupled researchers have noted the incompleteness
with this challenge, the demanding or help- of medical therapy without the prescription
rejecting nature of the drug dependent of prayers20.
populations may drain staff of clinical The Muslim client has every opportunity to
emergency departments16. benefit from Islamic PST. For the non-
Non-hospital therapeutic groups whose Muslim believers of God, they can also
interest and cooperation can complement gain from a PST that is managed by a well-
the services of conventional Western trained Muslim therapist. Meditation and
hospital care are welcome to serve and prayers are necessary in the management
alleviate the stress on medical services. of the cacophony of post-modern social
Looking back at the holistic model of disorder. They are able to help us retain
managing the drug abuser, the psycho- our sanity in facing the challenges of life.
social aspect must not be overlooked when Without them, we stand to lose our
the psychospiritual domain is looked into. psycho-spiritual bearing.
Punishment (which is the psychosocial Islamic PST has its relevance in treating
aspect of the outcome) must be meted out those who are dependents on and involved
to abusers who break the law. But efforts in the misuse of psychoactive substances.
to help them overcome their addiction
must not be neglected. References:
Concluding Remarks: 1.Stevan Nielsan, W Brad Johnson, Albert Ellis, 2001.

Counseling and Psychotherapy with Religious Persons: A
Rational Emotive Behaviour Therapy Approach. London:
For Muslim drug abusers and addicts, the Lawrence Erlbaum, p ix.
psycho-spiritual method has been shown to 2. Mohamed Hatta Shaharom, 2009. Allah: A
Psychospiritual Contemplation on His Name. Kuala
be helpful in their efforts to overcome the Lumpur: CERT Publications, pp 155-157.
problem while they return to the path of a 3. Hanafiah M Salleh, S Mohamed Hatta, et al., 2000.
practising Muslim. Whether it is in South Hatta Islamic Religiosity Scale 1996 (HIRS) A
Reliability and Validity Study. Malaysian Journal of
Africa17, Malaysia18 or Indonesia19 psycho- Psychiatry Vol. 8, No. 1, March 2000: 5-14.
spiritual approaches have been successful. 4. The Glorious Quran, Ash-Shuara (The Poets) 26:80.
However two main issues need further 5. Martha Davis, Elizabeth Esheman, Matthew McKay,
1988. The Relaxation & Stress Reduction Workbook.
attention: Oakland, CA: New Harbinger, pp 37-38.
1. Empirical studies on the methodologies 6. Mohamed Hatta Shaharom, 2007. 7-Day Stress Relief
and outcomes must be enhanced to Plan. Kuala Lumpur: CERT Publications, pp 50-51.
7. Al-Adzkar Imam an-Nawawi (Malay-Indonesian
ensure the approaches meet basic Translation with Original Arabic Text) Jakarta,
international standards of therapy and Indonesia: Pustaka as-Sunnah, 2006.
research. 8. Al-Ma'thurat of Imam Shahid Hasan al-Banna (English
Translation with Original Arabic Text) Swansea, UK:
2. It must always be ascertained that Awakening Publications 2nd Edition, 2007.
therapies that employ sufi dhikr and 9. The Glorious Quran, Al-Maidah (The Table Spread)
other spiritual techniques must abide 5:69.
10. The Glorious Quran, Al-Baqarah (The Heifer)
with Islamic Shariàh principles. 2:186.
Prayers are not only confined to Islam and 11. The Glorious Quran, Al-Baqarah (The Heifer) 2:10.

12. Sahih al-Bukhari, Hadith 545 (Vol. 7), Book 70:

Patients. Wister Hadith.
http://www.gowister.com/sahihbukhari-7-545.html.
Retrieved 26 May 2013.
13. American Psychiatric Associations Diagnostic and
Statistical Manual-IV (Text Revision, 2000), cited in
Mohamed Hatta Shaharom, 2007. 7-Day Stress Relief
Plan. Kuala Lumpur: CERT Publications, pp 38-42.
14. G Hussein Rassool, 2009. Alcohol and Drug Misuse:
A Handbook for Students and Health Professionals.
London: Routledge, p 7.
15. Stephen A Maisto et al., 2011. Drug Use and Abuse.
Belmont: Wadsworth, p 63.
16. Richard Gallagher et al, 2010. Addiction and
Emergency Psychiatry. In David Bariser and Ricardo
Castaneda. Clinical Addiction Psychiatry. Cambridge:
Cambridge University Press, p 228.
17. Selma Cook. The Islamic Approach to Overcoming
Addiction.
http://www.thekhalids.org/index.php/newsletter-
archive/810-islamic-approach-to-overcoming-addiction
(Retrieved 25 April 2014).
18. Dini Farhana Baharuddin, Abd. Halim Mohd. Hussin,
Melati Sumari et al. Developing A Family Intervention
Model For the Treatment and Rehabilitation of Drug
Addiction.
http://acreda.usim.edu.my/aktiviti-acreda/kajian-acreda;
http://www.sinarharian.com.my/rencana/bimbingan-
terapi-psikospritual-1.169732; http://www.alhidayah-
medic.com/coretan-hj-lokman/rawatan-ketagihan-dadah
(Retrieved 28 May 2014).
19. Subandi Taufik, Achmad DP, Fuad Hamsyah.
Returning to God: The Role of Dhikr (A Sufi Meditation)
Practice in Treating Drug Addicts in Indonesia.
http://psikologi.ugm.ac.id/uploads/resources/File/Databas
e%20Penelitian%20Dosen/dhikr_drug.pdf (Retrieved 28
May 2014).
20. Dadang Hawari, 2002. Dimensi Religi Dalam Praktek
Psikiatri Dan Psikologi (The Religious Dimension in
Psychiatric and Psychological Practice). Jakarta: Fakultas
Kedokteran Universitas Indonesia (Medical Faculty,
University of Indonesia), pp 182-191.

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e

He (Allah) allows them as lawful what

Abul Fadl Mohsin Ebrahim

Musa bin Mohammad Nordin

ADDICTION: Medical, Psychosocial and Islamic Perspectives

First Edition: October, 2014

Jordan Society for Islamic Medical Sciences

Printed in Amman-Jordan, Al-Dustour Printing.

FIMA YEAR BOOK 2014 VII

FIMA YEAR BOOK 2014 IX

Dr Hawari discusses tobacco dependence. Smoking is probably as widespread as alcohol intake.

X FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 XI

XII FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 XIII

XIV FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 XV

XVI FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 XVII

Federation Of Islamic Medical

Established at the outset of the 15th Hijrah century, December 1981, in

FIMA YEAR BOOK 2014 XIX

2. Collaboration with regional and international organizations in areas of

FIMA President: Dr. Tanveer Zubairi- Pakistan

FIMA General Secretary: Prof. Abdul Rashid Abdul Rahman- Malaysia

FIMA Executive Director: Dr. Aly A. Mishal

FIMA Executive Director in USA: Dr. Parvaiz Malik

FIMA WEBSITE: www.fimaweb.net

XX FIMA YEAR BOOK 2014

Addiction is a behavioral disorder related to alterations in neurobiological systems

Keywords: addiction, mechanism, abuse, dependence, neurobiology

Drug addiction is a chronic, relapsing ator systems. Generally, the discussion

*Prof. Dr. Ilhan Yargic

FIMA YEAR BOOK 2014 1

2 FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 3

4 FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 5

6 FIMA YEAR BOOK 2014

Mohammad Ali Albar*, and Aly A. Mishal

Keywords: Alcohol, dependence, alcohol use disorders, intoxication, Islam.

*Dr. Mohammad Ali Albar (FRCP London)

FIMA YEAR BOOK 2014 7

8 FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 9

10 FIMA YEAR BOOK 2014

disease. These changes were not Highlighting the rising levels of

FIMA YEAR BOOK 2014 11

industry is increasingly globalized, and the WHO publications provided significant

12 FIMA YEAR BOOK 2014

Gastrointestinal (GI) Cancer: In the Nurses Health Study, women who

FIMA YEAR BOOK 2014 13

in heavier alcohol consumption, especially Heavy drinking is detrimental to the

14 FIMA YEAR BOOK 2014

FIMA YEAR BOOK 2014 15