Substance misuse and Toxicity

GEC1015/GEH1049 Public Health in Action

Tan Yeong Lan, PhD

AY2024/2025, Semester 1

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 Overview
• What is substance use disorder?

• Case studies on substance use disorder

• Methamphetamine
• Alcohol
• Opioids

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 Substance use disorder
“Substance Use Disorders (SUDs) are treatable, chronic diseases
characterized by a problematic pattern of use of a substance or
substances leading to___________________________________
impairments in health, social function
_______________________________________________________.
and control over substance use
It is a cluster of cognitive, behavioural, and physiological symptoms
indicating that the individual continues using the substance
despite harmful consequences”

Centers for Disease Control and Prevention (CDC)

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 Substance use disorder
“A substance use disorder (SUD) is a mental disorder that affects
a person's brain and behaviour, leading to a person’s
____________________________________________________
inability to control their use of substances
such as legal or illegal drugs, alcohol, or medications.”

National Institute of Mental Health (NIH)

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 Other similar terminologies

Substance Substance Substance Substance

misuse dependance addiction tolerance

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 Substance misuse
Using any substance at high doses or in ___________________
inappropriate situations
resulting in a health or social problem, immediately or overtime is
known as substance misuse.

Transactions of the American Clinical and Climatological Association (2017). Substance Misuse and Substance use Disorders: Why do they Matter in Healthcare?
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 Substance dependence vs addiction
Dependence Addiction

Adaptation that results in The _______________

loss of control over
________________
withdrawal symptoms when the intense urges to take the
substances are substance even at the
discontinued. expense of adverse
consequences.
It is an ordinary biological
consequence of taking a It is the continued substance
substance for weeks or use that persists in face of
years. negative experience.
American Journal of Pyschiatry (2006). What's in a word? Addiction versus dependence in DSM-V
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 Substance tolerance
A condition that occurs when the body gets used to a medicine
so that either more medicine is needed or different medicine
is needed.
National Institute of Mental Health (NIH)

Diminished response to a substance over the course of

repeated or prolonged exposure

Alcohol research and heath (2008).

The molecular basis of tolerance.
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 Why is SUD a public health issue?
35.6 million suffered from a drug-use disorder in 2020.
United Nations Office on Drugs and Crime (2020). World Drug Report 2020.

Substance-use was directly and indirectly responsible for

11.8 million deaths globally.
Lancet (2018) Global Burden of Disease Study 2017

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 Why is SUD a public health issue?
Globally, the number of
disability-adjusted life-
years (DALYs) caused
by DUDs approximately
increased by 2.6%
yearly from 1990 to
2019
DALYs is the sum of the years
of life lost due to premature
mortality (YLLs) and the years
lived with a disability (YLDs)
due to a disease or health
condition in a population
Global Burden of Disease Collaborative Network
(2021). Global Burden of Disease Study 2019 Results.
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 Why is SUD a public health issue?
• Lost of lives
• Prevalence of health deterioration and physical injuries
• Quality of life adversely affected
• High financial burden for families and economy
• Disrupts social systems and order

Biology Psychology Cognitive Social Cultural

Science development structures
Multi-disciplinary
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Substance
misuse case
studies
• Psychoactive substances
(i.e. methamphetamines)
• Alcohol
• Prescription drugs (i.e.
opioids

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Methamphetamine

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 Surge in Methamphetamine use from 2015-2019
despite heightened law enforcement response

Pew (2022). Methamphetamine Use, Overdose Deaths, and Arrests Soared From 2015 to 2019
https://www.pewtrusts.org/en/research-and-analysis/articles/2022/08/16/methamphetamine-use-overdose-deaths-and-arrests-soared-from-2015-to-2019
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Global market for
methamphetamine
from 1998-2022

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Most abused drug in Singapore – Methamphetamine

Central Narcotics Bureau (2023)

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 History of methamphetamines
Methamphetamine was
widely used by German
Amphetamine was first and Japanese soldiers in
synthesised in 1887 in World War II for its
Germany by Romanian stimulant effect and
chemist Lazăr Edeleanu. extended wakefulness

Methamphetamine was
first synthesized in 1893 by
Japanese chemist Nagai
Nagayoshi

Vermont Department of Health (2012). Historical overview of methamphetamine

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 History of methamphetamines
In 1980s, US tighten
regulations around the
In 1950s, sale and use of
methamphet __________
ephedrine and illegal
amines was drug production turned
indicated for to using
treatment of pseudoephedrine as a
obesity precursor.

In 1970s, In 1990s, there was a

methamphetamine widespread use of
became a controlled methamphetamines
drug in US.
Vermont Department of Health (2012). Historical overview of methamphetamine
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One of the main
producers of
methamphetamines
– Golden Triangle
• Mountainous regions bordering
Northern Thailand, Myammar and
Laos.
• Seizures of methamphetamines at
golden triangle have grown 4-fold
from 2013 to 2022.
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 Methamphetamines (Effects)
o __________________________________
Euphoria, increased energy and alertness

o Chronic mood and cognitive changes

o irritability, aggression, panic, hallucination, memory impairment
o Increased risk of early mortality and suicide attempts
o Cardiovascular complications
o arrhythmia, myocardial infarction, heart failure
o Stroke

Uptodate (2023). Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis
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 Methamphetamines
(Enforcement and treatment in Singapore)
o Legal Enforcement: Illegal to possess or consume within or outside of
Singapore (Misuse of Drugs Act, listed as Class A controlled drug)

o Screening and assessment: prompted by signs and symptoms from

patient’s presentation, history and/or physical examination

o Drug testing: urine, saliva, blood and hair

o Diagnosis: DSM-5 diagnostic criteria

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
o Management: psychosocial interventions largely
Motivational interviewing
Uptodate (2023). Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis
Drug counselling
Uptdoate (2022). Approach to treatment of stimulant use disorder in adults Cognitive-behavioural therapy
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 Challenges for preventing drug
misuse in Singapore
Challenge #1: Source: CNB Annual Statistics (2023)
__________________________
Surge in young drug abusers

https://www.channelnewsasia.com/singapore/young-drug-abusers-
singapore-youths-mental-health-family-relationships-stress-4144626 In 2023, 51% of the new drug abusers
were <30 years old.
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 Challenges for preventing drug
misuse in Singapore
Challenge #2:
_____________________________
New Psychoactive Substances (NPS)

NPS are compounds designed to mimic

established illicit drugs.
▪ Its malleability of chemical structure
makes detection a challenge.
▪ Low cost and easy to produce.
▪ By 2020, there were >1000 NPS in the
market.
▪ Falsely marketed as legal and safe.

Source: CNB Annual Statistics (2023)

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 Alcohol

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 Alcohol use disorder is the most prevalent
mental disorder globally
Risk factors:

-Drinking at an
early age

- Family history
of alcohol
problems

- Mental health
condition and a
history of trauma
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 Alcohol (effects)
5.1% of the global burden of
disease and injury is
attributable to alcohol, as
measured in disability-
adjusted life years (DALYs).

Causal link and risk factor found in

more than 200 diseases and injury

WHO (2022). Alcohol

https://www.who.int/news-room/fact-sheets/detail/alcohol#:~:text=Worldwide%2C%203%20million%20deaths%20every,adjusted%20life%20years%20(DALYs).
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 Alcohol consumption centered
approaches
Reduce _________________
population-level consumption by:
o Raise alcohol taxes
o Raise the minimum price of alcohol sold at
retail
o Raising legal minimum drinking age
o Reduce permitted hours for sale of alcohol
late at night
o Advertising restrictions

Injury centered approaches

Reduce alcohol-related road injuries by:
o Publicity campaigns
Global Disability Adjusted Life Years (DALYs) lost due to o Police enforcement of drink-driving laws –
alcohol-attributable injuries, 2019. Data source: Institute for fines, driving license suspension etc.
Health Metrics and Evaluation
o Random breath testing
Nutrients (2021). Alcohol and risk of injury
© Copyright National University of Singapore. All Rights Reserved. o Ignition or alcohol interlock devices
 Prevention of alcohol misuse in
Singapore
Legal drinking
Legality:
Anyone caughtage
driving
is 18with
yearsa breath
old. alcohol content > 30 mcg alcohol in 100 mL of breath; or > 80 mg of alcohol in 100 mL of blood can be charged with drink-driving. If found guilty, persons can be liable for a maximum fine of SGD 10,000 and/or up to one year’s jail

o Legality:

o Legal drinking age is 18 years old.

o Anyone caught driving with a breath alcohol content > 30 mcg alcohol
in 100 mL of breath; or > 80 mg of alcohol in 100 mL of blood can be
charged with drink-driving. If found guilty, persons can be liable for a
maximum fine of SGD 10,000 and/or up to one year’s jail

Singapore Medical Journal (2021). Managing unhealthy alcohol use in general practice
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 Ignition interlock devices
Introduced in several EU countries including Belgium, Denmark,
Finland, France, Netherlands, Poland, Sweden and Austria.

SWOV, the Netherlands Institute for Road Safety Research (2016) Alcohol interlocks and drink driving rehabilitation in the European union.
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 Long-term effectiveness
of the alcohol ignition
interlock programme: A
retrospective cohort study
in the Netherlands
Accident analysis and prevention (2021).

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 Injury centered approaches
Reduce alcohol-related interpersonal
violence by:

o Reduce trading hours for licensed

venues
o Improve venue security

Global Disability Adjusted Life Years (DALYs) lost due to

alcohol-attributable injuries, 2019. Data source: Institute for
Health Metrics and Evaluation
Nutrients (2021). Alcohol and risk of injury
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 Prevention of alcohol misuse in
Singapore
o Recommendation:

o 2 standard drinks per day for men and 1 standard drink per day for
women.
- Men have a lower
percentage of body fat
than women.

- Men produce more

alcohol dehydrogenase
enzyme.

Singapore Medical Journal (2021). Managing unhealthy alcohol use in general practice
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 Prevention of alcohol misuse in
Singapore
o Screening and
assessment:

o Patient’s alcohol history,

physical examination on
potential comorbidities
and complications,
laboratory investigation.

o Diagnosis: DSM-5 criteria

Singapore Medical Journal (2021). Managing unhealthy alcohol use in general practice
© Copyright National University of Singapore. All Rights Reserved. Details in the table is for general knowledge only.
 Prevention of alcohol misuse in
Singapore
o Management:

o Patient education on drinking limits and law

o Psychosocial interventions
o Consider referral to community resources or psychiatric services
where appropriate

Singapore Medical Journal (2021). Managing unhealthy alcohol use in general practice
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 Opioids

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 Opioids (effects)
o A class of prescription
drug used to reduce pain.
o Act on the opioid receptors
in the brain and/or spinal
cord for:
o _______________
Analgesia
o Cough suppression
o Sedation
o Respiratory depression
o Euphoria
Uptodate (2022). Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis
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 History of opioids Opium poppy

Friedrich Sertürner

Centers for disease control and prevention (2022).

Understanding the opioid overdose epidemic.
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 Opioid overdose
oSymptoms:
o Constricted pupils
o Breathing difficulty
o Unconsciousness
o May have seizures

oManagement:
o Antidote: ____________
Naloxone (opioid
antagonist)
o Supportive care: to improve
breathing and ventilation

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 Opioid withdrawal
oSweating
Management:
oBone or joint aches
oRunny nose or tearing o Pharmacological:
oTremor o _______________/Naloxone
Buprenorphine

oRestlessness
o Symptomatic management
oAnxiety or irritability

Uptodate (2022). Medically supervised opioid withdrawal during treatment for addiction
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 Prevention of opioid misuse
oIncrease the availability of opioid dependence treatment
oReduce and prevent irrational or inappropriate opioid
prescribing
oMonitoring opioid prescribing and dispensing
oLimit inappropriate over-the-counter sales of opioids.

World Health Organisation (2021). Opioid overdose.

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 Prevention of opioid misuse in Singapore
Legal regulations → Opioids are _________________
controlled drugs in Singapore

o License requirement to import, store, wholesale, export or manufacture

controlled drugs

o Regulations for bringing personal medication to Singapore

o Requires approval from Health Science Authority (HSA)

o Restriction on supply by retail sale of codeine cough preparations

Singapore Statutes Online (2021) Misuse of Drugs Act 1973.

Health Science Authority (2022).Regulations for bringing personal medications into Singapore.
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 Prevention of opioid misuse in Singapore
National guidelines on safe prescribing of opioids

o Opioids should not be prescribed as first line treatment for acute and
chronic pain.

o Identify risk factors and patient factors before initiating opioid therapy

o Monitoring of patients under opioid therapy

o Patient education

Ministry of Health, Singapore (2021). National guidelines for the safe prescribing of opioids 2021.
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 In summary
• Substance misuse may occur
for both legally approved
substances and illicit drugs.

• The issue of substance use

disorder and its management
strategies may extend across
multiple disciplinaries.

• The substance misuse

landscape and climate can be
influenced by social,
economical and political
factors.
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 Readings
Required reading:
McLellan AT. Substance Misuse and Substance use Disorders: Why do
they Matter in Healthcare? Trans Am Clin Climatol Assoc.
2017;128:112-130. PMID: 28790493; PMCID: PMC5525418.

Recommended reading:
Jahan AR, Burgess DM. Substance Use Disorder. [Updated 2022 Jun
13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK570642/

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 Substance misuse and Toxicity
(PART II – Case Study)
GEC1015/GEH1049 Public Health in Action
Tan Yeong Lan, PhD
AY2024/2025, Semester 1

©©Copyright
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NationalUniversity
UniversityofofSingapore.
Singapore.All
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 Instructions
Part II of this lecture is a case study discussion. Students can expect
frequent use of Poll Everywhere to engage in the case study
discussion.

Slides for Part II lecture will only be released by Friday of the week,
after 2pm on Canvas.

Case study discussions can be examinable for open-ended critical

reflection question in end-of-semester assessment. This pertains not
just to week 7 lecture, but all subsequent 3-hour lectures involving a
Part II discussion.

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THANK YOU

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