CC BY
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Induction into anesthesia dormicum 0,15-0,2 mg\kg, fentanyl 3 mkg\kg, ketamin 0,8-1mg\kg with the aime of NMDA receptors block. Myoplegia — arcuronium 0,08-0,1 mg\kg, dithylin 1-1,5 mg\kg.
Anesthesia maintenance Hypnotic component- isophluran approx. 0,8-1 об%; Analgetic component EDA (bupivacaine 0,5% 15-25 mg or lydocaine 2%- 80 mg) + bolus dosing of fentanyl into traumatic periods of operation 0,1 mg. i\v. Myoplegia — arcuronium 0,025 mg\kg\h
Postoperative period NSAID ketonal 300 mg i\m; EDA bupivacaine 0,25%-50 mg each 5-6 hours (or lydocaine 1%-100 mg each 3-4 hours); Morphine 10 mg i\m at necessity
References:
1. Volchkov V. A., Ignatov Yu. D., Strashnov V. I. Pain syndromes in anesthesiology and reanimatology. М 2006; 166-186.
2. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis.\\Br J Anaesth. 2013.111: 711-20.
3. Barratt S., Smith R., Kee J. Multimodal analgesia and intravenous nutrition preserves total body protein following major abdominal surgery.//Red.Anesth. Pain. Med. 2008. 27: 15-22.
4. Bernucci F., Carli F. Functional outcome after major orthopedic surgery: the role of regional anesthesia rederned.\\Curr Opin Anaesthesiol. 2012. 25: 621-628.
5. Bolivar M., Bolivar A., Vargas G. Multimodal postoperative analgesia with nonsteroidal anti-inflammatory drugs and the epidural hematoma “myth”//Book Abstr. 9th World Congress on Pain, Vienna, Austria, 2009. - P.439.
6. Duale C., Sibaud F., Guastella V., Vallet L., Gimbert YA., Taheri H., Filaire M., Schoeffler P., Dubray C. Perioperative ketamine does not prevent chronic pain after thoracotomy.\\Eur J Pain. 2009.13:497-505.
7. Eric B., Rosero et al. Preemptive, Preventive, Multimodal Analgesia: What Do They Really Mean?\\Plastic and Reconstructive Surgery. 2014. 134 (4S-2): 85-93.
8. Fabian O. Kooij., Wolfgang S. Does Regional Analgesia for Major Surgery Improve Outcome? Focus on Epidural Analge-sia.\\Anesthesia & Analgesia. September 2014. 119 (3): 740-744.
9. McDaid C., Maund E., Rice S., Wright K., Jenkins B., Woolacott N. Paracetamol and selective and non-selective non-steroidal antiinflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review.\\Health Technol Assess. 2010. 14: 1.153.
10. Sigtermans M., van Hilten J., Bauer M. et al. Ketamine produces effective and long-term pain relief in patients with complex regional pain syndrome type 1.\\Pain. 2009.145: 304-11.
Shigakova Faniya Anvarovna, Tashkent Medical Academy Academic Department of Psychiatry and Addiction Medicine
E-mail: pilar.buranova@mail.
Transcultural aspects of opium addiction in the Republic of Uzbekistan
Abstract: Ethno-cultural and socio-economic factors have an effect both on the prevalence of the disease in question across given territory and on peculiarities of its clinical dynamics. Many studies demonstrated direct relationship between various ethnic and socio-cultural characteristics, clinical structure, and dynamics of mental disorders. The work was initiated to study transcultural characteristics of opium addicts among Uzbek indigenous inhabitants and Slavs born and residing in Uzbekistan.
Keywords: ethno-cultural peculiarities, opium addiction, transcultural aspects
1. Introduction
Opium addiction is a potentially life-threatening condition (UNODC, World Drug Report, 2010) bringing about adverse social consequences, such as an addict’s low social integration, economic dependence, and criminal activity. On the one hand, globalization of economic and public relations characterizes the present stage of humanity’s development; on the other hand, cultural diversity and ethnic heterogeneity of population can be seen in many countries.
Up-to-datedness of transcultural aspects of addiction is corroborated by the necessity to understand mechanisms of addictive attraction and its essential characteristics. Findings from considerable number of studies addressing various aspects of drug addiction demonstrated that its epidemiological and clinical peculiarities are determined by a number of factors. Ethno-cultural and socio-economic factors have an effect both on the prevalence of the disease in question across given territory, and on peculiarities of its clinical dynamics
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(Malakhov, 2004; Dech, Ndtei & Machleidt, 2003; Ingman, Ollendick & Akande, 1999; Maramba & Hall, 2002). Ethnic background of an individual is an extremely significant factor for transcultural addiction medicine, as it anchors definite characteristics of a microenvironment for a personality to form. It is a key to conceptualization of ethno-psychiatry and ethnic addiction medicine (Sayed M. A., 2003).
Today, the cases when medical teamwork is based upon procedures and approaches marginally meeting a patient’s ethno-cultural needs are quite frequent. In this context, it is intriguing to use literature data to study peculiarities of medical teamwork in the ambiguous context of cultural situation influencing its productivity.
Geographic and geopolitical position of Uzbekistan as well as economic, social, natural, climatic, and ethnic peculiarities of its different regions produce an effect on spread of non-medical use of substances and drug addiction. They have impact on clinical picture and dynamics of the latter, willingness of drug addicts to seek medical care, and, eventually, on its efficacy. To a large extent, socio-psychological relations in each of these communities are determined by cultural stereotypes and traditions taking shape throughout history.
Formation of Uzbek ethnic group dates back as far as XI century. Islam plays a great role in both social and family life of Uzbeks.
Religion determined and still determines family and everyday life, a person’s world outlook; its impact on political processes, the art, and the way of life is extremely strong.
There is a strict hierarchy in an extended Uzbek family members of which belong to different generations but live together. Unhesitating obedience to a head of the family and respect to the seniors is the basis to form relationships in this family. A woman’s role in Uzbek family is dual: she is mother and a family head’s wife, on the one hand, but a subordinate to her husband, her husband’s father or mother, on the other. This is not discrimination but a century-old tradition based on experience of living in local challenging conditions. The Slav ethnic group started forming in Uzbekistan within the period from 1904 to 1924. This ethnic group includes Russians, Ukrainians and Byelorussians who confess Eastern Orthodox Christianity.
Many studies demonstrated a direct relationship between various ethnic and socio-cultural characteristics, clinical structure, and dynamics of mental disorders. This relationship is a precondition for development of differential approaches to diagnosis and treatment of these disorders with ethno-cultural factors taken into account (Comas-Diaz & Jakobsen, 1987; Hall, 2001; Triandis, 1989). The purpose of the current study was to study transcultural characteristics of opium addicts among Uzbek indigenous inhabitants, and Slavs born and residing in Uzbekistan.
2. Materials and methods
The study was conducted at the Tertiary Detox Center, Public Health Ministry, Republic of Uzbekistan (Tashkent) within the period from February 3, 2010 to June 24, 2013. We
examined 112 patients aged over 17 years matching criteria of DSM-IV (American Association: Diagnostic and Statistical Manual of Mental Diseases, 2000) who underwent detoxification at the Center within the period not longer than 20 days and abused no substances within < 7 days.
The patients who sought treatment voluntarily and had any significant other, such as a parent or a relative to make up an objective medical history were included. Patients with endogenic mental derangements complicated with drug addiction, those unattainable for a follow-up, and persons combining drugs or replacing other psychoactive substances with heroin were excluded. The study which neither impaired trial subjects’ rights nor threaten their health was performed in compliance with biomedical ethics requirements, as stated by World Medical Association Declaration of Helsinki. All patients signed written informed consent to take part in the study.
The patients were divided into two groups. The first group included sixty one Uzbek indigenous inhabitants, 39 (63.9%) men and 22 (36.1%) women among them who were selected on the basis of data from nationality information field in a passport, and appropriate information from relatives about nationality of the patient’s parents. Fifty one Slavs born and residing in Uzbekistan, 19 (37.3%) men and 32 (62.7%) women among them who were selected according to the above procedure were included into the second group.
The patients were examined after arrest of clinical manifestations of acute intoxication and withdrawal syndrome. A set of socio-demographic and ethno-cultural data for each patient was included into a form for clinical-epidemiological and ethno-cultural study (Reference Data Collection Form). Also, the form included a set of general and drug dependence data as well as clinical-dynamic characteristics of drug dependence syndrome as per ICD 10 (International Statistical Classification of Diseases and Related Health Problems) and DSM-IV-TR. Formal data and information from the patient’s relatives was added. Protocol of the study was developed by the author in cooperation with specialists in addiction medicine, such as physicians, psychologists, and social workers.
All data were processed by means of a Microsoft Excel, STATISTICA 6 and BIOSTAT software packet. Logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Statistical significance of differences between parameters was assessed by means of non-parametric X2 test (Pearson’s criterion). Quantitative parameters are presented as M ± SD, Median (Me) and 25th and 75th percentiles (IQR, Inter Quartile Range). Intergroup differences were considered significant at p < 0.05.
3. Results
One hundred sixty seven patients were invited to participate, 112 of them signed the informed consent form.
Patients in the first group were confidently older (mean age 35.3 ± 7.38; Me 35.0 years; IQR 31.0-40.0) than those in the second one (mean age 32.4 ± 6.62; Me 33.0 years; IQR
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28.5-36.0; P=0.03). Patients in the second group started abus- Me 22.0 years; IQR 19.0-27.0 versus 26.0 ± 7.28 years; Me
ing heroin earlier than those in the first one (23.2 ± 5.91 years; 25.0 years; IQR 20.0-31.0: P=0.03) (Table).
Table 1. - Clinical-demographic characteristics of opium addicts
1st group, n=61 2-nd group, n=51
Men Women Men Women
Age, years 35.9 ± 6.39 34.5 ± 8.97 Px= 0.48 34.6 ± 4.76 P = 0.44 1m 31.0 ± 7.25 P2= 0.06 P,. = 0.12
Me; IQR 36.0; 31.0-40.0 33.0; 28.5-40.5 36.0; 32.0-38.0 30.5; 27.0-34,3
Disease duration, years 35.9 ± 6.39 35.9 ± 6.39 Px= 0.06 35.9 ± 6.39 P= 0.85 35.9 ± 6.39 P2= 0.08 P„ = 0.59
Me; IQR 10.0; 7.5-13.0 8.0; 4.3-9.8 11.0; 6.0-15.0 8.5; 3.8-12.0
Age of abuse onset, years 25.4 ± 6.37 27.0 ± 8.72 Px= 0.41 23.9 ± 5.29 P = 0.38 1m 22.8 ± 6.99 P2= 0.56 P„ = 0.06
Me; IQR 25.0; 20.0-29.0 25.0; 20.0-31.8 22.0; 20.0-28.0 21.0; 18.0-25.5
Education University/college Secondary school No education 9 (23.1%)/ 23 (59.0%) 7 (17.9%) 3 (13.6%)/ 12 (54.5%) 7 (31.8%) 3 (15.8%)/ 8 (42.1%) 8 (42.1%) 2 (6.3%)/ 22 (68.8%) 7 (21.9%) 1 (3.1%)
Note: P — men to women relation, P1m — in relation to men in the 1stgroup, P2 — in relation to men in the 2nd group, P1w — in relation to women in the 1stgroup
In general, hereditary alcoholic or drug abuse burden was observed in 8.2% of Uzbeks versus 17.7% of Slavs (OR 2.40; 95%CI 0.75-7.69; P=0.22). In the Slav women it was observed more frequently though insignificantly (25.0% versus 18.2%; OR 1.50; 95%CI 0.39-5.77; P=0.80). High proportion of patients with hereditary alcoholic and drug abuse burden is the evidence for the role of negative home environment associated with alcohol or drug abuse of parents, and initiation of drug abuse in the family.
The proportion of patients with excitable accentuation of personality traits manifested by typical discontent, anger, and exasperation followed by rage, excessive exigency to the others, fault-finding, and straightforwardness was high in both groups (51.3% of Uzbeks versus 31.6% of Slavs; OR 2.28; 95%CI 0.72-7.23; P=0.26). Among Uzbek women number of patients with hysteric accentuation of personality traits was greater than among Slav women (50.0% versus 31.3%; OR 2.20; 95%CI 0.72-6.75; P=0.27). Hysteric accentuation of personality traits was more typical of Uzbek women than of Uzbek men (50.0% versus 10.3% OR 8.75; 95%CI 2.31-33.1; P=0.002); the tendency was absent in the Slavs (31.3% of women versus 10.5% of men; OR 3.86; 95%CI 0.75-20.0; P=0.18). Egocentrism, wish to gain in any situation at the expense of the others one way or another (mostly when obtaining money for a “fix”), ostentation, deceitfulness, and melodrama were among typical manifestations. Prone to objection, the patients overacted in response to criticism. The findings highlight significant role of premorbid hereditary burden and accentuation of personality traits in formation of drug addiction. As adverse social environment aggravated by
alcohol abuse of parents facilitates accentuation of personal traits, to our mind, these clinical-dynamic parameters should be considered as the interrelated ones.
Forty one (70.7%) men were raised in the two-parent family, 36 Uzbeks (87.8%) and 5 Slavs (12.2%) among them. A male teenager often starts his way towards drug addiction due to abandonment in the family with his falling under the influence of a so-called gang lord. Number of women raised in the two-parent family was almost half as much as men (70.7% versus 37.0%; OR 4.10: 95%CI 1.86-9.04; P<0.0001); there were almost three times more Uzbek women raised in the two-parent family than Slav ones (59.1% versus 21.9%, OR 5.16; 95%CI 1.56-17.0). 34 (63.0%) women were raised in the single-parent family; number of Uzbek women in this category was significantly less (n=9, 26.5%) than Slav ones (n=25, 73.5%) (OR 0.13; 95%CI 0.04-0.38; P<0.0001).
Among causes of the single-parent Uzbek family death of female patient’s father or mother in her infancy or adolescence was the foremost one (n=6, 17.6%) followed by the divorce (n=3, 8.8%). In the Slav group the divorce came the first (n=14, 41.2%) followed by death of a female patient’s father or mother in her infancy or adolescence (n=4, 11.8%). Seven Slav women were raised by single mother in complete ignorance of father.
Uzbek patients started abusing drugs later (at 17-18 years, in the average) than Slav ones (at 14-15 years, in the average). When seeking medical care, contrary to Slav patients, the Uzbek ones turned to the state-run detox settings less frequently (36.1% versus 64.6%; OR 0.31; 95%CI 0.14-0.68; P=0.006). They usually sought treatment by folk healers (“tabibs” in
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Uzbek) and preferred to be treated by folk medicine methods. Given the influence of folk medicine and religious methods of treatment in some regions, this is an ethno-cultural peculiarity commonly found in the indigenous inhabitants.
Most patients were wholly dependent of their relatives and led parasitic mode of life. There were no significant intergroup differences by the parameter. As to marital status, the number of married Uzbek men was greater than the number of Slav ones, though insignificantly (71.8% versus 52.6%, OR 0.95; 95%CI 0.32-2.84; P= 0.85) Half of Uzbek female drug addicts (n=11, 50.0%) were married; a substance abusing husband was an incentive for them to start substance abusing themselves. Five (22.7%) Uzbek women were divorced; 6 (27.3%) were single; 13 (59.1%) cohabited with an addict. In the Slav group seven (21.9%) women were married (OR 0.28; 95%CI 0.09-0.91; P=0.06); 12 (37.5%) women were divorced (OR 2.04; 95%CI 0.60-6.96; P=0.40); 13 (40.6%) patients were single (OR 1.82; 95%CI 0.56-5.90; P=0.47), and 17 (53.1%) cohabited with an addict (OR 0.78; 95%CI 0.26-2.35; P=0.88).
Confessing Islam, the traditional faith, all Uzbek patients keep up religious views and traditions. 64% of the Slav patients identified themselves as believers acknowledging Eastern Orthodox Christianity but they did not observe traditions or ceremonies appropriate to their belief.
Seeking medical care the Uzbek female drug addicts, as a rule, visited the detox setting accompanied by either father or elder brother (n=15, 68.2%), mother (n=4, 18.2%), a helpmate, or a friend (n=3, 13.6%). A help-mate (n=18, 56.3%), a cohabiter (n=11, 34.4%), either mother or sister (n=3, 9.4%) usually accompanied the Slav females.
4. Discussion
The findings from our study suggest that it is the integrated effect of an individual’s socio-psychological and biological peculiarities in combination with ethno- and trans-cultural
factors that underlies formation of drug dependence with its clinical-dynamic characteristics.
As a rule, after sudden death of a parent orphaned children of minority age in Uzbek families are patronized by full-aged able-bodied brothers and sisters, grandmothers and grandfathers, or any other relatives. In addition, an Uzbek family is built upon traditional patriarchal relations inferring juniors-to-seniors and woman- to- man submission as well as on strict division of duties by age and sex. All above are Uzbek population’s ethno-cultural peculiarities vital for prevention of the youngsters’ deviant behavior patterns and formation of social key points. Positive social influence confirms significant role of the community dominant personalities, parents, wives and the clergy in prevention and spread of drug addiction as well as in treatment and medical-social rehabilitation of drug addicts.
Predomination of married persons among Uzbeks is another ethno-cultural peculiarity. It is typical of Uzbeks to start a family at a young age, to have responsibility both before society and near relatives. As we have already mentioned, seeking medical care significantly greater proportion of the Uzbek female drug addicts visited the detox setting accompanied by relatives (68.3% versus 13.6%). This fact reflects ethno-cultural peculiarity of the Uzbek woman to recognize father’s or elder’s domination.
It should be noted that, irrespective ofethnicity, a substance using husband or cohabiter was an incentive for women to start using substance herself (59.1% and 53.1% of Uzbek and Slav females, respectively). It is extremely important to consider the fact for development of rehabilitation measures and prevention of drug addiction.
The findings of our study suggest that national heritages, adherence to traditional religion, and cultural valuables as well as well-established patterns of family life feature potent factor for formation of counter-narcotic resistance.
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