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93Preventive Healthcare
environmentally friendly manner. Pharmaceuticals and
chemicals must be disposed of appropriately because they can
impact human life as well as the environment. Environmental
and health concerns in this sector are primarily related to the
release of pharmaceuticals into the environment. Sources of
releases of pharmaceuticals to the environment include direct
emissions from drug manufacturing, patient and animal
excretion, aqua farming, and disposal of unused or expired
medicines. One of the most significant impacts of
environmental residues of pharmaceuticals is the development
of antimicrobial resistance (AMR).
Environmentally persistent pharmaceutical pollutants
(EPPPs) are substances, which persist or disseminate in the
environment. Governments and the general public are also
concerned about the environmental impact of pesticides used
in agriculture.
Pharmaceutical pollution is easily caused by wastewater
from pharmaceutical manufacturers if discharged into open
fields and nearby water bodies. Pollution of water systems,
where pharmaceuticals are released into the environment and
reach aquatic systems such as lakes, oceans, rivers, and
groundwater; leads to environmental pollution. Pharmaceutical
plants are often incapable of filtering out all the chemical
compounds used in their manufacturing process. Therefore
the chemicals will seep into the surrounding freshwater systems
and eventually into the oceans, lakes, streams, and rivers. This
is responsible for increasing the pharmaceutical waste or their
by-product load in the environment, landfills, or dumping
areas.
The main sources of pharmaceutical pollution in the
environment include raw and treated effluent from pharma-
ceutical factories, hospital waste, excretion by livestock
treated with antibiotics, runoff from agricultural fields, and
municipal wastewater treatment plants. Pharmaceutical
products with a long half-life are environmentally sustainable,
remain at the wastewater treatment stages and will enter the
environment.
94 Social Pharmacy
Pharmaceutical products may be abundant in sewage
treatment plants, surface water, ground water, and in
drinking water. Antibiotics that are widely used in the
treatment of infections are considered to be toxic to nitrifying
bacteria in the waste water treatment process. Pharmaceutical
production has been considered one of the most polluting
industries in various parts of India.
Although pharmaceutical products are necessary and
inevitable for human health these should be produced in such
a way as to cause the least harm to the environment. High
consumption of drugs should be monitored. People in the
community must be familiar with the consequences of drug
contaminants. Strict legal measures must be announced and
strictly implemented.
Pharmaceutical Waste
Pharmaceutical waste includes drug products that are expired,
unused, unwanted or discontinued, contaminated, damaged,
or no longer needed. Pharmacists can appreciate that unused/
leftover/expired medicines should not be flushed down the
toilet or drain.
The three rules of waste management—reduce, reuse, and
recycle (3R): Conserve natural resources, landfill space, and
energy by cutting down on the amount of waste.
Biomedical waste (BMW) or hospital waste is any kind of waste
containing infectious or potentially infectious materials. BMW is
generated from biological and medical sources and activities,
such as the diagnosis, prevention, or treatment of diseases.
BMW must be disposed of according to the Bio-Medical Waste
Management Rules, 2016.
Psychosocial Pharmacy
Drug may be defined as a natural or synthetic substance other
than food, which when taken, affects the functioning or
structure of the body or mind and is used in the diagnosis,
mitigation, treatment, or prevention of a disease or relief of
discomfort.
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Drug Abuse (Substance abuse)
It is excessive, self-administration of habit-forming drugs or
substances, leading to addiction, dependence, serious physical,
social, or psychological harm (e.g. dysfunctional behavior
patterns, hallucinations, memory loss), or physiological harm
(such as damage to kidneys damage, liver damage, heart
failure) or death.
Types of drug abuse
The types of drug abuse are as follows:
1. Due to the wrong use of the drug.
2. Due to the intake of too much of drugs.
3. Due to the use of wrong combinations of drugs.
4. Due to prolonged use of drugs.
Reasons for drug abuse
The main reasons that lead to drug abuse are:
1. Easy availability
2. Curiosity
3. Emotional pleasure
4. Social pressure
5. Unemployment
6. Family disputes
7. Genetic predisposition.
Identification of abusers
The following changes are observed in drug abusers and at
their homes, workplace, etc.:
1. Academic changes:
a. Poor attendance at school/college
b. Decline in academic performance
2. Physical changes: Slurred speech, sweating, loss of appetite.
Withdrawal symptoms
Common withdrawal symptoms include: Tremors, gastro-
intestinal symptoms, pain, sweating, depression.
96 Social Pharmacy
Drug Addiction
It is the ultimate result of drug abuse, which produces both
tolerance and dependence.
Drug Dependence
Drug or substance dependence is an adaptive state that involves
an urge to take the drug continuously or intermittently to
experience its psychic effects and to prevent the distress that
develops due to specific withdrawal symptoms upon cessation
of drug use.
Types of drug dependence
i. Physical dependence: It is a physiological state in which
the body develops a physiological dependence on a drug,
and needs more of it to achieve a certain effect (tolerance),
the withdrawal of which elicits unpleasant drug-specific
physical or mental symptoms and signs of withdrawal. It
is likely to be physically dependent on a drug without
being addicted to it but mostly physical dependence often
accompanies addiction. Physical dependence is caused by
chronic use of many drugs-including many prescription
drugs (opiates like heroin), benzodiazepines, barbiturates,
alcohol, and nicotine), even if taken as instructed. It is the
result of physical changes in the brain.
ii. Psychological dependence: It is a state in which the person
becomes mentally dependent on certain drugs (usually
mind-altering like cocaine and amphetamines) and
continues to use them even though the person realizes the
harm that these drugs are causing. Psychological depen-
dence often affects a person emotionally and mentally
rather than, or in addition to, physiologically; and the
person develops emotional-motivational withdrawal
symptoms such as irritability, cravings, insomnia, anxiety,
depression, anorexia, etc. upon cessation of drug use. To
overcome psychological dependence, willpower alone is
often not enough.
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Drugs of Misuse and Abuse
Drugs mainly reported to be connected with drug misuse and
abuse include:
1. Alcohol
2. Inhalants
3. Caffeine
4. Sedatives
5. Hypnotics and anxiolytics
6. Stimulants
7. Barbiturates
8. Benzodiazepines
9. Cannabis
10. Cocaine
11. Methaqualone
12. Opioids/Narcotics
13. Tobacco and substituted amphetamines.
Psychoactive Substances
Psychoactive substances or drugs are agents that act mainly
upon the central nervous system and may change brain
function, resulting in temporary changes in mood, perception,
and behavior. These agents may be used (i) to purposefully
alter one’s consciousness, (ii) behavior for ritual, spiritual, or
shamanic purposes, and (iii) as a tool for studying or
augmenting the mind. Some categories of psychoactive drugs
like anesthetics, analgesics, hypnotics, anxiolytics, CNS
stimulants, hormonal preparations, anticonvulsants, and anti-
Parkinsonian drugs have therapeutic value.
Types of Psychoactive Substances
Table 2.8 shows the main classes of psychoactive substances
and their effects.
1. Depressants
A depressant or central depressant is a drug that lowers
neurotransmission levels, which depresss or reduces arousal
or stimulation, in various areas of the brain. Depressants are
98 Social Pharmacy
also occasionally referred to as ‘downers’ as they lower the
level of arousal when taken. Depressants are widely used
throughout the world as prescription medicines and as illicit
substances. Depressants exert their effects through many
different pharmacological mechanisms, the most prominent of
which include facilitation of GABA (-aminobutyric acid), and
inhibition of glutamatergic or monoaminergic activity. The
effects of depressants often include ataxia, anxiolysis, pain
relief, sedation or somnolence, and cognitive/memory
impairment. In some instances, euphoria, dissociation, muscle
relaxation, lowered blood pressure or heart rate, respiratory
depression, anticonvulsant effects, and even complete
anesthesia or death at high doses may also occur. Other
examples are chemicals that modify the electrical signaling
inside the body. The most important are bromides and channel
blockers. Depressants are used medicinally to relieve anxiety.
Alcohol
Alcohol is a very prominent depressant. Alcohol is creating a
large problem among teenagers and young adults. Depending
upon the quantity consumed, alcohol is considered a sedative,
Table 2.8: Psychoactive substances and their effects
Class of Common main effects Examples
substance
Depressants Relaxation, anxiety Alcohol, valium, barbiturates
reduction, sleep (Seconal, nembutal)
Stimulants Alertness or arousal, Amphetamines, benzedrine
euphoria dexdrine
Alertness or euphoria Cocaine
Alertness Caffeine
Nicotine
Hallucinations Ecstasy (MDMA)
Opiates/ Pain control, euphoria Heroin
Narcotics Pain control, euphoria Morphine, percodan,
demorol
Euphoria Opium
Psychedelics Altered perceptions, LSD, PCP
hallucinations
99Preventive Healthcare
tranquilizer, hypnotic, or anesthetic. It has a marked effect on
CNS. Alcohol abuse or alcoholism is a worldwide psychiatric
problem in which there is recurring harmful use of alcohol
despite its negative consequences. There are two types of
alcohol abuse; (i) those who have anti-social and pleasure-
seeking tendencies, and (ii) those who are anxiety-ridden
people who can go without drinking for long periods but are
unable to control themselves once they start. Risky situations
include drinking and driving among others. Alcohol use can
affect all parts of the body but particularly affects the brain,
heart, liver, pancreas, and immune system. This can result in
mental illness, peripheral neuropathy,Wernicke–Korsakoff
syndrome, cardiomyopathy, liver cirrhosis, pancreatitis,
gastritis, and an increase in the risk of cancer, among other
diseases. Drinking during pregnancy can cause damage to the
baby resulting in fetal alcohol syndrome (retarded growth,
mental retardation, abortion). Generally, women are more
sensitive to alcohol’s harmful physical and mental effects than
men.
2. Stimulants
Stimulants are psychoactive substances that stimulate the CNS
and are likely to give the user a feeling of increased alertness
or arousal, relieved fatigue, an increased perception of energy,
and an improved sense of well-being. Physiological reactions
include an increased heart rate, increased blood pressure,
increased breathing frequency, flushed skin, and perspiration.
Excessive stimulant use may result in psychic dependence and
may cause dizziness, mood swings, headache, irritability, heart
palpitations, chest pain, hallucinations, and death. The most
commonly used stimulants are amphetamines, nicotine present
in tobacco, and caffeine present in coffee, tea, and other
beverages and foods.
Tobacco
Tobacco is legally used throughout the world for its stimulating
and calming effects even though it is causing more deaths as
compared to all other psychoactive drugs. Nicotine is the active
100 Social Pharmacy
and addictive chemical component in tobacco that is available
in various forms, including cigars, cigarettes, chewing tobacco,
and smoking cessation aids like nicotine patches, nicotine gum,
and electronic cigarettes. Nicotine is quickly absorbed into the
bloodstream and immediately stimulates the release of the
hormone adrenaline. Adrenaline stimulates the CNS and
increases blood pressure, respiration, and heart rate. Nicotine
also triggers an increase in levels of the neurotransmitter
dopamine, which stimulates the brain pathways linked with
pleasure and reward. Like any other drug, the use of tobacco
over time can cause a physical and psychological addiction.
Tobacco use can cause cancers of the lungs, mouth, throat, and
stroke, cardiovascular diseases, and chronic lung diseases like
chronic bronchitis and emphysema. Each one of these
conditions can be fatal. Even once the disease has been
diagnosed; quitting or stopping tobacco use can improve
treatment efforts. This is also true for smokeless forms of
tobacco like snuff and chewing tobacco. Women who smoke
have even more risk than men. The increased undesirable
effects of oral contraceptives, miscarriages, low birth weight
babies, intrauterine growth retardation, and osteoporosis, are
known outcomes of smoking during pregnancy.
Symptoms of tobacco and nicotine addiction: Nicotine
dependence is characterized by cravings and tolerance.
Withdrawal symptoms: Attention difficulties, anxiety,
irritability, frustration, sleep disturbances, headache, increased
appetite, tremors, lethargy, restlessness, and powerful cravings
for tobacco. Treatments can help smokers manage these
symptoms and improve the likelihood of successfully quitting.
Treatments for tobacco and nicotine addiction: Tobacco
addiction can be one of the most difficult addictions to manage,
despite the availability of so many treatment options. Many
users find that even after nicotine cravings have passed, the
ritual of smoking can lead to a relapse.
Treatment options
There are several different treatment options for those battling
a tobacco addiction:
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a. The patch: The patch is known as a nicotine replacement
therapy (NRT). It is a small, bandage-like sticker that the
user applies to the arm or back. The patch delivers low
levels of nicotine to the body. This helps wean the body
gradually.
b. Nicotine gum: Another form of NRT, nicotine gum can
help users who need the oral fixation of smoking or
chewing. This is common, as the addict may have the urge
to put something into his or her mouth. The gum also
delivers small doses of nicotine to help the user manage
cravings.
c. Spray or inhaler: Nicotine sprays and inhalers can also
help by giving low doses of nicotine without tobacco use.
These are sold over the counter and are widely available.
The spray is inhaled, sending nicotine into the lungs.
d. Medications: Some doctors recommend the use of
medication to help with tobacco addictions. Certain
antidepressants or high blood pressure drugs might be
able to help manage cravings.
e. Psychological and behavioral treatments: Some tobacco
users have success with methods like hypnotherapy,
cognitive-behavioral therapy, or neuro-linguistic pro-
gramming (NLP). These help the user change their
thoughts about addiction and work to alter feelings or
behaviors the brain associates with tobacco use.
In most cases, treatment for tobacco addiction requires a
combination of methods and will vary from one person to
another. Individuals should talk to their doctor when
considering NRT methods or medication to ensure the safety
and effectiveness of treatment. A doctor may also have good
treatment advice.
3. Narcotics
The term “narcotic” comes from the Greek word “stupor” and
originally referred to a variety of substances that dulled the
senses, inducing sleep and relieving pain. Today “narcotic”
refers to opium, opium derivatives, and their semi-synthetic
substitutes. Examples include heroin and pharmaceutical drugs
102 Social Pharmacy
like OxyContin
®
, Vicodin
®
, codeine, morphine, methadone, and
fentanyl.
Origin: The poppy Papaver somniferum is the source of all-
natural opioids like morphine, codeine, and thebaine whereas
synthetic opioids are made entirely in a lab and include
fentanyl, pethidine, meperidine, levorphanol, methadone,
tramadol, and dextropropoxyphene. Semisynthetic opioids are
synthesized from naturally occurring opium products, such
as heroin, hydromorphone, hydrocodone, oxycodone,
oxymorphone, ethylmorphine, and buprenorphine.
Narcotics/opioids come in various forms including tablets,
capsules, skin patches, powder, chunks in varying colors (from
white to shades of brown and black), liquid form for oral use
and injection, syrups, suppositories, and lollipops. Narcotics/
opioids can be swallowed, smoked, sniffed, or injected. These
opioids result in psychic dependence.
Effects: Narcotics/opioids are prescribed by doctors to treat
pain, suppress cough, cure diarrhea, and put people to sleep.
Besides their medical use, narcotics/opioids produce a general
sense of well-being by reducing tension, anxiety, and
aggression. These effects are helpful in a therapeutic setting
but contribute to the drugs abuse. Narcotic/opioid use comes
with a variety of unwanted effects, including drowsiness,
confusion, inability to concentrate, apathy, Slowed physical
activity, slowed breathing constriction of the pupils, flushing
of the face and neck, constipation, nausea, vomiting, slowed
breathing, cold clammy skin, and convulsions.
Drug dependence: Physical and psychological dependence
is a consequence of chronic opioid use. Withdrawal symptoms
appear when drug use is discontinued.
Withdrawal symptoms: The level and type of withdrawal
symptoms are directly connected with the specific drug used,
the total daily dose, the time between doses, the extent of use,
and the health condition of the user. These symptoms generally
appear soon before the time of the subsequent scheduled dose.
Withdrawal symptoms include watery eyes, yawning, runny
nose, sweating, restlessness, loss of appetite, irritability, nausea,