The fear of social stigmatisation as well as cultural, religious, and ethnic background prevents users from coming forward to divulge correct information regarding their drug habits and therefore, the use of illicit drugs represents an iceberg phenomenon.
These observations were made in a story based on case reports titled “Changing patterns in the types and methods of the abuse of illegal drugs in Sri Lanka: A study based on five recent case series" which was authored by S. Raveendran (attached to the Office of the Judicial Medical Officer of the Colombo South Teaching Hospital, Kalubowila) and S.R. Hulathduwa (attached to the Sri Jayewardenepura University's Medical Sciences Faculty's Forensic Medicine Department) and published in the Medico-Legal Journal of Sri Lanka 9(1) in June 2021.
This case series highlights the increasing trend to use more expensive and newer forms of drugs such as ice, ecstasy, and occasionally cocaine, together with longstanding illegal drugs such as cannabis and heroin, which were prevalent in Sri Lanka for many decades. The national statistics further show that the usage of illicit drugs had doubled within a period of five years from 2013 to 2018. The drug-using population consists of all age groups, both genders, and individuals from all ethnic, religious, cultural, and social strata. Geographically, according to I. Mahir and T. Wazeema’s “Social aspects of drug addiction in Sri Lanka” and P. De Silva and P. Fonseka’s “Drug addicts and their behaviour related to drug addiction among the institutionalised addicts of the Galle District”, the highest incidences are reported from the Colombo, Gampaha, and Kurunegala districts. An increasing trend of drug abuse among teenagers, young adults, and especially adolescent females had been noted in the comparative national statistics, per M. Margaret and N. Guy’s “Substance misuse”.
Illicit drugs may be administered in different ways. Data obtained in 2018 at the time of admission to rehabilitation centres show the common methods as being in the form of eating and drinking (47%), smoking (73.4%), sniffing (2%), injection (3%), the Chinese method (63% – inhaling the vapour from a heated solution of a powdered psychoactive drug on a sheet of aluminium foil where the moving vapour is chased after with a tube, which is often a rolled foil through which the user inhales), and other routes (2.4%). These figures overlap, as one abuser tends to use several methods of administration depending on the type of drugs they abuse and the occasion.
Most of the new-generation drugs are administered through sublingual (under the tongue), buccal (cheek/mouth), and oral routes, because they are easily available as stamps, patches, blotting papers, tablets, capsules, powders, solutions, gelatin sticks, and sugar cubes, which are easily transferred and sold in night parties and dances within a short period of time without the notice of the law enforcement authorities, even when the event has been organised with a proper licence. Most of the time, first-time users or experimenters start their first experience during the adolescent or young adult period.
Complications are more in adolescents, young adults, and females. The growth and development of adolescents may be adversely affected by the use of certain drugs especially opioids, due to their effects on the hypothalamo pituitary (the central regulator of metabolism in vertebrates, which also controls important physiological functions) growth axis and ovarian axis in maturing individuals. The augmentation of gonadotropins (peptide hormones that regulate the ovarian and testicular function and are essential for normal growth, sexual development and reproduction) during deep sleep and during the early teenage period may be impaired by the interference of Stage IV sleep (the deepest level of sleep) by stimulants such as cocaine and amphetamines. These stimulants are now becoming popular among Sri Lankan teenagers, students, dancers, stage artistes and sportsmen. The pubertal growth spurt and peak may be interfered with by the depletion of protein which is necessary for muscle and skeletal building and for the calorie requirement in young abusers of drug cocktails containing alcohol.
Adolescent females may experience secondary amenorrhoea (the absence of menstruation, missing one or more menstrual periods) and menstrual irregularities even in the absence of weight loss.
Some teenage females were not aware of their pregnancy status until it had been found out during the gynaecological referral following the medico-legal examination. Some could not even remember being engaged in sexual activity. This may well be due to the amnesia following the administration of date-rape drugs and confusion, disorientation, the impairment of judgment, the elevation of mood, and the aphrodisiac properties of drug cocktails.
Sweetmeats prepared from bhang (majun, subjee [a vegetable dish]) and certain beverages or cocktails with stimulants are known to show such effects. Willful intoxication with these drugs or administration by a third party with or without the knowledge of the recipient in rave parties is considered as one contributory factor for sexual crimes, including rape and unnatural sexual offences, as well as unprotected sexual intercourse, leading to STIs, unwanted pregnancies, teenage pregnancies, illegal abortions, and even maternal deaths and other complications of teenage pregnancies.
The state of mind caused by drugs may also contribute to the failure to take precautionary measures following the episode, such as the failure to take post-coital contraception and post-exposure prophylaxis (treatment given or action taken to prevent a disease) for human immunodeficiency virus (HIV). The increased metabolism of hormonal contraceptive preparations due to elevated liver enzymes following the continued abuse of alcohol and drug cocktails may lead to contraceptive failure, thus making precautionary measures futile.
A “relaxed state of mind” and heightened sexual desire caused by some drugs at rave parties will reduce social inhibitions and remove the conscience about morality and social taboos, thus making the person more vulnerable to having unsafe sex, engaging in adventurous sexual practices, and casual sexual intercourse with multiple partners. Some may especially take cocktails of stimulant drugs in rave parties with the sole intention of increasing their sexual desires and performance, while achieving a “relaxed and high” state of mind during the hours of ongoing sex.
The “chem sex” property of drugs may make teenagers and young adults engage in unsafe and risky activities, in turn making them more vulnerable to contracting blood borne infections and STIs. Some young adult males claimed that they felt an intense orgasm-like feeling even without ejaculation and also that this feeling stimulates them to engage in continued sexual activity due to the difficulty in ejaculation. The male physiological sexual response comes to an end with ejaculation and the male goes into a transient refractory period of varying lengths before the next arousal. This may be the reason why teenagers, young adults, and commercial sex workers (hustlers) tend to abuse such drugs continuously with the intention of evading and/or modifying this physiological response.
The abuse of alcohol and drugs may adversely affect the foetus. Foetal alcohol syndrome with congenital foetal malformations, early abortions, abruptio placentae (placental abruption occurs when the placenta separates from the inner wall of the uterus before birth, which can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother), intra-uterine deaths, pre-term deliveries, low birth weight and the cognitive impairment of the newborn are documented among alcohol and stimulant (especially cocaine and amphetamine) abusing and tobacco smoking young females, per J. Barbara’s “Metabolic disturbances”. This type of pregnancy is not an indication for legal or therapeutic abortions in Sri Lanka and therefore may end up as illegal abortions.
Further, a doctor may be confronted with a serious ethical dilemma when the doctor advises the expectant mother to quit alcohol, smoking and the abuse of drugs for the benefit of the foetus and when she does not comply with the compromise of foetal well-being. Physiological addiction to narcotics is common in most infants of actively addicted mothers as opioids cross the placenta. Withdrawal may be manifested even before birth by the increased activity of the foetus when the mother feels an urge for the drug or withdrawal symptoms develop in the mother.