Wednesday, November 24, 1999

Drug addiction in Punjab — I
By Dr. Rajeev Gupta
IN recent years, the menace of drug addiction has assumed alarming proportions. Statistics from various medical centres in Punjab reveal that the number of cases of various addictions in all parts of the state is increasing rapidly.

Exercise—the best medicine
By Dr G.D. Thapar
There is no longer any doubt that moderate exercise prolongs the life-span and, more importantly, the health-span by preventing or delaying the occurrence of chronic diseases of degeneration such as heart attacks, angina, strokes and even cancer.

Workshop on palliative cancer care
Seven-day course with GCC help
A seven-day course-cum-workshop in "Palliative Care in Cancer" will be organised from today (November 24) by the Department of Radiotherapy, PGI, Chandigarh, in collaboration with Global Cancer Concern, India, an NGO group whose aim is to promote palliative care facilities.

Aspects of surgical care
By Dr J.D. Wig

We are now living in the "century of old age". The group of those who are 75 years of age or older is growing fast. The medical profession should prepare itself for the care of this group.

Innovations and improvements in the care of elderly surgical patients has allowed us to be more and more successful with such patients receiving larger surgical procedures. The list of procedures is growing longer with each passing day. This has become possible because of improved surgical technique's safer anaesthetic agents and better perioperative and postoperative care.

Making surgical decisions with the elderly patient is a formidable challenge. Such patients have had a lifetime of experience in making serious decisions both with and without advice. The elderly are by nature sceptical and are not about to follow the advice blindly.

Elderly patients have unique standards for assessing the risks, and benefits in clinical decision-making with a limited amount of anticipated life ahead of them. Such people do not like to be hurried, and such a patient should be given time to consider the options and to talk them over with the family.

Elderly patients seldom accurately estimate their life expectancy. Most fail to understand either the anticipated duration or the degree of dependency they will experience during the months and years after surgery. They have understandable ignorance of the effects of the disease or operative interventions on their performance. It is the responsibility of the surgeon to participate in such decisions.

Success requires being thoroughly familiar with the topic to be discussed, as well as being completely honest. The patients' options must be accompanied by a clear-cut statement of what the surgeon believes is the wisest course of action.

An elderly patient, who is faced with a life-threatening disease and serious surgery, may want to know the probability of dying. This knowledge may affect not only the choice of treatment but also how the patient tends to structure the remaining months. Such information has an important effect on lifestyle and practical decisions.

With limited life expectancy, most elderly patients value the quality of their final years. They zealously protect every vestige of independence and self-sufficiency, which they equate with self-respect. Such perceptions are important to the elderly when they evaluate clinical management options. The wise surgeon should take into consideration the altered outlook of the elderly patient and adjust the suggested management programme accordingly.

Both the family and the elderly patient, who is about to undergo a major surgery, are better served if they realistically anticipate what lies ahead in the postoperative period. Elderly patients dislike carrying out orders without a chance to ask questions or get an explanation. They want to be recognised as the final arbiters in such decision making as may seriously affect their lives in the near future.

With the advancement in information technology, the questions the elderly ask have become increasingly more complex and those asked by family members are often quite difficult to answer. A surgeon should avoid forcing an elderly patient to submit to an operation whose consequences the patient or the family does not thoroughly understand.

The surgeon must do his best to accommodate the patient's wishes. All that an elderly patient desires is relief from pain, independence and self-esteem. Allow the elderly patient time to make decisions and help them choose a logical form of treatment.

Chronic illnesses, associated with advancing age, do not affect the results of surgical care to the degree one might expect. The most important factor for good results in the surgical care of the elderly is the timing of the procedure. The patient's tolerance for the delay in treatment is much lower. Elective operations are tolerated well as compared to emergency procedures.

Better methods of choosing patients, who will tolerate and benefit considerably from large and risky surgical procedures, need more development. A significant effort is needed to prepare future surgeons of all specialities to respond to the problem of treating large numbers of elderly patients. The task ahead is not an easy one.

The author is a renowned surgeon, clinician and teacher.

Drug addiction in Punjab — I
By Dr. Rajeev Gupta

IN recent years, the menace of drug addiction has assumed alarming proportions. Statistics from various medical centres in Punjab reveal that the number of cases of various addictions in all parts of the state is increasing rapidly.

Drug addiction, if not checked in time, may lead to catastrophic consequences for the addict, his family and society at large. It is sad to note that there has been no consistent effort to create awareness among the people regarding the harmful impact of drugs on the individual and society.

While government and other social organisations are aware of the menace of AIDS, the monster of drug addiction is set at large and is playing havoc with the youth who are the future of the land. The present two-part article is an attempt to answer certain questions which are of paramount significance to the general public.

Q. (I) Is drug addiction on the rise?

Ans. Drug addiction is certainly on the rise. It is quite evident from the number of patients reporting to medical and psychiatric centres engaged in the treatment of patients suffering from drug addiction. Rural areas of Punjab too have become a victim. Ask any responsible villager about the number of drug-addict youth in his village. The answer will be anywhere between 10 to 40 per cent. This figure may appear shocking but this observation can be supported from many other sources. Though there is a definite variation from one geographical area to another, this rising trend throughout the state is indeed alarming and needs the urgent attention of the authorities, voluntary organisations and religious institutions.

Drug addiction is equally on the rise among the urban population of the state. There is hardly any part that has been left untouched by this evil.

Q. (II) Which is the most vulnerable age group?

Ans. Youth is highly vulnerable. Young persons succumb to peer pressure in schools and colleges. The bleak prospects of unemployment loom large on their horizon. They see nothing but blankness and despair before them. The system of education does not ensure them any vocation in life. Degrees have lost their value and, consequently, they face a vacuum so far as their future is concerned. Failure and the resultant frustration drive them into dark wells of despair and they seek refuge in drugs that provide them temporary solace from the ills of life. Addicts feel secure and reassured in the company of their peer group, where their status and position is "understood", maintained and ensured.

Q. (III) Which are the commonly misused drugs and substances?

Ans. Alcohol addiction is definitely on the rise in Punjab. Unlike a decade ago, when alcohol was a taboo, today there is social sanction in favour of alcohol consumption. The number of outlets selling alcohol have multiplied all over the state. Unfortunately, the present-day alcohol-user is comparatively 10 to 15 years younger than the earlier users and has many more reasons or occasions to consume alcohol. Hospitals are getting flooded with patients with alcohol-related medical and psychological problems. Patients afflicted with alcohol-related liver diseases keep on straining the already exhausted resources of the families and society.

Commonly misused drugs are tranquillisers; sleeping pills; codeine-containing cough syrups; narcotic pain killers like Proxyvon, Charysoma; injections of Morphine, Fortwin etc; antidiarroheal drugs like Lomotil; hard drugs like smack heroin and cannabis preparations like bhang, ganja and charas. Opium in various forms continues to be frequently misused in rural Punjab. Its use in cities is restricted to only a small segment. Studies have shown that intravenous drug-users become vulnerable to infections like hepatitis and HIV.

Q.(IV) Why is there a big rise in the number of drug addicts ?

Easy access to all sorts of drugs and narcotic substances in the state has been the major cause of its fast spread over. There is a mushroom growth of chemist shops in urban and rural areas of the state. Many chemist shops have become easy outlets for the illegal sale of these drugs. In most of the areas monitoring of these shops is not adequate, leaving the field completely free for antisocial elements. Though the sale of narcotic drugs is restricted by law, they are freely sold without any prescription and at a very high premium that entices many others to join this trade.

There is hardly any scope of employment in rural Punjab. Most of the Punjabis have lost their traditional love for physical labour in the fields. Manual work has been completely taken up by the migrant labour from Bihar, Orissa and UP. The increased mechanisation of agriculture has also reduced dependence on manual labour. The Green Revolution has brought prosperity to rural Punjab. The prices of agricultural land have shot up. Many families have become rich by the sale of their agricultural land. Today, an average Punjabi in the rural area enjoys all the luxuries of urban life. In many areas, NRI money has also led to the change in the lifestyle of the rural Punjabi.

Leisure and money lead to pleasure which is the mark of Punjabi culture. The extrovert, pleasure-seeking and highly risk-taking personality of the common Punjabi has led to the fast increase in drug addiction. An innocuous looking pill that gives a thrill ultimately puts the user into a state of complete physical and psychological dependence. When the drug is withdrawn, an addict experiences severe withdrawal symptoms.

The smuggling of smack and heroin from across the border has made the situation worse in the border districts of the state. Smack addiction is becoming a common clinical and law and order problem in Amritsar district — ( To be concluded)

The writer is a consultant psychiatrist and a deaddiction specialist based in Ludhiana.

Exercise—the best medicine
By Dr G.D. Thapar

There is no longer any doubt that moderate exercise prolongs the life-span and, more importantly, the health-span by preventing or delaying the occurrence of chronic diseases of degeneration such as heart attacks, angina, strokes and even cancer. This beneficial effect occurs by the following actions:

*Burning of calories and the prevention of obesity.

*Preventing insulin-resistance and diabetes.

*Lowering blood pressure.

*Improving the lipid profile of blood, raising the level of good cholesterol (HDL-C) and lowering the level of bad cholesterol (LDL-C).

*Increasing the flow of blood in the arteries of the heart (coronary arteries) and thus preventing the deposition of cholesterol on their walls.

*Reducing the chance of blood-clotting in the arteries

*Conditioning of the heart: as mentioned in my earlier article, exercise opens up the dormant collateral channels of blood supply which act as natural bypasses in case obstruction develops in one or more of the coronary arteries.

These collateral channels are of great importance to the safety of the heart because they keep the blood flowing in the coronary arteries and thus prevent angina and heart attacks.

How much exercise?

For a beneficial effect to occur, the exercise needs to be moderately intense. There is no need for a marathon. In fact, too intense and prolonged an exercise defeats its own purpose and can be dangerous in the elderly. It should be just intense enough to produce a bit of rapid breathing and some sweating with 70—80 per cent of the age-adjusted maximal heart rate (i.e, the pulse rate). Keep it up for 20 to 30 minutes, four or five times a week. Before and after exercise there should be warm-up and cool-down periods of a few minutes each.

The age-adjusted maximal heart rate can be arrived at very simply by deducting your age in years from 220. For example, if you are 50, your maximal heart rate should be 220-50=170 per minute. Hence you should be exercising to produce a pulse rate of 70-80 per cent of 170, i.e 120 to 136 beats per minute to bring about a beneficial effect on your body and heart.

The type of exercise should be such as to involve large muscle masses such as walking, dancing, swimming or cycling. There is no doubt that in middle age and beyond, walking is the best form of exercise and in old age it is almost the only exercise that you should indulge in unless you are used to some other form of exercise. If you walk with rubber-soled canvas shoes at a pace of 116 to 120 paces per minute, you will produce the desired heart rate.

It may be reiterated that simple outdoor exercises at moderate intensity are the best thing to do. Complicated gadgets may be reserved for indoor exercises when it is not possible to go outdoors as, for example, in rain.

The accumulated daily activity programme
Recently, a panel of experts of the US National Institute of Health has issued very practical recommendations, which should suit every town-dweller who does not seem to find time for exercise:

"All children and adults should gradually build 30 minutes of physical activity of moderate intensity on most, preferably all, days of the week".

These 30 minutes can be accumulated through segments of about 10 minutes' duration. The moderate intensity activity may be brisk walking, use of stairs, gardening, cycling, swimming, etc. Most people can easily incorporate activities of moderate intensity into their daily lives without having to disturb their routine.

The frequent use of stairs alone or coming to work on a cycle or on foot in preference to one's car can make an important contribution to an accumulated daily activity programme.

Physically active lifestyle
Build physical activity into your lifestyle. Do not miss any opportunity to be physically active. Bring your glass of water from the fridge yourself. Walk to the marketplace instead of using your car. Go up the stairs and do not use the lift. Once you have made up your mind to be physically active, you will find unlimited opportunities for activity. The advantages are obvious. It is natural and does not need any special precaution or gadgets, and is cost-effective.

Precautions
If you are over 40 (men) and 50 (women), consult your physician before embarking on an exercise programme, particularly if you have multiple risk factors like smoking, high blood pressure, and diabetes. All those already having evidence of ischaemic heart disease should get medical advice.

Build up the duration and intensity of the exercise slowly and gradually. It may take many months before you reach the ideal level, particularly if you are an elderly person.

Whatever the form of exercise or game, it should be such that it produces a pleasant feeling of tiredness which disappears after rest or sleep. Acclimatise yourself first and gradually increase the quantum of exercise and its intensity, particularly if you are in middle-age or have gone beyond. It presupposes that this age group should not indulge in games with the idea of competition but only for fun and exercise.

If you experience any adverse symptom such as pain, pressure or tightness in the chest or undue breathlessness or weakness, you should immediately stop all activity and consult your physician.

If you are a diabetic on insulin or oral drugs, beware of hypoglycaemia. Always carry a packet of sugar to be taken immediately if such symptoms appear. If you are hypertensive, exercise is good for you, but do not exercise if the blood pressure is too high or too low.

Avoid vigorous exercise in too hot or too cold weather. Exercise either before meals or two hours after, because much blood is diverted to the abdomen for digestion and less is left for the use of the heart. Rest a while after meals.

In middle age and beyond, do not test your limits of tolerance for exercise; it will serve no useful purpose but can prove dangerous.

Conclusion
Physical activity and exercise afford protection to the heart and the rest of the body as nothing else does. You must modify your lifestyle if it is sedentary, and build physical activity into it.

Take moderate-intensity exercise regularly — say, five times a week, choosing an activity that requires the use of most of the large muscles of the body such as walking or swimming.

If you are 65 or older, walking is the only suitable form of exercise, unless you are used to a more vigorous game or exercise for a long time, whose intensity should be gradually toned down.

To be effective, the exercise must be continued for progressively longer periods week by week till it can be maintained for 20 to 30 minutes continuously. The other approach of accumulated daily activity in segments of 10 minutes may also be effective and more suited to your age or pattern of daily activity.

Generally, the exercise taken should increase in small stages, each taking about two months or so. This slow progression is particularly important for the elderly, those unaccustomed to exercise and those with evidence of ischaemic heart disease.

The long-term aim, in general, is to ensure that you are able to walk at least one mile (1.6 km) or more on level ground without interruption at a brisk speed of 120 paces per minute, using light rubber-soled canvas shoes.

The author is the former chief of the Medical Unit at the Willingdon (now Ram Manohar Lohia) Hospital, New Delhi, and physician and cardiologist at the INAS Hospital, University of Tripoli.

Workshop on palliative cancer care
Seven-day course with GCC help

A seven-day course-cum-workshop in "Palliative Care in Cancer" will be organised from today (November 24) by the Department of Radiotherapy, PGI, Chandigarh, in collaboration with Global Cancer Concern, India, an NGO group whose aim is to promote palliative care facilities.

The workshop has been planned keeping in view the facts that palliative care should be an integral part of cancer care and that it should be available to every patient from diagnosis to the course of one's treatment.

Thus the aim is to train physicians and nurses involved in cancer patients with pain, and symptom management. The very important topic of morphine use and procurement will also be covered.

Very often the patient's agenda is different from the physician's agenda and emphasis will be laid on this aspect along with the psycho-oncological problems of cancer patients.

Another area which will be dealt with in detail is the delicate topic of doctor-patient interaction and ways to break sad news.

Since most of the sessions will be interactive, the number of participants will be limited to 25 physicians and nurses from government hospitals, private hospitals and NGOs.

The aim is to train manpower in the field of palliative care so that it can be integrated into the education and practice of oncology.

Along with the main course for the participants two other groups will benefit from interacting with the resource persons (faculty). The members of the Department of Physiotherapy will have one day with Ms Tole from the Tata Memorial Hospital, Mumbai, and they will also have the opportunity to gain from her vast experience on lymphoedema care. "Sahayata" volunteers from Chandigarh will be present with Dr Santosh Chaturvedi of the National Institute of Mental Health and Neurosciences, Bangalore, for one afternoon.

— Dr Firuza D. Patel, PGI