La tunisie Medicale - 2016 ; Vol 94 ( n°08 ) : 531-534
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Résumé

RESUME
Introduction: En dépit des contraintes culturelles, religieuses et juridiques, l'usage et l'abus des drogues existent. La toxicomanie en Tunisie est devenue un problème largement répandu et est en train de détruire de nombreuses personnes et familles. Objectifs: Examiner les caractéristiques socio -démographiques des consommateurs de drogues et identifier les substances couramment utilisées.
Méthodes: Il s'agit d'une étude transversale. Tous les patients qui ont formé cette étude sont admis au centre de désintoxication '' Aide et Ecoute '' durant la période du mois de Janvier 2014 au mois de Septembre 2014. L'étude a été réalisée à l'aide d'un questionnaire explorant les caractéristiques socio démographiques et celles de la consommation.
Résultats: Seuls les hommes ont été admis au centre de désintoxication pour diverses addictions. Parmi les deux cents patients, 65,9% ont été célibataires et 59,5% ont eu des démêlés judiciaires. L'âge moyen à l'admission a été de 33,32 ans et l'âge moyen à la première consommation de la substance a été de 17,30 ans. La consommation de substance a été plus élevée (90,6%) chez les personnes moins instruites (secondaire ou au -dessous) et dans la population urbaine (73,2%). La substance la plus couramment consommée a été la Buprénorphine (34,8%). Il y a eu une relation significative entre la consommation de Buprénorphine et l'immigration p = 0,013. Conclusion  Au terme de cette étude, nous avons constaté une vulnérabilité des sujets les plus jeunes et des immigres concernant la consommation des drogues. D’où la nécessité de la mise en place d’un programme de lutte et de prévention contre la toxicomanie urgent et pertinent.

Mots Clés
Article

Introduction
Drug addiction is a complex and multidimensional problem and is the result of the interaction between an individual, a drug and a community (1). Despite cultural, social, religious, and legal constraints on Muslims against the consumption of drugs, usage and misuse do exist and it increases in all social classes (2).  It's a universal medico-social problem, starts to spread in Tunisia. Even if it appeared a long time ago, one is unaware of the real characteristics of this plague in our country.
The aim of our study is to examine the socio-demographic characteristics of Tunisian substance users and to identify the drugs commonly used.
Methods
 We conducted a descriptive cross -sectional study during January 2014 -September 2014 at the addiction treatment center ''Aide et Ecoute'' runs by a non -Government organization ''ATUPRET''. This center is situated in Thyna, south of Sfax and currently the only center in Tunisia, offering medical and psychological care. Only men were admitted in this center and women came for a medical consultation. In the future, a new department for female will be built. The study relevant data included socio -demographic details as recorded in the structured pro forma, developed and routinely used at this center. Patients stay on an average for 1 month for completion of detoxification course that includes withdrawal and co -morbidity management. Major exclusion criteria included the presence of past or present significant psychotic, affective disorders; current use of psychotropic medications such as antidepressants, mood stabilizers, antipsychotic; or having an unstable medical condition.  Demographic data of missing records (N=2) and available case records (N=200) were comparable in gross terms; small number of missing records precluded the application of inferential statistics for comparison. Analyses were carried out using SPSS 20. All statistical tests used the 5% level of significance, and all p -values were two -tailed. Mean (SD) and percentages were used for descriptive statistics.
Results
Socio demographic characteristics
Over a period of six month, 202 patients were admitted to the center ''Aide et Ecoute''. Only 200 questionnaires were able to be used. All were Muslim and male, with a mean age of 33.32 years (SD 9.71). Mean age for starting substance was 17.30 years (SD 4.89). More than half (57.4%) had started taking drugs below 18 years of age and for an average duration of 15.48 years. Substance use was higher (90.6%) in less educated people (secondary or 32 33 below) and in urban population (73.2%). More than half (59.6%) were unemployed and had never married (65.9 %). The majority (68.3%) had a poor and middle socio -economic background. We found 59.5 % of patients who had involvement with criminal justice. In the present study, the family types were: nuclear (63.5%) and single parenting resulting from separation (9.5%) or resulting from a death of a partner 46 47 (27%). We found that 61.5% of adolescents were from single parenting family. Among patients who were from nuclear family, 66.7% stayed for treatment between 3 and 4 weeks. There was a significant link between family type and duration of treatment p=0.005.
Substance use
The most common drug on initiation includes cannabis (38.8%), alcohol (32.9%), prescription medications (13.8%) and inhalants (9.9%). Inhalant use as initiation drug was seen pre -dominantly among minors in comparison to adults (p=0.003). In the present study, it was revealed that using inhalant substance as initiation drug was more common in a poor and middle socio economic classes (p=0.035). The most common substance misused was Buprenorphine (34.8%), followed by cannabis (23.4%), misuse of medication (12.6%), alcohol (10.1%) and use of heroine (6.3%). The proportion of poly drug abusers was 11.4%. Injecting drug users (IDUs) were 39%. Among them, 91.6% were sharing their needles. They reported always cleaning their needle before use with tap water or soap. They were mostly likely to report injecting at public toilets (10%), at home (80%), or in public parks (10%). Ninety per cent of IDUs reported injecting alone. The majority (80%) of them were economically disadvantaged. There was a link between poor and middle socio economic class and sharing needles (p=0.002). Half of them reported having vaginal or anal intercourse without condom. Among them, 16% of participants exchanged money or drugs for sex. In this study, 37.3% of subjects had immigrated once at least during their lifetime. Most of them (82.4%) had immigrated to Europe. There was a significant relation between buprenorphine consumption and immigration (p= 0.013). Most of the patients had come on their own (47%) or referred by private practitioners (22.1%), whereas 18.1% were accompanied by their family members and 11.4% had referred by a patient from the center and 1.3% was brought by police. Different reasons cited for substance abuse included peer pressure and curiosity (69.5%), stressful environment (27.7%), and prescription medicine abuse (2.8%).


Discussion

Socio demographic characteristics
The mean age at admission was 33.32 ± 9.71 years. This observation correlated with other studies (3, 4). This is explained by the fact that substance abusers did consulting only after the appearance of negative impact on family and health. Mean age of initiation of the substance use was 17.30 ± 4.89 years. More than half (57.4%) had started taking drugs below age of 18 and for an average duration of 15.48 years. Worldwide there is a rising trend in the number of people who resort to substance abuse at an early age (5 - 7). As the mean age of initiation of substance use was early twenties, in liaison with schools and colleges some recreational activities can be generated to prevent diversion of zest and zeal of youth towards the devil of drug abuse. Drug addiction was higher (90.6%) in less educated people (secondary or below). This is a finding similar to some earlier reports (8, 9). It may reflect the possibility of impaired cognitive function, lower scholastic performance, and school dropout, especially if the substance abuse starts in pre -adolescence.
More than half (68.3%) of our patients were reported to be from middle and poor socioeconomic classes. This did not rule out the presence of substance users amongst the affluent class (6). The center ''Aide et Ecoute'' is less preferred by upper socioeconomic class people. They preferred private clinic.
We found 59.5 % of patients who had involvement with criminal justice. This finding was comparable to other studies (10, 11). There was a link between the age of onset for delinquent behavior such as a history of conduct disorder, poor social adaptation, aggression and breaking rules, and substance abuse (11).
We found that 61.5% of adolescents from single family were more likely to use a substance comparable to other study (12). Disintegrating family values exposes adolescents to alcohol and other substance use.

Substance use
The most common drug on initiation includes cannabis (38.8%). This finding is similar to a Moroccan study (5). Inhalant use was seen pre -dominantly among minors in comparison to adults (p=0.003) and in the poor middle socio economic class (p=0.035). This finding was similar to others researches (6). This was shown because of easy accessibility, cheap price, faster onset of action, and a regular ‘high’ with such substances.
The most common substance misused was Buprenorphine (34.8%), followed by cannabis (23.4%), misuse of medication (12.6%), alcohol (10.1%) and use of heroine (6.3%). This finding is similar to Finland research (13) and different from Arabian studies which the most commonly abused drugs are alcohol, heroin, and hashish (14). The recent increases in buprenorphine misuse are due to the fact that it  serves a variety of functions for the opioid -abusing population: to get high, manage withdrawal sickness, as a substitute for more preferred drugs especially heroine taking in Europe, to treat pain and as a self-directed effort to wean themselves off opioids ( 15,16 ) .
There was a significant link between buprenorphine consumption and immigration p=0.013. Buprenorphine misuse has replaced heroin use among our patients who immigrated to Europe. The reasons for this are not clear, but it may be related to better availability and ease of access (low price…) compared to heroin.
There was a link between poor and middle socio economic and sharing needles (p=0.002). They reported sexual risk behaviors. These findings were similar to another study conducted in morocco which indicated a major risk factor for infectious transmission (17). This habit reflects the cultural aspect of the larger Arab society, in the sense that these collectivist cultures are known for their sharing of food and goods as a symbol of bonding, brotherhood, and hospitality. One might also speculate that needle -sharing may be due to financial reasons during hard economic times, as the partage of one syringe between multiple users is less costly (17). In this study, most injection drug users reported cleaning their needles before and after use suggesting some risk perception related to repeated use of needles. However, the majority used tap water or soap and water for cleaning, which is insufficient to effectively disinfect injection equipment. Interventions need to include education not only about needle sharing but also about needle hygiene and safe acquisition and disposal.
Peer presser and curiosity to experience the effects of the drug was one of the most important factors for trial of substance in our study. The same result was revealed by Egyptian and Moroccan studies (5, 18).
Several other studies identified risk factors for substance use like lack of protective housing, social and neighborhoods problems, inter personal pressure, isolation, no recreation, lack of trust and social security (19, 20).

Limitations
The results of our study must be considered with its limitations. It focused only on treatment seekers. The study population may not be representative of Tunisian users given that all clients were men. Additionally other groups such the subjects who are underage (10 -18) were not included. Despite the study’s limitations, the findings do provide preliminary data about drug addiction patterns and demographic information of substance users who seek treatment in Tunisia.

Conclusion
This is the first national study on the profile of Tunisian users. Our patients were commonly not married, unemployed and from poor and middle socio economic classes. It was observed that they had involvement with criminal justice and had immigrated at least one time. Also, we observed lower mean age of initiation of substance use. So, more studies about immigrated and adolescent population are necessary. These findings call for the organization of educational and social support services, as well as the provision of relapse prevention program. Our results also suggest that beyond health education, interventions targeted at the families could play a crucial role in this setting. Additionally, pharmacies should be considered as a venue for interventions targeted at injection drug users given that the majority of users acquire their needles from them. Tunisian health authorities must implement public health campaigns to address this issue of high prevalence of drug use and misuse.

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