Evaluation of a self-rating screening test for areca quid abusers in Taiwan
Introduction
Areca quid chewing is a popular habit in many southeast Asian areas, including India, Indochina, Taiwan, southern China, the islands of the South Pacific, the north and northwest of Australia and east Africa.1, 2 Chewing areca quid is similar to smoking cigarettes or other well-known ethnopsychopharmalogic agents (including Asian karg, poppy and pituri, Peruvian coca, Indian hemp and American tobacco etc.) that are culture-related substances and abused by certain people. Many native culture-related substances, eg coca, hemp and tobacco in America are pharmacological stimulators as is areca/betel chewing in Asia. The geographical area covered by the areca/betel-chewing custom appears to be a large crescentic region to the north and northwest of Australia, Tanzania, Madagascar in east Africa and the Indo-Pakistan subcontinent, Sri Lanka in east Asia as well as southeast Asia.3 However, the contents of areca quid have less-known psychoactive properties, and rather produce a sense of well-being, release, euphoric state and change of consciousness.1, 4 According to Von Euler5 and Goodman,3 areca quid has markedly parasympathomimetic activity and peripheral muscarinic–nicotic effect of arecoline, a tertiary amine, and less potent cholinergic agonist and an inhibitor of gamma-amino butyric acid (GABA) uptake of arecaidine, hydrolytic agent of arecoline chewing with lime. Their peripheral physical reactions of parasympathetic activity of areca quid chewing have the main symptoms via vagus nervus, micronerve of blood vessels, including lower blood pressure, dilated blood vessels, decreased heart rate, facial flush, salivation, and bowel hypoactivity.1, 6
The central nervous response during areca quid chewing has no significant effect upon simple visual choice-reaction time, digit span, time on target on the pursuit rotor (eye–hand coordination).1, 7 However, areca quid chewing does produce some EEG changes consistent with alert response, lesser degree calming affect, and facilitation in choice-reaction time.1 Chewing overall increases the level of three sympathetic-related catecholamines: nor-epinephrine, epinephrine, and dopamine or their contents have reached statistically significant differences. The reactions included cardioacceleratory response, increase in heart rate, alteration of skin response, and a warm sensation of the body were noted, but its sympathetic reaction is weaker than its parasympathetic effect under areca/betel chewing.6, 7 On the other hand, the other compounds in areca/betel quid, inflorescence of Piper Betle Linn., give a refreshing pleasant odor. It contains aromatic substances, such as safrole, hydroxychavicol, isoeugenol and eugenol.1, 8, 9 They are strong stimulators to release catecholamine from chromaffin cells in vitro. Therefore, it enhances the sympathetic reaction during areca/betel quid chewing, users claim that chewing areca/betel quids reduces tension and irritability, combats hunger and fatigue, and creates alertness and a euphoric feeling. So it induces the operators of large vehicles, farmers and laborers to chew areca/betel quids. These people consider areca/betel quid chewing as an institutionalized tension-reducing and pleasure-promoting agent. In Taiwan, the areca/betel quid chewing behavior involves youngsters, low-education and low-social class groups. Hence, areca/betel quid abuse is a more severe, obvious and persistent substance-abuse than tobacco and alcohol. In some parts of Taiwan, chewing areca/betel quid is not only legal, but also socially acceptable and encouraged. The consumption of areca/betel quid has been steadily increasing for the past 15 years.1 An estimated 2.5 million Taiwan residents, including 17% of men and 1% of women, chew areca quid regularly.10
There are three major types of quid in Taiwan. ‘Lao-hwa quid’, which is commonly seen in urban areas, is made by putting a piece of inflorescence of Piper Betle Linn. with slaked lime and some local flavoring into an unripe areca fruit. The second, betel quid, is made by wrapping an unripe areca fruit and slaked lime paste with a piece of betel leaf, and is often seen in rural and aboriginal areas. The third type of quid, stem quid, is also considered as an areca quid. It is similar to the ‘lao-hwa quid’ except for the piece of inflorescence of Piper Betle Linn., which is replaced by a piece of stem of Piper Betle Linn.
Chewing areca/betel quid is highly correlated with the increasing risk of oral cancer10 and oral pre-cancerous lesions, and the decreasing onset age of oral cancer.11 From the Taiwan government's official records of mortality due to cancer, oral cancer was one of the top 10 in the year 2000. The major prevention strategies in the health department of Taiwan include the promotion of early diagnosis for pre-cancerous lesions as well as efforts towards prevention of areca/betel quid chewing.
In terms of find strategies of stopping the areca/betel quid chewing habit, it is important to identify whether a chewer is an abuser or not. The screening procedure usually required a psychiatrist. However, in Taiwan the number of psychiatrists is insufficient to perform clinical assessments for all of areca/betel quid chewers. Hence, the development of a self-report screening test for areca/betel quid abusers is important. Although areca/betel quid chewing is also a popular habit in many countries of southeast Asia,1, 2 such a self-report screening test for areca/betel quid abusers had not been explored. The purpose of this study was to introduce a Self-report Screening Test for Areca quid Abusers (SSTAA), which was modified from the famous SCAN SYSTEM (Schedules for Clinical Assessment in Neuropsychiatry, 1995) for clinic practice.
Section snippets
Methods
The initial screening questions were developed based on the SCAN (Version 2, Glossary, Schedules for Clinical Assessment in Neuropsychiatry, World Health Organisation, 1995), ICD-10 (Clinical descriptions and diagnostic guidelines: The ICD-10 Classification of Mental and Behavioural disorder, WHO, 1992), DSM-IV (DSM-IV Diagnostic and Statistical Manual of Mental disorders, American Psychiatric Association, 1994). These questions were divided into three components, which included the Present
Results
The demographic characteristics and the consumption of areca/betel quid between the abuser and non-abuser groups are compared in Table 1, Table 2. The abusers tended to have older age, less education, and had a higher daily consumption of areca/betel quid. The proportion of ‘yes’ answers between the abuser and non-abuser for the top 20 questions with higher absolute differences are shown in Table 3. For question no. 2 ‘Do you like to chew areca/betel quid?’, 82% of abusers answered ‘yes’
Discussion
According to DSM-IV, published by the American Psychiatric Association, substance dependence and abuse is a maladaptive pattern of substance use, leading to clinically significant impairment or distress. Diagnostic main criteria of substance dependence illustrates the obvious tolerance, withdrawal syndrome and psychosocial dysfunction and disability. Psychiatrists consider ‘any abnormal substance-chewing behavior’ as the field of ‘substance use disorder’ on DSM IV. They regard the plant-related
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