People Now Smoke Dead People’s Bones and New Babies’ Faeces — Professor Lasebikan

Professor Victor Olufolahan Lasebikan, a professor of psychiatry at the College of Medicine, University of Ibadan, and a consultant psychiatrist and addiction specialist at the University College Hospital, Ibadan, in this interview with Sade Oguntola, speaks to concerns on substance disorders, particularly new psychoactive substances, and their implications on the health of Nigerians.

Studies generally in Nigeria are saying alcohol use is revealing concerning trends and patterns. So, what is the implication of alcohol use on the mental health of people in particular?

It is true that alcohol use is increasing in Nigeria among both men and women. However, the situation is more concerning with psychoactive substances, particularly the newer synthetic variants. The incidence and prevalence of these new psychoactive substances are rising exponentially compared to traditional substances such as alcohol and tobacco.

It is important to distinguish between substance use and substance use disorder. For example, a person may consume alcohol occasionally without developing a disorder. Someone might take alcohol today and not consume it again for six months; that is use. It becomes a disorder when the use is habitual and causes significant impairment, whether physical, legal, social, or health related. This includes issues such as family conflict, intimate partner violence, or a compulsion towards continued use. Furthermore, when substance use becomes the primary or alternative source of pleasure, it qualifies as a disorder.

In most substance use treatment facilities in Nigeria, at least seven out of every 10 adolescents or young adults are found to be using new psychoactive substances, as opposed to the traditional alcohol and cannabis that were more common several decades ago.

Can you give examples of these new psychoactive substances?

The United Nations Office on Drugs and Crime (UNODC) has identified over 900 different types of new psychoactive substances (NPS). Some are culture-specific, while others are region-specific. These NPS are not truly new inventions; many were first synthesised several decades ago but have recently become more available on the streets due to their growing markets. One of the major drivers of NPS use is their potent pharmacological properties, which make them highly addictive. Consequently, most individuals seeking treatment in addiction facilities present with florid psychotic symptoms compared to those using traditional psychoactive substances. The psychosis often persists for longer periods, even in the absence of a prior history of mental illness, sometimes meeting criteria for a mental disorder such as schizophrenia.

While some NPS are common across countries, six are particularly notable. A widely used NPS is synthetic cannabis, available in several variants, including “Scottish loud,” “Canadian loud”, and “K2”. Synthetic cannabis is laboratory-prepared and is estimated to be 20 to 30 times more potent than natural cannabis (Cannabis sativa).

Other NPS include: cocktails such as “gutter water” or “skushi” (a mixture of tramadol, cannabis, codeine, and liquor) and “monkey tails” (locally produced gin mixed with cannabis seeds, leaves, stems, and roots). Some adolescents and young adults also consume unusual substances such as lizard waste, dry pawpaw leaves and seeds, zakami seeds, moringa leaves, mandrakes, sewage gas, and gunpowder. Others inhale or ingest dangerous mixtures such as sodium hypochlorite solution (bleach) with carbonated soft drinks and fermented urine; smoked cassava and plantain leaves; spirogyra; dry human faeces; or burnt tyres. Prescription opioids (e.g., DF-118), cough syrups containing codeine, and sedatives such as rohypnol are also commonly mixed into cocktails, sometimes flavoured with vanilla or strawberry to enhance their appeal. Another emerging mixture is “nyaope” or “whoonga”, a combination of tobacco, cannabis, heroin, and antiretroviral drugs used to treat HIV infection.

Equally disturbing are reports of individuals smoking human bones, a practice sometimes referred to as “Kush”. It is suggested that this may be due to the high sulphur content of bones or residual drug content in the bones of deceased drug users, such as those previously dependent on fentanyl or tramadol. Some individuals reportedly roam cemeteries in search of such bones. Others even smoke tungsten filaments. The public health impact of these practices is enormous. For example, “Kush” users risk inhaling toxic sulphur dioxide and other harmful inorganic compounds, in addition to the usual physical, social, and psychological consequences of substance use.

There is also another variant of “Kush”, a cocktail prepared by local criminal gangs that may include synthetic cannabis, fentanyl, tramadol, formaldehyde, and powdered human bones. Some of these cocktails also contain nitazenes and phencyclidine, both highly dangerous synthetic NPS.

We already know the health hazards of alcohol use. However, when several substances, sometimes five, six, or more, are combined in a single cocktail, it becomes nearly impossible for the attending physician, psychiatrist, or toxicologist to identify and manage the full range of potential complications.

The increasing incidence of NPS use is a major concern for the UNODC. It presents serious public health risks that may take decades to fully understand, as new substances and combinations continue to emerge daily.

So, is psychoactive substance use more in an age group, gender, socioeconomic class or profession?

The use of psychoactive substances is a global phenomenon, often referred to as the globalisation of drug use. The advent of the internet has greatly accelerated this trend, making substances more accessible worldwide. Both the incidence (number of new cases) and prevalence (number of existing cases) of substance use are rising among both men and women. It is particularly common among adolescents and young adults, compared to older age groups. Older individuals are more likely to use traditional substances such as cannabis and cocaine and may occasionally use amphetamines, but they tend not to engage with the newer synthetic substances as frequently as younger people.

One of the most concerning aspects of addiction is that, regardless of the substance or behaviour involved, whether synthetic cannabis, traditional cannabis, alcohol, gambling, or internet use, the same biological pathway in the brain is affected. This pathway is driven by dopamine, the neurotransmitter responsible for the experience of pleasure. Everyday activities such as eating a favourite meal or sexual intercourse can trigger a dopamine release. However, in addition, the dopamine surge is far greater, often thousands of times higher than normal. This makes it extremely difficult for individuals to stop, as it feels like being cut off from their primary source of pleasure. That is why prevention is critical: the best treatment for addiction is never to start. Addiction is not a simple habit; it is a chronic relapsing disease.

So, what are the consequences of psychoactive substance addiction?

The consequences of psychoactive substance addiction can be physical, social, and psychological in nature. There may be physical health challenges; anything you take passes through the intestine, is metabolised in the liver, and is eventually excreted through the kidneys. Therefore, a person who takes substances loaded with heavy metals has a high risk of developing liver and chronic kidney diseases. This is also the reason they have a higher incidence of neurological diseases, particularly degenerative diseases of the brain that are characterised by progressive memory impairment and problems with attention, concentration, and orientation. Unfortunately, this tends to have an early onset in them and persists because they often do not seek any treatment. Similarly, they are at risk of myriad infections along the entire gastrointestinal tract.

Again, these are brain-altering substances, so many end up with depression, mania, or frank psychosis depending on whether the substance is a central nervous system depressant, a stimulant, or a hallucinogen.

Dependence is a serious matter because it tends to narrow the individual’s repertoire of life. That is what happens to substance users: because they neglect quality aspects of life, they develop progressive impairment in social and emotional functioning. They cannot hold on to marriages, jobs, or relationships.

Classically, substance use has been more common among the lower social class, the low socioeconomic class, and those from dysfunctional family settings. But this is now changing; it cuts across all demographics. You see children of professors, clergymen of high repute, and business moguls coming to our facility for treatment. This points to substance use disorder being more of a biological problem. The wiring of the brains of adolescents and young people, unlike the older generations, makes them more prone to substance addiction. Their brains are more malleable and responsive to receiving various types of information. Their brain reward memory system, that is, their ability to appreciate, is primed with so much plasticity. Thus, they are more susceptible to these novel psychoactive substances.

In the past, there was a theory called the gateway hypothesis. “Gateway” meant that before you started taking illicit substances, you must have taken alcohol and tobacco. When your brain was primed, you then moved on to cannabis. Today, that hypothesis no longer holds. Some people are straight illicit substance users. This cuts across all age groups, genders, and socioeconomic classes.

Is our policy then catching up? Are there things that we need to adjust in our policies?

Nigeria has policies on drug use, but the policies are not enforced because drug use cuts across the strata of Nigeria, including law enforcement agencies. Imagine what happens in the commercial motor parks; you will see law enforcement agents patronising people who deal in cannabis and alcoholic drinks, like motor park operatives. In fact, cannabis came into Nigeria through the military. In 1945, when they returned from the Second World War, they came back with seeds of Cannabis sativa to plant for their use. So, if we have to do something, the first group of people that requires rehabilitation is the members of law enforcement agencies who take substances.

Q: Do we have accessible rehabilitation facilities for people into drugs that are pocket-friendly and can actually help?

A: Most people with substance use disorders also have additional psychiatric problems, such as depression, anxiety disorder, or schizophrenia. Many also have associated medical conditions. Therefore, when you talk about rehabilitation for drug users, a good programme would be one that is led primarily by a psychiatrist. It may surprise you that at least half of adolescents and young adults who use substances started because of primary anxiety disorder or untreated or unrecognised depression. They turned to substance use as a form of self-medication. By attending a rehabilitation facility, the underlying problem can be identified and treated, allowing the rehabilitation to be more successful.

Q: What are those root problems that are often left untouched that can contribute to a successful rehabilitation?

A: Many adolescents turned to substance use because of poor or bad parenting, family problems, and family dysfunction. Imagine a father who keeps smacking his wife or a woman who refuses to take care of her husband. Children are very sensitive, and they begin to act out or rebel. As a result, they often experience anxiety and depression, and some end up with psychosis or schizophrenia.

Q: What are the things that can help to identify good rehabilitation facilities?

A: Currently, these rehabilitation centres operate under social welfare, which is wrong. They use a backdoor to enter medicine, whereas they should go in through medicine. The Association of Psychiatrists of Nigeria is also looking into registering all rehabilitation facilities for substance use. One patient was brought to my hospital from a rehabilitation facility in Ibadan. The patient’s arm was swollen; when we investigated the cause, we found that he had been injected in the artery at the facility. It was a rehabilitation centre without any medical personnel. The hand was later amputated at the University College Hospital. That is why we are launching our NGO with a focus on substance use and its rehabilitation. The groundwork will begin by first factoring in all the other NGOs and groups that provide rehabilitation for substance use in Oyo State.

As things stand, for the safety of people who need this service, we must regulate it. The Association of Psychiatrists needs to control rehabilitation facilities for either psychiatric disorders or drug use. At UCH Ibadan, where I work, we have psychologists, social workers, and clerics from both religious groups as part of the team that helps with rehabilitation. It is anchored by a psychiatrist.

Q: What are those things that the government should consider including in the national policy on rehabilitation facilities for substance use to guarantee access to good care?

A: We need to focus more on education about substance use, starting from elementary schools to tertiary institutions. From childhood, they should understand what drugs are and their dangers. Aside from that, substance use and its consequences must be part of the things embedded in the culture of the workplace and different sectors of society. Substance use is everywhere; many people have substance use disorders. There must be a way of identifying those who have substance use problems and getting them to access advice and interventions to help with their addiction.