Substance use disorders in Saudi Arabia: a scoping review

Background Substance use disorders (SUD) are mental health conditions that arise from chronic drug use. There is an increased recognition of this problem in Saudi Arabia. Objective Conduct a comprehensive review of published literature on SUD to identify knowledge gaps and to guide future research. Methods PubMed, Embase and Cochrane databases were searched with suitable keywords for SUD publications up to June 10, 2019. Eligible studies (primary research conducted in Saudi Arabia) were organized into three broad domains: (1) risk (or protective) factors of SUD, (2) perspectives on drug use of people who use drugs, and (3) impact on family. The quality of the included studies was assessed with the Newcastle-Ottawa Scale. Results Of the 113 search records, 23 were eligible for analysis (19 cross-sectional and 4 case-control). All studies were conducted in clinical settings; all but two included males only. There were 4 studies about SUD risk factors, 6 studies about the perspectives of people who use drugs, and none about family impact. None of the cross-sectional studies (0%) and 25% of case-control studies were of good quality. Conclusions The available studies were few in number, weak in methodology, and poor in quality. Quantitative as well as qualitative studies about SUD are warranted in each domain and should represent both genders.


Introduction
Substance (drug) use disorder (SUD) is a medical condition that arises from chronic drug use and is characterized by a cluster of cognitive, behavioral, and physiological symptoms that a person who uses drugs (PWUD) exhibits [1]. A hallmark of this condition is that the PWUD continues to use the drug despite experiencing significant negative consequences. SUD renders huge physical, psychological, and financial costs to the PWUD, the family members, and the society at large [2]. According to the latest United Nations 2019 Drug Report (UNODC), an estimated 271 million people (5.5% of the global population, aged 15-64) had used drugs in the previous year [3]. Additionally, 35 million people were diagnosed with and received treatment services for SUD [3].
Saudi Arabia is an Islamic country, and the societal norms and values are deeply rooted in religion. There are religious as well as legal prohibitions against possession or consumption of alcohol and narcotic substances, yet a portion of Saudis consume alcohol and use drugs [4]. Around 7 to 8% of Saudis report having used drugs [5,6]; 70% of all PWUDs are 12-22 years old [5]. The most commonly abused substances among Saudis are amphetamines, heroin, alcohol, and cannabis, and a majority of PWUDs are addicted to multiple substances [7]. Over the past decade, the use of cannabis and amphetamines has increased, while the use of heroin and volatile substances has decreased [4,8]. A portion of Saudi females also uses drugs, and the usage among them may be on the rise [9]. Drugs are not as accessible to women as they are to men in Saudi Arabia due to the conservative nature of the society and the strict gender segregation. Therefore, women are prone to using primitive and volatile substances such as glue, gasoline, and shisha [9].
The existing data on SUD among Saudis are outdated and non-specific. According to the World Health Organization, 0.01% of men ≥15 years of age had substance use disorders (2004 estimate) [10,11]. Nearly 10, 000 Saudis inject drugs; prevalence of human immunodeficiency virus (HIV), hepatitis C (HCV), and hepatitis B (HBV) among them were 3.5, 77.8 and 7.7%, respectively [12]. The SUD estimate is likely an underestimation because of the stigma and fear of disclosure associated with substance use. There is indirect evidence that points to a growing SUD problem. For example, more centers have been established in major cities, and a large budget has been allocated (one billion dollars per year) for the treatment and rehabilitation of PWUDs [13].
Hence, a multidimensional understanding of SUD is needed at this point in order to develop a comprehensive program to manage this problem in the society. Some of the major dimensions include risk (or protective) factors for SUD, perspectives of PWUDs, treatment and rehabilitation, and the impact on family members. International studies provide evidence for each of these dimensions. For example, family and religious values play an important protective role in drug use [14][15][16], common motivations for drug use include curiosity, relaxation, and peer pressure [17], knowledge about drugs and their effects depend on users' age and education [18], and substance use takes a physical (e.g., violence), psychological (e.g., depression, break-up of relationship), and financial toll on family members [19,20].
Therefore, a comprehensive review on SUD research in Saudi Arabia is timely and can be the starting point for understanding this problem for both the policymakers and local researchers. The most recent review on substance use in Saudi Arabia was by Bassiony in 2013 [4]. It was not specific to SUD but rather described substance use in general over the preceding two decades. It also did not assess the methodological quality of the included studies. The rationale for the current review is that the absolute number of people who have a substance use problem is likely high in Saudi Arabia because its demographic distribution is heavily tilted toward youth (around 15% of the total population is between 15 and 24 years old) [21], and youth are most affected by substance use. This review is also important in the context of the changing nature of Saudi society, which has traditionally been deeply religiously conservative, sustained by the Islamic principles of balance, restraint, and modesty. Its values are challenged in this information age, where countries are connected in the virtual realm to western cultures that promote individual identity, glorify drug use, and peddle pop culture. Saudi youth is most affected by this clash of cultures. They are increasingly alienated from their relatively more traditional parents, and it is in this vacuum where societal problems like substance use likely arise.
This review compiled all SUD-related publications from Saudi Arabia until the present. The specific objectives were to (1) describe the characteristics of the published studies, (2) assess their methodological quality, (3) identify areas where there is limited research evidence, and (4) make specific recommendations for future SUD research. The findings of this paper will help policymakers identify priority areas for SUD research and will guide prospective researchers in designing studies in areas that are currently deficient.

Literature review and data sources
Three databases were searched in June of 2019: PubMed, Embase and Cochrane Controlled Register of Trials (CENTRAL). Studies published up until June 10, 2019 were included. The search terms used in PubMed were ("Substance-Related Disorders"[Mesh]) AND "Saudi Arabia"[Mesh]). The Medical Subject Heading (MeSH) was used in both PubMed and CENTRAL and the search terms were ("Substance-Related Disorders"[-Mesh]) AND "Saudi Arabia"[Mesh]). A multi-field search was used in Embase to search the following: "substance use disorder" AND "Saudi Arabia". Additionally, national journals (Saudi Medical Journal and Annals of Saudi Medicine) and the reference lists of eligible articles were searched to identify additional published studies.

Eligibility criteria
All published studies that (1) either included patients with SUD as the sample or used SUD as an outcome, and (2) were conducted in Saudi were eligible for review (i.e., inclusion criteria). Publications about SUD that did not stem from primary research (e.g., opinion, letters to editor) as well as conference proceedings or abstracts were not included (i.e., exclusion criteria).

Search outcomes
Respectively, 61, 48, and 4 records were retrieved from PubMed, Embase, and CENTRAL (total = 113). These produced 55 unique records after the duplicates (n = 58) were removed through a careful read of the study titles. They were screened, and 35 did not meet the inclusion criteria, producing 20 eligible articles. An additional 7 articles that met the eligibility criteria were found after searching the national journals and scanning the reference lists of the primary 20 articles (total eligible =27). The full texts of 4 articles could not be retrieved despite making efforts (e.g., contacting the authors via e-mail) [22][23][24][25]. The total articles included in this review were therefore, 23 (Fig. 1).

Data extraction process
From each included study, data were abstracted on (1) authors' names, (2) publication year, (3) study design, (4) sample age and size, (5) study population, (6) location, (7) criteria used to diagnose SUD, and (8) main findings. Initially, the data of the included studies were charted by one co-author and then were reviewed independently by the lead and senior authors. Any discrepancy was resolved through discussion and consensus among the authors.

Quality assessment of the included studies
The quality of the eligible studies was evaluated using the Newcastle-Ottawa Scale (NOS) for both cross-sectional (adapted from the cohort scale) and casecontrol studies [26,27] (see supplementary materials). The scale (7 items for cross-sectional, and 8 items for case-control) uses a star system for evaluation of studies in three broad areas: the selection of the study groups, the comparability of the groups, and the ascertainment of either the outcome or exposure of interest for crosssectional and case-control, respectively. Cross-sectional studies were classified from the summary score as very good (9-10), good (7)(8), satisfactory (5-6) and unsatisfactory (0-4) [26]. The cut-off values for case-control studies were slightly different: very good (7-9), good (5-6), satisfactory (4) and unsatisfactory (0-3) [27].

Data analysis
Characteristics of the included studies, along with the main results, were tabulated and categorized under broad themes. In addition, cross-sectional and casecontrol studies were summarized separately according to
Of the total 23 studies, 12 described the demographic characteristics of SUD patients and the types of drugs they used [7, 17, 28-35, 46, 47]; 5 studies were about co-existent conditions of SUD patients, such as anxiety, depression and suicide [9,[41][42][43][44]; 5 studies evaluated blood samples of SUD patients in order to determine the prevalence of viral diseases (i.e., HBV, HCV, and HIV) and the accuracy of blood assays [36][37][38][39][40]; 1 study evaluated the psychometric properties of an Arabic version of the University of Rhode Island Change Assessment (URICA) scale with an SUD sample [45].

Risk (protective) factors of SUD
A total of 4 studies assessed risk factors of SUD. Of them, 3 were cross-sectional and 1 was a case-control study [9,29,32,34]. The case-control study assessed the risk factors among females who use drugs and identified that the SUD patients were more likely to be unemployed, have unstable marriages, less education, low family income, and unstable family conditions than the controls [9]. The cross-sectional studies reported that older age, being single, unemployment, peer pressure, and family and social stresses were associated with SUD [29,32,34].

Substance use and comorbidity
Three studies reported on the relationship between substance use and comorbidity suicide [9,[42][43][44]. The use of alcohol, amphetamines, and volatile substances showed significant association with suicidal ideation [42]. The use of heroin and amphetamines were significantly associated with depression; all people who used heroin (100%), and 80% of those who used amphetamines reported depression [44]. People who abused alcohol obtained significantly higher scores in the scales of psychosis, neuroticism, and anxiety [43].

Stages of progression in substance use
Only one study was available on the topic of stages of substance use progression [28]. Adolescents initiated drugs and tobacco use at the same age, while adults, on average, initiated drug use 6 years after tobacco use. In other cultures, alcohol and cannabis are commonly used in the drug initiation phase (gateway hypothesis) [49]. However, the choice of drug in Saudi Arabia is amphetamines for both adolescents and adults.

Relapse and its predictors
Three studies addressed SUD relapse. In one, older age, unemployment, peer pressure, and family and social stressors were significantly associated with relapse [32]. A second study also found a correlation with the presence of severe psychosocial stressors, but additionally reported the following factors for relapse: heroin dependence, criminal record, divorce, duration of abuse, and family history of addiction [29]; 60% of the patients in this study relapsed within the first 17 months of completion of and discharge from a detoxification/rehabilitation program. The third study found opium and stimulant abuse as significant correlates of relapse [46].

Perspectives and experiences of drug use
A total of 6 studies described the patterns of drug use among SUD patients [7,17,31,33,41,42]; of them, 5 were cross-sectional and 1 was case-control. These studies described the common types of substances being used, number of substances (single versus poly use), and method of administration (inhalation, ingestion, or injection). Curiosity, peer group influence, travelling abroad, and psychiatric disturbances were cited as reasons for the initiation of drug use [17].

Impact of substance use on family members
No study was found that assessed the impact of substance use on family members of SUD patients. One qualitative study, written in Arabic, was found during the search process. It included in-depth interviews of members from 20 families with a PWUD. They reported rejection of marriage proposal, family isolation from other relatives/friends, financial burden, physical violence, and psychological stress resulting from having a PWUD in the family [50].

Cross-sectional studies (n = 19)
None of the cross-sectional studies were deemed good or very good (0%), 42% were satisfactory, and 58% were unsatisfactory. The areas of weakness identified were non-participation (no study described how many declined to participate and what their characteristics were), sample size (90% of the studies did not provide a sample size calculation), and comparability (84% of the studies did not adjust analyses for confounders). Around 42% did not clearly describe the statistical test that was used including confidence intervals and probability level (pvalue). The studies scored well in sample representativeness (68% recruited all patients available during the study period) and in the ascertainment of SUD (through the use of diagnostic tools) ( Table 2).

Case-control studies (n = 4)
Of the 4 case-control studies, 1 was of good, 1 was of satisfactory, and 2 were of unsatisfactory quality. None of the studies (0%) enrolled controls from the community, described the non-participants, or ascertained exposure information from records or blinded interviews. Only 1 study described the criteria it used to define the cases (DSM-IV), and only 2 defined the controls. All studies scored well in the selection of representative cases, similarity of ascertainment, and comparability between cases and controls (Table 3).

Summary of results
There have only been a small number of SUD publications in Saudi Arabia until the present. The studies that have been published were weak in quality and deficient in methodology. All the studies were observational, with the majority being cross-sectional. The overwhelming majority of the studies did not include females. Only 1 study was suitable for assessing SUD risk factors, and the few studies that assessed experiences of PWUDs were very limited in their scope of inquiry. No study addressed the impact on family members of having a PWUD in the family.

Limitations of the included studies
Most studies on SUD enrolled only patients and did not have a reference group; a few identified peer pressure, substance use by family members, and family problems as the reasons for substance use [4,46]. However, in the absence of a reference group, these factors cannot be determined with certainty to be the risk factors of SUD.
Additionally, all the studies obtained their samples from treatments settings; hence, their findings might not be generalizable. Another limitation was that all but two enrolled male patients only; therefore, the SUD data on Saudi females who use drugs is rather limited. The qualitative study was published in Arabic and is therefore not known to the wider scientific community [50]. In addition, around a quarter of the studies chose diseaseoriented outcomes (e.g., co-morbid infection) and not any patient-oriented outcome.
To date, only one review on substance use (Bassiony, 2013) has been published [4]. It included 25 studies, and out of them, approximately 14 were included in the current review. These two reviews reported similar results in terms of types of substance that Saudis use, the comorbid conditions, and factors related to relapse. The current review presented results that were not in the previous review, such as perspectives on drug use by PWUDs, and the impact on family members. Additionally, the quality of the studies was not assessed in the earlier review.

Knowledge gap
Family and religion are central to Saudi life, yet these have not been assessed in detail in the context of SUD. For example, family size is much larger for typical Saudis than their counterparts in the West, and many Saudi men have multiple wives. How these affect the parentchild relationship is not known. Similarly, parents' occupation and education, parental and sibling drug use, parental enabling behaviors, and family's religious environment likely play important roles in the development of substance use among the youngsters.
Data is also missing regarding the relationship between the father and mother when an offspring is using drugs or for that matter between siblings who use drugs and those who do not. Little is also known about the coping strategies that family members adopt to deal with a drug problem in the family or the actions that they take in response, for example, whether they cope differently when the PWUD is the son versus the daughter or how they approach treatment (whether they start rehabilitation immediately or they try alternative methods). Additionally, it is not known whether family members enable the PWUD to continue using drugs, and if so, through which means.
Likewise, very little is known about the experience of PWUDs with drug use. Data is needed on factors related to drug initiation (peer, media, and family influence, age at first use), drug culture (availability, cost, network), knowledge and experience of adverse effects (overdose, signs and symptoms), and treatment-seeking behaviors (cessation attempts and relapses). Substance use has unwanted consequences, one of which is transmission of diseases through needle sharing or promiscuous sexual behavior. The majority of Saudis who inject drugs are young (< 50 years old), and are therefore able to spread infections to their sexual partners and to other PWUDs with whom they share needles [36]. Consequently, data show that Saudis who inject drugs have a high prevalence of blood borne infections including HIV, HCV, and HBV [36][37][38][39][40]51]. In order to reduce harm, many western societies have adopted various harm reduction policies, such as needle and syringe exchange programs (NSPs), opioids stimulation therapy (OST), peer distribution of naloxone, overdose response and drug consumption rooms (DCRs), supervised injection facilities, and outreach services for injecting drug users [11,12]. Saudi Arabia does not have such harm reduction programs in place although it has policies and government-funded programs for treatment and rehabilitation for people with SUD [11].

Strengths and limitations of this review paper
This review was the outcome of a comprehensive search of multiple databases with specific keywords. Therefore, it is unlikely that it missed any eligible studies. However, it likely missed publications in Arabic and any unpublished data on SUD. In addition, a few screened papers may have been excluded because the sample characteristics of those studies were not clear enough to be assessed for eligibility in this review. Additionally, this review assessed the quality of all included studies using validated scales and identified areas of weakness for these studies.

Drug use and recent social change
Saudi Arabia has been experiencing rapid social change in recent years. Some of the major changes include the introduction of movie theatres and music concerts, attendance of women at sporting events, permission for women to drive, the replacement of expatriate male workers with Saudi women, and the commencement of tourism. These changes will likely decrease the conservatism and open up the society to outside influences. Saudi youth is already connected, through the internet, to western cultures, which promote drug use and magnify its pleasurable effects. Coupled with this connectivity, these social changes may lead to an unintended increase in substance use.

Conclusions
The findings of this review underscore the need for rigorous scientific inquiry in multiple domains of SUD. Large epidemiological studies (e.g., case-control) with wider geographical representation are warranted to elicit risk (or protective) factors of SUD, with particular attention given to those that arise from the family environment and/or religious practices. On the other hand, qualitative studies may be more suitable for a better understanding of the universe of SUD patients, including the drug culture in Saudi Arabia or the struggles that family members of a PWUD encounter in their daily lives. Irrespective of study type, there should be an adequate representation of female patients/participants.
The information that can come out of these types of future scientific inquires will be of value when designing community educational and/or awareness campaign so that parents are better informed and better equipped to deal with substance use in the family. Second, this information can be used as the basis for developing and testing interventions aimed at preventing drug initiation, reducing harm, and improving and tailoring rehabilitation programs.