Perceived devaluation, alienation, discrimination, and consequences of methamphetamine (Mkpurummiri) misuse among young people in South-eastern Nigeria: an exploratory study

ABSTRACT

Background

The increasing misuse of methamphetamine in South-eastern Nigeria has raised serious public health concerns. The study aimed to explore perceived devaluation, alienation, discrimination, and consequences of methamphetamine (Mkpurummiri) misuse among young people in South-eastern Nigeria.

Methods

Using a cross-sectional study design, we purposively recruited 18 users of methamphetamine in the setting. Perceived devaluation, alienation, and discrimination were measured with the Illicit Drug Use Stigma Scale, while Substance misuse behaviors were measured using the Drug Abuse Screening Test.

Results

Only 22.2% of study participants had ever received treatment for methamphetamine misuse. Perceived devaluation was prevalent, with 100% of study participants reporting that most people think someone who uses drugs is unreliable. For alienation, 94.4% of study participants reported avoiding people because they might be looked down upon for using drugs. Over half (58.8%) experienced discrimination in accessing medical care. The majority (72.2%) have experienced blackouts or flashbacks due to methamphetamine misuse.

Conclusion

The rates of devaluation, alienation, and discrimination by young persons who misuse Mkpurummiri in southeastern Nigeria are high and with social and health consequences. Multilevel interventions must be utilized to mitigate stigma and discrimination and to provide treatment and rehabilitation for affected individuals.

KEYWORDS:

• Stigma
• discrimination
• drug misuse
• Mkpurummiri
• methamphetamine
• Nigeria

Background

Global estimates suggest that substance use disorder (SUD) is responsible for 31·8 million disability-adjusted life years (DALYs), representing 1·3% of all DALYs (Degenhardt, Charlson, et al., 2018). According to the World Health Organization (WHO), less than 10% of individuals in need of SUD or addiction treatment ever receive treatment (World Health Organization [WHO], 2019), and this may be worse in low- and middle-income countries (LMICs) such as Nigeria (Chia & Mashika, 2022; Nelson et al., 2021; Onifade et al., 2011). In Nigeria, substance use and misuse for diverse purposes (e.g., recreational, enhancement, etc.) are rising (Dumbili et al., 2021; UNODC, 2018). Unfortunately, in Nigeria only about 12% of the 14.3 million persons with SUD ever receive treatment (UNODC, 2018). The reasons for the lack of treatment for SUD may include socio-political and health system factors that may present as access and demand factors (UNODC, 2018).

The social factors emanate from the moral model of addiction that perceives addiction as an individual misconduct or failure in behavior (Cavaiola & Smith, 2020; Heather et al., 2018; Pickard, 2020), while the political factors include policy level and governance factors related to the availability and provision of substance use treatment (Ebuenyi et al., 2022). The socio-political factors are related to the health system factors that manifest in the form of a lack of available treatment for SUD, apathy for training in addiction psychiatry and lack of treatment facilities for the drug rehabilitation (Ebuenyi et al., 2022). These factors related to access may include the general lack of mental health professionals, specifically addiction treatment worldwide, mainly in LMICs (Chia & Mashika, 2022). These barriers to access to treatment worsen health inequities and thrive on account of social determinants of health.

A study on perceptions of SUD training among Nigerian resident doctors indicated that although 70.6% were interested in addiction psychiatry, 52.9% were unsatisfied with their training due to a lack of facilities and training centers (Chikezie et al., 2021). In Nigeria, there are few training centers for drug rehabilitation (Nelson et al., 2021). Factors related to demand revolve around the healthcare financing that precludes individuals without the resources for out-of-pocket spending for healthcare services (Onifade et al., 2011). The demand factors also include the stigma for mental health and cultural beliefs regarding the etiology and effective treatment for mental health and substance use (Ebigbo et al., 2012). The moral or cultural perceptions regarding mental illness sometimes prevent the utilization of care (Ebigbo et al., 2012), while the perception that SUD is a behavioral conduct problem prevents the use of care and support for individuals with SUD challenges (Cavaiola & Smith, 2020; Karamouzian et al., 2019; Pickard, 2020).

The implications of these factors are that individuals with SUD experience several consequences, including stigma (Ducray & Pilch, 2017; Nyblade et al., 2019; Tostes et al., 2020; Van Boekel et al., 2013). Studies indicate that individuals with SUD have a higher risk of morbidity and mortality than the general population (Dickey et al., 2002). The bidirectional relationship between SUD and mental health problems has been previously reported (Degenhardt, Saha, et al., 2018; Dickey et al., 2002). SUD may predispose to mental health disorders and worsen preexisting mental illness, while mental health problems may predispose to SUD (Degenhardt, Saha, et al., 2018; Dickey et al., 2002). In addition, individuals with dual diagnosis are more likely to experience serious adverse complications, such as a higher frequency of psychiatric relapse and rehospitalization, disruptive behavior and violence, residential instability, decreased functional status, and medication noncompliance (Alsuhaibani et al., 2021; Ouimette et al., 2006). SUD disorders impose a heavier burden and expose patients to greater health risks (Alsuhaibani et al., 2021; Ouimette et al., 2006). From an economic standpoint, co-occurring disorders are also expected to raise healthcare expenses and societal burdens.

Misuse of methamphetamine (Mkpurummiri) in Southeastern Nigeria

Methamphetamine was developed early in the 20th century from its parent drug, amphetamine, and was used originally in nasal decongestants and bronchial inhalers (Farrell et al., 2002). Like amphetamine, methamphetamine induces increased activity and sociability, decreased appetite, and a pleasant sense of well-being or euphoria (Panenka et al., 2013). In places, it poses an even bigger hazard than opioids and is the drug most responsible for violent crime (Panenka et al., 2013). Methamphetamine has substantial adverse health effects, including dermatological or cardiovascular diseases and mental health problems such as depression or psychosis (Hoffmann et al., 2016).

According to the 2021 World Drug Report, about 27 million people used methamphetamine and amphetamine in 2019 (UNODC, 2021). Several studies in Africa have reported the misuse and consequences (including mental health disorders and aggression) of methamphetamine (Dumbili & Ebuenyi, 2021; Ogundipe et al., 2018). In Nigeria, a survey by UNODC indicated a 0.1 prevalence rate of methamphetamine (UNODC, 2018). However, several reports indicated an epidemic of that methamphetamine use in a local form Mkpurummiri (meaning ice in Igbo) (Dumbili & Ebuenyi, 2021). Dumbili and Ebuenyi (2021) review on the use of Mkpurummiri in Southeastern Nigeria indicated that its use was widespread, and youth vigilantes and community groups resorted to corporal punishment of identified users. This action toward users of Mkpurummiri emanates from the misperceptions and beliefs in the moral etiology of SUD (Pickard, 2020); these forms of retributive punishment are considered ineffective (Olofinbiyi & Mulaudzi, 2022). Also, punitive measure to curb SUD negates the disease and socio-cultural model of addiction, suggesting biological and social determinants etiologies, respectively (Heather et al., 2018; Pickard, 2020). Understanding the perspectives and experiences of affected individuals may help unravel the root cause of the problem and identify context-relevant solutions. Although several media reports exist (e.g (Akenzua, 2021; Okoli et al., 2021), on the use and action by communities toward users of Mkpurummiri, there is no empirical study on experienced discrimination and consequences of Mkpurummiri misuse amongst young people in the region (Dumbili & Ebuenyi, 2021). Also, it is unclear if treatment exists and to what extent affected individuals utilize available care. This study aimed to explore the pattern of experienced discrimination and consequences of Mkpurummiri (methamphetamine) misuse amongst young people in south-eastern Nigeria and identify pathways to addressing the problem. It is part of a larger study on the misuse of methamphetamine in young persons in Nigeria (MOTION).

Methods

Study design and population

We used a cross-sectional study design to explore the pattern of experienced discrimination and consequences Mkpurummiri misuse among young persons who misuse methamphetamine in the South-eastern region of Nigeria. Between July and August 2022, 18 young persons who reported using Mkpurummiri were purposively recruited through a network of substance use treatment providers in south-eastern Nigeria. Eligibility included being 18 and above years of age and residing in South-eastern Nigeria. Participant informed consent was obtained prior to beginning the survey. This study was approved by the Ministry of Health, Anambra state, Nigeria (MH/AWK/M/321/403) and the Human Research Ethics Committee (LS-22-28) of University College Dublin, Ireland.

Measures

Demographic and socioeconomic characteristics such as age, gender, employment status, and marital status were collected from the respondents using a researcher designed questionnaire self-administered by study participants.

Perceived devaluation, alienation, discrimination

We used the Illicit Drug Use Stigma Scale to capture the domains of perceived devaluation, alienation, discrimination, and responses to discrimination and stigma found in the literature assessing the different domains of stress experienced by illicit drug users (Ahern et al., 2007; Link et al., 1997; Palamar et al., 2011). The Illicit Drug Stigma Scale has a good criterion construct, incremental validity and is effective in analyzing predictor of use (Palamar et al., 2011). The reported internal consistency of the three subscales are as follows: discrimination (Cronbach alpha = 0.61); alienation (Cronbach alpha = 0.66) and perceived devaluation (Cronbach alpha = 0.67) (Ahern et al., 2007). The Illicit Drug Use Stigma Scale contains a total of 10 questions with 3 subscales (i) Discrimination subscale (4 items) (ii) Alienation subscale (3 items), and (iii) Perceived devaluation (3 items) (Ahern et al., 2007). It can be physician or individual administered. Study participants rated items yes or no, with affirmative responses corresponding to 1 point. Items were summed to create a score ranging from 0–4 for the Discrimination subscale; 0–3 for both the Alienation and Perceived devaluation subscales. Higher scores correspond to higher stigma.

Consequences related to drug abuse

The Drug Abuse Screening Test 10 (DAST-10) is a self-report screening test that provides a quantitative index of the degree of consequences related to drug abuse (Skinner, 1982). The DAST-10 has good concurrent validity and internal consistency reliability (Cronbach alpha = 0.92) (Skinner, 1982). The reported internal consistency using Cronbach’s alpha coefficients from two different studies from Iran and Turkey were 0.93 and 0.92 respectively (Evren et al., 2014; Shirinbayan et al., 2020); Study participants rated items yes or no, with positive responses corresponding to 1 point. Items were summed to create a score ranging from 0 to 10. A score of 1–2 represents low-level drug-related problems; 3–5 represents moderate-level drug-related problems, 6–8 and 9–10 represent substantial and severe level drug-related problems, respectively.

Data management and analysis

In the analysis, we described the study population using frequencies and percentages for categorical variables and means and standard deviations for continuous variables (Gray, 2013). Collinearity among the perceived devaluation, alienation, discrimination and Substance use behaviors scores was assessed using Pearson’s correlation coefficients (Ahern et al., 2007). Mann-Whitney U test was used to compare discrimination scores, alienation scores, perceived devaluation and DATS-10 scores by employment status, level of education, treatment, and rehabilitation status.

Results

Study participant characteristics

Table 1 describes the sociodemographic characteristics of the study participants (n = 18). Of the 18 study participants, 94.1% were males, and 55.6% were single. The mean age of the study population was 29.3 (SD = 5.16). In terms of education, 47.1% had a secondary level of education, while 52.9% had a diploma/graduate education. The majority (72.2%) of study participants reported being employed, while 27.8% reported being unemployed. All the study participants reported using methamphetamine, and only 22.2% received any treatment. All those who have received treatment reported using a private hospital, while 58.8% reported no available treatment source. Slightly over half (55.6%) indicated they were willing to accept drug misuse rehabilitation treatment or therapy, while 44.4% reported unwillingness to accept treatment. When asked the person they are willing to talk to about drug abuse, the majority (55.6%) indicated their friends, while 38.9%, 27.1% and 11.1% indicated family, health care providers and native/traditional medicine providers, respectively.

Table 1. Socio-demographics and other characteristics.

Variable	Category	Frequency (N=18)	Percentage (%)
Gender	Male	16	94.1
	Female	1	5.9
	Non-Response	1
Marital status	Single	10	55.6
	Married	7	38.9
	Separated/divorced	1	5.6
Has Children	No	10	58.8
	Yes	7	41.2
	Non-Response	1
Number of Children	Mean±SD; Range	0.9±1.3	[0–4]
Age	<30 Years	8	57.1
	>30 Years	6	42.9
	Non-Response	4
Age in years	Mean±SD; Range	29.3±5.6	[19–41]
Education Level	Secondary and below	8	47.1
	Diploma/Graduate	9	52.9
	Non-Response	1
Employed status	Unemployed	5	27.8
	Employed	13	72.2
Employment Sector	Private	12	92.3
	Public	1	7.7
Received treatment for the use of Methamphetamine	No	14	77.8
	Yes	4	22.2
Place Received Treatment	Private Hospital	4	100.0
Accept drug misuse rehabilitation treatment/therapy if you are offered	No	8	44.4
	Yes	10	55.6
Person willing to talk to about drug abuse	Family	7	38.9
	Friends	10	55.6
	Health Care Providers	5	27.8
	Native/traditional medicine providers;	2	11.1

Perceived devaluation, alienation, discrimination

Perceived devaluation was prevalent, with 100% of study participants reporting that most people think someone who uses drugs is unreliable, 94.4% reporting that most people think drug users are dangerous and a comparable percent (94.4%) reporting that most people think that someone who uses drugs is not a good person (Table 2).

Table 2. Illicit drug use stigma.

Stigma and discrimination scales		N (Yes/Agree)	% (Yes/Agree)
Discrimination	Did some of your friends reject you because you use drugs?	9	50.0
	Did some of your family reject you because you use drugs?	8	44.4
	Have you been prevented from obtaining medical care because you use drugs?	10	58.8
	Have you not gotten housing because other people know you use drugs?	6	33.3
	Mean±SD; Range	1.8±1.2	[0–4]
Alienation	Do you sometimes avoid people because you think they might look down on you because you use drugs?	17	94.4
	Do you feel you have to prove yourself because you use drugs?	12	66.7
	Do you feel ashamed you use drugs?	10	55.6
	Mean±SD; Range	2.2±0.9	[1–3]
Perceived devaluation	Most people believe that someone who uses drugs is dangerous?	17	94.4
	Most people think that someone who uses drugs is not a good person?	17	94.4
	Most people think that someone who uses drugs is unreliable?	18	100.0
	Mean±SD; Range	2.9±0.3	[2–3]

Alienation due to illicit drug use was also common, with 94.4% of study participants reporting that they sometimes avoided people because they might be looked down upon for using drugs.

Study participants reported high rates of discrimination. The most common types of discrimination experienced were attributed to accessing medical care (58.8%), friends (50.0%), family (44.4%) and housing (33.3%).

Consequences related to drug abuse

The majority (94.4%) of study participants reported having used drugs other than those required for medical reasons, while 88.9% reported having used more than one drug at a time (Table 3). Over half (72.2%) reported experiencing blackouts or flashbacks due to drug use, while 38.9% reported being neglected by their family and having a medical problem due to drug use. The mean of DAST-10 scores was 5.8 (SD = 1.7), median = 5 and ranged from 3–9. In terms of the degree of problems related to drug abuse, study participants were classified at moderate (55.6%), substantial (38.9%) and severe (5.6%) levels.

Table 3. Substance misuse behaviors using the drug abuse screening test (DAST-10).

DAST-10 Items	N (Yes/Agree)	%( Yes/Agree)
(1) Have you used drugs other than those required for medical reasons?	17	94.4
(2) Do you abuse more than one drug at a time?	16	88.9
(3) Are you always able to stop using drugs when you want to? (If never use drugs, answer “Yes.”	8	44.4
(4) Have you had “blackouts” or “flashbacks” as a result of drug use?	13	72.2
(5) Do you ever feel bad or guilty about your drug use? If never use drugs, choose “No.”	8	44.4
(6) Does your spouse (or parents) ever complain about your involvement with drugs?	11	61.1
(7) Have you neglected your family because of your use of drugs?	7	38.9
(8) Have you engaged in illegal activities in order to obtain drugs?	5	27.8
(9) Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?	12	66.7
(10) Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?	7	38.9
DAST-10 Score Mean±SD; Median; Range	5.8±1.7	5.0; [3–9]
Degree of Problems Related to Drug Abuse	Frequency	Percentage
Moderate Level	10	55.6
Substantial Level	7	38.9
Severe Level	1	5.5

The correlations among the Illicit Drug Use Stigma Scale domains (perceived devaluation, alienation, discrimination) were all non-significant (p > .05); yet the correlation between the discrimination domain and DAST-10 scale was significant (p < .001) r = 0.536, classified as moderate.

Comparisons between Discrimination, alienation, perceived devaluation, DAST-10 scores and selected socio-demographic characteristics

There was a significant association between alienation scores and employment status (Table 4). Study participants who were not employed had significantly higher scores of alienations (Mean = 2.8 (SD = 1.4)) as compared to those who were employed (Mean = 1.9 (SD = 0.9)). There was a significant association between discrimination and the study participants who had received treatment for methamphetamine and those who had not (p = .036), with those who had received treatment having higher discrimination scores (Mean = 3.0 (SD = 1.2)) as compared to those who had not (Mean = 1.5 (SD = 1.1)). Similarly, respondents who would accept rehabilitation if offered had significantly higher scores of discriminations (Mean = 2.5 (SD = 1.3)) as compared to those who would not accept (Mean = 1.0 (SD = 0.5)).

Table 4. Comparisons between discrimination, alienation, perceived devaluation, DAST-10 scores and selected socio-demographic characteristics.

Measures	Employed		P-value	Level of Education		P-value	Received treatment		P-value	Accept Rehabilitation		P-value
	No	Yes		Below Secondary	Tertiary		No	Yes		No	Yes
(1) Discrimination Score	1.8±0.8	1.8±1.4	0.878	2.4±1.4	1.2±0.8	0.118	1.5±1.1	3.0±1.2	0.036	1.0±0.5	2.5±1.3	0.006
(2) Alienation Score	2.8±0.4	1.9±0.9	0.051	2.3±0.7	2.0±1.0	0.609	2.1±0.8	2.5±1.0	0.334	1.9±0.8	2.4±0.8	0.183
(3) Perceived Devaluation	3.0±0.0	2.8±0.4	0.366	2.8±0.5	3.0±0.0	0.121	2.9±0.4	3.0±0.0	0.436	3.0±0.0	2.8±0.4	0.192
(4) DAST-10 scores	6.8±1.8	5.4±1.6	0.130	5.8±1.8	5.7±1.7	0.882	5.6±1.8	6.5±1.3	0.253	5.3±2.1	6.2±1.2	0.122

Discussion

The health and social consequences of substance use are clearly reported, with SUD associated with higher morbidity, mortality and suicidality (Dickey et al., 2002; Link et al., 1997; UNODC, 2021). A Worldwide estimation of treatment coverage for SUD indicates that only 7.1% of those with past-year SUD received minimally adequate treatment, and this was reported to be 1% in LMICS (Degenhardt et al., 2017). In Nigeria, it is estimated that 14.3 million persons have SUD, with only 12% receiving treatment (UNODC, 2018). However, there is limited data and evidence on SUD from LMICs, which therefore requires continued and further investigation to understand both the scope of the problem and relevant solutions.

Our study is one of the first to explore the experiences of stigma and discrimination and the consequences of using Mkpurummiri (methamphetamine) amongst young persons in Southeastern Nigeria. We found that in our study population, only 22.2% of the participants had ever received treatment for methamphetamine misuse; however, the quality of this treatment is unclear. 58.8% indicated no available treatment source, and this lack of treatment implies that many affected individuals, and particularly those more vulnerable, will experience the sequelae of treatment SUD and its consequences.

In this study, the perceived devaluation was prevalent, with 100% of study participants reporting that most people think someone who uses drugs is unreliable. This is extremely concerning given that perceived devaluation is a barrier to seeking medical and social care for substance users (Karamouzian et al., 2019). The rates of perceived devaluation found in our study are higher and comparable to the 85% found in Ahern et al.’s (2007) study conducted in the United States. Concerning alienation, 94.4% of our study participants reported that they sometimes avoided people because they might be looked down upon for using drugs. Again, this rate of alienation is higher and comparable to the 74.4% reported by Ahern et al.’s (2007). The implication is also grim and may explain the perceived lack of support and treatment for affected individuals. This form of alienation may have social and occupational outcomes, as we found higher rates of alienation among unemployed people than those employed in our study.

The most common types of discrimination experienced by participants in our study were attributed to accessing medical care (58.8%). Discrimination and stigma toward people who use illegal drugs from healthcare providers are common worldwide (Ducray & Pilch, 2017; Van Boekel et al., 2013) and are a key barrier to seeking or re-seeking medical care (Nyblade et al., 2019).

Conversely, Ahern et al. reported that the most common types of discrimination experienced by participants in their study were attributed to family (75.2%) and friends (65.8%). Only 23.5% of their study participants reported discrimination in accessing care. This difference in experience in accessing care may be explained by health system factors such as healthcare financing, available in the United States where Ahern and colleagues conducted their study (Ahern et al., 2007). The lack of universal coverage and heightened cultural beliefs and misconceptions about SUD may explain our cohort’s higher rates of discrimination.

The consequences of drug abuse include effects from using drugs other than those required for medical reasons (94.4%) and the experience of blackouts or flashbacks (72.2%). The consequences of the use of methamphetamine have been extensively reported in the literature (Evren et al., 2014; Hoffmann et al., 2016; Shirinbayan et al., 2020), and these consequences may be heightened in settings such as Nigeria, with a dearth of addiction treatment centers and retributive punishment implies that individuals may experience severe consequences from both the side effects of the drugs and the corporal punishment from community members (Dumbili & Ebuenyi, 2021; Olofinbiyi & Mulaudzi, 2022).

We found those study participants who had received treatment for methamphetamine and those who would accept rehabilitation had higher scores of self-reported discriminations. We believe these higher discrimination scores may be due to the inherent stigma and discrimination in the treatment centers (Ebigbo et al., 2012; Nelson et al., 2021). Unsurprisingly, a treatment provider or treatment centers for SUD may also exhibit stigma and discrimination. A study on the perspectives of mental healthcare providers on pathways to improved employment for persons with mental disorders in two lower-middle-income countries highlighted the experience of stigma in psychiatric treatment centers (Ebuenyi et al., 2020).

The findings from our study have several implications for addiction treatment and support. They highlight the lack of treatment for addiction and the need for investment in public addiction treatment centers to support affected individuals. It is also essential to develop public health education programs to educate communities about the need to support individuals with addiction that will help to reduce the heightened rates of stigma and discrimination experienced by affected individuals. Additionally, addressing stigma and discrimination within healthcare settings is essential; however, there is limited evidence on the effectiveness of interventions to this end (Tostes et al., 2020). Stigma and discrimination will deprive affected persons of treatment and worsen addiction’s impact and health outcomes (Nyblade et al., 2019). It is imperative that the Nigerian government prioritize addiction treatment and training to bridge the unmet need for SUD services (Dumbili et al., 2021; Ebuenyi et al., 2022).

Despite the interesting findings from our study, the low sample size and study design limit its generalization. Although it was conceived as an exploratory study, the retributive justice meted out to individuals who misuse methamphetamine, made it very hard for us to identify individuals willing to participate in the study. Future work on this area could benefit from conducting a larger survey and using qualitative methods with participants to further explore the key concepts identified throughout this work.

Conclusion

The rates of devaluation, alienation and discrimination by young persons who misuse Mkpurummiri in southeastern Nigeria are high and with social and health consequences. Although some would accept treatment, there is a dearth of treatment and support for those who need treatment. It is essential that multilevel interventions be evolved to reduce the experience of stigma and discrimination and provide treatment for and rehabilitation for affected individuals.

Author contributions

IDE and EWD conceived the study. ECE collected the data with support from IDE and EWD. IDE analyzed the data with support from CST and BG. IDE drafted the manuscript. All authors reviewed and approved the final version of the manuscript.

Acknowledgments

The authors are grateful to all the study participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The study was supported by funding from University College Dublin Output Based Research Support Scheme (OBRSS) 2021 received by the first author (IDE).