Research Article - Journal of Drug and Alcohol Research ( 2022) Volume 11, Issue 12
An Explorative Study to Investigate the Abdominal Pain Experienced by Nyaope UsersMokwena KE1*, Kgopane TT2 and Koto Z2
2Department of General Surgery, Sefako Makgatho Health Sciences University, South Africa
Mokwena KE, Department of Public Health, Sefako Makgatho Health Sciences University, South Africa, Email: Kebogile.Mokwena@smu.ac.za
Received: 30-Nov-2022, Manuscript No. JDAR-22-82113;;Accepted Date: Dec 21, 2022; Editor assigned: 02-Dec-2022, Pre QC No. JDAR-22-82113 (PQ); Reviewed: 16-Dec-2022, QC No. JDAR-22-82113; Revised: 21-Dec-2022, Manuscript No. JDAR-22-82113 (R); Published: 28-Dec-2022, DOI: 10.4303/JDAR/236213
Background: Nyaope, a South African Novel Psychoactive Substance (NPS), is commonly used in Black townships. It is highly addictive with high relapse rates. A common complaint among users is abdominal pain, which occurs when the users have not used the drug for some time. Because the pain is relieved by using nyaope, users continue to use the drug even when they want to quit. Despite this, there have been no studies to explain the occurrence of this pain.
Purpose: The purpose of this study was to explore the pathological reasons for the abdominal pain experienced by nyaope users.
Methodology: The study design was clinical, descriptive and exploratory, and data collection occurred at the premises of Dr George Mukhari academic hospital. The sample of convenience consisted of 17 male and 4 female participants, who had used nyaope for a period of at least 2 years, and have a history of abdominal pain that is associated with nyaope use. A questionnaire was used to collect socio-demographic data, as well as experience of pain. Endoscopy was used to investigate the condition of the upper gastrointestinal tract. Histology samples were taken for examination of the tissue structure.
Results: The ages of the sample ranged from 25 years to 47 years, with a mean of 32 years. The period of nyaope use ranged from 36 months to 252 months, with a mean of 128.5 months. The majority reported sharp pain in the umbilical, para-umbilical and the whole abdomen. All the participants reported that not smoking nyaope for some time triggers the pain, and smoking nyaope relieves the pain. Clinical tests identified oesophageal candida, chronic gastritis and Helicobacter pylori infections.
Conclusion: The abdominal pain experienced by nyaope users can be explained by the pathological destruction of the gastro-intestinal tract and the esophageal candidiasis. The clinical implications are that the treatment of Nyaope users should include non-invasive h pylori testing, and positive individuals are treated using current available regimens.
Nyaope; Abdominal pain; Gastro-Intestinal tract; Chronic gastritis; H pylori
In the context of the global increase in the prevalence of the use of psychoactive substances, a new category of psychoactive substances, the Novel Psychoactive Substances (NPSs) was introduced into the drug market. NPSs are cocktails which contain several components which make it difficult to be identified by international drug treaties and are often missed by law enforcement authorities, which result in the surge. Because of their nature, the effects of NPSs in the body varies with the type, number and combination of compounds used. Although the effects for many NPSs may not be fully understood, they are reported to be very toxic with major negative health consequences. The toxicity of NPS is reported to be due to adverse drug reactions or overdose, and reports of cardiac arrest, hypertension, hyperthermia, coma, depression, and pulmonary oedema and urinary tract infections have been associated with the use of various NPSs , which is an indication that NPSs have a multi-systemic impact.
Nyaope is South Africa’s version of NPS, and is reported to have emerged in one of the Pretoria townships in the late 1990’s and early 2000’s. Its use has been spreading to other areas of the country, and it continues to trap thousands of users into addiction and related negative social and health consequences. Despite its wide use, there is dearth of literature on its health impacts. However, chronic users of nyaope have reported various health consequences, which include chest pain, abdominal cramps, excessive drowsiness and diarrhea . The interaction of the various components of nyaope have significant pathological impacts on the body, and this occurs because some of the components share pathways with the cytochrome P450 family of enzymes in the liver cell cytoplasm, their enzyme actions at certain receptors in the brain have effects on one another, and thus result in the complex nature of their combined actions .
Studies on the pathological effects of nyaope reported a wide range of toxic effects of this cocktail drug [1,4,5], and often result in considerable damage to body organs and systems. Examples of such damage to body organs and systems include reports of growth restriction of the fetus and pre-term delivery of the baby if used by a pregnant woman , as well as compromised functioning of the respiratory system in infants after birth . A range of pathological changes in the liver and the gonads, as well as blood cell count abnormalities have also been associated with nyaope use . It has also been reported to result in impairment of erectile function in men .
Nyaope use is common in Black townships in South Africa, where it is easily accessed due to the high number of dealers and lax law enforcement in these areas, which results in a continuous increase in the number of users. Nyaope is highly addictive and takes over the lives of the users, who drop out of school or employment and spend their time looking for ways of getting their next fix. The users can be easily identified as they assemble in groups in public places like community parks, taxi ranks and entrances of malls . They are known for stealing various items to sell and support their habits, have very poor personal hygiene, slow and slurred speech and uncoordinated and slow physical movements . The users find it difficult to quit even with the assistance of rehabilitation programs. For these reasons, the number of users continues to increase, especially because of lack of custom made rehabilitation programs, and lack of after-care facilities for those who have completed rehabilitation programs. Because most of the users are not able to access the needed effective help, they are considered to be a lost generation in despair .
Abdominal pain is the main complaint of nyaope users and it occurs after they have not used the drug for some time. This abdominal pain has been reported to be a major barrier to quitting the use of nyaope because the pain is relieved by nyaope use, which compels the users to continue nyaope use. The pain is described as sharp and severe, and the users describe it as a stabbing pain (‘ukusika’) in Isizulu and an explosion (‘go phatloga’) in Setswana, which are two languages commonly used in South Africa . Despite this pain being significant in reducing the quality of life, as well as the rehabilitation outcomes of nyaope users, no known studies have been conducted to investigate it, hence this study, whose aim was to explore the impact of nyaope on the gastro-intestinal tract, which is the area of pain. This study is one of a range of studies on the health impact of nyaope.
The study design is a case descriptive clinical study to explain the abdominal pain experienced by nyaope users.
The study was conducted at the endoscopy department of Dr. George Mukhari Academic Hospital, in Ga-Rankuwa, Pretoria, Gauteng province.
The recruitment strategy was that used with previous studies, where the participants were recruited from where they assemble, which included taxi ranks and parks [2,8]. The potential participants were approached individually, the purpose of the study was explained and they were requested to participate. If they were willing to participate, they were transported by the university vehicle to the hospital, where data collection occurred. Screening for eligibility was done at the recruitment site, and this entailed confirmation of the age, the period of nyaope use and whether the potential participants had gastro-intestinal symptoms.
Population and sampling technique
The population of the study was both male and female nyaope users from Ga-Rankuwa, which is where Dr George Mukhari Academic Hospital is situated. Purposive convenient sampling was used, which was determined by the availability of the participants at the recruitment site, eligibility for the study and ability and willingness to participate.
Male or female nyaope users who were 18 years and older, had used Nyaope for more than 2 years, and had experienced abdominal pain related to nyaope use.
The sample consisted of 21 participants, which was determined by the exploratory design of the study, as well as the limited financial resources of conducting the required tests.
Data collection tools
• A researcher developed questionnaire was used to collect socio-demographic data.
• A gastroscope was used for visual examination of the gastro-intestinal tract, and also takes images of the GIT.
• A findings chart was used to report the findings of the gastroscope.
Data collection was conducted with assistance from nursing personnel and a surgical consultant, who is a clinical leader and qualified surgeon with vast experience of performing gastroscopies and managing upper gastrointestinal pathology. The nurse helped with suctioning and protecting the airway, and the consultant and the researcher were performing the gastroscopies and assessing the findings. Participants were brought into the endoscopy unit one at a time. The purpose of the study was explained to the participants again by the researcher, which was then followed by the participants being requested to sign an informed consent. Demographic data was collected by use of a questionnaire. The gastrointestinal data was collected by using gastroscopy and identified pathological changes in the gastro- intestinal tract of the participants.
The demographic data was captured by the researcher onto a Microsoft Excel™ spread sheet, checked and cleaned, and analyzed descriptively. Pictures from the gastroscope were analyzed by the researcher and the consultant to make a diagnosis on the gastro-intestinal tract. The findings were described according to the location and macroscopic findings which included the oesophagus pathology, stomach mucosa appearance and duodenum pathology. Data captured from the pictures was verified and validated as a means of clinical analysis.
Validity, reliable and bias
The validity of the results was enhanced by the use of the endoscopy, which is globally confirmed for accurate diagdiagnosis of pathological changes in the gastro-intestinal tract. The reliability of the endoscope was further confirmed to correlate with histological findings, which was required for this study [12,13]. The examination by the surgical consultant enhanced clinical accuracy of the diagnosis. Selection bias is in-built in the study design and recruitment of the participants (sample of convenience), but was necessary for this exploratory study.
Ethical clearance was obtained from the Research and Ethics Committee of Sefako Makgatho Health Sciences University (SMUREC). The permission to conduct the study was obtained from the management of the hospital, and authorization to conduct the study was obtained from the head of department of the Endoscopy within the hospital. All the participants provided written informed consent, with all attached rights and privileges, before data was collected.
Demographic profile of the sample
The sample consisted of 17 (81%) males and 4 females. Their ages ranged from 25 years to 47 years, with a mean of 32 years. The period of nyaope use ranged from 36 months to 252 months, with a mean of 128, 5 months. Figure 1 shows the distribution of period of nyaope use in months.
Figure 1: Period of nyaope use in months
Anatomical location of the abdominal pain
The majority of the participants (71.43%, n=15) described the pain as sharp, followed by 23.815 (n=5) as colicky, and only one described the pain as dull. All participants identified not smoking nyaope for some time as a trigger for the pain, with 20 reporting that smoking nyaope relieves the pain and one reporting that relief results from both smoking and defecation. Table 1 shows the reported anatomical location of the abdominal pain.
|Location of abdominal pain|
|Epigastric and suprapubic||2||9.52|
|Suprapubic and back||1||4.76|
Table 1: Anatomical location of the abdominal pain
Table 2 shows the clinical findings of the examination of the oesophagus hernia.
|Clinical findings on the oesophagus|
|esophagitis and candida||1||4.76|
Table 2: Clinical findings of the Oesophagus
Findings in the stomach
The stomach mucosa appeared normal in 47, 62% (n=10) of the participants, one had a Forrest 3 ulcer and 47, 62% (n=10) had gastritis. The majority of the participants (85.71, n=18) had a normal pylorus, with deformed pylorus identified in 3 of the participants. Of the 21 samples taken for histology analysis, 19 specimens could be reported, one could not be traced and one was not of adequate size for processing and reporting.
Of the 19 samples which were reported, 18 of them showed chronic gastritis with 1 having acute on chronic gastritis (2 samples were missing). The majority of chronic gastritis reported (73.68%, n=14) showed active gastritis, and 5 cases accounted for the inactive form of chronic gastritis.
Helicobater pylori was identified in 57, 89% (n=11) of the samples.
The participants were mostly males, which confirms previous findings that males are more inclined to use substances in general  and nyaope in particular [9,10]. This may be explained by the perception that society finds it more acceptable for males to use substances . However, the gap between the prevalence of substance abuse between males and females is reported to be getting narrower , although this growth among females is largely ignored . The wide age range of 25 years to 47 years, as well as the mean age of 32 years is higher than those previously reported, which were 18 years to 36 years, with a mean of 25.2 years . This can be explained by the reports that nyaope is difficult to quit and many of those that started using the substance in the early 2000’s continue to use it in their 40’s and even 50’s.
Abdominal pain is the main symptom among nyaope users, which is reported to occur when they do not smoke nyaope for some time. According to the users, this pain is the driving factor that prevents them from quitting nyaope, even when the wish to quit is . It therefore follows that alleviating this pain may go a long way in enabling the users to quit nyaope.
The pain was mainly experienced in the umbilical region by 47, 62% of the participants. As with previous studies, the pain experienced was described sharp by the majority of the participants was triggered by not using nyaope for some time. Because nyaope contains opioids as one of the constituents, this might explain the abdominal pains, which have been previously associated with frequent use of opioids . The abdominal pain can also be explained by the interaction of the various drugs of nyaope, due to the synergistic effect of major drug groups, leading to potentiated adverse effects . However, the relief brought by smoking nyaope is yet to be investigated and explained.
Oesophageal candidiasis and esophagitis were the two abnormal oesophageal findings in the study. Oesophageal candidiasis was the dominating abnormality, which was found in almost 24% of the study participants. The finding is much higher than those reported amongst the general population which is at 0, 32%-5% , which is an indication of an association with nyaope use. Oesophageal candidiasis is also higher among HIV positive individuals who are commonly reported to acquire this infection at a rate of 12% [21,22]. This suggests that Nyaope use compromises the immune system of the users just as HIV infection does. Moreover, this compromised immunity was previously reported, that nyaope use results in organ dysfunction and compromised immunity . The impact of nyaope use is therefore not only social but also causes physical pathological changes. Oesophageal candidiasis may also contribute to decreased appetite among nyaope users, which results in poor eating habits and the resultant loss of weight which has been commonly reported among them [3,23]. Moreover, this candidiasis can have serious outcomes, such as the development of oesophageal stricture and even oesophageal cancer .
Of the 19 participants who tested positive for gastritis, 18 showed chronic gastritis with one showing acute on chronic gastritis. Gastritis is associated with mucosal inflammation, and has been previously reported to be common among people who use psychoactive substances . The most common cause of chronic gastritis is h pylori, which has been reported to be prevalent among the African population. In the current study, h pylori was found in 11 out of the 19 samples (2 missing), which is within the global range of 30%-95%. However, lower rates have been reported in developed countries . The higher rates might be explained by the background of the participants, as most have poor socioeconomic status, which has been associated with higher prevalence of h pylori . Moreover, the interaction of the various compounds in nyaope results in either opposing or stimulating effects on one another thus is making the complex nature of their combined actions more potent . As a cocktail drug, nyaope has various components, which makes it particularly challenging to identify the exact link between its use and a pathological risk or complications. However, H pylori-infected individuals have been reported to experience complications like gastritis, duodenal ulcer and gastritis ulcer . In the current study, nyaope and h pylori might have synergistic effects towards abdominal pains experienced by the participants. Gastritis may further complicate to peptic ulcer, hemorrhage, gastric perforation and cancer , which highlights the need to treat nyaope users for gastritis, as failure to do so may result in serious but preventable complications.
The study was conducted to assess pathological changes in their upper gastrointestinal tract of nyaope users, and this interest emerged from observations of clinicians who have picked up trends of young individuals with a history of nyaope use who present with non-specific abdominal pain. Pain experienced by participants was associated with not smoking nyaope for some time, and was relieved by use of nyaope, and this suggests that the pain is due to the withdrawal from the cocktail.
The study identified oesophageal candidiasis which was not typical for the age group under study, thus the suggestion that this candidiasis is associated with nyaope use. Gastritis was found in high numbers as compared to the average population, h pylori was only found in just above 50% of the cases which does not address all the gastritis cases, and this may suggest that remainder of the cases have chemical associated gastritis, further studies need to be carried out to support the suggestion. The reported h pylori may be synergistic or an individual cause of gastritis and further research is needed to explore the potential causal stomach link. The study identified multiple upper gastrointestinal pathologies which suggest that attention to the upper GIT needs attention as part of clinical management of nyaope addiction. So, the abdominal pain reported by nyaope users may be explained by candidiasis, chronic gastritis and h pylori.
The following recommendations emerge from this study:
• As this was an exploratory study with a small sample size, it is recommended that the study be repeated with a bigger sample size, to confirm the results.
• Those nyaope users who complain about abdominal pain be treated for inflammation in the gastro-intestinal tract, which may be oesophageal candidiasis, h pylori or gastritis. The indication of the pain will guide the possible diagnosis.
• That the rehabilitation protocol of nyaope addiction include treatment for inflammation in the gastro-intestinal tract. This should be treated as a clinical trial in collaboration with clinical departments of general surgery or gastroenterology.
The clinical consultant in the Department of General Surgery is acknowledged for his role in the performing the gastroscopies and assessing the findings. Mulalo Salane and Khomotso Maaga, the research assistants, are acknowledged for their role in the recruitment of the study participants and assisted with data collection.
The research reported in this publication was supported by the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development, as well as The National Research Foundation, under NRF Research Chair in substance abuse and population Mental Health grant.
- S. Elliott, R. Sedefov, M. Evans‐Brown, Assessing the toxicological significance of new psychoactive substances in fatalities. Drug test anal, 10(2018):120-126.
- A.A. Khine, K.E. Mokwena, V. Moodley, Assessment of organ dysfunction and laboratory parameters in chronic Nyaope users, Med Tech SA, 32(2018):20-24.
- A.A. Khine, K.E. Mokwena, Drug interaction s in the constituents of street drug mixture “Nyaope” in South Africa: A mini-review, AJDAS, 15(2016):91-101.
- D.M. Wood, P.I. Dargan, Novel psychoactive substances: How to understand the acute toxicity associated with the use of these substances, Ther Drug Monit, 34(2012):363-367.
- K.N. Ellefsen, E.A. Taylor, P. Simmons, V. Willoughby, B.J. Hall, Multiple drug-toxicity involving novel psychoactive substances, 3-fluorophenmetrazine and U-47700, J Anal Toxicol, 41(2017):765-770.
- R. Thomas, S. Velaphi, Abuse of antiretroviral drugs combined with addictive drugs by pregnant women is associated with adverse effects in infants and risk of resistance, SAJCH, 8(2014):78-79.
- C.P. Mashiloane, P.H. Jeena, S.A. Thula, S.A. Singh, R. Masekela, Maternal use of a combination of recreational and antiretroviral drugs (nyaope/whoonga): Case reports of their effects on the respiratory system in infants, Afr J Thorac Crit Care Med, 27(2021):120-122.
- Moroatshehla SM, Mokwena K, Mutambirwa S, Impact of nyaope use on erectile function of the users: An exploratory study in three townships of Tshwane district, South Africa, J Drug Alcohol Res, 9(2020):1-8.
- K.E. Mokwena, M. Huma, Experiences of 'nyaope' users in three provinces of South Africa: Substance abuse, Afr J Phys Health Educ Recreat Dance, 20(2014):352-63.
- K.E. Mokwena, N. Morojele, Unemployment and unfavourable social environment as contributory factors to nyaope use in three provinces of South Africa: Substance abuse, Afr J Phys Health Educ Recreat Dance, 20(2014):374-84.
- L. Fernandes, K.E. Mokwena, Nyaope addiction: The despair of a lost generation, AJDAS, 19(2020):37-51.
- J.R. Logan, T. Mccashland, D.A. Lieberman, Evaluation of reliability in the use of endoscopic terminology. Stud Health Technol Inform, 107(2004):396-400.
- D. Liu, N. Rao, X. Mei, H. Jiang, Q. Li, et al. Annotating early esophageal cancers based on two saliency levels of gastroscopic images, J Med Syst, 42(2018):237
- E. Tuchman, Women and addiction: The importance of gender issues in substance abuse research, J Addict Dis, 29(2010):127-138.
- S. Ramlagan, K. Peltzer, G. Matseke, Epidemiology of drug abuse treatment in South Africa. SAJP, 16(2010):40-50.
- F. Fonseca, M. Robles-Martínez, J. Tirado-Muñoz , M. Alías-Ferri, J.I. Mestre-Pintó, et al. A gender perspective of addictive disorders, Curr Addict Rep, 8(2021):89-99.
- S. Bala, S.M. Kang’ethe, The dangers associated with female adolescents consuming Nyaope Drug in Butterworth, South Africa. JHRW, 6(2021):307-17.
- K. Mokwena, “Consider our plight”: A cry for help from nyaope users, Health SA gesondheid, 21(2016):137-142.
- G.J. Gutierrez, J. Rodante, M.J. Desai, Opioids in abdominal pain, Chronic Abdominal Pain, Springer, New York, NY, 5(2015):135-142.
- A.A. Mohamed, X.L. Lu, F.A. Mounmin, Diagnosis and treatment of esophageal candidiasis: Current updates, Can J Gastroenterol Hepatol, 2019:3585136.
- A.R. Lifson, J. Neuhaus, J.R. Arribas, M. van den Berg-Wolf, A.M. Labriola, et al. Smoking-related health risks among persons with HIV in the strategies for management of antiretroviral therapy clinical trial. Am J Public Health, 100(2010):1896-1903.
- A.R. Lifson, H.A. Lando, Smoking and HIV: Prevalence, health risks, and cessation strategies, Curr HIV/AIDS Rep, 9(2012):223-30.
- P. Baloyi, Nyaope-the dangers of the Bluetooth craze. Servamus Comm Saf Sec Mag, 111(2018):50-52.
- Koo S, Kejariwal D, Al-Shehri T, Dhar A, Lilic D. Oesophageal candidiasis and squamous cell cancer in patients with gain-of-function STAT1 gene mutation. United European Gastroenterol J, 5(2017):625-631.
- Z.T. Feyisa, B.T. Woldeamanuel, Prevalence and associated risk factors of gastritis among patients visiting saint paul hospital millennium medical college, addis ababa, Ethiopia. Plos one, 16(2021):e0246619.
- G. Khoder, J.S. Muhammad, I. Mahmoud, S.S. Soliman, C. Burucoa, Prevalence of Helicobacter pylori and its associated factors among healthy asymptomatic residents in the United Arab Emirates, Pathogens, 8(2019):44.
- S. Gupta, L.I. Tao, J.D. Murphy, M.C. Camargo, E. Oren, et al. Race/ethnicity-, socioeconomic status-, and anatomic subsite-specific risks for gastric cancer, Gastroenterology, 156(2019):59-62.
- S. Smith, M. Fowora, R. Pellicano, Infections with Helicobacter pylori and challenges encountered in Africa, World J Gastroenterol, 25(2019):3183.
- N.K. Alkhaldi, W.K. Alghamdi, M.H. Alharbi, A.S. Almutairi, F.T. Alghamdi, The association between oral helicobacter pylori and gastric complications: A comprehensive review, Cureus, 14(2022):e24703.
Copyright: © 2022 Mokwena KE, et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.