Egyptian Journal of Psychiatry

: 2014  |  Volume : 35  |  Issue : 3  |  Page : 161--166

Prevalence of substance abuse among adolescent school students in Zagazig

Mohamed G Negm, Amira A Fouad 
 Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Correspondence Address:
Mohamed G Negm
Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig


Introduction The 20th century ended with the conviction that drug abuse was a global problem and thus global solutions were required. This is a cross-sectional study that was carried out in Zagazig Center, Sharkia governorate, in the year of 2013 (September to October). Participants and methods The study included 204 preparatory and secondary school students. The mean age of the participants was15.26 ± 1.59 years. The school students were met in their classrooms, in the presence of their teachers, and assessed for substance abuse using the Drug Use Disorders Identification Test (DUDIT) and the Drug Use Disorders Identification Test-Extended (DUDIT-E); urine samples were then collected for all participants during the interviews using the multidrug one-step test. Results The prevalence of smoking and substance abuse among school students were 8.3 and 8.8%, respectively, and the majority of them used substances once a month or less. The most common substances used by the students included tramadol, cannabis, and alcohol (83.3, 27.8, and 16.7%, respectively), with a mean age of onset of smoking of 16.06 ± 1.39 years and a mean age of onset of substance abuse of 16.5 ± 1.098 years. Conclusion Substance abuse and smoking were common among adolescents, and the age at onset was almost the same for both. DUDIT and DUDIT-E may significantly contribute to more effective screening of drug problems in research and clinical settings with groups at risk and it may be useful for mapping drug use among different groups in public health contexts.

How to cite this article:
Negm MG, Fouad AA. Prevalence of substance abuse among adolescent school students in Zagazig.Egypt J Psychiatr 2014;35:161-166

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Negm MG, Fouad AA. Prevalence of substance abuse among adolescent school students in Zagazig. Egypt J Psychiatr [serial online] 2014 [cited 2022 Jan 26 ];35:161-166
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The 20th century ended with the conviction that drug abuse was a global problem and thus global solutions were required. The apparently neat boundary between producer, transit, and consumer countries has clearly broken down [United Nations Office on Drugs and Crime (UNODC), 2009). A 2007 National Survey report stated that 8.5% of Egyptians - or six million people - are addicted to drugs, that the majority of them are between 15 and 25 years old and that the addicts are considered as criminals rather than patients in need for treatment (Khoweiled et al., 2012).

Soueif et al. (1986) found that 20% of Egyptian male students have used drugs at some time in their lives, and among them, ~25% have continued to do so. Among secondary school male students, 5.05% abused hashish, 0.84% abused opiates, 2.72% abused tranquilizers, 1.79% abused stimulants, and 2.26% abused hypnotics (Soueif et al., 1990). After these surveys, no study estimated the prevalence and risk factors of substance abuse among adolescents during the last two decades.


Although substance abuse has become a public health problem in Egypt and the prevalence of prescription drug use and/or other substance use disorders should continue to be monitored, there has been no study that estimates the prevalence and risk factors of substance abuse in adolescents in Egypt recently. The objective of this study was to find out the prevalence and associated factors of substance abuse among school students (13-18 years) in Zagazig, Sharkia governorate.

 Participants and methods

This is a cross-sectional study that was carried out in Zagazig Center, Sharkia governorate, in the year of 2013 (September to October). Zagazig has two educational administrations (east and west Zagazig), from which six schools were selected randomly. Three schools were selected from the west Zagazig area and three from the east Zagazig area. The total number of the target population was 86567 (three grades of preparatory school students and of secondary school students, 13-18 years old), obtained from the Statistics Bureau (Office)-Educational Directorate, Sharkia governorate. The sample size of the study was 204 students according to EPI-INFO (version 6, The Division of Surveillance and Epidemiology, Epidemiology Program Office Centers for Disease Control and Prevention (CDC) Atlanta, Georgia 30333).

Before the beginning of the study, a written permission from the Dean of the Faculty of Medicine, Zagazig University, was obtained to facilitate the administration approval. A written permission was obtained from Zagazig Educational Directorate and directed to both east and west Zagazig administrations. Six written permissions were obtained for the six selected preparatory and secondary schools, which were accepted by the school headmasters.

The school students were met in their classrooms, in the presence of their teachers or the social worker, to obtain their consent for participation in the study after explaining the objectives of the study and assuring confidentiality of their information.

Data collection and measures

Screening questionnaire

Participants were assessed for substance abuse using the Drug Use Disorders Identification Test (DUDIT) and the Drug Use Disorders Identification Test-Extended (DUDIT-E).

The Drug Use Disorders Identification Test

The DUDIT (Berman et al., 2005) was developed to facilitate screening for drug use problems and is intended to be a parallel to the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993) developed by the WHO. The questionnaire contains 11 items mapping the frequency of drug use, harmful consequences of drug use, and symptoms of dependence.

For screening individuals having the problem that the treatment provider is interested in assessing, treating, or referring elsewhere, the DUDIT serves as a valuable instrument that will identify individuals who appear to have a drug problem or drug dependence as well as screen out those who do not have such problems.

For deeper analysis of the extent and the nature of the problem, the DUDIT-E can be used at this step to give both the client and the treatment provider a sense of the drug-related issues that could be focused upon in later treatment.


When the DUDIT is used in a group in which one does not expect to find many drug users, we suggest that men with drug-related problems be identified at a cut-off score of 6 or more. Women with drug-related problems are identified at a cut-off score of 2 points or more.

If a male client shows a score of 6 or more points, he probably has drug-related problems, either substance abuse/harmful use or dependence. A woman with a score of 2 or more points probably has drug-related problems. If a client (both sexes) shows a score of 25 points or more, it is highly probable that he or she is dependent on one or more drugs.

The Drug Use Disorders Identification Test-Extended

The DUDIT-E (Berman et al., 2007) was developed to elicit detailed information about patients' views of the pros and cons of their drug use.

The rationale for focusing on patients' perceptions of positive and negative aspects of drug use is that these perceptions are assumed to be critical to patient's motivation to either continue or cease using drugs. The DUDIT-E is not explicitly linked to any theory of motivation, but relates to the decisional balance component of both the transtheoretical model and the expectancy theory. The DUDIT-E was developed because existing instruments for assessing motivation did not map the positive incentives for drug use adequately (Berman et al., 2009).

The DUDIT-E is used after the identification of a drug problem by DUDIT (Berman et al., 2007). The first section of DUDIT-E consists of 17 items investigating the positive incentives of drug use. This section is labeled the P (positive) section. The second section of the questionnaire explores the negative aspects of drug use and is consequently labeled the N section. The third and final section contains ten items on treatment readiness and is labeled the T section. Separate scores can be calculated for each section of the DUDIT-E. By multiplying the negative (N) and treatment readiness (T) scores and dividing by the positive (P) score, the 'motivational index' is obtained. The assumption behind the motivational index is that a relatively negative view of the consequences of drug use will potentiate treatment readiness, whereas a positive view will diminish it.


The results are shown in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}


Substance use among the youth worldwide is a major problem that has elicited concern from different individuals and groups (Yeung, 1997; Egbuonu et al., 2004). In the current study, the mean age of the participants was 15.26 ± 1.59: the majority of them were male (72.5%), at secondary level (52%), and about 55.9% were rural residents.

The prevalence of smoking was 8.3%, which is consistent with the Global Youth Tobacco Survey (GYTS), in which 7.9% of students had smoked (Pandey et al., 2007). Also, this finding is supported by Soueif et al. (1990), who found that the prevalence of tobacco smoking was 10.77% among male secondary school students in Egypt.

According to a review (Bassiony, 2009), the prevalence of smoking among school students in Saudi Arabia ranged from 12 to 29.8%. This difference in the prevalence rates among studies was due to the inclusion of different populations, using different measures for current smoking and estimating the prevalence in different countries and at different times.

El-Sawy et al. (2010) found that the majority of the addicts studied were smokers, and similar studies in Egypt reported the same observation (Wahdan, 1986; UNDP, 2000).

In Saudi Arabia, Bassiony (2013) found that the prevalence of smoking among substance abuse patients (48-97%) was much higher than that among the general population (2.4-52.3%).

In the current study, the prevalence of substance abuse was 8.8%. This finding is comparable to the results of a study involving 14656 Egyptian secondary school students, which revealed that 5.94% of them abused drugs (Soueif et al., 1990). Also, the National Addiction Survey third phase in the years 2005-2007, which covered eight governorates of Egypt, found that 9.8% of the total sample used drugs at least once (Hamdi et al., 2009). The lower substance abuse rates among adolescents in the current study are mostly related to the following:

(1) Religious and legal prohibition of alcohol use and legal prohibition of other drugs;

(2) Substance abuse being regarded to be against cultural values of Egyptian families, especially among adolescents; and

(3) Harsh disapproval of the adolescents' substance abuse by parents.

However, in the western culture, experimentation with drugs and alcohol may be considered developmentally normative among adolescents (Shedler and Block, 1990).

The most commonly abused substances among abusers in our study were tramadol, cannabis, and alcohol (83.3, 27.8, and 16.7%, respectively) [Figure 1]. This high prevalence of tramadol use was supported by a previous study by Fawzy (2010), who reported 32.1% prevalence of tramadol use among children and adolescents who presented to the Emergency Unit of the Poison Control Center of Ain Shams University Hospitals (PCC-ASU), Egypt, for toxicological assessment. Also, nonmedical use of prescription opioids, including tramadol, has increased in the USA over the last several years (Zacny, 2005).

Tramadol abuse is noted most frequently due to its wider availability without prescription, illegal smuggling, and cheaper prices than other types of abused drugs; the unplanned indirect media advertising for tramadol abuse through movies and show series also played a remarkable role in promoting tramadol abuse (Fawzy, 2010). Social perceptions among the youth about tramadol being safer due to it being prescribed is a major factor leading to its abuse; other concerning youth-held beliefs around prescription tramadol include the following: it is easier to hide, the effects last longer and they would be less likely to get in trouble if caught. Students also often use tramadol during examination periods to give them energy and remain awake for a longer time to study (Lord et al., 2011).{Figure 1}

In Saudi Arabia, our study found that two-thirds of those who use drugs used tramadol as the first drug after tobacco smoking, 22% used cannabis, whereas the remaining used more than one substance.

In Saudi Arabia, Bassiony (2008) reported that amphetamine (nonprescription drug) was the second most common drug to be used after tobacco in both adolescents and adults. According to the last National Report in Egypt, among those who used at least once (9.8%), 93% of them used hashish, 22% alcohol, 11% nonprescribed drugs, 7% opium, 5% cocaine and stimulants, and 0.13% solvents (Hamdi et al., 2009).

Regarding the one-time use of addictive substances, the National Addiction Survey found that the male-to-female ratio was greater in Cairo (2 : 1) compared with other governorates, where it reaches 13 : 1, indicating that there is a growing addiction problem among women in Cairo (Hamdi et al., 2011). The current study demonstrated a statistically significant association between smoking and urban residence, but no statistically significant association between the residence and the use of substance. Our study found that the prevalence of drug-related problems among male substance abusers was 38.9%, whereas dependence was 5.6%, which is consistent with El-Sawy et al. (2010), who reported that the prevalence of drug dependence among students was 9.09%. Also, the National Addiction Survey reported that about 10% of the Egyptian population used drugs at least once, and 6.4% used drugs regularly or were dependent on drugs (Hamdi et al., 2009).

Our study also showed that 75% of substance abusers used substances once a month or less, 8.3% reported using them 2-4 times monthly, whereas 16.7% reported four or more times weekly. This finding is supported by a US study that reported that although more than 58% of students in the 10th grade have initiated the use of alcohol, only 29% report using it monthly, 16% reported having had five or more drinks in a row in the past 2 weeks and only 1% report daily use (Johnston et al., 2008). The same investigators also reported that in 2008, about 30% of students in the tenth grade had initiated marijuana use, 14% had used it in the past month, and 2.7% used it daily. Regarding the educational level, our study reported that no statistically significant association was found between DUDIT and DUDIT-E among substance abusers and their education level. The mean score of DUDIT and DUDIT-E (positive and thought items) were significantly higher among urban residents in comparison with rural residents, but there was no statistically significant association between DUDIT-E (negative and motivation index items) and the residence.

DUDIT and DUDIT-E were tested before among heavy drug users with particular characteristics in Sweden (Berman et al., 2005). To our knowledge, this is the first study to use this instrument in school students, particularly in Egypt, and so we do not have similar studies to compare our results with. In a study on illicit drugs in Greater Cairo, peer pressure and curiosity were cited as the main motives for drug use (UNODCCP, 2001). Curiosity followed by the desire to have fun was reported by another study in Egypt (Akabawi, 2001). However many studies reported peer pressure and pleasure seeking as the main motives for starting drug use (UNDCP, 2002).

In Saudi Arabia, Qureshi and Al-Habeeb (2000) found that substance abuse was initiated as a result of peer pressure, seeking pleasure, and curiosity. Another study reported peer pressure (68%) and problems associated with unsatisfactory integration in society (28%), family (25%), marriage (10%), workplace (10%), or health problems (8%) as the main stressors leading to the onset of drug abuse (Al-Naheda, 1999). Oshadi et al. (2010) reported that about three-quarters of the respondents (73.0%) were unaware of problems or complications that could arise from substance use. About 10.5% of them believed poor physical health could complicate substance use. Others perceived complications or problems to include poor finance (7.1%), declined academic performance (3.9%), problems with family relationships (2.9%), and emotional problems (1.6%). El-Sawy et al. (2010) found the main motives for seeking treatment trial among men to be family problems (17.24%), dissatisfaction with being an addict (16.3%), financial problems (15.98%), work problems (12.53%), and health problems (11.28%). However, in women, the main motives for seeking treatment trial were found to be family problems (23.1%), health problems (18.11%), behavioral and psychological disturbances (15.94%), and financial problems; problems such as violence (99%), imprisonment (50.9%), financial problems (30.5%), health problems (32.4%), job loss (13.5%), drug overdose (9.5%), and divorce (6.9%) were associated with substance abuse (Qureshi and Al-Habeeb, 2000).

Our results after using the anonymous questionnaire and urine screening reported six false-negative cases with no false-positive cases, which suggested that the sensitivity of the self-report questionnaire was 66.7%, the specificity was 100% and its accuracy was 97.1%. This study estimated that two-thirds of the school students admitted that they are using substances, whereas one-third denied such use. This finding confirms the fact that self-rating questionnaires could be reliable in certain settings, but in other settings, urine screening should be mandatory.


Several limitations should be considered with regard to our study:

First, the study was cross-sectional, which limits the extent to which conclusions can be drawn about the causal nature of the associations between the correlates and substance abuse.

Second, study limitations also include the somewhat attenuated response rate and the limited sample size relative to other national epidemiological studies, which might limit the generalizability of the findings.

Third, the potential bias resulting from the absence of some students on the day of the survey was another limitation as these students might have higher rates of substance use.

Fourth, some headmasters refused to conduct the survey in their schools due to their belief that knowing the prevalence of substance abuse among school students will have a negative impact on them.


Large population-based studies that involve at-risk groups (adolescents and young adults) are needed to estimate the prevalence, risk factors, and consequences of substance abuse in Egypt[30].

We recommend that future longitudinal studies be conducted to investigate the risk factors of tramadol abuse and the possible role of tramadol as a gateway drug in the development of substance abuse and dependence, and suggest the use of urine analysis for tramadol abuse in all psychiatric and epileptic patients.



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