
==== Front
Saudi Pharm J
Saudi Pharm J
Saudi Pharmaceutical Journal : SPJ
1319-0164
2213-7475
Elsevier

S1319-0164(24)00213-5
10.1016/j.jsps.2024.102163
102163
Article
Substance misuse disorder in Saudi Arabia: A comprehensive examination of current demographic patterns, trends, and intervention requirements
Tobaiqy Mansour a
Al-Asmari Ahmed I. aalasmari1@kfshrc.edu.sa
b⁎
a Department of Pharmacology, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia
b Special Toxicological Analysis Section, Pathology and Laboratory Medicine Department, King Faisal Special Hospital and Research Center, P.O. Box 3354, Riyadh 11211, Saudi Arabia
⁎ Corresponding author. aalasmari1@kfshrc.edu.sa
16 8 2024
10 2024
16 8 2024
32 10 102163© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

This review examines substance misuse disorder (SMD) in Saudi Arabia, drawing insights from 43 prior studies. It explores the prevalence and patterns of SMD across diverse demographics.

Methodology

Our analysis integrated data from various studies involving adolescents, university students, psychiatric patients, and the general population as well as postmortem cases. It identifies key risk factors and challenges in managing SMD, underscoring the importance of comprehensive data collection for evidence-based policymaking.

Results

SMD in Saudi Arabia were categorized into two groups: common traditionally abused drugs (such as Captagon, khat, heroin, ethanol, and cannabis) and substances that have emerged in recent years (e.g., methamphetamine “Shabu”, pregabalin, and benzodiazepines). Trends in SMD include early substance initiation and increased amphetamine and polysubstance use.

Conclusion and recommendations

Drug-related challenges persist in Saudi Arabia; however, because of limited data from recent epidemiological studies on drug disorders, the full extent is unknown. Saudi Arabia is unique because it as an Islamic country with strict regulations against drug trafficking and a religious prohibition on drugs and alcohol, which contributes to distinct trends in substance misuse disorder (SMD). Although some aspects mirror global patterns, others exhibit regional characteristics specific to the country. Despite data variability, actionable recommendations have emerged for SMD prevention and treatment. During the COVID-19 pandemic, a high number of reports was evident; however, SMD publications often reiterate old findings and overlook emerging psychoactive substances (EPS), such as ‘Shabu”, pregabalin, and benzodiazepines. Further studies are needed, including educational initiatives, national surveys, stricter drug regulations, and an early warning system for traditional SMD and EPS.

Keywords

Substance use disorder
Saudi Arabia
“Shabu”
Captagon
Hashish
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pmc1 Introduction

Substance misuse disorder (SMD) is a public health crisis that affects various regions and populations worldwide. In 2024, approximately 292 million people experimented with drugs, resulting in 64 million individuals acquiring drug use disorders, which represents an increase of 3 % compared with a previous report (United Nation Office on Drugs and Crime, 2024). The United Nations Office on Drugs and Crime (UNODC) reported that approximately 14 million people globally engage in drug injection, and nearly 8 million suffer from infectious diseases (United Nation Office on Drugs and Crime, 2024). Alcohol misuse is also prevalent and impacts 2.3 billion individuals globally and contributes significantly to the disease burden (World Health Organization, 2018). The World Drug Report 2023 confirms a similar drug use rate, which highlights the substantial impact of substance abuse on the global health system (United Nation Office on Drug and Crime, 2023).

In Saudi Arabia, drug-related problems persist; however, because of limited data from recent epidemiological studies on drug disorders, the full extent of these issues is unclear (Al-Asmari et al., 2024). Saudi Arabia is unique because it is an Islamic country with strict regulations against drug trafficking and a religious prohibition on drugs and alcohol, which contributes to distinct trends in substance misuse disorder (SMD). Although some aspects are consistent with global patterns, others exhibit regional characteristics that are specific to the country. The World Drug Report 2019 highlights the prevalence of drug use disorders in Saudi Arabia, particularly involving opioids, amphetamines, and cannabis (United Nations Office on Drugs and Crime, 2019). Moreover, the dominant use of amphetamine “Captagon” accounts for 40 % of the drug misuse in Saudi Arabia (Al-Asmari et al., 2022, AL-Imam et al., 2017), with estimated of 150 million Captagon tablets seized in 2019 (United Nations Office on Drugs and Crime, 2019). Recent epidemiological studies are consistent with the broader trends in the countries of the Middle East and North Africa (MENA), where stimulants are common (Sweileh et al., 2014). Al-Asmari et al. (Al-Asmari et al., 2024) recently highlighted methamphetamine (“Shabu”) as a particularly challenging drug-related problem in the MENA region. In fact, postmortem data revealed a 500 % increase in “Shabu” cases from 2016 to 2018 in Jeddah, Saudi Arabia (Al-Asmari, 2021), and a 400 % increase in amphetamine-related deaths over seven years (2012–2018) in the same city (Al-Asmari et al., 2022).

SMD data among Saudis are outdated and lack specificity. Even records from the World Health Organization are not completely accurate. For example, the prevalence of SMD among men aged 15 years and older is approximately 0.01 %, whereas nearly 10,000 Saudis inject drugs (Saquib et al., 2020, World Health Organization, 2006, World Health Organization, 2010). Nonetheless, certain data can be quite surprising, particularly the reported rates of the human immunodeficiency virus (HIV), hepatitis C (HCV), and hepatitis B (HBV) among incarcerated individuals with substance misuse disorder (SMD) at 3.5 %, 77.8 %, and 7.7 %, respectively (Stone and Shirley-Beavan, 2018). However, there is no government data to support these claims. Consequently, estimating the true extent of SMD remains challenging for various reasons, including the sensitivity of this information. Studies are scarce, weak in methodology, and poor in quality (Al-Asmari et al., 2024, Al-Asmari et al., 2023, Saquib et al., 2020); thus, additional studies are urgently needed. Although much of the evidence is indirect, there are indications of a growing SMD problem. This is evident from the establishment of more treatment centers in major cities and the increase in licenses for private treatment options.

Research gaps persist, which necessitates further studies to effectively address substance use disorders and raise public health awareness (Al-Asmari et al., 2024). It is imperative to conduct studies to effectively address SMD and enhance public health awareness. Recent studies indicate that alcohol consumption prior to death is prevalent, although the sample size of the studied cases was small (Al-Asmari and Al-Amoudi, 2020); however, it was confirmed that this issue is encountered among autopsy cases. The authors emphasized the importance of comprehensive forensic practices and further examination of the underlying causes of alcohol-related problems is needed.

Exploring the SMD pattern in Saudi Arabia presents challenges because of limited information. Comprehensive records of SMD cases are lacking in many cities. In addition, reporting practices vary and not all regions report their SMD data consistently. Therefore, it is challenging to obtain a holistic view of SMD prevalence and trends across the country. Efforts to enhance data collection and reporting are essential to establish public health strategies and effective interventions.

This review summarizes the direct and indirect impact of substance abuse among Saudis and aims to provide actionable insights into the current state of SMD in Saudi Arabia. The study examines SMD by reviewing the various studies conducted within the country and identifying key findings, limitations, and future directions. This represents the largest population-based study conducted in Saudi Arabia and includes, for the first time, SMD related to “Shabu” and methanol, drawing attention to these dangerous drugs and informing preventive programs.

2 Material and methods

2.1 Study design

The research methodology involved analyzing data from multiple studies conducted in Saudi Arabia between March 2008 and May 2024, which focused on SMD, including prevention, early intervention, drug-related fatalities, and treatment efforts. The literature, published in peer-reviewed journals, was queried with keywords related to substance use disorders, poisoning, intoxication, overdoses, addiction, and misuse.

Table 1 lists the classification encompassing various categories of research related to substance abuse in Saudi Arabia. Epidemiological studies analyzed population-level patterns, causes, and effects of substance abuse, which shed light on the prevalence, risk factors, and overdose trends. Research Al-Amal (Addiction rehabilitation centers) or psychiatric hospitals focuses on patients undergoing treatment at specialized rehabilitation centers, including the examination of treatment outcomes and relapse rates. Academic-based research, often performed by university students, studies diverse aspects of substance abuse, including risk factors and prevention strategies. Fatality-related death studies examine fatal outcomes resulting from drug overdose and analyze mortality rates and causes. Emergency department observations specifically study cases involving drug overdose or intoxication and evaluate interventions. Finally, region-specific substance abuse disorders explore unique patterns within specific geographic areas or cultural contexts, such as khat use in the Jazan region or Captagon abuse in other regions.Table 1 Comprehensive classification of substance abuse studies: insights and context.

Classification	Description	Examples	References	
Epidemiological Studies	Analyze patterns, causes, and effects of substance abuse at a population level. Provide insight into prevalence, risk factors, and trends related to drug overdose and intoxication.	Retrospective analyses of drug overdose cases across different demographics and regions.	(AbuMadini et al., 2008, Al-Asmari et al., 2023, Al-Asmari et al., 2022, Al-Asmari and Al-Amoudi, 2020)	
Research from Eradah (Al-Amal) Hospitals	Examine patients receiving treatment at Eradah Centers (formerly Al-Amal Hospital) for substance abuse. Examine treatment outcomes, relapse rates, and patient responses to therapy within these specialized rehabilitation centers.	Examples: Studies focusing on Al-Amal center patients and their rehabilitation progress.	(Kayal et al., 2014, Ramadan et al., 2023, Siwar et al., 2023)	
Academic-Based Research (University Student Investigation)	Studies conducted by university students explore various aspects of substance abuse, including risk factors, prevention, and treatment.	Examples: Student-led surveys on drug use behavior among peers.	(Al-Haqwi, 2010)	
Fatalities-Related Deaths Studies	Focus on fatal outcomes associated with drug overdose. Analyze mortality rates, causes of death, and associated risk factors.	Investigations into drug-related overdose deaths and their geographic distribution.	(Al-Asmari, 2021, Al-Asmari et al., 2023, Al-Asmari et al., 2022, Al-Asmari and Al-Amoudi, 2020)	
Emergency Department Observations for Drug-Related Overdose or Intoxication	Examine specific cases at emergency departments resulting from drug overdose or intoxication. Assess interventions delivered during and after the ED visit.	Observations of opioid overdose presentations and post-discharge interventions.	(Alageel et al., 2023, Bakhaidar et al., 2015)	
Region-Specific Substance Abuse Disorders	Investigate substance abuse patterns unique to specific geographic areas or cultural contexts.	Examples: Khat use in the Jazan region or Captagon abuse in the western region.	Alshahrani et al., 2021a, El-Setouhy et al., 2019, Shaikhain et al., 2023, Awadalla and Suwaydi, 2017)	

3 Results

3.1 Study population and demographics

A review of 43 studies (Table 2) on SMD and fatalities in Saudi Arabia was conducted between 2008 and 2024. These studies examined various populations and settings, and shed light on the prevalence, risk factors, and substance abuse patterns. They encompassed a diverse range of study designs, including retrospective studies, cross-sectional surveys, and epidemiological studies.Table 2 Studies on Substance Abuse in Saudi Arabia (2010–2024).

Studies	Year	Type of Study	Institute, (City), populations	Substance Abused	Limitations	Recommendations	Finding	Reference	
1	2008	Retrospective study (1986 and 2006)	Al-Amal Hospital, [Dammam, Saudi Arabia (SA)]
n: 12,743 patients.	Amphetamines, cannabis, heroin, sedatives, and volatile substances	• The study focused on a specific rehabilitation facility (Amal Hospital in Dammam)

Sociodemographic changes were not explored in depth

	• Community-based epidemiologic studies are needed

Establishing a comprehensive drug information system in Saudi Arabia is imperative

	• Adolescents who abuse drugs

Over two decades, SMD treatment seekers increased significantlyMost patients seeking treatment were male

(94.5 %)

The most abused substances were amphetamines, followed by cannabis and heroinTreatment-seeking patterns varied over time, with fluctuations in substance preferences

	(AbuMadini et al., 2008)	
2	2010	Cross-sectional survey	Medical students. (Riyadh, SA), n = 215 medical students,	Alcohol, Amphetamines, Heroin, cannabis, Cocaine	• Only medical students, self-reported data

	• Early educational interventions Broader population studies, longitudinal research

	• 75 % believed substance abuse is prevalent, with alcohol most common

	(Al-Haqwi, 2010)	
3	2012	Retrospective study	Al-Amal Hospital, (Jeddah, SA), n = 69 adolescent drug users	Amphetamines, cannabis, Cocaine, Opioids	• Small sample size, specific to adolescents

	• Targeted services for adolescents More comprehensive studies on psychotic symptoms

	• Adolescent drug users dependent on illicit substances often experience psychotic symptoms during use or withdrawal

The severity of dependence on amphetamines, cannabis, cocaine, and opiates correlates with an increase in psychotic symptoms

Amphetamines: 48.1 %, Cannabis: 46.5 %, Cocaine: 22.5 %, and Opiates: 7.3 %

	(Alibrahim et al., 2012)	
4	2013	Review	A comprehensive review paper incorporates data from PubMed searches, UNODC reports, WHO reports, and conference proceedings	General description of substance use in Saudi Arabia over the preceding two decades	• All studies had a cross-sectional design

relying on retrospective data

impact the reliability of findings

SMD prevalence and co-morbid disorders varied among the included studiesFindings from treatment-based studies may not directly apply to the general population

	• Drug control involves both demand reduction and supply reduction strategies

	• Commonly Abused Substances:Amphetamine

(4–70.7 %)Heroin

(6.6–83.6 %)Alcohol

(9–70.3 %)Cannabis

(1–60 %)

Trends Over the Past Decade:

Increased use of cannabis and amphetamine.

Decreased use of heroin and volatile substances.

Risk Factors:Peer pressure and psychosocial stresses contribute to the initiation and relapse of substance abuse

	(Bassiony, 2013)	
5	2014	Observational study (Male patients)	Al-Amal Hospital, (Jeddah, SA), n = 57.	Cannabis, amphetamines, alcohol, heroin and cocaine	• Small sample size

	• Not specified

	• All participants had some form of periodontitis

Moderate chronic periodontitis affected 60 % of the sampleCocaine and heroin users showed higher mean clinical attachment loss

	(Kayal et al., 2014)	
6	2015	Retrospective analysis	King Khalid National Guard Hospital, (Jeddah, SA),
Emergency department patients, n = 129, 50 % Female)	Pharmaceuticals, household chemicals, pesticides	• Data limitations, retrospective design

	• Public education, surveillance enhancement, collaboration

	• January 2008 to December 2012.

The study identified common substances involved in overdose and poisoning, including pharmaceutical drugs, household chemicals, and pesticides

The majority of cases were accidental, but intentional self-harm was also observed

The most affected age group was young adults

The study highlighted the need for better prevention strategies and public awareness

	(Bakhaidar et al., 2015)	
7	2016	Retrospective study(amphetamine-positive urine drug screening (APUDS)	King Abdulaziz Medical City-Riyadh, (Riyad, SA): n-42 male	Amphetamine	• Retrospective design

Single-center study

Limited sample size

	• Increased awareness about ATS-related CV complications

Early recognition and management of CV events in APUDS patients

	• Increased risk of cardiovascular complications and mortality in young Saudi men with APUDS. 9.6 % of APUDS test positive for amphetamineMost common presentation: Acute coronary syndrome/myocardial infarction

(74 %).Other complications include myopericarditis, cardiomyopathy, and arrhythmia

	(Alghamdi et al., 2016)	
8	2016	Cross-sectional design	Secondary school students, (Abha, SA), n = 350 Male.	Alcohol, cannabis, glue/solvents, amphetamine, khat	• Not specified

	• Not specified

	• Alcohol intake: 9.3 %–

Substance abusers: 8.8 %Main illicit drug: cannabis

(51.4 %), followed by glue/solvents (48.6 %) and amphetamine (45.7 %)

Khat chewing: 4 % −Prevalence of substance abuse increases with students’ age

	(Al-Musa and Al-Montashri, 2016)	
9	2017	Cross-sectional study	Road traffic accidents, (Jazan, SA), n: 215 male.	Khat	• Lack of detailed historical data on substance use

	• Raise awareness about khat risks

Address impaired work ability and productivityPromote adherence to traffic rules

	• Khat chewing associated with:

Shorter working hoursHigher average number of significant road traffic accidents

(RTA)

Increased frequency of traffic violations

	(Awadalla and Suwaydi, 2017)	
10	2017	Case-control	Al-Amal Hospital, (Jeddah, SA),n = 207 female patients undergoing treatment and rehabilitation of substance abuse at Al-Amal Hospital, Jeddah)	Not specified	• Not specified

	• Not specified

	• Unstable marriage, low education, unemployment, low family income, and unstable family conditions were significantly higher among patients. Substance use was associated with family conflicts, substance abuse by husband, peers, and siblings, sexual abuse, low family income, and sickle cell anemia

	(Khalawi et al., 2017)	
11	2018	Cross-sectional survey	Al-Amal Hospital, (Jeddah SA),n = 101 patients.	Amphetamines, Alcohol	• Retrospective cross-sectional design

Single-center study

Limited sample size.

	• Raise awareness about substance-related driving risks

Target prevention efforts toward young individuals

	• 93.1 % admitted to driving under the influence, amphetamines most common

	(Almarhabi et al., 2018)	
12	2018	Hospital-based Survey	Al-Amal Hospital, (Riyadh, SA), n = 197 patients.	Combination of substances	• Short duration of the study

	• Raise awareness about substance risks

	• Substance abuse is a significant concern in Riyadh

	(Aldlgan et al., 2019)	
13	2018	Retrospective study	NS., (Al-Qassim, SA)n = 612.	Amphetamines, Polysubstance	• No female patients, no data on tobacco

	• Integrated efforts to explore causes.Inclusion of females, broader substance categories

	• A total of 101 patients participated (mean age: 33.28 years)

93.1 % drove under the influence of an abused substance

Amphetamines and alcohol were the most abused substances

The mean age at first substance abuse was 18.76 years

	(Ibrahim et al., 2018)	
14	2019	Postmortem Investigation	JPCC, (Jeddah, SA),n = 31 Postmortem samples	Δ9-Tetrahydrocannabinol (THC), 11-hydroxy-Δ9-THC (THC-OH), and 11-nor-Δ9-THC-9-carboxylic acid (THC-COOH)	• Lack of information regarding history of abuse

Single cityNew psychoactive substances i.e., synthetic cannabinoids were not included in the method

	• Forensic toxicology should include cannabinoid testing in routine postmortem investigations

This assessment helps determine the impact of cannabinoids in accidents and investigates their role in crimes and fatalities

	• Cannabinoids are rarely directly related to deaths

However, their role in other contexts cannot be ignored:

Crime

Car accidents

SuicidesHomicides

	(Al-Asmari, 2019)	
15	2019	Cross-sectional survey	Al-Amal Psychiatric Hospital, (Jazan, SA).n = 350 khat chewers.	Khat	• Lack of information regarding history of abuse

	• Implement law enforcement strategies to disrupt the supply chain

	• Increased khat prices would significantly decrease demand.Recommends law enforcement strategies to disrupt the khat supply chain and discourage use

	(El-Setouhy et al., 2019)	
16	2019	Review	Not specified.	Alcohol, khat, cannabis, amphetamine, cocaine, opioids	• Limited research and unreported cases.Several studies were not conducted in Saudi Arabia

	• Enhance reporting, raise awareness

	• Amphetamines: Most commonly abused substance

Khat: Prevalent in the southern region

Alcohol: Underestimated prevalence

Comorbidities: Include hepatitis, liver cirrhosis, depression, and anxiety

Cannabis: More common among adolescentsSeverity: Linked to psychotic symptoms

	(Al-Jerani et al., 2019)	
17	2020	Postmortem Investigation	JPCC, (Jeddah, SA),n = 450 Postmortem case samples.	Multiple substances including prescribed drugs and drugs of abuse	• Lack of information regarding history of abuse.

Single cityNew psychoactive substances were not included in the method

	• This method used Targeted analysis, it is recommended in the future to use non-targeted analysis to include more about NPS

	• The most frequent drug detected in Jeddah city was reported for the first time in the postmortem population

Amphetamine

Opioids

Cannabis

Methamphetamine

Benzodiazepine

CocainePregabalin

	(Al-Asmari, 2020b)	
18	2020	Review (Scoping)	Not specified	Not specified	• Limited number of studies, weak methodology, and poor quality

	• Conduct quantitative and qualitative studies on SMD in each domain, representing both genders

	• Available studies were few, weak in methodology, and poor in quality. Further research is needed.

	(Saquib et al., 2020)	
19	2020	Retrospective cohort	JPCC, (Jeddah, SA),n = 32 Postmortem samples)	Ethanol	• Lack of information regarding history of abuse

	• Routine testing for ethanol and its polar metabolism in postmortem examinations is crucial.

the significance of this practice

	• High percentage of antemortem ethanol consumption cases

Deaths related to antemortem consumption are often associated with violence

41 % of antemortem consumption cases in this study involved violence

	(Al-Asmari and Al-Amoudi, 2020)	
20	2021	Retrospective cohort	King Fahad Medical City, (Riyadh, SA): n:113 khat users)	Khat	• Lack of information regarding history of abuse

	• Improved genetic screening.Further investigation into khat-related cancer risks

	• Oral cancer-related gene mutations

	(Alshahrani et al., 2021a)	
21	2021	Epidemiological study	JPCC, (Jeddah, SA):n = 235 postmortem cases	Methamphetamine	• First Study: Addresses ethanol consumption in Saudi Arabia

Validation Needed: Further research is required to confirm these findings

	• Raise awareness

Implement education programs

Enhance treatment options

Aim to reduce addiction, crimes, suicide, and fatalities related to methamphetamine abuse

	• Deaths increased by 500 % between (2016–2018

Largest number of cases: Age group 31–40 years (86 cases)

Methamphetamine co-ingested with other drugs in 55 % of cases

23 % of deaths due to other co-ingested drugs

Methamphetamine sole cause of death in 16 % of cases

Combination of methamphetamine and pre-existing disease observed in 9.4 % of deaths

	(Al-Asmari, 2021)	
22	2021	Retrospective cohort	King Fahad Medical City, (Jazan, SA). n: 492, khat users)	Khat	• Retrospective design

Single-center studyLimited sample size

	• Improved treatment decisions

Further studies are essential to investigate treatment decisions for this group of patients

	• The study included 483 khat users (48 % of the sample)

Olanzapine, haloperidol, and aripiprazole were commonly used antipsychotic drugs.

Khat users had a lower retention rate of the initial drug compared to non-users.

Moderate and heavy khat users were more likely to change their initial drug due to lack of efficacy

	(Hakami et al., 2021)	
23	2021	Experimental study	N.S., (Najran SA)l(n: 53 Individuals with chronic substance abuse)	Amphetamine, Alcohol	• Limited sample size

	• Investigate immune system interventions

	• This research sheds light on the immunological effects of chronic substance abuse

	(Mehdar and Alrafiah, 2021)	
24	2021	Retrospective observational	King Khalid Hospital, (Najran, SA),n: 852 Adult patients)	Therapeutic drugs, Alcohol, Household chemicals	• Sample Size: Not adequately justified for patient selection or exclusion from records

	• Acute intoxication incidence and profile

	• Predominance of accidental intoxication.

Common use of therapeutic drugs

Alcohol overdoses observed

Household chemicals implicated.

Low mortality

	(Wahba et al., 2021)	
25	2021	Cross-sectional study	N.S. (Assir region, SA), Community pharmacists in the Aseer region	Pregabalin	• The questionnaire was answered by community pharmacists in the Aseer area, which may not fully represent Saudi Arabia overall.

	• Further monitoring and regulations on the prescribing and procurement of pregabalin are needed to prevent abuse.

	• This study sheds light on pharmacist perceptions regarding customer misuse and abuse of pregabalin in the Aseer region, Saudi Arabia

	(Alshahrani et al., 2021b)	
26	2022	Workplace drug testing	Prince Sultan Military Medical City, (Riyadh, SA),n = 52 Suspicious clinical and forensic urine samples, Saud	Synthetic cathinone	• Lack of individual-level data

	• Implement effective public health education programs to raise awareness about risk factors for acute toxicity, including overdoses and suicide attempts

	• This study confirms the presence of NPS abuse in Saudi Arabia

Among suspicious urine samples, 5.8 % contained mephedrone and N-ethylpentylone, along with their metabolitesPolydrug use was observed, with synthetic cathinone co-occurring with other classical stimulant drugs

	(Aldubayyan et al., 2022)	
27	2022	Retrospective cross-sectional	Psychiatry hospital (Jeddah, SA), n = 200 female patients	Psychoactive substances, Amphetamines, cannabis, Nicotine	• Small sample size (200 female patients)

Retrospective design

Single-center study

Limited exploration of sociodemographic factors

	• Screen for substance use disorders in psychiatric settings

Develop rehabilitation programs to address drug dependence among female psychiatric patients

	• Psychoactive substances were the most common (58 %).Central nervous system (CNS)

depressants were used by 22 %

Cannabinol was used by 9.5 %The highest substance use pattern was amphetamine-cannabis-nicotine

(46.6 %)Heroin-alcohol-benzodiazepine was the second most common pattern

(16.4 %)Benzodiazepine-nicotine had the lowest prevalence

(1.7 %)

	(Alodhayani et al., 2022)	
28	2022	Case series	Adult ED at King Abdulaziz Medical City, (Riyadh, SA),n = 9 patients.	Methanol	• Limited to ED cases

	• Swift diagnosis and combined fomepizole therapy with hemodialysis

	• Multifaceted clinical presentation; 17.4 % mortality rate; prompt treatment mitigates mortality and minimizes visual sequelae

	(Eskandrani et al., 2022)	
29	2022	Retrospective cohort	JPCC, (Jeddah, SA), n = 235 Postmortem samples.	Amphetamine	• Lack of information regarding history of abuseThe study focused on Jeddah, limiting generalizability

	• Implement preventive programs targeting youth to curb amphetamine abuse

Address violence associated with amphetamine-related deaths

	• Most cases occurred in the age group of 31–40 years

Amphetamine was often co-ingested with other drugs

Approximately 16 % of deaths were solely due to amphetamineCauses of death included accidents

(47 %), homicides (26 %), and suicides (11 %)

	(Al-Asmari et al., 2022)	
30	2023	Retrospective chart review	King Saud University Medical City. (Riyadh, SA), n = 582 patients	Cannabis, Amphetamines	• Screening for active substance use should involve both patient histories and laboratory testing

Clinical assessment alone may miss cases of substance use

	• Screening for active substance use should involve both patient histories and laboratory testingClinical assessment alone may miss cases of substance use

	• Cannabis was the most used substance (60 % of patients)

Patients are presented with various clinical conditions, including medical illnessesTraumatic injuries (e.g., motor vehicle collisions)

accounted for 15.3 % of cases.Males had higher rates of medical illness presentations compared to females

	(Alageel et al., 2023)	
31	2023	Cross-sectional survey	A survey among secondary school (Riyadh, SA),n = 400 400 male high school students	Tobacco, Alcohol, Drugs	• Responses were self-reported

Possible underreporting due to social desirability bias

	• Health authorities should educate students

Provide structural and emotional support

Address misuse, long-term use, and addiction.

	• Most students (>70 %) were aware of the harmful effects of smoking, alcohol, and drugsPrevalence: Smoking

(27.8 %), alcohol intake (11.5 %), drug abuse (9.5 %)Early initiation: Smoking

(<15 years), alcohol (<20 years), drug use (as early as 14 years)Students often obtained substances from friends or procured them themselves

	(Alenazi et al., 2023)	
32	2018	Autopsy	JPCC, (Jazan, SA),n = 30 Postmortem samples	Khat (cathinone and cathine)	• Lack of data on reference concentrations

	• N/A

	• 3 % of fatalities involved khat

	(Shaikhain et al., 2023)	
33	2023	Cross-sectional	Al Amal Mental Health Hospital, (Assir region, SA), n = 100 cannabis
Abusers.	Cannabis	• Limited sample size

	• N/A

	• Cannabis addiction harms various body systems. After treatment, body mass index remained unchanged, but other indicators improved (e.g., blood glucose levels, liver function, and renal function)

	(Siwar et al., 2023)	
34	2023	Retrospective cohort	JPCC, (Jeddah, SA),n = 97 Postmortem samples	Heroin abuse	• Limited sample size, Not detailed in all cases

HIV and hepatitis were reported in < 1 % and 3 % of cases

HIV deaths related to heroin addiction may be underreported

	• Educate about heroin risks

Provide support for abusers

Investigate opioid type and time of death.

	• Highest deaths in the 21–30 age group

Heroin deaths remained stable over the study period

Most deaths likely occurred within groups

Fear prevented users from calling ambulances

Only 24 % had medical records indicating better health reporting on drug abuse

Most patients were unemployed and started heroin use in their teensLoss of tolerance after detox may cause many heroin-related deaths

	(Al-Asmari et al., 2023)	
35	2023	Retrospective analysis	King Abdulaziz University Hospital, (Jeddah, SA),n = 78 Emergency Department patients	• Various drugs (Overdose toxicity

Drug interactions

Accidental and suicidal drug ingestions

Drug abuse

	• Actual drug overdose cases may be higher due to underreporting, misreporting, and misdiagnosis

The study was conducted in a single academic institution and does not fully represent the entire population of the researched geographic area

Testing for toxicological substances relies on blood or urine samples sent to a regional laboratory, and results were often not recorded

	• Improve prescriber awareness

	• Drug-related problems led to hospital admissions and deaths

Accidental overdose represented the majority of cases

	(Reda et al., 2023)	
36	2023	Case Reports	King Abdulaziz Specialist Hospital, (Taif, Saudi Arabia), n = 6 patients.	Homemade alcoholic beverages and colonia	• Limited availability of ethanol/methanol testing in blood at hospitals

Laboratory test limitations and time constraints

	• To address treatment variability, it is recommended to establish national guidelines and diagnostic criteria for methanol poisoningImprove diagnostic testing and availability of antidotes

	• Despite resource limitations, the dramatic consequences of methanol poisoning outbreaks can be anticipated with available resources

	(Alqurashi et al., 2023)	
37	2023	Ecological study	Al-Amal Rehabilitation Hospital, (Dammam, SA),n = 910 patients.	Amphetamine	• The study only establishes correlations, not causal relationships

Conclusions are inferred from aggregate data, assuming average characteristics for individuals within the datasets

	• Conduct rigorous, multidisciplinary studiesEvaluate factors related to ATS and illicit drug abuse

	• The admission rates for AUD have increased significantly from 1.33 % in 2005 to 18.27 % in 2018

The quantity of illicit amphetamine seizures appears to be associated with the rise in AUD-related admissions in Saudi Arabia

	(Ramadan et al., 2023)	
38	2023	Postmortem analysis	JPCC, (Jeddah, SA),n = 43 Postmortem samples.	Cannabinoid-positive cases	• Lack of Evidence on Cannabis-Related Morbidity and Mortality, Absence of Detailed Cannabis Intake History, No Exploration of Early-Age Cannabis Use Causes

	• Longitudinal Studies: Track chronic cannabis use’s impact on morbidity and mortality

Larger Sample Sizes: Enhance statistical power by increasing sample size

Detailed Intake Assessment: Collect comprehensive cannabis use data

Age-Specific Investigations: Explore early-age cannabis consumption effects

	• Longitudinal Studies: Track chronic cannabis use’s impact on morbidity and mortality

Larger Sample Sizes: Enhance statistical power by increasing sample size

Detailed Intake Assessment: Collect comprehensive cannabis use dataAge-Specific Investigations: Explore early-age cannabis consumption effects

	(Zughaibi et al., 2023)	
39	2023	A systematic review and methodological analysis	Not specified	Various toxic substances	• Followed PRISMA guidelines

	• Not specified

	• Methodological review of drug-related toxicological studies in Saudi Arabia

	(Alwafi et al., 2023)	
40	2023	Qualitative study	Physicians, (Riyadh, Jeddah, Abha,
and Jazan, SA), n = 105.	Codeine	• Limited to physician perspectives.

Lack of patient data.

Potential bias in self-reported data.

	• Implement stricter regulations on codeine prescriptions.

Increase awareness and education on codeine misuse.

Conduct comprehensive epidemiological studies involving patients.

	• Physicians are concerned about the accessibility and misuse of codeine.

Codeine is often prescribed in combination with paracetamol.

There is a lack of data on codeine addiction patterns in Saudi Arabia.

Physicians emphasize the need for better regulation and monitoring of codeine prescriptions.

	(Syed et al., 2023)	
41	2024	Cross-sectional	Eradah
Hospital, (Qassim region, SA.), n = 50 patients..	Amphetamines and cannabis	• Limited sample size

	• N/A

	• Significant changes in leukocyte blood cells (neutrophils, lymphocytes, monocytes, eosinophils, and basophils) were observed. Microscopic examination of blood films revealed hazardous alterations in neutrophils

	(Mohammed et al., 2024)	
42	2024	Descriptive	Not specified, (Tabuk region, SA), n = 1179 parents	Methamphetamine (“Shabu”)	• − Limited sample sizeSelf-reported data

	• − Implement educational programs for parents

Raise awareness about methamphetamine risks

	• − 11 % hadn’t heard of “Shabu”

38 % unaware of the main symptoms of addiction

46 % didn’t know long-term effects

97 % considered “Shabu” dangerous

	(Ibrahiem et al., 2024)	
43	2024	Retrospective case series	Adult ED at King Abdulaziz Medical City, (Riyadh, SA),n = 22
Patients.	Methanol	• Limited to ED cases

	• Swift diagnosis and combined fomepizole therapy with hemodialysis

	• Multifaceted clinical presentation; 17.4 % mortality rate; prompt treatment mitigates mortality and minimizes visual sequelae

	(Alhusain et al., 2024)	

The total study population consisted of more than 20,000 individuals and represented a broad demographic spectrum. Participants included psychiatric patients, addicts, general hospital patients, driving under the influence of alcohol and drugs, and drug-related fatalities. By analyzing these diverse groups, our study contributes significantly to a better understanding of SMD across different age groups and settings in Saudi Arabia. To our knowledge, this is the largest study conducted on SMD in Saudi Arabia.

3.2 Traditional and known SMD

3.2.1 Alcohol

In Saudi Arabia and other Islamic countries, alcohol (ethanol, ethyl alcohol) consumption is strictly forbidden because of religious prohibition. Research conducted at the Al-Amal Hospital in Jeddah revealed that alcohol abuse was prevalent among the admitted cases; however, it is important to note that much of this research is outdated. Surprisingly, during a 10-month study, it was found that 87 % of patients were using alcohol (Iqbal, 2000). In addition, approximately 16.1 % of patients in the same hospital clinics were diagnosed with alcohol abuse disorder (Osman, 1992). A comprehensive review spanning two decades identified alcohol as one of the most used substances among Saudi residents seeking addiction treatment (Bassiony, 2013). In a study conducted over four months at the AL-Amal Hospital in Riyadh, alcohol was the third most commonly abused substance among 197 patients. Approximately 23 % of these patients were using alcohol (Aldlgan et al., 2019). A retrospective study on psychiatric rehabilitation center patients revealed that 60 % of participants abused multiple drugs, including alcohol, amphetamines, and cannabis; however, it should be noted that this study reviewed outdated reports (Ibrahim et al., 2018).

Almarhabi and colleagues examined driving under the influence of drugs and alcohol among young drivers. They found that nearly 26 % of hospitalized drivers were impaired from alcohol use (Almarhabi et al., 2018). Rarely reported information indicated that alcohol-related accidents were infrequently documented. In Najran, alcohol-related intoxication cases accounted for 11 % of admissions to the emergency department among 825 intoxicated patients (Wahba et al., 2021), which is consistent with Almarhabi et al.’s study (Almarhabi et al., 2018). In addition, Al-Asmari examined the role of ethanol in deaths in Jeddah city and confirmed that 32 % of deceased individuals tested positive for alcohol use before death (Al-Asmari and Al-Amoudi, 2020).

During the early 20th century, alcohol was surprisingly accessible in Saudi Arabia, despite religious prohibitions. Although some data relied on the media rather than direct case studies, a cross-sectional survey among medical students in Riyadh revealed that approximately 75 % of the participants considered alcohol and substance abuse a common problem in the community. They classified alcohol as more harmful to society than amphetamines, cannabis, and heroin in 2008 (Al-Haqwi, 2010). Fifteen years later, another survey was conducted on high school students in Riyadh, which revealed that alcohol use had decreased significantly to 11.5 %. This change may be attributed to a shift in media exposure and the availability of other sources of information (Alenazi et al., 2023).

3.3 Amphetamine “Captagon”

Saudi Arabia has emerged as a significant hub for drug trafficking, with amphetamine (commonly known as “Captagon”) at the forefront. The notoriety of Captagon stems from its widespread use and trade across the Middle East (Al-Asmari et al., 2024, Al-Asmari et al., 2022, Al-Asmari, 2021). Reports found that up to 40 % of individuals with substance SMD in Saudi Arabia are Captagon users (AL-Imam et al., 2017). Despite educational efforts aimed at prevention, the number of SMD cases related to amphetamines continues to increase.

The impact of Captagon extends throughout all regions of Saudi Arabia, consistently appearing in addiction hospitals (AbuMadini et al., 2008, Alibrahim et al., 2012, Bassiony, 2013), Driving Under the Influence of Drugs (DUID) incidents (Almarhabi et al., 2018), and postmortem investigations (Al-Asmari et al., 2022). Among Saudis seeking treatment for addiction, the prevalence of amphetamine abuse significantly varies. In Jeddah, up to 48 % of the residents in addiction centers report amphetamine abuse disorder. Over the past decade (Alibrahim et al., 2012), a similar trend was observed at the Amal Hospital in Dammam, where amphetamine addiction increased to 48.1 % between 1986 and 2006 (AbuMadini et al., 2008). In Al-Qassim, 24 % of the study participants exclusively used amphetamine (Ibrahim et al., 2018, Qureshi and Al-Habeeb, 2000). In addition, among the admitted patients, the prevalence of amphetamine abuse was 38.6 %. A cross-sectional study of male high school students in Abha City revealed that 8.8 % were abusing drugs and 45.7 % of these drug abusers were amphetamine-dependent (Al-Musa and Al-Montashri, 2016).

In a study focusing on DUID and patients hospitalized at Riyadh Hospital, 34 % tested positive for amphetamine, which places amphetamine as the second most abused substance among incidents of intoxication (Alageel et al., 2023). In a recent study by Al-Asmari in Jeddah, Saudi Arabia, 235 cases of amphetamine-related deaths were examined (Al-Asmari et al., 2022). The study revealed that approximately 44 % of individuals who died in car accidents were polydrug users. Of these cases, approximately 40 % of deaths were linked to violent incidents. The median age of the deceased individuals was 30 years (with most cases falling within the 21–40 age range). Moreover, 10 % of the cases were associated with natural diseases, particularly cardiovascular conditions. These results are consistent with other studies indicating that amphetamine users face an elevated risk of heart-related illnesses (Åhman et al., 2018).

In a study conducted in Riyadh, Saudi Arabia, cardiovascular complications related to amphetamine use were examined. Among individuals testing positive for amphetamines in a urine drug screen, acute coronary syndrome/myocardial infarction was the most frequent clinical presentation. Other complications included myopericarditis, cardiomyopathy, and arrhythmia. This study highlighted the increased risk of cardiovascular complications and in-hospital mortality associated with amphetamine use (Alghamdi et al., 2016). Mehdar and Alrafiah examined the effect of chronic amphetamine abuse with concurrent alcohol use on immunity. They specifically focused on CD3 T cells and the response of CD4 and CD8 T cells. The results provide insight into the potential impact of amphetamine use on immune function (Mehdar and Alrafiah, 2021).

3.4 Khat

Khat abuse stands out from other types of substance abuser because of its cultural and traditional history. Derived from the Catha edulis plant, khat is frequently chewed in the southern region of Saudi Arabia, particularly in Jazan. Its prevalence extends to various segments of the population, including high school students (estimated at up to 18.8 %). Interestingly, the pattern of khat use diverges from that of other substances, as it is more common among females. In one study, 11.3 % of users were female. Khat is frequently used by married individuals during community and family gatherings. It serves as a recreational activity and is often self-funded and readily accessible (Al-Sanosy, 2009, Mahfouz et al., 2015).

Although it may be tempting to deny the fact that khat is an abused substance, research specifically related to khat-related SMD was not available until 2016 (Al-Musa and Al-Montashri, 2016, Awadalla and Suwaydi, 2017). This paucity of research may be attributed to challenges in obtaining ethical approval and the fact that khat users often suffer from illnesses that are not usually treated in addiction centers, such as stroke and oral cancer (Alshahrani et al., 2021a, Shaikhain et al., 2023). It should be noted that khat is considered a traditional practice among the Jazan population, even when they are outside of their region for work. The fact that 4 % of male secondary students in Abha City (which is close to Jazan) reported khat chewing raises some intriguing questions. Exploring the cultural factors and regional influences may shed light on its prevalence (Al-Musa and Al-Montashri, 2016).

In a retrospective study, the effect of khat use on the response to antipsychotic medications in patients newly diagnosed with schizophrenia was examined. Approximately 48 % of patients were khat users. Khat use inhibited the response to initial antipsychotic drug treatment, leading to lower retention rates of the initial drug and an increased likelihood of changing the drug because of a lack of efficacy. Further studies are needed to explore treatment decisions for this patient group (Hakami et al., 2021).

Khat is cultivated in rural areas in the southern region of Saudi Arabia; however, primary source on the Yemeni border. During the COVID-19 lockdown, the tightening of the Saudi-Yemeni border resulted in a significant decrease in khat smuggling within Saudi Arabia, which increased khat prices. Interestingly, for every 1 % increase in price, there was a corresponding 1 %–2% reduction in the demand (El-Setouhy et al., 2019).

In a study by Shaikhain et al. (Shaikhain et al., 2023), 3 % of fatalities in Jazan were associated with khat use. Khat was often used in conjunction with other drugs, with amphetamine being the most frequent. Notably, homicides were the most common type of fatality associated with khat use alone, accounting for 77 % of the cases in that study.

3.5 Cannabis

Cannabis or marijuana (referred to as hashish in Arabic), is derived from the psychoactive plant cannabis sativa. Its prevalence remains overlooked and underreported in Saudi Arabia. Although it shares similarities with Captagon use, cannabis consumption varies widely, ranging from 1 % to 60 %. Among adults, approximately 11 % reported cannabis use, whereas adolescents exhibited a higher prevalence, with up to 20 % reporting using it. A study at Al-Amal Hospital in Jeddah found that 24.8 % of patients consumed cannabis (Bassiony, 2013).

Existing studies, both old and recent, consistently highlight cannabinoids as the most commonly identified drugs in SMD. In Abha City, cannabis emerged as the predominant substance, representing nearly 51 % of tested samples in 2016 (Al-Musa and Al-Montashri, 2016). Similarly, at an addiction center in Riyadh, both cannabinoids and amphetamine were equally prevalent, accounting for 30 % of the SMD patients (Aldlgan et al., 2019). In contrast, patients admitted to emergency departments predominantly used cannabis as a primary drug. A study by Alageel et al. revealed that cannabis was the most frequently used substance (60 % of patients) and was associated with various clinical conditions observed, including medical illnesses. Traumatic injuries, such as motor vehicle accidents, accounted for 15.3 % of the cases (Alageel et al., 2023).

Limited data exists regarding cannabis-related health outcomes. A recent study conducted in Jeddah evaluated cannabinoid metabolites in postmortem cases. Although not designed for epidemiological tracking of cannabis misuse, the large sample size and routine cannabinoid testing made it noteworthy (Al-Asmari, 2019, Zughaibi et al., 2023). By examining cannabinoid prevalence among the deceased and its role in death and crime, the study addressed an important public health concern; however, limitations included the absence of a detailed cannabis intake history and the exploration of the cause of early-age use. Future studies should prioritize longitudinal studies, larger sample sizes, comprehensive intake data collection, and age-specific investigations to improve our understanding of cannabis-related health effects.

In a study on the health status of cannabis addicts following treatment, their vital signs improved, blood glucose levels decreased, and liver function showed changes; however, oxidative stress biomarkers were unchanged (Siwar et al., 2023). In a study assessing the health status of cannabis addicts, body function impairment because of drug use was observed; however, after treatment, vital signs showed improvement (Mohammed et al., 2024).

Recent studies highlight the increasing use of electronic cigarettes, including those containing cannabis extracts, which pose significant health risks. Research has found that vaping marijuana is linked to more severe respiratory symptoms compared to vaping or smoking nicotine (Holt et al., 2024). A study conducted in Saudi Arabia found a notable prevalence of e-cigarette use among the general population, with many users unaware of the associated risks (Alzahrani et al., 2021). This emerging trend requires further research to understand its prevalence and impact. Therefore, it is crucial to conduct future research on electronic cigarette preparations, especially among addicts, to enhance our knowledge of drug use via electronic cigarettes.

3.6 Heroin

Heroin addiction is a multifaceted and poorly understood challenge with both social and medical repercussions. Beyond the often-exaggerated socioreligious stigma, heroin addiction can result in life-threatening medical problems, including systemic infections, thrombophlebitis, deep vein thrombosis, hepatitis, HIV, acute pulmonary edema, rhabdomyolysis, renal failure, and accidental or deliberate overdose with a potential fatality (Al-Asmari et al., 2023, Osman and Shawoosh, 2003).

In 2003, Osman and Shawoosh (Osman and Shawoosh, 2003) raised a critical issue concerning heroin intoxication. Despite the short six-month duration, King Fahad General Hospital in Jeddah reported 48 patients (including 3 females) with at least 67 serious medical complications resulting from heroin addiction. This study indicates that heroin addiction is a significant problem in Saudi Arabia, particularly in Jeddah city, and it extends beyond behavioral aspects. Although these patients sought treatment at the hospital, further well-controlled epidemiological studies are needed to assess the full scale of this issue and establish effective preventive measures.

Since 2003, heroin abuse has gradually increased; however, documented cases remain limited. The media has played an important role in educating society (Al-Asmari et al., 2023); however, heroin continues to be the archetype of addiction. Despite the emergence of other stimulants, heroin has remained a significant problem during this period. The lack of reports and epidemiological studies may stem from ethical considerations and a persistent focus on examining “Captagon” and alcohol abuse. Initial studies specifically addressing heroin addiction emerged in 2020, with a primary focus on postmortem cases in Jeddah (Al-Asmari, 2020a).

Before 2020, reported cases of heroin use faced challenges because of limitations in upgrading local poison control centers with modern instrumentation. To confirm heroin use, sophisticated tools and expert opinions are required. Most previous cases have relied primarily on self-reporting or the discovery of syringes and heroin-related paraphernalia; however, in laboratory settings, the detection of heroin biomarkers is a complex process that requires time to establish, especially considering cross-reactivity issues that occur with other opiates and opioids commonly prescribed in Saudi Arabia. In a previous report from Dammam, postmortem cases revealed that nearly 50 % of the total overdose cases were attributed to opiates (116 out of 191 deaths between 1990 and 1997). Interestingly, the authors specifically reported morphine and codeine concentrations (Elfawal, 1999).

In the first epidemiological study investigating heroin-related fatalities in Saudi Arabia, the Middle East, and the North African region (Al-Asmari et al., 2023), researchers focused on Jeddah. Over 10 years (from January 2008 to July 2018), they reviewed 97 heroin-related deaths. Most of these deceased were heroin-dependent abusers from a middle-aged group. The study found that the rate of heroin-related deaths in Jeddah remained stable, but increased slightly toward the end of the study period.

Epidemiological studies on SMD in Saudi Arabia often discuss heroin abuse; however, the findings vary even within the same city and hospital. Previous studies lacked direct communication with addiction centers and primarily rely on published papers, with some authored by non-Saudis. For example, a study from Dammam over two decades revealed a decrease in heroin abuse among Al-Amal Hospital admitted patients (from 51 % to 15 % between 1986 and 2006) (AbuMadini et al., 2008), whereas another study by Bassioni in 2013 found heroin abuse among Saudi patients in addiction treatment settings, with a prevalence ranging from 7 % to 84 % (Bassiony, 2013). Interestingly, Ibrahim’s study reported no heroin abuse in the Al-Qassim region (Ibrahim et al., 2018). Al-Asmari’s research was based on a test of 1000 postmortem blood samples in Jeddah. Heroin was identified as the second most abused substance (Al-Asmari, 2020b). Although some data on heroin abuse is now available because of increased medical reporting and patient outcome histories, further studies are needed to draw conclusive findings regarding heroin abuse in Saudi Arabia. Therefore, linking Erada (Al-Amal Hospital) to the national database and creating an annual report on the prevalence of addiction for each substance of abuse would be beneficial.

3.7 Other Unveiled SMD

3.7.1 Methamphetamine

Methamphetamine “Shabu” abuse is a significant problem in Saudi Arabia. Epidemiological studies revealed an alarming increase in methamphetamine-related deaths, with approximately 40 % of the cases involving violence (Al-Asmari et al., 2024), based on a trend noted by the UNODC (United Nation Office on Drugs and Crime, 2022). In addition, cases of methamphetamine intoxication have been reported; however, an examination of the broader Middle East and North Africa (MENA) region revealed the existence of a persistent data gap. Among the 13 MENA countries reporting drug seizures to UNODC, methamphetamine remains a significant concern. Studies are needed to address this important issue and inform preventive measures (Al-Asmari et al., 2024). The staggering surge in methamphetamine-related deaths in Saudi Arabia, which has experienced over a 500 % increase within just three years in Jeddah city (2016–2018), underscores the pressing need for comprehensive research and preventive interventions (Al-Asmari, 2021). Unfortunately, data from postmortem cases are rarely reported in the MENA region, particularly from Saudi Arabia. Bridging this gap is necessary to effectively combat methamphetamine abuse. Parents generally possess an awareness of methamphetamine (commonly known as “Shabu”) (Ibrahiem et al., 2024).

Taken together, “Shabu” abuse is a significant problem in Saudi Arabia that affects individuals, families, and communities (Alasmari et al., 2024). Efforts to raise awareness, provide preventive education, and address addiction are essential to combat its effects on crime and public health. Awareness about “Shabu” has significantly increased, making it a major contributor to crime, even without official announcements. This is consistent with the media’s proactive efforts since the 1980 s to raise awareness about heroin risks and abuse, which resulted in decreased heroin availability in the country. Although the first reports of “Shabu”-related fatalities appeared in 2021 (Al-Asmari, 2021), a national campaign against all drugs, with a specific focus on “Shabu,” was launched in 2023 (Al-Asmari et al., 2024). This campaign appeared to crack down on drug trafficking and dealer networks, and the media played a role in promoting these efforts.

3.8 Cocaine

Cocaine is a powerful stimulant that is derived from the leaves of the coca plant, which is native to South America. It is used in the clinic as a local anesthetic, particularly in ophthalmology; however, it is also widely known for its illegal use as a recreational drug. Cocaine increases the levels of dopamine in brain circuits associated with pleasure and movement, thus creating short-term euphoria, energy, and talkativeness. However, it can also lead to dangerous physical and psychological effects, including addiction. Its use is associated with serious health risks, such as heart attack, stroke, and mental health issues.

Many studies spanning from 2008 to 2024 have examined the disorders related to the misuse of substances, including cocaine; however, the incidence of cocaine misuse remains notably lower compared with that of other drugs, or in some cases, it goes unreported, particularly in specific areas. Most findings have been reported in Riyadh and Jeddah (Alibrahim et al., 2012), and according to Bassiony, the occurrence of cocaine misuse ranges from 0.1 % to 2.3 % (Bassiony, 2013). In contrast, Kayal et al. found that 9 % of their cases (amounting to 57 cases) involved cocaine (Kayal et al., 2014), whereas a separate study at the AL-Amal Hospital in Riyadh in 2019 reported a low prevalence of only 0.4 % among patients (Aldlgan et al., 2019). The dangerous effects of combining cocaine with other strong central nervous system stimulants are underscored by a few studies from Jeddah that linked such combinations to overdose deaths involving heroin and methamphetamine (Al-Asmari, 2021, Al-Asmari et al., 2023).

Several factors may explain the rare instances of cocaine misuse in Saudi Arabia, which include rigorous drug enforcement measures, cultural and religious values that discourage their use, and the availability of other substances. The high cost and scarcity of cocaine relative to other drugs may deter its abuse. Moreover, local drug dealers may distribute drugs other than cocaine, which affects its availability. These elements combined may account for the low rates of cocaine misuse observed.

3.9 Volatile substance abuse

Volatile substance abuse involves inhaling volatile chemicals or solvents, such as glue, paint thinner, or gasoline, to achieve a psychoactive effect. These substances result in intoxication, hallucinations, and serious health problems. In Saudi Arabia, there is growing awareness of this issue; however, there are a limited number of studies, and most have weak methodologies and suffer from poor quality. Inhalant use in Saudi Arabia has shown a trend over the years. Between the 1990s and 2000s, studies reported varying prevalence rates, ranging from 0.9 % to 17.9 % in patients (Bassiony, 2013). In 1993, a school-based study found that 5.3 % of male students (ages 11–14) in the Eastern region used inhalants (Al-Umran et al., 1993); however, it is important to note that no specific studies on volatile substance abuse were conducted between 2008 and 2023. One obstacle is the lack of reporting from poison control centers and emergency departments because of the complexity of the analysis methods. In addition, considering the age of users, some intoxication events may go unreported. The analysis of volatile substances in patient blood or urine samples is intricate and requires the expertise of forensic toxicologists, particularly when using gas chromatography. The availability of reference materials and reliable quantitation methods is essential for the routine analysis of volatile substances.

A comprehensive study spanning two decades in Saudi Arabia, specifically in Dammam, accumulated data from 12,743 patients admitted to Al-Amal Hospital between 1986 and 2006. During this period, 355 patients sought treatment for volatile substance abuse, with a median of 17 patients annually (AbuMadini et al., 2008). Bassioni’s 2013 estimate suggests that volatile substance users constitute 9 %–17 % of the SMD population in Saudi Arabia, based on outdated studies (Bassiony, 2013). Similarly, a review by Saquib et al. (Saquib et al., 2020) lacked a scientific foundation and relied on obsolete research. Their assertion that women are more susceptible to volatile substances because of limited access to other drugs lacks coherence. In Jeddah, two studies examined patients admitted with volatile substance abuse (sample sizes: 43 and 50), with heroin addicts serving as the control group. The results indicated a comparable age distribution between volatile substance abusers and the control group consisting of heroin addicts. The primary substances that were commonly abused were paint and glue. Abnormal urine analysis results indicated potential renal problems (Omer and Ezzat, 1999). These findings emphasize the need for accurate and current data in this field.

3.10 Methanol

Methanol (methyl alcohol) causes severe intoxication, metabolic acidosis, and visual impairment. In Saudi Arabia, where alcohol consumption is prohibited for religious and health reasons, multiple methanol poisoning outbreaks occurred during the COVID-19 pandemic. Because of disruption in access to regulated alcoholic beverages, increased consumption of unregulated alternatives contaminated with methanol likely occurred (Alhusain et al., 2024). Methanol poisoning or abuse is often overlooked in Saudi Arabia because of religious, cultural, and social norms. In many cases, patients with mild symptoms avoid seeking treatment out of fear of legal repercussions. Unfortunately, some patients experience worsening symptoms, which results in permanent vision loss (Alqurashi et al., 2023).

Two outbreaks of methanol poisoning in Riyadh were retrospectively analyzed. Common symptoms, such as nausea, vomiting, altered consciousness, and visual disturbances were reported. Prompt diagnosis and timely treatment, which include combined fomepizole therapy and hemodialysis, are critical for mitigating mortality and minimizing the chronic visual sequelae associated with methanol poisoning (Eskandrani et al., 2022). A case study series in Saudi Arabia identified severe metabolic acidosis and visual impairment among patients who consumed alcohol containing methanol. These incidents occurred in several cities, including Jeddah (Alqurashi et al., 2023) and Taif (Alqurashi et al., 2023). Unfortunately, underreporting is prevalent in many regions because of cultural factors and lack of awareness. Research is essential to improve prevention and management strategies for this important public health issue.

3.11 Codeine

Codeine is a prescription drug in Saudi Arabia, typically formulated in low concentrations and often combined with paracetamol, which reduces the likelihood of intoxication or abuse. However, the potential for misuse and its impact on work and family life cannot be ignored, especially when used recreationally or for self-medication in higher doses or for longer periods than prescribed, where the risks outweigh the benefits (Al-Asmari et al., 2023, Algarni et al., 2022, Ali et al., 2023, Syed et al., 2023). Recent discussions have highlighted the general effects of codeine abuse on work and family dynamics, referencing global studies for context. (Syed et al., 2023) report that physicians have expressed concerns about the accessibility and misuse of codeine, which is frequently prescribed in combination with paracetamol. There is a lack of data on codeine addiction patterns in Saudi Arabia, underscoring the need for better regulation and monitoring of codeine prescriptions.

3.12 Psychotropics and hypnotics

Benzodiazepines are a broad class of drugs commonly prescribed to manage anxiety, sleep disorders, and epileptic seizures because of their calming and sleep-inducing properties; however, the risk of addiction and misuse is high, particularly when taken recreationally or without medical guidance. Improper use can result in addiction, withdrawal challenges, and serious long-term effects (de la Iglesia-Larrad et al., 2020). Often abused alongside opioids and alcohol, benzodiazepine misuse amplifies these dangers and has resulted in a surge in emergency room visits and deaths (Ford and Carnwath, 2021, Rintoul et al., 2013). Individuals who inject drugs consume benzodiazepines for various purposes, such as to amplify the euphoric effects of heroin or other opioids, alleviate anxiety, or mitigate the symptoms associated with withdrawal (Jones et al., 2012).

In Saudi Arabia, benzodiazepines are regulated substances, which makes access to these drugs challenging (Saudi Food and Drugs Authority, 2019). Consequently, smuggling across borders occurs, and some of these drugs may be counterfeit and contain ingredients that differ from the original formulation. In addition, the dosage of these smuggled tablets can vary, being either lower or higher than the standard amount.

Benzodiazepine abuse is a factor in many deaths in Saudi Arabia. Although these deaths are not solely attributed to benzodiazepines, their contribution to the fatalities should be considered (Al-Asmari, 2021, Al-Asmari et al., 2023, Al-Asmari and Al-Amoudi, 2020). Unfortunately, detailed data on the scope of benzodiazepine abuse or the most abused type of drugs is scarce. Bassiony estimated that the prevalence of benzodiazepine misuse is between 0.5 % and 14.2 %, based on studies conducted up to 2013 (Bassiony, 2013).

Al-Asmari et al. found that alprazolam was present in 4 out of 15 polydrug overdose cases in Saudi Arabia in 2018. These involved drugs, such as heroin and methamphetamine, suggesting increased black-market circulation (Al-Asmari et al., 2023). In addition, the increase in methamphetamine-related deaths in Jeddah indicates widespread alprazolam abuse (Al-Asmari, 2021), possibly because of prescription leaks or illegal sales. Other reports have identified chlordiazepoxide, diazepam, oxazepam, and temazepam (Al-Asmari, 2019, Al-Asmari and Al-Amoudi, 2020). Because of the global emergence of synthetic benzodiazepines (Marland et al., 2024), toxicologists are urged to update their analytical methods from broad immunoassays to more precise techniques, such as low-resolution LC-MS/MS/GC-MS, or high-resolution LC-MS or GC-MS, to document the extent of benzodiazepine abuse, which often goes undetected because of inadequate testing (Gerona and French, 2022, Rossi et al., 2021).

Psychotropics and hypnotics are classes of medications used for treating mental health disorders and sleep-related issues, such as schizophrenia, depression, or sleep induction. However, there are complex challenges associated with prescribing these medications, including the risk of misuse, abuse, dependence, and addiction. This is further complicated by the emergence of new psychoactive substances (NPS), which has changed the landscape of drug abuse and highlights the need for monitoring through pharmacovigilance studies. The misuse of these substances for non-medical purposes can result in serious health complications and contribute to the increasing problem of SMD (Chiappini et al., 2021).

In both current and past reviews of substance abuse disorder in Saudi Arabia (AbuMadini et al., 2008, Al-Jerani et al., 2019, Bassiony, 2013, Ibrahim et al., 2018), the problems associated with antipsychotics and hypnotics have not received significant attention. This lack of attention may stem from inadequate analytical methods for these drugs. Although they are regulated in Saudi Arabia (Saudi Food and Drugs Authority, 2019) and have not been linked to accidental harm or reported in the media, they frequently appear in postmortem studies of fatalities (Al-Asmari, 2019, Al-Asmari et al., 2023). Detecting these substances is necessary for differentiating between natural and accidental deaths. Therefore, these drugs should be included in therapeutic drug monitoring lists, which can be done through LC-MS techniques. Epidemiologists, psychiatrists, and scientists are urged to conduct studies on these drugs to provide insight into their involvement in SMD.

3.13 Pregabalin

Pregabalin, also known as Lyrica, is often prescribed to manage nerve pain related to chronic conditions, such as diabetes and herpes zoster. Recently, it was regulated as a controlled drug in Saudi Arabia because of reported cases of misuse (Saudi Food and Drugs Authority, 2019). In the Aseer region of Saudi Arabia, a survey was conducted by community pharmacists to assess their awareness of pregabalin misuse and abuse. In the past six months in that study, two-thirds of the participants (66.0 %) were suspicious of pregabalin abuse. The majority of those suspected abusers were male (80.1 %). Nearly one-fifth (19.4 %) indicated that pregabalin was being demanded without a prescription. This suggests the need for immediate enhanced surveillance and stricter control measures to curb abuse. Nonetheless, the results are localized to the Aseer region and may not accurately reflect the situation across the entire kingdom (Alshahrani et al., 2021b).

In Jeddah, multiple autopsy reports have not specifically implicated pregabalin abuse in related deaths; however, it has been identified alongside toxic substances, such as heroin and methamphetamine, suggesting its misuse in these cases (Al-Asmari, 2021, Al-Asmari, 2020b, Al-Asmari et al., 2023).

3.14 New psychoactive substances

A variety of synthetic substances, known as new psychoactive substances (NPS), are engineered to imitate the effects of traditional illegal drugs, such as stimulants, hallucinogens, opioids, and cannabinoids. A primary reason for NPS usage is to circumvent drug screenings while achieving effects, such as conventional drugs. Unfortunately, NPS can result in unpredictable and sometimes toxic pharmacological reactions. This issue has become increasingly global as the variety of NPS compounds has surpassed 1200, with a rapid turnover in the market (United Nation Office on Drugs and Crime, 2022, United Nation Office on Drugs and Crime, 2024). For example, once an NPS is identified and regulated, it is often replaced by a new variant with similar characteristics, which is often more potent and even lethal (Al-Asmari, 2024). Remarkably, there has been only one documented case in Saudi Arabia with confirmed NPS detection. Aldubayyan and colleagues discovered that 5.8 % of their tested samples were positive for at least one of the substances they were testing for, specifically mephedrone and N-ethylpentylone, along with their dihydro-metabolites (Aldubayyan et al., 2022). This marked the inaugural documentation of NPS consumption in Saudi Arabia and has raised concerns regarding designer stimulant drugs.

Drug scarcity in Saudi Arabia is an issue that has prompted a deeper inquiry. Are drugs truly absent or is it a matter of inadequate detection capabilities? Addressing this requires thorough studies (Al-Asmari et al., 2024). Forensic toxicologists in Saudi Arabia can assist by testing for NPS in various samples using advanced technologies to bypass the lack of reference standards. This approach will significantly enhance education and awareness, and potentially save lives during drug-related emergencies.

3.15 Tobacco

Tobacco use is a major global health issue, resulting in approximately 7 million global deaths annually, including 70,000 in Saudi Arabia (Asma et al., 2015). The link between cigarette smoking and long-term SMD outcomes has been examined and has revealed significant associations with SMD relapse. Weinberger et al. analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions, which focused on 5,515 adults with remitted SMDs (Weinberger et al., 2017). They found that continued smoking among initial smokers and new smoking initiation among initial non-smokers significantly increased the risk of SMD relapse. This suggests that smoking cessation could improve long-term SMD outcomes.

A study by Tobaiqy et al. (Tobaiqy et al., 2021) surveyed 666 university students and staff in Jeddah and found that 10.8 % were current smokers. Significant challenges to quitting included withdrawal symptoms (37.8 %) and addiction (34.8 %), whereas extrinsic factors were less significant. Many respondents were asked about smoking by healthcare professionals (83.3 % staff, 71.1 % students), and face-to-face counseling was considered helpful (75.0 % staff, 34.5 % students). These findings emphasize the need for healthcare practitioners to prioritize smoking cessation efforts.

A systematic review by Tobaiqy et al. (Tobaiqy et al., 2020) examined the attitudes toward smoking cessation in Saudi Arabia. They noted that challenges persist despite solid support from the Ministry of Health, Saudi Arabia, for education programs and policies to reduce secondhand smoke. Therefore, integrating smoking cessation into substance abuse treatment may be beneficial for improving long-term outcomes.

To effectively combat substance abuse, Saudi Arabia requires a multifaceted approach that includes prevention, treatment, and policy intervention. Evidence-based prevention programs tailored to the cultural and social context of the kingdom, accessible treatment services, and supportive policies are important components of a comprehensive strategy to mitigate the adverse effects of substance abuse (Babor et al., 2010).

4 Discussion

This review comprehensively analyzes the findings of 43 studies to provide an assessment of SMD across various cities in Saudi Arabia. The analysis encompassed a diverse demographic spectrum, including youths, healthy individuals, mental health patients, the general population, and case studies of deceased individuals. These studies collectively provide insight into the multifaceted nature of substance abuse within the country.

The increase in Substance Misuse Disorder (SMD) in Saudi Arabia can be partly attributed to drug smuggling from neighboring countries such as Syria, Lebanon, and Yemen, which are plagued by mafia activities and conflict. This situation mirrors the influence of Colombian cartels on the U.S. drug market, as detailed in studies by Garcés (2005) (Garcés, 2005) and Ibáñez de Foerster (2013) (Ibáñez de Foerster, 2013), which highlight the connection between organized crime and drug trafficking. Benítez (2019) (Benítez, 2019) further maps the extensive counternarcotics networks in Latin America, illustrating the global reach of these criminal organizations. Additionally, Ciccarone et al. (2009) (Ciccarone et al., 2009) discuss the impact of South American heroin on the U.S. market, emphasizing how structural factors and international partnerships contribute to the spread of drug use. The most detected drug in Saudi Arabia is amphetamine, specifically Captagon, and the country is a primary destination for drug smugglers from Syria and Lebanon, as noted in the World Drug Report (United Nation Office on Drug and Crime, 2023). By understanding these parallels, we can better comprehend the complex dynamics that contribute to the rise of SMD in Saudi Arabia despite religious prohibitions.

Because of the rising prevalence of Captagon smuggling and the surge in violent incidents related to “Shabu”, Saudi Arabia has embarked on a nationwide campaign against drug abuse (Al-Asmari et al., 2024). The initiative targets drug traffickers and dealers aggressively and has resulted in increased drug seizures at border crossings and during security operations. The primary focus is to combat the flow of the highly dangerous and “Shabu”, which poses significant health risks. Raising awareness about the dangers of “Shabu” and other hazardous substances remains a priority, with education as the most potent weapon against these hidden adversaries (Al-Asmari, 2021).

In a study conducted in the Al-Qassim region of Saudi Arabia (Ibrahim et al., 2018), substance abuse patterns, and sociodemographic characteristics were evaluated among patients attending a local rehabilitation center. The study found that most patients (73 %) were aged 21–40. Polysubstance abuse was prevalent (60 %), particularly among 20–40-year-olds (45 %) and patients with lower levels of education (41 %). On average, polysubstance abusers used 2.5 drugs (maximum 6). Interestingly, there was no significant relationship between a family history of drug abuse and mental illness. It is also observed an increase in polysubstance and amphetamine use, although prescription drug abuse appeared to decrease. In addition, the prevalence of heroin and alcohol abuse declined. Although this information is significant for the region, Saudi Arabia is a large country with diverse cultural and sociodemographic characteristics. Interestingly, no opioid use in the Al-Qassim region was found, whereas they were the second most-encountered drug in Jeddah city (Al-Asmari, 2020b). This underscores the importance of conducting further epidemiological studies to identify drug-related disorders among the Saudi population. The same group identified consistent methamphetamine concentrations in postmortem analyses in 2024 (Alasmari et al., 2024).

Stimulants and cannabis are the most abused drugs during adolescence because of their availability and peer influence. Early substance use increases the risk of future substance use disorders, cognitive impairment, mental health issues, and criminal behavior (Marshall, 2014). In Saudi Arabia, peer pressure, family dynamics, and social stressors are factors that contribute to adolescent substance use. One study found that smoking typically begins before age 15, drinking before age 20, and drug use as early as age 14, although the sample size was limited to 400 male high school students (Alenazi et al., 2023).

SMD is a growing concern in Saudi Arabia. Although a limited number of reports exist, recent studies have compared medical records in postmortem cases between 1999 (Elfawal, 1999) and 2018 (Al-Asmari et al., 2023), revealing a 24 % increase in the availability of medical history regarding SMD. Young adults (aged 12–22) are particularly affected, and sociocultural factors play a significant role. Despite the religious and legal prohibition, alcohol abuse remains a concern; however, research gaps persist, necessitating further studies to address substance use disorders effectively and to promote public health awareness (Alenazi et al., 2023, Alharbi et al., 2023, Saquib et al., 2020).

4.1 Geographic impact on substance use disorder reporting

The study highlights significant trends and challenges related to SMD across major cities in Saudi Arabia, particularly Jeddah and Riyadh (Al-Asmari, 2020b, Alodhayani et al., 2022, Bassiony, 2013). Although data were scarce for the Eastern, Central, North, and South regions, most of the available information was from Jeddah, Riyadh, Dammam and Jazan. Notably, publications from Jazan covered the traditional abuse of khat (Alshahrani et al., 2021a, El-Setouhy et al., 2019, Hakami et al., 2021, Awadalla and Suwaydi, 2017) and there were also reports from the Al-Qassim (Qureshi and Al-Habeeb, 2000) and Najran (Mehdar and Alrafiah, 2021, Wahba et al., 2021) and Eastern (AbuMadini et al., 2008, Ramadan et al., 2023) regions; however, the findings from these areas differed from those of the other major cities. Interestingly, cities such as Tabuk, Al-Baha, and Al-Taif, which are also considered major cities in Saudi Arabia, had no reported SMD data. The study found a prevalence of substance abuse, with opioids, amphetamines, and cannabis being the most abused substances (Al-Asmari, 2020b, Al-Asmari et al., 2022, Alodhayani et al., 2022, Bassiony, 2013).

It is not surprising that limited information is reported from some major cities, while more robust data is available from cities such as Jeddah, Riyadh, and Dammam. Several factors contribute to this disparity. First, the presence of psychiatric and rehabilitation hospitals in these cities has facilitated SMD research and reporting. In addition, the availability of poison control centers and universities in these cities facilitates data collection from healthcare providers and collaboration with scientists. Some cities lacked academic universities and poison control centers until a decade ago, which may have hindered research efforts in those specific regions.

4.2 Risk factors and influence

In studies focused on SMD in adolescent students, several risk factors and influences have been identified. These risk factors include impulsivity, emotional regulation impairment, previous e-cigarette exposure, low-perceived risk, and positive attitudes toward synthetic drugs. In addition, family factors, such as prenatal maternal smoking and substance-using family members, play a significant role. Peer pressure is also noteworthy. Conversely, protective factors encompass optimism, mindfulness, strong beliefs against substance abuse, and religious convictions (Aldlgan et al., 2019, Al-Haqwi, 2010, Alibrahim et al., 2012, Al-Jerani et al., 2019, Saquib et al., 2020). Therefore, educating students and raising health awareness are essential preventive measures (Saquib et al., 2020). High dependency rates were associated with an increased risk of psychotic symptoms, particularly among adolescent drug users. The risk of psychotic symptoms varied significantly across different substances (Alibrahim et al., 2012).. Early initiation of smoking and drug use among adolescents highlights the need for robust intervention and education programs. In addition, integrating smoking cessation into substance abuse treatment will help to reduce relapse rates (Alenazi et al., 2023, Al-Jerani et al., 2019).

4.3 Prevalence and patterns

Substance use is a significant issue, with a varying prevalence associated with different substances. Captagon, “Shabu”, alcohol, opioids, and cannabis are the most reported drugs (AbuMadini et al., 2008, Al-Jerani et al., 2019, Bassiony, 2013). Although some studies indicate that a notable shift in substance abuse patterns was observed, the postmortem cases were considered the result of mono-drug intoxication (Al-Asmari, 2021), with an increase in polysubstance and amphetamine abuse, and a decline in the abuse of prescription drugs (Ibrahim et al., 2018), heroin, and alcohol (Al-Jerani et al., 2019, Ibrahim et al., 2018). Although cannabis was thought to be highly used among older patients, Captagon was highly abused in young patients. With respect to drug effects and fatalities, the increase in “Shabu” deaths cannot be ignored (Al-Asmari et al., 2024, Al-Asmari, 2021). Although khat was not associated with deaths, the financial and health-related consequences are evident (Kayal et al., 2014, Shaikhain et al., 2023).

Almarhabi et al. reported a high rate of driving under the influence of amphetamines and alcohol in Jeddah (Almarhabi et al., 2018). Al-Haqwi (2010) found that 75 % of medical students in Riyadh believed substance abuse was prevalent (Al-Haqwi, 2010). Alenazi et al. (2023) revealed that 27.8 % of male high school students in Riyadh reported smoking and had begun at an early age (Alenazi et al., 2023). Alibrahim et al. (2012) identified significant dependency rates and psychotic symptoms among adolescent drug users in Jeddah (Alibrahim et al., 2012). In addition, Alageel et al. (2023) found that cannabis was the most frequent substance used among patients with medical issues in Riyadh (Alageel et al., 2023). Finally, a scoping review by Saquib et al. (2020) emphasized the need for more robust, gender-inclusive research on substance use disorders in Saudi Arabia (Saquib et al., 2020).

Cocaine is rarely reported as an SMD in patient samples, however, few cases were indirectly reported in combination with other CNS depression drugs, such as heroin and methamphetamine in postmortem cases. This indicates that in most cases, other drugs were suspected and cocaine may be overlocked (Al-Asmari, 2021, Al-Asmari et al., 2023). Cocaine reported in Jeddah postmortem cases in combination with heroin and other drugs suggest that cocaine users are considered polypharmacy drug abusers. In fact, drugs such as pregabalin also share the same trend as cocaine. Al-Asmari reported that heroin was present in 13 out of 32 cases of methamphetamine-related deaths (Al-Asmari, 2021). Alprazolam, which is classified as a controlled drug in Saudi Arabia, has no information regarding the abuse drug map in Saudi Arabia, although it is commonly found in seized materials at poison control centers in Saudi Arabia. In a report in 2018 involving 15 cases of heroin-related fatalities, alprazolam was detected (Al-Asmari et al., 2023). This study referred to an increase in the black market, and the same observation was reported in Victorian Heroin-Related Deaths (Rintoul et al, 2013).

4.4 Challenges in studying SMD

Another factor affecting the reporting of SMDs is the ethical approval process for conducting such studies. In a country where SMDs are often viewed as sensitive and potentially dishonest information, researchers face significant barriers and obstacles when studying this issue. The majority of reported cases stem from questionnaires and literature reviews (Al-Jerani et al., 2019, Bassiony, 2013, Ibrahim et al., 2018, Saquib et al., 2020, Siddiqui and Salim, 2016), with limited data available from direct communication with individuals affected by SMDs (Aldlgan et al., 2019).

4.5 Strengths and limitations

This study provides an extensive evaluation of various studies across Saudi Arabia, offering an expansive view of the substance abuse landscape. It encompasses a wide array of demographics, including young individuals, students, mental health patients, the general public, and cases of deceased individuals, thereby broadening our understanding of substance-related issues. The evidence-based suggestions in the present study are designed to inform healthcare professionals and decision-makers on crafting focused interventions and policies. It highlights the principal risk factors and obstacles associated with SMD, shedding light on areas for future studies and intervention methods.

Alternatively, the study encountered challenges, such as inconsistent data, limited applicability to certain groups, biases inherent in self-reported information, and time constraints that may not capture the evolving trends in SMD. The reliance on published reports may also neglect unpublished or non-mainstream literature, and a focus on particular substances may not fully represent all types of substance abuse in the area. Despite these hurdles, we strived to provide a comprehensive and insightful analysis that contributes to the reduction of substance abuse in Saudi Arabia.

4.6 Recommendations

To effectively address substance abuse in Saudi Arabia, healthcare professionals and policymakers must establish multifaceted strategies focused on prevention, early intervention, and comprehensive treatment. Key recommendations include enhancing education programs targeting adolescents, as early initiation significantly increases the risk of developing SMDs (Alenazi et al., 2023). In addition, regular training for healthcare providers on emerging substance abuse trends, particularly the rise in “Shabu” and polysubstance use, is essential. Incorporating routine substance use screenings into clinical assessments will facilitate early identification and intervention (Alageel et al., 2023). Developing specialized protocols to manage psychotic symptoms associated with substance dependency, particularly in adolescents, can improve outcomes (Alibrahim et al., 2012). Policymakers should conduct national surveys to gather accurate data on substance use and abuse patterns and support integrated treatment programs for multiple substance dependencies. Establishing comprehensive mental health services and promoting healthy lifestyle choices will help to mitigate risk factors (Saquib et al., 2020).

Furthermore, the rise in substance abuse necessitates stricter drug laws and enforcement, along with more comprehensive policies to control the distribution and use of prescription medications. There is a need to establish a national database to monitor substance abuse trends and the effectiveness of interventions (Al-Asmari et al., 2024). These combined efforts will help to develop effective interventions and policies to combat the growing challenge of substance abuse in Saudi Arabia.

5 Conclusions

This study highlights the significant and multifaceted issues of substance abuse in Saudi Arabia, emphasizing the need for targeted and culturally relevant interventions. The prevalence of substance use among various demographics underscores the importance of early prevention and comprehensive treatment strategies. Overall, our findings suggest that coordinated efforts between healthcare professionals and policymakers are necessary to effectively reduce substance abuse and its associated health and social consequences. By addressing both intrinsic and extrinsic factors and enhancing support systems, Saudi Arabia can make significant strides in mitigating the impact of substance abuse. Comprehensive and culturally tailored strategies involving healthcare professionals and policymakers are essential to effectively address and mitigate the impact of substance abuse in Saudi Arabia.

CRediT authorship contribution statement

Mansour Tobaiqy: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Ahmed I. Al-Asmari: .

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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