substance use disorders

SUBSTANCE USE DISORDERS

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Dr. HARTATI KURNIADI Sp.KJ (K).,MHA

ETIOLOGY OF SUBSTANCE USE DISORDER

SUBSTANCE

- EFFECT

- PRICE

- EASY TO GET

ENVIRONMENTAL INDIVIDUAL

FACTORS FACTORS - PEER GROUP - PERSONALITY

- FAMILY INTERACTION - MENTAL ILLNESS

- Genetic

THE QUICKEST WAY TO THE BRAIN

METHOD TIME TO BRAIN1. SMOKING 7– 10 SECONDS2. INJECTING : - IV 15 – 30 SECONDS - IM 3 – 5 MINUTES3. SNORTING 3 – 5 MINUTES4. CONTACT : - EYE 3 – 5 MINUTES - SKIN & OTHER 15 – 30 MINUTES

5. INGESTING 20 – 30 MINUTES

PREVENTION OF RELAPSE

PSYCHOACTIVE SUBSTANCE DEPENDENCESPECIFIC TREATMENT INDIVIDUAL FACTORSDRUG TREATMENT MOTIVATIONCOUNSELING SOCIAL SUPPORTSRESIDENTIAL EXTENT OF PHYSICAL ANDREHABILITATION PSYCHOLOGICAL DAMAGE PAST EXPERIENCE OF TREATMENT PREPARED TO ATTEND SELF- HELP GROUPS, VOLUNTARY ORGANIZATION

LIFELONG ABSTINENCEFROM PSYCHOACTIVE SUBSTANCE

DATA KASUS NARKOBA DI INDONESIASELAMA 5 TAHUN TERAKHIR (1998 – 2002)

No. Pekerjaan 1998 1999 2000 2001 2002 Jumlah

1. PNS 12 21 36 39 29 137

2. Polri/TNI 6 10 37 6 33 92

3. Swasta 357 698 1268 1228 1639 5190

4. Wiraswasta 265 423 669 769 619 2745

5. Petani 90 95 154 127 91 557

6. Buruh 149 263 569 833 554 2368

7. Mahasiswa 61 127 260 202 241 891

8. Pelajar 35 105 206 141 145 632

9. Pengangguran 333 848 1756 1579 1668 6184

J U M L A H : 1308 2590 4955 4924 5019 18769

DATA KASUS NARKOBA DI INDONESIA SELAMA 5 TAHUN TERAKHIR (1998 – 2002)

(BERDASARKAN PEKERJAAN TERSANGKA)

NO PEK. Thn

Jml

1998

%

Thn

Jml

1999

%

Thn

Jml

2000

%

Thn

Jml

2001

%

Thn

Jml

2002

%

1. PNS 12 0,92 21 0,81 36 0,72 39 0,79 29 0,5

2. POLRI 6 0,46 10 0,39 37 0,75 6 0,12 33 0,66

3. SWASTA 357 27,29 698 26,95 1268 25,59 1228 24,94 1639 32,66

4. WRSWT 265 20,26 423 16,33 669 13,50 769 15,62 619 12,33

5. PETANI 90 6,88 95 3,67 154 3,11 127 2,58 91 1,81

6. BURUH 149 11,39 263 10,15 569 11,48 833 16,92 554 11,04

7. MHSW 61 4,66 127 4,90 260 5,25 202 4,10 241 4,80

8. PELAJAR 35 2,68 105 4,05 206 4,16 141 2,86 145 2,89

9. PENGANGGURAN

333 25,46 848 32,74 1756 35,44 1579 32,07 1668 33,23

JML 1308 100 2590 100 4955 100 4924 100 5019 100

DRUG USE DISORDER

• DRUG DEPENDENCE HAS MULTIPLE ORIGINS, WITH A MIX OF PHARMACOLOGICAL, PSYCHOLOGICAL, SOCIAL, AND CULTURAL DETERMINANTS.

• DIFFERENT MODELS OF DRUG USE WILL LEAD TO DIFFERENT PREVENTION AND TREATMENT APPROACH.

• PARTICULAR PATTERNS OF DRUG USE AND DRUG-RELATED HARM ARE A PRODUCT OF THE SOCIAL, CULTURAL, AND ECONOMIC CONTEXT OF USE, AS WELL AS OF THE PHARMACOLOGICAL AND TOXICOLOGICAL PROPERTIES OF DRUG ITSELF.

ASSESSMENT & DIAGNOSIS

A. ANAMNESIS 1. NAME OF EACH DRUG

EVER USED2. CURRENT USE3. PAST USE4. DRUG(S) OF CHOICE5. MOST PROBLEMATIC

DRUG6. PURPOSE AND MEANING

OF THE SUBSTANCE USE FOR CLIENT

7. FAMILY HISTORY

8. TREATMENT HISTORY

9. ASSESS RISK-TAKING

BEHAVIOUR

10.ASSESS MOTIVATION FOR

CHANGE

B. ALLOANAMNESIS

C. EXAMINATION

1. GENERAL

2. PSYCHIATRY

D. LABORATORY TESTS

CENTRAL NERVOUS SYSTEM STIMULANT USE DISORDERS

1. COCAINE AND AMPHETAMINE ARE CNS STIMULANTS.

2. CNS STIMULANTS CAN CAUSE TRANSIENT PSYCHOSIS (e.g., “COKE BUGS” OR PARANOIA).

3. WITHDRAWAL SYMPTOMS (FATIGUE, DEPRESSION, NIGHTMARES, ETC.) PEAK IN 2 TO 4 DAYS.

4. WITHDRAWAL FROM CNS STIMULANT IS SELF-LIMITED.

COCAINE OR AMPHETAMINE INTOXICATION

(CLINICAL MANIFESTATION)

1. MALADAPTIVE BEHAVIORAL CHANGES ( e.g., EUPHORIA OR HYPERVIGILANCE);

2. TACHYCARDIA OR BRADYCARDIA;3. PUPILLARY DILATATION;4. HYPER- OR HYPOTENSION;5. PERSPIRATION OR CHILLS;6. NAUSEA OR VOMITING;7. WEIGHT LOSS;8. PSYCHOMOTOR AGITATION OR RETARDATION;9. MUSCULAR WEAKNESS, RESPIRATORY DEPRESSION,

CHEST PAIN, CARDIAC DYSRHTHMIAS;

10. CONFUSION, SEIZURES, DYSKINESIA, OR COMA.

SEDATIVE, HYPNOTIC, AND ANXIOLYTIC SUBSTANCE USE

DISORDERS

1. SEDATIVE-HYPNOTIC DRUGS ARE CROSS-TOLERANT WITH ALCOHOL

2. THEY HAVE INTOXICATION EFFECTS AND RESULT IN WITHDRAWAL STATES SIMILAR TO ALCOHOL.

3. TOLERANCE CAN BE MEASURED BY A PENTOBARBITAL CHALLENGE TEST.

4. TREATMENT RESEMBLES THAT FOR ALCOHOLISM.

SIGNS AND SYMPTOMS OF SEDATIVE-HYPNOTIC WITHDRAWAL

MINOR WITHDRAWAL MORE SEVERE WITHDRAWAL

RESTLESSNESS COARSE TREMORS

APPREHENSION WEAKNESS

ANXIETY VOMITING

SWEATING

HYPERREFLEXIA

NAUSEA

ORTHOSTATIC HYPOTENSION

SEIZURES

ALCOHOL-RELATED DISORDERS1. IN ALCOHOL DEPENDENCE, DENIAL AND MINIMIZATION ARE

COMMON.2. WITHDRAWAL AND DELIRIUM TREMENS ARE TREATED WITH

BENZODIAZEPINES.3. PEAK INCIDENCE OF ALCOHOLIC SEIZURES IS WITHIN 24 TO 48 HOURS.4. REHABILITATION IS AIMED AT ABSTINENCE AND TREATING

COMORBID DISORDERS.5. REHABILITATION INVOLVES AA AND GROUP AND FAMILY THERAPIES.6. FIFTY PERCENT OF TREATED ALCOHOLICS WILL RELAPSE.7. WERNICKE-KORSAKOFF SYNDROME IS DUE TO THIAMINE

DEFICIENCY.8. WERNICKE’S TRIAD CONSISTS OF NYSTAGMUS, ATAXIA, AND MENTAL

CONFUSION.9. KORSAKOFF’S SYMPTOMS ARE ANTEROGRADE AMNESIA AND

CONFABULATION.

HOSPITALIZATION IS INDICATED FOR PATIENT WHO:

• ARE AT RISK FOR DANGEROUS OR UNCOMFORTABLE WITHDRAWAL SYNDROMES (ALCOHOL, SEDATIVE-HYPNOTICS, OPIOIDS).

• HAVE MEDICAL COMPLICATION FROM INTOXICATION OR WITHDRAWAL (SUCH AS COCAINE-INDUCED ISCHEMIA OR ALCOHOL WITHDRAWAL SEIZURES).

• HAVE PERSISTING SUBSTANCE- INDUCED PSYCHOTIC SYMPTOMS AND CANNOT BE DISCHARGED TO AN ADEQUATELY SUPERVISED OUTPATIENT ENVIRONMENT.

• ARE AT RISK FOR COMPLETED SUICIDE SECONDARY TO COMORBID PSYCHOSOCIAL CONDITIONS THAT ARE COMPLICATED BY SUBSTANCE USE.

EFFECT OF DIFFERENT BACs IN NON-DEPENDENT INDIVIDUALS

BAC EFFECT0.02 to 0.03% SLIGHT INCREASES IN TALKATIVENESS; RELAXATION

0.05% IMPAIRMENT IN SOME TASKS REQUIRING SKILL

0.06 to 0.10% VERY TALKATIVE; SPEECH IS LOUDER, ACTS & FEELS

SELF-CONFIDENT. LESS CAUTIOUS AND INHIBITED

THAN USUAL. SLOWED REACTION TIME.

0.20% SEDATED RATHER THAN ACTIVE, MAY BE SLEEPY.

IMPAIRMENT NOW INCLUDES SLURRED SPEECH,

CLUMSINESS, REDUCED RESPONSIVENESS, AND

MARKED INTELLECTUAL IMPAIRMENT. AMNESIA.

0.30 to 0.40% SEMICONSCIOUS OR UNCONSCIOUS. BODY FUNCTION

ARE BEGINNING TO BREAK DOWN. FATALITIES

OCCUR AT AND ABOVE THESE CONCENTRATIONS.

TREATMENT OF DRUG ABUSE/DEPENDENCE

• A NUMBER AT DIFFERENT APPROACH ARE AVAILABLE, AND PACKAGES OF CARE SHOULD BE DESIGNED TO MEET INDIVIDUAL NEEDS.

• TREATMENT OPTIONS INCLUDE THE FOLLOWING :1. HARM REDUCTION2. PSYCHOTHERAPY3. RESIDENTIAL REHABILITATION4. MEDICAL DETOXIFICATION : i.e. - METHADONE FOR OPIATE WITHDRAWAL - BENZODIAZEPINE FOR ALCOHOL WITHDRAWAL - SYMPTOMATIC5. COLD TURKEY

TWELVE-STEP PROGRAM• STEP 1 : ADMITTED WE WERE POWERLESS OVER ALCOHOL-

THAT OUR LIVES HAD BECOME UNMANAGEABLE.• STEP 2 : COME TO BELIEVE THAT A POWER GREATER THAN

OURSELVES COULD RESTORE US TO SANITY.• STEP 3 : MADE A DECISION TO TURN OUR WILL AND OUR LIVES

OVER TO THE CASE OF GOD AS WE UNDERSTOOD HIM.• STEP 4 : MADE A SEARCHING AND FEARLESS MORAL

INVENTORY OF OURSELVES.• STEP 5 : ADMITTED TO GOD, TO OURSELVES, AND TO ANOTHER

HUMAN BEING THE EXACT NATURE OF OUR WRONGS.• STEP 6 : WERE ENTIRELY READY TO HAVE GOD REMOVE ALL

THESE DEFECTS OF CHARACTER.• STEP 7 : HUMBLY ASKED HIM TO REMOVE OUR

SHORTCOMINGS.

TWELVE-STEP PROGRAM

• STEP 8 : MADE A LIST OF ALL PERSONS WE HAD HARMED, AND BECAME WILLING TO MAKE AMENDS TO THEM ALL.

• STEP 9 : MADE DIRECT AMENDS TO SUCH PEOPLE WHEREVER IMPOSSIBLE, EXCEPT WHEN TO DO SO WOULD INJURE THEM ALL.

• STEP 10 : CONTINUED TO TAKE PERSONAL INVENTORY AND WHEN WE WERE WRONG PROMPTLY ADMITTED IT.

• STEP 11 : SOUGHT THROUGH PRAYER AND MEDITATION TO IMPROVE OUR CONSCIOUS CONTACT WITH GOD AS WE UNDERSTOOD HIM, PRAYING ONLY FOR KNOWLEDGE OF HIS WILL FOR US AND THE POWER TO CARRY THAT OUT.

• STEP 12 : HAVING HAD A SPIRITUAL AWAKENING AS THE RESULT OF THESE STEPS, WE TRIED TO CARRY THIS MESSAGE TO ALCOHOLICS, AND TO PRACTICE THESE PRINCIPLES IN ALL OUR AFFAIRS.

SUBSTANCE ABUSETHE DSM-IV DEFINES SUBSTANCE ABUSE AS A

MALADAPTIVE PATTERN OF SUBSTANCE USE LEADING TO CLINICALLY SIGNIFICANT IMPAIRMENT OR DISTRESS AS MANIFEST BY

• FAILURE TO FULFILL MAJOR ROLE OBLIGATIONS AT HOME, SCHOOL, OR WORK;

• RECURRENT SUBSTANCE USE IN SITUATIONS IN WHICH IT IS PHYSICALLY HAZARDOUS;

• RECURRENT SUBSTANCE-RELATED LEGAL PROBLEMS;• RECURRENT SUBSTANCE USE DESPITE PERSISTENT OR

RECURRENT SOCIAL OR INTERPERSONAL PROBLEMS CAUSED OR EXACERBATED BY THE EFFECTS OF THE SUBSTANCE.

SUBSTANCE DEPENDENCESUBSTANCE DEPENDENCE IS DEFINED AS A MALADAPTIVE

PATTERN OF SUBSTANCE USE LEADING TO CLINICALLY SIGNIFICANT IMPAIRMENT OR DISTRESS, AS MANIFESTED BY THREE (OR MORE) OF THE FOLLOWING :

1. TOLERANCE2. WITHDRAWAL3. REPEATED, UNINTENDED, EXCESSIVE USE4. PERSISTENT FAILED EFFORT TO CUT DOWN5. EXCESSIVE TIME SPENT TRYING TO OBTAIN THE SUBSTANCE6. REDUCTION IN IMPORTANT SOCIAL, OCCUPATIONAL, OR

RECREATIONAL ACTIVITIES7. CONTINUED USE DESPITE AWARENESS THAT SUBSTANCE IS

THE CAUSE OF PSYCHOLOGICAL OR PHYSICAL DIFFICULTIES.

MENTAL AND BEHAVIOURAL DISORDERS DUE TO

PSYCHOACTIVE SUBSTANCE USEF10.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOLF11.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDSF12.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF CANNABINOIDSF13.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICSF14.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINEF15.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINEF16.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENSF17.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF TOBACCOF18.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF VOLATILE SOLVENTSF19.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCE

FOUR CODES MAY BE USED TO SPECIFY THE CLINICAL

CONDITIONS, AS FOLLOWS :F1x.0 ACUTE INTOXICATIONF1x.1 HARMFUL USEF1x.2 DEPENDENCE SYNDROMEF1x.3 WITHDRAWAL STATEF1x.4 WITHDRAWAL STATE WITH DELIRIUMF1x.5 PSYCHOTIC DISORDERF1x.6 AMNESIC SYNDROMEF1x.7 RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDERF1x.8 OTHER MENTAL AND BEHAVIOURAL DISORDERSF1x.9 UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER

F1x.0 ACUTE INTOXICATION• A TRANSIENT CONDITION FOLLOWING THE

ADMINISTRATION OF ALCOHOL OR OTHER PSYCHOACTIVE SUBSTANCE, RESULTING IN DISTURBANCES IN LEVEL OF CONSCIOUSNESS, COGNITION, PERCEPTION, AFFECT OR BEHAVIOUR, OR OTHER PSYCHOPHYSIOLOGICAL FUNCTIONS AND RESPONSES.

• THIS SHOULD BE A MAIN DIAGNOSIS ONLY IN CASES WHERE INTOXICATION OCCURS WITHOUT MORE PERSISTENT ALCOHOL-OR DRUG-RELATED PROBLEMS BEING CONCOMITANTLY PRESENT. WHERE THERE ARE SUCH PROBLEMS, PRECEDENCE SHOULD BE GIVEN TO DIAGNOSES OF HARMFULL USE, DEPENDENCE SYNDROME OR PSYCHOTIC DISORDER.

• ACUTE INTOXICATION IS USUALLY CLOSELY RELATED TO DOSE LEVELS.

F1x.1 HARMFUL USE

• A PATTERN OF PSYCHOACTIVE SUBSTANCE USE THAT IS CAUSING DAMAGE TO HEALTH.

• THE DAMAGE MAY BE PHYSICAL OR MENTAL.

F1x.2 DEPENDENCE SYNDROME

SHOULD USUALLY BE MADE ONLY IF THREE OR MORE OF

THE FOLLOWING HAVE BEEN EXPERIENCED OR EXHIBITED AT SOME TIME DURING THE PREVIOUS YEAR:

(a) A STRONG DESIRE OR SENSE OF COMPULSION TO TAKE THE SUBSTANCE

(b) DIFFICULTIES IN CONTRLOLLING SUBSTANCE-TAKING BEHAVIOUR ;

(c) A PHYSIOLOGICAL WITHDRAWAL STATE WHEN SUBTANCE USE HAS CEASED OR BEEN REDUCED;

(d) EVIDENCE OF TOLERANCE;(e) PROGRESSIVE NEGLECT OF ALTERNATIVE PLEASURE OR

INTERESTS BECAUSE OF PSYCHOACTIVE SUBSTANCE USE;(f) PERSISTING WITH SUBSTANCE USE DESPITE CLEAR EVIDENCE

OF OVERTLY HARMFUL CONSEQUENCES.

F1x.3 WITHDRAWAL STATE

• A GROUP OF SYMPTOMS OF VARIABLE CLUSTERING AND SEVERITY OCCURRING ON ABSOLUTE OR RELATIVE WITHDRAWAL OF A SUBSTANCE AFTER REPEATED, AND USUALLY PROLONGED AND/OR HIGH-DOSE, USE OF THAT SUBSTANCE.

• THE WITHDRAWAL STATE MAY BE COMPLICATED BY CONVULSIONS.

F1x.4 WITHDRAWAL STATE WITH DELIRIUM

• A CONDITION IN WHICH THE WITHDRAWAL STATE IS COMPLICATED BY DELIRIUM.

F1x.5 PSYCHOTIC DISORDER

• A CLUSTER OF PSYCHOTIC PHENOMENA THAT OCCUR DURING OR IMMEDIATELY AFTER PSYCHOACTIVE SUBSTANCE USE AND ARE CHARACTERIZED BY VIVID HALLUCINATIONS, MISIDENTIFICATIONS, DELUSIONS AND/OR IDEAS OF REFERENCE, PSYCHOMOTOR DISTURBANCE, AND AN ABNORMAL AFFECT, WHICH MAY RANGE FROM INTENSE FEAR TO ECSTASY.

F1x.6 AMNESIC SYNDROME

• A SYNDROME ASSOCIATED WITH CHRONIC PROMINENT IMPAIRMENT OF RECENT MEMORY;

• REMOTE MEMORY IS SOMETIMES IMPAIRED, WHILE IMMEDIATE RECALL IS PRESERVED.

F1x.7 RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDER

• A DISORDER IN WHICH ALCOHOL OR PSYCHOACTIVE SUBSTANCE-INDUCED CHANGES OF COGNITION, AFFECT, PERSONALITY, OR BEHAVIOUR PERSIST BEYOND THE PERIOD DURING WHICH A DIRECT PSYCHOACTIVE SUBSTANCE-RELATED EFFECT MIGHT REASONABLY BE ASSUMED TO BE OPERATING.

ALCOHOL & SEDATIVES/HYPNOTICS CLINICAL FEATURES OF

WITHDRAWAL• AUTONOMIC INSTABILITY ( DIAPHORESIS,

ELEVATED HEART RATE, ELEVATED BP, ANXIETY)• TREMOR• N/V• INSOMNIA• PSYCHOMOTOR AGITATION• DELIRIUM WITH VISUAL, AUDITORY, OR TACTILE

HALLUCINATIONS• GENERALIZED TONIC-CLONIC SEIZURES• IRRITABILITY

ALCOHOL & SEDATIVES/HYPNOTIC

CLINICAL FEATURES OF INTOXICATION :

• DYSARTHRIA

• ATAXIA

• IMPAIRED ATTENTION OR MEMORY

• AMNESIA (BLACKOUTS)

• NYSTAGMUS

• STUPOR OR COMA

• AFFECTIVE LABILITY

• DELIRIUM OR HALLUCINOSIS MAY BE PRESENT

TREATMENT OF ALCOHOL & SEDATIVES/HYPNOTICS

DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES (e.g.,MAJOR DEPRESSION, ANXIETY DISORDERS)

• TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE.

• COGNITIVE BEHAVIORAL THERAPY FOCUSES ON UNDERSTANDING TRIGGERS, THOUGHTS, AND FEELING ASSOCIATED WITH USE.

• OPIATE ANTAGONISTS, SUCH AS NALTREXONE, 25-50 mg PO HAVE BEEN DEMONSTRATED TO REDUCE THE FREQUENCY AND SEVERITY OF RELAPSE FOR ALCOHOL DEPENDENCE.

• DISULFIRAM (ANTABUSE) IS EFFECTIVE TREATMENT FOR ALCOHOL DEPENDENCE PROVIDED COMPLIANCE CAN BE ENFORCED AND THE PATIENT IS WILLING.

TREATMENT OF ALCOHOL & SEDATIVES/HYPNOTICS INTOXICATION

• INTERRUPT USE• MONITOR VITAL SIGNS HOURLY FOR SYMPTOMS OF

WITHDRAWAL.• GASTRIC LAVAGE WITH ACTIVATED CHARCOAL MAY BE USEFUL.• SUPPORT RESPIRATION IF INTOXICATION IS SEVERE.• IV FLUID REPLACEMENT MAY BE NECESSARY IF THE PATIENT

HAS BEEN VOMITING OR IS OTHERWISE UNABLE TO TAKE PO FLUIDS.

• PLACE PATIENT IN A QUIET, CONTROLLED ENVIRONMENT WITH REDUCED SENSORY STIMULATION.

• LOW-DOSE, HIGH-POTENCY ANTIPSYCHOTICS MAY BE USED TO CONTROL SUBSTANCE-INDUCED PSYCHOSIS.

• GIVE THIAMINE, 100-200 mg IV, BEFORE GLUCOSE ADMINISTRATION (ALCOHOL USE).

TREATMENT OF ALCOHOL & SEDATIVES/HYPNOTICS WITHDRAWAL

• MONITOR VITALS FREQUENTLY AT FIRST

• USE BENZODIAZEPINES.

• CONSOLIDATE PRN DOSE FROM THE FIRST 24 HRS INTO A SCHEDULED DOSE TO BE TAPERED OVER THE NEXT 4-5 DAYS.

• REPLACE VITAMIN DEFICIENCIES WITH FOLATE, 1 mg PO qd; THIAMINE, 100 mg PO qd; MULTIVITAMIN; AND PROPER NUTRITION.

• MANAGE DELIRIUM FROM WITHDRAWAL WITH BENZODIAZEPINES. LOW-DOSE, HIGH-POTENCY ANTIPSYCHOTICS MAY BE USED ADJUNCTIVELY TO TREAT SEVERE PSYCHOTIC AGITATION.

• SEIZURES CAN GENERALLY BE ABORTED WITH LORAZEPAM, 2 mg IV; HOW-EVER, SOMETIMES PHENYTOIN (DILATIN) LOADING IS NECESSARY

COCAINE, AMPHETAMINE & AMPHETAMINE-LIKE DRUGS

CLINICAL FEATURES OF INTOXICATION

• EUPHORIC, EXPANSIVE, IRRITABLE, OR LABILE MOOD• HYPERTALKATIVENESS• PSYCHOMOTOR ACTIVATION INCLUDING STEREOTYPED

MOVEMENTS SUCH AS BRUXISM, LIP SMACKING, OR LICKING.• ANXIETY OR HYPERVIGILANCE• AUTONOMIC ACTIVATION• PERSPIRATION• CARDIOVASCULAR MANIFESTATION• N/V• PSYCHOSIS, INCLUDING PERSECUTORY OR GRANDIOSE

DELUSIONS AND VISUAL, AUDITORY, OR TACTILE HALLUCINATIONS.

• DELIRIUM AND SEIZURES MAY OCCUR WITH INTOXICATION.

COCAINE, AMPHETAMINE & AMPHETAMINE-LIKE DRUGS

CLINICAL FEATURES OF WITHDRAWAL

• OCCURS SHORTLY AFTER CESSATION FROM PROLONGED USE (12 HRS) AND CAN PERSIST FOR DAYS TO MONTHS.

• DYSPHORIC OR DYSTHYMIC MOOD.

• FATIGUE AND SLEEP CHANGES (USUALLY HYPERSOMNIA).

• PSYCHOMOTOR RETARDATION OR ACTIVATION.

• VIVID OR UNPLEASANT DREAMS (OFTEN “CRACK DREAMS” ARE OF USING).

• PATIENTS MAY DEVELOP SUICIDAL IDEATION AND A PROFOUND SENSE OF GUILT AND HOPELESSNESS.

TREATMENT OF COCAINE, AMPHETAMINE & AMPHETAMINE-

LIKE DRUGS DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES (e.g., MAJOR DEPRESSION, ANXIETY DISORDERS).


• USE OF ANTIDEPRESSANTS TO MANAGE DEPRESSIVE SYMPTOMS THAT APPEAR DURING WITHDRAWAL MAY IMPROVE QUALITY OF LIFE BUT HAVE LITTLE EFFECT ON USE.

TREATMENT OF COCAINE, AMPHETAMINE & AMPHETAMINE-

LIKE DRUGS INTOXICATION• INTERRUPT USE

• OBTAIN ECG AND MONITOR VITALS CONTINUOUSLY.

• BETA-NORADRENERGIC ANTAGONISTS MAY BE USED TO TREAT SYMPTOMATIC HYPERTENSION OR TACHYCARDIA.

• BENZODIAZEPINES (LORAZEPAM, 2 mg PO/IM/IV) CAN BE USED TO REDUCE ANXIETY OR AGITATION.

• GIVE HIGH-POTENCY ANTIPSYCHOTICS IF PSYCHOTIC SYMPTOMS ARE PRESENT.

• ACIDIFICATION OF URINE FACILITATES ELIMINATION OF AMPHETAMINE.

• PROVIDE A QUIET, SAFE ENVIRONMENT WITH REDUCED STIMULATION.

TREATMENT OF COCAINE, AMPHETAMINE &

AMPHETAMINE- LIKE DRUGS WITHDRAWAL

• WITH THE EXCEPTION OF SUICIDE RISK, THERE ARE NO DANGEROUS PHYSIOLOGIC SEQUELAE TO COCAINE OR AMPHETAMINE WITHDRAWAL.

• MOOD SYMPTOMS ARE USUALLY MILD AND SELF-LIMITED, RESOLVING OVER DAYS TO WEEKS.

• DESIPRAMINE MAY REDUCE COCAINE CRAVING, ALTHOUGH THIS TREATMENT IS CONTROVERSIAL.

• ANTIDEPRESSANTS ARE USED TO TREAT ANY PERSISTING OR SEVERE MOOD SYMPTOMS.

OPIOID USE DISORDERS

1. RECREATION USE OF OPIATES OFTEN LEADS TO ADDICTION.

2. OPIATE ADDICTS ARE AT INCREASED RISK OF HIV, PNEUMONIA, ENDOCARDITIS, HEPATITIS, AND CELLULITIS.

3. HIGH MORTALITY OCCURS FROM ACCIDENTAL OVERDOSE, SUICIDE, AND ACCIDENTS.

4. OPIATE WITHDRAWAL BEGINS 10 HOURS AFTER LAST DOSE.

5. WITHDRAWAL IS UNCOMFORTABLE BUT NOT USUALLY MEDICALLY COMPLICATED.

O P I O I D SCLINICAL FEATURES OF INTOXICATION

• EUPHORIA• SEDATION OR

SLEEPINES (“NODDING”)

• RESPIRATORY DEPRESSION

• PUPILLARY CONSTRICTION (PINPOINT PUPILS)

• DYSARTHRIA• PERCEPTUAL

DISTURBANCES

• IMPAIRMENT OF MEMORY OR ATTENTION

• NAUSEA• CONSTIPATION WITH

DECREASED BOWEL SOUNDS

• REDUCED SEXUAL DESIRE

• DELIRIUM MAY OCCUR WITH INTOXICATION

O P I O I D SCLINICAL FEATURES OF WITHDRAWAL

• USUALLY DEVELOPS WITHIN HOURS OF CESSATION OF IV USAGE, OR 1-2 DAYS AFTER CESSATION OF ORAL USAGE

• ANXIETY, IRRITABILITY

• INSOMNIA

• MYALGIA OR MUSCLE CRAMPING

• HEADACHE

• NAUSEA/VOMITING

• DIARRHEA OR ABDOMINAL CRAMPING

• PILOERECTION (“GOOSE FLESH”)

• DIAPHORESIS

• PUPILLARY DILATION

• LACRIMATION

• RHINORRHEA

• YAWNING

• FEVER

SYMPTOMS OF OPIATE WITHDRAWAL

MILD WITHDRAWAL MORE SEVERE WITHDRAWALDYSPHORIC MOOD, ANXIETY, NAUSEA AND RESTLESSNESS VOMITINGLACRIMATION OR RHINORRHEA MUSCLE ACHESPUPILLARY DILATATION SEIZURESPILOERECTION (IN MEPERIDINESWEATING WITHDRAWAL)HYPERTENSION ABDOMINAL CRAMPSTACHYCARDIA HOT AND COLD FLASHESFEVER SEVERE ANXIETYDIARRHEA INSOMNIAYAWNING

TREATMENT OF OPIOIDS WITHDRAWAL

• NONMEDICAL MANAGEMENT: INVOLVES RESTRICTING ACCESS TO DRUG UNTIL WITHDRAWAL SYMPTOMS HAVE RUN THEIR COURSE.

• SYMPTOMATIC MANAGEMENT: CLONIDINE (CATAPRES) (0,1-0,3 mg PO TID-QID PRN TO CONTROL AUTONOMIC WITHDRAWAL SYMPTOMS) AND LOPERAMIDE FOR DIARRHEA.

• METHADONE DETOXIFICATION: START 5-20 mg TID DEPENDING ON DAILY USE AND TAPER OVER 4-7 DAYS.

TREATMENT OF OPIOIDS INTOXICATION

• INTERRUPT USE

• MONITOR VITAL SIGN CONTINUOUSLY. RESPIRATORY DEPRESSION REPRESENTS THE GREATEST THREAT TO LIFE.

• PROVIDE RESPIRATORY SUPPORT IF NECESSARY

• IF THE PATIENT IS SEVERELY OBTUNDED, NALOXONE (NARCAN), 0,4 mg IV GIVEN SLOWLY. IT MAY BE REPEATED IF NO EFFECTS ARE OBSERVED. NALOXONE CAN PRECIPITATE WITHDRAWAL SYMPTOMS. MONITOR THE PATIENT CONTINUALLY AS THE HALF-LIFE OF MOST OPIATES IS GREATER THAN THAT OF NALOXONE, AND ADMINISTRATION MAY NEED TO BE REPEATED.

TREATMENT OF OPIOIDS DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES ( e.g., MAJOR DEPRESSION, ANXIETY DISORDERS).


• NALTREXONE (ReVia), 50 mg PO qd, BLOCKS THE REWARDING EFFECTS OF OPIOIDS..

• METHADONE, 60-100 mg PO qd, REDUCES DRUG CRAVING AND ALLEVIATES SOME OF THE PSYCHOSOCIAL CONSEQUENCES AND MEDICAL COMORBIDITIES OF ILLEGAL DRUG USE.

• LAAM (LEVO-ALPHA-ACETYLMETHADOL) IS A LONG-ACTING OPIATE AGONIST (HALF-LIFE OF 92 HRS) THAT CAN BE USED SIMILARLY TO METHADONE, WITH THE ADVANTAGE THAT IT CAN BE DOSED EVERY 2-3 DAYS.

• BOTH METHADONE AND LAAM MAINTENANCE THERAPY CAN ONLY BE PRESCRIBERD THROUGH GOVERNMENT-REGULATED PROGRAMS.

C A N N A B I S CLINICAL FEATURES OF INTOXICATION

• EUPHORIA• DEPERSONALIZATION• DEREALIZATION• SENSATION OF SLOWED

TIME• IMPAIRED COORDINATION• SILLY OR INAPPROPRIATE

AFFECT OR LAUGHING• AMOTIVATION• CONJUNCTIVAL

INJECTION• INCREASED APPETITE• DRY MOUTH

• TACHYCARDIA• PERCEPTUAL

DISTURBANCES• PSYCHOSIS, INCLUDING

AUDITORY AND VISUAL HALLUCINATIONS AND PARANOID DELUSIONS (USUALLY THAT PEOPLE ARE WATCHING THEM OR ARE AWARE OF THEIR USE).

• DELIRIUM MAY OCCUR WITH INTOXICATION.

C A N N A B I SCLINICAL FEATURES OF WITHDRAWAL

NOTE : NO DSM CATEGORY

• INSOMNIA• NAUSEA• IRRITABILITY AND

RESTLESSNESS• YAWNING• CHILLS• DIARRHEA• INFREQUENT

OCCURRENCE, ONLY IN CHRONIC USERS OF LARGE AMOUNTS.

• SYMPTOMS ARE SELF-LIMITED AND MILD, AND NO PHARMACOLOGIC MANAGEMENT HAS BEEN DEMONSTRATED TO BE USEFUL.

TREATMENT OF CANNABIS INTOXICATION

• INTERRUPT USE• BENZODIAZEPINES (LORAZEPAM, 2 mg

PO/IM/IV) CAN BE USED TO REDUCE ANXIETY OR AGITATION

• GIVE ANTIPSYCHOTICS IF PSYCHOTIC SYMPTOMS ARE PRESENT

• PROVIDE A QUIET, SAFE ENVIRONMENT WITH REDUCED STIMULATION.

TREATMENT OF CANNABIS DEPENDENCE

• TREAT PSYCHIATRIC COMORDIBITIES (e.g., MAJOR DEPRESSION, ANXIETY DISORDERS).


PHENCYCLIDINECLINICAL FEATURES OF INTOXICATION

• HYPERTENSION• TACHYCARDIA• ANALGESIA• VERTICAL, HORIZONTAL OR

ROTATORY NYSTAGMUS• ATAXIA• DYSARTHRIA• HYPERTONIA• SEIZURE AND COMA• HYPERSALIVATION• DIAPHORESIS• FEVER

• AUDITORY HALLUCINATIONS AND DELUSIONS

• AFFECT MAY BE LABILE OR BLUNTED

• DISSOCIATION AND INATTENTION

• ODD POSTURING OR REPETITIVE MOVEMENTS

• CATATONIA• DELIRIUM MAY OCCUR

WITH INTOXICATION.

TREATMENT OF PHENCYCLIDINE INTOXICATION• INTERRUPT USE• MONITOR VITAL SIGN CONTINUOUSLY IF UNSTABLE.• BETA-NORADRENERGIC ANTAGONIS (PROPRANOLOL, 1 mg IV,

GIVEN SLOWLY) MAY BE USED TO TREAT SYMPTOMATIC HYPERTENSION OR TACHYCARDIA.

• PLACE PATIENT IN A QUIET ENVIRONMENT WITH DECREASED STIMULATION. BECAUSE OF THE DISSOCIATIVE NATURE OF INTOXICATION, REASONING WITH PATIENT OR “TALKING THEM DOWN” IS USUALLY NOT USEFUL.

• BENZODIAZEPINES MAY BE USED TO TREAT ANXIETY OR AGITATION.

• ANTIPSYCHOTICS MAY BE USED ADJUNCTIVELY FOR SEDATION AND TO CONTROL PSYCHOSIS IF THE PATIENT IS AGITATED OR DANGEROUS.

TREATMENT OF PHENCYCLIDINE DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES (e.g.,MAJOR DEPRESSION, ANXIETY DISORDERS).


• THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH PHENCYCLIDINE DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

HALLUCINOGENSCLINICAL FEATURES OF INTOXICATION

• TREMOR• BLURRED VISION• INCOORDINATION• GI SYMPTOMS, INCLUDING N/V, CRAMPING, FLATULENCE,

AND DIARRHEA, ARE COMMON WITH MESCALINE AND MUSHROOM.

• MDMA INTOXICATION IS MORE LIKELY TO CAUSE HEIGHTENED SOCIABILITY, WITH INCREASED SPEECH, TACTILE PREOCCUPATION, AND HYPERSEXUALITY.

BECAUSE OF THE CONTEXT IN WHICH MDMA IS USED, IT IS MORE LIKELY TO BE ASSOCIATED WITH THE PHYSIOLOGY SEQUELAE OF AUTONOMIC HYPERACTIVITY (e.g.,DEHYDRATION, CARDIOVASCULAR CRISIS).

HALLUCINOGENSCLINICAL FEATURES OF INTOXICATION

• VISUAL AND AUDITORY ILLUSIONS AND HALLUCINATIONS.

• SYNESTHESIA: THE EXPERIENCE OF PERCEIVING SENSORY INPUT FROM ONE MODALITY IN ANOTHER MODALITY (e.g.,HEARING COLOR OR SEEING SOUNDS).

• SUBJECTIVE HEIGHTENED AWARENESS OF SENSORY INPUT.

• FEELING OF DEPERSONALIZATION OR DEREALIZATION.• IDEAS OF REFERENCE.• PARANOIA OR FEAR OF LOSING ONE’S MIND.• ANXIETY OR AFFECTIVE LABILITY.• AUTONOMIC ACTIVATION (PUPILLARY DILATATION,

TACHYCARDIA, SWEATING, HYPERTENSION, FEVER).

TREATMENT OF HALLUCINOGENS INTOXICATION

• INTERRUPT USE• MONITOR VITALS CONTINUOUSLY IF UNSTABLE.• REHYDRATE IF NECESSARY• BETA-NORADRENERGIC ANTAGONISTS (PROPRANOLOL 1 mg IV,

GIVEN SLOWLY) MAY BE USED TO TREAT SYMPTOMATIC HYPERTENSION OR TACHYCARDIA.

• PLACE PATIENT IN A QUIET ENVIRONMENT WITH DECREASED STIMULATION. FAMILIAR, CALM FRIENDS ARE USEFUL IN REASSURING PATIENT THAT SYMPTOMS ARE RELATED TO DRUG USE AND WILL PASS.

• BENZODIAZEPINES MAY BE USED TO TREAT ANXIETY OR AGITATION.

• LOW-DOSE ANTIPSYCHOTICS MAY BE USED ADJUNCTIVELY FOR SEDATION AND TO CONTROL PSYCHOSIS IF THE PATIENT IS AGITATED OR DANGEROUS.

TREATMENT OF HALLUCINOGENS DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES (e.g.,MAJOR DEPRESSION, ANXIETY DISORDERS).


• THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH HALLUCINOGEN DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

INHALANTSCLINICAL FEATURES OF INTOXICATION

• EUPHORIA• DISORIENTATION• MEMORY IMPAIRMENT• DIZZINESS• CONFUSION• HEADACHE• DIPLOPIA• DYSARTHRIA, ATAXIA,

NYSTAGMUS• HYPOTENSION,

BRADYCARDIA, ARRHYTHMIA.

• INJECTED SCLERA

• LACRIMATION

• SALIVATION

• RHINORRHEA

• RESPIRATORY WHEEZING

• SEIZURES OR COMA

• NAUSEA/VOMITING

• HEPATOXICITY

• CHEMICAL PNEUMONITIS

• THE ODOR OF SOLVENTS DETECTED ON BREATH AND CLOTHING

TREATMENT OF INHALANTS INTOXICATION

• INTERRUPT USE

• MONITOR VITAL SIGN

• MOST SYMPTOMS RESOLVE WITH ADMINISTRATION OF OXYGEN.

TREATMENT OF INHALANTS DEPENDENCE

• TREAT PSYCHIATRIC COMORBIDITIES (e.g., MAJOR DEPRESSION, ANXIETY DISORDERS).


• THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH INHALANT DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

DIAGNOSTIC CRITERIA FOR NICOTINE WITHDRAWAL

(DSM IV)

1. DYSPHORIA OR DEPRESSED MOOD

2. INSOMNIA

3. IRRITABILITY, FRUSTRATION OR ANGER

4. ANXIETY

5. DIFFICULTY CONCENTRATING

6. BREATHLESSNESS

7. DECREASED HEART RATE

8. INCREASED APPETITE OR WEIGHT GAIN

substance use disorders

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