SUBSTANCE USE DISORDERS

B Y

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

ETIOLOGY OF SUBSTANCE USE DISORDER

SUBSTANCE
- EFFECT - PRICE - EASY TO GET

ENVIRONMENTAL FACTORS
- PEER GROUP

INDIVIDUAL FACTORS
- PERSONALITY

- FAMILY INTERACTION

- MENTAL ILLNESS - Genetic

THE QUICKEST WAY TO THE BRAIN

METHOD
1. 2.

TIME TO BRAIN

SMOKING 7 10 SECONDS INJECTING : - IV 15 30 SECONDS - IM 3 5 MINUTES 3. SNORTING 3 5 MINUTES 4. CONTACT : - EYE 3 5 MINUTES - SKIN & OTHER 15 30 MINUTES 5. INGESTING 20 30 MINUTES

PREVENTION OF RELAPSE
PSYCHOACTIVE SUBSTANCE DEPENDENCE
SPECIFIC TREATMENT
DRUG TREATMENT COUNSELING RESIDENTIAL REHABILITATION

INDIVIDUAL FACTORS
MOTIVATION SOCIAL SUPPORTS EXTENT OF PHYSICAL AND PSYCHOLOGICAL DAMAGE PAST EXPERIENCE OF TREATMENT PREPARED TO ATTEND SELFHELP GROUPS, VOLUNTARY ORGANIZATION

LIFELONG ABSTINENCE FROM PSYCHOACTIVE SUBSTANCE

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

No. Pekerjaan 1. 2. 3. 4. 5. 6. 7. PNS Polri/TNI Swasta Wiraswasta Petani Buruh Mahasiswa 1998 12 6 357 265 90 149 61 1999 2000 2001 2002 21 10 698 423 95 263 127 36 37 669 154 569 260 39 6 769 127 833 202 29 33 619 91 554 241 Jumlah 137 92 5190 2745 557 2368 891

1268 1228 1639

8.
9.

Pelajar
Pengangguran J U M LAH :

35
333 1308

105
848

206

141

145

632
6184 18769

1756 1579 1668

2590 4955 4924 5019

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

(BERDASARKAN PEKERJAAN TERSANGKA)
NO 1. 2. PEK.
PNS POLRI

Thn Jml 12 6

1998 % 0,92 0,46

Thn Jml 21 10

1999 % 0,81 0,39

Thn Jml 36 37

2000 % 0,72 0,75

Thn Jml 39 6

2001 % 0,79 0,12

Thn Jml 29 33

2002 % 0,5 0,66

3.
4. 5. 6. 7. 8. 9.

SWASTA
WRSWT PETANI BURUH MHSW PELAJAR
PENGANG GURAN

357
265 90 149 61 35 333
1308

27,29
20,26 6,88 11,39 4,66 2,68 25,46 100

698
423 95 263 127 105 848
2590

26,95
16,33 3,67 10,15 4,90 4,05 32,74 100

1268
669 154 569 260 206 1756 4955

25,59
13,50 3,11 11,48 5,25 4,16 35,44 100

1228
769 127 833 202 141 1579 4924

24,94
15,62 2,58 16,92 4,10 2,86 32,07 100

1639
619 91 554 241 145 1668 5019

32,66
12,33 1,81 11,04 4,80 2,89 33,23 100

JML

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 USED 2. CURRENT USE 3. PAST USE 4. DRUG(S) OF CHOICE 5. MOST PROBLEMATIC DRUG 6. 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. MALADAPTIVE BEHAVIORAL CHANGES ( e.g., EUPHORIA OR HYPERVIGILANCE); TACHYCARDIA OR BRADYCARDIA; PUPILLARY DILATATION; HYPER- OR HYPOTENSION; PERSPIRATION OR CHILLS; NAUSEA OR VOMITING; WEIGHT LOSS; PSYCHOMOTOR AGITATION OR RETARDATION; MUSCULAR WEAKNESS, RESPIRATORY DEPRESSION, CHEST PAIN, CARDIAC DYSRHTHMIAS; 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 RESTLESSNESS APPREHENSION ANXIETY MORE SEVERE WITHDRAWAL COARSE TREMORS WEAKNESS VOMITING SWEATING HYPERREFLEXIA NAUSEA ORTHOSTATIC HYPOTENSION SEIZURES

ALCOHOL-RELATED DISORDERS
1. 2. 3. 4. IN ALCOHOL DEPENDENCE, DENIAL AND MINIMIZATION ARE COMMON. WITHDRAWAL AND DELIRIUM TREMENS ARE TREATED WITH BENZODIAZEPINES. PEAK INCIDENCE OF ALCOHOLIC SEIZURES IS WITHIN 24 TO 48 HOURS. REHABILITATION IS AIMED AT ABSTINENCE AND TREATING COMORBID DISORDERS. REHABILITATION INVOLVES AA AND GROUP AND FAMILY THERAPIES. FIFTY PERCENT OF TREATED ALCOHOLICS WILL RELAPSE. WERNICKE-KORSAKOFF SYNDROME IS DUE TO THIAMINE DEFICIENCY. WERNICKES TRIAD CONSISTS OF NYSTAGMUS, ATAXIA, AND MENTAL CONFUSION. KORSAKOFFS SYMPTOMS ARE ANTEROGRADE AMNESIA AND CONFABULATION.

5.
6. 7. 8. 9.

HOSPITALIZATION
IS INDICATED FOR PATIENT WHO:
ARE AT RISK FOR DANGEROUS OR UNCOMFORTABLE WITHDRAWAL SYNDROMES (ALCOHOL, SEDATIVEHYPNOTICS, 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 EFFECT
0.02 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

1. 2. 3. 4.

5.

A NUMBER AT DIFFERENT APPROACH ARE AVAILABLE, AND PACKAGES OF CARE SHOULD BE DESIGNED TO MEET INDIVIDUAL NEEDS. TREATMENT OPTIONS INCLUDE THE FOLLOWING : HARM REDUCTION PSYCHOTHERAPY RESIDENTIAL REHABILITATION MEDICAL DETOXIFICATION : i.e. - METHADONE FOR OPIATE WITHDRAWAL - BENZODIAZEPINE FOR ALCOHOL WITHDRAWAL - SYMPTOMATIC 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 ABUSE
THE 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 DEPENDENCE
SUBSTANCE 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. TOLERANCE 2. WITHDRAWAL 3. REPEATED, UNINTENDED, EXCESSIVE USE 4. PERSISTENT FAILED EFFORT TO CUT DOWN 5. EXCESSIVE TIME SPENT TRYING TO OBTAIN THE SUBSTANCE 6. REDUCTION IN IMPORTANT SOCIAL, OCCUPATIONAL, OR RECREATIONAL ACTIVITIES 7. CONTINUED USE DESPITE AWARENESS THAT SUBSTANCE IS THE CAUSE OF PSYCHOLOGICAL OR PHYSICAL DIFFICULTIES.

MENTAL AND BEHAVIOURAL DISORDERS DUE TO PSYCHOACTIVE SUBSTANCE USE

F10.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL F11.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDS F12.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF CANNABINOIDS F13.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS F14.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE F15.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE F16.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS F17.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF TOBACCO F18.- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF VOLATILE SOLVENTS F19.- 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 INTOXICATION F1x.1 HARMFUL USE F1x.2 DEPENDENCE SYNDROME F1x.3 WITHDRAWAL STATE F1x.4 WITHDRAWAL STATE WITH DELIRIUM F1x.5 PSYCHOTIC DISORDER F1x.6 AMNESIC SYNDROME F1x.7 RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDER F1x.8 OTHER MENTAL AND BEHAVIOURAL DISORDERS F1x.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 STRONG DESIRE OR SENSE OF COMPULSION TO TAKE THE SUBSTANCE DIFFICULTIES IN CONTRLOLLING SUBSTANCE-TAKING BEHAVIOUR ; A PHYSIOLOGICAL WITHDRAWAL STATE WHEN SUBTANCE USE HAS CEASED OR BEEN REDUCED; EVIDENCE OF TOLERANCE; PROGRESSIVE NEGLECT OF ALTERNATIVE PLEASURE OR INTERESTS BECAUSE OF PSYCHOACTIVE SUBSTANCE USE; PERSISTING WITH SUBSTANCE USE DESPITE CLEAR EVIDENCE OF OVERTLY HARMFUL CONSEQUENCES.

(a) (b)

(c)
(d) (e)

(f)

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 LATEONSET 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 SUBSTANCERELATED 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 & AMPHETAMINELIKE DRUGS DEPENDENCE

TREAT PSYCHIATRIC COMORBIDITIES (e.g., MAJOR DEPRESSION, ANXIETY DISORDERS). TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE. 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 & AMPHETAMINELIKE 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.
2.

3. 4. 5.

RECREATION USE OF OPIATES OFTEN LEADS TO ADDICTION. OPIATE ADDICTS ARE AT INCREASED RISK OF HIV, PNEUMONIA, ENDOCARDITIS, HEPATITIS, AND CELLULITIS. HIGH MORTALITY OCCURS FROM ACCIDENTAL OVERDOSE, SUICIDE, AND ACCIDENTS. OPIATE WITHDRAWAL BEGINS 10 HOURS AFTER LAST DOSE. WITHDRAWAL IS UNCOMFORTABLE BUT NOT USUALLY MEDICALLY COMPLICATED.

OPIOIDS
CLINICAL 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

OPIOIDS
CLINICAL 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
DYSPHORIC MOOD, ANXIETY, AND RESTLESSNESS LACRIMATION OR RHINORRHEA PUPILLARY DILATATION PILOERECTION SWEATING HYPERTENSION TACHYCARDIA FEVER DIARRHEA INSOMNIA YAWNING

MORE SEVERE WITHDRAWAL

NAUSEA VOMITING MUSCLE ACHES SEIZURES (IN MEPERIDINE WITHDRAWAL) ABDOMINAL CRAMPS HOT AND COLD FLASHES SEVERE ANXIETY

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

CANNABIS
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.

CANNABIS
CLINICAL 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 SELFLIMITED 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). TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE.

PHENCYCLIDINE
CLINICAL 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). TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE. THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH PHENCYCLIDINE DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

HALLUCINOGENS
CLINICAL 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).

HALLUCINOGENS
CLINICAL 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 ONES 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). TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE. THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH HALLUCINOGEN DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

INHALANTS
CLINICAL 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). TWELVE-STEP RECOVERY MODELS REPRESENT THE MOST SUCCESSFUL BEHAVIORAL APPROACH TO ABSTINENCE. THERE IS NO WITHDRAWAL SYNDROME ASSOCIATED WITH INHALANT DEPENDENCE, NOR IS PHARMACOLOGIC MANAGEMENT INDICATED.

DIAGNOSTIC CRITERIA FOR NICOTINE WITHDRAWAL (DSM IV)

1. 2. 3. 4. 5. 6. 7. 8. DYSPHORIA OR DEPRESSED MOOD INSOMNIA IRRITABILITY, FRUSTRATION OR ANGER ANXIETY DIFFICULTY CONCENTRATING BREATHLESSNESS DECREASED HEART RATE INCREASED APPETITE OR WEIGHT GAIN