Substance use disorders

Introduction

Abuse of substances such as marijuana, benzodiazepines, heroine, cocaine etc. is prevalent in many communities around the country.
Typically, individuals with such disorders request help only after they are forced to do so by family members.
They may also begin to have withdrawal symptoms when on admission for serious physical illness.
This is because they have no access to the substance being abused.
This may complicate treatment of the primary disease for which they were admitted.

Causes of substance abuse disorders

  1. Social factors
    • Peer pressure (e.g. family members, friends)
    • Lack of coping skills (e.g. with life’s difficulties, aids to coping in times of trouble)
  2. Addiction
  3. Tolerance (increased requirement of substance to maintain the same feeling)
  4. Withdrawal effects (unpleasant effects lead to a return to drug use)

Symptoms of substance abuse disorders

Symptoms of Cannabis withdrawal

  1. Insomnia
  2. Shakiness
  3. Irritability
  4. Restlessness
  5. Anxiety
  6. Anger

Onset:

  • Within 24 hours of drug use

Duration:

  • 1-2 weeks

Symptoms of Benzodiazepine withdrawal

  1. Anxiety
  2. Headache.
  3. Insomnia
  4. Muscle aching and twitching
  5. Perceptual changes
  6. Feelings of unreality
  7. Depersonalization
  8. Seizures

Onset:

  • 1-10 days (depending on half-life of drug)

Duration:

  • 3-6 weeks (may be longer)

Symptoms of Opioid withdrawal

  1. Anxiety
  2. Craving
  3. Muscle tension
  4. Muscle and bone ache
  5. Muscle cramps and sustained contractions
  6. Sleep disturbance
  7. Sweating
  8. Hot and cold flushes
  9. Piloerection
  10. Yawning
  11. Lacrimation and rhinorrhoea
  12. Abdominal cramps
  13. Nausea, vomiting and diarrhoea
  14. Palpitations
  15. Elevated pulse and blood pressure
  16. Dilated pupils

Onset:

  • 6-24 hours (may be later with longer-acting opioids)

Duration:

  • peaks 2-4 days, ceases 5-10 days (more prolonged longer-acting opioids)

Symptoms of Psychostimulant withdrawal

  1. Crash (fatigue, flat affect, increased sleep, reduced cravings)
  2. Withdrawal (fluctuating mood and energy levels, cravings, disturbed sleep, poor concentration)
  3. Extinction (persistence of withdrawal features, gradually subsiding)

Onset:

  • 6-12 hours (cocaine); 12-24 hours (amphetamines)

Duration:

  1. Several weeks for withdrawal phase, then months for extinction

Signs of substance abuse disorders

Signs of cannabis withdrawal

  • Same as symptoms

Signs of Benzodiazepine withdrawal

  • Same as symptoms

Signs of Opioid withdrawal

  • Same as symptoms

Signs of Psychostimulant withdrawal

  • Same as symptoms

Investigations

  • Toxicology screen for suspected substances

Screening of patients suspected of substance abuse

Physical appearance

  • Sweating, tremor, agitation, problem with coordination, gait. Rate these appearances and reassess them at regular intervals to monitor the progress of symptoms. If symptoms are increasing in severity, notify a senior staff member, or if available, a doctor

Suicide risk assessment

  • To determine the level of risk at a given time and to provide appropriate clinical care and management. Possible suicidal behaviour includes thinking about suicide, harming oneself or attempting suicide.
  • Screening questions of suicide risk:
    • Have things been so bad lately that you have thought you would rather not be here?
    • Have you had any thoughts of harming yourself?
    • Are you thinking of suicide?
    • Do you have any plans to commit suicide?
    • Have you ever tried to harm yourself?
    • Have you made any current plans?
    • Do you have access to any thing with which to hurt yourself?

Mental state examination
To determine:

  • The need for other psychological therapies
  • Concomitant psychiatric conditions which place the patient others at risk
  • The patient’s capacity informed consent and active participation in treatment planning

Assessment of psychosocial factors affecting withdrawal

  • Ask patient about: Reasons for presenting for withdrawal management at this time
  • Past experiences, current knowledge and fears of withdrawal Perceived ability to cope with withdrawal and its treatment.
  • Family supports and social networks available for withdrawal treatment:

Potential barriers to successful withdrawal

  • Care of children (assess possible neglect or physical or sexual abuse of children or exposure to such harm from others and intervene to protect as soon as possible or refer to appropriate agency)
  • Drug use of cohabitants
  • Current legal issues
  • Financial problems
  • Work commitments

Treatment for substance abuse disorders

Treatment objectives

The treatment objectives of substance abuse disorders include the following

  1. To provide supportive care (information, stress reduction, reassurance)
  2. To teach coping skills (relaxation techniques, dietary guidelines, methods to reduce craving for the substance, sleep disturbance management)
  3. To manage difficult behavior (anxiety, agitation, panic and aggression)
  4. To manage confusion, disorientation and hallucinations
  5. To plan an organised discharge, follow up and after-care to relapse

Non-pharmacological treatment

  1. Cognitive Behaviour Therapy
  2. Stress management to reduce craving

Pharmacological treatment

A. Management of withdrawal symptoms – cannabis

  • Requires no medical intervention

B. Management of withdrawal symptoms – stimulants

  • Requires observation but does not require a specific intervention

C. Management of withdrawal symptoms- benzodiazapines

  • Substitute with equivalent dose of benzodiazapine for a few days, then taper off dose over 2-3 weeks D.

D. Management of withdrawal symptoms – opiates

  • Oral rehydration fluids or IV fluids may be required
  • Long acting benzodiazapines e.g. diazepam, to control insomnia and muscle cramps (See drug doses under appropriate sections)
  • Anti-emetics e.g. promethazine etc., for nausea and vomiting (See drug doses under appropriate sections)
  • Methadone, buprenorphine and clonidine may be used, where available and with caution, to reduce the severity of symptoms (See drug doses under appropriate sections)
  • NSAIDs e.g. ibuprofen, diclofenac etc., for pain relief (See drug doses under appropriate sections)

Referral Criteria

  • Refer for specialist psychiatrist/clinical psychologist care and management if withdrawal symptoms are particularly distressful and do not respond to treatment or when there are repeated relapses.
  • Refer for Cognitive Behaviour Therapy to a clinical psychologist.