Psychoactive substance use disorders

By

Dr Dapap D.D

Department of Psychiatry

College of Medicine and Health Sciences

Bingham University

�Objectives�

• At the end of this lecture you will be able to:
• 1. Understand what psychoactive substances are, their list and their classes
• 2. Understand the epidemiology of alcohol and other drug abuse
• 3. understand substance misuse disorders
• 3. Understand aetiological/risk factors associated with drug use disorders
• 4. Understand the phases of drug abuse management

Introduction

• The use of alcohol and other psychoactive substances has been associated with man, from time immemorial – with alcohol being referred to as the oldest known drug.
• The dangers of alcohol use are multiplied by the social acceptability conferred on it and wrong notions about its limited harmfulness. It is however, an established fact that Alcohol and Psychoactive substance use poses a significant threat to the health, social and economic fabric of families, communities and nations.

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Introduction II

• Furthermore, use of psychoactive substances is frequently associated with crime, thus necessitating legislation and the involvement of law enforcement agencies.
• It also explains the rationale for the establishment of the United Nations Organization for Drugs and Crime (UNODC) which attempts to combat the two interwoven evils.
• According to the WHO, The extent of worldwide psychoactive substance use is estimated at 2 billion alcohol users, 1.3 billion smokers and 185 million drug users.

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Epidemiology

• National Epidemiological Network on Drug Use (NENDU) in Nigeria.
• 11 treatment Centres across the country. This provides drug treatment data for Nigeria.
• January -December 2015,
• 1044 patients entered for treatment in the 11 treatment centers currently part of the NENDU reporting system.
• Cannabis (36.2%)
• Opiates (28.3%) {Tramadol 71%,Codeine 15.1%,Pentazocine 9.9%, Heroine and Morphine 3.3%
• Alcohol (17.1%).

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• In Nigeria,2018 survey shows that one in seven persons aged 15-64 years had used a drug (other than tobacco and alcohol) in the past year.
• The past year prevalence of any drug use in Nigeria was estimated at 14.4 per cent or 14.3 million people aged between 15 and 64 years
• Among every 4 drug users in Nigeria 1 is a woman. men (annual prevalence of 21.8 %), women (annual prevalence of 7.0 %)
• Cannabis was the most commonly use drug (10.8%)
• A dichotomy in the past year prevalence of drug use was found between the North and South geopolitical zones.
• Highest past-year prevalence of drug use was found in the southern political zones: south (13.8 – 22.4%), north (10 - 14.9%)

Epidemiology II

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• A survey done by the United Nations Office on Drugs and Crime (UNODC) found that,
• In 2014, 247million people between ages 15 and 64 used illicit substances at least once in the previous year.
• The survey found that 29 million suffer from drug use disorders
• Up to 12 million people injected drugs
• About 14 percent of those who inject drugs are HIV positive
• About 52 percent of those who inject drugs are infected with the hepatitis C virus

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Defination

• Psychoactive substances affect the body’s central nervous system
• Change how people behave or perceive what is happening around them
• i.e the alter:
• Mood
• Thoughts
• Sensory perceptions
• Behavior

Drug

• In medicine: Any substance with the potential to prevent or cure a disease or the potential to enhance physical or mental well-being

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• In pharmacology: Any chemical agent that alters the biochemical or physiological processes of body tissues or organisms

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• In common usage: A substance that is used for nonmedical (e.g., recreational) reasons

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• Drugs, in the context of abuse, are psychoactive substances that alter: mood, cognition, thoughts and behaviour

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Substance Misuse Disorders

• Acute Intoxication
• At Risk use
• Harmful Use
• Dependence
• Withdrawal
• Substance induced Psychotic Disorder
• Amnesic syndrome
• Residual Disorders
• Other mental and behavioural disorders
• Unspecified mental and behavioural disorder

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Acute intoxication

• This is a transient condition following the use of a psychoactive substance, resulting in disturbance of one or more of the following:
• consciousness level
• cognition
• perception
• affect
• behaviour
• Its intensity is closely related to dose, lessening with time, and the effects disappear when following cessation of the intake of the psychoactive substance. Recovery is usually complete.

At risk use

• At risk use occurs when the amount and or the rate of substance use increase the risk of health problem

HARMFUL USE

A Pattern of psychoactive substance use causing damage to health:

- physical Health

and or

- psychological Health

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Dependence

• This is diagnosed if three or more of the following have been present together at some time in the previous year:
• Strong compulsion or urge to take substance
• Tolerance
• Withdrawal symptoms
• Difficulty controlling substance taking behavior
• Neglect of important activities to feed the habit
• Continued substance use despite clear evidence of harmful effects

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Withdrawal

• Symptoms occur upon withdrawal or reduction of a substance after repeated, usually high dose, and prolonged use.
• Onset and course are time-limited, dose-related and differ according to the substance involved.
• Convulsions may complicate withdrawal.

Psychotic disorder

• Psychotic symptoms occur during or immediately after psychoactive substance use, in relatively clear sensorium (some clouding of consciousness but not severe confusion).
• It is not a manifestation of drug withdrawal or a functional psychosis.
• The characteristics of the psychosis vary according to the substance used, but the following are common:
• vivid hallucinations in more than one modality
• delusions
• psychomotor disturbances
• abnormal affect

Amnestic syndrome

• This is induced by alcohol or other psychoactive substances.
• Requirements for diagnosis include:
• chronic prominent impairment of recent memory; remote memory may be impaired; difficulty learning new material; disturbance of time sense
• immediate recall preserved; other cognitive functions are usually relatively preserved and consciousness is clear
• A history of chronic and usually high-dose use of alcohol or drugs.
• Confabulation may be present,but not invariably so.
• Korsakov’s psychosis is included here.

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Residual and late-onset psychotic disorder

• Alcohol- or psychoactive substance-induced changes of cognition, affect, personality or behaviour persist beyond the period during which the substance might reasonably be assumed to be operating.
• The onset is directly related to substance use.

Classification of psychoactive substances

• Some psychoactive substances do not fit neatly into the basic categories. For example:

• Marijuana may be somewhat sedating or relaxing at low doses but have some hallucinogenic effects at high doses.

• Miraa (khat) can induce mild euphoria and excitement at low doses but at higher doses it can also induce manic behaviors and hyperactivity and can lead to serious physical and psychological illness.

• Dissociative anesthetics (PCP) can have hallucinogenic effects but can also have depressant or stimulant effects.

• Inhalants generally have depressant effects but can also have stimulant or hallucinogenic effects.

CLASSES OF SUBSTANCES

DSM-V ICD-10*

Alcohol Alcohol

Amphetamines Other stimulants including caffeine

Caffeine

Cannabis Cannabinoids

Cocaine Cocaine

Hallucinogens Hallucinogens

Inhalants Volatile Solvents

Nicotine Tobacco

Opioids Opioids

Phencyclidine

Sedatives, hypnotics or Sedatives or hypnotics

Anxiolytics

Polysubstance Multiple drug use

Others

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Common effects of psychoactive drugs�

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• Affect mental processes and behaviour
• Affect thought processes and actions
• Alter perceptions of reality
• Change level of alertness, response time, and perception of the world
• Achieve effects by interacting with the central nervous system (CNS)
• Excessive psychoactive drug use can lead to:
• Σ physical morbidity
• Σ psychiatric morbidity
• Σ social morbidity.

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Alcohol

• In common speech the word alcohol refers specifically to ethanol (C2H5OH)
• Still the most popular “drug”
• In some societies over 80% of population drink
• 8% drink daily, peak in males +60 yrs (23%).
• 40% drink weekly

Forms of alcohol

• Light beer
• Regular beer
• Wine
• Fortified wine
• Spirits
• Palm wine
• Burukutu
• Others

� Units vs standard drinks

• A unit of alcohol is defined as 10 millilitres of pure alcohol (ethanol)
• A unit of alcohol is, more or less, the amount of alcohol that an average healthy adult can metabolize in one hour.
• It is not the same thing as a standard drink. The size of standard drinks varies significantly from country to country.

How to calculate the units in alcoholic drink

• Requirements:
• Alcohol By Volume (ABV) and
• volume in milliliters (mils)
• units = (% ABV Xvolume)/ 1000
• What are the forms of alcohol you know and their ABVs?
• Calculate the unit of alcohol in 400 mills calabash of wine containing 3% alcohol by volume.

Responsible drinking (WHO)�

• Men
• Three units per day, with a maximum of 21 units per week spread throughout the week (including at least two alcohol-free days per week)
• Women
• Two units per day with a maximum of 14 units per week spread throughout the week (including at least two alcohol-free days per week)

Physical (medical) morbidity of alcohol consumption

• Alcohol accounts for one-fifth to one-third of medical admissions to hospital

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Gastrointestinal disorders

• These include:
• Σ nausea and vomiting, particularly in the morning, prevented by drinking more alcohol
• Σ gastritis
• Σ peptic ulcers
• Σ diarrhoea
• Σ Mallory–Weiss tears
• Σ oesophageal varices

Malnutrition

• This may result from:
• Σ poor intake
• Σ malabsorption
• Σ impaired metabolism.

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• Results of malnutrition may include:
• Σ thiamine deficiency presenting with Wernicke’s encephalopathy acutely, leading in a high
• proportion of cases to Korsakov’s psychosis (may also present with high output heart failure of
• beri-beri)
• Σ niacin deficiency (vitamin B3) presenting with pellagra, causing confusion, diarrhoea and lightsensitive rash
• Σ vitamin C deficiency presenting with skin haemorrhages and gingivitis

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Liver

• Hepatic damage is another important result of excessive alcohol intake.
• Fatty infiltration
• Alcoholic hepatitis
• Liver cell necrosis and inflammation occurs, presenting with:
• right hypochondrial pain,jaundice, sometimes accompanied by ascites and encephalopathy

• Cirrhosis with permanent fibrotic changes occurs. This may present with signs of liver failure,
• including:
• Σ ascites
• Σ encephalopathy
• Σ bleeding oesophageal varices.
• However, cirrhosis may be symptomless initially

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Pancrease

• Acute and chronic pancreatitis lead to food malabsorption and diabetes in some cases

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Cardiovascular system

• Cardiovascular system disorders include:
• Σ hypertension, poorly responsive to conventional treatment but responsive to abstinence
• Σ cardiac arrhythmias particularly after binge-drinking (holiday heart syndrome)
• Σ cardiomyopathy, presenting with gradual onset of heart failure (the prognosis is poor with continued drinking)
• Σ haemorrhagic and thrombotic CVA, even in the young

Blood

• Haematological changes may occur, since alcohol is a bone marrow toxin, resulting in the following:
• Σ macrocytosis
• Σ folate deficiency
• Σ impaired clotting caused by vitamin K deficiency and/or reduced platelet functioning
• Σ iron-deficiency anaemia, often as a result of gastrointestinal haemorrhage.

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Endocrine and sexual disorders

• Endocrine and sexual disorders can occur. There is gonadal atrophy which affects both sexes.
• Direct toxic effects upon the gonads result in reduced sex hormone synthesis.
• Liver disease results in oestrogenization in men resulting in gynaecomastia.
• Fertility may recover with abstinence.
• Autonomic nervous system dysfunction may result in erectile dysfuction/ impotence and central effects cause anorgasmia.
• There is an increased risk of miscarriage and recurrent abortion in women

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• Chronic heavy drinking in men can cause:
• Σ loss of libido
• Σ reduction in the size of the testes
• Σ reduction in the size of the penis
• Σ loss of body hair
• Σ gynaecomastia.
• In women, chronic heavy drinking can cause:
• Σ menstrual cycle abnormalities
• Σ loss of breast tissue
• Σ vaginal dryness

• Alcoholic pseudo-Cushing’s syndrome may cause:
• Σ obesity
• Σ hirsuitism
• Σ hypertension

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Neoplasm

• There is an increased incidence of the following types of cancer:
• Σ oropharygeal
• Σ oesophageal
• Σ colorectal
• Σ pancreatic
• Σ hepatic
• Σ lung

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Pregnancy

• Excessive alcohol consumption in pregnancy can lead to permanent fetal damage. Features of the
• resulting fetal alcohol syndrome include:
• Σ low IQ (mean 70)
• Σ cardiac abnormalities (e.g. atrial septal defect)
• Σ low-set ears
• Σ absent philtrum
• Σ long upper lip with narrow vermilion border
• Σ depressed bridge of the nose

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• Σ small nose
• Σ ocular hypertelorism
• Σ microcephaly
• Σ strabismus
• Σ pectus excavatum
• Σ poor growth
• Σ increased neonatal mortality

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Trauma

• Accidents and trauma may result from alcohol consumption. These include:
• Σ road accidents
• Σ assaults (including head injuries)
• Σ falls (including head injuries)
• Σ drowning
• Σ burns
• Σ death by fire.
• The most common traumatic injuries include:
• Σ rib fractures
• Σ head injuries
• Σ subdural/extradural haematomata
• Σ long-bone fractures

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Metabolism

• A variety of metabolic abnormalities may occur, including:
• Σ alcohol-induced lactic acidosis
• Σ alcoholic ketoacidosis
• Σ hyperlipidemia in one-third of alcohol-dependent subjects (low levels of intake appear
• Σ hypoglycaemia
• Σ hyperuricaemia
• Σ haemochromatosis
• Σ porphyria cutanea tarda

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Skin, muscle and skeleton

• Dermatological disorders that may occur include acne and rhinophyma.
• Musculoskeletal disorders that are associated with excessive drinking include:
• Σ myopathy, presenting acutely with pain and tenderness of swollen muscles (usually
• symmetrical; if severe may cause renal failure due to myoglobinuria)
• Σ proximal muscle weakness and wasting (common in alcoholics)
• Σ osteoporosis
• Σ avascular necrosis

Nervous system

• Neurological disorders that are associated with excessive drinking include:
• Σ peripheral neuropathy resulting in numbness and paraesthesias in glove and stocking distribution
• Σ cerebellar degeneration, affecting mainly the vermis, resulting in ataxia of gait
• Σ convulsions occurring mainly secondary to alcohol withdrawal, within the first 48 hours (also secondary to brain damage or hypoglycaemia)

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• Σ optic atrophy
• Σ central pontine myelinolysis.
• Marchiafava–Bignami disease is a rare fatal demyelinating disease characterized neuropathologically
• by widespread demyelination affecting the central corpus callosum, and often also the middle cerebellar peduncles, the white matter of the cerebral hemispheres, and the optic tracts

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Psychiatric morbidity of alcohol consumption

• The major types of psychiatric morbidity that are associated with excessive alcohol intake are:
• Σ mood disorders
• Σ personality disorder
• Σ alcoholic hallucinosis
• Σ pathological jealousy
• Σ neurotic disorders
• Σ psychosexual disorders
• Σ organic brain syndromes

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Social mobidity of alcohol use

• Heavy drinking is often associated with gambling and the use of other psychoactive substances. The social costs of excessive alcohol consumption are high. They include:
• Σ family breakdown
• Σ crime
• Σ accidents and trauma
• Σ economic harm.

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Alcohol

Cannabis

Cocaine

Methamphetamine

Opiates

Tobacco

Aetiology

• It is very important to understand that substance use has no single causation….just like most mental health conditions. It rather occurs as a product of complex interactions between the individual, the substance (effects of it) and the environment.
• It has Biological, Psychological and Social components.

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Biological: Between 40-60% of a person’s vulnerability to addiction is genetic.

a). Genetics (strongest evidence for alcohol):

• Family studies show 7-fold increased risk among 1^st degree relatives.
• Twin studies show MZ:DZ = 70%:40% (Males)

and 50%:30% (Females).

• Adoption studies indicate that sons of alcoholics are 4x more likely to become alcoholics than sons of non-alcoholics, regardless of the drinking patterns of adoptive parents.

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b). Neurochemical:

• Dopamine plays an important role via the so-called “brain-reward circuitry”, as most pleasurable effects mediated by dopamine release in the Nucleus Accumbens. Other important neurotransmitters include opioid, GABA and 5-HT systems. Endogenous receptor systems may play a role in modulating susceptibility and risk of dependence (e.g opiate receptors).
• Neurobiology of addiction (Addiction pathway): Dopaminergic pathway involving the mesolimbic system – VTA –NAC – MFB/prefrontal cortex. Role of NTs, mechanisms underpinning tolerance, physiological withdrawal features and dependence. Role of sensitization and counter-regulatory mechanisms also important.

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Brain-reward circuitry.

Brain-reward circuitry: Extended Amygdala system involvement.

. Psychological.

a). Psychoanalytic: Fixation at the oral phase of development, intoxication as a gain that allows dis-inhibition and wish fulfillment, masturbatory equivalent, defense against anxiety and compensation for defects in the ego functions.

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Learning and Behavioural:

• It can be learned and positively reinforced by the effects of the drugs.
• Conditioned learning also plays a role in the association of cues/paraphernalia with drug effects and craving.
• Modelling from parents and peers also frequently occurs.

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Personality: Strong correlation between substance use and individuals with Anti-social personality disorder. Evidence is less strong for dependent and avoidant personality types.

3. Social/environmental.

Availability of the drug, societal and cultural norms, peer group influences, dysfunctional family backgrounds, and occupation (long distance drivers, menial laborers, entertainment industry – Micheal Jackson, Britney Spears, Fela, Majek Fashek e.t.c) all play a role.

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Other Risk Factors for Drug Use

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• Mental health disorders
• Family neglect and abuse (lack of involvement, abusive parenting, chaotic environment)
• Poor attachment to school and the community (poor early education, negative school environment)
• Growing up in marginalized and deprived communities

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• Lack of social Skills
• Coping with physical pain/illness.
• In summary, an interplay between biology (genes) and the environment.

Treatment modalities in alcohol and other�drug use disorders�

OBJECTIVES

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► Have an overview of the treatments

options.

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► Decide on the option(s) that would best

suit the patient.

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WHY TREAT

• Treatment is required because drug addiction is a disease. (Jellinek, 1960, Mclellan, 2000.

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. Evidence abound that treatment is effective and it leads to a reduction in illicit use of drugs (Hubbard et al, 1986)

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• A treated patient will not recruit others into drugs, hence treatment is needed for prevention.

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• Treatment reduces the prevalence of drug related crimes.

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• It reduces the transmission of HIV/AIDS, and hence it is an essential tool for public health control of these disorders [Public Health Report, 1986, Ghodse, 198.

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• Treatment enables the addicted person to reduce or stop his drug use, and enables him to live a more organized and stable lifestyle.

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• Clinical trials have shown that treatment interventions are more effective than non-treatment. (Mertzger al, 1993)

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• Treatment reduces the economic cost of alcohol and drug use disorders on the society.

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• The addicted person gets the message that he is not rejected by the society and can be helped

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PHASES OF DRUG ABUSE MANAGEMENT

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► Assessment & Diagnosis

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► Detoxification/Stabilization

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► Main Treatment/Rehabilitation

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► Relapse Prevention/Continuing Care

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ASSESSMENT

Patient must be assessed for treatment and for what type of treatment.

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Assessment will include:

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(A) HISTORY TAKING AND MENTAL

STATE EVALUATION :

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• The type[s] of drugs being abused.
• How often and quantity.
• The level of motivation of the patient.
• Symptoms when drug is unavailable.
• Typical drug day.

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• The presence of co-morbid psychiatric conditions e.g. depression, anxiety, personality disorders, schizophrenia and others.
• The presence of comorbid medical conditions (e.g. liver disease, heart condition).
• The degree of social problems.
• The degree of social support.

- Level of motivation for change.

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MEDICAL EXAMINATION

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A thorough medical examination is mandatory

in the initial assessment of the patient.

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Assessment is made for:

♦ Drug injection sites

♦ Cutaneous manifestations of drugs use

♦ Medical conditions.

♦ Withdrawal symptoms

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INVESTIGATION

Investigation for various medical problems and

diseased organs directly or indirectly related to

drug use must be carried out. These include.

♦ FBC

♦ Urinalysis

♦ Urine drug analysis

♦ HIV

♦ Mantoux Test

♦ Hepatitis B/C Virus

♦ Chest X-Ray

♦ Any other as indicated.

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• The initial assessment helps one to decide on:

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• What type of treatment to give and

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• Where the treatment is to be offered – in-patient, out-patient or others.

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• Psychiatric/medical interventions for comorbid conditions.

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• Level of Social intervention.

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STAGES IN DRUG TREATMENT�

DETOXIFICATION

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Detoxification is the sudden or graded withdrawal of the

drug of abuse from the abuser

The process of:

• Stopping substance use
• Clearing the substance from the body
• Managing the withdrawal syndrome

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Sudden Withdrawal - Withdraw all the

drugs of abuse at once.

♦ Have a withdrawal symptom chart opened.

♦ Give decreasing doses of sedatives or other drugs found effective in withdrawal.

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►DRUGS IN USE FOR WITHDRAWAL

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- Benzodiazipines Gold standard for use in withdrawal.

- Chlordiazepoxide (Librium)

- Clonazepam [Rivotril]

- Diazepam [Valium]

- Abecamil (a benzodiazyine receptor agonist.

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► Anticonvulsants

- Barbiturate (Phenobarbitone)

- Carbamazepine [Tegretol)/Na Valproate (mild →moderate withdrawal)

- Vigabatrin (GABA-T-Inhibitor, in trial)

- Over a 3-7 day period hardly longer and stop all withdrawal medications.

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GRADED WITHDRAWAL

In graded withdrawal usually in opiod dependence, (heroine, fortwin etc) the drug being abused is substituted with another agonist drug e.g. methadone, buprenorphine, for morphine or heroine

The dose of the substituted drug is then gradually withdrawn.

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• Reasons for detoxification
• To provide a safe withdrawal from substances of dependence and to enable the person to become drug free
• To provide a withdrawal that is humane
• To prepare the person for ongoing treatment

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NB Detoxification is ONLY a first step toward recovery; it is NOT treatment

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Treat other clinical problems symptomatically viz persistent diarrhoe, abdominal cramps etc.

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MAIN TREATMENT

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MODELS

▼ Drug Free (Abstinent) Treatment Model

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▼ Drug Maintenance Treatment Models.

- Agonist Drugs e.g. Methadone, Buprenorphine.

- Antagonist Drugs e.g.

- Naltrexone or Naloxone for opiate dependence.

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▼ Other Pharmacotherapies:

- Anticraving drug e.g. Desipramine, Amantandine

- Flupenthixol for cocaine.

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▼ Combination of the above programmes

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• Drug Free (Abstinence) Treatment Model:

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• These include:
• Twelve-steps model
• Therapeutic Community Treatment (TC) model
• Minnesota Treatment Model
• Self-Help Groups
• Spiritual Approach Treatment Model
• Combination of the approaches

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Most Drug Free (Abstinence) programs incorporate some or all of

the following:

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 Drug Education (Education only is not effective because

drug abuse is not due to lack of knowledge)

 Use of Group in counseling/psychotherapy. Psychotherapy

include:

- Behavioural

- Cognitive Behavioural Therapy

- Interpersonal

- Family approaches

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• Use of Rules/Regulations
• Relaxation Exercise/Recreational Sessions (Abusers have ↑ stresslevels.
• Social Intervention (Services)
• Group Culture
• Individual/Family/Marital Sessions
• Patient Governance
• Skills Training/Retraining
• Spiritual Therapy

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DRUG MAINTENANCE PROGRAM�

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• Drug Maintenance Using

- Angonist drugs

- Partial agonist drugs and

- Antagonist drugs.

Some of these drugs can be used for withdrawal,

as well as for maintenance treatment.

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Agonist drugs

▼Methadone (Dole & Nyswandar, 1956)

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• Synthetic Narcotic Agonist, Longer Acting
• Lasts 24 – 36 hours if taken in adequate oral doses
• Relieves narcotic craving
• Cross tolerance or blockade occurs which blocks the narcotic effects of street doses of heroine.
• shorter acting narcotics.
• Less harm with overdose
• Nil Euphoric, sedative or analgesic effects with oral methadone dose
• Adequate doses not <60mg daily (Hartel, 1989). Usually 80-120mg
• Available in syrup and tablet forms

▼ CLONIDINE

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• Adrenergic Agonist
• Used to treat Hypertension
• Useful in withdrawal of : Alcohol
• Tobacco
• Opiates
• Methadone
• Limited Utility because of its
• Sedating and Hypotensive effects

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DRUG AVERSION PROGRAM�

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• Disulfiram [antabuse, abstem] for alcohol dependence.
• Apomorphine [Alcohol dependence]
• Treatments based on behavioural learning paradigm [classical]
• Disulfiram blocks the enzyme alcohol ← dehydrogenase which blocks the
• Conversion of [→] Acetaldehyde →H20 + C02 → acetaldehyde → accumulation → Flushing → Sweating.
• Heat, piloerection
• ↑ B/P
• Problem of drug adherence
• Requires Supervised ingestion and contigency management strategies.
• Goal should still be total abstinence.

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PARTIAL AGONIST

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▼ BUPRENORPHINE

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• MU – Agonist [Partial]
• 25-25 x more potent than morphine
• Effective sublingually/IV
• Dose 2-4 mg daily
• Has poor oral bioavailability
• Lasts 72 hrs

● Available sublingual tables (subutex,

suboxone) 4-12mg/dly, max 24mg/dy

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● Available in Patches 5, 10, 20mg, mainly for pain

treatment. The drugs for maintenance can also be

used for detoxification and then withdrawn.

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Antagonist Drugs

Naltrexone, Naloxone

- Bind to opiate receptors

- Block morphine-like euphoric effects of opiates

- Competes with: Exogenous

& Endogenous Opiates

- Safe and well tolerated.

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- Naloxone/Naltrexone (Pure MU-Antagonist) (Have

no Agonist Properties).

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Naloxone: Naltrexone

Poorly absorbed Better absorbed orally

Few Hours of action after oral Lasts ↑72 hours after oral use. Ingestion.

Has weak agonist properties

- Depot preparation of Naltrexone now available 380mg.1.m

mthly.

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DISADVANTAGES

- Opiate antagonist could

1. Interfere with normal central pain inhibitory systems

2. High drop-out (70%)

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OTHER DRUG ABUSE TREATMENTS MODELS INCLUDE:

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HARM-REDUCTION

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- Driven by the upsurge in HIV/Hepatitis C infection.

- Aim to ↑ the number of abusers in treatment

- Intermediate treatment goals, not total abstinence is targetted

- All the same such intermediate treatment goals help to ↓ drug

abuse in individual/society.

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- Strategies include  Education on safe injection methods.

 Administration of sterile needles, syringes and injection equipments

 Counselling and screening for HIV/Hepatitis B/C

 Giving Hepatitis B Vaccination.

 Drug maintenance may also be offered

OTHER PHARMACOTHERAPIES

• Anticraving drugs e.g
• Desipramine )
• Amantandine ) for cocaine
• Flupenthixol )

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• Combination of drug free programs and drug maintenance programmes

REHABILITATION

The rehabilitation of the patient must be commenced immediately he gets into treatment. Rehabilitation means the proper re-integration of the patient back into the society. It implies re-integration into.

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a. A job

b. Education

c. Apprenticeship training

d. Family and the

e. Social community

In such a way that the individual is not disadvantaged at every point. Improper rehabilitation is a potential cause of relapse.

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Family members are an integral part of the rehabilitation work, they form a useful link between the care-givers, and the society.

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A good social-network with linkage organizations are important for effective rehabilitation in Nigeria.

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- link up with National Directorate of Unemployment

- link up with voluntary Organizations (Lions Club,

Rotary Club etc)

- Religion Organizations are a good link

- Plus others

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RELAPSE PREVENTION

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DEFINITION

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• Maintenance of abstinence is actually “ Relapse Prevention”. One of the hallmark of drug dependences is the propensity to relapse, that is initiation of drug use after a period of abstinence

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Motivation for Abstinence

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> Maintain Motivation (Reinforcers Motivational interview)

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> Set out clear Abstinence Goals

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▲ Ensure adequate Coping Skills

* Employment - Seeking

- Keeping

* Social Skills - No to Friends

- Drug-Free Networks

> Assertiveness training

> Self-Esteem building

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Social Support

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> Proper Housing

> Family harmony

> Social Acceptance (Neighbourhoods)

> Mobilization of Non-Familiar Systems

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Emotions

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● Negative Affect - Sadness

- Frustration

- Disappointment

● Positive Emotions - Happiness

- Celebration

- Good times

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• Attend self help group meetings
• Adhere to follow up visits

Conclusion

• The use of psychoactive substances is a universal problem that is very prevalent in our society.
• 40-60% of why people become addicted is genetic, the rest in environmental
• All of these factors have implications for clinical therapy/management and public mental health efforts aimed at preventing/minimizing psychoactive substance use.
• Treatment menu include a wide range of options including pharmacological and non pharmacologicalmethods.

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