Substance problem treatment

1. 1
SUBSTANCE USE DISORDERS III
TREATMENT APPROACHES
BEING
THE TEXT OF LECTURE DELIVERED AT THE FACULTY
OF PSYCHIATRY, NATIONAL POST GRADUATE
MEDICAL COLLEGE OF NIGERIA REVISION COURSE
IN PSYCHIATRY JANUARY, 2019
BY
DR. [MRS] T.A. ADAMSON
MBBS [Ib], DPM [Eng.], MRC PSYCH [U.K],
FMC PSYCH [Nig], FWACP

2. 2
TREATMENT MODALITIES IN ALCOHOL AND
DRUG USE DISORDERS
INTRODUCTION
OBJECTIVES
► Have an overview of the treatments
options.
► Decide on the option(s) that would best
suit the patient.

3. 3
WHY TREAT
• Treatment is required because AOD is a disease.
(Jellinek, 1960, Mclellan, 2000.
. Evidence abound that treatment is effective and it
leads to a reduction in illicit use of drugs (Hubbard
et al, 1986)
• A treatment addict will not recruit others into drugs,
hence treatment is needed for prevention.
• Treatment reduces the prevalence of drug related
crimes.
• 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, 1987.

4. 4
• Treatment enables the addict to reduce or stop his drug
use, and enables him to live a more organized and
stable lifestyle.
• Clinical trials have shown that treatment interventions
are more effective than non-treatment. (Mertzger al,
1993)
• Treatment reduces the economic cost of alcohol and
drug use disorders on the society.
• The addict gets the message that he is not rejected by
the society and can be helped.

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PHASES OF DRUG ABUSE MANAGEMENT
► Assessment & Diagnosis
► Detoxification/Stabilization
► Main Treatment/Rehabilitation
► Relapse Prevention/Continuing Care

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▀ ASSESSMENT
Patient must be assessed for treatment and for what
type of treatment.
Assessment will include:
(A) HISTORY TAKING AND MENTAL
STATE EVALUATION :
– 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
A thorough medical examination is mandatory
in the initial assessment of the patient.
Assessment is made for:
♦ Drug injection sites
♦ Cutaneous manifestations of drugs use
♦ Medical conditions.
♦ Withdrawal symptoms
Among Others

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INVESTIGATION
Investigation for various medical problems and
diseased organs directly or indirectly related to
drug use must be carried our. These include.
♦ FBC
♦ Urinalysis
♦ Urine drug analysis
♦ HIV
♦ Mantoux Test
♦ Hepatitis B/C Virus
♦ Chest X-Ray
♦ Any others as indicated.

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▀ The initial assessment helps one to decide
on:
– What type of treatment to give and
– Where the treatment is to be offered – in-patient, out-patient
or others.
- Psychiatric/medical interventions for comorbid conditions.
- Level of Social intervention.

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MOTIVATIONAL INTERVIEWING
Patients can be motivated to want to change their maladaptive
substance use, especially during the initial assessment.
STEPS IN MOTIVATIONAL INTERVIEW
● Avoid confrontation
● Encourage patient to personally assess the balance of the
positive and negative effects of substance use.
● Reiterate what gains he would derive from not doing drugs, using
what he says.
● Express empathy.
● Point out discrepancies in the history he narrates.
● Make aware of where he wants to be and how drug use is
contrasting that.

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STAGES OF CHANGE
Pre-contemplative
Does not believe there is a problem although other see this
Contemplation
Starts to consider the pros and cons and possibility that
change is essential.
Decision
Decision is taken either to act or not to act.
Action
Patient chooses a strategy for change and pursues it.
Maintenance
Gains are maintained and considered. Failure may lead to relapse.
Relapse
Return to previous pattern of behaviour.

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Generally, there are 4 levels of treatment interventions
in decreasing levels of treatment intensity.
TREATMENT INTERVENTION LEVELS
These are:
 Advise/Self-help.
 Brief interventions (usually five counseling sessions or less)
lasting about 1 week.
> Advice is given on safe use of drugs especially
alcohol
> Not ideal for those with severe problems.

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> Mainly education lasting 5-30 minutes.
> Usually include self-help manuals.
> Aim to guide the individual to achieve desired
behavioural change.

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TYPES OF TREATMENT INTENSITY INTERVENTIONS
In Nigeria most patients are managed as
Residential In-Patient for various reasons. Some
of these reasons include:
♦ Adequate treatment personnel, equipment
and adequate resources in In-Patient
setting.
♦ Transportation difficulties (Drug
abusers may come from far distances)
♦ In-patient treatment allows better control
over treatment variables, although not a
real life environment.

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STAGES IN DRUG TREATMENT
DETOXIFICATION
Detoxification is the sudden or graded withdrawal of the
drug of abuse from the abuser. Drug withdrawal can
result in psycho-physiological symptoms (withdrawal
symptoms) which can be quiet disturbing and life
threatening for alcohol, opiod and hypno-sedative.
Detoxification therefore is better managed in a
residential setting (in-patient) in Nigeria.

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Withdrawal symptoms (Syndrome)
♦ These are a constellations of psycho-
physiological symptoms brought on by the
sudden withdrawal or reduction in the drug of
abuse.
♦ The symptoms are drug specific.
♦ They vary in severity and duration.
1 – 3 days for caffeine
1 – 14 days or  for cocaine, amphetamine
or heroine

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♦ While very uncomfortable, the
symptoms will subside without
medication.
♦ However, the symptoms may be
life-threatening in some patients
e.g. chronic alcoholic with
compromised immunity.

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Sudden Withdrawal - Withdraw all the
drugs of abuse at once.
♦ Have a withdrawal symptom chart opened.
♦ Give decreasing doses of hypno-sedatives or other
drugs found effective in withdrawal.
►DRUGS IN USE FOR WITHDRAWAL
- Benzodiazipines (Gold standard for use in
withdrawal).
- Chlordiazepoxide (Librium)
- Clonazepam [Rivotril]
- Diazepam [Valium]
- Abecamil (a benzodiazepine receptor agonist)

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► Anticonvulsants
- Barbiturate (Phenobarbitone)
- Carbamazepine [Tegretol)/Na
Valproate (mild →moderate withdrawal)
- Vigabatrin (GABA-T-Inhibitor, in trial)
- Acomprosate
Give decreasing dose of the drug over a 3-10 day
period, hardly longer and stop all withdrawal
medications.
 Monitor patients vital signs during detox
 Increase fluid intake markedly
 Document Detox chart appropriately

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Other withdrawal Procedures include:
♦ Acupuncture
♦ Inhalation Nitrous Oxide [South Africa]
♦ Transcendental Meditation
♦ Spiritual Treatment
Treat other clinical problems symptomatically viz
persistent diarrhoe, abdominal cramps etc.

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GRADED WITHDRAWAL
• In graded withdrawal usually in opiod dependence,
(heroine, pentazocine 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.
• Methadone dose should be calculated based on the
level of opiod in use before treatment. (usually 80 –
100mg p.o dly)
• Buprenorphine sublingually 2-4mg lasts 72 hours

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Progress of Alcohol Withdrawal from
Time of Last Drink
deCrespigny & Cusack (2003)
Adapted from NSW Health Detoxification Clinical Practice Guidelines (2000–2003)

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MAIN TREATMENT
MODELS
▼ Drug Free (Abstinent) Treatment Model
▼Drug Maintenance Treatment Models.
- Agonist Drugs e.g. Methadone, Buprenorphine.
- Antagonist Drugs e.g.
- Naltrexone or Naloxone for opiate dependence.
▼ Other Pharmacotherapies:
- Anticraving drug e.g. Desipramine, Amantandine
- Flupenthixol for cocaine.
▼ Be aware that abstinence is not the only goal for all
individuals e.g. controlled drinking, harm reduction can be
useful in a few.

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Drug Free (Abstinence) Treatment Model:
These include:
– Twelve-steps model
– Therapeutic Community Treatment (TC) model
– Minnesota Treatment Model
– Self-Help Groups
– Behavioural Treatment Models viz Cognitive,
Rational-Emotive
– Spiritual Approach Treatment Model
– Combination of the Approaches

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Where treatment is to be offered viz:
– Residential (In-Patient) – Short term –
treatment lasting <90 days.
- Long term – treatment lasting > 90 days.
• The status of the patient
– Dual diagnosis with comorbid mental/medical
disorders.
– Self-Referred Patient
– Patient brought under coersion or criminal
justice system.

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FIGURE 1
Sudden Graded
Withdrawal (Gradual withdrawal)
Residential Non Residential Out-Patient
Relief Graded
Psychophysiological/ Drugs
Behavioural Symptoms Reduction (Methadone)
- Anxiety/Agitation - Nil Withdrawal
- Fear/tremors Symptoms or
- Sleep Disturbances - Minimal Symptom
- Diarrhoe Calculate
- Others Methadone dose
5-14 days
- Depend on – severity of abuse
- Dose before withdrawal

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DRUG FREE (ABSTINENCE PROGRAM)
Residential Out-Patient
TC Minnesota Others
- Daytop
- Phoenix
- Second Genesis
Rxt models

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TC MINNESOTA OTHERS
12 Steps - Disease Model - Groups
Confrontational/ - 12 Steps - Psychotherapy
Encounter
Hierachichal - AA - Spiritual
- Education - Video Feedback
- Relaxation - Education
- Bio Feed Back

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Out-Patient
Self-Help Groups/Others
AA NA Twelve Steps

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▀ PREDICTORS OF TREATMENT OUTCOME
– More than 250 therapies available (Parloff, 1980)
– Too many choices but few data to decide the
treatment of choice
– No Treatment model found superior to another
– A combination of-detoxification
Group work
Education
Appropriate rehabilitation and
Relapse prevention (O’brien, 1991 Mclellan,
1992)
Have been found to be most effective.

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Treatment episodes shorter than 90 days have
been shown to predict poorer outcome with
percentage of favourable outcome improving in
direct proportion to the time spent in treatment.
(Simpson et al, 1982,1984).

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Most Drug Free (Abstinence) programs incorporate some or all of
the following:
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
• 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
• 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)
– 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.

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ADVANTAGES
– Enable better organized lifestyle
 Crime related problems
– HIV/AIDS
– Addict available for rehabilitation
– Illicit drug use

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Methadone treatment not available in
Nigeria yet and moreover it should be a
short-term, treatment strategy. Aim should
still be for total abstinence. Not feasible in
Nigeria presently because of:
– Problems of multiple dosing
– Many abusers not IV injection users
– Logistics of transportation
– Substituting one addiction for another

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▼ CLONIDINE
– 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
– 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
▼ BUPRENORPHINE
– 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
● 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
& Opiates
Endogenous
- Safe and well tolerated.

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- Naloxone/Naltrexone (Pure MU-Antagonist) (Have
no Agonist Properties).
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.
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:
HARM-REDUCTION
- 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.
- 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.

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Controlled-Drinking
> This may be useful in people whose alcohol abuse
has been detected early and who are not
dependent.
> Individuals with lesser levels of alcohol-related
disorders may benefit from this.
> Individual must be counselled on safe levels of
alcohol.

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Acamprosate
- Derivative of amino-acid taurine →
- ↑ level of taurine an inhibitory neurotransmitter
- Safe, well tolerated (nausea, diarrhoe, headache)
- 2g P.O/dly in divided doses.
- Combination of Natrexone + Acamprosate safe and
superior to Acamprosate alone.
- Combination of Disulfiram + Acamprosate also
safe.

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Potentially lethal dose
Positive
effect
=
addictive
potential
Negative
effect
Full agonist -
morphine/heroin
hydromorphone
Antagonist - naltrexone
dose
Antagonist + agonist/partial agonist
Agonist + partial agonist
Super agonist -
fentanyl
Partial agonist
- buprenorphine
Mu efficacy and opiate addiction

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OTHER PHARMACOTHERAPIES
– Anticraving drugs e.g
– Desipramine )
– Amantandine ) for cocaine
– Flupenthixol )

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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.
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.
A good social-network with linkage organizations are
important for effective rehabilitation in Nigeria.
- 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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PREVENTION
1. Primary Prevention - This ensures that drug
use is not commenced
2. Secondary Prevention - This ensures that those
already abusing drugs
get early and adequate
treatment.
3. Tertiary Prevention - This ensures limiting of
disabilities in terms of
medical, psychological,
social, occupational and
employment disabilities in
those already abusing.

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RELAPSE PREVENTION
DEFINITION
– 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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WHAT IS RELAPSE
Rounsaville, 1986 described relapse as “Resumption of
substance abuse following a period of abstinence”.
However, questions arise as to the followig:
1. What amount of drug use constitute relapse?
• Some believe any amount.
2. For how long?
• Once for some [slip]
• 7 consecutive days of use [more appropriate for nicotine]
• Return to baseline use
3. After what length of time of abstinence
• 48 hours of abstinence [acceptable criterion]

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Precipitants that have been associated with
return to drugs (Marlatt & Gordon, 1980)
include:
– Emotional states
– Interpersonal conflicts
– Social pressures
– Specific drug cues

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STAGES OF RELAPSE
There are 3 stages to relapse:
Stage 1 - The First lapse or “Slip”
after a quit episode
Stage 2 - Transition – between
slip and relapse
Stage 3 - Relapse – defined
as continued use of the
drug

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However, individuals tend to transit to pre-treatment
levels of drug use quickly. There are however, many
variables about relapse that are yet unknown such as:
– What variables lead to the first Lapse or Slip
– Are these variables different from those that
control the Relapse itself
– Are the variables that lead to Relapse different for
different drugs
– What is the length of time an individual spends at
the various levels of relapse.

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WHY RELAPSE OCCURS
The real reasons for relapse are still not fully understood
but some theoretical models have been proposed. These
are:
▲ Cognitive – Behavioural Models (Marlatt &
Gordon, 1985)
• In this Marlatt & Gordon, 1985 suggested that the relapse
process begins when an Ex-Drug User confronts a situation or
risk which he has no effective coping response to. Situations
of risks include:
– Negative/Positive Emotions – anger, depression, frustration,
happiness
– Peer or Social Pressures

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• Drug Availability
• Unemployment/Idleness
• Money Availability
• Drug Paraphernalia
• Faulty Cognition - Positive expectancies
on the effects of the
drugs.
- Cognitive
reminiscences of
earlier use and its
effects.
• Drug-Using-Networks

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• The situation of risk coupled with the positive
expectancies for the initial effective of the drug
results in a slip, which may lead to a full-blown
relapse via the “Abstinence Violation Effect”
(AVE). A core construct in the cognitive-
behavioural model.
• AVE – This occurs in individuals who are
committed to absolute abstinence. A slip in such
individuals results in continued drug use
(relapse) through:

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– The individual attributing responsibility to
himself for the slip which results in a negative
affect which the individual has always dealt
with in the past with drug use, leading to a full
blown relapse.
– He may also develop wrong cognition, “I am a
helpless, hopeless addict”, thus giving up all
efforts at controlling further drug use.

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Conditioning Model
The conditioning model emphasizes craving
(Wikler, 1948). This is based on the classical
conditioning paradigm in which drug effects and
or withdrawal symptoms are conditioned on
environment/ interoceptive stimuli. Later on, the
environment/interoceptive stimuli elicit drug
craving.

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VARIABLES IMPORTANT IN RELAPSE PREVENTION
▲ Commitment/Motivation to Abstinence (Miller, 985)
– Studies have shown that a commitment to total
abstinence as a goal after treatment predict a
better short-term outcome than a commitment to
less stringent goals (e.g. cigarettes only, one slip
only)
– Motivation or commitment may be maintained by
contingency management using positive or
negative reinforcements (monetary rewards, loss
of privileges) etc and these have been found
effective (Anker & Crowley, 1982).

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However, the drawback of contingencies is that
once reinforced are removed then the motivation
may wane. Contingency management should
be transferred to communities or families for
continuity.

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Coping Skills
• Individuals can be trained in skills that should
prevent relapse. Such coping skills include:
– Job-Seeking Skills (unemployed)
– Job-Holding Skills
– Parenting Skills
– Assertiveness Skills
– Social Skills for developing non-drug using
networks
– Self-Esteem Enhancing skills etc.

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Social Support
• Lack or inadequate social support can
easily predispose to relapse. There are 2
major dimensions to social support, that is:
– Structural Social Support – This is the
existence of relationship with others in social
structures e.g. marriage, group membership,
(club, church), family.
– Functional Social Support – This is how these
relationships provide emotional, informational
and material resources.

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Research has shown that social support may be
particularly important to drug-abusing women.
Family support is important for successful
treatment of women, mostly families may be
reluctant in accepting that the woman addict
goes into treatment as child-care may fall on
them. So also is the responsibility of caring for
the whole family.

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▲Emotions (Negative Affect)
• Drug abuses have high rates of depression/Anxiety
Negative moods and depression predict higher
relapses rates.
. Patients with depression should be treated.
. Those without depression may be dysphoric most of
the time, psychological interventions/cognitive-
behavioural treatment have been found useful in
such individuals.

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▲Drug Cues and Reactivity
• Environmental cues can lead to internal responses
(craving) which can result in relapse.
• Drugs cues can spark off powerful drug craving through
possible stimulation and increased activity of specific
brain centers (Dorsolateral Prefrontal Cortex, Amygdala,
and Cerebellum).
• These are areas in the brain that are involved in the
cognitive aspects of
• Memory and the emotional colouring to memory (Grant
et al 1996). Memory may therefore be more critical to
drug craving than the traditional concept of
reinforcement

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Drug Cues include:
– Drug or Drug Paraphernalia
– Drug-Using Social Network
– Emotions
The specific cues for the individual must be
established.

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Action
● Exposure technique and response
prevention for reducing cue responsiveness
(exposure to cues)
● Drug – Avoidance
● Priming Doses of Drugs and Response
Prevention.
Some drugs serve as cues for other drugs e.g.
Alcohol consumption has an important cue to
cocaine relapse.
Extinction methods must transfer from treatment
setting to the outside world.

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▲ Stress
• Stress has long been implicated in drug abuse.
Addicts tend to experience a high level of
stressful events. One of these events may
precede a lapse but may still not be causative.
What to do
• Stress-Reduction Training. (Relaxation
techniques)

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▲ “Abstinence Violation Effect” (AVE)
A lapse or slip in an individual already committed
to total abstinence result in:
– Attributing responsibility of slip to self resulting
in negative affect. Negative affect had been dealt
with by the individual with drug use, hence
recourse to this.
– Slip results in cognitive dissonance or faulty
cognition in the individual “I am a failure, I cannot
control my drug use, I am hopeless and helpless”,
resulting in more drug use.
• AVE has been studied more in nicotine addicts.

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SUMMARY
▲ Motivation for Abstinence
> Maintain Motivation (Reinforcers Motivational interview)
> Set out clear Abstinence Goals
▲ 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
> Proper Housing
> Family harmony
> Social Acceptance (Neighbourhoods)
> Mobilization of Non-Familiar Systems

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▲ Emotions
● Negative Affect - Sadness
- Frustration
- Disappointment
● Positive Emotions - Happiness
- Celebration
- Good times

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▲Cognition
● Faulty Cognition - Cognitive Dissonance
“I am Helpless”
● Cognitive - Memory of Drug
Reminiscences
● Hence Use of Cognitive Behavioural Therapy in Drug
Abuse treatment
▲Drug Cues and Reactivity
● Drugs
● Drug Paraphernalia
● Drug-Using Social Networks
● Cognitive-Reminiscences
● Extinction Methods must transfer from
Treatment Setting to the Outside World

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DUALLY DIAGNOSED
These are individuals with alcohol and drug abuse
problems co-existing with other psychiatric
psychopathology e.g. These may include:
◄ Affective Disorders (Depression Common)
◄ Personality Disorder (Anti-Social Personality:
ASP Common)
◄ Schizophrenia
◄ Others

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WHY COMORBID PSYCHIATRIC CONDITION
Comorbid condition can be due to:
◄ Acute drug effects (organic psychotic
condition)
◄ Drug withdrawal effects (illusions,
hallucinations etc)
◄ Persistent (Residual) drug effects (Schiz-like)
◄ Funtional non-related psychiatric conditions.

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MANAGEMENT
Manage the psychiatric illness or symptoms
first to make patient available to effective
drug treatment:
◄ Manage in General Wards then transfer
to Drug Unit
• Some advocate managing the Drug Abuse first.
• Depression - Antidepressants
- Psychotherapy
• Schiz drug intervention

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*Personality disorder especially ASP anti-social-
personality, use behavioural treatment with
rules/regulations most with ASP are used to
doing what they like.
PATIENT – TREATMENT – MATCHING
• What type of patient should be matched with what
Type of Treatment
HARM REDUCTION ISSUES (DISCUSS)

80. 80
REFERENCE
Hubbard, R.L. and Marsden, M.E. (1986). Relapse to the use of
Heroin, Cocaine and other drugs in the first year of treatment.
NIDA Research Monograph 72. DHHS Pub. No. (ADM) 86-1473
Jellinek, E.M. (1960). The Disease Concept of Alcoholism. New
Brunswick: Hillhouse Press.
Mclellan A.T. et al, (2000). Drug Addiction, a Chronic Medical
illness: Implication for Treatment, insurance and outcome
evaluation. Journal of American Med. Assoc. 284:13
Metzger D.S. et al, (1993). HIV Seroconversion in an our of
treatment introvenous drug users: an 18 month prospective
follow-up. AIDs 6:9; 1049-1056