REPUBLIC OF KENYA
MINISTRY OF MEDICAL SERVICES
2012
ACKNOWLEDGEMENTS
This protocol and guidelines to substance use disorders treatment is a result of collaborative effort between the Government of Kenya and the United Nations System in Kenya, and namely between Ministry of Medical Services (MoMS), the National Campaign Against Drug Abuse Authority (NACADAA), National AIDS Control Council (NACC), University of Nairobi (UoN), Civil Society, drug user involvement, service providers, the United Nations Office on Drugs and Crime (UNODC) and World Health Organization (WHO).
A special recognition is due to the Director of Mental Health, Ministry of Medical Services, and the Medical Superintendent and staff of the Mathari Referral Hospital, in Nairobi, and Coast Province General Hospital, in Mombasa.
A number of key documents and recommendations from WHO, UNODC and Treatment were reviewed in the preparation of this protocol.
The staff of the above-named institutions and organizations has done a commendable job to contribute to provide better health care to individuals with substance use disorders.
Dr. David M. Kiima
Director of Mental Health
FOREWORD
Substance (Drug) Abuse is increasing in Kenya and especially among the youth. Current statistics indicate that more than half of drug users are aged (10-19 years). The youth are the backbone of any country of Socio-economic development and any disruption to the social fabric within this age group results in decline in literacy levels, loss of productivity and therefore economic loss to the country. In line with our Vision 2030 of becoming a globally competitive middle income economy and prosperous nation, urgent measures are required to curb this menace of substance.
Most studies done in the country indicate that the commonly used drugs are nicotine, alcohol and cannabis. Due to the strategic location f Kenya in the East African region and Nairobi being an economic hub in the region, there has been an upsurge of international narcotic drug trafficking leading to increased injecting drug users (IDU)s. The Kenya HIV/ AIDs Indicator Survey (KAIS) 2009 report indicates that HIV prevalence rate among IDUs stands at 18.3% compared to 6.7% among the general population.
The Kenya Constitution 2010 under CHAPTER FOUR (the Bill of Rights) recognizes the right to the highest attainable level of health care to all. In this regard, persons with substance use disorders are entitled to access quality healthcare services. Therefore these guidelines have been developed with a view to disseminating them to all service providers countrywide for use in provision of standardized and quality healthcare services to drug users.
This National Treatment Protocol for substance use disorders will enable appropriate management of substance use and its related health and social consequences including HIV. It is based on international best practice to manage substance use disorders. It will be a useful and practical guide for practitioners dealing with substance abuse problems in Kenya.
This protocol outlines the pharmacological treatment, psychosocial interventions and aftercare support which will be provided in line with international standards and procedures, while respecting the national social, cultural and economic realities. It provides a humane and scientific approach delivered by skilled practitioners in order to assist the drug dependent person to attain the highest level of personal, professional, familial and social functioning.
This protocol was developed through the effort by the Government of Kenya in partnership with United Nations Office on Drugs and Crime (UNODC). The Ministry of Medical Services in collaboration with UNODC offered stewardship. I wish to thank the; Ministries of Health (Ministry of Medical Services and Ministry of Public Health and Sanitation), the National Campaign Against Drug and Alcohol Abuse Authority (NACADAA), National AIDS Control Council (NACC), University of Nairobi (UoN),
Civil Society, the United Nations Office on Drugs and Crime (UNODC) and World Health Organization (WHO), for having tirelessly worked on this treatment protocol which will go a long way in enhancement of substance use disorders treatment in the country. Finally I would like to appreciate and thank the Minister for Medical Services Hon. (Prof.) Peter A. Nyong’o and the Permanent Secretary Ngari M.W.(MS) CBS for their overall stewardship and guidance in the health sector policy.
Dr. Francis M. Kimani
Director of Medical Services
Table of Contents
NATIONAL TREATMENT PROTOCOL FOR SUBSTANCE USE TREATMENT IN KENYA
Acknowlegments
Foreword …………………………………………………………………………………….………….2-3
List of Abbreviations
Introduction
1. Outreach Services
2. Out-patient Treatment
3. Residential treatment and Inpatient Treatment.
4. Suggested Criteria for the choice of treatment setting ……………………….. 10
Phases and components of Treatment
1. Patients’ Rights11
Evaluation
1.1. Diagnosis
1.2. Assessment…-15
Medical Assessment
Psychiatric Assessment16
Nutritional Assessment
Social and Emotional Assessment
Family Assessment
Occupational Therapy Assessment
Nursing Assessment18
Recreational, Stress, and Leisure Assessment
Legal History
1.3. Assessment Tools:
1.4. Treatment Planning
Treatment Interventions................................................................................................21
Introduction.
Pharmacological Treatment Interventions
Alcohol
Nicotine…………………………………………………………………………………………21
Heroin/Opioids
1..... Non-Opioid Substitute Treatment26
2. Medication Assisted Treatment (MAT)…………………………………………..27 - 37
Psychosocial Treatment Interventions37-41
Psychosocial assessment
Important Psychosocial Interventions
Motivational enhancement therapy
Contingency management
Individual and Group Psychotherapy
Family and Marital Therapy
Supportive Expressive Psychotherapy
Continuing Care and Aftercare41
LIST OF ABBREVIATIONS
AA Alcoholics Anonymous
ADS Alcohol Dependence Scale
AIDS Acquired Immune Deficiency Syndrome
ARV Anti-Retroviral Treatment
ASI Addiction Severerity Index
ASSIST Alcohol, Smoking & Substance Involvement Screening Test
AUDIT Alcohol Use Disorder Identification Test
BID Twelve Hourly Dose
CAGE Cut down, Angry, Guilt, Eye opener
CBT Cognitive Behavior Therapy
CNS Central Nervous System
DHHS Department of Human Health and Human Services
DSM IV-TR Diagnostic and Statistical Manual of Mental Disorders. 4thEdition. Text Revised
GABA Gamma Amino Butyric Acid
HIV Human Immunodeficiency Virus
ICD - 10 International Classification of Diseases -10
ICU Intensive Care Unit
IM Intra-Muscular
IV Intravenous
LFTs Liver Function Tests
MAT Medication Assisted Treatment
MAST Michigan Alcoholism Screening Test
MAOIs Mono Amine Oxidase Inhibitors
MOH Medical Officer of Health
MOMS Ministry of Medical Services
MT Methadone Treatment
NA Narcotics Anonymous
NACADAA National Authority for the Campaign Against Alcohol and Drug
Abuse
NGO Non Governmental Organization
OD Once Daily Dose
PMO Provincial Medical Officer
PRN As required medication
QID Six Hourly Doses
SSRIs Selective Serotonin Re- uptake Inhibitors
STIs Sexually Transmitted Infections
TDS Eight Hourly Dose
THC Tetra Hydro Cannabinol
TIP Treatment Improved Protocol
U.S. United States
UNODC United Nations Office on Drugs and Crime
W.H.O World Health Organization
Guidelines for Substance Use Disorders Treatment
Introduction
These Guidelines are not intended to be a comprehensive textbook or manual for the treatment of drug use. Doctors and other professionals should access more detailed information and specialist advice about interventions described in the Guidelines. These guidelines are intended for all clinicians and NGOs, especially those providing pharmacological and psychological interventions for drug users as a component of substance use disorders treatment
Several studies have highlighted the serious nature of substance use in Kenya, ranging from alcohol and tobacco to cannabis, khat, heroin and others. UNODC World Drug Report 2011 indicates an annual prevalence use of 2.1% for cannabis, 0.73% for opiates and 0.3% of cocaine. Injecting drug use of heroin has been documented in the country, contributing to 3.8 to 6% of new HIV infections.
For the purpose of these Guidelines, treatment is divided into assessment, management of dependence, and relapse prevention.These guidelines will be a guide for the treatment of substance use disorders for services under the Ministry of Health. Drug users with coexisting mental and physical disorders should be treated in a holistic and systematic way to address their physical, psychological, social, and spiritual needs of addiction, not only for themselves, but also for their family and significant others.
Appropriate medical detoxification will adequately manage the acute physical symptoms of withdrawal associated with stopping drug use. This is not sufficient to help drug users to achieve effective recovery, but is a strongly indicated precursor to effective drug dependence treatment. The ideal detoxification method should be relatively short, affordable, and painless and should leave the patient with a desire to seek longer-term help. Whatever method is chosen, appropriate psychosocial interventions and education must be available to prepare the patient for the next stage.
Therapy for substance use disorders may include didactic and experiential learning, group, family and individual counseling and participation in the twelve-step groups such as Alcoholic Anonymous (AA) and/or Narcotic Anonymous (NA) or any other self-help groups. Treatment should be individually tailored to meet the specific needs of drug users and family members.
Treatment Settings
Globally, the effectiveness of well-delivered, evidence-informed drug dependence treatment is well established. The international evidence consistently show that drug dependence treatment – covering different types of drug problems, using different treatment interventions, and in different treatment settings – impacts positively on levels of drug use, offending, overdose risk and the spread of blood-borne viruses. Services are provided in different settings:
Outreach services
Out-patient treatment services
Residential/Inpatient services
1. Outreach services
Outreach services aim to provide information and harm reduction interventions to those that are not in touch with drug treatment services. Outreach workers visit community settings and work at the drug using sites. This means that outreach workers may have to come from the very same drug using community but not necessarily so. Some may be in recovery or are concerned members of the community. For an effective recruitment therefore, members of the outreach groups should be respected and knowledgeable members within drug using community to have a good impact.
Members of the outreach groups play an important role in educating drug users on the consequences of their habit and the spread of HIV. An individual’s lifetime experience may be a source of knowledge but care should be taken as this is not enough to turn that person to a health worker. Some of the functions of the outreach groups include the following:
· Helping drug dependent individuals to get out of the shadows and to seek treatment for their drug problem and to learn to protect themselves against HIV.
· Helping drug users to improve their self esteem by participating in a drug prevention or harm reduction programme and acquiring a sense of responsibility.
· Decreasing stigma associated with drug use especially in women who hide their addiction.
· Engaging in community education to change the public perception of drug users, and reducing the stigma attached to them and thereby reducing their social exclusion and criminal activities.
· Improving access to in-patients care prior to discharge for appropriate follow up and after care.
2. Outpatient Treatment
Outpatient services are offered to those who don’t require close supervision for the treatment of their substance use disorders. This is reserved for those identified to be well motivated and whose guardians, relatives and friends are keen to support them. A stable and supportive social and family environment that recognizes the existence of the problem, and have a strong desire to help is crucial. Education on the patient’s problems and on the nature of addiction as a disease is important to both parties. Treatment may involve medical detoxification and various counseling modalities and after care. There are two types of outpatient treatment; (i) low threshold and (ii) intensive outpatient treatment, as described below.
2.1 Low threshold outpatient treatment
This involves less contact hours (2 to 3 days a week) with the patient. It is recommended for patients who do not have intense treatment needs and are probably employed or in school/college or stable enough to manage in the community
2.2 Intensive Outpatient Treatment
This describes a moderate to intensive level of care. Compared to low threshold outpatient treatment, intensive out-patient treatment offers more structure and more hours (3 to 5 days a week) in areas like;
· Relapse prevention
· Stress management
· Relationships
· Assertiveness
· Nutrition
· Emotional well being
This level of care allows greater access to family, group and individual therapy, therapeutic exercises and drug-free recreational activities. It increases bonding among peers in treatment.
3. Residential/inpatient treatment
Residential treatment is indicated for patients with history of alcohol withdrawal hallucinations, seizures or delirium. Those with very heavy heroin/opiate use, with high tolerance, conferring substantial risk of a severe withdrawal syndrome, a residential program are recommended. Patients with severe general medical or psychiatric disorder, pregnant women, those who do not have a reliable social support and clients with a significant risk of committing suicide and the poorly motivated are also considered for residential treatment. Treatment involves the modalities listed as in out-patient/intensive out-patient treatment together with any other underlying condition.
4. CRITERIA FOR THE DIFFERENT LEVELS OF CARE
Phases and components of Treatment
This spells out the structured way, a client is likely to engage in from the time of entry to the programme until he/she exits.
The phases of drug dependence treatment include patient’s rights, evaluation and assessment, treatment planning, medical and psychiatric management, psychosocial rehabilitation, and continuing of care.
1. Patients’ rights
Formalized in 1948, the Universal Declaration of Human Rights recognizes “the inherent dignity” and the “equal and unalienable rights of all members of the human family”. And it is on the basis of this concept of the person, and the fundamental dignity and equality of all human beings, that the notion of patient’s rights was developed. The right to health is a fundamental part of our human rights and right to live in dignity. This includes the right to the enjoyment of the highest attainable standard of physical and mental health as enshrined in the Kenyan Constitution. Therefore,
· Health services, goods and facilities must be provided to all without any discrimination.
· All services, goods and facilities must be available, accessible, acceptable and of good quality
· The right to health contains freedoms.
· The right to health contains entitlements.
The risks, side effects, and potential benefits of drug dependence treatment and the various steps and activities involved in the treatment process shall be explained to the patient. Patients shall be given a written consent to sign before any treatment is begun. Consent forms should be available in both English and Kiswahili.
Whenever a patient who is illiterate is admitted, all required written materials shall be explained to the patient and a notation shall be placed in the file explaining exactly how the required information was given to the patient, when, and by whom. Each patient of an outpatient/drop-in facility has the right to:
1. Request permission to see his/her treatment plan and have all questions answered regarding the confidentiality of that treatment plan; and
2. Insist on his/her prior written consent before release of any information, unless otherwise authorized by law.
Medical or surgical procedures require written consent unless the patient is incapable of caring for him/herself. In the latter case, consent may be provided by the patient’s guardian or next of kin. No patient may be placed involuntarily in seclusion or mechanical restraint unless necessary because of imminent physical danger to self/others and a medical practitioner so orders.
The risks, side effects, and potential benefit of different forms of treatment are to be explained to all patients. Staffs are obliged to tell the patient the various steps and activities involved in each treatment option.
Upon admission, each patient is to be given a copy of the treatment program’s rules and regulations; these are to be explained to the patient. Patients should sign a statement indicating that he/she understands the rules; that statement should be kept with his/her record. Patients should be promptly appraised of any changes in the program rules.
If any patient violates program rules or regulations, the patient may be discharged, upon risk assessment to self and/or others. Upon discharge, the patient should receive a written statement explaining why he/she is being discharged. If the person has been involuntarily discharged, he/she may request that the decision to discharge be reviewed.
2. Evaluation
The assessment will include a drug history, physical examination by the doctor and sufficient information to determine dependence. At assessment clients must be made aware of the different treatment options available. A full assessment should be carried out by a qualified health worker before any decision to prescribe is taken in case pharmacological intervention is indicated. This will include making a diagnosis, assessments with various assessment tools and treatment planning
1.1 Diagnosis
There are two internationally accepted diagnostic criteria that cover drug dependence: the tenth revision of the International Classification of Diseases (ICD 10) published by the World Health Organisation (WHO) in 1992, and the fourth edition of the Diagnostic Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association in 1994.
The ICD 10 defines Dependency syndrome as: “A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had a greater value”. (WHO Expert Committee on Drug Dependence, 1998).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines Dependency Syndrome as “a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period”: (See table below)
1.2 Assessment.2.2.1 Introduction
A good assessment is essential to the continuing care of the patient. Not only can it enable the patient to become engaged in treatment but it can begin a process of change even before a full assessment is complete. Assessment skills are vital for all members of the multidisciplinary team, including drugs workers, psychologists, nurses and doctors.
This entails clerkship, physical examination and a diagnosis made by a psychiatrist, a physician, a clinical officer, a nurse and/or a trained counselor. Effective interviewing techniques by clinicians and covering key areas are important in that, patients are assisted in confronting their addiction and getting their views on behavior change. Basic requirements like blood pressure machines, stethoscopes, thermometers etc are important. A good and reliable laboratory service to screen for HIV, LFTs, hepatitis, sexually transmitted infections, urine tests, blood alcohol levels, gamma glutamyl transpeptidase, etc is absolutely essential.
A comprehensive assessment should include:
· Screening for drug dependence.
· Identification of treatment needs: done through a series of multidisciplinary assessments (Fig.1). The more intensive the required intervention, the wider the variety and intensity of assessments.
· Intake evaluation: documents the patient’s medical condition and medical history and includes an analysis of the patient’s current neurological and psychological status. The intake evaluation is often the basis for a decision to admit the patient or to make a referral to a more appropriate emergency or psychiatric programme. A standardized intake format will be used.
- Figure 1: Multidisciplinary Assessment
A Management Plan will carefully involve identifying environmental and social support systems i.e. DSM IV-TR Axis IV factors and their influence on the road to recovery from one’s drug dependence. Patient management will be provided either as:
1. Outpatient drug dependence treatment
2. Intensive outpatient drug dependence treatment
3. Residential /inpatient drug dependence treatment.
A standardized intake format will be adopted in assessing patients in all levels of care. A signed informed consent and treatment contract on the risks of treatment are important in all levels of care.
2.2.1 Medical Assessment
This helps to determine whether patients have a current or imminent medical problem that needs attention. These include related problems such as withdrawal, anemia, HIV and AIDS hepatitis or medical conditions unrelated to the addiction (perhaps ignored for many years), abscesses, malnutrition, substance induced psychoses, etc.
Physical examination:
· Check for; needle track marks, skin abscesses, and signs of withdrawal or intoxication.
· Determine the presence of any complications of drug use such as viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental decay.
· Nurses assess patient’s response to drug cessation, response to medication, skills of planning care, identifying solutions, setting goals, formulating goals, producing the care plan and care management. Interaction with other patients and staff is also covered.
2.2.2 Psychiatric Assessment
Psychiatrists and psychologists may conduct various psychological tests during the initial assessment phase of treatment. Some tests are used to confirm and assess the presence of severity of substance use disorders. These are generally questions and answers, self report tests and/or structured interviews.
Important to note that;
Psychiatric problems sometimes co-exist with drug and alcohol use, in particular there is increased risk of suicide and self-harm. Drug use often has a psychoactive component, hence can cause hallucinations, depression or anxiety, either during use or as part of withdrawal.
The psychiatric examination should address the following but not limited to:
· General behaviour: e.g. restlessness, anxiety, irritability which can be caused by either intoxication with stimulants or hallucinogens or by withdrawal from opiates.
· Mood: depressed Mood can be caused by withdrawal from stimulants (‘crash’ of cocaine or amphetamine withdrawal) or by alcohol or sedative drugs. Assess the risk of self-harm.
· Delusions and hallucinations: common with stimulant and hallucinogens use.
· Cognitive states
2.2.3 Nutritional Assessment
Some patients may have significant nutritional deficits that may need to be corrected shortly after assessment before proper treatment is commenced. The following should be checked:
· Malnutrition
· Vitamin deficiency
· Anaemia ,especially megaloblastic anaemia in alcoholics
· Micronutrient deficiency
2.2.4 Social and Emotional Assessment
Various social and emotional problems may have played a role in people’s initial drug use, as well as in their continued drug use. Identification of these issues can be important for relapse prevention. Again, people differ with regard to social and emotional strengths and weaknesses. Treatment Plans should address poor skills and encourage the use of existing positive skills for personal growth.
Individuals with multiple social problems need to be linked into the appropriate local support networks.
2.2.5 Family Assessment
This may be done through interview with other family members to obtain a clearer understanding of the individual’s family dynamics such as:
· Effect of addiction on the functioning of the family
· Effects of family structure on the individual’s addiction.
· Family readiness and support for treatment
· Family understanding of the problem
· Signs and symptoms of co-dependence
2.2.6 Occupational Assessment
Assessment is required on the following areas:
· Occupational performance on his/her profession or employment
· Mental ability to follow instructions in occupational functioning
· The acceptance to lead a productive and useful life
· Individuals ability to perform tasks in their daily living and work
· Prevocational exploration and training on different skills.
· Achievement of independent, productive and satisfying life.
2.2.7 Nursing Assessment:
The complex needs of drug users and a combination of different factors has led to the development of effective collaboration between professional groups such as medical doctors, psychiatrists, pharmacists, nurses, psychologists and NGOs.
The aims of the nursing assessment are to;
· determine type of drugs used, drug-using history;
· assess problems associated with drug use;
· assess risk;
· identify medical, mental, social and environmental needs;
· determine client's motivation;
· explore client's treatment requests and expectations;
· Inform and explain the treatment options available to clients, and determine those most suited to their needs.
2.2.8 Recreational, Stress, and Leisure Assessment
There is need to determine an individual’s:
· Level of stress
· Level of social skills
· Ability to trust others
· Healthy interests
· Ability to co-operate with others
· General level of physical activity and exercise
· Previous drug-free experiences of having healthy fun
2.2.9 Legal History /assessment
Legal problems can become a potent area of stress and anxiety, and they can be identified as subjects for discussion in a therapeutic setting.
Some people have legal problems hence assess for any charge on;
· illegal selling of drugs
· Using prescription drugs, not prescribed for a particular condition.
· Stealing items or embezzles money to support their addiction.
· not paying taxes
· Alimony.
· Assault
1.3 Assessment Tools
These tools are used to collect data on key behaviours including drug use, HIV risk behavior, criminal activity, physical and psychological health and social functioning. Some of the tools that can be used in treatment settings: include :( must be availed in the treatment centers)
· The Addiction Severity Index (ASI): Semi-structured interview designed to address seven potential problem areas in substance use patients: medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status.
· The Addiction Severity Index – LITE(ASI-LITE): shortened version of the ASI
· ASSIST: the Alcohol, Smoking and Substance Involvement Screening Test is a brief screening questionnaire developed by WHO and an international team as a simple method of screening for hazardous, harmful and dependent use of alcohol, tobacco and other psychoactive substances.
· The CAGE Test: Screening test for alcohol dependence.
· AUDIT: Alcohol Use disorders Identification Test.
1.4 Treatment Planning
It is mandatory to plan each treatment carefully and clearly. In planning treatment systems, resources should be distributed in a way that delivers effective treatment to as many people as possible. Quality of treatment should be consistent regardless of how patients enter treatment. Assessments inform about an individual’s treatment needs as well as the strengths and resources that can be used to meet those treatment needs.
The treatment plan, developed with the patient, establishes goals based on the patient’s identified needs and sets interventions to meet those goals. A care or treatment plan is a written description of the treatment to be provided and its anticipated course. Care plans set the specific needs of the individual patient and how they are going to be met by the service. The plan is then monitored and revised periodically as required to respond to the patient’s changing situation. While current research results do not support matching patient profiles to specific treatment approaches, there is evidence that matching responses and interventions to client needs following a serious diagnostic process and extensive assessment improves the treatment outcomes.
After taking a full history and completing an assessment, a care or treatment plan should be agreed with the patient. It should normally cover patient needs (and how these will be met) in one or more of the following domains:
· Drug and alcohol use: Drug use, including types of drugs, quantity and frequency of use, pattern of use, route of administration, symptoms of dependence, source of drug (including preparation), and including prescribed medication and tobacco use. Alcohol use, including quantity and frequency of use, pattern of use, whether in excess of safe levels and alcohol dependence symptoms.
· Physical and psychological health: Physical problems, including complications of drugs and alcohol use, blood-borne infections and risk behaviours, liver disease, abscesses, overdose, enduring severe physical disabilities and sexual health. Pregnancy may need to be assessed.
· Psychological problems, including personality problems or disorders, self-harm, history of abuse or trauma, depression and anxiety and severe psychiatric co-morbidity. Contact with mental health services will need to be recorded.
· Criminal involvement and offending: Legal issues including arrests, fines, outstanding charges and warrants, probation, imprisonment, violent offences and criminal activity, and involvement with workers in the criminal justice system, for example probation workers.
· Social functioning: Social issues, including partners, domestic violence, family, housing, education, employment, benefits and financial problems.
· Childcare issues, including parenting, pregnancy, child protection. It is seldom the case that a clinician will be able to meet all of a patient’s needs if the patient has a serious drug misuse problem or unmet needs in a range of domains. A patient may need prescribing interventions plus psychosocial interventions, help with housing or benefits etc. This often requires clinicians to have input from or facilitate referral to a range of other professionals.
The assessment of young people will require additional components, such as comprehensive educational needs and development needs.
Clinicians will need to be able to track progress with patients around their range of needs and record progress in the care plan. There may be several clinicians involved in the patient’s treatment – these should be named in the care plan along with a clear identified lead clinician.
3. Treatment Interventions
Evidence-based good practice and accumulated scientific knowledge on the nature of drug dependence should guide interventions and investments in drug dependence treatment. The high quality of standards required for approval of pharmacological or psychosocial interventions in all the other medical disciplines should be applied to the field of drug dependence.
3.0 Introduction.
There are mainly two complementary types interventions in drug treatment namely:
· Pharmacological intervention
· Psychosocial intervention.
A multidisciplinary approach is a must to give effective drug treatment. Drug users often present for drug treatment with a myriad of health and social problems. Treatment for drug use should always involve a psychosocial component. Psychosocial interventions encompass a wide range of actions from ‘talking therapies’, such as cognitive behavioural or family therapy, to supportive work such as help with benefits
Psychosocially assisted pharmacological treatment refers to the combination of specific pharmacological and psychosocial measures used to reduce both illicit opioids use and harms related to drug use and improve quality of life.
3.1 Pharmacological Treatment Interventions
Pharmacological treatment is done at two levels, that is, for detoxification and as medication assisted treatment (MAT). Medical detoxification is the use of medications in the treatment of withdrawal syndrome mostly in severe dependence.
Detoxification can be done both at in-patient or out-patient levels, depending on severity of the condition and type of drugs used. Medical detoxification is indicated in cases with severe withdrawal symptoms. Detoxification is generally viewed as particularly appropriate for patients who present with acute medical and psychiatric problems, in particular those with a history of seizure and depression, and also those who have concurrent acute alcohol dependence. Each case should therefore be handled on the basis of a careful assessment of the above factors. Stabilization of acute withdrawal problems is typically completed within 3-5 days, but this may need to be extended for patients with co-morbid conditions as mentioned above.
The detoxification regimen offered in this protocol is a general guideline and may need to be customized according to the individual patient’s needs. During detoxification various psychosocial interventions and education must be initiated.
(i). Alcohol
Alcohol (ethanol) is a CNS depressant. It exerts its effects by several mechanisms and binds directly to γ-amino butyric acid (GABA) receptors in the CNS, causing sedation and also directly affecting cardiac, hepatic, and thyroid tissues .Large amounts consumed rapidly or chronically can cause respiratory depression, coma, and death. Alcohol withdrawal manifests as a continuum, ranging from tremors to seizures, hallucinations, and life-threatening autonomic instability in severe withdrawal (delirium tremens).
Detoxification from alcohol is mainly done as an inpatient procedure and regular monitoring of vital signs is absolutely essential. Symptoms of alcohol effects on a person are proportionate to the BAC. Levels required to produce given symptoms vary with tolerance, but in typical users:
• 20 to 50 mg/dL: Tranquility, mild sedation, and some decrease in fine motor coordination
• 50 to 100 mg/dL: Impaired judgment and a further decrease in coordination
• 100 to 150 mg/dL: Unsteady gait, nystagmus, slurred speech, loss of behavioral inhibitions, and memory impairment
- 150 to 300 mg/dL: Delirium and lethargy.
A mild withdrawal syndrome includes tremor, weakness, headache, sweating, hyperreflexia, and GI symptoms. Symptoms usually begin within 6 hours of cessation. Some patients have generalized tonic-clonic seizures (called alcoholic epilepsy, or rum fits) but usually not more than two seizures in short succession.
Hallucinations without other impairment of consciousness follow abrupt cessation from prolonged, excessive alcohol use, usually within 12 to 24 hours. Hallucinations are typically visual but may also include auditory illusions with vivid and frightening dreams. The syndrome may resemble schizophrenia and other pathologic reactions associated with withdrawal.
Benzodiazepines are the mainstay of therapy. Diazepam, Lorazepam, Alprazolam and chlordiazepoxide have been used for the management of acute alcohol withdrawal symptoms. Diazepam is given 5 to 10 mg IV or PO hourly until sedation occurs. Lorazepam 1 to 2 mg IV or PO is an alternative. Chlordiazepoxide 50 to 100 mg PO 4 to 6 hourly, then tapered off is an older acceptable alternative for less severe cases of withdrawal. Chlordiazepoxide dosages of upto 250mg daily may be prescribed in alcohol detoxification. More typically, doses of 120mg to 160mg of chlordiazepoxide daily are prescribed as starting doses in this context. Starting doses of less than 80mg chlordiazepoxide daily may lead to unnecessary risk of development of damaging or fatal alcohol withdrawal symptoms. Typically, chlordiazepoxide is reduced in dosage at a rate of 10-20mg daily through the alcohol detoxification process.
Phenobarbitone (a barbiturate) may help if benzodiazepines are ineffective, but respiratory depression is a risk with concomitant use. Phenothiazines and haloperidol are not recommended initially because they may lower the seizure threshold. For patients with a significant liver disorder, a short-acting benzodiazepine (Lorazepam) or one metabolized by glucuronidation (oxazepam) is preferred. (Note: Benzodiazepines may cause intoxication, physical dependence, and withdrawal in alcoholics and therefore should not be continued after the detoxification period). Carbamazepine 200 mg po qid may be used as an alternative and then tapered. Carbamazepine is an anticonvulsant and mood stabilizing drug used in clinical practice in the management of alcohol-related withdrawal symptoms. Common adverse effects include drowsiness, headaches and migraines, motor coordination impairment and upset stomach. For severe hyperadrenergic activity or to reduce benzodiazepine requirements, short-term therapy (12 to 48 h) with titrated β-blockers (e.g., metoprolol 25 to 50 mg PO or 5 mg IV given 4 to 6 h) and clonidine 0.1 to 0.2 mg given 2 to 4 h can be used.
Chlormethiazoleis a sedative and hypnotic that is widely used in treating and preventing symptoms of acute alcohol withdrawal. It is a drug which is structurally related to thiamine (vitamin B1) but acts like a sedative, hypnotic, muscle relaxant and anticonvulsant. Chlormethiazole is extremely useful and flexible drug for use in the management of acute alcohol withdrawal. It is not a treatment for alcohol abuse and should not be used other than in the withdrawal period, and then for less than 10 days. Chlormethiazole is particularly toxic and dangerous in overdose.
Haloperidol is an older antipsychotic used in the treatment of schizophrenia and, more acutely, in the treatment of acute psychotic states and delirium. In detoxification, it is used in the management of delirium tremens. Administration is as single doses of 1 mg to 5 mg (up to 10 mg) oral or i.m., usually repeated every 4 to 8 hours. Do not exceed an oral dose of 100 mg daily
A seizure, if brief and isolated, needs no specific therapy. However, some clinicians routinely give a single dose of Lorazepam 1 to 2 mg IV as prophylaxis against another seizure. Repeated or longer-lasting (i.e., > 2 to 3 min) seizures should be treated and often respond to Lorazepam 1 to 3 mg IV. Routine use of phenytoin is unnecessary and unlikely to be effective. Outpatient therapy with phenytoin is rarely indicated for patients with simple alcohol withdrawal seizures when no other source of seizure activity has been identified because seizures occur only under the stress of alcohol withdrawal, and patients who are withdrawing or heavily drinking may not take the anticonvulsant.
Delirium Tremens (DT) may be fatal and thus must be treated promptly with high-dose IV benzodiazepines, preferably in an ICU. Dosing is higher and more frequent than in mild withdrawal. Diazepam 5 to 10 mg IV or Lorazepam 1 to 2 mg q 10 min is given as needed to control delirium; some patients require several hundred mg over the first few hours. Severe drug-resistant DT can be treated with a continuous infusion of Lorazepam, diazepam or midazolam usually with concomitant mechanical ventilation. Physical restraints should be avoided if possible to minimize additional agitation, but patients must not be allowed to elope, remove IVs, or otherwise endanger themselves. Intravascular volume must be maintained with IV fluids, and large doses of vitamins B and C, particularly thiamine, must be given promptly.
(ii). Nicotine
Tobacco, “kuber” and ‘snuff” contain nicotine. A smoking cessation program should be encouraged during the early phases of a drug dependency treatment. One approach is to help patients quit smoking while being maintained on nicotine via a transdermal patch or nicotine gum.
Nicotine is a highly addictive drug. Smoking is not only a physical addiction, but also becomes linked with many social activities and coping needs, making it a difficult habit to break. When someone addicted to nicotine stops smoking they may experience withdrawal symptoms such as increased anger, hostility, and anxiety. Nicotine replacement therapies combined with behavior change programs providing psychological support and skills training result in the highest long-term abstinence rates. Generally, rates of relapse for smoking cessation are highest in the first few weeks and months and lessen considerably after about three months.
Nicotine Addiction Medications
Nicotine replacement products provide nicotine without smoking. This helps to lessen the body's craving for nicotine and to reduce withdrawal symptoms. Replacement products come in several forms: gum, patch, nasal spray, inhaler and lozenge. Nicotine gum, patch and lozenges can be bought over-the-counter. The nasal spray and inhaler (brand name Nicotrol) require a doctor's prescription.
Bupropion (brand names Zyban® or Wellbutrin)is an antidepressant drug that can be used to help some people stop smoking. It is taken as a pill and requires a doctor's prescription. Although it does not contain nicotine, it can help people resist the urge to smoke. Bupropion is often used for 7-12 weeks, beginning 1 or 2 weeks before smoking is stopped. It can be used for smoking cessation maintenance for up to six months. Side effects may include insomnia and dry mouth.
Varenicline (Chantix) - is the first treatment that specifically targets the neurobiological mechanism of nicotine dependence. Studies show that the drug successfully stimulates dopamine (the brain's pleasure chemical) and blocks nicotine receptors. This reduces nicotine withdrawal symptoms and cravings, helping to prevent a full relapse. The drug also blocks the effects of nicotine if you begin to smoke again.
Chantix is a prescription medication sold in tablet form. It is generally prescribed for 12 weeks. If you quit smoking during that time, your doctor may prescribe Chantix for another 12 weeks to enhance long-term success. Side effects may include nausea, vomiting, gas, headache and insomnia.
(iii). Khat
Khat is a natural stimulant from the Catha Edulis plant, found in the flowering evergreen tree or large shrub which grows in East Africa and Southern Arabia. It reaches heights from 10 feet to 20 feet and its scrawny leaves resemble withered basil.
Khat leaves contain psychoactive ingredients known as cathinone, which is structurally and chemically similar to d-amphetamine, and cathine, a milder form of cathinone. Fresh khat leaves, when chewed over several hours, produce a mild cocaine- or amphetamine-like euphoria and generate intense thirst.
Khat is a sympathomimetic and its pharmacological effects are believed to parallel those of amphetamine. Psychiatric manifestations induced by khat are similar to the effects of other known stimulants. Some authors described a recent, successful attempt to treat 2 cases of Khat dependency using protocols similar to those developed for cocaine. Both patients presented for treatment with psychiatric manifestations and were screened for stimulant and depressant drug addiction since substances other than khat were involved in each case. Specific procedures for treatment entailed an inpatient detoxification phase of 1-2 weeks followed by long-term attendance at outpatient recovery programmes. Khat is also known as khat, muguka, chat, Miraa, Catha, Quat, and Abyssinian Tea. (iv). Cannabis
Cannabis (also known as marijuana, grass, skunk, weed, hash and ganja) is usually sold as either a dark brown lump of resin, or as bags of dried herbs, flower heads and seeds. Its active principle is tetra-hydro-cannabinol (THC).
Heavy users tend to smoke cannabis more frequently after building up a tolerance to the drug. Regular use of cannabis results in a range of long-term effects and risks, which includes social withdrawal and lack of motivation (Amotivational Syndrome), breathing problems such as asthma, high blood pressure and heart problems, short-term memory loss, paranoia and anxiety, lung cancer, infertility, loss of coordination and concentration problems, psychosis and depression. Cannabis induced psychoses should be managed with appropriate neuroleptics e.g. Haloperidol.
(v). Opiates
The management of Opioids abuse and dependence should be holistic and long term. The client should be assessed to identify their varying needs and strengths by a multidisciplinary team which maps out an agreed working plan with the client and their family or guardian if they are available. The management involves both psychosocial and pharmacological (medication) interventions done in residential or non residential treatment settings. The withdrawal signs and symptoms are often pronounced and dramatic, 'cold turkey,’ and begin 8 to12 hours after last dose and lasts 5 to 7 days. The treatment interventions include;
· Replacement/substitution therapy using oral Opioids e.g. methadone, partial Opioids agonist e.g. buprenorphine.
· Symptomatic treatment (non-Opioids treatment regime) e.g. clonidine e.t.c
· Treatment of co-morbid physical illnesses
Other interventions to prevent transmission of HIV, Hepatitis B, C and other infections are needle exchange programs.
Symptomatic (non Opioids treatment regime)
| Opioids withdrawal signs and symptoms | Treatment | Dosages | ||
| · Restlessness, irritability, low moods. · Running nose, tearing a lot. · Nausea, yawning, vomiting, abdominal cramps and diarrhea. · Body temperature dysregulations i.e. fever or chills. · Skin goose pimples and sweating. · Muscle aches and cramps. · Lack of sleep and craving for the drug. · Fast heart beats increased blood pressure and wide open (dilated) eye pupils. | Clonidine (tapered dosage) NB; Blood pressure monitoring is mandatory | Tapered dosage: 300μg qid×3days 150μg tds×3days 75μg bd×3days | ||
| Benzodiazepines | Diazepam 10mgs qid×3days 10mgs tds x 3days 10mgs bd x 3days 10mgs od x 3days
| |||
| Anti-emetics when presence of vomiting | Metoclopromide 10mgs PRN | |||
| Analgesics/Antipyretics for pain management | Non steroidal anti-inflammatory; Paracetamol PRN | |||
| Antispasmodics for colic pain (cramps) | Hyoscine butylbromide 10 mg PRN | |||
| Beta blockers for tachycardia & palpitations | Propanolol 40 mg PRN | |||
| Muscle relaxants | Baclofen PRN | |||
| Intravenous fluids | Correct water, electrolytes and acid disturbances PRN | |||
| Others | Co-morbid psychiatric and physical disorder are managed accordingly TCA e.g. Imipramine, SSRI e.g. Fluoxetine and Trazodone | |||
| | |
Medication Assisted Treatment (MAT)
(a)Methadone
A large body of scientific evidence suggests that methadone treatment, when delivered to an appropriate standard of care, is a safe substitution medication for opioids dependence. Methadone has proved to be an effective means in retaining people in treatment and hence, averts heroin use when in treatment. Methadone reduces the risk of HIV infection, and improves both physical and mental health as well as the quality of life of the patients and their families. Methadone also reduces criminal activities. Methadone treatment has also proved to be cost effective. Moreover, methadone treatment reduced demands upon the criminal justice system.
Methadone is mostly orally administered once daily for therapeutic purposes of preventing or substantially reducing the consumption of illicit opioids such as heroin. Its primary function is to improve the health status and psychological well-being of the opioids-dependent persons. Methadone Treatment (MT) is now a well-established treatment modality across a variety of treatment settings and supported by both research evidence and clinical practice.
The aim of methadone maintenance treatment is to improve the quality of life of opioids-dependent patients and to reduce the potential harm of using illicit drugs. MT greatly reduces mortality, illicit drug use and criminal activity, and attracts and retains more patients in treatment than other treatments. There is good evidence that MT reduces transmission of HIV, although the evidence for effectiveness at reducing transmission of hepatitis B virus and hepatitis C virus is less convincing.
Clinical Pharmacology
Methadone is a potent synthetic opioids agonist which is well absorbed orally and has a long, although variable plasma half life. The effects of methadone are qualitatively similar to morphine and other opioids.
Most people who have used heroin will experience few side effects from methadone. Once on a stable dose, tolerance develops until cognitive skills and attention are not impaired. Symptoms of constipation, sexual dysfunction and occasionally increased sweating can continue to be troubling for the duration of MT.
Figure 1: Methadone: Actions and Side Effects
Pharmacokinetics
There is wide individual variability in the pharmacokinetics of methadone but in general, blood levels rise for about 3-4 hours following ingestion of oral methadone and then begin to fall. Onset of effects occurs approximately 30 minutes after ingestion. The apparent half life of a single first dose is 12 – 18 hours with a mean of 15 hours. With ongoing dosing, the half life of methadone is extended to between 13 and 47 hours with a mean of 24 hours. This prolonged half life contributes to the fact that methadone blood levels continue to rise during the first week of daily dosing and fall relatively slowly between doses.
Methadone reaches steady state in the body (where drug elimination equals the rate of drug administration) after a period equivalent to 4-5 half lives or approximately 3-10 days (Figure 6). Once stabilisation has been achieved, variations in blood concentration levels are relatively small and good suppression of withdrawal is achieved. For some, however, fluctuations in methadone concentrations may lead to withdrawal in the latter part of the inter-dosing interval. If dose increases or multiple dosing within a twenty four hour period do not prevent this, other agonist replacement treatment approaches such as buprenorphine should be considered.
Induction/Titration
Objectives during induction to methadone are to retain individuals in treatment by reducing the signs and symptoms of withdrawal and to ensure their safety. This can be achieved by careful explanation regarding intoxicating effects and withdrawal during the induction and maintenance phases of methadone treatment, establishment of a therapeutic relationship, safe dosing and repeated observation of patients.
Before starting methadone oral solution for the first time:
Figure 2: Before prescribing guidelines
Note: Starting methadone on the first presentation is usually not possible as results, other than on-site tests, often take days to return. Use this time to continue the assessment, provide harm reduction advice and ask the patient to keep a drugs diary. Supervised consumption should be used for the titration period and at least the first three months.
If opioids dependence is confirmed and a substitute prescription of methadone oral solution is appropriate, there are a number of different methods of initiating methadone treatment.
The ideal is as follows:
After stabilisation, the patient should feel comfortable throughout 24 hours with no subjective or objective withdrawal before doses and no sedation or euphoria after doses. Stabilisation involves finding a suitable dose that keeps the patient engaged in treatment without the need to supplement with heroin and other drugs. The aim is to enable the patient to put their dependence into the background while tackling any associated health or social goals. Attempts to keep the dose minimal, leaving the patient with daily morning craving or disturbed sleep due to falling serum levels, are counter-productive.
Optimal outcomes with methadone maintenance occur:
1.1. When the dose is right, usually between 60 to 120 mg.
1.2. Stable relationship with a key individual, e.g. Dr or drug worker, practitioner, etc.
1.3. When a range of non-pharmacological interventions, such as counselling and lifestyle support, are also available.
1.4. Together these enhance the likelihood of positive outcomes from methadone maintenance treatment.
Drug Interactions with Methadone
Oral methadone is generally very well tolerated with minimal drug interactions but interactions are becoming increasingly important as new drugs are developed and more complicated regimens are used to treat chronic diseases. The main drug interactions of methadone are associated with its central nervous system (CNS) depressant activity and liver metabolism. Deaths have also been reported from interaction of methadone which can prolong the QT interval and other drugs that do this such as phenothiazines.
Benzodiazepines
Taking benzodiazepines with methadone may cause additional CNS depression and result in enhanced sedative effect. Large numbers of opioids drug users also use benzodiazepines (between 40 to 90%). Deaths involving methadone are frequently associated with concomitant use of benzodiazepines and/or alcohol. While it may occasionally be advisable to prescribe benzodiazepines with methadone, caution is recommended and thorough assessment and on-going review plans should be in place. Benzodiazepines should usually be prescribed on a short-term, reducing basis.
Alcohol
Alcohol intake may alter the metabolism of methadone, increase CNS depression and result in serious respiratory depression and hypotension. Alcohol is a high risk factor for toxicity especially binge or high level dependent use. In late stage alcohol misuse there may be impaired liver function and reduced methadone metabolism, requiring reduction in methadone dose. Alcohol use should be assessed specifically and help with withdrawal offered to those who need it.
Other opioids
Mixing methadone with other opioids agonists or other central nervous system depressants can be dangerous. Caution is advised, as are thorough assessment and review procedures.
Anti-depressants
Some anti-depressants, including tricyclic antidepressants, should be prescribed with caution due to possible enhanced sedation. Selective Serotonin reuptake inhibitors (SSRIs) theoretically raise serum methadone levels but do not (except fluvoxamine) cause sedation. Monoamine oxidase inhibitors (MAOIs) are now very rarely used and should not be prescribed with methadone.
Cocaine
There are few reports of a significant interaction with cocaine but cocaine does accelerate methadone elimination. Cocaine is also associated with cardiac rhythm disturbances and is best avoided when on methadone. Risk of accidental overdose has recently been linked to the use of these substances concomitantly.
Cocaine is often included in poly-drug use which increases problems.
Opioids antagonists and partial agonists
Opioids withdrawal syndrome is precipitated by the use of naltrexone and naloxone
and to a lesser extent buprenorphine.
HIV medications
As with other opioids, patients on methadone being treated with HIV combination therapies may require dose levels to be adjusted but these adjustments are likely to be minor and in keeping with titration principles, sufficient to ensure patient comfort. It may be useful to prescribe treatment in conjunction with a HIV specialist.
Enzyme induction by some HIV medications may necessitate a higher dose of methadone due to increased metabolism e.g. nevirapine, efavirenz, abacavir and nelfinavir. An increase in methadone could be needed and zidovudine concentration and side-effects are increased.
HCV medications
HCV medications such as pegylated interferon and ribavirin are usually well tolerated by patients on methadone. Sometimes side-effects can mimic opioids withdrawal symptoms and methadone dose is increased. Depression is a common side-effect of hepatitis C combination therapy, as well as opioids dependence so caution is required. Regular liver function tests and full blood count are advised.
Tuberculosis treatment: rifampicin
Rifampicin reduces methadone levels by stimulating the hepatic enzymes involved in methadone metabolism. Cases of severe withdrawal have been reported.
Anticonvulsants
Phenytoin and carbamazepine cause a sharp decrease in methadone due to enzyme induction.
(b) Buprenorphine
Buprenorphine is an effective and safe medication for use in the treatment of opioids dependence. It is a partial opioids agonist, appears safer in overdose than methadone and may have an easier withdrawal phase. It can be used for maintenance or detoxification. There is a growing body of evidence that treatment for opioids dependence can be effective. Methadone substitute prescribing is one well-established treatment modality and is supported by a substantial body of research literature and clinical practice5. However, methadone is not suitable for, or popular with, all opioids users seeking treatment. The provision of a flexible menu of effective treatment options, and some degree of choice for those seeking treatment, is likely to optimize the outcomes and process of treatment of opioids dependence.
Buprenorphine is an effective, safe medication for use in the treatment of opioids dependence and is a valuable addition to the formulary of medications for treating opioids dependence. It is a partial opioids agonist, appears safer in overdose than methadone and may have an easier withdrawal phase. It can be used for maintenance or detoxification.
Clinical pharmacology.
Buprenorphine is a semi-synthetic opioids derived from the morphine alkaloid thebaine. It is a mixed agonist-antagonist and its primary action is as a partial opiate agonist. An understanding of its pharmacology will help guide its clinical use.
Buprenorphine sublingual tablets contain buprenorphine hydrochloride and are available in 400 micrograms (or 0.4 mg), 2 mg and 8 mg strengths. The tablets are administered sublingually because it has poor oral bioavailability (inactivated by gastric acid and a high first pass metabolism).
Induction/Titration
The purpose of induction is to safely establish the patients quickly as possible on a dose of buprenorphine that prevents opioids withdrawal, reduces the need to take additional illicit opioids and keeps side effects to a minimum. It is usual to start on a low dose and increase rapidly, over the course of a few days, until a stabilizing dose (e.g. 16 mg) is reached. Induction can be effected for patients using heroin or methadone. The key to understanding buprenorphine induction is the phenomenon of precipitated withdrawal.
This form of opiate withdrawal can occur in someone commencing buprenorphine who has recently used heroin (less than 8 hours previously) or methadone (less than 24 hours previously). It is caused by the high affinity of buprenorphine displacing other opioids (e.g. methadone, heroin) from opioids receptors, but having less opioids activity (partial agonist). This rapid reduction in opiate effects can be experienced as precipitated withdrawal, typically occurring within 1 to 3 hours after the first buprenorphine dose, peaking in severity over the first 3 to 6 hours, and then generally subsiding. If it occurs, reassure the patient and carer and offer symptomatic treatment such as lofexidine (e.g. 400 to 600 mcg 8 hourly for 1 to 2 days), as appropriate, if withdrawal symptoms are severe. Do not prescribe more buprenorphine until the opiate withdrawal symptoms have settled.
Figure 3: Principles of safe induction with Buprenorphine
Transition to buprenorphine from heroin or low dose methadone (30 mg or below) can usually be accomplished with minimal complications, although restlessness, insomnia, headache, diarrhoea and other mild opioids withdrawal-like symptoms are not uncommon in the first 1 to 3 days. Lofexidine may be helpful with these unpleasant effects. It can be used for 1 to 2 days two tablets four times a day Some patients transferring from methadone to buprenorphine find it difficult to stabilize and feel uncomfortable on buprenorphine for 1 or 2 weeks. Steady state in blood concentration levels is reached after about 5 to 8 days. Advice about sleep hygiene should be given.
The dose range of buprenorphine maintenance prescribing is 8 to 32 mg daily. The most usual range used to achieve abstinence from heroin use is between 12 to 24 mg daily. As a partial agonist, higher doses of buprenorphine may not produce corresponding increases in effects, so increasing the dose may not make any difference in subjective effects (e.g. increased euphoria), but may further reduce illicit opioids use by increasing the blockade effect.
Optimal outcomes with buprenorphine maintenance will occur when a range of other non-pharmacological interventions, such as counselling, support the prescribing of buprenorphine.
Drug interactions with buprenorphine
The main drug interactions of buprenorphine are due to its opioids activity.
Benzodiazepines:
Many drug users also use benzodiazepines and deaths have been known to occur as a result of the combination of buprenorphine with benzodiazepines and / or alcohol22. As with other opiate substitute treatments, caution is advised and review procedures are recommended when prescribing benzodiazepines.
Alcohol, other sedatives, anti-depressants:
Alcohol intake may impair the metabolism of buprenorphine. Mixing buprenorphine with alcohol or other CNS depressants can be dangerous. Caution is advised, as are thorough assessment and review procedures. Some anti-depressants including tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) should be prescribed with caution due to possible sedation.
Cocaine:
No reports of a significant interaction with cocaine. This is likely to be due to cocaine being metabolised by different enzymes
Other full opioids agonists (e.g. opiate analgesia):
Buprenorphine may precipitate opioids withdrawal syndrome when given to those taking full opioids agonists (e.g. morphine). Buprenorphine reduces the effects of other opioids given for analgesia.
Opioids antagonists:
Delayed opioids withdrawal syndrome can be precipitated by the use of naltrexone.
HIV medications:
There is no known interaction with HIV combination therapies. As with other opioids, patients being treated with HIV combination therapies may require buprenorphine dose levels to be adjusted but these adjustments are likely to be minor, and in keeping with titration principles, sufficient to ensure patient comfort. It is advisable to offer substitute prescribing treatment in conjunction with an HIV specialist.
Hepatitis C (HCV) medications:
There is good data on interferon / ribavirin and methadone showing that there are no problems. It is likely to be similar with anti-HCV therapy and buprenorphine but further research and experience is required.
(vi). Cocaine and methamphetamine
Cocaine
The use of cocaine has been rising steadily over the past decade. Cocaine is extracted from the leaves of the coca plant, growing in the Andean mountains in South America. The leaves are processed into cocaine hydrochloride powder. Cocaine is a powerful stimulant whose effects wear off quickly, prompting the user to repeat the dose. High dose users, especially of crack, are likely to need treatment for a large range of physical and psychological problems.
Cocaine is most commonly snorted in its hydrochloride powder form. Crack is most commonly smoked through a pipe. This is the quickest way to get the drug to the brain. Glass pipes, tin cans or plastic water bottles are used as conduits. Excessive doses can cause severe medical problems and even death, from pulmonary oedema, heart failure, myocardial infarction, cerebral haemorrhage, stroke and hyperthermia. The after-effects of crack use may include fatigue, depression, paranoid ideation and depersonalisation as people ‘come down’ from the high. Chronic high-dose crack use can result in some physical, and marked psychological dependence.
Methamphetamine
Methamphetamine generally takes the form of clear crystallised chunks. It will dissolve in water and breaks down to smaller particles. Methamphetamine induces a profound sense of euphoria in the user and stimulates the release, of dopamine and noradrenaline in the central nervous system. It is a "power drug" whose use is typically followed by prolonged depression and fatigue. Smoking methamphetamine will extend its effects for up to 24 hrs per ingestion. Smoked in a base form, “meth” is known on the street as Ice.
The effects of using methamphetamine may include: extreme elation, wakefulness, alertness, enhanced self-confidence, aggression, talkativeness, loss of appetite, increased initiative, increased physical activity. Withdrawal symptoms may include: severe craving, deep depression, fatigue, inertia, paranoia, and psychosis.
No specific pharmacological detoxification regimen is required for cocaine, crack cocaine, or methamphetamine. Symptomatic treatment with chlordiazepoxide 10-25mg nocte for a few days provides some amelioration of agitation and insomnia. Benzodiazepines may also be used for short periods.
(vii). Prescription drugs
These include a large range of medications such as benzodiazepines, which are widely used as sedatives/ hypnotics and anxiolytics. They have a high potential for dependence when used without medical supervision, on higher doses or for longer duration than prescribed. Treatment needs to be done under strict medical supervision as the effects of withdrawal are severe and may lead to seizures.
Management of intoxication and overdose
.Cannabis intoxication
The acutely intoxicated patient who is anxious and agitated may be helped by verbal support and use of benzodiazepines such as lorazepam, 1 to 2mg.
Cannabis intoxication may mask psychotic and panic disorders and mood symptoms in others which must be addressed
Opioids and Opiate intoxication
The intoxication may be inadvertent, caused by the use of an unusually potent and pure form of heroin, or may be intentional for example the result of a suicide attempt by overdose. To reverse acute intoxication, IM or IV naloxone, 0.4-0.8mg every 1-2 minutes until arousal sufficient enough for airway maintenance and adequate ventilation. The dose can repeat after 2 minutes if no enough response to a maximum of 10 mg.
The effects of naloxone lasts for an hour hence should be repeated until the opioids agent is cleared from the systemic circulation. The naloxone may bring a person rapidly from coma, but one should be prepared to deal with withdrawal in case of chronic heroin users.
Sedative Hypnotic intoxication
Flumazenil can antagonize the intoxication caused by benzodiazepines and may be used in a dose of 0.2mg given intravenously every 15 seconds upto a dose of 1 to 2 mg.
Flumazenil may induce acute withdrawal symptoms including seizures and hence iv lorazepam or diazepam should be available during treatment with flumazenil. Barbiturates are life threatening in overdose and may not respond to flumazenil therapy.
Supportive measures such as assisted respiration and cardiovascular support may be needed during the acute intoxication phase.
Cocaine intoxication
During intoxication, beta blockers may decrease the autonomic arousal and limit the risk of cardiovascular complication
Psychotic symptoms can be controlled by low doses of sedating antipsychotic such as quetipine 50 to 100mg or chlorpromazine in similar doses. Benzodiazepines can also be used to treat stimulant intoxication and have a lower risk of inducing seizures than antipsychotics.
The post intoxication crash or acute dysphoria and depression tend to resolve in 24 to 48 hours. Rest and supportive care is indicated.
Hallucinogen intoxication
Verbal reassurance and talking down helps. Lorazepam or other benzodiazepines may be used. Anticholinergics or stimulants are contraindicated because they worsen the confusion and hallucinatory phenomena
3.2 Psychosocial Interventions
This is an umbrella term that covers an array of non-pharmacological interventions for effective management of drug use. Psychosocial interventions enhance pharmacological treatment efficacy by increasing medication compliance, retention in treatment, and acquisition of skills that reinforce the effects of medication.
3.2.1 Psychosocial assessment
This will involve the following domains:-
· Drug use
· Motivation and readiness to change
· Family history
· Vocational history
· Treatment history
3.2.2 Important Psychosocial Interventions
Cognitive behavior therapy (CBT)
· It is a form of ‘talk therapy’ used to teach, encourage and support individuals about how to reduce or stop their harmful drug use.
· It provides skills that are valuable in assisting people in gaining initial abstinence from drugs or in reducing their drug use
· It provides skills to help people sustain abstinence through relapse prevention
3.3.3 Motivational enhancement therapy
This approach involves using motivational interviewing strategies and interventions that are based on a stage of change model
3.3.4 Contingency management
This approach includes behavioral contracting where clients have opportunities to earn rewards for a specific desirable behavior.
3.3.5 Individual and Group Psychotherapy
This includes setting the resolve to stop substance use, teaching coping skills, changing reinforcement contingencies, fostering management of painful effects, improving interpersonal functioning and enhancing social support.
3.3.6 Family and Marital Therapy
One has to define the problem, and involves negotiating the contact, establishing the context for a drug free life, ceasing substance abuse, managing the crisis and stabilizing the family, and family reorganization and recovery.
3.3.7 Crisis Intervention Therapy
This approach is an emergency psychological care aimed at assisting an individual return to normal levels of functioning and to prevent or alleviate potential psychological trauma. It is indicated for acute stress, anxiety, fear of the unknown, abuse or life events such as death, divorce, separation, assaults, rape, imprisonment, etc, common with drug users.
The Matrix Model
The Matrix Model is a multi-element package of therapeutic strategies that complement each other and combine to produce an integrated outpatient treatment experience. It is a set of evidence-based practices delivered in a clinically coordinated manner as a programme”.
Treatment is delivered in a 16-week intensive outpatient program primarily in structured group sessions targeting the skills needed in early recovery and for relapse prevention. A primary therapist conducts both the individual and group sessions for a particular patient and is responsible for coordinating the whole treatment experience. There is also a 12-week family and patient education group series and induction into an ongoing weekly social support group for continuing care. Weekly urine testing is another program component and participants are encouraged to attend 12-step meetings as an important supplement to intensive treatment and a continuing source of positive emotional and social support.
The elements of the treatment approach are a collection of group sessions (early recovery skills, relapse prevention, family education and social support) and 3 to 10 individual sessions delivered over a 16-week intensive treatment period. Patients are scheduled three times per week to attend two Relapse Preventions groups (Monday and Friday) and one Family/education group (Wednesdays). During the first four weeks patients also attend two Early Recovery Skills groups per week (these groups occur on the same days as the Relapse Prevention groups just prior to them). After 12 weeks they attend a Social Support group on Wednesdays instead of the Family/education group.
Sample Schedule
| Monday | Wednesday | Friday |
| Early Recovery Skills Weeks1-4 | Family/education Weeks 1-12 | Early Recovery Skills Weeks1-4 |
| Relapse Prevention Weeks 1-16 | Social Support Weeks 13-16 Continues past week 16 | Relapse Prevention Weeks 1-16 |
Program Components
Individual counseling. These sessions are critical to the development of the crucial relationship between the patient and the therapist. The content of the individual sessions is primarily concerned with setting and checking on the progress of the patient’s individual goals. These sessions can be combined with conjoint sessions, including significant others in the treatment planning. Extra sessions are sometimes necessary during times of crisis to change the treatment plan. These individual sessions are the glue that ensures the continuity of the primary treatment dyad and, thereby, retention of the patient in the treatment process.
Early Recovery Skills Groups. The eight Early Recovery Skills Groups are designed for patients in the first month of treatment or those who need extra tutoring in how to stop using drugs and alcohol. The purpose of the group is to teach patients: 1) how to use cognitive tools to reduce craving, 2) the nature of classically-conditioned cravings, 3) how to schedule their time, 4) about the need to discontinue use of secondary substances and 5) to connect patients with community support services necessary for a successful recovery. The reduced size of the groups allows the therapist to spend more individual time with each patient of these critical early skills and tasks. Patients who destabilize during treatment are often encouraged to return to the Early Recovery group until they re-stabilize.
Relapse Prevention Groups. The Relapse Prevention groups occur at the beginning and end of each week from the beginning of treatment through Week 16. They are the central component of the Matrix Model treatment package. They are open groups run with a very specific format for a very specific purpose. Most patients who have attempted recovery will agree that stopping using is not that difficult; it is staying stopped that makes the difference. These groups are the means by which patients are taught how to stay in sobriety.
The purpose of the Relapse Prevention groups is to provide a setting where information about relapse can be learned and shared. The 32 relapse prevention topics are focused on behavior change, changing the patient’s cognitive/affective orientation, and connecting patients with 12-step support systems. Each group is structured with a consistent format during which: 1) Patients are introduced if there are new members, 2) Patients give an up to the moment report on their progress in recovery, 3) Patients read the topic of the day and relate it to their own experience, 4) Patients share their schedules, plans, and commitment to recovery from the end of group until the group meets again. Input and encouragement from other group members is solicited but the group leader does not relinquish control of the group or promote directionless cross talk about how each member feels about what the others have said. The therapist maintains control and keeps the groups topic centered and positive with a strong educational element. Care is taken not to allow group members to share graphic stories of their drug and alcohol use. Therapists specifically avoid allowing the groups to become confrontational or extremely emotional. Whenever possible the use of a co-leader who has at least 6 months of recovery is employed. The co-leader serves as a peer support person who can share his or her own recovery experiences.
Family Education Groups. The 12-week series is presented to patients and their families in a group setting using slide presentations, videotapes, panels, and group discussions. The educational component includes such program topics as: (a) the biology of addiction, describing concepts such as neurotransmitters, brain structure and function and drug tolerance; (b) conditioning and addiction, including concepts such as conditioned cues, extinction, and conditioned abstinence; (c) medical effects of drugs and alcohol on the heart, lungs, reproductive system, and brain; and (d) addiction and the family, describing how relationships are affected during addiction and recovery. Successfully engaging families in this component of treatment can significantly improve the probability of retaining the primary patient in treatment for the entire 16 weeks.
12-Step Meetings. The optimal arrangement is to have a 12-Step meeting on site at the treatment centre one night each week. This meeting does not have to be an official meeting. Rather, the patients presently in treatment and graduated members can conduct an "Introduction to 12-Step Meeting" using the same format as an outside meeting with the purpose of orienting patients unfamiliar to the meetings in a safe setting with people they already know. Attending these meetings often makes going to an outside meeting for the first time much easier and less anxiety provoking. These meetings, along with outside 12-step meetings chosen by patients and the Social Support Group provide strong continuing support for graduated group members.
Urine/Breath Tests. Urine testing is done randomly on a weekly basis. Positive urine tests revealing previously undisclosed drug use serve as points of discussion rather than incrimination. Patients struggling with secondary drug or alcohol use should also be tested for those substances.
Relapses Analysis A specific exercise is used when a patient relapses unexpectedly or repeatedly and does not seem .to understands the causes of the relapses. The optional exercise and forms are designed to help the therapist and the patient understand the issues and events that occurred preceding the relapse(s) in order to help prevent future relapses. This exercise is typically conducted during an individual session with the patient and, possibly, a significant other.
Social Support. Designed to help patients establish new nondrug-related friends and activities, these groups are less structured and topic-focused than the Relapse Prevention Groups. Patients begin the groups during the last month in treatment at the end of the family education series, in order to ensure that they feel connected before they graduate from the Relapse Prevention Groups. The content of the groups is determined by the needs of those members attending. If patients have relapsed, relapse prevention work may be in order, unstable patients are given direction to help stabilize them and patients moving successfully through the stages of recovery are aided and encouraged to continue with the lifestyle changes that they are making.
Supportive Expressive Psychotherapy
It has two components i.e. supportive techniques to help patients feel comfortable in discussing their personal experiences, and expressive techniques to help- patients identify and work through interpersonal relationship issues.
Group Therapy in Substance Use Treatment
· Psycho-educational groups
· Skill development groups
· Cognitive behavior groups
· Support groups
· Interpersonal; process group psychotherapy
3.2.3 Continuing Care and Aftercare
Substance use and dependency services are viewed as a continuum of prevention, intervention, treatment, and aftercare. As with all continuums, the boundaries are not always clearly drawn. A comprehensive substance use continuum combines many programs, policies and practices, in order to reduce substance use and relapse in communities. A local continuum of care may include local services ranging from follow ups in pharmacological, psychosocial and occupational interventions.
Aftercare or Continuing Care
Client is placed in appropriate programmes and support structures to enable the effective transition to their families and reintegration into their communities. The goal of aftercare and continuing care is to support the person's abstinence through relapse prevention after primary care and throughout their recovery. Aftercare is the stage following more intensive services.
Related aftercare and relapse prevention services for individuals who are part of a treatment continuum include but are not limited to:
- Periodic outpatient aftercare
- Relapse/recovery groups
- Recovery support group
- Halfway Houses
- Job placement/reintegration/re –training into alternative occupation of interest.
Aftercare arrangements
Some structured treatment programs distinguish a period of less intensive treatment after a client has completed the main program, called aftercare. It may be limited to a month or substantially longer after treatment has finished, but is based on the intention to provide ongoing support to clients at the level required to maintain the earlier benefits and goals. Regular phone contact, scheduled appointments and unscheduled or drop in visits may all be available.
In addition to aftercare services offered by the structured program, clients may also be encouraged to access self help groups and other general community support and advice services. Clearly, a supportive family and community environment will also be conducive to helping in the recovery of people who have received alcohol and drug use treatment.
Suggested Steps:
1. Regular visit after every two weeks which are tapered off to after every month, then three months, six months for a total of 2 years or more.
2. Blood/urine tests for drug use
3. Ensure attendance to support groups meetings.
4. Monitoring compliance to recovery goals by liaising with family and sponsors
Bibliography
1. Textbook of substance abuse Treatment The American Psychiatric publishing Inc Third edition
2. New Oxford Textbook of Psychiatry, Gelder Lopez-Ibor Jr Andreasen Vol. 1
3. Psychology by WCB Brown and Benchmark Second Edition
4. Improvement Protocol-24 (TIP-24) and (TIP-35) Series by the U.S. Department of Health and Human Services (DHHS)
5. The tenth revision of the International Classification of Diseases (ICD 10) published by the World Health Organisation (WHO) in1992,
6. The fourth edition of the Diagnostic Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association in 1994.
7. WHO Expert Committee on Drug Dependence, 1998.
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