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Penagihan, Detox, Pemulihan,

Jenis Dadah Membahaya

Jenis-jenis dadah

candu, morfin, heroin dan kodein Opiat

bahan perubatan untuk menidur atau melegakan kesakitan mempunyai potensi yang tinggi kelihatan

Canabinoid

Stimulan

Depresen

Halusinogen

ganja, hashish dan marijuana semua bentuk dadah diperolehi dari pokok genus canabis. THC (Tetra Hydrocannibol) phetamine kokain phetamine kokain (daun koka, paste koka, kokain freebase dan crack kokain) methaqualone, traquliser dan rohypnol bahan perubatan, ubat penenang untuk menukarkan sistem saraf pusat lysergic acid, halluceno-genic mushroom, dietthylamide (LSD), diymethyltrp tamine (DMT), phenlyclidine (PCP) dan ketamine

dadah asli dan sintatik, mengubah pandangan visual iaitu susah untuk membezakan yang benar atau tidak

Psikotrapik (ATS)

methamphetamine, amphetamine, MDMA (Methylene Dioxymetham phetamine) dan pil ecstasy (XTC)

adalah dadah yang bertindak kepada otak dan merangsang fizikal

gam, ubat nyamuk, minyak petrol, cat cair, thinner, cecair pemetik api, spray rambut, krim pencuci, marker pen dan lain-lain Inhalant

tidak ditakrifkan sebagai dadah walaubagaimanapun banyak persamaan dengan dadah dari segi kesannya

Dependence Syndrome
WHO: 3 or more of the following 7 components over the preceeding 12 months:

Tolerance(memerlu lagi banyak kuantiti dadah untuk kesan yang sama) Withdrawal syndrome(gian) Perlu dadah untuk kurang kesan gian Compulsion to use the drug, especially when trying to stop Narrowing repertoire of behaviours associated with use of the drug Drug related behaviours attain greater importance than other activities or behaviours that were previously more important Jatuh balik(relaps) setelah berhenti gian

Amygdala

Compulsive to take drugs

Personality
Family Genetic Underlying depression anxiety attention deficits Social/environment

Experimenting
Voluntarily act

Abuse

Permanent Biological changes in the brain

Dependence (lost of control over substance use)


compulsion

Detoxification
Is the first small step towards treatment of heroin addiction.(It may not be necessary for certain form of medical treatment).saperti direman atau dalam pusat serenti.

Once a person is detoxified, the neurobiological changes in the brain still persist; resulting in a high change of relapse if not treated with medication.

Detoxification
Autotoxin concept The concept of "detoxification" comes from the discredited autotoxin theory of Dr. George E. Pettey and others. David F. Musto says that "according to Pettey, opiates stimulated the production of toxins in the intestines, which had the physiological effect associated with withdrawal phenomena... Therefore treatment would consist of purging the body of toxins and any lurking morphine that might remain to stimulate toxin production in the future.

Rx: Heroin Intoxication & Overdose

Sign and symptom Drowsiness nodding off, analgesia, euphoria, tranquility, miosis, constipation, orthostatic hypotension, respiratory depression, decreased level of consciousness, rarely delirium
Can rapidly progress to overdose

Medical Emergency: Heroin Intoxication

Medical Rx: Supportive care and medical treatment

Medical Emergency: Heroin Overdose


S/S: Slow respiration, subnormal temperature, miosis, cyanosis, weak pulse, difficult to rouse, decrease consciousness, bradycardia, muscle twitching, possible pulmonary edema Medical Mx: ABC, CPR Noloxone (narcan) 0.8 to 2 mg at interval 2 to 3 min; max 10mg

Rx: Heroin withdrawal

Rx: Heroin withdrawal


S/S: lacrimation, rhinorrhoea, yawning, sweating, piloerection, hot & cold flushes, mydriasis, tremor, restlessness, anxiety, muscle twitches, nausea & vomiting, abd. Cramps, mus. & joint aches and craving Usually 6 to 12 hrs after the last dose and last 5 to 7 days

Short term intervention with the following objectives:


To alleviate withdrawal discomfort 2. To prevent complications 3. To interrupt a pattern of heavy & regular heroin use 4. To facilitate to post-withdrawal treatment linkages
1.

Withdrawal is not a cure for heroin dependence !

Detoxification
Drug detoxification (often shortened to "detox") is a collective of interventions directed at controlling acute drug intoxication and drug withdrawal. It refers to a purging from the body of the substances to which a patient is addicted and acutely under the influence. The process of detoxification aims at lessening the physical effects caused by the addictive substances.

Detoxification programs do not necessarily treat the other aspects of drug addiction: namely, psychological aspects of addiction, social factors, and the often complex behavioral issues that are intermingled with addiction.

Detoxification
3 steps to drug detoxification: Evaluation:
Upon beginning drug detoxification, a patient is first tested to see which specific substances are presently circulating in their bloodstream and the amount. potential co-occurring disorders, dual diagnosis, and mental/behavioral issues.

Stabilization:
the patient is guided through the process of detoxification. with or without the use of medications but for the most part the former is more common. explaining to the patient what to expect during treatment and the recovery process. Where appropriate, people close to the addict are brought in at this time to become involved and show support.

Detoxification
3 steps to drug detoxification:

Guiding Patient into Treatment:


The last step of the detoxification process is to ready the patient for the actual recovery process. As drug detoxification only deals with the physical dependency and addiction to drugs, it does not address the psychological aspects of drug addiction. This stage entails obtaining agreement from the patient to complete the process by enrolling in a drug rehabilitation program.

Detoxification
Rapid Detoxification The often painful symptoms of drug withdrawal may last for several days and can stand as a barrier to the treatment of a drug abuse problem. Some practitioners use "rapid" or "ultra rapid" detoxification methods to condense the withdrawal process into a considerably shorter period of time, about two hours, while the addict is asleep. Rapid detox patients placed under anesthesia while given treatment drugs, such as naltrexone, can avoid the extreme pain associated with such treatments, say proponents, and bypass the major effects of withdrawal

How the Process Works


Drug of choice. Different drugs of addiction have different protocols in terms of detox and treatment. Types of available treatments and medications. Alcohol, cocaine, and opiates like heroin and prescription painkillers, to name a few, have specific medications that have been proven to be effective during detox. Medical and health issues. Some detox protocols will not be recommended in the event that there are co-occurring mental health disorders or underlying medical conditions that would be complicated. Patient preference. Some patients feel very strongly that no medications should be introduced during the detox process, while others want all the help they can get.

Detoxification"Cold Turkey"

A cold turkey detox describes


a detox patient stops using all drugs and alcohol abruptly uses no drugs or medications of any kind to mitigate the withdrawal symptoms. This can be extremely difficult both emotionally and physically and can mean intense cravings. Patients are not recommended to attempt this kind of detox without the supervision of professionals at an inpatient facility in order to avoid complications and/or the risk of relapse an issue that can mean overdose in this context.

Detoxification- Maintenance
Medically Asissted Detox A maintenance detox is another way for patients to rid themselves of the toxin buildup brought on by extended use of drugs and alcohol but with the assistance of prescription medication to ease the withdrawal symptoms.
The medications vary depending upon the withdrawal symptoms For example, a heroin addict may choose to detox medically by using buprenorphine or methadone maintenance and slowly decrease the medication until he or she is free from addiction. Withdrawal symptoms will still be an issue but they will not be as significant as they would be without medication.

Components of Withdrawal treatment Services:


Assessment Supportive care - Supportive counseling - Safe environment - Provision of information

Monitoring
Medications Post-withdrawal linkages

General Intervention Plan


Supportive care Medical treatment Monitoring Medical Rx Psychiatric Rx Pharmacology for neuroadaptation reversal Monitoring Symptomatic Substitution

Monitoring Environment Information reassurance

Inpatient Setting
Objective and subjective withdraw scale Self help information ( getting through heroin withdrawal) Create a supportive environment ( reassurance & encouragement) Provide information to counter negative expectations Pharmacotherapy and the effect Manage drug seeking behaviour with alternative to medication

Detoxification regime
Clonidine ( reduction of withdrawal symp)
10 to 17 mu g /kg per day for 5 to 10 days

Buprenorphine (2 to 8 mg per day) & methadone (10 to 40


mg per day)

(induction of substitution and maintenance therapy)


Naltrexone ( 50 mg per day) (relapse prevention)

Detoxification
Physical Discomfort Caused by Withdrawal Symptoms Many patients fear the withdrawal symptoms associated with detox and, for that reason, avoid entering treatment even after they recognize that addiction is a serious and debilitating issue. detox is uncomfortable and that cravings to relapse are high.
However, drug and alcohol rehab programs offer support through peer groups, personal therapy, gentle exercise and nutritional meals all chosen to work together to facilitate the detox process and aid patients in getting through the withdrawal symptoms as quickly and efficiently as possible.

Detoxification
Detoxing alone is not recommended. In most cases, it wont work and it endangers patients
when they eventually use their drug of choice at the same dose that they were using prior to detox, causing an overdose that can be deadly due to the shift in tolerance during the dry period.

Detoxification- OPIATE DEPENDENCE


For people struggling with an opiate addiction, detoxification might seem terrifying. While they may know that
the process is rarely life threatening, they may also be quite familiar with the extreme discomfort that withdrawal from opiates can bring.

Detoxification- OPIATE DEPENDENCE


Abdominal cramping Diarrhea Chills and goose bumps Nausea Vomiting

Mild symptoms might be treated with supportive care, including aspirin and plenty of fluids medications can be used to ease gastrointestinal distress and agitation.
NSAID Ponstan Buscopan Diazepam

If symptoms increase even more, stronger medications might also be provided. clonidine, was originally created to address high blood pressure issues, but it's also been proven helpful in reducing feelings of stress and anxiety in people undergoing opiate withdrawal.

Abstinence
Relapse

Relapse Prevention
Residential (drug-free) Outpatient (drug-free) Psychological counselling Support group Antagonist (eg. naltrexone)

Detoxification
Cessation Partial agonist assisted Opioid agonist assisted 2 agonist assisted Rapid detoxification

Substitution Treatment
Buprenorphine Methadone

Harm Reduction
Dependence
Education about overdose HIV risk reduction info

Heroin use

Detoxification- OPIATE DEPENDENCE


SUBSTITUTION
Methadone or Suboxone Tapers off Gradually Antagonist - Naltrexone

POST WITHDRAWAL INTERVENTION


Relapse Prevention Counseling Cognitive Behavioural Therapy Motivational Interviewing Therapy Self help Group Narcotics Anonymous / Rakan Pembimbing

MAINTENANCE long term ----- Abstinence Psychosocial Service Medical treatment HIV / Hep C/ Tuberculosis

Substitution maintenance therapy Outpatient


BUPRENORPHINE / SUBOXONE

Dose : Average 4 - 8 mg but up to 16mg/day may be prescribed depending on patient clinical status. Administration : A single daily sublingual dose.

Substitution maintenance therapy Outpatient


Methadone

Dose : Average 20 - 40 mg but up to 80mg/day may be prescribed depending on patient clinical status. Administration : A single daily syrup

PSYCHOSTIMULANTS
ATS- Amphetamine Type Stimulants

Features of Psychostimulant intoxication


Hyperactivity Tremor Tachycardia Hypertension Dilated pupils May be aggressive Disinhibited and confused Severe - Arrhythmias or
stroke ; nausea & vomiting, dehydration and hypothermia

Cerebral edema and death

Acute Management
In all cases
supportive care a cool, low-stimulus environment hydration and nutrition
(particularly for those who have been using the stimulant(s) continuously over a period of days).

Treatment will depend on the signs and symptoms; and management of the secondary pathological events. Overdose on these drugs is a medical emergency

- Acidification of urine to increase excretion and Chlorpromazine which to control both central and peripheral alpha adrenergic effects.

Other Complication
Deaths frequently occur because of long delays between onset of symptoms and presentation for treatment.

MDMA 'ecstasy' 1. Liver damage 2. risk of toxicity with combinations: Antidepressants (eg SSRIs, moclobemide) 3. neurotoxic ( serotonergic neurones), increase vulnerability to lifetime depression and other aspects of cognitive function

Features of Psychostimulant Withdrawal


Habitual usage Neuroadaption Withdrawal syndrome
Discontinuation or withdrawal states are commonly associated with abstinence following high-dose stimulant use.
Psychostimulant withdrawal characterised by Crash withdrawal Extinction (prolong withdrawal)

Withdrawal

This is often initially a period of excessive tiredness for 2448 hours (crash). exhaustion, increase sleep needs and dyphoria Low craving Following this there may be a period of 1014 days during which the following symptoms may be experienced (Withdrawal): Anxiety, irritability, racing thoughts, difficulty sleeping, severe craving, mood swing and poor concentration Appetite may increases

Withdrawal cont..

Some time mood swing and irritability may persist longer. Extinction phase: Anhedonia, Craving and depression may last for many months after cessation of use. This may be associated with elevated risk of suicide, particularly in the first few weeks after cessation. Paranoid delusion and other psychotic phenomenon may present in susceptible person

Planning withdrawal & Treatment


A. Engagement and providing verbal and written information B. Supportive counseling : coping strategies for craving ,maintaining motivation, sleep hygiene relaxation technique and patience C. Harm Reduction concept and Controlled drug use intervention D. Medication

C. Harm Reduction concept


(Lintzeris & Spry-Bailey 1998)

Steps of Harm reduction


1.
2. 3. 4.

5.
6.

Be familiar with the potential harms associated with all types of drug use Assess the harms and risks associated with the clients drug use Provide information and feedback about how the clients behaviour is contributing to the harms he/she is experiencing Use a collaborative approach with the client to examine the harm reduction strategies he/she employ to reduce harms Have the client identify his/her goals regarding drug use and related behaviours Monitor the clients behaviour, reinforce positive changes in behaviours and address difficulties

C. Controlled Drug Use Intervention


(Holgate et al 1996)

Steps for Controlled drug use intervention

1. 2. 3. 4. 5. 6.

Assessment Initial monitoring of drug use Goal; and limit setting Establish of an action plan Ongoing monitoring Review of action plan , goals and limits

D. Medication
No medication has been shown to be particularly effective in the treatment of amphetamine withdrawal Commonly used medication Benzodiazepines Antipsychotics Antidepressants

Benzodiazepines
Benzodiazepines may be useful to reduce irritability. Anxiolytic effect and sleep problem

Diazepam - 5 to 10 mg , max 40 mg daily. Reduce the dose over 7 to 10 days (not more than 14 days)

Antipsychotic
to manage the psychosis, thought disorder & perceptual disturbance Management of aggressive patient : calming effect Symptom usually last for about 2 weeks
Chlorpromazine 25 to 200 mg / Haloperidol 3 to 5 mg in BD or QID / Risperidone/ Aripiprazole

Antidepressants
Antidepressants may be helpful for treatment of depression arising from stimulant withdrawal. Alleviate sleep problem or agitation and anxiety
Should continue for short term but if indicated may need long term treatment

Choice : SSRI eg - fluoxetine 20 mg Note : there is risk of overdose/deliberate self harm

Other pharmacotherapies for problematic psychostimulant !


Dopamine agonist Disulfiram CNS stimulant : Dexamphetamine, mehylphenidate Modafinil Calciun blockers Opioid agonists and antagonist

Alternative treatment
Residential Therapeutic community Spirituality
the main focus are self awareness and engaging in the process of self discovery

5: Matching BI strategy to the persons needs and circumstances


Precontemplation

Maintenance

Lapse & Relapse

Contemplation

Action

Determination to Change