Prison & Addiction Conference 2018

Topic 1:
Biomedical
Understanding of
Addiction
Dr. Luke Woon Sy-Cherng
Clinical Specialist (Psychiatry)
Outline
Basic brain anatomy and functions – reward pathway
Pathophysiology of addiction
Major types of substances
Aetiological (Causal) factors
Epidemiology – Worldwide & Malaysia
General understanding of major mental disorders
 Emotions, memory and arousal
Reward Pathway of the Brain
 Neurotransmission Synapse

(Stahl, 2010)
Neurotransmitters
Serotonin (5-HT)
Dopamine (DA) Monoamines
Norepinephrine (NE)
Acetylcholine (Ach)
Glutamate
GABA (γ-aminobutyric acid)
Targets of Psychotropic Agents
Transporters
Receptors
Enzymes
Blockade of reuptake
transporter

↑ availability of
neurotransmitter at
the synaptic cleft

(Stahl, 2010)
Inhibition of enzyme Reduced breakdown of NT More NT available

(Stahl, 2010)
 Action of Psychotropic Agents at
Receptors

(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Koob & Volkow, 2016)
(Stahl, 2010)
Addiction

Impulsivity Compulsivity
Substances listed in DSM-5
Diagnostic & Statistical Manual, 5th Edition is a set of
diagnostic criteria published by the American Psychiatric
Association that has been widely used internationally
Substances included in DSM-5 are:
oAlcohol o Opioids
oCaffeine o Sedatives/Hypnotics/Anxiolytics
oCannabis o Stimulants
oHallucinogens o Tobacco
oInhalants o Others/Unknown Substances
(Stahl, 2010)
 Actions of Substances in the Brain
Substance Receptor Action Corresponding Neurotransmitter

Tobacco Nicotinic Acethylcholine

receptor
Alcohol GABA receptor Gamma butyric acid (GABA)
Heroin, Opioid receptor Endorphins, enkephalins, dynorphins
morphine
Cannabis Cannabinoid Endocannabinoids e.g. Anandamide
receptor
Amphetamine Dopamine Dopamine
receptor
(Stahl, 2010)
 Aetiological Factors
Genetics
Strong evidence from twin adoptees studies indicates that the
cause of alcohol abuse has a genetic component.
Many less conclusive data show that other substance
abuse/dependence have genetic pattern in their development.
Associations to genes that affect dopamine production have
been postulated.

(Sadock et al., 2014)

 Aetiological Factors
Psychological
Substance use:
 A defence against anxious impulses
 A manifestation of (oral) dependency
Disturbed ego function – inability to deal with reality
A form of self-medication
Alexithymia – inability to recognize inner emotional states
Learning and conditioning

(Sadock et al., 2014)

 Aetiological Factors
Social
Drug availability
Social acceptability
Laws
Peer pressure
Parental drug use

(Sadock et al., 2014)

 Epidemiology - Malaysia

(AADK, 2017)
(AADK, 2017)
(AADK, 2017)
(AADK, 2017)
Schizophrenia
POSITIVE SYMPTOMS NEGATIVE SYMPTOMS
Delusions Affective blunting
Hallucinations Avolition
Disorganized speech & Alogia
disorganized behaviours
Asociality
Anhedonia
 A) Nigrostriatal
pathway
B) Mesolimbic pathway
C) Mesocortical
pathway
D) Tuberoinfundibular
pathway

(Stahl, 2010)
Mesolimbic pathway
Too much dopamine
Positive symptoms

(Stahl, 2010)
(Stahl, 2010)
 EPS = extrapyramidal
symptoms
- Acute dystonias
- Parkinsonism
- Akathisia
- Tardive dyskinesia

(Stahl, 2010)
 Hyperprolactinemia:
-Galactorrhoea
(breast secretions)
-Amenorrhoea
(irregular menses)

(Stahl, 2010)
 Anticholinergic Effect

(Stahl, 2010)
 Typical Antipsychotics
Generic name Brand name
Haloperidol Haldol
Sulpiride Dogmatil
Trifluoperazine Stelazine
Thioridazine Mellaril
Perphenazine Trilafon
Chlorpromazine Thorazine
Fluphenazine decanoate* Modecate
Flupenthixol decanoate* Fluanxol
Zuclopenthixol decanoate* Clopixol
*IM depot injection
Atypical Antipsychotics
Dopamine antagonism (D2 antagonist) at:
Mesolimbic pathway – improve positive symptoms

Additional activities at serotonin pathways (5-HT2A antagonist

+/- activities at other receptors) lead to no or little EPS &
hyperprolactinemia
Atypical Antipsychotics
*Higher risk of metabolic side effects compared to typical
antipsychotics

Metabolic syndrome:
Central obesity
Hypertension
High triglyceride level
Low HDL level
High blood sugar level
Atypical Antipsychotics
Generic name Brand name
Clozapine Clozaril
Olanzapine Zydis
Quetiapine Seroquel
Asenapine Saphris
Risperidone Risperdal
Paliperidone Invega
Aripiprazole Abilify
Clozapine
2nd line treatment
Indicated for treatment-resistant schizophrenia

Associated with metabolic syndrome

Risk of agranulocytosis (depletion of immune cells) – risk of
infections
Needs regular blood monitoring
- weekly full blood count (FBC) up to 18 weeks
- then monthly FBC
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
Classes of Antidepressants
SSRIs (Serotonin reuptake inhibitors)
SNRIs (Serotonin-norepinephrine reuptake inhibitors)
NDRI (Norepinephrine-dopamine reuptake inhibitor)
- Bupropion (Wellbutrin)
NaSSA (Noradrenergic & specific serotonergic antidepressant)
- Mirtazapine (Remeron)
Agomelatine
Classes of Antidepressants
(cont’d)
TCAs (Tricyclic antidepressants)
MAOIs (Monoamine oxidase inhibitors)

Multimodal antidepressant
- Vortioxetine (Brintellix)
SSRIs
Generic name Brand name
Fluoxetine Prozac
Sertraline Zoloft
Paroxetine Paxil
Fluvoxamine Luvox
Escitalopram Lexapro
Citalopram Celexa
Common side effects:
 Nausea, vomiting, abdominal pain, diarrhoea
 Headache, anxiety, insomnia
 Sexual dysfunction
 Discontinuation symptoms
SNRIs
Generic name Brand name
Venlafaxine Effexor
Desvenlafaxine Pristiq
Duloxetine Cymbalta
Common side effects:
 Nausea, dry mouth, constipation
 Headache, dizziness, insomnia
 Discontinuation symptoms

*Elevation of blood pressure

Mood Stabilizers

(Stahl, 2010)
Mood Stabilizers

(Stahl, 2010)
Classes of Mood Stabilizers
Lithium
Anticonvulsants
Atypical antipsychotics
Lithium
Treatment of moderate to severe mania
Prophylaxis of bipolar disorder
Reduces risk of suicide

Risk of toxicity – needs blood level monitoring

Common side effects: mild gastrointestinal upset, fine tremor,
polyuria & polydipsia
 Anticonvulsants

(Stahl, 2010)
Valproate
Sodium valproate: Also known as valproic acid (Brand name:
Epilim)
Treatment of bipolar mania & depression
Prophylaxis of bipolar disorder

Adverse effects: nausea, weight gain, hair loss, tremor,

confusion
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
Benzodiazepines
Anxiolytics
Also known as sedative
hypnotics

Positive allosteric modulators

at
GABA receptors

(Stahl, 2010)
(Stahl, 2010)
Benzodiazepines
Generic name Brand name
Alprazolam Xanax
Midazolam Dormicum
Lorazepam Ativan
Clonazepam Rivotril
Diazepam Valium
Side effects:
 Headache, confusion, blurred vision
 Risk of falls and fractures
 Respiratory depression

*Dependence
 Serotonergic Agents
- Almost all SSRIs and some other antidepressants

(Stahl, 2010)
Prison & Addiction Conference 2018

Topic 2:
Substance Use &
Related Disorders -
Focusing on Stimulants
Dr. Luke Woon Sy-Cherng
Clinical Specialist (Psychiatry)
Outline
Spectrum of substance-related disorders
Substance use & mental disorders
General principles of treatment
Stimulant use and related disorders
Emerging synthetic drugs (New psychoactive substances)
Spectrum of Substance-related Disorders
Substance use disorder
Substance intoxication
Substance withdrawal
Substance-induced disorders, e.g.
 Psychotic disorder
 Bipolar disorder
 Depressive disorder
 Anxiety disorder
Substance Use Disorder
DSM-5 does not separate the diagnoses of substance abuse
and dependence as in DSM-IV.
Rather, criteria are provided for substance use disorder,
accompanied by criteria for intoxication, withdrawal and
substance-induced disorders
The threshold for substance use disorder diagnosis is set at 2
or more criteria
Severity: 2–3 criteria indicate a mild disorder; 4–5 criteria, a
moderate disorder; and 6 or more, a severe disorder.
Early remission: at least 3 but less than 12 months
Sustained remission: at least 12 months
Diagnostic Criteria: Stimulant Use
Disorder
A. A pattern of amphetamine-type substance, cocaine, or other stimulant
use leading to clinically significant impairment or distress, as manifested by
at least two of the following, occurring within a 12-month period:
1. The stimulant is often taken in larger amounts or over a longer period
than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control
stimulant use.
3. A great deal of time is spent in activities necessary to obtain the
stimulant, use the stimulant, or recover from its effects.
4. Craving, or a strong desire or urge to use the stimulant.
5. Recurrent stimulant use resulting in a failure to fulfill major role
obligations at work, school, or home.
6. Continued stimulant use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the
stimulant.
Diagnostic Criteria: Stimulant Use
Disorder
7. Important social, occupational, or recreational activities are given up or
reduced because of stimulant use.
8. Recurrent stimulant use in situations in which it is physically hazardous.
9. Stimulant use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the stimulant.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the stimulant to achieve
intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of
the stimulant.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the stimulant
b. The stimulant (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms.

(APA, 2013)
Diagnostic Criteria: Stimulant
Intoxication
A. Recent use of an amphetamine-type substance, cocaine, or other
stimulant.
B. Clinically significant problematic behavioral or psychological changes (e.g.,
euphoria or affective blunting: changes in sociability: hypervigilance:
interpersonal sensitivity: anxiety, tension, or anger; stereotyped behaviors:
impaired judgment) that developed during, or shortly after, use of a
stimulant.
C. Two (or more) of the following signs or symptoms, developing during, or
shortly after, stimulant use:
1. Tachycardia or bradycardia.
2. Pupillary dilation.
3. Elevated or lowered blood pressure.
4. Perspiration or chills.
5. Nausea or vomiting.
Diagnostic Criteria: Stimulant
Intoxication
6. Evidence of weight loss.
7. Psychomotor agitation or retardation.
8. Muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias.
9. Confusion, seizures, dyskinesias, dystonias, or coma.
D. The signs or symptoms are not attributable to another medical condition
and are not better explained by another mental disorder, including
intoxication with another substance.

(APA, 2013)
Diagnostic Criteria: Stimulant
Withdrawal
A. Cessation of (or reduction in) prolonged amphetamine-type substance,
cocaine, or other stimulant use.
B. Dysphoric mood and two (or more) of the following physiological changes,
developing within a few hours to several days after Criterion A:
1. Fatigue.
2. Vivid, unpleasant dreams.
3. Insomnia or hypersomnia.
4. Increased appetite.
5. Psychomotor retardation or agitation.
C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition
and are not better explained by another mental disorder, including
intoxication or withdrawal from another substance.
(APA, 2013)
Substance Use & Mental
Disorders
Addiction is a chronic relapsing and remitting disorder that
severely impacts the course, treatment and prognosis of mental
illness.
Conversely, mental illness also impacts the course and
treatment of the substance use disorder (SUD).
Historically, patients with co-occurring disorder (COD) would
receive treatment for one disorder after another, or in different
settings.

(Yuodelis-Flores et al., 2012)

Substance Use & Mental
Disorders
COD patients was then shown to do poorly in traditional
addiction treatment without some emphasis on their comorbid
psychiatric conditions.
Increasing awareness has led to evidenced-based model of
integrated treatment of COD concurrently in the same
programme (Drake et al, 2001).

(Yuodelis-Flores et al., 2012)

Scope of COD in the Community
According to the Ecological Catchment Area (ECA) Study,
among those with a mental disorder, the odds ratio of having
some addictive disorder was 2.7, with a lifetime prevalence of
about 29% (including an overlapping 22% with an alcohol and
15% with another drug disorder).
For those with either an alcohol or other drug disorder, the
odds of having the other addictive disorder were seven times
greater than in the rest of the population.

(Regier et al., 1990)

Scope of COD in the Community

(SAMHSA, 2014)
Scope of COD in the Community

Among the 20.3 million adults aged 18 or older in 2013 who

had a past year substance use disorder, 11.4 percent (2.3
million adults) also had SMI in the past year.
(SAMHSA, 2014)
Scope of COD in the Community

(SAMHSA, 2014)
Complications of Comorbid
Disorders
•Dual diagnosis has much higher rate of adverse outcome than
single diagnosis (Drake, 2007):
 Higher rate of relapse and hospitalization
 Victimization
 Violence
 Incarceration
 Homelessness
 Serious blood-borne infection (HIV, Hepatitis C)
 Completed suicide

(Drake, 2007)
Complications of Comorbid
Disorders
Subjects with co-occurring depressive disorder and AUD
report more previous depressive episodes and suicide
attempts.
More than a third of panic disorder patients have a lifetime
history of SUD.
Patients with PTSD have 2 to 4 times greater than non-PTSD
patients risk for SUD.
SUD worsens the course and treatment outcome in bipolar
disorder and is associated with violence against self and
others.

(Yuodelis-Flores et al., 2012)

Complications of Comorbid
Disorders
Comorbid addiction and schizophrenia increases likelihood of
homelessness, legal problems, treatment non-compliance and
suicidal behaviour.
Co-occurrence of SUD in axis II personality disorders
increases the risk of suicide attempts.

(Yuodelis-Flores et al., 2012)

Integrated Treatment for Co-
Occurring Disorders
 Integrated Treatment is a research-proven model of
treatment for people with serious mental illnesses and co-
occurring substance use disorders.

 Consumers receive combined treatment for mental illnesses

and substance use disorders from the same practitioner or
treatment team. They receive one consistent message about
treatment and recovery.

(SAMHSA, 2005)
Integrated Treatment
 Mental health and substance abuse treatment are
evaluated and addressed by:
 Same team
 Same location
 Same time

 Treatment targets the individual needs of people with

co-occurring disorders and is integrated on organizational
and clinical levels.

(SAMHSA, 2005)
Stage-wise Treatment
Intervention tailored to the person’s stage of treatment or
recovery, based on concept of stages of change.
It consist of 4 stages:
1. Engagement interventions
2. Motivational intervention
3. Active treatment
4. Relapse prevention

(SAMHSA, 2005)
Stage-wise Treatment
Engagement
interventions – to
address with difficulty in
engagement into the
system

Motivational
intervention – address
Relapse prevention
unmotivated person for
changes

Active treatment
– help patient to acquire skills
and supports, promote
adherence, self, vocational,
medications
(SAMHSA, 2005)
Stage-wise Treatment
Pre-contemplation — Engagement
Assertive outreach, practical help
(housing, entitlements, other), and an
introduction to individual, family,
group, and self-help treatment
formats
Action — Active treatment
Counseling and treatment
based on cognitive-behavioral
techniques, skills training,
and support from families
and self-help groups
(SAMHSA, 2005)
Contemplation and Preparation —
Persuasion
Education, goal setting, and building
awareness of problem through
motivational counseling
Maintenance — Relapse prevention
Continued counseling and treatment
based on relapse prevention
techniques, skill building, and ongoing
support
to promote recovery
Evidence-based Psychosocial
Treatments
Motivational Enhancement Therapy (MET)
Brief, patient-centred directive therapy focusing on
interventions designed to enhance motivation for change and
facilitate transition from one stage of change to the next
(Prochaska et al, 1992).
5 identifiable stages: pre-contemplation, contemplation,
preparation, action, and maintenance.
Clinician facilitates greater awareness by exploring substance
use patterns around times of stress or illness exacerbation.
Exploring pros and cons of behaviour change via a decisional
balance analysis.
(Yuodelis-Flores et al., 2012)
The Trans-theoretical Model

(Prochaska et al., 1992)

Evidence-based Psychosocial
Treatments
Relapse Prevention Therapy (RPT)
A form of CBT which focuses on the relapse prevention model
of Marlatt and Gordon (1985).
The goal is abstinence through functional analysis of high-risk
situations or “triggers” for relapse followed by development of
coping strategies.
Educates about the impact of drugs and alcohol on SMI.
Clients are taught to manage both of these illnesses.
Emphasizing behavioural techniques over cognitive therapy,
problem-solving skills & social skills training.

(Yuodelis-Flores et al., 2012)

Evidence-based Psychosocial
Treatments
Twelve Step Facilitation Therapy
Encourage illness acceptance, abstinence, spirituality and
attendance at Alcoholics Anonymous (AA) and other 12-step
meetings.
Dual Recovery Anonymous (DRA) for clients with COD 
emphasizes peer support and insight enhancement by
addressing recovery from both disorders.

(Yuodelis-Flores et al., 2012)

Evidence-based Psychosocial
Treatments
Contingency Management Therapy
Based on the systematic application of positive reinforcement
to reward achievement.
E.g. Patient receives vouchers for reward contingent upon
negative urine toxicology screens.
CM has been studied and shows evidence of efficacy across
drug types and also with COD patients.

(Yuodelis-Flores et al., 2012)

Stimulant & Severe Mental Illness
A study in Thailand found that among methamphetamine
psychosis patients, after first hospitalisation 38% were given a
diagnosis of schizophrenia (Kittirattanapaiboon et al. 2010).
Relationship between amphetamines & psychosis remains
unresolved: drug exposure (amphetamine-induced psychosis);
amphetamines use triggering primary psychotic disorder; or
both.
An alternative term is suggested: “substance-associated
psychosis” (Mathias et al. 2008).
(Bramness et al. 2012)
Case Vignette
Ms. F was a 28 years old divorced lady with a history of regular
methamphetamine use.
Presented to hospital for wandering around & reduced sleep
associated with auditory hallucination & persecutory delusion
that her sister was trying to snatch away her boyfriend.
A month earlier, she experienced work-related stress and
increased her methamphetamine use to 2 to 3 times per week.
Last intake of methamphetamine was on the day prior to
admission to HRPB.
Case Vignette
She had 3 previous episodes acute psychotic symptoms after
heavy methamphetamine use & rapid resolution after
treatment initiation.
Did not adhere to treatment as outpatient.
No history of lifetime manic or depressive symptoms.
No medical illness –Negative for infectious screening.
Long history of multiple substance use since teenage.
Began experimenting with substances under peer influence, &
subsequently by persuasions of her partners.
Case Vignette
Job as GRO also exposed her alcohol & drugs.
Used methamphetamine in a more consistent manner since 10
years ago; became dependent since 4 years ago.
History of marked reduction in substance use when she was
married and in a more stable environment.
Strong family history of schizophrenia (biological mother &
eldest sister both suffer from the illness).
Detached from her mother; relationship with her late father
was strained.
Case Vignette
Poor academic records at school.
Disciplinary problems since teenage both at school & at home.
Known to have lied repeatedly to relatives & doctors.
Tendency to gain acceptance through drug use & multiple
short-lived intimate relationships.
History of indiscriminate sexual encounters & abortions.
Aetiology
Predisposing factors
Genetics
Family history of schizophrenia is a risk factor for psychosis
following amphetamines use (Chen et al. 2003).
Relatives of methamphetamine-users with a lifetime history of
amphetamine psychosis are 5 times more likely to have
schizophrenia than methamphetamine-users without a history
of psychosis (Chen et al. 2005).
Aetiology
Several susceptibility genes have been found in common for
methamphetamine-induced psychosis and schizophrenia
(Bousman et al. 2011):
Aetiology
Amphetamines – Sensitization
Sensitization to the rewarding effects of amphetamines is seen
in human subjects (Strakowski et al. 2001).
An earlier psychosis leads to increased risk of future psychotic
episodes due to this sensitization (Ujike & Sato 2004).
Aetiology
Personality traits
Traits such as recklessness, impulsivity, and sensation seeking
lead to experimentation with drugs.
Lack of remorse and disregard of laws & regulations also
embolden the person to abuse drugs.
Low psychological self-regulation in conjunction with a
facilitating environment leads to initiation of substance use at a
young age (Tarter 2002).
Aetiology
Attachment theory
Substance abuse can be viewed as a faulty activation of
attachment strategies stemming from insecure attachment
relationships in infancy and early childhood (Cihan et al. 2014).
Schindler et al. (2005) studied 71 German drug dependent
adolescents (DDAs) & 39 non-clinical controls.
 Fearful attachment was predominant in DDAs, while
controls were predominantly secure.
 Severity of drug use was positively correlated with fearful
attachment.
Aetiology
Attachment theory
Data on connections between patterns of attachment and
pathways towards SUD point to disorganized & externalizing
pathways (Schindler & Broning 2014) – Intermediary to
substance abuse (Brook et al. 1986).

Deficient parenting skills, inconsistent & conflictual

communication, low supervision, neglectful parenting &
punitive discipline amplify risk for initiating SU and
subsequently developing SUD (Zhai et al. 2014).
Aetiology
Social learning
Social learning theory (Bandura 1971) can be applied to drug
taking behaviour

Acquisition of drug-taking behaviour through modeling

process, which involves:
 Differential association: interaction and identity with different
groups
 Definitions: norms, attitudes, orientations
 Imitation: modelling of others' behavior
 Differential reinforcement: rewards or punishments for the
behavior and for alternative behavior (Akers et al. 1979)
Aetiology
Precipitating factors

Stressful life event:

Problem at work (Social)
Resulting in increased stimulant use and precipitated the
psychotic episode (Biological)
Aetiology
Perpetuating factors
Classical and operant conditioning
1. Operant conditioning
Drug use: behaviour maintained by its consequences
Drug reinforces antecedent behaviour by positive
reinforcement (euphoria, social approval) & negative
reinforcement (relief of withdrawal symptoms, alleviation of
disturbed affects)
Aetiology
2. Classical conditioning:
Aetiology
Female gender
Women may be particularly vulnerable to the reinforcing
effects of stimulant drugs in comparison to men (Westermeyer
& Boedicker 2000).
Substance-dependent females had attenuated
neuroendocrine stress response following exposure to drugs –
HPA dysregulation in women may lead to enhanced
vulnerability to relapse (Back et al. 2008).
“Telescoping”: accelerated progression of substance use
disorders among women compared to men (Greenfield et al.
2010).
Aetiology
Social and domestic environment
Illicit substances are easily available at workplace.
Offers of drugs from previous partners.
Women substance abusers are often drawn into substance use
by partners (el-Guebaly 1995).
Absence of stable family environment to provide a regular
lifestyle.
Women substance abusers were found frequently initiating
substance use as a result of traumatic life events such as
disruption in family life (Nelson-Zlupko et al. 1995).
Management
Pharmacological aspect
Treatment of choice for stimulant-induced psychotic disorder
is antipsychotic medication on short-term basis.
A Cochrane Review in 2009 (Shoptaw et al.) found only 1 RCT
of treatment for amphetamine psychosis that met the inclusion
criteria. Both olanzapine & haloperidol at clinically relevant
doses were efficacious in resolving psychotic symptoms.
Management
There are no effective pharmacotherapies for the treatment of
stimulant dependence.
Effective medications are available for some psychiatric
complications of stimulant use.
For example, antidepressants have a role in treating major
depressive disorder associated with stimulant use as do
antipsychotics for amphetamine psychosis.
However, neither class of drug is efficacious in treating
stimulant dependence itself
The recommended treatment for dependence on stimulants is
psychosocial

(Taylor et al., 2012)

Management
Potential future treatment options
3 RCTs using modafinil, bupropion & naltrexone showed
positive results in reducing amphetamine or methamphetamine
use (Karila et al. 2010).
A Cochrane Review done in 2013 (Pérez-Mañá et al.) on the
use of psychostimulants as a replacement therapy for
amphetamine abuse/dependence
 Included 11 studies on dexamphetamine, bupropion,
methylphenidate and modafinil
 Found no reduction in amfetamine use or craving
 No increase in sustained abstinence
Management
Detoxification
Treatment should focus on symptomatic relief.
Although many symptoms of amphetamine withdrawal (low
mood, listlessness, fatigue, etc.) are short-lived and may not be
amenable to pharmacological treatment.
Insomnia can be treated with short courses of hypnotics.

(Taylor et al., 2012)

Management
Maintenance
Dexamphetamine maintenance should not be initiated.
No good evidence for this practice.

Polysubstance abuse
For those dependent on opioids and stimulant, the provision
of effective substitution therapy for treatment of the opioid
dependence with methadone/buprenorphine can lead to a
reduction in stimulant use.

(Taylor et al., 2012)

Management
Psychosocial aspect
Individual psychoeducation/psychotherapies
 Establish therapeutic alliance & motivate the patient; tackle
underlying psychological issues

Family and/or couple intervention

 Enlist the help & support of close relatives and resolve
relational conflicts

Support for employment

 Ensure financial stability and avoid environmental stimuli
Management
Motivational interviewing
Motivational interviewing (MI) is a treatment philosophy & set
of methods developed by Miller & Rollnick (1991).
Employed to help people increase intrinsic motivation by
exploring and resolving ambivalence about behavioral change.
Principles of MI:
 Express empathy
 Develop discrepancy
 Roll with resistance
 Support self-efficacy
Management
Motivational interviewing
A review of 4 meta-analyses found that:
 MI is significantly (10–20%) more effective than no treatment
 Generally equal to other treatments for a wide variety of
problems ranging from substance use (alcohol, marijuana,
tobacco & other drugs)
 Reduced risky behaviours and increased client engagement in
treatment

(Lundahl & Burke 2009)

Management
Cognitive behaviour therapy
Based on principles of conditioning & learning that is used to
teach, encourage & support individuals about how to
reduce/stop harmful drug use.
An umbrella term that encompasses a range of interventions
with specific protocols (Carroll & Rawson 2005):
 Relapse prevention
 Coping skills therapy
 Cognitive therapy (CT)
 Mindfulness based cognitive therapy
Management
Cognitive behaviour therapy
A systematic review of RCT of cognitive-behavioural and
behavioural interventions for methamphetamine users found
that:
 CBT is associated with reductions in methamphetamine use
and other positive changes
 Even over very short periods of treatment (2 & 4 sessions)

(Lee & Rawson 2008)

Management
Contingency management (CM)
Positive reinforcement influences behaviour change by means
of operant conditioning.
Monetary reward/redeemable vouchers for the choice of
abstinence.
Associated cost is a considerable barrier to the community use
of CM (Carroll & Onken 2005).
Management
Behavioural Couples Therapy (BCT)
Family members, specifically spouses or other intimate
partners, can reward abstinence
Reduction of relationship distress & conflict leads to improved
substance-use outcomes by reducing possible antecedents to
relapse and heavy use.
Significantly higher rates of marital satisfaction, lower
substance-use severity, greater improvements in psychosocial
functioning of children & better cost-effectiveness compared
with individual-based treatments (Fals-Stewart et al. 2006).
Management
Family therapy
Recognized as an effective approach for treating both adults &
adolescents with drug problem.
Adult-focused models based on behavioral and systems
theories of change show strong effects with drug abusers and
their families (Rowe 2012).
Example: Family Behaviour Therapy.
Management
Substance use and personality issues:

Evidence for the general effectiveness of psychotherapy for

personality disorder; but little support for treatment on out-
patient basis (Bateman & Fonagy 2000).

Psychotherapy for concomitant substance dependence &

personality disorder – small body of evidence for DBT in BPD
(Kienast & Foerster 2008).
Management
Support for Employment
Women with SUDs face more barriers to employment than
men, including limited education, vocational training & work
experience.
Interventions e.g. vocational services (Luchansky et al. 2000)
& intensive case management (Morgenstern et al. 2009) are
associated with better employment outcomes than “standard”
care.
Protective factor against relapse to substance abuse in women
(Kissin et al. 2015).
Management
Support for Employment
Reductions in substance use were associated with an increase
in economic autonomy.
Women living in drug-free social environments had higher
rates of abstinence and better overall functioning (Gregoire &
Snively 2001).
New Psychoactive Substances
Once known as ‘designer drugs’, but in recent times have been
described informally as ‘legal highs’.
The preferred term, as adopted by the European Community
in 2005 is ‘new psychoactive substances’.
The word ‘new’ means newly misused; in reality, nearly all of
the substances encountered were first synthesized many years
ago.
These compounds can be distinguished from what we might
call the classical drugs of misuse (e.g. amphetamine, cocaine,
heroin, cannabis) because the former have had little or no
history of medicinal use.

(King & Kicman, 2011)

New Psychoactive Substances
Various substances have appeared over the years
Herbal blends (e.g. ‘Spice’)
Synthetic cannabinoids (obtained pure)
Branded stimulants (e.g. ‘bath salts’)
Stimulants/empathogens/nootropics (obtained pure, e.g.
mephedrone, MDPV, a-PVP)
Psychedelics (e.g. NBOMe-x, 2C-x)
Dissociatives (e.g. methoxetamine)

(Benschop et al., 2017)

New Psychoactive Substances
Many were manufactured in clandestine laboratories and
marketed through criminal networks
E.g. MDMA as ‘Ecstasy’ - tablets bearing characteristic logos --
later became much broader to include other synthetic drugs.
Manufacturers of new substances were now trawling the
world’s scientific and patent literature in search of failed
pharmaceuticals or, as they also became known, ‘designer
medicines’.
Key groups at greater risk include participants in nightlife,
MSM, people in custodial settings, young people and IVDU.

(King & Kicman, 2011)

(King & Kicman, 2011)
(Benschop et al., 2017)
(Benschop et al., 2017)
(Benschop et al., 2017)
New Psychoactive Substances
NPS users may require additional support for polydrug use,
physical and mental ill health, offending behaviour, housing and
employment problems, and sexual health concerns.
Inpatient treatment for NPS users with related mental
disorders does not differ substantially from those offered to
patients using drugs from similar classes.
Unlike drugs such as opioids, there are no
maintenance/substitution pharmacotherapies currently
available for NPS.
Pharmacotherapy may be appropriate for symptom relief
upon discontinuation.
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Thank You