Substance use disorder

F10–19

SUBSTANCE USE DISORDER

DESCRIPTION

The essential feature of a substance use disorder (SUD) is a cluster of cognitive, behavioural and physiological symptoms that indicate that the individual continues to use the substance despite significant substance-related problems.

Age of onset of substance abuse can be as early as 8 years. Illicit drugs such as cocaine, amphetamines and cannabis, as well as alcohol abuse are associated with a greater risk for psychosis. Behavioural disturbance in the context of a SUD may be due to intoxication, withdrawal, or due to a substance-induced mood or psychotic disorder. Initial treatment of SUDs begins with medical stabilisation of the patient ideally in a medical facility. About one third of youth with SUDs, present with a ‘dual diagnosis’ i.e. a co-occurring psychiatric disorder. Be aware of the mental state changes associated with illicit drugs.

DIAGNOSTIC CRITERIA (DSM 5)

  • Substance is used in larger amounts or for longer period than intended
  • A persistent desire or unsuccessful efforts to cut down or control use
  • A great deal of time is spent in activities to obtain, use or recover from the substance
  • Cravings or strong urges to use the substance
  • Failure to meet obligations at work, home or school
  • Continued use despite social and interpersonal problems caused by effects of the substance
  • Use results in decreased or stopping social or recreational activities
  • Continued use in hazardous situations
  • Ongoing use despite knowing of a physical or psychological problem caused by substance
  • Withdrawal
  • Tolerance

SUBSTANCE-INDUCED PSYCHOTIC DISORDER

  • Prominent hallucination or delusions.
  • Symptoms occur during or within one month of proven substance abuse or intoxication.
  • A psychiatric disorder such as schizophrenia or a general medical condition is not the cause of the psychosis.
  • The disturbance does not occur in the course of a delirium, which must be excluded.

SUBSTANCE-INDUCED MOOD DISORDER

  • A significant and sustained disturbance in mood i.e. depressed, irritable, expansive or elevated.
  • Symptoms occur during or within one month of proven substance abuse or intoxication.
  • A psychiatric disorder such as bipolar or a general medical condition is not the cause of the mood disturbance.

GENERAL AND SUPPORTIVE MEASURES

  • Conduct a medical assessment (pulse rate, temperature, blood pressure, ECG) and laboratory investigations (FBC, U&E, LFT, BHCG, urine toxicology), depending on the specific drug of abuse.
  • Manage withdrawal states, depending on substance of abuse.
  • Refer to a social worker for an evaluation of the family circumstances and for brief motivational interviewing.

MEDICATION TREATMENT

Several medications have been approved by the FDA for treating addiction to opioids, alcohol or nicotine in adults, but not in adolescents. Only preliminary evidence exists for the effectiveness and safety of these medications in individuals under 18 years and no evidence exists for the neurobiological impact of these medications on the developing brain. There are currently no FDA-approved medications to treat addiction to cannabis, cocaine or methamphetamine in any age group.

SUBSTANCE WITHDRAWAL

MEDICATION TREATMENT

Consult with a psychiatrist or specialised referral unit. Mild withdrawal states can be managed as an outpatient whereas more severe cases should be referred to the local casualty for medical stabilisation. Children under 6 years old should be referred immediately to casualty.

Alcohol, Benzodiazepines, Stimulants (Cocaine, Methamphetamine) and less commonly Cannabis/Mandrax withdrawal

Management of mild withdrawal:

  • Diazepam, oral,
    • 6 – 14 years: 2 – 10 mg daily in 2–3 divided doses.
    • > 14 years up to 20 mg daily in 2–3 divided doses.
    • Taper dose over 3–5 days.

Hallucinogens/Volatile solvents

No detoxification indicated.

ALCOHOL WITHDRAWAL

F10.239

GENERAL AND SUPPORTIVE MEASURES

Refer children under 6 years old and patients with:

  • convulsions
  • psychiatric illnesses: psychosis, intellectual impairment
  • suicidal ideation
  • significant medical comorbidity such as heart disease; pregnancy
  • inadequate social support
  • history of withdrawal delirium

Assess for comorbid infections and other pathology.
Ensure adequate hydration. Overhydration is a common error made in this setting.

MEDICATION TREATMENT

Alcohol detoxification may be managed on an outpatient basis in cases of mild, uncomplicated alcohol withdrawal.

  • Thiamine: oral.
    • Children: 0.5 – 1 mg/kg daily for 14 days.
    • Adults: 50 mg daily for 14 days.
  • Diazepam: oral.
    • 1 – 6 years: 1 – 6 mg/day.
    • 6 – 14 years: 2 – 10 mg daily in 2–3 divided doses.
    • > 14 years: up to 20 mg daily in 2–3 divided doses.
    • Wean dose from 8 hourly, to 12 hourly, to daily every 3-5 days.

ALCOHOL WITHDRAWAL DELIRIUM

F10.232

DESCRIPTION

Although the typical delirium occurs 2–3 days following cessation of prolonged alcohol intake, reaching a peak at around 5 days, some withdrawal symptoms, such as the typical tremor, may start within 12 hours.

Typical clinical features include:

  • predominantly visual hallucinations, may have delusions
  • disorientation, fluctuating level of consciousness
  • agitation
  • seizures (tonic-clonic)
  • hypertension, tachycardia

A low-grade fever may be present. Withdrawal tonic-clonic seizures may occur between 24 and 48 hours following cessation of alcohol intake. General medical conditions, e.g. meningitis and other substance use e.g. sedative-hypnotics should be excluded.

Mortality 1-5%.

GENERAL AND SUPPORTIVE MEASURES

  • Monitor vital signs regularly.
  • Cardiac monitoring and oximetry should be used when administering large doses of benzodiazepines.
  • Correct dehydration and abnormalities of electrolytes and nutrition.
  • Consider parenteral fluids to compensate for severe losses i.e. in hyperthermia.

MEDICATION TREATMENT

Adult management can be applied to adolescents (for young children, management and dosing to be determined in conjunction with a specialist):

  • Thiamine: IV
    • Thiamine must be given prior to glucose to prevent Wernicke-Korsakoff syndrome.
    • 500 mg 8 hourly, diluted in 100ml normal saline or 5% glucose infused over 30 minutes for 3 days.
    • Followed by 250 mg 8 hourly.
  • Thiamine: oral
    • 100 mg daily once stable.

Benzodiazepines:

  • Diazepam: slow IV: 10 mg (Not IM due to erratic absorption).
    • Repeat dose after 5–10 minutes if required.
    • If this dose is not sufficient, use 10 mg every 5–10 minutes for another 1–2 doses.
    • If patient is not yet sedated, continue with doses of 20 mg.
    • Usual initial dose is 10–20 mg, but up to 60 mg is occasionally required.

Where intravenous access is not possible:

  • Clonazepam: IM: 1 – 2 mg as a single dose.
    • If no response, repeat dose after 60 minutes.
    • Maximum daily dose: 10 mg.

OR

  • Lorazepam: IM: 1 – 4 mg every 30–60 minutes until the patient is sedated.
    • Repeat doses hourly to maintain mild sedation.
    • Maximum daily dose: 6 mg.

Once patient is sedated, i.e. light somnolence; maintain mild sedation with:

  • Diazepam, oral, 5–20 mg 2–6 hourly.

Severe agitation and restlessness:

  • Haloperidol, IV/IM, 0.5 – 5 mg.
    • Repeat after 4–8 hours as required to a maximum of 10 mg daily.
    • Once patient has responded and is able to take oral medication: Haloperidol, oral, 0.5 – 5 mg 6–8 hourly.

Note: haloperidol, may reduce the seizure threshold. Consider only for severe agitation and restlessness and give in combination with one of the sedative-hypnotic agents above.

For children with hyperactive delirium:

  • Medication may be considered to reduce symptoms such as anxiety, agitation, hallucinations and disturbed sleep. Pharmacokinetics in children is different from adults. Before starting pharmacological treatment, the risk of side effects and interactions with other medications and the route of administration have to be considered and weighed against the potential benefits of treatment.
  • Diazepam, IV:
    • 0.2 mg/kg, very slowly over 3 minutes.
    • This may be repeated over 24 hours to a maximum of 5mg for < 5 years and 10mg for > 5 years.
    • The IV solution can be given rectally if IV route is inaccessible. Maximum dose over 24 hours of 5 mg for < 3 years and 10mg for > 3 years.
  • Haloperidol, IV for hyperactive paediatric delirium:

Age: 0 – 1 year (weight: 3.5 – 10 kg)

  • Maximum loading dose (IV): 0.05 mg in 30 minutes.
  • Maintenance dose (IV): 0.01-0.05 mg/kg/day, divided into 2-4 times daily.

Age: 1 – 3 years (weight: 10 – 15 kg)

  • Maximum loading dose (IV): 0.15 mg in 30 minutes
  • Maintenance dose (IV): 0.025 mg/kg/day divided into 2-4 times daily

Age: 3 – 18 years (weight: > 15 kg)

  • Maximum loading dose (IV): 0.3-0.5 mg in 30 minutes.
  • Maintenance dose (IV): 0.05 mg/kg/day divided into 2-4 times daily
  • Maximum dose (IV): adolescents aged 16 years or older: 5 mg per day divided into 2-4 doses

Oral therapy
Oral doses of haloperidol and risperidone are the same for hyperactive paediatric delirium.

  • Risperidone/haloperidol, oral:

Weight: < 45 kg

  • Loading dose: 0.02 mg/kg.
  • Maintenance dose: 0.01-0.08 mg/kg/day divided into 2 to 4 doses.
  • Maximum dose: 4 mg/day divided into 2 to 4 doses.

Weight: > 45 kg

  • Loading dose: 0.5-1 mg.
  • Maximum 2 mg/day divided into 2 to 4 doses.
  • Maintenance dose: 0.01-0.08 mg/kg/day divided into 2 to 4 doses.
  • Maximum dose: 6 mg/day divided into 2 to 4 doses.
  • Dosages > 6 mg have not been studied.

  • Extrapyramidal symptoms are seen frequently, particularly if antipsychotics are increased rapidly. Start low and go slow is an important principle. It can take 24 to 48 hours before an adequate response is achieved. Recognizing and treating adverse effects is important.
  • Treatment consists in reducing the dose of antipsychotic and administration of an anticholinergic medication such as biperiden (50 mcg/kg IV over 15 minutes).
  • In adult patients lengthening of the QTc interval has been reported with the possibility of Torsade’s de Pointes. This has not been reported in children. An ECG is required before starting treatment with haloperidol.
  • Risperidone has fewer adverse effects than haloperidol and is thus the treatment of choice when symptoms are not extreme and oral administration is possible.
  • When no benefit is obtained with one medication, a switch to the other should be considered.
  • A paediatric delirium rating scale should be used at least three times daily to score delirium when medication is started and for as long as the patient receives medication.
  • It is not known for how long treatment should continue. Experts advise to continue treatment at least until symptoms have disappeared and until risk factors that possibly led to the delirium have lessened. Medication should be weaned gradually, over a few days.

REFERRAL

  • Refer all children and adolescents with suspected alcohol withdrawal delirium immediately once stabilised.

OPIOID WITHDRAWAL

F11.23

DESCRIPTION

The illicit use of prescription medication and opioids in children and adolescents has risen significantly. Behavioural manifestations of withdrawal include anxiety, agitation, insomnia, and tremors. Physiological changes linked to withdrawal include increased muscle tone, nausea, vomiting, diarrhoea, decreased appetite, tachycardia, fever, sweating, and hypertension.
Most patients who take an opioid for less than a week do not experience withdrawal and can have their medication discontinued quickly. However, a prevention approach is preferred for those exposed for longer than 14 days. These children will usually need to be weaned, by gradually decreasing the opioid dose with time.
The only validated tool to assess withdrawal symptoms in children is the Sophia Observation Withdrawal Symptoms Scale.

MEDICATION TREATMENT

Mild withdrawal may be managed as an outpatient.

Symptomatic treatment:

  • Diazepam: oral
    • 6 – 14 years: 2 – 10 mg daily in 2–3 divided doses.
    • > 14 years up to 20 mg daily in 2–3 divided doses.
    • Wean dose from 8 hourly, to 12 hourly, to daily every 3-5 days.

For stomach cramps:

  • Hyoscine butyl bromide: oral
    • 1 – 3 years: 5 – 10 mg 8 hourly.
    • 3 – 6 years: 10 mg 8 hourly.
    • 6 – 18 years: 10 – 20 mg 8 hourly.

For diarrhoea:

  • Loperamide: oral
    • Over 2 years: initially 1mg/12.5kg body mass. Followed by 0.5 mg/12.5kg after each loose stool. Alternatively, 0.08-0.24 mg/kg/day in 2 - 3 divided doses.
    • 12 – 18 years: initially 4 mg. Followed by 2 mg after each loose stool. Maximum dose of 6mg in 24 hours.

The weaning protocol should take into account the length of opioid exposure and total daily opioid dose. The general approach is to transition to a longer-acting opioid formulation, such as extended-release morphine. Weaning is usually accomplished by steps of a 10% to 20% decrease in the original dose every 24 to 48 hours.

  • Morphine:
    • Oral: 0.05 mg/kg/dose 3 hourly.
    • IV: 0.02 mg/kg/dose 3 hourly.
      Weaning after 48 hours:
    • Oral: 0.01 mg/kg/dose 3 hourly.
    • IV: 0.005 mg/kg/dose 3 hourly.

For CNS disturbances (e.g. seizures):

  • Phenobarbitone: oral
    • 5 mg/kg/dose 12 hourly or daily.
      OR
  • Phenytoin: oral
    • 5 mg/kg/day in 2-3 divided doses.
    • Maximum dose: 300mg daily.
    • Maintenance dose: 5-8 mg/kg/day.

Patients with moderate to severe withdrawal should be admitted.
Substitution treatment is reserved for a specialist rehabilitation centre.

STIMULANT/METHAQUALONE (MANDRAX)/CANNABIS WITHDRAWAL

F14.23; F15.23

GENERAL AND SUPPORTIVE MEASURES

Patients do not usually require admission but assess for depression and suicide risk.

MEDICATION TREATMENT

No substitution medication available for detoxification.

For symptomatic treatment of anxiety, irritability and insomnia:

  • Diazepam: oral
    • 6 – 14 years: 2 – 10 mg daily in 2–3 divided doses.
    • > 14 years up to 20 mg daily in 2–3 divided doses.
    • Wean dose from 8 hourly, to 12 hourly, to daily every 3-5 days.

BENZODIAZEPINE WITHDRAWAL

F13.239; F13.232

GENERAL AND SUPPORTIVE MEASURES

Psycho-education about dependence including withdrawal and tolerance within a close therapeutic relationship will assist with compliance. Encourage the patient and caregivers not to seek medication from other doctors and negotiate each reduction with the patient and caregivers. Withdrawal from benzodiazepines takes time. The patient will require regular monitoring and motivation.

MEDICATION TREATMENT

Replace short-acting benzodiazepines with an equivalent long acting benzodiazepine (diazepam) dose. Patients may present with medicines that are unavailable in the public sector.
Approximate equivalent doses to diazepam 5 mg are:

  • lorazepam 1 mg
  • alprazolam 0.5 mg
  • bromazepam 1.5 mg
  • flunitrazepam 0.5 mg
  • nitrazepam 5 mg
  • oxazepam 15 mg
  • temazepam 10 mg
  • zopiclone 7.5 mg
  • zolpidem 10 mg

Decrease the dose of diazepam every 2 weeks by 2.5 mg. If symptoms reappear increase the dose a little and reduce more slowly.

MEDICATION TREATMENT OF COMORBID PSYCHIATRIC CONDITIONS

REFERRAL

  • All for psychotherapeutic interventions or drug rehabilitation.
  • Outpatient treatment: refer to SANCA (South African National Council on Alcoholism and Drug Dependence).

Tel: 011 8923829 or toll free: 0861472622.

  • In-patient treatment: refer for in-patient drug rehabilitation.
  • Patients with severe and persistent behavioural disturbance, psychotic or manic symptoms to an in-patient child and adolescent psychiatric facility, for ongoing containment and management of psychiatric symptoms.