Treatment of Drug Addicts

Essentials

• It is essential to recognize addiction (alcohol, drugs) Recognition of Alcohol and Drug Abuse and always act professionally and pertinently, see Providing Care for an Alcohol or Drug Abuser.
• A general practitioner may encounter a drug addict in various situations:
  • after an accident, either at the doctor's appointment or emergency department
  • when he/she is trying to obtain addictive drugs A Patient with Legal Drug Addiction in Primary Care
  • in the state of acute psychosis with anxiety and hallucinations
  • somatically ill: acute hepatitis, endocarditis, any severe disease from pneumonia to sepsis, an epileptic attack, poisoning Treatment of Poisoning Alcohol Poisoning etc.
• An addict may also seek withdrawal or substitution therapy. Withdrawal in ambulatory care with the help of e.g. codeine, ethylmorphine or tramadol that the patient may have requested will hardly be successful. The use of buprenorphine and methadone in withdrawal substitution or maintenance therapy is defined in national legislation and/or other regulations.
• Because of the threat of spreading HIV and hepatitis C and B, the risks associated with intravenous drug use should be discussed in all contacts with addicted persons.

Common somatic diseases, symptoms and signs

• Cannabis users often have erythematous conjuctivae and oral mucous membranes.
• Opioid users have small, non-reactive pupils.
• Amphetamine users are often hyperkinetic and have hypertension and tachycardia.
• There are increasing numbers of pregnant young women who are addicted to heroin, buprenorphine, amphetamine or use a mixture of substances and who are unable to break the cycle without treatment Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment GuidelinesPregnant Substance Abuser.
• Infections ranging from infected needle punctures to endocarditis.
  • Needle punctures can be found anywhere in addition to the cubital area. Patients who have used injected drugs for a long time often inject between the fingers and toes.
  • Accidental injections into peripheral arteries causes necroses of the distal parts of the extremities and may even lead to amputations.
• Epidemics of hepatitis A occur among drug users.
• Hepatitis C is very common in patients who use i.v. drugs (60-80%), sometimes concomitantly with hepatitis B. In acute cases, symptoms include icterus, poor general condition and hepatomegaly. The majority of cases are asymptomatic carriers of the disease. See Viral Hepatitis.
• Trends in the incidence of HIV-infections vary from country to country.
• Central nervous system complications, rhabdomyolysis and peripheral compression damage resulting from anoxia and unconsciousness caused by overdosage.
• Toxic states induced by gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL), requiring emergency care; see also Treatment of Poisoning Alcohol Poisoning.

Psychiatric diseases, symptoms and signs

• Anxiety, poor impulse control, and change of mood are common.
• Most patients who abuse drugs are also heavy drinkers. In addition to alcohol or drug abuse, personality disorders as well as mood and anxiety disorders are very common.
• There are increasing numbers of drug-dependent persons with a chronic psychiatric disorder (schizophrenia).
• Pay particular attention to psychotic symptoms.
  • Massive paranoid or hallucinatory symptoms warrant treatment in a psychiatric hospital in a closed ward.
  • Milder paranoid symptoms and auditory hallucinations often subside quickly and do not necessarily require antipsychotic medication, provided that the patient is familiar with these symptoms.
• Acute depression is typical when the effect of amphetamine or cocaine ceases; a more chronic depression and apathy can be associated with any drug either primarily or secondarily.
• Anxiety, sleep disorders and adverse effects of the abused drugs have made many drug addicts additionally dependent on benzodiazepines.

Examination in a health centre

• Basic blood count with platelets, CRP, ALT, ALP, GGT, serum HBsAg, hepatitis C antibodies, HIV antibodies and a urine rapid test for drugs or a broader drug screening test that also identifies the use of designer drugs.
  • Codeine (antitussives containing codeine) and paracetamol-codeine combinations may give positive results in the urine test.
  • Consult the laboratory regarding other possible cross-reactions.
• Other laboratory tests and x-ray as indicated by clinical signs.
  • Official guidance on laboratory examinations is available at the national or regional level.

Vaccinations and infection tests and treatments

• All persons who use i.v. drugs and those in close contact with them should be given vaccinations against hepatitis A and B.
• Anonymous testing for hepatitis and HIV should be available within health care services.
• Patient groups which earlier were left without treatment for hepatitis C because of having contraindications to the therapy, such as intravenous drug users, should be referred for a therapeutic assessment, in order to determine the severity of the disease, and for treatment with new generation antiviral drugs if the severity of the liver disease warrants therapy and the patient is motivated to it.
• The price of antiviral therapy has decreased to the extent that it is no longer a reason not to treat even drug addicts.
• Local and national policies may vary.

Drug therapy

• Benzodiazepines should be avoided. It is important to diagnose possible concomitant benzodiazepine dependence and arrange treatment.
• If there is a risk of convulsions (benzodiazepine dependence, previous convulsions), carbamazepine and, for patients with hepatitis C, oxcarbazepine should be used. These drugs can also be used in the treatment of aggression problems and mood changes.
• Psychosis and anxiety caused by amphetamine or other stimulants may be treated in short-term with diazepam. Haloperidol or second-generation antipsychotic drugs are suitable for treating severe symptoms. Tachycardia and hypertension associated with amphetamine intoxication may be treated with clonidine at a dose of 75-150 µg 2-3 times daily (dampens also the withdrawal symptoms from opioids in cases of polysubstance abuse), with propranolol 20-40 mg 2-3 times daily or with labetalol 100-200 mg twice daily.
• Prefer short courses maximally 3 to 5 days of short-acting benzodiazepines. If insomnia is long lasting, prescribe melatonin or quetiapine, or levomepromazine or sedative tricyclic antidepressants provided there is a good and stable patient-doctor relationship, the patient has no liver or heart disease, and there is no uncontrolled polysubstance abuse.
• In prolonged depression citalopram and sulpiride, for example, are safe alternatives. Concomitant use of serotonin uptake inhibitors and amphetamine derivatives may lead to dangerous adverse effects.
• Withdrawal and substitution therapy in opioid-dependence, see below.

Referring to further treatment

• Acute somatic conditions are treated according to normal criteria. It is useful to discuss the possibilities of treating addiction already in this initial phase Combining Psychosocial and Agonist Maintenance Treatments for Opioid Dependence, Psychosocial Treatment for Opiate Abuse and Dependence.
• Consider referral to involuntary psychiatric evaluation if the patient is psychotic.
• In minors, serious cases of substance abuse justify compulsory care or at least child protection measures; see Substance Abuse of Adolescents.
• Treatment locations: see Providing Care for an Alcohol or Drug Abuser and local guidance
• Initial assessment considering the commencement of withdrawal or substitution therapy requires several visits to the outpatient department. The following aspects are to be considered:
  • age, livelihood, housing and family relations (are there other members in the family with drug abuse problems; are there any children?)
  • possible pending criminal matters
  • current use of drugs, previous (documented) history of abuse and its treatments
  • history of opioid withdrawals and withdrawal attempts
  • verification of abuse by laboratory screening; results of other laboratory tests
  • somatic and mental condition
  • motivation (and reason) for treatment.
• Withdrawal treatment usually lasts for 2-4 weeks and is carried out in an institutionalized setting.
• If withdrawal treatments fail, substitution therapy should be considered. The assessment and the treatment decision are made according to the local care pathway. Later on, substitution therapy may be continued in primary care.

Withdrawal and substitution treatment of opioid addiction

Physician's duty of confidentiality in drug offences

• Specific legal requirements and principles apply concerning physicians' role in drug offences and their duty of confidentiality. Such situations may concern, for example,
  • the duty to report to the police imminent crimes that the physician is aware of or
  • the physician's responsibility to act as a witness in the court.
• In some cases the physician may have the right to perform some action although there is no duty to perform it, while in some other cases the action may be an actual duty of a physician.
• Find out about national legislation and other relevant regulations concerning these issues.