These are syndromes arising out of repeated maladaptive use of substance. A substance is defined as any chemical with brain altering properties. Substance abuse disorders are characterized by significant impairment in psychological, social, and occupational functioning as observed over a 12-month period. Commonly abused substances in Kenya include, cannabis sativa, khat(miraa), opioids (heroin), cocaine including crack cocaine, and solvents (glue, petrol, wood varnish). Substance-related syndromes include intoxication, dependence, withdrawal, psychosis, mood disorder, anxiety, sleep disorder, and sexual disorders. Those at high risk include children aged 12-20 years and patients with primary mental disorders.
Management
Substance specific detoxification
Patient/family education/counseling
Alternative leisure activities
Work/school rehabilitation
Involvement of community agencies, e.g., religious organizations, Alcoholics Anonymous, Narcotic Anonymous where available
Refer for a long-term management by psychiatrist
SUBSTANCE ABUSE BY THE ADOLESCENT
Such patients usually present with self-neglect, slovenliness, deteriorating school performance, excessive sleeping, rough appearance, increasing and unexplained demand for money from caregivers, involvement in petty crime (pilfering), and running away from home-in addition to aforementioned substance-related disorders.
Management-General principles
Substance specific detoxification
Patient/family education/counseling
Alternative leisure activities
Work/school rehabilitation
Involvement of community agencies, e.g., religious organizations, Alcoholics Anonymous, Narcotics Anonymous where available.
Refer for long-term management by psychiatrist.
Management-Pharmacological
For agitation, use: Diazepam 0.2-0.8mg/kg/dose max 0.6mg/kg/dose PO dailyto be tapered off in 10 days.
For the parasympathetic upsurge use: Clonidine 5-7ug/kg/24 hour, max dose 0.9mg/24 hours PO daily for 10 days.
For any assaultive behavior, use: Haloperidol 0.05-0.15mg/kg/24 hour; children over 12 years 2-5mg/dose TDS PO; OR chlorpromazine 2.5-6mg/kg/24 hour 4-6 hourly TDS as necessary.
For pain, use: Paracetamol 20-40mg/kg/24 hours 4-6 hourly PO as necessary.
Management of selected substances of Abuse
Opioid detoxification: Opioids abused include heroin, morphine, dihydrocodeine, and pethidine. Tolerance develops rapidly and withdrawal features include agitation, lethargy, sweating, goose flesh, runny nose, shivering, musco-skeletal pains, diarrhea and abdominal cramps. These effects peak at 48 hours and subside over a period of 10 days. Owing to the highly addictive nature of opioids, admission to hospitals is necessary.
Cannabis dependence: Chronic users may develop psychosis, anxiety, mood disorders, and a withdrawal state. Admission is usually necessary for initiating abstinence. Treatment of psychiatric complications is the same as for the primary syndromes.
Khat (miraa) dependence: Chronic users (“2 kilos” or more per day) may develop anxiety, mood disorders, and schizophrenia-like psychosis. Abstinence is to be encouraged. Treatment of the psychiatric complication is the same as for the primary syndromes.
Solvent abuse: Solvents have powerful euphoriant properties. They are mainly abused by street children and the homeless. Chronic users may develop organ damage (liver, heart, kidney), apart from neurological damage. Patient education is vital. Involve family and relevant authorities in rehabilitation if possible.