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Substance Use disorders [alcohol-excluded]

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Title: Substance Use disorders [alcohol-excluded]


1
Dr. Awosusi AbiodunNeuropsychiatry
UnitWGH,Ilesha
  • Substance Use disorders alcohol-excluded

2
Outline
  • Introduction
  • Definitions
  • Classification
  • Diagnostic criteria
  • Classes of psychoactive substances
  • General facts
  • Epidemiology
  • Aetiology
  • Consequences of substance abuse
  • Assessment of patients
  • Treatment and prevention
  • Specific drug description

3
  • Introduction
  • Substance use disorders are used to refer to
    conditions arising from the misuse of alcohol,
    psychoactive drugs and other chemicals such as
    volatile substances.
  • These substances include amphetamines, caffeine,
    cannabis, cocaine, hallucinogens, inhalants,
    nicotine, opioids, PCP, sedatives, hypnotics or
    anxiolytics.

4
Definitions
  • Intoxication is a transient syndrome due to
    recent ingestion that produce clinically
    significant psychological and physical
    impairment. These changes disappear when the
    substance is eliminated from the body.
  • Abuse refers to maladaptive patterns of
    substance use that impair health.
  • Dependence refers to certain physiological and
    psychological phenomena induced by the repeated
    taking of a substance.
  • Tolerance is a state in which after repeated
    administration, a drug produces a decreased
    effect, or increasing doses are required to
    produce the same effect
  • Withdrawal state refers to a group of symptoms
    and signs occuring when a drug is reduced in
    amount or withdrawn, which last for a limited
    time.

5
  • Classification
  • It is important to specify the class of drug.
    When the patient uses more than one drug or the
    judgment of drug use is difficult to make
    polysubstance or multiple substance use can be
    used. It is important to distinguish between
    abuse and dependence based on the diagnostic
    criteria.

6
DSM-IV ICD-1O
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, or mental health as manifested by one or more of the following occurring within a 12-month period A. A pattern of psychoactive substance use that is causing damage to health the damage may be due to physical or mental health
1. Recurrent substance use resulting failure to fulfill major role obligations at work, school or home
2. Recurrent substance abuse in situations that are physically hazardous
3. Recurrent substance abuse-related legal problems
4. Continued substance abuse despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance
B. Has never met the criteria for substance dependence for this class of substance
7
DSM-IV ICD-10
A. Diagnosis of dependence should be made if three or more of the following have been experienced or exhibited at any time in the same 12-month period A. Diagnosis of dependence should be made if three of more of the following have been experienced or exhibited at some time during the last year
1. Tolerance defined by either need for markedly increased amounts of substance to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of the substance 1. A strong desire or sense of compulsion to take the substance
2. Withdrawal as evidenced by either of the following the characteristic withdrawal syndrome for the substance or the same or closely related substance is taken to relieve or avoid withdrawal symptoms 2. Difficulties in controlling substance taking behaviour in term of its onset, termination or levels of use
3. The substance is often taken in larger amounts over a longer period of time than was intended 3. Physiological withdrawal state when substance use has ceased or been reduced, as evidenced by either of the following the characteristic withdrawal syndrome for the substance or use of closely related substance with the intention of relieving or avoiding withdrawal symptoms
4. Persistent desire of repeated unsuccessful efforts to cut down or control substance use 4. Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
5. A great deal of time in spent in activities necessary to obtain the substance, use the substance or recover from its effects 5. Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects
6. Important social, occupational or recreational activities given up or reduced because of substance use 6. Persisting with substance use despite clear evidence of overtly harmful consequences physical or mental
7. Continued substance use despite knowledge of having had a persistent or recurrent physical or psychological problem that was likely to have been caused or exacerbated by the substance
8
Classes of psychoactive substances
  • Alcohol
  • Opioids
  • Cannabinioids
  • Sedatives and hypnotics
  • Cocaine
  • Other stimulants including caffeine, amphetamine
  • Hallucinogens
  • Tobacco
  • Volatile solvents
  • Multiple drug use and use of other psychoactive
    substance

9
Epidemiology
  • Illicit drug use
  • Studies in the US and UK show similar
    percentages 14.7 and 12 of the population of
    adults respectively have used an illicit drug in
    the past year. Same studies show that life time
    prevalence of drug use is 46.4 and 42,
    respectively.
  • It is commoner in boys than girls but the
    differences are not large. Is found among the
    unemployed. Experimentation with illicit drug is
    common among young people. Cannabis is the
    commonest drug used.

10
  • Drug misuse and dependence
  • Little is known about the prevalence of different
    types of drug misuse and drug dependence. This
    even varies with countries because of different
    methods of ascertainment.
  • Common among young adults, 16-25 years.
    Adolescents are at increased risk. The rate is
    high in disadvantaged areas of large cities and
    unemployed with unstable relationships.

11
Aetiology
  • Biophysical genetics family, adoption, twin and
    linkage studies biological factors
    physiological reward centers in the brain and
    neurochemicals psychiatric disorders
  • Psychological personality antisocial and
    borderline personality psychodynamic theories
    fixation at oral stage, disturbed ego function
    and mastubatory equivalent behavioural theories
    learning and conditioning modelling
  • Social cultural factors, social attitudes, peer
    pressure, availability of drugs, single parents
    and separation of parents

12
Neurobiology of drug use, misuse and dependence
  • Many use but do not misuse while many misuse but
    not do not become dependent. Drugs are used as
    positive reinforcers because they increase the
    frequency of behaviours that lead to their use
    e.g. euphoria.
  • Neurobiological mechanisms dopamine system which
    innervates the forebrain particularly the nucleus
    accumbens is part of physiological reward system
    which has the ability to increase the behaviours
    that caused it.
  • Besides there is a consequence of interactions
    between the pharmacological properties of the
    drugs, the biological disposition and personality
    of the user, and the social environment.

13
  • Current neurobiological formulations of drug
    dependence implicate changes in gene expression
    and synaptic connectivity in prefrontal cortical
    regions as well as the limbic areas involved in
    reward and motivation.
  • Dependence in drugs has been described as either
    physiological or psychological. Physiological
    dependence is diagnosed when a substrate user
    demonstrates either tolerance to the
    pharmacological effects of the drug or a
    characteristic withdrawal syndrome when use of
    the drug is diminished. In Non-physiological
    dependence, craving and dysphoria are associated
    with altered brain dysfunction. A cardinal
    feature of both is the desire for the drug and
    drug-seeking behavior.

14
  • The phenomena of tolerance and dependence are
    believed to be a result of adaptive changes in
    neurotransmission in the brain. These changes
    occur in the sensitivity of the appropriate
    receptorsThese are a part of homeostatic effects
    that occur when a drug is administered. This can
    be used to explain the concept of cross-tolerance
    between anxiolytics and hypnotics and alcohol.
  • While the major factor for continued drug use is
    the positive reinforcing effects, others include
    the withdrawal effects, psychological and social
    stimuli. A single exposure to the drug again
    after withdrawal may cause a relapse, a
    phenomenon known as reinforcement effect.

15
  • Personal factor
  • A vulnerable personality has been implicated
    those who develop problems have disrupted
    families or young age of onset they could have
    associated behavior like poor school record,
    truancy, delinquency or traits such as
    sensation-seeking or impulsivity. There could
    also be a family history of drug use or
    personality disorder.

16
  • Social factor
  • The risk is higher in societies that condone drug
    use is influenced by peer pressure. Drug misuse
    has also been linked to indices of social
    deprivation such as unemployment and
    homelessness.
  • Availability of drugs
  • There are three major ways
  • Taking drugs that can be bought legally without
    prescription nicotine, opioids
  • Taking prescribed drugs opioids, barbiturates,
    benzodiazepinesanticholinergics like benzehxol
  • Taking drugs obtained via illicit sources street
    drugs

17
Adverse effects of drug misuse
  • Drug misuse has many undesirable effects both for
    individual and society.
  • Physical health drug misuse can lead people to
    neglect their health in addition to the physical
    consequences of the substance itself. HIV
    infection, hepatitis and accidental drug
    overdose. IV drug misuse consequences could be
    local vein thrombosis, infection of injection
    site and damage of arteries or
    systemicbacterial endocardiitis, HBV,HCV, HIV
    and accidental overdose

18
  • Drug misuse in pregnancy If used early, there is
    increased risk of fetal abnormality if late, the
    fetus may become dependent on them with
    withdrawal symptoms at birth.
  • There is a strong association between substance
    misuse and psychiatric comorbidity often
    described as dual diagnosis. It increases
    morbidity of the underlying disorder and
    heightens the risk of violence and self-harm.

19
Social consequences of drug misuse
  • There are three reasons
  • Chronic intoxication may affect the behavior
    adversely, leading to unemployment, motoring
    offences, accidents and family problems including
    neglect of children.
  • Illicit drugs are generally expensive the user
    may steal or sell sexual favors to obtain money.
  • Drug misusers often keep company with one
    another, and those wth previously stable social
    behavior may be under pressure to conform to a
    group ethos of antisocial or criminal activity.

20
Assessment of drug user
  • History
  • Biodata NAMAROTS
  • Reason for consultation
  • Current drug use ask about drugs taken over the
    past 4weeks, frequency of use and no of times
    taken per day. Amount taken and route. Episodes
    of withdrawal and about tolerance.
  • IV user find out about needle or other equipment
    sharing
  • Lifetime drug use age of first use of drug,
    changing pattern of drug use, period of
    abstinence or stability, reason for this
  • Complication overdose, cellulitis, HBV, HCV, HIV
    status

21
  • Previous treatments and psychiatric history
  • Family history
  • Social history accommodation, sexual
    orientation, no of parents
  • Forensic history-previous or pending conviction,
    imprisonment
  • Patients aim in seeking treatment attitude to
    drug use, preferred treatment

22
  • MSE
  • Signs of mood changes, suicidal thought/plan,
    anxiety and panic attack, paranoid ideas and
    hallucinatory experience, relationship with drug
  • PE
  • Signs of IV use needle tracks, phlebitis,
    abscess, old scarring, signs of withdrawal
  • Investigations
  • Depends of history and examination
  • Urine screening
  • Blood investigation FBC, LFT, HBV, HCV, HIV
  • Saliva
  • Breast milk

23
Urine screening
  • Cannabis single use 3days, moderate 4, heavy use
    10 and chronic use 21-27
  • Cocaine metabolites 2-3d
  • Amphetamine 48hrs
  • Codeine/morphine 48hrs
  • PCP 8d
  • Benzodiazepine
  • Ultrashort acting midazolam 12hrs
  • Short acting trixolam 24hrs
  • Intermediate tamazepam 40-48hrs
  • Long-acting diazepam 7days

24
Prevention, treatment and rehabilitation-general
principles
  • Prevention because treatment is difficult,
    prevention is important it includes
  • Primary reduce availability. Control on sale,
    advertisement, and prescription health education
  • Secondary treatment the disorder
  • Tertiary effective rehabilitation to reduce
    disability

25
Treatment
  • When drug misuse has begun, treatment is more
    effective before dependence is established. Here,
    motivate patient to control drug-use.
  • Biological The ultimate aim of treatment is to
    withdraw the drug of dependence. On the other
    hand, harm reduction can be adopted where it is
    difficult to withdraw the drug. Maintenance
    therapy may be indicated here, doctor prescribes
    another less dependent drug with slower action to
    replace the original drug. This reduces the need
    to obtain the latter and the psychosocial changes
    associated with that act. It helps patient
    acquire skills to control drug use. Drug misusers
    can be managed by general practitioner and also
    by specialists. Treat physical complications.

26
  • Psychological counseling, group psychotherapy
    and CBT are useful. Involve friends and family
    members. Cue exposure eliminates craving.
  • Rehabilitation this aims at enabling the
    dependent person to leave the subculture and to
    develop new social contacts. Unless this is
    achieved, the treatment is likely to fail.
    Continuing social support is inevitable here.

27
  • Dual diagnosis patients are difficult to operate.
    Management includes
  • Multidisciplinary case management with assertive
    outreach
  • Ready availability of crisis intervention
  • Emphasis on motivational interviewing and harm
    reduction
  • Use of coercion where applicable and appropriate
  • Close monitoring with medication supervision and
    urine screening
  • Long-term community support including day-care
    and residual care
  • Supported housing
  • Pharmacotherapy consider clozapine for schizo
    and substance abuse disorders

28
Opioids
  • These include morphine, heroin, codeine and
    synthetic analgesics such as pethidine,
    methadone, and dipipanone. The medical use of
    opioids is mainly for their powerful analgesic
    effect but they are misused for their euphoriant
    and anxiolytics effects.
  • Epidemiology
  • Lifetime prevalence is about 1.6. high rates are
    found in the homeless and prisoners.
    Epidemiological data indicate that many people
    use heroin without becoming dependent on it.
  • Methods include IV, subcutaneous or sniffing.

29
  • Clinical features
  • Euphoria, analgesia, respiratory depression,
    constipation, reduced appetite and low libido.
    Tolerance develops rapidly, and also diminished
    rapidly when the drug is withdrawn.
  • Withdrawal symptoms
  • Intense craving for the drug, restlessness and
    insomnia, pain the muscles and joints, running
    nose and eyes, abdominal cramps, vomiting,
    diarrhea, piloerection, sweating, dilated pupils,
    raised pulse rate and disturbance of temperature
    control.
  • The features begin with 6hours after the last
    dose, reach a peak after 36-48hours, and then
    wane. They cause distress but no death threat!

30
  • Methadone is as potent as morphine. It causes
    cough suppression, constipation and depression of
    the central nervous system. Its withdrawal
    symptom is similar to that of heroin and
    morphine. It has a long half-life, symptoms of
    withdrawal may begin after 36hours and reach a
    peak after 3-5days.
  • Natural course of opioids dependence
  • It runs a chronic relapsing and remitting course.
    Death results from accidental overdose, suicide,
    infection.

31
Management
  • Prevention is the key, because dependence
    develops rapidly.
  • Treatment of crisis Patient presents with
    withdrawal symptoms, effects of drug overdose or
    acute complication of IV drug abuse.
  • Withdrawal With low dose treat withdrawal
    symptoms with drugs such as loperamide or
    metoclopromide for GIT symptoms. Use analgesics
    for pain/ache. With high dose, use methadone as
    part of a maintenance treatment 10-40mg. other
    durgs that can be used include buprenorphine, a
    partial agonist at opioids receptors and
    naltrexone an opioids antagonist. The latter
    helps to prevent relapse in detoxified opioids
    dependent subjects.
  • Theres also a new method of rapid
    detoxification.
  • Psychosocial counseling, group therapy and
    communal living are also important.

32
Benzodiazepines
  • These are used for their euphoriant and calming
    effects.
  • The use is extremely widespread. It is estimated
    that about 10 of the population of Europe and US
    use the drug. Common in older women but there is
    significant misuse in young people. A significant
    proportion of people who are dependent on alcohol
    are also dependent on benzodiazepines.
  • Withdrawal symptoms
  • Anxiety symptoms anxiety, irritability,
    sweating, tremor and sleep disturbance
  • Altered perception depersonalization,
    derealization, hypersensitivity to stimuli,
    abnormal body sensations, abnormal sensation of
    movement
  • Other features depression, suicidal behaviour,
    psychosis, seizures, delirium tremens
  • Dependence often results from prolonged medical
    use by is also available as a street drug.

33
  • Treatment gradual withdrawal and counseling.
    Current evidence is that the dose of
    benzodiazepine be lowered by about 1/8th every
    fortnight. For short acting drugs, switch to
    long-acting ones like diazepam, and taper
    downwards.
  • Psychological treatment is useful to control the
    anxiety symptoms. Adopt a non-pharmacological
    approach for the insomnia.
  • Prevention restrict prescription.

34
Cannabis
  • Cannabis sativa
  • It is consumed either as the dried vegetative
    parts in the form known as marijuana or grass, or
    as resin. It contains many active substances but
    the most important is d-9tetrahydrocannabinol.
    Action is mediated via specific cannabinoid
    receptor in the CNS.
  • Similar prevalence across the world
  • Clinical effects this varies with the dose,
    patients mood and expectation and the social
    setting. There is exaggeration of pre-existing
    mood, increased enjoyment of aesthetic
    experiences with distortion of time and space.
    There also exists reddening of the eyes, dry
    mouth, tachycardia, irritation of the respiratory
    tract and coughing.

35
  • Adverse effects no serious adverse effects.
    Notable ones include carcinogenicity, anxiety,
    mild paranoid ideation, toxic confusional states
    and psychosis. Amotivational syndrome.
  • It is well established that cannabis can modify
    the course of an established schizophrenic
    illness. Cannabis use in adolescence increased
    the risk of developing schizophrenia about
    two-fold. Removal of cannabis from society would
    prevent 8 of schizophrenia.
  • There is evidence that tolerance to cannabis can
    occur in subjects exposed to prolonged high doses
    but less in those who use small/intermittent
    doses. However, epidemiological date show that
    those who use the drug do not misuse it or become
    dependent on it.

36
treatment
  • Detoxification
  • If psychotic, antipsychotic drug
  • Group/individual psychotherapy, CBT
  • Abstinece is the goal.

37
Stimulants
  • These include amphetamines, related substances
    such as phenmetrazine and methylphenidate.
    Cocaine also belongs to this group.
  • Amphetamine
  • It has been abandoned except for their use in
    ADHD and narcolepsy. They block re-uptake of
    dopamine and noradrenaline.
  • Epidemiology
  • 1 time users 9 US, 22UK. About 105 of
    those presenting to specialist drug abuse unit
    have used it as a primary drug while a further
    10 have used it as a secondary drug usually in
    conjunction with opiates rule of 10
  • In the past, they were available as prescription
    but they have now become street drugs. It can be
    administered IV, orally, or by snuffing. It can
    also be smoked or injected.

38
  • Clinical effects
  • Over-talkactiveness, overactivity, insomnia,
    dryness of lips, mouth and nose, and anorexia.
    The pupils dilate, pulse rate increases and the
    blood pressure rises. With high doses, there
    could be cardiac arrhythmia, severe hypertension,
    CVA and occasionally circulatory collapse.
  • Adverse effects
  • Dysphoria, irritability, insomnia and confusion,
    anxiety and panic, paranoid psychosis and
    stereotyped behaviour e.g. repeated tidying. Can
    also cause miscarriage, premature labour and
    placental abruption.
  • It is not certain whether this is drug-induced
    psychosis, schizophrenia provoked y durg misuse
    or merely coincidental. Besides, the ability of
    amphetamines to provoke psychosis support the
    dopamine theory of schizophrenia.

39
  • Withdrawal symptoms depression, tremulousness,
    lethargy, fatigue and nightmares, craving and
    suicidal ideation
  • Prevention restrict drug use and availability
  • Treatment acute overdose can be treated by
    sedation and management of hyperpyrexia and
    cardiac arrhythmias. Withdraw drug, or use
    antipsychotics for the psychosis.
    Benzodiazepines and antidepressants may be
    indicated.

40
Cocaine- erythroxylum coca
  • It is a CNS stimulant with the ability to block
    dopamine re-uptake into pre-synaptic vesicles
    this leads to increased dopamine levels in the
    nucleus accumbens and concomitant activation of
    the physiological reward system.
  • It is administered by injection, smoking,
    sniffing into nostrils. The crack derivative
    has rapid onset of action.
  • Epidemiology
  • Lifetime use 15US, 6UK. Its use is high
    among young people, socially marginalized and
    with people with opiate dependence. It has also
    been associated with violent crime.

41
  • Clinical effects
  • Excitement, increased energy and euphoria,
    dilated pupils, tachycardia, hypertention
  • Adverse effects
  • Perforation of the nasal septum is associated
    with sniffing. Grandiose thinking, impaired
    judgment, sexual indiscretion, hallucinations,
    paranoid ideation and aggressive behaviour,
    paranoid psychosis, formication or cocaine bug.
  • Severe adverse effects include cardiac
    arrhythmias, MI, myocarditis and cardiomyopathy.
    CNS effects include CVD subarachnoid
    haemorrhage, TIA and cerebral infarction, and
    seizures.
  • Withdrawal effects
  • Dysphoria, anhenodia, anxiety, irritability,
    fatigue, hypersomnolence, intense craving,
    depression and sometimes suicidal ideation.

42
  • Treatment
  • Acute intoxication
  • sedation with benzodiazepines and or
    antipsychotics. Detoxification and harm
    reduction. Evidence does not support use of
    antidepressants, benzodiazepines or dopamine
    agonists.
  • Treat any accompanying physical condition.
  • psychological CBT and individual/group therapy
    and social support are inevitable. In severe
    cases, inpatient management may be necessary.

43
MDMA
  • 3,4-methylenedioxymethamphetamine or ecstasy is
    available for recreational use as a stimulant
    with mild hallucinogenic effect. It increases
    release of dopamine and serotonin. It is taken as
    tablet or capsule.
  • Clinical effects
  • Euphoria, sociability, intimacy, sensations of
    newly discovered insights and heightened
    perceptions.
  • Adverse effects
  • Cardiac arrhymias, hyperthermia and intracerebral
    haemorrhage. Acute and chronic paranoid
    psychosis, flashbacks. It also causes
    degeneration of serotonin nerve terminals in the
    cortex and forebrain.
  • Prevention Inform use about acute reaction and
    potential hazard of long term use.

44
Hallucinogens
  • Also called psychedelics or psychotomimetics.
    Examples include lysergic acid diethylamide LSD,
    dimethyltryptamine and methyldimethoxyamphetamine.
  • LSD is the commonest. They possibly act as
    partial agonists as brain 5-HT2A receptors.
  • Epidemiology
  • Increasing incidence. Lifetime use 14.5US and
    29UK

45
  • Clinical effects
  • Distortion or intensification of sensory
    perception, confusion between sensory modalities.
  • Adverse effects
  • Initial sympathomimetic activity can cause
    cardiac and cerbrovascular accidents. Distortion
    of body image and flashbacks also occurs. There
    could also be unpredictable and extremely
    dangerous behaviour.
  • Withdrawal symtoms have not been described.

46
Treatment
  • Talk down the patient.
  • Use anxiolytics e.g. diazepam if necessary
  • Benzodiazepines and anticonvulsants are useful in
    the treatment of flashbacks.

47
Phencyclidine
  • It has anaesthetic and hallucinogenic effects. It
    is taken by mouth, smoked or injected. It acts by
    as an antagonist of N-methyl-D-aspartate NMDA
    receptors.
  • Clinical effects
  • Small doses cause drunkenness, analgesia of the
    hands and toes and anaesthesia.
  • Adverse effects
  • Depressed consciousness, aggressiveness,
    psychotic-like symptoms
  • Ataxia, muscle rigidity, convulsions
  • Adrenergic crisis hypertensive crisis, CVD,
    malignant hyperthermia
  • Treatment is symptomatic. CPZ should be avoided
    because it enhances the anticholinergic effect of
    the drug.

48
Volatile substances
  •  Also called solvents or inhalants. Solvents,
    adhesives, petrol, cleaning fluid, aerosols of
    all kinds, agents in fire extinguishers, butane,
    toluene, acetone. Usually taken with other drugs
    and alcohol.
  • Specific action is unknown but may increase GABA
    function.
  • Epidemiology
  • It is a worldwide problem. Common among young
    people, men, homeless an people of low
    socio-economic status or antisocial personality
    disorder. Date show that it is used for a short
    period of time and stopped.

49
  • Clinical effects
  • CNS is first stimulated and then depressed
    euphoria, blurring of vision, slurring of speech,
    staggering gait, incoordination, nausea, vomiting
    and coma. Effect starts and wanes fast.
  • Adverse effects
  • Direct toxic effects such as cardiac arrhythmias
    and respiratory depression. Trauma and asphyxia
  • Neutotoxic effects include peripheral neuropathy,
    impaired cerebellar function, encephalitis and
    dementia. Other organs can also be damaged.
  • Withdrawal symptoms incude sleep disturbance,
    irritability, nausea, tachycardia and rarely
    hallucinations and delusions.

50
  • Diagnosis acute intoxication can be diagnosed by
    physical clues glue on the face, hands or
    clothes chemical smell disorientation in TPP. A
    facial rash glue-sniffers rash is caused by
    sniffing from a bag.
  • Treatment
  • Counseling and support. Drugs may be useful,
    particularly for depression.
  • Prevention
  • Restrictive policies on substance availability
  • Education and provision of recreational
    facilities.

51
Conclusion
  • Prevention should be emphasized.
  • Abstinence is the goal of every management plan.
    Drugs, psychological and social support are
    important in this regime.
  • As doctors, treat patients with substance use
    disorders with empathy!
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