Substance Use Disorders
Description General Measures Referral Alcohol withdrawal Alcohol withdrawal delirium (delirium tremens) Opiate (e.g. heroin, unga, whoonga, nyaope) withdrawal Stimulant withdrawal, including cocaine and amphetamine type stimulants (e.g. methamphetamine/ tik, methcathinone/ cat Methaqualone (mandrax/whitepipe) withdrawal Cannabis withdrawal Benzodiazepine withdrawal Description Substance misuse is
Alcohol withdrawal delirium (delirium tremens)
Opiate (e.g. heroin, unga, whoonga, nyaope) withdrawal
Methaqualone (mandrax/whitepipe) withdrawal
Description
Substance misuse is a general term which encompasses a range of substance use patterns including:
- Hazardous use – a risk of harmful consequences (social, mental, physical) to the user or others;
- Harmful use – the substance use causes harm to the user or others, may be continuous or episodic (e.g. interpersonal violence after an alcohol binge).
- Dependence - characterised by a loss of self-regulation, repeated use despite harm, substance-induced mental illness, and withdrawal syndromes.
People with substance misuse present for related or comorbid health problems e.g. to emergency rooms, infectious disease services (e.g. TB, HIV, Hepatitis, etc.), antenatal clinics, STD services, and mental health services. Early identification and intervention of the substance use is advised to prevent further harm or dependence.
General Measures
- Screen for substance use disorders as a routine part of patient assessment, e.g. with WHO ASSISTlvii. The outcome of the screen should determine the level of intervention that is recommended– e.g. brief advice, a brief intervention (ASSIST linked brief interventionlviii ) or referral to a local substance treatment programme (through a social worker or a registered NGO).
- Elective detoxification: plan in conjunction with a comprehensive substance treatment plan, co-ordinated by the Department of Social Development.
- Unplanned withdrawal: may occur during treatment for another medical condition or may be the presenting complaint. Provide brief intervention counselling and refer to a substance treatment programme.
- Injection drug use: counsel on harm reduction measures and refer to needle and syringe programmes, e.g. StepUp projectlix (TB HIV Care), OUT, Anovalx and COSUPlxi.
Referral
- All patients treated for substance withdrawal should be referred to Social Services and/or a rehabilitation service for management of their substance use and aftercare.
- Discuss those with comorbid mental disorders with a psychiatrist; refer to specialist dual diagnosis services where available.
- Family and/or partners of people who use substances to registered counsellors and support groups (e.g., Al-anon family groups, https://www.alanon.org.za/)
Alcohol Withdrawal
ICD-10 code: F10.3-4
General Measures
The following patients should be admitted for detoxification:
- past history of convulsions
- past history of psychosis
- suicidal ideation
- significant medical comorbidity such as heart failure and liver disease
- inadequate support at home
- history of withdrawal delirium
- >60 years of age
- pregnancy
- cognitive impairment
- previous failed community detoxification attempts
Medicine Treatment
Alcohol detoxification may be managed on an outpatient basis in most patients.
- Thiamine, oral, 300 mg daily for 14 days.
AND
- Diazepam, oral, 10 mg immediately.
- Then 5 mg 6 hourly for 3 days.
- Then 5 mg 12 hourly for 2 days.
- Then 5 mg daily for 2 days.
- Then stop.
Note:
Higher doses may be needed in individual patients.
Alcohol withdrawal delirium (Delirium Tremens)
ICD-10 code: F10.4
Description
Delirium typically occurs 2–3 days following cessation of prolonged alcohol intake, reaching a peak at around 5 days. However, some withdrawal symptoms, such as tremor, may start within 12 hours.
- Typical clinical features include:
- visual hallucinations
- delusions
- disorientation, fluctuating level of consciousness,
- agitation
- tonic-clonic seizures – these do not generally need long term anticonvulsant therapy
- tachycardia
- hypertension
- It is important to consider alternative diagnoses, especially true in cases with an atypical presentation.
- Similar symptoms may occur following withdrawal from other sedative-hypnotic agents.
- Mortality varies from 1–5%.
General Measures
- For non-pharmacological management: See: Delirium.
- Cardiac monitoring and oximetry should be used when administering large doses of benzodiazepines.
- Assess for infections and other co-morbid conditions.
- Ensure adequate hydration. Overhydration is a common error made in this setting.
- Correct abnormalities of electrolytes.
- Provide nutritional support.
- Consider referring appropriate patients to a rehabilitation programme after recovery from delirium tremens.
Medicine Treatment
Administer medicine doses according to severity of symptoms. These patients may require high doses of benzodiazepines because of hepatic enzyme induction.
- Benzodiazepines, e.g.:
- Diazepam, slow IV, (max rate <5 mg/minute), 10 mg (Not IM).
- Repeat dose after 5–10 minutes if required.
- If this dose is not sufficient, use 10 mg every 5–10 minutes for another 1– 3 doses to a maximum of 50 mg.
Where intravenous access is not possible:
- Clonazepam, IM, 2 mg as a single dose.
- If no response, repeat dose after 60 minutes until patient is sedated.
- Repeat dose regularly to maintain mild sedation.
OR
- Lorazepam, IM, 1–4 mg every 30–60 minutes until patient is sedated.
- Repeat dose regularly to maintain mild sedation.
Once patient is sedated, i.e. light somnolence, maintain mild sedation with:
- Diazepam, oral, 5–20 mg.
- Repeat dose regularly to maintain mild sedation.
CAUTION
Benzodiazepines, especially diazepam IV, can cause respiratory depression. Monitor patients closely as benzodiazepines can exacerbate an abnormal mental state or mask important neurological signs of deterioration.
Note:
- Lorazepam IM has slower onset of sedation than midazolam IM (32 vs 18 minutes) and longer duration of sedation (217 vs 82 minutes).
- Clonazepam oral or IM may be used if longer duration of sedation is required. Onset of action may be 30-60 minutes, time to maximum concentration is 1-4 hours. Long half-life (18-50 hours) increases risk of accumulation. Allow at least 12 hours between repeat doses.
When administering glucose-containing fluids:
- Thiamine, oral/IM, 300 mg daily.
Note:
- Neuroleptic medicines such as haloperidol are associated with a reduced seizure threshold and QTc prolongation.
- It is preferable to increase the dose of benzodiazepines than to add haloperidol.
However, oral haloperidol may assist with managing hallucinations and agitation:
- Haloperidol, oral, 0.75–2.5 mg 12 hourly.
- Maximum dose: 5mg per 24 hours.
Do NOT use olanzapine, IM in the management of alcohol withdrawal. Olanzapine, IM may increase risk of respiratory depression if combined with parenteral benzodiazepines particularly if alcohol has been consumed.
Opiate (e.g. Heroin, Unga, Whoonga, Nyaope) Withdrawal
ICD-10 code: F11.2/F11.8-9
Description
Opioid withdrawal is generally poorly tolerated, but not dangerous, except in very frail debilitated patients or during pregnancy, with an increased risk of miscarriage in the first trimester and of preterm delivery in the third trimester.
Signs and symptoms of opiate intoxication:
- Pinpoint pupils
- Drowsiness
- Clammy skin
- Euphoria
- Respiratory depression
- Hallucinations
Signs and symptoms of opiate withdrawal:
- Nausea/ vomitting
- Myalgia
- Gooseflesh
- Diarrhoea
- Abdominal cramps
- Restlessness/ agitation
- Rhinorrhoea and lacrimation
General Measures
- The identification and evidence-based management of opioid dependence among patients who are admitted to hospital will increase their likelihood of completing their primary admission-related treatment. Sub-optimal management of opioid withdrawal will increase the likelihood of absconding from hospital.
- It is extremely important to counsel patients managed for opioid withdrawal upon discharge. Patients’ opioid tolerance will be reduced after the down-tapering of methadone (or similar medication) during hospital stay. Upon discharge, patients should be advised to use opioids with caution due to their increased risk of accidental overdose. Opioid related overdose deaths must be prevented.
- Special considerations apply during pregnancy, consult an expert.
- Concomitant withdrawal from opioids and other “downer” drugs, like benzodiazepines or alcohol may complicate withdrawal, consult an expert.
Medicine Treatment
Monitor for objective signs of withdrawal using a rating scale like the objective opioid withdrawal scale (OOWS) https://medicine.yale.edu/sbirt/OOWS_251773_284_5_v1.pdf
Mild withdrawal (OOWS <4)
May be managed on an outpatient basis.
Symptomatic treatment
- Diazepam, oral, 5–20 mg/day in 2-3 divided doses.
- Taper off over 5–7 days.
For stomach cramps:
- Hyoscine butylbromide, oral, 20 mg 8 hourly as required.
For headaches:
- Paracetamol, oral, 500mg-1 g, 4–6 hourly as required (to a maximum of 4g in 24 hours).
- Maximum dose: 15 mg/kg/dose.
For muscle pains:
- NSAID, e.g.:
- Ibuprofen, oral 400 mg 8 hourly, with meals, as required.
For diarrhoea:
- Loperamide, oral, 4 mg immediately.
- Then 2 mg after each loose stool.
- Maximum dose: 16 mg in 24 hours.
Moderate to severe withdrawal (OOWS ≥4)
Hospitalise patient.
Opioid assisted withdrawal
- Goal is to safely alleviate withdrawal symptoms without causing intoxication or overdose.
- Symptomatic medication listed above may be used to reduce methadone need.
Day 1:
- Wait for early evidence of withdrawal (OOWS ≥4), then:
- Methadone, oral, 5–10 mg.
- If symptoms are still present after 2-4 hour, give another 5–10 mg.
- Repeat until objective withdrawal symptoms are adequately managed (OOWS <4).
- The total 24 hour dose should rarely be more than 30 mg. Consult a person experienced in opioid withdrawal when prescribing >30 mg/day is required.
Day 2:
- Methadone, oral.
- Repeat total dose of day 1 as a single or 2 divided doses.
- Monitor for on-going sign and symptoms of withdrawal.
- If the signs and symptoms of withdrawal are still present on day 2, top-up doses of 5 mg may be given at 2–4 hourly intervals with a total daily dose of up to 30 mg. Consult a person experienced in opioid withdrawal if symptoms not controlled on 30 mg/day.
Day 3 onwards:
- Methadone, oral.
- Repeat total dose of day 2 if top-ups were needed and begin reductions on the following day (e.g. day 4).
- If no top-ups required on the previous day (e.g. day 2) and withdrawal symptoms are adequately controlled, begin dose reduction.
- Decrease dose by 10–20% per day over a period of 3–10 days.
- The withdrawal regimen may be shortened, if the patient’s withdrawal symptoms allow it.
If methadone is unavailable:
- Tramadol, oral, 200 mg 12 hourly for 14 days may attenuate withdrawal symptoms.
Opioid poisoning
See Opioid poisoning.
Referral
- Patients with an opioid use disorder should be offered a referral to access opioid substitution therapy and/or other evidence-based treatment and support.
- Patients identified with current/recent history of intravenous drug use should be provided with sterile injecting equipment (1 ml insulin needles and alcohol swabs) upon discharge from hospital, as well as referral to a community-based needle and syringe programme (See: Substance use disorders – General measures).
Stimulant withdrawal, including Cocaine and Amphetamine type stimulants (e.g. Methamphetamine/Tik, Methcathione/CAT
ICD-10 code: F14.2/F15.2/F15.8-9
General Measures
- These patients usually do not require admission.
- Beware of depression and assess suicide risk.
- Assess and monitor for psychosis.
Medicine Treatment
No substitute medication available for detoxification.
For severe anxiety, irritability, or withdrawal-related insomnia:
- Benzodiazepines, short-term, e.g.:
- Diazepam, oral, 5–10 mg 8 hourly for 5–7 days.
Methaqualone (Mandrax/Whitepipe) withdrawal
ICD-10 code: F19.2-4/F19.8-9
Withdrawal can be dangerous and may lead to seizures (see PHC STGs and EML: Seizures and status epilepticus) or delirium (see Adult Hospital STGs and EML: Delirium)
If withdrawal is symptomatic:
- Diazepam, oral, 5 mg 8 hourly.
- Reduce over 3–5 days depending on clinical response.
Cannabis Withdrawal
ICD-10 code: F12.2
- Withdrawal is rarely dangerous and poorly tolerated.
- Assess for other accompanying psychiatric disorders e.g. mood or psychosis.
Benzodiazepine withdrawal
ICD-10 code: F13.2
Description
Benzodiazepine addiction may occur after only a few weeks of use. Withdrawal symptoms may occur with abrupt dose reduction or cessation and include anxiety, nervousness, irritability, depersonalisation, delirium and seizures, increased sweating, sound sensitivity, nausea, difficulty concentrating, myoclonus, tremor, weakness, and fatigue. Gradual tapering of the benzodiazepine is recommended to facilitate discontinuation.
General Measures
- The therapeutic relationship between client and doctor is extremely important in initiating dose reduction.
- Confirm benzodiazepine dependence – ascertain usage, history of previous withdrawal symptoms; a urine screen may be necessary.
- Establish full dosage of all benzodiazepines being taken, including those prescribed by other medical practitioners.
- Take time to explain negative impact of ongoing benzodiazepine use, benefits of stopping, and concepts like tolerance and withdrawal.
- Encourage the patient not to seek medication from other doctors.
- Evaluate and optimise management of comorbid substance use disorders, mental illness, and general health conditions.
- Avoid abrupt withdrawal of benzodiazepines; be prepared to take time. Negotiate each reduction with the patient. Individualise regular monitoring and motivation
- Refer for substance use rehabilitation, e.g. SANCA (https://www.sancanational.info).
- Long-term follow-up with repeated motivation may be necessary to prevent relapse.
Medicine Treatment
- Replace short-acting benzodiazepine with an equivalent diazepam (long acting benzodiazepine) dose.
- Patients may present with medicines that are unavailable in the public sector.
Approximate equivalent doses to diazepam 5 mg are:
- Alprazolam - 0.25 mg
- Bromazepam - 1.5 mg
- Clobazam - 10 mg
- Chlordiazepoxide - 12.5 mg
- Clonazepam 0.25–1 mg
- Flunitrazepam - 0.5 mg
- Lorazepam - 0.5 mg
- Nitrazepam - 5 mg
- Oxazepam - 15 mg
- Temazepam - 10 mg
- Zolpidem - 10 mg
- Zopiclone - 7.5 mg
Note:
- Medicines have only been included for comparison of estimated equivalent doses.
- Higher doses may be required for patients who are dependent on both alcohol and benzodiazepines. Inpatient assessment and initiation of benzodiazepine tapering may be warranted in these patients.
Reduction is done according to clinical response (See table below).
- Diazepam, oral.
Table 15.1: Dose reduction of diazepam-rquivalent benzodiazepines
| Daily diazepam-equivalent doses used | Dose reduction recommendation |
| > 50 mg/day | Reduce daily dose every 1–2 weeks by 10 mg/day until a daily dose of 50 mg is reached. |
| 30-50 mg/day | Reduce every 1–2 weeks by 5 mg/day until a daily dose of 30 mg is reached. |
| 20-29 mg/day | Reduce every 1–2 weeks by 2.5 mg/day until a daily dose of 20 mg is reached. |
| < 20 mg/day | Reduce every 1–2 weeks by 1.25 mg/day until stopped. |
Note:
- If symptoms reappear, increase the dose by 2.5 or 5mg a day and then reduce dose using 2–4 week intervals.
- Do not prescribe more than one week’s duration of medication at a time.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults_Chapter 15: Mental Health Conditions and Substance Misuse_NEMLC Recommendations for Medicine Amendments 2020-2023
Drugs mentioned
ICD-10 codes
- F10.3Mental and behavioural disorders due to use of alcohol, withdrawal state
- F10.4Mental and behavioural disorders due to use of alcohol, withdrawal state with delirium
- F11.2Mental and behavioural disorders due to use of opioids, dependence syndrome
- F11.8Mental and behavioural disorders due to use of opioids, other mental and behavioural disorders
- F11.9Mental and behavioural disorders due to use of opioids, unspecified mental and behavioural disorder
- F12.2Mental and behavioural disorders due to use of cannabinoids, dependence syndrome
- F13.2Mental and behavioural disorders due to use of sedatives or hypnotics, dependence syndrome
- F14.2Mental and behavioural disorders due to use of cocaine, dependence syndrome
- F15.2Mental and behavioural disorders due to use of other stimulants, including caffeine, dependence syndrome
- F15.8Mental and behavioural disorders due to use of other stimulants, including caffeine, other mental and behavioural disorders
- F15.9Mental and behavioural disorders due to use of other stimulants, including caffeine, unspecified mental and behavioural disorder
- F19.2Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances, dependence syndrome
- F19.3Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances, withdrawal state
- F19.4Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances, withdrawal state with delirium
- F19.8Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances, other mental and behavioural disorders
- F19.9Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances, unspecified mental and behavioural disorder