What Types of Rehabilitation Services are Available for a Heroin Addict?

1. Drugs, also known as psychoactive substances, addictive substances or substances, refer to a class of chemical substances that can affect human emotions, behaviors, change the state of consciousness, and cause dependence. People use these substances to obtain or maintain certain substances. Special psychological and physiological conditions.

Hao Wei	(Chief physician)	Institute of Mental Health, Second Xiangya Hospital, Central South University
Liu Tieqiao	(Chief physician)	Institute of Mental Health, Second Xiangya Hospital, Central South University
Wang Xuyi	(Doctor)	Institute of Mental Health, Second Xiangya Hospital, Central South University

Drug dependence is a group of cognitive, behavioral, and physiological symptoms that users continue to use, even though they understand the problems associated with the use of addictive substances. Drug abuse and dependence are the result of the interaction of social, psychological, and biological factors. The existence and pharmacological characteristics of drugs are necessary conditions for abuse and dependence, but whether or not they become "addicts" is also related to individual personality and biological susceptibility. Socio-cultural factors have played an incentive role in drug abuse and dependence.

Western Medicine Name: Drug dependence

Affiliated Department: Internal Medicine-
Contagious: Non-contagious

Introduction to Drug Dependent Diseases

Drug Dependence (I) Basic Concepts

Drugs are a sociological concept, referring to chemicals that are highly addictive and banned in society. Drugs in China mainly refer to drugs such as opioids, cocaine, cannabis, and amphetamine-type stimulants.

2. Dependence ^[1]

Dependence is a group of cognitive, behavioral, and physiological symptoms that users continue to use, even though they understand the use of addictive substances can cause problems. Self-administration led to increased tolerance, withdrawal symptoms, and mandatory drug-seeking behavior. The so-called compulsory drug-seeking behavior refers to the impulsive use of drugs by users, regardless of all consequences, and is a manifestation of self-uncontrol. It is not necessarily a problem of weak will and moral corruption that people often understand.

Dependence is traditionally divided into physical dependence and psychological dependence. Physical dependence is also called physiological dependence. It is a pathological adaptation state caused by repeated medication, which is mainly manifested by increased tolerance and withdrawal symptoms. Psychological dependence, also known as mental dependence, causes the user to have a pleasant, satisfying or euphoric feeling, which drives the user to repeatedly use drugs to seek this feeling, showing the so-called craving state.

3. abuse

Abuse, also known as harmful use, is a form of maladaptiveness. Repeated use of drugs has led to significant adverse consequences, such as inability to complete important work, schoolwork, damage to physical and mental health, and legal problems. Abuse emphasizes the adverse consequences. The abuser does not have a noticeable increase in tolerance or withdrawal symptoms. Instead, he is dependent.

Tolerance

Tolerance is a state where the user of a drug must increase the dose to obtain the desired effect, or the original dose cannot achieve the desired effect.

5. Withdrawal status

Withdrawal status refers to a special group of psychophysiological symptoms that occurs after stopping the use of drugs or reducing the use of doses or using antagonists to occupy receptors. The mechanism is due to the adaptive rebound caused by sudden withdrawal after long-term use of the drug. Withdrawal symptoms caused by different drugs are different due to their different pharmacological properties, and generally show symptoms opposite to the pharmacological effects of the drugs used. For example, after alcohol (central nervous system inhibitor) withdrawal, symptoms such as excitement, insomnia, and even epileptic seizures appear.

Drug dependence (2) classification of psychoactive substances

According to the pharmacological properties of psychoactive substances, they are divided into the following categories:

1. Central nervous system inhibitors can inhibit the central nervous system, such as barbiturates, benzodiazepines (word making 001), alcohol and so on.

2. Central nervous system stimulants can excite the central nervous system, such as caffeine, amphetamines, cocaine and so on.

3 Cannabis Cannabis is the oldest and most famous hallucinogen in the world. Moderate inhalation or consumption can make people euphoric. Increasing the dose can make people enter dreams and fall into deep and refreshing sleep. The main ingredient is 9-tetrahydrocannabis. phenol.

4 Hallucinogens can change the state of consciousness or perception, such as lysergic acid diacetamide (LSD), cactus toxin, phencyclidine (PCP), ketamine (K powder), and so on.

5. Opioids include natural, synthetic, or semi-synthetic opioids, such as heroin, morphine, opium, methadone, dihydroetorphine, durotin, buprenorphine, and so on.

6. Volatile solvents such as acetone, gasoline, thin materials, toluene, olfactory glue, etc.

7. tobacco

Cause of drug dependence

The cause of drug abuse cannot be explained by a single model, and is closely related to social environment, psychological characteristics and biological factors. They cross each other, influence each other, and cause each other.

Common social factors include:

easy to obtain;

Family factors, such as family conflicts, single-parent families, poor communication among family members, and drug abuse by family members are important risk factors for drug use, especially among young people;

peer influence, peer pressure, etc .;

cultural background, social environment and other factors.

Drug users often have obvious personality problems, such as antisocialism, poor emotional control, impulsiveness, lack of effective defense mechanisms, and the pursuit of immediate satisfaction. However, it is not completely clear whether these personality problems lead to drug use or change due to drug use. The personality of the drug addict, or the two are mutually causal. In addition, differences in the metabolic rate of addictive substances and genetic factors also play a role in the formation of addictive behaviors.

After the dependence of humans and animals is formed, there are a series of changes in neurotransmitters, receptors, second signal transduction systems, and even transcription and structure in the central nervous system. Therefore, some scholars have defined dependence behavior as chronic brain. Department of Disease. The reward system located in the limbic system is the structural basis for drug dependence. Changes in transmitters such as monoamines are a direct consequence of the action of psychoactive substances. The resulting series of receptors and post-receptor changes are caused by drug-dependent behavior. Important conditions. The effect of drugs on the reward system is the fundamental cause of mental dependence and drug-seeking behavior. Reward response is an emotional response mechanism inherent in humans (including some higher animals). The occurrence of this mechanism is primitive, but has great potential. The psychoactive substances abused by humans work through the stimulation and continuous stimulation of this potential

In short, drug abuse and dependence are the result of the interaction of social, psychological and biological factors. The existence and pharmacological characteristics of drugs are necessary conditions for abuse and dependence, but whether or not they become "addicts" is also related to individual personality and biological susceptibility. Socio-cultural factors have played a role in inducement of drug abuse and dependence.

Drug dependence diagnosis and treatment

The diagnosis of drug dependence is not difficult to make by asking about the taking of the drug and testing the patient with blood or urine drugs. The treatment of different drug dependence is different. Basically, the treatment of drug dependence can be divided into two steps. The first step is detoxification. This step mainly treats drug withdrawal symptoms. The second step is rehabilitation and relapse prevention treatment, which aims to completely eliminate drug dependence ^[2] .

Drug dependence opioid dependence

I. Overview

Opiates are any class of drugs, natural or synthetic, that have a morphine-like effect on the body. Opioids are crude fatty exudates extracted from poppy fruit and contain a variety of ingredients including morphine and codeine.

Opioid abuse is a public health and social problem worldwide, and China has suffered from opioids for more than a century. By 1949, the number of opium and heroin users in China was about 20 million, which became one of the important reasons for poverty and backwardness in modern China. Since the 1980s, the problem of drug abuse in China has revived. According to data released by the public security department, the number of drug addicts recorded in China in 1990 was about 70,000, 250,000 in 1993, 520,000 in 1995, 1.01 million in 2002, more than 1.04 million in 2003, and 116 in 2005 Million.

Clinical manifestations of opioid addiction

Opioids have analgesic and sedative effects, can inhibit breathing, coughing center, and gastrointestinal motility, and can stimulate the vomiting center and reduce the pupil. Opioids can act on the limbic system of the midbrain and produce a strong thrill.

Withdrawal response to opioids:

Due to the different doses of opioids, the degree of effect on the central nervous system, the length of time used, the route of use, the speed of withdrawal, etc., the intensity of withdrawal symptoms is also not consistent. Short-acting drugs, such as morphine and heroin, usually appear 8 to 12 hours after discontinuation, and the extreme period is 48 to 72 hours for 7 to 10 days. Long-acting drugs, such as methadone withdrawal symptoms, appear in 1 to 3 days, and their properties are similar to short-acting drugs. The extreme period is 3 to 8 days, and the symptoms last for several weeks.

Typical withdrawal symptoms can be divided into two categories: objective signs such as increased blood pressure, increased pulse, increased body temperature, goose bumps, dilated pupils, runny nose, tremor, diarrhea, vomiting, insomnia, etc .; subjective symptoms such as nausea , Muscle pain, bone pain, abdominal pain, restlessness, poor appetite, weakness, fatigue, sneezing, chills, fever, craving for medication, etc.

Third, treatment

The treatment is divided into two parts, namely, detoxification treatment in the acute phase and relapse prevention and psychosocial rehabilitation treatment after detoxification.

(1) Detoxification treatment

Detoxification refers to the process of reducing withdrawal symptoms through physical therapy and preventing physical health problems that may be caused by sudden withdrawal. Due to the particular nature of drug users, detoxification of opioids is generally performed in a closed environment.

1. Replacement therapy The theoretical basis of replacement therapy is to use drugs that have similar effects to drugs to replace drugs in order to reduce the severity of withdrawal symptoms and enable patients to tolerate better. Then within a certain period of time (such as 14 to 21 days), the alternative medicine will be gradually reduced and finally discontinued. Methadone and buprenorphine are currently used as alternative medicines. The dosage depends on the patient's condition. The first day of methadone dosage is 30mg ~ 60mg, buprenorphine is 0.9mg ~ 2.1mg, and then according to The patient's physical response is gradually reduced. The principle is to reduce but not increase, fast first, then slow, and decrease in time.

2. Non-replacement therapy clonidine: 2 receptor agonist, starting dose is 0.1mg ~ 0.3mg, 3 times a day, side effects are hypotension, dry mouth and sleepiness, the dose must be individualized. Clonin is less effective at cravings and muscle pain. It is mainly used for adjuvant treatment of detoxification treatment; Chinese herbal medicine and acupuncture: Compared with alternative treatment, Chinese medicine is less effective in alleviating withdrawal symptoms in the first three days after abstinence, but it can effectively promote the body's recovery and appetite. It is important not to have difficulty withdrawing the drug. Acupuncture also has a certain effect; others: such as sedative hypnotics, scopolamine.

(Two) prevent relapse, social psychological intervention

1. Opioid blockers In theory, by blocking the euphoric effects of opioids, conditioned reflexes will subside. These drugs are mainly naloxone and naldrone, the latter being effective orally. Since these drugs are -blockers, they can block the effects of opioids and have low toxicity. Since 1960, they have been widely used in clinical practice, but only 30% of drug addicts can continue to use such drugs.

2. Most psychosocial studies have shown that psychosocial interventions can be effective in treating certain problems such as recurrence.

(1) Cognitive-Behavioral Therapy: The main objectives are to: change the cognitive style that leads to maladaptive behavior; change the behavior style that leads to drug abuse; help patients cope with acute or chronic cravings; promote patients 'social skills and strengthen patients' non-drug use behavior.

(2) Prevention of relapse: Based on cognitive behavioral therapy, it helps patients increase their self-control ability to avoid relapse. The basic methods are: discuss the ambivalence of drug use and detoxification; find out the emotional and environmental factors that induce craving and relapse; find out how to cope with internal and external adverse stimuli, and break the vicious cycle of re-drug use.

(3) Group therapy: Group therapy gives patients the opportunity to discover common problems between them and develop practical treatment plans; it can promote their mutual understanding and allow them to learn how to correctly express their emotions and wishes, so that they have the opportunity To share experiences of successful detoxification and lessons learned from failure; they can also monitor and support each other during treatment, promote their contact with physicians, help prevent relapse, and promote rehabilitation.

(4) Family therapy: Family therapy emphasizes that bad relationships between people and family members are the main reasons for drug addiction and relapse after treatment. Effective family therapy can break denials, break resistance to therapy, and promote emotional communication among family members.

(Three) methadone maintenance treatment

Despite the above treatments, not all drug addicts can successfully detoxify. The drug use process will inevitably disrupt society and families due to drug problems and cause the spread of various infectious diseases (such as HIV). Based on the consideration of harm reduction, methadone maintenance treatment came into being.

Methadone maintenance treatment is the use of methadone to supplement the deficiency of endogenous opioid peptides in heroin-dependent people, so that heroin-dependent people can restore their normal physiological and psychological functions and live like normal people. It is not the same as "detoxification treatment", nor is it commonly referred to as "detoxification", but a treatment method, just like the treatment of hypertension and diabetes requires long-term or life-long use of drugs to control symptoms and maintenance treatment.

The follow-up study found that although the patients were still in a dependent state, the drug use, crime, and mutual infection caused by injections in patients receiving maintenance treatment were significantly reduced, and social functions, employment, and overall health were improved, and more importantly, The patient is out of treatment and has the opportunity to undergo psychosocial rehabilitation.

Drug dependence alcohol dependence

I. Overview

In the past 20 years or more, with the development of China's economy, the production of alcohol and per capita consumption have increased significantly, and various harms caused by drinking and hospitalization rates of alcohol dependence have also increased. Compared with developed countries, although China s per capita alcohol consumption and the incidence of alcohol-related problems are relatively low, in contrast to this trend, the consumption of alcohol and related diseases in China have increased significantly, which should be given full attention.

Most of the alcohol consumed by the mouth is absorbed in the upper part of the small intestine and enters the organs of the body through blood circulation. About 2% to 10% of alcohol is excreted by expiration, urine, and sweat; the remaining part is metabolized into acetaldehyde, Acetic acid is finally metabolized into water and carbon dioxide.

The metabolic site of alcohol is mainly in the liver. There are two major systems involved in the metabolism of alcohol: the alcohol dehydrogenase system and the microsomal ethanol oxidation system. Most of the alcohol is metabolized by the alcohol dehydrogenase system, of which acetaldehyde dehydrogenase is the rate-limiting enzyme.

In the above metabolism, the participation of some enzymes and coenzymes is required, and some intermediate products are produced, such as hydrogen ions, pyruvate, and purines. Clinically, we often see that after a large amount of alcohol consumption, hyperlactic acidemia, Hyperuricemia (gout attack). Long-term heavy alcohol consumption hinders fat oxidation in the body, a large amount of fatty acids and neutral fat are accumulated and accumulated in the liver, forming fatty liver, hyperlipidemia, arteriosclerosis, etc. A large amount of alcohol can damage liver cells, leading to alcoholic hepatitis, liver Hardening, etc.

Pharmacological effects of alcohol

People's responses to alcohol vary widely and their sensitivities are different. In general, the degree and extent of inhibition varies depending on the amount of alcohol consumed or the concentration of alcohol in the blood. Alcohol first inhibits the cerebral cortex, causing subcortical release, a sense of relaxation and emotional release; as the amount of alcohol increases, the inhibition further deepens, the so-called drunken state appears, and the inhibition of mental activity, speech, and motor function deepens, which manifests itself in the surroundings. Things are less responsive, feel sluggish, judgement memory is impaired, self-control is reduced, movement is unstable, articulation is vague, etc .; after that, the brain is in a highly inhibited state, unable to get drunk, vomiting, and drowning completely unknown. When the blood concentration exceeds 0.40%, coma, respiratory heartbeat suppression may occur, and the possibility of death is very high.

The effects of alcohol on the body can be divided into acute and chronic effects. Its acute effects are mainly acute gastric and esophageal bleeding. Chronic effects refer to heavy drinking throughout the year, causing damage to various organs, which are manifested in the central and peripheral nervous system, muscles, heart, liver, pancreas, and digestive tract.

Drinking and mental disorders

(A) acute alcoholism

Has a lot of drinking history, the severity of drunkenness is closely related to blood alcohol concentration, mainly manifested as impulsive behavior, irritability, impaired judgement and social function, and has problems such as slurred speech, ataxia, and unstable gait , Nystagmus, red complexion, vomiting and other manifestations. If the poisoning is deep, it can cause breathing, heartbeat suppression, and even life-threatening.

(2) Withdrawal response

1. Simple withdrawal reaction Stops or reduces alcohol consumption after long-term heavy drinking, and tremor of the hand, tongue, or eyelids appears after a few hours, and there is nausea or vomiting, insomnia, headache, anxiety, emotional instability, and autonomic nervous function such as heartbeat Speed up, sweating, increased blood pressure, etc., a few patients may have transient hallucinations or illusions.

2. Tremor and delirium For a long time, if a large number of drinkers suddenly stop drinking, tremor and delirium will appear after about 48 hours, manifested as blurred consciousness, can not distinguish between east and west, north and south, ignorance of relatives, and time, there are a large number of perceptual abnormalities, such as common image distortion and terror The serpents and beasts, monsters and monsters, the patient was extremely restless, emotionally agitated, and shouted. Another important feature is tremor of large muscles throughout the body. There were still fever, sweating, and rapid heartbeat. Some patients died of high fever, exhaustion, infection, and trauma.

3 Epilepsy-like seizures usually occur 12 to 48 hours after stopping drinking, and most of them are major seizures.

(Three) memory and mental retardation

For long-term heavy drinkers, due to changes in dietary structure and loss of appetite, they cannot take in sufficient amounts of vitamins, proteins, minerals and other essential substances in the body, and are often accompanied by physical diseases such as liver dysfunction and chronic gastritis. The condition is poor, and anemia and malnutrition are not uncommon. Long-term malnutrition is bound to affect the function and structure of the nervous system.

One of the unique symptoms of the nervous system of alcohol addicts is memory impairment, called Korsakoff syndrome, which is mainly characterized by memory impairment, fiction, and disorientation. Patients may also have hallucinations and nocturnal delirium.

Wernicke encephalopathy is caused by lack of vitamin B1, which is manifested as nystagmus, inability of eyeball abduction and obvious disturbance of consciousness, accompanied by disorientation, memory impairment, delirium tremor, etc., a large amount of vitamin B1 supplementation can quickly disappear the symptoms of the eyeball, but The recovery of memory disorders is more difficult, and some patients have turned into Korsakoff syndrome, which has become an irreversible disease.

Alcoholic dementia refers to persistent mental decline after long-term and heavy drinking, which is manifested as short-term and long-term memory impairment, abstract thinking and understanding and judgment disorders, personality changes, and some patients have impaired cortical function, such as aphasia, loss of identity, Misuse, etc. Alcoholic dementia is generally irreversible.

(4) Other mental disorders

1. Alcoholic hallucinations are long-lasting psychotic disorders that occur in patients with chronic alcohol dependence, and may also be organic hallucinations after alcoholics suddenly stop drinking (usually after 48 hours). Sexual audiovisual hallucinations.

2. Alcoholic delusions are mainly manifested in a delusional state with clear consciousness, especially jealousy delusions.

3 Personality changes Patients are only interested in drinking, become self-centered, do not care about others, fall in responsibility, lie, etc.

Fourth, treatment

First of all, we must overcome the "denial" from the patient and obtain the cooperation of the patient. Second, we must actively treat the primary disease and comorbidities, such as personality disorders, anxiety disorders, depression disorders, and schizophrenia-like symptoms. Attention should also be paid to strengthening patient nutrition and supplementing the body with proteins, vitamins, minerals, fatty acids and other substances.

(I) Acute treatment (treatment of withdrawal symptoms)

1. General treatment of patients with long-term heavy alcohol consumption is often physical damage, so pay attention to correct water, electrolyte and acid-base balance disorders. Alcohol-dependent patients generally need to add large doses of vitamins, especially B vitamins.

2. Withdrawal symptoms are simple. Because alcohol has a similar pharmacological effect to diazepam, these drugs are commonly used in clinical practice to relieve alcohol withdrawal symptoms. Do not take medicine slowly for the first time. This will not only suppress withdrawal symptoms, but also prevent possible tremor delirium and withdrawal seizures. Taking diazepam as an example, the dosage is generally 10mg / times, 3 times / day, the first dose can be larger, can be taken orally, and gradually reduced after 2-3 days, without the need to add antipsychotic drugs. Because alcohol dependent people have dependent qualities, special care should be taken not to take medicine for too long, so as to avoid dependence on benzodiazepines. If you have anxiety and sleep disturbances during the late withdrawal period, try a tricyclic antidepressant.

3 Tremor delirium occurs 48 hours after alcohol withdrawal, and reaches the extreme phase 72 to 96 hours. Other delirium, brain, metabolism, and endocrine problems can also occur and should be identified.

General Precautions: Those who have delirium have more excitement, need a quiet environment, and the light should not be too strong. If there are obvious disturbances of consciousness, disorder of behavior, horror hallucinations, or illusions, someone needs to take care to avoid accidents. If there is sweat and tremor, there may be a problem with temperature regulation. You should pay attention to insulation. At the same time, because the body is in a stress state, the immune function is impaired, and it is easy to cause infection. Attention should be paid to preventing various infections, especially lung infections.

Sedation: Diazepam should be the first choice, diazepam 10mg once, 2 to 3 times / day, if oral administration is difficult, the injection route should be selected. The dose is adjusted according to the patient's excitement and autonomic symptoms, and can be intravenously infused if necessary, usually for one week, until the delirium disappears.

Control of psychiatric symptoms: Haloperidol, 5 mg / time, 1 to 3 times / day, intramuscular injection can be used, and the dose can be increased or decreased according to the response of the patient.

Others: including correcting water, electrolyte and acid-base balance disorders, supplementing large doses of vitamins, etc.

4 Alcoholic hallucinations and delusions Most of the withdrawal hallucinations and delusions do not last long and are effective with antipsychotics. Haloperidol or perphenazine can be used orally or by injection. New antipsychotics can also be used. For example, if risperidone and quetiaxine are equal, the dose should not be too large. After the hallucinations and delusions are controlled, the drug can be gradually reduced without the need to maintain medication as long as the treatment of schizophrenia.

5. Alcoholic epilepsy is uncommon, and valproic acid or phenobarbital can be used. Patients with a previous history of epilepsy should use large doses of antipsychotic drugs or preventive antiepileptic drugs in the early stage of withdrawal. .

(2) Treatment during rehabilitation (treatment to prevent or reduce re-drinking)

Alcohol sensitizer

Quit alcohol (TETD) can inhibit acetaldehyde dehydrogenase in liver cells. TETD itself is a non-toxic substance. However, pre-administration of TETD can keep the alcohol metabolism in the acetaldehyde stage and show significant signs or symptoms. Facial fever occurs after about 5 to 10 minutes after drinking, and flushing, vasodilatation, and intense pulsations in the head and neck occur soon. , Pulsatile headache; dyspnea, nausea, vomiting, sweating, thirst, hypotension, orthopaedic syncope, extreme discomfort, weakness, etc., severe cases may appear insanity and shock. Taken every morning, it is best to use under medical supervision, a dose of 250mg, can be used continuously for one to several months. A small number of people in the application of TETD treatment can have serious adverse reactions and even risk of death even if they drink a small amount of alcohol. Therefore, those with cardiovascular disease and old and infirm should be disabled or used with caution. During the application period, in addition to necessary monitoring measures, patients should be particularly warned not to drink alcohol while taking the medication.

2. Drugs that reduce cravings for alcohol

Studies have found that opioid blocker naltrexone can reduce alcohol consumption in experimental animals, and can reduce alcohol consumption and relapse rates in patients with alcohol dependence, especially when used in combination with psychotherapy. Naldrone dose is 25-50mg per day. In addition, the GABA receptor agonist calcium acetyl homotaurate (calcium acamprosate, acamprosate) also has a certain anti-craving effect, which can reduce relapse after drinking.

(4) Other treatments

Many patients with alcohol dependence also suffer from other mental disorders, such as depression, anxiety, and obsessive-compulsive disorder. These mental disorders may be the cause of alcohol dependence or the result of alcohol dependence. Improving mental symptoms will help with the treatment of alcohol dependence.