1.  General guidelines about Opioids Use Disorder

Opioid use disorder (OUD) is a complex illness characterized by compulsive use of opioid drugs even when the person wants to stop, or when using the drugs negatively affects the person’s physical and emotional well-being.

Ø  3 or more of the following characteristics for a period of 1 year:

1.     Strong desire or compulsion to take the substance

2.     Difficulties in controlling substance – taking behaviour in terms of onset, termination, or levels of use

3.     Physiological withdrawal state when substance use has ceased or been reduced (Anxiety, tremors, headache, nausea, vomiting, insomnia, sweating)

4.     Evidence of tolerance - need to increase alcohol dosage to gain the desired effect

5.     A lot of time is spent on drinking alcohol; Recreational, social activities are given up because of alcohol use

6.     Alcohol used despite knowledge that it creates physical and psychological problems

History taking and examination including MSE                                                                                                            Annexure 1 Special emphasis -

·       Daily dosage

·       length of use and last dosage

·       also multiple substance use

2.     a) Investigations required

i.                Psychometric investigations: Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST)

ii.                Laboratory: (if physical complications are present)

a)    Comorbidity

i.                Anxiety Disorder

ii.                Mood Disorder

b)    Differential Diagnosis

·       Consider acute head injury and hypoglycaemia. Consider also the possibility of intoxication as the result of substance use. The following five-character codes may be used to indicate whether the acute intoxication was associated with any complications.

·       Uncomplicated (Symptoms of varying severity, usually dose- dependent, particularly at high dose levels.

·       With trauma or other bodily injury

·       With other medical complications, such as haematemesis, inhalation of vomitus.

·       With Delerium

·       Intoxication with other substance

3.  Treatment

a)     Psychopharmacology

·       Acute intoxification - Naloxone

·       Detoxification with sofer opiates

·       Buprenorphine

·       Symptomatic and supportive

2.  Opioid use disorders (Heroin-No 4)

Herion-No 4 dose should be calculated from the average daily dose. for example, if the daily dose is 3 caps (insulin syringe cap), taking this into account the effects of the drug, the following drugs should be given

i.             Tramadol tablets 100 mg should be given three times daily, i.e. Two tablets in the morning, two tablets in the afternoon and three tablets in the evening. The dose should be decreased daily or weekly within 7-10 days. If the treatment is still slow, continue for 3 to 5 days.

ii.             Nitrazepam 10 rng/Lorazeparn 2 ng/Zolpiden 10 mg mum should be given if the patient cannot take it.

iii.              Inj Haloperidol and Inj Promethazine lampule IM, darnlo should be given if the problem or symptoms appear

iv.             Treatment should be given according to the patient's condition

3.  Multiple Substance Use Disorder

Point No II (1) and (2) above should be used to reduced or remove the drug from the body.

I.    FOLLOW UP

1.  Patient should be advised to revisit Psychiatry OPDs/ DMHP OPDs- district towns after discharge from Centres

2.    Patients and their caregivers can call Psychiatrists, Clinical Psychologists and DMHP Mental Health Professionals on State helpline 102 (toll free) if necessary.

b)     Psychosocial Intervention

Psychoeducation – nature of illness, etiology, progression, consequences, prognosis, treatment.

c)     Psychotherapy

i. Relapse Prevention Therapy -

·       Identifying the triggers

·       Strategies for coping with triggers (5 D’s) delayed, drink, divert,discuss,deep breath

ii.  Motivation               Enhancement                Therapy-Motivational enhancement therapy (MET) is a directive, person-centered approach to therapy that focuses on improving an individual's motivation to change.

ü  pre contemplation- not interested/not even thinking about behaviour change

ü  Contemplation- ambivalent/ considering change

ü  Preparation- ready for action/change is necessary and possible

ü  Action- initiating action/actively working toward behaviour change

ü  Maintenance/recovery- already acting/sustaining new behaviour

iii.   Family therapy

iv.   Physical Activity / Activity Scheduling

ü  Exercising: Physical Exercises, calisthenics exercises, stretching, brisk walking Playing basketball, going to the gym, or getting out for a hike.

ü  Nurturing relationships: Going out to dinner, seeing a movie, or attending a play with friends or family

ü  Self-education: Taking a class, going to the library, reading more

ü  Participating in hobbies: Taking a cooking class, learning how to knit or paint, learning to play an instrument, learning new languages, new game, carpentry or clay modelling etc

ü  Expanding self-care: Learning mindfulness techniques, practicing relaxation therapy, visualizing, or doing yoga.

a)    Combined Treatment

4.  Follow-up

a.  Psychiatry opd/ DMHP

b.  Physical check-up at OPD

c.  Through telephonic conversation TeleManas14416/18008914416

5.  Referrals

a)     Depending upon the severity and complications of the patient, he/she may need to be referred to Psychiatry/medicine department.

b)     To TeleManas

c)     To the nearest DMHP

d)     To psychiatry OPD at Kulikawn Hospital and ZMC

e)     To higher centers outside Mizoram through Referral Board.