REPUBLIC
OF KENYA
MINISTRY OF MEDICAL
SERVICES
2012
ACKNOWLEDGEMENTS
This protocol and guidelines to substance use disorders
treatment is a result of collaborative effort between the Government of Kenya
and the United Nations System in Kenya, and namely between Ministry of Medical
Services (MoMS), the National Campaign Against Drug Abuse Authority (NACADAA),
National AIDS Control Council (NACC), University of Nairobi (UoN), Civil Society,
drug user involvement, service providers, the United Nations Office on Drugs
and Crime (UNODC) and World Health Organization (WHO).
A special recognition is due to the Director of Mental Health,
Ministry of Medical Services, and the Medical Superintendent and staff of the
Mathari Referral Hospital, in Nairobi, and Coast Province General Hospital, in
Mombasa.
A number of key documents and recommendations from WHO, UNODC
and Treatment were reviewed in the preparation of this protocol.
The staff of the above-named institutions and organizations has
done a commendable job to contribute to provide better health care to
individuals with substance use disorders.
Dr. David M. Kiima
Director of Mental Health
FOREWORD
Substance (Drug) Abuse is increasing in Kenya and
especially among the youth. Current statistics indicate that more than half of
drug users are aged (10-19 years). The youth are the backbone of any country of
Socio-economic development and any disruption to the social fabric within this
age group results in decline in literacy levels, loss of productivity and
therefore economic loss to the country. In line with our Vision 2030 of
becoming a globally competitive middle income economy and prosperous nation,
urgent measures are required to curb this menace of substance.
Most studies done in the country indicate that the
commonly used drugs are nicotine, alcohol and cannabis. Due to the strategic
location f Kenya in the East African region and Nairobi being an economic hub
in the region, there has been an upsurge of international narcotic drug
trafficking leading to increased injecting drug users (IDU)s. The Kenya HIV/ AIDs Indicator Survey (KAIS) 2009 report indicates that HIV prevalence
rate among IDUs stands at 18.3% compared to 6.7% among the general population.
The Kenya Constitution 2010 under CHAPTER FOUR (the Bill
of Rights) recognizes the right to the highest attainable level of health care
to all. In this regard, persons with substance use disorders are entitled to
access quality healthcare services. Therefore these guidelines have been
developed with a view to disseminating them to all service providers
countrywide for use in provision of standardized and quality healthcare services
to drug users.
This National Treatment Protocol for substance use
disorders will enable appropriate management of substance use and its related
health and social consequences including HIV. It is based on international best
practice to manage substance use disorders. It will be a useful and practical
guide for practitioners dealing with substance abuse problems in Kenya.
This protocol outlines the pharmacological treatment,
psychosocial interventions and aftercare support which will be provided in line
with international standards and procedures, while respecting the national
social, cultural and economic realities. It provides a humane and scientific
approach delivered by skilled practitioners in order to assist the drug
dependent person to attain the highest level of personal, professional,
familial and social functioning.
This protocol was developed through the effort by the
Government of Kenya in partnership with United Nations Office on Drugs and
Crime (UNODC). The Ministry of Medical Services in collaboration with UNODC
offered stewardship. I wish to thank the; Ministries of Health (Ministry of
Medical Services and Ministry of Public
Health and Sanitation), the National Campaign Against Drug and Alcohol Abuse Authority (NACADAA),
National AIDS Control Council (NACC), University of Nairobi (UoN),
Civil Society, the United Nations Office on Drugs and
Crime (UNODC) and World Health Organization (WHO), for having tirelessly worked
on this treatment protocol which will go a long way in enhancement of substance
use disorders treatment in the country.
Finally I would like to appreciate and thank the Minister for Medical
Services Hon. (Prof.) Peter A. Nyong’o and the Permanent Secretary Ngari M.W.(MS)
CBS for their overall stewardship and
guidance in the health sector policy.
Dr.
Francis M. Kimani
Director
of Medical Services
Table of Contents
Foreword …………………………………………………………………………………….………….2-3
4. Suggested Criteria for the choice of
treatment setting ……………………….. 10
Treatment
Interventions................................................................................................21
Nicotine…………………………………………………………………………………………21
AA Alcoholics
Anonymous
ADS Alcohol Dependence Scale
AIDS Acquired Immune
Deficiency Syndrome
ARV Anti-Retroviral
Treatment
ASI Addiction Severerity Index
ASSIST Alcohol, Smoking &
Substance Involvement Screening Test
AUDIT Alcohol Use Disorder Identification Test
BID Twelve Hourly Dose
CAGE Cut
down, Angry, Guilt, Eye opener
CBT Cognitive Behavior Therapy
CNS Central Nervous System
DHHS Department of Human
Health and Human Services
DSM IV-TR Diagnostic and Statistical Manual of Mental Disorders. 4th
Edition. Text Revised
GABA Gamma Amino Butyric Acid
HIV Human
Immunodeficiency Virus
ICD - 10 International Classification of Diseases -10
ICU Intensive
Care Unit
IM Intra-Muscular
IV Intravenous
LFTs Liver Function Tests
MAT Medication Assisted Treatment
MAST Michigan Alcoholism Screening Test
MAOIs Mono Amine Oxidase Inhibitors
MOH Medical
Officer of Health
MOMS Ministry of Medical Services
MT Methadone Treatment
NA Narcotics
Anonymous
NACADAA
National
Authority for the Campaign Against Alcohol and Drug
Abuse
NGO Non Governmental Organization
OD Once
Daily Dose
PMO Provincial
Medical Officer
PRN As
required medication
QID
Six Hourly Doses
SSRIs Selective Serotonin Re- uptake Inhibitors
STIs Sexually Transmitted Infections
TDS Eight
Hourly Dose
THC Tetra
Hydro Cannabinol
TIP Treatment Improved Protocol
U.S. United
States
UNODC United
Nations Office on Drugs and Crime
W.H.O World
Health Organization
Guidelines for Substance Use
Disorders Treatment
Introduction
These Guidelines are not intended to be a
comprehensive textbook or manual for the treatment of drug use. Doctors and
other professionals should access more detailed information and specialist
advice about interventions described in the Guidelines. These guidelines are intended for
all clinicians and NGOs, especially those providing pharmacological and
psychological interventions for drug users as a component of substance use
disorders treatment
Several
studies have highlighted the serious nature of substance use in Kenya, ranging
from alcohol and tobacco to cannabis, khat, heroin and others. UNODC World Drug
Report 2011 indicates an annual prevalence use of 2.1% for cannabis, 0.73% for
opiates and 0.3% of cocaine. Injecting drug use of heroin has been documented
in the country, contributing to 3.8 to 6% of new HIV infections.
For the
purpose of these Guidelines, treatment is divided into assessment, management
of dependence, and relapse prevention.These guidelines will be a guide
for the treatment of substance use disorders for services under the Ministry of
Health. Drug users with coexisting mental and physical disorders should be
treated in a holistic and systematic way to address their physical,
psychological, social, and spiritual needs of addiction, not only for themselves,
but also for their family and significant others.
Appropriate medical detoxification will adequately manage the
acute physical symptoms of withdrawal associated with stopping drug use. This
is not sufficient to help drug users to achieve effective recovery, but is a
strongly indicated precursor to effective drug dependence treatment. The ideal
detoxification method should be relatively short, affordable, and painless and
should leave the patient with a desire to seek longer-term help. Whatever
method is chosen, appropriate psychosocial interventions and education must be
available to prepare the patient for the next stage.
Therapy for substance use disorders may include didactic and
experiential learning, group, family and individual counseling and participation
in the twelve-step groups such as Alcoholic Anonymous (AA) and/or Narcotic
Anonymous (NA) or any other self-help groups. Treatment should be individually
tailored to meet the specific needs of drug users and family members.
Treatment Settings
Globally, the
effectiveness of well-delivered, evidence-informed drug dependence treatment is
well established. The international evidence consistently show that drug dependence treatment – covering different
types of drug problems, using different treatment interventions, and in
different treatment settings – impacts
positively on levels of drug use, offending, overdose risk and the spread of
blood-borne viruses. Services are provided in different settings:
Outreach
services
Out-patient
treatment services
1. Outreach services
Outreach services aim to provide information and harm reduction
interventions to those that are not in touch with drug treatment services.
Outreach workers visit community settings and work at the drug using sites.
This means that outreach workers may have to come from the very same drug using
community but not necessarily so. Some may be in recovery or are concerned
members of the community. For an effective recruitment therefore, members of
the outreach groups should be respected and knowledgeable members within drug
using community to have a good impact.
Members of the outreach groups play an important role in
educating drug users on the consequences of their habit and the spread of HIV.
An individual’s lifetime experience may be a source of knowledge but care
should be taken as this is not enough to turn that person to a health worker.
Some of the functions of the outreach groups include the following:
·
Helping drug dependent individuals to get out of
the shadows and to seek treatment for their drug problem and to learn to
protect themselves against HIV.
·
Helping drug users to improve their self esteem
by participating in a drug prevention or harm reduction programme and acquiring
a sense of responsibility.
·
Decreasing stigma associated with drug use
especially in women who hide their addiction.
·
Engaging in community education to change the
public perception of drug users, and reducing the stigma attached to them and
thereby reducing their social exclusion and criminal activities.
·
Improving access to in-patients care prior to
discharge for appropriate follow up and after care.
Outpatient services are offered to those who don’t require
close supervision for the treatment of their substance use disorders. This is
reserved for those identified to be well motivated and whose guardians,
relatives and friends are keen to support them. A stable and supportive social
and family environment that recognizes the existence of the problem, and have a
strong desire to help is crucial. Education on the patient’s problems and on
the nature of addiction as a disease is important to both parties. Treatment
may involve medical detoxification and various counseling modalities and after
care. There are two types of outpatient treatment; (i) low threshold and (ii)
intensive outpatient treatment, as described below.
2.1 Low threshold outpatient treatment
This involves less contact hours (2 to 3 days a week) with the
patient. It is recommended for patients who do not have intense treatment needs
and are probably employed or in school/college or stable enough to manage in
the community
2.2 Intensive Outpatient Treatment
This describes a moderate to intensive level of care. Compared
to low threshold outpatient treatment, intensive out-patient treatment offers
more structure and more hours (3 to 5 days a week) in areas like;
·
Relapse prevention
·
Stress management
·
Relationships
·
Assertiveness
·
Nutrition
·
Emotional well being
This level of care allows greater access to family, group and
individual therapy, therapeutic exercises and drug-free recreational
activities. It increases bonding among peers in treatment.
3. Residential/inpatient
treatment
Residential treatment is indicated for patients with history of
alcohol withdrawal hallucinations, seizures or delirium. Those with very heavy
heroin/opiate use, with high tolerance, conferring substantial risk of a severe
withdrawal syndrome, a residential program are recommended. Patients with
severe general medical or psychiatric disorder, pregnant women, those who do
not have a reliable social support and clients with a significant risk of
committing suicide and the poorly motivated are also considered for residential
treatment. Treatment involves the modalities listed as in out-patient/intensive
out-patient treatment together with any other underlying condition.
4. CRITERIA FOR THE DIFFERENT LEVELS OF
CARE
Phases and components of
Treatment
This
spells out the structured way, a client is likely to engage in from the time of
entry to the programme until he/she exits.
The phases of drug dependence treatment include patient’s
rights, evaluation and assessment, treatment planning, medical and psychiatric
management, psychosocial rehabilitation, and continuing of care.
1.
Patients’
rights
Formalized in 1948, the Universal Declaration of Human Rights
recognizes “the inherent dignity” and the “equal and unalienable rights of all
members of the human family”. And it is on the basis of this concept of the
person, and the fundamental dignity and equality of all human beings, that the
notion of patient’s rights was developed. The right to health is a fundamental part of our human rights and right
to live in dignity. This includes the
right to the enjoyment of the highest attainable standard of physical and
mental health as
enshrined in the Kenyan Constitution. Therefore,
·
Health
services, goods and facilities must be provided to all without any
discrimination.
·
All
services, goods and facilities must be available, accessible, acceptable and of
good quality
·
The
right to health contains freedoms.
·
The
right to health contains entitlements.
The risks, side effects, and potential benefits of drug
dependence treatment and the various steps and activities involved in the
treatment process shall be explained to the patient. Patients shall be given a
written consent to sign before any treatment is begun. Consent forms
should be available in both English and Kiswahili.
Whenever a patient who is illiterate is admitted, all required
written materials shall be explained to the patient and a notation shall be
placed in the file explaining exactly how the required information was given to
the patient, when, and by whom. Each patient of an outpatient/drop-in facility
has the right to:
1. Request permission to see his/her treatment plan and
have all questions answered regarding the confidentiality of that treatment
plan; and
2. Insist on his/her prior written consent before release
of any information, unless otherwise authorized by law.
Medical or surgical procedures require written consent unless
the patient is incapable of caring for him/herself. In the latter case,
consent may be provided by the patient’s guardian or next of kin. No patient
may be placed involuntarily in seclusion or mechanical restraint unless
necessary because of imminent physical danger to self/others and a medical
practitioner so orders.
The risks, side effects, and potential benefit of different
forms of treatment are to be explained to all patients. Staffs are
obliged to tell the patient the various steps and activities involved in each
treatment option.
Upon admission, each patient is to be given a copy of the
treatment program’s rules and regulations; these are to be explained to the
patient. Patients should sign a statement indicating that he/she
understands the rules; that statement should be kept with his/her record.
Patients should be promptly appraised of any changes in the program rules.
If any patient violates program rules or regulations, the
patient may be discharged, upon risk assessment to self and/or others. Upon
discharge, the patient should receive a written statement explaining why he/she
is being discharged. If the person has been involuntarily discharged, he/she
may request that the decision to discharge be reviewed.
2. Evaluation
The assessment
will include a drug history, physical examination by the doctor and sufficient
information to determine dependence. At assessment clients must be made aware
of the different treatment options available. A full assessment should be
carried out by a qualified health worker before any decision to prescribe is
taken in case pharmacological intervention is indicated. This will include making a diagnosis,
assessments with various assessment tools and treatment planning
There are two
internationally accepted diagnostic criteria that cover drug dependence: the
tenth revision of the International Classification of Diseases (ICD 10)
published by the World Health Organisation (WHO) in 1992, and the fourth edition of the Diagnostic Manual of Mental
Disorders (DSM-IV) published by the American Psychiatric Association in
1994.
The ICD 10
defines Dependency syndrome as: “A cluster of physiological, behavioural, and
cognitive phenomena in which the use of a substance or a class of substances
takes on a much higher priority for a given individual than other behaviours
that once had a greater value”. (WHO Expert Committee on Drug Dependence, 1998).
The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) defines Dependency Syndrome as “a maladaptive pattern
of substance use leading to clinically significant impairment or distress as
manifested by three (or more) of the following, occurring at any time in the
same 12-month period”: (See table below)
1.2 Assessment.
2.2.1 Introduction
A good assessment is essential to the continuing care of the patient. Not
only can it enable the patient to become engaged in treatment but it can begin
a process of change even before a full assessment is complete. Assessment
skills are vital for all members of the multidisciplinary team, including drugs
workers, psychologists, nurses and doctors.
This entails
clerkship, physical examination and a diagnosis made by a psychiatrist, a physician,
a clinical officer, a nurse and/or a trained counselor. Effective interviewing
techniques by clinicians and covering key areas are important in that, patients
are assisted in confronting their addiction and getting their views on behavior
change. Basic requirements like blood pressure machines, stethoscopes,
thermometers etc are important. A good and reliable laboratory service to
screen for HIV, LFTs, hepatitis, sexually transmitted infections, urine tests,
blood alcohol levels, gamma glutamyl transpeptidase, etc is absolutely
essential.
A comprehensive assessment should
include:
·
Screening for drug dependence.
·
Identification of treatment needs: done through
a series of multidisciplinary assessments (Fig.1). The more intensive the
required intervention, the wider the variety and intensity of assessments.
·
Intake evaluation: documents the patient’s
medical condition and medical history and includes an analysis of the patient’s
current neurological and psychological status. The intake evaluation is often
the basis for a decision to admit the patient or to make a referral to a more
appropriate emergency or psychiatric programme. A standardized intake format
will be used.
- Figure 1: Multidisciplinary Assessment
A Management Plan will carefully involve identifying
environmental and social support systems i.e. DSM IV-TR Axis IV factors and
their influence on the road to recovery from one’s drug dependence. Patient
management will be provided either as:
1. Outpatient drug dependence treatment
2. Intensive outpatient drug dependence treatment
3. Residential /inpatient drug dependence treatment.
A standardized intake format will be adopted in assessing
patients in all levels of care. A signed informed consent and treatment
contract on the risks of treatment are important in all levels of care.
This helps to determine whether patients have a current or
imminent medical problem that needs attention. These include related problems
such as withdrawal, anemia, HIV and AIDS hepatitis
or medical conditions unrelated to the addiction (perhaps ignored for many
years), abscesses,
malnutrition, substance induced psychoses, etc.
Physical
examination:
·
Check
for; needle track marks, skin abscesses, and signs of withdrawal or
intoxication.
·
Determine
the presence of any complications of drug use such as viral hepatitis,
bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein
thrombosis, pulmonary emboli, abscesses and dental decay.
·
Nurses assess patient’s response to drug cessation,
response to medication, skills of planning care, identifying solutions, setting
goals, formulating goals, producing the care plan and care management.
Interaction with
other patients and staff is also covered.
2.2.2 Psychiatric Assessment
Psychiatrists and psychologists may conduct various
psychological tests during the initial assessment phase of treatment. Some
tests are used to confirm and assess the presence of severity of substance use
disorders. These are generally questions and answers, self report tests and/or
structured interviews.
Important to
note that;
Psychiatric
problems sometimes co-exist with drug and alcohol use, in particular there is
increased risk of suicide and self-harm. Drug use often has a psychoactive
component, hence can cause hallucinations, depression or anxiety, either during
use or as part of withdrawal.
The psychiatric examination should address the following but
not limited to:
·
General
behaviour: e.g. restlessness, anxiety, irritability which can be caused by
either intoxication with stimulants or hallucinogens or by withdrawal from
opiates.
·
Mood:
depressed Mood can be caused by withdrawal from stimulants (‘crash’ of cocaine
or amphetamine withdrawal) or by alcohol or sedative drugs. Assess the risk of
self-harm.
·
Delusions
and hallucinations: common with stimulant and hallucinogens use.
·
Cognitive
states
Some patients may have significant nutritional deficits that
may need to be corrected shortly after assessment before proper treatment is
commenced. The following should be checked:
·
Malnutrition
·
Vitamin deficiency
·
Anaemia ,especially megaloblastic anaemia in
alcoholics
·
Micronutrient deficiency
Various social and emotional problems
may have played a role in people’s initial drug use, as well as in their
continued drug use. Identification of these issues can be important for relapse
prevention. Again, people differ with regard to social and emotional strengths
and weaknesses. Treatment Plans should address poor skills and encourage the
use of existing positive skills for personal growth.
Individuals with multiple social problems need
to be linked into the appropriate local support networks.
This may be done through interview with other family members to
obtain a clearer understanding of the individual’s family dynamics such as:
·
Effect of addiction on the functioning of the
family
·
Effects of family structure on the individual’s
addiction.
·
Family readiness and support for treatment
·
Family understanding of the problem
·
Signs and symptoms of co-dependence
Assessment is required on the following areas:
·
Occupational performance on his/her profession
or employment
·
Mental ability to follow instructions in
occupational functioning
·
The acceptance to lead a productive and useful
life
·
Individuals ability to perform tasks in their
daily living and work
·
Prevocational exploration and training on
different skills.
·
Achievement of independent, productive and
satisfying life.
2.2.7 Nursing Assessment:
The complex needs of drug users and a
combination of different factors has led to the development of effective
collaboration between professional groups such as medical doctors,
psychiatrists, pharmacists, nurses, psychologists and NGOs.
The aims of the nursing assessment are to;
·
determine
type of drugs used, drug-using history;
·
assess
problems associated with drug use;
·
assess
risk;
·
identify
medical, mental, social and environmental needs;
·
determine
client's motivation;
·
explore
client's treatment requests and expectations;
·
Inform
and explain the treatment options available to clients, and determine those
most suited to their needs.
2.2.8 Recreational, Stress, and Leisure Assessment
There is need to determine an individual’s:
·
Level of stress
·
Level of social skills
·
Ability to trust others
·
Healthy interests
·
Ability to co-operate with others
·
General level of physical activity and exercise
·
Previous drug-free experiences of having healthy
fun
Legal problems can
become a potent area of stress and anxiety, and they can be identified as
subjects for discussion in a therapeutic setting.
Some people have legal problems hence assess for any charge on;
·
illegal selling of drugs
·
Using prescription drugs, not prescribed for a
particular condition.
·
Stealing items or embezzles money to support
their addiction.
·
not paying taxes
·
Alimony.
·
Assault
These tools are used to collect data on key behaviours
including drug use, HIV risk behavior, criminal activity, physical and
psychological health and social functioning. Some of the tools that can be used
in treatment settings: include :( must
be availed in the treatment centers)
·
The Addiction Severity Index (ASI): Semi-structured interview designed to
address seven potential problem areas in substance use patients: medical
status, employment and support, drug use, alcohol use, legal status,
family/social status, and psychiatric status.
·
The Addiction Severity Index – LITE
(ASI-LITE): shortened version of the ASI
·
ASSIST: the Alcohol, Smoking and Substance Involvement
Screening Test is a brief screening questionnaire developed by WHO and an
international team as a simple method of screening for hazardous, harmful and
dependent use of alcohol, tobacco and other psychoactive substances.
·
The CAGE Test: Screening test for alcohol dependence.
·
AUDIT: Alcohol Use disorders Identification Test.
1.4 Treatment Planning
It is mandatory to plan each treatment carefully and clearly. In planning treatment systems, resources
should be distributed in a way that delivers effective treatment to as many
people as possible. Quality of treatment should be consistent regardless of how
patients enter treatment. Assessments inform about an individual’s
treatment needs as well as the strengths and resources that can be used to meet
those treatment needs.
The treatment plan,
developed with the patient, establishes goals based on the patient’s identified
needs and sets interventions to meet those goals. A care or treatment plan is a
written description of the treatment to be provided and its anticipated course.
Care plans set the specific needs of the individual patient and how they are
going to be met by the service. The plan is then monitored and revised
periodically as required to respond to the patient’s changing situation. While
current research results do not support matching patient profiles to specific
treatment approaches, there is evidence that matching responses and
interventions to client needs following a serious diagnostic process and
extensive assessment improves the treatment outcomes.
After taking a full
history and completing an assessment, a care or treatment plan should be agreed
with the patient. It should normally cover patient needs (and how these will be
met) in one or more of the following domains:
·
Drug and alcohol use: Drug use,
including types of drugs, quantity and frequency of use, pattern of use, route
of administration, symptoms of dependence, source of drug (including
preparation), and including prescribed medication and tobacco use. Alcohol use,
including quantity and frequency of use, pattern of use, whether in excess of
safe levels and alcohol dependence symptoms.
·
Physical and psychological health:
Physical problems, including complications of drugs and alcohol use,
blood-borne infections and risk behaviours, liver disease, abscesses, overdose,
enduring severe physical disabilities and sexual health. Pregnancy may need to
be assessed.
·
Psychological problems, including
personality problems or disorders, self-harm, history of abuse or trauma,
depression and anxiety and severe psychiatric co-morbidity. Contact with mental
health services will need to be recorded.
·
Criminal involvement and offending: Legal issues including arrests, fines,
outstanding charges and warrants, probation, imprisonment, violent offences and
criminal activity, and involvement with workers in the criminal justice system,
for example probation workers.
·
Social functioning: Social issues,
including partners, domestic violence, family, housing, education, employment,
benefits and financial problems.
·
Childcare issues, including parenting,
pregnancy, child protection. It is seldom the case that a clinician will be
able to meet all of a patient’s needs if the patient has a serious drug misuse
problem or unmet needs in a range of domains. A patient may need prescribing
interventions plus psychosocial interventions, help with housing or benefits
etc. This often requires clinicians to have input from or facilitate referral
to a range of other professionals.
The assessment of young
people will require additional components, such as comprehensive educational
needs and development needs.
Clinicians will need to
be able to track progress with patients around their range of needs and record
progress in the care plan. There may be several clinicians involved in the
patient’s treatment – these should be named in the care plan along with a clear
identified lead clinician.
Evidence-based good practice and accumulated scientific
knowledge on the nature of drug dependence should guide interventions and
investments in drug dependence treatment. The high quality of standards
required for approval of pharmacological or psychosocial interventions in all
the other medical disciplines should be applied to the field of drug
dependence.
There are mainly two complementary types interventions in drug
treatment namely:
·
Pharmacological intervention
·
Psychosocial intervention.
A multidisciplinary approach is a must to give effective drug
treatment. Drug users often
present for drug treatment with a myriad of health and social problems. Treatment
for drug use should always involve a psychosocial component. Psychosocial
interventions encompass a wide range of actions from ‘talking therapies’, such
as cognitive behavioural or family therapy, to supportive work such as help
with benefits
Psychosocially
assisted pharmacological treatment refers to the combination of specific
pharmacological and psychosocial measures used to reduce both illicit opioids
use and harms related to drug use and improve quality of life.
Pharmacological treatment is done at two levels, that is, for
detoxification and as medication assisted treatment (MAT). Medical
detoxification is the use of medications in the treatment of withdrawal
syndrome mostly in severe dependence.
Detoxification can be done both at in-patient or out-patient
levels, depending on severity of the condition and type of drugs used. Medical
detoxification is indicated in cases with severe withdrawal symptoms.
Detoxification is generally viewed as particularly appropriate for patients who
present with acute medical and psychiatric problems, in particular those with a
history of seizure and depression, and also those who have concurrent acute
alcohol dependence. Each case should therefore be handled on the basis of a
careful assessment of the above factors. Stabilization of acute withdrawal
problems is typically completed within 3-5 days, but this may need to be
extended for patients with co-morbid conditions as mentioned above.
The detoxification regimen offered in this protocol is a
general guideline and may need to be customized according to the individual
patient’s needs. During detoxification various psychosocial interventions and
education must be initiated.
Alcohol (ethanol) is a CNS depressant. It exerts its
effects by several mechanisms and binds directly to γ-amino butyric acid (GABA)
receptors in the CNS, causing sedation and also directly affecting cardiac,
hepatic, and thyroid tissues .Large amounts consumed rapidly or chronically can
cause respiratory depression, coma, and death. Alcohol withdrawal manifests as
a continuum, ranging from tremors to seizures, hallucinations, and
life-threatening autonomic instability in severe withdrawal (delirium tremens).
Detoxification from alcohol is mainly done as
an inpatient procedure and regular monitoring of vital signs is absolutely
essential. Symptoms of alcohol effects on a person are proportionate to the
BAC. Levels required to produce given symptoms vary with tolerance, but in
typical users:
•
20 to 50 mg/dL: Tranquility, mild
sedation, and some decrease in fine motor coordination
•
50 to 100 mg/dL: Impaired judgment and a
further decrease in coordination
•
100 to 150 mg/dL: Unsteady gait,
nystagmus, slurred speech, loss of behavioral inhibitions, and memory
impairment
- 150 to 300
mg/dL: Delirium and lethargy.
A mild withdrawal syndrome includes tremor,
weakness, headache, sweating, hyperreflexia, and GI symptoms. Symptoms usually
begin within 6 hours of cessation. Some patients have generalized tonic-clonic
seizures (called alcoholic epilepsy, or rum fits) but usually not more than two
seizures in short succession.
Hallucinations without other impairment of
consciousness follow abrupt cessation from prolonged, excessive alcohol use,
usually within 12 to 24 hours. Hallucinations are typically visual but may also
include auditory illusions with vivid and frightening dreams. The syndrome may
resemble schizophrenia and other pathologic reactions associated with
withdrawal.
Benzodiazepines are the mainstay of therapy.
Diazepam, Lorazepam, Alprazolam and chlordiazepoxide have been used for the
management of acute alcohol withdrawal symptoms. Diazepam is given 5 to 10 mg IV or PO hourly
until sedation occurs. Lorazepam 1 to 2 mg IV or PO is an alternative.
Chlordiazepoxide 50 to 100 mg PO 4 to 6 hourly, then tapered off is an older acceptable alternative for less
severe cases of withdrawal. Chlordiazepoxide dosages of upto 250mg daily may be
prescribed in alcohol detoxification. More typically, doses of 120mg to 160mg
of chlordiazepoxide daily are prescribed as starting doses in this context.
Starting doses of less than 80mg chlordiazepoxide daily may lead to unnecessary
risk of development of damaging or fatal alcohol withdrawal symptoms.
Typically, chlordiazepoxide is reduced in dosage at a rate of 10-20mg daily
through the alcohol detoxification process.
Phenobarbitone (a barbiturate) may help if
benzodiazepines are ineffective, but respiratory depression is a risk with
concomitant use. Phenothiazines and haloperidol are not recommended initially
because they may lower the seizure threshold. For patients with a significant
liver disorder, a short-acting benzodiazepine (Lorazepam) or one metabolized by
glucuronidation (oxazepam) is preferred. (Note: Benzodiazepines may cause
intoxication, physical dependence, and withdrawal in alcoholics and therefore
should not be continued after the detoxification period). Carbamazepine 200 mg
po qid may be used as an alternative and then tapered. Carbamazepine is
an anticonvulsant and mood
stabilizing drug used in clinical practice in the management of
alcohol-related withdrawal symptoms. Common adverse effects include
drowsiness, headaches and migraines, motor coordination impairment
and upset stomach. For severe hyperadrenergic activity or to reduce
benzodiazepine requirements, short-term therapy (12 to 48 h) with titrated
β-blockers (e.g., metoprolol 25 to 50 mg PO or 5 mg IV given 4 to 6 h) and clonidine 0.1 to 0.2 mg
given 2 to 4 h can be used.
Chlormethiazole
is a sedative and hypnotic that is widely used in treating
and preventing symptoms of acute alcohol withdrawal. It is a drug which is
structurally related to thiamine (vitamin B1) but acts
like a sedative, hypnotic, muscle relaxant and anticonvulsant.
Chlormethiazole is extremely useful and flexible drug for use in the management
of acute alcohol withdrawal. It is not a treatment for alcohol abuse and should
not be used other than in the withdrawal period, and then for less than 10
days. Chlormethiazole is particularly toxic and dangerous in overdose.
Haloperidol
is an older antipsychotic used in the treatment of schizophrenia and,
more acutely, in the treatment of acute psychotic states
and delirium. In detoxification, it is used in the management of delirium
tremens. Administration is as single doses of 1 mg to 5 mg (up
to 10 mg) oral or i.m., usually repeated every 4 to 8 hours. Do not exceed
an oral dose of 100 mg daily
A seizure, if brief and isolated, needs no specific
therapy. However, some clinicians routinely give a single dose of Lorazepam 1
to 2 mg IV as prophylaxis against another seizure. Repeated or longer-lasting
(i.e., > 2 to 3 min) seizures should be treated and often respond to
Lorazepam 1 to 3 mg IV. Routine use of phenytoin is unnecessary and unlikely to
be effective. Outpatient therapy with phenytoin is rarely indicated for
patients with simple alcohol withdrawal seizures when no other source of
seizure activity has been identified because seizures occur only under the
stress of alcohol withdrawal, and patients who are withdrawing or heavily
drinking may not take the anticonvulsant.
Delirium Tremens (DT) may be fatal and thus must be treated
promptly with high-dose IV benzodiazepines, preferably in an ICU. Dosing is
higher and more frequent than in mild withdrawal. Diazepam 5 to 10 mg IV or
Lorazepam 1 to 2 mg q 10 min is given as needed to control delirium; some
patients require several hundred mg over the first few hours. Severe drug-resistant DT can be treated with
a continuous infusion of Lorazepam, diazepam or midazolam usually with
concomitant mechanical ventilation. Physical restraints should be avoided if
possible to minimize additional agitation, but patients must not be allowed to
elope, remove IVs, or otherwise endanger themselves. Intravascular volume must
be maintained with IV fluids, and large doses of vitamins B and C, particularly
thiamine, must be given promptly.
(ii). Nicotine
Tobacco,
“kuber” and ‘snuff” contain nicotine. A smoking cessation program should be
encouraged during the early phases of a drug dependency treatment. One approach
is to help patients quit smoking while being maintained on nicotine via a
transdermal patch or nicotine gum.
Nicotine
is a highly addictive drug. Smoking is not only a physical addiction, but also
becomes linked with many social activities and coping needs, making it a
difficult habit to break. When someone addicted to nicotine stops smoking they
may experience withdrawal symptoms such as increased anger, hostility, and
anxiety. Nicotine replacement therapies combined with behavior change programs
providing psychological support and skills training result in the highest long-term
abstinence rates. Generally, rates of relapse for smoking cessation are highest
in the first few weeks and months and lessen considerably after about three
months.
Nicotine Addiction Medications
Nicotine replacement products provide nicotine without smoking. This
helps to lessen the body's craving for nicotine and to reduce withdrawal
symptoms. Replacement products come in several forms: gum, patch, nasal spray,
inhaler and lozenge. Nicotine gum, patch and lozenges can be bought
over-the-counter. The nasal spray and inhaler (brand name Nicotrol) require a
doctor's prescription.
Bupropion (brand names Zyban® or
Wellbutrin)
is an antidepressant drug that can be used to help some people stop smoking. It
is taken as a pill and requires a doctor's prescription. Although it does not
contain nicotine, it can help people resist the urge to smoke. Bupropion is
often used for 7-12 weeks, beginning 1 or 2 weeks before smoking is stopped. It
can be used for smoking cessation maintenance for up to six months. Side effects
may include insomnia and dry mouth.
Varenicline (Chantix) - is the first treatment that
specifically targets the neurobiological mechanism of nicotine dependence.
Studies show that the drug successfully stimulates dopamine (the brain's
pleasure chemical) and blocks nicotine receptors. This reduces nicotine
withdrawal symptoms and cravings, helping to prevent a full relapse. The drug
also blocks the effects of nicotine if you begin to smoke again.
Chantix is a prescription medication
sold in tablet form. It is generally prescribed for 12 weeks. If you quit
smoking during that time, your doctor may prescribe Chantix for another 12
weeks to enhance long-term success. Side effects may include nausea, vomiting,
gas, headache and insomnia.
(iii). Khat
Khat
is a natural stimulant from the Catha Edulis plant, found in the flowering
evergreen tree or large shrub which grows in East Africa and Southern Arabia.
It reaches heights from 10 feet to 20 feet and its scrawny leaves resemble
withered basil.
Khat
leaves contain psychoactive ingredients known as cathinone, which is
structurally and chemically similar to d-amphetamine, and cathine, a milder
form of cathinone. Fresh khat leaves, when chewed over several hours, produce a
mild cocaine- or amphetamine-like euphoria and generate intense thirst.
Khat is a sympathomimetic and its
pharmacological effects are believed to parallel those of amphetamine.
Psychiatric manifestations induced by khat are similar to the effects of other
known stimulants. Some authors described a recent, successful attempt to treat
2 cases of Khat dependency using protocols similar to those developed for
cocaine. Both patients presented for treatment with psychiatric manifestations
and were screened for stimulant and depressant drug addiction since substances
other than khat were involved in each case. Specific procedures for treatment
entailed an inpatient detoxification phase of 1-2 weeks followed by long-term
attendance at outpatient recovery programmes. Khat is also known as khat, muguka,
chat, Miraa, Catha, Quat, and Abyssinian Tea.
(iv). Cannabis
Cannabis
(also known as marijuana, grass, skunk, weed, hash and ganja) is usually sold
as either a dark brown lump of resin, or as bags of dried herbs, flower heads
and seeds. Its active principle is tetra-hydro-cannabinol (THC).
Heavy users tend to
smoke cannabis more frequently after building up a tolerance to the drug.
Regular use of cannabis results in a range of long-term effects and risks,
which includes social withdrawal and
lack of motivation (Amotivational Syndrome), breathing problems such as asthma,
high blood pressure and heart problems, short-term memory loss, paranoia and
anxiety, lung cancer, infertility, loss of coordination and concentration
problems, psychosis and depression. Cannabis induced psychoses should be
managed with appropriate neuroleptics e.g. Haloperidol.
The management of Opioids abuse and
dependence should be holistic and long term. The client should be assessed to
identify their varying needs and strengths by a multidisciplinary team which
maps out an agreed working plan with the client and their family or guardian if
they are available. The management involves both psychosocial and
pharmacological (medication) interventions done in residential or non
residential treatment settings. The withdrawal signs and symptoms are often
pronounced and dramatic, 'cold turkey,’ and begin 8 to12
hours after last dose and lasts 5 to 7 days. The treatment interventions include;
·
Replacement/substitution
therapy using oral Opioids e.g. methadone, partial Opioids agonist e.g.
buprenorphine.
·
Symptomatic
treatment (non-Opioids treatment regime) e.g. clonidine e.t.c
·
Treatment
of co-morbid physical illnesses
Other interventions to prevent transmission
of HIV, Hepatitis B, C and other infections are needle exchange programs.
Symptomatic (non
Opioids treatment regime)
|
Opioids withdrawal signs and symptoms
|
Treatment
|
Dosages
|
||
|
·
Restlessness, irritability, low moods.
·
Running nose, tearing a lot.
·
Nausea, yawning, vomiting, abdominal cramps and diarrhea.
·
Body temperature dysregulations i.e. fever or chills.
·
Skin goose pimples and sweating.
·
Muscle aches and cramps.
·
Lack of sleep and craving for the drug.
·
Fast heart beats increased blood pressure and wide open (dilated) eye
pupils.
|
Clonidine (tapered dosage)
NB; Blood pressure
monitoring is mandatory
|
Tapered
dosage:
300μg qid×3days
150μg tds×3days
75μg
bd×3days
|
||
|
Benzodiazepines
|
Diazepam
10mgs qid×3days
10mgs tds x 3days
10mgs bd x 3days
10mgs od x 3days
|
|||
|
Anti-emetics when presence
of vomiting
|
Metoclopromide
10mgs PRN
|
|||
|
Analgesics/Antipyretics
for pain management
|
Non steroidal
anti-inflammatory; Paracetamol PRN
|
|||
|
Antispasmodics for colic
pain (cramps)
|
Hyoscine butylbromide 10 mg PRN
|
|||
|
Beta blockers for
tachycardia & palpitations
|
Propanolol 40 mg PRN
|
|||
|
Muscle relaxants
|
Baclofen PRN
|
|||
|
Intravenous fluids
|
Correct water, electrolytes and acid disturbances PRN
|
|||
|
Others
|
Co-morbid psychiatric and physical disorder are
managed accordingly
TCA e.g. Imipramine, SSRI e.g. Fluoxetine and
Trazodone
|
|||
|
|
|
Medication
Assisted Treatment (MAT)
(a)Methadone
A large body of scientific
evidence suggests that methadone treatment, when delivered to an appropriate
standard of care, is a safe substitution
medication for opioids dependence. Methadone has proved to be an effective
means in retaining people in treatment and hence, averts heroin use when in
treatment. Methadone reduces the risk of HIV infection, and improves both
physical and mental health as well as the quality of life of the patients and
their families. Methadone also reduces criminal activities. Methadone treatment
has also proved to be cost effective. Moreover, methadone treatment reduced
demands upon the criminal justice system.
Methadone is mostly orally administered once
daily for therapeutic purposes of preventing or substantially reducing the
consumption of illicit opioids such as heroin. Its primary function is to
improve the health status and psychological well-being of the opioids-dependent
persons. Methadone Treatment (MT) is now a well-established treatment modality
across a variety of treatment settings and supported by both research evidence
and clinical practice.
The aim of methadone maintenance treatment is
to improve the quality of life of opioids-dependent patients and to reduce the
potential harm of using illicit drugs. MT greatly reduces mortality, illicit
drug use and criminal activity, and attracts and retains more patients in
treatment than other treatments. There is good evidence that MT reduces transmission
of HIV, although the evidence for effectiveness at reducing transmission of
hepatitis B virus and hepatitis C virus is less convincing.
Clinical Pharmacology
Methadone is a
potent synthetic opioids agonist which is well absorbed orally and has a long,
although variable plasma half life. The effects of methadone are qualitatively
similar to morphine and other opioids.
Most people
who have used heroin will experience few side effects from methadone. Once on a
stable dose, tolerance develops until cognitive skills and attention are not
impaired. Symptoms of constipation, sexual dysfunction and occasionally
increased sweating can continue to be troubling for the duration of MT.
Figure
1: Methadone: Actions and Side
Effects
Pharmacokinetics
There is wide individual
variability in the pharmacokinetics of methadone but in general, blood levels
rise for about 3-4 hours following ingestion of oral methadone and then begin
to fall. Onset of effects occurs approximately 30 minutes after ingestion. The
apparent half life of a single first dose is 12 – 18 hours with a mean of 15
hours. With ongoing dosing, the half life of methadone is extended to between
13 and 47 hours with a mean of 24 hours. This prolonged half life contributes to
the fact that methadone blood levels continue to rise during the first week of
daily dosing and fall relatively slowly between doses.
Methadone reaches steady
state in the body (where drug elimination equals the rate of drug
administration) after a period equivalent to 4-5 half lives or approximately
3-10 days (Figure 6). Once stabilisation has been achieved, variations in blood
concentration levels are relatively small and good suppression of withdrawal is
achieved. For some, however, fluctuations in methadone concentrations may lead
to withdrawal in the latter part of the inter-dosing interval. If dose
increases or multiple dosing within a twenty four hour period do not prevent
this, other agonist replacement treatment approaches such as buprenorphine should
be considered.
Induction/Titration
Objectives during induction
to methadone are to retain individuals in treatment by reducing the signs and
symptoms of withdrawal and to ensure their safety. This can be achieved by
careful explanation regarding intoxicating effects and withdrawal during the
induction and maintenance phases of methadone treatment, establishment of a
therapeutic relationship, safe dosing and repeated observation of patients.
Before starting
methadone oral solution for the first time:
Figure 2: Before prescribing guidelines
Note: Starting methadone
on the first presentation is usually not possible as results, other than
on-site tests, often take days to return. Use this time to continue the
assessment, provide harm reduction advice and ask the patient to keep a drugs
diary. Supervised consumption should be used for the titration period and at
least the first three months.
If opioids dependence is confirmed and a substitute prescription of
methadone oral solution is appropriate, there are a number of different methods
of initiating methadone treatment.
The ideal is as follows:
After
stabilisation, the patient should feel comfortable throughout 24 hours with no
subjective or objective withdrawal before doses and no sedation or euphoria
after doses. Stabilisation involves finding a suitable dose that keeps the
patient engaged in treatment without the need to supplement with heroin and
other drugs. The aim is to enable the patient to put their dependence into the
background while tackling any associated health or social goals. Attempts to
keep the dose minimal, leaving the patient with daily morning craving or
disturbed sleep due to falling serum levels, are counter-productive.
Optimal
outcomes with methadone maintenance occur:
1.1. When the
dose is right, usually between 60 to 120 mg.
1.2. Stable
relationship with a key individual, e.g. Dr or drug worker, practitioner, etc.
1.3. When a
range of non-pharmacological interventions, such as counselling and lifestyle
support, are also available.
1.4.
Together these enhance the
likelihood of positive outcomes from methadone maintenance treatment.
Drug Interactions with Methadone
Oral
methadone is generally very well tolerated with minimal drug interactions but
interactions are becoming increasingly important as new drugs are developed and
more complicated regimens are used to treat chronic diseases. The main drug
interactions of methadone are associated with its central nervous system (CNS)
depressant activity and liver metabolism. Deaths have also been reported from
interaction of methadone which can prolong the QT interval and other drugs that
do this such as phenothiazines.
Benzodiazepines
Taking
benzodiazepines with methadone may cause additional CNS depression and result
in enhanced sedative effect. Large numbers of opioids drug users also use
benzodiazepines (between 40 to 90%). Deaths involving methadone are frequently
associated with concomitant use of benzodiazepines and/or alcohol. While it may
occasionally be advisable to prescribe benzodiazepines with methadone, caution
is recommended and thorough assessment and on-going review plans should be in
place. Benzodiazepines should usually be prescribed on a short-term, reducing
basis.
Alcohol
Alcohol
intake may alter the metabolism of methadone, increase CNS depression and
result in serious respiratory depression and hypotension. Alcohol is a high
risk factor for toxicity especially binge or high level dependent use. In late
stage alcohol misuse there may be impaired liver function and reduced methadone
metabolism, requiring reduction in methadone dose. Alcohol use should be
assessed specifically and help with withdrawal offered to those who need it.
Other
opioids
Mixing
methadone with other opioids agonists or other central nervous system
depressants can be dangerous. Caution is advised, as are thorough assessment
and review procedures.
Anti-depressants
Some
anti-depressants, including tricyclic antidepressants, should be prescribed
with caution due to possible enhanced sedation. Selective Serotonin reuptake
inhibitors (SSRIs) theoretically raise serum methadone levels but do not (except fluvoxamine) cause sedation.
Monoamine oxidase inhibitors (MAOIs) are now very rarely used and should not be
prescribed with methadone.
Cocaine
There
are few reports of a significant interaction with cocaine but cocaine does
accelerate methadone elimination. Cocaine is also associated with cardiac
rhythm disturbances and is best avoided when on methadone. Risk of accidental
overdose has recently been linked to the use of these substances concomitantly.
Cocaine
is often included in poly-drug use which increases problems.
Opioids
antagonists and partial agonists
Opioids
withdrawal syndrome is precipitated by the use of naltrexone and naloxone
and to a lesser extent buprenorphine.
HIV
medications
As
with other opioids, patients on methadone being treated with HIV combination
therapies may require dose levels to be adjusted but these adjustments are
likely to be minor and in keeping with titration principles, sufficient to
ensure patient comfort. It may be useful
to prescribe treatment in conjunction with a HIV specialist.
Enzyme
induction by some HIV medications may necessitate a higher dose of methadone
due to increased metabolism e.g. nevirapine, efavirenz, abacavir and
nelfinavir. An increase in methadone could be needed and zidovudine
concentration and side-effects are increased.
HCV
medications
HCV
medications such as pegylated interferon and ribavirin are usually well
tolerated by patients on methadone. Sometimes side-effects can mimic opioids
withdrawal symptoms and methadone dose is increased. Depression is a common
side-effect of hepatitis C combination therapy, as well as opioids dependence
so caution is required. Regular liver function tests and full blood count are
advised.
Tuberculosis
treatment: rifampicin
Rifampicin
reduces methadone levels by stimulating the hepatic enzymes involved in
methadone metabolism. Cases of severe withdrawal have been reported.
Anticonvulsants
Phenytoin
and carbamazepine cause a sharp decrease in methadone due to enzyme induction.
(b) Buprenorphine
Buprenorphine
is an effective and safe medication for use in the treatment of opioids
dependence. It is a partial opioids agonist, appears safer in overdose than
methadone and may have an easier withdrawal phase. It can be used for
maintenance or detoxification. There is a growing body of evidence that
treatment for opioids dependence can be effective. Methadone substitute prescribing is one
well-established treatment modality and is supported by a substantial body of
research literature and clinical practice5. However, methadone is not suitable
for, or popular with, all opioids users seeking treatment. The provision of a
flexible menu of effective treatment options, and some degree of choice for
those seeking treatment, is likely to optimize the outcomes and process of
treatment of opioids dependence.
Buprenorphine
is an effective, safe medication for use in the treatment of opioids dependence
and is a valuable addition to the formulary of medications for treating opioids
dependence. It is a partial opioids
agonist, appears safer in overdose than methadone and may have an easier
withdrawal phase. It can be used for maintenance or detoxification.
Clinical pharmacology.
Buprenorphine
is a semi-synthetic opioids derived from the morphine alkaloid thebaine. It is
a mixed agonist-antagonist and its primary action is as a partial opiate
agonist. An understanding of its pharmacology will help guide its clinical use.
Buprenorphine
sublingual tablets contain buprenorphine hydrochloride and are available in 400
micrograms (or 0.4 mg), 2 mg and 8 mg strengths. The tablets are administered
sublingually because it has poor oral bioavailability (inactivated by gastric
acid and a high first pass metabolism).
Induction/Titration
The
purpose of induction is to safely establish the patients quickly as possible on
a dose of buprenorphine that prevents opioids withdrawal, reduces the need to
take additional illicit opioids and keeps side effects to a minimum. It is
usual to start on a low dose and increase rapidly, over the course of a few
days, until a stabilizing dose (e.g. 16 mg) is reached. Induction can be
effected for patients using heroin or methadone. The key to understanding
buprenorphine induction is the phenomenon of precipitated withdrawal.
This
form of opiate withdrawal can occur in someone commencing buprenorphine who has
recently used heroin (less than 8 hours previously) or methadone (less than 24
hours previously). It is caused by the high affinity of buprenorphine
displacing other opioids (e.g. methadone, heroin) from opioids receptors, but
having less opioids activity (partial agonist). This rapid reduction in opiate
effects can be experienced as precipitated withdrawal, typically occurring
within 1 to 3 hours after the first buprenorphine dose, peaking in severity
over the first 3 to 6 hours, and then generally subsiding. If it occurs,
reassure the patient and carer and offer symptomatic treatment such as
lofexidine (e.g. 400 to 600 mcg 8 hourly for 1 to 2 days), as appropriate, if
withdrawal symptoms are severe. Do not prescribe more buprenorphine until the
opiate withdrawal symptoms have settled.
Figure
3: Principles of safe induction with Buprenorphine
Transition
to buprenorphine from heroin or low dose methadone (30 mg or below) can usually
be accomplished with minimal complications, although restlessness, insomnia,
headache, diarrhoea and other mild opioids withdrawal-like symptoms are not
uncommon in the first 1 to 3 days. Lofexidine may be helpful with these
unpleasant effects. It can be used for 1 to 2 days two tablets four times a day
Some patients transferring from methadone to buprenorphine find it difficult to
stabilize and feel uncomfortable on buprenorphine for 1 or 2 weeks. Steady
state in blood concentration levels is reached after about 5 to 8 days. Advice
about sleep hygiene should be given.
The
dose range of buprenorphine maintenance prescribing is 8 to 32 mg daily. The
most usual range used to achieve abstinence from heroin use is between 12 to 24
mg daily. As a partial agonist, higher doses of buprenorphine may not produce
corresponding increases in effects, so increasing the dose may not make any
difference in subjective effects (e.g. increased euphoria), but may further
reduce illicit opioids use by increasing the blockade effect.
Optimal
outcomes with buprenorphine maintenance will occur when a range of other
non-pharmacological interventions, such as counselling, support the prescribing
of buprenorphine.
Drug
interactions with buprenorphine
The
main drug interactions of buprenorphine are due to its opioids activity.
Benzodiazepines:
Many
drug users also use benzodiazepines and deaths have been known to occur as a
result of the combination of buprenorphine with benzodiazepines and / or
alcohol22. As with other opiate substitute treatments, caution is advised and
review procedures are recommended when prescribing benzodiazepines.
Alcohol,
other sedatives, anti-depressants:
Alcohol
intake may impair the metabolism of buprenorphine. Mixing buprenorphine with
alcohol or other CNS depressants can be dangerous. Caution is advised, as are
thorough assessment and review procedures. Some anti-depressants including tricyclic
antidepressants and monoamine oxidase inhibitors (MAOIs) should be prescribed
with caution due to possible sedation.
Cocaine:
No
reports of a significant interaction with cocaine. This is likely to be due to
cocaine being metabolised by different enzymes
Other full
opioids agonists (e.g. opiate analgesia):
Buprenorphine
may precipitate opioids withdrawal syndrome when given to those taking full
opioids agonists (e.g. morphine). Buprenorphine reduces the effects of other
opioids given for analgesia.
Opioids
antagonists:
Delayed
opioids withdrawal syndrome can be precipitated by the use of naltrexone.
HIV
medications:
There
is no known interaction with HIV combination therapies. As with other opioids,
patients being treated with HIV combination therapies may require buprenorphine
dose levels to be adjusted but these adjustments are likely to be minor, and in
keeping with titration principles, sufficient to
ensure patient comfort. It is advisable to offer substitute prescribing treatment in
conjunction with an HIV specialist.
Hepatitis C
(HCV) medications:
There
is good data on interferon / ribavirin and methadone showing that there are no
problems. It is likely to be similar with anti-HCV therapy and buprenorphine
but further research and experience is required.
(vi).
Cocaine and methamphetamine
Cocaine
The use of
cocaine has been rising steadily over the past decade. Cocaine is extracted
from the leaves of the coca plant, growing in the Andean mountains in South
America. The leaves are processed into cocaine hydrochloride powder. Cocaine is
a powerful stimulant whose effects wear off quickly, prompting the user to
repeat the dose. High dose users, especially of crack, are likely to need
treatment for a large range of physical and psychological problems.
Cocaine is
most commonly snorted in its hydrochloride powder form. Crack is most commonly
smoked through a pipe. This is the quickest way to get the drug to the brain.
Glass pipes, tin cans or plastic water bottles are used as conduits. Excessive
doses can cause severe medical problems and even death, from pulmonary oedema,
heart failure, myocardial infarction, cerebral haemorrhage, stroke and
hyperthermia. The after-effects of crack
use may include fatigue, depression, paranoid ideation and depersonalisation as
people ‘come down’ from the high. Chronic high-dose crack use can result in
some physical, and marked psychological dependence.
Methamphetamine
Methamphetamine
generally takes the form of clear crystallised chunks. It will dissolve in
water and breaks down to smaller particles. Methamphetamine induces a profound
sense of euphoria in the user and stimulates the release, of dopamine and
noradrenaline in the central nervous system. It is a "power drug"
whose use is typically followed by prolonged depression and fatigue. Smoking
methamphetamine will extend its effects for up to 24 hrs per ingestion. Smoked
in a base form, “meth” is known on the street as Ice.
The effects of
using methamphetamine may include: extreme elation, wakefulness, alertness,
enhanced self-confidence, aggression, talkativeness, loss of appetite,
increased initiative, increased physical activity. Withdrawal symptoms may
include: severe craving, deep depression, fatigue, inertia, paranoia, and
psychosis.
No specific pharmacological detoxification regimen is required
for cocaine, crack cocaine, or methamphetamine. Symptomatic treatment with
chlordiazepoxide 10-25mg nocte for a few days provides some amelioration of
agitation and insomnia. Benzodiazepines may also be used for short
periods.
(vii). Prescription
drugs
These include a large range of medications such as
benzodiazepines, which are widely used as sedatives/ hypnotics and anxiolytics.
They have a high potential for dependence when used without medical
supervision, on higher doses or for longer duration than prescribed. Treatment
needs to be done under strict medical supervision as the effects of withdrawal
are severe and may lead to seizures.
.Cannabis intoxication
The
acutely intoxicated patient who is anxious and agitated may be helped by verbal
support and use of benzodiazepines such
as lorazepam, 1 to 2mg.
Cannabis
intoxication may mask psychotic and panic disorders and mood symptoms in others
which must be addressed
Opioids and Opiate intoxication
The
intoxication may be inadvertent, caused by the use of an unusually potent and
pure form of heroin, or may be intentional for example the result of a suicide
attempt by overdose. To reverse acute intoxication, IM or IV naloxone, 0.4-0.8mg every 1-2 minutes until arousal
sufficient enough for airway maintenance and adequate ventilation. The dose can
repeat after 2 minutes if no enough response to a maximum of 10 mg.
The
effects of naloxone lasts for an hour hence should be repeated until the
opioids agent is cleared from the systemic circulation. The naloxone may bring
a person rapidly from coma, but one should be prepared to deal with withdrawal
in case of chronic heroin users.
Sedative Hypnotic intoxication
Flumazenil
can antagonize the intoxication caused by benzodiazepines and may be used in a dose of 0.2mg given intravenously every 15
seconds upto a dose of 1 to 2 mg.
Flumazenil
may induce acute withdrawal symptoms including seizures and hence iv lorazepam
or diazepam should be available during treatment with flumazenil. Barbiturates
are life threatening in overdose and may not respond to flumazenil therapy.
Supportive
measures such as assisted respiration and cardiovascular support may be needed
during the acute intoxication phase.
Cocaine intoxication
During
intoxication, beta blockers may decrease the autonomic arousal and limit the
risk of cardiovascular complication
Psychotic
symptoms can be controlled by low doses of sedating antipsychotic such as
quetipine 50 to 100mg or chlorpromazine in similar doses. Benzodiazepines
can also be used to treat stimulant intoxication and have a lower risk of
inducing seizures than antipsychotics.
The
post intoxication crash or acute dysphoria and depression tend to resolve in 24
to 48 hours. Rest and supportive care is indicated.
Hallucinogen intoxication
Verbal
reassurance and talking down helps. Lorazepam or other benzodiazepines may be
used. Anticholinergics or stimulants are contraindicated because they worsen
the confusion and hallucinatory phenomena
3.2 Psychosocial Interventions
This is an umbrella term that covers an array of
non-pharmacological interventions for
effective management of drug use. Psychosocial interventions enhance
pharmacological treatment efficacy by increasing medication compliance,
retention in treatment, and acquisition of skills that reinforce the effects of
medication.
This will involve the following domains:-
·
Drug use
·
Motivation and readiness to change
·
Family history
·
Vocational history
·
Treatment
history
Cognitive behavior
therapy (CBT)
·
It is a form of ‘talk therapy’ used to teach,
encourage and support individuals about how to reduce or stop their harmful
drug use.
·
It
provides skills that are valuable in assisting people in gaining initial
abstinence from drugs or in reducing their drug use
·
It provides skills to help people sustain
abstinence through relapse prevention
3.3.3 Motivational enhancement
therapy
This approach involves
using motivational interviewing strategies and interventions that are based on
a stage of change model
This approach includes behavioral contracting where clients
have opportunities to earn rewards for a specific desirable behavior.
This includes setting the resolve to stop substance use,
teaching coping skills, changing reinforcement contingencies, fostering
management of painful effects, improving interpersonal functioning and enhancing
social support.
One has to define the problem, and involves negotiating the
contact, establishing the context for a drug free life, ceasing substance
abuse, managing the crisis and stabilizing the family, and family reorganization
and recovery.
3.3.7 Crisis
Intervention Therapy
This approach
is an emergency psychological care aimed at assisting an individual return to
normal levels of functioning and to prevent or alleviate potential
psychological trauma. It is indicated for acute stress, anxiety, fear of the
unknown, abuse or life events such as death, divorce, separation, assaults,
rape, imprisonment, etc, common with drug users.
The Matrix Model
The Matrix Model is a
multi-element package of therapeutic strategies that complement each other and
combine to produce an integrated outpatient treatment experience. It is a set
of evidence-based practices delivered in a clinically coordinated manner as a
programme”.
Treatment is delivered
in a 16-week intensive outpatient program primarily in structured group
sessions targeting the skills needed in early recovery and for relapse
prevention. A primary therapist conducts both the individual and group sessions
for a particular patient and is responsible for coordinating the whole treatment
experience. There is also a 12-week family and patient education group series
and induction into an ongoing weekly social support group for continuing care.
Weekly urine testing is another program component and participants are
encouraged to attend 12-step meetings as an important supplement to intensive
treatment and a continuing source of positive emotional and social support.
The elements of the
treatment approach are a collection of group sessions (early recovery skills,
relapse prevention, family education and social support) and 3 to 10 individual
sessions delivered over a 16-week intensive treatment period. Patients are
scheduled three times per week to attend two Relapse Preventions groups (Monday
and Friday) and one Family/education group (Wednesdays). During the first four
weeks patients also attend two Early Recovery Skills groups per week (these
groups occur on the same days as the Relapse Prevention groups just prior to
them). After 12 weeks they attend a Social Support group on Wednesdays instead
of the Family/education group.
Sample Schedule
|
Monday
|
Wednesday
|
Friday
|
|
Early Recovery Skills
Weeks1-4
|
Family/education
Weeks 1-12
|
Early Recovery Skills
Weeks1-4
|
|
Relapse Prevention
Weeks 1-16
|
Social Support
Weeks 13-16
Continues past week 16
|
Relapse Prevention
Weeks 1-16
|
Program
Components
Individual
counseling. These sessions are critical to the development of
the crucial relationship between the patient and the therapist. The content of
the individual sessions is primarily concerned with setting and checking on the
progress of the patient’s individual goals. These sessions can be combined with
conjoint sessions, including significant others in the treatment planning.
Extra sessions are sometimes necessary during times of crisis to change the
treatment plan. These individual sessions are the glue that ensures the
continuity of the primary treatment dyad and, thereby, retention of the patient
in the treatment process.
Early
Recovery Skills Groups. The eight Early Recovery Skills
Groups are designed for patients in the first month of treatment or those who
need extra tutoring in how to stop using drugs and alcohol. The purpose of the
group is to teach patients: 1) how to use cognitive tools to reduce craving, 2)
the nature of classically-conditioned cravings, 3) how to schedule their time,
4) about the need to discontinue use of secondary substances and 5) to connect
patients with community support services necessary for a successful recovery.
The reduced size of the groups allows the therapist to spend more individual
time with each patient of these critical early skills and tasks. Patients who
destabilize during treatment are often encouraged to return to the Early
Recovery group until they re-stabilize.
Relapse
Prevention Groups. The Relapse Prevention groups occur at
the beginning and end of each week from the beginning of treatment through Week
16. They are the central component of the Matrix Model treatment package. They
are open groups run with a very specific format for a very specific purpose.
Most patients who have attempted recovery will agree that stopping using is not
that difficult; it is staying stopped that makes the difference. These groups
are the means by which patients are taught how to stay in sobriety.
The purpose of the
Relapse Prevention groups is to provide a setting where information about
relapse can be learned and shared. The 32 relapse prevention topics are focused
on behavior change, changing the patient’s cognitive/affective orientation, and
connecting patients with 12-step support systems. Each group is structured with
a consistent format during which: 1) Patients are introduced if there are new
members, 2) Patients give an up to the moment report on their progress in
recovery, 3) Patients read the topic of the day and relate it to their own
experience, 4) Patients share their schedules, plans, and commitment to
recovery from the end of group until the group meets again. Input and
encouragement from other group members is solicited but the group leader does
not relinquish control of the group or promote directionless cross talk about
how each member feels about what the others have said. The therapist maintains
control and keeps the groups topic centered and positive with a strong
educational element. Care is taken not to allow group members to share graphic
stories of their drug and alcohol use. Therapists specifically avoid allowing
the groups to become confrontational or extremely emotional. Whenever possible
the use of a co-leader who has at least 6 months of recovery is employed. The
co-leader serves as a peer support person who can share his or her own recovery
experiences.
Family
Education Groups. The 12-week series is presented to
patients and their families in a group setting using slide presentations,
videotapes, panels, and group discussions. The educational component includes
such program topics as: (a) the biology of addiction, describing concepts such
as neurotransmitters, brain structure and function and drug tolerance; (b)
conditioning and addiction, including concepts such as conditioned cues,
extinction, and conditioned abstinence; (c) medical effects of drugs and
alcohol on the heart, lungs, reproductive system, and brain; and (d) addiction
and the family, describing how relationships are affected during addiction and
recovery. Successfully engaging families in this component of treatment can
significantly improve the probability of retaining the primary patient in
treatment for the entire 16 weeks.
12-Step
Meetings. The optimal arrangement is to have a 12-Step
meeting on site at the treatment centre one night each week. This meeting does
not have to be an official meeting. Rather, the patients presently in treatment
and graduated members can conduct an "Introduction to 12-Step Meeting"
using the same format as an outside meeting with the purpose of orienting
patients unfamiliar to the meetings in a safe setting with people they already
know. Attending these meetings often makes going to an outside meeting for the
first time much easier and less anxiety provoking. These meetings, along with
outside 12-step meetings chosen by patients and the Social Support Group
provide strong continuing support for graduated group members.
Urine/Breath
Tests. Urine testing is done randomly on a weekly basis.
Positive urine tests revealing previously undisclosed drug use serve as points
of discussion rather than incrimination. Patients struggling with secondary
drug or alcohol use should also be tested for those substances.
Relapses
Analysis A specific exercise is used when a patient relapses
unexpectedly or repeatedly and does not seem .to understands the causes of the
relapses. The optional exercise and forms are designed to help the therapist
and the patient understand the issues and events that occurred preceding the
relapse(s) in order to help prevent future relapses. This exercise is typically
conducted during an individual session with the patient and, possibly, a
significant other.
Social
Support. Designed to help patients establish new
nondrug-related friends and activities, these groups are less structured and
topic-focused than the Relapse Prevention Groups. Patients begin the groups
during the last month in treatment at the end of the family education series,
in order to ensure that they feel connected before they graduate from the
Relapse Prevention Groups. The content of the groups is determined by the needs
of those members attending. If patients have relapsed, relapse prevention work
may be in order, unstable patients are given direction to help stabilize them
and patients moving successfully through the stages of recovery are aided and
encouraged to continue with the lifestyle changes that they are making.
Supportive Expressive Psychotherapy
It has two components i.e. supportive techniques to help patients
feel comfortable in discussing their personal experiences, and expressive
techniques to help- patients identify and work through interpersonal
relationship issues.
Group Therapy in Substance Use Treatment
·
Psycho-educational groups
·
Skill development groups
·
Cognitive behavior groups
·
Support groups
·
Interpersonal; process group psychotherapy
Substance use and dependency services are viewed as a continuum of
prevention, intervention, treatment, and aftercare. As with all continuums, the boundaries are not always clearly
drawn. A comprehensive substance use continuum combines many programs, policies
and practices, in order to reduce substance use and relapse in communities. A
local continuum of care may include local services ranging from follow ups in
pharmacological, psychosocial and occupational interventions.
Aftercare or
Continuing Care
Client is placed in
appropriate programmes and support structures to enable the effective
transition to their families and reintegration into their communities. The goal
of aftercare and continuing care is to support the person's abstinence
through relapse prevention after primary care and throughout their recovery.
Aftercare is the stage following more intensive services.
Related aftercare and
relapse prevention services for individuals who are part of a treatment
continuum include but are not limited to:
- Periodic outpatient
aftercare
- Relapse/recovery
groups
- Recovery support
group
- Halfway Houses
- Job
placement/reintegration/re –training into alternative occupation of
interest.
Aftercare
arrangements
Some structured
treatment programs distinguish a period of less intensive treatment after a client
has completed the main program, called aftercare. It may be limited to a month or substantially
longer after treatment has finished, but is based on the intention to provide
ongoing support to clients at the level required to maintain the earlier benefits
and goals. Regular phone contact, scheduled appointments and unscheduled or
drop in visits may all be available.
In addition to
aftercare services offered by the structured program, clients may also be
encouraged to access self help groups and other general community support and
advice services. Clearly, a supportive
family and community environment will also be conducive to helping in the
recovery of people who have received alcohol and drug use treatment.
Suggested
Steps:
1.
Regular visit after every two weeks
which are tapered off to after every month, then three months, six months for a
total of 2 years or more.
2.
Blood/urine tests for drug use
3.
Ensure attendance to support groups
meetings.
4.
Monitoring compliance to recovery goals
by liaising with family and sponsors
Bibliography
1. Textbook of substance abuse
Treatment The American Psychiatric publishing Inc Third edition
2. New Oxford Textbook of Psychiatry,
Gelder Lopez-Ibor Jr Andreasen Vol. 1
3. Psychology by WCB Brown and Benchmark
Second Edition
4. Improvement
Protocol-24 (TIP-24) and (TIP-35) Series by the
U.S. Department of Health and Human Services (DHHS)
5. The tenth revision of the International Classification of Diseases (ICD
10) published by the World Health
Organisation (WHO) in1992,
6. The fourth edition of the Diagnostic Manual of Mental Disorders (DSM-IV)
published by the American Psychiatric
Association in 1994.
7. WHO Expert Committee on Drug Dependence, 1998.
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