Substance use disorders

Lize Weich
 Classification of substances of
abuse

Cannabis Ecstasy

“Downers” “Psychedelics” “Uppers”

GABA Volatile
opioids Stimulants
agonists substances

Dissociative Other
hallucinogens
anaesthetics
 Disease progression

Not static Static

Occasional and Misuse

Experiment controlled use Hazardous use Dependence
Harmful use
Recreational use Abuse
Fixed
state
Cannot
return to
prior
stages
 Substance abuse
• implies that someone either
persistently or sporadically uses
substances in a manner that is
unacceptable.
• DSM-IV:
– Risk of bodily harm? (drinking and
driving, operating machines, swimming
etc.)
– Relationship trouble? (family, friends,
colleagues)
– Role failures? (work, home, school?)
– Run-ins with law? (legal problems or
arrests)
• Any 1+ = abuse
 What is substance dependence?
• A maladaptive pattern of substance use which
can be recognized by signs of
• physical adaptation of the body to the drug
– Tolerance
– Withdrawal
• signs of loss of control over taking of the drug
– taking more or for longer than intended
– desire or unsuccessful efforts to cut down or
control use
• And salience
– great deal of time is spent to obtain, use or
recover from the drug
– important activities are given up
– the drug is used despite knowledge that it is
harmful
• 3+ over 12/12 = dependence
 PREVENTION:
• 1° prevention: prevent drug use
education, careful prescribing, media,
campaigns, legislation, community
ownership etc.
• 2° prevention: prevent harm by early
detection and intervention
early recognition with appropriate
interventions
• 3° prevention: limit harm by
intervening
rehabilitation
harm reduction
 Treatment of substance use disorders
(SUD): Continuum of interventions according to
Disease Severity
Experimentation Recreational use/ Misuse Addiction/
Occasional and Hazardous use Dependence
controlled use Harmful use
Abuse

Primary Primary/ secondary Secondary Tertiary

prevention Prevention prevention Prevention
E.g., provide E.g., provide E.g., brief early e.g., motivation,
accurate accurate information; intervention; +/- detoxification;
information Brief early +/-outpatient in or outpatient
intervention; rehabilitation or rehabilitation or
Brief motivational Harm reduction Harm reduction
interviewing strategies strategies
Secondary prevention for
substance abuse:
Brief interventions (Bien)

• Feedback
• Responsibility for
change
• Advice
• Menu of change options
• Empathy
• Self-efficacy
 Motivational interviewing
• Motivational Interviewing, Preparing People for
Change (2nd Edition) by W.Miller, S.Rollnick
and K.Conforti (Guilford Press, 2002)

• Express empathy (acceptance facilitates change, use

skilful reflective listening)
• Avoid arguments (they are counterproductive and
increase resistance, don’t label e.g. “Alcoholic”)
• Develop discrepancy (discrepancy between behavior
and goals motivate change, the client should present
the arguments for change)
• Roll with resistance (use momentum, new
perspectives are invited, not imposed, the client finds
solutions to problems)
• Support self efficacy
 Treatment process for substance
dependence

Identification Detoxification Relapse Aftercare

Motivation Medical prevention
stabilization
Referral
Rx Psycho-social
rehabilitation
Psychosocial rehabilitation

Rehab
needs
 Skills to
stay sober
Re-
integration
needs
Spiritual needs -Family
-Work
-Housing

Physical,
mental
health,
emotional
needs
 Harm reduction
• A philosophy of public health that offers an
alternative to the prohibition of certain potentially
dangerous lifestyle choices
– Some people will always engage in risky behaviors
– Quitting immediately may not be realistic or desired
by everyone
– Strategies that mitigate the potential dangers and
health risks associated with these risky behaviours
and to reduce associated harm
– Need to be seen in context of the limited
effectiveness of sobriety-driven treatment approaches
where the only success is sobriety
• Education that encourages harm-reducing
behaviours
– Designated driver
– Reduce amounts consumed
– Alter the route e.g. stop needle sharing
– sterilising gear
– Overdose risk and prevention
• Harm reduction policies
– Needle exchange programs
– Safe injection sites
– Naloxone/CPR training for buddies
• Facilitate capacity and motivation for change:
e.g. address social needs like homelessness,
unemployment, etc.
• Substitution prescribing
• “Noah, who was
a farmer, was
the first man to
plant a
vineyard. After
he drank some
of the wine, he
became
drunk…” Gen 9:
20-21 G N Bible
 Safe drinking
• Men less than 14 Units / week and women less
than 8 Units / week
• Not daily (at least 2 alcohol free days/week)
• Not all on one day (avoid binges)
– Men <60y: no more than 4U/day
– Women, men>60y: no more than 3U/day
• Not during pregnancy
• Never before or during driving, swimming,
active sport or use of machinery, electrical
equipment, ladders or in other potentially
dangerous situations
A standard drink
Alcohol
 How much is a “unit”?
• 10 ml Alcohol = 8 g Alcohol = 1 Unit
• Number of Units = volume of alcohol in ml
x alcohol percentage / 1000

• E.g.
– Bottle of spirits: (40%) (750ml) = 30 U
– Bottle of red wine: (13,5%) (750 ml) = 10 U
– Can of beer: (5%) (500ml) = 2,5
 Alcohol Intoxication
Units BAC Signs and symptoms
consumed mg/ml
0-2 30 Euphoria, mildly disinhibited, talkativeness

3 50 Joviality, judgment

5 80  reaction times, inattention

10 150 Ataxia, obvious drunkenness

12 200 Diplopia, amnesic, staggering

25 400 Respiratory depression, Coma

30+ 500+ Death

Women are more susceptible, liver disease or drug interactions may affect
tolerance
 Alcohol withdrawal

• Nausea, sweating, tachycardia,

insomnia, tremors, craving
• Usually start within 6-8 hours of
cessation
• Risk of seizures- up to 1/3 of those who
stop abruptly, max risk in 1st 48 hours
• Focal seizure indicate other pathology
 Delirium Tremens
• Up to 5% of alcoholics who stop abruptly
• Onset usually 2-5 days after stopping, often at
night.
• Present with
– clouded consciousness
– anxiety, signs of withdrawal
– delusions
– hallucinations (“the horrors”)
• Lasts +/- 5 days
• Risk of death
 Wernicke’s encephalopathy
• Thiamine deficiency
• acute encephalopathy
– Delirium
– Ataxia
– Opthamoplegia
• Reversible with parental thiamine
 Korsakoff’s syndrome
(alcohol induced amnesic disorder)
• Untreated Wernicke’s
– no new STM retained, patient unaware of this
– LTM ok
– Confabulation
• Treat with Thiamine
• Only about 20% of cases are reversible
 Merck manual 1899
“Alcohol addiction”
• “Take cocaine to remove the craving for
alcohol”
• Spirit of ammonia as a “substitute for
alcohol…to be taken when the craving
comes”
• “one pint of water, drunk as hot as
possible, an hour before meals will remove
craving”
 Treatment process for substance
dependence

Identification Detoxification Relapse Aftercare

Motivation Medical prevention
stabilization
Referral
Rx Psycho-social
rehabilitation
 Medical complications
Liver disease Elevated liver enzyme Fatty liver, alcoholic hepatitis, cirrhosis
levels
Pancreatic Acute pancreatitis, chronic pancreatitis
disease
Cardiovascular Hypertension Cardiomyopathy, arrhythmias, stroke
disease
Gastro- Gastritis, gastro Esophageal varices, Mallory-Weiss tears
intestinal esophageal reflux
problems disease, diarrhea,
peptic ulcer disease
Neurological Headaches, blackouts, Alcohol withdrawal syndrome, seizures,
disorders peripheral neuropathy Wernicke's encephalopathy, dementia,
cerebral atrophy, peripheral neuropathy,
cognitive deficits, impaired motor functioning
Reproductive Fetal alcohol effects, Sexual dysfunction, amenorrhea, anovulation,
system fetal alcohol syndrome early menopause, spontaneous abortion
disorders
Cancers Neoplasm of the liver, neoplasm of the head
and neck, neoplasm of the pancreas,
neoplasm of the esophagus
 Should you anticipate problems
doing withdrawal?
• Severe dependence (extended history of continuous heavy
drinking with high levels of tolerance or severe withdrawal
symptoms on presentation e.g. evidence of marked autonomic
over-activity)
• Past history of convulsions
• Past history of DT’s
• Older age
• Pregnancy
• Significant concomitant medical comorbidity (e.g. liver disease,
cardiac disease, severe infections etc.)
• Significant concomitant psychiatric comorbidity (e.g. psychosis,
suicidality)
• Lack of support at home
• Previous failed outpatient detoxification attempts
ADMISSION
for detox
 Alcohol detoxification
• relatively short acting drug - withdrawal starts
around 6-8 hours after the last intake
• Must detox - withdrawal may be dangerous (fits or
Delirium Tremens) and even lethal
• Diazepam is used- substitute drug at the GABA
receptor, it is given at the level of tolerance (dose
that suppress withdrawal symptoms without
causing symptoms of intoxication) and it is slowly
reducing this over several days
• Vitamins especially thiamine, are also prescribed
to avoid complications from deficiencies due to
their poor diet
 Treatment process for substance
dependence

Identification Detoxification Relapse Aftercare

Motivation Medical prevention
stabilization
Referral
Rx Psycho-social
rehabilitation
Medication for alcohol dependence
• Aversion
– Disulfiram
• Anti-craving
– Acamprosate
– Naltrexone
– Anti-epileptic drugs e.g. topiramate
 Antabuse:
Antabuse
Acetaldehyde
dehydrogenase

Alcohol Acetaldehyde Acetate

Flushing, throbbing of head and
neck
Shortness of breath
Sweating, thirst, chest pains
Heart palpitations, dizziness,
fear, weakness
Epileptic attack
Unconsciousness or death
 Acamprosate
• normalizes the dysregulation of the NMDA
mediated glutaminergic neurotransmission
(a physiological mechanism that may
prompt relapse)
• ?blocks NMDA R and activate GABA-A R
 Naltrexone
• opioid receptor antagonist- blocks the
endogenous opioid reward system
 Alcohol and psychiatry
• Mood disorders
• Anxiety disorders
• Psychotic disorders – hallucinosis
• Pathological jealousy “Othello
syndrome”
• Sexual disorders
• Sleep disorders
• Amnesic disorders
• Dementia
• Personality disorders
“marijuana”, “dagga”, “weed”, “dope”, “pot”, “slow boat”, “ganja”,
“herb”, “boom”, “bung”, “Durban poison”, “groengoud”, instangu
 Cannabis

• From Cannabis Sativa plant

• The most potent agent is delta9-
tetrahydrocannabinol (THC)
• Stalks, flowers, leaves and seeds are used and ♀
plants secrete resin.
• Hashish: potent cannabis mostly from resin
• Hashish oil: concentrated resin distillate
• Smoked in joints, pipes or buckets, baked, or
taken as an extract
• Cannabis is the most commonly used
illicit drug in South Africa.
• According to Interpol, South Africa is
one of the top four cannabis suppliers in
the world.
• vs. other hallucinogens sedating, lower
hallucinogenic properties, generally
smoked
• Patterns of abuse is very varied
– Experiment
– Occasional users
– Regular users (3-5x/week)
– Heavy daily use
• Complex relationship with mental illness
 Effects
• After smoking: effects within 15-30
minutes, lasts 2-6 hours
• After ingestion: effects within 30-60
minutes, lasts 5-12 hours
• Lipid-soluble
• Accumulates in the body after
repeated use
• Liver metabolised
• Urine excretion, also bile, faeces
 Mechanism of action
• Agonist at endogenous cannabinoid
receptors
– CB1 receptors (CNS)
– CB2 receptors (peripheral tissue, mainly
immune system)
• 1st endogenous cannabinoid 
anandamide
• since 2nd and 3rd have been discovered
 Is Cannabis physically
addictive?

1960- 10mgTHC NOW- 150-300mgTHC

Effects are dose related: research 1970’s
done using 5-25mg THC ?thus obsolete
Tolerance and withdrawal : thus physically
addictive
 Intoxication
• Generally, relaxation and sharpend awareness
• Vasodilatation: red eyes, tachycardia, postural
hypotension
• No pupil size change
• ↑ appetite, dry mouth
•  REM sleep
• ↓estimation of time and distance
• variable psychological reactions like euphoria,
anxiety, perceptual distortions/ hallucinations,
paranoid thoughts
• ↓STM
• Altered information processing so that boring
and repetitive tasks are performed with
interest and concentration
• Impaired complex goal-orientated task
performance
• ↓motor in-coordination
• impaired judgment
• Analgesia, anti-emetic, anti-epileptic
 Chronic heavy use:
 Amotivational syndrome: Apathy, dullness,
diminished goal-directed activities, impaired
concentration, deteriorated personal
appearance,
 long-term impairment in performance,
especially of attention, memory, ability to
process complex information can last weeks
months or even years
 ? permanent cognitive impairment
 Cannabis withdrawal:
 Withdrawal usually mild
 4 to 5 days of irritability, restlessness,
nervousness, decreased appetite, agitation,
tremor, insomnia (with rebound increased REM)
 Usually does not require detox, but if client is
very uncomfortable so that this discourages
abstinence, withdrawal medication can be given
 Diazepam 5mg TDS, reduced over 3-5 days
 Medical complications
• Cardiac: Postural hypotension and fainting,
Acute cardiac incidents
• Lungs: Cannabis smoke contains same carbon
monoxide, bronchial irritants, tumour initiators
and promoters and carcinogens as cigarettes,
3x>tar retained, higher combustion
temperature → more bronchitis and
emphysema, lung cancer (3/4 joints=20
cigarettes)
• Immunosuppressant
• Endocrine effects
 Psychiatric complications of
Cannabis:

• Acute “toxic” responses: panic, anxiety,

depression, psychosis
• Cannabis induced psychosis
• Amotivational syndrome (impaired attention,
memory, learning, drive)
• Effects on pre-existing mental illness
• Cannabis as risk factor for mental illness
• Withdrawal effects
 Therapeutic uses:
• 1st used in China 5000 years ago for malaria,
constipation, rheumatic pains, childbirth, surgical
analgesic
• Reynolds (Queen Victoria’s physician) : “Indian hemp …
is one of the most valuable medicines we possess”
• Nausea and vomiting in cancer chemoth.
• Multiple sclerosis
• Weight loss in cancer and AIDS patients
• Pain
• Raised intra-ocular pressure
• Asthma
“Crystal”, “Ice” ,“Glass”,
“Tik”, “Globe”, “Tuk-tuk”
 Methamphetamine
• Psycho-stimulant
• White or off-white crystal
• Long T½ of 8-12 hours
• Synthetic drug
– Manufactured locally - availability
– Easy and cost-efficient to
manufacture
 Effects of stimulants:
“high”

• initial rush
• followed by a prolonged period of
feeling “high”
• Often taken in binges- “tweaking”
 Effects:

• A sense of wellbeing and alertness,

increased energy
– Appeals to youngsters
– High novelty seeking, low harm avoidance
personalities
• Increased libido
– Appeals to groups involved in casual sex with
multiple partners
• Suppressed appetite
– Appeals to females
• Feelings of alertness and aggression
– Appeals to gangsters
 Methamphetamine
Acute Physical Effects
• Increases Decreases
– pulse – Sleep
– Blood pressure – Reaction time
– Pupil size – appetite
– Respiration
– Sensory acuity
 Effects of stimulants:
“crash”

• Agitation, loss of appetite, depression (may

have suicidal ideas), exhaustion and severe
craving.
• Oversleeping and often an increased appetite.
• Last for a few to several days
 Effects of stimulants:
“withdrawal”

• Low energy levels, inability to to enjoy

anything (anhedonia), anxiety and
depression (may have suicidal thoughts)
• Severe cravings
• High risk of relapse
• Can last for months
 Effects of stimulants:
“extinction”

• The mood returns to normal

• Episodes of craving brought on by
“conditioned triggers” (things that are
associated with drug use, e.g. a place,
person, object etc.)
 How does amphetamines
damage the brain?
• Due to excess of DA in cytoplasm  auto oxidation of
DA, producing neurotoxic quinones and reactive oxygen
species that are thought to cause neural damage.
• Damage DA-rich areas
• Also depletion of 5HT and its precursors
 MA and cognitive effects
• Single dose: improved cognitive
functioning
• Long-term exposure: deficits in
– Working memory
– Attention
– Executive functioning
• Extensive use: also deficits in
episodic memory
 Types of psychotic experiences
described
• Sudden short-lived toxic psychotic symptoms at
high doses (sleep deprivation)
• More enduring psychosis
• “Flashbacks”
• May be a feature of withdrawal
• 5-15% fail to recover completely(? Scizophrenia)
 Some other mental health
consequences/ associations
• Common
• Violence
• Suicidal behaviour
• Poly-drug use
• Mood disorders
• Anxiety disorders
• Sleep disorders
• Eating disorders
• Sex addiction
• Pathological gambling
• Personality disorders
 High risk HIV behaviour
• Sexually arousing and
disinhibitory
• “loss of control”
• Unprotected sex
• Multiple partners
• HIV infection renders the
brain vunrable to
damage from MA and
visa versa
 Amphetamines
and violence

• Canadian study found that violence was the

leading cause of amphetamine-related deaths
– accidental, self -inflicted, or perpetrated by others
• Violent death was at least four times as
common among regular users of
amphetamines as among non-users of the
same age and sex.
• In South Africa, methamphetamine is often
associated with gangster-related violence
 Treatment process for substance
dependence

Identification Detoxification Relapse Aftercare

Motivation Medical prevention
stabilization
Referral
Rx Psycho-social
rehabilitation
 Detoxification
• No specific detoxification regime
• Often irritable, explosive, cravings for
about 5-7 days
• Support and empathy
• Asses for comorbid depression or
psychosis
• Symptomatic treatment
– Phenergan
– Benzodiazepines (with caution)
Health complications of MA
use disorders
• Hyperthermia, muscle breakdown
• Convulsions
• Heart and blood vessels: abnormalities
of heart rhythm, hypertension, heart
failure or attacks, irreversible damage
to small blood vessels in the brain and
can lead to hemorrhages or strokes.
• Jaw clenching, dental problems,
twitching, jitteriness, and repetitive
behavior, movement disorders, like
parkinsonism
METH Use Leads to Severe Tooth
Decay

Source: Richards, JR and Brofeldt, BT, J

Periodontology, August 2000.
 Medical complications
(continue)

• Nutritional deficiencies and body wasting

• Renal failure
• Lung and breathing problems
• Impaired sexual performance and
reproductive functioning
• Birth abnormalities and pregnancy related
complications, like premature delivery, and
altered neonatal behavioral patterns, such
as abnormal reflexes and extreme irritability
• Death
 Welcanol
(pinks, pink heroin, SA heroin)
• Opiates:
– derived from opium
– examples include morphine, heroin, codeine

• Synthetic opioids
– examples include Pethidine®, Wellconal®,
Doloxene®, Valoron®, Methadone
 Heroin:
• “Thai white”, “brown sugar”, “smack”, “H”,
“skag,”, “junk”, “smack”, “horse”, “dreamer”,
“herries”, “Unga”
• May be dissolved in water for injection, smoked
with dagga, snorted or heated over tinfoil and
then inhaled (“chasing the dragon”).
• Opioid solutions may be injected under the skin
("skin popping"), directly into a vein
(“mainlining”) or into a muscle.
• Mixed with cocaine – (“speedballing”)
 Intoxication
• Euphoria, profound relief from anxiety and
tension, followed by apathy
• Initial mild brief increased energy,
followed by psychomotor retardation
• “nodding”- state between arousal and
sleep, where individual is rousable
• Pupillary constriction
• Hypoactive bowels
• Slow regular respiration,  coughing
• Slurred speech
•  judgement, concentration, memory
• dulling of pain
• difficult passing urine
• nausea and vomiting
• Sweating, warm flushing of the skin, itching
• dry mouth
• loss of sex drive, menstrual irregularities
• rarely convulsions
• Needle marks, hyperaemic mucosa etc.
• Large doses of heroin may result in a potentially
lethal overdose
 Heroin: Overdose:

• Potentially lethal
• Depressant - may present in a coma with
respiratory depression.
• Also a risk of hypoglycemia and seizures.
• Rx : Naloxone (Narcan®) 0,4mg I.V. slowly at 5-
minute intervals.
• NB: the duration of action of Naloxone is much
shorter than most opiates of abuse and thus careful
observation and repeat of doses of Naloxone may
be necessary.
• If the patient is opiate dependent, Naloxone may
precipitate a severe opioid withdrawal.
 Withdrawal – 4 main types of
symptoms
• Gastrointestinal
distress (diarrhoea,
nausea or vomiting)
• Pain (arthralgias or
myalgias, abdominal
cramping)
• Anxiety
• Insomnia
• Etc.
 Withdrawal:

• Withdrawal symptoms include abdominal

cramps, anxiety, craving, irritability, unpleasant
or depressed mood, fatigue, hot and cold
flushes, muscle aches, nausea, restlessness
and yawning.
• Signs of opiate withdrawal include diarrhea,
increased blood pressure and pulse, tearing of
eyes, runny nose, sweating, muscle spasms
("kicking the habit"), dilated pupils, goose
bumps (“cold turkey”), vomiting and fever.
 Time to withdrawal
Drug Time to Peak Duration
withdrawal
Pethidine 4 – 6 hours 8 – 12 hours

Heroin 6 – 12 hours 36 – 72 hours 5-10 days

Morphine 8 – 20 hours

Codeine 24 hours

Methadone 36 – 72 hours 72 – 96 hours up to 3

weeks
 Withdrawal:

• Heroin withdrawal is highly unpleasant, but

is considered to be safe, except is
medically severely compromised clients or
in pregnancy
Medical management of opioid
dependence

Achieving total
abstinence rapidly
using standard
rapid detoxification
procedures

rehabilitation
Options available for detoxification:
• Symptomatic relief of symptoms
– Clonidine
• Reduce “adrenaline-like” symptoms
– Other symptomatic treatments
• E.g. symptomatic relief of aches and pains, diarrhoea,
insomnia, etc.
• Substitution detoxification
– Give a similar medication to the drug at a dose
that relieves withdrawal symptoms (level of
tolerance) without causing intoxication and
gradually withdraw over days (bring down the
tolerance)
 Methadone
• μ agonist
• T ½ is about 24 hours
• Pregnancy: effect of methadone on foetus
vs. effect of heroin, recurrent intoxication
and withdrawal, adulterated street drugs
on foetus
 Buprenorphine

• Partial μ agonist, κ antagonist

• Ceiling effect
• Safer than full agonists
– Never full effect
– Safer option than full agonist, e.g. methadone
• Lower dependence
• Less sedation
– Block effect of “extra” opiates
• Tight receptor binding
– Long duration of action (T ½ >24 hours)
– Slow onset of mild abstinence
• Risk of precipitated withdrawal if used incorrectly
 Classification of spectrum of
drugs that act on the opioid
receptor
Agonists Partial agonists Antagonists

60
Heroin, morphine, methadone
50
Opiate effect

40

30
Buprenorphine
20

10 Naltrexone, naloxone

Dose
Outcome of rapid detoxification
from all opioids and relapse
prevention
• NTORS (Gossop et al)
– 34% relapsed to heroin use in 3 days
– 45% in 7 days
– 50% in 14 days
– 60% in 90 days
Substitution prescribing for opioid
dependence
• Heroin dependence has a 1-2% annual
mortality
• Natural history of heroin dependence over
time is remission
• Harm reduction until ready
• Provide the user in a safe, structured and
controlled manner, an individualised dose of
long-acting oral opioid to allow them time to
stabilise their lifestyle, develop insight and
reduce harm from illicit drug use (“slow
detox”)
Medical management of opioid
dependence
Transfer
patient from
abused opioids
Achieving total onto
abstinence rapidly substitute opioids
using standard until their life is stable
rapid detoxification and they are ready
procedures

Slow
detoxification
 Substitution treatment

Assessment: Stabilize of Psycho-social Slow

individualised interventions - detoxification
Goal is dose of stabilization
stabilization of substitute lifestyle
life-style, opioid
abstaining from
illicit drugs Medical
stabilization
 Outcome…
• From international experience
• Effective, providing adequate doses and
appropriate supervision
– Reduce morbidity including HIV risk,
incarceration, use of other substances
– Reduced mortality
– Better treatment retention
– Better outcome than detoxification and
relapse prevention
 Concerns…
• Methadone formulation available
– Physeptone ® Cough syrup with sugar content, high
viscosity, contains alcohol, very weak concentration,
expensive
• Buprenorphine is the safer alternative, but is
expensive
• Unsafe and unethical practices by medical
practitioners if unregulated
• Black market diversion
• Doctor hopping
Elements of a safe program:

• Accreditation, guidelines, regulation

• Legislation
• Patient register
• Regular monitoring of patients
• Supervised consumption
• Random drug screens
• Ongoing psychosocial program
 Problems…
• Substitution not widely accepted in
South Africa
– Social model vs. medical model
– “Swapping one drug for another”
• No legislation
• Limited infrastructure
– e.g. supervised consumption
– Co-operation between medical and non-
medical drug treatment fraternity
Medication for relapse prevention in
opioid dependence:
antagonist treatment
• Naltrexone
– Oral (Revia®)
– Slow release injectable
– Slow release implant
• Not available in South Africa
• Can be imported and used with per
patient approval from the MCC