HOW TO TREAT MENTAL AND BEHAVIORAL DISORDERS DUE TO POLYSUBSTANCE DRUG USE 2025

HOW TO TREAT MENTAL AND BEHAVIORAL DISORDERS DUE TO POLYSUBSTANCE DRUG USE 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 12

MENTAL AND BEHAVIORAL DISORDERS DUE TO POLYSUBSTANCE DRUG USE

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 12

MENTAL AND BEHAVIORAL DISORDERS DUE TO POLYSUBSTANCE DRUG USE

I. DEFINITION  

Drugs are substances that affect the central nervous system, producing euphoria and leading to psychological and physical dependence. When an individual uses multiple drugs (two or more types), it can result in mental and behavioral disorders.

II. ETIOLOGY  

– Ease of illegal synthesis and distribution of drugs.  

– Multiple administration methods: smoking, snorting, swallowing, injecting.  

– Misconceptions among certain groups, especially youth, that drug use is trendy or modern, leading to peer pressure or coercion to use.

III. DIAGNOSIS  

Common mental and behavioral disorders associated with polysubstance use include psychotic disorders (e.g., delusions, hallucinations, agitation, violent behavior) and mood disorders (e.g., anxiety, depression, mania).

1. Diagnosis of Polysubstance Dependence  

According to ICD-10 (1992), dependence is diagnosed when three or more of the following occur together for at least one month or recur over 12 months:  

– Intense craving or compulsion to use drugs.  

– Difficulty controlling drug use (timing, cessation, or quantity).  

– Physiological withdrawal state upon cessation or reduction of use.  

– Evidence of tolerance (e.g., increasing doses to alleviate discomfort from abstinence).  

– Progressive neglect of previous interests or pleasures.  

– Continued use despite clear evidence of harmful consequences.  

Note: Diagnosis can be challenging as withdrawal symptoms may be atypical, sometimes manifesting only as physical and mental fatigue.

2. Diagnosis of Polysubstance-Induced Psychiatric Disorders  

General Diagnostic Criteria:  

– Symptom onset during or within 2 weeks of polysubstance use.  

– Symptoms persist >48 hours.  

– Disorder duration does not exceed 6 months (if longer, consider late-onset persistent psychotic disorder, F19.7).  

Clinical Presentations:  

– 2.1. Sleep Disorders: Reduced sleep, complete insomnia, or hypersomnia in some cases.  

– 2.2. Anxiety Disorders: Fearfulness, trembling, and worry about physical/mental health.  

– 2.3. Depressive Disorders: Low mood, loss of interest/pleasure, reduced energy, fatigue, decreased activity; irritability or aggression in some cases, with potential for suicide.  

– 2.4. Hallucinations: Diverse types, starting with perceptual distortions (e.g., vivid or eerie colors, menacing surroundings), progressing to true hallucinations—often auditory (commentary, praise, criticism, threats, or accusations).  

– 2.5. Delusions: Initial suspiciousness or bewilderment with anxiety/fear, leading to full delusions (e.g., jealousy, persecution, being controlled, or harmed), common in methamphetamine users.  

– 2.6. Agitation and Violent Behavior: Initial euphoria, increased energy, and physical activity (sometimes sexual), followed by loss of control, disorientation, and agitation (e.g., shouting, destruction, attacking others, disregard for personal safety), often in intoxication or delusion/hallucination-driven states.

Differential Diagnosis:  

– Agitation in schizophrenia or bipolar mania.  

– Organic brain disorders (e.g., tumors, encephalitis, temporal lobe epilepsy).

3. Ancillary Testing  

– Rapid Urine Tests: 4- or 6-panel (detecting multiple drugs).  

– Blood Biochemistry: Drug screening at qualified toxicology labs.  

– Hematology: Complete blood count (pre/post-treatment; daily in first week if abnormal).  

– Biochemistry: Glucose, urea, creatinine, uric acid, CK (pre/post-treatment; daily in first week if abnormal); electrolytes (pre/post-treatment; daily in first week if abnormal); GOT, GPT (pre-treatment, 1-2 weeks post-treatment), GGT, protein, albumin, bilirubin, lipids (cholesterol, triglycerides, LDL, HDL).  

– Coagulation Profile: Alternate days if bleeding risk/history.  

– Microbiology: HIV, HBsAg, anti-HCV, syphilis serology.  

– Urinalysis.  

– Imaging: Chest X-ray, abdominal ultrasound, gastric endoscopy.  

– Psychological Assessments: Depression (HDRS, Beck), anxiety (HARS, Zung), alcohol use (AUDIT) if applicable, personality (EPI, MMPI), sleep (PSQI); pre/post-treatment. Optional: cognition (MMSE), stress-anxiety-depression (DASS).  

– Functional Studies: ECG, EEG, cerebral blood flow, brain CT/MRI.  

– Daily testing for abnormalities, with specialist consultation if needed.

IV. TREATMENT  

1. Treatment Principles  

– Confirm diagnosis of polysubstance-related mental and behavioral disorders.  

– Prioritize life-sustaining functions; provide urgent care if life-threatening, with injectable antipsychotics for agitation if needed.  

– Once stabilized, address psychiatric symptoms (anxiety, panic, depression, psychosis) with anxiolytics, antidepressants, or antipsychotics as appropriate.

2. Treatment Framework  

– Pharmacotherapy: Sedatives, antipsychotics, antidepressants.  

– Psychotherapy: Individual, family-based.

3. Specific Treatments  

Tailored to individual and clinical presentation:  

3.1. Antipsychotics  

– 1-3 agents (prefer monotherapy; switch or combine up to 3 if ineffective):  

+ Typical:  

  + Chlorpromazine (25 mg tabs/vials; 50-250 mg/24h).  

  + Levomepromazine (25 mg tabs; 25-250 mg/24h).  

  + Haloperidol (1.5-5 mg tabs, 5 mg vials; 5-30 mg/24h).  

+ Atypical:  

  + Amisulpride (50-400 mg tabs; 200-800 mg/24h).  

  + Clozapine (25-100 mg tabs; 50-800 mg/24h).  

  + Risperidone (1-2 mg tabs; 1-12 mg/24h).  

  + Olanzapine (5-10 mg tabs; 5-60 mg/24h).  

  + Quetiapine (50-300 mg tabs; 600-800 mg/day).  

  + Aripiprazole (5-30 mg tabs; 10-30 mg/day).  

3.2. Antidepressants  

– 1-3 agents (prefer monotherapy; switch or combine up to 3 if ineffective):  

+ SSRIs:  

  + Fluoxetine (20 mg; 10-40 mg/day).  

  + Paroxetine (20 mg; 20-60 mg/day).  

  + Sertraline (50 mg; 50-200 mg/day).  

  + Fluvoxamine (100 mg; 100-300 mg/day).  

  + Escitalopram (10-20 mg; 10-20 mg/day).  

  + Citalopram (10-60 mg/day).  

+ Dual-Acting:  

  + Venlafaxine (37.5 mg; 75-225 mg/day).  

  + Mirtazapine (30 mg; 30-60 mg/day).  

+ Tricyclics:  

  + Amitriptyline (25 mg; 50-100 mg/day).  

  + Clomipramine (25 mg; 50-75 mg/day).  

  + Imipramine (10-150 mg/day).  

+ Other: Tianeptine (12.5-50 mg/day).  

3.3. Mood Stabilizers  

– 1-2 agents (prefer monotherapy; switch or combine up to 2 if ineffective):  

+ Valproate (200-2500 mg/day).  

+ Divalproex (750 mg/day to 60 mg/kg/day).  

+ Carbamazepine (400-1200 mg/day).  

+ Oxcarbazepine (1200-2400 mg/day).  

+ Lamotrigine (100-400 mg/day).  

+ Topiramate (50-400 mg/day).  

+ Gabapentin (300-1800 mg/day).  

3.4. Benzodiazepines  

– 1 agent:  

+ Diazepam (5-30 mg/day).  

+ Lorazepam (1-4 mg/day).  

+ Clonazepam (1-8 mg/day).  

+ Bromazepam (3-6 mg/day).  

3.5. Other Anxiolytics/Sedatives  

– 1 agent: Etifoxine, tofisopam, passionflower extract, zopiclone, eszopiclone, melatonin.  

3.6. Adjunctive Therapies  

– Cerebral circulation/cognitive enhancers (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine), vitamins, trace elements, antihistamines (hydroxyzine), beta-blockers.  

– Supportive care: Vitamins, nutrition, IV fluids.  

– Hepatic support: Aminoleban, silymarin, boganic, branched-chain amino acids.  

– Cognitive enhancers.  

– Physical/occupational therapy.

3.7. Psychotherapy  

– Individual, family, motivational, cognitive-behavioral, social reintegration therapies.  

– Treat comorbidities.  

– Nutrition: Balanced, digestible, nutrient-rich diet across four food groups.  

– Community Rehabilitation: Occupational therapy.

V. PROGNOSIS AND COMPLICATIONS  

– Timely treatment yields a good prognosis; however, some cases progress to chronic psychosis or mental deterioration.

VI. PREVENTION  

Primary Prevention:  

– Governmental regulation of addictive substances.  

– Public education on drug harms to reduce use.

Secondary Prevention:  

– Screen drug users to detect early psychiatric disorders.

Tertiary Prevention:  

– Aggressively treat polysubstance-related mental and behavioral disorders.  

– Provide detoxification or harm reduction strategies.  

– Implement relapse prevention measures.

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