HOW TO TREAT MENTAL AND BEHAVIORAL DISORDERS DUE TO HALLUCINOGEN USE 2025

HOW TO TREAT MENTAL AND BEHAVIORAL DISORDERS DUE TO HALLUCINOGEN 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 11

MENTAL AND BEHAVIORAL DISORDERS DUE TO HALLUCINOGEN 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 11

MENTAL AND BEHAVIORAL DISORDERS DUE TO HALLUCINOGEN USE

I. DEFINITION  

Hallucinogens are substances that stimulate the central nervous system, increasing alertness, physical activity, and euphoria, while also inducing psychiatric disorders such as anxiety, depression, sleep disturbances, paranoia, hallucinations, agitation, and violent behavior. This group includes lysergic acid diethylamide (LSD), psilocybin, mescaline, peyote, amphetamine-type stimulants (ATS), and certain organic solvents.

II. ETIOLOGY  

– Ease of illegal synthesis and distribution of hallucinogens.  

– Multiple administration routes: smoking, snorting, swallowing.  

– Misconceptions among some groups, particularly youth, viewing hallucinogen use as fashionable or modern, encouraging peer involvement.

III. DIAGNOSIS  

1. Diagnosis of Hallucinogen Dependence  

According to ICD-10 (1992), dependence on amphetamine-type stimulants (ATS) or similar hallucinogens 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 the substance.  

– Difficulty controlling frequency or dosage of use.  

– Withdrawal syndrome upon cessation or reduction of use.  

– Increasing tolerance, requiring higher doses.  

– Neglect of previous habits or interests.  

– Continued use despite awareness of harmful consequences.

2. Diagnosis of Hallucinogen-Induced Psychiatric Disorders  

General Diagnostic Criteria (ICD-10):  

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

– Symptoms persist >48 hours.  

– Disorder duration does not exceed 6 months (if longer, consider late-onset persistent psychotic disorder, F16.7).  

– Not diagnosed if psychosis predates hallucinogen abuse.  

– Psychiatric manifestations (e.g., due to methamphetamine) may include sleep disturbances, anxiety, depression, delusions, hallucinations, agitation, and violent behavior.

2.1. Sleep Disorders  

– Reduced sleep or complete insomnia; some cases exhibit hypersomnia.

2.2. Anxiety Disorders  

– Fearfulness, trembling, and excessive worry about physical and 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 hallucinations, initially presenting as perceptual distortions (e.g., vivid, fantastical colors; menacing or supernatural surroundings).  

– Sounds become amplified or chaotic, leading to a sense of being in an alien world, followed by true hallucinations—often auditory (commentary, praise, criticism, threats, or accusations).

2.5. Delusions  

– Initial suspiciousness or bewilderment, often with anxiety or fear, progressing to full delusions.  

– Common in methamphetamine users, with varied presentations: jealousy, persecution, being watched, controlled, or harmed.

2.6. Agitation and Violent Behavior  

– Initial euphoria, increased energy, physical activity, and sometimes sexual behavior, followed by loss of control, disorientation, and agitation (e.g., shouting, destruction, attacking others, disregard for personal safety).  

– Frequently seen in intoxication or when delusions/hallucinations dominate.

Differential Diagnosis:  

– Agitation in schizophrenia or bipolar mania.  

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

– Agitation due to alcohol, other drugs, or psychotropic medications.

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).  

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

– Urinalysis.  

– Imaging: Chest X-ray, abdominal ultrasound.  

– 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  

– Prioritize life-sustaining functions as in other medical emergencies; provide urgent care if life-threatening.  

– For agitation, combine injectable antipsychotics if needed.  

– Once stabilized, address psychiatric symptoms based on clinical presentation.

2. Treatment Framework  

Tailored to individual and clinical symptoms:  

– Sedatives/Anxiolytics: 1-3 agents:  

+ Benzodiazepines (5-30 mg/day, e.g., diazepam) for 1 week (avoid long-term use unless necessary).  

+ Non-benzodiazepines: Etifoxine (50-200 mg/day), sedanxio.  

+ Sleep aids: Zopiclone (3.75-15 mg/day), melatonin.  

+ Contraindications: Hypersensitivity, myasthenia gravis, severe respiratory/hepatic/renal failure.  

– 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).  

– 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).  

  + Thioridazine (50 mg tabs; 100-300 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).  

– 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).  

– 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.  

– Psychotherapy: Individual, family, motivational, CBT, social reintegration.  

– 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, including ATS and hallucinogens.  

– Public education on the harms of hallucinogen use to reduce initiation.

Secondary Prevention: 

– Screen hallucinogen users to detect early psychiatric disorders.

Tertiary Prevention: 

– Aggressively treat psychiatric and behavioral disorders related to hallucinogen use.  

– Provide detoxification and relapse prevention strategies.

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