Posted: December 28th, 2014

medical cases – Substance abuse-heroin

medical cases – Substance abuse-heroin

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Refer your cases in to mount carmel hospital in Valletta, Malta.( The whole case study should be in Malta)
Find a related topic about Substance abuse-heroin
I’II upload my friend assignment which was perfectly done by him last year.
You can see my friend assignment and please please make my case study, Substance abuse-heroin, in the same approach and pattern he did, but not the same person in his

assignment, starting from:

Introduction and presenting complaint
History of presenting complaint
Past psychiatric history
Past medical/ surgical history
Drug history and allergies
Family history
Social history
Personal history
Premorbid history
Mental State Examination
Differential diagnosis

Case. Substance abuse- heroin

Introduction and presenting complaint:
Mr. JH is a 38 year old gentle man, from Paola, who was seen on 4/10/2013, is married but currently separated from his wife of four years; he also has a daughter aged

eleven whom he conceived out of wedlock with his previous girlfriend. He has not seen his daughter in five years. He is employed in office maintenance, and is being

seen at detox clinic for his heroin addiction.
History of presenting complaint:
Mr. JH’s problem with addiction began when he was twelve years old, where he describes using heroin for the first time with a friend, however he did not know what it

was at the time but remembered enjoying the feeling of it but not continuing to use it.  The patient admits that his addiction probably began because he wanted to be

like his older brother, so he started to imitate him in almost every aspect. His brother was known to use drugs extensively and would sometimes sell them, which gave

the patient the opportunity to steal from his brother marijuana and valium. According to Mr. JH, the availability of drugs from people around him, including constant

pressure from his friends, are what added to his acceptance of using drugs, as he described that everything seemed completely normal. The patient recalls using heroin

officially at the age of sixteen years were he started with smoking it, after that at the age of seventeen years he started injecting himself up until the age of

thirty two years, because he said that he ran out of veins, and also out of fear that he would damage his kidneys. The patient would mainly inject in his arms and

feet, and admits that he has never shared needles or appliances. The use of drugs throughout the years has caused Mr. JH to become isolated from everyone around him,

as he is no longer close with his friends or family, as they are troubled to see him in this condition. The addiction has taken a toll on his daily activities, as he

says that he spends most of time trying to find money by burrowing and sometimes stealing in order to purchase his drugs, therefore most of his days are unproductive.

He admits to lying to his parent’s along with his wife over the money he burrows from them, and uses it mostly to purchase his drugs. He expressed that when things

don’t go his way, he becomes quite aggressive and his been abusive to his current wife and his previous girlfriend. He is no longer in contact with his daughter, as

the courts ordered that she be removed from him, because of providing unsafe environment for her, when he would use drugs around her in the apartment. Although he says

that after all that is happened in his life he does sometimes feel guilty, but he does not know why he keeps using drugs and is unable to break the habit. Mr. JH

refuses to see a psychiatrist, and is only willing to speak to the doctors at the detox clinic. The patient has been attending the detox clinic to receive methadone

since he was seventeen years old and still continues to this day, however it has not seem to ease his addiction as he describes that he uses now than he ever did

before. He has recently been experiencing the following symptoms: low mood, anhedonia, as well decreased appetite.
Past psychiatric history:
–  The patient has no known psychiatric history and has never been admitted to Mount Carmel hospital.
Past medical/ surgical history:
–    The patient suffered from hemolytic disease of the newborn (rhesus disease), and has received many blood transfusions as a child.
–    The patient has been suffering from kidney problems due stones since the age of seventeen years has multiple operations to treat the condition, but has since

been fine.
–    The patient suffers from high blood pressure and is not receiving any treatment for it.
Drug history and allergies:
–    Methadone 50 mg daily
–    The patient is not taking any other regular medications(prescribed or over the counter)
–    The patient has no known drug allergies.
–
Family history
His father is eighty eight years old and suffers from high blood pressure and had a heart attack when he was sixty six years old (the patient was sixteen years at the

time).
His mother is seventy four years old and has high blood cholesterol and also suffered from cancer when she was fifty nine (the patient was twenty three years at the

time).
The patient has two brothers: one who is forty seven years old and has no addiction problems, and another who is forty four years old who had an addiction problem but

currently is clean, however he was recently convicted of selling illegal DVD’s and was sentenced to fifteen years in jail.
There is no history of psychiatric problems in the family.
Social history
Mr. JH at the moment lives alone in apartment but he previously was living with his wife in their prior to the separation. He has no friends at the moment, and states

that his friends abandoned him after they discovered his heroin addiction. He always seemed to have financial problems but has managed to get by, mainly through the

support of his family (for whom he retains a very good relationship) and his wife. He reports that he has never had a problem with gambling. He is regularly in contact

with his parents and siblings and they have been supportive of his condition ever since the beginning.

Personal history
Early life and development: The patient had did not suffer from any complications before birth, although he does remember his mother telling him that he suffered from

a blood condition during birth (rhesus disease) which caused him to be in and out the hospital during his childhood, which he and his family remember quiet well. Mr.

JH’s family (which includes his parents and his siblings) lived in a normal house of two stories in what he described was a nice neighborhood. He states that they were

well off finically as his father worked as a sea captain while his mother was a house wife. Due to his father’s profession, he would be away for long periods of time

extending up to nine months a year, which lead the patient to feel like he did not have a stable father figure in his life. His parents were happily married and he did

not suffer from any childhood abuse.
Educational history: the patient attended private school during his earlier years of his education and said to have never suffered any problems whatsoever and also

said to have been intelligent by many of his teachers. However at the age of twelve years, the patient was transferred to a public school, and started meeting new

friends and getting into trouble and suffering academically, which ended in the patient not completing his secondary education, and he dropped out by the age of

sixteen.
Occupational history: since he started working at the age of sixteen the patient changed his job three times. His first job was at SGS where he was an operator (he

stayed in this job for six years and his longest period of stable employment); he changed his job to a confectionary worker at the age of twenty two to earn a higher

income, however he was fired from this job after he was caught using the store as a hideout sell drugs. After spending time in prison for his crime, he attained a job

in office maintenance, for which he still works in till this day.
Relationship history: Mr. JH started his first relationship at the age of twenty years with his girlfriend, which he remained with her for another twelve years and

never got married, and had one daughter with her. He described their relationship as troubled at most times and he would become abusive when he did not get his way,

but nevertheless he loved  her and said that was she was always taken care of. At the age of thirty two years he was sent to rehabilitation clinic for three months to

treat his addiction to heroin after a court order, and during that period his girlfriend decided to leave him and prevent him from seeing his daughter, which in his

own words caused him to slip into a depressive state and even further his addiction. After one year from being separated from his girlfriend the patient met his future

wife (who is not Maltese) after selling her some drugs. He says that she was from a rich family abroad, and married her only after three months from meeting each

other, in order for her to fund his addiction. They have been together for the past 4 years but have recently gone through a separation. The relationship they share,

as describe by the patient, has been dysfunctional to say the least. He admits to beating her for not providing him with money, and she has been sent to the hospital

on several occasions. The patient’s partner is a known drug addict and has tested positive for both HIV and HebC, which has caused the patient to abstain from marital

relations or even sharing needles with her.
The patient has two brothers: one who is forty seven years old and has no addiction problems, and another who is forty four years old who had an addiction problem but

currently is clean, however he was recently convicted of selling illegal DVD’s and was sentenced to fifteen years years in jail.
When asked about his daughter, he explained that he has not seen her for the past five years, and has not spoken to her either. When she was born, he made an effort to

quit using drugs in order to become a good father for her, but he relapsed only after three months of quitting. He says that she is the only reason he has to keep

living, and hopes that one day the courts will allow him to visit her.
Overall the patient has a good relationship with his family and explains that they are very supportive and are helping him with his addiction.
Substances abuse the patient has a long history of substance abuse which is still standing till this day. The patient has used the following recreational drugs during

his lifetime:
1- Heroin (experimented at twelve however got addicted to it a sixeen, and continues till this day)
2- Alcohol (started at thirteen years but now only drinks during the weekends, about 12 units a week)
3- Marijuana (started at thirteen years and continues till this day)
4- Valium and unprescribed benzo’s (started at sixteen years but discontinued after trying other stronger drugs)
5- Heroin (became addicted at sixteen years and started injecting two years later)
Mr. JH started smoking at the age of seventeen and he smokes one pack of cigarettes in two days.
Hobbies He likes to walk and read books in his spare time.
Forensic History: Mr. JH has been convicted for several crimes in the past that mostly involved his drug use. He currently has two pending cases, one for possession of

illegal drugs during his second job which is he still is appealing, and the other for beating his wife. He spent about three months in jail when he was thirty two.
Premorbid history:
The patient describes to having a normal life prior to his addiction, he can remember that he was a very shy and quiet person but he always had this affection to be

with friends who were older than him and never with people his age, for which he regrets deeply.

Mental State Examination:

Appearance and Behavior:  Mr. JH is of normal build, looks disheveled and unkempt; he appeared older than his stated age and looked a bit emaciated. He had evidence of

track marking and needle injections all over his arms and legs along with several tattoos. The patient was polite, cooperative, appropriate in behavior, and maintained

good eye contact.  It was easy to establish a rapport with him.
Speech and thought form: his speech was that of a lowered tone, rate, and volume. He had normal thought form, and showed no evidence of thought disorder.
Mood:  when asked about mood the patient was subjectively ’okay’, but objectively dysthymic
Affect:  reactive
Thought content:  the patient had depressed cognitions of low self-esteem and hopelessness. During the interview the patient did not show any intention to harm neither

himself nor his family. No evidence of any delusions or abnormal beliefs.
Perception: the patient did not show signs of seeing illusions or experiencing any hallucinations.
Cognition:  the patient was alert, oriented to time, place, and person. Both short and long term memory were good.
Insight:  Mr. JH is aware of his condition, and accepts the fact that he needs treatment. Nevertheless, the patient is still resistant to increase his methadone dose

to reach treatment levels; therefore he seems reluctant to better his condition.

Differential diagnosis:

Antisocial personality disorder: the patient exhibits clear sign of this personality disorder, most notably his low threshold for aggression, his inability to learn

from past experiences, a disregard for his safety as well as the safety of those around him including his own daughters, and most importantly his deceitfulness which

he has used quite extensively to exploit his drug abuse needs. For these reasons, this diagnosis is most probable cause of his addiction.

Depression: he does have symptoms of depression like low mood and anhedonia, for which he has been feeling for quite some time; however it is unlikely to be causing

his addiction as he states that these symptoms have appeared only in recent years after as a result of his drug abuse. Another likely cause of his seemingly depressive

state is the use of cocaine that can result in patients experiencing symptoms of depression, and he admitted to have taken it prior to coming to the clinic.

Normal with no underlying psychiatric disease: as the patient has stated, peer pressure and involvement may have been the primary force behind his addiction followed

by inner desire for pleasurable effects of drugs.

Management:

First step of management starts with risk assessment, which involves assessing the patient for any signs that would suggest he could harm himself or those around. It

is suggested from the patient’s mental state exam that he is not suffering from any delusions (persecutory or others) and has not expressed any intentions to harm

those around him nor does he have any abnormalities in his thought form. However, his previous history of battery towards his wife and girlfriend, along with acts of

aggression and previous detention, puts him at high risk of future episodes of violence. It is therefore crucial to involve those who are close with the patient to

report and document any episodes of violence.  What is also important is to regularly follow up patients in order to assess their mental state and as simple changes in

their life could lead to detrimental effects on their mental health. (At a glance, 2012)
The second step is to establish the patient’s willingness to accept and undergo treatment, for not all patients are committed to receive it, as is the case in this

patient. However it is crucial to advise patients on how treatment is important for them in order to counteract their addiction, and perhaps build their lives back

together. It is important to explain to patient’s that substance abuse is a disease, and the matter will not resolve on it’s on and is likely to get worse. Once

patient’s become willing to undergo treatment, it should be done under the biopsychosocial aspect.  Since the patient’s addiction most likely due to an antisocial

personality disorder along with elements of depression as suggested by the symptoms, treatment will be as follows:
Biological: to tackle the patient’s heroin addiction, it is best to use a opioid agonist such as methadone under the methadone maintenance therapy, or a partial

agonist such as buprenorphine. (NICE,2007)
To treat the patient’s depression, the use of antidepressant agent like SSRI’s, SNRI’s, and tricyclic anti-depressants could alleviate symptoms; however they are more

beneficial in severe cases of depression. (At a glance, 2012)
Psychological treatment:  the patient’s heroin addiction, along with his associated depression can be targeted with behavioral therapy such as CBT. (ABC, 2009) As for

his addiction to other drugs such cannabis, and valium, these can usually be treated by community psychology therapy. (at a glance, 2012) Group based CBT and

interventional therapy can be of benefit for patients with anti-social personality. (NICE, 2009)
Social: A contingency program that involves psychosocial support can be of great benefit to patients with substance abuse.  Also the social worker can aid the patient

in finding a job that is more profitable, and eventually he can become more financially stable. He can also get in touch with self-help groups and other organization

such as APOGG in order to help him see his daughter again.

Discussion of management:

Biological treatment:
The use of opioid agonist therapy to treat heroin addiction has been the gold standard for many years, with methadone being the preferred drug of use. (Grella,

Lovinger, 2011) It is a synthetic opioid agonist, which has a long half-life, therefore if taken once daily, It can reduce the need to take multiple doses of heroin by

the patient, therefore the risks of taking street bough heroin like needle sharing and criminal activity. The intended benefit of however is to eventually get the

patient to abstain from using heroin while preventing withdrawal symptoms and reduce craving. Once the patient is maintained and is completely off heroin, relapses can

be prevented by using naltrexone (an opioid antagonist) that can cause withdrawal symptoms in patients which further prevents them from re-using heroin. (Amato et al,

2005).
Buprenorphine is a another important drug to treat addiction, it is a partial opioid antagonist and has the benefit of being safer than methadone at high doses, which

is why it has gained popularity recently as a better treatment method for heroin addiction.(McCance, 2004)

Psychological treatment:
Psychotherapy has been proven to be the truly beneficial modality of treatment for personality disorders, as it allows patients to cope with both social and

environmental stressors that these patients struggle with as they lack the skills to do so. (Stoffers et al, 2012) Psychodynamic therapy relies on exploring

unconscious forces  that develop in early life, which is usually the case in antisocial personality disorder, and how adapt into more positive perceptions by

transference from the therapist, which usually takes several years to achieve.( Goodman et al, 2012) CBT however employs identifying how the patient has inner beliefs

(sometimes false) that arise from life experiences, and when social or environmental stressors arise, these beliefs come into effect and negatively impact the patient,

which could also be the case in antisocial personalities. The aim is to allow patients to recognize these negative false beliefs in order to modulate them and

eventually change their personality. (Beck, Freeman, 1990)
Another method of treating antisocial personality disorder involves dialect therapy which helps the patient to develop skills that help them cope with impulsive events

and those that could lead to self-harm, thus reducing the impact of these symptoms on patients. (Widiger, Sanderson, 1997)

References:

1.    ABC of mental health BMJ, 2nd edition, 2009, Ed Teifon Davies, Tom Craig, BMJ books, ISBN: 978-0-7279-1638-6
2.    Amato L, Davoli M, A Perucci C, et al. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform

clinical practice and research. J Subst Abuse Treat. Jun 2005;28(4):321-9.
3.    Beck AT, Freeman A. Cognitive Therapy of Personality Disorders. London, England: Guilford Press; 1990.
4.    Goodman G, Edwards K, Chung H. Interaction structures formed in the psychodynamic therapy of five patients with borderline personality disorder in crisis.

Psychol Psychother. Dec 3 2012.
5.    Grella CE, Lovinger K. 30-Year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California. Drug Alcohol

Depend. Nov 1 2011;118(2-3):251-8.
6.    McCance-Katz EF. Office-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry. Nov-Dec 2004;12(6):321-38.
7.    National institute for health and care,2007, drug misuse- opioid detoxification, CG 52.
8.    National institute for health and care,2009, antisocial personality disorder: treatment, management, and prevention, CG 77.
9.    Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst

Rev. Aug 15 2012;8:CD005652.
10.    Widiger TA, Sanderson CJ. Personality disorders. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. Philadelphia, Pa: Harcourt Brace & Co; 1997:1291-1317.

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