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Mental Health & Substance Use

Substance Abuse (Other than Alcohol)

Problematic pattern of using substances other than alcohol (e.g., cannabis, khat, opioids, cocaine, stimulants, sedatives, inhalants) leading to health damage (physical/mental), social dysfunction, or dependence.

Also known as: Drug Abuse, Substance Use Disorder (Other), Drug Dependence, Illicit Drug Use

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Referral and warning signs

When to refer

Refer to higher level care / specialist (Mental Health, Addiction Services - RR/NRH) for: Patients meeting criteria for Substance Dependence requiring detoxification or MAT. Severe withdrawal symptoms (esp. sedative/hypnotic). Patients with significant medical or psychiatric comorbidities. Overdose requiring intensive management. Failure of initial brief interventions/counselling.

Red flags

  • Signs of acute overdose (respiratory depression, coma, seizures, severe agitation/psychosis, cardiovascular instability)
  • Signs of severe withdrawal (seizures, delirium - esp. benzodiazepines/barbiturates)
  • High risk behaviors (e.g., sharing needles, severe neglect of self-care)
  • Suicidal ideation
  • Severe co-occurring medical or psychiatric illness

Signs and symptoms

  • General signs pointing to potential substance use disorder:
  • - Behavioral changes: Increased secrecy, irritability, mood swings, neglect of responsibilities (school/work/family), change in friends/hangouts, unexplained financial problems, stealing, involvement in illegal activities.
  • - Physical changes: Weight loss/gain, changes in appearance/hygiene, red eyes, abnormal pupil size, track marks (injection use), nasal irritation (snorting), burns (smoking), tremors, slurred speech, unsteady gait.
  • - Psychological changes: Anxiety, depression, paranoia, memory problems, lack of motivation, psychosis.
  • - Social changes: Relationship problems, conflicts, social isolation.
  • Specific signs depend on substance:
  • - Cannabis (Marijuana, Bhangi): Red eyes, increased appetite, dry mouth, impaired coordination/memory, slowed reaction time, anxiety/paranoia (esp. high doses). Withdrawal: Irritability, anxiety, insomnia, decreased appetite.
  • - Stimulants (Khat/Mairungi, Cocaine, Amphetamines): Euphoria, increased energy/alertness, decreased appetite, insomnia, rapid speech, dilated pupils, tachycardia, hypertension, paranoia, agitation, aggression, psychosis. Withdrawal: Depression, fatigue, increased appetite, unpleasant dreams.
  • - Opioids (Heroin, Morphine, Pethidine, Tramadol): Euphoria, drowsiness, constricted pupils, constipation, respiratory depression (overdose risk - see TOX009). Withdrawal: Flu-like symptoms (muscle aches, chills, sweating, runny nose, yawning), nausea/vomiting/diarrhea, dilated pupils, anxiety, insomnia.
  • - Sedatives/Hypnotics (Benzodiazepines, Barbiturates): Drowsiness, slurred speech, poor coordination, confusion, memory impairment, respiratory depression (overdose risk - see TOX008). Withdrawal: Anxiety, insomnia, tremors, seizures (potentially life-threatening for benzo/barbiturate withdrawal).
  • - Inhalants (Petrol fumes, Solvents, Glue): Dizziness, euphoria, slurred speech, unsteady gait, confusion, potential for sudden sniffing death (arrhythmia), long-term organ damage.

Risk factors

  • Social factors (peer pressure, availability, poverty, unemployment, cultural norms).
  • Psychological factors (stress, trauma, low self-esteem, co-occurring mental health disorders - self-medication).
  • Genetic predisposition.
  • Early age of initiation.
  • Family environment (parental substance use, family dysfunction).

Diagnosis

Clinical assessment

Based on history of substance use pattern (type, frequency, amount, route), presence of dependence criteria (similar to alcohol dependence - compulsion, loss of control, tolerance, withdrawal, neglect of activities, use despite harm), and evidence of negative consequences. Screening tools may be used. Urine/blood toxicology can confirm recent use but doesn't diagnose disorder.

Investigations

  • Detailed substance use history (essential).
  • Assess for dependence criteria.
  • Assess for co-occurring physical and mental health conditions (HIV, Hepatitis, TB, depression, psychosis).
  • Urine/Blood Toxicology screen (confirm recent use, identify substances).
  • Consider tests for associated health problems (LFTs, RFTs, infectious disease screening).

Diagnostic criteria

Meet criteria for Substance Use Disorder (mild, moderate, severe) based on established diagnostic systems (e.g., DSM-5) involving impaired control, social impairment, risky use, and pharmacological criteria (tolerance/withdrawal).

Management

Non-pharmacological management

  • Brief Intervention & Counselling: For harmful/hazardous use.
  • Motivational Interviewing.
  • Psychosocial Interventions (for Dependence):
  • - Psychoeducation (patient and family).
  • - Counselling / Psychotherapy (CBT, Contingency Management, Relapse Prevention).
  • - Mutual Help Groups (Narcotics Anonymous - NA, etc.).
  • - Family support.
  • Harm Reduction Strategies (where applicable/available): Needle exchange programs, overdose prevention education (naloxone distribution).

Pharmacological treatment

  • Management of Acute Intoxication/Overdose: Depends on substance (e.g., Naloxone for opioids - TOX009; supportive care for stimulants/cannabis; Benzodiazepines for stimulant-induced agitation/seizures; supportive care for sedatives - TOX008).
  • Management of Withdrawal:
  • - Opioid Withdrawal: Symptomatic treatment (clonidine, antiemetics, analgesics) or opioid agonist therapy (Methadone, Buprenorphine - requires specialized programs).
  • - Benzodiazepine/Barbiturate Withdrawal: Requires slow taper of the agent or substitution with long-acting benzodiazepine (e.g., Diazepam) and gradual taper, often inpatient due to seizure risk.
  • - Stimulant/Cannabis Withdrawal: Primarily supportive care.
  • Medication-Assisted Treatment (MAT) for Dependence (Specialist initiation/supervision - RR/NRH):
  • - Opioid Use Disorder: Methadone maintenance, Buprenorphine (often combined with naloxone), Naltrexone (oral or long-acting injection - requires detoxification first).
  • - Nicotine Use Disorder (Tobacco): Nicotine replacement therapy (patch, gum), Bupropion, Varenicline.
  • - Other SUDs: Limited specific MAT options, focus on psychosocial treatment and managing co-occurring disorders. Naltrexone may have role for some.
  • Treat co-occurring medical (HIV, Hep C, TB) and psychiatric conditions.

Monitoring

Monitor substance use patterns (self-report, toxicology screens). Monitor for withdrawal symptoms. Assess for cravings. Monitor adherence to treatment (psychosocial, pharmacological). Monitor physical and mental health status. Monitor social functioning and stability.

Complications

  • Overdose (potentially fatal depending on substance)
  • Infectious diseases (HIV, Hepatitis B/C, TB, skin infections - esp. with injection use)
  • Physical health problems (cardiovascular, respiratory, neurological, liver, kidney damage - varies by substance)
  • Mental health disorders (depression, anxiety, psychosis - triggered or exacerbated)
  • Accidents and injuries
  • Social consequences (legal problems, unemployment, homelessness, relationship breakdown)
  • Withdrawal syndromes (can be severe/life-threatening for some substances)
  • Cognitive impairment
  • Death

Prevention

  • School-based prevention programs.
  • Public awareness campaigns about risks.
  • Addressing social determinants (poverty, unemployment).
  • Early intervention for mental health problems.
  • Reducing availability of illicit drugs.
  • Promoting healthy coping strategies.

Patient education

  • Educate about the specific substance used, its risks, and the nature of dependence/addiction.
  • Explain treatment options (psychosocial, MAT if applicable).
  • Discuss harm reduction strategies.
  • Explain withdrawal symptoms and management.
  • Encourage engagement with support groups (NA) and psychosocial treatment.
  • Provide information on preventing infectious complications (safe injection, safe sex).
  • Involve family support where appropriate.

Uganda-specific notes

Commonly abused substances include cannabis (njaga), khat (mairungi), heroin, cocaine (often less pure forms), benzodiazepines, tramadol, and inhalants (glue, petrol). Injection drug use contributes to HIV/Hepatitis spread. Access to specialized addiction treatment (detox, MAT like Methadone/Buprenorphine, Naltrexone) is very limited, mainly at RRH/NRH level. Harm reduction services are expanding but not universally available. Focus on psychosocial support, brief interventions, and managing complications.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.6 (Note: UCG text incorrectly labels this 9.1.2, but content aligns with Substance Abuse)

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