PS3.1 | Psychoactive Substance Use Disorders — Summary & Reflection

KEY TAKEAWAYS

Substance use disorders are the most prevalent psychiatric conditions in India. Key take-aways:

• ICD-11 dependence requires all three: impaired control + increasing priority + physiological features (tolerance/withdrawal). Never diagnose dependence from a single heavy-use episode.
• Alcohol withdrawal timeline: minor symptoms at 6–12 h → seizures at 24–48 h → delirium tremens (DTs) at 48–72 h. DTs carry up to 20% mortality if untreated.
• Treatment of alcohol withdrawal: benzodiazepines (chlordiazepoxide oral, diazepam IV for severe cases), titrated by CIWA-Ar severity. Thiamine 100 mg IV BEFORE glucose — prevents Wernicke encephalopathy.
• Tobacco cessation: 5 A's brief advice + NRT (patch/gum) + bupropion or varenicline (first-line, most effective).
• Opioid use disorder: withdrawal not life-threatening; maintenance with buprenorphine (partial agonist, safer) or methadone (full agonist) via NDDTCP programme.
• Screening tools: CAGE (≥2 positive = likely problem); AUDIT (scores 8–15 hazardous, ≥20 probable dependence).
• Primary care role: identify, screen (AUDIT/CAGE), brief intervention, manage withdrawal, refer for maintenance/psychosocial support.

REFLECT

Consider a patient in your future practice — a 38-year-old construction worker who drinks every evening to 'sleep' and has tried unsuccessfully three times to stop. He has never had a seizure. He is worried about what will happen if he stops again. He has a wife and two children dependent on him financially. How would you frame your conversation with him? What combination of medical management, counselling, and social support would you offer, and how would you involve his family? The science of addiction gives us tools; the art of medicine is knowing how to deploy them in a context of stigma, limited resources, and a patient's complex life. What does this patient need from his doctor that he cannot get from a prescription alone?