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Dear Shafern
Good write up and discussion. Some things that needed to
be explored - frequency of injections. where does he
smoke or inject. Sharing needles, if they do, do they clean
the needle and technique. History of psychosis needs to be
ruled out. Under investigations x-ray chest required and
screening for TB. Since he is thin and emancipated rule out
deficiency - FBP (full blood picture). Why the risk
assessment when he has no suicidal thoughts or intent
now?
Identifying Data
Referral Source
Presenting Complaint
History of Present Illness
Previous Psychiatric History
History of Self Harm
Previous Medical/ Surgical History
Drug and Alcohol History
Family Psychiatric History
Personal History
Psychosexual History
Social History
Forensic History
Premorbid Personality
Current Mental State
Physical Examination
Risk Assessment for Suicide
Screening for Depression
Summary
Management
Record Current Treatment
Discussion
Identifying Data
Name:
Age:
Adenan (Mr A)
53 years old
Referral Source
Presenting Complaints
Mr A walked in to the clinic for his daily Methadone replacement. There was no
active complain.
D
much it weighs. One week later, he started using two packs per day. The
following week it increased to three packs per day. Eventually he required at
least 5 packs per day to avoid withdrawal symptoms. The maximum he had
consumed in a day was 10 packs, especially after collecting his meagre salary.
He barely ate anything and was very thin after spending all of his money on
opiates.
He tried to stop his addiction 6 times but was unsuccessful. He was admitted
once in year 2002 to rehabilitation centre (Pusat Serenti). For the past 25 years,
he spent the whole day thinking and working to make cash to sustain his
addiction. His cravings for opioids were constant and persistent. In addition, he
was only able to work part time and never had a full time job more than one
year. The reasons were because he kept missing work, unable to perform his
duties well and he gets sick easily. He went to prison three times and
incarcerated for 8 months to 1 year each time. He only managed to recall that
his last prison term was in 2011. Even after being released, his cravings soon
returned and he relapsed. Mr A had lost interest in doing what he loved. He
loved playing football in school but he had stopped getting involved in sports. He
was terribly scolded by his parents but to no avail. He was then sent out from his
home at 28 years old. His parents remained together and had a loving
relationship. When he did not have enough amount of opioids, he develop severe
body ache, sweats, shivers, constantly yawning and fever. Mr A described that
his head hurt so bad that he cant think and function. After taking morphine, his
symptoms would gradually go away. He denied any reaction or rash at injection
site.
He voluntarily requested to be referred for methadone replacement because he
was fed up of himself, he had no money, starving and in pain. Mr A was
commenced on 20 mg of methadone liquid and titrated to 80 mg. He takes it
daily for the past 1 year and is able to last one full day without any withdrawal
symptoms. When asked to compare between morphine and methadone, he
claims that methadone is equally effective. Mr A admits that he still takes opioids
once every 3 months. He is able to remain working full time for the past 2 years.
Nevertheless, Mr A feels that his life has improved tremendously with methadone
replacement and he looks forward to the day he is free from methadone.
E
Apart from Opioid use, Mr A started smoking at 19 years old and is currently
taking 2 boxes per day. No intention of quitting smoking.
Used to consume beer and hard liquor occasionally (never drunk) before 35
years old. Last alcohol intake was approximately 15 years ago.
I
Personal History
During his childhood, he enjoyed the company of his friends, was not bullied
and never gotten into a fight. He nevertheless did skipped school to play football
and hang out with his friends in the mall. He denied any problems between his
parents and lived in a flat together with his elder brother. Mr A could not recall
any financial concerns in his family because his father made enough to put food
on the table. He was educated at Abdullah Munsyi Secondary School in Penang
until 17 years old. He did not pass his fifth form exam but manage to pass PMR
with grades which he could not recall. Mr A did not have any difficulties with his
friends or teachers. He loved playing football and even represented his school for
competition.
For his work record, he previously had no stable job and took on a variety of work
such as a waiter, cleaner, labourer and security guard. Mr A changed jobs
because he kept on missing work and unable to concentrate on his work. His
longest full time employment is with his current employer as a security guard
since 2 years ago. He makes RM1100 per month.
K
Psychosexual History
Mr A is currently single with no children. He had paid sex twice when he was 25
years old and none since.
L
Social History
Mr A is currently renting a room at bayan lepas. He pays RM 100 per month for
his room and has basic necessities such as water, gas and electricity. His friends
are those he meets at the methadone clinic. Whenever he has free time, he
watches television.
M
Forensic History
Went into prison 3 times caught in possession of drugs, most recent in 2011 for 8
months. No history of violence.
N
Premorbid Personality
Form of Thought
Mood
Affect
Thought Content
Perceptions
Cognitive Function
Orientation
Memory
Information and
vocabulary
Abstraction
Attention and
Concentration
Judgement: Mr A is able to share his vision about his goals and future with me.
He would like to cut down methadone and be free from it in the near future. Mr A
also loves his job and hopes to maintain his work.
Insight: Mr A has good insight. He is able to admit that taking drugs is bad for
him. He wants to change his life for the better hence he voluntarily came to
methadone replacement clinic. Mr A also knows the function of methadone.
Physical Examination
and spleen is not enlarged, kidneys are not ballotable, bowel sounds heard, no
renal bruit.
Q
Patient Demographics:
Mr A did not feel sad or low for the past two weeks. He is able to carry out his
work, function well, and no loss of interest in activities which he finds
pleasurable.
S
Summary
Management
chronic substance abuse. They tend to eat and drink very little. All money spent
on drugs.
Rapid Plasma Reagent: To test for syphilis because patient has history of paid
sexual services and IV drug use.
Hepatitis Viral Testing: To determine presence of viral hepatitis especially
hepatitis B and C in this patient due to history of IV drug use.
HIV Test: Test is carried out to determine presence of HIV because Mr A has
history of chronic IV drug abuse and paid sexual services.
Urine Toxicology Test: To determine presence of opioids in urine and presence
of any other drugs which Mr A may have taken but not told to health
professionals. Concomitant use of other drugs such as high dose hypnotic,
sedative or alcohol may lead to aggravation of respiratory depression. It is also
useful used as a baseline for future monitoring.
Results Summary: Latest test two weeks ago shows normal LFT, HIV negative,
RPR negative, Urine toxicology test negative for opiates and also cannabis,
benzodiazepine. No abnormalities noted in full blood count and electrolytes
levels.
U
Biological
Drug Substitution Therapy (Methadone Replacement)
Methadone is administered under medical supervision and replaces dangerous
drugs such as morphine in this patient, Mr A. Methadone is a partial opioid
agonist which has similar action to morphine but of much lower addictive effects.
Methadone replacement prevent consequences associated with risky behaviours
of injecting drugs.
In Mr A, Methadone was commenced at 20mg doses, and titrated upwards to the
amount sufficient for Mr A to avoid withdrawal symptoms. Mr A is currently on
80mg dose daily.
Current Medical Condition
Treat any underlying medical condition if present after initial investigation.
Psychological
Psychoeducational - To educate Mr A regarding dangers of taking dangerous
drugs like morphine and how the hospital will help him with his drug addiction
problem. Educate Mr A about benefits of methadone replacement. Educate Mr A
regarding negative consequences of high risk behaviour particularly injecting
dangerous drugs and sexual relationships.
Group Discussion- Mr A has poor family support because he lives alone and is not
married. Group discussion with individuals with similar problems may help Mr A.
Group discussion should reinforce importance of adherence and benefits to
Discussion
Comparison of Rehabilitation Programme and Methadone Replacement
as Treatment Options
Reference
1. Vicknasingam and Mahmud Mazlan (2008). Malaysian Drug Treatment
Policy: An Evolution from Total Abstinence to Harm Reduction. Journal
Antidadah Malaysia 107-121.
2. Centres for Disease Control and Prevention (2002). Methadone
Maintenance Treatment. IDU HIV Prevention.
Website accessed 8 May 2015:
http://www.cdc.gov/idu/facts/MethadoneFin.pdf
3. Jeffrey and Marcus (2012). Implementing methadone maintenance
treatment in prisons in Malaysia. Bulletin of World Health Organisation
124-129.