• Self-neglect
  • Slovenliness
  • Deteriorating school performance
  • Excessive sleeping
  • Rough appearance
  • Increasing and unexplained demand for money from care givers
  • Involvement in petty crime (pilfering)
  • Running away from home – in addition to aforementioned substance-related disorders.

Management – General Principles

  • Substance specific detoxification
  • Patient/family education/counselling
  • Alternative leisure activities
  • Work/school rehabilitation
  • Involvement of community agencies, e.g., religious organizations, Alcoholics Anonymous, Narcotic Anonymous where available.
  • Refer for long-term management by psychiatrist.

Management – Pharmacological

  • For agitation, use: Diazepam 0.2–0.8mg/kg/dose. max 0.6mg/kg/dose PO daily to be tapered off in 10 days.
  • For the parasympathetic upsurge, use: Clonidine 5–7μg/kg/24 hour, max dose 0.9mg/24 hour PO daily for 10 days.
  • For any assaultive behaviour, use: Haloperidol 0.05–0.15mg/kg/24 hour; children over 12 years 2–5mg/dose TDS PO; OR chlorpromazine 2.5–6mg/kg/ 24 hour 4–6-hourly TDS as necessary.
  • For pain, use: Paracetamol 20–40mg/kg/24 hour 4–6-hourly PO as necessary

Management of Selected Substances of Abuse

  • Opioid detoxification: Opioids abused include heroin, morphine, dihydrocodeine, and pethidine. Tolerance develops rapidly and withdrawal features include agitation, lethargy, sweating, goose flesh, running nose, shivering,
    musculo-skeletal pains, diarrhoea, and abdominal cramps. These effects peak at 48 hours and subside over a period of 10 days. Owing to the highly addictive nature of opioids, admission to hospitals is necessary.
  • Cannabis dependence: Chronic users may develop psychosis, anxiety, mood disorders, and a withdrawal state. Admission is usually necessary for initiating abstinence. Treatment of the psychiatric complication is the same as
    for the primary syndromes.
  • Khat (miraa) dependence: Chronic users (2 kilos or more per day) may develop anxiety, mood disorders, and schizophrenia-like psychosis. Abstinence is to be encouraged. Treatment of the related psychiatric disorders is the same as for the primary syndromes.
  • Solvent abuse: Solvents have powerful euphoriant properties. They are mainly abused by street children and the homeless. Chronic users may develop organ damage (liver, heart, kidney), apart from neurological damage.
    Patient education is vital. Involve family and relevant authorities in rehabilitation if possible.