You are on page 1of 11

Feedback

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?

Psychiatry Case Write Up


Students name : Shafern Tan Cheng Li
Student ID
: 2014132
Report
: Psychiatry, Addiction Case
Group
: Group B, A1
Sections for case
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V

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

Gender: Malay Male


Marital Status: Single
Occupational Status: Security Guard
Living Situation: Rented room, Living along
Legal Status: Voluntary
B

Referral Source

Outpatient Department Penang General Hospital


C

Presenting Complaints

Mr A walked in to the clinic for his daily Methadone replacement. There was no
active complain.
D

History of Present Illness

Mr A was introduced to Cannabis (Marijuana) at the age of 23 by his friends. All


he hoped for was to be happy and accepted into his group of friends. His method
of consumption was smoking marijuana in paper-wrapped joints. He remained so
for two years. When he approached 25 years old, he felt that he needed
something stronger. He tried several others which he could not recall but
eventually his friends introduced Opioids (Morphine) and he was hooked.
Mr A took opiates either by injection or smoking via chasing the dragon. He
alternates between both, taking one or the other. Mr A began with 1 small pack
per day which cost RM10 each. The quantity was little but he was unsure how

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

Previous Psychiatric History

No previous admission or history of any mental illness.


F

History of Self Harm

No history of self-harm. Absence of suicidal thoughts and plan.


G

Previous Medical/ Surgical History

Completed Tuberculosis treatment one year ago. HIV negative. No other


significant medical or surgical illness.
H

Drug and Alcohol History

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

Family Psychiatric History

No family history of psychiatric illness or suicide. He is the only member of his


family who has substance misuse.
J

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

His friends would describe him as friendly and helpful.


O

Mental State Examination

General Appearance and


Behaviour

Form of Thought

Mr A is alert and conscious. He used a walking aid


and was smiling. Well-groomed and dressed in
security guard uniform. He was calm, good rapport
and gave full co-operation.
Bahasa Malaysia language was used, good amount
and volume of speech. Mr A was coherent and

Mood

Affect
Thought Content

Perceptions

relevant. Flow is normal and absence of thought


disorder such as looseness of association or thought
block.
Mr A is euthymic for the past two weeks. Mr A did
not express hopelessness or suicidal thoughts. No
suicidal intent or plans.
Currently he is normal and congruent.
Absence of any thought content disorder. No
delusions, thought broadcasting, feeling of passivity
or thought withdrawal.
Absence of delusions and hallucinations.

Cognitive Function
Orientation
Memory

Information and
vocabulary
Abstraction
Attention and
Concentration

Well oriented. Mr A knows where he is, time, date


and day.
Immediate recall was normal. He is able to perfoem
five minute memory test. His remote memory is
also good because he is able to recall past events.
His intelligence level is normal and appropriate. He
has no difficulties understanding and answering
questions.
Normal. He is able to understand three proverbs and
list a few similarities between two objects.
Normal. Mr A is able to perform serial seven test
correctly.

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

On general examination, Mr A uses a walking stick. He is alert, conscious and


well oriented. There were no conjunctiva pallor. Presence of scleral icterus. Did
not notice deviation of nasal septum, no nasal bleeding or rhinitis. Tongue is pink.
Dentition is poor with tar staining. Tar staining on finger nails as well. No
clubbing, absence of palmar crease pallor, no palmar erythema. Healed injection
scars noted at cubital fossa with absence of inflammation, no abscess or ulcers.
Good pulse volume, regular rhythm and rate.
On auscultation of his lungs, vesicular breath sounds noted, equal air entry and
no added sounds. On auscultation of his heart, apex beat is not displaced, first
and second heart sounds heard, no murmur or added sounds, no parasternal
heave or thrills. On abdominal examination, no tenderness or mass felt. Kidney

and spleen is not enlarged, kidneys are not ballotable, bowel sounds heard, no
renal bruit.
Q

Suicide Risk Assessment

Patient Demographics:

53 years old Malay Male, Single.

Past and current suicidality:

Have never hurt himself, no thoughts of suicide.

Psychiatric Diagnosis & symptoms: Substance abuse. No other psychiatric


diagnosis or symptoms
Personal History:
neglect.

No family history of psychiatric illness, no violence, abuse or


Psychosocial history- He is currently living alone with no
family support. Has a full time job. No recent stressful event.
Medical History- No existing medical illness. Mr A is
independent and not functionally or cognitively impaired.

Personality, strengths and weakness: Mr A is healthy and independent strong


man. He dislikes giving his family members
trouble. He never gives up trying to change his
life for the better. Even though he is living alone,
he is able to find a job, pay his bills and care for
himself.
Protective factors: Absence of mental disorder, and employment. He however
does not have good social support.
Suicide Risk: Low

Screening for Depression

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

Mr A is a 53 years old Malay gentleman who came for methadone replacement.


He has been taking morphine for the past 25 years. Mr A uses increasing amount
of opioids, have unsuccessful attempts to cut down opioid usage, spent most of
his time thinking on how to obtain morphine, severe cravings, no full time job,
went to prison three times, loss of interest in doing sports. He was admitted once
in 2002 to rehabilitation centre (Pusat Serenti). When he does not take morphine,
he has severe body ache, fever, sweats and shiver. It is relieved by taking
opioids. On physical examination, healed injection scars were noted on both of
his cubital fossa with absence of inflammation. His current mental state is good.
Using the biopsychosocial model, his precipitating factors were substance misuse
and early relationships with friends which negatively influenced him. His
precipitating factors were substance misuse, arguments with his parents
regarding his opioid addiction, lack of support and financial difficulties. The

perpetuating factors were lack of support from family, substance misuse,


unemployment, financial difficulties and socially isolated from the society due to
his substance misuse behaviour.
Preferred Diagnosis
Opioid Use Disorder. Mr A fulfils more than 2 out of 11 of DSM V criteria. He
took larger amounts of opioids over 25 years, unsuccessful efforts to cut down on
opioid use, spent most of his time in activities necessary to obtain opioid, strong
cravings, no stable job, gave up football, withdrawal symptoms, relieve only with
opioids, went into prison three times for the past 25 years. Mr A is currently in
early remission and on methadone replacement. None of the criteria for opioid
use disorder have been met for at least 3 months but less than 12 months
except that he still has cravings for opioids.
Differential Diagnosis
Antisocial Personality
Pros: Failure to conform to social norms with respect to lawful behaviours as
evident by three times of prison terms. Consistent irresponsibility as evident by
no full time job and constant changing of jobs.
Cons: Did not fulfil 3 out of 7 DSM V criteria for antisocial personality disorder. Mr
A began to misuse substances at the age of 23, not 15 years old. Mr A feels
remorse for his actions and knows it is wrong. Absence of deceitfulness, no
impulsivity, not irritable and aggressive.
Panic Attacks
Pros: Mr A exhibits symptoms such as sweating and trembling or shaking.
Cons: He does not have manifestation of symptoms such as shortness of breath,
feelings of choking, light headedness of fear or dying and losing control. Four out
of thirteen in Criteria A for DSM V is not fulfilled. Criteria C is also not met as this
disturbance can be attributed to physiologic effects of substance misuse.
T

Management

Collateral History was not taken because patient came alone.


Investigations:
Assess vitals Blood Pressure, Heart Rate and Body Mass Index. This is to
determine any underlying co morbids such as hypertension and obesity. It may
also be used as a baseline for future follow up.
Full Blood Count: To rule out any underlying infections and anemia.
Liver Function Test and Renal Function Test: Mr A has a history of
Intravenous Drug abuse. LFT needs to be done to determine presence of any
liver damage due to prolong exposure to toxins. Renal Function test used to
exclude any acute kidney injury due to prolong drug use. Both are useful as a
baseline for future treatments and monitoring.
Electrolytes : Determine any abnormality in electrolytes to rule out any
dehydration or lack of electrolytes which is especially common in individuals with

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

Record Current Treatment

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

methadone replacement, negative consequences and avoidance from injecting


drug use and unprotected sex.
Social
Environmental modification- Attempt to relocate Mr A to another area or change
his daily routine activities which may trigger his cravings. Because Mr A is
vulnerable and easily influenced by friends, advise him to change the group of
friends which takes illegal drugs.
Therapeutic communities- Introduce and advice patients to community social
support groups for individuals with similar problems so that they can discuss,
manage and support each other whenever they encounter any problems.
Mr A still carries out his prayers and occasionally attend prayer sessions to seek
strength and direction from God. Encourage him to continue doing so and refer
him to any Islamic religious motivational talks which may help him to pull
through this difficult time.

Discussion
Comparison of Rehabilitation Programme and Methadone Replacement
as Treatment Options

Rehabilitation Programme in Malaysia, also known as Pusat Serenti is based on


an institutional concept and comprises of 29 treatment centres. Three treatment
modalities used are; cold turkey detoxification in the institution, two years of
institutional rehabilitation and lastly aftercare supervision for a duration of one to
two years.1 Multi-disciplinary approach which is carried out in phases include
spiritual, vocational, military style physical training and psychosocial
interventions are used. The final phase includes re-entry programmes which
assist individuals with integrating in to the community. Rehabilitation
programmes essentially based on a total abstinence approach.
The disadvantages are high relapse rate, associated stigma with rehabilitated
individuals, loss of two years productivity and the use of illicit means to obtain
drugs were not addressed. Rehabilitation programme was shown to be not
successful with a relapse rate ranging from 70-90%. 1 For decades, this was the
only method employed to help drug addicts. The withdrawal symptoms
experienced with no supportive help from medication to relieve pain deters many
from embarking on this programme. Stigma associated with rehabilitation makes
it difficult for individuals to blend in with the society and may worsen social
isolation. While institutionalised for 2 years, individuals lose working years and
are unable to contribute to the productivity of the country, while ironically using
even more finances to sustain rehabilitation programmes. While institutionalised,
those with family may not even see their loved ones for support and unable to
care for their wife and children. This will destroy any love relationship left and
sense of responsibility remaining which may help drug addicts to recover.
Methadone is a synthetic, long acting opioid agonist that works by occupying
the brain receptor sites affected by opiates. 2 It relieves craving for opiates,
relieves withdrawal symptoms, inhibits the euphoric and sedating effects of
opiates, does not cause euphoria or intoxication itself (with stable dosing) and it
is excreted slowly so it is taken once a day. 2 In Malaysia, Methadone can be
obtained from several general hospitals in Malaysia for free.
Methadone replacement is the most effective treatment for opioid addiction as
compared to rehabilitation programmes because it reduces the illicit usage of
injection drugs, decreases risk of transmitted diseases such as HIV, hepatitis B or
C and endocarditis.2 Because methadone is given free of charge, criminal activity
is decreased. Individual is able to concentrate and employment potential is
improved hence better family stability. Recovering addicts can focus on
managing their family and strengthening social support which is important in
advancing towards a drug-free life.2 On the contrary, the disadvantages are drug
addicts may built tolerance and dependence on methadone, potential abuse of
methadone and drop out from programme before minimum 12 month treatment
period. 2 Patients dropped out either because they do not comply with
programme regulations or clinic encouraged them to leave. 2 Those who drop out
eventually relapses.
In Malaysia, the implementation of methadone replacement programme in
prisons is not widely available.3 A drug addict which is caught possessing drugs is
thrown into prison for at least 8 months. Upon release, a drug addicts cravings
return and he or she then relapses. My patient for example was put in prison
three times for at least 3 years in total. More cost is incurred for law enforcement
and keeping drug addicts in prison as compared to early introduction of

methadone maintenance programme. Implementing methadone replacement in


prison saves cost in the long run and hence all prison in Malaysia should have
this programme in place. In summary, methadone replacement programme is
the way forward and should also be implemented in all Malaysias prison in a
systematic and sustainable manner.3

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.