Substance abuseSubstance abuse in Tin Shui Wai District: in Tin Shui Wai District:

2009 Primary Care 2009 Primary Care Case SharingCase Sharing

Dr Aaron Lee Fook KayDr Aaron Lee Fook KayMB,BS(HK), PgDipCommPsyMed(HK)MB,BS(HK), PgDipCommPsyMed(HK)

Chairman of HKCPMAChairman of HKCPMA21st September 200921st September 2009

Tuen Mun HospitalTuen Mun Hospital

Case SharingCase Sharing

Female/ 29 years old.Female/ 29 years old. First presented to my clinic on 19 September 2First presented to my clinic on 19 September 2

008 for insomnia for 1 year.008 for insomnia for 1 year. Socially withdrawn, living with boyfriend, deprSocially withdrawn, living with boyfriend, depr

essive mood, crying, unemployed, decreased aessive mood, crying, unemployed, decreased appetite, weight loss of >10 lbs, loss of energy, lppetite, weight loss of >10 lbs, loss of energy, loss of concentration, loss of interest, obsessivoss of concentration, loss of interest, obsessive-compulsive behavior of handwashing.e-compulsive behavior of handwashing.

admitted taking sleeping pills from another doadmitted taking sleeping pills from another doctorctor

Feeling worthless, helpless and uselessFeeling worthless, helpless and useless Denied any suicidal thoughts, delusional ideas Denied any suicidal thoughts, delusional ideas

or hallucinationor hallucination Self-inflicted injury by wrist-cuttingSelf-inflicted injury by wrist-cutting Father committed suicide, with self-blaming oFather committed suicide, with self-blaming o

f not doing anything to help, mind full of sense f not doing anything to help, mind full of sense of guiltof guilt

Premorbid personality: extrovertPremorbid personality: extrovert No smoking, no alcohol use, no medicationsNo smoking, no alcohol use, no medications

Prescribed SSRI to treat her major Prescribed SSRI to treat her major depressive disorderdepressive disorder

Advised to come back for follow up in Advised to come back for follow up in one weeks’ time for reassessmentone weeks’ time for reassessment

Second VisitSecond Visit

Return on 26 September 2008Return on 26 September 2008 Still sleepless and socially withdrawnStill sleepless and socially withdrawn Daytime somnolence, palpitation, with anxiouDaytime somnolence, palpitation, with anxiou

s mood for the past few dayss mood for the past few days Now developed agoraphobiaNow developed agoraphobia Also presented with microscopic haematuria Also presented with microscopic haematuria

(Urine Stix=RBC2+; WBC2+; Alb+)(Urine Stix=RBC2+; WBC2+; Alb+) Admitted taking TCM for urinary symptom (freAdmitted taking TCM for urinary symptom (fre

quency and dysuria)quency and dysuria)

Patient refused to talk further about her Patient refused to talk further about her urinary problems and said she was careurinary problems and said she was cared by residents in Ruttonjee hospitald by residents in Ruttonjee hospital

Not much improved with her depressive Not much improved with her depressive symptoms and denied suicidal ideationsymptoms and denied suicidal ideation

Advise to continue with SSRI and to comAdvise to continue with SSRI and to come back in one week’s timee back in one week’s time

Third VisitThird Visit

Third visit on 2 October 2008Third visit on 2 October 2008 Frightening sensations in crowded placesFrightening sensations in crowded places Sleepless(4 hours) with early morning wakeninSleepless(4 hours) with early morning wakenin

g, socially withdrawng, socially withdrawn Palpitation and tremor, agoraphobiaPalpitation and tremor, agoraphobia Complained of gross haematuria 2 times with Complained of gross haematuria 2 times with

urgency and frequencyurgency and frequency Urine stix=RBC2+, WBC2+, Alb2+Urine stix=RBC2+, WBC2+, Alb2+ See specialist on 13 October in RH for IxSee specialist on 13 October in RH for Ix

Suicidal ideation with no improvement Suicidal ideation with no improvement of depressive symptomsof depressive symptoms

Sense of fear, wandering in street, memSense of fear, wandering in street, memory loss, panic attack once with sense of ory loss, panic attack once with sense of derealisation and depersonalizationderealisation and depersonalization

Admitted breaking up with boyfriend recAdmitted breaking up with boyfriend recentlyently

Urgent referral to psychiatric outpatient Urgent referral to psychiatric outpatient unit of CPHunit of CPH

Fourth VisitFourth Visit

Attended RH on 6 October and referred to UrolAttended RH on 6 October and referred to Urology clinic TMH ACC for haematuriaogy clinic TMH ACC for haematuria

Attended CPH Psychiatric OPD, and referred to Attended CPH Psychiatric OPD, and referred to EASI clinic, but patient refused to go, insisted tEASI clinic, but patient refused to go, insisted that she is “not crazy” and defaulted follow uhat she is “not crazy” and defaulted follow up, case under FU by SWp, case under FU by SW

Increased urinary symptoms with Urine stix=RIncreased urinary symptoms with Urine stix=RBC4+, WBC2+, Alb+BC4+, WBC2+, Alb+

Started oral antibiotics for ?UTIStarted oral antibiotics for ?UTI Patient refused lab testingPatient refused lab testing

Fifth VisitFifth Visit

Not turning up for 4 monthsNot turning up for 4 monthsReappear on 26 Feb 2009Reappear on 26 Feb 2009Still complained of sleep disturbance buStill complained of sleep disturbance bu

t improved moodt improved moodUrine stix=normalUrine stix=normalRefused to see psychiatrist at CPHRefused to see psychiatrist at CPHRefused for urine testingRefused for urine testingRefused any medications, just wish to taRefused any medications, just wish to ta

lklk

Sixth VisitSixth Visit

Presented on 12 March 2009, with severe Presented on 12 March 2009, with severe psychomotor retardation, accompanied by psychomotor retardation, accompanied by mothermother

Depressive mood again, urinary symptoms Depressive mood again, urinary symptoms reappear, loss of concentration, feeling reappear, loss of concentration, feeling very tired, sleepless (2 hours), nightmares, very tired, sleepless (2 hours), nightmares, memory lossmemory loss

Called Samaritan anti-suicide hotline last Called Samaritan anti-suicide hotline last night after quarreling with new boyfriend, night after quarreling with new boyfriend, feeling discarded by bf, cryingfeeling discarded by bf, crying

Advise mother to take patient to AED TMH Advise mother to take patient to AED TMH immediately because of high suicidal riskimmediately because of high suicidal risk

Seventh VisitSeventh Visit

Come back alone on 20 April 2009Come back alone on 20 April 2009Admitted to CPH and stayed for one week, Admitted to CPH and stayed for one week,

but forgot what has happened inpatientlybut forgot what has happened inpatientlyBetterBetterRefused oral medications and wishes to haRefused oral medications and wishes to ha

ve psychotherapy in CPH onlyve psychotherapy in CPH only still suffered urinary symptomsstill suffered urinary symptomsUrine stix= RBC4+, WBC+, Alb3+Urine stix= RBC4+, WBC+, Alb3+

Discussed about kidney damage with heDiscussed about kidney damage with heavy proteinuriaavy proteinuria

Patient finally admitted Ketamine usePatient finally admitted Ketamine useUrine Rapid Test X Ketamine +veUrine Rapid Test X Ketamine +veExplained Ketamine use may cause irrevExplained Ketamine use may cause irrev

ersible renal injuryersible renal injuryPatient motivated to stop ketamine and Patient motivated to stop ketamine and

referred to Substance abuse clinic of CPreferred to Substance abuse clinic of CPH and Urology clinic in TMHH and Urology clinic in TMH

What is a positive test?What is a positive test?

What is this?What is this?

K, Ket or my favourite, “Special KK, Ket or my favourite, “Special K”..”..

Ketamine you say? Yes it is used in veteriKetamine you say? Yes it is used in veterinary medicine and also people medicine nary medicine and also people medicine too!too!

It’s main function is acting as a general It’s main function is acting as a general anaesthetic, the sort that puts you to sleanaesthetic, the sort that puts you to sleep during operations. Someone please eep during operations. Someone please explain how the hell that’s recreational?xplain how the hell that’s recreational?

I’m sure it has many upsides, but for nI’m sure it has many upsides, but for now lets just think about the downers:ow lets just think about the downers:

K, Ket or my favourite, “Special KK, Ket or my favourite, “Special K”.. ”..

Users may be physically incapable of moving Users may be physically incapable of moving while under the influence.while under the influence.

Ketamine can cause panic attacks, depression,Ketamine can cause panic attacks, depression, and taken in large doses, can make existing m and taken in large doses, can make existing mental health problems worse.ental health problems worse.

Because you don’t feel any pain when you’rBecause you don’t feel any pain when you’re on ketamine, you can injure yourself badly ae on ketamine, you can injure yourself badly and not know you’ve done it.nd not know you’ve done it.

K, Ket or my favourite, “Special KK, Ket or my favourite, “Special K”..”..

High doses, especially with other depresHigh doses, especially with other depressant drugs like alcohol, can dangerously sant drugs like alcohol, can dangerously suppress breathing and heart function asuppress breathing and heart function and can lead to unconsciousness.nd can lead to unconsciousness.

Ketamine is very dangerous when mixed Ketamine is very dangerous when mixed with ecstasy or amphetamines. It can rewith ecstasy or amphetamines. It can result in high blood pressure.sult in high blood pressure.

K, Ket or my favourite, “Special KK, Ket or my favourite, “Special K”..”..

If high enough doses are taken, the anesIf high enough doses are taken, the anesthetic effect can result in death, for exathetic effect can result in death, for example due to unconsciousness and inhalmple due to unconsciousness and inhalation of vomit.ation of vomit.

There have been recent reports in the mThere have been recent reports in the medical literature of serious bladder and redical literature of serious bladder and related problems found in ketamine userelated problems found in ketamine users. s.

Take Home MessagesTake Home Messages

1. Mood disorder may be presented as a como1. Mood disorder may be presented as a comorbidity of substance abuse itself.rbidity of substance abuse itself.

2. Patients with ketamine abuse usually prese2. Patients with ketamine abuse usually present with urinary symptoms.nt with urinary symptoms.

3. Ketamine is the most common substance ab3. Ketamine is the most common substance abused in New Territories West.used in New Territories West.

4. Substance abusers are using multiple drugs 4. Substance abusers are using multiple drugs instead of a single entity of drug alone.instead of a single entity of drug alone.

HKCPMA-What is this?HKCPMA-What is this?

HKCPMA=HK + CPM + AHKCPMA=HK + CPM + AHK=Hong Kong HK=Hong Kong CPM=Community Psychological CPM=Community Psychological

Medicine Medicine A=(Alumni) AssociationA=(Alumni) Association

Postgraduate diploma in community Postgraduate diploma in community psychological medicinepsychological medicine

Hong Kong University (HKU) Family Medicine Hong Kong University (HKU) Family Medicine Unit (FMU) and Psychiatry department has joiUnit (FMU) and Psychiatry department has jointly organized various activities to increase thntly organized various activities to increase the knowledge and alertness of Hong Kong docte knowledge and alertness of Hong Kong doctors and people towards mental health issues.ors and people towards mental health issues.

One of these steps was the establishment of thOne of these steps was the establishment of the HKU Postgraduate diploma course in comme HKU Postgraduate diploma course in community psychological medicine (PgDipCommPsyunity psychological medicine (PgDipCommPsyMed) in the year 2003.Med) in the year 2003.

Postgraduate diploma in community Postgraduate diploma in community psychological medicinepsychological medicine

This diploma course lasts for one year, which includes This diploma course lasts for one year, which includes important topics on community important topics on community psychological medicine (via lectures) ,as well as clinicpsychological medicine (via lectures) ,as well as clinical attachment to various HA Psychiatric al attachment to various HA Psychiatric hospitals (like Queen Mary/Castle Peak/ Kwai Chung hhospitals (like Queen Mary/Castle Peak/ Kwai Chung hospitals, etc).ospitals, etc).

It is the aim of setting up the Hong Kong Community PIt is the aim of setting up the Hong Kong Community Psyhological Medical Association (HKCPMA) to further syhological Medical Association (HKCPMA) to further increase public awareness of the importance of commincrease public awareness of the importance of community psychological medicine amongst the unity psychological medicine amongst the Hong Kong people.Hong Kong people.

HKCPMAHKCPMA

Email address: admin@hkcpmaEmail address: admin@hkcpmaWebsite: Website: http://www.hkcpma.comhttp://www.hkcpma.com

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