Case Report

opioid dependent

PRECEPTOR:
DR. ADHI WIBOWO NURHIDAYAT, SPKJ, MPH

COMPILED BY:
DEBY ARIANDINY
108103000024
DISCA ARIELLA RUCITA 108103000042
FARIDA NUR AINI
108103000053
LELIANA SALEH
108103000008
M. IHSAN SASRANINGRAT
108103000019

Main complaints
Patients come to the Methadone maintenance
program for his own desire to break away
from dependence putau use.

Disease History Now

In 1999 (class 1 high school)

Patients started high school education.

In addition to schools, the patient was also working parttime at his uncle's restaurant field.
Patients were first tried cigarettes, opioid, benzodiazepam,
methamphetamine, marijuana, and alcohol. But not
necessarily the amount of usage and dosage of the substance
used.

Disease History Now

In 2002 (class 3 high school)

Patients began to routinely use 200 thousand packets

opioid 2-3 times a day with burning using lead then
inhaled.
Sometimes, patients using marijuana rolled 2-3 by way of
sucked.
When patient hanging out with his friends, patients often
consume alcohol in an amount not necessarily.

Disease History Now

In 2005, the patient tried abstance and can last for 5

months.
From 2006 to 2009 , the patient only uses putau

alone. Putau used as much as half a gram , 2-3 times

a day by means of injected through a vein.
During the drug use, the patient had experienced

sakau or overdose, but forget how many times and

when.

Disease History Now

In 2008, the patient

In 2010, the patient tried

experienced visual

to replace putau with

hallucinations such as

Subutex. Patients get

seeing a large black shadow

Subutex prescription from

and auditory hallucinations

Pasar Rebo Hospital.

in the form of hearing his

Patients using Subutex 8

friends who had died asked

mg per day by way of oral

her to do something.

or injectable for 1 year

Patients do not have

delusions.

Disease History Now

In 2011, the patient began to follow Methadone

maintenance program in RSKO. Patients wishing to

escape from dependence putau because it was tired
of his routine, many of his friends who died with
HIV- positive and want to return to normal
activities. First time using methadone, patients
experiencing body aches and intolerable
drowsiness.

Disease History Now

However, now they do not feel it. The dose of

methadone that is used when the patient is 185

mg per day. The dose for the patient because it
felt enough not to cause withdrawal. Patients
have not dared to lower the dose of methadone
for fear of re- use putau.

Disease History Now

Early Methadone maintenance programs, examination of

HIV patients and is said to be HIV positive with CD4 test

results 234 cells / ul. Then, the patients followed for 1
year of antiretroviral treatment and dismiss.
Patients often experience thrush. The patient had a

history of fungus on the tongue, tooth loss patients and

there are some that date, all of the patient's hands and
feet nails color black.

Disease History Now

The patient had a history of skin arising rolled in the

back of both hands on the area until the elbow and

the back of both legs up to the knee, but now lives
just colored black scar. Friends in the work place a
lot of patients who died of drug use with HIVpositive .
According to the mother the patient, the patient's

emotions easily provoked.

LIFE SEXUAL HISTORY

Patients were not married. The patient had a history of sexual
intercourse with her boyfriend. Patients sometimes use a condom
during intercourse. The patient knows he has HIV disease after not
having a girlfriend.

HISTORY USING A SYRINGE

The patient had a history of needle use interchangeably with friends
and rarely sterilization before injecting.

HOSPITAL CHART
HIV-positive.

Usage History Psychoactive Substances

Psychosocial Stressors
1.

Parents

: none

2.

Other Family

: the first child of four siblings

3.

Friend

: none

4.

Occupation

: none

5.

Financial

: none

6.

Marriage

: unmarried patients with HIV disease

RELATING TO THE LEGAL HISTORY

Nothing

HISTORY PSYCHIATRIC DISORDERS

Nothing

FAMILY HISTORY
The patient is the first child of four siblings. Third sister female patients.
The first patient's sister had been married and lived with her husband.
Dad worked as a patient while the patient's mother was a housewife.
Currently, patients living with both parents and two sisters. The
patient was very close to his mother than with other family members.

Genogram

S, 53

J, 31

A, 57

E, 28

T, 51

J, 48

R, 45

M,
25

T, 21

A, 12

T, 42

W, 39

PHYSICAL CONDITION
General condition: Good

Head: normocephale, no deformity

Awareness: Compos Mentis

Hair: Black, short and not easily

Blood pressure: 120/70 mmHg

Nadi: 86 x / min
Respiratory: 18 x / min
Temperature: 36.7 C
Nutritional status: normal

impression
Skin: tan

removed
Eyes: not pale conjunctiva, sclera

jaundice is not
Ear nose and throat : No wax; was no

septal deviation; pharyngeal arch no

hyperemia, T1-T1
Teeth and mouth: incomplete teeth,

oral hygiene is not good

PHYSICAL CONDITION
Neck: no lymphadenopathy
Heart: I-II heart sounds normal, no murmurs and gallops
Lungs: symmetrical right and left as static and dynamic, vesicular,

rhonki and no wheezing

Abdomen: flat, no tenderness, bowel sounds normal positive
Extremities: warm akral, no edema
Localist Status: Needle track (-)
There is a black-colored crusts on the upper and lower extremities

Diagnosis Psychiatric
General Description

Appearance : attitude good

behavior , how dressed,

Mood and Afek

Mood : eutim

Afek : mismatched

Harmony : harmonious and

looked calm

Awareness : compos mentis

Behavior and psychomotor
activity : good

Discussion : spontaneous , no
language disorders

Attitudes toward the examiner

: cooperative

feelings of the patient can feel the

palpable

 Intellectual function

Level of education :

immediate : good

intellectual functioning in

Short-term : good

accordance with the

medium term : good

Long-term good

education and intelligence

Memory :

Concentration : good
Orientation :

Abstract thought : good

Creative talent : good

place : good

The ability to help ourselves :

time : good

good

people : good

Impaired perception : no

Diagnosis Psychiatric
Mind

Processes and forms of thought

: coherent

The contents of thought : either

Impulse Control : Good

power value

Power of social values : good

Test power value : good

Assessment reality : good

Insight : insight into the

degree of VI
Reliable level : as a whole

can be trusted .

Laboratory Examination Result

27 April 2011

CD4: 234 cells / ul

6 September 2011

Benzodiazepines: negative

Cannabis: negative

Opiate: negative

Resume

Formula Diagnosis

Aksis I
the patient had no history of
head injury due to an accident.
On physical examination
found no common medical
conditions that affect brain
function.
the patient's routine use of inhaled putau
since 2002 and injected since 2006.
Initially, patients using 200 thousand putau
use 2-3 times per day and last use as much as
half a gram putau, 2-3 times per day.
If the patient discontinue the use of putau
will feel withdrawal symptoms so that the
patient continues to use putau.

organic mental
disorders can be
ruled out.

dependence of
the opioid

Formula Diagnosiss

Aksis II
Alloanamnesis:
Personality

it is known that patients with

disorder threshold

problems easily provoked

emotions although small

Formula Diagnosiss
Aksis III
Friends in the working environment of patients who died of drug use
with HIV positive and often exchanging syringes.
Patients said doctors RSKO declared HIV positive patients with CD4
results 234 sl / ul.
From the results of a physical examination found a blackish colored
crusting

Aksis IV
patients having marital problems, namely the desire to have
a life partner but has a positive HIV disease.

Formula Diagnosiss
Aksis V
Based on the Global Assessment of Functioning scale
(GAF)

the highest level of the past year (HLPY) obtained a value of 83

is able to socialize with family members and friends at home in
poly methadone.

GAF scale (current) value of 87 obtained in which patients can

work as a retail merchant at Poli Methadone RSKO.

Evaluation Multiaxial
Axis I

: F11.2.22 Mental and behavioral disorders due to

use opioida and other medical complications, are now in

clinical supervision or with substitute medication (controlled
dependence)
Axis II

: F60.3.31 Personality disorders threshold

Axis III

: B20.0 HIV disease

L00-99 papules kruritik eruption

Axis IV

: marriage problems

Axis V

: GAF current 87; GAF HLPY = 83

Problem List
Organobiologis: HIV-positive
Psychology: not married
Environmental and socio-economic: no

Prognosis
Quo ad vitam: dubia ad malam
The patient was diagnosed HIV positive in 2011 and only ARV
treatment for 1 year and did not continue the treatment
Quo ad functionam: dubia ad malam
Patients diagnosed HIV-positive and had a history of oral and
papules kruritik candidiasi eruption. This suggests HIV patients
had grade III
Quo ad sanationam: dubia ad bonam
Patients already undergoing methadone maintenance treatment for
approximately 3 years and do not mix it with the use of any substance. In
theory, the use of methadone as a substitution therapy in opioid dependence
is shown to have many uses one of which

Management
Initial dose: 1 x 25 mg Metadone
The current dose: 1 x 185 mg Metadone
Methadone is an opioid substitution
therapy that are agonists. the initial
phase, a given dose of methadone is 2040 mg per day.
In order to reach the threshold value of
methadone in the blood, plus or minus the
initial dose of 5-10 mg for 3-24 hours.
To achieve longer considered adequate dose
increase or decrease the dosage until the
detoxification
opioida
continued
with
methadone maintenance therapy.

In patients, the initial

dosing phase is 25 mg

Now, the dose given

to the patient is a
maintenance dose.

Prompts examination
Follow-up CD4 every 6 months.

Patients only been checked once the outcome CD4

234 cells / ul. CD4 cell count monitoring to monitor
the severity of HIV-induced immune damage. To
that end, there should be periodic inspection CD4
levels.

Opiate dependence
Define
Opioid dependence is a cluster of physiological, behavioral,

and cognitive symptoms, which together indicates repeated

and continuing use of opioid drugs, despite significant
problems related to such use.
Drug dependence, in general, has also been defined by the

World Health Organization (WHO) as a syndrome in which

the use of a drug or class of drugs takes on a much higher
priority for a given person than other behaviors that once
had a higher value.

Opioid
Morphine

Codeine

Heroin (diacetylmorphine)

Hydrocodone

Hydromorphone

(dihydromorphinone)
Oxymorphone

(dihydrohydroxymorphinone)
Levorphanol
Methadone
Meperidine (pethidine)
Pethadol Fentanyl

(dihydrocodeinone)
Drocode (dihydrocodeine)
Oxycodone

(dihydrohydroxycodeinone)
Propoxyphene
Buprenorphine
Pentazocine

Neuropharmocology

Heroin
35
Heroin is an illegal drug with the

following features:

A highly addictive drug derived

from morphine, which is
obtained from the opium

Heroin is a white to dark

brown powder or tar-like

substance.
Since it is derived from the

poppy.

opium poppy, it is a main

It is a "downer" or depressant

stay of income for

that affects the brain's pleasure

Afghanistan and many other

systems and interferes with the

countries that depend on

brain's ability to perceive pain.

drugs for income.

Heroin
Black Tar
Heroin

Powder Heroin

36

Sign for using Heroin

Euphoria
Drowsiness
Impaired mental functioning
Slowed down respiration
Constricted pupils
Nausea

37

Short-term Effects
Appears soon after a single dose and disappears in a few hours
After injection, a surge of euphoria ("rush") accompanied by a

warm flushing of the skin, a dry mouth, and heavy extremities

Following initial euphoria, "on the nod," an alternately wakeful

and drowsy state

Mental functioning becomes clouded due to depression of

central nervous system

Other effects included slowed and slurred speech, slow gait,

constricted pupils, droopy eyelids, impaired night vision,

vomiting and constipation
38

Long-term Effects
Collapsed veins, infection of heart lining and valves,

abscesses, cellulites, and liver disease

Pulmonary complications, including various types of

pneumonia
Additives that do not dissolve result in clogging the blood

vessels that lead to the lungs, liver, kidneys or brain

Over time, physical dependence and addiction develop
Sudden withdrawal by heavily dependent users who are in

poor health can be fatal

39

DSM-IV-TR Diagnostic Criteria for Opioid

Withdrawal

Mangement
Observation of vital sign
Anamnesis about drug use
Overdoses of opioid Naloxone is administered IV

at a slow rate initially about 0.8 mg observate if

response IV naloxone 0.4 mg / h.

Opioid substitute
Opioid detoxification methadone (A daily dosage of 20 to 80 mg, up to

120 mg )
Levomethadyl (LAAM) It is no longer used
Buprenorphine (a daily dose of 8 to 10 mg)
Clonidine
Pentazocine

Complication:
HIV /AIDS
Hepatitis
Death

Human Immunodeficiency Virus

HIV is a virus that attacks the

Due to the reduced value of

human immune system and

CD4 cell in the human body

can cause AIDS. HIV attacks a

showed reduced white blood

type of white blood cells which

served to ward off infection.
The white blood cells,
especially lymphocytes that
have CD4 as a marker or
markers that are on the
surface of lymphocytes.

cells or lymphocytes were

supposed to play a role in
overcoming infections that
enter the human body. In
people with a good immune
system, CD4 values ranged
from 1400 to 1500 cells / ul

Human Immunodeficiency Virus

HIV are mainly in human body fluids. Fluids that contain
HIV are potentially blood, semen, vaginal fluids and breast
milk. HIV transmission can occur through a variety of
ways, namely:
sexual contact,
contact with infectious blood or secretions,
mother to child during pregnancy,
labor and
breastfeed

Pathogenesis
Classified as having HIV retrovirus RNA genetic

material. When the virus into the patient's body

(the host cell), the viral RNA is converted into DNA
by the enzyme reverse transcriptase owned by HIV.
Pro-viral DNA is then integrated into the host cell
and subsequently programmed to form the viral
gene.

Early Diagnosis of HIV infection.

In people who will do the HIV test on their own, pre-test counseling
should be done. Early diagnosis is confirmed through laboratory tests
with the instructions of the clinical symptoms of the presence or behavior
of certain high-risk individuals. Laboratory diagnosis can be done by 2
methods:
1.Jump: isolation of virus from the sample, generally by electron

microscopy or detection of viral antigen, for example by Polymerase

Chain Reaction (PCR).
2.Indirect: by looking at the response of specific antibodies, eg Linked

Immuno

Sorbent

with

enzymes

Assay

(ELISA),

Western

blot,

Immunofluorescent Assay (IFA) or Radioimmunoprecipitation Assay

(RIPA)

Clinical symptoms of HIV

Minor symptoms:

Major symptoms:
Body weight decreased by more

than 10% in 1 month.

Generalized dermatitis.

Chronic diarrhea that lasts more

than 1 month.
month.
of

The presence of herpes zoster and

herpes

Prolonged fever of more than 1

Loss

Cough lasts more than 1 month.

consciousness

and

neurological disorders.
Dementia / HIV encephalopathy.

zoster

recurrent

multisegmental.
Kandidias oropharyngeal.
Herpes simplex chronic progressive.
Generalized lymphadenopathy.
Cytomegalovirus retinitis

HIV Treatment
Anti Retroviral Reverse Transcriptase Nucleoside
Inhibitors Enzyme .
1 . AZT ( Azidothimidine ) / Zidovudin
2.Didanosine (ddI)
3.Stavudine ( d4T )
4.Lamivudine

Non Nukleosida: Nevirapine, Delavirdine

Protease inhibitors: saquinavir, ritonavir, indinavir

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