Psychiatry Learning Map

Psychiatry: disorder groups

Substance use disorders & addiction

Substance use disorders cover harmful use of and dependence on alcohol, opioids, stimulants such as methamphetamine, cannabis, nicotine and other drugs. Psychiatrists treat intoxication, withdrawal and addiction, and manage the many mental illnesses that occur alongside them.

Depth by stage, Pre-U → Consultant (details)

What is it?

Addiction is a health condition in which a person loses control over use of a substance despite harm. ICD-11 distinguishes harmful patterns of use from substance dependence, and also covers intoxication, withdrawal and substance-induced mental disorders such as psychosis.

In Malaysia, the substances most often seen in psychiatric services include methamphetamine (syabu, ice), opioids such as heroin, alcohol, cannabis, kratom (ketum) and nicotine. Methamphetamine-induced psychosis is a common reason for psychiatric admission.

Treatment works best as a long-term approach combining medical care, psychological therapy and social support. Malaysia offers methadone maintenance therapy, needle and syringe programmes, and the National Anti-Drugs Agency (AADK) runs treatment and rehabilitation services including Cure and Care clinics.

Why does a psychiatrist need it?

Substance use complicates almost every area of psychiatry: psychosis, depression, suicide, violence, liver and infectious disease, and legal problems. Psychiatrists must recognise and safely manage withdrawal (alcohol withdrawal can be fatal), prescribe opioid substitution, use motivational approaches, and work with AADK, police and courts within the law.

What level is expected at each stage?

Scale: 1. Aware → 2. Understands → 3. Applies → 4. Masters / Teaches. What the levels mean.

  1. Pre-UNot expected
  2. Pre-clinicalAwareLearns pharmacology of drugs of abuse and reward pathways.
  3. ClinicalUnderstandsTakes an alcohol and drug history and uses brief screening tools such as AUDIT.
  4. HousemanshipAppliesManages alcohol withdrawal, overdose and intoxication on wards and in casualty.
  5. Medical officerAppliesManages substance-induced psychosis and withdrawal, starts addiction treatment and refers to services.
  6. Psych traineeMasters / TeachesManages dependence, comorbidity and opioid substitution; addiction rotation; examined throughout.
  7. Specialist / consultantMasters / TeachesLeads services; addiction subspecialists run specialist programmes.

What are the key topics?

Substances

  • Alcohol: harmful use, dependence, withdrawal, delirium tremens, Wernicke-Korsakoff syndrome
  • Opioids: heroin, prescription opioids; overdose and naloxone
  • Amphetamine-type stimulants, especially methamphetamine, and stimulant psychosis
  • Cannabis and synthetic cannabinoids
  • Kratom (ketum) — common in parts of Malaysia
  • Nicotine and smoking cessation
  • Benzodiazepines, inhalants, hallucinogens, new psychoactive substances

Concepts

  • ICD-11 harmful pattern of use vs dependence; DSM-5-TR substance use disorder severity
  • Tolerance, withdrawal, craving
  • Reward pathway (mesolimbic dopamine) and neuroadaptation
  • Stages of change and readiness
  • Dual diagnosis: comorbid mental illness

Assessment

  • Substance history: type, amount, route, pattern, last use
  • Screening tools such as AUDIT, ASSIST; withdrawal scales such as CIWA-Ar and COWS
  • Urine drug screens and blood tests (liver function, hepatitis, HIV)
  • Physical complications and infections
  • Risk: overdose, suicide, violence, driving

Treatment

  • Medically supervised withdrawal; thiamine before glucose in alcohol dependence
  • Relapse prevention medicines: acamprosate, naltrexone, disulfiram
  • Opioid agonist treatment: methadone, buprenorphine
  • Motivational interviewing, CBT, contingency management, mutual-help groups
  • Harm reduction approaches
  • Treating co-occurring psychosis, depression and anxiety

Malaysian context

  • Methadone maintenance therapy delivered through MOH facilities and partners (since the mid-2000s)
  • National Anti-Drugs Agency (AADK) and Cure and Care clinics
  • Drug Dependants (Treatment and Rehabilitation) Act 1983
  • Religious and family attitudes, stigma and the shift from punishment to health approaches

How is it learned and assessed?

  • Pharmacology in pre-clinical years
  • Medical and emergency postings in housemanship (withdrawal, overdose)
  • Addiction rotations during psychiatry training
  • MMed Part I (pharmacology) and Part II; MRCPsych Papers A and B; CASC stations such as alcohol history or motivational interviewing

Typical textbooks and resources

  • Shorter Oxford Textbook of Psychiatry — Oxford University Press
  • The Maudsley Prescribing Guidelines in Psychiatry — Wiley (substance misuse chapter)
  • Motivational Interviewing: Helping People Change — Miller & Rollnick, Guilford Press
  • Drug Misuse and Dependence: UK Guidelines on Clinical Management — UK Department of Health (the 'Orange Book')
  • WHO resources on substance use — World Health Organization

Titles are widely used examples; editions change. Use university libraries or legitimate purchases.

Common questions

Is addiction a choice or an illness?

Starting to use a substance often involves choice, but dependence changes brain reward and control systems so that stopping becomes very hard. Treating it as a health condition, with support and treatment, gives better results than punishment alone.

Why can alcohol withdrawal be dangerous?

In people with heavy, long-term drinking, stopping suddenly can cause seizures and delirium tremens, which can be fatal. Withdrawal should be medically supervised.

Related subjects

Official sources to check