NATIONAL INSTITUTE OF MENTAL HEALTH AND

NEURO SCIENCES (INI) – BENGALURU

CASE PRESENTATION ON: - ODS (ACTIVE USE) WITH NDS

SUBMITTED TO: SUBMITTED BY:

Dr. Prasanthi Nattala Monalisha Sharma

Professor & HOD Hepsie Sharon T.

Department of Nursing Mahalakshmi D.

NIMHANS, Bengaluru Kajal Dwivedi

Dikshya Das

M.Sc. Psychiatry Nursing

Second-Year,

Department of Nursing

NIMHANS, Bengaluru

Date of Submission-

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GENERAL INFORMATION:

Name: Mr.P

Age: 21 years

Sex: Male

Education: Std-10th drop out

Occupation: Currently unemployed(Used to work as a two-wheeler mechanic)

Family Income: BPL (Below the poverty line)

Address: Banashankari, Bengaluru

Religion: Islam

Language: Hindi, Urdu, Kannada

Date of admission:23/03/2023

MRD NO: ----------

UHID No: -----------

Informant: Mother and patient himself

Information: Reliable and adequate

CHIEF COMPLAINTS:

 Using T Tydol in injectable form for the past 2 years.

 Smoking cigarettes for the past 3 years.

HISTORY OF PRESENT ILLNESS

Onset: Insidious

Precipitating factors:

Course: continuous, gradually progressive

Duration of the illness: 3 years

The patient reports that he has been using Tydol as an IV Injection since the age of 18.5 years
that is for the past 2 years. The patient reports he first used it as his friend told him to try it
once this was a new thing and it will feel very good. So, on the friend's insistence, the patient
borrowed the tablet from the friend and asked him to give it once. The patient reported using

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a new syringe and needle for the first time. That time his friend gave him the injection and
soon pt reported he felt a kind of orange-like flavor in his throat. Soon after that, he had an
episode of vomiting once. After that, he started feeling light-headed and relaxed which was
enjoyable for him and he slept very well that night. Soon after that pleasant experience when
his friend asked him again, he accepted the offer within one week he had his second injection
initially used to get an injection from his friend but later learned to do it himself within one or
two months. He would crush the tablet with his mobile phone put it in an inverted cap of a
bottle add bisleri water make a solution and later using a cigarette filter take the liquid in an
insulin syringe and inject himself while injecting they would not clean the site or would not
take any safety precaution. After injecting they would pull back to look for blood and then
later inject the whole solution. The patient would take injections in the veins of both arms.
They would hold the arms tightly to make the veins prominent. Later after 2-3 months pt
would inject himself on his own while he was alone at home or in any quiet street and later
throw the needle and syringe there on the road. After the first week, he would take one
injection with one tablet 2-3 times a week. Till next one month.

By the end of the first month, the patient started taking one tablet daily. The patient reports
that he would have an intense desire to take an injection throughout the day and that he had
started taking more than one injection during the day as he was now not getting the same
amount of high with just one injection. He reports that to satisfy this urge and craving he
started taking 2 tablets injection in the night making it around 3-4 tablets every day. The
patient reported that since around the age of 19 years, he noted he would have body aches and
joint pain along with sleeping difficulties and occasional complaints of runny nose, tiredness,
and tremors for which pt would again take injections and it would stop. For the past 1 year
patient would try to reduce his use or stop but he would not be able to feel bad later. Pt
reports that 1 year back he broke up with his girlfriend after which he his increased use a 500
mg daily on some occasions, The Patient reported he would get the tablet from his friend and
would pay around 100 to 150 for each tablet and spend every day on average at which was
around 70 percent of his salary and so patient shopped giving money at home. The mother
reports patient would also be here in his room and started avoiding family interactions and
functions, he started missing his namaaz on Jumma which was not like him. The patient also
reports incidents of sharing needles and syringes during the initial days of use; later infections
can be spread through this. patient also reported that there were incidences when he would
reuse the needle and syringe but only for himself patient denies having any knowledge of any

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missing vein and would inject in the thin leading to a bubble-like formation which would heal
in one week by applying balm.1 year back patient's parents found the empty syringe in their
house and later on questioning came to know about his substance use. After that since last
year April, he was started on treatment at NIMHANS and was on out with Addnok-N 2 mg.
But still patient continued to use the IV injection in the same amount. Last year in September
at the age of 20 patient was kept in the Jamaat hostel for 6 months where the patient was off
both medications and drug use. After 6 months pt came out and within the week pt restarted
taking injections he reported that again 1 tablet was enough for him and gradually after 2-3
weeks he again started using 300-400 mg per day. Currently, the patient presented with the
last use of Tydol on the day before admission 100 mg and had been off buprenorphine for the
past 10 days.

After that patient was admitted to a male Centre of Addiction Medicine in view of the failure
of Outpatient-based management. There is a history of smoking cigarettes since the age of 17
years that started under the influence of friends for trying out, leading to daily use within 3-4
months. The patient reports of intense urge to smoke throughout the day which would make
him irritable and stressed unless he smokes. Reports he started smoking early in the morning
at the age of 18 to avoid irritability and restlessness and daily intake of around 5-6
cigarettes/day. Last intake on the day of admission.

NEGATIVE HISTORY

 No h/o of any other substance use.

 No h/o fever/diarrhea/ abdominal pain.

PAST HEALTH HISTORY

a) Medical History: nil

b) Surgical History: nil

c) Psychiatric history: No significant psychiatry history

d) No h/o fever, seizure, or any head injury

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FAMILY HISTORY:

o Firstborn out of a non-consanguineous marriage

o ADS in third-degree relative
o Seizure disorder in grandfather

PERSONAL HISTORY

1. Birth and early development: Full-term normal delivery at hospital, no prenatal,

natal, or postnatal complications. Development milestones are normal.
2. Behaviors during childhood: Was stubborn, used to bunk classes frequently and used
to get angry easily No history of mannerism, thumb sucking, temperamental issues,
tics, or conduct disorder.
3. Physical illness during childhood: No history of significant childhood illness.
4. Schooling: Started schooling at 5 years of age. He was below average in his studies.
He used to participate in extracurricular activities.
5. Sexual and marital history: No significant marital history as he is not married. The
patient reports having a heterosexual orientation and was in a relationship at the age of
19 years for a few months.
6. Occupational history- Nil as he is currently unemployed. Used to work as a two-
wheeler mechanic till last year.

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 7. Substance abuse: 300-400 mg per day (Started at the age of 18.5 years )
5-6 cigarettes per day (Started at the age of 17 years)

PREMORBID PERSONALITY:

 Social relationship: Cordial relation with friends and family, no IPR issues.
 Intellectual activities: None
 Mood: Bright, Cheerful, Stable
 Character:
a) Attitude to work and responsibility: Responsible
b) Interpersonal relationship: Cordial, outspoken, stable & trusting but rigid relation
c) Energy and initiative: Energetic, sustained output
d) Fantasy life: None
e) Hobbies: None

MENTAL STATUS EXAMINATION

General appearance and behavior: Patient is conscious, oriented, well kempt. He looked
hygienic and well-groomed. He is cooperative, and oriented to surroundings. He came to the
interview room on calling, sat on the chair, and greeted me. Attention was held, adequate
rapport was established and eye contact was maintained during the session.

Psychomotor activity: Normal

Speech: Speech was spontaneous while having the conversation, initiated with normal tone,
volume, tempo and reaction time was normal. It was coherent and relevant. Prosody was
maintained

Thought:

Sample – Rain

“Rain is important, it comes during the month of June- August, and it is important for crops
and agriculture. There are days when rain is less and it is a reason for concern for everybody”

No FTD

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Stream of thought: there is no stream of thought disorders like- flight of ideas, thought
retardation, circumstantiality, perseveration.

No possession, compulsion, and obsession

Mood:

Q: How are you?

Subjectively:” I am ok “.

Objectively: Euthymic

Normal intensity, depth, normal range, and reactivity present

Communicability present, coherent, and appropriate, no liability

Perception: No significant perceptual disorder was noticed.

Contemplation stage of motivation

Cognitive function test:

Orientation

Time: Q: What is the time now?

A: He told 4.30 pm evening
Inference: oriented to time.
Place: Q: Can you tell me where are you now?
A: “NIMHANS hospital [Bangalore], first floor”
Inference: oriented to place.
Person: Q: Who is she? (Pointing to her mother)
A: “My mother”.
Inference: oriented to person.

Attention and concentration

Digit span test

Digit forward: able to repeat 4-digits.

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Digit backward: able to repeat 3-digits.

Serial subtraction

100-7= able to do in 120 seconds

Days and months forward and backward-

Able to forward and backward.

Inference: attention is aroused and concentration is sustained

Memory

Immediate: Digit span test – able to complete. (2, 3 5, 7)

Also, she can say what he had for Lunch (Dal Rice)

Recent: Able to recall what he had at dinner last night.

What did you have for dinner? (Chapati and Sabzi)

Remote memory: What is your date of birth?

He was able to answer. (Verified with his mother)

Inference: immediate, recent, and remote memory is intact

Intelligence

General information:
PM- Narendra Modi
River- Kaveri, Triveni, Sangama, Krishna
Capital of India- Delhi
Inference: The general fund of information is adequate
Comprehension:

What will you do when you feel cold?

He told I would take one blanket and will wrap it up.

What will you do if it rains when you start to work?

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I will keep doing my work.

What will you do when you miss the bus when you are on a journey?

I will check for the next one

What will you do if you lose your mobile?

He replied she would go to the police station.

Inference: Comprehension is intact.

Arithmetic:

Q: How much is 4 rupees and 5 rupees?

A: Rupees 9.

Q: I borrowed 10 rupees from you and returned 4 rupees, how much do I still more to give?

A: Rupees 6.

Q: If one pen is 2 rupees how much costs for 5 pens?

A: Rupees 10.

Q: If 18 boys are divided into groups of 6, how many groups will be there?

A: 3.
Inference: Adequate.
Abstraction

Similarities: Orange and banana- fruits

Dog & Lion – Animal

Eye & Ear –Both are in the head

Table & Chair - thing

Differences: Cinema & Radio – one can be watched other can be listened

Stone & potato- One can be collected other we can eat

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Proverb: given the proverb “Little knowledge is dangerous

Q: Tell the actual and inner meaning of the proverb

A: “Knowing a little can be harmful so you should acquire adequate knowledge”

Inference: Adequate.

Judgment

Personal judgment: Q: What’s your future plan?

A: I want to succeed in interviews and do a proper job.
Social judgment: Q: What will you do when fire catches to your home?
A:I will put water on it and will call the fire station.
Test judgment: Q: Tested by letter
A: He said he would not do anything.
Inference: Personal, social & test judgment is intact.
Insight
Explain to the patient that you have a substance dependence that requires treatment.
Would you like to take the medication?
Ans-I want to get better and want to stop using those tablets.
Awareness: Present
Attribution: Verbalizes that he wants to cut down his habits.
Acceptance: Started accepting. Ready to get treated
Inference: Insight is present

PHYSICAL EXAMINATION
General appearance:
Body build: Thin built
Level of hygiene and grooming: Adequate
Level of consciousness: Conscious
Activity: Normal
Weight:56 kgs
Height: 168cms
BMI: 19.8 kg/m2
Vital signs

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Temperature: 98.40 F
Pulse: 78 beats/ mts
Respiration: 24 breaths/ mts
Blood pressure: 120/70 mmHg

INTEGUMENTARY SYSTEM:
SKIN:
Color: Normal skin color
Condition: Normal in texture
Temperature: Warm.
Pigmentation: Normal skin pigmentation
Edema: Absent
Injury marks: Nil
NAIL:
Color: Pale in color
Clubbing: Absent
Cyanosis: Absent

FACE:
Symmetrical in size and there is no facial puffiness or edema.
HEAD:
Hair: Normal, equally distributed, and healthy hair
Scalp: No dandruff or any other infection.

SPECIAL SENSES:
Eyes and Vision:
Eyelids: Opens and closes normally
Conjunctiva: Pink in color
Sclera: White in color
Pupils: Bilaterally equally round and reacting to light.
Vision: Field of vision is normal
Eyeball movements: Normal

Ears and Hearing:

Position of the external ear: Symmetrical

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Hearing: Hearing acuity is normal
Using of hearing aids: Nil
Other complaints: No history of infection, Itching, discharge, ringing, cerumen, vertigo
Nose and Sinuses:
Deformity, discharge: No deviated nasal septum
Mucous membrane: Normal pale red in color
Allergies: No history of allergies
Obstruction: Nil
Epistaxis: Absent
Sinuses: Not infected

Mouth and Throat:

Lips: Dry and ulcer not present
Teeth: Normal in alignment, no dental caries.
Gums: Brown in color, no swelling
Buccal mucosa: No infection.
Tongue: Normal.
Tonsils: No inflammation/ pain
The odor of breath: No bad odor.

Neck:
Movements: Normal
Pain: Absent
Jugular vein: Not distended
Lymph nodes: Not enlarged, no inflammation.
Thyroid gland: Normal

RESPIRATORY SYSTEM (THORAX AND LUNGS)

Shape of the chest: Normal in shape

Movements: Symmetrical movements

Breath sounds: Bilateral normal vesicular breath sounds.

Respiratory rate: 24 breaths/ mts

Auscultation: Chest is clear.

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CARDIO-VASCULAR SYSTEM:

Auscultation : S1 and S2 are present. No murmur.

: HR= 78 beats / mts. B. P= 120/70mmHg.

GASTROINTESTINAL SYSTEM:

Abdomen: liver not palpable

: Bowel sounds present.

: No tenderness or organomegaly.

GENITOURINARY SYSTEM:

Absence of Nocturia, Dysuria, Incontinence, Dribbling, Infection, Urgency, Hematuria.

MUSCULOSKELETAL SYSTEM:

Muscular pain/ cramps: Nil

Pain and swelling of the joint: Absent.

Ability to perform ADL: able to do ADL

Muscle strength: Strong, 5/5 present.

BACK:

Absence of scoliosis, kyphosis, lordosis, and injuries.

NERVOUS SYSTEM:

Mental Status Examination:

Level of consciousness: Conscious.

Orientation: The patient is oriented to time, place, and person.

Glasgow coma scale: Score is 15 / 15 (E- 4, M- 6, V- 5)

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Motor system:

Muscle power: 5/5 for upper and lower extremities.

Muscle tone: a bit weak.

Sensory system:

The patient recognizes light touch, pain, and vibration in all extremities. Two-point
discrimination is intact.

Reflexes:

Biceps : ++ Triceps: ++ Patellar: ++ Plantar: ++ Achilles: ++

IMPRESSION

The patient is moderately built, BMI 19.8kg/m 2 No significant abnormal findings.

DIAGNOSTIC FORMULATION:

21-year-old single gentleman, aborted schooling previously working as a two-wheeler

mechanic profession, currently not working for last few months, , belonging to lower socio
economic status from Banashankari Bangalore with temperamentally poor frustration
tolerance, anger control, and stubborn with a personal history of Aborted schooling after
failure in class 10, early age of starting job and family history of Alcohol dependent
syndrome and nicotine-dependent syndrome in multiple first and second-degree relatives
currently presenting with illness duration of 3 years, Insidious onset, continuous course
characterized by Tapentadol intake by means of injection with development of craving,
tolerance by 18 years of age, withdrawal loss of control and salience since 19 years of age
with history of sharing of needle, solution sharing and unsafe injection practices with average
quantity of 300-400 mg per day in 2-3 sessions followed by admission in NIMHANS and
was started on Syrup Methadone up to 125 mg/ day due to previous history of failed
treatment on Buprenorphine at which he developed vomiting and was changed back to
Buprenorphine due to inability of patient coming every day to take the former medication.
The patient was discharged on T. Buprenorphine 2 mg on which he maintained abstinent for
1 week before he stopped taking it due to nausea and vomiting and reported of relapse 2
weeks after discharge due to craving and peer influence with a maximum abstinence period

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of 6 months in past while in a rehabilitation center with maintaining factors being peer
influence, craving, tolerance and withdrawal resulting in occupational dysfunction,
involvement in anti-social activities (no further details available ) and inability to abstain by
self, due to the above-mentioned reasons with last intake the day before presentation
associated with tobacco use in the form of cigarettes from the age of 18 along with craving,
tolerance withdrawal and loss of control with current use of 5-6 cigarettes per day last use
being the day of presentation. On mental status examination, no significant abnormalities
were found with intact judgment, insight present, and level of motivation in contemplation.
On general physical examination thin built, BMI-19.8 kg/m 2, afebrile, Pulse-78 bpm, BP-
120/70 mmHg. & no other significant abnormalities, Currently on T.Buprenorphine OD 2
mg & T. Diazepam 5 mg OD.

IMPRESSION:

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BOOK PICTURE PATIENT PICTURE

Tobacco dependence syndrome

 A strong desire or sense of compulsion to take the substance;  Strong urge to take cigarette
 Difficulties in controlling substance-taking behavior in terms of  Gradual increase in Number
its onset, termination, or levels of use: of cigarette smoke per day
 Evidence of tolerance, such that increased doses of the (from 1 cigarette to 4
psychoactive substance are required in order to achieve effects packets per day)
originally produced by lower doses.

Complications

Using tobacco leads to complications, including grave health

 Respiratory system: lung cancer, emphysema. chronic

bronchitis, cancer, especially in the respiratory system
 Hematologic: Leukemia
 Cardiovascular system: Heart disease Nervous System: Stroke.
loss of sense of taste or smell.
 Diabetes
 Optic: Eye issues, such as cataracts and macular degeneration
 Reproductive system: Infertility, impotence.
 Miscarriage and pregnancy complications Immune system: The
weakened immune system. cold, flu, and respiratory infections.
 Weak immunity
gum
 Premature aging
 Disease and dental issues The appearance of premature aging
 Digestive system: Peptic ulcer disease Musculoskeletal System:
Osteoporosis

Treatment

Pharmacological:

 Antidepressant
 Bupropion (Wellbutrin)
 Varenicline tartrate (Chantix) reduces the craving and rewarding
effects of nicotine by preventing nicotine from accessing one of
the acetylcholine receptor sites involved with nicotine
dependence, but it can cause depression and related psychiatric
symptoms in some people.
 Nicotine replacements
 Transdermal patches, nicotine gum, nasal spray, 16
and inhalers
have been used successfully to assist in withdrawal by reducing
the craving for tobacco.