N. O. Mykhalchuk2,3, A. M. Chepurna1, I. F. Zdoryk1 CRITERIA FOR DIAGNOSTICS AND TREATMENT OF SOMATIC PATIENTS WHO USE PSYCHOACTIVE SUBSTANCES IN THE PRACTICE OF FAMILY MEDICINE

S. I. Tabachnikov1,3 *, I. Ya. Pinchuk1, Ye. M. Kharchenko1,3, N. O. Mykhalchuk2,3, A. M. Chepurna1, I. F. Zdoryk1 CRITERIA FOR DIAGNOSTICS AND TREATMENT OF SOMATIC PATIENTS WHO USE PSYCHOACTIVE SUBSTANCES IN THE PRACTICE OF FAMILY MEDICINE 1Research Institute of Psychiatry Ministry of Health of Ukraine, Kyiv, Ukraine 2Rivne State University of the Humanities, Rivne, Ukraine 3Public organization «National Academy of Higher Education of Ukraine», Kyiv, Ukraine


Архів психіатрії
Т. 25, № 1 (96)' 2019 ISSN 2410-7484 Background. The problem of the usage of psychoactive substances (PS) is one of the most urgent among other medical and social issues of nowadays in the world in general and in Ukraine [1][2][3][4]. One of the aspects of the threatening nature of this phenomenon, in addition to prevalence, is psychological and somatic consequences, so called comorbid conditions, which lead in the future to severe psychosomatic disorders, more significant for young or elderly patients [5,6]. Contemporary medical reform in Ukraine based on the world experience of the leading countries of the world, reoriented general medical care of somatic patients to family doctors. This process requires the creation of professional scientific and practical issues for qualified assistance in the complex of treatment of somatic patients [7][8][9].
The objective of the research -to develop of the system of diagnostic and medical care for somatic patients who use PS in the practice of family medicine.

Materials and methods of research
In accordance with the relevant methods (clinical, anamnestic, socio-demographic, psycho-diagnostic, clinical-psychopathological and statistical), 220 thematic patients who applied with somatic complaints to the family doctor were examined. All these patients take different kinds of PS. These patients applied to family doctors during 2017-2019. The number of men was 54%, women -46%. Respondents were divided into 2 groups by age: 18-35 years old, 36-60 years old.
Ключевые слова: психоактивные вещества, соматические заболевания, семейная медицина, диагностика, лечебная помощь. conflicts in the families, material problems, burdened heredity, imbalance in the nature of emotional fluctuations of the mother, concomitant somatic illnesses (28%). In such a way it is possible to calculate the amount of indicated problems as a probable interconnection with the addictive behavior of respondents who used psychoactive substances. At the same time, the majority of those respondents began to use PS (more often alcohol or tobacco) in small or young age (66%), much less (34%) -in the elderly age. The motivation for the usage of psychoactive substances by respondents, especially young people, is the influence of friends, companies, fashion, contemporary surrounding, the negative microenvironment, the desire for pleasure, the desire to have unusual feelings. At the elder age it is a subjective deprivation or leveling of difficult personal circumstances, mood swings, a positive departure from micro-and macro-problems, improving the general mental and physical states.
Proceeding from the situations of different degrees of using PS by patients, and, according to this, different psychosomatic effects of PS, we were more oriented towards the degree of «usage of surfactants with harmful effects». The research was based on the usage of alcohol and nicotine (tobacco) as the most common psychoactive substances. General complaints of somatic patients who used alcohol when they appeal to a family doctor were: depressed mood, asthenia, nervousness, insomnia, memory impairment, problems with attention; signs of withdrawal syndrome were: sweating, limb tremor, coordination disorders, nausea, illusory disturbances; characteristics of various somatic profile were: cardiovascular problems (CP), gastrointestinal problems (GS), pulmonary-respiratory problems (PP) with their characteristic complaints. These disorders are formed in the case of such diseases: cardiovascular ones -cardiopathy, myocardial dystrophy, ischemic heart diseases, heart failure, early myocardial infarction; gastrointestinal diseases: gastritis, exacerbation of gastric ulcer, hepatitis, liver cirrhosis; pulmonary-respiratory diseases: in a case of cardiac pathology (especially with comorbidity because of tobacco-smoking) -it is pulmonary heart failure. The factors of treatment of patients by a family doctor are often accidents or injuries due to alcohol, sometimes there are various manifestations of skin pathology -they are as a result of inadequate hygiene and reduced self-care skills. The complaints of these patients are often associated with violations of legal and social problems: violence in the family, ill-treatment of children, neglect to relatives, their work, absenteeism, and so on. Quite often, their relatives are close to the negative behavior of such patients, trying to find ways of general care according to patients. It is significant that the patients themselves often deny or conceal the abuse of alcohol, do not consider it to be a disease, do not associate somatic problems as a consequence of the action of PS. Based on these factors, it becomes clear the significance of the role of a family doctor in identifying the usage of alcohol or other surfactants by somatic patients.
Deterministic analysis of the usage of psychoactive substances by means of the AUDIT-tests found that, based on 100% of cases for the characterization of each of the most common types of surfactants, most often patients prefer tobacco smoking -63,6%; slightly less they drink alcohol -56,4%; psycho-stimulants use 9,1% of respondents; cannabinoids prefer 5,5%; the usage of opiates (opioids) was not detected; combined forms of psychoactive substances use 72% of patients. According to age, the most common psychoactive substance (tobacco and alcohol) prefer the elder age group (36-60 years old), narcotic substances use, as a rule, more young people (18-35 years old). Of course, a significant number of respondents who hide the usage of surfactants, especially narcotic PS, should be taken into account. The usage of alcohol most patients try to explain as a result of behavior or mentality of the population. According to these, the explanation for smoking in many cases is even more groundless in a case of understanding the disease or psychosomatic consequences. Having examined the clinical-psychopathological symptoms with alcohol usage, the prevalence of depressive (12,5%) and anxious (10%) states was found in the initial stages («A», «B»); in a case of increasing the severity of mental and somatic pathology the symptoms were transformed into anxiety-depressive (37,5% of «C») and astheno-depressive (degree «D» is 40%). In a case of tobacco-dynamics the dynamics is somewhat similar, however, with an exacerbation of the psychosomatic state, the more disturbing component prevails (in a degree of «C» it is 48,3% of patients), asteno-depressive component is dominant (in a degree of «D» it is for 30.3% of patients). Compared with the effects of alcohol usage, the tobacco status of the asthenic background is slightly lower. In the somatic plan the growth of negative dynamics because of use of alcohol in main cases leads to an exacerbation of cardiovascular system (48%) and gastrointestinal pathology (32%); and tobacco-fueled leads to pulmonary-respiratory pathology (20%). When combined with the use of different types of PS, the severity of mental and physical states have significantly exceeded. Proceeding from the revealed clinical characteristics of the examined patients, as well as according to their personal traits, more often accentuations were noticed in 54% of cases, anxiety -in 29% ones, demonstration -in 32% of cases, exaltation -in 16% of ones, hypertension in 9% of cases, cyclotomy -in 7% of ones, excitability -in 5% of cases, etc.
The use of the system of so called AUDIT-tests in the research of people with addictive behavior who use psychoactive substances can be characterized not only by the nature of the affinity of surfactants, but also by the degree of its usage. In our research, we proceeded from the objective relationship between the level of alcohol used by patients and the degree of the process of using PS.
Accordingly, the level of comparatively safe use of alcohol is determined by the following parameters:

Архів психіатрії
Т. 25, № 1 (96)' 2019 ISSN 2410-7484 a) the total volume of alcohol consumed -it is not more than 20 grams of ethanol, that is 3-4-SDA for men and 2-3 SDA for women; b) a model of usage -2-3 free of alcohol days per week. SDA is a standard dose of alcohol -it is the amount of alcohol consumed by the human body for an hour. In such a way it is: 13 grams of ethanol or ~ 40 ml of 40% vodka, or ~ 70 ml of 25% liqueur, or ~ 90 ml of 18% of wine, or ~ 140 ml of 12% of wine, or ~ 330 ml of 5% beer.
The level of risky usage of alcohol: • for men it is 7 or more SDA per one meal and more than 21 SDA per week; • for women it is 5 or more SDA per one meal and more than 14 SDA per week. Screening I for diagnostics of significant alcohol usage was determined by the appropriate diagnostic test.
I. How much alcohol do you usually drink when you drink? II. How many days a week do you usually drink alcohol? 1. Is it not possible for you to stop drinking or reduce the amount of alcohol when you eat?
2. Did you feel a great desire or inner motivation to drink alcohol that you could not resist it?
3. Did you stop or reduce the amount of alcohol because of the following symptoms (underline the symptoms which are observed): tremor; insomnia; sweating; palpitation; headache; attack)?
4. Did you continue to drink alcohol despite the problems that will worsen as a result of this process? 5. Did any of your relatives, friends, doctor, or other healthcare professional express concerning about your drunkenness and suggest you to reduce the amount of alcohol you use?
Interpretation of the results. If the multiplication of I and II (ІхІІ =) is 21 SDA for men or 14 SDA for women we'll tell that there is a probability of alcohol problems; Positive answer to question I and any question 1-5 means the problems with the use of alcohol.

Criteria for diagnostics for a family doctor
Drinking alcohol with harmful effects: a) alcohol abuse (e.g.: >28 units per week for men and >21 units per week for women); b) excessive consumption of alcohol has caused physical harm (liver disease, gastrointestinal bleeding), psychological harm (for example, depression or anxiety), or has led to harmful social consequences (for example, loss of work or destruction of family relationships).
Alcohol dependence occurs when there are three of the following symptoms: a) strong desire or internal «coercion» for using alcohol; b) the severity (decreasing) of alcohol control; c) the presence of abstinent syndrome (for example, anxiety, tremor, sweating) when abstaining from drinking alcohol; d) high level of tolerance (for example, the person can use a large amount of alcohol without intoxication); e) continued usage of alcohol, despite the harmful consequences; g) neglect of other activities due to the usage of alcohol.

Confirmation of the diagnosis
Laboratory confirmation: blood test for gamma-glutamyl transferase (GGT), the average amount of red blood cells (RBC) can help identify individuals who have difficulties with alcohol use.

Differential diagnosis and concomitant states
Excessive use of alcohol can cause symptoms of anxiety and depression, and vice versa. The use of alcohol can also mask other diseases, such as agoraphobia, social phobia, and generalized anxiety disorder. If these symptoms take a place after a period of abstention from alcohol, the person will use the criteria for diagnostics of depression (F32) or generalized anxiety disorder (F41.1).
The use of surfactant with harmful effects can coexist with other mental disorders. In a case of clinical symptoms or mental disorders, the doctor LP-SM should conduct a screening survey of the patient regarding the use of alcohol and assess the affair of using surfactants.

Treatment
Detoxification in a case of conditions of abolition of alcohol.
In a case of mild symptoms of alcohol withdrawal, it can be useful to provide frequent monitoring of physical and mental states, to apply psychological support, to show a favorable exit from the state of being, to prove adequate drinking and food regimens. In turn, the treatment with drugs is inappropriate.
In a case of withdrawal syndrome of moderate severity, benzodiazepines and vitamins are additionally prescribed. Treatment of patients out of hospital or treatment at home can also apply a positive result, but detoxification should be restricted to specialists with appropriate training. Support for refraining from drinking alcohol. Anxiety and depression are often comorbid with alcohol use. The patient can use alcohol to self-correct these conditions.
If symptoms of anxiety or depression increase or remain after a retention period >2-3 weeks, depression therapy should be used.
The best medicine is serotonin reuptake inhibitors (SRI), as they do not cause side effects while drinking alcohol.
The algorithm for providing medical and social assistance, having been proposed by us, was specified the correlation between the clinical characteristics and the recommended measures: a) «A» degree -it is relatively safe use of surfactants, such as psycho-hygienic and psycho-prophylaxis measures, which included: • educational work according to the use of psychoactive substances and taking into account their consequences; • medical and psychological applying of professional and educational activities; • counseling assistance for maladaptive behavior (learning skills for effective communication, decision making and elaboration of life position); • the development of skills for counteracting various risk factors; • the development of emotional regulation skills, conflict resolution; • joint work of general practitioners, psychiatrists, nar-cologists, psychotherapists and medical psychologists according to the prevention of mental and behavioral disorders due to the use of PS through a comprehensive survey of risk groups with their subsequent sociopsychological rehabilitation and correction; b) «B» degree -dangerous use of surfactants -includes psycho-prophylaxis and socio-psychological help, such as: • monitoring -it is selection and registration of slight aspects of behavior which need to be changed; • method of stimulus control -the definition of environment and incentives that provide non-adaptive behavior; • therapy focused on the process of solving problemshelping the person to find an adequate solution of different problems; • auto-training -the process of preparation of the addict to severe stressful situations by owning self-control skills (coping strategies); • positive instructing, which increases the ability to master the problem; c) «C» degree -the use of surfactants with harmful effects. There were ecommended psycho-correction and psycho-therapeutic assistance, such as: • emotional-volitional sphere of the person -self-observation, self-organization, ordering of the person's own life, frustration tolerance, inclusion of addicts into the process of socially useful work activities, increasing of general background of mood through indirect influences; • communicative sphere -the development of skills of constructive communication and providing their coordination with the communication needs and skills of the person to organize the process of constructive communication; the ability to perceive other people adequately, the development of empathy, psycho-correction of family relationships; • cognitive sphere -it is the development of self-awareness, the formation of adequate self-esteem and realistic worldview, the constructive completion of traumatic gestalt, the emphasizing on irrational cognition and the wrong purposes, providing the replacement of them with constructive, changing stereotypes of the perception of cognitive reactions and attitudes; • value-sense sphere -awareness and restructuring of the person's own system of values, conscious assimilation of the system of more higher values that make sense to human existence in all real conditions of everyday life; • a moral sphere of the person -the development of the internal control locus, the formation of the person's consciousness as a factor of behavior self-regulation, providing of human attitudes to other peopkle, the ability to choose them in problem situations; • the development of motivation and skills of psychological, psycho-therapeutic work in the direction of providing constructive changes of the person in order to correct the mental state, as well as assuring personal development in general; d) «D» degree -dependence of psycho-pharmacotherapy (these patients should be sent by a family doctor to a specialistnarcologist): • pharmacological correction (antidepressants, anxiolytics); • individual psycho-therapy (rational, person-oriented, indirect, reconstructive, cognitive-behavioral, «psycho-therapy through understanding»), self-monitoring education (self-observation, self-criticism, independent relaxation), autogenous training in conjunction with autosuggestion; • group psycho-therapy using the «feedback» exercise, «role-playing», «role-sharing», «psychodrama», family psycho-therapy with such kind of exercises, as: «family roles», «family law», «family chronology», emotional and stress psycho-therapy (ESP) and others.
Information to be provided to the patient and his/her members of the family Alcohol dependence is a serious illness. Suspension or reduction of alcohol consumption leads to mental and physical health being improved.
Drinking alcohol during pregnancy is harmful to the fetus. Solving alcohol problems should meet individual needs and somatic status, as well as a general picture of alcohol use and the degree of alcohol dependence.
For most patients who are abusing alcohol, accompanied by somatic complications or mental disorders, a sharp abandonment of alcohol leads to a withdrawal syndrome, therefore it is necessary to provide medical observation under these circumstances.
In some cases, the use of alcohol with harmful effects, control or reduction of alcohol consumption is a wise start of the fight against alcohol addiction when the patient wants, but can not throw this habit.
Comparing with other chronic behavioral disorders, relapses are common. Several attempts are often required to control the use or provide termination of abuse. The result depends on the patient's motivation and confidence.
Consulting a patient according to the problem of lowering or stopping drinking 1. In a case of absence of physical or psychological harm as a result of alcohol use, and if the patient is not dependent, one should discuss with him the following problems: • to make a clear, understandable plan to reduce alcohol consumption (for example, no more than two portions of alcohol per day, with two non-alcoholic days per week); • strategies for avoiding or controlling situations where there is a high risk of alcohol increasing (for example, social and stress situations); • the need for self-control of alcohol use (for example, writing a diary of alcohol use) and safe drinking behavior (for example, limiting the time of consumption, drinking alcohol slowly, alternating with non-alcoholic beverages). 2. For patients with physical or mental disorders and/or in conditions of dependence, or in a case of unsuccessful attempts of controlled use of alcohol, the following is recommended.
Tactics of GP-SM with patients who are ready to stop using PS now: • set a certain day to throw the habit away; • discuss the symptoms of alcohol withdrawal and providing measures according to it; • identify abandonment or control strategies in high-risk situations (for example, social and stress situations); Архів психіатрії Т. 25, № 1 (96)' 2019 ISSN 2410-7484 • formulate specific plans to avoid alcohol (for example, ways to control yourself in stressful events without alcohol, how to react to friends who are still drinking); • to help patients to identify family members or friends who will support the termination of alcohol use; • to consider support options after the release. Tactics of GP-SM doctor with patients who do not want to stop or reduce alcohol use: • the doctor should not reject or condemn such patients; • the doctor should state clearly that all medical and social problems are caused by alcohol; • prescribe thiamine medicine; • determine the time to re-evaluate health and use alcohol. Tactics of GP-SM physician with patients who failed to throw because of relapse: • identify hopes for having success; • discuss the situation that led to relapse; • return to the actions described above; • avoid accusations and criticism; • to be interested about the state and feelings of the patient in a case of refusal or self-criticism and provide a support which is necessary. It is advisable to contact self-help organizations, voluntary and non-governmental institutions that are often useful to patients and their families and provide them with additional support.

Prevention
Prevention of the use of PS is divided into primary, secondary and tertiary. Primary prevention includes measures to prevent the use of surfactants long before they can occur. The areas of primary prevention are such as: informing the population about the types of surfactants, their negative impact on the psycho-physiological state of a man, his/her behavior, the formation of motivation for effective sociopsychological and physical development, the skills of adaptive rational behavior in a society, to organize communication in micro-and macro-environment, the formation of social and personal competencies. Secondary prophylaxis includes: early diagnosis of the use of surfactants, disclosure of psychological disadvantages of the person associated with the factors of narcosis, the proposal of wide psychological assistance (organizing work with the family, micro-environment of the patient, etc.). The main objective of secondary prevention is to change the maladaptive and pseudo-adaptive forms of behavior into the adaptive healthy model. The main areas of secondary prevention should be: the formation of motivation for rational behavior, the change of the maladaptive forms into adaptive ones, the development of social support in the paradigm of network, the formation of emotional, cognitive and behavioral strategies in overcoming the negative problems associated with PS. Psychological correction according to this condition of prevention includes the development of communicative resources, social competence, value orientations, taking responsibility for the person's lives, behavior and its consequences, perceptions of social support, changing stereotypes of the man's behavior and emphasizing the role of interaction in the family, the formation of psychological resistance to the pressure of drug environment. Tertiary prophylaxis refers to the help the patients to recover from alcohol or other forms of PS dependence. This work can be matched by partnerships of other patients with PS dependence, organization of psychological counseling, special programs of treatment-related appointment and rehabilitation measures based on the methods of psycho-therapeutic correction of non-tropic and somatic therapy in accordance with the somatic effects of the use of surfactants. The main focus of tertiary prevention is the development of advisory and social competence of personal resources and form adaptive doping skills. In general, medical technologies consist of a qualified psychological counseling, psycho-therapeutic or psycho-pharmacological intervention at various stages of work with these patients. Such activity can be largely carried out by a family doctor in a paradigm of complex treatment of comorbid patients with the presence of psychosomatic pathology, if it is necessary to provide the involvement of a narcologist (or a psychiatrist). The best option for general medical and social assistance for these patients is the availability of a medical psychologist and sociologist, interaction of whose intensifies the treatment effect.

Conclusions
1. According to developed toolkit the criteria for early diagnosis of the use of PS by somatic patients in the practice of family medicine were identified.
2. The characteristic features of socio-demographic, clinical-psychopathological and psychological types that are formed on the background of the use of psychoactive substances, as well as various pathogenic profiles of the somatic type of a patient with a consistent negative dynamics of the combination of the effects of surfactant and psychosomatization of patients have been identified.
3. The leading profiles of somatization in these cases were outlined (cardiovascular disorders take a place in 48% of cases, gastrointestinal tract disorders -in 32% of ones, pulmonaryrespiratory system disorders -in 20% of cases). These profiles of somatization are combined with mental illnesses. 4. A system of step-by-step diagnostics of the usage of psychoactive substances (patients with somatic effects and their manifestations) was developed. This system was based on the use of the system of AUDIT-tests, a number of parallel psychodiagnostic techniques and appropriate laboratory methods.
5. On the basis of characteristic features of anamnesis, socio-demographic, clinical psychopathological and somatic data, the system of psycho-therapeutic, rehabilitation and psycho-prophylaxis was developed for the patients in the practice of general family medicine.