Kridsadadanudej Wongwejwiwat

Abstract

Background: Tramadol misuse among Thai adolescents and young adults has become an increasing psychiatric and community health concern (1)(2). Misuse patterns often involve concurrent use of sedating antihistamines such as cetirizine to enhance euphoric effects (3). Community pharmacies are among the first points of contact for these individuals; yet, pharmacists often refuse sales without offering supportive interventions. In community psychiatry, such encounters represent a crucial opportunity for early behavioral and pharmacologic engagement (4)(5). This study illustrates the application of the STAND BY ME Framework as a structured community-pharmacy model for managing tramadol misuse within a psychiatric support context (6).

Aim: To apply the STAND BY ME Framework as a community-based psychiatric care model enabling pharmacists to provide early intervention, behavioral counseling, and relapse prevention for adolescents misusing tramadol and antihistamines.

Case and Methods: A Thai male in his late 20s had purchased tramadol 50 mg (20 tablets) and cetirizine syrup (1 bottle) weekly for approximately one year. In August, he requested assistance to discontinue tramadol use. Following psychiatric-informed principles for substance use treatment (7)(8)(9), the pharmacist implemented the STAND BY ME Framework, a nine-step model integrating community psychiatry, behavioral therapy, and medication-assisted transition:

1. Selling with Counseling – engaging the patient with empathy, avoiding stigma, and documenting use history.


2. Take Time – establishing trust through regular, non-judgmental dialogue.


3. Adherence – educating on dependence and withdrawal using motivational interviewing techniques.


4. Neutralize – initiating pharmacologic support with trazodone 50 mg nightly for insomnia and mood stabilization.


5. Distinguish – encouraging separation from peers and social triggers of misuse.


6. Build – supporting goal setting and re-engagement in daily routines.


7. Yield – after experiencing tachycardia and dizziness, trazodone was discontinued; sertraline 50 mg nightly was prescribed as an SSRI consistent with evidence-based management of opioid withdrawal-related dysphoria (10)(11).


8. Make Sure – regular monitoring confirmed decreased consumption from one bottle/day to one every 4–5 days or when the patient comes to the pharmacy.


9. Encourage – ongoing reinforcement of abstinence, self-efficacy, and emotional regulation.

Results: Within three months, the patient achieved a substantial reduction in tramadol use, improved sleep, and emotional stability. Pharmacist–patient rapport facilitated adherence and relapse prevention. The pharmacy served as a non-stigmatizing environment, supporting recovery and community reintegration—aligning with WHO’s integrated model of mental health and substance-use services at the primary-care level (9)(12).

Conclusion: The STAND BY ME Framework demonstrates the role of community pharmacists as accessible mental health gatekeepers for adolescent and young adult substance-misuse cases. By combining psychiatric counseling, behavioral support, and evidence-based pharmacotherapy, community pharmacies can function as first-line recovery hubs in addiction psychiatry. This approach contributes to the WHO’s call for task-shifting in community addiction care, bridging gaps between pharmacy practice and mental health systems in low-resource settings (9)(12)(13).

References

1. Wongveerasin P, Othong R, Rittirak P, et al. Clinical presentation and management of acute dystonia from drug abuse or misuse in adolescents and young adults in Bangkok, Thailand. Emergency Medicine International. 2023;2725974.


2. Dallas JC, Jullamate P, Vatanasin D, et al. Resilience and influencing factors among youths undergoing substance abuse treatment in Thailand. SAGE Open Nursing. 2023;9:23779608231157986.


3. Buasumlee B, Boonyarattanasoontorn J. The application of Buddhist principles to solving the misuse of tramadol. Journal of Buddhist Anthropology. 2023;8(4):257–267.


4. Saitz R, et al. Role of health professionals in addressing substance misuse. New England Journal of Medicine. 2021;384(8):736–745.


5. Kaner E, et al. Effectiveness of brief alcohol and drug interventions in primary care: an overview. Cochrane Database Syst Rev. 2018;Issue 2:CD012784.


6. Wongwejwiwat, K. & Wongwejwiwat, S. (2025, August 31 – September 3). STAND BY ME: A Framework for Community Pharmacists to Intervene in Substance Misuse Patients. [Poster presentation]. FIP Copenhagen 2025: Community pharmacy. (2025). Pharmacy Education, 25(4), p. 1–124.


7. American Psychiatric Association (APA). Practice Guideline for the Pharmacological Treatment of Patients with Substance Use Disorders. 2023.


8. National Institute for Health and Care Excellence (NICE). Drug Misuse: Opioid Detoxification (CG52). London: NICE; 2022.


9. World Health Organization (WHO). Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. Geneva: WHO; 2019.


10. Schifano F, et al. Pharmacological approaches to manage tramadol dependence and withdrawal. Front Psychiatry. 2020;11:623.


11. Fareed A, et al. Role of SSRIs in managing post-withdrawal depression among opioid users. J Addict Dis. 2019;38(3):258–265.


12. WHO. Integrating Mental Health and Substance Use Services in Primary Care. Geneva: WHO; 2020.


13. Nutt D, et al. Community models of addiction psychiatry. World Psychiatry. 2022;21(2):212–223.

Audience take away from presentation:

1. A practical, replicable model for early psychiatric intervention in community pharmacies
   
   
   
   1. Attendees will learn how the community pharmacist–patient relationship can be leveraged to provide front-line psychiatric support for adolescents with substance misuse.
   
   
   2. The session will demonstrate how to apply structured counseling and behavioral monitoring directly within routine pharmacy operations, without requiring specialized mental health infrastructure.
   
   
   
   


2. Integration of behavioral and pharmaceutical care in addiction recovery
   
   
   
   1. Participants will understand how non-psychiatric professionals (e.g., pharmacists, primary-care providers) can apply basic psychotherapeutic approaches—such as motivational interviewing and relapse prevention—alongside evidence-based pharmacotherapy (e.g., trazodone, sertraline).
   
   
   2. This will help clinicians design multidisciplinary interventions that bridge addiction care and mental health services.
   
   
   
   


3. A framework adaptable for teaching, training, and policy development
   
   
   
   1. Educators and researchers can adopt this case-based framework in pharmacy or public health curricula to teach patient-centered addiction counseling and community psychiatry principles.
   
   
   2. The model also provides a foundation for further academic research, particularly in task-shifting and pharmacist-led behavioral health within low- and middle-income countries.
   
   
   
   


4. Evidence that pharmacies can function as accessible, stigma-free mental health hubs
   
   
   
   1. The case demonstrates how pharmacies can transform from transactional medicine outlets into therapeutic environments for psychiatric rehabilitation, consistent with the WHO’s integrated community health model.
   
   
   2. This can inspire policymakers to include pharmacists in national addiction-care strategies.