13 - Substance Misuse Flashcards
What is the difference between crack and powder cocaine?
Once in blood stream it is the same
Crack = Smoked
Powder = Snorted
How is LSD taken?
- Brewed in bath
- Blotting paper soaked in LSD and tab put under tongue
What is the difference between brown and white heroin?
Brown: Smoke/Chase the Dragon or Injected in warm acid
White: Injected in water
Always ask what people mean when they are snorting lines, doesn’t just mean cocaine
What is the world’s biggest drug following alcohol and smoking?
Benzodiazepines
What drugs are more addictive?
Ones that are injected or smoked as higher reinforcement
Alcohol is biggest problem drug though!!
How does tolerance develop?
- Increased metabolism
- Dowregulation of receptors
Dopamine is cause of tolerance/addiction
What are some mental/behavioural disorders that are recognised in the ICD-10 as being secondary to substance misuse?
7 ways:
- Acute intoxication
- Harmful use (damage to health, either physical or mental)
- Dependence syndrome
- Withdrawal state
- Withdrawal state with delirium
- Psychotic disorder
- Amnesic syndrome
- Residual and late-onset psychotic disorder
How do you take a drug history?
- When do you feel like it became a problem?
- What happens if you don’t have it?
- Previous treatment episodes?
- Have you ever overdosed and what happened?
- BBV test and vaccine
TRAP: Trigger, Route, Amount, Pattern
What are features of opioid intoxication?
- Drowsiness
- Confusion
- Decreased respiratory rate
- Decreased heart rate
- Constricted pupils
- Track marks if heroin
- Collapsed veins
What are signs of cannabis intoxication?
- Drowsiness
- Impaired memory
- Slowed reflexes and motor skills
- Bloodshot eyes
- Increased appetite
- Dry mouth
- Increased heart rate
- Paranoia
What are signs of LSD intoxication?
- Labile mood
- Hallucinations
- Increased blood pressure
- Increased heart rate
- Increased temperature
- Sweating
- Insomnia
- Dry mouth
LSD primarily acts at dopamine receptors
What are signs of stimulant intoxication?
- Euphoria
- Increased blood pressure
- Increased heart rate
- Increased temperature
Stimulants such as cocaine or methamphetamine can, in low doses, produce a feeling of increased concentration and focus. Cocaine acts at dopamine receptors. Methamphetamine acts at TAAR1. Both increase the available amount of dopamine in the brain, producing the associated pleasurable effects of the drugs.
What are the features of dependence syndrome?
Requires 3 or more of the following:
1 A strong desire or sense of compulsion to take the substance (craving)
2 Difficulty in controlling substance use (onset, termination, level of use)
3 Physiological withdrawal when decreasing or ceasing
4 Tolerance: increased doses are required to produce the original effect
5 Progressive neglect of alternative pleasures or interests
6 Persisting use despite clear evidence of harmful consequence
What are some risk factors for substance misuse?
What is the difference between alcohol abuse and alcohol addiction?
Alcohol abuse implies that repeated drinking harms a person’s work or social life
Addiction implies dependence syndrome symptoms
What is the epidemiology, pathophysiology and risk factors for alcohol addiction?
Pathophysiology
Down regulation of inhibitory GABA receptors and upregulation of excitatory glutamate receptors so when alcohol is withdrawn it results in CNS hyperexcitability
Epidemiology:
4% prevalence of alcohol dependence
25% M and 15% F drink over recommended limit
What are the consequences of alcohol dependence to someone’s health?
- Fights/Falls
- Pancreatitis
- Chronic liver disease/failure
- Withdrawal
- Delirium Tremens
- Wernicke’s Encephalopathy
- Respiratory depression
How do you work out 1 unit of alcohol?
% x Volume
If someone is in ED and they are a drinker, what are some worrying symptoms?
Think about everything that can go wrong and then symptoms of those
What are some screening tools you can use to uncover at-risk drinking?
CAGE: 2 or more
TWEAK: Tolerance, Worried, Eye opener, Amnesia, Cut down >6
They do not pick up abuse or dependence
How can you assess the level that someone is drinking to?
- AUDIT questionnaire
- SADQ
What are the different stages of alcohol withdrawal and the time frames this occurs in?
- Acute withdrawal: 6-12 hours
- Hallucinations 12-24 hours
- Seizures: 36 hours
- DT After 72 hours
How does early withdrawal present and when do the withdrawals start?
6-12 hours post drink
- Insomnia
- Tremor
- Anxiety
- Agitation
- Nausea and vomiting
- Sweating
- Palpitations
How may late alcohol withdrawal present?
- Hallucinations of visual, tactile or auditory origin
- Delirium tremens
- High blood pressure
- Increased pulse
What is Delirium Tremens and why is it dangerous?
Usually around 48-72 hours after stopping
10% mortality due to seizures
- Visual and tactile hallucinations (formication)
- Paranoid delusions
- Tremor
- Confusion
- Seizures
- Tachycardia
- Hypertension
- Hyperthermia
When is assisted alcohol withdrawal warranted?
Drinking over 15 units per day or in those scoring over 20 on the AUDIT questionnaire
Who needs inpatient care for alcohol withdrawal symptoms?
- >30 units per day
- Over 30 on the SADQ score
- High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
- Concurrent withdrawal from benzodiazepines
- Significant medical or psychiatric comorbidity
- Vulnerable patients
- Patients under 18
Who is given Pabrinex (oral thiamine) in the alcohol dependent patient population and why?
To prevent Wernicke’s encephalopathy. Given IV
- Suspected Wernicke’s encephalopathy
- Malnourished or at risk of malnourishment
- Decompensated liver disease
- Attending hospital for acute treatment
- Acute withdrawal
- Before and during assisted alcohol withdrawal.
How is alcohol withdrawal treated?
(Important card)
- Long acting benzodiazepines (Chlordiazepoxide or Diazepam): prescribed in a reducing regimen
- Alcohol-withdrawal seizure: rapid-acting benzodiazepine (IV lorazepam)
- Pabrinex (1 pair of ampoules once daily to prevent Wernicke’s encephalopathy. If signs give 2 TDS).
How is delirium tremens treated?
Characterised by agitation, confusion, paranoia, and visual and auditory hallucinations
- IV diazepam or PO Lorazepam
- Haloperidol
- Flumazenil if needed (diazepam antidote)
What medication can you give after alcohol withdrawal to prevent relapse?
Always give in conjunction with psychological therapies like AA to reduce relapse rate:
- Acamprosate
- Naltrexone
- Disulfiram (last line)
What are signs of Wernicke’s encephalopathy and how is it treated?
Due to Vit B1 deficiency: (CAN)
- Opthalmoplegia
- Confusion
- Ataxia
IM/IV Pabrinex 2 ampoules TDS
Also give this before any glucose as glucose can precipitate Wernicke’s
What are signs of Korsakoff’s syndrome and how is it diagnosed?
- Retrograde/Antegrade amnesia
- Confabulation
- Psychosis
This is irreversible!!!
How many alcoholics develop Wernicke’s and how can we prevent it?
Give PO Thiamine prophylactically to harmful drinkers if they are malnourished or have decompensated liver disease
What are some complications of substance misuse?
Physical: Death, BBV infection, S.Aureus infection, Endocarditis, PE, DVT
Psychological: Craving, Anxiety, Drug-Induced Psychosis
Social: Crime, Imprisonment, Homelessness, Prostitution
What are the three different classes of drug with examples and how long can you be imprisoned for if you are in possession of these?
What investigations should you do if you suspect somebody is taking an illicit substance?
- HIV, Hep B/C and TB screen
- U+Es
- LFTs and clotting
- Drug levels
- Urinalysis
- ECG for arrhythmias
- ECHO if suspect endocarditis
How can we manage someone with substance abuse?
Detoxification or Maintenance (Harm minimisation)
What investigations should you do if you suspect someone has alcohol dependence?
- FBC: anaemia
- U+Es
- LFTs and Gamma GT
- MCV
- Folate/B12/TFTs: alternate cause of macrocytosis
- Amylase: pancreatitis
- Hepatitis serology
- Glucose: hypoglycaemia
How can we manage someone with alcohol dependence?
BIOPSYCHOSOCIAL
- Alcoholics Anonymous
- Also patient needs to inform DVLA
What is in the stages of change model?
What 3 drugs can be used in the treatment of alcohol dependence to try and stop relapse and how do they work?
- Disulfiram: build up of acetaldehyde on consumption of alcohol causing very unpleasant symptoms e.g anxiety, flushing, headache
- Acamprosate: Reduces craving by enhancing GABA transmission
- Naltrexone: Blocks opioid receptors reducing the pleasurable effects of alcohol
What are the side effects of the following maintenance drugs:
- Disulfiram
- Acamprosate
- Naltrexone
Disulfiram: hypotension and vomiting when mixing with alcohol
Naltrexone: vomiting, drowsiness, dizziness, joint pain. CI: hepatitis; liver failure; monitor LFT
Acamprosate: D+V, change to libido CI: pregnancy, severe liver failure, creatinine >120μmol/L
What are some signs of opioid withdrawal?
- Agitation
- Anxiety
- Muscle aches or cramps
- Chills
- Runny eyes
- Runny nose
- Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting
- Dilated pupils
- ‘Goose bump’ skin
Symptoms occur within 12 hours of stopping the drug, peak at 36 hours, finish by 5 days. The withdrawal syndrome is unpleasant but not life-threatening.
What drugs are used for opioid dependence to detox?
Used for both detoxification AND maintenance
- Methadone: First line
- Buprenorphine
- Naltrexone: only for maintenance, causes withdrawal symptoms if any opioids used
What is the mechanism of action of buprenorphine and methadone and what are the side effects of each?
Used for opioid detox and maintenance
Buprenorphine: partial agonist at μ-opioid receptors
Methadone: agonist at μ-opioid receptors
How long does opioid withdrawal take?
Inpatient: 4 weeks
Outpatient: 12 weeks
Need maintenance support for 6 months after
Why may buprenorphine be used instead of methadone?
- Less sedating so better for driving
- Less interactions with drugs
- Less risk of overdose
Has more withdrawal symptoms than methadone though
How is opioid overdose treated?
Naloxone
Some people can dissolve Buprenorphine and inject it to get opioid effect. How can this be by passed?
Give buprenorphine with naloxone (Suboxone®)
The naloxonecomponent precipitates withdrawal if the preparation is injected, but it has little effect when the preparation is taken sublingually
How do you do opioid substitution during pregnancy?
- Do not do acute withdrawal as can cause fetal death
- Best to withdraw in second trimester as if in first can cause miscarriage and if in third can cause fetal distress and still birth
- Increase dose of substitute in third trimester as metabolism increases
- Monitor neonate for signs of respiratory depression
Apart from methadone and buprenorphine, what are some other drugs that can be used to help relieve the symptoms of opioid withdrawal?
- Loperamide: for diarrhoea
- Mebeverine: for stomach cramps
- Paracetamol and NSAIDs: for muscle pains and headaches
- Metoclopramide or Prochlorperazine: for nausea
How can we harm minimise for a patient that is using opioids and does not want to stop?
Give supply of naloxone in case of accidental overdose
What methods are used in motivational interviewing?
- Roll with resistance
- Express empahty
- Develop discrepancy
- Support self-efficacy
What psychiatric co-morbidities can arise with the use of the following:
- Opioids
- Stimulants
- Alcohol
- Cannabis
Alcohol and depression
Stimulants and psychosis
How long is Chlordiazepoxide given for in alcohol withdrawal?
10 days, PO
It is a benzodiazepine
What medication would you give to treat and prevent WE?
IM Pabrinex. Followed by oral thiamine and multivitamins
What are the three symptoms of Korsakoff’s?
- Retrograde and Antegrade amnesia
- Confabulation
- Inability to learn new information
What illicit drugs can cause a schizophrenia like state?
- LSD
- Cannabis
- Cocaine
- Amphetamines
