1b Substance Misuse & Addiction Flashcards
Which substances can cause addiction (13)?
- Alcohol
- Nicotine
- Cannabis
-
Stimulants
- Amphetamine
- Cocaine
- Crack
- Ecstasy
-
Opioids (prescribed, OTC)
- Heroin, fentanyl
- DF118
- Ketamine
- Solvents
-
G-drugs
- GHB, GBL
- Benzodiazepines
-
Psychedelics
- LSD
- Magic mushrooms
- Nitrous oxide
- Khat
-
‘Novel psychoactive substances’
- ~950 synthetic (UNODC);
- new: ~1/wk
- Categories: Depressant, stimulant, hallucinogenic, cannabinoid
What are the 3 categories of reasons that one may experiment with addictive substances for recreational reasons?
- Positive reinforcement
- Negative reinforcement
- ‘Normal’
Experimental/‘recreational’ use: causing no/limited difficulties (majority of population)
Give examples of positive reinforcement in terms of alcohol / drug use (4).
- Escapism
- Stay awake
- Get high
- Like it
Give examples of negative reinforcement in terms of alcohol / drug use (4).
- Boredom
- To get to sleep
- Reduce anxiety
- Feel better
Give examples of ‘normal’ reasons in terms of alcohol / drug use (5).
- To fit in
- Why not?
- Rebel
- Everyone does
- Curious
Define intoxication.
- A transient syndrome due to recent substance ingestion that produces clinically significant psychological or physical impairment
- These changes disappear when the substance is eliminated from the body
Define withdrawal state.
- A group of symptoms and signs that occur when a drug is reduced in amount or withdrawn entirely
Define tolerance.
- A state in which after repeated administration, a drug produces a decreased effect
- Increasing doses are therefore required to produce the same effect
Define harmful use.
- A pattern of psychoactive substance use that is causing damage to health (physical or mental)
What are the requirement to diagnose dependence syndrome (6)?
Classification: ICD 10
CLoWN PT (compulsion, lack of control, withdrawal, neglect, persistence, tolerance)
3 or more of the following in past year:
* A strong desire or sense of compulsion to take a substance.
* Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use.
* A physiological withdrawal state when substance use has ceased or been reduced (This is mainly relevant to alcohol, opiates, benzodiazepines, G-drugs).
* Tolerance (ie. need to take more of the substance to get the same effect).
* Progressive neglect of alternative pleasures or interests because of substance use, increased amount of time necessary to obtain or take alcohol or to recover from its effects.
* Persisting with substance use despite clear evidence of overtly harmful consequences.
A client/patient CANNOT have a diagnosis of BOTH harmful use AND dependence
What are the requirements to diagnose harmful use (4)?
Classification: ICD 10
- A pattern of substance use that causes damage to health.
- The damage may be: (1) physical or (2) mental (This criterion MUST be present if harmful use is diagnosed).
- Adverse social consequences.
- Harmful use includes bingeing on substances. Does not include ‘hangover’ alone.
- Does not fulfil any other diagnosis within substance use e.g. dependence
A client/patient CANNOT have a diagnosis of BOTH harmful use AND dependence
What are the differences between harmful use (ICD 10) and harmful use (ICD 11) (2)?
- A new category to denote single episodes of harmful use from a pattern of harmful use
-
Harm to health of others.
- This includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour related to substance use on the part of the person to whom the diagnosis of Harmful pattern of use of the substance/alcohol applies
What are the requirements to diagnose dependence (3)?
Classification: ICD 11
PLaN- Precedence, Lack of control, Neuroadaptation
- Impaired control over substance use (i.e. onset, frequency, intensity, duration, termination, context).
- Increasing precedence of substance use over other aspects of life (e.g. repeated relationship disruption, occupational or scholastic consequences, negative impact on health).
- Physiological features indicative of neuroadaptation to the substance, (e.g. tolerance, withdrawal, use of pharmacologically similar substances to prevent or alleviate withdrawal symptoms.
The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months.
What are the criteria to diagnose opioid use disorder?
Classification: DSM 5
What is the course of behaviour for individuals with harmful use of alcohol / drugs?
- There is a shift in motivational desire, as the urgency & necessity increases (regular use → period of stress where the euphoric effects subside the fears)
- It is reversible
- Experimental / recreational use, cause no / limited difficulties
- Want: Increasingly regular use (fewer people) (harmful)
- Need: Spiralling: dependence (smaller number) (majority of population) (Like)
What does alcohol do to the brain’s inhibitory system?
- Alcohol behaves as a modulator of GABA-benzodiazepine coupling leading to an enhanced inhibitory system
- Concerns the GABA-A receptor
Which receptor is predominantly involved in terms of the brain’s inhibitory system?
- GABA-A receptor
Which receptors are concerned with the excitatory glutamate system?
- NMDA receptors
What impact does alcohol have on NMDA receptors?
- Alcohol alters the coupling and modulatory sites of the receptor, impairing the excitatory system
What neuroadaptations take place due to chronic alcohol exposure?
- GABA-A receptor subunit becomes less sensitive to alcohol - there is a reduced function in the inhibitory function - tolerance, given that alcohol consumption retains a GABAergic balance
- Chronic alcohol consumption also leads to an upregulation in the excitatory system (NMDA receptors)
What are the physical effects of alcohol harmful use / dependency?
There are a lot, learn 5.
What are the symptoms of alcohol withdrawl?
6-12 hrs
Minor Withdrawal Symptoms: tremulousness (hand, tongue, eyelids), diaphoresis, fever (with or without infection), anxiety, agitation, nausea, vomiting and retching.
12-24 hrs
Alcoholic Hallucinosis: visual and auditory (usually accusatory or derogatory voices) hallucinations, tactile disturbances
12-48 hrs
Withdrawal Seizures
48-72 hrs
Delirium Tremens (DTs): hallucinations, confusion and disorientation, hypertension, agitation, tachycardia >100/min, fever (with or without infection), severe tremor in hands and body.
DTs represent a medical emergency.
Patient may need observations for 72 hours after cessation of drinking.
What are the appearance & behaviour signs in a mental state examination of drug (heroin) harmful use / dependency (6)?
- Nil abnormal movements
- Dressed in tracksuit
- Reasonable rapport
- Looks downcast
- Collapsed veins (described)
- Restless
What aspects of history taking are specific to alcohol harmful use / dependency?
-
History of:
- Alcohol related seizures, Delirium Tremens, Alcohol psychosis, haematemesis, melaena
-
Examination:
- Comment on the presence of jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT
-
Investigations:
- Fibro scan / Ultrasound
- Bloods (LFT, GGT, Lipids, U&E, amylase)
- Breathalyser
- Urine Drug Screen
What’s the scoring of the alcohol use disorder identification test (AUDIT)?
- 0-7: low risk
- 8-15: increasing risk
- 16-19: higher risk
- >20: possible dependence
Which drugs are used to help boost GABA function in patients in the withdrawal state of chronic alcohol exposure?
- Benzodiazepines
What are the symptoms of opiate withdrawl (11)?
ARMY FINDS:
ACHES (muscular/ bones)
Runny nose (or lacrimation), Eye dialation
MOOD- irritable/ anxious
YAWNING
FEVER
INSOMNIA
NAUSEA (or vomiting)- GI upset
DIARRHEA
SWEATING, gooseflesh skin
+
* Tachycardia
* Restlessness
* Tremor
What happens to patients in an alcohol withdrawal state?
- There is an upregulation of the excitatory system:
- An increase in calcium dynamics is toxic, leading to hyperexcitability (seizures) & atrophy
What is the pattern of glutamate release in patients with alcohol withdrawal?
- There is a significant increase in glutamate (Both metabolic and synaptic) due to upregulation of excitatory neurones
What drugs are used to treat patients with alcohol withdrawal (2)?
- Lorazepam
- Diazepam (benzodiazepines)
What is the effect of acamprosate in alcohol - dependent individuals?
- Reduction in MRS glutamate & NMDA function → Downregulate the excitatory system
What are the signs of harmful use / dependency of drugs (heroin) (6)?
- Injecting for 1 year, x3 per day
- Withdrawal features: feel sick, shivers, gooseflesh
- Craving
- Loss of control
- Restricted interests / preoccupied with getting heroin
- Distressed if cannot get heroin
What aspects of history taking are specific to drug (heroin) harmful use / dependency?
-
Examination
- Collapsed veins / track marks
- Endocarditis
- Skin abscesses
- Hepatitis / HIV
- Pneumonia
-
Investigations:
- Bloods (LFT, U&E, GGT, Glucose)
- Breathalyser
- Urine Drug Screen
- Sexual health screening / BBV
Name some examples of natural rewards (2):
- Sex
- Food
Which hormone is associated with natural rewards?
- Dopamine
Which region of the brain is concerned with natural rewards?
- Ventral striatum
Which pathway is concerned with the pleasure - reward motivation system?
- Dopamine pathway
Which hormone is a key modulator in the opioid system?
- Mu opioid
What impact is exhibited by mu opioids?
- Mediates pleasurable effects, leading to an endorphin rush
What type of reward state is exhibited by patients with addiction?
- Reward deficient state
What impact does cocaine, and amphetamines have on the dopaminergic system (2)?
- Blocks dopamine transport re-uptake proteins, elevating concentrations of dopamine within the synaptic cleft
- Amphetamine also enhances the release of dopamine
What impact does nicotine, opiates and alcohol have on the dopaminergic system?
- Increase dopamine neurone firing in the ventral tegmental area
What is the proposed relationship between D2 receptors and drug use?
- Low levels of D2 receptors predispose subjects to use drugs
What is the relationship between ventral striatum activity and problematic drug use?
- There is a reward deficiency thus activity in the ventral striatum
Which cerebral structure is associated with preoccupation and craving?
- Prefrontal cortex
Which cerebral structure is concerned with negative reinforcement?
- Amygdala
Which type of reinforcement develops and dominates in patients with dependence?
- Negative reinforcement
Which hormones are released in a stressed system (3)?
- Kappa opioids (dynorphine)
- NA
- CRF (corticotropin releasing factor)
Which system is dysregulated in alcohol addiciton?
- Amygdala
What is the pattern of amygdala regulation in patients with polydrug addiction compared to alcoholism?
- In polydrug, there is a heightened response to aversive stimuli
What are the 3 types of opioids?
Give examples
- Natural (opium, morphine’s codeine)
- Synthetic (fentanyl)
- Semi-synthetic (heroin)
What are G drugs (GHB-gamma hydroxybutynate & GBL-gamma butyrolactone)?
-
Depressant drugs which can produce a high with small doses, and cause sedation with only slightly higher doses (Very easy to overdose)
- Euphoric
- Loss of inhibitions
- Increased confidence
- Higher sex drive
What is gambling disorder defined as?
- Behavioural addiction in DSM-5
What type of use is this case:
Drinks four pints of Stella most evenings. Says his drinking doesn’t cause problems.
- Hazardous alcohol use
What type of use is this case:
Drinks a bottle of wine most evenings, more at the weekends. Occasionally misses work because of hangovers.
-
Harmful alcohol use
- Consequences: Physical, psychological, social impact
What pattern of drinking is this case:
Drinks cider first thing each morning to stop himself shaking. Regards drink as a medicine, believes he wouldn’t get by without it. Doesn’t tend to get drunk.
- Addiction / dependence
What type of drug use is this case:
Broke her ankle 6 months ago which healed well and is back to playing football. Is still taking her opioid painkillers which are on repeat prescription
- Likely biologically dependent as has been taking opioids for many months; no evidence of taking more than is prescribed (ie suggesting ‘abuse’) however need to ask if this is the case and why it is on repeat – has it just happened through error/lack of review or has she requested it?
What type of drug use is this case:
Broke his ankle 3 months ago and says he is still in pain. Is still taking his opioid painkillers and often requests his prescription earlier.
- Likely biologically dependent as has been taking opioids for many months; is taking more than is prescribed so need to ask why – for pain or to deal with withdrawal or “likes how it makes him feel”
- Consider harmful use, ask about any other addiction behaviours to clarify if addicted
How does one calculate units in alcohol?
Units = % strength x ml /1000
What does CAGE stand for in alcohol use disorder?
Can help tell if you have a substance use disorder
- Have you ever felt you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (Eye-opener)
What do Opioids do?
- Relieve pain – analgesic effect
- Create a sense of euphoria
Opioid receptors mu, delta, kappa effected by opioid agonists (heroin, methadone, fentanyl, codeine), partial agonists (Buprenorphine), antagonists (Naltrexone)
How is opioid overdose managed?
-
Naloxone: inject into upper arm or thigh (400mcg), or nasal spray (50% each nostril)
- If no response after 3 mins, repeat.
- Provide airway support, recovery position
What medication is used in the abstinence of alcohol (4)?
- Acamprosate
- Disulfiram (Antabuse)
- Naltrexone
- Nalmefene
What medication is used in the abstinence of opioids (2)?
- Methadone
- Buprenorphine
What medication is used in the detox regimes of alcohol?
- Chlordiazepoxide (a benzodiazepine)
(both inpatient and community settings)
What methods is used in the detox regimes of opioids?
Maintenance treatment, for at least 12 months to sustain changes in lifestyle, before dose reduction over several months.
What is the mechanism of action of acamprosate?
- An NMDA antagonist that increases GABA
- Possible neuro protective role in withdrawl / detox
What is the mechanism of action of disulfiram (antabuse)?
- Inhibits acetaldehyde dehydrogenase, leading to feeling nauseous / flushes if mixed with alcohol
What is the mechanism of action of nalmefene?
- Opioid antagonist
What medication is used for benzodiazepine / G drugs withdrawl (abstinence)?
- Maintenance on Diazepam with a reducing regime of 1mg per week
What medication is used for benzodiazepine / G drugs withdrawl (detox regimes)?
- Balcofen (GABA agonist)
- Benzodiazepine (Diazepam)
