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PSYCHIATRY > 1b Substance Use and Addiction > Flashcards

1b Substance Use and Addiction Flashcards

1
Q

What is meant by positive reinforcement?

A

Taking a substance to gain a positive state

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2
Q

What are some examples of reasons to take substances fot positive reinforcement?

A

Escapism
Get high
Like it
Stay Awake

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3
Q

What are some examples of reasons to take substances for negative reinforcement?

A

Boredrom
To get to sleep
Feel Better
Reduce Anxiety

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4
Q

What is negative reinforcement?

A

Taking substances in order to overcome an adverse state

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5
Q

Describe the course of alcohol/drug use which leads to addiction

A
  1. Experimental / recreational use which causes limited difficulties - “LIKE”
  2. Increasingly regular use - “WANT”
  3. Leads to harmful use as there is a shift in motivational desire
  4. Finally = spiralling dependance on the drug = “NEED”
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6
Q

What is the definition of a harmful substance?

A

A substance which when using it, places the mental and physical health of the user in danger

Hazardous = likely to cause harm if use continues at this level

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7
Q

What are the key diagnostic criteria of Dependance Syndrome?

A
  1. Strong desire or sense of compulsion to take the substance
  2. Difficulty controlling the substance in terms of termination of use - think who has control, you or the drug
  3. A physiological withdrawal state when the drug is stopped
  4. Tolerance = need to take more to get the same effect
  5. Neglect of alternative interests
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8
Q

What is the definition of Addiction?

A

Compulsive drug use despite harmful consequences, characterised by an inability to stop using the drug; failure to meet work, social and family obligation and depending on the drug, tolerance and withdrawal

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9
Q

What is the biological definition of dependance?

A

Refers to a physical adaptation to a substance = Patients can be depedant but not addicted

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10
Q

What are behavioural addictions?

A

Gambling disorder = similarities in neurobiology and treatment approaches therefore reclassified

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11
Q

How does entry of the drug impact addiction?

A

faster brain entry = more “rush” and more addiction

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12
Q

Describe the path from use to addiction?

A
  1. Pre existing vulnerability - family history and age play large roles
  2. Drug exposure = compensatory neuroadaptations to maintain brain functions
  3. Leads to cycles of remission and relapse, or sometimes recovery which can be sustained
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13
Q

What happens once someone is tolerant to a drug?

A

Once they become tolerant, they then begin to experience withdrawal once the drug is not there

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14
Q

How does alcohol affect the brain?

A

Alters the balance between the brains inhibitory and excitatory systems

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15
Q

What is excitatory system of the brain?

A

Glutamate system

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16
Q

Which receptor does the glutamate system work on?

A

NMDA receptor

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17
Q

What is the inhibitory system of the brain?

A

GABA-A system

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18
Q

What are two common reasons to drink alcohol?

A

To get to sleep
To reduce anxiety

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19
Q

Describe the effects of acute alcohol drinking on the excitatory system?

A

Blocks the excitatory system = results in impaired memory (leading to blackouts)

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20
Q

How does memory get impaired with drinking alcohol?

A

Changes to the NMDA receptor result in memory loss

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21
Q

How does the inhibitory system get affected when acutely drinking alcohol?

A

Boosts the inhibitory system
- Sedation
- Anxiolysis

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22
Q

What does chronic alcohol exposure lead to?

A

Results in neuroadaptations so GABA and glutamate remain in balance in the presence of alcohol

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23
Q

What happens to the excitatory and inhibitory systems in chronic alcohol use?

A

Upregulation of the excitatory system and reduced function in the inhibitory system = tolerance

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24
Q

How does the GABA-A receptor change in chronic alcohol drinking?

A

Switch in sub-units to make it less sensitive to alcohol

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25
Q

Describe the withdrawal state of alcohol?

A

When the alcohol is taken away - there is still the large up-regulation of the excitatory system

This imbalance is toxic and can lead to hyperexcitability (seizures) and cell death (atrophy)

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26
Q

How does the NMDA receptor change in the state of withdrawal?

A

Increase in Ca2+

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27
Q

How is alcohol withdrawal treated?

A

Treat with benzodiazepines to boost GABA function to restore the balance and counteract the glutaminergic hyperactivity

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28
Q

What is the medication which reduces NMDA function?

A

Acamprosate

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29
Q

What do natural rewards (food, sex) do?

A

They increase the levels of dopamine in a part of the brain called the ventral striatum

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30
Q

What is the dopamine pathway referred to as?

A

Pleasure-rewards-motivation system

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31
Q

What is a key regulator of the dopamine system?

A

Opioid system - Mu opioid which mediates pleasureable effects - endorphin rush

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32
Q

What is the reward-deficient state?

A

Addiction

33
Q

How do cocaine and amphetamines interact with the dopamine system?

A

They block the reuptake of dopamine into the pre-synpatic neurone, meaning there is a lot more dopamine available in the synapse

34
Q

How does amphetamine work? (2)

A

Amphetamine enhances the release of Dopamine, as well as blocking the reuptake

35
Q

How do alcohol and nicotine affect the dopamine pathway?

A

They increase the dopamine neurone firing in the VTA (ventral tegmental area)

36
Q

What is the relationship between “liking” psychostimulants and the levels of V2 receptors in the brain?

A

Pleasurable outcome = have fewer dopamine receptors - this might be due to the fact they started with less

Non-pleasurable outcome = More dopamine = too much can lead to symptoms like schizophrenia and hallucinations and other negative effects - started with enough therefore too much is not enjoyable

37
Q

How can the function of the reward pathway be assessed?

A

fMRI

38
Q

What region of the brain is involved in the withdrawal / negative effect?

A

Amygdala and brainstem

39
Q

What happens to the level of high as dependance and addiction develops?

A

The level of high decreases as the allostatic set point is lower than the homeostatic one, therefore the “high” felt is significantly less

40
Q

Describe the change from positive to negative reinforcement as addiction develops?

A

Positive reinforcement drops, and and negative increases, with primary motivation being negative reinforcement

41
Q

Describe the “stress” system?

A

The ‘stress’ system: increased activity in many including kappa opioid (dynorphin), noradrenaline (arousal system) CRF (stress) etc

42
Q

Dysregulation in which key brain area is key for negative states during addiction?

A

Amygdala

43
Q

Describe the changes in neurobiology when drug addiction changes from habits to compulsion?

A

Involves transition from Prefrontal to striatal control over drug taking

And, ventral (limbic or emotional) to dorsal (habit) striatum

The prefrontal “top-down” control is diminished with greater striatal reward drive

44
Q

What is Naltrexone?

A

An opioid antagonist - used to block heroin use in opioid addicts and modulate the rewards system in alocholism

45
Q

What is meant by harmful use?

A

A pattern of psychoactive substance use that is causing damage to health (physical or mental)

46
Q

What is new that is included in the ICD 11?

A

Harm to the health of others - any form of physical hard including trauma or mental disorder

47
Q

What are the three categories in the new ICD11 classification?

A
  1. Impaired control over substance use
  2. Increasing precedence of substance use over other aspects of life
    3, Physiological features indicative of neuroadaption to the substance
48
Q

What are the DSM5 Classification differences?

A

Opioid Use Disorder
Alcohol Use Disorder

49
Q

Which conditions are important to ask about in a past medical history when doing a history taking in addiction?

A

Cirrhosis (Alcohol)
Endocarditis (IV)
Abscesses (IV)
BBV: Hepatitis B/C & HIV (IV)
(ask about vaccinations)

50
Q

Which patient population is most likely to develop an alcohol problem?

A

Younger men

51
Q

After what time frame is the maximum alcohol concentration reached?

A

Alcohol is well absorbed from the mouth, stomach and small bowel and maximum blood concentration is reached within 60 minutes of ingestion.

52
Q

What property of alcohol makes it well distributed in the body?

A

It is hydrophilic and therefore widely distributed in all bodily tissues

53
Q

What does alcohol do to cause anxiolysis?

A

Alcohol enhances neurotransmission at GABA-A receptors

54
Q

What part of the brain is responsible for the reward pathway after drinking alcohol?

A

It also stimulates dopamine release in the mesolimbic system

55
Q

Describe the metabolism of alcohol?

A

Oxidised by alcohol dehydrogenase to acetaldehyde

Acetaldehyde is then oxidised by ACETALDEHYDE DEHYDROGENASE to carbon dioxide and water

56
Q

What is targeted commonly in drugs to treat alcohol addiction / dependance?

A

Drugs to stop alcohol dehydrogenase

57
Q

What clinical features are looked on examination for when making an alcohol assessment?

A

It also stimulates dopamine release in the mesolimbic system

58
Q

What are the neurological signs which might be found in patients with alcohol problems?

A

Consider Wernicke’s encephalopathy and Korsakoff’s syndrome

59
Q

What are the symptoms of Wernicke’s encephalopathy?

A

Ataxia, confusion and opthalmoplegia

60
Q

What is given to patients with Wernicke’s encephalopathy?

A

Intramuscular, and then oral thiamine in order to reverse the effects seen in wernicke’s encepthalopathy

61
Q

what happens if thiamine is given to patients with Korsakoff’s sign?

A

Nothing - damage is irreversible at this point

62
Q

What must you do if a patient is CAGE positive?

A

Do a substance misuse history

63
Q

Which is worse, alcohol or opiate withdrawal?

A

Alcohol - worsening pattern or symptoms which can lead to death

hallucinations and delirium tremors

64
Q

What is the difference between Opiates and Opioids?

A

OPIATES - refer to naturalopioidssuch as morphineandcodeine and heroin to some extent

OPIOIDS - refer to all natural, semisyntheticandsyntheticopioids

65
Q

What do Opioids do?

A

Relieve pain - analgesic effect
Create a sense of Euphoria

66
Q

What might patients who are going through a heroin withdrawal experience?

A

Diarrhoea

67
Q

What are the three opioid receptors called?

A

mu, delta, kappa

68
Q

What are examples of opioid agonists?

A

Heroin, methadone, fentanyl, codeine

69
Q

What is buprenorphine used to do?

A

As a substitute for heroin

70
Q

What might you see on examination in a patient for opiate assessment?

A

Collapsed veins / track marks
Endocarditis
Skin abscesses
Hepatitis / HIV
Pneumonia

71
Q

What assessment is done to measure opiate withdrawal?

A

COWS - Clinical Opiate Withdrawal Scale

72
Q

What medication is given to people who have had a heroin overdose?

A

Naloxone (Narcan) - inject into upper arm / thigh , if no response in 3 minutes then repeat

provide airway support, recovery position

73
Q

How does Disulfiram work as an anti-alcohol medication?

A

Works by blocking the breakdown of alcohol in the body. This leads to buildup of a toxic alcohol-related compound that can cause people who drink alcohol while taking this medication to become very sick. This reaction helps encourage people to avoid alcohol while taking the medication.

74
Q

Which antibiotic also inhibits acetaldehyde dehydrogenase?

A

Metronidazole

75
Q

What treatment is given to promote Opioid Abstinence?

A

Methadone
Buprenorphine

Give them as a substitute for the opioid in a controlled manner, and in such a way that hey can slowly reduce their useage

76
Q

What is a medical emergency which can occur due to alcohol withdrawal?

A

Delirium tremens / seizures

77
Q

What medication is used for acute alcohol intoxification?

A

Chlordiazepoxide (Librium) is the most
commonly used medication for acute alcohol
detoxification.

78
Q

Which medication is used in both alcohol and opioid abstinence?

A

Naltrexone is used in both alcohol and opioid abstinence.

PSYCHIATRY (7 decks)

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