4 - PSY - Alcohol and substance misuse Flashcards
Acute intoxication
Transient physical and mental abnormalities
May causes disturbed consciousness, cognition, perception, affect, behaviours etc
Specific for each substance
Harmful use
Continuation of use despite damage to user’s physical/mental health or to social well-being - may be denied/minimised by user
Withdrawal
Due to cessation after physical dependence
Clinically significant withdrawals = alcohol, opiates, benzos, cocaine, amphetamines
Complicated by development of seizures, delirium or psychotic symptoms
Tolerance
More must be taken to achieve same intensity of effect
6 core features of dependence syndrome
Primacy - drug and getting it = priority in life
Continued use despite negative consequences
Loss of control of consumption
Narrowing of the repertoire
Rapid reinstatement of dependent use after abstinence
Tolerance and withdrawal
Substance induced psychotic disorder
Psychotic as direct result of substance neuro-toxicity
Psychotic features either during intoxication/withdrawal, or on background of chronic use
Can be difficult differentiating between this and primary psychotic illness
Most common cause of alcohol related death?
Alcoholic liver disease
Cost of alcohol to NHS?
Estimated as £3.5bn per year
One unit =
8g/10ml of pure ethanol
Guideline weekly drinking for men and women?
14 units
Biological alcohol misuse aetiology
Risk 7x if first degree relative is alcohol dependent
Alcohol dependent parents = increased risk (even if adopted!!)
No specific genes - although some determine metabolising capacity (SEAsian’s may not be able to metabolise -> unpleasant flushing reaction)
Psychological alcohol misuse aetiology
Mental illness increases risk
Stress, high social anxiety + low self esteem
Negative and Positive reinforcement models can be applied. E.G. - using alcohol to deal with stress, or using alcohol to be happy in social situations
Social/Occupational alcohol misuse
Men>women - women increasing over last 20y Mortality higher in lower socio-economic classes Social isolation + loss of spouse = higher risk Certain professions (bar-tending, farming)
Complications of Alcohol misuse - Neuro
CNS - cog and mem impaired, brain shrinks, Wernicke-Korsakoff syndrome, Cenral Pontine Myelinolysis, Cerebellar degeneration
PNS - alcoholic peripheral neuropathy and myopathy, optic atrophy and visual changes
Complications of Alcohol misuse - Resp
increases susceptibility to aspiration pneumonia and infections
Complications of Alcohol misuse - CV
Alcoholic cardiomyopathy
Arrhythmia - esp AF
HTN
Cerebrovascular events - esp haemm strokes
Complications of Alcohol misuse - Hepatic
Alcohol hepatitis
Fatty liver changes - vast majority changes reverse with abstinence
Cirrhosis at end stage of either of above - females increased risk of cirrhosis
Hepatocellular carcinoma
Complications of Alcohol misuse - renal
Cirrhosis can predispose to hepato-renal syndrome
HTN > CKD
Complications of Alcohol misuse - Pancreas
Commonest cause of chronic pancreatitis > malabsorption > DM
Also Acute pancreatitis
Complications of Alcohol misuse - Spleen
Splenomegaly secondary to cirrhosis and portal HTN
Complications of Alcohol misuse - S + L Bowel
Malabsorption
Chronic diarrhoea
Lower GI Ca risk factor
Complications of Alcohol misuse - Gastro-oesophageal
Oesophageal - Mallory Weiss tears from vomiting, varices +/- haemorrhage, Barretts oesophagus and CA
Gastric - gastritis and gastric erosions, peptic ulcer +/_ haemorrhage, gastric CA
Complications of Alcohol misuse - Sexual health
Women - sexual dysfunction, fertility problems risk, teratogenic
Men - ED + hypogonadism
Complications of Alcohol misuse - Psychiatric
Alcoholic hallucinosis - occurs during clear consciousness (sober)
ARBrainDamage - 60% of chronic heavy drinkers - impaired memory and executive function
Pathological jealousy - Primary delusion that partner has/is being unfaithful
Other PSY co-morbidity - anxiety and depression, suicide, schizophrenia
Risk factors for more severe alcohol withdrawal
Increased amount + time of heavy drinking
Intercurrent medical illness
Liver disease
Previous withdrawal episodes
When to prophylactically treat AWS
- known alcohol dependence
- Hx of alcohol withdrawal
- consumed >10 units for >10 days
- current withdrawal symptoms
Mild/uncomplicated alcohol withdrawal
Occurs 4-12 hours after the last alcoholic drink
Features: coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation, anxiety
The patient may occasionally experience transient hallucinations
Intense cravings for alcohol
Typically lasts 2-5 days
Seizures in AWS
5-15% of cases
6-48 hours after the last drink
Risk factors for seizures include: heavy, prolonged alcohol consumption, previous withdrawal seizures, idiopathic epilepsy and history of head injury
Delirium Tremens - background
medical emergency
1-7 days after last drink
5% of AWS patients
40% mortality if untreated
Delirium Tremens - symptoms
clouded consciousness time, place, person disorientation amnesia hallucinations and delusions severe psychomotor agitation and tremor Fever Autonomic disturbances and E imbalances
AWS Key management
Benzos for Sx relief
Nutritional and Vitamin supplementation (thiamine)
Close physical and psychiatric complication monitoring
Thiamine deficiency - alcoholic causes
-drinkers dietary habits
Chronic alcohol reduces thiamine absorption from gut
Drinkers>liver disease - capacity for thiamine storage is reduced
How is Wernicke’s encephalopathy caused?
Secondary to Thiamine (Vit B1) deficiency
Wernicke’s symptom triad ?
Ataxic gait, Ocular motor signs, Acute confusional state
Wernicke’s treatment
ALL PT’s with symptoms/high risk of WE -> parenteral vitamin replacement
High potency Thiamine replacement
Glucose rehydration AFTER thiamine - glucose makes worse
Wernicke’s Prognosis
untreated - 80% to Korsakoff’s
15% mortality if untreated
Korsakoff’s Syndrome aetiological features
usually results from thiamine deficiency
Rare causes - head injury, CO poisoning, encephalitis
Can present w/o WE and in chronic form
Korsakoffs - Clinical features
Anterograde amnesia ( can’t lay down new memories)
(Less marked) retrograde amnesia
Confabulaiton (false memories covering amnesia
Apathy
Korsakoffs Treatment
aggressively treat preceding WE
Oral thiamine and vitamins for 2 years
Pyschosocial interventions for cog imp
Alcoholic History - In depth areas:
- Lifetime pattern of alcohol consumption
- Current consumption
- Signs of dependence
- Social/occupational problems
- Previous treatment attempts
- Physical and mental health
Alcoholic Investigations
MCV - high specificity - raised 3-6 months after abstinence (life of RBC)
GGT - alcohol related liver inflammation
Liver US if indicated
Heroin - route? harmful effects?
- most commonly smoked - many progress to IV use
- Acute -N+V, constipation, resp depression + lost consciousness
- IV use - Hep B C + HIV, abscesses, cellulitis, septicaemia
Cocaine - harmful effects
Acute - ^HR, HTN, Vasoconstriction —- increasing risk fo CVA, MI and Arrhythmias —- acute anxiety, panic, impulsivity, impaired judgement
Chronic - Nasal septum ad sinus necrosis, CKD 2ndary to HTN, Panic disorder, GAD, Psychosis
Harm reduction strategy examples…
- needle distribution + education
- Take home naloxone
- Substitute prescribing
- treat co-morbidities
- safe sex education
6 stages of change?
— Pre-contemplation (no intention of changing) — contemplation (aware of problem) — Preparation (intent to take action) — Action — Maintenance (sustained change) — Relapse —
4 principles of motivational interviewing
Develop discrepancy (between behaviour and personal goals)
Roll with resistance
Express empathy with reflective listening
Support self efficacy (improve pt confidence in ability to change)
Disulfiram
deterrent to alcohol abuse - unpleasant symptoms of flushing, headache, tachycardia,N+V if you drink
Acamprosate
to reduce cravings of alcohol - by enhancing GABA transmission in brain
Lofexidine
alpha agonist - reduces opiate withdrawal symptoms
Loperamide or Metoclopramide - why?
to treaet diarrhoea and N+V commonly seen in withdrawal
Substitute prescribing
- 2 drugs
Methadone - 24h half life - suitable for once daily dosing - orally - long acting synthetic opioid
Buprenorphine - partial mu agonist - once daily sublingual preparation
Both have street value
