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Year 2 - BRS > 4.7 - Substance misuse & addiction > Flashcards

4.7 - Substance misuse & addiction Flashcards

1
Q

What is the clinical definition of intoxication (in both the DSM and ICD)?

A
  • intoxication is considered to be 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
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2
Q

What is the clinical definition of withdrawal state?

A

This refers to a group of signs and symptoms that occur when a drug is reduced in dose or withdrawn entirely

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3
Q

What is the clinical definition of tolerance?

A
  • this is a state in which, after repeated administration, a drug produces a decreased effect
  • increasing doses are therefore required to produce the same effect
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4
Q

What is the clinical definition of harmful use?

A

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

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5
Q

What are the three diagnostic criteria used?

A
  • ICD-10
  • ICD-11 (new edition)
  • DSM-V
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6
Q

What are the 6 criteria for dependence syndrome according to ICD-10?

A
  1. a strong desire or sense of compulsion to take a substance
  2. difficulties in controlling substance taking behaviour in terms of its onset, termination, or levels of use
  3. a physical withdrawal state when substance use has ceased or been reduced (mainly relevant to alcohol, opiates, BZs, G-drugs)
  4. tolerance (i.e. need to take more of the substance to get the same effect)
  5. 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
  6. persisting with substance use despite clear evidence of overtly harmful consequences
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7
Q

How many of the 6 criteria are required to diagnose dependence syndrome according to the ICD-10?

A

3 or more in the past year

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8
Q

What are the criteria for harmful use according to ICD-10? (5)

A
  • a pattern of substance use that causes damage to health
  • the damage may be: (1) physical or (2) mental
  • 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)
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9
Q

What can a patient not have a diagnosis of in relation to substance misuse & addiction?

A

A patient cannot have a diagnosis of BOTH harmful use AND dependence

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10
Q

What remains the same between the ICD-10 and ICD-11 in relation to dependence syndrome and harmful use?

A

Distinction between dependence and harmful use is preserved

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11
Q

What is different in the ICD-11 in relation to harmful use?

A
  • a new category to delineate single episodes of harmful use from a pattern of harmful use
  • now includes: harm to health of others - this includes any form of physical harm, including trauma, or a 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 use applies
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12
Q

What is different in the ICD-11 in relation to dependence?

A
  • the former 6 diagnostic criteria for dependence have been bundled into 3 pairs - fulfilment of one criterion is sufficient:
  1. impaired control over substance use (i.e. onset, frequency, intensity, duration, termination, context)
  2. increasing precedence of substance use over other aspects of life (e.g. repeated relationship disruption, occupational or scholastic consequences, negative impact on health)
  3. physiological features indicative of neuroadaptation to the substance (e.g. tolerance, withdrawal, use of pharmacologically similar substances to prevent or alleviate withdrawal symptoms)
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13
Q

How long are the features of dependence typically evident for and when can a diagnosis be made? (ICD-11)

A

The features of dependence are usually evident over a period of at least 12 months, but a diagnosis may be made if use is continuous (daily/almost daily) for at least 3 months

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14
Q

How is the DSM-V different to ICD in terms of diagnosis of harmful use/dependence? (3)

A
  • renamed:
    • opioid use disorder
    • alcohol use disorder
  • single continuum of mild, moderate, severe (dimensional approach)
  • no longer uses the terms abuse or dependence
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15
Q

How is alcohol use disorder/opiate use disorder diagnosed using the DSM-V?

A
  • 11 criteria checklist
  • presence of 2+ symptoms indicates AUD/OUD
  • severity defined as:
    • mild: 2-3 symptoms
    • moderate: 4-5 symptoms
    • severe: 6+ symptoms
  • (note - tolerance and withdrawal not considered to be met for individuals taking opioids under appropriate medical supervision)
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16
Q

What is included in history taking for addictions? (6)

A
  • presenting complaint (PC)
  • history of PC (HPC)
  • substance misuse history
  • family history
  • past psychiatric history
  • personal history
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17
Q

What is presenting complaint (PC)?

A

Snapshot of main problem/s

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18
Q

What is history of presenting complaint (HPC)?

A

Duration of current problem/s, onset, precipitating factors, signs and symptoms

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19
Q

What areas should be assessed for each substance in substance misuse history? (9)

A
  • length of current use and when last used
  • current amount (units/grams/pounds per day) and for how long at this level
  • total length of use, maximum use and any periods of abstinence
  • mode/method of administration (e.g. inhalation, ingestion, IV)
  • evidence of withdrawal syndrome and severity (e.g. seizures, admissions)
  • any previous treatments - medication, psychotherapy, detox/rehab admissions
  • any previous substance overdoses (accidental vs deliberate)
  • any triggers to use substances/alcohol
  • assess motivation to change/engage in treatment
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20
Q

What do we include in family history for addictions?

A

Include both mental illnesses and addiction disorders

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21
Q

What should be assessed in past psychiatric history for addictions? (2)

A
  • consider the presence of previous trauma including domestic violence, neglect and abuse (this feeds into risk assessment)
  • screen for developmental disorders especially ADHD (25% have comorbid ADHD)
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22
Q

What common comorbid conditions are there with substance misuse? (6)

A
  • depression (15% in community, 32% in alcohol treatment, 43% in drug treatment)
  • anxiety (17%)
  • suicidality (x6 risk increase)
  • personality disorders
  • PTSD
  • bipolar affective disorder
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23
Q

What do we assess in personal history in substance misuse history? (6)

A
  • relationships - partner, family, children (violence in household?)
  • safeguarding concerns?
  • accommodation problems?
  • money and debt? (how is use being funded)
  • employed/benefits
  • forensic history - cautions, convictions, ongoing court cases, crimes committed but not prosecuted for
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24
Q

What are the major causes of morbidity and mortality associated with substance misuse? (9)

A
  • trauma (e.g. broken bones from fights)
  • road traffic accidents
  • homicide
  • suicide
  • overdose (deliberate and accidental)
  • past medical history:
    • cirrhosis (alcohol)
    • endocarditis (IV use)
    • abscesses (IV use)
    • BBV: hepatitis B/C & HIV (IV use) - ask about vaccinations
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25
Q

How do you calculate units of alcohol?

A

% strength x ml/1000 = units

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26
Q

What is the excretion rate of alcohol?

A

Excretion rate is 1 unit per hour

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27
Q

What are the recommended unit intakes per week?

A

14 units per week for men and women with this being spread over 3 or more days

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28
Q

What are some examples of units in common drinks? (7)

A
  • 1 bottle of premium beer = 1.6
  • 1 pint of beer = 2.3
  • 1 pint of cider = 2.6
  • 1 glass of 25ml measured spirits = 1
  • 1 bottle of alcopops = 1.1
  • 1 medium glass of wine = 2.3
  • 1 bottle of wine = 9.8
29
Q

Describe the epidemiology of alcohol

A
  • 30% UK population drink above safe limits
  • 280,000 hospital admissions due to alcohol in 2019/2020 (65% of these were in males)
  • 9,641 alcohol deaths in 2021 (14.8 per 100k)
  • rates higher in Scotland (22.4 per 100k) and Northern Ireland (19.3 per 100k)
  • 15-24 year olds have heaviest use
  • unemployed > employed
  • separated > single > married
30
Q

How is alcohol absorbed?

A
  • alcohol is well absorbed from the mouth, stomach and small bowel
  • maximum blood concentration reached within 60 minutes of ingestion
  • alcohol absorption is slowed by food and sped up by the ingestion of effervescent drinks
  • it is hydrophilic and therefore widely distributed in all body tissues
31
Q

What are the pharmacodynamics of alcohol?

A
  • alcohol enhances neurotransmission at GABA-A receptors –> anxiolysis
  • stimulates dopamine release in mesolimbic system –> reward
  • inhibits NMDA mediated glutamate release –> amnesic effects
32
Q

What is the metabolism of alcohol?

A
  • ethanol is oxidised by alcohol dehydrogenase to acetaldehyde
  • this is oxidised by acetaldehyde dehydrogenase to CO2 and water
  • 98% of alcohol metabolism occurs in the liver and 1 unit of alcohol (8g) can be metabolised per hour
  • illicit brew may contain methanol which is broken down to formaldehyde and causes marked toxicity on retina
33
Q

What aspects of history are specific to alcohol assessment? (4)

A
  • alcohol related seizures
  • delirium tremens / alcohol hallucinosis
  • haematemesis
  • melaena
34
Q

What findings on examination are specific to alcohol assessment? (6)

A
  • jaundice
  • bruising
  • clubbing
  • oedema
  • ascites
  • spider naevi
35
Q

What neurological signs are specific to alcohol assessment? (2)

A
  • Wernicke’s encephalopathy (ataxia, confusion, ophthalmoplegia)
  • Korsakoff’s syndrome (memory impairment)
36
Q

What investigations are specific to alcohol assessment? (4)

A
  • liver fibro scan/ultrasound
  • bloods (LFTs, FBC, GGT, lipids, clotting, amylase)
  • breathalyser
  • urine drug screen
37
Q

What are the stages of liver damage? (4)

A
  • healthy liver
  • fatty liver
  • liver fibrosis
  • cirrhosis
38
Q

What is the CAGE screening alcohol assessment tool?

And what is another alcohol assessment tool used?

A

Have you ever felt the need to:

  • Cut down on drinking?
  • Annoyed when people tell you to decrease drinking/criticise it?
  • Guilty about drinking?
  • have a drink first thing in morning (Eye-opener)

AUDIT - Alcohol use disorders identification test
- 10 questions, scored 0-4
- 0-7 low risk, 8-15 increasing risk, 16-19 higher risk, 20+ dependence

39
Q

Describe the onset of alcohol withdrawal

A
  • more dangerous than opioid withdrawal
  • worsening pattern of symptoms
  • onset usually from 6 hours
  • hallucinations can occur any time
  • delirium tremens is a late sign and a medical emergency
40
Q

What are the four stages of alcohol withdrawal symptoms and how long after cessation of alcohol use do they usually present?

A
  • minor withdrawal symptoms 6-12h
  • alcoholic hallucinosis 12-24h
  • withdrawal seizures 12-48h
  • delirium tremens 48-72h
41
Q

Which condition, related to alcohol withdrawal, represents a life-threatening medical emergency?

A

Delirium tremens - characterised by confusion, tremor, hallucinations, fever, sweating, tachycardia and hypertension

42
Q

What is the neurotransmitter system targeted by medication typically given for alcohol detoxification (withdrawal symptoms)?

A

GABA-A

43
Q

What do you give to someone with alcohol detoxification/withdrawal?

A

Replacement treatment with benzodiazepines

44
Q

Describe the epidemiology for opiate deaths.

A
  • 4359 deaths from drug poisoning in 2018
  • this is up 16% from the previous year and is the highest annual increase since records began in 1993
  • deaths amongst men increased from 89.6 per million in 2017 to 105.4 per million in 2018 - 2/3 linked to misuse of drugs
  • opioids e.g. heroin and morphine continue to be the most frequently mentioned substances on death certificates
45
Q

What is now the leading cause of death among Americans under 50?

A

Overdose

46
Q

What is the difference between opiates and opioids?

A
  • opiates refer to natural opioids e.g. morphine, codeine and heroin to some extent
  • opioids refer to all natural, semisynthetic and synthetic opioids
47
Q

What natural opioids (alkaloids) are there? (4)

A
  • opium (contains morphine, codeine, thebaine, papaverine)
  • morphine
  • codeine
  • thebaine
48
Q

What synthetic opioids are there? (4)

A
  • fentanyl (100x more potent than morphine)
  • pethidine
  • methadone
  • tramadol
49
Q

What semi-synthetic opioids are there? (4)

A
  • heroin (2x more potent than morphine)
  • oxycodone (oxycontin)
  • hydrocodone
  • hydromorphone
50
Q

What are the two main effects of opioids?

A
  • relieve pain - analgesic effect
  • create a sense of euphoria in high doses
51
Q

What are two types of opioids?

A
  • endogenous opioids (endorphins) - regulate pain and mood
  • exogeneous drugs
52
Q

What are the three types of opioid receptor?

A
  • mu
  • delta
  • kappa
53
Q

What kinds of substances bind to the opioid receptors?

A
  • agonists - heroin, methadone, fentanyl, codeine
  • partial agonists - buprenorphine
  • antagonists - naltrexone
54
Q

What findings on examination are specific to opioid assessment? (5)

A
  • collapsed veins / track marks
  • endocarditis (murmurs, splinter haemorrhages)
  • skin abscesses
  • signs of hepatitis / HIV
  • pneumonia
55
Q

What investigations are specific to opioid assessment? (4)

A
  • bloods (FBC, LFT, U&E, GGT, glucose, CRP, BBV viral screen)
  • breathalyser
  • urine drug screen
  • blood cultures (endocarditis)
56
Q

What are the signs of opioid withdrawal? (12)

A
  • tachycardia
  • sweating
  • restlessness
  • dilated pupils
  • bone pain
  • rhinorrhoea
  • diarrhoea
  • abdominal pain
  • tremor
  • yawning
  • anxiety/irritability
  • gooseflesh skin
57
Q

What is COWS?

A

Clinical Opiate Withdrawal Scale - tests opioid withdrawal

58
Q

What are the signs of opiate overdose? (6)

A
  • not moving and cannot be woken
  • slow or no breathing
  • choking, gurgling sounds or snoring
  • tiny pupils
  • clammy or cold skin
  • blue lips and nails
59
Q

How do we manage an opiate overdose?

A
  • inject naloxone into upper arm or thigh (400mcg), or nasal spray (50% each nostril)
  • if no response after 3 mins, repeat
  • provide airway support and recovery position
60
Q

What medication do we give for abstinence of alcohol? (4)

A
  • acamprosate
  • disulfiram
  • naltrexone
  • nalmefene
61
Q

What medication do we give for abstinence of opioids? (2)

A
  • methadone
  • buprenorphine
62
Q

What medication do we give for abstinence of benzos/G drugs?

A

For BZ dependence, maintenance on diazepam with a reducing regime of 1mg per week (wean off dependence using diazepam)

63
Q

What medication do we give for detox regimes for alcohol? (2)

A
  • benzodiazepines
  • chlordiazepoxide
64
Q

What medication do we give for detox regimes for opioids?

A

Maintenance treatment for at least 12 months to sustain lifestyle changes, then dose reduction over several months

65
Q

What medication do we give for detox regimes for benzos/G drugs?

A
  • baclofen (GABA agonist) used
  • requires medical supervision but can be done in community
66
Q

Which medication is most commonly used in hospital for acute detoxification in alcohol withdrawal, to prevent complications?

A

Chlordiazepoxide (Librium)

67
Q

What medications are used in opioid abstinence? (2)

A
  • Buprenorphine
  • Methadone
68
Q

What medication is used in alcohol abstinence?

A

Acamprosate

(Think Abstinence = Acamprosate)

69
Q

Which medication is most commonly used in hospital for acute detoxification in alcohol and opioid abstinence?

A

Naltrexone

Year 2 - BRS (84 decks)

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