7. Substance Flashcards
Clinical criteria for alcohol use disorder
3 or more of the following manifestations that occur together for at least 1 month (or if less than 1 month, then repeatedly within 1 year)
- Compulsion
- Control (inability to control)
- Withdrawal
- Tolerance
- Preoccupation (other interests given up due to drinking)
- Persistence (despite knowing the harmful consequences)
DSM 5 diagnostic criteria for alcohol use disorder
Problematic usage of alcohol that has led to significant impairments occurring over a total of 12 months duration, manifested by at least 2 of the following:
- Increasing usage of alcohol, or over a longer period than originally intended
- Control: Repeated unsuccessful efforts to cut down or control
- Compulsion to drink
- Withdrawal
- Characteristic symptoms
- Drinking to avoid symptoms - Tolerance
- Need for more to achieve same effects
- Reduced effects with same amount - Pre-occupation: Give up on other interests due to drinking
- Pre-occupation: A lot of time spent trying to obtain, use or recover from alcohol
- Pre-occupation: Resulting in significant failure to fulfil major roles
- Persistent use despite having social/interpersonal issues due to drinking
- Persistent use despite effect on physical health
- Persistent use despite having physical or psychological problems
Early remission vs sustained remission
None of the criteria for alcohol use has been met for 3 months or more but less than 12 months vs 12 months or longer
DSM 5 diagnostic criteria for acute alcohol intoxication
SAMS GIN
Slurred speech
Attention impaired
Memory impaired
Stupor/coma
Gait unsteady
Incoordination
Nystagmus
Acute deficiency of thiamine will lead to
Wernicke’s encephalopathy
Triad of wernicke’s encephalopathy
- Gait ataxia
- Ophthalmoplegia (first sign to respond to meds)
- Confusion
Chronic deficiency of thiamine will lead to
Korsakoff psychosis (confabulation, retrograde amnesia)
DSM 5 diagnostic criteria for alcohol withdrawal syndrome
Cessation or reduction in alcohol usage that was previously heavy and prolonged.
At least 2 of the following signs must have developed within several hours to few days after stopping the usage of alcohol:
PASTNITES+Delirium/Clouded consciousness (DT)
Psychomotor agitation
Anxiety
Seizures
Transient hallucinations (visual hallucinations - liliputian)
Nausea/vomiting
Insomnia
Tremor
Excitability
Sweating
Peak for delirium tremens is within
48-72 hours of last drink
What is delirium tremens?
Toxic confusion state when AWS is severe
Triad of delirium tremens
- Clouding of consciousness and confusion
- Vivid visual hallucinations
- Marked tremor
Why is delirium tremens life threatening?
Due to autonomic instability
Management of alcohol withdrawal
- Long acting benzodiazepine (diazepam)**: alleviates withdrawal symptoms and prophylaxis for seizure
Route of administration: ORAL
(IM diazepam has poor absorption) - Short acting benzodiazepine (IM lorazepam): if there is liver impairment or oral diazepam not tolerated
- Thiamine**: prophylaxis/treatment for wernicke encephalopathy
Route of administration: IM/IV - Antipsychotics: treat hallucinations and agitation
How will benzodiazepine help with alcohol withdrawal symptoms?
GABA is a CNS depressant = Glutamate is CNS excitatory
When CNS depression increases, CNS excitatory will also increase to maintain equilibrium
Alcohol is also a CNS depressant
In alcohol withdrawal, the excitatory will exceed the depressants -> disequilibrium
Therefore give GABA to restore equilibrium
Non-pharmacological for alcohol use disorder
Cognitive Psychotherapy
- Motivational Interviewing
- Stages of Change Model
Cue exposure
Alcoholic Anonymous
Cognitive Behavioural Therapy
Pharmacotherapy for alcohol use disorder (abstinence medications)
- Naltrexone (usually 1st line)
- Acamprosate (reduce craving)
- Disulfiram (not avail in SG)
- aversive agent: cannot take alcohol before starting onwards
- inhibits aldehyde dehydrogenase -> leads to acetaldehyde accumulation if taken with alcohol -> leads to aversion effect
Aversive effects with ingestion of alcohol
Small amount of alcohol ingested: Flushing, headache, tachycardia, nausea, vomiting
Large amount of alcohol ingested: Air hunger, arrhythmia, severe hypotension
DSM 5 diagnostic criteria for Opioid use disorder
Problematic usage of opioid that has led to significant impairments in terms of functioning over a 12 months period.
(remaining criteria are similar to that of alcohol use disorder)
Opioid intoxication
Recent usage of opioid with the presence of pupillary constriction (pinpoint pupil) + at least 1 of the following sx:
SAD+
- Slurred speech
- Attention or memory impairment
- Drowsy or losing consciousness
+ miosis
+ significant problematic behavioural or psychological changes that have arisen during or shortly after the usage
Opioid withdrawal
Either (a) recent cessation of the usage of opioid that was previously heavy and prolonged or (b) recent administration of an opioid antagonist after a period of opioid usage
Manifested by at least 3 of the following, which develops within minutes to several days:
AMRY FINDS+
Aches
Rhinorrhea/lacrimation
Mood (dysphoric)
Yawning
Fever
Insomnia
Nausea/vomiting
Diarrhoea
Sweating
+mydriasis, piloerection
Pharmacotherapy for opioid overdose
IV Naloxone
Pharmacotherapy for opioid use disorder
Methadone (mu receptor agonist)
Buprenorphine
Pharmacotherapy for nicotine use ie SMOKING
Bupropion
Nicotine replacement therapy
DSM 5 Diagnostic criteria for Gambling disorder
Persistent and recurrent problematic gambling behaviour over the past 12 months that has led to significant impairment and distress, accompanied by at least 4 of the following:
- Need to gamble with an increasing amount of money to achieve the same level of excitement
- Restlessness or irritability when attempting to cut down or stop gambling
- Repeated unsuccessful attempts at cutting down or stopping
- Preoccupation with gambling
- Tendency to gamble when feeling distressed
- Tendency to return to chase one’s losses even after losing money
- Tendency to lie to minimise the extent of involvement with gambling
- Gambling has affected significant relationships and has caused the individual to miss opportunities
- Relying on others to help bail out of a difficult financial situation
- Clinicians to exclude the possibility of an underlying bipolar disorder
