Addiction

Question 1

How would you define substance misuse? What are important aspects of a substance abuse Hx?

Answer 1

A pattern of substance use causing physical, mental, social or occupational dysfunction. ICD10 definitions vary by substance and type of disorder

Current Use:

• > [TRAP] - Type, routes, amount and pattern
• > Dependency
• > Effect on life
• > Past use
• > Future use

Question 2

What is withdrawal and what substances cause physical withdrawal?

Answer 2

Withdrawal = transient state whilst re-adjusting to lower levels of a drug in the body

Physical withdrawal only with: Alcohol, opiates and benzodiazepines

Question 3

What is the epidemiology of substance misuse?

Answer 3

Males&raquo_space; Females

• > 2x M for alcohol
• > 4x M for substance

5.4% prevalence for alcohol and 14.6% for drug misuse (3% for dependence)

Question 4

What are features of dependency according to ICD10?

Answer 4

Dependence syndrome = at least 3/+ of the below together in the last month

• Tolerance (inc amount to get same effect)
• Craving
• Withdrawal (symptoms)
• Problems controlling use
• Continued use despite harm
• Salience/primacy
• Narrowing repetoire (loss of variation in use of substance)
• Reinstatement after abstinence

‘SN RaW TUCH’

Question 5

What are the normal and risk-stratified levels of alcohol consumption?

Answer 5

Normal - shouldn’t exceed over 14 units per week for M+F

Low risk = <14 units/week
Hazardous = 15-25 units/week
Harmful (alcohol misuse) = >35 units/week (i.e. >6 units a day)

Question 6

What is the aetiology and epidemiology of alcohol abuse?

Answer 6

2:1 of males > females
5.4% lifetime prevalence
1% UK drink harmfully

Bio - genetics, ethnicity (E.Asians have lower dependency rates due to enzyme deficiency) and psychiatric illness (PDs, mania, depression, social phobia/anxiety)

Psychosocial - occupation (publicans, Drs, armed forces), social background, co-morbid psychiatric disorders

Question 7

How may someone with alcohol dependence present?

Answer 7

Sx:

• > Intoxication
• > Withdrawal:
• 4-12h after last drink = course tremor, sweating, insomnia, psychomotor agitation, anxiety, tachycardia, N&V, hallucinations (tactile, auditory)
• ~36h (6-28h) = peak incidence of grand-mal/generalised tonic-clonic seizures
• 48-72h - Delirium Tremens = disorientation, anterograde amnesia, Liliputian hallucinations of little people/animals, worse at night/fluctuations by hour, if severe then may have heavy sweating, fear, paranoid delusions, fever, sudden V collapse
• > Dependence syndrome
• > Psychotic disorder = alcoholic hallucinosis (auditory hallucinations, often persecutory derogatory), Liliputian hallucinations, morbid jealousy (delusion that partner is unfaithful)
• > Amnesia = anterograde i.e in Korsakoff syndrome

Question 8

What is one unit of alcohol?

Answer 8

unit = %ABV x volume/1000
OR
8g pure ethanol
OR
[amount of alcohol to be metabolised in 1h]

Question 9

How would you Ix someone with a concerning alcohol history?

Answer 9

Ix:

• > Full history (timeline) and physical exam (sx disease)
• > Bedside obs
• > SCREENING = CAGE screening (2/+ positive answers indicates further investigation*)
• > Rating scale: 1st line, screening = AUDIT (alcohol use disorders identification test) - score >20 then do full assessment, 2nd line = SADQ (severity and dependence), FAST is the first 4Qs of AUDIT, often used in A&E (3/+ is positive), CIWA for withdrawal, APQ for nature and extent of problems from alcohol misuse

–> CAGE = have you tried to CUT down, have you ever been ANNOYED when someone criticises your drinking, have you ever felt GUILTY about drinking and have you ever needed a drink to get you going in the morning (EYE opener)?

Question 10

How would you manage a patient generally for alcohol abuse+ what would warrant admission?

Answer 10

Mx:

• Start by triaging the patient using AUDIT
• MDT approach
• Identify risks (driving, co-dependents, work)
• Triage to admission detox regiment or community management
• –> ADMISSION = acute alcohol withdrawal or Wernicke’s encephalopathy (ataxia, ophthalmoplegia, confusion)
• —> Specialist management (alcohol addiction service) if less serious signs of dependence

Question 11

How would you manage a patient with acute alcohol withdrawal? Acute vs Chronic, inpatient vs community, detox mx…?

Answer 11

Inpatient/Home depending on level of dependency:

• > Inpatient = >30units a day or >30 on SADQ, PMH of epilepsy, DT, withdrawal-related seizures
• > Community-based assisted withdrawal = >15units/day or >20 on AUDIT - have 2-4 meetings/week for up to 3w

Withdrawal regimen then progress to detox management:
-> Manage expectations that detox will be worst in first 48h and DON’T stop abruptly
-> Acute treatment (up to 7d)
= Inpatient: oral lorazepam +/- IV/IM Thiamine/Pabrinex on rapid reducing dose
= Community: oral chlordiazepoxide +/- IV/IM Thiamine/Pabrinex on reducing dose
** IF hypoglycaemic, give dextrose AFTER pabrinex as can precipitate Sx
-> Chronic treatment (after 7d - Detox management)
1st line = acamprosate or naltrexone
2nd line = disulfiram
+ Individualised psychosocial intervention plan:

BIOPSYCHOSOCIAL model for detox management^^:
Bio = Acamprosate (removes craving but increasing GABA) or Naltrexone (reduces high of alcohol) -> Difulfiram (causes bad hangover Sx as an irreversible acetaldehyde dehydrogenase inhibitor)

Psychosocial = FRAMES* intervention + Support (CGL, AA, Smart recovery), 1st line = motivational interviewing (establish goals, explore beliefs, encourage self-efficacy), 2nd line = psychosocial interventions like CBT, couples therapy, residential abstinence centres e.g. if homeless for max 3m

For those presenting with:

• Alcohol withdrawal seizures (~36h) = IV lorazepam on rapid reducing dose
• DT (48-72h) = Oral lorazepam AND IV/IM Thiamine/pabrinex
• Wernicke’s (confusion, ophthalmoplegia, ataxia) = IV/IM Thiamine/Pabrinex

FRAMES = advice on drinking:
- feedback - responsibility - advice - menu - empathy - self-efficacy

Question 12

What are some complications of alcohol abuse?

Answer 12

Bio:

• Wernicke’s encephalopathy (reversible) due to B12 deficiency –> triad of ataxia, ophthalmoplegia, confusion (treated with IV/IM Pabrinex/Thiamine, if not can lead to …
• Korsakoff’s psychosis (irreversible) –> anterograde+retrograde amnesia, confabulation, peripheral neuropathy, cerebellar degeneration
• Liver disease, Varices + GI disease, pancreatitis
• Seizures, dementia
• Cancer - bowel, breast, oesophageal
• HTN, cardiomyopathy
• FAS in pregnancy

Psychological:

• Depression, mania, anxiety disorder, psychosis, SH
• Delusions and hallucinations
• amnesia
• Cognitive impairment

Social:

• Family and relationship breakdown
• Job loss/unemployment
• Child neglect/abuse

Question 13

What is the prognosis of alcohol abuse?

Answer 13

40% die prematurely
30% have lifelong alcohol problems
30% have favourable outcome

Question 14

What are some types of opiate abuse? How do they exert their effect?

Answer 14

Opiates - from Papaver somniferum; types include:

• HEROIN (brown, smack, skag, horse, gear)
• Pethidine
• Morphine, diamorphine, codeine, dihydrocodeine

Heroin is a mu opiate agonist –> immediate euphoria, diminished pain, detachment

ROA:

• Smoking
• Sniffing/snorting
• Oral
• IV (note complications like cellulitis, abcess, sepsis, IE and BBV, emboli and DVT)
• IM/SC

Question 15

What are some signs and symptoms of opiate abuse - intoxication (+OD), withdrawal and complications?

Answer 15

Sx:

Complications:
= DVT, IE and BBV such as HepC, cellulitis and abcesses, emboli, sepsis

Intoxication:

• -> Euphoria and warmth -> sedation and bradycardia
• -> Overdose = miosis/pinpoint pupils and low RR (Tx = IV NALOXONE)
• -> Low dose SE = constipation, anorexia, decreased libido

Withdrawal symptoms:

• Starts 6h after injection, peak at 36-48h, lasts 5-7d
• Common sx = goosebumps, mydriasis, runs (D&V, lacrimation, rhinorrhoea), craving, insomnia, agitation, flu-like (fever, aches, cramps)
• RARELY life-threatening
• Due to noradrenergic storm

Question 16

What Ix would you do in someone with opiate abuse?

Answer 16

Ix:

• Full Hx and physical exam
• Bedside obs
• UDS (2d in urine)
• Bloods = FBC (anaemia/infection), U&Es (malnutrition), LFTs (pre-meds), BBV tests (HBV, HCV, HIV)
• Contact key worker before prescribing replacement opiates (note: opiate IV pain management does NOT increase relapse rates)

Question 17

How would you manage opiate abuse?

Answer 17

Mx:
- Similar to alcohol in that you triage for admission/treatment and MDT approach - D&A services:

According to NICE:

• Appoint a key worker and develop a care plan (agree recovery goals and progress)
• Harm reduction (vaccines and virus testing, needle-exchanges for IVDU as unlikely to get complete abstinence)
• Health education (SMART recovery, NA, sleep hygiene and support)
• Family/carer assessment
• Discuss if they want to undergo an opioid substitution therapy (OST) ‘withdrawal’ OR ‘maintenance’ programme
• -> 1st maintenance where goal is to stabilise lifestyle and reduce harm
• -> 2nd detoxification where goal is abstinence and detox
• -> For OST, admission may be necessary as give in a controlled environment for 3-6m and then if suitable, given some take-home medications:

Maintenance:
1st line = methadone (green liquid) or buprenophine (sub-lingual)
- if still using heroin, low dose methadone
- if wanting to stop heroin, high dose methadone or buprenoprhine
- offer naloxone for take-home and how to use

Detoxification:
MUST be committed to stopping, stable environment and on stable OST maintenance
- lasts 12w as an outpatient (4w inpatient)
- notify that they will lose tolerance if they start again so they should take a lot less
1st line = methadone or buprenophine + offer naloxone for home if needed
2nd line = Lofexidine (if rapid detox/mild dependence)
- Ultra-rapid detoxing regimens are not pleasant but exist (use naloxone)

Withdrawal symptom medications = clonidine, lofexidine, anti-diarrheals, anti-emetics

FOLLOW UP with drugs and alcohol service for at least 6m

• look for withdrawal signs
• check other drug use
• ECG (QTc for those on methadone)
• CBT to reduce relapse chance
• Contingency management through frequent screenings (incentives for negative UDS)

Other types of detoxification = ultra rapid (<24h w GA - NOT offered), rapid (1-5d w moderate sedation - consider if pt requests) and accelerated detoxification (no sedation)–> uses naltrexone/naloxone (opioid antagonists)

Question 18

What is the active agent in cannabis + what are some other terms for it?

Answer 18

Cannabis has delta-9-tetrahydrocannabinol

Terms: grass/weed, hash, skunk and sinsemilla are strong types (w skunk the most commonly used)

Question 19

What are some signs of cannabis use?

Answer 19

Sx depend on expectations and original mood state:

• > Spectrum ranges from euphoria and relaxation to paranoia, anxiety and panic
• > Perceptual and time distortion
• > Hunger
• > Nausea and vomiting

Question 20

How would one use cannabis + what is the half-life?

Answer 20

Smoking - quicker onset, peaks at 30m, lasts 2-5h

PO - slower onset, lasts longer

Question 21

How would you Ix and Mx someone using cannabis? What are some complications?

Answer 21

Ix:
-> UDS (up to 4w)

Mx:

• > Abstinence in those with major mental illness
• > Irregular use can be free from major problems

Complications

• > Use in developing years can cause schizophrenia
• > Acute - can precipitate psychotic episode
• > Chronic - anxiety/depressive illness, dysthymia
• > NO physical dependency but mild withdrawal syndrome in heavy users (insomnia, anxiety, irritability)

Question 22

What are hallucinogens? Give 4 examples and how they act?

Answer 22

Hallucinogens produce a psychological (heightened perception, illusions) and physiological (dilated pupils, peripheral vasoconstriction, increased temperature) but no dependence

LSD - affects dopamine and 5-HT receptors, taken via ‘tabs’ –> euphoria/perceptual changes and trips lasting up to 12h

PCP (Phencyclidine, angel dust) - associated with violent outburst and ongoing psychosis, taken via liquid or powder which is snorted/smoked

Ketamine (special K) - similar structure to PCP, anaesthetic effect that can lead to unknowingly SH, small doses = disassociation, larger = hallucinations, synaethesia

Magic mushrooms (liberty cap) - eaten raw or drunk, small doses = euphoria, larger = euphoria (similar to LSD). Tolerance develops quickly so continued use is unlikely

Question 23

How may someone present on hallucinogens?

Answer 23

Sx:

• Euphoria
• Perceptual changes - hallucination, visual illusions, depersonalisation, derealisation
• Synaesthesia (e.g. hear a smell)
• Behavioural toxicity - acting on drug-induced beliefs i.e. being able to fly
• SEs of drugs:
• -> LSD: acute = due to behavioural toxicity, chronic = flashbacks, anxiety, depression
• -> PCP: seratonergic/cholinergic (confusion, violence)
• -> Ketamine: large amounts = nausea, ataxia, slurred speech
• -> MM: behavioural toxicity, accidental poison consumption

Question 24

How would you manage hallucinogen use?

Answer 24

Mx:

• > Health education
• > Harm reduction (needle exchanges, vaccines/testing for BBV for other IVDU)
• > Short term withdrawal relief as an inpatient with benzodiazepines

Question 25

What are stimulant drugs and give some examples and how they act?

Answer 25

Potentiate neurotransmission and increase cortical excitability –> increased alertness, endurance, reduced need for sleep + confidence

Cocaine

• AKA Charlie, coke, snow
• ROA = intranasal, IV

Crack cocaine

• AKA rocks, base, freebase
• ROA = concentrated smokeable form
• Causes an immediate, extreme high but wears off quickly (5-10mins)
• Highly addictive

Amphetamine

• AKA speed
• ROA = IV, PO, intranasal
• Withdrawal meds include dexamphetamine

Khat

• AKA Quat, chat
• Mild stimulant, used in E. African communities
• Causes psychosis

Ecstasy

• AKA MDMA, E (3,4-methylenedioxymethamphetamine)
• Causes 5HT release and blocks reuptake
• Hallucinogenic + stimulant properties
• Initial 3h rush, bruxism, agitation received by dancing/movement
• hangover at 24-48h (fatigue, anorexia, depressed mood)

Question 26

How may someone on stimulants present? What are some SE’s of specific stimulant drugs?

Answer 26

Sx:

• Increased alertness, endurance and confidence
• Risky behaviour
• Unpleasant ‘crash period’
• No dependence apart from amphetamines

SEs:
–> Cocaine:
[acute] = arrhythmia, intense anxiety, HTN, impaired judgement
[chronic] = septal necrosis, foetal damage, delusions and psychosis, panic and anxiety , no dependence but can become ‘habit’
–> Amphetamines:
[acute] = tachycardia, arrhythmia, hyperpyrexia, irritability, post-use depression, quasi-psychotic state with visual, auditory and tactile hallucinations, v regular use associated with dependence
–> Ecstasy:
[acute] = increased sweating, nausea, vomiting, diminished potency despite increased libido, death associated with dehydration and hyperthermia

Question 27

How may someone who is undergoing cocaine withdrawal present?

Answer 27

Occurs in 2 stages:
[1] Crash phase - from 3h: depression, exhaustion, agitation and irritability
[2] Withdrawal - lasting 1-10w: cravings, irritability, anergia, poor concentration, insomnia, slowed movements

Question 28

How would you Ix and Mx someone with stimulant abuse?

Answer 28

Ix:

• Full drug Hx and physical examination for signs of disease/chronic use
• UDS (cocaine can last in urine for 5-7d)
• Bloods - FBC for infection, BBV and HIV testing?

Mx:

• Health education (support, + family and social help, NA)
• Harm reduction (needle exchanges, BBV testing)
• Short term withdrawal symptom relief can be provided with BDZ as an inpatient

Question 29

What are BDZ used for normally and what are the short-term and long-term risks of their use?

Answer 29

Uses of BDZ = sedation, hypnotic, anxiolytic, anticonvulsant, muscle relaxant (enhances GABA transmission)

Should only be used for a short time (2-4w)

Risks of BDZ use
[short-term] = drowsiness, reduced concentration
[long-term] = cognitive impairment, WORSENING OF anxiety and depression, DEPENDENCE, sleep disruption

Question 30

How may someone present with BDZ i) misuse ii) overdose and iii) withdrawal ?

Answer 30

i) Misuse
- Similar to alcohol; calm and mild euphoria
- Slurred speech, ataxia, stupor

ii) OD
- Respiratory depression, low GCS, low BP, mydriasis, hyporeflexia
- Tx = IV flumazenil

iii) Withdrawal
- Similar to alcohol; ANXIETY, tremor, insomnia, palpitations + tachycardia/tachypnoea, delusions, depersonalisation, irritably, hyperreflexia, ataxia, sweating, mydriasis, depression and anterograde amnesia, tinnitus, seizures
- Sudden withdrawal may present with a DT-like picture!!

Question 31

How would you Ix and Mx BDZ withdrawal and abuse?

Answer 31

Ix:

• Full Hx and physical exam (neuro - reflexes, ataxia)
• Hx –> use of BDZ, where from, how often/dose
• Obs (HR, BP, RR)

Mx:
-> Address underlying need for BDZ (anxiety, sleep, depression) and the long term complications of use (cognitive impairment, anxiety, depression, insomnia)
-> Check willingness to withdraw and whether this can be done in primary care
-> Withdrawal Mx:
2 methods=
[1] Slow dose reduction
[2] Switch to equivalent dose of Diazepam and slow dose reduction (preferred: used in those on short-acting, potent BDZ such as lorazepam, and difficulty with physically tapering dose)
–> Withdraw 1/8th daily dose reduction every 2w
-> Advice:
- If done properly, there will be few, if any, withdrawal SEs
- Anxiety is the most common SE and is normal; treat with conservative mx such as relaxation/breathing techniques
- May take 3m-1y or longer
- Assess driving risk as can’t drive on certain amounts of BDZ (DONT drive if feeling drowsy)
- Offer CBT

**EG 1/8th daily dose reduction every 2 weeks – e.g. diazepam 40 mg per day:
• Reduce dose by 5 mg every 2 weeks until reaching 20 mg per day -> 8 weeks
• Reduce dose by 2 mg every 2 weeks until reaching 10 mg per day -> 10 weeks
• Reduce dose by 1 mg every 2 weeks until reaching 5 mg per day -> 10 weeks
• Reduce dose by 0.5 mg every 2 weeks until completely stopped -> 20 weeks
THEREFORE Estimated total withdrawal time = 30–60 weeks

NOTE: short acting BDZ e.g. lorazepam, long-acting e.g. chlordiazepoxide, diazepam

Question 32

How many people smoke in the UK and what is an indicator for abstinence?

Answer 32

14. 7% of UK smoke

- > A CO level of =/< 10ppm indicates abstinence from smoking (5-9ppm)

Question 33

How would you manage smoking cessation? Conservative and Pharmacological?

Answer 33

Mx:

• > Very brief advice (given anytime and anywhere)
• ask about current and past smoking behaviour
• Provide written AND verbal information on RISKS (cancer, CLD i.e. bronchitis, COPD, hospital admissions) and BENEFITS of stopping (whatever time you stop its beneficial, cost saving, health)
• Advise options for smoking cessation like behavioural support and medication: refer to local cessation service if they wish to stop
• If they don’t want to quit, enquire to a harm reduction policy i.e. use of NRT as most problems attributed to tobacco smoke, not nicotine and these NRTs provide nicotine slowly and less-addictively than smoking
• > 1st line = ADVICE
• Behavioural support and medication is best for stopping
• Set a quit date and commit to it
• First few days are most difficult, may experience withdrawal, but passes by 3-4d

-> 2nd line = MEDS
[] NRT varies on preference, but can’t prescribe in combination with medications. Types = lozenges, mouth spray, patches
- Start on agreed quit date
- 24h patches useful is smoking shortly after waking, on combined NRT so the patch is for ‘background craving’

[] Varenicline

• Partial nicotine receptor agonist
• Dose = 1mg BD, titrated up from 500mcg OD over 1w
• Started 7-14d before quit date, whilst still smoking
• Contraindicated in those <18y and those with renal disease

[] Buproprion
- Weak but selective DA and NA reuptake inhibitor
- 150mg BD, titrated up from 150mg OD over 1w
- Max use for 7-9w, then discontinue
Started 7-14d before quit date, whilst still smoking
- Contraindicated in those <18y, eating disorders, BPAD, cirrhosis, CNS disorders and seizures

DO NOT RECOMMEND E-CIGARETTES as unclear health impact

• > Follow up - 2w if on NRT, 3-4w if on medications
• Measure CO levels 4w after quitting
• Check progress and withdrawal sx
• If relapse/partial release then encourage and set new quit date