Addiction Flashcards
How would you define substance misuse? What are important aspects of a substance abuse Hx?
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
What is withdrawal and what substances cause physical withdrawal?
Withdrawal = transient state whilst re-adjusting to lower levels of a drug in the body
Physical withdrawal only with: Alcohol, opiates and benzodiazepines
What is the epidemiology of substance misuse?
Males»_space; Females
- > 2x M for alcohol
- > 4x M for substance
5.4% prevalence for alcohol and 14.6% for drug misuse (3% for dependence)
What are features of dependency according to ICD10?
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’
What are the normal and risk-stratified levels of alcohol consumption?
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)
What is the aetiology and epidemiology of alcohol abuse?
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
How may someone with alcohol dependence present?
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
What is one unit of alcohol?
unit = %ABV x volume/1000 OR 8g pure ethanol OR [amount of alcohol to be metabolised in 1h]
How would you Ix someone with a concerning alcohol history?
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)?
How would you manage a patient generally for alcohol abuse+ what would warrant admission?
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
How would you manage a patient with acute alcohol withdrawal? Acute vs Chronic, inpatient vs community, detox mx…?
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
What are some complications of alcohol abuse?
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
What is the prognosis of alcohol abuse?
40% die prematurely
30% have lifelong alcohol problems
30% have favourable outcome
What are some types of opiate abuse? How do they exert their effect?
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
What are some signs and symptoms of opiate abuse - intoxication (+OD), withdrawal and complications?
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
What Ix would you do in someone with opiate abuse?
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)
How would you manage opiate abuse?
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)
What is the active agent in cannabis + what are some other terms for it?
Cannabis has delta-9-tetrahydrocannabinol
Terms: grass/weed, hash, skunk and sinsemilla are strong types (w skunk the most commonly used)
What are some signs of cannabis use?
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
How would one use cannabis + what is the half-life?
Smoking - quicker onset, peaks at 30m, lasts 2-5h
PO - slower onset, lasts longer
How would you Ix and Mx someone using cannabis? What are some complications?
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)
What are hallucinogens? Give 4 examples and how they act?
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
How may someone present on hallucinogens?
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
How would you manage hallucinogen use?
Mx:
- > Health education
- > Harm reduction (needle exchanges, vaccines/testing for BBV for other IVDU)
- > Short term withdrawal relief as an inpatient with benzodiazepines
What are stimulant drugs and give some examples and how they act?
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)
How may someone on stimulants present? What are some SE’s of specific stimulant drugs?
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
How may someone who is undergoing cocaine withdrawal present?
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
How would you Ix and Mx someone with stimulant abuse?
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
What are BDZ used for normally and what are the short-term and long-term risks of their use?
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
How may someone present with BDZ i) misuse ii) overdose and iii) withdrawal ?
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!!
How would you Ix and Mx BDZ withdrawal and abuse?
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
How many people smoke in the UK and what is an indicator for abstinence?
- 7% of UK smoke
- > A CO level of =/< 10ppm indicates abstinence from smoking (5-9ppm)
How would you manage smoking cessation? Conservative and Pharmacological?
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
