addiction Flashcards
diagnosis of alcohol misuse
harmful use - pattern causing damage to physical or mental health, use >1month or repeatedly over 12months
dependence - 3 or more of the following for >1m/repeatedly over 12
- cravings to take, difficulty controlling use, primacy, increased tolerance, withdrawals on reduction/abstinence, persist despite consequences
withdrawal state - variable clustering/severity
alcohol misuse screening tool
CAGE - 2 or more = likely alcohol problem
Have u tried to Cut down?
Have you felt Annoyed by people criticizing your drinking?
Have you felt Guilty about drinking?
Have you felt the need to have an Eye-opener?
others - AUDIT, FAST, PAT (A&E)
medical management of alcohol misuse
thiamine - prevent Wernicke-Korsakoff
benzodiazepines, chlordiazepoxide - manage withdrawals
disulfiram (antabuse) - aversion/deterrent medications
anticraving med - acamprostate, naltrexone, nalmefene
assessment of alcohol withdrawals
CIWA-Ar
- severity of alcohol withdrawal
- >=15 = severe withdrawal
management of alcohol withdrawal
chlordiazepoxide - librium
IV high dose B vitamins - pabrinex
- should be followed by regular dose of thiamine
delirium tremens
medical emergency assoc with alcohol withdrawal - can be fatal due to high risk of seizure
variable levels of consciousness usually 48-72hrs after alcohol stopped
pathopysio of delirium tremens
alcohol stimulates GABA receptors in brain - these have relaxing effect
alcohol also inhibits glutamate receptors (NMDA) - further inhibitory effect on elec activity
chronic alcohol results in
-> down regulated GABA
-> up regulated glutamate
> extreme excitability of brain with excess adrenergic activity presents as confusion, tremor etc
delirium tremens presentation
profoundly confused
tremor, autonomic overactivity
agitation, sleeplessness
hallucinations, delusions - things crawling on skin
sweating, high BP
delirium tremens management
benzodiazepines (chlordiazepoxide, diazepam) regularly + targeted to symptoms
fluid, elecctrolyte + vitamin replacement
delirium tremens prognosis
mortality = 5% (Z2f 35%)
death by
- cardiovascular collapse
- infection
- hyperthermia
- seizures
- self-injury
alcohol related brain damage
wernicke’s encephalopathy - comes before Korsakoff syndrome
Korsakoff syndrome
myelin sheath degradation
neuroinflammation
fall -> subdural haematoma
excess alcohol leads to thiamine (vit B1) deficiency
Wernickes encephalopathy
medical emergency + high mortality iif untreated
thiamine deficiency
- ophthalmoplegia
- confusion
- ataxia
wernicke’s encephalopathy presentation
ophthalmoplegia, confusion, ataxia
- visual impairment - nystagmus
- hearing impairment
- reduced conscious level
- hypothermia
- lactic acidosis
- circulatory change
Korsakoffs psychosis
comes after wernickes
often irreversible + results in full time institutional care
-> forget to turn hobs off, lock door
korsakoffs psychosis
memory impairment - retrograde + antegrade
behavioural changes
may exhibit nystagmus + ataxia
korsakoffs ppsychosis management
thiamine supplementation
abstaining from alcohol
what is a natural or drug induced high mediated by?
mesolimbic pathway
- sometimes referred to as pleasure centreof brain
-> dopamine = pleasure neurotransmitter
ICD 10 dependence criteria
3 or more for a least 1 month
- sense of compulsion
- craving
- physiological withdrawal
- evidence of tolerance
- preoccupation with substance use
- persistent use despite harmful consequences
management of opiod dependence
safety bundles - drug diaries, risk assessment
ORT (opiod replacement therapy) - methadone, buprenorphine
opiod replacement therapy (ORT)
substitute prescribing - deliberate prescribing in a controlled manner
phases - induction, optimisation, maintenance, reduction
supervised in front of pharmicist
–> methadone, buprenorphine - compliance monitored using urinanalysis
methadone
Mu receptor agonist
long half life
peak plasma conc - 4hrs
steady state - 5 days
higher doses (60-100ml) = more effective
-> start on lower dose
liquid preparation
high dependance, low lethal dose
buprenorphine
Mu receptor partial agonist with low intrinsic activity + affinity
peak plasma levels 1.5-2.5hrs
duration of effect doses - 12-24mg
sublingual tablets
side effects of methadone
prolong QTc interval
sedation
other drug interactions - liver metabolism
might give to others
why does chronic stress encourage highly rewarding behaviours?
chronic stress leads to dampening of dopaminergic activity through down regulation of D receptors
- reduces sensitivity to normal rewards
- encourages exposure to highly rewarding behaviours
rapid increase in stress can motivate drug seeking in dependent individuals
importance of prefrontal cortex in addiction
-puts brakes on reward pathway
- matures late + is vulnerable whilt developing
- dysfunctional in addicted people
