Addiction Flashcards
proper use of alcohol i.e. recommended = how many units?
14
hazardous use (of alcohol) meaning?
use of a drug other than directed
what type of alcohol use would be associated with problems at work or home, legal problems, drink driving and continued use despite adverse consequences?
harmful
what type of alcohol use would compulsion, tolernace, withdrawal and silence of behaviour be associated with?
dependence
why/ how is alcohol tolerance brought on?
liver breaks down quicker as accustomed to it = have to dirnk more to get same effect
what does SBIRT refer to in regards to the screening that any HCP can initially undertake?
screening, brief intervention and referral to treatment
interventions to alcohol aimed at individuals can help make people aware of the potential risks they are taking at an early stage, patients are most likely to change their behaviour if it is tackled early, true or false?
true
3 stages to dealing with alcohol dependence?
screen
brief advice (intervention brief)
behaviour change counselling (extended intervention)
what is the audit C used for?
front line workers who meet patients with alcohol dependence
what equation can you use to work out the units of alcohol?
(total drink vol in ml x % abv ) / 1000
what tools might you use for initial screening questions for alcohol?
audit c or sasq
what would be your course of action if a patient has a audit c score of 5+ and or a sasq of never or less than monthly?
administer audit
if a patient has a lower risk betwene 0-7, what might you provide the patient with?
information
for patients with an increasing risk (8-15) or a higher risk (16-19) what would you provide the patient with?
brief advice and lifestyle intervention
if a person has possible dependence they will have a score of around 20. What should be your course of action for these patients?
refer for specialist support
what does the FRAMES acronym for interventions stand for?
3 important things to DO
feedback,
responsibility,
advice,
3 important things to BE
menu,
empathy
self efficacy
what is the term given to the inability to resist urges and act without foresight?
impulsivity
what is the term given to the stimulus (drug) that increases the probability of further drug taking?
positive reinforcement
what is the term given to the removal (withdrawal) of a stimulus that increases the probability of further drug taking?
negative reinforcement
what is the term given to repetitive behaviour despite the adverse consequences and reduces stress, anxiety and tension?
compulsivity
addiction is fundamentally about?
compulsive behaviour
compulsive drug seeking is initiated outside of what
consciousness
normal flexibility of human behaviour is eroded to a state of compulsive behaviour.
4 symptoms of behavioural syndrome?
dyscontrol
slaience
neuroadaption
compulsive behaviour
which part of the basal ganglia is associated with the reward pathway and motivation?
nucleus accumbens
what part of the basal ganglia is associated with forming habits and routine?
nucleus accumbens
what part of the basal ganglia is associated with forming habits and routine?
dorsal striatium
what part of the brain is associated with withdrawal, unease and anxiety?
extended amygdala
what part of the brain is associated with executive function: planning, priotising, managing time, making decisions and control over substance taking?
prefrontal cortex
addiction (compulsive behaviour) is mediated by a ?
compulsive unit:
- nucleus accumbens
- ventral pallidum
- thalamus
- prefontal cortex
dopamine d2 receptors are lower or higher in addiction?
lower
(less DA receptors to then –> reward circuits)
why do natural reqrds become devalued in drug abusers?
as drug associated cues usurp the motivational circuits
the addiction cycle: 3 stages?
basal ganglia:
1) binge/intoxication
extended amygdala
2) withdrawal/ negative affect
prefrontal cortex
3) preoccupational/ anticipation
when executive function is disrupted in prefrontal cortex, what system inc and what dec?
inc GO system, release glutamate, strong urge
dec STOP system, compulsive drug seeking
what brain structure puts drug seeking into motion without conscious initiation?
nucleus accumbens
what 2 drugs can manage alcohol withdrawal?
chlordiazepoxide
thiamine
chlordiaepoxide is the benzodiazepine of choice for managing alcohol withdrawal. why is this drug class good for this purpose?
dampen noradrenaline response from alcohol withdrawal
what is the rationale behind using thiamine for managing alcohol wtihdrawal?
b vitamin helps replace those not taken in diet
what 5 drugs used for alcohol relapse prevention?
disulfiram
naltrexone
acamprosate
nalmefene
?baclofen
2 drugs used for Opioid substitution therapy? (OST)
methadone
buprenorphine
drug that stops liver breaking down alcohol?
disulfuram
anti craving drug?
acamprosate
drug for managed withdrawal of opioids?
lofexidine
or clonidine?
opioids relapse prevention drug?
naltrexone
harm reduction:
antidote to heroin / opiates?
naloxone
antisychotics
bromocriptine
aripiprazole
all act on what?
dopamine neuron
acamprosate
memantine
topiramate
all act on?
glutamate- excitatory input
((also GABA inhibitory neuron))
which antipsychotics are best to be used as co morbidity therapies? 3
clozapine, olanzapine and risperidone
up to 1/3 of ppl w alcohol dependence will achieve abstinence following treatment in XX term
short - medium (3-12 months)
less than 10% ppl w alcohol dependence/ opioid dpeendence will have XXXX
long term continuous abstinence following treatment
after learning, what –> craving (conditioned response)?
needle (conditioned stimulus)
which antipsychotic drug is the most effective at reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia?
clozapine
IPE reading…..
different types of substance misuse in order to enhance image and performance
Normally injected, taken orally, or applied topically using a cream or gel.
Most common type of IPED: anabolic steroids
reasons for IPE drug abuse?
- promote weight loss
- change skin colour
- build muscle
- allow longer, more intense training
what hormones are commonly included in injectable anabolic steroids?
hgh, epo and melanotan
what might IPEDS that contain clenbuterol and DNP be used for?
fat burners
what is the most popular IPED that is used amongst men?
methandrostenolone
what are the most popular IPEDs used amongst women?
oxandrolone and melantonan
list 6 psychological side effects?
addiction, depression, mood changes, paranoia, agression and euphoria
list 6 physiological side effects?
male pattern baldness, acne, excess body hair, infertility, heart attack and stroke
some IPED users do stacking which when several agents are used in a complex high dose regimen. Name one drug that these users may take additionally as they believe it will combat some of the side effects associated with steroid use?
tamoxifen
name 2 dangers that users who inject steroids are exposed to?
HIV and hep B
Workshop…..
infective endocarditis likely cause?
Staphylococcus aureus (found on the skin)- would help diagnosis and treatment.
Drug + Px history (illicit and normal) that you need before making diagnosis of infective endocarditis?
drugs px misused and if administer themselves
- taken any IV: to check for infections.
- History of drug abuse: most likely heroin dependant. Injecting using dirty/ contaminated needles… bacteria ends up in bloodstream
Smoking, alcohol consumption, exercise (can affect heart)
Previous heart surgery/ prosthetic valves. Any trauma to heart valve.
why ask a heroin dependant/ any px w suspected infective endocarditis if they’ve had precious heart surgery?
Previous heart surgery/ prosthetic valves. Any trauma to heart valve —> damage to endothelial cells on surface, becomes susceptible to infections
Suspected infective endocarditis
Usually bacterial but may be due to
…
rickettsia, chlamydia or fungus
why are symptoms alone not enough to diagnose IE?
vague. e.g.:
fever, anorexia, night sweats, weight loss, arthralgia
why are IV drug users more susceptible to IE infection?
Staphylococcus Aureus
* Lives on skin making IV drug users more susceptible to this infection
empirical first line antibiotic treatment for Staphylococcus Aureus infection (IE)?
guided by microbiology, local Trust guidelines
Initial blind therapy amoxicillin + low dose gentamicin BNF – gentamicin now may not be started until results of cultures available (synergistic activity)
antibiotic treatment for Staphylococcus Aureus infection (IE) IF PX PENICILLIN ALLERGIC?
Vancomycin + gentamicin
Longer courses of treatment (4-6 weeks) needed for staphylococcus Aureus infection (IE) why?
due to difficulty penetrating vegetations and biofilms
synergistic meaning in context of antibiotics?
interaction of two or more drugs when their combined effect is greater than the sum of the effects seen when each drug is given alone.
why give 2 different antibiotics for treating IE?
synergy.
Adding 2 antibiotics together different susceptibilities between the bacteria and work by disrupting cell wall
Gentamicin: keep dose low why?
narrow therap window
normal course antibiotics for infection?
3 days or 7 for UTI
Staphylococcus is aerobic/anerobic bacteria?
aerobic
gentamicin given for what type of bacteria treatment and why?
aerobic
as G needs oxygen to treat
gentamicin 2 main SEs?
oto and nephrotox
which group of patients are most at risk of developing IE?
- congenital heart disease,
- artificial heart or valves,
- damaged heart valves,
- hypertrophic cardiomyopathy,
- valvular heart disease patients who are immunocompromised
dental pxs = more likely to be susceptible to infective endocarditis caused by streptococci as …?
this bacteria lives in the resp. tract and mouth
what is Neonatal abstinence syndrome (NAS)?
when babies exposed to drugs in womb before birth due to passage from mothers bloodstream, then experience withdrawal symptoms:
tremor, irritability (excessive crying and high pitched), seizures, poor feeding, diarrhoea
Testing to find most appropriate management for NAS?
- Urine test & meconium test
- Blood test
- Lipsitz Neonatal drug-withdrawal scoring system or Finnegan system
guidelines to follow for NAS treatment?
Glasgow and Carlisle
Wales neonatal network guideline
NAS management?
- Wrap baby in blanket
(swaddling) - Minimise sensory stimulation
- Use of dummies
pharmacological:
- same class as those exposed to prior to birth (opiate only/ plus benzo)
other drug classes commonly causing NAS?
Opioids: heroin, prescribed meds eg codeine, oxycodone
Stimulants: amphetamines /cocaine. effects on baby more likely from drug itself instead of withdrawal.
Antidepressants (SSRIs)
Depressants: barbiturates, or alcohol, or marijuana
Nicotine from cigarette smoking
morphine half life is short/long and how does it compare w t1/2 of methadone?
morphine = long
but shorter than methodone
problem with morphine in renal failure?
Variable bioavailability, glucuronide metabolites accumulate in renal failure (M6G toxicity) mu, kappa, delta
methadone has low oral bioavailability as…
Highly bound to plasma proteins
methadone is extensively metabolised by enzyme:
CYP3A4
how are methadone metabolites excreted?
in urine
methadone pharmacolical effects on px?
analgesia, depression of respiration, suppression of cough, nausea and vomiting (via an effect on the chemoreceptor trigger zone) and constipation.
describe action of methadone
Strong opioid agonist with actions predominantly at the µ receptor. Also has some agonist actions at the K and δ (delta) opiate receptors.
methadone half-life after a single oral dose is 12-18 (mean 15) hours, partly reflecting what?
distribution into tissue stores, as well as metabolic and renal clearance. With regular doses, the tissue reservoir is already partly filled, and so the half-life is extended to 13-47 (mean 25) hours reflecting only clearance.
methadone is Xphilic and has Y Vd
lipophilic and high Vd
methadone t1/2 compared w diamorphine (heroin)?
Longer
Accumulate in tissues on repeated dosing, potential for accumulation, complicated PK
diamorphine half life is long/short and whats it metabolised into?
rapid: 2-3 minutes half life to be metabolised into morphine
Prodrug for morphine?
Diamorphine (heroin)
Buprenorphine
Interacts with what receptor?
opioid mu-receptor (binding sites in brain, SC, other tissues)
= Partial agonist (mu receptor and ORL-1)
Buprenorphine route of admin and why?
SC/ IV = highest bioavailability
buprenorphine metabolism and Vd?
- High first pass metabolism on SL absorption
- High Vd
how does the sedation intensity and withdrawal symptoms of buprenorphine compare w full agonists? (as its only a partial agonist)
`Less sedation than full agonists but more likely to be associated with withdrawal symptoms
naloxone MoA? it is a…
opioid receptor antagonist
naloxone half life IV and clearance?
IV: 1.2 hours
.. and v high clearance 2500L/day
naloxone half life compared w methadone?
comparative half life shorter than methadone
preparations of medications for the management of opioid dependency?
Methadone formulations:1mg/ml
Suboxone (buprenorphine/ naloxone)SL tablets
opioid dependency- why should buprenorphine not be given until at least 6hrs after heroin dose?
as it can cause withdrawal.
Suboxone (buprenorphine/ naloxone) for opioid dependancy. describe the use of naloxone in this prep?
When taken SL, naloxone is not absorbed, but if tablets are crushed and injected naloxone will cause withdrawal effects. Naloxone was added to prevent diversion onto illicit market
difference between the preparation of buprenorphine licensed for opioid dependence vs treatment of pain?
Preparations licensed for opioid dependency have higher doses (0.8mg-32mg)- due to tolerance
for pain have lower dose (average 450mcg)
codeine side effects OTC and POM misuse abuse
confusion; constipation; dizziness; drowsiness; dry mouth
what is lorazepam?
Short-acting benzodiazepine commonly used to treat panic disorders, severe anxiety, and seizures.
describe lorazepam (benzo) half life
short half life (10 - 20 hrs) and short onset of action so will be difficult for patient to withdraw, will need to keep taking it.
what type of drug is benzo: lorazepam?
is a GABA mimetic (usually GABA produces inhibitory functions in CNS)
why use lorazepam (benzo) w caution in elderly px?
risk of falls, continuous use could cause respiratory depression. Should be used for short term symptomatic relief of severe and debilitating anxiety.
how long after admin are peak lorazepam serum levels reached?
in 2 hours and half life is 12 hours
lorazepam works by enhancing inhibitory effects of …
GABA, CNS depressant induces calm, sleep, drowsiness
Lorazepam is metabolised by simple one-step process to ..?
a pharmacologically inert glucuronide. There are no major active metabolites.
how high is the risk of excessive accumulation of lorazepam?
Elimination half-life is about 12 hours and there is minimal risk of excessive accumulation.
how must benzos like lorazepam be stopped in px esp elderly?
Tapering: gradual reduction of dose (reduce seizure risk)
OR
switch to appropriate dose of diazepam (longer acting benzo so stays in the body longer and helps minimise withdrawal) + slowly withdraw
Non pharmacological: Bereavement counselling. CBT
1mg lorazepam = 5-10mg diazepam
How to switch form the short -> longer acting benzo?
convert to longer acting drug and slowly withdraw
Reduce over greater than 4 weeks to over one year
