Addiction Flashcards
Where in the digestive system is the majority of alcohol consumed absorbed?
Proximal small instestine
A 30-year-old woman presents to her general practitioner having missed her doses of methadone for six consecutive days. She is currently experiencing cravings, lacrimation, rhinorrhoea, as well as mild nausea and vomiting. She has a 3-year history of heroin dependence. She has been receiving maintenance therapy with methadone for the past 3 months. She denies alcohol or any other substance use.
Which is the most appropriate management of methadone prescription?
A. Increase dose of methadone
B. Reduce dose of methadone
C. Maintain dose of methadone
D. Cessation of methadone
E. Reinduction of methadone
E. Reinduction of methadone
If methadone doses are missed for 5 or more consecutive days, reassessment of the patient’s current condition should take place, and reinduction is recommended. This is important to determine the suitable dose of methadone to minimise withdrawal symptoms and prevent overdose.
Your next patient is a 24-year-old man who complains of feeling depressed. He states that he is allergic to all selective serotonin reuptake inhibitors and asks for dothiepin and temazepam. He is thin and unkempt. You notice that he has rhinorrhoea, watering eyes and is constantly yawning. What is the most likely underlying problem?
A. Schizophrenia
B. Cocaine abuse
C. Heroin abuse
D. Alcohol withdrawal
E. Cannabis abuse
The majority of people who abuse drugs take more than one type. Dothiepin (TCA) has sedative properties but is very dangerous in overdose.
Opioids are substances which bind to opioid receptors. This includes both naturally occurring opiates such as morphine and synthetic opioids such as buprenorphine and methadone.
Features of opioid misuse
-rhinorrhoea
-needle track marks
-pinpoint pupils
-drowsiness
-watering eyes
- yawning
Complications of opioid misuse
viral infection secondary to sharing needles: HIV, hepatitis B & C
bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
venous thromboembolism
overdose may lead to respiratory depression and death
psychological problems: craving
social problems: crime, prostitution, homelessness
Emergency management of opioid overdose
IV or IM naloxone: has a rapid onset and relatively short duration of action
Harm reduction interventions may include
needle exchange
offering testing for HIV, hepatitis B & C
Management of opioid dependence
patients are usually managed by specialist drug dependence clinics although some GPs with a specialist interest offer similar services
patients may be offered maintenance therapy or detoxification
NICE recommend methadone or buprenorphine as the first-line treatment in opioid detoxification
compliance is monitored using urinalysis
detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
ecstasy/cocaine overdose symptoms
(i.e. predominantly auditory hallucinations but can be tactile eg sensation of insects crawling over skin with cocaine, large pupils, sudden onset following a night out, physiological signs such as sweating)
-cocaine-induced delusional disorder (grandiose ideas, similar presentation to mania)
What specific questionnaire can be used to further assess alcohol intake after an initial CAGE questionnaire has been completed?
AUDIT (alcohol use disorders identification test)
Wernicke’s encephalopathy triad:
- Confusion
- Ataxia
- Ophthalmoplegia/nystagmus.
A 50-year-old man presents with agitation in the medical ward. He is pacing around and wanting to leave the ward. He is drenched in sweat. He says that a member of the nursing staff is a spy and is going to harm him with needles. He hears voices that tell him to leave the ward because it is unsafe to be here. He was admitted 3 days ago with pneumonia. He is taking acamprosate and co-amoxiclav.
His observations are as follows:
Temperature 38.0 °C
Heart rate 118 bpm
Respiratory rate 20 breaths/min
Blood pressure 122/84 mmHg
Which is the most appropriate initial pharmacotherapy?
A. IV chlordiazepoxide
B. IM haloperidol
C. Oral lorazepam
D. IV thiamine (Pabrinex)
E. IM (intramuscular) olanzapine
C. Oral lorazepam
This man has paranoid delusions and auditory hallucinations, together with symptoms of agitation and diaphoresis. He is having pyrexia and tachycardia. He is taking acamprosate for alcohol dependence. The most likely diagnosis here is delirium tremens. This is likely to occur when a patient with alcohol dependence is abstinent from alcohol for a few days. The first-line treatment for this medical emergency is oral lorazepam. Lorazepam is a short-acting benzodiazepine. If oral medication is declined or the symptoms persist, give parenteral (or IM) lorazepam or haloperidol. This is an off-label use of lorazepam and haloperidol.
Not: A: IV chlordiazepoxide
Chlordiazepoxide is a long-acting benzodiazepine. A reducing regimen of chlordiazepoxide is prescribed to patients with acute alcohol withdrawal. Some hospitals utilise a symptom-triggered drug regimen, where a dose of chlordiazepoxide or diazepam is given when the patient experiences symptoms of alcohol withdrawal. This man is experiencing delirium tremens, a medical emergency, which should be managed initially with a shorter-acting benzodiazepine, ie. lorazepam.
symptoms of delirium tremens
Symptoms usually peak on day 4-5. Symptoms include confusion, hallucinations (particularly visual hallucinations and tactile hallucinations (such as formication - the sensation of crawling insects on or under the skin), sweating, hypertension and (rarely) seizures.
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
maintenance management of alcohol withdrawal:
- Chlordiazepoxide
- Fluids
- Anti-emetics
- Pabrinex
- Refer to local drug and alcohol liaison teams
A 24-year-old male attends his GP surgery feeling generally unwell. He is a regular user of heroin, but has recently run out of money and so has not taken any heroin for the last 24 hours.
During the consultation he reports feeling extremely anxious, with watering eyes and a stomach ache. His most troubling symptom is the diarrhoea, which has occurred five times already since waking.
Which of the following is the most appropriate first line management?
A. Sertraline
B. Loperamide
C. Oral morphine sulphate.
D. Tramadol
E. Fentanyl patches
B. Loperamide
In acute heroin withdrawal, NICE specifically advises against prescribing opiates and instead recommends symptomatic management. As this man’s most troubling symptom is diarrhoea, loperamide is the most appropriate option.
-antiemetics for vomiting
Alternatively lofexidine (an alpha 2 receptor agonist) can be used to help relieve physical symptoms, and benzodiazepines can be given for agitation.-
opioid overdose symptoms/treatment:
opioid withdrawal symptoms:
Opiate withdrawal can present with symptoms of sweating, watering eyes, dilated pupuls, rhinorrhoea, yawning, flu-like manner: GI upset (abdominal pain/diarrhoea), anxiety and irritability as well as general aches and pains.
-sympathetic hyperactivity: tachycardia and hypertension, hyperreflexia, hairs standing on end
Withdrawal from heroin can begin as early as 6 hours after the last dose, with symptoms peaking at 36-72 hours. Unlike alcohol withdrawal, it is unpleasant but not especially dangerous.
cocaine intoxication symptoms
anxiety, agitation, euphoria, enlarged pupils, palpitations.
severe intoxication: delirium, hyperactivity, hyperthermia & psychosis
cocaine withdrawal symptoms:
fatigue, agitation, vivid & unpleasant dreams, increased appetite & psychomotor retardation
IV Pabrinex (or vitamin B1, thiamine)
