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MRCPsych Part B > Addiction > Flashcards

Addiction Flashcards

1
Q

What is the current prevalence of heroin use in the UK

A

< 1 %

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2
Q

What rate of patients taking benzodiazepines for 3 months, 3 - 12 months and > 12 months will develop dependence?

A

3 months: Few
3 - 12 months: 10 - 20%
> 12 months: 25 - 40%

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3
Q

How much does a typical heroin dependent user take in a day?

A

0.25 - 2g

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4
Q

For cocaine use which psychosocial management has the most evidence?

A

Contigency management (often used alone or combination with community reinforcement or CBT)

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5
Q

What are the most common side effects of benzodiazepines?

A

Dizziness, ataxia and drowsiness

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6
Q

Flunitrazepam has been implicated in cases of?

A

Date rape - it is super fast acting and tasteless

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7
Q

Which trimester should opiod detoxification be chosen to be performed in if conducted?

A

2nd trimester (no faster than intervals of 2-3g of methadone every 3-5 days)

1st trimester - risk of spontaneous abortion
3rd trimester - risk of foetal distress, pre-term birth and still birth

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8
Q

Name some common side effects of clonidine?

A

Sedation
Dizziness
Dry Mouth/eyes
Fatigue
Hypotension
Constipation

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9
Q

LSD is detectable in the urine for?

A

4 days

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10
Q

What is the seizure risk with buproprion?

A

0.4% for TDS immediate release
0.1% for extended release

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11
Q

When does heroin withdrawal peak?

A

32 - 72hrs
Begins at 6 hours

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12
Q

NRT treatment should be continued for?

A

8 - 12 months

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13
Q

What type of hallucinations are associated with benzodiazepine withdrawal?

A

Kinasthetic - feeling like the joints are flying through the air

Can also occur in acute alcohol intoxication

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14
Q

Candida endopthalmitis can arise from which heroin practice?

A

Using lemon choice to reconstitute heroin (or cocaine too)

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15
Q

Name some side effects of Varencicline?

A

Nausea, sleep disturbance and vivid dreams
(It is a partial nicotinic receptor antagnosit)

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16
Q

Which unwanted side effect may women / patients from a lower socioeconomic class be susceptible to?

A

Weight gain

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17
Q

What percentage of individuals in acute alcohol withdrawal go onto develop delirium tremens?

A

5%

RF - older age, longer history of alcohol dependence, poor nutritional state, being medically comprimised

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18
Q

In Wernicke’s encephalopathy the classical triad is?

A

Opthalmoplegia, ataxia and confusion

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19
Q

What is the risk of suicide in individuals with alcohol dependence and alcohol problems?

A

Alcohol dependence 10-15%
Alcohol problems 4%

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20
Q

Outline the ICD-11 criteria for alcohol dependence?

A

A period of 12 months (or 3 months if daily/near daily drinking) characterised by:
- Impaired control of alcohol
- Increased priority to alcohol > other substances
- Persistent use despite negative consequences
- Accompanied by cravings and other physical features of dependence

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21
Q

How long should acamprosate be continued for?

A

6 months - should be started in detoxification

Works by normalising NMDAr dysregulation
Cautions: Cirrhosis, underweight
SE: Diarrhoea, pruritis and a rash

Most effective at maintaining abstinence
NNT for placebo and acamprosate is 9 - 12

n.b acamprosate should not be given to < 18 years or > 65 years

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22
Q

Outline the mechanism of naltrexone?

A

Mu-opiod antagonist

Cautions: Cirrhosis, opiods
SE: Nausea, headaches and anxiety

Most effective at reducing a lapse becoming a relapse

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23
Q

Describe Disulfuram’s mechanism?

A

Aledehyde dehydrogenase inhibitor

Cautions: suicidal patient, high cardiovascular risk
SE: metallic taste, halitosis, peripheral neuropathy, liver damage and interactions with alcohol

Most effective if intake is witnessed

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24
Q

When does Delirium Tremens tend to appear after stopping drinking?

A

72 - 96hrs

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25
Q

Which neurotransmitters does Acamprosate work on?

A

Glutamate - inhibits
GABA - enhances

n.b in alcohol withdrawal there is glutamate over-excitation and GABA deficiency - Acamprosate can stabilise these effects

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26
Q

When thiamine is used to treat Wernicke Encephalopathy which symptoms resolve quickest?

A

Confusion and opthalmoplegia

Ataxia, nystagmus and neuropathy may be prolonged

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27
Q

What did the MATCH study show for treatment for alcohol consumption?

A

That matching participants to preferred treatments did not lead to increased response

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28
Q

When may shorter acting benzodiazepines be preferred for alcohol detoxification?

A
  • Liver disease - risk of over sedation
  • COPD - risk of respiratory depression

Oxazepam is a good option
Be wary of risk of breakthrough seizures and potential for misuse

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29
Q

Differentiate type 1 and type alcoholism as defined by Cloniger?

A

Type 1 - late onset, starts after 25 years, not much family history, males and females

Type 2 - early onset, starts < 25 years, ASPD traits, family history, mostly males

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30
Q

Does alcoholic hallucinosis respond to antipsychotics?

A

Yes

  • ## often it resolves on cessation of drinking < 1 week but can persist in 5%
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31
Q

For mild alcohol withdrawal after how many days does symptoms subside?

A

3 - 7 days

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32
Q

How long does NICE suggest inpatient and community detoxification be conducted over for opiod dependence?

A

Inpatient 7 - 14 days
Community 14 - 21 days

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33
Q

What score on the audit indicates hazardous or harmful alcohol use?

A

8

34
Q

Outline some markers for excess alcohol consumption?

A

Breathlyser levels - 6hrs in blood / 12hrs in breath - highly specific best used in detox environments

GGT - 4 weeks - moderate specificity and low sensitivity

AST/ALT - 4 weeks - low specificity and low sensitivity

CDT - 4 weeks - highly specific and moderately sensitive - best used to monitor relapse but not much availability

MCV - 3-6 months - moderate specificity and low sensitivity

Urine ethyl glucuronide - several days

35
Q

Machiafava Bigmani syndrome has been linked to?

A

The consumption of certain red wines

36
Q

When is risk of seizure highest following sudden cessation of alcohol?

A

12 - 18hrs

37
Q

For patients who fail on oral methadone and buprenorphine opioid substitution programmes which is the next step?

A

Injectable diamorphine - requires home office license and is supervised in a specialist facility twice a day alongside an adjunctive psychosocial intervention

38
Q

First degree relatives of alcoholics are at what risk of developing alcohol problems themselves?

A

2 x as likely

39
Q

Which opioid substitution treatment can precipitate withdrawal symptoms?

A

Buprenorphine as it is a partial agonist - when it replaces the full agonist this can lead to withdrawal symptoms

40
Q

What are the symptoms of opioid dependence?

A

Nausea / vomiting / abdominal (later)
Diarrhoea
Insomnia
Hypertension
Tachycardia
Piloerection - gooseflesh (later)
Lacrimation / rhinorrhea
Dilated pupils (later)
Yawning

Signs of advanced withdrawal are muscle spasm and twitching

41
Q

Differentiate ICD-11s harmful and hazardous patterns of use of substances?

A

Harmful
- 12 months if episodic / 1 month if continuous
- Harm has been caused to physical/mental health of own person or behaviour leading to harm to others

Hazardous
- No time frame
- Pattern of psychoactive use that increases the risk of harm to self/others and has led the individual to come to the attention of health professionals but has not resulted yet in specific identifiable harm
- Often there is awareness

42
Q

Outline some signs of PCP intoxication?

A

Aggression
Impulsiveness
Unpredictability
Anxiety
Psychomotor agitation
Impaired judgement
Diminished pain response
Slurred speech
Dystonia

Physical signs
- Dysarthria
- Dystonia
- Nystagmus
- Hypertension
- Tachycardia
- Ataxia
- Muscle rigidity

43
Q

For ICD-11 diagnosis of alcohol dependence how long do symptoms need to be present for?

A

12 months or if daily/near continuous use it can be 3 months

44
Q

What are the Edward and Gross criteria for dependence?

A
  1. Tolerance
  2. Salience
  3. Narrowing of repertoire
  4. Compulsion (subjective awareness)
  5. Reinstatement after abstinence
  6. Withdrawal symptoms
  7. Drinking to prevent withdrawals
45
Q

Differentiate the purposes of drug classes and drug scheduling?

A

Classes - indicates the threat they pose on society and categorise drugs for purpose of specifying criminal punishment

Scheduling - categories with respect to potential for abuse and if they have a therapeutic value has implications on how they can be transported

46
Q

Outline some drugs that belong to classes A, B and C and their penalty for possession?

A

A - cocaine, heroin, MDMA, LSD, meth –> 7 years

B - cannabis, codeine, ketamine, GHB, GBL, methylphenidate –> 5 years

C - Anabolic steroids, BDZ, khat, pregabalin, gabapentin –> 2 years

47
Q

Outline the drug schedules 1 to 5 in terms of their perceived therapeutic value and name a drug that belongs to each schedule

A

1 - perceived to have no therapeutic value therefore not allowed to possess with/without prescription. Only for research with home office license (LSD, MDMA, Raw opion)

2 - has therapeutic value but illegal to have without prescription. Requires full controlled drug prescription requirements and need a controlled drugs register (Amphetamines, Cocaine, Pethidine, Methylphenidate, medicinal cannabis products, morphine, methadone)

3 - same as 2 but without need for CD register (barbiturates
flunitrazepam (Rohypnol), temazepam)

4 - No CD requirements or safe custody (Part one drugs - benzodiazepines (except temazepam and midazolam, which are in Schedule 3), non-benzodiazepine hypnotics (zaleplon, zolpidem tartrate, and zopiclone) and Sativex®.
Part two drugs - androgenic and anabolic steroids, clenbuterol, chorionic gonadotrophin (HCG), non-human chorionic gonadotrophin, somatotropin, somatrem, and somatropin)

5 - Certain CD but due to low strength preparations only restriction is maintaining the invoice for 2 years (Codeine Phosphate or morphine < 2mg/ml)

48
Q

Name some questionnaires to assess for pathological gaming?

A

NODS-CLiP (Cut down, lied, period of two weeks thinking about/planning future bets) - score of 1 indicative

South Oaks Gambling Screen - score above 5 indicates a problem gambler

49
Q

What medication may be used for pathological gambling co-morbid with impulse control disorders?

A

Naltrexone

50
Q

What is nalmefene?

A

An opioid antagonist licensed by NICE as treatment for alcohol dependence. SE include nausea, dizziness, headache and insomnia

51
Q

What is the equation for units of alcohol drank?

A

Total volume drank x ABV / 1000

52
Q

False positives in drug testing for Benzodiazepine can result from?

A

Sertraline + NSAIDS

53
Q

In Marchiafava-Bignami disease where are lesions found?

A

Corpus Callosum - seen in alcoholic with malnutrition which causes demylination and necrosis

Symptoms include cognitive disturbance, spasticity, dysarthria and inability to walk

Very varying course

54
Q

In Wernicke’s Encephalopathy where does neuronal damage occur?

A
  • Periventricular grey matter
  • Haemorrhage and small vessel proliferation in thalamus, mammillary bodies, cerebellar vermis and pons
55
Q

Does Wernicke’s encephalopathy present with lateral or vertical nystagmus?

A

Nystagmus is typically on lateral gaze

56
Q

What clues might there be that urine sample is not valid?

A

Temperature outside of 32 - 38
pH < 3 and > 11 (normal range 4 - 8)
Specific gravity < 1.002 or > 1.030

57
Q

Name some false positives for Amphetamines, Benzodiazepines, Cannabis, Opiates, Methadone, PCP and LSD?

A

Amphetamines:
- Atomoxetine, Bupropion, Metformin, Labetalol, Promethazine

Benzodiazepines:
- Sertraline, Efavirenz

Cocaine:
- Coca tea

Cannabis:
- Efaviranez, promethazine, NSAIDs (ibuprofen and naproxen), pantoprazole

Opiates:
- Poppy seed containing foods, levofloxacin, ofloxacin, imipramine, naltrexone/naloxone, rifampicin

Methadone:
- Verapamil, Quetiapine

PCP:
- Venlafaxine, Dextromethorphan, Ibuprofen, Ketamine, Lamotrigine

LSD:
- Fluoxetine, Buspirone, Haloperidol, Risperidone, Trazadone, Metoclopramide,

58
Q

What is the maximum length of time an individual should be prescribed benzodiazepines for?

A

4 weeks

59
Q

Describe some physical and psychological side effects that may be witnessed on a reducing regime of diazepam?

A

Physical:
- Stiffness
- Weakness
- GI disturbance
- Parasthesia
- Flu-like symptoms
- Vivid dreams

Psychological:
- Anxiety
- Delusions/Hallucinations
- Depersonalisation
- Depression
- Insomnia
- Decreased memory and concentration

60
Q

Describe how bupropion treatment should be given to those wanting to quit smoking?

A

Start 7 - 14 days prior to stopping

Course length of 7 - 9 weeks (can be stopped suddenly without tapering the dose)

SE - dry mouth, insomnia, headache, impaired concentration

Avoid if - Bipolar disorder, pregnancy and breast feeding or epilepsy

Buproprion is a relatively weak and selective reuptake inhibitor of noradrenaline and dopamine

61
Q

How should varencicline be given for smoking cessation?

A

Start 7-14 days before stopping
Give for 12 weeks

Avoid if:
- Epilepsy
- Renal impairment
- Pregnancy and breast feeding

Commonest side effect is nausea - rarely stops people from taking. Has been noted to cause depression

62
Q

Synthetic cannaboids are classed as?

A

Type B

63
Q

Outline the circumstances in which opioid detoxification should not be routinely offered?

A
  • If they have a medical condition urgently needing treatment
  • In custody or prison sentences - priority should be treating opioid withdrawal
  • In A&E –> treat withdrawal symptoms

n.b if presenting with concurrent alcohol dependence/misuse - priority should be to treat alcohol use first

64
Q

The lifetime prevalence of suicide in alcohol dependence is?

A

7%

65
Q

For the following “legal highs” outline where they are classed in the misuse of drugs schedule?

  • Mephedrone
  • Piperazines
  • Benzofuran compounds
  • Synthetic cannaboids
  • GBL
A
  • Mephedrone - B (ecstacy / amphetamine like)
  • Piperazines - C (ecstasy like)
  • Benzofuran compounds - B (ecstasy like)
  • Synthetic cannaboids - B (cannabis like)
  • GBL - B (BDZ, alcohol like)
66
Q

The micro-counselling skills used in motivational interviewing are?

A

O - Open Ended Questions
A - Affirmation
R - Reflection
S - Summaries

OARS

67
Q

How does the abbreviation DARN - CAT summarise different types of change in motivational interviewing?

A

D - Desire to change
A - Ability to change
R - Reason why change is needed
N - Understand why they need to change

C - Commitment
A - Activation
T - Taking steps to change

68
Q

How do the withdrawal symptoms associated with opioids differ?

A

Short acting (heroin):
- Begin 4-6hrs
- Peak 32-72hrs
- May last 5 days

Long acting (methadone):
- Begin 30-72hrs
- Peak 4-6 days
- Resolve over 10 days

Note even after 5 day course of opioids withdrawal symptoms may be seen

69
Q

In the change model how do action and maintenance differ?

A

Action - first 6 months of change

Maintenance - ongoing efforts to maintain change after 6 months

70
Q

How long is cocaine detected in drug testing for?

A

< 1 day if cocaine
5 days if metabolite benzoylecgonine

71
Q

Name some side effects for disulfuram?

A

Psychosis, suicidal risk, uncontrolled HF, previous history of CVA, severe personality disorder

Serious side effects of a reaction include:
Heart failure
Myocardial infarction
Arrhythmia
Bradycardia
Respiratory depression
Hypotension

72
Q

How long is alcohol detectable in the urine for?

A

12 hours

73
Q

How long is LSD detectable in the urine for?

A

< 1 day
The metabolite may be up to 5 days (2 - oxo - 3 - hydroxy - LSD)

74
Q

How long are opioids detectable in the urine for?

A

3 days or more

75
Q

How long are benzodiazepines detectable in the urine for?

A

Midazolam - 2 days
Other BDZ (Lorazepam inc.) 5 days
Diazepam 10 days

76
Q

Outline some models for the link between substance use disorders (SUDs) and mental illness?

A

Common factor model - i.e. genetic vulnerability, low socioeconomic class or anti-social personality traits lead to both illnesses

Secondary use model - the substance “self-medicates” to alleviate the pain of the disorder

Supersensitivity - that mentally ill patients are unusually sensitive to negative social and health consequences of substance exposure

Secondary illness model - SUD leads to mental illness through kindling or behavioural sensitisation

77
Q

Name some indications for inpatient alcohol detoxification?

A
  • Past DTs or seizure
  • Psychiatric morbidity with risk of suicide or risk to physical health
  • Wernicke’s encephalopathy or Korsakoff syndrome
  • Homelessness or social disability
78
Q

When may community detox for opioid prescription not be routinely made for patients?

A
  • Previous failure of community detox
  • Significant additional physical or mental health problems
  • Polydrug detoxification
  • Considerable social problems
79
Q

What approaches have evidence base for treating cocaine addiction?

A

Contingency programmes - prizes/rewards for positive behavioural changes (also recommended by NICE alongside opioid substitutions treatments)

80
Q

If prescribing of bupropion or NRT is unsuccessful how long does NICE wait before trying again?

A

6 months

81
Q
A

MRCPsych Part B (13 decks)

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