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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
Which neurotransmitters does Acamprosate work on?
Glutamate - inhibits GABA - enhances n.b in alcohol withdrawal there is glutamate over-excitation and GABA deficiency - Acamprosate can stabilise these effects
26
When thiamine is used to treat Wernicke Encephalopathy which symptoms resolve quickest?
Confusion and opthalmoplegia Ataxia, nystagmus and neuropathy may be prolonged
27
What did the MATCH study show for treatment for alcohol consumption?
That matching participants to preferred treatments did not lead to increased response
28
When may shorter acting benzodiazepines be preferred for alcohol detoxification?
- 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
29
Differentiate type 1 and type alcoholism as defined by Cloniger?
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
30
Does alcoholic hallucinosis respond to antipsychotics?
Yes - often it resolves on cessation of drinking < 1 week but can persist in 5% -
31
For mild alcohol withdrawal after how many days does symptoms subside?
3 - 7 days
32
How long does NICE suggest inpatient and community detoxification be conducted over for opiod dependence?
Inpatient 7 - 14 days Community 14 - 21 days
33
What score on the audit indicates hazardous or harmful alcohol use?
8
34
Outline some markers for excess alcohol consumption?
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
Machiafava Bigmani syndrome has been linked to?
The consumption of certain red wines
36
When is risk of seizure highest following sudden cessation of alcohol?
12 - 18hrs
37
For patients who fail on oral methadone and buprenorphine opioid substitution programmes which is the next step?
Injectable diamorphine - requires home office license and is supervised in a specialist facility twice a day alongside an adjunctive psychosocial intervention
38
First degree relatives of alcoholics are at what risk of developing alcohol problems themselves?
2 x as likely
39
Which opioid substitution treatment can precipitate withdrawal symptoms?
Buprenorphine as it is a partial agonist - when it replaces the full agonist this can lead to withdrawal symptoms
40
What are the symptoms of opioid dependence?
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
Differentiate ICD-11s harmful and hazardous patterns of use of substances?
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
Outline some signs of PCP intoxication?
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
For ICD-11 diagnosis of alcohol dependence how long do symptoms need to be present for?
12 months or if daily/near continuous use it can be 3 months
44
What are the Edward and Gross criteria for dependence?
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
Differentiate the purposes of drug classes and drug scheduling?
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
Outline some drugs that belong to classes A, B and C and their penalty for possession?
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
Outline the drug schedules 1 to 5 in terms of their perceived therapeutic value and name a drug that belongs to each schedule
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
Name some questionnaires to assess for pathological gaming?
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
What medication may be used for pathological gambling co-morbid with impulse control disorders?
Naltrexone
50
What is nalmefene?
An opioid antagonist licensed by NICE as treatment for alcohol dependence. SE include nausea, dizziness, headache and insomnia
51
What is the equation for units of alcohol drank?
Total volume drank x ABV / 1000
52
False positives in drug testing for Benzodiazepine can result from?
Sertraline + NSAIDS
53
In Marchiafava-Bignami disease where are lesions found?
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
In Wernicke's Encephalopathy where does neuronal damage occur?
- Periventricular grey matter - Haemorrhage and small vessel proliferation in thalamus, mammillary bodies, cerebellar vermis and pons
55
Does Wernicke's encephalopathy present with lateral or vertical nystagmus?
Nystagmus is typically on lateral gaze
56
What clues might there be that urine sample is not valid?
Temperature outside of 32 - 38 pH < 3 and > 11 (normal range 4 - 8) Specific gravity < 1.002 or > 1.030
57
Name some false positives for Amphetamines, Benzodiazepines, Cannabis, Opiates, Methadone, PCP and LSD?
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
What is the maximum length of time an individual should be prescribed benzodiazepines for?
4 weeks
59
Describe some physical and psychological side effects that may be witnessed on a reducing regime of diazepam?
Physical: - Stiffness - Weakness - GI disturbance - Parasthesia - Flu-like symptoms - Vivid dreams Psychological: - Anxiety - Delusions/Hallucinations - Depersonalisation - Depression - Insomnia - Decreased memory and concentration
60
Describe how bupropion treatment should be given to those wanting to quit smoking?
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
How should varencicline be given for smoking cessation?
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
Synthetic cannaboids are classed as?
Type B
63
Outline the circumstances in which opioid detoxification should not be routinely offered?
- 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
The lifetime prevalence of suicide in alcohol dependence is?
7%
65
For the following "legal highs" outline where they are classed in the misuse of drugs schedule? - Mephedrone - Piperazines - Benzofuran compounds - Synthetic cannaboids - GBL
- 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
The micro-counselling skills used in motivational interviewing are?
O - Open Ended Questions A - Affirmation R - Reflection S - Summaries OARS
67
How does the abbreviation DARN - CAT summarise different types of change in motivational interviewing?
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
How do the withdrawal symptoms associated with opioids differ?
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
In the change model how do action and maintenance differ?
Action - first 6 months of change Maintenance - ongoing efforts to maintain change after 6 months
70
How long is cocaine detected in drug testing for?
< 1 day if cocaine 5 days if metabolite benzoylecgonine
71
Name some side effects for disulfuram?
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
How long is alcohol detectable in the urine for?
12 hours
73
How long is LSD detectable in the urine for?
< 1 day The metabolite may be up to 5 days (2 - oxo - 3 - hydroxy - LSD)
74
How long are opioids detectable in the urine for?
3 days or more
75
How long are benzodiazepines detectable in the urine for?
Midazolam - 2 days Other BDZ (Lorazepam inc.) 5 days Diazepam 10 days
76
Outline some models for the link between substance use disorders (SUDs) and mental illness?
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
Name some indications for inpatient alcohol detoxification?
- 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
When may community detox for opioid prescription not be routinely made for patients?
- Previous failure of community detox - Significant additional physical or mental health problems - Polydrug detoxification - Considerable social problems
79
What approaches have evidence base for treating cocaine addiction?
Contingency programmes - prizes/rewards for positive behavioural changes (also recommended by NICE alongside opioid substitutions treatments)
80
If prescribing of bupropion or NRT is unsuccessful how long does NICE wait before trying again?
6 months
81

MRCPsych Part B (13 decks)

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