Addiction Flashcards
What is the current prevalence of heroin use in the UK
< 1 %
What rate of patients taking benzodiazepines for 3 months, 3 - 12 months and > 12 months will develop dependence?
3 months: Few
3 - 12 months: 10 - 20%
> 12 months: 25 - 40%
How much does a typical heroin dependent user take in a day?
0.25 - 2g
For cocaine use which psychosocial management has the most evidence?
Contigency management (often used alone or combination with community reinforcement or CBT)
What are the most common side effects of benzodiazepines?
Dizziness, ataxia and drowsiness
Flunitrazepam has been implicated in cases of?
Date rape - it is super fast acting and tasteless
Which trimester should opiod detoxification be chosen to be performed in if conducted?
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
Name some common side effects of clonidine?
Sedation
Dizziness
Dry Mouth/eyes
Fatigue
Hypotension
Constipation
LSD is detectable in the urine for?
4 days
What is the seizure risk with buproprion?
0.4% for TDS immediate release
0.1% for extended release
When does heroin withdrawal peak?
32 - 72hrs
Begins at 6 hours
NRT treatment should be continued for?
8 - 12 months
What type of hallucinations are associated with benzodiazepine withdrawal?
Kinasthetic - feeling like the joints are flying through the air
Can also occur in acute alcohol intoxication
Candida endopthalmitis can arise from which heroin practice?
Using lemon choice to reconstitute heroin (or cocaine too)
Name some side effects of Varencicline?
Nausea, sleep disturbance and vivid dreams
(It is a partial nicotinic receptor antagnosit)
Which unwanted side effect may women / patients from a lower socioeconomic class be susceptible to?
Weight gain
What percentage of individuals in acute alcohol withdrawal go onto develop delirium tremens?
5%
RF - older age, longer history of alcohol dependence, poor nutritional state, being medically comprimised
In Wernicke’s encephalopathy the classical triad is?
Opthalmoplegia, ataxia and confusion
What is the risk of suicide in individuals with alcohol dependence and alcohol problems?
Alcohol dependence 10-15%
Alcohol problems 4%
Outline the ICD-11 criteria for alcohol dependence?
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
How long should acamprosate be continued for?
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
Outline the mechanism of naltrexone?
Mu-opiod antagonist
Cautions: Cirrhosis, opiods
SE: Nausea, headaches and anxiety
Most effective at reducing a lapse becoming a relapse
Describe Disulfuram’s mechanism?
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
When does Delirium Tremens tend to appear after stopping drinking?
72 - 96hrs
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
When thiamine is used to treat Wernicke Encephalopathy which symptoms resolve quickest?
Confusion and opthalmoplegia
Ataxia, nystagmus and neuropathy may be prolonged
What did the MATCH study show for treatment for alcohol consumption?
That matching participants to preferred treatments did not lead to increased response
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
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
Does alcoholic hallucinosis respond to antipsychotics?
Yes
- ## often it resolves on cessation of drinking < 1 week but can persist in 5%
For mild alcohol withdrawal after how many days does symptoms subside?
3 - 7 days
How long does NICE suggest inpatient and community detoxification be conducted over for opiod dependence?
Inpatient 7 - 14 days
Community 14 - 21 days
What score on the audit indicates hazardous or harmful alcohol use?
8
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
Machiafava Bigmani syndrome has been linked to?
The consumption of certain red wines
When is risk of seizure highest following sudden cessation of alcohol?
12 - 18hrs
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
First degree relatives of alcoholics are at what risk of developing alcohol problems themselves?
2 x as likely
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
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
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
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
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
What are the Edward and Gross criteria for dependence?
- Tolerance
- Salience
- Narrowing of repertoire
- Compulsion (subjective awareness)
- Reinstatement after abstinence
- Withdrawal symptoms
- Drinking to prevent withdrawals
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
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
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)
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
What medication may be used for pathological gambling co-morbid with impulse control disorders?
Naltrexone
What is nalmefene?
An opioid antagonist licensed by NICE as treatment for alcohol dependence. SE include nausea, dizziness, headache and insomnia
What is the equation for units of alcohol drank?
Total volume drank x ABV / 1000
False positives in drug testing for Benzodiazepine can result from?
Sertraline + NSAIDS
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
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
Does Wernicke’s encephalopathy present with lateral or vertical nystagmus?
Nystagmus is typically on lateral gaze
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
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,
What is the maximum length of time an individual should be prescribed benzodiazepines for?
4 weeks
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
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
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
Synthetic cannaboids are classed as?
Type B
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
The lifetime prevalence of suicide in alcohol dependence is?
7%
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)
The micro-counselling skills used in motivational interviewing are?
O - Open Ended Questions
A - Affirmation
R - Reflection
S - Summaries
OARS
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
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
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
How long is cocaine detected in drug testing for?
< 1 day if cocaine
5 days if metabolite benzoylecgonine
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
How long is alcohol detectable in the urine for?
12 hours
How long is LSD detectable in the urine for?
< 1 day
The metabolite may be up to 5 days (2 - oxo - 3 - hydroxy - LSD)
How long are opioids detectable in the urine for?
3 days or more
How long are benzodiazepines detectable in the urine for?
Midazolam - 2 days
Other BDZ (Lorazepam inc.) 5 days
Diazepam 10 days
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
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
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
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)
If prescribing of bupropion or NRT is unsuccessful how long does NICE wait before trying again?
6 months
