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3a Psychiatry > Addiction > Flashcards

Addiction Flashcards

1
Q

Define tolerance

A

Tolerance = loss of effect when taking the same dose

  • The person may keep increasing the dose to achieve the desired effects.
  • Tolerance occurs with most psychoactive substances over time.
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2
Q

Define dependence

A

Dependence = a physiological + psychological need to keep using a drug

Dependence may occue due to:
* Physiological changes (notable with alcohol, opiates, benzodiazepines)
* Psychological factors (e.g. cravings and compulsions to use the drug)

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3
Q

Why do withdrawal symptoms occur?

A

Withdrawal symptoms = occur due to physiological adaptations to the drug

E.g.:
* Benzodiazepines = stimulate GABA receptors
* GABA = an inhibitory neurotransmitter - has a relaxing effect
* Long-term use of benzodiazepines = results in the body reducing its natural production of GABA to balance the stimulating effects of the drug
* When drug is withdrawn → under-activity of GABA system → withdrawal symptoms - anxiety, irritability, tremors, insomnia, seizures

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4
Q

Define addiction

A

Drug addiction = the compulsive use of substances, often leading to harmful physical, psychological and social consequences

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5
Q

Which pathway in the brain is the reward pathway?

A

Mesolimbic pathway
* Primary neurotransmitter = dopamine

Key areas:
* Ventral tegmental area
* Nucleus accumbens
* Amygdala
* Prefrontal

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6
Q

Pathway of psyhcological addiction

A

Addictive substances or behaviours = release dopamine within the mesolimbic pathway → providing a pleasurable reward

Repeated exposure to this stimulus = reduces the number and sensitivity of the dopamine receptors in this pathway, requiring an increasingly strong stimulus (e.g., a higher dose or frequency) to produce the same reward. The response to everyday activities reduces (everyday life becomes less rewarding). As a result, the person increasingly seeks out the substance or behaviour to stimulate the reward pathway.

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7
Q

Which part of the brain are the cues for the addictive substance or behaviour embedded into?

A

Amygdala

  • People, events, places or objects = can act as cues, triggering cravings.
  • Stress = a common trigger → prompting the substance or behaviour as a** coping mechanism**.
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8
Q

What region of the brain that is responsible for executive functions (decision-making, assessing risk, controlling impulses) is also changed during addiction?

A

Prefrontal cortex

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9
Q

Examples of opioids and basic mechanism of action

A

Heroin, morphine, oxycodone, codeine
Stimulates opioid receptors

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10
Q

Examples of stimulants and basic mechanism of action

A

Cocaine, MDMA (ecstasy), methamphetamine
* Cocaine = blocks reuptake of dopamine by the presynaptic membrane
* MDMA = stimulates the release of serotonin + blocks its reuptake
* Meth = stimulates the release of dopamine + blocks its reuptake

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11
Q

Examples of depressants and basic mechanism of action

A

Alcohol, benzodiazepines
Stimulates gamma-aminobutyric acid (GABA) receptors

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12
Q

Examples of hallucinogens and basic mechanism of action

A

LSD, psilocybin
Stimulate serotonin receptors, particularly 5-HT2A receptors

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13
Q

Name a cannabinoids and basic mechanism of action

A

Cannabis
Stimulates cannabinoid receptors (CB1 + CB2)

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14
Q

Name some anticonvulsants and the basic mechanism of action

A

Pregabalin, gabapentin
Blocks voltage-gated calcium channels in the presynaptic membrane, reducing the release of excretory neurotransmitters

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15
Q

Name some nicotine products and the basic mechanism of action

A

Cigarettes, vapes
Stimulates nicotinic acetylcholine receptors

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16
Q

What is the management plan for drug and alcohol addiction?

A
  • Detoxification (may be coordinated at home or as an inpatient)
  • Medication to help maintain abstinence
  • Psychological + behavioural therapies (e.g., cognitive behavioural therapy)
  • Ongoing support (e.g., a recovery coordinator and support groups)
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17
Q

Name some medication used for opioid dependence

A
  • Methadone (binds to opioid receptors)
  • Buprenorphine (binds to opioid receptors)
  • Naltrexone (helps prevent relapse)
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18
Q

Name some medication used for nicotine dependence (smoking)

A
  • Nicotine replacement therapy (e.g., patches, gum or lozenges)
  • Bupropion
  • Varenicline
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19
Q

Define alcohol dependence

A

Alcohol dependence = involves daily alcohol consumption, strong urges and cravings for alcohol, difficulty controlling consumption, tolerance to the effects of alcohol + withdrawal symptoms when stopping.

20
Q

Mechanism of action for alcohol

A
  • Alcohol = a depressant
  • Alcohol = stimulates GABA receptors (which have a relaxing effect on the brain)
  • Alcohol = also **inhibits glutamate receptors (NMDA receptors) **→ causing further relaxing effct on the brain (glutamate = excitatory neurotransmitter)
21
Q

Mechanism of action for alcohol dependence

A
  • Long-term alcohol use = down-regulates the GABA system + up-regulates the glutamate system (balancing the effects of alcohol)
  • The patient must continue drinking alcohol, or they will experience unpleasant, uncomfortable and potentially dangerous withdrawal symptoms.
22
Q

Formula to calculate alcohol units

A

Volume (ml) x Alcohol Content (%) ÷ 1000 = Units of Alcohol

23
Q

Tom Tip: Calculating alcohol units

A

Calculating alcohol units is a very common exam question. The simplest way is to multiply the volume in litres by the percentage. For example:

  • For 750 mls of 12% wine: 0.75 x 12 = 9 units
  • For a 25 ml shot of 40% vodka: 0.025 x 40 = 1 unit
  • For 500 mls of 5.2% lager: 0.5 x 5.2 = 2.6 units
24
Q

What are the recommended alcohol consumption

A
  • Not more than 14 units per week
  • Spread evenly over 3 or more days
  • Not more than 5 units in a single day
25
Q

Define binge drinking

A

Single session involving:
* Women: 6 or more units
* Men: 8 or more units

26
Q

Name the complications of alcohol use during pregnancy

A
  • Miscarriage
  • Small for dates
  • Preterm delivery
  • Fetal alcohol syndrome
27
Q

Name some complications of alcohol excess

A
  • Alcohol-related liver disease
  • Cirrhosis and its complications (e.g., oesophageal varices, ascites and hepatocellular carcinoma)
  • Alcohol dependence and withdrawal
  • Wernicke-Korsakoff syndrome (WKS)
  • Pancreatitis
  • Alcoholic cardiomyopathy
  • Alcoholic myopathy - with proximal muscle wasting and weakness
  • Increased risk of cardiovascular disease (e.g., stroke or myocardial infarction)
  • Increased risk of cancer, particularly breast, mouth and throat cancer
28
Q

What questionnaire is used to screen for harmful alcohol use?

A

Alcohol Use Disorders Identification Test (AUDIT)

29
Q

What are the CAGE questions can be used to screen for harmful alcohol use quickly?

A

The CAGE questions can be used to screen for harmful alcohol use quickly:

C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?

30
Q

Name some examinations findings with excess alcohol use

A
  • Smelling of alcohol
  • Slurred speech
  • Bloodshot eyes
  • Dilated capillaries on the face (telangiectasia)
  • Tremor
31
Q

What would blood test look liek for someome using alcohol in excess?

A
  • Raised mean corpuscular volume (MCV)
  • Raised alanine transaminase (ALT) + aspartate transferase (AST)
  • AST:ALT ratio **above 1.5 **particularly = suggests alcohol-related liver disease
  • Raised gamma-glutamyl transferase (gamma-GT) (particularly notable with alcohol-related liver disease)
  • ↑ MCV
  • ↑ ALT + AST
  • AST:ALT above 1.5 → suggests alcohol-related liver disease
    * ↑ GGT → alcohol-related liver disease
32
Q

What is the time course for alcohol withdrawal?

A
  • 6-12 hours: tremor, sweating, headache, craving and anxiety
  • 12-24 hours: hallucinations
  • 24-48 hours: seizures
  • 24-72 hours: delirium tremens
33
Q

What is the medical emergency associated with alcohol withdrawal?

A

Delirium tremens
Untreated → mortality rate is 35%

34
Q

Why does delirium tremens occur?

A
  • Long-term alcohol use = results in the GABA system becoming down-regulated → the glutamate system becomes up-regulated to balance the effects of alcohol
  • Alcohol removed → the GABA system = under-functions + glutamate system over-functions
  • Causes extreme excitability + excessive adrenergic (adrenaline-related) activity
35
Q

How does delirium tremens present?

A

starts after 2d and can last up to 14d. It consists of:

Impaired mental status:
* Profound confusion
* Visual, auditory, tactile hallucinations (often insects under skin)
* Delusions
* Psychomotor agitation

Autonomic instability:
* Tachycardia + hypertension + arrhythmias
* Tachypnoea
* Hyperthermia
* Anxiety

Neurological impairment:
* Tonic-clonic seizures
* Coarse tremor
* Hyperreflexia
* Ataxia (difficulties with coordinated movements)

36
Q

What tool can be used to score a patient on their withdrawal symptoms from alcohol and guide their treatment?

A

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised)

36
Q

What benzodiazepine is used to combat the effects of alcohol withdrawal?

A
  • Chlordiazepoxide (Librium)
  • Diazepam = less commonly used alternative
  • Orally given

Given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g., 10 – 40 mg every 1 – 4 hours). The dose is reduced over 5-7 days.

37
Q

Apart from benzodiazepines (chlordiazepoxide) what are the other medications used in alcohol withdrawal?

A
  • High-dose B vitamins (Pabrinex) (IV and IM)
  • Long term thiamine (oral) → prevent Wernicke-Korsakoff syndrome
38
Q

What are the 3 medications given for acute alcohol withdrawal?

A
  • Benzodiazepine (chlorodiazepoxide (Librium))
  • High-dose B vitamins (Pabrinex)
  • Long-term oral thiamine
39
Q

What are long-term management options are available for alcohol withdrawal?

A
  • Specialist alcohol service involvement
  • Alcohol detoxification programme
  • Oral thiamine to prevent Wernicke-Korsakoff syndrome
  • Psychological therapy (e.g., cognitive behavioural therapy)
  • Acamprosate, naltrexone or disulfiram are medications used to help maintain abstinence
  • Informing the DVLA (their driving licence will be revoked until an extended period of abstinence)
40
Q

What medications can be used to help maintain abstinence?

A
  • Naltrexone
  • Disulfiram
  • Acamprosate
41
Q

What deficiency does alcohol excess lead to?

A

Thiamine (vitamin B1) deficiency

  • Thiamine = poorly absorbed in the presence of alcohol.
  • Alcoholics = often have poor diets + get many of their calories from alcohol
42
Q

What can thiamine (vitamin B1) deficiency lead to?

A
  • Wernicke’s encephalopathy
  • Korsakoff syndrome
43
Q

Features of Wernicke’s encephalopathy

A
  • Confusion
  • Oculomotor disturbances (disturbances of eye movements)
  • Ataxia (difficulties with coordinated movements)
44
Q

Features od Korsakoff syndrome

  • Wernicke’s encephalopathy → wobbly
  • Korsakoff syndrome → kaught up in mind
A
  • Memory impairment (retrograde + anterograde)
  • Behavioural changes

  • Wernicke’s encephalopathy → wobbly
  • Korsakoff syndrome → kaught up in mind
45
Q

Why is Wernicke’s encephalopathy and Korsakoff syndrome so important to prevent and involve thiamine supplementation from abstaining from alcohol?

A
  • Wernicke’s encephalopathy = medical emergency w/ a high mortality rate
  • Korsakoff syndrome = often irreversible + results in patients requiring full-time institutional care
46
Q
A

3a Psychiatry (9 decks)

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