Addiction Flashcards
According to the ICD 10 to have a dependance on something you need….
3 or more in that last year Strong desire to take substance Difficulties in controlling substance use Physiological withdrawal state Tolerance Neglect alternative pleasure Persistence despite evidence of harm
What is the ICD-11 definition of a Gaming Disorder?
Impaired control over gaming
Increased priority over other activities
Disregard of negative consequences
Significant impairment to function
CAGE - addiction
Cut down - felt need to cut down
Annoyed - at people criticising levels of usage
Guilty - about amount spent
Eye opener - first thing you do in the morning
What is Incentive Salience?
Cognitive attributing want to a substance
What pathway drives the Incentive Salience?
Mesolimbic pathway
Dopamine is a motivating and incentivising neurotransmitter
What do all addictive drugs act upon?
Dopaminergic activity
How does a craving develop?
Chronic overexposure to dopamine - reduced D2 receptor expression
Tolerance builds up as more and more dopamine needed to evoke same response.
Why do addicts usually find normality dull and unfulfilling?
Normal stimuli don’t trigger enough dopamine to be released.
What type of reinforcement is an acute addiction and why?
Positive reinforcement - to reach a high
What type of reinforcement is a chronic addiction and why?
Negative reinforcement - to prevent the negative affects of withdrawal - protective
How does the prefrontal cortex affect addiction?
Modulates the affects of reward pathway as ability to override mesolimbic pathway and resist the cravings.
Sets goals and focuses attention
What can be a predisposing factor to acquiring an addiction?
Underactivity or dysfunction of the prefrontal cortex
Unable to consciously override urges
Why does early age drug experimentation have an impact on addiction?
Due to the plasticity of the prefrontal cortex long exposure can lead to alterations to promote such urges
What is the function of the hippocampus and amygdala?
Consolidation and acquisition of memories and learning
How can the hippocampus and the amygdala have an affect on addiction?
Expression of drug stimulus learning, as a result learned associations can trigger urges.
What is the function of the Orbitofrontal cortex?
Collates stimuli and attaches importance to them
Key creator of motivation to act
How are addicts Orbitofrontal cortex wired?
Show increased activity when exposed to drug cues
What gene is linked to higher risk activities to gain a high?
Low DRD2 receptor expression
What is the affect of Acute stress on dopamine?
Dopamine release in neural reward pathway
What is the affect of Chronic stress on dopamine?
Dampening of dopaminergic pathways
Reduced reaction to normal - encourages to seek highly rewarding often dangerous behaviour.
AUDIT - what is it?
Quantifies level of hazardous drinking
Less sensitive to harmful drinking and dependance
What is hazardous drinking?
Pattern of consumption that increases their risk of physical mental and social consequences.
How many units would be classed as Hazardous drinking?
Between 14-35 units per week
Equation for Units
Units = (Strength ABV x volume (ml)) / 1000
What cancers have an increased incidence in those who drink over 14 units a week?
Mouth Upper throat Larynx oesophagus Breast Liver Bowel
What is the most important question in the Fast Alcohol Screening done in A and E?
How often have you had 6 units (Female) 8 units (Male) or more units on a single occasion in the past year?
If somoene has an audit score over 5 what do they require?
A brief intervetion
What is a Brief Intervention?
5- 15 minutes FRAMES Feedback review problems due to alcohol Responsibility is down to patients Advice factual is best Menu provide options for change Empathy Self Efficacy encourage optimism
Alcohol dependance syndrome
3 or more of the following Strong desire or compulsion Difficulty in controlling - onset termination or level of use Physiological withdrawal star Evidence of tolerance Progressive neglect Persistence despite evidence of harm
What is alcohols affect on the CNS?
Suppression by acting on GABA A receptors
Why do you get withdrawal symptoms from alcohol?
Due to over activation of GABA receptors -brain unregulated Glutamate activity and down regulates expression of GABA receptors.
Withdrawal leads to massive imbalance - excessive glutamate is toxic to nerves - unregulated glutamate excitation.
Describe alcohol withdrawal syndromes course.
First symptoms generally occur within hours the peak is between 24-48 hours.
Generally resolved between 5-7 days
What are the common symptoms of Alcohol withdrawal syndrome?
Restlessness Tremor Sweating Anxiety N+V Loss of appetite Insomnia
What are some of the more serious symptoms of Alcohol withdrawal syndrome?
Tachychardia
Systolic Hypertension
generalised seizures - <24hrs
What is a medical emergency in regards to alcohol withdrawal?
Delirium tremens
When and what proportion of withdrawals result in delirium tremens?
2 days post abstinences
5% of cases
Describe delirium tremens
Often insidious onset - night time confusion
Confusion , disorientation, agitation, hypertensive, fever, visual auditory hallucinations , paranoid ideations.
What is the mortality rate of delirium tremens?
2-5% - with medical intervention much higher without
What is it that kills you in Delirium Tremens?
Cardiovascular Collapse and infection
What should you never advice a dependant drinker to do?
Go cold turkey without support or observation
How do you manage a withdrawal?
General support advice and reassurance
BDZ - titrate against severity reduce over 7 days
Vitamin supplementation
What BDZ are used in alcohol withdrawal ?
Diazepam
Chlordiazepoxide
What vitamin is especially important in alcohol withdrawal management?
Thiamine prophylaxis to prevent Wernickes Encephalopathy
When should an inpatient detox be undertaken?
Severe dependance AUDIT >30 or 30 units
History of seizures or Delirium Tremens
Cognitive impairment or poor physical health
Poor social support
When should specialist services be involved?
Moderate to Severe dependance
Failed to benefit from brief or extended interventions
What can be provided in inpatient detox that improve chances of going clean?
Adequate hydration
Analgaesia
Antiemetic
Treat infections and other physical conditions that might be driving them towards substance abuse
What are some effective psychosocial therapies for relapse prevention?
CBT
motivational enhancement therapy
behavioural self control training
12 step facilitation therapy e.i AA
When are BDZ used in alcohol dependance?
Only used acutely
MOA of Disulfiram
Inhibits Acetaldehyde Dehydrogenase
Accumulation of acetaldehyde if ingested leads to unpleasant side effects
What does a patient on Disulfiram experience if they ingest alcohol?
Flushed skin Tachycardia N+V Arrhythmias Hypotension
What medication can be used to prevent alcohol relapse?
Naltroxene - 1st line
Acamprosate
Disulfiram
What is an issue with Disulfiram?
Efficacy is entirely dependance on compliance
Making someone take a drug that makes them feel horrendous in difficult
Acamprosate MOA
Acts on glutamate and GABA
Reduces cravings needs to be started ASAP
Used alongside psychosocial interventiona
Acamprosate sideffects
Headaches Diarrhoea Nausea
Naltrexone
Opiod antagonist reduces reward gained from alcohol
What are some natural Opiates?
Morphine
Codeine
What are some semi-synthetic opiates?
Hydrocodone
Hydromorphone
What are some fully synthetic opiates?
Methadone
Tramadol
How do opiates work?
Induce dopamine release into the mesolimbic pathway.
What is the definition of opioid replacement therapy?
Deliberate introduction of prescribed drugs in a controlled manner.
What are the stages of opioid replacement therapy?
Induction
Optimization
Maintenance
Reduction
What is optimisation?
Completely eliminating illicit drug use
What medication can be used in opioid replacement therapy?
Methadone
Buprenophine
What is Methadone?
A Mu receptor agonist
Long half life peak plasma at 4 hrs
Describe the course of Methadone.
1x daily
Steady state is achieved by day 5
What dosage of methadone is given?
Start at 30ml and titrate up
60-100ml is normal effective dose
What metabolism does methadone undergo?
CY3P4 in liver
When is Methadone contraindicated?
Prolongs QT
Anyone with a cardiac history or in combination with others drugs which prolong QT
What risks are associated with methadone?
Sedative
Diversion- sell their methadone onto others
What is Buprenophine?
Mu partial agonist
Low intrinsic activity but high affinity for receptor
When are peak plasma levels of buprenophine reached?
1.5-2.5 hours
What is the effective dosage of Buprenophine?
12-24mg
How is Buprenophine delivered and what could the possible benefits of this be?
Sublingually
Pharmacist is able to observe it being taken
What models of addiction are there?
Moral Dispositional Personality Biological Behavioural Cognitive
Moral model of addiction.
Wilful violation of societal rules due to human weakness
Individual is primary causative factor
According to the moral model how is someone treated for addiction?
Moral persuasion
Imprisonment
Spiritual guidance
Dispositional disease model of addiction.
Primary cause is the individual
According to the dispositional model how is someone treated for addiction?
Addiction is irreversible only total abstinence is the cure.
Personality model
Abnormal individual with poor impulse control and unable to deal with stress and low self esteem
Biological medical model.
Emphasis on genetic and physiological process - individual is still the cause.
What region of the brain is associated with binge or intoxication?
Ventral striatum
What region of the brain is associated with withdrawal ?
Amgydala
What region of the brain is associated with preoccupation anticipation?
Cortex
Hippocampus
Cingulate gyrus
What is the basis behind the behaviour model?
Addiction is the result of well rehearsed over learned repertoires.
Actions are influenced by the associations we make between our behaviour and environment.
What two doctrines define the behavioural model?
Pavlovs Associative learning
Operant (instrumental) conditioning
Pavlovs Associative learning
Through repeated pairing a previously neutral stimuli will come too illicit a response.
Give an example of pavlovs associative learning.
Sensory stimuli e.g. clinking of glasses results in cravings
Operant (Instrumental) Learning
Learning by connecting the consequences of an action with the preceding behaviour.
e.g entering pub = good time
Operant (Instrumental) Learning - Positive
Applies the stimuli
Operant Instrumental Learning - Negative
Removes the stimuli
Operant Instrumental Learning - Reinforces
Increases the frequency of the behaviour
Operant Instrumental Learning - Punishment
Decreases the frequency of the behaviour
What is an example of positive reinforcement?
You are more relaxed after use
What is an example of negative reinforcement?
Removes the withdrawal symptoms
What is an example of Positive Punishment?
Shouted at by partner for using
What is an example of negative punishment?
Losing family and home for using
What is habit formation?
Acquired behaviour due to repetition of action until involuntary
Cognitive theory
Addiction recruits and influences through
Attention bias Memory bias
Selective recall and implicit bias
How can cognitive processing help addiction?
Slow down to prevent autonomic responses which allow biases to creep in.
What are some common thinking errors?
Its just a treat - permission giving Its only one - Minimisation She made me angry I had to - Blaming I can use and stay in control - Denial Ive been good all week - Rationalisation
What is the best treatment for addiction?
Biopsychosocial - Medication + psychology + social work
