Addiction And Substance Use Disorders Flashcards
Definitions in substance
Compulsion to take substance
Continuing escalation of amount used
Withdrawal syndrome following cessation or reduction
Developing tolerance
Neglect of other activities in favour of substance use
Persistent use despite evidence
Loss of self control
Rapid re-in statement of previous pattern after abstinence
Substance misuse definition
Using non therapeutic dose of drugs in a manner potentially harmful but not meeting criteria for dependence
DSM4
Hazardous substance misuse
Substance use disorder spectrum of mild moderate and severe
ICD-10
Harmful substance use
Hazardous drinking
More than weekly limit (14 units for both men and women) but without obvious harm
Harmful drinking
More than weekly limit with clear evidence of alcohol related problems – e.g. Accidents, Pancreatitis, Gastritis
Risk factors and aetiology
Neurobiology with dopamine theory of addiction
Vulnerability and genes
Persnaolity traits: impulsivity, risk taking
Environmental influences
Neurobiology the dopamine theory of addiction
Dopamine reinforcement pathway
VTA
Ventral striatum
Nucleus accumbens
Prefrontal cortex
Brain endogenous opioid system
Repeated drug use leads to pathways of reward drive and memory become over established
Tolerance as a neuroadaptive response
Environmental influences
Deprivation
Abuse
Cultural acceptance
Role modelling
Behavioural and psychological factors
Operant conditioning
Operant conditioning
Reinforcement of positive stimuli – Drug stimulates neural reward mechanisms (e.g. Dopamine / Endorphins) which promotes repetition of drug using behaviours. (positive reinforcement)
Removal of aversive stimuli such as craving and withdrawal
symptoms by using the substance again (negative reinforcement)
Different substances
Alcohol
•Opioids
•Cannabinoids
•Hypnotics / Tranquilizers
•Cocaine
•Other stimulants – e.g. Amphetamine, Methamphetamine
•Hallucinogens
•Tobacco
•Volatile solvents
•Others (include Caffeine, Anabolic Steroids and some OTC medicines)
What are the UK legal categories
A
B
C
Based on harm
Class A drugs
Ecstasy, LSD, heroin, cocaine, crack, magic mushrooms, amphetamines (if prepared for injection). Possession - Up to 7 years in prison, an unlimited fine or both. Production / Supply - Up to life in prison, an unlimited fine or both
Class B drugs
Amphetamines, Cannabis, Methylphenidate
(Ritalin), MKAT, Ketamine. Possession - Up to 5 years in prison, an unlimited fine or both. Production / Supply - Up to 14 years in prison, an unlimited fine or both
Class C drugs
Tranquilisers, some painkillers, Gamma hydroxybutyrate (GHB) Possession - Up to 2 years in prison, an unlimited fine or both. Production / Supply - Up to 14 years in prison, an unlimited fine or both
Addictive behaviours
Compulsive buying, oniomania
Pathological gambling
Kleptomania
Compulsive eating
Compulsive sexual activity
Internet gaming disorder
Alcohol mechanism of actions
Increases cell wall fluidity and permeability
Enhancement of GABA-A transmission (anxiolitic effect)
Release of dopamine in mesolimbic system (euphoriant effect)
Inhibition of NMDA glutaminergic transmission (amnesic effect)
Acute effects of alcohol
Disinhibition, elevation of mood, increased socialization, disinhibition
•Lability of mood, impaired judgement, aggressiveness, slurred speech, ataxia
Alcohol metabolism
Aetiology of alcohol problems
Genetics
Psychological trauma and abuse
Behaviours modelling and peer influences
Sociocultural deprivation or poor family support and structure
Alcohol medical complications
Acute toxicity: unconscious coma and death
Chronic medical conditions: alcoholic liver disease, alcoholic hepatitis, cirrhosis, fatty change
Gastrointestinal: gastritis, metaplasia, Mallory-Weiss, pancreatitis
Cancers
Cardiovascular, high bp, cardiomyopathy and atrial fibrillation
Respiratory
Neurological medical complications of alcohol
Wernicke-Korsakoff syndrome
•Peripheral neuropathy
•Central pontine myelinolysis
•Corpus callosum degeneration
•Cerebellar degeneration
•Optic atrophy
•Alcoholic myopathy
Genitourinary alcohol medical complications
Erectile problems
Hypogonadism
Other medical complications
Haematology
Impaired absorption of vitamins and food
Gout
Foetal alcohol syndrome
Foetal alcohol syndrome
Foetal growth restriction
•CNS problems, including cognitive dysfunction and neurological abnormalities
•Cluster of characteristic facial abnormalities
•Failure to thrive
Psychosocial problems from alcohol
Relationships
Financial
Housing
Occupationa
Legal
Relationship problems
Unsafe Promiscuity – Breakdown of long term relationships – Domestic Violence
Financial alcohol problems
Mounting debt
Bankruptcy
Housing alcohol problem.
Re possession
Loss of stable circumstances
Homelessness
Occupational alcohol problems
Job loss
Redundancy
Loss of reputation
Legal alcohol problems
Driving offences
Loss of listened
Public disorder
Assaults violence
Theft or fraud
Psychiatric complications from alcohol
Harmful Use and Dependency
•Withdrawals complicated by seizures and acute
confusional state – Delirium Tremens
•Acute alcohol induced amnesia
•Alcoholic hallucinosis
•Alcohol-induced delusional disorder and pathological jealousy
•Wernicke – Korsakoff syndrome
•Cognitive impairment and dementia
•Development or exacerbation of anxiety/ depressive symptoms, Deliberate Self Harm and Suicide
Assessment of patient with alcohol problems
Lifetime and current pattern/ amount (units)
•Signs of dependence
•Physical/mental health
•Problems related to alcohol
•Previous treatment attempts
•Family hx
•Attitude to referral / motivation / goals
•Physical examination
•Blood testing
Alcohol screening questionnaire
CAGE
AUDIT
Testing alcohol screening
Breath testing
Bloods, all raised;
MCV
GGALT
CDT
Alcohol consumption
Men and women shouldn’t exceed 2-3 units per day on regular basis
>14 is associated with greater risk of harm
How to calculate units
Volume in litres x strength as percentage
Alcohol principles of treatment
Stages of change model (Prochaska and DiClemente) and motivational interviewing
• Establishing Goals : continue current drinking pattern, change to safer pattern (harm reduction), attempt abstinence
•Abstinence vs controlled drinking
•Detoxification
•Maintenance of sobriety / relapse prevention
Alcohol withdrawal symptoms
Onset: 6-24 h after last drink
•Peak: 24-48 h
•Duration 5-7 days
•Sweating, tremor, tachycardia, high BP, anxiety, insomnia
•Seizures – in 2-5% cases
Delirium tremens
Potential life threatening
•Onset 48-72 h
•Duration 3-10 days
•Fever, severe anxiety and agitation, clouding of counsciousness/ delirium, hallucinations (visual, tactile)
•Untreated 15% mortality
Treatment for withdrawals
Vitamin B complex oral or im/iv Pabrinex
•Benzodiazepines in reducing regime over several days: chlordiazepoxide, diazepam, lorazepam
•Fluids and electrolytes
•Antipsychotic meds for agitation/hallucinations
•At home / inpatient elective / hospital
Wernickes encephalopathy, acute neurological complication of withdrawals
- Triad
•Ataxia
•Nystagmus & diplopia
•Confusional state
•Reversible with Tx – Thiamine parenterally (iv)
•Medical emergency – mortality 10-20%
•Can be precipitated by carbohydrate load, vomiting, upper GI disease
Korsakoff syndrome
Sequel of untreated Wernicke’s
•Structural changes in mammilary bodies, hippocampus
•Persisting short-term memory loss, confabulation
Alcohol treatments medication
Acamprosate
•Naltrexone
•Nalmefene
•Disulfiram
Non pharmacological alcohol treatments
Relapse prevention
•Residential rehab programmes
•AA, peer support
•Alcohol treatment orders
Opiates
Papaver Somniferum – Opium Poppy
•Opioid analgesics (e.gs - Codeine, DihydroCodeine, Morphine, Pethidine)
•Heroin = Diamorphine
•Smoking, injecting
•Mu, kappa, delta receptors
Intoxication acute effects of opiates
Drowsiness
•Nausea, vomiting
•Cool moist skin
•Slow deep respiration
•Hypothermia
•Hypotension
•Pin-point pupils
•Coma – death – respiratory depression
Withdrawal symptoms opiates
Rhinorrhoea
•Dilated pupils
•Lacrimation
•Yawning
•Sweating
•Hot and cold flushes
•Piloerection (cold turkey)
•Diarrhoea
•Bone and muscle pain
•Abdominal Cramps
•Nausea / Vomiting
•Insomnia
•Anxiety / Depression
Acute OD treatment opiates
Naloxone 0.4 – 2 mg iv
Treatment principles for opiates
•Advice and information
•Harm reduction
•Needle exchanges
•Community prescribing – Methadone substitution and maintenance or reduction
•Naltrexone / Buprenorphine – “Suboxone”
•Psychosocial treatment: counselling, Structured Day Care, addressing housing / family / other
social problems
•Narcotics Anonymous – 12 Steps Approach
•Detox = medically assisted withdrawal
•Aftercare
•Relapse prevention
•Motivational interviewing (Miller & Rollnick 2002)
•Therapeutic communities and residential rehabilitation
•Drug treatment and testing/rehabilitating orders
How is drug treatment provided
NHS, through GP surgeries, hospitals and specialist clinics
•Voluntary organisations and charities - community and residential settings
•Private sector organisations – e.g. The Priory
•Prisons – provided by a combination of HM Prison Service and various providers
Sedatives examples
Benzodiazepines “benzo’s”, “pills”
•Hypnotics – zolpidem, zopiclone
•Barbiturates
•Cross-tolerance
Intoxication sedatives
Intoxication: euphoria, sedation, paradoxical agitation, nystagmus, ataxia, dysarthria, impaired memory
•Severe intoxication: coma, respiratory depression, hypotension, hypothermia, death
Withdrawals sedatives
Withdrawals: prolonged - worse for short-acting agents
- Similar to alcohol but more persistent
Stimulants general effects and side effects
Increased performance, well- being, excitement, the “rush”, stereotyped behaviour, insomnia, promiscuity, psychosis
•increase in Pulse and BP, dry mouth, urinary retention, Arrhythmias, MIs, CVAs
•Exhaustion, extended sleep, lethargy, depression
Cocaine
Alkaloid – derived from Erythroxylum Coca
•Snorted, smoking, iv
•“Coke”, “Charlie”, “Snow”, “Crack”
•Crack = Cocaine free base, heated in alkaline solution
•”Snowballing” = iv Cocaine + heroin
Intoxication cocaine
Intoxication
•Euphoria
•Increased energy
•Enhanced libido
•Insomnia
•Aggressive behavior
•Psychosis
•Tachycardia
•Hypertension
•Vasoconstriction
•Stroke, MI
Cocaine side effects
The stimulant “crash”
•“Suicide Tuesday”
•Fatigue
•Hypersomnia
•Hyperphagia
•Low mood
•Acute monoamine depletion
Amphetamines
Stimulating the release of norepinephrine and dopamine from nerve endings, also MAO inhibition
•Benzedrine – 1939 – cold remedy
•Amphetamine sulphate -“speed”, “whiz”
•Methamphetamine (“ice”, “crystal meth”) – smoked or injected)
•Dexedrine (Dexamphetamine) for depression and obesity, narcolepsy
•Treatment for obesity – Duramine - “phen-fen” mixture – banned due to cardiotoxicity
•ADHD – Methylphenidate (Ritalin) and Dexamphetamine (Adderall)
•Ecstasy = MDMA – amphetamine like but also has an effect on serotonin
•Cathinone and some of its derivatives : Khat, Methcathinone, Pyrovalerone
•Mephedrone (also known as: 4‐MMC, ‘Meow’, ‘M‐Cat’)
Hallucinogens
LSD – Lysergic Acid
•Synthetics – “Smiles” “N-Bomb”
•Mescaline –Peyote cactus
•Psilocybin -magic mushrooms
•PCP phencyclidine – Angel Dust
•Ketamine
Cannabis
Derived from Cannabis Sativa plant
•Hashish, Resin,Dope, Grass, Weed
•Skunk – more potent version – made from unpollinated plants bred for high THC content - buds / tips
•4Tetra Hydro-Cannabinol (THC) – active constituent
•The most widely used illicit drug
• Smoked via “joint” or Bong
•Synthetic cannabinoids: very potent, toxic, sold in sachets with attractive names / “legal highs” or “NPS” – New Psychoactive Substances
Cannabis intoxication
euphoria, anxiety, distortion of time and space, red conjunctivae, dry mouth, tachycardia
What may early cannabis use predispose
Schizophrenia development
Treatment tobacco
Nicotine replacement therapy
•Varenicycline
•Bupropion
•? Vaping
