Addiction Psychiatry 1.3 Flashcards
1
Q
What was project MATCH?
A
Multisite (9) USA based RCT of 1726 patients testing the hypothesis that matching patient characteristics to specific treatments would improve alcohol dependence.
2
Q
What did project MATCH find?
A
Patients with low support for drinking derived more benefit from motivational enhancement therapy.
Readiness to change and self-efficacy were the strongest predictors of long-term drinking outcomes.
3
Q
What was the UKATT?
A
Multicentre (7) pragmatic effectiveness RCT of 742 patients comparing MET and Social Behaviour and Network therapy.
4
Q
Results of UKATT
A
No difference in therapies used for alcohol dependence
5
Q
Who did a meta-analysis into therapies for alcohol dependence
A
Slattery et al 2003
6
Q
What do meta analyses of therapies for alcohol dependence show
A
No difference in therapies re efficacy
7
Q
What happens in behavioural self-control training?
A
Placing limits on number of drinks Self-monitoring Using non-alcoholic spacers Using food before/after drink Assertiveness to refuse drink Reward oneself for goals
8
Q
What is the FRAMES approach to alcohol?
A
Feedback of risks Responsibility highlighted Advised to abstain or cut down Menu of alternative options Empathic interviewing Self-efficacy enhanced
9
Q
What is AA an example of
A
Twelve step facilitation programme (TSR)
10
Q
What is the idea behind AA
A
Once someone becomes an alcohol, they remain to be so. This helps by being continuously vigilant and modifying lifestyle accordingly.
11
Q
Twelve steps of AA
A
Accept powerlessness in front of alcoholism Admit only a greater power can help Make a decision to turn to care of god Make a searching and fearless moral inventory Admit wrongs done to others Become ready for removal of defects Ask him to help now Be willing to make amends to all Make direct amends where possible Continue personal inventory Prayer and meditation Practice and preach
12
Q
What model is motivational interviewing based on
A
Transtheoretical model of change
13
Q
Aim of motivational interviewing
A
Help patients explore and resolve their ambivalence about behaviour change
Create dissonance in drinker until they are willing to consider alternatives
14
Q
Principles of motivational interviewing
A
Empathy
Attitude-behaviour discrepancy
Roll with resistance w/o confrontation
Support self-efficacy for change
15
Q
Aim of CBT for relapse prevention
A
Enhance capacity to maintain abstinence
16
Q
Impact of CBT on relapse re alcohol
A
Reduces relapse
Reduces intensity of relapse
17
Q
Describe the minnesota rehab model
A
Use of detox, psychoeducation and AA attendance with 4 weeks stay on the ward followed by aftercare at rehab residences
18
Q
What is a concept house?
A
Works on a therapeutic community model
Slightly confrontational style, firm feedback given, responsibility emphasized.
Residents have a role in running the house.
19
Q
Give an example of a concept house
A
Phoenix house
20
Q
Px of naloxone for opioid OD
A
IV at 0.8mg per 70kg of body weight
21
Q
Harm reduction advice in opioid use
A
Do not use opiates while alone
Not to use in combination with other routes
Avoid IV
Inject in direction of blood flow
Rotate injection sites
Avoid neck, groin
Ensure complete dissolution before injection - else emboli can occur
Use sterile needles and syringes on each occassion
Use sterile water
Avoid lemon juice - can cause candida endophthalmitis
Never share needles
22
Q
Drugs available to treat opioid withdrawal
A
Methadone
Buprenorphine
Alpha 2 agonists
23
Q
How to decide which drug to give for opioid withdrawal
A
Patient choice
Duration of treatment
Adverse effects
Withdrawal severity
24
Q
Which drugs should be used in opioid withdrawal if short duration is desirable
A
Alpha 2 adrenergic agonists
Buprenorphine
25
What is Buspirone not helpful in opioid withdrawal?
Chronic pain syndrome
26
Why does Buspirone not cause withdrawal symptoms on abrupt discontinuation?
Partial agonist
27
When is methadone for opioid withdrawal more effective?
If carried out slowly or with linear dose reduction
28
How long can methadone suppress withdrawal for?
24-36 hours
29
When should alpha 2 agonists be avoided?
Concerns for bradycardia or hypotension
30
What dose of methadone reduces withdrawal sx?
40-60mg/day
31
What might high doses of Buprenorphine produce in a dependent patient?
Withdrawal sx as acts as antagonist at high doses
32
What is methadone effective at?
Reducing heroin use, injecting and sharing equipment
33
At what doses is methadone effective as maintenance treatment?
60-120mg
34
Doses of buprenorphine for maintenance treatment
8-16mg
35
Drugs for relapse prevention with maintenance treatment in opioid misuse
Methadone
Buprenorphine
LAAM
Suboxone
36
What is LAAM?
Long-acting congener of methadone
37
How long does LAAM suppress withdrawal for?
48-72 hours
38
Advantage of LAAM over methadone
Less frequent clinic visits as suppresses withdrawal for longer
39
Why is LAAM no longer used?
Prolonged QT and Torsades de Pointes
40
What does Suboxone contain
Buprenorphine
| Naloxone
41
Advantage of Naloxone in Suboxone?
Deters abuse of tablets by IV injection
42
What does of buspirone and naloxone produces unpleasant withdrawal sx if taken IV?
4:1
43
What is naltrexone used for?
To nullify effects of heroin if relapse occurs
44
How long does naltrexone last for
72 hours
45
Who is Naltrexone suitable for?
Adjuvant therapy
Highly motivated patients
Those who fear consequences if they do not stop opioid use
46
What forms of Naltrexone need to be tested
Implants
| Depot
47
SEs of Naltrexone
```
Insomnia
Dysphoria
Abdominal pain
Nausea/vomiting
Joint and muscle pain
Headaches
```
48
What must services do if an opioid dependent patient requests to become abstinent
Offer detox
Provide information
Offer community based approach
Offer first line treatment
49
What information must services provide to opioid dependent patients wishing to become abstinent?
Withdrawal experience
Management approaches
Loss of opioid tolerance on successful detox and so risk of intoxication rises
50
When should community based detox for opioid use not be ffered
Previous failure of community detox
Significant additional physical/MH problems
Polydrug detox
Considerable social problems
51
What is first line treatment for opioid withdrawal
Buprenorphine
| Methadone
52
When should Lofexidine be considered in opioid withdrawal?
Those with mild or uncertain dependence
53
What must opioid dependent patients be warned about if given Lofexidine?
Need for adjuvant medications to manage nausea, vomiting and shivering
54
What psychosocial interventions should be offered to opioid withdrawal patients?
Self-help groups
Drug misuse services
Contingency management
Urine tests
55
Who with opioid dependence should be offered opportunistic brief interventions?
People with limited contact with services
56
What is contingency management
Incentives e.g. vouchers if clean urine test
57
How often to do urine tests in those who are in opioid withdrawal
Three tests a week for first three weeks
Two tests a week for next three weeks
Once weekly until stability achieved
58
Recommendation for treatment of amphetamine dependence
CBT and Contingency management
59
What pharmacological agents reduce intensity of cocaine withdrawal?
None
60
What is the fish bowl procedure?
Allowing patients to draw a voucher from a bowel after each negative drug test
61
Evidence for contingency management in cocaine use?
Evidence supporting its use
62
What do NICE guidelines recommend contingency management should be used for?
Treatment of primary stimulant misuse and illcit drug use in methadone maintenance treatment
63
Which psychosocial intervention has the most evidence for cocaine users?
Contingency management
64
Problem with contingency management
Reduction or loss of response when reinforcement is stopped
65
Acceptable outcome of smoking cessation in trials?
6 months or longer
66
Relapse rates of smoking after 6 months?
8%
67
How many smokers quit without assistance?
5-10%
68
How long is nicotine replacement therapy (NRT) given for?
2 weeks
69
How many patients are compliant with patch NRT?
82%
70
How many patients are compliant with gum NRT?
38%
71
How many patients are compliant with nasal spray NRT?
15%
72
How many patients are compliant with inhaler NRT?
11%
73
Over how long does the transdermal patch NRT deliver nicotine?
16-24 hours
74
Which NRT method delivers nicotine fastest?
Nasal spray - 5-10 minutes
75
How quickly does nicotine reach blood when NRT gum or inhaler is used?
20 minutes
76
Which NRT method delivers nicotine faster than smoking?
None
77
Drugs used for smoking cessatino
```
NRT
Bupropion
Nortiptyline
Clonidine
Varenicline
```
78
Who is Bupropion not licensed for in smoking cessation?
Adolescents
| Pregnant women
79
Contraindications for Bupropion?
Hx of seizures or ED
80
Dose of starting Bupropion for smoking cessation
150mg OD for six days
| Then increased to 300mg OD
81
By what stage should a smoker on Bupropion stop smoking?
Day 8 of treatment
82
How many weeks of treatment required on Bupropion for smoking cessatino?
8
83
What does NICE recommend if a smokers attempt to quit is unsuccessful?
Do not px NRT or Bupropion within 6 months
84
What was pathological gambling classified as in DSM IV?
Impulse Control disorder
85
Where is pathological gambling in DSM V?
Alongside substance use disorder
86
How many patients with pathological gambling have comorbid substance misuse?
30-50%
87
What is associated with pathological gambling?
Genetic markers influencing dopamine transmission
| Impulsivity
88
What drugs reduce gambling frequency
```
Naltrexone
Fluvoxamine
CItalopram
Sertraline
Lithium
```
89
Who first described internet addiction?
Young - 1998
90
Which classification has internet addiction?
Neither
91
Categories of internet addiction
```
Cybersexual
Syberrelationship
Net compulsion (gambling/shopping)
Information overload
Computer addiction (gaming)
```
92
Which countries is internet addiction more common?
China
Taiwan
Southeast Asia
93
What is oniomania?
Compulsive buying
94
Which classificatinos have compulsive buying?
Neither
95
Definition of compulsive buying
Uncontrollable
Distressing, time-consuming and resulting in family, social, vocational and/or financial difficulties
Not occurring in context of hypomania or mania
96
Prevalence of compulsive buying
2-8%
97
Gender ratio of compulsive buying
>80% are females
98
Medications used for compulsive buying
High-dose citalopram
| Escitalopram
99
Therapies used for compulsive buying
CBT with self-monitoring
100
What is an ergogenic agent?
One used to enhance performance
101
What does ICD 10 classify steroids as?
Non-psychoactive substance
102
Where does ICD 10 classify steroid abuse?
F50.xx - disorders of physiology
103
How many fitness users use anabolic steroids?
13%
104
How are steroids taken?
PO
| IM
105
What do steroids do when misused?
Support frequency and intensity of workouts
Enhance muscle bulk
Enhance strength and endurance
Speed up healing from sports injuries
106
Doses of steroids when misused
10-100 times greater than therapeutic doses
107
Patterns of steroid abuse
Cycling
Stacking
Pyramiding
108
What is cycling abuse of steroids?
Use for 4-12 weeks in cyclical fashion
109
What is stacking misuse of steroids?
Regular use of multiple preparations
110
What is pyramiding abuse of steroids?
Gradually building the dose to a peak and then tapering
111
What are anabolic steroid uses associated with?
```
Aggression
Violence
Psychosis
Mania
Depression
Endocrine abnormalities
```
112
Endocrine abnormalities associated with steroid abuse
Acne - 50%
Testicular atrophy - 33%
Gynaecomastia
113
How many young people in Europe have taken legal highs in the past year?
5-10%
114
How much is the cost to test the harm of a psychoactive substance?
£1 million
115
How long does it take to test the harm of a psychoactive substance?
1 year
116
How do stimulant legal highs work?
Act via monoamine reuptake transporter - SERT, DAT or NAT blockade
117
Primary stimulant legal high
Mephedrone (meow moew)
118
Other stimulant legal highs
```
Benzylpiperazine
Naphyrone
NBOMe-series 2C-series
Benzo fury
Ivory Wave
```
119
Desired effects of stimulant legal highs
Euphoria
| Disinhibition
120
Adverse effects of stimulant legal highs
```
Serotonin syndrome
Psychosis
Mania
Hyperthermia
Cardiovascular sx
```
121
How do psychedelic-like legal highs work
Act via 5HT1A, 2A and 2C receptors
122
Name some psychedelic legal highs
```
DMT
Bromo DragonFLY
5-MeO-DAlt
NBOMe-series
2C series
Salvia
```
123
Desired effects of psychedelic legal highs
Perceptual alterations
| Feelings of being boundless
124
Name some cannabis-like legal highs
JWH-018, 081, 122
AM-2201
UR-144
XLR-11
125
Desired efefcts of cannabis legal highs
Relaxation
Pain and anxiety reduction
Sedation
Euphoria
126
Adverse effects of cannabis legal highs
Paranoia
Psychosis
Anxiety
Seizures
127
Name some benzomimetic legal highs
Pyrazolam
Flubromazepam
Phenazepam
128
Desired effects of benzomimetic legal highs
Relaxation
Anxiety reduction
Sedation
129
Adverse effects of benzomimetic legal highs
Respiratory depression
| Withdrawal seizures
130
How do dissociative anaesthetic legal highs work?
NMDA antagonism
131
Name some dissociative anaesthetic legal highs
```
Mexxy
MXE
Diphenidine
3 or 4-MeO-PCP
N-EK
2-MK
```
132
Desired effects of dissociative anaesthetic legal highs
Dissociative state
Pain reduction
Weightlessness
133
Adverse effects of dissociative anaesthetic legal highs
Headache
Psychosis
GI sx
Cognitive impairment
134
What is the commonest non-genetic cause of learning disability?
Fetal alcohol syndrome
135
Sx in fetal alcohol syndrome
Intellectual impairment
Dysmorphic facial features
Disruptive behaviour
136
Guidelines for alcohol use in pregnant women
None
| Maximum one a day
137
Treatment of alcohol use in preganncy
Psychosocial interventinos
138
Medication use for alcohol use in pregnancy
Avoid
139
Risk to the baby in opioid use in pregnancy
Injections: infection, drug-induced stillbirth, premature birth, antenatal complications,
Low birth weight
Microcephaly
Neonatal withdrawal
140
Mean reduction of baby in patients who use heroin during pregnancy
500grams
141
Principles of managing pregnant opioid user
```
Therapeutic alliance
Reduce risk taking behaviours
Stabilise on non-injectable alternatives
Close liaison with obstetric, midwifery and paediatric teams
HIV and hepatitis screening
```
142
When should detox for opioid use be used in pregnant women?
Middle trimester
If done in first trimester - abortion risk
Laster trimester - possible premature birth
143
Initial aim of treating pregnant opioid user
Stabilise on oral substitute
144
What needs to be done if a woman starts pregnancy while on methadone
Reduce 1mg every 3 days
| Fetal monitoring
145
What dose of methadone is advocated during maintenance while pregnant
15mg
146
How much more likely is methadone to induce neonatal withdrawal than heroin?
60-80%
147
Impact of cocaine use in pregnancy on the baby?
Small for gestational age
| Microcephalu
148
Impact of cannabis use during pregnancy on the baby
Affects neurodevelopment
| 2 fold risk of low birth weight
149
Mean weight reduction in babes of mothers who used cannabis during pregnancy
275grams
150
When is alcohol withdrawal seen in neonates
3-12 hours of delivery
151
Signs of alcohol withdrawal in the neonate
```
Hyperactivity
Poor sucking
Tremors
Seizures
Hyperphagia
Poor sleeping pattern
Diaphoresis
```
152
Signs of barbituate withdrawal in the neonate
```
Severe tremors
Hyperacusis
Excessive crying
Vasomotor instability
Diarrhoea
Increased tone
Hyperphagia
Vomiting
Disturbed sleep
```
153
Signs of marijuana withdrawal in neonates
Fine tremors
Hyperacusis
Prominent Monro reflex
154
Signs of nicotine withdrawal in the neonate
Fine tremors
Variations in tone
Poor self-regulation
155
When does opiate withdrawal begin in the neonate?
24-48 hours after birth
156
When do signs of opiate withdrawal show in the neonate?
3-4 days after birth
157
Signs of opiate withdrawal in the neonate
```
Hyperirritability
GI dysfunction
Respiratory dystress
High-pitched cry
Jittery movements
Increased muscle tone
```
158
When do methadone withdrawal sx begin in neonates?
48-72 hours
| May not start until 3 weeks
159
Signs shown in neonates when antidepressants are used in pregnant mothers
Jittery
| Respiratory distress
160
What type of antidepressants lead to signs in the neonate?
Short-acting SSRIs like Paroxetine
