Addictions/Alcohol & substance misuse Flashcards
What is the epidemiology of alcohol?
- 57% of adults had a drink in the last week
- Higher income earners have higher prevalences of drinking
- Most alcohol is given by parents and then by friends (kids)
- 2.1% all hospital admissions due to alcohol
- 33% A&E admissions are due to alcohol
- Majority hospital admissions due to alcohol are mainly male and in the middle age 45-64
- Highest link to cardiovascular disease(1), cancer(2), diseases of the nervous system (3), unintentional injuries (4) (ALL PARTIALLY ATTRIBUTE)
- WHOLY ATTRIBUTE → mental and behavioural disorders due to alcohol use (1), alcoholic liver disease (2), toxic effect of alcohol (3)
- Alcohol related deaths higher in males
What is the aetiology of alcohol disorders?
- Individual factors
- Genetic
- Close family 4x higher risk, Adoptees have risk of alcoholism as biological family
- Learning Factors
- Personality Factors
- Risk taking / Novelty seeking / Antisocial
- Psychiatric disorder
- For example, anxiety / Depression
- Genetic
- Social or environmental factors
- Availability
- Peer pressure
- Social environment (higher association with deprived areas)and social network
- Societal influences
Excessive consumption is more common in…
Excess consumption more prevalent in
–Males (3x)
–Under 45’s
–White vs other races
–Chefs, barmen (easy access)
–Executives / Salesmen
–Entertainers, seamen, journalists
–Doctors
What physical harm does alcohol misuse have?
- Accident & injury
- Acute alcohol poisoning
- Aspiration pneumonia
- Mallory Weiss Syndrome
- Oesophagitis
- Gastritis
- Pancreatitis
- Malabsorption + refeeding
- Hypertension
- Cardiomyopathy
- Strokes
- Seizures and DTs
- Liver damage
- Brain damage
- Peripheral neuropathy
- Myopathy
- Osteoporosis
- Skin disorders
- Malignancies
- Sexual dysfunction
- Infertility
- Foetal damage
What psychological harm can alcohol misuse have?
- Insomnia
- Depression
- Suicide
- Attempted suicide
- Anxiety states
- Personality changes
- Psychotic illness
- AmnesiaoAlcoholic hallucinosis
- Morbid jealousy
- Delirium tremens
What social harm does alcohol misuse have?
- Relationships
- domestic violence, divorce, child neglect & abuse
- Work
- unemployment, absenteeism, under-performance
- Criminal behavior
- drunkenness, drunk & disorderly, drink driving, criminal damage, theft, burglary, violence
- Social disintegration
- financial difficulties, homelessness, vagrancy
How do people present with alcohol use disorder?
- Intoxication
- A transient condition following the administration of alcohol resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psycho-physiological functions and responses
- Harmful use
- A pattern of alcohol use that is causing (actual) damage to physical or mental health. Excludes simple hangovers
- Dependence
What is alcohol dependence?
Alcohol Dependence (ICD-11)
>=2 of…
-
Control (Powerlessness)
- … over onset, intensity, duration, termination, frequency, context
-
Priority
- … over other aspects of health “despite harm or negative consequences”
- bio-psycho-social
-
Physiological
- … tolerance, withdrawal, use to prevent/alleviate withdrawal
- Time course: >12 months (or 3 months if continuous)
Alcohol dependance has gone down over time
What are the symptoms of alcohol withdrawal?
- Withdrawal
- Symptoms occurring on absolute or relative withdrawal of alcohol after repeated / high dose use. Occur within 12 hours of the last drink.
- Delirium Tremens
- Toxic confusional state due to severe alcohol withdrawal. Characterised by cognitive impairment, disorientation, agitation, fluctuating levels of confusion and sometimes psychotic symptoms.
- Wernicke- Korsakoff’s syndrome; spectrum of disease resulting from thiamine deficiency consisting of
- Wernicke’s encephalopathy; neurological sx (classic triad of confusion, ataxia and Opthalmoplegia rarely present)
- Korsakoff’s syndrome; late manifestation where WE has progressed
- Marked deficits in anterograde memory, apathy, confabulation, relative preservation of other intellectual abilities
Recognition and assessment of alcohol misuse?
- Any risk factors, harms, presentations as per previous slides
-
General
- Do they drink, what do they drink, how much, how often, any drink free days, previous support, screen for harmful use / dependence, mental health illnesses and associated harms
-
CAGE:
- Have you ever felt you ought to cut down on your drinking?
- Have people annoyed you by criticising your drinking?
- Have you ever felt guilty about your drinking?
- Have you ever had an ‘eye opener’ drink first thing in the morning to steady your nerves or get rid of a hangover?
- 2 positive answers to identify alcohol misuse
Explain the amount of units in an alcoholic drink
multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000. For example, to work out the number of units in a pint (568ml) of strong lager (ABV 5.2%): 5.2 (%) x 568 (ml) ÷ 1,000 = 2.95 units.
Explain the AUDIT screening questionnaire for dependence
How to access severity of dependence?
SADQ
What would you see on a physical exam and bloods of an alcoholic?
-
Physical exam
- Neglect, gynaecomastia, liver disease, ascites, face, neuropathy,
- Mental state and Psychiatric co-morbidities
-
Bloods
- Of note FBC may show increased MCV, LFTs including GGT, USG liver, liver biopsy
What are the risk factors of alcohol withdrawal?
- Risk factors
- Regular use of >8 units of alcohol per day for men, >6 for women
- Previous withdrawal
Explain the management of alcohol withdrawal
CIWA-Ar → clinical institute withdrawal assessment - alcohol reviseed
What is required in low risk alcoholics?
Oral thiamine
What is required in high risk alcoholics?
Pabrinex IM (thiamine) for alcohol dependent patients
- In severe liver disease lorazepam should be used as an alternative - contact pharmacy for advice
- For withdrawal seizures/status epilepticus use rectal diazepam 10mg, repeated after 15 mins as necessary OR buccal midazolam 10mg, repeated after 10 mins if required
What is delirium tremens?
- Onset 2-5 days, duration 12 days
- Severe AWS and altered consciousness
- Marked over arousal
- Hallucinations, delusions
- 10% Mortality
- Oral lorazepam first line, can use haloperidol as well. IM if refusing PO.
- If develops during detox review regime
What is Wernicke’s encephalopathy?
Wernicke’s encephalopathy
Pabrinex
- often classic triad is rarely seen
- Initially reversible, untreated 20% mortality
- If no symptoms but high risk give Pabrinex
- Presume WE if any of the following present
- Ataxia
- Hypothermia and hypotension
- Confusion (only sign in majority of patients)
- Opthalamoplegia, nystagmus
- Memory disturbance
- Unconscious
Long term management in alcohol misuse
-
Psychosocial
- Engagement and building up rapport essential
- Psychosocial interventions underpin all management of AUD, exclusively so at increased risk drinking levels
- From advice, information leaflets, self monitoring of alcohol intake to more intense interventions
- NICE recommends for higher risk drinkers and mild dependence, psychological interventions such as CBT, motivational interviewing, or other therapies looking at alcohol related cognitions, behaviour, problems and social network be used
- Specialist alcohol services and other support networks such as AA
- Identify and treat co-morbidities such as depression
What are some psychotherapies?
- Brief Interventions
- Motivational Interviewing
- CBT
- Behavioural Therapy Interventions
- Relapse Prevention
- AA: 12 Step Approach
- SMART recovery
FRAMES is a goof acronym
Feedback → risk for alcohol problems
Responsibility → responsible for change
Advice → reduction/explicit direction to change
Menu → variety of strategies for change
Empathy → warm, reflective, empathetic and understanding approach
Self-efficacy → misusing person in making a change
Explain the cycle of change
Explain Controlled drinking
Controlled drinking (better than abstinence as more likely compliance)
- Age <40
- detected early
- no/minimal dependence
- no major medical complications
- no psychiatric co-morbidity
- no impulsivity
- social stability
- good compliance with treatment/agrees with monitoring
- agreement from partner
- patient preference
Explain the biological (medication) treatment of alcohol misuse
- NICE recommends Acamprosate or Naltrexone as first line for relapse prevention for patients with moderate to severe alcohol dependence.
- Generally Acamprosate (anti-craving) has better evidence for maintaining abstinence.
- Naltrexone is better for occasional lapses or preventing a return to heavy drinking
- Disulfiram as a deterrent
- Nalmefene as an option if detox not required
Explain acamprosate and how it works?
- Acamprosate
- Modulatory effects on NMDA and GABA receptors, mechanism not fully understood
- Reduces cravings; NNT 8•GI side-effects most common
- Start as soon as detox finishes
Explain how disulfiram works
- Blocks alcohol dehydrogenase, accumulation leads to flushing, N&V, headache, palpitations if alcohol is consumed
- Dose dependant reaction – can lead to death if a large amount of alcohol is used
What are the physical, psychological, social harms of drugs?
Physical
HIV / Hepatitis B&C / Endocarditis / Thrombosis / OD
Foetal Abnormalities / Accidents / RTAs
Psychological
Exacerbation of underlying disorders
Mood Disorders / Psychosis / Personality change
Social
Poverty / Unemployment / Homelessness
Prostitution / Child neglect
Sickness absence / Healthcare expenditure
Crime (Victim and Perpetrator)
Drug link to mental health treatment
The majority of people consuming drugs have a mental health need
What is the aetiology behind drug misuse?
- Availability of Drugs
- Vulnerable Personality
- Poor school record / truancy / delinquency
- Sensation seeking / impulsive
- Adverse Social Environment
- Peer pressure / peer drug use / social deprivation / unemployment / homelessness
- Pharmacological factors
- Drug acts as positive re-inforcer ? Via dopamine ‘reward’ systems
- Physiological Dependence – tolerance / withdrawal syndrome
- Non physiological Dependence – psychological / social stimuli
Explain cannabis (symptoms, withdrawal, long term, management)
- Most common drug used in the last year
- 7.8% of 16-59 year olds have used cannabis in the last year (2.6m people)
- Usually smoked
- Psychoactive effects from THC acting on central cannabinoid receptors
- Intoxication
- Euphoria, perceptual changes, impaired motor skills, dry mouth, tachycardia, increased appetite, sedation
- Withdrawal
- Irritability, insomnia, nausea
- Longer term
- Apathy, amotivational state, increases risk of schizophrenia and psychosis up to 4 fold for heavy users, strong dose dependent effect on risk
- Management: Psychosocial interventions
Explain heroin (symptoms, withdrawal, long term, management)
- Most commonly abused opiate
- 4-5x stronger than oral morphine
- Smoked, snorted or injected
- Half life <3 minutes
- Intoxication
- Euphoria, followed by dysphoria, drowsiness, slurred speech
- Withdrawal
- 6-8 hours after last dose, peaks in 2 days, reduces over 1 week
- Dysphoric mood, N&V, muscle aches, diarrhoea, yawning, fever, insomnia, pupil dilation, sweating
- Risks include accidental overdose, respiratory depression and death
Management of heroin dependence & overdose
- In addition to Psychosocial interventions including specialist addiction services and self-help (NA, AA, SMART recovery groups)
- Overdose: Naloxone
- Withdrawal (Detox): Methadone or Buprenorphine first line
- Methadone (full agonist): daily dosing, better if chronic pain syndrome, better if long period of withdrawal expected
- Buprenorphine (partial agonist): Better for short term treatment of withdrawals, lower severity of withdrawal symptoms vs Clonidine
- Clonidine or Lofexidine: avoid if CVS concerns, if short duration of treatment needed then preferable to methadone
- Symptomatic treatment: anti-emetics, hypnotics, antidepressants
Explain how to prevent heroin relapse
- Relapse prevention
- If unwilling or multiple failed attempts at abstinence, then following can be used
- Methadone or Buprenorphine
- ‘Clearer head’ with Buprenorphine, it also acts to block effects of heroin so an option if there is topping up of heroin on top of methadone
- People may also struggle with s/e of Methadone such as nausea, constipation, drowsiness)
- Suboxone: Combination of Buprenorphine and Naloxone
- Naltrexone: long acting oral antagonist – blocks effects of Heroin
Methadone
- Daily pick up
- Supervised consumption: 3-6 months
- Regular and Spot urine testing
Harm reduction
- advice of ‘safest’ ways to use
- needle and syringe exchange,
- safe disposal of equipment,
- advice and treatment for vaccinations, blood borne viruses etc.
Rehabilitation and aftercare
How does smoking crack cocaine work compared to IV?
- Smoking crack cocaine acts as rapidly as IV
- 2nd most commonly used drug
Explain the intoxication symptoms that cocaine can cause
- Intoxication
- Euphoria, increased energy, Confidence and self esteem, irritability, Impulsiveness, impaired judgement, aggression, formication
- Can cause mania and psychosis
Explain the withdrawal symptoms cocaine can cause
- Withdrawal
- Can be rapid in onset. End within 18 hours, heavy use can last up to a week, peaking after 3 days
- Dysphoria, anxiety, irritability, hypersomnolence
What are the risks of cocaine use?
- Risks
- Nasal perforation, cerebral infarctions, intracranial haemorrhage, TIA, seizures (3-8% of A&E visits), MI, arrhythmia, death
What is the management of cocaine use?
Psychosocial interventions
How to manage stimulant dependence?
- Mainly Psychological Treatment (CBT)
- ?Benzodiazepines- short course
- Antidepressants
- Anti-craving agents and Dopamine agonists don’t have a role
- Dexamphetamine (substitution in amphetamine dependence)
How to manage benzodiazepine dependence?
- Mainly psychological
- If prescribed rarely over 40mg and reducing regime
- Risk of seizures on withdrawal from >40mg/d
