Addictive behaviours, substance abuse, substance misuse, Drug overdose, alcoholism and withdrawal Flashcards
ICD-10 criteria for substance abuse
- Acute intoxication: The acute, usually transient, effect of the substance.
- Harmful use: Recurrent misuse associated with physical, psychological and social
consequences, but without dependence.
139 - Dependence syndrome (see Key facts 1): Prolonged, compulsive substance use leading to
addiction, tolerance and the potential for withdrawal syndromes. - Withdrawal state: Physical and/or psychological effects from complete (or partial) cessation
of a substance after prolonged, repeated or high level of use. - Psychotic disorder: Onset of psychotic symptoms within 2 weeks of substance use. Must
persist for more than 48 hours. - Amnesic syndrome: Memory impairment in recent memory (impaired learning of new
material) and ability to recall past experiences. Also defect in recall, clouding of
consciousness and global intellectual decline. - Residual disorder: Specific features (flashbacks, personality disorder, affective disorder,
dementia, persisting cognitive impairment) subsequent to substance misuse.
Aetiology of substance misuse?
Biological: Genetics + Neurochemical (abnormalities in dopamine, GABA and opioid systems)
Environmental: Peer pressure, life stressors, Parental drug use, cultural acceptability, personal vulnerability eg lack of resources to cope with stressors
Pathophysiology of Addictive behaviours
Take substance (Cost, availability, effect of drug, route) > Positive reinforcement ((Psychosocial reinforcement: from peers or pleasurable effects) + Biological reinforcement: activates mesolimbic dopaminergic reward pathways) > Dependance: Positive reinforcement over time, eventually causes dependence
Epidemiology and RFs of Substance abuse?
Substance misuse is more common in ♂ at a ratio of 3:1 (♂:♀).
Cannabis is the most consumed illegal drug, used by 5% of the population
Clinical features of substance abuse?
Clinical features vary depending on the drug consumed. Commonly misused substances are
opioids, cannabinoids, stimulants, sedative-hypnotics, hallucinogens, volatile solvents and
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anabolic steroids.
Complications of substance misuse can be divided in physical, psychological and social
Physical: Death, infection(HIV, hepatitis, SA,TB) endocartitis, DVT, PE
Psychological: Craving, anxiety, cognitive disturbance, drug-induced psychosis
Social: Crime, imprisonment, homelessness, prostitution, relationship problems
History of substance abuse?
‘Have you ever taken any recreational drugs? If so, how often do you take them,
and for how long have you done this?’, ‘How much money do you spend, per week,
on drugs?’ (quantity)
‘What are the effects when you take the drug?’ (drug effects)
‘What impact has the drug had on your life?’ (occupation, relationships, forensic
history)
‘Do you feel that taking the drug is always at the forefront of your mind?’
(preoccupation)
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‘Have you ever tried reducing the substance you’re taking? Any problems with
this?’ (withdrawal)
‘Are you able to control your consumption?’ (control)
‘Do you recently feel that you have to take more of the drug to get the same effect?’
(tolerance)
‘Are you aware of the harmful effects?’ (knowledge of harm)
MSE of substance abuse
Dependent upon the drug consumed and whether patient is acutely intoxicated or
withdrawing.
Investigations of substance abuse
Bloods including: (1) HIV screen, Hep B, Hep C and tuberculosis testing → risk of
blood-borne infections is thought to be greater through needle sharing; (2) U&Es to
check renal function; (3) LFTs and clotting to check hepatic function; (4) Drug
levels.
Urinalysis: drug metabolites (e.g. cannabis, opioids) can be detected in urine.
ECG for arrhythmias, ECHO if endocarditis suspected (secondary to needle
sharing).
DDs of substance abuse
Psychiatric disorders: Psychosis, mood disorders, anxiety disorders, delirium.
Organic disorders: Hyperthyroidism, CVA, intracranial haemorrhage, neurological
disorders (e.g. cerebellar pathology).
Management of substance abuse
A keyworker with a therapeutic alliance is best placed to offer psychosocial support.
Hep B immunization must be considered for those at risk.
Motivational interviewing to help with controlling the substance misuse and CBT (for co-morbid
depression or anxiety) may be offered.
Contingency management is a technique that focuses on changing specified behaviours by
offering incentives (e.g. financial) for positive behaviours such as abstinence.
Supportive help can be in housing, finance and employment. Help with co-existing alcohol
misuse and smoking cessation should be offered.
Self-help groups, e.g. Narcotics Anonymous and Cocaine Anonymous.
Consider the issue of driving and review the DVLA guidelines.
Opioid dependence management
Biological therapies include methadone (first-line) or buprenorphine for detoxification AND
maintenance (see Key facts 3).
Naltrexone is recommended for those who were formerly opioid-dependent but have now
stopped and are motivated to continue abstinence.
Intravenous naloxone (opioid antagonist) can be used as an antidote to opioid overdose.
Detoxification vs maintenance
Detoxification refers to a process in which the effects of the drug are eliminated in a safe manner
(a replacement drug is weaned) such that withdrawal symptoms are avoided, in an attempt to
attain abstinence. In maintenance therapy abstinence is not the priority, rather the aim is to
minimize harm (e.g. from IV drug use).
What is the definition of alcohol abuse
Alcohol abuse is the consumption of alcohol at a level sufficient to cause physical, psychiatric
and/or social harm. Binge drinking is drinking over twice the recommended level of alcohol per day,
in one session (>8 units for ♂ and >6 units for ♀). Harmful alcohol use is defined as drinking above
safe levels with evidence of alcohol-related problems (>50 units/week for ♂ and >35 units/week for
♀).
Pathophysiology/ aetiology of alcohol abuse?
Alcohol affects several neurotransmitter systems in the brain (e.g. its effect on GABA causes
anxiolytic and sedative effects).
The pleasurable and stimulant effects of alcohol are mediated by a dopaminergic pathway in
the brain. Repeated, excessive alcohol ingestion sensitizes this pathway and leads to the
development of dependence.
Long-term exposure to alcohol causes adaptive changes in several neurotransmitter systems,
including down-regulation of inhibitory neuronal GABA receptors and up-regulation of
excitatory glutamate receptors, so when alcohol is withdrawn, it results in central nervous
system hyper-excitability.
Patients with alcohol-use disorders often experience craving (a conscious desire or urge to
drink alcohol). This has been linked to dopaminergic, serotonergic, and opioid systems that
mediate positive reinforcement, and to the GABA, glutamatergic, and noradrenergic systems
that mediate withdrawal.
The social learning theory suggests that drinking behaviour is modelled on imitation of
relatives or friends. Operant conditioning states that positive or negative reinforcement from
the effects of drinking will either perpetuate or deter drinking habits, respectively
Epidemiology of Alcohol abuse
Roughly 25% of ♂ and 15% of ♀ drink over the recommended level in the UK.
Alcohol dependence affects 4% of people between the ages of 16 and 65 in England.
RFs for alcohol abuse
Male: Males are at increased risk of alcohol abuse and have increased metabolism
of alcohol, thus allowing them to have higher quantities.
Younger
adults :16.2% among 18–29 year olds; 9.7% among 30–44 year olds have alcoholrelated disorders.
Genetics: Monozygotic twins have higher concordance rates than dizygotic. Studies show
increased risk of dependence in relatives of those affected.
Antisocial
behaviour:
Pre-morbid antisocial behaviour has been found to predict alcoholism.
Lack of facia lflushing: The risk of alcoholism is ↓ in individuals who show alcohol-induced facial
flushing due to a mutation of gene coding for aldehyde dehydrogenase so that
it metabolizes acetaldehyde more slowly. Commoner in some East Asian
populations.
Life
stressors:
E.g. Financial problems, marital issues and certain occupations can increase
the risk.
