alcohol and addiction Flashcards
what drugs have the worst physical withdrawal problems
opiates barbiturates alchohol benzopdiazepines cocaine
what drugs have the worst psychological withdrawal problems
opiates
crack/ cocaine
cigarettes
amphetamines, barbiturates, benbodiaspeines, alcohol, gambling
what are the 2 different mechanisms of substance abuse
Tolerance (the basis of physical dependence) Reward centre (the basis of psychological craving)
what is tolerance defined as
Reduced responsiveness to a drug caused by previous administration
what drugs does tolerance develop to
opioids, ethanol, barbiturates, benzodiazepines
how does less drug reach the active site in tolerance
¥ decreased rate of absorption
¥ increased rate of metabolism to inactive metabolites (broken down before reaching receptor)
¥ decreased rate of metabolism to active metabolites
¥ increased rate of excretion (liver and kidney)
how is the site of action less affected by the drug in tolerance
¥ down-regulation or internalisation of drug receptors – smaller response
¥ reduced signalling down stream of drug receptors (2nd messengers)
¥ some other compensatory mechanism
why do withdrawal symptoms occur in tolerance
The body becomes dependent to keep in normal state so when these substances are removed, adverse effects are seen
what is the withdrawal phenomena
the withdrawal effect of a drug is usually the reverse of the acute effect
give examples of 3 withdrawal phenomena
opiod - contipation > diarrhoea
barbiturate - anticonvulsant > convulsion
cocaine - elevated mood > depressed mood
what neurones fire dopamine
ventral tegmental area
what feeling does dopamine release cause
a sensation of pleasure/reward
where do neurones from the ventral segmental area project (dopamine)
nucleus accumbens & prefrontal cortex.
what normally activates the reward pathway and why
eating, drinking and sex to encourages those “healthy” behaviours that lead to propagation of your genes
what drugs of abuse tap into reward pathway to increase dopamine levels
heroin
amphetamine
cocaine - inhibits uptake
alcohol - inhibits
why do some people crave things more than others
genetic component to addictive personalities
what is the prison sentence for possession of class A, B and C drugs
A - 10 years
B - 5 years
C - 3 years
name some class A drugs
heroin cocaine strret methadone 4-MTA LSD ecstasy
name some class B drugs
barbiturates
amphetamine
methylphenidate
name some class C drugs
ketamine benzodiazepines buprenorphine cannabis anabloic steeds GHB
what is cocaine extracted from
leaves of coca plant
what is the difference between the associates of crack and cocaine
crack - violence
powder - wealth, sex
what is the difference in effect of cocaine between smoking, injecting and snorting
smoking - immediates
injecting - 15-30s
sporting - 3-5 mins
what are complications of snorting cocoaine
nose bleeds
lose nasal septum
what is the mechanism of cocaine in the body
powerful vasoconstrictor
what are some positive effects of cocaine
Ð stimulant and euphoriant
Ð increased alertness and energy
Ð increased confidence and impaired judgement
Ð lessens appetite and desire for sleep
Ð No cessation – can keep going as long as they can afford
what are some negative effects of cocaine
Ð damage to nose and airways Ð convulsions with respiratory failure Ð cardiac arrhythmia's and MI Ð hypertension and stroke Ð toxic confusion – acute if taken a lot paranoid psychosis
what are some withdrawal effects seen with cocaine
• Depression, Irritability, Agitation • Craving • Hyperphagia – eat too much • Hypersomnia – sleep too much More psychological than physical dependence (due to dopamine)
what are the complications with amphetamine
Toxic confusion occasionally with convulsions and death
Amphetamine psychosis in heavy chronic use
what drug are the effects of amphetamine similar to
cocaine
list some examples of opiates
meorphine
heroin
methadone
codeine + dihydrocodeine
what does opium come from
the dried milky juice of unripe seedpods of the opium poppy (Papavera somniferum).
how is heroin taken
snorting, smoking(chasing the dragon) and injection
Smoking is safest, injecting the most dangerous method of use
what are some drawbacks of opiates
Respiratory depression (<8 breaths/ min)
Cough reflex depression
Sensitisation of the labyrinth with nausea and vomiting
Decreased sympathetic outflow (bradycardia and hypotension)
Lowering of body temperature
Pupillary constriction – pinpoint pupils unreactive to light
Constipation
Respiratory arrest with a pulse (overdose)
Varying degree of reduced consciousness/ coma
what are the benefits of opiates
Analgesia
Drowsiness and sleep
Mood change (euporia, intense pleasure)
A rush
what can be side effects of opiates with short term use
nausea/vomiting and headache
dose wrong - die
what can be side effects of opiates with medium term use
phlebitis from injecting
Anorexia – loss of weight
Constipation
what can be side effects of opiates with long term use
tolerance
Withdrawal – craving, insomnia, yawning, muscle pain and cramps, increased salivary, nasal and lacrimal secretions, dilated pupils, piloerection (hence ‘cold turkey’)
Social and health problems – money
why was methadone introduced
to decriminalise drug use and allow normalisation of lifestyle
Methadone reduces iv misuse and harm – 7x less likely to die
how is ecstasy (MDMA) taken
orally
what are the effects of ecstasy
likened to mixture of LSD and amphetamine
euphoria followed by feeling of calm
increased sociability
inability to distinguish between what is and isn’t desirable
what are the side effects fo ecstasy
Nausea and dry mouth increased blood pressure and temperature in clubs users risk dehydration large doses can cause anxiety and panic drug induced psychosis liver and brain cell damage Loss of serotonin in brain – causes long term depression, anxiety and insomnia
how long do the effects of ecstasy last
2-4 hours
after 20 minutes
what is the most commonly used illicit drug
cannabis
what are the 2 components of cannabis
tetrahydrocannabinol (THC) is the psychoactive agent and CBD is the antipsychotic, low risk
how is cannabis taken
eaten or smoked
what are the psychological effects of cannabis
relaxing or stimulating, euphoriant, increases sociability and hilarity, increases appetite, changes in time perception, synaesthesia (changes in perception)
in higher dose - anxiety, panic, persecutory ideation, hallucinatory activity
what are some of the ill effects of cannabis
- respiratory problems as with tobacco
- toxic confusion
- exacerbation of major mental illness
- cannabis psychosis
why are legal highs becoming more popular
internet
what are legal highs
illegal chemical compound slightly changed that may mimic effects of the drug but is still legal
what is the change in the law to make legal highs illegal
every psychoactive drug is illegal apart from a list etc prescribed, caffeine nicotine etc.
what population use anabolic steroid
athletes and sports requiring muscle mass
what are some side effects of anabolic steroids
Skin – acne, stretch marks, baldness
Feminisation in males with hypogonadism and gynaecomastia
Virilisation in women including hirsutism, deep voice, clitoral enlargement, menstrual irregularities, hair thinning
Cardiovascular – increased cholesterol and hypertension
Growth deficits due to premature closure of epiphyses
Liver Disease – cholestatic jaundice, liver tumours
Irritability and anger – ‘roid rage’
hypomania and mania
Depression and suicidality on withdrawal
what are the effects of alcohol at low dose
euphoria, reduced anxiety, relaxation, sociability in society
what are effects of alcohol at higher doses
intoxication
impaired attention and judgement, unsteadiness, flushing, nystagmus, mood instability, disinhibition, slurring, stupor, unconsciousness
what is intoxication
the pathological state produced by a drug, serum, alcohol or any toxic substance
what is the diagnosis of acute intoxication based on
disturbances of level of consciousness, cognition, perception, affect or behaviour
what is the diagnosis of harfmful use of alcohol based on
pattern of use causing damage to physical or mental health. Use >1 month or repeatedly over 12 months
what is the diagnosis of alcohol dependence based on
¥ 3 or more of the following for >1month or repeatedly over 12 months:
- Cravings/compulsions to take
- Difficulty controlling use
- Primacy
- Increased tolerance
- Physiological withdrawal on reduction/cessation
- Persistence despite harmful consequences
- Narrowed drinking repertoire & rapid reinstatement after abstinence (Edwards & Grosss)
what is the withdrawal state
Group of symptoms of variable clustering and severity on complete/relative withdrawal of a psychoactive substance, after persistent use of that substance
what symptoms are seen in the withdrawal state form alcohol
Tremor, weakness, nausea, vomiting, anxiety, seizures, confusion, agitation, death
what is delirium tremens
Acute Profound confusion, tremor, agitation, visual hallucinations, delusions, sleeplessness, autonomic over-activity (high HR, low BP)
mortality 5%
what is the risk period for delirium tremens
48-72 hours after alcohol stopped
what do people in delirium tremens die of
cardiovascular collapse, infection, hyperthermia, seizures or self injury
what impact does alcohol have on relationships
o Aggression - Verbal , Physical
o Marital difficulties
o Morbid jealousy
o Poor parenting/neglect +/- loss of parenting rights
o Loss of friendships and social supports
what are the 4 Ls of alcohol to consider
Liver - physical
Livelihood - mental health
Lover - relatiosnhsips
legal
what mental health effects can alcohol have
Anxiety, Depression (70-80%), Sleep disruption, Morbid Jealousy (Othello syndrome), Alcoholic hallucinosis, Deliberate self-injury, Suicidal thoughts/acts
describe the CAGE screening tool
CAGE (2 or more = likely alcohol problem)
¥ Have you tried to Cut down?
¥ Have you felt Annoyed by people criticising your drinking?
¥ Have you felt Guilty about drinking?
¥ Have you felt the need to have an Eye-opener?
what are some screening tools used for alcohol
CAGE
AUDIT (Alcohol Use Disorders Identification Test)
FAST (4 questions)
PAT (Paddington Alcohol Test; used in A&Es)
what non -pharmacological ways is alcohol dependence managed
Ð Support for patient and family
Ð Psychological help (e.g. CBT, group therapy)
Ð Social work input (benefits, housing, child protection)
Ð Skills training
Ð Community Support (eg AA, ADA)
Ð Inpatient or residential treatment
what dug is given to prevent wernicke-larsakoff syndrome
thiamine
what drugs are given to manage alcohol withdrawal
Benzodiazepines , commonly Chlordiazepoxide
name some anti-craving mediations
Acamprosate (Campral) (not rapid, 3 months,)
Naltrexone,
Nalmefene,
(Baclofen) – not licesnsed in UK, used for spasticity
which organ processes alcohol
liver
what are the main functions of the liver
carb metabolism - glycogen fat metabolism - cholesterol protein metabolism - AA, ammonia, albumin synthesis storage - glucose, iron, copper, vits synthesis - fibrinogen, thrombopoietin kupffer cellls - macrophages bile production
What should I do if my patient is drinking more than the low risk guidance?
¥ Opportunity to reduce their risk of health harm
¥ If alcohol dependence is likely – refer to treatment services
¥ Offer feedback, assess how willing they are to change and offer support strategies
what neurochemical changes occur when alcohol is consumed
opiate release
Alcohol ENHANCES inhibitory GABA A, Glycine and Adenosine; alcohol REDUCES excitatory NMDA glutamate and Aspartate.
What is the most appropriate treatment to commence in an inpatient who is at risk of alcohol withdrawal
chlordiazepoxide
what is alcohol converted to in the liver
Alcohol >Acetylaldehyde (toxic) >Acetate >fatty acids, C20, H20
what enzymes help the processing of alcohol in the liver
alcohol dehydrogenase (ADH) acetyldehydrogenase (ALDH
what is the rate of 1 unit of alcohol processed by a healthy liver
1 unit per hour
what part of the alcohol metabolism is a carcinogen in excess
Acetaldehyde
which gender are more susceptible to liver damage
females
what are the main causes of cirrhosis
alcohol related liver disease
fatty liver sidease
hep C virus
autoimmune disease
what is the progression of disease from a normal liver to liver cirrhosis
normal liver fatty liver (steatosis) steatophepatitis Fibrosis Liver Cirrhosis
what stage of liver pathology is reversible with abstinence
normal liver to fatty liver (steatosis)
why does steatosis occur
alcohol is broken down into fatty acids and is also calorie rich. Fat is deposited around the central veins then parenchyma
give some indications of chronic alcohol abuse
- HISTORY
- Elevated gamma GT (liver enzyme)
- Macrocytosis (large red blood cells- fat pads out)
- Low platelets – hypersplenism, bone marrow suppression
- Elevated ferritin
- Enlarged smooth edged liver on AUSS
what is alcoholic hepatitis
Fatty change within the liver AND Infiltration with leucocytes/ Hepatic necrosis
how may alcoholic hepatitis present
Hepatomegaly, Jaundice, Abdominal Pain, Fever, +/- Hepatic decompensation
May or may not be cirrhotic (can be on top of cirrhosis or fatty liver)
what is your 28 day survival rate is GAHS > 9 and < 9
Day 1 GAHS <9 87%
Day 1 GAHS >9 46%
what things are considered in the Glasgow Alcoholic Hepatitis Score
Age, markers of inflammation and liver function
how do you treat alcoholic hepatitis
ABSTINENCE, Steroids, management of infection and nutrition
what are complications of alcoholic hepatitis
Renal impairment and coagulopathy , ascites
what are symptoms of wernickes encephalopathy
Confusion, ataxia, opthalmoplegia, nystagmus
what is Korsakoff’s Psychosis
Prominent impairment of recent and remote memory, preservation of immediate recall, no general cognitive impairment, retrograde and anterograde memory, impaired learning and disorientation, may exhibit nystagmus and ataxia
what does wernickes encephalopathy progress to if left untreated
Korsakoff’s Psychosis
what causes a wernickes encephalopathy
thiamine deficiency (Poor intake and absorption, poor hepatic function, increased requirement for alcohol metabolism Problem because they don’t eat well Directly toxic to gut lining)
what affects can alcohol have on the CNS
poor memory/ cognition, cortical/ cerebellar atrophy, retrobulbar neuropathy, fits, falls, accidents, neuropathy, Korsakoff’s/ Wernickes encephalopathy
what affects can alcohol have on the heart
arrhythmias, hypertension, cardiomyopathy
what affects can alcohol have on the gut
D&V, peptic ulcer, erosions, varices, pancreatitis
what affects can alcohol have on sperm
decreased fertility, decreased sperm motility
what is the recommended drinking limits
< 14 units per week
Regular consumption – spread over >3 days
how many units a week will lead to serious liver disease
> 100
how do you calculate a unit of alcohol
ABV (%) x volume/ 1000
what age group have the highest alcohol associated deaths
49-59
what are the most common alcohol related deaths
alcoholic liver disease, liver cirrhosis and mental and behavioural disorders due to alcohol.
describe the pathogenesis of fibrosis
Chronic inflammation
Activation of stellate cells
Collagen production bridging between veins/ tracts– stiffer, scarring
Loss of lobule structure
describe the pathogenesis of cirrhosis
pan lobular – pseudo lobules (nodules) formed – thick bands of fibrous tissue between lobule
what are complications of liver cirrhosis
Variceal haemorrhage
Encephalopathy (build up of ammonia)
Ascites (Na/ H20 balance)
Hepatocellular carcinoma
what are the difference in outcomes of you stop drinking
5 year survival if abstinent 65%,
5 year survival if ongoing alcohol consumption 35%
