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psychiatry > alcohol and addiction > Flashcards

alcohol and addiction Flashcards

1
Q

what drugs have the worst physical withdrawal problems

A 
opiates
barbiturates
alchohol
benzopdiazepines
cocaine
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2
Q

what drugs have the worst psychological withdrawal problems

A

opiates
crack/ cocaine
cigarettes
amphetamines, barbiturates, benbodiaspeines, alcohol, gambling

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3
Q

what are the 2 different mechanisms of substance abuse

A 
Tolerance (the basis of physical dependence)
Reward centre (the basis of psychological craving)
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4
Q

what is tolerance defined as

A

Reduced responsiveness to a drug caused by previous administration

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5
Q

what drugs does tolerance develop to

A

opioids, ethanol, barbiturates, benzodiazepines

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6
Q

how does less drug reach the active site in tolerance

A

¥ 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)

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7
Q

how is the site of action less affected by the drug in tolerance

A

¥ down-regulation or internalisation of drug receptors – smaller response
¥ reduced signalling down stream of drug receptors (2nd messengers)
¥ some other compensatory mechanism

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8
Q

why do withdrawal symptoms occur in tolerance

A

The body becomes dependent to keep in normal state so when these substances are removed, adverse effects are seen

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9
Q

what is the withdrawal phenomena

A

the withdrawal effect of a drug is usually the reverse of the acute effect

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10
Q

give examples of 3 withdrawal phenomena

A

opiod - contipation > diarrhoea
barbiturate - anticonvulsant > convulsion
cocaine - elevated mood > depressed mood

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11
Q

what neurones fire dopamine

A

ventral tegmental area

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12
Q

what feeling does dopamine release cause

A

a sensation of pleasure/reward

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13
Q

where do neurones from the ventral segmental area project (dopamine)

A

nucleus accumbens & prefrontal cortex.

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14
Q

what normally activates the reward pathway and why

A

eating, drinking and sex to encourages those “healthy” behaviours that lead to propagation of your genes

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15
Q

what drugs of abuse tap into reward pathway to increase dopamine levels

A

heroin
amphetamine
cocaine - inhibits uptake
alcohol - inhibits

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16
Q

why do some people crave things more than others

A

genetic component to addictive personalities

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17
Q

what is the prison sentence for possession of class A, B and C drugs

A

A - 10 years
B - 5 years
C - 3 years

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18
Q

name some class A drugs

A 
heroin 
cocaine
strret methadone
4-MTA
LSD
ecstasy
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19
Q

name some class B drugs

A

barbiturates
amphetamine
methylphenidate

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20
Q

name some class C drugs

A 
ketamine
benzodiazepines 
buprenorphine
cannabis
anabloic steeds
GHB
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21
Q

what is cocaine extracted from

A

leaves of coca plant

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22
Q

what is the difference between the associates of crack and cocaine

A

crack - violence

powder - wealth, sex

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23
Q

what is the difference in effect of cocaine between smoking, injecting and snorting

A

smoking - immediates
injecting - 15-30s
sporting - 3-5 mins

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24
Q

what are complications of snorting cocoaine

A

nose bleeds

lose nasal septum

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25
Q

what is the mechanism of cocaine in the body

A

powerful vasoconstrictor

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26
Q

what are some positive effects of cocaine

A

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

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27
Q

what are some negative effects of cocaine

A 
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
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28
Q

what are some withdrawal effects seen with cocaine

A 
•	Depression, Irritability, Agitation
•	Craving
•	Hyperphagia – eat too much
•	Hypersomnia – sleep too much 
More psychological than physical dependence (due to dopamine)
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29
Q

what are the complications with amphetamine

A

Toxic confusion occasionally with convulsions and death

Amphetamine psychosis in heavy chronic use

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30
Q

what drug are the effects of amphetamine similar to

A

cocaine

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31
Q

list some examples of opiates

A

meorphine
heroin
methadone
codeine + dihydrocodeine

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32
Q

what does opium come from

A

the dried milky juice of unripe seedpods of the opium poppy (Papavera somniferum).

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33
Q

how is heroin taken

A

snorting, smoking(chasing the dragon) and injection

Smoking is safest, injecting the most dangerous method of use

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34
Q

what are some drawbacks of opiates

A

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

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35
Q

what are the benefits of opiates

A

Analgesia
Drowsiness and sleep
Mood change (euporia, intense pleasure)
A rush

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36
Q

what can be side effects of opiates with short term use

A

nausea/vomiting and headache

dose wrong - die

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37
Q

what can be side effects of opiates with medium term use

A

phlebitis from injecting
Anorexia – loss of weight
Constipation

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38
Q

what can be side effects of opiates with long term use

A

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

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39
Q

why was methadone introduced

A

to decriminalise drug use and allow normalisation of lifestyle
Methadone reduces iv misuse and harm – 7x less likely to die

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40
Q

how is ecstasy (MDMA) taken

A

orally

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41
Q

what are the effects of ecstasy

A

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

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42
Q

what are the side effects fo ecstasy

A 
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
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43
Q

how long do the effects of ecstasy last

A

2-4 hours

after 20 minutes

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44
Q

what is the most commonly used illicit drug

A

cannabis

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45
Q

what are the 2 components of cannabis

A

tetrahydrocannabinol (THC) is the psychoactive agent and CBD is the antipsychotic, low risk

46
Q

how is cannabis taken

A

eaten or smoked

47
Q

what are the psychological effects of cannabis

A

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

48
Q

what are some of the ill effects of cannabis

A
  • respiratory problems as with tobacco
  • toxic confusion
  • exacerbation of major mental illness
  • cannabis psychosis
49
Q

why are legal highs becoming more popular

A

internet

50
Q

what are legal highs

A

illegal chemical compound slightly changed that may mimic effects of the drug but is still legal

51
Q

what is the change in the law to make legal highs illegal

A

every psychoactive drug is illegal apart from a list etc prescribed, caffeine nicotine etc.

52
Q

what population use anabolic steroid

A

athletes and sports requiring muscle mass

53
Q

what are some side effects of anabolic steroids

A

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

54
Q

what are the effects of alcohol at low dose

A

euphoria, reduced anxiety, relaxation, sociability in society

55
Q

what are effects of alcohol at higher doses

A

intoxication
impaired attention and judgement, unsteadiness, flushing, nystagmus, mood instability, disinhibition, slurring, stupor, unconsciousness

56
Q

what is intoxication

A

the pathological state produced by a drug, serum, alcohol or any toxic substance

57
Q

what is the diagnosis of acute intoxication based on

A

disturbances of level of consciousness, cognition, perception, affect or behaviour

58
Q

what is the diagnosis of harfmful use of alcohol based on

A

pattern of use causing damage to physical or mental health. Use >1 month or repeatedly over 12 months

59
Q

what is the diagnosis of alcohol dependence based on

A

¥ 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)
60
Q

what is the withdrawal state

A

Group of symptoms of variable clustering and severity on complete/relative withdrawal of a psychoactive substance, after persistent use of that substance

61
Q

what symptoms are seen in the withdrawal state form alcohol

A

Tremor, weakness, nausea, vomiting, anxiety, seizures, confusion, agitation, death

62
Q

what is delirium tremens

A

Acute Profound confusion, tremor, agitation, visual hallucinations, delusions, sleeplessness, autonomic over-activity (high HR, low BP)
mortality 5%

63
Q

what is the risk period for delirium tremens

A

48-72 hours after alcohol stopped

64
Q

what do people in delirium tremens die of

A

cardiovascular collapse, infection, hyperthermia, seizures or self injury

65
Q

what impact does alcohol have on relationships

A

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

66
Q

what are the 4 Ls of alcohol to consider

A

Liver - physical
Livelihood - mental health
Lover - relatiosnhsips
legal

67
Q

what mental health effects can alcohol have

A

Anxiety, Depression (70-80%), Sleep disruption, Morbid Jealousy (Othello syndrome), Alcoholic hallucinosis, Deliberate self-injury, Suicidal thoughts/acts

68
Q

describe the CAGE screening tool

A

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?

69
Q

what are some screening tools used for alcohol

A

CAGE
AUDIT (Alcohol Use Disorders Identification Test)
FAST (4 questions)
PAT (Paddington Alcohol Test; used in A&Es)

70
Q

what non -pharmacological ways is alcohol dependence managed

A

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

71
Q

what dug is given to prevent wernicke-larsakoff syndrome

A

thiamine

72
Q

what drugs are given to manage alcohol withdrawal

A

Benzodiazepines , commonly Chlordiazepoxide

73
Q

name some anti-craving mediations

A

Acamprosate (Campral) (not rapid, 3 months,)
Naltrexone,
Nalmefene,
(Baclofen) – not licesnsed in UK, used for spasticity

74
Q

which organ processes alcohol

A

liver

75
Q

what are the main functions of the liver

A 
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
76
Q

What should I do if my patient is drinking more than the low risk guidance?

A

¥ 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

77
Q

what neurochemical changes occur when alcohol is consumed

A

opiate release

Alcohol ENHANCES inhibitory GABA A, Glycine and Adenosine; alcohol REDUCES excitatory NMDA glutamate and Aspartate.

78
Q

What is the most appropriate treatment to commence in an inpatient who is at risk of alcohol withdrawal

A

chlordiazepoxide

79
Q

what is alcohol converted to in the liver

A

Alcohol >Acetylaldehyde (toxic) >Acetate >fatty acids, C20, H20

80
Q

what enzymes help the processing of alcohol in the liver

A

alcohol dehydrogenase (ADH) acetyldehydrogenase (ALDH

81
Q

what is the rate of 1 unit of alcohol processed by a healthy liver

A

1 unit per hour

82
Q

what part of the alcohol metabolism is a carcinogen in excess

A

Acetaldehyde

83
Q

which gender are more susceptible to liver damage

A

females

84
Q

what are the main causes of cirrhosis

A

alcohol related liver disease
fatty liver sidease
hep C virus
autoimmune disease

85
Q

what is the progression of disease from a normal liver to liver cirrhosis

A 
normal liver
fatty liver (steatosis)
steatophepatitis
Fibrosis
Liver Cirrhosis
86
Q

what stage of liver pathology is reversible with abstinence

A

normal liver to fatty liver (steatosis)

87
Q

why does steatosis occur

A

alcohol is broken down into fatty acids and is also calorie rich. Fat is deposited around the central veins then parenchyma

88
Q

give some indications of chronic alcohol abuse

A
  • 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
89
Q

what is alcoholic hepatitis

A

Fatty change within the liver AND Infiltration with leucocytes/ Hepatic necrosis

90
Q

how may alcoholic hepatitis present

A

Hepatomegaly, Jaundice, Abdominal Pain, Fever, +/- Hepatic decompensation
May or may not be cirrhotic (can be on top of cirrhosis or fatty liver)

91
Q

what is your 28 day survival rate is GAHS > 9 and < 9

A

Day 1 GAHS <9 87%

Day 1 GAHS >9 46%

92
Q

what things are considered in the Glasgow Alcoholic Hepatitis Score

A

Age, markers of inflammation and liver function

93
Q

how do you treat alcoholic hepatitis

A

ABSTINENCE, Steroids, management of infection and nutrition

94
Q

what are complications of alcoholic hepatitis

A

Renal impairment and coagulopathy , ascites

95
Q

what are symptoms of wernickes encephalopathy

A

Confusion, ataxia, opthalmoplegia, nystagmus

96
Q

what is Korsakoff’s Psychosis

A

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

97
Q

what does wernickes encephalopathy progress to if left untreated

A

Korsakoff’s Psychosis

98
Q

what causes a wernickes encephalopathy

A 
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)
99
Q

what affects can alcohol have on the CNS

A

poor memory/ cognition, cortical/ cerebellar atrophy, retrobulbar neuropathy, fits, falls, accidents, neuropathy, Korsakoff’s/ Wernickes encephalopathy

100
Q

what affects can alcohol have on the heart

A

arrhythmias, hypertension, cardiomyopathy

101
Q

what affects can alcohol have on the gut

A

D&V, peptic ulcer, erosions, varices, pancreatitis

102
Q

what affects can alcohol have on sperm

A

decreased fertility, decreased sperm motility

103
Q

what is the recommended drinking limits

A

< 14 units per week

Regular consumption – spread over >3 days

104
Q

how many units a week will lead to serious liver disease

A

> 100

105
Q

how do you calculate a unit of alcohol

A

ABV (%) x volume/ 1000

106
Q

what age group have the highest alcohol associated deaths

A

49-59

107
Q

what are the most common alcohol related deaths

A

alcoholic liver disease, liver cirrhosis and mental and behavioural disorders due to alcohol.

108
Q

describe the pathogenesis of fibrosis

A

Chronic inflammation
Activation of stellate cells
Collagen production bridging between veins/ tracts– stiffer, scarring
Loss of lobule structure

109
Q

describe the pathogenesis of cirrhosis

A

pan lobular – pseudo lobules (nodules) formed – thick bands of fibrous tissue between lobule

110
Q

what are complications of liver cirrhosis

A

Variceal haemorrhage
Encephalopathy (build up of ammonia)
Ascites (Na/ H20 balance)
Hepatocellular carcinoma

111
Q

what are the difference in outcomes of you stop drinking

A

5 year survival if abstinent 65%,

5 year survival if ongoing alcohol consumption 35%

psychiatry (5 decks)

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