Alcohol and drug misuse and dependence Flashcards
What is alcohol misuse?
Drinking in a way that regularly causes problems to the patient or others
What are the classifications of alcohol misuse and dependence?
Problem drinker - one who causes or experiences physical, psychological and/or social harm as a consequence of drinking alcohol
Heavy drinker - drinking significantly more in terms of quantity and/or frequency than is safe in the long term
Binge drinker - excessively drinking in short bouts separated by quite long lengths of abstinence
Alcohol dependence - physical dependence or addiction to alcohol
What are the screening questions for alcohol addiction called?
CAGE
AUDIT-C
What are the questions in CAGE?
Have you ever felt that you should CUT down on your drinking?
Have people ever ANNOYED you by criticising your drinking?
Have you ever felt bad or GUILTY about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (EYE OPENER)
Score over 2 = problematic drinking
What are the questions in AUDIT-C?
How often do you have a drink containing alcohol? - Never 0 - Monthly or less 1 - 2-4 times per month 2 - 2-3 times a week 3 - 4 or more times a week 4 How many units of alcohol do you drink on a typical day when you are drinking? - 1 or 2 - 0 - 3 or 4 - 1 - 5 or 6 - 2 - 7 to 9 - 3 - 10 or more - 4 How often have you had 6 or more units if female, or 8 or more if male on a single occasion in the last year? - Never 0 - Less than monthly 1 - Monthly 2 - Weekly 3 - Daily or almost daily 4 3 or more out of 12 then ask the full audit questionnaire
What is also important to ask in an alcohol history?
When did you first notice an increase in the amount of alcohol you were drinking?
Anything going on at the time to play a role in this?
How often do you drink?
How much do you drink on an average day?
Where and who do you drink with?
Have you tried to stop drinking before?
What happened? Support?
What may you find in a physical examination that may demonstrate alcohol dependence?
Tremors Sweating N&V Tachycardia/hypertension Anxiety Psychomotor agitation Headache Insomnia Malaise and weakness Transient visual, tactile, or auditory hallucinations or illusions Generalised tonic-clonic convulsions
Name 3 risk factors for alcohol misuse
Mental health disorders - EUPD, depression, anxiety, schizophrenia, mania
Binge drinking
Abuse
Parents with a history of alcoholism
How common is alcohol misuse?
20% men and 10% women drink more than recommended 3 units per day
Amount of alcohol consumed has doubled in the UK over the last 50 years
2-3 times risk of dying that the general population
1 in 5 male admissions directly/indirectly due to alcohol
What conditions could alcohol misuse been seen as a self-treatment for?
GAD Social phobia Dysthymic disorder Major depression Bipolar mania Insomnia
How does alcohol dependence present?
Unable to limit the amount they drink Difficulty in avoiding getting drunk Spending a lot of time drinking Missing meals Memory lapses, blackouts Restlessness without a drink Trembling after drinking the day before Morning retching and vomiting Sweating excessively at night Withdrawal fis Morning drinking Increased tolerance Hallucinations Delirium tremens
What genetic factors could cause alcohol misuse?
Serotonin transporter gene
D2 receptor allele A1
Alcohol dehydrogenase subtypes
MAO B activity
What environmental factors could cause alcohol misuse?
Childhood maltreatment
Parental alcohol dependence
Other substance misuse
What biochemical factors could cause alcohol misuse?
Abnormalities in alcohol dehydrogenase
Neurotransmitter substances
Brain amino acids (GABA)
What else could lead to alcohol misuse?
Excess consumption in the community
What could you do to diagnose alcohol dependence?
Questionnaires - over 36 units per week poses long term health risks
Bloods - elevated gamma-GT and MCV
Blood and breath alcohol tests
How do you manage alcohol dependence?
Motivational therapy
Psychological treatment
Admission
Correct electrolyte abnormalities and dehydration
Treat other disorders
Thiamine (more if have Wernicke’s)
Phenytoin/carbamazepine if previous history of withdrawal fits
Diazepam/chlordiazepoxide
Additional benzodiazepine if symptoms and signs not controlled
How can you prevent alcohol dependence relapse?
Naltrexone
Acamprosate
Disulfiram
What is the prognosis of alcohol dependence?
30-50% of alcohol dependent drinkers abstinent or drinking much less up to 2 years following additional intervention
What are the risks of alcohol?
Alcohol dependence
Alcohol poisoning
Wernicke’s encephalopathy/Korsakoff’s sydrome
Sleep problems
Effects on day-to-day life - relationships, occupation, diet, alcohol-related crime
Dangers to attacking his wife/other family members
Injuries from alcohol - car accidents
Other medical problems - heart problems, gut problems, pancreatitis, cancers - oral, laryngeal, oesophageal, colon, pancreatic, hepatic, small intestine, liver disease, diabetes
Weight gain
Mental health problems - depression, suicidal thoughts
What are the risks of suddenly stopping drinking?
Delirium tremens
Seizures
Alcohol withdrawal
Wernicke’s encephalopathy and Korsakoff’s - loss of mammillary bodies
What does an alcohol detox involve?
Alcohol completely flushed out of body
Substitution of drugs that have similar effects to alcohol to prevent withdrawal - chlordiazepoxide for 10 days tapering down drugs
Therapies, counselling and support
How does naltrexone work?
Blocks opiate receptors and so stops pleasure from drinking
How does disulphiram work?
Stops liver processing alcohol and makes them feel unwell when they drink alcohol
Stays in the system for 10 days
What is the definition of drug misuse?
Inappropriate, illegal, or excessive use of a drug
What drugs are common in addiction?
Inhaled substances eg glue and NO Amphetamines eg speed/meth/ecstasy (MDMA) Cocaine Hallucinogenic eg LSD Cannabis Tranquilisers eg benzodiazepines Opiates
What happens with addiction to inhaled substances?
Tolerance develops over weeks/months
Intoxication - euphoria, excitement, floating sensation, dizziness, slurred speech, and ataxia
Amnesia and visual hallucinations
What happens with addiction to amphetamines?
Temporary stimulant and euphoric effects Followed by fatigue and depression Activates neural award transmitters Can induce paranoid psychosis and manic presentation Psychedelic
What happens with addiction to cocaine?
CNS stimulant
Similar affects to amphetamines
Addiction more common if smoking it
Withdrawal - depression, tremor, muscule pains
Hyperarousal
Prolonged high doses - irritability, restlessness, paranoia, convulsions
Perforation of nasal septum if sniffing
What happens in an overdose of cocaine?
MI
Cerebrovascular disease
Hyperthermia
Arrhythmias
What happens in addiction to hallucinogenics?
Distortion and intensification of sensory perceptions
Hallucinations in intoxication
Psychosis is long-term complication
What happens in addiction to cannabis?
Exaggerates pre-existing moods
Analgesic properties
Amotivational syndrome with apathy and memory problems - chronic daily use
Psychosis
What happens with addiction to tranquilisers?
Dependence can happen with prescriptions
Discontinuation of treatment may cause withdrawal symptoms
What happens with addiction to opiates?
Tolerance rapidly develops and quickly lost
Opiate withdrawal syndrome
Withdrawal dangerous in people with heart disease or other chronic debilitating conditions
High mortality rate - accidental overdose, BB infections, heart disease (IE), TB, AIDS, hep B and C
What questions should you ask in a history?
What drug? How often? HIV screens? How do you use drug? Any symptoms of dependence?
What are the risk factors for drug misuse?
Early aggressive behaviour Lack of parental supervision Substance abuse Drug availability Poverty Vulnerable personality Social pressures eg peer pressure
How common is drug misuse?
Tramadol most common addiction
Cannabis most abused substance after alcohol
2 million people use cannabis regularly
1 million people use cocaine regularly
What is drug misuse seen as a self-treatment for?
Depression Anxiety Bipolar Hyperthyroidism Hyperparathyroidism Abuse/trauma Iatrogenic effect ADD
What is the clinical presentation of drug addiction?
Feeling of having to use the drugs regularly
Intense urges to take the drug
Needing more drug to get the same effect
Taking larger amounts than you intended
Making sure you maintain a supply
Not meeting obligations or work responsibilities
Doing things you wouldn’t normally do whilst under the influence
Spending a good deal of time getting the drug
Experiencing withdrawal symptoms when you stop taking it
Why do people take drugs?
Feelings of reward when taking the drug
What investigations in drug misuse?
Blood and urine tests
Lab tests
How should you manage someone with a drug addiction?
Refer to psychiatrist or drug misuse clinic
Prescriptions of illegal drug to help control addiction
Treat overdose with naloxone
What is the prognosis of a drug addiction?
40-60% of people relapse
What are common drugs that people overdose on?
Heroin
Paracetamol
Cocaine
Methamphetamines
How do you treat a heroin overdose?
Naloxone (competitive antagonist of opiate receptors)
How do you treat a paracetamol overdose?
Acetylcysteine
What are the symptoms of an opiate overdose?
Pinpoint pupils
Unconscious
Respiratory depression
Track marks (could also mean amphetamines)
What are the short term risks of heroin?
N&V dehydration Loss of consciousness Clouded mental function - may do dangerous things Respiratory arrest Coma Permanent brain damage
What are the long term of heroin?
Brain deterioration
Withdrawal symptoms
Dependence
What are the risks in heroin usage?
Withdrawal Abuse Homelessness Death Infections - HIV, Hep B, skin infections, septicaemia Hypothermia Miscarriage if pregnant Risks to child - born addicted to opiates, death Seizures Nutrition Safeguarding issues
How do you manage heroin addictions?
Methadone treatment
Refer to psychiatry/addiction teams
Psychological therapies
Support with social situation
What is important when treating with naloxone?
Give basal IM dose NOT IV
Sit with them in case they wake up
What can you do with methadone treatment?
Collect from pharmacy every day and pharmacist has to watch them take the medication
Can take home if more stable
Very stable gets it once a week
See drug service every few weeks and have bloods done and if have taken illicit drugs on top then take them off the once per day due to risk of overdose
