Alcohol and Substance Abuse Flashcards
Definition of psychoactive substance, harmful use and hazardous use
Psychoactive substance: has effect on CNS
Harmful use: CAUSE adverse consequences, without dependence e.g. health, safety, interpersonal relationships
Hazardous use: place user AT RISK OF adverse consequences, without dependence
Hx taking
All substances used
Pattern of use - frequency, dosage, typical day (stereotyped pattern? 規律), daily consumption
Route of access
When, why
Features of dependence
Related physical (GI, Neurocognitive) and social disability (work, finance, housing, accidents, crime, marital)
Related neuropsychiatric disorders
Past history of psychiatric illness/substance misuse
FHx
CAGE questionnaire for alcohol
- any need to Cut down, ever had people Annoyed and criticise about drinking, ever felt Guilty, need Eye-opener?
Physical examination for alcohol/substance
- nutritional status
- evidence of acute use or intoxication e.g. pupil constriction in opiate use, incoordination/slurred speech in alcohol use
- signs of withdrawal e.g. tremor, sweating, n/v, tachycardia, pupil dilation
- short term complications e.g. head injury, infection by IVDA
- long term complications e.g. CLD, HBV/HCV/HIV in IVDA
Investigations for alcohol/substance
Urine or saliva drug screening CBC - MCV U&E LFT - GGT, AST, ALT Clotting - prolonged PT in liver damage ECG HBV/HCV/HIV if IVDA
Aetiology of alcohol related disorders - biology, psychological, presence of other illnesses, social and environmental
Biological
- strong genetic component
- deficiency in aldehyde dehydrogenase (50% East Asians) = reduced alcohol consumption and dependence
- chronic alcohol consumption = decrease GABA activity and increase glutamate –> increase neuroexcitability on intoxication and withdrawal seizures on cessation
Psychological
- positive reinforcement: pleasant effects of alcohol consumption
- negative reinforcement: negative effects of withdrawal
- modelling (relatives and peers)
Presence of psychiatric or physical illness increases risk of alcohol abuse and dependence
- self-medication
- coping mech
- impulsivity, lack of insight into risks, lack of support
Social and environmental
- cultural attitude
- association of certain occupations with death from alcoholic liver disease e.g. leisure, catering, doctors, journalists
- frequent significant life events
Harmful use of alcohol - safe limits, complications of excessive use
Safe limits
- men: 3-4 units/day (<21/wk)
- women: 2-3 units/day (<14/wk)
(1 small glass of wine = 1 unit; 1 can of beer = 1.5 units; 1 catty of Chinese wine = 16 units; 1 bottle of brandy = 30 units) - vol in L x % alcohol = units
[alcohol can protect from CHD in men >40 and postmenopausal women; max 1-2 units/day]
Complications of excessive alcohol use
- psychological: self-harm
- social: absenteeism, legal problems/violence, interpersonal problems
- physical:
- -> delirium tremens, seizures, wernicke-korsakoff, cerebellar degeneration, haemorrhagic stroke
- -> alcoholic liver disease, pancreatitis, peptic ulceration, cancers
- -> HT, IHD, arrhythmias
- -> hypoBG, hyperTG, hyperUr, hypoMg, hypoPO4, hypoNa, pseudo-Cushing’s
- -> macrocytosis, anaemia, neutropenia
- -> osteoporosis, myopathy
- -> fetal alcohol syndrome, intrauterine growth retardation, impotence
- -> increased trauma risk
Alcohol Use Disorder (alcohol dependence syndrome)
AT LEAST TWO of the following, in a 12 MONTH PERIOD:
- alcohol taken in larger amounts or over a longer period than intended
- persistent desire or unsuccessful efforts to cut down or control use (have they tried? result? why fail?)
- craving (compelled to drink) 心癮
- failure in fulfilling major role obligations at work/school/home
- continued use despite having persistent social or interpersonal problems
- primacy – important activities are given up or reduced because of alcohol use (家庭，工作，興趣，飲酒 - which is most important)
- recurrent use in physically hazardous situations e.g. driving
- continued use despite having knowledge of having persistent or recurrent physical or psychological problem
- tolerance
- -> need for increased amounts to achieve desired effect or diminished effect with use of same amount
- withdrawal
- -> characteristic symptoms e.g. sweating, palpitations, tremor, n/v or respite drinking (take to relieve/avoid symptoms)
Epidemiology and Aetiology of AUD
Male 3%, Female 0.4%
(middle aged, unemployed, chronic drinking)
Aetiology
- neurochemical basis for dependence: ethanol increases fluidity of membrane lipid, hence later varies receptors’ function
- -> anxiolytic - increase Cl- flux effect of GABA on GABA receptor
- -> stimulant - increase release of DA in forebrain projections to nucleus accumbens (via opioid release)
- -> anaesthetic - inhibitory action on NMDA receptors for glutamate
Genetics
- 60%
- polymorphism of ADH and ALDH has protective effects
CAGE questionnaire for alcoholism sensitivity and specificity
Sensitivity 39-83%
Specificity 92-96% (score>2)
Management of AUD - what to rule out, controlled drinking vs abstinence, pharmacological Tx
- RULE OUT COMPLICATIONS and treat comorbidities
- LFT, injury, anaemia, ulcer
- drug abuse, depression - Controlled drinking vs abstinence
- controversial evidence of efficacy
- no more than 2 (1) drinks per day
- NOT SUITABLE FOR CLEARLY DEPENDENT PATIENTS (chronic drinker with complications, failure to abstain – likely to relapse once taste alcohol)
- suitable for patients with good social support - Detoxification
- done inpatient if there are risks of failing/past complications/co-morbidities
- LONG ACTING BZD e.g. Diazepam (valium) to substitute alcohol with CNS suppression
- Gradual TAPERING DOSE OVER A WEEK (consume liquid, oral vitamins)
- relieve severe symptoms and reduce risk of developing withdrawal seizures or DT - Thiamine, parenterally or orally
- easy deficiency in alcoholics due to interrupted absorption in small intestine
- to prevent Wernicke-Korsakoff syndrome
- IV for immediate cases (prevent wernicke encephalopathy)
- +2 yrs oral for Korsakoff syndrome - Disulfuram or Naltrexone (MAINTENANCE therapy)
- disulfuram suppresses aldehyde dehydrogenase to increase aldehyde and vasodilation/flushing/palpitations/headache/nausea after drinking (taken orally, need supervision)
- Naltrexone - opioid antagonist to prevent relapse by decreasing DA effect in stimulant pathway to reduce craving for alcohol and reduce pleasant effect
- -> >3-4 months treatment, check liver enzymes
Management of AUD - non-pharmacological
Also for maintenance
Psychotherapies
- CBT (set goals, alternative response to triggers, interpersonal/social problems, behavioural contracting, relapse prevention)
- Self-help groups
- motivational interviewing to assess stage of change
Psychoeducation, skill development
Social support: social workers, probation officers
Others
- avoid high risk settings or old acquaintances
- set limits
- self-monitoring e.g. diary
- reward systems
- rate control (spacing out drinks)
AUD prognosis and prognostic factors
Poor prognosis
- 71% not in remission after 1 yr
- 66% not in remission after 5 yrs
Prognostic factors:
- severity, duration
- low IQ, impaired cognition
- personality
- social stability
- motivation
- comorbid mental disorders
Alcohol intoxication - risks, criteria
Potentially life threatening due to risk of respiratory depression, aspiration of vomit, hypoBG, hypothermia and trauma
- Recent ingestion
- Problematic behavioural/psychological changes e.g. aggression, mood lability, impaired judgement
- > 1 of the following:
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- impairment of attention or memory
- stupor or coma - Not attributable to another medical condition and not better explained by another mental disorder (including other substances)
- -> may have anterograde amnesia (blackouts)
- -> idiosyncratic intoxication - very rare, senseless violent behaviour after small amount of alcohol, prolonged terminal sleep, total or partial amnesia about event
Alcohol withdrawal criteria and possible consequences
ALL states are potentially life threatening due to association with autonomic hyperactivity - MUST COVER WITH DIAZEPAM
- Cessation in alcohol use that has been heavy and prolonged
- > 2 of the following developing within several hrs-days:
- autonomic hyperactivity e.g. sweating, palpitations
- tremor
- insomnia
- nausea, vomiting
- transient hallucinations
- psychomotor agitation
- anxiety
- generalised tonic clonic seizure - Causes clinically significant distress or impairment
- Not due to another medical condition or another mental disorder (including other substances)
Possible consequences:
- uncomplicated withdrawal
- perceptual disturbances
- withdrawal seizures
- delirium tremens
Uncomplicated alcohol withdrawal syndrome - severity, onset, symptoms, Tx
Mild
4-12 hrs after cessation
Tremor, sweating, n/v Mood disturbance - anxiety, depression Hyperacusis Autonomic hyperactivity - tachycardia, HT, mydriasis, pyrexia Sleep disturbance Psychomotor agitation
Tx: BZD (long acting) - give loading dose then reassess Q1H vitals
- prevent seizures
Alcohol withdrawal with perceptual disturbances and withdrawal seizures - onset, symptoms, Tx
Perceptual disturbances
- illusions or hallucinations (TYPICALLY VISUAL)
- delusions secondary to hallucinations
Tx: Haloperidol (also sedative)
Withdrawal seizures (“rum fit seizures”)
- 6-48 hrs after cessation
- 5-15% patients
- generalised tonic clonic
- can be life threatening and occur without any other symptoms
- predisposing: previous Hx, concurrent epilepsy, hypoK or Mg
Tx: phenytoin for seizures
Delirium Tremens - severity, onset, symptoms, course, mortality, ddx
SEVERE
1-7 days after cessation
Altered consciousness and marked cognitive impairment (disorientation, confusion, agitation, inattention etc.) - fluctuating
Vivid hallucinations and illusions
Marked tremor
Autonomic arousal (heavy sweating, raised BP/HR, fever)
Paranoid delusions
Course:
2-4 days if untreated
5-15% mortality from CVS collapse, hypo/hyperthermia, infection
Predisposing factors: physical illness
5-20% patients undergoing detox
Ddx: other causes of delirium
Management of Delirium Tremens - environment, medications, monitoring
Emergency hospitalisation
Environment - well lighted, quiet room
Search for MEDICAL COMPLICATIONS e.g. infection, head injury, liver failure, GI haemorrhage, Wernicke’s encephalopathy –> ADMIT TO MEDICAL if any
Hydration
Medication
- HIGH DOSE BZD e.g. DIAZEPAM
- antipsychotics e.g. HALOPERIDOL for severe psychosis
- HIGH DOSE PARENTERAL THIAMINE (not oral in DT)
Monitoring –> alcohol withdrawal chart
- temperature – hyperthermia
- fluid – dehydration
- electrolytes – hypoMg, hypoK
- glucose – hypoBG
(other general measures for delirium refer to other deck)
Alcohol-related cognitive disorders (3)
Wernicke Korsakoff Syndrome
- THIAMINE DEFICIENCY
Wernicke’s encephalopathy
- acute brain damage with haemorrhagic lesions in grey matter around 3rd and 4th ventricles
- ATAXIA, OPTHALMOPLEGIA, DELIRIUM
–> nystagmus, 6th nerve palsy
Prognosis – 25% recover completely, 10-20% die, 84% of survivors develop Korsakoff’s syndrome
Korsakoff’s syndrome
- chronic state after Wernicke’s
- EXTENSIVE ANTEROGRADE AND RETROGRADE AMNESIA, frontal lobe dysfunction and PSYCHOTIC SYMPTOMS in absence of delirium
- further causes AMNESIC SYNDROME –> impaired recent memory, disorientation, confabulation with other cognition preserved
Tx: PARENTERAL THIAMINE
Alcoholic dementia
- 10% of all dementia in HK community
- long term misuse leads to impairment of memory, learning, visuospatial skills, impulse control with cortical atrophy and ventricular enlargement
- abstinence leads to some improvement
Alcohol-related psychotic disorders - associated delusions, severity, difference from intoxication/withdrawal, alcoholic hallucinosis vs schizophrenia, prognosis
Bi-directional: hallucinations and delusions can occur in heavy alcohol consumption — common comorbidity of psychotic disorders is alcohol misuse
Alcohol strongly a/w overvalued ideas or delusions of infidelity
Can be fleeting disturbances with retained insight or more persistent AH/VH or persecutory/grandiose delusions
ABSENCE OF COGNITIVE IMPAIRMENT – different from acute intoxication or withdrawal
Alcoholic hallucinosis vs Schizophrenia
- >40 vs <40
- acute vs insidious
- 3 months vs chronic
- +ve drinking hx vs not significant
- delusions secondary to hallucinations vs any delusion
- no thought disorder vs formal thought disorder
- appropriate affect vs blunted, incongruent affect
- FHx of alcoholism vs schizophrenia
(AH most common for both)
Prognosis of alcoholic hallucinosis
- 73% duration <3 months, 14% >1 yr
- 16% relapse
- 9% revise Dx to schizophrenia
Alcohol-related mood disorder - depression, mania, suicide
Low mood and alcohol consumption cause each other
- social damage of alcohol on personal lives
- difficult to differentiate alcohol-induced and true MDD
Mania can also cause problematic drinking (disinhibition)
- excessive alcohol a/w relapse of manic illness in BAD
Alcohol and suicide
- impairs judgement and cause impulsivity –> NEED RISK ASSESSMENT
- 16-29% lifetime risk for suicide, 7% completed suicide
- present in 27-54% suicide attempts and 15-56% completed
Alcohol-related anxiety disorder
Anxiety and alcohol consumption cause each other
Anxiolytic properties of alcohol often results in attempts of self-medication in patients with PHOBIA
Alcohol withdrawal can mimic anxiety and panic symptoms
Substance-related disorders - psychostimulants and CNS depressants, Chinese names
Psychostimulant e.g. cocaine, methamphetamine, MDMA, ephedrine in cough medicine
CNS depressant e.g. BZD, Z drugs, alcohol, opioids
Methamphetamine 冰 Heroin 白粉 Midazolam 藍精靈 Methadone 美 za don Hypnotics 安眠藥 MDMA fing 頭 Cannabis 草，大麻 Cocaine 可樂 Zoplicone 白瓜子 Ketamine K仔
Psychostimulants and their effects (psychological and physical)
Alertness, hyperactivity, euphoria, irritability, aggression, hallucinations (especially cocaine – formication), psychosis
Physical effects: HT, tachycardia, arrhythmia, tremor, sweating, dilated pupil (mydriasis)
- perforated nasal septum (cocaine)
- fever (ecstasy)
CNS depressants and their effects (psychological and physical)
Opiates e.g. heroin, methadone
- euphoria, drowsiness, apathy
- physical effects: miosis, conjunctival injection (hyperaemia), nausea, pruritus, constipation
Sedatives e.g BZD
- drowsiness, disinhibition, confusion, poor concentration, reduced anxiety, feeling of well-being
- physical effects: miosis, hypotension, withdrawal seizures, respiratory depression, impaired coordination
Hallucinogens, Dissociative anaesthetics examples and effects
Hallucinogens e.g. LSD
- marked perceptual disturbances with chronic flashbacks, paranoid ideas, psychosis, suicidal ideas
- physical: mydriasis, conjunctival injection, HT, tachycardia, sweating, fever, tremors, LOA
Dissociative anaesthetics e.g. Ketamine
- hallucinations, paranoid ideas, thought disorganisation, aggression
- physical: mydriasis, tachycardia, HT, perforated nasal septum
Cannabinoids effects
Euphoria, relaxation, ALTERED TIME PERCEPTION, psychosis
Impaired coordination and reactive time, conjunctival injection, nystagmus, dry mouth
Inhalants examples and effects
Aerosols, glue, light fluid, petrol
Disinhibition, stimulation, euphoria, clouded consciousness, hallucinations, psychosis
Physical: headache, nausea, slurred speech, loss of motor coordination, muscle weakness, damage to brain/BM/liver/kidneys/myocardium, sudden death
Stimulant use disorder criteria, determining severity
AT LEAST TWO of the following in a 12 MONTH PERIOD
- (same as alcohol use disorder)
Mild 2-3
Moderate 4-5
Severe >6
Aetiology of dependence syndrome - which drugs more likely, risk factors, conditioning
Drugs with strong potential for dependence e.g. cocaine, opiates
A/w increasing DA release from mesolimbic pathway
- operant conditioning (association of behaviour and consequence – reward or punishment)
Price, availability and cultural attitude
Risk factors:
Social deprivation, family environment, conduct disorder in childhood, antisocial personality disorder, severe mental illness
Hx taking for substance abuse
Nature, extent and pattern of use
- quantity (may ask cost if patient can’t specify), method, circumstances, form of drug, frequency
- primary drug of abuse
- why use?
- recent use/last use (past use = >12 mths)
- effects – drug induced psychosis most common
Dependence features
Complications and risk assessment
- Bio e.g. blood borne disease such as HIV/HBV for Heroin, liver/HT/pancreatitis for alcohol, **cystopathy/cholangiopathy/nasal problems for ketamine, head injury
- Psycho e.g. stimulants (psychosis causing violent risk especially meth, depression on withdrawal with suicidal risk) vs depressants (depression, cognitive impairment with risk of self-neglect, withdrawal seizure)
- rmb OPIOIDS WON’T HAVE SEIZURES
- Social e.g. interpersonal, financial, vocational, legal, family, children
FHx of suicide, drug abuse, psychiatric illness
Other hx as usual
MSE – assess stage of change and motivation
Physical examination and Ix for substance abuse
Signs of intoxication
Heroin –> IVDA - thrombophlebitis; pinpoint pupil
Meth –> meth bugs (due to tactile hallucination and delusion of infestation, itchiness of skin), teeth grinding, poor hygiene
Ketamine –> perforated nasal septum (ischaemic necrosis by vasoconstriction)
Cough med –> teeth cavities (sweetness, xerostomia)
Cannabis –> conjunctival injection
Ix: urine toxicology
Management of opiate abuse - overdose, primary objective, short term approach, medications, symptoms and risk of withdrawal, psychological therapy, addressing perpetuating factors
If overdose: NALOXONE antidote
Primary objective: DETOX (gradual reduction of dosage, until zero)
Short term: HARM REDUCTION principle
- education on risks of contaminated equipment, unsafe sexual behaviour
SUBSTITUTION therapy
- Methadone 老美 (long acting opiate) with gradual reduction
- Bupropion (partial agonist) may be used but can precipitate withdrawal in high dependence
Lofexidine (alpha2A adrenergic receptor agonist) can also help with withdrawal (insomnia, muscle ache/chills, sweating, diarrhoea, vomiting, flu-like symptoms) by reducing sympathetic outflow
Remember - OPIATE WITHDRAWAL NOT LIFE THREATENING, NOT 100% HAVE TO COVER WITH DRUG
After detox, naltrexone used to block euphoriant effects of future opiate use
Psychological: motivational interviewing, CBT, group therapy
Address perpetuating factors e.g. issues with family and peers, housing, criminality, prostitution, engagement with healthcare and social services
Management of BZD abuse - symptoms of withdrawal, risks, medications/approach
Benzodiazepine withdrawal syndrome
- hallucinations, convulsions, delirium, tingling, numbness, sensory hypersensitivity, muscle twitches, tinnitus, DEATH
SWITCH to LONG ACTING drugs e.g. diazepam then DOSE REDUCED VERY SLOWLY every wk depending on response – usually around 1/8 REDUCTION EVERY 14 DAYS
(shorter acting = easier seizure such as midazolam)
–> withdrawal chart to monitor
Criteria for stimulant withdrawal
- Cessation of prolonged stimulant use
- DYSPHORIC mood and >2 of the following
- fatigue
- increased appetite
- vivid, unpleasant dreams
- insomnia, hypersomnia
- psychomotor agitation or retardation - Cause significant distress or impairment
- Not due to another medical condition or disorder
Methamphetamine - Chinese names, type of drug, route of administration, usual dose/pattern of use, acute mental and physical effects, withdrawal symptoms, psychiatric comorbidities
ICE
冰，凍嘢，麻古，滑雪
Causes dopamine release
Tx of ADHD, narcolepsy but not prescribed in HK
Stimulant, usually smoked (heated and vaporised into bottle/Ice bong with juice, then inhaled)
- 0.1-0.2g daily consumption, median 0.3
- usually use a lot in one go then stop when euphoria decreases (11.9+/- 9.3 hrs)
Effects:
- acute mental/intoxication - euphoria, alertness, energy, increased libido, PREOCCUPATION IN OWN THOUGHTS, psychotic symptoms at high dose
- acute physical - HT, tachycardia, mydriasis, hyperthermia, seizures, anorexia (APPETITE SUPPRESSION), stereotypy (repeating actions), renal failure
Prolonged sleep and mild dysphoria as drug effects wear off
Withdrawal 熔雪
- dysphoria (depressed mood, anxiety)
- disturbed sleep
- reduced energy
- cognitive impairment
- craving
- increased appetite
Psychiatric comorbidities
- 76% PSYCHOSIS
- 11% mood
- 1% anxiety
ICE induced psychosis - common forms, duration/dose/onset, criteria for drug induced psychosis
Hallucinations 85% auditory, 46% visual
Delusions of reference 63%, persecutory 42%
Variability in dose required and onset of symptoms
Duration also variable
Dx of drug induced psychosis
- delusions/hallucinations
- related to intoxication of drug with KNOWN PSYCHOTIC EFFECTS
- excluding other psychiatric disorders e.g. Hx of non-drug related psychosis, psychotic symptoms persisting >1 month after last drug use
- presence of psychosis in non-delirium state
But in reality, usually patients constantly take drugs so can’t tell from underlying schizophrenia (assume organic cause in Ddx)
Cocaine - type of drug, pattern of use/route, acute effects, long term effects, intoxication and withdrawal symptoms, psychiatric comorbidities
可卡因
- action similar to ICE
Stimulant, usually snorted, also smoked (crack cocaine)
Average 0.7g daily consumption
Very expensive – financial problems in patients
Effects:
- acute mental: euphoria, arousal, focus and alertness, libido, talkative, improved fatigue and performance, LOA
- acute physical: increased HR/BP, mydriasis, increased light sensitivity, rapid speech, dyskinesia, n/v
Long term use:
- nasal septum perforation (ischaemic effect), damage to cribriform plate leading to loss of smell
- rashes, skin reddening itching, picking, scratching
Intoxication: 1-2g (lethal dose)
- chest pain, sweating, tremors, confusion, hyperthermia, renal damage, seizures, stroke, arrhythmia
Withdrawal: 1-3 wks
- craving, dysphoria, depression, increased appetite, hypersomnia
Psychiatric comorbidities
- substance induced psychosis –> 90% delusional, 83% AH, 38% VH, 21% tactile (FORMICATION)
- MDD
- substance induced mood disorder
- schizophrenia
- GAD
Ketamine - type of drug, pattern of use/route, psychological effects, brain damage effects, physical complications, toxicity, psychiatric comorbidities, treatment
K仔
- NMDA receptor blockade
- medical use for pain control
- common abuse in HK and China
Hallucinogen, usually snorted, 0.5-20g daily
Effects:
- acute in healthy ppl - perceptual disturbances (dissociation, delusions, hallucinations), schizophrenia-like negative symptoms/positive symptoms/cognitive symptoms (executive fx, episodic memory)
- acute in psychiatric patients - exacerbate schizophrenia positive symptoms, impairs cognition, rapid but transient antidepressant effect
Brain damage:
- reduced regional grey matter volume at orbitofrontal, medial prefrontal and hippocampus
- -> affect attention, executive function, visual/verbal memory
Physical complications:
- CYSTITIS –> dysuria, frequency, urge incontinence, urgency, painful haematuria, reduced bladder capacity
- cholangiopathy (strictures)
- perforated nasal septum
Toxicity: respiratory depression, coma (lethal dose unknown)
Psychiatric comorbidities
- mood, psychotic, anxiety disorders
Tx: psychosocial interventions, no specific medications, may require long term (12 months) residential tx e.g. rehab centres
Cannabis - forms of drug, addictive content, pattern of use/route, mental and physical effects, intoxication, comorbidities, increases risk of which disease
MOST COMMONLY ABUSED - 30% can become addicted
草,牛,花,大麻
Forms: herbal cannabis (chopped dried leaves), resin 糕 secreted by plant (10-20% THC), hashish oil product of extraction by organic solvents (15-30% THC)
Tetrahydrocannabinol THC interacts with endogenous receptors to increase dopamine release
- not legal in HK; legal in other countries
Smoked (roll into cigarette), 0.5-6g per joint
–> can be used more regularly than ICE (establish regular, persistent or solitary use in history)
Effects:
- acute mental - relaxation, euphoria, disorientation, ALTERED PERCEPTION OF TIME AND SPACE (everything feels slower), lack of concentration, MORE VIVID SENSES (everything magnified), sedation, mood changes e.g. paranoia
- acute physical - increased HR, conjunctival injection, dry mouth, increased appetite, vasodilation
Intoxication
- dulling of attention
- psychosis, image distortion
Toxicity: overdose uncommon, not fatal
Psychiatric comorbidities
- substance induced psychosis (1/6)
- **SCHIZOPHRENIA (most a/w with increased risk of schizo)
- MDD
- substance induced mood disorder
Treatment of Cannabis use disorder - first line, other options
Psychosocial interventions first line
- CBT, motivational enhancement therapy, multidimensional family therapy
Medication for withdrawal symptoms (anxiety, irritability, tremors, nausea)
- cannabinoid-1-agonists
- zolpidem +/- nabilone
- nabilone with lofexidine
- nabiximols
Cough medicine - main ingredients, effect, withdrawal, cormorbidities, overdose effects
3 main ingredients
- ephedrine – vasoconstriction, decrease drowsiness
- codeine or dextromethorphan – opioid, affect airway
- promethazine – 1st gen antihistamine, drowsiness
Effects:
- acute mental - euphoria, dissociation
- acute physical - slurred speech, ataxia, nystagmus
- chronic mental - hallucinations, manic, irritability, paranoia, disorganised behaviour
- chronic physical - muscle aches, stomach upset/abd pain, n/v/d, night sweats, agitation
Withdrawal:
- v/d, night sweats, muscle aches, restlessness, early insomnia, feeling cold and sweaty
Psychiatric comorbidities:
- many (drug induced psychosis, MDD, dysthymia, drug induced mood disorder, GAD, schizo etc)
Overdose: lethal, drug conc of dextromethorphan 950 microgram/L
MDMA/Ectasy - type of drug, route, effects, chronic mental effects, psychiatric comorbidities
Derivative of meth, potency 1/8 of meth
Stimulant and Hallucinogen
Swallowed, 1 tablet/day (70-140 mg)
Effects:
- acute mental - relaxation, euphoria, increased energy, increase sociability, increased responsiveness to touch; agitation/panic attacks/hallucinations at high dose
- acute physical - mydriasis, increased HR/BP, fever, increased light sensitivity, rapid speech, n/v, dyskinesia
- chronic mental effects - poor memory recall, panic attacks, psychosis, depersonalisation
Psychiatric comorbidity
- many
Sleeping pills - examples, Chinese names, detox regime, acute mental/physical effects, chronic mental/physical effects, psychiatric comorbidities
Z drugs
- zoplicone, zolpidem 瓜子
BZD
- midazolam 藍精靈, nimetazepam 花仔/五仔
Detox: Switch to LONG ACTING BZD, Q1H monitor vitals and withdrawal symptoms, taper down gradually
Acute mental effects:
- both sedative, hypnotic, anxiolytic
- Z drug euphoria in high dose
Acute physical effects:
- Z drug - muscle relaxant, respiratory inhibition, psychomotor and coordination problems, danger of falls
- BZD - muscle weakness, ataxia, confusion, headache, blurred vision, GI disturbances
Chronic mental effects:
- tolerance/addiction, psychiatric symptoms e.g. depression, anxiety, cognition impairment, amnesia
- Z drugs - psychosis, sleep walking, compulsive behaviour
- BZD - confusion
Chronic physical effects:
- renal/hepatic impairment
- Z drugs - urinary incontinence, palpitations
- BZD - weakness, dizziness, paraesthesia, visual disturbances, GI disturbances, flu-like symptoms
Toxicity
- delirium, cognition impairment, shallow breathing, coma, death
- Z drugs - psychosis
Withdrawal
- rebound insomnia, anxiety, depression, tremor, seizures, delirium
- Z drugs - psychotic reactions, n/v, lightheadedness
- BZD - numbness, muscle twitching, tinnitus, hallucinations, decreased memory/attention, death!
Psychiatric comorbidities
- MDD, substance induced psychosis
- GAD
- dysthymia, substance induced mood disorder
- schizophrenia
Stages of change to assess motivation
- Precontemplation
- denial, ignoring problem, not considering change - Contemplation
- ambivalence, conflicting emotions (positive benefits of change vs costs of change)
- may last a long time - Preparation
- experimenting with small changes, collecting information about change - Action
- direct action towards a goal - Maintenance
- maintenance of new behaviour and avoiding temptations - Relapse
- may feel frustrated, disappointed, failed
