Alcohol and Substance Abuse Flashcards
How does ICD-10 classify substance misuse disorders?
According to the type of substance and type of disorder
What are the types of substance misuse disorders - ICD-10?
Acute intoxication Harmful use - recurrent misuse associated with physical, psychological and social consequences Dependence syndrome Withdrawal state Psychotic disorder Amnesic syndrome Residual disorder
What is psychotic disorder in substance misuse?
Onset of psychotic symptoms within 2 weeks of substance use, must persist for more than 48 hours
What is amnesic syndrome in substance misuse?
Memory impairment in recent memory, impaired learning of new material, and inability to recall past experiences.
What is residual disorder in substance abuse?
Specific features e.g. flashbacks, personality disorder, affective disorder, dementia, persisting cognitive impairment - subsequent to substance misuse.
What is the pathophysiology of substance misuse?
Biological - genetic or neurochemical variations
Environmental - peer pressure, life stressors, parental drug use, cultural acceptability, personal vulnerability
What is the chain of events and factors that are involved in substance dependence?
Initial factors
Takes substance - cost, availability, effect of drug, route
Positive reinforcement - psychosocial reinforcement from peers, biological reinforcement - activates mesolimbic dopaminergic reward pathways.
What are some examples of opiates?
Morphine
Diamorphine - heroin
Codeine
Methadone
What are the routes of administration of opiates?
Morphine - PO, IV
Diamorphine - IN, IV, smoked
Codeine/methadone - PO
What are the psychological effects of opiates?
Apathy Disinhibition Psychomotor retardation Impaired judgement and attention Drowsiness Slurred speech
What are the physical effects of opiates?
Respiratory depression Hypoxia Decreased BP Hypothermia Coma Pupillary constriction
What is the withdrawal state symptoms from opitates?
Craving Rhinorrhoea Lacrimation Myalgia Abdominal cramps Nausea and vomiting Diarrhoea Pupillary dilatation Piloerection Increase HR, BP
What are the routes of cannabis?
PO, smoked
What are the psychological effects of cannabis?
Euphoria Disinhibition Agitation Paranoid ideation Temporal slowing Impaired judgement Illusions and hallucinations
what are the physical effects of cannabis?
Increased appetite
Dry mouth
Conjunctival injection - enlargement of conjunctival vessels
Increased HR
What are the symptoms of a withdrawal state from cannabis?
Anxiety Irritability Tremor of outstretched hands Sweating Myalgia
What are stimulants?
Cocaine, crack cocaine, ecstasy (MDMA) amphetamine
What are the psychological effects of stimulants?
Euphoria Increased energy Grandiose beliefs Aggression Hallucinations Labile mood
What are the physical effects of stimulants?
Increase in HR Increase in BP Arrhythmias Sweating, N+V, pupillary dilatation Psychomotor agitation Muscular weakness Chest pain Convulsions
What are the withdrawal symptoms of stimulants?
Dysphoric mood must be present Lethargy Psychomotor agitation Craving Increased appetite Insomnia or hypersomnia Bizarre/unpleasant dreams
What are examples of hallucinogens?
LSD
Magic mushrooms
What are the psychological effects of hallucinogens?
Anxiety Illusions Hallucinations Depersonalisation Derealisation Paranoia Hyperactivity Impulsivity
What are the physical effects of hallucinogens?
HR increased Palpitations Sweating Tremor Blurred vision Pupillary dilatation Incoordination
What are the physical complications of substance misuse?
Death
Infection - HIV, Hep A/B/C, staph aureus, TB, endocarditis, DVT, PE
What are the psychological complications of substance misuse?
Craving
Anxiety
Cognitive disturbance
Drug-induced psychosis
What are the social complications of substance misuse?
Crime, imprisonment, homelessness, prostitution, relationship problems
What manifestations must have occurred over 1 month to be classed as substance dependence?
DRUG PROBLEMS WILL CONTINUE TO HARM
strong Desire (compulsions) to consume substance
Preoccupation with substance use
Withdrawal state
impaired ability to Control substance-taking behaviour
Tolerance to substance, require more for effect
persist with use, despite Harmful effects
What should be acquired in the history of substance misuse?
Quantity - how often, how long, how much money spent per week Effects experienced Impact on life Do you feel taking the drug is at the forefront of your mind - preoccupation Any withdrawal problems Can you control consumption Tolerance Aware of harmful effects
TRAP = type, route, amount, pattern
Complete risk assessment - suicide, self-harm, IV use, needle sharing
What are examples of class A drugs?
Crack cocaine, cocaine, ecstasy, heroin, LSD
Methadone, magic mushrooms
What are examples of class B drugs?
Amphetamines, barbiturates, cannabis, ketamine
What are examples of class C drugs?
Anabolic steroids, benzodiazepines
What are the investigations for substance misuse?
Bloods: HIV screen, Hep B, Hep C, Tb testing
U&Es for renal function
LFTs and clotting to check hepatic function
Drug levels
Urinalysis
ECG for arrhythmias, ECHO if endocarditis suspected
What are the differentials for substance misuse?
Psychiatric disorders e.g. psychosis, mood disorders, anxiety disorders, delirium
Organic disorders - hyperparathyroidism, cva, intercranial haemorrhage, neurological disorders
What is detoxification vs maintenance therapy?
Detox is when the effects of a drug are eliminated in a safe manner, replacement drug is weaned, and withdrawal symptoms avoided
Maintenance therapy - abstinence not priority, minimise harm e.g. IV drug use
What is the management of substance misuse?
Keyworker with therapeutic alliance assigned.
Hep B immunisation.
Motivational interviewing and CBT for co-morbid depression or anxiety.
Contingency management focuses on changing specified behaviours by offering incentives e.g. financial for positive behaviours e.g. abstinence.
Supportive help for housing, finance and employment.
Self help groups e.g. Narcotics Anonymous, cocaine anonymous
Driving and DVLA
What is the management of opioid dependence?
Biological therapies e.g. methadone first-line or buprenorphine for detoxification AND maintenance
Naltrexone for those formerly opioid dependent, now stopped and motivated to continue abstinence.
IV naloxone - opioid antagonist can be used as an antidote to opioid overdose.
What are the physical health risks of misusing cocaine?
CARDIAC: MI, dissection, coronary vasospasm, HTN, QT prolongation
NEURO: seizures, stroke (haemorrhagic or ischaemic), increased tone (rhabdomyolysis)
GI: ischaemic colitis
OTHER: DVT
How is cocaine toxicity managed?
Benzodiazepines (inc. for cocaine induced chest pain)
+/- GTN for chest pain
+/- sodium nitroprusside for HTN
How could someone presenting with MDMA/ecstasy toxicity present? Signs, symptoms, bloods?
Agitated, confused, ataxic
Tachycardic, hypertensive, pyrexic, dilated pupils
Rhabdomyolysis
Hyponatraemia
How could MDMA associated pyrexia be managed?
Dantrolene if supportive measures don’t work
How is LSD toxicity managed?
Benzodiazepines for a “bad trip” causing agitation
Antipsychotics for drug induced psychosis
How would someone who has taken “spice” present?
Catatonic state
Respiratory depression
How would someone who has taken GHB/ liquid ecstasy present?
Respiratory depression
Bradycardic, hypotensive
Can have a GCS of 3
How would someone who has taken an opioid OD present?
Bradycardic, bradypnoeic, pinpoint pupils
Drowsy
What are the long term effects of opioid misuse?
Infective endocarditis
Septic arthritis
HIV
Crime and prostitution
How would organophosphate poisoning present?
Salivation, lacrimation, urinate, diarrhoea
Bradycardic and hypotensive
Small pupils
How is organophosphate poisoning managed?
Atropine
How would a benzodiazepine OD managed?
Drowsy
Respiratory depression
Slurred speech
Ataxia
When and how is a benzodiazepine OD managed?
Only in iatrogenic - related to illness caused by medical examination or treatment
Flumazenil
What are some supportive management strategies used for symptomatic control of drug ODs?
BB for tachycardia Nifedipine for HTN Cool fluids for pyrexia Benzodiazepines for agitation Sodium bicarbonate for agitation Insulin/glucose for K
How do you calculate the units of alcohol in a drink?
What is considered safe?
Units = volume (litres) x % alcohol content (ABV)
No more than 14 units a week, spread over 3 or more days
Describe the timing and progression of symptoms occurring in alcohol withdrawal
Alcohol withdrawal syndrome can manifest as early as 6-12 hours following abrupt cessation.
Tachycardia, HTN, tremor, sweating, pyrexia, nausea, retching, insomnia, hyperactivity, anxiety.
Symptoms peak between 10-30 hours, subside by 40-50 hours.
Transient visual and auditory hallucinations may develop and last for 5-6 days.
What signs and symptoms define delirium tremens?
Impaired consciousness Confusion Hallucinations Agitation Marked tremor Paranoid ideation Agitation Insomnia Autonomic hyperactivity - tachycardia, hypertension, pyrexia, sweating.
Typically peak at 72-96 hours after cessation of drinking, can last up to 3 days.
Hyperpyrexia, ketoacidosis, profound circulatory collapse may develop.
How is alcohol withdrawal managed?
General management - close observation, monitor vital signs, baseline ECG, correction of dehydration or electrolyte imbalance
Monitor for risk of re-feeding
Treatment of concurrent conditions
Random breathalyser and urine drug screen
Management of common symptoms: Good sleep hygiene Regular food intake for poor appetite Oral or IM cyclizine for nausea if severe diarrhoea, loperamide Check for signs of liver disease if itching, give chlorphenamine
What are the investigations for alcohol withdrawal?
Medication history of prescribed and non-prescribed drugs FBC, B12, folate Liver function tests including Gamma GT U&Es HbA1C Amylase Breathalyser test Urine drug screen Routine observations; ECG, baseline bp, pulse
Who is at risk of delirium tremens?
Elderly
Malnourished
Those with major co-morbidities.
History of alcohol related seizures or previous DTs may act as a trigger for onset.
How can an assessment of alcohol use be made?
Take alcohol history
Contact local alcohol support service provider e.g. Turning Point to determine if patient is known to services.
Determine units and drinking pattern.
Use of AUDIT - alcohol use disorders identification test, and SADQ - severity of alcohol dependence questionnaire.
20 item questionnaire scoring maximum of 60 points, 0 - almost never, 3 - nearly always.
What is Wernicke’s encephalopathy?
Presence of neurological symptoms caused by biochemical lesions of the CNS after exhaustion of B-vitamin reserves e.g. thiamine.
Characterised by a triad of opthalmoplegia, ataxia and confusion.
Opthalmoplegia - most commonly affects lateral rectus gives nystagmus.
What is Wernicke-Korsakoff syndrome?
Combined presence of Wernicke encephalopathy and Korsakoff syndrome.
Acute Wernicke encephalopathy phase followed by development of Korsakoff syndrome phase.
Thiamine deficiency in alcohol abuse and malnutrition.
What is Korsakoff syndrome?
Disorder of CNS
Characterised by amnesia, deficits in explicit memory and confabulation.
Due to thiamine deficiency and associated with and exacerbated by prolonged, excessive ingestion of alcohol.
What are the seven major symptoms of Korsakoff syndrome?
Anterograde amnesia - memory loss for events after onset of syndrome
Retrograde amnesia - memory loss extends back for some time before onset
Amnesia of fixation - loss of immediate memory, person unable to remember events of past few minutes
Confabulation - invented memories taken as true, due to gaps in memory
Minimal content in conversation
Lack of insight
Apathy - interest in things is quickly lost, indifference to change
What other symptoms can patients show in WE?
Confusion - typically quiet global confusion Ataxia not due to intoxication Memory disturbance Hypothermia Hypotension Coma/unconsciousness Drowsiness and stupor
How often should withdrawal symptoms be monitored?
Twice a day for first 4 days, and daily thereafter
What are the drugs of choice for withdrawal symptoms?
Benzodiazepines
Long acting e.g. diazepam and chlordiazepoxide more effective in preventing withdrawal seizures
Short acting e.g. lorazepam and oxazepam may have lower risk of over sedation
When should benzos be avoided in treating withdrawal symptoms?
Avoided in severe liver impairment
Use of oxazepam should be considered as not metabolised in the liver, has a short half-life and less prone to accumulation and toxicity.
What vitamin supplementation should be offered in withdrawal?
Parenteral vitamins prophylactically to all detoxification inpatients as the risk of WE-K is high.
Vitamin B & C IM injections
1 pair a day for 3-5 days
When is parenteral thiamine essential?
Alcohol withdrawal seizures DTs Malnutrition Physical illness Acute peripheral neuritis Decompensated liver disease
What is important to ask in drugs and alcohol history?
What drug(s) How long How much Money How often Withdrawal
Previous treatment episodes
Complications
Overdose
BBV
Past medical hx
Social hx esp housing and support
What are the main causes of mortality in relation to alcohol?
Fights and falls Liver failure Pancreatitis Overdose - respiratory depression Withdrawal Wernicke's Encephalopathy
What are worrying symptoms in alcohol use?
Head injury Confusion Shaking/seizures Hallucinations Vomit blood - coffee ground Severe abdo pain Suddenly yellow - acute hepatitis
Need admission
What are the early symptoms of alcohol withdrawal?
Tremor, sweating
Nausea, anxiety
Tachycardia
What are the late symptoms of alcohol withdrawal?
Delirium tremens Disorientation Hallucination Tremor BP, pulse, fever, motor incoordination
What are signs of opiate misuse?
Not many signs Pin point pupils Decreasing consciousness Slow breathing Death
Recovery position, 999, artificial resp and naloxone
What is naloxone?
Used to counter decreased breathing in opioid overdose
Can also be used with an opioid in same pill to decrease the risk of opioid misuse
Is a non-selective and competitive opioid receptor antagonist.
What are the signs of opiate withdrawal?
Early - sweaty clammy skin, persistent yawning, rhinorrhoea, tachycardia
Dilated pupils, lacrimation
Goosebumps
Late - nausea and vomiting, diarrhoea, insomnia, abdominal cramps, muscle pains
