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Mental Health > Alcohol and Substance Abuse > Flashcards

Alcohol and Substance Abuse Flashcards

1
Q

How does ICD-10 classify substance misuse disorders?

A

According to the type of substance and type of disorder

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2
Q

What are the types of substance misuse disorders - ICD-10?

A 
Acute intoxication
Harmful use - recurrent misuse associated with physical, psychological and social consequences
Dependence syndrome
Withdrawal state
Psychotic disorder
Amnesic syndrome
Residual disorder
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3
Q

What is psychotic disorder in substance misuse?

A

Onset of psychotic symptoms within 2 weeks of substance use, must persist for more than 48 hours

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4
Q

What is amnesic syndrome in substance misuse?

A

Memory impairment in recent memory, impaired learning of new material, and inability to recall past experiences.

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5
Q

What is residual disorder in substance abuse?

A

Specific features e.g. flashbacks, personality disorder, affective disorder, dementia, persisting cognitive impairment - subsequent to substance misuse.

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6
Q

What is the pathophysiology of substance misuse?

A

Biological - genetic or neurochemical variations

Environmental - peer pressure, life stressors, parental drug use, cultural acceptability, personal vulnerability

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7
Q

What is the chain of events and factors that are involved in substance dependence?

A

Initial factors

Takes substance - cost, availability, effect of drug, route

Positive reinforcement - psychosocial reinforcement from peers, biological reinforcement - activates mesolimbic dopaminergic reward pathways.

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8
Q

What are some examples of opiates?

A

Morphine
Diamorphine - heroin
Codeine
Methadone

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9
Q

What are the routes of administration of opiates?

A

Morphine - PO, IV
Diamorphine - IN, IV, smoked
Codeine/methadone - PO

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10
Q

What are the psychological effects of opiates?

A 
Apathy
Disinhibition
Psychomotor retardation
Impaired judgement and attention
Drowsiness
Slurred speech
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11
Q

What are the physical effects of opiates?

A 
Respiratory depression
Hypoxia
Decreased BP
Hypothermia
Coma
Pupillary constriction
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12
Q

What is the withdrawal state symptoms from opitates?

A 
Craving
Rhinorrhoea
Lacrimation
Myalgia
Abdominal cramps
Nausea and vomiting
Diarrhoea
Pupillary dilatation
Piloerection
Increase HR, BP
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13
Q

What are the routes of cannabis?

A

PO, smoked

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14
Q

What are the psychological effects of cannabis?

A 
Euphoria
Disinhibition
Agitation
Paranoid ideation
Temporal slowing
Impaired judgement
Illusions and hallucinations
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15
Q

what are the physical effects of cannabis?

A

Increased appetite
Dry mouth
Conjunctival injection - enlargement of conjunctival vessels
Increased HR

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16
Q

What are the symptoms of a withdrawal state from cannabis?

A 
Anxiety
Irritability
Tremor of outstretched hands
Sweating
Myalgia
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17
Q

What are stimulants?

A

Cocaine, crack cocaine, ecstasy (MDMA) amphetamine

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18
Q

What are the psychological effects of stimulants?

A 
Euphoria
Increased energy
Grandiose beliefs
Aggression
Hallucinations
Labile mood
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19
Q

What are the physical effects of stimulants?

A 
Increase in HR
Increase in BP
Arrhythmias
Sweating, N+V, pupillary dilatation
Psychomotor agitation
Muscular weakness
Chest pain
Convulsions
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20
Q

What are the withdrawal symptoms of stimulants?

A 
Dysphoric mood must be present
Lethargy
Psychomotor agitation
Craving
Increased appetite
Insomnia or hypersomnia
Bizarre/unpleasant dreams
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21
Q

What are examples of hallucinogens?

A

LSD

Magic mushrooms

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22
Q

What are the psychological effects of hallucinogens?

A 
Anxiety
Illusions
Hallucinations
Depersonalisation
Derealisation
Paranoia
Hyperactivity
Impulsivity
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23
Q

What are the physical effects of hallucinogens?

A 
HR increased
Palpitations
Sweating
Tremor
Blurred vision
Pupillary dilatation
Incoordination
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24
Q

What are the physical complications of substance misuse?

A

Death

Infection - HIV, Hep A/B/C, staph aureus, TB, endocarditis, DVT, PE

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25
Q

What are the psychological complications of substance misuse?

A

Craving
Anxiety
Cognitive disturbance
Drug-induced psychosis

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26
Q

What are the social complications of substance misuse?

A

Crime, imprisonment, homelessness, prostitution, relationship problems

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27
Q

What manifestations must have occurred over 1 month to be classed as substance dependence?

A

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

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28
Q

What should be acquired in the history of substance misuse?

A 
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

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29
Q

What are examples of class A drugs?

A

Crack cocaine, cocaine, ecstasy, heroin, LSD

Methadone, magic mushrooms

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30
Q

What are examples of class B drugs?

A

Amphetamines, barbiturates, cannabis, ketamine

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31
Q

What are examples of class C drugs?

A

Anabolic steroids, benzodiazepines

32
Q

What are the investigations for substance misuse?

A

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

33
Q

What are the differentials for substance misuse?

A

Psychiatric disorders e.g. psychosis, mood disorders, anxiety disorders, delirium

Organic disorders - hyperparathyroidism, cva, intercranial haemorrhage, neurological disorders

34
Q

What is detoxification vs maintenance therapy?

A

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

35
Q

What is the management of substance misuse?

A

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

36
Q

What is the management of opioid dependence?

A

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.

37
Q

What are the physical health risks of misusing cocaine?

A

CARDIAC: MI, dissection, coronary vasospasm, HTN, QT prolongation
NEURO: seizures, stroke (haemorrhagic or ischaemic), increased tone (rhabdomyolysis)
GI: ischaemic colitis
OTHER: DVT

38
Q

How is cocaine toxicity managed?

A

Benzodiazepines (inc. for cocaine induced chest pain)

+/- GTN for chest pain
+/- sodium nitroprusside for HTN

39
Q

How could someone presenting with MDMA/ecstasy toxicity present? Signs, symptoms, bloods?

A

Agitated, confused, ataxic
Tachycardic, hypertensive, pyrexic, dilated pupils
Rhabdomyolysis
Hyponatraemia

40
Q

How could MDMA associated pyrexia be managed?

A

Dantrolene if supportive measures don’t work

41
Q

How is LSD toxicity managed?

A

Benzodiazepines for a “bad trip” causing agitation

Antipsychotics for drug induced psychosis

42
Q

How would someone who has taken “spice” present?

A

Catatonic state

Respiratory depression

43
Q

How would someone who has taken GHB/ liquid ecstasy present?

A

Respiratory depression
Bradycardic, hypotensive
Can have a GCS of 3

44
Q

How would someone who has taken an opioid OD present?

A

Bradycardic, bradypnoeic, pinpoint pupils

Drowsy

45
Q

What are the long term effects of opioid misuse?

A

Infective endocarditis
Septic arthritis
HIV
Crime and prostitution

46
Q

How would organophosphate poisoning present?

A

Salivation, lacrimation, urinate, diarrhoea
Bradycardic and hypotensive
Small pupils

47
Q

How is organophosphate poisoning managed?

A

Atropine

48
Q

How would a benzodiazepine OD managed?

A

Drowsy
Respiratory depression
Slurred speech
Ataxia

49
Q

When and how is a benzodiazepine OD managed?

A

Only in iatrogenic - related to illness caused by medical examination or treatment
Flumazenil

50
Q

What are some supportive management strategies used for symptomatic control of drug ODs?

A 
BB for tachycardia
Nifedipine for HTN
Cool fluids for pyrexia
Benzodiazepines for agitation
Sodium bicarbonate for agitation
Insulin/glucose for K
51
Q

How do you calculate the units of alcohol in a drink?

What is considered safe?

A

Units = volume (litres) x % alcohol content (ABV)

No more than 14 units a week, spread over 3 or more days

52
Q

Describe the timing and progression of symptoms occurring in alcohol withdrawal

A

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.

53
Q

What signs and symptoms define delirium tremens?

A 
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.

54
Q

How is alcohol withdrawal managed?

A

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
55
Q

What are the investigations for alcohol withdrawal?

A 
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
56
Q

Who is at risk of delirium tremens?

A

Elderly
Malnourished
Those with major co-morbidities.

History of alcohol related seizures or previous DTs may act as a trigger for onset.

57
Q

How can an assessment of alcohol use be made?

A

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.

58
Q

What is Wernicke’s encephalopathy?

A

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.

59
Q

What is Wernicke-Korsakoff syndrome?

A

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.

60
Q

What is Korsakoff syndrome?

A

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.

61
Q

What are the seven major symptoms of Korsakoff syndrome?

A

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

62
Q

What other symptoms can patients show in WE?

A 
Confusion - typically quiet global confusion
Ataxia not due to intoxication
Memory disturbance
Hypothermia
Hypotension
Coma/unconsciousness
Drowsiness and stupor
63
Q

How often should withdrawal symptoms be monitored?

A

Twice a day for first 4 days, and daily thereafter

64
Q

What are the drugs of choice for withdrawal symptoms?

A

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

65
Q

When should benzos be avoided in treating withdrawal symptoms?

A

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.

66
Q

What vitamin supplementation should be offered in withdrawal?

A

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

67
Q

When is parenteral thiamine essential?

A 
Alcohol withdrawal seizures
DTs
Malnutrition
Physical illness
Acute peripheral neuritis
Decompensated liver disease
68
Q

What is important to ask in drugs and alcohol history?

A 
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

69
Q

What are the main causes of mortality in relation to alcohol?

A 
Fights and falls
Liver failure
Pancreatitis
Overdose - respiratory depression
Withdrawal
Wernicke's Encephalopathy
70
Q

What are worrying symptoms in alcohol use?

A 
Head injury
Confusion
Shaking/seizures
Hallucinations
Vomit blood - coffee ground
Severe abdo pain
Suddenly yellow - acute hepatitis

Need admission

71
Q

What are the early symptoms of alcohol withdrawal?

A

Tremor, sweating
Nausea, anxiety
Tachycardia

72
Q

What are the late symptoms of alcohol withdrawal?

A 
Delirium tremens
Disorientation
Hallucination
Tremor
BP, pulse, fever, motor incoordination
73
Q

What are signs of opiate misuse?

A 
Not many signs
Pin point pupils
Decreasing consciousness
Slow breathing
Death

Recovery position, 999, artificial resp and naloxone

74
Q

What is naloxone?

A

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.

75
Q

What are the signs of opiate withdrawal?

A

Early - sweaty clammy skin, persistent yawning, rhinorrhoea, tachycardia
Dilated pupils, lacrimation
Goosebumps

Late - nausea and vomiting, diarrhoea, insomnia, abdominal cramps, muscle pains

Mental Health (15 decks)

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