Alcohol and Substance Misuse Flashcards
State the seven ICD10 categories of Substance Misuse
1 - Acute Intoxication
2 - Harmful Use (but no dependence)
3 - Dependence Syndrome
4 - Withdrawal State
5 - Psychotic Disorder
6 - Amnesic Syndrome
7 - Residual Disorder (Personality disorder etc as a result of substance misuse)
Describe the Biological Aetiology behind Substance Misuse
- Genetics (variations in enzymes that metabolise drugs)
- Neurochemical Abnormalities
- Mesolimbic Dopaminergic Reward Pathway - biological reinforcement
- Psychosocial reinforcement from peers of pleasurable effects
- peer pressure
- life stressors
- parental drug use
- cultural acceptability
- cost
- availability
- effect of drug
- route
leads to dependence
Substance Dependence requires more than three of the following symptoms over a period of 1 month
Drug Problems Will Continue To Harm
strong Desire to consume substance
Preoccupation with substance
Withdrawal state when stopped/reduced
impaired ability to Control
Tolerance to substance requiring more consumption for desired effect
persisting with use despite clear Harm
Give 4 examples of Stimulant Drugs and their route
- Cocaine (IN, IV, smoked)
- Crack cocaine (IN, IV, smoked)
- Ecstasy (PO)
- Amphetamine (PO, IV, IN, smoked)
Describe the psychological effects of Stimulant Drugs
Euphoria
Increased Energy
Grandiose beliefs
Aggression
Arguemtative
Illusions
Hallucinations
Describe the physical effects of Stimulant Drugs
- Tachycardia
- Hypertension
- Arrhythmias
- N&V
- Dilated pupils
- psychomotor agitation
- muscular weakness
- chest pain
- convulsions
Describe the withdrawal effects of Stimulant Drugs
- Dysphoric mood - must be present
- Lethargy
- Psychomotor Agitation
- Craving
- Increased Appetite
- Insomnia
- Bizarre or unpleasant dreams
Name two Hallucinogens and their route
LSD
Magic Mushrooms
both PO
Describe the psychological effects of Hallucinogenic Drugs
- Anxiety
- Illusions
- Hallucinations
- Derealisation/Depersonalisation
- Paranoid
- Ideas of reference
- Hyperactivity
- Impulsivity
- Inattention
Describe the physical effects of Hallucinogenic Drugs
- Tachycardia
- Palpitations
- Sweating
- Tremor
- blurred vision
- pupillary dilation
- incoordination
Describe the psychological effects of Volatile Solvent Drugs (aerosols, paint, glue, petrol which are inhaled)
- Apathy
- lethargy
- Aggression
- Impaired attention and judgement
- Psychomotor retardation
Describe the physical effects of Volatile Solvent Drugs
- Unsteady Gait
- Diplopia
- Nystagmus
- Decreased consciousness
- Muscle weakness
Describe the psychological effects of Anabolic Steroids (testosterone, androstenedione, danazol which can all be taken PO and IM)
- Euphoria
- Depression
- Aggression
- Hyperactivity
- Mood Swings
- Hallucinations
- Delusions
Describe the physical effects of Anabolic Steroids
- Increased muscle mass
- Reduced fat
- Acne
- Reduced sperm count
- Male pattern baldness
- Stunted growth
Describe psychological effects of opiates
- Apathy
- Disinhibition
- Psychomotor retardation
- Impaired judgement and attention
- Drowsiness
- Slurred speech
Describe physical effects of opiates
- respiratory depression
- hypoxia
- decreased BP
- hypothermia
- low bp
- coma
- pupillary constriction
describe the withdrawl signs of opiates
craving
rhinorrhoea
lacrimation
myalgia
abdominal cramps
N&V
dirrhoea
dilated pupils
piloerection
raised heart rate and BP
describe the psychological effects of cannabis (cannabinoids)
(PO or smoked)
- euphoria
- disinhibition
- agitation
- paranoid ideation
- temporal slowing
- impaired judgement/attention/reaction time
- illusions
- hallucinations
describe the physical effects of cannabis
increased appetite
dry mouth
conjunctival injection
increased heart rate
describe the withdrawl signs of cannabis
anxiety
irritability
tremor of outstretched hands
sweating
myalgia
describe the psychological effects of sedative-hypnotics such as benzodiazepines and barbiturates (PO, IV)
euphoria
disinhibition
apathy
aggression
anterograde amnesia
labile mood
describe the physical effects of sedative-hypnotics
- unsteady gait
- difficulty standing
- slurred speech
- nystagmus
- erythematous skin lesions
- low bp
- hypothermia
- depression of gag reflex
- coma
what are the withdrawl signs of sedative-hypnotics
- tremor of hands
- tongue or eyelids
- N&V
- increased heart rate
- postural drop in BP
- headache
- agitation
- malaise
- transient illusions/hallucinations
- paranoid ideation
- grand mal convulsions
Give 5 potential consequences of Substance Misuse
Endocarditis Drug Induced Psychosis DVT Crime Homelessness
Give an example of a Class A drug and the subsequent UK law
Cocaine
7 years prison for possession, up to life for supply
Give an example of a Class B drug and the subsequent UK law
Ketamine
5 years for possession, up to 14 years for supply
Give an example of a Class C drug and the subsequent UK law
Benzodiazepines
Up to 2y possession and 14y for supply
Name four investigations for a known substance abuser
Bloods - BBV (HIV, HEP B &C, LFTs, & clotting, U&Es, drug levels
Urinalysis - Drug Metabolites
ECG - Arrhythmias
Echo - Endocarditis
Describe the management of Opioid Dependence
Detoxification and Maintenance- Methadone/Buprenorphine
Continued Abstinence (ie after detoxification) - Naltrexone
Overdose antidote = Naloxone
Describe four psychosocial interventions for Substance Misuse
- Keyworker with a therapeutic alliance for psychosocial support
- Hep B immunization if risk
- Motivational interviewing and CBT
- Contingency Management (changing specific behaviours by offering incentives for positive behaviours)
- Supportive help with finance/housing/employment
- Narcotics Anonymous
- Driving - DVLA guidelines
whats the difference between detoxification and maintenance?
detoxification refers to a process in which the effects of the drug are eliminated in a safe manner (replacement drug) such that the withdrawl symptoms are avoided in an attempt to attain abstinence
maintenance therapy - aim is to minimise harm rather than abstain
Define Alcohol Abuse
Consumption of alcohol at a level enough to cause physical psychiatric and social harm
Define Binge Drinking
Drinking twice over recommended level of alcohol per day in one session
>8 units for males
>6 units for females
Define Harmful Alcohol Use
Drinking above safe levels with evidence of alcohol related problems
>50 units per week for males and >35 units per week for females
Describe the biological effects of alcohol
Affects GABA causing Anxiolytic and Sedative effects
Pleasurable and stimulant effect from dopaminergic pathway sensitises and leads to dependence
Long term decreases GABA and increases Glutamate = hyper-excitability of the CNS when alcohol is withdrawn
long term use often experince cravings which has been linked to dopaminergic, serotonergic, opioid systems that mediate positive reinforcement
Describe the psychological theories behind alcohol dependence
Social Learning Theory
Operant Conditioning Therapy
what are some risk factors for alcohol abuse?
male
young adults
genetics
antisocial behaviour
lack of facial flushing
life stressors
Describe the ICD10 criteria for Alcohol Intoxication
A - Clear evidence of psychoactive substance, Disturbance in consciousness/cognition/behaviour, Not accounted for by mental/medical disorder
B - Evidence of dysfunctional behaviour, and one of unsteady gait/slurred speech/nystagmus/flushing
Describe the clinical features of Alcohol Dependence (SAW DRINk)
- *S**ubjective awareness of compulsion
- *A**voidance of withdrawal symptoms by drinking
- *W**ithdrawal symptoms
- *D**rink seeking behaviour predominates
- *R**einstatement if drinking after failed abstinence
- *I**ncrease tolerance
- *N**arrowing of drinking repertoire (fixed times)
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Describe the ICD10 criteria for Alcohol Withdrawal
A) General criteria for withdrawal state met (not accounted for by mental/medical disorders)
B) 3 of Tremor/Sweating/N and V/ Tachycardia/ Headache/Insomnia/Transient Hallucinations
Occurs 6-12hrs after abstinence
Give 5 long term manifestations of Alcoholism
Cirrhosis
HCC
Peptic Ulcers
Pancreatitis
Wernickes and Korsakoff
What is the CAGE questionnaire for Alcohol Abuse?
C - Have you ever felt you should CUT down on your drinking
A- Have people ANNOYED you by criticising your drinking
G - Have you ever felt GUILTY about your drinking
E - Do you ever have a drink EARLY in the morning
Describe the expected MSE for an Alcohol Intoxicated patient
Appearance - Poor coordination, alcohol smell
Speech - Slurred
Mood - Elevated or depressed
Thought - Variable
Perception- Normal
Cognition - Impaired judgement, reduced concentration
Insight - Poor
Describe the expected MSE for an Alcohol Withdrawn patient
Appearance - Agitated, Sweaty
Speech - Confused
Mood - Anxious
Thoughts - Paranoid Delusions
Perception - Visual Hallucinations, Illusions
Cognition - Delirium, Inattention
Insight - Poor
what blood tests would you do in excess alcohol consumption
blood alcohol level
FBC (anaemia)
U&Es (dehydration, low urea)
LFTs including gamma GT (may be raised)
blood alcohol concentration, MCV (macrocytosis)
vitamin B12/folate/TFTs (alternative causes of raised MCV)
amylase (pancreatitis)
hepatitis serology
glucose (hypoglycaemia).
Name three questionnaires for Alcohol Abuse
AUDIT (Alcohol Use Disorders Identification Test)
SADQ (Severity of Alcohol Dependence Questionnaire)
FAST screening tool
Describe the biological management of Alcohol withdrawal
High Dose Benzodiazepines (clordiazepoxide) used and tapered over 5-9 days
Thiamine Orally or IV as Pabrinex
Describe the long term Biological management of Alcohol Dependence
Disulfiram
Acamprosate (reduces craving by enhancing GABA)
Naltrexone
Describe the Psychological management of Alcohol Abuse
Motivational Interviewing
CBT
Environment based therapy
Motivational interviewing uses the Stages Of Change Model, describe it
1) Precontemplation
2) Contemplation
3) Determination
4) Action
5) Maintenance
6) Relapse
Describe the social management of Alcohol abuse
Alcoholics Anonymous (AA)
How do you calculate alcohol units?
how many ml in 1 unit of alcohol
10ml (8g) of ethanol
strengths x ml / 1000
bio-psychosocial approach to management of alcohol abuse
what is Karsakoff’s psychosis
profound irreversible short term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation of time
what is Wernicke’s encephalopathy
acute encephalopathy due to thiamine deficiency, presenting with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia
urgent treatment - as may progress to Karsakoff’s psychosis
treat with parenteral thiamine
what is the triad of Wernicke’s encephalopathy?
altered mental state
ataxia
ophthalmoplegia
what is delirium tremens?
withdrawl delirium develops between 24 hours and 1 week after alcohol cessation
peak at 72 hours
cognitive impairment, vivid perceptual abnormalities, paranoid delusion, marked tremor, autonomic arousal
treated with benzodiazepines, haloperidol for psychotic features and iv Pabrinex
