Alcohol And Substance Misuse

Question 1

What are the ICD criteria for substance misuse?

Answer 1

Acute intoxication- Acute, transient effect of substance
Harmful use- Produces physical, psychological and social consequences but without the dependence
Dependence syndrome- Addiction, tolerance and withdrawal symptoms
Physical/psychological effects from complete/partial cessation of substances after prolongued/repeated or high levels of use
Psychotic disorder- Psychotic symptoms within 2wks of substance use, lasting >48hrs
Amnesic syndrome- Impaired learning memory, poor memory recall, clouded consciousness
Residual disorder- flashbacks, personality disorder, affective disorder subsequent to substance misuse.

Question 2

What is the pathophysiology of substance misuse?

Answer 2

Genetically people have abnor malities in their neurochemicals and so when their environemnt favours it they may take substances.
Enviornmental factors include peer pressure, life stressors, parental drug use, cultural acceptibility and personal vulnerability.

They take the drug and positive reinforcment from both peers and own chemical pathways over time lead to substance dependence.

M:F 3:1
Most common is cannabis

Question 3

What are the effects of opiates and the withdrawal symptoms?

Answer 3

Morphine (PO/IV), dimorphine (IN, IV, smoked), codeine/methadone (PO)

Pychological- Apathy, disinhibition, psychomotor retardation, impaired judgement, slurred speech etc.
Physical- Respiratory depression, hypoxia, low BP, hypothermia, coma, pupillary contriction.
Withdrawal (need 3)- Craving, rhinorrhoea, lacrimation, myalgia, N+V, pupillary dilation, piloerection, increased HR and BP.

Question 4

What are the effects of cannabinoids the withdrawal symptoms?

Answer 4

Cannabis (PO, smoked)

Psychological- Euphoria, disinhibition, paranoid, impaired judgement, hallucinations, impaired attention and reaction time.
Physcial- Increased appetite, dry mouth, conjunctival injection, increased HR
Withdrawal (need 3)- Anxiety, irritability, tremor of OSH, sweating, myalgia.

Question 5

What are the effects of sedative hypnotics and the withdrawal symptoms?

Answer 5

Benzodiazepines and barbiturates (PO, IV)
Psychological- Euphoria, disinhibiton, apathy, aggression, labile mood, anterograde amnesia.
Physical- Unsteady gait, difficulty standing, slurred speech, nystagm,us, skin lesions, reduced BP
Withdrawal (need 3)- hand tremor, N+V, increased HR, postural hypotension, malaise, hallucinations, paranoid ideation, grand mal convulsions

Question 6

What are the effects of stimulants and the withdrawal symptoms?

Answer 6

Cocaine/crack cocaine (IV, IN, smoked), ecstasy (PO), amphetamine (Po, IV, IN, smoked)
Psychological- Euphopria, increased energy, grandiose beliefs, illusions, hallucinations, paranoid ideations.
Physical- Increased HR and BP, arrhythmias, N+V, pupillary dilatation, psychomotor agitation, convulsions, chest pain
Withdrawal (need 3)- Dysphoric mood (needs to be present), lethargy, psychomotor agitation, cravings, insomnia, increased appetite. bizarre/unpleasant dreams

Question 7

What are the effects of hallucinogens and the withdrawal symptoms?

Answer 7

LSD, magic mushrooms (PO)
Psychological- Anxiety, illusions, hallucinations, depersonalisation, paranoi, hyperactivity, impulsivity, inattention.
Physical- Increased HR, palpitations, sweating, tremor, blurred vision, pupillary dilatation, incoordination
Withdrawal (need 3)- N/A

Question 8

What are the effects of volatile solvents and the withdrawal symptoms?

Answer 8

Aerosols, paint, glue, petrol (inhaled)
Psychological- apathy, lethargy, aggression, impaired attention and judgement, psychomotor retardation.
Physical- unsteady gait, diplopia, nystagmus, decreased consciousness, muscle weakness.
Withdrawal (at least 3)- N/A

Question 9

What are the effects of anabolic steroids and the withdrawal symptoms?

Answer 9

Testosterone, androstenedione, danazol (PO, IM)
Psychological- Euphoria, depression, aggression, hyperactivity, mood swings, hallucinations, delusions.
Physical- Increased muscle mass, reduced fat, acne, male pattern baldness, reduced sperm count/infertility, stunted growth.
Withdrawal (at least 3)- N/A

Question 10

What are some complications of substance misuse?

Answer 10

Physical- death, infection (HepA/B/C/HIV), endocarditis, VTE.
Psychological- cravings, psychosis, anxiety, cognitive disturbance.
Social- crime, imprisonment, poor relationships, prostitution, homelessness.

Question 11

What is substance dependence?

Answer 11

Occurs if patient experiences withdrawal or show tolerance.
Must have at least 3 of the following over 1 month.

Drug Problems Will Continue To Harm.
Desire- compulsion to take the drug
Preoccupation with substance
Withdrawal symptoms which are reduced or stopped on ingestion
Controlling substance taking behaviour is an impaired ability
Tolerance- as such has to take more of the drug to gain its effects
Harmful effects- but despite this drugs are still taken

Question 12

How is substance misuse diagnosed?

Answer 12

Hx- may be difficult to illicit since illegal in the UK.
Ask questions relating to the quantity of drugs, the effects, impact on a persons life, preoccupation (is it always on the forefront of your mind?), control, tolerance, knowledge of harm, type, route, amount, pattern etc.

Bloods- HIV, Hep B, Hep C, TB Screening. U+Es for renal function. LFTs and clotting for hepatic function. Drug levels.
Urinalysis (cannabis, opioids etc)
ECG- arrhythmias, ECHO for endocarditis.

Question 13

What are the drug classes?

Answer 13

Class A- cocaine, heroin, hallucinogens, amphetamines. Possession= 7rs prison and/or unlimited fine, supply= life prison and/or unlimited fine.

Class B- amphetamines, cannabis, barbiturates, ketamine. Possession= 5yrs prison and/or unlimited fine, supply= 14yrs prison and/or unlimited fine.

Class C- anabolic steroids, benzodiazepines, GHB. Possession= 2yrs prison and/or unlimited fine (not steroids), supply= 14yrs prison and/or unlimited fine.

Question 14

What are the differentials for substance misuse?

Answer 14

Psychiatric disorder- psychosis, mood disorders, anxiety, delirium etc.
Organic disorder- hyperthyroidism, CVA, IC h’hage, cerebellum pathology etc.

Question 15

How is substance misuse managed?

Answer 15

Psychosocial support from a key worker.
Hep B immunisation
CBT and motivational interviewing
Contingency management- offer incentives for abstinence i.e. money
Support in housing, finance, employment. Help with any smoking, alcohol misuse.
Self hell groups I.e. cocaine anonymous, narcotics anonymous.
Review driving concerns with DVLA.

Opioid dependence- methadone (1st line) or buprenorphine for detox and maintenance.
Naltrexone- previously opioid dependence now practising abstinence and wish to continue.
IV naloxone- antidote if opioid overdose

Question 16

What is the difference between detoxification and maintenance?

Answer 16

Detox- Weaning a person off with a replacement drug to avoid withdrawal symptoms and attain abstinence.
Maintenance- aim is to minimise harm (I.e. from IV), aim is not abstinence.

Question 17

What is alcohol abuse?

Answer 17

Drinking enough alcohol to cause physical, psychological and/or social harm.

Binge drinking is drinking more than the recommended alcohol per day in one session. M>8 units, F>6 Units

Harmful alcohol consumption is drinking above safe levels of alcohol with alcohol related problems. M>50units/wk, F>35units/wk

Question 18

What is the pathophysiology of alcohol abuse?

Answer 18

Alcohol affects many neurotransmitters in the brain.
Stimulant affect mediated by dopaminergic pathways, XS alcohol leads to sensitisation of these pathways and so dependence.
Long term exposure leads to down regulation of GABA receptors and up regulation of glutamate receptors, resulting in CNS hyper-excitability.
Cravings are linked with positive reinforcement from dopaminergic, serotonergic and opioid systems, whereas withdrawal is linked with GABA, glutaminergic and noradrenergic systems.

Question 19

What are the RF for alcohol abuse?

Answer 19

Male- also have increased metabolism of alcohol so can drink in higher quantities.
Young adults
Genetics
Anti-social behaviour
Lack of facial flushing- facial flushing suggests presence of gene which metabolises alcohol more slowly.
Life stressors

Question 20

What are the types of alcohol related disorders?

Answer 20

Alcohol intoxication
Alcohol dependence
Alcohol withdrawal

Question 21

What are the clinical features of alcohol intoxication?

Answer 21

Slurred speech
Labile affect
Impaired judgement
Poor coordination

Severe cases may present with hypoglycaemia, stupor or coma.

ICD 10-
Criteria for acute intoxication- (1) evidence of psychoactive substance use at high levels, (2) disturbance in cognition, consciousness, perception or behaviour, (3) not accounted for by medical mental disorder.
Criteria for dysfunctional behaviour- aggression, disinhibition, labile mood, impaired attention/concentration, interference with personal functioning. Need on of signs- unsteady gait, nystagmus, slurred speech, difficulty standing, flushing, reduced consciousness, conjunctival injection.

Question 22

What are the clinical features of alcohol dependence?

Answer 22

SAW DRINk
Subjective awareness to their compulsion to drink
Avoidance/relief of withdrawal symptoms by drinking
Drink seeking behaviours
Reinstatement of drinking post abstinence
Increased tolerance to alcohol
Narrowing of drinking repertoire I.e. drinking fixed times

Question 23

What are the clinical features of alcohol withdrawal?

Answer 23

Malaise
Tremor
Insomnia 
Nausea
Transient hallucinations
Hyperactivity 6-12hrs after abstinence 
Peak incidence of seizures at 36hrs 
Severe- get delirium peaking at 72hrs

ICD 10-
General criteria- (1) clear evidence of cessation/reduction, (2) not accounted for by medical or mental disorder.
Any three of the following- tremor, N+V, sweating, tachycardia, headache, increased BP, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions.

Question 24

What are the long term affects of alcohol abuse?

Answer 24

Hepatic- cirrhosis, fatty liver, hepatitis, carcinoma.
GI- oesophageal carcinoma, peptic ulcer, o.varices, pancreatitis.
CVS- HTN, cardiomyopathy, arrhythmias
Haematological- anaemia, thrombocytopenia
Neurological- seizures, peripheral neuropathy, Wernickes encephalopathy, Korsakoff’s psychosis, head injury.
Morbid jealousy, anxiety disorders, hallucinations, alcohol-related dementia, mood disorders, self harm/suicide, delirium.
Domestic violence, drink driving, employment difficulties, financial problems, accidents, relationships problems, homelessness etc.

Question 25

What is delirium tremens?

Answer 25

Occurs 24hrs-1wk post cessation of alcohol, peak at 72hrs.
More at risk if physical illness present.
Have dehydration and electrolyte imbalance.
Cognitive impairment
Vivid perceptual abnormalities I.e. illusion/hallucinations
Paranoid delusion
Marked tremor
Autonomic arousal

Manage with large doses of benzodiazepines, haloperidol for psychotic symptoms and IV pabrinex.

Question 26

How would you screen for alcohol dependence?

Answer 26

CAGE.

C- have you ever thought about CUTTING down on your drinking?
A- have people ANNOYED you by criticising you on your drinking?
G- have you ever felt GUILTY about your drinking?
E- do you feel you need to have a drink early in the morning to steady your nerves or wake you up properly? EYE opener

Question 27

What are the investigations for alcohol dependence?

Answer 27

Bloods- blood alcohol level, FBC (anaemia), U+Es (dehydration, reduced urea), LFTs increased, MCV, B12, folate, TFTs, amylase (pancreatitis), hepatitis, glucose (hypoglycaemia)
Questionnaires- Alcohol Use Disorders Identification Test (AUDIT), Severity of Alcohol Dependence Questionnaire (SADQ), FAST screening tool.
CT head (injury)
ECG (arrhythmias)

Question 28

What are the differentials for alcohol disorders?

Answer 28

Psychosis
Mood disorders
Anxiety
Delirium
Head injury
Cerebral tumour
CVA

Question 29

How are alcohol disorders managed?

Answer 29

Biopsychosocial model.

Biological-
Alcohol withdrawal- better treat as inpatient if high risk of suicide or if history of sever withdrawal reactions. High dose benzodiazepines (chlordiazepoxide) and dose tapered down over 5-9 days. Give thiamine to prevent Wernicke’s encephalopathy either oral or as IV Pabrinex.
Alcohol dependence- disulfiram (build up actealdehyde so gives unpleasant feeling from drinking), acamprosate (reduce cravings by enhancing GABA), naltrexone (blocks opioid receptors thus reducing pleasurable effects).
Treat any medical or psychiatric complications.

Psychological-
Motivational interviewing (guides person to want to change- most effective in pre-contemplation/contemplation phase). Useful for dependence.
CBT (dependence)

Social-
Alcoholics Anonymous- dependence. For patients who accept they have a drinking problem. 12 step approach which uses the psychosocial model to change behaviour. Each resin has an assigned supervisor.

Question 30

How can alcohol be discouraged?

Answer 30

Increased taxation
Restricted advertising
Restricted sales
Education in schools

If there are harmful drinkers looking malnourished or have decompensated liver disease, give prophylactic oral thiamine (50mg OD).

Question 31

Who is responsible to notify the DVLA in alcohol misuse?

Answer 31

The patient is responsible to inform the DVLA.
If at the follow up, they still have not then get advice from your union.
Inform the patient in writing of your decision, so they have a final chance to inform the DVLA, otherwise, inform the DVLA.