Alcohol and Substance Misuse Flashcards
Is caffeine a psychoactive substance?
Yes - can be harmful and can cause withdrawal issues
Which receptors are used by the following types of substances?
- Opioids
- Stimulants
- Sedatives
- Hallucinogens
- Cannabinoids
- Opioids = Opioid receptors
- Stimulants = Dopa, NOR and ADR receptors
- Sedatives = GABA A and B receptors
- Hallucinogens = 5HT and ACh receptors
- Cannabinoids = CB1 and CB2 receptors
What type of substance is alcohol?
Sedative - works primarily on inhibitory GABA A and B pathways
Which drugs are considered stimulants?
Stimulants inc crack, amphetamines, ADHD meds, MDMA - stimulate the release of NOR, ADR and Dopa.
Why is substance misuse important?
Lots of deaths resulting from their misuse and this number is still rising
Also has lots of impact on society
Crime from acute intoxication as well
40% of violent incidents thought to be under influence of alcohol and 35% of sexual assaults
Nearly 50% of homicides can be linked to drug use
Increase of child abuse and neglect
Substantial social services resources are taken up by this
What do you need to ask about current use when taking a substance Hx?
Ask about ALL substances - inc OTC, prescribed and poss misuse
Maintain a non-judgment and curious approach - lots of reasons why people
Always ask the patient and never assume
Alcohol - ask what strength (percentage) - calculate usage, pattern of use - daily, binge? Frequency.
Drugs - how often
When did they last use? - correlate physical Sx
Always ask the route of administration - oral, nasal, injection - never assume
What do you need to ask about past use when taking a substance Hx?
PHx - needs clear timeline of each substance - what age they were when they started using, reasons why, pattern over time/. Previous treatments, relapses, triggers for relapse, periods of abstinence. Want to formulate a management plan.
Exploring triggers for relapse will be helpful for future management plan
What consequences do you need to ask about when taking a substance Hx?
All substances do have potential to cause harm
Social consequences - relationships, occupational, social, forensic (drunk driving), financial.
What is the toxic trio of safeguarding that you should assess when taking a substance Hx?
Domestic violence, mental health issues and substance abuse = Toxic trio
Always consider safeguarding - especially if children are in the picture
When asking about dependence - what are you trying to work out in a substance Hx?
Where there is potential for withdrawal and physical harm from this
When asking a patient about opioid use - what questions do you need to ask about their use?
Opioids and other injectables - don’t ever assume that people are taking in a certain way - always determine whether they are injecting.
HIV, Hepatitis status
Any recent tests, vaccines, Hx of exposure
Unsafe needle practises? Sharing needles, unprotected sex
Do they check injection sites for abscesses
OD - periods of prolonged absence or given a stronger substance than they are used to = can lead to OD
Always do a sexual health screen - esp if at risk of sexual exploitation for money to fund habit, or if they are at risk of risky sexual encounters when intoxicated.
What questions do you need to ask about alcohol misuse?
Quantify the units used per week
ABV = alcohol by volume
Units = ABV x Volume /1000 - calculate on daily or weekly basis
Huge variation in strength of alcohol - ensure what they are using
How often they are drinking
Periods of binge drinking
Driving - DVLA requirement to inform if there is a Hx of alcohol dependance
Cognitive impairment - typically affects the frontal lobe
AUDIT C = questionnaire for alcohol misuse
How does ICD-11 categories substance misuse disorders?
There is a separate code for each substance
Whether there is harmful use - continuous use causing harm for >1m
Whether there is dependence
How is dependence defined by ICD11?
Whether there is recurrent episodic or continuous use with impaired regulation manifested by:
- impaired control over the substance use
- increasing precedence of substance use over other aspects of life
- if there is tolerance or withdrawal to the substance
What do you look for when doing a physical exam on a patient with alcohol or substance misuse?
Decompensated liver disease - looking for ascites, palmar erythema, spider naevi
What are the harm reduction strategies for alcohol?
Dont stop drinking suddenly
Supplement with thiamine to prevent Wernickes
Give vitamins
Do USS for liver to screen for cirrhosis
What are the harm reduction strategies for opioids?
Needle exchange
Hep B vaccine
Hep B, C & HIV screening
Safe injecting advice - dont inject alone
Give naloxone pens for reversal in OD situations
What RF exist that can increase chances of addiction?
Trauma
Mental Illness
Poverty
Genetics
Stress
Aetiology of misuse is v complex - not one RF - cumulative effect
Even with RF - protective factors may mitigate
What protective factors can mitigate against the risk of substance addiction?
Positive self image, good self control, good social skills
Good family involvement, positive parental influence etc
What mental health Sx do Ps try and sometimes self-medicate?
Anxiety and substance misuse = strong link - probably due to calming effect
What is the connection between cannabis and psychosis?
Huge body of evidence between cannabis and psychosis = not causal but if there is a genetic vulnerability to psychosis the cannabis can push them over
What are the Sx of Wernicke’s encephalopathy?
Wernicke’s encephalopathy can be difficult to identify –particularly if a person is still intoxicated with alcohol. The symptoms can sometimes be mistaken for alcohol withdrawal.
The symptoms of Wernicke’s encephalopathy include:
* being disorientated, confused or having mild memory loss
* having difficulty controlling eye movements
* having poor balance, being unsteady and walking with their legs wide apart
* being undernourished – for example, being very underweight or having lost a lot of weight in the previous months.
It is unusual for someone with Wernicke’s encephalopathy to have all of these symptoms. However, most people will be disoriented and confused.
What is the metabolic pathway of alcohol in the body?
How does alcohol affect the brain?
Acts as a GABA A agonist and an NMDA antagonist - these increase Dopa release in the nucleus accumbens = pleasure pathways in the brain
What affect does high fat content / food in the stomach have on the absorption of alcohol?
Slows down the absorption of alcohol. Why drinking on an empty stomach is and idea. Is absorbed quicker if gastric emptying if faster.
How much alcohol does the liver metabolise under normal conditions?
About 1 unit per hour
Disulfiram can be given to patients to help with abstinence from alcohol. How does it work?
Inhibits aldehyde dehydrogenase - will be a build up toxic metabolite acetaldehyde - which increases hangover Sx. Dangerous if you do continue drinking on it. Can cause flushing, tachycardia, HT
What are the acute effects of alcohol?
What are the LT effects of alcohol consumption?
Why do you get alcohol withdrawal with chronic alcohol use?
Tolerance -> GABA A down regulation and NMDA upregulation.
I.e. there is a loss of inhibitory system in the brain - alcohol is used instead to calm the brain.
Therefore when the alcohol use discontinues - the neurons become hyperexcitable -> withdrawal Sx, tremors, anxiety, sweating, tachycardia, insomnia, agitation
What Sx do you get with withdrawal of alcohol?
What type of seizures do you tend to get in alcohol withdrawal?
Tonic clonic seizures
At what point in withdrawal do Ps tend to get alcohol withdrawal seizures?
24-48 hours after last drink
How are alcohol withdrawal seizures treated?
PR Diazepam
How long into withdrawal does delirium tremens tend to start?
About 72 hours into withdrawal
What percentage of Ps undergoing alcohol withdrawal with experience delirium tremens?
What is the mortality for this condition?
5% - rare
15%
What are the Sx of delirium tremens?
Confusion, agitation, impending doom, sweating, paranoia, severe tremors, perceptual disturbances, reduced GCS - clouding of consciousness
How is delirium tremens managed?
Chlordiazepoxide (reducing regime)
Thiamine - IV Pabrinex
APs are not first line - should be used with extreme caution as they can precipitate seizures and worsen the delirium.
If they are declining Rx - consider whether the MCA is appropriate for admission and Rx
What are the common Sx of Wernicke’s encephalopathy?
Confusion
Ataxia
Opthalmoplegia
Also - nystagmus, reduced GCS, hypothermia
What is the treatment for Wernicke’s encephalopathy?
IV Pabrinex
What can opioids do to the heart on ECG?
Cause prolongation of QTc (mainly methadone)
Normal values for the QTc range from 350 to 450 ms for adult men and from 360 to 460 ms for adult women; however, 10%-20% of otherwise healthy persons may have QTc values outside this range.
What are the ST effects of opioids?
What are the risks from IV use of opioids?
Why do opioids cause sexual dysfunction?
Interfere with normal release -> reduced testosterone & HPAA dysfunction. Can cause hypogonadism and adrenal insufficiency.
Can also cause inc risk of fractures
What scale is used to measure opioid withdrawal?
COWS - Clinical Opioid Withdrawal Scale
What withdrawal Sx can you get from opioids?
How do Benzos act?
Act on GABA A receptors - causing inhibition in the brain = calming and sedative effect
GABA = principal inhibitory neuron in the brain
- reduced activity in spinal cord = muscle relaxant effect, reduced in amygdala = reduced fear and panic.
What benzodiazepines can you name?
Diazepam
Chlordiazepoxide
Clonazepam
Lorazepam
Midazolam
What are the short term effect of benzodiazepines?
How do withdrawal Sx from benzos present?
Anxiety / panic, insomnia, sweating, tremor, seizures
What is floppy baby syndrome?
Occurs in babies whose mothers took benzos in pregnancy - they can develop withdrawal at birth +/- may have trouble breathing, poor circulation, and low muscle tone (floppy baby syndrome).
What is the effect on sleep of taking benzos for a long period?
Is reduced REM sleep and reduced total sleep
What are the signs of acute intoxication from cannabis?
