Alcohol and Substance Misuse Flashcards
How common is alcohol excess?
37% of M and 29% of F in the UK frequently exceed the safe daily alcohol limits
What causes alcohol withdrawal symptoms?
decreased GABA and increased NMDA
What are some of the problems associated with alcohol use and dependence?
- Psychiatric or physical illness increases the risk of alcohol use and dependence (or vice versa)
- Alcohol dependence is linked to antisocial and borderline personality traits
- Age of first drink is relevant to risk of dependence and harmful drinking
- Cirrhosis F>M
- Alcohol dependence increases risk of arrhythmias i.e. AF, cardiomyopathy and haemorrhagic stroke
- Alcohol = commonest cause of chronic pancreatitis
- Also increases risk of suicide
- Common cause of seizures – be aware of this for detox
What is Wernicke’s encephalopathy/what are the symptoms?
acute confusion
oculomotor signs
ataxic gait
What is Korsakoff’s encephalopathy?
- Anterograde (+/- retrograde) amnesia
- Confabulation – false memories
- Apathy
How is Wernickes treated? What are the outcomes?
untreated mortality - 15%
- 80% progress to Korsakoff’s
Pabrinex
How is Korsakoff’s treated? What are the outcomes?
May require OT input, home care etc.
Oral pabrinex usually sufficient
20% recover completely, 25% significant recovery
Describe alcohol related brain damage (ABRD)
Affects short-term memory, long-term recall and executive function
Cortical and subcortical atrophy and white matter loss on CT
How is alcohol misuse managed?
- Outpatient or community detox is used unless: severe dependence, Hx of withdrawal seizures or delirium tremens, unsupportive home, previous failed detox.
- Benzodiazepines can be given short term to relieve severe symptoms
- Give thiamine B1 to prevent Wernicke’s Encephalopathy (Pabrinex if oral is inadequate)
- Also multivitamins
- Chlordiazepoxide (Librium) for initial detox and decreased seizure incidence
- May need symptomatic relief i.e. Loperamide, anti-emetics
How does disulfiram (antabuse) work?
Causes unpleasant symptoms – vomiting, anxiety, flushing, palpitations etc. if alcohol consumed
C/I if Hx cardiorespiratory disease
How does acamprosate (cameral) work?
Reduces craving and relapse rates
Can use while drinking
How does naltrexone (nalorex) work?
Reduces cravings and pleasant effects of alcohol
“Sinclair Method”
Should you use antidepressants or benzos when treating alcohol misuse?
Only if treating comorbid psychiatric illness
What psychosocial interventions can be used?
- Motivational interviewing
- CBT
- Group therapy
- AA – 12 step programme
- Social support
- Primary prevention – alcohol cost increase is most effective
- Drug and alcohol services
What is the recommended limit of alcohol consumption?
Not more than 14 units a week regularly
What is the ICD-10 criteria for diagnosing criteria of substance misuse?
TWO STEP
1 - specify the substance or class of the substance
examples - alcohol, opioids, cocaine, solvents
2 - specify the type of disorder acute intoxication, harmful use, dependence syndrome, withdrawal state (with/without delirium), psychotic disorder, amnestic disorder
What is acute intoxication?
- transient physical and mental abnormalities occurring shortly after administration and caused by the direct effects of the psychoactive substance
- may cause disturbances in level of consciousness, cognition, perception affect, behaviour and or other physiological functions
- effects are specific and characteristic of each substance
How is harmful use defined?
- the continuation of substance use despite evidence of damage to the user’s physical or mental health or to their social, occupational or familial well-being
- damage may be denied or minimised by the individual concerned
What is the withdrawal state?
- Where there is physical dependence on a drug, abrupt cessation or partial withdrawal of the substance generally leads to withdrawal symptoms
- Some drugs are not associated with withdrawal and some only mild withdrawal
- Clinically significant withdrawal symptoms opiates, alcohol, benzodiazepines, cocaine and amphetamines
- Withdrawal symptoms seizures, delirium, psychotic symptoms
What is dependence syndrome?
Comprises a cluster of physiological, behavioural and cognitive phenomena relevant to a person’s relationship with a particular substance or a class of substance
What are the core features of dependence syndrome?
6 features and descriptions
Primacy - the drug and need to obtain it become the most important thing in the person’s life
Continued use despite negative consequences - the user continues with substance use even when threatened with significant losses as a direct consequence of continued use
Loss of control of consumption - a subjective sense of inability to control or restrict further consumption once the drug is taken
Narrowing of the repertoire - user moves to taking a single drug in preference to all others
Rapid reinstatement of dependent use after abstinence
Tolerance and withdrawal
What is tolerance?
- Over time more of the drug must be taken to achieve the same intensity of pleasurable effects
- Able to consume large quantities of specific substances while showing no or few signs of intoxication
What is substance induced psychotic disorder?
• Individual presents with psychotic symptoms as a direct result of substance-induced neurotoxicity
What percentage of men and women are dependent on alcohol?
9% men
4% women
What is the most common cause of alcohol related death?
Alcoholic liver disease
What are some BIO causes of alcohol dependence?
family of alcohol dependent pts have an increased risk
What are some PSYCHOLOGICAL causes of alcohol dependence?
mental illness increased risk
stress, social anxiety, low self esteem are associated with alcohol misuse
What are some SOCIAL causes of alcohol dependence?
heavy drinking is more common in MEN
morality is higher is more deprived class
RFs - social isolation, lack of spouse, profession - bartender, farmer, medics
What medical problems can alcohol misuse cause?
See notes
cognitive impairment wernicke-korsakoff syndrome cerebellar degeneration increased susceptibility to infection CV - HTN, arrhythmias, CV events Cirrhosis --> hepato-renal syndrome CKD Alcoholic liver disease Alcoholic hepatitis Splenomegaly Mallory-weiss tears gastric erosions Erectile dysfunction sexual dysfunction
What are some psychiatric complications of alcohol misuse?
Alcoholic hallucinosis
Alcohol related brain injury - cognitive impairment
Psych comorbidity - anxiety, suicide, schizophrenia
Pathological jealousy
What are SOCIAL consequences of alcohol misuse?
- Psychological harm to family members
- Marital disharmony and divorce
- Risky sexual activity
- Domestic violence
- Missed days of work and poor work performance
- Financial and legal problems
How common is illicit drug use?
lifetime prevalence is 36% in adults
How is opiate detoxification carried out? BIO
- Substitutes i.e. methadone, buprenorphine
- Lofexidine
- Loperamide, metoclopramide for symptomatic relief
Naloxone or Naltrexone in the community to decrease overdose risk
What are the psychosocial aspects of opiate detoxification?
• Drug and Alcohol services • Narcotics Anonymous • Social support: housing, child care, finances, employment • Individual counselling • Motivational Interviewing • CBT • Psychoeducation Rehab
What are the withdrawal symptoms of benzos?
hallucinations, convulsions delirium
How is benzo withdrawal managed?
• Mx involves switching to a longer acting benzo and then reducing the dose slowly over a number of weeks
What are the initial investigations carried out for substance misuse?
- Bloods - MCV is best indicator of alcohol abuse, will be low even after 6 months of abstinence, FBC, TFTs
- LFTs - GGT best indicator of alcohol abuse
- U+Es
- BM
- Urine drug and alcohol screen
- Breathalyse as necessary on admission
Why is a physical exam important in substance misuse?
- IVDU are at risk of abscesses, infected injection sites, DVTs, PEs, endocarditis etc.
- SM patients are unlikely to present to GP regularly so they are at higher risk of undiagnosed physical conditions
