Alcohol and substance misuse | Flashcards
1
Q
According to ICD-10, what is the 2-step approach in the diagnosis of mental and behavioural disorders due to psychoactive substance abuse?
A
- Specify the substance or class of substance
a. Alcohol
b. Opioids
c. Cannabinoids
d. Sedative or hypnotics
e. Cocaine
f. Stimulants (inc. caffeine)
g. Hallucinogens
h. Solvents
i. Multiple drug use - Specify the type of disorder
a. Acute intoxication
b. Harmful use
c. Dependence syndrome
d. Withdrawal state
e. Withdrawal state with delirium
f. Psychotic disorder
g. Amnestic disorder
h. Other mental and behavioural disorders (e.g. dementia)
2
Q
What is the definition of acute intoxication?
A
- Transient physical and mental abnormalities occurring shortly after administration and caused by the direct effects of the psychoactive substance.
- Acute intoxication may cause disturbances in the level of consciousness, cognition, perception, affect, behaviour or other psychophysiological functions.
- The effects are specific and characteristic for each substance (e.g. disinhibition with alcohol, visual and sensory distortions with LSD).
3
Q
What is the definition of harmful use?
A
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. The damage may be denied or minimised by the individual concerned.
4
Q
What is the definition of withdrawal?
A
- Where there is physical dependence on a drug, abrupt cessation or partial withdrawal of the substance generally leads to withdrawal symptoms.
- Clinically significant withdrawal symptoms are recognised in dependence on alcohol, opiates, benzodiazepines, cocaine and amphetamines.
- Withdrawal syndromes can be simple or complicated by the development of seizures, delirium or psychotic symptoms.
5
Q
What is the definition of tolerance?
A
Over time, the user finds that more of the drug must be taken to achieve the same intensity of pleasurable effects. They may attempt to combat increasing tolerance by choosing a more rapidly acting route of administration (e.g. intravenous rather than smoking).
6
Q
What is dependence syndrome?
A
The dependence syndrome comprises a cluster of physiological, behavioural and cognitive phenomena relevant to a person’s relationship with a particular substance or class of substance.
The core features are:
1. Primacy
-The drug and need to obtain it becomes the most important things in the person’s life taking priority over all other responsibilities, activities and interests
2. Continued use despite negative consequences
3. Loss of control of consumption
4. Narrowing of the repertoire
-The user moves from using a range of psychoactive substances to a single drug taken in preference to all others. Over time, the user tends to take the drug in the same setting with the same individuals and uses the same route of administration
5. Rapid reinstatement of dependent use after abstinence
-when the user relapses to drug use after a period of abstinence they are at risk of rapidly returning to the pattern of dependent use in a much shorter period of time
6. Tolerance and withdrawal
7
Q
What is substance induced psychotic disorder?
A
- The individual presents with psychotic symptoms (e.g. hallucinations and/or delusions) which occur as a direct result of substance-induced neurotoxicity.
- Psychotic features may develop either during intoxication or withdrawal states or on a background of chronic harmful or dependent use.
- It can be difficult to differentiate diagnostically between these individuals and those presenting with a primary psychotic illness
8
Q
Around what % of men and women consume alcohol in the UK?
A
M - 93%
F - 87%
9
Q
Around how many people in the UK drink more than the recommended daily units?
A
9 million
10
Q
What % of M and F are dependent on alcohol?
A
M 9%
F 4%
11
Q
What is the most common alcohol-related death?
A
alcoholic liver disease
12
Q
What is the estimated cost of alcohol harm to society per year?
A
£21 billion per year
13
Q
How many grams of pure ethanol is 1 unit?
A
8g
14
Q
What is the recommended weekly alcohol allowance for an adult male and female?
A
14 units
- no more than three units in any one day and have at least two alcohol-free days a week
15
Q
What are the biological causes of alcohol misuse (3)?
A
- Genetics - but no specific causative genes have been found
- x7 more likely if first degree relatives have alcohol problems
- Children of alcohol-dependent parents have an increased risk of development of alcohol misuse problems themselves even when adopted into families without alcohol problems
16
Q
What are the psychological causes of alcohol misuse (3)?
A
- Mental illness (including depression, anxiety disorders and schizophrenia) increases risk
- Stress, high social anxiety levels and low self-esteem are particularly associated with alcohol misuse
- Psychological theories of negative and positive reinforcement can be applied to alcohol misuse.
17
Q
What are the negative reinforcement
A
,
18
Q
What are the social/occupational causes of alcohol misuse (6)?
A
- More common in men but increased in women
- Higher in deprived socio-economic classes
- Alcoholmore affordable now
- Social isolation
- Loss of spouse
- Certain professions e.g. bartending, farming, medical professionals
19
Q
What are some medical complications of alcohol misuse?
- Neurological
- Cardiovascular
- Hepatic
- Gastro-oesophageal
- Pancreas
- Small and large bowel
A
Neurological
- Cognitive and memory impairment
- Wernicke-Korsakoff Syndrome
- Alcoholic peripheral neuropathy and myopathy
Cardiovascular
- Alcoholic cardiomyopathy
- Arrhythmias (especially atrial fibrillation)
- Hypertension
- Cerebrovascular events (especially haemorrhagic strokes)
Hepatic
- Alcoholic liver disease
- Fatty liver
- Alcoholic hepatitis
- Cirrhosis occurs as end-stage of the 2 above
Gastro-oesophageal
- Mallory-Weiss tears secondary to vomiting
- Oesophageal varices +/- haemorrhage
- Barretts oesophagus and oesophageal carcinoma
- Gastritis and gastric erosions
- Peptic ulcer disease +/- haemorrhage
- Gastric carcinoma
Pancreas
1. Acute/chronic pancreatitis
Small and large bowel
- Malabsorption
- Chronic diarrhoea
- Risk factor for lower GI carcinoma
20
Q
What psychiatric complications is alcohol misuse associated with (6)?
A
- Alcoholic hallucinosis
- Alcohol-related brain damage
- Pathological jealousy
- Anxiety and depressive disorders
- Suicide
- Schizophrenia
21
Q
What is alcoholic hallucinosis? What symptoms does the patient experience?
A
- Substance-induced psychotic illness which is a rare complication of prolonged heavy alcohol use.
- Usually experience hallucinations (usually auditory) in clear consciousness while sober
- The auditory hallucinations may begin as “elemental hallucinations” such as banging or murmuring sounds but, with ongoing alcohol use, progress to formed voices.
22
Q
What are the ddx of alcoholic hallucinosis (2)?
A
- Acute psychotic episode
2. Delirium tremens - in a confusional state
23
Q
What is the prognosis of alcoholic hallucinosis?
A
in 95%, there is spontaneous resolution of symptoms after cessation of alcohol use
24
Q
What are features of alcoholic related brain damage (ARBD)?
A
- Alcohol-related cognitive impairment and dementia
- 60% of chronic heavy drinkers will display some degree of cognitive impairment on cognitive testing while sober
- Impairment of short-term memory, long-term recall, new skill acquisition, executive functioning, but with relative preservation of IQ and language skills.
- CT/MRI shows cortical and subcortical atrophy with prominent white matter loss
25
What is pathological jealousy?
How do they present?
1. Monosymptomatic delusional disorder seen most commonly secondary to current or previous heavy alcohol misuse
2. Presents with the primary delusion that his partner or spouse has or is being unfaithful. They may go to great lengths to obtain "evidence" of infidelity
3. Significant association with violence and even homicide towards the supposedly unfaithful partner
26
What is the relationship between alcohol and anxiety/depressive disorders?
1. Two-way relationship
2. Symptoms such as low mood, generalised anxiety, social phobia and panic attacks are frequently reported in alcohol abusers.
3. Individuals may have a primary mood or neurotic illness and be using alcohol to self-medicate, however chronic alcohol use has a direct depressogenic effect and the cycle of drinking and withdrawal can provoke and exacerbate symptoms of anxiety
27
What is the relationship between suicide and alcohol?
1. Alcohol misuse is associated with an increased risk of suicide (10-15%)
2. Psychiatric co-morbidity, social isolation and repeated failed attempts at abstinence are risk increasing
28
What is the relationship between schizophrenia and alcohol?
1. Rates of harmful use and dependence on alcohol are significantly higher among people with schizophrenia compared to gen pop
2. Alcohol misuse in those with schizophrenia is a risk factor for psychotic relapse, re-hospitalisation, non-concordance with treatment and violence
29
What are the social and occupational complications of alcohol misuse (6)?
1. Marital disharmony and divorce
2. Domestic violence
3. Missed days off work and poor work performance
4. Financial and legal problems
5. Risky sexual activity
6. Psychological harm to family members
30
Which patients are at risk of acute alcohol withdrawal syndrome (AWS)?
Any patient who is dependent on alcohol who abruptly stops drinking
31
What are risk factors for more severe alcohol withdrawal?
1. Intercurrent medical illness (e.g. infection)
2. Advanced liver disease/cirrhosis
3. Previous withdrawal episodes
4. High amounts of alcohol
5. Longer period of time of heavy drinking
32
What features should you look for when anticipating and prophylactically treating a patient for AWS (4)?
1. Known alcohol dependence
2. History of alcohol withdrawal
3. Consumed >10 units alcohol for >10days
4. Current withdrawal symptoms
33
What are the different presentations of AWS in relation to the time of the last alcoholic drink?
1. Mild withdrawal - occurs 4-12 hours after last drink (lasts around 2-5 days)
2. Severe withdrawal - occurs slower but lasts longer (days-weeks)
3. Seizures - occurs within 6-48 hours after last drink
34
What are the clinical features of mild/uncomplicated alcohol withdrawal (9)?
1. Coarse tremor
2. Sweating
3. Insomnia
4. Tachycardia
5. Nausea and vomiting
6. Psychomotor agitation
7. Anxiety
8. May occasionally experience transient hallucinations (tactile or visual)
9. Intense cravings for alcohol
35
What % of AWS are complicated by grand-mal seizures?
5-15%
36
What are the risk factors for seizures in AWS (4)?
1. Heavy, prolonged alcohol consumption
2. Previous withdrawal seizures
3. Idiopathic epilepsy
4. History of head injury
37
What are the features of severe withdrawal in AWS?
1. Acute confusion
2. Amnesia
3. Psychomotor agitation
4. Psychosis
5. Delirium tremens (DTs)
38
How serious is a delirium tremens (DT)?
Medical emergency
39
How long after the last drink do DTs usually occur?
1-7 days
40
What % of patients get DTs?
5%
41
What are symptoms of a DT (6)?
1. Clouding of consciousness and disorientation to time, place and person
2. Amnesia for recent events
3. Hallucinations (visual, tactile and auditory) and delusions
- often insects crawling up skin
4. Severe psychomotor agitation and tremor
5. Fever
6. Autonomic disturbances and electrolyte imbalances
plus symptoms of uncomplicated withdrawal
42
What is the mortality of DT if left untreated?
40%
43
What is a ddx of DT (3)?
1. Alternative cause of delirium
2. Head injury
3. Hepatic/Wernicke encephalopathy
44
What are the key components of the management of AWS?
1. Medications (Benzodiazepines) for symptomatic relief
2. Nutritional and vitamin supplementation
3. Close monitoring for severe physical and psychiatric complications throughout the withdrawal period
45
How do you choose whether AWS is treated as an outpatient or inpatient setting?
Outpatient:
1. Preferred as relatively inexpensive
2. Research indicates that outcomes (such as patient concordance and abstinence at 6 months following treatment) are comparable to inpatient detoxification treatment
Inpatient should be considered for patients with:
1. Past history of severe and complicated withdrawals (e.g. seizures, delirium)
2. Current psychiatric symptoms: delirium, confusion, psychosis, suicidality
3. Co-morbid physical illness, severe malnutrition or frailty
4. Severe nausea and vomiting or biochemical abnormalities
46
What is the pharmacological management of AWS?
A reducing regime of benzodiazepines for patients with:
1. Active symptoms of withdrawal
2. History of dependence syndrome
3. Consumption of greater than 10 units/day over the previous 10 days
47
Which benzodiazepine is usually used for AWS and why?
Chlordiazepoxide - lower abuse potential
48
How many days does the patient benzodiazepine reducing regime last for in AWS treatment?
How many x a day?
7 days - usually 4x a day and dose lowers each day
49
What needs to be done while a patient is on the reducing regime for AWS and after?
1. Closely monitored for breakthrough symptoms - additional meds may need to be prescribed.
2. Supplements with thiamine and multivitamins as they are often deficient
3. Follow up after
4. Psychosocial interventions after
50
What are Wernicke's encephalopathy and Korsakoff psychosis?
Represent the acute (Wernicke's) and chronic (Korsakoff) phases of a single disease process - Wernicke-Korsakoff syndrome - which is caused by neuronal degeneration secondary to thiamine (vitamin B1). The syndrome is most commonly seen in heavy drinkers.
51
What is the cause of Wernicke's encephalopathy?
Occurs secondary to thiamine (vitamin B1) deficiency.
52
Why are alcohol dependent individuals particularly susceptible to thiamine deficiency (3)?
1. Heavy drinkers tend to have poor dietary habits and their vitamin intake is poor
2. Chronic alcohol intake reduces thiamine absorption from the GI tract
3. Many heavy drinkers have liver disease and the capacity for hepatic storage of thiamine is reduced
53
What is the classic symptom triad found in Wernicke's encephalopathy?
1. Acute confusional state
2. Ocular-motor signs (ophthalmoplegia, nystagmus)
3. Ataxic gait
54
What are the associated features of Wernicke's encephalopathy?
1. Peripheral neuropathy
2. Resting tachycardia
3. Stigmata of nutritional deficiency
55
How commonly is the triad of symptoms seen in Wernicke's encephalopathy?
What is the most common presenting symptom?
Complete triad seen in 10% of cases
Confusion most common presenting symptom - 80%
56
What is the pathophysiology of Wernicke's encephalopathy shown on brain imaging?
Brain imaging may show haemorrhages and secondary gliosis in periventricular and periaqueductal grey matter particularly involving the mamillary bodies, hypothalamus and tegmentum of the midbrain
57
What is the treatment of Wernicke's encephalopathy (4)?
1. All patients who have symptoms or are at high risk of developing WE should be given parenteral vitamin replacement
2. Give high potency vitamin B1 replacement - IV Pabrinex - 2 ampoules over 30 minutes twice daily for 3-7 days
3. Do not rehydrate with glucose solutions before giving thiamine. The glucose will have the effect of exacerbating the thiamine deficiency
4. Treat co-existing alcohol withdrawal syndrome
58
What is the prognosis of Wernicke's encephalopathy?
1. if untreated, 80% progress to Korsakoff syndrome
| 2. Mortality ~15% if left untreated
59
What is the main cause of Korsakoff syndrome?
Thiamine deficiency
Korsakoff syndrome is not necessarily preceded by Wernicke's Encephalopathy and can present in a "chronic" form.
60
What are the clinical features of Korsakoff syndrome (4)?
1. Absence or significant impairment in the ability to lay down new memories (anterograde amnesia)
2. There may be some degree of retrograde amnesia (but this is usually less marked)
3. Confabulation - the person may describe false memories for a period for which they have amnesia
4. Apathy: the patients lose interest in things quickly, and generally appear indifferent to change.
61
What is the treatment of Korsakoff syndrome (3)?
1. Aggressively treat initial Wernicke's encephalopathy if present
2. Continue oral thiamine and multivitamins for up to two years
3. Appropriate psychosocial interventions for cognitive impairment (e.g. occupational therapy input, carer support etc.)
62
What is the prognosis of Kosakoff syndrome?
20% of cases show complete recovery and 25% show significant recovery over time with the remainder largely showing no improvement
63
What are 2 screening tools more commonly used in primary and secondary healthcare settings to assess the diseases related to alcohol misuse?
1. CAGE and CAGE-AID screening
| 2. Fast Alcoholic Screening Test (FAST)
64
What are the 4 questions asked in CAGE?
1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Eye Opener: Have you ever had a drink first thing in the morning to steady your nerves or
to get rid of a hangover?
65
What are the 4 CAGE-AID questions?
1. Have you ever felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or
to get rid of a hangover?
66
What areas should you ask about with regards to a history of alcohol misuse?
1. Lifetime pattern of alcohol consumption
2. Current alcohol consumption
3. Signs of dependence (remember features of alcohol dependence)
4. Social/Occupational Problems
5. Previous Treatment Attempts
6. Physical and Mental Health
67
In a history of alcohol misuse, what specific qs would you ask concerning lifetime pattern of alcohol consumption (4)?
1. Age of first alcoholic drink
2. Age when began to drink regularly
3. When (if ever) did they begin to feel they had a problem with alcohol
4. Period of abstinence and more heavy drinking and the reasons for these
68
In a history of alcohol misuse, what specific qs would you ask concerning current alcohol consumption (5)?
1. Description of a typical day and a heavy day's drinking
2. How often
3. What type of drink and how much
4. When is the first drink taken
5. What setting
69
In a history of alcohol misuse, what specific qs would you ask about concerning Signs of dependence (3)?
1. Experience withdrawal symptoms in the morning or when unable to obtain alcohol
2. Having to drink larger volumes to reach the same level of intoxication
3. Episodes of memory loss ("blackouts")
70
In a history of alcohol misuse, what specific qs would you ask about concerning Social/Occupational Problems (4)?
1. Have they missed days of work, had warnings or lost job as a result of alcohol
2. Relationship difficulties/breakdown due to drinking
3. Financial problems
4. Criminal charges
71
In a history of alcohol misuse, what specific qs would you ask about concerning previous treatment attempts (3)?
1. Has the patient previously sought support
2. Nature of previous treatments
3. Describe subsequent return to drinking
72
In a history of alcohol misuse, what specific qs would you ask about concerning physical and mental health (2)?
1. Physical health problems as a consequence of drinking
| 2. Any mental illness that is contributing or being exacerbated by drinking
73
What do you need to look for in particular in an examination of a patient with alcohol misuse (6)?
1. General condition
2. Symptoms of withdrawal syndrome
3. Facial capillarization
4. Stigmata of liver disease
5. Cerebellar signs
6. Peripheral neuropathy
74
What investigations would you do for a patient with alcohol misuse (3)?
1. MCV - high specificity. Remains raised for 3-6 months after abstinence achieved due to lifespan of red blood cell
2. GGT - (sensitivity 20-90%) More specific than other LFTs for alcohol-related liver inflammation
3. Liver ultrasound scan if indicated
75
What are the 4 main categories of psychoactive drugs?
1. Opiates
2. Depressants
3. Stimulants
4. Hallucinogens
76
What are some examples of opiate drugs and their effects?
heroin, morphine, opium, methadone
Potent analgesic properties
77
What are some examples of depressants and their effects?
Alcohol, cannabis, barbiturates and benzodiazepines
Suppress central nervous system activity causing relief from anxiety
78
What are some examples of stimulants and their effects?
cocaine, crack cocaine, amphetamines and MDMA
Act on the central nervous system and are associated with feelings of extreme well-being, increased mental and motor activity
79
What are some examples of hallucinogens and their effects?
cannabis, Lysergic acid diethylamide (LSD), Phenylcyclidine (PCP), Ketamine and Psilocybin (magic mushrooms)
A heterogeneous group of natural and synthetic substances which produce altered sensory and perceptual experiences
80
What is heroin? What are its features?
1. derived from morphine which is extracted from the opium poppy
2. It is a very strong painkiller and gives the user a feeling of warmth, sedation and well-being
3. It is a Class A illicit drug
4. Most commonly smoked, but many users progress to iv use
81
What is the mechanism of action of heroin?
Works by crossing the BBB and binds at mu opioid receptors, which inhibits release of GABA, reducing inhibitory effect of GABA on dopaminergic neurones. This increases dopamine release into synaptic left leading to feelings of euphoria
82
What are the harmful effects of heroin?
1. Acute medical problems associated with heroin use by any route include nausea and vomiting, constipation, respiratory depression and loss of consciousness (with risk of aspiration)
2. Intravenous use adds the risk of local abscesses, cellulitis, osteomyelitis, bacterial endocarditis, septicaemia and transmission of viral infections including Hepatitis B, C and HIV.
3. Opiate dependency develops after weeks of regular use and is associated with an unpleasant (but generally not medically dangerous) withdrawal syndrome
83
What is cocaine? What are its features?
1. A potent and highly addictive stimulant drug
2. The user typically feels a greatly elevated sense of well-being, alertness, energy and confidence.
3. Signs of cocaine use include pupil dilation
4. It can be associated with aggression and risk taking behaviour
5. Cocaine is a Class A drug
84
What are the routes of administration of cocaine?
How long do the effects last for?
1. Cocaine Hydrochloride is a refined white powder which is usually taken by inhalation (snorting) but may be dissolved and injected
2. Crack ("freebase") cocaine is a form of cocaine that can be smoked. It is usually sold in crystal form ("rocks"). The rapidity of onset of action and peak blood levels are similar to those for IV use.
3. The stimulant effects of cocaine are relatively short-lived and last for only 20-30 minutes. Typically, when the effects begin to diminish there is a strong craving to take more
85
What is the mechanism of action of cocaine?
Inhibits reuptake of monoamines i.e. dopamine, NA and serotonin, increasing their levels in synaptic cleft
86
What are the acute (3) and chronic (4) harmful effects of cocaine?
Acute:
1. Tachycardia, HTN, generalised vasoconstriction
2. Effects increase the risk of CVA, MI and cardiac arrhythmias
3. May also cause acute anxiety, panic attacks, impaired judgement and impulsivity
Chronic
1. Necrosis of nasal septum and sinuses
2. CKD secondary to HTN
3. Use in pregnancy: increased risk of miscarriage, and placental abruption
4. Psychiatric complications: panic disorder, generalised anxiety and psychosis
Also when used regularly for a prolonged period tolerance and dependence may occur
87
What are the typical withdrawal symptoms of abrupt cessation of cocaine use (4)?
How long does it last for?
1. dysphoria and anxiety
2. fatigue and difficulty concentrating
3. craving for cocaine
4. muscle aches and tremors
Symptoms usually resolve in less than a fortnight. Withdrawal is unpleasant but rarely medically serious
88
What is cannabis and its features?
1. The active chemical in cannabis is tetrahydrocannabinol (THC)
which causes the user to feel very relaxed and happy. It can also cause the person to hallucinate.
2. Therefore, cannabis is categorised as a depressant and a hallucinogen
3. Class B drug
4. Usually smoked but can be distributed as hash or oil
89
What is the mechanism of action of cannabis?
1. THC binds to and activates the cannabinoid CB1 receptors on pre-synaptic nerve terminals in the brain.
2. CB1 receptors are distributed in parts of the brain associated with memory, concentration, time perception, coordination and executive functioning.
90
What are the physical (4) and psychological (2) effects of cannabis?
Physical:
1. Increased heart rate
2. Dizziness
3. Increased appetite
4. Increased risk of respiratory disease and other smoking-related pathology
Psychological:
1. Cannabis use may provoke acute anxiety, panic attacks. Some users may develop acute psychotic symptoms.
2. Chronic harmful use may cause dysthymia, reduced motivation and anxiety disorders
3. Associated with increased risk of schizophrenia
91
What is MDMA and its features?
1. A synthetic drug that alters mood and perception producing feelings of increased energy, pleasure, emotional warmth, and distortions in sensory and time perception.
2. Users describe feeling euphoric and "in tune" with their surroundings and having increased feelings of affection for others around them
3. Categorised as both a stimulant and a hallucinogen
4. Class A drug
92
What are the routes of administration of MDMA?
How long does it last for?
Orally
7 hours
93
What is the mechanism of action of MDMA?
It is thought that the physical and psychological effects of MDMA are primarily due to its action on serotonin. It causes serotonin release and also blocks its reuptake from the synaptic cleft.
94
What are the acute (5) and chronic (2) harmful effects of MDMA?
Acute:
1. Jaw clenching and teeth grinding
2. Nausea
3. Blurred vision
4. Increased body temp potentially leading to dehydration
5. Come down effects begin 12-48 hours after consumption and include fatigue and depression
Chronic:
1. Chronic users develop tolerance to MDMA but dependence syndrome does not occur
2. Depression and anxiety are associated with chronic use
95
What is LSD and its features?
1. Lysergic acid diethylamide (LSD) - synthesised and occurs naturally
2. Typically the user experiences a sense of euphoria, detachment and "a sense of novelty in the familiar and a sense of wonder at the normal"
3. Perceptual distortions may occur in all sensory modalities and synasthesia (a stimulus usually perceived in one sensory modality is experienced in another e.g. "tasting colours", "seeing sounds"
4. LSD is a Class A drug
96
What are the routes of administration of LSD?
Very soluble, sold either impregnated onto paper, as a powder, or in tablet form
97
What is the mechanism of action of LSD?
1. LSD is an indolealkylamine and is structurally very similar to the serotonin molecule
2. It acts as an agonist on most of the serotonin receptor subtypes in the brain. It also has indirect effects on the dopaminergic pathways
98
What are the harmful acute (3) and chronic (2) effects of LSD?
Acute
1. Dilated pupils, tachycardia and hypertension
2. Acute intoxication can be associated with perceptual distortions and high-risk behaviour (e.g. believing one is able to fly)
3. A "bad trip" may be associated with terrifying delusions and hallucinations
Chronic
1. LSD not known to be associated with physiological dependence or withdrawal
2. Regular use can cause long-term psychiatric complications including chronic psychotic illness and depressive/anxiety disorders
99
What are benzodiaepines and their features?
1. Prescribed as anxiolytics and anti-convulsants
2. Produce a feeling of euphoria and a marked reduction in anxiety
3. Diazepam, Lorazepam, Clonazepam
100
What are the routes of administration of benzodiazepines?
1. Usually orally as a tablet or liquid
| 2. Less commonly via im or iv injection
101
What is the mechanism of action of benzodiazepines?
Benzodiazepines potentiate the effects of Gamma-aminobutyric (GABA) at the GABAa receptor
102
What are the acute (6) and chronic (6) harmful effects of benzodiazepines?
Acute:
1. Intoxication
2. Drowsiness
3. Dizziness and blurred vision
4. Impaired concentration
5. Impaired coordination (falls and driving risk)
6. Hypotension and respiratory depression may occur in OD or IV use
Chronic:
1. Impaired memory and concentration
2. Depression
3. Tolerance and dependence occur within 3-6 weeks of regular use
4. Dependence is associated with very unpleasant withdrawal syndrome characterised by agitation, anxiety and insomnia
5. Withdrawal may be complicated by seizures, delirium and psychosis
6. Withdrawal often requires medical management and may be fatal
103
In the management of alcohol and substance misuse, what is the policy of harm reduction?
Refers to policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unwilling or unable to achieve abstinence. It focuses on prevention of harmful consequences of drug use rather than of drug use itself
104
What are the features of the "harm reduction" hierarchy?
1. Don't use
2. Don't inject - use in other ways e.g. snort, smoke, sniff etc
3. Use only sterile equipment for injecting and don't share
4. Re-use or share cleaned equipment
5. Re-use or share uncleaned equipment
Try to support an individual up the pyramid, even if it is just one step
105
What are some harm-reduction strategies on an individual level?
1. Needle distribution/exchange programmes and advice regarding safer injecting practice
2. "Take home naloxone" programmes to provide individuals with means to reverse opiate overdose
3. Substitute prescribing (e.g. methadone programmes)
4. Assessment and treatment of comorbid physical and mental illness
5. Education about safe-sex practice
106
What are some harm-reduction strategies on community level?
1. Prescription of methadone may reduce criminality in an opiate-dependent individual with a consequent wider community benefit
107
What is the rationale behind the stages of change model in the treatment of patients presenting with alcohol and drug misuse disorders?
The Stages-of-Change model recognises that different people are at different stages of "readiness for change". By identifying a person's stage in the change process a healthcare worker may more appropriately match interventions to the individual's needs.
108
What are the 6 stages of the stages of change model?
1. Precontemplation
- No intention on changing behaviour, they may be unaware that a problem exists
2. Contemplation
- Aware a problem exists but with no commitment to action
3. Preparation
- Intent on taking action to address the problem. The client is convinced that change is good and has increased self-efficacy (believes they can make change)
4. Action
- Active modification of behaviour
5. Maintenance
- Sustained change. New behaviour replaces old ones
6. Relapse
- Falls back to old patterns of behaviour
Upward spiral - each time a person goes through the cycle they learn from each relapse and grow stronger so that the relapse is shorter or less devastating
109
What are 5 positive prognostic factors for treatment of alcohol and substance misuse disorders?
1. Motivated to change
2. Supportive family or relationship
3. In employment
4. Treatable co-morbid mental illness (e.g. depression, anxiety disorder)
5. Alcoholics anonymous or drug and alcohol service involvement
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What are 7 negative prognostic factors for treatment of alcohol and substance misuse disorders?
1. Ambivalent about change
2. Unstable accommodation or homelessness
3. Absence of pro-social relationships
4. Unemployment
5. Primacy (limited pursuits outside of alcohol or drug use)
6. Repeated treatment failures
7. Cognitive impairment
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What are the aims of treatment for individuals with alcohol and substance misuse disorders?
Achieving and maintaining change
-many patients find it difficult to maintain change in the longer-term so maintenance interventions are an important part of management
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Can dependence on alcohol/ilicit drugs be sufficient grounds for detaining a person in hospital under a section of the Mental Health Act?
No - only if alcohol or drug misuse may be accompanied by or associated with mental disorders for which the Mental Health Act may be used (e.g. drug-induced psychosis)
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What is the initial biological management of opiate misuse/withdrawal?
1. Symptomatic medication
2. Substitute prescribing
Symptomatic medication:
Non-opiate, oral medications ameliorate symptoms of opiate withdrawal. Unlike substitute-opiates (e.g. methadone) they not liable to abuse or diversion to the black market:
1. Lofexidine is an alpha-adrenergic agonist which is effective in reducing many of the unpleasant symptoms of opiate withdrawal. Effective detoxification can be achieved in as little as 3 days.
2. Loperamide and Metoclopramide (or other anti-emetic medications) are often prescribed to treat diarrhoea and nausea and vomiting commonly seen in withdrawal
Substitute prescribing
- used in detoxification and maintenance regimes
1. Methadone is a long-acting synthetic opioid. It has a half-life of 24 hours and therefore it is suitable for once daily dosing. It is taken orally as a coloured liquid
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What is the longer term biological management of opiate misuse/withdrawal?
Longer term prescribing of substitute opiate medications i.e. methadone as an alternate to the ilicit opiate drug that the individual is dependent on.
After stabilisation and complete abstinence from street opiates, a decision should be made as to whether the aim is dose reduction or maintenance.
Rapid reduction regimes reduce the dose over 14-21 days although the reduction usually is more gradual (weeks to months)
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What are the psychosocial management options for alcohol and illicit substance misuse?
1. Drug and alcohol services
2. Narcotics anonymous
3. Individual counselling
- social skills and assertiveness training (learning to say no)
4. Motivational interviewing and CBT
5. Self help resources
6. Social support
- Housing
- Child care/social services
- Finances/employment
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What is the biological management of Alcohol misuse?
1. Detoxification
2. Maintenance treatment to: i. deter drinking
- Disulfiram
ii. reduce individuals craving for alcohol
- Acamprosate
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How does disulfiram work?
Deters drinking as it causes irreversible inhibition of ALDH which converts alcohol to Co2 and water. If alcohol is consumed there is build up of acetaldehyde in bloodstream causing unpleasant symptoms such as flushing, headache, tachycardia, nausea and vomiting
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How does acamprosate work?
Reduces cravings for alcohol and acts through enhancing GABA transmission in the brain
119
What is motivational interviewing (MI)?
A style of patient-centred counselling developed to facilitate change in health-harming behaviours
120
What are the principles of MI (3)?
1. To help patients explore and resolve their ambivalence towards stopping or reducing health-harming behaviours
2. aims to enable patients to move through the stages of change described in the model by Prochaska and Diclemente
3. The therapist does not take a directive or "expert" role but supports the patient to evaluate the pros and cons of their substance misuse behaviour
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What are the 4 components of MI?
1. Develop discrepancy
2. Express empathy
3. Support self efficacy
4. Roll with resistance
122
In MI, what is the principle of developing discrepancy?
Motivation for change is created when the person perceives a discrepancy between their present behaviour and important personal goals. This often involves identifying the person's own goals. The goals need to be those of the person and not those of the health care provider, otherwise, the person will feel they are being coerced and may become more resistant to change. An important objective of MI is to help a person recognise the discrepancy between their behaviour and their personal goals.
One technique is to ask the person what is good or positive about a particular behaviour and what is not so good about it
123
In MI, what is the principle of expressing empathy?
Motivational interviewing relies to a great extent on establishing and maintaining rapport with the person. The ability to express empathy is critical to this process. This requires skilful, reflective listening to understand a person's feelings and perspectives without judging, criticising, or blaming. An attitude of acceptance and respect contributes to the development of an effective, helping relationship and enhances the person's self-esteem. Empathic responses demonstrate that the health care provider understands the person's point of view and provides an important basis for engaging the person in a process of change
124
In MI, what is the principle of supporting self efficacy?
Self-efficacy is a person's belief or confidence in their ability to carry out a target behaviour successfully. A general goal of motivational interviewing is to enhance the person's confidence in their ability to overcome barriers and succeed in change.
Health care providers can support self-efficacy by recognising small positive steps that the person is taking to change their behaviour. Even when the person is simply contemplating a change, there is an opportunity to provide recognition and support.
Setting reasonable and reachable goals that the person can actually accomplish will also help build confidence. It is important that the person is involved in setting the goal.
125
In MI, what is the principle of supporting roll with resistance?
Resistance can take several forms, such negating, blaming, excusing, minimising, arguing, challenging, interrupting, and ignoring. In motivational interviewing one does not directly oppose resistance but, rather, rolls or flows with it. Direct confrontation will create additional barriers that will make change more difficult. A person's resistance during motivational interviewing is expected and should not be viewed as a negative outcome. In fact, a person who resists is providing information about factors that foster or reduce motivation to adhere to behavioural change. Rolling with resistance, then, includes involving the person actively in the process of problem-solving.
126
What specific qs should you ask in the history about alcohol (12)?
1. CAGE:
- Have you ever thought you should CUT down?
- Are you ever ANNOYED by others’ complaints?
- Have you ever felt GUILTY over drinking?
- Have you ever had an EYE OPENER?
2. Quantity (concrete amount)?
3. Frequency?
4. What is type of alcohol do you typically drink?
5. When did you start drinking?
6. Who do you drink with?
7. Where do you normally drink?
8. What time of day do you drink?
9. Have you ever tried to stop drinking?
10. How do you pay for the alcohol?
11. Why do you drink?
12. How does drinking make you feel?
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Some useful qs to ask about alochol:
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
Have you ever found that you were not able to stop drinking once you started?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or someone else been injured as a result of your drinking?
Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
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What questions should you ask about in a drug history (10)?
1. CAGE
2. What type of drugs?
3. When did this start?
4. Frequency?
5. Method of administration
6. Have you ever been in trouble because of your drug use?
7. Who do you do the drugs with?
8. Have you ever tried to stop using?
9. How do you pay for the drugs?
10. How do they make you feel?
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How do you manage withdrawal from benzodiazepines?
1. Gradual reduction such as 5–10% reduction every 1–2 weeks. Can take months- a year depending on how much they are on
2. If they are on short-acting, potent benzodiazepines switch to diazepam as it has a long half-life, so avoids sharp fluctuations in plasma level
