Alcohol and Substance Misuse Flashcards
ICD-10 criteria for substance misuse for acute intoxication
Acute, usually transient, effects of the substance
ICD-10 criteria for substance misuse for harmful use
Recurrent misuse associated with physical, psychological and social consequences
- but without dependence
ICD-10 criteria for substance misuse for dependence syndrome
Prolonged, compulsive substances use leading to addiction, tolerance and the potential for withdrawal syndromes
ICD-10 criteria for substance misuse for withdrawal state
Physical and/or psychological effects from complete cessation of a substance after prolonged, repeated or high level of use
ICD-10 criteria for substance misuse for psychotic disorder
Onset of psychotic symptoms within 2 weeks of substance use
- must persist for more than 48 hours
ICD-10 criteria for substance misuse for amnesic syndrome
Memory impairment in recent memory and ability to recall past experiences
- impaired learning of new material
- defect in recall
- clouding of consciousness
- global intellectual decline
ICD-10 criteria for substance misuse for residual disorder
Specific features subsequent to substance misuse
- flashbacks, personality disorder, affective disorder, dementia, persisting cognitive impairment
Chain of events leading to substance dependence
Biological
- genetic variations in enzymes that metabolise drugs, neurochemical - abnormalities in dopamine, GABA and opioid systems
Environmental
- peer pressure, life stressors, parental drug use, cultural acceptability, personal vulnerability - lack of resources to cope with stressors
Takes substance
- cost, availability, effect of drug itself, route
Positive reinforcement
- psychosocial - from peer or pleasurable effects of drugs
- biological - activates mesolimbic dopaminergic reward pathways
Dependence
Examples of opiates
Morphine - PO and IV
Diamorphine (heroin) - IN, IV, smoked
Codeine/methadone - PO
Effects of opiates
Psychological
- apathy, disinhibition, psychomotor retardation, impaired judgement and attention, drowsiness, slurred speech
Physical
- respiratory depression, hypoxia, low BP, hypothermia, coma, pupillary constriction
Withdrawal state of opiates
Craving Rhinorrhoea Lacrimation Myalgia Abdo cramps N+V Diarrhoea Pupillary dilation Piloerection Increased HR/BP
Effects of cannabinoids
Psychological
- euphoria, disinhibition, agitation, paranoid ideation, temporal slowing, impaired judgement/attention/reaction time, hallucinations
Physical
- increased appetite, dry mouth, conjunctival injection, increased HR
Features of withdrawal state of canabinoiods
Anxiety, irritability, tremor of outstretched hands, sweating, myalgia
Types of sedative-hypnotics
Benzodiazepines
Barbiturates
Taken PO or IV
Effects of benzodiazepines
Psychological
- euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
Physical
- unsteady gait, difficulty standing, slurred speech, nystagmus, erythematous skin lesions, reduced BP, hypothermia, depression of gag reflex, coma
Features of withdrawal state of benzodiazepines
Tremor of hands, tongue or eyelids, N+V, increased HR, postural hypotension, headache, agitation, malaise, transient illusions/hallucinations, paranoid ideation, grand mal convulsions
Complications of substance misuse
Physical
- death, infection (HIV, hep A, B or C, Staph aureus, group A strep, clostridium, TB), endocarditis, superficial thrombosis, DVT, PE
Psychological
- craving, anxiety, cognitive disturbances, drug-induced psychosis
Social
- crime, imprisonment, homelessness, prostitution, relationship problems
Features of substance dependence
> 3 manifestations over 1 month
- strong desire to consume substance
- preoccupation with substance use
- withdrawal state when substance ingestion is reduced or stopped
- impaired ability to control substance-taking behaviour
- tolerance to substance
- persisting with use despite evidence of harmful effects
Management of substance misuse
Key worker with therapeutic alliance - psychosocial support
Hep B immunisation
Motivational interviewing and CBT
Contingency management - changing specified behaviours by offering incentives for positive behaviours
Supportive help - housing, finance and employment
Self help groups
Define detoxification
Process in which the effects of the drug are eliminated in a safe manner
- withdrawal symptoms avoided
- attempt to attain abstinence
Define maintenance thearpy
Abstinence not priority
Aim is to minimise harm
Management of opioid dependence
Biological
- methadone
- buprenorphine for detoxification or morphine
IV naloxone for antidote to opioid overdose
Define alcohol abuse
Consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm
Define binge drinking
Drinking over twice the recommended level of alcohol per day in one session
Define harmful alcohol use
Drinking above safe levels with evidence of alcohol related problems
Pathophysiology of alcohol abuse
Affects several neurotransmitters
- GABA -> anxiolytic and sedative effects
- dopamine -> sensitisation leads to dependence
Long term use leads to down-regulation of inhibitory neuronal GABA and up-regulation of excitatory glutamate receptors
Risk factors for alcohol abuse
Male - increased risk and increased metabolism
Younger adults
Genetics
Antisocial behaviour
Lack of facial flushing - metabolises acetaldehyde more slowly
Life stressors - financial problems, marital issues, certain occupations
Clinical features of alcohol intoxication
Slurred speech Labile affect Impaired judgement Poo co-ordination Severe cases - hypoglycaemia, stupor and coma
Clinical features of alcohol dependence
Subjective awareness of compulsion to drink
Avoidance or relief of withdrawal symptoms by further drinking
Withdrawal symptoms
Drink-seeking behaviours
Reinstatement of drinking after attempted abstinence
Increased tolerance
Narrowing of drinking repertoire -
Features of alcohol withdrawal
Malaise Tremor Nausea Insomnia Transient hallucinations Autonomic hyperactivity - 6-12 hrs Seizures - 36 hours
Negative effects of alcohol consumptoms
Medical - fatty liver, hepatitis, cirrhosis, hepatocellular carcinoma - peptic ulcer disease, oesophageal varices, pancreatitis, oesophageal carcinoma - hypertension, cardiomyopathy, arrhythmias - anaemia, thrombocytopenia - seizures, peripheral neuropathy, cerebellar degeneration, Wernicke's encephalopathy, Korsakoff's psychosis - foetal alcohol syndrome Psychiatric - morbid jealousy - self-harm and suicide - mood disorders - anxiety disorders - alcohol-related dementia - alcoholic hallucinations - delirium tremens Social - domestic violence - drink driving - employment difficulties - financial problems - homelessness - accidents - relationship problems
ICD-10 criteria for alcohol intoxication
General criteria for acute intoxication met
- clear evidence of psychoactive substance at high dose levels
- disturbance in consciousness, cognition, perception or behaviour
- not accounted for by medical or mental disorder
Evidence of dysfunctional behaviour
- disinhibition
- argumentativeness
- aggression
- labile mood
- impaired attention/concentration
- interference with personal functioning
One of the following
- unsteady gait, difficulty standing, slurred speech, nystagmus, flushing, reduced consciousness, conjunctival injection
ICD-10 criteria for alcohol withdrawal
General criteria for a withdrawal state met
- clear evidence of recent cessation or reduction of substance after prolonged or high level usage
- not accounted for by medical or mental disorder
Any three of the following
- tremor, sweating, N+V, tachycardia, increased BP, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions
Features of delirium tremens
Withdrawal delirium - develops between 24 hrs and one week after alcohol cessation Characterised by - cognitive impairment - vivid perceptual abnormalities - paranoid delusions - marked tremor - autonomic arousal
Treatment of delirium tremens
Large dose benzodiazepines
Haloperidol for psychotic features
IV pabrinex
Define Wernicke’s encephalopathy
Acute encephalopathy due to thiamine deficiency
Features of Wernicke’s encephalopathy
Delirium Nystagmus Ophthalmoplegia Hypothermia Ataxia
Management of Wernicke’s encephalopathy
Parenteral thiamine
Define Korsakoff’s psychosis
Profound, irreversible short-term memory loss with confabulation (unconscious filling of gaps with imaginary events) and disorientation to time
How to calculate alcohol units
Strength x volume / 1000
Management of alcohol abuse
Biological
- chlordiazepoxide detox regime + thiamine
- disulfiram - build up of acetaldehyde on consumption of alcohol
- Acamprosate - reduces craving by enhancing GABA transmission
- naltrexone - blocks opioid receptors
- treatment of medical and psychiatric complications
Psychological
- motivational interviewing
- social network and environment based therapies
Social
- alcoholics anonymous
- social support including family involvement
