Alcohol and substance misuse Flashcards
What are the risk factors for substance misuse?
- Peer pressure
- Life stressors
- Parental drugs use
- Cultural acceptability
- Positive reinforcement: from peers or effect of drus
Which sex uses drugs more?
Male
Which drugs are commonly misused?
Opiods
Cannabinoids
Stimulants
Sedative-hypnotics
Hallucinogens
Volatile solvents
Anabolic steroids
What are the physical, psychological and social complications of substance misuse?
Physical = death, infection (HIV, Hep A, B or C, S. Aureaus, TB), endocarditis, superficial thrombosis, PE
Psychological = craving, anxiety, cognitive disturbance, drug-induced psychosis
Social = Crime, imprisonment, homelessness, prostitution, relationship problems
What are the features of substance dependence?
- Compulsion to consume substance
- Preoccupation with substance use
- Withdrawal
- Tolerance
What to ask in substance misuse OSCE?
TRAP (type, route, amount and pattern)
Risk assessment (incl. needle sharing)
Possible triggers or stressful life events
Past substance use
Complications of drug abuse
What investigations for substance misuse?
- Bloods (HIV screen, Hep B, C and TB, U&Es for renal function, LFTs and clotting for hepatic function and drug levels)
Urinalysis: drug metabolites e.g. cannabis and opiods can be detected in urine
ECG for arrhythmias, ECHO for endocarditis
What are the differentials for substance misuse?
Psychosis
Mood disorder
Anxiety disorder
Delerium
Organic: Hyperthyroidism, CVA, intracranial haemorrhage, neurological disorders (e.g. cerebellar pathology)
What is the management of patients with substance misuse?
- Keyworker with training in substance misuse
- Hep B immunization
- Motivational interviewing and CBT (for co-morbid depression or anxiety)
- Supportive help e.g. housing, finance and employment
- Self-help groups e.g. NA or cocain anonymous
- Issue of driving and DVLA
What drug can be used to wean patient off of opiods?
Methadone or Buprenorphine for detoxification and maintenance
Naltrexone can be used for those who have recovered from an opiod-dependency (also used as an antidote to opiod overdose)
What is alcohol abuse?
Consumption of alcohol at a level sufficient to cause physical, psychitric and / or social harm.
Binge drinking is drinking twice the recommended level of alcohol per day, in one session
What is the effect of alcohol?
Affects neurotransmitters (effect on GABA causes anxiolytic and sedative effects)
What is the long term effect of alcohol consumption?
Down-regulation of inhibitory neuronal GABA receptors and up-regulation of excitatory glutamate receptor (when withdrawn causes CNS hyper-excitability)
Define operate conditioning and alcohol misuse?
Positive or negative reinforcement from the effects of drinking will either perpetuate or deter drinking habits, respectively
What are the risk factors for alcohol abuse?
- Male
- Younger adults
- Genetics
- Pre-morbid antisocial behaviour
- Life stressors (financial problems, marital issues, certain occupations)
What are the features of alcohol dependence?
CAGE
Cut back, annoyed at comments, guilty, eye-opener
What are some complications of alcohol abuse?
Medical = fatty liver, hepatitis, cirrhosis, hepatocellular carcinoma, peptic ulcer, varices, pancreatitis, HTN, cardiomyopathy, anaemia, seizures, peripheral neuropathy, Wernicke’s encephalopathy, Korsakoff’s psychosis, head injury, fetal alcohol syndrome
Psychatric = morbid jealousy, delf-harm, mood disorders, anxiety, delerium tremens
Social = domestic violence, drink driving, employment difficulties, financial problems, homelessness
What are some symptoms of alcohol withdrawal?
Malaise
Tremor
Nausea
Insomnia
Transient hallucinations
6-12 hours = automonic hyperactivity
36 hours = seizures
When is the peak incidence of delerium tremens?
48-72 hours
How does delerium tremens present?
- Cognitive impairment
- Vivid perceptual abnormalities
- Paranoid delusions
- Marked tremor
- Automonal arousal (tachycardia, fever, pupillary dilatation, increased sweating)
What is the medical treatment of delerium tremens?
- Large dose of benzodiazepines (e.g. chlordiazepoxide)
- Haloperidol for psychotic features
- IV Pabrinex (replacement vitamins)
Name some peripheral stigmata of chronic liver disease?
- Palmar erythema
- Dupuytren’s contracture
- Spider naevi
- Gynaecomastia
- Clubbing, caput medusa, oesophageal varices
What investigations for alcohol dependence?
- Bloods: alcohol level, FBC (anaemia), U&Es (dehydration, decreased urea), LFTs including gamma GT, MCV, vit B12/folate/ TFTs, amylase, hepatitis serology, glucose (hypoglycaemia)
- Alcohol questionnaires (FAST, SADQ)
- CT head
- ECGs
What is Wernicke’s encephalopathy?
Acute encephalopathy due to thiamine deficiency - presents with delerium, nystagmus, opthalmoplegia, hypothermia and ataxia
May progress to Korsakoff’s
Treat with parenteral thiamine
What is Korsakoff’s psychosis?
Irreversible short term memory loss with confabulation and disorientation to time
How to calculate the amount of units?
Volume of alcohol x volume (L)
What is the biopsychosocial management of alcohol abuse?
Bio = Chlorsiazepoxide detox + thiamine. Disulfiram / naltrexone. Treatment of medical complications.
Psycho = Motivational interviewing + CBT
Social = Alcoholics anonymous. Social support including family involvement. Advise patient to contact DVLA
What is the long term treatment of alcohol dependence?
Disulfiram = causing a build-up of acetaldehyde on consumption of alcohol causing anxiety, flushing and headaches
Acamprosate = reduces craving by enhancing GABA transmission
Naltrexone = blocks opiod receptors (antagonist) in the body, thus reducing the pleasurable effects of alcohol
Alcoholics anonymous = 12 step approach using psychosocial techniques with social support networks, rewards with a sponsor assigned
Motivational interviewing / CBT
Prophylactic oral thiamine if malnourished
