ALCOHOL AND SUBSTANCE RELATED DISORDERS Flashcards
In 2007, what proportion of men were found to engage in hazardous drinking?
33%
In 2007, what proportion of women were found to engage in hazardous drinking?
16%
In 2007, what proportion of men (16-75) were found to have a dependence to alcohol?
9%
In 2007, what proportion of women (16-75) were found to have a dependence to alcohol?
4%
What is the safe daily alcohol limit for men?
3-4 units a day with at least 2 alcohol free days a week
What is the safe daily alcohol limit for women?
2-3 units a day with at least 2 alcohol free days a week
What are the causes of and risk factors for alcohol dependence?
They are multifactorial:
Genetic element
Positive reinforcement - eg loss of inhibition
Negative reinforcement - eg withdrawal symptoms
Relatives and peers
Presence of other mental health problems
Culture
Social class
Profession - stress
Significant life event - eg. rape, bereavement
What are the 4 L’s which represent the areas affected by harmful use of alcohol?
Love
Livelihood
Liver
Law (crime)
What are the different psychoactive substance-related disorders?
Hazardous use of substance Harmful use of substance Substance dependence Substance intoxication Substance withdrawal Substance withdrawal delirium Substance-related cognitive disorders Substance-related psychotic disorder Substance-related mood disorder Substance-related anxiety disorder
What is the difference between harmful use and hazardous use of a substance?
Hazardous use - quantity or pattern of substance use that places the user AT RISK of adverse consequences, without dependence. eg drink driving
Harmful use - quantity or pattern of substance use that ACTUALLY CAUSES adverse consequences, without dependence. eg binge drinking
How does the ICD-10 define the diagnosis of dependence syndrome of any substance?
3 or more of the following have been present together at some time during the previous year:
- A strong desire or compulsion to take the substance
- Difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
- Physiological withdrawal state when substance use has reduced or ceased; or continued use of substance to avoid withdrawal symptoms
- Signs of tolerance: increased quantities of substance are required to produce same effect originally produced by lower doses.
- Neglect of other interests activities due to time spent acquiring and taking substance, or recovering from its effects.
- Persistence with substance use despite clear awareness of harmful consequences (physical or mental)
Are patients who do not display or report signs of tolerance or withdrawal considered not dependent on a substance?
No. They may be dependent despite not exhibiting either tolerance or withdrawal. However, if they do exhibit either tolerance or withdrawal they are likely to be dependent.
What are the ‘uncomplicated’ features of alcohol withdrawal syndrome?
Tremulousness Sweating Nausea and vomiting Mood disturbance Sensitivity to sound Tachycardia Hypertension Mydriasis Pyrexia Sleep disturbance Psychomotor agitation
These features tend to develop 4-12 hours after drinking cessation
What are the more ‘complicated’ features of alcohol withdrawal syndrome?
Perceptual disturbances - illusions, hallucinations
Withdrawal seizures
Delirium tremens
How long after cessation of drinking do withdrawal seizures tend to develop?
6-48 hours
In what proportions of alcohol-dependant drinkers do withdrawal seizures occur?
5-15%
What type of seizures are associated with alcohol withdrawal syndrome?
Generalized and tonic-clonic
What electrolyte disturbances in an alcoholic patient might precipitate withdrawal seizures?
Low potassium
Low magnesium
What are the features of delirium tremens?
Altered consciousness Marked cognitive impairment - delirium Vivid hallucinations and illusions Marked tremor Autonomic arousal - sweating, raised BP and HR, pyrexia Paranoid delusions
How long after cessation of drinking does delirium tremens tend to develop?
1-7 days
What is the deficiency associated with Wernicke’s encephalopathy and Korsakoff psychosis?
Vitamin B1 - thiamine
What is the difference between Wernicke’s encephalopathy and Korsakoff psychosis?
Wernicke’s encephalopathy occurs in the acute brain damage phase due to thiamine deficiency whereas Korsakoff psychosis is the chronic state that emerges after Wernicke’s encephalopathy. They represent a continuum.
What is the classical triad that characterises Wernicke’s encephalopathy?
Delirium
Opthalmoplegia - nystagmus, sixth nerve palsy or conjugate gaze palsy
Ataxia
What features is Korsakoff’s psychosis characterised by?
Extensive anterograde amnesia
Frontal lobe dysfunction
Psychotic symptoms occurring in the absence of delirium
How do you treat Wernicke’s encephalopathy?
Parenteral thiamine (Pabrinex)
What types of psychotic symptoms are most commonly associated with alcohol related psychotic disorder?
Visual (alcohol hallucinosis) and auditory hallucinations
Grandiose delusions
What are the common psychological effects of opiate misuse?
Euphoria
Drowsiness
Apathy
Personality change
What are the physical effects of opiate misuse?
Miosis (pin point pupils) Conjunctival injection Nausea Pruritus Constipation Bradycardia Respiratory depression Coma
What are the psychological effects of misuse of sedatives such as benzodiazepines and GHB?
Drowsiness Disinhibition Confusion Poor concentration Reduced anxiety Feeling of well being
What are the physical effects of misuse of sedatives such as benzodiazepines and GHB?
Miosis (pin point pupils) Hypotension Withdrawal seizures Impaired coordination Respiratory depression
What are the psychological effects of misuse of stimulants such as amphetamines, cocaine, MDMA, mephedrone and legal highs?
Alertness Hyperactivity Euphoria Irritability Aggression Paranoid ideas Hallucinations (especially cocaine) Psychosis
What are the physical effects of misuse of sedatives such as amphetamines, cocaine, MDMA, mephedrone and legal high?
Mydriasis (dilated pupils) Tremor Hypertension Tachycardia Arrythmias Perspiration Fever (especially MDMA) Convulsions Perforated nasal septum (cocaine)
What are the psychological effects of misuse of hallucinogens such as LSD and magic muschrooms?
Marked perceptual disturbances Flashbacks Paranoid ideas Suicidal and homicidal ideas Psychosis
What are the physical effects of misuse of hallucinogens such as LSD and magic muschrooms?
Mydriasis Conjunctival injection (red eye) Hypertension Tachycardia Perspiration Fever Loss of apetite Weakness Tremor
What are the psychological effects of misuse of cannabinoids such as cannabis, hashish, hash oil?
Euphoria
Relaxation
Altered time perception
Psychosis
What are the physical effects of misuse of cannabinoids such as cannabis, hashish, hash oil?
Impaired coordination and reaction time
Conjunctival injection
Nystagmus
Dry mouth
What are the psychological effects of misuse of ketamine?
Hallucinations
Paranoid ideas
Thought disorganisation
Aggression
What are the physical effects of misuse of ketamine?
Mydriasis
Tachycardia
Hypertension
What are the psychological effects of misuse of inhalants such as aerosols, glue, lighter fluid and petrol?
Disinhibition Stimulation Euphoria Clouded consciousness Hallucinations Psychosis
What are the physical effects of misuse of inhalants such as aerosols, glue, lighter fluid and petrol?
Headache Nausea Slurred speech Loss of motor coordination Muscle weakness Damage to brain/bone marrow/liver/kidneys/heart Sudden death
What are the main two questionnaires used for screening of alcohol dependence?
CAGE
AUDIT
What are the four parts of the CAGE screening questionnaire?
- Have you ever felt you ought to Cut down on your drinking?
- Have people ever made you Angry by criticising your drinking?
- Have you ever felt Guilty about your drinking?
- Have you ever needed an ‘Eye opener’ in the morning?
What are the main things you should look out for when examining a patient who you suspect is misusing a substance?
Signs of intoxication:
Pupi constriction
Slurred speech
Incoordination
Signs of withdrawal: Tremulousness Sweating Nausea and vomiting Tachycardia Pupil dilatation (alcohol)
Signs of complications:
Head injury
Infection through IV drug use (Hep C / HIV)
Liver disease
Which patients will need admitting for treatment of alcohol withdrawal?
Severe dependence
History of withdrawal seizures or delirium tremens
Unsupportive home environment
Previous failed community detoxification
What drugs can be used to treat alcohol withdrawal?
Benzodiazepines - chlordiazepoxide, diazepam, lorazepam
Initially started on high dose and gradually decreased over 5-7 days
How would you treat someone who presents to A&E with the signs and symptoms of delirium tremens?
Admit them
Search for medical complications (infection, head injury, liver failure, haemorrhage, Wernicke’s encephalopathy)
Large dose benzodiazepine. Use haloperidol for severe psychotic symptoms only (risk of seizures with antipsychotics)
Intramuscular thiamine. Oral is not adequate in delirium tremens.
Monitor and treat temperature, fluid, electrolytes and glucose.
What medications can be used to help the patient maintain abstinence?
(Brand name in brackets)
Disulfiram (Antabuse)
Acamprosate (Campral)
Naltrexone (Nalorex)
Antidepressants and benzodiazepines are not used in the maintenance of abstinence, but they can be useful for treatment of co-morbid psychiatric illness.
How does disulfiram work (drug used to help patients abstain from alcohol)?
Blocks aldehyde dehydrogenase which causes an accumulation of acetaldehyde when alcohol is consumed. This causes symptoms of anxiety, flushing, palpitations, headache and nausea. It is contraindicated in patients with cardiorespiratory problems.
How does acamprosate work (drug used to help patients abstain from alcohol)?
Enhances GABA transmission and appears to reduce craving. Safe to use while drinking.
How does naltrexone work (drug used to help patients abstain from alcohol)?
Blocks opioid receptors and appears to reduce cravings and also reduces pleasant effect of alcohol, thereby decreasing desire to drink.
What is the neurotransmitter associated with dependence and the brain’s reward system?
Dopamine in the mesolimbic pathway
Is opiate withdrawal life threatening?
No, but it is very unpleasant and patient may require help.
What drug can be used to help people with withdrawal symptoms of opiate dependence?
Lofexidine - centrally acting α-adrenoceptor agonist which reduces sympathetic outflow.
What is substitution therapy with reference to treatment of opiate dependence?
Another substance is prescribed as an alternative to illicit drug use. Oral opiate alternatives act to stabilise patient’s life and prevent complications of needle use. May be prescribed indefinitely but the aim is normally for gradual reduction with long term abstinence.
The two drugs used are methadrone and buprenorphine. Buprenorphine is a partial agonist so may precipitate withdrawal in those who are dependent on high doses of opiates.
Once a opiate dependent patient has been detoxified, what drug is used to block the euphoriant effects of future opiate use?
Naltrexone - opiate antagonist. It can induce withdrawal if the patient is still dependent.
Is benzodiazepine withdrawal life threatening?
Yes.
What are the symptoms of benzodiazepine withdrawal syndrome?
Hallucinations
Convulsions
Delirium
Symptoms can emerge within hours to days, depending on half life of benzodiazepine.
How is benzodiazepine withdrawal managed?
Initially converting drugs with a shorter half life (lorazopam) to drugs with longer half life (diazepam). Dose then reduced very slowly by small amount every few weeks.
A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?
2 hours
6 hours
24 hours
36 hours
72 hours
72 hours
