Alcohol and substance use problems Flashcards
Glossary
-Pyschoactive = acts on CNS
-Intoxication = transient, subspecific with altered mood, consciousness, perception or behaviour
-Hazardous use = increased risk of adverse outcome
- harmful use = adverse outcomes w/o dependence (relationships, occupation, physical, mental and legal
-deppendence = condition with biopsychoscoial elements
-misuse = abuse = use without legal or medical guidelines
-withdrawl = substance specific syndrome on reduction
/cessation of substance after repeated high dose use
ICD-10 depedence on substance
3 or more of the below for more than 1 month or for less than one moneth but occured repeatedly over the last 12 months
- Strong desire or compulsion to take substance
- difficulties in controlling substance taking behaviour (onset/termination/levels of use)
- phsiological withdrawl or continueing to avoid this
- Tolerance . . . increase dose needed for same effect
- Priority given to substance . . . eg time/money getting and time recovering from
- persistance despite knowing it causes harm
alcohol amounts
1 unit = amount metabolisd in one hour
- zero order kinetis
- abc * vol = units . . .. . 568ml (pint) of 5% = 5.3* 0.568 = 3 units
alcohol advice
- no sage level to drink alcohol
- < 14 units/week keeps risk low
- don’t drink all in one go
alcohol intoxication
-high = icoordination, slurred speech, ataxia, amnesia and impaired reaction times
- much higher = decreased consciousjness, respiratory depression, caoma and death
. . . .hypoglycaeemia, hypthermia, trauma and aspiration risk
- 7/10 completed suiicides are intoxicated
Alcohol complications
break it up bio (into systems) pscycho social
withdarawl
- uncomplicated
- -uncomplicated with perceptual changes
- uncomplicated with withdrawl seizures
- delirum tremens
- wernickes encepalopathy (withdrawl often precedes this)
Blackouts common and dementia
uncomplicated withdrawl
- 4-12 hours post cessation
- tremulousnes (shakes)
- sweating
- N+V
- Mood (anxiety/depression/ on edge)
- hyperacusis
- autonomic hyperactivity
- sleep disturbance
- agitation
With perceptial disturbances (illusions/hallucinations)
with withdrawl seizures
- 5-15% of dependence
- generalised and tonic clonic
- predisposed by hx of fits, concurrent epilepsy and decrease pottassium or magnesium
Delirium Tremens
- 1-7 days after (mean 48hrs)
-altered consciousness and decrease cognition
-viid hallucinations andillusions (lillipution and formication (insects)
-marked tremor
-autoomic arousal (BP, HR, SWEAT, TEMP)
-paranoid delusions
5-15% mortality
wernickes encephalopathy
Triad of ataxia, opthalmoplegia and decrease cognition
Risk of long term decrease in cognition ( Korskof syndrome) - extensive anteriograde/retrograde amnesia
Treat with parental thiamine (pabrinex)
Other alcohol related psychiatric condtions
alcohol related psychotic disorder
- from perceptial changes to severe delusions that resolve with alcohol cessation
- much more likely to be from underlying condition or withdrawl
alcohol related mood disorder
- anxiety and depression very interelatied
- which came first
- treat dependence first and should improve
alchol related anxiety disorder
-common to self medicate for PTSD, agoraphobia and social phobia
Psych-substance relationships
1 primary psychiatric disorder and substance used on top
- symptoms due to direct effect of substance
- Combination as psychoactive substances used can cause condition in predisposed
substance related psychiatric disorder indicated if:
- known association with specific drug
temporal relationship between drug and sx
-complete recovery after termination of drug use
-absence of evidence of previous psych history or familiy history
Substance Hx
- CAGE and AUDIT questionaires useful
- what is used?
- pattern?
- route?
- dependent?
- abstinence?
- controlled use?
- relapses?
- Previous Treatment?
consequences?
- biopsychosocial
- forensic/occupation
- remember polyuse
DRIVING!
Most common ODs
heroine
diazepam
alcohol
methadone
CAGE
- Cut down on drinking (felt need to?)
- Annoyed by people questioning it? (
- Guilty feelings about your drinking?
- Eye opener (need first thing in morning)
Alc epidemiology
- most harmul substance in common use
- middle aged most likely to be dependent
- males more dependent than females
- young more likely to drink hazardously (binge = 8 male and 6 female)
alcohol aetiology
Bio
- heritable (biochemical and personality traits)
- downregulation of GABAr and upregulation of NMDAr ( as alchol acts to mimic gabas affects)
Psycho
- postive reinforcement = good feeeling and negative = avoiding withdrawl
- observational learning
- presence of other psychiatric condition
- PD (antisocial and EUPD)
Social (environmental)
- social and cultural also
- How affordable
- risky jobs (DOCTORS,journalists, catering, leisure, shipping and travel)
Mx of alcohol use
- Brief alcohol intervention
- detoxificaiton
- withdrawl treatment
- mx of delirium tremens
- detox maintenance
- pharmacological therapy
Brief alcohol intervention
FRAMES
Feedback - link to health and presenting complaint after hx
Responsibility - emphasis its patients decision
Advice - cutting down = less risk for future health
Menu - options = diary, activities, acoiding high risk situations
Empathy - warm and reflective understanding
Self efficacy - empower them to say they can
Detoxification
Community based unless:
- severe dependence
- hx of withdrawl seizure or D tremens
- unsupportive home enironment
- significant physical or psychiatric co-morbidity
- advanced age
- pregnancy
- previous fail in community
work best if planned in advance
benzodiazepam (chlordiazepoxide) . .. gradulaly reduce over 5-7 days
may not need meds if <15/day in men or <10/day (w)
pabrinex if wernicke encepalopath a risk
delirium a risk . . .avoid >1 detox per 6/12
mx d tremens
Physical exam/ix (look for alternative cause and assess for wernickes)
- infection
- head injury
- liver failure
- GI
Medications
- benzos
- only use antipsychotics (haliperidole) if severe psychotic sx as they lower seizure threshold
prophylaxis/tx of wernickes
-2 x pabrinex ampuoles daily for 5/7
monitor
- temp (hyperthermia)
- fluid (dehydrated)
- electtrolytes (hypokalaemia/hypomagnesaemia)
- hypoglycaemia
detox maintenance
psycho
- motivational interviews
- CBT (ERP)
- mutual organisations (AA 12 steps)
- Social support (workers or probation officer)
- residential rehab
- peer support
Pharmaceutical
-Disulfaram (antabuse) _ acetaldehyde accumulation, anxiety, palpitations, N+V etc
(contraindicated in HF, CHD and stroke)
Acamprostate - increase gabba transmission and decrease glutamate transmission therefore decreaseing craving and safe while drinking
-Naltrexone (Nalorex) and nallmefine (selincro) = block opioid receptors to reduce cravings and pleasant affect of alcohol
-ADDs and benzos not recommended in maintenence
alchol prognosis
50-60% show improvement or abstinence 1y after treatment
other sunstances epidemioligy
recrearional use = 8% 2;1 M:F
MOSTLY CANNABIS WITH -1-2 for cocaine/md
0.3% opiod dependence but highest mortality risk
0.7% hospital admision s and 0.5% deaths
mx general
- harm reduction
- physical detoxificaiton
- maintenance of abstinence
opioid medications tx
methadone = long acting mu opioid receptor agonist SEs -constipation -sedation -euphoria -nausea -risk of ODs if other dpressants used
Buprenorphine = long acting mu opioid partial agonist
- less sedating and euphoric than methadone
- lower oOD risk
- only partial so less suitable for
- both need to have consumption observed
opioid dependence biopsychosocil stages?
harm reduction - education on dangers and harm reduction kit including naloxone kit
psyhchosocilal intervention - motivational interviewing
- trauma specific CBT
- behavioural couples therapy
- family interventions
- contingency management
- residential rehab
- signpost for social support and occupational training
substitue prescribing
- first need tox screens and attendence in withdrawl
- consider methadone and buprenorphine
- regular review for titration and then long term prescription
Detoxification
- minimise withdrawl sx and provide releif eg lafexidine alpha 2 adrenoceptor agonist for reange of sx
- loperamide for diarrhoea
- metoclopramide for nausea
- mebeverine for stomach cramps
- analgesics for pain
- propranolol/diazepam for anxiety
abstinence
- encourage mutual aid meetings and participation in recover community activities
- naltexone to block future euphoria (develop crisis plan and aware how to acess help rapidly
benzodiazepams
- dependence if used longer than 2-4 weeks
- withdrawl included hallucinations and delirum
- sx can appear in hours/days depending on half life
