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CP2 - Psych > Alcohol and substance use problems > Flashcards

Alcohol and substance use problems Flashcards

1
Q

Glossary

A

-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

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2
Q

ICD-10 depedence on substance

A

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

  1. Strong desire or compulsion to take substance
  2. difficulties in controlling substance taking behaviour (onset/termination/levels of use)
  3. phsiological withdrawl or continueing to avoid this
  4. Tolerance . . . increase dose needed for same effect
  5. Priority given to substance . . . eg time/money getting and time recovering from
  6. persistance despite knowing it causes harm
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3
Q

alcohol amounts

A

1 unit = amount metabolisd in one hour

  • zero order kinetis
  • abc * vol = units . . .. . 568ml (pint) of 5% = 5.3* 0.568 = 3 units
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4
Q

alcohol advice

A
  • no sage level to drink alcohol
  • < 14 units/week keeps risk low
  • don’t drink all in one go
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5
Q

alcohol intoxication

A

-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

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6
Q

Alcohol complications

A

break it up bio (into systems) pscycho social

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7
Q

withdarawl

A
  • uncomplicated
  • -uncomplicated with perceptual changes
  • uncomplicated with withdrawl seizures
  • delirum tremens
  • wernickes encepalopathy (withdrawl often precedes this)

Blackouts common and dementia

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8
Q

uncomplicated withdrawl

A
  • 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
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9
Q

Delirium Tremens

A
  • 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
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10
Q

wernickes encephalopathy

A

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)

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11
Q

Other alcohol related psychiatric condtions

A

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

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12
Q

Psych-substance relationships

A

1 primary psychiatric disorder and substance used on top

  1. symptoms due to direct effect of substance
  2. Combination as psychoactive substances used can cause condition in predisposed
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13
Q

substance related psychiatric disorder indicated if:

A
  • 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
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14
Q

Substance Hx

A
  • CAGE and AUDIT questionaires useful
  • what is used?
  • pattern?
  • route?
  • dependent?
  • abstinence?
  • controlled use?
  • relapses?
  • Previous Treatment?

consequences?

  • biopsychosocial
  • forensic/occupation
  • remember polyuse

DRIVING!

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15
Q

Most common ODs

A

heroine
diazepam
alcohol
methadone

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16
Q

CAGE

A
  • Cut down on drinking (felt need to?)
  • Annoyed by people questioning it? (
  • Guilty feelings about your drinking?
  • Eye opener (need first thing in morning)
17
Q

Alc epidemiology

A
  • 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)
18
Q

alcohol aetiology

A

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)
19
Q

Mx of alcohol use

A
  • Brief alcohol intervention
  • detoxificaiton
  • withdrawl treatment
  • mx of delirium tremens
  • detox maintenance
  • pharmacological therapy
20
Q

Brief alcohol intervention

A

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

21
Q

Detoxification

A

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

22
Q

mx d tremens

A

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
23
Q

detox maintenance

A

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

24
Q

alchol prognosis

A

50-60% show improvement or abstinence 1y after treatment

25
Q

other sunstances epidemioligy

A

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

26
Q

mx general

A
  • harm reduction
  • physical detoxificaiton
  • maintenance of abstinence
27
Q

opioid medications tx

A 
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
28
Q

opioid dependence biopsychosocil stages?

A

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
29
Q

benzodiazepams

A
  • dependence if used longer than 2-4 weeks
  • withdrawl included hallucinations and delirum
  • sx can appear in hours/days depending on half life

CP2 - Psych (6 decks)

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