Alcohol + substance misuse Flashcards
Describe the neurocircuitry of the addiction cycle
1) binge + intoxication - basal ganglia - reward circuits in the brain are activated during intoxication
2) withdrawal + negative effect - extended amygdala - activation of emotional circuitry in brain results in negative mood and enhanced sensitivity to stress during withdrawal
3) preoccupation + anticipation - prefrontal cortex - decreased prefrontal functioning impairs the balance of desire and ability to abstain
Describe clearance of alcohol
eliminated at constant rate
predominantly hepatic
Diagnostic criteria for alcohol misuse problems
pattern: episode of harmful use, harmful pattern of use, dependence
impact: intoxication, withdrawal, alcohol-induced delirium, alcohol-induced psychosis, mood + anxiety disorders
Describe alcohol dependence
pattern of recurrent episodic use (>12mo) or continuous (daily/almost daily >3mo) with evidence of impaired regulation AND >2 of:
- impaired control over use (onset, frequency, intensity, duration, termination, context)
- increasing precedence of use over other aspects of life (maintaining health, daily activities + responsibilities) with use continuing/escalating despite harm)
- physiological neuroadaptation (tolerance or withdrawal)
Aetiology of alcohol dependence
unclear molecular mechanisms
interacts with neuronal membranes > increase fluidity > more specific changes in neurotransmitter release > characteristic pharmacological actions
pleasure = dopamine + opioids in mesolimbic forebrain
anxiolytic effects = brain GABA activity
List some forms of 1 unit of alcohol
half a pint of regular beer, lager or cider
half a small glass of wine
1 single measure of spirits
1 small glass of sherry
1 single measure of aperitifs
What screening tools can be used for alcohol use?
AUDIT
FAST
SADQ
What questions should be asked in an alcohol history?
describe a typical day’s drinking
what time is the first drink of the day?
when did daily drinking start?
presence of withdrawal symptoms in the morning or after abstinence
previous attempts at treatment
physical health problems
patient’s attitude towards drinking
Alcohol treatment approach
raise individual’s awareness + motivation to change
support + advice from AA
withdraw alcohol (detox) or controlled drinking
NICE:
- harmful drinking + mild dependence = high-intensity psychotherapy
- mod-severe = after successful withdrawal, consider acamprosate/naltrexone
- >15 units/day or 15-30 on SADQ = community-based assisted withdrawal (inpatient if safety concerns)
Psychological treatments for alcohol dependence
motivational interviewing
behavioural techniques (with partner and social network)
social and interpersonal skills
cue exposure and relapse prevention
CBRT (cognitive behavioural relationship therapy)
AA
What substances can be detected on urine drug screen?
amphetamines + analogues
opioids (codeine, morphine, dihydrocodeine)
methadone
buprenorphine + metabolites
cannabinoids
cannabis
Effects of cannabis
increased enjoyment of aesthetic experiences + distortion of time + space
red eyes, dry mouth, tachycardia, irritated airway
toxic confusional states, occasional psychosis
Cannabis withdrawal symptoms
generally mild
irritability
nausea
insomnia
anorexia
Pharmacological treatment of tobacco addiction
transdermal nicotine patches
nicotine gum
nicotine lozenges
nicotine inhalers
nicotine nasal spray
sublingual nicotine tablets
varenicline
e-cigarettes
Effect of MDMA (ecstasy)
stimulant + mild hallucinogen
mood: positive state (euphoria, sociability + intimacy, sensations of new insights + perceptions)
physical: loss of appetite, tachycardia, bruxism, sweating
Adverse effects of MDMA
rare
hyperthermia
arrhythmias
intracerebral haemorrhage
associated with acute and chronic paranoid psychoses
How long does it take for the body to eliminate 1 unit of alcohol?
~1 hour/unit
Symptoms 6-12 hours after last alcoholic drink
insomnia
tremors
anxiety
agitation
nausea + vomiting
sweating
palpitations
Symptoms 12-24 hours after last alcoholic drink
visual hallucinations
auditory hallucinations
tactile disturbances eg. sensations of crawling bugs on skin
When are alcohol withdrawal seizures most likely to occur?
normally 24-48 hours post-last alcoholic drink
Symptoms 28-72 hours after last alcoholic drink
delirium tremens may occur:
- delirium + agitation
- hallucinations + delusions
- tachycardia
- hypertension
- hyperthermia
- diaphoresis
- coarse tremor
What tests should be done in suspected alcohol withdrawal?
ECG
Capillary blood glucose
FBC + CRP
LFTs
U&Es
bone profile + magnesium
blood cultures
CXR if signs of aspiration
CT head if injury or ongoing seizures
What is CIWA and what is it used for?
clinical institute withdrawal assessment of alcohol scoring system
standardised way of assessing severity of alcohol withdrawal symptoms
0-9 = mild or no withdrawal
10-19 = moderate withdrawal
>20 = severe withdrawal
What is the CIWA score used to guide?
prescription of benzodiazepines which may be given PRN to manage withdrawal symptoms or regularly in a fixed-dose reducing regime over several days
What is the 1st line benzodiazepine used in alcohol withdrawal?
chlordiazepoxide
What drug is used for alcohol withdrawal in patients with liver disease?
shorter-acting benzodiazepines eg. lorazepam, oxazepam
How should alcohol withdrawal seizures be treated?
short-acting benzodiazepines eg. IV lorazepam
What preventative medication should be given to patients in alcohol withdrawal?
Pabrinex (1 pair of ampoules once daily) to prevent Wernicke’s encephalopathy
if signs or symptoms eg. ataxia/nystagmus - give treatment dose (2 pairs of ampoules TDS)
What should be monitored in bloods in alcohol withdrawal patients?
refeeding syndrome in malnourished patients
