Alcohol use disorders/substance misuse

Question 1

how much is 1 unit of alcohol?

Answer 1

10mls of 100% alcohol

Question 2

how many units of alcohol are recommended per week?

Answer 2

14

-spread over three or four days

Question 3

describe the stages of change in motivational enhancement therapy for alcohol use disorders

Answer 3

pre-contemplation
contemplation
planning
action
maintenance
-relapse
pre-contemplation...etc

Question 4

what are the 6 factors that encompass dependance syndrome

Answer 4

Tolerance: need signifcant increased amounts of substance to = desired effects
Withdrawal state: when substance is reduced or ceased
Compulsion: strong desire to take substance
Impaired capacity to control substance taking behavior: onset/termination/usage levels
Preoccupation with substance use: neglecting activities and interests
Persistant substance use: despite clear evidence of harmful substances

Question 5

What is higher risk drinking classed as?

Answer 5

regularly consuming over 35 units a week

Question 6

What is increased risk drinking?

Answer 6

regularly consuming between 15-35unites per week

Question 7

What is the definition for ‘harmful use of alcohol’?

Answer 7

A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected psychoactive substances) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Question 8

What are the 7 different tools that can be used to assess alcohol use?

Answer 8

AUDIT – Alcohol User Disorders Identification Test: 10 q’s which aim to detect hazardous drinking
CAGE: CAGE – Cut down, Annoyed, Guilty, Eye Opener
T-ACE – Tolerance, Annoyed, Cut down, Eye Opener
TWEAK – Tolerance, Worried, Eye opener, Kut down.: screens for alcohol use in pregnant women
MAST – Michigan alcohol screening test.: full version avail. for psych. settings
PAT - paddington alcohol test
FAST - fast alcohol screening test
(PAT/FAST - A&E screening)

Question 9

What lab tests can be used to identify alcohol misuse?

Answer 9

GGT - indicator of liver injury
Carbohydrate Deficient Transferin - identifies men drinking 5+ units per day for 1 year or more
MCV - alcoholism most common cause of raised MCV

Question 10

What is a brief intervention when managing alcohol use disorders? What is the target audience

Answer 10

5-15 minute session discussing alcohol use
Target audience:
-adults who have been identified via screening as drinking a hazardous or harmful amount of alcohol.
-Attending NHS or NHS-commissioned services or services offered by other public institutes

Question 11

What is discussed during a brief intervention when managing alcohol misuse?

Answer 11

FRAMES
Feedback - review problems experienced because of alcohol.
Responsibility – patient is responsible for change.
Advice – advise reduction or abstinence.
Menu – provide options for changing behaviour.
Empathy – use empathic approach.
Self-efficacy –encourage optimism about changing behaviour.

Question 12

When would you consider a referral for specialist treatment for alcohol misuse?

Answer 12

Show signs of moderate or severe alcohol dependence
Have failed to benefit from structured brief advice and an extended intervention and wish to receive further help for an alcohol problem
Show signs of severe alcohol-related impairment or have a related co-morbid condition

Question 13

What are the two specialist interventions that are involved when managing alcohol misuse?

Answer 13

Detoxification
The process by which patients become alcohol free.

Relapse prevention
A combination of psychosocial and pharmacological interventions aimed at maintaining abstinence or problem free drinking following detoxification

Question 14

Describe the effect on the brain of alcohol withdrawal

Answer 14

Alcohol inhibits the action of excitatory NMDA-glutamate controlled ion channels (chronic use leads to upregulation of receptors)
Alcohol potentiates the actions of inhibitory GABA type A controlled ion channels (chronic use leads to downregulation of receptors).
Alcohol withdrawal leads to excess glutamate activity and reduced GABA activity
Excessive glutamate activity is toxic to the nerve cell
Acute withdrawal of alcohol in the dependent subjects leads to CNS excitability and neurotoxicity.

Question 15

Describe symptoms/signs of alcohol withdrawal syndrome, when do these symptoms occur?

Answer 15

First symptoms occur within hours and peak at 24-48 hours.
Restlessness, tremor, sweating, anxiety, n+v, loss of appetite and insomnia.
Tachycardia and systolic hypertension evident.
withdrawal seizures (0-48hrs)
In most, symptoms resolve in 5-7 days.

Question 16

What is delirium tremens? when does it present? how common and what is the mortality?

Answer 16

48-72hrs
-coarse tremor
-confusion/disorientation/agitation
-fever
-delusions (paranoid)
-hallucinations (visual/auditory)
Often presents insidiously with night time confusion
5% cases
Mortality 2-5% (assoc. with cardiovascular collapse and infection

Question 17

What drugs are used in medically assisted alcohol withdrawal? How is this done? where is this done?

Answer 17

Benzodiazepines:
Cross tolerant with alcohol (act on GABA A receptiors)
Use long acting agents eg. Diazepam, chlordiazepoxide
Titrate against severity of withdrawal symptoms
Reduce gradually over 7 days or more.
Be guided by withdrawal rating scales eg CIWA-Ar

Vitamin supplementation:
Thiamine (vitB1) as prophylaxis against Wernickes Encephalopathy Must be parenteral Increase dose if Wernickes suspected

majority in community, inpatient in general hosp if DT’s

Question 18

What is wernickes encephalopathy? mortality?

Answer 18

staggering gait
ophthalmoplegia
confusion
-20% mortality

Question 19

What is korsakoffs syndrome? prognosis?

Answer 19

short term memory loss
confabulation
clear consciousness
-20% improve with thiamine, 25% need long term care`

Question 20

When is Pabrinex used and how?

Answer 20

Overt wernickes symptoms: Pabrinex first 7 days then thiamine
Increased risk wernickes: Pabrinex first 5 days then thiamine

Question 21

What 4 relapse prevention medications exist?

Answer 21

Acamprosate: decreases glutaminergic activity, decreases alcohol cravings = adjunct to maintain alcohol avoidance
Disulfiram (Antabuse): inhibits acetylealdehyde dehydrogenase leading to accumalation acetylaldehyde on ingestion alcohol = flushing/tachycardia/n+v/arrythmias/hypotension
Naltrexone: opioid recpetor antagonist which decreases the pleasure reinforcing alcohol = decreases the risk of a lapse becoming a relapse
Nalmefene: opioid receptor antagonist

Question 22

How is acamprosate/naltrexone prescribed?

Answer 22

Acamprosate: start as soon as detox complete, continue through relapses
Naltrexone: first line agent for relapse prevention

Question 23

What are the CAGE questions?

Answer 23

C - have you ever thought of cutting down your drinking
A - have you ever felt annoyed when others comment on your drinking
G - have you ever felt guilty or bad about your drinking
E - have you ever had an ‘eye-opener’ first thing to steady nerves/rid a hangover

Question 24

what does prioritising survival mean?

Answer 24

• identify, select and pursue behavior leading to important goals (food/shelter)
• prioritise these goals over others = necessary (do this efficiently/effectively)

Question 25

What is the reward pathway in the brain? what is the neurotransmitter?

Answer 25

Mesolimbic pathway

dopamine (acts as a motivating signal that incentivises behavior and is involved in normal pleasurable activities)

Question 26

What do most addictive drugs (nicotine/morphine/cocaine/amphetamine) do to dopamine levels

Answer 26

Increase them drastically

Question 27

What happens to dopamine receptors in the brain in addicts?

Answer 27

-D2 receptors are decreased by addiction

Question 28

Describe what is meant by tolerance to reward in addiction? do these changes correct or persist with prolonged abstinence?

Answer 28

• if addicted, brain reward thresholds are increased and normal pleasurable experiences don’t evoke reward response
• these changes persist despite prolonged abstinence

Question 29

What is the anhedonic process involved with substance misuse? what does this lead to with regards to drug taking?

Answer 29

-the hedonic rush that pleasurable experiences bring is followed by longer and longer anhedonic periods (-ve motivational state)
= leads to drug taking becoming a thirst: -ve reinforcement

Question 30

Which part of the brain cortex is a key creator of motivation to act? what does hyperactivity of this region correlate with?

Answer 30

Orbitofrontal cortex

• addicts show increased activation of OFC when presented with drug cues
• hyperactivity correlates with self-reported drug cravings following exposure to cues

Question 31

Which part of the brain cortex helps intention guide behavior? (puts brakes on reward pathway)

Answer 31

-prefrontal cortex

Question 32

What is the role of the prefrontal cortex with regards to reward/goal making?

Answer 32

-modulates reward pathway
-sets goals and focuses attention
-makes sound decisions
(keeps emotion and impulses under control to achieve long term goals)

Question 33

describe the development of frontal lobe areas in comparison to limbic systems? what does this mean for stimulus seeking and impulse control for adolescent/immature brains?

Answer 33

• Frontal lobe areas that mediate executive functioning mature later than limbic systems (emotion)
• Frontal lobe maturation progresses forward from posterior to anterior beginning in the primary motor cortex and spreading anteriorly over superior and inferior frontal gyri, finishing with prefrontal cortex in late 20’s
• THEREFORE in adolescent/immature brains = stimulus seeking and lack impulse control

Question 34

What is the development of the prefrontal cortext found to be in addicts?

Answer 34

-prefrontal cortex = less developed

Question 35

What is the effect of dopamine release in the brain with regards to pre-frontal cortex/goal creating/behavior repetition?
What does addictive drug taking do to these effects?

Answer 35

• ability to update new information in the pre-frontal cortex
• ability to set new goals
• ability to avoid compulsive repetition of a behavior

-addictive drugs provide a potent signal that disrupts normal dopamine-related learning in the pre-frontal cortex

Question 36

What is synaptic plasticity? What does this mean for people who experiment with drugs at younger ages? what does this mean for depression?

Answer 36

• neurons that fire together, wire together
• long term potentiation = nerve pulses increase in strength when used repetitively
• long term depression - if pathways aren’t used they become weakened

-the earlier age at which drug experimentation starts, the longer the relationship with the drugs

Question 37

which area of the brain is assoc. with habit learning, which is assoc. with declarative?
How does this implicate drug associative stimuli?

Answer 37

Habit - striatum
Declarative - hippocampus

-learned drug assoc. can then cue internal states of craving of drug stimulus learning

Question 38

Draw out the circuit involved in drug abuse/addiction:

• inhibitory pathway
• motivation/drive pathway
• memory/learning
• reward pathway

Answer 38

Inhibitory pathway (Prefrontal cortex/ant. cingulate gyrus)
Motivational/drive (orbitofrontal cortex/subcallosal cortex)
Memory learning (amydala/hippocampus
Reward (NA - nucleus accumbens, VTA - ventral tegmental area)

Question 39

Is addiction heritable? why could this be?

Answer 39

• most heritable complex psych condition
• may affect way people: respond to drugs metabolically, behavioral traits that predispose use (impulsivity), how rewarding drug taking is (expression of receptors), receptor levels (lower levels of dopamine receptor so need bigger stimulus = reward)
• genetic based heightened sensitivity to stress may increase the vulnerability to addiction

Question 40

How can acute stress affect reward pathway?

How can chronic stress affect the reward pathway?

Answer 40

• acute stress triggers release of dopamine in the reward pathway
• rapid increase can motivate drug seeking behavior in dependant patients
• chronic stress can lead to dampening of dopaminergic activity = down regulation
• dopamine receptors = decrease in sensitivity to normal rewards = need bigger stimulus

Question 41

which is the best screening tool for harmful alcohol drinking and dependance?

Answer 41

AUDIT

10 item questionnaire, 

takes about 2-3 minutes to complete

has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems

minimum score = 0, maximum score = 40

a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption

a score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence

AUDIT-C is an abbreviated form consisting of 3 questions

Question 42

Describe the FAST screening tool for alcohol misuse?

Answer 42

4 item questionnaire
minimum score = 0, maximum score = 16
the score for hazardous drinking is 3 or more
with relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
if the answer to the first question is ‘never’ then the patient is not misusing alcohol
if the response to the first question is ‘Weekly’ or ‘Daily or almost daily’ then the patient is a hazardous, harmful or dependent drinker. Over 50% of people will be classified using just this one question