Clinical Handbook - Alcohol and Substance Abuse Flashcards
What is substance dependence?
a syndrome including behavioural, physiological and psychological elements. Patients are physiologically dependent if they show tolerance or withdrawal.
DRUG PROBLEMS WILL CONTINUE TO HARM
≥3 of the following manifestations must have occurred over 1 month
(1) strong Desire (compulsion) to consume substance
(2) Preoccupation with substance use
(3) Withdrawal state when substance ingestion is reduced or stopped
(4) Impaired ability to Control substance-taking behaviour
(5) Tolerance to substance, requiring more consumption for desired effect
(6) Persisting with use, despite clear evidence of harmful effects.
What key things should you ask in a history of substance abuse?
TRAP
Type, route, amount, pattern
How should you investigate a patient who is abusing substances?
Bloods including:
(1) HIV screen, Hep B, Hep C and tuberculosis testing → risk of blood-borne infections is thought to be greater through needle sharing
(2) U&Es to check renal function
(3) LFTs and clotting to check hepatic function
(4) Drug levels
Urinalysis: drug metabolites (e.g. cannabis, opioids) can be detected in urine.
ECG for arrhythmias, ECHO if endocarditis suspected (secondary to needle sharing)
DDx for substance misuse?
Psychiatric disorders: Psychosis, mood disorders, anxiety disorders, delirium
Organic disorders: Hyperthyroidism, CVA, intracranial haemorrhage, neurological disorders (e.g. cerebellar pathology).
How should substance misuse be managed?
Hep B immunisation if at risk
Motivational interviewing and CBT
Self help groups e.g. narcotics anonymous and cocaine anonymous
Review DVLA guidance
Biological: (for opioid misuse - stimulants do not have a biological tx)
methadone (first line) or buprenorphine
naltrexone for formerly opioid dependent patients
IV naloxone can be used as an antidote to opioid overdose
What is the difference between detoxification and maintenance in substance misuse?
Detoxification refers to a process in which the effects of the drug are eliminated in a safe manner (a replacement drug is weaned) in an attempt to attain abstinence.
In maintenance therapy abstinence is not the priority, rather the aim is to minimize harm (e.g. from IV drug use).
Risk of opioids? Risk of stimulants e.g. cocaine? Risk of cannabis?
opioid- respiratory depression
stimulants - cardiac risk
cannabis - psychosis
Define alcohol abuse
the consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm
Define binge drinking
drinking over twice the recommended level of alcohol per day, in one session (>8 units for ♂ and >6 units for ♀)
Risk factors for alcohol abuse?
male
younger adults
antisocial behaviour
lack of facial flushing
life stressors e.g. financial problems, marital issues
What features may alcohol intoxication present with?
slurred speech, labile affect, impaired judgement and poor co-ordination
In severe cases, there may be hypoglycaemia, stupor and coma
What is the Edward and Gross criteria for alcohol dependence?
SAW DRINk
Subjective awareness of compulsion to drink
Avoidance of withdrawal symptoms by further drinking (relief drinking)
Withdrawal symptoms
Drink-seeking behaviour predominates
Reinstatement of drinking after attempted abstinence
Increased tolerance to alcohol
Narrowing of drinking repertoire (i.e. a stereotyped pattern of drinking – individuals have fixed as opposed to variable times for drinking, with reduced influence from environmental cues).
What symptoms may occur after 6-12 hours of abstinence from alcohol?
malaise, tremor, nausea, insomnia, transient hallucinations and autonomic hyperactivity
Give some long term effects of alcohol abuse
Medical:
fatty liver, hepatitis, cirrhosis
peptic ulcer disease, oesophageal varices, pancreatitis
seizures, peripheral neuropathy
delirium tremens
Wernicke’s encephalopathy, Korsakoff’s syndrome
Psychiatric:
Depression
Alcohol related dementia
Social:
accidental injury
financial issues, unemployment
relationship breakdown
drink driving
Define delirium tremens
Delirium tremens is a complication of alcohol withdrawal which usually develops between 24 hours to one week after alcohol cessation
Peak incidence of delirium tremens is at 72 hours of alcohol withdrawal. What is it characterised by?
Cognitive impairment
Vivid perceptual abnormalities (hallucinations and/or illusions)
Paranoid delusions
Marked tremor
Autonomic arousal (e.g. tachycardia, fever, pupillary dilatation and increased sweating)
Give examples of peripheral stigmata of chronic liver disease in alcoholics
palmar erythema
clubbing
Dupuytren’s contracture
spider naevi
gynaecomastia
caput medusa
What can be used as a screening test for problematic drinking?
C – Have you ever felt you should Cut down on your drinking?
A – Have people Annoyed you by criticizing your drinking?
G – Have you ever felt Guilty about your drinking?
E – Do you ever have a drink early in the morning to steady your nerves or wake you up? (Eye opener)
How could you investigate a patient with suspected alcohol dependence?
Bloods including: FBC (anaemia), U&Es (dehydration, ↓ urea), LFTs, blood alcohol concentration, MCV (macrocytosis), vitamin B12/folate/TFTs (alternative causes of ↑MCV), amylase (pancreatitis), hepatitis serology, glucose (hypoglycaemia)
Alcohol questionnaires: Alcohol Use Disorders Identification Test (AUDIT), Severity of Alcohol Dependence Questionnaire (SADQ), FAST screening tool (4 items, designed for busy settings)
CT head (if head injury is suspected)
ECG (for arrhythmias)
DDx for alcohol dependence?
Psychiatric disorders:
Psychosis.
Mood disorders (including bipolar). Anxiety disorders.
Delirium
Medical disorders: Head injury.
Cerebral tumour.
Stroke (slurred speech)
What is Wernicke’s encephalopathy?
An acute encephalopathy due to thiamine deficiency, presenting with delirium, nystagmus, ophthalmoplegia and ataxia
What is Korsakoff’s psychosis?
Profound, irreversible short-term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation to time.
How do you calculate alcohol units?
[strength (alcohol by volume) × volume (ml)] ÷ 1000
Give an overview of the bio-psychosocial management of alcohol abuse
Biological:
withdrawal: high dose benzos (chlordiazepoxide) tapered down over one week + thiamine
disulfiram / acamprosate
tx of any medical complications
Psych:
Motivational intervewing +CBT
Social:
AA meetings and social support
How does disulfiram work?
Works by causing a build-up of acetaldehyde on consumption of alcohol, causing unpleasant symptoms e.g. anxiety, flushing and headache.
How does acamprosate work?
Reduces craving by enhancing GABA transmission
how does naltrexone work?
Blocks opioid receptors (antagonist) in the body, thus reducing the pleasurable effects of alcohol
How does AA work?
It is a 12-step approach that utilizes psychosocial techniques in order to change behaviour (e.g. social support networks, rewards). Each new member is assigned a ‘sponsor’ (a supervisor recovering from alcoholism).
Outline the stages of change model
pre-contemplation
contemplation
preparation
action
maintenance
relapse
Who should be given thiamine prophylactically?
Prophylactic oral thiamine (50 mg once daily) should be offered to harmful drinkers if they are malnourished (or at risk of malnourishment) or have decompensated liver disease.
Public health measures to reduce alcoholism?
raising taxation on alcohol, restricted advertising or sales, and more education on alcohol issues in schools
