Clinical Handbook - Alcohol and Substance Abuse

Question 1

What is substance dependence?

Answer 1

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.

Question 2

What key things should you ask in a history of substance abuse?

Answer 2

TRAP

Type, route, amount, pattern

Question 3

How should you investigate a patient who is abusing substances?

Answer 3

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)

Question 4

DDx for substance misuse?

Answer 4

Psychiatric disorders: Psychosis, mood disorders, anxiety disorders, delirium

Organic disorders: Hyperthyroidism, CVA, intracranial haemorrhage, neurological disorders (e.g. cerebellar pathology).

Question 5

How should substance misuse be managed?

Answer 5

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

Question 6

What is the difference between detoxification and maintenance in substance misuse?

Answer 6

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).

Question 7

Risk of opioids? Risk of stimulants e.g. cocaine? Risk of cannabis?

Answer 7

opioid- respiratory depression
stimulants - cardiac risk
cannabis - psychosis

Question 8

Define alcohol abuse

Answer 8

the consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm

Question 9

Define binge drinking

Answer 9

drinking over twice the recommended level of alcohol per day, in one session (>8 units for ♂ and >6 units for ♀)

Question 10

Risk factors for alcohol abuse?

Answer 10

male
younger adults
antisocial behaviour
lack of facial flushing
life stressors e.g. financial problems, marital issues

Question 11

What features may alcohol intoxication present with?

Answer 11

slurred speech, labile affect, impaired judgement and poor co-ordination

In severe cases, there may be hypoglycaemia, stupor and coma

Question 12

What is the Edward and Gross criteria for alcohol dependence?

Answer 12

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).

Question 13

What symptoms may occur after 6-12 hours of abstinence from alcohol?

Answer 13

malaise, tremor, nausea, insomnia, transient hallucinations and autonomic hyperactivity

Question 14

Give some long term effects of alcohol abuse

Answer 14

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

Question 15

Define delirium tremens

Answer 15

Delirium tremens is a complication of alcohol withdrawal which usually develops between 24 hours to one week after alcohol cessation

Question 16

Peak incidence of delirium tremens is at 72 hours of alcohol withdrawal. What is it characterised by?

Answer 16

Cognitive impairment
Vivid perceptual abnormalities (hallucinations and/or illusions)
Paranoid delusions
Marked tremor
Autonomic arousal (e.g. tachycardia, fever, pupillary dilatation and increased sweating)

Question 17

Give examples of peripheral stigmata of chronic liver disease in alcoholics

Answer 17

palmar erythema
clubbing
Dupuytren’s contracture
spider naevi
gynaecomastia
caput medusa

Question 18

What can be used as a screening test for problematic drinking?

Answer 18

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)

Question 19

How could you investigate a patient with suspected alcohol dependence?

Answer 19

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)

Question 20

DDx for alcohol dependence?

Answer 20

Psychiatric disorders:
Psychosis.
Mood disorders (including bipolar). Anxiety disorders.
Delirium

Medical disorders: Head injury.
Cerebral tumour.
Stroke (slurred speech)

Question 21

What is Wernicke’s encephalopathy?

Answer 21

An acute encephalopathy due to thiamine deficiency, presenting with delirium, nystagmus, ophthalmoplegia and ataxia

Question 22

What is Korsakoff’s psychosis?

Answer 22

Profound, irreversible short-term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation to time.

Question 23

How do you calculate alcohol units?

Answer 23

[strength (alcohol by volume) × volume (ml)] ÷ 1000

Question 24

Give an overview of the bio-psychosocial management of alcohol abuse

Answer 24

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

Question 25

How does disulfiram work?

Answer 25

Works by causing a build-up of acetaldehyde on consumption of alcohol, causing unpleasant symptoms e.g. anxiety, flushing and headache.

Question 26

How does acamprosate work?

Answer 26

Reduces craving by enhancing GABA transmission

Question 27

how does naltrexone work?

Answer 27

Blocks opioid receptors (antagonist) in the body, thus reducing the pleasurable effects of alcohol

Question 28

How does AA work?

Answer 28

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).

Question 29

Outline the stages of change model

Answer 29

pre-contemplation
contemplation
preparation
action
maintenance
relapse

Question 30

Who should be given thiamine prophylactically?

Answer 30

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.

Question 31

Public health measures to reduce alcoholism?

Answer 31

raising taxation on alcohol, restricted advertising or sales, and more education on alcohol issues in schools