Drug, alcohol, addiction behaviour Flashcards
Components of addiction
- Emotional/psychological
- Behavioural
- Functional impairment
Important points in assessment of pathological gambling
Full psychiatric hx Assess gambling behaviour - initiation - progression - current frequency/severity - types - maintaining factors - features of dependence Consequences- financial, vocational, interpersonal, legal, social MI Assess suicide risk- high rates Axis 1 and 2 co-morbidity Substance misuse
General features to encourage smoking cessation
4A's Ask Advise Assist Arrange
Smoking cessation interventions
- NRT
combine
can use alongside smoking reduction
background + breakthrough - Bupropion
DA and NE RI
reduces wthdrawal and post cessation weight gain
SE- psychiatric, seizures
NRT + bup doubles cessation rates - Varenicline
Nicotine partial receptor agonist, significantly higher cessation rates
SE- nausea, dry outh, psychiatric disturbances, case report of manic episode, ?suicide.depression - Nortryptiline- effective
- Clozapine enhaces smoking cessation in schizophrenia
- Brief advice from GPs increases abstinence rates at 6 months by 1-3% above controls
Relationship between smoking and schizophrenia
- May be marker of more severe illness
Smokers are young and male
Earlier onset
Increased # hospital admissions
Higher dose of antipsychotics
Higher scores on BPRS scale for positive and neg symptoms - Self medication
decrease in negative and positive and SE through increase DA in mesolimbic DA system
Worsening of symptoms reported on withdrawal
Smokers smoke more after initiation of AP - Smoking may act as etiological risk factor for schizophrenia
Repeated activation of mesolimbic system by nicotine over long time may precipitate onset in vulnerable individuals - Genetic and environmental factors may predispose to both
Effects of smoking in SZC
Increases CVD risk/mortality risk
Induces hepatic enzymes, through CYP1A2 induction, therefore reducing levels of clozapine (up to 40% lower) and olanzapine.
Increased risk of TD
Nicotine withdrawal may worsen sx
Alcohol use disorder DSM 5
2 + leading to significant impairment and distress
- larger amounts
- desire/unsuccessful to cut down/control
- time++ to obtain
- craving, strong desire
- recurrent use + failure to fulfil obligations
- use despite problems
- important things given up in preference
- physically hazardous
- continued despite knowledge of -physical/psychological problems
- Tolerance
- Withdrawal
Alcohol misuse vs dependence
No tolerance, withdrawal, craving
use results in failure to fulfil duties, physically hazardous, legal problems, use despite persistent interpersonal/social problems
Management of alcohol withdrawal
1. Supportive care Environment- quiet, bright, safe, private Psychoeducation- risks, withdrawal course Reassurance Coping skills- relaxation, mindfulness, dietary guidelines, sleep hygiene, methods to reduce cravings 2. Monitoring CIWA, AWS Vitals Level of hydration Bloods 3. Treatment Diazepam sliding scale 5-10mg , max 80mg Prevention of dehydration Thiamine 100mg TDS or 300/500mg TDS IV for 3-5 days If liver disease- oxazepam ir lorazepam Psychosis/hallucinations- haloperidol, risperidone Pain/diarrhea symptomatic Anticraving 4. Discharge planning Relapse prevention strategies Social factors Drug and alcohol services
Core features of korsakoff’s
Severe retro and anterograde amnesia (++anterograde) Telescoping of events Confabulation Polyneuropathy Lack of insight Apathy Deficiency of thiamine Necrosis and hemorrhage in mammillary bodies
Hallucinations in delirium tremens
Lilliputian (Alice in Wonderland)
management principles in delirium tremens
Medical emergency Benzodiazepine +/- tranquilisation (haloperidol) IVF Electrolyte replacement Thiamine Treat concurrent medical Reassurance Treat behavioural problems Education patient, staff and family
Psychotropics with extensive first pass metabolism
Tricyclic antidepressants - first-pass metabolism greater than 50% after oral administration
SNRI antidepressants - venlafaxine
SSRI antidepressants - sertraline
NRI antidepressants - bupropion
Typical antipsychotics - chloropromazine
Atypical antipsychotics - olanzapine (40%), quetiapine
Although olanzapine has great first-pass metabolism, it is mostly metabolized by second-phase liver metabolic processes (preserved in liver disease), so it might not be an important factor for this particular drug
- Avoid drugs with extensive first-pass metabolism
Avoid Tricyclic Antidepressants (first-pass metabolism 50%), venlafaxine, sertraline, bupropion, chlorpromazine, quetiapine - Avoid highly protein bound drugs
Avoid most psychotropic drugs (specially fluoxetine, aripiprazole and benzodiazepines). Except: Venlafaxine, lithium, topiramate, a gabapentin, a pregabalin, memantine - Avoid drugs depending on phase I hepatic metabolic reactions
Preferable: Lithium, gabapentin, topiramate, amisulpride (depending mainly on renal excretion) and some benzodiazepines (oxazepam, temazepam, lorazepam) that depend on phase II reaction or glucuronidation, which is preserved in cirrhosis
Principles of motivational interviewing
Developed by Miller and Rollnick Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self efficacy
Evaluated in Match and UKATT study for alcohol dependence, equal effective in benefit AA, CBT (Marlatt and Gordon)
Transtheoretical model of change
Procheska and DiClemente
Precontemplation Contemplation Determination Action Maintainence
