Drug and Alcohol Misuse Disorders

Question 1

Alcohol Withdrawal:

Symptoms occur _______
Seizures occur ______
Delirium Tremens occurs ______

Answer 1

6-12 hours
36 hours
72 hours

Question 2

What pathway is the reward pathway? What is the motivating signal that incentivises behaviour and is involved in normal pleasurable experiences?

Answer 2

mesolimbic pathway
dopaminergic activity

Question 3

All drugs of abuse have effects on ______ and end result is ________

Answer 3

dopamine level
dopaminergic activity within the mesolimbic pathway

Question 4

Repeated exposure to the drug leads to down regulation of _________ meaning ________ the concept of ________

Answer 4

down regulation of dopamine receptors meaning more is needed to get the same response (concept of tolerance)

Question 5

What puts the “brakes” on the reward pathway? When is it fully mature?

Answer 5

prefrontal cortex
not fully mature until 20s

Question 6

What is dysfunctional in addicted people?

Answer 6

prefrontal cortex

Question 7

Criteria for dependence syndrome?

Answer 7

1) Sense of compulsion
2) Craving
3) Physiological withdrawal
4) Evidence of tolerance
5) Preoccupation with substance use
6) Persistent use despite harmful consequences

Question 8

Define hazardous drinking?

Answer 8

• A pattern of alcohol consumption that increases the harmful consequences for the user (not currently a diagnostic term)
• In women it is defined as > 14 units but < 35 units a week
• In men it is defined as > 14 units but < 50 units a week

Question 9

Define harmful drinking?

Answer 9

• A pattern of alcohol consumption that is causing mental or physical damage
• In women it is defined as > 35 units a week
• In men it is defined as > 50 units a week

Question 10

List some symptoms of alcohol withdrawal?

Answer 10

• Tremor of outstretched hands, tongue or eyelids
• Sweating
• Nausea, wretching or vomiting
• Tachycardia or hypertension
• Anxiety
• Psychomotor agitation
• Headache
• Insomnia
• Malaise or weakness
• Transient visual, tactile or auditory hallucinations or illusions
• Generalized tonic clonic seizures

Question 11

What is the most serious withdrawal state? How do symptoms differ from normal withdrawal?

Answer 11

• Most serious withdrawal state – medical emergency
• The symptoms differ from normal withdrawal because there are signs of altered mental status

Question 12

Presentation of delirium tremens?

Answer 12

• Patients are disorientated, agitated and have a marked tremor as well as tactile visual hallucinations (insects or small animals crawling on them)
• Signs include sweating, tachycardia, tachypnoea and pyrexia

Question 13

Management of delirium tremens?

Answer 13

Can be treated with general measures such as correcting dehydration, electrolyte abnormalities and thiamine replacement as well as giving oral lorazepam

Question 14

Wernicke Korsakoff syndrome is due to _____ which is due to ______

Answer 14

both are due to thiamine deficiency

Thiamine deficiency occurs in alcoholism for several reasons:
1. Ethanol interferes with conversion of thiamine to active form
2. Ethanol prevents absorption of thiamine
3. Cirrhosis of the liver interferes with liver storage of thiamine
4. Likely to have poor nutritional intake if an alcoholic

Question 15

Wernicke / Korsakoff - acute or chronic?

Answer 15

Wernicke is acute
Korsakoff is chronic

Question 16

What is happening in the brain in Wernicke’s encephalopathy?

Answer 16

cytotoxic oedema in mamillary bodies

Question 17

What is happening in the brain in Korsakoff’s syndrome?

Answer 17

cerebral atrophy

Question 18

Symptoms in Wernickes encephalopathy?

Answer 18

triad:
ocular dysfunction/ ophthalmoplegia
ataxia
acute confusion

Question 19

Presentation of Korsakoff’s syndrome?

Answer 19

profound anterograde (cant remember anything new) and retrograde (cant remember anything from the past) amnesia
key feature is confabulation - patients basically make things up to fill in the gaps in their memory
there is generally a lack of insight

Question 20

Management of Wernicke Korsakoff syndrome?

Answer 20

wernickes needs urgent recognition and thiamine replacement to prevent progression to korsakoff - generally normalise thiamine then also give glucose

korsakoff has low change of recovery but abstinence and nutrition are still important

Question 21

What are two diagnostic markers of alcohol misuse in recent weeks?

Answer 21

elevated GGT and elevated mean corpuscular volume

Question 22

Management of alcohol withdrawal?

Answer 22

• Reassurance
• If you speak to someone and they are coming back – do not tell them to stop drinking suddenly before next appointment – they need gradual withdrawal or at risk of DTs
• Long-acting benzodiazepines are used to help alleviate symptoms (they are cross tolerant with alcohol due to action on GABAA) usually chlorodiazepoxide is used and titrated against the severity of withdrawal symptoms
• The dose of chlorodizepoxide is reduced gradually over 7 days or more
• Vitamin supplementation should be given
• Thiamine should be given as prophylaxis for Wernicke’s encephalopathy and dose should be increased if the patient develops symptoms
• Most patients can be detoxified in the community but if they have severe dependence they may want to be detoxified as inpatients
• Development of delirium tremens requires immediate transfer to a medical ward

Question 23

Should you tell people to stop drinking on their own?

Answer 23

no - suddenly stopping drinking is risky in those with alcohol dependence - tell them to keep drinking !

Question 24

What drug is used to manage alcohol withdrawal?

Answer 24

chlorodiazepoxide - long acting benzodiazepine

Question 25

Relapse for alcohol dependence - psychosocial ?

Answer 25

• CBT
• Motivational enhancement therapy
• 12 step facilitation therapy
• Behavioural self control therapy
• Family and couple therapy

Question 26

Relapse for alcohol dependence - pharmacological?

Answer 26

• There is no place for benzodiazepines beyond detox
• Naltrexone is usually 1st line, it is an opioid antagonist that reduces the reward from alcohol
• Acamprosate acts centrally on GABA and glutamate to reduce cravings
• Disulfiram (Antabuse) inhibits alcohol dehydrogenase leading to accumulation of acetaldehyde if alcohol is ingested causing unpleasant reaction of flushed skin, tachycardia, nausea and vomiting, arrhythmias and hypotension, however this drug needs patient compliance, often a patient may plan to drink so then they won’t take their medication

Question 27

Management of opioid misuse - psychosocial ?

Answer 27

similar to that for alcohol dependence

Question 28

Treatment for opioid overdose? How do you give it?

Answer 28

• Naloxone is the treatment of choice for opioid overdose
• By intravenous injection (only IM if IV route not feasible): Initially 400 micrograms, then 800 micrograms for up to 2 doses at 1 minute intervals if no response to preceding dose, then increased to 2 mg for 1 dose if still no response (4 mg dose may be required in seriously poisoned patients), then review diagnosis

Question 29

Pharmacological management of opioid dependence?

Answer 29

• Methadone or buprenorphine can be used as a substitute for heroin and can be used to withdraw someone
• There is cross tolerance preventing withdrawal symptoms, methadone can be taken orally and buprenorphine sublingually reducing the risk of non-sterile needles, because they are taken once daily there are less peaks in opioid levels
• These drugs have a long half-life so levels are more stable, drugs like heroin and morphine have a short half-life – hence are more addictive
• Some people who cannot manage abstinence may be maintained on one of these drugs

Question 30

Why is methadone better to be on that heroin/ morphine?

Answer 30

has less peaks due to long half life, so easier to gradually wean off of - less risks of overdose

Question 31

Treatment of DTs?

Answer 31

NICE guidelines:
1st line is lorazepam
if symptoms persist or oral medication is declined offer parenteral lorazepam or haloperidol