Drugs and Alcohol - lecture Flashcards
1
Q
What to ask re current drug history?
A
- What drugs
- How long been taking for?
- How much?
- How much money do they spend on it?
- How often do they do it?
- Do they get withdrawal symptoms? - if yes, need to reduce gradually
2
Q
Current risks with heroin
A
- Currently there is reduced production of pure heroin
- It is being cut with synthetic opioids such as nitazenes which are much stronger than heroin (some 100x or more as strong)
- Increase risk of overdose
3
Q
What to ask re past drug history?
A
- Previous treatment episodes
- Complications from drug use?
- Any previous overdoses?
- Any BBV? inc testing and vaccines
4
Q
Risk of methadone
A
- Prolong QTc too
- If have cardiac complications should definetly get pre-treatment ECG
5
Q
Why do we prescribe opioid replacement?
A
- Minimise harm - prevent accidental overdose
- NTORS study - showed that it saves NHS and MOJ money - reduced crime
- Allows interaction with that cohort of patients - inform them of current risks etc
6
Q
Risks of prescribing opioid replacements
A
- Diversion - sell it onto others
- Misuse - combine with other drugs, snort/inject it
- Overdose
- Dependency
- Responsibility - they then put all the responsibility on the drug to try and get clean, they don’t take as much accountability
7
Q
What are recovery workers at TP?
A
- Often ex drug users who have worked through recovery
- Give them support - know what they are experiencing
8
Q
What to do if someone in A&E appears to have used substances?
A
- Ask them
- Full examination - check for track marks etc
- Drug screen - urine
9
Q
Early symptoms/signs of opiate withdrawal
A
- Sweaty, clammy skin
- Persistent yawning
- Rhinorrhoea
- Tachycardia
- Restlessness
- Dilated pupils
- Lacrimation
- Goosebumps
10
Q
Methadone vs buprenorphine in terms of taking other drugs
A
- Methadone is opioid agonist - can still get high via other drugs while using this
- Buprenorphine is partial agonist, less risk of OD and very hard to get high on this - high affinity
11
Q
Later (day 2-3) signs/symptoms of opiate withdrawal
A
- Nausea and vomitting
- Diarrhoea
- Insomnia
- Abdominal cramps
- Muscle pain
12
Q
What to do before prescribing opioid replacement eg methodone?
A
- Confirm dose with prescriber - can call TP, GP or private Dr
- Check dotes at patients community pharmacy
- Do urine drug screen
- If patient already on methodone, there may be delay of more than 24hrs before withdrawal symptoms begin - you have time.
13
Q
How is methodone prescribed including dosages?
A
- Use methodone mixture 1mg/ml (avoid tablets and ampoules due to risk of misuse)
- Initial dose 20mg
- If after 2hrs withdrawal symptoms continue give another 10mg
- Then following day, give total from day before in the morning
14
Q
Max dose methadone and why
A
- Don’t give more than 60mg (unless they are already on that amount prescribed)
- Methodone has long half life - tends to accumulate over first few days of treatment
15
Q
What is buprenorphine?
A
- Partial agonist
- Sometimes given in combination with naloxone in tablet form to avoid people abusing it (snorting and injecting)
16
Q
Prescribing buprenorphine - dose and conditions
A
- Need to be in withdrawal to begin - otherwise will initiate withdrawal symptoms
- 4mg then 4mg PRN as in patient
- Unlikely to need more than 16mg (32mg max dose)
17
Q
Working out units
A
% x litres
OR % x ml / 1000
18
Q
Early signs and symptoms of alcohol withdrawal - 6-12hrs
A
- Tremor
- Sweating
- Nausea
- Anxiety
- Tachycardia
19
Q
Late signs of alcohol withdrawal
A
- Delirium tremens (peak at 48-72hrs)
- Disorientation
- Hallucinations
- Tremor
- Fever
- Motor incoordination
20
Q
Why does alcohol withdrawal occur?
A
- Chronic consumption enhances GABA mediated inhibition of CNS (same as benzos) and inhibits NMDA glutamate receptors
- Withdrawal = opposite - reduced GABA inhibition and increased NMDA glutamate transmission
21
Q
Peak incidence seizures alcohol withdrawal
A
36hrs
22
Q
Delirium tremens features
A
- Coarse tremor
- Confusion
- Delusions
- Auditory and visual hallucinations
- Fever
- Tachycardia
23
Q
Management of alcohol withdrawal
A
- If history of complex withdrawal - admit for monitoring
- Chlordiazepoxide (benzo)
- Lorazapam instead if hepatic failure
- Reducing doses
24
Q
Features of Wernickes encephalopathy
A
- Opthalmoplegia (unilateral or bilateral dysfunction of eye movement most often medial and lateral rectus)
- Nystagmus - horizontal, vertigal or rotatory, exacerbated by lateral gaze
- Ataxia - unsteady gait, difficult maintain upright posture
25
Management of WE
* IV thiamine - minimum 5 days
* Careful with glucose administration - reduces thiamine levels, administer thiamine before or with any glucose treatment needed
| NOA got the ick
26
What happens in wernickes encephalopathy, why does it happen?
* Alcoholic malnutrition = vitamin B1 deficiency
* Brain lesions in the midbrain
* Thiamine stores last approx 1 month but features can occur in week or so of intake
* 10% will develop if alcoholic
* Mortality 15-20%
27
What is Korsakoff syndrome?
* Prominent impairement of recent and remote memory
* Damage and haemorrhage in mammillary bodies of hypothalamus and medial thalamus
28
Triad of Korsakoffs
* Anterograde amnesia - inability to acquire new memories/learn new things
* Retrograde amnesia - memory affected
* Confabulation - unconsciously fills gaps in memory with false/distorted recollections
| Also disordered time sense
29
Bloods for someone in withdrawal being admitted
* U&E
* FBC
* LFT
* INR - synthetic function
* B12 and folate
* Repeat these
30
Hallucinations from benzodiazepines specific type
* Often kinaesthetic
* Sensation of body movement without actual movement
31
Benzodiazepine dose and which one to prescribe
* Diazepam is least bad - longer acting so less addictive (short acting are worse)
* 40mg diazepam equivalent max
* Risk of hallucination
32
How to wean benzodiazepines as inpatient?
* Reduce by 5mg every 2 days
* When hit 10mg, reduce by 2mg every 2 days
* Then weekly
Outpatient reduction is much slower
33
How to manage stimulant withdrawal/addiction?
* Nothing for addiction
* Diazepam can be used for withdrawal
* Risk of psychosis using diazepam and prolonging QTc
* DO NOT use antipsychotics if suspect drug induced psychosis - need to see if drug induced
34
Plan for discharge after someone has detoxed or has problem with drugs/alcohol
* Contact turning point as early as possuble
* Plan discharge jointly - espoused if prescription of methadone or buprenorphine, need to liase supply
* Plan for community prescribing
* Ask re safety of storage at home - do they have somewhere that children can't access etc
35
Managing someone with alcohol/drug problem as inpatient - key things to do
* If known to TP, their keyworker should visit
* If unknown they need new ward round and assessment
* Don't try to detox for opioids as inpatient - likely to fail
* Need to manage risk on leave
36
What psychological therapy is the only one known to work for addiction?
* Motivational interviewing
* Paraphrase what they say and pay attention
* Roll with resistance - eg I see you are concerned it may fail
* Amplify change talk
37
Key points of motivational interviewing
* Collaborative
* Empathetic
* Reflective on what person has said
* Notice resistance but do not respond to it
* Notice and amplify change talk
38
Where is drug detox centre for leicestershire?
* Is in Nottingham
39
Referring to TP
* Can refer patients via phone number and online form
* Also asks patients to self refer too - can be good first step to recovery
