ETOH and drugs of abuse Flashcards
Define alcohol use disorder as per the DSM-V criteria
1) Alcohol is taken in larger amounts or over a longer period than was intended
2) There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
3) A great deal of time is spent in activities necessary to obtain alcohol , use alcohol or recover from its effects
4) craving or a strong urge to use alcohol
5) Recurrent alcohol use results in a failure to fulfil
major role obligations at work, school or home
6) Important occupational or recreational activities are given up or reduced due to ETOh use
7) Alcohol use continues despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect
8) Alcohol use is continued despite knowledge of having a persistent physical or psychological problem that is likley to be cause or exacerbated
9) Recurrent alcohol use occurs in situation in which it is physically hazardous
10) Tolerance occurs defined as either
- - A need for markeldy increased amounts of alcochol to achieve intoxication or desired effect
- – markedly diminished effect with continued use of the same amount of ETOH
11) Withdrawal occurs as minifested by either of the following
- - The characteristic withdrawal syndrome for ETOH
- ETOH or closely realted substance is taken to avoid withdrawal symptoms
The presence of at least 2 of the above inticates alchole use disorder
Mild -2-3 symptoms
Moderate -4-5 symptoms
Severe - 6 or more symptoms
Discuss the alcohol use disorders identification test (AUDIT)
Identifies patietn at-risk of hazardous or harmful drinking with a sensitivity of 51-97%
Questions include (questions are scores 0-4 pointes )
1) How often do you have drink containing ETOH
2) How many drinks containing alcohol do you have on a typical day when you are drinking
3) How often do you have 6 or more drinks on one occasion
4) How often during the last year have you found that you were not able to stop drinking once you had started
5) How often during the last year have you failed to do what was normally expected from you because of drinking
6) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session
7) How often during the last year have you had a feeling of guilt or remorse after drinking
8) How often during the last year have you been unable to remember what happened the night before because you had been drinking
9) Have you or someone else been injured as a result of your drinking
10) Has a relative or friend or doctor been concerned by your drinking
Discuss CAGE questions
Detect ETOH abuse and dependence with a sensitivity of 43-94% and specificity of 70-97%
Two or more positive responses identify patients with lifetime risk of ETOH problems
Cut Down - have you ever tried to cute your drinking
Annoyed - have you ever been annoyed by criticism of your drinking
Guilty : do you ever feel quilty about your drinking
Eye-opener: do you need an eye opener when you get up in the morning
Discuss FRAMES strategy to decrease ETOh consumption in a non-dependent patient
F: feedback - review problems caused by ETOH with the patient
R: respondibility - point out that changing behaviour is the patients responsibility
A: advise the patient to cut down or abstain from ETOH
M: Provide options to assist the patient to change behaviour
E: use an empathetic approach
S: self efficacy - encourge optimis that the patient can change behvaioru
Discuss ETOH withdrawal
Usually develops within 6-24 hours of cessation or reduction in ETOH consumption
Dependence affects multiple neurotransmitter systems. Down regulation of neuro-inhibitory GABA receptors leads to symptoms of GABA excess in withdrawal
It also inhibits the excitatory NMDA glutamate receptor and withdrawal abruptly removes this inhibition. Increased Dopaminergic and noradrenergic neurotransmission also occurs.
Discuss clinical features of ETOH withdrawal
Autonomic excitation Occurs within hours of cessation and peaks at 24-48 hours
- Tremor
- anxiety and agitation
- Sweating
- Tachycartdia
- HTN
- Nausea and Vomiting
- Hyperthermia
Neuro-excitation occurs within 12-48 hours
- Hyperreflexia
- Nightmares
- hallucinations
- generalised tonic clonic seizures - usually singular or breif flurry seizures - recurrent or status seizure need to prompt further investigation
DT - typically begins 48-96 hours post last drink
- Severe form with mortality approaching 8%
- Associated with medical co-morbidities and delayed presentation
- Hallucination, confusion, clouding of consciousness, autonomic hyperactivity, Respiratory and CVs collapse
Discuss co-morbidities associated with ETOH abuse
GIT
- Acute gastric erosions
- GIT bleeding from varicies, erosions, mallory weiss tear, PUD
- Pancreatitis
- Diarrhoea - watery due to ETOH itself or steatorrhea from chornic alcoholism
- Hepatamegaly - fatty liver or Chronic liver disease
- Chornic liver disease (alcoholic hepatitis, cirrhosis) and associated complications
- Cancer (oesophagus, cardia of stomach, liver and pancreaus)
CVS
- Cardiomyopathy
- arrythmias
- HTN
CNS
- Wernickes/korsakoffs
- peripheral neuopathy
- Pellagra ( 4ds, diarrhoea, dematitis, dementia and death)
- Withdrawal
- Alcoholic dementia
- alcoholic myopathy
- increase risk of subdural
Haem
- Anaemia (folate deficiency from diet, iron deficiency from blood loss, direct toxic effect of ETOH causing bone marrow suppression, rare b12 deficiency, or sideroblastic)
- Thrombocytopenia from bone marrow suppression or hypersplenism
Metabolic
-Hypoglycaemia
Discuss Signs of Wernickes
Acute confusion Reduced LOC Memory disturbance Ataxia Othalmoplegia Nystagmus Unexplained hypotension Hypothermia
Discuss management of ETOH withdrawal
Mild forms are treated with simple supportive care
Symptoms typically settle in 2-7 days but relapse is exceedingly common wihtout appropriate pychosocial supports put in place
Severe - RSI -Florid DT is a medical emergency and is managed in resus area -ABC -Seizure control wtih benzoes -Detection and treatment of hypoglycaemia AWS scorring - 5-20mg of oral diazapem thiamine supllementation Fluids and electrolyte balance
Labs
- EUC, FBC, LFT, coags, lipase
Discuss AWS score
Orientation -0-2
- fully oriented
- disoriented but co-operative
- disoriented and uncoperative
Agitation/anxiety
- Rest normally
- appears anxious
- very agitated all the time, panics or gets out of bed for no reason
Hallucination
- none
- anxious
- cant dissuage
Perspiration
- nil
- mil
- soaking
Tremor
- nil
- with intention
- at rest
Temperature
- 0-37.6
- 37.6-38.5
- > 38.5
Discuss opioid withdrawal syndrome
Physiologcical response that develops when there is abrupt cessation or rapid reduction in opiod dose in a dependent individual
Opioids exert their analgeisic effect by agonist activity at the CNS U receptroes - by decreasing cAMP via membrane bound G proteins. Prolonged opiod use leads to cellular adaptation and down-regulation through multiple mechanisms.
Discuss clinical features of opioid withdrawal
Although unpleasent is not a life threat unlike those seen from ETOH withdrawal or sedative hypnotics.
Onset of symptoms depends on the elimination kinetics of the specific opiate.
Symptoms may begin wtihin 6 hours of the last heroin dose and peak at 36-48hours and resolve within a week - compared to onset at 2-3days for methadone peak at several days and last up to 2 weeks/.
Clinical manifestation include
- intense craving
- dysphoria
- autonomic hyperactivity
- GIT distress
- myalgia and arthralgia
Discuss management of opiate withdrawal syndrome
Most patient can be managed in an outpatient setting Admission to hospital is requried if -severe withdrawl syndrome -signfiicant complications -significant intercurrent illness -psychiatric co-morbidity
Pharmalogical treatment of opioid withdrawal is categorized into 3 types
- opioid replacement therapy (e.g methadone, buprenorphine)
- antagonist detoxifications (naltrexone)
- symptomatic management
Discuss Opioid replacement therapy
Methadone is used in opioid withdrawal and for maintenance in abstinence progmas
Typically starts at 20-40mg/day and is tapered over many weeks
Buprenorphine is a high affinity partial Uopioid agnoist used as an alternative to methadone – as effective in maintenance treatment of heroin dependence but less effective in achieving treatment retnetion
Discuss detoxifications programs
Rapid detoxification using naltrexone, buprenorphine and clonidine in various combinations or rapid tapering of methadone has been successful in select patients
Discuss symptomatic treatment of opioid withdrawal
Dehrdation
-fluid resus
Nausea and vomiting
-antiemetics choose your poison
Abdominal cramping and diarrhoea
-Hyoscine 20mg PO QID
Myalgia and arthralgia
-paracetamol and ibuprofen
Anxiety, dysphoria and insomnia
- Diazepam 5-10mg PO Q6hourly for 2-3days
- Clonidine -centrally acting A2 agonist is useful in attenuating physical and psychological symptoms of opioid withdrawal.
Discuss sedative hypnotic abuse
There is a high degree of interindividual difference in the rate of onset , type and severity of withdrawal symptoms
Onset is generally within 2-10 days of abrupt cessation although withdrawal of vershortacting agents may produce symptoms within hours.
Severe and potentially lethal syndrome similar to DT- Similar symptomology as ETOH withdrawal
Discuss management of sedative hypnotic abuse
If withdrawal develops as a result of an interruption in regular benzodiazepine use due to intercurrent medeical illness it is best to reeverse the withdrawal with re-introduction of the offending agent.
If goal is cessation of abuse – long acting benzopdiazpems are used and weened slowly/
Most patients can be managed in an outpatient setting
