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MPharm Y3S2 > Mental Health Substance Abuse > Flashcards

Mental Health Substance Abuse Flashcards

1
Q

What are the potential harms from using illicit drugs?

A

Psychological e.g stigma
Socio-economic effects on self/family/others
Addiction or diversion inc gateway to others
Physical consequences e.g sedation
Route of admin e.g blood born virus
Self neglect, poor dental hygiene, poor nutrition
Withdrawl symptoms
Poor pregnancy outcomes

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2
Q

What are the potential risk factors for using illicit drugs?

A

Personal/ FH of substance misuse (inc alcohol)
Hx of pain issues
Easy access of medicines e.g working in healthcare
Time spent in secure environment e.g prison
Difficult life events
Chronic/severe mental/physical healthy problems

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3
Q

Describe the ‘dual diagnosis’ of substance abuse:

A

People with severe mental health problems- expect 25% misuse- find its 33-50% misuse
People with substance misuse problems- expect 25% have mental health problem- find its 50-75% problem

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4
Q

Describe the relationship between Asian heritage and alcohol?

A

Decreased risk of alcohol problems due to about 50% having non-functional aldehyde dehydrogenase genes resulting in ‘asian flush’, N&V, (like what happens with disulfiram)

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5
Q

Describe the prevalence of alcohol use in the UK:

A

In England around 603K dependant drinkers
Alcohol misuse is the biggest RF for death, ill health and disability among 15-49 year olds

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6
Q

What are the risks of long term alcohol intake?

A

Death= 20,000 premature deaths
Liver damage- 90%, 40% hepatitis
Accidents
Cancer- 3% of cancers are alcohol related
Gut- major bleeds

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7
Q

What are the genetic risk factors for getting an alcohol dependence?

A

FH: no single gene but up to 400 genes influence
50% of overall risk

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8
Q

What are the other factors for getting an alcohol dependence?

A

Starting at an earlier age
Mental health problem
Sweet tasting

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9
Q

What are the risks of chronic alcohol consumption in the CNS?

A

Cognitive impairment
Wernicke-Korsakoff syndrome

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10
Q

Describe how chronic alcohol consumption can cause cognitive impairment?

A

Alcohol is neurotoxic, causes cognitive impairment:
alcohol dementia, neuropathy, cerebral atrophy (smaller/holes)

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11
Q

Describe what Wernicke-Korsakoff is:

A

A neuropsychiatric disorder of acute onset caused by thiamine deficiency and includes confabulation (memory gone)
Wernicke’s Encaphalopathy is a neurodegerative brain disorder caused by severe lack of thiamine and presents as confusion, apathy, disorientation, vomiting and disturbed memory

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12
Q

What can Wernicke-Korsakoff be treated with?

A

Pabrinex (thiamine supplementation)

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13
Q

What is the acute treatment for Wernicke-Korsakoff?

A

One pair of ampoules IM or IV for 3-5 days- essential

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14
Q

What is the chronic treatment for Wernicke-Korsakoff?

A

100mg TDS is common but oral absorption is poor
Humans can only absorb up to 4mg an hour so OD dosing is pointless, has to be spread out

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15
Q

What are the first set of symptoms of alcohol withdrawl and when do these occur?

A

Onset 6-8 hours
Peak 10-30 hours
Subsides 40-50 hours
Generalised hyperactivity, tremor, sweating, nausea, retching, mood fluctuation, tachy, increased resp, HTN, pyrexia

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16
Q

What are the second set of symptoms of alcohol withdrawl and when do these occur?

A

Onset 0-48 hours
Withdrawl seizures

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17
Q

What are the third set of symptoms of alcohol withdrawl and when do these occur?

A

Onset: 12 hours
Duration: 5-6 hours
Auditory and visual hallucinations

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18
Q

What are the last set of symptoms of alcohol withdrawl and when do these occur?

A

Onset 48-72 hours
Delirium temens: coarse temor, agitation, tachcardia, delusions, hallucinations- classically ‘lilliputian’= snakes, spiders

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19
Q

Name benzodiazepines used in alcohol detoxification:

A

Main- chlordiazepoxide
Lorazepam, oxazepam in hepatic impairment

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20
Q

Describe the use of benzodiazepines in alcohol detoxification:

A

Chlordiazepoxide:
-long acting benzo, anticonvulsant, cross tolerant with alcohol
-no need to wait for withdrawl
-usual dose range 20-40mg QDS, then decrease over 9 days
When required ‘on demand’ doses should be prescribed
Withdrawl symptoms measured using CIWA (clinal institute withdrawl assessment for alcohol)

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21
Q

Name special care groups when using benzodiazepines for alcohol detoxification:

A

Elderly and those with hepatic impairment may need to decrease dose as risk of accumulation (use short acting benzodiazepines)

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22
Q

Name different drugs used in the maintenance therapy of alcohol dependence:

A

Disulfiram (Antabuse)
Acamprosate (Compral)
Naltrexone
Nalmefene

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23
Q

Describe the use of disulfiram for alcohol dependence:

A

A pro drug, activated in liver, prevents conversion of acetaldehyde to acetic acid and dopamine to NA
An adversive therapy
When a person consumes a small amount of alcohol, mild symptoms of acetaldehyde and dopamine excess is experienced; vasodilation, palpitations and headache
Combo with alcohol can be fatal

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24
Q

Describe the use of acamprosate for alcohol dependence:

A

Glutamate antagonist, better safety profile, decreased reward
Effectiveness overall is marginal but can help some people

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25
Q

Describe the use of naltrexone for alcohol dependence:

A

Licensed for alcohol misuse disorder, opioid antagonist
Well tolerated and has a significant effect on drinking behaviour
Blocks the opioid r that modulate release of dopamine in the brain reward system thus blocking the rewarding effects from heroin and alcohol

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26
Q

Describe the use of nalmefene for alcohol dependence:

A

Also an opioid antagonist
It effectively decreases heavy drinking days by decreasing the reward
Can be used on a ‘when required’ basis

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27
Q

When can nalmefene be used on a when required basis?

A

People who have failed to achieve abstinence and for whome a decrease strategy would be more suitable
Those who can’t achieve abstinence but require some form of intervention with psychosocial support

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28
Q

How many units are in:
-pint lager
-pint bitter
-white wine (175ml)
-single spirit
-bottle of wine
-bottle of lager

A

-pint lager= 3
-pint bitter= 2.3
-white wine (175ml)= 2.3
-single spirit= 1
-bottle of wine= 10
-bottle of lager= 1.7

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29
Q

What are the CMO’s low risk drinking guidelines?

A

People are safest not to regularly drink more than 14 units a week
Spread drinking over 3 days or more
Have atleast 2 drink free days each week

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30
Q

What is IBA?

A

Alcohol Identificant and Brief Advice
Simple brief advice, identify how much patient is drinking and what effects they have

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31
Q

What are the steps in IBA?

A

Gain permission to talk- do at beginning
Screen for alcohol consumption levels (FAST)
Complete a validated screening questionnaire:
-AUDIT/C
Give advice, refer, resources

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32
Q

Describe the FAST test:

A

Fast Alcohol Screening Test
An overall total score of 3 or more on the first or all 4 questions is a FAST positive

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33
Q

Describe the AUDIT test:

A

If FAST positive, complete an AUDIT
A total of 5+ score indicates a higher risk of drinking
12 is the highest score

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34
Q

Should you advise someone to stop drinking alcohol suddenly if they use it chronically?

A

No- can leads to seizures- death

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35
Q

Name full agonist opioids:

A

Codeine
Diamorphine
Morphine
Dihydrocodeine
Fentanyl
Methadone
Pethidine
Oxycodone

36
Q

Name partial agonist opioids:

A

Buprenorphine (SL only)

37
Q

Name opioid antagonists:

A

Naloxone (Narcan- injection)
Naltrexone (orally absorbed, decreased reward, opioid and alcohol)

38
Q

What is the difference between an opiate and an opioid?

A

Opiate- natural opioids e.g heroin, morphine, codeine
Opioid- all types inc natural and synthetic

39
Q

Describe the stages of quitting opioids:

A

Drug use- detox (1-2 weeks)- early abstinence (4-7 years)- later abstinence

40
Q

Describe the steps for the treatment for opioid dependence:

A

Assessment- confirm dependence (no one dies from withdrawl, but can with toxicity)
Detoxification and induction onto maintenance
Maintenance with opioid substance
Gradual discontinuation with support, can be 1-3 months after or decades

41
Q

What are the medications to withdraw from opioids?

A

Buprenorphine
Methadone

42
Q

Describe the withdrawl symptoms of opioids:

A

Runny nose
Watery eyes
Dilated pupils
Yawning
N&V
Diarrhoea
Restlessness

43
Q

How does methadone work?

A

Full agonist
Decrease peak levels from injecting
Longer t1/2 than diamorphine so suppresses withdrawl

44
Q

How does buprenorphine work?

A

Partial agonist, also decreases peak levels from injecting
Longer t1/2 than methadone so suppresses withdrawl and craving

45
Q

What are the advantages of methadone?

A

Established and familiar
Good evidence based
Sedating
Cheap
Easy to supervise
Orally absorbed

46
Q

What are the advantages of buprenorphine?

A

More difficult to use on top
Safer in overdose
Less stigmatised
Easier to detox from
Less sedating
Better in pregnancy
Initial titration rapid

47
Q

What are the disadvantages of methadone?

A

Easy to overdose
Can use on top
Syrup rots teeth
Stigmatised drug
Can accumulate into fatty tissues
Long detoxification
Sedating
Doesn’t stop craving
Toxic drug for naive adults (40mg) and children (10mg)

48
Q

What are the disadvantages of buprenorphine?

A

Not orally absorbed
Unpleasant taste
More difficult to supervise
Less evidence
Can be injected-bad
Expensive

49
Q

What is the titration dosing of methadone?

A

20-30mg day 1, increase 5-10mg every few days up to max total 30mg above starting dose each week, then increase once or twice weekly (10-15mg) as needed
Take about 5 days for blood levels to reach steady state

50
Q

What is the maintenance dosing of methadone?

A

40-120mg daily dosing
May spilt dosing in inpatients and prison

51
Q

What are the CNS effects of methadone?

A

Euphoria
Pleasant, warm feeling in stomach
Pain relief
Drowsiness
N&V
Resp depression
Histaniergic effect

52
Q

What are the other effects of methadone?

A

Decrease or absent menstrual cycle- still can become pregnant
Sexual dysfunction
Dry mouth/eyes
Dental problems
Constipation
Constricted pupils
QT prolongation ≥100mg

53
Q

What should be the monitoring requirements for the SE of QT prolongation when taking methadone?

A

Other drugs can increase the risk too e.g SSRIs, lithium, TCA, macrolides
If taking over 100mg a day offer ECG, measure every 6-12 months if normal

54
Q

When is buprenorphine given?

A

First dose given when there are objective symptoms of withdrawl to decrease risk of precipitated withdrawl

55
Q

What are the formulations of buprenorphine?

A

SL tabs with naloxone
Buvidal (weekly and monthly injections)
Sixmo (one off implant, rod, lasting 6/12)

56
Q

Why is naloxone given with buprenorphine if naloxone isn’t orally absorbed?

A

If it is injected then it will counteract the buprenorphine

57
Q

Describe naltrexone:

A

Long lasting opioid antagonist
Blocks euphoric effects, minimise +ve rewards
Licensed as an adjunctive prophylactic treatment for detoxified formerly opioid dependent pts

58
Q

What is the risk when taking naltrexone in patients?

A

Fatal overdoses if relapse while taking it due to resp depression

59
Q

What is the dosing of naltrexone?

A

Test dose of 25mg at least 7 days after last dose of opioid, followed by 50mg/day
Continue for at least 3 months
If adherence problematic, larger doses may be given on alternative days (e.g 100mg mon, 100mg wed, 150mg fri)

60
Q

Describe naloxone:

A

Opioid receptor antagonist
Emergency antidote for overdoses
Naloxone blocks opioid effect and can rapidly reverse breathing difficulties
POM but drug services can supply without a prescription

61
Q

Name different stimulants:

A

Amphetamines
Caffeine
Cocaine
Tobacco

62
Q

Name different sedatives:

A

Benzodiazepines
Alcohol

63
Q

Name different psychedelics:

A

Psilocybin (magic mushrooms)
LSD

64
Q

Name other types of misused drugs:

A

Cannabis
Pregabalin/ gabapentin
Nitrous oxide
Ketamine
MDMA (ecstasy)

65
Q

Name the 3 major species of cannabis:

A

The plant is called hemp
Dried flower buds smoked/resin
Cannabis is the plant

66
Q

Name and describe the different chemicals in cannabis:

A

THC (tetrahydrocannabinol)
-over 120, different potencies, t1/2, r affinities
CBD (cannabidiols)
-over 100 identified
Turpenes
-aroma, some CNS effects

67
Q

Name some synthetic cannabinoids:

A

Spice, black mamba

68
Q

Describe some undesired effects of synthetic cannabinoids:

A

CNS toxicity: agitation, temor, confusion, hallucinations
Cardiac: tachycardia, HTN, palpitations
Others: renal damage, memory loss, bloodshot eyes

69
Q

Name and describe the different cannabis receptors in humans:

A

CB1 (brain)
CB2 (peripheral)
Endocannabinoids include two distinct systems

70
Q

Describe the psychopharmacology of cannabis:

A

CB1 controls appetite, movement, higher cognitive functions, decreases stress, decreases nausea, decreases pain sensation
CB2 involved in immune function
Phytocannabinoids occur in the cannabis plant
Release may be stress induced

71
Q

Describe the good evidence medical use of cannabis:

A

Derived medicinal products (DMP)
Chronic and neuropathic pain
Paediatric epilepsies- dravet syndrome
Nausea in chemo- stops feeling, not being
Spasticity and pain in MS

72
Q

Describe the modest evidence medical use of cannabis:

A

Sleep disturbances
PTSD
PD
Migraine
Restless legs
Anxiety

73
Q

Describe the use of cannabidiol products which can be purchased in shops:

A

Obtained from cannabis/ industrial hemp
Very low conc- may not have any action at all
Products are unregulated so contents not reliable
Oral bioavailability 4-6%
CBD has no effects on the cannabinoid receptors

74
Q

Describe the correlation between schizophrenia and cannabis:

A

Doesn’t cause it, makes it worse if susceptible
Smoking in a susceptible person:
-exacerbation of mental health problems
-anxiety and panic attacks
-paranoia/psychosis
Starting before 15 increases risk to develop psychotic illness 4 fold

75
Q

What are the consequences of benzodiazepine use?

A

Recognised harms associated with long term (>3 months)
Sudden cessation of longer term high doses (>50mg/day) can cause seizures
Risk of overdose with other sedatives

76
Q

What should be the requirements if a benzodiazepine is prescribed?

A

Clear treatment plan, discussed and agreed
Have at least 2 +ve drug screens (make sure they’re taking it)
Have no -ve benzo screen in last 4 months
Review reg

77
Q

Describe the detoxification process of benzodiazepines:

A

Very gradually withdrawl (months if not years)
Consider giving in divided doses and loading at night
Consolidate multiple benzos to diazepam first (as long acting)
If withdrawl symptoms, don’t decrease further until symptoms improve
Decrease by 1/8 of daily dose every 2-4* weeks, or longer

78
Q

What are the lowering doses of the gabapentinoids?

A

Pregabalin: decrease daily dose at a max of 50-100mg/week
Gabapentin: decrease daily dose at a max rate of 300mg every 4 days

79
Q

Name the DSMIV caffeine induced disorders:

A

Caffeine intoxication
Caffeine induced anxiety disorder
Caffeine induced sleep disorder
Caffeine related disorder not other wise specified

80
Q

What is the amount of caffeine consumed considered moderate use?

A

Up to 500mg a day

81
Q

What is caffeinism considered as:

A

600-750mg a day

82
Q

What are toxic doses of caffeine?

A

More than 1000mg

83
Q

What are the SEs of low- moderate doses of caffeine?

A

Passing more urine, tremor, anxiety, heart palpitations

84
Q

What are the SEs of high doses of caffeine?

A

Insomnia, nervousness, tremor, dizziness, hallucinations, seizures, stomach pains, agitation

85
Q

What are the methods of caffeine reduction?

A

Making sure know all caffeine sources in diet
Gradual reduction e.g weaker drinks, less often
Caffeine free analgesia for withdrawl headaches
Doesn’t need to be complete abstinence

86
Q

Are antidepressants addictive?

A

No
There is no craving, reward or tolerance
But a person can get some withdrawl/discontinuation symptoms if stopped too quickly

87
Q

Name other drugs with withdrawl symptoms:

A

ACEi
Lithium
PPIs

MPharm Y3S2 (22 decks)

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