Mental Health: Substance Abuse Flashcards
Criteria for ‘dependence’
Three or more of :
- Strong desire / compulsion to take the substance
- Impaired control of substance taking behaviour in terms of onset, termination or levels of use
- Physiological withdrawal state when use is reduced or stopped
- Tolerance to effects of the substance leading to increased use
- Preoccupation with use, to exclusion of other pleasures or interests
- Persistence despite clear harm
What’s intoxication?
- Follows administration of a psychoactive substance
- Disturbances in:
–Level of consciousness
–Cognition
–Perception
–Affect
–Behaviour
- Disturbance directly related to effect of the substance
- Resolve with time
What’s harmful use?
- Pattern of psychoactive substance use that is causing damage to health
- Clear evidence of harm → physical or psychological
- Nature of the harm should be identifiable
- Pattern of use has persisted for at least one month, or has occurred repeatedly over a 12 month period
What’s Salience/Primacy?
- Obtaining & using the substance takes over
- Other interests & pursuits are neglected
What’s tolerance?
- Increased doses of the psychoactive substance are required to achieve effects originally produced by lower doses
- Contributes to escalation of use
What’s narrowing of repertoire?
Loss in variation in the use of the substance
What’s Reinstatement?
Occurs after a period of abstinence, when the patient re-starts the substance and rapidly increases use to previous harmful levels
Hx in substance abuse
Stages of change
Pre Contemplation
–Person feels there is no problem, though others recognise it
Contemplation
–Person weighs up pros & cons and considers if change is necessary
Decision
–Person decides to act (or not)
Action
–Person chooses strategy for change & pursues it
Maintenance
–Gains are maintained & consolidated
Relapse
–Return to previous pattern, but relapse may help learning
What’s the relationship between psychiatric illness and substance misuse?
- ntoxication & / or dependence may lead to psychological symptoms and social difficulties
- Substance misuse & / or withdrawal may cause psychiatric symptoms or illness & may trigger illness in those who are predisposed
Safe levels of alcohol intake
Men & Women now advised:
2-3 units / day
14 units / week
Harmful levels of alcohol intake
Harmful levels:
–Women > 6 units / day = >35 units / week
–Men > 8 units / day = >50 units / week
Aetiology of alcohol dependence
- Gender → Males > females
- Genetics → 25-50% of predisposition may be inherited
- Occupation → Publicans, doctors, journalists, salesmen, actors, entertainers, seamen
- Social → childhood difficulties / problems, parental separation, low educational achievement
Symptoms of alcohol intoxication
- Relaxation & euphoria followed by disinhibition, various emotional states (irritable, weepy, morose), impulsive & irresponsible behaviour
- Slurred speech, ataxia, sedation, confusion, flushed face, nystagmus, conjunctival injection
Symptoms of alcohol withdrawal with timeframe
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Mechanism of alcohol withdrawal
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Physical complications of alcohol abuse
Liver
–Hepatitis
–Cirrhosis in 10 – 20% of dependent persons
Gastrointestinal
–Pancreatitis
–Oesophageal varices
–Gastritis
–Peptic ulceration
Neurological
–Peripheral neuropathy
–Seizures
–Dementia
Cancer
–Bowel, breast, oesophageal & liver all associated
Cardiovascular
–Hypertension & cardiomyopathy
Head injury / accidents
–Risk increased while intoxicated
Foetal alcohol syndrome
–In infants born to those who drink during pregnancy
Management of alcohol withdrawal
- patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- firstline: benzodiazepines e.g. chlordiazepoxide.
Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin* is said not to be as effective in the treatment of alcohol withdrawal seizures
Examples of one unit of alcohol
- 25ml single measure of spirits (ABV 40%)
- a third of a pint of beer (ABV 5 to 6%)
- half a 175ml ‘standard’ glass of red wine (ABV 12%)
Psychological complications of alcohol dependence
- Depression & Anxiety rates increased (also self medication can lead to dependence)
- Self harm & suicide risk increased
- Amnesia / blackouts (due to intoxication
- Cognitive impairment
–Alcoholic dementia
–Korsakoff’s psychosis
- Alcoholic hallucinations
- Morbid Jealousy
How to calculate a number of units in a drink?
To calculate the number of units in a drink multiply the number of millilitres by the ABV and divide by 1,000. For example:
- half a 175ml ‘standard’ glass of red wine = 87.5 * 12 / 1000 = 1.05 units
- one bottle of wine = 750 * 12 / 1000 = 9 units
- one pint of 5% beer or lager = 568 * 5 / 1000 = 2.8 units
Drugs used in detoxification
Detoxification
- Benzodiazepines
- Vitamins (Thiamine)
Relapse prevention
- Psychological support (group, individual, AA)
- Medical
- Acamprosate – reduces craving
- Disulfiram – induces flushing if alcohol taken
Medications used in relapse prevention (alcohol)
- Acamprosate →reduces craving
- Disulfiram → induces flushing if alcohol taken
MoA of Disulfiram
- contraindications
disulfram → promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase
Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms.
Contraindications: ischaemic heart disease and psychosis
MoA of Acamprosate
Acamprosate:
- reduces craving, known to be a weak antagonist of NMDA receptors
- improves abstinence in placebo controlled trials
Delirium Tremens
- when does it start
- symptoms
- treatment
Delirium Tremens
- Onset in 48h after abstinence
- Confusion, hallucinations & illusions, agitation, sweating, tachycardia, tremor, seizures
- Treat with reducing benzodiazepine regime & parenteral B vitamins (Pabrinex) - to avoid Wernicke – Korsakoff Syndrome
Wernicke’s Encephalopathy
- classic triad
- cause
- treatment
Wernicke’s Encephalopathy
Classic triad: of confusion, ataxia & ophthalmoplegia
Cause: Acute thiamine (vitamin B1) deficiency
Treatment: a course of parenteral B vitamins (Pabrinex) given IV or IM
*if untreated leads to Korsakoff’s Psychosis (IRREVERSIBLE anterograde amnesia with confabulation)
Amphetamines
- class
- unofficial names
- routes of administration
- effects
Amphetamines
Class: stimulant
Names: “speed”, “whizz”
Routes of administration: Snorted, injected, eaten / put on gum
Physical & Psychological Effects:
–Cardiovascular strain
–Enlarged pupils
–Talkative, agitated, full of energy, irritable
- Psychosis (schizophreniform)
‘Illegal’ Benzodiazepines
- what effect they produce?
- Diazepam, Lorazepam, Temazepam
- Prescribed or bought (often online)
- Usually ingested orally, can be prepared for injection
Effects: sedation, euphoria, disinhibition, lability of mood, anterograde amnesia, unsteady gait, slurred speech, nystagmus, reduced consciousness, respiratory depression
Withdrawal of benzodiazepines
- what can happen
- treatment
Withdrawal can cause: delirium tremens – like presentation with psychotic symptoms and seizures
Treatment: convert to diazepam equivalent dose & withdraw gradually over 8 + weeks
Cocaine
- class
- effects it produces
Cocaine → Stimulant
- Alert, confident, strong, disinhibited
- Short- acting → need to repeat dose
- “come down” – fatigue, depression / dysphoria, paranoid ideation, depersonalisation
Two forms of cocaine
Two forms:
1. Powder (hydrochloride)
- Sniff / snort / inject
2. Crack (alkaloid) - Heated & inhaled through pipe
- Quick acting with fast high
- Can be injected if added to acid (vit C) – often with heroin (‘speedball’)
What’s ‘speedball’?
Cocaine that can be injected if added to acid (vit C) – often with heroin (‘speedball’)
- very fast effect of high
Management of Cocaine abuse
- Intense craving is a major problem
- No replacement therapy available
- Acute Psychotic episodes → antipsychotic & benzodiazepines (short term) for symptom control
- Self help and support groups available (Cocaine Anonymous)
Mechanism of action of cocaine
cocaine blocks the uptake of dopamine, noradrenaline and serotonin
Side effects of cocaine abuse
Cardiovascular effects
- myocardial infarction
- both tachycardia and bradycardia may occur
- hypertension
- QRS widening and QT prolongation
- aortic dissection
Neurological effects
- seizures
- mydriasis
- hypertonia
- hyperreflexia
Psychiatric effects
- agitation
- psychosis
- hallucinations
Others
- ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding
- hyperthermia
- metabolic acidosis
- rhabdomyolysis
Management of cocaine toxicity
Management of cocaine toxicity
- benzodiazepines are generally first-line for most cocaine-related problems
- chest pain: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary percutaneous coronary intervention
- hypertension: benzodiazepines + sodium nitroprusside
Cannabis
- routes of administration
- active substance
- other name
Administration: dried vegetative state or resin → eat or smoke
Active substance tetrahydrocannabinol → 75% of available cannabis is “Skunk” (genetically engineered to have more THC)
SEs of cannabis
Produces “high”
SEs:
- can exaggerate previous mood state, anxiety, “paranoia”, distortion of time, mild hallucinogen
- conjunctival injection, dry mouth, tachycardia, respiratory tract symptoms
- Association with schizophrenia
Ecstasy
- class
- route of administration
MDMA → 3,4 methylenedioxymethylamphetamine
Sold in tablet (usually) or powder form
Effects and SEs of ecstasy use
• increased energy, hyperaesthesias, increased feeling of wellbeing and love
SEs:
- panic
- dysphoria
- depression
•Has been associated with raised temp, dehydration, tachycardia & DIC (disseminated intravascular coagulation)
Heroin
- class
- other (informal) names
Class: opiate derivative → highly addictive
Names: “brown”, “smack”, “gear”
Routes of administration of Heroin
•Injected
–If combined with crack cocaine is called “speedballing”
•Smoked
–By heating on tinfoil and inhaling the smoke
–“chasing the dragon”
–can also be snorted (less common)
Heroin
- effects
- withdrawal symptoms
Effects: gives strong sense / rush of relaxation / wellbeing
Withdrawal symptoms:
–Vomiting, diarrhoea, cramps, sweats, dysphoria
Physical effects of Heroin
- Pin point pupils
- “Track marks” → injection sites
- Constipation
- Poor nutrition
- Poor dental state (reduced salivary flow)
- Respiratory depressant
- Blood borne viruses (injecting patients)
–Hepatitis C
–Hepatitis B
–HIV
Education for Heroin users
Harm Reduction
–Needle exchange, stop sharing gear / works
–Encourage smoke rather than inject
–Raise awareness of overdose & how to manage it, especially if been abstinent (some areas give naloxone packs)
-Narcotics Anonymous
Pharmacological management of Heroin abuse (3)
Opioid Substitution Treatment (OST)
Methadone
- Full agonist, prolongs QT interval (monitor ECG 6 monthly)
- Cheap, large evidence base
Buprenorphine (Subutex)
•Partial agonist, less sedative, less risk of OD
Others
- Dihydrocodiene (short term stop-gap only)
- Patient Choice of aim of OST
–Maintenance
- Detoxification
What’s Khat?
- Plant grown in East African regions
- Has to be taken fresh
- Recently made illegal
- Usually consumed by Somali and other East African and Arab communities
- Produces a stimulant like effect
- Has been known to precipitate psychosis
- Is used to make miaow-miaow
Ketamine
- class
- routes of administration
Ketamine
- an anaesthetic agent
- commonly in powder or tablet form
Ketamine
- effects
- side effects
Effects: produces hallucinations, reduced pain sensation, drowsiness, sedation, respiratory depression
SEs: Prolonged use can cause “ketamine bladder” – haematuria, scarring and severe pain – severe cases have necessitated removal of the bladder
LSD
- administration method
- effects
- SEs
LSD
Administration: taken as a “tab” on a tiny square of paper
Effects: hyperaesthesias, hallucinations, and other altered perceptions & experiences aka “trip”
*trips can be pleasant or unpleasant & frightening “bad trip”
SEs: Flashbacks can occur days / months later, can precipitate mental health problems in people with predisposition
Novel Psychoactive Substances
- names
- previously known as “legal highs’’
Brand names include “Clockwork Orange”, “Bliss” and “Mary Jane’’
Forms in which Novel Psychoactive Substances come in
Come in different forms - powders, pills, smoking mixtures, liquids, capsules, or on perforated tabs.
Novel Psychoactive Substances
- stimulants - names, eddects
Stimulants - e.g. mephedrone, naphyrone
Act like amphetamines, cocaine, or ecstasy.
Make you feel energised, physically active, fast-thinking, very chatty and euphoric.
Novel Psychoactive Substances
- downers/ sedatives - names, effects
Downers or sedatives - e.g. GBH / GBL.
Act like benzodiazepines. Make you feel euphoric, relaxed, sleepy.
Novel Psychoactive Substances
- Hallucinogens
Hallucinogens or psychedelics
Act like LSD, magic mushrooms, ketamine
Synthetic cannabinoids
- names
- effects
Synthetic cannabinoids - novel psychoactive substnces
Names: e.g. “Spice”, “Black Mamba.”
Act similar to cannabis
Effects: relaxation, altered consciousness, disinhibition, feeling energised and euphoria
Spice
- what’s that
- class
Spice
- synthetic cannabinoid
- more potent than natural cannabis.
- usually smoked
- Class B drug.
Effects of Spice
Typical effects:
- Feeling happy, euphoric, relaxed
- Some people get “the giggles”, feel hunger pangs and become very talkative, others become drowsy
- Mood and perception can change and concentration and co-ordination may become difficult
- More likely to be associated with hallucinations than natural cannabis
*Some people have bad reactions, e.g. paranoia, panic attacks, forgetfulness.
Can make users “freeze.”
What’s drug classification (in general)
Defined by the government and changes from time to time
- Class A
- Class B
- Class C
- Different classes carry different penalties & usually (but not always) reflect potential level of harm
Class A drugs
- the length of penalty
Class A
–Possession
•7 years & unlimited fine
–Possession with intent to supply
•Life & unlimited fine
Class B drugs
- the length of penalty
Class B
–Possession
•5 years & unlimited fine
–Possession with intent to supply
•14 years & unlimited fine
Class C drugs
- length of penalty
Class C
–Possession
•2 Years & unlimited fine
–Possession with intent to supply
•14 years & unlimited fine
