PH2113 - Abuse of drugs in theory & practice 3

Question 1

What is psychological dependence?

Answer 1

Condition where there is an emotional/mental drive to continue taking drug to maintain a sense of well being

Question 2

What are the symptoms of drug withdrawal when psychologically dependent?

Answer 2

Emotional discomfort
Ill-defined dissatisfaction
Mild desire to take drug
Intense craving
- or perceived effects
Drug seeking behaviour
- positive motivational drive

Question 3

What is physical dependence?

Answer 3

Altered or adaptive physiological state produced by repeated administration of drug

• when drug (or metabolites) are necessary for continued functioning of certain body processes which is related to
• dose + pharmacological action of drug

Question 4

What are the symptoms of drug withdrawal when physically dependent?

Answer 4

Physical signs
- abstinence syndrome
Psychological signs
- hallucinations
- mania
- depression
Negative motivational drive
- aversive

Question 5

What are the phases to the effect of dependence on a drug?

Answer 5

Rush
- tachycardia
- sweating
- sensation of speed
- being out of control
High
- euphoria
- self-confidence
- sociability
Low
- negative emotions
- anxiety
- paranoia
- loss of feelings of pleasure
- dysphoria
Craving
- desire to take more drug
- positive motivation

Question 6

Which areas of the brain are involved in salience?

Answer 6

Nucleus accumbens
- identifying stimulants by assessing reward and saliency
Orbitofrontal cortex
- decision-making and determining the expected rewards and punishments of an action
Amygdala and hippocampus
- forming memories of the stimulus/reward relationship
- positive
- negative
Prefrontal cortex and anterior cingulate gyrus
- inhibitory control
- emotional regulation

Question 7

Which areas of the brain and involved with the tolerance, dependence and addiction cycle?

Answer 7

Binge/intoxication
- caudate/Ventral Tegmental Area (VTA)
- dopamine
Withdrawal/negative effect
- amygdala
Preoccupation/anticipation (of next drug taking)
- prefrontal cortex/orbitofrontal cortex
- hippocampus

Question 8

How do addictive drugs affect dopamine?

Answer 8

Disinhibition
- opioids
- mu receptor
- cannabinoids
- CB1 receptor
- benzodiazepines
- GABA(B)
Excitation
- nicotine
- nACh receptor
- alcohol
- GABA(A)
- 5-HT3
- NMDA
- nACh
Block dopamine uptake
- cocaine
- DAT
- SERT
- NET
- amphetamine
- DAT
- SERT
- NET
- VMAT
- ecstasy
- SERT
- DAT/NET

Question 9

What are the direct effects of dopaminergic agents?

Answer 9

Cocaine

• inhibits dopamine transporter
• less dopamine reuptake

Amphetamine

• stimulates dopamine transporter
• more dopamine reuptake
• inhibits VMAT
• more dopamine efflux into synapse

Question 10

What is a Schedule 1 Controlled Drug?

Answer 10

CD Lic POM

• mainly includes drugs which are not used medicinally
• LSD
• ectasy-type substances
• cannabis

Question 11

What is a Schedule 2 Controlled Drug?

Answer 11

CD POM

• cocaine
• opiates
• diamorphine
• methadone
• morphine
• oxycodone
• pethidine
• major stimulants
• (lis)dexamfetamine
• ketamine

Question 12

What is a Schedule 3 Controlled Drug?

Answer 12

CD No Register POM

• barbiturates
• phenobarbital
• buprenorphine
• subutex
• midazolam
• temazepam
• tramadol

Question 13

What is a Schedule 4 Controlled Drug?

Answer 13

Part 1 (CD Benz POM)
- sativex spray
- benzodiazepines and z-drugs
- diazepam
- zolpidem
- zopiclone
Part 2 (CD Anab POM)
- androgenic steroids
- anabolic steroids
- growth hormones

Question 14

What is a Schedule 5 Controlled Drug?

Answer 14

CD Inv POM or CD Inv P

• preparations of controlled drugs at low concentration
• codeine 8mg

Question 15

What is safe custody?

Answer 15

Within retail premises, private hospitals or care homes, the drugs must be kept in a locked safe, cabinet or room which complies with the specifications outlined in the Misuse of Drugs (Safe Custody) Regulations 1973 as amended

This does not apply when the drug is under the direct personal control of a pharmacist
- when dispensing a prescription

Question 16

What does safe custody requirements apply to?

Answer 16

Schedule 1 CDs
Schedule 2 CDs
- except quinalbarbitone
- some liquid preparations
Schedule 3 CDs except for
- any 5,5-disubstituted barbituric acid
- phenobarbital
- cathine
- ethclorvynol
- ethinamate
- gabapentin
- mazindol
- meprobamate
- methylphenobarbitone
- methprylone
- midazolam
- pentazocine
- phentermine
- pregabalin
- tramadol
or any stereoisomeric forms or salts of the above

Some non-injectable liquids, such as amphetamine and methylphenidate, are also exempt but it is still good practice to keep them in the CD cabinet

Also applies to patient-returned, obsolete and out-of-date controlled drugs which should be segregated from other pharmacy stock and clearly marked within the CD cabinet until they can be destroyed

Question 17

Which schedules of controlled drugs must records be kept for?

Answer 17

Schedule 1
Schedule 2

Sativex (Sch 4 part 1) must also be recorded

Question 18

What information needs to be record on a CD register?

Answer 18

Obtained
- date received
- name and address from whom received
- wholesaler
- quantity received
(many also record invoice number but not legal requirement)

Supplied

• date supplied
• name and address of person or firm supplied
• patient
• quantity supplied
• person collecting
• patient
• patient’s representative
• healthcare professional
• name and address
• proof of identity requested?
• proof of identity provided?

Question 19

What requirements are there of the CD register?

Answer 19

Entries must be in chronological sequence
Entries must be made on day of transaction or the following day
Separate register or part of register must be used for each class of drug
Separate page should be used for each different
- strength
- form
- brand of drug
Class, strength and form must be stated at the top of each page
No cancellation or alterations may be made
- correction must be made via a dated footnote or marginal note
- marked to show who made the amendments
- name
- initials/signature
- GPhC number
- do NOT cross out mistake
Must be indelible
- if computerised should be attributable and auditable
Bound book or electronic
- kept at premises to which it related
- kept for 2 years from last date of entry

Question 20

When might the destruction of CDs be required?

Answer 20

Obsolete/expired/unwanted stock

Patient (or representation) has returned unwanted medication

Question 21

How are obsolete, expired or unwanted stock of controlled drugs destroyed?

Answer 21

Schedule 2 CDs
- only destroyed in the presence of an authorised witness
- name, form, strength, date and quantity must be recorded in the CD register
- signed by witness
Schedule 3 and 4 CDs
- need only be witnessed if the pharmacy has a licence for production, import or export of CDs
Schedule 5
- need not be witnessed by an authorised person under any circumstances

Question 22

What is the process for destroying controlled drugs?

Answer 22

Schedules 2, 3 and 4(I) CDs must be denatured
- drug rendered irretrievable
before being placed in appropriate waste containers
- sent for incineration

Tablets and capsules
- grind or crush before placing in CD denaturing kit
Liquids
- add to normal CD denaturing kit
Patches
- remove backing and fold over onto itself
Ampoules
- liquid
- open ampoule and empty contents into a CD denaturing kit and ampoule into sharps bin
- powder
- open ampoule and add water to dissolve powder inside
- resulting mixture can be poured into CD denaturing kit and ampoule into sharps bin
Aerosols
- expel into water and dispose as per liquids

Question 23

What are the prescription requirements for a Controlled Drug?

Answer 23

A prescription for a CD in schedule 2, 3 or 4 needs to include a date, and is only valid for 28 days after the appropriate date on the prescription

• if you make a part supply due to insufficient stock the remainder must be supplied within 28 days of the appropriate date on the prescription
• if it is requested after this date, the balance cannot be supplied
• new prescription needed