(psych) clinical management and presentation of addiction

Question 1

what is the unit equation for alcohol?

Answer 1

% strength x (ml/1000) = units

Question 2

what is the recommended weekly limit for alcohol?

Answer 2

for both men and women, a maximum of 14 units a week

Question 3

what is the excretion rate of alcohol?

Answer 3

approx 1 unit per hour

Question 4

what are signs of harmful drug use or drug dependency?

Answer 4

craving

loss of control

restricted interest (preoccupied w getting high)

distress if cannot procure drug

regular injecting

WITHDRAWAL effects

Question 5

what are the symptoms of opiate withdrawal?

Answer 5

tachycardia
sweating
restlessness
dilated pupils
bone/joint aches
runny nose
upset GI tract
tremor
yawning
anxiety and irritability
gooseflesh skin

Question 6

what is COWS?

Answer 6

clinical opiate withdrawal scale

an 11-item scale designed to be administered by a clinician that rate and monitor the progression of common signs and symptoms
of opiate withdrawal

Question 7

what can IV drug use cause?

Answer 7

infective endocarditis

Question 8

how can IV drug use cause infective endocarditis?

Answer 8

increased risk of infection due to unsterilised needles = infective endocarditis

Question 9

how is dependence syndrome classified?

Answer 9

three or more of the following in past year:

• sense of compulsion to take a substance
• difficulties in controlling substance-taking behaviour
• a physical withdrawal state when substance use has ceased or been reduced (mainly alcohol, opiates, benzodiazepines, G-drugs)
• tolerance (ie. need to take more of the substance to get the same effect)
• progressive neglect of alternative pleasures or interests because of substance use (increased amount of time necessary to obtain or take alcohol or to recover from its effects)
• persisting with substance use despite clear evidence of overtly harmful consequences

Question 10

summarise how dependence syndrome is classified

Answer 10

three OR more of the following in the last year:

• compulsion to take a substance
• difficulty controlling
• withdrawal symptoms
• tolerance
• neglect (of other aspects in life)
• persistence with the habit

Question 11

what is harmful use?

Answer 11

a pattern of substance use that causes damage to health

damage = physical OR mental AND has adverse social consequences

= bingeing on substances also counts as harmful use but a hangover alone does not (!!!)

Question 12

what are the classifications of harmful use?

Answer 12

1) physical
2) mental

= has adverse social consequences

Question 13

can harmful use and dependence both be present in a patient?

Answer 13

a patient CANNOT have a diagnosis of BOTH harmful use AND dependence

Question 14

what is used instead of the term ‘alcohol/opioid abuse’ and ‘dependence’ according to DSM-5?

Answer 14

opioid use disorder

alcohol use disorder

Question 15

how is the severity of substance use disorders classified?

Answer 15

mild, moderate and severe

Question 16

how is a history taken in addiction patients?

Answer 16

presenting complaint 
HPC
past psychiatric history
past medical history
medication & allergies
drug history
family history
social history
personal history
premorbid personality
risk assessment

and MSE

Question 17

how is a substance misuse history taken?

Answer 17

length of current use and when last used

current amount (units/grammes per day) and for how long at this level

total length of use, max use, and any periods of abstinenc

mode/method of use

evidence of withdrawals and severity (e.g. seizures, admissions)

any previous treatments - medication, psychotherapy, detox, rehab.

any previous substance overdoses (accidental vs deliberate)

assess triggers to use substances/alcohol

assess motivation to change/engage in treatment

Question 18

what are common co-morbid conditions in addiction?

Answer 18

depression
anxiety
suicidality
personality disorder
PTSD
bipolar disorder

Question 19

what must you screen for when taking a past psychiatric history?

Answer 19

screen for developmental disorders especially ADHD, and ascertain general developmental and educational history

Question 20

in addiction, what is the most common template of past psychiatric history?

Answer 20

history of trauma most commonly = always think traumatic life experiences (especially in childhood)

e.g. neglect and abuse; family history of substance misuse/violence

Question 21

how is a social history taken for addiction?

Answer 21

• relationships – partner, family, children (violence?)
• safeguarding concerns?
• accommodation problems?
• money and debt?
• employed/benefits?
• forensic history? (cautions, convictions, time served, funding of habit, ongoing court cases)

Question 22

what is drug-induced psychosis?

Answer 22

a cluster of psychotic phenomena that could occur during or immediately after substance use, especially stimulants

= vivid hallucinations, paranoid delusions (usually resolve in 1-6 months)

Question 23

which stimulants cause drug-induced psychosis?

Answer 23

crack, methamphetamine

Question 24

how does drug-induced psychosis present?

Answer 24

vivid hallucinations, often auditory

paranoid delusions (can be severe)

= usually resolves within 1-6 months

Question 25

what is drug-induced psychosis similar to?

Answer 25

schizophrenic episode (that can be triggered by substance use too)

Question 26

what are the major causes of morbidity and mortality associated with substance abuse?

Answer 26

trauma (e.g. fracture) road traffic accidents homicide and suicide overdose (deliberate, but frequently accidental) cirrhosis (alcohol) endocarditis (IV) abscesses (IV) blood-borne viruses: Hep B/C, HIV (IV)

Question 27

what does the examination for alcohol addiction consist of?

Answer 27

comment on the presence of jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT

Question 28

which investigations are done for alcohol addiction?

Answer 28

fibro scan/ultrasound bloods (LFT, GGT, lipids, U&E, amylase) breathalyser urine drug screen

Question 29

what does the examination for opioid addiction consist of?

Answer 29

collapsed veins/track marks endocarditis skin abscesses hepatitis/HIV pneumonia

Question 30

which investigations are done for opioid addiction?

Answer 30

bloods (LFT, U&E, GGT, glucose) breathalyser urine drug screen sexual health screening blood-borne viruses

Question 31

what is the epidemiology of alcohol?

Answer 31

- 15-24 year-olds have heaviest use - unemployed > employed - divorced/separated > single > married - approx 30% of the UK population drink above safe limits

Question 32

what is the CAGE test for alcohol use?

Answer 32

a series of four questions that doctors can use to check for signs of possible alcohol dependency

Question 33

why is a CAGE test used?

Answer 33

less obtrusive question than asking someone directly if they have an alcohol problem

Question 34

what four questions are asked in a CAGE test?

Answer 34

have you ever felt you needed to Cut down on your drinking? have people Annoyed you by criticizing your drinking? have you ever felt Guilty about drinking? have you ever felt you needed a drink first thing in the morning? (Eye-opener)

Question 35

what is the alcohol AUDIT tool?

Answer 35

simple screening tool to pick up the early signs of hazardous and harmful drinking and identify mild dependence answer a series of questions and the resultant score indicates risk

Question 36

how are the results of an alcohol AUDIT assessment interpreted?

Answer 36

0-7 = low risk (consider VBA) 8-15 = increasing risk 16-19 = higher risk 20+ = possibility of dependence (refer to alcohol harm assessment team)

Question 37

what are the immediate physical effects of alcohol use?

Answer 37

CNS = impaired reaction time and motor coordination, impaired judgement senses = poor visual acuity, smell, taste, hearing stomach = nausea, inflammation skin = sweating, heat loss, hypothermia sexual = reduced erection response, reduced vaginal lubrication

Question 38

what are the systemic effects of chronic alcohol use?

Answer 38

CNS = brain atrophy, reduced brain size, damaged brain cells CVS = weakened cardiac muscle, hypertension, arrhythmias immune system = lower resistance to disease digestive system = increased risk of cancers, cirrhosis obesity bone = increased osteoporosis, fractures

Question 39

what is alcohol withdrawal?

Answer 39

worsening pattern of symptoms after cessation of alcohol use consists of tremors, fever, anxiety, hallucinosis, seizures, delirium tremors (rare but emergency)

Question 40

what is the onset of alcohol withdrawal?

Answer 40

usually after 6 hours

Question 41

what are delirium tremors?

Answer 41

confusion, auditory and visual hallucinations, agitation, fever, tachycardia = medical emergency as mortality is 15-20% consider admitting and treating symptoms

Question 42

what are the risk factors for delirium tremors?

Answer 42

heavy daily alcohol use (60+ units) history of DTs older age abnormal LFTs

Question 43

what is the function of opioids?

Answer 43

1) relieve pain = analgesic effect | 2) creates a sense of euphoria, increasing pleasure and well-being

Question 44

what are endorphins?

Answer 44

type of endogenous opioid (along with enkephalins) endorphins are peptides that act on the opiate receptors in the brain = to relieve pain AND produce feelings of pleasure

Question 45

where are endorphins produced?

Answer 45

endogenous endorphins produced in the pituitary gland can also be exogenous (i.e. opioid drug use)

Question 46

what are the opioid receptors?

Answer 46

mu, delta, kappa opioid receptors in the CNS (activate pain inhibitory pathways)

Question 47

which substances activate opioid receptors?

Answer 47

opioid agonists (heroin, methodone, fentanyl, codeine) partial agonists (buprenorphine) antagonists (naltrexone)

Question 48

name opioid receptor agonists

Answer 48

heroin, methodone, fentanyl, codeine

Question 49

name opioid receptor partial agonists

Answer 49

buprenorphine

Question 50

name opioid receptor anagonists

Answer 50

naltrexone

Question 51

define opioids

Answer 51

refer to all natural, semisynthetic, and synthetic opioids

Question 52

define opiates

Answer 52

refer specifically to ONLY natural opioids such as morphine and codeine, and heroin to some extent

Question 53

differentiate between opiates and opioids

Answer 53

opioids = natural, semisynthetic and synthetic opioids opiates = only NATURAL opioids

Question 54

name natural opioids

Answer 54

opium (mixture of morphine, codeine, thebaine, papaverine) morphine codeine thebaine

Question 55

name synthetic opioids

Answer 55

fentanyl (x100 > than morphine) methodone tramadol pethidine

Question 56

name semisynthetic opioids

Answer 56

heroin (x2 more potent than morphine) hydrocodone oxycodone hydromorphone

Question 57

what are the signs of an opiate overdose?

Answer 57

not moving, cannot be woken up slow/no breathing choking tiny pupils clammy/cold skin blue lips/nails

Question 58

how is an opiate overdose treated?

Answer 58

inject NALOXONE into upper arm or thigh, or nasal spray (50% each nostril) if no response after 3 mins = repeat provide airway support, recovery position

Question 59

which medications are given to alcohol dependents during abstinence?

Answer 59

acamprosate disulfiram naltrexone (opioid antagonist) nalmefene (opioid antagonist)

Question 60

which medications are given to opioid dependents during abstinence?

Answer 60

methadone (synthetic opioid) buprenorphine (partial agonist)

Question 61

which medications are given to benzodiazepine dependents during abstinence?

Answer 61

maintenance on diazepam with a reducing regime (but many people struggle)

Question 62

what is the detox regime for alcohol dependents?

Answer 62

benzodiazepines

Question 63

what is the detox regime for opiate dependents?

Answer 63

maintenance treatment for at least 12 months before dose reduction

Question 64

what is the detox regime for benzodiazepine dependents?

Answer 64

medical supervision but must have access to an inpatient setting baclofen (GABA agonist)

Question 65

what are G drugs?

Answer 65

the name given to the drugs GHB (gamma hydroxybutyrate) and GBL (gamma butyrolactone)

Question 66

how do G drugs interact with alcohol?

Answer 66

can lead to death

Question 67

what impact do G drugs have on the body?

Answer 67

effects usually occur in 15-20 mins and last up to 3-4 hours precursor GBL is converted into GHB inside the body

Question 68

how do G drugs work?

Answer 68

depressant drugs produce a high with small doses and cause sedation with only slightly higher doses = euphoria, loss of inhibition, increased confidence

Question 69

what are the risks of G drugs?

Answer 69

easy to overdose as not much difference between the dose required for high and that required for overdose highly addictive leads rapidly to dependence