Psychiatry - Addictive behaviour Flashcards
Define TOLERANCE
Higher dose of drug required to produce the same response
Define WITHDRAWAL
Transient state occurring whilst readjusting to lower levels of drug in the body
Define DEPENDENCE SYNDROME
Cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours that once had a greater value
Outline 5 key criteria of a dependence syndrome
- Withdrawal
- Desire to take substance
- Difficulty in controlling substance taking behaviour
- Tolerance
- Neglect of alternative pleasures
- Primacy
- Persisting despite harmful consequences
What two features are seen in alcohol dependence which are not seen in drug dependence?
- Narrowing of repertoire
- Rapid reinstalment (people who stop when they start again wil get back to the level of tolerance they had previously, very quickly)
Allowed weekly units for men and women including per day
14
3 per day
More than how many units for women and men would be classified as a binge?
Women 6
Men 8
How many mls of pure alcohol in a unit
10
Give three risk factors for substance abuse
- Genetics
- Occupation - doctor, armed forces, journalist
- Social background - difficult childhood, parental separation, poor educational achievement
- Psychiatric illness
Presenting features of a patient intoxicated with alcohol?
- Initially relaxed and euphoric
- Then aggressive, irritated, weepy, disinhibited
- Impulsive
- Poor judgement
- Physical: ataxic gate, dysarthria, sedation, confusion, coma
- Narrowing of repertoire
Give two questionnaires that you could use to determine alcohol dependence?
- CAGE
2. AUDIT (alcohol use disorder identification test)
What investigations would you do in an individual suspected to have alcohol dependence?
- FBC (Macrocytic anaemia due to B12 deficiency)
- LFT (yGT rises with recent heavy alcohol use and raises transaminases)
- CAGE/audit
What are the 6 phases of the stages of change model?
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
What would the management of a patient with alcohol dependence syndrome entail?
- Motivational interviewing
- Stages of change model - where are they
- Detoxification
What is the standard detoxification regime for a patient with alcohol dependence syndrome?
- Chlordiazepoxide to replace alcohol and prevent withdrawal symptoms including seizures and DT
- Thiamine (vit B1 as prophylaxis against Wernicke’s encephalopathy)
How do you decide whether a patient will have a detox regime at home or as an inpatient?
Do at home if uncomplicated using Chlordiazepoxide regime for 5-7 days
If patient drinking more than 30 units a day keep as inpatient
If patient has history of withdrawal fits, or comorbid medical or psychiatric illness or patient lacks support can be done as inpatient
How is Thiamine delivered to a patient in a detox regime?
Either IV or IM (Parenterally)
Not PO because poorly absorbed in the gut
What type of drug is chlordiazepoxide?
Long acting benzodiazepine
What is the purpose of giving benzodiazepines in alcohol detox?
Prevents delirium tremens
What is the name of the medical emergency that occurs as a result of alcohol withdrawal?
Delirium tremens
What two medications are used to prevent relapse in an individual with previous alcohol dependence syndrome?
- Acamprosate (anti-craving)
2. Disulfuram (mimics flush reaction so makes drinking unpleasant)
Give 5 alcohol withdrawal symptoms
- Headache
- Nausea
- AUTONOMIC Sweating, tachycardia, hypotension, tremor
- Insomnia
- Agitation
Why can dependent drinkers get delirium tremens when they stop drinking?
Alcohol is a CNS depressant
Stimulates GABA inhibitory system to reduce brain excitability
When don’t drink neuro pathways become hyper excitable and seizures can occur or if severe DT
How long after abstinence begins does DT tend to occur?
48
How long does DT last?
3-4 days
Mortality rate of DT?
10-15%
Presenting factors of DT?
- Autonomic disturbance (sweating, tachycardia, hypertension, dilated pupils, fever)
- Delusions
- Hallucinations (visual and tactile)
- Affective changes (extreme fear and hilarity)
- Gross tremor
How is DT managed?
- Benzodiazepine (DIAZEPAM)
- Paraenteral thiamine
- Manage dehydration and electrolyte abnormalities
Give 5 physical consequences of excess alcohol consumption
- GI - alcoholic hepatitis, liver cirrhosis in 10-20%, pancreatitis, oesophageal varices, gastritis, PUD, malnutrition
- Neuro - peripheral neuropathy, seizures, dementia, subdural haematoma
- Cancer - bowel, breast, oesophageal, liver
- Cardiovascular- hypertension, dilated cardiomyopathy
Give 5 psychological consequences of long-term alcohol consumption
- Depression, anxiety, self-harm, suicide
- Amnesia
- Cognitive impairment - dementia/Korsakoff
- Alcoholic hallucinosis
- Morbid jealousy
Social consequences of long term alcohol consumption (5)?
Unemployment
Domestic violence
Separation
Law breaking
What is the encephalopathy related to long term alcohol consumption?
Wernicke’s encephalopathy
If Wernicke’s isn’t treated what happens?
Korsakoff syndrome
What causes Wernicke’s encephalopathy?
Acute thiamine (b1) deficiency
Why does chronic alcohol consumption result in thiamine deficiency?
- Inadequate nutritional intake
- Decreased absorption from GI tract
- Impaired utilisation in the cells
What is the triad of symptoms seen in Wenicke’s?
- Ataxia
- Mental confusion
- Opthalmoplegia
How is Wernicke’s treated?
Thiamine (parenteral)
Give two signs of Korsakoff syndrome
- Anterograde amnesia (can register new events but can’t recall them within a few minutes)
- Patients often confabulate to fill gaps
What antibiotic should not be taken with alcohol
Metranidazole
What are illegal highs?
Drugs containing one or more chemical substances that produce similar effects to drugs like cocaine, cannabis or ecstasy. Since 2016 psychoactive substances act it has been illegal to give away or sell them but there is no penalty for possession
How does Heroin work?
Mu opiate agonist.
How is Heroin taken?
Smoked and as tolerance builds is injected IV
Give 3 complications ofIV drug use
- Abscess/cellulitis/septicaemia
- DVT/ emboli –> gangrene
- Infective endocarditis
- BBI
- Overdose
Why are IVDU’s more at risk of DVT
Injecting into femoral veins damages valves which slows venous return
Clinical presentation of opiate intoxication
- Intense rush or buzz (euphoria, warmth)
- Followed by sedation and analgesia
- Vomit/dizziness
- Bradycardia and respiratory depression
- Pinpoint pupils
What effects are seen from opiate use non-IV?
- Constipation
- Anorexia
- Decreased libido
How is opiate overdose managed?
Naloxone
What type of drug is naloxone?
Opiate receptor antagonist
How long after last injection of opiate (heroine) does withdrawal start?
6 hours
When does opiate withdrawal peak after last taking?
36-48 hours
Drug withdrawal symptoms?
- GI - nausea, abdo cramps
- Insomnia
- Agitation
- Fever
- Aching muscles
Everything runs - diarrhoea, vomiting, lacrimation, rhinorrhoea
What symptoms do babies with neonatal abstinence syndrome have?
- High pitched cry
- Convulsions
- Hypertonia
- Tremor
- Loose stools and vomiting
- Sweats
- Fever
How are babies with neonatal abstinence syndrome treated?
Paediatric opiate preparations and anti-convulsants
What other morbidities do babies with neonatal abstinence syndrome have?
- IUGR
- LBW
- Prematurity
- SIDS
Management of IV drug use?
- Harm reduction
2. Substitute prescribing (detox)
What is the difference between alcohol and drug withdrawal?
Not life threatening with drugs
Give three methods of harm reduction in management of IV drug use
- Sterile needles
- Free condoms
- Injecting drug users and sex workers offered vaccination and testing for BBV
- Accessible sexual health services
What two drugs can be prescribed in a opiate detox regime?
- Methadone - liquid
2. Buprenorphine - sublingual tablet
What type of drug is methadone?
Full mu receptor agonist
Why is methadone prescribed in detox regime?
Controlled drug - given orally
Has a longer half life than heroin so withdrawal is longer but milder. Only need to take once a day
How can you test whether a patient has taken heroin?
Urine test - will show up up to a week after
What drugs cannot be tested on urine test?
- Spice (synthetic cannabinoid)
- Pregabalin
- Gabapentin
How does buprenorphine work and how is it different to methadone?
Partial mu receptor agonist. Blocks euphoric effects but prevents withdrawal
What drug is prescribed to prevent relapse in opiate use?
Naltrexone
What type of drug is naltrexone?
Mu receptor antagonist
How does naltrexone work?
Blocks euphoric effects of opiates
What drugs other than methadone and buprenorphine can be prescribed during a detox of opiates as adjuncts to improve comfort?
- Anti-emetic - metoclopramide
2. Anti-diarrhoeal (loperamide)
