Psychiatry- Substance Misuse Flashcards by Shahaab Shameem

What is alcohol dependence

DEPENDENCE: Harmful use + dependence. Characterised by CRAVING, TOLERANCE, pre-occupation and continued drinking in spite of harmful consequences

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Pathophysiology of chronic alcohol use

enhances GABA-mediated inhibition in CNS and inhibits NMDA-type glutamate receptors

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What is alcoholic hallucinosis

‣ Auditory hallucinations while drinking (usually persecutory or derogatory)

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Presentation 4-12 hours after alcohol withdrawal

• Coarse tremor
• Sweating
• Anxiety
• Insomnia
• Tachycardia
• N&V
• Psychomotor agitation
• Craving

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Presentation after 36 hours after alcohol withdrawal

‣ Grand-Mal seizures

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Presentation after 48-72 hours after alcohol withdrawal

• DELIRIUM TREMENS:
◦ Disorientation
◦ Hallucinations (Lilliputian- little people or animals hallucinations))
◦ Agitation

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Presentation of Wernicke’s encephalopathy

• Confusion
• Ataxia
• Opthalmoplegia
• Reversible

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Presentation of Korsakoff’s syndrome

◦ Anterograde amnesia: inability to make new memories after disease onset
◦ Retrograde amnesia
◦ Confabulation: Unintentionally making false memories
◦ Irreversible

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Bedside screening for alcohol abuse

‣ CAGE screening questions for alcohol abuse:
◦ 2 or more positive answers indicate further investigations
◦ Have you tried to cut down?
◦ Have you been annoyed by people suggesting you have a problem?
◦ Ever felt guilty about drinking?
◦ Ever needed to drink as an eye opener in the morning?

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General investigations for alcohol abuse

• Urinary Drug Screen
• FBC (MCV)
• LFTs
• U&Es (Thiamine)
• GLUCOSE: acute alcohol intoxication, you should check for hypoglycaemia

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Severity of dependence and severity of withdrawal scales

AUDIT

CIWA-Ar

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When to admit for alcohol abuse

‣ If Acute Alcohol Withdrawal symptoms
‣ Delirium tremens
‣ Wernicke’s Encephalopathy

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Where are patients referred for management of alcohol withdrawal

• Assisted Alcohol Withdrawal: refer to Alcohol Services for assessment and help (e.g. CGL services)
• Patient should not be advised to stop or reduce alcohol intake while waiting for outpatient services due to withdrawal symptoms risk
• Symptoms worse in first 48 hours

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What is acute treatment of alcohol withdrawal in the community

Community-based assisted withdrawal:
◦ Oral Chlordiazepoxide + IV/IM Pabrinex (Thiamine)
◦ Reducing dose

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Acute management of alcohol withdrawal as an inpatient

Inpatient withdrawal:
◦ Oral Lorazepam + IV/IM Pabrinex (Thiamine)
◦ Rapid reducing dose

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Alcohol withdrawal seizures management

IV lorazepam

Delirium tremens management

◦ Oral Lorazepam + IV/IM Pabrinex

Wernicke’s encephalopathy management

• IV Pabrinex/Thiamine (Vitamin B1)

Long-term management of alcohol withdrawal

• Craving control after successful withdrawal

1) Acamprostate (anti-craving) or Naltrexone (anti-pleasure)
◦ Prescribed for up to 6 months

2) Disulfiram (creates bad hangover- aversion therapy)

Examples of opiates

• Examples:
‣ Heroin
‣ Morphine, diamorphine
‣ Codeine, dihydrocodeine

Mechanism of action of heroin

• Heroin acts as a mu opiate receptor agonist
• Can be smoked, snorted or injected

Opiate intoxication presentation

Intoxication:
‣ Drowsiness
‣ Confusion
‣ Low respiratory rate
‣ Deconstructed ‘pinpoint’ pupils
‣ Decreased heart rate
‣ Track marks

Opiate withdrawal presentation

Withdrawal:
‣ Begins 6 hours after last injection, peaks at 36-48 hours, lasts 5-7 days
‣ Flu-like symptoms (feverish, muscle+joint pains, abdominal cramps)
‣ Agitation
‣ Insomnia
‣ ‘Everything runs’ (diarrhoea + vomiting, lacrimation, rhinorrhoea, diaphoresis)
‣ Dilated pupils (mydriasis)
‣ ‘Goose-flesh’ (piloerection)

Investigations for opiate misuse

• Urine Drug Screen:
◦ Can detects drugs up to 2 days

• Blood bourne virus screen:
• High risk of HEP C
• Also check Hep B, HIV, RPR (syphilis)

Opiate intoxication management

1) IV/IM Naloxone: but can lead to withdrawal symptoms

Pharmacological management of opiate dependence

1) Methadone: • Long-acting liquid • Full opioid agonist • Can affect QTc • If dose missed for >5 consecutive days, then reassessment and re induction of methadone should occur (as tolerance to opioids has likely changed) 1) or Buprenorphine: ◦ Sublingual tablet ◦ Partial opioid agonist ◦ Indicated in patients on anticonvulsants or rifampicin

Duration of pharmacological management of opiate dependence

• Detoxification for 12 weeks as outpatient and 4 weeks as inpatient • Makes them lose tolerance

Psychosocial management of opiate dependence

• Appoint a KEY WORKER: ‣ Single point of contact ‣ Helps monitor progress and develop care plan • Follow-up with Drug and Alcohol Service: to check for withdrawal symptoms, prolonged QTc, UDS

Mechanism of action of benzodiazepines

• Enhances effect on GABA by increasing frequency of chloride channels

Benzodiazepines overdose symptoms

• Respiratory depression • Euphoria • Slurred speech • Ataxia • Stupor • LowGCS • Low BP • Hyporeflexia

Benzodiazepine withdrawal symptoms

• Insomnia • Irritability • Anxiety • Tremor • sweating • Tinnitus • Loss of appetite

Benzodiazepine overdose management

1) IM Flumazenil

Benzodiazepine withdrawal management

1) Switch patients to equivalent dose of Diazepam: ◦ As diazepam is long-acting ◦ Withdraw in steps of 1/8 daily dose every fortnight ◦ Can take 3months-1 year to withdraw

Example of stimulants

• Cocaine, Amphetamine (Speed), Ecstasy (MDMA)

Symptoms of cocaine use

‣ Acute: arrhythmia, intense anxiety, formication, dilated pupils, hypertension ‣ Chronic: nasal septum necrosis, foetal damage, panic and anxiety, delusions (cocaine-induced delusional disorder), psychosis

Symptoms of ecstasy (MDMA) use

• Initial 3-hour rush, agitation relieved by dancing/movement, bruxism (teeth-grinding).

Management of stimulant abuse

• Supportive Management • Dantrolene can be used to treat hyperthermia if supportive measures fail