Psychiatry- Substance Misuse Flashcards
What is alcohol dependence
DEPENDENCE: Harmful use + dependence. Characterised by CRAVING, TOLERANCE, pre-occupation and continued drinking in spite of harmful consequences
Pathophysiology of chronic alcohol use
enhances GABA-mediated inhibition in CNS and inhibits NMDA-type glutamate receptors
What is alcoholic hallucinosis
‣ Auditory hallucinations while drinking (usually persecutory or derogatory)
Presentation 4-12 hours of withdrawal
• Coarse tremor
• Sweating
• Anxiety
• Insomnia
• Tachycardia
• N&V
• Psychomotor agitation
• Craving
Presentation after 36 hours of withdrawal
‣ Grand-Mal seizures
Presentation after 48-72 hours of withdrawal
• DELIRIUM TREMENS:
◦ Disorientation
◦ Hallucinations (Lilliputian- little people or animals hallucinations))
◦ Agitation
Presentation of Wernicke’s encephalopathy
• Confusion
• Ataxia
• Opthalmoplegia
• Reversible
Presentation of Korsakoff’s syndrome
◦ Anterograde amnesia: inability to make new memories after disease onset
◦ Retrograde amnesia
◦ Confabulation: Unintentionally making false memories
◦ Irreversible
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?
General investigations for alcohol abuse
• Urinary Drug Screen
• FBC (MCV)
• LFTs
• U&Es (Thiamine)
• GLUCOSE: acute alcohol intoxication, you should check for hypoglycaemia
Severity of dependence and severity of withdrawal scales
AUDIT
CIWA-Ar
When to admit for alcohol abuse
‣ If Acute Alcohol Withdrawal symptoms
‣ Delirium tremens
‣ Wernicke’s Encephalopathy
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
What is acute treatment of alcohol withdrawal in the community
Community-based assisted withdrawal:
◦ Oral Chlordiazepoxide + IV/IM Pabrinex (Thiamine)
◦ Reducing dose
Acute management of alcohol withdrawal as an inpatient
Inpatient withdrawal:
◦ Oral Lorazepam + IV/IM Pabrinex (Thiamine)
◦ Rapid reducing dose
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
