Psychoactive Substances and Psychotic Disorders Flashcards
What does the term ‘hazardous drinking’ mean?
A level or pattern of drinking that will eventually cause harm. It applies to anyone drinking above the recommended limits, but without current alcohol-related problems
What does the term ‘harmful drinking’ mean?
A pattern of use that has already caused physical, mental, or social damage to the user. It excludes those with dependence syndrome
Damage may be acute or chronic
What does the term ‘alcohol abuse’ mean?
Continued drinking of alcohol despite significant employment, social, legal, or dangerous problems resulting from it
What are the characteristics of dependent drinking?
3 must have been present in the previous year to make a diagnosis:
1) Tolerance
- A need for markedly increased amounts of alcohol to achieve desired effect
- A markedly diminished effect with continued use of the same amount of alcohol
2) Withdrawal
3) Alcohol taken in larger amounts or over longer periods than was intended
4) Persistent desire for or unsuccessful efforts to cut down
5) Great deal of time is spent
What is the safe level of alcohol consumption in M and F?
M = up to 21 units / week F = up to 14 units / week
Been changed to 14 / week for both
List some GI effects of excessive use of alcohol (7)
1) Malnutrition and vit def - A, B, C, D E
2) Carcinoma of the lip, tongue, pharynx and larynx
3) Gastritis and peptic ulcer
4) Oesophageal varices
5) Oesophageal carcinoma
6) Acute and chronic pancreatitis
7) Fatty liver, hepatitis, cirrhosis and primary liver carcinoma
List some neurological effects of excessive use of alcohol (7)
1) Peripheal neuropathy
2) Dementia
3) Wernicke’s encephalopathy
4) Korsakoff’s syndrome
5) Cerebellar degeneration
6) Epilepsy
7) Fetal alcohol syndrome
What is the pathophysiology of alcohol addiction?
Alcohol has a variety of effects from which euphoric effects arise such as GABA, DA, 5HT and glutamate
In addiction = upregulation of glutamate to compensate for depressive effects on CNS of alcohol (thus why suddenly removing alcohol leads to CNS hyperexcitability)
Alcohol interferes with thiamine absorption from GIT
Alcohol causes decreased production of ADH = excessive urination and dehydration
List some features of alcohol dependence
CANT STOP
Compulsion to drink
Awareness of consequences but continues to drink
Narrowing of drinking repertoire
Tolerance increases
Stopping leads to withdrawal
Time spent using alcohol - other activities neglected
Out of control
Pattern resumes after abstinence
Describe alcohol withdrawal symptoms / when they happen
Occur in chronic heavy drinkers 4-12hrs after last drink
Anxiety Sweating Tremor Vomiting Tachycardia Sleep disturbance
Grand mal seizures in 10% (6-48hrs)
Severe cases - delirium tremens
What is delirium tremens?
Medical emergency
Presents 1-3 days after alcohol withdrawal (in 4% withdrawing)
Altered mental state Clouding of consciousness Visual hallucinations (eg insects / small animals) Confusion Delusions Sever agitation Fever Seizures
What is Wenicke-Korsakoff syndrome?
Wernicke’s encephalopathy and Korsakoff psychosis are the acute and chronic parts of a single disease, caused by neuronal degradation due to thiamine deficiency
What is Wernicke’s encephalopathy?
Triad of:
1) Mental confusion
2) Gait ataxia
3) Ophthalmoplegia
Only 10% have all three
What may be found on examination of someone presenting with Wernicke’s encephalopathy?
1) Vision changes:
- Double vision
- Eye movement abnormalities
- Eyelid drooping
2) Loss of muscle co-ordination:
- Unsteady, unco-ordinated walking
3) Loss of memory
4) Inability to form new memories
5) Hallucinations
6) Confabulation
OE:
- Polyneuopathy
- Decreased reflexes
- Abnormal gait
- Nystagmus
- Low BP
- Tachycardia
- Cachexia
What happens if Wernicke’s encephalopathy is left untreated?
Acute phase lasts 2 weeks
84% will develop Korsakoff psychosis
How does Korsakoff’s psychosis present?
Anterograde and retrograde amnesia = loss of old memories and failure to make new ones
Working memory unimpaired
Confabulation
How does chronic alcohol consumption lead to thiamine deficiency?
1) Inadequate nutritional thiamine intake
2) Decreased absorption of thiamine from GIT
3) Impaired thiamine utilisation in cells
List 3 differentials for delirium tremens
1) Hypoglycaemia
2) Drug misuse / OD
3) Physical cause of delirium eg UTI
List 3 differentials for Wernicke’s-Korsakoff’s syndrome
1) Hypoglycaemia
2) Hepatic encephalopathy
3) Subdural haemorrhage
What alcohol screening tools are used?
CAGE + AUDIT questionnaire
Have you ever thought about CUTTING BACK?
Have you ever become ANGRY when someone comments on your drinking?
Have you ever felt GUILTY about your drinking?
Have you ever had an EYE-OPENER to get up in the morning?
(+2)
What is the most you have drunk in a DAY?
What is the most you have drunk in a WEEK?
Outline an alcohol history
1) CAGE
2) Alcohol intake
3) Assess impact of alcohol
4) PMH
5) Psychological assessment
- INC RISK
6) Conclude - leaflet / ?alcohol rehabilitation service referral
What questions should be asked to assess alcohol intake?
When did they have their first drink?
- Good / bad experience
When did they notice their alcohol intake increase?
- Gradual / sudden
- Any triggers
Current drinking pattern:
- Every day / weekends
- Time of day: mornings / evening / all day
Do you drink with other people? Where?
Why do you drink?
How long has this been going on for?
- What did you used to drink / where / when?
How much do you spend on alcohol?
What questions should be asked to assess the impact of alcohol?
Dependence:
Biological
- If you stop drinking do you get the shakes / sweat / feel sick?
- Do you have to drink more to get the same effects?
Physiological
- Do you feel a compulsion / need to drink?
- How important is drinking to you?
- If you stop drinking, do you feel down / angry / anxious?
Effects on ADL:
- Diet
- Occupation
- Relationships
- Alcohol related crime = “have you ever been in contact with the police as a result of alcohol related incidents?”
- Living situation
- Previous attempts at abstinence = “have you ever tried to stop drinking before / why? Why do you think it was unsuccessful”
Assess desire to stop drinking
What PMH should be asked in an alcohol history?
General medical screen
Alcohol specific - liver disease, peptic ulcers, pancreatitis, IHD
DH
Allergies
FH - alcohol / drugs / mental illness
What questions should be asked in a psychological assessment in an alcohol history?
Risk to self:
- Mood / appetite / sleep
- Are there things you enjoy in lie? What?
- How is your concentration?
- Have you had any thoughts of hurting yourself?
- Have you ever thought of ending it all? If so, plans?
Risk to others:
- Do you have any thoughts of harming others
What is the management of acute alcohol toxicity?
Maintain patent airway and wait for alcohol to metabolise
What is the management alcohol of withdrawal?
PO thiamine 100mg TDS for 1 month
Benzodiazepines help with tremor and agitation
- Diazepam
- Chlordiazepoxide
IV lorzepam can be given for seizures
Avoid NSAIDs and paracetamol due to compounding effects on liver
What is the management of delirium tremens?
Parenteral thiamine = Pabrinex
Benzodiazpeines = lorazepam
What is the management of Wernicke’s encephalopathy?
IV thiamine (Pabrinex) - 2 ampoules BD for 3-7days
Parenteral vitamins
What is the management of Korsakoff’s?
Continue PO thiamine replacement for up to 2 years
What can be given to deter people from drinking alcohol?
Disulfram (antabuse) - makes people sick when they drink alcohol (do not use until blood alcohol level returns to 0)
Acamprosate = neuroprotective Naltrexone = reduces cravings
What psychological methods can be used in alcohol addiction?
Techniques of controlled drinking:
- Daily / weekly limits
- Don’t drink alone or with heavy drinkers
- Alternate with soft drinks
- Drink with a meal
- Rehearse a refusal for a drink offer
AA - 12 steps
What is the prognosis of alcoholism?
Relapsing common (60%) before achieving long-standing abstinence
4 x inc risk of mortality
What is the prognosis of delirium tremens?
10% mortality if untreated
What is the prognosis of Wernicke’s encephalopathy?
Untreated mortality - 15%
With treatment:
- Ophthalmoplegia and confusion resolve in days
- Ataxia, neuropathy and nystagmus may be permanent
What is the prognosis of Korsakoff’s?
25% may improve some degree over time
25% require long term institutional care
List some risk factors for drug addiction
Either lower social class or 'social drift' Young age Male Unemployed Single Opiate = under 30yr BNZ = middle aged
Give examples of opioids
Morphine Diamorphine Codeine Dihydrocodeine Heroin Oxycodone Methadone Opium Tramadol Loperamide Meptazinol Pentazocine
What is the mechanism of action of opioids?
Act on opioid mu receptors in CNS, reducing neuronal excitability and pain transmission
- In medulla = blunt response to hypoxia and hypercapnoea, reducing respiratory drive and breathlessness
By relieving pain, breathlessness and associated anxiety, they reduce the sympathetic nervous system
What are the effects of opioids?
Cortical inhibition Euphoria Analgesia Constipation Respiratory depression Anorexia Loss of libido Pruritus Miosis
= Effects almost immediate
What can happen in opioid overdose?
Respiratory depression and death
When are withdrawal symptoms experienced in opioid addiction?
Symptoms begin 8-12hrs after last dose, peak at 36-72hrs and subside over 7-10 days
Longer for methadone
List some symptoms of opioid withdrawal?
Anxiety Pain Breathlessness Intense craving Restlessness Insomnia Tachycardia Dilated pupils Running nose and eyes Sweating Piloerection = "cold turkey" Abdo cramps D&V
What is the treatment of an opioid overdose?
IV Naloxone
beware has a shorter half-life than heroin so revived pt can relapse unconscious again
What can be given to detoxify and prevent relapse of opioids?
Naltrexone
= Long acting opioid antagonist
What can be given to help treat the withdrawal symptoms from opioids?
Lofezidine = alpha-adrenergic agonist
Loperamide
Metoclopramide
Ibuprofen
What can be given as a substitute to opioids?
Methadone = long acting synthetic opioid
- 24hr half-life so useful for daily dosing
- Unsuitable for injection (given PO)
Buprenorphine = partial opioid agonist, less euphoria at higher doses than methadone
- Can be given IV
What is loperamide?
An opioid
But cannot penetrate CNS so has no analgesic effects
Acts on mu eceptors in GIT slowing bowel transit = anti-diarrhoea
List some types of benzodiazepines
Diazepam Temazepam Lorazepam Chlordiazepoxide Midazolam
What is the mechanism of action of benzodiazepines?
Facilitate and enhance binding of GABA to GABA receptor
GABA = main inhibitory neurotransmitter in brain
Thus benzos cause widespread depressant effect on synaptic transmission
What effects do benzodiazepines have on the body?
Reduced anxiety Sleepiness Sedation Anti-convulsive effects Forgetfullness
Chronic use associated with depression, impaired memory and concentration
Why are benzos used in alcohol withdrawal?
Ethanol also acts on GABA, and in chronic excessive use the pt becomes tolerant to its presence
Abrupt cessation = excitatory state of alcohol withdrawal, which can be treated with benzos
How long does it take for addiction to develop with benzos?
3-6 weeks of regular use
What are the risks of benzo overdose?
Over-sedation
Coma
Death
What are the symptoms of benzo withdrawal?
Anxiety Insomnia Tremor Headache Nausea Depersonalisation Seizures Delirium
When do symptoms of benzo withdrawal present?
24hrs (short acting) or up to weeks (long acting) after last dose
What is the management of benzodiazepam:
- Over dose
- Detox
- Dose reduction?
Overdose - Flumazenil = BDZ receptor antagonist
Detox - switch from short half life (eg temazepam / oxazepam)
Dose-reduction - no more than 30mg diazepam
What is the mechanism of action of cocaine?
Blocks reuptake of serotonin and catecholamines (esp dopamine)
What are the effects of cocaine?
Increased energy Increased confidence Euphoria Reduced need for sleep Local anaesthesia Dilated pupils Tachycardia HTN Hyperthermia Aggression
= A few minutes after consumption
What can happen in a cocaine overdose?
Tremor Confusion Seizures Arrhythmia MI Perforation of nasal septum
What symptoms are experienced in cocaine withdrawal?
Intense craving Anxiety Dysphoria Irritability Formication (feeling of insects under the skin v common)
What is the treatment of acute cocaine toxicity?
Symptomatic benzodiazepines and/or antipsychotics
Is dependency seen in amphetamines?
No but psychological addiction occurs based on social situations
What is the mechanism of action of amphetamines?
Monoamine agonist stimulants
Block reuptake or noradrenaline and dopamine
(used in treatment of narcolepsy and hyperactivity)
What are the effects of amphetamines?
Increased energy Increased confidence Disinhibition Euphoria Reduced need for sleep Tachycardia HTN Hyperthermia Post-use depression
Chronic use - associated with anxiety and depression
In what way do the effects of amphetamines differ from cocaine?
Similar effects but metabolism slower so effects are longer
What can happen in an overdose of amphetamines?
Arrhythmia Severe HTN Dehydration Seizures Coma
What are the effects of amphetamine withdrawal?
Dysphoria Decreased energy Depression Anxiety Fatigue Nightmares
What is the management of acute amphetamine toxicity?
Symptomatic benzodiazepines and/or antipsychotics
Is dependency seen in ecstasy use?
No but tolerance increases
What is the mechanism of action of ecstasy?
Cause serotonin release and blocks reuptake
What are the effects of ecstasy?
Euphoria / sweating / tachycardia / hyperthermia etc etc
What can happen in ecstasy overdose?
Death from dehydration and hyperthermia
What is LSD?
Lysergic acid diethylamide
What is the mechanism of action of LSD?
Partial agonist of 5HT2A
Dopaminergic effects
What are the effects of LSD?
Distortion or intensification of senses Synaesthesia = crossing of senses eg hearing colours Mood changes Pupil dilation Tachycardia HTN
Effects begin 15-30min after ingestion and last 8-14hrs
What does cannabis contain?
> 60 psychoactive cannabinoids
Most importantly 9-delta-tetrahydrocannavinol (THC)
What is the timeframe of cannabis effects?
If smoked, effects felt within minutes, reach peak at 30 mins, last 2-5hrs
What is chronic cannabis use associated with?
Dysthymia Anxiety Amotivation Paranoia Schizophrenia / psychotic episodes
What can cannabis withdrawal lead to?
Heavy users who stop suddenly may experience insomnia, anxiety and irritability
What is the “craving centre” in the brain?
Nucleus accumbens
What areas of the brain are involved in addiction?
Nucleus accumbens is stimulated but is down regulated over time with repeated stimulation
This causes up regulation of the ventral tegmental area which is responsible for compulsion = compulsive behaviour continues even though you no longer get pleasure
Pre-frontal cortex also changes so that overtime it feeds into the system to regulate and sustain these behaviours
What are the 4 x C’s for addiction
1) Control - loss of control and some attempts to control it
2) Compulsion - feeling compelled to use
3) Continued - continued use despite consequences
4) Cravings
