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Y5 Psychiatry > Substance Abuse > Flashcards

Substance Abuse Flashcards

1
Q

Define Substance Abuse.

A

A pattern of substance use causing physical, mental, social, or occupational dysfunction.

  • ICD-10 defines it by the substance and type of disorder
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2
Q

Define Acute Intoxication.

A

Transient state of emotional & behavioural change after psychoactive substance use.

  • Dose dependent
  • Time limited
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3
Q

Define Harmful Use.

A

A pattern of use likely to cause physical or psychological damage.

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4
Q

Define Dependency.

A

A cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours.

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5
Q

Define Withdrawal.

A

Transient state occurring while re-adjusting to lower levels of a drug in the body.

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6
Q

Define Psychotic Disorder.

A

Psychotic symptoms occurring during or immediately after psychoactive substance use, characterised by vivid hallucinations, abnormal affect, psychomotor disturbances, persecutory delusions and delusions of reference.

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7
Q

Define Amnesic Disorder.

A

Memory and other cognitive impairments caused by substance use (i.e. Wernicke’s).

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8
Q

Define Residual and Late Onset Psychotic Disorders.

A

Where effects on behaviour, affect, personality or cognition lasting beyond the period during which direct psychoactive substances effect might be expected.

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9
Q

What is Classical Conditioning in the context of substance abuse?

A
  • Association
  • i.e. seeing a needle leading to craving heroin
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10
Q

What is Operant Conditioning in the context of substance abuse?

A
  • Rewarding behaviours are repeated
  • i.e. drug provide pleasure and behaviours that relieve unpleasant experiences are repeated
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11
Q

What is Social Learning Theory in the context of substance abuse?

A
  • Coping behaviour of others
  • i.e. Vietnam Heroin use
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12
Q

Which drugs activate the dopaminergic reward centre via blocking DA re-uptake?

A
  • Cocaine
  • Amphetamines
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13
Q

Which drugs activate the dopaminergic reward centre via increasing DA and others NTs?

A
  • Alcohol
  • Opiates
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14
Q

What are the features of substance dependency?

A
  • Dependence syndrome = ≥3 of the below together at some point in last month
    • Tolerance
    • Craving
    • Withdrawal
    • Problems controlling use
    • Continued use despite harm
    • Salience / primacy
    • Reinstatement
    • Narrowing repertoire
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15
Q

What alcohol consumption is linked to low risk, hazardous and harmful drinking?

A
  • Low risk = ≤14 U / week
  • Hazardous drinking (increased risk of alcohol related harm) = 15-35 U / week
  • Harmful drinking / Alcohol misuse = >35 U / week - i.e. >6 U/day
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16
Q

What are the risk factors for Alcohol Abuse?

A
  • Biological
    • Genetics - 25-50% predisposition
    • Neurotransmitter effects
    • Ethnicity - East Asians have lower dependency rates due to enzyme deficiency
    • Psychiatric illness
  • Psychosocial
    • Occupation - publicans, doctors, armed forces etc.
    • Social Background - difficult upbringing
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17
Q

What are the signs and symptoms of Alcohol Abuse?

A
  • Intoxication
  • Dependence syndrome
  • Psychotic disorder
    • Alcoholic hallucinosis - auditory hallucinations while drinking – often persecutory or derogatory
    • Lilliputian hallucinations
    • Morbid jealousy - delusion that partner is unfaithful
  • Amnesia - i.e. anterograde amnesia in Korsakoff’s syndrome
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18
Q

What are the signs and symptoms of Alcohol Withdrawal after 4-12 hours?

A
  • Course tremor
  • Sweating
  • Insomnia
  • Tachycardia
  • N&V
  • Psychomotor agitation
  • Anxiety
  • Hallucinations - transitory visual, tactile to auditory
  • Alcohol craving
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19
Q

What are the signs and symptoms of Alcohol Withdrawal after 36 hours?

A
  • Grand-mal seizures
  • Plus those of 4-12 hours:
    • Course tremor
    • Sweating
    • Insomnia
    • Tachycardia
    • N&V
    • Psychomotor agitation
    • Anxiety
    • Hallucinations - transitory visual, tactile to auditory
    • Alcohol craving
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20
Q

What are the signs and symptoms of Alcohol Withdrawal after 48 hours?

A
  • Delirium Tremens
    • Disorientation
    • Anterograde amnesia
    • Psychomotor agitation
    • Hallucinations - Lilliputian hallucinations of little people or animals
    • Hour by hour fluctuations (worse at night)
    • If severe - heavy sweating, fear, paranoid delusions, agitation, fever, sudden CV collapse
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21
Q

What are the appropriate investigations for suspected Alcohol Abuse?

A
  • Full History
    • CAGE questionnaire - ≥2 positive answers indicates you should do more investigation
      • Have you tried to cut down?
      • Have you ever been annoyed by people suggesting that you have a problem with you drinking?
      • Have you ever felt guilty about drinking?
      • Have you ever needed a drink to get you going in the morning – eye opener?
    • Who is in control? You or the drink? - if they think about it, query dependence
    • Lifetime pattern - age when first started, age regular drinking, age realised you had a problem
    • Current consumption
    • Social impacts - have you missed work, been in financial problems, relationships, etc.
  • Rating Scales
    • 1st line: AUDIT (Alcohol Use Disorders Identification Test)
    • If >20, 2nd line: SADQ (Severity And Dependence Questionnaire)
  • Physical Examination - jaundice, spider naevi, liver disease signs etc
  • Bloods - FBC (MCV), LFT, B12, folate, U&E, clotting screen, glucose, film (macrocytosis, no anaemia)
  • Urine - drug screen
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22
Q

What is the management of Alcohol Abuse?

A
  • Brief intervention if identified at risk (5-10 minutes)
  • Establish risks (i.e. driving, co-dependents, work, etc.)
  • Admission for those with
    • Acute alcoholic withdrawal symptoms
    • Wernicke’s encephalopathy (ataxia, ophthalmoplegia, confusion)
  • Acute alcoholic withdrawal management
  • Detox management
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23
Q

Describe the withdrawal regimen for Alcohol Abuse.

A
  • Manage expectations
    • Detox is worst in first 48hrs
  • Community-based assisted withdrawal
    • Criteria: >15U/day or ≥20 on AUDIT
    • 2-4 meetings / week (up to 3 weeks)
  • Inpatient admission **:
    • Criteria: >30U/day or ≥30 on SADQ, PMHx (epilepsy, DT, withdrawal-related seizures)
  • Acute treatment (up to 7d):
    • Mild to Moderate = Oral chlordiazepoxide ± IV/IM thiamine / Pabrinex
    • Severe = Oral lorazepam (oxazepam if hepatic impairment) ± IV/IM thiamine / Pabrinex
  • Chronic treatment (after 7d):
    • 1st line: acamprosate or naltrexon
    • 2nd line: disulfiram
    • Individualised psychosocial intervention plan and advice
      • CBT, couple’s therapy
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24
Q

What is the management of Alcohol Withdrawal Seizures?

A
  • IV lorazepam or oxazepam (if hepatic impairment)
  • Rapidly reduces the dose to avoid dependence
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25
Q

What is the management of Delirium Tremens?

A
  • Oral lorazepam
  • IV/IM thiamine / Pabrinex (vitamin B1)
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26
Q

What is the management of Wernicke’s encephalopathy?

A
  • IV/IM thiamine / Pabrinex (vitamin B1)
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27
Q

What are the signs and symptoms of Wernicke’s encephalopathy?

A
  • Ataxia
  • Ophthalmoplegia
  • Confusion
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28
Q

What are the complications of Alcohol Abuse?

A
  • Wernicke’s encephalopathy (reversible)
  • Korsakoff’s psychosis (progression from Wernicke’s - irreversible)
    • Many impacts on life (mainly social complications) – marriage, occupational, friendships, etc.
  • Liver and GI - alcoholic hepatitis, cirrhosis, pancreatitis, varices, gastritis, peptic ulcers
  • Neurological - peripheral neuropathy, seizures, dementia
  • Cancer - bowel, breast, oesophageal, liver
  • Cardiovascular - HTN, cardiomyopathy
  • Feotal Alcohol Syndrome
  • Psychiatric - depression, mania, anxiety, psychosis, self-harm, morbid jealousy, alcoholic hallucinosis
  • Social - unemployment, poor work performance, domestic violence, poor relationships, law breaking, child neglect/abuse
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29
Q

What are the signs and symptoms of Korsakoff’s psychosis?

A
  • Anterograde amnesia
  • Confabulation
  • Peripheral neuropathy
  • Cerebellar degeneration
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30
Q

Name some opiates.

A
  • Heroin (aka: brown, smack, horse, gear, H, skag) - medically = diamorphine
  • Morphine
  • Pethidine
  • Codeine
  • Dihydrocodeine
31
Q

What is the mechanism of action of heroin?

A
  • µ (mu) opiate agonist
    • Immediate euphoria
    • Diminished pain sensation
    • Feelings of detachment
32
Q

What routes of administration exist for opiates?

A
  • Smoking - ‘chasing the dragon’
  • Sniffing - ‘snorting’
  • Oral
  • IV - ‘mainlining’
  • IM or SC - ‘skin popping’
33
Q

What are the complications of IV drug use?

A
  • Abscess
  • Cellulitis
  • DVT
  • Emboli - can cause gangrene causing amputation
  • Septicaemia
  • Infective endocarditis
  • Blood-borne infection - Hep B & C, HIV etc
  • Increased risk of overdose
  • Pseudoaneurysm
34
Q

What are the signs and symptoms of opiate intoxication?

A
  • Euphoria
  • ‘Warmth’
  • Sedation
  • Bradycardia
  • Low-dose SEs - constipation, anorexia, decreased libido
35
Q

What are the signs of opiate overdose?

A
  • Pinpoint pupils
  • Low RR / Respiratory depression
36
Q

What is the treatment of opiate overdose?

A

Naloxone (opiate antagonist)

37
Q

What are the signs and symptoms of opiate withdrawal?

A
  • ‘Runs’ - i.e. D+V, lacrimation, rhinorrhoea
  • Goose-flesh (pilomotor unit erection)
  • Mydriasis
  • Yawning
  • Flu-like (feverish, abdominal cramps, aches) *‘
  • Craving
  • Nausea
  • Insomnia
  • Agitation
  • Begins 6hrs post-injection; peak at 36-48hrs; lasts 5-7 days
38
Q

What are the appropriate investigations for suspected opiate abuse?

A
  • Physical examination - establish baseline physical state
  • Urine drugs screen - 2 days in the urine
  • U&E - features of malnutrition
  • FBC - anaemia due to malnutrition or signs of infection
  • LFTs - may impact medication dosing
  • Blood borne infections
39
Q

What are the 2 types of Opioid Substitution Therapy?

A
  • Maintenance = stabilise lifestyle and reduce harm
  • Detoxification = detoxification and abstinence
    • Maintenance on OST is required before you start on detoxification
40
Q

What non-medical/psychiatric approaches are involved in opiate abuse management?

A
  • Appoint a key worker (single point of contact) and develop a care plan:
    • Agreed treatment and recovery goals with specific actions to achieve those goals
    • Monitoring of progress
  • Harm reduction - pragmatic approach if complete abstinence unlikely
    • Needle-exchanges for IVDUs
    • Offer vaccinations and testing for blood-borne pathogens
  • Health education - i.e. sleep hygiene, support groups, diet, etc.
    • SMART recovery
    • Narcotics Anonymous
41
Q

Describe Opioid Substitution Therapy - Maintenance.

A
  • 1st line = Methadone (liquid) or Buprenorphine (sublingual)
    • If still using heroin = low-dose methadone
    • If wanting to stop heroin completely = high-dose methadone OR buprenorphine
    • Offer naloxone and train on when/how to use it
42
Q

Describe Opioid Substitution Therapy - Detoxification.

A
  • Must be committed to stopping and be on a stable OST maintenance before you start detoxification
  • 1st line = Methadone (liquid) or Buprenorphine (sublingual)
    • Offer naloxone and train on when/how to use it
  • 2nd line: Lofexidine (alpha-2 agonist)
    • Indications = Rapid detox, Mild dependence, Preference
  • Inform them they will lose tolerance so if they start again, they should take a lot less
43
Q

What are the medicinal options for opiate withdrawal symptom management?

A
  • Clonidine or Lofexidine (alpha-2 agonist)
  • Anti-diarrheals (loperamide), anti-emetics (metoclopramide), etc.
44
Q

Does ultra-rapid opiate detoxing exist?

A
  • Yes
  • Not pleasant at all and is therefore not routinely offered
  • Uses Naloxone
45
Q

What follow-up care should be given for opiate detox/maintenance?

A
  • For at least 6 months:
    • Check for signs of withdrawal
    • Check other drug use (urine drug screens)
    • ECG (QTc) for those on methadone
    • CBT (to reduce relapse chance)
    • Contingency management
      • Incentives for -ve drug test results
      • Urinalysis preferred
46
Q

Name some types of Cannabis.

A
  • Grass/Weed – made from dried cannabis leaves
  • Hash – squidgy, brown-black lump made from resin and flowers
  • Skunk and Sinsemilla – particularly strong varieties
    • Skunk is the most commonly used
47
Q

What are the signs and symptoms of Cannabis use?

A
  • Effects depend largely on expectations and the original mood state:
    • Euphoria, relaxation through to paranoia, anxiety and panic
    • Perceptual/time distortion
    • Hunger pangs
    • Nausea and vomiting (‘greening’)
48
Q

What are the investigations for suspected Cannabis use?

A
  • Urine drug screen – in urine for up to 4 weeks
49
Q

What is the management for Cannabis Abuse?

A
  • Abstinence is advised for those with major mental illness
  • Clinical experience suggests that irregular use can be free from major problems
50
Q

What are the complications of Cannabis use?

A
  • Acute complications = paranoia, panic attacks, accidents associated with delayed reaction time (driving)
    • If susceptible, cannabis can precipitate an episode of psychosis or schizophrenia
  • Chronic complications = dysthymia, anxiety/depressive illness, amotivational syndrome, possible link to Schizophrenia
  • No physical dependency - there is a mild withdrawal syndrome in heavy users = insomnia, anxiety, irritability
51
Q

Name some Hallucinogens.

A
  • LSD (Lyseric acid diethylamide, acid)
  • PCP (Phencyclidine)
  • Ketamine (Special K)
  • Magic Mushrooms
52
Q

What are the signs and symptoms of Hallucinogens?

A
  • Euphoria
  • Visual illusions, hallucinations, depersonalisation, derealisation
  • Synaesthesia - experience sensation in another modality – i.e. hear a smell
  • Behavioural toxicity - acting on drug-induced beliefs – e.g. being able to fly
  • PCP = violent outbursts and ongoing psychosis
53
Q

What are the side effects of Hallucinogens?

A
  • LSD – acute SEs due to behavioural toxicity; chronic SEs include flashbacks, anxiety, depression
  • Phencyclidine – serotoninergic/cholinergic effects (confusion, violence)
  • Ketamine – LARGE amounts à nausea, ataxia, slurred speech
  • Magic mushrooms – behavioural toxicity, accidental poison consumption
54
Q

What is the management of Hallucinogen Abuse?

A
  • Harm reduction - pragmatic approach if complete abstinence unlikely
    • Needle-exchanges for IVDUs
    • Offer vaccinations and testing for blood-borne pathogens
  • Short-term withdrawal symptom relief as an inpatient with BDZ
55
Q

Name some Stimulants.

A
  • Cocaine - Charlie, coke, snow
  • Crack cocaine - rocks, base, freebase
  • Amphetamine - speed
  • Khat - quat, chat
  • Ecstasy - E, MDMA
56
Q

What are the signs and symptoms of Stimulants?

A
  • Increased alertness, endurance and confidence
  • Risky behaviour
  • Unpleasant ‘crash’ period - dysphoria - i.e. dissatisfaction with life and lethargy
57
Q

What are the side effects of Stimulants?

A
  • Cocaine - not associated with dependency but can become a habit
    • Acute – arrhythmia, intense anxiety, hypertension, CVA impulsivity, impaired judgement, death due to cardiac effects
    • Chronic – nasal septum necrosis, foetal damage, panic & anxiety, delusions (i.e. “Cocaine-induced Delusional Disorder” – believes performance in excess of ability), psychosis
  • Amphetamines - associated with dependence
    • Acute – tachycardia, arrhythmia, hyperpyrexia, irritability, post-use depression, Quasi-psychotic state with visual, auditory and tactile hallucinations
  • Ecstasy – not associated with dependence
    • Acute – increased sweating, nausea, vomiting, diminished potency despite increased libido
    • Death associated with dehydration & hyperthermia (some chronic liver & cognitive disease)
58
Q

What are the stages of Cocaine withdrawal?

A
  • Crash phase – from 3 hours
    • S/S: depression, exhaustion, agitation, irritability
  • Withdrawal – Lasts 1-10 weeks
    • S/S: cravings, irritability, anergia, poor concentration, insomnia, slowed movements
59
Q

What are the investigations for Stimulant Abuse?

A
  • Urine drug screen – cocaine in urine for up to 5-7 days
60
Q

What is the management of Stimulant Abuse?

A
  • Harm reduction - pragmatic approach if complete abstinence unlikely
    • Needle-exchanges for IVDUs
    • Offer vaccinations and testing for blood-borne pathogens
  • Short-term withdrawal symptom relief as an inpatient with BDZ
61
Q

What are the clinical uses of Benzodiazepines?

A
  • Sedation
  • Hypnotic
  • Anxiolytic
  • Anticonvulsant
  • Muscle relaxant
62
Q

How long should Benzodiazepines be prescribed for?

A

Short - 2-4 weeks

63
Q

What are the side effects/risks of Benzodiazepine use?

A
  • Short-Term = drowsiness, reduced concentration
  • Long-Term = cognitive impairment, anxiety and depression, sleep disruption, dependence
64
Q

What are the signs and symptoms of Benzodiazepine use?

A
  • Calm and mild euphoria
  • Slurred speech
  • Ataxia
  • Stupor
65
Q

What are the signs and symptoms of Benzodiazepine Overdose?

A
  • Respiratory depression
  • Low GCS
  • Low BP
  • Mydriasis
  • Hyporeflexia
66
Q

What is the management of Benzodiazepine Overdose?

A

IV flumazenil - GABA-A receptor antagonist

67
Q

What are the signs and symptoms of Benzodiazepine Withdrawal?

A
  • Anxiety
  • Insomnia
  • Irritability
  • Tachypnoea
  • Tachycardia
  • Ataxia
  • Tremor
  • Tinnitus
  • Sweating
  • Hyperreflexia
  • Seizures
  • Mydriasis
  • Palpitations
  • Delusions
  • Depression
  • Derealisation
  • Depersonalisation
  • Anterograde amnesia
68
Q

What are the signs and symptoms of sudden Benzodiazepine Withdrawal?

A
  • Delirium Tremens
    • Disorientation
    • Anterograde amnesia
    • Psychomotor agitation
    • Hallucinations (Lilliputian hallucinations of little people or animals)
    • Hour by hour fluctuations (worse at night)
    • If severe = heavy sweating, fear, paranoid delusions, agitation, fever, sudden CV collapse
    • 5-10% mortality
69
Q

What is the management of Benzodiazepine Abuse?

A
  • Address underlying need for BDZ - i.e. anxiety, sleep, depression
  • Address long-term complications of use - i.e. cognitive impairment, anxiety, depression, insomnia
  • Check willingness to withdraw
  • Withdrawal management – 2 methods of reduction:
    • Slow-dose reduction
    • Switch to equivalent dose of Diazepam, and slow-dose reduction
      • Useful if:
        • Difficult to physically taper down the dose
        • On short-acting potent BDZs (i.e. lorazepam)
  • Advice:
    • If done properly, there will be few, if any, withdrawal side effects
      • Anxiety is most common side effect and is normal
    • May take 3m to 1 year or longer (if necessary)
    • Assess driving risk (DVLA regulations) and advise cannot drive on certain levels of BDZs
70
Q

Describe the withdrawal process for Benzodiazepines for a patient starting on 40mg of Diazepam.

A
  • 1/8th daily dose reduction every 2 weeks
    1. Reduce dose by 5 mg every 2 weeks until reaching 20 mg per day
    2. Reduce dose by 2 mg every 2 weeks until reaching 10 mg per day
    3. Reduce dose by 1 mg every 2 weeks until reaching 5 mg per day
    4. Reduce dose by 0.5 mg every 2 weeks until completely stopped
  • Estimated total withdrawal time = 30–60 weeks
71
Q

What investigation can prove abstinence from smoking?

A
  • CO level of ≤10ppm indicates abstinence from smoking
72
Q

What are the management strategies for Cigarette Smoking Cessation?

A
  • 1st: Advice:
    • Stopping is best done through behavioural support + medication
    • Set a quit date, and commit to it
    • The first few days are often the most difficult (may experience withdrawal)
  • 2nd: Medications
    • Nicotine Replacement Therapy (lozenges, mouth spray, patches)
    • Varenicline (partial nicotine receptor agonist)
    • Bupropion (selective DA and NA re-uptake inhibitor (weak))
  • 3rd: Follow-up:
    • 2 weeks if on NRT; 3-4 weeks if on medications
    • Measure CO levels 4 weeks after quitting
    • Check progress, withdrawal symptoms
    • Of relapse, or partial relapse, provide encouragement and set a new quit date
  • Do not recommend e-cigarettes or vapes (unclear health impacts)
73
Q

What is the treatment of benzodiazepine toxicity?

A

Flumazenil

Y5 Psychiatry (11 decks)

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