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
2
Q
Define Acute Intoxication.
A
Transient state of emotional & behavioural change after psychoactive substance use.
- Dose dependent
- Time limited
3
Q
Define Harmful Use.
A
A pattern of use likely to cause physical or psychological damage.
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.
5
Q
Define Withdrawal.
A
Transient state occurring while re-adjusting to lower levels of a drug in the body.
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.
7
Q
Define Amnesic Disorder.
A
Memory and other cognitive impairments caused by substance use (i.e. Wernicke’s).
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.
9
Q
What is Classical Conditioning in the context of substance abuse?
A
- Association
- i.e. seeing a needle leading to craving heroin
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
11
Q
What is Social Learning Theory in the context of substance abuse?
A
- Coping behaviour of others
- i.e. Vietnam Heroin use
12
Q
Which drugs activate the dopaminergic reward centre via blocking DA re-uptake?
A
- Cocaine
- Amphetamines
13
Q
Which drugs activate the dopaminergic reward centre via increasing DA and others NTs?
A
- Alcohol
- Opiates
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
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
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
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
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
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
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
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.
-
CAGE questionnaire - ≥2 positive answers indicates you should do more investigation
- 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
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
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
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
25
What is the management of Delirium Tremens?
* Oral lorazepam
* IV/IM thiamine / Pabrinex (vitamin B1)
26
What is the management of Wernicke's encephalopathy?
* IV/IM thiamine / Pabrinex (vitamin B1)
27
What are the signs and symptoms of Wernicke's encephalopathy?
* Ataxia
* Ophthalmoplegia
* Confusion
28
What are the complications of Alcohol Abuse?
* 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*
29
What are the signs and symptoms of Korsakoff's psychosis?
* Anterograde amnesia
* Confabulation
* Peripheral neuropathy
* Cerebellar degeneration
30
Name some opiates.
* Heroin (aka: brown, smack, horse, gear, H, skag) - *medically = diamorphine*
* Morphine
* Pethidine
* Codeine
* Dihydrocodeine
31
What is the mechanism of action of heroin?
* **µ (mu) opiate agonist**
* Immediate euphoria
* Diminished pain sensation
* Feelings of detachment
32
What routes of administration exist for opiates?
* Smoking - *‘chasing the dragon’*
* Sniffing - *'snorting’*
* Oral
* IV - *'mainlining’*
* IM or SC - *‘skin popping’*
33
What are the complications of IV drug use?
* 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
What are the signs and symptoms of opiate intoxication?
* Euphoria
* ‘Warmth’
* Sedation
* Bradycardia
* Low-dose SEs - constipation, anorexia, decreased libido
35
What are the signs of opiate overdose?
* Pinpoint pupils
* Low RR / Respiratory depression
36
What is the treatment of opiate overdose?
Naloxone (opiate antagonist)
37
What are the signs and symptoms of opiate withdrawal?
* **‘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
What are the appropriate investigations for suspected opiate abuse?
* 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
What are the 2 types of Opioid Substitution Therapy?
* Maintenance = stabilise lifestyle and reduce harm
* Detoxification = detoxification and abstinence
* Maintenance on OST is required before you start on detoxification
40
What non-medical/psychiatric approaches are involved in opiate abuse management?
* 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
Describe Opioid Substitution Therapy - Maintenance.
* 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
Describe Opioid Substitution Therapy - Detoxification.
* 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
What are the medicinal options for opiate withdrawal symptom management?
* **Clonidine** or **Lofexidine** (alpha-2 agonist)
* Anti-diarrheals (loperamide), anti-emetics (metoclopramide), etc.
44
Does ultra-rapid opiate detoxing exist?
* Yes
* Not pleasant at all and is therefore not routinely offered
* Uses Naloxone
45
What follow-up care should be given for opiate detox/maintenance?
* 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
Name some types of Cannabis.
* **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
What are the signs and symptoms of Cannabis use?
* 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
What are the investigations for suspected Cannabis use?
* Urine drug screen – *in urine for up to 4 weeks*
49
What is the management for Cannabis Abuse?
* Abstinence is advised for those with major mental illness
* Clinical experience suggests that irregular use can be free from major problems
50
What are the complications of Cannabis use?
* 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
Name some Hallucinogens.
* LSD (Lyseric acid diethylamide, acid)
* PCP (Phencyclidine)
* Ketamine (Special K)
* Magic Mushrooms
52
What are the signs and symptoms of Hallucinogens?
* 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
What are the side effects of Hallucinogens?
* 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
What is the management of Hallucinogen Abuse?
* 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
Name some Stimulants.
* Cocaine - Charlie, coke, snow
* Crack cocaine - rocks, base, freebase
* Amphetamine - speed
* Khat - quat, chat
* Ecstasy - E, MDMA
56
What are the signs and symptoms of Stimulants?
* Increased alertness, endurance and confidence
* Risky behaviour
* Unpleasant ‘crash’ period - dysphoria - *i.e. dissatisfaction with life and lethargy*
57
What are the side effects of Stimulants?
* 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
What are the stages of Cocaine withdrawal?
* **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
What are the investigations for Stimulant Abuse?
* Urine drug screen – *cocaine in urine for up to 5-7 days*
60
What is the management of Stimulant Abuse?
* 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
What are the clinical uses of Benzodiazepines?
* Sedation
* Hypnotic
* Anxiolytic
* Anticonvulsant
* Muscle relaxant
62
How long should Benzodiazepines be prescribed for?
Short - 2-4 weeks
63
What are the side effects/risks of Benzodiazepine use?
* Short-Term = drowsiness, reduced concentration
* Long-Term = cognitive impairment, anxiety and depression, sleep disruption, **dependence**
64
What are the signs and symptoms of Benzodiazepine use?
* Calm and mild euphoria
* Slurred speech
* Ataxia
* Stupor
65
What are the signs and symptoms of Benzodiazepine Overdose?
* **Respiratory depression**
* Low GCS
* Low BP
* Mydriasis
* Hyporeflexia
66
What is the management of Benzodiazepine Overdose?
IV flumazenil - *GABA-A receptor antagonist*
67
What are the signs and symptoms of Benzodiazepine Withdrawal?
* **Anxiety**
* Insomnia
* Irritability
* Tachypnoea
* Tachycardia
* Ataxia
* Tremor
* Tinnitus
* Sweating
* Hyperreflexia
* Seizures
* Mydriasis
* Palpitations
* Delusions
* Depression
* Derealisation
* Depersonalisation
* Anterograde amnesia
68
What are the signs and symptoms of sudden Benzodiazepine Withdrawal?
* **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
What is the management of Benzodiazepine Abuse?
* 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
Describe the withdrawal process for Benzodiazepines for a patient starting on 40mg of Diazepam.
* **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
What investigation can prove abstinence from smoking?
* CO level of ≤10ppm indicates abstinence from smoking
72
What are the management strategies for Cigarette Smoking Cessation?
* **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
What is the treatment of benzodiazepine toxicity?
Flumazenil
