Substance abuse Flashcards
Define substance use disorder
Drug or alcohol use that causes physical, mental or social dysfunction
Define intoxication
dose-dependent, transient state following drug use
Define harmful drug use
pattern of use likely to cause physical or psychological damage
Define dependence
need to use a substance to feel or function normally, after a period of regular use
What are the features of dependence
A strong desire or sense of compulsion to use
Difficulty in controlling use.
A physiological withdrawal state when use has ceased or been reduced.
Evidence of tolerance.
Progressive neglect of alternative pleasures and interests.
Persistence with use despite clear evidence of overtly harmful consequences.
What is a dual diagnosis
the presence of substance use with a comorbid mental health problem
Define tolerance
Bigger doses are increasingly needed to get the same effect
Define withdrawal
Psychological state when the substance is stopped/decreased, causing:
- A characteristic withdrawal syndrome for that substance
- Substance use to prevent/relieve withdrawal symptoms
Define compulsion
Strong desire to use
Define loss of control
Difficulty controlling starting, stopping, or amount used
Define salience
Obtaining and using the substance becomes so important that other social priorities are neglected
What is the aetiology of substance use disorder
Genetic: 40-60% heritability, reduced D2 receptors
ACEs
Social theory
Operant conditioning
Classical conditioning
Motivational theory
Dopamine theory
What are the risk factors for substance use disorder
Adolescence
Male gender
Low parental socioeconomic group and educational achievement
Parental substance dependence
Ineffective parenting
Family breakdown
Childhood abuse
Occupations: publicans, journalists, doctors, military personnel, people in the entertainment industry
Co-morbid psychiatric disorders e.g. personality disorders, depression, BPAD, ADHD, psychosis, anxiety disorders
What is the 12 month and lifetime prevalence of substance use disorder
12 month: 3.8%
llifetime: 14.6%
What investigations should be done for suspected substance use disorder
Bedside: ECG, urine toxicology, saliva drug screen, hair samples
Bloods: FBC, MCV, vit B12, LFTs, U&Es, blood toxicology
What are the differentials for substance use disorder
Head injury
Subdural haematoma
Depression
Mania
Psychosis
Anxiety disorder
Personality disorder
Give examples of opioids (strongest to weakest)
Fentanyl
Heroin (diamorphine)
Buprenorphine
Methadone
Oxycodone
Morphine
Hydrocodone
dihydrocodeine
tramadol
Codeine
What is the MOA for opioids
Opioid receptor (µ/mu) agonist → dopaminergic mesolimbic stimulation → dopamine release into the nucleus accumbens → mmediate euphoria, diminished pain sensation, feelings of detachment):
What are the methods of ingestion for opioids
IV (mainlining)
IM
SC
smoked/ inhaled (‘chasing the dragon’)
snorted/sniffed
oral
What is the epidemiology for opioid use
Opioid dependence can develop within a relatively short period of continuous use (2-10 days)
More common in men than women
Most common 16-24yo
What are the symptoms of opioid intoxication
Intense rush or buzz, feelings of euphoria, warmth, and well being
Sedation, analgesia
Itching and scratching
Pinpoint pupils
N&V
Dizziness
Bradycardia
Respiratory depression
What are the symptoms of opioid withdrawal and when does it occur
6 hours post injection (peak 36-48h)
Watering eyes, Rhinorrhoea, sneezing, cough
Yawning
Clammy skin
Dilated pupils (mydriasis)
Abdominal cramps, nausea, vomiting, diarrhoea
Tremor
Sleep disorder, restlessness, anxiety, irritability
Goosebumps
Hypertension
What investigations should be done for suspected opioid intoxication/withdrawal
Bedside: Urine toxicology, naloxone trial, mouth swab tests, ECG
Bloods: hepB/C serology, HIV serology, LFTs, U&Es, TFTs, FBC
Other: CXR, AXR
What is the long-term management for opioid abuse
MDT approach: primary care, practice nurse, pharmacists, addiction specialists
seek patient’s consent for informing the National Drug Treatment Monitoring System
Bio
Substitution therapy
Psycho
Drugs and alcohol service (DALS)
Motivational interviewing
Social
Key worker appointment
Harm reduction
Health education
Narcotics anonymous or self-management and recovery training (SMART)
DVLA notification
Sleep hygiene
Diet
What does harm reduction and health education for opioid abuse involve
Advise on needle exchanges for IVDUs
Vaccination and testing for blood-borne pathogens (hep A/B, tetanus)
Safety net on signs and symptoms of overdose and ensure family/friends are also aware
Overdose prevention training
Take home naloxone
Contraception and advice on safe sex
Dental services
Describe substitution therapy
- Maintenance - stabilise lifestyle and reduce harm, get use to the dose of OST
- Detoxification - drive abstinence
Maintenance:
1st line: methadone (liquid) or buprenorphine (sublingual) patient preference
- If still using heroin → low-dose methadone
- If wanting to stop heroin completely → high-dose methadone OR buprenorphine
Detoxification – must be committed to stopping (committed, fully aware, stable environment):
1st line: methadone (liquid) or buprenorphine (sublingual)
+ Take-home naloxone, training on when/how to use it
+ Naltrexone (opiate antagonist) may be given after detoxification to prevent relapse as it blocks the euphoric effects of opiates
2nd line: lofexidine (alpha-2 agonist) – indications: rapid detox, mild dependence, preference
What should you warn the patient before detoxification therapy
- Must be on a stable OST maintenance before you start detoxification
- May require admission - requires a controlled environment for 3-6 months
- Lasts 12w as an outpatient (can be inpatient if deemed appropriate) or 28 days as an inpatient
- Inform them they will lose tolerance so if they start again, they should take a lot less
What is the management for opioid withdrawal
- A-E
- Clonidine or lofexidine (alpha-2 agonist)
- Lofexidine 800 micrograms daily for 7-10 days - Symptomatic:
- Diarrhoea: loperamide
- Nausea and vomiting: metoclopramide or prochlorperazine
- Stomach cramps: mebeverine
- General aches and pains: paracetamol, ibuprofen, NSAIDs
- Agitation/anxiety/sleeplessness: diazepam - Monitor clinical opiate withdrawal scale (COWS), temp, BP, pulse, ECG, consciousness
What are the complications of opioid use
Overdose → death, violence, accidents
Infection: S. aureus, group A strep, HIV, hep B/C, clostridium, bacilus anthrax, TB, HCV
DVT/PE
Poor nutrition and dental disease
Psychological: craving, anxiety, loss of memory or cognitive skills
What is the prognosis for opioid use disorder
Chronic relapsing-remitting disease
Relapse rates >90% in untreated people
With treatment, relapse rates are similar to those in other chronic medical illnesses e.g. diabetes, HTN, asthma
Mortality risk of people dependent on illicit heroin is 12x that of the greater population
Poorer prognosis if there is a coexisting condition e.g. mental health problems, cognitive impairment
Treatment for opioid use had the lowest rate of successful exits (26%) compared to alcohol or non-opioid
What are the forms 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
What are the two main components of cannabis
Active ingredient delta-9-tetrahydrocannabinol (THC)
Cannabidiol (CBD) from the Cannabis sativa plant
What are the symptoms of cannabis intoxication
Euphoria, relaxation to paranoia, anxiety and panic (spectrum)
Perceptual/time distortion, hunger pangs (munchies)
Nausea and vomiting (‘greening’/whitey)
Bloodshot eyes
Tachycardia
Poor coordination
Dry mouth (‘cotton mouth’)
What are the symptoms of cannabis withdrawal
No specific physiological withdrawal syndrome
Anxiety
Irritability
Restlessness
Nausea
Headaches
Poor sleep
Poor appetite
Poor concentration
What are the complications of cannabis use
Acute complications – paranoia, panic attacks, accidents associated with delayed reaction time (driving)
Risk factor for schizophrenia development
Give examples of stimulant drugs
Cocaine (Charlie, coke, snow)
Crack cocaine (rocks, base, freebase)
Amphetamine (speed)
Methamphetamine (crystal meth)
Khat (quat, chat)
Ecstasy (E, MDMA)
What are the symptoms of stimulant intoxication
Increased alertness, endurance and confidence
Euphoria
Frenzies or prolonged activities
Reduce appetite and sleep
Risky behaviour and impulsivity
Bruxism (teeth grinding)
What are the symptoms of stimulant withdrawal
Unpleasant ‘crash’ period (dysphoria [i.e. dissatisfaction with life] and lethargy) within 24h of stopping
May last for several weeks
Depression
Irritability
Lethargy
Cravings
amphetamine: hyperphagia, fatigue, hypersomnia, depression, anxiety, craving
Describe the progression of cocaine withdrawal
(1) Crash phase
a. From 3 hours
b. S/S: depression, exhaustion, agitation, irritability
(2) Withdrawal
a. S/S: cravings, irritability, anergia, poor concentration, insomnia, slowed movements
b. Lasts 1-10 weeks
What are the complications of stimulant abuse
Insomnia
Weight loss
Arrhythmias
Hypertension
Anxiety, panic, aggression, psychosis
Formication (cocaine bugs): sensation of insects crawling on/below the skin
Cocaine: damage to the nasal mucosa → necrosis and septal perforation
Methamphetamine/khat: tooth decay and loss
Ecstasy: overheating, dehydration
Give examples of hallucinogens
LSD (Lysergic acid diethylamide, acid)
Phencyclidine (PCP, angel dust)
Ketamine (Special K) – a similar structure to PCP:
Magic mushrooms (e.g. the liberty cap / psilocybin semilanceata)
What are the symptoms of hallucinogen intoxication
Visual illusions, hallucinations, depersonalisation, derealisation
Distortion of sound, time, colour and objects
Synaesthesia (experience sensation in another modality – i.e. hear a smell)
Behavioural toxicity (i.e. acting on drug-induced beliefs – e.g. being able to fly)
Ketamine and PCP also cause anaesthesia, and feelings of dreaminess, floating, and detachment from reality
Ketamine (LARGE) → nausea, ataxia, slurred speech
What are the symptoms of hallucinogen withdrawal
None - does not cause dependence or withdrawal
What are the complications of hallucinogen use
Accidents or violent
PCP: hyperthermia
Ketamine: bladder ulceration, frank haematuria
Magic mushroom: risk of eating a poisonous species
“bad trip”: hallucinogenic experiences become frightening and unpleasant
Anxiety and depression
give examples of inhalant drugs
Nitrous oxide
Nitrites (poppers, TNT, rush)
Paint
Glue
Nail varnish remover
Cigarette lighter refills
Petrol
Aerosols
What are the complications of inhalant use
Hangovers: severe headache, fatigue, depression
Ataxia
Vomiting
Dizziness
Muddled thinking
Hallucinations
Heart failure
Coma
Death from vomit aspiration
Squirting: swelling and asphyxiation
Inhalation: suffocation (blistering and redness around the mouth and nose)
Nitrous oxide: vitamin B12 deficiency, anaemia, subacute degeneration of the spinal cord
What are benzodiazepines
gamma-aminobutyric acid (GABA) receptor agonists which have hypnotic, anxiolytic, anticonvulsant, and muscle relaxant properties.
What is the difference between hypnotics and anxiolytics
Hypnotics = short term treatment of insomnia e.g. nitrazepam and flurazepam (longer-acting) and loprazolam, lormetazepam, and temazepam (short-acting).
Anxiolytics = alleviates anxiety states e.g. diazepam, alprazolam, chlordiazepoxide, and clobazam (sustained action), and lorazepam and oxazepam (shorter acting).
What are z-drugs and give examples
non-benzodiazepine hypnotics, developed with the intention of overcoming some of the adverse effects of benzodiazepines (such as next-day sedation, dependence and withdrawal), but there is no firm evidence of difference
e.g. zolpidem, zopiclone
What is GHB
gamma hydroxybutyrate
Strongly sedative anaesthetic
GBL (gamma butyrolactone) and 1,4- BD (1,4- butanediol) convert to GHB after ingestion
GHB and GBL have been used to facilitate sexual assaults (‘date rape’) → disinhibited or unconscious, often with amnesia for the assault
What are the symptoms of benzodiazepine abuse
Calm and mild euphoria
Slurred speech, ataxia, stupor
Loss of inhibitions
Sedation
What are the symptoms of benzodiazepine withdrawal
Similar to alcohol
Insomnia, Irritability, Anxiety (the biggest SE)
Tachypnoea, Tachycardia, palpitations
Ataxia
Tremor
Tinnitus
Sweating
Hyperreflexia, Seizures, Mydriasis
Delusions, Derealisation, Depersonalisation, Anterograde amnesia
Depression
What is the relapse prevention for OST
Naltrexone- opioid antagonist
Acamprosate- anti-craving drug
Monitor for 4 hours after 1st dose, monitor LFTs
May have possible withdrawal reaction
What is the management for acute opioid withdrawal
1st Line: IV Naloxone
- Given every 1-2 mins depending on response
- Titrate dose up
Supportive management
IVDU Heroin Inpatient Admission
- Contact the key worker before prescribing replacement opiates
- Opiate IV pain management does NOT increase relapse rates (but, inadequately controlled pain may)
- Check if they are complying with OST and doses
What are the symptoms of opioid overdose
Respiratory depression
Low GCS
Low BP
Miosis
Hyporeflexia
What is the management for benzodiazepine overdose
Flumazenil (benzodiazepine antagonist)
Use in small amounts and slowly
Follow up
Address underlying need for BDZ (i.e. anxiety, sleep, depression)
Address long-term complications of use (cognitive impairment, anxiety, depression, insomnia)
Check willingness to withdraw from use and whether it can be done successfully in primary care
What is the management for patients wanting to stop benzodiazepine use
Address underlying need for BDZ (i.e. anxiety, sleep, depression)
Address long-term complications of use (cognitive impairment, anxiety, depression, insomnia)
Check willingness to withdraw from use and whether it can be done successfully in primary care
Withdrawal therapy
Can take 3 months to a year or longer if needed
Psychological therapy: CBT
DVLA notification
Severe, physical symptoms e.g. palpitations, tremor, sweating → propranolol
Depression or panic disorder co-exists → antidepressants
What is the withdrawal therapy for benzodiazepine use
Supervised by the addiction service
Options:
- Slow-dose reduction (1/8th daily dose reduction every 2 weeks)
- Switch to equivalent dose of diazepam and slow dose reduction (used if on short acting BDZ, high degree of dependency and experiencing difficulty withdrawing)
If done properly, there will be few, if any, withdrawal side effects, anxiety is the most common
May take 3m to 1 year or longer
What is the management for the following overdoses: paracetamol, benzodiazepine, salicylates, opioids
Paracetamol: N-acetylcysteine
Benzo: flumezanil
Salicaylates: activated charcoal
Opioid overdose: naloxone
What is the management for opioid overdose
- A-E approach, special consideration for airway and ventilation
- IV naloxone 0.4mg
- Monitor: BP, pulse, ECG, sats, Resp rate, GCS
When can you prescribe methadone after withdrawal
Urine sample for urgent opiate + methadone screen ± pregnancy test
Contact the community pharmacy or addiction services to check the patient is on substitution therapy, their current dose, and usage
Contact key worker/psych team/pharmacy and inform you have given methadone
