Substance Abuse Flashcards
- What questionnaires could be used to screen for alcohol dependence
- AUDIT
- CAGE
What do the AUDIT scores indicate ?
- 0 to 7 indicates low risk
- 8 to 15 indicates increasing risk
- 16 to 19 indicates higher risk
- 20 or more indicates possible dependence
What questions are part of the CAGE questionnaire ?
- Do you feel like you need to cut down on your drinking ?
- Have you ever been angered at someone commenting on your drinking ?
- Have you ever felt guilty about your drinking ?
- Have you ever needed a drink in the morning to get yourself going ?
A CAGE score of how many indicates further assessment ?
- 2
How can the physiological levels of alcohol use be investigated ?
- Breath test – mg of alcohol per 100 ml of blood
- Blood Test
- Elevated MCV – raised
- Gamma Glutamyl Transferase (GGT) – raised
- Carbohydrate transferrin – raised
- Describe substance Tolerance
- A reduced reaction to a drug following its repeated use. Increasing the dosage may re-amplify the drugs effects however this may accelerate tolerance further reducing the drugs effects e.g. a pt who has to drink larger amounts of alcohol to obtain a similar effect
Describe Withdrawal
- Physical and emotions problems that are experienced if you are dependent on a substance and then suddenly stop or drastically reduce your intake of a substance
Signs of dependence
- Withdrawals
- Cravings
- Drinking despite negative consequences (on mental/physical health, work/social life)
- Tolerance
- Primacy – putting drinking before other activities
- Rapid re-instatement – people who have stopped drinking, once they start again, rapidly get up to a level they were previously drinking
- Narrowing of repertoire
- As people become more dependent on alcohol the range of beverages they drink decline and they may only drink 1-2 types of drink (usually the cheapest)
- Drinking habits also alter – now start to drink by themselves at home and at the pub
Reasons for people to continue to drink
- Negative reinforcement – drink to avoid reinforcement symptoms
- Positive reinforcement – drink to feel euphoric
- Both combined leads to alcohol addiction
Long term effects of alcohol on the heart
- Dilated cardiomyopathy
- Arrhythmias
- Stroke
Long term effects of alcohol on the liver
- Steatosis
- Steatohepatitis
- Fibrosis
- Cirrhosis
Cancers that are linked to alcohol use
- Mouth
- Esophagus
- Liver
- Breast
Conditions linked to vitamin deficiencies resulting from long term alcohol use
- Thiamine – Wernicke’s encephalopathy and Korsakoff syndrome
What is the basic mechanism of action for ethanol on the nervous system and why is this important for withdrawal treatment ?
- Ethanol = CNS depressant which enhances the effect of inhibitory neurotransmitter GABA which inhibits NMDA-type glutamate receptors
- Same MOA as benzodiazepines there use chlordiazepoxide to treat withdrawal
When does onset of symptoms of alcohol withdrawal occur ?
- 6-12 hours
When is the patient most likely to suffer a seizure during withdrawal ?
- 36 hours
When is the most likely onset of delirium tremens ?
- 48-72 hours
Management of a patient in alcohol withdrawal ?
- Admit to hospital
- Chlordiazepoxide
- Thiamine (Vit B1) or Pabrinex (Vit B and C) – must be given before fluids to prevent Wernicke’s
- IV fluids
Psychological treatments available to patients with substance addictions
- CBT
- Motivational interviewing
- Support groups e.g. alcoholics anonymous
Medications to help maintain abstinence
- Disulfiram – induces hangover symptoms even after minor amounts of alcohol
- Naltrexone – blocks euphoric effects of alcohol
- Acamprosate – reduces cravings
How does Disulfiram help maintain abstinence
- Indices hangover symptoms even after minor amounts of alcohol
- I.e. makes alcohol unpleasant to drink
How does Naltrexone help maintain abstinence
- Blocks euphoric effect of alcohol
How does Acamprosate help maintain abstinence
- Reduces cravings
What is the basic physiology of Wernicke’s and Korsakoff
- Thymine deficiency as a result of neglecting to eat or not absorbing thymine efficiently
- Petechial hemorrhages occur in a variety of structures in the brain, including mamillary bodies and ventricle walls
Pneumonic for Wernicke’s and Korsakoff
- COAT RACK
- Confusion
- Ophthalmoplegia
- Ataxia
- Thiamine deficiency
- Retrograde amnesia
- Anterograde amnesia
- Confabulation
- Korsakoff Syndrome
Features of opioid misuse
- Rhinorrhoea
- Needle track marks
- Pinpoint pupils
- Drowsiness
- Watering eyes
- Yawning
Complications of opioid misuse
- Viral infection secondary to sharing needles: HIV, hepatitis B & C
- Bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
- Venous thromboembolism
- Overdose may lead to respiratory depression and death
- Psychological problems: craving
- Social problems: crime, prostitution, homelessness
Additional presenting features of Wernicke’s encephalopathy
- Clouding of consciousness
- Disorientation
- Amnesia for recent events
- Marked psychomotor agitation
- Visual, auditory and tactile hallucinations - Classically Lilliputian hallucinations (tiny people/ animals seen at night)
- Marked fluctuations in severity hour by hour (usually worse at night)
- Severe cases – heavy sweating, fear, paranoid delusions, agitation, suggestibility, raised temp, sudden CV collapse
Harm reduction approach to opioids
- Needle exchange
- Offering testing for HIV, hepatitis B & C
Opioid OD treatment ?
- Naloxone
Opioid detox/maintenance therapy
- Methadone
- Buprenorphine
Treatment for benzodiazepine OD
- Flumazenil
Most common cause of death in MDMA and cocaine OD ?
- Hyperthermia
Triad of serotonin syndrome ?
- Autonomic hyperactivity – Agitation, tremor, sweating, HTN
- Altered mental state – Confusion, drowsiness, coma
- Neuromuscular excitation – Rigidity, hyperreflexia, myoclonus
Management for serotonin syndrome ?
- Supportive including IV fluids
- Benzodiazepines
- More severe cases are managed using serotonin - antagonists such as cyproheptadine and chlorpromazine
Give the recommended alcohol drinking limits (in units) per week for men and women
- 14 units
What is narrowing of repertoire ?
- A sign of dependence when a pt will only consume one or two types of alcoholic beverages
- Often the strongest
Describe tolerance ?
When more of a substance needs to be taken to induce the same effect
State 3 blood tests to screen for alcohol dependence and state how each is affected
- GGT (raised)
- RBC mean corpuscular volume (raised)
- Carbohydrate deficient transferrin
The patient presents with agitation, tremors and dilated pupils. He is also observed to be responding to visual hallucinations which consist of “little spiders”. What is the diagnosis ?
- Delirium tremens
A pt presents ataxia, ophthalmoplegia and nystagmus. What syndrome is he presenting with?
- Wernicke’s encephalopathy
What would you use to prevent Wernicke’s developing into Korsakoff’s ?
- Thiamine
- Pabrinex
