Substance Abuse Flashcards
Scoring system in PCM overdose?
Kings Criteria
Determines liver failure requiring immediate liver transplant
Creatinine, INR, acidaemia, encephalopathy, high lactate/phosphate
Causes of opiate overdose?
Iatrogenic
- Medication overdosing
- Lack of opiate clearing (poor renal function)
Recreational
- Heroin, prescription opiates
Symptoms of opiate overdose/toxicity?
Toxicity = hallucinations, drowsiness
OD = reduced RR, pinpoint pupils, low GCS
Management of opiate overodse?
IV Naloxone 400mg (100mg if frail/lower level toxicity)
- Very short half life - may require infusion
- Monitor patient to ensure naloxone does not wear off and slip back into unconsciousness
- Patient may wake agitated as naloxone acts very quickly, removing the effects of opioids and resulting in quick withdrawal
- If RR <8 VENTILATE
Other things to think about in IVDUs with apparent opiate overdose?
- Groin abscess
- Psoas abscess
- Infective endocarditis
- Bacteraemia
- Blood-borne virus
- Malingering
Recommended alcohol consumption for males and females?
14 units a week
What constitutes 1, 2 and 3 units?
Pint of beer = 2/3
175ml wine = 2
250 ml wine = 3
25 ml spirit = 1
CAGE questionnaire?
C – Have you thought about cutting down?
A – Do you ever become annoyed if someone asks you to cut down?
G – Have you ever felt guilty about your drinking?
E – Ever had an eye opener?
2 or more = indicative.
Features of alcohol dependence?
- Compulsion to drink
- Increased tolerance to alcohol
- Stereotyped pattern of drinking/Less variability
- Repeated withdrawal symptoms
- Relief drinking to avoid withdrawal symptoms
- Primacy of drinking over other activities
- Reinstatement after abstinence
Obsessesion, Expansion, Constriction, Afflication, Alleviation, Prioritisation, Continuation
Bloods in alcohol dependence?
- Gamma-glutamyl-transferase (GGT) – raised in 80% - BINGES
- Alkaline phosphatase (ALP) – 60% - raised in CHRONIC ABUSE
- ↑Mean corpuscular volume (MCV) – 50% (highest specificity for alcohol misuse) – Macrocytic anaemia (parietal cell destruction)
- INR
- Chronic = inducer - reduced INR
- Acute = inhibitor = increased INR
Management of alcohol dependence?
Early
- Advice and support, appraisal of current medical, psychological and social problems.
Post-Dependence - Detoxification
- Reducing course of benzodiazepine in lieu of alcohol, supplemented by thiamine
Abstention
- Naltrexone (opiate antagonist)
- Acamprosate (anti-craving - enhances GABA)
- Disulfiram (deterrent - aldehyde dehydrogenase inhibitor
- Psychological Therapies
- Support groups, psychotherapy, CBT, social skills training
Aspects of alcohol hx?
- Drinking pattern
- CAGE
- Features of dependence
- Mental problems - RISK
- Physical symptoms
- Forensic/social hx
Features of alcohol intoxiciation?
Ataxiate, dysarthria, nystagmus and drowsiness
Dizziness, loss of inhibition, N+V, elation, depression
Investigations and management in alcohol intoxication?
Investigations
- Bloods = U+E, BM, LFTs
- Toxicology screen - if patient not able to give full hx
- CT scan if possibility of head injusry
- ABG if patient in coma
Management
- Maintain clear airway and prevent aspiration
- Measure BM and give glucose if hypo
Features of delirium tremens?
Delirious Disorder
- Clouding of consciousness
- Disorientation (time and place)
- Impairment of recent memory
- Fear, agitation and restlessness
- Vivid hallucinations and delusions
- Insomnia
- Autonomic disturbances
- Coarse tremor
- N+V, dehydration, electrolyte disturnaces
- Seizures
Features of Wernicke-Korsakov syndrome?
Classical triad = confusion, ataxia and ocular palsy
- Acute onset
- Impaired consciousness and confusion
- Episodic memory impairment
- Ataxia
- Nystagmus, abducens and conjugate gaze palsies, pupillary abnormalities
- Peripheral neuropathy
Results from vitamin B1 deficiency
What happens in Korsakov’s syndrome?
- Irreversible syndrome of prominent impairment of recent memory.
- Confabulation (falsification of memory in clear consciousness) is marked feature
- Immediate recall, perception and other cognitive functions usually intact.
Stages of addiction and recovery?
Management of acute alcohol withdrawal?
Alleviating Withdrawal
- Reducing dose of chlordiazepoxide (benzo - PO) – over days (dose depending on CIWA-Ar score)
- If cannot tolerate oral - 10mg slow IV diazepam or 500 micrograms/kg rectal diazepam solution
- Correct electrolyte abnormalities – IV phosphates if low
Prevention of *Wernicke’s*
- Thiamine 25mg/24h PO and vitamin B
- High-risk = IV Pabrinex 2 pairs/8h IV for 5 days – a high-potency combination of B and C vitamins – may sometimes cause anaphylaxis).
- Prophylactic/Treatment dose
Management of alcohol cessation?
Want To Stop
- Refer to AA, involve family and friends
Detoxification in Community
- Reducing regimen of chlorodiazopoxide with thiamine replacement (200mg OD for 7 days)
Unwilling to Change
- Provide info, reassess and re-inform subsequently, support family
Things to screen for in smoking cessation?
Cancer
Cardiovascular
Chronic lung disease
Pregnancy Risk
Others
- Diabetes, osteoporosis, thrombosis, dyspepsia, gastric ulcer
- Passive smoking - increased risk in kids, cot death etc.
Management of smoking cessation?
Support Servies
- Group education, conselling and support +/- individual support.
Smoking Cessation Aids
-
NRT (gum, patch) – continue for 3 months, tail off dose over 2 weeks.
- Contraindicated immediately post MI, stroke or TIA or in patients with arrhythmia
-
Bupropion – tablets 2x quit rate.
- Contraindications: increased risk of seizures, eating disorder, bipolar disorder
-
Varenicline (Champix). Lower dose in renal impairment.
- Contraindications: psychiatric illness
Heroin?
- Effect
- Drowsiness, sense of warmth and well being
- Harm
- Physical dependence and tolerance, overdose, HIV or HEP infection
Cocaine?
- Effect
- Sense of wellbeing, alertness, confidence
- Harm
- Dependence, restlessness, paranoia, damage to nasal septum
Amphetamine?
- Effect
- Wakefulness, energy and confidence
- Harm
- Insomnia, mood swings, irritability, panic. Comedown severe
Ectsasy?
- Effect
- Alert and energetic, heightened senses and feeling of well being
- Harm
- Nausea and panic, overheating and dehydration (can be fatal), liver and kidney problems, risk of mental illness and depression
Cannabis?
- Effect
- Relaxed, talkative state, heightened senses
- Harm
- Impaired coordination and increased injury, poor concentration, anxiety and depression, increased risk of resp. disease including lung cancer
Management of recreational drug abuse?
Investigations
- Urine toxicology to confirm drug misuse
- FBC, UEs, LFTs, hep B, C and HIV serology (with counselling)
General focus on…
- Education inc. safe injecting/sex advice, specific risk of drugs
- Medical care: treat/advice re. complications of drugs use/blood borne viruses
- Hep B immunisation
- Treatment of dependence: refer to specialist team, give support, review regularly, set achievable goals.
Desired effects and harmful effects of solvent abuse?
Desired
- Like being drunk
- Thick headed, dizziness, possible hallucinations
- Slurred speech, dizziness and impaired judgement, reduced RR and HR
Harmful
- Fatal arrhythmias can cause instant death
- Suffocation inhaling from plastic bag
- Nausea, blackouts, increased risk of accidents
- May develop tolerance
Management of solvent abuse?
Warn of risks. Encourage abstinence.
- Psychologically rather than physically addictive
- May have mild withdrawal symptoms such as tremors, dizziness, nausea, anxiety or depression.
Presentation of beta blocker overodse?
- Usually bradycardia
- Sotalol = ventricular tachyarrhythmias including torsades de pointes
- Propanonlol = coma and convulsions
Management of beta blocker overdose?
Maintain clear air way and ventilate
- IV Atropine sulfate
- Or Glucagon 5-10mg IM if this fails
Presentation of digoxin toxicity?
- GI: Nausea, vomiting, anorexia, diarrhoea
- Visual: Blurred vision, yellow/green discolouration, haloes
- CVS: Palpitations, syncope, dyspnoea
- CNS: Confusion, dizziness, delirium, fatigue
Investigations in Digoxin toxicity?
ECG =” reverse tick”
- Down-sloping ST depression with a characteristic “Salvador Dali sagging” appearance
- Flattened, inverted, or biphasic T waves.
- Shortened QT interval.
