Substance abuse (F1) Flashcards
1.*
Quantify alcohol misuse
- Define unit
- Calculation for standard drink
- Safe drinking limit
Volume of alcohol to unit
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Neuropsychiatric complications of alcohol abuse
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Cardiovascular, GI and Hematological complications of alcohol abuse
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Endocrine, MSS, Reproductive complications of alcohol abuse
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Metabolic, fetal and psychosocial complications of alcohol abuse
Alcohol abuse
Criteria
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Define use disorder, dependence, acute intoxication #
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Define withdrawal, tolerance, dangerous drinking #
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ICD 10
Criteria of harmful use #
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ICD - 10
Dependence syndrome criteria #
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DSM-5
Alcohol use disorder criteria #
Craving
Desire to stop/ unsuccessful efforts
Larger amount or longer time
Time to obtain, use or recover
Despite interpersonal and social problem
Despite knowledge of physical and psychological problem
Despite use in situations that are physically harzardous
Failure to fulfil major role obligations
Reduce important social, occupation, recreational activities
Tolerance
Withdrawal
Alcohol abuse
Pathophysiology
Etiologies of alcohol abuse
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Alcohol abuse
Approach to effect of abuse, drinking history
CAGE
- Cut-down, annoyed by others, guilt, eye-opener
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Alcohol abuse
Ix
Outline AUDIT questions for alcohol dependence
Alcohol abuse
Questions to assess pattern of use
Alcohol abuse
Questions to assess dependence
Alcohol abuse
Questions to assess impact and complications
Alcohol abuse
Questions to assess quitting, attitude
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Approach to management of alcohol misuse
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Alcohol abuse
Drug options for maintaining abstinence
Disulfiram – Aldehyde dehydrogenase for unpleasant reaction
Naltrexone – opioid antagonist
Acamprosate – Increase GABA effect, Lower Glutamate effect
Topiramate = Increase GABA effect at AMPA receptors
Antidepressant
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Alcohol abuse
Psychosocial treatment options
Acute intoxication
S/S at different alcohol level
Define alcohol blackouts and alcoholic hypoglycemia
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Acute alcohol intoxication
Management
IV fluid +/- Glucose
Thiamine
BZD
Antipsychotic if needed
Alcohol withdrawal syndrome
Clinical presentation
Alcohol withdrawal syndrome
Ix
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Alcohol withdrawal syndrome
DSM-5 criteria
ATIN-PHAS
Autonomic
Tremor
Insomnia
N/V
Psychomotor agitation
Hallucination
Anxiety
Seizure
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Alcohol withdrawal syndrome
Management
Alcohol withdrawal
- Inpatient detox
- NPO, fluid, electrolyte
- Thamine + glucose, Multivitamin + folate
- BDZ (diazepam) for agitation
- Barbiturates or propofol for refractory Delirium Tremens
- Status epilepticus
Alcohol withdrawal syndrome
Prophylaxis
Indication
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Alcohol related amnesic syndromes
Definition
Causes
D/dx
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Alcohol related amnesic syndromes
Clinical presentation
Korsakoff syndrome
- Confabulation (imaginative thinking as reality)
- No insight
- Other cognitive function normal
- Apathy/ inertia
- Diencephalic lesion
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Thiamine deficiency in alcoholism
Cause
Consequence
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Wernicke’s encephalopathy
S/S
Dx
Mx
S/S:
Encephalopathy
Oculomotor dysfunction
Truncal ataxia
Test: Caine criteria, Red cell transketolase, Blood Thiamine level, CT for diencephalon abnormalities
Mx: Thiamine (Oral or IV)
Alcohol related dementia
Pathophysiology
S/S
Dx
Neurological findings/ features
Alcoholic cerebellar degeneration
Pathogenesis
S/S
Dx
Mx
Marchiafava-BIgnami disease
Pathology
S/S
Neuroimaging feature
Vitamin B deficiency in alcoholism
Physiology
S/S
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Long-term psychiatric sequalae of alcoholism
Mood: Depression, Anxiety, Bipolar I
Antisocial personality disorder
Schizophrenia
Drug abuse
Alcohol related sleep disorders
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Alcohol related psychotic disorders
Types
S/S
Management
Othello syndrome (jealousy) > Antipsychotics
Alcoholic hallucinosis > Antipsychotics and abstinence
Schizophrenia > Abstinence
Effect of alcohol on suicide
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Substance dependence
Define: Misuse, Craving, dependence, addiction
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Substance dependence
ICD-10 criteria
CANT Control Withdrawal
at least 3/6
Outline stages of substance abuse
First biological stage of addiction
Second stage of addiction and neurbiological effects
Third stage of addiction and neurobiological effects
Etiologies of substance abuse
Common drugs of abuse
Stimulants – Meth, Cocaine, MDMA
Hallucinogens – LSD, PCP, Ketamine
Depressants – Opiates, Barbituates, Sedatives, Cannabis
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CNS stimulants
Examples
Effects
Withdrawal effects
Effect – Sympathetic overdrive + Positive psychotic symptoms (hallucinations, paranoid ideas) + Positive mood symptoms (Disinhibition, high activity, aggression)
Withdrawal is opposite – depression, anxiety, lethargy, sleep
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Hallucinogens
Examples
Pharmacology
Effects
Hallucinogens
Effect: Weaker sympathetic effect + Strong disturbance of senses (paranoid ideas, senses distortion) + Variable mood
Withdrawal: no dependence, no withdrawal symptoms
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Depressants
Examples
Pharmacology
Effects
Depressants
Effect: Parasympathetic overdrive, negative mood changes (relaxation, anxiolytic, drowsy)
Withdrawal: Sympathetic rebound
Route of administration and effect on addiction
Injection fastest = more addicting
Oral longest
Assessment of substance abuse
Clinical presentation of SA
Injection marks
Behavior/ miss olbigations
Medical complications
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Substance abuse
History taking questions
Use: start, type, amount, pattern, dependence
Effect and problem list: Medical, Psychiatric, Social
Person: Coping, support, personality, reason for drug abuse (pleasure, medication, pleasure)
Lab test
Management of drug abuse
Aim
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Substance abuse
Management options
Bio – Medical complications, Detox/ withdrawal, Maintenance
Psycho – MI, CBT, Psychoeducation, Psychiatric diseases mx
Social – Rehab programs, harm reduction programs
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Opioids
Examples
Pharmacology
Medical use
RoA
Agonist at opioid receptors
Inhibit GABA»_space; Increase DA activity at VTA
Withdrawal = Sympathetic overdrive
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Ketamine
Clinical S/S
Withdrawal S/S
Dependence rate
Complications
Tx
Ketamine = Hallucinogen
Effect: Mood depressing and parasympathetic
Withdrawal: Sympathetic overdrive, Positive mood (anxious, craving, restless)
Fast Tolerance, Fast OD
Tx
ABC
Naloxone until RR>12
Chronic:
Non-opioid: Anti-emetics, NSAIDs, a2 agonist
Opioid: Methadone + tapering, Buphrenorphine
Naltrexone
Ketamine
Treatment
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BDZ
Examples
Pharmacology
Medical use
S/S
Tx
Benzo = depressant
Use = CNS depressant, anxiolytic/ hypnotics
Withdraw = Sympathetic overdrive, psychosis, seizure
Withdrawal is life threatening
Tx:
Urgent
ABC
IV Flumazenil
Chronic
Long acting BDZ (Diazepam) + Slow tapering over 8 weeks
BDZ
Clinical presentation
Dependence
BDZ abuse
Treatment
Cannabis
Examples
Pharmacology
Medical use
Misuse
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Cannabis
Clinical presentation
Dependence
Treatment
Cannabis = Depressant. CBD, THC most important
Use: Physiological sympathetic drive + Psychological CNS depressant
Chronic use: High risk of schizophrenia, low risk dependence
Withdraw: Mild irritable, insomnia, anorexia
Treatment: BDZ sedation, Psychotherapy (MI, CBT)
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LSD
Examples
Pharmacology
Misuse
Clinical presentation
Dependence
Treatment
LSD = Hallucinogen
Use: Mild sympathetic + Strong sensory distortion + Variable mood changes
Withdrawal: Minimal
Treatment: No antidote. BZD, IV Haldol
PCP
Examples
Pharmacology
Medical use
Clinical presentation
Dependence
Treatment
Meth
Examples
Pharmacology
Medical use
Misuse
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Meth
Clinical presentation
Dependence
Treatment
Meth = Stimulant
Use: Sympathetic overdrive
Withdrawal: Parasympathetic crash
Treatment:
Urgent: ABC, IV BDZ for agitation/ hyperthermia, Antipsychotics
Chronic: CBT/MI mainly, BDZ for acute withdrawal +/- Mirtazapine/ Bupropion
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Cocaine
Pharmacology
Use
Clinical presentation
Cocaine = Stimulant
Use: Sympathetic overdrive + Positive psychological symptoms
Withdrawal: CNS depression (fatigue, sleep, anhedonia, depression), no physiological symptoms
Tx:
Urgent: ABC, BDZ +/- Phentolamine
Chronic: CBT, Dopamine agonist, Disulfiram
Cocaine
Dependence
Treatment
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MDMA
Pharmacology
Use
Presentation
Dependence
Treatment
MDMA = Stimulant
Use: Sympathetic overdrive + Serotonin syndrome + Positive psychological symptoms
Withdrawl: CNS depression crash, no physical symptoms
Tx:
Urgent: ABC, BDZ, Cyproheptadine (Serotonin syndrome)
Chronic: CBT/ MI, Harm reduction
