substance abuse tutorial

Question 1

How do you calculate units of alcohol?

Answer 1

%strength x ml / 1000

Question 2

What are the terms used for alcohol addiction & opioid addiction?

Answer 2

Opioid use disorder, alcohol use disorder (continuum of mild, moderate, severe)

Question 3

What are criteria of dependence syndrome?

Answer 3

3 or more in past year:

1. strong desire/sense of compulsion to take it.
2. difficulties controlling substance taking (onset, termination, level)
3. physical withdrawal state when substance stopped or reduced
4. tolerance (need to take more for same effect)
5. progressive neglect of other pleasures or interests because of substance use, increased time to take or recover from substance
6. persisting with use despite evidence of harmful consequences

Question 4

What are criteria for harmful use?

Answer 4

Pattern of use that damages health. Damage may be physical or mental (must have this criterion). Adverse social consequences.

• Harmful use includes bingeing, does not include hangover alone.
• Does not fulfil other diagnosis within substance use (eg. Dependence)

Question 5

Can a patient have both harmful use & dependence?

Answer 5

no

Question 6

What scale is used for opiate withdrawal?

Answer 6

COWS scale

Question 7

What are symptoms of opiate withdrawal?

Answer 7

Tachycardia, sweating, restlessness, dilated pupils, bone aches, runny nose, GI upset, tremor, yawning, anxiety/irritability, gooseflesh skin (keratosis pilaris)

Question 8

When do you prescribe substitute for opioid use? What substitute?

Answer 8

Only prescribe methodone when they are in withdrawal. If already on opioid can make them stop breathing.

Question 9

How should a standard history & MSE be adjusted for substance use?

Answer 9

C & HPC, past psychiatric history, past medical history, meds & allergies, family history, personal history, premorbid personality, risk assessment. 2. appearance & behaviour, speech, mood, thought (content), perceptions, cognition, insight

Question 10

What should be included in substance misuse history?

Answer 10

Assess following for each substance: length of use & when last used, current amount & how long at this level, total length of use, max use & periods of abstinence, mode/method of use, evidence of withdrawals & severity, previous treatments, previous substance overdoses (accidental vs deliberate), assess triggers to use, assess motivation to change/have treatment

Question 11

What should be included in family history ?

Answer 11

Mental illnesses & addiction disorders

Question 12

What should be included in past psychiatric history?

Answer 12

-History of trauma (traumatic life experiences esp in childhood), including neglect & abuse. Ask about family history or substance misuse/violence. Screen for developmental disorders eg. ADHD & ascertain general developmental & educational history. Assess common comorbid conditions: depression, anxiety, suicididality, personality disorder, PTSD, bipolar disorder

Question 13

What should be included in social/personal history?

Answer 13

Relationships (+ violence), safeguarding concerns, accommodation problems, money & debt, employment/benefits, forensic history.

Question 14

What is drug induced psychosis?

Answer 14

-Cluster of psychotic pnenomena that can happen during or after substance use (especially stimulants) & includes:
vivid hallucinations (often auditory), paranoid delusions (can be severe), usually resolves within 1-6 months.
-Care to not diagnose them with something more serious like schizophrenia.

Question 15

What are the major causes of mortality & morbidity associated with substance misuse?

Answer 15

Trauma, road traffic accidents, homicide, suicide, overdose (deliberate or accidental), cirrhosis (alc), endocarditis, abscesses, BBV (hepatitis B/C & HIV)–> IV

Question 16

What are specific assessments specific to alcohol use?

Answer 16

• History of alcohol related seizures, delirium tremens, alcohol psychosis, haematemesis, malaena.
• Examination–> jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT.
• Investigations –> fibro scan/US, bloods (LFT, GGT, lipids, U&E, amylase), breathalyse, urine drug screen

Question 17

What specific assessments should be done for opioid use (examination/investigations)?

Answer 17

• Examination –> collapsed veins/track marks, endocarditis, skin abscesses, hepatitis/HIV, pneumonia.
• Investigations –> bloods (LFT, U&E, GGT, glucose), breathalyser, urine drug screen, sexual health screening/BBV

Question 18

What is epidemiology of alcohol use in UK?

Answer 18

30% of population drinks above safe limits, 1/4 of men have drinking problem at some point, 15-24 yrs olds have heaviest use, unemployed > employed. Divorced/separated > single > married.

Question 19

What screening tool is used for alcohol assesment?

Answer 19

CAGE screening. 1. have you felt need to cut down on drinking? Have people annoyed you by critisising your drinking? Have you ever felt guilty about drinking? Have you ever felt you needed a drink first thing in morning (eye-opener)

Question 20

What are aspects of alcohol withdrawal?

Answer 20

Worsening pattern of symptoms, onset usually from 6h, hallucinations can occur at any time, delirium tremens is late sign (medical emergency).
-Minor withdrawal symptoms –> alcoholic hallucinosis –> withdrawal seizures –> delirium tremens

Question 21

What are some features of delirium tremens?

Answer 21

Auditory/visual hallucinations, confusion/disorientation, hypertension, agitation, tachycardia, fever, severe tremor in hands & body

Question 22

What are the effects of opioids?

Answer 22

1. relieve pain - analgesic effect
2. create sense of euphoria.

Endogenous endorphins also regulate pain & mood vs exogenous drugs.
Opioid receptors mu, delta, kappa effected by opioid agonists (heroin, methadone, fenatnyl, codeine), partial agonists (buprenorphine), antagonists (naltrexone)

Question 23

What are features of opiate overdose? What do you do?

Answer 23

• Not moving/cant be woken, slow/no breathing, choking/gurgling sounds, tiny pupils, clammy/cold skin, blue lips/nails.
• Inject naloxone (opioid antagonist) into upper arm/thigh or nasal spray. If no response after 3 minutes, repeat. Provide airway support + recovery position

Question 24

What drug is used for alcohol abstinence?

Answer 24

acamprosate

Question 25

What drug is used for alcohol withdrawal?

Answer 25

benzos

Question 26

What drugs are used for opioid abstinence?

Answer 26

Methadone, buprenorphine

Question 27

What happens during opioid detox?

Answer 27

Maintenance treatment for at least 12 months to sustain changes in lifestyle before dose reduction over several months

Question 28

What are G drugs/ what do they do?

Answer 28

GHB (gamma hydroxybutryate) & GBI (gamma butyrolactone).

• Quick effects, get high with small doses & sedation with dose a little higher.
• Euphoric, loss of inhibitions, confidence, higher sex drive.
• Easy to overdose, highly addictive, mixing with alcohol can lead to death.