Substance/Alcohol Misuse Flashcards
What is the underlying pathophysiology behind addiction and substance misuse?
Most dependencies feature excess activity of the mesolimbic system, a dopaminergic reward pathway running from the ventral tegmental area (VTA) in the midbrain to the nucleus accumbens (NA) in the striatum.
This makes substances extremely rewarding, leading to craving and compulsive use.
How is dependency defined?
Dependency
≥3 out of 6 of WANTIN:
Physical Withdrawal symptoms.
Persisting despite Adverse effects.
Neglect of other things.
Tolerance: need more to get the same effect.
Intense desire (craving).
No control over use in terms of starting, stopping, or amount.
How are the terms harmful use and acute intoxication defined?
Harmful use
Physical or mental health damage resulting from substance use.
Acute intoxication
Acutely altered consciousness, behaviour, perception, affect, and/or cognition, due to substance use.
Which signs suggest injected drug use?
Injection drug use:
Track marks: injection scars along the route of a vein.
Vascular: thrombophlebitis, VTE.
Infection: abscesses, endocarditis, hepatitis, HIV.
Which signs suggest opioid withdrawal?
↑RR, sweating.
Face: rhinorrhea, lacrimation, yawning, mydriasis.
Abdo pain.
Later: ↑HR, tremor, fever, diarrhoea and vomiting.
Which signs suggest cannabis use?
Paranoid ideation.
Cannabinoid hyperemesis syndrome, in which vomiting is relieved by taking a hot shower.
Which signs suggest cocaine use?
Paranoid psychosis.
Formication: sensation of insects crawling on skin.
Nasal discharge.
Which features might suggest amphetamine or hallucinagen use?
Amphetamines: florid psychosis.
Hallucinogens: flashbacks.
Which investigations should be done in suspected drug use?
Urine drug testing:
Indications: initial assessment for detox, including for substances besides the one being treated. Also for monitoring use during contingency management.
Bedside testing is usually sufficient, but laboratory analysis should be used at first assessment or when bedside tests are inconsistent with the clinical impression.
Consider testing for blood-borne viruses in injection drug users.
How is opioid dependency managed?
Overview
General principles:
First step is to establish goals: withdrawal and abstinence, replacement and maintenance, or harm reduction. This can be part of a therapeutic approach – motivational interviewing – which is a non-confrontational way of guiding a user towards positive change.
Involve family in so far as the patient is happy for this to be done.
Inpatient or residential treatment can be offered to those with significant physical, psychiatric, or social problems (e.g. homelessness). Range of treatments is the same, however.
A biopsychosocial approach should be used regardless of the goal.
If withdrawal is the goal:
Opioid detoxification is a planned process designed to minimize withdrawal symptoms. It should combine drug and psychosocial interventions.
Typically takes 4 weeks as an inpatient or 12 weeks as an outpatient. It should not be initiated when an acute medical problem needs treatment, and it should only be done cautiously in pregnant women.
Consider other dependencies when initiating detox e.g. alcohol, benzodiazepines. Withdrawal can be done concurrently or sequentially.
Biological
Opioid replacement:
Methadone or buprenorphine can be used for maintenance, or to help minimize withdrawal symptoms during opioid detoxification.
Lofexidine – an α2 adrenergic agonist – is a 2nd line choice for detoxification.
If there are concerns about diversion, supervised consumption may be necessary. Similarly, buprenorphine can be given as Suboxone, which contains naloxone and thus removes enjoyment from injection use.
Opioid receptor blockers:
Naltrexone is used after detoxification for at least 6 months to help prevent relapse. Combining with psychological interventions improves adherence.
Naloxone is used in overdose.
Psychological
Brief interventions and self-help:
Opportunistically use any contact with services – drug misuse or otherwise – as a chance for basic interventions. Use motivational interviewing to encourage change, and provide advice on harm-reduction e.g. safe injection behaviour.
Narcotics Anonymous is a self-help group using 12-step. Facilitate attendance if required e.g. have them accompanied to their first session.
Formal interventions:
Contingency management: aims to encourage change by rewarding positive behaviour – e.g. a clean drug test – as opposed to punishing negative behaviour. Incentives should be agreed with the patient and can include vouchers, modest financial rewards, or certain ‘privileges’ (e.g. take-home methadone). For detoxification, should be used during and for 6 months afterwards.
Behavioural couples therapy: 12 weekly sessions for those with a partner who doesn’t misuse drugs.
CBT should only be used for co-morbid depression, not for drug misuse itself.
Social
They will need to inform the DVLA if they are drivers.
Support with any difficulties regarding income, work, or housing.
Assess needs and provide support for family. Offer guided self-help and information on support groups.
How can smoking cessation be managed?
Smoking cessation
Treatment can be in primary care or from specialist smoking cessation services.
Psychological interventions
Brief interventions: use any contact with services to advise smoking cessation. Provide self-help material if interested.
Individual behavioural counselling or group behavioural therapy, which include psychoeducation and elements of CBT. Provide at least 4 weekly sessions after quitting. Combine with pharmacotherapy.
Pharmacotherapy
Treatment approach:
Treatment should be started before cessation, to reduce withdrawal symptoms.
Avoid combining different drugs, but people with severe dependency can be offered multiple NRT types.
Nicotine replacement therapy (NRT):
Patches, nasal spray, gum, or lozenges.
Generally safe in all those ≥12 years old.
Carries risks in pregnant women, but is preferable to smoking, so can be offered if willpower alone is ineffective.
Avoid in cardiac disease.
Alternative 1st line treatments to NRT:
Bupropion, a dopamine and noradrenaline reuptake inhibitor. Contraindicated in epilepsy.
Varenicline, a nicotine receptor partial agonist. Can cause suicidal thoughts, so caution in those with history of depression or self-harm
Neither should be used in breastfeeding or pregnancy, or in people under 18.
How are hazardous drinking and harmful drinking defined?
Hazardous drinking: consumption that increases the risk of harm. The stage before harmful drinking.
Harmful drinking: drinking that adversely affects physical or mental health.
What is the lifetime risk of alcohol abuse and how does it present?
5-10% lifetime risk.
Commoner in men.
Presentation
Liver:
Begins with fatty liver disease and can progress to cirrhosis and liver failure.
However, many of those who misuse alcohol do not have detectable liver disease, and its absence is not a sign that everything’s OK.
GI:
Diarrhoea and vomiting. PUD Varices, presenting with haematemesis and/or melena. Oesophageal erosions. Pancreatitis GI cancer. Neurological:
Memory and cognitive impairments. Peripheral neuropathy. Seizures Falls Wernicke's encephalopathy and Korsakoff's syndrome. Psychological:
Psychosis
Morbid jealousy e.g. delusion that their partner is unfaithful.
Alcoholic hallucinosis. In chronic alcoholism, the hallucinations are auditory, while in withdrawal they are often visual or tactile.
CV:
Arrhythmia
HTN
Cardiomyopathy
Others:
Anaemia Osteoporosis ↓Fertility Breast cancer. Accidents Social problems.
Which investigations should be carried out in suspected alcohol abuse?
Initial identification:
Screen as part of routine care, as many with alcohol misuse may not actively seek help (due to stigma and nature of addiction).
Consider using tool such as CAGE.
Further assessment:
AUDIT (Alcohol Use Disorders Identification Test) to assess pattern and severity. Proceed to following steps if >15.
SADQ (Severity of Alcohol Dependence Questionnaire) to assess severity.
APQ (Alcohol Problems Questionnaire) to assess secondary problems.
Detailed consumption history, both current and historical: typical day, frequency, and volume.
Detailed assessment of physical and psychiatric problems.
Investigations if health problems suspected:
FBC: macrocytic anaemia.
LFT: ↑GGT, ↑↑AST, ↑ALT.
Offer transient elastography (FibroScan) to diagnose cirrhosis in all persistent heavy drinkers.
How can alcohol abuse be managed?
Overview:
Management takes place within specialist alcohol services.
Determine where you are first with motivational interviewing. Decide on whether harm reduction or abstinence is the goal, encouraging the latter.
Monitor closely for the various physical health consequences of long-term dependency.
Assisted withdrawal (aka detoxification)
Should be offered if drinking >15 units/day or AUDIT >20.
A combination of drug therapy and individual, group, and self-help psychotherapy.
3 weeks of community-based treatment for most. 2-4 meetings per week in moderate dependence, or intensive day programmes for most of the week in severe dependence.
Inpatient or residential care is for those who drink >30 units/day, have significant psychiatric or cognitive co-morbidities, and/or have a history of epilepsy or withdrawal seizures.
Biological
During withdrawal:
Benzodiazepine – chlordiazepoxide or diazepam – titrated to severity. If community-based, monitor every 2 days and prescribe treatment for that duration.
Thiamine to prevent neurological complications.
Maintenance:
Acamprosate or naltrexone for relapse prevention after withdrawal is completed. Acamprosate is a GABA agonist and glutamate antagonist which reduces craving. Naltrexone is an opioid receptor blocker which reduces pleasure; side effects include nausea, anorexia, fatigue, and headaches; it should not be used alongside opioids.
Disulfiram if acamprosate or naltrexone are not suitable. Nalmefene, an opioid receptor blocker, is another option.
Continue medication for at least 6 months, but stop if drinking persists for 4 weeks after starting.
Do baseline U&E and LFT before starting acamprosate, naltrexone, or disulfiram.
Psychological
Psychological treatment can be offered alone for mild dependence, or combined with pharmacotherapy for withdrawal and relapse prevention. Options include:
Psychoeducation for patients and carers.
Motivational interviewing.
CBT: individual, group, or behavioural couples therapy. Weekly sessions for 12 weeks.
Community support and self-help e.g. AA.
Social
Involve families in care, in negotiation with the patient. Offer a carer’s assessment, as well as guided self-help and support groups for families.
Will need to contact DVLA if they drive, and are unlikely to be allowed to drive until alcohol-free for 1 year.
Think about any safeguarding issues e.g. child neglect, domestic abuse.
3 months residential rehabilitation should be offered to those who are homeless. Try to find long-term housing before discharge.
