Substance Dependence Flashcards
What does substance dependence describe?
What must a pt be exhibiting to be described as dependent?
- A syndrome that incorporates physiological, physiological and behavioural elements
- A pt exhibiting either tolerance or withdrawal is said to be dependent
Dependence syndrome is diagnosed if 3 or more of the following are present
- A strong desire or compulsion to take the substance
- Difficulties in controlling substance taking behaviour
- Physiological withdrawal state when reducing dose, or continuing to use substance to avoid this state
- Signs of tolerance: increased quantities needed to provide the same effect originally produced by a lower dose
- Neglect of other interests and activities due to time spent acquiring and taking substance or recovering from its effects
- Persistence with substance use despite clear awareness of harmful consequences
Not all dependent pts experience significant withdrawal symptoms.
What should be regarded when a pt is detoxing?
-What are contraindication to detoxing at home?
-How are severe symptoms of withdrawal ameliorated?
-How is a wernicke’s encephalopathy prevented
- It is possible to safely and effectively detox most pts in the community as an out-patient over the course of 1 week
- CIs include; severe dependence, a history of withdrawal seizures or delerium tremens, an unsupportive home environment and a previously failed community detoxification. In these cases in pt stay is advised
- A drug with cross tolerance to alcohol is used (usually diazepam or lorazepam). High doses are initally given and then tapered down over 5-7 days.
- Thiamine (vit 12) is given daily 100mg
How should delirium tremens be managed?
-What is there a risk of developing?
- 1st search for medical complications including, infection, head injury, liver failure, GI haemorrhage or wernicke’s encephalopathy
- Then give large doses of drugs with alcohol cross tolerance, large doses of parenteral thiamine and consider antipsychotics for only severe psychotic symptoms as they lower seizure threshold
- There is a risk of hyperthermia, dehydration, hypoglycaemia, hypokalaemia and hypomagnesaemia. These should all be monitored
- Wernicker’s encephalopathy can also lead to Korsakoff’s syndrome (amnesia -80%)
Maintenance
Does detox remove addiction?
What pharamcological support can be given to prevent re-drinking?
- No but it helps the pt manage withdrawal symptoms
- Disulfiram (antabuse) blocks alcohol oxidation and leads to an accumulation of acetaldehyde. This leads to anxiety, flushing, palpitations, headaches and a choking sensation within 20 minutes
Psychosocial interventions
How does motivational interviewing help a pt?
What other psychosocial interventions are available
-Motivational interviewing and the application fo Prochaska and DiClemente’s stages of change model, which moves pts through a cycle of change from precontemplation to contemplation to determination to action to maintenance
- CBT
- Group therapy
- Alcoholics anonymous
- Social support; social workers, probation officers and citizens advice agencies can all help
- Primary prevention; increasing the cost of alcohol through taxation ect
Course and prognosis
-What is the 1 year abstinence rate for highly functioning individuals following treatment?
What are some good prognostic indicators?
-What is an alcohol dependent individuals increased excess mortality and what is there suicide risk?
- Following good treatment individuals show a >65% 1 year abstinence rate
- Stable relationship, employment, stable living conditions, good insight, good motivation and good social support
- Alcohol dependent individuals have a 3.6 fold excess mortality compared with age matched controls
- Lifetime suicide risk is 3-4% which is 60-120x that of the general population
Opiate addiction
- What are some harm minimisation strategies?
- What level of dependence can withdrawal be attempted in
- Symptoms of withdrawal can be ameliorated by which drug, and how does it work?
- Clean needles and injecting equipment, Hep B vaccination, Condoms
- Mild to moderate dependence
- Lofexidine, a centrally acting alpha-adrenoceptor agonist that reduces sympathetic outflow
What can be given to severely dependent pts?
- How can the level of a pts dependence be determined
- What partial opiate agonist can be used as a substitute therapy in moderate dependence?
- What drug can be used to block the euphoric effects of continued opiate use?
- Pts are offered a maintenance dose of the longer acting oral opiate methadone. Methadone can be used indefinitely, should aim to reduce the dose over time
- A urine drug screen
- Sublingual buprenorphine, may cause withdrawal in pts who are highly dependent
- Naltrexone, an opiate antagonist
- Psychological interventions are also vital; motivational interviewing, CBT and social support
Benzodiazepines
What can withdrawal from benzodiazepines cause?
-what is the initial treatment?
- Death, hallucinations, convulsions and delirium
- Convert from short acting compounds e.g. loazepam, to longer acting compounds e.g diazepam. Doses are then reduced very slowly by a small amount each week
Cocaine and amphetamine
- Can these be stopped abruptly
- What can help with the ensuing mood?
- What disorders can be induced by these drugs? and what can be used for symptomatic treatment?
- Yes
- Antidepressants may help with the ensuing depressed mood that follows withdrawal
- Symptoms of psychotic disorders induced by these drugs benefit from a short course of benzodiazepines and antipsychotics
