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Exam 2 (and 3) - CNS, mental health, renal and liver > Substance missues > Flashcards

Substance missues Flashcards

1
Q

Risk factors for substance abuse?

A
  • Personal or family history
  • history of pain issues- trying to manage pain
  • Easy access to meds as working in healthcare
  • Time spent in environment like prison- lots of drugs
  • Difficult life events- childhood trauma, divorce, bereavement
  • Severe mental or physical health problems
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2
Q

What does the term ‘dual diagnosis’ mean in substance misuse?

A

25% (1in 4) patients with severe mental health problems are expected to have substance missuse- it Is actually more like 35-50%

People with substance misuse, 25% are expected to have mental health problems- actually about 50-75%

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3
Q

What are warning signs of missuse?

A
  • Taking higher doses than prescribed/advised
  • Running out of prescription early
  • ‘Losing’ meds or prescriptions
  • Requesting specific drugs- stating that others don’t work or are allergic
  • risky behaviours e.g. criminal activity
  • falls, injuries
  • troubled relationships, money problems

Presentations:
- intoxicated, sedated, withdrawal symptoms
- unkempt appearance, lack of self care
- mood swings or hostility
- changes in sleep patter.
- avoiding random drug testing

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4
Q

What are non-pharmaceutical options for helping someone with substance missuse?

A
  • harm reduction advice
  • peer support
  • drug diaries
  • counselling
  • therapy
  • exercise
  • educational opportunities
  • encourage hobbies/activities
  • mindfullness, good sleep hygiene, relaxation techniques
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5
Q

What heritage has a lower risk alcohol problems and why?

A

People of Asian heritage have a lower risk of alcohol problems due to about 50% having non-functional aldehyde dehydrogenase genes resulting in the so-called ‘Asian flush’, and nausea and vomiting

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6
Q

what percentage of the uk’s dependent drinkers are receiving treatment?

A

Of 60k dependent drinkers, only 18% are receiving treatment

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7
Q

What percentage of the uk regularly drink over the guidelines?

A

24%

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8
Q

What is the statistic for the risk factor of alcohol misuse?

A

Is the biggest risk factor for death, ill-health and disability along 15-49 year olds in the uk and fifth biggest risk across all ages.

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9
Q

What are some potential risks of long-term high alcohol intake?

A

Death: about 20,000 premature deaths a year are alcohol-related
◼ Liver damage - in 90% alcoholics, hepatitis in nearly 40%
◼ Accidents – up to 75% UK A&E visits may be due to alcohol misuse
◼ Cancer – 3% cancers thought to be alcohol-related e.g. liver, stomach, breast, mouth area
◼ Gut e.g. major bleeds from the gut, stomach ulcers
◼ Mental health problems - in up to 80% people e.g. depression, anxiety
◼ Social problems – 30% divorces, 40% of domestic violence, 20% of child abuse
◼ Weight gain
◼ Brain damage e.g. seizures or fits, stroke, dementia
◼ Nerve damage e.g. peripheral neuropathy
◼ Pancreatitis
◼ Heart disease – hypertension, heart attacks, irregular heart
◼ Sexual problems e.g. impotence, premature ejaculation, reduced fertility
◼ Bones e.g. osteoporosis
◼ Skin – worsening of skin diseases like psoriasis and eczema.
◼ Insomnia and sleep problems
◼ Strokes
◼ Loss of driving license
◼ Risk to any unborn child

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10
Q

What are the risk factors for developing an alcohol problem?

A
  • Genetics:
    Family history- no single gene but up t0 400 may influence the development
    Genes account for about 50% of overall risk
  • Starting drinking younger
  • Regular drinking very day
  • mental health problems e.g. anxiety, depression, PTSD
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11
Q

Can alcohol cause cancer?

A

many people are aware of tis risk on liver disease, but not its contribution to cancers

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12
Q

What are the potential risks of chronic alcohol consumption on the CNS?

A
  • Cognitive impairment- is neurotoxic and can lead to alcohol demential and longterm neuropathy, cerebral atrophy
  • Wernicke-Korsakoff syndrome- neuropsychiatric disorder caused by a thiamine deficiency
    Presents as confusion, apathy, disorientation, vomiting, memory problems
    Occurs in as many as 12.5% of alcohol misuses
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13
Q

What are the presentations of Wernicke’s-korsakoff syndrome?

A
  • Wernicke-Korsakoff syndrome- neuropsychiatric disorder caused by a thiamine deficiency
    Presents as confusion, apathy, disorientation, vomiting, memory problems
    Occurs in as many as 12.5% of alcohol misuses
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14
Q

How is Wernicke’s Korsakoff treated?

A

Via Thiamine supplementation:
- Acute treatment with Pabrinex- 1 pair of ampules IM or IV daily for 3-5 days.
- Maintenance- oral Thiamine 100mg TDS

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15
Q

Why does thiamine dosing need to be spread out across the day?

A

Because oral absorption is poor- humans can only absorb about 4mg per hour so 100-300mg once a day is pointless- must be spread out

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16
Q

What are the current management procedures for established alcohol dependence?

A
  • Assessment of alcohol dependence
    Pharmacist interventions
    Psychosicial interventions e.g. AA, NORCAS
  • Detoxification
    Assisted detox, withdrawal programe
    Anti-convulsants for safe detox
  • Assisted maintenance
    Pharmacological interventions e.g. Acamprosate, disulfram, naltrexone
    Treat underlying cause
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17
Q

What is important regarding alcohol withdrawal?

A

Acue alcohol withdrawal can be fatal

18
Q

What drugs are given in alcohol withdrawal/detoxification?

A

Benzodiazepines:
e.g Chlordiazepoxide at a 20-40mg four times a day, reduced over 9 days.

19
Q

Who might need a reduced dose of benzos for withdrawal?

A

elderly
Hepatic impairement
- due to risk of accumulation

20
Q

What is the CIWA?

A

The Clinical Institute Withdrawal Assessment for Alcohol, commonly abbreviated (CIWA), is a 10-item scale used in the assessment and management of alcohol withdrawal.
- Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal (impending delirium tremens)

21
Q

What alternatives Benzo to chlordiazepoxide may be given in hepatic impairment?

A

lorazepam
Oxazepam

22
Q

What drugs may be given for maintenance of alcohol dependence?

A
  • Disulfiram - pro-drug activated in the liver that prevents conversion of acetaldehyde to acetic acid and dopamine to noradrenaline. Is an adverse therapy- consumption of alcohol cause symptoms e.g. vasodilations, palpiatations and headache. Combination with alcohol can be fatal
  • Acamprosate- glutamate antagonist. Has a better safety profile, but efficacy is marginal
  • Naltrexone- licenced for alcohol misuse disorder (opioid antagonist). Well tolerated. It blocks the opioid receptors that modulate dopamine release in the brains reward system = blocks the rewarding effect of alcohol.
  • Nalmefene- Also opioid antagonist. Reduces the reward.
23
Q

What does the alcoholic identification and brief advice (IBA) service process include?

A
  • Gain permission to talk about drinking
  • Screen for alcohol consumption (FAST)- alcohol harm assessment tool. It consists of a subset of questions from the full alcohol use disorders identification test (AUDIT).
  • Complete a validated screening questionnaire e.g. AUDIT (alcohol use disorders identification test)
  • Give advice, resources, refer
24
Q

What is a positive score on the FAST and what should you do

A

Overall total score of 3 or more is FAST positive, if positive complete an AUDIT or AUDIT-C test

25
Q

What score on the AUDIT-C test is AUDIT-C positive?

A

A score of 5+ indicated increasing risk drinking. An overall score of 5 or above is AUDIT-C +ve

26
Q

What is the NNT for alcohol brief interventions?

A

NNT = 8

27
Q

What is used for opioid overdose/toxicity?

A

Naloxone- is an emergency antidote

28
Q

What is the treatment process for opioid dependence?

A
  • Assessment- confirm depndence
  • Detoxification and induction onto maintenance- titrate over several days to curb withdrawal symptoms
  • Maintenance with opioid substitute
  • Gradual discontinuation with support- the hardest part
29
Q

Examples of opioid withdrawal symptoms?

A

Runny nose
eye watering
dilated pupils
N+V
diarrhoea
muscle aches
restlessness

30
Q

What pharmacotherapy is used for maintenance of opioid dependence?

A

Methadone:
- Full agonist
- reduces peak levels from injecting
- supresses withdrawal and craving- has longer t1/2
- People can and do still “use on top”

Buprenorphine:
- Partial agonist
- longer half life than methadone
- not totally absorbed- sub-lingual or injections
- Cant use on top- buprenorphine blocks the effects of additional opioid use by preventing occupation of opioid receptors

31
Q

What are the advantages and disadvantages of methadone?

A
  • Established and familiar
    ◼ Good evidence base for MMT (Methadone Maintenance Treatment)
    ◼ Sedating
    ◼ Cheap
    ◼ Full agonist
    ◼ Variety routes/forms
    ◼ Easy to supervise
    ◼ Orally absorbed

Established and familiar
◼ Good evidence base for MMT (Methadone Maintenance Treatment)
◼ Sedating
◼ Cheap
◼ Full agonist
◼ Variety routes/forms
◼ Easy to supervise
◼ Orally absorbed

32
Q

What are the advantages and disadvantages of Buprenorphine?

A

◼ More difficult to use “on top” (maintenance minimises drug seeking behaviour, negative reinforcement)
◼ Safer in overdose
◼ Good for those at risk of overdosing
◼ Less stigmatised
◼ Easier to detox from, easier switch to naltrexone
◼ Less sedating
◼ Better outcomes of new-borns ◼ Can’t be adulterated
◼ Initial titration rapid
◼ Range of long-acting products also now available (LAI and rods)

◼ Not orally absorbed
◼ Unpleasant taste (S/L)
◼ More difficult to supervise (concealment)
◼ Poorer evidence base/less experience
◼ Can be injected
◼ Suboxone resolves this
◼ Only one dosage form
◼ Less sedating
◼ Can precipitate withdrawal, especially on induction
◼ Relatively expensive

33
Q

What is the usual maintenance dose of methadone?

A

40-120mg/day

34
Q

What is the common titration procedure for methadone?

A
  • 20-30mg day 1, increase 5-10mg every few days up to max total 30mg above starting dose/week, then increase once or twice weekly (10-15mg) as needed
  • Takes about 5 days for blood levels to reach steady state
35
Q

What are potential side effects of methadone?

A

CNS effects:
◼ Euphoria - not as marked as heroin
◼ Pleasant, warm feeling in stomach
◼ Pain relief
◼ Drowsiness – which wears off
◼ Nausea/vomiting - stimulation of chemoreceptor trigger zone
◼ Respiratory depression, especially at higher doses
◼ Cough reflex depression
◼ Histaminergic effects (itching, sweating, blushing, flushing, constricting of the airways)
Other effects:
◼ Reduced or absent menstrual cycle - may still become pregnant
◼ Sexual dysfunction
◼ Dry mouth, eyes, nose
◼ less secretion of saliva, tears and mucous
◼ Dental problems
◼ 57% report, methadone is acidic
◼ Constipation
◼ Opioids slow passage of food
◼ People require high fibre & high fluid
◼ Laxatives may be needed
◼ Constricted pupils
◼ Reliable indicator of the level of opioids in blood stream

36
Q

What is a major risk/side effect of methadone?

A

Can cause QT prolongation especially in doses over 100mg/day.
- So need to be cautious with other drugs that raise QT .g. lithium, TCAs, SSRIs, macrolide), heart disease, stimulant usage

37
Q

What should be done if a patient is at risk of QT prolongation and is on methadone?

A

Offer an ECG
- If this is normal, repeat 6-12 monthly
- If QT is prolonged, discussed treatment options:
possible alternatives to methadone e.g. buprenorphine
possible cardiology referral
consider dose reduction- cautious

38
Q

What is the risk of relapse with patients on Naltrexone for prophylaxis of previously opioid dependents?

A

Risk of respiratory depression if they relapse while taking Naltrexone = fatal

39
Q

What are the symptoms of an opioid overdose?

A
  • Pinpoint/constricted pupils
  • Nausea/vomiting
  • Pale skin colour, bluish tinge to lips, tip of nose, under the eyes, fingertips, or nails
  • Low blood pressure, slow pulse (hypotension/bradycardia)
  • Sedation, which may be getting worse, including:
    o No response to noise (no response to shouting)
    o No response to touch (no response to being shaken by the shoulders) o Loss of consciousness (cannot be woken)
    o Breathing problem (slow/shallow/infrequent breaths, snoring/rasping sounds, or no breathing)
40
Q

When would you contact the prescriber of a patient on methadone?

A
  • Note every time a dose is missed/erratic attendance

Must contact presider if:
- missed 3 or more doses
- concerns about dose or prescriptuon
- dispensing error or near misses
- unacceptable behaviour
- whole dose not consumers
- concerns about physical or mental health

41
Q

What harm reduction advice can be given to known drug users?

A
  • Do not use (drugs) while alone
  • If things go wrong, get help fast
  • Beware of loss of tolerance (dose increases needed)
  • Avoid polypharmacy (e.g. Cocaethylene with cocaine and alcohol)
  • Try a small amount first and wait to see effects
  • Use smaller amounts and less often
  • Avoiding combination products
  • e.g.ibuprofen→GIbleed; paracetamol→overdose
  • Don’t share injecting equipment
  • Avoid injecting
  • Safe injecting advice
  • Check BBV testing/vaccination stats
  • Contraception/sexual health advice
  • Needle exchange…
42
Q

What are the possible effects of synthetic canabis?

A

Desired effects: relaxation, altered consciousness, disinhibition, energy & euphoria
◼ CNS toxicity: agitation, tremor, confusion, somnolence, syncope, hallucinations, acute psychosis, nystagmus, convulsions
◼ Cardiac: tachycardia, hypertension, palpitations, ECG changes
◼ Others: renal damage, disinhibition, memory loss, bloodshot eyes, time distortion

these can change as the composition us unknown and changes from batch to batch

Exam 2 (and 3) - CNS, mental health, renal and liver (23 decks)

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