Substance missues Flashcards
Risk factors for substance abuse?
- 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
What does the term ‘dual diagnosis’ mean in substance misuse?
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%
What are warning signs of missuse?
- 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
What are non-pharmaceutical options for helping someone with substance missuse?
- harm reduction advice
- peer support
- drug diaries
- counselling
- therapy
- exercise
- educational opportunities
- encourage hobbies/activities
- mindfullness, good sleep hygiene, relaxation techniques
What heritage has a lower risk alcohol problems and why?
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
what percentage of the uk’s dependent drinkers are receiving treatment?
Of 60k dependent drinkers, only 18% are receiving treatment
What percentage of the uk regularly drink over the guidelines?
24%
What is the statistic for the risk factor of alcohol misuse?
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.
What are some potential risks of long-term high alcohol intake?
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
What are the risk factors for developing an alcohol problem?
- 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
Can alcohol cause cancer?
many people are aware of tis risk on liver disease, but not its contribution to cancers
What are the potential risks of chronic alcohol consumption on the CNS?
- 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
What are the presentations of Wernicke’s-korsakoff syndrome?
- 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
How is Wernicke’s Korsakoff treated?
Via Thiamine supplementation:
- Acute treatment with Pabrinex- 1 pair of ampules IM or IV daily for 3-5 days.
- Maintenance- oral Thiamine 100mg TDS
Why does thiamine dosing need to be spread out across the day?
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
What are the current management procedures for established alcohol dependence?
- 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
What is important regarding alcohol withdrawal?
Acue alcohol withdrawal can be fatal
What drugs are given in alcohol withdrawal/detoxification?
Benzodiazepines:
e.g Chlordiazepoxide at a 20-40mg four times a day, reduced over 9 days.
Who might need a reduced dose of benzos for withdrawal?
elderly
Hepatic impairement
- due to risk of accumulation
What is the CIWA?
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)
What alternatives Benzo to chlordiazepoxide may be given in hepatic impairment?
lorazepam
Oxazepam
What drugs may be given for maintenance of alcohol dependence?
- 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.
What does the alcoholic identification and brief advice (IBA) service process include?
- 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
What is a positive score on the FAST and what should you do
Overall total score of 3 or more is FAST positive, if positive complete an AUDIT or AUDIT-C test
What score on the AUDIT-C test is AUDIT-C positive?
A score of 5+ indicated increasing risk drinking. An overall score of 5 or above is AUDIT-C +ve
What is the NNT for alcohol brief interventions?
NNT = 8
What is used for opioid overdose/toxicity?
Naloxone- is an emergency antidote
What is the treatment process for opioid dependence?
- 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
Examples of opioid withdrawal symptoms?
Runny nose
eye watering
dilated pupils
N+V
diarrhoea
muscle aches
restlessness
What pharmacotherapy is used for maintenance of opioid dependence?
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
What are the advantages and disadvantages of methadone?
- 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
What are the advantages and disadvantages of Buprenorphine?
◼ 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
What is the usual maintenance dose of methadone?
40-120mg/day
What is the common titration procedure for methadone?
- 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
What are potential side effects of methadone?
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
What is a major risk/side effect of methadone?
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
What should be done if a patient is at risk of QT prolongation and is on methadone?
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
What is the risk of relapse with patients on Naltrexone for prophylaxis of previously opioid dependents?
Risk of respiratory depression if they relapse while taking Naltrexone = fatal
What are the symptoms of an opioid overdose?
- 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)
When would you contact the prescriber of a patient on methadone?
- 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
What harm reduction advice can be given to known drug users?
- 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…
What are the possible effects of synthetic canabis?
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
