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Psychiatry > Substance Misuse > Flashcards

Substance Misuse Flashcards

1
Q

What is the difference between harmful use and dependency?

A

Harmful use: any use of alcohol/substances that has the potential to cause physical or psychological harm
Dependency: a syndrome of physical, cognitive and behavioural signs and symptoms

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2
Q

What is the single common thing uniting drugs of abuse?

A

They all affect the dopaminergic reward system

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3
Q

Describe the reward pathways in the brain. How is this affected by substances?

A

Dopaminergic neurons extend from the ventral tegmental area (VTA) to the cortex and the limbic system
AKA Mesocortical pathway, mesolimbic pathway
-Cocaine and amphetamines: block DA reuptake
-Alcohol, opiates: increase DA levels

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4
Q

What are some features of dependency?

A 
Tolerance
Compulsion
Withdrawal
Loss of control 
Continuing use despite harm
Primacy 
Narrowing of repertoire
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5
Q

Define withdrawal

A

A state of adjustment to lower levels of a drug, with specific signs and symptoms

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6
Q

What are some risk factors for alcohol dependency?

A
  • Family history
  • Social stressors
  • Depression, anxiety disorders
  • Occupation
  • Early life difficulties
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7
Q

What are some signs of alcohol intoxication?

A 
Elation
Ataxia
Stupor
Disinhibition: talkative, social, risky behaviours
Irritability, aggressiveness, weepy
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8
Q

What are some signs of alcohol withdrawal?

A 
Sweating
Tremor
Nausea and vomiting
Palpitations
Headache
Insomnia
Anxiety
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9
Q

What are some signs of delirium tremens?

A

Withdrawal +
Confusion
Hallucinations (visual, formication), delusions
Gross tremor
Autonomic disturbance: sweating, ^HR, temp
Seizures

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10
Q

When do withdrawal symptoms appear? DT?

A

Withdrawal symptoms start about 6-12 hours after cessation

DT usually happens after 48 hours, can last for several days

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11
Q

When should you consider inpatient treatment for alcohol withdrawal?

A

If the person is at high risk of DT (eg very large use, previous DT), has other comorbidities, <16 years, poor social support, etc

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12
Q

How can you screen for harmful alcohol use?

A

-CAGE: cutting down, annoyed by criticism, guilt, eye-opener
-> Consider formal screening with
-AUDIT (alcohol use disorders identification test)
-FAST (fast alcohol screening test) in A&E
This will help determine if any intervention is necessary
-SADQ (severity of alcohol dependence questionnaire) to determine severity of dependence

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13
Q

How should alcohol withdrawal be treated?

A
  • Assess severity using CIWA (Clinical Institute Withdrawal Assessment) to determine treatment
  • Consider need for admission
  • Long-acting benzos for 7-10 days (chlordiazepoxide)
  • IV pabrinex
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14
Q

What is the management of DT?

A

Oral/parenteral lorazepam

-> long-acting benzo when stable, pabrinex

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15
Q

Name some complications of alcohol misuse

A
  • Liver disease
  • Pancreatitis
  • Vitamin deficiency, malnutrition
  • Wernicke-Korsakoff syndrome
  • Cancer
  • Cardiomyopathy
  • Dependency, withdrawal
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16
Q

What is the presentation of Wernicke’s? What is the management?

A

Confusion
Ataxia
Ophthalmoplegia
Mx: IV pabrinex, chlordiazepoxide. Check for physical injuries eg head CT

17
Q

What is the management of Korsakoff?

A

Irreversible damage. Management is to support, ie with supported independent living/24-hour care facility

18
Q

Describe the features of Korsakoff

A
  • Irreversible anterograde amnesia
  • Retrograde amnesia of semantic info, not procedural
  • Confabulation
19
Q

If you identify someone as having harmful use of alcohol when taking a history, what should you do?

A

Consider formal screening eg AUDIT
Give brief advice:
-Explain the harms of alcohol use and reasons for quit
-Identify any barriers to change
-Outline practical strategies for reducing consumption
-Work to create goals
Identify any physical health problems eg. LFTs, FBC
Inform them that they must tell the DVLA if drink driving
Consider a drink diary
Follow-up

20
Q

When should you refer someone to specialist alcohol services?

A
  • Signs of alcohol dependence
  • No response to motivational interviewing
  • If they have any complications of alcohol use eg liver disease, mental health problems related to use
21
Q

What is the goal of treatment for alcohol misuse?

A

Complete abstinence

22
Q

Describe the management of alcohol misuse

A

Assess for severity, dependence etc (AUDIT, SADQ)
Advice -> motivational interviewing
CBT can be used in heavy drinking, mild dependence
Medical:
-Nalmefene for heavy use without dependence

23
Q

When is alcohol withdrawal recommended?

When is inpatient withdrawal recommended?

A

-Using >15 units a day
-Signs of alcohol dependence
-Wanting to stop
Inpatient/residential:
->30 units a day
-History of epilepsy or previous DT
-Significant medical history eg liver disease

24
Q

A patient has supported alcohol withdrawal in the community. Do they need any more management?

A

Preventing relapse:
Community programme that includes individual therapy (CBT), group therapy, support groups (AA), peer support (eg sponsor)
Social support with employment, finances, housing
Can offer medications:
-Acamprosate, naltrexone
-Disulfiram 2nd line

25
Q

Which medications can be used for maintaining abstinence from alcohol use?

A

Acamprosate: glutamine antagonist, maintains abstinence
Naltrexone: opioid antagonist, prevents relapse
Disulfiram: inhibits liver enzymes that metabolises alcohol, causing sickness after drinking

26
Q

What are the stages of change?

A 
Pre-contemplation
Contemplation
Planning
Action
Maintenance
Relapse
27
Q

If a person wants to stop using alcohol, what would you recommend?

A

Assess their use and associated problems to inform options eg. AUDIT, SADQ, APQ
Consider the need for detoxification programs. Inpatient, residential, community options.
Refer to alcohol specialist services

28
Q

Name some opiate drugs

A
  • Heroin
  • Morphine
  • Methadone
  • Codeine
29
Q

Describe the features of opioid intoxication

A 
Euphoria
Sedation
Pinpoint pupils
Bradycardia and respiratory depression
Constipation
30
Q

Describe the features of opioid withdrawal

A 
Goosebumps
Shivering, sweating
Yawning
Diarrhoea, lacrimation, rhinorrhoea
Irritability, anxiety
31
Q

How do you manage opioid overdose?

A

IM naloxone

32
Q

How do you manage a patient who would like to stop opioid use?

A

Assess for severity of use, any other substances, support, etc
Refer to specialist service
Typically a community based detoxification regime with methadone, group support. Over 12 weeks
Following detox -> continue support for 6 months

33
Q

How would you deliver a brief intervention for alcohol misuse?

A

FRAMES model

  • Feedback: tell them that their current habits are risky and briefly explain
  • Responsibility: Nobody can make that change for you, it is up to you to make any change
  • Advice: however, as your doctor I would strongly advise you consider cutting down
  • Menu of options: There are several things we can do to help, which I am happy to discuss with you, such as….
  • Empathy
  • Self-efficacy: It can be difficult, but with the right support I think you can do it.
34
Q

What are some symptoms of benzo withdrawal? How is it managed?

A

Irritability, anxiety, restlessness, tremor, sweating, insomnia
Confusion, psychosis, seizures
Mx: diazepam with slow titration

35
Q

What is the treatment of benzo overdose?

A

Flumezanil

Psychiatry (10 decks)

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