Substance Misuse Flashcards
What is the difference between harmful use and dependency?
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
What is the single common thing uniting drugs of abuse?
They all affect the dopaminergic reward system
Describe the reward pathways in the brain. How is this affected by substances?
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
What are some features of dependency?
Tolerance Compulsion Withdrawal Loss of control Continuing use despite harm Primacy Narrowing of repertoire
Define withdrawal
A state of adjustment to lower levels of a drug, with specific signs and symptoms
What are some risk factors for alcohol dependency?
- Family history
- Social stressors
- Depression, anxiety disorders
- Occupation
- Early life difficulties
What are some signs of alcohol intoxication?
Elation Ataxia Stupor Disinhibition: talkative, social, risky behaviours Irritability, aggressiveness, weepy
What are some signs of alcohol withdrawal?
Sweating Tremor Nausea and vomiting Palpitations Headache Insomnia Anxiety
What are some signs of delirium tremens?
Withdrawal +
Confusion
Hallucinations (visual, formication), delusions
Gross tremor
Autonomic disturbance: sweating, ^HR, temp
Seizures
When do withdrawal symptoms appear? DT?
Withdrawal symptoms start about 6-12 hours after cessation
DT usually happens after 48 hours, can last for several days
When should you consider inpatient treatment for alcohol withdrawal?
If the person is at high risk of DT (eg very large use, previous DT), has other comorbidities, <16 years, poor social support, etc
How can you screen for harmful alcohol use?
-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
How should alcohol withdrawal be treated?
- 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
What is the management of DT?
Oral/parenteral lorazepam
-> long-acting benzo when stable, pabrinex
Name some complications of alcohol misuse
- Liver disease
- Pancreatitis
- Vitamin deficiency, malnutrition
- Wernicke-Korsakoff syndrome
- Cancer
- Cardiomyopathy
- Dependency, withdrawal
What is the presentation of Wernicke’s? What is the management?
Confusion
Ataxia
Ophthalmoplegia
Mx: IV pabrinex, chlordiazepoxide. Check for physical injuries eg head CT
What is the management of Korsakoff?
Irreversible damage. Management is to support, ie with supported independent living/24-hour care facility
Describe the features of Korsakoff
- Irreversible anterograde amnesia
- Retrograde amnesia of semantic info, not procedural
- Confabulation
If you identify someone as having harmful use of alcohol when taking a history, what should you do?
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
When should you refer someone to specialist alcohol services?
- 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
What is the goal of treatment for alcohol misuse?
Complete abstinence
Describe the management of alcohol misuse
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
When is alcohol withdrawal recommended?
When is inpatient withdrawal recommended?
-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
A patient has supported alcohol withdrawal in the community. Do they need any more management?
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
Which medications can be used for maintaining abstinence from alcohol use?
Acamprosate: glutamine antagonist, maintains abstinence
Naltrexone: opioid antagonist, prevents relapse
Disulfiram: inhibits liver enzymes that metabolises alcohol, causing sickness after drinking
What are the stages of change?
Pre-contemplation Contemplation Planning Action Maintenance Relapse
If a person wants to stop using alcohol, what would you recommend?
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
Name some opiate drugs
- Heroin
- Morphine
- Methadone
- Codeine
Describe the features of opioid intoxication
Euphoria Sedation Pinpoint pupils Bradycardia and respiratory depression Constipation
Describe the features of opioid withdrawal
Goosebumps Shivering, sweating Yawning Diarrhoea, lacrimation, rhinorrhoea Irritability, anxiety
How do you manage opioid overdose?
IM naloxone
How do you manage a patient who would like to stop opioid use?
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
How would you deliver a brief intervention for alcohol misuse?
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.
What are some symptoms of benzo withdrawal? How is it managed?
Irritability, anxiety, restlessness, tremor, sweating, insomnia
Confusion, psychosis, seizures
Mx: diazepam with slow titration
What is the treatment of benzo overdose?
Flumezanil
