Substance Misuse Flashcards
ICD-10 classifies substance misuse disorders according to both the type of substance and type of disorder; state 7 types of substance misuse disorders in ICD-10.
Briefly desribe each
*NOTE: this includes alcohol!
- Acute intoxication: acute, usually transient, effect of a substance
- Harmful use: reccurrent use resulting in physical, psychological & social consequences but without dependence
- Dependence syndrome: prolonged substance misuse leading to addiction, tolerance and potential for withdrawal
- Withdrawal state: physical and/or psychological effects from complete or partial cessation of a substance after prolonged or high level of use
- Psychotic disorder: onset of psychotic symptoms within 2 weeks of substance use; must persist >48hrs
- Amensic syndrome: memory impairment in recent memory (impaired learning of new material); sometimes remote memory is also impaired. Disturbances of time sense & ordering of events
- Residual disorder: specific features due to substance misuse (e.g. flashbacks, personality disorder, affective disorder, dementia)
What is meant by tolerance?
Decrease in the response to a drug, requiring a higher dose to obtain the same effect after repeated use.
What is meant by dependence?
Inidividual is dependent on/needs the drug for normal physiological funtioning; not having the drug can lead to withdrawal.
What is meant by withdrawal?
Group of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications or recreational drugs.
State some factors that contribute to an individual mis-using substances, consider the following factors:
- Biological
- Environmental
- The substance they take
- Positive reinforcement
- *NOTE: reinforcement can be negative (e.g. don’t take feel bad) and positive (take and feel good)*
- Attachment
State some examples of commonly misused substances (drugs)
- Opiods
- Cannabinoids
- Stimulants
- Sedative-hypnotics
- Hallucinogens
- Volatile solvents
- Anabolic steroids
What is the most commonly consumed illegal drug in uk?
Cannabis
For opiates state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
Take because get “intensely pleasurable buzz or rush- peaceful”. Heroin is an anxiolytic.
For cannabinoids, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
For sedatives/hypnotics, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
For stimulants, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
For hallucinogens, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
For volatie solvents, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
For anabolic steroids, state:
- Example drugs
- Routes taken
- Psychological effects
- Physical effects
- Withdrawal sate effects
State some potential physical consequences of drug use
- Death
- Infection (HIV, hep A/B/C, TB, Staphylococcus aureus)
- DVT
- PE
- Endocarditis
- Arrhythmias
… and many more!
State some potential psychological consequences of drug use
- Craving
- Anxiety
- Cognitive disturbance
- Drug-induced psychosis
State some potential social consequences of drug use
- Crime
- Imprisonment
- Homelessness
- Prostitution
- Relationship problems
- Homelessness
When taking a history about sustance misuse it is helpful to have a structure; describe an example structure you could use
-
Current use
- Type
- Route
- Amount (this can be clarified by money spent)
- Pattern/how often
- Dependence & withdrawal
- Possible triggers
-
Past substance misuse
- Details
- Any complications
- Any treatment
- Any overdose
-
Impact of drug use (physical, psychological, social)
- BBV’s (hep B, hep C, HIV)
- Complications of injection
- Criminal record
- PMH
-
Social history
- e.g. housing who live with, children
- Coping strategies
- Risk assessment (suicide, self-harm, needle sharing, safeguarding)
What invesigations would you want to do in a pt who admits to substance misuse?
Bedside
- Urine drug screen
- ECG: arrhythmias
- TB testing
Bloods
- HIV screen
- Hep B & C screen
- U&Es: renal func
- LFTs: liver func
- Clotting: liver func
- Drug levels
Imaging & other
- ECHO: if suspect endocarditis
- *Would also do a full examination of all body systems*
Discuss the general management of substance misuse (think about biopsychosocial model to help you think of ideas)
Management can be residential rehabilitation, hospital or community
- Medication (relevant for specific drugs)
- Hep B immunisation (for those at risk)
- Contingency management (offering incentives/rewards for abstinence e.g. financial)
- Motivational interviewing
- CBT for comorbid depression & anxiety
- Support groups e.g. Narcotics anonymous
- Supportive help with e.g. housing, finance, employment
- Educate about safe use iniatives e.g. needle exchange
What’s the difference between maintenace and detoxification?
- Detoxification: is essentially weaning someone off the drug. Replacement drug is given in large enough dose at start to satisfy cravings & prevent withdrawal symptoms then dose is gradually tapered down (eventually to zero) in attempt to attain abstinence.
- Maintenance: find optimal dose of replacement drug that elimates a person’s withdrawal symtpoms and keep them on this dose until they no longer struggle with symptoms of residual withdrawal. Priority is to minimise harm, not abstinence. Can be on replacement drug for years. Eventually the aim is progress to detoxifiationa and abstinence.
What drugs can be used for opiate detoxification & maintenance?
- Methadone (opiod agonist)
- Buprenorphine (partial opiod agonist)
What is the antidote to opiod overdose?
Naloxone (IV)
Discuss two approaches for benzodiazepine detoxification to prevent withdrawal
Either do slow reduction of their current benzo or switch to equivalent dose of diazepam (as has long half life) and taper this down gradually.
*NOTE: benzodiazepine withdrawal is similar to alcohol withdrawal except in benzo withdrawal get hallucinations early and autonomic symptoms later
What is dependence syndrome?
A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value.
Remind yourself of how most of alcohol is metabolised in liver (MEH revision)
State some potential phsycial complications of excessive alchol use
State some potential psycological complications of excessive alcohol use
State some potential social complications of excessive alcohol use
State 7 signs of alcohol dependence
*HINT: mneumonic SAW DRINk
Remind yourself of the CAGE questions
0 or 1: low risk drinking problem
2 or 3: suspicion of alcoholism
4: virtually diagnostic for alcoholism
* *Remember: if someone scores >2 on CAGE questionnaire should prompt further action using other questionnaires; can use AUDIT or SADQ*
Suggest a structure for taking an alcohol history
Remind yourself how to calcualte units of alcohol using ABV and volume
State approximately how many units in common drinks such as pint of beer, glass of wine, shot of spirits
1 unit= 10ml (8g) of ethanol
Units= ABV x vol (ml)/1000
Discuss the possible MSE of a pt who is intoxicated with alcohol
Discuss possible MSE of a pt who has alcohol withdrawal
Summarise the management for alcohol abuse; think about the biopsychosocial model
*NOTE: question not specific to withdrawal just any alcohol abuse
Extra notes:
- Family involvement may involve family/systematic therpy
- Education for pt and family (e.g. safe drinking advice, who to contact if concerned, risks of chronic alcohol abuse)
- Inform pt they must tell DVLA
An alcohol detoxification regime offers controlled withdrawal; describe the regime used to prevent alcohol withdrawal
Can be inpatient or outpatient:
-
Benzodiazepines- commonly chlordiazepoxide
- 10 day course
- PO
- Initially high dose
- Then dose tapered down
-
Thiamine(to prevent Wernicke’s encephalopathy)
- IV (pabrinex) or IM
- Or PO
- Consider prescribing PRN lorazepam 10mg PR in case of seizure
An example regime of chlordiazepoxide is shown below but always use local guidelines (don’t need to remember just have an idea). Patients with seizures or delerium tremens may need higher doses for longer.
Discuss the mangement of alcohol dependence (think about biopsychosocial model)
Biological
- Disulfiram: irreversibly inhibits acetaldehyde dehydrogenase causing a build up of acetaldehyde on consumption of alcohol which causes unpleasant symptoms such as headache, flushing, anxiety, choking sensations.
- Acamprosate: enhances GABA transmission reducing cravings
- Naltrexone: opiod receptor antagonist which inhibits action of endogenous endorphins released when alcohol is drunk hence reduces pleasurable effects of alcohol and so reduces urge to drink it
Psychological
- CBT: focusing on alcohol-related beliefs & behaviour
- Motivational interviewing: guides the person into wanting to change- most effective in pre-contemplation & contemplation stage
- Family therapy
Social
- Support groups e.g. alcoholics anonymous 12 step programme
Motivational interviewing is a commonly used technique in substance misuse; discuss what it involves
Collaborative, goal-orientated style of communication. Aims to strengthen an individual’s motivation & comitment to change by exploring their own reasons for change.
