Substance Misuse

Question 1

Key questions to cover in an alcohol and SM history

Answer 1

Overview of use - current and past

• what do they take
• units, route, amount
• first time

Use pattern

• duration of this use pattern
• time of day
• binges, chronic use, substance free days
• alone, social

Alcohol Hx

• past DAA/GP team input
• past police involvement
• periods of abstinence
• periods of abstinence?

Impacts of substance

• withdrawal, dependence
• past treatments
• physical/mental complications

Question 2

Describe alcohol withdrawal symptoms

• onset
• risks of acute withdrawal

Answer 2

48-72hrs after last drink

Sweats
N+V+D
Anxiety
Blackouts
DT - hallucinations, extreme agitation, confusion, tremors

Seizures and death

Question 3

Describe features of alcohol dependence

-acute

Answer 3

Withdrawal symptoms => addressed by drinking

No 1 priority - drinking
Cravings
High tolerance
Drinking past the point of harm with inability to control intake
Narrow repertoire of drinks
Drinking after abstinence

Question 4

How could you screen for alcohol misuse

Answer 4

Cut down (felt the need to?)
Annoyed (by others criticising your drinking?)
Guilty (about your drinking?)
Eye opener (drink in the morning to steady nerves/rid yourself of hangover?)

AUDIT

Question 5

Key questions to cover in a drug history

Answer 5

Type of drug

• illicit/prescription/OTC?
• form (smoking, PO, IH, IV?)

Patterns of use

• when use started and duration
• amount and type
• last use?
• any clean periods?

Any input from drug/GP support services?

Question 6

Risky behaviours associated with drug use

Answer 6

Injecting behaviours
-needle sharing/reuse => HIV, HepBC, infection risk

Use alone => unwitnessed OD?
Polydrug use (methadone, heroin) => OD risk

Sexual behaviour/STIs?

Violence/driving under influence/convictions or sentences => police involvement?

Question 7

FHx

SHx

Answer 7

FHx

• family alcohol and drug use
• psych Hx?

SHx
Accommodation - stability/eviction risk?
Employment, finances - current job? Benefits, debts?
Relationships - level of support? domestic violence?
Children - social services involvement? schooling?
Impact of substance use on life?

Risk assessment
-physical, emotional, sexual, neglect?

Question 8

Questions you could ask to understand their motivations and desires to stop

Answer 8

What are their current risks and concerns
Understanding of the problem
What is their current motivation?

Question 9

Treatment options for substance misuse

-non medical

Answer 9

GP AA/NA - must have goal of abstinence

Voluntary agencies/groups, Community Harm Reduction Teams - for those who want to cut down but not stop

• 1on1/group sessions
• needle exchange and harm reduction programme

DAA/SM teams - must have goal of abstinence

• 1on1/group sessions
• psychological therapies

Question 10

Treatment options for substance misuse

-pharmacological

Answer 10

DAA/SM team - in home setting

• Alcohol, stimulants (amphetamines, cocaine) => BZ reducing regimen
• Heroin, opiates => methadone, buprenorphine replacement and reduction

Individual medications

• Acamprosate => reduce alcohol cravings in abstinence
• Pabrinex => VitB deficiency in alcohol abuse

Opiate withdrawal/non opiate detox symptom management

• ibuprofen
• antiemetics, antidiarrhoea

Question 11

Physical risks of alcohol dependence

Answer 11

GI

• alcoholic hepatitis => cirrhosis
• esophageal varices, Barretts esophagus
• gastritis

Neuro from VitB def

• WKsyndrome
• peripheral neuropathy

CV and haem

• HTN
• cardiomyopathy
• macrocytic anemia
• IC

Cancer

Question 12

Risk assessment

Answer 12

To self

• self neglect, accidental harm
• MH problems - A+D

To others

• violence
• family, dependents, social relationships

From others
-increased vulnerability to assault, rape, exploitation

Question 13

Wernicke Korsakoff Syndrome

• pathophysiology
• presentation
• management

Answer 13

Thiamine deficiency => BS ischemia

WE - acute onset, high morbidity and mortality

• ataxia, confusion and nystagmus
• IM Pabrinex needed urgently to prevent progression to KS

KS - WE resolve => anterograde, retrograde amnesia
-confabulation

Question 14

Delirium Tremens

• presentation
• management

Answer 14

Most severe withdrawal state 
1-3 days after last drink
-disorientation
-visual hallucinations (insects, small creature, people)
-sweating, fever, high RR HR

BZ
Correct electrolyte and vitamin abnormalities
Rehydrate
Reduce delirium by managing in well lit, consistent environment

Question 15

Common drugs that can be abused

Answer 15

Marijuana (cannabis)
Heroin
Crack, cocaine
Ecstacy
Hypnotics (LSD, magic mushrooms)
Amphetamines
BZ, sleepers
OTCs (codeine)
Prescribed medications

Question 16

Management of drug abuse

-non medical

Answer 16

Psychological support and harm reduction programmes

• needle exchange
• OD education
• family education and support

If mental health problems are more severe => MH team
If SM problems are more severe => SM team

Question 17

Management of drug abuse

-pharmacological

Answer 17

Methadone => heroin replacement
Buprenorphine => heroin replacement, blocks effects of other opiates

Lofexedine => reduce opiate withdrawal symptoms
Naltrexone => prevents opiate reuse due to unpleasant physical symptoms

Question 18

What is a dual diagnosis

Answer 18

Concurrent substance misuse + 1 or more mental disorders

More likely to have

• more severe mental health
• increased suicide risk, victimisation, violence
• less compliance with medication and other treatment
• more contact with the criminal justice system
• family problems, history of sexual/physical childhood abuse

Question 19

What are the 6 stages of change

Answer 19

Precontemplation - unaware of problem
Contemplation - aware of problem but with no plan
Determination - wants to take action
Action - active change
Relapse - fall back into old patterns
Maintenance - sustain new behaviour