Substance Misuse Flashcards
What is the pathophysiology of alcohol withdrawal?
chronic alcohol consumption:
-ENHANCES GABA mediated inhibition in the CNS (similar to benzodiazepines)
-INHIBITS NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to decreased inhibitory GABA and increased NMDA glutamate transmission
At what stage to symptoms of alcohol withdrawal begin?
6-12 hours
Features of alcohol withdrawal
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
In alcohol withdrawal, when is the peak incidence of seizures?
36 hours
In alcohol withdrawal, when is the peak incidence of delirium tremens?
Around 48-72 hours
In alcohol withdrawal, when is the peak of symptoms delirium tremens?
Days 4 to 5
Signs and symptoms of delirium tremens
Confusion
Coarse tremor
Fever
Tachycardia
Delusions
Hallucinations (particularly visual hallucinations and tactile hallucinations (such as formication - the sensation of crawling insects on or under the skin), Sweating
Hypertension
(rarely) seizures
Management of alcohol withdrawal?
Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
Fluids
Anti-emetics
Pabrinex
Refer to local drug and alcohol liaison teams
first-line: long-acting benzodiazepines e.g. CHLORDIAZEPOXIDE or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
NICE guidelines state in people with acute delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol
Carbamazepine also effective in treatment of alcohol withdrawal
How can opiate withdrawal present?
Agitation
Anxiety
Muscle aches or cramps
Chills
Runny eyes
Runny nose (Rhinorrhoea)
Sweating
Yawning
Insomnia
Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting
Dilated pupils
‘Goose bump’ skin
Increased heart rate and blood pressure
Symptoms usually occur within 12 hours of stopping the drug. The withdrawal syndrome is unpleasant but not life-threatening.
Course of heroin withdrawal?
Withdrawal from heroin can begin as early as 6 hours after the last dose, with symptoms peaking at 36-72 hours.
How does the severity of alcohol withdrawal differ to opioid withdrawal?
Unlike alcohol withdrawal, opioid it is unpleasant but not especially dangerous.
Management of opioid withdrawal
NICE specifically advises against prescribing opiates in withdrawal, favouring either
- lofexidine (an alpha 2 receptor agonist)
- symptomatic management with medications such as benzodiazepines for agitation and anti-emetics/loperamide for GI symptoms.
Withdrawal from opiates will resolve spontaneously, but can also be pharmacologically supported by detoxification with methadone or buprenorphine.
Symptoms of Opiate Intoxication
Drowsiness
Confusion
Decreased respiratory rate
Decreased heart rate
Constricted pupils
Symptoms of cannabis intoxication
Common symptoms of cannabis intoxication include:
Drowsiness
Impaired memory
Slowed reflexes and motor skills
Bloodshot eyes
Increased appetite
Dry mouth
Increased heart rate and paranoia
Cannabis acts at cannabinoid receptors
Symptoms of LSD intoxication
Labile mood
Hallucinations
Increased blood pressure
Increased heart rate
Increased temperature
Sweating
Insomnia
Dry mouth
Symptoms of stimulant intoxication
Euphoria
Increased blood pressure
Increased heart rate
Increased temperature
Role of naloxone
Naloxone is an opioid antagonist and can precipitate withdrawal symptoms in opioid-dependent patients.
Therefore, it is used to prevent relapse for patients who are formerly opioid-dependent and have now stopped taking opioids. It is also an antidote for opioid overdose.
Benzodiazepine withdrawal signs/symptoms
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
depersonalisation
Weight loss
In what ways may excessive use of alcohol present to the psychiatrist?
Withdrawal symptoms (6-12 hours) anxiety and tremor, (48-72 hours) DT: confusion, delusions, hallucinations
Consequences of opioid
What are the health risks (physical and psychosocial) of illicit opioid use?
What does harm minimisation mean?
Harm reduction/minimisation can be described as a strategy directed toward individuals or groups that aims to reduce the harms associated with certain behaviours.
When applied to substance abuse, harm reduction accepts that a continuing level of drug use (both licit and illicit) in society is inevitable and defines objectives as reducing adverse consequences. It emphasizes the measurement of health, social and economic outcomes, as opposed to the measurement of drug consumption
Recommended maximum alcohol intake for men and women
NHS:
No more than 14 units of alcohol a week, spread across 3 days or more. That’s around 6 medium (175ml) glasses of wine, or 6 pints of 4% beer.
UHL:
2-3 units a day or approximately 21 units a week.
This is the equivalent of two bottles of wine a week.
2-3 units a day
How to calculate units of alchol
the total volume of a drink (in ml) X ABV (measured as a percentage)
—————————————————————————————————-
1000
Alcohol withdrawal timeline
Which illicit drugs may produce a schizophrenia-like state?
Cocaine
Cannabis (THC component)
Amphetamines and methamphetamine
Psychedelic drugs such as LSD or magic mushrooms
Club drugs such as ecstasy and MDMA
ICD 10 criteria for dependence syndrome
strong desire or sense of compulsion (strong desire)
difficulties in controlling substance-taking behavior (difficulties in controlling)
a physiological withdrawal state (withdrawal)
evidence of tolerance (tolerance)
progressive neglect of alternative pleasures or interests (neglect of pleasures)
and persisting with substance use despite overtly harmful consequences (harmful consequences)
How does chronic alcoholism lead to the occurrence of wernicke korsakoff syndrome
Substance misuse history
How did it begin? - when did it begin, when do they feel it began a problem
How often?
What is used?
How much, including how much MONEY?
Which method (injection, smoking, etc)
Use of clean needles if using clean needles
Blood borne virus screens - if using needles (HIV, Hep B and C)
If injecting - problems with veins, abscesses
Where are they getting the substance
How are they funding the substance use
Impact socially - work, relationships
Any previous treatment
Any overdose history - what happened, did they go to hospital, was it intentional
What is Naltrexone and when is it used?
An opioid antagonist used to manage alcohol use or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder
an opioid-dependent person should not receive naltrexone before detoxification.
It is taken by mouth or by injection into a muscle.
Effects begin within 30 minutes, though a decreased desire for opioids may take a few weeks to occur
Why are drugs which reach peak concentration faster more addictive?
More reinforcing (instant gratification)
Why is oral consumption of cocaine less common than snorting?
Oral: 1st pass metabolism - liver removes 1/3
Snorting: effects within 15 mins vs 45 mins orally
What is the concept of reinforcement
when human beings experience behaviour with a pleasant outcome, that behaviour is likely to be repeated, and behaviour that has unpleasant results is unlikely to be repeated.
What is tolerance
Higher amounts of a subtance required to achieve same effect, person’s body has become less responsive to a drug or alcohol, after repeated use and exposure
How does tolerance occur in cocaine use
Cocaine is a dopamine reuptake inhibitor
Blocks pre synaptic reuptake of dopamine, increasing dopamine at the synapse, increased firing of post synaptic dopamine neurone
Chronic use - down regulation of number of post-synaptic dopamine receptors - normal response to same amount of cocaine despire increase dopamine levels at synapse
How does tolerance occur in alcohol use
Inducing of enzymes in the liver which breakdown alcohol
What is substance dependence
State of needing a drug to be in homeostasis
Substance dependence is the medical term used to describe use of drugs or alcohol that continues even when significant problems related to their use have developed. Signs of dependence include:
Tolerance to or need for increased amounts of the drug to get an effect
Withdrawal symptoms that happen if you decrease or stop using the drug that you find difficult to cut down or quit
Spending a lot of time to get, use, and recover from the effects of using drugs
Withdrawal from social and recreational activities
Continued use of the drug even though you are aware of the physical, psychological, and family or social problems that are caused by your ongoing drug use
Aetiological factors in addiction
Genetic
Neurobiological (dopamine level increase - cannaboniod response increase leading to increase of dopamine in cannabis use, Cocaine is a dopamine reuptake inhibitor)
Social
Behavioural (reward response when taking, negative response in withdrawal)
Environmental
Attachment (neglectful primary carers leading to reduced opiate responses in the brain)
What factor is implicated in most substance abuse initially?
Social factors
How does alcohol dependence prevalence differ in homeless populations
Gen pop - 9% of men, 4% of women
Homeless - 38%
Causes of alcohol related death?
- Fights and falls
- Liver failure (sudden insidious death more common)
- Sudden / Long slow
- Pancreatitis (can be due to one off binge)
- Overdose (emetogenic + inhibition of respiratory centre - aspiration)
- Withdrawal
- Wernikes Encephalopathy
Worrying symptoms in patient with hx of ETOH
Head Injury
Confusion
Shaking / Seizures
Hallucinations (esp visual)
Vomit blood or coffee grinds
Severe abdo pain
Sudden yellow
Early symptoms of alcohol withdrawal?
Tremor
Sweating
Tachycardia
Anxiety
Nausea
Late symptoms of alcohol withdrawal?
Delirium Tremens
Disorientation
Hallucination
Tremor
BP, pulse, fever, motor incoordination
How do benzodiazepines treat alcohol withdrawal?
chronic alcohol consumption:
-ENHANCES GABA mediated inhibition in the CNS (similar to benzodiazepines)
-INHIBITS NMDA-type glutamate receptors
Alcohol withdrawal:
- decreased inhibitory GABA and
- increased NMDA glutamate transmission
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels - given in leiu of the alcohol and then slowly withdrawn while homeostasis is restored
What type of nystagmus occurs in WE?
Horizontal
Eye abnromalities in WE
Opthalmoplegia
6th nerve palsy
Horizontal nystagmus
Abnormally pupilary reflexes (non reactive miotic pupil)
Pstosis
Memory impairment in Korsakoffs
Prominent impairment of recent and remote memory
Confabulation marked but not always present
Immediate recall usually preserved
Disordering of time
Impaired ability to learn new things
Most common sign in opioid intoxication
Pin point pupils
Management of opioid overdose
ABCDE
IM naloxone (veins may be sclerosed in IVDU, IM works as quickly as IV)
Why might known heroin users be given IM naloxone preperations to take away
If using socially, to give to other users if they overdose
Early opioid withdrawal?
~12 hrs
Sweaty clammy skin
Dilated pupils
Persistent yawning
Lacrimation
Rhinorrhoea
Goosebumps
Tachycardia
Restlessness
Late opioid withdrawal?
Days 2-3
Nausea and vomiting
Diarrhoea
Abdominal cramps
Insomnia
Muscle pains
How long does opioid withdrawal last without treatment (ie. not using methadone)
7-9 days
Methadone advantages
Less addictive:
Heroin (4-6 hour half life), methadone half life over 24 hours
Reduced mortality in heroin users
Why is methadone always started at 30mg and only if symptoms of withdrawal present?
40mg fatal in non tolerant
Extra 10mg can be used if withdrawal symptoms persist after using 30mg
Buprenorphine (subutex) drug class
Opioid partial agonist-antagonists
Why is Buprenorphine (subutex) not used when patients are actively using opioids?
More tightly bound to opioid receptor than heroin or methadone
If used in patient with dependence who is using methadone or heroin - displaces opioid - causing withdrawal
When might use of Buprenorphine (subutex) be dangerous
Overdose unlikely when used alone, but may pose risk if using over drugs that cause respiratory depression (alcohol, benzodiazepines)
Why is opiate detox dangerous?
Increased mortality (relapse)
Why is alcohol detox dangerous?
High risk of relapse, and detox its self is dangerous to the brain
How does benzo withdrawal differ symptom wise from alcohol withdrawal?
Hallucinations tend to occur earlier
Less autonomic symptoms early on (tremor, tachycardia)
Which benzodiazepine is used in benzo withdrawal
Diazepam - 70 hour half life
Which benzodiazepines are more addictive?
Shorter acting - e.g. lorazepam, temazepam
Stimulants that are often abused?
Cocaine
Amphetamines
Stimulant abuse consequences?
Haemorrhagic stroke
Reduced blood supply to heart - MI
Vasoconstriction - increased BP (more so in cocaine than amphetamines)
What compound can cocaine and alcohol form in the blood stream if used together?
Cocaethylene
Cocaine has a short half life - Cocaethylene lasts twice as long
Cocaethylene - more vasoconstrictive than cocaine
Cocaethylene - subjectively patients feel less drunk (but are objectively more drunk)
Hallucinogens which may lead to acute psychosis
Cannabis
LSD
Ketamine
Magic mushrooms
Novel psychiatric substances
Mamba and spice - artifical Cannabinoids
Can cause psychosis, seizures
Dual diagnosis
Dual diagnosis is the term used to describe patients with both severe mental illness (mainly psychotic disorders) and problematic drug and/or alcohol use
Opiates are more Anti-psychotic
Stimulants can directly cause psychosis
Cannabis: Increase prevalence psychosis
Alcohol: Depresso-genic
What is ABV
ABV is a measure of the amount of pure alcohol as a percentage of the total volume of liquid in a drink.
Medications in alcohol withdrawal
Chlordiazepoxide – which is a benzodiazepine. Prescribed at high doses initially, and gradually reduced and stopped over about 10 days. This is an oral medication to help with the symptoms of alcohol withdrawal.
IV or IM Pabrinex – a b vitamin compound to prevent the development of Wernickes Encephalitis. Oral Thiamine and multivitamins should be prescribed after a course of Pabrinex. With the amount this patient is drinking oral supplements will not be sufficient.
Need to consider a PRN/as required medication in case the patient has a seizure. This could be 10mg diazepam PR.
What tool can be used to quantify alcohol dependence
SADQ
SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE
Alcohol dependence: investigations
Full blood count,
INR,
Urea and electrolytes,
Liver function tests inc Gamma-glutamyl transferase, Thyroid function tests,
Lipid profile,
Vitamin B12, folate,
Calcium, Magnesium, Phosphate, Glucose, ECG
Observations at regular intervals (at least every 6 hours). Temperature, pulse, respiratory rate & blood pressure must be monitored. May need to be more frequent for patients judged to be at risk of developing Delirium Tremens or other serious complications. This should be continued for the first 24 hours from admission and then twice daily for the duration of the detoxification therapy.
Obeservations in alcohol dependence
At least every 6 hours for the first 24 hours from admission and then twice daily for the duration of the detoxification therapy
What specific questionaire can be used quickly to screen for alcohol abuse
CAGE
What scoring system is appropriate to assess patients in alcohol withdrawal
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale can be used to assess alcohol withdrawal severity
