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Year 4 Psychiatry > Substance Misuse > Flashcards

Substance Misuse Flashcards

1
Q

What is the pathophysiology of alcohol withdrawal?

A

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

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2
Q

At what stage to symptoms of alcohol withdrawal begin?

A

6-12 hours

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3
Q

Features of alcohol withdrawal

A

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

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4
Q

In alcohol withdrawal, when is the peak incidence of seizures?

A

36 hours

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5
Q

In alcohol withdrawal, when is the peak incidence of delirium tremens?

A

Around 48-72 hours

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6
Q

In alcohol withdrawal, when is the peak of symptoms delirium tremens?

A

Days 4 to 5

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7
Q

Signs and symptoms of delirium tremens

A

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

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8
Q

Management of alcohol withdrawal?

A

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

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9
Q

How can opiate withdrawal present?

A

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.

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10
Q

Course of heroin withdrawal?

A

Withdrawal from heroin can begin as early as 6 hours after the last dose, with symptoms peaking at 36-72 hours.

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11
Q

How does the severity of alcohol withdrawal differ to opioid withdrawal?

A

Unlike alcohol withdrawal, opioid it is unpleasant but not especially dangerous.

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12
Q

Management of opioid withdrawal

A

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.

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13
Q

Symptoms of Opiate Intoxication

A

Drowsiness
Confusion
Decreased respiratory rate
Decreased heart rate
Constricted pupils

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14
Q

Symptoms of cannabis intoxication

A

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

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15
Q

Symptoms of LSD intoxication

A

Labile mood
Hallucinations
Increased blood pressure
Increased heart rate
Increased temperature
Sweating
Insomnia
Dry mouth

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16
Q

Symptoms of stimulant intoxication

A

Euphoria
Increased blood pressure
Increased heart rate
Increased temperature

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17
Q

Role of naloxone

A

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.

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18
Q

Benzodiazepine withdrawal signs/symptoms

A

insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
depersonalisation
Weight loss

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19
Q

In what ways may excessive use of alcohol present to the psychiatrist?

A

Withdrawal symptoms (6-12 hours) anxiety and tremor, (48-72 hours) DT: confusion, delusions, hallucinations

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20
Q

Consequences of opioid

A
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21
Q

What are the health risks (physical and psychosocial) of illicit opioid use?

A
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22
Q

What does harm minimisation mean?

A

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

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23
Q

Recommended maximum alcohol intake for men and women

A

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

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24
Q

How to calculate units of alchol

A

the total volume of a drink (in ml) X ABV (measured as a percentage)

—————————————————————————————————-

                                                   1000
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25
Q

Alcohol withdrawal timeline

A
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26
Q

Which illicit drugs may produce a schizophrenia-like state?

A

Cocaine
Cannabis (THC component)

Amphetamines and methamphetamine
Psychedelic drugs such as LSD or magic mushrooms
Club drugs such as ecstasy and MDMA

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27
Q

ICD 10 criteria for dependence syndrome

A

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)

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28
Q

How does chronic alcoholism lead to the occurrence of wernicke korsakoff syndrome

A
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29
Q

Substance misuse history

A

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

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30
Q

What is Naltrexone and when is it used?

A

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

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31
Q

Why are drugs which reach peak concentration faster more addictive?

A

More reinforcing (instant gratification)

32
Q

Why is oral consumption of cocaine less common than snorting?

A

Oral: 1st pass metabolism - liver removes 1/3

Snorting: effects within 15 mins vs 45 mins orally

33
Q

What is the concept of reinforcement

A

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.

34
Q

What is tolerance

A

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

35
Q

How does tolerance occur in cocaine use

A

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

36
Q

How does tolerance occur in alcohol use

A

Inducing of enzymes in the liver which breakdown alcohol

37
Q

What is substance dependence

A

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

38
Q

Aetiological factors in addiction

A

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)

39
Q

What factor is implicated in most substance abuse initially?

A

Social factors

40
Q

How does alcohol dependence prevalence differ in homeless populations

A

Gen pop - 9% of men, 4% of women
Homeless - 38%

41
Q

Causes of alcohol related death?

A
  • 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
42
Q

Worrying symptoms in patient with hx of ETOH

A

 Head Injury
 Confusion
 Shaking / Seizures
 Hallucinations (esp visual)
 Vomit blood or coffee grinds
 Severe abdo pain
 Sudden yellow

43
Q

Early symptoms of alcohol withdrawal?

A

Tremor
Sweating
Tachycardia
Anxiety
Nausea

44
Q

Late symptoms of alcohol withdrawal?

A

Delirium Tremens
Disorientation
Hallucination
Tremor
BP, pulse, fever, motor incoordination

45
Q

How do benzodiazepines treat alcohol withdrawal?

A

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

46
Q

What type of nystagmus occurs in WE?

A

Horizontal

47
Q

Eye abnromalities in WE

A

Opthalmoplegia
6th nerve palsy
Horizontal nystagmus
Abnormally pupilary reflexes (non reactive miotic pupil)
Pstosis

48
Q

Memory impairment in Korsakoffs

A

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

49
Q

Most common sign in opioid intoxication

A

Pin point pupils

50
Q

Management of opioid overdose

A

ABCDE
IM naloxone (veins may be sclerosed in IVDU, IM works as quickly as IV)

51
Q

Why might known heroin users be given IM naloxone preperations to take away

A

If using socially, to give to other users if they overdose

52
Q

Early opioid withdrawal?

A

~12 hrs
Sweaty clammy skin
Dilated pupils
Persistent yawning
Lacrimation
Rhinorrhoea
Goosebumps
Tachycardia
Restlessness

53
Q

Late opioid withdrawal?

A

Days 2-3

Nausea and vomiting
Diarrhoea
Abdominal cramps
Insomnia
Muscle pains

54
Q

How long does opioid withdrawal last without treatment (ie. not using methadone)

A

7-9 days

55
Q

Methadone advantages

A

Less addictive:
Heroin (4-6 hour half life), methadone half life over 24 hours

Reduced mortality in heroin users

56
Q

Why is methadone always started at 30mg and only if symptoms of withdrawal present?

A

40mg fatal in non tolerant

Extra 10mg can be used if withdrawal symptoms persist after using 30mg

57
Q

Buprenorphine (subutex) drug class

A

Opioid partial agonist-antagonists

58
Q

Why is Buprenorphine (subutex) not used when patients are actively using opioids?

A

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

59
Q

When might use of Buprenorphine (subutex) be dangerous

A

Overdose unlikely when used alone, but may pose risk if using over drugs that cause respiratory depression (alcohol, benzodiazepines)

60
Q

Why is opiate detox dangerous?

A

Increased mortality (relapse)

61
Q

Why is alcohol detox dangerous?

A

High risk of relapse, and detox its self is dangerous to the brain

62
Q

How does benzo withdrawal differ symptom wise from alcohol withdrawal?

A

Hallucinations tend to occur earlier
Less autonomic symptoms early on (tremor, tachycardia)

63
Q

Which benzodiazepine is used in benzo withdrawal

A

Diazepam - 70 hour half life

64
Q

Which benzodiazepines are more addictive?

A

Shorter acting - e.g. lorazepam, temazepam

65
Q

Stimulants that are often abused?

A

Cocaine
Amphetamines

66
Q

Stimulant abuse consequences?

A

Haemorrhagic stroke
Reduced blood supply to heart - MI
Vasoconstriction - increased BP (more so in cocaine than amphetamines)

67
Q

What compound can cocaine and alcohol form in the blood stream if used together?

A

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)

68
Q

Hallucinogens which may lead to acute psychosis

A

Cannabis
LSD
Ketamine
Magic mushrooms

69
Q

Novel psychiatric substances

A

Mamba and spice - artifical Cannabinoids
Can cause psychosis, seizures

70
Q

Dual diagnosis

A

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

71
Q

What is ABV

A

ABV is a measure of the amount of pure alcohol as a percentage of the total volume of liquid in a drink.

72
Q

Medications in alcohol withdrawal

A

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.

73
Q

What tool can be used to quantify alcohol dependence

A

SADQ
SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE

74
Q

Alcohol dependence: investigations

A

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.
75
Q

Obeservations in alcohol dependence

A

At least every 6 hours for the first 24 hours from admission and then twice daily for the duration of the detoxification therapy

76
Q

What specific questionaire can be used quickly to screen for alcohol abuse

A

CAGE

77
Q

What scoring system is appropriate to assess patients in alcohol withdrawal

A

The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale can be used to assess alcohol withdrawal severity

Year 4 Psychiatry (18 decks)

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