Substance Misuse Flashcards
How to assess alcoholism?
CAGE
Cut down - has anyone asked you
Annoyed - when people ask you to stop
Guilt
Eye opener - start mornings with a drink
Score on CAGE that is concerning
More than 2
What score do you use after CAGE to gauge severity of alcoholism?
AUDIT-C
What questions ask in AUDIT-C?
How often did you have a drink containing alcohol in the past year? - Never, monthly or less, 2-4 x a month, 2-3 x a week, 4+ x a week (+4)
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? - 1 or 2 drinks = 0, 3 or 4, 5 or 6, 7- 9, 10+ = 4 points
How often did you have six or more drinks on one occasion in the past year? - never, less than monthly, monthly, weekly, daily or almost (+4)
How long does it take to metabolise a unit of alcohol?
one hour
Classical drinking HbA1c?
Anaemia in alcoholism
B12/folate
Macrocytic
Fe deficient - iron absorption not done properly
What is concordant with alcohol misuse in females vs males off AUDIT c?
Females > 3
Males >4
Specific liver test for alcohol function
GGT
What does GGT test for?
Liver inflammation
What can you do in emergency situation for alcohol?
Blood alcohol level
What does a score over 5 from AUDIT C mean?
Alcohol misuse, possible liver damage
What do when alcoholics come in?
Refer to self help groups
Explore reasons behind it
What can you give to alcoholics in withdrawal adn DTS
Chlordiazapoxide
Banana bag - with vitamins to support them
Benzodiazapines
(Delirium tremens - IV fluids, antipsychotic meds, anticonvulsants, paracetemol)
What to tell people about stopping alcohol?
Do not stop cold turkey
What can immediate cessation of alcohol cause?
Alcohol withdrawal syndrome Wernickes/Brocas
Seizures
What classifies as heavy drinking?
Men >15 drinks per week
Women > 8 drinks per week
Alcohol affects on neurotransmitters
GABA increased
Glutamate decreased
What causes alcohol withdrawal syndrome?
Unnaturally low GABA levels
Glutamate spikes
Mild symptoms of withdrawal
Anxiety
Irritability
Headache
Shakiness
Sweating
Depression
Mood swings
Loss of appetite
Mild confusion
N+V
Moderate symptoms comon with alcohol withdrawal
12 - 24 hours after last drink
Confusion
Disorientation
Hallucinations
Seizures
Severe symptoms common with alcohol withdrawal and when occurs
High BP
Increase HR, RR, pulse
Extreme confusion and agitiation
Persistent hallucinations (visual, auditory, tactile)
Seizures
Tremors (DTS)
Fever
What is delirium tremens?
Psychotic condition involving tremors, hallucinations, anxiety, disorientation
Phases of alcohol withdrawal?
Stage 1 - 6-24 hours
Stage 2 - 24-48 hours
Stage 3 - 48-96 hours
Stage 1 alcohol withdrawal
N+V
Heachaes
Insomnia
Anxiety
Stage 2 alcohol withdrawal
24-48 hours
Heightened HR, BP, elevate body temo, seizures, hallucinations
Stage 3 acohol withdrawal
48-96 hours
Seizures and tremors
Mood changes and agitation
Severe adn allucinations
Stage 3 acohol withdrawal
48-96 hours
Seizures and tremors
Mood changes and agitation
Severe adn allucinations
AUDIT vs AUDTI-C
AUDIT-C is 3 qs gives indication if need to ask 10 qs of AUDIT
Risk factors for delirium tremens
Cirrhosis
Alcoholuc cardiomyopathy
Alcoholic neuropathy
Presence of co-occurring mental disorders
Questions to ask about delirium tremens
When did the person last have a drink?
How much does the person typically drink per day?
Since when does he or she drink?
Has he or she ever had delirium tremens before, including a seizure?
Has he or she tried to stop drinking before? If so, were there any withdrawal symptoms?
Does the person have a mental or physical disorder? Are they getting treatment for it?
Do they take illegal drugs or prescription medication?
What domains does the AUDIT test?
- alcohol intake;
- potential dependence on alcohol, and;
- experience of alcohol-related harm.
What domains does the AUDIT test?
- alcohol intake;
- potential dependence on alcohol, and;
- experience of alcohol-related harm.
How is the AUDIT scored?
Out of 40
10 questions each 0-4
What AUDIT score suggests a harmful or hazardous alcohol consumption?
8-14
What AUDIT score suggests a harmful or hazardous alcohol consumption?
8-14
What does a score of 15 or more on the audit suggest?
Likelihood of alcohol dependence - modersate-severe alcohol use disorder
What level of risk factor is alcohol in UK for death and disability?
Third after smoking and obesity
What can alcohol be a causal factor in?
Over 60 medical conditions including:
-Liver disease
-Mouth
-Throat, stomach, liver and breast cancers, heart disease and depression
What is caused by drinking in pregnancy?
Foetal alcohol spectrum disorder
What to do if audit score 8-15
Hazardous drinking - brief inervention
What to do if audit score 16-19
Harmful drinking
Extended brief interventionn
Review and refer to speicalist if noimprovenent
What to do if audit score over 20
Probably alcohol dependencce
Withdrawaal assessment/specialtist assessment
How sensitice is GGT to dirnking?
Low sensitivity and specificit y
What biomarker has the best sensitivity and sensitivity for alcohol use?
Carbohydrate deficient transferrin
Alchol withdrawal syndromes
Uncomplicated alcohol withdrawal syndrome
Alcohol withdrawal syndrome with seizures
Delirium tremens
Alchol withdrawal syndromes
Uncomplicated alcohol withdrawal syndrome
Alcohol withdrawal syndrome with seizures
Delirium tremens
When is carbohydrate deficient transferrin used?
Rarely in clincial practise
In community to prove someone is no longer drinking over long period of time
When does uncomplicated alcohol withdrawal syndrome occur?
4-12 hours after last drink
What happens in uncomplicated alcohol withdrawal syndrome?
Coarse tremor
Nausea and vomitting
Sweating
Insomnia
Tachycardia
Agitation
Anxiety
Hallucinations
What % of withdrawal syndromes are with seizure?
5-15%
Delirium tremens additional features
Clouding of consciousness
Amnesia of recent events
Psychomotor agitiation
Disorientation
Tactile/visual hallucinations
Heavy sweating
Paranoid Delusions
Raised temperature
Sudden cardiovascular collapse
Detailed assessment for people with harmful drinking and dependence
Quantitiy, frequency and pattern of consumption
Severity of dependence Alochol related problems
Use of other drugs
Physical or mental health co-morbidity
Risk to self or others
Family hisotry
Motivation or readiness to change
Sociodemographic favtprs
Plannning treatment for alcohol addictionn
Make diagnosis - hazardous, harmful, dependent etc
Assess stafe of change - pre-contemplatice
Gial of intervation - continue current drinking pattern, change to a safer one, abstinence
Family support
Strategies
What is brief intervention used fir?
Hazardous and harmful drinkers
Infographics eg compared to general pop, consequences of drinking at the level that they are
22What is brief intervention used fir?
Hazardous and harmful drinkers
Infographics eg compared to general pop, consequences of drinking at the level that they are
Alcohol psych
Depression
Insomnia
Suicide
Anxiety
Personality change
Pscyhotic changes
Amnesia
Hallcuinations
Delirium tremens
Morbid jealousy - obsession about partner cheating
Social disintegration
Financial difficulties, homelessness
Risk factors
FH addiction
depression and anxiety
Types of harmful drinking
ICD-11
One episode eg binge drinking
Repeated pattern of harmful use
Acute intpxication
Transient confition after intake psychoactive substance -> disturbance of consciousness, cognition, perception or behaviour
Dependence ICD-11
> 2 of
Control - lack of/powerless - onset, intensity, termination, frequency, context
Precedence - over otjher aspects of healh
Physiological
Time - over 3 months
Dependence ICD-11
> 2 of
Control - lack of/powerless - onset, intensity, termination, frequency, context
Precedence - over otjher aspects of healh
Physiological
Time - over 3 months
Alcohol MOA
Enhances GABA
Downregulates NMDA and glutamate
why get withdrawal
decrease GABA
over active CNS
Increase glutamate - excitatory, sympathetic overdrive
What can cause fatality in withdrawal
Seizures
Symptoms of alcohol withdrawak
Sweating
Tremor hands, tongue, eyelids
Agitation/anxiety
Tachy
Fever
Nausea, vommitting, diarrhoea
HPTN
Hallucination - tactile - spiders/bugs etc
Delirium tremens vs withdrawal
Hallucinations or psychosis - visual
Significant tremor
What hallucinations in alchol withdrawal
Auditory and visual
Often still remian orientated
What is severity of withdrawal determined by?
How much alcohol drinking not length
What is the problem with chlordiazapine with addicts?
Its a benzo eg can be addictive
When is AUDIT used to screen for alcohol?
On admission to mental health hospital
When is AUDIT used to screen for alcohol?
On admission to mental health hospital
Alcohol hisotry
A typical days drinking - max in one day, frequenct etc
Presnce/severity of cdependence
Alcohol related physical, pscyhological and social probkems incl forensic hisotry
Risk
Previous interventions for problem and outcome
Patients expectations
What is the cycle of change
Prochaska and Diclemente
Precontemplation, contemplation, prep, action, maintenance, termination
OR relaspse -> contemplation again
Alcohol exam
Face
Hands and body
CNS
CVS
Abdo
Bloods in alcohol dependence
Raised LFTs
High GGT, ALT, AST
B12 and folate low
FBC - low Hb, High MCV
Controlled drinking
Below 40, detect ealy
No minimal
No major medical complications
No psych comorbidity
No impulsicity
Social stability
Patients choice
Controlled drinking
Below 40, detect ealy
No minimal
Pharmacotherapy options for alcohol addiciton - deterrent, anti craving, adjunctive
Deterrent - disulfiram - nasty sympotms after take
Anti craving - acamprosate
Adjunctive - antidepressants
Others - naltrexone
What interviewing use with alcohol problems?
Motivational interviewing
Assisted alcohol withdrawal
> 15 units a day or scroe over 20 on audit
Why is thiamine deficient in alcoholism
Helps break down carbs - alcohol is carbs, more thiamine needed
Alcohol stops thiamine absorption
Poor diet/malnourishment
How many people with wernickes go on to develop
80%
20% die
Treat wernickes
IV pabrinex for 5 days
What precedes korsakoffs
Wernickes
Symptoms of korsakoffs
Loss short term memory - anterograde
Hallucinations
Receptive aphasia
Confabulation
Recovery from korsakoffs
25% recover
50% improve but dont fully recover
Cocaine symptoms
Wired, dilated pupils, tremor
Presentation of heroin
Lethargic, sleepy
Presentation of opiate misuse
Pinprick pupils
Drowsy
Reduced respiratory rate
Drugs that can be targets of drug seeking behaviour
Tramadol
Cyclizine
Gabapentin
Pregabalin
