Substance misuse Flashcards
Name substances commonly misused
Opiates - heroin
Cannabis
LSD
Amphetamines - cocaine and meth
Nitrous oxide
GHB
Alcohol
Benzodiazepines
Anabolic steriods
Route of administration of cocaine?
Snorted (powder)
Smoked (crack cocaine)
Route of administration of heroin?
- ** injecting** either into a vein (“mainlining,” intravenous or IV use), into a muscle (intramuscular or IM use) or under the skin (“skin-popping” or subcutaneous use)
- **snorting **the powder through the nose (also called sniffing)
- inhaling or smoking (“chasing the dragon”), which involves gently heating the heroin on aluminum foil and inhaling the smoke and vapours through a tube.
Route of administration of cannabis?
Inhalation
Smoked - as shatter
Edibles
Route of administration of LSD?
Submucosal - on blotter paper which is put under tongue to be absorbed via mucous membranes
Injected - rarely done
Route of administration of nitrous oxide?
Inhaled
Route of administration of anabolic steriods?
Anabolic steroids come in the form of tablets, capsules, a solution for injection and a cream or gel to rub into the skin
Route of administration of GHB/GBL?
It is usually sold as a liquid in small vials.
GHB is also available as a white powder or capsule.
Why might a person have an addiction problem/ substance misuse issue?
- Genetic
- Neurobiological - related to dopamine receptors
- Social - being in social settings where drugs are
- Behavioural - pt drug use provides a high, which is like a reward.
- Attachment - (from lecture speaker) neglect as a child led to reduced dopamine in brain, so drugs can satisfy this ‘deficiency’
What should you ask in Hx of pt presenting with substance misues
- What drug
- How long have you had it? (when did they 1st try it? when did it become a problem?)
- How much? (in money terms, e.g. how much are you spending on this per day/week?)
- How often are you taking it?
- Withdrawal - what happens if you don’t have it?
- Previous treatment episodes - what was it?
- Complications to drug/ treatment?
- Overdose - what happened? What did they do at the hospital?
- BBV - have they been tested for HIv, HepB, HepC. Are vaccinations up to date?
- PMHx
- Social Hx - especially housing and support
How can alcohol (addiction/misuse) lead to mortality?
- fights and falls - head injuries
- liver failure
- pancreatiitis
- overdose –> vomit –> aspiration and choking
- withdrawal
- Wernike’s encephalopathy
How are units of alcohol calculated?
% alcohol X volume (ml)
then divide by 1000
For example, to work out the number of units in a pint (568ml) of strong lager (ABV 5.2%): 5.2 (%) x 568 (ml) ÷ 1,000 = 2.95 units.
Clincal features of alcohol intoxication?
Early:
* flushed skin
* impaired judgment
* reduced inhibition.
Late:
* impaired attention
* reduced muscle control
* slowed reflexes
* staggering gait
* slurred speech
* double or blurred vision.
then…
* black out
* inability to stand
* vomiting
* unresponsivness
* coma and death
Features of early alcohol withdrawal?
These symptoms start at 6-12 hours: Tremor
Nausea
Sweating
Anxiety
Tachycardia
Late clinical features of alcohol withdrawal?
At around 36hrs withdrawal: can get seizures
These usually happen at 48-72hours from withdrawal:
Delirium tremens
Disorientation/confusion
Hallucination (visual +auditory)
Coarse tremor
BP, tachycardia, fever, motor incoordination
How is alcohol withdrawal managed?
If have later features (delirium tremens, seizures, blackouts) = need to be admitted to hospital for monitoring until withdrawals stabilised.
1st line =long acting benzodiazepines e.g. chlordiazepoxide or diazepam. Given as part of a reducing dose protocol
Carbamazepine can also be effective.
+ high strength regular vitamin B replacement e.g. IM or IV
Clinical featurs of opiod misuse?
- not much !
- decreased consciousness
O/E:
- decreased RR
- decreased HR
- pin point pupils
Complications of opiod misuse (passmed)
- viral infection secondary to sharing needles: HIV, hepatitis B & C
- bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
- venous thromboembolism
- overdose may lead to respiratory depression and death
- psychological problems: craving
- social problems: crime, prostitution, homelessness
Emergency management of an opiod overdose?
A-E assessment
IM (or IV) naloxone - has a rapid onset and relatively short duration of action
What interventions could you apply to reduce harm reduction in an IV drug user?
Needle exchange
Offer testing for HIV, Hep B and Hep C
Management of opiod dependence?
passmed
- patients are usually managed by specialist drug dependence clinics although some GPs with a specialist interest offer similar services
- patients may be offered maintenance therapy or detoxification
- NICE recommend methadone or buprenorphine as the first-line treatment in opioid detoxification
- compliance is monitored using urinalysis
Clinical features of cannabis intoxication/misuse?
- drowsiness
- impaired memory
- slowed reflexes and motor skills
- bloodshot eyes
- increased appetite
- dry mouth
- increased HR
- Paranoia
Use of what drug can lead to psychosis?
Cannabis
Clinical features of LSD intoxication?
- labile mood
- hallucinations
- sweating
- insomnia
- dry mouth
Beside tests could show:
* increased BP
* increased HR
* increased temp
What condition do we worry about in patients with alcohol dependence?
Wernicke’s encephalopathy
which can progress to Korsakoff’s syndrome
What symptoms are present in early opiate withdrawal (the first 12hours)?
- Sweaty, clammy skin
- persistant yawning
- rhinorrhoea
- tachycardia
- restlessness
- dilated pupils
- lacrimation
- goosebumps
What are symptoms of late opiate withdrawal (days 2-3)?
- N+V
- diarrhoea
- insomnia
- abdo cramps
- muscle pains
What are the benefits of methadone for pts who have opiate substance misuse?
Saves lives
Less addictive
Allows people to move on, get support and therapy
What two drugs can be offered for opiod detoxification?
Methadone
Buprenorphine
How does buprenorphine work in heroin detoxification?
(ICPP)
- It is a partial agonist (aka mixed agonist-antagonist)
- It has a higher affinity for receptors compared to heroin, so herion will be unable to access all the receptors.
- this allows a more controlled response
What are the clinical features of stimulant intoxication (cocaine, methamphetamine)?
- euphoria
- increased BP
- increased HR
- increased temp
for cocaine (pass med) - agitation, psychosis, hallucinations
Mechanism of action of cocaine?
Blocks the re-uptake of dopamine, noradrenaline and serotonin
So these remain in blood for longer = pleasurable effects
What are cardiovascular effects of cocaine?
- Coronary artery spasm –> lead to MI
- Tachycardia or bradycardia
- HTN
- On ECG: QRS widening and QT prolongation
- Aortic dissection
What are neurological effects of cocaine?
- seizures
- mydriasis
- hypertonia
- hyperreflexia
aneurysmal subarachnoid haemorrhage
What is the management of cocaine toxicity?
- 1st line: Benzodiazepines
- for chest pain - benzo + glyceryl trinitrate. If MI develops - need primary percutaneous coronary intervention
- for HTN - benzo + sodium nitroprusside
Mechanism of action of benzodiazepines?
Enhance effect of inhibitory neurotransmitter GABA by increasing the frequency of chloride channels.
- How long should benzos be prescribed for?
- If a pt is on benzos, how should they be withdrawn?
- 2-4 weeks max
- withdrawn in steps based on the daily dose every fortnight.
What is the risk of withdrawing from benzodiazepines too quickly?
Pt may experience benzodiazepine withdrawal syndrome
What are features of benzodiazepine withdrawal syndrome?
- Seizures
- insomnia
- irritability
- anxiety
- tremor
- loss of appetite
- tinnitus
- perspiration
- perceptual disturbances
Who is at risk of substance misuse?
- people with MH problems
- sexually assulted / exploited
- commercial sex work
- unemployed
- children who live in families who use drugs
- homeless/ supported accomm or hostels
- people who attend nightclubs/festivals
- gyms - performance enhancing drugs
- low socioeconomic background
from passmed
How is alcohol dependence managed?
- need oral thiamine
- benzodiazepines for acute withdrawal
- disulfram - promotes abstienence
- acamprosate - reduces craving.
from passmed
How long does detoxification last for substance misuse?
Up to 4 weeks in an inpatient/residential setting
Up to 12 weeks in the community
What are social management options for someone who has substance misuse? (i.e. what could you implement regarding their social circumstances)
- Appts / routine contact for needle exchange and offer testing for BBV
- social support for housing
- financial support
add any others if you find them
What are psychological management options for someone with substance misuse?
Behavioural therapy
Behavioural family interventions
CBT
Motivational interviewing (?)
Group based talking therapies
Self help guides/ self help groups - e.g. Narcotics Anonymous
