Substance misuse Flashcards

1
Q

Dependence and recommended alcohol intake

A

Recommended units per week- 14 for men and women, 5-6 glasses of wine or pints of beer.

Dependence: ICD-11 criteria (>2= of)
* Control (Powerlessness): over onset, intensity, duration, termination, frequency, context
* Precedence: over other aspects of health (bio-psycho-social)
* Physiological: tolerance, withdrawal, used to prevent/alleviate withdrawal

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2
Q

Symptoms of addiction

A
  • Impaired control of substance: duration, context
  • Craving
  • Increasing prioritisation
  • Physiological features i.e. hallucinations. Not required for diagnosis
  • Tolerance and withdrawal, insufficient in themself for diagnosis
  • Physical and mental harm, often seen not required for diagnosis
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3
Q

If not dependence: what is it?

A
  • Hazardous drinking is a risk factor for adverse consequences (bio-psycho-social) for self or others
  • Harmful drinking is a pattern of alcohol consumption that results in adverse consequences (bio-psycho-social). >12 months (or 1 month if continuous)
  • An Episode of Harmful drinking is drinking that leads to harm, but without a pattern
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4
Q

Psychological harm from alcohol dependence

A

Insomnia, Depression, Suicide, Attempted suicide, Anxiety state, Personality change, Psychotic illness, Amnesia, Alcoholic halllucinosis, Morbid jealousy, Delirium tremens

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5
Q

Alcohol withdrawal manifestations

A
  • Onset 3-12 hours
  • Peaks 24-48 hours
  • Duration up to 14 days
  • Agitation/ anxiety/ irritability
  • Tremor hands/ tongue/ eyelid
  • Sweating, fever, tachycardia, hypertension, general malaise
  • Nausea/ vomiting/ diarhhoea
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6
Q

Severe alcohol withdrawal/complications

A
  • Seizures: may commence before blood alcohol zero
  • Delirium tremens: clouding of consciousness, hallucinations/psychosis. Tremor +++, sympathetic overdrive
  • Delirium tremens: develops on 5%. Mortality 10-20% if untreated. Medical emergency, needs prompt transfer to general medical setting
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7
Q

Mechanism: alcohol withdrawal

A
  • chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
  • alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission). This causes over- activity of the central nervous system and increase in the action of glutamate. Leading to profound excitatory action and sympathetic overdrive
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8
Q

Features: 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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9
Q

Management: 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
  • 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
  • carbamazepine also effective in treatment of alcohol withdrawal
  • phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
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10
Q

Alcohol withdrawal treatment plan

A
  • ABC
  • +DEFG!
  • Physical observations, ECG
  • Bloods – incl. FBC, U and E, LFTs, clotting, amylase +/- CK +/- blood cultures
  • IV thiamine
  • Diazepam / chlordiazepoxide; likely symptom triggered
  • PRN medication in case of seizure; midazolam/ diazepam as per policy
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11
Q

Treating alcohol dependence

A
  • Alcohol Detoxification
  • Pharmacotherapy
  • Manage physical illness occurring as consequence of alcohol (e.g. Liver Transplant)
  • Psychotherapy
  • Social Interventions
  • Residential Rehabilitation
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12
Q

Alcohol detoxification: management

A
  • Where: home, partial hospitalisation, inpatient
  • General support/advice
  • Drug of choice- longer acting benzodiazepines
  • Regular monitoring: observe for withdrawal/ over-sedation. BAC/CIWA
  • Treat withdrawal: symptoms triggered/ fixed dose etc. Risk of undertreatment (DT’s/fits). Risk of overtreatment (over-sedation)
  • Oral/IM vitamins as indicated
  • Reducing regime
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13
Q

Alcoholism: Wernicke-Korsakoff syndrome

A
  • Occurs secondary to thiamine deficiency
  • Triad of: ocular disturbances, gait disturbance, confusion
  • Korsakoff’s: global impairment including confabulation
  • Wernicke’s= acute syndrome. Korsakoff’s= long term neurological sequelae of Wernicke’s. In reality distinction between the two syndromes is often difficult. Degree of reversibility if treated promptly
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14
Q

Features of Wernicke- Korsakoff syndrome

A
  • oculomotor dysfunction: nystagmus (the most common ocular sign), ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
  • gait ataxia
  • encephalopathy: confusion, disorientation, indifference, and inattentiveness
  • peripheral sensory neuropathy
  • Korsakoff: confabulation, amnesia
  • Investigations: decreased red cell trasketolase, MRI
  • Causes: poor dietary intake and reduction in duodenal capacity for absorption secondary to low alcohol intake
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15
Q

Longer term prevention of alcoholism

A
  • Deterrent= Disulfiram
  • Anti-craving= Acamprosate
  • Treatment of co-morbid conditions i.e. Antideppressants
  • Others i.e. Naltrexone
  • For patients who do not require detoxification- consider nalmefene
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16
Q

Hazardous vs harmful vs binge drinking

A

hazardous: >15 U/week

harmful: >50 U/week (men), >35/week (women)

binge: >8 U in a single session (men), >6 U (women)

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17
Q

FAST screening tool for drinking

A
  1. How often do you have 8+ drinks on one occasion?
  2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
  3. How often during the last year have you failed to do what was normally expected of you because of your drinking?
  4. Has a relative or friend, a doctor or other health worker been concerned about your drinking or suggested you cut down?
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18
Q

AUDIT screening tool and biological markers

A

A 10-item screen can quickly identify substance abuse problems (known as Alcohol Use Disorders Identification Test)

Distinguishes between low risk, hazardous drinking, harmful drinking, and possible dependence.

Which biological marker has the best sensitivity and specificity for alcohol abuse: Carbohydrate deficient transferrin

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19
Q

Alcoholism screening tests and smoking cessation

A

Screening tests: AUDIT, AUDIT-C (shortened version), AUDIT- PC, FAST, M-SASQ

Smoking cessation= big overlap with alcoholics. Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

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20
Q

Drugs

A

Drugs= a substance which produces a non-nutritional physiological effect when introduced to the body.

Cannabis is the most widely used illegal drug

Almost half of all drug poisonings involve an opiate, over half of all drug poisonings involve more than one drug.

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21
Q

Withdrawal

A

The experience of a set of unpleasant symptoms following the abrupt cessation or reduction in dose of a psychoactive substance; it has been consumed in high enough doses and for a long enough duration for the person to be physically or mentally dependent on it. Withdrawal symptoms are, essentially, opposite to those that are produced by the psychoactive substance itself.

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22
Q

Acute intoxication and Overdose

A

ACUTE INTOXICATION is a transient condition following intake of a psychoactive substance resulting in disturbances of consciousness, cognition, perception, affect, or behaviour.

OVERDOSE is the use of any drug in such an amount that acute adverse physical or mental effects are produced.

23
Q

Dependence

A

> =2 of
* Control (Powerlessnes): over onset, intensity, duration, termination, frequency, context
* Precedence: over other aspects of health (bio-psycho-social)
* Physiological: tolerance, withdrawal, use to prevent/alleviate withdrawal
* Time course: >12 months (or 3 months if continuous)

24
Q

Harmful use of drugs

A

A pattern of use that has caused damage to the persons physical or mental health or has resulted in behaviour leading to harm to the health of other (bio-psycho-social). >12 months or 1 month if continuous.

25
Q

Diacetylmorphine (Heroin)

A
  • Heroin and other opiates are depressants of the nervous system: Act via opioid receptor. Brain, spinal cord, peripheral neurons, and digestive tract.
  • They slow down body functioning and are strong painkillers.
  • The effect is usually to give a feeling of warmth, relaxation and detachment with a lessening of anxiety.
  • Effects start quickly and can last several hours.
26
Q

Opiate withdrawal

A
  • Early= agitation, muscle ache, restlessness, anxiety, increased tearing, runny nose, excessive sweating, yawning often
  • Later= Diarrhoea, abdominal cramping, nausea and vomiting, skin goose bumps, dilated pupils, rapid heartbeat, high blood pressure
27
Q

Diagnosing: substance misuse

A
  • History: Substance, quantity, pattern, recent events. Control (initiation, cessation etc). Impact on life, other info sources
  • Examination: features of withdrawl/intoxication. Needle marks
  • Investigation: UDS/ formal toxicology
  • Alcohol and other drugs
  • Needle sharing and other risky behaviour
  • Mental/physical/social health
  • General examination
  • BBV (blood born virus) screening
28
Q

Pharmacological treatment of opioid dependence

A
  • Agonism: short acting (heroin assisted treatment), long acting (methadone)
  • Partial agonism: Long acting (buprenorphine), Very long acting (extended release buprenorphine)
  • Antagonism: Short acting (naloxene), long acting (naltrexone), very long acting (extended release naloxene)
29
Q

Features of opioid misuse and emergency treatment of overdose

A
  • rhinorrhoea
  • needle track marks
  • pinpoint pupils
  • drowsiness
  • watering eyes
  • yawning

Emergency management of opioid overdose= IV or IM naloxone: has a rapid onset and relatively short duration of action

30
Q

Complications of opioid misuse

A
  • 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
31
Q

Opioid addiction: harm reduction interventions may include

A
  • needle exchange
  • offering testing for HIV, hepatitis B & C
32
Q

Management of opioid dependence

A
  • 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
  • detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
33
Q

What is cocaine and crack

A
  • Natural product of coca-leaves
  • Processed to produce cocaine hydrochloride (powder), acid- insufflated or injected
  • Freebase (inc. crack): solid (rocks), alkaline w/low melting point- smoked
34
Q

Comparing powdered cocaine and crack

A
  • Powdered cocaine (acid): mainly snorted (+/- inj). Starts in a few mins, full high at 15-30 mins, gradual come down. £40-50 per gram
  • Crack: crystalised (alkaloid), mainly smoked (+/- inj). Starts in a few seconds but very short with rapid come down. £15-20per rock, smaller rocks are cheaper
35
Q

How cocaine and other amphetamine like stimulants work

A
  • Binds to monoamine transporters increasing Dopamine, Serotonin and Noradrenaline in the synaptic cleft.
  • Dopamine transporters are all throughout the brain
  • Important action on the limbic system (emotional responses and memories): dopamine responsive cells are highly concentrated in this system. Nucleus accumbens important in cocaine high
36
Q

Effects of cocaine

A
  • Excited, confident and/or anxious, happy, panicky, risk-taking
  • Tachycardia, tachypnoea, hypertension, hyperthermia, nausea, sweating, shaking
  • If use continues: Decreased need for sleep, appetite suppression, paranoia, hallucinations, mood swings/depression
  • The way the drug affects memories of the euphoric sensation, keeps users coming back to it, chasing the first high
  • The way the brain adapts to the disrupted dopamine and other mono-amines produces mood instability or depression.
37
Q

Management of cocaine toxicity

A
  • in general, benzodiazepines are generally first-line for most cocaine-related problems
  • chest pain: benzodiazepines + glyceryl trinitrate, if myocardial infarction develops then primary percutaneous coronary intervention
  • hypertension: benzodiazepines + sodium nitroprusside
  • the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue: The American heart association advises against it but some cardiologists still do
38
Q

Adverse effects of cocaine

A
  • Cardiovascular= coronary artery spasm → myocardial ischaemia/infarction, both tachycardia and bradycardia may occur. Hypertension, QRS widening and QT prolongation, aortic dissection
  • Neurological= seizures, mydriasis, hypertonia, hyperreflexia
  • psychiatric effects= agitation, psychosis, hallucinations
  • others= ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding. Hyperthermia, metabolic acidosis, rhabdomyolysis
39
Q

Cocaine abuse: education

A
  • Risks of specific combinations
  • Not dangerous to stop suddenly
  • Health risks: Stroke, MI, Cognitive impairment, Parkinsons disease, seizures, Psychotic illness, Anxiety/depression
40
Q

Cocaine abuse: Harm reduction

A
  • BBV testing & treatment
  • Safe injecting advice
  • Safe environment
  • Clean equipment + avoid home made pipes
  • Mucous membrane care (Vaseline)
  • Eat before using
  • Stay hydrated
  • Buy less (effect reduces after the first hit anyway)
41
Q

Cycle of change

A
  • Pre-contemplation: no intention of changing behaviour
  • Contemplation: aware a problem exists but with no commitment to action
  • Preparation: intent on taking action to address the problem
  • Action: active modification of behaviour
  • Maintenance: sustained change, new behaviour replaces old
  • Relapse: fall back into old patterns of behaviour
42
Q

Motivational interviewing: substance abuse

A
  • Principle 1: Express Empathy= shows acceptance and increases the chance of the counselor and participant developing a rapport.
  • Principle 2: Develop Discrepancy= enables the participant to see that her present situation does not necessarily fit into her values and what she would like in the future.
  • Principle 3: Roll with Resistance= prevents a breakdown in communication between participant and counselor. Avoid arguing for change. Do not directly oppose resistance. New perspectives are offered but not imposed. The participant is a primary resource in finding answers and solutions. Resistance is a signal for the counselor to respond differently.
  • Principle 4: Support Self-efficacy= If a participant believes that she has the ability to change, the likelihood of change occurring is greatly increased.
43
Q

Substance misuse: other psychosocial interventions

A
  • Psychoeducation
  • Practical strategies to reduce safely
  • Harm reduction
  • Mutual help groups
  • Online self help
  • Carer support
  • Employment and Accommodation support
44
Q

5 principles of the Mental Capacity act 2005

A
  1. Presumption of capacity: assume a person has the capacity to make a decision themselves, unless it’s proved otherwise
  2. Individuals being supported to make their own decisions wherever possible
  3. Unwise decisions: do not treat a person as lacking the capacity to make a decision just because they make an unwise decision
  4. Best interests: if you make a decision for someone who does not have capacity, it must be in their best interests
  5. Least restrictive option: treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms
45
Q

2 stage test of capacity

A
  • Does the person have an impairment of the mind or brain, or is there some sort of disturbance affecting the way their mind works? (It doesn’t matter whether the impairment or disturbance is permanent or temporary)
  • If yes, does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?
46
Q

When does lack capacity to make a decision

A

Are unable to:
- understand the information relevant to the decision
- retain that information
- use or weigh up that information as part of the process of making the decision
- communicate their decision (by talking, sign language, or any other means)

Where appropriate, people should be allowed the time to make a decision themselves. Capacity is time- and decision-specific.

47
Q

What is deprivation of liberty safeguard

A

Occurs when:
- a person is under continuous supervision and control in a care home or hospital, and
- is not free to leave, and
- the person lacks capacity to consent to these arrangements

48
Q

3 main criteria under the mental health act

A
  • mental disorder of a nature/degree that makes it appropriate for them to receive treatment in hospital
  • risk to self/others
  • appropriate treatment is available
49
Q

Features of delirium

A
  • Acute onset
  • Impairment of consciousness
  • Fluctuation of symptoms: worse at night, periods of normality
  • Abnormal perception i.e. illusions and hallucinations
  • Agitation, fear
  • Delusions
50
Q

Define delirium

A
  • Acute confusional state
  • Disturbed consciousness
  • Disturbed cognitive function
  • Or disturbed perception
  • May have an acute onset and fluctuating course
51
Q

Risk factors for delirium

A

Age, pre-existing dementia/neuro disorders (Parkinson’s), severe medical illness, hx previous delirium, audio-vis impairment, depression, polypharmacy, multi-morbidity, abnormal sodium-potassium-glucose, alcohol/benzo use

52
Q

Precipitating factors for delirium

A

Pain, surgery, malnutrition and dehydration, metabolic and electrolyte imbalance, anesthesia and hypoxia, use of physical restraint, use of indwelling catheter, adding 2+ meds, multiple bed moves/environment, prolonged hospital stay

53
Q

Causes of delirium

A
  • Pain
  • Infection (34%)
  • Neoplasm or nutrition
  • Constipation
  • Hydration
  • Medication (10%)
  • Environment
  • Other - strokes (10%), MI, fractures, heart failure, metabolic imbalances, toxins, alcohol/drugs, sensory deficits…