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Psychiatry > Substance Misuse > Flashcards

Substance Misuse Flashcards

1
Q

ICD classifications for substance misuse

A
  1. Acute intoxication - Acute and usually transient effect of the substance
  2. Harmful use
  3. Dependence syndrome
  4. Withdrawal state
  5. Psychotic disorder
  6. Amnesic syndrome
  7. Residual disorder
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2
Q

ICD 10 criteria substance abuse

A

Drug Problems Will Continue To Harm

  • ≥3 of the following manifestations to have occurred over one month
  • Desire (strong compulsion) to consume substance.
  • Preoccupation with substance use
  • Withdrawal state when substance ingestions is reduced or stopped
  • Control of substance taking behaviour is impaired
  • Tolerance to substance leading to increased consumption for desired effect
  • Harmful effects known yet persisting.
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3
Q

Pathophys for substance abuse

A

Biological - Genetics or neurochemical (dopamine, GABA, and opioid systems)

Environmental - peer pressure, life stressors, parental drug use, cultural acceptability

Takes substance - cost, availability, effect of drug itself, route

Positive reinforcement - Psychosocial from peers or pleasurable effects, Biological from activating mesoliimbif dopaminergic reward pathways

Dependence - Positive reinforcement overtime eventually causes dependence.

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4
Q

RF SA

A
  • Low SES
  • Drug vibrant area
  • Social grouping
  • Parental Drug use
  • Financial issues.
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5
Q

Types of SA

A

Depend on the drug consumed

  • Opioids
  • Cannabinoids
  • Stimulants
  • Sedative hypnotics
  • Hallucinogens
  • Volatile solvents
  • Anabolic Steroids
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6
Q

Examination of SA

A

Full systems investigations

MSE will vary depending on level of intoxication at time

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7
Q

Investigations SA

A

Bloods - HIV screen, Hep BC, and TB testing

U+E to check renal function

LFT and Clotting to check hepatic function

Drug Levels

Urinalysis - drug metabolites can be detected in urine

ECG - arrhythmias, ECHO if endocarditis suspected.

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8
Q

Treatment SA generally

A
  • Keyworker with therapeutic alliance
  • Hep B immunisation
  • Motivational interviewing and CBT
  • Contingency management - changing specified behaviours by offering incentives for positive behaviours such as abstinence
  • Supportive help can be in housing, finance and employment.
  • Self-help groups - narcotics anonymous and AA
  • Driving and DVLA guidelines
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9
Q

Treatment SA Opioid

A
  • Biological - methadone or buprenorphine for detox and maintenance
  • Naltrexone recommended for those formerly opioid dependent but have not stopped and are motivated to continue abstinence
  • IV naloxone - antidote to overdose.
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10
Q

Detoxication vs maintenance

A

Detox = the effects of a drug are eliminated in a safe manner such that withdrawal is avoided
Main = abstinence is not priority rather the aim is to minimise harm

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11
Q

Ddx of SA

A

Psychiatric disorders - Psychosis, mood disorders, anxiety disorders and delirium

Organic disorders - Hyperthyroidism, CVA, intracranial haemorrhage, neurological disorders

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12
Q

Class A drugs

A

Cocaine, ecstacy, heroin, lsd, methamphetamine, methadone, magic mushrooms

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13
Q

Class B drugs

A

Amphetamines, barbiturates, cannabis, ketamine, methylphenidate

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14
Q

Class C drugs

A

anabolic steroids, benzodiazepines, khat and GHB.

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15
Q

History taking of drug use

A

TRAP
Type
Route
Amount
Pattern

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16
Q

Physical Complications SA

A
  • Death
  • Infection of HIV, hepatitis ABC
  • Staph aureus
  • Group A strep / clostridium / TB
  • Endocarditis
  • Superficial thrombosis
  • DVT
  • Pulmonary embolus
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17
Q

Psychological complications SA

A

Craving, anxiety, cognitive disturbance, drug-induced psychosis

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18
Q

Social complications SA

A

Crime, imprisonment, homelessness, prostitution, relationship problems.

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19
Q

Examples of Opiates

A

Morphine, dimorphine, codeine, methadone

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20
Q

Examples of cannabiinoiuds

A

cannabis

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21
Q

Examples of sedatives-hypnotics

A

benzos, barbiturates

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22
Q

Psych effects of opiates

A

apathy,
disinhibition,
psychomotor retardation
impaired judgement
drowsiness
slurred speech

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23
Q

Psych effects of cannabinoids

A

euphoria
disinhibition
agitation
paranoia
ideation
temporal slowing
impaired judgement
illusions
hallucinations

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24
Q

Psych effects of sedative hypnotics

A

euphoria
disinhibiting
apathy
aggression
anterograde amnesia
labile mood

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25
Q

Physical effects of opioids

A

resp depression
hypoxia
dec bp
hypothermia
coma
pupillary constriction

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26
Q

Physical effects of cannabinoids

A

increased appetite
dry mouth
conjunctival injection
inc hr

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27
Q

Physical effects of sedative hypnotics

A

unsteady gait
difficulty standing
slurred speech
nystagmus
erythematous skin lesions
dec bp
hypothermia
depression of gag reflex
coma

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28
Q

Withdrawal state of opioids

A

craving
rhinorrhoea
lacrimation
myalgia
abdo cramps
N+V
diarrhoea
pupillary dilation
piloerection
inc hr and bp

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29
Q

Withdrawal state of cannabis

A

anxiety
irritability
tremor
sweating
myalgia

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30
Q

Withdrawal state of sedative hypnotics

A

tremor hands, tongue or eyelids
n+v
inc hr
postural hypotension
headache
agitation
malaise
transient hallucinations
paranoid ideation
grand mal convulsions

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31
Q

Examples of Stimulants

A

cocaine
crack
ecstacy
MDMA
amphetamine

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32
Q

Examples of hallucinogens

A

LSD
magic mushrooms

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33
Q

Examples of volatile solvents

A

AEROSOLS
paint
glue
petrol

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34
Q

Examples of anabolic steroids

A

testosterone
androstenedione
danazol

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35
Q

Psych effects of stimulants

A

euphoria
increased energy
grandiose beliefs
aggression
argumentative
illusions
hallucinations
paranoid ideation
labile mood

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36
Q

Psych effects of hallucinogens

A

anxiety
illusions
hallucinations
depersonalisation
derealisation
paranoia
ideas of refernce
hyperactivity
inattention
impulsivity

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37
Q

Psych effects of volatile solvents

A

apathy
lethargy
aggression
impaired attention
psychomotor retardation

38
Q

Psych effects of anabolic steroids

A

euphoria
depression
aggression
hyperactivity
mood swings
hallucinations
delusions

39
Q

Physical effects of stimulants

A

inc hr and bp
arrhythymias
sweating
n+v
pupillary dilation
psychomotor agitation
muscular weakness
chest pain
convulsions

40
Q

Physical effects of hallucinogens

A

inc hr
palpitations
sweating
tremor
blurred vision
pupillary dilations
incoordination

40
Q

Physical effects of volatile solvents

A

unsteady gait
diplopia
nystagmus
decreased consciousness
muscle weakness

41
Q

Physical effects of anabolic steroids

A

increased muscle mass
reduced fat
acne
male pattern baldness
reduced sperm count
infertility
stunted growth

42
Q

Withdrawal symptoms of stimulants

A

dysmorphic mood
lethargy
psychomotor agitation
craving
inc apetite
insomnia
bizarre pr unpleasant dreams

43
Q

Withdrawal symptoms of hallucinogens

A

na

43
Q

Withdrawal symptoms of volatile solvents

A

na

44
Q

Withdrawal symptoms of anabolic steroids

A

na

45
Q

Most common illegal drug

A

cannabis

46
Q

Alcohol abuse

A

consumption of alcohol at a sufficient level to cause physical, psychiatric and or social harm.

47
Q

Binge drinking

A

Drinking over twice the recommended level of alcohol per day in one session - >8 units for men or 6 for women.

48
Q

Weekly and daily alcohol units

A

14 units for both men and women

Daily recommended - 3-4 for men and 2-3 for women.

48
Q

Harmful alcohol use

A

Drinking above safe levels with evidence of alcohol related problems >50 units/week for men and 35 for women.

49
Q

pathophys of alcohol withdrawal

A

Pt experience a craving, linked to dopaminergic, serotonergic and opioid systems that mediate positive reinforcement and is also linked to the GABA, glutaminergic, and noradrenergic systems that mediate withdrawal.

49
Q

Pathophys of alcohol addiction

A

Neurotransmitters - effect on GABA causes anxiolytic and sedative effects

Dopaminergic pathway causes pleasurable and stimulant effects of alcohol. Repeated and excessive alcohol insertion sensitises this pathway and leads to the development of dependence.

Long term exposure - down regulation of inhibitory neuronal GABA, and up-regulation of excitatory glutamate receptors so when alcohol is withdrawn it leads to hyper-excitability.

50
Q

SLT of AA

A

social learning theory - drinking behaviour is modelled on imitation of relatives or friends. Operant conditioning states that positive or negative reinforcement from the effects of drinking will either perpetuate or deter drinking habits.

50
Q

RF AA

A

25% men and 15% women drink over recommended level

Alcohol dependence is 4% in UK between 16 and 65

Male - increased risk and have increased metabolism of alcohol, allowing them to drink in higher quantities

Younger adults - 16.2% among 18-29 year olds. and 9.7% among 30-44

Genetics - Monozygotic twins have higher concordance

Antisocial Behaviour - Pre-morbid antisocial behaviour predicts alcoholism

Lack of facial flushing -

Life stressors - Financial problems, marital issues and certain occupations

51
Q

Why does red facial flushing lead to red risk alcoholism

A

Risk of alcoholism dec in individuals who show alcohol induced facial flushing due to mutation of gene coding of aldehyde dehydrogenase so that it metabolises acetaldehyde more slowly.

52
Q

Symptoms alcohol intoxication

A

Slurred speech, labile affect, impaired judgement, poor co-ordination. Severe cases may be hypoglycaemia, stupor, and coma

53
Q

symptoms alcohol withdrawal

A

Malaise, tremor, nausea, insomnia, transient hallucinations, autonomic hyperactivity occurance 6-12 hour post abstinence. Peak incidence of seizures at 36 hours.

53
Q

symptoms alcohol dependence

A

SAW DRINk

  • Subjective awareness of compulsion to drink
  • Avoidance or relief of withdrawal symptoms by further drinking
  • Withdrawal symptoms
  • Drink-seeking behaviour
  • Reinstatement of drinking
  • Increased tolerance
  • Narrowing of drinking repertoire.
54
Q

When does delirium tremens occur

A

72 hours post abstinence.

54
Q

CAGE questionnaire

A

C - have you ever felt you should Cut down

A - Annoyed you by criticising your drinking

G - Have you ever felt guilty about your drinking

E - Do you ever have a drink early in the morning to steady nerves or wake you up - EYE opener

54
Q

Examination steps of alcohol abuse

A
  1. Screen for alcohol dependence - CAGE
  2. Establish drinking pattern and quantity consumed
  3. Explore features of alcohol dependence - Withdrawal effects, inc tolerance, compulsive need to drink, narrowing of drinking repertoire
  4. Explore possible risk factors - Fhx
  5. Establish impact - psychiatric, physical and social
54
Q

ICD 10 alcohol intoxication

A

General criteria for acute intoxication met :
- Clear evidence of psychoactive substance use at high levels
- Disturbance in consciousness, cognition, perception or behaviour
- Not accounted for by a mental or medical disorder

Evidence of dysfunctional behaviour
- Disinhibition
- Argumentativeness
- Agression
- Labile mood
- Impaired attention or concentration
- Unsteady gait / difficulty standing / slurred speech / nystagmus / flushing / dec consciousness and conjunctival injection.

55
Q

ICD 10 alcohol withdrawal

A

General criteria for withdrawal being met
- Clear evidence of recent cessation
- Not acounted for by mental or medical disorder

Any three of following
- Sweating
- N+V
- Tachycardia
- inc BP
- Headache
- Psychomotor agitation
- Insomnia
- Malaise
- Transient hallucinations

55
Q

Ix AA

A
  • FBC including blood alcohol level
  • MCV - macrocytosis or Vit B12 / folate / TFT which can also inc MCV
  • Alcohol questionnaires
  • CT head
  • ECG - arrhythmias
55
Q

Treatment AA

A

Biological -

  • Chlordiazepoxide detox regime + thiamine
  • Disulfiram / Naltrexone / Acamprosate
  • Treatment of medical and psychotic conditions

Psychological -

  • Motivational interviewing + CBT
  • Social network and environment based therapies

Social -

  • AA
  • Social support with familial involvement
56
Q

Treatment alcohol dependence

A
  1. Disulfiram
  2. Acamprosate
  3. Naltrexone
56
Q

What does disulfiram do

A

Causes a build up of acetaldehyde on consumption of alcohol, causing unpleasant symptoms - anxiety, flushing and headache

56
Q

What does naltrexone do

A

Blocks opioid receptors in the body, reducing the pleasurable effects of alcohol.

57
Q

Treatment Alcohol Withdrawal

A
  • Alcohol detoxification regime - Benzodiazepines and Thiamine. Reduction over 9 days roughly
    • As inpatient if risk of suicide, poor social support or history of severe withdrawal reactions
    • Thiamine to prevent Wernickes E - orally or IV as pabrinex.
58
Q

What does acamprosate do

A

Reduces craving by enhancing GABA transmission

59
Q

How does AA work

A

12 step approach using psychosocial techniques to change behaviour. Each person is rewarded and assigned a sponsor.

60
Q

Prevention of alcohol dependence

A
  • Raising taxation on alcohol, restricted advertising and sales and more education of impacts of alcohol issues
  • Prophylactic oral thymine should be offered to harmful drinkers if they are malnourished or have decompensated liver disease.
61
Q

Ddx AA

A
  • Psychosis
  • Mood disorders
  • Anxiety Disorders
  • Delirium
  • Head injury
  • Cerebral tumour
  • Cerebrovascular accident
62
Q

DVLA for AA

A

DVLA - pt responsibility to contact but if not ask your union for advice, give pt notice, and advise yourself.

62
Q

Alcohol units calculation

A

alcohol units = (strength of alcohol by volume x volume in ml ) / 1000

63
Q

What wernickes encephalopathy

A

Acute encephalopathy due to thiamine deficiency, presenting with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia.

64
Q

Korsakoffs psychosis

A

Profound, irreversible short term memory loss with confabulation (filling of gaps in memory with imaginary events) and disorientation to time.

It’s features include: anterograde amnesia, retrograde amnesia, and confabulation

65
Q

Hepatic complications of alcohol dependence

A

Fatty liver, hepatitis, cirrhosis, hepatocellular carcinoma

66
Q

Gi complications of AA

A

PUD, Oesophageal varices, pancreatitis, oesophageal carcinoma.

67
Q

CVD complications of AA

A

Hypertension, cardiomyopathy, arrhythmias

68
Q

Haem complications of AA

A

Anaemia, thrombocytopenia

69
Q

Neuro complications AA

A

seizures, peripheral neuropathy, cerebellar degeneration, wernickes E, Korsakoffs, head injury

70
Q

Obstetric complications AA

A

fetal alcohol syndrome

71
Q

Psych complications AA

A
  • Morbid jealousy
  • SH and Suicide
  • Mood disorder
  • Anxiety disorder
  • Alcohol-related dementia
  • Alcoholic hallucinosis
  • Delirium tremens
72
Q

Social complications AA

A
  • Domestic violence
  • Drink driving
  • Employment difficulties
  • Financial problems
  • Homelessness
  • Accidents
  • Relationship problems
73
Q

Delirium tremens characteristics

A
  • Withdrawal delirium - 24 hours to one week after cessation
  • Delirium peaks at 72 hours
  • Characterised by -
    • Cognitive impairement
    • Vivid perceptual abnormalities
    • Paranoid delusions
    • Marked tremor
    • Autonomic arousal
74
Q

Treatment delirium tremens

A

benzodiazepines, haloperidol and IV pabrinex

75
Q

How much alcohol is in one unit

A

10 ml / 8g of ethanol

76
Q

Vitamin associated with korsakoffs

A

The underlying cause of Korsakoff’s syndrome is untreated thiamine deficiency B1

77
Q
A

Psychiatry (17 decks)

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