Substance Misuse Flashcards
Definitions of alcohol abuse
-Intoxication: transient behavioural, perceptual or cognitive symptoms shortly after use
-Hazardous use: if use places at high risk for harm
-Harmful use: if use causes harm but not dependent
=Substance related cognitive, psychotic, mood and anxiety disorders
Dependence on substance (ICD-10)
3 or more criteria present together at some time during the previous year:
1. A strong desire or compulsion to take the substance
2. Difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
3. Physiological withdrawal state when substance use has reduced or ceased; or continued use of the substance to relieve or avoid withdrawal symptoms
4. Tolerance where increased quantities of the substance are required to produce the same effect originally produced by lower amounts
5. Priority given to substance with neglect of other interests and activities due to time spent acquiring and taking substance, or recovering from its effects
6. Persistence despite harm where use of the substance is continued despite a clear awareness of its harmful consequences (physical or mental)
Recommended limits for alcohol
National recommendations:
-No safe level at which to drink alcohol
-Drink no more than 14 units/week (male or female)
-Avoid bingeing: spread intake evenly over ≥ 3 days (or fewer days if <14 units/week)
-Have several drink-free days per week
-Limit the total amount consumed on a single occasion (no maximum daily limit suggested due to variations between individuals and contexts)
Units = alcohol by volume (ABV) X volume in litres
E.g. a pint (568 mL) of 5.3% lager (5.3 X 0.568) = 3 units
Describe alcohol intoxication
-Initial enhanced sense of well-being, greater confidence, relief of anxiety
-Inappropriate sexual / aggressive behaviour / sullen and withdrawn / labile mood / possibly self-injurious behaviour(↑ likelihood of having and acting upon thoughts of self-harm or suicide)
-Incoordination, slurred speech, ataxia, amnesia, impaired reaction times
-Low GCS, respiratory depression, coma and death
Social consequences of harmful use of alcohol
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Physical health consequences of harmful use of alcohol
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Describe alcohol withdrawal
-Uncomplicated alcohol withdrawal syndrome: 4-12 hours after cessation
=Tremulousness, sweating, nausea and vomiting
=Mood disturbance (anxiety, depression, ‘feeling edgy’)
=Sensitivity to sound (hyperacusis)
=Autonomic hyperactivity (tachycardia, hypertension, mydriasis, pyrexia)
=Sleep disturbance, psychomotor agitation
-With perceptual disturbances
=Illusions or hallucinations (typically visual, auditory, or tactile)
-With withdrawal seizures: 6-48 hours after cessation (peak 36)
=5%-15% of all alcohol-dependent drinkers
=Generalized and tonic-clonic
-Withdrawal delirium (delirium tremens): 1-7 days after cessation (mean 48 hrs)
=Altered consciousness and marked cognitive impairment (i.e. delirium)
=Vivid hallucinations and illusions in any sensory modality
=Marked coarse tremor
=Autonomic arousal (heavy sweating, raised pulse and blood pressure, fever)
=Paranoid delusions (often associated with intense fear)
=Mortality (5%-15% with delirium tremens die from cardiovascular collapse, hypothermia/hyperthermia, infection)
=Predisposing factors e.g. physical illness
-Patients in withdrawal are also at risk of Wernicke encephalopathy
=Tetrad of acute confusion, ataxia, nystagmus, and ophthalmoplegia
=Risk of Korsakoff syndrome: amnesia, frontal lobe dysfunction, psychosis
Mechanism of alcohol withdrawal
-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)
-Long-term use of alcohol leads to upregulation of excitatory glutamate receptors and downregulation of GABA receptors. If the patient stops drinking alcohol suddenly, there is an excess of excitatory action, and the patient will present with symptoms of an overactive sympathetic nervous system.
Epidemiology of alcohol use
-57% drank alcohol within last week (63% M, 51% F)
-15% binge drank within previous week (1 M : 1 F)
-1.4% alcohol dependence (3 M : 1 F)
-7% of all hospital admissions related to alcohol (2 M : 1 F)
-1.4% of all deaths (2 M : 1 F)
Aetiology of alcohol use
-Genetics
-Biochemical factors (GABA, NMDA)
-Psychological factors
=Positive reinforcement
=Modelling
=Psychiatric or physical illness
-Social and environmental factors
=Cultural attitudes
=Price
=Occupation
Differential diagnosis of alcohol use
-Primary psychiatric disorder (e.g. depression, schizophrenia) and patient is co-incidentally using alcohol and drugs
-Symptoms due to direct effect of substance and no primary psychiatric disorder exists
-Combination of the above
=Substance-induced psychiatric disorder includes cognitive impairment, psychosis, depressive episode, manic episode, anxiety
Assessment of alcohol use
-History
=CAGE or AUDIT questionnaire to screen alcohol dependence* Ask about all substances used, pattern and route of use, features of dependence, consequences of use (e.g. relationships, work, physical and mental health, crime)
=If previously abstinent, reasons for relapse
=Previous treatments
=PMHx and FHx – substance use, mental health conditions
=Red flags – driving, children or vulnerable adults at home
=Collateral history
-Examination
=MSE to establish psychiatric comorbidity, suicidality, insight
=Acute intoxication signs (e.g. coordination, slurred speech)
=Withdrawal signs (e.g. tremors, sweating, nausea, tachycardia)
=Medical complications (e.g. head injury, alcohol-related liver disease)
-Investigations
=Urine or saliva drug-screening test
=Breath alcohol level (via a breathalyser)
=Long-term complications: FBC, U&Es, LFTs, clotting screen, ECG
=If withdrawal delirium, consider brain imaging to exclude alternative cause (e.g. infection, head injury, stroke)
Treatment of alcohol withdrawal
-Majority undergo outpatient or community-based detoxification
-Inpatient detoxification if severe dependence, history of withdrawal seizures / delirium tremens, unsupportive home environment, significant comorbidity, advanced age, pregnancy, failed community detox
-Planned in advance to address perpetuating factors of dependence
-Benzodiazepine (e.g. chlordiazepoxide, diazepam or lorazepam long acting, carbamazepine)
-IM/IV thiamine (Pabrinex)
-Avoid repeated detoxes, usually not indicated in months immediately after relapse
Management of delirium tremens
-Emergency hospitalisation essential
-Examine and investigate alternative causes of delirium associated with alcohol use, e.g. infection, head injury, liver failure, GI haemorrhage
-Medication:
=Control symptoms and reduce risk of seizures: Benzodiazepines are first line drugs with antipsychotics as adjuncts for severe disturbance or psychotic features
=Prophylaxis / treatment of Wernicke Encephalopathy: IM/IV thiamine (2 Pabrinex ampoules twice daily for 5 days)
-Monitor temperature, fluid, electrolyte and glucose
Maintenance after detoxication
-Psycho
=Motivational interviewing (NB: technique primarily used before detoxification)
=CBT
=Mutual aid organisations (e.g. Alcohol Anonymous)
-Social
=Social support
=Residential rehabilitation communities
=Peer support
-Bio
=Disulfiram
=Acamprosate
=Naltrexone and nalmefene
