Substance Misuse

Question 1

What is considered binge drinking for women?

Answer 1

Above 4-6 units in one sitting.

Question 2

What is considered binge drinking for men?

Answer 2

7-8 units in one sitting.

Question 3

What is harmful use of alcohol?

Answer 3

Pattern of psychoactive substance use which causes physical or mental damage and associated with adverse social consequences.

Question 4

What is acute intoxication?

Answer 4

Reversible physical and mental abnormalities caused by the consumption of a substance.

Question 5

What is dependence syndrome?

Answer 5

Clinical syndrome of physiological, behavioural and cognitive phenomena where use of a substance is characterised by:
-> Salience, a strong desire to consume the drug which is prioritised over other commitments and leads to neglect
-> Narrowing of substance type
->Difficulty in controlling use of substance despite negative consequences
->Higher tolerance
->Withdrawal on abstinence and rapid return to drug use

Question 6

What is tolerance?

Answer 6

Greater amount of substance is required to achieve intoxication compared to initial amount.

Question 7

What is the epidemiology of alcohol dependence?

Answer 7

Family history
Male
Late teens/early 20s
Co-morbidity with depression
Low socioeconomic group
Lower educational levels
Certain occupations such as doctors, drinks industry workers and travelling saleemen

Question 8

What are the biochemical actions of alcohol?

Answer 8

Alcohol increases:
->Neuronal cell wall fluidity and permeability
->Transmission of GABA
->Release of doapmine from the mesolimbic system for euphoria and reward effects
->Inhibits glutamate transmission, leading to amnesia
->Increases serotonin at 5-HT3 receptors

Question 9

What is the aetiology of alcohol dependence?

Answer 9

-> Genetics
-> Behavioural conditioning, where euphoriant effect acts as a reinforcer and with stress/negative life events
-> Personality type
1 is an anxious, dependent and guilty alcoholic with family history
2 has early onset severe problems, confident and socially detached, secondary to alcoholism

Question 10

What are the physical consequences of alcohol use?

Answer 10

Women are more susceptible than men to the toxic effects of acetaldehyde:
-> Hepatitis, most commonly fatty liver and cirrhosis
-> Gastrointestinal issues such as oesophageal varices and carcinoma
-> Macrocytosis is the most common cause of
-

Question 11

What is delirium tremens?

Answer 11

Acute confusional state/ delirium that occurs 1-3 days of alcohol withdrawal with a peak incidence of 48 hours, characterised by:
->disorientation
-> shaking
-> sweating
->amnesia of recent events ->visual and auditory hallucinations
-> Heavy sweating and paranoid delusions

There is a greater risk of delirium tremens with severe dependence, infection and pre-existing liver damage. Delirium tremens is associated with an intake of over 12 units of alcohol per day.

Question 12

What is Wernicke’s encephalopathy?

Answer 12

Acute onset of delirium caused by a deficiency of B1 thiamine, which alcoholics are at a greater risk of as a result of impaired absorption of thiamine from the intestine. Those who are at risk include severe malnutrition, liver disease and hyperthyroidism.

Wernicke’s is characterised by ataxia, opthalmoplegia and confusion.

Question 13

What are the clinical features of Wernicke’s encephalopathy?

Answer 13

->Acute confusional state
->Ocular signs such as nystagmus
->Ataxic gait
->Peripheral neuropathy
->Resting tachycardia

Question 14

What is Korsakoff’s syndrome?

Answer 14

Neuropsychiatric disorder of global cortical impairment where immediate memory is maintained but there are deficits in anterograde and retrograde memory and confabulation (generating false memory without deceit.)

A major risk factor is thiamine deficiency and previous history of Wernicke’s encephalopathy associated with alcohol dependence.

Treatment is oral thiamine replacement and multivitamin supplementation. Majority of patients will not have complete recovery.

Question 15

What are the common psychiatric co-morbidity with alcohol dependence?

Answer 15

Affective disorders
Depression
Anxiety
Schizophrenia
Morbid jealousy

Question 16

What are the common psychiatric co-morbidity with alcohol dependence?

Answer 16

Affective disorders
Depression
Anxiety
Schizophrenia
Morbid jealousy

Question 17

What is the initial management for drug use?

Answer 17

History of lifetime pattern of alcohol consumption and current alcohol history depending on recent drinking day
Physical investigations for blood test, urine drug test and liver enzyme function
Physical examination for neurological symptoms or stigmata of liver disease
Cognitive testing
Family history
Consequences of alcohol dependence

Question 18

What is the framework used for alcohol?

Answer 18

CAGE:
->Cutting down on drinking
->Annoyed for criticism of drinking
->Guilt about drinking
->Eye opener for drink first thing in the morning to steady nerves or get rid of hangover

Question 19

What are the physical symptoms of alcohol withdrawal?

Answer 19

Depression
Anxiety
Tremors
Shaking
Sweating

Question 20

What is an alcohol screening tool?

Answer 20

MCV which is raised for 3-6 months due to the effects of alcohol altering erythrocyte metabolism. MC is a sensitive screeening tool for alcohol, compared to the false positives with B12 and folate deficiency.

Question 21

What is the management of alcohol dependence?

Answer 21

Detoxification using benzodiazepine to reduce unpleasant withdrawal symptoms to reduce the development of secondary iatrogenic dependence at a fixed dose schedule

Supplementary vitamins

Any required psychotropic drugs

Group therapy or individual counselling

Question 22

What are the principles of motivational interviewing?

Answer 22

It is patient centred counselling that aims to encourage behaviour change in patients based on 4 principles:

-> Express empathy through reflective listening
-> Develop discrepancy between patient’s values and their current behaviours
-> Respond to resistance with empathy
-> Support self-efficacy

Question 23

What is the stages of change model in addiction?

Answer 23

Pre-contemplation
Contemplation
Decision
Action
Maintenance
Relapse

Question 24

What are the features of taking an alcohol/drug history?

Answer 24

Lifetime pattern of alcohol consumption surrounding first drink and history
Current alcohol consumption
Any signs of dependence
Impact on physical or mental health
Issues due to alcohol consumption on work and relationships
Previous treatment attempts
Family history

Question 25

What are the screening tests for alcohol consumption?

Answer 25

->Measures recent alcohol consumption in mg per 100 ml of blood to measure alcohol blood
concentration.
-> Urine or hair testing for the alcohol metabolite ethyl glucuronide
-> MCV level is the most sensitivity
-> Blood levels of GGT and carbohydrate-deficient transferrin

Question 26

What is cognitive impairment syndrome?

Answer 26

Reversible cognitive defects that occur during intoxication, associated with heavy chronic use that leads to gradual deterioration with continual use of the substance. It is assoicated with alcohol intake, cannabis use, benzodiazepines and volatile chemicals such as poppers.

Question 27

What is alcohol induced amnesia?

Answer 27

Short lived amnesiac episodes related to intoxication, that leads to a gap in memory for several hours. There are two types:
-> Dense amnesia with clear start and finish points
-> Partial amnesia, episodes with clear start and finish points, but some preserved memory and recall

Question 28

What are the impacts of alcohol dependence on society?

Answer 28

Increases unemployment rates
Greater risk of drunk driving and manslaughter
Homelessness
Increased likelihood of crime such as domestic abuse and sexual assault
Greater health expenditure on preventable chronic conditions and transplants

Question 29

What are the impacts of alcohol dependence on families and individuals?

Answer 29

Loss of household income from potential source
Breakdown of familial relationships
Anxiety, depression and guilt on relatives
Greater risk of alcoholism for children in the family
Loss of security in the home
Domestic abuse and violence

Question 30

Which factors are involved in maintenance of drug use?

Answer 30

Drug availability and cost
Low perception of risk
Relationship conflict and abuse
Normalisation of drug use within their community
Young onset of use

Question 31

What are the effects of tobacco use?

Answer 31

Tobacco can be smoked as cigarettes, chewed or snuffed. The titular neurochemical agent nicotine drives addiction and is rapidly absorbed across the alveoli when smoked or rapidly absorbed across mucous membranes. It acts on incontinence ACh receptors for flux of cations and depolarisation of the plasma membrane to induce:
-> Arousal
-> Alertness
-> Anxiety
It typically leads to lung disease and increases the risk of certain cancers.

Question 32

What are the effects of opiate use?

Answer 32

Stimulates endogenous opioid receptors on the brain and spinal cord which produce cortical inhibitory effects of
-> Diminished pain sensation
-> Euphoria
-> Anxiolyitc effects
-> Reduced respiratory rate and constipation
-> Increased risk of infection

Opiates can be in the form of heroin by smoking, orally, parenterally or subcutaneously. This also includes codeine,

Question 33

What are the features of depressant use?

Answer 33

Includes alcohol, benzodiazepines and barbiturates which cause cortical depression and lead to anxiolytic and relaxant properties.

Question 34

What are the types of stimulants??

Answer 34

Cocaine
Amphetamines
MDMA

Question 35

What are the physiological effects of cocaine?

Answer 35

Typically in powder form which can be inhaled, dissolved or injected. Inhaled cocaine undergoes rapid first-pass liver metabolism and crack cocaine is the form of cocaine when smoked.

It acts as a local anaesthetic at mucous membranes for
-> Increasing dopamine, serotonin and noradrenaline transmission

This leads to increased energy, confidence, euphoria and reduced need for sleep. However it can lead to arrythmias, hypertension, anxiety and impaired judgement.

Question 36

What are the physiological effects of amphetamines?

Answer 36

In the form of tablets or powders which may be swallowed, inhaled, dissolved or injected and reduce the reuptake of dopamine and noradrenaline to cause:
-> Tachycardia
-> Arrythmia
-> Hyperpyrrexia
-> Irritability
-> Psychotic state with visual, auditory and tactile hallucinations

Question 37

What are the physiological effects of MDMA?

Answer 37

MDMA can be taken in tablet form and acts by causing serotonin release and blocking reuptake, leading to hallucinogenic and stimulant properties, with intoxication lasting up to 3 hours and psychomotor agitation and high energy.

Acute harmful effects include:
-> Increased sweating, nausea, hyponatremia, vomiting, libido with decreased potency
-> Neurotoxicity, hepatotoxicity and cognitive impairment

Question 38

What are the effects of LSD?

Answer 38

Sold in the form of tablets or powder, which is structurally similar to serotonin and dopamine to lead to effects developing 15-30 minutes after ingestion and lasting up to 6 hours.

There is initial euphoria, with a sense of detachment and novelty in the familiar, Distorted body image, visual distortions, Dizziness, tremors and synaesthesia.

Harmful effects include behavioural toxicity by acting on delusions however, LSD had no risk of overdose and there is no physiological dependence and withdrawal. Flashbacks can occur years after consumption and lead to persistent psychosis and depression

Agitation with LSD can be treated with benzodiazepines.

Question 39

What are the effects of ketamine?

Answer 39

Sedation and agitation
Euphoric mood and pain relief
Visual and auditory hallucinations
Altered badder function over time, causing UTI and incontinence

Question 40

What are the effects of magic mushrooms?

Answer 40

Hallucinogenic mushrooms which can be eaten raw, cooked, dried or as a drink. Small doses can cause euphoria while larger doses can lead to perceptual abnormality. There is a fast buildup of tolerance, however there is no withdrawal or dependence with discontinued use.

Harmful effects are nausea, vomiting, dizziness, diarrhoea and behavioural toxicity.

Question 41

What are the effects of cannabis?

Answer 41

Most commonly used illicit drug which acts as an agonist of cabbanoid receptors by the psychoactive agent THC to lead to weak opioid-like and barbiturate-like effects as a depressant. It has immediate effects of mild euphoria, enhanced wellbeing and sensation, relaxation, altered sense of time and increased appetite.

Question 42

What are the harmful effects of cannabis?

Answer 42

It can lead to mild paranoia, panic attacks, mild tachycardia, dysarthria and ataxia. Longer term effects include depressed mood, anxiety/depressive illness and a motivational illness.

Question 43

What is the physiological theory for alcohol dependence?

Answer 43

Drugs target the Mesolimbic doapminergic pathway, involved in reward from the ventral tegmental area to the prefrontal cortex for motivation and planning. Dopamine release in the nucleus accumbens is important for the sensation of pleasure and the main input in the basal ganglia, which is mediated by alcohol and cannabis.

There is a switch to drug use to avoid the unpleasant physical side effect, where chronic exposure to a drug causes changes within the nucleus accumbens for drug-related dopamine use required for normal functioning.

Question 44

What is the harm reduction theory?

Answer 44

Method of managing drug users to reduce mortality and morbidity for user without insisting on abstinence from drugs based on advice for:
-> Safer drug use, administration and injection
-> Safer sex
-> Prescription of maintenance opiates
-> Assessment and treatment of comorbidity
-> Engagement with other sources of help

Question 45

What is the psychological theory of alcohol dependence?

Answer 45

Alcohol dependence is reinforced by:
Positive reinforcement
Negative reinforcement
Sensitisation where there is a salience for the drug
Tolerance
Withdrawal

Question 46

What is uncomplicated alcohol withdrawal syndrome?

Answer 46

Occurs 6-12 hours after the last use of alcohol where symptoms peak in severity after 48 hours and last 5 days. There are coarse tremors, shaking, sweating, insomnia, psychomotor agitation and generalised anxiety.

Question 47

What is the psychological and social management of substance misuse?

Answer 47

CBT and individualised counselling such as anger management and relaxation training, group support and advice
Alcoholics Anonymous that view alcoholism as a lifelong incurable disease that can be managed by lifelong abstinence.
SMART therapy (self-management and recovery training) for people who want to manage problematic behaviour.
Incentives for healthy eating like vouchers
National charities

Question 48

What is the pharmacological management for substance misuse?

Answer 48

The pharmacological treatment for alcohol addiction is disulfiram which causes irreversible inhibition of acetaldehyde to prevent the breakdown of alcohol, inducing toxic symptoms such as facial flushing, palpitations and hypotension that creates negative reinforcement.

Acamprosate reduces GABA transmission to prevent alcohol cravings.

Naltrexone is used for alcohol and opioid addiction which antagonises the effect of endogenous endorphins by alcohol consumption to reduce the high and positive associations with substance use.

Question 49

How does working with other non NHS specialities help provide effective care?

Answer 49

Addaction
Alcoholics Anonymous
National association for children and alcoholics

Question 50

What is the effectiveness for psychological and social interventions for substance misuse?

Answer 50

With SMART therapy, 61% of individuals stopped using drugs and alcohol within 6 months of the programme

Question 51

What is the effectiveness for psychological and social interventions for substance misuse?

Answer 51

With SMART therapy, 61% of individuals stopped using drugs and alcohol within 6 months of the programme