Substance misuse Flashcards
Harmful use of a substance
A quantity or pattern of substance use that actually causes adverse consequences, without dependence
The 4Ls of harmful substance use
Love - difficulties with interpersonal relationships (impotence, domestic violence)
Livelihood - problems meeting work or educational obligations (absenteeism)
Liver - impact on physical health or safety
Law - legal difficulties e.g. disorderly conduct, stealing to fund habit
Hazardous use of a substance
A quantity or pattern of substance use that places the user at risk of adverse consequences, without dependence
Substance dependence
A syndrome that incorporates physiological, psychological and behavioural elements.
Dependence syndrome (ICD-10) (6)
Three or more of the following have been present together at some time over the previous year:
- A strong desire or compulsion to take the substance
- Difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
- Physiological withdrawal state when substance use has reduced or ceased; or continued use to relieve or avoid withdrawal symptoms
- Signs of tolerance: increased quantities required to produce the same effect
- Neglect of other interests and activities due to time spent acquiring and taking substance, or recovering from its effects
- Persistence with substance use despite clear awareness of harmful consequences (physical or mental)
Physiological dependence
When a person exhibits signs of tolerance and/or withdrawal
Substance intoxication
A transient, substance-specific condition that occurs following the use of a psychoactive substance. Symptoms include disturbances of consciousness, perception, mood, behaviour and physiological function
Substance withdrawal
A substance-specific syndrome that occurs on reduction or cessation of a psychoactive substance that has usually been used repeatedly, in high doses, for a prolonged period
How to calculate units of alcohol
Alcohol by volume (in %) x volume (in litres)
e.g. ABV x vol = units
Safe daily alcohol limits for men and women
Men: 3-4 units/day (
What are the potential life-threatening risks associated with acute alcohol intoxication? (5)
Respiratory depression Aspiration of vomit Hypoglycaemia Hypothermia Trauma
Physical complications of excessive alcohol use - nervous system (7)
Intoxication or withdrawal delirium (delirium tremens) Withdrawal seizures Cerebellar degeneration Haemorrhagic stroke Peripheral and optic neuropathy Wernicke-Korsakoff syndrome Alcohol-related cognitive impairment
Physical complications of excessive alcohol use - gastroenterological system (4)
Alcoholic liver disease (fatty liver, alcoholic hepatitis, alcoholic cirrhosis)
Acute and chronic pancreatitis
Peptic ulceration and gastritis
Cancers: oropharynx, larynx, oesophagus, liver
Physical complications of excessive alcohol use - Cardiovascular system (4)
Hypertension
Arrhythmias
Ischaemic heart disease (in heavy drinkers)
Alcoholic cardiomyopathy
Physical complications of excessive alcohol use - immune system (1)
Increased risk of infections (especially meningitis and pneumonia)
Physical complications of excessive alcohol use - haematological system (4)
Red cell macrocytosis
Anaemia
Neutropenia
Thrombocytopenia
Physical complications of excessive alcohol use - musculoskeletal system (2)
Acute and chronic myopathy
Osteoporosis
Physical complications of excessive alcohol use - reproductive system (3)
IUGR
Foetal alcohol syndrome
Impotence, erectile dysfunction
Physical complications of excessive alcohol use - metabolic and endocrine system (5)
Hypoglycaemia
Hyperlipidaemia/ hypertriglycerididaemia
Hyperuricaemia
Hypomagnesaemia, hypophosphataemia, hyponatraemia
Alcohol-induced pseudo-Cushing’s syndrome
Alcohol dependence syndrome (Edwards & Gross)
- Narrowing of repertoire
- Increased salience of drinking
- Increased tolerance to alcohol
- Withdrawal symptoms
- Relief or avoidance of withdrawal symptoms by further drinking
- Subjective awareness of the compulsion to drink
- Rapid reinstatement after abstinence
Clinical features of uncomplicated alcohol withdrawal syndrome (9)
- Symptoms develop 4–12 hours after drinking cessation
- Tremulousness (‘the shakes’)
- Sweating
- Nausea and vomiting
- Mood disturbance (anxiety, depression, ‘feeling edgy’)
- Sensitivity to sound (hyperacusis)
- Autonomic hyperactivity (tachycardia, hypertension, mydriasis, pyrexia)
- Sleep disturbance
- Psychomotor agitation
Clinical features of alcohol withdrawal with perceptual disturbances
As for uncomplicated alcohol withdrawal syndrome (9)
Plus illusions or hallucinations (typically visual, auditory or tactile)
Clinical features of alcohol withdrawal seizures (4)
- Develop 6–48 hours after drinking cessation
- Occurs in 5–15% of all alcohol-dependant drinkers
- Generalized and tonic–clonic
- Predisposing factors: previous history of withdrawal fits, concurrent epilepsy, low potassium or magnesium
Clinical features of delirium tremens (8)
• Develops 1–7 days after drinking cessation, mean 48 hours
• Altered consciousness and marked cognitive impairment
• Vivid hallucinations and illusions in any sensory modality (patients often interact or are horrified by them; Lilliputian
visual hallucinations, miniature humans/animals; formication, sensation of insects crawling on the skin)
• Marked tremor
• Autonomic arousal (heavy sweating, raised pulse and blood pressure, fever)
• Paranoid delusions (often associated with intense fear)
• Mortality: 5–15% from cardiovascular collapse, hypo-/hyperthermia, infection
• Predisposing factors: physical illness (hepatitis, pancreatitis, pneumonia)
Blackouts
Episodes of anterograde amnesia during acute alcohol intoxication. Memory loss may be patchy, or for a discrete block of time during which nothing can be remembered.
Common - experienced by 2/3rd of dependent drinkers and 1/3rd of young men in the general population
Wernicke-Korsakoff syndrome
Due to thiamine (vitamin B1) deficiency
Wernicke’s encephalopathy occurs during acute brain damage due to thiamine deficiency:
-Triad of delirium, ophthalmoplegia (nystagmus, 6th nerve palsy or conjugate gaze palsy) and ataxia
Korsakoff’s psychosis is chronic state that emerges after untreated Wernicke’s:
-Extensive anterograde and retrograde amnesia, frontal lobe dysfunction and psychotic symptoms in the absence of delirium
Treatment for Wernicke’s encephalopathy
Parenteral thiamine (Pabrinex)
The lifetime risk of suicide in problem drinkers
3-4% (60-120x greater than the normal population)
Due to alcohol-related psychiatric disorders (mainly low mood), comorbid alcohol misuse with other psychiatric and personality disorders, or through impaired judgement or disinhibition secondary to alcohol
Psychological and physical effects of opiates
Heroin, dihydrocodeine, methadone, buprenorphine
Psychological:
Euphoria, drowsiness, apathy, personality change
Physical:
Miosis, conjunctival injection, nausea, pruritus, constipation, bradycardia, respiratory depression, coma
Psychological and physical effects of sedatives
Temazapam, diazepam, GHB, rohypnol
Psychological:
Drowsiness, disinhibition, confusion, poor concentration, reduced anxiety, feeling of well- being
Physical:
Miosis, hypotension, withdrawal seizures, impaired coordination, respiratory depression
Psychological and physical effects of stimulants
Amphetamine, cocaine, crack cocaine, MDMA, mephedrone, legal highs
Psychological:
Alertness, hyperactivity, euphoria, irritability, aggression, paranoid ideas, hallucinations (especially cocaine – formication), psychosis
Physical:
Mydriasis, tremor, hypertension, tachycardia, arrhythmias, perspiration, fever (especially Ecstasy), convulsions, perforated nasal septum (cocaine)
Psychological and physical effects of hallucinogens
LSD, magic mushrooms
Psychological:
Marked perceptual disturbances including chronic flashbacks,
paranoid ideas, suicidal and homicidal ideas, psychosis
Physical:
Mydriasis, conjunctival injection, hypertension, tachycardia, perspiration, fever, loss of appetite, weakness, tremors
Psychological and physical effects of cannabinoids
Cannabis, hashish, hash oil
Psychological:
Euphoria, relaxation, altered perception, psychosis
Physical:
Impaired coordination and reaction time, conjunctival
injection, nystagmus, dry mouth
Psychological and physical effects of dissociative anaesthetics (ketamine)
Psychological:
Hallucinations, paranoid ideas, thought disorganisation, aggression
Physical:
Mydriasis, tachycardia, hypertension
Psychological and physical effects of inhalants
Aerosols, glue, lighter fluid, petrol
Psychological:
Disinhibition, stimulation, euphoria, clouded consciousness, hallucinations, psychosis
Physical:
Headache, nausea, slurred speech, loss of motor coordination, muscle weakness, damage to brain/bone marrow/liver/kidneys/myocardium, sudden death
Three diagnostic relationships between substance use and psychiatric symptoms
- Primary psychiatric disorder, with the patient coincidentally using drugs (or to obtain relief from symptoms)
- Symptoms are entirely due to the direct effect of the substance
- Psychiatric symptoms are due to a combination of the above (somebody might have a predisposing vulnerability to schizophrenia then starts smoking cannabis)
Features suggesting a substance-related psychiatric disorder (4)
- The symptoms are known to be associated with the drug in question
- There is a temporal relationship (hours or days) between the use of the drug and the development of symptoms
- There is complete recovery from all psychiatric symptoms after termination of the suspected drug use
- There is absence of evidence to suggest an alternative explanation for psychiatric symptoms (e.g. a family or personal history)
What 4 key topics must you address when taking a substance misuse history
- All substances used
- Pattern of use (times, methods)
- Features of dependence
- Consequences of substance use (relationships, employment, physical health, criminality)
CAGE questionnaire
Tool to screen for alcohol dependence. Positive if answer yes to 2 or more
- Cut down - have you ever thought you should?
- Annoyed - do others annoy you by criticising your drinking?
- Guilty - have you ever felt guilty about your drinking?
- Eye-Opener - have you ever needed one?
AUDIT
Alcohol Use Disorders Identification Test
10-item screening questionnaire for problem drinking, takes 3 mins
