Substance misuse

Question 1

What are the questions to ask in the CAGE screening tool?

Answer 1

Have you ever felt like you should CUT DOWN from drinking?
Have people become ANNOYED/criticised your drinking?
Have you ever felt GUILTY about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves/get rid of a hangover? Or any other EYE-OPENING experience?

Question 2

What are some clinical features of alcohol dependency?

Answer 2

Compulsion to drink
Stereotyped patterns of drinking
Prominent drink-seeking behaviours (prioritising)
Difficulty controlling onset, termination, quality
Physiological withdrawal state
Tolerance
Neglect of alternative pleasures/interests
Persistence despite evidence of self harm

Question 3

What is the Mx for alcohol dependence?

Answer 3

Individual/supporting psychotherapy, eg AA, behavioural therapy.
Disulfiram (Antabuse) as adjunctive therapy,
Acamprosate for cravings,
Drinking diary

Question 4

What is the indication for Acamprosate?

Answer 4

Reduces cravings, useful in maintaining abstinence in alcohol dependence. Take TDS in combo with counselling for ≥1y.

Question 5

What is the indication for Disulfiram (Antabuse)?

Answer 5

Prophylactic adjunctive therapy for alcohol dependence.
Ingesting even the tiniest amount of alcohol leads to v unpleasant systemic rxns, inc facial flushing, headache, tachycardia, nausea, vomiting.
Large amounts of alcohol can lead to arrhythmias/severe hypotension.

Question 6

What are the symptoms of alcohol withdrawal?

Answer 6

Malaise, nausea, autonomic hyperactivity, lability of mood, insomnia, transient hallucinations
Severe = delerium tremens
Occurs w/in 1-2 days of abstinence

Question 7

What is the treatment for alcohol withdrawal?

Answer 7

Support and explanation
Rehydration, correct electrolyte imbalance
Oral thiamine
Reducing regimine of 5-7/7 with benzodiazapines or chlormethiazole (prevents seizures, controls hallucinations)

Question 8

What is Delirium Tremens?

Answer 8

Potentially life-threatening confusional state (mortality = 15%)
Tremor, clouding of consciousness, autonomic instability, disorientation, mood instability, illusions, nightmare, hallucinations, delusions, convulsions

Question 9

What is the management for delirium tremens?

Answer 9

Exclude alternative cause (e.g. head injury, infections)
Chlordiazepoxide / benzodiazepine reducing regimen
Correct fluid / electrolyte imbalances
Supportive measures
General treatment for an acute confusional state

Question 10

What is Wernicke’s encephalopathy, and how is it managed?

Answer 10

Most dramatic neuropsychiatric complication of withdrawal
Secondary to thiamine (Vitamin B1) deficiency
Px: ataxia, nystagmus, opthalmoplegia and acute confusion
May recover with acute administration of thiamine
If untreated, may develop in to Korsakoff’s psychosis

Question 11

What is confabulation?

Answer 11

Disturbance of memory, defined as the production of fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive.
(Korsakoff’s psychosis)

Question 12

What are the two types of memory loss in Korsakoff’s psychosis?

Answer 12

Retrograde amnesia – pathological inability to recall events that occurred prior to the onset of the illness
Anterograde amnesia – pathological inability to lay down new memories after the onset of the illness

Question 13

What are the features of Korsakoff’s psychosis?

Answer 13

Prominent impairment of recent and remote memory with preservation of immediate recall, in the absence of generalised cognitive impairment.
Confabulation (recalling fake memories in absence of real memories, without realising)

Question 14

What are the symptoms of acute heroin overdose?

Answer 14

Drowsiness, nausea, vomiting, respiratory depression, hypotension, pinpoint pupils

Question 15

How is opiate overdose treated?

Answer 15

NALOXONE

Question 16

What is the presentation of opiate withdrawal?

Answer 16

Agitation, anxiety, hot and cold sweats, intense cravings, piloerection, muscle aches, stomach cramps, diarrhoea, restlessness, insomnia, mood swings
~6-12h, lasts ~5/7 (but cravings for 6/12)

Question 17

What are the physical effects of opiates?

Answer 17

Nausea, vomiting, sweating, itching
Decrease respiratory rate, pulse, BP and temperature
Pinpoint pupils, reduced gag reflex
Constipation, weight loss

Question 18

What are the effects of amphetamines? (early effects, risks)

Answer 18

Monoamine agonist/antagonist
Wide awake, excited, talkative, reduced
hunger/appetite, more energy.

Risks/negative effects: Dependency insomnia, poor concentration, anxiety, depression, irritability, aggression and paranoia, psychosis, cardiac problems

Question 19

What are the effects of cannabis? (early effects, withdrawal, risks)

Answer 19

Chilled out, relaxed and
happy, giggles, very talkative.
hungry

Withdrawal: Irritability, mood changes, feeling sick, loss of appetite, difficulty sleeping; and even sweating, shaking and diarrhoea in some people.

Risks/negative effects: Cravings & psychological dependency, anxiety, paranoia, poor concentration, poor memory, apathy, psychosis, precipitate schizophrenia

Question 20

What are the early effects/withdrawal px/risks of cocaine?

Answer 20

Early effects: feel on top of the world, wide awake, confident , reduces hunger, short acting.

Withdrawal: Low mood, generally unwell,

Risks: psychological dependence, tachycardia, raised temperature, MI, heart failure, hypertension, seizure, depression, anxiety, panic attacks, paranoia

Question 21

What are the early effects/withdrawal px/risks of MDMA?

Answer 21

Early effects: Energised, happy, alertness,
increased affection, chatty, dilated pupils

WIthdrawal: Lethargy, depression,
memory problems

Risks: Anxiety, panic attacks, confused episodes, paranoia, psychosis, tachycardia, hyperpyrexia, electrolyte disturbances, de- and over -hydration

Question 22

What are the early effects, withdrawal symptoms, and risks of benzodiazapines?

Answer 22

Early effects: GABA agonist. Relaxed, calm, less anxious, sedated

Withdrawal: decreased concentration, tremors, nausea, vomiting, headaches, anxiety, panic attacks, confusion, depression, seizures

Risks: Respiratory depression, falls, hangover, memory loss, sedation, death with injection

Question 23

What are the early effects, withdrawal symptoms, and risks of GHB/GBL?

Answer 23

Early effects: GABA agonist. Euphoria, reduced inhibitions and drowsiness.

Withdrawal: insomnia, anxiety, tremor,
delirium

Risks: nausea, dizziness, drowsiness, agitation, visual disturbances, respiratory depression, unconsciousness, coma, death (esp. if mixed with alcohol)

Question 24

What are the effects and risks of ketamine?

Answer 24

NMDA antagonist
Early effects: Relaxation, altered bodily sensations, floating feelings, dissociation, altered perceptions, hallucinations

Used as an anaesthetic (WHO Model List
of Essential Medicines
injectable general anaesthetic (also propofol)

Risks: ulcerative cystitis, bladder pain, memory problems, dependency, panic attacks, confusion, agitation

Question 25

What are the effects and risks of LSD?

Answer 25

Dopamine (+5HT) agonist
Early effects: Hallucinations, sensory distortions and altered perceptions,

Risks: fear (“bad trips”), anxiety, panic, depression, flashbacks, accidents, psychosis

Question 26

What are the effects and risks of mephedrone?

Answer 26

Monoamine agonist/antagonist
Effects: feel alert, confident, talkative, euphoric, increased affection, reduced appetite

Risks: Nausea, anxiety, headaches, vomiting, agitation, hallucinations, seizures, reduced peripheral circulation, epistaxis, addiction paranoia, self-harm

Question 27

What are the effects and risks of psilocybin mushrooms?

Answer 27

5HT partial agonist
Effects: disorientation, lethargy, giddiness, relaxed, euphoria, perceptual and sensory
changes, hallucinations

Risks: Poisoning, death, nausea, disorientation, diarrhoea, stomach pains, depression, anxiety, paranoia, panic attacks, “bad trips”, flashbacks