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3a psychiatry > Substance misuse > Flashcards

Substance misuse Flashcards

1
Q

Define “harmful use”

A

continuation of substance use despite evidence of damage to the users physical or mental health or social wellbeing

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2
Q

Define “dependence”

A

an associated neglect of important social, occupation or recreation activities and a physical and psychological dependence

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3
Q

Define “withdrawal state”

A

when there is physical dependence of a drug, abstinence will lead to undesirable symptoms of withdrawal

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4
Q

What are the risk factors for substance abuse?

A 
availability 
peer pressure
desire for pleasurable effects 
prescribed drugs misuse 
psychiatric illness e.g. borderline personality disorder, anxiety, depression
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5
Q

What are the signs of dependence?

A

C- compulsion to take substance
A- aware of harm but persist
N’- neglect of other activities
T- tolerance

S- stopping causes withdrawal
T- time preoccupied with substance increases
O- out of control of use
P- persistent wish to cut down

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6
Q

What effect do opiates (heroin, morphine, methadone) have?

A 
intense euphoria
relaxation and peace
detachment 
CNS depression
emotional numbing
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7
Q

What negative effects do opiates have?

A 
constipation
pin point pupils 
tremor 
myosis 
yawning
flu like symptoms/ rhinorrhoea
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8
Q

What symptoms does an opiate overdose cause?

A

respiratory depression

miosis

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9
Q

What is opiate detoxification treatment?

A

methadone (opioid agonist) or buprenorphine for 4-12 weeks with psychosocial support for over 6 months - supervised consumption

+ inform National Drug Treatment Monitoring System

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10
Q

what is the aim of opiate maintenance therapy?

A

harm reduction and stabilising lifestyle

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11
Q

What are the negative effects of stimulants?

A 
depression
tiredness
psychosis 
sweating
anxiety 
increased blood pressure
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12
Q

What are the negative effects of hallucinogens?

A

hyponatraemia (thirsty)
flashbacks
psychosis
seizures (LSD overdose)

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13
Q

What are the negative effects of cannabis?

A

flashbacks
transient psychosis
depression
conjunctival irritations

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14
Q

What are the early withdrawal symptoms (24-48hr) of opiates?

A 
craving
flu like symptoms
sweating
yawning 
dilated pupils 
irritable/ aggressive
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15
Q

What is given for an overdose of opiates?

A

naloxone IM or IV

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16
Q

What are the negative effects of benzodiazepines (depressants)?

A 
depressed
loss of memory
impaired attention
disinhibited
delirium
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17
Q

What are the symptoms of benzodiazepine withdrawal?

A 
anxiety
insomnia 
tremor
agitation
nausea
seizures
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18
Q

What are the clinical consequences of injecting drugs?

A 
cellulitis
abscesses
osteomyelitis
bacterial endocarditis
septicaemia 
transmission of viral infections e.g. HIV, HepB
staph aureus infections
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19
Q

What are “harm reduction” techniques?

A

= method of managing drug users by reducing mortality and morbid without insisting abstinence from drugs

advice of use of safer drugs or routes of administration
safer injecting practice
advice on safe sex
prescription of maintenance opiates
engagement with other sources of help e.g. social work

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20
Q

Define “substance prescribing”

A

move from unstable street use to prescribed dependence use of facilitated change now with abstinence later

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21
Q

Define “maintenance prescribing”

A

convert from street to prescribed drug with stabilisation via maintenance prescribing

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22
Q

Define “alcohol abuse”

A

regular or binge consumption of alcohol sufficient to cause physical, neuropsychiatric or social damage

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23
Q

Define “tolerance”

A

when the individual has to drink larger amount of alcohol to obtain a similar effect

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24
Q

What is a unit of alcohol

A

10ml/8g e.g. small glass of wine, half pint beer, single spirit

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25
Q

What is the recommended daily/ weekly units of alcohol for men and women?

A

MEN and WOMEN <14 units/ week with >2 drink free days

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26
Q

How is units of alcohol calculated

A

unit = volume drunk (L) x % of alcohol

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27
Q

what are the risk factors of alcohol dependence and misuse?

A

genetics - family history of alcohol abuse or depression
occupation e.g. journaliste, doctors, armed forces
cultural influences
lower social economic group - early age, availability
psychological factors e.g. impulsive, behavioural issues, anxiety

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28
Q

What are some of the key clinical symptoms of alcohol dependence?

A

Cardio - hypertension, arrthymias (AF)

GI- duodenal peptic ulcers, mallory weiss tear, gastritis , oesophageal/ gastric cancer

Hepatic- hypoglycaemia, cirrhosis, hepatitis, alcoholic liver disease, oesophageal varies, pancreatitis

Neuro- peripheral neuropathy, subdural haematoma, wernickes encephalophy, amnesia, korsakovs

Pscyh- depression, anxiety, suicide, alcohol induced psychosis

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29
Q

what is the effect of alcohol on the brain?

A

ethanol = CNS depressant
ethanol increase the effect of GABA (inhibitory) which inhibits neurones so feel relaxed and disinhibited
also releases dopamine in mesolimbic system

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30
Q

Describe the CAGE questionnaire?

A

have you tried to Cut down?
have people Annoyed you by suggesting you do so?
have you felt Guilty about drinking?
have you needed an Eye opener (early morning drink)?

SCORE: never=0, monthly= 2, weekly=3, daily=4

31
Q

Describe the FAST questionnaire?

A

Fast Alcohol Scoring test

> 8 drinks (men) or >6 drinks (women)
can’t remember the night before
failed to function normally because of alcohol
someone else is concerned about your drinking

> 2 = hazardous drinking

32
Q

Which blood tests are used to screen for alcohol dependence and what would they show?

A

Full blood count - increased MCV

Liver Function Tests - raised gamma glutamyl transferase (GGT), raised ALT and AST, carbohydrate deficient trasnferin (CDT)

breath taking

urinary test - increased urinary ethyl glucoronide

33
Q

Which screening tests are used for alcohol dependence?

A
  1. CAGE questionnaire
  2. AUDIT questionnaire
  3. FAST questionnaire
34
Q

What would you expect to find in a urinary test of someone with alcohol dependence?

A

increased urinary ethyl glucoronide

= marker of alcohol

35
Q

What physical examination signs with you see in a patient with alcohol dependence?

A 
alcohol stigmata= signs of liver disease...
jaundice
spider naevi 
palmar erythema
gynaecomastia
peripheral neuropathy
36
Q

What are the stages of change model?

A
  1. pre contemplation
  2. contemplation
  3. preparation
  4. action
  5. maintenance
  6. relapse
37
Q

What is involved in the management of acute detoxification?

A
  1. admitted to hospital if at risk of delirium tremens
  2. high rapid tailing benzodiazepines - controls withdrawal symptoms and prevents seizures
  3. rehydration
  4. correction of electrolyte disturbance
  5. thiamine (oral and parenteral)
38
Q

What therapies are used in the management of detoxification?

A

THIAMINE **
motivational interviewing - use FRAMES
psychological therapies e.g. 5 sessions of talking therapy
self help groups e.g. alcoholics anonymous

39
Q

Which medication is used in alcohol detoxification?

A

1st line - anti craving e.g. amaprosate, naltrexone

2nd line - disulfiram (need to outline the risks of the drug to patient - can cause mortality if drink with it as the alcohol cannot be metabolised)

40
Q

What is the mechanism of disulfiram?

A

= aversive drugs
inhibits acetaldehyde dehydrogenase to maintain abstinence
if alcohol consumed, build up acetaldehyde and causes unpleasant symptoms like a hangover- dangerous if drink alcohol

41
Q

What is the mechanism of acamprosate?

A

= anti craving

acts to enhance GABA transmission to reduce cravings and relapse

42
Q

What is the mechanism of naltrexone?

A

= anti craving

opioid receptor antagonist

43
Q

List the early symptoms of alcohol withdrawal

A 
tremor
nausea
sweating
agitation
tachycardia
raised blood pressure
craving for alcohol
44
Q

List the late symptoms (24-48 hours) of alcohol withdrawal

A 
delusions
confusion
diarrhoea
epileptic seizures
auditory hallucinations
45
Q

Define delirium tremens

A

acute confusional state secondary to alcohol withdrawal (MEDICAL EMERGENCY)

46
Q

What are the triad of symptoms for delirium tremens?

A
  1. marked tremor
  2. vivid/ disturbing perceptions
  3. confusion and clouding of consciousness
47
Q

List some of the symptoms of delirium tremens

A

TRIAD: tremor, disturbing perceptions, confusion

restlessness
paranoia
confusion
ataxia
tachycardia
hallucinations
disorientation
48
Q

When does delirium tremens occur?

A

3-4 days after withdrawal

49
Q

What is the treatment for delirium tremens?

A

chlordiazepoxide (benzodiazepine)
vitamins (pabrinex and thiamine)
fluids
dextrose

50
Q

Define wernickes encephalopathy

A

acute reversible syndrome cause by thiamine deficiency

51
Q

What is thiamine (vitamin B1) deficiency caused by?

A

chronic alcohol abuse
starvation
anorexia

52
Q

What is the classic triad of wernickes encephalopathy?

A
  1. ataxia
  2. acute confusion
  3. eye signs e.g. nystagmus, ophthalmoplegia
53
Q

How is wernickes encephalopathy treated?

A
  1. pabrinex IM/IV - 2 ampules twice daily for 3-7 days
  2. sedation
  3. fluids/ electrolytes
54
Q

Define Korsakoffs syndrome

A

state of impaired memory function after signs of wernickes encephalopathy have subsided due to vitamin B1 malnutrition

55
Q

What are the clinical features of Korsakoffs syndrome?

A 
anterograde memory disorder - new memories cannot be consolidated
confabulation
distorted sense of time
peripheral neuropathy
irreversible
56
Q

How is Korsakoffs syndrome managed?

A

oral thiamine replacement
multivitamins

LIFE LONG CHRONIC ILLNESS WITH NO CURE, JUST SLOW THE SYMPTOMS

57
Q

what are the 4 features of addiction?

A
  1. craving
  2. tolerance
  3. compulsive drug seeking behaviour
  4. physiological withdrawal state
58
Q

What are the acute and chronic physical effects of dependent drug use?

A

ACUTE
complications of injecting - DVT, abscesses
overdose - resp depression
side effects - constipation, low salivary flow

CHRONIC
blood borne virus transmission e..g hepatitis
effects of poverty
side effects of cocaine - vasoconstriction

59
Q

What are the social effects of dependent drug use?

A

effects on families
drive to criminality
imprisonment
social exclusion

60
Q

What are the chronic effects of cocaine use?

A 
depression
panic
paranoia 
psychosis
damaged nasal septum
respiratory problems
61
Q

What are the modalities of treatment for drug dependent users?

A
  1. harm reduction
  2. detoxification
  3. maintenance
  4. relapse prevention
  5. psychological interventions
  6. alternative therapies
  7. referral for allied problems
62
Q

What can a doctor offer a newly presenting drug user?

A
  1. health check
  2. screening for blood borne viruses
  3. contraception, smear
  4. sexual health advice
  5. check immunisation status
  6. signpost to additional help - counselling, benefits, housing
63
Q

What are the basic harm reduction techniques?

A
  1. action to prevent death - safer injection, reducing amount taken
  2. action to prevent blood borne virus transmission - needed exchange programs, safer sex
  3. referral where appropriate
64
Q

Why are women drinking more?

A

more socially acceptable
more disposable income
more drinks marketed at women
more drinking places aimed at women customers

65
Q

What are the most common causes of death due to alcohol?

A

accidents and violence
malignancies
cerebrovascular disease
coronary heart disease

66
Q

Describe the later withdrawal symptoms (7-10 days) of opioid dependence?

A 
dilation of pupils 
abdominal cramps
diarrhoea/ vomiting 
agitation 
restlessness
tachycardia
67
Q

What are the complications of opioid misuse?

A

viral infection secondary to sharing needles e.g. HIV, Hep C
bacterial infections secondary to injection e.g. infective endocarditis, septic arthritis, sepsis, necrotising fasciitis
VTE
overdose
psychological problems
social problems e.g. crime, prostitution, homelessness

68
Q

what are the signs of alcohol dependence?

A

C- compulsion to drink alcohol
A- aware of physiological/ psychological harm but persists
N - neglect of other activities
T - tolerance

S- stereotyped pattern of behaviour (narrowing of repertoire)
S- stopping causes withdrawal symptoms
T- time taking alcohol increases
O - out of control use
P - persistent futile wish to cut down
69
Q

How is FRAMES used when talking to alcoholic patients about stopping?

A 
F- feedback
R- responsibility
A - advice
M - menu of options
E - empathy
S - self efficacy and optimism
70
Q

What is used to assess severity of alcohol withdrawal?

A

Clinical Institute of Withdrawal of Alcohol (CIWA)

71
Q

How is alcohol withdrawal categorised?

A
  1. uncomplicated : 4-12 hrs after last drink, persists for 5 days
  2. withdrawal with seizures: 36 hrs after, 15% of cases
  3. delirium tremens: 3-4 days after last drink, 5% of cases
72
Q

How is acute alcohol withdrawal managed?

A
  1. benzodiazepine: chlorodiazepoxide 5-7 days
  2. pabrinex (thiamine = vitamin B1)
  3. rehydrate
  4. correct electrolyte imbalance
73
Q

when should you admit someone to hospital when withdrawing from alcohol?

A

delirium tremens
alcohol withdrawal seizures
psychiatric problems
suspected wernickes

3a psychiatry (9 decks)

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