Substance Misuse Flashcards
Dependence - definition
Three or more of :
- Strong desire / compulsion to take the substance
- Impaired control of substance taking behaviour
- Physiological withdrawal state when reduced/stopped
- Tolerance to effects leads to increased use
- Preoccupation with use, to exclusion of other pleasures
- Persistence despite clear harm
Intoxication - definition
- Disturbances in: Level of consciousness Cognition Perception Affect Behaviour - Disturbance directly related to effect of the substance - Resolve with time
Harmful use - definition
Substance use that is causing damage to health
- Clear evidence of harm: Physical or psychological
- Nature of the harm should be identifiable
- Pattern of use has persisted for at least one month, or has occurred repeatedly over a 12 month period
Salience/Primacy
Tolerance
Abstinence
Salience/Primacy
Obtaining & using the substance takes over
Other interests & pursuits are neglected
Tolerance
Increased doses of the psychoactive substance are required to achieve effects originally produced by lower doses
Abstinence
Period during which no substance is used
Withdrawal State
vs
Detoxification
Withdrawal State
Symptoms & signs compatible with known features of withdrawal of that substance
Symptoms & signs not attributable to other disorder
In some, will be aborted by reinstating the substance
Detoxification
Process of reducing and stopping the use of an addictive substance
Medical assistance (in the form of prescribed medication) may be required for some substances
Stages of cycle of change described by Prochaska and Di Clemente
- Pre Contemplation: Person feels there is no problem, though others recognise it
- Contemplation: Person weighs up pros & cons and considers if change is necessary
- Decision: Person decides to act (or not)
- Action: Person chooses strategy for change & pursues it
- Maintenance: Gains are maintained & consolidated
- Relapse: Return to previous pattern, but relapse may help learning
Dual Diagnosis
- Primary psychiatric illness may precipitate substance misuse
- Substance misuse may worsen course of psychiatric illness - Intoxication & / or dependence may lead to psychological symptoms and social difficulties
- Substance misuse & / or withdrawal may cause psychiatric symptoms or illness & may trigger illness in those who are predisposed
- Rates vary – 22% to 44% of psychiatric inpatients have problematic drug or alcohol use
- Highest rates in urban, inner city areas (36% in survey of Inner London Psychiatric Service)
Alcohol intoxication - presentation
Relaxation & euphoria followed by disinhibition, various emotional states (irritable, weepy, morose), impulsive & irresponsible behaviour, AMS
Slurred speech, ataxia, sedation, confusion, flushed face, nystagmus, conjunctival injection, N+V
Alcohol withdrawal - presentation
Headache, nausea, retching, vomiting, diaphoresis, tremor, insomnia, anxiety, agitation, tachycardia, hypotension, confusion, delirium tremens, seizures
Alcohol dependence - management
- Detoxification
- Benzodiazepines (eg chlordiazepoxide, diazepam) using fixed-dose reducing regimens (gradual decrease)
- Vitamins (Thiamine) - Relapse prevention
- Psychological support (CBT, individual, AA)
- Rx: Acamprosate – reduces craving (GABA agonist)
Naltrexone
Disulfiram – induces hangover symptoms eg flushing, throbbing headache, N+V etc.
If pt presents “found down” –> coma: give coma cocktail = thiamine first, dextrose and naloxone
Alcohol dependence - complications
- Liver: cirrhosis, hepatitis
- GI: pancreatitis, oesophageal varices, gastritis, peptic ulcers, GI bleeds
- Brain: peripheral neuropathy, head injury, seizures, dementia/ wernicke’s and korsakoff
- CVS: HTN, cardiomyopathy
- Cancer: bowel, breast, oesophageal, liver
- Foetal alcohol syndrome
Alcohol dependence - psychological and social complications
- Depression & Anxiety, suicide and self harm rates increased
- Amnesia / blackouts (due to intoxication)
- Cognitive impairment
- Alcoholic hallucinations
- Morbid Jealousy (othello syndrome)
- Poor work performance, unemployment
- Domestic violence, marital breakdown, child neglect
- Legal issues: drink driving, assault, theft
Alcoholic emergency - Delirium Tremens
Delirium Tremens
- Onset in 48h after abstinence
- Confusion, hallucinations & illusions, agitation, paranoia, sweating, tachycardia, tremor, seizures
- Treat with reducing benzodiazepine regime & parenteral B vitamins (Pabrinex) - to avoid Wernicke – Korsakoff Syndrome
((– NICE: consider reducing the dose or stopping meds that can precipitate delirium (such as opioids, benzodiazepines, and anticholinergics). Avoid abrupt withdrawal of drug of misuse.
– BNF: 1st line –> oral lorazepam
2nd line –> parenteral lorazepam [unlicensed], or haloperidol [unlicensed] as adjunctive therapy.))
Alcoholic emergency - Wernicke’s Encephalopathy
Wernicke’s Encephalopathy
- Classic triad of confusion, ataxia & ophthalmoplegia
- Acute thiamine (vitamin B1) deficiency
- Treated with a course of parenteral B vitamins (Pabrinex) given IV or IM (see BNF)
- If untreated leads to Korsakoff’s Psychosis (IRREVERSIBLE anterograde amnesia with confabulation)
Amphetamines - examples
- dexamphetamine, which is used for ADHD
- amphetamine sulphate, known mainly as speed
- methamphetamine, which is a more potent amphetamine known as ‘crystal’, ‘meth’, ‘rock’ or ‘ice’
- MDMA, aka ecstasy or molly*
*ecstasy is structurally related to amphetamines but it’s a class A drug, while amphetamines are class B
Amphetamines - characteristics and effects
- stimulate release of endogenous catecholamines
- increase levels of serotonin and dopamine
Physical & Psychological Effects: - Cardiovascular strain
- Enlarged pupils
- Talkative, agitated, full of energy, irritable
- Psychosis (schizophreniform)
Ecstasy –> altered sensations, feeling of pleasure, empathy. Can cause hyperthermia and dehydration
Benzodiazepine OD
- Produce sedation, euphoria, disinhibition, lability of mood, anterograde amnesia, unsteady gait, slurred speech, nystagmus, reduced consciousness, respiratory depression, AMS, confusion
- Mx is supportive, watch and wait, sometimes give benzo antidote - flumazenil (but risk of seizures and arrhythmias so not usually prescribed)
- Withdrawal can cause delirium tremens – like presentation with psychotic symptoms and seizures
Treatment – convert to diazepam equivalent dose & withdraw gradually over 8 + weeks
Cocaine - effects and management
Two forms:
- Powder (hydrochloride)
- Crack (alkaloid) - Heated & inhaled through pipe or
Can be injected if added to acid (vit C) – often with heroin (speedball)
Effects: Stimulant, dilated pupils, tachy, HTN, risk of MI
- Alert, confident, strong, disinhibited, agitated
- “come down” – fatigue, depression / dysphoria, paranoid ideation, depersonalisation
- No replacement therapy available
- Acute Psychotic episodes may require antipsychotic & benzodiazepines (short term) for symptom control
Heroin - effects
- Opiate derivative, highly addictive
- Can be injected, smoked, snorted or combined with crack cocaine (speedballing)
- Gives strong sense / rush of relaxation / wellbeing / arousal, pleasure
- Intoxication: Pin point pupils, “Track marks” – injection sites, constipation, poor nutrition, poor dental state (reduced salivary flow), respiratory depressant
- Association with blood borne viruses (injecting patients): Hepatitis C, Hepatitis B, HIV
- Withdrawal symptoms: vomiting, diarrhoea, cramps, sweats, dysphoria
Heroin use - management
- Harm Reduction
- Needle exchange, stop sharing gear / works
- Encourage smoke rather than inject
- Raise awareness of overdose & how to manage it, (some areas give naloxone packs)
- Narcotics Anonymous - Opioid Substitution Treatment (OST) - for maintenance or detoxification. Short period of stabilisation, followed by either a withdrawal regimen or by maintenance.
- Methadone: full agonist, prolongs QT interval (monitor ECG 6 monthly)
- Buprenorphine: partial agonist, less sedative, less risk of OD
Detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
Other
- Naltrexone: Adjunct to prevent relapse in formerly opioid-dependent patients (who have remained opioid-free for at least 7–10 days)
- Naloxone: used for opioid overdose
Ketamine - important facts
- An anaesthetic agent
- NMDA (glutamate) antagonist*
- Commonly in powder or tablet form
- Produces hallucinations, reduced pain sensation, drowsiness, sedation, respiratory depression
- Prolonged use can cause “ketamine bladder” – haematuria, scarring and severe pain – severe cases have necessitated removal of the bladder
*another example of NMDA antagonist is PCP - hallucinations, distorted perceptions of sounds, and violent behavior
LSD - important facts
aka acid
- synthetic hallucinogen, serotonin agonist and dopaminergic
- taken as a “tab” on a tiny square of paper
- Produces hyperaesthesias, hallucinations, and other altered perceptions/ distorted images aka “trip”
- trips can be pleasant or not & frightening “bad trip”
- Flashbacks can occur days / months later
- Can precipitate mental health problems in people with predisposition
Classes of drugs and penalties
Class A
Possession: 7 years & unlimited fine
Possession with intent to supply: Life & unlimited fine
Class B
Possession: 5 years & unlimited fine
Possession with intent to supply: 14 years & unlimited fine
Class C
Possession: 2 Years & unlimited fine
Possession with intent to supply: 14 years & unlimited fine
