Substance Misuse Flashcards
Define the following categories of substance misuse: intoxication, harmful use, dependency, withdrawal
- Intoxication: a transient state of emotional and behavioural change following drug use. It is dose-dependent and time-limited.
- Harmful Use: a pattern of use likely to cause physical or psychological damage.
- Dependency: a cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours that once had greater value.
- Withdrawal: a transient state occurring while re-adjusting to lower levels of the drug in the body.
Define the following features of dependency: tolerance, compulsion, withdrawal, problems controlling use
• Tolerance: larger doses required to gain the same effect as previously.
o E.g. an opiate-addict may easily inject enough heroin to kill a non-addict
• Compulsion: strong desire to use the substance.
o E.g. craving a cigarette
• Withdrawal: physiological withdrawal state when the substance is stopped/decreased, demonstrated by:
o Characteristic withdrawal syndrome for the substance
• E.g. alcohol withdrawal fits
o OR Substance use to prevent or relieve withdrawal
symptoms
• E.g. early morning drinking
• Problems Controlling Use: difficulties controlling starting, stopping or amounts used.
o E.g. it becomes hard to say no
Define the following features of dependency: controlled use despite harm, salience, reinstatement after abstinence, narrowing of the repertoire
• Continued Use Despite Harm: despite clear problems caused by the substance, the person can’t stop using.
o E.g. injecting heroin despite developing an abscess
• Salience (Primacy): obtaining and using the substance becomes so important that other interests are neglected.
o E.g. not eating because the money is needed for cocaine
• Reinstatement after Abstinence: tendency to return to the previous pattern and level of use after a period of abstinence.
o E.g. someone who stops smoking for a year may return quickly to their previous 20/day habit
• Narrowing of the Repertoire: loss of variation in use of the substance.
o E.g. only having exactly 12 pints of snakebite every day at the same time. Drinking the same amount of same drink in the same way every day
Give some aetiological risk factors for excess alcohol use
- Some genetic component
- Occupation: more common in publicans, journalists, doctors, armed forces and entertainment industry
- Social Background: difficult childhood, parental separation, poor educational achievement, juvenile delinquency
- Psychiatric Illness: personality disorders, mania, depression and anxiety disorders (especially social phobia)
Give some signs and symptoms of alcohol intoxication
- Relaxation, euphoria
- Irritable, aggressive, weepy, disinhibited
- Impulsivity and poor judgement
Give some symptoms of alcohol withdrawal
- Headache
- Nausea, retching and vomiting
- Tremor
- Sweating
Explain the key signs of delirium tremens and its management (medical emergency of alcohol withdrawal)
- Happens around 48 hours into abstinence
- Duration: 3-4 days
- Confusion
- Hallucinations (especially visual e.g. formication)
- Affective changes (extreme fear and hilarity may alternate)
- Gross tremor (especially hands)
- Autonomic disturbance (sweating, tachycardia, hypertension, fever)
- Delusions
MANAGEMENT
• Reducing benzodiazepine (chlordiazepoxide) regime and parenteral thiamine (pabrinex)
• Manage potentially fatal dehydration and electrolyte abnormalities
Give some biological, physical complications of excess alcohol use (think systems)
- Liver: alcoholic hepatitis, cirrhosis
- GI: pancreatitis, oesophageal varices, PUD
- Neurological: peripheral neuropathy, seizures, dementia
- Cancers: bowel, breast, oesophageal and liver
- CVS: hypertension, cardiomyopathy
- Head injuries/accidents
- Foetal alcohol syndrome
Give some psychological and social complications of excess alcohol use
Psychological
• Depression, anxiety, self-harm and suicide
• Amnesia
• Alcoholic hallucinosis (experience of auditory hallucinations in clear consciousness while drinking alcohol (often persecutory/derogatory))
• Morbid jealousy (overvalued idea or delusion that the partner is unfaithful)
Social
• Unemployment, domestic violence, separation and divorce
• DRINK DRIVING - always ask alcoholics about this
Explain Wernicke-Korsakoff’s syndrome as a complication of alcohol use (include management)
Wernicke’s Encephalopathy:
- Acute thiamine deficiency
- Triad: confusion, ataxia, ophthalmoplegia
- Medical emergency
Can progress to Korsakoff’s psychosis
- Irreverisible antegrade amnesia (cannot recall recent events)
- Confabulation to fill gaps in memory
Management: IV/IM Thiamine
What is the differential diagnosis of substance misuse?
Organic
- Physical causes (e.g trauma)
Psychiatric illness (could be either primary or comorbid)
- Depression/mania
- Functional psychosis
- Anxiety disorder
- Personality disorder
Give some investigations for alcohol misuse
• FBC
o Macrocytic anaemia due to B12 deficiency in alcoholism
• LFTs
o GGT rises with recent heavy alcohol use
o Raised ALT and AST suggests hepatocellular damage
• Other investigations based on presentation (e.g. ECG, urine drug screen, hepatitis if IVDU)
Outline the different stages of the Stages of Change Model
• Pre-contemplation
Pt doesn’t see a problem or doesn’t want to change
• Contemplation
Recognises the problem, but doesn’t want to change yet
• Preparation
Willing to change, planning to do this soon
• Action
Change becomes reality, being put into practice
• Maintenance
Remains in abstinence or agreed low level of use
• Relapse
Understand and identify the triggers for relapse
Give a biopsychosocial approach to alcohol misuse management
First identify the type of support needed and time frame:
- Short term: reduce consumption
- Medium term: undergo detox
- Long term: attend college/life goals
Biological
- Detoxification
- Long acting benzodiazepines (replace alcohol and prevent withdrawal symptoms)
- Thiamine (prophylaxis for Wernicke’s-Korsakoff’s)
- Community (home) detox: fixed dosage regime of benzo for 5-7 days
Psychological
- Motivational interviewing: form of counselling which aims to empower person to change
- Relapse prevention: CBT, problem solving therapies
Social
- Group therapy (e.g AA)
- Rehabilitation programmes (can be residential or day programmes). Involves skill based groups (e.g IT training)
Outline which drugs can be picked up on a UDS (urine drug screen)
- Amphetamine: 2 days
- Heroin: 2 days
- Cocaine: 5-7 days
- Methadone: 7 days
- Cannabis: up to 1 month
Give examples of opiates and how they are commonly administered
Heroin, morphine, codeine
Heroin route of administration:
o Initially smoked (chasing)
o As tolerance builds, people progress to IV infection
o May inject SC (skin popping) or IM once venous access becomes difficult
Give some local and systemic complications of IV drug use
o Local: abscess, cellulitis, DVT, emboli
o Systemic: septicaemia, infective endocarditis, blood-borne infections, increased risk of overdose
Outline the clinical presentation of opiate intoxication
- IV heroin produces an intense rush or buzz
- Euphoria, warmth and wellbeing
- Sedation and analgesia
- Vomiting and dizziness
- Bradycardia and respiratory depression (can die from aspiration)
- Pinpoint pupils
What is the antidote for opiate OD
Naloxone
• WARNING: after giving naloxone, patients may be plunged into withdrawal
Give some signs of opiate withdrawal
Everything runs:
• Dysphoria (state of unease)
• Nausea
• Agitation
• 'The runs' - diarrhoea, vomiting, lacrimation, rhinorrhoea
• Piloerection ('goose flesh')
• Feverish
• Abdominal cramps
• Aching joints and muscles
• Yawning irresistibly
• Dilated pupilsOutline the management for opiate misuse
o Harm Reduction
• Pragmatic approach involving assessing and minimising risk rather than insisting on abstinence
• Information should be provided on improving safety of drug use (e.g sterile needle exchanges for IVDU)
Biological
- Substitute prescribing/Detoxification:
• Deliberate prescribing of drugs in a controlled manner
• Methadone (liquid) and buprenorphine (sublingual tablet) are oral preparations that replace injectable opiates
• Doses titrated down until there are no withdrawal symptoms
Psychological: Follow up - Refer to Drugs and Alcohol Service o For at least 6 months o CBT: to prevent relapse and address underlying mental health issues
Give some synonyms for cannabis, and the symptoms associated with its use
Weed, grass, marijuana, pot, blow, hash, skunk (particularly strong)
Perceptual distortion, the munchies, nausea and vomiting (greening)
• Early heavy use is going to precipitate psychosis
• Lethargy and poor motivation are features of chronic heavy use
Give some examples of stimulants and the symptoms associated with its use
Cocaine, crack cocaine, amphetamine (speed), ecstasy
- Increase confidence and impulsivity (risky behaviour)
- Side-effects: arrhythmia, hypertension, stroke, anxiety, panic and drug-induced psychosis
Outline the management for stimulant misuse
Harm reduction
Short-term benzodiazepines may be offered to help withdrawal anxiety
Give examples of hallucinogens and the side effects associated with its use
LSD, ketamine, phenylcyclidine, magic mushrooms
Visual illusions/hallucinations
Synaesthesia
Behavioural toxicity
Increases risk of: depression, anxiety, self-harm, psychosis
What are the risks of sedative misuse? Include side effects and withdrawal
Sedatives are sleepers (e.g benzodiazepine)
Side effects:
Drowsiness, reduced concentration
Cognitive impairment, worsening depression/anxiety, sleep disruption
Features of withdrawal:
Insomnia, Irritability, Anxiety, Tremor
Tinnitus
Seizures
How is best to withdraw benzodiazepines after chronic use?
Biological:
Withdraw in steps of about 1/8 of the daily dose every fortnight
o Consider switching patients to equivalent dose of diazepam (Oxazepam if liver failure)
o Duration: may take 3 months to a year or more
o Warning: do not drive if you are feeling drowsy
Psychological Therapy
o Offer CBT (help address underlying mental health issues and provide advice about
sleep hygiene etc.)
