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Psychiatry > Substance Misuse > Flashcards

Substance Misuse Flashcards

1
Q

Define the following categories of substance misuse: intoxication, harmful use, dependency, withdrawal

A
  • 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.
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2
Q

Define the following features of dependency: tolerance, compulsion, withdrawal, problems controlling use

A

• 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

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3
Q

Define the following features of dependency: controlled use despite harm, salience, reinstatement after abstinence, narrowing of the repertoire

A

• 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

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4
Q

Give some aetiological risk factors for excess alcohol use

A
  • 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)
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5
Q

Give some signs and symptoms of alcohol intoxication

A
  • Relaxation, euphoria
  • Irritable, aggressive, weepy, disinhibited
  • Impulsivity and poor judgement
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6
Q

Give some symptoms of alcohol withdrawal

A
  • Headache
  • Nausea, retching and vomiting
  • Tremor
  • Sweating
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7
Q

Explain the key signs of delirium tremens and its management (medical emergency of alcohol withdrawal)

A
  • 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

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8
Q

Give some biological, physical complications of excess alcohol use (think systems)

A
  • 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
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9
Q

Give some psychological and social complications of excess alcohol use

A

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

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10
Q

Explain Wernicke-Korsakoff’s syndrome as a complication of alcohol use (include management)

A

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

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11
Q

What is the differential diagnosis of substance misuse?

A

Organic
- Physical causes (e.g trauma)

Psychiatric illness (could be either primary or comorbid)

  • Depression/mania
  • Functional psychosis
  • Anxiety disorder
  • Personality disorder
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12
Q

Give some investigations for alcohol misuse

A

• 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)

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13
Q

Outline the different stages of the Stages of Change Model

A

• 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

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14
Q

Give a biopsychosocial approach to alcohol misuse management

A

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)
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15
Q

Outline which drugs can be picked up on a UDS (urine drug screen)

A
  • Amphetamine: 2 days
  • Heroin: 2 days
  • Cocaine: 5-7 days
  • Methadone: 7 days
  • Cannabis: up to 1 month
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16
Q

Give examples of opiates and how they are commonly administered

A

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

17
Q

Give some local and systemic complications of IV drug use

A

o Local: abscess, cellulitis, DVT, emboli

o Systemic: septicaemia, infective endocarditis, blood-borne infections, increased risk of overdose

18
Q

Outline the clinical presentation of opiate intoxication

A
  • 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
19
Q

What is the antidote for opiate OD

A

Naloxone

• WARNING: after giving naloxone, patients may be plunged into withdrawal

20
Q

Give some signs of opiate withdrawal

A 
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 pupils
21
Q

Outline the management for opiate misuse

A

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
22
Q

Give some synonyms for cannabis, and the symptoms associated with its use

A

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

23
Q

Give some examples of stimulants and the symptoms associated with its use

A

Cocaine, crack cocaine, amphetamine (speed), ecstasy

  • Increase confidence and impulsivity (risky behaviour)
  • Side-effects: arrhythmia, hypertension, stroke, anxiety, panic and drug-induced psychosis
24
Q

Outline the management for stimulant misuse

A

Harm reduction

Short-term benzodiazepines may be offered to help withdrawal anxiety

25
Q

Give examples of hallucinogens and the side effects associated with its use

A

LSD, ketamine, phenylcyclidine, magic mushrooms

Visual illusions/hallucinations
Synaesthesia
Behavioural toxicity
Increases risk of: depression, anxiety, self-harm, psychosis

26
Q

What are the risks of sedative misuse? Include side effects and withdrawal

A

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

27
Q

How is best to withdraw benzodiazepines after chronic use?

A

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.)

Psychiatry (14 decks)

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