Substance misuse Flashcards
What are the different categories of recreational drugs?
Depressants: opioids, benzodiazepines, alcohol.
Stimulants: cocaine, amphetamines, MDMA, caffeine.
Hallucinogens: LSD, PCP, ketamine.
Cannabis, nicotine.
What are novel psychoactive substances?
Designed to mimic controlled club drugs
Banned but used to be legal highs, e.g. mephedrone, methoxetamine, GHB/GBL.
Spice.
Most NPS are not detected by routine urinary drug testing- false negatives.
What is the most harmful drug to an individual user? (death, illness, dependence, psychiatric, social losses).
Put the drugs in order for most to least harmful: ketamine, cocaine, heroin, mephedrone, crack cocaine, ecstasy, alcohol, tobacco, cannabis.
Crack cocaine Heroin Alcohol Cocaine Tobacco Mephedrone Cannabis Ketamine Ecstasy
What is the most harmful drug to society? (harm to others, crime, environment, family, international, economic cost, community).
Put the drugs in order for most to least harmful: ketamine, cocaine, heroin, mephedrone, crack cocaine, ecstasy, alcohol, tobacco, cannabis.
Alcohol Heroin Crack cocaine Tobacco Cannabis Cocaine Ketamine Mephedrone Ecstasy
Why do people take recreational drugs and get intoxicated
What are some consequences?
Social lubrication.
Pleasure seeking.
Counter stress/anxiety/ chronic pain.
Peer pressure.
Consequences:
Disinhibition.
Risk taking.
Aggression.
Dyspraxia.
Coma.
Illness/ injury.
What is dependence syndrome? (ICD-10)
3 or more at once in the last year:
- strong desire or compulsion to use substance
- difficulty controlling use/ amount/ recidivism-relapse after quitting
- tolerance to the effects of the drug
- neglect of other activities/ primacy
- persistent use despite adverse consequences
- withdrawal symptoms
What are the harmful physical consequences of alcohol?
Encephalopathy
Neuropathy
Ambylopia
Osteoporosis/ fractures
Cancers
Anaemia
Aspiration
Gastritis
Pancreatitis
Hepatitis
Cirrhosis- jaundice, ascites
Cardiomyopathy
Atrial fibrillation
Endocrine abnormalities
Impotence
Infertility
Depression
Anxiety
Dementia
Behavioural disturbance
What are some symptoms of recreational drug withdrawal?
Cold turkey (opiates)- not actually dangerous- just v unpleasant Delirium tremens- alcohol, dangerous
Sweats
Shaking
Muscular aches
Nausea
Diarrhoea
Gooseflesh
Seizures
Irritability
Depression
Psychosis
Define addiction.
Chronic relapsing brain disorder characterised by neurobiological changes that lead to compulsion to take a drug (or activity) + loss of control over the activity.
Transition from recreational to obsessive use.
From positive [taking to gain positive effect] to negative reinforcement [taking to reduce negative effect].
Psychological factors drive the behaviour.
What is the mechanism of alcohol withdrawal?
Alcohol increases inhibitory GABA-R activity, and antagonises excitatory NMDA-R.
Excitatory activity then upregulated.
Withdrawal- still increased excitatory activity, but inhibition now gone
What signs of drug use should you look out for on examination?
Injecting: punctures, track marks, cellulitis, DVTs, bacterial endocarditis.’
Inhaling: burns,
stains- teeth, fingers, respiratory signs, poor dentition, septal deformity in nose
Intoxication/ withdrawal (mental state, pupils).
Abnormal mental state.
Acquired illnesses due to drug use: hepatitis (alcohol, HBV, HCV), HIV
Injuries- falling, self inflicted
Case 1:
A 47y/o woman presents with recent onset of jaundice.
On further questioning she has had bouts of pruritis for several months.
LFTs are abnormal with raised bilirubin, a very high alkaline phosphatase and normal transaminases.
Other tests include a rabies IgM and high serum cholesterol.
An auto-antibody screen shows antimitochondrial antibodies in a titre of 1.256.
Liver biopsy shows expansion of the portal tracts by lymphocytes, plasma cells and occasional granulomas.
Bile ducts are scarce.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Primary biliary cirrhosis.
Case 2:
38y/o publican presents to his GP with increasing symptoms of anxiety and depression.
Routine blood screen reveals LFTs which are abnormal with high transaminases but normal bilirubin and normal alkaline phosphatase.
He is referred to hospital and a later liver biopsy shows moderate-severe chronic inflammation with a moderate fibrosis.
Special stains identify antigens from a double stranded DNA virus within the cytoplasm of many hepatocytes.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Chronic hepatitis B.
Case 3:
56y/o man, a known chronic alcoholic, presents with repeated attacks of abdominal pain precipitated by bouts of heavy drinking.
The pain radiates to his back and is relieved by leaning forwards. On further questioning he admits to loose, pale, greasy stools that are difficult to flush.
A plain abdominal radiograph reveals calcification in the peritoneal cavity.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Chronic pancreatitis.
What is Wernicke’s encephalopathy?
What is Korsakoff’s syndrome?
2 syndromes.
Wernicke (acute/subacute): confusion, ataxia, nystagmus/ophthalmoplegia.
Korsakoff (chronic): anterograde amnesia + confabulation.
What is the cause of Wernicke/Korsakoff syndrome?
Thiamine (B1) deficiency.
18 days of stores.
Why does thiamine deficiency?
> EtOH reduces duodenal transport and absorption of thiamine
> Chronic liver disease reduces activation and storage of thiamine.
> Nutritional deficiency.
What are the signs of Wernicke/Korsakoff syndrome on examination?
Eye signs: diplopia, nystagmus, lateral rectus palsy.
Motor signs: ataxia, broad based gait, dysdiadochokinesia.
Cognitive: MSE = disorientation, poor attention/concentration, poor memory, confabulation
Case 4:
22y/o woman presents with anxiety attacks, weight loss, loose stools and oligomenorrhoea.
On examination she has a tremor, tachycardia and warm peripheries.
She also has hypopigmented patches over the dorsal of her hands.
What is the diagnosis?
a) anorexia nervosa
b) thyrotoxicosis
c) alcohol dependency
d) giardiasis
Thyrotoxicosis.
Case 5:
41y/o woman presents to GP with weight loss and anxiety.
She confesses to feeling low since her divorce some 18 months ago.
On examination she is thin and mildly icteric.
CV and respiratory examinations are normal, but abdominal examination reveals 3cm hepatomegaly.
Hb 9.4, MCV 101, WCC 4.2, Na 131, K 4.1, Bil 27, AST 76, ALT 59, INR 1.3.
What is the diagnosis?
a) anorexia nervosa
b) thyrotoxicosis
c) alcohol dependency
d) giardiasis
Alcohol dependency.
Case 6: 30y/o Irishman presents to his GP with double vision, increasing unsteadiness, falls, vertigo, speech and swallowing problems. On examination he is unsteady with an ataxic gait, he is dysarthria and has signs of internuclear ophthalmoplegia. What is the diagnosis? a) cerebellar infarction b) demyelinating disease c) alcohol excess d) Friedrich's ataxia
Demyelinating disease.
Case 7: 37y/o woman presents to GP with falls. On examination she has marked bruising, leukonychia, spider naevi. She has an ataxic gait and an intention tremor bilaterally. What is the most likely cause? a) cerebellar infarction b) demyelinating disease c) alcohol excess d) Friedrich's ataxia
Alcohol excess.
Case 8:
A young woman is brought into A&E by a friend who reports that she has taken an overdose and then runs off.
She is unrousable and appears cyanotic with a respiratory rate of 3/min.
Her pulse and NP are reduced and she has pinpoint pupils.
What is the most likely cause?
a) benzodiazepine overdose
b) opiate overdose
c) cocaine overdose
d) alcohol poisoning
e) antidepressant overdose
Opiate overdose.
Frontal lobe dementia due to chronic alcohol misuse typically leads to abnormal results in each of the following clinical tests except:
a) Luria’s fist-palm-edge motor sequencing
b) Stroop test of inhibition
c) understanding of proverbs and metaphors
d) Wernicke’s aphasia
e) verbal fluency
[NOT IN LECTURE]
Wernicke’s aphasia.
In terms of their overall effect, opiate drugs are:
a) hallucinogens
b) stimulants
c) depressants
d) novel psychoactive substances
e) cannabinoids
Depressants.
You are an F1 doctor clerking in a patient who discloses history of regular alcohol consumption (120sau per week). Your plan must include:
a) giving harm immunisation adivce
b) referring them to a drug and alcohol clinic
c) prescribing methadone in accordance with a withdrawal score
d) prescribing regular chlordiazepoxide
e) the patient is likely malnourished, give IV dextrose as quickly as possible
Prescribing regular chlordiazepoxide. Prevents delirium and seizures.
Which of the following behaviours is suggestive of a diagnosis of dependence syndrome?
a) using lots of different substances
b) trying to quit and starting again
c) never going cold turkey when abstaining
d) occasional enjoyable use
e) getting irritable when asked about substance use
Trying to quit and starting again.
What are club drugs?
Club drugs: recreational drugs used in nightclubs, festivals, gigs, bars, circuit and house parties, e.g. amphetamine, methamphetamine, MDMA, cocaine.
What three adverse effects can drugs cause?
Intoxication
Withdrawal
Dependence
Taking a substance misuse history?
- Ask everyone
- How much
- What
- Administration route
Hx
- First use
- Regularity of use
- Heaviest use
- Dependency/withdrawal symptoms
- Negative effects
How to calculate alcohol units from ABV?
ABV percentage= number of units in one litre
Symptoms of alcohol withdrawal- stages?
MINOR- 6-24hr
- Nausea and vomiting
- Tremor
- Anxiety and insomnia
MAJOR-10-72hr
- Hallucinations [visual, auditory, tactile]
- Tremor
- Sweating
- Hypertension
SEIZURES- 6-48hr
- Multiple brief generalised tonic clonic seizures
- 3% status epilepticus
DELIRIUM TREMENS 72hr-10 days
- Delirium
- Agitation, intense fear
- Fever
- High BP, high HR, sweating
- Medical emergency- arrthymia etc- high mortality
What are the risk factors of delirium tremens?
Heavy EtOH intake
Past history of withdrawal symptoms- seizures and deilirum tremens
Management of alcohol withdrawal
- Chlordiazepoxide- benzodiazepine
[depressant to wean] - Pabrinex
- IV diazepam PRN -> for seizures
Crystal methamphetamine
Type of drug?
Admin method?
Associations:
Prevalence?
Crystal methamphetamine
Type of drug?
Stimulant
Admin method?
Smoked/injected mainly
Associations?
Psychosis
Chem sex
Prevalence?
Rare
What are other consequences of substance misuse?
Unsafe sex
STIs
Blood borne disease
How can alcohol affect fertility?
Disruption of menstrual cycle
Impotence
Low sperm count
What happens if alcohol is drunk during pregnancy?
- Placental transmission
- Transmitted through breast milk
- Spontaneous miscarriage
- Foetal Alcohol Distress Syndrome/Spectrum Disorder
= Restricted growth
= Behavioural abnormalities
= Facial abnormalities
Can doctors inform the DVLA if drug misuse?
Yes
Alcohol dependence
And misuse of multiple drugs
