Substance Misuse

Question 1

Alcohol misuse Ix

Answer 1

Blood: FBC, LFT, B12, folate, U+E, Clotting, glucose
blood alcohol level
Urine drug screen
Rating (AUDIT, CIWA-Ar, APQ)
SADQ

Question 2

Alcohol misuse needs of family/carers

Answer 2

Offer carers assessment
Consider guided self help for families
Resources
Consider offering family meetings

Question 3

Alcohol misuse assessment

Answer 3

1. AUDIT: alcohol use disorder ID test >15 req. comprehensive assessment
2. SADQ
3. CIWA-Ar (withdrawal severity)
4. APQ (assess nature and extent of alcohol related problems)

Question 4

Alcohol misuse Establishing goals

Answer 4

Abstinence is best Rx goal (but more moderate goals may be preferred)
If comorbid mental health issues dont improve after 3-4weeks of abstinence consider referral

Question 5

Principles of interventions Alcohol misuse

Answer 5

Carry out motivational interview
?Intensive structured community based interventions
If NFA offer residential rehab for max 3m
Routinely monitor
Info: AA, SMART, Recovery, CGL
Case management/individualised care plan if at risk drop out

Question 6

Interventions for harmful drinkers and mild dependence

Answer 6

Offer psych intervention ((C)BT) focused on alcohol related cognitions (12 sessions)
Offer behavioural couples therapy
If no response or pharm. Rx requested, offer alongside psych therapy: Acamprosate (anticraving) naltrexone

Question 7

Assisted withdrawal Alcohol misuse

Answer 7

Pabrinex if risk of Wernicke
Expectations: Sx worst within 48hrs, takes 3-7 total
If >15u/day, or >20 AUDIT consider:
- community based assisted withdrawal (at least 2-4meetings in first week)
- Mx in specialsit alcohol services

Question 8

When to consider inpatient assisted withdrawal

Answer 8

> 30 units/d
30 on SADQ
Hx epilepsy, delirium tremens, withdrawal related seizure
Need concurrent alcohol and benzo withdrawal
Sig psych. comorbidity or learning disability
Lower threshold in vulnerable groups
Children 10-17 (also family therapy for 3months)

Question 9

Drug regimens for assisted withdrawal

Answer 9

Fixed dose or symptom triggered
Preferred: chlordiazepoxide, diazepam (lorazepam if hepatic impairment)
Titrate dose based on alcohol severity
Gradually reduce dose over 7-10d (longer if concurrent BZ withdrawal)
Give no more than 2d dose at once

Question 10

After successful withdrawal alcohol

Answer 10

Consider acamprosate or naltrexone w/individualised psychological intervention
Consider disulfiram if both unacceptable
Prescribe for 6m
Careful medical assessment (inc. LFT + U+E)

Question 11

PACES alcohol withdrawal

Answer 11

establish risks (driving, suicide)
Assess social issues
Establish goals
Explain Sx will be worst in 48hrs gone by 7d
Advise against stopping abruptly
Explain referral to D+A service and process of assisted withdrawal

Question 12

Acute alcohol withdrawal

Answer 12

Offer BZ (loraz) or carbamazepine (alt. clomethiazole)
Offer advice on support services
DT:
- 1L: PO loraz (if persistent IV loraz/haloperidol) (Alt. chlordiazepoxide)
-IV thiamine
If seizure: fast acting BZ (loraz) to reduce likelihood of future seizures

Question 13

Opiate misuse Ix

Answer 13

Physical exam (baseline)
Urine drug screen
U+E
FBC (anaemia/infection)
LFTs
Blood borne infection (RPR, hepatitis serology, HIV test)

Question 14

Opiate misuse harm reduction

Answer 14

Pragmatic approach involving assessing and minimising risk rather than insisting on abstinence
Provide information on safe use
Needle exchange
Vaccination for sex workers/IVDU

Question 15

Opiate misuse general recommendations

Answer 15

Counsel on aspects of healthy lifestyle
Information about self help (12 step guide)
Assess family members and carers
do NOT offer withdrawal tretment:
-Concurrent medical problem req. urgent treatment
- in police custody
- Presenting in acute/emergency setting
- careful w/pregnant women

Question 16

Medication for opiate detoxification

Answer 16

Key worker supports pts
1L: methadone (PO) buprenorphine (sublingual) consider lofexidine (a2 agonist) if others unacceptable, or mild dependence or keen for short detox
Dosing regime determined by pt. and healthcare factors
Duration:
-inpt: up to 4wks
- community: up to 12w
W/D Sx: clonidine, lofexidine
Sx: anti-diarrhoeal, anti emetic, painkiller

Question 17

inpt opiate detox

Answer 17

only for very severe, w/physical comorbidity

basically unsafe for community

Question 18

Ultra-rapid, rapid, and accelerated detox (opiate)

Answer 18

W/d precipitated by using high dose of opioid antagonists (naltrexone/naloxone)
Ultrarapid: 24hrs under GA or heavy sedation (should NOT be offered)
Rapid detox: 1-5d w/moderate sedation (consider if requested)
Accelerated detox: no sedation

Question 19

FU for opiate detox

Answer 19

Refer to D+A service
at least 6m
Offer talking therapy (CBT) to prevent relapse and address underlying mental health issues
Appoint key worker
Consider contingency management after completion of detox:
- incentives for negative drug test
- screening could be 3/wk early and then reduce
- urinalysis preferred method

Question 20

PACES Counselling of opiate detoxification

Answer 20

Get tests/vax for blood borne infections
Sx of w/d: restless, sweaty, abdo cramps, N+V
Timescale: peaks within 2-3d should improve by week
Detox reigme and drugs
Sx treatments for nausea, diarrhoea
Psychological therapies
key worker
support groups

Question 21

Benzodiazepine misuse

Answer 21

BZ should only be used for 2-4wk
Risks:
Short term: drowsiness, reduced concentration
Long term: cognitive impairment, worsening anxiety and depression
Address underlying problems

Question 22

Clinical features of BZ w/d

Answer 22

Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Sweating
Seizures
Perception disturbance

Question 23

How to w/d from benzos

Answer 23

W/d in steps of about 1/8 of daily dose every 2w
Consider switching patients to eqiv. dose of diazepam (oxazepam if liver failure)
Duration: 3m-1y+
Do NOT drive if drowsy

Question 24

Psych therapy for BZ

Answer 24

Offer CBT (underlying issues, advise about sleep hygiene)

Question 25

PACES counselling in BZ use

Answer 25

harmful effects (long term worsening of psych sx)
BZ can be reduced v gradually, wrt sx pt. reports
Explain role of CBT
Advise against driving if drowsy