Substance misuse

Question 1

Why does addiction occur?

Answer 1

Addiction occurs due to a combination of individual factors e.g. age, gender and family and external factors e.g. culture, price, availability, and advertising. Having a novelty seeking or impulsive personality as well as genetic vulnerability increasing the risk.

The quicker a drug reaches peak concentration in the blood the more positive the reinforcement and so the more addictive it will seem. Therefore, drugs that are smoked or injected are inherently more addictive.

Question 2

What causes tolerance of drugs?

Answer 2

Tolerance can come about from increase in metabolism e.g. liver enzymes and alcohol or from up or downregulation of receptors e.g. decrease in number of postsynaptic dopamine receptors with cocaine.

Question 3

What is dependence?

Answer 3

Dependence syndrome – a state where the administration of substances takes on a higher priority than other behaviours which previously had a greater value. Requires 3 of the following:

1. A strong desire or sense of compulsion to take the substance (craving)
2. Difficulty in controlling substance use (onset, termination, and level of use)
3. A physiological withdrawal state when reducing or ceasing substance use (or using the same or similar to avoid withdrawal)
4. Tolerance meaning increased doses required to produce the original effect
5. Progressive neglect or alternative pleasures or interests
6. Persisting use despite clear evidence of harmful consequences

Question 4

When does a use of a substance become harmful?

Answer 4

Harmful use – pattern of substance use that is causing damage to health, either physical or psychological such as depression and alcohol.

Question 5

What behaviour is associated with drug addiction?

Answer 5

Arrests for thefts to buy drugs
Odd transient behaviour e.g. visual hallucinations, elation, mania
Unexplained nasal discharge (cocaine sniffing or opiate withdrawal)
Withdrawal symptoms such as shaking and red eye
Injection stigmata – marked veins, abscesses, hepatitis, HIV
Repeated requests for Analgesia where only opiates are acceptable or sedatives

Question 6

What should you ask in the history for a patient who is a substance missuser?

Answer 6

What drugs
How long – when did you first start, when was it first a problem
How much – best to ask how much money is being spent
How often
Do you get withdrawal and what happens?
Any previous treatments
Complications
Have you ever overdosed – what happened?
Have you been tested/vaccinated for BBV?

Question 7

What is acute intoxication?

Answer 7

Acute intoxication – administration of a psychoactive substance resulting in disturbances of level of consciousness, cognition, perception, affect or behaviour

Question 8

What are the clinical features of opiate overdose?

Answer 8

Clinical features

Pinpoint pupils, decreasing consciousness and slow breathing.

Question 9

How is opiate overdose managed?

Answer 9

ABCDE 
Naloxone IM (not IV as IVDU too difficult to get a line in)

Question 10

What are the early and late symptoms of opiate withdrawel?

Answer 10

Early (12 hours)
Sweaty clammy skin 
Persisting yawning
Rhinorrhoea 
Tachycardia + hypertension
Restlessness, agitation and anxiety 

Late (2-3 days)
Nausea and vomiting 
Diarrhoea 
Insomnia 
Dilated pupils 
Lacrimation 
Goose bumps 
Abdominal cramps 
Muscle pains

Question 11

When should opiate withdrawal be managed?

Answer 11

Do not manage withdrawal until there are signs. Also note you do not die from opiate withdrawal, but you do from alcohol or benzo withdrawal.

Question 12

What is the aim in opiate detoxification?

Answer 12

This should be a contract agreed with the patient that allows a safe withdrawal to abstinence. In many cases abstinence is not possible and maintenance on methadone occurs instead.

Question 13

How is methadone used to treat opiate addiction?

Answer 13

Methadone use still feeds an opiate addiction however it is safer as it is free, so people do not have to resort to crime or prostitution and does not involve injection as it is taken orally. It is preferred to have daily observed methadone dosing however there is little evidence that monthly prescriptions would be abused. Biggest problem is cocaine abuse when on methadone and disulfiram can have a role here.

Question 14

How is lofexidine used to treat opiate addiction?

Answer 14

Lofexidine is a non-addictive alternative to methadone which has the side effects of drowsiness, reduced BP and pulse, dry mouth, and rebound hypertension on withdrawal.

Question 15

How is buprenorphine used to treat opiate addiction?

Answer 15

Buprenorphine is a partial opioid agonist (sublingual tablet) and may be safer than methadone but has cautions with liver dysfunction and intoxication with other drugs. Note it will put them into a withdrawal unless they are already in one as it displaces the heroin/methadone.

Question 16

What is naltrexone used for?

Answer 16

Naltrexone is an opioid antagonist and can be used in former addicts to prevent relapse in both opioid and alcohol addiction. Warn patients of possible withdrawal reactions and monitor for 4hours after the first dose.

Question 17

What is the cause of most auditory hallucinations?

Answer 17

Most auditory hallucination not associated with falling asleep or waking up are caused by schizophrenia or depression

Question 18

What is the cause of most non-auditory hallucinations?

Answer 18

90% of those with non-auditory hallucinations the cause is substance abuse, drug withdrawal or physical disease

Question 19

What evidence would suggest a psychosis is drug related?

Answer 19

Evidence that substance abuse is to blame includes
• History – if >4 weeks between abuse and symptoms then substance abuse is unlikely but could be precipitating factor
• Severity – does the severity match the quantity of drugs
• Is there any drug seeking behaviour?
• Does physical examination reveal any signs of drug abuse?

Diagnosing a substance abuse psychosis implies the patient believes the hallucinations/delusions. If they recognise them as not then consider substance intoxication, withdrawal, or flashbacks.

Question 20

What is the name of benzodiazepines used as illicit drugs?

Answer 20

Vallium yellows and blues.

Pregabalin and gabapentin act in similar way on GABA receptors.

Question 21

What are the withdrawel signs and symptoms of benzos?

Answer 21

Withdrawal is very similar to alcohol except that hallucinations happen earlier, and autonomic symptoms are slightly less. Later on, go into tremor and tachycardia and eventually seizure.

Question 22

How should benzo withdrawal be managed?

Answer 22

Use diazepam for withdrawal as it has a very long half-life.

Question 23

What are the main problems associated with amphetamine and cocaine use?

Answer 23

Morbidity and mortality come from heart attacks and strokes. As cocaine is a potent vasoconstrictor and makes the heart work harder as well. As such it increases blood pressure significantly. Amphetamines less dangerous than cocaine.

Question 24

Why is combining cocaine and alcohol particularly dangerous?

Answer 24

Combining cocaine and alcohol forms a new product called cocaethylene which has a much longer half-life, is harder on the liver and also makes you more drunk without you realising.

Question 25

Why can all amphetamines cause psychosis?

Answer 25

All stimulants (amphetamines) can cause psychosis as they are dopamine agonists.

Question 26

What is alcohol abuse?

Answer 26

Alcohol abuse implies repeated drinking that harms a person’s work or social life
Addiction implies
• Increased tolerance
• Narrowing of drinking repertoire
• Difficulty or failure in abstinence
• Withdrawal symptoms such as sweats, nausea, and tremor
• Priority becomes maintaining alcohol intake
• Aware of compulsion to drink

Question 27

What causes death in alcohol abuse?

Answer 27

Fights and falls 
Liver failure 
Sudden/long slow 
Pancreatitis 
Overdose 
Withdrawal 
Wernicke’s encephalopathy

Question 28

What is CAGE?

Answer 28

CAGE
Cut down – have you ever considered this?
Annoyed – has anyone ever annoyed you by criticising your drinking
Guilty – have you ever felt bad about your drinking
Eye-opener – have you ever drank first thing in the morning to steady nerves or cure a hangover

Score of 2 or more is clinically significant
Good at finding alcohol abusers but not those who are at risk

Question 29

What is TWEAC?

Answer 29

TWEAC
Tolerance – how many drinks does it take to feel high/how many can you tolerate
Worried – has anyone close to you ever worried about your drinking
Eye-opener – do you have a drink in the morning when you first get up
Amnesia – have you ever completely forgot periods of time whilst drinking
Cut down – do you ever feel the need to cut down

Q1 two points if > 6
Q2 two points if yes
Q3-5 one point for each positive answer

Score of above 3 denotes a problem with alcohol

Question 30

What are the features of alcohol withdrawal?

Answer 30

Alcohol withdrawal
Features
• Symptoms start at 6-12 hours: tremor, sweating, nausea, tachycardia, anxiety
• Peak incidence of seizures at 36 hours
• Peak incidence of delirium tremens (10% mortality) is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 31

How should alcohol withdrawal be managed?

Answer 31

Management
• Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
• First-line: benzodiazepines e.g. diazepam and chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Given generously for the first 3 days then reduce diazepam slowly over the next 5 days. Carbamazepine also effective in treatment of alcohol withdrawal
• Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Question 32

How should alcohol abuse be managed?

Answer 32

Does the patient want to change? If yes, then be optimistic with them. Choose an aim is it going to be total abstinence or controlled intake.
Treat coexisting depression
Refer to specialists and self-help groups
Can prescribe drugs that give a nasty reaction if alcohol is taken e.g. disulfiram

Question 33

How can you help a patient to maintain abstinence from opioids?

Answer 33

After abstinence is reached can prescribe Naltrexone to prevent relapses (reduced pleasure and cravings from alcohol).

Acamprosate can improve abstinence rates but is contraindicated in pregnancy, severe liver failure and creatinine >120umol

Question 34

What are the side effects and contraindications to Naltrexone?

Answer 34

SE = vomiting, drowsiness, dizziness, joint pain. CI = hepatitis, liver failure and monitor LFT.

Question 35

What physiological problems can alcohol cause?

Answer 35

Liver – fatty liver disease, acute reversible hepatitis, liver cirrhosis and liver failure
CNS – poor memory, cortical atrophy, seizures (36 hours), falls, Korsakoff’s/Wernicke’s encephalopathy
Gut – D+V, peptic ulcer, erosions, varices, pancreatitis
Heart – arrhythmias, raised BP, cardiomyopathy,
Skeleton – increased osteoporosis risk (disruption of Ca metabolism)
Sperm – reduced fertility, sperm motility
Malignancy – GI and breast
Marrow – reduced Hb and increased MCV

Enzymes – regular heavy drinking induces hepatic enzymes, binging inhibits them

Question 36

What is Wernicke’s Encephalopathy?

Answer 36

Occurs due to thiamine deficiency (Vitamin B1). Resulting in haemorrhaging in the mid brain causing a triad of confusion, wide based ataxic gait and ophthalmoplegia (nystagmus, conjugate gaze, and bilateral rectus palsies). Other symptoms include clouding of consciousness, memory disturbance, peripheral neuropathy, hypotension, hypothermia and ptosis.

Question 37

How should wernicke’s encephalopathy be managed?

Answer 37

Management – give high dose IV/IM thiamine (pabrinex) over 1 week then oral supplementation until no longer at risk (can’t be oral as alcohol destroys the thiamine pumps in the small bowel).
If there is coexisting hypoglycaemia, ensure that thiamine is given before glucose to prevent precipitation of Wernicke’s.

Question 38

What is Korsaoff’s syndrome/psychosis?

Answer 38

Korsakoff’s syndrome – occurs as a result of repeated hypothalamic damage and cerebral atrophy due to thiamine deficiency. Causes an inability to acquire new memories, (anterograde and retrograde amnesia) confabulation, lack of insight and apathy. ¼ of cases are recoverable but it is a slow and often incomplete process.

Question 39

How do opiates, stimulants, cannabis and alcohol affect psychosis?

Answer 39

Opiates – Anti-psychotic (probably more anxiolytic)
Stimulates – Psychosis inducing
Cannabis – increase prevalence of psychosis
Alcohol – Depresso-genic