Substance Misuse Flashcards by Hannah Farquhar

What is the ICD categories for substance misuse?

acute intoxication
acute withdrawal
alcohol dependence
psychotic disorders
amnesic disorder
residual/late onset disorders

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What is hazardous drinking?

Pattern of alcohol consumption that increases someones risk of harm. Physical, mental and social consequences.
Applies to anyone drinking >14 units/week.

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What is the difference between hazardous and harmful drinking?

Hazardous - >14 units

Harmful >35 units

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How do you calculate units?

Units = strength x volume/1000

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What screening tools can be used in alcohol misuse?

CAGE
FAST
Audit and audit C

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Describe the FAST screening

How often have you had 6+(female) 8+ (male) units on a single occasion in the last year?
Can’t remember the night before
Failed to function properly due to alcohol
Someone else is concerned about drinking
Scored by frequency Never =0 daily=4
>2 classes as hazardous

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Describe CAGE screening

Have you tried to cut down?
Annoyed when someone else suggested it?
Guilty about drinking?
Eye opening (early morning drink)?

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How does the audit score correlate to management?

8-19 = brief intervention 
20+ = refer to a specialist

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What must a brief intervention consist of?

Feedback - review problems 
Responsibility - empowerment 
Advice - factual 
Menu - options available 
Empathy 
Self-efficacy - optimism

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Describe the term motivational interviewing

Patient-centred counselling explores ambivalence to seeking treatment, drinking cessation or both. Collaborative conversation, drinking cessation. Helps to achieve insight and desire to change.

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Describe Wernicke’s and Korsakoff’s

Wernicke’s - ataxia, nystagmus, ophalmoplegia, acute confusion
Korsakoff - profound short term memory loss and confabulation

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What is the criteria for diagnosis for dependence syndrome?

Strong desire or sense of compulsion to take drug
Difficulty controlling use of substance
Physiological withdrawal
Evidence of tolerance
Neglect of other pleasures/preoccupation
Persistence despite harmful consequences
3 or more present together at some point in the previous year

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Why does alcohol withdrawal occur?

Alcohol inhibits the action of NMDA glutamate ion channels and chronic use leads to up regulation
Alcohol potentiates GABA A receptors and chronic use leads to down regulation
Overall a sudden stop causes unopposed excitation and excess glutamate which is neurotoxic

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What are the symptoms of alcohol withdrawal?

Restlessness, tremor, sweating, nausea, vomiting, loss of appetite, insomnia, tachycardia, systolic hypertension, generalised seizures

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What is the worst consequence of alcohol withdrawal?

Delirium tremens

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How does delirium tremens present?

2 days of abstinence, often insidious with nighttime confusion

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What are the symptoms of delirium tremens?

Confusion, disorientation, agitation, hypertension, fever, hallucinations, paranoid ideation

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Where should people with delirium tremens be managed?

General medical ward

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What is the medical management for alcohol withdrawal?

Benzodiazepines (cross tolerant with alcohol)
Vitamin supplement (pabrinex)
Thiamine - parenteral, increase in wernicke’s
Hydration, analgesia, antiemetic, treat infections

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Describe the indications for inpatient detox

Severe dependence 
History of delirium tremens 
History of failed community detox 
Poor social support 
Cognitive impairment 
Psychiatric co-morbidity 
Poor physical health

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What psychosocial interventions help to prevent relapse?

CBT, motivational enhancement, 12 steps (AA), self control training, family/couple therapy

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What pharmacological measures can help prevent relapse?

Disulfiram
Acamprosate
Naltrexone

Describe disulfiram

Inhibits acetaldehyde dehydrogenase causes an accumulation of acetaldehyde if alcohol is ingested leading to nausea/vomiting, arrhythmias, hypotension

Describe acamprosate

Reduces cravings and moderate treatment. Acts on GABA system - side effects; headache, diarrhoea, nausea

Describe naltrexone

First line for relapse prevention, opioid antagonist reduces reward from alcohol. Very effective.

What are the different forms of opiate?

Natural - morphine, codeine Semi-synthetic - hydrocodone, hydromorphine Synthetic - methadone, tramadol

What are the different forms of heroin?

Brown powder from poppy, smoking gives immediate effect, snorting takes 15 minutes or can be injected

Which parts of the brain do opioids affect?

Mesolimbic pathway uses dopamine as the neurotransmitter - ventral segmental area (midbrain) is connected to the vernal striatal area (basal ganglia and forebrain) Desire and motivation leads to reinforcement

Describe safety bundles

``` Drug diaries Drug screens - urine test Withdrawal scale - COWS Recovery care plan Risk assessment ```

What is opioid replacement therapy?

Substitute prescribing - the deliberate prescribing of drugs in controlled manner to introduce control and order into lifestyle

What are the four phases of opioid replacement?

Induction Optimisation Maintenance Reduction

Name three forms of psychosocial intervention in opioid dependence

CBT Motivational interviewing Self help

How does methadone work?

Mu receptor agonist, long half life with peak plasma at 4 hours and steady state after 5 days

How is methadone metabolised and administered?

Hepatic metabolism - CY3P4 | Controlled liquid preparation supervised - start at 30mg and increase by 10mg a day until 60mg

How does buprenorphine work?

Mu receptor partial agonist with low intrinsic activity but high affinity peak plasma 1.5-2.5 hours and duration is dose dependent

How is buprenorphine administered?

Sublingually - 12-24mg supervised

Why would buprenorphine be used instead of methadone?

ECG - methadone can cause long QT Other drugs - drugs involved in CY3P4 may impact metabolism Diversion and sedation

What are the early signs of opioid withdrawal?

Craving, flu like symptoms

What are the late signs of opioid withdrawal?

Cramps, agitation, piloerection, tachycardia, restlessness, mydraisis

What are the signs of opioid overdose and how is it treated?

Naloxone - opioid antagonist | Presents - miosis and respiratory depression

Define incentive salience

Attributing 'want' to a stimulus (how much we desire something) leads to appetite and consumption

Name the five components for the mesolimbic pathway

- ventral tegmental area - nucleus accumbent - prefrontal cortex - hippocampus - amygdala

What neurotransmitter is involved in the mesolimbic pathway?

Dopamine - motivating signal, incentivises behaviour and is involved in normal pleasurable experience

What is the effect of drugs of abuse on the mesolimbic pathway?

Act on dopamine receptors to alter dopamine levels, repeated exposure leads to down regulation and less available for stimulation

What is the result of increased threshold in terms of how a patient feels?

Normal pleasurable experience does not evoke adequate reward response

Describe the difference between positive and negative reinforcement

Positive reinforcement - initial stages of drug taking, driven by reward Negative reinforcement - drug taking becomes thirst, behaviour is carried out to prevent bad experience

What is the function of the pre-frontal cortex?

Prevents addiction by executive functions - helps intention guide behaviour and modulates the powerful effects of the reward pathway - sets goals, focuses attention and makes sound decisions

How is the pre-frontal cortex development different from the rest of the brain?

It is late to develop and continues into the 20s - executive functions mature later than emotion and impulse

What does dopamine release effect?

- ability to update PFC information - ability to select new goals - ability to avoid compulsive repetition of a behaviour

Where are memories and habits formed?

Hippocampal and amygdala are critical in acquisition, consolidation and expression of drug learning - this cues internal states of craving

What is the function of the orbit-frontal cortex?

Provides internal representation of the importance of events and assigns values to them - key creator of motivation to act (changes persist into abstinence)

What percentage of addiction risk is related to genetics?

40-60%

How can stress cause mesolimbic changes?

Triggers dopamine release in neural pathways, chronic stress leads to dampening of dopaminergic activity through down regulation of receptors - reducing sensitivity to normal rewards therefore encouraging highly rewarding behaviours