Substance Misuse Flashcards
What could doing lines mean?
Either cocaine or smoking heroin (which leaves line marks on the tin foil). Be careful to clarify from patients.
What theories (or groups of theories) have been put forward to explain why people become addicted to drugs?
- Genetic (MZ/DZ studies have shown addiction runs in families)
- Neurobiological (very strong link between addiction and Dopamine, al drugs somewhere along their chemical pathway affect dopamine)
- Social (all drugs are taken socially, addictions can be reinforced socially)
- Behavioural (behavioural responses and rewards)
- Attachment (supposedly babies get opioid receptor hit when comforted by mum, link between poor attachment and addiction may be mediated by this link)
Important to remember these factors when treating addiction.
What are the important questions to ask in a drug use history?
Drug Hx:
- What drugs - most people take more than one?
- How long have they been taking them for?
- When did you first try it, and when do you think it became a problem?
- How much do they use?
- How much money do they spend per day/week?
- How often are they doing it (look for every day)?
- When was the last time they went three days without using?
- Have you ever experienced withdrawal? How often and how bad?
- How tolerant are they?
Medical Hx:
- Have they ever sought treatment before? If so of what kind?
- Any complications from the substance?
- Any overdoses? If so were they hospitalised?
- Protective factors: Have they been immunised vs BBVs?
- Any depression or anxiety?
General PMHx, Social Hx and support.
Why is alcohol mortality so far (or what can kill you from alcohol use)?
- Fights and Falls = number 1 cause
- Liver failure (mostly from sudden varix and blood loss, less often from slow liver failure)
- Pancreatitis
- Overdose (death by respiratory depression, or vomiting + respiratory depression that causes vomit inhalation)
- Withdrawal
- Wernicke’s
How do you calculate units of alcohol?
Strength (in %) x Volume (in L)
So 500ml of 6% beer is 3 units
What symptoms in a person with alcohol dependency issues would be worrying (if they’ve presented to A and E)?
- Any head injury
- Confusion
- Shaking/seizures
- Hallucinations
- Vomit blood/ Coffee grinds
- Severe abdominal pain
- Sudden yellowness
What are the symptoms of early alcohol withdrawal?
- Tremor
- Sweating
- Nausea
- Anxiety
- Tachycardia
What are the symptoms of late alcohol withdrawal?
- Delirium Tremens
- Disorientation
- Hallucination
- Tremor
- BP, Pulse, Fever, Motor incoordination
What are the core symptoms of Wernicke’s Encephalopathy?
5 most common = CANON:
- Confusion
- Ataxia
- Nystagmus
- Ophthalmoplegia
- (peripheral) Neuropathy
But Ataxia, Nystagmus and Ophthalmoplegia is considered the classic triad.
How is Wernicke’s treated?
Parenteral Thiamine (Pabrinex).
What is the difference between Wernicke’s and Korsakoff’s?
Wernicke’s = effects of acute thiamine deficiency caused by alcohol withdrawal, causing bleeding into the midbrain and subsequently neurological symptoms
Korsakoff = effects of multiple episodes of Wernicke’s on the brain
What are the symptoms of Korsakoff’s?
- Essentially a form of dementia
- Prominent impairment of recent and remote memory, with immediate recall usually preserved.
- Disordering of time sense and ordering of events. Impaired ability to learn new things.
- +/- Confabulation, brain spontaneously makes things up to make the world make sense.
What is the only reliable sign of Heroin use?
Pinpoint pupils.
At high levels you will see:
- Decreasing consciousness
- Slow breathing
- Potentially death
But the only sign that essentially confirms opiate use/OD is pinpoint pupils.
How do you manage Opiate overdose?
- Respiratory support! Death comes from respiratory depression, so can be bagged and masked to buy time.
- Definitive treatment = NALOXONE IM, veins are most likely fucked.
What are the early (first 12 hours) symptoms of opiate withdrawal?
- Sweaty clammy skin
- Persistent yawning
- Rhinorrhoea
- Tachycardia
- Restlessness
- Dilated pupils
- Lacrimation
- Goosebumps
These symptoms indicate early withdrawal and therefore indicate a person can go on methadone
What are the symptoms of late (2-3 days) opiate withdrawal?
- Nausea and vomiting
- Diarrhoea
- Insomnia
- Abdominal cramps
- Muscle pains
How long does opiate withdrawal last?
6-7 days.
How dangerous is opiate withdrawal?
Not very, unlikely to cause any permanent harm although it is deeply unpleasant.
Benzo or alcohol withdrawal will kill though.
Why is methadone (Buprenorphine) such an effective intervention?
- Demonstrably safer, reduces deaths by up to half.
- Long half life (24 hours+) means people take it less often (it also reaches a steady state within the body after 3 days) meaning there is less ‘hit’ and behavioural reinforcement from taking it, meaning it helps people overcome addiction.
Why do many people who detox/ get clean off methadone then relapse?
Their life hasn’t changed in any fundamentally protective way e.g. they will go back and still have triggers for addiction without any social support.
This is why support groups and other social interventions are vital for helping people recover from addiction.
What must happen before someone can go on Buprenorphine?
They have to enter withdrawal, as if they still have heroin in their system when they ingest the B they’ll go into potentially dangerous acute withdrawal (because B displaces H on the receptors and causes instant withdrawal).
How does Buprenorphine work chemically?
Partial agonist, causes a blockade of the receptors so even if someone does take heroin they feel nothing.
What precaution must people on Buprenorphine take?
Must abstain from alcohol and benzos. Most deaths on B come from use of these.
What is the difference between Detox and Rehab?
Detox = the process of coming off a drug, to the point where there is no longer any in your system. Mostly done in the community.
Rehab = Post-detox. People using therapeutic and social interventions to try and rehabilitate themselves back into the community.
