substance misuse Flashcards
what is acute intoxication
acute
transient
effect of the substance
what is harmful use
recurrent misuse ass w physical, psychologica and social consequences but WO dependence
what is alcohol dependence syndrome
Edward adn Gross criteria
Subjective awareness of compulsion to drink.
Avoidance or relief of withdrawal symptoms by further drinking (also known as relief drinking).
Withdrawal symptoms.
Drink-seeking behaviour predominates.
Reinstatement of drinking after attempted abstinence.
Increased tolerance to alcohol.
Narrowing of drinking repertoire
- primacy of drug seeking behaviour “salience”
- narrowing of the drug taking repertoire - when they have chosen their favourites
- increased tolerance to the effects of the drug - they have to keep on taking more to get the same effect
- loss of control consumption - when they cant stop taking it
- signs of withdrawal on attempted abstinence
- drug taking to avoid development of withdrawal Sx
- continued drug use despite negative consequences
- rapid reinstatement of previous pattern of drug use after abstinence
have 3 at the same time
what is withdrawal state
physical and/or psychological effects from complete or partial cessation of a substance prolonged, repeated or high level of use
what is psychotic disorder
onset of psychotic Sx within 2 weeks of substance use
must persist for more than 48 hours
what is amnesic syndrome
memory impairment in recent memory and ability to recall past experiences
defect in recall
clouding od consciousness
global intellectual decline
what is residual disorder
specific features
- flashbacks
- personality disorder
- affective disorder
- dementia
- persisting cognitive impairment
subsequent to substance misuse
physical problems of substance misuse
death
infection HIV hep A,B or C
psychological problems of substance misuse
craving
anxiety
cognitive disturbance
drug-induced psychosis
social problems of substance misuse
crime imprisonment homelessness prostitution relationship problems
what is substance dependence
Drug Problems Will Continue To Harm >= 3 over 1 month 1. strong desire (compulsion) 2. Preoccupation w sub use 3. Withdrawal state 4. Impaired ability to Control substance taking behavious 5. Tolerance 6. Harmful effects
Ix for substance misuse
Bloods 1. HIV screen Hep B, Hep C + TB testing 2. U&Es 3. LFTs 4. Drug levels
Urinalysis - drug metabolites
ECG for arryhthmias
ECHO endocarditis
DDx for substance misue
psychosis
mood disorders
anxiety disorders
delirium
hyperthyroidism
CVA
Intracranial haemorrhage
neurological disorders (cerebellar pathology)
biological therapies for opioid dependence
methadone 1st line
buprenorphine for detoxification and maintenance - sublingual tablet
naltrexone - continue abstinence
IV naloxone - antidote
alcohol withdrawal pt signs
tremor
heroin withdrawal pt signs
pupils <3mm
alcohol withdrawal treatment
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
drink diary
slowing it down
water it down
alcohol action on brain
enhances GABA transmission (anxiolytic effects)
release of DA in the mesolimbic system (euphoriant and ‘reward’ effects)
inhibition of NMDA mediated (amnesic effects)
disulfiriam
role
Sx
antabuse
an irreversible inhibitor of acetaldehyde dehydrogenase
facial flushing and nausea and vomiting.
feel so sick that you dont want to drink the alcohol
what are the stages of change
model for understanding motivation and action towards change in harmful patterns of drug use
Pre-contemplation - they dont think they have a problems
contemplation - accept they have a problem and they look at the pros and cons of it
Decision - continue drug use or attempt change
action - attempts change
Maintenance - maintaining gains made and attempting to improve those areas of life harmed by use
Relapse - return to previous behaviour
what is CAGE questionnaire
C- have u ever felt u should Cut back on ur drinking
A - has anyone ever Annoyed you by criticising your drinking
G- have u ever felt Guilty about ur drinking
E - have u ever had a drink early in the morning as an Eye-opener
opioid withdrawal treatment
motivational interviewing
methadone
Made to have treatment ie CJS
what is methadone
full agon - given as a liquid to monitor easily - impossible to inject - pharmacists do directly observed consumption longer half life taken once a day respiratory depression urinary test - make sure they are dependent - looking for breakdown products highly dangerous
buprenoprphine
Partial agonist
ppl who want to get off opiates quickly
start withdrawal Sx
“rattling”
opiate wihtdrawal Sx
Craving, rhinorrhoea, lacrimation, myalgia, abdominal cramps, N+V, diarrhoea, pupillary dilatation, piloerection, HR/ BP
leg restlessness - load of painkillers - leg become sensitive to even small pain - hyperalfesic - any sensation will irritate them
Mx
sleeping tablet
NSAID
buscapan - colon awake -> stop stomach spasms and cramps
most dangerous time to use opiates when they start when they go back
as they have low tolerance
opiate overdose
naloxone shorter half life than opiates
cannabis effects psychological and physical
withdrawal
psychological
Euphoria, disinhibition, agitation, paranoid ideation, temporal slowing (time passes slowly), impaired judgement/ attention/reaction time, illusions, hallucinations
physical
Increased appetite, dry mouth, conjunctival injection, HR
withdrawal
Anxiety, irritability, tremor of outstretched hands, sweating, myalgia
anxiolytic
CBD calms you down
THC gives you the high - increases the dopamine - more sensitive to senses
drug induced psychosis
too much CBD is bad for you - apathetic, no drive, no motivation
NO Mx programme - they can get over it
stimulants effects psychological and physical
Psychological
Euphoria, increased energy, grandiose beliefs, aggression, argumentative, illusions, hallucinations (intact orientation), paranoid ideation, labile mood
Physical
HR, BP, arrhythmias, sweating, N+V, pupillary dilatation, psychomotor agitation, muscular weakness, chest pain, convulsions
Ketamine
horse tranquilliser given in anaestheitcs dissociated - their not with it hallucinogenic altered consciousness fibrosis of the bladder - impotence
used in depression - releases glutamate - stimulator, neuroplasticity
Legal highs novel psychotropic substances
poor ppl can take it
spice - synthetic cannabis - too much conscious or violent
what scale is used to determine alcohol withdrawal severity
Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale
what screening tool can be used to udetify pts who may have drinking behaviours or alcohol misuse
Alcohol Use Disorders Identification Test (AUDIT) and the CAGE
mechanism of alcohol withdrawal
- > chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- > alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
features of alcohol withdrawal
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety, malaise, nausea, transient hallucinations
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
pathophysiology/aetiology alcohol
effect on GABA -> anxiolytic and sedative effects
The pleasurable and stimulant effects of alcohol are mediated by a dopaminergic pathway in the brain. Repeated, excessive alcohol ingestion sensitizes this pathway and leads to the development of dependence.
down-regulation of inhibitory
neuronal GABA receptors and up-regulation of excitatory glutamate receptors, so when alcohol is withdrawn, it results in central nervous system hyper-excitability.
RFs of alcohol abuse
Male
Males are at increased risk of alcohol abuse and have increased metabolism of alcohol, thus allowing them to have higher quantities.
Younger adults
Genetics
Antisocial behaviour
lack of facial flushing
life stressors ie financial problems, marital issues and certain occupations
characteristics of alcohol intoxications
lurred speech, labile affect, impaired judgement and poor co-ordination.
In severe cases, there may be hypoglycaemia, stupor and coma.
what is delirium tremens
Mx
This withdrawal delirium develops between 24 hours and one week after alcohol cessation. Peak incidence of delirium tremens is at 72 hours.
Physical illness is a predisposing factor.
Dehydration and electrolytic disturbances are a feature.
It is characterized by:
Cognitive impairment
Vivid perceptual abnormalities (hallucinations and/or illusions) -
Paranoid delusions
Marked tremor
Autonomic arousal (e.g. tachycardia, fever, pupillary dilatation and increased sweating).
Mx
Medical treatment can be with large doses of benzodiazepines (e.g. chlordiazepoxide), haloperidol for any psychotic features, and intravenous Pabrinex.
DDc of alcohol abuse
Psychiatric disorders: Psychosis. Mood disorders (including bipolar). Anxiety disorders Delirium.
Medical disorders:
Head injury.
Cerebral tumour.
Cerebrovascular accident (e.g. stroke).
what is wernicke’s encephalopathy
features
Mx
An acute encephalopathy due to thiamine deficiency, primarliy affecting the PNS/CNS
- delirium
- nystagmus
- ophthalmoplegia, hypothermia
- ataxia.
- hypothermia
- hypotension
Requires urgent treatment and may progress to Korsakoff’s psychosis (AKA amnesic syndrome).
Treated with IM pabrinex.
2 - 3 pairs three times a day for 2 days
followed by 1 pair a day for 5 days
Followed by oral thiamine and multivitamins
what is korsakoff’s psychosis
Mx
Korsakoff psychosis is a late complication of persistent Wernicke encephalopathy and results
in memory deficits, confusion, and behavioral changes
. It is
predominately anterograde and retrograde amnesia, an inability to learn new information.
Korsakoff’s is permanent and there is no cure
Mx of alcohol abuse
biological
- chlordiazepoxide -
psychological
- motivational interviewing +CBT
- social network and environment based therapies
Social
AA
Social support
Mx for alcohol dependence
biological
1. Disulfiram: Works by causing a build-up of acetaldehyde on consumption of alcohol,
causing unpleasant symptoms e.g. anxiety, flushing and headache.
- Acamprosate: ANTI-CRAVING by enhancing GABA transmission.
- Naltrexone:Blocksopioid receptors (antagonist) in
the body, thus reducing the pleasurable effects of alcohol.
Motivational interviewing
CBT
AA
psychological and physical effects of opiates
psychological
Apathy, disinhibition, psychomotor retardation, impaired judgement and attention, drowsiness, slurred speech
physical
Respiratory depression, hypoxia, reduced BP, hypothermia, coma, pupillary constriction
psychological and physical effects of sedative hypnotics ie benzodiazepines, barbituates
Euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
Unsteady gait, difficulty standing, slurred speech, nystagmus, erythematous skin lesions, BP, hypothermia, depression of gag reflex, coma
withdrawal Sx of hypnotics ie benzos, barbituates
Tremor of hands, tongue or eyelids, N+V, HR, postural
BP, headache, agitation, malaise, transient illusions/ hallucinations, paranoid ideation, grand mal convulsions
hallucinogens ie LSD
psychological and physical effects
Anxiety, illusions, hallucinations, depersonalization, derealization, paranoia, ideas of reference, hyperactivity, impulsivity, inattention
physical
HR, palpitations, sweating, tremor, blurred vision, pupillary dilatation, incoordination
complications of substance misuse
Physical
Death, infection (HIV, hepatitis A, B or C, Staphylococcus aureus, group A Streptococci, Clostridium, TB), endocarditis, superficial thrombosis, deep vein thrombosis, pulmonary embolus.
Psychological
Craving, anxiety, cognitive disturbance, drug-induced psychosis.
Social
Crime, imprisonment, homelessness, prostitution, relationship
problems
What is the formula for working out how many units the patient is drinking?
multiplying the total volume of a
drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000.
Mx for alcohol withdrawal
Prescribed at high doses initially, and
gradually reduced and stopped over about 10 days. This is an oral medication to help
with the symptoms of alcohol withdrawal.
- disulfiram/naltroxene/acamprosate
IV or IM Pabrinex – a b vitamin compound to prevent the development of Wernickes
Encephalitis. Oral Thiamine and multivitamins should be prescribed after a course of
Pabrinex
Need to consider a PRN/as required medication in case the patient has a seizure. This
could be 10mg diazepam PR.
how to score severity of alcohol toxicity
SADQ
(SEVERITY OF ALCOHOL
DEPENDENCE QUESTIONAIRE))
Ix for alcohol detox
Medication history of prescribed and non-prescribed drugs
Full blood count, B12, folate
Liver function tests (including Gamma GT)
Urea and Electrolytes, including calcium, phosphate and magnesium in severely
dependent/malnourished patients at risk of re-feeding syndrome.
HbA1c/random blood glucose
Amylase
Breathalyser test
Urine drug screen
Routine observations i.e. ECG, baseline blood pressure (supine and orthostatic) and pulse
Other investigations such as abdominal ultrasound may be necessary depending on their
history, severity, physical signs and co-morbidities
which illicit drugs may produce a schizophrenia-like state
cannabis, cocaine, LSD or amphetamines,
what is harm minimisation
policies and practices that try to reduce the harm that people do to themselves or others from their drug use. It can be contrasted with primary prevention which tries to prevent people using drugs in the first place, or to stop them using once they’ve started.
RFs of completed suicide
persistent suicidal ideas, being male, previous attempts, use of violent/lethal methods, mental disorder, poor physical health, physical /sexual abuse, parental mental illness, lack of social support, psychological factors e.g impulsivity.
Which one of the following is the most common method of completed suicide in males in the UK?
hanging/strangulation
Which one of the following is the most common method of completed suicide in females in the UK?
hanging/strangulation
