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substance misuse Flashcards

1
Q

what is acute intoxication

A

acute
transient
effect of the substance

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2
Q

what is harmful use

A

recurrent misuse ass w physical, psychologica and social consequences but WO dependence

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3
Q

what is alcohol dependence syndrome

A

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

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4
Q

what is withdrawal state

A

physical and/or psychological effects from complete or partial cessation of a substance prolonged, repeated or high level of use

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5
Q

what is psychotic disorder

A

onset of psychotic Sx within 2 weeks of substance use

must persist for more than 48 hours

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6
Q

what is amnesic syndrome

A

memory impairment in recent memory and ability to recall past experiences
defect in recall
clouding od consciousness
global intellectual decline

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7
Q

what is residual disorder

A

specific features

  • flashbacks
  • personality disorder
  • affective disorder
  • dementia
  • persisting cognitive impairment

subsequent to substance misuse

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8
Q

physical problems of substance misuse

A

death

infection HIV hep A,B or C

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9
Q

psychological problems of substance misuse

A

craving
anxiety
cognitive disturbance
drug-induced psychosis

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10
Q

social problems of substance misuse

A 
crime 
imprisonment
homelessness
prostitution
relationship problems
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11
Q

what is substance dependence

A 
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
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12
Q

Ix for substance misuse

A 
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

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13
Q

DDx for substance misue

A

psychosis
mood disorders
anxiety disorders
delirium

hyperthyroidism
CVA
Intracranial haemorrhage
neurological disorders (cerebellar pathology)

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14
Q

biological therapies for opioid dependence

A

methadone 1st line

buprenorphine for detoxification and maintenance - sublingual tablet

naltrexone - continue abstinence

IV naloxone - antidote

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15
Q

alcohol withdrawal pt signs

A

tremor

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16
Q

heroin withdrawal pt signs

A

pupils <3mm

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17
Q

alcohol withdrawal treatment

A

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

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18
Q

alcohol action on brain

A

enhances GABA transmission (anxiolytic effects)

release of DA in the mesolimbic system (euphoriant and ‘reward’ effects)

inhibition of NMDA mediated (amnesic effects)

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19
Q

disulfiriam

role
Sx

A

antabuse
an irreversible inhibitor of acetaldehyde dehydrogenase

facial flushing and nausea and vomiting.

feel so sick that you dont want to drink the alcohol

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20
Q

what are the stages of change

A

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

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21
Q

what is CAGE questionnaire

A

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

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22
Q

opioid withdrawal treatment

A

motivational interviewing
methadone
Made to have treatment ie CJS

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23
Q

what is methadone

A 
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
24
Q

buprenoprphine

A

Partial agonist
ppl who want to get off opiates quickly
start withdrawal Sx
“rattling”

25
Q

opiate wihtdrawal Sx

A

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

26
Q

opiate overdose

A

naloxone shorter half life than opiates

27
Q

cannabis effects psychological and physical

withdrawal

A

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

28
Q

stimulants effects psychological and physical

A

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

29
Q

Ketamine

A 
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

30
Q

Legal highs novel psychotropic substances

A

poor ppl can take it

spice - synthetic cannabis - too much conscious or violent

31
Q

what scale is used to determine alcohol withdrawal severity

A

Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale

32
Q

what screening tool can be used to udetify pts who may have drinking behaviours or alcohol misuse

A

Alcohol Use Disorders Identification Test (AUDIT) and the CAGE

33
Q

mechanism of alcohol withdrawal

A
  • > 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)
34
Q

features of alcohol withdrawal

A
  • 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
35
Q

pathophysiology/aetiology alcohol

A

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.

36
Q

RFs of alcohol abuse

A

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

37
Q

characteristics of alcohol intoxications

A

lurred speech, labile affect, impaired judgement and poor co-ordination.
􏰃 In severe cases, there may be hypoglycaemia, stupor and coma.

38
Q

what is delirium tremens

Mx

A

􏰃 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.

39
Q

DDc of alcohol abuse

A 
Psychiatric disorders:
􏰃 Psychosis.
􏰃 Mood disorders (including bipolar).
􏰃 Anxiety disorders
􏰃 Delirium.

Medical disorders:
􏰃 Head injury.
􏰃 Cerebral tumour.
􏰃 Cerebrovascular accident (e.g. stroke).

40
Q

what is wernicke’s encephalopathy

features

Mx

A

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

41
Q

what is korsakoff’s psychosis

Mx

A

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

42
Q

Mx of alcohol abuse

A

biological
- chlordiazepoxide -

psychological

  • motivational interviewing +CBT
  • social network and environment based therapies

Social
AA
Social support

43
Q

Mx for alcohol dependence

A

biological
1. Disulfiram: Works by causing a build-up of acetaldehyde on consumption of alcohol,
causing unpleasant symptoms e.g. anxiety, flushing and headache.

  1. Acamprosate: ANTI-CRAVING by enhancing GABA transmission.
  2. Naltrexone:Blocksopioid receptors (antagonist) in
    the body, thus reducing the pleasurable effects of alcohol.

Motivational interviewing

CBT

AA

44
Q

psychological and physical effects of opiates

A

psychological
Apathy, disinhibition, psychomotor retardation, impaired judgement and attention, drowsiness, slurred speech

physical
Respiratory depression, hypoxia, reduced BP, hypothermia, coma, pupillary constriction

45
Q

psychological and physical effects of sedative hypnotics ie benzodiazepines, barbituates

A

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

46
Q

withdrawal Sx of hypnotics ie benzos, barbituates

A

Tremor of hands, tongue or eyelids, N+V, 􏰄 HR, postural

􏰃 BP, headache, agitation, malaise, transient illusions/ hallucinations, paranoid ideation, grand mal convulsions

47
Q

hallucinogens ie LSD

psychological and physical effects

A

Anxiety, illusions, hallucinations, depersonalization, derealization, paranoia, ideas of reference, hyperactivity, impulsivity, inattention

physical
􏰄 HR, palpitations, sweating, tremor, blurred vision, pupillary dilatation, incoordination

48
Q

complications of substance misuse

A

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

49
Q

What is the formula for working out how many units the patient is drinking?

A

multiplying the total volume of a

drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000.

50
Q

Mx for alcohol withdrawal

A

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.

51
Q

how to score severity of alcohol toxicity

A

SADQ
(SEVERITY OF ALCOHOL
DEPENDENCE QUESTIONAIRE))

52
Q

Ix for alcohol detox

A

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

53
Q

which illicit drugs may produce a schizophrenia-like state

A

cannabis, cocaine, LSD or amphetamines,

54
Q

what is harm minimisation

A

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.

55
Q

RFs of completed suicide

A

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.

56
Q

Which one of the following is the most common method of completed suicide in males in the UK?

A

hanging/strangulation

57
Q

Which one of the following is the most common method of completed suicide in females in the UK?

A

hanging/strangulation

psychiatry (14 decks)

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