Substance misuse (alcohol and drugs) Flashcards
What is the recommended units of alcohol consumed within a week for men and women?
14 for both
What is the prevalence of alcohol use disorders within the UK in men and women?
Men: 6%
Women: 2%
What proportion of men and women drink in a harmful and hazardous way?
Men: 1/3
Women: 1/6
What neurotransmitters does alcohol have an effect on?
Gamma aminobutyric acid (GABA)
Dopamine
Serotonin
Glutamate
What neurotransmitters cause the reinforcing effect of alcohol?
GABA
Dopamine
Serotonin
What effects happen in terms of neurotransmitters in alcohol dependence and what happens when you withdraw alcohol?
Compensatory up-regulation of glutamate to counterbalance the GABAergic CNS depressant effects of alcohol.
Suddenly withdrawing alcohol therefore leads to symptoms of CNS hyperexcitation
What are the seven key features of alcohol dependence?
- Compulsion to drink or craving
- Primacy of drinking over other activities
- Stereotyped pattern of drinking, e.g. narrowing of drinking repetoire
- Increased tolerance to alcohol, i.e. needing more and more to produce the same effect
- Repeated withdrawal symptoms
- Relief drinking to avoid withdrawal symptoms e.g ‘eye opener’ first thing in the morning
- Reinstatement after abstinence
How do you get diagnosed with alcohol dependence in the ICD-10?
At least three from a list of features occurring at any time during a 12-month period.
What are the symptoms of alcohol withdrawal?
Range from mild anxiety and sleep disturbance to life-threatening delirium tremens.
Agitation Tremor Perspiration Nausea Vomiting
Most likely to occur first thin in the morning
In how many people with alcohol dependence will delirium tremens occur?
Its a medical emergency that occurs in 5% of people after one-to-three days without alcohol
Untreated mortality is rate is around 10%
How is delirium tremens characterised?
Clouding of consciousness Disorientation of recent memory Impairment of recent memory Fear, agitation, and restlessness Vivid hallucinations (most commonly visual) and delusions (most commonly paranoid) Insomnia Autonomic disturbances (tachycardia, hypertension, hyperthermia, perspiration, dilated pupils) Coarse tremor Nausea and vomiting Dehydration and electrolyte imbalances Seizures
What are the important differential diagnoses of delirium tremens?
Hypoglycaemia Drug overdose Other causes of delirium (UTI) Alcohol hallucinosis Wernicke's encepholopathy
How do you treat delirium tremens?
Benzodiazepines
Correction of fluid and electrolyte imbalances
Treatment of concurrent infections
Parenteral multivitamin injections
What is Wernicke’s encephelopathy?
It is a medical emergency. It is a disorder of acute onset that results from thiamine (vitamin B1) deficiency, most commonly secondary to alcohol dependence.
What are the symptoms of Wernicke’s encephelopathy?
Impaired consciousness Confusion Episodic memory impairment Ataxia Nystagmus Abducens and conjugate gaze palsies Pupillary abnormalities Peripheral neuropathy
Classic triad - Confusion, ataxia, ocular palsy
What are the other causes of thiamine deficiency?
Starvation
Malabsorption
Hyperemesis
Carbon monoxide poisoning
What is the treatment for Wernicke’s encephelopathy?
Parenteral thiamine
What are the differential diagnoses for Wernicke’s encephelopathy?
Hypoglycaemia
Hepatic encephelopathy
Subdural haemorrhage
What are the results of treatment in Wernicke’s? How many recover, die and what happens to the rest?
20% recover
10% die from haemorrhages in the brainstem and hypothalamus
The rest develop Korsakov syndrome
What causes Korsakov syndrome?
Neuronal loss
Gliosis
Haemorrhage in the mamimillary bodies
Damage to the dorsomedial nucleus of the thalamus
What is Korsakov syndrome?
An irreversible amnestic syndrome characterised by impairment of recent and, to a lesser extent, remote memory (memories from years ago.
Confabulation
Immediate recall, perception, and other cognitive functions are usually intact.
What are the psychiatric complications of alcohol misuse and dependence?
Mood and anxiety disorders Suicide and deliberate self-harm Partially reversible cognitive impairment Alcoholic hallucinosis Othello syndrome Pathological intoxication
What are the neurological complications of alcohol misuse and dependence?
Episodic anterograde (short term) amnesia Seizures Peripheral neuropathy Cerebellar degeneration Optic atrophy
What are the gastrointestinal complications of alcohol misuse and dependence?
Oesophagitis Oesophageal varices Gastritis Peptic ulceration Acute and chronic pancreatitis Alcoholic hepatitis Cirrhosis: 10-20% of dependents Cancer of the oesophagus, stomach and liver
What are the cardiovascular complications of alcohol misuse and dependence?
Hypertension
Cardiac arrhythmias
Cardiomyopathy
What are the other medical complications of alcohol misuse and dependence?
Episodic hypoglycaemia Vitamin deficiencies and anaemia Accidents, especially head injury Hypothermia Respiratory depression Aspiration pneumonia Increased susceptibility to infections Sexual problems: decreased libido, impotence
What are the social complications of alcohol misuse and dependence?
Family and marital difficulties Employment difficulties Financial problems Vagrancy and homelessness Crime and its repercussions
What three tests are usually raised in heavy drinkers and can be useful in diagnosis?
Gamma-glutamyltransferase (GGT) - raised in 80% Alkaline phosphatase (ALP) - raised in 60% Mean corpuscular volume (MCV) - raised in 50%
Which of the three tests has the highest specificity for alcohol misuse?
MCV, but owing to the long half-life of red blood cells (120 days) may remain elevated for a long time after the patient has stopped drinking.
When alcohol dependence has been established detoxification is required. What does this involve?
Reducing course of a benzodiazepine in lieu of alcohol.
Chlordiazepoxide 20mg QDS reducing daily over 5-7 days and supplemented with thiamine 200m OD.
What should be advised after the patient has stopped drinking alcohol and how can it aided?
Aid abstention rather than controlled drinking as has a higher success rate
Can be encouraged by maintenance treatments such as naltrexone, acamprosate, or disulfiram
What are the psychosocial interventions for alcohol dependence?
Groups run by the community drug and alcohol service Alcoholic Anonymous Supportive therapy Cognitive behavioural therapy Marital and family therapy
How many people in England and Wales between the ages of 16-59 have tried an illicit drug and how many have taken a class A?
- 7% - tried
15. 5% - Class A
