Substance Misuse And Addiction 2

Question 1

Intoxication

Answer 1

transient syndrome → recent substance use → clinically significant psychological/physical impairment. These changes disappear when drug is eliminated from the body

Question 2

ICD 10/11 classification criteria of harmful use?

Answer 2

pattern of substance use that causes damage to health (self or others)

damage can be physical or mental

adverse social consequences

does not fulfil any other diagnosis e.g. dependence

Question 3

ICD 11 criteria for dependence?

Answer 3

fulfil one of:

impaired control over substance use

increasing precedence of substance use over other aspects of life

neuroadaptation to substance

Usually evident over a period of 12 months but diagnosis may be made if there’s continuous use (ie daily or almost) for at least three months

Question 4

additional elements of addiction history?

Answer 4

how long used, when last, current amount, time at this level

total length of use, abstinence periods

mode of administration

evidence and severity of withdrawal syndrome

previous treatments and overdoses

triggers to use, willingness to be treated

Include family history

Question 5

common comorbid conditions to keep an eye out for?

Answer 5

ADHD, depression, previous trauma, personality disorders

addiction can cause suicidality

Also screen for domestic violence,neglect,abuse and ADHD

Question 6

potential clinically relevant elements of medical Hx?

Answer 6

cirrhosis (alc)

endocarditis, abscesses, hep B/C, HIV (IV use)

Question 7

• how to calculate alcohol units?

Answer 7

%strength x ml/1000

Question 8

recommended limits for alcohol consumption

Answer 8

14 units spread over 3 or more days

Question 9

how is alcohol metabolised?

Answer 9

liver → ethanol broken down to acetaldehyde by alcohol dehydrogenase → broken down to CO2 and water via oxidation via acetaldehyde dehydrogenase

1 unit per hour

Illicit brew may contain methanol which is broken down into formaldehyde

Question 10

stages of liver damage?

Answer 10

healthy → fatty → fibrosis → cirrhosis

Question 11

relevant examination findings?

Answer 11

jaundice, bruising, oedema, ascites,clubbing and spider naevia

Question 12

what is wernicke’s encephalopathy?

Answer 12

confusion, ataxia, ophthalmoplegia (paralysis of eye muscles)
Caused by thiamine deficiency (vit b1)

Question 13

what is korsakoff’s syndrome?

Answer 13

involves memory impairment

Question 14

liver investigations?

Answer 14

ultrasound, fibroscan, blood tests e.g. LFTs,breathalyzers,drug screen

Question 15

what is CAGE screening?

Answer 15

have you ever felt you needed to cut down on drinking

have people annoyed you by criticising your drinking

have you ever felt guilty about drinking

do you need alcohol first thing in the morning (eye-opener)

Question 16

alcohol withdrawal symptoms?

Answer 16

• 6-12 hours afterminor withdrawal symptoms e.g. vomiting, anxiety, tremulousness,diaphoresis(sweating)
• 12-24 hours afteralcoholic hallucinosis usually accusatory or deragotory
• 12-48 hours afterwithdrawal seizures as early as 2 hours after cessation of alcohol and before blood levels fall to 0
• 48-72 hours afterdelirium tremens

Question 17

What is delirium tremens

Answer 17

medical emergency

fever, tachycardia, hallucinations, confusion, hypertension, agitation, severe tremor

Pt may need observation 72 hours later too

Risk factors for DT include age,heavy alcohol use (60+),abnormal LFTs

Question 18

risk factors for development of DT?

Answer 18

concurrent acute illness, deranged LFTs, history of DTs and alcohol withdrawal symptoms, heavy daily alcohol use

Question 19

what is the difference between opiates and opioids?

Answer 19

opiates are natural opioids such as morphine and codeine

opioids refers to natural and synthetic opioids

Question 20

what do opioids do?

Answer 20

analgesic effect, euphoria in high doses

endogenous regulate pain and mood

Question 21

what receptors are relevant in opioid use

Answer 21

kappa, mu and delta opioid receptors

Question 22

examination findings for opioid addiction?

Answer 22

collapsed veins, endocarditis, skin abscesses, signs of pneumonia/hepatitis/HIV

Question 23

opioid withdrawal symptoms?

Answer 23

tachycardia, sweating, dilated pupils, abdominal pain, anxiety,bone pain,rhinorrhoea,tremor,yawning,goose flesh skin
Use clinical opiate withdrawal scale (cows)

Question 24

signs of opioid overdose?

Answer 24

unresponsive, slow/no breathing, choking/gurgling/snoring, tiny pupils, clammy skin, blue lips or nails

Question 25

treatment for opioid

Answer 25

naloxone (intramuscular or intranasal spray) used in overdose,inject into upper arm or thigh and if no response then repeat

Question 26

examples of medications used to assist abstinence?

Answer 26

alcohol: acamprosate(increases GABA,NMDA antagonist), naltrexone,disulfiram(inhibits acetaldehyde dehydrogenase so feel sick if have alcohol),nalmefene(given on days of high risk drinking)

opioids: methadone, buprenorphine

benzodiazepines: reducing doses of diazepam but many pt struggle and so remain in addiction services

Question 27

examples of medications used in detox regimes?

Answer 27

alcohol: benzodiazepines

opioids: maintenance treatment of methadone, buprenorphine before dose reduction

benzo: baclafen (GABA agonist). G drugs detox requires medical supervision which can be done in the community

Question 28

Tolerance

Answer 28

After repeated administration drug produces a decreased effect so larger doses are needed

Question 29

Alcohol absorption and pharmacodynamics

Answer 29

Alcohol is well absorbed and reaches max concentration in 60 mins of ingestion. Its absorption is slowed by food and sped up by effervescent drinks.

Alcohol enhances neurotransmission at GABA-A causing anxiolysis. Also stimulates dopamine release in mesolimbic system and inhibits NMDA mediated glutamate release

Question 30

Types of opioids

Answer 30

Natural (alkaloids)-opium,morphine,codeine,thebaine

Synthetic-
Fentanyl,pethidine,methadone,tramadol

Semi synthetic-
Heroine,hydrocodone,oxycodone,hydromorphone