Substance Misuse and Clinical Specialities Flashcards
What are the classes of drugs?
Depressant - opioids, alcohol,
Stimulants - cocaine, amphetamines, MDMA, caffeine
Halllucinogens - LSD, PCP, ketamine
Cannabis, nicotine
What are novel psychoactive substanced?
Mimic controlled drugs - most weren’t illegal when they first came out e.g. mephedrone. Just as dangerous as the drugs they were trying to mimic.
Ask patient what the drug is similar to…
- Depressant - GBL/GHB, phenibut
- Stimmulants - m-cat, NRG-1, BZP
- Hallucinogens - AMT, methoxetamine
- Other - Spice (mimics cannabis)
What is the problem with the NPS clinically?
Not detected by routine urinary testing
What are the most harmful drugs to the individual?
- Crack cocaine
- Heroin
- Alcohol
- Cocaine
- Tobaccco
(death/illness /dependence /psychiatric /social issues)
What are the most harmful drugs to society?
- Alcohol
- Heroin
- Crack cocaine
- Tobacco
- Cannabis
- Cocaine
- Ketamine
- Mephedrone
(harm to others/ crime/ environmental/families/international trade/economic issues)
What are the main 3 areas related to substance misuse that we are concerned about?
Intoxication
Dependance
WIthdrawal
Effects of alcohol.
- Social lubrication
- Pleasure seeking
- Counter stress
- Disinhibition
- Risk taking
- Aggression
- Dyspraxia (co-ordination disorder)
What are the features of dependence syndrome (ICD-10)?
Three or more at least once in the last year:
- Strong desire or compulsion to use the substance
- Difficulty controlling use/amount/recidivism
- Tolerance to the effects of the drug
- Neglect of other activites/primacy
- Persistent use despite adverse consequences
- Withdrawal symptoms
- Narrowing of repertoire e.g. only smoking one type of cigarette/drinking one type of alcohol
What are the physical effects of alcohol?
- Encephalopathy
- Neuropathy
- Amblyopia (n eye fails to achieve normal visual acuity, even with prescription eyeglasses or contact lenses)
- Aspiration
- Cardiomyopathy
- Atrial fibrillation
- Gastritis
- Pancreatutis
- Behavioural disturbance
List some withdrawal symptoms.
“Cold turkey” (opiates)
Sweats
Shaking
Muscular aches
Nausea
Seizures
Delirium (“tremens”)
Chronic relapsing brain disorder characterised by neurobiological changes that lead to compulsion to take a drug with loss of control over activity.
- Transition from recreational to obsessive
- From positive to negative (you do it because not doing it will be worse)
What happens to the brain in addiction?
The more an individual uses substances the reward centres of the brain become less available so you need to use more of the substance to get the same impact.
What happens in alcohol withdrawal?
Alcohol is a depressant - increases inhibitory GABA, reduced excitatory NMDA-R
Withdrawal - increased excitatiory activity (more upregulation of “breaks”, causes delirium tremens, seizures)
What should you ask in a history of substance abuse?
- Where?
- What substance?
- Use - quantity/ route/when and whey
- First use/regular use/heaviest use
- Features of dependance and withdrawal symptoms
- Negative effects - physical, psychological, social.
“Joint years” - a joint a day for a year
How do you calculate alcohol by volume?
% aBV is the number of units in a litre
What should you look for on examination?
- Injecting drug use - punctures, track marks, cellulitis, DVTs
- Signs of inhaled drug use - burns stains, respiratory signs, stains
- Intoxication/withdrawal
- Abnormal mental state
- Acquired illness due to drug use (hepatitis from alcohol, HBV etc), injuries
What is formication?
Formication - sensation that resembles small insects crawling on the skin
What is the spectrum of withdrawal symptoms?
- Minor (6-24hrs)
- Major
- Seizures (6-48hrs) - multiple brief, generalised seizures and 3% develop status epilecticus
- Delirium tremens - 3-10days (autonomic hyperactivity)
What is the pharmacological treatment of alcohol withdrawal?
- Chlordiazepoxide reducing regime
- Prophylaxis vs Wernicke’s (prescribe B vitamins)
- Seizures i.v. Diazepam
Anti-mitochondrial antibodies
Jaundice
Liver infiltrated with plasma cells, WBC etc
Primary biliary cirrhosis
2 syndromes alcohol?
Wenicke’s
Korsakoff
W/K syndrome cause?
18 days of stores of thiamine
EtOG reduces duodenal absorption
CLD reduced activation and storage of thiamine
Nutritional deficiency –> demyelination of brain
W/K syndrome exam?
- Gait - Broad based gait (cerebellar ataxia)
- Eye signs - Ophthalmoplegia (lateral rectus palsy)
- Mental - Cognitive disturbance
Why do HIV crystal meth users have higher viral loads?
- Weakened immune system
- Poor complicance
- Drug interactions esp with ritonavir
What are the effects of alcohol on fertility? On the female/male/fetus?
Placental transmission
Spontanoeus miscarriage
Fetal alcohol syndrome
- Disrupted menstrual cycle
- Impotence, lower sperm count
What should you do if persuading thealcoholic patient not to drive does not work ?
Report to DVLA. Licence willl probably be suspended for:
Alcohol misue - 6 months
Alcohol dependancy - 12 months
What is the recommended limit of alcohol units per week?
14 units
Why is excessive drinking in the medical profession potentially problematic?
33% excessive drinking - less likey to counsel patients about alcohol abuse and less likely to recognise a problem related to alcohol
What are the treatments for addiction?
- Public interventions
- Brief intervention
- Prevent withdrawal/Wernicke’s
- Stabilisation
- Replacement e.g. heroin with methadone
- Detoxification
- Rehabilitation
Paddington alcohol test?
- How often do you drink?
- Whats the most you drink any day?
- Do you feel that your admission to hospital is related to alcohol?
If regularly more than twice daly limits (8units/day) or if yes to Q3 then give brief advice and offer referral/booklet.
What are the 5 stages of change (e.g. in addiction)?
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
What should you say when you meet someone in pre-contemplation admission for alcohol?
Feedback for patient - “I think that your abnormal LFTS are to do with alcohol”
Advise about support and where to go
