Substance misuse: Illegal drugs Flashcards
What percentage of adults have tried illegal drugs in their lifetime, and how many were in the previous year?
33% lifetime
10% in previous year
What percentage of Under 25s have tried illegal drugs in their lifetime, and how many were in the previous year?
50% lifetime
33% in previous year
Name 3 risk factors for illegal drug use
Male (3-4:1)
Younger age (Under 25: 50%)
Lower socioeconomic class
Psychiatric illness
What are the 5 patterns of drug use?
Experimental use - typically softer drugs
Situation use - mainly stimulants and hallucinogenics
Recreational use - regular but not dependent
Dependent use
Dual diagnosis - drug users with major mental illness
What is the diagnostic criteria for dependence syndrome?
At least 3 symptoms over a 12 month period:
- Compulsion to take substance
- Impaired control over use
- Salience (prioritisation above all else)
- Tolerance
- Withdrawal or relief use
- Persistent use despite clear evidence of harm
- Rapid reinstatement after abstinence
What are the categories of drugs of abuse?
Opiates Depressants Stimulants Hallucinogenics Others
Name 3 opiates commonly abused
Heroin Methadone Codeine Pethidine Buprenorphine
Name 3 depressants commonly abused
Alcohol
Benzodiazepines e.g. Diazepam
GHB
Name 3 stimulants commonly abused
Cocaine “Coke”
Amphetamines “Speed”
MDMA “Ecstasy”
Name 3 hallucinogenics commonly abused
LSD “Acid”
Mushrooms
Ketamine “Vitamin K”
PCP “Angel dust”
Name 3 other commonly abused drugs
Cannabis “Weed/Dope”
Volatile chemicals (Glues, gases and aerosols)
Anabolic steroids
What is the difference between opiates and opioids?
Opiates - naturally occurring
Opioids - synthetically produced
What are the desirable properties of opiates/opioids?
Euphoriant
Anxiolytic
Potent analgesic (medical use)
How can heroin be taken?
Smoking “Chasing”
Oral
Snorted
Parental IV, IM, or SC
What acute medical problems are associated with heroin?
Constipation NaV Respiratory depression Aspiration and loss of consciousness Death
Name 3 complications that may occur as a result of IVDU?
Local abscess Cellulitis Bacterial endocarditis - tends to occur in right heart Osteomyelitis Sepsis Hep B and C, and HIV
What sign and symptoms present in heroin toxicity?
Coma
Respiratory depression
Mitosis - Pinpoint pupils
Track marks
Fresh puncture wounds
What are the early signs and symptoms of opiate withdrawal?
Lacrimation and sweating Muscle ache Agitation Tachycardia Hypertension Sleep disturbance Anxiety
What are the late signs and symptoms of opiate withdrawal?
Diarrhoea NaV Goosebumps Stomach cramps Cravings and depression
Outline the general management of substance misuse
Therapeutic alliance Harm reduction Substitution Detox Maintaining abstinence Preventing relapse Social recovery
What harm reduction steps can be taken in drug misuse?
Do not use while alone Do not use with other drugs Avoid IV route If injecting, use safe injective advice -Sterile needles/syringes/water -Don't share needles -Rotate injection site
What social problems are associated with illegal drug dependence?
Crime
Homelessness
Name the 2 types of drug substitution therapy, and state their indications
Maintenance therapy - harm reduction and stabilisation, better for longterm addicts.
Detoxification - aim to come off a drug, suitable for highly motivated individuals looking to detox from all drugs within that class. Circumstance must be stable to maintain abstinence.
What investigations should be done when assessing suitability for substitution therapy?
FBC
LFTs
ECG - QTc
What drugs are used in maintenance treatment of opioid withdrawal? Which is preferred in the majority of cases?
Methadone - first choice, people settle better
Buprenorphine
Name a contraindication to Methadone?
Long QTc interval. Methadone may prolong this and induce Torsades de points and sudden cardiac death.
In what situations would Buprenorphine be used over Methadone for opioid maintenance therapy?
Previous bad experiences with methadone
Prefer ‘clear head’ response of buprenorphine over the ‘clouding’ of methadone and heroin
Hx of relapsing whilst taking methadone
Abnormal LFTs - buprenorphine is less affected by liver enzymes
How is compliance to opioid maintenance therapy monitored?
Urine tests
What drugs are used in opioid detox? What determines the drug of choice?
Methadone
Buprenorphine
Detox normally uses same opioid as that in maintenance.
What important safety advice should be given whilst a patient is undergoing opioid detox?
Advise about the risks of overdose due to loss of tolerance.
This risk may be potentiated by use of alcohol or benzodiazepines.
How quickly do withdrawal symptoms appear in opiate-dependent individuals? How long does withdrawal last?
6-24hrs after last dose
Withdrawal typically lasts 5-7 days
What is the mechanism of action of Methadone?
Long-acting full mu-opioid agonist. 24hr half-life, OD
Why is methadone the first choice of treatment for opioid dependency?
Long-acting opiate taken OD - increases compliance
Full agonist of opioid receptors
Cannot be injected due to high viscosity
What is the mechanism of action of Buprenorphine?
Partial opiate agonist.
What medication can be prescribed to prevent opioid relapse?
Naltrexone - opiate antagonist
What are the desirable effects of antidepressants?
GABA Receptor agonists
Anxiolytic
Relaxant
Counteracts side-effects of other drugs
Hypnotic
Anticonvulsant
How can benzodiazepines be taken?
Orally
Injection
What acute medical problems are associated with benzodiazepines?
Forgetfulness
Drowsiness
Impaired concentration and coordination
Increased risk of accidents
How does benzodiazepine overdose present?
"Classic" isolated OD: Coma with normal vital signs Dizziness Confusion Drowsiness Anxiety and agitation
Name 3 symptoms of benzodiazepine withdrawal
Anxiety and agitation Depression Insomnia Tremor Headache and nausea Depersonalisation
Can be complicated by seizures and delirium
What are the main reasons for prescribing less benzodiazepines in primary care?
Tolerance
Dependence
What drug is used in substitute prescribing of benzodiazepine dependency?
Diazepam, for is long half-life and variety of strengths and formulations.
What is the mechanisms of action of Diazepam?
Long-acting GABA agonist
When do withdrawal symptoms appear in benzo-dependent individuals?
Appear within 24hr of last short-acting benzodiazepine, may be up to 3 weeks for long-acting benzodiazepines.
What are the route of cocaine abuse?
Inhaled/snorted
Injected
Smoked - crack cocaine
What are the desirable effects of cocaine?
Increased alertness and endurance
Diminished need for sleep
Euphoria
Confidence
Local anaesthetic at mucous membranes
Name 2 acute medical problems associated with cocaine
Arrhythmias
Intense anxiety
Hypertension ➔ stroke
Impulsivity and impaired judgement
Name 2 chronic medical problems associated with cocaine
Necrosis of nasal septum
Foetal damage
Panic and anxiety disorders
Psychosis - esp persecutory delusions
Outline the management of cocaine abuse
Harm reduction advice.
Cocaine is not associated with dependence, so there is no role for substitute prescribing.
How is MDMA taken?
Orally
What is the mechanism of action of MDMA?
Causes serotonin release, and inhibits reuptake
What are the desirable effects of MDMA?
Feeling of increased camaraderie
Pleasurable agitation
Hallucinations
Decreased fatigue - stimulant properties
Name 2 acute medical problems associated with MDMA
Increased sweating ➔ deaths associated with dehydration
Nausea
Vomiting
Decreased potency despite increased libido
Outline the management of MDMA abuse
Harm reduction advice.
MDMA is not associated with dependence, so there is no role for substitute prescribing.
How can cannabis be taken?
Smoked
Eaten
What are the immediate effects of cannabis?
Mild euphoria - giggles Sense of enhanced wellbeing Relaxation Altered time sense Increased appetite - munchies
Name 2 acute medical problems associated with cannabis?
Mild paranoia
Panic attacks
Accidents due to delayed reaction time
Why is it important to ask specifically about cannabis in psychiatry?
Cannabis use can precipitate an episode or relapse of schizophrenia.
Regular use is associated with paranoid ideation and other psychotic features.
