Substance misuse in the clinical specialties Flashcards
categories of drugs and examples
depressants
- opioids, benzodiazepines, alcohol
stimulants
- cocaine, amphetamines, NMDA, caffeine
hallucinogens
- LSF, PCP, ketamine
cannabis, nicotine
epidemiology of substance abuse
UK highest user in Europe of amphetamine
cocaine most used
what are club drugs
recreational drugs in parties etc
amphetamine, methamphetamine, MDMA, cocaine
what are novel psychoactive substances
Newer drugs – more recently synthesised/misused
mimic club drugs - try to avoid the illegality of them - make tweaks to the molecule
legal highs - Now illegal
- mephedrone (meow meow)
- methoxetamine – ketamine ,
- GHB/GBL – solvent
Could buy on internet, shops
not detected by urinary drug testing
ask and have high degree of suspicion, and ask what expected effect
where do novel psychoactive substances fit into the drug categories
depressants
- GBL/GHB
- phenibut
stimulants
- m-cat
- NRG-1
- BZP
- MDAI
- synthacaine
- 5/6-APB
hallucinogens
- AMT
- methoxetamine
spice
most harmful drug to the user
crack cocaine
on basis of death, illness, dependence, psychiatric, social losses
brain pathways involved in addiction
Pathways that lead to reward in the nucleus accumbens
Mediators around dopamine/opiate receptors in nucleus accumbens that become reinforcing
Same pleasure get from drug as activities, both may be mediated through reward system in brain
what is the most harmful drug to society
alcohol
in terms of: harm to others, crime, env, family, international, economic cost, community
No rationale why harmful things are legal, and illegal things are more harmless
Just because a drug is more illegal doesn’t mean it is more harmful
why do people use substance
intoxication:
- social lubrication,
- pleasure seeking,
- reason to counter stress or pain,
- peer pressure – social industry to use illicit substances
what can intoxication syndrome lead to
disinhibition, risk taking, aggression, dyspraxia
OD = coma, illness, injury, death
ICD-10 classification of dependence
dependant of 3 or more:
- strong desire or compulsion to use
- difficulty controlling use/amount/recidivism (unable to quit)
- tolerance of effect
- neglect of activities/primacy (putting drug 1st)
- persistent use despite adverse consequences
- withdrawal sx
Narrowing of repertoire – narrative description but not one of criteria – focus down and use narrower type of substance or in a certain way
harms caused by drugs
drug specific mortality
drug related mortality
drug specific damage
drug related damage
dependence
drug specific mental disturbance
drug related mental disturbance
loss of tangibles
loss of relationships
injury
crime
env damage
family adversities
economic damage
effects of alcohol
withdrawal sx
vary depending on the drug
Withdrawal syndrome will vary depending on the drug
Depressants slow brain down –> brain upregulates everything to counteract. If suddenly stop taking the drug – still accelerater.
Opiate – uncomfortable:
- sweats, shaking, muscle aches, nausea, diarrhoea, gooseflesh
GHB and alcohol – work on GABA – withdrawal seizures
irritability, depression, delerium, psychosis
Mx of withdrawal sx
Always want to predict and prevent – encourage people to wean themselves off
Or cross intoxicate something that you can gradually reduce in safe way eg heroin -> methodrone?
alcohol -> benzodiazepine eg Chlordiazepoxide
why do people become addicted
chronic relapsing brain disorder - has neurobiological changes -> compulsion to taking drug and loss of control
transition from recreational to obsessive use
Go from positive reinforce because doing it is fun
To negative because not doing is not fun
psychological factors drive behaviour
d2 receptor availability does change - Need more of the substance to have the reward
shift homeostatic point downwards – to reach steady state mood need the +ve encouragement of the substance
why do you get alcohol withdrawal
alcohol increases inhib GABA-R activity
antagonises excitatory NMDA-R
withdrawal = increased excitatory activity
= delerium tremor, shake and seizures
substance misuse history
everyone
where - every encounter
what substances
current use - quantity, which route(s), when/why - pattern – eg if use to give confidence = address anxiety. pain – mx pain
history - first use, first regular use, heaviest use/cumulative use eg spliff yrs
features of withdrawal/dependence
negative effects - physical, psychological or social
what is ABV
units you would have in 1L
substance misuse signs o/e
signs of injecting:
- punctures, track marks
- cellulitis, DVT, bacterial endocarditis
signs of inhaled drug use
- burns, stains, resp signs
signs of intoxication/withdrawal - mental state/pupils
signs of acquired illness due to drug use
- hepatitis (alcohol, HBV, HCV), HIV, injuries
signs of intoxication - change to pupils
heart features from cocaine
Cardiomegaly – coronary artery vasospasm
Insufflation of corrosive substances
tests for frontal lobe dementia
luria’s dist palm edge motor sequencing
stroop test of inhibition - ask pt to read out the colour and not the word
understanding of proverb’s and metaphors – this language is processed in the frontal lobe.
verbal fluency - ability to generate words eg beginning with F. if deficit get stuck in one set of thing – eg all kind of the same thing. Or jump to expletives
drug use and sexual health
more likely to have unprotected sex under alcohol influence, that they regret or wouldnt normally find attractive
increase in legal age and tax = reduction in STIs
crystal methamphetamine
stimulant
easily sythesised
smoked/injected/PO/nasal/PR
risk with HIV/HCV
association with ‘chem sex’
associated with psychosis
epidemiology of crystal meth
Prevalent in small populations in UK, London in particular
more in gay men
more in gay men who use gym
HIV +ve gay men more than HIV -ve
-ve effects of crystal meth on HIV
weakened immune system/nutrition
poor compliance with ART
drug interactions with ritonavir
risks of drug resistant HIV
other STIs - syphillis, HBV, HCV
alcohol use in OBGNY
infertility - disrupted menstrual cycle, impotence, low sperm count/motility
pregnancy - placental transmission, spontaenous miscarriage, foetal alcohol spectrum disorder: (restricted growth, behavioural/learning difficulties, facial abnormalities)
breast feeding
need to safeguard
substance use and DVLA
ensure pt knows condition affects ability to drive
make every effort to get pt to stop driving
disclose relevant info to medical advisor at DVLA
multiple substance misuse (inc alcohol) is incompatible with licensing fitness
- alcohol persistent use - 6mo
- alcohol dependence - 12mo
- cannabis, e, speed - 6mo
- heroin, cocaine, meth - 12mo
legal limit of alcohol
Daily recommended allowance 1-2units a day, men 2-3. Should also have alcohol free days
Used to be <14 units/week
Massive underestimate of units
effect of alcohol consumption as medical professional
medical students reporting excessive drinking were less likely to counsel patients about alcohol misuse or see it as relevant
have responsibility to offer treatment to people with alcohol problems
put career at risk - GMC
may be using alcohol for stress/depression/anxiety - get help
recreational drugs illegal so even if doesnt affect practice you can be struck off
alcohol - fine, but if becomes a problem -> struck off
paddington alcohol test
Number 3 is the most important – this is a trigger to give brief advice or offer referral
As a public health intervention
This is detecting whether the patient has any insight into the idea it is causing an effect
stages of change
At any stage it is possible to go back to an earlier stage
Paddington test is to move people from pre-contemplation to contemplation
This is a brief intervention
‘identification and brief advice (IBA)’ for alcohol
identify problem drinkers
provide brief feedback/advice
offer further support to drinkers experiencing harm
for every 8 people who recieve simple alcohol advice - 1 will lower drinkung to within lower risk levels
Mx if people drinking excessively
Stabalise people on current drinking – interventions eg drink diaries or monitor the amount they spend
Cross intoxicate eg methadone or chlordiazepoxide
Detox people – gradually reduce the amount they are consuming until abstinent – then need to rehab ie learn to live w/o the substance – need lifestyle changes
