Substance misuse: need to add overdose

Question 1

substance misuse hierarchy

Answer 1

Question 2

Substance dependence requires at least two of the following:

Answer 2

1. Impaired control over substance use
2. Increasing priority over other aspects of life or responsibility
3. Psychological features suggestive of tolerance and withdrawal

Question 3

Pathophysiology of addiction including withdrawal

Answer 3

Question 4

ccording to UK guidance, the threshold for alcohol consumption is

Answer 4

14 units a week spread evenly over three days or more

Question 5

the difference between hazardous drinking, harmful drinking, and alcohol dependence.

Answer 5

• Hazardous drinking: individual consumes more than 14 units of alcohol a week, which may increase their risk of harm.
• Harmful drinking is when the pattern of alcohol consumption directly causes physiological complications and illnesses as discussed below.
• alcohol dependence is characterised by craving and tolerance of alcohol consumption despite the negative complications experienced.

Question 6

Alcohol misuse clinical features

Answer 6

• short term harm: alcohol poisoning and accidents
• liver cirrhosis, alcoholic liver disease.
• chronic alcohol misuse can present with bleeding oesophageal varices, hepatic failure, and stigmata of liver diseases.

Withdrawal symptoms
* Within 6-12 hours: tremors, and autonomic arousal (e.g. tachycardia, fever, pupillary dilation, and increased sweating).
* 34h: peak seizures
* Between 12-48 hours of cessation, patients can experience alcohol hallucinosis (typically auditory or tactile).
* Between 72-96 hours, patients can present with delirium tremens. They may experience altered mental status, agitation, and tactile hallucination.

Question 7

Screening questionnnaire alcohol misuse

Answer 7

The AUDIT-C questionnaire is a common screening tool that looks at the risk of dependency of alcohol misuse.7

Other questionnaires include the SAD-Q questionnaire which looks at the severity of alcohol dependence and the CAGE questionnaire.

Question 7

investigations in alcohol misuse

Answer 7

• Full blood count: raised MCV, raised platelets, anaemia
• Liver function tests: increased GGT, AST:ALT > 2:1
• Haematinics (B12/folate): alcohol can cause folate deficiency
• Thyroid function tests

Question 8

Alcohol misuse management

Answer 8

Question 9

Alcohol misuse complications

Answer 9

Question 10

Opioid misuse includes the use of

Answer 10

morphine, heroin, and codeine.

Question 11

opiod MOA

Answer 11

central nervous system depressants that slow brain activity and relax muscles.

Question 12

Clinical features of opiod misuse

Answer 12

• Physiological: euphoria and reduced pain, sedation, respiratory depression, meiosis, constipation, skin warmth and flushing
• Psychological: apathy, disinhibition, drowsiness, impaired judgment and attention, slurred speech

When withdrawing from opioids, increased sympathetic nervous system activity causes rhinorrhoea, lacrimation, diarrhoea, pupillary dilation, piloerection, tachycardia, and hypertension.

Question 13

Investigations of opiod misuse

Answer 13

Question 14

opioid misuse management

Answer 14

Question 15

Opioid misuse complications

Answer 15

• Opioid misuse also increases the risk of blood-borne diseases such as HIV, hepatitis B, and C
• Overdose, death

Question 16

Benzodiazepine misuse includes the use of

Answer 16

use of diazepam, oxazepam and lorazepam.

Question 17

Benzodiazepines MOA

Answer 17

central nervous system depressants.

Question 18

The clinical features of benzodiazepine misuse include:

Answer 18

Question 19

Investigations for benzodiazapines misuse

Answer 19

The clinical institute withdrawal assessment scale – benzodiazepines (CIWA-B) can be used to determine the severity of withdrawal from the substance.

Question 20

benzodiazapines misuse management

Answer 20

assisted withdrawal and supportive treatments.

Question 21

CNS stimulants examples

Answer 21

Amphetamine use (e.g. Adderall and methylphenidate) and cocaine are:

Question 22

CNS stimulants clinical features including withdrawal

Answer 22

CNS stimulants activate the sympathetic nervous system which causes symptoms such as tachycardia, hypertension, and mydriasis.

Patients using cocaine may develop tactile hallucinations and chest pain.

Clinical features of CNS stimulant withdrawal include dysphoria, lethargy, psychomotor agitation, craving, increased appetite, insomnia, and bizarre dreams.

Question 23

Screening tools used for CNS stimulants

Answer 23

Screening tools used for CNS stimulants are the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).

Question 24

CNS stimulants management

Answer 24

There is no specific drug treatment available for CNS stimulant use. Treatment is supportive and aimed at managing withdrawal symptoms.

Question 25

Hallucinogens include

Answer 25

lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP)

Question 26

Hallucinogens can cause:

Answer 26

euphoria, visual and auditory hallucinations and psychosis.

Question 27

Clinical features of hallucinogens: inlcuding specific symptoms relating to the specific drugs

Answer 27

Hallucinogens mainly cause visual or auditory hallucinations and the feeling of euphoria. Specific clinical features depend on the substance used: * **LSD**: lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams * **Marijuana**: increased appetite and conjunctival injection * **Ecstasy**: bruxism, hyperthermia, hyponatremia, and hepatotoxicity * **PCP**: loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation

Question 28

screening tools for hallucinogens misuse

Answer 28

Screening tools used for hallucinogens are the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).

Question 29

hallucinogens misuse management

Answer 29

no specific interventions for hallucinogen misuse, and the mainstay treatment is supportive. This includes medically supervised detox by slowly tapering the dose, referral to a rehabilitation centre, cognitive behavioural therapy, and treatment of withdrawal symptoms.

Question 30

Opioid replacement therapy that can be use sublingually

Answer 30

**Buprenorphine** is a mixed opioid agonist/antagonist. It is typically given as a **sublingual tablet** and provides an alternative opiate replacement therapy to methadone. Patient's often describe buprenorphine as less sedating, which can be a benefit or drawback depending on the context and patient. Prescribers must also be aware that because of the opioid antagonist properties of methadone it can render regularly prescribed analgesia, such as co-codamol, ineffective.

Question 31

SSRIs overdose symptoms

Answer 31

fever hyperreflexia tremor sweating diarrhoea (serotonin syndrome)

Question 32

TCA overdose

Answer 32

fever mydriasis confusion seizures cholinergic features (e.g. blurred vision)

Question 33

MAOIs overdose can cause what?

Answer 33

MAOIs plus tyramine can cause hypertensive crisis

Question 34

heroin acts on which receptors?

Answer 34

heroin, an opiate which acts at opioid receptors

Question 35

WIthdrawal and Overdose summary for all substances

Answer 35

heroin intoxication = constricted pupils -> naloxone for OD heroin withdrawal = dilated pupils -> supportive Tx, symptom relief ->>> methadone, buprenorphine stimulate intoxication (MDMA, cocaine, meth) = dilated pupils -> cooling, antihypertensives e.g. nitroprusside or GTN

Question 36

Methyphenidate is used for what?

Answer 36

Methylphenidate, more commonly known as 'Ritalin', is a stimulant prescription drug usually used in the treatment of Attention Deficit Hyperactivity Disorder. However, it has potential for illicit abuse and can be found among student populations who believe it improves their concentration and focus. This woman presents with insomnia, restlessness, increased temperature, increased blood pressure and increased heart rate, all likely to be caused by the illicit use of Methylphenidate