Substance related/addictive disorders Flashcards
Discuss and distinguish the terms substance use, abuse, hazardous use, harmful use and dependence
- describe nicotine, gambling and over-the-counter/prescription substance abuse
- Describe the physiological and psychological aspects of the aetiology of substance dependence
- Describe the clinical presentation, diagnosis and management of substance abuse and dependence, with particular regard to alcohol, opiates, amphetamines, cannabis , kava and solvents
- Describe the neuropsychiatric consequences of alcohol abuse
- Establish empathic rapport with a patient with a drug or alcohol problem
- Take a psychiatric history from a patient with a drug or alcohol problem
- Screen for alcohol related problems using the CAGE and AUDIT
- Take a comprehensive substance use history
- Give simple counselling or advice to a patient with a drug or alcohol problem
o no
What are the 5 As of smoking cessation?
- ask
- assess nicotine dependence
- how many minutes after waking for first cig?
- no. of cigs/day?
- cravings or withdrawal?
- advise
- “the best thing you can do for your health is to stop smoking”
- assist
- give QuitPack
- arrange follow up
What is harmful use?
A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis following injection of drugs) or mental (e.g. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of harmful use.
What is hazardous use?
A pattern of substance use that increases the risk of harmful consequences for the user. Some would limit the consequences to physical and mental health (as in harmful use); some would also include social consequences. In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user. The term is used currently by WHO but is not a diagnostic term in ICD-10.
What is dependence?
A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:
- A strong desire or sense of compulsion to take the substance;
- Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use;
- A physiological withdrawal state when substance use has ceased or have been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms;
- Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users);
- Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;
- Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the har
What are the symptoms of nicotine withdrawal?
low mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite
List some medications for that aid in smoking cessation
Nicotine replacement
- patches
- gum
- inhaler
- lozenges
- oral spray
- sublinguial tablets
Varenicline
- nicotine antagonist
- most common side effect = nausea
- causes weird mood - be more careful in schizos
- start when the person is still smoking
Bupropion - antidepresant
- PO
- uncommon side effect = seizures, don’t use in patients with seizure history, eating disorder, or taking MAOI
- take caution with drugs that lower seizure threshold - antidepressants , antipsychotics
Nortriptyline - TCA
- adverse effects:
- dry mouth
- constipation
- nausea
- sedation and headache
- risk of causing arrhythmia in patients with CVD
- can be toxic in overdose.
What is CAGE?
screening tool for alcohol abuse
CAGE:
C ever felt the need to Cut down on drinking?
A ever felt Annoyed at criticism of your drinking?
G ever feel Guilty about your drinking?
E ever need a drink first thing in morning (Eye opener)?
How do you calculate no. of standard drinks?
litres of alcohol x percentage x 0.789 = std drinks
One stubbie of 375mL of full strength beer 5% alcohol by volume:
0.375 x 5 x 0.789 = 1.5 standard drinks
A standard drink is any drink containing 10 grams of alcohol
DSM criteria for alcohol withdrawal
A. Cessation of or reduction in alcohol intake, which has previously been
prolonged/heavy
B. Criterion A, plus any 2 of the following symptoms developing within several
hours to a few days:
• Autonomic hyperactivity
• Worsening tremor
• Insomnia
• Vomiting and nausea
• Hallucinations
• Psychomotor agitation
• Anxiety
• Generalised tonic-clonic seizures
C. The above symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
D. The above symptoms are not attributable to other causes; for example,
another mental disorder, intoxication, or withdrawal from another substance.
What is the management of someone in alcohol withdrawal?
INITIAL MANAGEMENT
- Move patient to a quiet room and dim the lighting
- Initiate an alcohol withdrawal chart.
- Give IV fluids
The patient is likely to be dehydrated and this could be helpful. However, you
may have to wait until he is sedated before you can insert a cannula. Start with normal saline because administration of glucose before thiamine may
precipitate Wernicke’s encephalopathy.
PHARMACOLOGICAL
- diazepam 20 mg orally, every 2 hours until symptoms subside
- thiamine 300mg IM or IV, daily for 3-5 days, then thiamine 300mg orally daily for several weeks
MONITORING
- regular observations, level of hydration
- withdrawal scale - CIWA-AR
What is delirium tremens? How is it treated?
- Rapid onset of confusion caused by alcohol withdrawal
- Often occurs 3 days into withdrawal symptoms
- Lasts for 3 days
Symptoms
- Shaking
- Shivering
- Agitation
- Disorientation
- tactile hallucinations
- Irregular heart rate
- Sweating, fever
- High body temperature
- Seizures
- Death
TREATMENT
- haloperidol PO
For severe psychotic symptoms when oral administration is not possible:
- droperidol 5 mg IM, as a single dose
- haloperidol 5 mg IM, as a single dose
Obvs benzos + thiamine and fluid rehydration as well
What is Wernicke’s encephalopathy?
The presence of neurological symptoms caused by exhaustion of B- vitamin reserves (particularly thiamine - vit B1)
Characterised by the triad:
- opthalmoplegia
- ataxia
- confusion
• Only 10% of patients experience all 3 symptoms
What is Korsakoff’s syndrome?
Caused by lack of thiamine (vit B1)
- *6 major symptoms**
1. anterograde amnesia
2. reterograde amnesia
3. confabulation – invented memories
4. minimal content in conversation
5. lack of insight
6. apathy – patients lose interest in things quickly and generally appear indifferent to change
