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BRS YR2 > Substance Use and Addiction > Flashcards

Substance Use and Addiction Flashcards

1
Q

What are the main three things to flag for abuse?

A
  • quantity/frequency
  • consequences (physical, psychological, social impact)
  • dependence/addiction
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2
Q

What are the main red flags for dependence?

A
  • tolerance and morning drinking

- withdrawal

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3
Q

What are the different types of stimulants?

A
  • amphetamine
  • cocaine (crack)
  • ecstacy
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4
Q

What are ‘novel psychoactive substances’?

A
  • new 1/week
  • tend to be synthetic
  • can be put into 4 categories: depressant, stimulant, hallucinogenic, cannaboid
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5
Q

Why is it important to know why drugs are being used?

A

Because it informs treatment

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6
Q

What is positive reinforcement (drugs)?

A

drugs are used to gain a positive state

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7
Q

What is negative reinforcement?

A

drugs are used to overcome an adverse state

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8
Q

What is the course of drug addiction?

A
  • experimental use, causes no/limited difficulties
  • increasingly regular until harmful
    (can bounce back from here)
  • spiral into dependence
    (point of no return)
  • like>want>need
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9
Q

What is the ICD-10 diagnostic criteria?

A
  • strong compulsion to take the substance
  • difficulties in controlling the substance (onset, termination or usage levels)
  • negative physiological withdrawal when substance use is stopped
  • tolerance: more to get the same effect
  • neglect of alternative interest
  • persistence with use despite harmful consequences
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10
Q

What classifies harmful use?

A

Actual damage should’ve been caused to the health of the user in the absence of diagnosis of dependence

  • physical or mental damage (required)
  • adverse social consequences
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11
Q

What is the estimated prevalence of alcohol dependence?

A

595,000 people

only 103,471 in treatment, 82% not receiving treatment

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12
Q

What is the estimated prevalence of opiate dependence?

A

257,476 people

170,032 in treatment, 46% not receiving treatment

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13
Q

What has been the impact of COVID-19 on alcohol and opiate dependency?

A

100% more people are at high risk

20% more cases

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14
Q

What is the definition of Addiction?

A

Compulsive drug use despite harmful consequences, characterised by the inability to stop using a drug; failure to meet personal, or professional obligations; and (drug dependent) tolerance and withdrawal

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15
Q

What is the definition of Dependence?

A

A physical adaptation to a substance
- tolerance/withdrawal
(can be dependent but not addicted)

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16
Q

What are some examples of behavioural addictions ?

A
  • gambling disorder
    (similar: neurobiology, treatment and co-morbidity and substance dependence)
  • internet gaming
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17
Q

What causes a larger ‘rush’ and addiction?

A

faster brain entry/onset

crosses the blood-brain barrier, lipophylic

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18
Q

What are the 3 main elements involved in alcohol/drug use and addiction?

A
  • Social, environmental factors
  • Personal factors (genetic)
  • Drug factors
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19
Q

What are the changes to the brain pre and post addiction?

A
  • pre-existing vulnerabilities, age and family history
  • exposure leads to compensatory neuroadaptations to maintain brain function
  • recovery: lead to cycles of remission and relapse
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20
Q

Why drink alcohol?

A

Alters the balance between the brain’s inhibitory (GABA-A, glutamate system) and excitatory system (glutamate system, NMDA receptor)

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21
Q

What impact does alcohol have on the excitatory system?

A

Blocks the excitatory system

- Impaired memory (alcoholic blackouts)

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22
Q

What is the impact of alcohol on the inhibitory system?

A

Stimulates the glutamate system

  • anxiolysis
  • sedation
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23
Q

What are the neuroadaptations caused by chronic alcohol exposure?

A

means that GABA and glutamate remain in balance in the presence of alcohol
- up-regulation of the excitatory system
- reduced function of the inhibitory system > tolerance
(switch in GABA-A receptors to make it less sensitive to alcohol)

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24
Q

How do you treat the neuroadaptation causing reduced function in the inhibitory system?

A

-benzodiazepines, to boost GABA function

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25
Q

What does the up-regulation of the excitatory system cause?

A

Increase in Ca2+, toxic leading to:

  • hyper-excitability (seizures)
  • cell death (atrophy)
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26
Q

What is Acamprosate?

A

drugs used to help people remain abstinent (reduced NMDA function)
- potentially neuroprotective (reduction in MRS glutamate)

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27
Q

What are the models of addiction?

A
  • reward deficiency (positive reinforcement)
  • overcoming adverse state (negative reinforcement)
  • impulsivity/compulsivity
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28
Q

What is the neurobiology behind a withdrawal state?

A

In the absence of alcohol, GABA and glutamate are no longer in balance

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29
Q

Why are drugs addictive?

A
  • increase the levels of dopamine

- activates the: ‘pleasure-reward-motivation’ system

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30
Q

What is a key modulator of the ‘pleasure-reward-motivation’n system

A
  • mu opioid system

- mediates the pleasurable effects of drugs

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31
Q

What is the biological mechanism of cocaine and amphetamine?

A
  • block dopamine re-uptake

- amphetamine: enhances the release of dopamine

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32
Q

What is the biological mechanism of other drugs (alcohol, opiates, nicotine)

A

Increase dopamine firing in the VTA (ventral tegmental area)

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33
Q

What are the possible impacts of dopamine D2 receptor levels on reinforcing responses?

A
  • low D2 levels may predispose those to enjoy drugs

- high D2 levels may be protective

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34
Q

What is the impact of addiction on the reward system?

A
  • blunted activation of the reward system (in abstinent addicts) due to the increased tolerance
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35
Q

What is the impact of a blunted response in the brain to reward anticipation?

A
  • more likely to relapse
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36
Q

What region of the brain is involved in binge/intoxication?

A
  • Dorsal Striatum
  • Thalamus
  • DGP
  • VGP
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37
Q

What is the region of the brain involved in the withdrawal/negative effect?

A
  • hypothalamus
  • brainstem
  • effectors (autonomic, somatic, neuroendocrine)
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38
Q

What regions of the brain are involved in preoccupation/anticipation?

A
  • pre-frontal cortex
  • hippocampus
  • BLA
  • Insula
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39
Q

What happens to the models of addiction as the addiction develops?

A

Changes from positive to negative reinforcement

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40
Q

What are the targets for treatment?

A

The brain regions associated with withdrawal

  • the ‘reward’ system
  • the ‘stress’ system
  • the amygdala
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41
Q

What is the impact of withdrawal and negative emotional states on the ‘reward’ system?

A
  • reduced dopamine

- reduced mu opioid function

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42
Q

What is the impact of withdrawal and negative emotional states on the ‘stress’ system?

A

increased activity in:

  • kappa opioid (dynorphin)
  • noradrenaline (arousal system)
  • CRF (stress)
  • etc…
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43
Q

What is the impact of withdrawal and negative emotional states on the amygdala?

A

leads to dysregulation

44
Q

How do you assess amygdalar function with an fMRI?

A
  • emotional processing of aversive images

- select neutral and aversive images (NO DRUGS/ALCOHOL)

45
Q

What are the general trends found in amygdala function?

A
  • high brain response (to aversive images) in the left amygdala in abstinent drug addicts but not in alcoholism
46
Q

What parts of the brain are involved in the transition from voluntary drug use to compulsive drug use?

A
  • prefrontal to striatal control over drug taking
    (prefrontal top-down control is diminished with greater striatal reward drive)
  • ventral (limbic or emotional ) to dorsal (habit) striatum
47
Q

What is the effect of time on the region of control of drug use?

A

the longer time abstinent, the greater the response of the frontal pole/inferior frontal gyrus

48
Q

What do you use benzodiazepines to treat?

A

Alcohol withdrawal

49
Q

What do you use naltrexone (opioid antagonist) to treat?

A

to block heroin use in opioid addicts, to modulate reward system in alcoholism

50
Q

What is the public health guidance for treating drug abuse?

A
  • community based interventions

- healthcare workers to recognise the signs of drug abuse

51
Q

What are synthetic cannaboid receptor agonists (SCRAs)?

A

eg: spice: 100 x more potent than THC

52
Q

What is important to remember with Novel Psychoactive Substances?

A
  • packets may not have the same contents batch to batch
  • may be misleadingly named
  • new products appear regularly
  • use internet to check contents
  • unlikely to show up on usual/standard drug tests
53
Q

What is the minimum score on the ICD-10 diagnostic criteria for dependency?

A

3/6

54
Q

What is the CAGE screening?

A
  • Have you ever felt the need to Cut your drinking?
  • Have people Annoyed you by criticising your drinking?
  • Have you ever felt Guilty about drinking?
  • Have you ever felt the need to drink in the morning (Eye-opener) to steady nerves/get rid of a hangover?
55
Q

What screening can be done to assess addiction?

A
  • ICD-10
  • CAGE
  • MSE
  • DRUGS: blood-transmissible diseases (screen for)
56
Q

What are the symptoms of withdrawal?

A
  • shivering
  • goosebumps
  • nausea
  • vomiting
  • bone ache (heroin
  • sweating
57
Q

Why is it important to objectively observe withdrawal?

A
  • administrating drugs for withdrawal while simultaneously high can lead to OD
    LOOK FOR:
  • constricted pupils (heroin and opiates)
  • dilated pupils (stimulants and alcohol)
58
Q

Why do veins get worse with frequent injected heroin use?

A
  • heroin mixed with ascorbic acid to break down before injection
  • acids directly injected in the vein is highly damaging and causes vein collapse
59
Q

What are the main symptoms mentioned on the COWS (clinical opiate withdrawal scale)?

A
  • tachycardia
  • sweating
  • restlessness
  • dilated pupils
  • bone aches
  • runny nose
  • GI upset
  • tremor
  • yawning
  • anxiety/irritability
  • gooseflesh skin
60
Q

Changes made by DSM-5 to classification:

A

Dimensional approach:
2-3: mild opioid use disorder
4-5: moderate opioid use disorder
>6: severe opioid use disorder

61
Q

What is in the standard history for substance abuse?

A
  • presenting complaint + history
  • psychiatric history
  • medical history
  • medication + allergies
  • family history
  • personal history
  • permorbid history
  • risk assessment
62
Q

What is the requirements of the substance misuse history?

A

Must be repeated for each separate substance

63
Q

What is included in a substance misuse history?

A
  • length of use, last taken?
  • current amount (units, grammes/day), how long taking this much?
  • method of use
  • total length of use, max use and periods of abstinence
  • evidence of withdrawals + severity
  • previous treatments
  • previous substance OD (accidental or deliberate)
  • assess triggers of use
  • assess motivation to change
64
Q

What is important to be aware of when helping someone in withdrawal?

A

whether there is a history of seizures?

- if yes, close monitoring necessary?

65
Q

What developmental disorder has a high link with addiction?

A

ADHD, due to high impulsivity

- 25% of SUDs have co-morbid ADHD

66
Q

What can cause drug-induced psychosis?

A

Almost EVERYTHING
Stimulants (crack, methamphetamine)
Mainly: Cannabis (THC paranoia, counteracted by CBD)
EG: skunk, high THC, low CBD

67
Q

What are specific aspects of an assessment for alcohol?

A 
Examination:
- jaundice
- anaemia
- clubbing 
- cyanosis
- oedema
- ascities 
- lymphodenopathy
- DVT
Investigation:
- US/Fibro scan
- Bloods (LFT, GGT, Lipids, U&E, amylase)
- breathalyser
- urine drug screen
68
Q

What are specific aspects of an assessment for IV drug use (opioids)?

A 
Examination:
- collapsed veins
- endocarditis 
- skin abscesses
- hepatitis/HIV
- pneumonia
Investigations:
- Bloods (LFT, U&E, GGT, Glucose)
- Breathalyser
- Urine Drug Screen
- BBV
- STI screening
69
Q

How big of a problem is alcohol?

A
  • 30% of UK drink above safe limits
  • 25% have had a drinking problem
  • 15-24yo highest use
70
Q

What is the progression of withdrawal?

A
  • minor withdrawal symptoms (fever, agitation, nausea, tremulousness)
  • alcoholic hallucinations
    (visual and auditory hallucinations, tactile disturbances)
  • withdrawal seizures
    (2 hours after cessation, rare after 48 hours)
  • Delirium Tremens
    (auditory and visual hallucinations, confusion, disorientation, hypertension, tachycardia >100/min, fever, severe tremor)
71
Q

What are opiates?

A

natural opioids (morphine, codeine - to a certain extent heroin)

72
Q

What are opioids?

A

All natural, semi-synthetic and synthetic opioids

73
Q

What is important about Harmful Use and Dependence?

A

A patient can not have a diagnosis of BOTH harmful use and dependence

74
Q

What should be included in a past psychiatric history for addiction?

A
  • history of trauma?
  • neglect or abuse?
  • family substance abuse?
  • education?
  • development?
  • ADHD? (25%)
  • Depression (15%-community, 32% - alcohol treatment, 43% - drug treatment)
  • Anxiety (17%)
  • Suicidality (6 x risk)
  • Personality disorder
  • PTSD
  • BPD
75
Q

What does drug-induced psychosis often include?

A

during or immediately after substance use

  • vivid hallucinations, often auditory
  • paranoid delusions (severe)
  • resolves in 1-6 months
76
Q

What needs to be taken into account when diagnosing drug induced psychosis?

A
  • misdiagnosing a schizophrenic episode as psychosis (may be triggered by substance use)
77
Q

What should be accounted for in a personal/social history?

A
  • relationships?
  • safeguarding?
  • accommodation?
  • money, debt?
  • employed?
  • forensic history?
78
Q

What are the main causes to morbidity and mortality associated with substance abuse?

A
  • trauma
  • road accidents
  • homocide
  • suicide
  • OD
  • cirrhosis (alcohol)
  • endocarditis (IV)
  • Abscesses (IV)
  • BBV (IV), vaccinated?
79
Q

What does Delirium Tremens represent?

A
  • medical emergency
  • 5% prevalence, 15-20% mortality
  • admission for 24 hours and observation highly
80
Q

What are the risk factors of developing Delirium Tremens?

A
  • heavy daily alcohol use (60+ units)
  • history of DTs
  • older age
  • abnormal LFTs
81
Q

What are examples of natural opioids (opiates)?

A
  • opium
  • morphine
  • codeine
  • thebaine
82
Q

What are examples of synthetic opioids?

A
  • fentanyl (100 x morphine)
  • pethidine
  • methadone
  • tramadol
83
Q

What are examples of semi-synthetic opioids?

A
  • heroin (2 x morphine)
  • hydrocodone
  • oxycodone
  • hydromorphone
84
Q

What do opioids do?

A
  • analgesia

- euphoria

85
Q

What are opioid receptors mu, delta and kappa effected by?

A 
Opioid agonists:
- heroin
- fentanyl
- methadone
- codeine
Partial agonists:
- buprenorphine
Antagonists:
- naltrexone
86
Q

What apart from opioids (exogenous drugs) regulate pain and mood?

A

endogenous endorphins

87
Q

What are the symptoms of opiate overdose?

A
  • unconscious
  • slow/no breathing
  • choking, gurgling or snoring
  • tiny pupils
  • clammy/cold skin
  • blue lips and nails
88
Q

How do you treat an opiate overdose?

A 
Naloxone
- inject in upper arm or thigh
- nasal spray: 50% each nostril
If no response after 3 minutes, repeat
(airway support, recovery position)
89
Q

What medications are used to support abstinence from alcohol?

A
  • Acamprosate
  • Disulfiram (Antabuse)
  • Naltrexone
  • Nalmefene
90
Q

How does Acamprosate work?

A
  • Increases GABA< NMDA antagonist
  • 333-666mg TDS
  • possible neuroprotective role during withdrawal
91
Q

How does Disulfiram (Antabuse) work?

A
  • 200-500mg daily

- inhibits acetaldehyde dehydrogenase, leads to nausea/flushes if mixed with alcohol

92
Q

How does Naltrexone work?

A
  • 50mg daily

- Used in other dependencies (opioids, G-drugs, methamphetamine)

93
Q

How does Nalmefene work?

A
  • opioid inverse agonist
  • 18mg PRN (single daily dose) on days with high drinking risk
  • for those dependent but without withdrawal, reduce alcohol intake
94
Q

What drugs are used for detox regimes for alcohol abuse?

A
  • benzodiazapines

- chlorodiazepoxide

95
Q

How does Chlorodiazepoxide (Librium) work?

A
  • both inpatient and community
  • 20-40mg QDS, reducing over 7-10 days
  • Thiamine (B12), Folate
96
Q

What drugs are used for abstinence from opioids?

A
  • methadone
    (60-120mg, maintenance dose)
  • buprenorphine
    (12-14mg, maintenance dose)
97
Q

What drugs are used in detox regimes from opioids?

A
  • maintenance treatment (methadone and buprenorphine)
  • at least 12 months to sustain lifestyle changes
  • then, dose reduction over several months
98
Q

What drugs are used to treat benzodiazepine dependence?

A

maintenance on diazepam, reducing regime of 1mg/week, but difficult to wean off of

GPs reluctant to prescribe, therefore remain in addiction services for addiction

99
Q

What drugs are used to support a detox regime from benzos/g-drugs?

A
  • medical supervision
  • community, but inpatient access required
  • baclofen (GABA agonist)
  • benzos used
100
Q

What are G-drugs?

A
  • GHB (gamma hydroxybutyrate)

- GBL (gamma butyrolactone)

101
Q

What is GHB?

A
  • clear, oily liquid
  • onset: 15-20 minutes
  • lasts: 3-4 hours
102
Q

What is GBL?

A
  • precursor to GHB

- converted after swallowing

103
Q

What is a massive contraindication of G-drugs?

A
  • alcohol

- can lead to death

104
Q

What do G-drugs do?

A
  • depressants
  • high produced with low dosage
  • sedation with slightly high dosages
  • euphoria
  • inhibition loss
  • increased confidence
  • increased sex drive
105
Q

What are the risks of G-drugs?

A
  • easy to OD, <1ml difference between high and unconsciousness
  • highly addictive, leads to dependence (every 1-3 hours)

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