Substance Use and Addiction Flashcards
What are the main three things to flag for abuse?
- quantity/frequency
- consequences (physical, psychological, social impact)
- dependence/addiction
What are the main red flags for dependence?
- tolerance and morning drinking
- withdrawal
What are the different types of stimulants?
- amphetamine
- cocaine (crack)
- ecstacy
What are ‘novel psychoactive substances’?
- new 1/week
- tend to be synthetic
- can be put into 4 categories: depressant, stimulant, hallucinogenic, cannaboid
Why is it important to know why drugs are being used?
Because it informs treatment
What is positive reinforcement (drugs)?
drugs are used to gain a positive state
What is negative reinforcement?
drugs are used to overcome an adverse state
What is the course of drug addiction?
- 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
What is the ICD-10 diagnostic criteria?
- 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
What classifies harmful use?
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
What is the estimated prevalence of alcohol dependence?
595,000 people
only 103,471 in treatment, 82% not receiving treatment
What is the estimated prevalence of opiate dependence?
257,476 people
170,032 in treatment, 46% not receiving treatment
What has been the impact of COVID-19 on alcohol and opiate dependency?
100% more people are at high risk
20% more cases
What is the definition of Addiction?
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
What is the definition of Dependence?
A physical adaptation to a substance
- tolerance/withdrawal
(can be dependent but not addicted)
What are some examples of behavioural addictions ?
- gambling disorder
(similar: neurobiology, treatment and co-morbidity and substance dependence) - internet gaming
What causes a larger ‘rush’ and addiction?
faster brain entry/onset
crosses the blood-brain barrier, lipophylic
What are the 3 main elements involved in alcohol/drug use and addiction?
- Social, environmental factors
- Personal factors (genetic)
- Drug factors
What are the changes to the brain pre and post addiction?
- pre-existing vulnerabilities, age and family history
- exposure leads to compensatory neuroadaptations to maintain brain function
- recovery: lead to cycles of remission and relapse
Why drink alcohol?
Alters the balance between the brain’s inhibitory (GABA-A, glutamate system) and excitatory system (glutamate system, NMDA receptor)
What impact does alcohol have on the excitatory system?
Blocks the excitatory system
- Impaired memory (alcoholic blackouts)
What is the impact of alcohol on the inhibitory system?
Stimulates the glutamate system
- anxiolysis
- sedation
What are the neuroadaptations caused by chronic alcohol exposure?
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)
How do you treat the neuroadaptation causing reduced function in the inhibitory system?
-benzodiazepines, to boost GABA function
What does the up-regulation of the excitatory system cause?
Increase in Ca2+, toxic leading to:
- hyper-excitability (seizures)
- cell death (atrophy)
What is Acamprosate?
drugs used to help people remain abstinent (reduced NMDA function)
- potentially neuroprotective (reduction in MRS glutamate)
What are the models of addiction?
- reward deficiency (positive reinforcement)
- overcoming adverse state (negative reinforcement)
- impulsivity/compulsivity
What is the neurobiology behind a withdrawal state?
In the absence of alcohol, GABA and glutamate are no longer in balance
Why are drugs addictive?
- increase the levels of dopamine
- activates the: ‘pleasure-reward-motivation’ system
What is a key modulator of the ‘pleasure-reward-motivation’n system
- mu opioid system
- mediates the pleasurable effects of drugs
What is the biological mechanism of cocaine and amphetamine?
- block dopamine re-uptake
- amphetamine: enhances the release of dopamine
What is the biological mechanism of other drugs (alcohol, opiates, nicotine)
Increase dopamine firing in the VTA (ventral tegmental area)
What are the possible impacts of dopamine D2 receptor levels on reinforcing responses?
- low D2 levels may predispose those to enjoy drugs
- high D2 levels may be protective
What is the impact of addiction on the reward system?
- blunted activation of the reward system (in abstinent addicts) due to the increased tolerance
What is the impact of a blunted response in the brain to reward anticipation?
- more likely to relapse
What region of the brain is involved in binge/intoxication?
- Dorsal Striatum
- Thalamus
- DGP
- VGP
What is the region of the brain involved in the withdrawal/negative effect?
- hypothalamus
- brainstem
- effectors (autonomic, somatic, neuroendocrine)
What regions of the brain are involved in preoccupation/anticipation?
- pre-frontal cortex
- hippocampus
- BLA
- Insula
What happens to the models of addiction as the addiction develops?
Changes from positive to negative reinforcement
What are the targets for treatment?
The brain regions associated with withdrawal
- the ‘reward’ system
- the ‘stress’ system
- the amygdala
What is the impact of withdrawal and negative emotional states on the ‘reward’ system?
- reduced dopamine
- reduced mu opioid function
What is the impact of withdrawal and negative emotional states on the ‘stress’ system?
increased activity in:
- kappa opioid (dynorphin)
- noradrenaline (arousal system)
- CRF (stress)
- etc…
What is the impact of withdrawal and negative emotional states on the amygdala?
leads to dysregulation
How do you assess amygdalar function with an fMRI?
- emotional processing of aversive images
- select neutral and aversive images (NO DRUGS/ALCOHOL)
What are the general trends found in amygdala function?
- high brain response (to aversive images) in the left amygdala in abstinent drug addicts but not in alcoholism
What parts of the brain are involved in the transition from voluntary drug use to compulsive drug use?
- 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
What is the effect of time on the region of control of drug use?
the longer time abstinent, the greater the response of the frontal pole/inferior frontal gyrus
What do you use benzodiazepines to treat?
Alcohol withdrawal
What do you use naltrexone (opioid antagonist) to treat?
to block heroin use in opioid addicts, to modulate reward system in alcoholism
What is the public health guidance for treating drug abuse?
- community based interventions
- healthcare workers to recognise the signs of drug abuse
What are synthetic cannaboid receptor agonists (SCRAs)?
eg: spice: 100 x more potent than THC
What is important to remember with Novel Psychoactive Substances?
- 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
What is the minimum score on the ICD-10 diagnostic criteria for dependency?
3/6
What is the CAGE screening?
- 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?
What screening can be done to assess addiction?
- ICD-10
- CAGE
- MSE
- DRUGS: blood-transmissible diseases (screen for)
What are the symptoms of withdrawal?
- shivering
- goosebumps
- nausea
- vomiting
- bone ache (heroin
- sweating
Why is it important to objectively observe withdrawal?
- administrating drugs for withdrawal while simultaneously high can lead to OD
LOOK FOR: - constricted pupils (heroin and opiates)
- dilated pupils (stimulants and alcohol)
Why do veins get worse with frequent injected heroin use?
- heroin mixed with ascorbic acid to break down before injection
- acids directly injected in the vein is highly damaging and causes vein collapse
What are the main symptoms mentioned on the COWS (clinical opiate withdrawal scale)?
- tachycardia
- sweating
- restlessness
- dilated pupils
- bone aches
- runny nose
- GI upset
- tremor
- yawning
- anxiety/irritability
- gooseflesh skin
Changes made by DSM-5 to classification:
Dimensional approach:
2-3: mild opioid use disorder
4-5: moderate opioid use disorder
>6: severe opioid use disorder
What is in the standard history for substance abuse?
- presenting complaint + history
- psychiatric history
- medical history
- medication + allergies
- family history
- personal history
- permorbid history
- risk assessment
What is the requirements of the substance misuse history?
Must be repeated for each separate substance
What is included in a substance misuse history?
- 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
What is important to be aware of when helping someone in withdrawal?
whether there is a history of seizures?
- if yes, close monitoring necessary?
What developmental disorder has a high link with addiction?
ADHD, due to high impulsivity
- 25% of SUDs have co-morbid ADHD
What can cause drug-induced psychosis?
Almost EVERYTHING
Stimulants (crack, methamphetamine)
Mainly: Cannabis (THC paranoia, counteracted by CBD)
EG: skunk, high THC, low CBD
What are specific aspects of an assessment for alcohol?
Examination: - jaundice - anaemia - clubbing - cyanosis - oedema - ascities - lymphodenopathy - DVT Investigation: - US/Fibro scan - Bloods (LFT, GGT, Lipids, U&E, amylase) - breathalyser - urine drug screen
What are specific aspects of an assessment for IV drug use (opioids)?
Examination: - collapsed veins - endocarditis - skin abscesses - hepatitis/HIV - pneumonia Investigations: - Bloods (LFT, U&E, GGT, Glucose) - Breathalyser - Urine Drug Screen - BBV - STI screening
How big of a problem is alcohol?
- 30% of UK drink above safe limits
- 25% have had a drinking problem
- 15-24yo highest use
What is the progression of withdrawal?
- 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)
What are opiates?
natural opioids (morphine, codeine - to a certain extent heroin)
What are opioids?
All natural, semi-synthetic and synthetic opioids
What is important about Harmful Use and Dependence?
A patient can not have a diagnosis of BOTH harmful use and dependence
What should be included in a past psychiatric history for addiction?
- 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
What does drug-induced psychosis often include?
during or immediately after substance use
- vivid hallucinations, often auditory
- paranoid delusions (severe)
- resolves in 1-6 months
What needs to be taken into account when diagnosing drug induced psychosis?
- misdiagnosing a schizophrenic episode as psychosis (may be triggered by substance use)
What should be accounted for in a personal/social history?
- relationships?
- safeguarding?
- accommodation?
- money, debt?
- employed?
- forensic history?
What are the main causes to morbidity and mortality associated with substance abuse?
- trauma
- road accidents
- homocide
- suicide
- OD
- cirrhosis (alcohol)
- endocarditis (IV)
- Abscesses (IV)
- BBV (IV), vaccinated?
What does Delirium Tremens represent?
- medical emergency
- 5% prevalence, 15-20% mortality
- admission for 24 hours and observation highly
What are the risk factors of developing Delirium Tremens?
- heavy daily alcohol use (60+ units)
- history of DTs
- older age
- abnormal LFTs
What are examples of natural opioids (opiates)?
- opium
- morphine
- codeine
- thebaine
What are examples of synthetic opioids?
- fentanyl (100 x morphine)
- pethidine
- methadone
- tramadol
What are examples of semi-synthetic opioids?
- heroin (2 x morphine)
- hydrocodone
- oxycodone
- hydromorphone
What do opioids do?
- analgesia
- euphoria
What are opioid receptors mu, delta and kappa effected by?
Opioid agonists: - heroin - fentanyl - methadone - codeine Partial agonists: - buprenorphine Antagonists: - naltrexone
What apart from opioids (exogenous drugs) regulate pain and mood?
endogenous endorphins
What are the symptoms of opiate overdose?
- unconscious
- slow/no breathing
- choking, gurgling or snoring
- tiny pupils
- clammy/cold skin
- blue lips and nails
How do you treat an opiate overdose?
Naloxone - inject in upper arm or thigh - nasal spray: 50% each nostril If no response after 3 minutes, repeat (airway support, recovery position)
What medications are used to support abstinence from alcohol?
- Acamprosate
- Disulfiram (Antabuse)
- Naltrexone
- Nalmefene
How does Acamprosate work?
- Increases GABA< NMDA antagonist
- 333-666mg TDS
- possible neuroprotective role during withdrawal
How does Disulfiram (Antabuse) work?
- 200-500mg daily
- inhibits acetaldehyde dehydrogenase, leads to nausea/flushes if mixed with alcohol
How does Naltrexone work?
- 50mg daily
- Used in other dependencies (opioids, G-drugs, methamphetamine)
How does Nalmefene work?
- opioid inverse agonist
- 18mg PRN (single daily dose) on days with high drinking risk
- for those dependent but without withdrawal, reduce alcohol intake
What drugs are used for detox regimes for alcohol abuse?
- benzodiazapines
- chlorodiazepoxide
How does Chlorodiazepoxide (Librium) work?
- both inpatient and community
- 20-40mg QDS, reducing over 7-10 days
- Thiamine (B12), Folate
What drugs are used for abstinence from opioids?
- methadone
(60-120mg, maintenance dose) - buprenorphine
(12-14mg, maintenance dose)
What drugs are used in detox regimes from opioids?
- maintenance treatment (methadone and buprenorphine)
- at least 12 months to sustain lifestyle changes
- then, dose reduction over several months
What drugs are used to treat benzodiazepine dependence?
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
What drugs are used to support a detox regime from benzos/g-drugs?
- medical supervision
- community, but inpatient access required
- baclofen (GABA agonist)
- benzos used
What are G-drugs?
- GHB (gamma hydroxybutyrate)
- GBL (gamma butyrolactone)
What is GHB?
- clear, oily liquid
- onset: 15-20 minutes
- lasts: 3-4 hours
What is GBL?
- precursor to GHB
- converted after swallowing
What is a massive contraindication of G-drugs?
- alcohol
- can lead to death
What do G-drugs do?
- depressants
- high produced with low dosage
- sedation with slightly high dosages
- euphoria
- inhibition loss
- increased confidence
- increased sex drive
What are the risks of G-drugs?
- easy to OD, <1ml difference between high and unconsciousness
- highly addictive, leads to dependence (every 1-3 hours)
