Substance use and addiction Flashcards
What is meant by “intoxication”?
In both the DSM and ICD, intoxication is considered to be a transient syndrome due to recent substance ingestion that produces clinically significant psychological or physical impairment. These changes disappear when the substance is eliminated from the body
What is meant by “withdrawal state”?
This refers to a group of symptoms and signs that occur when a drug is reduced in amount or withdrawn entirely
What is meant by “tolerance”?
This is a state in which after repeated administration, a drug produces a decreased effect. Increasing doses are therefore required to produce the same effect
How would you define a drug of abuse?
The use of illegal drugs or the use of prescription or over-the-counter drugs for purposes other than those for which they are meant to be used, or in excessive amounts
definition from slides:
A pattern of substance use that has caused damage to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others
Eg depression, anxiety, liver problems, high blood pressure, aggression
What are examples of drugs of abuse?
- Alcohol
- Nicotine
- Cannabis
- Stimulants:
- Amphetamine
- Cocainn/ Crack
*Ecstasy - Opioids (prescribed, OTC):
- Heroin, fentanyl
- DF118
- Ketamine
- Solvents
- GHB, GBL
- Benzodiazepines
- Psychedelics:
- LSD, Magic mushrooms
- Nitrous oxide
- Khat
- ‘Novel psychoactive substances’
List reasons why someone would take a drug for ‘recreational use’?
- Rebel
- To fit in
- Everyone does
- Curious
- Why not
1. Positive reinforcement: Wanting to get something from the drug - get high
- escapism
- like it
- stay awake
2. Negative reinforcement: Wanting the drug to overcome something - Reduce anxiety
- Boredom
- Feel better
- To get to sleep
Describe the course of alcohol/ drug use, to harmful use to addicition
- Starts as experimental/‘recreational’ use, causes no/limited difficulties (majority of population)
- shifts to increasingly regular use (fewer people) harmful
NOTE: people can shift back into more recreational use with no issues (b/t the first 2) - Finally turns into spiralling: dependence
(smaller number)
NOTE: once someone has become dependent, can’t usually get control/stop - Shift in motivational desire from like -> want -> need
- Can be caused in specific events/ environments
What is meant by “Harmful substance use” according to the ICD-10?
- A pattern of substance use that causes damage to health.
- The damage may be: (1) physical or (2) mental (This criterion MUST be present if harmful use is diagnosed)
- Adverse social consequences
- Harmful use includes bingeing on substances. Does not include ‘hangover’ alone
- Does not fulfil any other diagnosis within substance use e.g. dependence: A client/patient CANNOT have a diagnosis of BOTH harmful use AND dependence
What is meant by “Harmful substance use” according to ICD-11?
New from ICD-10:
What remains same?
- Distinction between substance dependence and harmful use is preserved
Harmful Use= A new category to denote single episodes of harmful use from a pattern of harmful use
* Harmful use also now includes: Harm to health of others. This includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour related to substance use on the part of the person to whom the diagnosis of Harmful pattern of use of the substance/alcohol applies
What is meant by “dependence syndrome” according to the ICD-10 criteria?
- 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 (can’t stop/ take more than you want to take):
* who has control, you or ‘the drug/behaviour’?
* when did you last have a drink/drug? (even if a patient hasn’t had the drink/ drig in a while they still don’t have control when they do- binge on/ off) - a physiological withdrawal state when substance use has stopped or been reduced:
* a ‘negative’ state (from uncomfortable to intolerable) so user takes drug/alcohol to ger relief from it or ‘treat’ it - evidence of tolerance: need to take more to get same effect (body has adapted to it)
- progressive neglect of alternative interests
- persisting with substance use despite clear evidence of overtly harmful consequences
What is meant by “addicition”?
Addiction - compulsive drug use despite harmful consequences, characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, (depending on the drug) tolerance and withdrawal.
What is meant by “addiction”?
Addiction - compulsive drug use despite harmful consequences, characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, (depending on the drug) tolerance and withdrawal.
What is meant by “dependence”?
In biology/pharmacology, dependence refers to a physical adaptation to a substance
- Tolerance/withdrawal (Eg opioid, benzodiazepine, alcohol)
- So can be dependent and not addicted
Gambling disorder and internet gaming disorder are classified as behavioural addictions, true or false?
TRUE:
gambling disorder- Reclassified as behavioural addiction in DSM-5/ICD-11 from an ‘impulse control disorder’ previously.
internet gaming disorder:
- added to ICD-11 under addictive disorders
- in the DSM-5 is under “Conditions for Further Study
What is the difference between hazardous use and harmful use?
Hazardous= a quantity or pattern of alcohol consumption/ drug use that places individuals at risk for adverse health event
harmful= alcohol consumption/ drug use that results in physical, social or psychological harm
What affect does brain entry have on addicition?
Faster brain entry (reaching the brain, crossing the blood-brain barrier, lipophylic) = more addiction
What elements are involved in alcohol/ drug use and addiction?
- Social, environmental factors
- Drug factors
- Personal factors (e.g. genetic, personality traits)
Describe how to brain goes from use to addicition
Risk factors: pre-exisiting vulnerability, family history and age (younger- brain not fully developed= increased vulnerability)
- can lead to drug exposure= Compensatory neuroadaptations to maintain brain function (use becomes chronic)
- can lead to resilience
- can either cause:
1. sustained recovery
2. cycles of remission and relapse (esp if dependent)
How can drinking help people get more sleep/ reduce anxiety?
Acute alcohol consumption alters the balance between brain’s inhibitory and excitatory system, boosting the inhibitory system and blocking the excitatory:
1. Alcohol targets the NMDA receptor; alters the coupling (alters some of the modulatory sites) to block excitatory system:
- Impaired memory (alcohol blackout)
2. Alcohol enhances the activity of benzodiazepine- GABA coupling; makes it more effective at inhibitory activity
- Anxiolysis
- Sedation
How does chronic alcohol exposure affect the brains inhibitory and excitatory systems?
Chronic alcohol exposure results in neuroadaptations so that GABA & glutamate remain in balance in presence of alcohol:
- Upregulation of excitatory system
- Reduced function in inhibitory system - tolerance
How does alcohol absence, following chronic alcohol exposure affect the brains inhibitory and excitatory systems?
Chronic alcohol exposure results in neuroadaptations: in absence of alcohol GABA & glutamate are no longer in balance – withdrawal state:
- Upregulation of excitatory system:
* NMDA receptor: increase in Ca2+
* toxic leading to hyperexcitability (seizures) and cell death (atrophy)
- Reduced function in inhibitory system
How are withdrawal symptoms of alcohol treated?
- Treat with benzodiazepines to boost GABA function
Treated with lorazepam / diazepam (benzodiazepines) - Acamprosate is a medication to help people remain abstinent – it reduces NMDA function
Addiction has been conceptualized as a ‘reward deficient’ state, how can addiction increase rewards?
- Natural rewards such as food, sex increase levels of a chemical – dopamine - dopaminergic projections in the brain stem in the central tegmental area and project into the ventral striatum & front cortex
- Drugs of abuse also increase levels of dopamine here.
- This dopamine pathway has been referred to as the ‘pleasure-reward-motivation’ system
- A key modulator is opioid system
- particularly mu opioid that mediates pleasurable effects (eg of alcohol, ‘endorphin ‘rush’); others include GABA-B, cannabinoids, glutamate etc that are targets for treatment
- As you graduate into dependence dopamine system goes from being about pleasure/ reward to motivation to get more drugs
- Addiction has been conceptualized as a ‘reward deficient’ state
Describe the interaction between substances of abuse and dopamine
NORMALLY:
1. dopamine is released
2. attaches onto post-synaptic receptors
3. Re- uptake occurs back to the pre-synaptic cell
*Cocaine, Amphetamine block re- uptake: increasing dopamine in the synapse
* Amphetamine enhances release of dopamine
* Other drugs of abuse eg alcohol, opiates, nicotine increase dopamine neuron firing in VTA
What is the relationship between dopamine and “liking” drugs?
Studies suggest that low levels of D2 receptors predispose subjects to use drugs
- PET scans show that patients who had high D2 receptor availability, did not find pleasure from the stimuli
- This meant that patients with low dopaminergic function in their natural pleasure- reward system, were more likely to take a drug to increase their feelings of pleasure
- Also reward deficiency can lead to vulnerability to problematic drug use: Novelty seeking adolescents who develop problematic drug use (PDU) aged 16, show blunted brain activation in striatum
- in abstinent addicts, those with blunted response in the brain to ‘anticipation of reward’ are more likely to relapse (treatment attempts to reverse this blunted effec)
What regions of the brain are involved in bige/ intoxication?
- Thalamus
- Ventral globus pallidus & dorsal globus pallidus
- Dorsal striatum
What regions of the brain are involved in withdrawal/ negative affect?
- Brainstem
- amygdala
What regions of the brain are involved in preoccupation/ anticipation “craving”?
- Insula
- Basolateral amygdala
- Hippocampus
- Prefrontal cortex
How does motivation for drug use change as addiction/ dependence develops?
- Change from positive to negative reinforcement as addiction/dependence develops.
- pleasure from the drug decreases, as the patients become more fearful/ aggressive to get their drug (want turns to need)
- your affective state/ the “high” decreases but the withdrawal/ negative affect gets worse
Which systems and brain regions associated with withdrawal and negative emotional states in addiction?
Dyregulation of amygdala is key:
1. The ‘reward’ system: reduced dopamine and mu opioid function
2. The ‘stress’ system: increased activity in many including kappa opioid (dynorphin- kappa system is the complete opposite to the u opioid and endorphin rush), noradrenaline (arousal system) CRF (stress) etc
What is the kappa system?
Kappa= disphoric/ unpleasant state
How is amygdala function tested?
Emotional processing of aversive images + fMRI scan:
- patients select which photos are “neutral” and “aversive” from photo library
How can compulsion develop?
- Change from voluntary drug use to more habitual and compulsive drug use involves transition from:
- prefrontal to striatal control over drug taking: i.e. prefrontal ‘top-down’ control is diminished with greater striatal reward drive
- ventral (limbic or emotional) to dorsal (habit) striatum (area involved in Parkinson’s habits
- Role for ‘memory’ (eg hippocampus) in craving
What is abstinence?
If an individual does not engage in the addictive behavior at all, either indefinitely or for a short period of time
What are the components of history taking in addiction?
- Presenting Complaint (PC) – Snapshot of main problem/s
- History of PC (HPC) – Length of current problem/s, onset, causes, signs and symptoms etc
- Substance Misuse History - The following areas should be assessed for each substance:
- Length of current use and when last used
- Current amount (units/grams per day) and for how long at this level
- Total length of use, maximum use and any periods of abstinence
- Mode/method of administration
- Evidence of withdrawal syndrome and severity (e.g. seizures, admissions)
- Any previous treatments - medication, psychotherapy, detox/rehab admissions
- Any previous substance overdoses (accidental vs deliberate)
- Assess triggers to use substances/alcohol
- Assess motivation to change/engage in treatment - Family History – Include mental illnesses and addiction disorders
- Past Psychiatric History:
- Consider the presence of previous trauma including domestic violence, neglect and abuse (this feeds in to risk assessment)
- Screen for developmental disorders especially ADHD - Personal History:
- Relationships – partner, family, children (violence?)
- Safeguarding concerns?
- Accommodation problems?
- Money and debt?
- Employed / Benefits
- Forensic history – cautions, convictions, time served, funding of habit, ongoing court cases - Past Medical History
Harmful use/ dependent are terms that are no longer used, true or false?
TRUE: renamed to “opioid use disorder” adm “alcohol use disorder”
- terms of abuse or dependence no longer used
Describe the absorption of alcohol
Alcohol is well absorbed from the mouth, stomach and small bowel and maximum blood concentration is reached within 60 minutes of ingestion. (This is why you need to wait an hour after drinking before driving) Alcohol absorption is slowed by food and sped up by the ingestion of effervescent drinks. It is hydrophilic and therefore widely distributed in all bodily tissues
Describe the metabolism of alcohol in the body
- Ethanol is oxidised by alcohol dehydrogenase to acetaldehyde.
(The accumulation of acetaldehyde= flushing, withdrawal symptoms) - This is oxidised by acetaldehyde dehydrogenase to carbon dioxide and water.
(This enzyme is different in different people; some people feel the effects of alcohol more than others, treatment targets this enzyme) - 98% of alcohol metabolism occurs in the liver and 1 unit of alcohol (8g) can be metabolized per hour. Illicit brew may contain methanol which is broken down to formaldehyde and causes marked toxicity on the retina
What are the aspects of alcohol assessment?
Examination:
Jaundice, bruising, clubbing, oedema, ascites, spider naevi
Neurological signs – Consider Wernicke’s encephalopathy (ataxia, confusion, ophthalmoplegia- weakness in the eye muscles but reversible) and Korsakoff’s syndrome (memory impairment)
Investigations:
Liver Fibro scan / Ultrasound
Bloods (LFT, GGT, Lipids, U&E, amylase)
Breathalyser
Urine Drug Screen
What alcohol assessment tool is used?
CAGE screening:
Questions asked + scoring system from 0-4, total audit score calculated
- Scoring:
0 to 7 indicates low risk
8 to 15 indicates increasing risk
16 to 19 indicates higher risk
20 or more indicates possible dependence
Provide feedback & advice if the score is 8 or above
Why is alcohol withdrawal more dangerous than opiate withdrawal?
- Worsening pattern of symptoms
- Onset usually from 6 hours
- Hallucinations can occur any time
- Delirium tremens is a late sign and a medical emergency
What is the difference between “opiates” and “opioids”?
Opioidsrefer to all natural, semisyntheticandsyntheticopioids, whereas
Opiatesrefer only to naturalopioidssuch as morphineandcodeine and heroin to some extent
What do opioids do?
- Relieve pain – ANALGESIC effect
- Create a sense of EUPHORIA
- Opioid receptors mu, delta, kappa effected by opioid agonists (heroin, methadone, fentanyl, codeine), partial agonists (Buprenorphine), antagonists (Naltrexone)
What are the aspects of opiate assessment?
Examination
Collapsed veins / track marks
Endocarditis (murmurs, splinter haemorrages)
Skin abscesses
Hepatitis / HIV
Pneumonia
Investigations:
Bloods (FBC, LFT, U&E, GGT, Glucose, CRP, BBB viral screen)
Breathalyser
Urine Drug Screen
Blood cultures (endocarditis)
How is opiate withdrawal tested?
COWS= Clinical opiate withdrawal scale
What are the symptoms of opioid withdrawal?
Tachycardia
Sweating
Restlessness
Dilated pupils
Bone pain
Rhinorrhoea
Dirrahoea
Abdominal pain
Tremor
Yawning
Anxiety/Irritability
Gooseflesh skin
What are the signs of opiate overdose and how is it treated?
- Not moving and can’t be woken up
- Slow or no breathing
- Chocking, gurgling sounds or snoring
- Tiny pupils
- Clammy or cold skin
- Blue lips and blue nails
Naloxone: (narcan)
inject into upper arm or thigh (400mcg), or nasal
spray (50% each nostril). If no response after 3 mins,
Repeat. Provide airway support, recovery position
