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 for dependance syndrome?
- strong compulsion to take the substance
- difficulties in controlling substance taking behaviour
- 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
How many of the ICD-10 criteria must be met to be diagnosed with dependance sydnrome?
3 or more symptoms
What classifies as hazardous use?
Likely to cause harm if use continues at this level
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
- inability to stop using a drug
- failure to meet personal, or professional obligations
- 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
- internet gaming disorder
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: can lead to cycles of remission and relapse
What controls the brain’s excitatory system?
Glutamate acting on the NMDA receptor
What controls the brain’s inhibitory system?
GABA acting on GABA-A receptors
What does alcohol do to the brain acutely?
- blocks excitatory system causing memory impairment
- boosts inhibitory system causing anxiolysis and sedation
What are the neuroadaptations from chronic alcohol use?
- increased number of NMDA receptors
- decreased inhibitroy function leading to tolerance
What happens to the brain in alcohol withdrawal?
- increased calcium influx causes hyperexcitability leading to withdrawal seizures
- cell death
- GABA function is reduced
How do you treat the neuroadaptation causing reduced function in the inhibitory system?
- benzodiazepines to boost GABA function
- acamprosate to reduce NMDA function
What are some examples of benzodiazapenes?
- lorazepram
- diazepram
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 the route of dopamine release that leads to positive reinforcment
From the ventral tegmental area (VTA) to the ventral striata
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 from the VTA
What are the possible impacts of dopamine D2 receptor levels on reinforcing responses? (Reward deficiency theory)
- low D2 levels (reward deficient) 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?
dysregulation in the amygdala
What regions of the brain are involved in impulsivity/compulsivity?
- control in drug taking switches from pre-frontal to striatal
- ventral (emotional) to dorsal (habitual) striatum
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 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 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 and 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 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)
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 alcohol 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 are the symptoms of delerium tremens?
- hallucinations
- confusion and disorientation
- hypertension
- agitation
- tachyardia
- fever
- severe tremor in hands and body
What is the epidemiology of delerium tremens?
- 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 and 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 the three levels of problems to look for in substance abuse?
- Hazardous use - increased quantity or frequency of use
- Harmful use - using drugs despite their negative physical, psychological or social impact
- Dependence/addiction - tolerance and withdrawal
