Substance use and Addictions Flashcards
Why might people take recreational drugs?
Reduce anxiety Rebel Get high Escapism Everyone does Curious to fit in Why not? Stay awake
What reasons for taking drugs are positively reinforced?
Escapism
Get high
Stay awake
Like it
What reasons for taking drugs are negatively reinforced?
Boredom
Reduce anxiety
To get to sleep
Feel better
What is the course of alcohol/drug use , harmful uses, addiction?
I like
I want
I nees
When does substance use become harmful?
damage to their physical or mental health
What is hazardous use?
Likely to cause harm if they continue
What are the ICD-10 diagnostic criteria for dependence syndrome?
Strong desire to take the substance
Difficulties in controlling onset, termination or levels of use
Physiological withdrawal state
Evidence of tolerance: need to take more to get same effect
What is addiction?
Compulsive drug use despite harmful consequences, characterised but an inability to stop using
Failure to meet work, social or family obligations
What is dependence?
Refers to adaptation to a substance
Can be dependent not addicted
e.g. opiod
What are other behavioural addictions?
gambling disorder
internet gambling disorder
How are drugs made more addictive?
Speeding up brain entry
What elements are involved in alcohol/drug use and addiction?
Social, environmental factors
Drug factors
Personal factors e.g. genetic personality traits
What is the pathway from use to addiction?
Pre-existing vulnerability Family history Age Drug exposure Tolerance Resilience Recovery sustained Cycles of remission
Why do people drink?
To get to sleep
Reduce anxiety
What does alcohol do?
Alters the balance between brain’s inhibitory and excitatory system
What happens when you acutely drink alcohol?
Boosts inhibitory system
(anxilysis and sedation)
Blocks excitatory system
(impaired memory)
What does chronic alcohol exposure result in?
Neurodaptations so GABA and glutamate remain in balance in presence of alcohol
Upregulation of excitatory system
Reduced function in inhibitory system tolerance
GABA-A receptors: switch in subunits to make less sensitive to alcohol
What happens after chronic alcohol exposure when alcohol is no longer present?
GABA and glutamate are no longer in balance - withdrawal state
NMDA receptor
increase in Ca2+
toxic leading to hyper excitability (seizure) and cell death (atrophy)
What are the models of addiction?
Rewards deficiency
Overcoming adverse state
Impulsivity/Compulsivity
What has the dopamine pathway been referred to?
pleasure-reward-motivation system
What can addiction be conceptualised as?
Reward deficient state
How can drugs of abuse modulate dopamine?
Drugs block dopamine reuptake
Increased conc in the synapse
Or increase dopamine neurone firing
How can you assess function in the reward pathway?
fMRI
Monetary incentive delay task - anticipation of winning money
Ventral striatum lights up
What are targets for treatment?
Brain regions associated with withdrawal and negative emotional states in addiction
What is the target in the reward system?
Reduced dopamine and mu opiod function
What is the target in the stress system?
Increased activity in many including kappa opioid, noradrenaline, stress etc.
What is seen on fMRI in withdrawal?
Heightened brain response in left amygdala in abstinent polydrug addicts to aversive images
What does a change from voluntary drug use to more habitual and compulsive use involve?
prefrontal to stratal control over drug taking
Ventral (limbic or emotional) to dorsal (habit) striatum
When are benzodiazepines used?
To treat alcohol withdrawal
When is acamprosate used?
To support abstinence, neuroprotection in alcoholism
When is naltrexone used?
Opioid antagonist
Block heroin use in opioid addicts and to modulate reward system in alcoholism
What is harmful use?
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
How do you classify dependence disorder?
3 or more of the following in past year:
A strong desire or sense of compulsion to take a substance
Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use
A physical withdrawal state when substance use has ceased or been reduced
(This is mainly relevant to alcohol, opiates, benzodiazepines, G-drugs)
Tolerance (ie. need to take more of the substance to get the same effect)
Progressive neglect of alternative pleasures or interests because of substance use,
increased amount of time necessary to obtain or take alcohol or to recover from its effects
Persisting with substance use despite clear evidence of overtly harmful consequences
What were the DSM5 changes for classification?
Renamed:
OPIOID USE DISORDER
ALCOHOL USE DISORDER
Single continuum of MILD, MODERATE, SEVERE, so a dimensional approach
No longer uses the terms ABUSE or DEPENDENCE
What comprises a substance misuse history?
Length of current use and when last used.
Current amount (units/grammes per day) and for how long at this level.
Total length of use, max use, and any periods of abstinence.
Mode/method of use
Evidence of withdrawals and severity (e.g. seizures, admissions)
Any previous treatments - medication, psychotherapy, detox, rehab.
Any previous substance overdoses (accidental vs deliberate)
Assess triggers to use substances/alcohol
Assess motivation to change/engage in treatment
What are common co-morbid conditions?
Depression (15% in community, 32% in Alcohol treatment, 43% in Drug treatment) Anxiety (17%) Suicidality (x6 risk increase) Personality Disorder PTSD Bipolar Disorder
What features of an examination are specific to alcohol?
Comment on the presence of jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT
What investigations are specific to alcohol?
Fibro scan / Ultrasound
Bloods (LFT, GGT, Lipids, U&E, amylase)
Breathalyser
Urine Drug Screen
What must you note when assessing for alcohol misuse?
Note any history of Alcohol related seizures, Delirium Tremens, Alcohol psychosis, haematemesis, melaena
What features of an examination are specific to opioids?
Collapsed veins / track marks Endocarditis Skin abscesses Hepatitis / HIV Pneumonia
What investigations are specific to opiods?
Bloods (LFT, U&E, GGT, Glucose)
Breathalyser
Urine Drug Screen
Sexual health screening/BBV
How is a CAGE screening conducted?
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener)
Why is alcohol withdrawal more dangerous than opiate?
You can have seizures
Onset usually from 6 hours
Hallucinations can occur any time
DT is a late sign
(Delirium Tremens)
What do opioids do?
Relieve pain – ANALGESIC effect
Create a sense of EUPHORIA
What are the differences between opioids and opiates?
Opiatesrefer to naturalopioidssuch as morphineandcodeine, and heroin to some extent.
Opioidsrefer to all natural, semisynthetic,andsyntheticopioids.
What are the features of opiate overdose?
Not moving cannot be waken Slow/no breathing Chocking/Gurgling Tiny pupils Clammy cold skin Blue lips and nails
What drugs are used to help with abstinence from alcohol?
Acamprosate
Disulfiram
Naletrexone
Nalmefene
What drugs are used to help with abstinence from opiods?
Methadone
Buprenorphine
What other drugs should we be aware of?
Cannabis / synthetic cannabinoids (Spice) Cocaine / Crack Amphetamines Methamphetamine MDMA / Ecstasy Ketamine Mephedrone Hallucinogens (LSD, Psilocybin, DMT) NPS (Novel Psychoactive Substances
