substance use and misuse Flashcards
what are the potential harms of substance use and misuse
- Psychological issues
- Socio-economic issues
- Physical consequences
- Addiction or diversion
- Physical consequences
- Route of administration
- Self-neglect
- Poor pregnancy outcomes
Withdrawal symptoms
what are the risk factors for substance use and misuse
- Family history of substance abuse
- History of pain
- Easy access to medicines
- Difficult life events
- Time spent in secure environments
- Chronic/severe mental/physical health problems
what are the behavioural warning signs for substance use and misuse
- Taking a higher dose than prescribed
- Running out early
- Continually losing meds
- Healthcare professional shopping
- Requesting specific medicines
- Stealing or forging scripts
- Drug hoarding
- Risky behaviours
- Unexplained falls
- Debt
- Reduced social function
what are the physical warnings signs of substance use and misuse
- Presenting as intoxicated, sedated or withdrawing
- Unkempt appearance
- Mood swings
- Changes in sleep patterns
- Avoiding drug testing
what are the risk factors for alcohol dependence
genetics
starting at a young age
regular drinking
mental health problems
ignorance
what are the risks of long term high alcohol intake
death
liver damage
accidents
cancer
GI/mental health/social issues
brain damage
pancreatitis
social issues
heart disease
osteoporosis
what are the risks of chronic alcohol consumption on the CNS
cognitive impairment
wernicke korsakoff syndrome
what is wernicke korsakoff syndrome
acute onset neuropsychiatric disorder caused by thiamine deficiency - can go on to encephalopathy - confusion, apathy, disorientation and vomiting
how is wernicke korsakoff syndrome treated
- IM/IV pabrinex for 3-5 days
- maintenance thiamine 100mg TDS
what are the steps in managing alcohol dependency
- assessment
- detox
- assisted maintenance
how are patients detoxed from alcohol
chlordiazepoxide/oxazepam (in hepatic impairment)
- long acting benzo
- 20-40mg QDS or PRN
- risk of accumulation in elderly
what medications can be used for assisted maintenance in alcohol dependency
disulfiram
acamprosate
naltrexone
nalmefene
what is disulfiram
§ Aversive therapy - pro-drug
§ Prevents the liver converting acetaldehyde to acetic acid and dopamine to noradrenaline
When a person consumes a small amount of alcohol, mild symptoms of acetaldehyde and dopamine excess are experienced: vasodilation, palpitations and headache
what is acamprosate
glutamate antagonist
reduces reward from alcohol
what is naltrexone
§ Opioid antagonist licensed for alcohol misuse disorder
§ Blocks opioid receptors that modulate the release of dopamine in the brain reward system - blocking reward from alcohol and heroin
what is nalmefene
§ Opioid antagonist - reduces reward
§ When required for
□ Reduction strategy for those who have failed abstinence
□ For those who cannot achieve abstinence but require intervention with psychosocial support
what are the symptoms of alcohol withdrawal 6-30 hours after last drink
hyperactivity
tremor
sweating
nausea
retching
mood fluctuation
tachycardia
increased RR
HT
what are the symptoms of alcohol withdrawal 48 hours after last drink
withdrawal seizures
what are the symptoms of alcohol withdrawal 12 hours to 6 days after last drink
auditory and visual hallucinations
what are the symptoms of alcohol withdrawal 48-72 hours after last drink
delerium tremens
- coarse tremor
- agitation
- confusion
- delusions and hallucinations
how is opioid dependence treated
- assessment
- detox
- maintenance
- gradual discontinuation
how is opioid dependence detoxed
Replacement that prevents withdrawal but no high with symptomatic relief
what are the symptoms of opioid withdrawal
runny nose/eyes
dilated pupils
yawning
nausea
vomiting
diarrhoea
muscle aches
restlessness
what medications are used in maintenance for treating opioid dependence
methadone
buprenorphine
what is buprenorphine
partial opioid agonist
not absorber orally
harder to supervise
cannot use on top
what is methadone
full opioid agonist
long half life to suppress withdrawals and cravings
can use on top but it is dangerous
- has street value
what medications can be used to support opioid users to come off of maintenance therapy
naltrexone
long acting opioid antagonist with high affinity
minimises reward from opioids and alcohol
Test dose of 25mg at least 7 days after last opioid dose, then 50mg/day
what are the advantages to using methadone
good EBM
sedating
cheap
full agonist
variety of routes and forms
easy to supervise
orally absorbed
what are the disadvantages to using methadone
easy overdose
can use on top
stigma
rots teeth
accumulation in fatty tissue
3 days to steady state
long detox
does not stop cravings
what are the CNS S/E of methadone
euphoria
pain relief
drowsiness
N&V - triggers CTZ
Resp depression at high doses
cough reflex suppression
what are the histaminergic S/E of methadone
itching
sweating
blushing
flushing
airway constriction
what are the non-CNS S/E of methadone
absent menstrual cycle
sexual dysfunction
dry mouth/eyes/nose
dental issues
constipation
constricted pupils
QTc interval prolongation - r=monitor 6-12m
what are the risk factors for QTc prolongation in methadone use
other meds prolonging QTc
hx of heart disease
stimulant use
what are the advantages of using buprenorphine
difficult to use on top
safer in overdose
easier to detox/switch to naltrexone
less sedating
better newborn outcomes
rapid initial titration
what are the disadvantages of using buprenorphine
not orall absorbed
pooer EBM
tastes bad
only one dosage form
less sedating
expensive
what are the symptoms of opioid overdose
pinpoint pupils
N&V
pale skin
blueish tinge to lips, nose, under eyes, finger and nails
low BP
slow pulse
sedation
how is opioid overdose treated
naloxone - opioid receptor antagonist
when do you need to contact the prescriber of a opioid dependent patient
> 3 doses missed
intoxication
unacceptable behaviour
whole dose not consumed
concerns about mental/physical health needs
what are the effects of using synthetic cannabis
agitation, tremor, confusion, hallucinations
tachycardia, hypertension, palpitations
renal damage
what are the two CB receptors and what do they control
CB1 - brain - appetite, movement, higher cognitive functions, stress, nausea and pain
CB2 - periphery- immune function
how does cannabis affect schizophrenia
moking in a susceptible person can cause
§ Exacerbation of mental health problems
§ Anxiety/panic attacks
§ Paranoia/psychosis
○ Smoking before 15 increases risk of psychotic illness 4 fold
which illnesses have good evidence for cannabis use
chronic/neuropathic pain
paediatric epilepsies
nausea associated with chemotherapy
spasticity and pain in MS
which illnesses have modest evidence for cannabis use
sleep disturbances
PTSD
chronic fatigue
migraine
restless legs
anxiety and stress
what are the 4 disorders associated with caffeine
○ Caffeine intoxication
○ Caffeine induced anxiety disorder
○ Caffeine induced sleep disorder
○ Caffeine related disorder otherwise not specified
what are the recommended daily maximum caffeine intake levels
500mg/day is moderate
600mg/day is caffeinism
>1000mg/day is toxic
what are the signs and symptoms of low to moderate caffeine doses
passing more urine
tremor
increased physical stamina
anxiety
heart palpitations
nervousness
what are the signs and symptoms of high caffeine doses
chronic insomnia
anxiety
restless legs
irritability and agitation
poor concentration
disorientation
paranoia
seizures
vertigo
hallucinations
how should pregabalin be reduced
daily dose at a maximum of 50-100mg/week
how should gabapentin be reduced
daily dose at a maximum of 300mg every 4 days
