Substance Use Disorder Flashcards
What is substance misuse disorder?
Maladaptive pattern of substance use
What is dependence?
Inability to feel ‘normal’ without using substance
What is addiction?
Compulsive substance use to achieve reward stimuli, despite negative effects
What are the most commonly used substances?
- Cannabis
- Cocaine
- Ecstasy
- Alcohol
What substances are part of substance misuse disorder?
Alcohol
CNS depressants
CNS stimulants
Hallucinogens
What are the subtypes of substance misuse disorder?
low-risk use, hazardous substance use, harmful substance use, and substance dependence
What does substance dependence require?
AT LEAST 2 of:
- Impaired control over substance use
- Increasing priority over other aspects of life or responsibility
- Psychological features suggestive of tolerance and withdrawal
What areas of the brain does substance misuse affect?
specifically the basal ganglia, amygdala, and prefrontal cortex
What neurotransmitters does substance misuse affect?
Balance between glutamate, GABA and dopamine.
What happens when an individual consumes a substance (pathophysiology)?
- Affects the mesolimbic dopamine system in the nucleus accumbent and dorsal striatum in the basal ganglia.
- The release of dopamine gives off pleasurable feelings which trigger the reward system and positively reinforce the behaviour of substance consumption.
- This process is known as operant conditioning and is the basis of addiction and cravings.
- Some substances (eg. alcohol, opioids) interact with the inhibitory neurotransmitter GABA, which disrupts the equilibrium between GABA and glutamate.
- When an individual consumes substances, this disrupts the equilibrium as there are more sedative hormones (GABA).
- When exposed chronically, this results in neuroadaptation.
- The brain will upregulate the natural stimulants to achieve equilibrium.
- Withdrawal symptoms occur when there is a sudden drop in GABA, resulting in disrupted homeostasis and too much glutamate.
- The excess natural stimulants lead to withdrawal symptoms such as anxiety, sweating, and shaking.
What does continued consumption of substance cause?
Tolerance
- Receptors become less sensitive or neurons have fewer receptors (down regulation)
- Must consume more of substance to feel same effect
What does stopping substance use cause?
Withdrawal
- Body protectively counters consumption sx (so if there is no consumption, there is nothing to counter)
- So pts have to consume to voice discomfort (negative reinforcement)
May have fatal complications (eg. cancer, heart attack, OD)
What are signs and sx of substance use disorder?
- Tolerance
Withdrawal
- Anxiety, depression, irritability
- Fatigue
- Palpitations
- Clammy skin, sweating
- Dilated pupils
- Difficulty sleeping
- Vomiting,
- Seizures
- Change in vital signs
How Is substance use disorder diagnosed?
TWO or more of:
- Consuming more of a substance than intended
- Inability to cut down
- Use takes up a lot of time
- Cravings
- Use affects responsibilities
- Using in spite of social problems caused
- Use replaces important activities
- Using in physically dangerous situations
- Using even if its worsens problem
- Tolerance
- Feeling withdrawal sx
Mild = 2-3 sx
Moderate = 4-5 sx
Severe = 6 or more sx
How is substance use disorder managed?
Medications
- To reduce cravings, mimic substance, or change its effects
Psychotherapy
- Eg. motivational interviewing, CBT, peer-support programs
What is the max alcohol consumption recommended?
14 units / week spread evenly across 3 days or more
What is hazardous drinking?
individual consumes more than 14 units of alcohol / week
What is harmful drinking?
when the pattern of alcohol consumption directly causes physiological complications and illnesses
What is alcohol dependence?
craving and tolerance of alcohol consumption despite the negative complications experienced.
What is alcohol use disorder?
Maladaptive pattern of alcohol consumption
How does alcohol tolerance develop?
GABA, glutamate, dopamine, serotonin receptors become less sensitive/neurons have fewer receptors (downregulation)
Must drink more to feel euphoric (positive reinforcement)
Is alcohol a stimulant or depressant?
Depressant
What are clinical features of alcohol misuse?
Short-term harm:
- Alcohol poisoning
- Accidents
Liver:
- Liver cirrhosis and Alcoholic liver disease
- Chronic users can present w: leeding oesophageal varices, hepatic failure, and stigmata of liver diseases.
Withdrawal sx:
- Within few hrs of alcohol cessation
- 6-12 hrs: tremors, autonomic arousal (tachycardia, fever, pupillary dilatation, increased sweating)
- 12-48 hrs: alcohol hallucinosis (typically auditory or tactile)
- 72-96 hrs: delirium tremens (altered mental status, agitation, tactile hallucination)
What may investigations show in alcohol misuse?
FBC: raised MCV, raised platelets, anaemia
LFTs: increased GGT, AST:ALT > 2:1
Haematinics (B12/folate): alcohol can cause folate deficiency
TFTs
What questionnaire is used in alcohol misuse?
AUDIT-C Questionnaire
Others: SAD-Q, CAGE
How is alcohol misuse managed?
- Alcohol detox: but it can cause serious withdrawal sx
- Medications eg. Chlordiazepoxide, Naltrexone (reduces cravings), Acramprosate (stabilises withdrawal), Disulfiram (increases ethanol sensitivity)
- Psychological interventions
- Oral Thiamine
How is Chlordiazepoxide prescribed?
20-40 mg QDS
What are complications of alcohol misuse?
Neurological: ischaemic stroke, encephalopathy, seizures, peripheral neuropathy
Cardiovascular: increased rate of MI and stroke, hypertension, dilated cardiomyopathy
Hepatology: alcoholic liver disease, liver cirrhosis, liver fibrosis, pancreatitis
Oncology: increased risk of head and neck cancer, oesophageal cancer, liver cancer, breast cancer, colorectal cancer
Psychiatric: alcoholic hallucinosis, delirium tremens, Wernicke-Korsakoff syndrome
Wernicke-Korsakoff Syndrome
Alcohol prevents the absorption of thiamine by blocking thiamine pyrophosphate synthetase, resulting in thiamine deficiency.
The main symptoms of Wernicke encephalopathy are ataxia, confusion and ophthalmoplegia.
Korsakoff syndrome involves symptoms of Wernicke encephalopathy plus short-term memory loss and hallucinations
The treatment is the intravenous replacement of thiamine (e.g. Pabrinex).
Wernicke-Korsakoff triad
CAN
Confusion
Ataxia
Nystagmus
Wernicke’s encephalopathy and Korsakoff’s psychosis sx
COAT RACK
W:
Confusion
Ophthalmoplegia
Ataxia
Thiamine tx
K:
Retrograde amnesia
Anterograde amnesia
Confabulation
Korsakoff’s psychosis
Is Cannabis a depressant or stimulant?
Both
What does continued cannabis use lead to and how?
What are complications of cannabis misuse?
Anxiety, depression, psychotic disorders (eg. schizo), hyper-inflated lungs (when smoking cannabis), chronic bronchitis, respiratory infection, heart attacks, strokes
Teenagers at higher risk
What are signs and sx of cannabis misuse?
Increased cannabis tolerance
Upon withdrawal - cravings, irritability, anxiety, difficulty, sleeping
How is cannabis misuse treated?
Psychotherapy - motivational interviewing
Is cocaine a stimulant or depressant?
Stimulant
How does cocaine misuse cause tolerance?
What are complications of cocaine misuse?
Hyperthermia, seizures, stroke, brain haemorrhage, heart attack, death by overdose
Signs and sx of cocaine misuse?
Tolerance
Signs and sx of withdrawal
Perforated nasal septum
How is cocaine misuse treated?
Meds - Modafinil (stimulates, reduces cravings)
Psychotherapy - motivational interviewing, peer-support programs
Opioid misuse - have notes for this
Is tobacco a depressant or stimulant?
Both
What are complications of tobacco misuse?
Heart attack
Stroke
PVD
Pulmonary disease
Cancer (mouth, throat, lungs, bladder, pancreas, uterus)
How is tobacco misuse managed?
Medications
- Nicotine replacement therapies (gum, sprays, patches)
- Bupropion (anti depressant which reduces cravings and withdrawal sx)
- Varenicline (reduces cravings, enjoyment of tobacco)
Psychotherapy
- Motivational interviewing, peer-support programs
Other intervention
- Switch to e-cigarettes
What are hallucinogens
Hallucinogens include lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP).
What effects to hallucinogens cause when ingestion?
Euphoria, visual and auditory hallucinations and psychosis.
Substance-specific sx:
- LSD: lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams
- Marijuana: increased appetite and conjunctival injection
- Ecstasy: bruxism, hyperthermia, hyponatremia, and hepatotoxicity
- PCP: loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation
Investigations in hallucinogenic features?
Screening tools used for hallucinogens are the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).
How is hallucinogen misuse managed?
There are no specific interventions for hallucinogen misuse, and the mainstay treatment is supportive.
This includes medically supervised detox by slowly tapering the dose, referral to a rehabilitation centre, cognitive behavioural therapy, and treatment of withdrawal symptoms.
What may GP’s refer pt’s do presenting with substance misuse disorder?
to your local drug service.
Can use Frank website to find support near a person
Can use Adam website
What should GP ask at first visit?
At first appt for drug treatment, staff will ask you about your drug use. They’ll also ask about your work, family and housing situation.
You may be asked to provide a sample of urine or saliva.
Staff will talk you through all of your treatment options and agree a treatment plan with you.
They can tell you about local support groups for drug users and their families or carers.
You’ll also be given a keyworker, who will support you throughout your treatment.
What does treatment involve?
- Drug tx
- Talking therapies
- Tx with medicines (eg methadone or buprenorphine for heroin or opioid)
- Detoxification
- Self-help (eg. UKNA - UK narcotics anonymous)
- Reducing harm - reduce risks a/w drug taking eg. testing and tx for hepatitis, HIV, AIDS
What are signs a young person may have substance use disorder?
Getting drunk or high a lot
Using substances before or during school
Selling drugs
Hiding alcohol or drugs in their room
Skipping school a lot
Doing worse in school than they used to
No longer seeing old friends
No longer doing activities they used to enjoy
Dangerous behavior such as fighting, or driving while drunk or high
Strong cravings for a specific substance
Needing to take more and more of the substance to get the same effect
Withdrawal symptoms when they can’t get the substance
How is substance use disorder diagnosed in paeds?
Substance use disorder can take many forms. To be diagnosed, a teenager’s substance use must cause issues in school, social problems, and/or dangerous behavior. Developing tolerance to the substance (needing more to feel drunk or high) is also a sign that professional help may be necessary.
How is substance use disorder managed?
Psychotherapy
Family counselling
Self-help groups for teen and/or family
