Substance use disorder

Question 1

Screening questions for substance abuse

Answer 1

o Do you drink alcohol / use drugs?
QUANTIFY
- Typical use - How much per week, How often
- age at first use, use over time ?abstinence
-effects and motivations to use

MOTIVATION TO CHANGE
- Have you ever been concerned about your drinking?
- When you drink, do you often drink more than you had planned?
- Do you spend a lot of time planning ways to get alcohol or get strong cravings?

ABUSE
ROLE IMPAIRMENT
- Have you had problems at work /at school
- at home- with relationships with family and friends

do you miss time from other activities due to spending time drinking - prev hobbies, friends and fam

HAZARDOUS
- Have you ever gotten in trouble with police when you’ve been drinking before
? driven under the influence ? been arrested
- are you still caring for your children, doing ADLS

Question 2

Screening questions for substance dependence (mainly alcohol)

Answer 2

TOLERANCE
- Overtime have you noticed you need more to achieve the same effects?

WITHDRAWAL
Do you feel shaky, sweaty, tachy, nauseous when you stop drinking?
- how soon do they come
- how do you manage withdrawal symptoms ?first thing in the morning

AMOUNT
- Do you drink larger amounts than intended?

CUTTING DOWN
Have you had thoughts of cutting down on drinking? Did you ever try to cut down but couldn’t?
ACCESSING ALCOHOL
- - “Do you spend a lot of time doing things and planning ways to get alcohol?”
CONSEQUENCES
- Any physical problems,
- worsening mental health problems ?
- do you still drink despite these ?

o C.A.G.E. =
- Have you been angry when people talk about your drinking?
Have you felt guilty about the amount your drinking

Question 3

What are the other questions apart from screening that you need to ask for sud

Answer 3

Other questions
- Screen for depression, mania, psychos and anxiety - comorbid disorders may have triggered the substance abuse
- Elicit history of trauma
- Family history of substance abuse

Question 4

What are the DSM criteria for substance use disorder
(11)

Answer 4

≥ 2 of the following, happening over a 12-month period
1. Drinking more or drinking for longer than planned
2. Persistently tries and fails to cut down
3. Much time spent on obtaining, using and recovering
4. Craving alcohol
5. Recurrent use resulting in a failure to fulfil obligations at work, school or home.
6. Continuing to drink alcohol despite it causing social or interpersonal problems
7. Giving up social, occupational or recreational activities because of alcohol use.
8. Recurrent alcohol use in physically hazardous situations (driving)
9. Continues using despite physical or psychological problems / consequences
10. Tolerance = either
a. More alcohol is needed to achieve intoxication
b. Less effects when drinking the same amount of alcohol
11. Withdrawal = either
a. Characteristic withdrawal syndrome sx
b. Alcohol or other substance (e.g - benzos) are taken to relieve or avoid withdrawal sx

Question 5

What are the withdrawal symptoms of alcohol/sedatives, cannabis, opioids and stimulants, benzo

Answer 5

Alcohol:
sweating, tachy, tremor,N&V, hallucinations, agitation/restless, anxiety,seizures

Cannabis = irritable, anxiety, insomnia /
disturbing dreams, decreased appetite / weight loss, restlessness, depressed mood, physical sx (shaking, stomach pain, tremor, sweating, fever,
chills, headache)

Opioids = depressed / irritable, N&V, muscle aches, rhinorrhoea, sweating / dilated pupils / goosebumps, diarrhoea, fever, yawning, less sleep

Stimulants = depressed / irritable, fatigue, vivid unpleasant dreams, sleep changes, increased appetite, restless or slowed

Benzo: anxiety, panic attacks, sleep disturbance, muscle spasm, depersonalisation, derealisation, generalised seizure, delirium/psychosis

Question 6

What is the safety and further investigations for substance use disorder (spec alcohol)

Answer 6

Immediate Safety
- Inpatient detoxification-alcohol,opiates
- Allows for correction of medical concerns e.g.nutrition
- Community or home detoxification - less severe addiction
Confirming Diagnosis
- Collateral history

Examination & Investigations
- AUDIT - Alcohol Use Disorder Identification Test (10MCQs on frequency. amount, functional impact of drinking. Harmful, hazardous, dependent use.
- CAGE screening
- Physical examination

Bloods
- LFTS - GGT, AST&raquo_space;> ALT ratio
Carbohydrate deficient transferrin (dependence) albumin, FBC (anaemia), vitamins (B, C, Magnesium, calcium, zinc, iron, potassium)
- Urine tox and blood alcohol level

Question 7

What is the bio treatment of addiction - alcohol and

Answer 7

o EtOH detox:
- Diazepam (minimises autonomic symptoms and anxiety, prevents delirium tremens) - monitor with CIWAr and physical obs
- 200mg Thiamine daily IM/IV for 3 days then 50mg po QID after (often deficient)

Relapse prevention in alcoholics:
- Naltrexone: opioid antagonist for craving/ reward from alcohol
- Disulfiram - aldehyde dehydrogenase inhibitor causing flusing, palpitations, hypotension, nausea/vom, sweating (Antabuse)

o Opioid Substitution: Methadone (long acting full opioid agonst)
Buprenorphine (partial opioid agonist)
o Benzo substitution: diazepam
o Stimulant substitution:
dexamphetamine

Question 8

What is the psych + social treatment of SUD

Answer 8

Referral to
- CADs - provides specialist services,
counselling, community and inpatient
detoxification and rehab programs
- Residential rehab and detoxification
- Inpatient detoxification

Psychoeducation
- - 5-30 minute education sessions on
substance use - targets harmful effects and impact on the individual
- Screen for problem use
- Advice to reduce use to safe levels
- Advise on harm minimization strategies
- Involves personally linking information to current symptoms and problems
- Provision of self-help materials etc.

Motivational interviewing : - Determine motivation and stage of change
- “What are the good things about drinking?
What are the less good things?”
- “Tell me about a usual day and how your drug/alcohol use fits into this?”
- “Does this ever make you worried or
concerned?”
- “Looking back, how are things now
compared to then? How would you like
things to be?”

CBT and counselling
- Family/group therapy (e.g. AA), social
behaviour network - focuses on changing beliefs and behaviours by learning other ways of coping

Harm prevention/reduction
- Reduce intake
- Safety planning (reducing levels of use,
changing to a safer mode of use, education around reducing health risk etc.)
- Relapse prevention - certain beliefs and behaviours increase chance of relapse - CBT focuses on understanding and learning other ways to cope with high risk situations

Social
- - Encourage family/friend support
- Work/school
- Income and benefits
- Housing concerns
- Spiritual and cultural

Question 9

how to explain SUD to layman

Answer 9

• You came here today concerned about your reduced functioning at work and concerns from others about your substance use.
• Substance use is quite common and there are many reasons for using substances, we start to worry that people have an unhealthy relationship with substances when a person continues to use substances despite it causing negative effects for their health, work life, family life and relationships. The symptoms that we talked about today suggest this diagnosis of Substance use disorder.
• There are multiple reasons why someone can develop an unhealthy relationship with substances. The substances themselves activate the reward circuits in the brain which leads to a craving to use them repeatedly. With extended use it can overexcite the danger sensing circuits in your brain which makes you feel anxious or stressed when not using drugs/ alcohol
• Over time repeated use of drugs can damage the front part of the brain involved in decision making and recognising the harm of substances. Other things that increase risk for substance use disorder include family hx of substance misuse, social pressure, chronic pain or stress where people use substances as a way of coping with stress, trauma or pain.
• Treatment for substance use disorder depends on the drug being used, but it typically involves the support of a specific alcohol and drug service which supports people with detoxifying the community and counselling like CBT which focuses on unpacking the thought processes that lead to substance use and finding alternative ways with coping with stress. Family support and support groups help people remain committed to stopping use of the drug. There will also be a screen for physical complications of drug use and treatment for this. Often if substance use was for a very long time they can support you to have a controlled step down of your use to prevent withdrawal. For alcohol use we use diazepam to treat symptoms of withdrawal and have other agents to prevent relapse.