Substance Use Disorders Flashcards
What is a substance use disorder?
A pattern of substance use causing physical, mental, social, or occupational dysfunction
What is acute intoxication?
Transient state of emotional & behavioural change after PS use
- Dose dependent
- Time limited
How does ICD-10 define withdrawal?
A transient state occurring while re-adjusting to lower levels of a drug in the body.
N.B. physical withdrawal only occurs from: ETOH, opiates, BDZ
How does ICD-10 define psychotic disorder (substance use)?
Psychotic symptoms occurring during or immediately after PS use, characterised by vivid hallucinations, abnormal affect, psychomotor disturbances, persecutory delusions and delusions of reference
How does ICD-10 define amnesic disorder?
Memory and other cognitive impairments caused by substance use (i.e. Wernicke’s)
How does ICD-10 define residual and late onset psychotic disorders?
Where effects on behaviour, affect, personality or cognition lasting beyond the period during which direct PS effect might be expected
What are the RFs for substance abuse?
- Peer pressure
- Deprivation
- Availability of substances
- Iatrogenic factors, e.g. prescription of BZN / analgesics long term
- Pre-existing psychiatric conditions, e.g. personality disorder, may increase the likelihood of substance misuse
What is the difference between harmful and dependant alcohol use?
Harmful = continues despite established harm (social, mental, etc.) but non-dependant
Dependence = harmful use + dependence syndrome (cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours that once had a greater value - ≥3 of 6 features required)
What are the levels of alcohol consumption?
Low risk: ≤14 U / week (men AND women)
Hazardous drinking: 15-35 U / week (intake increases risk of alcohol related harm)
Harmful drinking: >35 U / week (i.e. >6 U/day) (synonymous with alcohol misuse)
What is the aetiology of alcohol use disorder?
- Genetics
- East Asians = lower dependency rates (enzyme deficiency)
- Publicans, doctors, armed forces, etc.
- Difficult upbringing
- Dependency associated with personality disorders, mania, depression, and anxiety disorders (social phobia)
What are the S/S of acute alcohol withdrawal?
Uncomplicated alcohol withdrawal syndrome:
- 4-12hrs after last drink
- S/S = course tremor, sweating, insomnia, tachycardia, N&V, psychomotor agitation, anxiety, hallucinations (transitory visual, tactile to auditory), alcohol craving
Alcohol withdrawal with seizures:
- 6-48hrs after last drink (~36hrs)
- S/S = grand-mal seizures (in 5-15% of withdrawals)
Delirium Tremens
- 48-72hrs after last drink
- S/S = disorientation, anterograde amnesia, psychomotor agitation, hallucinations (Lilliputian hallucinations of little people or animals), hour by hour fluctuations (worse at night)
- If severe > heavy sweating, fear, paranoid delusions, agitation, fever, sudden CV collapse
- Mortality of 5-10%
What is the CAGE questionnaire?
> SCREENING TEST
≥2 positive answers indicates you should do more investigation…
- Have you tried to cut down?
- Have you ever been annoyed by people suggesting that you have a problem with you drinking?
- Have you ever felt guilty about drinking?
- Have you ever needed a drink to get you going in the morning – eye opener?
What are the investigations for alcohol use disorder?
Obtain full history from patient:
- Quantify units of alcohol consumed & any binge drinking
- Lifetime pattern (age when first started, age regular drinking, age realised you had a problem…)
- Current consumption (describe a day’s drinking including approximate timings)
- Social impacts (have you missed work, been in financial problems, relationships, etc.)
+ Obtain collateral history
Bloods:
- FBC (MCV), LFTs, B12, folate, U&E, clotting screen, glucose, film (macrocytosis, no anaemia)
Rating scale:
- AUDIT to identify disorder
- SADQ to determine severity of dependence
- APQ to assess nature of problems arising from alcohol
Urine:
- Drug screen
+ Consider USS of abdomen:
- To look for evidence of cirrhosis
What rating scales are used for alcohol abuse?
1st line = AUDIT (Alcohol Use Disorders Identification Test)
- 0-7 = low risk
- 8-15 = increasing risk
- 16-19 = higher risk
- > 20 = possible dependence
If >20, move to 2nd line full assessment
2nd line = SADQ (Severity And Dependence Questionnaire)
Others:
- CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol) = scale for severity of withdrawal
- APQ (Alcohol Problems Questionnaire) = to assess nature and extent of problems from alcohol misuse
- AUDIT-PC = shortened 5-q version of AUDIT
- FAST (Fast Alcohol Screening Test) = shortened 4-q version of AUDIT for use in A&E (scores 0 to 16; ≥3 = FAST positive)
Is alcohol withdrawal managed as inpatient or at home?
- Depends on level of dependency
- Community-based assisted withdrawal (i.e. through CGL, or through specialist centres) = >15U/day or ≥20 on AUDIT
- Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
What is the management of acute alcoholic withdrawal?
Without delirium/seizures:
- 1st line = long-acting oral BZN e.g. chlordiazepoxide or diazepam
- 2nd line = carbamazepine
- If hepatic failure or cannot tolerate oral = IV lorazepam
Alcohol Withdrawal Seizures:
- IV lorazepam
Delirium Tremens:
- Oral lorazepam
- If cannot tolerate / doesn’t respond, switch to IV lorazepam
Adjuncts:
- IV thiamine (vitamin B1) e.g. Pabrinex
- Supportive care e.g. correct metabolic abnormalities
- Treat concurrent acute medical illness
Describe assisted withdrawal
- Used fixed-dose drug regimen of chlordiazepoxide or diazepam
- Dose based on severity of alcohol dependence
- Gradually reduce the dose over 7-10 days to 0
- +Thiamine supplementation
- After successful withdrawal, consider acamprosate or naltrexone (for 6 months)
- Individualised psychological intervention - CBT
- Expectations: withdrawal symptoms are worst within the first 48 hours, and takes about 3-7 days after the last drink to completely disappear
What is the management of Wernicke’s encephalopathy?
- Stabilisation & resuscitation (airway protection, IV access)
- IV thiamine (vitamin B1) e.g. Pabrinex
- +Magnesium sulphate & multivitamin
What is the psychosocial management of alcohol misuse?
Brief intervention / FRAMES (5-10 minutes) + information
- AA, SMART Recovery and Change, Grow, Live (CGL)
1st line / mild-moderate dependance:
- Motivational interviewing (establish goals > explore beliefs > encourage self-efficacy)
2nd line / moderate-severe dependance:
- Psychosocial interventions (CBT, couple’s therapy)
- Residential abstinence centres (if homeless, for maximum of 3 months)
What is Korsakoff’s psychosis?
Comes after Wernicke’s encephalopathy, is irreversible
RESULTS FROM THIAMINE (B1) DEFICIENCY
- S/S = anterograde amnesia (can’t form new memories), confabulation, peripheral neuropathy, cerebellar degeneration
- Many impacts on life (mainly social complications) – marriage, occupational, friendships, etc.
What are the complications of alcohol abuse?
BIOLOGICAL
- Liver and GI – alcoholic hepatitis, cirrhosis, pancreatitis, varices (oesophageal, rectal), gastritis, peptic ulceration
- Neurological – peripheral neuropathy, seizures, dementia
- Cancer – bowel, breast, oesophageal, liver
- Cardiovascular – HTN, cardiomyopathy
- Foetal Alcohol Syndrome
PSYCHOLOGICAL
- Depression/mania, anxiety disorder, psychosis, self-harm
- Amnesia
- Morbid jealousy, alcoholic hallucinosis
- Cognitive impairment (Korsakoff’s or acute)
SOCIAL
- Misc. – unemployment, poor work performance, domestic violence, poor relationships, law breaking, child neglect/abuse
What are different types of opiate?
- Heroin (aka: brown, smack, horse, gear, H, skag)
- Morphine, diamorphine
- Pethidine
- Codeine, dihydrocodeine
What are the different routes of administration of opiates?
- Smoking (‘chasing the dragon’)
- Sniffing (‘snorting’)
- Oral
- IV (‘mainlining’) – many complications
- IM or SC (‘skin popping’)
(Often starts with smoking and progresses to IV to skin popping)
What are the S/S of opiate intoxication?
- Euphoria and ‘warmth’
- Then sedation, bradycardia
- Low-dose SEs: constipation, anorexia, decreased libido
What are the S/S of opiate OD?
- Shallow respiration / low RR
- Thready pulse
- Pinpoint pupils (miosis)
- Complication symptoms + pseudoaneurysm
What are the S/S of opiate withdrawal?
Begins 6 hours after injection, peak 36-48hrs, last 5-7 days
- Agitation
- Paraesthesiae
- Dilated pupils
- Epiphora, rhinorrhoea
- Piloerection
- Yawning
- Shivering / sweating
- Tachycardia
- Depression
- Craving
- D&V / abdominal cramps
- Goosebumps
What are the investigations for opiate misuse?
- Physical examination (establish baseline physical state)
- Urine drugs screen (2 days in the urine)
- U&E (features of malnutrition)
- FBC (anaemia due to malnutrition or signs of infection)
- LFTs (may impact medication dosing)
- Blood borne infections (RPR, hepatitis serology, HIV test)
What are general recommendations for the management of opiate misuse?
Appoint a key worker (single point of contact) and develop a care plan:
- (1) Agreed treatment and recovery goals
- (2) Specific, clear, action to be taken to achieve those goals
- (3) Clarity about who is taking the actions
- (4) Monitoring of progress
Harm reduction (pragmatic approach) – complete abstinence unlikely, be pragmatic:
- Needle-exchanges for IVDUs
- Offer vaccinations and testing for blood-borne pathogens
Health education:
- Sleep hygiene
- Support groups e.g. SMART recovery, Narcotics Anonymous
- Diet advise
What is the management for opiate use disorder?
Acute withdrawal:
- Outpatient unless co-morbid physical or mental illness, multi-drug detox required, social problems
- Treat with clonidine and BZN
Opiate Substitution Therapy (OST)
1. Maintenance
- 1st line induction therapy = buprenorphine (sublingual) OR methadone (liquid)
- Patient preference
- Offer naloxone and train how to use it
2. Detoxification:
- Lasts 12w as outpatient
- They will lose tolerance, so if take drug again, must be much less
- 1st line = buprenorphine OR methadone (lpatient preference)
- Withdrawal symptoms meds - clonidine or lofexidine, antidiarrhoeals, anti-emetics
What is the follow-up care for opiate use disorder?
Follow-up care (with the Drugs and Alcohol Service) – for at least 6 months:
- Look for signs of withdrawal
- Check other drug use (urine drug screens)
- ECG (QTc) for those on methadone
- CBT (to reduce relapse chance)
- Contingency management (through frequent screenings > less frequent screenings as time goes on):
Incentives for -ve drug test results
Urinalysis preferred
What are the complications of opiate misuse disorder?
Local:
- Abscess
- Cellulitis
- DVT
- Emboli
Systemic:
- Sepsis
- Infective endocarditis
- Blood-borne infections e.g. hep B/C, HIV
- Increased risk of OD
What is cannabis?
Active ingredient = delta-9-tetrahydrocannabinol
- Grass/weed – made from dried cannabis leaves
- Hash – squidgy, brown-black lump made from resin and flowers
- Skunk and sinsemilla – particularly strong varieties
- “Skunk” is the most commonly used
What are the S/S of cannabis use?
Effects depend largely on expectations and the original mood state:
- Euphoria, relaxation to… paranoia, anxiety and panic (spectrum)
- Perceptual/time distortion, hunger pangs
- Nausea and vomiting (‘greening’)
What are the pharmacokinetics of cannabis use?
- Smoking > peak at 30m, last 2-5 hours
- PO > slower onset, lasts longer
What are the investigations for cannabis use disorder?
Urine drug screen – in urine for up to 4 weeks
What is the management of cannabis misuse disorder?
Abstinence:
- Advise gradual reduction in amount of cannabis used
- Suggest delaying first use of cannabis till later in the day
- Suggest psychoeducation sessions
N.B. Clinical experience suggests that irregular use can be free from major problems
What are the complications of cannabis use?
Acute:
- Paranoia, panic attacks, accidents associated with delayed reaction time (driving)
- If susceptible, cannabis can precipitate an episode of psychosis or schizophrenia (and/or dose-related paranoid ideation and other psychotic features)
Chronic:
- Dysthymia, anxiety/depressive illness, amotivational syndrome
- No physical dependency (there is a mild withdrawal syndrome in heavy users – insomnia, anxiety, irritability)
What are hallucinogens?
Hallucinogens produce psychological (heightened perception, illusions) and physiological (dilated pupils, peripheral vasoconstriction, increased temperature) effects but NO DEPENDENCE
What are the different types of hallucinogens?
LSD (Lysergic acid diethylamide, acid)
- Impregnated on tabs > trips last up to 12 hours (perceptual changes and euphoria)
Phencyclidine (PCP, angel dust)
- Liquid or powder > snorted or smoked in a joint
- Associated with violent outburst and ongoing psychosis
Ketamine (Special K) – a similar structure to PCP:
- Anaesthetic effect can lead to unknowingly self-harming
- Unique anaesthesia in that it blocks cortical awareness of pain
- Small doses = dissociation; larger doses = hallucinations, synaesthesia
Magic mushrooms (e.g. the liberty cap / psilocybin semilanceata)
- Eaten (raw) or drunk (cooked, dried and made into a drink)
- Small doses = euphoria; larger doses = hallucinations (similar to LSD)
- Tolerance develops quickly so continued use unlikely
What are the S/S of hallucinogens use?
- Visual illusions, hallucinations, depersonalisation, derealisation
- Synaesthesia (experience sensation in another modality – i.e. hear a smell)
- Behavioural toxicity (i.e. acting on drug-induced beliefs – e.g. being able to fly)
Side effects:
- LSD – acute SEs due to behavioural toxicity; chronic SEs include flashbacks, anxiety, depression
- Phencyclidine – serotoninergic/cholinergic effects (confusion, violence)
- Ketamine – LARGE amounts = nausea, ataxia, slurred speech
- Magic mushrooms – behavioural toxicity, accidental poison consumption
What is the management of hallucinogen use disorder?
- Harm reduction (see Opiates)
- Short-term withdrawal symptom relief as an inpatient with BDZ
What are the different types of stimulant?
Cocaine (Charlie, coke, snow)
- Routes = intranasal, IV
Crack cocaine (rocks, base, freebase)
- Routes = inhalational
- ‘Concentrated smokable form’ > immediate, extreme high > wears off quickly (5-10 minutes)
- Highly addictive
Amphetamine (speed)
- Routes = IV, PO, intranasal
- Withdrawal medications include dexamphetamine
Khat (quat, chat)
- Mild stimulant, used in East African communities
- Causes psychosis
Ecstasy (MDMA)
- Causes serotonin release and blocks reuptake
- Hallucinogenic as well as stimulant properties
- S/S: initial 3-hour rush, agitation relieved by dancing/movement, bruxism (teeth-grinding)
- Hangover at 24-48 hours (fatigue, anorexia, depressed mood)
What are the SEs of stimulants?
- Anxiety/panic disorders
- Drug-induced psychosis
Cocaine – n.b. no dependence (but can become ‘habit’):
- Acute = arrhythmia, intense anxiety, hypertension > CVA impulsivity, impaired judgement
- Chronic = nasal septum necrosis, foetal damage, panic & anxiety, delusions, psychosis
- I.E. “Cocaine-induced Delusional Disorder” – believes performance in excess of ability
Amphetamines – n.b. very regular use associated with dependence:
- Acute = tachycardia, arrhythmia, hyperpyrexia, irritability, post-use depression
- Quasi-psychotic state with visual, auditory and tactile hallucinations
Ecstasy – n.b. tolerance but no dependence:
- Acute = increased sweating, nausea, vomiting, diminished potency despite increased libido
- Death associated with dehydration & hyperthermia (some chronic liver & cognitive disease)
What are the S/S of stimulants?
- Increased alertness, endurance and confidence
- Risky behaviour
- Unpleasant ‘crash’ period (dysphoria [i.e. dissatisfaction with life] and lethargy)
What is cocaine withdrawal?
> Occurs in 2 stages:
(1) Crash phase:
- From 3 hours
- S/S: depression, exhaustion, agitation, irritability
(2) Withdrawal:
- S/S: cravings, irritability, anergia, poor concentration, insomnia, slowed movements
- Lasts 1-10 weeks
What is the investigations for stimulant use?
Urine drug screen – cocaine in urine for up to 5-7 days
What is the management for stimulant use?
- Harm reduction (see Opiates)
- Short-term withdrawal symptom relief as an inpatient with BDZ
What are benzodiazepines?
Uses:
- Sedation, hypnotic, anxiolytic, anticonvulsant, muscle relaxant
- Should only be used for a short time (2-4 weeks)
Risks
- Short-Term: drowsiness, reduced concentration
- Long-Term: cognitive impairment, anxiety and depression, sleep disruption, dependence
Short-acting BDZs = lorazepam
Long-acting BDZs = chlordiazepoxide, diazepam
What are the S/S of BZN use?
- Calm and mild euphoria
- Slurred speech, ataxia, stupor
Overdose:
- S/S = low GCS, respiratory depression, low BP, mydriasis, hyporeflexia
- Mx = IV flumazenil
Withdrawal – similar to alcohol:
- Anxiety (biggest SE)
- Insomnia
- Irritability
- Tachypnoea / tachycardia
- Ataxia
- Tremor
- Tinnitus
- Sweating
- Hyperreflexia
- Seizures
- Mydriasis
- Palpitations
- Delusions
- Depression
- Derealisation
- Depersonalisation
- Anterograde amnesia
> Sudden withdrawal can lead to a delirium tremens-like picture
What is the management of BZN use disorder?
Options for withdrawal:
- Slow-dose reduction
- Switch to equivalent dose of Diazepam, and slow-dose reduction; used in those…
- Difficult to physically taper down the dose
- On short-acting potent BDZs (i.e. lorazepam)
Withdrawal process =
1/8th daily dose reduction every 2 weeks
E.g. diazepam 40 mg per day:
- Reduce dose by 5 mg every 2 weeks until reaching 20 mg per day, then (8 weeks)
- Reduce dose by 2 mg every 2 weeks until reaching 10 mg per day, then (10 weeks)
- Reduce dose by 1 mg every 2 weeks until reaching 5 mg per day, then (10 weeks)
- Reduce dose by 0.5 mg every 2 weeks until completely stopped
(20 weeks) - Estimated total withdrawal time = 30–60 weeks
Advice:
- If done properly, there will be few, if any, withdrawal side effects
- Anxiety is most common side effect and is normal > treat with non-pharmacological management (e.g. relaxation breathing techniques)
- May take 3m to 1 year or longer (if necessary)
- Assess driving risk (DVLA regulations) and advise cannot drive on certain levels of BDZs
What are the investigations for smoking?
CO level of ≤10ppm indicates abstinence from smoking
What is the management for smoking?
1st: Advice:
- Stopping is best done through behavioural support + medication
- Set a quit date, and commit to it
- First few days are often most difficult (may experience withdrawal), but passes by 3-4 days
- Do not recommend e-cigarettes (unclear health impacts)
2nd: Medications: Depends on individual preference, do not offer NRT, varenicline or bupropion in any combination
Nicotine Replacement Therapy (i.e. lozenges, mouth spray, patches)
- Start on the agreed quit date
- Patches (24hr) useful if > smoking shortly after waking, on combination NRT (as patch is for ‘background’ cravings)
- Adverse effects include nausea & vomiting, headaches and flu-like symptoms
Varenicline
- Started 7-14 days before quit date, whilst still smoking
- Recommended course of treatment is 12w (but patients should be monitored regularly and treatment only continued if not smoking)
- Contraindications: <18yo, renal disease, pregnancy, breast feeding, used with caution in patients with a history of depression or self-harm.
Bupropion
- Started 7-14 days before quit date, whilst still smoking
- Maximum use for 7-9w, then discontinue
- Contraindications: <18yo, seizures, CNS disorder, eating disorder, BPAD, cirrhosis
3rd: Follow-up:
- 2 weeks if on NRT; 3-4 weeks if on medications
- Measure CO levels 4 weeks after quitting
- Check progress, withdrawal symptoms
- If relapse, or partial relapse, provide encouragement and set a new quit date
- If unsuccessful, do not offer a repeat prescription within 6 months unless special circumstances have intervened
What scoring system should be used to determine the severity of withdrawal?
revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale
- Collates scores of symptom severity
- Useful in deciding the next stage of treatment for the patient, including whether to prescribe benzodiazepines for seizure prophylaxis.
Which electrolyte abnormality is common in patients who drink excessive amounts of alcohol?
Low magnesium
What is Disulfiram (also known as Antabuse) used for?
Used to treat chronic alcoholism
- It causes unpleasant effects when even small amounts of alcohol are consumed.
- It is taken once daily and its effects last seven days, working as a deterrent to prevent alcohol relapse.
Effects:
- Within 20-30 minutes of alcohol consumption - unpleasant symptoms, including facial flushing and nausea and vomiting, headache, blurred vision
- The reaction can be life-threatening, so disulfiram is not recommended for patients with underlying frailty, neurological, cardiac or hepatic conditions.
What is Acamprosate (or Campral) used for?
- Typically described as an ‘anti-craving’ medication
- Taken three times a day
- Effective in preventing alcohol relapse in combination with psychological support following detoxification
- Minimal side-effect and risk profile
- Safe in combination with alcohol
What blood tests can be used to assess a patients alcohol intake?
- MCV (increased)
- LFTs
- GGT
What are the signs of dependence?
- Tolerance
- Salience (increased importance at the neglect of other activities)
- Narrowing of repertoire
- Difficulty controlling / compulsion
- Persistence despited knowledge of harmful effects
- Withdrawal
3 or more = dependence
What is the management of alcohol dependency?
Firstly establish their motivation
- Refer to specialist alcohol service (not managed by GP)
- Detoxification - BZN e.g. chlordiazepoxide
- Other medications for withdrawal symptoms
- Talking based therapy e.g. CBT
- Social support e.g. AA
