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Substance Use Disorders Flashcards

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1
Q

What is a substance use disorder?

A

A pattern of substance use causing physical, mental, social, or occupational dysfunction

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2
Q

What is acute intoxication?

A

Transient state of emotional & behavioural change after PS use

  • Dose dependent
  • Time limited
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3
Q

How does ICD-10 define withdrawal?

A

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

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4
Q

How does ICD-10 define psychotic disorder (substance use)?

A

Psychotic symptoms occurring during or immediately after PS use, characterised by vivid hallucinations, abnormal affect, psychomotor disturbances, persecutory delusions and delusions of reference

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5
Q

How does ICD-10 define amnesic disorder?

A

Memory and other cognitive impairments caused by substance use (i.e. Wernicke’s)

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6
Q

How does ICD-10 define residual and late onset psychotic disorders?

A

Where effects on behaviour, affect, personality or cognition lasting beyond the period during which direct PS effect might be expected

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7
Q

What are the RFs for substance abuse?

A
  • 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
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8
Q

What is the difference between harmful and dependant alcohol use?

A

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)

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9
Q

What are the levels of alcohol consumption?

A

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)

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10
Q

What is the aetiology of alcohol use disorder?

A
  • 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)
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11
Q

What are the S/S of acute alcohol withdrawal?

A

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%
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12
Q

What is the CAGE questionnaire?

A

> 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?
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13
Q

What are the investigations for alcohol use disorder?

A

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
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14
Q

What rating scales are used for alcohol abuse?

A

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)
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15
Q

Is alcohol withdrawal managed as inpatient or at home?

A
  • 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
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16
Q

What is the management of acute alcoholic withdrawal?

A

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
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17
Q

Describe assisted withdrawal

A
  • 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
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18
Q

What is the management of Wernicke’s encephalopathy?

A
  1. Stabilisation & resuscitation (airway protection, IV access)
  2. IV thiamine (vitamin B1) e.g. Pabrinex
  3. +Magnesium sulphate & multivitamin
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19
Q

What is the psychosocial management of alcohol misuse?

A

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)
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20
Q

What is Korsakoff’s psychosis?

A

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.
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21
Q

What are the complications of alcohol abuse?

A

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
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22
Q

What are different types of opiate?

A
  • Heroin (aka: brown, smack, horse, gear, H, skag)
  • Morphine, diamorphine
  • Pethidine
  • Codeine, dihydrocodeine
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23
Q

What are the different routes of administration of opiates?

A
  • 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)

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24
Q

What are the S/S of opiate intoxication?

A
  • Euphoria and ‘warmth’
  • Then sedation, bradycardia
  • Low-dose SEs: constipation, anorexia, decreased libido
25
Q

What are the S/S of opiate OD?

A
  • Shallow respiration / low RR
  • Thready pulse
  • Pinpoint pupils (miosis)
  • Complication symptoms + pseudoaneurysm
26
Q

What are the S/S of opiate withdrawal?

A

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
27
Q

What are the investigations for opiate misuse?

A
  • 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)
28
Q

What are general recommendations for the management of opiate misuse?

A

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
29
Q

What is the management for opiate use disorder?

A

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
30
Q

What is the follow-up care for opiate use disorder?

A

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
31
Q

What are the complications of opiate misuse disorder?

A

Local:

  • Abscess
  • Cellulitis
  • DVT
  • Emboli

Systemic:

  • Sepsis
  • Infective endocarditis
  • Blood-borne infections e.g. hep B/C, HIV
  • Increased risk of OD
32
Q

What is cannabis?

A

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
33
Q

What are the S/S of cannabis use?

A

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’)
34
Q

What are the pharmacokinetics of cannabis use?

A
  • Smoking > peak at 30m, last 2-5 hours
  • PO > slower onset, lasts longer
35
Q

What are the investigations for cannabis use disorder?

A

Urine drug screen – in urine for up to 4 weeks

36
Q

What is the management of cannabis misuse disorder?

A

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

37
Q

What are the complications of cannabis use?

A

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)
38
Q

What are hallucinogens?

A

Hallucinogens produce psychological (heightened perception, illusions) and physiological (dilated pupils, peripheral vasoconstriction, increased temperature) effects but NO DEPENDENCE

39
Q

What are the different types of hallucinogens?

A

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
40
Q

What are the S/S of hallucinogens use?

A
  • 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
41
Q

What is the management of hallucinogen use disorder?

A
  • Harm reduction (see Opiates)
  • Short-term withdrawal symptom relief as an inpatient with BDZ
42
Q

What are the different types of stimulant?

A

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)
43
Q

What are the SEs of stimulants?

A
  • 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)
44
Q

What are the S/S of stimulants?

A
  • Increased alertness, endurance and confidence
  • Risky behaviour
  • Unpleasant ‘crash’ period (dysphoria [i.e. dissatisfaction with life] and lethargy)
45
Q

What is cocaine withdrawal?

A

> 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
46
Q

What is the investigations for stimulant use?

A

Urine drug screen – cocaine in urine for up to 5-7 days

47
Q

What is the management for stimulant use?

A
  • Harm reduction (see Opiates)
  • Short-term withdrawal symptom relief as an inpatient with BDZ
48
Q

What are benzodiazepines?

A

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

49
Q

What are the S/S of BZN use?

A
  • 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

50
Q

What is the management of BZN use disorder?

A

Options for withdrawal:

  1. Slow-dose reduction
  2. 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
51
Q

What are the investigations for smoking?

A

CO level of ≤10ppm indicates abstinence from smoking

52
Q

What is the management for smoking?

A

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
53
Q

What scoring system should be used to determine the severity of withdrawal?

A

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.
54
Q

Which electrolyte abnormality is common in patients who drink excessive amounts of alcohol?

A

Low magnesium

55
Q

What is Disulfiram (also known as Antabuse) used for?

A

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.
56
Q

What is Acamprosate (or Campral) used for?

A
  • 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
57
Q

What blood tests can be used to assess a patients alcohol intake?

A
  • MCV (increased)
  • LFTs
  • GGT
58
Q

What are the signs of dependence?

A
  • 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

59
Q

What is the management of alcohol dependency?

A

Firstly establish their motivation

  1. Refer to specialist alcohol service (not managed by GP)
  2. Detoxification - BZN e.g. chlordiazepoxide
  3. Other medications for withdrawal symptoms
  4. Talking based therapy e.g. CBT
  5. Social support e.g. AA

Psych (18 decks)

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