tutorial on alcohol and addiction Flashcards
intoxication definition
transient syndorme die to recent substance ingestion that produces CLINICALLY SIGNIFICANT psychological or physical impairment. changes disappear when substance cleared from body
what is withdrawal state
when you are suddenly reducing dose or withdrawing completely
what is tolerance:
after repeated administration the drug starts having less of an effect
so you need more dose for same effect
what is harmful use
A pattern of psychoactive substance use that is causing damage to health (physical or mental/ social)
what are the features of harmful use
- a pattern of substance that causes damage to health
- new ICD 11 catgeory for single episode instead of pattern
- negative effects on physical or mental health
-affects social life
-involves BINGEING on substances
- affects someone ELSES health
- does not fulfil any other diagnosis (More serious) within substance use eg dependency
can harmful use and dependency syndrome coexist as diagnoses?
no, you either have one or the other, dependency syndrome is the more serious one
dependence under cd11 criteria - areas of interest
1) impaired CONTROL of substance use: amount, onset, frequency, context, duration, duration, intensity)
2) if its constantly PRECEDING other aspects of life (relationships, work, hobbies, health)
3) signs of NEUROADAPTATIONS (withdrawal symptoms, taking drugs that mimmic the substance pharmacologically to alleviate symptoms, tolerance)
what is the diagnostic method under dsm 5
all of the substance related stuff is called opioid use disorder or alcohol use disorder (instead of the 2 separate terms in icd) and the 2 disorders are in a continuum - mild - moderate- severe
actual criteria are the same
important history components in addictions
presenting complaint
history of presenting complaint
substance misuse history
family history
past psychiatric history
personal history
past medical history
what goes under substance misuse history
LENGTH of current use and when LAST USED
current AMOUNT and for how long at this level
METHOD of administration
SEVERITY: evidence of withdrawal symptoms, neuroadaptations ect
length of use in general and any periods of abstinence
any medications tried for abstinence ect
any previous overdoses
assess triggers to use
assess motivation to change
family history points
include mental illness and addiction disorders
past psychiatric history
1) consider presence of trauma: domestic violence, neglect, abuse
2) screen for developmental disorders especially add - 25% have com orbid add
3) look for other comorbid psych conditions
what are some common comorbid mental health conditions?
depresison
anxiety
suicidality
personality disorders
ptsd
bipolar affective disorder
personal history
Relationships:
- partner, family, children (violence in household?)
Safeguarding concerns?
money:
Accommodation problems?
Money and debt? (how is use being funded)
Employed / Benefits
Forensic history:
- cautions, convictions, ongoing court cases, crimes committed but not prosecuted for
past medical history common stuff with addictions
Cirrhosis (Alcohol)
Endocarditis (IV use)
Abscesses (IV use)
BBV: Hepatitis B/C & HIV (IV use) (ask about vaccinations)
The major causes of morbidity and mortality
associated with substance abuse:
Trauma (e.g. broken bones from fights)
Road Traffic Accidents
Homicide (alchohol is actually involved at high % of homicide)
Suicide
Overdose (deliberate and accidental)
how do you calculate units?
% strength x ml/ 1000= units
what is our alcohol excretion rate? (body)
1 unit per hour
how many grams of pure alcohol is 1 unit
8g
what is the alcohol limit for men and women?
same! 14 units per week spaced over 3 or more days
what factors does an MSE- mental state examination examination look at?
appearance- movements and all that
speech- rate and structure
thoughts - structure and content
mood and affect
cognition - orientation to time and place ect
insight - into their problem- whether they need treatment
what percentage of uk population drinks above safe limits?
30%
what part of uk has worst alchohol problems
Northern Ireland and Scotland
ages of heaviest use
15-24
psychosocial stressor risks
unemployment
separated > single > married
in which parts of the gi tract is alcohol absorbed
mouth, stomach, small bowel
how long does it take for alcohol to reach max blood conc
60 mins
what factor slows down and what speeds up alcohol absorption
fizzy drinks speed up and food slows down
what chemical property of alcohol makes it widely distribute to all bodily tissues?
HYDROPHILIC
what parts of the brain does alchohol reach and what are the effects? (pharmacodynamics)
anxiolysis, reward, losing senses+ memories due to glutamergic inhibition
binds on+ enhances GABA a receptors: anxiolysis.
stimulates dopamine release in the mesolimbic system (reward)
inhibits NMDA mediated glutamate release - amnesia (since glut is main excitatory neurotransm) - but this inhibition can reach any part of brian with dif effects ex. in crebellum: cant see straight, walk straight ect.
what are the metabolic reactions involved in breakdown of alchohol
ethanol—alchohol dehydrogenase—> acetaldehyde
—-acetaldehyde dehydrogensase—-> carbon dioxide and water
where does majority of alchohol get metabolised
liver 98%
what are the 4 aspects of alchohol assesment
note about alchohol related health history
clinical examinations
neurological signs (we didnt focus on these that much iin this)
investigations
what things do you need to note about alchohol related helath history
history of alchohol related seizures,
delirium tremens/ alchoholic hallucinosis
haematemesis
malaena
what are alchohol related signs
jaundice, bruising, clubbing (fingers chubbing up), oedema, ascites, spider naevi- red skin rash that looks like spider web
alchohol relate dinvestigations
liver fibro scan/ ultrasound
bloods (LFTs, FBC, GGT, lipids, clotting, amylase)
breathalyser
urine drug screen to see if there also other substances
neurological alchohol related signs
wernickes encephalopathy (Ataxia, confusion, opthalmoplegia)
korsakoffs syndrome (memory impairment- like alzheimers but alchohol caused)
what are some alchohol assesment tools - screening tools- question tools basically
AUDIT - alchohol use disorders identification test- very analytical questions score out of 20: incr with seriousness
CAGE:
have you ever felt you need to CUT DOWN your alchohol use?
have you ever been ANNOYED by people criticising your drinking
have you ever felt GUILTY about drinking
Have you ever felt you need a drink first thing in the morning? (EYE OPENER)
does alchohol withdrawal escalate to more serious forms as time goes by?
yes in general but you can also get some of the serious symptoms from early such as seizure as soon as 2 hours after cessation of alchohol consumption.
what usually happens 6-12 hrs after alchohol cessation in withdrawal
mild withdrawal state- nausea, dizzy, vomiting, TREMULOUSNESS!! (hand, tongue, fever)
fever, diaphoresis
what usually may happen 12-24 hrs after cessation in withdrawal?
alchoholic hallucinosis: visual and auditory or even tactile disturbance
how many hours after cessation is someone most and least likely to have a withdrawal seizure?
most likely 12-48 hrs after, can even after 2 hrs, unlikely after 48 h
what is a medical emergency related to alchohol withdrawal? when doe sit happen - post sessation
delirium tremens, ITS A LATE SIGN so 48-72 hrs post cessation.
percentage of poeple with withdrawal that get DT and pecentage that die form it.
5% get and 15-20% die
does dt need hospital admisison?
yes, at least for 24 hrs if they present with dt. may need observations for 72 hours after cessationof drinking
which people are at higher risk of developing DTs:
people with concurrent acute medical illness,
heavy daily alchohol use - over 60 units,
history of DTs and alchohol withdrawal symptoms, older age,
abnormal LFTs
what is the most frequently mentioned substance on death certificates?
opioids such as heroin and morphine
how do you die from drugs?
drug poisoning (general term describing harmful effects occuring when a toxic amount of drug is in body) - includes overdose
what is the usa opiod epidemic?
basically so so so many deaths form opiods in USA
first wave from opiod perscriptions, second involving heroin third involving synthetic opiods such as fentanyl
difference between opiates and opiods
opiates are only the natural opioids -
main opiates and other names for them
natural/ alkaloids :
morphine
codeine
thebaine
(heroine to some extent- its actually semi synth)
main synthetic opioids
fentanyl
pethidine
methadone
tramadol
main semi synthetic opioids
heroine
hydrocodone
oxycodone (oxycontin)
hydromorphone
potency rank of synth, semi synth and natural?
synth (fentanyl x100 of morphine) > semi synth 2x morphine> natural
what is the name for endogneous opioids and what is their role?
endorphins regulate pain and mood
what do opioids do?
euphoria and analgestic effect
is opioid or alchohol withdrawal more dang?
alchohol more dang- lead to death but opiod withdr feels worse, like you are dying
examinations to do on opiod assesment
Collapsed veins / track marks
Endocarditis (murmurs, splinter haemorrhages)
Skin abscesses
Signs (symptoms) of Hepatitis / HIV
Pneumonia
investigations to do for opioid assessment
Bloods (FBC, LFT, U&E, GGT, Glucose, CRP, BBB viral screen)
Breathalyser
Urine Drug Screen
Blood cultures (endocarditis)
what scale is used for opioid withdrawal question assesment
COWS - clinical opiate withdrawal scale
symptoms of opioid withdrawal
Tachycardia
Sweating
Restlessness
Dilated pupils
Bone pain
Rhinorrhoea
Diarrhoea (
Abdominal pain
Tremor
Yawning
Anxiety/Irritability
Gooseflesh skin
is intentional or unintentional overdose more common?
unintentional
what are the symptoms of opiate overdose
blue lips and nails, cant be woken, tiny pupils, clammy or cold skin, chocking, gurgling sounds or snoring, slow or no breathing
what to do to manage acutely opiate overdose
1) naloxone inject in upper arm or thigh OR nasal spray half in each nostril
2) airway support
3) recovery position
if no responce after 3 mins repeat naloxone
what is the difference between “abstinence” maintnance and detox regimes
detox regime is a short term supervised plan to detox of a substance vs abstinence maintnance is a long term plan to remain abstinent form substance
