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Year 5 - Psychiatry > Substance use disorder: drugs > Flashcards

Substance use disorder: drugs Flashcards

1
Q

What are the 4 categories of recreational drugs?

A

Analgesics e.g. heroin, morphine, fentanyl, codeine

Depressants e.g. alcohol, barbituates, tranquilizers, nicotine

Stimulants e.g. cocaine, methamphetamine, ecstasy (MDMA)

Hallucinogens e.g. LSD (acid), peyote (mescaline), magic mushrooms (psilocybin), salvia divinorum (diviner’s sage)

NB: Cannabinoids - has depressant, stimulant and hallucinogen effects.

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2
Q

Define harmful use in terms of substance problems.

A

A pattern of psychoactive substance use that is causing damage to health.

The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol)

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3
Q

Define substance abuse or misuse.

A

The continued misuse of any psychoactive substance that severely affects person’s physical and mental health, social situation and responsibilities.

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4
Q

Define psychoactive substance.

A

Substance that has an effect on the central nervous system

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5
Q

What is the ICD-10 criteria for dependence?

A
  1. Compulsion - strong desire
  2. Control - difficulties in controlling substance-taking behaviour (onset, termination, levels)
  3. Withdrawal - when substance use has ceased
  4. Tolerance - increased doses required
  5. Salience - little alternative pleasure
  6. Persistance - use despite clear evidence of harm

3 or more of the following manifestations should have occurred together for at >1 month or, if persisting for periods of <1 month, should have occurred together repeatedly within a 12-month period.

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6
Q

Define ‘legal highs’.

A

a.k.a. novel psychoactive substances is the medical term for the many new substances which are chemically related to established recreational drugs such as MDMA and cannabis

Illegal since 2016, so no longer ‘legal’ highs

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7
Q

Give an example of each category of legal highs.

A

Stimulants - similar to NMDA, amphetamines and cocaine e.g. mephedrone called ‘bath salts’

Cannabinoids - ‘spice’ which is a synthetic cannabinoid receptor antagonist sprayed on herbal mixtures which are then smoked

Hallucinogenics

  • Dissociatives - similar effect to ketamine e.g. methoxetamine ‘mexxy’.
  • Psychedelics - similar effect to LSD but also sometimes stimulant

Depressant - either opioid or benzo based but often have a longer half-life

Other e.g. GHB ‘liquid ecstasy’, ‘Geebs’ or ‘G’; nitrous oxide ‘hippie crack’.

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8
Q

What is the MOA of stimulant legal highs?

A

Similar to MDMA, amphetamines and cocaine –> increased levels of serotonin, dopamine and noradrenaline –> in a ‘high’ and feeling of euphoria

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9
Q

What form is ‘spice’ often used in?

A
  • Sprayed on herbal mixtures and smoked or
  • Liquid inhaled using e-cigarettes
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10
Q

What is a dangerous side effect of GHB use?

A

Respiratory depression - when taken with other respiratory depressants, most commonly alcohol, this can be potentially life threatening

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11
Q

What is the MOA of benzodiazepines?

A

Enhance the effect of the inhibitory neurotransmitter GABA* by increasing the frequency of chloride channels.

*gamma-aminobutyric acid

NB: GABAA drugs

  • benzodiazipines increase the frequency of chloride channels
  • barbiturates increase the duration of chloride channel opening
  • Barbidurates increase duration & Frendodiazepines increase frequency
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12
Q

What are the 5 effects/uses of benzodiazepines?

A
  • sedation
  • hypnotic
  • anxiolytic
  • anticonvulsant
  • muscle relaxant
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13
Q

What are the short and long-term risks of using benzodiazepines?

A

Short-Term: drowsiness (do not drive), reduced concentration

Long-Term: cognitive impairment, worsening anxiety and depression, sleep disruption

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14
Q

What are the symptoms of benzodiazepine withdrawal?

A

Can occur up to 3 weeks after stopping a long-acting drug. Features include:

  • insomnia
  • irritability
  • anxiety
  • tremor
  • loss of appetite
  • tinnitus
  • perspiration
  • perceptual disturbances
  • seizure
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15
Q

What is the protocol for withdrawing benzodiazepines?

A

Withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every 2 weeks. Suggested protocol:

  1. Switch patients to the equivalent dose of diazepam (up to 40mg OD)
  2. Reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
    • time needed for withdrawal can vary from 4 weeks to a year or more
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16
Q

What are the clinical features of benzodiazepine toxcity? What is the antidote?

A
  • CNS depression
  • Ataxia
  • Slurred speech
  • Coma
  • Respiratory depression

Tx: flumazenil (GABA receptor antagonist) - majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.

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17
Q

What is the MOA of cocaine?

A

Stimulant – classified as such as they clinically resemble a state of increased sympathetic activity.

MOA: Blocks the uptake of dopamine, noradrenaline and serotonin.

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18
Q

Name 2 other stimulants.

A
  • Amphetamines
  • Ecstasy (MDMA)
  • Mephedrone
  • Cocaine
19
Q

What are the clinical effects of stimulants?

A
  • euphoria
  • talkativeness, overactivity
  • increased concentration
  • large pupils
20
Q

What is a distinctive side effect of ecstasy use?

A

Hyperthermia - can cause users to drink excessive amounts of water - leading to hyponatraemia.

Bruxism - can last up to 24hrs after taking the drug

It is also a mild hallucinogen in addition to its stimulant effect.

21
Q

What are the adverse psychological effects of stimulants?

A

Pscyhological:

  • Dsyphoria
  • Irritability/agitation
  • Insomnia
  • Anxiety
  • Hallucinations

Stimulant induced psychosis - stereotyped behaviour, paranoid delusion, auditory and visual hallucination, sometimes aggression.

22
Q

What are the adverse non-psychological effects of stimulants?

A

Cardiovascular:

  • coronary artery spasm → myocardial ischaemia/infarction
  • both tachycardia and bradycardia may occur
  • HTN
  • QRS widening and QT prolongation
  • aortic dissection

Neurological:

  • seizures
  • mydriasis
  • hypertonia
  • hyperreflexia
  • orofacial dyskinesia

Other:

  • ischaemic colitis
  • hyperthermia
  • metabolic acidosis
  • rhabdomyolysis
23
Q

What adverse effects is a patient likely to be experiencing if they have used stimulants (cocaine) and are now complaning of severe abdominal pain with rectal bleeding?

A

Ischaemic colitis = recognised in patients following cocaine ingestion

24
Q

What are the withdrawal symptoms of stimulants?

A

N.B. Many of the withdrawal effects are clinically the opposite of the dose effects:

  • Mood –> Depression with irritability and agitation
  • GI –> Craving and hyperphagia
  • Psychological –> Hypersomnia

DSM-V criteria:

Intense depressed mood +/- suicidal ideation AND

_>_2 symptoms developing withing hours to days of stimulant cessation:

  • Fatigue
  • Vivid or unpleasant dreams
  • Sleep problems (insomnia or hypersomnia)
  • Increased appetite
  • Psychomotor retardation or Agitation

Bradycardia is often present. Anhedonia and drug craving can also be present (but is not part of the diagnostic criteria).

Acute withdrawal symptoms (post-use “crash”) can be seen after repeated high-dose use (“binges”).

25
Q

How do you manage stimulant toxicity?

A

IV benzodiazepines are first line for most problems

  • chest pain - benzodiazepines and glyceryl niintrate. If MI develops –> primary percutaneous coronary intervention
  • hypertension - benzodiazepines and sodium nitroprusside
  • antipsychotics if necessary

There is no antidote.

26
Q

What is the MOA of opioids? What are the types?

A

MOA: act on opioid receptors to produce morphine-like effects

Types:

  • Naturally occurring opiates such as morphine and
  • Synthetic opioids such as buprenorphine and methadone
27
Q

What are the clinical features of opioid withdrawal?

A

Begin within 24 hours, peaks after 2-3 days and should be significantly better by 1 week.

  • Restlessness
  • Anxiety
  • Sweating
  • Yawning
  • Diarrhoea
  • Abdominal cramps
  • Nausea and vomiting
  • Palpitations
  • Rhinorrhoea and flu-like symptoms
  • Piloerection (goosebumps)
28
Q

What scale can be used to assess opioid withdrawal?

A

COWS - clinical opiate withdrawal scale

  • Mild -5-12
  • Moderate - 13-24
  • Moderately severe - 25-36
  • Severe - >36
29
Q

What are the features of opioid misuse?

A

Features of opioid misuse

  • rhinorrhoea
  • needle track marks
  • pinpoint pupils
  • drowsiness
  • watering eyes
  • yawning
30
Q

What are the features of opioid overdose?

A
  • Reduced GCS/unresponsive
  • Respiratory depression
  • Hypotension (accompanied by tachycardia)
  • Hypotonic/hyporeflexic coma
  • Pin point pupils (Miosis)
31
Q

What is the managment of opioid overdose?

A
  1. ABC approach including airway management and IV fluids
  2. IV naloxone: a short acting opiate antagonist (prevents opiates binding).
  3. Given IV every 1-2 minutes depending on response.
  4. Titrate the dose i.e. 400mcg then 800mcg then 2mg then 4mg.

NB: IM Naloxone - given to patients who abuse opiates and/or prescribed Methadone or buprenorphine

32
Q

What harm reduction methods can be used in opioid misuse?

A
  • Needle exchanges for IV drug users
  • Vaccination and testing for blood-borne viruses for sex-workers and IVDU
33
Q

What is the protocol for opioid detoxification?

A

Appoint key worker to support the patient

Offer opioid withdrawal treatment - dosing regimen based on severity, stability and setting for detoxification:

  • Inpatient - 4 weeks - usually only for those with comorbid conditions and mental health problems or requiring detox of other substances
  • Community - 12 weeks

Promote abstinence from illicit drugs, prevent relapse, reduce HIV and hepatitis C risk, reduce mortality, and decrease criminality - most require medication to maintain this

Refer to Drugs and Alcohol Service

Follow up for at least 6 months

Offer CBT

Offer support e.g. Narcotics Anonymous, SMART recovery

34
Q

What medications can be used to manage opioid detoxification?

A

1st line - methadone (liquid) or buprenorphine (sublingual)

2nd line - lofexidine/clonidine (alpha-2 agonist) if keen to detox over a short time or the above are unacceptable

Medications to manage symptoms e.g.

  • Anti-diarrhoeals
  • Anti-emetics
  • Pain killers
35
Q

What are the three types of rapid opioid withdrawal techniques?

A
  1. Ultra-Rapid: 24 hours under general anaesthesia or heavy sedation. This should not be offered
  2. Rapid Detoxification: 1-5 days with moderate sedation Can be considered if patient specifically requests it
  3. Accelerated Detoxification: no sedation

Withdrawal is actively precipitated by using high doses of opioid antagonists (e.g. naltrexone or naloxone)

36
Q

What medication can be used in the long term to promote stabilisation and maintenance after opioid detoxification?

A

Long-acting opioid agonists e.g. methadone or buprenorphine

Opioid antagonists e.g. injectable extended-release naltrexone

37
Q

What are the differences between buprenorphine and methadone as opiate substitution therapies?

A

Methadone

  • long half life (taken OD)
  • less euphoria than heroin, causes lethargy, constipation, reduces saliva
  • respiratory depression can occur at high doses esp with alcohol

Buprenorphine

  • long half life (administered OD)
  • less sedation/euphoria /positive reinforcement than heroin
  • less respiratory depression
38
Q

What is the difference with timing of heroin vs methadone withdrawal?

A

Heroin: starts 6 hrs later and reaches peak 36-48 hours; withdrawal usually completed after 5 days

Methadone: (half life: 1-2 days): starts 36 hours and reaches peak 3-5 days; withdrawal lasts longer than for heroin

39
Q

What is suboxone?

A

Combination of buprenorphine and naloxone

40
Q

How do you monitor compliance during opioid detoxification?

A

Urinalysis is the preferred method of screening

Offer incentives for every drug-negative test

Screening could be frequent at first (3/week) and then reduced

41
Q

What are the complications of opioid misuse? (excluding side effects)

A

Biological:

  • Viral infection secondary to sharing needles: HIV, hepatitis B & C
  • Bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
  • VTE
  • Respiratory depression and death following overdose

Psychological:

  • Craving

Social:

  • Social problems: crime, prostitution, homelessness
42
Q

What is the source of cannabinoids? What is the active substance in cannabis?

A

Source: Cannabis is grown from the plant strains cannabis Sattiva and Indica

  • The active stimulatory ingredient is tetrahydrocannabinol (THC) which binds CB1 receptors causing a high
  • The other component is CBD (cannabidiol) which is known to dampen the THC effects
43
Q

What are the clinical effects of cannabinoids?

A
  • Euphoria and relaxation
  • Distortion of sense of time and place
44
Q

What are the withdrawal symptoms of cannabis?

A

Usually only psychological - anxiety and depression.

Other symptoms:

  • Respiratory –> red eyes, dry mouth and coughing
  • Psychological –> Leads to paranoid thinking, anxiety and increases risk of depression and schizophrenia
  • GI –> Increased appetite after the high

Withdrawal is not dangerous

Year 5 - Psychiatry (53 decks)

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