addiction

Question 1

diagnosis of alcohol misuse

Answer 1

harmful use - pattern causing damage to physical or mental health, use >1month or repeatedly over 12months

dependence - 3 or more of the following for >1m/repeatedly over 12
- cravings to take, difficulty controlling use, primacy, increased tolerance, withdrawals on reduction/abstinence, persist despite consequences

withdrawal state - variable clustering/severity

Question 2

alcohol misuse screening tool

Answer 2

CAGE - 2 or more = likely alcohol problem

 Have u tried to Cut down?
 Have you felt Annoyed by people criticizing your drinking?
 Have you felt Guilty about drinking?
 Have you felt the need to have an Eye-opener?

others - AUDIT, FAST, PAT (A&E)

Question 3

medical management of alcohol misuse

Answer 3

thiamine - prevent Wernicke-Korsakoff
benzodiazepines, chlordiazepoxide - manage withdrawals
disulfiram (antabuse) - aversion/deterrent medications

anticraving med - acamprostate, naltrexone, nalmefene

Question 4

assessment of alcohol withdrawals

Answer 4

CIWA-Ar
- severity of alcohol withdrawal
- >=15 = severe withdrawal

Question 5

management of alcohol withdrawal

Answer 5

chlordiazepoxide - librium

IV high dose B vitamins - pabrinex
- should be followed by regular dose of thiamine

Question 6

delirium tremens

Answer 6

medical emergency assoc with alcohol withdrawal - can be fatal due to high risk of seizure

variable levels of consciousness usually 48-72hrs after alcohol stopped

Question 7

pathopysio of delirium tremens

Answer 7

alcohol stimulates GABA receptors in brain - these have relaxing effect

alcohol also inhibits glutamate receptors (NMDA) - further inhibitory effect on elec activity

chronic alcohol results in
-> down regulated GABA
-> up regulated glutamate

> extreme excitability of brain with excess adrenergic activity presents as confusion, tremor etc

Question 8

delirium tremens presentation

Answer 8

profoundly confused
tremor, autonomic overactivity
agitation, sleeplessness
hallucinations, delusions - things crawling on skin
sweating, high BP

Question 9

delirium tremens management

Answer 9

benzodiazepines (chlordiazepoxide, diazepam) regularly + targeted to symptoms

fluid, elecctrolyte + vitamin replacement

Question 10

delirium tremens prognosis

Answer 10

mortality = 5% (Z2f 35%)

death by
- cardiovascular collapse
- infection
- hyperthermia
- seizures
- self-injury

Question 11

alcohol related brain damage

Answer 11

wernicke’s encephalopathy - comes before Korsakoff syndrome
Korsakoff syndrome
myelin sheath degradation
neuroinflammation
fall -> subdural haematoma

excess alcohol leads to thiamine (vit B1) deficiency

Question 12

Wernickes encephalopathy

Answer 12

medical emergency + high mortality iif untreated

thiamine deficiency
- ophthalmoplegia
- confusion
- ataxia

Question 13

wernicke’s encephalopathy presentation

Answer 13

ophthalmoplegia, confusion, ataxia

• visual impairment - nystagmus
• hearing impairment
• reduced conscious level
• hypothermia
• lactic acidosis
• circulatory change

Question 14

Korsakoffs psychosis

Answer 14

comes after wernickes
often irreversible + results in full time institutional care
-> forget to turn hobs off, lock door

Question 15

korsakoffs psychosis

Answer 15

memory impairment - retrograde + antegrade
behavioural changes

may exhibit nystagmus + ataxia

Question 16

korsakoffs ppsychosis management

Answer 16

thiamine supplementation
abstaining from alcohol

Question 17

what is a natural or drug induced high mediated by?

Answer 17

mesolimbic pathway
- sometimes referred to as pleasure centreof brain
-> dopamine = pleasure neurotransmitter

Question 18

ICD 10 dependence criteria

Answer 18

3 or more for a least 1 month
- sense of compulsion
- craving
- physiological withdrawal
- evidence of tolerance
- preoccupation with substance use
- persistent use despite harmful consequences

Question 19

management of opiod dependence

Answer 19

safety bundles - drug diaries, risk assessment

ORT (opiod replacement therapy) - methadone, buprenorphine

Question 20

opiod replacement therapy (ORT)

Answer 20

substitute prescribing - deliberate prescribing in a controlled manner

phases - induction, optimisation, maintenance, reduction

supervised in front of pharmicist

–> methadone, buprenorphine - compliance monitored using urinanalysis

Question 21

methadone

Answer 21

Mu receptor agonist
long half life
peak plasma conc - 4hrs
steady state - 5 days
higher doses (60-100ml) = more effective
-> start on lower dose
liquid preparation

high dependance, low lethal dose

Question 22

buprenorphine

Answer 22

Mu receptor partial agonist with low intrinsic activity + affinity
peak plasma levels 1.5-2.5hrs
duration of effect doses - 12-24mg
sublingual tablets

Question 23

side effects of methadone

Answer 23

prolong QTc interval
sedation
other drug interactions - liver metabolism
might give to others

Question 24

why does chronic stress encourage highly rewarding behaviours?

Answer 24

chronic stress leads to dampening of dopaminergic activity through down regulation of D receptors
- reduces sensitivity to normal rewards
- encourages exposure to highly rewarding behaviours

rapid increase in stress can motivate drug seeking in dependent individuals

Question 25

importance of prefrontal cortex in addiction

Answer 25

-puts brakes on reward pathway
- matures late + is vulnerable whilt developing
- dysfunctional in addicted people