1b Substance Misuse & Addiction Flashcards
Which substances can cause addiction (13)?
- Alcohol
- Nicotine
- Cannabis
-
Stimulants
- Amphetamine
- Cocaine
- Crack
- Ecstasy
-
Opioids (prescribed, OTC)
- Heroin, fentanyl
- DF118
- Ketamine
- Solvents
-
G-drugs
- GHB, GBL
- Benzodiazepines
-
Psychedelics
- LSD
- Magic mushrooms
- Nitrous oxide
- Khat
-
‘Novel psychoactive substances’
- ~950 synthetic (UNODC);
- new: ~1/wk
- Categories: Depressant, stimulant, hallucinogenic, cannabinoid
What are the 3 categories of reasons that one may experiment with addictive substances for recreational reasons?
- Positive reinforcement
- Negative reinforcement
- ‘Normal’
Experimental/‘recreational’ use: causing no/limited difficulties (majority of population)
Give examples of positive reinforcement in terms of alcohol / drug use (4).
- Escapism
- Stay awake
- Get high
- Like it
Give examples of negative reinforcement in terms of alcohol / drug use (4).
- Boredom
- To get to sleep
- Reduce anxiety
- Feel better
Give examples of ‘normal’ reasons in terms of alcohol / drug use (5).
- To fit in
- Why not?
- Rebel
- Everyone does
- Curious
Define intoxication.
- A transient syndrome due to recent substance ingestion that produces clinically significant psychological or physical impairment
- These changes disappear when the substance is eliminated from the body
Define withdrawal state.
- A group of symptoms and signs that occur when a drug is reduced in amount or withdrawn entirely
Define tolerance.
- A state in which after repeated administration, a drug produces a decreased effect
- Increasing doses are therefore required to produce the same effect
Define harmful use.
- A pattern of psychoactive substance use that is causing damage to health (physical or mental)
What are the requirement to diagnose dependence syndrome (6)?
Classification: ICD 10
CLoWN PT (compulsion, lack of control, withdrawal, neglect, persistence, tolerance)
3 or more of the following in past year:
* A strong desire or sense of compulsion to take a substance.
* Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use.
* A physiological withdrawal state when substance use has ceased or been reduced (This is mainly relevant to alcohol, opiates, benzodiazepines, G-drugs).
* Tolerance (ie. need to take more of the substance to get the same effect).
* Progressive neglect of alternative pleasures or interests because of substance use, increased amount of time necessary to obtain or take alcohol or to recover from its effects.
* Persisting with substance use despite clear evidence of overtly harmful consequences.
A client/patient CANNOT have a diagnosis of BOTH harmful use AND dependence
What are the requirements to diagnose harmful use (4)?
Classification: ICD 10
- A pattern of substance use that causes damage to health.
- The damage may be: (1) physical or (2) mental (This criterion MUST be present if harmful use is diagnosed).
- Adverse social consequences.
- Harmful use includes bingeing on substances. Does not include ‘hangover’ alone.
- Does not fulfil any other diagnosis within substance use e.g. dependence
A client/patient CANNOT have a diagnosis of BOTH harmful use AND dependence
What are the differences between harmful use (ICD 10) and harmful use (ICD 11) (2)?
- A new category to denote single episodes of harmful use from a pattern of harmful use
-
Harm to health of others.
- This includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour related to substance use on the part of the person to whom the diagnosis of Harmful pattern of use of the substance/alcohol applies
What are the requirements to diagnose dependence (3)?
Classification: ICD 11
PLaN- Precedence, Lack of control, Neuroadaptation
- Impaired control over substance use (i.e. onset, frequency, intensity, duration, termination, context).
- Increasing precedence of substance use over other aspects of life (e.g. repeated relationship disruption, occupational or scholastic consequences, negative impact on health).
- Physiological features indicative of neuroadaptation to the substance, (e.g. tolerance, withdrawal, use of pharmacologically similar substances to prevent or alleviate withdrawal symptoms.
The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months.
What are the criteria to diagnose opioid use disorder?
Classification: DSM 5
What is the course of behaviour for individuals with harmful use of alcohol / drugs?
- There is a shift in motivational desire, as the urgency & necessity increases (regular use → period of stress where the euphoric effects subside the fears)
- It is reversible
- Experimental / recreational use, cause no / limited difficulties
- Want: Increasingly regular use (fewer people) (harmful)
- Need: Spiralling: dependence (smaller number) (majority of population) (Like)
What does alcohol do to the brain’s inhibitory system?
- Alcohol behaves as a modulator of GABA-benzodiazepine coupling leading to an enhanced inhibitory system
- Concerns the GABA-A receptor
Which receptor is predominantly involved in terms of the brain’s inhibitory system?
- GABA-A receptor
Which receptors are concerned with the excitatory glutamate system?
- NMDA receptors
What impact does alcohol have on NMDA receptors?
- Alcohol alters the coupling and modulatory sites of the receptor, impairing the excitatory system
What neuroadaptations take place due to chronic alcohol exposure?
- GABA-A receptor subunit becomes less sensitive to alcohol - there is a reduced function in the inhibitory function - tolerance, given that alcohol consumption retains a GABAergic balance
- Chronic alcohol consumption also leads to an upregulation in the excitatory system (NMDA receptors)
What are the physical effects of alcohol harmful use / dependency?
There are a lot, learn 5.
What are the symptoms of alcohol withdrawl?
6-12 hrs
Minor Withdrawal Symptoms: tremulousness (hand, tongue, eyelids), diaphoresis, fever (with or without infection), anxiety, agitation, nausea, vomiting and retching.
12-24 hrs
Alcoholic Hallucinosis: visual and auditory (usually accusatory or derogatory voices) hallucinations, tactile disturbances
12-48 hrs
Withdrawal Seizures
48-72 hrs
Delirium Tremens (DTs): hallucinations, confusion and disorientation, hypertension, agitation, tachycardia >100/min, fever (with or without infection), severe tremor in hands and body.
DTs represent a medical emergency.
Patient may need observations for 72 hours after cessation of drinking.
What are the appearance & behaviour signs in a mental state examination of drug (heroin) harmful use / dependency (6)?
- Nil abnormal movements
- Dressed in tracksuit
- Reasonable rapport
- Looks downcast
- Collapsed veins (described)
- Restless
What aspects of history taking are specific to alcohol harmful use / dependency?
-
History of:
- Alcohol related seizures, Delirium Tremens, Alcohol psychosis, haematemesis, melaena
-
Examination:
- Comment on the presence of jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT
-
Investigations:
- Fibro scan / Ultrasound
- Bloods (LFT, GGT, Lipids, U&E, amylase)
- Breathalyser
- Urine Drug Screen
What’s the scoring of the alcohol use disorder identification test (AUDIT)?
- 0-7: low risk
- 8-15: increasing risk
- 16-19: higher risk
- >20: possible dependence
Which drugs are used to help boost GABA function in patients in the withdrawal state of chronic alcohol exposure?
- Benzodiazepines
What are the symptoms of opiate withdrawl (11)?
ARMY FINDS:
ACHES (muscular/ bones)
Runny nose (or lacrimation), Eye dialation
MOOD- irritable/ anxious
YAWNING
FEVER
INSOMNIA
NAUSEA (or vomiting)- GI upset
DIARRHEA
SWEATING, gooseflesh skin
+
* Tachycardia
* Restlessness
* Tremor
What happens to patients in an alcohol withdrawal state?
- There is an upregulation of the excitatory system:
- An increase in calcium dynamics is toxic, leading to hyperexcitability (seizures) & atrophy
How does one calculate units in alcohol?
Units = % strength x ml /1000
How is opioid overdose managed?
-
Naloxone: inject into upper arm or thigh (400mcg), or nasal spray (50% each nostril)
- If no response after 3 mins, repeat.
- Provide airway support, recovery position
