4 - PSY - Alcohol and substance misuse Flashcards by Vish Gossain

Acute intoxication

Transient physical and mental abnormalities
May causes disturbed consciousness, cognition, perception, affect, behaviours etc
Specific for each substance

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Harmful use

Continuation of use despite damage to user’s physical/mental health or to social well-being - may be denied/minimised by user

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Withdrawal

Due to cessation after physical dependence
Clinically significant withdrawals = alcohol, opiates, benzos, cocaine, amphetamines
Complicated by development of seizures, delirium or psychotic symptoms

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Tolerance

More must be taken to achieve same intensity of effect

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6 core features of dependence syndrome

Primacy - drug and getting it = priority in life
Continued use despite negative consequences
Loss of control of consumption
Narrowing of the repertoire
Rapid reinstatement of dependent use after abstinence
Tolerance and withdrawal

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Substance induced psychotic disorder

Psychotic as direct result of substance neuro-toxicity
Psychotic features either during intoxication/withdrawal, or on background of chronic use
Can be difficult differentiating between this and primary psychotic illness

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Most common cause of alcohol related death?

Alcoholic liver disease

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Cost of alcohol to NHS?

Estimated as £3.5bn per year

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One unit =

8g/10ml of pure ethanol

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Guideline weekly drinking for men and women?

14 units

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Biological alcohol misuse aetiology

Risk 7x if first degree relative is alcohol dependent
Alcohol dependent parents = increased risk (even if adopted!!)
No specific genes - although some determine metabolising capacity (SEAsian’s may not be able to metabolise -> unpleasant flushing reaction)

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Psychological alcohol misuse aetiology

Mental illness increases risk
Stress, high social anxiety + low self esteem
Negative and Positive reinforcement models can be applied. E.G. - using alcohol to deal with stress, or using alcohol to be happy in social situations

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Social/Occupational alcohol misuse

Men>women - women increasing over last 20y
Mortality higher in lower socio-economic classes
Social isolation + loss of spouse = higher risk
Certain professions (bar-tending, farming)

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Complications of Alcohol misuse - Neuro

CNS - cog and mem impaired, brain shrinks, Wernicke-Korsakoff syndrome, Cenral Pontine Myelinolysis, Cerebellar degeneration
PNS - alcoholic peripheral neuropathy and myopathy, optic atrophy and visual changes

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Complications of Alcohol misuse - Resp

increases susceptibility to aspiration pneumonia and infections

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Complications of Alcohol misuse - CV

Alcoholic cardiomyopathy
Arrhythmia - esp AF
HTN
Cerebrovascular events - esp haemm strokes

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Complications of Alcohol misuse - Hepatic

Alcohol hepatitis
Fatty liver changes - vast majority changes reverse with abstinence
Cirrhosis at end stage of either of above - females increased risk of cirrhosis
Hepatocellular carcinoma

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Complications of Alcohol misuse - renal

Cirrhosis can predispose to hepato-renal syndrome

HTN > CKD

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Complications of Alcohol misuse - Pancreas

Commonest cause of chronic pancreatitis > malabsorption > DM

Also Acute pancreatitis

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Complications of Alcohol misuse - Spleen

Splenomegaly secondary to cirrhosis and portal HTN

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Complications of Alcohol misuse - S + L Bowel

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Malabsorption
Chronic diarrhoea
Lower GI Ca risk factor

Complications of Alcohol misuse - Gastro-oesophageal

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Oesophageal - Mallory Weiss tears from vomiting, varices +/- haemorrhage, Barretts oesophagus and CA
Gastric - gastritis and gastric erosions, peptic ulcer +/_ haemorrhage, gastric CA

Complications of Alcohol misuse - Sexual health

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Women - sexual dysfunction, fertility problems risk, teratogenic
Men - ED + hypogonadism

Complications of Alcohol misuse - Psychiatric

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Alcoholic hallucinosis - occurs during clear consciousness (sober)
ARBrainDamage - 60% of chronic heavy drinkers - impaired memory and executive function
Pathological jealousy - Primary delusion that partner has/is being unfaithful
Other PSY co-morbidity - anxiety and depression, suicide, schizophrenia

Risk factors for more severe alcohol withdrawal

Increased amount + time of heavy drinking Intercurrent medical illness Liver disease Previous withdrawal episodes

When to prophylactically treat AWS

- known alcohol dependence - Hx of alcohol withdrawal - consumed >10 units for >10 days - current withdrawal symptoms

Mild/uncomplicated alcohol withdrawal

Occurs 4-12 hours after the last alcoholic drink Features: coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation, anxiety The patient may occasionally experience transient hallucinations Intense cravings for alcohol Typically lasts 2-5 days

Seizures in AWS

5-15% of cases 6-48 hours after the last drink Risk factors for seizures include: heavy, prolonged alcohol consumption, previous withdrawal seizures, idiopathic epilepsy and history of head injury

Delirium Tremens - background

medical emergency 1-7 days after last drink 5% of AWS patients 40% mortality if untreated

Delirium Tremens - symptoms

``` clouded consciousness time, place, person disorientation amnesia hallucinations and delusions severe psychomotor agitation and tremor Fever Autonomic disturbances and E imbalances ```

AWS Key management

Benzos for Sx relief Nutritional and Vitamin supplementation (thiamine) Close physical and psychiatric complication monitoring

Thiamine deficiency - alcoholic causes

-drinkers dietary habits Chronic alcohol reduces thiamine absorption from gut Drinkers>liver disease - capacity for thiamine storage is reduced

How is Wernicke's encephalopathy caused?

Secondary to Thiamine (Vit B1) deficiency

Wernicke's symptom triad ?

Ataxic gait, Ocular motor signs, Acute confusional state

Wernicke's treatment

ALL PT's with symptoms/high risk of WE -> parenteral vitamin replacement High potency Thiamine replacement Glucose rehydration AFTER thiamine - glucose makes worse

Wernicke's Prognosis

untreated - 80% to Korsakoff's | 15% mortality if untreated

Korsakoff's Syndrome aetiological features

usually results from thiamine deficiency Rare causes - head injury, CO poisoning, encephalitis Can present w/o WE and in chronic form

Korsakoffs - Clinical features

Anterograde amnesia ( can't lay down new memories) (Less marked) retrograde amnesia Confabulaiton (false memories covering amnesia Apathy

Korsakoffs Treatment

aggressively treat preceding WE Oral thiamine and vitamins for 2 years Pyschosocial interventions for cog imp

Alcoholic History - In depth areas:

- Lifetime pattern of alcohol consumption - Current consumption - Signs of dependence - Social/occupational problems - Previous treatment attempts - Physical and mental health

Alcoholic Investigations

MCV - high specificity - raised 3-6 months after abstinence (life of RBC) GGT - alcohol related liver inflammation Liver US if indicated

Heroin - route? harmful effects?

- most commonly smoked - many progress to IV use - Acute -N+V, constipation, resp depression + lost consciousness - IV use - Hep B C + HIV, abscesses, cellulitis, septicaemia

Cocaine - harmful effects

Acute - ^HR, HTN, Vasoconstriction ---- increasing risk fo CVA, MI and Arrhythmias ---- acute anxiety, panic, impulsivity, impaired judgement Chronic - Nasal septum ad sinus necrosis, CKD 2ndary to HTN, Panic disorder, GAD, Psychosis

Harm reduction strategy examples...

- needle distribution + education - Take home naloxone - Substitute prescribing - treat co-morbidities - safe sex education

6 stages of change?

--- Pre-contemplation (no intention of changing) --- contemplation (aware of problem) --- Preparation (intent to take action) --- Action --- Maintenance (sustained change) --- Relapse ---

4 principles of motivational interviewing

Develop discrepancy (between behaviour and personal goals) Roll with resistance Express empathy with reflective listening Support self efficacy (improve pt confidence in ability to change)

Disulfiram

deterrent to alcohol abuse - unpleasant symptoms of flushing, headache, tachycardia,N+V if you drink

Acamprosate

to reduce cravings of alcohol - by enhancing GABA transmission in brain

Lofexidine

alpha agonist - reduces opiate withdrawal symptoms

Loperamide or Metoclopramide - why?

to treaet diarrhoea and N+V commonly seen in withdrawal

Substitute prescribing | - 2 drugs

Methadone - 24h half life - suitable for once daily dosing - orally - long acting synthetic opioid Buprenorphine - partial mu agonist - once daily sublingual preparation Both have street value

4 - PSY - Alcohol and substance misuse Flashcards

(51 cards)