Alcohol/Substance Use Problems Flashcards
DEFINITIONS:
- Harmful use
- Hazardous use
- Substance dependence
- Substance intoxication
- Substance withdrawal
- Substance Misuse
- Pattern of use such that it has adverse consequences(4L’s: love, livelihood, liver, law) without dependence.
- Pattern of use such that it puts user at risk of adverse consequences without dependence.
- Incorporates physiological, psychological and behavioural components that develop after repeated substance use. ≥3 ICD-10 criteria over previous year.
- Transient, substance-specific condition.
- Substance-specific syndrome that occurs on withdrawal/cessation of psychoactive substance that has been used in high doses for prolonged periods.
- Harmful/hazardous use of psychoactive substances
ALCOHOL DEPENDENCE SYNDROME(from Edwards and Gross 1976)
- Narrowing of repertoire
- increasingly stereotyped pattern of drinking. - Increased salience of drinking.
- drinking becomes priority over other things. - Increased tolerance to alcohol.
- Withdrawal Sx.
- heavier degrees reflected in early morning withdrawal.
- tremors, N+V, sweating and mood disturbances. - Relief/avoidance of withdrawal Sx. with further drinking.
- Subjective awareness of compulsion to drink
- described as craving - Rapid reinstatement after abstinence
MEASURING ALCOHOL UNITS
- 1 unit=10 mL/8g pure alcohol
2. ≤14 units/week over ≥3d for both men and women
CLINICAL FEATURES OF ALCOHOL WITHDRAWAL:
- Uncomplicated alcohol withdrawal syndrome
a) With withdrawal seizures
b) Withdrawal delirium(delirium tremens)
- Symptoms develop 4-12h after drinking cessation.
- Tremulousness, sweating, N+V, mood disturbance(anxiety, depression, feeling edgy), psychomotor agitation, hyperacusis, autonomic hyperactiviy(tachycardia, hypertension, mydriasis, pyrexia), sleep disturbance
- can be with perceptual disturbances
- Symptoms develop 4-12h after drinking cessation.
a) - 6-48h after drinking cessation, peak incidence at 36h
- in 5-15% dependent drinkers
- usually generalised tonic-clonic
- Predisposing f: previous history, concurrent epilepsy, low K+/Mg2+
b) - 1-7d after cessation, mean 48h, peak incidence 72h
- Altered consciousness, marked cognitive impairment
- Vivid hallucinations and illusions ie Lilliputian visual hallucinations, formication
- Marked tremor, autonomal arousal(heavy sweating, raised pulse and BP, fever), paranoid delusions
- 5-15% Mortality from CV collapse, hypo/hyperthermia, infection
- Predisposing: physical illness(hepatitis, pancreatitis, pneumonia)
ALCOHOL-RELATED COGNITIVE DISORDERS:
- Blackouts
- Wernicke-Korsakoff Syndrome
- Dementia
- Refers to episodes of anterograde amnesia, not collapsing/passing out
- Due to thiamine deficiency
- classic triad in Wernicke’s encephalopathy: delirium, opthalmoplegia(6th nerve palsy/nystagmus/conjugate nerve palsy), ataxia.
- Korsakoff’s psychosis: extensive anterograde and retrograde amnesia, frontal lobe dysfunction and psychotic Sx(in the absence of delirium)
- Due to thiamine deficiency
- With long-term alcohol misuse.
ALCOHOL-RELATED PSYCHOTIC DISORDER
- Can occur with heavy alcohol consumption but also alcohol misuse tends to be a common comorbidity in people with mental disorders with psychotic symptoms.
- Distinguished from acute intoxication/alcohol withdrawal delirium by absence of cognitive impairment and by clarifying when was last drink.
ALCOHOL-RELATED MOOD DISORDERS
- People with low mood more likely to drink heavily and vice versa.
- Pharmacological treatment of depression becomes less effective
- Heavy intake can precipitate/relapse manic illness in people with bipolar affective disorders
SUICIDE AND SELF-HARM RISK
- Lifetime risk 3-4% among problem drinkers
- 60-120x greater than general population
- Either due to development of alcohol-related psychiatric disorder or impaired judgement/disinhibition secondary to alcohol.
ALCOHOL-RELATED ANXIETY DISORDER
- Short term anxiolytic
- Withdrawal symptoms mimic anxiety and panic symptoms.
CAGE QUESTIONNAIRE
- ≥2 is positive, warrants questioning for dependence syndrome
1. Have you ever felt you ought to Cut down on your drinking?
2. Have people ever Annoyed you by criticizing your drinking?
3. Have you felt Guilty about your drinking?
4. Have you ever needed an ‘Eye-opener’(drink first thing in the morning to steady nerves/get rid of hangover)
ALCOHOL USE DISORDERS IDENTIFICATION TEST(AUDIT)
- 10 questions scored 0-4
- Score ≥8 indicator of harmful/hazardous use
- Score ≥15 in men and ≥13 in women indicates likely dependence
INVESTIGATIONS
- Urine or saliva drug-screen
- Breath alcohol test
- high reading with no signs of intoxication indicative of tolerance - FBC
- raised MCV - U&E
- LFT
- Raised AST, ALT, GGT - Clotting screen
- Prolonged PT, sensitive marker of liver function - ECG
- HIV and Hepatitis serology if injected
- Brain imaging
- when have withdrawal delirium
- rules out additional complications ie infection, head injury, abcess
AETIOLOGY(ALCOHOL DEPENDENCE):
- Genetic and biochemical factors:
- East Asian deficient in aldehyde-dehydrogenase, explains reduced rates of consumption and dependence among these cultures.
- higher concordance in monozygotic twins > dizygotic twins. - Psychological factors:
a) operant conditioning
- Positive reinforcement: pleasant effects of alcohol consumption reinforce drinking behaviour.
- Negative reinforcement: continued drinking reinforced by desire to avoid negative effects of alcohol withdrawal symptoms.
b) Observational learning theory(modelling)
- relatives/peers
c) Presence of psychiatric/physical illness - Social and environmental factors
- Cultural attitudes
- Pricing
- Certain professions: members of leisure and catering trades, doctors, journalists, those involved with shipping and travel.
TREATMENT OF ALCOHOL WITHDRAWAL:
- Contraindications to home treatment
- Managing delirium tremens(and Wernicke’s encephalopathy)
- Severe dependence, Hx. of withdrawal seizures/delirium tremens, unsupportive home environment, previous failed community detox.
- a) Emergency hospitalization
- Search for other medical complications ie infection, head injury, liver failure, GI haemorrhage, Wernicke’s encephalopathy
b) Medications:
- Benzodiazepine in high doses(eg: chlordiazepoxide/diazepam/lorazepam to treat seizures. Start on high doses then gradually reduce over 5-7d
- Large dose of parenteral(IM/slow IVI) thiamine(Pabrinex ampoules x2 BD for 5d) to prevent development of Wernicke-Korsakoff Syndrome. If suspected Wernicke’s encephalopathy, IV Pabrinex ampoules x4 TDS for 2d)
c) Monitor Temperature, fluid, electrolytes and glucose
- risk of hyperthermia, dehydration, hypoglycaemia, hypokalaemia, hypomagnesaemia
MAINTENANCE AFTER DETOX:
- Pharmacological therapy
- Psychosocial interventions
- a) Disulfiram(Antabuse)
- blocks ALDH
- causes unpleasant symptoms of anxiety, flushing, palpitations, headache and nausea very soon after alcohol consumption.
- CI: patients with compromised cardiorespiratory function and psychosis
b) Acamprosate(Campral)
- enhances GABA transmission, weak antagonist of NMDA receptors
- reduces craving, safe to use while drinking
c) Naltrexone(Nalorex)
- Sinclair method
- Blocks opioid receptors, reducing pleasant effects of alcohol
d) Antidepresants and benzodiazepines only for treating comorbid psychiatric illnesses.
- a) Motivational interviewing
b) CBT
c) Alcoholics anonymours
d) Group theropy
e) Social support: social workers, probation officers, citizens advice agencies
