Substance Abuse Disorders

Question 1

Defn of substance misuse?

Answer 1

Use of a substance in excess, or in a different way to its prescribed or intended use

Question 2

Defn of hazardous substance use?

Answer 2

A pattern of substance use that increases someone’s risk of harmful consequences to themselves

Question 3

Defn of harmful substance use?

Answer 3

Pattern of misuse that damages individual’s physical or mental health

Question 4

Substance use disorder defn according to DSM-V?

Answer 4

A maladaptive pattern of substance use, leading to impairment or distress, manifesting itself in any of the following:

• Role failure: fails to fulfill important obligations at school, home or work
• Risky drug taking: uses in a manner that is physically hazardous
• Run-ins with the law: legal problems
• Relationship problems: social or interpersonal problems

Question 5

Intoxication defn

Answer 5

When the substance is used and the user is “under the influence” of the substance –> reversible

Question 6

Tolerance defn

Answer 6

The body adapts to the effects of a substance, and higher doses are needed to achieve the same initial effect (“chasing the dragon”)

Question 7

Withdrawal defn

Answer 7

An indicator of tolerance, effects can be the opposite of intoxication symptoms. Manifests as abnormal physical or psychological features that follow the abrupt discontinuation of a drug of dependance

Question 8

Detoxification defn

Answer 8

Process of using medicines to reduce the level of tolerance gradually and safely, to relieve withdrawal symptoms

Question 9

Classes of substances of abuse

Answer 9

• Psychedelics
• Stimulants
• Depressants

Question 10

Signs of cannabis intoxication

Answer 10

CNS: Euphoria, anxiety, impaired short-term memory, poor judgment and co-ordination
Physical: Red eyes, dry mouth, increased appetite, tachycardia, hypotension
Severe intoxication: Ataxia, sedation, poor concentration, slurred speech

Question 11

What is amotivational syndrome?

Answer 11

Syndrome associated with chronic cannabis use: users show apathy, dullness, diminished goal-directed activities

Question 12

Cannabis withdrawal

Answer 12

Restlessness, insomnia, anxiety, aggression, anorexia, muscle tremors
Similar to, but much less severe than alcohol, opioid, benzodiazepine withdrawal

Question 13

Management of cannabis withdrawal

Answer 13

Detoxification is unnecessary

Treat uncomfortable symptoms with diazepam 5mg PO tds tapered down over a few days

Question 14

Cannabis-induced psychiatric effects

Answer 14

• Acute ‘toxic’ responses: panic, anxiety, depression, psychosis
• Withdrawal syndromes
• Cannabis-induced psychotic disorder
• Amotivational syndrome
• Effects on pre-existing mental illness

Question 15

Symptoms of tik use

Answer 15

Rush of intense arousal, euphoria, increased energy, excessive speech, increased libido, reduced appetite

Question 16

Symptoms of tik withdrawal

Answer 16

“Crash”, agitated, exhaustion, insomnia, hyperphagia
Withdrawal syndrome can have a very long course
From day 45-120 can experience symptoms of depression, anxiety, lethargy, insomnia, drug cravings

Question 17

Management of tik withdrawal

Answer 17

Doesn’t normally require detoxification
Support, empathic counseling, occasionally medically manage symptoms
Intensive long-term outpatient rehabilitation
If they have SIPD, treat with atypical antipsychotics

Question 18

Psychiatric complications of tik use

Answer 18

• SIPD
• Anxiety disorder
• MDD
• Sleep disorder
• Sexual dysfunction
• Intoxication delirium
• Cognitive impairment

Question 19

DSM-V criteria for alcohol use disorder

Answer 19

At least 2 of the following, within a 12 month period:

1. Alcohol often taken in large amounts
2. Persistent desire/unnecessary effort to cut down
3. Great deal of time spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
4. Craving/strong desire to use alcohol
5. Recurrent alcohol use leads to failure to fulfil major obligations at work, school or home
6. Continued use despite recurrent social or interpersonal problems caused/exacerbated by effects of alcohol
7. Give up/reduce important activities because of alcohol
8. Recurrent use in situations in which it is physically hazardous
9. Use continued despite knowledge of having a persistent physical or psychological problem due to alcohol
10. Tolerance: either need increased amounts to reach desired effect, or diminished effect with continued use
11. Withdrawal: either characteristic withdrawal syndrome, or alcohol or a closely related substance (e.g. benzo) taken to relieve or avoid withdrawal symptoms

Question 20

DSM-V criteria for alcohol use disorder (less wordy)

Answer 20

At least 2 within 12 month period:

1. Use alcohol in large amounts
2. Unable to cut down
3. Time spent using, getting or recovering from use
4. Craving for alcohol
5. Use leads to failure to meet obligations
6. Continued use despite it causing problems
7. Reduce activities because of alcohol
8. Use when physically hazardous
9. Continued use despite known harms
10. Tolerance
11. Withdrawal

Question 21

Alcohol intoxication: low dose

Answer 21

• Disinhibited –> risky behaviour
• Talkative
• Outgoing
• Belligerent
• Emotional

Question 22

Alcohol intoxication: high dose

Answer 22

• CNS depressant
• Impaired judgment
• Slurred speech
• Staggering gait

Question 23

Alcohol poisoning

Answer 23

• Respiratory depression
• Coma
• Death

Question 24

Uncomplicated alcohol withdrawal

Answer 24

• Anxiety
• Agitation
• Nausea/vomiting
• Insomnia
• Cravings

Question 25

Complicated alcohol withdrawal (Delirium Tremens)

Answer 25

• Perceptual disturbances
• Disorientation
• Agitation
• Hypertension
• Tachycardia
• Fever + sweating + rigors
• Psychosis
• Tonic-clonic seizures

Question 26

Management of alcohol dependance

Answer 26

• Assessment
• Detailed history (NB collateral)
• CAGE questionnaire
• Motivational interviewing and establish goals with patient
• Treat co-morbidities
• Antidepressants (for after detoxification)
• Opioid receptor blockers e.g. naloxone/naltrexone
• Disulfiram (with caution)
• Rehabilitation programme
• Support groups e.g. AA

Question 27

Side effects of disulfiram

Answer 27

• Drowsiness
• Forgetfulness
• Abdominal discomfort
• Hepatotoxicity
• Peripheral neuropathy
• CVS abnormalities

Question 28

Alcohol detoxification

Answer 28

• Replace alcohol with long-acting benzodiazepine: find dose that suppresses symptoms without causing intoxication
• Gradually reduce dose
• Haloperidol if severe DT with hallucinations
• Check for vitamin deficiencies and supplement: NB thiamine. Also Vit B Co, Vit C
• Replace fluids, but only give dextrose after thiamine given (can develop acute encephalopathy)

Question 29

Benzo’s for mild DT’s

Answer 29

Diazepam 5-10mg PO 6hrly, gradually reduced over a week

Question 30

Benzo’s for moderate DT’s

Answer 30

Diazepam 10-20mg PO 6hrly, gradually reduced over a week

Question 31

Benzo’s for severe DT’s

Answer 31

Diazepam IV injection 10mg, repeat after 30min if necessary
Thereafter, maintenance dose of 1-5mg/hour
NB: danger of apnoea

Question 32

Rx for DT’s with severe hallucinations

Answer 32

Diazepam either PO or IV (depending on pt needs)
+
Haloperidol 2-5mg PO