Substance Misuse and Disorder Flashcards
Factors that contribute to the likelihood of a person developing a substance misuse or dependence
- Genetic factors are key
- Childhood experiences such as abandonment, bereavement, abuse, and conditions like ADHD
- Adolescent experiences such as learning or conduct disorders, family breakdown, and the actions of peers
- Environmental factors such as the economic and physical availability of the substance, stress, loss events, and the actions of peers
Features of dependence syndrome
- Salience (a change in life priorities to primacy of drug seeking behaviour)
- Tolerance
- Impaired control of consumption
- Compulsion
- Withdrawal syndrome, the user will learn to anticipate and avoid withdrawals alongside relief use
- Continued drug use despite harm
- Reinstatement of the previous pattern of drug use after abstinence
States of Change Model for Motivation and Action towards change
- Pre-contemplation: the user does not recognise that the problem exists
- Contemplation: the user accepts that there is a problem, and begins to weigh up the positive and negative aspects of continued drug use
- Decision: the user decides whether to continue using the drug
- Action: the user attempts change
- Maintenance: this is a stage of maintaining gains made and attempting to improve those areas of life that have been harmed by drug use
- Relapse: a return to previous behaviour, but with the possibility of gaining useful strategies to extend the maintenance period on the user’s next attempt
Pathological Intoxication
Pathological intoxication is incredibly dangerous, and can follow ingestion of only a small amount of alcohol.
This is the murder or injury of another person, followed by complete amnesia of the event
- The patient is observed to be in a trance-like state (automatism), and EEG abnormalities support this
It can be used as a defence in murder cases “mania a potu”, but is incredibly rare.
Alcohol Related Amnesia
Transient amnesia related to intoxication is relatively common, the amnesia stems from inability to recall memories rather than register them.
Once experienced it is more likely to become a regular occurrence
- This can be total with abrupt onset and when the patient recovers from intoxication there is no subsequent recall of events
- It can also be patchy amnesia, where there are indistinct boundaries with islands of memory
An example of this is journey syndrome, where patients regain awareness and they are in a strange place and cannot recall how they arrived there
Wernicke-Korsakoff Syndrome Pathophysiology
10% of chronic alcoholics will develop W-K. The condition develops due to thiamine deficiency, which occurs as the primary source of energy in alcoholism is ethanol and the patient’s thiamine absorption is impaired
- Thiamine is a cofactor for the breakdown of glucose by the Kreb’s cycle, meaning that when the patient is given IV glucose/ eats a meal they quickly deplete their remaining thiamine stores
- Thiamine deficiency leads to petechial haemorrhages of the floor of the third ventricle, mammillary bodies, brain stem, and thalamic nuclei
Wernicke’s Encephalopathy
Wernicke’s presents acutely with 6th nerve palsy and nystagmus, clouding of consciousness and ataxia. If untreated Wernicke’s has a high mortality, and of the patients that survive the majority will go on to develop Korsakoff’s psychosis
Korsakoff’s Psychosis
- Korsakoff’s psychosis is a devastating anterograde loss of short term memory, visuospatial impairment, and reduced insight with preservation of other functions
- Patients attempt to compensate for their loss of memory by confabulating
Alcoholic Organic Brain Damage
There is a decrease in the volume of white matter and an increase in ventricular size in alcoholics, therefore the vast majority will show some form of cognitive impairment. This includes
- Impairment of judgement, dementia, cerebellar degeneration, and alcoholic amblyopia
Pathological Jealousy
Pathological jealousy is also known as Othello syndrome. These are delusions of infidelity combined with excessive ruminations over the delusions
- This is a dangerous condition for the partner of the affected person
Delirium Tremens
Delirium tremens (DTs) are a feature of severe alcohol withdrawal syndrome
1. Delirium. This is fluctuating and associated with clouding of consciousness and disorientation in time, place and person
2. Hallucinatory experiences, visual hallucinations are commonest and classically frightening.
3. Tremor
The symptoms are fluctuant, and tend to be worse during the night. The condition generally lasts around 3 – 5 days, and recurrent attacks are common once the initial attack has occurred.
- The DTs may be preceded by withdrawal fits (grand mal seizures) by around 12 to 24 hours
Screening for Alcohol Dependence
CAGE questionnaire or AUDIT questionnaire Breath or blood alcohol levels MCV (raised) LFTs-Particularly Gamma-GT Carbohydrate-deficient transferring Urinary ethyl glucuronide
Management of Alcohol Withdrawal
Management of alcohol withdrawal is with detoxification. This involves medication to reduce withdrawal symptoms, nutritional supplementation, and psychological support
Where patients are uncomplicated, there can be detox in the outpatient setting
- There is usually chlordiazepoxide 20 – 30mg QDS gradually reduced over 7 – 10 days, alongside 100mg thiamine TDS for 4 weeks
Inpatient Detox
Admission for detox is recommended in patients with severe symptoms
- Chlordiazepoxide or diazepam are used to ease withdrawal symptoms, these should also be used in delirium tremens at an adequate dose to control agitation
- If there are alcohol withdrawal seizures there should be use of diazepam (more effective than phenytoin) 10mg IV, alongside a 100mg loading dose of chlordiazepoxide
- IV pabrinex should be given in all patients, this contains B vitamins as well as nicotinic acid, folate and vitamin E. Patients can then be switched to B-complex vitamins after a few days
o The aim of this is to prevent Wernicke-Korsakoff’s
Psychological Interventions
- Brief interventions and motivational interviewing
- Cognitive behavioural therapies can include relaxation training, assertiveness, drink refusal skills, and developing alternative coping strategies
- Relapse prevention
- Alcoholics anonymous, this is a 12 step programme that takes place in a group setting
