10. Substance Misuse + Alcohol Abuse Flashcards
When should drug misuse be suspected?
Arrest for theft to buy drugs
Odd transient behaviour - visual hallucinations, elation, mania
Unexplained nasal discharge - cocaine sniffing, opioid withdrawal
Withdrawal Sx - shacking, red eyes
Injection stigmata - marked veins, abscesses, hepatitis, HIV
Repeated requests for analgesics
Outline opioid detoxification
Ideally in a special clinic
Methadone prescribing should be used as part of the transition to abstinence
- daily observed methadone dosing (30mg can have additional 10mg)
- cocaine use during is associated with poor prognosis
Buprenorphine (subtext)
- Partial agonist
- need to go into withdrawal first
Naltrexone = those formerly dependent, now stopped
Psychological support = counselling, motivational therapy, cognitive therapy, family therapy
***IV naloxone for acute overdose antidote
What is the role of Disulfiram?
Supports the treatment of chronic alcoholism by producing an acute sensitivity to ethanol
= inhibiting the enzyme acetaldehyde dehydrogenase, causing many of the effects of a hangover to be felt immediately following alcohol consumption
What screening questions are used to assess alcohol intake?
CAGE (>2 clinically sig)
- have you felt you should CUT down on drinking
- have people ANNOYED you by criticizing your drinking?
- have you ever felt GUILTY about drinking?
- have you ever had a drink first thing in the morning to stead nerves or get rid of a hangover (EYE opener)
TWEAK (>3 clinically sig)
- TOLERANCE = how many drinks can you hold? (2 points if >6)
- WORRIED = friends/family concerned? (2 points if yes)
- EYE-opener = do you drink when you first get up? (1 point if yes)
- AMNESIA = things you could not remember? (1 point if yes)
- CUT down = do you feel you should cut down? (1 point if yes)
GP = AUDIT PC, FAST
How should alcohol DEPENDENCE be managed?
BIOLOGICAL:
- diazepam/chlordiazepoxide detox regime + IV pabrinex
- disulfiram (hangover via acetaldehyde), naltrexone (reduce urge to drink, block opioid R), acamprosate (dec craving by enhanced GABA transmission)
- tx psychological complications
PSYCHOLOGICAL
- motivational interviewing (+ CBT)
- social network and environment-based therapies
SOCIAL
- self-help/group therapy (AA)
- family involvement
*** pts responsibility to contact DVLA, if you find they have not contact MDU for advice + inform the pt of your intended actions to give them the opportunity, if this does not work then contact DVLA personally
What are the possible complications of opioid misuse?
Sedation
Dizziness
N+V
Constipation
Physical dependence
Tolerance
Respiratory depression
What are the possible complications of alcohol misuse?
Fatty liver 80% progress to cirrhosis, liver failure in 10%
Cirrhosis: 5yr survival 48% if alcohol intake continues
CNS = poor memory/cognition, cortical/cerebella atrophy, fits, falls, neuropathy, Wernicke’s encephalopathy
GI = D+V, peptic ulcers, erosions, varices, pancreatitis
CVS = arrhythmia, HTN, cardiomyopathy
Skeletal = osteoporosis
Sperm = decreased fertility/motility
Malignancy = GI, breast
Marrow = decreased Hb, increased MCV
Social = related to violent crime, suicide, domestic violence, drink driving
What are the main causes of death related to alcohol misuse
- Fights/falls
- Liver failure
- Sudden/long slow
- Pancreatitis
- Overdose
- Withdrawal
- Wernikes encephalopathy
What calculation is used to work out alcohol units?
ml x % = ? / 1000
What are the signs of alcohol WITHDRAWAL and how should it be managed?
Early = tremor, sweating, nausea, anxiety, tachy
Late = delirium tremens, disorientation, hallucination, tremor, BP, increased pulse, fever, motor incoordination
Mx = benzodiazepines (chlordiazepoxide) + IV pabrinex (vit B1, B2, B6, nicotinamide, vitamin C, glucose)
***Alcohol activates GABA signaling = brain then down regulate GABA, when stop alcohol brain goes schizo as no GABA = withdrawal, benzo potentiate GABA = so stop withdrawals
What are the signs of opioid withdrawal?
Early = sweaty, yawning, rhinorrhoea, tachy, restlessness, dilated pupils, lacrimation, goosebumps
Late = N+V, diarrhoea, insomnia, abdo cramps, muscle pains
Outline the ICD-10 criteria for substance misuse
1) Acute intoxification
2) Harmful use
3) Dependence syndrome
4) Withdrawal state
5) Psychotic disorder
6) Amnesic syndrome
7) Residual disorder
Outline substance dependence
Physiologically dependent if they show tolerance or withdrawal
Drug Problems Will Continue To Harm (>3/1m)
1) Desire to take drug
2) Priority given to drug, than other activities/obligations
3) Withdrawal state
4) impaired ability to Control substance use
5) Tolerance
6) continue despite Harmful consequences
How should substance misuse be investigated?
***Full systems eval = resp, CVS, abdo, neuro, obs
Bloods = HIV, Hep B/C, TB, U+Es, LFTs/clotting, drug levels
Urinalysis = drug metabolites
ECG = arrhythmias
ECHO = suspected endocarditis
List the peripheral stigmata of chronic liver disease in alcoholics?
Palmar erythema
Dupuytren’s contracture
Spider Naevi
Gynaecomastia
Clubbing
Caput medusa
Oesophageal varices
