Addiction

Question 1

How do addictive substances work to cause addiction?

Answer 1

Increase the amount of dopamine in the reward pathway
This increases activity in the orbito-frontal cortex and reduces activity of the pre-frontal cortex
This increases substance taking and seeking behaviour

Question 2

What are the functions of the orbito-frontal cortex and the pre-frontal cortex?

Answer 2

Orbito-frontal cortex is involved in producing motivation to act
Pre-frontal cortex is involved in guiding behaviour and keeping impulses under control

Question 3

What is tolerance?

Answer 3

When increasing amounts of a substance are needed to achieve the same effect

Question 4

Why does tolerance occur?

Answer 4

Increased amount of dopamine in the reward pathway causes down-regulation of dopamine D2 receptors

Question 5

What is intoxication?

Answer 5

The dose dependent direct physiological effects of a substance

Question 6

What is classed as ‘harmful use’ of a substance?

Answer 6

A pattern of substance misuse that results in damage to either physical or mental health

Question 7

What are the features of dependence syndrome?

Answer 7

Cravings
Loss of control
Withdrawal
Tolerance
Preoccupation
Persistent use despite harm
Rapid reinstatement after period of abstinence

Question 8

What are cravings?

Answer 8

The strong desire to take a substance

Question 9

What is loss of control with regards to addiction?

Answer 9

A person is unable to control when or how much of a substance is taken

Question 10

What is withdrawal in addiction?

Answer 10

Physical symptoms that occur during a period of abstinence with associated use to avoid such symptoms

Question 11

What is preoccupation with regards to addiction?

Answer 11

Prioritisation of substance use, which results in neglect of other activities or interests

Question 12

What is the recommended weekly intake of alcohol?

Answer 12

14 units spread evenly across the week with several alcohol free days

Question 13

What is a calculation to determine the units in an amount of alcohol?

Answer 13

(Millilitres of drink x %alcohol) / 1000

Question 14

What is classed as binge drinking?

Answer 14

Males: >8 units per sitting
Females: >6 units per sitting

Question 15

What is classed as hazardous drinking?

Answer 15

Audit 8-14

Drinking over the recommended amount but currently not experiencing any alcohol related problems

Question 16

What is classed as harmful drinking?

Answer 16

Audit 15-19
Current drinking habits have resulted in physical or mental health complications
>35 units per week

Question 17

What is classed as dependency?

Answer 17

Audit >20
Consuming >15 units daily
High levels of alcohol use with at least 3 features of dependence syndrome

Question 18

What are some complications of alcohol misuse?

Answer 18

Malnutrition
Alcoholic liver disease, liver cirrhosis
Barrett's oesophagus
Mallory-Weiss tear
Peptic ulcer disease
HTN
AF
Stroke
Peripheral neuropathy
Wernicke's
Korsakoff's syndrome
Increased incidence of cancers
Gout
Psychiatric: depression, anxiety, suicidal ideation, delirium

Question 19

When do symptoms of alcohol withdrawal occur, when do they peak and when do they resolve?

Answer 19

Occur 4-12 hours after last drink
Peak at 24-48 hours
(Most) resolve in 5-7 days

Question 20

Why do alcohol withdrawal symptoms occur?

Answer 20

Due to chronic alcohol use causing an imbalance in neurotransmitters in the brain - increased GABA, decreased glutamate

Question 21

What are the symptoms of alcohol withdrawal?

Answer 21

Overwhelming desire to drink
Insomnia
Anxiety, agitation, restlessness
Shaking, sweating
Tachycardia
HTN
Pyrexia
Nausea ad vomiting
Generalised seizures
Delirium tremens

Question 22

What is delirium tremens?

Answer 22

A severe, potentially fatal form of withdrawal seen in physical dependence

Question 23

How common is delirium tremens?

Answer 23

5% of withdrawal cases

Question 24

What is the onset of delirium tremens?

Answer 24

Within 2 days of abstinence

Question 25

What are the symptoms of delirium tremens?

Answer 25

``` Same as withdrawal plus: Delirium Ataxia Course tremor Hallucinations and delusions ```

Question 26

What is Wernicke's encephalitis?

Answer 26

Acute onset degenerative inflammation of the brain due to thiamine (B1) deficiency

Question 27

Why are alcoholics more susceptible to Wernicke's encephalitis in withdrawal?

Answer 27

Due to the higher risk of malnutrition there is more risk of thiamine deficiency In withdrawal metabolism increases but the body sometimes might not have the nutrient stores to support this

Question 28

What are the symptoms of Wernicke's encephalitis?

Answer 28

Delirium Ataxia Nysagmus Ophthalmoplegia

Question 29

What is Korsakoff's syndrome?

Answer 29

Chronic memory impairment associated with thiamine deficiency and Wernicke’s

Question 30

What are the symptoms Korsakoff's syndrome?

Answer 30

Confabulations Anterograde amnesia - they have short term memory loss which is compensated for by making up stories that they believe are true

Question 31

What should be included in a history for alcohol dependence?

Answer 31

``` Current alcohol use Dependency screen Past alcohol history Consequences Insight and motivation ```

Question 32

What are examples of assessments of a person's drinking habits?

Answer 32

CAGE AUDIT FAST Comprehensive assessment: severity of alcohol dependence questionnaire (SADQ, MMSE, full medical and psych history)

Question 33

What is involved in brief intervention - and when is it given?

Answer 33

``` For hazardous or harmful drinking Feedback (of problems due to alcohol) Responsibility (patient for change) Advice Menu (options for change) Empathy Self-efficacy (encourage optimism) ```

Question 34

What motivational interviewing - and when is it done?

Answer 34

For harmful drinking Assessment of how motivated a patient is for making a change Encouragement towards the realisation that they need to change their drinking habits

Question 35

When is medically assisted withdrawal done?

Answer 35

For dependency

Question 36

When is medically assisted withdrawal done inpatient?

Answer 36

Severe dependence History of delirium tremens or withdrawal seizures History of failed community detoxifications Poor social support Psychotic co-morbidity Poor physical health

Question 37

When is specialist treatment given for medically assisted withdrawal?

Answer 37

Moderate or severe dependence If brief advice and motivational interviewing haven't worked and they want further help If severe alcohol-related impairment or related co-morbid condition

Question 38

What does specialist treatment for medically assisted withdrawal involve?

Answer 38

Detoxification and relapse prevention using prescription medications

Question 39

Which benzodiazepines are used in medically assisted withdrawal?

Answer 39

Diazepam | Chlordiazepoxidine

Question 40

How are benzodiazepines used in medically assisted withdrawal?

Answer 40

Reduce gradually over 7 days or more | Titrate against severity of withdrawal symptoms

Question 41

How do benzodiazepines help in medically assisted withdrawal?

Answer 41

Sedate patient and make physical and psychiatric symptoms less traumatic

Question 42

Why are B12 and other vitamins given in medically assisted withdrawal and how are they given?

Answer 42

Reduces likelihood of Wernicke's encephalopathy | Need to be given IV due to malnutrition being associated with villous atrophy and reduced absorption

Question 43

What are the pharmacological options for relapse prevention - and which is first line?

Answer 43

Naltrexone - first line Disulfiram Acamprosate

Question 44

What is naltrexone and how does it help relapse prevention?

Answer 44

Opioid agonist | Reduces reward from alcohol

Question 45

What are some physical risks in opiate misuse?

Answer 45

``` Skin infection DVT Blood-borne viruses Damage to nasal mucosa Physical dependence Anxiety, depression, psychosis Benzodiazepines - seizures ```

Question 46

What are signs of an acute overdose?

Answer 46

``` Pinpoint pupils Decreased GCS Respiratory depression Hypotension Bradycardia ```

Question 47

What is the management of an acute opiate overdose ?

Answer 47

Naloxone | Respiratory support

Question 48

What are symptoms of withdrawal from opiates?

Answer 48

``` Goosebumps Dilated pupils Tachycardia Hypertension Agitation Sweating Abdominal pain Diarrhoea ```

Question 49

What are the management options for relapse prevention of opiate addiction?

Answer 49

Opioid replacement therapy | Psychosocial intervention, counselling and input from other agencies

Question 50

What is opioid replacement therapy?

Answer 50

Deliberate prescribing of opioid drugs in a controlled manner to introduce some order and control into lifestyle

Question 51

What is the process of opioid replacement therapy?

Answer 51

Induction Optimisation Maintenance Dose reduction

Question 52

What drugs are options for opioid replacement therapy?

Answer 52

Methadone Buprenorphine Clonidine/Lofexidine

Question 53

What are the features of methadone?

Answer 53

``` Opioid agonist Long half life Can prolong QT interval Can cause sedation High dependence and low lethal dose ```

Question 54

What is the treatment for overdose of methadone?

Answer 54

Narcan