Addiction Flashcards
With thanks to Ed Underwood (42 cards)
1
Q
What is acute intoxication?
A
A transient state of emotional + behavioural change following drug use. It is dose dependent and time limited.
2
Q
What is harmful use?
A
A pattern of use likely to cause physical and/or psychological damage
3
Q
What is dependence syndrome?
A
A cluster of psychological, behavioural and cognitive symptoms in which the use of a substance takes on higher priority than other behaviours that once had greater value
4
Q
What is physical dependence?
A
A state of physiological adaptation of the body to a presence of a drug. It is defined by the development of withdrawal symptoms when the drug is removed or an antagonist is administered.
5
Q
What is psychological dependence?
A
Dependence on a psychoactive substance for the reinforcement in provides
6
Q
What is tolerance?
A
A physiological state characterised by a decrease in the effects of a drug
7
Q
What is withdrawal?
A
The distressing physical and psychological symptoms experienced by a person once a drug is removed
8
Q
What are the (ICD-10) features of dependence?
A
9
Q
What are the safe limit recommendations for alcohol consumption?
A
- men and woman should drink no more than 14 units of alcohol per week
- they advise ‘if you do drink as much as 14 unites per week, it is breast to spread this evenly over 3 days or more’
- pregnant women should not drink → risk of foetal alcohol syndrome
10
Q
What is an example of one unit of alcohol?
A
- 25ml single measure of spirit (ie. one shot)
- a third of a pint of beer
- half a 175ml ‘standard’ glass of red wine
11
Q
What are key points to ask in an alcohol history?
A
- CAGE screening
- details of alcohol intake
- assess impact of alcohol
- effects on daily living
- past medical history
- psychological assessment
12
Q
What are the signs and symptoms of acute intoxication?
A
Symptoms
Signs (depending on blood alcohol content)
- Low levels → Euphoria, relaxation
- Moderate levels → Irritability, aggression, weepy, disinhibited. Impulsivity and poor judgement are common
- High levels → Sedation, memory impairment, LOC
- Slurred speech
- Ataxic gait
- Sedation
- Confusion
- Coma
- Respiratory depression
13
Q
What is the management of acute intoxication?
A
- ABC approach
- manage hypoglycaemia w/ 50ml of 50% dextrose infusion (ethanol induced hypoglycaemia is unresponsive to glucagon)
- administer thiamine
- check U+Es to guide fluid replacement
- haemodialysis if concentrations are dangerously high
14
Q
Think about impact on body systems
Patients who have a chronic drinking problem may present with the complications of alcohol abuse; these may be direct (as a result of alcohol) or indirect (as a result of malnutrition).
What are the physical complications of chronic alcohol abuse?
A
- Liver → alcohol hepatitis (malaise, hepatomegaly, ascites), cirrhosis, hepatic encephalopathy
- GI → pancreatitis, varices, gastritis, peptic ulcers
- Neuro → peripheral neuropathy, seizures, dementia
- Cancer → bowel, breast, oesophageal, liver
- CVS → HTN, cardiomyopathy
- Obstetric → foetal alcohol syndrome
15
Q
What are psychological complications of chronic alcohol abuse?
A
- depression, anxiety + self-harm all increased
- amnesia (due to blackouts)
- cognitive impairment
- alcoholic halucinosis → experience of auditory hallucinations in clear consciousness
- morbid jealousy → overvalues idea that a partner is cheating on them
16
Q
What is the management of chronic alcohol abuse?
A
-
CONSERVATIVE
- Nutritional support → Oral thiamine (NICE)
- Psych therapies → CBT, AA meetings
-
MEDICAL
- Benzodiazepines for acute withdrawal
- Disulfiram → promotes abstinence - works by inhibiting enzyme acetaldehyde dehydrogenase ⇒ many of effects of hangover are felt immediately, even small amounts of alcohol produce: flushing, throbbing headache, nausea, copious vomiting, sweating, syncope, tachycardia + confusion
- Acamprosate → reduces craving, known to be a weak antagonist of NMDA receptors
17
Q
What is the metabolism of alcohol in the body?
A
- alcohol oxidised in liver by alcohol dehydrogenase to acetaldehyde
- acetaldehyde accumulates in liver
- aldehyde is toxic, XS may lead to cell death
18
Q
Wernicke’s encephalopathy is caused by acute thiamine (vitamin B1) deficiency, it’s a neurological emergency with varied neurocognitive manifestations. Thiamine is an important cofactor required by enzymes in carbohydrate metabolism. A reduction in thiamine can interfere with numerous cellular functions leading to serious brain disorders.
Why might alcoholics become deficient in thiamine?
A
- Inadequate nutritional intake → alcohol provides ‘empty’ calories
- Decreased absorption of thiamine from GI tract + reduced uptake into cells
- Impaired utilisation of thiamine in cells
19
Q
What are the clinical features of Wernicke’s encephalopathy?
A
- ataxia
- confusion + altered GCS
- opthalmoplegia
- nystagmus
- peripheral sensory neuropathy
- hypothermia + hypotension
- memory disturbances
- coma or unconsciousness
Investigations involve doing an MRI and also there is reduced red cell transketolase.
20
Q
What is Korsakoff’s syndrome?
A
- untreated Wernicke’s progresses to this → ‘Wernicke-Korsakoff syndrome’
- anterograde amnesia (and some retrograde)
- patients can register events but cannot recall them a few mins later
- patients confabulate to fill in gaps in their memory
21
Q
What is the treatment for Wernicke’s encephalopathy?
A
Urgent replacement of thiamine
22
Q
What is the mechanism/pathophys behind alcohol withdrawal?
A
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite - decreased inhibitory GABA and increased NMDA glutamate transmission (excitatory)
23
Q
As alcohol levels fall, withdrawal symptoms start to occur.
What are these symptoms, typically?
A
- headache
- nausea, retching, vomiting
- tremor + sweating
- insomnia is common and may persist for weeks
Rx → chlordiazepoxide (long-acting benzo): first-line for alcohol withdrawal, fixed-dose regimen
24
Q
A complication of withdrawal is delirium tremens.
What is delirium tremens and its management?
A
- neural pathways become hyper-excitable following withdrawal
- onset 2-3 days into abstinence
- duration 3-4 days
- clinical features → confusion, hallucinations (visual), affective changes, gross tremor, autonomic signs, delusions, seizures
- mortality 5%
- urgent benzos + thiamine (IV pabrinex) required
- oral chlordiazepoxide (or diazepam)
- antipsychotics (haloperidol) if severe psychotic symptoms
- death may occur from CVS compromise (arrhythmias)
25
What are useful **contacts** for alcohol problems?
* **Drinkline** → national alcohol helpline, free, confidential
* **Alcoholics Anonymous (AA)** → "12-step" programme involving getting sober w/ help of regular support
* **Al-Anon Family Groups** → offers support to families of problem drinkers
* **Addaction** → helps manage effects of drugs + alcohol
* **Adfam** → national charity working w/ families affected by drugs/alcohol + online message board
* **Nacoa helpline** → free confidential telephone + email helpline for children of alcoholic parents
* **SMART Recovery** → groups help participants decide whether they have problem + build motivation
26
What is the **mechanism of action** of **benzodiazepines**?
* target **GABAA** receptor: a chloride channel that opens when GABA binds - main inhibitory NT in brain
* opening channel allows chloride to flow into cell making cell more resistant to depolarisation
* **benzos facilitate + enhance binding of GABA to GABAA receptor**
* widespread depressant effect on synaptic transmission
* **clinically**: reduces anxiety, sleepiness, sedation + anticonvulsive effects
* **alcohol** also acts on GABAA receptor + in chronic use pt becomes tolerant to its presence
* abrupt cessation then provokes excitatory state of **alcohol withdrawal**
* treated by benzos which can be withdrawn in a gradual + more controlled way
27
What are the important **adverse effects** + contraindications of benzodiazepines?
* drowsiness, sedation + coma
* loss of airway reflexes → airway obstruction + death
* dependence can develop
* abrupt cessation → withdrawal rxn
Avoid in resp impairment or neuromuscular disease. Also avoid in **liver failure** as may precipitate hepatic encephalopathy; if use is essential (eg. alcohol withdrawal), **lorazepam** best choice as least hepato-toxic.
28
What is the **general management** of substance abuse?
Start with **assessment** (Hx, collateral, biochemistry, questionnaires) and establish **goals**
* **BIO** → ease withdrawal or facilitate abstinence; treat medical/psychiatric complications
* **PSYCH** → motivational interviewing; cue exposure to reduce craving
* **SOCIAL** → manipulation of environment incl rehab; self-help agencies
29
Smoke contains an array of harmful compounds, including tar, nicotine, carcinogens and harmful gases (such as carbon monoxide). **Cigarette smoke** is classified as a group 1 carcinogen (known to cause cancer in humans), and contains 10 of the 36 known group 1 carcinogens, as well as a numbers of group 2A chemicals (probably cause cancer).
What is **nicotine** and its physiological **effects**?
_Addictive_ component of cigarettes. It acts as a **parasympathomimetic**. In itself, nicotine is a relatively safe drug.
* **CVS Effects** → transiently increases HR, may be a problem for people prone to developing arryhthmias; some evidence suggests harmful to circulatory system in long term leading to MI, stroke etc.
* **Pregnancy** → nicotine harmful to developing brain
* **Sympathetic** → before tolerance develops, may cause: sweating, tachycardia + nausea
* **Addiction** → major problem; dopamine released into mesolimbic pathway; nicotine most addictive when smoked (higher + rapid peaks)
30
What is **tar** and its **effects** on the body?
Resinous, partially combusted particulate matter produced by burning of tobacco + other plant materials through act of smoking. Tar contains many of harmful + **carcinogenic** substances found in smoke (mutagens, carcinogens).
* **Cancer** → lung, upper resp tract, oeseophagus, pancreas, bladder; smoking 20/d inc risk of cancer x10
* **Chronic bronchitis** → elastic destruction + loss of alveolar SA
* **Ciliary dysfunction**
31
What are the **harmful effects** of smoking in general?
* **Neoplastic** → bladder, cervical, oeseophageal, renal, laryngeal, lung, oral etc.
* **CVS** → AAA rupture, atherosclerosis, stroke, coronary heart disease
* **Resp** → COPD, pneumonia, reduced lung function
* **Repro** → IUGR, foetal death, stillbirth, infertility
* **MSS** → osteoporosis + hip fractures
* **GI** → peptic ulcer disease
* **Eye** → cataracts
32
What is the **management** of smoking cessation?
* pts should be offered **nicotine replacement therapy** (NRT), **varenicline** or **bupropion** - NICE state clinicans should _not_ favour one over other
* NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date (**target stop date**)
* prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after target stop date
* normally this will be after **2 weeks** of **NRT therapy** and **3-4 weeks** for **varenicline + bupropion**, to allow diff methods of administration + mode of action
* further prescriptions only given to people who have demonstrated their quit attempt is _continuing_
* if unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription _within 6 months_ unless special circumstances have intervened
* do not offer NRT, varenicline or bupropion in any **combination**
33
What are key features of **nicotine replacement therapy**?
* adverse effects → **nausea, vomiting, headaches, flu-like symptoms**
* NICE recommend offering combo of **nicotine patches** _and another form of NRT_ (gum, inhalator, lozenge, nasal spray) to ppl who show high level of dependence on nicotine or who have found single forms of NRT inadequate in past
34
What are key features of **varenicline** (champix)?
* **nicotinic receptor partial agonist**
* started **1wk before** pts target date to stop
* recommended course of Rx is **12 weeks**
* pts monitored throughout + treatment only continued if not smoking
* more effective than bupropion
* _SEs_ → nausea, headache, insomnia, abnormal dreams
* use with caution in pts w/ hx of **self-harm** or **depression**
* **contraindicated** in pregnancy + breast feeding
35
What are key features of **bupropion** (zyban)?
* a **norepinephrine + dopamine reuptake inhibitor**
* also a **nicotinic antagonist**
* start **1-2wks** before target smoking stop date
* small risk of _seizures_ (1 in 1000)
* contraindicated in **epilepsy**, pregnancy + breast-feeding
* having an eating disorder is a relative contraindication
36
NICE recommended in 2010 that all **pregnant women** should be tested for smoking using carbon monoxide detectors, partly because *'some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.'.* All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to **NHS Stop Smoking Services**.
What are the **interventions** for pregnant women?
* **first-line** → CBT, motivational interviewing or structured self-help + support from NHS Stop Smoking Services
* NRT if above fails
* pregnant women should remove the NRT patches before going to bed
* as mentioned prev, varenicline and bupropion are _contraindicated_
37
What are key points to ask about in an **illicit drug history**?
* current use → type, amount, freq, periodicity, triggers
* reasons why they use them
* age of first use
* fluctuations in use
* periods of abstinence or lack of them
* symptoms of physical dependence
* implications (financial, social, psychological)
38
Give _examples_ of **psychoactive drugs** and features of their:
* **a) administration**
* **b) intoxication**
* **c) withdrawal**
39
Complications of **IVDU** can result from the use of the drug itself, or form the process of infection. IV drugs are rarely pure, and often come with contaminants/infections.
What are _specific_ **adverse effects** of IVDU?
* **Adulterants** → if tablets are crushed + injected, 'filler substances' such as cellulose + talc will also be injected; this can become trapped in pulm capillary bed causing inflammation + foreign body granulomatosis; filler agents also can damage valves of heart, predisposing to infective endocarditis
* **Infection**:
* **Local** → cutaneous abscess, cellulitis, lymphangitis, lymphadenitis, thrombophlebitis
* **Distant** → bacteraemia leading to infective endocarditis or distant abscesses; septic lung emboli + osteomyelitis are particularly common
* **Systemic** → due to sharing of needle equipment; HIV, Hep B/C
* Associated w/ but not caused by drug use → pneumonia, TB, vereneal disease
* **Damage to readily accessible veins** → sclerosis
* **Thromboembolic events**
40
What are **implications** of drug use?
* **Physical illness** → malnutrition, hepatitis, jaundice, abscesses, DVT, overdose, RTA, abstinence sydnrome
* **Mental illness** → drug induced psychosis, intoxication leading to drowsiness + confusion, dementia
* **Social problems** → criminal activities to fund drug use, time spent in obtaining drugs, neglect of other interest (friends, family, work)
* **Occupational** → difficult to hold down a job, suspension
* **Legal** → 2/3rd of crime is drug-related
41
What is a **toxicology screen**?
* **designed to detect presence or absence of drugs**
* in addition to toxicology screen, specific drug assays are available to measure concentration of that drug
* toxicology screen performed on a number of different biological substances, commonly **urine** or **blood**
* those that a generally tested are:
* **common pharmaceutical drugs** → paracetamol + aspirin
* **common rec drugs + metabolites** → opiates, cocaine, amphetamines, cannabis, benzodiazepines, alcohol
42
What support services are available for patients and families for drug abuse?
* **FRANK**
* **Adfam**
* **DrugFAM**
* **Families Anonymous**
* **Release**
