Alcohol and drug misuse and dependence

Question 1

What is alcohol misuse?

Answer 1

Drinking in a way that regularly causes problems to the patient or others

Question 2

What are the classifications of alcohol misuse and dependence?

Answer 2

Problem drinker - one who causes or experiences physical, psychological and/or social harm as a consequence of drinking alcohol
Heavy drinker - drinking significantly more in terms of quantity and/or frequency than is safe in the long term
Binge drinker - excessively drinking in short bouts separated by quite long lengths of abstinence
Alcohol dependence - physical dependence or addiction to alcohol

Question 3

What are the screening questions for alcohol addiction called?

Answer 3

CAGE

AUDIT-C

Question 4

What are the questions in CAGE?

Answer 4

Have you ever felt that you should CUT down on your drinking?
Have people ever ANNOYED you by criticising your drinking?
Have you ever felt bad or GUILTY about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (EYE OPENER)
Score over 2 = problematic drinking

Question 5

What are the questions in AUDIT-C?

Answer 5

How often do you have a drink containing alcohol?
- Never 0
- Monthly or less 1
- 2-4 times per month 2
- 2-3 times a week 3
- 4 or more times a week 4
How many units of alcohol do you drink on a typical day when you are drinking?
- 1 or 2 - 0
- 3 or 4 - 1
- 5 or 6 - 2
- 7 to 9 - 3
- 10 or more - 4
How often have you had 6 or more units if female, or 8 or more if male on a single occasion in the last year?
- Never 0
- Less than monthly 1
- Monthly 2
- Weekly 3
- Daily or almost daily 4
3 or more out of 12 then ask the full audit questionnaire

Question 6

What is also important to ask in an alcohol history?

Answer 6

When did you first notice an increase in the amount of alcohol you were drinking?
Anything going on at the time to play a role in this?
How often do you drink?
How much do you drink on an average day?
Where and who do you drink with?
Have you tried to stop drinking before?
What happened? Support?

Question 7

What may you find in a physical examination that may demonstrate alcohol dependence?

Answer 7

Tremors
Sweating
N&V
Tachycardia/hypertension
Anxiety
Psychomotor agitation
Headache
Insomnia
Malaise and weakness
Transient visual, tactile, or auditory hallucinations or illusions
Generalised tonic-clonic convulsions

Question 8

Name 3 risk factors for alcohol misuse

Answer 8

Mental health disorders - EUPD, depression, anxiety, schizophrenia, mania
Binge drinking
Abuse
Parents with a history of alcoholism

Question 9

How common is alcohol misuse?

Answer 9

20% men and 10% women drink more than recommended 3 units per day
Amount of alcohol consumed has doubled in the UK over the last 50 years
2-3 times risk of dying that the general population
1 in 5 male admissions directly/indirectly due to alcohol

Question 10

What conditions could alcohol misuse been seen as a self-treatment for?

Answer 10

GAD
Social phobia
Dysthymic disorder
Major depression
Bipolar mania
Insomnia

Question 11

How does alcohol dependence present?

Answer 11

Unable to limit the amount they drink
Difficulty in avoiding getting drunk
Spending a lot of time drinking
Missing meals
Memory lapses, blackouts
Restlessness without a drink
Trembling after drinking the day before
Morning retching and vomiting
Sweating excessively at night
Withdrawal fis
Morning drinking
Increased tolerance
Hallucinations
Delirium tremens

Question 12

What genetic factors could cause alcohol misuse?

Answer 12

Serotonin transporter gene
D2 receptor allele A1
Alcohol dehydrogenase subtypes
MAO B activity

Question 13

What environmental factors could cause alcohol misuse?

Answer 13

Childhood maltreatment
Parental alcohol dependence
Other substance misuse

Question 14

What biochemical factors could cause alcohol misuse?

Answer 14

Abnormalities in alcohol dehydrogenase
Neurotransmitter substances
Brain amino acids (GABA)

Question 15

What else could lead to alcohol misuse?

Answer 15

Excess consumption in the community

Question 16

What could you do to diagnose alcohol dependence?

Answer 16

Questionnaires - over 36 units per week poses long term health risks
Bloods - elevated gamma-GT and MCV
Blood and breath alcohol tests

Question 17

How do you manage alcohol dependence?

Answer 17

Motivational therapy
Psychological treatment
Admission
Correct electrolyte abnormalities and dehydration
Treat other disorders
Thiamine (more if have Wernicke’s)
Phenytoin/carbamazepine if previous history of withdrawal fits
Diazepam/chlordiazepoxide
Additional benzodiazepine if symptoms and signs not controlled

Question 18

How can you prevent alcohol dependence relapse?

Answer 18

Naltrexone
Acamprosate
Disulfiram

Question 19

What is the prognosis of alcohol dependence?

Answer 19

30-50% of alcohol dependent drinkers abstinent or drinking much less up to 2 years following additional intervention

Question 20

What are the risks of alcohol?

Answer 20

Alcohol dependence
Alcohol poisoning
Wernicke’s encephalopathy/Korsakoff’s sydrome
Sleep problems
Effects on day-to-day life - relationships, occupation, diet, alcohol-related crime
Dangers to attacking his wife/other family members
Injuries from alcohol - car accidents
Other medical problems - heart problems, gut problems, pancreatitis, cancers - oral, laryngeal, oesophageal, colon, pancreatic, hepatic, small intestine, liver disease, diabetes
Weight gain
Mental health problems - depression, suicidal thoughts

Question 21

What are the risks of suddenly stopping drinking?

Answer 21

Delirium tremens
Seizures
Alcohol withdrawal
Wernicke’s encephalopathy and Korsakoff’s - loss of mammillary bodies

Question 22

What does an alcohol detox involve?

Answer 22

Alcohol completely flushed out of body
Substitution of drugs that have similar effects to alcohol to prevent withdrawal - chlordiazepoxide for 10 days tapering down drugs
Therapies, counselling and support

Question 23

How does naltrexone work?

Answer 23

Blocks opiate receptors and so stops pleasure from drinking

Question 24

How does disulphiram work?

Answer 24

Stops liver processing alcohol and makes them feel unwell when they drink alcohol
Stays in the system for 10 days

Question 25

What is the definition of drug misuse?

Answer 25

Inappropriate, illegal, or excessive use of a drug

Question 26

What drugs are common in addiction?

Answer 26

``` Inhaled substances eg glue and NO Amphetamines eg speed/meth/ecstasy (MDMA) Cocaine Hallucinogenic eg LSD Cannabis Tranquilisers eg benzodiazepines Opiates ```

Question 27

What happens with addiction to inhaled substances?

Answer 27

Tolerance develops over weeks/months Intoxication - euphoria, excitement, floating sensation, dizziness, slurred speech, and ataxia Amnesia and visual hallucinations

Question 28

What happens with addiction to amphetamines?

Answer 28

``` Temporary stimulant and euphoric effects Followed by fatigue and depression Activates neural award transmitters Can induce paranoid psychosis and manic presentation Psychedelic ```

Question 29

What happens with addiction to cocaine?

Answer 29

CNS stimulant Similar affects to amphetamines Addiction more common if smoking it Withdrawal - depression, tremor, muscule pains Hyperarousal Prolonged high doses - irritability, restlessness, paranoia, convulsions Perforation of nasal septum if sniffing

Question 30

What happens in an overdose of cocaine?

Answer 30

MI Cerebrovascular disease Hyperthermia Arrhythmias

Question 31

What happens in addiction to hallucinogenics?

Answer 31

Distortion and intensification of sensory perceptions Hallucinations in intoxication Psychosis is long-term complication

Question 32

What happens in addiction to cannabis?

Answer 32

Exaggerates pre-existing moods Analgesic properties Amotivational syndrome with apathy and memory problems - chronic daily use Psychosis

Question 33

What happens with addiction to tranquilisers?

Answer 33

Dependence can happen with prescriptions | Discontinuation of treatment may cause withdrawal symptoms

Question 34

What happens with addiction to opiates?

Answer 34

Tolerance rapidly develops and quickly lost Opiate withdrawal syndrome Withdrawal dangerous in people with heart disease or other chronic debilitating conditions High mortality rate - accidental overdose, BB infections, heart disease (IE), TB, AIDS, hep B and C

Question 35

What questions should you ask in a history?

Answer 35

``` What drug? How often? HIV screens? How do you use drug? Any symptoms of dependence? ```

Question 36

What are the risk factors for drug misuse?

Answer 36

``` Early aggressive behaviour Lack of parental supervision Substance abuse Drug availability Poverty Vulnerable personality Social pressures eg peer pressure ```

Question 37

How common is drug misuse?

Answer 37

Tramadol most common addiction Cannabis most abused substance after alcohol 2 million people use cannabis regularly 1 million people use cocaine regularly

Question 38

What is drug misuse seen as a self-treatment for?

Answer 38

``` Depression Anxiety Bipolar Hyperthyroidism Hyperparathyroidism Abuse/trauma Iatrogenic effect ADD ```

Question 39

What is the clinical presentation of drug addiction?

Answer 39

Feeling of having to use the drugs regularly Intense urges to take the drug Needing more drug to get the same effect Taking larger amounts than you intended Making sure you maintain a supply Not meeting obligations or work responsibilities Doing things you wouldn't normally do whilst under the influence Spending a good deal of time getting the drug Experiencing withdrawal symptoms when you stop taking it

Question 40

Why do people take drugs?

Answer 40

Feelings of reward when taking the drug

Question 41

What investigations in drug misuse?

Answer 41

Blood and urine tests | Lab tests

Question 42

How should you manage someone with a drug addiction?

Answer 42

Refer to psychiatrist or drug misuse clinic Prescriptions of illegal drug to help control addiction Treat overdose with naloxone

Question 43

What is the prognosis of a drug addiction?

Answer 43

40-60% of people relapse

Question 44

What are common drugs that people overdose on?

Answer 44

Heroin Paracetamol Cocaine Methamphetamines

Question 45

How do you treat a heroin overdose?

Answer 45

Naloxone (competitive antagonist of opiate receptors)

Question 46

How do you treat a paracetamol overdose?

Answer 46

Acetylcysteine

Question 47

What are the symptoms of an opiate overdose?

Answer 47

Pinpoint pupils Unconscious Respiratory depression Track marks (could also mean amphetamines)

Question 48

What are the short term risks of heroin?

Answer 48

``` N&V dehydration Loss of consciousness Clouded mental function - may do dangerous things Respiratory arrest Coma Permanent brain damage ```

Question 49

What are the long term of heroin?

Answer 49

Brain deterioration Withdrawal symptoms Dependence

Question 50

What are the risks in heroin usage?

Answer 50

``` Withdrawal Abuse Homelessness Death Infections - HIV, Hep B, skin infections, septicaemia Hypothermia Miscarriage if pregnant Risks to child - born addicted to opiates, death Seizures Nutrition Safeguarding issues ```

Question 51

How do you manage heroin addictions?

Answer 51

Methadone treatment Refer to psychiatry/addiction teams Psychological therapies Support with social situation

Question 52

What is important when treating with naloxone?

Answer 52

Give basal IM dose NOT IV | Sit with them in case they wake up

Question 53

What can you do with methadone treatment?

Answer 53

Collect from pharmacy every day and pharmacist has to watch them take the medication Can take home if more stable Very stable gets it once a week See drug service every few weeks and have bloods done and if have taken illicit drugs on top then take them off the once per day due to risk of overdose