Alcohol and Substance Misuse

Question 1

ICD-10 criteria for substance misuse for acute intoxication

Answer 1

Acute, usually transient, effects of the substance

Question 2

ICD-10 criteria for substance misuse for harmful use

Answer 2

Recurrent misuse associated with physical, psychological and social consequences
- but without dependence

Question 3

ICD-10 criteria for substance misuse for dependence syndrome

Answer 3

Prolonged, compulsive substances use leading to addiction, tolerance and the potential for withdrawal syndromes

Question 4

ICD-10 criteria for substance misuse for withdrawal state

Answer 4

Physical and/or psychological effects from complete cessation of a substance after prolonged, repeated or high level of use

Question 5

ICD-10 criteria for substance misuse for psychotic disorder

Answer 5

Onset of psychotic symptoms within 2 weeks of substance use

- must persist for more than 48 hours

Question 6

ICD-10 criteria for substance misuse for amnesic syndrome

Answer 6

Memory impairment in recent memory and ability to recall past experiences

• impaired learning of new material
• defect in recall
• clouding of consciousness
• global intellectual decline

Question 7

ICD-10 criteria for substance misuse for residual disorder

Answer 7

Specific features subsequent to substance misuse

- flashbacks, personality disorder, affective disorder, dementia, persisting cognitive impairment

Question 8

Chain of events leading to substance dependence

Answer 8

Biological
- genetic variations in enzymes that metabolise drugs, neurochemical - abnormalities in dopamine, GABA and opioid systems
Environmental
- peer pressure, life stressors, parental drug use, cultural acceptability, personal vulnerability - lack of resources to cope with stressors
Takes substance
- cost, availability, effect of drug itself, route
Positive reinforcement
- psychosocial - from peer or pleasurable effects of drugs
- biological - activates mesolimbic dopaminergic reward pathways
Dependence

Question 9

Examples of opiates

Answer 9

Morphine - PO and IV
Diamorphine (heroin) - IN, IV, smoked
Codeine/methadone - PO

Question 10

Effects of opiates

Answer 10

Psychological
- apathy, disinhibition, psychomotor retardation, impaired judgement and attention, drowsiness, slurred speech
Physical
- respiratory depression, hypoxia, low BP, hypothermia, coma, pupillary constriction

Question 11

Withdrawal state of opiates

Answer 11

Craving
Rhinorrhoea
Lacrimation
Myalgia
Abdo cramps
N+V
Diarrhoea
Pupillary dilation
Piloerection
Increased HR/BP

Question 12

Effects of cannabinoids

Answer 12

Psychological
- euphoria, disinhibition, agitation, paranoid ideation, temporal slowing, impaired judgement/attention/reaction time, hallucinations
Physical
- increased appetite, dry mouth, conjunctival injection, increased HR

Question 13

Features of withdrawal state of canabinoiods

Answer 13

Anxiety, irritability, tremor of outstretched hands, sweating, myalgia

Question 14

Types of sedative-hypnotics

Answer 14

Benzodiazepines
Barbiturates
Taken PO or IV

Question 15

Effects of benzodiazepines

Answer 15

Psychological
- euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
Physical
- unsteady gait, difficulty standing, slurred speech, nystagmus, erythematous skin lesions, reduced BP, hypothermia, depression of gag reflex, coma

Question 16

Features of withdrawal state of benzodiazepines

Answer 16

Tremor of hands, tongue or eyelids, N+V, increased HR, postural hypotension, headache, agitation, malaise, transient illusions/hallucinations, paranoid ideation, grand mal convulsions

Question 17

Complications of substance misuse

Answer 17

Physical
- death, infection (HIV, hep A, B or C, Staph aureus, group A strep, clostridium, TB), endocarditis, superficial thrombosis, DVT, PE
Psychological
- craving, anxiety, cognitive disturbances, drug-induced psychosis
Social
- crime, imprisonment, homelessness, prostitution, relationship problems

Question 18

Features of substance dependence

Answer 18

> 3 manifestations over 1 month

• strong desire to consume substance
• preoccupation with substance use
• withdrawal state when substance ingestion is reduced or stopped
• impaired ability to control substance-taking behaviour
• tolerance to substance
• persisting with use despite evidence of harmful effects

Question 19

Management of substance misuse

Answer 19

Key worker with therapeutic alliance - psychosocial support
Hep B immunisation
Motivational interviewing and CBT
Contingency management - changing specified behaviours by offering incentives for positive behaviours
Supportive help - housing, finance and employment
Self help groups

Question 20

Define detoxification

Answer 20

Process in which the effects of the drug are eliminated in a safe manner

• withdrawal symptoms avoided
• attempt to attain abstinence

Question 21

Define maintenance thearpy

Answer 21

Abstinence not priority

Aim is to minimise harm

Question 22

Management of opioid dependence

Answer 22

Biological
- methadone
- buprenorphine for detoxification or morphine
IV naloxone for antidote to opioid overdose

Question 23

Define alcohol abuse

Answer 23

Consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm

Question 24

Define binge drinking

Answer 24

Drinking over twice the recommended level of alcohol per day in one session

Question 25

Define harmful alcohol use

Answer 25

Drinking above safe levels with evidence of alcohol related problems

Question 26

Pathophysiology of alcohol abuse

Answer 26

Affects several neurotransmitters - GABA -> anxiolytic and sedative effects - dopamine -> sensitisation leads to dependence Long term use leads to down-regulation of inhibitory neuronal GABA and up-regulation of excitatory glutamate receptors

Question 27

Risk factors for alcohol abuse

Answer 27

Male - increased risk and increased metabolism Younger adults Genetics Antisocial behaviour Lack of facial flushing - metabolises acetaldehyde more slowly Life stressors - financial problems, marital issues, certain occupations

Question 28

Clinical features of alcohol intoxication

Answer 28

``` Slurred speech Labile affect Impaired judgement Poo co-ordination Severe cases - hypoglycaemia, stupor and coma ```

Question 29

Clinical features of alcohol dependence

Answer 29

Subjective awareness of compulsion to drink Avoidance or relief of withdrawal symptoms by further drinking Withdrawal symptoms Drink-seeking behaviours Reinstatement of drinking after attempted abstinence Increased tolerance Narrowing of drinking repertoire -

Question 30

Features of alcohol withdrawal

Answer 30

``` Malaise Tremor Nausea Insomnia Transient hallucinations Autonomic hyperactivity - 6-12 hrs Seizures - 36 hours ```

Question 31

Negative effects of alcohol consumptoms

Answer 31

``` Medical - fatty liver, hepatitis, cirrhosis, hepatocellular carcinoma - peptic ulcer disease, oesophageal varices, pancreatitis, oesophageal carcinoma - hypertension, cardiomyopathy, arrhythmias - anaemia, thrombocytopenia - seizures, peripheral neuropathy, cerebellar degeneration, Wernicke's encephalopathy, Korsakoff's psychosis - foetal alcohol syndrome Psychiatric - morbid jealousy - self-harm and suicide - mood disorders - anxiety disorders - alcohol-related dementia - alcoholic hallucinations - delirium tremens Social - domestic violence - drink driving - employment difficulties - financial problems - homelessness - accidents - relationship problems ```

Question 32

ICD-10 criteria for alcohol intoxication

Answer 32

General criteria for acute intoxication met - clear evidence of psychoactive substance at high dose levels - disturbance in consciousness, cognition, perception or behaviour - not accounted for by medical or mental disorder Evidence of dysfunctional behaviour - disinhibition - argumentativeness - aggression - labile mood - impaired attention/concentration - interference with personal functioning One of the following - unsteady gait, difficulty standing, slurred speech, nystagmus, flushing, reduced consciousness, conjunctival injection

Question 33

ICD-10 criteria for alcohol withdrawal

Answer 33

General criteria for a withdrawal state met - clear evidence of recent cessation or reduction of substance after prolonged or high level usage - not accounted for by medical or mental disorder Any three of the following - tremor, sweating, N+V, tachycardia, increased BP, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions

Question 34

Features of delirium tremens

Answer 34

``` Withdrawal delirium - develops between 24 hrs and one week after alcohol cessation Characterised by - cognitive impairment - vivid perceptual abnormalities - paranoid delusions - marked tremor - autonomic arousal ```

Question 35

Treatment of delirium tremens

Answer 35

Large dose benzodiazepines Haloperidol for psychotic features IV pabrinex

Question 36

Define Wernicke's encephalopathy

Answer 36

Acute encephalopathy due to thiamine deficiency

Question 37

Features of Wernicke's encephalopathy

Answer 37

``` Delirium Nystagmus Ophthalmoplegia Hypothermia Ataxia ```

Question 38

Management of Wernicke's encephalopathy

Answer 38

Parenteral thiamine

Question 39

Define Korsakoff's psychosis

Answer 39

Profound, irreversible short-term memory loss with confabulation (unconscious filling of gaps with imaginary events) and disorientation to time

Question 40

How to calculate alcohol units

Answer 40

Strength x volume / 1000

Question 41

Management of alcohol abuse

Answer 41

Biological - chlordiazepoxide detox regime + thiamine - disulfiram - build up of acetaldehyde on consumption of alcohol - Acamprosate - reduces craving by enhancing GABA transmission - naltrexone - blocks opioid receptors - treatment of medical and psychiatric complications Psychological - motivational interviewing - social network and environment based therapies Social - alcoholics anonymous - social support including family involvement