Mental Health: Substance Abuse Flashcards
(65 cards)
1
Q
Criteria for ‘dependence’
A
Three or more of :
- Strong desire / compulsion to take the substance
- Impaired control of substance taking behaviour in terms of onset, termination or levels of use
- Physiological withdrawal state when use is reduced or stopped
- Tolerance to effects of the substance leading to increased use
- Preoccupation with use, to exclusion of other pleasures or interests
- Persistence despite clear harm
2
Q
What’s intoxication?
A
- Follows administration of a psychoactive substance
- Disturbances in:
–Level of consciousness
–Cognition
–Perception
–Affect
–Behaviour
- Disturbance directly related to effect of the substance
- Resolve with time
3
Q
What’s harmful use?
A
- Pattern of psychoactive substance use that is causing damage to health
- Clear evidence of harm → physical or psychological
- Nature of the harm should be identifiable
- Pattern of use has persisted for at least one month, or has occurred repeatedly over a 12 month period
4
Q
What’s Salience/Primacy?
A
- Obtaining & using the substance takes over
- Other interests & pursuits are neglected
5
Q
What’s tolerance?
A
- Increased doses of the psychoactive substance are required to achieve effects originally produced by lower doses
- Contributes to escalation of use
6
Q
What’s narrowing of repertoire?
A
Loss in variation in the use of the substance
7
Q
What’s Reinstatement?
A
Occurs after a period of abstinence, when the patient re-starts the substance and rapidly increases use to previous harmful levels
8
Q
Hx in substance abuse
A
9
Q
Stages of change
A
Pre Contemplation
–Person feels there is no problem, though others recognise it
Contemplation
–Person weighs up pros & cons and considers if change is necessary
Decision
–Person decides to act (or not)
Action
–Person chooses strategy for change & pursues it
Maintenance
–Gains are maintained & consolidated
Relapse
–Return to previous pattern, but relapse may help learning
10
Q
What’s the relationship between psychiatric illness and substance misuse?
A
- ntoxication & / or dependence may lead to psychological symptoms and social difficulties
- Substance misuse & / or withdrawal may cause psychiatric symptoms or illness & may trigger illness in those who are predisposed
11
Q
Safe levels of alcohol intake
A
Men & Women now advised:
2-3 units / day
14 units / week
12
Q
Harmful levels of alcohol intake
A
Harmful levels:
–Women > 6 units / day = >35 units / week
–Men > 8 units / day = >50 units / week
13
Q
Aetiology of alcohol dependence
A
- Gender → Males > females
- Genetics → 25-50% of predisposition may be inherited
- Occupation → Publicans, doctors, journalists, salesmen, actors, entertainers, seamen
- Social → childhood difficulties / problems, parental separation, low educational achievement
14
Q
Symptoms of alcohol intoxication
A
- Relaxation & euphoria followed by disinhibition, various emotional states (irritable, weepy, morose), impulsive & irresponsible behaviour
- Slurred speech, ataxia, sedation, confusion, flushed face, nystagmus, conjunctival injection
15
Q
Symptoms of alcohol withdrawal with timeframe
A
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
16
Q
Mechanism of 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)
17
Q
Physical complications of alcohol abuse
A
Liver
–Hepatitis
–Cirrhosis in 10 – 20% of dependent persons
Gastrointestinal
–Pancreatitis
–Oesophageal varices
–Gastritis
–Peptic ulceration
Neurological
–Peripheral neuropathy
–Seizures
–Dementia
Cancer
–Bowel, breast, oesophageal & liver all associated
Cardiovascular
–Hypertension & cardiomyopathy
Head injury / accidents
–Risk increased while intoxicated
Foetal alcohol syndrome
–In infants born to those who drink during pregnancy
18
Q
Management of alcohol withdrawal
A
- patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- firstline: benzodiazepines e.g. chlordiazepoxide.
Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin* is said not to be as effective in the treatment of alcohol withdrawal seizures
19
Q
Examples of one unit of alcohol
A
- 25ml single measure of spirits (ABV 40%)
- a third of a pint of beer (ABV 5 to 6%)
- half a 175ml ‘standard’ glass of red wine (ABV 12%)
20
Q
A
21
Q
Psychological complications of alcohol dependence
A
- Depression & Anxiety rates increased (also self medication can lead to dependence)
- Self harm & suicide risk increased
- Amnesia / blackouts (due to intoxication
- Cognitive impairment
–Alcoholic dementia
–Korsakoff’s psychosis
- Alcoholic hallucinations
- Morbid Jealousy
22
Q
How to calculate a number of units in a drink?
A
To calculate the number of units in a drink multiply the number of millilitres by the ABV and divide by 1,000. For example:
- half a 175ml ‘standard’ glass of red wine = 87.5 * 12 / 1000 = 1.05 units
- one bottle of wine = 750 * 12 / 1000 = 9 units
- one pint of 5% beer or lager = 568 * 5 / 1000 = 2.8 units
23
Q
Drugs used in detoxification
A
Detoxification
- Benzodiazepines
- Vitamins (Thiamine)
24
Q
Relapse prevention
A
- Psychological support (group, individual, AA)
- Medical
- Acamprosate – reduces craving
- Disulfiram – induces flushing if alcohol taken
25
Medications used in relapse prevention (alcohol)
* ***Acamprosate →***reduces craving
* ***Disulfiram*** → induces flushing if alcohol taken
26
MoA of ***Disulfiram***
- contraindications
disulfram → promotes abstinence - alcohol intake causes severe reaction due to inhibition of *acetaldehyde dehydrogenase*
Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms.
**Contraindications**: ischaemic heart disease and psychosis
27
MoA of ***Acamprosate***
***Acamprosate***:
* reduces craving, known to be a weak antagonist of NMDA receptors
* improves abstinence in placebo controlled trials
28
**Delirium Tremens**
* when does it start
* symptoms
* treatment
**Delirium Tremens**
* Onset in 48h after abstinence
* Confusion, hallucinations & illusions, agitation, sweating, tachycardia, tremor, seizures
* Treat with reducing *benzodiazepine* regime & parenteral B vitamins (*Pabrinex*) - to avoid Wernicke – Korsakoff Syndrome
29
Wernicke's Encephalopathy
* classic triad
* cause
* treatment
***Wernicke’s* Encephalopathy**
## Footnote
**Classic triad:** of confusion, ataxia & ophthalmoplegia
**Cause:** Acute thiamine (vitamin B1) deficiency
**Treatment:** a course of parenteral B vitamins (*Pabrinex*) given IV or IM
\*if untreated leads to Korsakoff’s Psychosis (IRREVERSIBLE anterograde amnesia with confabulation)
30
***Amphetamines***
- class
- unofficial names
- routes of administration
- effects
***Amphetamines***
## Footnote
**Class**: stimulant
**Names:** “speed”, “whizz”
**Routes of administration**: Snorted, injected, eaten / put on gum
Physical & Psychological **Effects**:
–Cardiovascular strain
–Enlarged pupils
–Talkative, agitated, full of energy, irritable
- Psychosis (schizophreniform)
31
'Illegal' Benzodiazepines
- what effect they produce?
* *Diazepam, Lorazepam, Temazepam*
* Prescribed or bought (often online)
* Usually ingested orally, can be prepared for injection
**Effects**: sedation, euphoria, disinhibition, lability of mood, anterograde amnesia, unsteady gait, slurred speech, nystagmus, reduced consciousness, respiratory depression
32
Withdrawal of benzodiazepines
- what can happen
- treatment
**Withdrawal can cause**: delirium tremens – like presentation with psychotic symptoms and seizures
**Treatment:** convert to diazepam equivalent dose & withdraw gradually over 8 + weeks
33
***Cocaine***
- class
- effects it produces
Cocaine → Stimulant
* Alert, confident, strong, disinhibited
* Short- acting → need to repeat dose
* “come down” – fatigue, depression / dysphoria, paranoid ideation, depersonalisation
34
Two forms of cocaine
Two forms:
**1. Powder** (hydrochloride)
- Sniff / snort / inject
2. **Crack** (alkaloid)
* Heated & inhaled through pipe
* Quick acting with fast high
* Can be injected if added to acid (vit C) – often with heroin ('speedball')
35
What's 'speedball'?
Cocaine that can be injected if added to acid (vit C) – often with heroin ('*speedball*')
- very fast effect of high
36
Management of Cocaine abuse
* Intense craving is a major problem
* No replacement therapy available
* Acute Psychotic episodes → antipsychotic & benzodiazepines (short term) for symptom control
* Self help and support groups available (Cocaine Anonymous)
37
Mechanism of action of cocaine
cocaine blocks the uptake of dopamine, noradrenaline and serotonin
38
Side effects of cocaine abuse
**Cardiovascular effects**
* myocardial infarction
* both tachycardia and bradycardia may occur
* hypertension
* QRS widening and QT prolongation
* aortic dissection
**Neurological effects**
* seizures
* mydriasis
* hypertonia
* hyperreflexia
**Psychiatric effects**
* agitation
* psychosis
* hallucinations
**Others**
* ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding
* hyperthermia
* metabolic acidosis
* rhabdomyolysis
39
Management of cocaine toxicity
Management of cocaine toxicity
* **benzodiazepines** are generally first-line for most cocaine-related problems
* **chest pain**: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary percutaneous coronary intervention
* **hypertension**: benzodiazepines + sodium nitroprusside
40
***Cannabis***
- routes of administration
- active substance
- other name
**Administration**: dried vegetative state or resin → eat or smoke
Active substance ***tetrahydrocannabinol*** → 75% of available cannabis is “**Skunk**” (genetically engineered to have more THC)
41
SEs of cannabis
Produces “high”
SEs:
* can exaggerate previous mood state, anxiety, “paranoia”, distortion of time, mild hallucinogen
* conjunctival injection, dry mouth, tachycardia, respiratory tract symptoms
* Association with schizophrenia
42
**Ecstasy**
- class
- route of administration
**MDMA** → 3,4 methylenedioxymethylamphetamine
Sold in tablet (usually) or powder form
43
Effects and SEs of ecstasy use
• increased energy, hyperaesthesias, increased feeling of wellbeing and love
SEs:
* panic
* dysphoria
* depression
•Has been associated with raised temp, dehydration, tachycardia & DIC (disseminated intravascular coagulation)
44
Heroin
- class
- other (informal) names
Class: opiate derivative → highly addictive
Names: “brown”, “smack”, “gear”
45
Routes of administration of Heroin
•**Injected**
–If combined with crack cocaine is called “speedballing”
•**Smoked**
–By heating on tinfoil and inhaling the smoke
–“chasing the dragon”
–can also be snorted (less common)
46
**Heroin**
- effects
- withdrawal symptoms
**Effects**: gives strong sense / rush of relaxation / wellbeing
**Withdrawal symptoms**:
–Vomiting, diarrhoea, cramps, sweats, dysphoria
47
Physical effects of Heroin
* Pin point pupils
* “Track marks” → injection sites
* Constipation
* Poor nutrition
* Poor dental state (reduced salivary flow)
* Respiratory depressant
* Blood borne viruses (injecting patients)
–Hepatitis C
–Hepatitis B
–HIV
48
Education for Heroin users
**Harm Reduction**
–Needle exchange, stop sharing gear / works
–Encourage smoke rather than inject
–Raise awareness of overdose & how to manage it, especially if been abstinent (some areas give naloxone packs)
-Narcotics Anonymous
49
Pharmacological management of Heroin abuse (3)
**Opioid Substitution Treatment (OST)**
## Footnote
**Methadone**
* Full agonist, prolongs QT interval (monitor ECG 6 monthly)
* Cheap, large evidence base
**Buprenorphine** (Subutex)
•Partial agonist, less sedative, less risk of OD
Others
* **Dihydrocodiene** (short term stop-gap only)
* Patient Choice of aim of OST
–Maintenance
- Detoxification
50
What's *Khat*?
* Plant grown in East African regions
* Has to be taken fresh
* Recently made illegal
* Usually consumed by Somali and other East African and Arab communities
* Produces a stimulant like effect
* Has been known to precipitate psychosis
* Is used to make miaow-miaow
51
**Ketamine**
- class
- routes of administration
***Ketamine***
* an anaesthetic agent
* commonly in powder or tablet form
52
**Ketamine**
* effects
* side effects
**Effects**: produces hallucinations, reduced pain sensation, drowsiness, sedation, respiratory depression
**SEs**: Prolonged use can cause “*ketamine bladder*” – haematuria, scarring and severe pain – severe cases have necessitated removal of the bladder
53
**LSD**
## Footnote
- administration method
- effects
- SEs
LSD
## Footnote
**Administration**: taken as a “tab” on a tiny square of paper
**Effects**: hyperaesthesias, hallucinations, and other altered perceptions & experiences aka “trip”
\*trips can be pleasant or unpleasant & frightening “bad trip”
**SEs**: Flashbacks can occur days / months later, can precipitate mental health problems in people with predisposition
54
Novel Psychoactive Substances
- names
* previously known as “legal highs''
Brand names include “*Clockwork Orange*”, “*Bliss*” and “*Mary Jane''*
55
Forms in which Novel Psychoactive Substances come in
Come in different forms - powders, pills, smoking mixtures, liquids, capsules, or on perforated tabs.
56
Novel Psychoactive Substances
* stimulants - names, eddects
**Stimulants** - e.g. *mephedrone, naphyrone*
Act like amphetamines, cocaine, or ecstasy.
Make you feel energised, physically active, fast-thinking, very chatty and euphoric.
57
Novel Psychoactive Substances
* downers/ sedatives - names, effects
Downers or sedatives - e.g. **GBH / GBL.**
Act like benzodiazepines. Make you feel euphoric, relaxed, sleepy.
58
Novel Psychoactive Substances
* Hallucinogens
Hallucinogens or psychedelics
Act like LSD, magic mushrooms, ketamine
59
**Synthetic cannabinoids**
* names
* effects
Synthetic cannabinoids - novel psychoactive substnces
## Footnote
Names: e.g. “Spice”, “Black Mamba.”
Act similar to cannabis
Effects: relaxation, altered consciousness, disinhibition, feeling energised and euphoria
60
***Spice***
- what's that
- class
***Spice***
* synthetic cannabinoid
* more potent than natural cannabis.
* usually smoked
* Class B drug.
61
Effects of *Spice*
**Typical effects:**
* Feeling happy, euphoric, relaxed
* Some people get “the giggles”, feel hunger pangs and become very talkative, others become drowsy
* Mood and perception can change and concentration and co-ordination may become difficult
* More likely to be associated with hallucinations than natural cannabis
\*Some people have bad reactions, e.g. paranoia, panic attacks, forgetfulness.
Can make users “freeze.”
62
What's drug classification (in general)
Defined by the government and changes from time to time
* Class A
* Class B
* Class C
* Different classes carry different penalties & usually (but not always) reflect potential level of harm
63
Class A drugs
- the length of penalty
Class A
–Possession
•7 years & unlimited fine
–Possession with intent to supply
•Life & unlimited fine
64
Class B drugs
- the length of penalty
Class B
–Possession
•5 years & unlimited fine
–Possession with intent to supply
•14 years & unlimited fine
65
Class C drugs
- length of penalty
Class C
–Possession
•2 Years & unlimited fine
–Possession with intent to supply
•14 years & unlimited fine
