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Exam 2 (and 3) - CNS, mental health, renal and liver > Substance missues > Flashcards

Substance missues Flashcards

(42 cards)

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1
Q

Risk factors for substance abuse?

A
  • Personal or family history
  • history of pain issues- trying to manage pain
  • Easy access to meds as working in healthcare
  • Time spent in environment like prison- lots of drugs
  • Difficult life events- childhood trauma, divorce, bereavement
  • Severe mental or physical health problems
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2
Q

What does the term ‘dual diagnosis’ mean in substance misuse?

A

25% (1in 4) patients with severe mental health problems are expected to have substance missuse- it Is actually more like 35-50%

People with substance misuse, 25% are expected to have mental health problems- actually about 50-75%

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3
Q

What are warning signs of missuse?

A
  • Taking higher doses than prescribed/advised
  • Running out of prescription early
  • ‘Losing’ meds or prescriptions
  • Requesting specific drugs- stating that others don’t work or are allergic
  • risky behaviours e.g. criminal activity
  • falls, injuries
  • troubled relationships, money problems

Presentations:
- intoxicated, sedated, withdrawal symptoms
- unkempt appearance, lack of self care
- mood swings or hostility
- changes in sleep patter.
- avoiding random drug testing

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4
Q

What are non-pharmaceutical options for helping someone with substance missuse?

A
  • harm reduction advice
  • peer support
  • drug diaries
  • counselling
  • therapy
  • exercise
  • educational opportunities
  • encourage hobbies/activities
  • mindfullness, good sleep hygiene, relaxation techniques
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5
Q

What heritage has a lower risk alcohol problems and why?

A

People of Asian heritage have a lower risk of alcohol problems due to about 50% having non-functional aldehyde dehydrogenase genes resulting in the so-called ‘Asian flush’, and nausea and vomiting

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6
Q

what percentage of the uk’s dependent drinkers are receiving treatment?

A

Of 60k dependent drinkers, only 18% are receiving treatment

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7
Q

What percentage of the uk regularly drink over the guidelines?

A

24%

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8
Q

What is the statistic for the risk factor of alcohol misuse?

A

Is the biggest risk factor for death, ill-health and disability along 15-49 year olds in the uk and fifth biggest risk across all ages.

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9
Q

What are some potential risks of long-term high alcohol intake?

A

Death: about 20,000 premature deaths a year are alcohol-related
◼ Liver damage - in 90% alcoholics, hepatitis in nearly 40%
◼ Accidents – up to 75% UK A&E visits may be due to alcohol misuse
◼ Cancer – 3% cancers thought to be alcohol-related e.g. liver, stomach, breast, mouth area
◼ Gut e.g. major bleeds from the gut, stomach ulcers
◼ Mental health problems - in up to 80% people e.g. depression, anxiety
◼ Social problems – 30% divorces, 40% of domestic violence, 20% of child abuse
◼ Weight gain
◼ Brain damage e.g. seizures or fits, stroke, dementia
◼ Nerve damage e.g. peripheral neuropathy
◼ Pancreatitis
◼ Heart disease – hypertension, heart attacks, irregular heart
◼ Sexual problems e.g. impotence, premature ejaculation, reduced fertility
◼ Bones e.g. osteoporosis
◼ Skin – worsening of skin diseases like psoriasis and eczema.
◼ Insomnia and sleep problems
◼ Strokes
◼ Loss of driving license
◼ Risk to any unborn child

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10
Q

What are the risk factors for developing an alcohol problem?

A
  • Genetics:
    Family history- no single gene but up t0 400 may influence the development
    Genes account for about 50% of overall risk
  • Starting drinking younger
  • Regular drinking very day
  • mental health problems e.g. anxiety, depression, PTSD
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11
Q

Can alcohol cause cancer?

A

many people are aware of tis risk on liver disease, but not its contribution to cancers

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12
Q

What are the potential risks of chronic alcohol consumption on the CNS?

A
  • Cognitive impairment- is neurotoxic and can lead to alcohol demential and longterm neuropathy, cerebral atrophy
  • Wernicke-Korsakoff syndrome- neuropsychiatric disorder caused by a thiamine deficiency
    Presents as confusion, apathy, disorientation, vomiting, memory problems
    Occurs in as many as 12.5% of alcohol misuses
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13
Q

What are the presentations of Wernicke’s-korsakoff syndrome?

A
  • Wernicke-Korsakoff syndrome- neuropsychiatric disorder caused by a thiamine deficiency
    Presents as confusion, apathy, disorientation, vomiting, memory problems
    Occurs in as many as 12.5% of alcohol misuses
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14
Q

How is Wernicke’s Korsakoff treated?

A

Via Thiamine supplementation:
- Acute treatment with Pabrinex- 1 pair of ampules IM or IV daily for 3-5 days.
- Maintenance- oral Thiamine 100mg TDS

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15
Q

Why does thiamine dosing need to be spread out across the day?

A

Because oral absorption is poor- humans can only absorb about 4mg per hour so 100-300mg once a day is pointless- must be spread out

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16
Q

What are the current management procedures for established alcohol dependence?

A
  • Assessment of alcohol dependence
    Pharmacist interventions
    Psychosicial interventions e.g. AA, NORCAS
  • Detoxification
    Assisted detox, withdrawal programe
    Anti-convulsants for safe detox
  • Assisted maintenance
    Pharmacological interventions e.g. Acamprosate, disulfram, naltrexone
    Treat underlying cause
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17
Q

What is important regarding alcohol withdrawal?

Study These Flashcards
A

Acue alcohol withdrawal can be fatal

18
Q

What drugs are given in alcohol withdrawal/detoxification?

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A

Benzodiazepines:
e.g Chlordiazepoxide at a 20-40mg four times a day, reduced over 9 days.

19
Q

Who might need a reduced dose of benzos for withdrawal?

Study These Flashcards
A

elderly
Hepatic impairement
- due to risk of accumulation

20
Q

What is the CIWA?

Study These Flashcards
A

The Clinical Institute Withdrawal Assessment for Alcohol, commonly abbreviated (CIWA), is a 10-item scale used in the assessment and management of alcohol withdrawal.
- Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal (impending delirium tremens)

21
Q

What alternatives Benzo to chlordiazepoxide may be given in hepatic impairment?

Study These Flashcards
A

lorazepam
Oxazepam

22
Q

What drugs may be given for maintenance of alcohol dependence?

Study These Flashcards
A
  • Disulfiram - pro-drug activated in the liver that prevents conversion of acetaldehyde to acetic acid and dopamine to noradrenaline. Is an adverse therapy- consumption of alcohol cause symptoms e.g. vasodilations, palpiatations and headache. Combination with alcohol can be fatal
  • Acamprosate- glutamate antagonist. Has a better safety profile, but efficacy is marginal
  • Naltrexone- licenced for alcohol misuse disorder (opioid antagonist). Well tolerated. It blocks the opioid receptors that modulate dopamine release in the brains reward system = blocks the rewarding effect of alcohol.
  • Nalmefene- Also opioid antagonist. Reduces the reward.
23
Q

What does the alcoholic identification and brief advice (IBA) service process include?

Study These Flashcards
A
  • Gain permission to talk about drinking
  • Screen for alcohol consumption (FAST)- alcohol harm assessment tool. It consists of a subset of questions from the full alcohol use disorders identification test (AUDIT).
  • Complete a validated screening questionnaire e.g. AUDIT (alcohol use disorders identification test)
  • Give advice, resources, refer
24
Q

What is a positive score on the FAST and what should you do

Study These Flashcards
A

Overall total score of 3 or more is FAST positive, if positive complete an AUDIT or AUDIT-C test

25
What score on the AUDIT-C test is AUDIT-C positive?
A score of 5+ indicated increasing risk drinking. An overall score of 5 or above is AUDIT-C +ve
26
What is the NNT for alcohol brief interventions?
NNT = 8
27
What is used for opioid overdose/toxicity?
Naloxone- is an emergency antidote
28
What is the treatment process for opioid dependence?
- Assessment- confirm depndence - Detoxification and induction onto maintenance- titrate over several days to curb withdrawal symptoms - Maintenance with opioid substitute - Gradual discontinuation with support- the hardest part
29
Examples of opioid withdrawal symptoms?
Runny nose eye watering dilated pupils N+V diarrhoea muscle aches restlessness
30
What pharmacotherapy is used for maintenance of opioid dependence?
Methadone: - Full agonist - reduces peak levels from injecting - supresses withdrawal and craving- has longer t1/2 - People can and do still "use on top" Buprenorphine: - Partial agonist - longer half life than methadone - not totally absorbed- sub-lingual or injections - Cant use on top- buprenorphine blocks the effects of additional opioid use by preventing occupation of opioid receptors
31
What are the advantages and disadvantages of methadone?
- Established and familiar ◼ Good evidence base for MMT (Methadone Maintenance Treatment) ◼ Sedating ◼ Cheap ◼ Full agonist ◼ Variety routes/forms ◼ Easy to supervise ◼ Orally absorbed Established and familiar ◼ Good evidence base for MMT (Methadone Maintenance Treatment) ◼ Sedating ◼ Cheap ◼ Full agonist ◼ Variety routes/forms ◼ Easy to supervise ◼ Orally absorbed
32
What are the advantages and disadvantages of Buprenorphine?
◼ More difficult to use “on top” (maintenance minimises drug seeking behaviour, negative reinforcement) ◼ Safer in overdose ◼ Good for those at risk of overdosing ◼ Less stigmatised ◼ Easier to detox from, easier switch to naltrexone ◼ Less sedating ◼ Better outcomes of new-borns ◼ Can’t be adulterated ◼ Initial titration rapid ◼ Range of long-acting products also now available (LAI and rods) ◼ Not orally absorbed ◼ Unpleasant taste (S/L) ◼ More difficult to supervise (concealment) ◼ Poorer evidence base/less experience ◼ Can be injected ◼ Suboxone resolves this ◼ Only one dosage form ◼ Less sedating ◼ Can precipitate withdrawal, especially on induction ◼ Relatively expensive
33
What is the usual maintenance dose of methadone?
40-120mg/day
34
What is the common titration procedure for methadone?
* 20-30mg day 1, increase 5-10mg every few days up to max total 30mg above starting dose/week, then increase once or twice weekly (10-15mg) as needed * Takes about 5 days for blood levels to reach steady state
35
What are potential side effects of methadone?
CNS effects: ◼ Euphoria - not as marked as heroin ◼ Pleasant, warm feeling in stomach ◼ Pain relief ◼ Drowsiness – which wears off ◼ Nausea/vomiting - stimulation of chemoreceptor trigger zone ◼ Respiratory depression, especially at higher doses ◼ Cough reflex depression ◼ Histaminergic effects (itching, sweating, blushing, flushing, constricting of the airways) Other effects: ◼ Reduced or absent menstrual cycle - may still become pregnant ◼ Sexual dysfunction ◼ Dry mouth, eyes, nose ◼ less secretion of saliva, tears and mucous ◼ Dental problems ◼ 57% report, methadone is acidic ◼ Constipation ◼ Opioids slow passage of food ◼ People require high fibre & high fluid ◼ Laxatives may be needed ◼ Constricted pupils ◼ Reliable indicator of the level of opioids in blood stream
36
What is a major risk/side effect of methadone?
Can cause QT prolongation especially in doses over 100mg/day. - So need to be cautious with other drugs that raise QT .g. lithium, TCAs, SSRIs, macrolide), heart disease, stimulant usage
37
What should be done if a patient is at risk of QT prolongation and is on methadone?
Offer an ECG - If this is normal, repeat 6-12 monthly - If QT is prolonged, discussed treatment options: possible alternatives to methadone e.g. buprenorphine possible cardiology referral consider dose reduction- cautious
38
What is the risk of relapse with patients on Naltrexone for prophylaxis of previously opioid dependents?
Risk of respiratory depression if they relapse while taking Naltrexone = fatal
39
What are the symptoms of an opioid overdose?
* Pinpoint/constricted pupils * Nausea/vomiting * Pale skin colour, bluish tinge to lips, tip of nose, under the eyes, fingertips, or nails * Low blood pressure, slow pulse (hypotension/bradycardia) * Sedation, which may be getting worse, including: o No response to noise (no response to shouting) o No response to touch (no response to being shaken by the shoulders) o Loss of consciousness (cannot be woken) o Breathing problem (slow/shallow/infrequent breaths, snoring/rasping sounds, or no breathing)
40
When would you contact the prescriber of a patient on methadone?
- Note every time a dose is missed/erratic attendance Must contact presider if: - missed 3 or more doses - concerns about dose or prescriptuon - dispensing error or near misses - unacceptable behaviour - whole dose not consumers - concerns about physical or mental health
41
What harm reduction advice can be given to known drug users?
* Do not use (drugs) while alone * If things go wrong, get help fast * Beware of loss of tolerance (dose increases needed) * Avoid polypharmacy (e.g. Cocaethylene with cocaine and alcohol) * Try a small amount first and wait to see effects * Use smaller amounts and less often * Avoiding combination products * e.g.ibuprofen→GIbleed; paracetamol→overdose * Don’t share injecting equipment * Avoid injecting * Safe injecting advice * Check BBV testing/vaccination stats * Contraception/sexual health advice * Needle exchange...
42
What are the possible effects of synthetic canabis?
Desired effects: relaxation, altered consciousness, disinhibition, energy & euphoria ◼ CNS toxicity: agitation, tremor, confusion, somnolence, syncope, hallucinations, acute psychosis, nystagmus, convulsions ◼ Cardiac: tachycardia, hypertension, palpitations, ECG changes ◼ Others: renal damage, disinhibition, memory loss, bloodshot eyes, time distortion these can change as the composition us unknown and changes from batch to batch

Exam 2 (and 3) - CNS, mental health, renal and liver (23 decks)

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