Substance misuse Flashcards
Dependence and recommended alcohol intake
Recommended units per week- 14 for men and women, 5-6 glasses of wine or pints of beer.
Dependence: ICD-11 criteria (>2= of)
* Control (Powerlessness): over onset, intensity, duration, termination, frequency, context
* Precedence: over other aspects of health (bio-psycho-social)
* Physiological: tolerance, withdrawal, used to prevent/alleviate withdrawal
Symptoms of addiction
- Impaired control of substance: duration, context
- Craving
- Increasing prioritisation
- Physiological features i.e. hallucinations. Not required for diagnosis
- Tolerance and withdrawal, insufficient in themself for diagnosis
- Physical and mental harm, often seen not required for diagnosis
If not dependence: what is it?
- Hazardous drinking is a risk factor for adverse consequences (bio-psycho-social) for self or others
- Harmful drinking is a pattern of alcohol consumption that results in adverse consequences (bio-psycho-social). >12 months (or 1 month if continuous)
- An Episode of Harmful drinking is drinking that leads to harm, but without a pattern
Psychological harm from alcohol dependence
Insomnia, Depression, Suicide, Attempted suicide, Anxiety state, Personality change, Psychotic illness, Amnesia, Alcoholic halllucinosis, Morbid jealousy, Delirium tremens
Alcohol withdrawal manifestations
- Onset 3-12 hours
- Peaks 24-48 hours
- Duration up to 14 days
- Agitation/ anxiety/ irritability
- Tremor hands/ tongue/ eyelid
- Sweating, fever, tachycardia, hypertension, general malaise
- Nausea/ vomiting/ diarhhoea
Severe alcohol withdrawal/complications
- Seizures: may commence before blood alcohol zero
- Delirium tremens: clouding of consciousness, hallucinations/psychosis. Tremor +++, sympathetic overdrive
- Delirium tremens: develops on 5%. Mortality 10-20% if untreated. Medical emergency, needs prompt transfer to general medical setting
Mechanism: alcohol withdrawal
- 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). This causes over- activity of the central nervous system and increase in the action of glutamate. Leading to profound excitatory action and sympathetic overdrive
Features: alcohol withdrawal
- 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
Management: alcohol withdrawal
- 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
- first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. 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
Alcohol withdrawal treatment plan
- ABC
- +DEFG!
- Physical observations, ECG
- Bloods – incl. FBC, U and E, LFTs, clotting, amylase +/- CK +/- blood cultures
- IV thiamine
- Diazepam / chlordiazepoxide; likely symptom triggered
- PRN medication in case of seizure; midazolam/ diazepam as per policy
Treating alcohol dependence
- Alcohol Detoxification
- Pharmacotherapy
- Manage physical illness occurring as consequence of alcohol (e.g. Liver Transplant)
- Psychotherapy
- Social Interventions
- Residential Rehabilitation
Alcohol detoxification: management
- Where: home, partial hospitalisation, inpatient
- General support/advice
- Drug of choice- longer acting benzodiazepines
- Regular monitoring: observe for withdrawal/ over-sedation. BAC/CIWA
- Treat withdrawal: symptoms triggered/ fixed dose etc. Risk of undertreatment (DT’s/fits). Risk of overtreatment (over-sedation)
- Oral/IM vitamins as indicated
- Reducing regime
Alcoholism: Wernicke-Korsakoff syndrome
- Occurs secondary to thiamine deficiency
- Triad of: ocular disturbances, gait disturbance, confusion
- Korsakoff’s: global impairment including confabulation
- Wernicke’s= acute syndrome. Korsakoff’s= long term neurological sequelae of Wernicke’s. In reality distinction between the two syndromes is often difficult. Degree of reversibility if treated promptly
Features of Wernicke- Korsakoff syndrome
- oculomotor dysfunction: nystagmus (the most common ocular sign), ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
- gait ataxia
- encephalopathy: confusion, disorientation, indifference, and inattentiveness
- peripheral sensory neuropathy
- Korsakoff: confabulation, amnesia
- Investigations: decreased red cell trasketolase, MRI
- Causes: poor dietary intake and reduction in duodenal capacity for absorption secondary to low alcohol intake
Longer term prevention of alcoholism
- Deterrent= Disulfiram
- Anti-craving= Acamprosate
- Treatment of co-morbid conditions i.e. Antideppressants
- Others i.e. Naltrexone
- For patients who do not require detoxification- consider nalmefene
Hazardous vs harmful vs binge drinking
hazardous: >15 U/week
harmful: >50 U/week (men), >35/week (women)
binge: >8 U in a single session (men), >6 U (women)
FAST screening tool for drinking
- How often do you have 8+ drinks on one occasion?
- How often during the last year have you been unable to remember what happened the night before because you had been drinking?
- How often during the last year have you failed to do what was normally expected of you because of your drinking?
- Has a relative or friend, a doctor or other health worker been concerned about your drinking or suggested you cut down?
AUDIT screening tool and biological markers
A 10-item screen can quickly identify substance abuse problems (known as Alcohol Use Disorders Identification Test)
Distinguishes between low risk, hazardous drinking, harmful drinking, and possible dependence.
Which biological marker has the best sensitivity and specificity for alcohol abuse: Carbohydrate deficient transferrin
Alcoholism screening tests and smoking cessation
Screening tests: AUDIT, AUDIT-C (shortened version), AUDIT- PC, FAST, M-SASQ
Smoking cessation= big overlap with alcoholics. Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
Drugs
Drugs= a substance which produces a non-nutritional physiological effect when introduced to the body.
Cannabis is the most widely used illegal drug
Almost half of all drug poisonings involve an opiate, over half of all drug poisonings involve more than one drug.
Withdrawal
The experience of a set of unpleasant symptoms following the abrupt cessation or reduction in dose of a psychoactive substance; it has been consumed in high enough doses and for a long enough duration for the person to be physically or mentally dependent on it. Withdrawal symptoms are, essentially, opposite to those that are produced by the psychoactive substance itself.
