Substance Misuse Flashcards
(22 cards)
Alcohol misuse classification
Harmful Drinking:
- Involves consumption leading to physical or mental harm.
- Can include health issues like liver damage or psychological problems.
Alcohol Dependence:
- Characterized by a strong craving for alcohol and loss of control.
- Includes withdrawal symptoms,
Alcohol misuse investigations
Bloods: FBC, LFT, B12, folate, U&E, clotting screen, glucose
Rating scale (e.g. AUDIT, CIWA-Ar, APQ)
Severity of Alcohol Dependence Questionnaire (SADQ)
Alcohol misuse assessment
AUDIT – alcohol use disorders identification test (>15 requires comprehensive assessment)
SADQ – severity of dependence
CIWA-Ar – clinical institute withdrawal assessment of alcohol scale (for severity of withdrawal)
APQ – alcohol problems questionnaire (assess the nature and extent of the
problems arising from alcohol misuse)
Alcohol misuse principles of intervention
Carry out a motivational interview (explore problems related to drinking, encourage belief in ability to change)
If homeless, offer residential rehabilitation services for maximum of 3 months
Provide information about Alcoholics Anonymous, SMART Recovery and Change, Grow, Live (CGL)
Interventions for Harmful Drinkers and Mild Alcohol Dependence
Psychological intervention
If no response to above or if pharmacological treatment requested, offer the following alongside psychological therapy:
- Acamprosate (anti-craving)
- Naltrexone
Alcohol misuse withdrawal
Benzodiazepines
Give Pabrinex if they are at risk of Wernicke’s encephalopathy
Symptoms worse within first 48 hours, take about 3-7 days after last drink to resolve
If >15 units/day or >20 on AUDIT - community based assisted withdrawal
Consider inpatient assisted withdrawal if
30+ units/day
30+ on SADQ
History of epilepsy, delirium tremens or withdrawal-related seizures
Need concurrent withdrawal of alcohol and benzodiazepines
Significant psychiatric comorbidity or significant learning disability
Lower threshold for inpatient treatment in vulnerable groups (e.g. homeless, older people)
Children (10-17)
- Should also receive family therapy for about 3 months
Alcohol withdrawal drug regimen
Chlordiazepoxide or diazepam
If liver impair consider lorazepam
No more than 2 days medication at once
Alcohol misuse after successful withdrawal
Consider acamprosate or naltrexone with individualised psychological intervention
Consider disulfiram otherwise
Usually prescribed for up to 6 months
Carry out thorough medical assessment to establish baseline
Acute alcohol withdrawal management
Consider offering a fast-acting benzodiazepine (e.g. lorazepam) or carbamazepine in the acute phase i.e in the case of alcohol withdrawal seizures
Switch to long-acting benzodiazepines (e.g. chlordiazepoxide or diazepam) in the outpatient setting
Alternatives: Clomethiazole or carbamazepine
Do not use clomethiazole in patient who may relapse as clomethiazole and alcohol, especially on a background of cirrhosis, can cause fatal respiratory depression even with short term use
Acute alcohol withdrawal delirium tremens
Oral lorazepam
- If symptoms persist offer parenteral lorazepam or haloperidol
- Otherwise chlordiazepoxide
IV thiamine
Acute alcohol withdrawal seizures
Fast acting benzodiazepine (lorazepam)
Do not offer phenytoin
Opiate misuse general management
Needle exchanges for IV drug users
Vaccination and testing for blood-borne viruses for sex-workers and IVDU
Self help groups (12 step groups)
Do not routinely offer opioid withdrawal treatment if
Concurrent medical problem requiring urgent treatment
In police custody
Presenting in acute or emergency settings
Be careful with pregnant women
Opiate misuse medication for detoxification
Appoint key worker
Methadone (liquid) or buprenorphine (sublingual)
Lofexidine otherwise
Inpatient for up to 4 weeks
Outpatient for up to 12 weeks
Opiate misuse withdrawal management
Clonidine and lofexidine
Opiate misuse detoxification
Withdrawal precipitated by using high dose opioid antagonists (naltrexone or naloxone)
Ultra-rapid - 24 hours under anaesthesia or heavy sedation - should not be used
Rapid - 1-5 days with moderate sedation - considered if patient requests
Accelerated - no sedation
Opiate misuse follow up
Refer to Drugs and Alcohol Service for at least 6 months
CBT to prevent relapse
Key worker
Contingency management
- Offer incentives for every drug-negative test
- Screening could be frequent at first (3/week) and then reduced
- Urinalysis is the preferred method of screening
Opioid overdose
IV, IM or nasal spray naloxone
Benzodiazepine misuse risks
Short-Term: drowsiness, reduced concentration
Long-Term: cognitive impairment, worsening anxiety and depression, sleep disruption
Benzodiazepine misuse withdrawal features
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Excessive sweating
Seizures
Perception disturbance
Benzodiazepine misuse withdrawal management
Address underlying issues that need benzodiazepine
Withdraw in steps of about 1/8 of the daily dose every fortnight
Consider switching patients to equivalent dose of diazepam
- Oxazepam may be considered instead in patients with liver failure
May take 3 months to a year or more
