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Flashcards in Substance Misuse Deck (61)
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1

What is harmful use?

A pattern of use likely to cause physical or psychological damage

2

What is dependency?

A cluster of physiological, behavioural and cognitive symptoms in which use of a substance takes on a much higher priority than other behaviours that once had grater value

3

What is withdrawal?

A transient state occurring while readjusting to lower levels of the drug in the body

4

What is the classical conditioning theory of dependence?

Cravings become conditioned to cues
So that a cue itself can trigger a craving and thus cause drug seeking behaviour

5

What is the operant conditioning theory of dependence?

Behaviours rewarded are repeated: positive reinforcement
Behaviours are repeated if they relieve unpleasant experiences: negative reinforcement

6

What are features of dependence?

Tolerance
Compulsion
Withdrawal
Problems controlling use
Continued use despite harm
Salience
Reinstatement following abstinence
Narrowing of the repertoire

7

What is tolerance?

Larger doses required to gain the same effect experienced previously

8

What is compulsion?

Strong desire to use the substance

9

What is salience?

Obtaining and using the substance becomes so important that other interests are neglected

10

What is narrowing the repertoire?

Loss of variation in use of the substance?

11

What is the social learning theory of dependence?

AKA vicarious learning

We learn by copying behaviours of others
Substance misuse can result from peer pressure

12

What is the neurobiological model for addiction?

All drugs if abuse affect the dopaminergic reward pathway in the brain:
Ventral tegmental area -> prefrontal cortex and lambic system
Prefrontal cortex has a role in motivation + planning
Dopamine release in nucleus accumbens= sensation of pleasure

13

How do cocaine and amphetamines give pleasure?

Block dopamine reuptake
= increased synaptic dopamine levels

14

Aetiology of alcohol misuse

Some genetic susceptibility: supported by adoption studies
Occupation: stressful work + socially sanctioned drinking
Social background: difficult childhood, poor educational achievement
Psychiatric illness: assoc with personality disorders, mania, depression, and anxiety disorders

15

1 unit of alcohol:

1/2 pint normal beer
Small 125ml glass wine
One measure (25ml) spirit
One measure (50ml) fortified win

Units= vol in ml x % alcohol /1000

16

What are safe levels of alcohol consumption?

Women: 2-3/day, 14/week
Men: 3-4/day, 21/week

17

What are harmful levels of alcohol consumption?

Women: >6 /day, >35 /wk
Men: >8 /day, >50 / wk

18

Delerium tremens

48hrs into abstinence, lasts 3-4 days
Symptoms:
Confusion, hallucinations, affective changes, gross tremor, autonomic disturbance, delusions
Mortality rate 5% (30% with sepsis)
Management: reducing benzodiazepine regime and parenteral thiamine, management of potentially fatal dehydration and electrolyte disturbance

19

What is Wernicke's encephalopathy

Due to acute thiamine (vit B1) deficiency
Confusion, ataxia, opthalmoplegia
Medical emergency!
Treat with parenteral thiamine

20

What is korsakoff's syndrome?

Cause by untreated Wernicke's encephalopathy
Irreversible antegrade amnesia
Can register new events but cannot recall them
Patients may confabulated to fill in gaps in memory

21

What is intoxication?

Transient state of emotional and behavioural change following drug use, dose dependent and time limited

22

How would you investigate a patient with apparent alcohol misuse?

FBC: macrocytic anaemia (incr MCV) due to B12 deficiency
LFTs: gammaGT rises with recent heavy alcohol use, raised transaminases indicate hepatocellular damage
UDS: if suspect drug misuse too
Hepatitis screen: if suspect IV drug use

23

What can a UDS: urine drug screen detect?

Amphetamine: 2 days
Heroin: 2 days
Cocaine: 5-7 days
Methadone: 7 days
Cannabis: up to 1 month

24

How do you assess a patients' motivation to change?

The stages of change model:
Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse
Identify support needed, set realistic goals e.g.
Short term: reduce consumption
Medium term: undergo detoxification
Long term: attend college

25

How is detoxification managed?

Planned = following period of preparation
Unplanned = e.g. after emergency hospital admission
Long-acting benzos: prevent withdrawal symptoms incl seizures + DT
Gradually withdrawn and stopped
Thiamine: parenteral prophylaxis

26

What methods are used to support relapse prevention?

Psychological: CBT + group therapy
Medical:
Acamprosate, anti craving drug thought to act in midbrain
Disulfiram, mimics flush reaction to alcohol making consumption highly unpleasant

27

How does heroin give pleasure?

A mu opiate agonist it stimulates brain and spinal cord receptors usually acted on by endogenous endorphins

28

How is heroin taken?

Initially often smoked
IV injection: antecubital fossa -> feet, backs of hands, groin
Veins become damaged
Subcutaneous 'skin popping' or IM

29

What are local complications of IVDU?

Abscess
Cellulitis
DVT: femoral injection damages valves slowing venous return
Emboli: can cause gangrene and consequently amputation

30

What are systemic complications of IVDU?

Septicaemia: direct injection of bacteria or from abscess/cellulitis
Infective endocarditis: tricuspid valve
Blood borne infections: hepB, hepC, HIV
Increased risk of OD less dose titration than in smoking

31

What are the features of opiate intoxication?

Intense rush, euphoria, warmth, well being
Sedation, analgesia
Vomiting dizziness
Bradycardia, respiratory depression
Pinpoint pupils
SE: constipation, anorexia, decr libido

32

What is the process in opiate withdrawal?

Withdrawal from IV heroin typically begins 6 hrs post injection
Peaks at 36-48 hrs, unpleasant but rarely life threatening
Dysphoria, nausea, insomnia, agitation
Diarrhoea, vomiting, lacrimation, rhinorrhoea
Feverish, abdo cramps, aching joints and muscles
Piloerection, yawning, pupil dilation

33

What is neonatal abstinence syndrome?

Babies born to opiate dependent mothers suffer withdrawal
Symptoms incl:
High pitched cry, restlessness, tremor, loose stools, vomiting, sweats, fever, hypertonia, convulsions, tachypnoea
Treatment: paeds opiate preparations, anticonvulsants, support

34

What harm reduction strategies are used in the treatment of opiate users?

Sterile needle provision
Vaccination and testing for blood borne viruses
Information and advice

35

What is substitute prescribing?

Deliberate prescription of drugs in a controlled manner
Methadone liquid
Buprenorphine sublingual tablets
Taken in supervised environment
Doses gradually titrated to avoid withdrawal symptoms

36

What is naltrexone?

Opiate antagonist: mu + kappa receptors
Blocks opiate receptors and thus euphoric effects of opiates
Used as a relapse prevention agent - alcohol + opioids
Can facilitate rapid detox - opioids

37

What is methadone?

Full opiate agonist
Longer half life than heroin
Longer milder withdrawal

38

What is buprenorphine?

Partial agonist at mu receptor
Blocks euphoric effects
Prevents withdrawal sx

39

What is the psychoactive compound in cannabis?

Delta-9-tetrahydrocannabinol
Aka THC
Acts on cannabinoid receptors in the brain

40

What are the features of cannabis intoxication?

Relaxation, euphoria, paranoia, anxiety, panic
Perceptual distortion
Hunger pangs
Nausea and vomiting
Coordination affected
Injected conjunctivae, tachycardia, dry mouth
Restless and irritability after use common despite lack of withdrawal

41

ICD10 criteria for dependence

Narrowing of repertoire
Tolerance
Loss of control of drinking
Compulsion
Continued use despite harm
Salience/primacy
Reinstatement after abstinence
Withdrawal
3 or more at any time

42

What is flumazenil

Treatment for benzo OD

43

How does disulfiram work?

Acetaldehyde dehydrogenase inhibitor
Unpleasant effects with alcohol:
Nausea, vomiting, flushing due to acetaldehyde build up
To help maintain abstinence

44

How does acamprosate work?

Blocks NMDA glutamate receptors -> enhances GABA transmission
Reduces alcohol craving
Discontinue with regular drinking!

45

How does chlordiazepoxide work?

Relieves alcohol withdrawal sx
Prevents withdrawal seizures

46

Where can patients undergo alcohol detox?

Normally in the community - give chlordiazepoxide
If hx of seizures, W-K sx, comorbid illness, suicidal ideation, lack of stable environment, prev failed outpatient detox:
Inpatient detox

47

When do sx of alcohol withdrawal present?

6 - 12 hrs

48

When do seizures present during alcohol withdrawal?

36 hrs

49

When does delerium tremens present during alcohol withdrawal?

72 hrs

50

What is delerium tremens?

Reduced GABA inhibition
Increased NMDA glutamate transmission

Manage:
Benzos
Carbamazepine
DON'T give phenytoin for seizures

51

Neuronal degeneration in the mammillary bodies secondary to thiamine deficiency

Wernicke-Korsakoff's syndrome

52

Alcoholic who become paralysed

Central pontine myelinolysis

53

Pinpoint pupils
Bradycardic
Resp depression
Constipation

Cocaine / opioids

54

Lasts 72 hrs
Depersonalisation
Illusions
Synaesthesia
Visual hallucinations
Dilated pupils
Hyperthermia
Tachycardia
SM contraction

LSD

55

Caffeine

Headache
Anxiety
Confusion
Tremors
Arrhythmia
Nausea + vom

56

Drowsiness
Confusion
Reduced anxiety

Benzos

57

Psilocybin/psilocin
Aka magic mushrooms

Visual disturbances
Enhanced perceptions
Euphoria
Relaxation
6hr duration
Awkward postures, don't feel fatigue or sense of time

58

Reckless activity
Nystagmus
Loss of balance
Raised T
Angel dust

PCP

59

Short lived hallucinations
Absence of sensory stimulation
Dizziness
Sense of detachment

Ketamine

60

Dilated pupils
Euphoria
Grinding teeth
Dehydration
Loss of appetite
Clubbing

MDMA aka ecstasy

61

Mild euphoria
Hyperactivity
Excitement
Chewed

Khat