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Substance misuse Flashcards

1
Q

Biological factors in aetiology of substance misuse

A

Genetic predisposition (up to 50% heritability)

Neurobiological differences in EEG activity

Differences in receptor systems (e.g. DA) in brain

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2
Q

Psychological factors in aetiology of substance misuse

A

Personality: Anxious (incl disorder, esp social anxiety), Impulsive (e.g. in ADHD)

Psychiatric Hx (esp childhood): depression, PD

Positive reinforcement: Drugs lead to behaviours that increase their use

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3
Q

Social factors in aetiology of substance misuse

A

Social network: Key component of recovery, peer pressure, FHx of substance use

Legal: Price/availability/illegal status

Social norms: Acceptability

Social status: Isolation, unemployment, relationship issues

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4
Q

ICD-10 criteria for substance dependence

A

3 or more of the following:

Tolerance

Withdrawal/drinking to stop withdrawal

Compulsion to drink

Persistent drinking in the face of harm

Loss of ability to control drinking (reinstatement after abstinence)

Neglect of other activities

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5
Q

ICD-10 criteria for ‘harmful use’ of substances

A

Clear evidence of harm to physical/mental health of user (i.e. already caused harm)

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6
Q

5 stages of change for stopping subtance abuse

A
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7
Q

Threshold for ‘lower risk’ drinking

A

<14 units per week

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8
Q

Threshold for higher risk drinking

A

>50 units pw for males

>35 units per week for females

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9
Q

Receptor systems affected by alcohol

A

GABA: Acts as agonist, responsible for most effects

NMDA: Antagonist, reduces glutamate transmission

Opioid/DA: To lesser extents

Net effect: GABA > glutamate (acutely)

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10
Q

Psychopharmacology of chronic alcohol dependence

A

Compensatory increase in glutamate –> imbalance (glutamate >>> GABA) during withdrawal –> excitotoxicity

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11
Q

Screening tools for alcohol dependence

A

CAGE

FAST (4-question)

AUDIT (10 question)

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12
Q

What is the CAGE questionnaire?

A

Screening tool for alcohol dependence

Have you ever felt you should Cut down?

Annoyed by people criticizing your drinking?

Guilty about your drinking?

Eye-opener drink in the morning?

2+ = CAGE +ve

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13
Q

Assessment for alcohol use

A
  • Type of drink + quantity
  • Duration
  • Withdrawal/dependence signs
  • Full neuro, cognitive + liver (abdo exam)
  • LFTs (esp GGT), FBC (esp MCV, anaemia), Urate (in men), Carbohydrate-deficient transferrin
  • AUDIT, CIWA
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14
Q

FAST questions

A
  1. How often have you consumed >8/>6 units of alcohol in one sitting in the last year?
  2. How often have you failed to do what was expected of you due to drinking in the last year?
  3. How often were you unable to remember what happened the night before due to drinking in the last year?
  4. Has a relative, friend, or healthcare professional ever been concerned about your drinking or suggested you cut down?
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15
Q

Blood test changes associated with alcohol misuse

A

Unexplained macrocytosis

Unexplained LFT disturbance

Reduced platelets

Raised carbohydrate-deficient transferrin (identifies drinking in past 1-2 weeks)

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16
Q

Medical harm from alcohol

A

Liver: Damage, cirrhosis

CV: Cardiomyopathy, HTN

GI: Pancreatitis, varices, peptic ulcer

Cancer: Mouth, throat, oesophagus, liver

Blood: Macrocytosis, anaemia, haemochromatosis

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17
Q

Neurological harm of alcohol misuse

A

Blackouts

Epilepsy

Wernicke/Korsakoff syndrome

Neuropathy

Cerebellar degeneration

Dementia

Fetal alcohol syndrome

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18
Q

Psychiatric harm of alcohol misuse

A

Alcoholic hallucinosis: auditory, occurs in clear consciousness c.f. withdrawal

Suicide (10% of alcohol dependent)

Anxiety

Depression

Pathological jealousy

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19
Q

Features of acute alcohol withdrawal

A

Tremors

Sweating

Nausea/vomiting

Agitation/anxiety

Seizures

Auditory hyperacusis

Visual disturbances

Delirium tremens (5%)

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20
Q

Screening tool for alcohol withdrawal

A

CIWA-Ar

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21
Q

Onset of alcohol withdrawal symptoms

A

4-12h after last drink, lasts 2-5d

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22
Q

Rationale for pharmacological detox during acute alcohol withdrawal

A

Give benzodiazepine (usually chlordiazepoxide) for 5-7d in reducing dose to allow GABA/GLU balance to normalise

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23
Q

Chlordiazepoxide alternative in severe liver failure

A

Oxazepam, lorazepam (shorter half-life –> less liver accumulation)

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24
Q

Pharmacological management of acute alcohol withdrawal

A

10-30mg chlordiazepoxide qds (up to 50 for severe dependence) in reducing dose for 7 days

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25
Autonomic features of delirium tremens
**Autonomic:** * Sweating * Pupil dilation * Hypertension, tachycardia, instability * Insomnia * Dehydration + electrolyte disturbance --\> fatal arrhythmia
26
Neurological features of delirium tremens
Coarse tremor Delirium - confusion, disorientation
27
Psychiatric featurers of delirium tremens
Classic triad: * Transient persecutory delusions, paranoia * Visual hallucinations * Fear/agitation
28
Onset of delirium tremens
24-48 hours (but up to 7d) after cessation of drinking, usually with intercurrent illness (e.g. UTI)
29
Management of delirium tremens
**Physical:** * ECG + electrolytes --\> fluid/haemodynamic management * Treat inter-current illness **Pharmacological:** * Oral/IM lorazepam for sedation * Optimise detox medication (raise dose) **General:** * Low-lit, quiet environment * 1:1 nursing * Inform security * MCA assessment + plan
30
Pathophysiology of wernicke's syndrome
Acute encephalopathy due to vitamin B1 deficiency leading to degeneration of mamillary bodies + frontal lobe white matter
31
Features of wernicke's syndrome
Delirium Ataxia Ophthalmoplegia/nystagmus Hypothermia/hypotension, tachycardia Neuropathy
32
Treatment of wernicke's encephalopathy
IV thiamine (Vitamin B1) for 3-7d (beware risk of anaphylaxis) Oral thiamine for 1/12
33
Prognosis for Wernicke's
20% mortality 80% of survivors develop Korsakoff's
34
Differential causes of Wernicke's
Brain tumour Prolonged vomiting: hyperemesis gravidarum in pregnancy, chemotherapy Malabsorption syndromes
35
Clinical features of Korsakoff's
Anterograde amnesia Some retrograde amnesia --\> islands of memory Confabulations Due to damage of hippocampus/mamillary bodies
36
Management of Korsakoff's
Thiamine for 2 years OT assessment + ongoing support
37
Prognosis of Korsakoff's
20% complete recovery 25% significant recovery 55% no change
38
How should you treat hypoglycaemia in alcohol-dependent patient
Give IV thiamine first to prevent precipitating Wernicke's
39
Role of acamprosate in treatment of alcohol misuse
Enhances GABA transmission Reduces cravings but pt must not be drinking Started on day 1 of detoxification
40
Role of naltrexone in alcohol misuse treatment
Blocks opioid --\> reduces reward from alcohol Can be taken while not abstaining (e.g. prophylactically before big night)
41
Role of disulfiram in alcohol abuse treatment
Blocks acetaldehyde dehydrogenase --\> increase acetaldehyde --\> flushing + headache + hypotension Threat of unpleasant consequences --\> -ve reinforcement of alcohol drinking Should **not** be used in severe liver damage, recent heart disease, suicidal ideation
42
Prognosis of relapse in alcohol misuse
50% relapse within 6 months
43
FRAMES approach to drinking interventions
**F**eedback about drinking **R**esponsibility of pt for change emphasised **A**dvice on how to stop drinking given **M**enu of options for stopping drinking **E**mpathy **S**elf-efficacy of patient --\> empowering
44
Management of alcohol dependence, biological
* **Withdrawal:** Inpatient detox, community detox with benzo/thiamine * **Relapse prevention:** Bio * Pharmacological: Disulfiram, acamprosate, naltrexone, nalmefene * Vitamin supplementation
45
Management of alcohol dependence, psychological
**Psychoeducation:** Family, patient, safe drinking/withdrawal advice, self-help guidance **Consultation:** FRAMES, motivational interviewing (decisional balance, readiness ruler) **Outpatient f/u:** screen for co-morbid psychiatric condition Turning point Marital/family therapy
46
Management of alcohol dependence, social
Employment, social support Residential/therapeutic communities (e.g. AA)
47
Positive prognostic factors for alcohol dependence
Strong motivation Strong social/occupational structure Good insight
48
Indications for inpatient detox
* Alcohol Hx: * Past Hx of seizures/DT * Hx of failed community detox * Severe alcohol dependence * Current psych: * Symptoms of Wernicke's-Korsakoff * Current confusion/delirium * Polysubstance misuse * High suicide risk * Lack of stable home environment * Current physical * Severe malnutrition/N+V * Concurrent physical/psychiatric illness * Older age
49
Effects of cannabis intoxication
Anxiety, paranoia Mellowness, giggling slurring of speech, reduced coordination Reddening of eyes
50
Active substances in cannabis
THC (main active ingredient) + cannabidiol (mild antagonist to THC, antipsychotic) Levels vary in different strains
51
Adverse effects of cannabis
Increased risk of pneumothorax Precipitate angina Worsen schizphrenia prognosis Precipitate schizophrenia Cognitive impairment in long-term heavy users Reduced concentration, memory, motivation Sleep disturbance
52
Effects of opioids
Euphoria Analgesia Pupillary constriction Respiratory depression, hypotension, hypothermia, bradycardia N+V, constipation
53
Features of opioid withdrawal
**GI**: Vomiting, diarrhoea, abdominal pain **Face:** Pupil dilation, runny nose + eyes **Neuromuscular:** Restlessness, insomnia, myalgia **Autonomic:** Sweating, tachycardia Onset 6h after last dose, peak 36-48h
54
First-line treatment for symptomatic relief of opioid withdrawal
Lofexidine
55
Onset of opioid withdrawal
8-12h after last dose
56
Duration of opioid withdrawal
10d, with peak at 24-48h
57
Adverse effects of opioids
**Infection:** Phlebitis, HIV, HCV **Psychiatric:** 14x risk of suicide Overdose Mortality 12x **Social:** Crime, poverty, etc..
58
Pharmacological management of opioid dependence
Methadone Buprenorphine
59
Dosing of methadone
Oral, start 30mg and increase slowly to reach therapeutic dose (60-120mg) High risk of overdose!
60
Benefits of buprenorphine over methadone
Partial agonist --\> ceiling effect --\> lower risk of OD + less sedating May ppt withdrawal during conversion
61
Psychological interventions for opioid dependence
Relapse prevention therapy (CBT) NA programme Residential programmes (therapeutic communities)
62
Relapse rate opioid dependence
40% at 6 months
63
Symptoms of opioid overdose
Respiratory depression/arrest Pinpoint pupils Bradycardia, hypotension
64
Management of opioid overdose
Naloxone until spontaneous ventilation returns
65
Features of stimulant use (amphetamines, cocaine, MDMA)
Elevated mood, energy, insomnia Over-talkativeness Pupil dilation, tachycardia, high BP, dry mucous membranes Hyperpyrexia + dehydration (esp MDMA)
66
Features of amphetamine withdrawal
Depression, lethargy, suicidality, craving
67
Psychiatric effect of prolonged amphetamine use
Paranoid psychosis Mood swings + depression Formication (somatic hallucination) --\> scabs
68
Management of acute stimulant misuse
Benzo and/or antipsychotic TCA for depression if necessary
69
Effects of ketamine intoxication
Euphoria Synaesthesia, hallucinations Nausea Ataxia, slurred speech
70
Adverse effects of ketamine
Fatal overdose Permanent bladder damage (haemmorhagic cystitis) Physical dependence Psychosis, depression Memory impairment
71
Management for harmful substance use, biological
_Bio:_ * Monitor physical health issues (eg. infx) * Substitute prescribing/withdrawal management * Contraception, needle exchange
72
Management for harmful substance use, psychological
Education Self-help, SMART goal setting Treatment of underlying psychiatric conditions Marital/family therapy
73
Management for harmful substance use, social
Employment/accommodation support (assigned social worker) Help establishing new interests Peer support group (e.g. NA)

Psychiatry (20 decks)

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