Substance misuse Flashcards
What are the different categories of recreational drugs?
Depressants: opioids, benzodiazepines, alcohol.
Stimulants: cocaine, amphetamines, MDMA, caffeine.
Hallucinogens: LSD, PCP, ketamine.
Cannabis, nicotine.
What are novel psychoactive substances?
Designed to mimic controlled club drugs
Banned but used to be legal highs, e.g. mephedrone, methoxetamine, GHB/GBL.
Spice.
Most NPS are not detected by routine urinary drug testing- false negatives.
What is the most harmful drug to an individual user? (death, illness, dependence, psychiatric, social losses).
Put the drugs in order for most to least harmful: ketamine, cocaine, heroin, mephedrone, crack cocaine, ecstasy, alcohol, tobacco, cannabis.
Crack cocaine Heroin Alcohol Cocaine Tobacco Mephedrone Cannabis Ketamine Ecstasy
What is the most harmful drug to society? (harm to others, crime, environment, family, international, economic cost, community).
Put the drugs in order for most to least harmful: ketamine, cocaine, heroin, mephedrone, crack cocaine, ecstasy, alcohol, tobacco, cannabis.
Alcohol Heroin Crack cocaine Tobacco Cannabis Cocaine Ketamine Mephedrone Ecstasy
Why do people take recreational drugs and get intoxicated
What are some consequences?
Social lubrication.
Pleasure seeking.
Counter stress/anxiety/ chronic pain.
Peer pressure.
Consequences:
Disinhibition.
Risk taking.
Aggression.
Dyspraxia.
Coma.
Illness/ injury.
What is dependence syndrome? (ICD-10)
3 or more at once in the last year:
- strong desire or compulsion to use substance
- difficulty controlling use/ amount/ recidivism-relapse after quitting
- tolerance to the effects of the drug
- neglect of other activities/ primacy
- persistent use despite adverse consequences
- withdrawal symptoms
What are the harmful physical consequences of alcohol?
Encephalopathy
Neuropathy
Ambylopia
Osteoporosis/ fractures
Cancers
Anaemia
Aspiration
Gastritis
Pancreatitis
Hepatitis
Cirrhosis- jaundice, ascites
Cardiomyopathy
Atrial fibrillation
Endocrine abnormalities
Impotence
Infertility
Depression
Anxiety
Dementia
Behavioural disturbance
What are some symptoms of recreational drug withdrawal?
Cold turkey (opiates)- not actually dangerous- just v unpleasant Delirium tremens- alcohol, dangerous
Sweats
Shaking
Muscular aches
Nausea
Diarrhoea
Gooseflesh
Seizures
Irritability
Depression
Psychosis
Define addiction.
Chronic relapsing brain disorder characterised by neurobiological changes that lead to compulsion to take a drug (or activity) + loss of control over the activity.
Transition from recreational to obsessive use.
From positive [taking to gain positive effect] to negative reinforcement [taking to reduce negative effect].
Psychological factors drive the behaviour.
What is the mechanism of alcohol withdrawal?
Alcohol increases inhibitory GABA-R activity, and antagonises excitatory NMDA-R.
Excitatory activity then upregulated.
Withdrawal- still increased excitatory activity, but inhibition now gone
What signs of drug use should you look out for on examination?
Injecting: punctures, track marks, cellulitis, DVTs, bacterial endocarditis.’
Inhaling: burns,
stains- teeth, fingers, respiratory signs, poor dentition, septal deformity in nose
Intoxication/ withdrawal (mental state, pupils).
Abnormal mental state.
Acquired illnesses due to drug use: hepatitis (alcohol, HBV, HCV), HIV
Injuries- falling, self inflicted
Case 1:
A 47y/o woman presents with recent onset of jaundice.
On further questioning she has had bouts of pruritis for several months.
LFTs are abnormal with raised bilirubin, a very high alkaline phosphatase and normal transaminases.
Other tests include a rabies IgM and high serum cholesterol.
An auto-antibody screen shows antimitochondrial antibodies in a titre of 1.256.
Liver biopsy shows expansion of the portal tracts by lymphocytes, plasma cells and occasional granulomas.
Bile ducts are scarce.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Primary biliary cirrhosis.
Case 2:
38y/o publican presents to his GP with increasing symptoms of anxiety and depression.
Routine blood screen reveals LFTs which are abnormal with high transaminases but normal bilirubin and normal alkaline phosphatase.
He is referred to hospital and a later liver biopsy shows moderate-severe chronic inflammation with a moderate fibrosis.
Special stains identify antigens from a double stranded DNA virus within the cytoplasm of many hepatocytes.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Chronic hepatitis B.
Case 3:
56y/o man, a known chronic alcoholic, presents with repeated attacks of abdominal pain precipitated by bouts of heavy drinking.
The pain radiates to his back and is relieved by leaning forwards. On further questioning he admits to loose, pale, greasy stools that are difficult to flush.
A plain abdominal radiograph reveals calcification in the peritoneal cavity.
What is the diagnosis?
a) alcoholic steatohepatitis
b) chronic hepatitis B
c) chronic pancreatitis
d) primary biliary cirrhosis
e) Wilson’s disease
Chronic pancreatitis.
What is Wernicke’s encephalopathy?
What is Korsakoff’s syndrome?
2 syndromes.
Wernicke (acute/subacute): confusion, ataxia, nystagmus/ophthalmoplegia.
Korsakoff (chronic): anterograde amnesia + confabulation.
What is the cause of Wernicke/Korsakoff syndrome?
Thiamine (B1) deficiency.
18 days of stores.
Why does thiamine deficiency?
> EtOH reduces duodenal transport and absorption of thiamine
> Chronic liver disease reduces activation and storage of thiamine.
> Nutritional deficiency.
What are the signs of Wernicke/Korsakoff syndrome on examination?
Eye signs: diplopia, nystagmus, lateral rectus palsy.
Motor signs: ataxia, broad based gait, dysdiadochokinesia.
Cognitive: MSE = disorientation, poor attention/concentration, poor memory, confabulation
Case 4:
22y/o woman presents with anxiety attacks, weight loss, loose stools and oligomenorrhoea.
On examination she has a tremor, tachycardia and warm peripheries.
She also has hypopigmented patches over the dorsal of her hands.
What is the diagnosis?
a) anorexia nervosa
b) thyrotoxicosis
c) alcohol dependency
d) giardiasis
Thyrotoxicosis.
Case 5:
41y/o woman presents to GP with weight loss and anxiety.
She confesses to feeling low since her divorce some 18 months ago.
On examination she is thin and mildly icteric.
CV and respiratory examinations are normal, but abdominal examination reveals 3cm hepatomegaly.
Hb 9.4, MCV 101, WCC 4.2, Na 131, K 4.1, Bil 27, AST 76, ALT 59, INR 1.3.
What is the diagnosis?
a) anorexia nervosa
b) thyrotoxicosis
c) alcohol dependency
d) giardiasis
Alcohol dependency.
Case 6: 30y/o Irishman presents to his GP with double vision, increasing unsteadiness, falls, vertigo, speech and swallowing problems. On examination he is unsteady with an ataxic gait, he is dysarthria and has signs of internuclear ophthalmoplegia. What is the diagnosis? a) cerebellar infarction b) demyelinating disease c) alcohol excess d) Friedrich's ataxia
Demyelinating disease.
Case 7: 37y/o woman presents to GP with falls. On examination she has marked bruising, leukonychia, spider naevi. She has an ataxic gait and an intention tremor bilaterally. What is the most likely cause? a) cerebellar infarction b) demyelinating disease c) alcohol excess d) Friedrich's ataxia
Alcohol excess.
Case 8:
A young woman is brought into A&E by a friend who reports that she has taken an overdose and then runs off.
She is unrousable and appears cyanotic with a respiratory rate of 3/min.
Her pulse and NP are reduced and she has pinpoint pupils.
What is the most likely cause?
a) benzodiazepine overdose
b) opiate overdose
c) cocaine overdose
d) alcohol poisoning
e) antidepressant overdose
Opiate overdose.
Frontal lobe dementia due to chronic alcohol misuse typically leads to abnormal results in each of the following clinical tests except:
a) Luria’s fist-palm-edge motor sequencing
b) Stroop test of inhibition
c) understanding of proverbs and metaphors
d) Wernicke’s aphasia
e) verbal fluency
[NOT IN LECTURE]
Wernicke’s aphasia.
In terms of their overall effect, opiate drugs are:
a) hallucinogens
b) stimulants
c) depressants
d) novel psychoactive substances
e) cannabinoids
Depressants.
