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Psychiatry > Substance Misuse > Flashcards

Substance Misuse Flashcards

1
Q

What is the ICD categories for substance misuse?

A
  • acute intoxication
  • acute withdrawal
  • alcohol dependence
  • psychotic disorders
  • amnesic disorder
  • residual/late onset disorders
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2
Q

What is hazardous drinking?

A

Pattern of alcohol consumption that increases someones risk of harm. Physical, mental and social consequences.
Applies to anyone drinking >14 units/week.

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3
Q

What is the difference between hazardous and harmful drinking?

A

Hazardous - >14 units

Harmful >35 units

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4
Q

How do you calculate units?

A

Units = strength x volume/1000

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5
Q

What screening tools can be used in alcohol misuse?

A

CAGE
FAST
Audit and audit C

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6
Q

Describe the FAST screening

A
  1. How often have you had 6+(female) 8+ (male) units on a single occasion in the last year?
  2. Can’t remember the night before
  3. Failed to function properly due to alcohol
  4. Someone else is concerned about drinking
    Scored by frequency Never =0 daily=4
    >2 classes as hazardous
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7
Q

Describe CAGE screening

A

Have you tried to cut down?
Annoyed when someone else suggested it?
Guilty about drinking?
Eye opening (early morning drink)?

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8
Q

How does the audit score correlate to management?

A 
8-19 = brief intervention 
20+ = refer to a specialist
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9
Q

What must a brief intervention consist of?

A 
Feedback - review problems 
Responsibility - empowerment 
Advice - factual 
Menu - options available 
Empathy 
Self-efficacy - optimism
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10
Q

Describe the term motivational interviewing

A

Patient-centred counselling explores ambivalence to seeking treatment, drinking cessation or both. Collaborative conversation, drinking cessation. Helps to achieve insight and desire to change.

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11
Q

Describe Wernicke’s and Korsakoff’s

A

Wernicke’s - ataxia, nystagmus, ophalmoplegia, acute confusion
Korsakoff - profound short term memory loss and confabulation

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12
Q

What is the criteria for diagnosis for dependence syndrome?

A
  1. Strong desire or sense of compulsion to take drug
  2. Difficulty controlling use of substance
  3. Physiological withdrawal
  4. Evidence of tolerance
  5. Neglect of other pleasures/preoccupation
  6. Persistence despite harmful consequences
    3 or more present together at some point in the previous year
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13
Q

Why does alcohol withdrawal occur?

A
  • Alcohol inhibits the action of NMDA glutamate ion channels and chronic use leads to up regulation
  • Alcohol potentiates GABA A receptors and chronic use leads to down regulation
    Overall a sudden stop causes unopposed excitation and excess glutamate which is neurotoxic
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14
Q

What are the symptoms of alcohol withdrawal?

A

Restlessness, tremor, sweating, nausea, vomiting, loss of appetite, insomnia, tachycardia, systolic hypertension, generalised seizures

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15
Q

What is the worst consequence of alcohol withdrawal?

A

Delirium tremens

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16
Q

How does delirium tremens present?

A

2 days of abstinence, often insidious with nighttime confusion

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17
Q

What are the symptoms of delirium tremens?

A

Confusion, disorientation, agitation, hypertension, fever, hallucinations, paranoid ideation

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18
Q

Where should people with delirium tremens be managed?

A

General medical ward

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19
Q

What is the medical management for alcohol withdrawal?

A

Benzodiazepines (cross tolerant with alcohol)
Vitamin supplement (pabrinex)
Thiamine - parenteral, increase in wernicke’s
Hydration, analgesia, antiemetic, treat infections

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20
Q

Describe the indications for inpatient detox

A 
Severe dependence 
History of delirium tremens 
History of failed community detox 
Poor social support 
Cognitive impairment 
Psychiatric co-morbidity 
Poor physical health
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21
Q

What psychosocial interventions help to prevent relapse?

A

CBT, motivational enhancement, 12 steps (AA), self control training, family/couple therapy

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22
Q

What pharmacological measures can help prevent relapse?

A
  • Disulfiram
  • Acamprosate
  • Naltrexone
23
Q

Describe disulfiram

A

Inhibits acetaldehyde dehydrogenase causes an accumulation of acetaldehyde if alcohol is ingested leading to nausea/vomiting, arrhythmias, hypotension

24
Q

Describe acamprosate

A

Reduces cravings and moderate treatment. Acts on GABA system - side effects; headache, diarrhoea, nausea

25
Q

Describe naltrexone

A

First line for relapse prevention, opioid antagonist reduces reward from alcohol. Very effective.

26
Q

What are the different forms of opiate?

A

Natural - morphine, codeine
Semi-synthetic - hydrocodone, hydromorphine
Synthetic - methadone, tramadol

27
Q

What are the different forms of heroin?

A

Brown powder from poppy, smoking gives immediate effect, snorting takes 15 minutes or can be injected

28
Q

Which parts of the brain do opioids affect?

A

Mesolimbic pathway uses dopamine as the neurotransmitter - ventral segmental area (midbrain) is connected to the vernal striatal area (basal ganglia and forebrain)
Desire and motivation leads to reinforcement

29
Q

Describe safety bundles

A 
Drug diaries
Drug screens - urine test 
Withdrawal scale - COWS
Recovery care plan 
Risk assessment
30
Q

What is opioid replacement therapy?

A

Substitute prescribing - the deliberate prescribing of drugs in controlled manner to introduce control and order into lifestyle

31
Q

What are the four phases of opioid replacement?

A

Induction
Optimisation
Maintenance
Reduction

32
Q

Name three forms of psychosocial intervention in opioid dependence

A

CBT
Motivational interviewing
Self help

33
Q

How does methadone work?

A

Mu receptor agonist, long half life with peak plasma at 4 hours and steady state after 5 days

34
Q

How is methadone metabolised and administered?

A

Hepatic metabolism - CY3P4

Controlled liquid preparation supervised - start at 30mg and increase by 10mg a day until 60mg

35
Q

How does buprenorphine work?

A

Mu receptor partial agonist with low intrinsic activity but high affinity peak plasma 1.5-2.5 hours and duration is dose dependent

36
Q

How is buprenorphine administered?

A

Sublingually - 12-24mg supervised

37
Q

Why would buprenorphine be used instead of methadone?

A

ECG - methadone can cause long QT
Other drugs - drugs involved in CY3P4 may impact metabolism
Diversion and sedation

38
Q

What are the early signs of opioid withdrawal?

A

Craving, flu like symptoms

39
Q

What are the late signs of opioid withdrawal?

A

Cramps, agitation, piloerection, tachycardia, restlessness, mydraisis

40
Q

What are the signs of opioid overdose and how is it treated?

A

Naloxone - opioid antagonist

Presents - miosis and respiratory depression

41
Q

Define incentive salience

A

Attributing ‘want’ to a stimulus (how much we desire something) leads to appetite and consumption

42
Q

Name the five components for the mesolimbic pathway

A
  • ventral tegmental area
  • nucleus accumbent
  • prefrontal cortex
  • hippocampus
  • amygdala
43
Q

What neurotransmitter is involved in the mesolimbic pathway?

A

Dopamine - motivating signal, incentivises behaviour and is involved in normal pleasurable experience

44
Q

What is the effect of drugs of abuse on the mesolimbic pathway?

A

Act on dopamine receptors to alter dopamine levels, repeated exposure leads to down regulation and less available for stimulation

45
Q

What is the result of increased threshold in terms of how a patient feels?

A

Normal pleasurable experience does not evoke adequate reward response

46
Q

Describe the difference between positive and negative reinforcement

A

Positive reinforcement - initial stages of drug taking, driven by reward
Negative reinforcement - drug taking becomes thirst, behaviour is carried out to prevent bad experience

47
Q

What is the function of the pre-frontal cortex?

A

Prevents addiction by executive functions - helps intention guide behaviour and modulates the powerful effects of the reward pathway - sets goals, focuses attention and makes sound decisions

48
Q

How is the pre-frontal cortex development different from the rest of the brain?

A

It is late to develop and continues into the 20s - executive functions mature later than emotion and impulse

49
Q

What does dopamine release effect?

A
  • ability to update PFC information
  • ability to select new goals
  • ability to avoid compulsive repetition of a behaviour
50
Q

Where are memories and habits formed?

A

Hippocampal and amygdala are critical in acquisition, consolidation and expression of drug learning - this cues internal states of craving

51
Q

What is the function of the orbit-frontal cortex?

A

Provides internal representation of the importance of events and assigns values to them - key creator of motivation to act (changes persist into abstinence)

52
Q

What percentage of addiction risk is related to genetics?

A

40-60%

53
Q

How can stress cause mesolimbic changes?

A

Triggers dopamine release in neural pathways, chronic stress leads to dampening of dopaminergic activity through down regulation of receptors - reducing sensitivity to normal rewards therefore encouraging highly rewarding behaviours

Psychiatry (18 decks)

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