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Flashcards in Substance use Deck (28):
1

Diagnoses possible with substance related and addictive disorders

Substance use disorders
Substance intoxication
Substance withdrawal
Substance induced
->psychotic
->Bipolar
->depressive
->anxiety
->OCD
->sleep
->sexual dysfunction
->delirium
->neurocognitive

2

Define harmful use

Pattern/quantity of substance use which causes adverse effects, without dependance
->Love
->Livelihood
->Liver
->Law

3

Define hazardous use

Use that places person at risk of adverse effects without dependance

4

Use disorder criteria

Pattern of use leading to clinically significant impairment or distress with 2 of following w/i 12 months
1. Larger/longer than intended
2. +Effort/desire to cut back
3. +Time spent in activities to obtain/use/recover
4. Craving
5. Recurrent use resulting in failure to fulfill roles
6. Use despite negative consequences on social/interpersonal
7. Important social/occupational/recreational activities givem up
8. Recurrent use in dangerous situations
9. Use despite knowledge of the recurrent physical/psychological problems
10. Tolerance
->Needing more for intoxication/desired effect
->Diminished effect with same amount
11. Withdrawal
->Withdrawal syndrome of substance
->Substance taken to avoid withdrawal

5

Calculating units of alcohol

1 UNIT OF ALCOHOL
(10ml pure alcohol)
=
1⁄2 pint of beer
(248ml)
(3.5% ABV)
or
1 small glass of wine
(125ml)
(8% ABV)
or
1 measure of spirits
(25ml)
(40% ABV)

6

Calculating units of alcohol

You can calculate units by multiplying alcohol by
volume (in%) with volume (in litres),
e.g. ABV x vol = units
For instance, a pint (568ml) of 5.3% ABV continental
lager would contain 5.3 x 0.568 = 3 units

7

Differential

1. There is a primary psychiatric illness and patient is using substance
2. Symptoms entirely due to substance and no primary psychiatric illness
3. Psychiatric problems are due to a combination

8

Features (4) suggesting substance-related psychiatric illness

1. Symptoms known to be caused by substance
2. Temporal relationship between use of substance and development of symptoms
3. Recovery of symptoms on cessation of substance use
4. No other explanation

9

History

CAGE and AUDIT
Substances used
Pattern
Features of dependance
Symptoms and relationship to substance, recovery of symptoms on cessation of substance use, temporal relationship
Consequences->family, relationships, law, work, psychiatric health
PHx psychiatric/substance use
Gambling
Family history
MSE
Suicidality
Insight

10

CAGE

1. Have you ever felt you ought to Cut down on your
drinking?
2. Have people ever Annoyed you by criticizing your
drinking?
3. Have you ever felt Guilty about your drinking?
4. Have you ever needed an ‘Eye-opener’ (a drink first
thing in the morning to steady your nerves or get rid
of a hangover)?

11

Examination

Should focus on:
1. Evidence of acute use or intoxication (e.g. pupil constriction with opiate use; incoordination and slurred
speech with alcohol use).
2. Signs of withdrawal (e.g. tremulousness, sweating,
nausea and vomiting, tachycardia and pupil dilatation
with alcohol withdrawal).
3. Immediate and short-term medical complications of
substance use (e.g. head injury following alcohol intoxication, infection caused by intravenous drug use).
4. Long-term medical complications (e.g. alcoholrelated
liver disease, hepatitis B or C or HIV infection
with intravenous drug use).

12

Investigations

Depends on presentation, but may include
UDS->essential
FBC
UEC
LFTs
Clotting/PLTs
ECG
Hepatitis serology
HIV
CT/imaging

13

Etiology of dependance

Socio-cultural->price, acceptability and availability
Pharmacology of the drug->pleasurable effects, rapid oset
Individual characteristics
Learning and conditioning

14

Individual characteristics predisposing to dependance

Disturbed ego function
Concurrent psychiatric illness
Genetic->+sensitivity to neurotransmitter
Upbringing: poor coping strategies
Personality: at risk children
->parental use
->impaired peer relationships
->poor academic
->limited problem solving skills
->poor impulse control
->negative mood states

15

Mechanism of learning and conditioning in relation to substance use

Behaviour maintained by consequences
1. Can ameliorate noxious/aversive states:
pain, anxiety, depression
2. Positive reinforcement
3. Alleviates disturbed effects of withdrawal
4. in withdrawal: the behaviours/environment that
was associated w. the addiction can trigger
withdrawal/craving. Example: watching someone use
or light a lighter etc.
5. Paraphernalia and behaviour becomes secondary reinforcements ++activity in limbic system

16

Features of cannabis use (4)

Conjunctival injection
Increased appetite
Dry mouth
TachyC

17

Features of cannabis withdrawal

Irritability
Nervous/anxiety
Sleep disturbance
+Appetite/wt loss
Restless
Depressed mood
Abdominal pain, shakiness, sweaty, fever, chills, HA

18

Features of PCP intoxication (8)

Vertical/horizontal nystagmus
HTN/Tachy
Numb/reduced response to pain
Dysarthria
Ataxia
Muscle rigid
Seizure/coma
Hyperacusis

19

Features of hallucinogen intoxication

Paranoia
Impaired judgement
Perceptual changes in wakefullness->derealise, hallucination
Pupillary dilation
Tachy
Sweaty
Palpitations
Blurring of vision
Tremor
Incoordination

20

Features of inhalant intoxications

Beligerent
Apathy
Assaultiveness
Dizziness
Nystagmus
Unsteady gait
Slurred speech
Psychomotor retardation
Blurred vision/diplopia
Tremor
Generalised weakness
Lethargy
Reduced reflexes
Stupor/coma
Euphoria

21

Features of opioid intoxication

Euphoria
Apathy
Dysphoria
Impaired judgement
Drowsiness/coma
SLurred speech
Impaired attention/memory
Pupillary constriction

22

Features of opioid withdrawal

Pupillary dilation/piloerection/sweating
Dysphoric mood
Nausea or vomiting
Muscle aches
Macrimation or rhinorrhea
Diarrhea
Yawning
Fever
Insomnia
Goose bumps

23

Features of sedative intoxication

Inappropiate behaviour
Slurred speech
Unstead gait
Incoordination
Nystagmus
Impaired cognition
Stupor or coma

24

Features of sedative withdrawal

Autonomic hyperA
Tremor
Insomnia
NV
Transient hallucinations
Psychomotor agitation
Anxiety
Tonic clonic seizures

25

Features of stimulant intoxication

Euphoria
Hypervigilance
Anxiety
Anger
Impaired judgement
Tachy/Brady
Pupillary dilation
+/-ve BP
Perspiration/chills
NV
Wt loss
Psychomotor
Muscle weakness, respiratory depression, chest pain, arrythmias
Confusion, seizures, dyskinesia, dystonias, coma

26

Features of stimulant withdrawal

Dysphoric mood
Fatigue
Vivid dreams
Insomnia/hypersomnia
+appetite
Psychomotos

27

Features of nicotine withdrawal

Irritability/anger
Anxiety
Poor concentration
+appetite
Restlessness
Depressed mood
Insomnia

28

Management of opioid withdrawal

1. Supportive therapy->fluids, ibuprofen for muscle aches, loperamide and promethazine for diarrhea, NV
2. Buprenorphine (partial agonist)
3. Diazepam 5-20mg 4 times daily
4. CBT, social, counselling
5. Methadone, Buprenorphine (+naloxone) programs in long term->requires specialist