Substance use & Addiction

Question 1

what is the typical course of alcohol/drug use, harmful use and addiction?

Answer 1

recreational use, no difficulties
want/need becomes increasingly regular use (harmful use)
need - spiralling dependence (addiction)

Question 2

what is harmful use of drugs/alcohol?

Answer 2

actual damage caused to mental/physical health in the absence of diagnosis of dependence syndrome

Question 3

what is dependence?

Answer 3

strong desire or compulsion to take drug
difficulties in controlling taking drug - onset, termination, levels of use
physiological withdrawal state when stopped/reduced
evidence of tolerance
progressive neglect of alternative interests
persisting with substance use despite evidence of consequences

Question 4

what drug causes the most harm in the UK?

Answer 4

alcohol in both harm to users and harm to others

Question 5

what is addiction vs dependence?

Answer 5

addiction is compulsive drug use despite harmful consequences (all impacts of drug use)
dependence is a physical and biological adaption to a substance

Question 6

what factors affect addiction?

Answer 6

social, environmental factors
specific drug factors
personal factors (genetic, personality etc)

Question 7

how does alcohol acutely affect brain chemistry?

Answer 7

blocks NMDA receptor (blocks excitatory)
therefore impaired memory
boosts GABA-A receptor (boosts inhibitory)
therefore anxiolysis, sedation

Question 8

how does alcohol chronically affect brain chemistry?

Answer 8

upregulation of excitatory system to adapt to NMDA receptor being blocked chronically
reduced function in inhibitory system as GABA-A switches subunits to be less sensitive to alcohol

Question 9

how do you treat alcohol withdrawal?

Answer 9

benzodiazepines to boost GABA function

Question 10

how does alcohol withdrawal affect brain chemistry?

Answer 10

NMDA receptor upregulated, increase of Ca2+ leading to hyperexcitability (seizures) cell death

Question 11

how is addiction reinforced?

Answer 11

reward deficiency - positive reinforcement
overcoming adverse state e.g anxiety/withdrawal - negative reinforcement
impulsivity and compulsivity

Question 12

what is the reward pathway in the brain?

Answer 12

ventral striatum dopamine system

Question 13

how do cocaine and amphetamines impact dopamine rewards?

Answer 13

block reuptake - prolonged effect of dopamine

amp also enhances dopamine release

Question 14

how can reinforcing brain responses be predicted?

Answer 14

levels of D2 receptors in the brain

higher D2 leads to less pleasurable responses

Question 15

what change in brain chemistry makes some addicts more likely to relapse?

Answer 15

blunted response to anticipation of reward in ventral striatum

Question 16

what regions of the brain are involved in bingeing/intoxication?

Answer 16

thalamus, dorsal striatum

Question 17

what regions of the brain are inolved in withdrawal?

Answer 17

brainstem, hypothalamus

Question 18

what regions of the brain are involved in craving?

Answer 18

hippocampus, insula, prefrontal cortex, basolateral amygdala

Question 19

how does reinforcement change over the course of addiction?

Answer 19

change from positive to negative reinforcement - avoiding bad effects so aggression, fear when unable to access it

Question 20

what regions are targets for addiction withdrawal drugs?

Answer 20

reward system: dopamine and mu opioid
stress system: kappa opioid, noradrenaline and CRF
amygdala

Question 21

what are the brain chemistry changes to compulsions from voluntary to habitual drug use?

Answer 21

transition from striatal control over drug taking
ventral to dorsal striatum
both to form habits
memory in hippocampus drives cravings

Question 22

what drugs are used to support alcohol withdrawal?

Answer 22

benzodiazapines

Question 23

what drugs are used to support abstinence and neuroprotection in alcoholism?

Answer 23

acamprosate

Question 24

what drugs are used to modulate reward system in alcoholism and block heroin use in opioid addicts?

Answer 24

naltrexone

Question 25

what are questions to test the signs of harmful use/dependency in alcoholism?

Answer 25

CAGE - cut down, angry, guilty, eye opener

Question 26

how do you perform a mental state examination?

Answer 26

``` appearance + behaviour speech mood thoughts perceptions cognition insight ```

Question 27

what is the clinical opiate withdrawal scale? COWS

Answer 27

``` heart rate sweating restlessness pupil size bone/joint aches runny nose/tears GI upset tremor (outstretched hands) yawning anxiety/irritability goosebumps ```

Question 28

what are the ICD-10 requirements for dependency syndrome?

Answer 28

3+ in past year: strong desire/sense of compulsion difficulties in controlling behaviour around substance physical withdrawal tolerance neglect of interests/pleasures/social life persisting with use despite harmful effects

Question 29

what are the ICD-10 requirements for harmful use classification?

Answer 29

a pattern of substance use causing damage to health adverse social consequences bingeing no other diagnosis e.g dependency syndrome

Question 30

what assessments are done for alcohol ab/use?

Answer 30

note history of seizures, delirium tremens, psychosis, haematemesis, melaena examine for jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT investigations: fibroscan/ultrasound, bloods (LFTs, GGT, lipids, U&E, amylase), breathalyser, urine drug screen

Question 31

what assessments are done for opioid ab/use?

Answer 31

examination for collapsed veins/track marks, endocarditis, skin abscesses, hep/HIV, pneumonia investigations: bloods (LFTs, U&E, GGT, glucose), breathalyser, urine drug screen, sexual health screening/BBV

Question 32

what are the immediate effects of alcohol?

Answer 32

CNS - impaired reaction time, motor coord/sedation, coma, death stomach - nausea, inflammation, bleeding skin - flushing, sweating, heat loss and hypothermia, formation of broken capillaries sexual - reduced erection response in men, reduced vaginal secretion in women

Question 33

what are the chronic effects of alcohol?

Answer 33

CNS - damaged/destroyed brain cells, reduced brain size, impaired memory, limb sensation loss cardiovascular - weakened muscle, high BP, irregular heartbeat, risk of stroke immune system - less resistance to disease digestive - cirrhosis, stomach/pancreas inflammation, risk of lip/mouth/larynx/eosophagus/liver/rectal/stomach/pancreatic cancers, kidney failure, obesity, nutrient deficiencies reproductive - menstrual irregularities, impotence and testicular atrophy bone - risk of osteoporosis, risk of fractures and falls

Question 34

what are the minor effects of alcohol withdrawal?

Answer 34

``` tremulousness diaphoresis fever anxiety agitation nausea/vomiting/retching ```

Question 35

when do alcohol withdrawal symptoms often start?

Answer 35

onset after 6hrs from last drink

Question 36

what is DT in alcohol withdrawal?

Answer 36

delirium tremens

Question 37

what is delirium tremens?

Answer 37

auditory/visual hallucinations, confusion, hypertension, agitation, tachycardia, fever, tremor in hands and body medical emergency - mortality 15-20%

Question 38

what are the effects of opioids?

Answer 38

analgesic effect | sense of euphoria

Question 39

what are the symptoms of an opioid overdose?

Answer 39

``` not moving/cant be woken slow/not breathing choking/gargling/snoring tiny pupils clammy or cold skin blue lips+nails ```

Question 40

how is an opioid overdose managed?

Answer 40

naloxone injection/nasal spray repeat if no response after 3 mins recovery position