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
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 does other drugs like alcohol etc affect the dopa pathway

Answer 14

increase ventral tegmental pathway firing

Question 15

levels of what can predict extent of reinforcing/rewarding brain responses?

Answer 15

levels of D2 receptors in the brain

higher D2 leads to less pleasurable responses

Question 16

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

Answer 16

blunted response to anticipation of reward in ventral striatum

Question 17

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

Answer 17

dorsal striatum

Question 18

what regions of the brain are inolved in withdrawal?

Answer 18

brainstem, hypothalamus

Question 19

what regions of the brain are involved in craving? PHIB

Answer 19

prefrontal cortex,
hippocampus,
insula,
basolateral amygdala

Question 20

how does reinforcement change over the course of addiction?

Answer 20

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

Question 21

what regions are targets for addiction withdrawal drugs?

Answer 21

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

Question 22

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

Answer 22

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

Question 23

what drugs are used to support alcohol withdrawal?

Answer 23

benzodiazapines

Question 24

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

Answer 24

acamprosate
disulfiam
naltrexone
namphiene

Question 25

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

Answer 25

naltrexone naloxone

Question 26

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

Answer 26

CAGE - cut down, angry, guilty, eye opener

Question 27

how do you perform a mental state examination?

Answer 27

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

Question 28

what is the clinical opiate withdrawal scale? COWS

Answer 28

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

Question 29

what are the ICD-10 requirements for dependency syndrome?

Answer 29

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 30

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

Answer 30

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

Question 31

what assessments are done for alcohol abuse?

Answer 31

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 32

what assessments are done for opioid ab/use?

Answer 32

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 33

what are the immediate effects of alcohol?

Answer 33

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 34

what are the chronic effects of alcohol?

Answer 34

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 35

what are the minor effects of alcohol withdrawal?

Answer 35

``` tremulousness diaphoresis (sweats) fever anxiety agitation nausea/vomiting/retching ```

Question 36

when do alcohol withdrawal symptoms often start?

Answer 36

onset after 6hrs from last drink

Question 37

what is DT in alcohol withdrawal?

Answer 37

delirium tremens

Question 38

what is delirium tremens?

Answer 38

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

Question 39

what are the effects of opioids?

Answer 39

analgesic effect | sense of euphoria

Question 40

what are the symptoms of an opioid overdose?

Answer 40

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

Question 41

how is an opioid overdose managed?

Answer 41

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

Question 42

How does brain function transition as voluntary drug use changes to more habitual and compulsive drug use? (4)

Answer 42

- Transition from prefrontal to striatal control over drug taking - i.e. prefrontal ‘top-down’ control is diminished with greater striatal reward drive - Relationship between dorsal striatum & frontal cortex becomes dysregulated - Ventral (limbic or emotional) to dorsal (habit) striatum - Role for memory (e.g. hippocampus) in craving the substance

Question 43

- What are the 3 types of opioid receptor?

Answer 43

- Mu - Delta - Kappa

Question 44

- What are signs of opioid overdose? **(6)**

Answer 44

- Not moving and can’t be woken - Slow or no breathing - Choking, gurgling or snoring - Tiny pupils - Clammy or cold skin - Blue lips and blue nails

Question 45

How to weane off benzos

Answer 45

diazapam

Question 46

- Opioids absitinence? **(2)**

Answer 46

- Methadone - Buprenorphine