Substance Use and Addiction Flashcards
(105 cards)
1
Q
What are the main three things to flag for abuse?
A
- quantity/frequency
- consequences (physical, psychological, social impact)
- dependence/addiction
2
Q
What are the main red flags for dependence?
A
- tolerance and morning drinking
- withdrawal
3
Q
What are the different types of stimulants?
A
- amphetamine
- cocaine (crack)
- ecstacy
4
Q
What are ‘novel psychoactive substances’?
A
- new 1/week
- tend to be synthetic
- can be put into 4 categories: depressant, stimulant, hallucinogenic, cannaboid
5
Q
Why is it important to know why drugs are being used?
A
Because it informs treatment
6
Q
What is positive reinforcement (drugs)?
A
drugs are used to gain a positive state
7
Q
What is negative reinforcement?
A
drugs are used to overcome an adverse state
8
Q
What is the course of drug addiction?
A
- experimental use, causes no/limited difficulties
- increasingly regular until harmful
(can bounce back from here) - spiral into dependence
(point of no return) - like>want>need
9
Q
What is the ICD-10 diagnostic criteria?
A
- strong compulsion to take the substance
- difficulties in controlling the substance (onset, termination or usage levels)
- negative physiological withdrawal when substance use is stopped
- tolerance: more to get the same effect
- neglect of alternative interest
- persistence with use despite harmful consequences
10
Q
What classifies harmful use?
A
Actual damage should’ve been caused to the health of the user in the absence of diagnosis of dependence
- physical or mental damage (required)
- adverse social consequences
11
Q
What is the estimated prevalence of alcohol dependence?
A
595,000 people
only 103,471 in treatment, 82% not receiving treatment
12
Q
What is the estimated prevalence of opiate dependence?
A
257,476 people
170,032 in treatment, 46% not receiving treatment
13
Q
What has been the impact of COVID-19 on alcohol and opiate dependency?
A
100% more people are at high risk
20% more cases
14
Q
What is the definition of Addiction?
A
Compulsive drug use despite harmful consequences, characterised by the inability to stop using a drug; failure to meet personal, or professional obligations; and (drug dependent) tolerance and withdrawal
15
Q
What is the definition of Dependence?
A
A physical adaptation to a substance
- tolerance/withdrawal
(can be dependent but not addicted)
16
Q
What are some examples of behavioural addictions ?
A
- gambling disorder
(similar: neurobiology, treatment and co-morbidity and substance dependence) - internet gaming
17
Q
What causes a larger ‘rush’ and addiction?
A
faster brain entry/onset
crosses the blood-brain barrier, lipophylic
18
Q
What are the 3 main elements involved in alcohol/drug use and addiction?
A
- Social, environmental factors
- Personal factors (genetic)
- Drug factors
19
Q
What are the changes to the brain pre and post addiction?
A
- pre-existing vulnerabilities, age and family history
- exposure leads to compensatory neuroadaptations to maintain brain function
- recovery: lead to cycles of remission and relapse
20
Q
Why drink alcohol?
A
Alters the balance between the brain’s inhibitory (GABA-A, glutamate system) and excitatory system (glutamate system, NMDA receptor)
21
Q
What impact does alcohol have on the excitatory system?
A
Blocks the excitatory system
- Impaired memory (alcoholic blackouts)
22
Q
What is the impact of alcohol on the inhibitory system?
A
Stimulates the glutamate system
- anxiolysis
- sedation
23
Q
What are the neuroadaptations caused by chronic alcohol exposure?
A
means that GABA and glutamate remain in balance in the presence of alcohol
- up-regulation of the excitatory system
- reduced function of the inhibitory system > tolerance
(switch in GABA-A receptors to make it less sensitive to alcohol)
24
Q
How do you treat the neuroadaptation causing reduced function in the inhibitory system?
A
-benzodiazepines, to boost GABA function
25
What does the up-regulation of the excitatory system cause?
Increase in Ca2+, toxic leading to:
- hyper-excitability (seizures)
- cell death (atrophy)
26
What is Acamprosate?
drugs used to help people remain abstinent (reduced NMDA function)
- potentially neuroprotective (reduction in MRS glutamate)
27
What are the models of addiction?
- reward deficiency (positive reinforcement)
- overcoming adverse state (negative reinforcement)
- impulsivity/compulsivity
28
What is the neurobiology behind a withdrawal state?
In the absence of alcohol, GABA and glutamate are no longer in balance
29
Why are drugs addictive?
- increase the levels of dopamine
| - activates the: 'pleasure-reward-motivation' system
30
What is a key modulator of the 'pleasure-reward-motivation'n system
- mu opioid system
| - mediates the pleasurable effects of drugs
31
What is the biological mechanism of cocaine and amphetamine?
- block dopamine re-uptake
| - amphetamine: enhances the release of dopamine
32
What is the biological mechanism of other drugs (alcohol, opiates, nicotine)
Increase dopamine firing in the VTA (ventral tegmental area)
33
What are the possible impacts of dopamine D2 receptor levels on reinforcing responses?
- low D2 levels may predispose those to enjoy drugs
| - high D2 levels may be protective
34
What is the impact of addiction on the reward system?
- blunted activation of the reward system (in abstinent addicts) due to the increased tolerance
35
What is the impact of a blunted response in the brain to reward anticipation?
- more likely to relapse
36
What region of the brain is involved in binge/intoxication?
- Dorsal Striatum
- Thalamus
- DGP
- VGP
37
What is the region of the brain involved in the withdrawal/negative effect?
- hypothalamus
- brainstem
- effectors (autonomic, somatic, neuroendocrine)
38
What regions of the brain are involved in preoccupation/anticipation?
- pre-frontal cortex
- hippocampus
- BLA
- Insula
39
What happens to the models of addiction as the addiction develops?
Changes from positive to negative reinforcement
40
What are the targets for treatment?
The brain regions associated with withdrawal
- the 'reward' system
- the 'stress' system
- the amygdala
41
What is the impact of withdrawal and negative emotional states on the 'reward' system?
- reduced dopamine
| - reduced mu opioid function
42
What is the impact of withdrawal and negative emotional states on the 'stress' system?
increased activity in:
- kappa opioid (dynorphin)
- noradrenaline (arousal system)
- CRF (stress)
- etc...
43
What is the impact of withdrawal and negative emotional states on the amygdala?
leads to dysregulation
44
How do you assess amygdalar function with an fMRI?
- emotional processing of aversive images
| - select neutral and aversive images (NO DRUGS/ALCOHOL)
45
What are the general trends found in amygdala function?
- high brain response (to aversive images) in the left amygdala in abstinent drug addicts but not in alcoholism
46
What parts of the brain are involved in the transition from voluntary drug use to compulsive drug use?
- prefrontal to striatal control over drug taking
(prefrontal top-down control is diminished with greater striatal reward drive)
- ventral (limbic or emotional ) to dorsal (habit) striatum
47
What is the effect of time on the region of control of drug use?
the longer time abstinent, the greater the response of the frontal pole/inferior frontal gyrus
48
What do you use benzodiazepines to treat?
Alcohol withdrawal
49
What do you use naltrexone (opioid antagonist) to treat?
to block heroin use in opioid addicts, to modulate reward system in alcoholism
50
What is the public health guidance for treating drug abuse?
- community based interventions
| - healthcare workers to recognise the signs of drug abuse
51
What are synthetic cannaboid receptor agonists (SCRAs)?
eg: spice: 100 x more potent than THC
52
What is important to remember with Novel Psychoactive Substances?
- packets may not have the same contents batch to batch
- may be misleadingly named
- new products appear regularly
- use internet to check contents
- unlikely to show up on usual/standard drug tests
53
What is the minimum score on the ICD-10 diagnostic criteria for dependency?
3/6
54
What is the CAGE screening?
- Have you ever felt the need to Cut your drinking?
- Have people Annoyed you by criticising your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt the need to drink in the morning (Eye-opener) to steady nerves/get rid of a hangover?
55
What screening can be done to assess addiction?
- ICD-10
- CAGE
- MSE
- DRUGS: blood-transmissible diseases (screen for)
56
What are the symptoms of withdrawal?
- shivering
- goosebumps
- nausea
- vomiting
- bone ache (heroin
- sweating
57
Why is it important to objectively observe withdrawal?
- administrating drugs for withdrawal while simultaneously high can lead to OD
LOOK FOR:
- constricted pupils (heroin and opiates)
- dilated pupils (stimulants and alcohol)
58
Why do veins get worse with frequent injected heroin use?
- heroin mixed with ascorbic acid to break down before injection
- acids directly injected in the vein is highly damaging and causes vein collapse
59
What are the main symptoms mentioned on the COWS (clinical opiate withdrawal scale)?
- tachycardia
- sweating
- restlessness
- dilated pupils
- bone aches
- runny nose
- GI upset
- tremor
- yawning
- anxiety/irritability
- gooseflesh skin
60
Changes made by DSM-5 to classification:
Dimensional approach:
2-3: mild opioid use disorder
4-5: moderate opioid use disorder
>6: severe opioid use disorder
61
What is in the standard history for substance abuse?
- presenting complaint + history
- psychiatric history
- medical history
- medication + allergies
- family history
- personal history
- permorbid history
- risk assessment
62
What is the requirements of the substance misuse history?
Must be repeated for each separate substance
63
What is included in a substance misuse history?
- length of use, last taken?
- current amount (units, grammes/day), how long taking this much?
- method of use
- total length of use, max use and periods of abstinence
- evidence of withdrawals + severity
- previous treatments
- previous substance OD (accidental or deliberate)
- assess triggers of use
- assess motivation to change
64
What is important to be aware of when helping someone in withdrawal?
whether there is a history of seizures?
| - if yes, close monitoring necessary?
65
What developmental disorder has a high link with addiction?
ADHD, due to high impulsivity
| - 25% of SUDs have co-morbid ADHD
66
What can cause drug-induced psychosis?
Almost EVERYTHING
Stimulants (crack, methamphetamine)
Mainly: Cannabis (THC paranoia, counteracted by CBD)
EG: skunk, high THC, low CBD
67
What are specific aspects of an assessment for alcohol?
```
Examination:
- jaundice
- anaemia
- clubbing
- cyanosis
- oedema
- ascities
- lymphodenopathy
- DVT
Investigation:
- US/Fibro scan
- Bloods (LFT, GGT, Lipids, U&E, amylase)
- breathalyser
- urine drug screen
```
68
What are specific aspects of an assessment for IV drug use (opioids)?
```
Examination:
- collapsed veins
- endocarditis
- skin abscesses
- hepatitis/HIV
- pneumonia
Investigations:
- Bloods (LFT, U&E, GGT, Glucose)
- Breathalyser
- Urine Drug Screen
- BBV
- STI screening
```
69
How big of a problem is alcohol?
- 30% of UK drink above safe limits
- 25% have had a drinking problem
- 15-24yo highest use
70
What is the progression of withdrawal?
- minor withdrawal symptoms (fever, agitation, nausea, tremulousness)
- alcoholic hallucinations
(visual and auditory hallucinations, tactile disturbances)
- withdrawal seizures
(2 hours after cessation, rare after 48 hours)
- Delirium Tremens
(auditory and visual hallucinations, confusion, disorientation, hypertension, tachycardia >100/min, fever, severe tremor)
71
What are opiates?
natural opioids (morphine, codeine - to a certain extent heroin)
72
What are opioids?
All natural, semi-synthetic and synthetic opioids
73
What is important about Harmful Use and Dependence?
A patient can not have a diagnosis of BOTH harmful use and dependence
74
What should be included in a past psychiatric history for addiction?
- history of trauma?
- neglect or abuse?
- family substance abuse?
- education?
- development?
- ADHD? (25%)
- Depression (15%-community, 32% - alcohol treatment, 43% - drug treatment)
- Anxiety (17%)
- Suicidality (6 x risk)
- Personality disorder
- PTSD
- BPD
75
What does drug-induced psychosis often include?
during or immediately after substance use
- vivid hallucinations, often auditory
- paranoid delusions (severe)
- resolves in 1-6 months
76
What needs to be taken into account when diagnosing drug induced psychosis?
- misdiagnosing a schizophrenic episode as psychosis (may be triggered by substance use)
77
What should be accounted for in a personal/social history?
- relationships?
- safeguarding?
- accommodation?
- money, debt?
- employed?
- forensic history?
78
What are the main causes to morbidity and mortality associated with substance abuse?
- trauma
- road accidents
- homocide
- suicide
- OD
- cirrhosis (alcohol)
- endocarditis (IV)
- Abscesses (IV)
- BBV (IV), vaccinated?
79
What does Delirium Tremens represent?
- medical emergency
- 5% prevalence, 15-20% mortality
- admission for 24 hours and observation highly
80
What are the risk factors of developing Delirium Tremens?
- heavy daily alcohol use (60+ units)
- history of DTs
- older age
- abnormal LFTs
81
What are examples of natural opioids (opiates)?
- opium
- morphine
- codeine
- thebaine
82
What are examples of synthetic opioids?
- fentanyl (100 x morphine)
- pethidine
- methadone
- tramadol
83
What are examples of semi-synthetic opioids?
- heroin (2 x morphine)
- hydrocodone
- oxycodone
- hydromorphone
84
What do opioids do?
- analgesia
| - euphoria
85
What are opioid receptors mu, delta and kappa effected by?
```
Opioid agonists:
- heroin
- fentanyl
- methadone
- codeine
Partial agonists:
- buprenorphine
Antagonists:
- naltrexone
```
86
What apart from opioids (exogenous drugs) regulate pain and mood?
endogenous endorphins
87
What are the symptoms of opiate overdose?
- unconscious
- slow/no breathing
- choking, gurgling or snoring
- tiny pupils
- clammy/cold skin
- blue lips and nails
88
How do you treat an opiate overdose?
```
Naloxone
- inject in upper arm or thigh
- nasal spray: 50% each nostril
If no response after 3 minutes, repeat
(airway support, recovery position)
```
89
What medications are used to support abstinence from alcohol?
- Acamprosate
- Disulfiram (Antabuse)
- Naltrexone
- Nalmefene
90
How does Acamprosate work?
- Increases GABA< NMDA antagonist
- 333-666mg TDS
- possible neuroprotective role during withdrawal
91
How does Disulfiram (Antabuse) work?
- 200-500mg daily
| - inhibits acetaldehyde dehydrogenase, leads to nausea/flushes if mixed with alcohol
92
How does Naltrexone work?
- 50mg daily
| - Used in other dependencies (opioids, G-drugs, methamphetamine)
93
How does Nalmefene work?
- opioid inverse agonist
- 18mg PRN (single daily dose) on days with high drinking risk
- for those dependent but without withdrawal, reduce alcohol intake
94
What drugs are used for detox regimes for alcohol abuse?
- benzodiazapines
| - chlorodiazepoxide
95
How does Chlorodiazepoxide (Librium) work?
- both inpatient and community
- 20-40mg QDS, reducing over 7-10 days
- Thiamine (B12), Folate
96
What drugs are used for abstinence from opioids?
- methadone
(60-120mg, maintenance dose)
- buprenorphine
(12-14mg, maintenance dose)
97
What drugs are used in detox regimes from opioids?
- maintenance treatment (methadone and buprenorphine)
- at least 12 months to sustain lifestyle changes
- then, dose reduction over several months
98
What drugs are used to treat benzodiazepine dependence?
maintenance on diazepam, reducing regime of 1mg/week, but difficult to wean off of
GPs reluctant to prescribe, therefore remain in addiction services for addiction
99
What drugs are used to support a detox regime from benzos/g-drugs?
- medical supervision
- community, but inpatient access required
- baclofen (GABA agonist)
- benzos used
100
What are G-drugs?
- GHB (gamma hydroxybutyrate)
| - GBL (gamma butyrolactone)
101
What is GHB?
- clear, oily liquid
- onset: 15-20 minutes
- lasts: 3-4 hours
102
What is GBL?
- precursor to GHB
| - converted after swallowing
103
What is a massive contraindication of G-drugs?
- alcohol
| - can lead to death
104
What do G-drugs do?
- depressants
- high produced with low dosage
- sedation with slightly high dosages
- euphoria
- inhibition loss
- increased confidence
- increased sex drive
105
What are the risks of G-drugs?
- easy to OD, <1ml difference between high and unconsciousness
- highly addictive, leads to dependence (every 1-3 hours)
