Substance Use and Addictions Flashcards by Alfie Saunders

Positive reinforcement?

Gain positive state:
-stay awake
-get high
-enjoy it
-escapism

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Negative reinforcement?

Overcome adverse state:
-boredom
-reduce anxiety
-to get to sleep
-feel better

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Course of addiction?

Like -> Want -> Need

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Dependence syndrome ICD-10?

3 or more of following
1. Strong DESIRE or sense of compulsion to take substance
2. DIFFICULTIES CONTROLLING substance taking behaviour (onset, termination, levels)
3. Physiological WITHDRAWAL state when stopped or reduced
4. TOLERANCE
5. Progressive NEGLECT of alternative interests
6. PERSISTING with use despite evidence of harmful consequences

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Addiction?

Continue using despite being harmful
Cannot stop using drug
Neglect of work, social, or family obligations
Tolerance and withdrawal

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Dependence?

Body physically adapted to drug
-tolerance/withdrawal

can be dependent and not addicted

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Behaviour addictions?

-gambling disorder
-internet gaming disorder

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3 levels of addiction?

Hazardous use (high quantity and frequency)
Harmful use (consequences - physical, social, psychological)
Dependence/addiction (tolerance, withdrawal)

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Elements involved in alcohol/drug use and addiction?

-social, environmental factors
-drug factors (faster entry=more addictive)
-personal factors (genetic, personality)

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Models of addiction?

-reward deficiency (positive reinforcement)
-overcoming adverse state (withdrawal, anxiety - negative reinforcement)
-impulsivity/compulsivity

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Alcohol acute effects?

Blocks excitatory system (through NMDA receptor) - impaired memory, alcoholic blackouts

Boosts inhibitory system (through GABA-A receptor) - anxiolysis, sedation

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Chronic alcohol exposure neuroadaptations?

Upregulation of excitatory system

Reduced function of inhibitory system (tolerance)

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Upregulation of excitatory system from chronic alcohol?

Increased number of NMDA receptors - increase in calcium release which is toxic

calcium is toxic leading to hyper excitability (seizures) and cell death (atrophy)

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Reduced function of inhibitory system from chronic alcohol?

GABA-A receptor - switch in subunits to make less sensitive to alcohol

TOLERANCE

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To boost GABA function?

Treat with benzodiazepines

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Ventral striatum

Natural rewards increase levels of dopamine in ventral striatum

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Dopamine pathway?

Pleasure-reward-motivation system

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Cocaine and amphetamine interaction with dopamine?

Block dopamine reuptake

amphetamines enhance release of dopamine

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Alcohol and nicotine effect on dopamine?

Increase dopamine neurone firing in VTA (ventral tegmental area)

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Reward system in abstinent addicts?

Blunted activation of reward system in abstinent addicts compared with controls

blunted response = more likely relapse (reward deficiency)

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Amygdala?

Emotional processing
Involved dysregulation of stress system, increase in kappa/dynorphin opioid system, noradrenergic activity

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Positive -> negative reinforcement?

As addiction/dependence develops

Ventral -> dorsal migration

Fronto-striatal connections with reduced frontal ‘control’ or striatal activity
Move from ventral (limbic) to dorsal (habit) striatum as dependence develops

Intoxication?

Transient, temporary state that disappears when drug is eliminated

Withdrawal?

Signs + symptoms when dose is reduced or stopped

Tolerance?

Drug produces decreased effect after repeated use

Harmful use? ICD-10

-pattern of substance that causes damage to health -physical or mental damage -adverse social consequences -harmful use including bingeing (doesn’t include hangover alone) -does not fulfil any other diagnosis within substance use (e.g dependence) *cannot be harmful use and dependence*

ICD-11 similarities? (Dependence and harmful use)

Distinction between dependence and harmful use is preserved

ICD-11 differences (harmful use)?

Single episodes of harmful use differentiated from pattern of harmful use *harmful use now also include harm to health of others*

ICD-11 differences (dependence)?

*former 6 criteria bundled into 3 pairs - 1 criteria sufficient* 1. *IMPAIRED CONTROL* over substance use 2. *INCREASING PRECEDENCE* of substance over other aspects of life 3. *NEUROADAPTATION* to substance *usually over 12 months but diagnosis can be made after 3 months continuous*

DSM-5 classification differences? Addiction

Remained opioid use disorder and alcohol use disorder Single continuum of mild, moderate, severe No longer uses terms abuse or dependence

Alcohol excretion rate?

1 unit per hour

Recommended intake units?

14 per week for men and women Spread over 3 or more days

CAGE?

Cut down Angry Guilty Eye opener

Absorption pharmacology alcohol?

60 mins for maximum blood concentration

Alcohol pharmacodynamics?

Enhances neurotransmission at GABA-A receptors (causing anxiolysis) Inhibits NMDA mediated glutamate release (amnesic)

Alcohol metabolism?

Ethanol oxidised by alcohol dehydrogenase to acetaldehyde Acetaldehyde dehydrogenase turns acetaldehyde to CO2 and water

Alcohol assessment? Physical examination

Examination - jaundice, bruising, clubbing, oedema, ascites, spider naevi

Wernicke’s encephalopathy triad?

Ataxia Confusion Opthalmoplegia

Alcohol withdrawal stages?

6-12 hours - minor withdrawal symptoms (tremulousness, anxiety, nausea…) 12-24 - alcoholic hallucinosis (usually accusatory or derogatory voices) 12-48 - withdrawal seizures 48-72 - *delirium tremens*

Delirium tremens?

Medical emergency Hallucinations, confusion and disorientation, hypertension, agitation, tachycardia, fever, severe tremor

Alcohol withdrawal management?

Benzodiazepines

Opioid effects?

1. Relieve pain - analgesic 2. Euphoria *endogenous (endorphins) regulate pain and mood*

Opioid receptors?

Mu, delta, kappa - affected by heroin, codeine

Opioid assessment examination?

Collapsed veins, track marks *endocarditis* Hep. B, HIV Pneumonia

Opioid withdrawal scale?

COWS Clinical opiate withdrawal scale

Opiate overdose treatment?

Naloxone

Opiate overdose signs?

Not moving, can’t be woken, slow or no breathing Choking or gurgling sounds, snoring Tiny pupils Clammy or cold skin Blue nails

Opioid addiction symptoms?

Tachycardia, snotty, achy, worry

All diagnostic criteria similar features?

-loss of control -functional impairment -neuroadaptation

Addiction history taking?

Triggers, method, withdrawal, previous treatment Willing to change?

Alcohol assessment? Neurological

Neurological - Wernicke’s encephalopathy, Korsakoff’s syndrome

Alcohol abstinence drug and effect?

Acamprosate - increases GABA, NMDA antagonist

Detox drug?

Benzodiazepines Chlordiazepine Thiamine, folate