substance use and misuse

Question 1

what are the potential harms of substance use and misuse

Answer 1

• Psychological issues
• Socio-economic issues
• Physical consequences
• Addiction or diversion
• Physical consequences
• Route of administration
• Self-neglect
• Poor pregnancy outcomes
  Withdrawal symptoms

Question 2

what are the risk factors for substance use and misuse

Answer 2

• Family history of substance abuse
• History of pain
• Easy access to medicines
• Difficult life events
• Time spent in secure environments
• Chronic/severe mental/physical health problems

Question 3

what are the behavioural warning signs for substance use and misuse

Answer 3

• Taking a higher dose than prescribed
• Running out early
• Continually losing meds
• Healthcare professional shopping
• Requesting specific medicines
• Stealing or forging scripts
• Drug hoarding
• Risky behaviours
• Unexplained falls
• Debt
• Reduced social function

Question 4

what are the physical warnings signs of substance use and misuse

Answer 4

• Presenting as intoxicated, sedated or withdrawing
• Unkempt appearance
• Mood swings
• Changes in sleep patterns
• Avoiding drug testing

Question 5

what are the risk factors for alcohol dependence

Answer 5

genetics
starting at a young age
regular drinking
mental health problems
ignorance

Question 6

what are the risks of long term high alcohol intake

Answer 6

death
liver damage
accidents
cancer
GI/mental health/social issues
brain damage
pancreatitis
social issues
heart disease
osteoporosis

Question 7

what are the risks of chronic alcohol consumption on the CNS

Answer 7

cognitive impairment
wernicke korsakoff syndrome

Question 8

what is wernicke korsakoff syndrome

Answer 8

acute onset neuropsychiatric disorder caused by thiamine deficiency - can go on to encephalopathy - confusion, apathy, disorientation and vomiting

Question 9

how is wernicke korsakoff syndrome treated

Answer 9

1. IM/IV pabrinex for 3-5 days
2. maintenance thiamine 100mg TDS

Question 10

what are the steps in managing alcohol dependency

Answer 10

1. assessment
2. detox
3. assisted maintenance

Question 11

how are patients detoxed from alcohol

Answer 11

chlordiazepoxide/oxazepam (in hepatic impairment)
- long acting benzo
- 20-40mg QDS or PRN
- risk of accumulation in elderly

Question 12

what medications can be used for assisted maintenance in alcohol dependency

Answer 12

disulfiram
acamprosate
naltrexone
nalmefene

Question 13

what is disulfiram

Answer 13

§ Aversive therapy - pro-drug
§ Prevents the liver converting acetaldehyde to acetic acid and dopamine to noradrenaline
When a person consumes a small amount of alcohol, mild symptoms of acetaldehyde and dopamine excess are experienced: vasodilation, palpitations and headache

Question 14

what is acamprosate

Answer 14

glutamate antagonist
reduces reward from alcohol

Question 15

what is naltrexone

Answer 15

§ Opioid antagonist licensed for alcohol misuse disorder
§ Blocks opioid receptors that modulate the release of dopamine in the brain reward system - blocking reward from alcohol and heroin

Question 16

what is nalmefene

Answer 16

§ Opioid antagonist - reduces reward
§ When required for
□ Reduction strategy for those who have failed abstinence
□ For those who cannot achieve abstinence but require intervention with psychosocial support

Question 17

what are the symptoms of alcohol withdrawal 6-30 hours after last drink

Answer 17

hyperactivity
tremor
sweating
nausea
retching
mood fluctuation
tachycardia
increased RR
HT

Question 18

what are the symptoms of alcohol withdrawal 48 hours after last drink

Answer 18

withdrawal seizures

Question 19

what are the symptoms of alcohol withdrawal 12 hours to 6 days after last drink

Answer 19

auditory and visual hallucinations

Question 20

what are the symptoms of alcohol withdrawal 48-72 hours after last drink

Answer 20

delerium tremens
- coarse tremor
- agitation
- confusion
- delusions and hallucinations

Question 21

how is opioid dependence treated

Answer 21

1. assessment
2. detox
3. maintenance
4. gradual discontinuation

Question 22

how is opioid dependence detoxed

Answer 22

Replacement that prevents withdrawal but no high with symptomatic relief

Question 23

what are the symptoms of opioid withdrawal

Answer 23

runny nose/eyes
dilated pupils
yawning
nausea
vomiting
diarrhoea
muscle aches
restlessness

Question 24

what medications are used in maintenance for treating opioid dependence

Answer 24

methadone
buprenorphine

Question 25

what is buprenorphine

Answer 25

partial opioid agonist not absorber orally harder to supervise cannot use on top

Question 26

what is methadone

Answer 26

full opioid agonist long half life to suppress withdrawals and cravings can use on top but it is dangerous - has street value

Question 27

what medications can be used to support opioid users to come off of maintenance therapy

Answer 27

naltrexone long acting opioid antagonist with high affinity minimises reward from opioids and alcohol Test dose of 25mg at least 7 days after last opioid dose, then 50mg/day

Question 28

what are the advantages to using methadone

Answer 28

good EBM sedating cheap full agonist variety of routes and forms easy to supervise orally absorbed

Question 29

what are the disadvantages to using methadone

Answer 29

easy overdose can use on top stigma rots teeth accumulation in fatty tissue 3 days to steady state long detox does not stop cravings

Question 30

what are the CNS S/E of methadone

Answer 30

euphoria pain relief drowsiness N&V - triggers CTZ Resp depression at high doses cough reflex suppression

Question 31

what are the histaminergic S/E of methadone

Answer 31

itching sweating blushing flushing airway constriction

Question 32

what are the non-CNS S/E of methadone

Answer 32

absent menstrual cycle sexual dysfunction dry mouth/eyes/nose dental issues constipation constricted pupils QTc interval prolongation - r=monitor 6-12m

Question 33

what are the risk factors for QTc prolongation in methadone use

Answer 33

other meds prolonging QTc hx of heart disease stimulant use

Question 34

what are the advantages of using buprenorphine

Answer 34

difficult to use on top safer in overdose easier to detox/switch to naltrexone less sedating better newborn outcomes rapid initial titration

Question 35

what are the disadvantages of using buprenorphine

Answer 35

not orall absorbed pooer EBM tastes bad only one dosage form less sedating expensive

Question 36

what are the symptoms of opioid overdose

Answer 36

pinpoint pupils N&V pale skin blueish tinge to lips, nose, under eyes, finger and nails low BP slow pulse sedation

Question 37

how is opioid overdose treated

Answer 37

naloxone - opioid receptor antagonist

Question 38

when do you need to contact the prescriber of a opioid dependent patient

Answer 38

>3 doses missed intoxication unacceptable behaviour whole dose not consumed concerns about mental/physical health needs

Question 39

what are the effects of using synthetic cannabis

Answer 39

agitation, tremor, confusion, hallucinations tachycardia, hypertension, palpitations renal damage

Question 40

what are the two CB receptors and what do they control

Answer 40

CB1 - brain - appetite, movement, higher cognitive functions, stress, nausea and pain CB2 - periphery- immune function

Question 41

how does cannabis affect schizophrenia

Answer 41

moking in a susceptible person can cause § Exacerbation of mental health problems § Anxiety/panic attacks § Paranoia/psychosis ○ Smoking before 15 increases risk of psychotic illness 4 fold

Question 42

which illnesses have good evidence for cannabis use

Answer 42

chronic/neuropathic pain paediatric epilepsies nausea associated with chemotherapy spasticity and pain in MS

Question 43

which illnesses have modest evidence for cannabis use

Answer 43

sleep disturbances PTSD chronic fatigue migraine restless legs anxiety and stress

Question 44

what are the 4 disorders associated with caffeine

Answer 44

○ Caffeine intoxication ○ Caffeine induced anxiety disorder ○ Caffeine induced sleep disorder ○ Caffeine related disorder otherwise not specified

Question 45

what are the recommended daily maximum caffeine intake levels

Answer 45

500mg/day is moderate 600mg/day is caffeinism >1000mg/day is toxic

Question 46

what are the signs and symptoms of low to moderate caffeine doses

Answer 46

passing more urine tremor increased physical stamina anxiety heart palpitations nervousness

Question 47

what are the signs and symptoms of high caffeine doses

Answer 47

chronic insomnia anxiety restless legs irritability and agitation poor concentration disorientation paranoia seizures vertigo hallucinations

Question 48

how should pregabalin be reduced

Answer 48

daily dose at a maximum of 50-100mg/week

Question 49

how should gabapentin be reduced

Answer 49

daily dose at a maximum of 300mg every 4 days