Substance Use Disorders

Question 1

Substance misuse disorder

Answer 1

consumption of substances causing social, psychological, physical, or legal problems; most common substance is cannabis, followed by cocaine and ecstasy.

Question 2

Common substances that are misused

Answer 2

Among people aged 16-59, the most common use substance is cannabis, followed by cocaine and ecstasy

Question 3

Epidemiology of alcohol misuse related death

Answer 3

alcohol misuse is the fifth biggest risk factor for death across all ages. The alcohol-specific death rate for 2020 was 18.6% higher than in previous years

Question 4

Substance dependence requires at least two of the following:

Answer 4

Impaired control over substance use
Increasing priority over other aspects of life or responsibility
Psychological features suggestive of tolerance and withdrawal

Question 5

Substance misuse affects different areas of the brain - which areas specifically?

Answer 5

basal ganglia, amygdala, and prefrontal cortex. It also affects the neurotransmitters such as the balance between glutamate, GABA and dopamine.

Question 6

What happens to the brain when a substance is consumed?

Answer 6

When an individual consumes a substance, this affects the mesolimbic dopamine system in the nucleus accumbens and dorsal striatum in the basal ganglia. The release of dopamine gives off pleasurable feelings which trigger the reward system and positively reinforce the behaviour of substance consumption. This process is known as operant conditioning and is the basis of addiction and cravings.

Question 7

How do alcohol and opiods affect the brain?

Answer 7

Some substances, such as alcohol and opioids, interact with the inhibitory neurotransmitter GABA, which disrupts the equilibrium between GABA and glutamate. It is believed that the number of natural stimulants (glutamate) and natural sedatives (GABA) are roughly the same. When an individual consumes substances, this disrupts the equilibrium as there are more sedative hormones (GABA).

Question 8

What is neuroadaptation?

Answer 8

When exposed chronically, this results in neuroadaptation. The brain will upregulate the natural stimulants to achieve equilibrium. Withdrawal symptoms occur when there is a sudden drop in GABA, resulting in disrupted homeostasis and too much glutamate. The excess natural stimulants lead to withdrawal symptoms such as anxiety, sweating, and shaking.

Question 9

According to UK guidance, the threshold for alcohol consumption is __ units a week spread evenly over three days or more.

Answer 9

14

Question 10

How much is 0ne unit of alcohol?

Answer 10

One unit of alcohol is 10ml (8g) of pure alcohol.

Question 11

How to calculate alcohol units?

Answer 11

ABV x volume (ml) ÷ 1000 = units

Question 12

What is hazardous drinking?

Answer 12

Hazardous drinking is when an individual consumes more than 14 units of alcohol a week, which may increase their risk of harm. Harmful drinking is when the pattern of alcohol consumption directly causes physiological complications and illnesses

Question 13

What is alcohol dependence ?

Answer 13

alcohol dependence is characterised by craving and tolerance of alcohol consumption despite the negative complications experienced

Question 14

How does alcohol affect the liver and how would these patients present?

Answer 14

It can also affect the liver, causing liver cirrhosis and alcoholic liver disease. Individuals with chronic alcohol misuse can present with bleeding oesophageal varices, hepatic failure, and stigmata of liver diseases. Other chronic physiological consequences are discussed in the section below.

Question 15

When do alcohol withdrawal symptoms occur after alchol cessation + what are they ?

Answer 15

Withdrawal symptoms can be experienced after a few hours of alcohol cessation. Within 6-12 hours, patients can experience tremors, and autonomic arousal (e.g. tachycardia, fever, pupillary dilation, and increased sweating).

Question 16

What happens with 12-48 hours of alcohol cessation ?

Answer 16

Between 12-48 hours of cessation, patients can experience alcohol hallucinosis (typically auditory or tactile). Between 72-96 hours, patients can present with delirium tremens. They may experience altered mental status, agitation, and tactile hallucination.

Question 17

Ix for alcohol misuse

Answer 17

Full blood count: raised MCV, raised platelets, anaemia
Liver function tests: increased GGT, AST:ALT > 2:1
Haematinics (B12/folate): alcohol can cause folate deficiency
Thyroid function tests

Question 18

Which screening tool is used to look at the risk of dependency of alcohol misuse?

Answer 18

AUDIT-C questionnaire

Question 19

What are the 3 questions asked in the AUDIT-C ?

Answer 19

How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Question 20

Points for : How often do you have a drink containing alcohol?

Answer 20

Never – 0 points
Monthly or less – 1 point
2 to 4 times a month – 2 points
2 to 3 times a week – 3 points
4 or more times a week – 4 points

Question 21

Points for : How many units of alcohol do you drink on a typical day when you are drinking?

Answer 21

0 to 2 – 0 points
3 to 4 – 1 point
5 to 6 – 2 points
7 to 9 – 3 points
10 or more – 4 points

Question 22

Points for: How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Answer 22

Never – 0 points
Less than monthly – 1 point
Monthly – 2 points
Weekly – 3 points
Daily or almost daily – 4 points

Question 23

If a patient scores __ or more out of 12, the full AUDIT questionnaire should be asked.

Answer 23

5

Question 24

Which questionnaires look at the severity of alcohol dependence?

Answer 24

Other questionnaires include the SAD-Q questionnaire which looks at the severity of alcohol dependence and the CAGE questionnaire

Question 25

What are the CAGE questions?

Answer 25

Have you ever felt that you should Cut down on your drinking? Have people Annoyed you by criticising your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (known as an Eye-opener)?

Question 26

Interpretation of the CAGE questionnaire?

Answer 26

The patient should be given 1 point for each question they answer yes to. A score of over 2 suggests problematic drinking.

Question 27

Main intervention of alcohol dependence

Answer 27

alcohol detox

Question 28

Alcohol detox can lead to ___

Answer 28

serious withdrawal symptoms, leading to tremors, seizures, and delirium tremens

Question 29

Which medications can be given during the detox phase to help with the symptoms of alcohol withdrawal?

Answer 29

Chlordiazepoxide (20-40 mg QDS) is often prescribed and monitored over the first few days. An alternative is oxazepam, used in patients with hepatic impairments and the elderly.

Question 30

What is Naltrexone?

Answer 30

Naltrexone is an opiate blocker that makes alcohol less enjoyable and less rewarding. It can be administered as an injection once a month or oral tablets.

Question 31

Common SE of Naltrexone

Answer 31

nausea, vomiting, decreased appetite, pain at the injection site, and increased liver enzymes

Question 32

CI for Naltrexone

Answer 32

opiate use and patients with liver failure.

Question 33

What is Acamprosate?

Answer 33

Acamprosate is a medication that increases GABA and decreases excitatory glutamate which reduces cravings. It has a good side effect profile and is generally well tolerated.

Question 34

What is Disulfiram?

Answer 34

Disulfiram inhibits acetaldehyde dehydrogenase which causes the accumulation of acetaldehyde with alcohol

Question 35

Unpleasaent symptoms of Disulfram

Answer 35

flushing, sweating, headache, nausea and vomiting, arrhythmias, and hypotensive collapse.

Question 36

What should patients avoid drinking with Disulfram?

Answer 36

Patients should avoid alcohol for 24 hours before taking disulfiram and 1 week after cessation of the medication. When taking the medication, they must avoid all contact with alcohol.

Question 37

CI for Disulfiram?

Answer 37

heart disease, psychosis, and those felt to be at high risk of suicide.

Question 38

Apart from alcohol detox and medications to help the withdrawal symptoms, what else can be given to patients who are being treated for their alcohol dependence?

Answer 38

Patients should be offered psychological interventions such as cognitive behavioural therapy. In addition, it is important to prescribe prophylactic oral thiamine, if they are malnourished or in acute withdrawal, or suffer from decompensated liver disease.

Question 39

Alcohol misuse can cause multiple physiological complications including:

Answer 39

Neurological: ischaemic stroke, encephalopathy, seizures, peripheral neuropathy Cardiovascular: increased rate of myocardial infarction and stroke, hypertension, dilated cardiomyopathy Hepatology: alcoholic liver disease, liver cirrhosis, liver fibrosis, pancreatitis Oncology: increased risk of head and neck cancer, oesophageal cancer, liver cancer, breast cancer, colorectal cancer Psychiatric: alcoholic hallucinosis, delirium tremens, Wernicke-Korsakoff syndrome

Question 40

What is Wernicke-Korsakoff syndrome ?

Answer 40

Alcohol prevents the absorption of thiamine by blocking thiamine pyrophosphate synthetase, resulting in thiamine deficiency.

Question 41

Symptoms of Wernicke Encephalopathy?

Answer 41

The main symptoms of Wernicke encephalopathy are ataxia, confusion and ophthalmoplegia.

Question 42

Symptoms of Korsakoff syndrome?

Answer 42

Korsakoff syndrome involves symptoms of Wernicke encephalopathy plus short-term memory loss and hallucinations

Question 43

Tx for Wernicke-Korsakoff syndrome

Answer 43

The treatment is the intravenous replacement of thiamine (e.g. Pabrinex).

Question 44

What does opioid misues involve?

Answer 44

Opioid misuse includes the use of morphine, heroin, oxycodone, and codeine. Opioids are central nervous system depressants that slow brain activity and relax muscles.

Question 45

What are the physiological effects of opioids ?

Answer 45

euphoria and reduced pain, sedation, respiratory depression, miosis, constipation, skin warmth and flushing

Question 46

What are the psychological effects of opioids ?

Answer 46

apathy, disinhibition, drowsiness, impaired judgment and attention, slurred speech

Question 47

What happens during opioid withdrawal?

Answer 47

When withdrawing from opioids, increased sympathetic nervous system activity causes rhinorrhoea, lacrimation, diarrhoea, pupillary dilation, piloerection, tachycardia, and hypertension.

Question 48

What are the relevant lab Ix for opioid misuse?

Answer 48

HIV and hepatitis B/C: due to the increased risk of blood-borne infection is greater through needle sharing Tuberculosis testing Urea & electrolytes Liver function tests and clotting screen: to check hepatic function Drug levels: to check for drug toxicity

Question 49

Name some drug screening questionnaires used in the context of opioid misuse?

Answer 49

Drug abuse screening test (DAST): assess drug use in the past 12 months CAGE-AID (adapted to include drugs) Addiction severity index (ASI): looks at the effect of the use of substances on law, family, social life, work and mental health Clinical opiate withdrawal scale (COWS): rates common signs and symptoms of opiate withdrawal and monitors symptoms

Question 50

Management of opioid misuse

Answer 50

The main intervention for opioid misuse is opioid detox using methadone reduction. An alternative to this is buprenorphine reduction. It can be helpful to refer the patient for counselling and rehabilitation.

Question 51

Medication used for opioid dependence include:

Answer 51

Methadone (binds to opioid receptors) Buprenorphine (binds to opioid receptors) Naltrexone (helps prevent relapse)

Question 52

Complications of opioid misuse

Answer 52

If taken in large doses, opioids can cause death. Of all drugs taken in overdose, opioids have been consistently shown to be the most likely to cause death. Opioid misuse also increases the risk of blood-borne diseases such as HIV, hepatitis B, and C.

Question 53

Name some depressants?

Answer 53

Alcohol and Benzodiazepines

Question 54

What is benzodiazepine misuse?

Answer 54

Benzodiazepine misuse includes the use of diazepam, oxazepam and lorazepam. Benzodiazepines are another example of central nervous system depressants.

Question 55

The clinical features of benzodiazepine misuse include:

Answer 55

Physiological effects: altered mental status, slurred speech, ataxia, respiratory distress, hypothermia, and coma if overdosed Psychological effects: euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood

Question 56

Withdrawal symptoms from benzodiazapine

Answer 56

Withdrawal from benzodiazepines may result in a wide range of clinical features including tremor, nausea & vomiting, tachycardia, postural hypotension, headache, agitation, malaise, transient illusions or hallucinations, paranoid ideation and seizures.

Question 57

What can be used to determine the severity of withdrawal from benzos?

Answer 57

The clinical institute withdrawal assessment scale – benzodiazepines (CIWA-B) can be used to determine the severity of withdrawal from the substance.

Question 58

Management of benzo misuse

Answer 58

The main intervention for benzodiazepine misuse is assisted withdrawal and supportive treatments.

Question 59

Name some central nervous system stimulants

Answer 59

Amphetamine use (e.g. Adderall and methylphenidate) and cocaine are central nervous system (CNS) stimulants. MDMA (ecstasy) Methamphetamine

Question 60

Symptoms of CNS stimulants

Answer 60

Amphetamine use (e.g. Adderall and methylphenidate) and cocaine are central nervous system (CNS) stimulants.

Question 61

Clinical features of CNS stimulat withdrawal

Answer 61

dysphoria, lethargy, psychomotor agitation, craving, increased appetite, insomnia, and bizarre dreams.

Question 62

How does cocaine work?

Answer 62

Cocaine blocks reuptake of dopamine by the presynaptic membrane

Question 63

How does MDMA work?

Answer 63

MDMA stimulates the release of serotonin and blocks its reuptake

Question 64

How does meth work?

Answer 64

Meth stimulates the release of dopamine and blocks its reuptake

Question 65

Ix for CNS stimulant misuse

Answer 65

Screening tools used for CNS stimulants are the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).

Question 66

Management for CNS stimulant misuse

Answer 66

There is no specific drug treatment available for CNS stimulant use. Treatment is supportive and aimed at managing withdrawal symptoms.

Question 67

Name some Hallucinogens

Answer 67

Hallucinogens include lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP). Psilocybin

Question 68

How do Hallucinogens work?

Answer 68

Stimulate serotonin receptors, particularly 5-HT2A receptors

Question 69

What does the consumption of Hallucinogens cause?

Answer 69

When consumed, they can cause euphoria, visual and auditory hallucinations and psychosis. Hallucinogens mainly cause visual or auditory hallucinations and the feeling of euphoria.

Question 70

LSD causes

Answer 70

lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams

Question 71

Marijuana causes

Answer 71

increased appetite and conjunctival injection

Question 72

Ecstasy causes

Answer 72

bruxism, hyperthermia, hyponatremia, and hepatotoxicity

Question 73

PCP causes

Answer 73

loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation

Question 74

Ix for hallucinogen misuse

Answer 74

Screening tools used for hallucinogens are the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).

Question 75

Management for hallucinogen misuse

Answer 75

There are no specific interventions for hallucinogen misuse, and the mainstay treatment is supportive. This includes medically supervised detox by slowly tapering the dose, referral to a rehabilitation centre, cognitive behavioural therapy, and treatment of withdrawal symptoms.

Question 76

How does Cannabis work?

Answer 76

Stimulates cannabinoid receptors (CB1 and CB2)

Question 77

Name some anticonvulsants

Answer 77

Pregabalin Gabapentin

Question 78

How do anticonvulsants work?

Answer 78

Blocks voltage-gated calcium channels in the presynaptic membrane, reducing the release of excretory neurotransmitters

Question 79

Name some types of nicotine

Answer 79

Cigarettes Vapes

Question 80

How does nicotine work?

Answer 80

Stimulates nicotinic acetylcholine receptors

Question 81

Medication used for nicotine dependence (smoking) include:

Answer 81

Nicotine replacement therapy (e.g., patches, gum or lozenges) Bupropion Varenicline

Question 82

What is drug addiction?

Answer 82

Drug addiction involves the compulsive use of substances, often leading to harmful physical, psychological and social consequences. There is debate about whether it is a disease or a choice. It is a long-term condition, typically involving relapses after stopping.

Question 83

What is tolerance?

Answer 83

Tolerance refers to a loss of effect when taking the same dose. The person may keep increasing the dose to achieve the desired effects. Tolerance occurs with most psychoactive substances over time.

Question 84

What is dependence?

Answer 84

Dependence refers to a physiological and psychological need to keep using a drug.

Question 85

Why may dependence occur?

Answer 85

Physiological changes (notable with alcohol, opiates and benzodiazepines) Psychological factors (e.g., cravings and compulsions to use the drug)

Question 86

Explain the brain's reward pathway

Answer 86

The brain has a reward pathway called the mesolimbic pathway. The primary neurotransmitter involved in this pathway is dopamine. The key structures involved in this pathway are the ventral tegmental area, nucleus accumbens, amygdala, and prefrontal cortex. At a very basic level, activation of this pathway by a behaviour provides pleasure and reinforces that behaviour.

Question 87

How do addictive substances or behaviours affect the brain?

Answer 87

Addictive substances or behaviours release dopamine within the mesolimbic pathway, providing a pleasurable reward. Repeated exposure to this stimulus reduces the number and sensitivity of the dopamine receptors in this pathway, requiring an increasingly strong stimulus (e.g., a higher dose or frequency) to produce the same reward. The response to everyday activities reduces (everyday life becomes less rewarding). As a result, the person increasingly seeks out the substance or behaviour to stimulate the reward pathway.

Question 88

What are cues in the context of addictive behaviours?

Answer 88

Cues for the substance or behaviour are embedded into the amygdala. People, events, places or objects can act as cues, triggering cravings. Stress is a common trigger, prompting the substance or behaviour as a coping mechanism.