Substance Use Disorders

Question 1

Who are the heaviest drinkers?

Answer 1

Young men (late teens/early 20s)

Question 2

What classifies as binge drinking?

Answer 2

> 8 units for men
6 units for women
in one sitting

Question 3

Why do asians get asian flush?

Answer 3

Ethanol > acetaldehyde > broken down via ADH (ALDEHYDE DEHYDROGENASE)

Asians have ineffective ADH > excess acetaldehyde accumulation > red face, nausea, palpitation

Question 4

What drinks are 1 unit of alcohol?

Answer 4

Half a pint
small glass of wine
Single spirit shot

Question 5

What phenomenon occurs with alcohol withdrawal?

Answer 5

Delirium tremens

Question 6

How long into alcohol withdrawal does delirium tremens occur?

Answer 6

48h-72h

Question 7

How long does DT last?

Answer 7

3-4 days

Question 8

What are symptoms of delirium tremens?

Answer 8

• acute confusion
• psychotic sx (hallucinations (visual, insects, Lilluputian), delusions)
• seizures

Question 9

How do you treat delirium tremens?

Answer 9

Long acting Benzodiazepine (chlordiazepoxide) reducing regimen
Pabrinex IV/IM

Question 10

What is the cause for Wernicke’s encephalopathy?

Answer 10

Acute thiamine (B1) deficiency

Question 11

What is triad of symptoms in Wernicke’s?

Answer 11

Ataxia
Confusion
Opthalmoplegia

Question 12

What are two symptoms of Korsakoffs?

Answer 12

Amnesia

Confabulation

Question 13

What is alcoholic hallucinosis?

Answer 13

auditory hallucinations in clear consciousness during/after heavy drinking

Question 14

What are symptoms of IV opioid intoxication?

Answer 14

euphoria
warmth
well being

Question 15

What are symptoms of IV opioid withdrawal?

Answer 15

dilated pupils 
dysphoria (miserable)
restless 
insomnia
diahrroea, vomiting
sweating lacrimation rhinorrhea

Question 16

What are causes of death with IV opioid?

Answer 16

respiratory failure

aspiration on vomit

Question 17

What can you give to prevent relapse in alcoholics?

Answer 17

Acamprosate (anticraving drug)

Disulfiram (inhibits ADH > excess acetaldehyde > unpleasant symptoms)

Question 18

What could you substitute prescribe for opioids?

Answer 18

Methadone

Buprenophine

Question 19

what is tolerance

Answer 19

Larger dose of drug required for same effect

OR

Same level of drug produces lesser effect

Question 20

What is withdrawal

Answer 20

symptoms that occur upon a substance leaving the system

Question 21

What is the effect of alcohol on the brain acutely

Answer 21

Alcohol inhibits NMDA R > reduced excitation

Alcohol stimulates GABA R> increased inhibition

Question 22

What does chronic use of alcohol cause on the brain

Answer 22

Upregulation of NMDA R
Down regulation of GABA R

Function remind normal as long as person keeps drinking

Question 23

What occurs when someone suddenly stops drinking

Answer 23

Excess NMDA R, insufficient GABA R
This causes a state of hyper excitation
This leads to symptoms of withdrawal (agitation, irritability, seizures, delirium tremens)

Question 24

What are symptoms of alcohol withdrawal

Answer 24

Headache
Nausea, retching, vomiting
Tremor, sweating, anxiety, agitation, insomnia, tachycardia

Question 25

What is mortality of delirium tremens

Answer 25

5%

Question 26

How do you assess alcohol misuse

Answer 26

CAGE questionnaire DSM5 Criteria AUDIT (Alcohol Use Disorder Identification Test) SADQ (Severity of Alcohol Dependance Questionnaire)

Question 27

Explain CAGE

Answer 27

Ever felt the need to Cut down Ever get Annoyed at people criticising your drinking Ever felt Guilty about your drinking Eye opener

Question 28

What investigations can you get specifically for alcohol misuse

Answer 28

FBC, B12, Folate (microcytic anaemia due to B12 deficiency) LFTs (raised GGT in drinking, raised ALT, AST in hepatic damage)

Question 29

How do you manage alcohol misuse

Answer 29

Assess motivation to change (Stages of Change Model) Use BIOPSYCHOSOCIAL approach - Social: refer to self help group (AA) carer's assessment offer guided self help to families and provide resources about support groups (families anonymous) - Psych support: offer psychological therapy -- CBT (challenges alcohol related conceptions) - Motivational interviewing (counselling that empowers person to change) - Bio: chlordiazepoxide (reducing dose), Thiamine Consider admission to treat withdrawal Relapse prevention

Question 30

What things do you consider in admission to treat withdrawal

Answer 30

- >30 units a day OR >30 on SADQ - History of withdrawal fits / delirium tremens on previous withdrawal - Regularly drinking 15-30U + comorbidity - LOWER THRESHOLD IF VULNERABLE (e.g. homeless)

Question 31

How do you prevent relapse of alcohol

Answer 31

BIOPSYCHOSOCIAL MODEL Social: AA (self help, group support in community) Psycho: CBT, Motivational interviewing Bio: Disulfiram, Acamprosate

Question 32

What re symptoms of opiate overdose

Answer 32

bradycardia respiratory depression pinpoint pupils

Question 33

How do you manage opiate overdose, and what should you keep in mind

Answer 33

Naxolone IV | It is SHORT ACTING, so you may have to give repeated doses

Question 34

How do you manage opioid misuse

Answer 34

Biopsychosocial Social: support group in community (narcotics anonymous) Psych: CBT, motivational interviewing - appoint a key worker Bio;: - Harm reduction: avoid needle exchanges if IVDU, vaccination and testing for BBV - substitute prescribing (methadone - liquid, buprenorphine - sublingual) - withdrawal symptoms (clonidine, lofexidine) Prevent relapse: naltrexone

Question 35

How do you meet family/carers needs for alcohol abuse

Answer 35

Offer carer's assessment if necessary | Offer guided self he

Question 36

What formal assessment do you use to assess scale of withdrawal?

Answer 36

CIWA-A | Clinical Institute Withdrawal Assessment for Alcohol

Question 37

What should you offer for withdrawal if >15 U per day or >20 on Audit

Answer 37

Community based assisted withdrawal through CGL (Change, Grow, LIve)

Question 38

what are community organisations for alcohollics

Answer 38

AA SMART recovery Change, Grow, Live

Question 39

How do you manage opiate misuse if not planning to be abstinent

Answer 39

Pragmatic approach: assessing and minimising risk rather than insisting on abstinence Provide information on improving safety of drug use - NO needle exchanges - vaccination and testing for blood borne viruses

Question 40

What other services should you get involved for someone who wants to stop using?

Answer 40

Refer to drugs and alcohol service | Appoint Key Worker

Question 41

PACES STATION: outline management of patient who wants to quit

Answer 41

1. Explain features of withdrawal - explain timescale 2. Explain detox regime (give a substitute that will diminish symptoms of withdrawal) 3. Explain that symptomatic treatment can also be given to reduce nausea, diarrhoea, autonomic sx 4. Explain role of psychological therapy 5. Explain role of key worker - Get test for blood borne disease and vaccinations - Support: NA, SMART Recovery