MEDI3004 MENTAL HEALTH ROTATION - YEAR 3 MBBS. Topic 7. Substance Abuse.docx

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University of Queensland
Associate Professor Jane Turner

SUBSTANCE ABUSE  Self-administeration of any substance for non-medical purposes with harmful effects  Includes 1. Alcohol 2. Illicit drugs 3. Prescription drugs 4. Drugs in sport  Some drugs that are abused have a low tendency to causes drug dependence – e.g. cannabinoids, LSD EPIDEMIOLOGY  47% of those with substance abuse have mental health problems  29% of those with a mental health disorder have a substance use disorder TYPES  Substance use disorders o Substance Abuse o Substance Dependence  Substance induced disorders o Substance intoxication: reversible psychological and behavioural changes due to recent exposure to a psychoactive substance o Substance withdrawal: substance-specific syndrome that develops following cessation of or a reduction in dosage of regularly used substances CRITERIA Dependence (≥3 in 12-month period): maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by >3 occurring at any time in the same 12 month period 1 Tolerance: need for increased amount to acheive intoxication or diminished effect with same amount of substance 2 Withdrawal 3 The substance is often taken in larger amounts for a longer period than intended 4 Unsuccessful efforts or a persistent desire to cut down or to control substance use 5 A great deal of time is spent in activities necessary to obtain the substance or to recover from its effects 6 Important social, occupational, or recreational activities given up or reduced because of substance use 7 Continued substance use despite knowledge of having had persistent or recurrent physical or psychological problems that are likely to be caused or exacerbated by the substance Abuse (≥1 in a 12-month period): maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by >1 of the following occurring within a 12 month period 1 Recurrent substance use resulting in failure to fulfill major obligations at work, school, or home 2 Recurrent substance use in situations in which it is physically hazardous 3 Recurrent substance-related legal problems 4 Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance and Never met criteria for dependence PATHOPHYSIOLOGY Psychology  Pleasure, escapism, euphoria or the ‘rush’ experienced by drugs results in positive reward or reinforcement  When person ‘feels normal’, experiences an anxiolytic effect from drugs or uses drugs to overcome withdrawal this is negative reinforcement Physiology  Ascending dopaminergic reward pathways DEPENDENCE SYNDROME  A cluster of physiological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takens on a much higher priority for a given individual than other behaviours that once had greater value.  A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may, or may not) have been medically prescribed, alcohol or tobacco.  There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with non- dependent individuals ICD10 system F1x.y X Y 0 – alcohol .0 – acute intoxication 1 – opioids .1 – harmful use 2 – cannabinoids .2 – dependence 3 – sedative and hypnotics .3 – withdrawal 4 – cocaine/crack .4 – withdrawal with delirium 5 – stimulants including caffeine .5 – psychotic 6 – hallucinogenics .6 – amnestic 7 - tobacco .7 – residual and late-onset psychotic disorder 8 – volatile solvents .8 – other specified problem 9 – multiple: drug or other .9 – unspecified problem HISTORY  Consumption in past 24 hours, month and 6 months  Pattern of daily consumption e.g. morning or weekends only  Substance use career – age began  Withdrawal problems/risks e.g. derlerium tremens, seizures  Previous treatments  Family history  Collateral history  Signs of dependence e.g. tolerance, compulsion to use  Periods of abstinence  Medical sequelae e.g. gastritis, cirrhosis  Psychiatric sequelae e.g. depression, anxiety, suicidality  Social sequelae e.g. marital, occupational or financial problems  Forensic sequelae ADDICTION COMORBIDITY  Substance use, abuse, dependence, intoxication and withdrawal may lead to, produce or exacerbate psychiatric symptoms  Psychological morbidity may precipitate substance use  Suicide o 60-120 times rate of suicide o slef-harm increases risk of completed suicide o In completed suicide – 26% of patients had known Hx of drug misuse o Suicide attempters in substance misuse population are more likely to be female, have additional psychiatric diagnoses, abuse more substances including alcohol and sedatives and have borderline personality traits  Anxiety o Self medication with alcohol o Alcoholism leads to anxiety disorders, particularly panic disorder o Shared underlying aetiology o Management: buspirone, imipramine, benzodiazepines ALCOHOL Clinical Syndromes 1. Acute intoxication 2. Alcohol Abuse (see criteria above) 3. Alcohol Dependence (see criteria above) 4. Alcohol Withdrawal ASSESSMENT CAGE  AUDIT: WHO Alcohol Use Disorders  Have you ever felt the need to Cut down on Identification Test – screening tool for detection of hazardous and drinking? harmful drinking  Have you ever felt Annoyed at criticism of your drinking?  Total Score  Have you ever felt Guilty about your drinking? o 8-12: Hazardous drinking  Do you need a drink first thing in the morning (Eye- o 13+: Alcohol dependence opener?) Drinking problem indicated by  Drinking over recommended guidelines: Men <2/day, Women <1/day  Drinking to reduce depression or anxiety  Loss of interest in food  Lying/hiding drinking habits  Drinking alone  Injuring self or others while intoxicated  Drink more than 3-4 times over the last year  Increasing tolerance  Withdrawal symptoms; irritability, resentful, unreasonable when not drinking  Experiencing medical, social or financial problems caused by drinking ALCOHOL WITHDRAWAL SYNDROME  Occurs within 12-48 hours after prolonged heavy drinking and can be life-threatening  Usually completely reversible in the young, the elderly are often left with cognitive deficits  Mortality rate 20% if untreated Stage 1 2 3 4 Time after 6-12hr 1-7 days 12-72hr up to 7 3-5 days last drink days Sx  tremor  visual,  seizures –  delirium tremens  sweating auditory, usually tonic-  insomnia  nausea olfactory or clonic, nonfocal  confusion, LOC  agitation tactile and brief  delusions  anorexia hallucinations  auditory hallucinations  cramps  agitation  diarrhea  tremors  mood: fear,  autonomic depression, hyperactivity: fever, anxiety HR, HTN, sweating  sleep disturbance “Delerium Tremens”  Relatively rare Seizures  Medical emergency: Can be life  Predisposing factors threatening if untreated. Death from heart o Previous history of seizures failure o Concurrent epilepsy  Sympathetic hyperactivity, agitation and o Trauma, head injury e.g. subdural tremulousness characterize onset of the haematoma syndrome o Hypoglycaemia  Sensory disturbances including o Hypokalaemia threatening/persecutory auditory or o Hypomagnesia visual hallucinations, confusion and delirium Management of Acute withdrawal  Many people require no meds but supportive care: information, monitoring, reassurance and low-stimulus environment  Most severe withdrawal requires inpatient care  Hospital special charts for monitoring e.g. CIWA-Ar or Alcohol Withdrawal Scale  Diazepam o Prevents and treats seizures o 10-20mg orally every 2 hours until Sx subside. o Cumulative dose of 60mg is usually adequate o Don't’ exceed 100mg daily o May be administered over the subsequent 2-7 days if Sx return o If severe liver disease/elderly, use short acting and renally excreted benzodiazepine e.g. oxazepam  Thiamin o 100mg IM as single dose o followed by 300mg orally daily in 3 divided doses o Higher doses may be appropriate in Wernicke’s encephalopathy o Give before glucose for hypoglycaemia as may precipitate Wernicke’s. Delerium Tremens  Always requires hospitalization  Diazepam o 10-20mg orally every 2 hours until Sx subside OR o 5mg IV every 30minutes or 1-5mg/hour by continuous IV infu
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