Psychiatry: Cads - Substance Dependence

Front 1

Give e.g.s of Acute Presentations of alcohol & drug misuse in different organ systems
(e.g Neuro, CVS, GI, General)

Back 1

-intoxication & withdrawal states
-CNS: convulsion, delirium, dementia
-CVS: infective bacterial endocarditis (IV use)
-GI: abdominal pain (acute alcoholic pancreatitis,
Hepatitis etc)
-General: fractures from MVA

Front 2

Alcohol misuse may lead to complications including...

Back 2

-HTN
-Hyperlipidemia
-Obesity
-Gout

Front 3

Symptoms of i) Acute & ii) Chronic Intoxication & Withdrawal from Psychoactive Substances

Back 3

ACUTE:
"SAD PAD"
-Sleep disturbance
-Anxiety
-Depression
-Psychosis
-Agitation
-Delirium

CHRONIC:
"2D3P"
-Depression
-Dementia
-Phobia
-Paranoia
-Psychosis

Front 4

What should be suspected when there is Unexplained Social/Occupational Malfunctioning
(e.g. failing business of previously successful businessman; reucrrent falls at home in elderly person who apperas phsyically healthy)

Back 4

Substance misuse

Front 5

Common cause of treatment failure for substance dependence is...

Back 5

Hidden substance misuse

-common scenario is when there is prompt improvement in a person's condition after hospital admission, but subsequently has sharp (&repeated) deterioration after discharge from hospital

Front 6

Describe the strategy/assessment re. substance use in ED setting

Back 6

i) Obtain key info on substance use that is necessary for immediate management
Esp. important in:
-Withdrawal state: important to assess if alc/sedative/opioid use is sufficiently high that a Withdrawal state may develop soon
-Analgesia: hx of opioid use is important in gauging patien't analgesic requirement
(e.g. if heroin dependent, usual doses of morphine is insuff)
-Injection hx: potential infectious risk

B) AMPLIFY
-minor forms of substance use & their influence on clinical management & soc/occupational functions can wait until patient is Stabilized & Recovering from the Acute illness.
-Hence, once stable&monitored for withdrawal states, need to amplify the alc/drug hx

Front 7

Reasons for under-reporting of Substance use

Back 7

-Feel: Guilty, Embarassed, Ambivalent re. their substance use

-Not Perceive misuse as a problem when:
a) despite hazardous lvl of use, it is similar to their peers
b) Unaware of -ve Physical/Soc/Psychological effects
c) Societal views:
-unacceptability on excess consumption (esp. alcohol)
-possible Punishment: e.g. heroin use in prisoners

NB: only minority of people strongly deny substance use or minimize severity of problem

Front 8

When assessing substance use, it is important to reinforce...(a)...
because you are only interested to ...(b)...

In order to increase the accuracy of info, approach that should be taken are ... (c) & (d)...

Back 8

a) reinforce confidentiality
b) only interested ... to the extent that substance use negatively effect physical/psychosoc well-being

c) establish the Legitimacy of enquiring re. substance use.
because:
-Dx: necessary for making Diagnosis
-Tx: ensure appropriate Tx is given
-no hazardous Interactions between prescribed drugs & those that patient has been taking
-reasons specific for certain drugs e.g. Heroin use: impt to gauge if patient is likely to be opioid tolerant

d) Optimal Care: outline Professional, Legal & Ethical responsiblity of the Dr to provide Optimal patient care

Front 9

Factors that may affect accuracy of Substance use assessment

Back 9

"PNS R attitude"
-Personality factors
-Neuropsychological impairment
-state of Intoxication/Withdrawal
-self-Referral (more accurate)
-*staff Attitude & Behav towards the patient

Front 10

2 most useful questions to ask for Smoking history, and what they assess.

Back 10

"How many cigarettes do you smoke each day?"
-assess risk of:
--Dependence
--Pulmonary complications
--other Malignant complications

"Do you smoke within half an hour of waking up in the morning?"
-assesses likelihood of person being Physically Dependent on Nicotine

Front 11

Info to be covered in Alcohol history

Back 11

Frequency
Quantity
Type of alcoholic beverage

Front 12

Info to be covered in Prescription drugs

Back 12

-Quantity (# of tablets, AND in mg / gram)
-Duration
-whether drug is taken only under medical Prescription or at least some have been obtained thru subterfuge/illegally
-whether the stated dose is within the therapeutic raneg or above

Front 13

Implication of Corroborative Information on Substance Use

Back 13

-from relaties, friends, other treating professionals e.g. GP, or from past records

Understatement
-may arise due to fear of Retribution or of negative Social/Legal consequences

Overstatement by relatives
-may arise from False Assumptions based on Previous behav or from a
"wish for Retribution"

Front 14

Techniques to Enchance Substance use Hx Taking

Back 14

1) Normalize
-Introduce Substance use as a Normal, Everyday experience
e.g. Alcohol
-"many men like to have a good drink with their mates after a day's work"

then give...
2) Permission:
-...to talk about substance use
e.g. "What do you like to drink, either after work or at other times?"

3) Assess Potential Symptoms:
-e.g. to establish th epresence of Physical Dependence:
-"Many regular drinkers feel shaky when they get up in the morning. When did you last feel like that?"

4) Suggesting High levels of Use
-"Top-High" method: person is more likely to admit to their intake if several quantities at High end of the range of use are suggested
--adjust for sex, socioeconomic background, any existing knolwedge about person's substance use
--pay attention for Facial expression & Body Language during the interview
--->often there is a Fleeting Look of recognition OR adoption of a Defensive body posture when the Correct intake is mentioned
--such level is often Higher than the one the pat is prepared to admit verbally
--If No acknowledgement, then progressively lower intakes in step-wise manner
--When there is acknowledgement of certain intake level, Probe further to establish a Consistent resposne
NB: important to pay attention to pat's rxn to this "Top-High" questioning because it may backfire badly.

Front 15

Effect of Substance Misuse in Global level of functioning is evidenced by...

Back 15

Poor "NAHH":
-general Appearance
-personal Hygiene
-overall Health
-Nutrition

Front 16

Physical assessment for Evidence of Alcohol&Drug use and its Complications should include...

Back 16

i) general Apperance:
-agitation (withdrawal state/stimulant use)
-malnutrition (gaunt apperance)
-premature aging (substance use)
-Cushingoid facies (alcohol dependent)
-arms covered with long sleeves in warm weather (injection mark)

ii) signs of Intoxication:
-garrulouseness (talkative)
-unclear thinking
-ataxia
-smell of alcohol on breath

iii) signs of Withdrawal
-Hand: tremor & sweating
-Face & Tongue: tremor

iv) Cutaneous Stigmata of Alcohol & Drug use:
-injection sites (antecubital fossae, back of the hand)
-Conjunctival Injection = Recent heavy alcohol/cannabis use
-facial Telangiectasia (alcohol)
-Rhinophyma (alochol)
-Inflamed Nsal Septum&Alae (cocaine)
-Periorbital Wrinkling (tobacco smoking)
-Skin Thinning (alcoho, heroin)
-Dupuytren's contractures (alcohol)
-Bruises, esp. of diff ages (alcohol, sedatives, opioids)
-Scars unrelated to surgery (alcohol, opioids, psychostimulants)

v) Cutaneous Stigmata of Liver disease
e.g. Spider naevi, palmar erythema

vi) CVS: Pulse rate & BP

vii) CVD evidence: esp. valvular, endocarditis, cardiac hypertrophy, or failure

viii) Abdo exam: Liver size& consistency; Splenomegaly; Ascites

ix) evid of Head Injury

x) CNS: Cranial Nerve
esp. Nystagmus or Ohthalmoplegia

xi) Ataxia esp. Stance & Gait

xii) sgns of Peripheral Neuropathy

Front 17

Key info from Mental State Exam for Substance use

NB: comment on formal cogntivie function testing

Back 17

PTEC

Perception:
-esp. visual & auditory

Thought
-Paranoid ideation
-Suicidal Ideation

Emotion (affect, mood)
-depression, anxiety, dysphoria, blunting, lability

Cognition
-Awareness of current events
-Memory: immediate/short/long
-Abstraction
-Conceptualization
-Planning

NB: Formal cognitive function testing should await the resolution of any clouding of conciousness

Front 18

Limitation of Urine Drug Testing

Back 18

-no info on freq or quantity (cf. history taking)
--can't assess likelihood of phsyical dependence, onset of withdrawal, dependence syndrome
-"-ve despite recent use" when substances are cleared rapidly from the body
--exceptions are:
-Long-acting BDZ (e.g. diazepam): metabolites detectable for several Days
-Cannabis (THC): detectable in urine & serum for several weeks

Front 19

Collateral Info:
-source
-purpose
-NB

Back 19

Source:
-relative
-friends
-involved professionals
-hospital/GP medical records

Purpose:
-reliability check
-indep persepective
-free from llimitation due to acute intoxication or neuropsychological impairment

NB:
-must be obtained with patient's permission
-any limitations or concerns about ethical issues are addressed (e.g. divulging info to the parents of an adolescents)
--UNLESS: prompt diagnosis outweighs privacy concerns
e.g. severe psychotic symptoms, accidental OD
-useful when pat shows strong denial of substance use disorder
--CAREFUL: avoid patient becoming alienated by solicitation of this info

Front 20

Typical Presenting Complaint for:
-BDZ
-Opioids

Back 20

BDZ:
-anxiety
-"tension"
-insomnia
NB: difficult to assess if it is genuine or not

Opioids
-acute/chronic pain
esp. Renal colic, Migraine, chronic Back pain

Front 21

E.g. of Warning signs of Drug Seeking Behavior during consultation

Back 21

-Visitor: claims to be "interstate" visitor, bringing discharge summaries & X-rays

-Name: nearly all cases the pat knows the desired medication by name

-Prefer: Short & Rapidly acting drugs (sustained action preparations)

-Abusive: when prescription is denied

Front 22

Alcohol History taking Strategy

Back 22

1) Approach: Convenient&Acceptable to pat
by introducing with other lifestyle issues
e.g. "We often find that people's eating, smoking and drinking habits may have sig impact on their Health or how they Feel about themselves. I'd like to ask you some questions in these areas"

2) Normalize as everyday experience:
"Most of us like to have a drink on a regular basis. How often would you have a drink during the week and at the weekends?

3. High-Top question: i.e. suggest high levels of drinking to patient
e.g. two dozen beers a t asitting, a bottle of gin a day
->this way, person is more likely to admit to a high intake; and allows pat to correct you downwards
(choose high value depending on sex, socioeconomic background, existing knolwedge about erson's alcohol consumption)

4) Don't let personal attitudes affect assessment:
-sometimes under-dx is due to Dr's own denial mchanisms (Dr's own problems with alcohol)
-Judgemental attitudes

5) Avoid Labels e.g Alcoholic
-Use terms:"drinking problem" or "problems related to alcohol"
-Unless the pat feels comfortable using that term
-If pat feels accused of being an alcoholic, pat may become defensive, be frightened away from tx

6) Home-poured drinks:
-tendency to underestimate the size of home-poured drinks
-try to estimate specific amount of alcohol consumed e.g. half a bottle of wine (cf. 4 glassfuls??)

7) Motivation for Change
-assess state of change by asking direct Qu's about change (interest, need, want, "other", confidence)
e.g.
"How Interested are you in changing your (substance) use now?
"Do you feel that you Need to stop using (substance)?"
"Do you really Want to stop using? (substance)"
"What do you feel you could do to get on top of your use of (substance)?"
"How Confident are you that you could achieve this?"

Front 23

DSM IV: Alcohol Abuse

Back 23

>1 for >1yr:
"FLPR"
-Function: impaired socal/occupational Function
-Legal problem assoc'd with alcohol use
-Physically Hazardous use e.g. DUI
-Role impairment e.g. failed work/home obligations

Front 24

DSM IV: Alcohol Dependence

Back 24

>3/7 for >1yr:
"More Time To Continually Withdrawal/Cut Activities"
-More dose/duration than intended
-Time: incr for procuring, using and withdrawal (hangover)
-Tolerance: higher dose for same effect; or same dose less effect
-Continued: use despite Physical/Psychological consequences
-Withdrawal: withdrawal/use to prevent withdrawal
-Cut: wants to but unsucessful attempts to cut down use
-Activities: Impaired Soc/Work Activities due to alcohol

Harm: Continue
Dyscontrol: More, Cut
Salience: Activity, Time
Biological Adaptation: Tolerance, Withdrawal

Front 25

Max Recommended Alcohol Units

Back 25

Males:
-6 units per session
-21 units per week

Females:
-4 units per session
-14 units per week

NB: such are not recommended for ppl with:
-Condition made worse by drinking
-Medication (most)
-Under 18
-Pregnant
-certain Activities: driving, longboard surfing, competitive tap dancing etc.

Front 26

Characteristic Withdrawal Syndrome:
-Minor
-Major

Back 26

Minor: "THAT"
-Tachycardia
-Headache
-Anxiety
-Tremor

Major: "Schdt"
-Seizure
-Confusion
-Hallucinations
-Delirium tremens

Front 27

Laboratory Investigations for:
-Alcohol
-Drugs

Back 27

Alcohol:
-MCV
-GGT
-ALP
-AST
-HDL, Cholesterol

Drugs:
-FBC
-GGT
-ALP
-AST
-Blood-borne: Hep B&C, HIV screen

Front 28

Physical Examination for Substance use

Back 28

e.g.s
General: IDU wounds
CVS: hypertension, cardiomyopathy
GI: liver, stomach, gallbladder
CNS: Delirium tremens, Withdrawal, Wernicke's encephalopathy

Front 29

Physical Stigmata of Alcohol

Back 29

-Spider naevae
-Hypertension ("great mimic")

Front 30

Brief Intervention Mnemonic

Back 30

Feedback
Responsibility
Advice
Menu of options
Empathy
Self-efficacy

Front 31

Alcohol Use Disorder: Tx

Back 31

Disulfiram
Naltrexone (antidipsotropic, Special Authority)
Thiamine (Vit B1)