Psychiatry- Drug And Alcohol Abuse

Front 1

Treatment of Alcohol Abuse 1

Benzodiazepine

Back 1

Chlordiazepoxide or diazepam. Clomethiazole used to be used but it has a high risk of dependence.

Used for sedative and anticonvulsant effects.
The dose is gradually reduced over 7-10 days, usually you start off reducing the dose by 20%.

Front 2

Treatment of Alcohol Abuse 2

Vitamins

Back 2

Thiamine (B1) and other vitamin supplements – these are essential! They help to prevent Wernicke’s encephalopathy. They often have to be given IV – and may need to be given for up to 1 month after.

Front 3

Treatment of Alcohol Abuse 3

Disulfiram

Back 3

Disulfiram- 200mg/24hrs po is a drug that inhibits acetaldehyde dehydrogenase and thus causes nasty side effect when taken with alcohol. It can help to maintain abstinence – although it usually needs to be given with psychotherapy to be effective.

5 to 10 minutes after alcohol intake, the patient may experience the effects of a severe hangover for a period of 30 minutes up to several hours. Symptoms include flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, throbbing headache, visual disturbance, mental confusion, postural syncope, and circulatory collapse.

Front 4

Treatment of Alcohol Abuse 4

Naltrexone

Back 4

Naltrexone 25-50mg/24hrs po- opioid receptor antagonist

Can halve relapse rates.

CI- hepatitis, liver failure; monitor LFTs

SE- vomiting, drowsiness, dizziness, joint pain

Front 5

Treatment of Alcohol Abuse 5

Acamprosate

Back 5

Acamprosate- 666mg/8hrs is >60kg and <65yo inhibits glutamate – which is an excitory amino acid implicated in cravings. Acamprosate can help reduce cravings. Can treble abstinence rates.

CI- pregnancy, severe hepatic failure, creatinine >120 micromol/L

S/E- D&V, libido up or down

Front 6

Signs of alcohol withdrawal

Back 6

Delirium Tremens
Pulse +
BP -
Tremor
Fits
Visual or tactile hallucinations e.g. insects crawling under skins (formication)

Front 7

Treatment of Delirium Tremens

Back 7

Delirium Tremens is a medical emergency!

Death occurs in around 10-15% of cases (up to 35% if untreated).

It results from epileptic seizure, heart failure, self-injury and infection. Treatment is similar to that of a controlled alcohol withdrawal.

Admit, monitor vitals (esp BP)

Benzodiazepine for first 3 days 10mg/6hrs po/pr/ivi– for sedation and anti-convulsant effects. Continue with these for up to 10 days at night to help avoid nightmares.

B vitamins – remember – the early you give these, the greater the chance of reducing encephalopathy

Fluid replacement

Dextrose – to avoid hypoglycaemia

Be aware of infection and (head) injury – as these commonly accompany DT

On recovery – check for signs of alcohol brain damage. Assess the patient motivation to permanently change.

Clonidine, carbamazepine, neuroleptics and beta-blockers can be used as adjuncts.

Front 8

Clinical features of drug use and withdrawal- Opiates

Back 8

Features of drug use: pinpoint pupils, low BP, venepuncture marks.

Features of withdrawal: dilated pupils, high BP, sweaty, runny nose (rhinorrhea), cramps

Heroin withdrawal: Cold/shivery, flu-like symptoms, body pain, cannot kill you!

Note how these may appear similar to psychostimulant use!

Front 9

Clinical features of drug use and withdrawal- Benzodiazepines

Back 9

Features of drug use: disinhibited or gives the impression of intoxicated, but is not drunk

Features of withdrawal: hypersensitivity, hyper-reflexia, depersonalisation

Front 10

Clinical features of drug use and withdrawal- Psychostimulants

Back 10

Cocaine, amphetamine, crystal meth, MDMA

Features of drug use: rapid speech, large pupils, agitation, restlessness, high BP.

Features of withdrawal: agitation, restlessness

Front 11

Clinical features of drug use and withdrawal- Barbiturates

Back 11

Allobarbital, Amobarbital, Aprobarbital, Alphenal, Barbital, Phenobarbital

Features of drug use: wide spectrum of effects, from mild sedation to total anesthesia.

Features of withdrawal: paranoia, strange behaviour, grand mal seizures, sluggishness, incoordination, difficulty in thinking, slowness of speech, faulty judgement, drowsiness, shallow breathing, staggering, and in severe cases coma and death.

Barbiturates bind to the GABA-A receptor at the beta subunit, which are binding sites distinct from GABA itself and also distinct from the benzodiazepine binding site. Like benzodiazepines, barbiturates potentiate the effect of GABA at this receptor.

Front 12

Opiate detoxification

Back 12

Daily observed Methadone dosing is the norm. There is no reliable formula for heroin dose equivalent.

20-70mg/12hours po, reducing by 20% every 2 days.

10mg every 60mins up to 40mg for opiate withdrawal.

Consider adding in disulfiram and lofexidine.

Buprenorphine sublingual- Some people feel more 'clear-headed' with buprenorphine than with methadone. Buprenorphine tends to be easier to detox than methadone. Some people take methadone long-term for 'maintenance', but switch to buprenorphine if they decide to detox. Buprenorphine is possibly safer if taken in overdose than methadone.

First dose of buprenorphine at least eight hours after last dose of heroin.
First dose of buprenorphine between 24 and 36 hours after last dose of methadone.