Undergradpsychiatryresources.files.wordpress.com



Year 4 Mental Health CBL 4

Substance Misuse

Session learning outcomes

• To define the terms dependency and misuse

• To be aware of the incidence, risk factors and associations of the main substances of misuse and be able to identify high risk individuals

• To describe the components of a substance misuse history, including consequences of misuse and motivation to change

• To describe the medical, psychological and social complications of the main substances of misuse

• To be aware of the treatment options available for the above and outcomes (short and long term)

Case 1

James is 39 years old. He presents at the Emergency Department in a confused and disorientated state. He is pyrexial, tremulous and sweating. He is unable to walk without stumbling or falling. His self-care is poor and he has vomited on his clothing.

His elderly mother with whom he lives arrives shortly afterwards. She tells you that James first started drinking at the age of thirteen. Home life was unhappy and his father was a drinker who could be violent to her and James at times. James’s alcohol intake steadily increased. His attendance at school was poor, and he has been unable to maintain work for any length of time, having often been dismissed or let go due to erratic behaviour and poor timekeeping. He was married but is now divorced and rarely sees his three children.

James currently drinks three 3-litre bottles of “Frosty Jack’s” cider (7.5 %) every day. He takes his first drink shortly after waking with his first cigarette of the day. He notices that he feels sweaty, shaky and nauseous every morning. He continues to drink through the rest of the day. He rarely finishes any of the meals his mother makes him and often feels tired and low in mood.

James has tried to cut down or stop his drinking several times before. He has had previous admissions to hospital following falls while intoxicated, and on other occasions has presented in a distressed state, smelling of alcohol and expressing ideas of deliberate self-harm. He decided to stop drinking the day before yesterday of his own accord, having been considering the need to make a change for some months.

Questions:

1) Does James have alcohol dependence? If so, what the symptoms of dependence that he presents with?

Yes, James does have alcohol dependence. He presents with the following symptoms of dependence:

- Subjective awareness of compulsion to drink

- Clinical features of acute withdrawal (sweating, shaking and nausea)

- Relief or avoidance of withdrawal symptoms by further drinking

- Reinstatement following periods of abstinence

- Narrowing of drinking repertoire

- Primacy (drinking becomes the most important aspect of the individual’s life)

2) Calculate the units of alcohol that he consumes per week.

No. of units of alcohol = 7.5 x (3 x 3) = 7.5 x 9 = 67.5 units

3) What are the stages of cycle of change described by Prochaska and

DiClemente? At what stage is James?

[pic]

James is in the “Action” stage.

4) What investigations and management plan would you need if he presents with delirium tremens?

Delirium tremens represents a medical emergency. The mortality rate can be as high as 35% if untreated.

Delirium tremens typically occurs 24 - 72 hours after alcohol consumption has been stopped. Investigations required in the patient with delirium tremens are: FBC, U and Es, LFTs, clotting screen, serum amylase level, serum creatinine kinase (CK) level - particularly if there are concerns about possible rhabdomyolysis) and blood glucose level. Dehydration or acute kidney injury and electrolyte disturbance may be present on the blood tests. The patient should have an arterial blood gas done to look for any metabolic acidosis. The patient should have blood cultures taken if there are any concerns about possible infection. An ECG will typically show sinus tachycardia, or possibly arrhythmia. Co-existing pneumonia is common and so a chest x-ray be indicated. If there is evidence of a recent head injury or seizure activity, a CT head scan is indicated.

Delirium tremens must be managed in a medical setting (ITU may be required). The first line treatment in the management of delirium tremens is oral Lorazepam. If symptoms persist, or the patient declines oral medication, parenteral (IM) Lorazepam or Haloperidol should be offered. Any hypoglycaemia should be corrected.

5) What are the indications of Disulfiram and Acamprosate? What are their mechanisms of action?

Disulfiram (aka Antabuse) is used for those patients who are alcohol dependent who wish to be prescribed a medication to deter them from consuming alcohol. Disulfiram works by inhibiting the liver enzyme aldehyde dehydrogenase, which leads to an accumulation of acetyldehyde in the body when alcohol is consumed (even in small amounts). This results in an unpleasant systemic reaction, which includes: flushing, headache, tachycardia, nausea and vomiting (this reaction occurs

within 10 minutes of consuming alcohol and typically lasts 30 - 60 minutes, or longer if large amounts of alcohol are consumed).

Acamprosate is used for patients who are alcohol dependent as an anti-craving drug. It works by stimulating GABAergic inhibitory neurotransmission and antagonising excitatory amino acids, particularly glutamate.

Case 2

Daniel is 20 years old. He moved back to live with his parents following problems which developed while he was away at University and which meant he had to drop out before completing his course.

As a younger teenager he experimented with cannabis and Ecstasy at the weekends. When he arrived at University he started to use Cannabis more regularly. He stopped using Ecstasy, preferring Amphetamines instead, which he took two or three times a week. He felt the Cannabis helped him to relax and sleep in the days after using the Amphetamines.

Gradually his mental state began to deteriorate. He felt anxious and agitated most of the time. His attendance at lectures declined, and he avoided small group tutorials due to a feeling that he was starting to draw attention to himself and that people were observing him. He spent more and more time alone in his room and became more convinced than ever when outside that he was being watched. He noticed that people started to pass secret signals between them, and that his thoughts were being read and passed around via a system of “codes” on various Facebook groups. He could hear people talking about him and discussing his every move. He decided to stop using the Amphetamines but his Cannabis use continued every day, which he felt helped him to relax.

After failing his exams at the end of second year his parents came to take him home. They noticed that he had lost weight and that he was dishevelled and malodorous. He confided his worries to them and they took him to see his GP who referred him to local Mental Health Services.

Questions:

1) What pattern of substance use qualifies as ‘harmful’ use?

According to ICD-10, “harmful” use is defined when there is clear evidence that use of the illicit substance is responsible for (or has substantially contributed to) physical or psychological harm, including impaired judgement or dysfunctional behaviour. The nature of the harm should be clearly identifiable (and specified). The pattern of use should have persisted for at least one month, or occurred repeatedly within a 12- month period.

2) How important is dual diagnosis - i.e. what rates of psychiatric patients have co-morbid substance misuse problems?

The literature indicates that there is a large degree of dual diagnosis, i.e. the presence of mental disorder (e.g. psychosis, schizophrenia) in individuals with comorbid substance misuse problems. The probability of developing a substance use disorder has been shown to be significantly higher in those patients with a psychotic illness compared with those without a psychotic illness.

In those patients with dual diagnosis, there are higher rates of relapse, hospitalisation, homelessness and hepatitis C and HIV infection than in those with either mental disorder or a substance misuse disorder alone.

3) What are Methadone and Naltrexone? What are their mechanisms of action? Methadone is an opiate substitute that is used in the management of opiate dependence syndrome. It is used in maintenance therapy. Methadone acts by binding to the μ-opioid receptor.

Naltrexone is a drug used in the management of opiate and alcohol dependence syndrome. It is a competitive antagonist at the μ-opioid receptor, the k-opioid receptor to a lesser extent, and, to a far lesser extent, the σ-opioid receptor (and thus reversibly blocks or attenuates the effects of opioids).

4) Some States in the USA have legalised recreational use of cannabis. In the

UK should cannabis use remain illegal, be de-criminalised or legalised?

There is no right or wrong answer to this question!

There are arguments for all three options. For example, those that favour cannabis remaining illegal worry that legalising cannabis may open up the floodgates to calls for other illicit substances, like cocaine and amphetamines, also being legalised. There is an argument that de-criminalising cannabis use would help to lower rates of offending caused by or attributed to illegal cannabis use. There is also an argument that legalising cannabis would enable society as a whole to have more control over the content of cannabis (e.g. THC content).

5) Should Daniel receive support from mental health services or substance misuse services?

Daniel should receive support from substance misuse services to address his substance misuse specifically and, at the same time, should receive support from mental health services with any comorbid mental health issues he has. Substance misuse services are not particularly skilled in or competent in the management of mental health problems. Similarly, mental health services are not particularly skilled in or competent in the management of substance misuse issues. Certainly, any psychotropic medication for any mental disorder(s) in an individual with comorbid substance misuse issues should be initiated, monitored and managed by mental health services. Similarly, any medication prescribed for substance misuse issues (e.g. Methadone, Buprenorphine, Naltrexone, Disulfiram, Acamprosate) should be initiated, monitored and managed by substance misuse practitioners.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download