Substance Use Disorders

 Alcohol Use Disorders Identification Test (AUDIT) 

Developed by the WHO, the total number of items is 10, the maximum score of each item is 4 and the minimum is 0, so the total score is 10x4=40, and the minimum 0. Item 0 to 8 has a scoring of 0,1,2,3,4 i.e. five anchors while item 8 and nine has 3 anchors each with scoring of 0,2,4.  It is used to assess alcohol consumption, drinking behaviours, and alcohol-related problems. It is most suited for primary care physicians and shows good sensitivity and specificity. If the score is above 8. 

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Important Questions About History of Drug Use

Important Points about the History of Drug Use

1. Regular or intermittent
2. Amount (know the units)
3. Pattern dependence/withdrawal 
4. Impact on work, relationships, money, police 
5. Screening questionnaires e.g. CAGE

WHO 2012 Guidelines for the Treatment of Alcohol Withdrawal

WHO 2012 Guidelines to treat Alcohol Withdrawal

1. Clinicians should advise supported withdrawal in patients before beginning treatment.
2. The World Health Organization recommends benzodiazepines as front-line medication for the management of alcohol withdrawal. 
3. Long-acting benzodiazepines are superior to shorter-acting ones, except in cases of impaired hepatic metabolism. 
4. Clinicians should determine the dose and duration individually. 
5. The duration of benzodiazepine treatment should be 3 to 7 days.
6. Clinicians should not use antipsychotic medications as stand-alone medications for the management of alcohol withdrawal. 
7. Advise Benzodiazepines, and not anticonvulsants, following an alcohol withdrawal seizure.
8. Clinicians should dispense psychoactive medication in small doses.  
9. Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably remain in an inpatient setting. 
10. As part of withdrawal management, we should give all patients oral thiamine. 
11. Patients at high risk of Wernicke's Encephalopathy (malnourished, severe withdrawal) should be given 3 days of parental thiamine. 

WHO Alcohol Withdrawal Treatment Guidelines

What interventions are safe and effective for the management of alcohol withdrawal, including treatment for alcohol withdrawal seizures and prevention and treatment for acute Wernicke's encephalopathy?

Alcohol withdrawal can be uncomfortable and occasionally life-threatening. Pharmacological management of alcohol withdrawal is an essential component of alcohol dependence. Benzodiazepines (BZDs), non-sedating anticonvulsants, and antipsychotics are commonly used in the treatment of alcohol withdrawal. 

Given that they are all potentially toxic medications, what is the evidence that the benefits of their use justify the risks? Which is more effective?

Below, I summarize the WHO 2012 Guidelines to treat Alcohol Withdrawal that explains the answers to these questions. 

Sample CASC-Opiate (opioid) Withdrawal Assessment

Opiate Withdrawal History and Physical Examination 

Opiate withdrawal symptoms peak between 36-72 hours. Symptoms run their course in 5-7 days, though craving continues for some time. 

Withdrawal from Heroin

Withdrawal from heroin may begin up to 8 hours after the last use. During the next few hours, the person experiences muscle pain, sneezing, sweating; tearfulness; yawning excessively. At 36 hours after the last use, symptoms are most severe. These symptoms include chills, muscle cramps, flushing, sweating, tachycardia, hypertension, inability to sleep, vomiting & diarrhoea. Symptoms typically continue for about 72 hours & gradually diminish over 5-10 days.

History 

This history part is in Urdu/Hindi. I will add the "Objective Opiate Withdrawal Scale" soon here so anyone can benefit.

 

For now: COWS 

1. Aap kia istemal karty
2. Akhri bar kab lia hai aap ne
3. Abhi dil chahta ke aap dobara se kar lyn? Kitna had tak? 
4. Gutno ya baqi jorhon mai dard ho raha hai? Baqi jisam or pat’tho mai takleef? Sar dard? 
5. Pait ma dard waghera? Ulti ya matli to nai arhaii? Pechas ya ihsal ki shikayat?
6. Hot and cold flushes? 
7. Cheenk to naii a rahy baar baar?
8. Nend kesi hai? Araam se soe rehty han?   
9. Koi bechainee, pareshani ki keffyat ya ghussa ata ho?  

Physical examination

Start from the hands. 

1. Inspect the hands and run a hand over the palm. Note any sweating or palmar erythema. 
2. Note if there is any piloerection if hair visible on the dorsal side of the hands. 
3. Then check the pulse. 
4. Inspect the arms for any signs of IV drug abuse. 
5. Check blood pressure, and then check the temperature. 
6. Check respiratory rate while checking the above. 
7. Inspect the face for lacrimation, rhinorrhea and check pupil size for dilation. 
8. Comment if the patient is shaking or yawning. 
9. Perform a cardiovascular examination and look for murmurs. 
10. Examine for the signs of liver failure

Best Choice of Treatment for Delirium Tremens

This topic has moved to the main topic on Delirium Tremens

Disulfiramlike Reaction

Disulfiram irreversibly inhibits aldehyde dehydrogenase, by competing with nicotinamide adenine dinucleotide at the cysteine residue. Aldehyde dehydrogenase is a hepatic enzyme of alcohol metabolism converting ethanol to acetaldehyde. At therapeutic doses of disulfiram, alcohol consumption causes elevated serum acetaldehyde, causing manifestations given below.

Manifestations

• Diaphoresis
• Facial flushing
• Hypotension
• Nausea
• Palpitations
• Tachycardia
• Vertigo

We call this constellation of symptoms the disulfiram-alcohol reaction; it discourages alcohol intake. The severity of the reaction is proportional to the dose of disulfiram, and that of alcohol. It is NOT an anti-craving drug and DOES NOT affect the neurobiology of addiction.

NICE guidelines on the Use of Disulfiram

Disulfiram should be considered in combination with a psychological intervention for patients who wish to achieve abstinence, but for whom acamprosate or naltrexone is not suitable. Treatment should be started at least 24 hours after the last drink and should be overseen by a family member or a carer. Monitoring is recommended every 2 weeks for the first 2 months, then monthly for the following 4 months. Medical monitoring should be continued at 6 monthly intervals after the first 6 months. Patients must not consume any alcohol while taking disulfiram

Psychiatric Disorders Associated with Alchoholism

Psychiatric Disorders Associated with Alcoholism

I use the following mnemonic to remember the disorders associated with alcoholism.

BADS

1. Bipolar affective disorders
2. Anxiety disorders especially panic and social phobia
3. Depressive disorders, the delusion of infidelity 
4. Schizophrenia and sexual dysfunction