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``Substance Abuse

• compulsion to use drug
• increased tolerance
• withdrawal symptoms

Drugs

• alcohol
• opiates
• hallucinogens
• amphetamines
• cannabis
• solvents

Presentation

• when / why brought to medical attention 

Diagnosis of Dependence Syndrome

at least 3 or more together at some time during previous year

• strong desire or sense of compulsion to take substance
• difficulties in controlling substance-taking behaviours in terms of onset, termination or levels of use
• physiological withdrawal state when substance use has ceased or been reduced
• evidence of tolerance
• progressive neglect of alternative pleasures or interests
• persisting with the substance us despite clear evidence of overtly harmful consequences
• narrowing of personal repertoire of patterns of substance use

History

• Starting
  • When first took
  • when used regularly / heavily
• Why first took
  • peer pressure
  • anxiety
  • depression
  • availability
• Effects
  • past
  • present
• Problems
  • when started
  • what
• Obtaining / funding
• Route
• Tolerance
  • how developed
• Withdrawal effects
  • fits
  • Delirium Tremens
  • Cold turkey
  • Anxiety
• Other Symptoms of dependence

PMH

• depression / previous psychiatric
• chronic illness / pain

FHx

• increased addictive behaviour

Personal

• childhood exposure
  • addictive behaviour
  • abuse
  • neglected childhood
• poor performance at school
• poor employment record
• high risk occupation
  • barman
  • traveller
• criminal record
  • theft
  • violence
  • drink driving
  • prostitution
• poor marital history
  • divorce
  • aggression
• Poor standard of living

Premorbid personality

DHx

• any medication

smoking

• signs of addictive behaviour

Alcohol

• CAGE questionnaire
  • 2 or more "Yes"
    • Cut down
    • Annoyed by criticising
    • Guilty
    • Eye-opener

ROS

• in relation to particular drug
  • Alcohol
    • Chronic Liver Disease
    • Gastritis / Oesophagitis
    • Pancreatitis
    • Hepatitis
    • Stroke
    • Peripheral Neuropathy
    • Cerebellar Syndrome
    • Myopathy
    • Head Injuries
    • Wernicke's Encephalopathy
    • Korsakoff's Syndrome
  • IV drug use
    • HIV And AIDS
    • Chest infections
    • Cardiomyopathy
    • Infective Endocarditis

Examination

Mental State

• Behaviour
  • poor self-care
  • abnormal movements
  • withdrawal symptoms
• Speech
  • cerebellar (scanning)
    • halting
    • jerky
  • slurred
• Mood
  • anxiety
  • depression
• Thought
  • suicide
  • preoccupation with drugs
  • paranoid ideas
• Perception
• Orientation
  • abnormal if intoxicated
• Attention
  • poor
• Memory
  • Korsakoff's Syndrome
• Insight
  • "I can kick it" !?!

Physical

• General
  • complications
  • needle marks / phlebitis
  • AIDS
  • Chronic Liver Disease

Investigations

• FBC
• U&Es
• LFTs
• Social circumstances

Treatment

• Withdrawal
  • alcohol
    • chlordiazepoxide
  • opiates
    • symptomatic
    • methadone
• Long Term
  • psychological support
    • alcoholics anonymous
  • antabuse
  • methadone
  • underlying mood disorder