Makindo Medical Notes

💊 Substance Use Disorder (SUD) is a chronic, relapsing medical condition in which alcohol, drugs, or other substances are used compulsively despite harmful consequences. ⚠️ It involves brain reward pathway changes, cravings, tolerance, withdrawal, and loss of control. 🌍 Affects ~5% of adults worldwide, major public health burden.

📖 Key Features of SUD

• 🔥 Cravings: Overwhelming urge to use.
• ⬆️ Tolerance: Needing higher doses for same effect.
• 🤒 Withdrawal: Symptoms if use reduced/stopped.
• 🚫 Loss of Control: Larger/longer use than intended.
• 💼 Social/occupational impairment: Missed work, school, or family duties.
• 💥 Continued use despite harm: Worsening physical or psychological damage.

📊 Common Substances & Their Management

Substance	🔎 Signs & Symptoms	🧪 Diagnosis	💊 Treatment
🍷 Alcohol	Slurred speech, ataxia, tremors, liver disease, withdrawal (seizures, DTs)	AUDIT-C, LFTs, MCV, history	Detox (chlordiazepoxide), relapse prevention (acamprosate, naltrexone, disulfiram), AA
💉 Opioids	Drowsiness, pinpoint pupils, constipation, withdrawal (yawning, sweating, cramps)	Urine screen, Hx	Methadone/buprenorphine substitution, naloxone for overdose, CBT, needle exchange
⚡ Cocaine	Euphoria, insomnia, paranoia, chest pain, nasal septum damage	Urine screen, ECG, troponin	CBT, contingency management, manage cardiac risk, no licensed substitute drug
🌿 Cannabis	Red eyes, ↑ appetite, poor concentration, anxiety, amotivation	History, urine screen	Counseling, psychoeducation, CBT, relapse prevention
💊 Benzodiazepines	Drowsiness, confusion, ataxia, withdrawal → seizures	History, urine/serum screen	Gradual taper, switch to diazepam equivalent, CBT for anxiety

📋 DSM-5 Diagnosis of SUD

Diagnosis requires ≥2 criteria in 12 months (mild = 2–3, moderate = 4–5, severe = ≥6):

• ➡️ Using more/longer than intended.
• ➡️ Unsuccessful attempts to cut down.
• ➡️ Excessive time obtaining/using/recovering.
• ➡️ Craving.
• ➡️ Recurrent failure in obligations.
• ➡️ Continued use despite social problems.
• ➡️ Important activities abandoned.
• ➡️ Use in hazardous situations.
• ➡️ Continued use despite medical/psychological harm.
• ➡️ Tolerance.
• ➡️ Withdrawal.

💊 Management Principles

SUD management is multidisciplinary: combine medical treatment, psychological therapies, and social support.

• 🧹 Detoxification: Medically supervised withdrawal (e.g. benzodiazepine taper for alcohol).
• 💊 Medications:
  • Alcohol → acamprosate 666 mg TDS, disulfiram 200–400 mg OD, naltrexone 50 mg OD.
  • Opioids → methadone (20–60 mg daily titrated), buprenorphine (4–16 mg daily).
  • Nicotine → NRT, varenicline, bupropion.
• 🧠 Therapies: CBT, motivational interviewing, contingency management.
• 👥 Support groups: AA, NA, SMART Recovery.
• 🏥 Integrated care: GP, psychiatry, social services, housing and employment support.

🛡️ Prevention & Harm Reduction

• 📚 School & workplace education.
• 🧪 Early screening (AUDIT, ASSIST) in primary care.
• 💉 Needle exchange programs, opioid substitution therapy.
• 🚑 Take-home naloxone for opioid users & families.
• 🏠 Social support: housing, community rehab services.

🚨 Red Flags

• 💔 Suicidal ideation or self-harm.
• 🩸 Signs of overdose (respiratory depression, arrhythmia, coma).
• 🧠 Co-existing psychosis or severe depression.
• 👶 Pregnant women using alcohol/opiates → urgent referral.

📌 Exam Pearls

• 💡 Always assess for dual diagnosis (mental illness + SUD).
• 👀 Alcohol withdrawal → risk of seizures (12–48h) & delirium tremens (48–72h).
• 💊 Clozapine + alcohol/cannabis = increased seizure risk.
• ⚠️ Never stop benzodiazepines abruptly → taper slowly to avoid withdrawal seizures.

🔗 References

• NICE CG115: Alcohol-use Disorders
• NICE NG46: Drug Misuse Management
• NICE CKS – Drug Misuse