1: Substance Use Disorders Flashcards
common drugs of abuse: sedative hypnotics
- benzodiazepines
- barbiturates
- meprobamate gamma-hydroxybutyrate (GHB)
common drugs of abuse: stimulants
- cocaine
- amphetamines
- methylphenidate
- ephedrine
- caffeine
- MDMA (ecstasy)
- bath salts (substituted cathinones)
common drugs of abuse: hallucinogens
- LSD
- mescaline
- peyote
- psilocybin
- MDA (designer)
- DMT (designer)
- DOT (designer)
common drugs of abuse: dissociative anesthetics
- PCP
- ketamine
common drugs of abuse: inhalants
- solvents
- nitrous oxide
- alkyl nitrates
common drugs of abuse: anabolic
androgenic steroids
epidemiology of alcohol dependence (prevalence, incidence, gender)
- lifetime prevalence of 12-15%
- annual prevalence of 4-6%
- men 4-5x more than ladies
- incidence highest in younger ages then falls after 40 y/o
epidemiology of drug abuse (prevalence, incidence, gender)
- lifetime prevalence ~6%
- male > female, but less of a difference than alcohol
- incidence also declines with age, starting at earlier age than alcohol
neurobiology of addiction
- mesolimbic dopamine system
- nucleus accumbens “reward center” - dopamine
all drugs act either directly (stimulants) or indirectly (others) to increase dopaminergic activity in the mesolimbic areas of forebrain
‘you are what you expose your brain to’
genetics of alcoholism: what things are different in alcoholics vs. non-alcoholics
genetic component indicated, but unknown what exactly
- initial sensitivity to alcohol
- increased tolerance
- metabolism differences (ADH)
- event related potentials in EEGs after stimulus
mechanisms of alcoholism
- indirectly stimulates dopamine release in nuc accumbens
- directly stimulates GABA-a receptor (disinhibits)
- inhibits NMDA receptor (for Glu - excitatory)
mechanisms of cocaine**
- blocks reuptake of dopamine in mesolimbic system (inhibits dopamine transporters)
- stimulates norepi release in peripheral system
- blocks Na channels
mechanisms of amphetamines**
-directly stimulates dopamine release in mesolimbic system
mechanisms of opiates
- bind to mu, sigma, kappa receptors central and peripheral
- indirectly stimulate dopamine release in VTA
what class of drugs induces the strongest withdrawal symptoms?
opiates!
opiates don’t die, but are absolutely miserable
alcoholics are miserable and also can die
definition of an alcohol use disorder
maladaptive pattern of substance use leading to clinically significant impairment/distress w/i 12 mo:
- 2-3 criteria = mild
- 4-5 criteria = moderate
- 6 or more criteria = severe
the C’s of substance use disorder
Continued use despite consequence
Control
Compulsion and Craving
what are the 11 criteria for alcohol use disorder?
- alcohol taken in larger amts/longer time than intended
- persistent desire/unsuccessful effort to cut down
- long time spent to obtain/use/recover from effects
- craving
- recurrent use -> failure to fulfill major role obligations
- continued use despite persistent/recurrent social probs
- important social/work/rec activities given up for prob
- recurrent use in physically hazardous situations
- use continued despite knowledge of problem
- tolerance
- withdrawal
how is tolerance defined?
a need for markedly increased amts of the substance to achive intoxication or desired effect
markedly diminished effect with continued use of the same amount of the substance
how is withdrawal defined?
the characteristic withdrawal syndrome for the substance
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
what qualifies as AUD remission?
early: b/w 3-12 mo without use
sustained: at least 12 mo without use
making the AUD diagnosis: CAGE
C- have you ever CUT down on your drinking? or been CRITICIZED?
A-have you ever been ANNOYED by drinking criticism?
G- ever felt GUILTY about things done while drinking?
E- do you ever have an EYE opener?
3 ways to make AUD diagnosis
- CAGE
- AUDIT = AUD identification test
- two question screen
opioid misuse behaviors
loss of control
- lost prescriptions
- early refills
- doctor shopping
use despite negative consequences - family or financial
physical dependence
physical exam manifestations of AUD
- smell of alcohol
- parotid gland enlargement
- liver enlargement
- stigmata of chronic liver disease
- mental status
- track marks
- weight loss
- withdrawal symptoms
- pupil size
lab test results of AUD
- BAL (blood alcohol level)
- liver transaminases elevated (AST, ALT, GGT)
- usually AST > ALT
- usually mild elevations (100s)
- GGT more sensitive (induced by alcohol)
- MCV (mean corpuscular volume) elevation > 100
- urine and serum drug testing
how much does 1 beer raise BAL?
0.25
how fast does the body metabolize beer?
1 beer/hour
what are some factors that affect BAL between individuals?
- stomach contents
- body fat
- male vs. female
- carbonation
where can drug remnants show up which can be tested for drug use?
- urine
- blood
- saliva
- hair
- sweat
- tissue
urine drug testing
- screening (ELISA) vs. confirmation (chromatography)
- a single (+) urine does not make the diagnosis, but can confirm the diagnosis
relative sensitivity of urine drug testing for certain drugs: alcohol, marijuana, cocaine, amphetamines, opioids, benzodiazepines, designer drugs, hallucinogens
alcohol = marijuana = cocaine = amphetamines > opioids = benzodiazepines > designer drugs, hallucinogens
relative specificity of urine drug testing for certain drugs: alcohol, marijuana, cocaine, amphetamines, opioids, benzodiazepines, designer drugs, hallucinogens
cocaine > opioids > alcohol = marijuana = designer drugs, hallucinogens > benzodiazepines > amphetamines
comments on urine drug testing for the following drugs:
alcohol, marijuana, cocaine, amphetamines, opioids, benzodiazepines, designer drugs, hallucinogens
- alcohol: too sensitive
- marijuana: long excretion rate
- cocaine: very short half-life
- amphetamines: false positives
- opioids: false negatives
- benzodiazepines: many false positives and negatives
- designer drugs/hallucinogens: not even detected on most UDS
stages of change in overcoming substance addiction
- Pre-contemplation (not yet acknowledging the problem)
- Contemplation (acknowledging, but not ready to change)
- Action (changing)
- Maintenance (continuing the changed behaviors)
- Relapse (returning to old behaviors)
treatment of substance use disorders
- manage withdrawal
- behavior therapy (CBT, motivational, group, education, fam)
- treatment of co-existing mental health issues
- pharmocologic
what drugs require a detox?
- alcohol
- sedative hypnotics
- opiates
withdrawal symptoms of alcohol
- tremors
- diaphoresis
- elevated BP
- seizures
- DTs
withdrawal symptoms of sedative hypnotics
- anxiety
- myoclonus
- seizures
withdrawal symptoms of opiates
- diarrhea
- pain
- cramps
- anxiety
pharmacologic targets for substance use disorders
- detox agents
- aversion (disulfram)
- anti-craving (naltrexone, wellbutrin, acamprosate)
- replacement (methadone, nicotine)
- underlying disease (anti-anxiety, antidepressants)
disulfram: mechanism of action, side effects
- inhibits aldehyde DH -> accumulate aldehyde
- results in disulfram-ethanol rxn: flushing, nausea, low BP
-hepatotoxicity
naltrexone: mechanism of action, side effects
- blocks U receptor (opioid antagonist)
- believed to decrease reinforcing properties of alcohol
- may decrease risk and length of prolapse
- hepatotoxicity
- blocks opioid pain meds
methadone and buprenorphine: mechanism of action, other info
- replaces heroin/opiates that patient is addicted to
- given in controlled setting
- combined w/ counseling and other interventions
- most successful treatment available for heroin ***
