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M2 Psych > 10/18 Substance Abuse I - Williams > Flashcards

10/18 Substance Abuse I - Williams Flashcards

1
Q

alcohol/drug use disorders as chronic medical conditions

causative factors

A
  • genetic susceptibility
    • genetic risk is approx 50% (similar to other chronic conds)
  • chronic pathophysiologic/fx changes
  • risk factors influenced by choices
  • similar tx goals and strategies
  • similar clinical outcomes
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2
Q

substance use disorder

criteria

mild/moderate/severe

A

criteria can be lumped into 4 general buckets

2 or more in 12 months:

  1. phamarcological
    • ​​withdrawal
    • tolerance
  2. impaired control
    • desire or unsuccessful efforts to cut down/control use
    • great time spent obtaining/using
    • craving; strong urges to use
    • larger amounts consumed than intended
  3. risky use**​
    • use despite physical or psychological problems
    • use when it is hazardous
  4. social impairment​
    • use despite problems in relationships
    • failure to fulfill roles (work/school/home)
    • reduced occupational, recreational activity

mild → 2-3 sx

moderate → 4-5 sx

severe → 6+ sx

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3
Q

classification of substance use disorder

early/sustained remision,

A

early remission: 3-12mo abstinence

sustained remission: 12+mo abstinence

in controlled environment

on maintenance therapy (opioid)

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4
Q

substance induced disorders

A
  1. intoxication
  2. withdrawal
  3. substance induced mental disorder
  • delirium
  • dementia
  • amnesia
  • psychosis
  • mood disorder
  • anxiety
  • sexual dysfx
  • sleep disorder
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5
Q

clinician barriers

A
  • inadequate training/education
  • misperceptions/stereotyping
  • uncertain about what to do
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6
Q

at risk for drinking criteria

A

men

  • > 4 drinks/day or 14/wk

women

  • > 3 drinks/day or 7/wk

1/4 of all of these people will go on to have an alcohol use disorder

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7
Q

CAGE

A
  1. ever felt you should CUT DOWN on your drinking?
  2. every been ANNOYED by people criticizing your drinking?
  3. ever felt bad or GUILTY about your drinking?
  4. ever had a drink first thing in the morning to steady nerves or take care of a hangover? (EYE OPENER)

2 = positive test

1 = suspicious

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8
Q

assessment of SUD

A
  • clinical interview
  • amount, type, frequency
  • conseqs of use
    • legal
    • fxal
    • medical
    • psychological
    • social
  • physical exam and labs
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9
Q

alcohol use disorder

male/female

onset

risk factors

A

male: female = 3:1

onset between 16-30

risk factors:

  • tobacco use, depression/anxiety, antisocial personality disorder, some jobs, gambling, fam hx

women experience more medical consequences

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10
Q

fatty liver

A

experienced by almost all heavy drinkers

  • usually asymptomatic
  • reversible
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11
Q

alcoholic cirrhosis

4 fx of liver

how alcohol messes with these fxs

A

liver has many key fx; messing with them leads to issues

  1. portal HTN
  • hepatosplenomegaly
  • caput medusae
  • esophageal varices
  • hemorrhoids
  • affected: splenic, umbilical, esophageal, internal hemorrhoidal vv
  1. detoxifying fx
  • decr androgens → gynecomastia, testicular atrophy, decreased axillary/pubic hair, spider angioma or nevi
  • buildup of ammonia → asterixis, delirium, encephalopathy
  1. synthesizing fx
  • glucose
  • albumin → ascites, edema
  • coagulation factors (vitK-dep) → ecchymoses
  • bilirubin → jaundice, scleral icterus
  1. storage fx
  • thiamine (B1)
  • folate → macrocytic anemia/pallor
  • pyridoxine (B6) → pallor/anemia
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12
Q

what to look for in labs for alcohol use disorder

A

serum and urine toxicology/BAL

LFTs

  • GGT > 35; good marker for heavy drinking, normalizes after approx 5wk
  • AST, ALT; both abs value and ratio are important, but less sensitive than GGT
    • AST:ALT > 2 suggests AUD

MCV

triglycerides

platelets

carbohydrate deficient transferrin

  • abnormal form of transferrin
  • CDT > 20 g/L indicates heavy drinking
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13
Q

alcohol intoxication

A

1 or more of the following:

  • slurred speech
  • incoordination
  • unsteady gait
  • memory or attn impairment
  • stupor or coma
  • nystagmus
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14
Q

Wernicke encephalopathy

A

cause: acute thiamine (B1) deficiency due to dietary depletion

triad of sx:

  1. confusion
  2. ataxia
  3. ophtalmoplegia (eye muscle paralysis - usually lat rectus; nystagmus)
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15
Q

Korsakoff syndrome

A

cause: chronic thiamine (B1) depletion

NOT REVERSIBLE

sx:

  • impaired memory in alert, responsive pt
  • confabulation
  • retrograde and anterograde memory loss
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16
Q

Wernicke-Korsakoff syndrome

A

bilateral involvement of mammillary bodies → affects memory

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17
Q

alcohol tx

A
  1. intervention
  2. detox
  3. rehab

at risk drinkers?

  • help patients decrease drinking
  • minor intervention
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18
Q

substance withdrawal

diffs by substance type:

  • life threatening
  • severe discomfort
  • mild discomfort
  • no physio dep
A
  • life threatening
    • alcohol
    • sedative-hypnotic
  • severe discomfort
    • opiates
  • mild discomfort
    • cocaine
    • tobacco
    • amphetamine
    • cannabis
  • no physio dep
    • hallucinogens
19
Q

alcohol effects on neurotransmission

A

chronic alc use decreases GABAa receptor sensitivity

→→→ tolerance!

during withdrawal…

decreased GABAa receptor function (excitation more likely)

20
Q

signs of alcohol withdrawal

A
  • insomnia
  • flushing
  • tremor
  • nausea/vomiting
  • physical agitation, anxiety
  • sweating, rapid pulse
  • hyperreflexia
  • transient visual, tactile, auditory hallucinations or illusions
  • grand mal seizures (first 48hr)
21
Q

course of alcohol withdrawal

A

I : 12-48hr

  • peak severity at 36hr
  • 90% of AW seizure in this range
  • most cases self limited

II : 48-72hr

  • amplified StageI sx

III : 72-105hr

  • “delirium tremens”

IV (>7days)

  • protracted withdrawal
22
Q

predictors of AW severity

“complicated withdrawal”

A
  • severity of drinking/tolerance
  • older age
  • prior AW (“kindling”)
  • major medical/surgical problems
  • sedative/hypnotic use

complicated withdrawal: seizure, delirium, hallucinations, DTs

23
Q

delirium tremens

basics

sx

timecourse

A

MEDICAL EMERGENCY!

20% mortality if untreated

  • autonomic instability
  • perceptual disturbances
  • hyperactivity to lethargy

timecourse: preceded by seizure and lasts 3-7days

24
Q

tx of alcohol withdrawal

A

benzodiazepine taper (4-6days)

  • all types effective
  • incr GABAa receptor fx
  • decr seizures

carbemazapine, phenobarbital

thiamine and vitamin supplements

fluid/electrolytes (Mg and K)

check vitals frequently

25
opiate intoxication/OD sx
"everything closes up" * miosis * respiratory depression (in OD) * hypotension * hypothermia * bradycardia * constipation * slurred speech * drowsiness/coma
26
opiate antagonists
**naloxone (Narcan)** * IV/IM/SQ for opioid overdose (FDA approved) * this is the reason why adding naloxone to opiate (ex. oxy) deters pt from shooting up → precipitates opioid withdrawal **Naltrexone** * oral * FDA approved for alc dependence, opiate dependence
27
opiate withdrawal
"everything opens" * anxiety * yawning * diaphoresis * tearing, rhinorrhea * pupil dilation * piloerection/muscle twitching * nausea/vomiting * diarrhea, abd cramps * myalgias NOT LIFE THREATENING
28
opiate withdrawal tx
symptomatic relief detox via: * clonidine (alpha adrenergic) * phenergan (antiemetic) * benzodiazepines * muscle relaxants methadone (licensed facilities or for emergency tx) buprenorphine (early withdrawal)
29
opiate classification receptor types of interaction
mu receptor is the target of opiates full agonists * morphine * oxycodone * methadone partial agonist * buprenorphine antagonists * naloxone * naltrexone
30
buprenorphine mech of action what's special about it? types
_mech_: **partial mu agonist with ceiling effect** * can't OD on it bc it doesn't cause resp depression * lond duration of action * self tapering office-based tx for opiate dependence 1. suboxone: buprenorphine w/ naloxone * 4:1 → BUP:naloxone * sublingual bc naloxone not effective orally 2. subutex: buprenorphine (without naloxone)
31
can any doctor prescribe methadone?
**for pain???** * YES * less commonly used due to complex med interactions and long halflife * accumulation → sedation and resp depression **for addiction???** * NO - can only be prescribed by licensed facility * reduces/eliminates use of non-prescribed opiates and use of cocaine * reduces risk of HIV and needle use
32
hallucinogens
5HT2 receptor action * produce changes in thoughts, perceptions, mood * only minimal sedation * no change in memory or intellectual fx hallucinations or illusions in a clear consciousness ex. PCP, angel dust, ketamine, mescaline/peyote, marijuana, MDMA/MDA, etc
33
hallucinogens dependence, addiction withdrawal
no abstinence syndrome no detox needed lethal OD is rare instead...**psychological dependence/compulsive use**
34
PCP
dissociative anesthetic (Schedule II) long halflife: 24 hours oral, IV, smoke, snort * psychosis resembling schizophrenia (agitates, paranoid, violent) * marked neuro signs: vertical nystagmus, ataxia * profound autonomic effects (v. dangerous) mech: affects glutamate system via NMDA receptor
35
marijuana
cannabis sativa #1 illicit drug in US THC: delta-9-tetrahydrocannabinol is the major active chemical WITHDRAWAL: psych symptoms * most occur within 2-3 days, but can last weeks * cravings * anxiety/depression * no libido * appetite incr or decr * boredom * shakes/tremor * insomnia/irritability
36
dranabinol
synthetic oral cannabinoid delta9 THC * anti-emetic for chemo * anorexia from AIDS low abuse potential
37
proposed medical uses for marijuana
* anti-emetic * anti-spasticity * analgesic * appetite stimulation * anti-glaucoma * anticonvulsant * anti-asthmatic
38
cocaine onset/effect intoxication sx
rapid onset (seconds) and short window (minutes) intoxication sx: * hyperalertness * restlessness/pacing * talkative/pressured speech * aggression or elation * impulsivity * chest pain, other ischemia
39
cocaine withdrawal (crash)
* agitation/restless behavior * depressed mood * fatigue * generalized malaise * incr appetite * vivid and unpleasant dreams * slowing of activity * craving
40
cocaine treatment
* no cocaine-specific treatment * no detox needed * medications not proven effective
41
D-methamphetamine
"meth", "speed", "chalk" schedule II stimulant * oral, intranasal, injection, smoking _mechanism_: releases high levels of DA * damages neuron cell endings (DA and 5HT) * reduced motor speed and impaired verbal lerning * chronic abusers: severe structural and fx changes in memory/emotion parts of brain
42
psychological stimuland and sympathomimetic effect timecourse
8-24hr: * incr wakefulness, physical activity, resp, HR, BP, hyperthermia, irreg heartbeat, decr appetite * irritability, anx, insomnia, confusion, tremors, convulsions, CV collapse/death long term: * paranoia, aggressiveness, extreme anorexia, mem loss, visual and auditory hallucinations, delusions, severe dental problems
43
principles of strategic prescribing
* avoid freq drug switching * follow evidence-based recs * be cautious about telephone prescriptions * start only one new drug at a time * don't stretch indications * discontinue drugs that dont work
44
what types of meds to avoid????
* dependence liability * OD risk * cause seizures * cause sedation * cause liver tox

M2 Psych (24 decks)

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