10/18 Substance Abuse I - Williams Flashcards
alcohol/drug use disorders as chronic medical conditions
causative factors
- 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
substance use disorder
criteria
mild/moderate/severe
criteria can be lumped into 4 general buckets
2 or more in 12 months:
-
phamarcological
- withdrawal
- tolerance
- 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
-
risky use**
- use despite physical or psychological problems
- use when it is hazardous
- 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
classification of substance use disorder
early/sustained remision,
early remission: 3-12mo abstinence
sustained remission: 12+mo abstinence
in controlled environment
on maintenance therapy (opioid)
substance induced disorders
- intoxication
- withdrawal
- substance induced mental disorder
- delirium
- dementia
- amnesia
- psychosis
- mood disorder
- anxiety
- sexual dysfx
- sleep disorder
clinician barriers
- inadequate training/education
- misperceptions/stereotyping
- uncertain about what to do
at risk for drinking criteria
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
CAGE
- ever felt you should CUT DOWN on your drinking?
- every been ANNOYED by people criticizing your drinking?
- ever felt bad or GUILTY about your drinking?
- 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
assessment of SUD
- clinical interview
- amount, type, frequency
- conseqs of use
- legal
- fxal
- medical
- psychological
- social
- physical exam and labs
alcohol use disorder
male/female
onset
risk factors
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
fatty liver
experienced by almost all heavy drinkers
- usually asymptomatic
- reversible
alcoholic cirrhosis
4 fx of liver
how alcohol messes with these fxs
liver has many key fx; messing with them leads to issues
- portal HTN
- hepatosplenomegaly
- caput medusae
- esophageal varices
- hemorrhoids
- affected: splenic, umbilical, esophageal, internal hemorrhoidal vv
- detoxifying fx
- decr androgens → gynecomastia, testicular atrophy, decreased axillary/pubic hair, spider angioma or nevi
- buildup of ammonia → asterixis, delirium, encephalopathy
- synthesizing fx
- glucose
- albumin → ascites, edema
- coagulation factors (vitK-dep) → ecchymoses
- bilirubin → jaundice, scleral icterus
- storage fx
- thiamine (B1)
- folate → macrocytic anemia/pallor
- pyridoxine (B6) → pallor/anemia
what to look for in labs for alcohol use disorder
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
alcohol intoxication
1 or more of the following:
- slurred speech
- incoordination
- unsteady gait
- memory or attn impairment
- stupor or coma
- nystagmus
Wernicke encephalopathy
cause: acute thiamine (B1) deficiency due to dietary depletion
triad of sx:
- confusion
- ataxia
- ophtalmoplegia (eye muscle paralysis - usually lat rectus; nystagmus)
Korsakoff syndrome
cause: chronic thiamine (B1) depletion
NOT REVERSIBLE
sx:
- impaired memory in alert, responsive pt
- confabulation
- retrograde and anterograde memory loss
Wernicke-Korsakoff syndrome
bilateral involvement of mammillary bodies → affects memory
alcohol tx
- intervention
- detox
- rehab
at risk drinkers?
- help patients decrease drinking
- minor intervention
substance withdrawal
diffs by substance type:
- life threatening
- severe discomfort
- mild discomfort
- no physio dep
- life threatening
- alcohol
- sedative-hypnotic
- severe discomfort
- opiates
- mild discomfort
- cocaine
- tobacco
- amphetamine
- cannabis
- no physio dep
- hallucinogens
alcohol effects on neurotransmission
chronic alc use decreases GABAa receptor sensitivity
→→→ tolerance!
during withdrawal…
decreased GABAa receptor function (excitation more likely)
signs of alcohol withdrawal
- insomnia
- flushing
- tremor
- nausea/vomiting
- physical agitation, anxiety
- sweating, rapid pulse
- hyperreflexia
- transient visual, tactile, auditory hallucinations or illusions
- grand mal seizures (first 48hr)
course of alcohol withdrawal
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
predictors of AW severity
“complicated withdrawal”
- severity of drinking/tolerance
- older age
- prior AW (“kindling”)
- major medical/surgical problems
- sedative/hypnotic use
complicated withdrawal: seizure, delirium, hallucinations, DTs
delirium tremens
basics
sx
timecourse
MEDICAL EMERGENCY!
20% mortality if untreated
- autonomic instability
- perceptual disturbances
- hyperactivity to lethargy
timecourse: preceded by seizure and lasts 3-7days
tx of alcohol withdrawal
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
opiate intoxication/OD sx
“everything closes up”
- miosis
- respiratory depression (in OD)
- hypotension
- hypothermia
- bradycardia
- constipation
- slurred speech
- drowsiness/coma
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
opiate withdrawal
“everything opens”
- anxiety
- yawning
- diaphoresis
- tearing, rhinorrhea
- pupil dilation
- piloerection/muscle twitching
- nausea/vomiting
- diarrhea, abd cramps
- myalgias
NOT LIFE THREATENING
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)
opiate classification
receptor
types of interaction
mu receptor is the target of opiates
full agonists
- morphine
- oxycodone
- methadone
partial agonist
- buprenorphine
antagonists
- naloxone
- naltrexone
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
- suboxone: buprenorphine w/ naloxone
- 4:1 → BUP:naloxone
- sublingual bc naloxone not effective orally
- subutex: buprenorphine (without naloxone)
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
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
hallucinogens
dependence, addiction
withdrawal
no abstinence syndrome
no detox needed
lethal OD is rare
instead…psychological dependence/compulsive use
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
marijuana
1 illicit drug in US
cannabis sativa
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
dranabinol
synthetic oral cannabinoid
delta9 THC
- anti-emetic for chemo
- anorexia from AIDS
low abuse potential
proposed medical uses for marijuana
- anti-emetic
- anti-spasticity
- analgesic
- appetite stimulation
- anti-glaucoma
- anticonvulsant
- anti-asthmatic
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
cocaine withdrawal (crash)
- agitation/restless behavior
- depressed mood
- fatigue
- generalized malaise
- incr appetite
- vivid and unpleasant dreams
- slowing of activity
- craving
cocaine treatment
- no cocaine-specific treatment
- no detox needed
- medications not proven effective
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
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
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
what types of meds to avoid????
- dependence liability
- OD risk
- cause seizures
- cause sedation
- cause liver tox
