14. Clinical Approach to Substance Abuse Disorders Flashcards
What is physical dependence?
The body’s NL physiological adaptation to chronic use of a drug, requiring more of it to acheive the same affect (tolerance) and causing withdrawal if the drug is DQ. Can occur under good medical care.
- Predictable
- Easily managed with meds
- Resolved with tapering off
Does someone have to be physically dependent to a drug to be addicted?
- No: you can be addicted to cocaine/ meth, but withdrawal syndrome is not apparent.
- You can be addicted to gambling or sex, but no physical dependence.
What is addiction?
Primary, chronic disease that involves brain reward, motivation, memory and related circuitry. Dysfunction => biological, psychological, and behavioral dysfunction => person pathologically/compulsively pursues reward and/or relief with drugs and other behaviors.
Addiction is characterized by what 4 things?
- Uncontrollable cravings
- Inability to control drug use
- Compulsive drug use
- Use despite harm to self and others.
What theory makes people vulnerable to addiction?
Reward-deficiency syndrome: defect in the DA-reward system, driving addicts to compulsively seek drugs for a “DA-fix”.
- Helps us understand “compulsive use” that differentiates addiction vs physical dependence.
Besides dopamine-reward syndrome, what else contributes to addiction?
- Learning and memory in the hippocampus
- Emotional regulation in the amygdala
- Development and maintenance of addiction
Regardless of the object of addiction, what is the ultimate common pathway for addictive behavior?
Neurobiological circuitry of the CNS
Genetic and environmental risk factors are ______________ for addictive behaviors.
Nonspecific
Addictophrenia specturm
Co-morbidies with substance abuse/addiction
-
50% of addicts have comorbid psychiatric disorder
- 1. Antisocial PD
- 2. Depression
- 3. Suicide
Diagnostic Criteria for Substance Use Disorder
- Mild substance abuse disorder = at least 2 symptoms;
- Moderate = at least 4;
- Severe = 6+
- Tolerance
- Withdrawal (except after repeated use of PCP, inhalants and hallucinogens)
- Cravings
- Using more/longer than intended.
- Wanting to stop/cut down but cant
- Spending a lot of time obtaining, using or recovering
- Not doing what you should do at (work, school, home)
- Persistent social/interpersonal problems
- Giving up social, occupational, recreational activities
- Puts you in dangerous situations
- Causes physical/psychological problems
Specifiers for Substance Use Disorder
- In early remission: no criteria for 3-12 months
- In sustained remission: no criteria for >12 months (except cravings)
- In a controlled environment: access to substance is restricted (jailed)
Diagnosis Criteria for Substance-Induced Mental Disorders
- Exhibit clinically significant symptomatic mental disorder.
- There is evidence from the history, physical examination, or laboratory findings of both of the following:
- A. Developed during or within 1 month after of a substance intoxication/ withdrawal/ exposure a medication; and
- B. The involved substance/medication is capable of producing the mental disorder.
- The disorder is not better explained by an independent mental disorder. Evidence of a independent mental disorder:
- A. Disorder occured BEFORE severe intoxication/withdrawal/exposure to meds; or
- B. The full mental disorder persisted for at least 1 month after the cessation of acute withdrawal/ severe intoxication/ taking the medication.
- ***This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which can last BEYOND the cessation of acute intoxication or withdrawal
- The disorder does not occur exclusively during the course of a delirium.
- The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What is intoxication?
Reversible substance-specific syndrome due to recent ingestion of a substance, that causes behavioral/psychological changes due to effects on CNS.
- Not due to another medical condition/mental disorder
- Does not apply tobacco
Clinical picture of intoxication depends on what 7 factors?
- Substance
- Dose/time since last dose
- Route of administration
- Duration/chronicity
- Ones degree of tolerance
- Persons expectations of substances effect
- Contextual, situational and culteral variables
What is withdrawal?
- Behavioral, physiological and cognitive changes that occur after stopping or reducing prolonged use; substance-specific
- Causes distress in areas of fx
What drugs do NOT cause withdrawal?
- PCP
- Hallucinogens
- Inhalants
What is neuroadaptation?
CNS changes (pharmacokinetic and pharmacodynamic) that occur when a person develops tolerance and/or withdrawal.
- Pharmacokinetic = adaptation of metabolizing system
- Pharmacodynamic = ability of CNS to function despite high blood levels.
What is tolerance?
- Increased amount of a substance in order to achieve the desired effect
- OR
- Markedly diminished effect with continued use of the same amount of the substance
When would you hospitlize someone with substance abuse?
- Drug OD
- Risk of severe withdrawal
- Medical comorbidities
- Needs RESTRICTED access to drugs,
- Mental disorder + suicidal ideations.
When would you send someone to a residential treatment unit with substance abuse?
- Dont need intensive medical/psychiatric monitoring
- Need a restricted environment
- Need partial hospitalization
When would you send someone to a outpatient program with substance abuse?
- Highly motivated
- No risk of med/psych morbiditity
When would you send someone to detox; what are the types?
Prepare for ongoing treatment
- Outpatient = “social detox” program
- Inpatient: close medical care
Treatment options for substance abuse
Manage intoxication and withdrawal.
- Motivational interviewings in primary care setting
- AA/ Narcotis Anonymous
- CBT
- Therpeutic communities
- Drugs
What should be discussed in motivational interviewing?
- Family involvement
- Relapse prevention
- 12-steps
What else should you treat in patients with substance abuse disorder?
- Co-occuring psychiatric disorders (50% will have)
- Assx medical conditions
Does aversion therapy work for substance abuse disorder?
no
What is alcohol intoxication?
- Blood alcohol level: 0.08 g/dl
- Mood lability, impaired judgement, poor coordination => severe dysrthria, amnesia, ataxia and obtundation => fatal (loss of airway protective reflexes, pulmonary aspiration and CNS depression)
Describe the 3 stages of alcohol withdrawal.
Test and Board Q!!!
-
Early (within 8-12 hours)
- anxiety/ irritability
- tremors
- insomnia
- autonomic hyperactivity _(_tachycardia, HTN, hyperthermia, hyperactive reflexes, nasea, HA)
- 12-48 hours later: grand mal seizures
- 48 - 96 hours; Delirium tremens (psychotic symptoms and confusion that is life-threatening): AMS, hallucinations (mainly visual), autonomic instability
What is the most severe manifestation of alcohol withdrawal and when does it occur?
Delirium tremors: 3 - 10 days after last drink
What are the symptoms of delirium tremens?
- Global confusion/AMS ***Hallmark
- Disorientation/hallucinations (visual***)
- Agitation
- Autonomic hyperreactivity: tachycardia, HTN, fever, diaphoresis
What is the neurobiology behind alcohol withdrawal?
Chronic alcohol intake =>
- ↑ release of endogenous opiods;
- of GABA-A-R => increased GABA inhibition => influx of Cl-;
- Upregulation of NMDA glutatmate receptor;
- Interaction of 5HT and DA.
Withdrawal=>
- no stimulation of GABA-A-R => decrease in influx of Cl- => tremors and autonomic hyperreactivity
- lack of inhibition of NMDA-R => seizures and delerium
What test is done to assess the severity of alcohol withdrawal?
CIWA (Clinical Institute Withdrawal Assessment for Alcohol)
- Gives a # value to
- orientation
- N/V
- Tremor
- Sweating
- Agitation
- Tactile/auditory/visual disturbances
- HA
> 10 = more severe withdrwaral
Treatment for Alcohol Withdrawal
-
Benzos (GABA AGO)
- ↓ risk of seizures; comfort and sedation
- Give when clearly withdrawing, bc cross-tolerant with alcohol
-
Anticonvulsants (Carbamazepine or Valproic Acid)
- ↓ risk of seizures and kindling; helpful for longer lasting withdrawal
- Thiamine
- Oupatient CD treatment: AA!!!!!
Top 2 drugs for Alcohol Treatment
-
Naltrexone (50mg po/daily):
- Opioid ANT that blocks mu receptors => ↓ euphoria and cravings
- High dose => hepatotoxicity; check LFT
- Acamprosate 666mg po/ tid
What drug does more harm than good with alcohol withdrawal?
Disulfiram
- Inhibits aldehyde DH and DA-B-hydroxylase, causing aversive reaction when alcohol is ingested: vasodilation, flushing, N/V, hypotension/HTN, coma/death.
What is benzo intoxication?
- Similar to alcohol, but less of cognitive/motor impairment.
Which benzos and barbs are most addicting?
- More lipophilic and shorter duration of action
