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NMSK Exam 1 > 14. Clinical Approach to Substance Abuse Disorders > Flashcards

14. Clinical Approach to Substance Abuse Disorders Flashcards

1
Q

What is physical dependence?

A

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
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2
Q

Does someone have to be physically dependent to a drug to be addicted?

A
  • 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.
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3
Q

What is addiction?

A

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.

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4
Q

Addiction is characterized by what 4 things?

A
  1. Uncontrollable cravings
  2. Inability to control drug use
  3. Compulsive drug use
  4. Use despite harm to self and others.
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5
Q

What theory makes people vulnerable to addiction?

A

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.
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6
Q

Besides dopamine-reward syndrome, what else contributes to addiction?

A
  1. Learning and memory in the hippocampus
  2. Emotional regulation in the amygdala
  3. Development and maintenance of addiction
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7
Q

Regardless of the object of addiction, what is the ultimate common pathway for addictive behavior?

A

Neurobiological circuitry of the CNS

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8
Q

Genetic and environmental risk factors are ______________ for addictive behaviors.

A

Nonspecific

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9
Q

Addictophrenia specturm

A
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10
Q

Co-morbidies with substance abuse/addiction

A
  • 50% of addicts have comorbid psychiatric disorder
    • 1. Antisocial PD
    • 2. Depression
    • 3. Suicide
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11
Q

Diagnostic Criteria for Substance Use Disorder

A
  • Mild substance abuse disorder = at least 2 symptoms;
  • Moderate = at least 4;
  • Severe = 6+
  1. Tolerance
  2. Withdrawal (except after repeated use of PCP, inhalants and hallucinogens)
  3. Cravings
  4. Using more/longer than intended.
  5. Wanting to stop/cut down but cant
  6. Spending a lot of time obtaining, using or recovering
  7. Not doing what you should do at (work, school, home)
  8. Persistent social/interpersonal problems
  9. Giving up social, occupational, recreational activities
  10. Puts you in dangerous situations
  11. Causes physical/psychological problems
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12
Q

Specifiers for Substance Use Disorder

A
  1. In early remission: no criteria for 3-12 months
  2. In sustained remission: no criteria for >12 months (except cravings)
  3. In a controlled environment: access to substance is restricted (jailed)
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13
Q

Diagnosis Criteria for Substance-Induced Mental Disorders

A
  1. Exhibit clinically significant symptomatic mental disorder.
  2. 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.
  3. 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
  4. The disorder does not occur exclusively during the course of a delirium.
  5. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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14
Q

What is intoxication?

A

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
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15
Q

Clinical picture of intoxication depends on what 7 factors?

A
  1. Substance
  2. Dose/time since last dose
  3. Route of administration
  4. Duration/chronicity
  5. Ones degree of tolerance
  6. Persons expectations of substances effect
  7. Contextual, situational and culteral variables
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16
Q

What is withdrawal?

A
  • Behavioral, physiological and cognitive changes that occur after stopping or reducing prolonged use; substance-specific
  • Causes distress in areas of fx
17
Q

What drugs do NOT cause withdrawal?

A
  1. PCP
  2. Hallucinogens
  3. Inhalants
18
Q

What is neuroadaptation?

A

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.
19
Q

What is tolerance?

A
  • 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
20
Q

When would you hospitlize someone with substance abuse?

A
  1. Drug OD
  2. Risk of severe withdrawal
  3. Medical comorbidities
  4. Needs RESTRICTED access to drugs,
  5. Mental disorder + suicidal ideations.
21
Q

When would you send someone to a residential treatment unit with substance abuse?

A
  1. Dont need intensive medical/psychiatric monitoring
  2. Need a restricted environment
  3. Need partial hospitalization
22
Q

When would you send someone to a outpatient program with substance abuse?

A
  1. Highly motivated
  2. No risk of med/psych morbiditity
23
Q

When would you send someone to detox; what are the types?

A

Prepare for ongoing treatment

  1. Outpatient = “social detox” program
  2. Inpatient: close medical care
24
Q

Treatment options for substance abuse

A

Manage intoxication and withdrawal.

  1. Motivational interviewings in primary care setting
  2. AA/ Narcotis Anonymous
  3. CBT
  4. Therpeutic communities
  5. Drugs
25
Q

What should be discussed in motivational interviewing?

A
  1. Family involvement
  2. Relapse prevention
  3. 12-steps
26
Q

What else should you treat in patients with substance abuse disorder?

A
  1. Co-occuring psychiatric disorders (50% will have)
  2. Assx medical conditions
27
Q

Does aversion therapy work for substance abuse disorder?

A

no

28
Q

What is alcohol intoxication?

A
  • 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)
29
Q

Describe the 3 stages of alcohol withdrawal.

Test and Board Q!!!

A
  • 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
30
Q

What is the most severe manifestation of alcohol withdrawal and when does it occur?

A

Delirium tremors: 3 - 10 days after last drink

31
Q

What are the symptoms of delirium tremens?

A
  1. Global confusion/AMS ***Hallmark
  2. Disorientation/hallucinations (visual***)
  3. Agitation
  4. Autonomic hyperreactivity: tachycardia, HTN, fever, diaphoresis
32
Q

What is the neurobiology behind alcohol withdrawal?

A

Chronic alcohol intake =>

  1. ↑ release of endogenous opiods;
    • of GABA-A-R => increased GABA inhibition => influx of Cl-;
  3. Upregulation of NMDA glutatmate receptor;
  4. 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
33
Q

What test is done to assess the severity of alcohol withdrawal?

A

CIWA (Clinical Institute Withdrawal Assessment for Alcohol)

  1. Gives a # value to
    1. orientation
    2. N/V
    3. Tremor
    4. Sweating
    5. Agitation
    6. Tactile/auditory/visual disturbances
    7. HA

> 10 = more severe withdrwaral

34
Q

Treatment for Alcohol Withdrawal

A
  1. Benzos (GABA AGO)
    1. ↓ risk of seizures; comfort and sedation
    2. Give when clearly withdrawing, bc cross-tolerant with alcohol
  2. Anticonvulsants (Carbamazepine or Valproic Acid)
    1. ↓ risk of seizures and kindling; helpful for longer lasting withdrawal
  3. Thiamine
  4. Oupatient CD treatment: AA!!!!!
35
Q

Top 2 drugs for Alcohol Treatment

A
  1. Naltrexone (50mg po/daily):
    1. ​Opioid ANT that blocks mu receptors => ↓ euphoria and cravings
    2. High dose => hepatotoxicity; check LFT
  2. Acamprosate 666mg po/ tid
36
Q

What drug does more harm than good with alcohol withdrawal?

A

Disulfiram

  • Inhibits aldehyde DH and DA-B-hydroxylase, causing aversive reaction when alcohol is ingested: vasodilation, flushing, N/V, hypotension/HTN, coma/death.
37
Q

What is benzo intoxication?

A
  • Similar to alcohol, but less of cognitive/motor impairment.
38
Q

Which benzos and barbs are most addicting?

A
  • More lipophilic and shorter duration of action
39
Q
A

NMSK Exam 1 (22 decks)

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