5. Substance-related disorders Flashcards
1
Q
What is the lifetime prevalence of substance abuse or dependence in the US?
A
17%
2
Q
How do you test for alcohol?
A
Blood/urine test
3
Q
How long does alcohol stay in the system?
A
only a few hours
4
Q
How long is urine tox positive for cocaine?
A
2-4 days
5
Q
How long is urine tox positive for amphetamines?
A
1-3 days
6
Q
How long is urine tox positive for PCP?
A
3-8 days
7
Q
What other lab values are also elevated in PCP use? (2)
A
CPK and AST
8
Q
How long is short acting barbiturate (pentobarbital) in the blood/urine?
A
24 hrs
9
Q
How long is long acting barbiturate (phenobarbital) in the blood/urine?
A
3 wks
10
Q
How long is short acting benzo (lorazepam) in the blood/urine?
A
3 days
11
Q
How long is long acting barbiturate (diazepam) in the blood/urine?
A
30 days
12
Q
Which opioids come up negative on a general screen? (2)
A
methadone, oxycodone
13
Q
How long is urine tox positive for SINGLE marijuana use?
A
3 days
14
Q
Why is urine + for chronic marijuana users for up to 4 wks?
A
THC is released from adipose stores
15
Q
How does alcohol work in terms of binding sites/receptors? (4)
A
- activates GABA
- activates serotonin receptors
- inhibits glutamate receptors
- inhibits voltage-gated calcium channels
16
Q
What is the lifetime prevalence of alcohol dependence in US for women and men?
A
3-5% women
10% men
17
Q
What is the alcohol metabolism?
A
Alcohol –> acetaldehyde –> acetic acid
18
Q
What are the 2 enzymes involved in metabolism of alcohol?
A
Alcohol dehydrogenase
Aldehyde dehydrogenase
19
Q
Why are Asians less tolerant to alcohol?
A
Have less aldehyde dehydrogenase
- results in flushing and nausea
- protecting against alcohol dependence
20
Q
What is the most common co-ingestant in drug overdose?
A
Alcohol
21
Q
At what BAL do you start seeing signs of intoxication?
A
BAL > 100
22
Q
What is the tx for alcohol withdrawal?
A
Benzodiazepine taper
- usually chlordiazepoxide (Librium) considered drug of choice
23
Q
Signs and symptoms of mild alcohol withdrawal syndrome? (3)
A
irritability, tremor, insomnia
24
Q
Signs and symptoms of moderate alcohol withdrawal syndrome? (5)
A
diaphoresis, htn, tachycardia, fever, disorientation
25
Signs and symptoms of severe alcohol withdrawal syndrome? (3)
tonic-clonic seizures, DTs, hallucinations
26
When does EtOH withdrawal syndrome begin, and how long does it last?
begin in 6-24 hrs
| lasts 2-7 days
27
What electrolyte abnormality can predispose to EtOH withdrawal seizures?
hypomagnesemia
28
What are seizures in EtOH withdrawal syndrome treated with?
Benzodiazepines
29
What % of patients hospitalized for EtOH withdrawal develop DTs?
5%
30
When does DTs usually begin?
48-72 hrs after last drink, but can occur later
| 90% of cases within 7 days
31
Prevalence of DTs in men vs. women
Men develop DTs 4-5x more
32
What are some symptoms of delirium tremens? (6)
Seizures
Delirium
Hallucinations (most commonly visual; also tactile)
Gross tremor
Autonomic instability (increased RR, HR, BP)
33
What can be used to treat DT? (2)
Benzodiazepines
| Dilantin (phenytoin) - anticonvulsant
34
In addition to benzo taper, what else can be used to treat alcohol withdrawal? (2)
Carbamazepine or VPA taper
35
What are the medications indicated for alcohol dependence? (4)
1. Disulfiram (Antabuse)
2. Naltrexone (Revia, IM-Vivitrol)
3. Acamprosate (Campral)
4. Topiramate (Topamax)
36
What MCV (mean corpuscular volume) changes are seen in alcohol dependence?
macrocytosis (increased MCV)
37
How does disulfiram work?
Blocks aldehyde dehydrogenase in the liver --> causes aversive rxn to alcohol (flushing, headaches, nausea/vomiting, palpitations, SOB)
38
Who are disulfiram best for?
Highly motivated pts (better medication adherence)
39
How does Naltrexone work?
Blocks opioid receptor
| - works by decreasing desire/craving and "high" associated with alcohol
40
Greatest benefit of Natrexone seen in which patients?
pts w/ family hx of alcoholism
41
How does Acamprosate work?
structurally similar to GABA
| - thought to inhibit glutamatergic system
42
What is Acamprosate indicated for?
Post-detox for relapse prevention in pts who have stopped drinking
43
What is the major advantage of Acamprosate?
can use in pts with liver disease
44
Contraindication of Acamprosate?
pts with severe renal disease
45
Mechanism of Topiramate in tx of alcohol dependence?
Anticonvulsant that potentiates GABA --> inhibits glutamate receptors
- reduces cravings for alcohol
46
Tx for Wernicke's encephalopathy?
THIAMINE tx! (before giving glucose)
47
What are features of Wernicke's encephalopathy? (3)
1. Ataxia
2. Confusion
3. Ocular abnormalities (nystagmus, gaze palsies)
48
What is Korsakoff syndrome?
Chronic amnestic syndrome = impaired recent memory, anterograde amnesia, compensatory confabulation
49
What % of pts can be reversed from Korsakoff syndrome?
Reversible in only 20% of pts
50
What is the mechanism of cocaine?
blocks pre-synaptic DA reuptake transporter --> increases DA signalling --> increases "reward" system
51
General intoxication symptoms of cocaine? (not dangerous)
euphoria, heightened self-esteem, change in BP, tachy or brady, nausea, DILATED pupils, weight loss, psychomotor agitation/depression, chills, sweating
52
Dangerous symptoms of cocaine intoxication? (5)
resp depression, seizures, arrhythmias, MI, stroke
53
How to manage cocaine intoxication?
- benzo (for mild-moderate agitation/anxiety)
- antipsychotics (for severe agitation/psychosis)
- ice bath/cooling blanket (for temp > 102F)
54
What is the mainstay of cocaine dependence treatment?
Psychological interventions (ex. contingency management, group tx)
55
Symptoms of cocaine withdrawal? (7)
"Crash" = malaise, fatigue, hypersomnolence, depression, CONSTRICTED pupils, vivid dreams, psychomotor agitation/retardation
56
How long does cocaine w/d last if mild-moderate use?
18 hrs
57
How long does cocaine w/d last if heavy/chronic use?
can last for weeks, but usually peak in several days
58
How does amphetamines work?
Blocks re-uptake and facilitates release of dopamine and NE from nerve endings --> causes stimulant effect
59
What are examples of amphetamines? (3)
- Dextroamphetamine (Dexedrine)
- Methylphenidate (Ritalin)
- Methamphetamine (Desoxyn = "ice", "speed" "crystal meth" "crank")
60
Symptoms of amphetamine abuse (5)
dilated pupils, increased libido, perspiration, resp depression, chest pain
61
What are "club drugs" (substituted/"designer" amphetamines) 2
MDMA (ecstasy)
| MDEA (eve)
62
Whats the difference of "designer" amphetamines in terms of mechanism (compared to amphetamines)
Releases DA, NE AND serotonin from nerve endings
63
What can happen if designer amphetamines are combined with SSRIs?
serotonin syndrome
64
What can happen from chronic amphetamine use? (2)
acne and accelerated tooth decay ("meth mouth")
65
Amphetamine intoxication symptoms?
Similar as cocaine
66
What can happen from of amphetamine overdose (4)?
hyperthermia
dehydration
rhabdomyolysis --> renal failure
67
Amphetamine withdrawal can lead to --? (2)
prolonged depression
| - occasionally heavy use can lead to amphetamine psychosis (mimic schiz)
68
How does PCP work?
antagonizes NMDA glutamate receptors --> activates DA neurons
69
Ketamine use can cause (4)
tachycardia, tachypnea, hallucinations, amnesia
70
What does it mean to smoke PCP as "wet" vs. "joint"?
```
"wet" = sprinkled on cigarette
"joint" = sprinkled on marijuana
```
71
Symptoms of PCP intoxication "RED DANES"
```
Rage
Erythema (redness of skin)
Dilated pupils
Delusions
Amnesia
Nystagmus
Excitation
Skin dryness
```
72
Difference of ketamine vs. PCP? (2)
Ketamine is less potent
| - sometimes used as a "date rape" drug b/c it's odorless and tasteless
73
Overdose of PCP can cause -- (3)
seizures, coma, even death
74
Rotatory nystagmus is pathognomonic for --?
PCP intoxication
75
Treatment of PCP intoxication
- benzos (lorazepam) to treat agitation, anxiety, muscle spasms, seizures
- antipsychotics (haloperidol) to control severe agitation/psychotic symptoms
76
2 drug classes that can cause tactile and visual hallucinations?
cocaine, PCP
77
Withdrawal from PCP?
no w/d syndrome, but "flashbacks" (recurrence of intoxication symptoms due to release of the drug from body lipid stores)
78
Which drug intoxication causes more violence?
PCP
79
How does benzos work vs. barbiturates?
- benzos potentiates effects of GABA by increasing the FREQUENCY of chloride channel opening
- barbiturates increases the DURATION of chloride channel opening
80
Common uses (medical) of benzos vs. barbiturates?
```
Benzos = anxiety disorders
Barbiturates = epilepsy, anesthetics
```
81
Of all kinds of drug withdrawals, which has the highest mortality rate?
barbiturate
82
Symptoms of GHB (gamma-hydroxybutyrate) abuse? (3)
memory loss, resp distress, coma
83
What are common "date rape" drugs? (2)
ketamine, GHB
84
Clinical symptoms of sedative intoxication?
drowsiness, confusion, hyPOtension, slurred speech, incoordination, ataxia, mood lability, impaired judgement, nystagmus, resp depression
85
What can long-term sedative use lead to?
dependence and may cause depressive symptoms
86
What can be used for treatment of benzo (BDZ) overdose?
Flumazenil (very short-acting BNZ antagonist)
87
Why must you use flumazenil with caution?
b/c it may precipitate seizures (during BDZ overdose)
88
What is used in opiate overdose?
Naloxone
89
What can be done as treatment for benzo/barbiturate use? (2)
ABCs, vitals
| - activated charcoal and gastric lavage to prevent further GI absorption (if drug was ingested in the last 4-6 hrs)
90
Specific barbiturate treatment?
Alkalinize urine w/ sodium bicarb to promote renal excretion
91
Withdrawal symptoms of sedatives?
same as alcohol w/d
92
Treatment of sedative w/d? (2)
benzo taper
| - carbamazepine/VPA taper may be used for seizure prevention
93
Mechanism of action of opioids?
Stimulate opiate receptors (mu, kappa, delta)
94
Examples of opioids? (7)
heroin, oxycodone, codeine, dextromethorphan, morphine, methadone, meperidine (demerol)
95
What are the most commonly abused opioids? (3)
```
Prescription opioids
(oxycodone, vicodin [hydrocodone/ acetaminophen], Percocet [oxycodone/acetaminophen])
```
96
What's the most common cause of death from street heroin usage?
Infection 2/2 needle sharing
97
Classic triad of opioid overdose?
pupil CONSTRICTION, resp depression, altered mental status
98
What's the one opioid that causes miosis?
Meperidine (Demerol Dilates pupils)
99
Meperidine and MAOIs in combination can cause ---?
serotonin syndrome
100
What are symptoms of serotonin syndrome? (4)
hyperthermia, confusion, hyper/hypotension, muscular rigidity
101
What 3 drugs can be used in tx of opioid dependence?
methadone, buprenorphine, naltrexone
102
Difference in the 3 drugs used for opioid dependence? (in terms of mechanism)
1. methadone = long-acting opioid receptor agonist
2. buprenorphine = partial opioid receptor agonist
3. Naltrexone = competitive opioid antagonist
103
What are the pros of using methadone in tx of opioid dependence? (3)
1. administered once/daily
2. sig reduces morbidity/mortality in opioid-dep persons
3. "gold standard" tx in pregnant women
104
Cons of using methadone in tx of opioid dependence? (2)
1. restricted to federally licensed substance abuse treatment programs
2. can cause QTc interval prolongation
105
Pro (1) of using buprenorphine in tx of opioid dependence?
1. sublingual preparation that is safer than methadone (b/c effects reach a plateau and make overdose unlikely)
106
What is suboxone?
contains buprenorphine and naloxone
| - more commonly used (than buprenorphine)
107
Naltrexone is indicated for which types of pts?
Highly motivated pts (for opioid dependence tx)
108
W/d syndrome of opioids? (7)
anxiety, insomnia, anorexia, fever, rhinorrhea, piloerection, nausea/vomiting
(note: this is not life threatening)
109
Tx for opioid w/d?
1. Clonidine (for autonomic symptoms of w/d)
2. NSAIDs (for pain)
3. Dicyclomine (for abdominal cramps; usually used as tx of IBS)
110
What are examples of hallucinogens? (3)
psilocybin (mushrooms), mescaline (peyote cactus), LSD
111
Effects of hallucinogens?
perceptual changes, labile affect, dilated pupils, tachycardia, htn, hyperthermia, tremors, incoordination, sweating, palpitations
112
How long are the effects of hallucinogens?
6-12 hrs
| - but may last for several days
113
What does it mean to have a "bad trip" w/ hallucinogens?
get marked anxiety, panic, psychotic symptoms (paranoia, hallucinations)
114
Tx of hallucinogen intoxication?
monitor for dangerous behavior and reassurance
| - use benzo/antipsychotics prn for agitation
115
What are w/d symptoms of hallucinogens?
no w/d or dependence
| - but may have "flashbacks" later in life
116
What is LSD flashback?
recurrence of symptoms mimicking prior LSD trip that occurs spontaneously; lasts for min to hours
117
What's the world's most commonly used illicit substance?
Marijuana (cannabis, pot, weed, grass)
118
What's the main active component in cannabis?
THC (tetrahydrocannabinol)
119
Mechanism of action of cannabis?
cannabinoid receptors in the brain inhibits adenylate cyclase
120
medical uses of marijuana? (5)
- treat nausea in chemo pts
- increase appetite in AIDS pts
- decrease intraocular pressure, muscle spasms, tremor
121
What is dronabinol?
pill form of THC that is FDA-approved for certain indications
122
intoxication symptoms of marijuana?
euphoria, anxiety, CONJUNCTIVAL INJECTION (red eyes), dry mouth, increased appetite
123
Chronic use of marijuana can cause --? (3)
1. resp problems (asthma, chronic bronchitis)
2. suppression of immune system
3. possible effects on repro hormones
124
What are some w/d symptoms of marijuana?
irritability, anxiety, aggression, strange dreams, depression, sweating, insomnia, decreased appetite
125
What are examples of inhalants?
solvents, glue, paint thinners, fuels, isobutyl nitrate ("huff", "laughing gas", "rush", "bolt")
126
Intoxication effects of inhalants?
perceptual disturbances, psychosis (esp paranoid states), lethargy, dizziness, N/V
127
Overdose of inhalants can be fatal due to--? (2)
may be fatal 2/2 resp depression or cardiac arrhythmias
128
Long term use of inhalants can lead to --?
permanent damage to CNS (ex. dementia, impaired memory, epilepsy, reduced IQ)
- damage to PNS, liver, kidney, heart, muscle
129
FDA approved pharmacotherapy for nicotine dependence? (2)
- Varenicline (Chantix): nicotinic cholinergic receptor partial agonist
- Bupropion (Zyban): antidepressant
