7. Substance-related or Addictive disorders Flashcards
An estimated __% of the population struggles with substance-related problems.
10%
There is a high prevalence of psychiatric disorders in substance users (up to __% ), and vice versa.
50%
DSM-5 identifies 10 different classes of drugs. Name them
- Alcohol
- Caffeine
- Cannabis
- Hallucinogens
- Inhalants
- Opioids
- Sedatives, hypnotics, and anxiolytics
- Stimulants
- Tobacco
- Other (or unknown) substances
Describe the pathophysiology of substance-related problems (5)
- The central psychophysiology is the direct activation of the brain reward circuitry, when any drug is taken in excess.
- Neurotransmitters with major roles in the brain reward system include opioid, dopamine, and GABA.
- Neuroimaging studies reveal the roles of these neurotransmitters in the mesolimbic, hippocampus, amygdala, thalamo-orbitofrontal, anterior cingulate, and frontal cortex regions in maintaining the hedonic effects, cravings, and disinhibited behaviors of addicting drugs.
- These pathways lead to reduced self-control, reinforcement of maladaptive behaviours, and neglect of normal daily activities.
- Genetic factors are strongly linked to alcohol use disorders, but not for other substances.
Name causal factors and DDx associated with substance use (15)
- Behavioral addictions
- Adverse childhood and traumatic experiences
- Genetic factors
- Co-morbid illness
- Psychosocial stressors
- Concurrent substance use
- Psychotic disorders
- Bipolar disorders
- Depressive disorders
- Anxiety disorders
- Obsessive-compulsive disorder
- Sleep disorders
- Sexual dysfunctions
- Delirium
- Neurocognitive disorders
Describe HX: Substance-related or Addictive disorders (15)
- Ensure personal safety during the interview, as patients with substance intoxication may be erratic, impulsive, and aggressive
- Collateral information gathered from family, caregivers, health care providers, ambulance, or police reports may be needed to corroborate information.
- Perform a structured interview, paying particular attention to drugs of choice and describing for each:
- Name of the specific drugs
- age of first use
- current usage
- modes of administration
- effects obtained from the substances
- duration of effects
- symptoms of intoxication
- symptoms of withdrawal
- use of concurrent substances
- and functional impairments
- Screen for psychiatric symptoms to assess comorbidities and differential diagnoses
- Ask about forensic history
Describe general observation and physical exam: Substance-related or Addictive disorders (5)
- Initial medical evaluation is critical.
- Obtain vital signs and assess level of consciousness
- Examine neurologic status, pupils, stigmata of drug or alcohol use, track marks, and other physical signs of substance intoxication and withdrawal
- Perform mental status exam, for instance:
- Appearance may be emaciated, dishevelled, unkempt, malodorous, poor hygiene.
- Speech may range from slow with increased latency in response, to pressured and rambling, to slurred and incomprehensible.
- Affect may be limited in range, or expansive and labile.
- Thought form may be incoherent, derailed, blocked.
- Perception may be disrupted by internal stimuli, paranoia, or delusions.
- Insight and judgment may be impaired.
- Assess for signs and symptoms of toxidromes
Name: Common toxidromes (6)
- Anticholinergic toxidrome
- Cholinergic toxidrome
- Opioid and sedative- hypnotic toxidromes
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Sympathomimetic toxidrome
Name Associated/Causative Substances: Anticholinergic toxidrome (6)
- Antihistamines
- Antiparkinson
- Antipsychotics
- Benztropine
- Carbamazepine
- Tricyclic antidepressants
Name sx (6) and signs (7): Anticholinergic toxidrome (6)
- Sx:
- Agitation
- Delirium
- Hallucination
- Memory loss
- Urinary retention
- Visual disturbance
- Signs:
- Hypertension
- Hyperthermia
- Tachycardia
- Flushing
- Mydriasis
- Decreased bowel sounds
- Seizures
Blind as a bat, dry as a bone, hot as a hare, red as a beet, mad as a hatter
Name Associated/Causative Substances: Cholinergic toxidrome (3)
- Anticholinesterase inhibitors
- Insecticides
- Nerve gases
Name sx (5) and signs (6): Cholinergic toxidrome (5)
- Sx:
- Confusion
- Lacrimation/salivation
- Vomiting
- Diarrhea
- Increased urination
- Signs:
- Bradycardia
- Hypotension
- Hypothermia
- Diaphoresis
- Miosis
- Seizures
Name Associated/Causative Substances: Opioid and sedative- hypnotic toxidromes (4)
- Opioids
- Benzodiazepines
- Alcohol
- Sedatives/hypnotics
Name sx (4) and signs (5): Opioid and sedative- hypnotic toxidromes (4)
- Sx:
- Altered mental status à
- Confusion
- Delirium
- Coma
- Signs:
- Hypotension
- Hypothermia
- Respiratory depression
- Miosis (opioids)
- Hyporeflexia
Name Associated/Causative Substances: Neuroleptic malignant syndrome (5)
- Antipsychotics
- Levodopa
- Lithium
- Desipramine
- Phenelzine
Name sx (7) and signs (6): Neuroleptic malignant syndrome
- Sx:
- Fever
- Diaphoresis
- Muscle cramps and stiffness
- Tremors
- Agitation
- Delirium
- Coma
- Signs:
- Hypertensive crisis
- Muscle rigidity
- Rhabdomyolysis
- Elevated WBC
- Elevated CPK
- Metabolic acidosis
Name Associated/Causative Substances: Serotonin syndrome (6)
- Antidepressants: SSRI, SNRI, MAOI, TCA, bupropion, trazodone, mirtazapine
- Opioids: fentanyl, meperidine, oxycodone, tramadol
- Amphetamines
- Cocaine
- Methylphenidate
- LSD
Name sx (6) and signs (6): Serotonin syndrome
- Sx:
- Diaphoresis
- Diarrhea
- Headache
- Agitation
- Hallucinations
- Coma
- Signs:
- Hypertension
- Hyperthermia
- Mydriasis
- Hyperreflexia
- Myoclonus
- Clonus
Name Associated/Causative Substances: Sympathomimetic toxidrome (6)
- Amphetamines
- Caffeine
- Cocaine
- Ephedrine/pseudoephedrine
- LSD
- PCP
Name sx (5) and signs (5): Sympathomimetic toxidrome (6)
- Sx:
- Diaphoresis
- Nausea and vomiting
- Anxiety
- Delusions
- Paranoia
- Signs:
- Hypertension
- Tachycardia
- Mydriasis
- Hyperreflexia
- Seizures
Name investigations: Substance-related or Addictive disorders (4)
- Serum and urine toxicology screens are essential.
- Assess baseline CBC + differential, electrolytes, renal function, liver function, thyroid function, fasting plasma glucose, lipid panel, and other laboratory investigations as indicated
- Test for communicable diseases, including hepatitis, syphilis, HIV, etc.
- Other investigations may include ECG, EEG, CT head, or MRI for structural brain abnormalities.
Describe general Pharmacologic treatments of substance intoxication and withdrawal: Alcohol (6)
CIWA protocol (Clinical Institute Withdrawal Assessment for Alcohol) is a widely accepted and utilized clinical approach in monitoring and treating alcohol withdrawal:
- Diazepam 20 mg PO q1–2h or 2–5 mg IV/min, maximum 10–20 mg q1h, until symptoms abate
- If elderly, severe liver impairment, severe asthma, or respiratory failure, use lorazepam 1–2 mg PO/SL t.i.d.–q.i.d.
- Thiamine 100 mg IM initial dose, then 100 mg PO once daily × 3 d
- Manage with antiepileptics if seizures occur or there is a history of seizures
- Manage with antipsychotics if hallucinosis occurs
- Supportive care for hydration and symptom management
Describe general Pharmacologic treatments of substance intoxication and withdrawal: Opioid (3)
To counter the effects of opioid intoxication, in adults:
- Naloxone 2 mg initial bolus IV/IM/SL/SC
- Increase by 2 mg increments until symptoms abate, maximum 10 mg
- Methadone is widely used for detoxification and maintenance in opioid addiction, with carefully titrated and adjusted doses
Describe general Pharmacologic treatments of substance intoxication and withdrawal: Tobacco (3)
- Nicotine replacement therapies
- Nicotine patch: apply one patch (7–21 mg) once daily
- Nicotine gum: 2 mg gum PO q1h prn, maximum 20 pieces/d
- Nicotine lozenge: 1 mg lozenge PO q1h prn, maximum 20 pieces/d
- Nicotine inhaler: 4 mg cartridge inhaler, maximum 12 cartridges/d
- Varenicline is approved for smoking cessation treatment in adults.
- Varenicline 0.5–1 mg PO b.i.d. for 12–24 wk, following 1 wk of titration
- Though not formally indicated, bupropion has been widely studied and used in smoking cessation.
- Bupropion 150 mg PO once daily for 3 d, then 150 mg PO b.i.d. up to 12 wk
