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Essentials - Psychiatry > 7. Substance-related or Addictive disorders > Flashcards

7. Substance-related or Addictive disorders Flashcards

1
Q

An estimated __% of the population struggles with substance-related problems.

A

10%

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2
Q

There is a high prevalence of psychiatric disorders in substance users (up to __% ), and vice versa.

A

50%

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3
Q

DSM-5 identifies 10 different classes of drugs. Name them

A
  • Alcohol
  • Caffeine
  • Cannabis
  • Hallucinogens
  • Inhalants
  • Opioids
  • Sedatives, hypnotics, and anxiolytics
  • Stimulants
  • Tobacco
  • Other (or unknown) substances
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4
Q

Describe the pathophysiology of substance-related problems (5)

A
  • 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.
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5
Q

Name causal factors and DDx associated with substance use (15)

A
  • 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
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6
Q

Describe HX: Substance-related or Addictive disorders (15)

A
  • 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
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7
Q

Describe general observation and physical exam: Substance-related or Addictive disorders (5)

A
  • 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
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8
Q

Name: Common toxidromes (6)

A
  • Anticholinergic toxidrome
  • Cholinergic toxidrome
  • Opioid and sedative- hypnotic toxidromes
  • Neuroleptic malignant syndrome
  • Serotonin syndrome
  • Sympathomimetic toxidrome
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9
Q

Name Associated/Causative Substances: Anticholinergic toxidrome (6)

A
  • Antihistamines
  • Antiparkinson
  • Antipsychotics
  • Benztropine
  • Carbamazepine
  • Tricyclic antidepressants
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10
Q

Name sx (6) and signs (7): Anticholinergic toxidrome (6)

A
  • 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

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11
Q

Name Associated/Causative Substances: Cholinergic toxidrome (3)

A
  • Anticholinesterase inhibitors
  • Insecticides
  • Nerve gases
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12
Q

Name sx (5) and signs (6): Cholinergic toxidrome (5)

A
  • Sx:
    • Confusion
    • Lacrimation/salivation
    • Vomiting
    • Diarrhea
    • Increased urination
  • Signs:
    • Bradycardia
    • Hypotension
    • Hypothermia
    • Diaphoresis
    • Miosis
    • Seizures
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13
Q

Name Associated/Causative Substances: Opioid and sedative- hypnotic toxidromes (4)

A
  • Opioids
  • Benzodiazepines
  • Alcohol
  • Sedatives/hypnotics
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14
Q

Name sx (4) and signs (5): Opioid and sedative- hypnotic toxidromes (4)

A
  • Sx:
    • Altered mental status à
    • Confusion
    • Delirium
    • Coma
  • Signs:
    • Hypotension
    • Hypothermia
    • Respiratory depression
    • Miosis (opioids)
    • Hyporeflexia
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15
Q

Name Associated/Causative Substances: Neuroleptic malignant syndrome (5)

A
  • Antipsychotics
  • Levodopa
  • Lithium
  • Desipramine
  • Phenelzine
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16
Q

Name sx (7) and signs (6): Neuroleptic malignant syndrome

A
  • Sx:
    • Fever
    • Diaphoresis
    • Muscle cramps and stiffness
    • Tremors
    • Agitation
    • Delirium
    • Coma
  • Signs:
    • Hypertensive crisis
    • Muscle rigidity
    • Rhabdomyolysis
    • Elevated WBC
    • Elevated CPK
    • Metabolic acidosis
17
Q

Name Associated/Causative Substances: Serotonin syndrome (6)

A
  • Antidepressants: SSRI, SNRI, MAOI, TCA, bupropion, trazodone, mirtazapine
  • Opioids: fentanyl, meperidine, oxycodone, tramadol
  • Amphetamines
  • Cocaine
  • Methylphenidate
  • LSD
18
Q

Name sx (6) and signs (6): Serotonin syndrome

A
  • Sx:
    • Diaphoresis
    • Diarrhea
    • Headache
    • Agitation
    • Hallucinations
    • Coma
  • Signs:
    • Hypertension
    • Hyperthermia
    • Mydriasis
    • Hyperreflexia
    • Myoclonus
    • Clonus
19
Q

Name Associated/Causative Substances: Sympathomimetic toxidrome (6)

A
  • Amphetamines
  • Caffeine
  • Cocaine
  • Ephedrine/pseudoephedrine
  • LSD
  • PCP
20
Q

Name sx (5) and signs (5): Sympathomimetic toxidrome (6)

A
  • Sx:
    • Diaphoresis
    • Nausea and vomiting
    • Anxiety
    • Delusions
    • Paranoia
  • Signs:
    • Hypertension
    • Tachycardia
    • Mydriasis
    • Hyperreflexia
    • Seizures
21
Q

Name investigations: Substance-related or Addictive disorders (4)

A
  • 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.
22
Q

Describe general Pharmacologic treatments of substance intoxication and withdrawal: Alcohol (6)

A

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
23
Q

Describe general Pharmacologic treatments of substance intoxication and withdrawal: Opioid (3)

A

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
24
Q

Describe general Pharmacologic treatments of substance intoxication and withdrawal: Tobacco (3)

A
  • 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
25
Q

Describe general Pharmacologic treatments of substance intoxication and withdrawal:

  • Cannabis
  • Stimulants
  • Hallucinogens
  • Caffeine
  • Inhalants
  • Sedatives, hypnotics, and anxiolytics
A

Supportive care for hydration and symptom management for acute intoxication or withdrawal:

  • Gastrointestinal decontamination if acute ingestion
  • Benzodiazepines for seizures or agitation
  • b -Blockers for hypertension
  • Vasopressors for hypotension
  • Antiarrhythmics for dysrhythmias
  • Antipsychotics for psychotic symptoms
26
Q

Name: Psychological and social treatment options for Substance-related or Addictive disorders (3)

A
  • Patient must be willing and committed to engage in behavioral modification and support programs.
  • Many psychological treatment modalities are available, and options may include motivational interviewing, CBT, DBT, relaxation, aversion therapy, assertive training, relapse prevention programs, biofeedback, neurofeedback, and hypnosis.
  • Social treatment options include detoxification centers, residential treatment centers, stabilization facilities, dual diagnoses treatment clinics, outreach programs, AlcoholicsAnonymous, NarcoticsAnonymous, and other peer support programs.

Essentials - Psychiatry (14 decks)

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