777 final SUD Flashcards
Substance Use D/Os:
- Alcohol-Use D/Os
- Caffeine-Use D/Os
- Cannabis-UseD/Os
- Hallucinogen-Use D/Os
- Inhalant-Use D/Os
- Opioid-Use D/Os
- Sedative-, Hypnotic-, and Anxiolytic-Use D/Os
- Stimulant- Use (amphetamine & cocaine use D/O)
- Tobacco –Use D/O.
(Non-Substance-Related D/O (includes one disorder)
Gambling Disorder )
Criteria to Diagnose
At least 2 of 11 criteria:
- Failure to fulfill major role obligations
- Physically hazardous situations of use
- Social and interpersonal problems
- Cravings
- Tolerance
- Withdrawal
- Larger amounts/longer time period
- Desire to cut down/control use
- Great amount of time spent to obtain/use/recover
- Activities given up
- Psycholgoical/physical problems
Alcohol Use Disorder The description and diagnostic criteria
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.
- Alcohol is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful effort to cut down or control alcohol use.
- A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
- Craving, or a strong desire or urge to use alcohol.
- Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
- Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Alcohol Use Disorder The description and diagnostic criteria, part 2
- Recurrent alcohol use in situations in which it is physically hazardous.
- Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
- Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol. - Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms)
Specifiers with AUD diagnosis
Specify current severity:
- 00 (F10.10) Mild: Presence of 2-3 symptoms
- 90 (F10.20) Moderate: Presence of 4-5 symptoms
- 90 (F10.20) Severe: Presence of 6 or more symptoms
Specify if:
In early remission
In sustained remission
In a controlled environment (rehab etc.)
Alcohol Intoxication
A. Recent ingestion of alcohol. B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: 1. Slurred speech 2. Incoordination 3. Unsteady gait 4. Nystagmus (rapid eye movements) 5. Impairment in attention or memory 6. Stupor or coma
Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use that has been heavy & prolonged
B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate > 100 bpm).
2. Increased hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Generalized tonic-clonic seizures.
C. Signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if: With perceptual disturbances
CAGE Questionnaire (CAGE)
Most widely used screening test for alcohol abuse & dependence
4 yes/no questions organized by a mnemonic acronym about alcohol consumption patterns and their psychosocial consequences
Takes only a few moments to administer
Yes answers to at least 2 of the 4 questions signify a positive screen and the necessity of a more extended work-up
Psychometric measures are significantly better than are single questions (“how much do you drink?) or lab values (e.g., breathalyzer or liver function tests)
Detects dependence but not risky drinking
Michigan Alcoholism Screening Test (MAST)
25 yes/no items concerning alcohol use Self-administered includes questions about tolerance and withdrawal and can point out longer term problems associated with chronic alcohol abuse no answers are scored as 0, yes answers are weighted from 1 to 5 based on the severity of the queried symptoms Scoring is: 0-4=no alcoholism 5-6=possible alcoholism >6=problable alcoholism.
Drug Abuse Screening Test (DAST)
Self-rated for drug abuse or dependency
28 yes/no questions; includes questions about tolerance and withdrawal so identifies chronic drug use problems
a briefer 20-item version is available and has psychometric properties that are nearly identical to the longer version
a total score of 5 or more is consistent with a probable drug abuse D/O
Fagerstrom Test for Nicotine Dependence (FTND)
High risk for medical problems
Smoking can interact with hepatic enzymes and alter the metabolism of psychotropic drugs
a 6-item, self-rated scale that provides an overview of smoking habits and likelihood of nicotine dependence
no recommended cutoff score but the average score in dependent smokers is 4 to 4.5.
SBIRT: Significant Progress in Screening for SUDs
A tool for integrating care of patients with SUDs into primary care
Facilitating care coordination with addiction services
SBIRT Components
Screen
Brief Intervention ( BI) or Brief Negotiated Intervention (BNI)
Raise subject
Ask permission
Establish rapport
Assess comfort regarding intake and consequences
Provide feedback
Review ATOD
Connect use and negative consequences
Make connection between use and medical visit
Discuss issues related to withdrawal and dependence (as necessary)
Enhance motivation
Assess readiness to change
Boost motivation
Negotiate and advise: Negotiate goal
Referral to treatment – abuse or dependence
Review ATOD use
Make connection with life issues
Make connection to medical visit
SBIRT -Evidence Base
Effective in decreasing excess alcohol intake in Primary Care, Emergency Departments Inpatient settings With adolescents
Therapeutic Communication
Encourage honest expression of feelings
Listen to what the individual is really saying
Express caring for the individual
Hold the individual responsible for behavior
Provide consequences for negative behavior that are fair and consistent
Talk about specific actions that are objectionable
Do not compromise your own values or nursing practice
Communicate the treatment plan to the patient and to others on the treatment team
Monitor your own reactions to the patient
Alcohol Use Disorder Medications
Acamprosate, disulfiram, and naltrexone (po and long aciting (Vivitrol) are the most common medications used to treat alcohol use disorder.
They do not provide a cure for the disorder but are most effective in people who participate in a Medication Assisted Treatment (MAT) program.
Stimulant Use Disoder
Amphetamine, cocaine, MDMA (molly, ecstasy), methamphetamine, nicotine, methylphenidate
How Consumed
injected, smoked, snorted, swallowed
Effects
↑ HR, BP, metabolism, feelings of exhilaration, energy, ↑ mental alertness
Consequences
rapid or irregular heart beat, ↓ appetite, weight loss, heart failure, nervousness, insomnia
Cocaine
CNS stimulant
Produces a sudden burst of mental alertness and energy and feelings of self-confidence, being in control, and sociability
“Cocaine rush” lasts 10 to 20 minutes
High is followed by an intense let-down effect in which the person feels irritable, depressed, and tired, and craves more of the drug
Biologic Responses to Cocaine
Increases the release and blockage of the reuptake of norepinephrine, serotonin, and dopamine
dopamine: euphoria and psychotic symptoms
norepinephrine: tachycardia, hypertension, dilated pupils and rising body temperature
serotonin: sleep disturbances, anorexia
Long-term use: depletion of dopamine
Cocaine Intoxication and Withdrawal
Intoxication
CNS stimulation followed by depression
Increasing doses: restlessness tremors and agitation convulsions CNS depression
Death: respiratory failure
Withdrawal
Norepinephrine depletion > person to sleep 12-18 hours
Then, sleep disturbances with rebound REM, anergia, decreased libido, depression, suicidality, anhedonia, poor concentration and cocaine craving
Other Stimulants
Amphetamines: Block reuptake of norepinephrine and dopamine, not as strong effect on serotonin (as cocaine does) Effect peripheral nervous system Methamphetamine Releases excess dopamine Highly addictive Used in a “binge and crash” pattern MDMA (Ecstasy) Causes hallucinations, confusion, depression, sleep problems, drug craving, severe anxiety, and paranoia
Nicotine
Pathophysiology
Stimulates the central, peripheral, & autonomic nervous systems, causing ↑ alertness, concentration, attention, & appetite suppression
Nicotine withdrawal
mood changes (craving, anxiety, irritability, depression)
physiologic changes (difficulty in concentrating, sleep disturbances, headaches, gastric distress, and increased appetite)
Psychopharmacological treatment
Replacement therapy: transdermal patches, nicotine gum, nasal spray, inhalers
NDRI:
bupropion (Wellbutrin XL) XL (150 – 450mg)
Zyban 150 mg BID
Tobacco Use Disorder
A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.
Tobacco taken in larger amounts than was intended
Persistent desire to cut down
Craving
Smoking in bed or other hazardous places
Caffeine
Stimulates the cerebral cortex and increases mental acuity
Dose of 300 mg > tremors, poor motor performance, insomnia
Dose > 500 mg > ↑heart rate; stimulate respiratory, vasomotor, and vagal centers and cardiac muscles; dilate pulmonary and coronary blood vessels; constrict blood flow to cerebral vascular system
Withdrawal:
Headache
Drowsiness
Fatigue
Impaired psychomotor performance
Difficulty concentrating
Craving
Psychophysiologic complaints, such as yawning or nausea
Caffeine Withdrawal
Prolonged daily use
Abrupt cessation with 3 or more in 24 hrs:
Headache
Marked fatigue/drowsiness
Depressed/dysphoric mood or irritability
Difficulty concentrating
Flu-like symptoms (N/V, muscle pain/stiffness)
Distress/impairment
Not due to another medical condition or mental disorder
Cannabis Withdrawal
Cessation of heavy, prolonged use Three or more symptoms within a week: Irritability, anger or aggression Nervousness or anxiety Sleep difficulty Decreased appetite or weight loss Restlessness Depressed mood Abdominal pain, tremors, sweating, fever, chills or headache Distress/impairment Not due to another medical condition or mental disorder
Cannabis
Binds with opioid receptors and blocks dopamine reuptake
Can be stored for weeks in fat tissue and brain
Impairs ability to form memories, recall events, and shift attention from one thing to another
Long-term marijuana use produces amotivational syndrome
Most widely used addictive substance in the US, following tobacco and alcohol; most commonly used illicit drug in the US
More than 16 million Americans use cannabis on a regular basis; most common age of onset falling during teenage years
Prevalence rate of cannabis usage continues to rise
Cannabis, part 2
Cannabis contains 2 major psychoactive components:
Delta-9-tetrahydrocannabinol (THC)
Cannabidiol (CBD)
THC & CBD act on the endocannabinoid system
Comprised of cannabinoid receptors (CB1 & CB2) & endogenous ligands
CB1 receptors found primarily in hippocampus, cerebral cortex, basal ganglia, & cerebellum
CB2 receptors expressed by cells of immune system, especially B cells
THC distributed throughout body tissues
Due to its lipid solubility & redistribution into fatty tissue, THC has long half-life (30-60 hrs)
THC metabolized by cytochrome P450 system
About 1/3 eliminated renally, 2/3 through fecal excretion
Cannabis, part 3
Psychotropic effects - due to THC actions on cannabinoid receptors in brain & regulation of GABA, glutamate, dopamine, noradrenaline, serotonin, & acetylcholine
PCP (Phencyclidine)
Originally used as an anesthetic for humans animal tranquilizer.
Dangerous side effects > removal from market, except for veterinary use
Easily synthesized by home chemist
Intoxication
People frequently arrive at ED in a psychotic, violent, and agitated state.
The high appears about 5 minutes after taking drug and lasts 4-6 hours.
Effects may last up to 48 hrs; may be recovered from the blood and urine for 7-10 days
Diazepam used for muscle spasms, seizures, and agitation.
Haloperidol for severe psychotic behavior.
Do not use phenothiazines since PCP is anticholinergic.
Depression, fatigue, memory loss, difficulty in concentration, & poor impulse control
Psychologic symptoms – euphoria, psychomotor agitation, anxiety, grandiosity, disorientation swings, emotional lability, sensation of slowed time, synesthesias (seeing colors when a loud sound occurs), facial grimacing, muscle rigidity, hallucinations, paranoid ideation
Physical symptoms – vertical & horizontal nystagmus, ↑blood pressure & HR, insensitivity to pain, dysarthria, ataxia, perspiration, salivation, vomiting
Dangers – violence, hypertension, respiratory depression and arrest, stupor, coma, convulsions, death, suicide
Dissociative Anesthetics
Reduce (or block) signals to the conscious mind from other parts of the brain
Ketamine, PCP (angel dust)
Intoxication can last 4 to 6 hours
Interventions to reduce stimuli, maintain a safe environment for the patient and others, manage behavior, and observe for medical and psychiatric complications
Opiates
Codeine, fentanyl, heroin, morphine, oxycodone, & hydrocodone
Effects are pleasure (or reward) and pain relief
Physical dependence can develop rapidly
Withdrawal syndrome includes rebound hyperexcitability
Naloxone (Narcan) given in emergency treatment of opiate intoxication
Drugs used to treat addiction:
Methadone
Naltrexone oral or depo (Vivitrol)
Buprenorphine, Suboxone
Opioid Pharmacology
Types of opioid receptors:
Mu
Kappa
Delta
Addictive effects of opioids occur through activation of mu receptors
Role of kappa and delta receptors in addictive process not well defined
Opioid ReceptorsMu Receptor Activators
Morphine Heroin Methadone Hydromorphone Buprenorphine Codeine Oxycodone Fentanyl Hydrocodone
Medication Assisted Treatment
Buprenorphine (Suboxone) , methadone, and naltrexone are used to treat opioid use disorders to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone.
These MAT medications are safe to use for months, years, or even a lifetime.
Opioid Overdose Prevention Medication
Naloxone is used to prevent opioid overdose by reversing the toxic effects of the overdose.
According to the World Health Organization (WHO), naloxone is one of several medications considered essential to a functioning health care system.
Methadone
…. is anopioid used for opioid maintenance therapy in opioid dependence and for chronic pain management.
Detoxification using methadone can be accomplished in less than a month, or it may be done gradually over as long as six months.
The half-life isfrom8 to 59 hours.
Buprenorphine (Suboxone)
Buprenorphine is known as a partial opioid agonist and the effect is weaker than full agonists like heroin and methadone.
It will prevent intoxication by opioids taken concurrently.
Buprenorphine, sold under the brand name Subutex, among others, is anopioid used to treat opioid use disorder,acute pain, andchronic pain.
It can be used under the tongue, in the cheek, by injection, as a skin patch, or as an implant.
*The half-life can vary from 24 to 60 hours
Barbituates
Highly addictive drugs that cause people to feel euphoric, yet relaxed
Prescribed for pain, anxiety, sleep
CNS depressant
Psychological symptoms:
Euphoria, mood lability, loquacity, irritability, anxiety, impaired attention and memory, aggressiveness
Physical symptoms
Drowsiness, slurred speech, fever, long periods of sleep, vomiting, postural hypotension, lack of coordination, unsteady gait
Withdrawal
N/V, malaise/weakness, autonomic hyperactivity, tachycardia, sweating, ↑ BP, anxiety, depression, irritability, orthosatic hypotension, coarse temor of hands, tongue, and eyelids, painful muscle contractions, convulsions, status epilepticus, hallucinations
Dangers:
CNS depression, overdose and death, esp if mixed with alcohol
Hallucinogens
More than 100 different hallucinogens Psilocybin (mushroom) D-lysergic acid diethylamide (LSD) Mescaline Numerous amphetamine derivatives Produce euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perception, confusion, incoordination, and impaired judgment and memory
Hallucinogens, part 2
LSD, Mescaline, Mushrooms
How Consumed
swallowed, smoked
Effects
↑ body temperature, HR, BP, loss of appetite, sleeplessness, numbness, weakness, tremors, altered states of perception and feeling, nausea
Consequences
persisting perception disorder (flashbacks)
Steroids
↑ irritability and aggression
Behavioral effects: euphoria, ↑ energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion
↑ risk for heart attacks and strokes, blood clotting, cholesterol changes, hypertension, depressed mood, fatigue, restlessness, loss of appetite, insomnia, reduced libido, muscle and joint pain, and severe liver problems
↓ sperm production, shrinking of testes, difficulty or pain in urinating
Breast enlargement in men and masculinization in women
Club Drugs
MDMA (Ecstasy, Molly)
Stimulant
Euphoria, energy
Tachycardia, ↓ serotonin
GHB
Sedative
Relaxation/well-being
Post-use anxiety
Rohypnol (Roofies )
Benzodiazepine
Relaxation/loss of consciousness
Post-use amnesia
Ketamine (Special K)
NMDA antagonist
Vivid dreams & hallucinations
Dissociation
Methamphetamine (crystal)
Stimulant
Euphoria, hyperactivity
Post-use depression & violence
LSD (Acid)
Hallucinogen
Hallucinations
Post-use flashbacks
Inhalant/Solvent Use
Types: Glue, solvents, aerosol sprays, paint thinners
Symptoms: slurred speech, lack of coordination, euphoria, dizziness, lightheadedness, hallucinations, delusions
Repeated inhalant abuse may result in loss of inhibitions, lack of control, drowsy feelings that last several hours, lingering headache, confusion, N/V
Effects:
Heart failure and death within minutes after repeated inhalation, known as sudden sniffing death; can result from a single session of inhalant use by an otherwise healthy person. In case of an inhalant addiction, risk ↑ substantially
Many people inhale vapors from common inhalants, referred to as huffing, not knowing that serious health problems can result. Side effects include:
Hearing loss (spray paints, glues, dewaxers, dry-cleaning chemicals, correction fluids)
Peripheral neuropathies resulting in difficulty with moving hands and feet or limb spasms (glues, gasoline, whipped cream dispensers, gas cylinders)
CNS damage (spray paints, glues, dewaxers)
Bone marrow damage (gasoline)
Liver and kidney damage (correction fluids, dry-cleaning fluids)
Blood oxygen depletion (varnish removers, paint thinners)
Non-Substance-Related Disorder
Gambling Disorder
Reclassified from Pathological Gambling in DSM-IV
Reflects increasing & consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and gambling disorder symptoms resemble substance use disorders to a certain extent.
4 of 9 symptoms (versus 5 or more of 10 in DSM IV)
Removed criterion: “has committed illegal acts to finance gambling”
12 month period added
SUD Etiology: Personality
Dependency: unable to cope by themselves, but resent authority and the people they depend upon
Impulsive: need immediate gratification because of low frustration tolerance; drink on impulse to relieve frustration and escape uncomfortable feelings
Difficulty in identifying and expressing feeling
Dominant and critical with underlying self-doubts and passivity
Tendency to be aggressive and domineering; uses anger and hostility to distance and control
Difficulty with intimacy and interpersonal relationships
Irresponsible and avoidant: don’t take responsibility for actions
SUD Etiology: Family
Conflict and violence is common
Dysfunctional family patterns:
involve all family members
tend to be transmitted through the generations
View that 1st problem person in family is the alcoholic, and then family tries to adapt to the changes
One fundamental flaw is that there is no healthy way to adapt to alcoholism
Therefore, as family tries to adapt to ↑ pressures and problems, they too become as sick as the alcoholic.
Since alcoholism is a progressive disease, the family’s disease also becomes progressive.
Etiology: The Codependent
Growing up in an addicted family creates certain patterns: Guessing at what normal is Judging self harshly Difficulty with intimacy Feeling different Super responsible or irresponsible Loyal even when undeserved Seeking crisis Avoiding conflict Fearing rejection and abandonment Cannot prioritize or manage time
More on Codependency
An emotional dysfunction present in families with an alcoholic member
Member who alternately rescues (enables) & blames (persecutes) alcoholic
Characteristics:
Super responsible Overachiever and workaholic Caretaker Highly organized Competent Resilient with a high tolerance for pain Energetic and not easily fatigued Able to defer gratification indefinitely Skilled at crisis intervention Strongly moral – sense of right and wrong crucial to this person’s thinking Loyal and willing to put the needs of an important group before own needs Out of touch with needs and feelings Hypochondria Powerlessness Self-blame ****Adult Children of Alcoholics (or other substances)****
Codependency Etiology: Family
In a family with a member with SUD… Roles of Children:
Hero – Actively parents the parents and siblings, covers up for them, and works to promote harmony and to placate in a volatile dysfunctional family.
Scapegoat – Behaves in negative ways so as to deflect blame from the alcoholic parent.
Lost Child – Escapes into fantasy and also is at high risk for addiction.
Mascot – Plays the role of the clown and diverts attention from the parents.
Therapeutic Interventions & Treatment
Brief Intervention
Advising how to reduce client’s drug use
Providing harm reduction info and/or relevant self-help manuals
Give client information about:
The consequences of a drug conviction on travel and employment
The consequences of further or heavier drug charges
Discussing harm reduction strategies especially those relating to
Overdose
Violence
Driving under the influence
Safe practices (e.g., safe injecting, safe sex)
Offering and arranging a follow-up visit
Codependence Etiology: Family
Enmeshed family systems where user feels dependent, inadequate, and fearful of separation
Substance user strives to preserve stability of the entangled family and keeps family in crisis and focused on problems brought about by the substance use
If user improves and begins to individuate and separate from the family, the underlying familial problems emerge
Thus, family has a stake in keeping the user addicted
Drug use allows the addict to pseudoindividuate – to be both in and out of the family
Families with alcoholic members suffer guilt, remorse, and alienation
Therapeutic Interventions & Treatment
Cognitive or psychoeducational groups Behavioral therapy Group psychotherapy Individual therapy Family therapy Relapse prevention Harm-reduction strategies Pharmacologic modalities
12 step programs(AA, NA, CA)
A support group for alcoholics, addicts etc.
Al-Anon and Al-Ateen are groups for spouses, parents, and teenagers who are involved with alcoholics.
The focus is on helping these non-alcoholics learn to live and work effectively with alcoholics. The underlying belief is that family members often assume the role of enablers or co-alcoholics, perpetuating the alcoholic’s drinking patterns.
As the family attempts to adjust to the alcoholic’s lifestyle, they develop behavioral and emotional problems. Protected by the enabler, the alcoholic is spared the consequences of his or her alcoholism. The alcoholic blames he enabler and the enabler feels guilty and attempts to control family life and the behaviors of the alcoholic, e.g., throwing out liquor, taking the car keys. This does not work. Consequently, enablers feel worthless and helpless because they are unsuccessful in terminating the alcoholism.
NA is Narcotics Anonymous and WFS is Women for Sobriety.
12 Steps of AA
