Abuse intoxication and withdrawal symptoms Flashcards
- Substance dependence
- Physiologic dependence
- Tolerance
- Withdrawal
- Sensitization
A. Substance Dependence (the disorder)- A maladaptive pattern of substance
use leading to significant impairment or distress. A chronic, progressive, relapsing disorder (disease?) of continued substance use despite negative consequences.
B. Physiologic Dependence- The state of the body as a result of the ongoing
exposure to a substance. An adaptation of the cells to the presence of a drug. Present if the person displays tolerance or withdrawal.
C. Tolerance- A diminished biological or behavioral response to repeated
administration of the same amount of a substance or, the need for increasing amounts of a substance to achieve the same effect.
D. Withdrawal- The physical and/or psychological disturbances that occur after
the cessation of use of a substance to which the body has developed tolerance.
E. Sensitization- (“Reverse Tolerance”) An increased biological or behavioral response
to repeated administration of the same amount of a substance.
Basic concepts
A. Intoxication & withdrawal syndromes are fairly specific to each class of substance
B. Time frame varies with route of administration and pharmacology of specific drug
C. Because many patients often use more than one substance at a time, the
syndromes are often not seen in their “pure” forms
D. Synergistic effects are seen when certain types of substances are combined – Such as sedatives or alcohol with opioids
E. Often, illicit drugs are “cut” with other substances. This can confuse the picture.
Intoxication you can die from
Cocaine Opioids Amphetamines Phencyclidine Benzodiazepines Steroids Alcohol Inhalants Barbiturates Designer Drugs
Withdrawal you can die from
Alcohol
Barbiturates
Benzos
Opioids –> neonates and severely ill
Cocaine intoxication
- May result in cardiac arrhythmia, MI, stroke, rhabdomyolysis and death
- Typically seen within 7 seconds to 30 minutes of use
a. onset depends on route of administration (smoked«<)
coma auditory hallucinations
headache anorexia
insomnia
hyper sexuality
nausea/vomiting
muscle aches
bruxism
Cocaine intoxication - treatment
a. largely supportive
i. medications generally needed only for agitation
ii. provide a quiet, stimulus-free environment
b. seizures
i. diazepam, phenytoin or phenobarbital
ii. intravenous or via nasogastric tube
c. psychosis
i. high potency neuroleptic
ii. only if psychosis is prolonged
iii. may worsen sympathomimetic, cardiovascular, and seizure effects
d. agitation
i. benzodiazepine
ii. rarely, causes further disinhibition
e. chest pain
i. benzodiazepine
ii. nitroglycerin, if severe, with EKG changes
Cocaine withdrawal
- Typically seen within a few hours to several days after last use
- May last for several days
- Severity depends on amount, chronicity, and route of administration
Signs & Symptoms fatigue dysphoric mood hypersomnia suicidal ideation increased appetite vivid, unpleasant dreams psychomotor retardation irritability lethargy cocaine craving
Treatment
a. supportive only
b. avoid temptation to start an antidepressant immediately as this does not
reverse the depression
Amphetamines intoxication
- Basically the same as for cocaine
- Effects may last up to 24 hours, depending on drug and route of administration
- Psychotic symptoms more common than with cocaine
- Treatment
a. basically the same as for cocaine
b. largely supportive
Amphetamines withdrawal
Same as cocaine, symptoms may last longer
Caffeine intoxication
- Typically seen with >250-500mg of caffeine (>3-5 cups brewed coffee)
- Can be lethal at doses of 5-10 grams
Signs & Symptoms
tachycardia restlessness
palpitations nervousness/excitement
frequent urination insomnia
diarrhea rambling/rapid speech
muscle twitching inexhaustibility
flushed face psychomotor agitation
Treatment
a. Primarily supportive
Caffeine withdrawal
- Not listed in DSM-IV but definitely seen clinically
- Generally mild
- Unclear relationship to dose or duration of use
a. Some reports of withdrawal after less than one week of use - Typically begins 12-24 hours after last dose of caffeine
- May last from 2-7 days
Signs & Symptoms headache difficulty concentrating nausea fatigue vomiting drowsiness muscle aches depressed mood hot & cold spells irritability anxiety
Treatment
a. tapered doses of caffeine
b. symptomatic treatments for headache, etc.
Hallucinagen intoxication
Rarely life-threatening except as related to delusions or perceptual distortion
- Typically seen within several minutes to a few hours of use
a. depends on specific drug, route of administration and setting - Effects typically last for several hours
a. exception with DMT which is very short-acting - Reality testing is usually intact
Signs & Symptoms tachycardia intensified perceptions diaphoresis depersonalization pupillary dilation derealization blurred vision illusions palpitations synesthesia tremulousness visual hallucinations incoordination auditory hallucinations nausea/vomitting tactile hallucinations restlessness delusions disorientation mood lability hyperthermia impaired judgment
Hallucinagen intoxication treatment
a. largely supportive
i. medications generally not necessary
b. agitation
i. benzodiazepine if moderate
ii. may add an antipsychotic if severe
a) . high potency safer
c. psychosis
i. a few studies have shown that antipsychotic shorten the episode
Hallucinagen withdrawal
Hallucinogen persisting perception disorder (“flashback”)
No real withdrawal syndrome
- Occurs after the cessation of use of hallucinogens
- May continue for several months to many years after last use
- Often triggered by stress, fatigue, anxiety, dark environment, other drug use
- Reality testing remains intact
Symptoms geometric hallucinations flashes of color trailing images intensified colors positive afterimages halos around objects macropsia/micropsia peripheral-field images
Opioid intoxication
- Can be fatal due to central respiratory depression
- Typically seen within seconds to minutes of use
a. onset depends on route of administration (smoked«<oral) - Effects typically last for several hours
a. largely dependent on half-life of the particular substance
Signs & Symptoms
pupillary constriction(except anoxia) euphoria (initially)
drowsiness
apathy
slurred speech impaired judgment
respiratory depression impaired attention
coma inattention to environment
seizures (extremely rare) psychomotor retardation
constipation psychomotor agitation(rare)
pruritis
Opioid intoxication treatment
a. first response is to establish adequate airway
b. Naloxone (Narcan)
i. a virtually pure mu antagonist
ii. short acting
iii. give IV (can be given IM if no IV access)
iv. 0.3-0.5mg is often enough to reverse respiratory depression
v. use cautious increments to avoid precipitating acute withdrawal
vi. response is typically seen in 1-2 minutes, generally, if no response to 5-10mg of naloxone, another etiology is likely to be responsible
vii. may need to repeat dose if overdose is with an opiate with a long t1/2
Opioid withdrawal
- Typically seen within 6-24 hours of last use (for shorter-acting drugs)
a. may be several days for longer-acting drugs (methadone and Oxycontin) - Acute symptoms last for one to seven days (peak within one to three days}
a. may last for weeks with longer-acting drugs - Sub-acute symptoms can last for weeks to months
- Not life-threatening except in neonates and severely debilitated
Signs & Symptoms pupillary dilation dysphoria piloerection anxiety diaphoresis irritability lacrimation restlessness rhinorrhea achy feeling (especially back and legs) nausea/vomiting abdominal cramping diarrhea craving fever insomnia tachycardia hyperalgesia hypertension yawning involuntary muscle movements seizures (in dependent neonates)
Opioid withdrawal treatment
a. usually treat pharmacologically even though not life threatening
b. Clonidine
i. alpha 2-adrenergic agonist
ii. appears to work by suppressing autonomic activity in locus ceruleus
iii. reduces some physiological signs/symptoms of withdrawal
iv. does not really reduce psychological symptoms (ie. craving, lethargy)
v. can be used alone or in combination with other treatments
vi. no time limitation as it is not a scheduled substance
vii. decreased blood pressure is most significant problem
viii. can also cause sedation
a) .caution patient about driving and operating equipment
ix. need to be cautious tapering too quickly (rebound hypertension)
x. use cautiously if patient on TCA or beta-blocker
xi. do not use if patient is pregnant
c. Lofexidine
i. similar to clonidine
ii. much less effect on blood pressure
iii. currently not used in U.S.
d. Methadone
i. long acting mu opioid agonist
ii. can be used legally for opioid withdrawal for 72 hours on out-patient basis
a) . needs to be administered by the physician
iii. can be used for as long as needed in general hospital
a) . provided patient admitted for reason other than addiction
iv. generally recommended to start with 20mg/day orally if moderate use is suspected and 30 mg/day orally if heavy use is suspected
v. should suppress withdrawal symptoms within 60 mins
a) . if not, an additional 5-10mg can be given
vi. taper by 5-10mg/day
e. Buprenorphine
i. a partial mu opioid agonist
ii. rapid onset
iii. dissociates slowly from opiate receptors
iv. ceiling effect on all mu opioid mediated effects
a) . minimal respiratory depression
b) . produces lower level withdrawal signs/symptoms
c) . analgesic effects good for mild to moderate pain
v. DEA schedule III
vi. sublingual form which combines buprenorphine with naloxone (Suboxone)
a) . theoretically reduces the potential for abuse
vii. DEA waiver required to use on out-patient basis
viii. can be used for as long as needed in general hospital without DEA waiver
a) . provided patient admitted for reason other than addiction
ix. generally recommended to start with 4-8mg/day sublingually
f. Other mixed agonist/antagonists or partial agonists
i. butorphanol, dezocine, nalbuphine, pentazocine
g. Other mu opioid agonists
i. not well studied
h. ”Rapid Detox”
i. uses clonidine, benzodiazepine and naltrexone
ii. naltrexone precipitates withdrawal to “speed up the process”
i. ”Ultra Rapid Detox”
i. uses clonidine, naltrexone and general anesthesia
ii. performed in “specialized” centers by anesthesiologists
iii. claim to achieve full detoxification in 24 hours
iv. no good studies demonstrating efficacy or benefits over other methods
v. added risk of general anesthesia
vi. expensive
