Abuse intoxication and withdrawal symptoms Flashcards

Question

Alcohol withdrawal

Answer 1

1. 95% of cases are self-limited and uncomplicated 2. Always try to get a history of previous DTs or seizures 3. Absolute blood alcohol level less important than tolerance a. it is the decrease in blood alcohol level that seems to be important b. more concerning if patient has very high level but doesn’t seem intoxicated 4. Can be fatal due to delirium tremens or seizures 5. Most cases progress in a fairly predictable fashion and time-course 6. This may be greatly delayed and prolonged if patient also dependent on other CNS depressant (eg. benzodiazepine)

Answer 2

``` Stage I i. typically seen within 24 hours of last use ii. in mild cases, symptoms generally abate in 24-48 hours iii. Signs & Symptoms tremulousness anxiety hypertension agitation tachycardia derealization (mild) diaphoresis slowed thinking nausea clouded sensorium (mild) hyperactive reflexes insomnia fever headache ``` Stage II i. typically seen within 48 hours of last use ii. signs and symptoms as in Stage I but more severe iii. in addition, see hallucinations a) . generally auditory but may be visual b) . generally non-threatening c) . often called “hallucinosis” iv. patient usually with intact reality testing Stage III (“Delirium Tremens”) i. < 1% of alcohol withdrawal cases ii. typically seen about 72 hours after last use iii. may last three to seven days (if patient doesn’t die first) iv. rarely, can see this without passing through Stage II v. usually seen in patients with another, complicating medical condition vi. signs and symptoms as in Stages I and II but even more severe vii. hallucinations may be visual, olfactory, auditory, or tactile a) . small animals or people-“classic” b) . often threatening viii. patient typically very anxious and fearful with severe affective lability ix. patient is markedly disoriented; generally worse at night

Answer 3

a. independent of delirium tremens b. generalized tonic-clonic c. typically seen 12- 48 hours after last use i. may occur as much as a week later d. <5% of withdrawal e. most are self-limited f. always evaluate for other causes of seizure i. head trauma, intracranial bleed, metabolic

Answer 4

a. suggested criteria for in-patient detoxification hepatic decompensation history of DTs or withdrawal seizures significant dehydration extreme agitation malnutrition tachycardia >100/minute infection severe tremor cardiovascular collapse fever > 38.5 C cardiac arrhythmias Wernicke’s encephalopathy confusion or delirium hallucinations recent head injury with loss of consciousness

Answer 5

i. most commonly used treatment ii. have anticonvulsant effects iii. low toxicity a).less respiratory depression (compared to other CNS depressants) iv. attenuate autonomic signs and symptoms of withdrawal v. can be given parenterally (IV/IM) if patient is uncooperative vi. evidence that they are best used if titrated according to severity vii. practically, due to staffing, etc. it is often better to place the patient on a standing dose with a fixed taper viii. no clear evidence that one benzodiazepine is better than another a). lorazepam & oxazepam preferable if patient is in liver failure b). longer acting(chlordiazepoxide; diazepam) provide smoother withdrawal ix. often need much higher doses once DTs have begun x. lower doses are needed if patient is in liver failure xi. generally start with a dose and taper by 20-25%/day a). chlordiazepoxide 25-50 mg p.o. q 6 hours b). diazepam 10-20 mg p.o. or i.v. q 4-6 hours xiii. depending on patient’s tolerance, may need much higher doses

Answer 6

ß adrenergic blockers i. few well-controlled data ii. may be helpful in mild-moderate withdrawal in addition to benzodiazepine iii. need to be cautious not to “mask” signs of impending DTs iv. no anti-seizure activity v. use in combination with a benzodiazepine, if used at all Carbamazepine i. used extensively in Europe for alcohol withdrawal ii. some studies show it to be equally effective to benzodiazepines iii. may suppress kindling effect (increased severity of withdrawal with repeated episodes) Valproic Acid i. limited, but growing, research ii. theoretically, effective because of action on GABA receptors iii. well tolerated

Answer 7

Gabapentin i. currently under investigation ii. likely to be effective because of action on GABA receptors Antipsychotics i. generally not used because of effect of lowering seizure threshold ii. only used in severe cases of DTs iii. if used, use high potency Ethanol i. used PO or IV ii. more popular on surgical/trauma services iii. no controlled studies showing superiority over benzodiazepines iv. no established dosing guidelines Propofol i. sedative anesthetic ii. several reports of efficacy in severe withdrawal iii. see significant respiratory depression a) . needs to be used in ICU setting other experimental agents i. GHB, chlormethiazole, magnesium, topiramate, dexmedetomidine

Answer 8

1. Basically as for alcohol 2. Onset and duration of symptoms largely dependent on various properties of the specific drug (half-life, absorption, active metabolites, lipid solubility) 3. Minimal direct respiratory effects when used alone a. rarely fatal 4. Potential for mortality much higher when combined with alcohol or barbiturate Treatment a. coma i. Flumazenil a) . specific benzodiazepine antagonist b) . use very cautiously!!! - -->. may precipitate withdrawal (DTs/seizures) if patient dependent ii. if serum levels very high, consider dialysis/charcoal resin hemoperfusion iii. alkalinization of urine not generally recommended any more

Answer 9

1. Can be fatal 2. Basically as for alcohol a. onset typically later i. depends on half-life of particular drug ii. may be one to two weeks after last use b. course typically longer i. symptoms may last for several weeks 3. Incidence of seizures may be higher than with alcohol withdrawal

Answer 10

a. detoxification often needs to be much more gradual than for alcohol b. several ways of performing detoxification: i. tapering the benzodiazepine that the patient is already taking a). can use if patient is being prescribed the medication and you are fairly confident of the amount being used b). taper may need to be slowed toward the end of the protocol ii. converting to a long-acting benzodiazepine and tapering it a). often used if patient is using a short-acting drug iii. converting to phenobarbital a). longer acting with more stable blood levels b). some clinicians feel it is psychologically easier for the patient to detox using a medication that they are not dependent on c. Tolerance testing i. used when it is not certain how much the patient is using a). Pentobarbital challenge b). Diazepam challenge d. Anticonvulsants i. Valproic acid & carbamazepine may be effective in treating withdrawal

Answer 11

Intoxication - same as alcohol | Withdrawal - same as benzos

Answer 12

1. Typically seen within 10 seconds to 30 minutes of use a. onset depends on route of administration (smoked

Answer 13

a. largely supportive i. medications generally not necessary b. agitation i. may use a benzodiazepine if severe a) .need to be cautious in case other CNS depressants were also used c. psychosis i. high potency neuroleptic ii. only if psychosis is prolonged d. acidification of the urine is not generally recommended any more

Answer 14

Supportive only

Answer 15

Volatile Organic Compounds(toluene, acetone,butane, xylene, gasoline, etc.) i. primarily CNS depressants (act first on cortex and then on brainstem) ii. decrease the partial pressure of inhaled oxygen causing hypoxia Nitrites (amyl nitrite, butyl nitrite, isobutyl nitrite) i. exact mechanism of euphoria is not fully understood a) . likely due to generalized CNS hypoxia ii. smooth muscle relaxation from dephosphorylation of myosin light chains a) . significant vasodilation, GI sphincter relaxation, decreased rectal tone, increased penile blood flow Nitrous Oxide i. CNS depressant ii. probably acts by altering neuronal membranes iii. may have effects on dopamine and opiate systems iv. blunts respiratory drive a) . displaces oxygen leading to decreased oxygen tension

Answer 16

1. Typically seen within several seconds to several minutes of use 2. Effects typically last for 30 seconds to one hour ``` Signs & Symptoms nystagmus dizziness/light-headedness unsteady gait psychomotor retardation slurred speech incoordination depressed reflexes euphoria tremulousness blurred vision/diplopia muscle weakness giddiness nausea/vomiting lethargy stupor headache coma ``` Treatment a. supportive measures generally sufficient b. may require supplemental oxygen

Answer 17

1. Not well defined 2. Typically seen within one to two days of last use 3. May last for two to five days Signs & Symptoms tremulousness irritability diaphoresis illusions (fleeting) nausea insomnia Treatment a. supportive measures generally sufficient

Answer 18

``` headaches anxiety diaphoresis emotional instability increased blood pressure irritability tachycardia aggressiveness (“roid rage”) abdominal pain increased self-confidence increased appetite combativeness impotence paranoid behavior insomnia depression ```

Answer 19

a. largely supportive i. medications generally needed only for agitation ii. provide a quiet, stimulus-free environment b. psychosis i. high potency neuroleptic ii. only if psychosis is prolonged iii. may worsen sympathomimetic, cardiovascular, and seizure effects c. agitation i. benzodiazepine ii. rarely, causes further disinhibition

Answer 20

1. Often very non-specific 2. May begin within one day of last use insomnia depression irritability paranoia decreased energy decreased motivation decreased appetite Treatment a. Detoxification from high doses of prescribed anabolic steroids is generally accomplished by a slow taper of the steroid being used. b.Theoretically, it would be possible to detoxify a person who is abusing illicitly obtained steroids using a slow taper of another steroid.

Answer 21

B. Intoxication 1. Similar to that of other substances in the related drug class 2. Time frames vary with specific drug 3. Treatment a. very little specific data b. treat as you would other substances in the related class C. Withdrawal 1. Similar to that of other substances in the related drug class 2. Time frames vary with specific drug 3. Treatment a. very little specific data b. treat as you would other substances in the related class

Answer 22

1. Many substances not benign 2. Very few data on abuse this but is felt to be common 3. Some evidence that it is more common in women & elderly 4. Can cause significant intoxication and withdrawal depending on the drug a. especially those with anticholinergic effects