Addiction Flashcards by Scott Murphy

What neurotransmitter systems plays a shared role in the binge/intoxication stage for all drugs of abuse?

Dopamine

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What behavioral phenomena is thought to be due to elevated brain reward thresholds during acute drug abstinence?

Increased negative motivational/affective state during acute abstinence

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What brain area or system is most directly implicated in emotional dysregulation during the withdrawal/negative affect stage of addictive behavior?

Hypothalamic-pituitary-adrenal (HPA) axis

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What brain area or system is most directly involved in executive control over incentive salience/preoccupation?

Prefrontal cortex, through projections to ventral tegmental area

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What is the correct sequence of physiological/molecular events leading to the synaptic plasticity that underlies addiction?

Reduction in inhibitory G-protein levels -> increased cyclic adenosine monophosphate (cAMP) levels -> increased protein kinase A (PKA) activity -> cAMP
response element binding protein (CREB) regulation of gene expression -> synaptic plasticity

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What statement best describes the genetic influences on the development of substance use disorders?

Substance use disorders are inherited via risk alleles that require a gene-by-environment interaction

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From the evidence to date, what statement about the heritability of alcohol and substance use disorders is most accurate?

Twin studies have estimated heritability of alcohol dependence, ranging from 50% to 60%.

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What statement about genetic susceptibility for developing alcohol dependence is most accurate?

Increased risk for alcohol dependence has been mapped to an alcohol dehydrogenase gene cluster on chromosome 4q (ADH4).

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Which of the following statements best describes the role of the DRD2 locus in susceptibility to drug or alcohol dependence?

For nicotine dependence risk, evidence of association is stronger for single nucleotide polymorphisms at loci TTC12 and ANKK1, which are located near the DRD2 locus on chromosome 11

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Genomewide association studies have mapped susceptibility for nicotine dependence to a cluster of nicotinic receptor genes where?

chromosome 15

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What is the most widely used illicit drug or drug class internationally?

Cannabis is the most widely used illicit drug internationally; it is used by an estimated 119–221 million people worldwide (2.6%–5.0% of the population)

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Globally, epidemiological surveys consistently show that men are much more likely than women to have a substance use disorder. In the United States, use of which substance is associated with being a white female?

Stimulant use is associated with being young, female, and white or Hispanic, with increased use in western and southwestern states of the United States

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What symptom has been removed from DSM-5 (American Psychiatric Association 2013) because it was of such high severity that it had little clinical utility?

substance-related legal problems

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The National Epidemiologic Survey on Alcohol and Related Conditions (Lopez-Quintero et al. 2011) indicated that transitions from alcohol use to dependence were associated with what factors?

young, black, male, with comorbid disorders and family history

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Epidemiological surveys are informative about who becomes addicted to substances. In developed countries, having an alcohol use disorder is associated with what?

Being male, young, unmarried, and of low socioeconomic status

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Culturally sensitive care can be delivered through several models, and each model has its own challenges. Which model runs the risk of marginalization?

separate services

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By the early 1920s, most of the opioid detoxification clinics were closed. What was an important factor in this change?

The clinics were deemed a failure because the

patients did not become abstinent

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Many well-known substance abuse treatment programs have historically expressed nonacceptance of medications as treatment options to prevent relapse. What best accounts for this decision?

Medication use conflicts with their treatment

philosophy

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Why is detoxification the most common form of treatment for substance use disorders?

Detoxification is covered by most insurance programs,

even state Medicaid programs

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What best describes the position taken by the Central Council of Alcoholics Anonymous (AA) regarding individuals who are taking physician prescribed treatment medications for substance dependence?

Use of physician-prescribed treatment medications is permitted

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Why have some clinicians denied that naltrexone is effective in patients with alcohol use disorder?

Naltrexone does not reliably produce longterm

abstinence from alcohol; rather, it reliably produces a reduction in heavy drinking.

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What best accounts for why there has been little motivation for pharmaceutical companies to pursue medications to treat substance use disorders?

Medications already available are used so

little

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Name 4 medical conditions associated with alcohol use disorder.

cerebellar degeneration, cardiomyopathy, pancreatitis, aspiration pneumonia

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What is the most useful brief screening for alcoholism?

AUDIT-C: How often did you have a drink containing alcohol in the past year? How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? How often did you have six or more drinks on one occasion in the past year?

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What is a proven effect of brief intervention (BI) for patients with alcohol use?

Reduction in risky drinking by 10% at 1 year

Define "risky" drinking.

The National Institute on Alcohol Abuse and Alcoholism (2007) defines “risky” amounts as more than 14 drinks per week on average or more than 4 drinks in a day for men less than 65 years of age, and more than 7 drinks per week or three in a day for women and for men age 65 or older. A standard drink has 12–14 grams of ethanol, which is the content found in 12 ounces of regular-strength beer, 5 ounces of nonfortified wine, and 1.5 ounces of 80-proof liquor.

What brain region is neural activity both correlated with cue-induced alcohol craving and reduced by successful treatments?

Ventral striatum/nucleus accumbens

What acute effect of alcohol is a phenotypic marker of alcoholism risk?

Low sedative-ataxic effects

What effect is linked to allelic variation of the OPRM1 gene?

Level of alcohol-induced dopamine release within the ventral striatum/nucleus accumbens

What physiological process is thought to be most directly involved in the acute withdrawal syndrome that occurs upon cessation of heavy drinking?

Rebound hyperactivity of glutamatergic neurotransmission

The binding of corticotropin-releasing hormone (CRH) to what brain region leads to increased behavioral reactivity to stress after cessation of heavy alcohol use?

Amygdala complex

What laboratory assay would be best to utilize during alcohol treatment if your goal is to detect heavy alcohol use and monitor drinking status?

Carbohydrate-deficient transferrin (CDT)

A 65-year-old patient with a history or delirium tremens is on your service for management of alcohol withdrawal. If the patient’s withdrawal is left untreated, when might you expect to see symptoms of delirium tremens emerge?

2–4 days from last drink of alcohol

What is delirium tremens?

fluctuating disturbance of consciousness, agitation and tremulousness, autonomic instability, hyperpyrexia, persistent visual and auditory hallucinations, and disorientation

To prevent precipitation of Wernicke’s encephalopathy in a patient with alcohol use disorder, thiamine should be administered before what?

glucose

A 33-year-old woman with a decade-long history of cocaine use tearfully states that she wants nothing more than to reconcile with her ex-husband, have more visits with her children, and get a job. However, she never spends much time on these goals before she prostitutes herself in order to use again. She knows she is making bad decisions, but when faced with a choice between feeling good quickly from cocaine versus possibly feeling good later upon achieving a goal, she always chooses the high. What is the term for this decision-making tendency related to chronic stimulant use?

Delayed discounting is the tendency to choose immediate rewards over larger, delayed rewards, associated with decreased recruitment of dorsal brain circuitry including dorsolateral prefrontal cortex and anterior cingulate cortex.

Methamphetamine and cocaine have similar properties, but methamphetamine is more neurotoxic because of which feature that cocaine lacks?

Promotion of dopamine release

N-methyl-D-aspartate (NMDA) antagonists prevent both dopaminergic and serotonergic neurotoxicity, suggesting these medications could decrease methamphetamine toxicity by interference with which NMDA receptor binding neurotransmitter?

Glutamate

Which GABA–modulating medication was found to decrease relapse in cocaine users?

Topiramate, which enhances GABA and blocks alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptors, decreased the likelihood of relapse to cocaine use.

What would the expected presentation be for a longtime methamphetamine user who abruptly discontinues use?

Depression

What approach to the treatment of cocaine addiction, when combined with contingency management, has been shown to reduce cocaine use more effectively than either treatment alone or placebo?

Bupropion

What medication targeting neuroadaptations to chronic cocaine use, when combined with amphetamine salts, has been shown to reduce cocaine use compared with placebo?

Topiramate

When compared with cocaine, methamphetamine (MA) exhibits what important difference in neuronal effects?

MA induces intracellular dopamine-containing vesicles to dock with the cell membrane and leak dopamine into the synaptic cleft.

The police bring a 27-year-old man with a history of anxiety and cannabis dependence to the emergency room with new-onset paranoid delusions and acute agitation. A friend provides history that the patient was smoking methamphetamine (MA) for the prior 2 days. To manage the patient’s toxicity, including the agitation, which of the following would be the most appropriate intervention?

Administer haloperidol combined with lorazepam in repeated doses over a 12-hour observation period

What is a problem uniquely experienced by adult MA-dependent women associated with their methamphetamine (MA) use?

Over 70% of adult MA-dependent women report histories of physical and sexual abuse and are more likely than men to present for treatment with greater psychological distress.

The Matrix Model, a blended treatment approach that has shown efficacy for treatment of methamphetamine (MA) use disorders, incorporates what components?

Individual and group cognitive-behavioral therapy (CBT), family education, motivational interviewing, and 12-step program participation.

There are no medications that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of methamphetamine (MA) addiction. What drugs have only positive results from clinical trials in human beings demonstrating reduced stimulant use/prevention of relapse to MA or amphetamine-type stimulants (ATSs)?

Mirtazapine, naltrexone, and bupropion

A cancer patient with painful bony lesions has been getting prescriptions for oxycodone from her oncologist for the pain. She reports to her oncologist that for 2 months her 8/10 pain would go down to 3/10 with the prescribed dose, but recently, she found she was getting less and less relief with that same dose. She tried an increased dose, and the pain went down to 3/10. She now worries about running out of medication too quickly. Which best describes the phenomenon?

Tolerance.

How long can a newly abstinent, seriously heroin-dependent person expect to experience the most intense signs and symptoms of withdrawal?

48–96 hours

What kind of neuron tonically inhibits dopaminergic neurons in the ventral tegmental area (VTA) and is of main importance in opioid addiction?

GABA

Which medication or category of medication is made from the opium poppy?

Opiate

The stress-responsive hypothalamic-pituitary-adrenal (HPA) axis is profoundly disrupted by heroin addiction and normalized by maintenance treatment with which substance?

Methadone

You admit a 25-year-old patient for opioid detoxification. He tells you he is using five bags of heroin intravenously per day. Approximately how many hours after his last heroin use would you expect withdrawal to begin?

8–12 hours

A 35-year-old woman presents to the emergency room in opioid withdrawal. What is the largest initial dose of methadone that you can safely give to her?

30 mg

What is one potential advantage of a clonidine-naltrexone opioid detoxification compared with either methadone taper or clonidine detoxification?

Reduction in time to detoxification

What distinguishes methadone from prior treatments for opioid dependence?

Efficacy

In treatment of opioid addiction, methadone exerts its therapeutic effect via which pharmacological mechanism?

Withdrawal suppression

In the United States, methadone treatment for opioid dependence is usually provided in which type of setting?

Opioid treatment programs

Which of the following correlates with better outcomes in methadone treatment for opioid dependence?

Nonpharmacological treatment

What is one of the most common adverse effects of methadone maintenance therapy?

Constipation.

What is the mechanism of action of buprenorphine?

Mixed opioid agonism-antagonism.

Who can prescribe buprenorphine for opioid dependence in the United States?

Physicians with special training and a special Drug Enforcement Administration number.

You start a patient on buprenorphine and the patient complains of anxiety, insomnia, nausea, and diaphoresis. What would be the best course of action to take?

Wait a few days or decrease the starting dose | to minimize opioid withdrawal.

What medication acts exclusively as a nonselective opioid antagonist, with no opioid agonist properties?

Naloxone

Naltrexone has what effect in addition to opioid antagonism?

partial, low-efficacy agonist at the K-opioid receptor

Naltrexone’s effect on hypothalamic-pituitary-adrenal (HPA) and hypothalamicpituitary-gonadal (HPG) activity may account for what adverse response in some patients upon treatment initiation?

Anxiety

What accounts for approximately half of the deaths of heroin users in the United States?

Overdose

In addition to supportive care, what is the treatment of choice in acute opioid overdose?

naloxone

Compared with those who discontinue opioid agonist treatment, individuals who discontinue opioid antagonist treatment are at much greater risk for what outcome, cited by experts as a reason that antagonist treatment is “unacceptable”?

Relapse and overdose

What two hallucinogenic drugs have addictive potential?

ketamine, PCP

A 22-year-old woman presents to the medical emergency department with friends after she complained to them of chest pain at a party. She admits to taking some sort of “pill” around 2 hours prior to presentation. In the emergency department, she tells staff members that she “is in love with them” and wanders into other patients’ rooms, trying to hug them. Her pupils are dilated, blood pressure is 180/ 100, and pulse is 120. Her affect is euphoric, and she exhibits no motor impairment. Which substance did the patient most likely ingest?

Methylenedioxymethamphetamine (MDMA)

What is the timing of onset and duration of the effects of MDMA?

onset of effects about 30–60 minutes after administration and effects lasting around 4–6 hours

Methylenedioxymethamphetamine (MDMA) has been found to have benefit for what psychiatric condition?

PTSD

What pharmacological properties make nicotine addictive and promote the maintenance of nicotine dependence?

Nicotine concentrations in the brain decline rapidly. Symptoms of cravings may emerge in dependent smokers in as little as 20–30 minutes after smoking a cigarette.

Your patient tells you that she smokes cigarettes. According to the U.S. Preventive Services Task Force recommendations, what should you do next?

Advise her to quit

What does motivational interviewing entail?

Asking questions designed to elicit client’s own incentives for behavior change.

Which psychosocial intervention helps individuals quit tobacco by promoting increased awareness of bodily sensations, acceptance of craving symptoms, and uncoupling of cravings and linked positive reinforcements?

Mindfulness.

Which nicotine replacement therapy (NRT) has the highest abuse liability?

Nasal spray.

You have a patient with schizophrenia and tobacco use disorder, treated with olanzapine and quetiapine. You have recently prescribed varenicline and nicotine replacement therapy (gum), and the patient was able to quit smoking. The patient reports increased sedation, hypersomnia, dizziness, and dry mouth. What would be the best course of action to take with this patient?

Decrease olanzapine dose because discontinuation | of tobacco increased olanzapine levels.

The weight of evidence suggests that all sedative-hypnotics as well as alcohol interact with which receptor?

GABA-A

For benzodiazepines, which of the following adverse effects is most likely to persist even after several years of daily administration?

Memory impairment.

Physiological dependence to benzodiazepines occurs in approximately half of patients who have received daily medication for which length of time?

> 4 months

A 52-year-old man with a history of sedative-hypnotic use disorder and comorbid panic disorder presents to a hospital seeking detoxification from alprazolam. He has been taking the drug daily for the past year at dosages as high as 12 mg/day. He has no other medical problems and is physically healthy on examination. He appears motivated for detoxification albeit fearful of side effects and admits that in the past he has left detoxification facilities prematurely because of a worsening of his anxiety symptoms. Which of the following first steps would be most helpful to successfully detoxify this patient?

Rapidly cross-taper the patient to clonazepam.

Which drug is often combined with anabolic-androgenic steroids (AASs) to reduce undesirable side effects?

Tamoxifen

What is the most likely physical exam finding associated with anabolic-androgenic steroid (AAS) use in men?

Testicular atrophy

What psychotropic medication is most appropriate for treating muscle dysmorphia, a form of body dysmorphic disorder seen in users of anabolic- androgenic steroids (AASs)?

Fluoxetine.

What are some typical lab abnormalities in users of steroids?

+AST, +ALT, +LDH, +CK, +T. bili., +RBC, -LH, -FSH, -HDL, +LDL

A 42-year-old man comes to your office reporting new onset of anhedonia, low mood, poor concentration, decreased sex drive, and fatigue. He admits that 1 week ago, he abruptly stopped using anabolic-androgenic steroids (AASs). What would the best treatment strategy be for you and your endocrinologist colleague to address the patient’s complaints?

Start clomiphene and human chorionic gonadotropin (HCG), with the addition of testosterone depending on level.

After consumption of marijuana, what symptom is most likely to persist?

Impairment in motor coordination

Which of the following acute symptoms is a person most likely to experience when smoking hash oil compared with marijuana?

Paranoid thoughts

What is a rough mixture of flowers, leaves, stems, and seeds with an average THC content of 1%–3%?

bhang or grass

What is a more refined selection of unfertilized female lowers with a THC content of 3%–8%?

ganja or sinsemilla,

What is a collection of resin glands (“trichomes”) obtained from the sterile buds of the plant with a THC content of 10%– 15%?

charas or hashish

What is produced by extraction of Cannabis preparations with an organic solvent, a product that contains up to 30%–35% THC?

hash oil, dabs, or shatter

What are some symptoms of marijuana withdrawal?

irritability, anger, or aggression; nervousness or anxiety; sleep difficulty; decreased appetite or weight loss; restlessness; depressed mood

What is a rationale for the illicit use of JWH-018 as an alternative to marijuana?

Psychotropic effects

Why was the clinical development of rimonabant stopped?

CB1 receptor blockade produces in human subjects a series of psychiatric adverse events (including anxiety, depression, and suicidal thoughts)

The synthetic cannabinoids such as K2 and Spice generally have what characteristics?

They are full agonists at CB1 and CB2 receptors and are more potent than THC, with a greater risk of adverse effects

The reinforcing effects of cannabis are attributable to what neurochemical property?

Cannabis use corresponds to dopamine release in the ventral striatum, increased extracellular dopamine in the nucleus accumbens, and increased activity of dopamine neurons in the ventral tegmental area.

What is a finding of randomized controlled trials (RCTs) studying medications for the treatment of cannabis use disorder?

N-Acetylcysteine (NAC) and gabapentin have been shown to reduce marijuana use.

What are the maximum safe drinking limits for men

4 drinks/day; 14 drinks/week

What are the maximum safe drinking limits for women

3 drinks/day; 7 drinks/week

As of 2011, what is the most common means of referral to Alcoholics Anonymous (AA)?

Referral by a health care provider.

According to the latest Alcoholics Anonymous (AA) survey, what is the most common length of sobriety among AA members?

> 10 years

During an Alcoholics Anonymous (AA) meeting, a member tells his story to the group in attendance, putting emphasis on the effect of alcohol in his life, how he got sober, and what he is doing now to stay sober. What type of AA meeting was this member most likely attending?

Speaker meeting.

According to Project MATCH, how did the rates of abstinence at 12-month followup differ among patients assigned to cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF)?

TSF clients reported the highest rate of abstinence

Which specific psychological mechanism is one of the most important and well-studied causal mechanisms explaining substance use behavior change among 12-step program members?

Self-efficacy, or confidence to remain abstinent

Increased Alcoholics Anonymous (AA) attendance has been associated with reduction in which of the following negative affect states?

Depression.

How prevalent are substance use disorders (SUDs) in women as compared with men?

The prevalence of SUDs in men (10.4%) was significantly higher than that in women (5.7%).

Which psychiatric comorbidity is more likely to occur in men with substance use disorders (SUDs) than in women?

Attention-deficit/hyperactivity disorder.

What is the “telescoping” effect of substance use disorders (SUDs) in women?

Women have significantly more medical, psychiatric, and adverse social consequences as a result of their addiction.

What is the relationship between temporal onset of substance use disorders (SUDs) and comorbid psychiatric disorders in women?

Women receiving treatment for SUDs are likely to have histories of physical or sexual abuse.

What is an important consideration in the treatment of women with substance use disorders (SUDs)?

Addressing psychiatric comorbidities leads to better outcomes.

Among all drugs of misuse, which ones have the most conclusive evidence indicating that prenatal exposure results in negative maternal, fetal, and later development outcomes?

Alcohol and tobacco

What treatment is recommended, because of its efficacy and safety profile, for treatment of nicotine use disorder in pregnant women?

Voucher-based reinforcement therapy

What is the appropriate recommendation to give to a pregnant woman using opioids regarding breastfeeding her baby?

Breastfeeding is recommended for opioidagonist– | maintained women who are not using other drugs, unless there are medical contraindications.

Current use of which illicit substance has been increasing among adolescents, after a prior period of decline?

Marijuana.

Developmental patterns in which brain regions lead to particular vulnerability for substance use disorders during adolescence?

Curvilinear development of the striatum.