Addiction I and II

Question 1

toxdrome and withdrawal of stimulants (amphetamines, methylphenidate, MDMA, cocaine)

Answer 1

tox: increase HR, BP, hot, diaphoretic, euphoria, mania, pyschomotor agitation, anxiety, psychosis, paranoia
withdrawal: hypersomnolence, depression, suicidality, dysphoria

Question 2

toxdrome and withdrawal of cannavis

Answer 2

tox: increase HR, red eyes, dry mouth, increase appetite
withdrawal: mood changes, decrease appetite/sleep

Question 3

toxdrome and withdrawal of opioids

Answer 3

toxidrome: decreased RR, decreased LOC, miosis
withdrawal: mydriasis, wet (N/V, diarrhea, rhinorrhea), increase pain, piloerection, yawning

Question 4

toxdrome and withdrawal of alcohol

Answer 4

tox: decreased LOC, impiared memory, incoordination
withdrawal: tremor, seizures, insomnia, delirium

Question 5

Risk Factors for Concurrent Disorders with Addiction

Answer 5

Family problems

Past or ongoing abuse or trauma

Family history of concurrent disorders

Discrimination

Genetic factors or predisposition

Unemployment, poverty, or unstable income

Lack of social network

Stress related to work or school

Adverse childhood experiences.

Question 6

DSM v CRITERIA FOR SUBSTNACE USE DISORDER

(chew that cop)

Answer 6

C; cut down

H; health

E; excessive use

W; withdrawal

T; time

H; hazardous use

A; activities

T; tolerance

C; craving

O; obligations

P; personal problems

Question 7

4 C’s of addiction

Answer 7

The 4C’s : compulsions, loss of control, consequences, cravings

Question 8

how many hours after the last drinke would you get the shakes? alcohol withdrawal seizures? visual/auditory hallucinations? delirium tremens?

Answer 8

Course of Withdrawal occurs 12-48hr after having drinking and can be life-threatening

• Stage 1 (12-18hr after last drink): “the shakes” tremors, sweating, agitation, anorexia, cramp, diarrhea, sleep disturbances (sympathetic overdrive)

• Stage 2 (7-48hr): alcohol withdrawal seizures (tonic-clonic)

• Stage 3 (48hr): visual/auditory/olfactory/tactile hallucinations

• Stage 4 (3-5d): delirium tremens (delirium + diaphoresis, ­HR, ­ RR, hand tremor, insomnia, psychomotor agitation, anxiety, N/V, visual/auditory/tactile hallucinations, seizures), confusion, agitation, tremors

Question 9

Outline the SBRIT way of managing alcohol use disorder

Answer 9

• SBRIT: screen, brief intervention, referral to treatment

o Screen with CAGE: 1+ in women and 2+ in men

o Motivational interviewing

o Intervention with FRAMES: feedback, responsibility, advice, menu of option, empathy and self-efficacy

Question 10

FRAMES intervention

Answer 10

feedback, responsibility, advice, menu of options, empathy, self-efficacy

Question 11

key lab investigations for alochol use disorder

Answer 11

• Blood ethanol levels, CBC (macrocytosis), LFTs, Vit B12, folate, lytes
• CIWA: these should be done often!

o Physical (5): N/V, tremors, agitation, paroxysmal sweats, headaches

o Psychological/cognitive (2): anxiety, orientation/clouding of sensorium

o Perceptual (3): tactile disturbance, auditory disturbances, visual disturbances

o Max score is 67. Mild<10; moderate 10-20; severe>20

Question 12

type of CBC findings with AUD

Answer 12

macrocytosis

Question 13

outline the scoring system for the CIWA scale

Answer 13

CIWA: these should be done often!

o Physical (5): N/V, tremors, agitation, paroxysmal sweats, headaches

o Perceptual (3): tactile disturbance, auditory disturbances, visual disturbances

o Psychological/cognitive (2): anxiety, orientation/c_louding of sensorium_

o Max score is 67. Mild<10; moderate 10-20; severe>20

Question 14

Key basics for withdrawal management of AUD

Answer 14

Basic: diazepam (if CIWA>10), thiamine, supportive hydration/nutrition, observe and repeat CIWA

Admit to hospital if

§ Still in withdrawal after >80mg of diazepam

§ Delirium tremens, recurrent arrhythmias or multiple seizures

§ Medically ill or unsafe for discharge

Question 15

treatment for AUD (not withdrawal symptoms– this is long term treatment)

Answer 15

first line: naltrexone and acamprosate

second line: gabapentin and topirameate

third line: disulfiram

psyco: AA, CBT, addiction counselling, SMART recovery

Question 16

contraindication for naltrexone

Answer 16

cannot have AST or ALT>3 times upper limit of normal

cannot have decompensated cirrhosis or acute hepatitis.

Question 17

contraindications of acamprosate

Answer 17

cannot have renal failure, pregnant, or breasfeeding.

CAN be used with cirrhosis

Question 18

key management for tobacco use disorder

Answer 18

Management: nicotine replacement therapy, bupropion/wellbutrin and varenicline

Question 19

Key screening tool for oioid use disorder

Answer 19

Screening: COWS score to measure inpatient withdrawal

Question 20

mandatory management for opiate use disorder

Answer 20

MUST OFFER OAT (opiate agonist therapy)

first line: suboxone (naloxone/buprenorphine)–> partial opioid agonist with high affinity, ceiling effect. Naloxone in it is just to prevent injection. can be in tabs

second line: methadone –> FULL mu opioid agonist. Methadone is nearly always daily witnessed ingestion. Typical titration is 10 mg/3 days. Can cause long Qtc. If >550, need immediate acute care cardiology and addiction med consult.

3rd line: Kadian (24 hour formulation of morphine)–> full mu agonist.

4th line: injectable hydromorphone (iOAT)

Question 21

first, second, third and fourth line therapies for opioid agonist therapies

Answer 21

first line: suboxone (naloxone/buprenorphine)–> partial opioid agonist with high affinity, ceiling effect. Naloxone in it is just to prevent injection. can be in tabs

second line: methadone –> FULL mu opioid agonist. Methadone is nearly always daily witnessed ingestion. Typical titration is 10 mg/3 days. Can cause long Qtc. If >550, need immediate acute care cardiology and addiction med consult.

3rd line: Kadian (24 hour formulation of morphine)–> full mu agonist.

4th line: injectable hydromorphone (iOAT)

Question 22

aspects of harm reduction for opioid use disorder

Answer 22

• Harm Reduction: naloxone kit, IVDU screening, supervision, safe prescribing of drugs with addictive prone drugs

Question 23

how should you manage a GHB overdose

Answer 23

benzos

Question 24

outline sequential, parallel or integrated treatment models for concurrent disorde rs

Question 25

definition of concurrent disorder

Answer 25

Definition: persistent mental illness + substance use disorder or gambling addiction +/- substance induced disorder

Epi: more of an expectation than an exception (ie very common in substance use disorders); 7.9M have a concurrent disorder. Highest in bipolar, schizophrenia, PTSD, ADHD and eating disorders

Question 26

4 steps to motivational interviewing

Answer 26

1. planning
2. evoking commitment/hope/confidence
3. identify and focusin a target of chagne
4. engaging and settling into a helpful conversation

Question 27

DBT for Addiction: increase ___, interpersonal __, ___ tolerance, ___ regulation → “replace pills with skills”

Answer 27

DBT for Addiction: increase mindfulness, interpersonal effectiveness, distress tolerance, emotional regulation → “replace pills with skills”

Question 28

12-Step Facilitation Model: highly accessible + free, modified extensively to cater to differing ____ system, emphasis on ____ addiction as a ___ that can be arrest but never ___, enhancing individual maturity and spiritual growth while minimizing self- centeredness

Answer 28

12-Step Facilitation Model: highly accessible + free, modified extensively to cater to differing belief system, emphasis on accepting addiction as a disease that can be arrest but never eliminated, enhancing individual maturity and spiritual growth while minimizing self- centeredness

Question 29

outline the acceptance and commitment therapy

Answer 29

Acceptance and Commitment Therapy: combination of acceptance, mindfulness and values- based therapy. Fosters a sense of psychological flexibility and being mindful of inner experience to better engage in a more values-focus life

Ask → what are your values in your new life? Then work towards fulfilling your values.

ex/ someone says creating relationships is a value → every week tailor therapy in such a way that makes them feel like they are cultivating and nurturing connections with other people.