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NB3 > Addiction Medicine 1 > Flashcards

Addiction Medicine 1 Flashcards

1
Q

What is a substance use disorder?

A

A maladaptive pattern of substance use over the past 12 months that leads to impairment in social, physical or occupational functioning. It is characterized by
≥2 of 11 symptoms within a 12-month period

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2
Q

What is substance dependence?

A

A non-DSM term referring to the compulsive use of a substance despite negative consequences.
• Psychological dependence: Compulsive substance use without withdrawal and tolerance
• Physical dependence: Compulsive drug use with withdrawal and tolerance

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3
Q

What is intoxication?

A

The development of physical or psychological symptoms due to the recent ingestion of a substance and its CNS effects.

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4
Q

What is withdrawal?

A

The development of physical or psychological symptoms after the reduction or cessation of intake of a substance.

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5
Q

What is tolerance?

A

A need for increased amounts of substance to achieve the same physical and psychological effects.

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6
Q

What are the symptoms of substance use disorder?

A
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7
Q

What causes addiction?

A

Initial drug use is a conscious decision, voluntary→attributable to multiple biopsychosocial factors.

• Continued, compulsive use of drugs (i.e. addiction) is due to the effects of the drug on brain functioning.

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8
Q

What are the biopsychosocial factors of addiction?

A 
Psychosocial:
• Factors that make a drug’s reinforcing effect more potent
• Age of first use
• Method of administration
• Presence of other mental illness 
• Coping strategy for emotions
  • Genetics:
  • Account for 40-60% of vulnerability
  • What is inherited is unknown (e.g. less dopamine availability making someone more vulnerable to the rewarding effects of drugs)
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9
Q

Explain the stimulation of the reward pathway

A
  1. Stimulation of reward pathway
    • Drugs of abuse stimulate the brain’s reward circuitry (directly or indirectly), signaling the person to repeat the behavior
  • Overrides the more evolved cortical areas underlying reasoning and logic
  • Activates the reward pathway with a force not seen with natural rewards (food, sex) and overrides punishing effects

Components of reward pathway:
• Neurons in the Ventral tegmental area (VTA) send their dopaminergic axons to nucleus accumbens, striatum & prefrontal cortex (structures involved in motivation)

• Nucleus accumbens (ventral striatum) – greater release of dopamine in the nucleus accumbens →mediates positive reinforcing effect of drugs

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10
Q

How does addiction impact the brain?

A

Dysfunction of the Prefrontal Cortex

• Stimulation of the reward pathway affects the functioning of the prefrontal cortex → alters self control

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11
Q

What are the acute withdrawal symptoms of addiction?

A

Acute Withdrawal Symptoms
• Drug use may cause brain changes that result in withdrawal symptoms upon drug cessation.
• Symptoms typically onset within 48-72 hours and last 1-2 weeks. This discomfort may drive relaps

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12
Q

What is protected abstinence syndrome?

A

Protracted Abstinence Syndrome
• Repeated drug use decreases the availability of DA as the brain adapts to having drug- induced dopaminergic spikes
• This is associated with prolonged feelings of anhedonia lasting several months, which may trigger relapse.

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13
Q

How does getting conditioned aid in addiction formation?

A

Classical Conditioning Effects
• Drug use has been paired with environment/internal cues
• These cues cause physiological changes that trigger drug seeking

Summary:
This is a “brain disease” that causes CNS changes that promote drug use

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14
Q

What are the main sedatives?

A

Alcohol
• Barbiturates
• Benzodiazepines
• Inhalants

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15
Q

What are the stimulants?

A 
Major stimulants
 ➢Cocaine 
➢Amphetamines
 ➢Ecstasy
➢Bath salts 
➢Designer K2

• Minor stimulants
➢Caffeine
➢Nicotine

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16
Q

What are the common features of intoxication?

A

Common Features of Intoxication:

a) Sedation, sleepiness, decreased anxiety
b) Disinhibited, impaired judgement
c) Slurred speech, incoordination
d) Stupor, coma
e) Respiratory depression
f) Overdose can be potentially fatal

Other Potential Features of Intoxication:
a) Anticonvulsant & anesthetic effects (decrease neuronal firing)

b) Alcohol-related brain damage (ARBD) (e.g., Wernicke-Korsakoff syndrome due to thiamine (B1) deficiency in chronic alcoholics)
c) Cross tolerance to other sedatives

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17
Q

What are the types of sedative withdrawl symptoms?

A

• Common Features of Withdrawal:

a) Agitation, insomnia, anxiety
b) ANS hyperactivity → can be fatal
i. Tachycardia
ii. Hypertension

c) Nausea, vomiting
d) Hand tremors
e) Seizures

Hallucinations

a) Any sensory modality, including tactile
b) Formication – sensation of bugs crawling on skin
c) Can occur as the main symptoms of withdrawal without physical symptoms (e.g. in “alcohol hallucinosis”)

Delirium Tremens (DTs)
• A delirium (confusional state) may also occur as part of sedative withdrawal
• Severe and uncommon
• Seen after chronic heavy use of sedative especially alcohol
• Associated with high mortality rate

18
Q

How to treat alcohol withdrawal?

A

Treatmentduringacutewithdrawal:
• Benzodiazepines→chlordiazepoxide, lorazepam, diazepam
• Effective in relieving the symptoms associated with withdrawal and preventing the DTs and seizures

  • Treatment to maintain abstinence:
  • Options:
  • Competitive inhibitor of the actions of opioids
  • Unknown mechanism of action
  • Producing unpleasant side effects when alcohol is used
19
Q

What treatment can be used to maintain alcohol abstinence ?

A
  • Treatment to maintain abstinence:
  • Options:
  • Competitive inhibitor of the actions of opioids
  • Unknown mechanism of action
  • Producing unpleasant side effects when alcohol is used

Competitive inhibitor of the actions of opioids:
a) Naltrexone:
• Opioid receptor antagonist that reduces the pleasurable effects of alcohol
• Reducing the rewarding effects→may reduce the amount of heavy drinking in those who do drink (cutting down)
• Allows person to stop or reduce their drinking behaviors enough to remain motivated to stay in treatment and avoid relapse

Unknown mechanism of action:
b) Acamprosate:
• NMDA receptor antagonist?? 
Incompletely understood 
• Restore neuronal activity ??
• Decreases the anhedonia of protracted abstinence→makes the person feel euthymic→decreases the cravings & helps to maintain abstinence

Treatment to maintain abstinence:
• Producing unpleasant side effects when alcohol is used:

➢ Disulfiram:
• Inhibits aldehyde dehydrogenase→acetaldehyde accumulates and causes a
toxic reaction (e.g. nausea) for 30-60 min.
• An alcohol aversion agent
• Due to poor compliance, it is only used short-term if the person will be in a high risk situation.
• May not reduce a patient’s urge to drink alcohol
• However, their expectation of a possible severe reaction if they drink alcohol may increase their motivation to remain abstinent

20
Q

What FDA approved drugs are used for sedative addiction?

A

FDA approved drugs for sedative addiction exist only for alcohol

21
Q

What are the types of benzpates and barbiturates?

A

Types:
• Benzodiazepines (diazepam, lorazepam)
• Barbiturates (phenobarbital, secobarbital)

22
Q

What are the benzodiazepine overdose/toxicity?

A

Treatment of Benzodiazepine overdose/toxicity • Flumazenil:
• Competitive antagonist
• High affinity for the benzodiazepine binding site on the GABAA receptor

  • Approved for use in:
  • Reversing the CNS depressant effects of benzodiazepine overdose
  • Quickening recovery following use of benzodiazepines in anesthetic and diagnostic procedures
23
Q

Describe inhalants of sedatives

A

Substances with psychoactive vapors (paint, glue, etc.)
• Teenager experimentation

• Signs: rash, red and runny nose, chemical smell, face discoloration

  • Intoxication: similar to sedative intoxication
    • Associated with organ failure & death (sudden sniffing death)
24
Q

What are the common features of intoxication of stimulants?

A 
Common Features of Intoxication:
• Psychological:
• Euphoria, grandiosity
• Psychomotor acceleration & stereotypies 
• Paranoia, hallucinations
  • Other features:
  • Loss of appetite, insomnia
  • Chest pains
  • Seizure
  • Dilated pupils (mydriasis)
  • Tachycardia, hypertension (life threatening)

Sounds like mania
Sounds like psychosis

Common features of intoxication mimic symptoms of other illnesses:
1. Schizophrenia
2. Bipolar I (manic) episodes
Both disorders may be clinically indistinguishable from stimulant use A drug screen is needed

Mania +/- psychotic features

25
Q

What are the common features of withdrawal ?

A

Common Features of Withdrawal:

a) Dysphoric mood (must be seen)
b) Fatigue, psychomotor slowing
c) Increasedappetite
d) Hypersomnia + vivid, unpleasant dreams
e) Non-life threatening
f) No approved treatment for stimulant addiction

Sounds like MDD
With atypical features

26
Q

Contrast the stimulants, methamphetamine vs cocaine

A
  1. Both are especially addictive→direct action on the reward pathway→produce an intense “rush” followed by euphoria
  2. Effects of cocaine shorter lasting than methamphetamine
    • Half life = 30 min (cocaine) vs 12 hrs (methamphetamine)
    • Cocaine use is thus more frequent
  3. Physical changes with methamphetamine (“meth mouth” and “meth face”)
27
Q

What are the physical hints of methamphetamine?

A
28
Q

Describe Ecstacy

A

MDMA (Methylenedioxymethamphetamine), Molly

• Feel good, party all night drug

    * Stimulant despite also having mild hallucinogenic effects * Psychological:
 * Empathy inducing
 * Perceptual changes→things seem more interesting, time and sensory distortion
  • Other features:
  • Increased thirst, increased temperature • Neurotoxicity
29
Q

Describe the impact of bath salts

A

Designer drug containing amphetamine-like chemicals. Symptoms more severe than cocaine intoxication with longer duration

Acute toxicity: agitation, paranoia, hallucinations, chest pain, tachycardia, hypertension, suicidality

30
Q

Describe the designer drug K2

A

Synthetic cannabinoid (K2, Spice, Joker, Black Mamba, Kush, and Kronic)

Acute toxicity: Perceptual disturbances, agitation, seizures

31
Q

Describe anabolic steroids

A

Used as performance enhancing agents to increase muscle mass and strength

Intoxication: acne, masculinization of females, hepatic dysfunction, increased risk of MI, increased libido, aggression

Withdrawal: fatigue, depressed mood

32
Q

What is caffeine?

A

DSM-5 does not recognize “caffeine-use” disorder

  • Consider:
  • Effects on sleep, anxiety, mood, other psychiatric illnesses • Interactional effects of caffeine with alcohol
33
Q

Contrast caffeine intoxication and withdrawal

A 
Caffeine Intoxication:
• Typically after a dose much > 250 mg of caffeine 
• Increased energy, insomnia, nervous
• Rambling thoughts
• Tachycardia
• Diuresis, GI disturbance
  • Caffeine Withdrawal:
  • Headache
  • Dysphoria
  • Fatigue
  • Decrease concentration
34
Q

Contrast nicotine intoxication and withdrawal

A

Nicotine Intoxication:
• DSM-5 does not recognize nicotine intoxication

  • Nicotine Withdrawal:
  • Dysphoricmood
  • Restless,anxious
  • Difficultiesconcentrating
  • Irritable,angry
  • Increased appetite
  • Decreased heart rate
35
Q

How do we treat nicotine replacement therapy?

A 
Treatment to maintain abstinence: 
• Options:
1. Nicotine replacement therapy
• Examples: nicotine patch, nicotine gum
• Low doses of nicotine to decrease craving
• Gradually taper the dose of nicotine
  1. Medications
    • Varenicline and bupropion
    • Increase levels of dopamine
    • Concerns of suicidal +/- erratic behavior
36
Q

What is Bupropion?

A

Bupropion is contraindicated in persons with bulimia nervosa due to seizure risk

37
Q

Describe drug schedule 1

A

High potential for abuse

No accepted medical use

heroin, marijuana, LSD, Ecstasy

38
Q

Describe schedule II drugs

A

High potential for abuse

Yes, but with potential for severe psychological or physical dependence

Cocaine, methamphetamine, methadone, oxycodone, fentanyl

39
Q

Describe schedule III drugs

A

Medium potential for abuse

Accepted for medical use

Ketamine, anabolic steroids

40
Q

Describe schedule IV drugs

A

Low potential for abuse

Accepted medical abuse

Ex.: diazepam

41
Q

Describe schedule V drugs

A

Lowest potential for abuse

Accepted medical use

Ex.: robitussin

NB3 (33 decks)

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