Addiction Medicine Flashcards
What are the hallucinogens & related substances?
• Hallucinogens • Lysergic acid diethylamide • Mescaline (cactus) • Psilocybin (mushroom) • Cannabis • Marijuana • Dissociative anesthetics • Ketamine • PCP
What are opioids?
Heroin • Morphine • Codeine • Methadone • Oxycodone • Fentanyl
Classify the hallucinogens?
Classic hallucinogens • Lysergic Acid Diethylamide (LSD) • Mescaline • Psilocybin (Magic Mushroom) Above cause Hallucinations
Cannabis
• Marijuana
• Hashish
Above cause Distortions
Dissociative Anesthetics
• Phencyclidine (PCP)
• Ketamine
Above cause Depersonalization
What’s the impact of hallucinogens and related substances?
Physical alterations
• Sympathomimetic drugs
Perceptual alterations
• Visual distortions (colors, trails, palinopsia)
• Auditory distortions (intensification and
echo)
Cognitive alterations
• Distorted thinking
• Trouble concentrating, working memory
impairment
What’s the effect of classic hallucinogens (LSD, Mescaline, Psilocybin)?
High potency (effects from 25 micrograms)
- No known direct deaths from overdose
- Effects last 8-12 hours
- No known withdrawal symptoms
- Low addiction rates
• Intoxication profile: increased heart rate, increased BP,
sweating, mydriasis, dehydration, euphoria, paranoia, sensory distortion, visual hallucinations, reduced appetite, wakefulness
What’s the impact of LSD in schizophrenia?
- LSD likely plays a role in precipitating the onset of acute psychosis in healthy individuals with risk of schizophrenia (family history)
- People with severe schizophrenia = higher likelihood of experiencing adverse effects from LSD
• Potential persistent psychosis
• Hallucinogen Persisting Perception Disorder (HPPD)
• Flashbacks of visual hallucinations / distortions experienced
during a previous hallucinogenic drug experience
What are the side effects of classic hallucinogens?
Negative experiences (“bad trips”) produce intense negative emotions:
- Irrational fears
- Anxiety
- Panic attacks
- Paranoia
- Rapid mood swings
- Hopelessness
- Intrusive thoughts of harming others
- Suicidal ideation
No predictive factors for bad trips
What classic hallucinogens are therapeutics?
• Current research is examining hallucinogens as treatment for intractable trauma/stress disorders and anxiety disorders
• Breakdown of “Ego” by introducing “impermanence of reality”
and separation of the self from thoughts and feelings
• Dissociation
• Hallucinations
• Cognitive distortions
• Time distortion
• Skilled psychotherapeutic guidance required when someone
is having a bad trip or under therapeutic circumstances
What is cannabis?
- Naturally-grown plant, number of species disputed:
- Cannabis sativa
- Cannabis indica
- Cannabis ruderalis
- Fourth most used recreational substance worldwide, after alcohol, caffeine, and tobacco
- 100 million+ Americans have tried cannabis at least once
- 25 million+ Americans used Cannabis within the past year
Describe general cannabis
Cannabis: 460+ chemical compounds, 80+ are cannabinoids
- Well-studied:
- Tetrahydrocannabinol (THC)
- Cannabidiol (CBD)
- Cannabinol (CBN)
• Triphasic psychoactive effects: 1. Relaxation and slight euphoria 2. Introspection & metacognition (also anxiety & paranoia) 3. Increased heart rate and appetite
Where are the cannabis receptors located?
• CB1/CB2 cannabinoid receptors = effects of cannabinoids
• CB1 receptors mostly in the brain = psychoactive effects
• CB2 receptors mostly peripherally throughout the body =
modulate pain and inflammation
- Effects last 2-4 hours (if smoked)
- Effective in chemotherapy-induced nausea and vomiting
- More data needed on chronic pain & inflammation
How are cannabis side effects similar to LSD?
Similar to LSD:
• Low addiction potential
• “Bad trips” produce intense negative emotions
• May precipitate the onset of acute psychosis in healthy
individuals with risk of schizophrenia (family history)
• People with severe schizophrenia = higher likelihood of
experiencing adverse effects from cannabis
• No evidence of long-term cognitive impairment
• Intoxication profile: Conjunctival injection, dry mouth, increased
appetite, poor muscle coordination, delayed reaction times
Describe cannabis withdrawal symptoms
Psychological • Irritability,nervous • Dysphoricmood • Sleepdisturbance(insomnia,vividdreams) • Decreased appetite
Physical
• Headaches, night sweats, stomach cramps
• Shakiness
What are the intoxication symptoms of dissociative symptoms(PCP, Ketamine)?
- First synthesized in 1926 and brought to market as an anesthetic medication in the 1950s.
- Removed from market in 1965 due to hallucinatory (and other) side effects
- Intoxication symptoms:
- Depersonalization & Decreased responsiveness to pain
- Increased heart rate, blood pressure, and respiration
- Agitation, belligerence, confusion
- Impulsivity, unpredictability
- Nystagmus, hyperacusis
- Ataxia, muscle rigidity, seizure, coma
How is PCP intoxication treated?
Psychiatric emergency if individual is violent & unpredictable
- Treatment of PCP Intoxication:
- Benzodiazepines/antipsychotics
- Reduce environmental stimulation
- Restraints if needed
• No withdrawal syndrome is recognized
What are the commonalities of hallucinogens and related substances?
Commonalities: Perceptual changes and no withdrawal syndrome EXCEPT cannabis
Describe LSD effect
Hallucinations
Moderate symptoms severity
Eyes: dilated
Calm Behavior
Describe cannabis
Distortions
Mild symptom severity
Red eyes
Amotivated behavior
Describe PCP
Depersonalized perceptions
Severe symptom severity
Nystagmus eyes
Volatile behavior
What are the opioids examples?
- Heroin
- Morphine
- Codeine
- Methadone
- Oxycodone
- Fentanyl
What are opioids?
- Morphine (naturally derived from poppy plants)
- Heroin (derived from morphine)
- Codeine (derived from morphine)
- Oxycodone (naturally derived from poppy plants, similar to morphine)
- Buprenorphine (naturally derived from poppy plants, similar to morphine)
- Fentanyl (synthetic opioid developed by Janssen in 1960)
- Methadone (synthetic opioid developed in Germany 1937)
What 8s the intoxication profiler of opioids?
Analgesics to reduce pain
- Side effects / Intoxication profile:
- Euphoria of varying intensity
- Decreased respiration
- Low blood pressure
- Constipation
- Drowsiness
- Impaired cognitive function
- Unconsciousness
- Miosis
What are the opioid withdrawal symptoms?
Withdrawal symptoms: • Dysphoria • Nausea, vomiting, diarrhea • Muscle aches • Lacrimation, rhinorrhea • Piloerection, sweating, fever • Yawning • Pupil dilation
Usually non-life threatening, but very uncomfortable, potentially leading to continued use. Overdose potentially deadly
How is an opioid overdose treated?
Naloxone • Short acting opioid receptor antagonist • Used for acute overdose • Not used for treatment of addiction • Reverses respiratory and CNS depression
How can we treat opioid addiction?
- Abstinence based therapy (Requires complete abstinence)
• Naltrexone
• Long-acting opioid receptor antagonist
• Block opioid effects if relapse occurs
• Does not treat physical symptoms of abstinence
• Protracted abstinence syndrome: Anhedonia from
downregulation of dopamine and opioid receptors
• Person feels physically unwell
• 90%+ failure rate - Replacement therapy (Reduces severe risk of harm)
• More successful that abstinence-based therapy because it avoids anhedonia and physical discomfort during withdrawal as seen with abstinence
• Special restrictions when used to treat opioid addiction
• Not a “silver bullet”
• Does not resolve mental health and social-environmental
systems that increase risk of addiction
• Why is the addict taking the drug in the first place?
2. Replacement therapy (Reduces severe risk of harm) • Methadone • Full opioid agonist • Addictive and potentially dangerous • Available at regulated Opioid Treatment Program (OTP) • Not prescribed – only administered
How can replacement therapy treat opioid addiction?
Replacement therapy (Reduces severe risk of harm)
• More successful that abstinence-based therapy because it avoids anhedonia and physical discomfort during withdrawal as seen with abstinence
• Special restrictions when used to treat opioid addiction
• Not a “silver bullet”
• Does not resolve mental health and social-environmental
systems that increase risk of addiction
• Why is the addict taking the drug in the first place?
2. Replacement therapy (Reduces severe risk of harm) • Methadone • Full opioid agonist • Addictive and potentially dangerous • Available at regulated Opioid Treatment Program (OTP) • Not prescribed – only administered
Replacement therapy (Reduces severe risk of harm)
• Buprenorphine
• Partial opioid agonist
• Less addictive and dangerous
• Available from physician (prescribed, administered,
dispensed)
• Buprenorphine + naloxone*
* Naloxone counteracts buprenorphine if it is abused (e.g., injected)
2. Replacement therapy (Reduces severe risk of harm) • Duration and Benefits • Usually continues for at least 1-2 years • Oral administration • Stable drug levels • Less euphoria and less drowsiness • Improved overall health, productivity • Reduced crime
Summarize pupil response of drugs known
How can we screen for alcohol and drug use?
Summary of pupil response
Miosis (pupil constriction):
• Opioid intoxication (pinpoint)
• Stimulant withdrawal
Mydriasis (pupil dilation):
• Stimulant intoxication
• LSD intoxication
• Opioid withdrawal
How can we screen for alcohol and drug use?
• Used in primary care: 1.History taking 2.Screening Tools (e.g., CAGE, AUDIT, NDA-Modified ASSIST) 3. Advising
What are the CAGE questions?
CAGE
– Have you ever felt you should Cut down your drinking?
– Have people Annoyed you by criticizing your drinking?
– Have you ever felt bad or Guilty about your drinking?
– Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
2 or more YES = clinically significant: Follow-up
What is the AUDIT?
What is the NIDA-Modified ASISST?
How should patient advising be held for the screeningif alcohol and drug use?
How should do drug rehabilitation occur?
Patient Advising:
• Review screening results
• Based on risk level:
– Review potential drug-related health consequences
– Recommend reducing/quitting drug use (with or without medical supervision)
– Evaluate for co-existing problems (e.g., depression, anxiety, infectious diseases)
– Refer for a comprehensive alcohol/drug assessment (screening tools do not provide a diagnosis)
– Educate about treatment options
– Assist in making changes, if patient is ready to change (goal setting, Rx meds)
Describe the acute treatment of drug rehabilitation
• In-patient setting for maximal environmental structure
• Usually 90+ days
• No “cure” - ongoing management
• Fraction receive help (20.7 million people (age 12+) needed
treatment for a SUD; 4 million (19%) received it (2017)
- Acute treatment phase:
- Detoxification and management of withdrawal symptoms/cravings • Treat associated medical problems
- Plan to address comorbid psychiatric illnesses
Explain the nuances of the rehabilitation of drug abuse
• Treating SUDs is complex
• Substance use can impact frontal cortex (executive functions):
• Impulse control & inhibition
• Judgement & Decision-making
• Planning
• Reward pathway, tolerance, withdrawal, craving
• Behavior conflict can cause justifications: denial, minimization, defiance,
rationalization
• “Replacement” of the frontal cortex (proxy executive
functions) followed by resilience-building to life stressors
• Just “suck it up and do it” not likely to work
Describe the recovery phase of drug rehabilitation
Recovery Phase – medium environmental structure
• Goal is to prevent relapse
• Avoid the Abstinence Violation Effect
• Multi-modal approach
• Cognitive therapy (identify & correct self-defeating thoughts)
• Behavioral therapy (remove/recondition cues, contingency
management)
• Community groups (12-step programs) for impulse control (sponsors)
• Family therapy
• Medication-assisted treatment to decrease craving or replacement
therapy (e.g., naltrexone, buprenorphine, disulfiram)
How can self help groups aid in drug rehabilitation?
Self-Help Groups for Relatives/Friends
- Forum to share experiences (challenges and successes) regarding loved- one’s addiction
- Learn effective ways to cope with loved-one’s addiction - avoidance of enabling behaviors:
- Actions and/or reactions to the addicted person that perpetuate the addictive behavior
What is gambling disorder?
Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting 4+ of the following (9 symptoms) in a 12-month period
- Not due to manic episode
- Related to impulse control
What are the symptoms of gambling disorder?
- Preoccupationwithgambling
- Gambling increasing amounts of money to achieve excitement
- Unable to control ,cut back or stop
- Used to escape from problems
- Gambling to recoup losses
- Lying to conceal extent of gambling
- Illegal acts to finance gambling
- Jeopardizing or losing relationships
- Reliant on others for money to pay debts
How can we manage gambling disorders?
SSRIs, opioid antagonists
• To control gambling “cravings”
Cognitive behavioral therapy
• Understand stress triggers
• Relaxation techniques to manage cravings
Gamblers anonymous
• 12-step process to admit and understand underlying contributing factors
Family therapy
• Support of loved ones for stress managemen
