Addiction Medicine Flashcards
diagnosis of substance use disorder
2+ in 12 months:
tolerance, withdrawal, more use than intended, craving, unsuccessful effort to cut down, spend excessive time in acquisition, give up activities to use, use despite negative effects, failure to fulfill roles, use in hazardous situations, use despite social problems
how to rate severity of substance use d/o
mild: 2-3 criteria
moderate: 4-5
severe: 6+
3 C’s of addiction
craving
compulsion
loss of control
diagnostic criteria for gambling disorder
4+ in 12 mos not explained by mania:
preoccupation w gambling, inc $ gambled, unsuccessful attempts to cut down/stop, irritability when trying to stop, use to escape problem, continue to try to break even after losing, lying to reveal extent, jeopardizing or losing relationship or career, relying on others for $ issue d/t gambling
substance-induced disorders
intoxication, withdrawal, delirium, persisting dementia or amnestic d/o, psychosis, mood or anxiety d/o, sexual or sleep d/o, hallucination/ perception d/o
intoxication
reversible substance-specific syndrome d/t ingestion or exposure
maladaptive behavior or physiological change d/t effect of substance on CNS
withdrawal
reversible substance-specific syndrome d/t decline in blood level of substance
causes clinically significant distress or functional impairment
how to recognize substance-induced d/o
disturbance not better accounted for by non-substance-induced d/o (sx before substance or persist after cessation)
pathway affected by all addictive drugs except LSD
mesocorticolimbic dopaminergic reward thresholds
components of addiction and relation to brain structures
reward pathway: mesolimbic DA circuit
VTA and NAcc - acute reinforcing effects of drugs
amygdala and hippo - memory and conditioned responses linked to craving
adolescent addiction screening
CRAFFT C = car intoxicated R = relax/fit in/peer influence A = alone F = forget/blackouts F = family/friends worry T = trouble bc of use If 1+, encourage to stop. If 2+, screen for substance dependence.
questions to ask about substance use
TRAPPED Tx history Route of administration Amount Pattern (and change over time) Prior abstinence Effects (OD, withdrawal) Duration of use (inc most recent and fam hx)
medical detox goals
safe withdrawal
human withdrawal
prepare pt for ongoing tx of dependence
*does little to change long-term drug use
impact of treatment on substance use
reduces drug use 40-60%
reduces crime 40-60%
*as successful as tx for DM, asthma, HTN
5 stages of change
precontemplation (unaware or unwilling to change)
contemplation (aware of problem, no commitment to change)
preparation (intend to change)
action (*requires a lot of time and energy)
maintenance (prevent relapse, indefinite)
motivational enhancement therapy
helps people recognize and change problem
useful for people ambivalent about change
importance of motivational interviewing
resolve ambivalence about changing behavior and instill ownership of change process in pt
AA vs CBT
CBT is more effective
detection in urine of THC, amphetamine, barbs, cocaine, methadone, PCP, opiates
THC: 3-30 days amph: 2-3 d barb: 1-3 d coke: 6h-3d methadone: 7-9 d PCP: 8 d opiates: 1-3d
opiates not detected in UA
buprenorphine, oxycodone, hydrocodone, fentanyl
*can screen for these specifically
how to test for alcohol use
short t1/2 in urine but detected up to 24 h ethyl glucuronide (metabolite) may be detected up to 5d
best biomarker of alcohol relapse
CDT (carb-deficient transferrin) - synthesis disturbed by EtOH metabolites - elevated in 2 wk and normalizes in 2 wk
12m and lifetime prevalence of EtOH and drug use d/o
EtOH: 13.9 and 29.1%
drug: 3.9 and 9.9%
long-term abstinence rates with and w/o treatment
without: 20% chance
with: 50-66% chance of 1+ years
sx alcohol withdrawal
2+ of: autonomic hyperactivity (inc HR, sweating), hand tremor, insomnia, n/v, transient hallucinations, agitation or anxiety, grand mal seizures (w/i 48 h)
formication
tactile hallucinations seen ONLY in cocaine intoxication and EtOH withdrawal
ex: delusional parasitosis
how to treat seizures in EtOH withdrawal
BZD not anti-convulsants!
OTL - “out the liver” - oxazepam, temazepam (not used), lorazepam
because glucuronidated not oxidized in liver - little functional liver needed
delirium tremens
48-72 hours post EtOH cessation; 20% mortality
sympathetic hyperactivity: tachy, HTN, fever, diaphoresis, hallucinations, delusions
Tx: prevention, BZD, fluids, support
predicting delirium tremens
hx of DT, early withdrawal sx (w/i 6h), use of sedative hypnotics (further decrease GABA-R), med problems (ID, hep, pancreatitis), withdrawal seizures on presentation, genetics
Wernicke’s encephalopathy
acute amnestic d/o d/t EtOH
ataxia, nystagmus, ophthalmoplegia, confusion
rare in
Korsakoff syndrome
chronic amnestic EtOH d/o
a/r-amnesia in responsive pt, +/- confabulation
tx: 3-12m thiamine (+ glucose)
21% completely recover, 25% significant recovery
disulfiram
for EtOH dependence
inhibits ALDH = inhibits metabolism
acamprosate
for EtOH dependence
glutamate receptors and transmission
naltrexone MOA, and daily PO vs monthyl IM
for EtOH dependence
synthetic opioid antagonist
monthly = improved compliance
acute cannabis use sx
euphoria, impaired motor coordination, sensation of slowed time, pupillary constriction and photophobia
2+ w/i 2 h of use: conjunctival injection, inc appetite, dry mouth, tachycardia
spice MOA and dangers
full potent agonist of CB1 (vs. partial for THC)
often contaminated with b2-agonist -> sympathomimetic effects like tremor, tachy, anxiety
can also produce psychosis and paranoia
chronic cannabis use sx
gynecomastia (relationship b/t CB1 and PRL receptors), reactive airway dz, dec sperm count, wt gain, lethargy
cannabis intoxication sx
panic, delirium, psychosis
tx: antipsychotic med
cannabis withdrawal diagnosis
3+ w/i 1 week of cessation:
irritable or aggressive, nervous/anxiety, sleep difficulty, dec appetite or wt loss, restless, depressed mood
1 of: stomach pain, shaky/tremor, sweating/fever, chills, headache
stimulant intoxication sx
2+ of:
tachy or bradycardia, pup dilation, high/low BP, sweat or chills, n/v, wt loss, psychomotor agitation or retardation, mm weakness or resp depression, chest pain or arrhythmia
confusion, seizure, dyskinesia, dystonia, or coma
cocaine or amphetamine intoxication vs schizophrenia
+ symptoms of SZ but no negative sx
reality testing intact
*if reality testing not intact, consider substance-induced psychotic d/o
stimulant withdrawal sx
dysphoric mood + 2+ of fatigue, unpleasant dreams, in/hypersomnia, inc appetite, psychomotor retardation or agitation
*won’t kill pt (vs. EtOH w/d)
life-threatening effects of amphetamines
hyperthermia, arrhythmias, renal failure
long-term effects of MDMA
reduced brain 5HT and metabolites
reduced 5HT transporters and degenerating terminals
managing stimulant intoxication
HTN crisis d/t unopposed alpha - labetolol (a1 and b-blocker) to maintain CO or phentolamine (a-blocker, less common) or nicardipine (2G CCB w high vascular selectivity and cerebral/coronary vasodilation) agitation/sleep problems: short-acting benzo - no anti-psychotics because dec seizure threshold
tx of stimulant dependence
DA agonist (bromocriptine, amantadine) - inconsistent results topiramate - ? glu-antagonist and GABA agonist
opioid intoxication sx
maladaptive behavior (euphoria -> apathy, dysphoria), pupillary constriction (dilation w anoxic brain injury) constipation, bradycardia, hypoTN, resp depression 1+ of: drowsiness, slurred speech, impaired attn/memory
opioid w/d sx
3+ of:
dysphoria, n/v/d, m ache (hamstrings), lacrimation/ rhinorrhea, pup dilation piloerection or sweating, yawning, fever, insomnia
clonidine
a2-agonist to reduce opioid w/d signs by decreasing sympathetic outflow
methadone
synthetic opioid agonist to help with withdrawal
safe for pregnancy
buprenorphine/ suboxone
buprenorphine + naloxone
bup: long-acting potent partial mu agonist with mixed ag/antag kappa - dec risk resp dep and fewer autonomic sx
induces acute w/d - start when pt in w/d or clean
for opioid withdrawal
nal: antagonist
drug interactions for suboxone (bup+nal)
azoles and protease inhibitors because metabolized by CYP 3A4
hallucinogen intoxication sx
anxiety, fear of losing mind, paranoia
perceptual changes while awake and alert: depersonalization, derealization, illusion, hallucination, synesthesia
2+: pup dil, tachy, sweating, palpitations, blurred vision, tremor, incoordination
physical effects of LSD/acid
hyperthermia, tachycardia, HTN, insomnia, loss of appetite
PCP/ phencyclidine intoxication
unpleasant psychological effects (out of body, vivid dream), violence/ suicidality
2+ in an hour: nystagmus (v or h), HTN or tachy, numbness/ diminished pain, ataxia, dysarthria, mm rigidity, seizures or coma, hyperacusis
very similar to SZ (+ and - sx and reality testing not intact)
ketamine
moderate version of PCP, odorless and tasteless
MOA PCP
potent glutamate NMDA antagonist
dextromethorphan
NMDA antagonist
less potent but similar effects to PCP and ketamine
sx: distorted visual perceptions to complete dissociation (for 6 h)
tx hallucinogen/PCP
acute LSD: support
acute PCP: diazepam for seizure/agitation, phentolamine for HTN
chronic: discontinue use
OD (panic, paranoia, psychosis): BZD, observation in quiet room, no anti-ACh like phenothiazines (will worsen effect and seizure risk)
why not to acidify urine in hallucinogen intoxication
although increased excretion of drug, risk of metabolic acidosis, rhabdomyolysis, etc.
hallucinogen persisting perception d/o
“flashbacks” of experiences after discontinuation of hallucinogen use that is not d/t another medical condition
inhalant intoxication sx
problematic behavior or psych changes (assault, belligerent, apathetic, impaired judgment) and 2+: dizzy, nystagmus, incoordination, slurred speech, unsteady gait, mm weakness, lethargy, euphoria, depressed reflexes, psychomotor retardation, tremor, blurred vision/ diplopia, stupor/coma
MOA of inhalants
agonist of GABA-R, glut-blocker
*can cause dementia d/t this (like EtOH, BZDs)
