Addiction Medicine

Question 1

Physical dependence alone is neither necessary nor sufficient to diagnose addiction, and it is important to be able to distinguish the two. What are some features of addiction?

Answer 1

Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, and behavioral dysfunction.

This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors

Question 2

Diagnostic criteria for substance use disorders

Answer 2

Using larger amounts or for longer time than indicated

Persistent desire or unsuccessful attempts to cut down or control use

Great deal of time obtaining, using, or recovering

Craving

Fail to fulfill major roles (work, school, home)

Persistent social or interpersonal problems caused by substance use

Important social, occupational, recreational activities given up or reduced

Use in physically hazardous situations

Use despite physical or psychological problems caused by use

Tolerance

Withdrawal

Question 3

Criteria of a substance-induced mental disorder (A—>E)

Answer 3

A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder

B. There is evidence of both of the following: the disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; AND the involved substance/med is capable of producing the mental disorder

C. The disorder is not better explained by an independent mental disorder; may include: the disorder preceded the onset of severe intoxication/withdrawal/exposure to med, OR the full mental d/o persisted for at least 1 month after cessation of acute withdrawal/intoxication/medication

D. The disorder does not occur exclusively during the course of a delirium

E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 4

Up to 50% of addicts with substance abuse disorder have comorbid ________ disorder

Answer 4

Psychiatric (i.e., antisocial PD, depression, suicide)

Question 5

T/F: PCP does not exhibit a withdrawal syndrome

Answer 5

True

Question 6

Treatment options for substance abuse disorders [and in what scenarios they are indicated]

Answer 6

Hospitalization — due to drug OD, risk of severe withdrawal, medical comorbidities, restricted access to drugs, psychiatric illness with suicidal ideation

Residential treatment unit — no intensive monitoring needs, require a restricted environment, partial hospitalization

Outpatient program — no risk of med/psych morbidity and highly motivated pt

Motivational interviewing in primary care setting — family involvement, relapse prevention, 12-step facilitation, cognitive behavioral therapy

Pharmacologic intervention

Treat associated medical conditions (CV, cancer, endocrine, hepatic, hematologic, infectious, neuro, etc…)

Question 7

The most severe manifestation of alcohol withdrawal; occurs 3-10 days following the last drink; hallmark is profound global confusion

Answer 7

Delirium tremens

Question 8

Clinical manifestations and hallmark of delirium tremens

Answer 8

Agitation, global confusion, disorientation, hallucinations, fever, HTN, diaphoresis, and autonomic hyperreactivity (tachycardia and HTN)

HALLMARK is profound global confusion

Question 9

Set of criteria that assigns numerical values to alcohol withdrawal-related sxs including: orientation, N/V, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances and HA. VS checked but not recorded. Total score of >10 indicates more severe withdrawal

Answer 9

Clinical Institute Withdrawal Assessment for Alcohol (CIWA)

Question 10

3 general pharmacologic tx for alcohol withdrawal

Answer 10

Benzodiazepines — GABA agonists that reduce risk of SZ; provide comfort/sedation

Anticonvulsants - reduce risk of SZ and may reduce kindling; helpful for protracted withdrawal; Carbamazepine or Valproic acid

Thiamine supplementation

Question 11

Medications historically used to treat alcohol abuse include disulfuram, naltrexone, and acamprosate.

T/F: Disulfiram is the most widely used option today d/t high efficacy

Answer 11

False — there is little evidence to support benefits of disulfiram, and it often does more harm than good

Question 12

What lab tests do you need to monitor while pt is on naltrexone vs. acamprosate for EtOH use disorder?

Answer 12

Naltrexone is hepatotoxic at high doses so check LFTs

Acamprosate is cleared renally so check renal function

Question 13

3 benzodiazepines metabolized through only glucuronidation in the liver, and not affected by age/hepatic insufficiency

Answer 13

Oxazepam
Temazepam
Lorazepam

Question 14

Opioid intoxication = pinpoint pupils, sedation, constipation, bradycardia, hypotension, and decreased RR. Withdrawal = dilated pupils, lacrimation, goosebumps, n/v, diarrhea, myalgias, arthralgias, dysphoria, agitation.

How is opioid withdrawal tx?

Answer 14

Symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant (methocarbamol), NSAIDs, clonidine, and maybe BZD

Question 15

Medication treatment for opiate use d/o

Answer 15

Methadone (opioid substitution)

Naltrexone

Buprenorphine (opioid substitution)

Question 16

Methadone maintenance is only available through a certified MAT program. It is an oral solution and a high-risk medication.

Why is it important to not combine benzodiazepines or other similar medications with methadone?

Answer 16

Methadone can be deadly when combined with a benzodiazepine — or other 3A4 substrate

Frequently causes QTC prolongation which may lead to torsade de pointes and sudden cardiac death

CARDIAC RISK

Question 17

Methadone maintenance is not used to treat pain. What is the protocol if a methadone maintenance patient is encountered in the ED and needs pain management?

Answer 17

Provider calls on-call service at methadone clinic and verifies dosage

The correct methadone dosage is continued while pt is hospitalized

If additional pain treatment is required, use another opioid like morphine — preferably not another 3A4 substrate like oxycodone or BZDs!!! Also, do not use additional methadone for pain as this will possibly disrupt the response to current methadone maintenance dosing

Question 18

Epidemiology of tobacco abuse

Answer 18

Most important preventable cause of death/disease in USA

20% of all US deaths

45% of smokers die of tobacco induced disorder

Second hand smoke causes significant death/morbidity

Psychiatric pts at risk for nicotine dependence — 75-90% of schizophrenic pts smoke

Question 19

Neuroadaptation associated with tobacco

Answer 19

nAChR on DA neurons in VTA release DA in nucleus accumbens

Question 20

Signs/sxs of MDMA toxicity

Answer 20

Common short term problems include tachycardia, sweating, muscle spasms, and EXTREMELY HIGH FEVER (38.5-43 C)

In cases of severe toxicity, the pt has high fever that can progress to rhabdomyolysis, renal failure, seizures, DIC, cardiac arrhythmias, and death

Question 21

MDMA affects serotonin, DA, and NE receptors, but they are considered predominantly ________ receptor agonists

Answer 21

5HT2

Question 22

Neuroadaptations to cannabis

Answer 22

CB1 and CB2 cannabinoid receptors coupled with G proteins and adenylate cyclase to Ca channel, inhibiting calcium influx

Neuromodulator effect; decrease uptake of GABA and DA

Question 23

T/F: adolescent males who use cannabis products regularly have a 7x decreased risk of psychosis

Answer 23

False; they have 7x increased risk of psychosis

Question 24

Drug of abuse associated with cerebellar symptoms like ataxia, dysarthria, NYSTAGMUS (vertical AND horizontal)

Answer 24

PCP (phenacyclidine)

Question 25

Neuroadaptation of PCP

Answer 25

Opiate receptor effects; allosteric modulator of glutamate NMDA receptor