Addiction Medicine Flashcards
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?
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
Diagnostic criteria for substance use disorders
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
Criteria of a substance-induced mental disorder (A—>E)
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
Up to 50% of addicts with substance abuse disorder have comorbid ________ disorder
Psychiatric (i.e., antisocial PD, depression, suicide)
T/F: PCP does not exhibit a withdrawal syndrome
True
Treatment options for substance abuse disorders [and in what scenarios they are indicated]
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…)
The most severe manifestation of alcohol withdrawal; occurs 3-10 days following the last drink; hallmark is profound global confusion
Delirium tremens
Clinical manifestations and hallmark of delirium tremens
Agitation, global confusion, disorientation, hallucinations, fever, HTN, diaphoresis, and autonomic hyperreactivity (tachycardia and HTN)
HALLMARK is profound global confusion
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
Clinical Institute Withdrawal Assessment for Alcohol (CIWA)
3 general pharmacologic tx for alcohol withdrawal
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
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
False — there is little evidence to support benefits of disulfiram, and it often does more harm than good
What lab tests do you need to monitor while pt is on naltrexone vs. acamprosate for EtOH use disorder?
Naltrexone is hepatotoxic at high doses so check LFTs
Acamprosate is cleared renally so check renal function
3 benzodiazepines metabolized through only glucuronidation in the liver, and not affected by age/hepatic insufficiency
Oxazepam
Temazepam
Lorazepam
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?
Symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant (methocarbamol), NSAIDs, clonidine, and maybe BZD
Medication treatment for opiate use d/o
Methadone (opioid substitution)
Naltrexone
Buprenorphine (opioid substitution)
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?
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
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?
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
Epidemiology of tobacco abuse
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
Neuroadaptation associated with tobacco
nAChR on DA neurons in VTA release DA in nucleus accumbens
Signs/sxs of MDMA toxicity
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
MDMA affects serotonin, DA, and NE receptors, but they are considered predominantly ________ receptor agonists
5HT2
Neuroadaptations to cannabis
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
T/F: adolescent males who use cannabis products regularly have a 7x decreased risk of psychosis
False; they have 7x increased risk of psychosis
Drug of abuse associated with cerebellar symptoms like ataxia, dysarthria, NYSTAGMUS (vertical AND horizontal)
PCP (phenacyclidine)
Neuroadaptation of PCP
Opiate receptor effects; allosteric modulator of glutamate NMDA receptor
