Addiction Medicine

Question 1

What is the definition of addiction?

Answer 1

• Primary, chronic disease of brain reward, motivation, memory and related circuitry
• Pathologically pursuing reward and/or relief by substance use and other behaviors***

Question 2

How does type I vs. type II alcoholism differ in the addictophrenia model?

Answer 2

• Type I: affects both men and women, requires presence of a genetic as well as an enviornmental predisposition, commences later in life after years of heavy drinking
• Type II: affects mainly sons of male alcoholics, is influenced only weakly by enviornmental factors; usually associated with criminal behavior

Question 3

Which type of addictophrenia is more associated with criminal behavior, risk taking, and gambling?

Answer 3

Type II

Question 4

Which type of addictophrenia is associated with a significant history of trauma and there is predominantly alcohol and benzo use?

Answer 4

Type III

Question 5

Which type of addictophrenia is associated with chronic use of high dose drugs known to cause severe physical dependency + presence of severe psychosocial stressors?

Answer 5

Type IV

Question 6

For diagnosis of a substance-induced mental disorder there is evidence from the hx, PE, or labratory findings of what 2 things?

Answer 6

• Disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication

and

• The involved substance/medication is capable of producing the mental disorder

Question 7

What are 2 pieces of evidence which would indicate that a mental disorder is independent and not substance-induced?

Answer 7

• The disorder preceded the onset of severe intoxication or withdrawal or exporsure to the medication

or

• The full mental disorder persisted for a substantial period of time (i.e. at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication

Question 8

What are the 5 criteria of substance-induced mental disorders?

Answer 8

• Disorder represents a clinically significant symptomatic presentation of a relevant mental disorder
• Evidence from the hx, PE, or lab findings: disorder developed during or within 1 month of intoxication, withdrawal or use
• Disorder is not better explained by an independent mental disorder
• Disorder does not occur exclusively during the course of delirium
• Disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 9

When do seizures most often arise during alcohol withdrawal?

Answer 9

24-48 hrs; most often Grand mal

Question 10

When does withdrawal delirium (DTs) develop during alcohol withdrawal?

Answer 10

48-72 hrs

Question 11

What is the most severe manifestation of alcohol withdrawal?

Answer 11

Delirium Tremens

Question 12

What are the signs/sx’s of delirium tremems; what is the hallmark?

Answer 12

• Agitation + global confusion + disorientation + hallucinations + fever + HTN + diaphoresis + autonomic hyperactivity = tachycardia + HTN
• Hallmark = profound global confusion

Question 13

What does CIWA stand for and what is it used for?

Answer 13

• Clinical Institute Withdrawal Assessment for Alcohol
• Assigns numerical values to orientation, N/V, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances and HA
• Total score >10 indicates more severe withdrawal

Question 14

Which 3 benzodiazepines are metabolized through glucuronidation in liver and can be used in the setting of alcohol and other withdrawals?

Answer 14

Oxazepam and Lorazepam and Temazepam

Question 15

What are 3 reasons that methadone is a high risk medication?

Answer 15

• Can be deadly when used with a benzodiazepine***
• Frequently causes QTC prolongation - sometimes fatal
• Dangers ↑ when used with another 3A4 substrate!***

Question 16

If a methadone maintenance patient is encountered in the ED and needs pain management what is the proper protocol?

Answer 16

• Provider calls on-call service at methadone clinic and verifies dosage
• The correct methadone dosage is continued while patient is hospitalized
• If additional pain mangement is required use another opioid: not another CYP3A4 substrate and no benzos!
• Do not use methadone as this will possibly disrupt the response to current methadone maintenance dosing

Question 17

What is a serious mental AE associated with chronic intoxication of stimulants?

Answer 17

Psychosis: sometimes with severe paranoia

Question 18

Cocaine works mainly by preventing the reuptake of what?

Answer 18

Dopamine

Question 19

Amphetamines can be fatal at lower doses in the setting of what underlying disease?

Answer 19

Brugada syndrome

Question 20

Adolescent males who use cannabis regularly have a 7-fold increased risk of?

Answer 20

Psychosis

Question 21

The neuromodulator effect of cannabis is due to decreased uptake of which NT’s?

Answer 21

GABA and Dopamine

Question 22

What are the cerebellar sx’s of PCP intoxication?

Answer 22

Ataxia, dysarthria, and NYSTAGMUS (vertical and horizontal)

Question 23

What are the 2 neuroadaptive effects of PCP?

Answer 23

• Opiate receptor effects
• Allosteric modulator of glutamate NMDA receptor

Question 24

What is the hallmark sx of MDMA (ecstacy) intoxication?

Answer 24

extremely high fever (38.5-43^oC)

–> rhabdomyolysis, renal failure, seizures, disseminated intravascular coagulopathy, cadiac arrhythmias, and death