Addiction Medicine (Bemski) (Midterm) Flashcards
The terms “dependency” and “abuse” were dropped from the DSM-5 in favor of what single term?
Substance use disorder (SUD)
-includes tobacco, alcohol, marijuana, opioids, and methamphetamines
What is the definition of addiction?
A chronic, relapsing disorder characterized by compulsive drug/alcohol seeking, continued use despite harmful consequences, and long-lasting changes in the brain
What are all the diagnostic criteria for substance use disorder according to the DSM-5?
- Hazardous use
- Social/interpersonal problem related to use
- Neglected major roles because of use
- Withdrawal
- Tolerance
- Used larger amounts/longer
- Repeated attempts to quit/control use
- Much time spent using
- Physical/psychological problems related to use
- Activities given up in order to use
- Craving
How many diagnostic criteria must be met to diagnose mild, moderate, and severe SUD?
Mild: 2-3
Moderate: 4-5
Severe: 6-7
What are factors that have caused a recent increase in the number of overdose deaths?
- Driven largely by fentanyl and similar synthetic opioids (tasteless, odorless, stronger)
- Easy access to drugs
- Low cost
In 2016 how many people were killed from overdose from prescription drugs? Excessive alcohol use?
Rx = 63,000
Excessive alcohol use = 88,000
What is the cost of addiction per year?
> $740 billion
How many drug overdose deaths occurred in 2020?
- Estimated > 93,000
- Highest number of overdose deaths ever recorded in a 12 month period
- Nearly 30% increase from 2019
How has COVID affected OD deaths/addiction in general?
- Social isolation
- Stress
- People using drugs alone
- Overall inc in rates of drug use
- Dec. access to substance use tx, harm reduction services, emergency services
What neurotransmitter regulates movement, emotion, cognition, motivation, and reinforcement of rewarding behaviors?
Dopamine
Describe the pathophysiology of dopamine
- DA receptors in brain are hyperstimulated in response to taking drugs
- Drugs, via excessive and repeated dopaminergic stimulation, induce persistent neruoplastic adaptation in midbrain DA neurons
Well-supported evidence suggests that the addiction process involves a three-stage cycle. What are the three stages?
- Binge/intoxication
- Withdrawal/Negative Affect
- Preoccupation/Anticipation (one seeks substances again after a period of abstinence)
What region of the brain is involved with stage 1 of the three-stage cycle (binge/intoxication)?
basal ganglia
What region of the brain is involved with stage 2 of the three-stage cycle (withdrawal/negative affect)?
extended amygdala
What region of the brain is involved with stage 3 of the three-stage cycle (preoccupation/anticipation)?
prefrontal cortex
Who is at increased risk of becoming addicted to drugs/alcohol?
Basically the scope is very broad
- From teens still living at home to professional people
- Males, females
- People with mental illness to highly educated people
- Adverse chilhood events (ACE)
- Family members with addiction hx
- Chronic pain
What are some of the main addiction risk factors?
- Genetics
- Psychological
- Age
What are genetic addiction risk factors?
- Studies have shown that as much as 50% of persons propensity to have addiction is genetic
- Children of addicts are 8 times more likely to develop an addiction
What are psychological addiction risk factors?
- About 50% of individuals who have mental illness also struggle with SUD
- Hx of physical or sexual abuse
- Peer pressure
For children and adolescents the risk of becoming a drug abuser involves what relationship?
The relationship among the number and type of risk factors (deviant attitudes and behaviors, ACEs) and protective factors (parental support)
Exposure to drugs or adverse environmental stimuli during critical time windows of childhood and adolescence can have what dire consequences?
- Consequences for normal brain development
- Addiction vulnerability
A critical factor in the susceptibility of adolescents to risky behaviors, including drug-taking, pertains to what fact regarding the brain?
Brain circuitry, which is necessary for self-regulation, is not fully developed until early adulthood
What substances have students tried at least once prior to the age of 18?
- Alcohol 91%
- Tobacco 40%
- Marijuana 47%
- Prescription Drugs 18%
- Illicit Substances 5%
What are some devastating effects of addiction on health, the brain, life in general?
- Overdose deaths
- Neonatal abstinence syndrome, removal of newborns from parental care
- Transmission of infectious diseases such as HIV, Hep C ,hepatitis, STDs
- Skin infections, organ damage, cardiac disease, neurotoxic changes in the brain
- Social consequences including loss of productivity, inc crime and violence, neglect of children, expanded health care costs
What are the low-risk drinking limits for men?
- No more than 4 drinks on any day
- No more than 14 drinks per week
What are the low-risk drinking limits for females?
- No more than 3 drinks on any day
- No more than 7 drinks per week
What is a standard drink?
How many deaths are annually attributed to escessive alcohol use?
95,000 (CDC 2019)
What is the 3rd leading lifestyle-related cause of death in the nation?
Alcoholism
What percentage of children 17 years old and younger live in a household where at least one parent is dependent on or has abused alcohol?
10%
What is the most common type of SUD in the US?
Alcohol use disorder
What factors are responsible for about 50% of vulnerabilities related to alcohol use disorder?
Genetics factors
People who misuse alcohol have a greater risk of developing what diseases?
- liver disease
- heart disease
- depression
- stroke
- stomach bleeding
- CA of oral cavity, esophagus, larynx, pharynx, liver, colon, rectum
Alcohol consumption is associated with increased risk of what events?
- Drowning
- Injuries from violence, falls, MVCs
In 2019, alcohol-impaired driving fatalities accounted for how many deaths?
10,142 deaths (28% of overall driving fatalities)
In 2019 how many people in the US had alcohol use disorder? How many Adolescents?
- 14.5 million people ages 12 and older
- 414,000 adolescents
In 2019 what percentage of people ages 18 and older reported that they engaged in binge drinking in the past month?
25.8%
T/F: alcohol withdrawal can be life-threatening
True duh
Alcohol withdrawal symptoms usually start __-__ hours after the last drink and last __-__ hours
Start 8-12 hours after the last drink and last 48-72 hours
When does mild alcohol withdrawal usually begin and what symptoms are present?
- Onset 6-12 hrs, can last 3 days
- Tremor
- Tachycardia
- Anxiety
- GI upset
When does severe alcohol withdrawal usually begin and what symptoms are present?
- Onset 24-48 hours
- Generalized tonic-clonic seizure
- Risk = h/o prior seizures
What three medications and what injectable medication are currently approved for treating alcohol dependence?
- Naltrexone
- Acamprosate
- Disulfiram
- Injectable Naltrexone (extended release)
What are the goals of alcohol dependence tx MAT?
- Reduce drinking
- Avoid relapse to heavy drinking
- Achieve and maintain abstinence
- Gain a combination of these effects
What medication can be prescribed while a patient is actively working towards abstinence?
Naltrexone
What medications requires a patient to be abstinent prior to initiation?
Acamprosate and Disulfiram
What is the minimum duration of alcohol dependence tx MAT?
3 months
What should you do if one alcohol dependence medication does not work after a 3 month trial?
Try another!
*Note that evidence does not show benefit from combination meds
What alcohol dependent medication tx can help people reduce heavy drinking by stopping the pleasureable effects of alcohol use?
Naltrexone
What alcohol dependence medication tx has antidrinking neurochemical effects?
Acamprosate
How does the alcohol dependence medication Disulfiram (Antabuse) work?
Blocks the breakdown (metabolism) of alcohol by the body, causing unpleasant symptoms such as nausea and flushing, which can help people avoid drinking
What are common stimulants and opioids that are prescribed?
- Fentanyl
- Adderall
- Vivance
- Dextroamphetamine
- Hydrocodone, Oxycodone
- Percocet
- Vicodin
- Morphine
- Codeine
What are illicit opioids and stimulants?
- Heroin
- Methamphetamines
- Cocaine
- Fentanyl
Nearly all people who used this specific drug also used at least 1 other drug
- Heroin
- Most used at least 3 other drugs
- Heroin is a highly addictive opioid with a high risk of overdose and death
People who use this specific drug are 40x more likely to be addicted to heroin
- Rx opioid painkillers
- Alcohol = 2x
- Marijuana = 3x
- Cocaine = 15x
What is the leading cause of accidental death in the US?
- Drug overdose
- Opioids are involved in more than 3 out of 5 overdoses
80% of heroin users started with what other drugs?
- Prescription drugs
- 75% of opioid misuse begins with using drugs not prescribed to that individual
What percentage of patients prescribed an opiate drug will misuse them?
21-29%
4-6% of them will then transition to heroin
What are the short term effects of methamphetamines?
- inc wakefullness and physical activity
- inc breathing, HR, BP, Temp
- dec appetite
- irregular heartbeat
What are long term effects of methamphetamines?
- anxiety, confusion
- insomnia
- mood problems, violent behavior, paranoia
- hallucinations, delusions
- weight loss
- severe dental problems “meth mouth”
- intense itching –> skin sores from scratching
T/F: There are some FDA-approved medications to treat methamphetamine addiction
False - NONE
What are the most effective treatments for methamphetamine addiction at this point?
Behavioral therapies: CBT and contingency management interventions
Cocaine stops ___ from being reabsorbed
Dopamine
What are methods for ingesting cocaine?
- Snorting powder
- Rubbing it onto gums
- Injecting it
- Injection combo of cocaine and heroin “Speedball”
Smoking cocaine that has been processed to make a rock crystal is also called?
Freebase cocaine
What is “Crack”
- When a rock crystal of cocaine is heated, it produces vapors that are inhaled
- “Crack” refers to the crackling sound of the rock as it’s heated
- Can be sprinkled on marijuana or tobacco and smoked
lol at all the drug lingo we are learning :)
What are the CNS depressant drugs?
- Benzodiazepines
- Diazepam (Valium)
- Clonazepam (Klonopin)
- Alprazolam (Xanax)
- Triazolam (Halcion)
- Estazolam (Prosom)
What are the Non-Benzodiazepine Sedative Hypnotic “Z” drugs?
- Zolpidem (Ambien)
- Eszopiclone (Lunesta)
- Zaleplon (Sonata)
What symptoms would a pt withdrawing from CNS depressants present with?
- Seizures
- Shakiness
- Anxiety, agitation
- Insomnia
- Overative reflexes
- Inc HR, BP, Temp
- Hallucinations
- Severe cravings
Discontinuation of benzodiazepines must be done extremely slowly because the high risk of?
Seizures
Taking benzos with opioids can have synergistic effects and when taken together increase what risk?
respiratory suppression
What is the opioid screening tool for withdrawal called?
Clinical Opiate Withdrawal Scale (COWS)
What is Tanxene (clorazepate) and how is it used for supported withdrawal?
- Long acting benzo used for alcohol withdrawal
- Titrated over 4-5 days
How is Buprenorphine/naltrexone used for supported withdrawal?
- Used for opioid withdrawal
- Titrated over 4-5 days
What is Clonidine/lofexidine and how is it used for supported withdrawal?
- Analgesic/central acting nonopioid
- Blocks release of norepinephrine (which causes anxiety, tachy, dysphoria)
How is Trazodone used for supported withdrawal?
Used for patients with insomnia
How is Baclofen used for supported withdrawal?
For muscle relaxation/spasticity
What is supervised withdrawal for addiction treatment?
- In office protocols define how to do “induction”, initializing buprenorphine
- Experienced pts can also successfully do home inductions
- Residential programs and outpatient detox facilities can manage pts through withdrawal and into maintenance
What are the 3 medications approved for treating opioid use disorder (MAT)?
- Methadone
- Buprenorphine (Suboxone)
- Naltrexone
Studies have shown that what type of treatment increases tx retention and decreases the risk of overdose?
Medication Assisted Treatment (MAT)
What are the 4 ways in which FDA-approved medications for opioid addiction, overdose, and withdrawal work?
- Opioid Receptor Agonist
- Opioid Receptor Partial agonist
- Opioid Receptor Antagonist
- Adrenergic Receptor Agonist
What addiction tx medication is an opioid receptor agonist?
- Methodone
- Daily liquid or tablet
- Attaches to receptors in brain to block withdrawal symptoms and cravings
What addiction tx medication is an opioid receptor partial agonist?
- Buprenorphine
- Daily tablet or monthly injection
- Partially activate opioid receptors in brain to ease withdrawal sx and cravings
What addiction tx medication is an opioid receptor partial agonist AND opioid receptor antagonist?
- Buprenorphine/Naloxone
- Daily film under tongue or tablet
What addiction tx medication is an opioid receptor antagonist?
- Naltrexone and Naloxone
- block activity of opioid receptors in brain to prevent euphoric effects of opioids and alcohol
- help reduce cravings
What addiction tx medication is an adrenergic receptor agonist?
- Lofexidine
- Tablet PRN
- Activates adrenergic receptors in brain and helps alleviate withdrawal symptoms
How does heroin activate opioid receptors?
Fully and quickly
Which two addiction tx medications act on opioid receptrs with a similar time course?
Methadone (full) and Buprenorphine (partial)
Which addiction tx medication prevents opioid receptor activation?
A. Lofexidine
B. Naltrexone
C. Methodone
D. Buprenorphine
B. Naltrexone
Use of drugs and alcohol for pain relief can actually give the patient ___ when in remission and during withdrawal
hyperalgesia
What are some unintended consequences of drug addiction?
- People who are in remission or incarcerated and are being released are at high risk of OD death if they resume use of the abused substance at previous levels due to changes in tolerance
- Deaths of children who accidentaly take MATs, other substances
Stigma against people with substance use disorder may stem from antiquated and incorrect beliefs that addiction is a moral failing, instead of what we know it to be:
A chronic, treatable brain disease from which patients can potentially recover and continue to lead healthy lives
How should you address a pt with SUD?
Use first person language: Person with/who uses…
What are some risk reduction strategies?
- Naloxone distribution to drug users, with discharge from justice system
- PDMP, monthly prescriber reports
- Academic detailing
- Screening for fentanyl
- 911 Good Samaritan laws
- MAT/treatment services referral when discharged from criminal justice system
- LEAD: Law Enforcement Assisted Diversion into intensive case management
- Syringe exchange programs/safe injection sites
How can new providers have a huge impact on their SUD patients?
- learning about prescribing pain treatment to begin with
- learning how to screen for and treat SUD subsequently
