Addictions Flashcards
What constitutes drug dependence (vs addiction)?
- development of tolerance (Physiological adaptation to the presence of a substance & Higher doses are required to produce the same effect experienced during initial use)
- withdrawal (What a person experiences, after a period of regular use, when the quantity of available substance in the brain is reduced)
What are the 4 C’s that constitute addiction?
- Craving for mood altering effects
- Control loss re: amount or frequency
- Compulsive use of substance or behaviour
- Consequences (continued use despite)
Examples of addictive behaviours?
Gambling Sexual activity, viewing pornography Overeating, binging, starving Video games, on-line activities TV watching Risk taking Working Exercising Self-harming Cleaning Shopping Spiritual obsession, idolizing
Categories of addictive depressants?
alcohol opioids anxiolytics hypnotics GHB (gamma hydroxybutyrate - date rape drug)
Categories of addictive stimulants?
tobacco
cocaine
caffeine
amphetamines
Cannabis addictive substances?
marijuana
hash
Hallucinogenic addictive substances?
PCP - phencyclidine (“angel dust”) - dissociative hallucinogen; distort perceptions of sight and sound and produce feelings of detachment – dissociation – from the environment and self. (dream-like state)
LSD - lysergic acid diethyl amide (“acid”) - however not highly addictive
MDMA (ecstasy/molly) - 3,4-methylenedioxy-methamphetamine; alters mood and perception; feelings of increased energy, pleasure, emotional warmth, and distorted sensory and time perception.
salvia
mescaline
psilocybin
Addictive potential of a substance is determined by?
Ability to produce:
- rapid onset of action
- powerful euphoric effect
- short duration of action
- tolerance and withdrawal
Who should be screen for substance use?
all patients over 10 yrs old
What is the lifetime prevalence of a psychiatric disorder in people with a current alcohol problem?
28%
What constitutes appropriate assessment of an individual with a substance abuse issue?
Medical & psychiatric hx
family & social hx
complete screening PE
routine blood work incl. CBC, chem panel, LFTs
screening of blood, breath, urine if substance use suspected
How does the DSM V organize substance use and abuse?
Combines substance use and abuse into one category:
“substance use disorder”
Divided into 10 subcategories (by class of drug)
- alcohol
- amphetamines
- cannabis
- cocaine
- hallucinogens
- inhalants
- opioids
- phencyclidines
- sedatives/hypnotics/anxiolytics
- tobacco
- other (unknown) substances
DSM V dx criteria?
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 or more of the following, occurring within a 12-month period:
- failure to fulfill major role obligations (work/school/home)
- use in situations it is physically hazardous
- social or interpersonal problems d/t substance
- tolerance (need more for same effect/diminished effect w/same amount)
- withdrawal (characteristic, or same/similar substance used to relieve/avoid symptoms)
- larger amounts taken over period of time
- unsuccessful efforts to cut down
- great deal of time spent in efforts to obtain substance, use, or recover
- important activities given up
- continued use despite knowledge of persistent/recurrent physical/psychological problem
- craving
Scoring
0-1 = no DSM diagnosis of a substance use disorder
2-3 = mild substance use disorder
4-5 = moderate substance use disorder
6 or more = severe substance use disorder
Doctor reporting obligations?
Doctors in Ontario are required to report patients who they believe have a condition that may make it dangerous to operate a motor vehicle to the Ministry of Transportation
The use of alcohol or other drugs is not in itself sufficient reason to report someone, however, any of the following, in combination with the doctor’s opinion, are reasonable grounds:
The patient admits to driving while impaired
A family member informs you that the patient often drives while impaired
The patient drinks or uses other drugs steadily throughout the day and regularly drives
The patient drove to your clinic while intoxicated
The patient has experienced a withdrawal seizure, regularly drives and continues to drink
The patient has substance-related medical complications that impair driving ability (e.g., alcohol-related cerebellar ataxia)
Risk factors for developing substance abuse?
Physical:
- naturally higher tolerance
- family hx addiction
- chronic illness/pain
Social:
- chronic relational problems
- access to addictive substance
- social pressures
Psychological:
- underlying mental illness
- inability to delay gratification
- low self-esteem
- unresolved grief or resentment
- heightened need for acceptance
- perfectionism
- timidity
- rebellious nature
- spiritual crisis
- inability to cope with stress
General treatment principles for managing addictions?
Establish and maintain a therapeutic alliance
Provide education
Assist in the creation of a support network
Motivate change
Assess safety and clinical status
Manage intoxication or withdrawal symptoms
Reduce morbidity & long-term sequelae
Facilitate adherence to an individualized treatment plan and then a plan to prevent relapse
Facilitate access to services and coordinate resources
What constitutes motivational interviewing in terms of addictions management?
An empathic, nonjudgmental, and supportive method of engaging intrinsic motivation to change behaviour by developing discrepancy, and exploring and resolving ambivalence within the patient
Suggests the problem of addiction is simply competing motivations
Provides patients with another perspective to increase their understanding of the consequences of their behaviour
“Why do you think you should you cut down or stop?”
Explore the importance for patients of cutting down or stopping
Encourage patients to weigh competing values, benefits, priorities and perceptions of risk
“Do you feel that you are going to be able to cut down or stop?”
Explore patients’ confidence in their ability to cut down or stop
This includes issues of self-efficacy, past experiences and alternative solutions
“When do you think you will be ready to cut down or stop?”
Explore patients’ readiness to cut down or stop in the near future
Allow patients to weigh the competing priorities in their own lives with their own assessment of their confidence
What are the “RULES” of Motivational Interviewing?
“RULE”:
RESIST righting reflex
UNDERSTAND patient’s motivations
LISTEN with empathy
EMPOWER the patient
What are the transtheoretical stages of change?
Pre-Contemplation
Contemplation
Determination
Action
Maintenance
{Relapse + start over from pre-contemplation}What constitutes pre-contemplation?
“Not ready”
No intention to start the healthy behavior within the next 6 months
May be unaware that there is a problem or a need to change
Typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes
What constitutes contemplation?
“Getting ready”
Patients are intending to start the healthy behavior within the next 6 months
Usually are more aware of the pros of changing but their cons are equal to their pros
What constitutes preparation?
“Ready”
Commitment to action
What constitutes Action?
1st step toward the modification of previous patterns
The individual becomes engaged and adopts a new attitude
People at this stage have changed their behavior within the last 6 months and need to work hard to keep moving ahead
They need to learn how to strengthen their commitments to change and to fight urges to slip back into old patterns
What constitutes maintenance?
Sustaining and integrating new habits
The aim is to avoid relapses and consolidate the gains made in the previous stage
People at this stage changed their behavior more than 6 months ago
What constitutes relapse/regression?
Relapse is an expected part of the process
People commonly cycle and recycle through the stages
Differentiate “relapse” vs a slip-up
Slip-up:
A recurrence of the behaviour the patient is trying to change, while remaining committed to the plan to reduce substance use or remain abstinent
Relapse:
A true relapse involves a regression to a previous stage of change and reversion to a previous pattern of behaviour
How do you refer to a treatment program in Ontario?
In Ontario you can call the Drug and Alcohol Registry of Treatment (DART) at 1-800-565-8603
Who are residential or inpatient treatment programs for?
Indicated for patients who have failed at community treatment, require medical management of withdrawal, or live in a chaotic or unsupportive home environment
Who are community treatment programs for?
Effective for socially stable patients with less severe psychosocial or substance use problems
Usually the patient’s first choice, as they do not disrupt work and normal living arrangements.
12-step programs
AA, NA, GA, SA, etc.
Al-Anon, Alateen, CODA, etc. for family & friends
Addictive substances affect neurotransmitter function by altering:
Neurotransmitter synthesis, metabolism & release
The excitability of neurons
The number of receptors on target cells
The electrolyte/mineral balance of the body
Addictive substances can also:
Mimic neurotransmitters
Directly damage neurons
Useful botanical actions in treating addictions?
- nervines
- adaptogens & alternatives
- digestive tonics
- hepatics & cholagogues
L-tryptophan is a precursor for which NT(s)?
serotonin
melatonin
Tryptophan -> 5-HTP -> serotonin -> melatonin
Glutamine is a precursor for which NT?
GABA
Glutamine -> glutamic acid -> GABA
Phenylalanine is a precursor for which NT(s)?
dopamine
norepinephrine
epinephrine
TCM treatment principles for addictions management?
- balance & harmonize shen
- tonify HT & move LV stasis
- nourish yin, blood & fluids
- strengthen qi & KD essence
What are opioids & what are some examples?
Opioids are medications that relieve pain. They reduce the intensity of pain signals reaching the brain and affect those brain areas controlling emotion, which diminishes the effects of a painful stimulus.
Medications that fall within this class include: hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContin, Percocet), morphine (e.g., Kadian, Avinza), codeine
Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, gastrointestinal tract, and other organs in the body. When these drugs attach to their receptors, they reduce the perception of pain. Opioids can also produce drowsiness, mental confusion, nausea, constipation, and, depending upon the amount of drug taken, can depress respiration. Some people experience a euphoric response to opioid medications, since these drugs also affect the brain regions involved in reward.
