Addictions Flashcards
1
Q
Substance use disorders criteria?
A
At least TWO for at least 12 months Categories - Impaired control - Social impairment - Risky use - Pharmacological (tolerance, withdrawal)
2
Q
Substance use disorders specifiers?
A
Early remission = 3 - 12 months Sustained remission = > 12 months On maintenance therapy In a controlled environment Severity (based on # of symptoms)
3
Q
Substance use disorders epidemiology?
A
Prevalence 17% excluding nicotine
Onset 18-20yo except THC
Heritability 50%
4
Q
What percentage substance use disorders have ASPD?
A
35-60%
5
Q
Which substance does not have intoxication?
A
Nicotine
6
Q
Which substance does not have use disorder?
A
Caffeine
But has intoxication and withdrawal criteria!
7
Q
Which substances don’t have withdrawal?
A
PCP, hallucinogens, solvents
8
Q
Which substances can causes OCD?
A
Stimulants (in both intoxication and withdrawal)
9
Q
Prevalence of SUD in other mental disorders
A
ASPD 84%
BAD 56%
Schizophrenia 47%
MDD 27%
10
Q
Timing of substance-induced mental disorder?
A
Within 1 month
11
Q
Alcohol use disorder types
A
Type 1 = environmental, >20yo, SSRI can help
Type 2 = genetic, < 20yo, SSRI can worsen
12
Q
Max alcohol amounts?
A
Men: 14-15 drinks/week, max 3/day
Women: 9-10 drinks/week, max 2/day
13
Q
Alcohol units?
A
13.6g of alcohol
Beer 5% 341ml
Wine 12% 142ml
Liquor 40% 44ml (1.5oz)
14
Q
Alcohol metabolism?
A
Zero order kinetics (rate stable regardless of plasma level)
90% small intestine
10% stomach
Mellanby effect: effects are more at same concentration if the concentration is increasing
90% liver (oxidation)
10% excreted piney –> lungs
EtOH –> ADH –> acetaldehyde –> ALDH –> acetyl-coenzyme A
15
Q
Alcohol metabolism in women?
A
Less ADH in blood/stomach/esophagus so intoxication is greater with same quantity of alcohol compared to men
16
Q
Ethanol mechanism?
A
NMDA antagonist
GABA agonist
17
Q
Average age of first alcohol intoxication?
A
15 years old
18
Q
Most sensitive and specific biological marker of alcohol?
A
CDT
19
Q
What is not a biological marker of alcohol?
A
LDH
20
Q
Fastest biological marker of alcohol relapse?
A
GGT
21
Q
Alcohol use disorder neurobiology?
A
Intoxication = GABA agonism, NMDA antagonism
Withdrawal = glutamate (unregulated due to inhibition by GABA)
Chronic use =increased sensitivity of NMDA receptors
22
Q
Alcoholic hallucinosis
A
Not altered sense of reality
Usually AUDITORY HALLUCINATIONS
Depression, anxiety
DOES NOT CAUSE OBSESSIONS
23
Q
Wernicke encephalopathy
A
WACO
- ataxia
- confusion
- ophthalmoplegia (nystagmus, paresis, abnormal pupils, 6th nerve palsy)
80% CONVERT TO KORSAKOFF
GIVE THIAMINE BEFORE GIVING GLUCOSE
100mg IM/IV x 3 days then PO
Death = 15-20% if untreated
40% remit
24
Q
Korsakoff syndrome
A
Permanent in > 50%
ANTEROGRADE amnesia CONFABULATION Possible hallucinations Poor recall Disorientation Poor insight
WORKING MEMORY INTACT
25
Stages of alcohol withdrawal
1. Tremors 6-8 hours
2. Hallucinations 8-12 hours, VISUAL
3. Seizures 12-24 hours tonic clonic, no aura, short post-ictal
4. DTs 24-72 hours 20% mortality if untreated, usually 30-40yo with chronic 5-15 year use, DON'T GIVE HALDOL (high risk EPS, seizure, hyperthermia)
26
Disulfiram
Irriversible inhibition of aldehyde dehydrogynesa
Results in accumulation of acetaldehyde
Need to be 12 hours post-drink, effects can last 1-2 weeks
CAN WORSEN PSYCHOSIS
Don't use in CAD
27
Risk of alcohol dependence?
All alcohol users = 5-10%
1 parent = 20% (RR 2-4)
2 parents = 20-50% (RR 2-10)
Father Etoh + criminal = 90% (RR 9-18)
28
Blood alcohol level
0.1% = mild euphoria
0.2% = decreased psychomotor
0.3% = decreased coordination, incoherent
> 0.3% = stupor, loss of coordination
29
Alcohol intoxication criteria
Intox = ONLY ONE SYMPTOM
```
Slurred speech
Incoordination
Unsteady gait
NYSTAGMUS
Impaired attention/memory
Stupor/coma
```
30
Alcohol withdrawal criteria
Withdrawal = AT LEAST 2 SYMPTOMS
```
Autonomic hyperactivity
Hand tremor
Insomnia
N/V
Transient hallucinations
Psychomotor agitation
Anxiety
Generalized tonic-clonic seizures (< 3%)
```
Specifier = with perceptual disturbances
31
Topiramate
Nephrolithiasis
| Acute myopia due to closed angle glaucoma
32
Naltrexone
```
Opioid antagonist
Decreases alcohol craving
Can't use if liver problem (elevated ALT/AST)
Can't use in pregnancy/breastfeeding
50-150mg/day
```
Works better for type 2 (genetic)
33
Acamprosate
```
NMDA glutamate antagonist
Can't use in kidney disease
Can't use in pregnancy
Diarrhea side effect
666mg TID
```
Works better for type 1 (environmental)
34
MDMA (ecstasy)
```
SEROTINERGIC activity (increases release and blocks recapture)
Both amphetamine and hallucinogen effects
```
35
Cocaine
DOPAMINERGIC activity (blocks dopamine recapture)
Effects on babies in mothers who use are due to INTOX not withdrawal from cocaine
AVOID B-BLOCKERS if intoxicated
Free base = IV
Crack = cocaine + HCL + Sodium bicarb
36
Cocaine withdrawal stages
1. Crash (NO CRAVINGS) hours up to 4 days
2. Craving 1-10 weeks
3. Extinction (craving if stimulus) after 10 weeks
Don't need hospitalization
37
Stimulant intoxication
Intox = at least 2 symptoms
```
HR changes (up or down)
Dilated pupils
BP changes (up or down)
Perspiration, chills
N/V
Weight loss
Psychomotor retardation or agitation
Muscle weakness, chest pain, respiratory depression, cardiac arrhythmia
Confusion, seizure, dyskinesia, dystonia, coma
```
**Vigilant watchfulness with suspicion**
(persecutory delusions + AH)
38
Stimulant withdrawal
Withdrawal = DYSPHORIC MOOD + TWO more symptoms
```
Fatigue
VIVID UNPLEASANT DREAMS
Insomnia/hypersomnia
Increased appetite
Psychomotor retardation or agitation
```
Bradycardia often present and reliable measure of stimulant withdrawal
39
Cocaine use complications
coronary artery spasm, MI, CVA
| IV/smoked most dangerous
40
Treatment for cocaine?
Abstinence
| Topamax, Modafinil, Disulfiram
41
Phencyclidine (PCP)
NMDA ANTAGONIST (anti-glutamate, pro-dopamine)
When intoxicated, AGGRESSIVE, DECREASED PAIN RESPONSE, sensitive to stimuli
50% psychosis
40% NYSTAGMUS + HYPERTENSION
Use Benzes for agitation not antipsychotics (acetylcholine activity)
42
PCP intoxication
AT LEAST 2 within 1 hour of use
```
Vertical or horizontal NYSTAGMUS
Hypertension or tachycardia
Decreased response to pain
Ataxia
Dysarthria
Muscle rigidity
Seizure or coma
Hyperacusis
```
43
LSD
Partial 5HT2a AGONIST
44
Other hallucinogen intoxication
(Pro-serotonergic effects)
Intox = AT LEAST 2 SYMPTOMS
```
Dilated pupiuls
Tachycardia
Sweating
Palpitations
BLURRED VISION
TREMORS
Incoordination
```
45
Hallucinogen persisting perception disorder
After stopping, re-experiencing at least ONE perpetual symptom experienced while intoxicated, associated with distress.
VISUAL HALLUCINATIONS seem to be prominent
4% of hallucinogen users
46
Which opioid does not cause pupillary constriction?
Meperidine
47
Opioid intoxication?
PUPILLARY CONSTRICTION + ONE symptom
Drowsiness or coma
Slurred speech
Impairment in attention or memory
48
Opioid withdrawal?
AT LEAST 3 symptoms
```
Dysphoric mood
N/V
Muscle aches
Lacrimation or rhinorrhea
Pupil dilation, piloerection, sweating
Diarrhea
Yawning
Fever
Insomnia
```
Males can get spontaneous ejaculation
Peaks at 1-3 days, then subsides over 5-7 days
49
Methadone
Full agonist
Can cause prolonged QTc
Need higher doses to control cravings, 40-60mg ok for withdrawal
Highest risk of overdose in first 2 weeks of treatment
10-40mg in pregnancy
NOT TERATOGENIC
Can't use naloxone or naltrexone in pregnancy
50
Cannabis receptors
CB1 = central, highest in basal ganglia, hippocampus and cerebellum (** remember C.B.H.)
CB2 = peripheral
51
Cannabis active metabolite?
11-hydroxy-delta 9 THC
52
Effect of IQ if regular cannabis use during adolescence?
Possibly decrease by up to 5-8 points
53
Cannabis use co-morbid use of other substances?
```
Tobacco (53%)
Alcohol (40%)
Cocaine (12%)
Meth (6%)
Heroin (2%)
```
54
Cannabis use co-morbid psychiatric illness?
ASPD (30%)
Anxiety (24%)
BAD (13%)
MDD (11%)
Externalizing 60%
Internalizing 33%
55
Cannabis intoxication
Intox = at least 2 symptoms
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
56
Cannabis withdrawal
Withdrawal = at least 3 symptoms within 1 week of stopping
```
Irritability/anger/aggression
Anxiety
Sleep problems
Decreased appetite
Restlessness
Depressed mood
Abdo pain/tremors/sweating/fever/chills/headache
```
Peak 1 week
Lasts 1-2 weeks
57
Caffeine
ADENOSINE RECEPTOR ANTAGONISM (increases dopamine activity)
Most used substance in the world
Decreases seizure threshold
OCPs DECREASE ELIMINATION OF CAFFEINE
Safe limit = 400mg
Half-life = 4-6 hours
58
Caffeine intoxication
> 250mg
At least 5 symptoms
```
Restlessness
Nervousness
Excitement
Insomnia
Flushed face
Diuresis
GI disturbance
Muscle twitching
Rambling thought/speech
Tachycardia/arrhythmia
Inexhaustibility
Psychomotor agitation
```
59
Caffeine withdrawal
At least 3 symptoms
```
HEADACHE
FATIGUE
Dysphoric mood/depressed/irritable
Difficulty concentrating
Flu-like symptoms
```
60
Tobacco mechanism
AGONIST OF NICOTINIC CHOLINERGIC RECEPTORS
Dependence = INDIRECTLY THROUGH DOPAMINE INCREASE
61
Smoking cessation
Stopping suddenly vs. progressively has same outcome so patient preference
62
Varenicline
Most efficacious treatment
EAGLES STUDY: No neuropsychiatric side effects (used to be a black box warning)
PARTIAL AGONIST A4B2
Start 1 week before stop date
Progressively increase to 1mg BID x 3-4 months
Main side effect = nausea
Contraindicated in PREGNANCY and < 18 YEARS OLD
63
Nicotine Replacement Therapy
ABSORPTION DECREASED BY COFFEE
Requires complete cessation
Max 24 gums per day q1-2H
Patch highest is 28mg then 21, 14, 7 over 3-4 months
64
Bupropion SR (Zyban)
Start 1 week before stop date
Can be combined with patch
1st line in patient with history of MDD
65
2nd line smoking cessation agents?
NORTRIPTYLINE
| CLONIDINE
66
Tobacco withdrawal
At least 4 symptoms
```
IRRITABILITY
ANXIETY
TROUBLE CONCENTRATING
Increased appetite
Restlessness
Depressed mood
Insomnia
```
Peaks 2-3 days
Lasts 2-3 weeks
67
Inhalant intoxication
NO WITHDRAWAL OR USE DISORDER criteria
Intoxication = at least 2 symptoms (episodes are brief)
```
Dizziness
NYSTAGMUS
Incoordination
Slurred speech
Unsteady gait
Lethargy
HYPOREFLEXIA
Psychomotor retardation
Tremor
Generalized muscle weakness
Blurred vision/diplopia
Stupor or coma
Euphoria
```
"Sudden sniffing death" not dose dependent!
68
Methanol intoxication
OPTIC NEURITIS
| PUTAMEN NECROSIS
69
Carbon monoxide poisoning
GLOBUS PALLIDUS lesion
70
Most common co-morbidity with gambling d/o?
MDD
71
Gambling disorder criteria?
AT LEAST 4 IN 12 MONTHS
```
Increasing amount of money spent to get excited
Irritable when tried to cut down
Unsuccessful efforts to cut down/stop
Pre-occupied with gambling
Gambles when feels distressed
Chases after loses
Lies to conceal involvement in gambling
Jeopardized social roles
Relies on others to provide money for debts
```
Not better explained by manic episode
Episodic vs. persistent
72
Gambling disorder
0.4-1%
M > F
17% have attempted suicide
PROGRESSES MORE RAPIDLY IN WOMEN
TACHYCARDIA + ANGINA more common
73
Motivational interviewing
Miller & Rollnick
74
Sedative intoxication
At least ONE
```
Slurred speech
Incoordination
Unsteady gait
NYSTAGMUS
Cognitive impairment
Stupor/coma
```
If severe, treat with flumazenil IV
75
Sedative withdrawal
At least TWO
```
Autonomic hyperactivity
Hand tremor
Insomnia
N/V
Transient visual/tactile/auditory hallucinations
Psychomotor agitation
Anxiety
Grand mal seizures
```
Symptom REBOUND = hours/days
Symptom RELAPSE = weeks
76
SUD co-morbidities
BAD 56%
MDD 30-50%
Psychosis 50%
Anxiety 36%
77
Neurobiological pathways
Stress = increase amygdala (CRF, NE)
Cues = glutamate (prefrontal cortex)
Low dose = re-initiates via D2/D3 pathways (blunted previously by external source of dopamine)
78
False positive urine tests
```
Benzos = SERTRALINE
Amphetamine = WELLBUTRIN, ABILIFY, TRAZODONE
Opioid = POPPY SEEDS, QUININE
PCP = VENLAFAXINE
```
79
Alcohol withdrawal mechanisms
REDUCED GABA NEUROTRANSMISSION
| SEIZURES = GLUTAMATE MEDIATED
