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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)
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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)
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3
Q

Substance use disorders epidemiology?

A

Prevalence 17% excluding nicotine
Onset 18-20yo except THC
Heritability 50%

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4
Q

What percentage substance use disorders have ASPD?

A

35-60%

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5
Q

Which substance does not have intoxication?

A

Nicotine

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6
Q

Which substance does not have use disorder?

A

Caffeine

But has intoxication and withdrawal criteria!

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7
Q

Which substances don’t have withdrawal?

A

PCP, hallucinogens, solvents

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8
Q

Which substances can causes OCD?

A

Stimulants (in both intoxication and withdrawal)

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9
Q

Prevalence of SUD in other mental disorders

A

ASPD 84%
BAD 56%
Schizophrenia 47%
MDD 27%

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10
Q

Timing of substance-induced mental disorder?

A

Within 1 month

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11
Q

Alcohol use disorder types

A

Type 1 = environmental, >20yo, SSRI can help

Type 2 = genetic, < 20yo, SSRI can worsen

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12
Q

Max alcohol amounts?

A

Men: 14-15 drinks/week, max 3/day
Women: 9-10 drinks/week, max 2/day

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13
Q

Alcohol units?

A

13.6g of alcohol

Beer 5% 341ml
Wine 12% 142ml
Liquor 40% 44ml (1.5oz)

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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

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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

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16
Q

Ethanol mechanism?

A

NMDA antagonist

GABA agonist

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17
Q

Average age of first alcohol intoxication?

A

15 years old

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18
Q

Most sensitive and specific biological marker of alcohol?

A

CDT

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19
Q

What is not a biological marker of alcohol?

A

LDH

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20
Q

Fastest biological marker of alcohol relapse?

A

GGT

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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

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22
Q

Alcoholic hallucinosis

A

Not altered sense of reality
Usually AUDITORY HALLUCINATIONS
Depression, anxiety
DOES NOT CAUSE OBSESSIONS

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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

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24
Q

Korsakoff syndrome

A

Permanent in > 50%

ANTEROGRADE amnesia
CONFABULATION
Possible hallucinations
Poor recall
Disorientation
Poor insight

WORKING MEMORY INTACT

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25
Q

Stages of alcohol withdrawal

A
  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)
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26
Q

Disulfiram

A

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

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27
Q

Risk of alcohol dependence?

A

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)

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28
Q

Blood alcohol level

A

0.1% = mild euphoria
0.2% = decreased psychomotor
0.3% = decreased coordination, incoherent
> 0.3% = stupor, loss of coordination

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29
Q

Alcohol intoxication criteria

A

Intox = ONLY ONE SYMPTOM

Slurred speech
Incoordination
Unsteady gait
NYSTAGMUS
Impaired attention/memory
Stupor/coma
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30
Q

Alcohol withdrawal criteria

A

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

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31
Q

Topiramate

A

Nephrolithiasis

Acute myopia due to closed angle glaucoma

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32
Q

Naltrexone

A 
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
Q

Acamprosate

A 
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
Q

MDMA (ecstasy)

A 
SEROTINERGIC activity (increases release and blocks recapture)
Both amphetamine and hallucinogen effects
35
Q

Cocaine

A

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
Q

Cocaine withdrawal stages

A
  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
Q

Stimulant intoxication

A

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
Q

Stimulant withdrawal

A

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
Q

Cocaine use complications

A

coronary artery spasm, MI, CVA

IV/smoked most dangerous

40
Q

Treatment for cocaine?

A

Abstinence

Topamax, Modafinil, Disulfiram

41
Q

Phencyclidine (PCP)

A

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
Q

PCP intoxication

A

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
Q

LSD

A

Partial 5HT2a AGONIST

44
Q

Other hallucinogen intoxication

A

(Pro-serotonergic effects)
Intox = AT LEAST 2 SYMPTOMS

Dilated pupiuls
Tachycardia
Sweating
Palpitations
BLURRED VISION
TREMORS
Incoordination
45
Q

Hallucinogen persisting perception disorder

A

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
Q

Which opioid does not cause pupillary constriction?

A

Meperidine

47
Q

Opioid intoxication?

A

PUPILLARY CONSTRICTION + ONE symptom

Drowsiness or coma
Slurred speech
Impairment in attention or memory

48
Q

Opioid withdrawal?

A

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
Q

Methadone

A

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
Q

Cannabis receptors

A

CB1 = central, highest in basal ganglia, hippocampus and cerebellum (** remember C.B.H.)

CB2 = peripheral

51
Q

Cannabis active metabolite?

A

11-hydroxy-delta 9 THC

52
Q

Effect of IQ if regular cannabis use during adolescence?

A

Possibly decrease by up to 5-8 points

53
Q

Cannabis use co-morbid use of other substances?

A 
Tobacco (53%)
Alcohol (40%)
Cocaine (12%)
Meth (6%)
Heroin (2%)
54
Q

Cannabis use co-morbid psychiatric illness?

A

ASPD (30%)
Anxiety (24%)
BAD (13%)
MDD (11%)

Externalizing 60%
Internalizing 33%

55
Q

Cannabis intoxication

A

Intox = at least 2 symptoms

Conjunctival injection
Increased appetite
Dry mouth
Tachycardia

56
Q

Cannabis withdrawal

A

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
Q

Caffeine

A

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
Q

Caffeine intoxication

A

> 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
Q

Caffeine withdrawal

A

At least 3 symptoms

HEADACHE
FATIGUE
Dysphoric mood/depressed/irritable
Difficulty concentrating
Flu-like symptoms
60
Q

Tobacco mechanism

A

AGONIST OF NICOTINIC CHOLINERGIC RECEPTORS

Dependence = INDIRECTLY THROUGH DOPAMINE INCREASE

61
Q

Smoking cessation

A

Stopping suddenly vs. progressively has same outcome so patient preference

62
Q

Varenicline

A

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
Q

Nicotine Replacement Therapy

A

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
Q

Bupropion SR (Zyban)

A

Start 1 week before stop date
Can be combined with patch
1st line in patient with history of MDD

65
Q

2nd line smoking cessation agents?

A

NORTRIPTYLINE

CLONIDINE

66
Q

Tobacco withdrawal

A

At least 4 symptoms

IRRITABILITY
ANXIETY
TROUBLE CONCENTRATING
Increased appetite
Restlessness
Depressed mood
Insomnia

Peaks 2-3 days
Lasts 2-3 weeks

67
Q

Inhalant intoxication

A

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
Q

Methanol intoxication

A

OPTIC NEURITIS

PUTAMEN NECROSIS

69
Q

Carbon monoxide poisoning

A

GLOBUS PALLIDUS lesion

70
Q

Most common co-morbidity with gambling d/o?

71
Q

Gambling disorder criteria?

A

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
Q

Gambling disorder

A

0.4-1%
M > F
17% have attempted suicide

PROGRESSES MORE RAPIDLY IN WOMEN
TACHYCARDIA + ANGINA more common

73
Q

Motivational interviewing

A

Miller & Rollnick

74
Q

Sedative intoxication

A

At least ONE

Slurred speech
Incoordination
Unsteady gait
NYSTAGMUS
Cognitive impairment
Stupor/coma

If severe, treat with flumazenil IV

75
Q

Sedative withdrawal

A

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
Q

SUD co-morbidities

A

BAD 56%
MDD 30-50%
Psychosis 50%
Anxiety 36%

77
Q

Neurobiological pathways

A

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
Q

False positive urine tests

A 
Benzos = SERTRALINE
Amphetamine = WELLBUTRIN, ABILIFY, TRAZODONE
Opioid = POPPY SEEDS, QUININE
PCP = VENLAFAXINE
79
Q

Alcohol withdrawal mechanisms

A

REDUCED GABA NEUROTRANSMISSION

SEIZURES = GLUTAMATE MEDIATED

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