Chapter 12 - Underwriting Alcohol and Substance Use Disorders

Question 1

Two groups of substance-related disorders are defined as

Answer 1

1. Substance use disorder -> Patterns of sx results from use of a substance that the individual continues to take, despite experiencing problems as a result.
2. Substance-induced disorder -> intoxication, withdrawal, and substance induced mental disorders (depressive, psychosis, bipolar, anxiety sleep, neurocognitive, sexual dysfunction, delirium.

Question 2

The presence and severity of substance use disorder is determine using the following 11 criteria

Answer 2

1. Often taken in large amounts or over longer period than was intended.
2. There is a persistent desire or unsuccessful effort to cut down or control use.
3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of the substance.
4. Craving or strong desire to use the substance is present
5. Recurrent use, resulting in a failure to fulfill major role obligations at work, school, or home occurs
6. Continued use despite having persistent or recurrent social or interpersonal problems caused by of exacerbated by the effects of the substance present
7. Important social, occupational, or recreational activities are given up or reduced because of use.
8. Recurrent use in situations where it is physically hazardous occurs.
9. Use is continued despite knowledge of having a persistent or recurrent physical of psychological problem that is likely to have been cause or exacerbated by the substance.
10. The presence of tolerance, as defined by either of the following a) a needed markedly increased amounts of the substance to achieve intoxication or desired effect, b)a markedly diminished effect with continue use of the same amount of the substance,
11. Occurrence of withdrawal, as manifested by either of the following, a) the characteristic withdrawal syndrome from the substance, b) the substance, or closely related substance, is taken to relieve or avoid withdrawal sx.

Question 3

The severity of the substance use disorder is based on the number of criteria met

Answer 3

1. Mild: the presence of 2-3 criteria
2. Moderate: the presence of 4-5 criteria
3. Severe: the presence of 6+ criteria

Question 4

Alcohol-use is the ____ leading cause of preventable death in the US

Answer 4

3rd

Question 5

Alcohol is

Answer 5

A central nervous system (CNS) depressant . The degree to which CNS function is impaired is directly proportional to the concentration of alcohol in the blood.
When ingested 1/4 is absorbed into the stomach, 3/4 in the small intestine where it rapidly enters the bloodstream.

Question 6

Cell membranes are very permeable to alcohol, which explains its wide range of effects on the body. The degree of these effects depends on:

Answer 6

1. the amount of alcohol consumed
2. the concentration of alcohol in the drink
3. the speed on consumption
4. the presence or absence of food in the stomach
5. level of hydration
   6 body type

Question 7

Alcohol is metabolized at a rate of

Answer 7

0.5 ounce/hour. 95% being metabolized in the liver; the remainder is excreted through urine, breath, sweat, feces, and saliva.

Question 8

Biphasic effect of alcohol on the CNS

Answer 8

At low concentrations is stimulates some nerves cells. As alcohol concentration increases, those same nerve cells become suppressed, which accounts for the changes in sx that are observed.

Question 9

Two of the neuronal receptors effected by alcohol

Answer 9

1. GABA (gamme-amminobutyric acid)
2. glutamate receptors, particularly the NMDA (N-methyl-D-aspartate) receptor
   Normally these two systems work together to maintain the balance between the inhibitory and excitatory activity in the brain.

Question 10

Alcohol’s effects on GABA

Answer 10

Alcohol increases the inhibitory activity of GABA receptors which is responsible for its sedative effects. With chronic use the GABA system becomes dependent on alcohol in order to function. At this point is alcohol is withdrawn the cells become hyper excitable, leading to irritability, insomnia, HTN, tachy, hallucinations, and seizures.

Question 11

Alcohol’s effects on NMDA

Answer 11

Alcohol decreases the excitatory activity of the NMDA receptors, which is involved in memory formation, complex thinking, and neuronal excitability. This inhibition leads to the memory deficits impaired judgement, and sedative effects of alcohol.
Withdrawal after chronic use, the NMDA receptor become excessively excited which can result in seizure activity and hypoxic damage.

Question 12

Dopamine and Alcohol

Answer 12

Alcohol increases the release of dopamine, activating the reward centers and providing the sensations of pleasure; however this activity occurs while the concentration of alcohol in the blood is rising. Because this sensation declines when alcohol levels in the blood decline, it can cause continued drinking in an attempt to reclaim the feeling.

Question 13

Percentage of adults meeting criteria for alcohol use disorder

Answer 13

8%
14-25% of males
5-7% of females
30% of the population engage in risky or unhealthy drinking patterns defined as at least 5 standard drinks per day or 15/wk for males.
4 per day or 8 per week for females.

Question 14

Enzyme associated with increased risk of dependency

Answer 14

Alterations in the metabolism of alcohol, particularly with ALDH enzyme are associated with an increased risk of dependence. Serotonin dysfunction has also repeatedly been implicated as a predisposing factor for alcohol abuse.

Question 15

Familial rate of alcoholism

Answer 15

4-5x’s the risk of developing the disorder. Only partially genetic.

Question 16

Factors in the risk for alcohol abuse

Answer 16

Continue exposure to large enough quantities of alcohol over time causes changes in the brain that can produce dependence. Increases with the consumption of more than 3-4 drinks per day.
Another risk is those who drink to self medication (anxiety/stress)

Question 17

Alcohol dependency in the elderly

Answer 17

Reported between 2-20%, largely unrecognized.

Question 18

Medical Consequences of alcohol

Answer 18

1. Gastrointestinal Tract
2. Liver
3. Cardiovascular
4. Nervous System
5. Immune System
6. Cancers

Question 19

Medical Consequences of alcohol - GI Tract

Answer 19

Malnutrition. It’s effects can cause appetite suppression. Alcoholics suffer from inflammation of the tongue and month, dental caries, and periodontitis. Malnutrition leads to vitamin deficiency which further promotes oral inflammation.
Causes decreased peristalsis and decreased esophageal sphincter tone which lead to reflux esophagitis.
Chronic vomiting can lead to Mallory-Weiss syndrome which is characterized by esophageal bleeding caused by a mucosal tear in the esophagus as a result of forceful vomiting and retching.
Also decrease gastric emptying and increases gastric secretion resulting in gastritis and gastrointestinal bleed.
Impairs enzyme activity and absorption in the small intestine including folate, Vit B12, thiamine, Vit A, amino acids and lipids
Pancreatitis (risk increased at 35 drinks/wk or more.

Question 20

Medical Consequences of alcohol - Liver

Answer 20

1. Hepatic steatosis (90% in heavy drinkers)
2. Alcoholic hepatitis (10-35%)
3. Cirrhosis (10-20%)
   The production of acetaldehyde, free radicals, and cytokines as alcohol is metabolise cause damage to damage liver.
   The enhanced passage of bacterial endotoxins through the intestinal wall in the presence of alcohol; and alcohol induced inflammation and cell death leads to scarring.
   Cirrhosis and alcoholic hepatitis is more common in women than men.

Question 21

Medical Consequences of alcohol - Cardiovascular System

Answer 21

Increased risk of cardiomyopathy, HTN, and stroke. Has also been associated with A Fib, atrial flutter, SVT, and ventricular arrhythmias, and sudden death.
What causes the cardiac damage is unknown - possibly d/t the effect of alcohol on the myocardium is a direct toxic result of ethanol or its metabolites - acetaldehyde, as well as increase systemic blood pressure.
Also associated with increased risk of ischemic and hemorrhagic stroke due to factors of alcohol induced HTN, coagulation disorders, A fib, and reduction in cerebral blood flow d/t vasoconstriction of cerebral blood vessels.

Question 22

Medical Consequences of alcohol - Nervous System

Answer 22

This is due to alcohol-induced alterations in the neurotransmitter levels and neuronal cell membrane function. The front lobe contains most of the dopamine sensitive neurons in the cerebral cortex and appear to be especially vulnerable to alcohol damage. Fontal lobes are responsible for executive function including reasoning, judgement, emotion, and complex problem solving. Also plays a role in retaining long-term memories and new memory formation.
Mental function compromised -> memory formation, abstract thinking, problem solving, attention, concentration, and perception of emotion.
Toxic polyneuropathy (d/t deficiency of thiamine and B Vit) will have distal sensory disturbances with pain, parenthesis, and numbness in a glove and stocking pattern. Weakness and atrophy of distal muscles, primarily in the lower extremities; loss of tendon jerks, and autonomic dysfunction.

Question 23

Medical Consequences of alcohol - Immune System

Answer 23

Occurs as a results of nutritional deficiencies particularly protein, combined with liver damage, significantly inhibit the production and function.
Alcohol increases Hep C virus replication especially in the early stages and reduces effectiveness of therapy. More likely to participate in behaviours that put them at risk for HIV.

Question 24

Medical Consequences of alcohol - Cancers

Answer 24

Classified as a group 1 carcinogen, which is defined as an agent (substance) that is carcinogenic to humans - it includes agents on which evidence of carcinogenicity in humans is less than sufficient but evidence of carcinogenicity in animals is strong.
Associated with cancers of the oral cavity, pharynx, esophagus, and larynx. Also increased sick for cancers of the stomach, liver, female breast and ovaries.
Alcohol is thought to act as a co-carcinogen by enhancing the carcinogenic effects of other chemicals and by stimulating tumour growth. Thoughts that acetaldehyde interferes with DNA replication and with repair of damaged DNA.
Alcohol can also inactivate the tumour suppressor gene BRCA 1 and increase estrogen responsiveness.

Question 25

Alcohol Treatment and Prognosis

Answer 25

Goal of treatment is abstinence. Effectiveness of tx depends on:

1. individual motivation
2. age at onset of abuse
3. duration and extent of abuse
4. compliance with treatment
5. successful treatment of co-morbid factors

Question 26

Tx

Answer 26

AA - uses psychosocial techniques such as rewards and social support networks, and role models to change behaviour.
CBT - has been a tool in treating alcohol use disorders teaching the individual new skills for changing the drinking behaviour. Helps tx associated mental health disorders.
Rx - however highly dependent on pt compliance
1. disulfiram - prevent the elimination of acetaldehyde leading to a range of significantly unpleasant effects including nausea, vomiting, flushing, sympathetic over activity and palpitations.
2. Naltrexone - a competitive antagonist for opioid receptors, reduces the craving for alcohol.
3. acamprosate - works by restoring the normal balance between neuronal excitation and inhibition that is altered by chronic alcohol use.

Question 27

Findings indicative of an alcohol use disorder

Answer 27

1. Hx of depression/mood disorder (hx of suicidal ideation/attempt)
2. Significant personal/professional stressors
3. Hx of violence
4. Hx of another substance use disorder
5. Adverse findings on MVR (DUI, speeding, reckless)
6. Unstable employment records (frequent job changes, poor attendance, unexplained period of unemployment)
7. FHx
8. Easy access to alcohol
9. Frequent falls/accidents
10. Participation in high right behaviours or avocations
11. Tobacco use (approx. 75% of alcohol users)
12. Physical signs/sx/medical hx (HTN, GI sx, enlarged or fatty liver, hx of pancreatitis, insomnia, tremors/neuropathy, memory difficulties).

Question 28

Alcohol - Lab Testing

Answer 28

1. Liver enzymes
2. Mean Corpuscular Volume (MCV)
3. HDL
4. Trigs and Uric Acid
5. Alcohol Markers

Question 29

Alcohol - Lab Testing - Liver Enzymes

Answer 29

AST and ALT are hepatocellular enzymes that are released in the serum when liver cells are damaged.
AST is also found in other tissues including brain, kidney, lungs, and cardiac and skeletal muscles.
ALT is mainly found in the liver and to a lesser extent in cardiac and skeletal muscles.
AST is a more sensitive marker for alcohol use.
AST/ALT ration greater than 2 is suspicious.
As liver disease becomes more severe and fibrotic change occur there are fewer healthy hepatocytes left to be damaged.
GGT - elevated in associate with steady, heavy alcohol use over time but sensitivity for detection is quite variable.

Question 30

Alcohol - Lab Testing - MCV

Answer 30

Measures the size of red blood cells. Al elevated MCV represents a macrocytosis - large RBCs. This is seen with B12 and folate deficiencies.

Question 31

Alcohol - Lab Testing - HDL Chol

Answer 31

Low to moderate use raises HDL cholesterol, providing a cardio-protective benefit. However, excessive alcohol use increases HDL levels to outside of normal range.

Question 32

Alcohol - Lab Testing - Trigs

Answer 32

Excessive alcohol ingestion increases trig levels d/t fatty liver changes.

Question 33

Alcohol - Lab Testing - Uric Acid

Answer 33

Will becomes increased and is thought to be d/t a result of increased lactic acid production during the breakdown and excretion of alcohol, which is excreted from the kidneys.

Question 34

Alcohol - Lab Testing - Alcohol Markers

Answer 34

Carbohydrate-Deficient Transferrin - used to transport iron and is synthesized primary in the liver. CDT elevation - thought that alcohol either interferes with the addition of carbohydrate groups or stimulates their removal from transferrin. Only a slightly better marker than GGT alone.
Hemoglobin-Associate Acetaldehyde -> When levels of acetaldehyde are chronically elevated in the blood it attaches to blood protein causing elevated HAA concentration. HAA becomes elevated w/ heavy, steady alcohol use over time. Not useful for binge drinking.

Question 35

Alcohol Screening tools

Answer 35

CAGE questionnaire -> Cut down on drinking, Annoyed by criticism of your drinking, Guilty about drinking, Eye-opener - a drink first thing in the morning.
MAST - oldest and most accurate, 22 questions w/ 98% accuracy.
AUDIT - 10 questions developed by WHO.

Question 36

Mortality Implications of Alcohol Abuse and Dependence

Answer 36

Increased rate of death from cirrhosis, cardiovascular disorders, cancers of the month, esophagus, pharynx, larynx, and liver. Unintentional deaths associated with MVA and high risk behaviours.
Leading chronic cause of death is AAD is alcoholic liver disease, and leading acute was injury d/t MVA.
Elderly population (age 65+) increased mortality was d/t alcohol-induced cognitive disorders, accidental deaths d/t injuries from falls, and unintentional poisoning d/t medical-alcohol interactions.

Question 37

Prevalence of illicit drug users

Answer 37

9.4%of the population 12 and over.
For marijuana – 7.5% of those age 12 or older
Marijuana is used by 80.6% of current illicit drug users.

Question 38

Marijuana

Answer 38

Effects of MJ are effect immediately after the drug enters the brain and lasts from one to three hours. Heavy MJ us impairs an individual’s ability to form memories, recall events, and shift attention from on thing to another. THC also disrupts coordination and balance by binding to receptors in the cerebellum and basal ganglia, which regulate balance, posture, coordination of movement, and reaction time.

Question 39

MJ Concerns

Answer 39

High doses of the drug can experience acute toxic psychosis, which includes hallucinations, delusions, and depersonalization. Long-term use increases risk of chronic lung disease and cancers of the head, neck, and lungs.

Question 40

Advantages of MJ

Answer 40

Thought to be helpful in relieving neuropathic pain, as an appetite stimulant for those with AIDS wasting syndrome, and for the control of nausea and vomiting associated with chemotherapy.

Question 41

Cocaine

Answer 41

Can be smoked, injected, snorted, or swallowed. Desired effects include euphoria with an increased level of energy and mental alertness. These effects appear almost immediately after a single dose and disappear within a few minutes or hours. The faster the absorption is, the more intense the high is, however, the faster the absorption is, the short the duration of action is.

Question 42

Short-term physiological effects of cocaine include:

Answer 42

Constricted blood vessels, dilated pupils,. And increased temperature, heart rate and blood pressure.

Question 43

Complications of cocaine:

Answer 43

1. Cardiovascular effects, including arrhythmia, and MI
2. Respiratory effects, including respiratory failure.
3. Neurological effects, including stroke, seizures, and headaches
4. GI effects, including abdominal pain and nausea.
   Sudden death can occur with first time use, especially when injecting cocaine or smoking freebase, which is a pure form of cocaine that is derived from the removal of hydrochloride salt and cutting agents.

Question 44

Heroin

Answer 44

Administered by injection or inhalation. Quickly passes the blood-brain barrier where it is converted to morphine and rapidly binds to opioid receptors. This produces a surge or “rush” of pleasurable sensation. The rush is usually accompanied by a warm flushing of the skin, dry mouth, and clouded mental functioning. It can also cause respiratory depression.

Question 45

Heroin Complications

Answer 45

High risk behaviours associated with heroin addiction, such as sharing of equipment and high-risk sexual behaviours, can lead to viral infections, including hep B and C and HIV. Also at risk of developing bacterial infections of the blood vessels and heart valves, abscesses and other soft tissue infections as well as liver and kidney disease.
Pneumonia and TB can result from the poor health conditions of the abuser as well as from depressed respiratory function.

Question 46

Methamphetamine

Answer 46

Man made substance similar in structure to amphetamine and the neurotransmitter dopamine. Increases alertness, decreases appetite, and provide a sensation of pleasure. Can be injected, snorted, smoked, or eaten. The drug is present in the brain longer than cocaine, producing a prolonged stimulant effect.

Question 47

Meth Consequences

Answer 47

Anxiety, confusion, insomnia, mood disturbances, and violent behaviour. Can also display psychotic features including paranoia, visual and auditory hallucination, and delusions. Chronic use has been shown to cause severe structural and functional changes in the brain, particularly in areas associated with emotion and memory.

Question 48

Methylenedioxymethamphetamine (MDMA)

Answer 48

A semi-synthetic stimulant and hallucinogen that is used to improve mood and maintain energy. Provides a distinct sense of euphoria, along with diminished feelings of fear and anxiety. Also produces significant reductions in mental abilities, impairing memory, and information-processing capabilities. These changes can last up to a week and perhaps longer in regular users. Other lingering effects include anxiety, restlessness, irritability, depression, impulsiveness, aggression, and sleep disturbances.

Question 49

Phencyclidine (PCP)

Answer 49

Classified as a dissociative anesthetic. It’s trance-like sedation effect produces an “out-of-body” experience and sense of detachment from reality. Can be snorted, smoked, or swallowed.

Question 50

PCP Consequences

Answer 50

Even in small doses – effects of PCP can be unpredictable. It can cause rapid, shallow breathing, elevated BP, tachycardia, and increased body temperature. More severe effects include severe HTN, arrhythmias, nausea, blurred vision, dizziness, severe muscle contractions, seizures, coma, and death.

Question 51

Ketamine

Answer 51

Dissociative anesthetic to replace PCP and is used human anesthesia and vet medicine. Effects are similar to PCP but it is much less potent.

Question 52

Lysergic Acid Diethylamide (LSD)

Answer 52

Semi synthetic hallucinogenic drug that is derived from rye fungus and is the most potent mood and perception-altering drug known. Dramatically intensifies the sense and alter sensory perception.
LSD Consequences
HTN, tachycardia, dizziness, dry month, sweating, numbness, and tremors. Emotions can shift rapidly from fear and paranoia to euphoria. Hallucinations distort or transform shapes and movements. Long-term effects of LSD use are persistent psychosis and hallucinogen-persisting perception disorder (HPPD) –“flashbacks”.

Question 53

Treatment of Substance Use Disorders

Answer 53

Drug rehabilitation is a long-term multi-phase process that begins with detoxification and continues with ongoing therapy, support, and treatment of underlying mental health conditions.

Question 54

Polysubstance Dependence

Answer 54

The use of at least 3 different types of substances used in the same 12 months period

Question 55

Most common disorders associated with chronic drug use:

Answer 55

Antisocial Personality Disorder, Schizophrenia, Bipolar Disorder, Major depressive disorder, ADHD, GAD, OCD, PTSD. 6/10 people with substance use disorder also suffer from another form of mental illness.

Question 56

Mortality and Morbidity among drug addicts

Answer 56

Quite high due to the high rates of suicide attempts, consequences of high-risk behaviour and unintentional deaths from overdose or injury. Increased mortality due to criminal activity associated with acquisition and use of these substances. High incidence of replace, particularly when multiple substances are abused.

Question 57

Factors that influence success of treatment include

Answer 57

1. Duration of use
2. The drug(s) used
3. Presence of poly-substance use
4. Co-morbid mental health disorder
5. Hx of relapse
6. Number of years drug-free

Question 58

Underwriting Consideration Factors:

Answer 58

1. The drug(s) used
2. Hx of poly-substance use, including alcohol
3. Use of prescription medication at risk of being abused (admitted use or discovered on prescription database search).
4. Hx of depression/mood disorder
5. Suicidal ideation/attempts
6. Duration of abuse
7. Duration of abstinence
8. Hx and number of relapses
9. Type of tx and compliance with tx
10. Presence of ongoing support
11. Hx of high risk behaviours, accidents/falls, or violent behaviour
12. Adverse MVR findings (e.g., DUI, speeding, or reckless driving)
13. Unstable employment record (poor attendance, unexplained periods of employment, frequent job changes)
14. Positive findings on drug screening done as part of underwriting requirements.

Question 59

Common prescription drugs of abuse

Answer 59

Pain relievers (hydrocodone, oxycodone, morphine, fentanyl, and codeine)
Tranquilizer/Sedatives (Benzodiazepines, particularly diazepam, and alprazolam)
Stimulants (detroamphetamine [Adderall, Dexedrine]

Question 60

Increased incidence of prescription drug abuse due a number of factors

Answer 60

1. The rising number of medicines being prescribed for a variety of health problems
2. The ease of obtaining these medicines online
3. Access by children and family members to the prescribed medicines of others in the household.

Question 61

Common cause of mortality with prescription drug abuse

Answer 61

Unintentional injury, suicide, and deaths from injury of undetermined intent

Question 62

Drug Abuse in the elderly

Answer 62

Drugs for insomnia, anxiety disorders, and chronic pain are commonly prescribed medications. Unintentional, inappropriate use of prescription drugs can occur due to impaired memory, poor understanding of dosing instructions or adverse interactions with other prescription medications or alcohol. Increase sensitivity or impaired excretion of these prescription drugs can lead to adverse effects. Increased mortality has been shown to be the result of cognitive impairments and injuries that occur in conjunction with the inappropriate use of these drugs.