Clin - Substance Abuse Flashcards
compare addiction and physical dependency
addiction: chronic disease of brain reward, motivation, memory, and related circuitry –> pathological pursuit of reward and/or relief by substance
physical dependency: development of tolerance and physical dependence denote normal physiological adaptations of the body to the presence of an opioid
describe the reward deficiency syndrome
a result of dopamine-system malfunction
–> a clinically significant deficiency of the essential neurotransmitter–Dopamine in the brain’s Reward Center
causes vulnerability to addiction
can be caused by genetics or environmental factors
aspects of a pts history that can lead to addictophrenia spectrum
- addictive disorders
- intractable mood disorders
- personality disorder or habitual criminal behavior
- polysubstance abuse
- trauma
- chronic psychosocial stressors
- borderline personality disorder
describe substance abuse comorbidity
50% of addicts have a comorbid psychiatric disorder - antisocial PD - depression - suicide
what is the diagnostic criteria for substance use disorders
1) using larger amounts for longer time than intended
2) persistent desire or unsuccessful attempts to cut down or control use
3) great deal of time obtaining, using, or recovering
4) craving
5) fail to fulfill major roles (work, school, home)
6) persistent social or interpersonal problems caused by substance abuse
7) important social, occupational, recreational activities given up or reduced
8) use in physically hazardous situations
9) use despite physical or psychological problems caused by use
10) tolerance
11) withdrawal
how to define severity of substance abuse
mild: 2-3 sx
moderate: 4-5 sx
severe: 6+ sx
compare early remission and sustained remission for substance use
early remission: no criteria for >3 months but <12 months
sustained remission: no criteria for >12 months except craving
diagnostic criteria for substance-induced mental disorders
1) disorder developed during or within 1 month of a substance intoxication or withdrawal
2) the involved substance/med is capable of producing the mental disorder
3) disorder does not occur during the course of a delirium
what is neuroadaptation
underlying CNS changes that occur following repeated use such that the person develops tolerance and/or withdrawal
when do you hospitalize a substance abuse patient
due to drug OD, risk of severe withdrawal, medical co-morbidities, requires restricted access to drugs, or psych illness with suicidal ideation
when do you use a residential treatment unit for a substance abuse patient
- no intensive medical/psych monitoring needs
- require a restricted environment
- partial hospitalization
when do you use an outpatient program for a substance abuse patient
when there is no risk of med/psych morbidity and have a highly motivated patient
what are outpatient treatment options for substance abuse patients
- motivational interviewing in primary care setting
- 12 step
- AA
- narcotics anonymous
- CBT
- therapeutic communities
describe the features of alcohol withdrawal
early: anxiety, irritability, tremors, HA, insomnia, nausea, tachycardia
24-48 hours: seizures (grand mal)
48-72 hours: withdrawal delirium
describe the most severe manifestation of alcohol withdrawal and when does it occur
delirium tremens: agitation, profound global confusion, disorientation, hallucinations, fever, HTN, diaphoresis
occurs 3-10 days after last drink
what does the CIWA (clinical institute withdrawal assessment for alcohol) do
assigns numerical values to orientation, N/V, tremors, sweating, anxiety, agitation, tactile/auditory/visual disturbances and HA
total score >10 indicates more severe withdrawal
what medications are given for alcohol withdrawal
- benzos
- anticonvulsants
- thiamine supplementation
what harm can disulfiram cause
- when alcohol ingested: vasodilation, flushing, N/V, hypotension/HTN, coma/death
- hepatotoxicity
- polyneuropathy/paresthesias
- psychosis, depression, confusion, anxiety
what medications are given for alcohol use disorder
- naltrexone 50mg PO daily
- acamprosate 666mg PO TID
benzo withdrawal sx
anxiety, irritability, insomnia, fatigue, HA, tremor, sweating, poor concentration
how to outpatient taper a pt off of benzos
decrease dose every 1-2 weeks and not more than 5mg diazepam equivalent
5 diazepam = 0.5 alprazolam = 25 chlordiazepoxide = 0.25 clonazepam = 1 lorazepam
what medications should you use for rapid taper off of benzos
carbamazepine or valproic acid
sx of opioid intoxication
pinpoint pupils, sedation, constipation, bradycardia, hypotension, decrease respiratory rate
sx of opioid withdrawal
NOT LIFE THREATENING
- extremely uncomfortable
- dilated pupils
- lacrimation
- goosebumps
- N/V/diarrhea
- myalgias, arthralgias
treatment for opioid withdrawal
symptomatically w/ antiemetic antacid, antidiarrheal, muscle relaxant, NSAIDs, clonidine
medications for opiate use disorder
- methadone
- naltrexone
- buprenorphine
what are the potential problems with methadone treatment for opioid use disorder
HIGH RISK MEDICATION
- can be deadly when used with a benzo
- frequently causes QTC prolongation
- dangers increase when used with another 3A4 substrate
- can be fatal
signs of chronic stimulant intoxicatoin
affective blunting, fatigue, sadness, social withdrawal, hypotension, bradycardia, muscle weakness
- psychosis —> sometimes with paranoia
severe complications of cocaine use
can get rhabdomyolysis with compartment syndrome from the hypermetabolic state
treatment for stimulant use disorder
- narcotics anonymous
- chemical dependency treatment including support, education, life skills
effects of chronic amphetamine use
neurotoxicity possibly from glutamate and axonal degeneration
fatality in the setting of brugada syndrome
drug interactions with tobacco
induces CYP1A2
tobacco withdrawal symptoms
dysphoria, irritability, anxiety, decreased concentration, insomnia, increased appetite
treatment for tobacco use disorder
- CBT
- agonist substitution therapy (nicotine gum, patch)
medication for tobacco use disorder
bupropion or varenicline
list the hallucinogens
- naturally occurring: peyote cactus, magic mushrooms
- LSD
- DM
- STP
- MDMA
sx of MDMA (ecstacy) intoxication
illusions, hyperacusis (hearing), sensitivity of touch/taste/smell, tearfulness, euphoria
3-6 hours
what are some short term problem with MDMA use
EXTREMELY HIGH FEVER
- tachycardia
- sweating
- muscle spasms
if patient presents appearing intoxicated with an extremely high fever, what should you suspect
MDMA use
severe effects from MDMDA use
high fever can progress to rhabdomyolysis, renal failure, seizures, DIC, arrhythmias, death
withdrawal sx of cannabis use
insomnia, irritability, anxiety, poor appetite, depression, physical discomfort
treatment for cannabis withdrawal
- detox and rehab
- behavioral model
- no specific pharm tx
sx of PCP intoxication
severe dissociative reactions –> paranoid delusions, hallucinations, agitation/violence, decreased awareness of pain
severe sx of PCP intoxication
NYSTAGMUS (HORIZONTAL AND VERTICAL)
also mute, catatonic, muscle rigidity, HTN, hyperthermia, rhabdomyolysis, seizures, coma/death
pt comes in with signs of intoxication and nystagmus, what should you suspect
PCP intoxication
treatment for PCP use
- antipsychotic drugs or BZD
- low stimulation environment
- acidify urine if severe toxicity
is there tolerance or withdrawal with PCP use?
nope
describe the neuroadaptation of PCP use
allosteric modulator of glutamate NDMA receptor
describe the neuroadaptation of MDMA use
affects serotonin, dopamine, NE receptors
predominantly serotonin receptor agonist
describe the neuroadaptation of amphetamine use
inhibits reuptake of dopamine, NE, and serotonin
greatest effect on dopamine
describe the neuroadaptation of cocaine use
prevents reuptake of dopamine
