Clinical Approach to Substance Use Disorders Flashcards
What is a substance use disorder?
- Include name of specific substance
- Maladaptive patterns of substance use
- Impairment in occupational, physical, social functioning
- Specify as mild, moderate, severe
What is substance induced disorders?
- Includes intoxication and withdrawal
What is addiction?
- An overwhelming involvement with seeking and using drugs or alcohol and a high tendency toward relapse after substance withdrawal
What is at risk drinking in men and women?
- Men: >14 drinks per week or >4 drinks per occasion
- Women: >7 drinks per week or >3 drinks per occasion
What is defined as moderate drinking?
- Men: 2 or fewer drinks per day
- Women and people over 65: 1 or fewer drinks per day
How many hospital admissions are related to alcohol?
- 40%
What from someone’s childhood might cause them to abuse alcohol?
- Environmental stressors
- ADHD
- Conduct disorder/antisocial personality disorder
What are some causes of alcohol abuse?
- Childhood history
- Psychodynamic factors
- Social/Cultural factors
Who do we see have a high rate of alcohol abuse?
- Native americans
- Non African American races
What race has low rates of drinking problems? Why?
- Asian races
- Genetically mediated inefficiency in metabolizing and excreting acetaldehyde
What is alcohol abuse disorder?
- Problematic pattern on use leading to clinically significant impairment or distress, as manifested by at least two of the following occuring in a 12 month:
1. Alcohol taken in larger amounts over a longer period of time than was intended
2. Persistent desire or unsuccessful efforts to cut down or control use
3. Excessive amount of time spent to obtain alcohol or recover from its effects
4. Cravings
5. Recurrent use despite failures to meet obligations
What is seen in someone with alcohol use disorder?
- Continued use despite negative consequences
- Giving up social, occupational, or recreational activities because of alcohol use
- Recurrent use in hazardous situations
- Continued use despite knowing it’s a problem
What is the tolerance seen in alcohol use disorder?
- Need for increased amounts to achieve desired effect
- Diminished effect with continued use and the same amount
What are some signs of withdrawal in alcohol use disorder?
- Autonomic hyperactivity
- Increased hand tremor
- Insomnia
- Nausea/vomiting
- Hallucinations
- Psychomotor agitation
- Seizures
What is the clinical presentation of someone with alcohol abuse disorder?
- Solitary drinking and rationalization the need to drink
- Daily or frequent drinking to function
- Loss of control over drinking; inability to stop or reduce drinking. Attempts to conceal drinking
- Violence associated with drinking, defensive or hostile when confronted about drinking
- Neglect of food intake, physical appearance, and hygiene
- Nausea and vomiting, shaking in the morning, numbness and tingling in extremities, confusion
What is the screening like for alcohol use disorder?
- CAGE questions
- Have you ever felt you ought to cut down on your drinking?
- Do you get annoyed at criticism of you drinking or drug use?
- Do you ever feel guilty about your drinking or drug use?
- Do you ever take an early morning drink first think in the morning to get the day started or to eliminate the ‘shakes’?
What are some alcohol induced doisorders?
- Intoxication
- Withdrawal
- Delirium
- Dementia
- Amnestic DO
- Psychotic DO
- Mood DO
- Sexual dysfunction
- Sleep DO
What is the clinical presentation of alcohol intoxication?
- Slurred speech
- Loss of coordination
- Unsteady gait
- Nystagmus
- Impaired attention or memory
- Stupor or coma
What is the clinical presentation of mild alcohol intoxication?
- Mild: overconfidence, mood swings, increased pain threshold, nausea/vomiting
What is the clinical presentation of severe alcohol intoxication?
- Severe: hypothermia, tachycardia, dilated pupils, slow respiration, increased intracranial pressure
What is the treatment for alcohol withdrawal?
- Detox order set:
- Benzodiazepine
- Antipsychotics
- Fluids
- Vitamins
- Restraints
What is the treatment for alcohol abuse?
- Wait it out
- Give IV thiamine in ER to prevent Wernicke’s encephalopathy and Korsakoff’s syndrome
What are some alcohol induced mood disorders?
- Depression
- Get from a good history, ask about moods prior to beginning alcohol abuse or during significant period of time while sober, family history
What guides the treatment for alcohol dependence?
- Guided by severity of the condition, previous treatment response or failure, the presence or severity of co-occurring psychiatric or medical conditions, and patient preference
What is the treatment for alcohol dependence?
- Encourage complete abstinence and lifestyle modification
- Psychotherapy: why is the person drinking?
- Behavioral therapy: Cognitive behavioral therapy
- Residential care: 30-60-90 day programs
- AA
- Halfway houses
- Community rehab programs
What is acamprosate? How is it used in alcohol dependence treatment?
- Used to maintain abstinence in alcoholics following withdrawal
- Reduces the voluntary ingestion of alcohol
- Does not treat withdrawal, prevent intoxication, interact with, or less any of the harmful effects of alchol
How does acamprosate work?
- Inhibits GABA in the CNS and antagonizes the receptor in a similar way to alcohol
What is naltrexone? How is it used in alcohol dependence treatment?
- Opioid antagonist, cuts cravings
- Improves abstinence in alcohol dependence
- Given via monthly injection
What is disulfiram? How is it used in alcohol dependence treatment?
- Used to control alcohol intake as a deterrent
- Produces unpleasant adverse effects if the patient drinks alcohol during the course of treatment
- Some patient do not experience effects or experience tolerable side effects
What are the unpleasant effects that disulfiram produces?
- Flushing of the skin
- Accelerated HR
- SOB
- N/V
- Throbbing headache
- Visual disturbance
- Mental confusion
- Postural fainting
What is a part of the initial management for someone who comes in drunk?
- Vitals: look for elevated BP/HR
- Labs: CBC (look at MVC and platelets), BMP, Hepatic function, BAC
- Urine drug screen
What is in the IV fluids given to someone with alcohol use?
- Thiamine and glucose
- Multivitamins
- Folic acid
What are the substances seen in stimulant related disorders?
- Amphetamines and cocaine
What are some symptoms going through stimulant related disorders?
- Increased energy and alertness
- Anxiety/irritability
- Insomnia, exhaustion
- Hyperthermia
- Loss of appetite and weight
- Visual/auditory hallucinations
- Dilated pupils
- Elevated BP and pulse
- Seizures
What is seen in withdrawal from stimulants?
- Increased sleep
- Nightmares
- Increased appetite
- Depression
- Suicide attempts
- Craving for drugs
What is the treatment for stimulant withdrawal?
- Antidepressants and hospitalization
- They will not die. Just there to sleep and eat
What is the treatment for hypertension and hyperthermia seen in stimulant intoxication?
- Phentolamine
What is the treatment for the psychotic symptoms seen in stimulant intoxication?
- Haloperidol
What are some symptoms of sedatives/hypnotics/anxiolytics intoxication?
- Euphoria
- Increased seizure threshold
- Sedation, coma
- Respiratory depression
- Depressed reflexes
- Hypotension
- Hypoxemia
- Hypothermia
What is the treatment for sedative/hypnotic/anxiolytic intoxication?
- Protection of airway
- Oxygen administration
- Ventilation
- Prevent loss of body heat
- Forced diuresis and alkalinization of urine
- Hemodialysis
What is seen in sedative/hypnotic/anxiolytic withdrawal?
- Anxiety/agitation
- Orthostatic hypotension
- Weakness and tremulousness
- Hyperreflexia
- Diaphoresis
- Delirium
- Seizures
What is the treatment of sedative/hypnotic/anxiolytic withdrawal?
- Phenobarbital
What does hallucinogen intoxication look like?
- Dilated pupils
- Increased HR and BP
- Paranoia and anxiety
- Hallucinations
What does someone on PCP look like?
- Violent behavior
- Hyperactivity
- Nystagmus
- Muscular rigidity
- Seizures
What is the treatment for hallucinogen intoxication?
- Diazepam
- Sedation with haloperidol if violent
What does hallucinogen withdrawal look like?
- Flashbacks (brief re-experiences of hallucinogenic state
What is the treatment of hallucinogen withdrawal?
- Reassurance
- Benzodiazepine administraion
What is a substance induced mental disorder?
- Develops within one month of a substance intoxication
- Substance is capable of producing the mental disorder
- No evidence of an independent mental disorder
- Does not occur exclusively during the course of a delirium
What are the psychiatric symptoms of someone on PCP?
- Agitation with blank stare
- Anxiety
- Stupor
- Aggression
- Panic
- Bizarre behavior
What are the psychiatric symptoms of someone on Amphetamine/cocaine?
- Agitation with persecutory delusions or euphoria with irritability
What are the psychiatric symptoms of someone on LSD?
- Sensory distortion
- Hypersensitivity of senses
- Euphoria
- Hallucinations
What are the symptoms of opioid intoxication?
- Analgesia with loss of consciousness
- Apathy/lethargy
- Euphoria
- Itching
- Constricted pupils
- Constipation
- Flushed, warm skin
- Respiratory depression
- Hypotension and depressed reflexes
What is the treatment of opioid intoxication?
- Supportive care
- Naloxone (reverses coma and apnea, causes vomiting, and can be given intranasally)
What does opioid withdrawal look like?
- Lacrimation, rhinorrhea, coryza
- Sweating
- Restlessness/sleepiness
- Gooseflesh
- Dilated pupils
- Irritability
- Violent yawning
- Craving for the drug
What is the treatment for opioid withdrawal?
- Buprenorphine or methadone
- Buprenorphine and naloxone
- Clonidine for elevated BP
- Diphenhydramine for itching and rhinorrhea
- Imodium for diarrhea
What are some advantages of using buprenorphine in maintenance of opioid withdrawal?
- Not an opioid but an agonist-antagonist on opioid receptor
- Prescribed by a physician with special training
- Not long term
What are some disadvantages of using buprenorphine in maintenance of opioid withdrawal?
- Cost
- Finding a legitimate licensed provider
What are some advantages in using methadone in maintenance of opioid withdrawal?
- Available through licensed clinics without prescription
- Long half life
What are some disadvantages in using methadone in maintenance of opioid withdrawal?
- Not closely monitored
- Have to go to a methadone clinic daily for dosing
- Doses are high
- Patients remain opioid dependent
What do you do with buprenorphine and methadone when treating acute pain?
- Buprenorphine: stop while in hospital and continue when discharged
- Methadone: continue outpatient dose and treat acute pain (monitor for sedation/respiratory depression)
What are the goals of treating substance related disorders?
- Detoxification
- Insistence on abstinence
- Avoidance of other substances
- Involvement of family
- Change in peer group
- Unscheduled toxicology screens
- Self-help groups
- Sanctioned treatment
What is K2?
- Synthetic cannabis
What are bath salts?
- Family of designer drug containing substituted cathinoines
What is molly?
- Powder or crystal form of MDMA, the chemical used in ectasy
What is Wet?
- Cocktail of PCP mixed with formaldehyde and dipped into cigarretes
What is ketamine?
- Used in induction and maintenance of anesthesia particularly in peds and field hospitals
What is seen in someone who has taken molly?
- Hyperthermia
- Jaw clenching and teeth grinding
- Nystagmus and dilated pupils
- Tremors
- Tachycardia and increased BP
- Psychogenic polydipsia
- Hyponatremia and cerebral edema
- Sensation of chills
- Auditory hallucinations
- Orthostatic problems, syncope
What is the treatment for molly?
- Hypertonic saline solution
- Hyperthermia ice bath for rapid cooling
- Benzodiazepines to control psychomotor agitation and shivering
- Cyproheptadine for signs of serotonin syndrome
