Need to use an increased amount to achieve a desired effect or Markedely diminished effect with continued use of the same amount of the substance

[CLMD CIS] Clinical Approach to Substance Abuse Disorders [Cooley] Flashcards by Fiu B

What is Physical Dependence vs Addiction?

Physical Dep –> Denotes normal physiologic adaptations of the body to the presence of an opioid. (Isnt used to diagnose addiction)

Addiction –> is a primary, chronic disease of brain reward motivation, memory and related circuitry (Pathologically pursuing reward and relief by substance use)

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What is reward deficiency syndrome?

A dopamine system malfunction –> leads to vulnerability and then to addiction.

(Makes them compulsive –> ADDICTION [not physical dep])

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What are some other considerations besides the dopamine reward system that influence the development and maintaince of addiction?

Learning and Memory (Hippocampus)

Emotional Regulation (Amygdala)

[Neurobiological Circuitry is the ultimate common pathway for addictive behaviors]

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Are there common molecular mechanisms and genetic vulnerability to compulsive behavior and additiciton?

Yes!

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What are some characteristics of a Substance Use Disorder?

Using Large Amounts for a longer than intended time

Persistent Desire

Great deal of time obtaining, using, or recovering

Craving

Fail to fulfill major roles

persistent social or interpersonal problems

Use in physically hazardous situations

Tolerance

Withdrawl (not seen when using PCP)

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For Substance Use Disorders what do these severities entail?

Mild

Moderate

Severe

Mild –> 2-3 Symptoms

Moderate –> 4-5 Symptoms

Severe –> 6+ Symptoms

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When someone has a substance use disorder with the following specifiers what is meant?

In Early Remission

In Sustained Remission

In Controlled Environment

Early Remission –> no criteria for 3-12 Months

Sustained Remission –> no criteria for +12 months

In Controlled Environment –> access to substance restricted (Jail)

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What are the guidelines for diagnosing a Substance-Induced Mental Disorder?

– Has a significant symptomatic presentation of a relevant mental disorder

– the disorder developed during or within 1 month of a substance intoxication or withdrawal

– the involved substance/med is capable of producing the mental disorder

(The last two must have History, PE, or Lab findings to prove it)*
–* Not explained by a indep mental disorder (didnt precede the intoxication / persisted after the intoxication for at least 1 month)

– Does not occur during delirium

– causes distress/impairment in social and other areas of functioning

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What is Intoxication?

Reversible substance specific syndrome due to recent ingestion of a substance

(Does not apply to tobacco)

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What is Withdrawal?

Substance specific syndrome problematic behavioral change due to stopping or reducing prolonged use

(physiological and cognitive components)

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What are some drugs that DONT cause withdrawal?

PCP, other Hallucinogens, Inhalants

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What is Neuroadaptation?

Underlying CNS changes that occur following repeated use –> person develops tolerance and/or withdrawal

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What is Tolerance?

Need to use an increased amount to achieve a desired effect

Markedely diminished effect with continued use of the same amount of the substance

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What are some options for treating Sustance Use Disorder patients?

Hospitilazation (for high risk pts)

Residential treatment unit (for pts who need restrictions)

Outpatient program (Low/No risk pts)

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When thinking of treatment options which option DOESNT work?

Which ones should you recommend in its place?

Aversion Therapies!

Alcholics Anonymous

Narcotics Anonymous

CBT

Therapeutic Comm

Motivation Interviewing in Clinic

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What is a blood alcohol level that would classify a pt as Intoxicated with Alcohol?

0.08 g/dl

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When a pt is going through Alcohol Withdrawal what is seen:

Early

24-48 Hrs

48-72 hrs

Early –> anxiety, irritability, tremors, HA, insomnia

24-48 Hrs –> Seizures (Grand Mal)

48-72 hrs –> Withdrawal Delirium

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What is Delirium Tremens

occurs 3-10 days after last drink

Agitation, Global Confusion, Disorientation, Hallucinations, Fever, HTN, Diaphoresis, Autonomic Hyperactivity.

Can progress to CV collapse

MEDICAL EMERGENCY!!!

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What is the form we use to grade alcohol withdrawal?

Treatment?

CIWA

Benzos/Anticonvulsants/Thamine

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What are some medications for Alcohol Treament?

Disulfram (little evidence for use)

Naltrexone

Acamprosate

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When giving Benzos and Barbituates to pts with intoxication problems what are some considerations?

The more lipophillic and short duration of action –> the more ADDICTING the drug

Can also cause withdrawal from the drugs

(BENZOS also can cause Alzhemiers and Dementia with long term use)

If needing to do a rapid taper for Intoxication disorders what are some better options than Benzos and Barbiturates?

Carbamezapine/Valproic Acid –> good for rapid taper

Gabapentin and Tizanidine (highly effective)

What are some Opiate use disorder treatment options?

CD treatment –> support, education, etc

Meds –> Methadone, Naltrexone, Buprenorphine

Methadone (an Opioid substitute) cannot be use with what?

Benzos and other CYP3A4 substrates

Cocaine abuse can lead to what from a hypermetabolic state?

Rhabdomyolysis with Compartment Syndrome

What are your treatment options for Stimulant Use Disorder?

No Medications Narcotics Anonymous

What are some treatment options for Tobacco Use Disorder?

CBT Agonist Substitution therapy (Nicotine Gum/Transdermal Patch) Buproprion or Varenicline

If you have a patient who comes in with tachycardia, sweating, muscle spasms, and an extremely high fever -- what substance did the person probably overdose on?

Ecstacy or MDMA

If a patient comes in with Ataxia, Dysarthria, Nystagmus (vertical and horizontal), paranoid delusions, hallucinations -- what did the person probably take?

PCP

What are the 3 benzodiazepines that are only metabolized through glucoronidation in the liver?

Oxazepam, Temazepam, Lorazepam

Is Opioid withdrawal life threatning?

Which drug is a High Risk medication, an Opioid substitution -- that can be deadly if taken with a benzo. Can cause QTC prolongation, and cant be used with any other CYP3A4 substrate?

Methadone | (it is not used to treat pain)

What is the definition of addiction?

- Primary, chronic disease of brain reward, motivation, memory and related circuitry - **Pathologically pursuing reward** and/or **relief** by **_substance use_** and **_other behaviors_\*\*\***

For diagnosis of a substance-induced mental disorder there is evidence from the hx, PE, or labratory findings of what 2 things?

- Disorder developed _**during** or **within 1 month**_ of a substance intoxication or withdrawal or taking a medication and - The involved substance/medication is **capable** of producing the **mental disorder**

What are 2 pieces of evidence which would indicate that a mental disorder is independent and not substance-induced?

- The disorder **_preceded_** the onset of **severe intoxication** or **withdrawal** or **exporsure** to the medication _or_ - The full mental disorder **persisted** for a substantial period of time (i.e. **at least 1 month**) after the cessation of acute withdrawal or severe intoxication or taking the medication

What are the 5 criteria of substance-induced mental disorders?

- Disorder represents a clinically significant symptomatic presentation of a relevant mental disorder - Evidence from the hx, PE, or lab findings: disorder developed during or within 1 month of intoxication, withdrawal or use - Disorder is not better explained by an independent mental disorder - Disorder does not occur exclusively during the course of delirium - Disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

When do seizures most often arise during alcohol withdrawal?

**24-48 hrs**; most often **Grand mal**

When does withdrawal delirium (DTs) develop during alcohol withdrawal?

**48-72 hrs**

What is the most severe manifestation of alcohol withdrawal?

Delirium Tremens

What are the signs/sx's of delirium tremems; what is the hallmark?

- **Agitation** + **global confusion** + **disorientation** + **hallucinations** + **fever** + **HTN** + **diaphoresis** + **autonomic hyperactivity** = **tachycardia** + **HTN** - **_Hallmark_** = profound **global confusion**

What does CIWA stand for and what is it used for?

- **C**linical **I**nstitute **W**ithdrawal **A**ssessment for **A**lcohol - Assigns numerical values to **orientation, N/V, tremor, sweating, anxiety, agitation, tactile/auditory/visual** disturbances and **HA** - **Total score \>10** indicates **_more severe_** withdrawal

What are 3 reasons that methadone is a high risk medication?

- Can be **deadly** when used with a **_benzodiazepine_****\*\*\*** - Frequently causes **QTC prolongation** - sometimes fatal - **Dangers** ↑ when used with another **_3A4 substrate!_****\*\*\***

If a methadone maintenance patient is encountered in the ED and needs pain management what is the proper protocol?

- Provider calls on-call service at methadone clinic and **verifies dosage** - The **correct methadone dosage is continued** while patient is hospitalized - If **additional pain mangement is required** use **another opioid**: not another CYP3A4 substrate and no benzos! - **Do not use methadone** as this will possibly disrupt the response to current methadone maintenance dosing

What is a serious mental AE associated with chronic intoxication of stimulants?

**Psychosis**: sometimes with _severe_ paranoia

What are the cerebellar sx's of PCP intoxication?

**Ataxia**, **dysarthria**, and **_NYSTAGMUS_** (**vertical** and **horizontal**)

What are the 2 neuroadaptive effects of PCP?

- **Opiate receptor effects** - **Allosteric modulator** of **glutamate NMDA receptor**

Which 3 benzodiazepines are metabolized through glucuronidation in liver and can be used in the setting of alcohol and other withdrawals?

**Oxazepam** and **Lorazepam** and **Temazepam**

Cocaine works mainly by preventing the reuptake of what?

Dopamine

Amphetamines can be fatal at lower doses in the setting of what underlying disease?

**Brugada syndrome**

Adolescent males who use cannabis regularly have a 7-fold increased risk of?

Psychosis

The neuromodulator effect of cannabis is due to decreased uptake of which NT's?

**GABA** and **Dopamine**