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Addiction Med > Exam I > Flashcards

Exam I Flashcards

1
Q

Nicotine: 2nd line drugs for smoking cessation include:

  1. Combination (nicotine + buproprione)
  2. Clonidine
  3. Nortriptyline

What are 1st line therapy drugs?

A
  1. Nicotine replacement (patch, gum, vaping)
  2. Buproprione (anti-depressant)
  3. Varenicline (nicotinic receptor agonist)
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2
Q

Nicotine: After smoking, nicotine can reach the brain in about 10 seconds. It acts by acting on ______ inc. dopamine release and eliciting positive reinforcement (reward, relaxation).

A

nACh receptors

  • nACh-R’s become desensitize (inactivated)
  • upregulation of receptors
  • inc. need

NOTE: withdrawal occurs when there is no nicotine

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3
Q

Nicotine: True/False - In the absence of nicotine, patient’s can undergo withdrawal symptoms including irritability, restlessness and increased craving (inc. desire to smoke)

A

True

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4
Q

Nicotine: 1 cigarette is equivalent to about ~10 puffs, meaning a person can receive ~10 positive reinforcements. Thus, > 5 ciggies/day can lead to dependence.

Dopamine is released in the ____, which is regulated by presynaptic nAChRs.

A

nucleus accumbens

*Nicotine activates nAChRs in the Ventral tegmental area

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5
Q

Nicotine: True/False - Treatment of tobacco dependence shoud address the physiological and the behavioral aspects of dependence

A

True

Physiologic:

  • -addiction to nicotine
  • -meds for cessation

Behavioral:

  • -habit
  • -behavior change program
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6
Q

Nicotine: Nicotine is an alkaloid obtained from the leaves of Nicotiana species.
It is a prototype agonist that stimulates different nAChRs (non-specific).

Nicotrine replacement therapy is approved (FDA) for smoking cessation. What are its actions?

A
  1. dec. withdrawal symptoms
    - -irritability, anxiety, concentration, inc. appetite
  2. decreases craving
    - -long term benefit

*nasal sprays = most efficacious

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7
Q

Nicotine: Nicotine is metabolized by the liver into a long-acting metabolite (cotinine).

What is the risk for individuals who are poor metabolizers?

A

Inc. risk of addiction

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8
Q

NIcotine: Adverse effects of nicotine (esp. high dose) include Nausea, Insomnia and Headache.

What are adverse effects of vaping?

A

coughing, pulmonary disease

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9
Q

Nicotine: What are drug interactions and contraindications of nicotine use?

A
  1. Interactions
    a. avoid smoking – N/V, tachycardia, nicotine overdose
  2. Contraindications
    - -pregnancy, lactating
    - -pulmonary diseases
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10
Q

Nicotine: _____ is FDA approved as a monotherapy for smoking cessation.

It releives symptoms of nicotine withdrawal and craving, and also improves long term abstinence

A

Buproprion

  • dec. weight gain after cessation
  • also used in MDD
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11
Q

Nicotine: Buproprione acts by inhibiting both ____ and _____, thereby increasing dopamine and NE. This leads to relief of symptoms.

It also acts by inhibiting _____, whih aids its function as an anti-depressant and in efficacy as a smoking cessation agent.

A
  1. Inhibits DAT and NET

2. Inhibits different nAChRs

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12
Q

Nicotine: Buproprione acts by inhibiting both ____ and _____, thereby increasing dopamine and NE. This leads to relief of symptoms.

It also acts by inhibiting _____, whih aids its function as an anti-depressant and its efficacy as a smoking cessation agent.

A
  1. Inhibits DAT and NET
  2. Inhibits different nAChRs

DAT: dopamine transporter

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13
Q

Nicotine: Contraindications to use of Buproprione include:

  1. Epilepsy
  2. Bipolar disorder

What are Interactions?

A
  1. Drugs that modify CYP enzyme

(e. g. MAO inhibitors) = increase the risk of hypertension.

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14
Q

Nicotine: ______ is FDA approved as monotherapy for smoking cessation. It acts by decreasing nicotine reward.

It relieves symptoms of nicotine withdrawal and craving, with higher efficacy thatn bupropion or NRT.

A

Veranicline (Chantix)

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15
Q

Nicotine:

  1. Nicotine binds __1___ nicotinic receptors promoting DA release.
  2. During smoking cessation, there is NO dopamine release
  3. Varenicline (partial agonist) binds ___1___ nAChRs with higher affinity than nicotine. This permits inhibition of nicotine binding, while activating nAChRs.
A

alpha 4 Beta 2 receptors

less DA release than nicotine

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16
Q

Nicotine: Varenicline has minimal liver metabolism and is excreted in the urine.

Side effects include:

  1. N/V
  2. Insomnia
  3. Potential psychiatric effects (black box)

What are contraindications?

A
  1. Kidney disease (renal metabolism)
  2. Psychiatric conditions
  3. Pregnant/Lactating women
    - -potential risk
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17
Q

Nicotine: 2nd line therapies for nicotine addiction include:

  1. Bupropioe + Nicotine patch
    OR buproprione + varenicline
  2. Nortriptyline
  3. Clonidine

_____ has a higher clinical efficacy than monotherapy as it provides sustained release. This therapy is most often used when monotherapy fails (heavy smokers)

A

Combination therapy (patch + buproprion)

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18
Q

Nicotine: 2nd line therapies for nicotine addiction include:

  1. Bupropion combined with nicotine patch or varenicline
  2. Nortriptyline
  3. Clonidine

Combination of bupropion and Varenicline has been shown to have a higher clinical efficacy than monotherapy.

A

*See slide 29

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19
Q

Nicotine: 2nd line therapies for nicotine addiction include:

  1. Bupropion combined with nicotine patch or varenicline
  2. Nortriptyline
  3. Clonidine

_____ is an NE transporter inhibitor (NET inhibitor) that is used when 1st line treatments fail or are contraindicated. It minimizes withdrawal symptoms, but is not FDA approved. It is effective in smokers w/out depression.

A

Nortriptyline

MOA: NE transporter; NET inhibitor

  • effective in smokers w/out depression
  • can be combined with nicotine patch
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20
Q

Nicotine: 2nd line therapies for nicotine addiction include:

  1. Bupropion combined with nicotine patch or varenicline
  2. Nortriptyline
  3. Clonidine

____ is very effective during the first stage of withdrawal. It minimizes withdrawal symptoms (from several addictive drugs, including nicotine). It however, does not improve craving

A

Clonidine

MOA: a2-agonist

*does not treat addiction (does not improve craving)

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21
Q

Nicotine: Which of the following is an adverse effect of Clonidine (anti-HTN)?

a. Dry mouth
b. Sedation
c. Weight gain
d. Dizziness

A

A and B

*hypotension

Cx: CV disease, pregnancy

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22
Q

Nicotine: Which of the following is an adverse effect of Nortriptyline (anti-depressant)?

a. dry mouth
b. sedation
c. hypertension
d. dizziness

A

Weight gain, dizziness, HTN

Cx: CV disease

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23
Q

Addiction Medicine: Addiction is a genetic, biological disease, NOT a moral failure.

Addiction may occur via many different substances including:

  1. Stimulants
  2. Depressants
  3. Hallucinogens

List examples of stimulants

A
  1. Cocaine
  2. Nicotine (deadliest in the world)
  3. Caffeine (most abused substance)
  4. AMphetamine and Methamphetamine
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24
Q

Addiction Medicine: Addiction is a genetic, biological disease, NOT a moral failure.

Addiction may occur via many different substances including:

  1. Stimulants
  2. Depressants
  3. Hallucinogens

Depressants include _____, opoids, benzos, and marijuana

a. alcohol
b. topiramate
c. caffeine
d. biotin

A

alcohol

*MJ - depressant/hallucinogen

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25
Q

Addiction Medicine: Addiction is a genetic, biological disease, NOT a moral failure.

Addiction may occur via many different substances including:

  1. Stimulants
  2. Depressants
  3. Hallucinogens

True/False - Hallucinogens include LSD, Xtacy, Pilocybin and Phencyclidine (PCP, Angel dust)

A

True

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26
Q

Addiction medicine: Mechanisms of use include:

  1. Nasal inhalation
  2. Ingestion (MJ brownies)
  3. Sublingual (acid - LSD)
  4. Injection (inc. risk transmission with HIV)
  5. Smoking
  6. Transdermal/mucosal
A

True

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27
Q

Addiction medicine: There are 3 broad categories associated with addiction

  1. Intoxication
  2. Withdrawal
  3. Dependence (“Use” Disorder)

____ occurs when the patient exhibits symptoms that are a direct physiologic effect of the chemical on a receptor. It is time limited (goes away) and occurs within hours of ingestion.

A

Intoxication

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28
Q

Addiction medicine: There are 3 broad categories associated with addiction

  1. Intoxication
  2. Withdrawal
  3. Dependence (“Use” Disorder)

_____ occurs when the px exhibits symptoms consistent with dysregulated numbers of receptors in relation to the availability of the substance. It can miserable, and deadly, and is often the reason people continue to use.

A

Withdrawal

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29
Q

Addiction medicine: There are 3 broad categories associated with addiction

  1. Intoxication
  2. Withdrawal
  3. Dependence (“Use” Disorder)

____ is characterized by long-standing use. It involves maladaptive behaviors (despite negative consequences). Individuals are normally “addicted” at this point.

A

“Use” Disorder

*previously dependence

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30
Q

Addiction medicine: Physicians are given the authority to prescribe controlled meds by the _______ agency and the __________. This authority comes as part of an agreement to abide by good medicine and to be responsible (safe use)

A

Drug enforcement agency (DEA) and OK Bureau of Drugs and Narcotics (OBN)

  • obtain after get medical license (PGY2)
  • must pay regular fee
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31
Q

Addiction med: True/False - Physicians must have continuing medical education every 2 years on “proper prescribing” to maintain their medical license.

A

True

*yearly for opoids

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32
Q

Addiction med: List the schedule I and schedule II drugs

A
  1. Schedule 1
    - -most potential for abuse/dependence + no medicinal qualities
    - -Heroin, LSD, MJ, ecstasy, peyote
  2. Schedule II
    - -high potential + some medicinal qualities
    - -vicodin, cocaine, caffeine, meth, oxycontin, adderal
  3. Schedule III
    - -moderate potential + acceptable medicinal qualities
    - -require prescription
    - -tylenol with codeine, ketamine
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33
Q

Addiction med: True/False - Controlled substances should almost always be used within their FDA indication and doses. It is possible to prescribe off label with a compelling reason, however, all prescriptions should be based on sound evaluation and Dx.

Physicians must demonstrate good vigilance

A

True

  • risk vs. benefit
  • shift based on change in clinical status or new info
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34
Q

Addiction med: Which of the following is true about proper prescribing?

a. should evaluate functional outcome (drugs promote ability of the px to function)
b. should be evaluating objective evidence
c. should be monitoring
d. not required to use within FDA indications

A

A-C

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35
Q

Addiction med: Forms of monitoring include:

  1. Checking Urine Drug Screens
  2. Checking PMP (prescription monitoring program)
  3. Document, Document (risks vs. benefits)

True/False - Positive results of other substances in the urine is important as well as negative results (as it may indicate px is not using the drug - may be selling)

A

True

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36
Q

Addiction med: Forms of monitoring include:

  1. Checking Urine Drug Screens
  2. Checking PMP (prescription monitoring program)

____ should be done every time a controlled substance is written. It must be done every 6 months

A

PMP

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37
Q

Addiction med: Which of the following is a red flag of addiction?

a. taking more than prescribed
b. taking routinely despite being prescribed prn
c. continued use outside of the prescribed window
d. admittance that they want to stop, but cannot

A

all of the above

*unsuccessful Tx programs (meetings, hospitalizations)

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38
Q

Addiction med: Which of the following is NOT a red flag of addiction?

a. small jobs/panhandling to get the next dose
b. criminal activity
c. excessive time incapacitated from the dose
d. excessive violence following consumption

A

D

*A-C = other red flags

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39
Q

Addiction med: True/False - Other red flags of addiction include:

  1. Missing work, deadlines due to intoxication/hungover
  2. Termination/dismissal from school
  3. Change in roles at home due to lack of responsibility
  4. Arguments with friends and family about use/consequences, but uses anyway
A

True

  • legal problems due to use
  • withdrawal from gatherings (holidays)
  • withdrawal from social groups
  • unemployment
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40
Q

Addiction med: True/False - Red flags of addiction may also go so far as to include reckless driving/driving under the influence, using heavy machinery, or altered ability to supervise children.

A

True

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41
Q

Addiction med: Red flags of addiction may also be associated with:

  1. overdose with continued use
  2. failure to adhere to physician recommendations to cease use
  3. failure to adhere to recommendations by a mental provider
  4. contraction of hepatitis, HIV, liver failure, or endocarditis as a direct consequence of using
A

True

  • need for inc. doses due to tolerance
  • transition to stronger formulations
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42
Q

Addiction med: Red flags of addiction may also be associated with:

  1. overdose with continued use
  2. failure to adhere to physician recommendations to cease use
  3. failure to adhere to recommendations by a mental provider
  4. contraction of hepatitis, HIV, liver failure, or endocarditis as a direct consequence of using
A

True

  • need for inc. doses due to tolerance
  • transition to stronger formulations
  • need for inc. amounts of substance to achieve intoxication
  • no effect from what is being taken
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43
Q

Addiction med: Social signs of addiction include:

  1. Personality changes
  2. Unusual favors
  3. Secretive
  4. Stealing

List examples of each

A
  1. Personality
    - -angry, irritable, defensive, demanding, selfish
  2. Unusual favors
    - -housing, transportation, borrow money
  3. Secretive
    - -territorial about personal space, vague about details, absent for long periods of time
  4. Stealing
    - -petty crimes (small items), assist others in access to one’s house
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44
Q

Neuro of Addiction: Addiction is a brain disease whose visible symptoms are bad/altered behaviors. It is biologically based on 3 things:

  1. Activation of the reward circuit
  2. Alteration of receptor densities (upreg/downreg)
  3. Alteration of NT levels

True/False - Drug abusers tend to have altered brain structures (resembling traumatic brain injury). Often they lose the capacity to experience pleasure

A

True

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45
Q

Neuro of Addiction: Addiction is a brain disease whose visible symptoms are bad/altered behaviors. It is biologically based on 3 things:

  1. Activation of the reward circuit
  2. Alteration of receptor densities (upreg/downreg)
  3. Alteration of NT levels

____ is the area of the brain that is involved in a feedback loop of reinforcement. It involves the nucleus accumbens and the ventral tegmental areas of the brain

A

Reward circuit

  • Involves: Food, Sex, Social interaction, Drugs
  • involves hippocampus = memories
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46
Q

Neuro of addiction: True/False - THe reward circuit tells the individual what to repeat in order to obtain reward. It builds pathways and connections that remain.

Drugs take advantage of and exaggerate this system

A

True

  • brain myelinates from back to front
  • initial drug use sends small messages, but inc. use/concentrations leads to stronger signals (inc. receptor numbers)
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47
Q

Neuro of addiction: What is the mechanism of withdrawal?

A

receptor dysregulatin

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48
Q

Neuro of addiction: True/False - The brain has many receptors for opoids. An overdose occurs when there is too much of an opois (e.g. heroin, oxycodone) that fits into too many receptors slowing the CNS and decreasing breathing

A

True

  • how long it binds
  • efficacy/potency
  • morphine is standard measure
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49
Q

Neuro of addiction: Dependence can occur within 2 weeks. Dependence is highly influenced by strength of the drug and tolerance.

Tolerance occurs by

A

downregulation (degradation) of receptors (desensitized)

*it then takes more substance to produce the same analgesic effect as when first established

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50
Q

Neuro of addiction: Treatment of addiction involves treating its biological basis (because it is a medical problem).

True/False - Standard therapeutics involve treatment towards medication. In other words, detox the patient first (get them through withdrawal period) and then provide long-term treatment/long term abstinence.

A

True

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51
Q

Neuro of addiction: Addiction is created by the science of the substance and all individuals are at risk, though some are at higher risk than others due to personality and genetics.

True/False - The only factor that causes addiction is exposing the brain to an addictive substance (causing dopamine surge

A

True

NOTE: Physician controls the volume (treatment); assume 10% of meds will be abused

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52
Q

Opoids: List the 3 opoids receptors found in the CNS

A
  1. Mu
  2. Kappa
  3. Delta
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53
Q

Opoids: Opoids act as agonists at the opioid receptor. They consist of two types:

  1. Opiates (non-synthetic opoids)
  2. Opoids (synthetic opoids and opiates)

Opoids receptors are present due to three naturally ocurring peptides (endorphins). List them

A
  1. Beta-endorphin
  2. Enkephalins
  3. Dynorphins
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54
Q

Opoids: Which of the following is an opoid?

a. Morphine
b. Heroine
c. Codeine
d. Lithium

A

A-C

-oxycodone, meperidine, pentazocine, hydromorphone, hydrocodone, methadone, levo-alpha-acetylmethadol, buprenorphine

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55
Q

Opoids: ______ is synthetically derived from morphine. It has a rapid onset of action and a very short half life.

It is most often used intravenously, but there is increased intranasal and smoking of this drug (higher availability of purer drug)

A

Heroin

*different color compounds based on climate

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56
Q

Opoids: ____ is a semi-synthetic compound derived from thebaine (found in opium – refined). It is a prescription opoid prescribed for treatment of acute and chronic pain.

A

Oxycodone

*immediate/extended releasde - oxycontin

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57
Q

Opoids: ____ is a form prescription pain medicine that is currently used to treat 5HT syndrome (other med interactions).

It should not be used for more than 48 hours.

A

Meperidine

*benefit in CNS (chemo rigors) and bowel obstruction

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58
Q

Opoids: ______ was the first agonist-antagonist. It works at both mu and kappa receptors. It is often mixed with Naloxone to prevent euphoria

a. Pentazocine
b. Methadone
c. Hydromorphone
d. Hydrocodone

A

Pentazocine

*not widely used

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59
Q

Opoids: _____ is one of the stronger analgesics that is used for moderate to severe pain. It may be administered IV, PO, nasally and/or rectally

a. Codeine
b. Morphine
c. Hydromorphone
d. Pentazocine

A

Hydromorphone

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60
Q

Opoids: ____ is a prescription drug frequently used for minor pain. It is often mixed with acetaminophen.

It is highly abused (OK’s poison!)

a. Hydrocodone
b. Methadone
c. Levo-acetyl-methadol
d. Meperidine

A

Hydrocodone (Lortab)

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61
Q

Opoids: ____ is a long acting synthetic that is used mainly as maintenance Tx for heroin addiction.

It is also used in chronic pain, but should NOT be used in opoid naiive patients, as it will cause respiratory depression

A

Methadone

  • high risk overdose
  • administered every morning
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62
Q

Opoids: ____ is a long acting, synthetic compound that is similar to methadone.

It was FDA approved for Tx of heroin addiction. However, post-marketing surveillance led to a black box warning. It is no longer available in the U.S.

A

Levo-alpha-acetylmethadol

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63
Q

Opoids: ______ is a partial agonist at mu and kappa, but an antagonist at delta. It is often mixed with naloxone.

It is used to treat pain and is a pillar of treatment for opoid use disorder

A

Buprenorphine

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64
Q

Opoids: Buprenorphine is a partial agonist of the mu receptor with high receptor affinity. Thus, it will displace most full mu agonists (e.g. heroin).

True/False - Buprenorphine has slow mu receptor dissociation. Thus, it will remain on the receptor for a long time, preventing the binding of full agonists

A

True

  • short analgesic effects
  • really good drug to fight addiction
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65
Q

Opioids: Which is true about partial Mu agonists?

a. results in high level of abuse
b. activates mu at lower levels
c. relatively less reinforcing (less reward circuit activ.)
d. includes buprenorphine

A

B-D

*less abuse

Full agonist: highly reinforcing, high abuse; morphine, methadone, codiene, fentanyl, heroine, codones…

NOTE: hydrocodone equiv. to morphine (slide 20)

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66
Q

Opoids: There are 12 criteria for the diagnosis of opioid use disorder:

  1. Opioids taken in larger amounts or over a longer period of time than intended
  2. There is persistent desire or _______ efforts to cut down or control opoid use
  3. There is a great deal of time spent performing activities necessary to obtain the opioid, use the opioid, or recover from its effect.
  4. _______, or a strong desire or urge to use opioids
A
  1. unsuccessful

4. craving

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67
Q

Opioids: There are 12 criteria for the diagnosis of opoid use disorder:

  1. recurrent opioid use resulting in a failure to fulfil major role obligations at work, home or school
  2. continued use despite having persistent or recurrent social or interpersonal problems due to opioids
  3. Important social, occupational, or _______ activities are given up or reduced due to opioid use
  4. recurrent use in situations where it is physically ______
  5. Continued use despite knowledge of having a persistent, recurrent physical or psych problem associated with the substance
A
  1. recreational

8. hazardous

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68
Q

Opioids: Tolerance and Withdrawal are also part of the criteria involved in diagnosing “Opioid Use Disorder.”

  1. _______ is defined as either a need for markedly inc. amounts to achieve intoxication/desired effect, OR a markedly diminished effect with continued use of the same amount.
  2. ______ is either characteristic opoid withdrawal syndrome OR when opioids are taken to relieve or avoid withdrawal symptoms.
A
  1. Tolerance
    - –does NOT apply when taken under medical supervision
  2. Withdrawal
    - -does NOT apply w/ medical supervision

*tolerance and withdrawal = physiologic dependence

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69
Q

Opioids: What is the purpose for treating Opioid Use disorder?

a. prevent death
b. prevent morbidity
c. manage withdrawal
d. pharmacologic management

A

all of the above

  • non-pharmacologic management
  • prevent public health morbidity
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70
Q

Opioids: True/False - Prevention of death involves

  1. education about risk behavior
  2. administration of naloxone (narcan) rescue kits
  3. avoid co-prescribing (opioids and benzos)

What are examples of education about risky behavior?

A
  1. mixing opioids with other meds/alcohol
  2. use of dangerous opioids (fentanyl/carfentanyl)

*test strips - determine if purely fentanyl

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71
Q

Opioids: Naloxone is a full opioid antagonist that can be used to rapidly reverse opioid overdose. However, it is important to be cautious of the short half-life

A

True

*lazarus effect

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72
Q

Opioids: True/False - Co-prescribing opioids with other depressants (BZD, OH, sleep aids) is extremely dangerous and should be avoided. It is important for physician’s to check the PMP for other meds the patient may be taking

A

True

**100% higher incidence of overdose when opioid is taken with Benzo

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73
Q

Opoids: With regard to preventing morbidity, ______ is the outcome of interest, NOT reduction of pain.

Furthermore, needle use is a public health emergency. There are programs (needle exchange, methadone clinics) that have been proven to reduce incidence of HIV and Hep C (harm reduction)

A

Functionality

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74
Q

Opoids: A patient presents with complaints of GI distress (N/V, diarrhea, cramping), lacrimation, goosebumps and pupillary dilation.

You suspect

A

Opioid withdrawal

*piloerection

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75
Q

Opioids: Which of the following is a method for management of opioid withdrawal?

a. slow taper of opioid
b. treat symptoms (anti-emetic/anti-diarrheal)
c. clonidine
d. buprenorphine (tapered)

A

all of the above

*cold turkey – not recommended (leading cause of overdose)

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76
Q

Opioids: Oral naltrexone was approved for the treatment of ______ in 1994, and is now being used for opioid addiction since the long-acting version has been approved.

It acts by blocking mu opioid receptors and preventing opioid agonists from binding

A

alcohol addiction

*long acting - alcohol dependence and opioid addiction

77
Q

Opioids: Oral naltrexone is absorbed orally. It has a half life of 4 hours, and 13 hours (if 6-B-naltrexone). It is metabolized by the CYP 450 system.

It is primarily excreted in the ______, with < 2% excreted unchanged in _____

A

urine, feces

78
Q

Mary Jane: Marijuana was recognized as a medication and listed in the U.S. Pharmacopoieia from 1850-1942.

However, medicinal use was abolished in 1937 by the enactment of the ___1____ Act. It was placed on Schedule _2__ of the US Controlled Substances Act in 1970.

A
  1. Marijuana Tax Act

2. Schedule I

79
Q

Mary Jane: ______ are substances or chemicals that are defined as drugs with no currently accepted medical use, and with high potential for abuse

A

Schedule I

  • -LSD, heroin, MDMA, MJ
  • -difficulty accessing drug for scientific study
80
Q

Mary Jane: ______ drugs are substances or chemicals with a high potential for abuse, with use potentially leading to severe psychologic or physical dependence. These drugs are also considered dangerous

A

Schedule II

*combos w/ < 15mg of hydrocodone, cocaine, meth, methadone, hydromorphone, meperidine, oxycodone, fentalin, adderall, ritalin

81
Q

Mary Jane: Cannabis is composed of over 400 chemcials, with THC and CBD being two of the primary compounds.

  1. ______ is the psychoactive component of cannabis, and acts as a partial CB1R agonist.
  2. ____ is the non-psychoactive component of cannabis. It’s MOA is unknown
A
  1. THC (delta-9-tetrahydrocannabidol)
  2. CBD (cannabidiol)
  • peak levels of THC reached in ~10 min of smoking (dec. to 5-10% within 1st hour)
  • ingested takes 1-3 hours to enter bloodstream; 11-hydroxy THCA detected in blood
82
Q

Mary Jane: The potency of marijuana depends on growing condition, genes, ratio of THC and the part of the plant that is used. There are 2 strains of cannabis:

  1. Indica
  2. Sativa

______ is increased CBD, while ___ has increased THC.

A
  1. Indica - Inc. CBD
  2. Sative - Inc. THC

*typical joint = 5-10mg THC

83
Q

Mary Jane: The concentration of THC varies among preparations. Common preparations include:

  1. Marijuana
  2. Hashish
  3. Hash oil
  4. Dab
  5. Hemp

_______ uses the dried flowering tops and leaves of the harvested plant. Potency dec. throught the upper leaves, lower leaves, stems and seeds.

A

Marijuana

  • conc. w/ leaves and stems = 0.5-5% THC
  • Sinsemilla (flowering tops) = 7-14%
84
Q

Mary Jane: The concentration of THC varies among preparations. Common preparations include:

  1. Marijuana
  2. Hashish
  3. Hash oil
  4. Dab
  5. Hemp

_____ is dried cannabis resin and compressed flowers. THC ranges from 2-8%. _____ is obtained by extracting THC from Hashish (or MJ) with an organic solvent. Concentration of TCH can range from 15-50%.

A
  1. Hashish
  2. Hash oil

Dab:

  • –use butane to extract THC – BHO
  • -can reach up to 90%
  • severe burns, lung injury

Hemp:

  • -fibrous form
  • -low TCH
  • -high cannabidiol
85
Q

Mary Jane: The MC routes of administration include:

  1. Smoke
  2. Edibles
  3. Vaporized
  4. Teas
  5. Sublingual/Oral mucosal
  6. Suppository

_____ occurs when it is rolled into cigarette paper (joint), prepared as a water pipe (bong), or hollowed out cigars (blunts).

A

Smoking

*tobacco cigarettes can have hashish oil dripped on them

86
Q

Mary Jane: Current formulations include oral preparation (FDA indications) and mouth sprays (Nabiximol).

  1. ______ is approved in the UK with standardized doses of THC/CBD.
  2. _____ is synthetic THC that is used as an appetite stimulant for HIV/AIDS patients. It may also be used as an anti-emetic for chemo px.
A
  1. Nabiximol
  2. Synthetic THC (dronabinol)
  3. synthetic analog THC (nabilone)
    - -chemo-induced N/V
87
Q

Mary Jane: _____ and _____ are endocannabinoids (endogenous cannabinoids) that are important for maintaining homeostasis and prevention of excessive neuronal activity. They are released from post-synaptic sites to signal pre-synaptic CB1 receptors.

They are rapidly removed from the extracellular space

A

Anandamide (AEA) and 2-Arachidonylglycerol (2-AG)

88
Q

Mary Jane:

  1. _______ receptors are found mainly in the brain, PNS, liver, thyroid, uterus, etc. Activation results in changes in multiple NT systems.
  2. ____ receptors are expressed mostly in immune cells, spleen and the GI (somewhat in brain, PNS, placenta).
A
  1. CB1

2. CB2

89
Q

Mary Jane: Much of the research that has been done on cannabis studied lower potency MJ, and therefore may not be applicable.

Why is this so?

A

Current MJ contains more potent (10.6%) THC with dec. CBD concentration

90
Q

Mary Jane: THC (metabolism) is deposited in _____ and slowly released. There is lack of correlation between blood concentration and pharmacological effects

A

fatty tissue

  • CYP2C9
  • inactive metabolite = detected in urine
91
Q

Mary Jane: A patient presents exhibiting euphoria and perceptual alterations (time distortion, intensified ordinary experiences). You note slurred speech, infectious laughter, talkativeness/friendliness and impaired memory.

PE reveals impaired motor skills, conjunctival injection. You supect

A

Intoxication (MJ use)

92
Q

Mary Jane: A patient presents with panic, delirium and confusion. She is hypotensive and tachycardic with complaints of chest pain.

She admits to ingesting a high dose of marijuana. You suspect

A

Overdose

  • MC ingested
  • Risk: Severe respiratory depression, sudden cardiac arrest (w/ other drugs combined)
  • MC < 5 and 15-19
93
Q

Mary Jane: _____ occurs at higher doses of THC. It may occur at low doses in susceptible individuals.

It results in visual and auditory hallucinations, delusional ideas, and thought disorders (in normal users)

A

Intoxication delirium

94
Q

Mary Jane: A patient presents with anger and irritability. He exhibits anxiety, and admits to depression. He complains of insomnia, appetite loss, and weight loss.

He admits these symptoms began 10 days after he stopped smoking marijuana. You suspect

A

Withdrawal

**1st 10 days after cessation

95
Q

Mary Jane: True/False - There is a sensitive window of development in adolescents where neurobiologic circuits are pruned and reinforced. They are highly sensitive to reward and have limited inhibitory signals. As a result, drug use inc. their risk of psychosis.

A

True

  • first use: mid-late teens
  • heaviest use: early 20s
96
Q

Mary Jane: Use of marijuana in adolescence is associated with low academic achievement and inc. rates of school drop out.

True/False - Furthermore, it has been found the disruption in cognitive function may persist longer, and may not be recoverable if MJ is used during adolescence.

A

True

97
Q

Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs

List the effects of Medical Marijuana on the CNS

A
  1. Anti-convulsant
    - –CBD > THC
  2. Muscle relaxant
    - -THC > CBD
    - -Tx MS-related spasticity, but inc. side effects (cognitive impairment)
  3. Improve sleep, pain
    - -Parkinson’s
    - ineffective for Levodopa induced dyskinesia
  4. Sedation, Ataxia @ high doses

**NUTSHELL: Tx MS related spasticity, anti-convulsant effects; ineffective for dyskinesia

98
Q

Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs

Which of the following is a short term effect of marijuana on cognition?

a. alters short term memory
b. alters sensory perception
c. alters attention span
d. alters verbal fluency

A

all of the above

*sense of time, problem solving, psychomotor control

99
Q

Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs

Which of the following is a long term effect of marijuana on cognition?

a. persistence of effect even after discontinuation of the drug
b. dec. activity in memory and attention with chronic marijuana use (or 28 days after abstinence)
c. dec. hippocampal and amygdala volume

A

all of the above

100
Q

Mary Jane: Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs

True/False - Driving under the influence of marijuana doubles or triples the risk of a crash as it impairs attention, reaction time and critical-tracking tasks.

A

True

  • alcohol + MJ = impairment greater than independent sum
  • impaired response to emergencies
101
Q

Mary Jane: Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs

True/False - Inhaled MJ can cause respiratory irritation and increases the risk of both acute and chronic bronchitis. Pound for pound, the quantity of tar inhaled through smoking MJ is > than that of tobacco smoke

A

True

*inc. risk lung cancer (metaplastic changes)

102
Q

Mary Jane: Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs
  5. Heart

CBD can cause both _____ and hypotension, while THC can cause ______ and hypertension (inc. work load).

A
  1. CBD
    - -bradycardia, hypo
  2. THC
    - -tachy, hyper

*4.8x more likely to have heart attacks (1 hr. after smoking)

103
Q

Mary Jane: Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs
  5. Heart
  6. GI

True/False - Both THC and CBD are strong anti-emetics.

A

True

THC has a greater ability to slow GI motility, and also stimulates appetite (AIDS anorexia). However, it may have negative metabolic effects. MJ has been shown to improve Crohn’s symptoms, but effects are short-lived.

104
Q

Mary Jane: _____ is a clinical syndrome characterized by repeated vomiting and compulsive hot water bathing behavior

A

Cannabinoid hyperemesis

*hot water alleviates symptoms of chronic use

105
Q

Mary Jane: Mary Jane: Marijuana can have effects on

  1. CNS
  2. Cognition
  3. Driving
  4. Lungs
  5. Heart
  6. Eyes

THC > CBD at reducing intraocular pressure, however, the AMerican Academy of Opthalmologists does NOT recommend treating glaucoma with MM because the effects are short lasting and can lead to

A

cognitive impairement

*dec. blood pressure – dec. blood flow to optic nerve = blindness

106
Q

Mary Jane: Cannabis smoke can lead to mutations in cells leading to cancer (esp. aerodigestive).

Furthermore, new studies have reported inc. risk of testicular cancer (non-seminoma) amongst cannabis users.

A

True

*CBD – chemotherapy for glioma cells; protective of normal cells

107
Q

Mary jane: Compounds in smoked marijuana cross the placenta and can pass into breast milk. These compounds can lead to low birth weight, developmental delay, behavioral problems and stillbirth.

ACOG encourages MJ cessation during pregnancy and while breastfeeding

A

True

*also affects GnRH, sperm, ovulation, fertilization, lactation, suckling, etc.

108
Q

Mary Jane: THC and CBD have been shown to have analgesic effects, improving CNS and PNS neuropathic pain, and pain associated with RA and fibromyalgia.

A

True

*30% pain reduction in px w/ regional pain syndrome, spinal cord injury, peripheral neuropathy, radiculopathy

109
Q

Mary Jane: True/False - Although cannabis is likely safer thatn opioids due to the difficulty of it to overdose, and decreased addictive qualities, there is a “therapeutic window” or optimal dose in which it reduces pain. Doses above that window can lead to higher incidence of pain.

A

True

*

110
Q

Mary Jane: True/False - Cannabis has been shown to provide some benefit in headache syndromes.

Different studies suggest that highly structured approaches may result in successful analgesia, however, other studies have shown no evidence of cannabis reducing pain severity.

A

True

111
Q

Mary Jane: Cannabis use follows a reciprocal model of pain and substance use. What does this mean?

A

Substance use inc. pain, and inc. pain is a motivator of inc. substance use (coping)

*slide 49

112
Q

Mary Jane: TCH has been shown to stimulate mesolimbic dopamine release, contibuting to addiction.

True/False - Adolescent initiators are 2-4x more likely to exhibit dependence within 2 years of their first use. In addition, tolerance may develop as quickly as 2-12 days of repeated use.

A

True

  • gateway drug - 9% of first time users get hooked
  • withdrawal: anorexia, irritabiity, anxiety, anger (1st 10 days)
113
Q

Mary Jane: True/False - Females who use cannabis were more likely to develop a cannabis disorder.

A

True

114
Q

Mary Jane: True/False - THC contributes to the development and expression of psychotic illness especially in vulnerable populations. It appears dose dependent and can nearly double the risk of psychosis.

THC may also make psychotic disorders worse (once already developed).

A

True

NOTE: high CBD has been associated with fewer psychotic experiences (may be protective)

115
Q

Mary Jane: ______ is the loss of connectivity to reality. It can be emotionally terrifying and can stimulate unsafe behavior.

There is mounting evidence that it is harmful to the brain.

A

Psychosis

  • THC contributes to dev. and expression of psychotic illness in vulnerable pops.
  • high CBD may be protective
116
Q

Mary Jane: THC is anxiogenic, while CBD has been shown to have anxiolytic effects.

Furthermore, those with higher THC levels were seen to have increased depression and anxiety, and poor memory.

A

True

  • paradoxical rxn - dejection, dysphoria, depressed mood
  • Amotivational syndrome
117
Q

Mary Jane: True/False - Withdrawal can also cause mood issues, which may improve by taking MJ, making it appear to treat mood problems

A

True

118
Q

Mary Jane: There is promising research suggesting the cannabinoids may rid of aversive memories and improve PTSD, sleep.

A

True

*strong association

119
Q

Mary Jane: True/False - in states where medical marijuana is legal, a px can receive a medical card from a physician.

Dispensaries are not subject to governmental standardization, and its constituents and potency are unknown

A

True

  • possession/use still prohibited under federal law
  • OK - legal and under emergency rules (px should have informed consent)
  • Tx is available for dependence
120
Q

Mary Jane: MM is not a good option for vulnerable populations, including adolescents and those with mental illness

A

True

*narrow empirical basis for efficacy

121
Q

Methamphetamine: Amphetamine-type stimulants date back thousands of years. They were first synthesized in Japan in 1918, and utilized to combat soldier’s fatigue during WWII.

What is the MOA of methamphetamine?

a. competitive inhibition of DA reuptake by DAT
b. phosporylation of DAT leading to internalization
c. inhibition of DA synaptosomal uptake by VMAT2
d. intracellular uptake of MA that leads to reverse transport of DA (via DAT) into the synapse

A

all of the above

*MA diffuses into synaptosomes – impairing storage of DNA

122
Q

Methamphetamine: True/False - Methamphetamine increases the release of dopamine by blocking MAO and preventing dopamine breakdown in the pre-synaptic neuron.

It also reverses dopamine transporter, preventing re-uptake of dopamine into the pre-synaptic neuron. It has the same effects with NE.

A

True

Methods:

  • inhale (smoke)
  • insufflation (snort)
  • I.V. (shooting)
  • oral
  • transdermal
123
Q

Methamphetamine: Methods of use include:

  • inhale (smoke)
  • insufflation (snort)
  • I.V. (shooting)
  • oral
  • transdermal

Methamphetamine is metabolized by CYP2D6/3A4 enzymes in the liver, and is eliminated in the urine. It can reach the brain in 6-8 seconds when ______, and is instantaneous when taken ______ (intense effects; peaks in 4-7 minutes).

A
  1. Smoking
  2. I.V.
    - -intense effects
  3. Snorting
    - -slowest, less peak, longer half life
124
Q

Methamphetamine: A patient presents with increased energy and alertness, decreased need for sleep, decreased appetite (skinny), and euphoria (at the top of a roller coaster).

PE reveals inc. HR and b.p, pupillary dilation, psychomotor agitation and analgesia. Hyperthermia (excited delirium) is also noted. This is a sign of

A

Intoxication

  • death due to stress on heart
  • taser - high risk of death (inc. heart rate)
125
Q

Methamphetamine: Which of the following is another sign of intoxication from methamphetamine?

a. tactile hallucinations
b. paranoia
c. agitation
d. violence

A

all of the above

  • hallucinations: skin picking, cocaine bugs (formication)
  • paranoia: “tweak peak” - keep checking to see if someone is there

*agitation and violence highly common **

126
Q

Methamphetamine: True/False - Chem sex is enhancement of sexual experience using a drug or chemical. Methamphetamine is the most common chemical used, especially amongst the gay males. This leads to inc. risk of HIV due to use of dirty needles

A

True

127
Q

Methamphetamine: Treatment of intoxication involves

  1. isolation with minimal stimulation (quiet, dark room)
  2. BZD (Adavan, Lorazepam; inc. GABA)
  3. Antipsychotic (dopamine blockade)

Under what situations would you use BZD? Antipsychotic?

A
  1. BZD
    - -meth induced high anxiety, agitation
  2. Antipsychotic
    - -hallucinations, paranoia, skin picking
128
Q

Methamphetamine: Withdrawal from methamphetamine is not life threatening, thus treatment is supportive.

Patients may present with depression or anhedonia, and suicidality in severe cases. Patients may also present with what other symptoms?

A
  1. Fatigue
    - -need for sleep
  2. Vivid dreams
  3. Sleep disturbance
  4. Inc. appetite
129
Q

Methamphetamine: What are consequences of Methamphetamine use?

a. rhabdomyolysis
b. grand mal seizures
c. cardiac arrhythmia
d. lung damage (smoke)
e. death

A

all of the above

  1. Acute:
    - - rhabdo: hyperthermia, seizures, dec. oral intake
  2. Severe intox:
    - -grand mal, stroke, heart, hyperpyrexia, death
130
Q

Methamphetamine: True/False - Prolonged exposure to NE causes fibrosis and is directly toxic to the myocardium. Thus, methamphetamines are associated with myocarditis, endocarditis, HTN, CVA, LVH and acute MI

A

True

131
Q

Methamphetamine: Patients who abuse methamphetamine are also at increased risk of acquiring HIV or Hep C.

Furthermore, they may develop skin abscesses associated with IV use and skin picking. They may also dig and/or pop skin.

A

True

**HIV crisis in OK

132
Q

Methamphetamine: Meth reduces salivary excretion. It also induces psychomotor agitation leading to bruxism and wearing down of enamel.

What can be done?

A

Fix teeth

“meth mouth”

133
Q

Methamphetamine: Psychiatric consequences of methamphetamine use include:

  1. Psychosis
  2. Poor inhibitory control
  3. Impaired attention
  4. Impaired risk-reward decision making

_____ is a large contributor to inpatient psych hospitalization

A

psychosis

134
Q

Methamphetamine: Use is evenly distributed between males and females, with 18-25 being the most likely to use. It is more prevalent in the Western 2/3 of the U.S.

There are two different kinds of meth: Powder and Liquid.

______ is domestically (locally) produced and is NOT very pure. Pseudoephedrine laws make it difficult to access materials.

A

Powder

  • pseudoephedrine - behind pharmacy shelves
  • smurfing - pharmacy to pharmacy to pick up pseudoephedrine

*60% methamphetamine

135
Q

Methamphetamine: _____ is foreign or domestic lab-made. It is 99% pure. It is much cheaper and widely available.

*It is common to put in a gasoline truck and transport.

A

Liquid methamphetamine

*OKC regional distribution hub

136
Q

Methamphetamine: True/False - Methamphetamine is considered OK’s greatest illicit drug threat, with #2 being prescription opioids and heroin emerging. Number 3 is marijuana.

Although domestic production has decreased, meth now comes from Mexico (controlled by DTO’s) and is more pure.

A

True

  • 330 meth deaths in 2017 (157 in tulsa county)
  • fewer “seized” labs due to production in Mexico
  • 950KG seized in 2016

cost: $40-100/gram

137
Q

Methamphetamine: True/False - More OK’s died of methamphetamine overdose than prescription opioid overdose (2018)

A

True

138
Q

Methamphetamine: True/False - There are no FDA approved medications. However, residential programs or inpatient treatment may be provided as well as CBT.

A

True

CBT: 1-2 sessions have shown benefit
Contingency management: reduced when used alone or with CBT

139
Q

Methamphetamine: Other forms of treatment may include

  1. Motivational interviewing
  2. 12 step groups (narcotics anonymous)
  3. Psychosocial therapies (not sustained following cessation)
  4. Possible meds (topiramate)
  5. Transmagnetic stimulation

Inpatient residential has been shown to be superior to detox or no treatment alone. However, effects are not maintained to year 3 or follow up.

A

True

140
Q

Cocaine: Cocaine is derived from crystalline tropane alkaloid obtained from the leaves of the coca plant.

Coca leaves have been chewed by indigenous peoples for thousands of years, prior to taxation of the coca plant by Spanish colonizers. When was the cocaine alkaloid extracted?

A

1855 by Friedrich Gaedcke

*German

141
Q

Cocaine:

  1. The cocaine molecule was first isolated by German chemist _____ in 1898
  2. Analgesic properties were first shown in 1879 by _____
  3. It was used as treatment for _____ addiction in 1879
A
  1. Richard WIllstater
  2. Vassili von ANrep
  3. Morphine addiction

*first documented analgesic use = 1884

142
Q

Cocaine: Cocaine was used in multiple commercial products in the late 19th century and 20th century (e.g. Mariani wine, Coca Colar, cigarettes). However, sales were outlawed by the ____ act in 1914. It is now considered a schedule II controlled substance by the DEA.

A

Harrison Narcotics Tax act

143
Q

Cocaine: The distribution of crack cocaine caused a major shift in the sociodemographics characteristics amongst cocaine users. Early use was directly proportionate to years of education, however, after crack cocaine was developed (~1980s), use became inversely proportionate to years of education.

Currently, cocaine is used medically for _____

A

CNS stimulation, as a local anesthetic, and as a vasoconstrictor (ENT)

144
Q

Cocaine: Cocaine can come in different forms including:

  1. Coca leaf infusions (tea)
  2. Powder cocaine
  3. Crack cocaine

______ cocaine is fine white, bitter tasting cocaine that is typically used via insufflation. ____, is the smoke-able form of cocaine made into “small rocks” by processing with baking soda.

A
  1. Powder

2. Crack

145
Q

Cocaine: Routes of use include:

  1. Oral (rubbed along gum lines or wrapped in paper and swallowed - parachute/snow bomb)
  2. Inhalation (pipe, rubbing powder on filter paper - cocoa puffs)
  3. Insufflation (snort/blow)
  4. Injection (IV)
  5. Suppository (anus/vagina - plugging)

What is the mechanism of action of cocaine?

A
  1. block reuptake of DA at pre-synaptic nerve membrane
    - -binds cocaine receptor = inc. DA in synaptic cleft
  2. Reuptake blockade of NE and 5HT

Net = transient inc. in extracellular DA in mesolimbic system

*primarily acts at VTA??

146
Q

Cocaine: Cocaine is metabolized by plasma _____. The major metabolite is benzoylecgonine (BE), which is inactive. BE is present in the urine for 48 hours post-use

A

plasma cholinesterases

147
Q

Cocaine: What is the route of administration with the fastest onset, but shortest duration of effect?

A

Inhalation

*slide 19 table

148
Q

Cocaine: Onset and duration depends of route of administration. Symptoms of cocaine intoxication will be similar to symptoms of amphetamine intoxication, but usually less severe

True/False - Psychotic symptoms are much less prevalent in cocaine intoxication compared to amphetamine intoxication

A

True

149
Q

Cocaine: The following are desired effects of cocaine intoxication:

  1. Euphoria
  2. Garrulousness
  3. Decreased sleep
  4. Decreased appetite
  5. Sexual stimulation

What are undesired effects?

A

Irritability
Anxiety
Restlessness
Paranoia (occurs in 2/3 of heavy users)

150
Q

Cocaine: True/False - Medication is usually not needed to Tx cocaine intoxication. First line treatment involves providing a quiet, low stimuli environment, followed by BZD’s for agitation if needed

A

True

  • neuroleptics/anti-psychotics cautioned = can worsen hyperthermia
  • HTN and tachy best Tx with BZD, followed by a-blocker (phentolamine)
151
Q

Cocaine: What should be provided if rhabdomyolysis is suspected?

A

IV fluid hydration

152
Q

Cocaine: A patient presents with dysphoric mood, fatigue, hypersomnia, increased appetite, anxiety, and agitation. Symptoms arose 24 hours following his last use of cocaine.

You suspect? YOu treat with?

A

COcaine withdrawal

*can last up to 2 weeks

Treatment:

  • -meds not needed normally
  • -BZD for anxiety/agitation
153
Q

Cocaine: What is a local complication of cocaine use?

a. Irritation and/or ulcers of nasal mucosa
b. Nasal septal perforation
c. Pulmonary dysfunction
d. Dental/gum problems

A

all of the above

*rhinorrhea

154
Q

Cocaine: Common Cardiovascular complications include:

  1. Myocardial infarction
  2. Ventricular dysrhythmias
  3. Cardiomyopathy
  4. Endocarditis

What are common neurologic complications?

A
  • Hemorrhagic stroke
  • Ischemic stroke
  • Grand mal seizures
155
Q

Cocaine: Patients who use cocaine are at increased risk of accidents, homicide and suicide.

What are common complications seen in pregnancy?

A
  • abruptio placentae
  • GU malformations
  • low birthweight
156
Q

Cocaine: Frequent co-occuring disorders with cocaine addiction include:

  1. Other substance use disorders
  2. Depressive and bipolar disorders
  3. ADHD
  4. PTSD
  5. Personality disorders

What are common drug combinations with cocaine?

A
  1. Cocaine and Heroin

2. Cocaine and OH

157
Q

Cocaine: ______ known as “speedball” causes an intense euphoria w/ dec. negative effects of cocaine. Once the cocaine wears off, heroin is unopposed leading to respiratory depression and death.

A

Cocaine and Heroin combination

158
Q

Cocaine: ______ is formed by the liver in the presence of alcohol and cocaine in the blood. It causes an intense euphoria w/ longer duration (than cocaine alone). It has 18-25 fold inc. over cocaine alone, and can lead to immediate cardiac death

A

Cocaethylene

159
Q

Cocaine: THe standard for treatment of cocaine use disorder is _____. There are no FDA approved pharmacotherapy treatments for cocaine addiction

A

Behavioral therapy

  • CBT/relapse prevention
  • contingency management
160
Q

Cocaine: Urine drug screening readily detects the cocaine metabolite, benzoylecgonine. The duration of detection is 2 days.

True/False - Patients with an initial positive urine were less than half as likely to complete treatment or attain initial abstinence

A

True

  • women = better outcomes
  • coexisting psych disorders DON”T predict outcome

NOTE: NO reported pharmaceuticals that cause a false positive for cocaine screening.

161
Q

Hallucinogens: ______ are agents that consistently produce alterations in thought, mood, and perception; produce minimal autonomic side effects and cravings; and fail to produce stupor or central nervous system stimulation

A

Hallucinogens

  • umbrella for a large number of substances
  • classical = arylalkylamines
162
Q

Hallucinogens: Hallucinogens fall under the following subtypes:

  1. Indolealkylamines
  2. Alphaalkyltryptamines
  3. Ergolines/Lysergamides
  4. Beta-carbolines
  5. Phenylalkylamines

List examples of each

A
  1. Indolealkylamines
    - –N-Alkyltryptamines (DMT, Psilocin, Psilocybin, Constituents of Shrooms)
  2. Ergolines/Lysergamides
    - -LSD
  3. Beta-Carbolines
    Harmaline, Harmine
  4. Phenylalkylamines
    –Phenylethylamines
    Mescaline
  5. Phenylisopropylamines
    - -DMA, TMA, DOM, MDA
163
Q

Hallucinogens: The majority of hallucinogens are consumed orally, with inhalation being the 2nd MC route of administration (esp. mescaline, DMT).

What is the MOA of hallucinogens?

A

5-HT2 receptor agonists

164
Q

Hallucinogens: Desired effects of Hallucinogen intoxication include:

  1. Hallucinations
  2. Increased color perception
  3. Body image changes
  4. Feeling several emotions at once
  5. Synesthesia

A patient who presents with disturbed thoughts, sleeplessness, dry mouth, tremor, and panic attacks is most likely experiencing

A

undesired effects

  • “bad trip” - terrifying thoughts, feelings; fear of losing control
  • rhabdomyolisis
165
Q

Hallucinogen: A patient who presents with terrifying thoughts or feelings and/or fear of losing control is most likely experiencing a bad trip.

What are treatment recommendations?

A
  1. Reassure and remove exvess stimuli
  2. BZD
    - -if #1 is not effective
166
Q

Hallucinogen: Which of the following is a potential long term effect of hallucinogen use?

a. halos and auras around objects
b. difficulty distinguishing colors
c. distortion in dimension
d. air assuming a grainy or textured appearance

A

all of the above

  • trails following objects in motion
  • shifts in hue
  • heightened awareness of floaters
167
Q

Hallucinogens: _____ is both a stimulant and hallucinogen pharmacologically. It results in empathy and profound feelings of relatedness to the world.

It is typically known as ecstacy, X or Molly

A

MDMA

–methylene-dioxy-methamphetamine

168
Q

Hallucinogens: Acute intoxication of MDMA leads to increased 5HT levels, blocking its reuptake. It also causes direct release of 5HT.

How does this differ from chronic intoxication?

A
  • dec. 5HT levels
  • depletes 5HT stores
  • inhibits 5HT synthesis
169
Q

Hallucinogens: A patient presents with excess energy, wakefulness and anorexia. You note diaphoresis, excessive teeth grinding (bruxism). He complains of inc. defecation.

You suspect

A

MDMA intoxication

  • defecation (disco dump)
  • trismus (lockjaw)
  • potential for 5HT syndrome if dehydrated
170
Q

Hallucinogens: A patient presents with depressed mood, lethargy, fatigue and anhedonia following use of hallucinogens.

He admits to suicidal thoughts. You suspect

A

MDMA withdrawal

171
Q

Hallucinogens: True/False - Long term effects of MDMA include depression, anxiety, panic disorder, impulsibity, sleep disturbance and cognitive dysfunction

A

True

172
Q

Dissociative drugs: Dissociative drugs include:

  1. Phencyclidine (PCP)
  2. Ketamine
  3. Dextromethorphan (DXM)

_____ can be ingested (oral or powder) or can be sprayed onto plant leaves and smoked.

A

PCP

  • Ketamine: baked into powder; insufflated
  • DXM: ingested (liquid/tablets)
173
Q

Dissociative drugs: A patient presents with distorted perception of his body, the environment and time. He lacks responsive awareness to pain the to the environment.

He demonstrates increased capacity to discern casual connections in things. You suspect

A

dissociative intoxication (desired effects)

*“higher” forms of consciouness

174
Q

Dissociative drugs: These drugs antagonize activity at the ____ receptor. They non-competitively block the effect of glutamate (excitatory) at this receptor.

The net result is dissociation or disconnection of the brain from its external and internal environments

A

NMDA receptor

175
Q

Dissociative drugs: A patient presents with hallucinations, agitation and combativeness, muscular rigidity, seizures and flashbacks. These best represent

A

undesired effects of intoxication

*stupor, coma, death

176
Q

Dissociative drugs: Treatment for drug-induced agitation and/or aggression should involve

A
  1. reassure and remove excess stimuli
  2. BZD’s
    - -if #1 not effective
177
Q

Dissociative drugs: True/False - Chronic (daily) use of PCP can lead to withdrawal and long term effects. These may include lack of energy, depression and permanent memory loss

A

True

178
Q

Inhalants: Prevalence of use of inhalants is greatest in individuals 12 to 17 years of age. Inhalants include:

  1. volatile alkyl nitrites,
  2. nitrous oxide
    3, solvents,
  3. fuels and anesthetics

The mechanism of action is unknown but it is assumed that they disrupt normal neuronal function. What are desired effects of inhalants?

A

Euphoria, well-being, relaxation, giggling/laughing

179
Q

Inhalants: A patient presents with slurred speech, inability to coordinate movements, behavioral inhibition (impaired judgment; aggressiveness).

You note she is experiencing hallucinations, delusions, and complains of headache. You suspect

A

Undesired effects of intoxication

180
Q

Inhalants: _____ can cause cardiac arrest via sensitizing the user to a sudden surge of epinephrine, causing a fatal cardiac arrhythmia.

Deaths have also been reported secondary to hypoxia and aspiration of vomit while unconscious

A

Sudden sniffing death syndrome

181
Q

Inhalants: Long term effects include

a. lack of coordination
b. limb spasms
c. memory impairment with diminished intelligence
d. hearing loss

A

all

  • bone marrow damage
  • irreversible damage to heart, liver, kidneys, lungs, brain
182
Q

Sedatives, Hypnotics, Anxiolytics: True/False - Alprazolam was responsible for nearly 125,000 ER visits in 2010, and 49 million alprazolam prescriptions were filled in 2011.

A

True

*alprazolam, clonazepam, lorazepam, diazepam…

183
Q

Sedative-Hypnotic…: These are divided into subcategories:

  1. BZDs
  2. Non-BZD hypnotics (z-hypnotics)
  3. Barbiturates
  4. Other (less commonly used in clinical practice (paraldehyde, chloral hydrate, ethchlorvynol, meprobamate))

______ include alprazolam, chlordiazepoxide, diazepam (“lams, pams”)

A

Benzos

184
Q

Sedative-Hypnotic…: Non-benzos include:

  1. Eszopiclone
  2. Zaleplon
  3. Zolpidem

List the commonly used barbiturates

A
  1. “barbital”
  2. “albital”
  3. “pental”

*butabarbital, methohexital, pentobarbital, phenobarbital, thiopental, primidone….

185
Q

Sedative-Hypnotic…: Which of the following is a clinical use of sedative hypnotics?

a. Procedural sedation
b. Anesthesia induction
c. OH and sedative withdrawal
d. Anxiety and panic
e. Acute agitation

A

all of the above

  • prevent seizures
  • insomnia
186
Q

Sedative-Hypnotic…: Which of the following can be a negative long term effect of sedative hypnotic use?

a. sleep disturbance
b. inc. anxiety
c. immune system suppression
d. depression

A

A-C

  • cognitive impairement w/ inc. risk dementia
  • withdrawal, addiction
187
Q

Sedative-Hypnotic…:

  1. BZD’s and Z-hypnotics indirectly bind at the ______ site of the GABA-A receptor causing the chloride to open more frequently
  2. Barbs bind directly to the ________ channel on the GABAA receptor causing the ion channel to remain open for the duration of the binding.
  3. Barbiturates also block _____ and kainate glutamate receptors
A
  1. benzodiazepine
  2. chloride ion channel
  3. AMPA
188
Q

Sedative-Hypnotic…: A patient presents with slurred speech, incoordination, unsteady gait and nystagmus. She exhibits impaired attention and memory.

You suspect sedative-hypnotic intoxication. What are behavioral effects that are most likely associated with her current state?

A

Finish

Addiction Med (1 decks)

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