Final: Addictive Disorders Flashcards
Clinical steps re addition tx
- assess, dx
- Referral (inpt v outpt)
- Detox protocols
- Rehab involvement (inpatient)
- Intensive Outpt (ie 3x/wk for 3 hr for 3m)
- Long term f/u (outpt)
describe the bio-psycho social model
Bio: genetic predisposition, cellular changes
Psycho: Cognitive Behavior
Social: environment, inner circle
Describe the systems of the brain
*Prefrontal cortex: judgment and willpower, EXECUTIVE CONTROL
Limbic system: basic emotions and learning
Amygdala: alerts brain to temptation
Substantia nigra: DA, (mvmt)
Locus Ceruleus
*Ventral tegmental area: REINFORCEMENT
– as a neutral disorder, the balance bw drive and control systems
describe the interactions bw the systems
Locus ceruleus to VTA (reinforcement) to nucleus accumbens to activate (+) prefrontal cortex (executive control)
Prefrontal cortex inhibits (-) Nucleus accumbens and VTA (reinforcement)
What underlies genetic predispositions for addiction
inherited abnormalities in DA system
DA transporter.. any compulsive disorder, there is some dysregulation of this receptor
cocaine blocks reuptake of DA
As a kid, exposure to chronic stress around age 4-6….
results in cortisol secretion that can prime brain pleasure pathway for addiction
Compulsive disorder cycle
anxiety/stress causes repetitive behaviors which serve as relief of anxiety/stress -> obsessions –> back to anxiety and stress
Levels of drug use include? where is America?
- Abstinence
- experimentation
- Social/recreational use**
- Habituation
- Abuse
- Addiction
most of Americans are social/rec use
3 step clinical process for recovery…
- Screen our job in Primary care: CAGE or AUDIT screen questions
- Dx: Psychiatry/addiction med via MAST, DSM etc
- Treat: inpt detox/rehab and/or outpatient rehab/follow up
how can we screen for addiction?
best to do so in context of other lifestyle questions in primary care setting
- CAGE
a) 2+ as cut off, quick and easy - AUDIT - 10 questions
a) best for ETOH abuse, problem drinking - MAST
a) best for alcohol dependence
– if positive screen, assess for referral & dx
What is the breakdown for DSMIV organization of addiction dx
know** for exam
CLASS: substance related disorders
GROUP: Substance USE disorders v Substance INDUCED disorders
DISORDER:
a) *under substance use: ABUSE vs DEPENDENCE
b) under substance induced: intoxication, withdrawal, delirium, dementia, amnesia, psychosis etc
DSM-IV criteria: use disorders - substance abuse
1 or more within 1 yr:
a) failure to fulfill work, school, or home obligations
b) physically hazardous situations
c) Legal problems
d) Recurrent social or interpersonal problems
[[failed obligations, physical health risk, legal trouble, relationships]]
obligations, health, law, relationship (one OHLR)
DSMIV criteria: use disorders: SUBSTANCE DEPENDENCE
*3D
THREE of more within 1 yr
- Tolerance
- Withdrawal
- Use over longer than intended
- Unsuccessful efforts to cut down
- Sig time to obtain/recover from substance
- Giving up social, work, recreation activities
- Use despite harm (physical/psych)
Mnemonic for dependence dx:
“totally will take U through absolute hell” - DEPEND on it
totally: tolerance Will: withdrawal take: time - use longer U: unsuccessful at cutting down through: time - sig to obtain/recover from absolute: activities sacrificed for drug Hell: harm to health (psych, physical)
Mnemonic for substance dependence dx (use disorders) - **remember, need 3 w/in a year
totally will take U through absolute hell - you can DEPEND on it
totally: tolerance Will: withdrawal take: time - use longer U: unsuccessful at cutting down through: time - sig to obtain/recover from absolute: activities sacrificed for drug Hell: harm to health (psych, physical)
Process for tx of substance abuse
how much is too much? tolerance + dependence + compulsion = NEED HELP
assessment: Primary care clinician in crisis center or ER
Tx: inpatient detox (hospital), inpatient rehab (14-28d+), outpatient rehab (IOP) or 1/2 way house, therapy (individual and group counseling-12step), inner circle support
principles of 12 step group therapy program
Admittance,
amends,
personal inventory,
service
Overall medical mgmt. of substance dependence/ abuse
COMBO of therapy and meds
- individual and group therapy
- 1:1 counseling ie motivational interviewing, CBT, behavioral modification
- -Groups: 12 step, specific support groups
- MEDS
- -detox (manage withdrawal sx)
- -anti craving (weak or partial agonist)
- -Long term maintenance (SSRIs, anxiolytics, naloxone, antabuse etc)
*be aware of Dual dx.. aka mentally ill, chemically addicted (that is, substance use disorder and co-morbid psych condition)
alcohol detox tx
INPT
Delirium tremens:
- Diazepam (valium)
- Lorazepam (Ativan)
- Phenobarbitol
Thiamine supplement
Long term: disulfiram (antabuse), Acamprosate (Campral), Naltrexone (revia), AA, individual counseling
Tx Opiate addiction
DETOX: inpt if mod/severe
- OD: naloxone (narcan)
- Clonidine for SNS overstimulation
- Substitution of longer acting opioid (methadone) - taper
Extended tx:
- Methadone or Buprenorphine (suboxone) maintenance program - taper off
- individual and group counseling (narcotics anonymous)
What is Buprenorphine (suboxone)? and how does it work?
First med developed to treat opiate addiction in physicians office
- binds same Mu receptors as Morphine w/o same effects
- weak agonist: reduces cravings (mild withdrawal sx)
- -Partial antagonist: prevents euphoria (low abuse potential)
- Long acting and decreased respiratory depression (high safety profile)
- requires DEA X license: addictionists
- careful monitoring provides best success
Conclusions/summaries re tx of substance abuse/dependence
be vigilant appreciate the pathophysiology know DSM Use favorite screening tools Have a plan (know where to refer) Be VERY familiar of meds you rx Be empathetic and supportive