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PSYCH ROTATION > First Aid: Substance Related Disorders > Flashcards

First Aid: Substance Related Disorders Flashcards

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1
Q

What is the DSM-IV criteria for substance abuse?

A

Pattern of substance use leading to impairment or distress for at least 1 year with 1 or more of the following manifestations:

  • Failure to fulfill obligations at work, school or home
  • Use in dangerous situations (ex. driving a car)
  • Recurrent substance-related legal problems
  • Continued use despite social or interpersonal problems due to the substance use
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2
Q

What is the DSM-IV criteria for substance dependence?

A

Dependence is substance use leading to impairment or distress manifested by at least 3 of the following within a 12-month period:

  • Tolerance
  • Withdrawal
  • Using substance more than originally intended
  • Persistent desire or unsuccessful efforts to cut down on use
  • Significant time spent in getting, using or recovering from substance
  • Decreased social, occupational, or recreational activities because of substance use
  • Continued use despite subsequent physical or psychological problem
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3
Q

What diagnosis supercedes substance abuse?

A

substance dependence

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4
Q

What is the lifetime prevalence of substance abuse or dependence in the US?

A

17%

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5
Q

What is the gender difference in substance use and dependence?

A

men > women

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6
Q

What are the most commonly used substances?

A

caffeine
alcohol
nicotine

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7
Q

What mood symptoms are common among those with substance abuse or dependence?

A

depressive symptoms

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8
Q

The development of a substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged.

A

withdrawal

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9
Q

The need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amount of the substance.

A

tolerance

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10
Q

What does ETOH do in the brain?

A
  • Activates GABA (inhibitory) and serotonin receptors

- Inhibits glutamate receptors

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11
Q

What percentage of Americans are alcoholics?

A

7-10%

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12
Q

List the first two steps in alcohol metabolism.

A

Alcohol dehydrogenase converts alcohol to acetaldehyde. Aldehyde dehydrogenase converts acetaldehyde to acetic acid.

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13
Q

True or false: alcohol is the most commonly abused substance in the USA?

A

true

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14
Q

What should be used to screen for alcohol abuse?

A

CAGE questionnaire

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15
Q

What is considered a positive CAGE?

A

two or more “yes” answer

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16
Q

At what BAL do most adults (>50%) show obvious signs of intoxication?

A

.15 mg%

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17
Q

What is the legal limit for intoxication in most states?

A

.08 - .10 mg%

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18
Q

At what BAL do you see decreased fine motor control

A

.02 - .05 mg%

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19
Q

At what BAL do you see impaired judgement and coordination?

A

.05 - .1 mg%

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20
Q

At what BAL do you see ataxic gait and poor balance?

A

.1 - .15 mg%

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21
Q

At what BAL do you see lethargy and difficulty sitting upright?

A

.15 - .25 mg%

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22
Q

At what BAL do you see coma in the NOVICE drinker?

A

.3 mg%

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23
Q

At what BAL do you see respiratory depression?

A

.4 mg%

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24
Q

What medical phenomenon can methanol, ethanol and ethylene glycol all cause?

A

increased anion gap metabolic acidosis

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25
Q

What medications should be given to patients who present with altered mental status?

A

thiamine
glucose
naloxone

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26
Q

What is the treatment for acute ETOH intoxication?

A
  • Ensure adequate airway, breathing and circulation
  • Monitor electrolytes and acid-base status
  • Obtain finger-stick glucose level to exclude hypoglycemia
  • Thiamine, naloxone and folate
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27
Q

Why do you give thiamine to an intoxicated person?

A

to prevent or treat Wernicke’s encephalopathy

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28
Q

Why do you give naloxone to an intoxicated person?

A

to reverse the effects of any opioids that may have been ingested

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29
Q

When would you use gastric lavage or charcoal in the treatment of ETOH overdose?

A

only if it is mixed ETOH-drug overdose

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30
Q

What is the treatment for alcohol dependence?

A
  • AA
  • Disulfiram (Antabuse)
  • Psychotherapy and SSRIs
  • Naltrexone
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31
Q

What is disulfiram?

A
  • Aversive therapy
  • Inhibits aldehyde dehydrogenase
  • Causes violent retching when the person drinks
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32
Q

How does naltrexone help with ETOH dependence?

A

Opioid antagonist but helps to reduce cravings for ETOH

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33
Q

Why does ETOH withdrawal occur?

A
  • Alcoholics have a chronically depressed CNS

- When the ETOH consumption ceases, the depressant effect is terminated and CNS excitation occurs

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34
Q

How long does it take ETOH withdrawal symptoms to occur after sober?

A

6-24 hours

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35
Q

How long do ETOH withdrawal symptoms last?

A

2-7 days

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36
Q

List some mild s/s of ETOH withdrawal.

A

Irritability
tremor
insomnia

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37
Q

List some moderate s/s of ETOH withdrawal.

A

diaphoresis
fever
disorientation

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38
Q

List some severe s/s of ETOH withdrawal.

A

Grand mal seizures

Delirium Tremens

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39
Q

What are delirium tremens?

A
  • The most serious form of ETOH withdrawal
  • Delirium, visual or tactile hallucinations, gross tremor, autonomic instability, fluctuating levels of psychomotor activity
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40
Q

When do DTs usually start after cessation of drinking?

A

within 72 hours

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41
Q

What percentage of patients hospitalized for ETOH withdrawal develop DTs?

A

5%

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42
Q

What is the prognosis for DTs?

A

15-20% mortality rate if untreated

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43
Q

How do you treat DTs?

A

adequate doses of benzodiazepines

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44
Q

How do you treat ETOH withdrawal?

A
  • Tapering doses of chlordiazepoxide or lorazepam (benzos)
  • Thiamine, folic acid and multivitamin (to treat nutritional deficiencies)
  • Magnesium sulfate (for post-withdrawal seizures)
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45
Q

What is the name of the syndrome caused by thiamine (B1) deficiency resulting from the poor diet of alcoholics?

A

Wernicke-Korsakoff syndrome

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46
Q

What are the symptoms of Wernicke’s encephalopathy?

A
  • Ataxia
  • Confusion
  • Ocular abnormalities (nystagmus, gaze palsies)
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47
Q

What does untreated Wernicke’s encephalopathy progress into?

A

Korsakoff’s syndrome (chronic and often irreversible)

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48
Q

What are the symptoms of Korsakoff’s syndrome?

A

Impaired recent memory
Anterograde amnesia
+/- Confabulation (making up answers when memory has failed)

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49
Q

What is VERY important to know when treated AMS?

A

Give thiamine BEFORE glucose (thiamine is coenzyme in carb metabolism and without it, W-K syndrome may be precipitated)

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50
Q

What is the MOA of cocaine?

A

-Blocks dopamine reuptake from the synaptic cleft, causing a stimulant effect on the reward system of the brain

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51
Q

List some s/s of cocaine intoxication.

A

Mimics “fight or flight” because it is a sympathomimetic:

  • Euphoria
  • Increased or decreased BP
  • Tachy or bradycardia
  • Nausea
  • DILATED pupils
  • Weight loss
  • Psychomotor agitation or depression
  • Chills
  • Sweating
  • Arrhythmias
  • Seizures
  • Resp. Depression
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52
Q

What types of hallucinations may be experienced by those on cocaine?

A

tactile

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53
Q

What cardiovascular complications are seen in those with cocaine intoxication?

A

MI or CVA due to vasoconstrictive effect

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54
Q

What is the differential diagnosis for cocaine intoxication?

A
  • Amphetamine intoxication
  • PCP intoxication
  • Sedative withdrawal
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55
Q

How long with cocaine show up in a urine drug screen?

A 
3 days
(longer in heavy users)
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56
Q

How do you treat cocaine intoxication?

A
  • Benzos (mild to moderate agitation)
  • Haloperidol (severe agitation or psychosis)
  • Symptomatic support
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57
Q

How do you treat cocaine dependence?

A
  • Psychotherapy
  • TCAs
  • DA agonists (amantadine, bromocriptine)
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58
Q

What happens when you abruptly abstain from cocaine?

A

dysphoric “crash”

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59
Q

What are symptoms of cocaine withdrawal?

A
  • Malaise
  • Fatigue
  • Depression
  • Hunger
  • Constricted pupils
  • Vivid dreams
  • Psychomotor agitation or retardation
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60
Q

How do you treat cocaine withdrawal?

A

supportive (sleep off)

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61
Q

List the classic amphetamines.

A
  • Dextroammphetamine (Dexedrine)
  • Methylphenidate (Ritalin)
  • Methamphetamine (Ice, speed, “crystal meth”, “crack”)
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62
Q

List the substituted (designer) amphetamines.

A
  • MDMA (ectasy)

- MDEA (eve)

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63
Q

What is the MOA of classic amphetamines?

A

-Release DA from nerve endings, causing a stimulant effect

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64
Q

What are classic amphetamines used to treat?

A
  • Narcolepsy
  • ADHD
  • Depressive disorders
65
Q

What is the MOA of designer amphetamines?

A

Release DA and serotonin from nerve endings, causing stimulant and hallucinogenic effect

66
Q

What does someone with amphetamine intoxication look like?

A

similar to someone on cocaine

67
Q

What is the differential for amphetamine intoxication?

A
  • Cocaine intoxication

- PCP intoxication

68
Q

What might chronic use of amphetamines in high doses cause?

A

Psychotic state that is similar to schizophrenia

69
Q

How long can amphetamines be detected in the urine?

A
  • Positive for 1-2 days

- Negative screen does not rule out amphetamines (usually most assays are not of adequate sensitivity)

70
Q

How do you treat amphetamine intoxication?

A

Similar to cocaine

71
Q

What is PCP also called?

A

angel dust

72
Q

What is the MOA of PCP?

A

Antagonizes NMDA (glutamate) receptors and activates dopaminergic neurons

73
Q

What drug developed for anesthesia is similar to PCP?

A

ketamine

74
Q

What is pathognomonic for PCP intoxication?

A

rotatory nystagmus

75
Q

What are some signs of PCP intoxication?

A
  • Recklessness
  • Impulsiveness
  • Impaired judgement
  • Assaultiveness (VIOLENCE)
  • Ataxia
  • HTN
  • Tachycardia
  • Muscle rigidity
  • High tolerance to pain
76
Q

What may a PCP overdose cause?

A

seizures or coma

77
Q

How do you treat PCP intoxication?

A
  • Monitor BP, temp and electrolytes
  • Acidify urine with ammonium chloride and ascorbic acid
  • Benzos of dopamine antagonists to control agitation and anxiety
  • Diazepam for muscle spasms and seizures
  • Haloperidol to control severe agitation or psychotic symptoms
78
Q

What is the differential diagnosis for PCP intoxication?

A
  • Acute psychotic states

- Schizophrenia

79
Q

How long will a urine drug screen remain positive for PCP?

A

> 1 week

80
Q

What enzymes are often elevated in patients who are on PCP?

A

CPK

AST

81
Q

Do patients on PCP have withdrawal symptoms?

A

no, but “flashbacks” may occur

82
Q

Why are sedative-hypnotics commonly abused in the USA?

A

they are readily available

83
Q

What is the MOA of benzos?

A

Potentiate effects of GABA by increasing FREQUENCY of chloride channel opening

84
Q

What is the MOA of barbiturates?

A

Potentiate effects of GABA by increasing DURATION of chloride channel opening. Act as direct GABA agonists at high doses.

85
Q

What are benzos used for?

A

anxiety disorders

86
Q

What are barbiturates used for?

A

epilepsy

anesthetics

87
Q

Which have a higher margin of safety, benzos or barbiturates?

A

benzos

88
Q

How do benzos and barbiturates act in combination?

A

synergistic (may cause respiratory depression)

89
Q

What are s/s of sedative intoxication?

A
  • Drowsiness
  • Slurred speech
  • Incoordination
  • Ataxia
  • Mood lability
  • Impaired judgement
  • Nystagmus
  • Respiratory depression
  • Coma
  • Death (esp barbiturates)
90
Q

Which dose-specific CNS depressant is commonly used as a date rape drug?

A

GHB (gamma-hydroxybutyrate)

91
Q

What are s/s of GHB intoxication?

A
  • Memory loss
  • Respiratory distress
  • Coma
92
Q

What is the differential diagnosis for sedative intoxication?

A
  • Alcohol intoxication

- Generalized cerebral dysfunction (ex. delirium)

93
Q

How long do sedatives remain in serum drug screens?

A

Positive for 1 week

94
Q

What is the general treatment for sedative intoxication?

A
  • Maintain ABCs
  • Activated charcoal to prevent GI absorption
  • Supportive care
95
Q

What do you do if patient is intoxicated specifically with barbiturates?

A

Alkalinize urine with sodium bicarb to promote renal excretion

96
Q

What do you give to a patient with benzo overdose?

A

Flumazenil (short acting benzo antagonist)

97
Q

What is a potential side effect of flumazenil treatment?

A

Can precipitate seizures

98
Q

Are short acting or long acting sedatives more likely to cause physicological dependence and withdrawal?

A

short acting (but long acting agents can as well)

99
Q

What are the s/s of sedative withdrawal?

A
  • Symptoms of autonomic hyperactivity (tachycardia, sweating, etc.)
  • Insomnia
  • Anxiety
  • Tremor
  • N/V
  • Delirium
  • Hallucinations
  • Seizures
100
Q

What is unique about sedative withdrawal?

A

it can be life-threatening (compared to stimulants and hallucinogens)

101
Q

What is the treatment for sedative-hypnotic withdrawal?

A
  • Long acting benzo (chlorodiazepoxide or diazepam) and taper dose
  • Tegretol or valproate for seizure control
102
Q

List examples of opiates.

A 
Heroin
Codeine
Dextromethorphan (cough syrup)
Morphine
Methadone
Meperidine
103
Q

What is the MOA of opiates?

A
  • Endogenous (endorphins and enkephalins) are involved in analgesia, sedation and dependence
  • Effects on DA system (addictive and rewarding)
104
Q

What is the different between opiates and opioids?

A

Opiates are naturally occurring chemicals that bind at opiate receptors. Opioids are synthetic chemicals that bind to the same receptors.

105
Q

List s/s of opiate intoxication.

A
  • Drowsiness
  • N/V
  • Constipation
  • Slurred speech
  • Constricted pupils
  • Seizures
  • Respiratory depression (may progress to coma or death in overdose)
106
Q

Which opiate, if taken with an MAOI, may lead to serotonin syndrome?

A

meperidine

107
Q

What are s/s of serotonin syndrome?

A
  • Hyperthermia
  • Confusion
  • Hyper or hypotension
  • Muscular rigidity
108
Q

What is the differential diagnosis for opiate intoxicity?

A
  • Sedative hypnotic intoxication

- Severe ETOH intoxication

109
Q

What is the classic triad of opioid overdose?

A
  • Respiratory depression
  • AMS
  • Miosis
110
Q

How do you diagnose opiate overdose?

A

rapid recovery of consciousness following IV naloxone (opiate antagonist)

111
Q

How long do opiates stay in urine and blood?

A

12-36 hours

can be positive in urine after a poppyseed muffin

112
Q

What is the risk with treating opiate OD with naloxone or naltrexone?

A

improve respiratory depression but may cause severe withdrawal in opiate-dependent patient

113
Q

How do you treat opiate dependence?

A
  • Oral methadone once daily, tapered over months to years

- Psychotherapy

114
Q

What is the only exception to opioids producing miosis?

A

Demerol (DILATES)

115
Q

What are some features of opiate withdrawal?

A
  • Dysphoria
  • Insomnia
  • Lacrimation
  • RHINORRHEA
  • YAWNING
  • WEakness
  • Sweating
  • PILOERECTION
  • N/V
  • Fever
  • Dilated pupils
  • Muscle ache
116
Q

How do you treat opiate withdrawal?

A
  • Moderate s/s: clonidine and/or buprenorphine

- Severe s/s: detox with methadone taper over 7 days

117
Q

List some hallucinogens.

A
  • Psilocybin (mushrooms)
  • Mescaline
  • Lysergic acid diethylamide (LSD)
118
Q

What is the MOA of LSD?

A

acts on serotonergic system

119
Q

True or false: hallucinogens show no tolerance

A

false: tolerance develops quickly and reduces rapidly after cessation

120
Q

True or false: hallucinogens do NOT cause physcial dependence or withdrawal

A

TRUE

121
Q

What are s/s of hallucinogen intoxication?

A
  • Perceptual changes
  • Pupillary dilation
  • Tachycardia
  • Tremors
  • Incoordination
  • Sweating
  • Palpitations
122
Q

What are the s/s of methyl pemoline (92C-B, U4EUH, Nexus) intoxication?

A
  • Psychedelic distortion of the senses

- Feelings of harmony, anxiety, paranoid, and panic

123
Q

How do you treat hallucinogen intoxication?

A

guidance and reassurance (talking down patient)

124
Q

Why might someone get a flashback of hallucinogens later in life?

A

reabsorption from lipid stores

125
Q

What drug can produce tachycardia, tachypnea, and hallucinations at high doses?

A

Ketamine (special K)

126
Q

What is the main active component of cannabis?

A

THC (tetrahyrocannabinol)

127
Q

What is the role of cannabinoid receptors in the brain?

A

inhibit adenylate cyclase

128
Q

What can increase the effect of cannabis on the brain?

A

ETOH concurrent use

129
Q

What is marijuana used to treat?

A
  • Nausea in cancer patients

- Increase appetite in AIDS patients

130
Q

What are s/s of marijuana intoxication?

A
  • Euphoria
  • Impaired coordination
  • Mild tachycardia
  • Conjunctival injection
  • Dry mouth
  • Increased appetite
131
Q

What is the effect of dipping joints in embalming fluid?

A

cognitive dulling

132
Q

How long is marijuana in the urine of a heavy smokr?

A
  • Positive for up to 4 weeks

- Released from adipose stores

133
Q

What are s/s of marijuana withdrawal?

A

NO WITHDRAWAL SYNDROME

  • Mild irritability
  • Insomnia
  • Nausea
  • Decreased appetite
134
Q

List some things used as inhalants.

A
  • Solvents
  • Glue
  • Paint thinners
  • Isobutyl nitrates (rush, bolt, locker room)
135
Q

Who typically uses inhalants?

A

adolescent male

136
Q

What is the chemical effect of inhalants?

A

generally act at CNS depressants

137
Q

What are s/s of inhalant intoxication?

A
  • Impaired judgment
  • Belligerence
  • Impulsivity
  • Perceptual disturbances
  • Lethargy
  • Dizziness
  • Nystagmus
  • Tremor
  • Muscle weakness/ hyporeflexia
  • Ataxia
  • Slurred speech
  • Euphoria
  • Stopor
  • Coma
138
Q

True or false: inhalants are not fatal.

A

FALSE: OD may be fatal 2/2 respiratory depression or arrhythmia

139
Q

How do you treat inhalant intoxication?

A
  • Monitor ABCs
  • Symptomatic treatment
  • Psychotherapy and counseling
140
Q

How long are inhalants detectable in serum drugs screens?

A

4-10 hours

141
Q

What are some symptoms of inhalant withdrawal?

A

NO SYNDROME

  • Irritability
  • N/V
  • Tachycardia
  • Occasionally hallucinations
142
Q

What is the most commonly used psychoactive substance in the USA?

A

caffeine

143
Q

What is the MOA of caffeine?

A

adenosine antagonist (increasing cAMP and stimulating DA system)

144
Q

How many mg of caffeine are in 1 cup of coffee?

A

100-150 mg

145
Q

How many mg of caffeine are in 1 cup of tea?

A

40-60 mg

146
Q

How many mg of caffeine can lead to intoxication?

A

> 250 mg

147
Q

What are s/s of caffeine intoxication?

A
  • Anxiety
  • Insomnia
  • Twitching
  • Rambing speech
  • Flushed face
  • Diuresis
  • GI disturbance
  • Restlessness
148
Q

How much caffeine must you intake to cause tinnitus, severe agitation and cardiac arrhythmias?

A

1 g

149
Q

How much caffeine must you intake to cause death secondary to seizures and respiratory failure?

A

> 10 g

150
Q

What are some symptoms of caffeine withdrawal?

A 
HA
N/V
Drowsiness
Anxiety
Depression
151
Q

How long does it take caffeine withdrawal symptoms to resolve?

A

within 1 week

152
Q

What is the treatment for caffeine withdrawal?

A
  • Taper consumption of caffeine-containing products
  • Use analgesics to treat HA
  • RARE short course of benzos to control anxiety
153
Q

Where does nicotine act in the body?

A

nicotinic receptors in autonomic ganglia of sympathetic and parasympathetic nervous systems

154
Q

Why is nicotine addictive?

A

effects DA system

155
Q

What are the s/s of nicotine use?

A
  • CNS stimulant (restlessness, insomnia, anxiety, increased GI motility)
  • Improved attention
  • Improved mood
  • Decreased tension
156
Q

What are some s/s of nicotine withdrawal?

A
  • Intense craving
  • Dysphoria
  • Anxiety
  • Increased appetite
  • Irritability
  • Insomnia
157
Q

What are treatment options for nicotine withdrawal?

A
  • Behavioral counseling
  • NRT (gum, patch)
  • Zyban (antidepressant that reduces cravings)
  • Clonidine
158
Q

What is cigarette smoking during pregnancy associated with?

A

low birth weight

persistent pulmonary HTN of the newborn

PSYCH ROTATION (18 decks)

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