First Aid: Substance Related Disorders Flashcards
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
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
3
Q
What diagnosis supercedes substance abuse?
A
substance dependence
4
Q
What is the lifetime prevalence of substance abuse or dependence in the US?
A
17%
5
Q
What is the gender difference in substance use and dependence?
A
men > women
6
Q
What are the most commonly used substances?
A
caffeine
alcohol
nicotine
7
Q
What mood symptoms are common among those with substance abuse or dependence?
A
depressive symptoms
8
Q
The development of a substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged.
A
withdrawal
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
10
Q
What does ETOH do in the brain?
A
- Activates GABA (inhibitory) and serotonin receptors
- Inhibits glutamate receptors
11
Q
What percentage of Americans are alcoholics?
A
7-10%
12
Q
List the first two steps in alcohol metabolism.
A
Alcohol dehydrogenase converts alcohol to acetaldehyde. Aldehyde dehydrogenase converts acetaldehyde to acetic acid.
13
Q
True or false: alcohol is the most commonly abused substance in the USA?
A
true
14
Q
What should be used to screen for alcohol abuse?
A
CAGE questionnaire
15
Q
What is considered a positive CAGE?
A
two or more “yes” answer
16
Q
At what BAL do most adults (>50%) show obvious signs of intoxication?
A
.15 mg%
17
Q
What is the legal limit for intoxication in most states?
A
.08 - .10 mg%
18
Q
At what BAL do you see decreased fine motor control
A
.02 - .05 mg%
19
Q
At what BAL do you see impaired judgement and coordination?
A
.05 - .1 mg%
20
Q
At what BAL do you see ataxic gait and poor balance?
A
.1 - .15 mg%
21
Q
At what BAL do you see lethargy and difficulty sitting upright?
A
.15 - .25 mg%
22
Q
At what BAL do you see coma in the NOVICE drinker?
A
.3 mg%
23
Q
At what BAL do you see respiratory depression?
A
.4 mg%
24
Q
What medical phenomenon can methanol, ethanol and ethylene glycol all cause?
A
increased anion gap metabolic acidosis
25
What medications should be given to patients who present with altered mental status?
thiamine
glucose
naloxone
26
What is the treatment for acute ETOH intoxication?
- Ensure adequate airway, breathing and circulation
- Monitor electrolytes and acid-base status
- Obtain finger-stick glucose level to exclude hypoglycemia
- Thiamine, naloxone and folate
27
Why do you give thiamine to an intoxicated person?
to prevent or treat Wernicke's encephalopathy
28
Why do you give naloxone to an intoxicated person?
to reverse the effects of any opioids that may have been ingested
29
When would you use gastric lavage or charcoal in the treatment of ETOH overdose?
only if it is mixed ETOH-drug overdose
30
What is the treatment for alcohol dependence?
- AA
- Disulfiram (Antabuse)
- Psychotherapy and SSRIs
- Naltrexone
31
What is disulfiram?
- Aversive therapy
- Inhibits aldehyde dehydrogenase
- Causes violent retching when the person drinks
32
How does naltrexone help with ETOH dependence?
Opioid antagonist but helps to reduce cravings for ETOH
33
Why does ETOH withdrawal occur?
- Alcoholics have a chronically depressed CNS
| - When the ETOH consumption ceases, the depressant effect is terminated and CNS excitation occurs
34
How long does it take ETOH withdrawal symptoms to occur after sober?
6-24 hours
35
How long do ETOH withdrawal symptoms last?
2-7 days
36
List some mild s/s of ETOH withdrawal.
Irritability
tremor
insomnia
37
List some moderate s/s of ETOH withdrawal.
diaphoresis
fever
disorientation
38
List some severe s/s of ETOH withdrawal.
Grand mal seizures
| Delirium Tremens
39
What are delirium tremens?
- The most serious form of ETOH withdrawal
- Delirium, visual or tactile hallucinations, gross tremor, autonomic instability, fluctuating levels of psychomotor activity
40
When do DTs usually start after cessation of drinking?
within 72 hours
41
What percentage of patients hospitalized for ETOH withdrawal develop DTs?
5%
42
What is the prognosis for DTs?
15-20% mortality rate if untreated
43
How do you treat DTs?
adequate doses of benzodiazepines
44
How do you treat ETOH withdrawal?
- Tapering doses of chlordiazepoxide or lorazepam (benzos)
- Thiamine, folic acid and multivitamin (to treat nutritional deficiencies)
- Magnesium sulfate (for post-withdrawal seizures)
45
What is the name of the syndrome caused by thiamine (B1) deficiency resulting from the poor diet of alcoholics?
Wernicke-Korsakoff syndrome
46
What are the symptoms of Wernicke's encephalopathy?
- Ataxia
- Confusion
- Ocular abnormalities (nystagmus, gaze palsies)
47
What does untreated Wernicke's encephalopathy progress into?
Korsakoff's syndrome (chronic and often irreversible)
48
What are the symptoms of Korsakoff's syndrome?
Impaired recent memory
Anterograde amnesia
+/- Confabulation (making up answers when memory has failed)
49
What is VERY important to know when treated AMS?
Give thiamine BEFORE glucose (thiamine is coenzyme in carb metabolism and without it, W-K syndrome may be precipitated)
50
What is the MOA of cocaine?
-Blocks dopamine reuptake from the synaptic cleft, causing a stimulant effect on the reward system of the brain
51
List some s/s of cocaine intoxication.
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
52
What types of hallucinations may be experienced by those on cocaine?
tactile
53
What cardiovascular complications are seen in those with cocaine intoxication?
MI or CVA due to vasoconstrictive effect
54
What is the differential diagnosis for cocaine intoxication?
- Amphetamine intoxication
- PCP intoxication
- Sedative withdrawal
55
How long with cocaine show up in a urine drug screen?
```
3 days
(longer in heavy users)
```
56
How do you treat cocaine intoxication?
- Benzos (mild to moderate agitation)
- Haloperidol (severe agitation or psychosis)
- Symptomatic support
57
How do you treat cocaine dependence?
- Psychotherapy
- TCAs
- DA agonists (amantadine, bromocriptine)
58
What happens when you abruptly abstain from cocaine?
dysphoric "crash"
59
What are symptoms of cocaine withdrawal?
- Malaise
- Fatigue
- Depression
- Hunger
- Constricted pupils
- Vivid dreams
- Psychomotor agitation or retardation
60
How do you treat cocaine withdrawal?
supportive (sleep off)
61
List the classic amphetamines.
- Dextroammphetamine (Dexedrine)
- Methylphenidate (Ritalin)
- Methamphetamine (Ice, speed, "crystal meth", "crack")
62
List the substituted (designer) amphetamines.
- MDMA (ectasy)
| - MDEA (eve)
63
What is the MOA of classic amphetamines?
-Release DA from nerve endings, causing a stimulant effect
64
What are classic amphetamines used to treat?
- Narcolepsy
- ADHD
- Depressive disorders
65
What is the MOA of designer amphetamines?
Release DA and serotonin from nerve endings, causing stimulant and hallucinogenic effect
66
What does someone with amphetamine intoxication look like?
similar to someone on cocaine
67
What is the differential for amphetamine intoxication?
- Cocaine intoxication
| - PCP intoxication
68
What might chronic use of amphetamines in high doses cause?
Psychotic state that is similar to schizophrenia
69
How long can amphetamines be detected in the urine?
- Positive for 1-2 days
| - Negative screen does not rule out amphetamines (usually most assays are not of adequate sensitivity)
70
How do you treat amphetamine intoxication?
Similar to cocaine
71
What is PCP also called?
angel dust
72
What is the MOA of PCP?
Antagonizes NMDA (glutamate) receptors and activates dopaminergic neurons
73
What drug developed for anesthesia is similar to PCP?
ketamine
74
What is pathognomonic for PCP intoxication?
rotatory nystagmus
75
What are some signs of PCP intoxication?
- Recklessness
- Impulsiveness
- Impaired judgement
- Assaultiveness (VIOLENCE)
- Ataxia
- HTN
- Tachycardia
- Muscle rigidity
- High tolerance to pain
76
What may a PCP overdose cause?
seizures or coma
77
How do you treat PCP intoxication?
- 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
What is the differential diagnosis for PCP intoxication?
- Acute psychotic states
| - Schizophrenia
79
How long will a urine drug screen remain positive for PCP?
>1 week
80
What enzymes are often elevated in patients who are on PCP?
CPK
| AST
81
Do patients on PCP have withdrawal symptoms?
no, but "flashbacks" may occur
82
Why are sedative-hypnotics commonly abused in the USA?
they are readily available
83
What is the MOA of benzos?
Potentiate effects of GABA by increasing FREQUENCY of chloride channel opening
84
What is the MOA of barbiturates?
Potentiate effects of GABA by increasing DURATION of chloride channel opening. Act as direct GABA agonists at high doses.
85
What are benzos used for?
anxiety disorders
86
What are barbiturates used for?
epilepsy
| anesthetics
87
Which have a higher margin of safety, benzos or barbiturates?
benzos
88
How do benzos and barbiturates act in combination?
synergistic (may cause respiratory depression)
89
What are s/s of sedative intoxication?
- Drowsiness
- Slurred speech
- Incoordination
- Ataxia
- Mood lability
- Impaired judgement
- Nystagmus
- Respiratory depression
- Coma
- Death (esp barbiturates)
90
Which dose-specific CNS depressant is commonly used as a date rape drug?
GHB (gamma-hydroxybutyrate)
91
What are s/s of GHB intoxication?
- Memory loss
- Respiratory distress
- Coma
92
What is the differential diagnosis for sedative intoxication?
- Alcohol intoxication
| - Generalized cerebral dysfunction (ex. delirium)
93
How long do sedatives remain in serum drug screens?
Positive for 1 week
94
What is the general treatment for sedative intoxication?
- Maintain ABCs
- Activated charcoal to prevent GI absorption
- Supportive care
95
What do you do if patient is intoxicated specifically with barbiturates?
Alkalinize urine with sodium bicarb to promote renal excretion
96
What do you give to a patient with benzo overdose?
Flumazenil (short acting benzo antagonist)
97
What is a potential side effect of flumazenil treatment?
Can precipitate seizures
98
Are short acting or long acting sedatives more likely to cause physicological dependence and withdrawal?
short acting (but long acting agents can as well)
99
What are the s/s of sedative withdrawal?
- Symptoms of autonomic hyperactivity (tachycardia, sweating, etc.)
- Insomnia
- Anxiety
- Tremor
- N/V
- Delirium
- Hallucinations
- Seizures
100
What is unique about sedative withdrawal?
it can be life-threatening (compared to stimulants and hallucinogens)
101
What is the treatment for sedative-hypnotic withdrawal?
- Long acting benzo (chlorodiazepoxide or diazepam) and taper dose
- Tegretol or valproate for seizure control
102
List examples of opiates.
```
Heroin
Codeine
Dextromethorphan (cough syrup)
Morphine
Methadone
Meperidine
```
103
What is the MOA of opiates?
- Endogenous (endorphins and enkephalins) are involved in analgesia, sedation and dependence
- Effects on DA system (addictive and rewarding)
104
What is the different between opiates and opioids?
Opiates are naturally occurring chemicals that bind at opiate receptors. Opioids are synthetic chemicals that bind to the same receptors.
105
List s/s of opiate intoxication.
- Drowsiness
- N/V
- Constipation
- Slurred speech
- Constricted pupils
- Seizures
- Respiratory depression (may progress to coma or death in overdose)
106
Which opiate, if taken with an MAOI, may lead to serotonin syndrome?
meperidine
107
What are s/s of serotonin syndrome?
- Hyperthermia
- Confusion
- Hyper or hypotension
- Muscular rigidity
108
What is the differential diagnosis for opiate intoxicity?
- Sedative hypnotic intoxication
| - Severe ETOH intoxication
109
What is the classic triad of opioid overdose?
- Respiratory depression
- AMS
- Miosis
110
How do you diagnose opiate overdose?
rapid recovery of consciousness following IV naloxone (opiate antagonist)
111
How long do opiates stay in urine and blood?
12-36 hours
| can be positive in urine after a poppyseed muffin
112
What is the risk with treating opiate OD with naloxone or naltrexone?
improve respiratory depression but may cause severe withdrawal in opiate-dependent patient
113
How do you treat opiate dependence?
- Oral methadone once daily, tapered over months to years
| - Psychotherapy
114
What is the only exception to opioids producing miosis?
Demerol (DILATES)
115
What are some features of opiate withdrawal?
- Dysphoria
- Insomnia
- Lacrimation
- RHINORRHEA
- YAWNING
- WEakness
- Sweating
- PILOERECTION
- N/V
- Fever
- Dilated pupils
- Muscle ache
116
How do you treat opiate withdrawal?
- Moderate s/s: clonidine and/or buprenorphine
| - Severe s/s: detox with methadone taper over 7 days
117
List some hallucinogens.
- Psilocybin (mushrooms)
- Mescaline
- Lysergic acid diethylamide (LSD)
118
What is the MOA of LSD?
acts on serotonergic system
119
True or false: hallucinogens show no tolerance
false: tolerance develops quickly and reduces rapidly after cessation
120
True or false: hallucinogens do NOT cause physcial dependence or withdrawal
TRUE
121
What are s/s of hallucinogen intoxication?
- Perceptual changes
- Pupillary dilation
- Tachycardia
- Tremors
- Incoordination
- Sweating
- Palpitations
122
What are the s/s of methyl pemoline (92C-B, U4EUH, Nexus) intoxication?
- Psychedelic distortion of the senses
| - Feelings of harmony, anxiety, paranoid, and panic
123
How do you treat hallucinogen intoxication?
guidance and reassurance (talking down patient)
124
Why might someone get a flashback of hallucinogens later in life?
reabsorption from lipid stores
125
What drug can produce tachycardia, tachypnea, and hallucinations at high doses?
Ketamine (special K)
126
What is the main active component of cannabis?
THC (tetrahyrocannabinol)
127
What is the role of cannabinoid receptors in the brain?
inhibit adenylate cyclase
128
What can increase the effect of cannabis on the brain?
ETOH concurrent use
129
What is marijuana used to treat?
- Nausea in cancer patients
| - Increase appetite in AIDS patients
130
What are s/s of marijuana intoxication?
- Euphoria
- Impaired coordination
- Mild tachycardia
- Conjunctival injection
- Dry mouth
- Increased appetite
131
What is the effect of dipping joints in embalming fluid?
cognitive dulling
132
How long is marijuana in the urine of a heavy smokr?
- Positive for up to 4 weeks
| - Released from adipose stores
133
What are s/s of marijuana withdrawal?
NO WITHDRAWAL SYNDROME
- Mild irritability
- Insomnia
- Nausea
- Decreased appetite
134
List some things used as inhalants.
- Solvents
- Glue
- Paint thinners
- Isobutyl nitrates (rush, bolt, locker room)
135
Who typically uses inhalants?
adolescent male
136
What is the chemical effect of inhalants?
generally act at CNS depressants
137
What are s/s of inhalant intoxication?
- Impaired judgment
- Belligerence
- Impulsivity
- Perceptual disturbances
- Lethargy
- Dizziness
- Nystagmus
- Tremor
- Muscle weakness/ hyporeflexia
- Ataxia
- Slurred speech
- Euphoria
- Stopor
- Coma
138
True or false: inhalants are not fatal.
FALSE: OD may be fatal 2/2 respiratory depression or arrhythmia
139
How do you treat inhalant intoxication?
- Monitor ABCs
- Symptomatic treatment
- Psychotherapy and counseling
140
How long are inhalants detectable in serum drugs screens?
4-10 hours
141
What are some symptoms of inhalant withdrawal?
NO SYNDROME
- Irritability
- N/V
- Tachycardia
- Occasionally hallucinations
142
What is the most commonly used psychoactive substance in the USA?
caffeine
143
What is the MOA of caffeine?
adenosine antagonist (increasing cAMP and stimulating DA system)
144
How many mg of caffeine are in 1 cup of coffee?
100-150 mg
145
How many mg of caffeine are in 1 cup of tea?
40-60 mg
146
How many mg of caffeine can lead to intoxication?
>250 mg
147
What are s/s of caffeine intoxication?
- Anxiety
- Insomnia
- Twitching
- Rambing speech
- Flushed face
- Diuresis
- GI disturbance
- Restlessness
148
How much caffeine must you intake to cause tinnitus, severe agitation and cardiac arrhythmias?
1 g
149
How much caffeine must you intake to cause death secondary to seizures and respiratory failure?
>10 g
150
What are some symptoms of caffeine withdrawal?
```
HA
N/V
Drowsiness
Anxiety
Depression
```
151
How long does it take caffeine withdrawal symptoms to resolve?
within 1 week
152
What is the treatment for caffeine withdrawal?
- Taper consumption of caffeine-containing products
- Use analgesics to treat HA
- RARE short course of benzos to control anxiety
153
Where does nicotine act in the body?
nicotinic receptors in autonomic ganglia of sympathetic and parasympathetic nervous systems
154
Why is nicotine addictive?
effects DA system
155
What are the s/s of nicotine use?
- CNS stimulant (restlessness, insomnia, anxiety, increased GI motility)
- Improved attention
- Improved mood
- Decreased tension
156
What are some s/s of nicotine withdrawal?
- Intense craving
- Dysphoria
- Anxiety
- Increased appetite
- Irritability
- Insomnia
157
What are treatment options for nicotine withdrawal?
- Behavioral counseling
- NRT (gum, patch)
- Zyban (antidepressant that reduces cravings)
- Clonidine
158
What is cigarette smoking during pregnancy associated with?
low birth weight
| persistent pulmonary HTN of the newborn
