Foundations Flashcards
What is ASAM Level 0.5?
Early Intervention
What is ASAM Level 1?
Outpatient Treatment
What is ASAM Level 2?
IOP (9 hours) and Partial Hospitalization (20 hours)
What is ASAM Level 3?
Inpatient / Residential
What is ASAM Level 4?
Medically Managed Intensive Inpatient
What is at risk drinking?
Drinking more than recommended limits without meeting SUD criteria
How common AUD?
30% population
Percentage of people who need SUD Tx and actually receive?
10%
10 people with AUD with chronic severe form?
10%
Percentage of population that are abstainers?
25
Percentage of population with social use?
50
Percentage of population hazardous use?
15
Percentage of population AUD?
10
What is primary prevention?
Preventing initiation of something
What is secondary prevention?
Achieve early detection, diagnosis and treatment of affected individuals
What is tertiary prevention?
Diminish the incidence of complication of a disease
What is universal prevention?
Targets the whole population
What is selective prevention?
Targeting those at slightly higher risk
What is indicated prevention?
Targeting those who are already at high risk
What should you do when giving narcan?
Call 911
Enzyme induction by tobacco smoke?
CYP1A2
Enzymes induced by nicotine
CYP2D6
CYP2B6
CYP2E1
Drugs impacted by CYP2D6
TCA’s
SSRI/SNRIs
BB
Tramadol
Methadone
Drugs impacted by CYP2B6?
Bupropion
Cyclophosphamide
Efavirenz
IFosfamide
Methadone
Drugs impacted by CYP2e1
Inhalational anesthetics
Acetaminophen
Ethanol
Theophylline
What happens when you induce a CYP?
Decreases level of drug, if stabalized before starting to smoke, you may not need higher dose. If already smoking your initial dose would be higher than norm, but levels will elevated if you stop
Drugs impacted by CYP1A2
1 and SGAs
Clozapine
Fluvoxamine
Theophylline
Caffeine
R-warfarin
Symptoms methyl etoh intox?
home distilled/grapes, grains:
toxic optic neuritis - blindness
severe metabolic acidosis
ATN
renal failure
What is Isopropyl alcohol and risk?
Cleaning solvent:
- usually mild acidosis
- rarely severe
- risk kidney failure
What is Ethylene glycol and risk?
(antifreeze):
increased excretion Ca2+ oxalate crystals
severe metabolic acidosis; ATN,
renal failure
What does the following suggest:
- level of intoxication incompatible with BAC
- high anion gap (>15)
- lactic acid not
sufficient to explain anion gap
Intoxication with another etoh subtype
Rx for intoxication in non common etoh?
Fomepizole
What is Marchiafava-Bignami syndrome?
Italian red wine: damage to corpus callosum, psychosis, seizures,
paralysis
What is Alcohol-tobacco amblyopia?
Blurred and/or double vision, muscle weakness
What does Vick’s inhaler give falst positive for?
Meth - run isomer study
Which med is positive on opiate assay?
hydromorphone
How does ADA impact drug screening?
-Employers with >15 employees
-Cannot discriminate SUD if in treatment for or hx of SUD
FMLA and SUD screening?
-Public agencies and private employers >50
*Employees on job > 1 year and >1,250 hours in past 12 months
-12 weeks of unpaid, job-protected leave to address own health or of family member
Drug-Free Workplace Act of 1988?
-Most employers not required to have a drug-free workplace policy
-Any employer receiving federal grants or contracts must be drug-free
-Does not specifically allow for workplace drug testing
Civil Rights Act of 1964?
- > 15 employees
-Drug testing programs must be, Culturally competent, Fairly enforced, and Sensitive
National Labor Relations Act of 1935?
-Drug testing affecting unionized workers must be Negotiated with union
– Even when another federal required
Can schools drug test?
Only for extracurriculars
What does oxycodone break down to?
Oxymorphone
What does clonazepam break down to?
7 amino clonazepam
What are the OARS?
The Four Core Skills of Motivational Interviewing (MI):
1.Open Questions
2.Affirming
3.Reflective Listening
4.Summarizing
What is the spirit of MI?
PACE
Partnership
Acceptance
Compassion
Evocation
Four processes of MI?
EFEP
Engaging
Evoking
Focusing
Planning
What for of arrhythmia is torsades?
V tach
Prevalence NAS in MOUD?
-40-60%
-Less common & Severe with Bup
What can Combination METHADONE + COCAINE cause?
Toxic leukoencephalopathy - initial recovery, then mental status
changes led to lethal catatonia. MRI findings of leukoencephalopathy
Common causes false positive stimulants?
High doses of caffeine,
Decongestants: pseudephedrine, ephedrine, oxymetazolone, PPA
What does uspstf recommend for tobacco screening?
All adults and pregnant woman
How does nida define heady drinking for men?
5 day / 14 week
How does nida define heady drinking for men?
4 day / 7 week
How many questions in Audit? What does it screen for?
10, etoh, self administered
7 low risk
15 - dependence
Safe etoh level for pregnant?
0
What does S2Bi screen for?
Adolescent use placing into risk category
Etoh screeners for pregnancy?
Tweak - T Ace
- Tolerance and Cutdown score higher
What is DAST?
Adults and older use for SUD
What is TAPS?
Daults only, nicotine, etoh, others
Screeners for adolescents placing in risk groups?
S2BI
BSTAD?
Brief screener eoth tobac other drugs
- For youth
What is CRAFFT?
Screener for adolescents and peds
Strength SBIRT etoh adults?
Grade B
when do most relapse occur?
in the first 90 days after discharge from treatment (80%). actually first 30.
number avg attempts b4 year sobriety?
5-7
odds recurence if sober at five years?
15%
completion rate LT community?
10-25%
% inmates with SUD?
60%
Compliance in disulfarim with spousal contract?
90%
Most common psychiatric disorder with SUD?
MDD
Increased risk of SUD with BPD?
4x
Most common SUD in psychiatric illness?
Tobacco, highest in schizo
Personality disorder highest in SUD?
Antisocial
Increased risk suicide in dual diagnosis?
11x
% getting treatment for mental illness and SUD?
10%
pathophys of why schizo smokes more?
lower level nicotinic ach receptors, involved in cognition and memory activated by ach and nicotine
Mortality decrease in MOUD?
2/3
Risk of suicide no MOUD?
4x
Stopping MOUD risk on suicide?
6x at two weeks
Number 1 and two behavioral health diagnosis risk for AUD?
- Antisocial
- BPD
What is the single model of treatment?
Single model of treatment: Treating primary psychiatric disorder and SUD will remit
What is the Sequential model of treatment?
Treat each problem sequentially
What is the Parallel model of treatment?
Treat both problems at different settings
What is the Integrated model of treatment?
Treat both problems in same setting (preferred)
What diagnosis is DBT helpful for?
Borderline
How does DBT work?
Helps with affective regulation and reducing self-harm (e.g., suicidal attempts, thoughts, or urges;
cutting; drug use)
What is Assertive Community Treatment (ACT)?
– Case management with emphasis on small case load, individualized approach, assertive outreach, close
contact, and team management
– An integrated treatment for severe mental illnesses
What is the Most effective and least utilized psychosocial treatment for SUDs?
Contingency Management
What is the Seeking Safety (SS)?
– Integrated present-focused therapy to learn skills for coping with trauma/posttraumatic stress disorder
AND substance use disorder
– Target trauma-related problems (including PTSD) and substance use disorder simultaneously
What is * Integrated Group Therapy (IGT)?
– Adjunct to Rx and is based on CBT principles, integrated therapy for patients with BP & SUD
– Helps patients understand te relationship between disorders, and link between thoughts
/ behaviors, and how they contribute to recovery and relapse
What is * Acceptance and Commitment Therapy (ACT)?
– Encourages embracing thoughts / feelings rather than fighting or feeling guilt
– Combines mindfulness with self-acceptance
– Help patients accept what is out of their control, and commit instead to actions that enrich lives
– Helpful for MH and SUD diagnoses and chronic pain
Preferred med AUD BPD?
valproate
Preffered med schizo SUD?
Clozapine
What enzyme does disulfiram inhibit that can lead to psychosis?
Dopamine-β-hydroxylase
- Low does and close monitoring in schizo
How does methadone prolong QT?
inhibits cardiac potassium channels
What can naltrexone worsen?
Depression
FDA approved meds for MTSD?
Sertraline and paroxetine
Prevalence TUD with ADD?
50%
What is cluster A?
Paranoid, schizoid, schizotypal
What is cluster B?
Antisocial, borderline, histrionic, narcissistic
What is cluster C?A
Avoidant, dependent, obsessive compulsive
Rate of AUD/ SUD in eating disorder?
AUD: 25%
SUD: 20%
cutoff at which to expect aws?
150: if showing intoxication at or below likely not tolerant
when seizure hallucination in aws?
24-48h
when DTs in AWS?
48-96
standard drink?
- 1.5 oz 80 proof spirits (40%)
- 4-5 oz table wine (8%-12%) – Fortified wines may be up to 20%
- 12 oz Beer (6%)
- All these contain from 13-15 grams ethanol
parenteral dose adjustmet benzos?
- oral 50% first pass hepatic metabolism
- use 1/2 dose adj if parenteral
success rate cold turkey smoking?
5%
What is the bioavailability of IV?
1
How many half lives to reach steady state?
5
What are zero order kinetics?
Rate of drug removal is constant: etoh
What is first pass metabolism?
Happens before drug reaches systemic circulation. More prevalent in oral and lipid soluble drugs
Main CYP in metahdone metabolism?
CYP3A4
How do psychoactive substances work in the nucleus acumbens?
Increase dopamine here
- Naturally rewarding activities
also increase De release in
mesolimbic pathway from
VTA to NA
What does acute administration of psychoactive drugs and dependence causes in the basal ganglia?
Increase in De transmission in basal ganglia
What activates the VTA-nucleus accumbens pathway?
- All psychoactive substances
-This pathway is important not only in drug dependence but also in physiological behaviors such as
eating, drinking, sleeping, sex
3 regions of brain involved in activation of behavior?
- Prefrontal cortex
- Amygdala
- Nucleus accumbens
Where do fear based behaviors live?
Amygdala
Where do motivation based behaviors live?
Nucleus acumbens
What does the VTA do?
- Projections from VTA release De in circuit in response to motivationally relevant event
- Facilitates cellular changes that establish learned associations with event
Part of brain involved in choice?
- Choice initiated in part by means of the PFC
- Activation of PFC precedes behavior
What is thought to be the final common pathway?
- Strong linkage between PFC and drug-seeking behavior
- Dysregulation in anterior cingulate cortex and orbitofrontal cortex is critically involved in difficulty
experienced by addicted individuals in control over drug-seeking behavior - Hyperactivity of anterior cingulate and orbitofrontal cortex contributes to compulsive behaviors
Effect of cocaine on NTs?
Inhibits monoamine reuptake transporters (MATs): reuptake of DA
Effect amphetamines on NTs?
- Inhibits MATs
- Increase quantity of DA release
Effects ETOH on NTs?
- Stimulates GABAA receptor
- Inhibits NMDA receptors
- Stimulates opioid and cannabinoid receptors
Effets nicotine on NTs?
Agonist at nicotinic acetylcholine
Effects Cannabis on NTs?
Agonists at cannabinoid (CB)
Effects hallucinogens on NTs?
Partial agonists at 5-HT2A
Effects PCP on NTs?
Antagonist at NMDA glutamate
What is Lofexidine?
α2-adrenergic agonist: produces cellular effects akin to OPR activation and lessens many of withdrawal symptoms/signs in humans
Which NT has emerged as a potential new target to prevent
relapse, especially from alcohol cues?
Glutamate - might have large role in relapse
What is Anandamide?
Neurotransmitter found in humans activating the cannabinoid receptors
CB1/CB2
Can you establish risk from case / control?
NO
What is a cohort study?
Investigators identify groups with and without exposure, then follow groups over time to compare incidence of disease
- Usually are prospective
- Risk can be established
What is the incidence proportion?
Number new cases of disease during specified period / Size population at start of period
What is incidence rate?
Number new cases during period /
Time each person observed totaled for all persons
- Can accommodate person coming into / leaving study (since person-time is calculated for each subject)
Definition prevalence?
Total number cases during a given period / Population during time period
What is the risk ratio (relative risk)?
Risk (cumulative incidence) in exposed group / Risk (cumulative incidence) in unexposed group
Another name for risk ratio?
Relative Risk
What does RR = 1 signify?
No difference in incidence among those with or without characteristic
RR < 1
Signifies a lower risk, which may indicate a protective effect
associated with the characteristic
What does RR greater than one mean?
Increased risk disease associated with characteristic
What does RR less that one mean?
Lower risk, may indicate protective effect associated with characteristic
What is the NNT?
1 / Absolute risk reduction
Definition sensitivity?
Number people w/ disease AND tested positive /
Number of people who have the disease
Number of people with no disease AND tested negative
Number of people with no disease
Definition specificity?
Number of people with no disease AND tested negative / Number of people with no disease
PPV?
True positive / True positive + False positive
NPV?
True Negative / True Negative + False Negative
What is the mean?
Average
What is the median?
50th percentile
What is the mode?
Number most frequent
What happens to standard deviation if sample size increases?
Decreases
Values that lie within various SDs?
As long as normal distribution, following rules apply:
– 68% lie within 1 SD of mean
– 95% lie within 2 SDs of mean
– 99.7% lie within 3 SDs of mean
Main factors influencing power of a study?
- Effect size: as magnitude of difference increases, power increases
- Variability of outcome measure: as variability of outcome decreases, power increases
- Sample size: as size of sample increases, power increases
Denition of power?
Probability of rejecting a false null hypothesis: likelihood a study will detect an effect when there is an effect there
What is a null hypothesis?
There is no association between exposure of interest and outcome
What is the P value?
Probability, under null hypothesis, of obtaining a result equal to or more extreme than what was observed
What P value is significant?
Less than 0.05
What is type 1 error?
Probability of rejecting null hypothesis when it is in fact true: saying you found something when you didn’t
- A false positive
What is type II error?
Probability of accepting null hypothesis when it is false: not finding something when there was something there
- A false negative
Gender risk AUD?
Males: 2:1
Ethnic low and high risk AUD?
High: native american
Low: Asian American
AUD more prevalent urban or rural?
Urban
Do men or woman progress more quickly in their SUD?
Woman
Increased death risk in woman AUD?
50%–100% higher than men, including deaths from suicides,
alcohol-related accidents, heart disease, stroke, and liver disease
When AUD most prevalent?
19 years of age
- Earlier the first use the higher the risk
Heavy drinking cutoff for men and woman?
Men: five drinks
Woman: 4 drinks
Most commonly used illicit substance?
THC
AUD vs. SUD prevalence?
AUD 2x more prevalent
- AUD: 30 percent lifetime
- Drug: 10% lifetime
How many people use etoh in past month?
50%
People die annually from etoh?
95k
Percent TCH use in past year by young adults?
35%
When smoked, how does nicotine compare in dependency?
Higher dependence liability than opiates, alcohol
Highest risk factor for disease burden in world?
Smoking, after hypertension
Leading cause of preventable death in US?
Tobacco: 1/5 deaths
Life expectancy of smoker?90
10 years less
- Quitting before 40 decreases that risk by 90%
What % opiate users used pills?
90
hcv rate ivdu?
1/3 positive in one year
-53% in five years
example opiates?
Morphine
Codeine
Thebaine
Semisynthetic opioids?
Heroin from morphine
Buprenorphine & oxycodone from thebaine
2 common synthetic opioids?
Methadone and fentanyl
where are opiods metabolized?
liver
renal and hepatic impact opiods?
Impaired hepatic function could increase concentrations of opioids and impaired renal function could
cause accumulation of metabolites
Effect based on neural binding site opiods?
Thalamus: produces analgesia
Cortex: impaired thinking/balance
Prefrontal cortex: decision about how important use of the drug is
VTA)/nucleus accumbens: euphoria
Hyperactivity of nor-adrenergic neurons in locus coeruleus causes in opioid withdrawal?
– Increased BP, HR, respirations
– Increased sweating, diarrhea
– Clonidine & opiates reverse these effects
Increased γ-Aminobutyric acid (GABA) effects in opioid withdrawal?
Reduced dopamine in the nucleus accumbens cause:
– Dysphoria, depression, craving
– Only opiates (methadone and buprenorphine) reverse these effects
Time course withdrawal short acting?
- Begins 6-12 hours after last dose
- Peaks 36-72 hours, and lasts about 5 days
Time course withdrawal long acting?
Methadone: 36-72 hours; may be as short as 20 hours in rapid metabolizers,
also a longer period before peak effects occur
How long does narcan dose last?
1-4 hours
