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(C) BD > Lecture 10: Substance Abuse Part 2 COPY > Flashcards

Lecture 10: Substance Abuse Part 2 COPY Flashcards

1
Q

What is the #1 preventable cause of death in the US? How many deaths does it cause?

A

Smoking.
1 in 5 of all deaths in the US are due to smoking.

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2
Q

What gender is smoking more prevalent in? How prevalent is it in WV?

A

Higher in men.

Nationwide is 11.5% for adults, but WV is 24%!!!

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3
Q

What other forms of tobacco exist outside of cigarettes?

A

Cigars/pipes (slightly lower risks of lung cancer)
Hookahs
Smokeless tobacco
E-cigs/Vaping

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4
Q

What demographic is MC for smokeless tobacco use?

A

White males of low socioeconomic status in southern US

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5
Q

What does vaping aerosolize?

A

Nicotine.

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6
Q

What is EVALI?

A

E-vaping associated lung injury.
It is an acute eosinophilic pneumonia.

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7
Q

How much nicotine is in a cigarette? Is absorption of nicotine higher in vaping or smoking?

A

10-15mg of nicotine in the avg cigarette.

Vaping absorbs 2-3x MORE NICOTINE.

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8
Q

What does nicotine do?

A

A highly addictive substance that stimulates nicotinic cholinergic receptors in the brain.

Releases dopamine and epinephrine release.

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9
Q

How fast is the onset of nicotine? Half-life?

A

15s onset to reach the brain.
Half-life of 1-2 hours.

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10
Q

What happens as someone continues to absorb nicotine?

A

Tolerance develops as there is an upregulation of nictonic receptors.

In withdrawal, there will be even less dopamine and less epinephrine.

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11
Q

What are the acute toxic effects of tobacco-related disorders?

A

Nausea, Salivation, Pallor
Tachycardia, poor concentration
Decreased REM sleep

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12
Q

What are the harmful effects of smoking?

A

All-causes!!!
Cancer, pulmonary, periodontal, immunologic, endocrine, MSK, reproductive, GI, Postop

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13
Q

What treatment does smoking increase the failure rate of?

A

H. pylori treatment

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14
Q

How can we detect tobacco use lab-wise?

A

Serum continine
Anabasine

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15
Q

What is continine?

A

A nicotine metabolite, present in the serum for 2/3 a day and in urine for weeks.
However, you can pick it up from secondhand smoke.

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16
Q

What is anabasine?

A

A product found in tobacco and vapes but not nicotine replacement.
You rarely pick it up from secondhand smoke.

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17
Q

Which lab test for tobacco use is more common?

A

Continine, but it is less accurate. (since you can pick it up from secondhand smoke.)

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18
Q

What are some ways we screen for tobacco use?

A

Cigarette smell
Tobacco staining on the tongue, teeth, or FINGERS (rollers)
Pharyngeal erythema
Increased carbon monoxide
Lab tests

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19
Q

What is the recommended treatment for adolescents wishing to quit smoking?

A

Nicotine replacement therapy.(NRT)

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20
Q

How is NRT dosed usually?

A

Long-acting patch + short acting oral

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21
Q

What is the simplest method of NRT?

A

Nicotine transdermal patch once a morning.

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22
Q

What counseling education should I provide a pt using nicotine patches?

A

Rotate it every morning to NON-HAIRY skin.
DO NOT LEAVE ON OVERNIGHT

Your skin may be irritated.
Possible insomnia and vivid dreams.

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23
Q

What is nicotine gum primarily used for?

A

Diminishing the withdrawal symptoms. (DOES NOT STOP WITHDRAWAL SYMPTOMS)

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24
Q

What counseling education should I provide a pt using nicotine gum?

A

Avoid acidic beverages before and during gum use.
You want to chew it until a peppery taste appears, then park it in your mouth. Resume chewing once the taste disappears and repeat until there is no more peppery taste.

Note:
Pepper taste/Slight tingling means the nicotine is released.

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25
Q

What kind of patients cannot use nicotine gum?

A

TMJ
Poor dentition
Dental appliances

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26
Q

What is a nicotine lozenge?

A

An oral lozenge that contains the highest amount of nicotine.

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27
Q

What counseling education should I provide a pt using oral nicotine lozenges?

A

DO NOT SWALLOW (just let it dissolve)

Reduce use of lozenges over time.

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28
Q

What is a nicotine inhaler?

A

Used for satisfying the sensory and behavioral cravings.

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29
Q

What kind of patients cannot use a nicotine inhaler?

A

Reactive airway diseases (Asthma)

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30
Q

What is a nicotine nasal spray?

A

IN administration that gives a faster peak than oral nicotine.

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31
Q

What is wellbutrin/bupropion’s MOA?

A

Blocks dopamine and NE reuptake (DNRI)
Antagonizes nicotinic cholinergic receptors (SR form recommended).

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32
Q

What are the SE of wellbutrin/bupropion?

A

Insomnia
Agitation
Dry mouth
HA
Seizure (Rare and dose-dependent)

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33
Q

What kind of patients cannot take wellbutrin/bupropion?

A

Epileptics
High seizure risks
Hx of anorexia or bulimia

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34
Q

What is chantix/varenicline’s MOA?

A

Partial agonist of nicotinic receptors.

It only does partial stimulation, so you don’t feel as rewarded, but you also don’t get withdrawals as bad.

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35
Q

When do I need to reduce chantix dosing?

A

Renal insufficiency.

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36
Q

What kind of patients cannot take Chantix?

A

Hypersensitivity or skin reaction to rx.

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37
Q

What is an emerging therapy for tobacco use?

A

Nicotine vaccine!

The antibodies will bind nicotine and stop it from crossing the BBB.

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38
Q

What should a patient expect post tobacco cessation?

A

Weight gain
Depression and anxiety
Increased cough and mouth ulcers

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39
Q

How common is heroin use?

A

2.1% of pts 12+ y/o

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40
Q

What are the types of opiates?

A

Natural: Codeine and morphine (Straight from the poppy plant)
Semi-synthetic: Everything else
Synthetic: Meperidine, fentanyl, methadone
Endogenous opioids: Endorphins, enkephalins, dynorphins, endomorphins
Other: Tramadol

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41
Q

What are the 3 types of opioid receptors in the body?

A

Mu - pain, resp depression, constipation, physical dependence.

Kappa - Analgesia, diuresis, sedation, psychological dependence

Delta - analgesia, dependence, antidepressant

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42
Q

Where are opioid receptors found in the body?

A

Brain
Digestive Tract
Spinal Cord

43
Q

What are 3 general positive effects of opioids?

A

Pain (analgesic effect)
Antitussive (Codeine is in cough syrup)
Psychiatric (euphoria, anxiolysis)

44
Q

What is indicative of mild opioid intoxication?

A

PUPILLARY CONSTRICTION
CONSTIPATION

45
Q

What is suggestive of severe opioid intoxication?

A

Respiration depression
Pinpoint pupils

46
Q

What is narcan/naloxone used for?

A

Short-acting opioid antagonist.

47
Q

What should you consider if narcan doesn’t work? What should you then do?

A

Consider other substances.
CPR may be indicated as well.

48
Q

What does long-term use of opioids do to the receptors?

A

Desensitization and downregulation (Opposite of nicotine!!!!!!)

49
Q

What kind of opioids produce tolerance more?

A

Short-acting, such as morphine or heroin.

50
Q

How many grades of opioid withdrawal are there? What grade should we treat at?

A

0-4.
Treat at grade 2, which is mydriasis, piloerection, anorexia, TREMORS, HOT AND COLD FLASHES, generalized aching.

51
Q

What opioid has an extremely long half-life?

A

Methadone

52
Q

How do people undergoing opioid withdrawal typically act?

A

Rebound hyperactivity for 3-6 months.

Restless, irriitable, and poor concentration.

53
Q

How do you treat acute opioid withdrawal?

A

Methadone
Buprenorphine
Alpha-2 agonists (Clonidine, Lofexidine)

54
Q

What is clonidine CId in?

A

Hypotensive patients. It drops BP a lot as well.

55
Q

What antagonist treatment is indicated for maintenance in chronic opioid use?

A

Naltrexone. Cannot be used for acute tx.

56
Q

What is nice about naltrexone dosing?

A

Can be given IM once a month.

57
Q

What is the BBW of naltrexone?

A

Hepatocellular injury.

Also, if someone goes back on opioids while on naltrexone, they might OD by accident because naltrexone is an antagonist.

58
Q

What agonist treatment is indicated for chronic opioid use?

A

Methadone!

Helps decrease withdrawal s/s and blocks the high from acute use.

59
Q

Why might patients accidentally OD while on methadone?

A

Methadone has a slow onset, so patients might get impatient waiting for it to take effect or think its not working.

60
Q

How does one qualify for methadone tx?

A

Must meet at least 1 of 4 criteria:
1+ yr of opioid use.
Hx of methadone maintenance and showing signs of imminent return to dependence.
Recently released from hospital/prison with hx of dependence.
Pregnant and opioid dependent.

61
Q

What opioid agonist combo discourages abuse?

A

Buprenorphine + naloxone (Suboxone)

62
Q

How is suboxone given?

A

Long acting implant or TAKE HOME THERAPY (low abuse potential)

63
Q

What are the non-pharmacological treatment options for opioid use?

A

CBT
Insight oriented therapy
Resident programs
Peer support groups

64
Q

What do psychostimulants do?

A

Cause a release and block the reuptake of Dopamine, NE, and serotonin.

65
Q

What are the psychostimulants (legal and illegal)?

A

Meth
MDMA (Ecstasy)
Ephedrine
ADHD meds

66
Q

Where do psychostimulants tend to accumulate?

A

In the brain (10x more than plasma)

67
Q

What are the two most common ways psychostimulants are taken?

A

Smoking
Snorting

68
Q

What is a key difference between acute amphetamine intoxication vs opioid?

A

DILATED pupils in amphetamines.

PINPOINT pupils in opioids.

69
Q

How do we treat amphetamine intoxication?

A

Symptomatic treatment.

Sedation/seizure control via IV Benzos (Haldol)
Airway management
AntiHTNs
Hyperthermia (cooling blankets, ice packs, NO ANTIPYRETICS)
Fluids

70
Q

Why are antipyretics not indicated in amphetamine treatment protocols?

A

The hyperthermia is due to muscle ridigity, not fever.

71
Q

What can amphetamines have cross-sensitivity with?

A

Cocaine

72
Q

How does long term amphetamine use cause motor and cognitive deficits?

A

Decreased dopamine receptors in the basal ganglia lead to motor deficits.
Decreased metabolic rate in the prefrontal cortex leads to cognitive deficits.

73
Q

Whats the main drug class we use for anyone in amphetamine withdrawal?

A

Benzos.

There is no general proven med treatment regimen.

74
Q

What are the pharmacologic options for treating chronic amphetamine use?

A

Bupropion + naltrexone (First-line)

Mirtazapine (2nd line)
Adjuncts/alts: Methylphenidate (stimulant), topamax (Anticonvulsant)

75
Q

What is the MC abused anxiolytic?

A

Benzos

76
Q

What is the MOA of benzos?

A

Enhancing the effect of GABA (Inhibitory NT)

77
Q

When are benzos indicated?

A

Sedation
Sleep-induction
Anticonvulsant
Anxiolytic
Muscle relaxant
Alcohol withdrawal

78
Q

What does chronic benzo use do?

A

Changes GABA receptor structure, leading to decreased affinity.

79
Q

What will just a benzo OD present as?

A

CNS depression with normal vitals.

80
Q

How do benzo ODs usually present in real life?

A

With alcohol as well, leading to CNS depression AND respiratory depression.

81
Q

What is the treatment protocol for anxiolytic OD?

A

Airway
Breathing
Circulation

82
Q

What medication is used to treat anxiolytic OD?

A

Flumazenil (controversial competitive antagonist of GABA receptors)

May precipitate withdrawal seizures.

83
Q

How is anxiolytic withdrawal treated?

A

Long-acting Benzos. (best for overall treatment)

Withdrawal from chronic benzo use can be very dangerous, so treatment requires precision.

84
Q

How are benzos titrated for chronic anxiolytic use?

A

Tapering over 6-12 months. (Diazepam, chlordiazepoxide)
Withdrawal is very dangerous!!

85
Q

What does cocaine do?

A

Blocks dopamine reuptake.

The purer it is, the more intense the high.

86
Q

What is a unique effect of snorting cocaine?

A

Local vasoconstriction.

Cocaine can be used in the ER to treat epistaxis.

87
Q

Use of what with cocaine can produce more intense and longer-lasting effects?

A

Alcohol

88
Q

What CV effect does cocaine use cause that is very dangerous?

A

MI, even without any risk factors.

89
Q

How is acute cocaine withdrawal treated?

A

Acute withdrawal requires a dopamine agonist like bromocriptine.
Antipsychotics for the other SE.

90
Q

How is chronic cocaine use treated?

A

Topamax (First-line)
Dopamine agonists/stimulants (Dextrometh, meth, modafinil)
Disulfiram
TA-CD Vaccine (Emerging therapy)

91
Q

What are the two primary things in marijuana?

A

THC (psychoactive agent)
CBD (Cannabidiol)

92
Q

What does marijuana mimic in the body?

A

Anandamide.

Increases dopamine levels.

93
Q

Why is smoking marijuana a concern pulmonary wise?

A

Has nearly all of the same combusted particles of tobacco smoke without the filter.

94
Q

What is cannabis hyperemesis syndrome?

A

N/V/D + Abd pain from hx of chronic cannabis use.

95
Q

How is cannabis hyperemesis syndrome treated?

A

Taking a hot shower/bath
Not taking cannabinoids, mainly the THC component.

96
Q

What is the goal of marijuana treatment?

A

Sustained abstinence.

Psychosocial intervention is preferred over medications.

97
Q

What are possible meds for treating marijuana use?

A

Acetylcysteine
Gabapentin
Topamax
Varenicline (Chantix)

98
Q

What are the schedules of the DEA drugs? Which has the most abuse & dependence potential?

A

Schedule 1 is the most potential.

There is schedule 1-5 for controlled substances.

99
Q

What notable drugs fall under schedule I?

A

Heroin
LSD
Marijuana
Ecstasy
Peyote (a spineless cactus lol)

100
Q

What notable drugs fall under schedule II?

A

ADHD meds
Opioids (hydrocodone products must be <15 mg)
Cocaine

101
Q

What notable drugs fall under schedule III?

A

Tylenol #3 + codeine
Ketamine
Testosterone

102
Q

What notable drugs fall under schedule IV?

A

Benzos
Tramadol, Soma, Ambien, Lunesta

103
Q

What notable drugs fall under schedule V?

A

Antidiarrheals, antittusives, or analgesics
Cough syrups with < 200mg of codeine per 100mL
Lomotil, Lyrica, Neurontin (state-dependent)

104
Q

At what schedule do drugs not get refills unless you’re in pain management?

A

Schedule II.

Example: In WV, PAs can write a 3-day supply with 0 refills.

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