Lecture 37/38 -- Alcohol/Tb/Illicit Substances Flashcards
name some drug intoxications you can die from
Cocaine, amphetamines, benzodiazepines, alcohol, barbituates,
Opioids, PCP, steroids, inhalants,
NOT MARIJUANA
name some drug Withdrawals you can die from
Sedative – alcohol, benzos, barbituates
very rarely: opioids, but only in infants
describe the metabolism of ETOH
enzmyes?
what is the rate limiting step?
elimination kinetics?
Alcohol DHG: ETOH –> Aldehyde
Aldehyde DHG: Aldehyde –> Acetic acid
(some metab through P450s)
RLH: Aldehyde DHG
Zero Order elimination
how do gender and ethnicity factor into metabolism of alcohol
Women – less alcohol DHG; smaller volume of distribution
Asians – less ADH and ALDH
Neuropharmacology of ETOH intoxication – what NTs are involved and to what effect
Euphoria – DA, Opioids
Sedation/anxiolytic – GABA, decreased NMDA
Nausea – 5HT
Treatment for ETOH intoxication
Supportive – airway; correct fluid and electrolyte imbalances
Examine for other signs of trauma
two types of fatal ETOH withdrawal
DTs and Sz
usually mutually exclusive
Stages of ETOH DTs
95% are self limiting
Stage 1 withdrawal – 24h after last drink.
Tremulous, HTN, tachy, sweating, nausea, anxiety, mild derealization
Stage 2 – 48 hours after last drink. More severe symptoms than in stage I.
+ hallucinations (auditory) and patients are aware of reality
stage 3 = DTs
<1% of all cases
Marked disorientation
Hallucinations – visual, tactile, auditory
ETOH withdrawal sz
12-48 hours after stopping drinking; usually earlier
Tonic Clonic
<5% of withdrawal cases
Usually self limited and no status epilepticus
treatment options for etoh withdrawal
Supportive –
BZDs – longer acting ones give a smoother taper;
Barbituates –
Beta Blockers – as an add on agent for tachy
Anti convulsant – carvemezepine; gabapentin
Ethanol – can be used, but rare; IV
Propofol – generlized sedation; may specifically help with ETOH withdrawal, but respiratory depression does occur
effects on body systems with chronic etoh abuse?
B1 Deficinecy - -Wernickes and Korsakoffs
Brain, liver, pancreas, GI, Oro-esophageal cancers, Varicies, PNA,
Cardiomyopathies –> pulm congestion
Endocrine – decreased testosterone and loss of secondary sex characterisitcs
Biomarkers for chronic heavy drinking
GGT (an liver enzyme) > 30
CDT (carbohydrate deficient transferrin) > 20
MCV > 90
three FDA approved drugs to help treat alcoholism ?
Mechanism
rationale for treatment
side effects/toxicity
Dilsulfram – (antabuse) – Aldehyde DHG inhibition; leading to aversive condition with consumption of ETOH.
SE: Liver toxicity; drowsiness, HTN
Naltrexone – opiate blocker
Mu Antagonist
Decrease positive reinforcement of drinking
side effects: Minor liver tox; N/HA/Sedation
Acomprosate (Calcium acetyl homotuarinate) –
NMDA Glutamate R modulator
Helps control cravings, triggers
Side effects: Diarrhea
no liver toxicity
nicotine Pharmacology —
assay to monitor nicotine consumpiton?
cotinine
nicotine intoxication –
can this be fatal?
symptoms
Can be fatal due to peripheral nicotinic receptor stimulation, but only in infants
Sx – tachy, htn, n/v, diaphoresis, palpitations, sz, anxiety
Tx of nicotine intoxication
Primarily supportive
Gastric lavage
Activated charcoal
treat Bradycardia with atropine
Nicotine withdrawal –
decreased HR, Insomnia, dysphoria, irritability, poor concentration
FDA approved medications for smoking cessation
mechanism?
Nicotine replacement
Patch/gum/nasal spray/inhaler/oral spray/lozenge
Bupropion (Zyban/wellbutrin)
Varenicline(Chantix) – nicotine partial agonist
rationale for nicotine replacement therapy
contraindications
Nicotine absorption is worse than cigarettes
Lower does is delivered
First pass metabolism can inactivate
Less rewarding –
Contraindications – Recent MI, smoke less than 10 cigs per day; use with caution in breast feeding/pregnant patients
Contraindications for Buproprion
Mechanism Verenicline (chantix) side effects
Bup: Contraidncated – SZ or Eating D/o
Varenicline (Chantix)
Mechansims – Nicotinic partial agonist; some effect on 5HT
Taken BID
Side effects – N/V/HA/ Insomnia/abnormal dreams
Increased risk of suicide
cocaine intoxication –
Phsyical effects?
behavioral/psychiatric effects?
what are a lot of the severe effects due to?
vasconstriction in the setting of cocaine use
tachy, midriasis, HTN, N/V, CP, SZ, HA, bruxisms
manic: Grandiosity, hyperactivity, delusions, paranoia, hallucinations (formication)
Cardiac arrythmia, MI, Stroke, Rhabdo, Death
cocaine withdrawal
sx?
tx?
opposite of intoxication: fatigue, hypersomnia, lethargy, irritability, dysphoria, SI
Tx – supportive; unless there is underlying depression
hallucinogen intoxication
fatal?
sx?
not life threatening expcept for impaired judgement which can lead to fatal decisions
Tachy, diaphoresis, palpitations, tremulous, disoriented, intesnified perceptions, illusions, visual distortions, hallucinations, delusions, distorted sense of time
tx of hallucinogen intoxication
Largely supportive Provide a quiet,stimulus-free environment Agitation benzodiazepine high-potency neuroleptic
hallucinogen withdrawal?
what is a manifestation than occur long after using hallucinogens?
No real withdrawal syndrome
HALLUCINOGEN PERSISTING PERCEPTION DISORDER (flashbacks)
Often triggered by stress, fatigue, anxiety, entry into a dark environment, drug use
classic finding for PCP
vertical nystagmus
Benzo intoxication:
symptoms
worse with?
treatment of benzo over-dose
what drug
Sx: same as alcohol; sedatiave;
Worse with Alcohol, opioids, barbituates
Flumezanil
benzo withdrawal
similar to alcohol
including seizures
main concern for fatality with opioids
Intoxication sx
Respiratory depression
Pinpoint pupils; resp depresion, drowsiness,
Pruritiis (histamines), euphoria, sedative
Opioid intoxication treatment:
difference if its a methadone overdose
Airway, oxygenation
Naloxone – short acting mu opioid antagonist; response within 1-2 minutes;
Methadone overdose – long half life; have to adminster multiple doses;
Opioid withdrawal
sx
peak if untreated
duration
Sx – Pupilary dilation, piloerection, diaphoresis, lacrimation, rhinorrhea, N/V/D
Involuntary muscle jerks
Dysphoria, irritable, hyperalgesia, craving
Peak – 1-3 days
Sub acute symptoms –can last for months;
Not life threatening
Treating opioid withdrawal
Clonidine
Opioids – methadone
Buprenorphine
symptomatic
(rationale for treating opioid withdrawal with clonidine)
opioid use can destroy LC, therefore decreasing NE
Rebound effect of NE when in withdrawal
Teat with A2 agonist to decrease NE release
Inhalants – 3 kinds
general mechanism
Volatile Compounds
Nitrites
Nitrous Oxide
mechanism – CNS depression and hypoxemia
Steroids
intoxication symptom
HA, diaphoresis, tachy,
anxiety, irritability
aggressive, combative, some psychosis, paranoid, depression
“roid rage”
Treatment of steroid intoxication
taking patients off steroids?
supportive
Psychosis – neuroleptics;
Agitated –Benzos
need to taper pts off steroids
