Lecture 6-Addiction day Flashcards
What is addiction?
Addiction is a chronic but treatable brain disorder in which people lose the ability to control their need for alcohol or other drugs.
The brains of addicted people “have been modified by the drug in such a way that absence of the drug makes a signal to their brain that is equivalent to the signal of when you are starving.”
Symptoms of addiction include tolerance (development of resistance to the effects of alcohol or other drugs over time) and withdrawal, a painful or unpleasant physical response when the substance is withheld. Many people with this illness deny that they are addicted. They often emphasize that they enjoy drinking or taking other drugs.
When is someone addicted–The American Psychiatric Association says that a person is dependent if their pattern of substance use leads to clinically significant impairment or distress shown by three or more of the following in a 12-month period:
- Tolerance as defined by any of the following:
a need for markedly increased amounts of the substance to achieve intoxication or desired effect
markedly diminished effect with continued use of the same amount of the substance - Withdrawal, as manifested by either of the following:
the characteristic withdrawal symptom of the substance
the same or a closely related substance is taken to relieve or avoid withdrawal symptoms - The substance is often taken in larger amounts or over a longer period than was intended (loss of control)
- There is a persistent desire or unsuccessful efforts to cut down or control substance use (loss of control)
- A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects (preoccupation)
- Important social, occupational or recreational activities are given up or reduced because of substance use (continuation despite adverse consequences)
- The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (adverse consequences)
Discuss addiction and the brain.
For example, all drugs of abuse affect the dopamine pathway in the brain. Dopamine is a kind of neurotransmitter - a chemical produced by nerve cells that process and transmit information in the brain. The dopamine neurotransmitter’s job is to produce feelings of pleasure so this pathway is commonly known as the “pleasure pathway.”
What happens when people develop a substance use disorder is that they tax the ability of their dopamine system to keep up.
“The amount of dopamine we have in our brain is limited by the substances that the brain uses to make dopamine. And if we release it too often, we get into a situation where the brain has less dopamine. What that means is that an individual who has depleted their dopamine source in their brain has a difficult time feeling pleasure from even the normal events that would make someone happy - a mother seeing her child, or having a good meal.”
Substance Abuse?
A maladaptive pattern of substance use over at least 12 months that leads to decreased functioning.
Dependence?
Substance abuse + withdrawal symptoms, tolerance, or compulsive use.
Note that dependence is the more severe form of abuse.
withdrawal?
Physical and psychological symptoms after the reduction or cessation of intake of a substance.
intoxication?
Intoxication is an abnormal state that is essentially a poisoning or it can refer to being drunk with alcohol.
What are the 12 steps of alcoholics anonymous?
- We admitted that we were powerless over alcohol–that our lives had become unmanageable.
- Came to beleive that a power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of god as we understood him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to god, to ourselves, and to another human being the exact nature of our wrongs.
- Were entirely ready to have god remove all these defects of character.
- Humbly asked god to remove our shortcomings.
- Made a list of all persons we had harmed and became willing to make amends to them all.
- Made direct amends to such peple whenever possible, except when to do so would injure them or others
- Continued to take personal inventory and when we were wrong promptly admitted it.
- Sought through prayer and meditation to improve our concious contact with god, as we understood him, praying only for knowledge of his will for us and the power to carry that out.
- Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
Nucleus _____ is the The “reward center” of the brain. It Integrates VTA (dopamine) and PFC (_____) inputs to determine motivational output.
accumbens; glutamate
Name some functions of the prefrontal cortex?
Exerts executive control over midbrain structures
Judgment
Cost-benefit analysis
What is the function of the Dorsolateral prefrontal cortex?
DLPFC-= statistical analysis, prioritizing, top down control center:(failure to assess the risks of a behavior ie drunk driving)
What is the function of the Ventromedial prefrontal cortex?
VMPFC= assigns emotional valience (drinking feels good, less stress, more social)
What is the function of the Orbitofrontal cortex?
OFC- impulse prevention ( I can beat up that football player, grope that model, drive my car)
What is the function of the Anterior cingulate cortex?
ACC= vigilance(Scanning environment for next beer, vodka, bar…)
Decision Making is ______ Driven via PFC structures
Glutamate
Limbic Drive is Dopamine Driven
D_ receptors govern static levels of DA neuronal activity to allow homeostatic wakefulness, alertness, etc
D_ receptors are pulsatile depending on motivation, drive, reward expectations
3; 2
Drugs and addictive begavior All act in brain limbic reward pathways to either:
_____ dopamine (DA) release
enhance DA effects in the Nucleus ____ (Nac) or related structures
produce effects similar to DA
enhance; Accumbens
The ______ supplies DA to the nucleus accumbens (NAc).
The _____ assigns a pleasure, threat, or an emotional value to the linkage between VTA & NAc.
This is the Limbic Addiction Pathway that is _____ in addictive behaviors.
VTA; Amygdala; excessive
- The ____ should suppress doing dangerous or addictive things
- The ______ should attach positive feelings to not doing dangerous things
- The _____ should calculate the true risk/benefit ratio of doing addictive things
- VMPFC, OFC, & DLPFC are in the cortex and are trying to control the _____ and manage the VTA.
Orbitofrontal Cortex (OFC); ventromedial prefrontal cortex (VMPFC); dorsolateral prefrontal cortex (DLPFC); NAc
With increasing addiction, frontal lobe structures can become less active (less glutamate) and even _____ allowing increasing, maladaptive addictive (more DA) behaviors to occur. (risk calculations are in error, emotional valence is put onto the addictive substance and response prevention falters
atrophy
Psychotherapy may strengthen the ______ in addicts.
prefrontal cortex
Normal physiology: Chloride ion hits the GABA-A receptor & ______ occurs (as long as GABA is present on the receptor).
Bezodiazepines & alcohol _____ the GABA-A receptor so more _______ occurs due to increasing Chloride influx (as long as GABA is present on the receptor). Benzodiazepine & alcohol intoxication & withdrawal are essentially the _____ due to simillar mechanisms.
hyperpolarization; agonize; hyperpolarization; same
What are symptoms treatments of alcohol intoxication?
Anxiolysis Disinhibition Slurred Speech Ataxia Sedation/Stupor Respiratory Supression Coma Death
What are symptoms treatments of alcohol withdrawl
Agitation, Insomnia Tremor GI upset Inc Pulse, HR, BP Seizures Hallucinations Delirium Death
How do we treat alcohol intoxication withdrawl
Rx with support, restraint, protect airway, ventilate
How do we treat alcohol withdrawl
Rx with benzodiazepines (cross reactive) until vital signs and withdrawal symptoms normalize
What are symptoms treatments of sedative intoxication with benzodiazepines or barbituates
Anxiolysis Slurred Speech Ataxia Sedation/Stupor Respiratory Supression Coma Death
What are symptoms treatments of sedative withdrawl with benzodiazepines or barbituates
Agitation, Insomnia Tremor GI cramps Hypereflexia Inc HR Seizures Hallucinations Delirium Death
How do we treat sedative intoxication
Rx with support, restraint, protect airway, ventilate
Reverse with flumazenil
For benzodiazepines
Will not work for alcohol or barbiturates
How do we treat sedative withdrawl
Rx with benzodiazepine replacement until vital signs and withdrawal symptoms normalize
Discuss what Stimulants like Cocaine & Amphetamine do at the D2 Receptor
Stimulants block dopamine reuptake, may reverse it
The net effect is more DA availability in the mesolimbic system which allows increased CNS arousal and excitability
Intoxication with Stimulants like Cocaine & Amphetamine give what symptoms?
Elevated mood and esteem irritability Insomnia Appetite loss Dilated pupils Racing heart Inc BP, elevated temp Hyperreflexia Psychosis Cardiac arrest seizure
Treat intoxication with Stimulants like Cocaine & Amphetamine with what
Rx with support, and use meds to reverse specific intoxication symptoms
Withdrawl from Stimulants like Cocaine & Amphetamine give what symptoms?
Fatigue Anhedonia Depression Increased sleep Increased appetite
Opiates affect the Affect Mu, delta, kappa receptors. What occurs when an opiat interacts with each one of these receptors? What is their mechanism of action?
Mu (OP3,MOP) reduces pain, increases positive emotion
Kappa(OP2, KOP) & delta(OP1, DOP) allows mild analgesia
They are g protein linked and cause neuronal hyperpolarization via cAMP reduction and increased K+ influx and decrease Ca++ efflux
List some opiat drugs. Why are they used clinically
Morphine, codeine,oxycodone, hydrocodone, tramadol
They tend to activate the Mu, OP3, MOP receptors to control pain and improve the emotional state associated with said pain
List symtoms of opiate intoxication
Elevated mood Pupil constriction Respiratory suppression Gag reflex loss Low HR, BP Constipation
List symtoms of opiate withdrawl
Restless Watery eyes Yawning Dilated pupils Goose flesh/Flushing Runny nose, sneezing Inc Hr and BP GI distress GI Cramps Muscle cramps
How do wo treat opiate intoxication
Rx with support, protect airway and use naloxone to reverse
How do wo treat opiate withdrawl
Rx with methadone (Full agonist replacement) or buprenorphine (partial agonist replacement)
What are symtoms of hallucinogen intoxicaiton
Intoxication= Perceptual distortion Hallucinations Depersonalization Nystagmus Tremors Hyperreflexia Racing heart Flashbacks Paranoia
Name some hallucinogens & what we do to treat intoxicaiton
Phencyclidine (PCP), lysergic acid (LSD), mescaline, peyote, psilocybin
Treatment is supportive
What are symtoms of cannabis intoxication
Elevated mood Expansive thought Sedation Pupil constriction Red conjunctiva Increased appetite Panic Paranoia
Name the stages of change (5)
Precontemplation (denial)
Contemplation
Preparation
Action
Maintenance
NOTE: The key to change is that the patient is ready, willing, and able. We try to get patient to get them to the next stage of change.
Describe some charictaristics of abstinence
Must stop all drugs
Must not use at all Ever
12 Step Model as an example
Name the 4 pharmacologic therapies to reduce smoking.
Nicotine patch
Nicotine gum
Brupropion antidepressant
Varenicline
Discuss how Bupropion antidepressant is used in smoking cessation
Brupropion blocks neuronal reuptake/recycling of NE and DA as it is a NE & DA reuptake inhibitor.
This may desensitize DA reward circuitry so cigarette based activation is not missed by the patient.
This may provide alertness, energy, better cognition and mood so that cigarette effects are not missed.
What are side effects of Brupropion?
Side effects:
Boxed Warning for Psychiatric Worsening, Agitation, Depression, Anxiety Suicidality especially age <25
Warning for induction of seizures in those with epilepsy or eating disorder
Precautions for inducing mania
Common Side effects include: Dry mouth, insomnia, nausea, tremor, rash,
What is the mechanism of Varenicline for inducing smoking cessation
Varenicline is a partial nicotine receptor agonist, it is the most effective pharmacological smoking cessation agent.
You can still smoke on it, but you do not feel a rush from smoking so you quit.
Instead of full nicotine agonism and reward pathway firing, Varenicline partially allows this system to be active, avoiding most withdrawal.
Side effects of Varenicline?
Insomnia, vomiting, constipation,, headache, abnormal dreams**.
Agitation, depression, psychosis, suicidal behavior**
*Most recent studies show this is not evident despite FDA warnings particularly in schizophrenia
Cardiovascular events may not be reduced (may cause more heart disease)*
A male patient has his gall bladder removed and several hours later is angry, belligerent, sweaty, shakey, and throws up on your new short white coat. His BP/HR monitor is beeping at you that his VS are elevated.
His labs are normal so there is no infection. What drug is patient likely withdrawing from?
A. Alcohol
B. Opioids
C. Stimulants
D. Hallucinogens
Alcohol
You ask the previous patient about his drinking history and he is a heavy daily drinker. You say “Hey, I think you should quit because withdrawal is dangerous stuff!” He says, “really, I am fine. I can handle my alcohol. No Problem and thanks for asking.” What stage of change is this person in?
A. Precontemplative
B. Contemplative
C. Active
D. Maintenance
A. Precontemplative
Considering stage of change/resistance level, what would you say to this patient?
A. You are going to have a seizure and die
B. When you are ready to quit, call me for a new appointment
C. Why do you drink?
D. What are the positives to your drinking
E. How has drinking affected your life positively or negatively
C. Why do you drink?
D. What are the positives to your drinking
E. How has drinking affected your life positively or negatively
If this patient goes into withdrawal, what type of medication would you give?
A. An SSRI antidepressant
B. An epilepsy medication like phenytoin
C. A sedative benzodiazepine
D. A few cans of beer
C. A sedative benzodiazepine
