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Speciality Medicine II > Lecture 6 (Psych)- Exam 3 > Flashcards

Lecture 6 (Psych)- Exam 3 Flashcards

1
Q

SUBSTANCE RELATED DISORDERS
* What is intoxication?
* Intoxication must result in what?

A

Intoxication is a separated disorder for each substance
* A reversible substance-specific syndrome resulting from the use of a substance
* Must result in clinically significant impairment or problematic behavioral or psychological changes

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2
Q

SUBSTANCE RELATED DISORDERS
* What is withdrawal?
* What is craving?

*

A

Withdrawal is listed for most substances as a distinct disorder
* Deprivation of the drug/substance or one of its components is associated with clinically important consequences

Craving- strong desire for the substance
* A symptom for substance use disorders

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3
Q

SUBSTANCE RELATED DISORDERS
* What is social impairment?
* May continue to use despite what?
* May withdraw from what?

*

A
  • May result in failure to fulfill major role obligations at work home, or at school
  • May continue use despite social or interpersonal problems caused or exacerbated by effects of substance
  • May withdraw from family activities and hobbies to use substance
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4
Q

SUBSTANCE RELATED DISORDERS
* What is risky use of substance?

A

Key issue in evaluating this criterion is not existence of the problem.. It is individual’s failure to abstain from using the substance despite difficulty it causes

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5
Q

SUBSTANCE RELATED DISORDERS-Pharm criteria
* What is tolerance?
* What suggest tolerance?
* Must distinguish from what?

A
  • Tolerance- requiring markedly increased dose of the substance to achieve the desired effect or markedly reduced effect when the usual dose is consumed
  • High blood levels of substance coupled with little evidence of intoxication suggest tolerance is likely (blood levels helpful)
  • Must distinguish from individual variability (1st time alcohol drinkers may not appear intoxicated after the same number of drinks that makes another individual have slurred speech and incoordination
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6
Q

SUBSTANCE RELATED DISORDERS
* What is withdrawal?
* Significant withdrawal not been document after repeated use of what?

*

A
  • Withdrawal- syndrome that occurs when blood or tissue concentrations of substance decline in individual who maintained prolonged heavy use of substance
  • Significant withdrawal not been document after repeated use of phencyclidine (PCP: angel dust), other hallucinogens, and inhalants (Criteria of withdrawal not included for these)
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7
Q

SUBSTANCE RELATED DISORDERS
* What is not counted when diagnosing a substance use disorder?
* When can prescription cause a dx of substance use disorder can be given?

A
  • Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are not counted when diagnosing a substance use disorder
  • When prescription medications used inappropriately, a dx of substance use disorder can be given (when there are other symptoms of compulsive, drug-seeking behavior)
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8
Q

SUBSTANCE-RELATED DISORDERS
* All drugs taken in excess do what?
* Drugs of abuse activate what?
* What drives use for most? What is the exception?

A
  • All drugs taken in excess activate the brain’s reward system
  • Drugs of abuse short circuit the normal processes that directly activate our reward system->normally reward system activation is achieved through adaptive behavior
  • A high drives use of substances except for hallucinogens-> curiosity rather than euphoria is a major motivator for taking them
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9
Q

Substance RELATED Disorders
* What is the stats on people using an illicit substance at one time?
* What is the stats on substance related disorder?

A
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10
Q

Substance RELATED Disorders-EVALUATION
* Many drugs can be tested in what?
* Urine tox usually postitive for how long?
* Note that mariguana can be detected for how long?

A
  • Many drugs can be tested in the urine
  • Urine toxicology usually positive for up to 2 days after drug ingested
  • Note that marijuana detected 3 days to 4 weeks depending on use
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11
Q

SIGNS ON PHYSICAL EXAM and CLINICAL STATES WHERE NEED TO R/O SUBSTANCE-RELATED DISORDERS
* What will you see with subcutaneous or IV abusers? (6)

A
  • Scars or infections from intravenous or subcutaneous injections
  • Abscesses
  • Bacterial endocarditis
  • Drug-induced or infectious hepatitis
  • Thrombophlebitis
  • Tetanus
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12
Q

SIGNS ON PHYSICAL EXAM associated with SUBSTANCE –RELATED DISORDERS
* What do you see for snorters of cocaine, heroin and etc? (3)

A
  • Deviated or perforated nasal septum
  • Nasal bleeding
  • Rhinitis
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13
Q

SIGNS ON PHYSICAL EXAM associated with SUBSTANCE –RELATED DISORDERS
* What do you see with cocaine freebasers, smokers of crack, mariguana or other drugs?(3)

A
  • Bronchitis
  • Asthma
  • Chronic respiratory conditions
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14
Q

Tobacco Use Disorder
* The DSM-5 defines it has what?

A

The DSM-5 defines tobacco use disorder as a “problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.”

Some fun facts:
* Smoking is the top cause of preventable death in U.S.
* Deaths per year: 434,000
* Deaths per day: >1000
* Overall adults: 25% (47 Million smoking)
* Ages 18-24 years: 33%

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15
Q

Tobacco Use Disorder
* Why do people smoke? (2)

A
  • Nicotine takes away unpleasant cravings (negative reinforcement) by triggering epi, NE, DA and endorphins
  • Nicotine itself is rewarding (positive reinforcement)
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16
Q

Nicotine Cessation
* What is the nicotine replacement therapy?

*

A
  • Eight-week course is sufficient with little added benefit to longer use
  • Base dose on Nicotine dependence
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17
Q

Nicotine Cessation
* What is the nicotine patch?

A
  • Start at 21 mg patch for those with more than 10 Cigarettes per day (more than one half pack), and 14 mg patch if less
  • Taper patch dose to off over 6-8 weeks
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18
Q

Nicotine Cessation
* What is bupropion?

A

Start XR 150 mg daily for 3 days, then 150 mg twice daily
* May also help avert the weight gain associated with Tobacco Cessation
* Effective for sustained cessation at 6 months, but adverse effects may limit use, and less effective than Varenicline

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19
Q

Nicotine Cessation
* What is varenicline?

*

A

Start 1 week before quit date, at 0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for 12 weeks
* ATS preferred agent for sustained Smoking Cessation at 6 months (NNT 7)
* More effective when combined with Nicotine Replacement

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20
Q

Nicotine Cessation
* What is nicotine gum?

A

Consider an occasional low dose gum (2 mg) as an adjunct to Nicotine Patch to treat breakthrough cravings

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21
Q

Nicotine Cessation
* What is nicotine nasal spary and inhaler?

A

Controller Medications (reduce the impulse to use Tobacco)

Background
* Consider controller medications even in those reluctant to quit
* ATS recommends as of 2021 extending controller medications up to one year for higher sustained quit rate (NNT 19)
* Controller medications have been previously limited to 12 week course

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22
Q

Nicotine Cessation
* What is nortiptyline?

A
  • Titrate to serum level 50-150 ng/ml (~75 mg/day)
  • As effective as Bupropion
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23
Q

ALCOHOL USE DISORDER
* What is the criteria for early remission?

A

In early remission- none of criteria for alcohol use disorder have been met for at least 3 months but less than 12 months (with exception of craving)

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24
Q

ALCOHOL USE DISORDER
* What is sustained remission?

A

In sustained remission: None of criteria for alcohol use disorder meet during period of 12 months or longer (except for craving)

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25
Q

ALCOHOL USE DISORDER
* how many people drink occasionally
* What is the gender prevalence
* Race?

A
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26
Q

ALCOHOL USE DISORDER
* Deaths?
* Drunken drivers are connected to what? increases when?

A
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27
Q

how does alcohol use disorder and education go hand and hand?

*

A

The higher the educational level, the more likely the current use of alcohol.

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28
Q

What is the legal intoxication for alcohol?

A

Legal intoxication (in Florida): blood alcohol content (BAC) 0.08

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29
Q

ETIOLOGY-ALCOHOL USE DISORDER
* Close family members of alcoholics have what risk?
* Adopted away children of alcoholic persons have what risk?
* Familial association is strongest for who?

A
  • Close family members of alcoholics have four-fold increased risk of being alcoholic
  • Adopted away children of alcoholic persons have a four-fold increased risk
  • Familial association is strongest for son of an alcohol-dependent father.
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30
Q

ETIOLOGY-ALCOHOL USE DISORDER
* What ethnicity and descent have lower rates of alcohol dependence?
* Many Asians show what?

A
  • Individuals of Jewish ethnicity and individuals of Asian descent have lower rates of alcohol dependence.
  • Many Asians show acute toxic effects after minimal consumption of alcohol
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31
Q

ALCOHOL USE DISORDER
* Early in the drinking period, as blood alcohol levels rise, symptoms often include what?
* Later, particularly when levels are falling, the individuals likely become what?

A
  • Early in the drinking period, as blood alcohol levels rise, symptoms often include talkativeness, a sense of well-being, and a bright expansive mood
  • Later, particularly when levels are falling, the individuals likely become progressively more depressed, withdrawn, and cognitively impaired
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32
Q

ALCOHOL USE DISORDER
* At very high levels, what are the sxs?

A

At very high levels, a non-tolerant person falls asleep and enters a first stage of anesthesia. Higher blood levels can cause inhibition of respiration and pulse and even death

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33
Q

ALCOHOL INTOXICATION- symptoms that might occur
* What is anterograde amnesia? Who is more susceptible?

A

ANTEROGRADE AMNESIA = Blackouts
* Appear as though alert and awake
* Can perform complex tasks without no recollection
* Individuals with brain damage more susceptible

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34
Q

ALCOHOL INTOXICATION- symptoms that might occur
* What is ALCOHOL IDIOSYNCRATIC INTOXICATION? Individuals become what? Who is more susceptible?

A
  • Occurs after ingestion of small amount of alcohol that for most people would not cause intoxication
  • Usually, individuals become aggressive
  • Individuals with brain damage more susceptible
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35
Q

ALCOHOL-THE CAGE
* What is the Questionnaire to screen for alcoholism?

A
  • CUT: Have you felt you should cut down on your drinking?
  • ANNOYED: Have people annoyed you by criticizing your drinking?
  • GUILT: Have you ever felt guilty about your drinking?
  • EYE-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
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36
Q

Alcohol Pharmacology
* How is it absorbed?
* Reaches peak concentration when?

A
  • 90% absorbed through stomach->Rest through small intestines
  • Reaches peak concentration (distributed throughout the body) in 30- 90 minutes
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37
Q

Alcohol Pharmacology
* Intoxication is more pronounced when ?
* 90% metabolized where?

A
  • Intoxication is more pronounced when levels rising than when going down
  • 90% metabolized in liver by hepatic oxidation. Remainder excreted unchanged through liver and lung
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38
Q

Metabolism of ETOH
* Research has established individual variation in alcohol metabolism is controlled by what?
* Several pathways to metabolism – most common involves what?
* ADH metabolizes what?

*

A
  • Research has established individual variation in alcohol metabolism is controlled by genetic factors and environmental factors.
  • Several pathways to metabolism – most common involves two enzymes; alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH)
  • ADH metabolizes alcohol to Acetaldehyde – highly toxic/carcinogen
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39
Q

What does disulfiram cause?

A

Disulfiram (Antabuse) inhibits the action of aldehyde dehydrogenase and produces toxic blood levels of acetaldehyde

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40
Q

ALCOHOL METABOLISM
* Individuals of Asian descent have lower levels of what? What does that cause? (2)

A

Individuals of Asian descent have lower levels of both alcohol dehydrogenase and aldehyde dehydrogenase.
* Metabolize alcohol more slowly.
* Become intoxicated on lower amounts of alcohol than do Caucasians

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41
Q

Alcohol Neurobiology
* What is alcohol?
* What does it decrease? What are similar substances?

A
  • Alcohol is a depressant
  • Decreases neuronal activity (action like sedative-anxiolytics: benzodiazepines, barbiturates, and carbamates
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42
Q

Alcohol Neurobiology
* What is the medicated pathway?

A
  • Activation of GABA
  • Opens chloride channels and depresses CNS
  • Releases opioid peptides and dopamine
  • Inhibits glutamate NMDA (N-methyl-D-Aspartate) receptors
  • Interacts with serotonin system
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43
Q

Alcohol Neurobiology:
* What happens to Neurotransmitters in chronic use? (3)

A
  • Upregulation of excitatory glutamate NMDA receptors
  • Downregulation of inhibitory neuronal GABA receptors
  • Increased central norepinephrine activity
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44
Q

Alcohol Neurobiology:
* What is the Response to termination of alcohol consumption?

A

CNS hyperactivity. Due to a lack of opposition to an alcohol-induced excitatory state

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45
Q
A
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45
Q

What are the Clinical Indicators of Increased Acetaldehyde? (4)

A
  • Flushing of face
  • Nausea
  • Rapid heart rate
  • Increased respiration rate
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46
Q

What are the physical findings of alcohol use? (12)

A
  • Acne rosacea
  • Palmar Erythema
  • Hepatomegaly (fatty liver)
  • Cirrhosis
  • Jaundice
  • Ascites
  • Testicular Atrophy
  • Gynecomastia
  • Dupuytren’s contractures
  • Telangiactasia
  • Peripheral wasting
  • Peripheral neuropathy
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47
Q

Alcohol (FINDINGS)
* What are the Laboratory Findings? (6)

A
  • Elevated Transaminases
  • Elevated Mean Corpuscular Volume
  • Increased HDL and Decreased LDL
  • Elevated Triglycerides
  • Elevated Bilirubin
  • Low Platelets
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48
Q

Alcohol (FINDINGS)
* What is the x-ray finding?

A

Evidence of fractures

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49
Q

MEDICAL WORKUP-alcohol
* Complete what?
* What labs need to be order?

A

Complete history and physical

CBC with diff

Comprehensive blood chemistry panel:
* Electrolytes-
* Ca and Mg
* LFT’s
* Bilirubin, Bun, creatinine, FBS prothrombin time, albumin, total protein

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50
Q

MEDICAL WORKUP-alcohol
* What tests?
* What vitamins?
* Serum what?
* What screen?
* What imaging?

A
  • Hepatitis type B surface antigen
  • Test for Hepatitis C
  • B Vitamins (especially B1- thiamine); and B 12 Folate
  • Serum amylase,
  • U/A and urine drug screen
  • EKG; Chest x-ray
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51
Q

ALCOHOL
* What test of hepatic function is most likely to be elevated in a patient with chronic alcoholism?

*

A

gamma-glutamyl transferase
* It is elevated in 80% of patients with chronic alcoholism

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52
Q

ALCOHOL
* Which subtype of anxiety disorder is most associated with alcohol-related disorders?

A

Panic Disorder

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53
Q

ALCOHOL WITHDRAWAL
* Begins when?

A

Begins several hours after consumption ends or when there is reduction in consumption if a person drinks heavily or for a *prolonged period of time.
* Prolonged = days.

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54
Q

ALCOHOL WITHDRAWAL
* Symptoms usually peak in intesitiy when?
* What are sxs?
* Fewer than 10% individuals who develop alcohol withdrawal develop what?

A
  • Symptoms usually peak in intensity during the second day of abstinence and usually improve significantly by the fourth or fifth day
  • Symptoms of anxiety, insomnia, and autonomic dysfunction may continue for up to 3-6 months (less intensity)
  • Fewer than 10% individuals who develop alcohol withdrawal develop dramatic sxs (e.g., severe autonomic hyperactivity, tremors, withdrawal delirium)
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55
Q

ALCOHOL WITHDRAWAL DELIRIUM (DT’s)
* Who does this occur in?
* What are sxs?

A

Usually in severe, heavy users who are medically compromised with long hx of dependence
* Delirium tremens ( DT’s)
* Paranoid delusions, visual hallucinations of insects or small animals and tactile hallucinations

Occurs in 1-3% dependent drinkers

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56
Q

Clinical Instrument for Withdrawal Assessment for Alcohol Scale (CIWA)
* Rates how?
* What are the different components?(5)

A

Rates the following on a scale from 1-7 (not present to extremely severe)
* Nausea and vomiting
* Paroxysmal sweats
* Anxiety
* Agitation
* Tremor

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57
Q

Clinical Instrument for Withdrawal Assessment for Alcohol Scale (CIWA)
* The CIWA should be used to monitor patients in what?
* Time between assessments increases as what?
* For patients receiving PO benzodiazepines, monitor when?
* What needs to be monitored? (3)

A
  • The CIWA should be used to monitor patients in severe withdrawal and receiving IV benzodiazepines every 10-15 minutes
  • Time between assessments increases as symptoms improve
  • For patients receiving PO benzodiazepines, monitor every four to six hours
  • Vital signs, tremor, and mental status
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58
Q

Treatment of alcohol withdrawal
* Check vital signs when?
* Correct what?
* Treat with what?
* Treat severe withdrawal with what?
* May treat hallucinations with what?

A
  • Check vital signs q 4-6 hrs
  • Correct electrolyte imbalances etc.
  • Treat with Benzos (Ativan, Librium or Serax) if BP/pulse rising
  • Treat severe withdrawal with anti-seizure medication and/or IV Benzodiazipines
  • May treat hallucinations with antipsychotics. But be careful. It could precipitate seizures
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59
Q

Alcohol Treatment
* What vitamins are given? (3)
* What do you need to give meds for?

A
  • Thiamine i.m. initially and then orally: 100 mg one to three times/day
  • Folic acid: 1 mg orally daily
  • Multivitamin daily
  • Provide medication for adequate sleep
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60
Q

What is the maximum length of time that one can detect alcohol metabolites in the body?

A

12 hours

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61
Q

What are the Alcohol-Induced Persisting Amnestic Disorders

A
  • Wernicke’s encephalopathy
  • Korsakoff’s Syndrome
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62
Q

Alcohol-Induced Persisting Amnestic Disorders-Wernicke’s
* What is it caused by?
* What are the sxs?
* Fear of what?

*

A
  • An ACUTE syndrome caused by thiamine deficiency
  • Nystagmus; abducens and conjugate gaze palsies
  • Ataxia; global confusion; confabulation; lethargy; indifference, mild delirium, anxious insomnia,
  • Fear of dark
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63
Q

Alcohol-Induced Encephalopathy-TREATMENT
* Treat with what?
* What do you also need to give bc it is a cofactor?
* With treatment, most sxs resolve except what?
* Sxs may clear when?

A
  • Treat with thiamine 100 mg im followed by 100 – 300 mg po qd. until opthalmoplegia resolves.
  • May need to give magnesium- a cofactor in thiamine metabolism
  • With treatment, most sxs resolve except ataxia, nystagmus, and sometimes peripheral neuropathy.
  • Sxs may clear in a few days or weeks or -> Korsakoff’s Syndrome
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64
Q

Alcohol-Induced Persisting Amnestic Disorders- Korsakoff
* Related to what?
* Also known as what?
* Usually when does this happen?
* Caused by what?

A
  • Related to alcohol dependence
  • Also known as Korsakoff’s Psychosis
  • Usually when person’s major caloric intake for years has been alcohol
  • Caused by thiamine deficiency (Vitamin B-1) because of inadequate nutrition
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65
Q

Alcohol-Induced Persisting Amnestic Disorders- Korsakoff
* What type of amnesia?
* What are some sxs?
* Often co-exists with what?
* What is the recovery rate?

A
  • Anterograde and retrograde amnesia
  • Confabulation; disorientation
  • Polyneuritis
  • Often co-exists with alcohol related dementia
  • Recovery rate 20-50%- therefore tends to be chronic
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66
Q

What is anterior grade amnesia? What is retrograde amnesia?

A
  • ANTERIOR GRADE AMNESIA =Amnesia for events that occur after a point in time
  • RETROGRADE AMNESIA=Amnesia for events occurring before a point in time
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67
Q

Alcohol-Induced Persisting Amnestic Disorders-Korsakoff’s
* What can be helpful?
* What is the recovery rate
* Rate of partial recovery with what?

A
  • Clonidine (Catapres) or Propranalol (Inderal) might be helpful
  • Full recovery- 25%
  • Rate of partial recovery with long term treatment with thiamine- 50- 100 mg daily: 50%
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68
Q

Alcohol Rehabilitation
* What was found to be the most effective followed by AA?

A

Salvation Army was found to be the most effective followed by AA.

How well did you know this?
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Not at all
2
3
4
5
Perfectly
69
Q

Alcohol Rehabilitation
* What medication can you give? What does it inhibit? May see what?

A

Antabuse (Disulfiram)
* Enforces sobriety by causing unpleasant (or worse) symptoms even with small amounts of alcohol
* Inhibits aldehyde dehydrogenase
* May see flushing, sweating, anxiety, confusion, headache, low blood pressure, difficulty breathing

70
Q

Alcohol Rehabilitation
* Disulfiram contraindicated with patients who have what? What can it cause?

A
  • Antabuse contraindicated with patients who have pre-existing heart disease, cerebral thrombosis, diabetes.
  • Can cause fatal reaction

Not a permanent treatment

71
Q

Alcohol Rehabilitation
* What does naltrexone (Naltrexone) do?
* What does Acamprosate (Campral) do?
* What does Topiramate (Topamax) help with?

A

ReVia (Naltrexone)- Decreases craving by blocking release of endogenous opioids
* Blocks the high

Acamprosate (Campral)- decreases cravings in abstinent patients

Topamax may help with cravings- off label possibility

72
Q

Alcohol Rehabilitation
* What can you do for families?

A

Al-Anon for families

73
Q

ALCOHOL REHABILITATION
* how many people will relapse?

A

50%

74
Q

Fetal Alcohol Spectrum Disorders Clinical Presentation
* What are the sxs?

A
  • Low body weight
  • Poor coordination
  • Hyperactive behavior
  • Poor memory
  • Difficulty in school (math issues predominate)
  • Learning disabilities
  • Speech/language delays
  • Low IQ
  • Poor reasoning and judgement skills
  • Sleep problems as a baby
  • Vision/hearing deficits
  • Short stature, small head
75
Q

FETAL ALCOHOL SYNDROME-Signs
* What can the baby show signs of?
* May have early stage what?
* What is common?
* What can happen? (2)

A
  • Affected infant may show signs of withdrawal
  • May have early stage of liver disease
  • Mental retardation common->44% had IQ of 79 or lower
  • 17% stillborn or die shortly after birth
  • 20% have birth defects. 32% show full sxs
76
Q

CAFFEINE INTOXICATION
* What are the sxs? (8)

A
  • Nausea
  • Muscle tension
  • Vomiting
  • tachypnea
  • Shock
  • Palpitations
  • Agitation
  • Tremor
77
Q

CANNABIS
* Regular users of cannabis can develop what?
* Frequently occurs along with use of what?

*

A
  • Regular users of cannabis can develop all the general diagnostic features of a substance abuse disorder
  • Frequently occurs along with use of other substances- alcohol, cocaine, and opioids
78
Q

CANNABIS
* Synthetic oral formulations (pill/capsules) of delta-9-tetrahydrocannabinol (delta-9-THC) available by prescription for several approved medical issues: (7)

A
  • Nausea and vomiting due to chemotherapy
  • Anorexia and weight loss in individuals with HIV
  • Glaucoma
  • Arthritis
  • Chronic pain
  • Epilepsy
  • PTSD
79
Q

CANNIBIS
* Early onset of use (prior to 15 years) is a robust predictor of what?
* Cannabinoids are what?
* Persist in bodily fluids for how long?
* Excreted at what rate?

A
  • Early onset of use (prior to 15 years) is a robust predictor of development of cannabis use disorder and other types of substance use disorders and metal disorders during young adulthood
  • Cannabinoids are fat soluble
  • Persist in bodily fluids for extended periods of time
  • Excreted slowly
80
Q

Cannabis (Marijuana)
* Long term use causes what?
* Mixed with formaldehyde it is called what?
* Often mixed with what?

*

A
  • Long term use causes AMOTIVATIONAL SYNDROME
  • Mixed with formaldehyde it is called “Illy” or “Wet”
  • Often mixed with PCP (“laced joint”)
81
Q

Cannabis (Marijuana)
* LANCET study found at least 50% of individuals who used cannabis in their lifetime exhibited what?

A

LANCET study found at least 50% of individuals who used cannabis in their lifetime exhibited psychosis. It might manifest early on or could be delayed until midlife (or anytime, for that matter)

82
Q

CANNIBIS
* What has happen with the teen population?

A

A 2021 systematic review found that past-year cannabis vaping nearly doubled from 2017 to 2020 in adolescents - jumping from 7.2 percent to 13.2 percent. A more recent study in five northeastern U.S. states found that 12.8 percent of adolescents vaped cannabis in the past 30 days, a narrower time frame that suggests potential increases in use. In addition, a 2020 study found that one-third of adolescents who vape do so with cannabis concentrates.

83
Q

Cannibis
* What happens happened with the increased use of cannabis and the potent levels of 9-tetrahydrocannabinol ?

A

This has unintended neurodevelopmental implications given the increased use of cannabis and the potent levels of 9-tetrahydrocannabinol today being consumed by pregnant women, young mothers and teens.

84
Q

Cannabis
* What was found to be impaired?

A

Bara et al. found impaired synaptic plasticity as characteristic of developmental exposure and the important contribution of epigenetic reprogramming that maintains the long-term impact into adulthood and across generations.

85
Q

CANNABIS WITHDRAWAL
* Cannabis withdrawal is included in the DSM-5, and the diagnostic criteria include what?

A

Cannabis withdrawal is included in the DSM-5, and the diagnostic criteria include stopping cannabis use that has been heavy and prolonged (typically daily or almost daily for at least a few months).

86
Q

CANNABIS WITHDRAWAL
* At least three of the following signs and symptoms must begin within one week of stopping cannabis use:

A
  • irritability
  • anger
  • aggression
  • nervousness or anxiety
  • difficulty sleeping
  • decreased appetite
  • restlessness
  • depressed mood
87
Q

SYNTHETIC LEGAL INTOXICATING DRUGS
* Generally sold where?
* Usually labeled as what?
* What does the label usually say? (3)

A

Generally sold over the counter in head shops

Usually labeled as bath salts or herbal incense

Often labels say
* “not for human consumption” (bypasses FDA regs)
* Herbal blends
* Marketed as “natural” substances

88
Q

SYNTHETIC LEGAL INTOXICATING DRUGS
* Bath salts and herbal incense abused for what type of effects?
* Attempts to mimic what?
* Sometimes marketed as what?

A
  • Bath salts and herbal incense abused for their psychogenic, hallucinogenic , and mood-altering effects
  • Attempts to mimic cocaine or methamphetamine
  • Sometimes marketed as substitute for methylphenidate- to sharpen concentration or to use as aphrodisiac
89
Q

BATH SALTS
* What are they?
* Powerful what?
* Creat similar effects as what?

A

Methcathinones
* Common components either
* Mephedrone (Similar to methamphetamine)
* 3,4-methylenedioxypyrovalerone (MDPV)
* Methylone (Similar to MDMA-Ecstacy)

Powerful stimulants

Create similar effects as methamphetamines

90
Q

BATH SALTS
* Mephedrone chemically similar to what?
* MDPV inhibits what?
* Sold under names as what?

A
  • Mephedrone chemically similar to cathinone- active ingredient of African Khat plant
  • MDPV inhibits reuptake of dopamine and norepinephrine
  • Sold under names as White Lightning, Cloud 9, Ivory Wave
91
Q

BATH SALTS
* How can it be used?
* Work how fast/slow?
* How long are the effects?
* Adverse effects may last how long?
* What is bumping?

A
  • May be inhaled, injected, snorted, swallowed, inserted into rectum or vagina
  • Works quickly- in 10-20 minutes
  • Desired effects typically last 2-4 hours
  • Adverse effects may last 8 hours or more
  • “Bumping”: Larger loading dose with several smaller doses q 2-3 hrs to maintain high
92
Q

BATH SALTS
* Intranasal rout produces more what?
* MDPV may be 10X addictive than what?

A
  • Intranasal rout produces more potent high and greater addictive potential than ingestion
  • MDPV may be 10X addictive than methanphetamine
93
Q

BATH SALTS- What to look for
* May mimic what?
* What are the most common signs of toxicity? (4)

A

May mimic psychiatric disorder

Most common signs of toxicity
* Dilated pupils with prominent nystagmus
* Lockjaw and teeth grinding
* Rapid, inappropriate, incoherent speech
* Emotionally, verbally, and physically abusive

94
Q

BATH SALTS
* Cannot be detected with what?
* Specialized labs use what?
* Components very and often changes by what?

A
  • Cannot be detected with standard urine drug tox screens
  • Specialized labs use chromatography-mass spectometry
  • Components very and often changes by manufacturers to avoid detection
95
Q

BATH SALTS- RX
* What do you give for anxiety, aggression, tremors, seizures, and psychosis?

A

benzodiazepines

96
Q

BATH SALTS- treatment
* What is a second line choice? Why?

A

Antipsychotics second-line choice
* Lower seizure threshold
* Potential for worsening hyperthermia gy triggering malignant neuroleptic syndrome

97
Q

BATH SALTS- long term consequences
* After resolution of psychosis, many experience what?
* Who is at the greatest risk for severe psychiatric reactions?

A
  • After resolution of psychosis, many experience depression and suicidal thoughts
  • Patients who have underlying psychiatric conditions are at the greatest risk for severe psychiatric reactions
98
Q

BATH SALTS
* What have they caused?

A
  • Myocardial infarction
  • Stroke
  • Cerebral edema
  • Coma
  • Cardiovascular collapse
  • Death
  • Effects vary with route of admin-swallowed, snorted, injected, per rectum or vagina
99
Q

SYNTHETIC CANNABINOIDS
* Known as what?
* Not from what?
* common among who?
* How is it used?
* Synthesized in labs and formulated to interact with what?

A
  • Known as K2; incense; spice
  • Not from cannabis
  • 1- year prevalence among 12th graders: 11.4%->2nd behind marijuana
  • Inhaled
  • Synthesized in labs and formulated to interact with endogenous cannabinoid receptors
100
Q

SYNTHETIC CANNABINOIDS- mechanism of action
* What does it decrease and increase?
* Carry a higher risk of what?

A
  • Decrease GABA levels
  • Increase glutamate and dopamine levels
  • Increases serotonin release
  • Carry a higher risk of causing psychosis
101
Q

SIGNS AND SYMPTOMS OF SYNTHETIC CANNABINOIDS
* What happens physically?

A
  • Hypertension
  • Tachycardia
  • Anticholinergic manifestations
  • Nausea
  • Seizures
102
Q

SIGNS AND SYMPTOMS OF SYNTHETIC CANNABINOIDS
* What happens mentally?

A
  • Agitation
  • Alteration of time perception
  • Amnesia
  • Anxiety
  • Dysphoria
  • Apathy
  • Terrifying hallucinations
  • Paranoia/psychosis
  • Self-destructive and violent behavior
103
Q

SIGNS AND SYMPTOMS OF SYNTHETIC CANNABINOIDS
* sxs last how long?

A

Symptoms typically last up to 6 hours

104
Q

SYNTHETIC CANNABINOIDS- Detection
* Can be detected by what?
* Suspect spice intoxication in any patient presenting with what?

A

Can be detected by commercial lab BUT
* Formulations change often
* Tests quickly become obsolete

Suspect spice intoxication in any patient presenting with bizarre behavior, anxiety, agitation, and/or psychosis who has no known psych history.

105
Q

SYNTHETIC CANNABINOIDS- RX
* What is the tx for agitation and seizures?

A

IV benzodiazepines most used to treat agitation and seizures

106
Q

SYNTHETIC CANNABINOIDS-outcome
* Possible 3X increased risk of causing what?
* Recurrence or exacerbation of what?
* Persistent what?
* Reduced volume where? What does this alter?

A
  • Possible 3X increased risk of causing psychosis
  • Recurrence or exacerbation of pre-existing psychotic symptoms
  • Persistent depression and suicidal ideation
  • Reduced volume in hippocampus and amygdala
    * Alterations in emotional processing and cognitive functioning
107
Q

Benzodiazepines
* What has a cross reaction?
* Any benzo can be what?
* All are agonists of what?
* Most _ medication

A
  • Benzodiazepines and alcohol- cross tolerance
  • Any benzo can be abused and result in dependence
  • All are agonists of gamma-aminobutyric acid A- (GABAA) receptors
  • Most prescribed medication
108
Q

Benzodiazepines
* What are the warning signs of abuse/dependence?

A
  • Need to progressively increase dose to maintain desired effect (tolerance)
  • “Doctor Shopping” or using multiple providers to obtain the drug
  • Frequently “runs out” of prescription before he/she should
  • Frequently “loses” the prescription
109
Q

Benzodiazepine Withdrawal
* Much like what?
* What is more likely to produce sxs?

A
  • Much like Alcohol Withdrawal
  • Short acting Benzo withdrawal is more likely to produce symptoms (e.g. Xanax = alprazolam)
110
Q

Benzodiazepine Withdrawal
* Easier to withdraw patients if switch to what?
* Some patients develop what?

A
  • Easier to withdraw patients if switch to longer acting benzodiazepine before the taper
  • Some patients develop withdrawal after regular use.
111
Q

DATE RAPE DRUGS- GHB (Gamma hydroxybutyrate)
* What is GHB naturally? Increases what?
* What does it cause to the CNS?
* Used to induce what?
* Recently studied to treat what?

A

GHB (liquid ecstacy)
* A naturally occurring brain transmitter that is related to sleep regulation->Increases dopamine in brain
* A CNS depressant. Affects endogenous opioid system
* Used to induce anesthesia->Unpredictable duration of action limits use
* Recently studied to treat alcohol, opioid withdrawal and narcolepsy

112
Q

GHB- date rape drug
* How it is absorbed?
* WHat is the onset of action?
* Effects last how long?
* Surreptitious sedation facilitates what?

A
  • Rapidly absorbed
  • Onset of action within 15 minutes after ingestion
  • Effects last 1.5-2 hours
  • Surreptitious sedation facilitates rape

  • Until 1990, GHB sold in US health food stores.
  • Body builders used it as steroid alternative
113
Q

GHB-Adverse effects
* What are some SE?

A
  • Nausea, vomiting respiratory problems,
  • Seizures, coma, death
  • Some reports- abuse linked to syndrome similar to Wernicke-Korsakoff syndrome
114
Q

DATE RAPE DRUGS-ROHYPNOL (ROOFIES)
* What is the generic name?
* Used to faciliate what?
* 7-10 times what?
* What is the onset?
* Duration?
* Freq causes what?

A
115
Q

OPIOIDS
* What are the examples?

A
116
Q

OPIOIDS
* Opiate analgesics have the same warning signs of abuse and dependence as what?

A

benzo

117
Q

OPIOID USE DISORDER
* Signs and symptoms reflect what?

A

Signs and symptoms reflect compulsive prolonged self-administration of opioid substances for no legitimate purpose, or more than amount needed to treat pain symptoms.

118
Q
A
119
Q

Heroin
* What is it?
* What are associated risks? (3)

A
120
Q

Opioid Intoxication
* What are the sxs of intoxication?

*

A

Pupillary constriction with drowsiness or coma; slurred speech; impairment of attention or memory; and pulmonary edema from central respiratory depression

121
Q

OPIOIDS
* Is withdrawal life threatening?
* May be seen in individuals who have become what?
* Babies born to mothers who abuse opioids may be what?

A
122
Q

OPIOID WITHDRAWAL
* What are the withdrawal sxs?

*

A

Disorientation, confusion,dysphoric mood, vertical nystagmus, increased muscle tone, dilated pupils, increased blood pressure and heart rate, marked diaphoresis, piloerection, lacrimation (or rhinorrhea), salivation, nausea or vomiting, yawning, fever, insomnia

123
Q

OPIOID WITHDRAWAL
* May be precipitated by what?
* Withdrawal may begin when?

A
  • May be precipitated by opioid antagonist, such as naltrexone, after period of opioid use (May be used to treat opioid use disorder)
  • Withdrawal may begin within 6-12 hours after last dose of short-acting drug such as heroin but within 2-4 days in case of longer-acting drugs such as methadone
124
Q

TREATMENT OF OPIOID WITHDRAWAL (one method)
* What can you give for N/V/D, pain, anxiety and sleep

A
125
Q

TREATMENT OF OPIOID WITHDRAWAL- Buprenorphine
* What is it?
* At high doses, its clinical effect does what?

A
  • A partial opioid mu-receptor agonist and weak kappa antagonist offers safety. Similar efficacy as methadone.
  • At high doses, its clinical effect plateaus and it acts more like an agonist, reducing the risk of overdose, respiratory depression and diversion to other opioid type substances
126
Q

TREATMENT OF OPIOID WITHDRAWAL- Buprenorphine
* Used for what?
* Comes in what?
* Also sold as what?

A
  • Used for withdrawal and maintenance
  • Comes in patch and sublingual form as well as im and iv
  • Also sold as Suboxone which is buprenorphine plus naloxone
127
Q

METHADONE
* What is methadone? What does it do?
* What can be abused?

A

Methadone is a sort of surrogate that replaces heroin
* Keeps addict from going into withdrawal
* Its gradual and mild onset of action keeps addict from getting high
* Other treatment use: Can give relief from chronic pain

Methadone Maintenance
* This program may be abused

128
Q

DEXTROMETHORPHAN ABUSE
* What can it cause?
* What is it?
* Excerts what type of effects?

A
  • hallucinations and /or psychosis
  • It is a synthetic dextro-isomer of codeine
  • Exerts anti-tussigenic effect via the sigma opioid receptor BUT lacks other opioid activity
129
Q

Dextromethorphan
* What is tolerated in patients older than 12 years old?
* What is benign reactions?

A
  • In patients 12 yrs or older tolerated when take 60- 120 mg (in cold meds)
  • Benign reactions- drowsiness, dizziness, upset stomach, nervousness and restlessness
130
Q

DEXTROMETHORPHAN
* What effects do you get and when?
* When does psychosis often?
* What has been described with use of 3600mg

A
  • Hallucinogenic effects at 160 to 300 + mgs.
  • Psychosis often occurs at greater than 600 mg
  • Non-suicidal use of 3600 mg been described
131
Q

DEXTROMETHORPHAN
* Individuals who are extensive metabolizers of CYP-450 2D6 what? Who is this important for?

A

Individuals who are extensive metabolizers of CYP-450 2D6 show higher blood dextromethorphan and increased potential to abuse it for its dissociative and hallucinogenic effects
* Of importance for individuals on SSRIs and SNRIs, even for normal metabolizers

132
Q

Cocaine:
* How can it be used?
* Referred to as what?
* What is the rock based form?
* What is the much more expensive form?
* What is a speedball?

A
  • Cocaine in powder form may be snorted, injected, smoked or rubbed on mucosa
  • Referred to as coke, crack, blow, or freebase.
  • Crack is rock based form
  • “Freebase” is much more expensive form than “Crack cocaine.” Both are smoked.
  • Cocaine mixed with Heroin is “speedball”
133
Q

Cocaine:
* How does cocaine work in the central nervous system?

A

A competitive blocker of dopamine . It inhibits dopamine reuptake and increases activation of dopaminergic pathways = dopamine agonist

134
Q

COCAINE-Clinical features of intoxication
* What happens mentally?
* What happens to cardiac?
* What are other sxs?

A
  • Mental: Euphoria, hypervigilance, agitation or psychomotor retardation, hallucinations
  • Cardiac: Tachycardia, bradycardia, high or low blood pressure, arrhythmia
  • Other: Pupillary dilation; perspiration or chills, nausea, or vomiting
135
Q

HELPFUL HINT
* DRINK COLA, DILATE PUPILS?

*

A

**See dilated pupils with Cocaine, Opioid withdrawal, LSD use, Amphetamine intoxication

136
Q

COCAINE
* What does it constrict?
* Is withdrawal life threatening?
* What is the metabolite? How long does it remain in urine?
* There is no what?

A
  • Constricts coronary arteries
  • Cocaine withdrawal is not life threatening
  • Metabolite of cocaine-benzoylecognine-typically remains in urine 1-3days after single dose use
  • May be present for 7-12 days if repeated high doses used
  • There are no neurobiological markers of diagnostic utility
137
Q

COCAINE
* What is A worrisome medical complication commonly associated with cocaine abuse?

A

MI

138
Q

COCAINE WITHDRAWAL
* Occurs when?
* Most common sign of withdrawal?

A
  • Occurs within hours to days after heavy cocaine use.
  • Most common sign of withdrawal, desire to use again- craving
139
Q

COCAINE WITHDRAWAL
* What are the sxs?
* Some have used to treat psychological withdrawal?

A
  • Dysphoria, increased appetite, fatigue, psychomotor retardation or agitation, and sleep abnormalities ( vivid, unpleasant dreams, insomnia, or hypersomnia)
  • Some have used desipramine to treat psychological withdrawal. Some trials using propranolol show promise
140
Q

COMPLICATIONS OF COCAINE USE
* What can happen with violence?
* Psychopathology: Chronic use depletes what?

A
  • Violence- suicide and homicide
  • Psychopathology: Chronic use depletes all neurotransmitters. Risk of dependence could occur after one use
141
Q

COMPLICATIONS OF COCAINE USE
* Chronic use depletes all neurotransmitters: what are the associated findings?

A

depression, fatigue, poor self-care, low self- esteem, low libido, mild parkinsonism. Psychosis, attention deficit sx and stereotypies may result from continued use.

142
Q

COMPLICATIONS OF COCAINE USE
* Can lead to what? Even in who? Route?
* What are more serious acute complications?

A
  • Can lead to death
  • Even in recreational low dose users
  • Route of consumption does not change risk
  • More serious acute complications- myocardial infarction, subarachnoid hemorrhage, metabolic and respiratory acidosis, arrhythmia, grand mal seizures, and respiratory arrest
143
Q

CHRONIC COMPLICATIONS OF COCAINE USE
* What can happen with intranasal abuse?

A

nasoseptal defects and dental neglect because of cocaine’s anesthetic properties.

144
Q

COCAINE
* What is common among cocaine users?

A

Pathologic gambling among cocaine dependent users 5 times > general population

145
Q

STIMULANTS- AMPHETAMINES- use for medical reasons
* Releases what?

A

Release catecholamines (mainly dopamine) from presynaptic stores (in the reward pathway from ventral tegmentum to cortex

146
Q

STIMULANTS- AMPHETAMINES- use for medical reasons
* What are acceptable uses?

A

ADHD

Narcolepsy

Methylphenidate-
* Sometimes depression
* More commonly in depressed bipolar patients (off-label use)

147
Q

Stimulants-Amphetamines and Methylphenidate
* Prescription use is for what?
* These drugs are sometimes what?
* What is unique about vyvanse?

A
148
Q

Stimulants-Amphetamines and Methylphenidate
* Methylphenidate does not act on what?

A

Methylphenidate does not act on dopamine neurons so thought to be less addictive than amphetamines

149
Q

Amphetamines
* Is withdrawal life threatening?
* What are Designer amphetamine-like drugs?

A
150
Q

Amphetamines
* What is ice or crystal?

A

Ice or crystal- pure form of methamphetamine
* Of all the club drugs, the most often cause for admission to ED

151
Q

Amphetamines
* Clinical syndromes similar to what?
* Oral route of admin produces what?
* Can induce what?

A
  • Clinical syndromes similar to cocaine abuse
  • Oral route of admin produces less rapid euphoria and less addiction
  • Can induce paranoid psychosis similar to schizophrenia, paranoid type
152
Q

What is khat and crank?

A
  • “Khat”: Canthinone from a bush which is chewed
  • “Crank”: Methcanthinone synthesized from ephedrine or pseudoephedrine (Sudafed)
153
Q

AMPHETAMINE ABUSE
* Long term sequelae of amphetamine abuse mimic those of what?
* Chronic use can cause a syndrome resembling what?

A
  • Long term sequelae of amphetamine abuse mimic those of cocaine abuse
  • Chronic use can cause a syndrome resembling Dysthymic Disorder.
154
Q

ECSTACY
* What is another name?
* Somtimes classified as what?
* Usually taken how?
* Has the effect of making the user feel what?
* Typically taken when?

A
155
Q

ECSTASY
* What is a usual dose?
* Onset of effect?
* Prinicipal desired effect is what?

A
156
Q

ECSTACY
* Desire for sex increased but what?
* Prescription drugs such as sildenafil (Viagra) sometimes taken in order to what?

A

Desire for sex increased but ability to achieve arousal and orgasm greatly diminished in both men and women
* Called sensual drug as opposed to sexual

Prescription drugs such as sildenafil (Viagra) sometimes taken in order to counteract diminished sexual performance

157
Q

ECSTACY
* Has been long known to damage what?
* MDMA can cause loss of what?

A
  • Has been long known to damage brain serotonin (5HT) neurons in laboratory animals
  • MDMA can cause loss of serotonergic neurons
158
Q

ECSTACY
* Damage to the brain may be what?

A

Damage to the brain may be permanent and is dependent on overall amount of MDMA consumed over time

159
Q

ECSTACY
* Acute dangers rare but can be serious and usually involve what?
* What is the most common reaction?

A
  • Acute dangers rare but can be serious and usually involve dehydration that could cause coma or death
  • SEIZURES the most common reason for admission to ED
160
Q

ECSTACY
* Intoxication or overdose of MDMA may be suspected in who?
* Classic dependence does not occur but some ?

A
161
Q

ECSTASY
* What does produce?
* What can increase?
* What are other sxs?
* Must treat what?

A
  • Produce amphetamine like effects
  • Hypertension and/or hyperthermia
  • Rhabdomyolysis, hyponatremia, cerebral infarction, disseminated intravascular coagulopathy, cardiac arrhythmias, hepatic and renal failure
  • Must treat hyperthermia and complications. Rapid cooling and dantrolene (Dantrium), a skeletal muscle relaxant, may be life saving
162
Q

ECSTASY- Other symptoms
* What are some of the other sxs?

A
  • Anorexia
  • Trismus
  • Impaired concentrating
  • Impaired balance
  • Perceptual and behavioral side effects->Users found to have higher levels of paranoid ideation, psychotic syndromes, somatization, obsessions, anxiety, hostility, phobic anxiety
163
Q

ECSTACY-Psych problems
* What are some sxs?
* What type of deficits?
* What type of problems?
* What is most common?

A
  • Depression, anxiety, panic, increased impulsiveness, and sleep disturbances –these sxs significantly higher in people who have used MDMA, even when abstinent and when last use was long time ago
  • Memory deficits
  • Attention problems
  • Most common- psychosis, anxiety, panic disorder and depression
164
Q

LSD
* Effects last how long?
* What are the sxs?

A
165
Q

LSD
* What can be impaired?
* What can be bad?
* What are flashbacks?

A
166
Q

LSD
* no significant what?
* What is the MOA?

A
  • No significant withdrawal symptoms
  • Mechanism of action: Partial agonist at postsynaptic serotonin receptor
167
Q

PCP and similar drugs:
* How can it be made?
* How can it be used?
* What is special K?
* Both are what?

A

PCP (usually laced with marijuana or nicotine to be smoked)
* Can also be eaten, injected or inhaled nasally
* “Special K”: Ketamine or Ketalar

Both are anesthetics and hallucinogenic

168
Q

KETAMINE
* Ketamine IV been extremely effective treating what?
* Intranasal ketamine being used in trials with what?

A
  • Ketamine IV been extremely effective treating resistant depression
  • Intranasal ketamine being used in trials with children who have bipolar illness and specific fearful phenotype- Dimitri Papolos MD, NIH grant
169
Q

MUSHROOMS- Psilocybin
* What are other names?
* Natural what?
* Psychoactive properties come from what?

he loves this *

A
  • “Magic Mushrooms,, “Shrooms”
  • Natural psychedelic
  • Psychoactive properties come from psilocybin, an indole hallucinogen similar to LSD but with a shorter duration of action: 4-6 hours
170
Q

Psilocybin
* COMPASS Pathways is a biotech company that has conducted a phase IIb clinical trial of what?
* The study showed that a single 25mg dose of COMP360 psilocybin, in combination with psychological support, was associated with what?

A
  • COMPASS Pathways is a biotech company that has conducted a phase IIb clinical trial of COMP360 psilocybin therapy for treatment-resistant depression.
  • associated with a highly statistically significant reduction in depressive symptoms after three weeks, with a rapid and durable response for up to 12 weeks.
171
Q

Psilocybin
* A study run by COMPASS Pathways and published in the New England Journal of Medicine found what?

A

study run by COMPASS Pathways and published in the New England Journal of Medicine found that a third of patients with treatment-resistant depression who took the highest dose of psilocybin saw their symptoms diminish.

172
Q

GAMBLING DISORDER
* Distortions of what?
* Belief of what?
* UP to 50% individuals in treatment for gambling disorder have what?

A
  • Distortions in thinking (e.g., denial, superstitions, a sense of power and control over the outcome of chance events, overconfidence)
  • Belief that money is cause and solution of and to problems
  • UP to 50% individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide

Speciality Medicine II (11 decks)

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