Lecture 9 (substance abuse) brendans Flashcards
Define substance.
Alcohol, tobacco, illicit drugs or improperly used medication
Define substance use.
Sporadic consumption with no major adverse consequences
Define at-risk substance use.
Consumption that risks major adverse consequences
Define codependency.
Condition characterized by an individual who is significantly affected by another person’s substance use or addiction
Define substance abuse.
Maladaptive use causing impairment or distress over a 12-month period where 1+ of the following has occurred.
Failure to fulfill major role obligations
Use of drugs in hazardous situations
Recurrent legal problems due to substance use
Continued drug use despite persistent social or interpersonal
problems because of use
Define dependence.
State of adaptation manifested by a substance class-specific withdrawal syndrome
what can withdrawal be produced by?
Rapid dose reduction or cessation of a substance
Administration of an antagonist
Increased Tolerance to the substance
What types of dependence are there? (2)
Psychological dependence
Physiologic dependence
Define addiction.
Primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
What behaviors characterize addiction?
Impaired control over substance use
Compulsive substance use
Continued substance use despite harm
Craving for substance
What is the difference between substance use and dependence/addiction?
Substance use a person still has control of their own use
Dependence/addiction: pts don’t have full control
What often predates the initial substance use?
Measurable brain abnormalities
thought to be genetically predisposed
How does substance use affect our hormones?
Affect dopamine levels in mesolimbic system
Changes are often permanent
Define substance use disorder.
Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2+ defining conditions within a 12-month period
What percentage of pts 12yrs and up with any illicit dug use in the past month? lifetime?
14% over 1 in 10
49% in lifetime about half
What percentage of pts 12 years and u p with marijuana use in the past 1 month? lifetime?
13% (over 1 in 10)
45% (almost half)
How many people are unaware that they have a substance abuse problem?
95%
alcohol or drug use is involved in ____% of medical admissions and ____% of psychiatric admissions
14%
26%
Who are the highest risk for substance abuse?
Late teens and early 20s
What increases the risk of later addiction?
The lower the age of first use
what is the lifetime prevalence of ETOH use in patients 12+
almost 4 out of 5 (78%)
what is the prevalence of ETOH use in the past 12 months of patients 12+
almost 2 out of 3 (62%)
what is the prevalence of ETOH use in the past 12 months in patients ages 12-20?
1 in 10 (15%)
how does being male impact drinking ETOH
Males are 2x as likely to participate in binge drinking and 3x as likley to participate in heavy drinking
what is the lifetime prevalence of cigarette or vape use in patients 12+
over 1 out of 2 patients (58%)
what is the prevalence of patients 12+ using cigarettes or vapes in the past 1 year
over 1 out of 5 (26%)
What are young adults now likely to use instead of cigarettes?
Vaporized cigarettes (vapes)
What is the #1 substance for dependence and abuse?
Alcohol
What it he most expensive substance abuse cost on society?
Tobacco
What is the most leading preventable cause of death in the US?
Tabacco
What medical conditions arise from substance abuse?
Hepatitis
Cirrhosis
HIV/AIDS
Sexually Transmitted Infections (STIs)
Motor vehicle crashes/fatalities
What social conditions arise from substance abuse?
Teenage pregnancy
Domestic violence
Child abuse
Physical fights
Overall crime
Homicide/Suicide
What are some risk factors for substance use?
Substance factors
Societal influence
Static pt demographics
Modifiable pt demographics
Personality traits
Associated psychiatric disorders
What are the substance factors?
Early onset tobacco use
Early experimentation with substances
Type of substance tried
What are the societal influence factors?
Family
Peer groups
Religious groups
Cultural and societal norms
What are the static patient demographics factor?
Male gender
Black, AI/AN or NHOPI ethnicity1
Gay or lesbian status
Genetic predisposition
What are the the modifiable pt demographics factors?
Low socioeconomic status
Single or divorced
Low educational level
Violent or high-crime neighborhood
Personal history of abuse
What are the patient personality traits factors?
Risk-takers, thrill-seekers, novelty seekers
Poor impulse control or emotional control
Difficulty relating to others
What are the associated psychiatric disorders with increased substance use risk?
Conduct disorder
MDD or Bipolar disorder
ADHD
Antisocial personality disorder
Why do people use substances?
To feel good/better (experience new feelings, and lessen anxiety)
To fit in (peer pressure)
How does anandamide affect the brain?
NT involved in regulation of pain, appetite, memory, mood
What is THC?
Active ingredient in marijuana
What is similar about THC and anandamide/
Similar chemical structure
What hormones does drug abuse affect?
Dopamine
Serotonin
Glutamate
Endorphins
GABA
What is the function of Dopamine?
Movement, motivation, reward, addiction, well-being
What is the function of serotonin?
Mood, memory, sleep, cognition
What is the function of glutamate?
Learning, memory
What is the function of endorphins?
Lessened pain, euphoria
What is the function of GABA?
Relaxation, anxiolytic
What are other naturally rewarding things?
Food
Sex
Exercise
Excitement
Comfort
What do nearly all drugs of abuse have in common?
Increase dopamine levels
Affect serotonin and glutamate levels
What are common cognitive defects with addiction?
Short-term memory loss
Impaired abstract thinking
Impaired problem-solving strategies
Loss of impulse control
…similar to those defects seen in brain damage
What are the 3 C’s of addiction?
Control
Compulsion
Chronicity
What are control factors?
Early social & recreational use
Eventual loss of emotional & behavioral control
Cognitive distortions (denial and minimization)
Tolerance and withdrawal
What are compulsion factors?
Drug-seeking activities and craving → addiction
Continued use despite adverse consequences
What are chronicity factors?
Natural history of multiple relapses preceding stable recovery
Possible relapse after years of sobriety
How does mental illness relate to substance use?
Self-medication (try to alleviate symptoms of mental illness)
Casual effects (increase vulnerability to mental illness)
Correlated causes (similar risk factors for substance abuse and mental illness)
How many substance abuse pts have a mental disorder?
50%
What is the opponent-process theory?
Process (either pleasant or unpleasant) has a 2ndary opponent(opposite) process that sets in after
With repetition, the primary gets weaker while opponent process is strengthened
How does drug addiction work over time?
Early: high pleasure, low withdrawal
Overtime: pleasure decreases, withdrawal increases
How do we treat drug addiction?
Interfering the cycle of withdrawal and use??
What other disorders are alcohol-related disorders commonly associated with?
Mood disorders(depression)
Anxiety disorders
Suicide
Personality disorders
Define at-risk drinking.
Repetitive use of alcohol, often to alleviate emotional problems
What is considered at-risk drinking for men?
15+/week
Moderate: 1-2/day
Binge: 5+/single occasion
What is considered at-risk drinking for women?
8+/week
Moderate: 1/day
Binge: 4+/day
What is considered at-risk drinking for elderly?
1+/day
7+/week
What is considered 1 “drink”
0.5-0.6oz of alcohol
Beer: 12oz 4%
Malt liquor: 8oz 7%
Wine: 5oz 12%
Hard liquor: 1.5oz(1shot) 40%
How much alcohol can a liver process?
0.5oz/hr
What is the telescoping effect?
Faster timeline from 1st drink to alcohol dependence?
Who is seen with the telescoping effect?
Women who use alcohol
Why are women more likely to be seen with the telescoping effect?
Lower EtOH dehydrogenase
Lower total body water
Smaller volume of distribution
Drink like partner
What specific psychiatric disorder is associated with alcohol-related disorders?
Depression
Who are likely to have alcohol-related disorders?
Males 4:1
Women are more likely to delay seeking help
What is the 3rd leading preventable cause of death in the US?
Excessive alcohol use
What are some effects of alcohol addiction?
Recurrent alcohol use despite disruption of social roles
Alcohol-related legal problems
Taking safety risks
What are risk factors for alcohol dependence?
Male
White, NA
Younger age (18-29)
Single
Low income
Past exposure to adverse events (military combat deployment)
Genetic disposition
Significant disability
Psych disorders(SUD, depression, BPD, personality d/o)
What are the key questions for Cage(screening substance abuse)?
Cutdown
Annoyed
Guility
Eye opener
How many “yes” do you need for the cage-aid questionnaire?
2+: need a more in depth assessment
1+: possible substance use
What other screening tools can we use to determine substance abuse?
Alcohol Use Disorders Identification Test (AUDIT)
Drug Abuse Screening Test (DAST-10)
NIDA Quick Screening Tool
What is the MOA of alcohol?
Crosses BBB
Acts as a sedative-hypotonic substance
Affects CNS receptors (GABA, NMDA(glutamate), 5HT-3(serotonin)
Facilitates dopamine release
Suppression of inhibitory control systems
What drug also affects GABA receptors?
Benzodiazepines
What are effects of alcohol?
Psychomotor dysfunction (disinhibition, dysarthria, ataxia, nystagmus, memory lapses)
N/V
Drowsiness; fragmented sleep
Respiratory depression
Hypoglycemia
Severe: stupor, coma, death
What are symptoms of 0.05% BAC?
Thought, judgement, and restraint are loosened
What are symptoms of 0.1% BAC?
Voluntary motor actions become clumsy
What are symptoms of 0.2% BAC?
Depression of motor control and emotional control areas of brain
What are symptoms of 0.3% BAC?
Confusion, stupor
What are symptoms of 0.4-0.5% BAC?
Coma; respiratory depression
What are effects of alcohol withdrawal?
Decreased cognitive function
Tremulousness
Anxiety, irritability, and hyperreactivity
Nausea and vomiting
Delirium Tremens
What are symptoms of delirium tremens?
Prolonged ETOH consumption → fewer GABA receptors
Unopposed sympathetic nervous system activity
Neuro: confusion, tremor, seizures, sensory hyperacuity, hallucinations, hyperreflexia
Psych: anxiety, agitation, panic attacks, paranoia
Diaphoresis, dehydration, electrolyte abnormalities
What are the affects of chronic use of alcohol?
Wernicke encephalopathy
Korsakoff psychosis
GI symptoms
Cardiac
Cancer
Endocrine
What are the affects of chronic use of alcohol?
Wernicke encephalopathy
Korsakoff psychosis
GI symptoms
Cardiac
Cancer
Endocrine
How does wernicke encephalopathy present as?
Confusion, ataxia, opthalmoplegia
Impaired vision/hearing, psychological dysfunction, memory deficit, hypothermia, hypotension
How do we treat wernicke encephalopathy?
Thiamine other B vitamins
Can be completely reversible with treatment
What are symptoms of Korsakoff psychosis?
Amnesia: anterograde and retrograde
Aphasia, apraxia, agnosia
20% are reversible
How is the liver affected with chronic alcohol use?
Fatty liver
Alcoholic hepatitis
Cirrhosis
How is the vascular system affected with chronic alcohol use?
Portal HTN, varices
How is the pancreas affected with chronic alcohol use?
Pancreatitis
Pancreatic insufficiency
Cancer
How is the GI affected with chronic alcohol use?
Esophagitis
Gastritis
Gastric ulcers
Cancers
How would labs be affected with chronic alcohol use?
Increased GGT, AST/ALT (ratio >2:1)
How is the CV system affected with chronic alcohol use?
HTN
Increase HR
Increased myocardial O2 consumption
Where are the cancers formed from chronic alcohol use?
Head/neck
Esophageal
Liver
Breast
Colorectal
Pancreas
How are the endocrine systemic affected from chronic alcohol use?
Dysregulation of lipoproteins and triglycerides
What are the stages of liver damage?
Fatty liver (deposits of fat cause liver enlargement)
Liver fibrosis(scar tissue forms)
Cirrhosis(connective tissue destroys liver cells0
When does alcohol withdrawal occur, when are the peak intensity of symptoms?
8-12hours
48-72hours
What is the main treatment for alcohol withdrawals? Examples?
Benzodiazepines(BZDs)
Diazepam(valium), lorazepam(altivan), chlordiazepoxide (Librium), Gabapentin or carbamazepine (Tegretol)
What are anti-hypertensives we give to alcohol withdrawal pts?
Clonidine
Atenolol
What nutritional supplements can we give to alcohol withdrawal supplements?
B vitamins, vitamin C
DONT give IV glucose before giving thiamine supplementation
Fluid replacement PRN
How do we assess withdrawal severity?
CIWA scoring
Facilities own standardized protocol
What are the stages of security for withdrawals?
Mild
Moderate
Severe
What type of consolation does a withdrawal pt may need?
Social work
Psychology
What can be given to treat chronic use?
Thiamine
Naltrexone
Acamprostae(Campral) (first-line)
Disulfiram(Antabuse) (2nd-line)
What are SE of thiamine use?
Low BP
Affect glucose metabolisms
(rare) anaphylaxis, bronchospasm
What is the MOA of naltrexone?
Blocks release of dopamine in the brain
Antagonist at Mu receptors in brain (decrease craving and reward)
What is naltrexone usually given together with?
Behaviorally therapy
Acamprosate
SSRI
What is the BBW for naltrexone?
Hepatocellular injury
Heptotoxicity
What are the SE of naltrexone?
N/V/D/C
Abd pain
Dizziness
HA
Anxiety
Fatigue
What is CI in naltrexone?
Hx if hypersensitivity
Opioid dependence on current use
What does naltrexone have drug interactions with?
Opiates
What do you have to monitor when taking neltrexone?
Liver function tests
What is the MOA of acamprosate?
Restore normal glutamate action
Interferes with glutamate release stopping excitation that happens with withdrawal
Affects GABA NT
Same rates of return to drinking/return to heavy drinking as naltrexone
What is the SE of
