PSYCH Substance Abuse DO

Question 1

Patient will present as → a 69-year-old male presents to the emergency department with sudden, severe onset epigastric pain that began while he was watching television. On physical exam is an unkempt male with pain upon palpation of the epigastric region. Labs are drawn and the patient has an elevated amylase and lipase. The patient is made NPO, an NG tube is placed, and the patient is given IV fluids. The patient is noted to be experiencing hallucinations. On his second hospital day, the patient has a seizure.

Answer 1

Alcohol Withdrawal –> Delirium Tremens

Question 2

Alcohol Use Disorder

Answer 2

→ Alcohol Use Disorder:
Alcoholic: Pattern of alcohol use that leads to impairment or distress within a 12 MONTH PERIOD:
Larger amounts, longer period, can’t cut down, activities always involve alcohol, cravings, recurrent use

2 Types:
1) At-Risk Drinking: continuous use of alcohol
Men: 4/day or 14/wk
Women: 3/day or 7/week
“A Drink” = 12oz Beer, 8oz Liq, 1.3oz spirits, 5oz wine

2) Mod-Severe Drinking: recurrent use despite personal, legal problems/risks

Tolerance: Need for more to get the same effects OR same amount with no effects

Withdrawal: Alcohol OR BENZI relieves symptoms

Question 3

Alcohol Intoxication

Answer 3

→ Alcohol INTOXICATION:
Recent ingestion of alcohol

Problematic/Psychological
Changes in Behavior:

Slurred Speech, Incoordination, Unsteady Gait, NYSTAGMUS, impairment, stupor/coma

Question 4

Alcohol Withdrawal

Answer 4

→ Alcohol WITHDRAWAL:
Cessation of alcohol after prolonged heavy use
2 or more: hours to days after the cessation

AUTONOMIC hyperactivity (sweating, tachycardic >100)
Tremor
Insomnia, N/V
Visual, tactile or auditory hallucinations
Agitation, anxiety, SEIZURES

TIMELINE:
6 Hrs: tremblings, irritable, anxiety, HA, tachy, insomnia

TX: Thiamine, Folate, Multivitamin, IV Fluids, Dextrose

12-24 Hrs: hallucinations
TX: Benzos to avoid seizures

48 hrs: Seizures (tonic-clonic)
TX: Benzos

48-96 hrs: DELIRIUM TREMENS/autonomic instability, disoriented, hallucinations, agitation
TX: High Dose- IV Benzos

Question 5

Alcohol Screening Tool

Answer 5

CAGE: Cutting down, annoyed, guilt, eye-opener

Question 6

~ DISULFIRAM:

Answer 6

~ DISULFIRAM:
Gives you bad symptoms if you do drink alcohol (HYPOTENSION, N/V, flushing, hyperventilation, HA, palpitations
→ MOA: Inhibits Aldehyde Dehydrogenases (can’t metabolize alcohol)
→ CI: heart ds, DM, Hypothyroid, epilepsy, kidney/liver ds
***DO NOT GIVE TO SOMEONE WHO IS DRINKING

Question 7

~ NALTREXONE:

Answer 7

~ NALTREXONE:
Reduces CRAVINGS and alcohol-induced euphoria
→ MOA: Opioid antagonist
**CANNOT BE GIVEN WITH OPIOIDS

Question 8

ACAMPROSATE:

Answer 8

ACAMPROSATE:
Helps overcome symptoms associated with sobriety

Changes brain chemistry to reduce anxiety, irritability and restlessness related to sobriety

Dose reduction with RENAL IMPAIRMENT

Question 9

Topiramate vs Gabapentin

Answer 9

T= Reduces Drinking
G= Decreased desire

Question 10

Alcohol Intoxication “Drunk”

Answer 10

→ Alcohol INTOXICATION:
Recent ingestion of alcohol
Problematic/Psychological Changes in Behavior:
Slurred Speech, Incoordination, Unsteady Gait, NYSTAGMUS, impairment, stupor/coma

Question 11

Alcohol Withdrawal (4 stages + TX)

Answer 11

→ Alcohol WITHDRAWAL:
Cessation of alcohol after prolonged heavy use

2 or more: hours to days after the cessation
AUTONOMIC hyperactivity (sweating, tachycardic >100)
Tremor
Insomnia, N/V
Visual, tactile or auditory hallucinations
Agitation, anxiety, SEIZURES

TIMELINE:
6 Hrs: tremblings, irritable, anxiety, HA, tachy, insomnia
TX: Thiamine, Folate, Multivitamin, IV Fluids, Dextrose

12-24 Hrs: hallucinations
TX: Benzos to avoid seizures

48 hrs: Seizures (tonic-clonic)
TX: Benzos

48-96 hrs: DELIRIUM TREMENS/autonomic instability, disoriented, hallucinations, agitation
TX: High Dose- IV Benzos

→ Alcohol Withdrawal TX:
→ Long-Acting BENZOS
** DIAZEPAM **
Depress the CNS excitation cause by the stop of alcohol
→ Replace:
THIAMINE = Prevents Wernicke’s Encephalopathy and Korsakoff Psychosis
– + IV fluids, Thiamine (B1), Magnesium, Multivitamins (B12 and Folate), electrolytes

Question 12

Delirium Tremens

Answer 12

2-5 days after last drink
- Rapid onside of disturbances of attention and cognition, DELIRIUM, hallucinations, tachy, HTN, fever, diaphoretic

Tx: High Dose IV Benzo

Question 13

Does alcohol withdrawal require hospitalization?

Answer 13

Yes - it can be fatal

Question 14

IV Benzos used for alcohol withdrawal

Answer 14

Diazepam, Lorazepam, Chlordiazepoxide, Oxazepam
(Alcohol mimics GABA = inhibits it)

Question 15

Other than Benzos, what else needs to be administered to patient who is suffering from alcohol withdrawal

Answer 15

IV fluids, Thiamine (B1), Magnesium, Multivitamins (B12 and Folate), electrolytes

Question 16

Patient will present as → a 17-year-old male is brought to your office by his parents due to his behavior - increased appetite, lack of motivation, and paranoia. When interviewing the patient, the physician notes a slowed speech and conjunctival injection.

Answer 16

Cannabis Intoxication

Question 17

Cannabis Intoxication

Answer 17

→ Cannabis INTOXICATION:
Within 10-20 mins of smoking hemp

–Pathophysiology:
ACTIVE INGREDIENT: Tetrahydrocannabinol
Drug test + for 4-6 days and 50 days in a chronic user (7 day half-life - stays in system a long time)
MOA:
Binds to CB1/2 Cannabinoid Receptors

2 Phases of Intoxication:

Moderate dose: euphoria, anxiety, conjunctival injection, slowed perception, dry mouth, increased appetite, tachy

High dose: PSYCHOSIS - hallucinations, paranoia, delusion

TX: Observation (self-limiting)

Question 18

Cannabis Withdrawal

Answer 18

→ Cannabis WITHDRAWAL:
Irritabile, insomnia, nausea, anorexia, depression, abdominal pain, shaking, fever, chills, tremors

Peak around 48 hours post smoke, lasting 5-7 days

Question 19

Effect of chronic use of Marijuana

Answer 19

→ CHRONIC USERS S/E:
Laryngitis, rhinitis, low testosterone, low sperm count, COPD

Question 20

Hyperemesis Syndrome:

Answer 20

→ Hyperemesis Syndrome:
Chronic severe emesis in chronic users
Tx: Stop Marijuana + Ondansetron or Metoclopramide

Question 21

Hallucinogens:
PCP aka “?”
-Intoxication & Withdrawal

Answer 21

→ PCP: PHENCYCLIDINE / aka “angel dust”
Dissociative anesthetic and hallucinogenic drug → NMDA GLUTAMATE Receptor Antagonist

• INTOXICATION:
  Short onset and only lasts 1-4 hrs
  SEVERE agitation, RAGE, bizarre violent behavior, hallucinations, delusions, diminished pain perception

** MULTIDIRECTIONAL NYSTAGMUS ** (vertical and horizontal) + HTN + Tachy
Dysarthria, Ataxia, Muscle Rigidity, Hyperacusis, seizures, numbness

TX: ABCs + keep in low stimulus area
BENZOS = 1st line for agitation (Haldol = 2nd)

• WITHDRAWAL:
  - Depression, irritable, anxious, insomnia

Question 22

Hallucinogens:
LSD

Answer 22

→ LSD:
MOA: Smoked → 5-HT Receptor
- INTOXICATION:
“Trips”, Visual Hallucinations, seeing sound as colors, delusions, PUPILLARY DILATION, anxiety/depression
*** EVALUATE FOR:
CK-MB (Rhabdo), AKI, CBC, CMO, UDS

Question 23

Patient will present as → a 15-year-old male who was brought in to the ED for respiratory failure following sniffing and inhalation of petroleum for an extended time. This patient has been admitted to the ED many times, last time for abusing bath salts. He comes from a foster home and is largely unsupervised.

Answer 23

Inhalant Intoxication

Question 24

Inhalant Toxicity

Answer 24

→ Inhalant INTOXICATION:
- Hydrocarbons →
PAIN, PETROLEUM/PROPANE, BATH SALTS, TOLUENE (paint thinner), GLUES, NAIL POLISH, BUTANE, FLUOROCARBONS

Mild Dose: Euphoria, slurred speech, confusion, dizzy, nystagmus, tremor, stupor, incoordination, Auditory and visual hallucinations

High Dose: Cardiopulmonary Failure, Liver and Kidney issues, Bone Marrow Suppression

• TX: Haldol if needed for aggression

Question 25

Patient will present as → a 30-year-old male brought to the ED by his friends, who state that he has been unresponsive to verbal cues. They reported that he had been abusing heroin and that “he overdid it this time.” On physical exam, he has several needle marks along the antecubital fossa, a respiratory rate of 4/min, and small, pinpoint pupils.

Answer 25

Opioid Intoxication

Question 26

Mydriasis vs Miosis

Answer 26

Mydriasis is when the pupils are dilated, or enlarged
–> Drugs, such as amphetamines, stimulants, cocaine, and LSD, can cause mydriasis

Miosis is when the pupils are constricted, or narrowed.
–> Opioids such as heroin, morphine, and fentanyl can cause miosis

Question 27

Pupils: Opioid INTOXICATION vs WITHDRAWAL

Answer 27

Intoxication = Pinpoint
Withdrawal = Dilated

Question 28

Opioid-Related Disorders:
MOA:

Answer 28

Mu receptor agonist (morphine, methadone, fentanyl, dextromethorphan, loperamide, diphenoxylate, heroin)

Question 29

Opioid INTOXICATION:

Answer 29

→ Opioid INTOXICATION:
Sedation, Euphoria, MIOSIS (pinpoint pupils), AMS, constipation, respiratory depression, seizures, slurred speech, confusion, LOC, Bradycardia/Hypotension, track marks (heroin)

Intoxication TX: “NARCAN”
NALOXONE/NALTREXONE
Opioid Antagonist that helps within 2 minutes

Question 30

Opioid WITHDRAWAL:

Answer 30

→ Opioid WITHDRAWAL:
MYDRIASIS (dilated pupils), anxiety, insomnia, anorexia, sweating, piloerection (goosebumps), fever/flu-like symptoms

Withdrawal TX:
Clonidine: Symptomatic Control
Alpha 2 Agonist → Decreases NE and sympathetic output (controls the symp. symptomS)

Methadone (Long-Acting/Maintenance)
MOA: Long acting opioid receptor agonist
SAFE in Pregnancy
Slowly tapers opioid effects that diminishes effects
S/E: QT Prolongation

Buprenorphine + Naloxone (Suboxone)
May start/worsen withdrawal if given too soon
-MOA of Buprenorphine: Partial opioid receptor agonist

Naltrexone:
MOA: Opioid antagonist
DECREASES CRAVINGS for ethanol and alcohol depency
PRECIPITATES WITHDRAWAL WITHIN 7 DAYS of HEROIN USE

Zofran for N/V

Question 31

A 57-year-old male is brought to the emergency department by his daughter who is concerned that he is dehydrated. The patient has been vomiting and experiencing severe diarrhea for the past 12 hours. The physical examination is notable for restlessness, mydriasis and excessive lacrimation as well as several needle puncture sites in his left antecubital fossa that are in various stages of healing. In addition to IV fluids, what is the appropriate treatment for this patient?

Answer 31

Methadone (or Clonidine) for opioid withdrawal tx

Question 32

Opioid Intoxication vs Withdrawal

Answer 32

Intoxication: Miosis, constipation

Withdrawal: Mydriasis, diaphoresis, rhinorrhea

Question 33

Patient will present as → a 45-year-old female with a PMH of anxiety and panic attacks was brought in by her husband for being “unresponsive for about 30 minutes now.” He states that the patient had been “popping Xanax” because she was “having one of her episodes of panic attacks.” On physical exam, she is hypotensive with a respiratory rate of 4/min.

Answer 33

Sedative-Hypnotic-Anxiolytic INTOXICATION

Question 34

Sedative-Hypnotic-Anxiolytic Related DOs:

Answer 34

Sedative-Hypnotic-Anxiolytic Related DOs:
*** BENZOS: Enhance GABA (slows things down)

→ INTOXICATION:
RESPIRATORY DEPRESSiON, HYPOTENSION, Amnesia, Ataxia, stupor/somnolence, COMA, death

→ WITHDRAWAL:
REBOUND ANXIETY, hyperactive, SEIZURES, tremors (especially with ALPRAZOLAM)

→ Treatment:
INTOXICATION = FLUMAZENIL
GABA ANTAGONIST
WITHDRAWAL = LONG-ACTING BENZO = CLONAZEPAM

Question 35

TX for Benzo Intoxication vs Withdrawal

Answer 35

Intoxication = Flumazenil
Withdrawal = Clonazepam

Question 36

Patient will present as → a 21-year-old male is brought into the ED by the police for an altercation. Last night, the patient was at a party and seemed much more active than usual according to his girlfriend. He punched another male at the party in the face claiming that he was hitting on his girlfriend. On exam, you see an agitated young male with dilated pupils, and his pulse is 128/min.

Answer 36

Stimulant Intoxication

Question 37

Stimulant-Related Disorders:

Answer 37

Stimulant-Related Disorders:
** Cocaine, ADHD Medications: Methamphetamines, Dextroamphetamines, Methylphenidate ***

MOA: Block Amine (Dopamine, NE, 5HT) Reuptake

→ INTOXICATION:
Mydriasis (pupillary DILATION), hyperactive, euphoria, HTN, TACHY, sweating, EXCESSIVE TALKING followed by depression, no sleep, weight loss, nose bleeds, paranoid

KINDLING: Chronic Stimulant use: Hallucinations and Paranoia

Cocaine Abuse = unexplained nosebleeds and septal perforation

→ WITHDRAWAL:
Depression, increased suicidal ideation, hyperphagia, hypersomnolence, fatigue, etc.

→ Treatment:
Intoxication TX:
Benzos
Antipsychotics/Haloperidol
Antihypertensives
VITAMIN C

Withdrawal:
Bupropion
Bromocriptine
SSRI

Stimulant Use Disorder (Long-Term):
Mild = Individual/Group Drug Therapy
IOT (Intensive Outpatient Therapy)

Question 38

What vitamin supplement helps with Stimulant Intoxication excretion?

Answer 38

Vitamin C

Question 39

Tx for Stimulant withdrawal?

Answer 39

Bupropion

Question 40

Patient will present as → a 45-year-old male who reports that he has felt more anxious and irritable lately. He states that he has been very stressed out at work lately and thinks that his symptoms are attributable to the stress. He smokes 1 pack per day, but lately has found himself smoking up to 4 packs per day to ease his stress. Upon further counseling, he says he is interested in quitting and wants your help.

Answer 40

Tobacco Use Disorder

Question 41

Cocaine intoxication SE

Answer 41

Tachy, HTN, dysrhythmias, coronary vasospasms (leading to Acute coronary syndrome, stroke, death), hyperactive, cardiac arrest

Question 42

1st line tx for cocaine intoxication

Answer 42

Benzos
(2nd = Haldol or Olanzipine)