PSYCH Substance Abuse DO Flashcards
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.
Alcohol Withdrawal –> Delirium Tremens
Alcohol Use Disorder
→ 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
Alcohol Intoxication
→ Alcohol INTOXICATION:
Recent ingestion of alcohol
Problematic/Psychological
Changes in Behavior:
Slurred Speech, Incoordination, Unsteady Gait, NYSTAGMUS, impairment, stupor/coma
Alcohol Withdrawal
→ 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 Screening Tool
CAGE: Cutting down, annoyed, guilt, eye-opener
~ DISULFIRAM:
~ 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
~ NALTREXONE:
~ NALTREXONE:
Reduces CRAVINGS and alcohol-induced euphoria
→ MOA: Opioid antagonist
**CANNOT BE GIVEN WITH OPIOIDS
ACAMPROSATE:
ACAMPROSATE:
Helps overcome symptoms associated with sobriety
Changes brain chemistry to reduce anxiety, irritability and restlessness related to sobriety
Dose reduction with RENAL IMPAIRMENT
Topiramate vs Gabapentin
T= Reduces Drinking
G= Decreased desire
Alcohol Intoxication “Drunk”
→ Alcohol INTOXICATION:
Recent ingestion of alcohol
Problematic/Psychological Changes in Behavior:
Slurred Speech, Incoordination, Unsteady Gait, NYSTAGMUS, impairment, stupor/coma
Alcohol Withdrawal (4 stages + TX)
→ 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
Delirium Tremens
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
Does alcohol withdrawal require hospitalization?
Yes - it can be fatal
IV Benzos used for alcohol withdrawal
Diazepam, Lorazepam, Chlordiazepoxide, Oxazepam
(Alcohol mimics GABA = inhibits it)
Other than Benzos, what else needs to be administered to patient who is suffering from alcohol withdrawal
IV fluids, Thiamine (B1), Magnesium, Multivitamins (B12 and Folate), electrolytes
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.
Cannabis Intoxication
Cannabis Intoxication
→ 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)
Cannabis Withdrawal
→ Cannabis WITHDRAWAL:
Irritabile, insomnia, nausea, anorexia, depression, abdominal pain, shaking, fever, chills, tremors
Peak around 48 hours post smoke, lasting 5-7 days
Effect of chronic use of Marijuana
→ CHRONIC USERS S/E:
Laryngitis, rhinitis, low testosterone, low sperm count, COPD
Hyperemesis Syndrome:
→ Hyperemesis Syndrome:
Chronic severe emesis in chronic users
Tx: Stop Marijuana + Ondansetron or Metoclopramide
Hallucinogens:
PCP aka “?”
-Intoxication & Withdrawal
→ 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
Hallucinogens:
LSD
→ 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
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.
Inhalant Intoxication
Inhalant Toxicity
→ 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
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.
Opioid Intoxication
Mydriasis vs Miosis
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
Pupils: Opioid INTOXICATION vs WITHDRAWAL
Intoxication = Pinpoint
Withdrawal = Dilated
Opioid-Related Disorders:
MOA:
Mu receptor agonist (morphine, methadone, fentanyl, dextromethorphan, loperamide, diphenoxylate, heroin)
Opioid INTOXICATION:
→ 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
Opioid WITHDRAWAL:
→ 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
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?
Methadone (or Clonidine) for opioid withdrawal tx
Opioid Intoxication vs Withdrawal
Intoxication: Miosis, constipation
Withdrawal: Mydriasis, diaphoresis, rhinorrhea
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.
Sedative-Hypnotic-Anxiolytic INTOXICATION
Sedative-Hypnotic-Anxiolytic Related DOs:
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
TX for Benzo Intoxication vs Withdrawal
Intoxication = Flumazenil
Withdrawal = Clonazepam
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.
Stimulant Intoxication
Stimulant-Related Disorders:
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)
What vitamin supplement helps with Stimulant Intoxication excretion?
Vitamin C
Tx for Stimulant withdrawal?
Bupropion
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.
Tobacco Use Disorder
Cocaine intoxication SE
Tachy, HTN, dysrhythmias, coronary vasospasms (leading to Acute coronary syndrome, stroke, death), hyperactive, cardiac arrest
1st line tx for cocaine intoxication
Benzos
(2nd = Haldol or Olanzipine)
