Random pearls from BEST Flashcards
Pharmacologic changes re MTD in pregnancy (4)
Increased gut transit time (increased absorption), 50% increase in blood volume (lower concentration), induction in CYP3A4 activity, Increase in accumulation in adipose (supposedly can be problematic in postpartum state)
“Seeking Safety”
evidence-based treatment approach for PTSD and SUD
Network therapy def
individual psychotherapy or family therapy in which an attempt is made to involve not only immediate family members but also other relatives, friends, and neighbors as sources of emotional support and possible vocational opportunity.
Screening tool for unhealthy substance use in adolescents
CRAFFT (ridden in Car, use Alone, Family/Friends concerned, gotten in Trouble)
Schedule 1 meds
no currently accepted medical use and high potential for abuse. Heroin, LSD, cannabis, MDMA, methaqualone, peyote
Schedule 2 meds
High potential for abuse, can only be prescribed in triplicate. Cocaine, methamphetamine, opioids, meperidine, dexadrine, adderall, ritalin
Schedule 3 meds
can be prescribed by phone. Moderate-to-low potential for dependence. APAP w codeine, ketamine, anabolic steroids, testosterone
Schedule 4 meds
can be prescribed by phone. “Low” potential for abuse. Benzos, ambien, tramadol
Schedule 5 meds
can be prescribed by phone . Limited quantities of certain opioids like robitussin with codeine, lomotil, lyrica
Limbic system (hippocampus and amygdala) role in addiction
memory and emotional context (triggers)
Orbito-frontal cortex role in addiction
reward processing
Nucleus accumbens role in addiction
dopaminergic / pleasure from drugs and behaviors
Insula role in addiction
integrating and giving meaning to sensations such as hot/cold as well as cravings
Pseudowithdrawal def
intensification of symptoms when wd is imminent
Rebound def
intensification of pre-treatment symptoms after discontinuation. Distinguish from “recurrence” by whether symptoms merely returned vs intensified
Sensitization def
opposite of tolerance (increased effect with repeat doses)
“stacking” in anabolic steroids
using multiple types simultaneously
“pyramid” in anabolic steroids
increasing dose, then tapering prior to competition
Effects of anabolic steroids
increase muscle strength, but not bone mass, aerobic capacity, injury time. Can increase irritability.
In women, masculinization, weight gain, irr periods
Toxicity of anabolic steroids
PO administration associated with LFT abnormalities
anabolic steroid withdrawal illness script
Looks like depression
Gambling disorder risk and meds
DSM-5 recognized, about 50% of risk attributable to genetic influences. Meds with evidence: naltrexone, lithium, paroxetine
rate of SUD in Eds
50% of patients with eating disorder have SUDs
Gene with variants that modulate naltrexone efficacy for AUD
OPRM1
Kratom pharmacology
mitragynine. Antagonist at kappa opioid receptor, agonist vs partial agonist at mu receptor.
Salvia pharmacology and effects
salvinorin A. kappa opioid agonist→ hallucinosis and dissociation, not reliably euphoria
methanol poisoning illness script
vision loss, hyperventilation, abd pain, parksinonian features, AGMA, increased ICP. Can occur with huffing.
Tx: fomepizole.
Stages of changes and their associated pitfalls for patients
Pre-contemplative → resistance
Contemplation → demoralization
Action → dropout
Maintenance → relapse
mechanism of LSD and psilocybin
serotonin 5HT-2A agonists
Features of therapeutic community
Structured daily regimen
Assigned role models
Use of peer community as healing agent (“community-as-method”)
Active metabolites of heroin
6-MAM
morphine
3-MAM
risk of SUD attributable to genetic factors
40-60% (supposedly)
Outweighs parental substance use in adoption studies
Principles of twelve-step facilitation
Abstinence (goal)
Acceptance (of one’s loss of control over substance consumption)
Spirituality (“power greater than oneself”)
Pragmatism (collaborative approach to do whatever is needed to avoid first drink)
Role of recovery coach
Encourage healthy structures and rituals. Best utilized as part of comprehensive treatment plan
Unique toxicity of meperidine
Decreased seizure threshold d/t normeperidine accumulation
PNPLA3 and MBOAT7
genes associated with incr risk of alcohol-related liver disease
GABRA2
gene likely associated with severity of AWS and daily alcohol use
CYP2A6
Metabolizes nicotine to cotinine. Reduced activity associated with reduced smoking risk due to increased adverse effects
GABA agonists
benzo - GABA-A
etoh - gaba-a
GHB - gaba-b
baclofen - gaba-b
benzo overdose mortality
remarkably low – lethal dose not established for most benzos
Problem is combination w other drugs
prevalence of tobacco use in OUD
75-90%
convergent therapy
combination of multiple modalities (eg meds and CBT)
cause drug testing
done when there is suspicion of use (distinguish from random)
CYP 2D6
hydrocodone –> hydromorphone
AND
Codeine –> morphine
slow metabolizers achieve very low levels, fast metabolizers can have rapid high levels
Harrison act and controlled substances act
Harrison 1914 - codified illegal vs legal and taxable
CSA - governs medical use
D4R gene
dopamine R. variants associated w lower dop tone –> incr risk of smoking and relapse
conditional confidentiality
generally afforded to adolescents 14-18
relative dopamine release of diff drugs
meth»_space; cocaine > heroin/nicotine > sex/food
MTD and NAS
higher doses not associated w incr risk for NAS
Fidelity ethical principle
Being truthful/faithful to duties as a medical professional. Includes CME and maintenance of competence
1976 Court case establishing that correctional authorities must reasonably assess and treat incarcerated people?
Estelle v Gamble
dopamine transporter A9 allele
associated with more severe AWS and DTs risk!
primary vs secondary vs tertiary prevention
primary - preventing incidence
secondary - identifying and intervening as early as possible (includes screening)
Tertiary - preventing complications by active treatment
quaternary - avoiding harm through overmedicalization
URICA
University of RI Change Assessment - measures motivation to change across range of behaviors
CRI
Coping Response inventory - measures coping skills
InDUC
Inventory of drug use consequences – measures adverse effects from drug use
RAATE
Recovery Attitude and treatment evaluator – measures resistance to change
MAST-G
Michigan Alcoholism Screening Test - Geri – older adult alcoholism screening instrument. 24-item scale, superior to other screening tests
Hyperalgesia vs allodynia
hyperalgesia - increased pain from painful stimulus
allodynia - pain from non-painful stimulus
DrInc vs AUDIT
DrInC - Drinker inventory of consequences : assesses adverse impacts in domains of physical, social, impulsive, interpersonal, and intrapersonal
AUDIT: assesses drinking patterns and failed efforts to control
Khat and bath salts
Cathinone - stimulant alkaloid derived from khat. MAO reuptake inhibitor
Bath salts - synthetic analogues
healthy drinking limits
men under 65 - 4 per sitting / 14 per week
women under 65 - 3 per sitting / 7 per week
over 65 - 2 per sitting / 7 per week
Above this is “heavy use” (per NIDAA)
Webb vs US
interpreted Harrison Act to declare that physicians maintaining patients with addiction on usual dose of prescribed opioid is not “good faith” and therefore indictable.
DATA-2000 was then necessary to allow physicians to prescribe schedule III-V opioids with FDA indication for OUD (currently describes only bup since methadone is schedule II)
FRAMES
Brief intervention outline:
Feedback
Responsibility
Advice
Menu of strategies
Empathy
Self-Efficacy
CDT
Carbohydrate deficient transferrin – biomarker for HEAVY alcohol use
Categorical levels of substance use (low risk, unhealthy, etc)
low risk - complete absence or use at very low risk for adverse events
Unhealthy: both hazardous and harmful
Hazardous: risky use that has not yet developed adverse effects
Harmful: +adverse effects
disulfiram toxicity/contraindication
psychosis - can precipitate!
Hepatic metabolism, not appropriate with impairment
phencyclidine false positive
venlafaxine
varenicline and alcohol
can increase toxic effects (drunkeness, blackouts). patients should be cautioned
Smoking cessation in pregnancy/lactation
NRT - less data, most trials stopped early for adverse pregnancy effects. Risk/benefit
Bupropion - generally safe, including lactation. probably first line
Varenicline - limited data, probably safe
Fentanyl patch –> increased drug delivery
fever/increase in skin temp
pharmacokinetics vs dynamics
PK - time course of concentration following administration (what body does to drug)
PD - drug effects relative to concentration (what drug does to body)
cocaine MOA
NE reuptake inhibitor
MA MOA
inhibits DA reuptake, promotes release
cocaethylene effects
incr cardiotoxicity, hepatotoxicity, seizures
e-cigarette solvent
propylene glycol
MDMA mechanism
releaser and/or reuptake inhibitor of presynaptic monamines (5HT, DA ,NE
dextromethorphan mechanism
at high doses, nonselective 5HT reuptake inhibitor, NMDAR antagonist (like ketamine) –> dissociative hallucinogen
phencyclidine mechanism
NMDAR antagonist, also has anticholinergic properties
Stark Law
prohibits physicians from referring Medicare patients for health services with which the physician (or family) have financial relationship
toluene illness script
paint thinner, extreme intoxication and AMS
low-acuity patient presenting for first episode of care requesting inpatient tx
should be referred for outpatient tx first.
evaluation for depression in AUD
should be done on admission to detox/treatment, even though many sx resolve with abstinence
standard drinks
1.5 oz liquor, 5 oz wine, 12 oz beer (standard mass-consumption beverages, not high ABV)
why is lorazepam preferred in cirrhosis?
undergoes gluconuridation to inactive metabolites (other bzd have active metabolites)
e-cigs regulation and outcomes
ENDS (electronic nicotine delivery systems) FDA regulated since 2016
helpful in harm reduction. At 52 weeks, 18% of people stop cigs (compared to 9% for NRT)– many ppl become dual-users. huge variability in nicotine levels and has harmful pregnancy outcomes. heavy metals present in both ENDS and cigarettes.
No approved meds for vaping use disorder
adolescent ENDS use
3X risk of cigarette smoking
top-line outcome for methadone and bup
50% relative risk reduction for death by overdose
smoking effects on life expectancy
on average, smokers die 10 yrs early. smoking leads to premature death in at least 50% of long-term smokers
factors increasing risk of overdose in LTOT
- OME >90
- long-acting opioids
- history of overdose
- OUD
- MDD
SSPs + MOUD impact on infectious risk
decr HIV and HCV by ~67%
CV effects of ecigs
improved endothelial function and vascular stiffness, no hard outcomes
Medial OFC
“stinking thinking” i.e. aberrant motivation/reward thinking
