Substance Abuse Flashcards
1
Q
People Take Drugs to
- Feel _____ (____ seeking)
- Feel _____ (self ______)
A
- Feel good (sensation seeking)
- Feel better (self medication)
2
Q
How do drugs work in the brain?
A
We know that despite their many differences, most abused substances enhance the Dopamine and Serotonin pathways
3
Q
Addiction Involves Multiple Factors
A
4
Q
Medical Model of Addiction
- ______ of addiction (phenotype) is based on a _____ predisposition (genotype) that is influenced by environmental factors
- Well-studied biological mechanism
- Treatment compliance is similar to other _____ medical conditions (diabetes, hypertension, asthma)
- Follows a re_____ and re______ course
- Most effectively managed as a chronic _____
- Both m_____ and b_____interventions are used
A
- Expression of addiction (phenotype) is based on a genetic predisposition (genotype) that is influenced by environmental factors
- Well-studied biological mechanism
- Treatment compliance is similar to other chronic medical conditions (diabetes, hypertension, asthma)
- Follows a relapsing and remitting course
- Most effectively managed as a chronic disease
- Both medical and behavioral interventions are used
5
Q
Substance Use Definitions
- (1) : Minimal or experimental use with minimal consequences
- (1) : Regular use or abuse with several and more severe consequences -
- (1) : Maladaptive patterns of use accompanied by clinically significant impairment or distress
A
- Substance use: Minimal or experimental use with minimal consequences
- Substance abuse: Regular use or abuse with several and more severe consequences -
- Substance use disorders: Maladaptive patterns of use accompanied by clinically significant impairment or distress
6
Q
DSM V Criteria for Substance Use Disorder
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by two (or more) of the following, occurring at any time in the same 12-month period
- Recurrent substance use resulting in a failure to fulfill (1)
- Recurrent substance use in situations in which it is (1)
- Continued substance use despite having persistent or recurrent (1) caused or exacerbated by the effects
A
- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
- Recurrent substance use in situations in which it is physically hazardous
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects
7
Q
DSM V Criteria for Substance Use Disorder
Tolerance- as defined by either of the following
- A need for markedly (1) of the substance to achieve intoxication or the desired effect, or
- Markedly (1) with continued use of the same amount of the substance
A
- A need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or
- Markedly diminished effect with continued use of the same amount of the substance
8
Q
DSM V Criteria for Substance Use Disorder
Withdrawal as manifested by either of the following
- The characteristic withdrawal ______ for the substance, or
- The same (or closely related) substance is taken to r____ or av____ withdrawal symptoms
A
- The characteristic withdrawal syndrome for the substance, or
- The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
9
Q
DSM V Criteria for Substance Use Disorder
- The substance is often taken in ____ amounts or over a _____ period than was intended
- There is a persistent d____ or unsuccessful _____ to cut down or control substance
- A great deal of _____ is spent in activities necessary to _____ the substance, use the substance, or recover from its effects
- Important so____, occ______, or rec_____ activities are given up or reduced because of substance use
- The substance use is _____ despite knowledge of having a persistent or recurrent physical or psychological ______ that is likely to have been caused or exacerbated by the substance
- Cr_____ or a strong desire to use a specific substance
Severity specifiers: Mild _-_, Moderate _-_ criteria, Severe >_
A
- The substance is often taken in larger amounts or over a longer period than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control substance
- A great deal of time is spent in activities necessary to abstain the substance, use the substance, or recover from its effects
- Important social, occupational, or recreational activities are given up or reduced because of substance use
- The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
- Craving or a strong desire to use a specific substance
Severity specifiers: Mild 2-3, Moderate 4-5 criteria, Severe >6
10
Q
What “Illicit” drugs are the top 2 most used (from a 2017 survey)?
A
Marijuana 1st, Opioids 2nd
11
Q
What age range has the largest % of people using illicit drugs?
A
18-20 yo
12
Q
Why have unintentional drug overdoses increased in NYC?
A
Dt introduction of fentanyl into urban setting
13
Q
Economic Impact of Substance Abuse
(3)
A
-
Health Care Expenditures
- alcohol and drug abuse services
- medical consequences
-
Productivity Impacts (Lost Earnings)
- premature death
- impaired productivity
- institutionalized population
- incarceration
- crime careers
- victims of crime
-
Other Impacts on Society
- crime
- social welfare administration
- motor vehicle crashes
- fire destruction
14
Q
Prevalence of Unhealthy Alcohol Use
Outpatient __-__%
Emergency department __-__%
Trauma Victims __%
A
Outpatient 7-20%
Emergency department 30-40%
Trauma Victims 50%
15
Q
Alcohol Use Disorder is most prevalent amongst what age group?
A
18-25 yo
16
Q
Universal Screening
- Significant Mor____ and Mor_____
- High Pr______
- Long A_______ Period
- V_____, Feasible Screening Test
- ______ Intervention Better Than Later
A
- Significant Morbidity and Mortality
- High Prevalence
- Long Asymptomatic Period
- Valid, Feasible Screening Test
- Early Intervention Better Than Later
17
Q
Screening Options - Alcohol
- _____ item screen
- A____ C
- C____
- M_____
- Lab tests: (3)
- Physical Exam
- Others (adolescence, pregnancy, elderly)
A
- Single item screen
- AUDIT, AUDIT C
- CAGE
- MAST
- Lab tests: MCV, AST, GGT
- Physical Exam
- Others (adolescence, pregnancy, elderly)
18
Q
Risky Drinking Definition
Drinks/week, Drinks/day
Men =
Women =
A
Men >14 drinks/week, >4 drinks/day
Women >7 drinks/week, >3 drinks/day
19
Q
Audit C Background
- Stands for AUDIT-_______ questions
- Consists of first __ items from the full AUDIT, q.v
- Takes __ minute to administer
- A score of ___ is indicative of hazardous or harmful drinking
- Men: 78% sensitivity & 75% specificity
- Women: 50% sensitivity & 93% specificity
- AUDIT-C _____ by itself be used to determine which level of brief intervention is appropriate or if a referral for treatment is called for.
- In the event of a positive result on AUDIT-C, these decisions should be based on clinical ______ or administration of the ____ AUDIT
A
- Stands for AUDIT-consumption questions
- Consists of first 3 items from the full AUDIT, q.v
- Takes 1 minute to administer
- A score of 5+ is indicative of hazardous or harmful drinking
- Men: 78% sensitivity & 75% specificity
- Women: 50% sensitivity & 93% specificity
- AUDIT-C cannot by itself be used to determine which level of brief intervention is appropriate or if a referral for treatment is called for.
- In the event of a positive result on AUDIT-C, these decisions should be based on clinical judgement or administration of the full AUDIT
20
Q
Audit C Questions
(3)
A
- How often do you have a drink?
- Never to 4x or >/wk
- How many standard drinks containing alcohol do you have on a typical day?
- 1-2 to 10 or >
- How often do you have 6 or more drinks on occasion?
- Never to daily or almost daily
21
Q
CAGE
=
Positive test if ___ positive responses
A
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
Positive test if 2 positive responses
22
Q
SASQ
(single alcohol screening questionnaire)
- Prescreen Question =
- NO = screening complete
- YES
- Ask the screening question about heavy drinking days =
- for men =
- for women =
A
-
Do you sometimes drink beer, wine, or other alcoholic beverages?
- NO = screening complete
- YES
-
How many times in the past year have you had
- 5 or more drinks in a day? (for men)
- 4 or more drinks in a day? (for women)
23
Q
SASQ cont.
Positive screen =
(or if pt used written self report such as the AUDIT - START HERE if score > ___ men, > __ for women)
If YES then = your patient is an at ___ drinker
- For a more complete picture of the drinking patter, determine the weekly average
- On ave how many ___ a week do you have an alcoholic drink?
- ON a typical drinking day, how to many _____ you have?
- Weekly average = ____ x ____
A
Positive Screen = 1 or more heavy drinking days
(or if pt used written self report such as the AUDIT - START HERE if score > 8 men, _>_4 for women)
If YES then = your patient is an at risk drinker
- For a more complete picture of the drinking patter, determine the weekly average
- On ave how many days a week do you have an alcoholic drink?
- ON a typical drinking day, how many drinks to you have?
- Weekly average = days x drinks
Sensitivity and specificity = 86% for detecting hazardous drinking past 3 months or alcohol use disorder in the past year Equally efficient among men and women
24
Q
What do the findings of the alcohol screenings mean?
- A positive screen indicates a high likelihood of alcohol-related r___ or h____
- Screening questionnaires are not ______ instruments
- However, they are highly acc_____
- Patients who screen positivitely will benefit from brief intervention
- Structured _____
- Extended/______ intervention
A
- A positive screen indicates a high likelihood of alcohol-related risk or harm
- Screening questionnaires are not diagnostic instruments
- However, they are highly accurate
- Patients who screen positivitely will benefit from brief intervention -
- Structured advice
- Extended/Motivational intervention
25
What's a Standard Drink?
Beer (5% alc) =
Liquor (7% alc) =
Wine (12% alc) =
Spirits (gin, vodka, whiskey, 40% alc) =
12 oz beer
8-9 oz malt liquor
5 oz wine
1.5 oz hard alcohol
26
Brief Intervention for Alcohol Use Disorder
(5-15 min)
**F**
**R**
**A**
**M**
**E**
**S**
**Feedback**: State concern + use specific personalized health concerns
**Responsibility**: Emphasize patient’s role
**Advice**: Advocate specific changes
**Menu**: Give options
**Empathy**: Reflect understanding
**Self**-**efficacy**: Reinforcement
27
Pharm Therapy for Alcohol Use Disorder
(3)
**Naltrexone**
**Acamprosate**
**Disulfram**
28
Naltrexone
MOA
Dose
Efficacy
Opiate antagonist (*binds to opioid receptors but does not activate them and can also knock off whatever substance is bound to a receptor, reduces cravings and effect of alcohol so becomes less reinforcing)*
50mg daily
Reduced risk heavy drinking days (HR .72) and Relapse preventions (54% vs. 31%)
29
Acamprosate
MOA
Dose
Efficacy = ____ at 6m (36% vs. 23%)
Affects GABA and the glutamate system
666mg TID
Efficacy = abstinent at 6m
30
Disulfram
MOA
Efficacy
Inhibits acetaldehyde dehydrogenase (this is the enzyme that metabolizes alcohol - so when blocked, ppl will feel very sick when they drink)
Data mixed, poorly tolerated
31
Minor Withdrawal Symptoms
Onset after last drink
Resolves in
S/S
6-36h
1-2d
Anxiety, tremor, diaphoresis, dyspepsia, HA but NO change in mental status
32
Withdrawal Seizures
Onset after last drink
⅓ pts will progress to \_\_\_
8-48h
⅓ pts will progress to DT
33
Alcoholic Hallucinosis (Withdrawal)
Onset after last drink
Resolves in
S/S
12-24h
24-48h
Visual hallucinations, Orientation preserved
34
Delirium Tremens
Onset after last drink
S/S
Risk Factors
Mortality
48-96h
Tachycardia, HTN, agitation, fever, disorientation, hallucinations
Prior DT, concurrent illness, age \>30, greater alc intake
Mortality \>5%
35
Management of Alcohol Withdrawal
* ______ triggered
* Check ____ at regular intervals
* Long acting (1) ideal for patient with normal liver function
* Prophylaxis with (1)
* Symptom triggered
* Check CIWA at regular intervals
* Long acting benzodiazepine ideal for patient with normal liver function
* Prophylaxis with chlordiazepoxide
36
Cannabinoids Background
* Available as (3)
* Potency: 1 joint was 10mg THC in 1970s → 150 mg in 1990’s
* Bioavailable in _____ after smoking
* ___ days to fully eliminate
* Binds ___ receptor
* Available as marijuana, hashish, hash oil -
* Potency: 1 joint was 10mg THC in 1970s → 150\_ mg in 1990’s
* Bioavailable in seconds after smoking
* 30 days to fully eliminate
* Binds CB1 receptor
37
Acute Effects of Smoked Marijuana
* Eu\_\_\_\_, rel\_\_\_\_\_
* I\_\_\_\_\_\_ of perception
* Distortion of t\_\_\_ and s\_\_\_\_
* M\_\_\_\_\_ impairment
* A\_\_\_\_\_ stimulation, “munchies”
* Can you die from overdose?
* Euphoria, relaxation
* Intensity of perception
* Distortion of time and space
* Memory impairment
* Appetite stimulation, “munchies”
* No death by overdose
38
Marijuana Use Trends
Has it been increasing or decreasing in young people?
Marijuana use disorder is most prevalent in which age group?
Going down in young people (12-17) bc less social interaction dt covid
18-25
39
Cognition, Brain Function with Marijuana Use
* Transient acute effects on episodic m\_\_\_\_ & l\_\_\_\_\_
* Motor & Visual tracking (\_\_\_\_) x 2-5hrs - ~2x odds of MVA
* Persistent effects of long term use on c\_\_\_\_\_
* Adolescents: slower psy\_\_\_\_\_ speed, diminished pl\_\_\_\_/seq\_\_\_\_\_ after abstinence x3 weeks
* Transient acute effects on episodic memory & learning
* Motor & Visual tracking (driving) x 2-5hrs - ~2x odds of MVA
* Persistent effects of long term use on cognition
* Adolescents: slower psychomotor speed, diminished planning/sequencing after abstinence x3 weeks
40
Cannabis and Pulmonary Problems
* Makes biologic sense from **smoked** form: carc\_\_\_\_/t\_\_
* C\_\_\_\_\_, increased sputum, increased respiratory _____ (less consistent)
* *Lung \_\_\_\_:*
* Associated with (1) changes consistent with precancerous state
* Associated with increased risk in combination with (1) use
* BUT: no decline in lung _____ or increased risk \_\_\_\_\_
* Makes biologic sense from smoked form: carcinogens/tar
* Cough, increased sputum, increased respiratory infections (less consistent)
* *Lung Ca:*
* Associated with cellular changes consistent with precancerous state
* Associated with increased risk in combination with tobacco use
* BUT: no decline in lung function or increased risk COPD
41
What might be presenting problems in primary care?
* Respiratory: exacerbation of (2)
* Mental Health: (2)
* Problems with (3)
* Difficulty st\_\_\_\_\_ or con\_\_\_\_\_ use
* Respiratory: exacerbation of asthma, cough/sputum
* Mental Health: depression, paranoia
* Problems with concentration, learning employment/school
* Difficulty stopping or controlling use
42
Some complexity and uncertainty
* S\_\_\_\_\_\_ effects - m\_\_\_\_\_ marijuana
* Impact of medical marijuana on addressing marijuana ab\_\_\_ and de\_\_\_\_\_\_\_ in primary care?
* Is there s\_\_\_\_ use, and for whom?
* Salutory effects - medical marijuana
* Impact of medical marijuana on addressing marijuana abuse and dependence in primary care?
* Is there safe use, and for whom?
43
What are Synthetic Cannabinoids?
=
* Designed to do what?
* Many variations
* Liquid sprayed on plant material
Chemical compounds made in laboratory
* Designed to mimic the action of THC
* Many variations
* Liquid sprayed on plant material
44
Common Names for Synthetic Cannabinoids
* K\_\_
* Sp\_\_\_\_
* H\_\_\_\_ Incense
* Mr. ____ Guy
* Green G\_\_\_\_
* Ex\_\_\_\_
* Fake Weed
* And many others..
* K2
* Spice
* Herbal Incense
* Mr. Nice Guy
* Green Giant
* Extreme
* Fake Weed
* And many others..
45
Desired Effects of Synthetic Cannabinoids
* Similar to marijuana
* Elevated m\_\_\_\_
* Re\_\_\_\_\_\_
* Altered per\_\_\_\_\_
* Similar to marijuana
* Elevated mood
* Relaxation
* Altered perception
46
Dangerous Effects of Synthetic Cannabinoids
* Two common clinical patterns
* Can appear similar to _____ overdose with lethargy, confusion, respiratory depression, vomiting, seizures, loss of consciousness
* Can appear similar to ____ intoxication - agitation, hallucinations, paranoia, aggressive behavior
* Symptoms are \_\_\_-limited
* Two common clinical patterns
* Can appear similar to opioid overdose with lethargy, confusion, respiratory depression, vomiting, seizures, loss of consciousness
* Can appear similar to PCP intoxication - agitation, hallucinations, paranoia, aggressive behavior
* Symptoms are self-limited
47
At highest risk for Dangerous Effects of Cannabinoids
(3)
Men
Adults
People with mental illness
48
Opioids Misuse
After alcohol, opioid probably has the biggest morbidity and mortality
Have the amount opioid misusers increased or decreased?
What is the most commonly misused opioid?
Significant decrease from 12.7M misusers in 2015
Hydrocodone → oxycodone → fentanyl
49
2 most common ways people get their opioids?
Given by, bought from, or took from friend or relative (47.2%)
Prescription or stolen from HCP (43.6%)
50
I-STOP
* NY State Department of Health
* (1) Program
* \_\_-prescribing
* P\_\_\_\_ Awareness efforts
* Safe dis\_\_\_\_ of unused pills
* *Will not see _____ in PMP- to protect pts (they will have methadone card though)*
* NY State Department of Health
* Prescription Monitoring Program
* E-prescribing
* Public Awareness efforts
* Safe disposal of unused pills
* *Will not see methadone in PMP- to protect pts (they will have methadone card though)*
51
Natural History of Opioid Dependence
=
Will develop tolerance
52
Opioid Intoxication S/S and Tx
* L\_\_\_\_\_
* _______ pupils
* Decreased ______ rate
Treatment =
* Lethargy
* Pinpoint pupils
* Decreased respiratory rate
Treatment = Naloxone (opioid antagonist)
53
Opioid Withdrawal S/S and Tx
* Ag\_\_\_\_\_/r\_\_\_lessness
* N/\_\_/di\_\_\_\_\_/abdominal p\_\_\_
* My\_\_\_\_\_/arth\_\_\_\_\_
* \_\_\_\_\_cardia/hyp\_\_tension
* Piloer\_\_\_\_/lac\_\_\_\_\_
* Y\_\_\_\_\_\_
* _______ pupils
Treatment (3)
* Agitation/restlessness
* N/V/diarrhea/abdominal pain
* Myalgias/arthralgias
* Tachycardia/hypertension
* Piloerection/lacrimation
* Yawning
* Dilated pupils
Opioid, Clonidine, Ibuprofen
54
Non Pharm Interventions for treating Opioid Dependence
* ______ Anonymous (NA)
* Couns\_\_\_\_\_
* De\_\_\_\_\_\_\_ (+/- opioid antagonist)
* Ac\_\_\_\_\_\_\_
* H\_\_\_\_ reduction
* Narcotics Anonymous (NA)
* Counseling
* Detoxification (+/- opioid antagonist)
* Acupuncture
* Harm reduction
55
Pharmacologic Interventions for Opioid Dependence
(3)
Naltrexone
Methadone
Buprenorphine
56
Naltrexone
* Pure opioid ______ with good oral absorption or injectable
* _______ mu receptors without \_\_\_\_\_\_
* Blocks abused agonist opioid drugs (*so even if they use opioids on naltrexone, will not feel the effects)*
* Duration of action 24-48h for oral formulation, one month if IM
* 1984: FDA approved to treat opioid dependence
* W\_\_\_\_ tolerated and s\_\_\_\_
* Pure opioid antagonist with good oral absorption or injectable
* Occupies mu receptors without activating
* Blocks abused agonist opioid drugs (*so even if they use opioids on naltrexone, will not feel the effects)*
* Duration of action 24-48h for oral formulation, one month if IM
* 1984: FDA approved to treat opioid dependence
* Well tolerated and safe
57
Oral Naltrexone
* Useful for patients after \_\_\_\_\_\_
* Low interest among “st\_\_\_\_ addicts”
* No better than placebo except in highly motivated patients
* Impaired physicians \>80% abstinence at 18m
* Useful for patients after detox
* Low interest among “street addicts”
* No better than placebo except in highly motivated patients
* Impaired physicians \>80% abstinence at 18m
58
Injectable Naltrexone
* Approved in 2010 to treat opioid dependence
* Also treats al\_\_\_\_\_ dependence
* Marketed by Alk\_\_\_\_ as Viv\_\_\_\_\_ (*treats alcohol and opioid abuse)*
* Efficacy currently being studied
* Bl\_\_\_\_\_ opioid effect, reduces cr\_\_\_\_
* Useful after de\_\_\_ or inc\_\_\_\_\_\_, y\_\_\_\_ people (*more useful in less severe opioid use disorder)*
* Approved in 2010 to treat opioid dependence
* Also treats alcohol dependence
* Marketed by Alkermes as Vivitrol (*treats alcohol and opioid abuse)*
* Efficacy currently being studied
* Blocks opioid effect, reduces craving
* Useful after detox or incarceration, young people (*more useful in less severe opioid use disorder)*
59
Buprenorphine Naloxone Combo vs. XR Naltrexone
(data from lancet)
=
Fewer participants successfully initiate XR-NT (72%) vs. BUP NX (94%)
24 wk relapse greater in XR-NT (65%) vs. BUP NX (57%)
More difficult to initiate XR-NTX than BUP-NX which negatively affected overall relapse, however once initiated both meds equally safe and effective
60
What is the gold standard medication for opioid dependence?
**Methadone Maintenance**
61
Methadone Maintenance The “Gold” Standard
* In a Comprehensive Rehabilitation Program..
* Improves overall sur\_\_\_\_\_
* Increases ret\_\_\_\_ in treatment
* Decreases illicit opioid \_\_\_
* Decreases ___ seroconversion
* Decreases cr\_\_\_\_\_ activity
* Increases emp\_\_\_\_\_\_
* Improves bi\_\_\_\_ outcomes
* In a Comprehensive Rehabilitation Program..
* Improves overall survival
* Increases retention in treatment
* Decreases illicit opioid use
* Decreases HIV seroconversion
* Decreases criminal activity
* Increases employment
* Improves birth outcomes
62
Methadone SE
(4)
Constipation
Sweating
Decreased libido
QT prolongation
63
Opioid Treatment Program Benefits
* Decrease div\_\_\_\_\_
* Su\_\_\_\_ services for patients - counseling, case management, vocational
* Co-located medical and ps\_\_\_\_\_\_ care (“Health Home”)
* Methadone effective for patients with ____ opioid tolerance
* Decrease diversion
* Support services for patients - counseling, case management, vocational
* Co-located medical and psychiatric care (“Health Home”)
* Methadone effective for patients with high opioid tolerance
64
Opioid Treatment Program Limitations
* St\_\_\_\_\_
* Limited acc\_\_\_\_/long w\_\_\_\_ lists
* Separate system not involving _____ care physicians or pharmacists
* Inconvenient and highly pun\_\_\_\_
* M\_\_\_\_\_ stable and unstable patients
* No ability to “gr\_\_\_\_\_” from program
* Stigma
* Limited access/long waiting lists
* Separate system not involving primary care physicians or pharmacists
* Inconvenient and highly punitive
* Mixes stable and unstable patients
* No ability to “graduate” from program
65
Buprenorpine with Naloxone
(Suboxone)
Routes (4)
1. Sublingual tablets (8mg/2mg and 2mg/0.5mg)
2. Sublingual film
3. Weekly injection
4. Implant
66
Buprenorphine Summary
**MOA**
* Efficacy vs. methadone?
* Safety?
* Combination with ______ further risk of abuse
* Available in ______ care settings
**A partial mu-opioid agonist**
* As effective as Methadone
* Greater safety
* Combination with naloxone further reduces risk of abuse
* Available in primary care settings
67
Patients not appropriate for buprenorphine?
* Ben\_\_\_\_\_\_\_ or al\_\_\_\_ abuse/dependence
* (1) women
* Patients with ____ level of opioid dependence
* Ch\_\_\_\_\_\_ pain
* Medically un\_\_\_\_\_\_
* (1) lab value \>5x upper limit of normal
* Benzodiazepine or alcohol abuse/dependence
* Pregnant women
* Patients with high level of opioid dependence
* Chronic pain
* Medically unstable
* Liver enzymes \>5x upper limit of normal
68
Patients not appropriate for office based treatment?
* S\_\_\_\_\_\_\_ substance use
* Unstable l\_\_\_\_\_ situation
* Poor social su\_\_\_\_\_\_
* Ps\_\_\_\_\_\_ co-morbidity
* Secondary substance use
* Unstable living situation
* Poor social supports
* Psychiatric co-morbidity
69
Heroin
Trend in Heroin use and deaths from 2015-2017?
Heroin users doubled, Heroin deaths 7.7x higher
70
Heroin Names
1. Generic name (1)
2. Spanish names (2)
3. Street names (5)
1. Diacetylmorphine
2. Heroina, Manteca
3. Dope, Smack, Horse, Boy, Tar
71
Heroin Effects
* Marketed by Bayer in 2895 as a _____ suppressant
* Produces serene eu\_\_\_\_\_, CNS \_\_\_\_\_\_
* Other effects include p\_\_\_ relief, ____ suppression, con\_\_\_\_\_\_\_
* Overdose death is dt _______ depression
* Marketed by Bayer in 2895 as a cough suppressant
* Produces serene euphoria, CNS depression
* Other effects include pain relief, cough suppression, constipation
* Overdose death is dt respiratory depression
72
Heroin Formulations
* (1) or (1) colored powder
* \_\_\_$ per bag
* Routes (3)
* ______ of street heroin varies (10-70%)
* Tan or white powder
* 10$ per bag
* Can be snorted, injected, and smoked *(rarely smoked)*
* Purity of street heroin varies (10-70%)
73
Cocaine History
When did the cocaine epidemic start?
What was it marketed as at first?
Then what happened in the early-mid 1980's?
Late 1970s - early 1980
Cocaine is safe, non-addictive, the high life (“The status symbol of the American middle class” (Newsweek), Cocaine: The Champagne of Drugs (NY Times), “Cocaine is not physically addictive...Cocaine, as currently used, usually does not result in serious social consequences such as crime, hospital ER admissions, or death” (Director of NIDA, 1975)
↑ cocaine consumption → ↑ cocaine production, Realization of cocaine’s addictive effect and interference with life, ↓ cocaine demand, Excess surplus of powder cocaine
74
Cocaine Formulations
**(1)****-** cocaine hydrochloride
* Spanish names (3)
* Street names: (4)
**(1)****-** similar to freebase
* Street names (3)
**Powder cocaine** **-** cocaine hydrochloride
* Spanish - cociana, perrico, yeyo
* Street names: coke, lady, white witch, nose candy
**Crack cocaine** - similar to freebase
* Street names: rock, ice, jammies
75
Cocaine Use
* ____ most commonly abused illicit drug
* 1.5-3 million active users in US
* Occurs naturally in erythr\_\_\_\_\_ c\_\_\_\_ leaves
* St\_\_\_\_\_\_ and local an\_\_\_\_\_\_
* Eu\_\_\_\_\_\_, \_\_creased energy and libido, \_\_creased appetite, increased self-con\_\_\_\_\_
* Street preparations \_\_**-**\_\_% cocaine
76
Cocaine Routes
* **(1)**- Cocaine hydrochloride
* **Intravenous or Subcutaneous** (2)
* **Smoked**
* **(1)**
* Extracted with alkali and ether
* Lipid soluable - rapid onset of effect
* **(1)**
* Preprepared, inexpensive
* Many impurities
* **(1)**
* Inert substances - talc, flour, cornstarch, sugars
* Local anesthetics - procaine, lidocaine
* Cheaper stimulants - amphetamines, caffeine, aminophylline, PCP
* **(1)**
* Bacteria, fungi, viruses
* **Intranasal** - Cocaine hydrochloride
* **Intravenous or Subcutaneous** (“mainlining”, “skin popping”)
* **Smoked**
* **Freebase**
* Extracted with alkali and ether
* Lipid soluable - rapid onset of effect
* **Crack**
* Preprepared, inexpensive
* Many impurities
* **Adulterants**
* Inert substances - talc, flour, cornstarch, sugars
* Local anesthetics - procaine, lidocaine
* Cheaper stimulants - amphetamines, caffeine, aminophylline, PCP
* **Contaminants**
* Bacteria, fungi, viruses
77
Differences in Cocaine Preparations
78
Cocaine Effects
* Acts as a ____ and local \_\_\_\_\_
* (4) effects
* _____ of pulse and blood pressure
* Stimulant and local anesthetic
* Euphoria, increased energy and libido, decreased appetite, increased self-confidence
* Elevation of pulse and blood pressure
79
Signs of Crack Use
* Burns/cuts on (1)
* Burns/calluses on (1)
* Burns on (1) or (1)
* “Crack d\_\_\_\_\_”
* Neurodermatitis =
* Sl\_\_\_\_\_\_ for days
* Weight \_\_\_\_
* Mi\_\_\_\_ appointments
* Burns/cuts on lips
* Burns/calluses on thumbs
* Burns on eyebrows or hairline
* “Crack dance”
* Neurodermatitis (*will pick at skin/sometimes bc they feel like there are bugs on their skin)*
* Sleeping for days
* Weight loss
* Missed appointments
80
Cocaine Withdrawal
* Dys\_\_\_\_\_ mood
* Fat\_\_\_\_
* Unpleasant dr\_\_\_\_
* \_\_\_somnia and \_\_\_somnia
* _____ appetite
* Ag\_\_\_\_\_
* Limited ability to experience pl\_\_\_\_\_
* Dysphoric mood
* Fatigue
* Unpleasant dreams
* Insomnia and hypersomnia
* Increased appetite
* Agitation
* Limited ability to experience pleasure
81
Cardiac effects of Crack/Cocaine Use
(3)
Ischemia/Infarctions (Vasospams, increased atherosclerosis)
Arrhythmia, *QT prolongation*
CHF
82
Pulmonary Effects of Crack/Cocaine Use
(1) exacerbation
Pneumo\_\_\_\_\_/pneumo mediastinum
Pulmonary (3)
? long term AE
asthma exacerbation
Pneumothorax/pneumo mediastinum
Pulmonary edema, hemorrhage, infarction
? long term AE
83
Neurologic Effects of Crack/Cocaine Use
S\_\_\_\_ (3)
S\_\_\_\_\_\_\_
\_\_\_\_\_\_ HA
Stroke: Cerebral hemorrhage, Cerebral infarction, Vasculitis
Seizures
Migraine HA
84
Psychiatric Effects of Crack/Cocaine Use
* (1): tactile, auditory, visual “coke bugs”
* (1) syndromes, delusions
* (1) disorders
* Hallucinations: tactile, auditory, visual “coke bugs”
* Schizophrenic syndromes, delusions
* Personality disorders
85
Risks Associated with Drug Use
* Le\_\_\_\_
* Fin\_\_\_\_\_
* \_\_\_\_dose
* Neglect of _____ to health issues
* Poor ad\_\_\_\_\_\_ to prescribed medications
* Vio\_\_\_\_\_/vict\_\_\_\_\_\_
* Acc\_\_\_\_\_
* Increased s\_\_\_\_\_ risk taking
* Legal
* Financial
* Overdose
* Neglect of chronic to health issues
* Poor adherence to prescribed medications
* Violence/victimization
* Accidents
* Increased sexual risk taking
86
Risks Associated with Injection Use
(4)
* Viral infections (HIV, hepatitis)
* Bacterial infections (skin, heart, bones)
* Loss of accessible veins
* Higher risk of overdose
87
Risks Associated with Intranasal Use
(3)
Nasal septal damage
Sinusitis
Overdose
88
How does active substance abuse effect HAART adherence?
Less adherence to HAART with active substance use
89
Efficacy of treatment options for cocaine use?
No good treatment options for cocaine use
90
Pharmacologic Treatment for Cocaine Dependence
Efficacy?
(6)
No clinically significant findings (*none really effective)*
Dilantin, Nimodipine, Tyrosine, Fluoxetine, Carbamazepine, Pergolide, Tricyclic antidepressants
91
Efficacy of complimentary and alternative therapies for cocaine dependence?
Conflicting results for auricular acupuncture → small RCT + results, large RCT - results, trial w/o payment showed auricular acupuncture arm had less cocaine in urine
92
Methamphetamine Names
Sp\_\_\_\_\_
Ch\_\_\_\_\_
M\_\_\_\_
Cr\_\_\_\_
Cr\_\_\_\_\_
I\_\_\_
Speed
Chalk
Meth
Crystal
Crank
Ice
93
Methamphetamine Background
* 1919 synthesized in Japan as de\_\_\_\_ and br\_\_\_\_\_\_
* Cheap, synthesized in clandestine laboratories directly from (1) rx
* Wh\_\_\_ \_\_\_\_less, b\_\_\_ tasting cr\_\_\_\_ powder dissolved in water or alcohol
* 1919 synthesized in Japan as decongestant and bronchodilator
* Cheap, synthesized in clandestine laboratories directly from pseudoephedrine or ephedrine
* White odorless, bitter tasting crystalline powder dissolved in water or alcohol
94
Methamphetamine Use and Effects
Routes (4)
Low dose effects: al\_\_\_ness, vig\_\_\_\_\_, ____ pupils
High dose effects: an\_\_\_\_\_, par\_\_\_\_\_
Subjective effects similar to (1)
Effects last \_\_**-**\_\_ hrs (~10x as long as cocaine) if orally ingested or snorted, briefer if smoked or injected
Snorted, orally ingested, injected, smoked
Low dose effects: alertness, vigilance, dilated pupils
High dose effects: anxiety, paranoia
Subjective effects similar to cocaine
Effects last 6-15 hrs (~10x as long as cocaine) if orally ingested or snorted, briefer if smoked or injected
95
Methamphetamine Effects
Used in a “\_\_\_\_ and \_\_\_\_” pattern, tolerance occurs within \_\_\_\_\_
1. **Smoke** → **r\_\_\_ or “fl\_\_\_\_”**
* Lasts only minutes
1. **Snorting or oral ingestion → (1) (not as intense as rush)**
* Snorting effects within 3-5 minutes
* Oral ingestion within 15-20 minutes
Used in a “binge and crash” pattern, tolerance occurs within minutes
1. **Smoke** → rush or “flash”
* Lasts only minutes
1. **Snorting or oral ingestion → euphoria (not as intense as rush)**
* Snorting effects within 3-5 minutes
* Oral ingestion within 15-20 minutes
96
Special Populations
(3)
**Adolescents**
**Women**
**Elderly**
97
Signs of Substance Abuse in Adolescents
* May present as ______ changes that affect _____ performance or ______ functioning
* Verbal or physical agg\_\_\_\_\_
* Ac\_\_\_\_ difficulties
* I\_\_\_sivity
* H\_\_\_\_activity
* D\_\_\_\_\_\_ mood
* Poor so\_\_\_\_ skills
* May present as behavioral changes that affect school performance or social functioning
* Verbal or physical aggression
* Academic difficulties
* Impulsivity
* Hyperactivity
* Depressed mood
* Poor social skills
98
Screening Test for Adolescence Substance Abuse
**(1)**
**_\>_ \_\_\_** “yes” answers suggest a significant problem
**CRAFFT Questionnaire**
* **C:** Have you ridden in a **CAR** driven by someone (including yourself) who was “high” or who had been using alcohol or drugs?
* **R:** Do you ever use alcohol or drugs to **RELAX**, feel better about yourself, or fit in?
* **A:** Do you ever use alcohol or drugs when you are **ALONE**?
* **F:** Do you ever **FORGET** things you did while using alcohol or drugs?
* **F:** Do your family or **FRIENDS** ever tell you that you should cut down on your drinking or drug use
* **T:** Have you gotten into **TROUBLE** while you were using alcohol or drugs?
**_\>_ 2** “yes” answers suggest a significant problem
99
Special Considerations for Women and Substance Abuse
* Comorbid m\_\_\_\_ disorders
* D\_\_\_\_\_\_ violence
* S\_\_\_ for money/drugs
* Substance use in pr\_\_\_\_\_\_
* Comorbid mood disorders
* Domestic violence
* Sex for money/drugs
* Substance use in pregnancy
100
Older Adults and Substance Abuse
* Don’t forget about substance abuse, esp in ddx of f\_\_\_\_, se\_\_\_\_\_, and mental st\_\_\_\_\_ changes!
* Social ______ can mask social impact of substance abuse
* MAST =
* Don’t forget about substance abuse, esp in ddx of falls, seizure, and mental status changes!
* Social isolation can mask social impact of substance abuse
* MAST = 25-question test that is used to help identify an alcohol dependency
101
A set of practical, public health strategies designed to reduce the negative consequences of drug use and promote healthy individual and communities
Harm Reduction
102
Principles of Harm Reduction
1. **(1) + (1)** public health interventions that minimize the harmful effects of drug use
2. **(1)** drug use as a complex, multi-faceted issue that encompasses behaviors from severe abuse to total abstinence
3. **(1)** people where they are in the course of their drug use
4. **(1)** that people who use drugs have a real voice in the creation of programs
5. **(1)** that people who use drugs are the primary agents of change
6. **(1)** communities to share information and support each other
1. **Design & Promotes** public health interventions that minimize the harmful effects of drug use
2. **Understands** drug use as a complex, multi-faceted issue that encompasses behaviors from severe abuse to total abstinence
3. **Meets** people where they are in the course of their drug use
4. **Ensures** that people who use drugs have a real voice in the creation of programs
5. **Affirms** that people who use drugs are the primary agents of change
6. **Empowers** communities to share information and support each other
103
Harm Reduction Practice Calls for
* **Non-j\_\_\_\_\_, non-co\_\_\_\_\_ provision of services**
* **\_\_\_-threshold program models**
* **Re\_\_\_\_\_\_** to people who use drugs
* **Non-judgmental, non-coercive provision of services**
* **Low-threshold program models**
* **Resources** to people who use drugs
104
Harm Reduction & Sterile Syringe Access: History and Timeline
* First started in Holland in response to (1) outbreak in the 1980s
* Frist legal program in the US started in Tacoma, ______ in 1988
* By 2002, 184 programs in 36 states
* First started in Holland in response to hep B outbreak in the 1980s
* Frist legal program in the US started in Tacoma, Washington in 1988
* By 2002, 184 programs in 36 states
105
Harm Reduction Examples
* Syringe ex\_\_\_\_\_
* D\_\_\_\_\_\_ driver
* Con\_\_\_\_ use
* Snus =
* Na\_\_\_\_\_ distribution
* Safer injection s\_\_\_\_
* H\_\_\_\_\_ maintenance
* Syringe exchange
* Designated driver
* Condom use
* Snus = oral tobacco placed behind upper lip
* Naloxone distribution
* Safer injection sites
* Heroin maintenance
106
Goals of Harm Reduction
* **Prevent disease**
* Sterile syringe access to prevent (2)
* S\_\_\_\_ injection
* **Reduce Mortality**
* \_\_\_\_\_dose prevention - training and n\_\_\_\_\_ distribution
* Access to medical care and social services
* (1) (DOT)
* Pill boxes
* **Treatment for drug dependence**
* Bup\_\_\_\_\_\_
* M\_\_\_\_\_\_ maintenance
* **Emp\_\_\_\_\_ communities and reduce st\_\_\_\_\_**
* Community organizing
107
Redefine Successful Healthcare
* Success is NOT just:
* Un\_\_\_\_\_\_ viral load
* Ab\_\_\_\_\_\_ from drug use
* Success also includes:
* Making it to app\_\_\_\_\_\_\_
* Pr\_\_\_\_\_\_ care (PAP, vaccinations, PCP/MAC prophylaxis, PPD)
* L\_\_\_, sa\_\_\_\_\_, more con\_\_\_\_\_ drug use
* Improvement in non-medial areas (hou\_\_\_\_, rel\_\_\_\_\_\_, cr\_\_\_\_\_ activity, etc)
* Success is NOT just:
* Undetectable viral load
* Abstinence from drug use
* Success also includes:
* Making it to appointments
* Preventative care (PAP, vaccinations, PCP/MAC prophylaxis, PPD)
* Less, safer, more controlled drug use
* Improvement in non-medial areas (housing, relationships, criminal activity, etc)
108
**ABC’s** **of Harm Reduction**
**=**
* **A**sk and Assess
* **B**e nonjudgemental
* **C**ounsel
* **S**creen and vaccine
109
**A**sk and Assess
**=**
110
**B**e nonjudgemental
=
* Avoid “clean” and “dirty”
* Don’t assume abstinence, even in those with recent or prolonged abstinence
* Frame drug use in terms of specific health risks
111
**C**ounsel
=
* Drug treatment
* Safer injection
* Overdose prevention
* Safer sex
* Smoking cessation
112
**S**creen and Vaccine
**Screen** (4)
**Vaccination** (4)
* **Screening**: HIV, Viral hepatitis, TB, Med adherence
* **Vaccination:** Hep A, B, Tetanus, Influenza
