Substance Abuse

Question 1

A college student is brought to the emergency department by a roommate who is concerned about symptoms of extreme restlessness, nausea, and vomiting. Physical examination reveals elevations of the pulse and blood pressure and pupillary dilation, along with hyperactive bowel sounds.
Which substance is the patient suspected to be withdrawing from?

LSD

Alcohol

Opiods

Cocaine

Answer 1

This patient has symptoms consistent with opioid withdrawal, which causes restlessness, hyperactive bowel sounds, pupillary dilation, and changes in vital signs.

Question 2

Alcohol Withdrawal

Answer 2

Tremors, confusion, hallucinations

Question 3

LSD Withdrawal

Answer 3

Hallucinations

Question 4

Cocaine Withdrawal

Answer 4

Muscle tension, teeth clenching, blurry vision

Question 5

Refer:

Answer 5

Withdrawal seizures
Delirium Tremens (severe alcohol withdrawal)
Overdose
Suicide or Homicide ideation
Patient states they are ready for treatment

Question 6

Delirium Tremens

Answer 6

Severe alcohol withdrawal
Usually occurs 72 hours after last consumption
Tachycardia, tremor, confusion, hallucinations, agitation, diaphoresis, fever, seizures

Question 7

Substance Use Disorder

Answer 7

Two items within the last 12 months:

• substance taken in larger amounts or longer than intended
• Persistent desire or failure to cut down
• Excessive time spent obtaining substance (or means to), or recover from it, or use it
• Urge or craving
• Recurrent failure to fulfill family or work obligations (or school / social)
• Continued use despite problems
• Activities given up in favor of use
• Used in situations when it is dangerous
• Use continues despite knowing risk or problem exists
• Tolerance effects
• Withdrawal effects

Question 8

Causes of Substance Use Disorder

Answer 8

Interplay of genetics, stress, environment

Co-morbid mental health issues often also occur

Question 9

Neuroplasticity

Answer 9

There are drug-induced plastic changes to brain circuitry with substance use. Therefore recovery from SUD includes brain recovery. During and after addiction treatment there is brain healing. Some changes may be permanent or take a long time to heal.

Question 10

Alcohol Effects

Answer 10

GABA and glutamate are affected by chronic alcohol use

Question 11

THC / Marijuana

Answer 11

The psychoactive ingredient in marijuana, tetrahydrocannabinol (THC), produces a variety of effects, including altered senses, changes in mood, and impaired thinking. Marijuana can be ingested via smoking, eating, or drinking. The amount of THC in marijuana and in concentrated edibles has been increasing. Although life-threatening overdose has not been observed, high doses of THC may result in unpleasant symptoms such as hallucinations, psychotic delusions, or paranoia.2

Question 12

Screening Questions

Answer 12

For Tobacco—“In the past year, how often have you used tobacco products?”
For Alcohol—“How many times in the past year have you had more than 5 drinks in a day (4 for women)?”
For other drugs—“In the past year, how often have you used any other drugs or taken prescription drugs for non-medical reasons?”

Question 13

Stimulant Effects

Answer 13

enhanced state of alertness, high energy, euphoria, appetite suppression, and decreased need for sleep. People who use stimulants repeatedly or at high doses may experience untoward effects ranging from anxiety and restlessness to paranoia and delusions or hallucinations

Question 14

Alcohol Use Disorder Treatment

Answer 14

Three Categories
1 - managing withdrawal
2 - managing cravings
3 - medication for nutrition deficiency - B12 and Folate

Question 15

Alcohol Withdrawal

Answer 15

Benzodiazepines

Question 16

Alcohol Craving Management

Answer 16

Naltrexone 50mg daily but not if hepatic disease exists or on chronic pain managment
Do not give if patient has received opioids in last 7 days
Often causes GI issues

Disulfiram does not reduce cravings but causes N/V and other symptoms to discourage alcohol intake

Question 17

Methadone for Opioid Use

Answer 17

methadone can be used in inpatient hospital and detoxification settings for the purposes of withdrawal. Titration of methadone for opioid withdrawal is usually done over a period of several days. Initial administration is usually between 10 and 30 mg daily and does not exceed 40 mg per day as gradual accumulation takes place over 48 to 72 hours and steady state is achieved at approximately 5 day

Not done by primary care

Question 18

Buprenorphine/naloxone

Answer 18

Buprenorphine/naloxone may also be used for opioid withdrawal and, when a patient situation calls for discontinuation as opposed to maintenance therapy, may be tapered over a 3- to 5-day period. Unlike methadone, buprenorphine is a partial opioid agonist. Because buprenorphine is a partial agonist with great affinity for opioid receptors, it may displace other opioids from receptors and lead to precipitated withdrawal

Question 19

Nicotine Therapy

Answer 19

Bupropion 150mg daily for 3 days then twice daily for 12 weeks

Varenicline - Blocks nicotine. 0.5mg daily for 3 days, twice daily for 3 days, then 1.0mg once daily for 12 weeks
Carries risk of nausea and disturbing dreams

CBT or Peer Support is recommended as adjunct in all smoking cessation