substance abuse Flashcards
alcohol, tobacco, illicit drugs or improperly used medication are considered what?
substances
sporadic consumption with no major adverse consequences is called ?
substance use
consumption that risks major adverse consequences is called ?
At-Risk Substance Use
condition characterized by an individual who is significantly affected by another person’s substance use or addiction
codependency
_____: maladaptive use causing impairment or distress over a 12-month period where 1+ has occurred:
substance abuse
1. Failure to fulfill major role obligations
2. Use of drugs in hazardous situations
3. Recurrent legal problems due to substance use
4. Continued drug use despite persistent social or interpersonal problems because of use
state of adaptation manifested by a substance class-specific withdrawal syndrome
dependence
dependence can be produced by?
- Rapid dose reduction or cessation of a substance
- Administration of an antagonist
- Tolerance to the substance
2 types of dependence that patients may manifest
- psychological dependence
- physiologic dependence
Primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
addiction
addiction can be characterized by behaviors including:
- Impaired control over substance use
- Compulsive substance use
- Continued substance use despite harm
- Craving for substance
difference between substance use and dependence/addiction
- Substance use - pts retain control of their use
- Control can be affected by poor judgement, social factors, environment - Dependence and Addiction - No longer have full control
- Brain is “hijacked” by substance - need as powerful as thirst or hunger
- Users may still have some degree of conscious control
___: often predate the initial substance use, thought to be genetically predisposed
Measurable brain abnormalities
- Substance use → changes that affect dopamine level in mesolimbic system
- Changes are often permanent - account for relapses
Patients 12 yrs and up with any illicit drug use in the past 1 month: ?%
14% - 1 in 10
About half (49%) of people over their entire lifetime
Almost ___% are unaware that they have a substance abuse problem
Often goes unrecognized in clinical practice!
95%
who is the highest age of risk of substance abuse
late teens and early 20s
↓ age at first use = ?
↑ risk of later addiction
- Lifetime prevalence of ETOH - __% of pts 12+
- ETOH within past 12 months - __%
- ETOH within past 12 months, ages 12-20 - __%
4/5 (78%)
2/3 (62%)
1/10 (15%)
who is nearly twice as likely to engage in binge drinking
Almost three times as likely to engage in heavy drinking
males
Cigarettes or Vaping:
__% - Lifetime, pts 12 and up
__% - Past 1 yr, pts 12 and up
1/2 (58%)
1/5 (26%)
who are are more likely to use vaporized cigarettes (vapes)
young adults
what is the #1 substance for dependence and abuse in US (17.3 million)
alcohol
substance abuse costs over ? annually in costs related to crime, work productivity and healthcare
$800 billion
1. tobacco
2. alcohol
3. illicit drugs
4. Rx opiates
what is the leading preventable cause of death in the US
tobacco
what is involved in up to 50% motor vehicle fatalities?
illicit drugs or alcohol
substance use has an effect on social, physical, mental and public health problems, including:
- Medical Conditions
- Hepatitis
- Cirrhosis
- HIV/AIDS
- STIs
- Motor vehicle crashes/fatalities - Social Conditions
- Teenage pregnancy
- Domestic violence
- Child abuse
- Physical fights
- Overall crime
- Homicide/Suicide
what are the risk factors for substance use?
- Substance Factors
- Early onset tobacco use
- Early experimentation with substances
- Type of substance tried - Societal Influence
- Family
- Peer groups
- Religious groups
- Cultural and societal norms - Patient Personality Traits
- Risk-takers, thrill-seekers, novelty seekers
- Poor impulse control or emotional control
- Difficulty relating to others - Associated Psychiatric Disorders
- Conduct disorder
- MDD or Bipolar disorder
- ADHD
- Antisocial personality disorder - static patient demographics
- male
- black, AI/AN or NHOPI ethnicity
- gay or lesbian
- genetic predisposition - modifiable patient demographics
- low socioeconomic status
- single or divorced
- low educational level
- violent or high-crime neighborhood
- personal history of abuse
why do ppl use substances?
- feel good
- feel better
- fit in
Chemical structure of many drugs is similar to ?
neurotransmitters
allows them to be recognized by neurons and alter brain messages
Neurotransmitter involved in regulation of pain, appetite, memory, mood
Anandamide
active ingredient in marijuana
THC
NT that involves movement, motivation, reward,
addiction, well-being
dopamine
NT involved with mood, memory, sleep, cognition
serotonin
NT involved with learning, memory
glutamate
NT involved with lessening pain/euphoria
endorphins
NT involved with relaxation, anxiolytic
GABA
what are the three C’s of addiction?
- Control
- Early social & recreational use
- Eventual loss of emotional & behavioral control
- Cognitive distortions (denial and minimization)
- Tolerance and withdrawal - Compulsion
- Drug-seeking activities and craving → addiction
- Continued use despite adverse consequences - Chronicity
- Natural history of multiple relapses preceding stable recovery
- Possible relapse after years of sobriety
the attempt to alleviate symptoms of mental illness
self-medication
May increase vulnerability to mental illness are called ?
casual effects
Same/similar risk factors for substance use and mental illness are called ?
correlated causes
Up to what percent of substance abuse pts also have a mental disorder?
50%
Up to 40% have comorbid substance abuse disorder aka what disorder?
mood disorder
Up to 59% of women in addiction treatment have what? Where they are 2-3x than males?
PTSD
what sex is more likely to have more alcoholics to have some comorbid mental illness
women
What do the NT do during intoxication?
- Dopamine: euphoria
- Opioid Peptides: analgesia, relaxation
- Serotonin: elevated mood
- Glutamate: relaxation
- GABA: decreased anxiety, less panic, relaxation
what do the NT do during withdrawal?
- Dopamine: dysphoria
- GABA: anxiety, panic attacks
- Opioid Peptides: increased pain
- Glutamate: hyperexcitability
- Serotonin: dysphoria
Every process that is either pleasant or unpleasant has a secondary “opponent” (opposite) process that sets in after
Opponent-Process Theory
With repetition, the primary process becomes ____ while the opponent process is ____
weaker, strengthened
result of pairing emotional pleasure (with substance use) and displeasure (with withdrawal)
drug addiction
describe the process during drug addiction
- Early in substance use - high pleasure, low withdrawal
- Over time - pleasure decreases, withdrawal increases
- Attempt to treat addiction by interfering with cycle
about how many US adults use alcohol in a risky manner and are at risk for substance use issues?
3 in 10
repetitive use of alcohol, often to alleviate emotional problems
at-risk drinking
how many oz is a “drink”
~0.5-0.6 oz
what has the most % alcohol and what has the least?
hard liquor - 1.5 oz, 40% alc
beer - 12 oz, 4% alc
liver can process about how much of alc?
0.5 oz/hr
faster timeline from first drink to alcohol dependence
telescoping effect
telescoping effect is usually seen in who?
women
- Lower EtOH dehydrogenase
- Lower total body water
- Smaller volume of distribution
- Drink like partner
recurrent use of alcohol despite disruption in social roles, alcohol-related legal problems, or taking safety risks
alcohol addiction
who is at risk for alcohol dependence
- Male gender
- White or Native American
- Younger age (18-29)
- Being single
- Lower income
- Past exposure to adverse events
- Genetic predisposition
- Significant disability
- Other psych disorders
- Other SUD, depression, BPD, personality d/o
What is CAGE?
Widely used substance use screening tool for at-risk patients
1. Have you felt you ought to Cut down on your drinking or drug use?
2. Have people Annoyed you by criticizing your drinking or drug use?
3. Have you felt Guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover or to get the day started? (Eye-opener)
2+ yes questions - more in-depth assessment
Even 1 yes - “red flag” - possible substance use problem
MOA of alcohol
- Suppression of inhibitory control systems
- Acts as a sedative-hypnotic substance
- Affects CNS receptors - GABA, NMDA (glutamate), 5HT-3 (serotonin)
- Facilitates dopamine release (reward system)
effects of acute intoxication
- Psychomotor dysfunction
- Disinhibition
- Dysarthria, ataxia, nystagmus
- Memory lapses
- Nausea and vomiting
- Drowsiness; fragmented sleep
- Respiratory depression
- Hypoglycemia
- Severe - stupor, coma, death
what medication has effects on GABA receptors
Benzodiazepines
Effects of alcohol withdrawals
- Decreased cognitive function
- Tremulousness
- Anxiety, irritability, and hyperreactivity
- Nausea and vomiting
-
Delirium Tremens
- Prolonged ETOH consumption → fewer GABA receptors
- Unopposed sympathetic nervous system activity
- Neuro - confusion, tremor, seizures, sensory hyperacuity, hallucinations, hyperreflexia
- Psych - anxiety, agitation, panic attacks, paranoia
- Diaphoresis, dehydration, electrolyte abnormalities
- Cardiovascular abnormalities
effects of chronic alcohol use?
- Wernicke Encephalopathy
- Triad - Confusion, ataxia, ophthalmoplegia
- Other s/s - impaired vision/hearing, psychological dysfunction, memory deficit, hypothermia, hypotension - Korsakoff Psychosis
- Amnesia - anterograde and retrograde
- Aphasia, apraxia, agnosia - Gastrointestinal
- Liver - Fatty liver, alcoholic hepatitis, cirrhosis
- Vascular - Portal hypertension, varices
- Pancreas - pancreatitis, pancreatic insufficiency, cancer
- GI tract - Esophagitis, gastritis, gastric ulcers, cancers
- Labs - Increased GGT, AST:ALT - Other Body Systems
- Cardiac - HTN, increased HR, increased myocardial O2 consumption
- Cancer - head/neck, esophageal, liver, breast, colorectal, pancreas
- Endocrine - dysregulation of lipoproteins and triglycerides
which can only be reversed by 20% with treatment via thiamine and other B vitamins
Korsakoff Psychosis
which can be completely reversed with thiamine and other B vitamins
wernicke encephalopathy
Withdrawal onset is about ___ after last drink
8-12 hrs
Peak intensity of symptoms - 48-72 hours
mainstay tx for alcohol withdrawal
Benzodiazepines (BZDs)
- Medium to long-acting BZDs like diazepam (Valium), lorazepam (Ativan) or chlordiazepoxide (Librium) usually preferred
what is comparable to BZDs and used for very mild cases of withdrawal
Gabapentin or carbamazepine (Tegretol) orally
what tx is used for CV and anxiety s/s from alcohol withdrawal
Anti-hypertensives
- Clonidine
- Atenolol
what general nutritious diet and vitamin supplementations can help with alcohol withdrawal
- B vitamins (thiamine, pyridoxine, folic acid), vitamin C (ascorbic acid)
- Do not give IV glucose before giving thiamine supplementation
- Fluid replacement if indicated
what is used to help assess withdrawal severity
CIWA scoring
Tx often begins at score of 8-10 (mild) or higher
short course of tapering BZD is considered for what level severity
mild
inpatient (hospital) treatment with regular BZD until stable
- diazepam orally 5-10 mg per hour depending on clinical need
- Monitor vitals and electrolytes
is for what level of severity
moderate
inpatient (hospital) treatment, regular BZD until stable
- diazepam IV till sedated, then may give orally every 8-12 hrs
- Reduce dose by 20% per 24 hrs - taper usually takes 1+ wks
is for what level of severity
severe
what types of consult must be included for alcohol withdrawal?
social work and psych
what is the tx for chronic alcohol use? SE?
Thiamine - Vitamin B1
low blood pressure, may affect glucose metabolism, rarely see anaphylaxis, bronchospasm
what must you give before glucose for alcoholism tx?
thiamine
the FDA-approved, 1st line tx for chronic alcohol use
Blocks the release of dopamine in the brain
Naltrexone (ReVia, Vivitrol)
- Antagonist at mu receptors in brain - ↓ craving, ↓ reward
naltrexone has better efficacy if given with what?
behavioral therapy, acamprosate, or SSRI
what medication tx can be given to a person while they are still drinking?
Naltrexone
No need to dose-adjust for mild-moderate renal or hepatic impairment
SE and BBW for Naltrexone
- Black-Box Warning - hepatocellular injury, hepatotoxicity
- SE - N/V/D/C, abd pain, dizziness, HA, anxiety, fatigue
- Can precipitate opioid withdrawal
CI for naltrexone
hx of hypersensitivity, opioid dependence or current use
DI with naltrexone
opiates
what must you monitor while taking naltrexone?
liver function tests
1st line therapy for chronic alcohol use (Not FDA approved)
Works to restore normal glutamate action
Acamprosate (Campral)
- Interferes with glutamate release thereby stopping excitation that happens with withdrawal
- Affects GABA neurotransmitter system as well
- Same rates of return to drinking/return to heavy drinking as naltrexone
what medication tx for chronic alcohol use is recommended to start after pt has been abstinent
Acamprosate (Campral)
who must you adjust the dosing for when taking Acamprosate (Campral)
renal - if CrCl 30-50 mL/min
no hepatic adjustment
SE of Acamprosate (Campral)
diarrhea, nausea, abd pain, fatigue, HA, amnesia
monitor mood: anxiety, depression, suicidality
what must you monitor when taking acamprosate
Monitor mood - anxiety, depression, suicidality
CI for acamprosate
Severe renal impairment (CrCl < 30 mL/min)
Second-line therapy for chronic alcohol use
Inhibits enzyme aldehyde dehydrogenase
Causes acetaldehyde to accumulate → sweating, headache, dyspnea, lowered BP, flushing, palpitations, N/V
disulfiram (antabuse)
which tx does NOT influence motivation/withdrawal directly and has no proven long-term efficacy in alcohol abuse
disulfiram
if a pt is using “hidden” ethanols (e.g., mouthwash), what medication must you avoid?
disulfiram
SE of disulfiram
often related to intentionally caused sx; metallic taste
Monitor for hepatotoxicity
DI with disulfiram
metronidazole, warfarin, amitriptyline
CI with disulfiram
severe heart disease or CAD, acute intoxication
what are the other second-line tx for chronic alcohol use?
- Anticonvulsants - topiramate (Topamax), gabapentin (Neurontin)
- Muscle relaxants - baclofen
- Antidepressants - SSRIs
- If comorbid psychiatric disorder present - Antinausea - ondansetron (Zofran)
- If early-onset (<25 y/o) problem drinking
- Greater serotonergic abnormality in this group
what are the psychosocial tx for chronic alcohol use?
- Motivational Interviewing - helps patient explore and resolve ambivalence about stopping alcohol use
- Cognitive Behavioral Therapy - explore how thought processes contribute to behavior
- Peer Support Groups - Alcoholics Anonymous
someone who has been drinking has thought, judgement, and restraint loosened, what could be their BAC %?
0.05% BAC
someone’s voluntary motor actions become clumsy after drinking, what could be their BAC %?
0.1% BAC
someone whose been drinking has depression of motor control and emotional control areas of brain
what could be their BAC %?
0.2% BAC
someone whose been drinking has confusion, stupor
what could be their BAC %?
0.3% BAC
someone who has been drinking recently fell into respiratory depression and led to a coma
what could have been their BAC %?
0.4-0.5% BAC
