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Psychiatry > Substance Abuse Disorders > Flashcards

Substance Abuse Disorders Flashcards

1
Q

taking more or for longer than intended, unsuccessful efforts to stop or cut down use, spending a great deal of time obtaining, using, or recovering from use, craving for substance.

A

Impaired control:

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2
Q

failure to fulfill major obligations due to use, continued use despite problems caused or exacerbated by use, important activities given up or reduced because of substance use.

A

social impairment:

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3
Q

recurrent use in hazardous situations, continued use despite physical or psychological problems that are caused or exacerbated by substance use.

A

Risky use:

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4
Q

tolerance to effects of the substance, withdrawal symptoms when not using or using less.*

A

Pharmacologic dependence:

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5
Q

Criteria for Use disorders

A
  • Mild: 2-3 Criteria
  • Moderate: 4-5 Criteria
  • Severe: 6 or more
  • Early Remission: 3-12 months
  • Sustained Remission: >12 months • Maintenance Therapy
  • In a Controlled Environment
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6
Q

Define Intoxication

A

Specific criteria for intoxication for each substance

Use of specific substance by history

Physiological correlates of use

Clinically significant maladaptive behavior or psychological changes

The symptoms are not due to a general medical condition and are not better accounting for by another mental disorder.

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7
Q

Define Withdrawal

A
  • Cessation of prolonged use
  • Specific physiological correlates
  • Clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not due to a general medical condition and not better accounted for by another mental disorder.
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8
Q

What aspects of person need to be addressed when treating addiciton?

A
  • Neurochemical • Behavioral
  • Genetic
  • Cultural
  • Developmental
  • Psychological/psychodynamic/personality
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9
Q

What is the role of the Neurochemical in addiction

A
  • Role of dopamine
  • Reward pathways
  • Prefrontal cortex
  • Nucleus accumbens
  • Ventral tegmental area
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10
Q

Role of Dopamine in addiction

A

Different Substances work at different receptors

If pleasurable, final common pathway usually involves dopamine.

All activate dopamine pathways:

• Food •Sex • Excitement • Comfort

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11
Q

Amphetamines, cocaine, opiods, cannabinoids, ethanol, barbituates, benzos all end in the

A

dopamine pathway

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12
Q

How is addiction work on biologic reinforces

Not necessarily dependent on ‘feeling good’

A

• e.g. cocaine-powerfully euphoric, but nicotine has less euphoria but still addictive

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13
Q

Almost all addictive drugs exhibit tolerance, at least to negative side effects

A

• Level of initial tolerance may predict likelihood of addiction

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14
Q

Almost all abused drugs are self-administered by rats
____ and ____ are exceptions

Opiates, cannabis, cocaine, alcohol, amphetamine all activate _______pathway

A

• LSD and marijuana

limbic dopamine

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15
Q

is the neurotransmitter most linked to addictive disorders

A

Dopamine

****• Relative dopamine deficiency in reward system when use is stopped, resulting in conscious dysphoria or unconscious craving

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16
Q

: opiate antagonism reduces alcohol cravings
•_____: ‘restore GABA equilibrium’
•_____: Nicotinic Ach receptor agonist

A

Naltrexone

Campral

Chantix

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17
Q
  • _______ to use of drug reinforces using behavior: Reward may be physiological or social
  • ________- Reinforced patterns of behavior

• ________- craving and euphoric recall in using setting; paraphernalia act as cues

A

Positive response

Operant conditioning

Classical conditioning

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18
Q
  • Use of drug removes a negative condition, resulting in reinforcement of the behavior
  • Especially important for benzodiazepines and opioids for avoiding anxiety and for avoiding symptoms of withdrawal.
A

Negative reinforcement

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19
Q

What do we see for genetic linkage in addiciton

A
  • Twin studies show genetic component
  • Also linked in adoption studies
  • Lower incidence in Asians due to tolerance and metabolism

• One third of alcoholics have no family history

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20
Q

What personality factors play into Substance abuse

A
  • Affective dysregulation
  • Impulse control deficits: more reliance on reward

•Ego defects- inability to cope with painful affects

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21
Q

What family dynamics do we see in abuse disorders

A
  • Codependence, Enabling
  • Multigenerational drug dependence
  • Parental loss through divorce, death, abandonment, or incarceration
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22
Q

What is the treatment approach for substance abuse

A

Medical, family services, vocational services, mental health, legal

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23
Q

What to keep in mind when tx substance abuse

A

No single treatment is appropriate for all individuals

Effective treatment attends to multiple needs of the individual, not just his/her drug use

Treatment must address medical, psychological, social, vocational, and legal problems

24
Q

What do we need to keep in mind during Detox

A
  • Risks vary by substance
  • ‘Cold turkey’ vs. Tapering
  • Usually attempted many times by addict
  • Higher ‘success’ if inpatient
  • Medications may be important or helpful
  • Range of settings, $$$
  • Business model: Rapid Detox
25
Q

What medications could we use for alcoholics during detox?

A

benzodiazepines, phenobarbital, folate, thiamine

26
Q

What medications may be helpful for optiate addicts during detox

A

Opiates: clonidine, loperamide, analgesics

27
Q

What is part of the “Active” Treament stage in addiction

A
  • Active Treatment •Separation from substance •Education
  • ‘Conversion process’ •Lifestyle changes •Family and relationship work
28
Q

What part of the Addiction Treatment stage is this?
•Often neglected
•Myth of treatment ‘cure’
•Change is key– and staying changed

  • Medications, aftercare,
  • Personal commitment
A

•Maintenance

29
Q
  • Common, especially with opioids
  • Often as bad or worse than former use
  • High morbidity
  • Changes in tolerance
A

Relapse

30
Q

What is the difference between abstinence and recovery

A
  • Abstinence is developed, not recovered
  • An abnormal condition, signifying an internal defect (disease)

Addicts want to be “normal,” that is, using drugs in control– ability is permanently removed. Abstinence alone does not ‘fix’ the defects of addiction

Recovery is designed as a guide towards a better way of living

• Newer medications bring up the question whether ‘Recovery’ is always necessary.

31
Q

What are the key steps in Motivation enhancement Therapy

A

Precontemplation: establish rapport and offer support for any positive changes

Contemplation: encourage ambivalence; show pros and cons of substance use/treatment, education

Preparation: encourage work toward goal

Action: continue to encourage; family ultimatums may be necessary

Maintenance: relapse prevention, education, preparation, vigilance

32
Q

What are the principles in MOtivational Enhancement Thearpy

A
  • Express Empathy
  • Develop Discrepancy

• Avoid Argumentation

  • Roll with Resistance
  • Support Self-Efficacy
33
Q
  • Model used by most residential centers
  • Confrontation used initially to break through denial
  • Emphasis on change and personal responsibility
  • Boundary enforcement, limits, consequences of actions
A

12-Step Approach

34
Q

Complements, extends, and confounds treatment efforts

Most commonly used models include 12-Step (AA, NA) and Smart Recovery

Most treatment programs encourage ongoing self- help participation during/after treatment

A

Self Help

35
Q

How Long Should Treatment Last ?

A
  • Depends on patient problems/needs
  • Less than 30 days is of limited effectiveness for residential/outpatient setting
  • Treatment duration often controlled by insurer or patient’s finances
  • Longer treatment is often indicated
36
Q

What is the Harm reduction Approach

A
  • Use a variety of interventions
  • Do not demand total sobriety
  • Many names over time, eg ‘Moderation Management,
  • CBT approach; moderate intake e.g. by drink- counting
37
Q

Naltrexone, disulfiram, acamprosate, topiramate, baclofen

These can all be used to aid in treatement of which substance abuse

A

Alcohol:

38
Q

Naltrexone, methadone, buprenorphine

recommended medicaiton for tx of which substance abuse?

A

Opiates:

39
Q

What meds can we use for nicotine addiction to help quit?

A

Nicotine replacement (gum, patches, spray), bupropion, Chantix

40
Q

What is a timeline we see often with people who develop opiod addiction

A

Often start using meds to treat pain

we need to watch overprescribing

also need to make sure we prescribe when necessary

41
Q

What is the trend in optiate abuse

A

continued to rise in treatment admissions, OPR sales and deaths

**HAS surpassed cocaine and heroin for cause of death in United States

(In milwaukee we’ve had spike of heroin deaths)

42
Q

How are opiates activated to active form?

A
  • Codeine transformed to morphine by CYP 2D6
  • Not active in 7% of caucasians •InhibitedbyPaxil, Prozac,Quinidine
  • Demerol toxic if MAOI; normeperidine causes seizures
43
Q

What is withdrawl like from opiates, what is sometimes used to help?

Why is there such a high death rate?

A

withdrawal after prolongued use, someone helped by clinidine

See high OD rate: changes the way body responds to CO2 levels and you lose the drive to breath until activated by O2 levels low which is much less sensitive

44
Q

Opiates

lipid solubility?

cross tolerance?

A

very lipid soluble

see cross tolerance among class

45
Q

What is the age group of opiate abusers?

How may this addiction present itself?

A

Onset is late teens/twenties with Male 1.5xs more liekly to use

Genetic predisposition: impulsivness, novelty seeking and peer selection

increasing abuse in white female middle class

can present as depression, sexual problems, cellulits and poverty

46
Q

Associated mortalities to opiate abuse

A

2% die: see OD, hepatitis, HIV, endocarditis and suicide

*Absent peirods are common; 20-30% have long term abstinence rate

47
Q

Describe opiate withdrawal

A

Three (or more) of the following, developing within minutes to several days after cessation of use: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or sweating; diarrhea; yawning; fever; insomnia

48
Q

What do we see in individual with opiate intoxication

A

Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use: drowsiness or coma; slurred speech, impairment in attention or memory

49
Q

n order to use______ for Opioid Addiction Therapy, one must obtain a special federal license and be affiliated with an opioid addiction treatment program

A

Methadone

50
Q

joined methadone and naltrexone as a medication for treating opiate addiction

  • May be used off label for pain
  • May be particularly effective in patients with pain and addiction
A

Buprenorphine

51
Q

What drug has a log scale ceiling effect, is a parital agonist and used to tx opiod addiciton

A

Buprenorphine; keeps you steady

*if you get off it and use opiates you have high chance of OD!

52
Q

How are Naloxone and Buprenorphine used together to tx opiod addiction

A

Addition of naloxone to buprenorphine to decrease abuse potential

If taken as medically directed (dissolve under tongue), predominant buprenorphine effect

If opioid dependent person dissolves tablet and injects, withdrawal induced

Naloxone NOT ACTIVE during oral use

53
Q

What are the risks of Buprenorphine

A

Highly safe medication (acute and chronic dosing)

Primary side effects: like other mu agonist opioids (e.g., nausea, constipation), but time-limited

No significant disruption in cognitive or psychomotor performance with buprenorphine maintenance

No organ damage with chronic dosing

54
Q

What are some controversies concerning Buprenorphine to tx opiod addiction

A
  • How long to treat?
  • ‘Risks’ of buprenorphine

• 35,000 overdose deaths per year; 40 linked to buprenorphine

  • Insurance, Medicaid coverage?
  • Value of ‘traditional’ treatment
55
Q

You are a psychiatrist and one of your pts has been on Buprenorphine for two years and doing great to tx her opiod addiciton. You get a call from her dentist stating he will need to extract a tooth to put in her implant. He wants to know how to work with the buprenorphine

A

Mild – moderate pain, i.e. dental extraction:

◦ Continue buprenorphine maintenance
◦ Use non-opioid treatments
◦ Use short acting opioids (effect may be blocked)

56
Q

A pt of yours is a recovering opiod abuser and has been succesfully on buprenorphine to tx her addition for 9 months. She was in a car accident and will need surgery on her leg. Her surgeon wants your opion for pain management

A

Moderate – Severe pain i.e. hip replacement

◦ Discontinue buprenorphine Treat pain with opioids

◦ Reinduction with buprenorphine
◦ Consider continuing buprenorphine

57
Q
A

Psychiatry (19 decks)

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