Substance Abuse Disorders Flashcards
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.
Impaired control:
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.
social impairment:
recurrent use in hazardous situations, continued use despite physical or psychological problems that are caused or exacerbated by substance use.
Risky use:
tolerance to effects of the substance, withdrawal symptoms when not using or using less.*
Pharmacologic dependence:
Criteria for Use disorders
- 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
Define Intoxication
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.
Define Withdrawal
- 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.
What aspects of person need to be addressed when treating addiciton?
- Neurochemical • Behavioral
- Genetic
- Cultural
- Developmental
- Psychological/psychodynamic/personality
What is the role of the Neurochemical in addiction
- Role of dopamine
- Reward pathways
- Prefrontal cortex
- Nucleus accumbens
- Ventral tegmental area
Role of Dopamine in addiction
Different Substances work at different receptors
If pleasurable, final common pathway usually involves dopamine.
All activate dopamine pathways:
• Food •Sex • Excitement • Comfort
Amphetamines, cocaine, opiods, cannabinoids, ethanol, barbituates, benzos all end in the
dopamine pathway
How is addiction work on biologic reinforces
Not necessarily dependent on ‘feeling good’
• e.g. cocaine-powerfully euphoric, but nicotine has less euphoria but still addictive
Almost all addictive drugs exhibit tolerance, at least to negative side effects
• Level of initial tolerance may predict likelihood of addiction
Almost all abused drugs are self-administered by rats
____ and ____ are exceptions
Opiates, cannabis, cocaine, alcohol, amphetamine all activate _______pathway
• LSD and marijuana
limbic dopamine
is the neurotransmitter most linked to addictive disorders
Dopamine
****• Relative dopamine deficiency in reward system when use is stopped, resulting in conscious dysphoria or unconscious craving
: opiate antagonism reduces alcohol cravings
•_____: ‘restore GABA equilibrium’
•_____: Nicotinic Ach receptor agonist
Naltrexone
Campral
Chantix
- _______ 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
Positive response
Operant conditioning
Classical conditioning
- 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.
Negative reinforcement
What do we see for genetic linkage in addiciton
- 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
What personality factors play into Substance abuse
- Affective dysregulation
- Impulse control deficits: more reliance on reward
•Ego defects- inability to cope with painful affects
What family dynamics do we see in abuse disorders
- Codependence, Enabling
- Multigenerational drug dependence
- Parental loss through divorce, death, abandonment, or incarceration
What is the treatment approach for substance abuse
Medical, family services, vocational services, mental health, legal
What to keep in mind when tx substance abuse
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
What do we need to keep in mind during Detox
- 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
What medications could we use for alcoholics during detox?
benzodiazepines, phenobarbital, folate, thiamine
What medications may be helpful for optiate addicts during detox
Opiates: clonidine, loperamide, analgesics
What is part of the “Active” Treament stage in addiction
- Active Treatment •Separation from substance •Education
- ‘Conversion process’ •Lifestyle changes •Family and relationship work
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
•Maintenance
- Common, especially with opioids
- Often as bad or worse than former use
- High morbidity
- Changes in tolerance
Relapse
What is the difference between abstinence and recovery
- 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.
What are the key steps in Motivation enhancement Therapy
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
What are the principles in MOtivational Enhancement Thearpy
- Express Empathy
- Develop Discrepancy
• Avoid Argumentation
- Roll with Resistance
- Support Self-Efficacy
- 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
12-Step Approach
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
Self Help
How Long Should Treatment Last ?
- 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
What is the Harm reduction Approach
- 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
Naltrexone, disulfiram, acamprosate, topiramate, baclofen
These can all be used to aid in treatement of which substance abuse
Alcohol:
Naltrexone, methadone, buprenorphine
recommended medicaiton for tx of which substance abuse?
Opiates:
What meds can we use for nicotine addiction to help quit?
Nicotine replacement (gum, patches, spray), bupropion, Chantix
What is a timeline we see often with people who develop opiod addiction
Often start using meds to treat pain
we need to watch overprescribing
also need to make sure we prescribe when necessary
What is the trend in optiate abuse
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)
How are opiates activated to active form?
- Codeine transformed to morphine by CYP 2D6
- Not active in 7% of caucasians •InhibitedbyPaxil, Prozac,Quinidine
- Demerol toxic if MAOI; normeperidine causes seizures
What is withdrawl like from opiates, what is sometimes used to help?
Why is there such a high death rate?
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
Opiates
lipid solubility?
cross tolerance?
very lipid soluble
see cross tolerance among class
What is the age group of opiate abusers?
How may this addiction present itself?
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
Associated mortalities to opiate abuse
2% die: see OD, hepatitis, HIV, endocarditis and suicide
*Absent peirods are common; 20-30% have long term abstinence rate
Describe opiate withdrawal
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
What do we see in individual with opiate intoxication
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
n order to use______ for Opioid Addiction Therapy, one must obtain a special federal license and be affiliated with an opioid addiction treatment program
Methadone
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
Buprenorphine
What drug has a log scale ceiling effect, is a parital agonist and used to tx opiod addiciton
Buprenorphine; keeps you steady
*if you get off it and use opiates you have high chance of OD!
How are Naloxone and Buprenorphine used together to tx opiod addiction
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
What are the risks of Buprenorphine
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
What are some controversies concerning Buprenorphine to tx opiod addiction
- How long to treat?
- ‘Risks’ of buprenorphine
• 35,000 overdose deaths per year; 40 linked to buprenorphine
- Insurance, Medicaid coverage?
- Value of ‘traditional’ treatment
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
Mild – moderate pain, i.e. dental extraction:
◦ Continue buprenorphine maintenance
◦ Use non-opioid treatments
◦ Use short acting opioids (effect may be blocked)
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
Moderate – Severe pain i.e. hip replacement
◦ Discontinue buprenorphine Treat pain with opioids
◦ Reinduction with buprenorphine
◦ Consider continuing buprenorphine
