Substance Abuse Disorders (SUDs) Flashcards
Opioid intoxication vs opioid withdrawal, pupils state?
Intoxication = pin-point/miosis
Withdraw = dilation/mydriasis
What are the substance classes?
Alcohol Caffeine Cannabis Hallucinogens (PCP, etc) Inhalants Opioids Sedatives, Hypnotics, Anxiolytics Stimulants Tobacco Gambling
Mild, Moderate, and Severe make up the severity scale/spectrum/range. What’s needed in each?
Mild: 2-3 sxs
Moderate: 4-5 sxs
Severe: 6 or more sxs
What’s the difference between early and sustained remission?
Early: no criteria for at least 3 months but < 1 yr
- first 3 months are the hardest
Sustained: remission for > 1 yr
Intoxication is.. due to ________, not ________.
Substance
Medical issue
What is the opposite of intoxication?
Withdrawal (“hang over”)
What neurotransmitter is associated w/ meth and coke?
DA (d/t drug inh of reuptake, DAT inh)
Can substance abuse lead to permanent mental disorders?
Yes, even after one use (ecstasy causes permanent psychosis)
Native Americans are more prone to alcoholism because?
Their alcohol dehydrogenase is genetically far more efficient, meaning they have to drink A LOT more to get the effects, easier for them to become constant drinkers and suffer the side-effects
What percentage of hospital admissions have an alcohol or drug association? Intoxication is involved w/ how many MVAs and DV cases?
40%
25% of all hospital deaths
50%.. and 50%
Ecstasy deals w/ what neurotransmitter?
5HT, reversal of SERT
Why does dependence occur?
After drug use (even proper use w/ opioids), the body’s natural ability to stimulate the pathway the drug did is reduced.. and falls behind what’s normal, creating an urge and reinforcing use of more drug. The brain will actually down-regulate production of Rs and neurotransmitter that’s in excess (d/t the drug), which contributes to the craving/withdrawal sxs.
How many addicts have comorbid psychiatric disorders? What does that mean?
50% (antisocial PD, depression, suicide)
ASK the pt about their mental history… think about more than what’s in front of you!
What’s being targeted in addictions regarding behavioral interventions?
Internal and external reinforcers
How can ETOH intoxication be fatal?
It’s a depressant that perpetuates GABA release in the CNS, GABA is NOT excitatory.. and an overabundance will depress medullary function, vomiting may also cause pulmonary aspiration (far more likely because protective reflexes are depressed as well)
What are the stages of alcohol withdrawal?
Early (first 24 hours): anxiety, irritability (crankiness), tremors, HA, insomnia, N/V, tachycardia and HTN, hyperthermia and hyper-active reflexes
24-48 hours: seizures (Grand mal), also no airway protection
48-72 hours: Delirium Tremens is LIFE-THREATENING (diaphoresis, tremors, confusion, hallucinations)
If CIWA (clinical institute withdrawal assessment) score is > 10, what’s prescribed? What’s the MOA?
Benzodiazepine (Diazepam = long-acting, Lorazepam or Oxazepam or Temazepam = short-acting and metabolism not based on liver health)
GABA agonist that’s cross-tolerant w/ ETOH
What should be partnered w/ Benzos to tx ETOH withdrawal?
Anticonvulsants
- Carbamazepine
- Valproic Acid
- both of these induce CYP450 enzymes
What additional info must you tell your pt about Disulfiram? What scenario is the drug def not used?
Don’t use mouthwashes, some sleep aids, or eat “beer dip”.. anything of that sort, can induce flu-like sxs of medication
Hepatitis/liver dx
What factors can change the half-life of Benzos?
Liver function and fat storage
- better liver function will clear drug
- less fat means less storage and faster clearance
How are Oxazepam, Temazepam, and Lorazepam metabolized?
In the liver via glucuronidation, not affected by age/hepatic insufficiency
What are the opioid intoxication and withdrawal presentations? What’s the neuro-adaptation at work?
Intoxication: pinpoint pupils, sedation, constipation, bradycardia and hyptension, dec resp rate
Withdrawal (not life-threatening): dilated pupils, lacrimation, n/v, diarrhea, myalgias and arthralgias, agitation and irritation
Increased DA (body was pumping its synthesis up to counteract over-stimulation of GABA, now that GABA signal is gone.. too much DA) and decreased NE
What’s a popular tx for opiate use disorders?
Suboxone (Naltrexone/antagonist + Buprenorphine/agonist)
What’s the presentation for (meth)amphetamine (stimulants) intoxication and withdrawal? What neurotransmitter is at work? Medication option? What can happen over time?
Intoxication (not life-threatening): rotted teeth, skin lesions, pupils are dilated, euphoria, hyperactivity and restlessness, anxiety, tension and anger, impaired judgement, paranoia, tachycardia and HTN
Chronic use: hypotension and bradycardia (body has adapted), m weakness, permanent psychosis
Withdrawal: sleep and hunger
DA (inh of reuptake/reversal of DAT), also NE and SE
No
Neurotoxicity d/t excessive glutamate > constant NMDA activity > short-circuiting of R > small insults and R removal > scar tissue/plaques > possible Alzheimers! (Very least brain lesions on MRI)
What’s the presentation of cocaine intoxication and withdrawal? What’s the neuroadaptation at work? Is there medication options?
Intoxication: rhabdomyolysis (get a CK level, myoglobin lvl) w/ compartment syndrome, psychosis, HTN
Prevents reuptake of DA and ultimately depletes it
No meds approved
What’s the most preventable cause of death/dx in the US?
Tobacco
Pschiatric pts are often at risk for dependence of what?
Nicotine
75-90% o Schizophrenics smoke
Carbamazepine/Tegretol does what?
Induces CYP450 enzymes
Teratogen, can cause neural-tube defects
What CYP enzyme do tobacco products induce?
CYP1A2
In the hospital, smoking pts smoke less.. induce less 1A2.. and thus their meds stick around longer
When they leave the hospital.. more smoking.. more 1A2 induction.. meds are gobbled up quicker and the pt decompensates (does not mean non-compliant!)
Can someone overdose/intoxicate themselves on tobacco/nicotine?
Withdrawal?
What drug can be helpful? Which one is avoided?
No
Yes, causing: dysphoria (unease and dissatisfaction w/ life), irritability, anxiety, decreased concentration, insomnia, inc appetite
Buproprion
Varenicline (suicidal ideations)
Where does nicotine act?
At nAChR on DA neurons in VTA, activation of them > DA release in nucleus accumbens
Bath salts and MDMA are both types of what?
Ecstasy
What are the intoxication and withdrawal states regarding ecstasy?
Intoxication (3-6h): enhanced empathy, euphoria, increased energy, illusions, enhanced senses, tearfulness, panic and paranoia, impaired judgement, teeth grinding and psychosis (long-term use), pt is sweating in a cold room
- too much 5HT (rev SERT)
Withdrawal: sleepiness
What’s the most commonly used illicit drug in the US?
Cannabis
How fast do THC levels peak? How fast do they clear (h/l)?
10-30 minutes
50 hours, longer if chronic user w/ lots of adipose tissue
What are the intoxication and withdrawal effects of cannabis? What neurotransmitter is being modulated?
Appetite and thirst inc, inc confidence/euphoria, relaxation, inc libido, anxiety and paranoia, tachycardia and dry “cotton” mouth, conjunctival injection, slowed reaction time, impaired cognition, psychosis
- inc in DA
Withdrawal: insomnia, irritability, anxiety, poor appetite, depression, physical discomfort
What are the intoxication and withdrawal sxs of PCP (“Angel Dust”)? What’s it similar to? Is there tx? What’s the neuroadaptation at work?
Intoxication: paranoid delusions, hallucinations, violent agitation w/ decreased awareness of pain, nystagmus
No withdrawal
Ketamine
Yes, FGA/SGA or BZD
Opiate R effects, modulates glutamate NMDA R
