Substance abuse-Exam 2 Flashcards
____ alcohol, tobacco, illicit drugs or improperly used medication
substance
_____ sporadic consumption with no major adverse consequences
substance use
______ consumption that risks major adverse consequences
at risk substance use
______ condition characterized by an individual who is significantly affected by another person’s substance use or addiction
codependency
Define substance abuse
maladaptive use causing impairment or distress over a 12-month period where 1+ has occurred:
Failure to fulfill major role obligations
Use of drugs in hazardous situations
Recurrent legal problems due to substance use
Continued drug use despite persistent social or interpersonal
problems because of use
_____ state of adaptation manifested by a substance class-specific withdrawal syndrome
dependence
What can dependence be produced by?
Rapid dose reduction or cessation of a substance
Administration of an antagonist
Tolerance to the substance
____ and ____ are both types of dependence that a patient can manifest
Psychological dependence
Physiologic dependence
______ primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
addiction
What are the characteristic behaviors of addiction?
Impaired control over substance use
Compulsive substance use
Continued substance use despite harm
Craving for substance
What is the difference between substance use and dependence/addiction?
Substance use - pts retain control of their use
Dependence and Addiction - No longer have full control
Dependence/addiction you can ????? often predate the initial substance use, thought to be genetically predisposed. What is this thought to be due to?
Measurable brain abnormalities
changes that affect dopamine level in mesolimbic system
What are some examples of psychological dependence?
irritable, agitation etc etc
What are some examples of physiological dependence?
heart palpitations, HA, N/V
Substance use disorder is defined as maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by ___ of the following within a ____:
2+
12-month period
**Patients 12 yrs and up with any illicit drug use in the past 1 month: is _____
almost 1 in 5 (17%)
**______ that they have a substance abuse problem
Almost 95% are unaware
** ______ age at first use = _____ risk of later addiction
younger age
increased risk
aka the younger you are when you first use, the greater the chance of addiction later
What ethnicity has the highest rates of substance abuse?
alaskan native and native american
**Lifetime prevalence of ETOH - Almost ______ of pts 12+
4 out of 5 (78%)
**ETOH within past 12 months - almost ______
2 out of 3 (63%)
**ETOH within past 12 months, ages 12-20 - about _____
3 in 20 (15%)
**Cigarettes or vaping: ______ - Lifetime, pts 12 and up (2022)
Over 1 out of 2 pts (57%)
**Cigarettes or vaping ______ - Past 1 yr, pts 12 and up (2022). Is this statistic getting better or worse?
Over 1 out of 5 pts (28%)
no improvement and trending up
Young adults are more likely to use ______.
vaporized cigarettes (vapes)
**What are the top 3 most abused substances? Know which ones are illicit
1: Alcohol
#2: Marijuana
#3: Pain relievers
**_____ is the leading cause of preventable death in the US
Tobacco use
What are some substance abuse risk factors
Early onset tobacco use
Early experimentation with substances
Type of substance tried
_____ neurotransmitter involved in regulation of pain, appetite, memory, mood
Anandamide
Why do people abuse substances?
Chemical structure of many drugs is similar to neurotransmitters
Drugs of abuse affect the motivation and pleasure
pathways in our brain!
Drugs of abuse ____ dopamine levels, and affect ___ and _____ levels
increase dopamine
serotonin and glutamate levels
What are some common cognitive defects with addiction?
Short-term memory loss
Impaired abstract thinking
Impaired problem-solving strategies
Loss of impulse control
What are the three C of addiction?
Control
Compulsion
Chronicity: multiple relapses precede stable recovery
There is a strong link between mental illness and substance use, which of the two should be treated first?
Should treat both at the same time
What is the opponent-process theory?
Every process that is either pleasant or unpleasant has a secondary “opponent” (opposite) process that sets in after
With repetition, the primary process becomes weaker while the opponent process is strengthened
aka: less of high/rush with more of the withdrawal
aka: over time its less about getting high and more about avoiding the withdrawal
What are most of the substance abuse medication aimed at treating?
medications aimed at preventing the rush and helping with the withdrawal to not be so terrible
**About _____ US adults use alcohol in a risky manner and are at risk for substance use issues!
1 in 4
_____ repetitive use of alcohol, often to alleviate emotional problems
at-risk drinking
What is considered moderate drinking for men? binge drinking?
moderate drinking: 1-2 drinks/day
binge: greater than 4 drinks on a single occasion
more than 14/drinks/week on average
What is considered moderate drinking for women? binge drinking?
moderate drinking: 1 drink/day
binge drinking: more than 3 drinks on a single occasion
more than 7 drinks a week on average
**What equals 1 drink?
How long does it take the liver to process 0.5oz of alcohol?
1 hour
What are some telescoping factors in women that speed up the timeline from first drunk to alcohol dependence?
Lower EtOH dehydrogenase
Lower total body water
Smaller volume of distribution
Drink like partner
What enzyme breaks down alcohol?
EtOH dehydrogenase
What psych disorder is common in alcohol abuse? What gender is more likely to abuse alcohol?
depression
males
What is the 3rd leading cause of preventable death in the US?
excessive alcohol use
_____ recurrent use of alcohol despite disruption in social roles, alcohol-related legal problems, or taking safety risks
alcohol addiction
What are some risks factors for alcohol dependence?
Male gender
White or Native American
Younger age (18-29)
Being single
Lower income
Past exposure to adverse events (think military combat)
Genetic predisposition
Significant disability
Other psych disorders (SUD, depressions, BPD, personality disorders)
What is the CAGE questionnaire?
CUT DOWN on your drinking?
felt ANNOYED by someone criticizing your drinking?
felt GUILTY about your drinking?
ever needed an EYE-OPENER?
2+ yes: need an more in depth assessment
1 yes: is a red flag, possible substance abuse problem
_____ is the more in depth CAGE survey
Alcohol Use Disorders Identification Test (AUDIT)
What is the MOA of alcohol?
Crosses the blood-brain barrier
Acts as a sedative-hypnotic substance
Affects CNS receptors - GABA, NMDA (glutamate), 5HT-3 (serotonin)
Facilitates dopamine release
suppression of the inhibitory control system
What is delirium tremens?
extreme alcohol withdraw due to prolonged alcohol consumption, results in fewer GABA receptors
confusion, tremor, seizures, sensory hyperacuity, hallucinations, hyperreflexia
anxiety, agitation, panic attacks, paranoia
Diaphoresis, dehydration, electrolyte abnormalities
What am I?
What are the 2 major ones?
delirium tremens
**tremor and seizures
**What is the triad of Wernicke Encephalopathy? What is the treatment? Is it reversible?
Confusion, ataxia, ophthalmoplegia
Thiamine, other B vitamins
Often completely reversible with treatment
What are the signs of Korsakoff Psychosis? What is the treatment? Is it reversible?
Amnesia: anterograde and retrograde
Aphasia
apraxia (unable to perform movements when asked)
agnosia (unable to process sensory information)
Thiamine, other B vitamins
Only about 20% are reversible with treatment
What is a classic chronic alcohol abuse abdominal s/s?
Portal hypertension, varices, caput medusae
When does alcohol withdrawal tend to set in? When are the peak intensity of symptoms?
about 8-12 hrs after last drink
48-72 hours
What is the mainstay treatment for alcohol withdrawal?
Medium to long-acting BZDs like diazepam (Valium), lorazepam (Ativan) usually preferred
consider adding on: clonidine or atenolol
B vitamins! (do NOT give IV glucose before giving thiamine supplementation)
Fluid replacement (if needed)
_____ is used to help asses alcohol withdrawal severity. When does treatment begin?
CIWA Scoring
Tx often begins at score of 8-10 (mild) or higher
What is the treatment for miild alcohol withdrawal?
moderate?
Severe?
short course of tapering BZD
e.g. - diazepam 20 mg orally on first day, then decrease by 5 mg/d
inpatient (hospital) treatment with regular BZD until stable
e.g. - diazepam orally 5-10 mg per hour depending on clinical need
Monitor vitals and electrolytes
inpatient (hospital) treatment, regular BZD until stable
e.g. - diazepam IV till sedated, then may give orally every 8-12 hrs
Reduce dose by 20% per 24 hrs - taper usually takes 1+ wks
social work and psych consult needed!!
What is the first line medication for chronic alcoholism? What is the MOA?
Naltrexone (ReVia, Vivitrol)
Blocks the release of dopamine in the brain, better efficacy if given with behavioral therapy
Can you start naltrexone while the patient is still drinking? What is the daily dose?
50 mg orally once daily - can start while person is still drinking
What are the BBW for Naltrexone? What are the CI? What tests do you need to monitor?
hepatocellular injury, hepatotoxicity
hx of hypersensitivity, opioid dependence or current use of opiates
LFT
_____ is first line therapy for chronic alcohol use and works to restore normal glutamate action. Interferes with glutamate release thereby stopping excitation that happens with withdrawal. Also affects GABA
Acamprosate (Campral)
_____ 666 mg orally TID - often recommend to start after pt has been ABSTINENT
Acamprosate (Campral)
What are the CI for Acamprosate (Campral)?
Severe renal impairment (CrCl < 30 mL/min)
aka good for bad livers but CI for bad kidneys
____ is 2nd line therapy. Inhibits enzyme aldehyde dehydrogenase. Not proven long-term efficacy in alcohol abuse.Does not influence motivation/withdrawal directly
Disulfiram (Antabuse)
aka makes you feel very sick if you drink alcohol
What are some other second-line therapies for alcohol abuse?
topiramate (Topamax), gabapentin (Neurontin)
baclofen, SSRIs, ondansetron
**_____ is the #1 preventable cause of mortality. and causes ____ deaths
Smoking
1 out of 5
What pt demo graphic has the highest risk for smoking?
male, AI/AN, multiracial, white, black, homosexual, low socioeconomic and education level
____ have a slightly lower risk of cancer due to it not being inhaled as deeply into the lungs. _____ is passed through a water chamber before being inhaled
Cigars/Pipes
Hookahs
____ is acute lung injury associated specifically with the use of vaping products.
Acute _____ reported after vape use
EVALI
eosinophilic pneumonia
The average cigarette contains ____ of nicotine. Body absorbs about ___ per cigarette. ____ absorption with vape vs. smoke
10-15mg
1-2 mg per cig
2-3X more absorption with vaping
____ stimulates nicotinic cholinergic receptors in the brain. Reaches brain in about ___ ; t½ about _____
nicotine
15 sec
1-2 hours
**Tobacco tolerance is due to ???
due to upregulation of nicotinic (acetylcholine) receptors → develops rapidly
What is the timeframe for tobacco withdrawal?
as early as 2 hrs after last cigarette, peaks in first 72 hrs, fades gradually over 3-4 weeks
Nausea, salivation, pallor
Tachycardia, poor concentration
Decreased REM sleep
What am I?
acute toxic effects of tobacco
Smokers on average die _____ earlier than non-smokers
10 years ealier
What is the correlation between smoking and H. Pylori?
smoking increases the risks that abx prescribed for H. Pylori will not be effective
Smokers will have an (increased/decreased) carbon monoxide level. What lab tests can you order to see if people have been smoking?
increased
Continine - nicotine metabolite (can be positive due to second hand smoke exposure)
Anabasine - present in tobacco and most vapes, not nicotine replacement
What is first line for tobacco cessation?
Nicotine Replacement Therapy: need both long acting and short acting
____ is the primary recommended treatment for adolescents who are smoking/vaping and wish to quit
Nicotine Replacement therapy
____ is the most common SE of transdermal patch. What are two additional SE? What are two pt education points?
skin irritation
need to change location of the patch daily, do not sleep in patch
insomnia, vivid dreams
_____ diminishes rather than stops nicotine withdrawal. What are the SE? What is the pt education?
Oral Nicotine Gum
N/V/D, HA, excess salivation, mouth irritation
Avoid acidic beverages before and during gum use
“Chew and park” method for 30 minutes
What are the pt education points for oral nicotine lozenges? SE?
Does not need to be chewed; most nicotine content
Maximum - 5 lozenges every 6 hrs or 20 lozenges/day
mouth irritation, N/V/D, palpitations, HA, insomnia
_____ absorbed through nasal mucosa - more rapid peak than oral
Nicotine Nasal Spray
_____ blocks dopamine and norepinephrine reuptake (DNRI), antagonizes nicotinic cholinergic receptors. What are the SE?
Bupropion
insomnia, agitation, dry mouth, headache
What are the CI to Bupropion?
epilepsy; high seizure risk; hx of anorexia or bulimia
_____ partial agonist of nicotinic cholinergic receptors. Partial stimulation of receptor to decrease withdrawal. Blocks nicotine from binding to receptor, interfering with “reward”
Varenicline (Chantix)
When ____ was first released there was concern about neuropsychiatric SE but the FDA has removed the BBW
Varenicline (Chantix)
_____ recommended most commonly as back-up or adjunct to first-line medication
Nortriptyline
The best success rates to quit smoking are achieved with plans that incorporate both ?????treatments.
pharmacologic and non-pharmacologic
What do you think happens after someone quits smoking with regard to mood, cough and weight?
Mood- irritable
Cough- increased coughing
Weight- increased weight, usually around 10 lbs
Opioid use during pregnancy can result in a drug withdrawal syndrome in newborns called _____
neonatal abstinence syndrome
____ and ____ are natural opiates and are derived from poppy plant
What are the semi-synthetic ones?
Derived from ???
codeine, morphine
heroin, oxycodone, buprenorphine, oxymorphone, hydrocodone, hydromorphone.
Derived from opium (extract of poppy plant)
What are the synthetic opiates?
meperidine, fentanyl, methadone
____ acts on mu and noradrenergic/serotonin receptors
tramadol
_____ acts on mu, kappa and delta opioid receptors in brain, digestive tract, spinal cord. What is each receptor responsible for?
Opioids
Mu – mediates pain, respiratory depression, constipation and physical dependence
Kappa – analgesia, diuresis, sedation , psychological dependence
Delta – analgesia, dependence, antidepressant
What are some effects of opioids on the body?
Pupillary constriction
Constipation
Pinpoint pupils
Respiratory depression
_____ is the short-acting opioid antagonist. What is the dosing for Cardiorespiratory arrest?
Spontaneous ventilations?
Naloxone (Narcan)
2mg
0.05mg IV
**What does long term use of opioid do to your brain?
desensitization and downregulation of opioid receptors
_____ opiates causes earlier development of tolerance
short-acting
What is the opioid withdrawal symptoms scale? When do you need to treat?
Grade 0-4.
0 is no cravings/axiety and 4 is all the signs
Treat if grade 2 or higher
What is the first line opioid agonist therapy?
Methadone or buprenorphine
Need to slowly taper up methadone to keep the symptoms at bay
buprenorphine 4-8 mg sublingually, IV, or IM
____ are full agonist of the opioid receptors
___ are partial agonist
____ are antagonist
Opioids: aka fully activate the receptor
buprenorphine: partially activates
Naloxone: blocks
What are some add on medications to give with opioid withdrawal?
Clonidine
Lofexidine: Associated with less hypotension than clonidine
BZD to help with agitation, ondansetron, loperamide
_____ is an opioid antagonist and indicated for maintenance treatment. NOT ACUTE TREATMENT
Naltrexone (Revia, Vivitrol)
will cause withdrawal if used in acute treatment and risk of overdose with concurrent opioid use
What is the BBW with Naltrexone (Revia, Vivitrol)? What is the MC SE?
hepatocellular injury
nausea
_____ long acting opioid agonist and helps decrease withdrawal s/s and block “high” from acute opioid use. What is the initial and maintenance doses?
Methadone
Initial: 20-30mg, maintenance dose of 80-120 mg/d
constipation, drowsiness, sweating, peripheral edema, reduced libido, erectile dysfunction
These are the SE of ____.
What test do you need to order to monitor on these patients?
What is the risk of overdose?
**Cardiac arrhythmias (QT prolongation) Need to order yearly EKGs
greater chance for lethal OD than with buprenorphine
What are the criteria to qualify for methadone treatment?
Just needs to meet 1 criteria:
One year of continuous use or intermittent use for > 1 year
Have been on methadone maintenance within the past
2 years and show signs of imminent return to opioid dependence
Be recently released from hospital or prison and have hx of dependence and signs of imminent return to opioid dependence
Pregnant and opioid dependent
Burpenorphine/nalozone is _____
Suboxone
______ is available as a take home therapy due to the lower drug abuse potential and also has a long-acting implant available
Buprenorphine
_____ cause release and block reuptake of dopamine, norepinephrine, serotonin. Give some examples of medication in this class
Psychostimulants
dextroamphetamine (Adderall), lisdexamfetamine (Vyvanse)
methylphenidate (Ritalin, Concerta)
Methamphetamines, MDMA (ecstasy), ephedrine
smoking/IV is the fastest effect then snorting, then oral
What are some s/s of an acute amphetamine intoxication?
Euphoria
Psychosis
dilated pupils
increased HR and BP
weight loss
tooth decay
Severe:
Hypertensive crisis
Hyperthermia
What is the treatment for amphetamine intoxication? What would you not want to give to a pt with amphetamine intoxication with hyperthermia?
IV BZD to control seizures
then treat s/s
no antipyretics (acetaminophen, ibuprofen, etc.)
____ increased hyperactivity even when doses are spread out over weeks
sensitization
Long term use of amphetamine can _____ in dopamine receptors in basal ganglia resulting in _____
decrease
motor deficit
Long term use of amphetamine can _____ in metabolic rate in prefrontal cortex leading to ______
decrease
cognitive deficit which can develop into long-term psychosis
_____ and ____ are recommended for chronic amphetamine use. Which is NOT safe to use on people taking opioids?
Naltrexone: not safe for opioid patients
Bupropion
_____ is recommended for chronic amphetamine use if patients do not tolerate or respond to bupropion and naltrexone combo
Mirtazapine
____ commonly abused by polydrug users but can be primary substance of abuse
BZDs
_____ MOA enhance effect of GABA. What does chronic use do?
BZD
structural GABA receptor changes - ↓ affinity for BZD aka: BZD receptors will change shape
**What does a BZD overdose alone look like? What other substance is commonly overdosed with it?
CNS depression with normal vital signs
alcohol
____ is competitive antagonist of GABA receptor but is controversial do to precipitating BZD withdrawal seizures
Flumazenil
What is the treatment for a BZD withdrawal? Is it life threatening? What is the goal?
long-acting BZD given IV and titrated to effect
YES! can be life-threatening
eliminate withdrawal s/s, avoid oversedation or respiratory depression then taper gradually over a period of months (6-12 months)
____ may help to reduce BZD cravings during treatment
valproic acid, gabapentin, topiramate, lamotrigine
____ primary effect blocks dopamine reuptake. What is it derived from?
Cocaine
coca plant
Cocaine causes _____ of tissue. When used with ____ can produce more intense and longer-lasting effects
vasoconstriction
alcohol
What are s/s of cocaine use?
Septal perforation
Spontaneous abortion
Placental abruption
Euphoria
Anxiety
Psychosis
Myocardial ischemia/infarction
Headaches/Migraines
Insomnia
What are some s/s of cocaine withdrawal?
Craving
Sleep disturbances
Hunger
Severe fatigue
Severe depression
What is the treatment for cocaine addiction? What do you give for acute withdrawal?
no set treatment regimen
dopamine agonist: Bromocriptine
What is the first line long-term treatment for cocaine use?
Topiramate: Anticonvulsant - acts on GABA
Marijuana is derived from ____. What is the primary psychoactive agent?
Cannabis sativa
Delta-9-tetrahydrocannabinol (THC)
THC content has ???? over the years. What are the numbers
increased from 1-5% in 1960s to 10-15% currently
Marijuana mimics ____ and increases _____ levels
anandamide
dopamine
What are s/s of acute marijuana use?
Euphoria
Disinhibition
Hunger
Conjunctival injection
psychotomimetic
N/V/D and abdominal pain
Hx of chronic _____ use (usually daily)
Relieved by hot showers/baths
Normal labs/GI work-up
What am I?
What is the treatment?
Cannabis hyperemesis syndrome
abstinence from cannabinoids, especially THC
What is the goal of marijuana treatment? What is the treatment?
sustained abstinence rather than a controlled low level of continued use
therapy!!
No medication has yet been shown to cause extended abstinence or reduce severity of cannabis use disorder
Cocaine is schedule ___
Ketamine and testosterone is schedule ____
2
3
BZDS, tramadol and insomnia meds are schedule ___
Name some examples of schedule 5 drugs
4
cough preparations with less than 200mg of codeine per 100mL, Lomotil, Lyrica
