Substance Abuse - Junig Flashcards
Characteristics of substance abuse disorders tend to break down into four categories:
- Impaired control
- Social impairment
- Risky use
- Pharmacologic dependence
Give a couple examples of each
- Impaired control
- taking more or longer than intended
- unsuccessful efforts to cut down
- craving
- spending lots of time seeking or recovering from
- Social impairment
- failure to fulfill major obligations
- continued use despite problems
- giving up important activities
- Risky use
- recurrent use in hazardous situations
- continued use despite problems or exacerbations of related problems (medical, etc)
- Pharmacologic dependence
- tolerance to effects
- withdrawal symptoms
To be considered in ‘sustained remission’, abstinence from substance abuse must last for at least how long?
>12 months
The final common pathway in most pleasureable activities tends to inlcude what neurotransmitter?
dopamine
Name a few drugs or substances that exert their effects primarily in the following areas
- Ventral tegmental area
- Nucleus accumbens
- VTA
- opioids
- ethanol
- barbiturates
- benzodiazepines
- NA
- amphetamines
- cocaine
- cannabinoids
- opioids
- phencyclidine
Is euphoria required for addiction?
No
Which neurotransmitter is most linked to addictive disorders?
Name three other neurotransmitters/receptors implicated in addiction and a drug that might be use to combat their role in addiction
dopamine
opiate receptors: naltrexone
GABA: campral
Nicotinic ACh receptor: Chantix
Describe the kind of conditioning implicated in each of the following:
- Repetitive, reinforced patterns of behavior that encourage use
- Craving or euphoric recall. Often prompted by paraphernalia
- Use of drug removes negative sensation (such as pain)
- operant conditioning
- classical conditioning
- negative reinforcement
Does addiction have a genetic component?
Yes
Examples: Twin studies and 2/3 of alcoholics have a family history.
Give some drugs used to facilitate detox of the following substances:
- Alcohol
- Opiates
- Stimulnts
- Alcohol: benzodiazepines, phenobarbital, folate, thiamine
- Opiates: clonidine, loperamide, analgesics
- Stimulants: food, sleep, water
Name (5) pertinent elements of the ‘Active Treatment’ phase
- separation from substance
- education
- ‘conversion process’
- lifestyle changes
- family and relationship work
Why is addiction ‘cure’ more or less a myth?
- Requires maintenence
- Continued anstinence requires personal commitment
- Requires sustained change in lifestyle and behavior
- Ongoing medications and aftercare help prevent relapse
- Neglect of this phase often leads to relapse
What characteristic of addiction contributes to the high rate of morbidity in relapse?
Tolerance
(patient loses tolerance in remission, then returns to old patterns of consumption - cannot handle it physically)
How is the concept of ‘recovery’ different than ‘abstinence’?
Abstinence involves removal of the substance abuse, but does not fix the underlying cause. Recovery is an ongoing process towards ‘better’ living and management of the underlying defects that led to substance abuse in the first place.
Give the (5) stages of motivation enhancement therapy and describe each
- Precontemplation
- establish rapport and support any positive changes
- Contemplation
- encourage ambivalence, educate w/ pros and cons
- Preparation
- encouragement towards goal
- Action
- continue to encourage
- family ultimatums?
- Maintenence
- relapse prevention
- maintenence
- education and continued vigilence
What tends to be the initial action of most 12-step programs?
Give some other major themes
Confrontation (to break through denial)
Themes: change, personal responsibility, boundary enforcement, limits, and consequences of actions
Alcohoics Anonymous is probably the most well-known of what type of program?
12-step program
Treatment should last how long?
As long as the patient needs (though this may be complicated by money and insurance policies)
Anything less than 30 days is usually considered ineffective
What is the key differentiator of the ‘Harm Reduction Approach’?
The Harm Reduction Approach does not demand total sobriety. Instead it focuses on ‘Moderation Management’ (eg: drink counting, etc)
Give some drugs use to maintain treatment for the following substance addictions:
- Alcohol
- Opiates
- Nicotine
- Cocaine
- Alcohol: naltrexone, disulfiram, acamprosate, topiramate, baclofen
- Opiates: Naltrexone, mehtadone, buprenorphine
- Nicotine: Nicotine replacement, chantix, buprorion
- Cocaine: Immune approach (?), stimulants (?)
What enzyme converts codeine to morphine?
Name three drugs that inhibit this enzyme.
CYP2D6
Paxil, Prozac, Quinidine
What opiate is particularily contraindicated in pts taking an MAOI?
Why?
Demerol
MAOIs prevent the breakdown of normeperidine, a metabolite of demerol.
Accumulation of normeperidine can cause convulsive seizures.
- Do opiates share cross tolerance?
- Can opiate withdrawal be fatal?
- What drug is somewhat useful in treating the symptoms of opiate withdrawal?
- Yes.
- Generally, no. But it is horrible.
- Clonidine.
What is the typical demographic of opiate abusers?
What demographic is showing increasing rates of opiate abuse?
- Typical onset is late teens or twenties
- Male:Female 1.5:1
- Decreasing prevalence with age
- White middle-class female demographic shows increasing use
What “symptoms” often concur with opiate abuse?
- Depression
- Sexual problems
- Cellulitis
- Poverty
What is the mortality rate of opiate abusers?
What are the top causes of this mortality?
- 2%
- OD
- Hepatitis
- HIV
- Endocarditis
- Suicide
What percentage of opiate abusers manage to reach long-term abstinence?
While periods of abstinence are common, long term abstinence is only seen in
20-30% of abusers.
What are the specific signs of opiate intoxication?
-
Pupillary constriction
- Can become pupillary dilation during severe OD due to anoxia (repiratory depression)
- Drowsiness or coma
- Slurred speech
- Memory or Attention impairment
What are the symptoms of opioid withdrawal?
- Three or more of the following, developing within minutes to days after cessation:
- Dysphoric mood
- Nausea or vomiting
- Diarrhea
- Muscle aches
- Lacrimation or rhinorrhea
- Pupillary dilation, Piloerection, or Sweating
- Yawning
- Fever
- Insomnia
What was the Harrison Act of 1914?
What exceptions are there to the Act?
Ban on nonmedical use of opioid and coccaine derivatives
Exceptions were made for methadone and buprenorphine after those compounds were developed (to treat addiction).
In order for an addict to use methadone for opioid addiction therapy, what must that person first do?
Obtain a special federal license and be affiliated with an opioid addiction treatment program, or “methadone clinic”
What was the DATA legislation passed in 2000 permit?
Permits qulified physicians to obtain a waiver to treat opioid addiction with approved Schedule III, IV, and V opioid medications or combinations thereof.
Why is buprenorphine useful in the treatment of opiate addiction, and in some ways better than methadone?
Buprenorphine is a partial agonist - it treats withdrawal sxs, but its effects quickly level off even with increasing the dose - lower abuse potential. Also acts as a competitive antagonist relative to full agonists.
Methadone is a full agonist and is thus more susceptible to abuse (thus necessitating its strict administration via methadone clinics).
How do buprenorphine/naloxone combination tablets work?
Why are they useful for treating opioid addiction?
- The combination provides relief from opiate withdrawal while containing a built-in anti-abuse mechanism.
- If taken as directed (dissolve under tongue), there is a predominant buprenorphine effect, as naloxone (an opioid antagonist) is not orally active
- If the patient tries to dissolve and inject the tablet, the naloxone goes to work and withdrawal symptoms are induced.
What are the side effects of buprenorphine?
What side effects does it NOT have? (i.e., why is it a good drug?)
- Highly (but not perfectly) safe medication, both acute and chronically
- Of 35,000 opioid OD deaths per year, 40 are linked to buprenorphine
- Primary S/Es are like other mu opioid agonists:
- Nausea, constipation
- but are time-limited
- No significant diruption in cognition or psychomotor function
- No organ damage with chronic dosing
How should acute pain in a patient taking buprenorphine for opiate withdrawal be handled?
- Mild to Moderate pain (e.g. dental extraction):
- Continue buprenorphine
- Use non-opioid treatments
- Can use short-acting opioids
- Effect may be blocked (partial agonist can act as an antagonist)
- Moderate to Severe pain (e.g. hip extraction):
- Discontinue buprenorphine
- Treat pain with opioids
- Reinduction with buprenorphine
