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Behavioral dynamics > substance abuse pt 2 > Flashcards

substance abuse pt 2 Flashcards

1
Q

MC preventable cause of mortality

A

smoking

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2
Q

smoking increases the risks of?

A

ASHD, COPD, stroke, cancer (especially lung)

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3
Q

who are the at-risk populations of smoking?

A

Divorced/widowed, lower income or education, AI/AN or multiracial, LGBTQ

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4
Q

risk factors for smoking?

A
  1. Relationships -
    - Parents, friends, housemate who smokes
    - Strained relationship with parent
  2. Psychiatric -
    - Low self-esteem
    - Comorbid psychiatric disorders
  3. Female - Preoccupation with weight and body image
  4. Male - Aggression and rebelliousness
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5
Q

other forms of tobacco?

A
  1. Cigars/Pipes - typically not inhaled as deeply into lungs
    - Slightly lower risk of lung cancer
  2. Hookahs - varying amounts of nicotine and toxins
    - Vapor/smoke from burning product (such as tobacco) is passed through a water chamber before being inhaled
    - Still linked to cancer, COPD
  3. Smokeless Tobacco - varying amounts of toxins
    - 3% of US adults
  4. E-Cigarettes/Vaping - aerosolized nicotine - similar vapor to cigarettes, fewer traditional toxins
    - Significantly increasing rates of use among adults and children/adolescents
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6
Q

who is the most likely to use smokeless tobacco?

A

white males of low socioeconomic status in southern US
Linked to nicotine addiction, cancer of oral cavity

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7
Q

what is EVALI?

A

acute lung injury associated specifically with the use of vaping products
Acute eosinophilic pneumonia reported after vape use

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8
Q

MOA of nicotine

A

stimulates nicotinic cholinergic receptors in the brain
Triggers dopamine release
Triggers epinephrine release

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9
Q

nicotine reaches the brain how fast?

A

15 sec; t½ about 1-2 hours
Some genetic variants - metabolize more slowly

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10
Q

what are the positive effects after nicotine intake

A
  1. Dopamine:
    - Decreased anxiety
    - Improved mood
  2. Epinephrine:
    - Increased alertness and memory
    - Decreased appetite
    - Improved problem solving skills
    - Improved reaction time
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11
Q

due to upregulation of nicotinic (acetylcholine) receptors → develops rapidly

A

tolerance

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12
Q

as early as 2 hrs after last cigarette, peaks in first 72 hrs, fades gradually over 3-4 weeks

A

withdrawal

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13
Q

what happens when you receive less dopamine than before (when smoking)? epinephrine?

A
  • Less dopamine - irritable, hostile, anxious, restlessness, cravings
  • Less epinephrine - decreased HR, insomnia, increased appetite, weight gain
  • Craving may persist for years even after withdrawal ends
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14
Q

what are the acute toxic effects from tobacco

A

Nausea, salivation, pallor
Tachycardia, poor concentration
Decreased REM sleep

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15
Q

harmful effects of smoking

A
  1. Increased all-cause mortality - die on average 10 years earlier
  2. Cancer
    -↑ risk - head and neck, lung, gastric, pancreatic, renal, ovarian, bladder, cervical, penile, anal
  3. Pulmonary
    -↑ risk - COPD
    - Worse clinical course for COPD, asthma, bronchiolitis
  4. Periodontal
    - ↑ risk - periodontal disease (gingivitis, periodontitis)
  5. Immunologic
    ↑ risk - several types of infections
    - TB, Pneumococcal pneumonia, meningococcal disease, Legionnaires
    disease, influenza, common cold
  6. Endocrine
    -↑ risk - type 2 DM
    - Nicotine causes impaired insulin sensitivity
    - May worsen course of type 2 DM
  7. Musculoskeletal
    -↑ risk - osteoporosis
    - Accelerates bone loss - increased risk of hip fractures in females
  8. Reproductive
    -↑ risk - pregnancy complications
    - Spontaneous abortion, ectopic pregnancy, low birth weight, fetal harm
    -↑ risk - premature menopause, erectile dysfunction, infertility
  9. Gastrointestinal
    -↑ risk - gastric and duodenal ulcers
    - Slower healing of gastric and duodenal ulcers
    - Increased failure rates of H. pylori treatment
  10. Postoperative
    ↑ risk - delayed wound healing, pulmonary complications, admission
    to ICU, post-operative infection
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16
Q

what is present in tobacco and most vapes, not nicotine replacement and is not usually picked up from secondhand smoke

A

Anabasine

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17
Q

what nicotine metabolite is in serum - 16 hrs, urine - several weeks and can pick up from secondhand smoke exposure

A

continine

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18
Q

routes for nicotine replacement therapy

A

transdermal patch, gum, lozenge, inhaler, nasal spray
Different absorption than cigarettes

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19
Q

what is the recommended combo for nicotine replacement therapy

A

long-acting (patch) and short-acting (oral)

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20
Q

T/F: E-cigarettes are not FDA approved for tobacco cessation

A

T

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21
Q

what nicotine replacement therapy has good patient compliance - simplest method
No chance to adjust nicotine dose - continuous

A

transdermal patch

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22
Q

what is the dosing for transdermal patch

A
  1. Apply one patch each morning to any non-hairy skin
  2. Rotate site of application and do not leave on overnight
  3. If >10 cigarettes/day: 21 mg x 6 wks, 14 mg x 2 wks, 7 mg x 2 wks
  4. If 10 or less cigarettes/day: 14 mg x 6 wks, 7 mg x 2 wks
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23
Q

SE of transdermal patch

A

skin irritation (most common), insomnia, vivid dreams
Will also see SE of nicotine administration

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24
Q

which nicotine replacement therapy diminishes rather than stops withdrawal

A

oral nicotine gum

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25
Q

4 mg of nicotine gum is for pt who smoke ?

A

25+ cigarettes per day

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26
Q

what must you avoid when chewing nicotine gum

A

Avoid acidic beverages before and during gum use
TMJ, poor dentition, dental appliances

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27
Q

SE of nicotine gum

A

N/V/D, HA, excess salivation, mouth irritation

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28
Q

what nicotine replacement therapy Does not need to be chewed and has most nicotine content

A

Oral Nicotine Lozenge

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29
Q

SE of nicotine lozenge

A

mouth irritation, N/V/D, palpitations, HA, insomnia

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30
Q

what nicotine replacement therapy is absorbed through oral mucosa, like lozenge and gum
Helps satisfy sensory and behavioral cravings

A

nicotine inhaler

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31
Q

SE of nicotine inhaler

A

oropharynx irritation, bronchospasm

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32
Q

who should avoid using nicotine inhalers?

A

reactive airway disease (asthma)

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33
Q

which nicotine therapy is absorbed through nasal mucosa - more rapid peak than oral? SE?

A

nicotine nasal spray
SE - nasal and throat irritation, sneezing, tearing

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34
Q

what nicotine replacement therapy is not available in the US

A

Nicotine Mouth Spray and Nicotine Sublingual

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35
Q

which tobacco tx blocks dopamine and norepinephrine reuptake (DNRI), antagonizes nicotinic cholinergic receptors

A

Bupropion (Wellbutrin, Zyban)

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36
Q

SE of bupropion

A

MC are insomnia, agitation, dry mouth, headache
Rarer - seizure (dose-dependent)

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37
Q

CI for bupropion

A

epilepsy; high seizure risk; hx of anorexia or bulimia

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38
Q

partial agonist of nicotinic cholinergic receptors
Partial stimulation of receptor to decrease withdrawal
Blocks nicotine from binding to receptor, interfering with “reward”

A

Varenicline (Chantix)

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39
Q

SE of Varenicline (Chantix)

A
  1. MC vivid dreams, nausea, insomnia, syncope
    - When first released - concern over neuropsychiatric SE (mood, behavior, suicidal thoughts)
    - Not as common as once thought - FDA has removed black box warning
    - Potential adverse events in CV disease (controversial - not as common as once thought)
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40
Q

CI for Varenicline (Chantix)

A

hypersensitivity or skin reactions to rx

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41
Q

antibodies bind nicotine and stop it from crossing the blood-brain barrier
Blocks nicotine from binding to CNS receptor, interfering with “reward”

A

Nicotine Vaccine
several ongoing trials, but so far inadequate antibody responses or no improvement over placebo therapy

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42
Q

nonpharmacologic tx for tobacco

A
  1. Behavioral counseling (including 5 A’s)
  2. Acupuncture (questionable benefit)
  3. Financial incentives
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43
Q

what are the types of opiates

A
  1. Natural - derived from poppy plant
    - codeine, morphine
  2. Semi-synthetic - derived from opium (extract of poppy plant)
    - heroin, oxycodone, buprenorphine, oxymorphone, hydrocodone, hydromorphone
  3. Synthetic
    - meperidine, fentanyl, methadone
  4. Endogenous Opioids
    - endorphins, enkephalins, dynorphins, endomorphins
  5. Other
    tramadol → acts on mu and noradrenergic/serotonin receptors
44
Q

acts on mu, kappa and delta opioid receptors in brain, digestive tract, spinal cord

A

opioids

45
Q

receptor that mediates pain, respiratory depression, constipation and physical dependence

A

Mu

46
Q

what pain receptor is responsible for analgesia, diuresis, sedation , psychological dependence

A

kappa

47
Q

what receptor is responsible for analgesia, dependence, antidepressant

A

delta

48
Q

effects of opioids in the body

A
  1. Positive Effects
    - Pain
    ↓ perception
    ↓ reaction
    ↑ tolerance
    ↓ cough
    - Psychiatric: Euphoria, Anxiolysis
  2. Mild intoxication
    - Pupillary constriction
    - Constipation
  3. Severe intoxication
    - Respiratory depression
    - Pinpoint pupils
49
Q

tx that is a short-acting opioid antagonist used for Cardiorespiratory arrest and Spontaneous ventilations

A

naloxone (narcan)

50
Q

long term effects from use of opioids

A
  1. desensitization and down-regulation of opioid receptors
    - Causes development of tolerance
    - Earlier onset and more pronounced in short-acting opiates like morphine, heroin
    - Physical and psychological dependence
51
Q

what is the grading for opioid withdrawal symptoms

A
  • Grade 0 - craving, anxiety
  • Grade 1 - Grade 0 + yawning, lacrimation, rhinorrhea, perspiration
  • Grade 2 - Grade 0, 1 + mydriasis, piloerection, anorexia, tremors, hot and cold flashes, generalized aching
  • Grade 3 - Grade 0, 1, 2 + increased temperature, blood pressure, pulse, and respiratory rate and depth
  • Grade 4 - Grade 0, 1, 2, 3, + vomiting, diarrhea, weight loss, hemoconcentration, spontaneous ejaculation or orgasm
  • Treat - if grade 2 or higher
52
Q

what is Rebound Hyperactivity

A

restlessness, irritability and poor concentration → lasts 3-6 months

53
Q

tx for acute opioid withdrawal

A
  1. Methadone
  2. buprenorphine
  3. Symptomatic treatment PRN
  4. Alpha-2 Agonists – ↓ autonomic withdrawal s/s
    - Clonidine
    - Lofexidine
54
Q

opioid antagonist
Indicated for maintenance treatment

A

Naltrexone (Revia, Vivitrol)

55
Q

long acting opioid agonist
Helps decrease withdrawal s/s and block “high” from acute opioid use

A

Methadone

56
Q

if Naltrexone is used for acute tx what will happen?

A

cause withdrawal

57
Q

SE and BBW for naltrexone

A
  1. Nausea (mc), V/D, dizziness, abdominal pain, HA, anxiety, syncope, arthralgia
  2. Black-Box Warning - hepatocellular injury
    - Risk of opioid overdose if resumed use
58
Q

SE of methadone

A
  1. constipation, drowsiness, sweating, peripheral edema, reduced libido, erectile dysfunction
    - Cardiac arrhythmias (QT prolongation)
    - Hyperalgesia
    - Overdose (greater chance for lethal OD than buprenorphine)
59
Q

To qualify for methadone tx, patient must meet one of the following criteria:

A
  1. One yr of continuous/intermittent use for > 1 year
  2. Have been on methadone maintenance within the past 2 yrs and show signs of imminent return to opioid dependence
  3. recently released from hospital/prison + hx of dependence and signs of return to opioid dependence
  4. Pregnant and opioid dependent
60
Q

partial opioid agonist also available as long-acting implant
Sublingual tablet - often combo with naloxone (Suboxone)
Discourages abuse of therapy

A

Buprenorphine (Buprenex, Subutex)

61
Q

how to taper buprenorphine?

A

reduce dose by 2 mg every 1-2 weeks

62
Q

what is able to give as take-home therapy due to lower abuse potential

A

Buprenorphine

63
Q

SE of buprenorphine

A

headache, nausea, pain, insomnia, withdrawal syndrome
Rare - liver disease and necrosis, anaphylaxis

64
Q

non-pharm tx for opioid use

A
  1. Individual and group counseling
    - Cognitive Behavioral Therapy
    - Insight-Oriented Therapy
  2. Drug-free residential programs
  3. Peer support groups
65
Q

what type of tx has best long-term outcomes for opioid tx?

A

Combination with medication (MAT) and non-pharm tx

66
Q

cause release and block reuptake of dopamine, norepinephrine, serotonin
Methamphetamines, MDMA (ecstasy), ephedrine
ADHD medications
Most often smoked or snorted

A

Psychostimulants

67
Q

Psychostimulants can accumulate how much more in the brain than in plasma

A

10 x

68
Q

how to tx amphetamine intoxication?

A
  1. Largely symptomatic
    - Sedation/Seizure control - IV benzodiazepines
    antipsychotics as adjunct treatment
    - Airway management - intubation if needed
    - Antihypertensives - IV medication
    - Hyperthermia - cooling blankets, ice packs, evaporative cooling techniques, benzodiazepines
    – no antipyretics (acetaminophen, ibuprofen, etc.)
    - Fluid resuscitation
69
Q

increased hyperactivity even when doses are spread out over weeks
Can have cross-sensitization with cocaine

A

Sensitization

70
Q

chronic use of amphetamine can cause?

A
  1. chronic insomnia, anxiety, appetite suppression, weight loss, HTN, hypersexuality
    - Increased all-cause mortality risk
    - decrease in dopamine receptors in basal ganglia → motor deficit
    - decrease in metabolic rate in prefrontal cortex → cognitive deficit
    - verbal/working memory, perceptual speed, attention and fluency
    - can develop long-term psychosis
71
Q

s/s of amphetamine withdrawals? (what types)

A
  1. develops in a few hours, peak in 1-2 days, and resolve in about 2 weeks
  2. Acute - dysphoria, anhedonia, fatigue, vivid dreams, insomnia or hypersomnia, agitation, anxiety, drug craving, increased appetite
  3. Subacute - insomnia/hypersomnia, appetite changes, depression, possible suicidal thoughts
72
Q

tx for Amphetamine Withdrawal

A

No proven medication treatment regimen
- Benzodiazepines, antidepressants, antipsychotics, behavioral therapy

73
Q

first-line tx for chronic amphetamine use?

A

Bupropion and naltrexone

74
Q

what is recommended if patients do not tolerate or respond to bupropion and naltrexone combo

A

Mirtazapine

75
Q

alternatives for chronic amphetamine use

A

methylphenidate (stimulant)
topiramate (anticonvulsant)

76
Q

MC abused anxiolytic

A

Benzodiazepines (BZDs)

77
Q
  1. enhances effect of GABA
  2. Indications - sedation, sleep-induction, anticonvulsant, anxiolytic, muscle relaxant, alcohol withdrawal
    - For anxiety - short term, panic attacks
A

Benzodiazepines

78
Q

what happens with chronic use of benzodiazepines

A

structural GABA receptor changes - ↓ affinity for BZD

79
Q

overdose of benzodiazepines alone causes ?

A

CNS depression with normal vital signs
Usually overdosed with other substances (especially alcohol)

80
Q

tx for anxiolytic overdose?

A
  1. Airway, breathing, and circulation
  2. Flumazenil - competitive antagonist of GABA receptor
81
Q

why is flumazenil controversial for anxiolytic overdose?

A

can precipitate withdrawal seizures

82
Q

tx for anxiolytic withdrawal?

A
  1. Long-acting BZD given IV and titrated to effect
    - Goal - eliminate withdrawal s/s, avoid oversedation or respiratory depression
    - Taper gradually over a period of months
83
Q

Adjunct Medications for anxiolytic withdrawal

A

Beta blockers, antipsychotics, SSRIs, antihistamines
All have been shown to be inferior to BZDs for tx of acute withdrawal

84
Q

Treatment for any underlying anxiety

A

Counseling and therapy
Antidepressants

85
Q

how must you taper with chronic anxiolytic use?

A

Gradual (6-12 mo) taper to avoid inducing withdrawal
Long-acting BZD - diazepam, chlordiazepoxide

86
Q

what drugs may help reduce anxiolytic cravings (4)

A

anticonvulsants
valproic acid, gabapentin, topiramate, lamotrigine

87
Q

what is the primary effect/MOA of cocaine

A

blocks dopamine reuptake

88
Q

Use with ___ can produce more intense and longer-lasting effects of cocaine

A

alcohol

89
Q

what can be used for tx of cocaine

A
  1. Acute withdrawal - dopamine agonist
    - Bromocriptine
  2. Psychosis - antipsychotic medications
  3. Symptomatic support
  4. Social services and psychological consult
  5. Support groups and counseling
90
Q

long term tx for cocaine

A
  1. Topiramate - first-line treatment
    - Anticonvulsant - acts on GABA
  2. Dopamine Agonists/Stimulants
    - dextroamphetamine, methamphetamine
    - modafinil - less abuse potential but not as strong evidence
  3. Disulfiram
  4. Emerging - TA-CD vaccine - no good
91
Q

Mimics anandamide and increases dopamine levels

A

marijuana

92
Q

long-term use of marijuana

A
  1. Pulmonary
    - Many of the same combusted particles as tobacco smoke, but nearly always unfiltered - 3x the amount of tar and 50% more carcinogens
    - Acute and chronic inflammatory changes - Exacerbations of pulmonary disease; Increased risk of lung cancer
  2. Cardiovascular
    - EKG changes (typically transient)
    - May cause exacerbation of underlying CV disease
  3. Reproductive
    - Males - Decreased testosterone, decreased sperm count
    - Females - Abnormal menstruation, infertility, appears in breastmilk
    - During pregnancy - increased stillbirth risk, poorer visual/motor coordination, increased behavioral problems
  4. Neuro/Psych
    - Cognition - mixed - some studies show no long-term deficits, others do
    - Atrophy - most studies note accelerated brain volume loss
    - Psychosis - most studies note significantly higher risk of long-term psychosis, schizophrenia
  5. Gastrointestinal
    - Gastroparesis - early satiety, N/V, postprandial fullness/heaviness
    - Liver - can accelerate course of pre-existing liver disease
    - Cannabis hyperemesis syndrome - N/V/D and abdominal pain
    – Hx of chronic cannabis use (usually daily)
    – Relieved by hot showers/bath
    – Normal labs/GI work-up
    – Tx - abstinence from cannabinoids, especially THC
93
Q

goal of tx for marijuana

A

sustained abstinence rather than a controlled low level of continued use

94
Q

what is the preferred tx for marijuana over meds

A

Psychosocial interventions
- Cognitive-behavioral therapy
- Motivational interviewing
- Peer support

95
Q

what are the possible meds for marijuana

A

acetylcysteine, gabapentin, topiramate, varenicline have some/mixed evidence
Antidepressants, synthetic THC - no evidence

96
Q

Drugs, substances, and certain chemicals used to make drugs split into five categories (“schedules”), depending on:

A

Drug’s acceptable medical use
Drug’s abuse or dependence potential

97
Q

which schedule of drugs are most abused and has dependence potential? least abuse and dependence potential?

A

I
V

98
Q

no accepted medical use; high potential for abuse
Most dangerous of all - potentially severe psychological/physical dependence
what schedule

A

I
illicit drugs - Heroin, LSD, marijuana, ecstasy, peyote

99
Q

high potential for abuse (less than Schedule I)
Potentially severe psychological or physical dependence
what schedule

A

II
1. Most ADHD medications (Adderall, Ritalin, methamphetamines)
2. Most opioid medications
- methadone, hydromorphone, meperidine, oxycodone, fentanyl
- Hydrocodone products with <15 mg of hydrocodone per dose
3. cocaine

100
Q

moderate-low potential for dependence
what schedule

A

III
- Codeine products with <90 mg of codeine per dose (Tylenol #3)
- Ketamine, anabolic steroids including testosterone

101
Q

low potential for abuse, low risk of dependence
what schedule

A

IV
- BZDs (alprazolam, lorazepam)
- Tramadol (Ultram), carisoprodol (Soma), insomnia meds (zolpidem (Ambien), eszopiclone (Lunesta))

102
Q

medications with limited quantities of certain opiates
what schedule

A

V
- Lower potential for abuse than Schedule IV
- Often used for antidiarrheal, antitussive, analgesic needs
- Cough preparations with <200 mg of codeine per 100 mL
- diphenoxylate/atropine (Lomotil), pregabalin (Lyrica)
- gabapentin (Neurontin) - in some states

103
Q

Require a written or electronically prescribed prescription signed by the practitioner
May vary by state and facility
No refills allowed
what schedule

A

II
- May be allowed to prescribe multiple prescriptions that would total a 90 day supply under special circumstances
- Physician Assistants often cannot prescribe

104
Q

Written script or e-prescribed
Refills generally allowed
what schedule

A

III, IV, V

105
Q

what do the written treatment agreements of controlled substances include?

A
  1. Clarify boundaries regarding pain tx with controlled substances
  2. Describe patient and provider responsibilities
  3. Describe possible consequences of violation of agreement
  4. Obtain agreement to:
    - Future drug testing as requested
    - Use of one pharmacy and one prescriber
    - Bringing in pill bottle for pill counts as requested
  5. Describe reasons and strategies for ending opioid treatment
    - Include criteria for ending opioid treatment
    - Include strategies for how to taper opioids humanely
106
Q

cons of treatment agreements

A
  1. Very limited evidence supporting effectiveness
  2. No guidelines or consensus
    - Wide variation in content, tone, and implementation
  3. Negative impact on the provider-patient relationship
    - Too much focus on prohibited behaviors, risks, and abuse monitoring
    - Discriminatory implementation
  4. May bias providers and patients against opioid therapy
    - Potential for undertreatment of pain or improper discontinuation
    - Stigmatization of opioid therapy
  5. May have overly demanding stipulations

Behavioral dynamics (19 decks)

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