Substance abuse-test 2 Flashcards
1
Q
What is substance abuse?
A
A chronic disorder characterized by the compulsive use of substance resulting in physical, psychological, or social harm to be user and continued use despite the harm.
2
Q
What is substance intoxication?
A
Reversible substance-specific syndrome
nDue to recent ingestion or exposure to a substance
Clinically significant maladaptive behavior or psychological changed due to the effect of the substance on the CNS
3
Q
What are the key components of the pathways activated by abused substances?
A
DA in mesocorticolimbic system Nucleus Accumbens (NA) to prefrontal cortex, amygdala and olfactory tubule.
4
Q
What do cocaine and other stimulants block?
A
DA reuptake
5
Q
What do opiods affect?
A
Activate u receptors resulting in increased release of DA in NA
6
Q
Where does nicotine act?
A
It acts with the opiod pathway
7
Q
What does the active ingredient of marijuana ( THC) work in the pathway?
A
binds to cannabinoid-1 (CB1) receptors resulting in activation of DA neurons in mesolimbic system
8
Q
What does chronic use lead to?
A
General decrease in DA neurotransmission
9
Q
What are the 2 explanations for the dev of substance dependence?
A
1) sensitization
2) counteradaptation
10
Q
What is sensitization?
A
Increased response following repeated intermittent administration of a drug, in contrast to tolerance to drug effects that occur secondary to continuous exposure to a drug
11
Q
What is counteradaptation?
A
Initial positive reward feeling followed by the opposing development of tolerance
12
Q
What 10 drug classes are encompassed in criterion A for DSM V diagnosis of substance abuse?
A
Alcohol, caffeine, hallucinogens, inhalants, opioids, sedatives, hypnotics, stimulants, and anxiolytics
13
Q
What are the categories for symptoms?
A
Impaired Control
Social Impairment
Risky Use
Pharmacological Criteria
14
Q
What are the qualifications of impaired control?
A
- Take substance in large amounts or over longer period than originally intended
- Individual may express persistent desire to cut down or regulate use and may report unsuccessful attempts
- Individual may spend a great deal of time obtaining substance, using the substance, or recovering from the effects
- Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely in an environment where the drug was previously obtained
15
Q
What constitutes social impairment?
A
- Failure to fulfill major role obligations at work, school, or home
- Continue substance abuse despite having persistent or recurrent social or interpersonal problems caused or exaggerated by the effects of the substance
- Important social, occupational, or recreational activities may be given up or reduced because of substance abuse
16
Q
What constitutes risky use?
A
- Recurrent use in situations in which it is physically hazardous
- Continue to use despite having knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the substance
17
Q
What is the criteria for tolerance?
A
signaled by requiring a markedly increased dose to achieve the desired effect
18
Q
What is the criteria for withdrawal?
A
The development of a substance-specific syndrome due to the cessation use that has been heavy and prolonged.
19
Q
What does the substance-specific syndrome cause?
A
clinically significant distress or impairment in social, occupational, or other important areas of functioning.
20
Q
What is severity rating for abuse?
A
Mild -2-3 of the above symptoms Moderate -4-5 of the above symptoms Severe -6 or more of the above symptoms
21
Q
What is alcohol? How does it work?
A
CNS depressant
Works in a dose dependent fashion: Sedative, sleep, unconsciousness, coma, respiratory depression and CV collapse
22
Q
What does alcohol affect in the brain?
A
GABA, glutamate and dopamine
Affects endogenous opioids (release)
23
Q
What is the definition of current use?
A
at least one drink in the past 30 days (includes binge and heavy use)
24
Q
What is the definition of binge use?
A
five or more drinks on the same occasion at least once in the past 30 days
25
What is the definition of heavy use?
five or more drinks on the same occasion on at least 5 different days in the past 30 days.
26
What is glutamate?
Major excitatory system in CNS
27
What is the NMDA receptor responsible for when activated?
Excitation
28
What affect does acute ethanol intoxication have on the NMDA receptors?
Inhibits, decreasing glutamate activity
| This is the sedative, incoordinating, amnestic, and anxiolytic effect of alchol
29
What affect does chronic ethanol intoxication have on the NMDA receptors?
Causes an upregulation of NMDA receptor number and function leading to hypersensitivity
30
What is GABA?
Major inhibitory system in CNS
31
What are the 2 principle receptor subtypes of GABA?
GABAA receptor subtypes
| GABAA R activation→ inhibition
32
What is the effect of acute ethanol intoxication on GABA?
Potentiates GABAA inhibition
| Sedative, incoordinating, amnestic, and anxiolytic effects of alcohol
33
What is the effect of chronic ethanol intoxication on GABA?
Down-regulation of GABAA R number and function
34
What happens with DA and ethanol?
Ethanol activates mesolimbic DA systems→
increases DA release in nucleus accumbens (NAc)
Positive reinforcement and pleasurable effects of ethanol
35
What is mild- mod intoxication? What are the s/s ?
BAL 0.08 to 0.1%
Lower limits of legal intoxication
Do not require formal treatment
Mood labilty, loud or inappropriate behavior, slurred speech, incoordination, unsteady gait
36
What is severe intoxication and s.s?
(BAL 0.2-0.3%) confusion, depressed consciousness, vomiting
(BAL 0.3-0.4%) stupor, coma
(BAL > 0.4%) cardiac arrhythmias, respiratory depression, death
37
What should be given if your pt has impaired consciousness?
thiamine should be given IV or IM for at least 3 days
38
how many yes need to happen in the CAGE questionnaire in order to be considered positive?
One
39
What does CAGE stand for?
Cut down
Anoyed
Guilty
Eye Opener
40
What drugs can be used to tx alcohol dependence?
nDisulfiram
nNaltrexone
Acamprosate
41
What is the disulfiram ethanol reaction?
```
Nausea/Vomiting
HA
Hypotension
MI
Weakness
Tachycardia
SOB
Sweating
Dizziness
Blurred vision
Confusion
```
42
What is the dosing for disulfiram?
Range from 125-500mg/d
| Start when abstinent from ETOH for at least 12 hours
43
How long does it take to get the full “protective” effect of disulfiram?
12-14 hours
44
How long of a washout do you need before there can be alcohol interaction?
2 weeks
45
What are predictors of success with disulfiram?
```
Motivated
Compliant
High risk situations (e.g. weddings) where behavior is important
Contingencies (e.g. loss of license)
Supervised administration
Stable home life
```
46
What is naltrexone approved for?
Narcotic abuse and alcohol dependence
47
What is the MOA of naltrexone and alcohol dependence?
```
Competitive mu (µ) opioid receptor antagonist
Naltrexone blocks ß- endorphin which stimulates dopamine release
Naltrexone blocks ethanol- induced DA release in NAC
```
48
What is the effect of natrxone and alcohol abuse?
Not really that great
49
What is acamprosate approved for?
To maintain abstinence after detox
50
What is the MOA of acamprosate?
Unknown
“restores balance” between glutamate and GABA
May ↓ glutamate overactivity
May ↓ ability of ethanol to activate mesolimbic dopamine system
51
How effective is acamprosate?
Moderate effects at best
| Similar decreases in drinking frequency, and similar relapse rates as naltrexone
52
What are the ADRs of acamprosate?
Only ADR reported in > 10% patients and at a rate > placebo was transient diarrhea
Asthenia (6%)
Anxiety (6%)
Insomnia (7%)
53
When does acamprosate need to be dose adjusted or when is it CI?
Renally eliminated
| Should not be used if CCI
54
What other meds is acamprosate safe to use with?
Disulfiram
| Naltrexone
55
What are minor alcohol withdrawal symptoms?
```
Tremor
GI (nausea/vomiting)
Mild diaphoresis
Vital signs increase (mild)
Sleep disturbance
Hallucinations
Seizures (7%)
```
56
What is the time course for minor withdrawal?
Onset: 8-12 Hours
Peak: 24-36 Hours
Duration: 60-72 hours
57
What are the s/s of major withdrawal?
```
Delirium
Delirium Tremems: (DT’s)
Hallucinations
Agitation
Tremors
Vital signs increased (Marked)
Diaphoresis (marked)
Sleep disturbance
```
58
What is the time course for major withdrawal symptoms?
Onset: 48-60 hours
Peak: 72 hours
Duration: 120-168 hours
59
What CIWA-Ar scoring for pharm therapy?
Mild:
60
What is the DOC for uncomplicated alcohol withdrawl?
BDZ
61
Should you tx a pt with no symptoms?
NO
62
What is the monitoring for pts when tx?
Monitoring patient every 4-8 h
| CIWA-Ar until score has been
63
When CIWA-Ar is >/= 8 what should you do?
Administer 1 of the following medications every hour
Chlordiazepoxide 50-100 mg
Diazepam 10-20 mg
Lorazepam 2-4 mg
** Repeat CIWA-Ar 1 after every dose to assess need to further medication
64
What are the preferred bdz for alcohol withdrawal?
Long acting:
Chlordiazepoxide (Librium)
Diazepam (Valium)
65
What are the preferred bdz for tx alcohol withdrawal in severe liver dz?
Short acting:
Lorazepam (Ativan)
Oxazepam (Serax)
66
What is the tx for alcohol withdrawal in a pt that is vomiting or NPO?
Parenteral BZD
Chlordiazepoxide 50mg PO = lorazepam 2-4mg IM
Supplement with lorazepam 2-4mg IM q1h for breakthrough signs/symptoms
67
What is the DOC in seizures associated with alcohol withdrawal?
```
1)Benzodiazepines drug of choice
IV diazepam 5-10mg may repeat q 5min till termination seizure
IM lorazepam 4mg
2)Correction of Electrolyte Imbalances
IV magnesium 1g q hours for 1st day
IV thiamine (as in intoxication)
```
68
How should delirium tremens be tx?
IV Benzos ‘till light somnolence is achieved
Haloperidol- given only for severe agitation unresponsive to benzos
IV thiamine
69
How are the BDZ tapered depending on length of tx?
If therapy > 8 weeks, 2-3 week taper is recommended
If therapy > 6 months, 4-8 week taper should be used
If therapy > 1 year, Strong consideration should be given to using long-acting agents (Diazepam, Clonazepam)
70
What is the simple taper for BDZ?
25% dose reduction per week until 50% of original dose is reached
Then decrease dose by 1/8 every 4-7 days
71
What can happen if BDZ are suddenly dc?
```
Rebound anxiety
Recurrence or relapse of symptoms
Withdrawal symptoms
Short-acting agents ~ 1-2 days
Longer-acting agents ~ 2-4 days
```
72
What are common BDZ withdrawal symptoms?
```
Anxiety
Insomnia
Restlessness
Muscle tension
irritability
```
73
What are rare BDZ withdrawal symptoms?
Seizures
Hallucinations
Paranoid delusions
Confusion
74
What are less frequent BDZ symptoms?
- Nausea
- Malaise
- Blurred vision
- Diaphoresis
- Nightmare
- Ataxia
- Hyperreflexia
75
What are risk factors for BDZ withdrawal?
High BDZ doses
Long duration of therapy
Concurrent meds/drugs that lower seizure threshold
76
What are s/s of stimulant intoxication?
```
Restlessness/anxiety
Euphoria
Grandiosity
Hypervigilance
Tachycardia/elevated blood pressure
Mydriasis
Sweating and/or chills
Nausea, vomiting, diarrhea
Psychosis
Cardiovascular collapse
death
```
77
What are signs of stimulant abuse?
- Dilated pupils (high dose)
- Dry mouth
- Bad breath
- Frequent lip licking
- Decreased appetite and sleep
- Irritable, argumentative
- Talkative but tangential
- Runny/bloody nose
- Paraphenalia
78
What problems need to be tx in stimulant intoxication?
Treat and monitor medical problems
Hyperthermia, Hypertension, Cardiac arrhythmias, Stroke
Psychiatric Problems
Benzodiazepines for anxiety
History and drug screen 1st because often used in combo with ethanol, opioids so benzos can increase sedation and respiratory depression
79
How can stimulant dependence be tx?
Therapy, groups, etc 12 step program
| No proven pharmacotherapy, Disulfiram shows some promise with cocaine
80
What does stimulant withdrawal often lead to?
to depressed or dysphoric mood
81
What may be helpful in the first 24 hours of stimulant withdrawal?
benzodiazepines or antipsychotics might be helpful for delusions, paranoia, compulsive behavior
82
What are life-threatening complications associated with stimulant withdrawal?
Seizures
Hyperthermia
Ischemic chest pain
Suicide
83
What are s/s of opioid intoxication?
```
Euphoria
Dysphoria
Apathy
Motor retardation
Sedation
Attention impairment
Miosis
```
84
What are s/s of opioid withdrawal?
```
Lacrimation
Rhinorrhea
Mydriasis
Piloerection
Diarrhea
Yawning
Insomnia
Muscle aching
```
85
What is tx for opioid intoxication?
Reverse intoxication with naloxone 0.4-2mg IV q 2-3 min up to 10mg
Secure airway
86
How can you tx opioid dependence?
Opioid agonists
| Opioid antagonists
87
What do opioids inhibit? What does chronic use discontinuation lead to?
inhibit cyclic AMP system
Leads to cyclic AMP in the adrenergic neurons becomes overactive
Noradrenergic brain activity increases
Contributes to withdrawal symptoms
88
What are s/s of grade I or mild opioid withdrawal?
```
Yawning
Lacrimation
Rhinorrhea
Perspiration
Restlessness
Insomnia
```
89
What are s/s of grade 2 or moderate opioid withdrawal?
```
Tremors
Dilated Pupils
Goosebumps
Anorexia
Muscle Twitching
Myalgia/arthralgia
Abdominal pain
```
90
What are s/s of grade 3 or marked opioid withdrawal?
```
Nausea
Extreme Restlessness
Vital Signs ↑
Tachycardia
Hypertension
Fever
Hot/Cold Flashes
```
91
What are s/s of grade 4 or severe opioid withdrawal?
```
Vomiting
Diarrhea
Weight loss
Dehydration
Hypotension
```
92
What is clonidine? What is it used for?
Alpha adrenergic autoreceptors
Heroin: 10 day treatment
Methadone: 14 day treatment
----Clonidine taper in both cases
93
What is the methadone dosing for opioid withdrawal?
```
Initial Dose (Max=40mg/d)
Grade I: 5mg q12h
Grade II: 10mg q12h
Grade III: 15mg q12h
Grade IV: 20mg q12h
```
94
What need to be taken before each dose of methadone?
Vital signs before each dose
Titration: ↑ 5-10mg QOD as tolerated
Dose range: 30-100mg/d
95
What dose can you give of methadone for breakthrough s/s?
5-10 PO/IM
96
What is the MOA of methadone?
µ and ō opioid withdrawal agonist
Suppresses opioid withdrawal symptoms
Blocks effect of other opioids
97
What are the side effects of methadone?
Constipation, sweating, urinary retention
| Respiratory depression in intolerant individuals
98
What is the starting dose for buprenorphine?
4mg (4/1) followed in 3-4 hrs with another 4mg (4/1mg) if indicated
2nd day 12-16mg/d (12/3-16/4mg/d) administered
99
What is the MOA of buprenorphine?
µ receptor partial agonist and weak K receptor antagonist
Similar effects as methadone
Opioid antagonist at higher doses
100
What can buprenorphine help with?
Controls cravings: Still some sense of euphoria
Safer than heroin: Not as addictive, little risk of overdose
Can be prescribed in physician office by specially trained physicians
101
What is the recommended dose of naltrexone?
Maintenance dose
50mg/d
100mg QOD
100mg MW + 150mg F
102
When can naltrexone be initiated?
Once patient is opioid free for 7-10d
103
What does nicotine affect in the brain?
DA, NE, 5-HT, glutamate, GABA, and endogenous opioid peptides
Activates nicotinic acetylcholine receptors in the brain
104
What do you use to assess nicotine dependence?
Fagerström Test (score >/= 4 indicates physical dependence)
105
What are nicotine replacement therapies?
```
Patch
Gum
Lozenge
Nasal Spray
Inhaler
```
106
What are some pharm options for smoking cessation assistance?
Buproprion
Varenicline
Clonidine
TCA’s
107
What is the MOA of buproprion?
Blocks reuptake of DA and NE
Acts as a noncompetitive antagonist on Ach receptor
Reduces nicotine reinforcement, withdrawal, and craving
108
Whan can buproprion be initiated?
1-2 weeks before quit date
109
What is the MOA of varenicline?
agonizes and blocks nicotinic acetylcholine receptors
110
How soon before taking this does the pt need to quit smoking?
After 7 days of tx they need to stop
111
What is the BBW for varencline?
Neuropsychiatric Symptoms and Suicidality
| **Weigh varenicline risks vs. benefits of smoking cessation
112
What are second line options for smoking cessation?
1) Clonidine
- Modest efficacy in smoking cessation trials
2) TCA’s
- Nortriptyline (inhibit reuptake NE and 5-HT)
- Significant disadvantages
- Anticholinergic burden
- Cardiac side effects
