Substance-related and addictive disorders Flashcards
Criteria for substance use disorder
Problematic pattern of substance use that leads to impairment or distress, manifested by at least two of:
- Using more than intended
- Persistent desire/inability to cut down
- Significant time spent in obtaining, using, or recovering from substance
- Failure to fulfill obligations (work, school, etc)
- Continued use despite social/personal probs
- Decreased social/occupational/recreational activities
- Use in dangerous situations (e.g. driving)
- Continued use despite subsequent physical or psychological problem (e.g. liver disease)
- Tolerance
- Withdrawal
How can you distinguish between substance-induced vs. primary mood symptoms/disorders?
Primary mood symptoms persist during periods of abstinence
Substance use can commonly present with what psychiatric symptoms?
Mood symptoms and mood disorders
Psychotic symptoms
Personality disorders
Anxiety disorders
Define withdrawal
The development of a substance-specific syndrome due to cessation/reduction of substance use
Define tolerance
The need for increasing amounts of the substance to achieve the desired effect
How long is alcohol detectable in a patient’s system and how do you test for it?
Only for a few hours
Breathalyzer in the field/police
Blood testing more accurate
How long is cocaine detectable in a patient’s system and how do you test for it?
UDS stays positive for 2-4 days
How long are amphetamines detectable in a patient’s system and how do you test for it?
UDS positive for 1-3 days
Most assays are not adequate sensitivity/specificity
How long is phencyclidine detectable in a patient’s system and how do you test for it?
UDS positive 4-7days
CPK and AST are often elevated
How long are benzos detectable in a patient’s system and how do you test for it?
Short-acting (lorazepam) for up to 5 days in blood or urine
Long-acting (diazepam) for up to 30 days in blood or urine
How long are barbiturates detectable in a patient’s system and how do you test for it?
Short acting (pentobarbital) 24 hours in urine or blood Long-acting (phenobarbital) 3 weeks in urine or blood
How long are opioids detectable in a patient’s system and how do you test for it?
UDS positive for 1-3 days (depending on drug)
Methadone comes up negative on a general screen
How long is marijuana/THC detectable in a patient’s system and how do you test for it?
3 days after a single use. Up to 4 weeks in heavy users, because THC is released from adipose stores
Alcohol activates what neurotransmitters/receptors in the CNS? Which does it inhibit?
Activates: GABA, Dopamine, Serotonin
Inhibits: Glutamate, voltage-gated calcium channels
Describe the metabolism of alcohol
Alcohol –> acetaldehyde (by alcohol dehydrogenase)
Acetaldehyde –> acetic acid (by acetaldehyde dehydrogenase (inhibited by disulfiram))
Presentation of alcohol intoxication
In order of increasing BALs: Loss of fine motor control Impaired judgment and coordination Ataxic gait and poor balance Lethargy, difficulty sitting upright, memory problems, nausea/vomiting Coma (in novice drinker) Respiratory depression and risk of death
Treatment of alcohol intoxication
Monitor: ABCs, glucose, lytes, acid-base status
Thiamine and folate
Naloxone (if opioid co-ingestion)
CT head if trauma
Liver will take care of the rest
If severely intoxicated, may need mechanical ventilation with monitoring of above variables
GI evacuation NOT indicated UNLESS significant ingestion within the last hour
Clinical presentation of alcohol withdrawal
Alcohol withdrawal syndrome: insomnia, anxiety, hand tremor, irritability, anorexia, nausea, vomiting, autonomic hyperactivity, psychomotor agitation, fever, seizures, hallucinations, delirium
When do the earliest symptoms of ethanol withdrawal appear?
6-24 hours after the patient’s last drink
When do seizures occur in alcohol withdrawal?
12-48 hours after last drink, with peak around 12-24hrs
What should be corrected promptly in alcohol-withdrawal patients to help prevent seizures?
Hypomagnesemia
When does delirium tremens usually begin?
48-96 hours after last drink, but may be later
What factors increase a patient’s risk for DTs?
Age >30, prior DTs, physical illness
Symptoms of DTs
Delirium, hallucinations (visual), agitation, gross tremor, autonomic instability, fluctuating psychomotor activity
Treatment for alcohol withdrawl
Benzodiazepines
Carbamazepine and valproate in mild withdrawl
Antipsychotics, restraints for severe agitation
Thiamine, folic acid, and multivitamin
Correct lyte/fluid abnormalities
CIWA
Check for signs of trauma, liver failure
Medications for alcohol use disorder
First-line: Naltrexone (opioid receptor blocker) or acamprosate (modulates glutamate transmission)
Second-line: disulfiram and topiramate
Considerations for using disulfiram
Only for highly-motivated patients who will maintain abstinence and take the med
Monitor LFTs
Considerations for using acamprosate
Contraindicated in patients with renal disease
Okay to use in patients with liver disease
What are the questions on the AUDIT-C questionnaire?
How often did you have a drink containing alcohol in the past year?
How many drinks did you have on a typical day when you drank alcohol in the past year?
How often did you have six or more drinks on one occasion in the past year?
What are the neurochemical effects of cocaine?
Blocks reuptake of dopamine, epinephrine, and norepinephrine, causing stimulant effect
General features of cocaine intoxication
Euphoria, heightened self-esteem, +/- blood pressure, +/- HR, nausea, mydriasis, psychomotor agitation or depression, chills, sweating
Dangerous features of cocaine intoxication
Respiratory depression, seizures, arrhythmias, hyperthermia, paranoia, hallucinations (esp tactile)
Life-threatening effects of cocaine
Vasoconstriction –> MI, ICH, or stroke
Management of cocaine intoxication
Mild-to-moderate: Reassurance and benzos
Severe or psychosis: antipsychotics (haldol)
Symptomatic treatment
Hyperthermia –> treat with ice bath, cooling blankets
Treatment of cocaine use disorder
No FDA-approved treatments
Consider disulfiram, modafinil, topiramate
Counseling
Features of cocaine withdrawal
Not life-threatening
Post-intoxication depression/crash, can become suicidal
May need hospitalization for psychiatric symptoms
What are the neurochemical effects of amphetamines?
Classic amphetamines (dextroamphetamine, methylphenidate, methamphetamine) block reuptake and facilitate release of dopamine and norepinephrine
Symptoms of amphetamine abuse
Euphoria, mydriasis, increased libido, tachycardia, perspiration, grinding teeth, chest pain
Presentation of amphetamine overdose
Hyperthermia, dehydration, rhabdo, renal failure
Treatment of amphetamine intoxication
Rehydrate, correct lytes, treat hyperthermia
Neurochemical effects of PCP
NMDA antagonist, dopamine agonist
Symptoms of PCP intoxication
Agitation, depersonalization, hallucinations, synesthesia, impaired judgment, memory impairment, violent behavior, nystagmus, ataxia, dysarthria, HTN, tachycardia, muscle rigidity
PCP overdose
Can cause seizures, delirium, coma, death
Treatment of PCP intoxication
Monitor vitals, temp, lytes
Benzos to treat agitation, anxiety, spasms, seizures
Antipsychotics to control sever agitation or psychotic symptoms
Clinical presentation of sedative-hypnotic intoxication (benzos or barbs, etc)
Drowsy, confused, hypotension, slurred speech, respiratory depression, ataxia, mood lability, impaired judgment, nystagmus, respiratory depression, coma or death
Synergistic when combined with EtOH or opioids
Treatment of sedative-hypnotic intoxication
ABCs, monitor vitals
Activated charcoal or gastric lavage (if ingestion in past 4-6 hrs)
Supportive care
What should you give in benzodiazepine overdose?
Flumazenil (benzo receptor antagonist)
What should you give in barbiturate overdose?
Alkalinize urine with NaHCO3 to promote renal excretion
Worst withdrawal (in terms of mortality)?
Barbiturates
Presentation of withdrawal from sedative-hypnotics?
Same presentation as EtOH withdrawal.
Tonic-clonic seizures
Treatment of sedative-hypnotic withdrawal?
Benzodiazepine taper
Clinical presentation of opioid intoxication
Drowsiness, nausea/vomiting, constipation, slurred speech, miosis, seizures, respiratory depression
Overdose –> respiratory depression, AMS, miosis, coma
Which opioid, when taken with MAOIs, can cause serotonin syndrome?
Meperidine.
**Also the only opioid to cause mydriasis
Treatment of opioid overdose
ABCs
Naloxone
May need ventilatory support
Syndrome of opioid withdrawal
Dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, nausea/vomiting, fever, mydriasis, etc.
Treatment of opioid withdrawal
Moderate: Treat with clonidine for autonomic signs, NSAIDs for pain, dicyclomine for abdominal carmps
Severe: Detox with buprenorphine or methadone
Monitor with COWS (based on pulse, pupil size, tremor)
Presentation of marijuana intoxication
Euphoria, anxiety, impaired coordination, tachycardia, conjunctival injection, dry mouth, and increased appetite
Can produce psychotic disorders rarely
Withdrawal syndrome of marijuana
Irritability, anxiety, restlessness, aggression, strange dreams, depression, HA, sweating, chills, insomnia, anorexia
