Substance‐Related and Addictive Disorders Flashcards
1
Q
Substance Abuse
Issues
A
-
Illicit drug use in America has been increasing
- Mostly marijuana, the most commonly used illicit drug
- 51% of America’s teenagers have tried an illicit drug by the time they finish high school
- Marijuana use has increased since 2007
- Use of most drugs other than marijuana has not changed appreciably over the past decade or has declined
- More than half of new illicit drug users begin with marijuana, then prescription pain relievers, followed by inhalants
2
Q
DSM IV
Changes
A
- We now use the term Substance Use Disorder
- Used to distinguish between abuse and dependence
- Dependence: neurobehavioral syndrome in which pt has not only signs of w/d but behavioral changes associated with the drugs
- Abuse was considered to be a mild or early phase of dependence
- Craving for a drug is added
- Legal consequences as a criterion removed
- Gambling Disorder /“Pathological gambling” added
3
Q
Substance Related and Addictive Disorders
DSM 5
A
- Substance Use Disorders
- Substance Induced Disorders
- Intoxication
- Withdrawal
- Neurocognitive disorders
- Psychotic disorder
- Mood disorder
- Anxiety disorder
- Sexual dysfunction
- Sleep disorder
4
Q
DSM 5:
Substance Use Disorder
A
NEED AT LEAST TWO:
- Taken in larger amounts or over a longer period of time then intended
- Unsuccessful attempts at cutting down
- Great deal of time spent on substance use
- Craving
- Failure to fulfill major role obligations at work/home/school
- Persistent social or interpersonal problems
- Important activities given up for substance use
- Use in hazardous situations
- Use in spite of physical and psychological problems
- Tolerance
- Withdrawal
5
Q
Substance Abuse
Classification
A
- Alcohol
- Opioids
- Stimulants
- Dissociative Anesthetics
- Hallucinogens
- Depressants
- Cannabinoids
- Others: Inhalants, Anabolic steroids
- 9. Tobacco
- 10. Caffeine
- And Gambling Disorder
6
Q
Alcohol
Prevalence of Drinking
A
- 86.4% of people ages 18 or older reported that they drank alcohol at some point in their lifetime
- 70.1% reported that they drank in the past year
- 56.0% reported that they drank in the past month
7
Q
Prevalence of Binge Drinking and Heavy Alcohol Use
A
- 26.9% of people ages 18 or older reported that they engaged in binge drinking in the past month
- 7.0% reported that they engaged in heavy alcohol use in the past month
8
Q
Alcohol
Epidemiology
A
- Caucasians have the highest rates of alcohol use
- Heavy drinking is the same across all races in US
- Gender: M>F
- Region: Rates highest in North Central US
- Higher in metropolitan areas compared to rural areas
- Education: Drinkers are likely to have had higher education compared to illicit drug use
- Socioeconomic status: No correlation
9
Q
Excess Alcohol Use
Definitions
A
-
Bing Drinking
- Pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL
- ♂ 5 drinks in 2 hours
- ♀ 4 drinks in 2 hours
- Pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL
-
At risk for alcohol‐related problems
- ♂ > 14 standard drinks per week or 4 drinks per day
- ♀ > 7 standard drinks per week or 3 drinks per day
- (Standard drink defined as one 12‐ounce bottle of beer, one 5‐ounce glass of wine, or 1.5 ounces of distilled spirits)
- Heavy Alcohol Use: Binge drinking on 5 or more days in the past month
10
Q
Alcohol
CAGE Questions
A
-
Cut
- Ever felt you ought to cut down on your drinking?
-
Annoyed
- Have people annoyed you by criticizing your drinking?
-
Guilt
- Ever felt bad or guilty about your drinking?
-
Eye Opener
- Ever had an eye‐opener to steady nerves in the AM?
11
Q
Cloninger
Alcoholism Classification
A
Type I and Type II Alcoholism
12
Q
Babor
Alcoholism Classification
A
13
Q
Alcohol and Women
A
- Drink alone
- Binge less
- Drink less
- Higher ethanol levels than men (less gastric alcohol dehydrogenase, less volume of distribution, less total body water)
- Faster progression from first drink to problems
- Reach criteria for dependence quicker
- Progress to liver disease with less ETOH and more quickly
- Higher mortality rate from Alcohol related liver disease
14
Q
Fetal Alcohol Syndrome
A
- Leading cause of Mental retardation
- Microcephaly
- Craniofacial malformations
- Short stature
- Maladaptive behavior
15
Q
Alcohol Related
Psychiatric Disorders
A
- Alcohol intoxication
- Alcohol withdrawal delirium
- Alcohol withdrawal seizures
- Alcohol‐Induced Amnestic disorder (Wernicke‐Korsakoff Syndrome)
- Neurocognitive Disorder associated w/ ETOH
- Alcohol induced psychotic disorder
- Alcohol induced mood disorder
16
Q
Alcohol Withdrawal
A
- Can be serious even without delirium
- Includes seizures and autonomic hyperactivity (BP, HR, temp)
- Begins 8‐24 hours after cessation or reduction in drinking
- Tremors (“shakes”; “jitters”)
- Other Sx: nausea/vomiting, anxiety, irritability, sweating, flushing
- Can progress on to develop delirium
17
Q
Delirium Tremens
“DTs”
A
- Delirium occurring during ETOH withdrawal
- Medical emergency
- Usually develops within 72 hrs
- Watch out for DTs for up to a week following cessation of ETOH
- High mortality – up to 20% in untreated cases
- Confusion and disorientation
- Autonomic instability
- Perceptual disturbances: Visual, tactile, auditory hallucinations, illusions
18
Q
Alcohol Treatment
A
- Intervention: Inpatient v Outpatient
- Detoxification: Benzodiazepines (Lorazepam, Oxazepam and Temazepam)
- Pharmacotherapy: (Dr. J. Horwitz)
- Rehabilitation
19
Q
Opioids & Morphine
Derivatives
A
- Heroin
- Morphine
- Codeine
- Oxycodone
- Hydrocodone
- Hydromorphone (DilaudidTM)
- Fentanyl
20
Q
Opioids
Epidemiology
A
- Life time prevalence: 1%
- Used at any time in their lives: 2 million
- Current users: 600‐800,000
- M:F ‐ 3:1
- Peak use in teen and 20’s. “Mature out” by the time they are 40.
- More in lower socioeconomic class
21
Q
Opioids
Biology
A
- Primary effects on Opioid receptors
- μ‐receptors: analgesia, respiratory depression, and dependence
- κ‐receptors: analgesia and sedation
- Significant effects on dopaminergic and noradrenergic system
22
Q
Opioids
Methods of Ingestion
A
- Oral
- Snorting
- Smoking (“chasing”)
- IV
- Subcutaneous (skin popping)
23
Q
Opioid Withdrawal
Symptoms
A
- Rhinorrhea
- Lacrimation
- Nausea and vomiting
- Diarrhea
- Piloerection
- Muscle aches
- Spontaneous ejaculation
- Yawning
- Insomnia
Clinical Opiate Withdrawal Scale (COWS)
24
Q
Opioid-related
Psychiatric disorders
A
- Psychiatric disorders
- Delirium
- Psychosis
- Mood Disorder
- Sleep disorder
- Sexual dysfunction
25
Opioid Treatment
* **Non-Opioid detoxification**: Clonidine (α2 agonist)
* **Methadone**: Detoxification and Maintenance
* **Buprenorphine**: detox and Maintenance (Suboxone & Subutex)
* **Opioid antagonists**: Naltrexone
* **SSRI’s**
* _Options after Detoxification_
* Methadone Maintenance Program
* Inpatient Rehabilitation
* Recovery House
* Intensive outpatient
* Narcotics Anonymous (NA)
26
Stimulants
* Cocaine
* Amphetamines
* Methamphetamine
* Methylphenidate
* Synthetic Cathinones (“Bath Salts”)
* Nicotine
27
Neurobiology of Stimulants
* **Cocaine**
* Binds dopamine transporter ⇒ **⊗** **reuptake of synaptic dopamine** ⇒ **dose‐dependent** ↑ **in extracellular levels of dopamine**
* Reuptake is the primary mechanism by which dopamine is inactivated
* Rewarding effects of cocaine are mediated thru the **mesocortical and mesolimbic dopaminergic pathways**
* **Amphetamines**
* Act on dopamine vesicles ⇒ ↑ release of dopamine
* **Methamphetamine**
* ↑ dopamine reuptake
* ↓ dopamine release via the dopamine transporter
* An important difference between methamphetamine and cocaine is their duration of action:
* Cocaine is rapidly metabolized
* Methamphetamine metabolism is relatively slow, with effects lasting several hours longer than cocaine
28
Cocaine
Epidemiology
* 10% of population
* Most common age 18‐25
* All social classes
* Males twice as likely as females
29
Cocaine
Methods of Ingestion
* Snorting
* Freebasing
* Injecting
30
Cocaine
Medical Complications
* **Seizures** (Most common illicit drug; Amphetamines next most common)
* Cardiovascular
* Strokes
* HTN
* CKD / End Stage Renal Disease
31
Cocaine
Psychiatric disorders
* **Intoxication**: hyperawareness, hypersexuality, hypervigilance, and psychomotor agitation
* **Delirium**: disorientation, confusion, anxiety.
* **Psychosis**: seen during high cocaine use. Delusions, stereotyped compulsive behavior
* **Withdrawal**: “crash”, dysphoria, craving
* Mood **disorder**: depression
32
Cocaine
Treatment
* Symptomatic
* No distinct withdrawal syndrome
* SSRI
* Bupropion
* TCA
* Dopamine agonists
* “Cocaine vaccine”
33
Amphetamines
* More common in Europe, Australia
* Methamphetamine increasing in popularity in the US
* “Khat”
* No specific withdrawal symptoms; “Crash”
* Amphetamines can produce a **psychosis** similar to **Paranoid schizophrenia**
* **Delusional Parasitosis** - mental disorder in which individuals have a persistent belief that they are infested with living or nonliving pathogens
34
Synthetic Cathinones
| (“Bath Salts”)
* **Cathinone** ⇒ amphetamine‐like stimulant found naturally in the Khat plant
* Typically take the form of a white or brown crystalline powder
* Sold in small plastic or foil packages labeled “not for human consumption”
* Sometimes also marketed as “plant food”—or, more recently, as “jewelry cleaner” or “phone screen cleaner”
* Sold online and in drug paraphernalia stores under a variety of brand names, such as “Ivory Wave," "Bloom," "Cloud Nine," "Lunar Wave," "Vanilla Sky," "White Lightning" and “Scarface”
35
Dissociative Anesthetics
Phencyclidine (PCP)
Ketamine
36
Phencyclidine (PCP)
Overview
* Easy to synthesize
* Angel dust, “Wet”, “Balming fluid”, “Dipper”
* Method of ingestion: **smoking**
* PCP acts as an **N‐methyl d‐aspartate (NMDA) receptor antagonist**
* PCP also acts on **dopaminergic neurons in VTA**
* PCP **does not cause any physical dependence**
37
PCP
Intoxication
**Psychiatric emergency**
* Symptoms:
* Vertical or horizontal nystagmus
* HTN, tachycardia
* Ataxia
* Reduced responsiveness to pain
* Perceptual disturbances
* Seizures
* Coma
* Management:
* **Airway, breathing, circulation, thermoregulation, and neurologic status** must be stabilized
* Physical restraints should be avoided as far as possible
* **Benzodiazepines** for agitation
* **Neuroleptics** if patient is psychotic
* Haloperidol, Ziprasidone
38
Hallucinogens
**Psychedelics** or **Psychotomimetics**
* _Naturally occurring_: Psilocybin and mescaline
* _Synthetic_: Lysergic acid diethylamide (LSD)
* Use more prevalent in whites as compared to AA or Hispanics
* More prevalent in younger population (\<20)
39
LSD
Overview
* Ingested: oral, smoking, IV
* Acts on **serotonergic receptors (5‐HT2)**
* Tolerance develops and reverses very quickly
* No physical dependence or withdrawal
40
LSD Intoxication
* Perceptual changes, illusions, depersonalization, derealization and hallucinations
* Pupillary dilatation
* Tachycardia
* Incoordination
* Sweating
41
LSD
Psychiatric Manifestations
* Hallucinogen persisting perception disorder
* “Flashbacks”
* Depression
42
Depressants
* Barbiturates
* Benzodiazepines: “Xanax”
* Flunitrazepam (Rohypnol)
* Gamma hydroxybutyrate (GHB)
43
Cannabis
Overview
* Cannabis is most commonly used illicit drug
* Plant: Cannabis sativa
* Active compound **Δ‐9 tetrahydrocannabinol (THC)**
* Most potent form: hash from the flowering tops
* Prevalence increases with age till age 35
* 85 million Americans over the age 12 have tried marijuana
* 50% of all 12th graders have tried it at least once
* **Cannabinoids receptor** is a **G‐protein linked receptor**
* Highest concentrations in **basal ganglia, hippocampus and cerebellum**
44
Cannabis
Effects
* _Physical effect_s: **Dilatation of conjunctival blood vessels, tachycardia, increased appetite and dry mouth**
* ? Long term effects
* There is **tolerance** to effects of cannabis but **no physical withdrawal**
* _Psychiatric manifestations:_
* **? Psychosis**
* **Depression**
* **Amotivational syndrom**e: seen in heavy cannabis users
* Apathy, dullness, lethargy, and impairment of judgment
45
Synthetic Cannabinoids
| (“Spice,” "K2,” etc.)
* Man‐made mind‐altering chemicals
* Sprayed on dried, shredded plant material so they can be smoked (herbal incense)
* Sold as liquids to be vaporized and inhaled in e‐cigarettes and other devices (liquid incense)
* “AMB‐FUBINACA” “AK‐47” “Karat Gold”
* Synthetic cannabinoids are **chemically related to THC**
* Their effects can be considerably more powerful and more dangerous than marijuana
* Users can experience:
* **Anxiety and agitation**
* **Nausea and vomiting**
* **High blood pressure**
* **Shaking and seizures**
* **Hallucinations and paranoia**
* **May act violently**
46
Inhalants
**Volatile substances** that produce chemical vapors that can be inhaled to induce a **psychoactive, or mind‐altering, effect.**
* Solvents, glues, paint thinners, fuels etc.
* Inhalants act as **CNS depressants**
* Additive effects to other CNS depressants
* **No specific withdrawal symptoms**
* **? long term cognitive deficits**
47
Anabolic Steroids
* Muscle building (Also think of GHB)
* “Feel good” after using
* Euphoria
* No specific withdrawal
* Physical complication: **Liver Ca, testicular atrophy**
* Psychiatric manifestations: **Euphoria, Rage, Depression**
48
Gambling Disorder
* Now under Substance Related and Addictive Disorders
* Preoccupation with gambling
* Restless when not gambling or cutting down
* Need to gamble with increasing amounts of money to get the excitement
* Unsuccessful efforts to control
* Gambling to escape problems
* Chasing one’s losses
* Lying to hide gambling / Jeopardize relationships, jobs
* Not due to another illness
* Treatment: **SSRI’s, Naltrexone, Mood Stabilizers**
* is preferred medication
* will help with depression but not the cravings
* **Increased risk of suicide**
49
Tobacco and Caffeine
* Tobacco use in the form of cigarettes may be declining, but vaping use is increasing among adolescents
* **Tobacco use is common among patients with mental illness**
* There a number of treatment options that are available
* **Caffeinism** can present with **anxiety, nervousness, jitters, muscle twitching**
