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5. HDS Neuro Psych > Substance‐Related and Addictive Disorders > Flashcards

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
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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
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3
Q

Substance Related and Addictive Disorders

DSM 5

A
  • Substance Use Disorders
  • Substance Induced Disorders
  1. Intoxication
  2. Withdrawal
  3. Neurocognitive disorders
  4. Psychotic disorder
  5. Mood disorder
  6. Anxiety disorder
  7. Sexual dysfunction
  8. Sleep disorder
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4
Q

DSM 5:

Substance Use Disorder

A

NEED AT LEAST TWO:

  1. Taken in larger amounts or over a longer period of time then intended
  2. Unsuccessful attempts at cutting down
  3. Great deal of time spent on substance use
  4. Craving
  5. Failure to fulfill major role obligations at work/home/school
  6. Persistent social or interpersonal problems
  7. Important activities given up for substance use
  8. Use in hazardous situations
  9. Use in spite of physical and psychological problems
  10. Tolerance
  11. Withdrawal
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5
Q

Substance Abuse

Classification

A
    1. Alcohol
    1. Opioids
    1. Stimulants
    1. Dissociative Anesthetics
    1. Hallucinogens
    1. Depressants
    1. Cannabinoids
    1. Others: Inhalants, Anabolic steroids
  • 9. Tobacco
  • 10. Caffeine
  • And Gambling Disorder
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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
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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
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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
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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
  • 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
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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?
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11
Q

Cloninger

Alcoholism Classification

A

Type I and Type II Alcoholism

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12
Q

Babor

Alcoholism Classification

A
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13
Q

Alcohol and Women

A
  1. Drink alone
  2. Binge less
  3. Drink less
  4. Higher ethanol levels than men (less gastric alcohol dehydrogenase, less volume of distribution, less total body water)
  5. Faster progression from first drink to problems
  6. Reach criteria for dependence quicker
  7. Progress to liver disease with less ETOH and more quickly
  8. Higher mortality rate from Alcohol related liver disease
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14
Q

Fetal Alcohol Syndrome

A
  • Leading cause of Mental retardation
  • Microcephaly
  • Craniofacial malformations
  • Short stature
  • Maladaptive behavior
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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
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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
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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
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18
Q

Alcohol Treatment

A
  • Intervention: Inpatient v Outpatient
  • Detoxification: Benzodiazepines (Lorazepam, Oxazepam and Temazepam)
  • Pharmacotherapy: (Dr. J. Horwitz)
  • Rehabilitation
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19
Q

Opioids & Morphine

Derivatives

A
  • Heroin
  • Morphine
  • Codeine
  • Oxycodone
  • Hydrocodone
  • Hydromorphone (DilaudidTM)
  • Fentanyl
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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
Q

Opioid Treatment

A
  • 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
Q

Stimulants

A
  • Cocaine
  • Amphetamines
  • Methamphetamine
  • Methylphenidate
  • Synthetic Cathinones (“Bath Salts”)
  • Nicotine
27
Q

Neurobiology of Stimulants

A
  • 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
Q

Cocaine

Epidemiology

A
  • 10% of population
  • Most common age 18‐25
  • All social classes
  • Males twice as likely as females
29
Q

Cocaine

Methods of Ingestion

A
  • Snorting
  • Freebasing
  • Injecting
30
Q

Cocaine

Medical Complications

A
  • Seizures (Most common illicit drug; Amphetamines next most common)
  • Cardiovascular
  • Strokes
  • HTN
  • CKD / End Stage Renal Disease
31
Q

Cocaine

Psychiatric disorders

A
  • 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
Q

Cocaine

Treatment

A
  • Symptomatic
    • No distinct withdrawal syndrome
  • SSRI
  • Bupropion
  • TCA
  • Dopamine agonists
  • “Cocaine vaccine”
33
Q

Amphetamines

A
  • 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
Q

Synthetic Cathinones

(“Bath Salts”)

A
  • 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
Q

Dissociative Anesthetics

A

Phencyclidine (PCP)

Ketamine

36
Q

Phencyclidine (PCP)

Overview

A
  • 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
Q

PCP

Intoxication

A

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
Q

Hallucinogens

A

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
Q

LSD

Overview

A
  • Ingested: oral, smoking, IV
  • Acts on serotonergic receptors (5‐HT2)
  • Tolerance develops and reverses very quickly
  • No physical dependence or withdrawal
40
Q

LSD Intoxication

A
  • Perceptual changes, illusions, depersonalization, derealization and hallucinations
  • Pupillary dilatation
  • Tachycardia
  • Incoordination
  • Sweating
41
Q

LSD

Psychiatric Manifestations

A
  • Hallucinogen persisting perception disorder
  • “Flashbacks”
  • Depression
42
Q

Depressants

A
  • Barbiturates
  • Benzodiazepines: “Xanax”
  • Flunitrazepam (Rohypnol)
  • Gamma hydroxybutyrate (GHB)
43
Q

Cannabis

Overview

A
  • 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
Q

Cannabis

Effects

A
  • _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 syndrome: seen in heavy cannabis users
      • Apathy, dullness, lethargy, and impairment of judgment
45
Q

Synthetic Cannabinoids

(“Spice,” “K2,” etc.)

A
  • 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
Q

Inhalants

A

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
Q

Anabolic Steroids

A
  • 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
Q

Gambling Disorder

A
  • 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
Q

Tobacco and Caffeine

A
  • 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

5. HDS Neuro Psych (46 decks)

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