Substance‐Related and Addictive Disorders Flashcards
Substance Abuse
Issues
-
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
DSM IV
Changes
- 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
Substance Related and Addictive Disorders
DSM 5
- Substance Use Disorders
- Substance Induced Disorders
- Intoxication
- Withdrawal
- Neurocognitive disorders
- Psychotic disorder
- Mood disorder
- Anxiety disorder
- Sexual dysfunction
- Sleep disorder
DSM 5:
Substance Use Disorder
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
Substance Abuse
Classification
- Alcohol
- Opioids
- Stimulants
- Dissociative Anesthetics
- Hallucinogens
- Depressants
- Cannabinoids
- Others: Inhalants, Anabolic steroids
- 9. Tobacco
- 10. Caffeine
- And Gambling Disorder
Alcohol
Prevalence of Drinking
- 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
Prevalence of Binge Drinking and Heavy Alcohol Use
- 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
Alcohol
Epidemiology
- 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
Excess Alcohol Use
Definitions
-
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
Alcohol
CAGE Questions
-
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?
Cloninger
Alcoholism Classification
Type I and Type II Alcoholism
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Babor
Alcoholism Classification
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Alcohol and Women
- 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
Fetal Alcohol Syndrome
- Leading cause of Mental retardation
- Microcephaly
- Craniofacial malformations
- Short stature
- Maladaptive behavior
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Alcohol Related
Psychiatric Disorders
- 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
Alcohol Withdrawal
- 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
Delirium Tremens
“DTs”
- 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
Alcohol Treatment
- Intervention: Inpatient v Outpatient
- Detoxification: Benzodiazepines (Lorazepam, Oxazepam and Temazepam)
- Pharmacotherapy: (Dr. J. Horwitz)
- Rehabilitation
Opioids & Morphine
Derivatives
- Heroin
- Morphine
- Codeine
- Oxycodone
- Hydrocodone
- Hydromorphone (DilaudidTM)
- Fentanyl
Opioids
Epidemiology
- 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
Opioids
Biology
- Primary effects on Opioid receptors
- μ‐receptors: analgesia, respiratory depression, and dependence
- κ‐receptors: analgesia and sedation
- Significant effects on dopaminergic and noradrenergic system
Opioids
Methods of Ingestion
- Oral
- Snorting
- Smoking (“chasing”)
- IV
- Subcutaneous (skin popping)
Opioid Withdrawal
Symptoms
- Rhinorrhea
- Lacrimation
- Nausea and vomiting
- Diarrhea
- Piloerection
- Muscle aches
- Spontaneous ejaculation
- Yawning
- Insomnia
Clinical Opiate Withdrawal Scale (COWS)
Opioid-related
Psychiatric disorders
- Psychiatric disorders
- Delirium
- Psychosis
- Mood Disorder
- Sleep disorder
- Sexual dysfunction
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)
Stimulants
- Cocaine
- Amphetamines
- Methamphetamine
- Methylphenidate
- Synthetic Cathinones (“Bath Salts”)
- Nicotine
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
Cocaine
Epidemiology
- 10% of population
- Most common age 18‐25
- All social classes
- Males twice as likely as females
Cocaine
Methods of Ingestion
- Snorting
- Freebasing
- Injecting
Cocaine
Medical Complications
- Seizures (Most common illicit drug; Amphetamines next most common)
- Cardiovascular
- Strokes
- HTN
- CKD / End Stage Renal Disease
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
Cocaine
Treatment
- Symptomatic
- No distinct withdrawal syndrome
- SSRI
- Bupropion
- TCA
- Dopamine agonists
- “Cocaine vaccine”
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
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”
Dissociative Anesthetics
Phencyclidine (PCP)
Ketamine
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
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
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)
LSD
Overview
- Ingested: oral, smoking, IV
- Acts on serotonergic receptors (5‐HT2)
- Tolerance develops and reverses very quickly
- No physical dependence or withdrawal
LSD Intoxication
- Perceptual changes, illusions, depersonalization, derealization and hallucinations
- Pupillary dilatation
- Tachycardia
- Incoordination
- Sweating
LSD
Psychiatric Manifestations
- Hallucinogen persisting perception disorder
- “Flashbacks”
- Depression
Depressants
- Barbiturates
- Benzodiazepines: “Xanax”
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
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
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 syndrome: seen in heavy cannabis users
- Apathy, dullness, lethargy, and impairment of judgment
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
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
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
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
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