Substance-related d/os Flashcards
Pathways and neurotransmitters involved in substance abuse
Opioid
Catecholamine
GABA
DSM-5 criteria for substance use d/o
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two or more of the following, occurring during a 12-mo period:
Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
Recurrent substance use in situations in which it is physically hazardous
Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
Tolerance, as defined by either of the following:
-A need for markedly increased amounts of the substance to achieve intoxication or desired effect
-Markedly diminished effect with continued use of the same amount of the substance
Withdrawal, as manifested by either of the following:
-The characteristic withdrawal syndrome for the substance
-The same (or a closely related) substance is taken to relieve or avoid withdrawal sx
The substance is often taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
Important social, occupational, or recreational activities are given up or reduced because of substance use
The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
Craving or a strong desire or urge to use a specific substance
Effects of alcohol on biochemistry
Nicotinic acetylcholine, serotonin 5-HT3, and GABA type A receptors are enhanced by alcohol
Ion channel activities associated with glutamate receptors and voltage-gated calcium channels are inhibited
Effects of alcohol on behavior
- 05%: Thought, judgement, and restraint are loosened and sometimes disrupted
- 1%: Voluntary motor actions usually become perceptibly clumsy
- 2%: the function of the entire motor area of the brain is measurably depressed, and the parts of the brain that control emotional behavior are also affected
- 3%: A person is commonly confused or may become stuporous
- 4-0.5%: the person falls into a coma
Effects of alcohol on sleep
Increases the ease of falling asleep but has adverse effects on sleep architecture
Decrease in REM and deep sleep and more sleep fragmentation
Effects of alcohol on theliver
Accumulation of fats and proteins
Associated with the development of alcoholic hepatitis and hepatic cirrhosis
Effects of alcohol on the GI system
Long-term heavy drinking is associated with developing esophagitis, gastritis, achlorhydria, and gastric ulcers
Particularly heavy EtOH abuse can lead to esophageal varices
Pancreatitis, pancreatic insufficiency, and pancreatic CA
Can interfere with normal processes of food digestion and absorption
-Can lead to vitamin deficiencies
Effects of alcohol on other body systems
Increased BP
Dysregulation of lipoprotein and triglyceride metabolism
Increased risk for MI and CVD
Can increase the incidence of head, neck, esophageal, stomach, hepatic, colonic, and lung CAs
Acute intoxication may also be associated with hypoglycemia
Labs that are affected by alcohol-related d/os
High gamma-glutamyl transpeptidase levels
High MCV
High uric acid, triglycerides, AST, ALT
What patterns can strongly suggest alcohol dependence and alcohol abuse?
A need for daily use of large amounts of alcohol for adequate functioning
A regular pattern of heavy drinking limited to weekends
Long periods of sobriety interspersed with binges of heavy alcohol intake lasting for weeks or months
Behaviors associated with alcohol abuse
Inability to cut down or stop drinking
Repeated efforts to control or reduce excessive drinking by periods of temporary abstinence or by restricting drinking to certain times of the day
Binges (remaining intoxicated throughout the day for at least 2 days)
Occasional consumption of a fifth of spirits (or its equivalent in wine or beer)
Amnestic periods for events occurring while intoxicated
The continuation of drinking despite a serious physical d/o that the person knows is exacerbated by alcohol use
Drinking non-beverage alcohol
DSM-5 criteria for alcohol intoxication
Recent ingestion of alcohol Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, alcohol ingestion One, or more, of the following signs or symptoms developing during or shortly after alcohol use: -Slurred speech -Incoordination -Unsteady gait -Nystagmus -Impairment in attention or memory -Stupor or coma
DSM-5 criteria for alcohol withdrawal
Cessation of (or reduction in) alcohol use that has been heavy and prolonged
Two or more of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use:
-Autonomic hypersensitivity (e.g., sweating or pulse rate >100 bpm)
-Increased hand tremor
-Insomnia
-Nausea or vomiting
-Transient visual, tactile, or auditory hallucinations or illusions
-Psychomotor agitation
-Anxiety
-Generalized tonic-clonic seizures
Tx of alcohol withdrawal sx
BZDs, PO or IV
Studies have shown that carbamazepine in daily doses of 800 mg is as effective and has less abuse potential
Beta-adrenergic receptor antagonists and clonidine
Alcohol-induced delirium- timeline
Delirium occurring within 1 wk after a person stops drinking or reduces the intake of alcohol
Features of alcohol intoxication delirium
Autonomic hyperactivity, such as tachycardia, diaphoresis, fever, anxiety, insomnia, and HTN
Perceptual distortions
Fluctuating levels of psychomotor activity
Essential feature of alcohol-induced persistent amnestic d/o
disturbance in short-term memory caused by prolonged heavy use of EtOH
Wernicke’s encephalopathy
An acute neurological d/o characterized by ataxia, vestibular dysfunction, confusion, and a variety of ocular motility abnormalities, including horizontal nystagmus, lateral orbital palsy, and gaze palsy
What is the pathophysiological connection between Wernicke’s encephalopathy and Korsakoff’s syndrome?
Thiamine deficiency
How does Korsakoff’s syndrome differ from Wernicke’s encephalopathy?
Only 20% of pts with Korsakoff’s syndrome recover
Wernicke’s encephalopathy can progress to Korsakoff’s syndrome
Cardinal features of Korsakoff’s syndrome
Impaired mental syndrome (esp memory) and anterograde amnesia in an alert and responsive pt
Tx of Wernicke-Korsakoff
Wernicke’s encephalopathy: large doses of parental thiamine, which is believed to be effective in preventing progression to Korsakoff’s syndrome
Korsakoff’s syndrome: less amount’s of thiamine than Wernicke’s for a longer period of time
What are the three general steps involved in treating the alcoholic person after the d/o has been diagnosed?
Intervention
Detoxification
Rehabilitation
These approaches assume that all possible efforts have been made to optimize medical functioning and to address psychiatric emergencies
What is the goal of the intervention step in alcoholics?
To break through feelings of denial and help the pt recognize the adverse consequences likely to occur if the d/o is not treated
Intervention techniques
Convince pts that they are responsible for their own actions while reminding them of how EtOH has created significant life impairments
Take advantage of the pt’s chief presenting complaint and explain how EtOH has either created or contributed to these problems
Reassure the pt that abstinence can be achieved with a minimum of discomfort
Alcoholic often needs multiple interventions
How family can help in an intervention with EtOH
Family members must learn not to protect the pt from the problems caused by EtOH
Tx of mild to moderate alcohol withdrawal
BZDs are most often used, then decreased over time
Tx of severe EtOH withdrawal
Use either BZDs or antipsychotics
Find out whether there is a concurrent medical condition that would contribute to the severity of the withdrawal
Tx for protracted EtOH withdrawal
Sx of anxiety, insomnia, and mild autonomic overactivity are likely to continue for 2-6 mos after acute withdrawal has disappeared
No pharm tx for this syndrome appears appropriate
Acamprosate may work
Discuss cognitive and behavioral approaches
Three major components of EtOH rehabilitation
Continued efforts to increase and maintain high levels of motivation for abstinence
Work to help the pt readjust to a lifestyle free of alcohol
Relapse prevention
Techniques of EtOH rehabilitation
Repeated presentations of similar materials because these steps are carried out in the context of acute and protracted withdrawal syndromes and life crises
Timeline of EtOH rehabilitation
Can be inpatient or outpatient
Use the first 2-4 wks of care as an intensive period of help, followed by at least 3-6 mos of less frequent outpatient care
Counseling is crucial
DSM-5 criteria for cannabis intoxication
A. Recent use of cannabis
B. Clinically significant problematic behavior or psychological changes that developed during, or shortly after, cannabis use
C. Two or more of the following signs or sx developing within 2 hrs of cannabis use:
1. Conjunctival injection
2. Increased appetite
3. Dry mouth
4. Tachycardia
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria for cannabis withdrawal
A. Cessation of cannabis use that has been heavy and prolonged
B. Three or more of the following signs and sx develop within approximately 1 wk after criterion A:
1. Irritability, anger, or aggression
2. Nervousness or anxiety
3. Sleep difficulty
4. Decreased appetite or wt loss
5. Restlessness
6. Depressed mood
7. At least one of the following physical sx causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or HA
C. The signs or sx in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication or withdrawal from another substance
DSM-5 criteria for phencyclidine intoxication
A. Recent use of phencyclidine or a pharmacologically similar substance
B. Clinically significant problematic behavioral changes that developed during, or shortly after, phencyclidine use
C. Within 1 hr, 2 or more of the following signs or sx:
1. HTN or tachycardia
2. Vertical or horizontal nystagmus
3. Numbness or diminished responsiveness to pain
4. Ataxia
5. Dysarthria
6. Muscle rigidity
7. Seizures or coma
8. Hyperacusis
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria for other hallucinogen intoxication
A. Recent use of a hallucinogen (other than phencyclidine)
B. Clinically significant problematic behavior or psychological changes that developed during, or shortly after, hallucinogen use
C. Perceptual changes occurring in a state of full wakefulness and alertness that developed during, or shortly after, hallucinogen use
D. Two or more of the following signs developing during, or shortly after, hallucinogen use:
1. Pupillary dilation
2. Tachycardia
3. Sweating
4. Palpitations
5. Blurring of vision
6. Tremors
7. Incoordination
E. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria for inhalant intoxication
A. Recent intended or unintended short-term, high-dose exposure to inhalant substances, including volatile hydrocarbons such as toluene or gasoline B. Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, exposure to inhalants. C. Two or more of the following signs or sx developing during, or shortly after, inhalant use or exposure: 1. Dizziness 2. Nystagmus 3. Incoordination 4. Slurred speech 5. Unsteady gait 6. Lethargy 7. Depressed reflexes 8. Psychomotor retardation 9. Tremor 10. Generalized muscle weakness 11. Blurred vision or diplopia 12. Stupor or coma 13. Euphoria D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria of opioid intoxication
A. Recent use of an opioid
B. Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, opioid use
C. Pupillary constriction (or pupillary dilation d/t anoxia from severe overdose) and one or more of the following signs or sx developing during, or shortly after, opioid use:
1. Drowsiness or coma
2. Slurred speech
3. Impairment in attention or memory
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance.
DSM-5 criteria of opioid withdrawal
A. Presence of either of the following:
1. Cessation of or reduction in opioid use that has been heavy and prolonged
2. Administration of an opioid antagonist after a period of opioid use
B. Three or more of the following developing within minutes to several days after criterion A:
1. Dysphoric mood
2. Nausea or vomiting
3. Muscle aches
4. Lacrimation or rhinorrhea
5. Pupillary dilation, piloerection, or sweating
6. Diarrhea
7. Yawning
8. Fever
9. Insomnia
C. The signs or sx in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication or withdrawal from another substance
DSM-5 criteria for sedative, hypnotic, or anxiolytic intoxication
A. Recent use of a sedative, hypnotic, or anxiolytic
B. Clinically significant maladaptive behavioral or psychological changes that developed during, or shortly after, sedative, hypnotic, or anxiolytic use
C. One or more of the following signs or sx developing during, or shortly after, sedative, hypnotic, or anxiolytic use:
1. Slurred speech
2. Incoordination
3. Unsteady gait
4. Nystagmus
5. Impairment in cognition
6. Stupor or coma
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria for sedative, hypnotic, or anxiolytic withdrawal
A. Cessation of or reduction in sedative, hypnotic, or anxiolytic use that has been prolonged
B. Two or more of the following, developing within several hours to a few days after the cessation of or reduction in sedative, hypnotic, or anxiolytic use described in criterion A:
1. Autonomic hyperactivity
2. Hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Grand mal seizures
C. The signs or sx in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication or withdrawal from another substance
DSM-5 criteria for stimulant intoxication
A. Recent use of an amphetamine-type substance, cocaine, or other stimulant
B. Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, use of a stimulant
C. Two or more of the following signs or sx, developing during, or shortly after, stimulant use:
1. Tachycardia or bradycardia
2. Pupillary dilation
3. Elevated or lowered BP
4. Perspiration or chills
5. Nausea or vomiting
6. Evidence of wt loss
7. Psychomotor agitation or retardation
8. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
9. Confusion, seizures, dyskinesias, dystonias, or coma
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication with another substance
DSM-5 criteria for stimulant withdrawal
A. Cessation of or reduction in prolonged amphetamine-type substance, cocaine, or other stimulant use
B. Dysphoric mood and two or more of the following physiological changes, developing within a few hrs to several days after criterion A:
1. Fatigue
2. Vivid, unpleasant dreams
3. Insomnia or hypersomnia
4. Increased appetite
5. Psychomotor retardation or agittaion
C. The signs or sx in criterion B cause clinically significant distress or impairment in social, occupation, or other important areas of functioning
D. The signs or sx are not attributable to another medical condition and are not better explained by another mental d/o, including intoxication or withdrawal from another substance
DSM-5 criteria for tobacco withdrawal
A. Daily use of tobacco for at least several weeks
B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hrs by four or more of the following signs or sx:
1. Irritability, frustration, or anger
2. Anxiety
3. Difficulty concentrating
4. Increased appetitie
5. Restlessness
6. Depressed mood
7. Insomnia
C. The signs or sx in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
D. The signs or sx are not attributable to another medical condition are are not better explained by another mental d/o, including intoxication or withdrawal from another substance
