substance related disorders Flashcards
1
Q
substance abuse: dx
A
- substance use causing impairment/distress for AT LEAST 12 MOs
1+ of:
- W: failure to fulfill obligations at Work/school/home
- I: Interpersonal/social probs
- L: Legal problems
- D: Dangerous use
2
Q
substance dependence: dx
A
- substance use causing impairment or distress
3+ of following WITHIN 12 MO PERIOD
- tolerance
- w/drawal
- using more than originally intended
- persistent desire/unsuccessful efforts to cut down
- significant time spent getting/using/recovering from substance
- decreased social/occupational/recreational activities
- continued use despite physical/physiological problem
3
Q
substance abuse/dependence: epidem
A
- lifetime prev: 17%
- men > women
- alcohol and nicotine most common
4
Q
alcohol use: physiology
A
- GABA and 5HT activation
- glu and Ca-channels inactivated
- overall: CNS depressant
- alcohol –> acetaldehyde by alcohol dehydrogenase
- acetaldehyde –> acetic acid by aldehyde dehydrogenase (lacking in Asians)
5
Q
alcohol use: epidem
A
- dependence: 3-5% of women and 10% of men
- many more meet criteria for abuse in their lifetime
6
Q
alcohol intoxication: clinical presentation
A
- decreased fine motor control
- impaired judgment and coordination
- ataxic gait and poor balance
- lethargy, difficulty sitting upright, memory probs
- coma in novice drinker
- respiratory depression, death possible at highest BAL
7
Q
alcohol intoxication: tx
A
- monitor: ABCs, glucose, electrolytes, acid-base status
- thiamine (Wernicke’s) and folate
- naloxone if co-ingested opioids
- CT to rule out brain injury
- may need resp support
DO NOT do GI evacuation unless significant ingestion w/in 30-60 min
8
Q
alcohol withdrawal: clinical
A
- insomnia, anxiety, hand tremor, irritability, anorexia, nausea, vomiting, autonomic hyperactivity, psychomotor agitation, fever, SZ, hallucinations, delirium
- earliest sx: 6-24 hrs
- sz: 6-48 hrs, peak at 13-24 hrs
- 1/3 of people with sz develop DTs
- tx of sz: BZOs
9
Q
DTs
A
- usually 48-72 hrs after last drink
- 15-25% mortality rate if untreated
- predisposition if physically ill
- men»_space;> women
- visual hallucinations, gross tremor, fluctuating levels of psychomotor activity
- tx: BZOs
10
Q
alcohol withdrawal: tx
A
- BZOs for sedation/agitation, then slow taper
- antipsychotics and restraints for severe agitation
- thiamine, folic acid, multivitamin = banana bag
- check for hepatic failure
11
Q
alcohol dependence: tx
A
- Antabuse = disulfiram: blocks aldehyde dehydrogenase –> flushing, HA, N/V, palpitations, SOB
- naltrexone: opioid rcptr blocker, best benefit in family hx of alcoholism, precipitates w/drawal in opioid dependents
- acamprosate: similar to GABA, inhibits glu system; start post detox, can be used in patients with liver dx (NOT with renal dz)
- topiramate: anticonvulsant, potentiates GABA and inhibits glu, decreases cravings
12
Q
alcohol use: lab values
A
- AST:ALT >= 2:1
- elevated GGT
- increased MCV
13
Q
Wernicke’s encephalopathy
A
- due to thiamine deficiency
- can be reversed with thiamine therapy
- broad-based ataxia, confusion, ocular: nystagmus, gaze palsies
14
Q
Korsakoff syndrome
A
- from untreated Wernicke’s
- chronic amnestic syndrome
- 80% NONreversible
- impaired recent memory, anterograde amnesia, compensatory confabulation
15
Q
cocaine use: physiology
A
- blocks dopa reuptake
- dopa –> reward
16
Q
cocaine intox: clinical
A
- euphoria, increased self-esteem, change in BP, tachy/bradycardia, nausea, dilated pupils, weight loss, chills, sweating
- resp depression, sz, arrhythmias, paranoia, hallucinations (TACTILE)
- vasoconstriction may –> MI or stroke
17
Q
cocaine intox: tx
A
- mild: reassurance, BZOs
- severe agitation/psychosis: haldol/antipsychotic
- symptomatic support
- aggressive tx of T > 102
18
Q
cocaine dependence: Tx
A
- off-label: disulfiram, aripiprazole
- psychological interventions: contingency management, group tx, etc
19
Q
cocaine withdrawal: clinical
A
- crash: malaise, fatigue, hypersomnolence, depression, hunger, constricted pupils, vivid dreams; occasional suicidality
- mild-moderate use: sx resolve w/in 18 hrs
- heavy use: may last for weeks
- tx: supportive unless psychotic sx require hospitalization
20
Q
classic amphetamine: physiology
A
- block reuptake and increase release of DA and NE
- e.g. dextroamphetamine, methylphenidate, methamphetamine
- used medically in tx of: narcolepsy, ADHD, depressive dos
21
Q
substituted amphetamine: physiology
A
- release DA, NE, and 5HT
- e.g. MDMA, MDEA
- stimulant and hallucinogenic properties
- potential for serotonin syndrome
22
Q
amphetamine use: sx
A
- dilated pupils, increased libido, persipiration, resp depression, chest pain
- chronic use: acne and accelerated tooth decay
- heavy use: amphetamine psychosis, mimics SCZ
- OD: hyperthermia, dehydration, rhabdo
- w/d: prolonged depression
23
Q
ketamine
A
- tachcardia
- tachypnea
- hallucinations
- amnesia
24
Q
PCP: pathophys
A
- antagonizes NMDA glu rcptrs, activates DA
- stimulant or depressant effects depending on dose
- wet = on cigarette, joint = on marijuana
- ketamine is similar but less potent
25
PCP: intoxication
- R: rage
- E: erythema
- D: dilated pupils
- D: delusions (tactile and visual hallucinations)
- A: amnesia
- N: nystagmus (rotatory = pathognomonic)
- E: excitation
- S: skin dryness
26
PCP: OD
- sz
- coma
- death
27
PCP: tx
- monitor vitals, temp, electrolytes, minimize sensory stim
- BZOs for agitation, anxiety, muscle spasms, sz
- antipsychotics as needed
28
PCP: w/d
- no syndrome
| - "flashbacks" due to release from lipid stores
29
BZOs: physiology
- potentiate GABA
| - increase frequency of Cl-channel opening
30
barbiturates: physiology
- potentiate GABA
- increase duration of Cl-channel opening
- high dose: act as direct GABA agonists
31
sedative intoxication: clinical
- drowsiness, confusion, hypoT, slurred speech, ataxia, modd lability, nystagmus, respiratory depression
- synergistic sx with EtOH and opiates
- long term use --> dependence, depressive sx
32
sedative intoxication: tx
- ABC, vitals
- charcoal, gastric lavage (if ingested in last 4-6 hrs)
- barbiturates: alkalinize urine with NaHCO3
- BZOs: flumazenil (may precipitate sz)
33
sedative withdrawal
- abrupt abstinence after chornic use: deadly
- especially for barbiturates
- seizures!
- tx: BZO taper
- possible carbamazepine or VPA taper for sz prevention
34
opioid physiology
- stimulate opiate rcptrs (mu, kappa, delta) --> sedation, analgesia, dependence
- effects on DA system --> reward, addiction
35
opioid intoxication: clinical
- drwosiness, N/V, contispation, slurred speech, miosis, sz, resp depression
- DEMEROL (meperidine) DILATES PUPILS
- meperidine and MAOis --> serotonin syndrome
36
opioid intox: tx
- ABCs
- naloxone/naltrexone (may cause withdrawal)
- ventilatory support if needed
37
opioid withdrawal
- unpleasant, NOT lethal
- anxiety, insomnia, anorexia, fever, dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, N/V, cramps, etc etc
- tx: moderate sx --> clonidine, NSAIDs, etc
- tx: severe sx --> buprenorphine or methadone detox
38
methadone
- long acting opioid antagonist
- gold standard for pregnant women
- can cause QTc prolongation
39
buprenorphine
- partial opioid antagonist
- sublingual, plateau of effects
- suboxone: buprenorphine + naloxone: limits diversion
40
naltrexone
- competitive opioid antagonist
- precipitates withdrawal
- problem: COMPLIANCE
41
hallucinogens: physiology
- LSD: 5HT
- no physical dependence or w/d
- rare psychological dependence
42
hallucinogenic intoxigation
- perceptual changes
- labile affect, dilated pupils, tachycardia, HTN, hyperthermia, tremors, sweating, palpitations
- lasts from 6 hrs to several days
- tx: monitor and reassurance
- tx as necessary for agitated psychosis
43
marijuana: physiology
- cannabinoid rcptrs in brain inhibit adenylate cyclase
| - decreases nausea, increases appetite; decreases intraocular P, muscle spasms, tremor
44
marijuana: intoxication
- CONJUNCTIVAL INJECTION
- euphoria, anxiety, impaired coordination, anxiety, increased appetite
- may induce psychosis
- 5%: marijuana dependence
- chronic use: resp problems, immue suppression
- tx: supportive, psychosocial
45
inhalants: intoxication
- perceptual disturbances, psychosis, lethargy, dizziness, N/V, HA, nystagmus, tremor, etc etc
- acute intoxication lasts minutes, stupor may last hours
- OD may be lethal 2/2 resp depression, arrhythmias
- long-term use: permanent CNS or PNS damage, or to liver/kidney/heart/muscle
46
caffeine: physiology
- adenosine antagonist
| - increased cAMP and DA stimulation
47
caffeine overdose
- 250mg (2-3 cups): anxiety, insomnia, mm twitching, rambling speech, diuresis, GI disturbance
- > 1g: tinnitus, severe agitation, visual light flashes, cardiac arrhythmias
- >10 g: death possible 2/2 sz or resp failure
48
caffeine withdrawal
- 50-75% of caffeine users
| - HA, fatigue, irritability, N/V, drowsiness, anxiety, mm pain, mild depression
49
nicotine: physiology
- nicotinic rcptrs in symp and parasymp NS
- also affects DA system --> addictive
- tolerance and physical dependence common
50
nicotine: tx
- varenicline: nAChR partial agonist, prevents w/d sx
- bupropion: partial agonist at nAChR and inhibits DA reuptake
- nicotine replacement therapy
- behavioral counseling
