Substance-related Disorders Flashcards
Define substance abuse.
it’s a pattern of substance use that leads to impairment or distress for at least 12 months with 1+ of the following:
- failure to fulfill obligations
- use in dangerous situations
- recurrent substance-related legal problems
- continued use despite social or interpersonal problems due to the use
Define substance dependence.
It’s substance use leading to impairment manifested by at least three of the following within a 12-month period:
- tolerance
- withdrawal
- using substance more than originally intended
- persistent desire or unsuccessful efforts to cut down on use
- significant time spent in getting, using or recovering from substance
- decreased social, occupational, of recreational activities because of substance use
- continued use despite subsequent physical or psychological problems
Is it possible to have substance dependence without having physiological dependence?
yes
What is the lifetime prevalence of substance abuse/dependence in the US?
17%
Substance abuse/dependence is more common in what gender?
males
What are the most commonly used substances?
alcohol and nicotine
Define withdrawal.
the development of a substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged
Define tolerance.
the need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amount of the substance.
What is the best way to test for alcohol?
it will stay in the system for only a few hours
breathalyzer will pick it up without those few hours, but blood/urine testing is more accurate
How long is a UDS positive for cocaine?
2-4 days
How long is a UDS positive for amphetamines?
1-3 days
How long is a UDS positive for PCP? What other lab values will often be abnormal?
3-8 days
CPK and AST are often elevated as well
How long will a short acting barbiturate be picked up on a urine or blood screen? How about a long acting?
short-acting: 24 hours
long-acting: 3 weeks
How long will a short-acting benzo be picked up on a urine or blood screen? A long-acting?
short-acting: 3 days
long-acting: 30 days
How long will a UDS be positive for opioids?
2-3 days
Which two opioids will come up negative on a general screen (and thus need a specific panel)?
methadone
oxycodone
How long can marijuana be detected in the urine in heavy users? How about for a one-time use?
heavy users: 4 weeks
one-time use: 3 days
Alcohol exacts its CNS depressant effects via action on what neurotransmitters?
activation of GABA and serotonin receptors
inhibition of glutamate and voltage-gated Ca channels
What two enzymes are involved in the metabolism of alcohol (the usual pathway)?
alcohol dehydrogenase (alcohol to acetaldehyde) aldehyde dehydrogenase (acetaldehyde to acetic acid)
Describe the clinical presentation of alcohol intoxication.
decreased fine motor control impaired judgment and coordination ataxic gait and poor balance lethargy, difficulty sleeping upright, difficulty w/ memory coma in a novice drinker respiratory depression, death possible
What is the treatment for alcohol poisoning?
monitor: airway, breathing, circulation, glucose, electrolytes, acid-based status
give thiamine and folate
GI evacuation is not indicated unless a significant amount of alcohol was ingested within the preceding 30-60 minutes, which is usually not the case.
naloxone may be necessary if co-ingested opioids
CT may be necessary to rule our subdural hematoma or other brain injury
Why do we give thiamine?
to prevent or treat wernicke’s encephalopathy
What are the signs and symptoms of alcohol withdrawal syndrome?
insomnia anxiety hand tremor irritability anorexia nausea/vomiting autonomic hyperactivity: diaphoresis, tachycardia, hypertension psychomotor agitation fever seizures hallucinations delerium
When do the earliest symptoms of alcohol withdrawal begin?
between 6-24 hours after the patient’s last drink
When would generalized tonic clonic seizures occur after the cessation of drinking?
between 6-48 hours with a peak at 13-24 hours
What proportion of patients with alcohol withdrawal seizures will develop the DTs?
1/3
What electrolyte abnormality can predispose to alcohol withdrawal seizures if not corrected?
hypomagenesemia
How do we treat alcohol withdrawal seizures?
benzodiazepines
When do the DTs usually begin?
48-72 hours after the last drink (but may occur later)
What is the mortality rate if DTs are not treated?
15-25%
What are the signs of DTs?
delirium, hallucinations (usually visual), tremor, autonomic instability and fluctuating levels of psychomotor activity
What benzos are preferred for DTs?
the long-acting: chlordiazepoxide, diazeopam, lorazepam
What assessment scale is usually used to monitor withdrawal signs and symptoms (like the MINDS protocol at the VA).
the clinical institute withdrawal assessment (CIWA) scale
What questionnaire is used to screen for alcohol abuse?
the CAGE questions
- Have you ever wanted to Cut down on your drinking
- Have you felt Annoyed by criticism of your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever needed to drink as an Eye opener?
What is considered heavy drinking for men?
over 4 drinks per day or over 14 drinks per week
What is considered heavy drinking for women?
Over 3 drinks per day or over 7 drinks per week
What lab abnormalities are strongly suggestive of excessive alcohol use?
AST:ALT ratio over 2:1 and elevated GGT
What can alcohol do to the mean corpuscular volume?
increase it
How does disulfiram (Antebuse) work?
It blocks aldehyde dehydrogenase in the liver and causes aversive reaction to alcohol
Disulfiram is contraindicated in what situations?
severe cardiac disease, pregnancy, psychosis
How does naltrexone work for alcohol abuse?
it’s an opioid receptor blocker that works by decreasing the desire/craving and “high” associated with alcohol
How does Acamprosate (campral) work?
it’s structurally similar to GABA, thought to inhibit the glutamatergic system
should be started postdetoxification for relapse prevention in patients who have stopped drinking
What is the major advantage to acamprosate in people with a history of excessive alcohol abuse?
it can be used safely in people with liver disease
How does topiramate work in alcohol abuse?
it potentiates GABA and inhibits glutamate receptors, reduces the cravings for alcohol
Wernicke’s encephalopathy is caused by a deficiency in what vitamin?
thiamine (vitamin B1)
What are the signs and symptoms of wernicke’s encephalopathy?
ataxia (broad-based), confusion, ocular abnormalities (nystagmus and gaze palsies)
If left untreated, wernicke’s encephalopathy may progress to what?
korsakoff syndrome - a chronic amnestic syndrome
korsakoff syndrome can be reversible in what percentage of patients?
20%
What are the main features of korsakoff syndrome?
impaired recent memory, anterograde amnesia, compensatory comfabulation
What are the general signs of cocaine intoxication?
euphoria, heightened self esteem, increased or decreased blood pressure, tachycardia or bradycardia, nausea, dilated pupils, weight loss, psychomotor agitation or depression, chills and sweating
respiratory depression, seizures, arrhythmias, paranoia, and hallucinations (especially tactile)
How can cocaine overdose kill you?
cardiac arrhythmia
MI
seizures
respiratory depression
Describe the range of management for cocaine intoxication?
- for mild to moderate agitation - reassurance +/- benzos
- for severe agitation or psychosis: haloperidol
- symptomatic support for HTN and arrhythmias
- temp over 102 is a medical emergency and should be treated with ice bath, cooling blankets, etc.
What is the mainstay of treatment for cocaine dependence?
psychological interventions like contingency management and group therapy
there are no FDA-approved pharmacotherapy options, but we sometimes use disulfiram and aripiprazole off-label
True of false: abrupt abstinence from cocaine is life-threatening.
false
What are the signs and symptoms of cocaine withdrawal?
depression (crash), malaise, fatigue, hypersomnolence, hunger, constricted pupils, vivid dreams, psychomotor agitation or retardation
How long are cocaine withdrawal symptoms typically present/
if use was mild to moderate - usually resolve within 18 hours
with heavy, chronic use, can last for weeks, but usually peak in several days
List some examples of amphetamines.
dextroamphetamine
methylphenidate (ritalin)
methamphetamine
MDMA
What are the symptoms of amphetamine abuse?
dilated pupils, increased libido, perspiration, respiratory depression, chest pain, a sense of closeness to others (MDMA/MDEA), hyperthermia, dehydration, rhabdomyolysis
What are some physical signs of long-term methamphetamine use?
acne and meth mouth
What are the symptoms of PCP (phencyclidine) intoxication? (mnemonic: red danes)
rage erythema of the skin dilated pupils delusions amnesia nystagmus (vertical, horizontal or rotary) excitation skin dryness
agitation, depersonalization, hallucinations, synesthesia, impaired judgement, memory impairment, assualtiveness, ataxia, dysarthria, HTN, tachycardia, muscle rigidity, high tolerance to pain
Describe PCP withdrawal.
there’s actually not a well-described withdrawal syndrome, but can have “flashbacks”, thought to be related to the release of the drug from body lipid stores
Describe the clinical presentation of sedative/hypnotic (esp benzos and barbs) intoxication.
drowsiness, confusion, hypotension, slurred speech, incoordination, ataxia, mood lability, impaired judgment, nystagmus, respiratory depression,
What is the treatment for barbiturate overdose?
alkalinize the urine with sodium bicarbonate to promote renal excretion
What is the treatment for benzodiazepine overdose? What life-threatening side effect do you need to be careful for?
flumazenil
seizures
When will activated charcol or gastric lavage be helpful here?
if the injection occurred in the prior 4-6 hours
Brabiturate withdrawal wins the prize for what?
of all the kinds of drug withdrawals, barbiturate withdrawal has the highest mortality rate
Describe opioid intoxication.
drowiness, nausea/vomiting, constipation, slurred speech, constricted pupils (!!!!) seizures and respiratory depression
Which of the opioids can lead to serotonin syndrome if taken with MOAIs?
meperidine
What is the treatment for opioid overdose?
nalozone or naltrexone
ventilatory support if necessary
What are the three main medications used to treat opioid dependence?
methadone
buprenorphine
neltrexone
How does methadone work?
it’s a long-acting opioid receptor agonist, administerd once daily
What is the main concerning side effect of methadone?
QTc prolongation, so screen with an EKG before starting
How does Buprenorphine work?
it’s a partial opioid receptor agonist, sublingual. safer than methadone as its effects reach a plateau and thus make OD unlikely
suboxone is actually buprenophine and naloxone together, which means melting it down and injecting it won’t give someone a high - less likely to be diverted
Which one can be used by pregnant women - methadone or buprenorphine?
methadone is the gold standard
Describe opioid withdrawal.
dysphoria insomnia, lacrimation, rhinorrhea, yawning, weakness , sweating, piloerection, nausea/vomiting, fever, dilated pupils, abdominal cramps, arthralgias, myalgias, hypertension, tachycardia
Describe management of opioid withdrawal.
Moderate symptoms: clonidine for autonomic signs and symptoms of withdrawal
NAIDS for pain
dicyclomine for abdominal cramps
severe symptoms: buprenorphine or methadone detox
True or false: hallucinogens do not cause physical dependence or withdrawal.
true
but psychological dependence can develop
How long do the effects of hallucinogens
typically last 6-12 hours, but may last for several days
Describe marijuana intoxication
euphoria, anxiety, impaired motor coordination, perceptual disturbances (slowed time), mild tachycardia, anxiety, conjunctival injection, dry mouth and increased appetite
Describe marijuana overdose.
Gotcha! doesn’t exist.
What percentage of marijuana users will experience dependence?
5%
Chronic use of marijuana can lead to what?
asthma and chronic bronchitis
suppression of immune system
possibly affects reproductive hormones
can have cannabis-induced psychotic disorders with paranoia, hallucinations, and/or delusions
What are the withdrawal symptoms for marijuana?
irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, sweating, insomnia, nausea, decreased appetite
How does caffeine work?
it’s an adenosine antagonist, causing increased cAMP
also stimulant effect via the dopaminergic system
Describe caffeine intoxication.
anxiety, insomnia, muscle twitching, rambling speech, flushed face, diuresis, GI disturbance, restlessness, excitement, tachycardia, arrhythmias, tinnitus, visual light flashes
What percentage of caffeine users will experience withdrawal?
50-75%
How long will caffeine withdrawal typically last?
about 1 week
What are the FDA-approved pharmacotherapies for nicotine dependence?
varenicline (chantix) - a nicotinic cholinergic receptor partial agonist that mimics the action of nicotine and prevents withdrawal
buproprion (zyban for this purpose)
Nicotine replacement therapy
