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Psychiatry - First Aid > Substance-related Disorders > Flashcards

Substance-related Disorders Flashcards

1
Q

Define substance abuse.

A

it’s a pattern of substance use that leads to impairment or distress for at least 12 months with 1+ of the following:

  1. failure to fulfill obligations
  2. use in dangerous situations
  3. recurrent substance-related legal problems
  4. continued use despite social or interpersonal problems due to the use
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2
Q

Define substance dependence.

A

It’s substance use leading to impairment manifested by at least three of the following within a 12-month period:

  1. tolerance
  2. withdrawal
  3. using substance more than originally intended
  4. persistent desire or unsuccessful efforts to cut down on use
  5. significant time spent in getting, using or recovering from substance
  6. decreased social, occupational, of recreational activities because of substance use
  7. continued use despite subsequent physical or psychological problems
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3
Q

Is it possible to have substance dependence without having physiological dependence?

A

yes

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4
Q

What is the lifetime prevalence of substance abuse/dependence in the US?

A

17%

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5
Q

Substance abuse/dependence is more common in what gender?

A

males

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6
Q

What are the most commonly used substances?

A

alcohol and nicotine

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7
Q

Define withdrawal.

A

the development of a substance-specific syndrome due to the cessation of substance use that has been heavy and prolonged

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8
Q

Define tolerance.

A

the need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amount of the substance.

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9
Q

What is the best way to test for alcohol?

A

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

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10
Q

How long is a UDS positive for cocaine?

A

2-4 days

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11
Q

How long is a UDS positive for amphetamines?

A

1-3 days

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12
Q

How long is a UDS positive for PCP? What other lab values will often be abnormal?

A

3-8 days

CPK and AST are often elevated as well

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13
Q

How long will a short acting barbiturate be picked up on a urine or blood screen? How about a long acting?

A

short-acting: 24 hours

long-acting: 3 weeks

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14
Q

How long will a short-acting benzo be picked up on a urine or blood screen? A long-acting?

A

short-acting: 3 days

long-acting: 30 days

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15
Q

How long will a UDS be positive for opioids?

A

2-3 days

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16
Q

Which two opioids will come up negative on a general screen (and thus need a specific panel)?

A

methadone

oxycodone

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17
Q

How long can marijuana be detected in the urine in heavy users? How about for a one-time use?

A

heavy users: 4 weeks

one-time use: 3 days

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18
Q

Alcohol exacts its CNS depressant effects via action on what neurotransmitters?

A

activation of GABA and serotonin receptors

inhibition of glutamate and voltage-gated Ca channels

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19
Q

What two enzymes are involved in the metabolism of alcohol (the usual pathway)?

A 
alcohol dehydrogenase (alcohol to acetaldehyde)
aldehyde dehydrogenase (acetaldehyde to acetic acid)
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20
Q

Describe the clinical presentation of alcohol intoxication.

A 
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
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21
Q

What is the treatment for alcohol poisoning?

A

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

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22
Q

Why do we give thiamine?

A

to prevent or treat wernicke’s encephalopathy

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23
Q

What are the signs and symptoms of alcohol withdrawal syndrome?

A 
insomnia
anxiety
hand tremor
irritability
anorexia
nausea/vomiting
autonomic hyperactivity: diaphoresis, tachycardia, hypertension
psychomotor agitation
fever
seizures
hallucinations
delerium
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24
Q

When do the earliest symptoms of alcohol withdrawal begin?

A

between 6-24 hours after the patient’s last drink

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25
Q

When would generalized tonic clonic seizures occur after the cessation of drinking?

A

between 6-48 hours with a peak at 13-24 hours

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26
Q

What proportion of patients with alcohol withdrawal seizures will develop the DTs?

A

1/3

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27
Q

What electrolyte abnormality can predispose to alcohol withdrawal seizures if not corrected?

A

hypomagenesemia

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28
Q

How do we treat alcohol withdrawal seizures?

A

benzodiazepines

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29
Q

When do the DTs usually begin?

A

48-72 hours after the last drink (but may occur later)

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30
Q

What is the mortality rate if DTs are not treated?

A

15-25%

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31
Q

What are the signs of DTs?

A

delirium, hallucinations (usually visual), tremor, autonomic instability and fluctuating levels of psychomotor activity

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32
Q

What benzos are preferred for DTs?

A

the long-acting: chlordiazepoxide, diazeopam, lorazepam

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33
Q

What assessment scale is usually used to monitor withdrawal signs and symptoms (like the MINDS protocol at the VA).

A

the clinical institute withdrawal assessment (CIWA) scale

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34
Q

What questionnaire is used to screen for alcohol abuse?

A

the CAGE questions

  1. Have you ever wanted to Cut down on your drinking
  2. Have you felt Annoyed by criticism of your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever needed to drink as an Eye opener?
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35
Q

What is considered heavy drinking for men?

A

over 4 drinks per day or over 14 drinks per week

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36
Q

What is considered heavy drinking for women?

A

Over 3 drinks per day or over 7 drinks per week

37
Q

What lab abnormalities are strongly suggestive of excessive alcohol use?

A

AST:ALT ratio over 2:1 and elevated GGT

38
Q

What can alcohol do to the mean corpuscular volume?

A

increase it

39
Q

How does disulfiram (Antebuse) work?

A

It blocks aldehyde dehydrogenase in the liver and causes aversive reaction to alcohol

40
Q

Disulfiram is contraindicated in what situations?

A

severe cardiac disease, pregnancy, psychosis

41
Q

How does naltrexone work for alcohol abuse?

A

it’s an opioid receptor blocker that works by decreasing the desire/craving and “high” associated with alcohol

42
Q

How does Acamprosate (campral) work?

A

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

43
Q

What is the major advantage to acamprosate in people with a history of excessive alcohol abuse?

A

it can be used safely in people with liver disease

44
Q

How does topiramate work in alcohol abuse?

A

it potentiates GABA and inhibits glutamate receptors, reduces the cravings for alcohol

45
Q

Wernicke’s encephalopathy is caused by a deficiency in what vitamin?

A

thiamine (vitamin B1)

46
Q

What are the signs and symptoms of wernicke’s encephalopathy?

A

ataxia (broad-based), confusion, ocular abnormalities (nystagmus and gaze palsies)

47
Q

If left untreated, wernicke’s encephalopathy may progress to what?

A

korsakoff syndrome - a chronic amnestic syndrome

48
Q

korsakoff syndrome can be reversible in what percentage of patients?

A

20%

49
Q

What are the main features of korsakoff syndrome?

A

impaired recent memory, anterograde amnesia, compensatory comfabulation

50
Q

What are the general signs of cocaine intoxication?

A

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)

51
Q

How can cocaine overdose kill you?

A

cardiac arrhythmia
MI
seizures
respiratory depression

52
Q

Describe the range of management for cocaine intoxication?

A
  1. for mild to moderate agitation - reassurance +/- benzos
  2. for severe agitation or psychosis: haloperidol
  3. symptomatic support for HTN and arrhythmias
  4. temp over 102 is a medical emergency and should be treated with ice bath, cooling blankets, etc.
53
Q

What is the mainstay of treatment for cocaine dependence?

A

psychological interventions like contingency management and group therapy

there are no FDA-approved pharmacotherapy options, but we sometimes use disulfiram and aripiprazole off-label

54
Q

True of false: abrupt abstinence from cocaine is life-threatening.

A

false

55
Q

What are the signs and symptoms of cocaine withdrawal?

A

depression (crash), malaise, fatigue, hypersomnolence, hunger, constricted pupils, vivid dreams, psychomotor agitation or retardation

56
Q

How long are cocaine withdrawal symptoms typically present/

A

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

57
Q

List some examples of amphetamines.

A

dextroamphetamine
methylphenidate (ritalin)
methamphetamine
MDMA

58
Q

What are the symptoms of amphetamine abuse?

A

dilated pupils, increased libido, perspiration, respiratory depression, chest pain, a sense of closeness to others (MDMA/MDEA), hyperthermia, dehydration, rhabdomyolysis

59
Q

What are some physical signs of long-term methamphetamine use?

A

acne and meth mouth

60
Q

What are the symptoms of PCP (phencyclidine) intoxication? (mnemonic: red danes)

A 
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

61
Q

Describe PCP withdrawal.

A

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

62
Q

Describe the clinical presentation of sedative/hypnotic (esp benzos and barbs) intoxication.

A

drowsiness, confusion, hypotension, slurred speech, incoordination, ataxia, mood lability, impaired judgment, nystagmus, respiratory depression,

63
Q

What is the treatment for barbiturate overdose?

A

alkalinize the urine with sodium bicarbonate to promote renal excretion

64
Q

What is the treatment for benzodiazepine overdose? What life-threatening side effect do you need to be careful for?

A

flumazenil

seizures

65
Q

When will activated charcol or gastric lavage be helpful here?

A

if the injection occurred in the prior 4-6 hours

66
Q

Brabiturate withdrawal wins the prize for what?

A

of all the kinds of drug withdrawals, barbiturate withdrawal has the highest mortality rate

67
Q

Describe opioid intoxication.

A

drowiness, nausea/vomiting, constipation, slurred speech, constricted pupils (!!!!) seizures and respiratory depression

68
Q

Which of the opioids can lead to serotonin syndrome if taken with MOAIs?

A

meperidine

69
Q

What is the treatment for opioid overdose?

A

nalozone or naltrexone

ventilatory support if necessary

70
Q

What are the three main medications used to treat opioid dependence?

A

methadone
buprenorphine
neltrexone

71
Q

How does methadone work?

A

it’s a long-acting opioid receptor agonist, administerd once daily

72
Q

What is the main concerning side effect of methadone?

A

QTc prolongation, so screen with an EKG before starting

73
Q

How does Buprenorphine work?

A

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

74
Q

Which one can be used by pregnant women - methadone or buprenorphine?

A

methadone is the gold standard

75
Q

Describe opioid withdrawal.

A

dysphoria insomnia, lacrimation, rhinorrhea, yawning, weakness , sweating, piloerection, nausea/vomiting, fever, dilated pupils, abdominal cramps, arthralgias, myalgias, hypertension, tachycardia

76
Q

Describe management of opioid withdrawal.

A

Moderate symptoms: clonidine for autonomic signs and symptoms of withdrawal
NAIDS for pain
dicyclomine for abdominal cramps

severe symptoms: buprenorphine or methadone detox

77
Q

True or false: hallucinogens do not cause physical dependence or withdrawal.

A

true

but psychological dependence can develop

78
Q

How long do the effects of hallucinogens

A

typically last 6-12 hours, but may last for several days

79
Q

Describe marijuana intoxication

A

euphoria, anxiety, impaired motor coordination, perceptual disturbances (slowed time), mild tachycardia, anxiety, conjunctival injection, dry mouth and increased appetite

80
Q

Describe marijuana overdose.

A

Gotcha! doesn’t exist.

81
Q

What percentage of marijuana users will experience dependence?

A

5%

82
Q

Chronic use of marijuana can lead to what?

A

asthma and chronic bronchitis
suppression of immune system
possibly affects reproductive hormones

can have cannabis-induced psychotic disorders with paranoia, hallucinations, and/or delusions

83
Q

What are the withdrawal symptoms for marijuana?

A

irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, sweating, insomnia, nausea, decreased appetite

84
Q

How does caffeine work?

A

it’s an adenosine antagonist, causing increased cAMP

also stimulant effect via the dopaminergic system

85
Q

Describe caffeine intoxication.

A

anxiety, insomnia, muscle twitching, rambling speech, flushed face, diuresis, GI disturbance, restlessness, excitement, tachycardia, arrhythmias, tinnitus, visual light flashes

86
Q

What percentage of caffeine users will experience withdrawal?

A

50-75%

87
Q

How long will caffeine withdrawal typically last?

A

about 1 week

88
Q

What are the FDA-approved pharmacotherapies for nicotine dependence?

A

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

Psychiatry - First Aid (18 decks)

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