Substance related disorders Flashcards
Most common psychoactive substances
Alcohol and nicotine
Substance use disorders
1) Abuse
2) Dependence (physical, psychological)
Substance-induced disorders
1) Intoxication
2) Withdrawal
3) Dementia/amnestic disorder (Korsakoff’s SY)
4) Psychotic disorder
5) Mood disorder, anxiety disorder, sleep disorder, sexual dysfunction
Promille that can lead to respiratory failure and coma
over 3,5 promille
Differential diagnosis alcohol intoxication
- Recent use of another substance
- General medical condition (intracranial hemorrhage!)
- Idiosyncratic intoxication
Numbers of units in one go likely to indicate dependence
Men: 6 units
Women 4 units
Lab findings supporting alcohol dependence
- Elevated GGT
- Macrocytic anemia
Alcohol dependence screening
- CAGE
- AUDIT
Alcohol dependence differential diagnosis
- Use of another substance
- Primary mental disorder
- Physical complications and comorbidities must be considered
Amnestic disorder (Korsakoff’s SY)
- Often combinde dwith Wernicke’s encephalopathy
- Thiamine deficiency and transketolase defect
- Anterograde amnesia, disorientation, confabulation
- Treat: 500 mg thiamine iv or im
Alcohol-induced psychotic disorder with hallucinations vs -//- with delusions
Hallucinations
- Sudden onset, pt alert and oriented
- Anxiety, depressed mood
Delusions
- Chronic course, often combined with other diseases
- Jealousy, violent acts, frequent suicidality
Alcohol-related mood disorder
- Chicken vs egg causality dilemma
- High suicidal risk
Neurological complications of alcohol abuse
1) Wernicke’s encephalopathy
2) Central pontine myelinosis
3) Marchiafava-Bignami disease
4) Cerebellar degeneration
5) Alcoholic neuropathy
Internal medicine complications of alcohol abuse
1) Liver diseases
2) Cardiovascular diseases
3) GI diseases
4) Infections (pneumonia, meningitis, sepsis - common causes of death!)
5) Traumas (intracranial hemorrhage!)
Mild or moderate withdrawal symptoms (alcohol)
- Autonomic: tremor, hyperhydrosis, tachycardia, subfebrility, vomiting ++
- Neurological: hyperreflexia, grand mal seizures
- Mental: anxiety, agitation, insomnia, craving ++
Severe withdrawal (delirium tremens) symptoms (alcohol)
Mild/moderate symptoms \+ Mental symptoms - Confused state of mind - Attention deficit - Disorientation - Complex hallucinations - Disorganized thinking, speech, behaviour (including psychomotor agitation)
Severe withdrawal - level of integrity and vigilance
- Low integrity
- Hypo- or hypervigilance
Most common physical complications and comorbidities in withdrawal (?)
- Fluid, electrolytes (hypokalemia!)
- Hypoglycemia
- Cardiac
- Infections
- Traumas (subdural hemorrhage)
- GI hemorrhage
- Liver failure, alcohol induced enceophalopathy (DDx)
Medicine that can be administered in case of withdrawal
1) BZD (high-pot, diazepam)
2) Thiamine
3) Beta blockers
4) PPIs
5) Subst. fluid, electrolytes, glucose
6) Antipsychotics
7) Anticonvulsants
Psychoactive drugs
1) Cannabis
2) Psychostimulants (cocaine, amphetamine)
3) Opioids (heroin, medical opioids)
4) Designer drugs (MDMA, mephedrone, “crystal” (not same as amphetamine!), “music”, “biograss”)
Cannabis
Intox: tachyc, dry mouth, increased appatite, depersonalization
Withdrawal: anxiety, dysphoria, craving
Induced disorders: psychosis, anxiety, amotivational syndrome
Psychostimulants
Intox: tachy or bradyc, pupil dilation, elevated or lower BP, psychomotor agitation or retardation, resp dep ++
Withdrawal: fatigue, dreams, altered sleep, anhedonia ++
Induced disorders: psychotic, mood, anxiety, sleeping, sexual
Opioids
Intox: euphoria, sedation, apathy, psychomotor, pupil constriction, memory problem++
Withdrawal: dysphoric, vomit, lacrimation, pupil dilation, piloerection ++
Induced disorders: psychotic, mood, sleeping, physical complications (HIV, HCV, endocarditis, sepsis)
Designer drugs
Intox: substance-specific (cannabis-like, hallucinogen-like), hyperthermia, DIC ++
Withdrawal: agitation, craving, dysphoria, altered sleep
Induced disorder: psychotic disorder
Test for drugs
Urine test (usually negative for designer drugs)
Treatment intoxications
- Usually nonspecific therapeutic interventions
- Monitoring and treatment of vital signs, prevention and recognition of complications
- Provision of safety for patients
- Administration of antidotes: naltrexon (opioids), flumazenile (benzodiazepines)
- Cautiousness about possible pharmaceutical interacions when administering medication!
Treatment withdrawal
- Substance-specific symptoms
- Rarely life-threatening conditions
- Primary goal is to relieve craving and behavioral symptoms (restlessness, hostility)
- Administraton of benzodiazepines, sometime antipsychotic (e.g, tiapride)
- Substitution in certain cases (e.g. methadon instead of heroin)
Treatment induced disorders
- Psychotic disorders are the most common in psychiatric emergency
- Quick and safe behavioral control is essential
- Administration of antipsychotics primarily, but benzodiazepines are also given
- Appropriate human resources and equipment are necessary as violent cases are common
