Substance-Related Disorders Flashcards
1
Q
screening for drugs of abuse
A
- CRAFFT
- C: have you ever ridden in a car driven by someone (including yourself) who was high, drunk, or had been using drugs?
- R: have you ever used drugs or alcohol to relax
- A: do you ever use alone
- F: do you ever forget things you did while using
- F: do family or friends tell you to cut down
- T: have you ever gotten into trouble when using
2
Q
Alcohol use disorder (alcohol intoxication) etiology, RF, and sxs
A
- leads to clinically significant distress or impairment
- M > F, more common in Native Americans
- MC age range: 18-29yo
- RF: + family hx in 50-70%
- Screening tests: AUDIT (alc use disorder identification test) = BEST
- CAGE
- sxs: slurred speech, incoordination, disinhibited behavior, impaired attention or memory, inapporpriate sexual or aggressive behavior, mood lability, impaired judgement
- signs: stupor or coma, HoTN, tachycardia, unsteady gait, nystagmus
- DSM 5 criteria: recurrent drinking resulting in failure to fulfill role obligations, recurrent drinking in hazardous situations, evidence of tolerance, evidence of withdrawal or use of ETOH for relief or avoidance of withdrawal, drinking in larger amnts over longer periods than intended, persistent desire or unsuccessful attempts to stop or reduce drinking, great deal of time spent obtaining, using, or recovering from ETOH, important activities given up or reduced because of drinking, continued drinking despite knowledge of physical or psychological problems, alcohol craving
3
Q
Alcohol use disorder (alcohol intoxication) dx and tx
A
- Dx: serum ethanol concentration, basic chemistry, serum glucose q8h
- inpt setting: ethyl glucuronide testing (EtG) - shows recent alc but not AMOUNT of consumption; GGT (most sensitive lab test to determine use of ETOH - shows heavy consumption), carbohydrate deficient transferrin, macrocytosis, elevated LFTs (AST:ALT >2:1), hypokalemia, hypomagnesemia, hypocalcemia, hypophosphatemia, increased serum uric acid and ttrigs, pancytopenia, hypoglycemia, lactic acidosis
- tx: supportive care and obs (dextrose infusion if hypoglycemic), benzos for agitation, thiamine or B1 (for coma to prevent Wernicke’s encephalopathy), if severe IV isotonic crystalloid
- Prophylaxis: chlordiazepoxide
- Bridge to maintenance: naltrexone
4
Q
alcohol withdrawal
A
- pts who suddenly stop or reduce alcohol intake, occurs 6-12hrs after last drink or after reduction in drinking amounts, lasts up to 2-3d
- acute course: can be life threatening; shorter course: persists for weeks
- sxs: within 6hrs - insomnia, confusion, disorientation, delusions, N/V, sweating, anxiety, anorexia, HA
- signs: sz or hallucinations (visual hallucinations and delirium tremens), tachycardia, HTN, palps, diaphoresis, tremor, agitation, death
- dx: CIWA-Ar: clinical institute withdrawal assessment for alcohol, revised; measures withdrawal severity (<8 = detox not needed; >15 = inpt referral more appropriate)
- tx: benzos, phenobarbital, propofol
- Maintenance tx: naltrexon
5
Q
Delirium tremens
A
- alcohol withdrawal, cocaine addiction; onset within 71-96hrs of last drink, lasts 1-5d
- RF: hx of sustained drinking, hx of previous DT, age >30, concurrent illness, significant ETOH withdrawal in presence of elevated ETOH level
- sxs: hallucinations, disorientation, sweating, fever, confusion, tremor, vomiting, delirium (only sx that is always present
- signs: severe tachycardia, tachypnea, HTN, hypertherm, agitation, drenching sweats, fever
- associated: seizure, cardiovasc abnlities
- dx: hypokalemia, hypomagnesemia, hypophos, hypovol, inc arterial pH (resp alk)
- tx: supportive care (IV isotonic fluids, nutritional supp, place in quiet, protective enviro), benzos, thiamine and folic acid to prevent wernicke enceph
- prophylaxis: librium (chlordiazepoxide)
- Prognosis: mortality <5%
6
Q
opioid intox and withdrawal
A
- intox:
- sxs: pruritis, euphoria, drowsiness, slurred speech
- signs: miosis, resp depression, hyporeflex, hypotherm, flushing, bradycardia, hoTN, dec bowel sounds, dep mental status
- dx: serum gluc, APAP leve, serum CK, urine tox should NOT be routinely obtained, EKG, CXR
- tx: supportive (tracheopharyngeal suctioning, supplemental O2), IV naloxone (intranasal narcan)
- death often dt resp dep
- withdrawal: dysphoria, craving, anxiety, salivation, myalgias, N/V/D, restless
- signs: rhinorrhea, yawning, lacrimation, diaphoresis, mydriasis, piloerection, tremor, inc bowel sounds
- tx: methadone, buprenorphine, naltrexone, behavior mod program required, clonidine
7
Q
stimulant intox
A
- ex: cocaine, amphetamines, methylphenidate (ritalin), dextroamphetamine
- cocaine is an indirect sympathomimetic agent → inc availability of amines at receptors → euphoric properties derived from inhib of serotonin reuptake
- local anasthetic
- cocaine assoc. psychosis differs from acute schizophrenic by less thought disorder, bizarre delusions, and fewer neg symtoms such as alogia and inattention; more visual and tactile callucinations common
- sxs: hyperarousal, sweating, alertness, self-confidence, euphoria, dec fatigue and need for sleep; with inc dose → delusions or hallucinations, wt loss, anxiety or dep, restlessness
- signs: HTN, tachycardia, mydriasis, diaphoresis, xerostomia, bruxism
- complications: accel. atherosclerosis → MI, CVA; psychomotor agitation, pneumothora/mediastinum/pericardium; SOB, perf ulcers, rhabdo, acute angle closure glaucoma, nasal septal perf
- dx: gluc, APAP, ASA leves, EKG (prolonged QRS), preg test, benzoylecgonin (urinary metab of cocaine - only in urine a few hours), troponin, CXR, CT head, CK, CMP
- tx: supportive care (O2, intub WITHOUT succinylcholine), phentolamine prior to BB (for HTN), diazepam for agitation, BB should not be used alone
8
Q
stimulant withdrawal
A
- sxs: depression, anxiety, fatigue, difficulty concentrating, anhedonia, craving, musculoskeletal pain, initial “crash” → psychomotor retardation, severe depression, SI
- signs: tremors, chills, involuntary motor mvmts, bradycardia
9
Q
BZD intox
A
- potnetiate GABAs inhib actions, inappropriate sexual or aggressive behavior, mood lability, impaired judgment
- sxs: slurred speech, ataxia, AMS, stupor or coma
- signs: unremarkable, normal VS
- dx: 1+ of the following → slurred speech, incoordination, unsteady gait, nystagmus, impaired cognition, stupor/coma
- r/o phenobarb and ETOH by checking blood
- tx: O2, flumazenil
10
Q
tobacco use disorder
A
- leading preventable COD, 2/3 smokers say they want to quit
- dependence determined by: age of smoking initiation, number cigarettes smoked daily, how soon after waking pt has first cigarette
- dependence degree predicts difficulty patient will have in quitting and intensity of tx required
- dx: 5As (ask about smoking, advise quitting, assess readiness to quit, assist with smoking cessation, arrange follow up visits)
- tx: FIRST LINE = varencicline (chantix → avoid in pts w/ current unstable psych hx or recent SI), bupropion SR (wellbutrin → CI in pts w/ siezure disorder and in pts w/ hx of anorexia or bulemia), nicotine replacement therapy
- second line = nortryptyline, clonidine, CBT (for every pt)
- most relapses occur w/in first 3 mos of quitting
- best success w/ pharm tx and psychotx
11
Q
tobacco withdrawal
A
- development of cravings w/in first 3d of smoking cessation and subside over 3-4wks
- common triggers for relapse: being around smokers, drinking ETOH, smoking cues (drinking coffee), stressful situations
- sxs: inc appetite → wt gain, mood changes, insomnia, irritability, difficulty concentrating, anxiety, restlessness
- sxs peak 1-2w after quitting
12
Q
Hallucinogens etiology, RF, sxs
A
- LSD, ecstasy, batth salts, angel dust, ketamine
- DDx: alc or BZD withdrawal, anticholinergic poisoning, thyrotoxicosis, CNS infxn, structural brain lesions, acute psychosis, hypoglycemia, hypoxia
- sxs: anxiety, N, V, abd pain, dizziness, jaw tension or teeth grinding, dry mouth
- signs: mydriasis (miosis with angel dust), tachycardia, nystagmus, muscle tension, ataxia, bruxism, agitation, diaphoresis, hypersalivation, conjunctival injection
- complications: hyperthermia, HTN, szs, psychosis, hyponat, arrhythmias, rhabdomyolysis, paranoia
13
Q
hallucinogens dx and tx
A
- dx: clinical dx, rapid serum gluc, chem, creatine phosphokinase, to rule out rhabdo, EKG (ro QT prolong)
- tx: supportive care, reassurance, correct hypoxia, hypoglycemia, electrolyte abnl, dehydration; sedation, BZD preferred (reversible with flumazenil)
14
Q
cannabis intoxication
A
- most commonly used illegal psychoactive substance worldwide
- RF: + Fhx, young adults, male 2x > F, lower education
- use disorder develops in 10%
- THC activates CB1 receptors - inc presynaptic dopamine
- sxs: inc appetite, inc time perception, dec rxn time, impaired motor coordination, euphoria, dec anxiety, inc sociability, depression, cog impairment
- signs: tachycardia, HTN, tachypnea, dilated pupils (mydriasis), yellowing fingertips, odor, dry mouth, tachycardia, conjunctival injection, nystagmus, ataxia, slurred speech
- complications: MI
- dx: urinalysis for THC - 4-6d
- tx: naloxone for opioid intox features, BZD for szs
- children: admit if sxs ≥ 48h, persistent vom, AMS
- adolescents and adults: dimly lit room, reassurance, dec stim, lorazepam for anxiety
- prognosis: diminished life satisfaction, associated with reduced IQ, may be associated with schizophrenia, small inc risk MI and CVA, periodontal dz, hyperemesis syndrome, lower sperm cnt
15
Q
cannabis withdrawal
A
- 50-95% of heavy users, chronic use down regulates CB1 receptors
- sxs: insomnia, irritability, anger, aggression, nervousness, anxiety, dec app, wt loss, restlessness, depressed mood, abd pain, N, F/C/NS
- signs: shakiness/tremors, diaphoresis
- tx: psychotx = 1st line, CBT
