Substance-Related Disorders Flashcards
What is alcohol use disorder?
a problematic pattern of alcohol use leading to clinically significant impairment or distress
What is alcohol intoxication?
- recent ingestion of alcohol
- clinically significant problematic behavioral or psychological changes (e.g. inappropriate sexual or aggressive behavior, mood lability, impaired judgement) that developed during, or shortly after, alcohol ingestion
- one (or more) of the following signs or symptoms developed during, or shortly after, alcohol use:
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- impairment in attention or memory
- stupor or coma
What is alcohol withdrawal?
- cessation or (or reduction in) alcohol use that has been heavy and prolonged
- two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use:
- autonomic hyperactivity (e.g. sweating or pulse rate greater than 100 bpm)
- increased hand tremor
- insomnia
- nausea or vomiting
- transient visual, tactile, or auditory hallucinations or illusions
- psychomotor agitation
- anxiety
- generalized tonic-clonic seizures
What is the treatment of alcohol-related disorders?
- thiamine, magnesium, multivitamin, dextrose (particularly if chronic alcoholism)
- benzodiazepines (if withdrawal)
What are the addiction medications?
- disulfiram (Antabuse) - inhibits acetaldehyde dehydrogenase, aversive conditioning
- 500 mg once daily for 1-2 weeks then decrease to the maintenance dose (range 12-500 mg once daily)
- not for use in persons actively drinking alcohol; avoid alcohol in other products
- Oral Naltrexone - decreases desire
- 50 mg once daily
- cannot be given to patients taking opioids
- Extended - Release Naltrexone - decreases desire
- 300 mg IM every 4 weeks; administer in the gluteal area with 1.5 inch 20-gauge needle
- cannot be given to patients taking opioids
- Acamprosate - changes brain chemistry in a way that reduces anxiety, irritability, and restlessness associated with early sobriety
- 666 mg three times daily
- dose reduction required with renal impairment
- Topiramate - reduces drinking at least as well as naltrexone and acamprosate
- begin at 25 mg daily and increases up to 150 mg BID
- gabapentin- decreases desire
- begin at 300 mg once daily and increase up to 600 mg TID
What is the treatment of DT?
DT may be fetal and thus must be treated promptly with high-dose IV benzodiazepines, preferably in an ICU
What is cannabis use disorder?
- a problematic pattern of cannabis use leading to clinically significant impairment or distress, occurring within a 12-month period
- urine drug test: can detect cannabis for 4-6 days in occasional users and up to 50 days in chronic users
- chronic use of cannabis has the following complications: laryngitis, rhinitis, low testosterone, low sperm count, COPD
What are the symptoms of cannabis intoxication?
euphoria, anxiety, disinhibition, paranoid delusions, a perception of slowed time, conjunctival injection, impaired judgment, social withdrawal, increase appetite, dry mouth, hallucinations
What are the symptoms of cannabis withdrawal?
irritability, depression, insomnia, nausea, and anorexia
-most symptoms peak at 48 hours and last for 5-7 days
What is the treatment of cannabis use disorder?
no specific treatment is required
-symptomatic treatment only
What is the mechanism of PCP?
NMDA receptor antagonist - Ketamine is a similar drug
What is the intoxication of PCP?
belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia
What is the tx of PCP?
Pharmacologic -antipsychotics (haloperidol) -benzodiazepines Further Management -low stimulus environment -restraints if needed to prevent the patient from hurting self/others
What is the withdrawal of PCP?
depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
-treatment: no specific treatment - symptomatic treatment only
What is the mechanism of LSD?
action at 5-HT receptor
What is the symptoms of LSD intoxication?
- visual hallucinations and synesthesias (e.g. seeing sound as color)
- marked anxiety or depression, delusions, pupillary dilation
- “bad trip” panic
What is the treatment of LSD?
Pharmacologic
- antipsychotics (e.g haloperidol)
- benzodiazepines
- talking down, supportive counseling
What are the symptoms of LSD withdrawal?
-largely no withdrawal because it does not affect dopamine
-flashbacks can occur years later
Treatment
-no specific treatment - symptomatic treatment only
What is inhalant-related disorders?
inhalation of certain gases found in paint, petroleum, toluene, glues, and nail polish produce the same effects of volatile anesthetic
-mechanism of action is unknown
What are the symptoms of intoxication from inhalant-related disorders?
depends on the dose of inhalant sniffed
- for mild to moderate dose: the following are noted: euphoria, slurring of speech, confused state, auditory and visual hallucinations
- physical exam: watery eyes, impaired vision, rhinorrhea, perinasal, and perioral rash, headache and nausea
- for high does: cardiopulmonary failure, liver problems, kidney problems, and bone marrow suppression
What are the symptoms of withdrawal form inhalant - related disorders?
not well characterized, no treatment
What is the treatment of inhalant-related disorders?
antipsychotics (haloperidol) if severe aggression
What is the mechanism of opioid-related disorders?
mu receptor agonist - examples: morphine, heroin, methadone
What are the symptoms of intoxication of opioid-related disorders?
- constipation - no tolerance to this side effect
- respiratory depression - life-threatening
- pupillary constriction (pinpoint pupils)
- seizures (overdose is life-threatening)
- for heroin use, look for track marks (needle injections)
What are the symptoms of withdrawal of opioid-related disorders?
- anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection (“cold turkey”)
- fever, rhinorrhea, nausea, stomach cramps, diarrhea (“flulike” symptoms)
- yawning
- unpleasant but not life-threatening
What is the treatment of intoxication of opioid-related disorders?
Naloxone/naltrexone
-opioid receptor antagonist
-opioid withdrawal is NOT fatal - it is just unpleasant
Symptomatic treatment
What is the treatment of withdrawal of opioid-related disorders?
- Clonidine: alpha 2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense
- Methadone (long-acting)
- Buprenorphine + naloxone (Suboxone): can precipitate withdrawal if given too soon (partial mu agonist)
- Zofran for nausea/vomiting
What is the treatment for addiction of opioid - related disorders?
Methadone
-typically oral
-long-acting IV opiate
-used for heroin detoxification or long-term maintenance
Suboxone (buprenorphine + naloxone)
-long acting oral administration with fewer withdrawal symptoms than methadone
-naloxone + buprenorphine (partial opioid agonist)
-naloxone is not active when taken orally, so withdrawal symptoms occur only if injected - intended to prevent overdose when Suboxone is injected
What are anxiolytics?
medications such as benzodiazepines used for the treatment of anxiety disorders
-they have additive effects with alcohol and tend to have a cumulative effect if doses are repeated indiscriminately
What is the mechanism of benzodiazepines?
through GABa channel-increased frequency of opening
What are the symptoms of intoxication of benzodiazepines?
respiratory depression, hypotension, amnesia, ataxia, stupor/somnolence, coma, death
What are the symptoms of withdrawal of benzodiazepines?
rebound anxiety, seizures (life-threatening), and tremor-most commonly found in short-acting Benzes such as alprazolam
What is the treatment of of benzodiazepine addiction?
treat life-threatening intoxication with flumaxenil which is a competitive GABA antagonist
-treat withdrawal with long-acting benzodiazepines such as clonazepam with an appropriate taper
What is the mechanism of barbiturates?
GABAa channel - increased duration of opening
What are the symptoms of intoxication of barbiturates?
respiratory/CNS depression - can be fatal
-does not have a depression “ceiling” in contrast to benzodiazepines
What are the symptoms of withdrawal from barbiturates?
anxiety, seizures, delirium, similar to alcohol, life-threatening, cardiovascular collapse
What is the treatment of intoxication from barbiturates?
symptom management, support BP, assist respiration, intubation, and bemegride
What is the treatment of withdrawal from barbiturates?
long-acting benzodiazepines with taper
What is mechanism of cocaine?
block biogenic amine (Dopamine (DA), norepinephrine (NE) and serotonin (5-hydroxytryptamine; 5-HT) reuptake
What are the symptoms of cocaine intoxication?
-mental status changes: euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
Sympathetic activation
-decrease appetite, tachycardia, pupillary dilation, hypertension, angina
-severe vasospasm
-MI - coronary vasospasm
-placental infarction - vasospasm of placental vessels
-nasal septum perforation - Kiesselbach’s plexus vasospasm
-stroke - CVA
Stereotyped behavior
-repetitive motions (e.g digging through trash)
What are the symptoms of withdrawal of cocaine intoxication?
- severe depression and suicidality
- hyperphagia, hypersomnolence, fatigue, malaise
- severe psychological craving
What is the treatment of intoxication of cocaine?
antipsychotics (haloperidol)
- benzodiazepines
- antihypertensives (labetalol - need alpha-1 blockade)
- Vitamin C - promotes excretion
- do not restrain patient - may result in rhabdomyolysis
What is the treatment of withdrawal of cocaine?
- bupropion
- bromociptine
- SSRIs fro depression
What are examples of amphetamines?
methamphetamine, dextroamphetamine (dexedrine), methylphenidate (Concentra)
What is the mechanism of amphetamines?
stimulates biogenic amine (Dopamine (DA), norepinephrine (NE), and serotonin (5-hydroxytryptamine; 5-HT) release + decreases reuptake (high dose)
What are the symptoms of amphetamines intoxication?
- mental status changes: euphoria, impaired judgement, delusions, hallucinations, prolonged wakefulness/attention
- sympathetic activation: psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
What is the treatment of amphetamines?
antipsychotics (haloperidol), benzodiazepines, vitamin C (promotes excretion), antihypertensives, propranolol (BP + tachycardia control)
What is the mechanism of MDMA (ecstasy)?
similar to amphetamines
-effects 5-HT more than dopamine, may damage serotonergic neurons
What are the symptoms of intoxication from MDMA (ecstasy)?
hyperthermia and social closeness, “club drug”, hyponatremia
What are the symptoms of withdrawal from MDMA (ecstasy)?
mood offset for several weeks
-no specific treatment: symptomatic treatment only
What is the leading preventable cause of death in the US?
cigarette smoking
What are the characteristics of tobacco-related disorders?
- cigarette smoking causes more than 480,000 deaths each year in the US, this is nearly one in five deaths
- smoking causes more death each year than the following causes combined: HIV, illegal drug use, alcohol use, motor vehicle injuries, firearm-related incidents
What are the symptoms of intoxication from cigarette smoking?
restlessness, insomnia, anxiety, arrhythmias
What are the symptoms of withdrawal from cigarette smoking?
irritability, headache, anxiety, weight gain, craving
What is the treatment of cessation?
- bupropion
- varenicline (chantix): partial nicotine receptor agonist, mediates partial reward of nicotine yet blocks reward of nicotine
- the high-test success rate of all anti-smoking drugs, particularly when stacked with nicotine patches
- nicotine administration via other routes
