Substance-Related Disorders and Treatment of Substance Abuse Flashcards
Substance use
Sporadic consumption of ETOH or drugs w/o adverse consequences
Abuse
Frequency of use may vary
Adverse consequences are experienced
Physical Dependency
Adaptation state with drug-class specific withdrawal syndrome
Tolerance
Have to increase intake amount in order to achieve same effect
Physiologic dependence
Subjective need for psychoactive substance for either positive effect or to avoid negative effect
Addiction
Primary, chronic, neurobiologic disease with multiple factors influencing development and manifestations
Impaired control over drug use - compulsive use or continued use despite harm
CAGE
Cut down on drinking
Annoyed by criticism of drinking
Guilty feelings about drinking
Eye-opener to steady nerves or eliminate hangover
Alcohol abuse criteria
1 or more w/in 12 month period:
- Fail to fulfill work, school, or social obligations
- Recurrent substance use in physically hazardous situations
- Recurrent legal problems related to substance abuse
- Continued use despite alcohol-related social/interpersonal problems
Alcohol dependence definition
Maladaptive pattern of use - 3 or more w/in 12 months
- Tolerance, withdrawal, larger quantity intake than intended
- Persistent desire to cut down/control use
- Time spent obtaining, using, or recovering from substance
- Sacrifice social, occupational, recreational activities
- Continued use despite physical and psychosocial problems
CRAFFT
For adolescents and college students - 2 or more indicates problem
Car while/with intoxicated driving
Relax by using substance
Alone use of substance
Forget things you did while using
Family/Friends tell you to cut down
Trouble while using
Alcohol Dehydrogenase (ADH)
Aldehyde Dehydrogenase (ALDH)
ADH catalyzes ETOH to acetaldehyde (toxic to liver)
ALDH catalyzes acetaldehyde to acetate
Wenicke-Korsakoff Syndrome
Heavy drinkers, usually >35 years old
Wernicke’s: acute gait ataxia, vestibular dysfunction, confusion, ocular abnormalities
-Treat w/ high dose thiamine
Korsakoff’s: chronic impaired recent memory and anterograde amnesia
-only 20% recover, Tx w/ PO thiamine
Withdrawal Symptoms
Mild symptoms - begin w/in 6 hours cessation, resolve in 24-48 hours
Seizures - w/in 48 hours, treat w/ benzodiazepine
Hallucinosis - w/in 12-24 hours, resolve in 24-48
Delirium Tremens
5% withdrawing patients - 5% die
Delirium, tachycardia, hypertension, agitation, fever, diaphoresis
Treat w/ phenobarbitol/propofol + Thiamine
Risk: sustained drinking, >30 yo, concurrent illness
Occurs 72 hours after last drink
Drugs to avoid with alcohol withdrawal
Ethanol
Antipsychotics
Anticonvulsants
Central acting alpha-2 agonists (Clonidine, Guanfacine, Methyldopa)
Baclofen (muscle relaxant)
Acamprosate (Campral)
Motivate not to drink - get sick
Relapse-prevention with counseling
SE: Diarrhea, low pulse, high/low BP, HA, impotence
CI: Kidney disease
Disulfiram (Antabuse)
Most effective
Inhibits ALDH - get acetaldehyde buildup when drinking
Flushing, dyspnea, N/V, HA, blurred vision, vertigo, anxiety
SE: Hepatotoxic, depression/psychosis - monitor LFTs and depression
Also increases levels phenytoin, isoniazid, anticoagulants
Methamphetamine
Displaces epi, NE, dopamine, and serotonin - inactivates reuptake
High energy, tachycardia, pupil dilation, HTN, agitation, psychosis
N/V, seizures, delirium
Protect airway, control BP and temp, sedate if agitated
Can result in cardiovascular collapse
Cocaine
MOA: Blocks presynaptic reuptake pump - dopamine, NE, serotonin
CV effects: vasoconstriction, thrombus formation, tachycardia, HTN
CNS: agitation, seizures, HA, coma, intracranial hemorrhage
Cannabis
THC crosses BBB and binds w/ endogenous cannabinoid (CB1) which activates mesolimbic dopamine system
Comorbid mood and anxiety disorders occur frequently w/ cannabis disorder
Tx: Buspirone (Buspar) for withdrawal
Hallucinogens
Affect serotonin, dopamine, glutamate to alter sensory perception, mood, and thought patterns
Can cause serotonin syndrome
LSD
Dextromethorphan - codeine analog
Mescaline - peyote
Bromo
Phencyclidine (PCP)
Phencyclidine (PCP)
Similar to ketamine
Bizarre, violent behavior, nystagmus
Catatonic stupor/coma at high doses
Sudden sniffing death
Due to CV collapse
Inhalants
CNS depression after initial bout of euphoria
CNS, GI effects
Hematologic effects w/ benzene - aplastic anemia and malignancy
Nicotine
Agonist of nicotinic subtype - dopamine receptor reward system
Reaches brain in 15 seconds, 1/2 life 2 hours
Treat with Chantix (1st line), Buproprion, patches/lozenges/gum
Varenicline (Chantix)
1st line
Partial nicotinic agonist - reduces withdrawals and blocks nicotine - no reward for smoking
BBW suicidality/depression - monitor closely
Buproprion (Zyban)
For smoking cessation
Enhances CNS noradrenergic and dopamine function
CI: Seizure disorder, pregnancy
SE: insomnia, HA, seizure, dry mouth
Naltrexone
For long-term treatment
After complete detox - prevents euphoric effects w/ drug use
Most effective in highly motivated
Under close supervision
Methadone
Opioid agonists - long term treatment
Schedule 2 drug
>180 day maintenance, <180 day detox
SE: Constipation, drowsy, decreased libido, increased sweating, edema, prolonged QT
Buprenorphine
Partial opioid agonist
Schedule 3 drug
Can be outpatient treatment from clinician
Clonidine
For low-dose opioid use in order to decrease withdrawal
SE: Orthostatic HOTN, dry mouth, constipation
Clonidine + Methadone = euphoric - abuse potential
Benzodiazepine withdrawal
Anxiolytics - highly addictive
Slow taper w/ mild/moderate
Severe: life-threatening; long-acting benzos +/- anticonvulsants
(Carbamazepine, Valproate)
Cardiovascular collapse
Catecholamine toxicity caused by excessive catecholamines release in PNS
Narrowing and spasm of blood vessels, tachycardia, hypertension, heart muscle death
Treatment: Aggressive fluid resuscitation, correct metabolic acidosis, and give vasoactive amines (histamine)
