Substance Related disorders + Impulse Control Disorders + Eating Disorders Flashcards
Amphetamine toxicity vs anticholinergic poisoning
Anticholinergic poisoning has dry skin and mucous membranes, motor sx (myoclonic jerks, tremors), ileus, and urinary retention - these are not in amphetamine poisoning
Preggers w/ current or prev dx of anorexia nervosa are at risk for complications…
Miscarriage Intrauterine growth retardation Hyperemesis gravidarum Premature birth C-section Postpartum depression
Alcohol Withdrawal progression
6 hrs = mild WD
- anxiety, tremulous, sweating, palps
12-48 hrs = WD seizures
- seizure!
12-24 hrs = EtOH hallucinosis
- AH, VH w/ nl VS and intact sensorium
48-96 hrs = Delirium tremens
- 5% mortality rate
- fever
- Hypo TN
- tachy
- diaphoresis
- hallucinations
- disorientation
Substance abuse criteria
drug use in spite of adverse consequences related to the substance
WILD for at least 12 mo
Work, school, or home role obligation failure
Interpersonal or social consequences
Legal problems
Dangerous use
Substance dependence criteria
physical or psychological need to continue taking a drug
for at least 12 mo:
Tolerance
WD
Using substance more than orig intended
Persistent desire or unsuccessful to cut down
Try to get all the time
continued use despite health problems from substance
Can you have substance dependence w/o physio dependence?
YES!
EtOH substance testing
Blood EtOH level
EtOH only in system fora few hrs
Cocaine substance testing
UDS + 2-4 days
Amphetamines substance testing
UDS + 1-3 days
PCP substance testing
UDS + 3-8 days
CPK and AST usually elevated
Barbituates substance testing
IN blood and urine
Pentobarbital = short acting = 24 hrs
Phenobarbital = long acting = 3 wks
Benzos substance testing
Blood and urine
Lorazepam = short acting = 3 days
Diazepam = long acting = 30 days
Opioids substance testing
UDS + 2-3 days
Methadone and oxycodone come up negative on general screen
Marijuana
UDS
Heavy users - 4 weeks
Single use - 3 days
EtOH bio effects
Activates:
- GABA R
- serotonin R
Inhibitis:
- glutamine R
- voltage gated calcium channels
EtOH is a depressant!!!
Tx EtOH intoxication
Monitor ABCs, glucose, electrolytes, acid base
+ thiamine
+ folate
Naloxone for co-ingested oioids
CT to r/o subdural or TBI if fell
Only do gastric lavage if a significant amount of EtOH ingested in preceding 30-60 min
EtOH Withdrawal progression
6 hrs = mild WD
- anxiety, tremulous, sweating, palps
12-48 hrs = WD seizures
- seizure!
12-24 hrs = EtOH hallucinosis
- AH, VH w/ nl VS and intact sensorium
48-96 hrs = Delirium tremens
- 5% mortality rate
- fever
- Hypo TN
- tachy
- diaphoresis
- hallucinations
- disorientation
How many ppl w/ EtOH WD get DTs? What is mortality rate?
5% get DTs
Mortality rate = 15-25%
Sx DTs
delirium Hallucinations Gross tremor Autonomic instability Fluctuating levels of psychomotor activity
Tx EtOH Withdrawal
Benzos, taper
Antipsychotics prn agitation
Thiamine, folic acid, MV
Correct electrolytes
Monitor WD w/ CIWA scale
At risk heavy drinking for men and women
Men:
>4 drinks / day
>14 drinks / week
Women:
> 3 drinks / day
> 7 drinks / week
Lab values in EtOH abuse
AST: ALT > 2:1
Inc GGT
Macrocytosis
Meds for EtOH dependence
Disulfiram
- —| aldehyde dehydrogenase
- not ok for severe heart dz, preggers, psychosis
Naltrexone
- opioid blocker
- dec desire/craving and high assoc w/ EtOH
Acamprosate
- inhibits GABA system
- start post detox for relapse prevention
- can use in liver dz
- DO NOT USE in renal dz
Topiramate
- anticonvulsant potentiating GABA and —| glutamate R
- reduces cravings for EtOH
Wernicke’s encephalopathy
Caused by thiamine deficiency
Acute and reversed w/ thiamine
Ataxia
Confusion
Ocular abnormalities (nystagmus, gaze palsies)
Korsakoff syndrome
Confabulations
- Pts unaware that they are making these up
Anterograde amnesia
Reversible in 20%
Dopamine bio effects
—| dopamine reuptake
STIMULANT!
Cocaine intoxication
Euphoria Tachy or brady Mydriasis Wt loss Agitation Cihlls Sweating
Death 2/2 Cardiac arrhythmia MI Seizure Respiratory depression
Tx cocaine intoxication
Benzos
Severe agitation or psychosis –> haloperidol
Symptomatic support (HTN, arrhythmias)
> 102 F = med emergency –> ice bath, cooling blanket
Tx cocaine dependence
Off label drugs
- disulfiram
- aripiprazole
Narcotics anonymous
Cocaine withdrawal sx
Malaise Fatigue constricted pupils depression hunger
Amphetamines bio effect
Block reuptake adn facilitate release of dopamine and norepi
STIMULANT
MDMA bio effect
THis is ecstasy
Type of amphetamine
Release dopamine, norepi, and serotonin from nerve endings
Stimulant and hallucinogenic properties
Amphetamine intoxication
Dilated pupils Increased libido Diaphoresis Resp depression Chest pain
OD:
Hyperthermia
Dehydration
Rhabdo –> renal failure
Chronic meth use
Acne
Accelerated tooth decay
Tx amphetamine intoxication
Rehydrate
Correct electolytes
Tx hyperthermia
PCP bio effects
AKA angel dust
antagonizes NMDA glutamate receptor
Activates dopaminergic neurons
STIMULATE OR DEPRESS CNS depending on dose
PCP intoxication
RED DANES
Rage Erythema of skin Dilated pupils Delusions Amnesia Nystagmus (horizontal, vertical, or rotary = pathognomonic) Excitation Skin dryness
Tx PCP intoxication
Monitor vitals, electolytes
Benzos for agitation
Antipsyhotics for severe agitation
PCP can be stored in fat so watch out for “flashbacks” = recurrence of PCP intoxication sx
Which drug withdrawal has highest mortality rate?
Barbituates
Sedatives-hypnotics
- ex
Benzos Barbituates Zolpidem Zaleplon GHB meprobamate
Sedatives-hypnotics intoxication
Drowsiness Confusion HYPO TN slurred speech ataxia respiratory depression
Sx synergistic when combo w/ EtOH
Tx sedatives-hypnotics intoxication
Maintain ABCs
Activated charcoal + gastric lavage to prevent more GI absorb (if last dose 4-6 hrs ago)
BARBS only –> + Na bicarb to urine to get more renal excretion
BENZOS only –> + flumazenil in OD
Tx sedatives-hypnotics withdrawal
Benzo taper
Carbamazepine or valproate taper for seizure ppx
Which opioid + MAOI can cause serotonin syndrome
Meperidine
What’s abused more - heroin or opioid medications?
Opioid medications
Opioid intoxication
N/V Sedation Dec pain perception Dec GI motility Miosis Respiratory depression
Meperidine is exception to miosis –> will dilate
Demerol Dilates pupils
Tx opioid intoxication
ABCs
OD –> + naloxone or naltrexone can help with resp depression but may cause severe WD
Opioid OD signs
Respiratory depression
AMS
Miosis
What do you come up + for on UDS after eat poppy seed bagels?
Opioids
Tx opioid dependence
Methadone
Buprenorphine
Naltrexone
Opioid withdrawal sx
Flu like sx - not life threatening
can start within 8 to 12 hours after the last dose and generally reach peak severity 48 hours after the last dose
Anxiety Insomnia Anorexia Fever Rhinorrhea PIloerection
Myalgias
Tachy
HTN
Tx opioid withdrawal
Clonidine for autonomic issues
NSAIDs for pain
Dicyclomine for ab cramps
If severe:
- detox w/ buprenorphine or methadone
Hallucinogen intoxication
LSD, psilocybin (shrroms), mescaline (peyote)
Believed to act on serotonergic sx
Perceptual changes Labile affect DILATED pupils Tachy, HTN Hyperthermia
Can have bad trip:
anxiety
panic
psychosis
Tx hallucinogen intoxication
Monitor dangerous behavior
Benzos or antipsychotics prn
Hallucinogen withdrawal
No WD syndrome
With long term use, pts can experience “flashbacks” later in life
Marijuana bio effects
Active component = THC
Cannabanoid R in brain —| adenylate cyclase
Can tx:
- Nausea in chemo
- inc appetite in AIDS pts
- dec intraocular pressure
Dronabinol is pill form of THC
Marijuana intoxication
Euphoria Anxiety Dry mouth Conjunctival injection Increased appetite
Tx marijuana intoxication
Supportive
Psychosocial interventions
Marijuana WD + Tx
Irritability Anxiety Restlessness dec appetite HA Diaphoresis
Tx: supportive + symptomatic
Inhalants bio effects
CNS depressants
Inhalants
- intoxication
- OD
- Tx
INtoxication
- paranoia
- perceptual disturbances
- hyporeflexes
- ataxia
- acute intoxication lasts minutes. Stupor may last hours
OD
- respiratory depression
- cardiac arrhythmias
Tx
- ABCs
- figure out solvent as some may need chelation
WD sx rare
Caffeine bio effects
Adenosine antagonist –> increases cAMP
Stimulant effect via dopamine system
How long for caffeine WD sx to resolve?
1 week
Nicotine bio effets
Stimulate Nicotine R in autonomic ganglia
Highly addictive through effects in dopaminergic system
Smoking –> tolerance and physical dependence
Cigarette smoking while preggers
Assoc w/ low birth weight and persistent pulm HTN of newborn
Tx nicotine dependence
Varenicline –> nicotinic cholinergic receptor (nAChR) partial agonist; mimics action of nicrotine and prevents WD sx
Bupropion –> partial agonist at nAChR and inhibits dopamine reuptake
Nicotine replacement therapy (patch, gum)
Core qualities of impulse control disorders
Repetitive or compulsive engagement in behavior despite adverse consequences
Little control over negative behavior
Anxiety or craving prior to doing impulsive behavior
Relief or satisfaction during or after completion of behavior
Associated lab findings in impulsive individuals
Low 5-HIAA concentration in CSF
Nonspecific EEG findings or abnormalities on neuropsych testing
Intermittent explosive disorder
Recurrent outbursts of aggression –> assault against ppl or property
Outburst out of proportion to triggering event
Episode stops quickly and spontaneously; pt feels remorse
Men > women
Tx intermittent explosive disorder
SSRI
Anticonvulsants
Lithium
Propanolol
Individual psychotherapy usually not helpful
Group therapy may be helpful to create plans to help manage episodes
Kleptomania
- can’t resist urges to steal things that are not needed for personal use or monetary reasons
- shame and guilt after stealing
Women > men
Sx often in times of stress
1/4 pts w/ bulimia have comorbid kleptomania
Tx: insight oriented psychotherapy, behavior therapy, SSRI
- naltrexone?
Kleptomania DDx
Shoplifting = theft for personal gain
Antisocial
Bipolar, manic episodes
Psychotic DO
Pathological gambling
Men > women
inc incidence of mood DO, anxiety DO, OCD
1/3 get recovery without treatment
Tx:
- Gamblers Anonymous most effective
- insight oriented psychotherapy after 3 months of NO GAMBLING
- tx comorbid mood disorders, anxiety DO, and substance abuse problems
Trichotillomania
Uncontrollable urge to pull hair –> relief after pulling
Women > men
Tx:
- SSRIs
- antipsychotics
- lithium
- behavioral interventions
Pyromania
Deliberate firesetting on more than 1 occasion
Feeling of tension or emotional arousal before setting fires
Fascination w/ fire or curiosity about situations concerning fire
Feeling of relief or pleasure from setting fires and witness their aftermath
No motive for setting fires, including financial, revenge, political, or impaired judgement from other factors (eg substance)
Not a part of conduct disorder, antisocial personality disorder, or manic episode
Tx:
behavior therapy
supervision
SSRIs
Anorexia clinical features
- Body wt < 85% of expected or BMI =< 17 kg/m2
- Anxiety about gaining wt
- Distorted views of body wt and shape
High serum BUN
Osteoporosis
Elevated cholesterol and carotene levels
Cardiac arrhythmias (prolonged QT)
Cardiomyopathy
Mitral valve prolapse
Euthyroid sick syndrome (hypothyroid)
H-P axis dysfunction –> anovulation, amenorrhea, estrogen deficiency
increased cortisol
Hypo Na 2/2 excess water drinking most common
Tx anorexia nervosa
Outpatient unless:
- > 20% below ideal body wt
- Hospitalization if dehydration, electrolyte disturbances, or bradycardia
Cognitive behavioral therapy
Family therapy
Nutritional rehab
Pharm:
- SSRIs
- Olanzapine - if no response to above
- Benzos before meals to relive anxiety
What do you worry about in hospitalized anorexics?
Onset of anabolism, can get refeeding syndrome
- electrolyte depletion (decreased Mg, P, Ca)
- arrhythmias
- heart failure
Monitor closely! Replace electolytes, slow feedings
Bulimia
Recurrent episodes of binge eating
Binge eating followed by compensatory behavior to prevent wt gain (at least 2x/wk for 3 mo)
Excess worrying about body shape + wt
Maintains normal body wt
Hypochloremic hypokalemic alkalosis metabolic acidosis (laxative abuse) elevated bicarb Hyper Na Elevated BUN, amylase
Esophagities
Tx bulimia
Cognitive behavioral therapy (#1)
Nutritional rehab
SSRI antidepressants 1st line med
- fluoxetine
Avoid buproprion b/c lower seizure threshold
Russel’s sign
Scars or calluses on hand from contact with teeth in people who have chronic purging
Difference between bulimia vs. anorexia w/ binging/purging
Anorexia is severely underweight
Bulimia has normal weight; bulimia also more ego-dystonic - sx are distressing and more likely to seek help
Binge eating disorder
Binge eating at least 2 d/wk for 6 months
NO compensatory behaviors
Tx: individual psychotherapy + CBT + strict diet and exercise
- stimulants to suppress appetite
- Orlistat (—| pancreatic lipase –> dec amt of fat absorbed from GI)
- Sibutramine ( –| reuptake of norepi, serotonin, dopamine)
