Substance Use *** Flashcards
RF
More EtOH than recommended
>4 joints a week
Any illicit drug use
Hx of personal or family addiction
Age <40
Active mental health disorder
DSM-V criteria for SUD
CHEW THAT COP
Cut down - unsuccessful
Health/ harm - continued use despite impact on health
Excessive use
Withdrawal
Time - spending lots procuring/ using/ recovering
Hazardous use
Activities - decreased participation
Tolerance - increases
Craving
Obligations - not met
Personal problems
DSM-V criteria for addiction - 4Cs
4Cs
Loss of Control
Use despite Consequences
Compulsion to use
Craving
Sx that should prompt screening
Warning signs in teens e.g. failing school
Resistant medical conditions such as increased triglycerides or poor asthma control
Absenteeism, depression, anxiety
Accidents
Unexplained GI S+S
Sexual dysfunction
Sleep dysfunction
Tremor
Screening for AUD
- AUDIT-C
Ix for SUD
HIV, Hep A/B/C, ALT, AST, bili, TB, STIs
General management
Support for pt + family
- CBT, family therapy
Vaccines (HPV, hepatitis)
Assess for comorbidity (STI, mental health)
Tx barriers
Harm reduction
Referral - mutual help meetings, supervised withdrawal, treatment programs, supervised consumption
Symptom management
Pain
Diarrhea
Sneezing/ tearing
N+V
Tachycardia/ HTN
Anxiety/ insomnia
Pain - OTC analgesia, NSAIDs
Diarrhea - immodium, Lomotil
Sneezing/ tearing - H1 antihistamine
N+V - ondansetron, promethazine
Tachycardia/ HTN - clonidine
Anxiety/ insomnia - benzo
Motivational interviewing fundamentals
PEARL
- pt’s motivation
- empower
- affirm
- reflect
- listen
Screen for comorbidities
Poverty
Crime
STIs
MH
Long term complications like cirrhosis
DV
ADHD
HIV/ hepatitis
Sympathomimetic causes + sx of intoxication
Causes: epinephrine, cocaine, amphetamines
Tachycardia, hypertensive, dyspnea, febrile, dilated pupils, increased BS, diaphoretic, N/V, hallucinations, increased reflexes
Anticholinergic causes + sx of intoxication
Causes: APs, TCAs, oxybutynin, ipratropium
Tachycardia, hypertensive, febrile, dilated pupils, reduced BS, dry
Cholinergic causes + sx of intoxication
Causes: ACh receptor antagonist
Pinpoint pupils, increased BS, diaphoretic
Toxins that cause sedation + sx of intoxication
Causes: benzos, antihistamines
Bradycardia, hypotension, reduced RR, afebrile, reduced BS, dry, nystagmus, ataxia
Opioid sx of intoxication
Bradycardia, hypotension, reduced RR, afebrile, reduced BS, dry, nystagmus, ataxia, pinpoint pupils
Toxins that cause Bradycardia
BB, opioids, antiarrhythmias, CCB, clonidine, digoxin
Toxins that cause Tachycardia
cocaIne, APs, amphetamines, alcohol withdrawal, TCA
Toxins that cause Hypothermia
CO, opioids, hypoglycemics, insulin, alcohol, sedatives
Toxins that cause Hyperthermia
NMS, nicotine, alcohol withdrawal, salicylates, serotonin syndrome, anticholinergics, antidepressants
Toxins that cause Hypotension
clonidine, CCB, antidepressants, antihypertensives, sedatives, opioids
Toxins that cause Hypertensive
cocaine, caffeine, anticholinergics, amphetamines, nicotine
Cannabis Problematic use
daily use, anxiety, unsuccessful attempts to quit, family concern, financial implications
Strategies to minimise use
Record on calendar
Purchase smaller amounts
Prepare smaller joints
Certain number of days without
Avoid high risk situations
Coping mechanisms
PCP sx
muscle rigidity, sz, rhabdomyolysis
Amphetamines (ecstasy) complications + withdrawal
Complications: coma, serotonin syndrome
Withdrawal: depression, increased appetite, diarrhea, HA, abdo pain
Cocaine complications + withdrawal
Complications: MI, stroke, pulmonary edema, rhabdomyolysis, sz, arrhythmias
Withdrawal: increased sleep, fatigue, irritability
Alcohol At risk
consuming more than amounts recommended but does not meet criteria for AUD
CAGE alcohol questions
Have you ever felt you should CUT down on your drinking?
Have people ANNOYED you by criticizing your drinking?
Have you ever felt bad or GUILTY about your drinking?
Have you ever had a drink first thing in the morning (EYE-OPENER) to steady your nerves or to get rid of a hangover?
AUD definition
Larger amount or longer periods than intended
Persistent desire, unable to cut down
++ time spent obtaining alcohol
Cravings
Recurrent use despite failure to fulfil obligations
Continued use despite social or interpersonal problems
Responsibilities given up d/t alcohol
Physically hazardous
Continued use despite harm
Increasing tolerance
Withdrawal sx
Recommended amounts of alcohol
<2/d
<9/wk for women and <14/wk men
Complications of AUD
CNS: wernicke’s encephalopathy (nystagmus, ataxia, confusion), Korsakoff’s psychosis, dementia
CVS: HTN, cardiomyopathy, AF
GI: cirrhosis, PUD, gastritis, pancreatitis, carcinoma
Psych: depression, anxiety
Sx of alcohol withdrawal
Irritability, Anxiety, Tremors, Sweating, Nausea, Vomiting, Headaches, Fatigue, Insomnia, Confusion, Racing heart, Hallucinations
Sx of B12 deficiency
Ataxia (sub-acute combined degeneration of the cord), Paresthesia, Cognitive impairment, Numbness, Personality changes, Gait changes, Dementia, Psychosis, Forgetfulness, Visual disturbances, Weakness/paraplegia/incontinence, Lhermitte sign, Extrapyramidal signs (dystonia, dysarthria, rigidity)
Motivational interviewing for AUD
Goal of amount/d and amount/wk, non-drinking days
Record drinks on calendar
Switch to less preferred alcoholic drink
Pace 1 drink/ hr
Alternate w/ non-alcoholic drink
Avoid triggers
Reduce stress
Support - AA or friends
Withdrawal management
PAWSS (prediction of alcohol withdrawal severity scale)
>4 = inpatient
Diazepam 5-10mg QID x 1 day, then decrease by 5mg/day
Consider carbamazipine 200mg QID, clonidine 0.1-0.2mg BID or gabapentin 300mg TID for sx relief
Pharmacotherapy for AUD
Naltrexone 12.5mg BID x3d then increase to 50mg/d (CI in liver failure or ongoing opioid use), check LFTs 1, 3 + 6mo. Use for abstinence or reduction
Acamprosate 666mg TID - use for abstinence
Topiramate or gabapentin 300mg TID
Disulfram 250mg/d - only use in pt preference
What lab results would you expect to see in alcohol abuse?
Elevated AST, Elevated ALT, AST/ALT Ratio (2:1), Elevated GGT, Elevated MCV
Hemoglobin (anemia)
Platelets (thrombocytopenia)
INR (increased; decreased clotting capability)
Albumin (hypoalbuminemia)
Thiamine (reduced)
Uric Acid (hyperuricemia)
Contraindications to outpt detox
<19 or >65 y/o
Hx of sz during withdrawal
Drinks non-beverage alcohol
Uncontrolled medical condition
Severe liver dz
Opioid use complications + withdrawal sx
Complications: pulmonary edema, resp failure, skin infections, endocarditis, HIV, hepatitis
Withdrawal: peaks 48-72hrsm subsides after 1wk
Tears, diarrhea, abdo pain, rhinorrhea
Acute opioid intoxication management
naloxone 0.4-0.8mg IV q3 min, up to 10mg
Norepinephrine dump rx
clonidine (start 17mcg/kg/d x several days then taper)
False positives for UDS:
Amphetamines
Opioids
Cocaine
Benzos
Amphetamines – ibuprofen, cough + cold, ranitidine
Opioids – codeine
Cocaine – usually true positive
Benzos – clonazepam doesn’t show up as a positive
Benzo withdrawal sx + rx for withdrawal
Withdrawal: grand mal sz, agitation, restless, insomnia, tremors, febrile
Rx for withdrawal: benzo taper
What tool to use to screen for AUD?
M-SASQ - how many times have you had >8 (men) or >6 (women) drinks in a single sitting?
SE of OAT
constipation, amenorrhea, low testosterone
