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Psychiatry > Substance Use > Flashcards

Substance Use Flashcards

1
Q

Substance use disorder VS physiological dependence

A

physiologic dependence = presence of …

  1. tolerance: need for increasing amounts of substance to achieve desired effect OR diminished effect from using same amt of substance
  2. withdrawal: substance-specific syndrome due to cessation/reduction in substance use that has been heavy and prolonged
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2
Q

How long do substances stay in blood/urine?

A

Alcohol: few hours
Cocaine: 2-4 days
Amphetamines: 1-3 days
PCP: 4-7 days
Barbiturates: short acting (24 hrs) vs long acting (3 wks)
BZ’s: short acting (5 days) vs long acting (up to 30 days)
Opioids: 1-3 days (methadone, oxycodone will come up neg)
Marijuana: 3 days (heavy users: 4 wks); passive inhalation rarely gives + urine test

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3
Q

ALCOHOL - general information (4)

A

activates: GABA (inhibitory), dopamine, serotonin
inhibits: glutamate-R (excitatory) and vg Ca channels

  • *[alcohol –> acetaldehyde –> acetic acid]
  • *most show signs of intoxication with BAL>100 and def with BAL>150
  • *potent CNS depressant
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4
Q

Alcohol intoxication

A

sx: decreased fine motor control –> impaired judgment, coordination –> ataxic gait and poor balance –> lethargy, diff sitting upright, diff with memory, n/v –> come in novice drinker –> resp depression, death possible

mgmt:

  1. monitor ABC, glucose, lytes, acid-base status
    * ethanol, methanol, ethylene glycol can cause m acidosis with AG
  2. thiamine (Wernicke’s), folate
  3. CT Head to r/o bleed
  4. GI evacuation only if significant amount of alc ingested in the last 30-60 minutes
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5
Q

Alcohol withdrawal

sx
tx
things to note

A

sx: autonomic hyperactivity, psychomotor agitation
12-48 hr: seizures (peak 12-24 hrs)
48-96 hr: DT’s (delirium, visual hallucin, agitation, gross tremor, autonomic instability)

tx: BZ’s with taper
thiamine, MV, folate
CIWA

Always think about: Wernicke encephalopathy, Korsakoff’s psychosis, cirrhosis (lorazepam&raquo_space; chlordiazepoxide)

Wernicke (reversible, CAN) –> Korsakoff (confabulation, anterograde amnesia, impaired recent memory)

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6
Q

Medications for alcohol use disorder

A

First line

  1. Naltrexone (opioid R antag) - decrease craving & high, increase days of abstinence
    * can be started if pt is still drinking
    * be careful in ppl with physiologic opioid dependence
    * CI with acute hepatitis, liver failure
  2. Acamprosate (glutamate) (NMDA R antag, GABA-A positive allosteric modulator)
    * start post detox for relapse prevention
    * can be used even if have liver ds
    * contraindic in severe renal ds

Second line

  1. Disulfiram (inhibits aldehyde dehydrogenase)
    * contraindic in severe heart ds, pregnancy, psychosis
  2. Topiramate (more GABA, inhibits glutamate R) - reduces craving, decreases use
  3. Gabapentin!
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7
Q

COCAINE - general info (2)

A

blocks: reuptake of dopa, epi, NE

Indirect sympathomimetic - STIMULANT

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8
Q

Cocaine intoxication

A

sx: MYDRIASIS, CHEST PAIN, SEIZURES
euphoria, heightened self esteem, labile BP and HR

deadly: cardiac arryhthmia, MI, resp depression, seizure

mgmt:

  1. mild-mod agitation: BZ’s
  2. severe agitation/psychosis: atypicals (haldol)
  3. sx support: cooling if high temp, control HTN, etc.
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9
Q

Treatment for cocaine use disorder

A

Offlabel meds (eh): disulfiram, modafinil, topiramate

BUT MAIN THING:
Psych interventions: contingency mgmt, relapse prevention, NA

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10
Q

Cocaine withdrawal

A

NOT life threatening;
“post-intoxication crash” - hypersomnolence, hyperphagia, miosis, vivid dreams, depression

RECOVERY times:
mild-mod use: 72 hrs
heavy: 1-2 wks

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11
Q

Amphetamines

A

block reuptake & facilitate release of dopa, NE
STIMULANT
medical use: ADHD, narcolepsy

sx: psych sx (agitation, psychosis), mydriasis

“designer” or “club drug” amphetamines: also release serotonin
(ie - MDMA)
STIMULANT + HALLUCINOGENIC
side effect: serotonin syndrome (if combined w SSRIs)

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12
Q

Amphetamine intoxication & withdrawal

A

sx: similar to those of cocaine (cp, mydriasis)
“meth mouth” (tooth decay) + “skin pickers” + skinny
MDMA: sense of closeness to others

overdose: hyperthermia, dehydration (esp after lot of dancing in a club), rhabdo, renal failure

mgmt: rehydrate, correct lytes, ts hyperthermia
_____
Withdrawal: can cause prolonged depression

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13
Q

PCP - general information (3)

A

NMDA antag + activates dopa neurons
DISSOCIATIVE, HALLUCINOGENIC

stimulant OR depressant effects, depending on dose

Ketamine is similar, but less potent

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14
Q

PCP intoxication

A

RED DANES + muscle rigidity
[rage, erythema, dilated pupils, delusions, amnesia, ROTARY NYSTAGMUS, excitation, skin dryness]
delusions of enhanced strength, psychosis, aggression

mgmt:
1. sx mgmt
2. BZ’s! (lorazepam) for agitation/muscle spasms/seizures
3. Haldol for severe agitation/psychosis
_____
Withdrawal: none … flashbacks ??

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15
Q

SEDATIVES-HYPNOTICS - general info (3)

A

BZ’s, barb’s, Z’s, GHB meprobamate

BZ's: tx anxiety
more GABA (increase FREQ of Cl channel opening)
Barb's: tx epilepsy; anesthetics
more GABA (increase DURATION of Cl ch opening)

GHB: gamma-hydroxybutyrate - dose specific CNS depressant; commonly used as date-rape drug; confusion, dizziness, drowsiness, memory loss, resp distress, coma

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16
Q

Sedatives-Hypnotics intoxication

A

sx: resp depression, CNS depression, hypotension, slurred speech
* synergistic with alcohol and opioids/narcotics (they are also depressants)
* barb withdrawal has highest mortality rate

mgmt:

  1. ABC, vitals.
  2. activated charcoal, gastric lavage to prevent more GI absorption (if ingested in the last 4-6 hrs)
  3. BARBS only: alkalinize urine with sodium bicarb
  4. BZ’s only: flumazenil for OD (can precip seizures)
  5. supportive care - resp status, hypotension
17
Q

2 presentations of a BZ abuser

A
  1. poly drug user
    - younger, male
    - illicitly obtained
  2. older abuser
    - more females
    - prescribed
    - more freq falls in elderly population
18
Q

Sedative-Hypnotic withdrawal

A

abrupt abstinence - LIFE THREATENING
sx: same as alc withdrawal

mgmt:
1. BZ taper

19
Q

OPIOIDS - general info (3)

A

stimulate mu, kappa, delta opiate R
also affect dopa system
[analgesia, sedation, dependence]

ex: heroin, oxycodone, codeine, DXM, morphine, methadone, meperidine (Demerol)
but most commonly used = Rx opioids (OcyContin, Vicodin, Percocet)

20
Q

Opioids intoxication

A

sx: MIOSIS, RESP DEPRESSION, CNS DEPRESSION

meperedine + MAOi –> serotonin syndrome (autonomic instability, AMS, muscular rigidity)

mgmt:
1. ABC
2. OD –> naloxone
3. +/- vent support

21
Q

Opiate withdrawal

A

UNCOMFORTABLE: anxiety, insomnia, anorexia, fever, rhinorrhea, piloerection

mgmt:

  1. mod sx: sx tx with clonidine, NSAIDs, dicyclomine (abd cramps), etc
  2. severe sx: detox with buprenorphine or methadone
  3. monitor degree of COWS (clinical opioid withdrawal scale)
22
Q

Medications for opiate use disorder

A
  1. Methadone (long acting mu R ag)
    - once daily admin
    - need certification to give; only dispensed from clinics
    - can cause QTc pr (need screening EKG)
    - great for pregnant opioid-dep women
  2. Buprenorphine (partial ag)
    - sublingual; need DEA certification to prescribe
    - Suboxone = bupre + naloxone (prevents IV abuse)
    - can’t give to intoxicated pt - must give to someone in withdrawal already (last opioid use 4-12 hr prior)
    - wait 24-36 hr after stopping methadone to state suboxone
  3. Naltrexone (competitive mu R antag)
    - precipitates w/drawal if used w/in 7d of heroin
    - daily PO or monthly injection
    - ehhh bc compliance; good for highly motivated pts
23
Q

HALLUCINOGENS - general info (3)

A

psilocybin (mushrooms), mescaline (peyote cactus), LSD

LSD: believed to work on serotonin system

do not cause physical dependence or withdrawal

24
Q

Hallucinogen intoxication & withdrawal

A

sx: perceptual changes (delusions, hallucin, body image distortions), labile affect, MYDRIASIS, stimulant effects (HTN, tachy, hyperthermia, diaphoresis, palp), incoordination
duration: 6-12 hrs, but can last several days

mgmt: monitor for dangerous behavior, reassurance
BZ’s for agitated psychosis
_________
no withdrawal. flashbacks aren’t real.

25
Q

MARIJUANA - general info (5)

A
  • main active part = THC
  • THC (higher in street weed), CBD (medical component)
  • inhibit adenylate cyclase
  • endogenous cannabinoids work as partial ags
  • fat bound, so stays in system for a while
26
Q

Marijuana intoxication and withdrawal

A

sx: CONJ INJECTION, orthostatic hypotension, etc
- chronic use may cause resp issues (asthma, chronic bronchitis), suppression of immune system, cancer
- cannabis-induced psychotic disorder: assoc with paranoia, hallucin, delusions

mgmt: supportive psychosocial interventions
______
Withdrawal (requires basically daily use; starts in 1-2d of stopping): irritability, sleep issues, anxiety, restlessness, aggression, depression, decreased appetite
Mgmt: supportive

27
Q

Possible medical uses of marijuana

A
  • n/v, in chemo pts
  • increased appetite, in AIDS pts
  • chronic pain, from cancer
  • decrease IOP, glaucoma
  • epilepsy
  • spasticity, in MS
  • PTSD

*no significant studies tho

28
Q

INHALANTS - general info (

A

CNS depressants

usually preadolescent or adolescent (it’s all they can get their hands on - solvents, glue, fuels, etc)

29
Q

Inhalant intoxication and withdrawal

A

sx: perceptual disturbances, paranoia, lethargy, hyporeflexia, clouding of consciousness, slurred speech

acute intox: 15-30 min
OD: resp depression, cardiac arrhythmias, permanent CNS damage w/ lognterm use

mgmt: ABC, O2 (sometimes chelation reqd - ie leaded gasoline)
__________
Withdrawal: eh - n/v, craving, sleep issues, etc

30
Q

CAFFEINE - general info, OD, withdrawal

A

adenosine antag –> incr CAMP, excitatory NT

OD:
>250mg (2 cups coffee): anxiety, muscle twitching, tachy, excitement
>1g: tinnitus, visual light flashes, agitation, arrhythmias
>10g: death sec to seizures, resp failure

mgmt: supportive
______
Withdrawal: HA, fatigue, irritability, n/v, drowsiness, muscle pain, depression
*usually resolves in 1.5 wks

31
Q

NICOTINE - general, withdrawal

A
  • stimulates nicotinic R in autonomic ganglia of symp and parasymp systems
  • highly addictive via dopa effects
  • can cause physical dependence
  • smoking during pregnancy –> low birth wt, SIDS, etc
    ________
    Withdrawal: intense craving, dysphoria, anxiety, poor concentration, increased appetite/wt gain, insomnia
32
Q

Treatment of nicotine dependence

A
  1. Varenicline (Chantix): a4B2 nicotinic cholinergic R partial ag …. reduce reward, prevent w/drawal
    * can cause mood changes, suicidality, and CV events in those with pre-existing CV disease
  2. Bupropion (Zyban): antidepressant; inhibitor of dop/NE reuptake … reduce cravings and w/drawal sx
  3. Nicotine replacement therapy
  4. Behavioral support/counseling - should always have
33
Q

Gambling disorder - how dx?

A

persistent, recurrent problematic gambling behavior, 4+ in 12 months:
- preoccupation w it
- need to gamble with incr amt money to get pleasure
- trying to “get even”
etc

  • lower rates in older people
  • 1/3 may get recovery w/o treatment

mgmt: Gamblers Anonymous + CBT; tx comorbid mood/anxiety/substance use disorders

Psychiatry (7 decks)

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