Substance Use Flashcards
Substance use disorder VS physiological dependence
physiologic dependence = presence of …
- tolerance: need for increasing amounts of substance to achieve desired effect OR diminished effect from using same amt of substance
- withdrawal: substance-specific syndrome due to cessation/reduction in substance use that has been heavy and prolonged
How long do substances stay in blood/urine?
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
ALCOHOL - general information (4)
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
Alcohol intoxication
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:
- monitor ABC, glucose, lytes, acid-base status
* ethanol, methanol, ethylene glycol can cause m acidosis with AG - thiamine (Wernicke’s), folate
- CT Head to r/o bleed
- GI evacuation only if significant amount of alc ingested in the last 30-60 minutes
Alcohol withdrawal
sx
tx
things to note
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»_space; chlordiazepoxide)
Wernicke (reversible, CAN) –> Korsakoff (confabulation, anterograde amnesia, impaired recent memory)
Medications for alcohol use disorder
First line
- 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 - 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
- Disulfiram (inhibits aldehyde dehydrogenase)
* contraindic in severe heart ds, pregnancy, psychosis - Topiramate (more GABA, inhibits glutamate R) - reduces craving, decreases use
- Gabapentin!
COCAINE - general info (2)
blocks: reuptake of dopa, epi, NE
Indirect sympathomimetic - STIMULANT
Cocaine intoxication
sx: MYDRIASIS, CHEST PAIN, SEIZURES
euphoria, heightened self esteem, labile BP and HR
deadly: cardiac arryhthmia, MI, resp depression, seizure
mgmt:
- mild-mod agitation: BZ’s
- severe agitation/psychosis: atypicals (haldol)
- sx support: cooling if high temp, control HTN, etc.
Treatment for cocaine use disorder
Offlabel meds (eh): disulfiram, modafinil, topiramate
BUT MAIN THING:
Psych interventions: contingency mgmt, relapse prevention, NA
Cocaine withdrawal
NOT life threatening;
“post-intoxication crash” - hypersomnolence, hyperphagia, miosis, vivid dreams, depression
RECOVERY times:
mild-mod use: 72 hrs
heavy: 1-2 wks
Amphetamines
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)
Amphetamine intoxication & withdrawal
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
PCP - general information (3)
NMDA antag + activates dopa neurons
DISSOCIATIVE, HALLUCINOGENIC
stimulant OR depressant effects, depending on dose
Ketamine is similar, but less potent
PCP intoxication
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 ??
SEDATIVES-HYPNOTICS - general info (3)
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
Sedatives-Hypnotics intoxication
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:
- ABC, vitals.
- activated charcoal, gastric lavage to prevent more GI absorption (if ingested in the last 4-6 hrs)
- BARBS only: alkalinize urine with sodium bicarb
- BZ’s only: flumazenil for OD (can precip seizures)
- supportive care - resp status, hypotension
2 presentations of a BZ abuser
- poly drug user
- younger, male
- illicitly obtained - older abuser
- more females
- prescribed
- more freq falls in elderly population
Sedative-Hypnotic withdrawal
abrupt abstinence - LIFE THREATENING
sx: same as alc withdrawal
mgmt:
1. BZ taper
OPIOIDS - general info (3)
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)
Opioids intoxication
sx: MIOSIS, RESP DEPRESSION, CNS DEPRESSION
meperedine + MAOi –> serotonin syndrome (autonomic instability, AMS, muscular rigidity)
mgmt:
1. ABC
2. OD –> naloxone
3. +/- vent support
Opiate withdrawal
UNCOMFORTABLE: anxiety, insomnia, anorexia, fever, rhinorrhea, piloerection
mgmt:
- mod sx: sx tx with clonidine, NSAIDs, dicyclomine (abd cramps), etc
- severe sx: detox with buprenorphine or methadone
- monitor degree of COWS (clinical opioid withdrawal scale)
Medications for opiate use disorder
- 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 - 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 - 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
HALLUCINOGENS - general info (3)
psilocybin (mushrooms), mescaline (peyote cactus), LSD
LSD: believed to work on serotonin system
do not cause physical dependence or withdrawal
Hallucinogen intoxication & withdrawal
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.
MARIJUANA - general info (5)
- 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
Marijuana intoxication and withdrawal
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
Possible medical uses of marijuana
- 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
INHALANTS - general info (
CNS depressants
usually preadolescent or adolescent (it’s all they can get their hands on - solvents, glue, fuels, etc)
Inhalant intoxication and withdrawal
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
CAFFEINE - general info, OD, withdrawal
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
NICOTINE - general, withdrawal
- 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
Treatment of nicotine dependence
- 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 - Bupropion (Zyban): antidepressant; inhibitor of dop/NE reuptake … reduce cravings and w/drawal sx
- Nicotine replacement therapy
- Behavioral support/counseling - should always have
Gambling disorder - how dx?
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
