Substance use disorder Flashcards
DSM-5 criteria for SUD
Someone who meets 2 criteria for a 12-month period
- Taken in larger amounts over a longer period of time
- Persistent desire or unsuccessful efforts to cut down or control use
- Great deal of time spent in activities necessary to obtain substance or recover from use
- Craving, strong desire to use
- Recurrent use in results in failure to fulfill major role obligations
- Continued despite consistent or recurrent social or interpersonal problems caused
- Important activities are given up or reduced
- Recurrent use in situations in which is physically hazardous
- Continued use despite knowing you have a problem
- Tolerance
- withdrawal
Absorption of alcohol
10% from stomach, the rest from intestine
Peak 30-90 min
Limited gastric emptying: food slows absorption
Increased acid release (secretagogue): GERD/ulcers
Distribution of alcohol
Distributed in total body water
Men dilute ethanol more due to increased total body water
Metabolism of alcohol
90% in the liver
- ADH and Microsomal ethanol oxidizing system
-MEOS only occurs at high alcohol concentrations
-CYP2E1 induced–> increased NAPQI
Ethanol–>Acetaldehyde - Acetaldehyde (toxic)–> acetate
Glucuronidation: test to measure alcohol concentration of a longer time
Elimination
Zero order kinetics above 10-20 mg/dL
Metabolize 1 drink per hour
Step 1 of alcohol metabolism
Alcohol dehydrogenase: liver, brain, or stomach
Men express higher levels of gastric ADH
Step 2 of alcohol metabolism
Acetaldehyde dehydrogenase
ALDH1B1 and ALDH2:
-50% of Asians only have ALDH2
-SNP in ALDH2 reduces activity–> ALDH2*2
Heterozygous ALDH2*2:
-Can still consume alcohol
-Flushing, increased temp
-Reduced metabolic activity
Homozygous ALDH2*2:
-Can not still consume alcohol
-Neurotoxicity, stronger hangover, alcohol neuropathy
-Reduced metabolic activity
MOA of alcohol
Binds directly (allosteric) GABA-A receptors
NMDA antagonist
Release opioids, Ne, 5-HT, Ach
Blood alcohol levels
0.10%=100 mg/dL=100 mg%
Legal driving limit=0.08%=80 mg/dL=80 mg%
Actions of alcohol
30-60 mg/dL: euphoria, disinhibition, talkative
60-90 mg/dL: analgesia
80-120 mg/dL: CNS stimulation
100-200 mg/dL: CNS depression
300-500 mg/dL: coma, respiratory depression, death
500 mg/dL: LD 50 for alcohol
Cardiovascular effects
Acute: vasodilation
warm, flush, reduced BP, Increase HR
Moderate use: reduced risk of coronary disease
Heavy/chronic: cardiomyopathy, arrhythmias, hypertension, hemostasis
Additional effects
hypothermia
gastritis
Appetite stimulant (low doses)
Appetite suppressant (high doses)
Long-term effects
Fatty liver and cirrhosis: increased fat metabolism
Vitamin deficiencies: Glutathione, folic acid
Edema
Anemia
LIver cancer
Drug interactions with alcohol
CNS depressants: opioids, antipsychotics, antihistamines, sedative
Aldehyde dehydrogenase inhibitors: metronidazole, cephalosporins, sulfonylureas
Acetaminophen
ASA
1 IN 8 ADULTS MEET ALCOHOL USE DISORDER
< 8% GET TREATMENT
1 IN 8 ADULTS MEET ALCOHOL USE DISORDER
< 8% GET TREATMENT
Stages of alcohol withdrawal
Stage 1: (6-8 hrs) anxiety, tremor, tachycardia, insomnia, n/v, sweating, craving
Stage 2: (24 hrs) auditory and visual hallucinations lasting 1-3 days
Stage 3: (1-2 days) seizures/tonic-clonic after 7-48 hrs after drop in BAC
Stage 4: (4 days) delirium tremens
Mortality associated with DTs 5-15% attribute to arrhythmias, shock, infection, or trauma
Risk factors for DTs
Prior hx
of detoxifications
consuming equivalent of 1 pint of whiskey per day for 10 to 14 days prior to admission
symptoms of withdrawal
hepatic dysfunction
Fixed dosing/prophylaxis
Chlordiazepoxide +/- Lorazepam PRN
Individualized
CIWA < 8: non-pharm
CIWA 8-15: medicate
no liver dysfunction: diazepam, chlordiazepoxide
Liver dysfunction: lorazepam, oxazepam
Thiamine!!!!!
100 mg daily IV/IM/PO
Wernicke’s encephalopathy
result of thiamine deficiency
give before dextrose-containing fluids
thiamine is co-factor in glucose metabolism, wernicke’s can be precipitated by high glucose loads
PHENYTOIN IS NOT EFFECTIVE FOR WITHDRAWAL SEIZURES
PHENYTOIN IS NOT EFFECTIVE FOR WITHDRAWAL SEIZURES
Disulfiram
alcoholism
aldehyde dehydrogenase inhibitor
SE: flushing, nausea, vomiting, tachycardia
PATIENTS SHOULD BE ALCOHOL FREE FOR 24 HOURS
Disulfiram reaction up to 14 days after d/c
Acamprosate
renal elimination, monitor renal function, avoid in renal impairment
Suicidality warning: side effects also include diarrhea, nausea, depression, anxiety
Naltrexone
Decreases binge drinking, helps increase time between drinking days
Elevated LFTs common, monitor baseline and routinely
Need to evaluate pain management needs, patient should have wallet card to be able to tell emergency providers that they are taking this
Best efficacy in 118G SNP
Warning for injection site reactions
Fomepizole
alcohol dehydrogenase inhibitor
ethylene glycol, MeOH poisoning
Effects: slow formation of formaldehyde and toxic metabolites
