Substance use disorder Flashcards
Addiction
General
is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, and social manifestations.
Addiction affects neurotransmission and interactions within reward structures of the brain, including….
The nucleus accumbens (the “reward center”)
The anterior cingulate cortex (ACC)
The basal forebrain
The amygdala
Genetic factors account for about half of the likelihood that an individual will develop addiction
The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors
ADHD, Anxiety Disorders, Depressive Disorders, Personality Disorders, Bipolar Disorders
addiction
patho- Reward
In a “normal brain” dopamine is released from the ACC to the NC when we do things that promote survival (drinking water, eating food, having sex, and sleeping) as a positive reinforcement mechanism.
Various substances, including all of the most commonly abused substances, hijack this system by releasing significantly higher levels of dopamine from the ACC into the NC, and for a greater duration of time. After this occurs, victims are now much more likely to repeat the behavior as nothing else is able to produce that type of euphoria - their reward center has been introduced to a new threshold of pleasure
Addiction
Patho- Memory
Addiction also affects neurotransmission and interactions between….
The cortical and hippocampal circuits and the nucleus accumbens, such that the memory of previous exposures to rewards (such as heroin) leads to a biological and behavioral response to external cues → triggering craving and/or engagement in addictive behaviors.
Addiction
Pathophysiology - The Frontal Lobe & Cortex
Frontal lobe is responsible for:
Storing negative consequences to avoid poor actions in the future
Inhibiting impulsivity and appropriately delay gratification
Patients with addiction have a severely underdeveloped frontal lobe. Meaning high impulsivity and difficulty recognizing consequences of poor choices.
Addiction
Pathophysiology - summary
Inactive front lobe
(decreased impulse control and decreased ability to utilize learned social behavior and logic)
+
Hyperactive reward center
(which now has a new standard for gratification)
=
a patient with very little control over their drug use
Addiction
Genetics
Resiliencies which the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavior and other manifestations of addiction
Patients can be born with underlying biological deficits in the function of reward circuits resulting in a exaggerated reward response within the NA
Substance abuse Disorder DSM Criteria
A problematic pattern of “substance” use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occuring within a 12 month period:
- Substance is taken in larger amounts or over a longer period than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control substance use.
- A great deal of time is spent in activities necessary to obtain, use, or recover from it’s effects
- Craving, or a strong desire or urge to use the substance
- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
- Important social/work/ rec activities are given up or reduced because of use
- Recurrent use in situations in which it is physically hazardous
- Use is continued despite knowledge of having a persistent or recurrent physical or psych problem that is likely to have been caused or worsened by substance
- Tolerance
- Withdrawal
SUD
Specifiers and severity
Specifiers
In early remission: no criteria met for at least 3 months, but less than 12 (except cravings)
In sustained remission: no criteria met for 12 months (except cravings)
In controlled environment
Severity
Mild: 2-3 symptom criteria met
Moderate: 4-5
Severe: 6+
Alcohol Use Disorder
RF
Family history of alcohol use disorder and other substance use disorders
Availability of alcohol
Heavy alcohol use
Binge drinking
Permissive societal attitudes towards alcohol use
History of childhood abuse
History of conduct or mood disorder in childhood
Having mental health conditions such as depression or post-traumatic stress disorder
Impulsivity
Alcohol Use Disorder
At-Risk Drinking criteria
At-Risk Drinking:
Men: more than 4 drinks/day, or more than 14 drinks/week
Women: more than 3 drinks/day, or more than 7 drinks/week
Men and Women over age 65: More than 3 drinks/day, or more than 7 drinks/week
alcohol use disorder
Binge Drinking criteria
Men: 5 or more drinks in a 2- to 3-hour period
Women: 4 or more drinks in a 2- to 3-hour period
Alcohol use disorder
SCREENING
AUDIT - 10 question - best screening tool
CAGE - 4 questions (cut down, annoyed, guilty, eye-opener)
MAST - 25 question
AUD
comorbidities
Repeated use in high amounts can impair nearly every organ system
Gastritis
Stomach/duodenal ulcers
Liver cirrhosis
Pancreatitis
Esophageal and stomach cancer
Hypertension
Cardiomyopathies, hypertriglyceridemia, elevated LDL
Myopathies
Severe memory impairment
Degenerative changes in the cerebellum
Thiamine deficiency → Wernicke-Korsakoff Syndrome
AUD
Lab markers
BAC, or blood alcohol concentration: (>200mg/dL in any non-tolerant pt should demonstrate severe intox)
GGT (gamma-glutamyltransferase) - high-normal - About 70% of patients with elevated GGT are persistently heavy drinkers (8+ per day)
CDT (carbohydrate-deficient transferrin) - levels of 20 units or higher can be useful in identifying individuals who drink/abuse alcohol regularly
MCV - high-normal, but not a good predictor of abstinence due to long lifespan of RBC’s
LFT’s - AST:ALT ratio > 2:1 is indicative of heavy alcohol use
Alcohol Intoxication
general
Slurred speech, Incoordination, Unsteady gait, Nystagmus, Impairment in attention/memory, Stupor/coma
BAC over 300-400 mg/dL can cause inhibition of respiration → death
In general, the body is able to metabolize about 1 drink per hour and BAC should fall about 15-20mg/dL per hour
THERE IS A SIGNIFICANTLY INCREASED RATE OF SUICIDE DURING ALCOHOL INTOXICATION
AUD -tx
Acamprosate (Campral)
666mg 3x daily (initial and therapeutic dose) - start lower if renal impairment is present
No labs required, but should be avoided in patients with severe renal impairment
Glutamate neurotransmission modulation at metabotropic-5 glutamate receptor sites
MC side effects: diarrhea, nervousness, and fatigue
Can take with naltrexone and disulfiram and in pts who continue to drink
Contraindication: severe renal impairment (CrCl 30 or less)
AUD - tx
Naltrexone (mu opioid receptor blocker)
Partial antagonist
50mg PO once daily or 380mg IM q4wks
Requires monitoring of LFTs q 6months
Mice that lack the mu-opioid receptor do not self-administer alcohol
Naltrexone also modifies the HPA axis to suppress ethanol consumption
Reduces heavy drinking by only about 25%
Contraindication: acute hepatitis and liver failure
AUD
Disulfiram (Antabuse)
125-500mg once daily
discourages drinking by causing an unpleasant physiologic reaction when alcohol is consumed
Inhibits aldehyde dehydrogenase and prevents the metabolism of alcohol’s primary metabolite, acetaldehyde
Results in sweating, headache, dyspnea, lowered blood pressure, flushing, sympathetic overactivity, palpitations, nausea, and vomiting if alcohol were to be consumed
initially dosed at 500 mg/day for 1-2 weeks, followed by an avg maintenance dose of 250 mg/day with a range from 125-500 mg based on the severity of adverse effect
Side effects; rash, drowsiness, HA, metallic taste, hepatitis
AUD
Disulfirm- contraindications
Contraindications: severe myocardial disease and/or coronary occlusion, psychosis, or known hypersensitivity to the medication or other thiuram derivatives. Also avoid in pregnancy and during breastfeeding
Alcohol Withdrawal
Sx
2 or more of the following begin shortly after cessation of prolonged drinking:
Autonomic hyperactivity (diaphoresis, tachycardia)
Increased hand tremor
Insomnia
nausea/vomiting
Transient hallucinations
Psychomotor agitation
Anxiety
Generalized tonic-clonic seizures (6 - 48 hours after last drink)
WITHDRAWAL FROM ALCOHOL CAN BE LETHAL
Tx short term acute symptoms with low dose benzodiazepines
AUD
CIWA
Withdrawal assessment
AUD
Alcohol withdrawal in severe cases
Alcoholic hallucinosis - visual, auditory, and/or tactile hallucinations with intact orientation and normal vital signs; 12-48 hours after last drink
Delirium Tremens - delirium, agitation, tachycardia, hypertension, fever, diaphoresis; 48-96 hours after last drink. Can be LETHAL
Wernicke-Korsakoff Syndrome - thiamine (B1) deficiency
Wernicke encephalopathy (WE)
Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity.
S/s: encephalopathy, oculomotor dysfunction, and gait ataxia.
Atrophy of the mamillary bodies is a relatively specific sign of prior WE
Acute
Wernicke-Korsakoff Syndrome - thiamine (B1) deficiency
Korsakoff syndrome (KS)
Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE
disorder of selective antegrade and retrograde amnesia (d/t lesions in the anterior thalamus), apathy, an intact sensorium, and relative preservation of long-term memory and other cognitive skills
Patients with KS rarely recover
chronic
Wernicke
Tx
The diagnosis of WE is difficult to confirm and, untreated, most patients progress to coma and death
Testing should not delay tx, so **if suspected immediately give thiamine **
A recommended regimen is 500 mg of thiamine IV, infused over 30 minutes, 3x daily for 2 consecutive days and 250 mg IV or IM once daily for an additional 5 days, in combination with other B vitamins
KEEP IN MIND: administration of glucose without thiamine can precipitate or worsen WE; thus, thiamine should be administered before glucose.
Because GI absorption of thiamine is erratic in alcoholic and malnourished patients, oral administration of thiamine is an unreliable initial treatment for WE = IV infusion!
Be proactive in prophylaxis - for example, patients admitted for alcohol withdrawal should receive thiamine 100 - 250mg daily, depending on their nutritional status and perceived risk of WE
Opioid use disorder
RF
Access to and availability of opioids
Previous exposure to substance use (e.g., having friends or family who use substances)
Current or past substance use disorder
Family history of substance use disorder
Having mental health conditions such as depression or post-traumatic stress disorder
History of abuse during childhood
History of conduct disorder as a child or adolescene
Opioid abuse
Intoxication Sx
Euphoria
Sedation
Slurred speech
Constipation
Analgesia
Decreased respirations
Attentional deficits
Pinpoint pupils
Opioid
Withdrawal Sx
Dysphoria, anxiety
Insomnia
Diarrhea, nausea, vomiting
Muscle and joint pain
Diaphoresis
Chills
Piloerection
Tearing
Yawning
Withdrawal is exceedingly uncomfortable, but not life-threatening
Opioid withdrawal
Tx
Primary Treatments:
Buprenorphine
Methadone (specific license required)
Clonidine
Adjunctive treatments:
NSAIDS for pain
Kaopectate or immodium for diarrhea
Hydroxyzine for anxiety or insomnia
Benzodiazepines can be used, if needed
Decongestants for rhinorhea
Phenergan for nausea and vomiting
Avoid using needles
Opioid Use Disorder
Treatment
For detox/withdrawal
Opioid agonists
Buprenorphine (partial)
Suboxone(+naloxone/narcan)
Subutex (bup only)
Bunavail (+naloxone/narcan)
Zubsolv (+naloxone/narcan)
Methadone (full)
For long term maintenance
Opioid antagonists
Naltrexone oral
Naltrexone IM (Vivitrol)
Buprenorphine
Methadone
Opioid abuse
Methadone
Pure opioid agonist → greater OD risk than buprenorphine
Best studied and longest used medication for treatment of opioid addiction
Methadone maintenance therapy is associated with overall lower mortality rates, including 70% lower than untreated heroin abusers
Methadone is first line for pregnant patients with OUD
Must be administered by certified center, typically dosed daily
Works by:
Prevents cravings
Prevents withdrawal symptoms for 24+ hrs
reduces the euphoric effects of subsequent illicit opioid use by maintaining high levels of opioid tolerance
OUD
Buprenorphine
Opioid partial agonist
Some pain relief, potential for diversion
Oral form combined with naloxone to decrease diversion to injection (Suboxone)
Long-acting injection available (Sublocade) and implant (Probuphine)
Patient should be experiencing withdrawal symptoms prior to starting (depends on half-life of drug)
Safe in pregnancy, but less research than methadone, so this is not first line
Patients are at higher risk of death if concurrently taking benzodiazepines, alcohol or using IV opiates in combination with Buprenorphine
Does not show up on standard drug screen
Contraindicated: severe hepatic impairment
OUD
Naltrexone
Partial Opioid antagonist
comes in oral daily form and long acting injection (1 month)
Must be free from opioids or will enter precipitated withdrawal
Can be started 3-6 days after last use of short-acting opioids, 7-10 days after last use of long-acting opioids (methadone/bup)
Can do in-office naloxone challenge test
Side effects: nausea, headache, dizziness, fatigue, liver damage - this is rare (seen with supra-therapeutic doses) and resolves with discontinuation of naltrexone
Very high risk of OD if patient relapses. Educate!
Research in pregnancy is limited; discontinue unless risk of relapse is high
Contraindication: acute hepatitis and liver failure
OUD
Naltrexone - special considerations
- Emergency pain management: In naltrexone-treated patients requiring emergency pain management, consider alternatives to opioid therapy (eg, regional analgesia, nonopioid analgesics, general anesthesia). If opioid therapy is required for pain therapy, patients should be under the direct care of a trained anesthesia provider.
- Surgery: In patients treated with naltrexone for opioid addiction who requiring surgery, discontinue oral naltrexone at least 72 hours before scheduled elective surgery if opioid use is anticipated; extended-release IM naltrexone should be discontinued at least 30 days prior to scheduled surgery (oral naltrexone may be used temporarily)
OUD
Naloxone
total Opioid antagonist that blocks effects of opioid analgesics and reverses the effects of overdose
No abuse potential
Can be administered in both healthcare settings and in community
Project DAWN (Deaths Avoided with Naloxone)
Demonstrated to decrease mortality, not cause opioid dose escalation and improve eventual entry into treatment
Cannabis Use Disorder
general
Cannabis is the most commonly used illegal psychoactive substance.
1 in 8 current regular cannabis users develops a cannabis use disorder
Cannabis use before age 17 years is strongly associated with lower educational attainment and increased use of other drugs
Cannabis acutely impairs attention, concentration, episodic memory, associative learning, and motor coordination in a dose-dependent manner
often use other psychoactive substances, especially alcohol and tobacco.
Chronic use associated with periodontal disease, hyperemesis, low sperm count and small increased risk of MI and stroke.
Substantial evidence suggests that chronic cannabis use, especially during adolescence, is associated with later development of schizophrenia
cannabis
intox Sx
Intox
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
Specifier: with perceptual disturbances
Effects can last up to 24 hours before most cannabinoids are fat soluble
Cannabis
Withdrawal - Sx
Irritability, anger, or aggression
Anxiety
Sleep difficulty
Decreased appetite or weight loss
Restlessness
Depressed mood
Abd pain, tremor, sweating, deveres, chills, headaches
Stimulant
Intox Sx
Tachycardia OR bradycardia
Mydriasis
HTN or hypotension
Perspiration or chills
N/V
Evidence of weight loss
Psychomotor agitation or retardation
Muscle weakness, respiratory depression, chest pain, cardiac arrhythmias
Confusion, seizures, dyskinesias, dystonias, or coma
Specifier: with perceptual disturbances
Stimulant
withdrawal Sx
Dysphoric mood - always present and required for diagnosis
Fatigue
Vivid, unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor retardation or agitation
Sedative, Hypnotic, Anxiolytic Use Disorder
Intox Sx
Xanax
Valium
Ativan
Lunesta
Ambien
Belsomra
Rozerem
Halcion
Slurred speech
Incoordination
Unsteady gait
Nystagmus
Impairment in cognition - attention/memory
Anterograde amnesia
Stupor or coma
Sedative, Hypnotic, Anxiolytic Use Disorder
Withdrawal Sx
Autonomic hyperactivity - diaphoresis, tachycardia
Hand tremor
Insomnia
N/V
Transient visual/tactile/auditory hallucinations
Psychomotor agitation
Anxiety
Grand mal seizures
Specifier: with perceptual disturbances
For the longer half-life meds (diazepam) - this can last for up to a month
Phencyclidine Use Disorder
Intox Sx/ withdrawal Sx
PCP
Angel Dust
Ketamine
chronic use can lead to deficits in memory, speech, and cognition that may last for months
Vertical or horizontal nystagmus
HTN or tachycardia
Numbness or diminished responsiveness to pain
Ataxia
Dysarthria
Muscle rigidity
Seizures or coma
Hyperacusis
**If toxicity occurs → intracranial hemorrhage, rhabdo, cardiac arrest
Withdrawal- None!
1. Hallucinogen Use Disorder
Intox / withdrawal Sx
Peyote
Psilocybin
LSD
Perceptual changes occurring in a state of full wakefulness and alertness- Depersonalization, derealization, illusions, hallucinations,
Mydriasis
Tachycardia
Diaphoresis
Palpitations
Blurring of vision
Tremors
Incoordination
Withdrawal - None!
Hallucinogen Persisting Perception Disorder
Following cessation of use of a hallucinogen, the reexperiencing of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen
- Geometric hallucinations, false perceptions of movement in the periphery, flashes of color, intensified colors, trails of images of moving objects, halos around objects, macropsia, micropsia
- Visual disturbances are predominant, and can be episodic or continually present
- Occurs primarily after LSD use, but not exclusively
- Does not appear to be correlated with # of uses
Inhalant Use Disorder
Intox/ Withdrawal Sx
Nitrous
Spray Paint
Butane
Markers
Glue
Cleaning sol.
AC refrigerant
Intox
Dizziness
Nystagmus
Incoordination
Slurred speech
Unsteady gait
Lethargy
Depressed reflexes
Psychomotor retardation
Tremor
Generalized muscle weakness
Blurred vision
Stupor, coma
Euphoria
Beware of “sudden sniffing death” which can occur when the inhalant causes cardiac arrhythmias
Withdrawal - None!
Tobacco Intoxication / Withdrawal
Intox/ withdrawal Sx
Intox
No formal intox criteria
Withdrawal
Irritability, frustration, or anger
Anxiety
Difficulty concentration
Increased appetite
Restlessness
Depressed mood
Insomnia
Peaks at 2-3 days after abstinence and lasts 2-3 weeks
Tobacco Use Disorder
treatment
Chantix/Varenicline
28 day treatment course
Day 1-3: 0.5 mg once daily
Day 4-7: 0.5 mg twice daily
Day 8-28: 1 mg twice daily
Reduces craving and withdrawal symptoms
Notorious for causing nightmares
Nicotine replacement
Patch, Gum, Lozenge, Spray, Inhaler
Dosing varies depending on how nicotine dependent the patient is - slowly decrease dose of nicotine replacement weekly until lowest dose is achieved (ie 21mg x 1 week, 14mg x 1 week, 7mg x 1 week, then stop)
Bupropion/Wellbutrin/Zyban
150-300mg XL once daily
