Substance use disorder

Question 1

Addiction

General

Answer 1

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

Question 2

addiction

patho- Reward

Answer 2

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

Question 3

Addiction

Patho- Memory

Answer 3

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.

Question 4

Addiction

Pathophysiology - The Frontal Lobe & Cortex

Answer 4

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.

Question 5

Addiction

Pathophysiology - summary

Answer 5

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

Question 6

Addiction

Genetics

Answer 6

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

Question 7

Substance abuse Disorder DSM Criteria

Answer 7

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

Question 8

SUD

Specifiers and severity

Answer 8

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+

Question 9

Alcohol Use Disorder

RF

Answer 9

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

Question 10

Alcohol Use Disorder

At-Risk Drinking criteria

Answer 10

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

Question 11

alcohol use disorder

Binge Drinking criteria

Answer 11

Men: 5 or more drinks in a 2- to 3-hour period

Women: 4 or more drinks in a 2- to 3-hour period

Question 12

Alcohol use disorder

SCREENING

Answer 12

AUDIT - 10 question - best screening tool
CAGE - 4 questions (cut down, annoyed, guilty, eye-opener)
MAST - 25 question

Question 13

AUD

comorbidities

Answer 13

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

Question 14

AUD

Lab markers

Answer 14

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

Question 15

Alcohol Intoxication

general

Answer 15

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

Question 16

AUD -tx

Acamprosate (Campral)

Answer 16

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)

Question 17

AUD - tx

Naltrexone (mu opioid receptor blocker)

Answer 17

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

Question 18

AUD

Disulfiram (Antabuse)

Answer 18

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

Question 19

AUD

Disulfirm- contraindications

Answer 19

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

Question 20

Alcohol Withdrawal

Sx

Answer 20

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

Question 21

AUD

CIWA

Answer 21

Withdrawal assessment

Question 22

AUD

Alcohol withdrawal in severe cases

Answer 22

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

Question 23

Wernicke-Korsakoff Syndrome - thiamine (B1) deficiency

Wernicke encephalopathy (WE)

Answer 23

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

Question 24

Wernicke-Korsakoff Syndrome - thiamine (B1) deficiency

Korsakoff syndrome (KS)

Answer 24

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

Question 25

# Wernicke Tx

Answer 25

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

Question 26

# Opioid use disorder RF

Answer 26

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

Question 27

# Opioid abuse Intoxication Sx

Answer 27

Euphoria Sedation Slurred speech Constipation Analgesia Decreased respirations Attentional deficits Pinpoint pupils

Question 28

# Opioid Withdrawal Sx

Answer 28

Dysphoria, anxiety Insomnia Diarrhea, nausea, vomiting Muscle and joint pain Diaphoresis Chills Piloerection Tearing Yawning Withdrawal is exceedingly uncomfortable, but **not life-threatening**

Question 29

# Opioid withdrawal Tx

Answer 29

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

Question 30

# Opioid Use Disorder Treatment

Answer 30

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

Question 31

# Opioid abuse Methadone

Answer 31

**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

Question 32

# OUD Buprenorphine

Answer 32

**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

Question 33

# OUD Naltrexone

Answer 33

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

Question 34

# OUD Naltrexone - special considerations

Answer 34

* 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)

Question 35

# OUD Naloxone

Answer 35

**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

Question 36

# Cannabis Use Disorder general

Answer 36

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

Question 37

# cannabis intox Sx

Answer 37

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

Question 38

# Cannabis Withdrawal - Sx

Answer 38

Irritability, anger, or aggression Anxiety Sleep difficulty Decreased appetite or weight loss Restlessness Depressed mood Abd pain, tremor, sweating, deveres, chills, headaches

Question 39

# Stimulant Intox Sx

Answer 39

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

Question 40

# Stimulant withdrawal Sx

Answer 40

Dysphoric mood - always present and required for diagnosis Fatigue Vivid, unpleasant dreams Insomnia or hypersomnia Increased appetite Psychomotor retardation or agitation

Question 41

# Sedative, Hypnotic, Anxiolytic Use Disorder Intox Sx | Xanax Valium Ativan Lunesta Ambien Belsomra Rozerem Halcion

Answer 41

Slurred speech Incoordination Unsteady gait Nystagmus Impairment in cognition - attention/memory Anterograde amnesia Stupor or coma

Question 42

# Sedative, Hypnotic, Anxiolytic Use Disorder Withdrawal Sx

Answer 42

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

Question 43

# Phencyclidine Use Disorder Intox Sx/ withdrawal Sx | PCP Angel Dust Ketamine

Answer 43

**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!**

Question 44

# 1. Hallucinogen Use Disorder Intox / withdrawal Sx Peyote Psilocybin | LSD

Answer 44

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!

Question 45

Hallucinogen Persisting Perception Disorder

Answer 45

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

Question 46

# Inhalant Use Disorder Intox/ Withdrawal Sx | Nitrous Spray Paint Butane Markers Glue Cleaning sol. AC refrigerant

Answer 46

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!**

Question 47

# Tobacco Intoxication / Withdrawal Intox/ withdrawal Sx

Answer 47

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

Question 48

# Tobacco Use Disorder treatment

Answer 48

**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