Substance use disorder Flashcards
To detail the evolving epidemiology of drug abuse
Fewer people testing positive for drugs overall
More people testing positive for selected “painkiller” drugs; cannabinoids, bath salts
Increasing fatalities from prescription drugs (oxycodone, fentanyl > heroin)
To apply the pharmacology of drugs to their “toxidromes”
Acute drug intoxication presents as “ toxidromes”
Acutely, clinical exam is often as useful as Urine Tox.
Awareness of “quick” urine tox. screen false –ve and + ve; & Comprehensive urine or blood toxicology - GC-MS assay - 3-5 days
Acute substance use –> hypoxia, ischemia, seizures and psychosis
49 year old caucasian female
Has been taking lorazepam 1-3 mg/day for anxiety & insomnia for 10 yrs; now wants to stop this medication
She has tried to stop it herself several times and developed anxiety/tremulousness/dizziness, dry retching, nausea /sleep disturbance
How would you proceed from a therapeutic perspective?
Lorazepam t 1/2 = 14h; without active metabolite
Because failed tapering on shorter-acting drug
1) Change to longer-acting drug - diazepam, chlordiazepoxite
2) Then taper down
3)
Why is lorazepam used for “CIWA protocol”
Better for the liver (
53 year old caucasian male
Chronic ethanol abuser, well known to the local hospital ER staff is admitted with a compound fracture of his right tibia and fibula sustained during a fight outside the NH liquor store. In the ER, his physical examination is remarkable only for the fracture of his right lower leg and a strong smell of ethanol on his breath. He has been drinking up to two quarts of whisky per day over the last several weeks. In the past he has experienced one episode of delirium tremens.
How would you manage the patient?
1) Ativan protocol –> switching to benzos b/c targets the same receptors (GABA)
2) Banana bag - thiamine, glucose, folate
18 y.o. male collapsed at Lebanon HS
No other Hx available
Physical Exam: Cyanosed, smells of ethanol
Pulse 55/min reg. BP 80/60 mmHg
Respiratory rate 4/min; few scattered exp. wheezes
No dolls head reflex, pupils 2 mm
Little or no response to naloxone 400/800mcg IV
What do you do now?
Fentanyl = “superagonist” 100x more potent in binding than heroin
Carfentanil = “super-superagonist” 1000x more potent in binding v. heroin
will require a LOT more naloxone
22 year old caucasian male, becomes confused and aggressive at a wedding reception
Intermittently confused, combative and hearing voices
Swearing profusely at his mother
Odd postures - jerky movements
PCP
27 year old Caucasian female
At a music festival ate some “special” candy
Initially, restless, irritable, tremor, flushed
Became confused, hyperactive-repetitive movements
Intermittently hallucinating, diaphoretic, tachycardic
Temp 38.1oC, sweating, pallor
Sinus tachycardia 110/min, BP 190/115 mmHg
Chest clear
Dilated reactive pupils, no focal neurological signs
U. Tox is negative!!
bath salts
22 y.o. male student, fell off his bicycle and was injured by a passing car Emergency Dept.
Hallucinating –nursing staff and MDs wearing no clothes !
Can remember the accident, has no evidence of head injury
Intoxicated, difficulty signing his name
Lethargic
HR 104/min reg: lying BP 125/78 & standing-105/68
Pupils slightly constricted, conjunctival suffusion
Tremor, but no other localizing neurological signs
marijuana
Patient with OD/intoxication seizes; which agents?
Cocaine, stimulants/hallucinogens/synthetic cannabinoids & (newer agents esp. benzylpiperazines)
TCA’s/SSRI’s
Ethanol & ethylene glycol etc.
Lithium
Opioids
Others - salicylates, theophylline, insulin, diphenhydramine, neuroleptics (anti-psychotics)
Patient OD/Intoxicationpsychosis; which agents?
Cocaine, amphetamines, cathinones, synth. cannabinoids
LSD, PCP, ketamine
MAO-I /TCAs /SSRI’s
L-Dopa
Diphenhydramine (ACh effects
