Substance Use Disorders 1 Flashcards
Among adults 18 or older, of those who first tried alcohol at age _____, 13.8% classified with dependence or abuse
14 or younger
(1.8% if age at first use age 21 or older)
Prevalence of alcohol use disorders
- 20 million alcohol-abusing or dependent
- Similar to the rates of chronic diseases (asthma, DM, depression)
(economic loss of $134 billion in productivity)
Alcohol use MC in _______.
men
Alcohol use in hospitilized patients
25-50%
________ (3) disorders more likely to be dependent on alcohol.
- Antisocial personality
- Anxiety
- Mood
Relation of blood alcohol levels (BAL) to symptoms dependent on _______.
tolerance
(legally intoxicated when but alcohol is greater than 0.08 g/dL)
- BAL: 0-100 → symtpoms
- BAL 100-150 →
- BAL 150-250 →
- BAL > 250 →
- BAL > 350 →
- Initially feel tranquil, sedated
- uncoordinated, irritable
- slurred speech, ataxicc
- pass out, unconscious
- comatose, death
CAGE questionnaire
- Ever felt you should Cut down on your drinking?
- Annoyed by criticism of your drinking?
- Feel bad or Guilty about your drinking?
- Eye-openers? (steady nerves to get rid of hangover)
(one positive answer = 90% chance of alcohol disorder)
Be suspicious of patients who
- Ability to drink more than others
- Have accidents or false
- Blacking out
- Lying to family or co-workers
Abnormal laboratory findings for alcohol-use disorder
- High blood alcohol concentration
- Increased MCV, high cholesterol, elevated liver enzymes (GGT acutely)
Physical findings alcohol use disorder (3)
- Enlarged red nose and reddened palms
- Enlarged liver and spider veins
- Gynecomastia and testicular atrophy
Medical complications of alcohol abuse include fatty liver, GI problems, pancreatitis, Wernicke’s encephalopathy, _____ (5).
- Cancers of many organs
- Cardiomyopathy → heart failure
- Cerebellar damage → ataxia
- Neuropathy
- Infections: TB, frequent pneumonias
(If pregnant → Fetal alcohol syndrome)
Psychiatric complications of alcohol abuse (6)
- Anxiety
- Dementia (from alcoholism)
- Depression
- Suicide
- Withdrawal problems
- Increased use of other drugs
Social complications of alcohol abuse (4)
- Accidents, fights & falls
- Legal problems
- Loss of jobs
- Marital and family problems
Alcohol use disorder: problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period:
- Drink more & longer than intended
- Desire or unable to quit
- Much time spent using or recovering from alcohol
- Craving
- Failure of obligations at work, school or home duties
- Use despite social or interpersonal problems
- Reduced social, occupational or recreational activities
- Use in situations where it is physically hazardous
- Use in spite of persistent physical or psychological problem caused or exacerbated
- Tolerance: the need for more for the desired effect or diminished effect of same amount
- Withdrawal: a characteristic syndrome of symptoms or the same or a closely related substance is taken to avoid/relieve withdrawal symptoms
Genetics of alcohol abuse
- Molecular genetics find differences in genes encoding for alcohol metabolizing genes
(High rates among other family members, Twin and adoption studies)
Mechanism of action of alcohol: neurotransmitters
- Positive reinforcement by dopamine action (mesolimbic DA pathway)
- Withdrawal symptoms due to disturbances in GABA and glutamine
Alcohol causes DA activation of neurons in the _______
mesolimbic structures is the main source of feelings of pleasure and therefore extremely rewarding (direct and indirect action)
(all drugs lead to dopamine)
Role of GABA and alcohol withdrawal
- Alcohol potentiates GABA → diminishes receptor sensitivity
- Chronic use of alcohol → reduced potentiation of GABA-mediated chloride flux through the GABAA receptor channel complex ⇒ tolerance
GABA-mediated neurotransmission is decreased in alcohol withdrawal, leading to the _____ symptoms
Thus ______, which also potentiate GABA, are effective against some of the withdrawal symptoms.
- hyperactivity
- benzodiazepines
Role of glutamate in alcohol withdrawal
Alcohol inhibits glutamate at the NMDA receptor→ patient feels calm → chronic use up regulates receptors → alcohol abstinence increases activated tone.
(partial seizures, anxiety & sleep problems)
Alcohol withdrawal symptoms (8)
- Autonomic hyperactivity (sweating or HR > 100)
- Anxiety
- Insomnia
- Hallucinations or Illusions (Transient)
- Psychomotor agitation
- Tremor (hands)
- Seizures
- N/V
(2 or more of the these → alcohol withdrawal)
Alcohol withdrawal is called
Delirium tremens
(because withdrawal can lead to delirium)
Alcohol withdrawal delirium symptoms usually develop shortly after or during withdrawal symptoms and include:
- Disturbance of consciousness with reduced ability to focus, sustain or shift attention
- Change in cognition (such as memory deficits, disorientation, or language) or perceptual disturbance
- Fluctuates during the course of the day
Alcohol withdrawal begins within ______ after sensation or significant decrease in use.
- 12 to 18 hours
(Dr. Slagle says 18-24 hours is more realistic)
Treatment of alcohol withdrawal (4)
- Benzodiazepines (BZD’s) (works similarly to alcohol in binding to GABA receptor) or chlordiazepoxide
- Day 1: aim to markedly depress the withdrawal symptoms, then decrease that amount by 20% over the next four days
- Replace fluids
- Thiamine and folic acid
(Usually accomplished in 5 days)
When are long-acting BZD used to treat alcohol withdrawal?
Those who do not have severe liver disease or brain damage
(diazepam or chlordiazepoxide)
Long-acting benzodiazepines used for alcohol withdrawal
- Diazepam
- Chlordiazepoxide
Short-acting drugs used for alcohol withdrawal
- Oxazepam
- Lorazepam
(more frequent dosing for those with liver or brain damage)
Treating alcohol withdrawal with anticonvulsants such as _______ (3) will prevent seizures, preserve cognition and may aid in relapse prevention.
- valproic acid
- carbamazepine
- gabapentin
Getting patients into treatment: 40% of medical and patient admissions are related to complications of alcohol dependence. Substance use disorders are often undetectable and undiagnosed. How do you help these patients?
- Thorough and accurate substance use history should be part of any medical or psychiatric interview
- SBIRT: Screen, Brief Intervention and Referral to Treatment
(pronounced “S-Birt”)
Goals of assessing substance abuse (4)
- Identify substance abuse
- Accurate diagnosis (including relation to medical or psychiatric problems)
- Be positive: help them believe substance abuse can actively be treated
- Assess patients willingness to change and stage of change
5 stages of change
- Precontemplation: not interested
- Contemplation: aware but not ready to commit
- Preparation: have decided to change
- Action: started modifying Behavior
- Maintenance: preventing relapse
Motivational interviewing is useful in the ______ Stage of Change. Therapist is supportive and non-judgemental. Explore ________. Desired outcome is _______.
(Avoid confrontational questions circumvent defensiveness and create open environment)
- contemplative
- ambivalence about changing addictive behaviors
- resolution of ambivalence and facilitation of increased readiness to consider change
Rehabilitation of alcohol abuse (3)
- CBT: Group & Individual
- 12 step programs ( AA – many choices based on gender, sexual orientation, age, religious focus)
- Tx underlying psychiatric illnesses
(Other therapies such as Network, Family, Couples, Inpatient Programs, Therapeutic Communities)
Pharmacological approach to alcohol dependence to prevent relapse
- Disulfiram
- Naltrexone
- Acamprosate
- Psychiatric medications for tx of co-occurring disorders
Disulfiram (Antabuse) MOA
(Discovered in the 1930s when workers exposed to it became ill after drinking alcohol)
Inhibits aldehyde dehydrogenase → Increasing the concentration of acetaldehyde → flushing, HA, N/V
Disulfiram (antabuse) produces sensations of ______ (4).
- feeling hot
- facial flushing
- pounding headaches
- N/V
Disulfiram (Antabuse) side effects (4)
- Metallic taste
- Sulfur-like odor
- Psychosis
- Neuropathy
(Rarely hepatotoxic)
Disulfiram (antabuse) FDA approved for managing _____.
chronic alcoholics who wish to remain abstinent so that psychotherapeutic treatment might be most effective
(Compliance is an important problem—medication works best if supervised by a spouse or partner)
Dose of disulfiram is usually _____ daily. If the patient decides they want to stop Disulfiram and continue to drink they must wait ______days
- 250 mg
- 5
Opioid antagonist: Alcohol consumption affects the production, release and activity of ____.
opioid peptides
Opioid peptides mediate some of alcohol’s rewarding effects by enhancing ________.
midbrain dopamine (DA) release
(Genetic high risk/FH+ individuals have an exaggerated alcohol-induced rise in Beta-endorphin levels. Naltrexone tx decreases pleasurable effects of EtOH)
________ drug may work best in those whose alcoholic disease is characterized by craving.
Naltrexone 50 mg/day
(Efficacy is best among motivated patients; Depot (IM shot) Naltrexone (Vivitrol), 380 mg once a month, may enhance compliance and has recently become available)
Naltraxone AE (4)
- Anxiety
- Headache
- Nausea
- Sedation
(Cannot be prescribed in patients with severe liver disease or in patients taking opioids)
Excitatory neurotransmitter N-methyl-D-aspartate (NMDA) contributes to alcohol’s _______ (3) effects. Therefore, NMDA antagonists reduce the intensity of ______.
- intoxicating
- cognitive
- dependence-forming
- Post-cessation alcohol craving on exposure to high-risk drinking situations
Acamprosate MOA
NMDA antagonist or inhibitory modulator
(poor bioavailability: 11%, no risk of liver damage)
