Substance Use Disorders Flashcards
What are some signs of inhalant intoxication
dizziness, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depression of reflexes, psychomotor retardation, tremor, generalized muscle weakness, blurred vision, diplopia, stupor, coma, euphoria
What are the 10 classes of substances?
1 - alcohol
2 - caffeine
3 - cannabis
4 - hallucinogens (phenylcyclidine)
5 - inhalants
6 - opioids
7 - sedatives/hypnotics/anxiolytics
8 - stimulants
9 - tobacco
10 - other
What is the general severity specifier for substance use disorders?
Mild - presence of two or three symptoms
Moderate - presence of four or five symptoms
Severe - presence of 6 or more symptoms
What are the DSM 5 criteria for alcohol use disorder?
A - problematic pattern of alcohol use leading to clinically significant impairment of distress as manifested by at least two of the following in a 12 month period
1 - often taken in larger amounts or over a longer period than intended
2 - persistent desire or unsuccessful efforts to cut down or control use
3 - great deal of time spent in activities necessary to obtain alcohol, use alcohol or recover from its effects
4 - craving or strong desire/urge to use alcohol
5 - use resulting in failure to fulfil major role obligations at work, school or home
6 - continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol
7 - important social, occupational or recreational activities are given up or reduced because of alcohol use
8 - recurrent use in situations where it would be physically hazardous
9 - alcohol use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
10 - tolerance - either a need for markedly increased amounts of alcohol to achieve the same intoxication or desired effect or a markedly diminished effect with continued use of the same amount of alcohol
11 - withdrawal - either having the classic withdrawal syndrome or alcohol is taken to relieve or avoid symptoms.
What are the clinical signs of opioid intoxication or OD
Respiratory depression
Unconsciousness
Pinpoint pupils
Behavioral and psychological changes such as apathy, dysphoria
Psychomotor agitation or retardation
Slurred speech, impaired attention or memory
What are some of the physical signs and symptoms of both short term and sustained opioid use
Dry mouth
Constipation - slows gut motility
Sclerosed veins and many puncture sites
If all veins are sclerosed, individuals may inject directly into the skin causing cellulitis, abscesses and tetanus
Bacterial endocarditis
HIV infection
Hepatitis C infection
Tuberculosis - (??)
Perforation of the nasal septum
Sexual dysfunction
Increased sensitivity to pain
Dependence among neonates
Sweating
Depressed cognitive functioning
Resp depression
What are the signs and symptoms of opioid withdrawal?
Dysphoric mood
Nausea and vomiting
Muscles aches
Lacrimation
Rhinorrhea
Pupil dilation
Piloerection
Sweating
Diarrhea
Yawning
Fever
Insomnia
Anxiety and restlessness
Pain - arthralgia and myalgia
Tachycardia
Miscarriage
What are the signs and symptoms of sedative intoxication?
Slurred speech
Incoordination
Unsteady gait
Nystagmus
Stupor
Coma
What are some of the physical and physiological effects of stimulants?
Short Term
Decreased appetite
Increased energy
Elevated temperature
Irregular heartbeat
Increased blood pressure
Seizures
Manic episodes
Paranoia
Aggression
Confusion
Tactile hallucinations
Loss of smell
Nose bleed
Inflamed runny nose
Lung damage and infections
HIV and Hep C for injectables
Long Term
Addiction
Suicidal ideation
Poor interpersonal relationships
Weight loss and wasting
What are some signs and symptoms of alcohol withdrawal?
Anxiety and restlessness
Insomnia
PDs
N and V
Diaphoresis
Tachycardia
Tremors
Psychosis
Seizures
Delirium tremens - decreased LOC, disorientation, tachycardia, hypertension, agitation, hallucinations - generally visual but may also be tactile or auditory
Treatment is long acting benzos such as clonazepam, monitor vitals, fluid resuscitation, vitamin B complex, thiamine, taper down the benzos slowly
What are some pharmacological options for the treatment of stimulant use disorder?
Modafinil and topiramate
What are some of the signs and symptoms of stimulant intoxication?
Tachycardia
Bradycardia
Pupillary dilatation
Elevated or low blood pressure
Perspiration or chills
N and V
Weight loss
Psychomotor agitation or retardation
Muscle weakness
Resp depression
Cardiac arrhythmias
Confusion
Coma
Dyskinesia or seizures
What are some of the signs and symptoms or stimulant withdrawal?
Dysphoric mood
Fatigue
Vivid unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor agitation or retardation
Describe the MOA of cocaine
Increases monoamine neurotransmitter activity in the central and peripheral nervous system through the blockade of presynaptic reuptake pumps - basically like a antidepressant MOA
Increase in dopamine in the corticomesolimbic pathway have proven to play a large role in its addictive qualities
The second MOA is that it blocks sodium ion channels, creating an anesthetic effect
Powder form is easily absorbed into any mucosal membrane
Comment briefly on the MOA of amphetamines
Sympathomimetic amine
Comment briefly on the MOA of metcathinone
Blocks reuptake of dopamine, norepinephrine and sodium
Stimulates dopamine release
What are some of the signs and symptoms of tobacco withdrawal?
Irritability
Frustration
Anger
Anxiety
Difficulty concentrating
Increased appetite
Restlessness
Depressed mood
Insomnia
What are some of the prominent symptoms of cocaine withdrawal?
Depression
Anorexia
Insomnia
Vivid unpleasant dreams
Severe cravings
Hypersomnia
Hyperphagia
Pregnancy - miscarriage
Cocaine withdrawal occurs in phases
What are some of the more severe effects of cocaine intoxication and how do you manage them?
CVS - tachy or brady, hypertension or hypotension, dose dependent risk of cardiac ischaemia. Reduced cardiac output with severe tachy
CNS - hyperthermia, dilated pupils, panic and seizures
Resp - resp depression, angioedema, pharyngeal burns, pulmonary embolism
GIT - N and V, perforation of peptic ulcers, bowel ischemia
Placental abruption
End organ toxicity in virtually every organ system, primarily through the hemodynamic effects
Management
Sedation
BP control
Heart rate control
Temp regulation - aggressive sedation, neuromuscular paralysis with a non-depolarizing paralytic agent
Antipyretics have no role in the treatment
Fluid resuscitation
What are some of the key steps in motivational interviewing?
Empathy
Ask Open questions
Listen with acceptance and reflectively
Affirm, compliment and use statements of appreciation
Summarize - use to link together and reinforce the material
Elicit self-motivating statements
Recognizing disadvantages of the status quo and the advantages of chance
Avoid argumentation and avoid confronting denial, rather encourage change
Roll with resistance - divert the client towards positive change
Develop discrepancy - promote awareness of consequences of continuous use
Support self-efficacy and elicit and support hope
Briefly comment on how opioids have both their analgesic and euphoric effects
Analgesic effects - inhibition of nociceptive information
Euphoric effects - increase dopamine release in the mesolimbic system
Comment briefly on the MOA of cannabis
Cannabinoid receptors are found in the central nervous system in the basal ganglia, substantia nigra, cerebellum, hippocampus and cerebral cortex.
Cannabis inhibits the release of multiple neurotransmitters including acetylcholine, L-glutamate, GABA, norepinephrine, dopamine
What are the signs and symptoms of cannabis intoxication?
Euphoria
Anxiety
Dysphoria
Paranoia
Tachycardia
Postural hypotension
Increased resp rate
Red eyes
Dry mouth
Increased appetite
Ataxia
Nystagmus
Slurred speech
Perceptual disturbance
Impairment in memory, attention, complex processing faculties
What are the signs and symptoms of cannabis withdrawal?
Unexplained mood changes
Restlessness
Aggression
Sleep disturbance
Decreased appetite or weight loss
Abdominal pain
Tremors
Headache
What are some of the long term effects of inhalant use?
Neurocognitive impairment
Cerebellar dysfunction
Peripheral neuropathy
What is a possible serious effect of inhalant withdrawal?
Increased susceptibility to seizures
Which areas of the brain are involved in the reward pathway?
Nucleus accumbens
Ventral tegmental area
Frontal cortex
How does alcohol’s effect on GABA receptors cause the depressive effects?
GABA is the major inhibitory neurotransmitter in the CNS. And this brings about the calming effect.
Alcohol enhances GABA’s effect
Chronic alcohol use causes a decrease in the GABA receptor function which means that there is a resistant GABA system - tolerance
Cessation causes a marked decrease in GABA activity
How does alcohol have an effect on NMDA receptors and action?
NMDA/glutamate causes neuronal firing - “accelerator”
NMDA activity is inhibited which causes a decrease in brain excitability
Chronic exposure causes an up-regulation of these receptors which means that they are more sensitive to glutamate
This means that stopping drinking causes an increase in NMDA activity which causes the glutamate mediated neuronal excito-toxicity
The mnemonic PAST-NITE lists the symptoms of acute alcohol withdrawal
What does it stand for?
P - perceptual abnormalities
A - agitation
S - seizures
T - tremor
N - nausea and vomiting
I - insomnia
T - tachycardia - autonomic hyperactivity (hr, BP, sweating etc)
anxiEty
What is the advised schedule for alcohol detoxification?
Thiamine 300mg oral daily for 14 days
Diazepam oral 10mg stat
Then 5mg 6hrly for 3 days
Then 5mg 12hrly for 2 days
Then 5mg daily for 2 days
Then stop
Describe the course of delirium tremens
Initial phase
- onset generally at night
- starts with restlessness, fear and insomnia
Intermediate phase
- ataxia
- tremor
- extreme agitation
- confusion
Late stage
- autonomic instability - sweating, flushing, pupillary dilatation, rapid thready pulse
- profuse illusions and hallucinations - loss of sense of reality and strong emotional responses
Seizures in 30% of patients that can progress to status is the last stage of DTs
Which patients should definitely be admitted for inpatient detoxification?
past convulsions
past psychosis
suicidal ideation
significant medical co-morbidity such as heart failure or liver disease
inadequate support at home
history of DTs
Greater than 60 years
Pregnant
Previous failed outpatient detox
Is there value in the use of antipsychotics in alcohol detoxification?
Useful in cases of severe agitation and restlessness - haloperidol 5mg imi/ivi to a maximum of 20mg per 24 hours
can convert to oral therapy
Haloperidol 0.5 - 5mg TDS
Or Risperidone 0.5 - 1mg 12 hourly
What is a rough guide to the tapering of benzos?
Replace all short acting benzos with an equivalent diazepam dose (to a maximum of 30mg per 24 hours)
Reduce by 10% of the dose every 2 weeks
Approximately 2.5mg
Which scale is used when considering tapering or stopping of opioids?
OOWS
Objective opioid withdrawal scale
What drugs are used for opioid substitution?
Methadone
Buprenorphrine
What are some of the risks of using methadone?
Long-acting opioid agonist that is a full agonist and therefore carries a risk for opioid overdose - increased risk when used in conjunction with other CNS depressants
Causes QTc prolongation
Hepatic and renal dysfunction
Describe the methadone regime?
Day 1 - if objective clinical signs are present
Methadone 5mg
If symptoms still present in 2 hours, give another 5mg and repeat if needed
The initial dose that successfully repressed the withdrawal symptoms can be repeated in 12 hours
Not to exceed 30mg in 24 hours
Day 2 - Repeat the total dose from Day 1 in 2 divided doses
If signs and symptoms not controlled, top doses of 5mg can be given at 2-4hhrly intervals
Day 3 onwards
Reduce the dose by 2mg per day
Comment on the relationship between cannabis and psychiatric disorders
- Cannabis induced psychosis
- Heavy cannabis use at a young age is associated with an 6x increased risk of later development of schizophrenia
- Amotivational syndrome can mimic the negative symptoms seen in schizophrenia - apathy, poor attention, concentration, memory, reduced goal-directed behavior and drive, poor personal hygiene
- Long term impairment in attention, memory and ability to process complex information
- panic attacks and anxiety in 20% of patients
- Major depressive disorder and persistent depressive disorder
Describe the FRAMES Model of Brief Intervention
F - feedback - give feedback to the patient about their personal risk of impairment
R - responsibility - emphasis on the personal responsibility for change
A - advice - give clear advice to change
M - menu - menu of alternative change options
E - empathy - therapeutic empathy as a counselling style
What are the alcohol metabolizing enzymes?
Alcohol dehydrogenase and aldehyde dehydrogenase
What is a structured assessment tool that can be used in screening for alcohol use disorder?
AUDIT tool
Alcohol use disorders identification test
SADQ
Severity of Alcohol Dependence Questionnaire
What is an important note about Phenytoin?
It does not prevent alcohol withdrawal related seizures when used on its own or in combination with benzos
Which tools are useful in managing alcohol withdrawal?
Clinical Institute Withdrawal Assessment of Alcohol Scale Revised
Short Alcohol Withdrawal Scale
The useful mnemonic for phenylcyclidine (angle dust) intoxication is MAP STAMP. What does it stand for?
M - muscle rigidity
A - acute sense of hearing
P - pain - numbness to pain
S - seizures or coma
T - tachycardia or hypertension
A - ataxia
N - nystagmus
D - dysarthria
What are the active compounds in inhalants?
include acetone/benzene and toulene
What are some of the possible life-threatening complications of inhalant use?
Respiratory/cardiac arrest
Irreversible hepatic/renal damage
Rhabdomyolysis
