Substance Use Disorders Flashcards
What medical problems are commonly associated with alcohol dependance?
- Withdrawal seizures
- Delirium tremens
- Wernicke Korsakoff syndrome
- Cerebellar degeneration
- Peripheral neuropathy
- Fetal alcohol syndrome (low birth weight, mental retardation, facial and cardiac abnormalities)
- Hepatic Encephalopathy
- Malabsorption syndromes
- Pancreatitis
- Cardiomyopathy
- Macrocytic anemia (increased MCV)
- Increased incidence of trauma
What is delirium tremens?
A delirium characterized by disorientation, fluctuation in the level of consciousness, elevated vital signs, and tremors as a result of an abrupt reduction in/cessation of heavy alcohol use
What is Korsakoff Syndrome?
State of amnesia (anterograde and retrograde) with confabulation that develops after chronic alcohol use.
- usually irreversible and also caused by thiamine (B1) deficiency.
What is Wernicke Encephalopathy?
An acute, but reversible encephalopathy resulting from thiamine (B1) deficiency and characterized by the triad of: delirium, opthalmoplegia (CN VI), and ataxia
What is the mechanism of action of Disulfiram (antabuse)?
Disulfiram blocks the enzyme acetaldehyde dehydrogenase => leads to nausea and vomiting upon consumption of alcohol
What is the mechanism of action of Naltrexone?
Naltrexone is an opioid antagonist and is believed to reduce the craving for alcohol through blocking the dopaminergic (rewarding) pathways in the brain
What is the mechanism of action of Acamprosate?
Acamprosate’s mechanism is unknown but is though to stabilize glutamtergic functioning => improves abstinence
How should thiamine be administered in relation to glucose in Wernicke encephalopathy?
IV thiamine should be given PRIOR to IV glucose administration
- giving dextrose before thiamine will exacerbate the process of cell death and worsen the condition because thiamine is a coenzyme used in carbohydrate metabolism
What behavioral changes are seen in cocaine use (narcotic)?
- Euphoria or blunting of feelings
- Hypervigilance or hypersensitivity
- Heightened anxiety or irritability/anger
- Impaired judgment
What physical changes are see in cocaine intoxication?
- Dilated pupils
- Autonomic instability: increased blood pressure, tachycardia (or bradycardia)
- Chills/sweating
- Nausea/vomiting
- Psychomotor agitation/retardation
- Chest pain/ arrhythmia
- Confusion, seizures, stupor, or coma
- Weight loss
What are the major health risks of cocaine use/dependance?
- cerebral infarctions
- transient ischemic attacks
- seizures
- myocardial infarctions
- cardiomyopathies
What are the symptoms of cocaine withdrawal?
- Cocaine withdrawal can last 2-4 days (or longer in heavy use)
- Dysphoria/ depression with suicidal ideation
- Irritability
- Anxiety
- Increased appetite
- Hypersomnia
- Cocaine cravings
What kind of hallucinations tend to occur 12-24 hours after alcohol abstinence in an alcohol dependent individual?
Patients dependent on alcohol who abstain from drinking may initially have visual hallucinations; however, they are often aware these are hallucinations
What is the mechanism of action of disulfiram/antabuse?
Inhibits Acetaldehyde Dehydrogenase => causing acetaldehyde to accumulate leading to acetaldehyde syndrome that can occur minutes after EtOH is consumed
- If alcohol is consumed while taking disulfiram: flushing, palpitations, n/v, diaphoresis, chest pain, etc. Severe rxns can lead to resp depression, CVS collapse (shock), seizures; death
Which drug is used to maintain alcohol abstinence after detox?
Acamprosate/campral
Why should acramprosate not be used in patients with renal disease?
Can cause acute renal failure
What are the indications for Naltrexone/ReVia?
- Chronic EtOH dependence
- Opiate addiction (does not decrease cravings)
What is the mechanism of action of Naltrexone?
Opioid mu receptor antagonist
What is the potential toxicity for Naltrexone?
Liver toxicity
What is the mechanism of action of Buprenorphrine/Naloxone/Suboxone?
Is a mixed opioid agonist (Buprenorphine) & antagonist (Naloxone) used to tx opioid dependence
What is the indication of Naloxone/buprenorphine?
Naloxone given to decrease pleasure/”high” of Buprenorphine & to deter abuse of medication via IV use
What is the indication of methadone?
µ-opioid receptor agonist used for severe chronic pain and detox/maintenance of opiate addiction
What is the mechanism of action of methadone?
Has cross tolereance with other opiods thus blocks access of opioids (heroin, morphine) to µ-opiate receptors, decreasing euphoric effects and craving of opiates
Why should a baseline EKG be taken before using methadone?
Can prolong QTc this baseline EKG recommeded
Describe the action of alcohol on the brain.
- Activates GABA and serotonin receptors in the CNS
- Inhibits glutamate receptors and voltage gated calcium channels
- Thus alcohol is a potent CNS depressant
What is the leading cause of mental retardation in the U.S.?
Fetal alcohol syndrome
What substances are a common cause of metabolic acidosis with an increased anion gap?
- Ethanol
- Methanol
- Ethylene glycol
What is the next step in treating alcohol intoxication?
- Monitor airway, breathing, circulation, glucose, electrolytes, and acid-base status
- Give thiamine and folate (folic acid)
- If opioids were ingested give naloxone
- CT may be necessary to rule out subdural hematoma or other brain injury
- Check for signs of hepatic failure (ascites, jaundice, kaput medusae, coagulopathy)
Describe the presentation of alcohol withdrawal.
- Compensatory CNS excitation (as intoxication is characterized by inhibition)
- Can be lethal
- Insomnia, anxiety, hand tremor, irritability, anorexia, N/V
- Autonomic hyperactivity (diaphoresis, tachycardia, hypertension)
- Psychomotor agitation
- Fever, seizures, hallucinations, delirium
When do the earliest signs of EtOH withdrawal occur?
6-24 hours after the patient’s last drink
When might tonic clonic seizures occur in alcohol withdrawal?
6-48hrs after cessation of drinking
What may predispose patients undergoing alcohol withdrawal to seizures?
Hypomagnesemia
What is the treatment for alcohol withdrawal seizures?
Benzodiazepines and anticonvulsants (phenytoin)
What is the most serious effect of alcohol withdrawal?
- Delirium Tremens
- Begins 48-72 hours after the last drink (but may occur later)
- Delirium, (visual) hallucinations, tremor, autonomic instability, fluctuating levels of psychomotor activity
- Tx with benzodiazepines
What liver function tests suggest excessive alcohol use?
AST: ALT > 2:1
Elevated GGT
- alcohol use can also cause macrocytosis (Increased MCV)
In what conditions is disulfiram/antabuse contraindicated in?
- Severe cardiac disease
- Pregnancy
- Psychosis
What is the mechanism of action of acamprosate/campral?
- Structurally similar to GABA => inhibits the glutamatergic system
What is the indication for acamprosate/campral?
- Used postdetoxification to prevent relapse
- CAN be used in patients with liver disease
In what group of patients is acamprosate/campral contraindicated in?
Patients with renal disease
How does topiramate/topamax work as an anti-alcohol abuse drug?
- Potentiates GABA and inhibits glutamate receptors
- Reduces cravings for alcohol
Describe the action of cocaine on the brain
Cocaine blocks dopamine reuptake from the synaptic cleft, causing a stimulant effect
What are the signs of cocaine intoxication?
- Euphoria, increased self esteem, change in BP, change in heart rate, nausea, dilated pupils, weight loss, psychomotor changes, chills, and sweating
What are the dangerous symptoms associated with cocaine intoxication?
- Respiratory depression
- Seizures
- Arrhythmias
- Paranoia and hallucinations
What are the deadly effects of cocaine intoxication?
- Cocaine’s vasoconstrictive effect may result in myocardial infarction or stroke.
How do you manage cocaine intoxication?
- Agitation and anxiety => benzodiazepines
- Severe agitation and/or psychosis => antipsychotics (haloperidol)
- Symptomatic support => hypertension, arrhythmias
- Temperature >102 is medical emergency => ice bath, cooling blanket, etc
What are the symptoms of cocaine withdrawal?
- NOT life threatening
- Malaise, fatigue, hypersomnolence, depression, hunger, constricted pupils, vivid dreams, occasionally suicidal
What are the effect of amphetamines on the CNS?
- Block reuptake and facilitate release of dopamine and norepinephrine from nerve endings => stimulant effect
What are the symptoms of amphetamine intoxication?
- Dilated pupils
- Increased libido
- Perspiration
- Respiratory depression
- Chest pain
What is the medical use of amphetamines?
- Treatment of: narcolepsy, ADHD, depressive disorders
How are designer amphetamines (club drugs) different from other amphetamines?
- Release dopamine, norepinephrine, AND serotonin from nerve endings
- stimulant and hallucinogenic properties
- May induce a sense of closeness to others (MDMA/MDEA)
What are some signs of chronic amphetamine use?
- Acne
- Accelerated tooth decay
What are signs of amphetamine overdose?
- Hyperthermia
- Dehydration
- Rhadomyolysis => renal failure
What are the symptoms of ketamine intoxication (special K)?
- Tachycardia
- Tachypnea
- Hallucinations
- Amnesia
- Odorless and tasteless=> can be used as a date rape drug
How is amphetamine intoxication treated?
- Rehydrate
- Correct electrolyte balance
- Treat hyperthermia
What is the mechanism of action of PCP/angel dust?
- Dissociative hallucinogenic drug that antagonizes NMDA glutamate receptors and activates dopaminergic neurons
- Stimulant OR depressive effect dependent on the dose
What are the signs/symptoms of PCP intoxication?
- Agitation, depersonalization, hallucinations, synesthesia
- Impaired judgment, memory impairment, assaultiveness/VIOLENCE
- Nystagmus (rotary, horizontal, or vertical)
- Rotary nystagmus is pathognomonic for PCP intoxication
- Ataxia, dysarthria
- Hypertension, tachycardia, dry/red skin
- Dilated pupils
- Muscle rigidity and high tolerance to pain
What are the potential consequences of PCP overdose?
- Seizures, coma and death
How should PCP intoxication be treated?
- Monitor vitals, temperature, and electrolytes, minimize sensory stimulation
- Benzodiazepines (lorazepam) for agitation, anxiety, muscle spasms, and seizures
- Antipsychotics (haloperidol) to treat severe agitation and psychotic symptoms
What withdrawal symptoms are associated with PCP use?
- NO withdrawal symptoms
- However, “flashbacks” may occur due to drug release from adipose stores
What is the mechanism of action of benzodiazepines?
- Potentiate the effects of GABA by increasing the frequency of chloride channel opening (inhibitory)
What is the mechanism of action of barbiturates?
- Potentiate the effects of GABA by increasing the duration of chloride channel opening
Which drug withdrawal has the highest mortality?
- Barbiturate withdrawal has the highest mortality rate
What is the clinical presentation of sedative (benzodiazipines/barbiturates) intoxication?
- Drowsiness, confusion, hypotension, slurred speech, incoordination, ataxia
- Mood lability, impaired judgment
- Nystagmus, respiratory depression, coma, death
What is used to treat benzodiazepine overdose and what is the primary precaution?
- Flumazenil is a short acting benzodiazepine antagonist
- Should be used with caution as it may precipitate seizures
What is the treatment for sedative intoxication?
- Maintain airway, breathing and circulation, monitor vitals
- Activated charcoal and gastric lavage to prevent GI absorption if drug was ingested in the last 4-6 hours
- Barbiturates => alkalinize urine with sodium bicarbonate to promote renal excretion
- Benzodiazepines => give flumazenil
In general what is the major difference between sedative and stimulant withdrawals?
- Sedative withdrawal can be life threatening (too much sympathetic response)
- Stimulant withdrawal is not generally life threatening
Sedative withdrawal symptoms are the same as which other drug?
Sedative withdrawal symptoms are the same as EtOH withdrawal
What is the treatment for sedative withdrawal?
- Benzodiazepine taper
- Carbamazepine or valproic acid taper may be used for seizure prevention
What are the signs/symptoms of opiate intoxication?
- Nausea/ vomiting
- Sedation
- Decreased pain perception
- Decreased GI motility
- Pupil constriction
- Respiratory depression (lethal)
Which opioid is the exception in that it produces miosis?
Meperidine/Demerol dilates pupils
What are the symptoms of opioid overdose?
- Respiratory depression
- Altered mental status
- Miosis
What is the mechanism of action of opioids?
- Stimulate opiate receptors (mu, kappa, and delta), which are normally stimulated by endogenous opiates and are involved in analgesia, sedation, and dependence
What are examples of opiates?
- Heroin
- Oxycodone (hydrocodone)
- Codeine
- Dextromethorphan
- Morphine
- Methadone
- Meperidine
What opiate and MAOIs can cause serotonin syndrome?
Meperidine and MAOIs can cause serotonin syndrome (hyperthermia, confusion, changes in BP, and muscular rigidity)
What is the treatment of opioid intoxication?
- Ensure adequate airway, breathing and circulation
- Naloxone or naltrexone => will improve respiratory depression but may cause severe withdrawal
- Possible ventilatory support
What drug is the gold standard in treating pregnant opioid dependent women?
Methadone => long acting opioid receptor agonist
What is the major risk in using methadone to treat opioid dependance?
Methadone can cause QT interval prolongation => get baseline EKG
What is buprenorphine?
Buprenorphine is a sublingual preparation that is safer than methadone for opioid dependence.
- Its effect reaches a plateau and makes overdose unlikely
What is the mechanism of action of Naltrexone?
- Competitive opioid antagonist
- Can precipitate withdrawal if used within 7 days of heroin use
What are the symptoms of withdrawal in opioid dependence?
- Not life threatening
- Dysphoria, insomnia
- Lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection
- Nausea, vomiting, fever
- Dilated pupils, abdominal cramps, arthralgia, myalgia
- Hypertension, tachycardia, and craving
How is opioid withdrawal treated?
- Moderate symptoms => symptomatic tx with clonidine (autonomic signs), NSAIDs (pain), Discyclomine (abdominal cramps)
- Severe symptoms => Detox with buprenorphine or methadone
What are the signs of hallucinogen intoxication?
- Illusions, hallucinations, body distortions, synesthesia, labile affect
- Dilated pupils, tachycardia, hypertension, hyperthermia, tremors, incoordination, sweating and palpitations
How is hallucinogen intoxication treated?
- Benzodiazepines and antipsychotics as needed for agitated psychosis
What is the mechanism of action of cannabis?
- Cannabinoid receptors in the brain inhibit adenylate cyclase
What are the signs of marijuana use?
- Euphoria, anxiety, impaired motor coordination, perceptual disturbances, mild tachycardia, anxiety, red eyes (conjunctival injection), dry mouth, and increased appetite
What are the withdrawal symptoms associated with marijuana use?
- Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, sweating, insomnia, nausea, craving, and decreased appetite
Cigarette smoking during pregnancy is associated with what conditions in the newborn?
- Pulmonary hypertension of the newborn
- Low birth weight
