Substance Use Disorders Flashcards
Define substance related disorder
- Progressive disease
- Use of psychoactive substances to the point of impaired functioning in health, occupation, psychosocial
- Sometimes fatal
Approximately how many over the age of 12 have used alcohol?
Over 51%
Approximately how much of the US population has used illicit substances?
40%
Epidemiology of substance abuse disorders
- Males, whites (55%)
- Co-morbid psych conditions (60-75%)
Alcohol use in the US?
On the decline in recent years
How many people who use alcohol become dependent for some period of time?
1 in 5
Cocaine use in the US?
Has remained fairly steady since its peak in the 1980s and early 1990s
What substance is on the rise in rural communities?
Crystal meth
Base ingredient of methamphetamine?
Pseudoephedrine
Effect of alcohol in low doses?
- Depress inhibitory centers
- Disinhibition leading to out of character activities
Effect of alcohol in higher doses?
Inhibition of excitatory centers
What type of alcohol is most consumed in US?
Beer (57%)
Liquor (30%)
What does 12 grams of alcohol equal?
- 12 oz can of beer
- 5 oz glass of wine
- 1.5 oz hard liquor
How much alcohol can a chronic alcoholic consume in a day?
Over a liter per day of hard liquor
Recommended alcohol use per day in men and women?
3 drinks/day for men
2 drinks/day for women
What is considered excessive alcohol use per day for men and women?
Over 4 drinks/day for men
Over 3 drinks/day for women
CAGE screening?
Used for any drug/addiction
- Cut down
- Annoyed
- Guilty
- Eye opener
Define anterograde amnesia
- “Black outs”
- Can’t remember what happened during or after drinking
- 64-90% of alcoholics experience black outs
Risk factors for anterograde amnesia
- Drinking on empty stomach
- Lack of sleep
What is the CIWA protocol?
- Clinical Institute Withdrawal Assessment
- Started on any pt admitted to hospital w/potential symptoms of alcohol withdrawal
Sample CIWA protocol
- Record BAC by breathalyzer on admission
- Vital signs
- Obtain serum glucose, HFP, CMP, CBC w/diff, urine for drug screen
- Give thiamine
During CIWA protocol, when should physician be called?
- Abnormal vitals (HR over 110, DBP over 120, SBP over 180)
- If pt requires over 6 mg of Lorazepam in 3 hours
Pharm treatment of alcohol use disorder
- Disulfiram
- Naltrexone
- Acamprosate
Describe Disulfiram
- Inhibits aldehyde dehydrogenase
- Use only temporarily to help establish sobriety
- Do NOT use if patient is intoxicated
Side effects of Disulfiram
When used with ETOH:
- Flushing
- HA
- Tachy, SOB, hypotension
Naltrexone MOA
Blocks endogenous opioid release which decreases ETOH craving
Describe Acamprosate
- Reduces craving for alcohol
- May involve both inhibitory and excitatory neuronal activity
- For abstinent pts only
Treatment programs for alcohol use disorder
- Detox (inpatient or outpatient)
- Rehab (inpatient)
- AA
Define abuse
Use of any drug outside of social precepts
Define misuse
Like abuse, but referring to prescribed meds
Define psychological dependence
Subjective sense for the need of a mind alerting substance for its positive effects OR to avoid negative effects
Define intoxication
Reversible condition due to a psychoactive substance affecting various mental functions
Define tolerance
Drug no longer produces same effect of original lower dose after repeated doses
Define behavioral tolerance
Ability to perform tasks under the influence of higher doses of psychoactive drugs
Describe addiction
- No longer officially used
- Replaced by “dependence”
Define dependence
- Repeated use of a drug with or w/o physical dependence
- Can escalate to physical dependence (resulting in tolerance/withdrawal symptoms)
Describe physical dependence that results in addiction
Abnormal response to physical dependence that results in:
- History of prior drug use
- Out of control use
- Sacrificing responsibilities
- Inability to hold a job
- Encounters w/law enforcement
Describe physical dependence that does NOT result in addiction
- Pseudo-addiction
- Can be physically dependent without a change in behavior
Factors to consider with substance disorders
- Addicting agent’s characteristics
- Host variables (the user)
- Environment
What is important to evaluate regarding the addicting agent’s characteristics in substance disorder?
- Degree of euphoria
- Reinforcement property (higher capacity to create desire = higher addiction risk)
- Rapidity of onset (based on specific drug AND route)
What is important to evaluate regarding the user in a substance disorder?
- Genetics (fam hx?)
- Underlying psych disease (greater addiction risk)
What is important to evaluate regarding the environment of someone with a substance disorder?
- Societal norms
- Peer pressure
- Rebellious against authority
- Income, education
Describe phencyclidine
- PCP, angel dust
- Anesthetic w/hallucinatory effects
- Can be smoked, injected, inhaled, eaten
Neuropsych effects of PCP
- Hallucinations
- No regard for their body (can easily hurt themselves/others)
- HTN
Treatment of acute PCP intoxication
- Seclude in quiet area
- Restrain to protect pt and others
- Use BZD for acute agitation
- Use Haldol if agitated AND psychotic
- Evaluate for co-existing diseases
Recovery from acute PCP intoxication?
Usually self limited and rapid
Opioids are deadly when taken with:
Alcohol
What are opioids?
Synthetic opiates
Types of opioids
- Natural (morphine, codeine)
- Semi synthetic (heroin)
- Synthetic (dilaudid, methadone, oxycodone)
What is dextromethophan?
- Opioid
- Cough suppressant
- Used by pre-teens and teens
- Hallucinations, resp depression, coma, rhabdo
Describe heroin use
- Males, 30-40s
- Routes: injected (IV/SC), inhaled, combined with cocaine IV (speedball)
Neuropsych effects of heroin
- CNS depression
- NV
- Miosis
- Euphoria
Life threatening effects of heroin
- Resp depression
- Decreased mental status (obtundation)
- Decreased tidal wave
- Hypoglycemia
- Pupillary miosis
Opioid OD treatment
- IV Naloxone
- IV hydration
- ICU admission
What is one of the most addictive drugs?
Cocaine because of intense exuberant euphoria lasting days (w/repeated use)
Clinical presentation of cocaine intoxication
- Can look like bipolar cycling
- Crashes are followed by profound fatigue, depression
What is the highest risk of cocaine addiction?
Freebasing (injecting/smoking)
Epidemiology of cocaine abuse
- Males
- 18-25 yo
- No difference in SES/race
Most prominent sign of cocaine withdrawal?
Intense cocaine craving
How should Haldol be given?
At lowest therapeutic doses (it can lower seizure threshold)
What is the MC abused illicit drug?
Marijuana
Who MC overuses marijuana?
Whites
Consequences of very high doses of marijuana
- Mild delirium w/panic symptoms
- Can see prolonged cannabis psychosis up to 6 wks
Chronic use of marijuana can lead to:
Apathetic amotivational syndrome
Treatment of marijuana overdose
- Anxiolytics for anxiety
- Antipsychotics for psychosis
Describe depressants
- Downers, barbs, benzos
- Diazepam, alprazolam
Treatment of depressant overdose
ABCs Flumazenil IV (antidote)
Describe ketamine
- Animal tranquilizer
- Depressant
- Anesthetic like effects
- Anterograde amnesia
Describe K-hole
With abuse of ketamine
- Near death experience
- Depersonalization
- Paralysis
How do amphetamines work?
- Releases DA into cortex via reward pathway (mesolimbic)
- Produces psychotic like symptoms when taken in high doses
- Effects similar to cocaine
Which route of amphetamines is less addictive?
PO - less euphoria too
Treatment for acute intoxication of amphetamines
Short acting BZDs for agitation
What are bath salts?
- Amphetamine like stimulant
- Synthetic cathinone
Treatment of acute intoxication of bath salts
- IV Lorazepam or Diazepam every 3 mins until calm
- Restraints
- NO antipsychotics (increased QT, hyperthermia, seizures)
What shouldn’t be given in acute intoxication of bath salts and why?
NO antipsychotics (increased QT, hyperthermia, seizures)
Effects of inhalants
One inhalation can cause immediate death
- Anesthesia
- Unconsciousness
- Heart failure
- Suffocation (hypoxia)
- Coma and death
Treatment of inhalant overdose
ABCs
Anti-arrhythmics
What are the common prescription drugs of abuse?
Narcotics
Stimulants
Sedatives
Components of ED evaluation for substance abuse disorders
- Assess need for treatment
- Placement into appropriate treatment
- Determination of physical suitability for treatment (medical clearance)
Which drug often causes fear of intimacy and inhibitions?
Alcohol
Which drug often causes low self-esteem?
Cocaine
Which drug often causes uncontrolled anger?
Heroin and opiates
Single positive response to CAGE?
Suggestive of an alcohol problem
2 or more positive responses to CAGE?
Presence of alcohol problem (90% sensitivity/specificity)
Should alcohol intake be quantified before or after CAGE questions?
Ask quantity of alcohol intake AFTER CAGE
CAGE score is less accurate in which patients?
White females
What alcohol screening tool is recommended for white females?
TWEAK Tolerance Worried Eye openers Amnesia K (cut down)
Most popular drug screen test?
Urine
- Yields detectable concentration for most drugs than other sample sites (blood)
- Does not measure impairment
What do all chronic alcoholics in the ED get?
“Banana bag”
- Thiamine 200 mg
- Folate 1 mg
- MVI
