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Psychiatry Clerkship > Substance Use Disorders > Flashcards

Substance Use Disorders Flashcards

1
Q

What is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment for people with SUDs and those at risk of developing them?

A

SBIRT (most widely used approach to early detection and response to SUDs)

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2
Q

What does SBIRT stand for?

A

Screening
Brief Intervention
Referral to Treatment

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3
Q

What are the core components of SBIRT?

A
  • Brief but comprehensive
  • Universal screening tool
  • 1+ specific behaviors are targeted
  • Occurs primarily in a non-substance use treatment healthcare setting
  • Strong research/evidence supporting effectiveness
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4
Q

___% people in the US age 12+ y/o meet medical criteria for addiction?

A

1/6 (~17%)

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5
Q

___ of the US population use addictive substances that can threaten their health and safety or that of others?

A

1/3

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6
Q

What is the largest preventable and most costly health problem in the US?

A

Risky substance use and addiction

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7
Q

___% of cases of addiction begin or are triggered by substance use before age 21 when the brain is still developing.

A

90

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8
Q

What is the critical period of risk for substance use and resulting consequences?

A

Adolescence

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9
Q

What occurs in screening via SBIRT?

A

Quick assessment of risky substance use and identification of the appropriate level of response

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10
Q

What is the NIAAA one question approach?

A

Do you sometimes drink beer, wine, or other alcohol beverages?

No - screen complete
Yes - ask how many times in the past year have you had 5+ (or 4+ for women) drinks in a day? - positive if 1+ heavy drinking days

How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reason? - >1 positive

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11
Q

List the screening assessments that can be done.

A
  1. AUDIT (Alcohol Use Disorders Identification Test) - 10 brief questions
  2. DAST-10 (Drug Abuse Screening Test) - 10 questions, previous 12 months
  3. CRAFFT for Adolescents
  4. ASSIST - 7 questions about each of 1 of 10 substances and 1 question about injection drug use
  5. CAGE-AID (includes drugs)
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12
Q

CRAFFT?

A

Car (ridden in a car driven by someone who was high or using alcohol/drugs)
Relax
Alone
Forget (forget things you did while using)
Family (cut down)
Friends
Trouble

1 point for each yes answer
2 or more positive items indicates need for further assessment

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13
Q

AUDIT Scores?

A 
0 = abstainers
1-7 = low risk drinkers
8-19 = high risk drinkers
20+ = probable alcohol dependence
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14
Q

CAGE?

A 
Cut down (Have you ever felt you ought to cut down on your drinking?)
Annoyed others (Have people annoyed you by criticizing your drinking?)
Guilty (Have you felt bad or guilty about your drinking?)
Eye opener (Have you had to drink first thing in the morning to steady your nerves or get rid of a hangover?)
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15
Q

Risky drinking (women, men, >65, any situation regardless of age or sex)?

A

Women: >2 drinks/occasion, >7/week
Men: >4 drinks/occasion, >14/week
Over 65: >2 drinks/occasion, >7/week
Any use when pregnant, driving, taking certain medications, having certain medical conditions, in recovery from SUD/cannot control drinking

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16
Q

Define Brief Intervention.

A

3-5 minutes
Provide education about current use and potential risks of current use pattern
Should match patient’s stage of change
Short discussion

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17
Q

Define Referral to Treatment.

A

Facilitate care for individuals who require further treatment

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18
Q

Efficacy of SBIRT for alcohol use?

A

Cost saving
Primary care setting - can reduce alcohol use/at-risk drinking by 10-30% during a 12-month follow-up
Trauma setting - can reduce drinking and subsequent visits among at-risk drinkers
Inpatient - inconclusive

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19
Q

True or false - limited evidence that SBIRT can reduce morbidity and mortality in the population of problem drinker.

A

True

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20
Q

Youth screen (9-14 years)?

A

Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year? Age 9-11 - how about you? Have you ever had more than a few sips?
Age 11-14 - How many days have you had more than a few sips?

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21
Q

Youth screen (14-18)?

A

In the past year how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?

If your friends drink, how many drinks do they usually drink on an occasion?

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22
Q

Among adults aged ___, accidental drug OD was the #1 cause of death in 2012-2013.

A

25-34

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23
Q

Most common cause of OD deaths?

A

Opioids

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24
Q

Among people ___ years old, drug OD caused more deaths than motor vehicle traffic crashes.

A

25-64

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25
Q

Compare the relative strength of common opioid painkillers.

A

Morphine (standard) < Oxycodone < Heroin < Fentanyl (100x stronger than morphine) < Carfentanil (10,000x stronger than morphine)

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26
Q

In 2013, what % of the population 12+ years old had used an illicit drug in the past month?

A

9.4%

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27
Q

Most common SUD?

A

Alcohol use disorder

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28
Q

Define addiction.

A

Compulsive drive to take a drug or engage in a behavior despite serious adverse consquences

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29
Q

DSM-V defines 4 categories of substance-related disorder - what are they?

A
  1. Intoxication
  2. Withdrawal
  3. Substance-induced disorders
  4. Substance Use Disorders
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30
Q

Specifiers for SUD?

A
  • Mild, Moderate, Severe

- Early remission, Sustained remission, in a controlled environment

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31
Q

DSM-5 Diagnostic Criteria - SUD?

A

A. Problematic pattern of substance use leading to clinically significant impairment or distress as manifested by 2+ of 11 symptoms occurring in a 12-month period (these symptoms highlight the impaired control, social impairment, risky use, and pharmacological criteria)

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32
Q

4 SUD criteria - impaired control

A
  1. Take larger amounts of substance or over longer period of time than intended
  2. Persistent desire to cut down or regulate substance use; may have already tried and failed multiple times
  3. Great deal of time spent obtaining the substance, using the substance, or recovering from its effects. For some, these take over the entire life.
  4. Craving or a strong desire or urge to use the substance`
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33
Q

3 SUD criteria - social impairment

A
  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
  2. Continued substance use despite having persistent recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
  3. Important social, occupational, or recreational activities given up or reduced because of substance use
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34
Q

2 SUD criteria - risky use

A
  1. Recurrent substance use in situations in which it is physically hazardous
  2. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
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35
Q

2 SUD criteria - pharmacologic criteria

A
  1. Tolerance (not counted for prescribed medications)
    - Markedly increased dose of the substance to achieve desired effect OR
    - Markedly reduced effect when the usual dose is consumed
  2. Withdrawal (not counted for prescribed medications)
    - Characteristic withdrawal syndrome for a specific substance
    - Substance taken to relieve or avoid withdrawal symptoms
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36
Q

Define mild/moderate/severe specifiers of SUDs

A
  1. Mild - 2-3 symptoms
  2. Moderate - 4-5 symptoms
  3. Severe - 6+ symptoms
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37
Q

What is motivational salience?

A

The extent to which a given object, event, thought, belief or physical/emotional sensation, captures attention and drives goal-directed behavior.

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38
Q

Hedonic tone, a sense of well-being, contentment, and happiness, is set by the ___ system. This system is hijacked in addiction.

A

Mesolimbic dopaminergic

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39
Q

What are the 2 main nuclei involved in the mesolimbic dopaminergic system?

A

VTA

NA

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40
Q

In general, how do substances lead to addiction?

A

Increase DA release to the NA

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41
Q

How does cocaine increase dopamine?

A

Blocks reuptake of transporter protein at the presynaptic terminal, leading to increased dopaminergic neural activation of the NA

42
Q

How does methamphetamine increase dopamine?

A

It is transported into presynaptic terminal of VTA and triggers release of sorted intracellular monoamines at the presynaptic terminal

43
Q

How do opiates increase dopamine?

A

Opioids act as a brake on an inhibitory system that normally dampens VTA transmission, leading to removal of inhibition and dopamine activation (less addictive, as this process is not direct)

44
Q

5 steps to treatment of SUDs?

A
  1. Identification
  2. Engagement
  3. Detoxification
  4. Relapse prevention
  5. Maintenance of recovery
45
Q

Define 1 drink.

A

12 oz standard beer
5 oz wine
1.5 oz of spirits (40% alcohol or 80 proof)

46
Q

Define risky alcohol use.

A

Healthy men up to age 65: 5+ drinks/day (binge) or >14 drinks/week

Health women up to age 65: 4+ drinks/day (binge) or >7 drinks/week

47
Q

Rx settings for SUDs?

A
  1. Inpatient - detox or acute inpatient psychiatry
  2. Non-hospital inpatient and residential - 28 day programs, long term residential programs/therapeutic communities
  3. Outpatient - day treatment (PHP or IOP), outpatient programs/clinics, solo practice
48
Q

Professional psychotherapeutic treatment models for SUD?

A
  • Group/individual therapy
  • CBT (best long-term data)
  • Contingency Management Interventions and Vouchers
  • Motivational Enhancement Therapy
  • Psychodynamic psychotherapy
  • SBIRT
  • Family therapy
49
Q

Contingency Management Interventions and Vouchers are particularly effective in the short term for what use disorders?

A

Cocaine and methamphetamines

50
Q

Pharmacologic treatment for Opioid Use Disorders?

A
  1. Methadone - full opioid agonist with tight opioid receptor binding
  2. Buprenorphine/Naloxone (Suboxone) - partial opioid agonist with very tight opioid receptor binding and slow dissociation from the receptor
  3. Naltrexone (PO or IM) - opioid receptor antagonist
51
Q

Pharmacologic treatment for Alcohol Use Disorders?

A
  1. Acamprosate
  2. Naltrexone
  3. Disulfuram (in special circumstances)
  4. Long-active Naltrexone (Vivitrol)
52
Q

Pharmacologic treatment for Nicotine Use Disorders?

A
  1. Varenicline
  2. Buproprion
  3. Nictoine replacement therapy
53
Q

Define in early remission/in sustained remission/in a controlled environment/on agonist therapy.

A
  • Early remission: none of the criteria have been met for at least 3 months but for less than 12 months
  • Sustained remission: none of the criteria have been met at any time during a period of 12+ months
  • In a controlled environment: access is restricted
  • On agonist therapy - methadone or buprenorphine
54
Q

Discuss the PK of EtOH.

A
  • Water-soluble
  • Empty stomach - peak blood levels are reached between 30-90 minutes after ingestion
  • Zero order metabolism rate (~15-20 mg/dL/hr)
55
Q

Common values for reporting BAL/BAC?

A

mg/dL (80 mg/dL = legal limit)

g/dL (0.08 g/dL = same thing)

56
Q

Primary pathway of ethanol metabolism occurs in the ___ via ___ (enzyme).

A

Liver; alcohol dehydrogenase

57
Q

Effects of alcohol on receptors?

A
  • GABA - increases GABAergic activity (inhibitory)
  • Glutamate-activated ion channels - decreases glutamate activity (decreases excitatory)
  • Dopamine - increases dopamine release in NA
  • Many others
58
Q

Approximate effects of various BALs for a non-alcoholic?

A
  • Between 10-100 mg/dL - euphoria, mild deficits in coordination, attention, and cognition
  • Between 100-200 mg/dL - increased deficits in coordination, psychomotor skills, attention and ataxia, impaired judgment, slurred speech, and mood variability
  • Between 200-300 mg/dL - lack of coordination, incoherent thoughts, confusion, and N/V
  • > 300 mg/dL - stupor and LOC can occur; some experience coma, respiratory depression, death
59
Q

Cause of Wernicke-Korsakoff syndrome?

A

Thiamine deficiency -> atrophy of mammillary bodies

60
Q

Classic triad of Wernicke encephalopathy?

A
  • Encephalopathy
  • Oculomotor dysfunction
  • Gait ataxia
61
Q

Symptoms of acute intoxication with alcohol?

A 
Slurred speech
Nystagmus
Disinhibited behavior
Uncoordination
Unsteady gait
Memory impairment
Stupor
Coma
Hypotension and tachycardia (ethanol-induced peripheral vasodilation, volume loss/dehydration)

Potential metabolic derangements:

  • Hypothermia
  • Hypoglycemia
  • Lactic acidosis
  • Hypokalemia
  • Hypomagnesemia/hypocalcemia
  • Hypoposphatemia`
62
Q

Rx of alcohol intoxication?

A
  • Primarily supportive
  • Mild: observe until sober
  • Moderate: may require IVF, if rapid testing of blood glucose not available, IV thiamine followed by IV dextrose should be given
  • Severe: frequent assessment of airway/breathing, IVF, IV thiamine 100 mg prior to/along with IV dextrose
  • Charcoal or gastric lavage not helpful (rapid absorption)
63
Q

What happens to the GABA/Glutamate balance in a withdrawal state?

A
  • Normal: balanced
  • Intoxication (occasional user): increased GABA
  • Chronic and regular alcohol use: balanced
  • Withdrawal: increased glutamate
64
Q

With repeated episodes of alcohol withdrawal, the likelihood of severe withdrawal symptoms increases - what is this called?

A

Kindling

65
Q

What are the 4 clinically meaningful states of alcohol withdrawal symptoms?

A
  • Autonomic hyperactivity
  • Hallucinations (alcoholic hallucinosis)
  • Neuronal excitation -> seizures
  • DT
66
Q

Symptoms and timing of autonomic hyperactivity due to alcohol withdrawal?

A

Starts ~6 hours post-last drink, peaks 24-48 hours

Tremulousness, diaphoresis, anxiety, psychomotor agitation, N/V, insomnia, headache, palpitations

67
Q

Symptoms and timing of alcohol withdrawal seizures?

A

Usually within 12-48 hours after the last drink, but may occur after only 2 hours of abstinence

Generalized tonic-clonic seizures are most common

68
Q

Symptoms and timing of alcoholic hallucinosis?

A

Develop within 12-24 hours, typically resolve within 24-48 hours

  • Patients have insight and are not delirious or disoriented
  • Visual hallucinations most frequent, though AH may be present
69
Q

Symptoms and timing of DT?

A

Begins between 48-96 hours after last drink, lasts 1-5 days after it starts, most occur between 48-72 hours

Hallucinations, disorientation, tachycardia, HTN, hyperthermia, hyperventilation, agitation, diaphoresis, electrolyte abnormalities, dehydration, hemodynamic instability

70
Q

Assessment of alcohol withdrawal?

A 
Daily dose of alcohol
Duration of steady alcohol use
Presence of withdrawal symptoms (CIWA)
History of withdrawal symptoms, seizures, or DTs
Vitals (elevated HR on admission)
BAC
Abnormal serum electrolytes
Medical comorbidity and infection
71
Q

Management of alcohol withdrawal?

A

1st line - Benzos (replaces GABA)
-Most common options include chlordiazepoxide (25-100 mg), diazepam (5-10 mg), and lorazepam (2-4 mg); oxazepam or midazolam sometimes used

-All pts with seizurs or DTs rquire IV administration of benzos, usually lorazepam or diazepam

72
Q

Physiologic effects of full opioid agonists at mu-opioid receptors?

A

CNS: heat regulation at hypothalamus (slight decrease in body temperature), sedation, analgesia, euphoria, constriction of pupils, seizures (in OD), release of Prl
Urinary retention
GI: constipation, nausea, weight gain/increased appetite, decreased acid secretion, slowing of entire digestive track
Respiratory: depression, pulmonary edema (in OD), suppression of cough
CV: vasodilation, prolonged qTC (especially methadone)
Increased sweating, pruritus, dizziness, histamine release

73
Q

Signs/symptoms of opioid OD?

A 
Stupor or coma
Respiratory depression
Pinpoint pupils, unless prolonged hypoxia, then can have dilated pupils
Pulmonary edema
Seizures
74
Q

Treatment of opioid intoxication?

A
  • ABCs
  • Rapid administration of naloxone
  • Treat hypotension with IVF
  • Check blood glucose and treat with dextrose if necessary
  • Re-evaluate frequently and observe for return of respiratory depressoin
75
Q

Classic triad of opioid intoxication?

A

AMS consistent with opioid intoxication (stupor or coma)
Depressed respiration
Miotic pupils

76
Q

When is it reasonable to give naloxone?

A

Altered level of consciousness consistent with opioid overdose (stupor or coma) + 1 of the following:
RR < 12
Miotic pupils
Circumstantial evidence of opioid use

77
Q

Signs and symptoms of opioid withdrawal?

A
  • Diaphoresis
  • Mydriasis
  • Tachycardia (not as severe as in amphetamines)
  • Goosebumps
  • Abdominal pain/cramps
  • Vomiting
  • Muscle cramps
78
Q

Discuss the role of the Locus Ceruleus in opioid intoxication.

A
  • Nucleus in the pons at the base of the brain
  • Primary site of NE synthesis
  • Activates ascending RAS, sympathetic nervous system, stimulates wakefulness, respiration, etc.
  • Exogenous opioids inhibit NE release by LC`
79
Q

Management of opioid/heroin withdrawal?

A
  • Longer acting opioid agonists (methadone, oxycodone or buprenorphine/naloxone can be used in hospital)
  • Alpha-2 agonists - treat excessive noradrenergic output from the LC (clonidine, lofexidine)
  • Hydroxyzine - anxiety, insomnia, antihistamine4, some anticholinergic
  • Dicyclomine - GI distress, strongly anticholinergic
  • Zofran - N/V
  • Trazodone - insomnia
  • Loperamide - diarrhea (opioid that works on the opioid receptors in the GI tract)
80
Q

What scale can be used to assess acute withdrawal symptoms?

A

COWS

81
Q

Heroin detox outcomes?

A
  • Relatively low rates of retention in treatment
  • Very high rates of relapse post-treatment
  • Risk of accidental OD increases 3-4 days after cessation of opioids as the respiratory drive becomes more sensitive to opioids quickly; by 2 weeks, their risk is much higher
82
Q

Methadone dosing?

A
  • Ranges between 80-120 mg/day for effective tolerance to IV heroin or hydromorphone
  • Studies show than doses >60 mg better than <60 mg
  • Low doses not successful
  • Generally well-tolerated once on a stable dose
83
Q

Suboxone dosing?

A
  • Usually combined with naloxone in 4:1 ratio to prevent diversion and parenteral use
  • Efficacy demonstrated, mostly comparable with methadone
84
Q

Main advantage of suboxone over methadone?

A

Can be done in an office-based practice, must less risk for accidental OD because of ceiling effect

85
Q

Treatment of choice for opioid use disorder (on exam at least)?

A

Methadone

86
Q

Most serious side effect of naltrexone?

A

Liver toxicity (tends to resolve with stoppage of naltrexone and does not progress to failure)

87
Q

How is depot XR naltrexone used?

A

Given every 4 weeks
Less side effects
380 mg dose for 30 days
Side effects: N/V, headache, dizziness, injection site reactions, possible hepatic toxicity
Efficacious
Risk - accidental OD after 30 days if patient no-shows

88
Q

What is the rate hypothesis of addiction?

A

If drugs can increase dopamine in the VTA-NA faster than the homeostatic mechanisms can adjust to keep up, then the euphoria is more intense.

89
Q

What are the 2 forms of cocaine?

A
  • Base cocaine = crack: low melting point, vaporizes easily at low temperatures, can be smoked, not water soluble so cannot easily be injected
  • Cocaine salt - higher melting point, can’t smoke as a result, highly water soluble, easily absorbed when injected
90
Q

Compare cocaine and meth with respect to MOA, euphoria level, metabolization rate, effect length, withdrawal length.

A

Cocaine

  • Monoamine reuptake inhibitor
  • Intense euphoria
  • Metabolizes rapidly
  • Effect lasts for 1-2 hours
  • Withdrawal lasts for 1-2 days

Meth

  • Promotes monoamine release
  • Triple intense euphoria
  • Metabolizes slowly
  • Effects last 10-20 hours
  • Withdrawal lasts for several days
91
Q

Initial effects of a single stimulant dose?

A 
Euphoria/elation
Sense of mastery
Sexual arousal
Increased energy
Increased alertness
Increased sociability
Decreased appetite
Decreased fatigue
Decreased need for sleep
Improved performance for those whose performance is impaired by fatigue or sleep deprivation
92
Q

Stimulant effects with increased dose, potency, or duration?

A 
Hyperfocus (non-productive)
Irritability
Panic, anxiety, paranoia
Aggression
Hypervigilance
Dysphoria
Impaired judgement
Interpersonal sensitivity
Suspiciousness
Grandiosity
Psychotic symptoms
93
Q

Define stimulant binge.

A

Pattern of use when person will keep taking stimulant until they no longer get any additional rush or high from it and are totally exhausted`

94
Q

Define stimulant crash

A

After a single dose, the associated rapid declie in the concentration of drug in the CNS - dysphoria combined with intense cravings to use again

95
Q

Symptoms of stimulant intoxication?

A 
Restlessness, agitation
Tremor
Repetitive or stereotyped behaviors
Skin picking
Hung up behaviors
Associated tachycardia (very high), pupil dilation, diaphoresis, nausea
96
Q

Features of stimulant psychosis?

A

Similar to mania with psychotic features or schizophrenia
Delusions may be less bizarre than schizophrenia
Less negative symptoms
AH/VH or somatosensory
Formication - classic

97
Q

Medical complications of stimulant use?

A

CV: MI, ventricular arrhythmias, sudden cardiac death, cardiomyopathy, myocarditis
CNS: seizure, stroke (thrombotic and hemorrhagic), movement disorders (excess dopamine), psychosis, depression, panic, suicide
Hyperpyrexia
Meth mouth

98
Q

Chronic effects of stimulants on CNS?

A

Cognitive impairment (visuomotor performance, attention, inhibitory control, verbal memory)
Decreased gray/weight matter volumes, enlarged basal ganglia
Psychotic syndrome, flashbcks

99
Q

Management of stimulant intoxication?

A

Avodi physical restraints if possible (increase risk for rhabdo and hyperthermia)
Observe pa tient in quiet environment with minimal sensory stimulation
ART approach:
-Accept immediate needs
-Reassurance
-Talk down
Preferred meds: benzos
-Avoid antipsychotics (increased risk for seizure and hyperthermia)
If necessary, use haloperidol or risperidone to avoid anticholinergic effects

100
Q

Signs of stimulant withdrawal?

A 
Lot life-threatening unless suicidal
Depression/despair
Anhedonia
Fatigue
Poor concentration
Increased total sleep and REM sleep duration but poor sleep quality
101
Q

Rx - stimulant dependence`

A

Difficult

  • No pharm rx
  • CBT and contingency management

Psychiatry Clerkship (8 decks)

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