Substance Use Disorders Flashcards
What happens to the concentration of D2 receptors in the striatum (i.e. nucleus accumbens) during addiction and why?
The concentration is decreased -> addictive substances cause massive amounts of dopamine to be released into Nucleus accumbens initially, until D2 receptors are downregulated -> addiction (from repeated overstimulation of D2 receptors)
What are the 11 behavioral criteria for any substance use disorder in the DSM?
- More excessive use than intended
- Persistent desire to control use
- Lots of time dedicated to finding, taking, and recovering from the drug
- Craving drug
- Failure to meet obligations of life
- Recurrent social / interpersonal problems because of drug
- Activities are given up / reduced for drug
- Use of alcohol where it is hazardous (i.e. DUI)
- Continued use despite knowledge that it is causing problems
- Tolerance
- Withdrawal
How is tolerance defined?
Need for markedly increased amounts of substance to achieve intoxication or desired effect
How many of the 11 symptoms need to be a present for a mild, moderate, and severe substance use disorder?
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6+ symptoms
What is considered moderate, at risk, and heavy drinking for males? This is, number of drinks per day. Females?
Moderate = 2 drinks a day
At risk = 4+ drinks a day
Heavy = 5+ drinks a day
Females is 1 less than this in all categories.
What is standard drink size for beer, wine, and liquor?
Beer - 12 oz
Wine - 5 oz
Liquor - 1.5 oz of 80 proof
What is the legal limit for driving in Michigan? When does voluntary movement become clumsy? When do you go into coma?
Legal limit = 0.08%
Clumsy movement = 0.1%
Coma = 0.4%
What happens to the eyes even in mild alcohol intoxication?
Nystagmus
What happens during severe alcohol intoxication?
Aggressiveness, labile mood, psychomotor retardation, blackouts!
What is a blackout, and is it predictive of longterm cognitive impairment?
Blocked consolidation of memory between hipoocampus and temporal lobe
-> not predictive of longterm cognitive impairment
What are some common behavioral and physical signs of alcohol withdrawal?
Behavioral: Anxiety, agitation, hallucinations
Physical: Autonomic hyperactivity (increased HR / BP due to lack of depressant), sweating, seizures, tremor, N/V
What is the rough timeline of withdrawal symptoms for alcohol?
6 hours - tremor
8 - 12 hours - visual hallucinations
12-24 hours - seizures
72 hours - delirium tremens (preventable)
What is Delirium tremens / its symptoms?
Delirium (confusion, disorientation) + physical symptoms of alcohol withdrawal.
Can be fatal due to cardiovascular collapse and hypothermia
What is the best catch-all screening questioning for alcoholism?
How many times in the past year have you had 5+ drinks in 1 day (4 for women)?
What is CIWA / what is it used for?
Clinical Institute Withdrawal Assessment of alcohol scale
-> used for rating patient’s withdrawal symptoms on a scale and monitoring them
What are the CAGE questions? When might you have a disorder?
Have you ever thought about CUTTING down?
Have you ever felt ANNOYED by people criticizing the drinking?
Have you ever felt GUILTY about your drinking?
Have you ever used a drink as an EYE-OPENER? (to alleviate morning hang-over / nerves) -> counts as 2
2+ points = probably AUD
All 4 questions yes = diagnostic
What is AUDIT?
Alcohol Use Disorder Identification Test - screening questions used to assess a possible AUD
What liver enzymes suggest alcoholic liver damage vs viral hepatitis?
Elevated AST > ALT, ratio of AST:ALT is increased.
Also, elevated GGT levels
Why is uric acid increased in alcohol?
Beer has high uric acid levels
What are the symptoms of Wernicke’s encephalopathy? Is it reversible? What is the main symptom of Korsakoff’s dementia?
Yes - reversible with vitamin B1
ACO Ataxia Confusion Ophthalmoplegia (lateral gaze paralysis) Vestibular dysfunction
Korsakoff’s - Anterograde amnesia compensated w/confabulation
What is alcohol-induced psychotic disorder and how does it differ from delirium?
Psychotic symptoms in chronic alcohol users within a week of intoxication or withdrawal
-> differs from delirium in that sensorium is clear
How does alcohol affect sleep?
Reduced sleep latency, middle insomnia occurs, decreased REM, and inhibition of stage 4
When do people typically first start using tobacco, and is this more of a problem in men or women?
Age 12-13 years
Dependence occurs in 3-4 weeks, worse of a problem in women than men
Why do users often report relaxation with nicotine use, and when is the craving the strongest?
Because they are alleviating their withdrawal symptoms -> nicotine shouldn’t relax you, it’s a stimulant which increases adrenaline and head rush
Craving strongest in AM (8 hours of withdrawal)
What are the characteristics of nicotine overdose and when is it most likely to occur?
Most likely to occur during cessation -> too much gum / patches
GI distress, vomiting, cold sweats, seizures, arrhythmias (pretty much the same as alcohol withdrawal)
How long does nicotine withdrawal last and what are its key symptoms?
Lasts 1-3 months, peaking 2-3 days.
Tingling of hands and feet, insomnia, difficult concentrating, sweating
How is oil extracted from cannabis? Is this easy to do?
Via using a solvent like butane
Not easy to do -> dangerous like meth labs?
What is the “crack” of marijuana
Dabbing, smoking concentrated (75%) THC which is extracted via the process just mentioned, called shatter or wax
What are the common behavioral effects of cannabis?
Decreased goal-directed mental activity, relaxation, slowed sense of time, heightened sensitivity to external stimuli (smell, sound, taste), anterograde amnesia, increased appetite
Why can you get a DUI for using marijuana?
Impairs your coordination and slows your reaction time
What is the #1 physical symptom of cannabis intoxication?
Tachycardia
What are the negative features of cannabis overdose?
Anxiety, Panic, Paranoia
Can lead to acute psychosis requiring ER
What are the most common features of Cannabis Withdrawal Syndrome?
3+ behavior symptoms: Decreased appetite, Irritability, Sleep difficulty
+
1+ physical symptoms: like sweating, tremors, headache
What can cannabis do to the lungs, to the psyche, and to the reproductive system?
Lungs - decreased lung capacity and increased infection risk
Psyche - Increased risk for anxiety / depression, worse mood disorders
Reproductive system - Decreased testosterone / gynecomastia. Reduced fertility
Is cannabis teratogenic?
yes - high rate of miscarriage, fetal alcohol syndrome, and it accumulates in breast milk
What are three definitive uses for medical marijuana?
- Anti-emetic
- Appetite stimulant
- Glaucoma - decreased IOP
What is the primary driver of the opioid epidemic?
Increased prescription writing by doctors
Why is heroin most commonly abused?
High lipid solubility -> crosses blood-brain barrier more quickly, leading to quicker high
What are four key physical symptoms of opioid intoxication?
- Drowsiness / coma - “on the nod”
- Pupillary constriction / miosis
- Respiratory depression
- Constipation
What is the clinical triad of opioid OVERDOSE?
Respiratory depression, pinpoint pupils, coma
What is the clinical presentation of opiate withdrawal?
Diaphoresis, diarrhea, lacrimation, vomiting, rhinorrhea
“leaking from every orifice”
-> also tachycardia
Can opiate withdrawal be fatal and how long does it last?
Lasts 7-10 days, peaking at 2-3 days
NOT fatal (like delirium tremens would be)
What causes skin popping in opioid users?
patches of skin are popped up due to subcutaneous injection of opioids, when all the veins are collapsed
Are all SES’s equally affected by opioid and cocaine use?
Opioid - disproportionately lower SES
Cocaine - everybody uses it cuz its great
What mediates the effects of opioids and cocaine?
Opioids - binds the mu receptor for euphoria and analgesia
cocaine - inhibits dopamine, norepinephrine, and serotonin reuptake
How is crack made?
Via ether “free basing” or ammonia + water and mixing it, heating it to remove HCl and make cocaine in its basic form
-> can be smoked for very rapid euphoria
What can happen to the nose in chronic cocaine use?
Nasal septum can collapse due to ulceration and perforation of the nasal septa
What are the psychological / physical effects of cocaine use?
Stimulant so:
Psychological - increased mental clarity, elevated mood, sexual arousal, agitation and anxiety, dizziness, insomnia, paranoia (aggressive with crack), violent behavior
Physical effects - hyperpyresis, increased BP, heart rate, dilated pupils (vs constricted with opiates)
How does death typically occur in cocaine overdose?
Constricted blood vessels + increased heart rate -> seizure, heart attack, arrhythmias, and stroke.
Paranoia + aggressive behavior can lead to fights.
Worst effects occur when taken with alcohol.
How does cocaine cause stroke?
Major vasoconstriction -> nonhemorrhagic cerebral infarct
What is it called when smoking damages lungs and bronchial passages from cocaine use?
“Crack lung”
What are two quite diagnostic physical changes for amphetamine overuse (i.e. methamphetamine or other sympathomimetics)
- Bruxism - teeth grinding
- Weight loss (appetite suppressant)
-> otherwise it looks just like cocaine use
What is one shared feature that cocaine and meth “speed” have in terms of withdrawal symptoms at night?
Cocaine - coke dreams
Meth - speed dreams
These are both really terrible nightmares.
What is the definition of a hallucinogen, and what is one drug which fits in this class which you might not expect?
Loss of sense of intact reality + expansion of consciousness without associated delirium, sedation, excessive stimulation, or cognitive impairment
-> marijuana is in this class
What are the primary receptors affected via hallucinogens?
Serotonergic and NMDA
Give examples of natural and synthetic hallucinogens?
Natural: Mescaline, psilocybin (mushrooms)
Synthetic: LSD
What are common perceptual / sensory changes with hallucinogens?
Visual hallucinations - changes / distorting shapes
Synesthesias - i.e. associations between senses
Altered sense of time
What is a good trip vs a bad trip?
Good trip - pleasurable, mentally stimulating, deeper levels of understanding
Bad trip - Acute dysphoric reaction - terrifying thoughts and memories emerge rapidly, nightmare-like feelings of anxiety and doom, fear that things will always be this way, panic and anxiety. Acute paranoia is common.
How can an LSD trip be told apart from an acute psychotic episode?
Absence of auditory hallucinations in LSD (visual only)
What is it called when chronic use of a hallucinogen causes random hallucinations and false perceptions even after cessation of use?
Hallucinogenic Persisting Perceptual DIsorder
What is the dissociative drug of choice and what is its mechanism of action? How is it used?
Ketamine
Non-competitive NMDA receptor antagonist
Usually smoked or snorted as a powder, can be dissolved in water for ingestion
What is the “line dose” of ketamine?
Dose at which primary senses are loss, but you are not quite yet unconscious -> you feel dissociated
What is fragmentation?
A symptom of ketamine intoxication, whereby you are spinning, unable to talk, see, or hear other in the room
What is “entering the K hole” or “going to K land”?
Descriptions of entering an alternate plane of existence, perceptual distortion and feelings of disconnection from self and environment. Can lead to terrifying sensations of loss of time and identity.
How do patients on ketamine look?
- Catatonic with rigid posturing and blank faces
- Open mouth, pupils dilated, sightless stare
- Social withdrawal, bizarre thought patterns and responses (ideas of reference, tangential thinking)
What are the negative consequences of chronic ketamine use?
Chronic mental impairment -> decreased memory, intellectual function, and speech problems like “word blocking”, not being able to find the word
Visual disturbances
persist >1 yr into abstinence
Does a withdrawal syndrome exist for hallucinogens? How do they differ from dissociative drugs?
NO
Differ from dissociative drugs because they expand your consciousness
Dissociative drugs distort your consciousness and detach you from it
Both will act on NMDA receptors
What is the mechanism of action of MDMA?
Amphetamine analog -> stimulant properties, but also mild hallucinogenic properties by acting on serotonergic receptors
What are the psychological effects of MDMA?
Euphoria, self confidence, extreme relatedness felt to others, increased energy + appreciation of music, emotional closeness / acceptance
How do kids these days typically deal with the negative effects of MDMA use?
- Pacifier - can cause bruxism (similar MoA as methamphetamine)
- Water bottles - can cause diaphoresis, dehydration, and hyperthermia
How can you die of an MDMA overdose?
Hyperthermia, dehydration, cardiovascular changes can lead to heart / kidney failure and extreme heat stroke
What is the medical name of roofies and its mechanism of action? How long do effects last?
Rohypnol - Flunitrazepam
Mechanism of action - GABA-A agonist, similar to other benzos. 7-10x as potent as diazepam, with effects lasting 4-6 hours
What type of drug is rohypnol considered? Why?
Club drug, like MDMA
At lower doses, causes a euphoric high typical of benzodiazepines, along with all the other benzo relaxation effects like a decrease in anxiety, increased muscle relaxation, somnolence, disinhibition
What do high levels of rohypnol and overdose cause?
High levels - Headache, anterograde amnesia (used for date rape
Overdose - Loss of reflexes, hypothermia, respiratory depression, hypotension, coma (regular benzodiazepine overdose, looks like opioid minus the miosis)
