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Psychiatry > Substance Use Disorders > Flashcards

Substance Use Disorders Flashcards

1
Q

Discuss Addiction and its pathophysiology

A 
4 Cs of Addiction
- loss of control
- craving
- continued use despite consequences
- compulsive use
Pathophysiology
- repeated administration of substance change brain functioning (increase dopamine in mesolimbic) -> loss of control over use of substance -> build tolerance and down regulate dopamine -> require more and frequent in order to allow for improved mood
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2
Q

Discuss how substance use presents in each age group

A 
Adolescents
- decline in school performance
- involvement in illegal activities
- change in peer group
- insomnia
- unexplained weight loss
Adults
- impaired pscyhosocial functioning (difficulty with work)
- fatigue, insomnia
- mood symptoms
- behavioural change
- suicide
Elderly
- confusion
- depression
- tremor
- social isolation
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3
Q

List the criteria for substance use disorder

A

> =2 in 12 month period
- substance taken in larger amount and over longer period of time
- persistent desire or unsuccessful attempt to cut down
- great deal of time is spent obtaining substances
- craving
- failure to fulfill major obligations at work, school, home
- continue use despite interpersonal problems
- important social activities given up
- use in situations when physically hazardous
- persistent use despite knowledge of physical or psychological problem due to substance
- tolerance (marked increase in order to have same effect or normal does not lead to same effect)
- withdrawal
Specifiers
- mild: 2-3
- moderate: 4-5
- severe: >=6

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4
Q

Differentiate between physical dependance and substance use

A

Dependence

- have tolerance or withdrawal at normal prescribed levels

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5
Q

List the criteria for substance intoxication

A
  • Patient used substance recently
  • patient has clinically significant problematic behaviour or psychological change due to substance
  • patient exhibits >= specified symptoms
  • symptoms and sign not due to anything else
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6
Q

List the criteria for substance withdrawal

A
  • cessation or reduction in heavy or prolonged use
  • patient exhibits >= specified number of symptoms
  • significant problematic behaviour due to withdrawal that impair functioning
  • not due to anything else
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7
Q

Discuss the stages of change and interventions at each

A

Pre-contemplation
- no intention to change in 6 months
- provide information
- discuss substance effects and role in life
Contemplation
- ambivalent with change <6 months
- motivate to increase confidence and elaborate on benefits
Preparation
- patient committed but has yet to change, <1 month
- negotiate on treatment plan
Action
- changed behaviour in last 30 days, <6 months
- encourage to continue
Maintenance
- reached goal for >6 months

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8
Q

List when patient require medical supervision for detoxification

A 
High risk of severe withdrawal
- previous alcohol withdrawal seizure
- previous delirium tremens
- high dose benzodiazepine
Medical condition that may be worsened
Concurrent disorder that may destabilize with medical support
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9
Q

List the CAGE questionnaire for alcohol use and breakdown recommended alcohol use

A

CAGE
- Cut down on your drinking
- Annoyed by people asking about drinking
- Guilty about drinking
- Eye opener regarding drinking
Amount of Alcohol
- 1 drink is 13.6g of or 1 350mL beer or 150mL wine or 50mL shot
- bottle of wine has 5 drinks
- bottle of liquor has 8 drinks
Recommended
- Women <=10 drinks/week, <=2 drinks/day and <=3 drinks/occassion
- Men <=15 drinks/week, <=3 drinks/day and <=4 drinks/occassion

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10
Q

List the presentation of alcohol use disorder

A 
Chronic Liver Disease
- jaundice
- scleral icterus
- hepatomegaly
- ascites
- spider nevi
- palmar erythema
Vitamin Deficiency
- Thiamine deficiency leading to Wernicke encephalopathy
      - triad of confusion, ataxia and opthalmoplegia
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11
Q

List the symptoms of alcohol intoxications

A

> =1 of:

  • slurred speech
  • incoordination
  • unsteady gait
  • nystagmus
  • impairement in attention or memory
  • stupor or coma
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12
Q

List the symptoms of alcohol withdrawal

A 
- usually begin 12 hours after last drink, peak at 2-3 days and improve by 4-5 days
>=2 of:
- autonomic hyperactivity
- increased hand tremor
- insomnia
- nausea/vomiting
- transient visual, tactile, or auditory hallucinations
- psychomotor agitation
- anxiety
- generalized tonic-clonic seizures
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13
Q

Discuss delirium tremens and risks for it

A 
- disturbance in consciousness and cognition with hallucinations
Risks
- increased quantity and frequency of use
- past withdrawal
- family history of withdrawal
- concurrent medical condition
- concurrent consumption of sedative
- past alcohol withdrawal seizure
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14
Q

Discuss the CIWA score

A
  • each section rated out of 7 and scores <10 do not need medical therapy
    Sections correlated with symptoms
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15
Q

List the different alcohol withdrawal management options

A

No risk of medical complications
- decrease alcohol as outpatient with community and family support
Community Withdrawal Management
- go to centre every day and staff can go to home
- centre does not administer medication, but meet with physician daily to give benzo dose
Residential Withdrawal Management Level 2
- no health professional onsite but do have addiciton managers
- monitored 24/7 and patient stay for 3 days to 2 weeks
Residential Withdrawal Management Level 3
- supervision by medical staff 24/7 and stay for 3 weeks
- used when have previous medical complication or high dose benzodiazepines

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16
Q

Discuss the treatment for alcohol withdrawal

A
  • all patients receive 100mg thiamine IM then 100mg PO for 3 days
    Fixed Dose Regimen
  • benzodiazpine (diazepam) used QID
  • done to prevent or treat withdrawal (acute medical or surgical illness)
    Front Loading Regimen
  • Diazepam 20mg q1-2 hours PRN for CIWA scores >=10 until <=8
    • observe for 2-4 hours after last dose
    • used most often in ED
      Symptom Triggered Regimen
  • individualize benzo dose and frequency based on CIWA score
17
Q

List the symptoms of benzodiazepine intoxication

A

> =1

  • slurred speech
  • incoordination
  • unsteady gait
  • nystagmus
  • impairement in attention or memory
  • stupor or coma
18
Q

List the symptoms of benzodiazepine withdrawal

A
  • Short acting (lorazapam (Ativan), Alprazolam (Xanax)) being in 24hrs, peak 1-5 days and over in 7-21
  • Long acting (diazepam (Valium), clonazepam) withdrawal in 7 days, peak 1-9 and over in 10-28
    >=2
  • autonomic hyperactivity
  • increased hand tremor
  • insomnia
  • nausea/vomiting
  • transient visual/tactile/auditory hallucination
  • psychomotor agitation
  • anxiety
  • generalized tonic-clonic seizures
19
Q

Discuss benzodiazepine taper

A

Taper with long acting benzodiazepine
- except if abusing alprazolam
Taper according to symptoms
- regular dispensing of daily, twice weekly, weekly
- low dose (<50mg/day diazepam) then outpatient
- moderate dose (50-110mg/day diazepam) then inpatient or outpatient only if stable and unlikely to use from other source
- high dose (>100mg/day diazepam) than inpatient
Outpatient Taper
- proportional dose taper (by 10% of dose until 20% of original dose then 5% ever 2-4 weeks)
- taper by amount (decrease by 5mg per week, or 3-4 days if >50mg, then once below 20mg slow pace
Inpatient Taper
- start at 1/2-1/3 of original dose administered TID or QID
- taper by 5-15 mg per day and slow as dose decreased

20
Q

List the symptoms of opioid intoxication

A 
>=1 (also have pupillary constriction with dilatation occurring with severe doses)
- drowsiness or coma
- slurred speech
- impairment in attention or memory
Management
- stabilize patient
- Naloxone 0.4-0.8mg IM
       - initiated withdrawal
21
Q

List the symptoms of opioid withdrawal

A 
- use COWS score for clinical opioid withdrawal
>=3
- dysphoria
- nausea/vomiting
- muscle aches
- lacrimation or rhinorrhea
- pupillary dilatation, piloerection or sweating
- diarrhea
- yawning
- fever
- insomnia
22
Q

List the opioid detoxification strategies

A 
Abstinence
- Medications for symptoms of withdrawal
      - Clonidine 0.05-0.1mg QID for hypertension
      - anti-diarrheals (loperamide)
      - anti-nausents (Gravol)
      - analgesic
      - night sedation (trazadone)
Taper with Long Acting Opioid
- decrease total dose by 10% each week
- weekly visit and drug screen
- treatment contract with daily dispensing
Substitution with Methadone or Suboxone
- on maintenance to prevent further use
- Methodone have daily dispensing and weekly drug screens
- Suboxone (Buprenorphine and Naloxone) need to stop for 1 day in order to begin withdrawal (COWS >=13) and is taken sublingually every 2-3 days
Contraindications for Methadone
- use of benzodiazepines or alcohol
- elderly
- dependent on codeine
- medication that interfere with methadone metabolism
- risk for prolonged QTc
23
Q

List the symptoms of stimulant intoxication

A 
Psychological Changes
- euphoria or affective blunting
- interpersonal sensitivity
- anxiety, anger
- impaired judgement
Behavioural Changes
- change in sociability
- hypervigilence
- stereotyped behaviour
>=2 of the following symptoms
- tachycardia
- pupillary dilatation
- hypertension
- perspiration
- nausea/vomiting
- weight loss
- psychomotor agitation or retardation
- muscle weakness, respiratory depression, arrhythmia
- confusion, seizure
24
Q

List the symptoms of stimulant withdrawal

A

> =2

  • fatigue
  • vivid and unpleasant dreams
  • insomnia
  • increased appetite
  • psychomotor agitation/retardation
25
Q

List the symptoms of cannabis intoxication

A 
Psychological Changes
- euphoria
- anxiety
- sensation of slowed time
- impaired judgement
Behavioural Changes
- social withdrawal
- impaired motor coordination
>=2 of the following
- conjunctival injection
- increased appetite
- dry mouth
- tachycardia
26
Q

List the symptoms of cannabis withdrawal

A

> =3

  • irritability, anger or aggression
  • nervousness or anxiety
  • sleep difficulty
  • decreased appetite
  • restlessness
  • depressed mood
  • abdominal pain, tremors, headache

Psychiatry (15 decks)

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