Substance Use Disorders Flashcards
Discuss Addiction and its pathophysiology
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
Discuss how substance use presents in each age group
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
List the criteria for substance use disorder
> =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
Differentiate between physical dependance and substance use
Dependence
- have tolerance or withdrawal at normal prescribed levels
List the criteria for substance intoxication
- 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
List the criteria for substance withdrawal
- 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
Discuss the stages of change and interventions at each
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
List when patient require medical supervision for detoxification
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
List the CAGE questionnaire for alcohol use and breakdown recommended alcohol use
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
List the presentation of alcohol use disorder
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 opthalmoplegiaList the symptoms of alcohol intoxications
> =1 of:
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- impairement in attention or memory
- stupor or coma
List the symptoms of alcohol withdrawal
- 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
Discuss delirium tremens and risks for it
- 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
Discuss the CIWA score
- each section rated out of 7 and scores <10 do not need medical therapy
Sections correlated with symptoms
List the different alcohol withdrawal management options
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
Discuss the treatment for alcohol withdrawal
- 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
List the symptoms of benzodiazepine intoxication
> =1
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- impairement in attention or memory
- stupor or coma
List the symptoms of benzodiazepine withdrawal
- 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
Discuss benzodiazepine taper
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
List the symptoms of opioid intoxication
>=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 withdrawalList the symptoms of opioid withdrawal
- 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
List the opioid detoxification strategies
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 QTcList the symptoms of stimulant intoxication
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
List the symptoms of stimulant withdrawal
> =2
- fatigue
- vivid and unpleasant dreams
- insomnia
- increased appetite
- psychomotor agitation/retardation
List the symptoms of cannabis intoxication
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
List the symptoms of cannabis withdrawal
> =3
- irritability, anger or aggression
- nervousness or anxiety
- sleep difficulty
- decreased appetite
- restlessness
- depressed mood
- abdominal pain, tremors, headache
