Substance use (including AUD, Smoking & Opioid) Flashcards
Substance use disorders
Substance abuse (C&G definition)
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more specific symptoms, occurring with a 12-month period.
Substance use disorders
Substance intoxication
A reversible substance-specific syndrome caused by ingestion
Substance use disorders
Substance dependence (C&G)
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) specific symptoms, occurring at any time in the 12-month period.
Substance use disorders
Substance withdrawal
A substance-specific syndrome caused by the cessation of (or reduction in) substance use that has been heavy and prolonged.
Substance use disorders
impaired control
Use of a substance in larger amounts or for longer time than originally intended.
Substance use disorders
Social impairment
Recurrent substance use leading to a failure to meet personal and social obligations.
Substance use disorders
risky use
Recurrent substance use leading to a failure to meet personal and social obligations
Substance use disorders
pharmacological criteria
Requirement for a markedly increased dose to achieve desired effect or markedly reduced effect at standard dose
Substance use disorders
Age (highest prevalence for substance use in general)
Youth age 15-24 years – highest report of illicit substance use and 5x more likely to report harm due to drug use.
Substance use disorders
Subjective Hx
- Onset, duration, and course of presenting complaints
- Question about relatives with hx of etoh, tobacco, or drug use problems.
- Assess when started, amount of use, type etc…with least invasive questions first.
- Start with past to present use (first to last use)
- -past treatment interventions (pharm managment/OAT, A&D counselling, residential treatment programs, etc), past withdrawal management, past complications (seizures, OD), length of sobriety
- OD hx,
- Follow CAGE (cutdown, annoyed, guilty, eye-opener): 2/4 is highly predictive of addiction
- Note usual weight and recent loss in what time frame.
- Review suicidal ideation and/or past hx.
- length of sobriety
- drug costs/day, source of money
- concurrent resp depressants (ETOH, benzo)
Trauma-informed social history:
- housing
- employment history
- legal history, current legal issues
- financial concerns
- social/emotional supports
- family history
- safety: interpersonal violence, children
- hx of trauma: ask about past trauma using ACE tool
Substance use disorders
Objective assessment
BP, RR, HR, WT
INSPECT:
-Gen appearance, dress, grooming, breath odour, wanted appearance, attitude, sad affect, impaired psychomotor ability, or tremors
- Conduct a dermal examination for spider angiomas, bruises, track marks, colour, pallor, rash, jaundice, petechiae, gynecomastia in men (hallucinogens)
- Examine the eyes for sclera colour and features, pupil size and reactivity
- Inspect the nasal mucosa or erythema, oedema, spider telangiectasia, and discharge; look for septal lesions or perforation, deviation, and polyps.
- Inspect the mouth/pharynx: oral lesions, poor dental hygiene, erythema, teeth for uneven surfaces and decay, and gum erosion.
PALPATE:
- Neck and thyroid
- Axilla and groin for lymphadenopathy
- Abdomen; note hepatomegaly/tenderness
PERCUSS:
- Chest, note pulmonary consolidation
Abdomen for hepatosplenomegal
AUSCULTATE:
- Heart for murmur, new S4 gallop, single S2, and arrhythmias.
Lungs for rales, effusion, and consolidation.
Substance use disorders
Smoking cessation pharm management (in adjunct or instead of NRT)
Buproprion – 7 to 12 week treatment. Pt can smoke for first 2 weeks. Risk seizures.
**Varenicline – client chooses stop date and medication is started 1-2 weeks before. Warn patient of adverse effects: vivid dreams, aggression, anxiety. Preferred.
Substance use disorders
Follow-up
weekly, then monthly
screen suicidality every visit
Substance use disorders
5 A’s of smoking cessation
Ask- Identify use
Advise- recommend reduction/cessation
Assess- readiness
Assist- non-pharm & pharm interventions
Arrange- Schedule follow-up
Substance use disorders
TWEAK
Tolerance Worry Eye-opener Amnesia K(cut-down)
- Use in pregnancy
Substance use disorders
5 A’s integrating substance use knowledge
Acquire knowledge
Anticipate harm that may be caused by your practices, reactions, judgements
Analyze the impact of policies
Avoid social judgements about SU
Approach all pt/s respectfully
Substance use disorders
CAGE
Cut down
Annoyed
Guilty
Eye-opener
Substance use disorders
SWIGECAPS
• Sleep • Worthlessness • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor changes Suicidal/Safety
Substance use disorders
What is OUD?
Chronic relapsing problematic use of and addiction to opioids
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Opioid use disorder Age and Sex
OD deaths
80% Age 29-49yrs
80% male
Substance use disorders
Risk factors for opioid OD
- social isolation (3/5 OD deaths were using alone)
- Indigenous (intergenerational trauma from colonization) over-represented in OD deaths
- untreated psychiatric conditions
- high ACE scores
Substance use disorders
Opioid patho
- dopamine reward pathway dysfunction
- Increased dopamine release in nucleus accumbens (responsible for motivation and goal-directed behaviour)
- dopamine is needed for memory to associate positive and negative emotions –> reinforces positive reward
- drugs (amphetamines, cocaine, nicotine, opioids) cause 2-10x amt of dopamine compared to naturally rewarding stimuli)
Substance use disorders
Tolerance
need for increased amount of drug to achieve effect
Substance use disorders
Time for moderate to severe withdrawal from pharmaceutical grade opioids
- Short acting opioids (heroin, morphine, IR oxycodone): 12-16 hours
- Intermediate acting opioids (SROM, CR HM, SR oxycodone); 17-24 hours
- Long acting opioids (methadone): 30-48 hours
Substance use disorders
How have fentanyl analogues complicated Suboxone inductions?
precipitated withdrawal can occur 24+ hours after stopping
Substance use disorders
What is a long term complication of opioid OD?
anoxic brain injury
Substance use disorders
Two-Item Conjoint Screen (TICS)?
- have you ever drunk/used drugs more than you meant to?
- have you felt you wanted/needed to cut down your drinking/drug use?
Substance use disorders
Screening for substance use, ask all patients:
“how many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”
Substance use disorders
Opioid withdrawal symptoms
HR Sweating GI upset (N/V/D/cramps) Tremor Restlessness Yawning Pupil dilation Anxiety/irritability Piloerrection Bone/joint aches Rhinorrhea/lacrimation Cravings
Substance use disorders
Opioid OD Signs
- Respiratory depression (RR<10-12/min is best clinical predictor of opioid intoxication)
- Gurgling/snoring
- Minimally responsive –> unresponsive
- Constricted pupils
- Slow erratic HR
- Cyanosis and cool/clammy skin
Substance use disorders
atypical opioid toxicity
- chest wall rigidity
- dyskinesia: involuntary muscle movement (ranging from twitching to chorea)
- decorticate posturing
- anisocoria (unequal pupils)
Substance use disorders
DSM criteria for opioid use disorder
Two or more of the following (* if only two are tolerance/withdrawal, excludes those using Rx’d opioids for chronic pain)
- often take > amts than intended
- persistent desire or attempt to control use
- ++ time spent securing substances
- cravings
- recurrent opioid use resulting in failure to fulfill social/professional/academic obligations
- continued use despite social consequences
- giving up social/work/rec pursuits
- physically hazardous use
- continued use despite physical/psych consequences
- tolerance
- withdrawal
Substance use disorders
Labs when initiating OAT
Labs: CBC, Cr, LFT (esp ALT, GGT), HIV, Hep A/B/C, syphilis, chlamydia, gonorrhea
• Preg test for women of childbearing age
• Repeat LFTs 4 weeks after initiation esp if pre-existing liver disease
Lab based urine drug screen: covers methadone, opiates, BZD, cocaine/cocaine metabolites, amphetamines
*fentanyl and synthetic opioids (eg buprenorphine, oxycodone, HM) must be specifically requested when ordering UDS
Substance use disorders
COWS/SOWS score to start Suboxone
COWS > 11
SOWS > 16
(moderate to severe withdrawal)
Substance use disorders
Refer to addiction’s specialist for OAT tx when:
- pregnant/breastfeeding
- concurrent chronic pain, complex comorbidities
- switching from another type of OAT
- previous unsuccessful inductions
- youth
- complex polysubstance use
- consideration for iOAT (injectable OAT: hydromorphone, diacetylmorphine)
Substance use disorders
Opioid harm reduction resources
- Take home naloxone kit: free for all patients, caregivers, practitioners. For all patients at risk of OD.
- Harm reduction supplies (sterile needles, pipes, etc)
- Access to supervised consumption sites
- Safer supply (prescription opioids): risk mitigation during dual public health emergency
- Drug testing, toxic supply reporting
- Education on safer use: where to inject, switch to intranasal/smoking, do not use alone
- Link to Overdose Outreach Teams
- Lifeguard app
Substance use disorders
Contraindications and precautions for Suboxone
Contraindications:
severe resp distress, delirium tremens, acute ETOH intoxication, severe liver failure
Precautions: caution with other sedating meds (increase risk of resp depression with BZD, ETOH, other sedatives), CYP medications
Monitoring:
Substance use disorders
Suboxone MOA
buprenorphine partial opioid agonist w/ high binding affinity –> binds rapidly to opioid receptors (knocks off full opioid agonists eg heroin/fentanyl that may be present)
naloxone helps to prevent diversion
Substance use disorders
Suboxone adverse reactions
1) Headache
2) Nausea, vomiting, constipation, abdominal pain
3) insomnia
4) hyperhidrosis
Substance use disorders
Methadone adverse rxn
overdose/resp depression (no ceiling, full opioid agonist)
prolonged QT!
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naloxone duration of action
20-90 min
Substance use disorders
BCCSU/Canada Low Risk Drinking Guidelines: definition risky drinking
- Males 3+ drinks/day or 15+ drinks/week
- Females 2+ drinks/day or 10+ drinks/week
Substance use disorders
C&G definition of binge drinking:
- males 5+ drinks on at least 1 day in last 30 days
- females 4+ drinks on at least 1 day in last 30 days
Substance use disorders
AUD prevalence
- age: 15-49 ETOH is leading cause of death/disability
- 18% of all Canadians age 15+ meet clinical criteria for AUD in their lifetime
- 20% of Canadians 12+ drink in excess of recommended limits
- Higher prevalence in sexual minority (LGBTQ)
Substance use disorders
AUD patho (C&G?)
- Brain disorder caused by combination of genetics and environment
- ?impaired metabolism, insensitivity to alcohol, alterations in brain wave
Substance use disorders
Complications of AUD
anemia HTN cardiomyopathy hepatitis/AFLD/Cirrhosis Gout DM CA gastritis/varices/UGIB pancreatitis polyneuropathy dementias psychosis
Substance use disorders
What is the PAWSS?
Prediction of alcohol withdrawal severity scale
Score < 4 –> low risk, manage without pharm or with gabapentine as outpatient
Score > 3 –> hospital admission, benzo for withdrawal management
Substance use disorders
2 first - line pharm management for AUD and their contraindications?
naltrexone –> contraindication in severe liver dysfunction or concurrent opioid use (best choice is patient wants to reduce drinking but isn’t necessarily planning abstinence)
acomprosate –> contraindicated in severe renal failure, breastfeeding A = abstinent (best choice if patient would like to stop altogether)
Substance use disorders
What are two 2nd line pharm options for AUD and their contraindications?
topiramate –> contraindicated pregnancy, narrow angle glaucoma, nephrolithiasis
gabapentine –> contraindicated in renal impairment, pregnancy, teens or > 65 yrs, concomitant CNS depressants, poor resp function, cognitive impairment
Substance use disorders
Supplements for AUD
Thiamine (100 mg)
folic acid (1 mg)
B6 (2 mg)
